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Indian Journal of Medical Sciences, Volume 57, Number 9, September 2003, pp. 400-404 AGE SPECIFIC INCIDENCE RATE AND PATHOLOGICAL SPECTRUM OF ORAL CANCER IN ALLAHABAD Ravi Mehrotra,1 Mamta Singh,2 D Kumar,*3 ANPandey,4 R K Gupta,5 U S Sinha**6 The Departments of *Pathology Social and **Preventive Medicine Forensic Medicine, Moti Lal Nehru Medical College, Allahabad.
Accepted Date: 04-07-2003. Code Number: ms03023 ABSTRACT BACKGROUND: Cancer of the oral cavity is one of the commonest cancers in India. Use of smokeless tobacco (Pan masala, Zarda etc ) is on the increase in North India and specially in Uttar Pradesh. Key words: Oral cancer, Age, Site specific incidence rate, Allahabad. INTRODUCTION It has been well recognized since the beginning of this century that oral cancer is one of the commonest cancers in India. For a long time this recognition was based upon hospital frequency statistics by looking at the proportion of oral cancer among all cancer cases diagnosed. The incidence from the National Cancer Registry Project of the Indian Council of Medical Research confirmed the fact that oral cancer was indeed a common form of cancer in India.1 Over the years, the incidence of oral submucous fibrosis in the population has increased manifold - especially among younger generation, possibly leading to a further increase in the incidence of oral cancer.2 This may be related to the rising trend of paan masaala and gutkha chewing in the population. In the developing world, the oral cavity is the fourth commonest site of carcinoma after lung, stomach and liver in males while in females it is the fifth commonest cancer after cervix, breast, stomach and lung.3 Oral cancer represents 14% of all cancer cases at Regional Cancer Centre (RCC), Kerala, India. It constituted 17% of all cancers in males and 10.5% of all cancers in females making it the commonest cancer in males and the third commonest cancer among females.4 The spectrum of cancer varies from place to place within our country. Site-specific data from the different parts provide the various trends and give clues to the etiological factors responsible for these significant variations. This is the first report of its kind from Allahabad in which an effort has been made to put oral cancers in perspective. MATERIAL AND METHODS This is a single institutional retrospective study of 11 years from 1990 to 2000. The catchment area of this study was in and around Allahabad. Data was collected year wise in the context of age, sex, site involved and histopathological findings. Records were maintained in the departmental patient registry. They were retrieved manually. Various malignancies were classified according to the International Classification of disease coding system devised by W.H.O. (9th revision) using ICD codes from 140 to 202. The study was cleared by the departmental ethics committee. Statistical analysis was done by utilizing the Kolomogroo-Smirnov two sample test.5 RESULTS A total of 40559 biopsies were examined in the department during 1990-2000, out of which 759 biopsies belonged to the oral cavity. Of these, 558 (73.52%) were males and 201 (26.48%) were females. Year wise trends (Table 1) of incidence revealed maximum incidence of 15.58 oral cancer cases per 1000 biopsies examined in 1997 followed by 11.67 per 1000 during 1999. Of the total of 759 biopsies from oral cavity, 303 malignant cases { 232 (76.57%) males and 71 (23.43%) females} were found with a male to female ratio of 3.27:1. On an average, 63 new cases of oral cavity per annum were detected during this period. Examination of biopsies from oral cavity revealed 267 (35.17%) benign lesions, 127 (16.73%) premalignant lesions including leukoplakia and 303 (39.92%) cases of oral cancers of different grades while 62 (8.17%) cases remained inconclusive (Table 2) Among both males and females, squamous cell carcinoma (SCC) of grade I was most prevalent. All cases of SCC grade III were males. Two cases of basal cell carcinoma of the oral cavity were also found. Distribution of histological findings among males and females were found to be statistically significant. (P<0.05) Table 3 presents histological grades in accordance with age. Majority of benign cases were reported in the age group 20-29 years, whereas maximum (13 cases, 20.97%) found inconclusive belonged to the 40-49 years of age. Premalignant lesions like leukoplakia, and dysplasia were found to be more prevalent in the age group of 50-59 years. 27.87% and 25.71% cases respectively belonged to this age group whereas majority of SMF cases (38.7%) belonged to the younger age group (20-29 years). Majority of malignant cases were observed in 50-59 years age group and all 4 cases of grade III belonged to this age group. Site wise analysis of histological findings (Table 4) revealed the tongue as the most common site involved observed in 129 (42.57%) followed by the cheek in 58 (19.14%) malignant cases. For benign and premalignant lesions the cheek was the most common site followed by tongue in benign and buccal mucosa in premalignant lesions. DISCUSSION Allahabad is a central eastern district of Uttar Pradesh (U.P.) with Pratapgarh, Fatehpur and Jaunpur in its north, Varanasi and Mirzapur in the east, Rewa (M.P.) in south and Banda in the west. Patients from these neighboring regions also approach for treatment at this institute. Oral cavity cancer is the commonest malignancy at Allahabad in this study and similar trends were reported from other parts of the state.6 Chewing of "dohra", an indigenous preparation of tobacco and slaked lime in and around Allahabad is one of the major factors for this high incidence of oral malignancy. Number of betel leaf (paan) chewed per day by an individual is also high (15-25/day) in Allahabad and Varanasi districts, which acts as a continuous irritant to the buccal mucosa. Betel nut chewing alone is rare in Allahabad though it is an equally important factor for oropharyngeal malignancy in Agra and Mainpuri belt.7 Use of smokeless tobacco (Pan Parag, Zarda etc ) is on the increase in North India and specially in Uttar Pradesh. Reports from America reveal a four-fold increase in the consumption of smokeless tobacco during the last 20 years. Incidence of Oral cancer is increasing in North India though reports from Sweden reveal a declining trend. A male to female ratio of 2.3:1 was observed by Iype as compared to 3.27:1 in our study. This could be attributed to more males seeking early medical intervention in U.P. vis-a-vis Kerala The commonest histological variety (squamous cell carcinoma) was nearly the same in our group - more than 99% of our patients as compared to 85% in the Trivandrum study. 8 Year wise trends of incidence revealed maximum incidence of 15.58 oral cancer cases per 1000 biopsies examined in 1997 followed by 11.67 per 1000 during 1999. No clear rising or decreasing trend could be discerned over the last 11 years. 267 Benign lesions constituted 35.17% of cases, premalignant lesions including leukoplakia made up 16.73% and oral cancers of different grades constituted 39.92%. Well differentiated i.e. Grade 1 squamous cell carcinoma was the highest in our group and this was similar to the findings of Iype who reported 52.6% of their patients had well-differentiated tumours. 8 The tongue was found to be the most common site involved by the malignant process and was observed in 42.57% of our patients followed by the cheek in 58(19.14%). This was similar to Iype's finding from Trivandrum who reported 52% of their patients had tongue involvement followed by 26% was the buccal mucosa.8 Interpretation of data from a single Institution has its clear limitations. The data reflects our specific patient population reporting to the hospital and not the community as a whole. Most of the patients had similar smoking or tobacco chewing habits. The highest rate of oral cancer is found in the developing world where oral cancer with pharynx combined is the third commonest site of cancer. In India, Bangladesh, Pakistan and Srilanka, it is most common and accounts for third of all cancers.9 Cultural differences in the use of tobacco lead to the variation in the geographic and anatomic incidence of oral and pharyngeal cancers in accordance with dose response principle. Among practicing Mormons who neither smoke nor drink, cancer of oral cavity and pharynx are all but non-existent.10 Histologically, Squamous cell carcinoma dominate the profile, similar trends were earlier also. India is the largest producer of tobacco. Approximately 80% of India's tobacco is used for its domestic consumption. Its consumption trends suggest that the habit of smoking is gaining ground over chewing. It appears that at least 62% of smoking related cancers, which is term of overall load of cancers get translated to one third of the cancers of all sites, are avoidable. There is an urgent need for appropriate prevention and cessation strategies for smoking and smokeless tobacco products along with a social war against alcoholism by intense education programme to revert back the present trend of preventable oral cancers. This study was limited by the fact that it was a retrospective survey and the specific histological subtype could not be correlated with dietary and tobacco habits. A prospective study is planned incorporating the dietary and clinical findings. Primary prevention measures including education and awareness programs are on the anvil. It is hoped that an early detection scheme will be started at this institution utilizing oral self-examination, toluidine blue staining, brush biopsy and scalpel biopsy as need. REFERENCES
Copyright 2003 - Indian Journal of Medical Sciences. The following images related to this document are available:Photo images[ms03023t4.jpg] [ms03023t1.jpg] [ms03023t2.jpg] [ms03023t3.jpg] |
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