Journal of Cancer Research and Therapeutics Medknow Publications on behalf of the Association of Radiation Oncologists of India (AROI) ISSN: 0973-1482 EISSN: 1998-4138 Vol. 6, Num. 4, 2010, pp. 473-477

Journal of Cancer Research and Therapeutics, Vol. 6, No. 4, October-December, 2010, pp. 473-477

Original Article

Pattern of malignant tumors registered at a referral oral and maxillofacial hospital in Sudan during 2006 and 2007

Tarig A Osman¹, Asim A Satti², Olav E Bøe³, Yi-Hsin Yang⁴, Salah O Ibrahim⁵, Ahmed M Suleiman⁶

¹ Centre for International Health, Department of Computing and Research, Khartoum Teaching Dental Hospital, Federal Ministry of Health, Sudan,
² Department of Computing and Research, Khartoum Teaching Dental Hospital, Federal Ministry of Health, Sudan
³ Department of Clinical Dentistry, Faculty of Medicine and Dentistry, University of Bergen, Norway
⁴ Department of Oral Hygiene, Kaohsiung Medical University, Taiwan
⁵ Department of Biomedicine, Faculty of Medicine and Dentistry, University of Bergen, Norway
⁶ Department of Computing and Research, Khartoum Teaching Dental Hospital, Federal Ministry of Health; Faculty of Dentistry, University of Khartoum, Sudan

Correspondence Address: Tarig A Osman, Centre for International Health, Årstadveien 21, 5th Floor, University of Bergen, 5020 Bergen, P.O. Box: 7804, Norway, tarigalhadi@gmail.com

PMID: 21358083

DOI: 10.4103/0973-1482.77112

Abstract

Keywords: Hospital records, squamous cell carcinoma, sudan, toombak

Introduction

Worldwide, the incidence of oral cancer (OC) is further increasing, rendering the problem as a considerable component of the global burden of cancers. ^[1],[2] The world cancer report of 2008 ranked OC as the fifth most common cancer type among males in the less developed countries. ^[3] In Sudan, OC is the fifth most common cancer type with incident rate (920/year), comprising 9% of the cases reported annually in Africa. ^[4] This is strongly attributed to the use of local type of snuff known as Toombak, a very popular material in the Sudanese community. ^[5],[6] The association between Toombak dipping and OC has been investigated thoroughly during the last three decades. ^{[7],[8],[9],[10]}

Updated population-based data on OC is not available in Sudan. The numbers available now are either from the Radiation and Isotope Centre in Khartoum, ^[9] or annual reports from governmental hospitals to the Ministry of Health. Lack of a well controlled disease notification and recording system tendered the reliability of these reports. Therefore, there is an urgent need for reliable data to justify launching intensive screening programs in order to curb the incidence of OC in the country.

In this study, we aimed to report on the number of OC cases and to describe the pattern of cancer cases diagnosed at a referral oral and maxillofacial hospital in Sudan during the period 2006-2007. Furthermore, we aimed to shed light on the urgent need for necessary measures for prevention, treatment and early detection.

Materials and Methods

This study has been conducted, in Khartoum Teaching Dental Hospital, as a cross-sectional study utilizing the hospital records as secondary data. It has been approved by the National Health Research Ethics Committee - Sudan. The hospital registry uses the 10 ^th version of the international classification of diseases (ICD-10) to record cases attending the Department of Oral and Maxillofacial Surgery. The codes of this classification system denote the type of the neoplasm and the anatomic site, by a letter followed by a number respectively. ^[11] From the hospital database, a report including all malignancy cases (ICD-10 code C00.0 through C14.8) registered during the period January 2006 to December 2007 was extracted. The report also included data on age, gender, state of residence, occupation, marital status, oral habits, date of diagnosis, histopathological diagnosis, clinical presentation and dates of appointments. In this study, clinical stages of the tumors have been reported using the tumor, node, metastasis (TNM) clinical staging system. The parameters of this system are clinical tumor size, extent of lymph nodes involvement assessed by palpation, and distant metastasis occurrence. ^[12],[13]

Statistics

Values of the study variables were entered into the program Statistical Package for Social Sciences (SPSS) version 12, and subjected to statistical analysis. To investigate the association between pairs of variables, the Chi-square test was applied and the level of significance was set to 0.01.

Results

In this two-year period study, 261 cases of head and neck cancer were found to be registered at the hospital. Of these, 152 (58.2%) were diagnosed in the year 2006 and 109 (41.8%) in 2007. The mean age for the males (54.6) was found to be slightly higher than that for the females (52.7) with 59.8% of the study subjects being older than 50 years. Basic information of study subjects are listed in [Table - 1].

Approximately half of the study subjects (48.7%) were living in states more than 5 h distant from the hospital by public transportation and only 23.8% were living in and around the capital where the hospital is located. Regarding the patient occupation, 36% belonged to low income groups and 51.6% were found to be financially dependant on other family members. The later group included housewives, students, children, pensioners and off work people. Most of the study subjects (78.5%) were married while 16.9% reported as single and 4.6% as widowed or divorced.

Of the 261 cases, 206 (78.9%) were classified as intraoral lesions and analysis of the ICD code revealed that 38.7% of the total study group was classified as overlapping lesion of the mouth [Table - 2]. Squamous cell carcinoma (SCC) was found to be reported in 192 (73.6%) of the study group [Table - 2] and its prevalence among subjects more than 50 years old (85.9%) was significantly greater than that observed in younger people (55.2%) (P = 0.000) [Table - 3].

Regarding the clinical presentation of the 261 cases studied, 36.4% were described as swelling with ulcerated surface. We observed that 94.5% of the total study subjects attended the hospital with stage 4 tumours according to the TNM classification system [Table - 2] and that 66.3% of the total study subjects had clinically involved regional lymph nodes.

Oral habits reported in this investigation were Toombak dipping, tobacco smoking and alcohol drinking. Of the total study subjects, 14.9% were found to have a history of more than one of these three habits. Toombak users represented 28.7% of the total number of study subjects [Table - 1]. Analysis of the site of lesion in study subjects showed that overlapping lesions of the mouth were found to be more prevalent among subjects with Toombak dipping history (56%) than in the rest of the study group (31.7%) (P = 0.000). Moreover, SCC was found to be more common in subjects with history of Toombak dipping (88%) than in the rest of the study group (67.7%) (P = 0.001), and that Toombak dippers attributed to 34.4% of all SCC cases included in the study [Table - 3]. On the other hand, smokers and alcohol drinkers were found to comprise 11.5% and 9.6% of the total study subjects, respectively.

Follow up information were found to be missing for 15 subjects. Evaluation of the remaining 246 subject′s appointments revealed that 41.9% of them had been surgically operated at the hospital, 35.4% were referred to other hospitals and the rest (22.8%) did not show up at the hospital after being biopsied and they did not follow the planned treatment [Table - 4]. From subjects dropped out right after the biopsy (56), 26.8% were residents of Khartoum state where the hospital is located [Table - 4] and [Table - 5].

Cases that had been operated in the hospital (103) comprised 41.9% of the 246 cases. Fifty two and a half percent of them stopped showing up during the first 6 months after surgery and therefore, no information is available about the recurrency and survival rates of these patients. Patients being referred after surgery to other centers to pursue additional means of treatment comprised 6.5% of the operated cases. For all cases that had been referred without or after surgery (104), no follow up or survival information could be obtained in this study [Table - 5] and [Table - 6]. Only 11% of the 246 cases are still attending their follow up appointments and only 5 patients (2%) had been registered as dead and all of them are cases operated in the hospital [Table - 5] and [Table - 6]. The relation between the follow up status and travel time of the 246 cases revealed that dropout percentage among residents of the capital (54.2%) were higher than among patients living in states more than 5 h distant from the capital (36.4%) [Table - 6]. However, the last finding was statistically not significant (P = 0.033).

Discussion

Oral cancer is and has been relatively neglected in some parts of the developing countries. This is attributed to the fact that the disease is a particularly complex oral health problem which consumes extensive human and financial resources. Some severely impoverished nations are beginning to divert more resources to the increasing problem of non-communicable diseases, the third largest of which is cancer. Nonetheless, available resources, particularly for cancer, within the developing countries remain inadequate to deal with this problem. In Sudan, updated information about OC is needed for more public health expenditure to be considered for prevention and early detection of the disease. Although the current study has used hospital records as secondary data, the use of ICD-10 and TNM systems could allow future comparison with reports from other hospitals in the country.

In this study, we found SCC to be the most prevalent histopathological variant of malignancies of the head and neck and it occurred intraorally as an overlapping lesion presented as a swelling with ulcerated surface in most of the cases attending the hospital during the study period. Regional lymph node involvement was found to be frequently associated with this presentation, and tumor staging revealed that most of the patients seek treatment at a very late stage of the disease. The clinical pattern observed in this study is usually difficult and costly to treat since it requires high surgical skills, facilities and staff. The fact that most of the cases were of low economic status illustrates the need of special considerations from the health authorities in Sudan. The observed geographical distribution and the tumor staging of the cases demonstrate the growing need for specialized centers outside the capital of the country.

In a hospital-based study from India in 2006, Khandekar et al. reported that the majority of the cases, as in the case of our study, are SCC presented at late stage. However, patients presented with stage 4 tumors comprised much lower proportion than observed in our investigation. ^[14] The authors defined the most common site as the alveolus, while in our study the highest presentation was lesions that exceeded one anatomical compartment to invade another neighboring one. This observation might be explained by differences in the etiological as well as the host factors between the two populations. Nevertheless, the observed association between Toombak use and the overlapping lesions of the mouth suggests a possible role of the habit in this aggressive pattern.

The oral habits of tobacco and alcohol use are known to cause OC but the percentages found in this study were far less than what has been estimated in previous studies. ^[6],[9],[15] A reason for this may be the stigmatization of use of tobacco and alcohol in the Sudanese community. However, additional investigations are needed to assess the current impact of these habits by thoroughly interviewing the subjects at their homes and not while they are at hospitals seeking treatment.

We observed that the dropout rates do not seem to be affected by the geographical distribution of the patient′s home states. Furthermore, the percentage of the dropouts among the residents of Khartoum state was alarmingly high which reflect the lack of public awareness of oral cancer even in the capital of the country, And this manditates launching more health promotion programs in Sudan. Moreover, the study also indicated that getting a solid survival and recurrence rate for cancer patients requires revising the patients referral system in the country in a way that ensure keeping in touch with the patients for longer periods of time.

To conclude, further population-based studies are needed to investigate the actual prevalence of tobacco and alcohol use in Sudan. Such studies are necessary to draw the attention of the authorities to the growing need of intensive public oral health efforts that aim to raise the population awareness about the risk factors of OC as well as the importance of early diagnosis and treatment. Establishing a national registry for cancer patients in Sudan is a necessary step to a proper referral system that ensures following up the patients, no matter where they are being treated.

Acknowledgment

The authors would like to thank the staff of Khartoum Teaching Dental Hospital for their support, the histopathology labs in the Sudan National Laboratories and the Faculty of Dentistry, University of Khartoum for diagnosing the biopsies.

References

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