|Year : 2017 | Volume
| Issue : 3 | Page : 430-435
Epidemiological profile of head and neck cancer patients in Western Uttar Pradesh and analysis of distributions of risk factors in relation to site of tumor
Mohammad Shadab Alam1, Shahid Ali Siddiqui1, Roshan Perween2
1 Department of Radiotherapy, J.N. Medical College and Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
2 Department of Obstetrics and Gynecology, J.N. Medical College and Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
|Date of Web Publication||31-Aug-2017|
Mohammad Shadab Alam
Department of Radiotherapy, J.N. Medical College and Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh - 202 002
Source of Support: None, Conflict of Interest: None
Background: Head and neck cancers (HNCs) are a major form of cancers in India. The spectrum varies from place to place within the country because of significant diversified risk factors.
Aims and Objective: To study, epidemiology and risk factors of HNC patients from Western Uttar Pradesh and to find out the correlation between risk factors and different anatomical regions involved.
Materials and Methods: All patients with histologically confirmed diagnoses of HNC between January 2011 and December 2013 were selected from hospital records. Data regarding age, gender, addiction habits, site of tumor, and other details were obtained from their clinical records, and statistical analysis was done.
Results and Conclusion: HNC accounts for 21.2% of total body malignancy and 47% of all malignancies in males and 2.5% in females. Squamous cell carcinoma was the most common histological type (97%). Maximum incidence of HNC (>60%) was in 40–60 year of age. Male:female ratio was 16:1. Oral cancers were most common HNC in patients below 40 year age group, whereas carcinoma oropharynx and larynx were more common in patients above 40 year age group. Tobacco smoking was a most prevalent risk factor for carcinoma oropharynx, larynx, and hypopharynx. Tobacco chewing was a most prevalent risk factor in females, young males, and carcinoma buccal mucosa patients. Habit of tobacco consumption in HNC patients was much higher than their normal counterpart. Alcohols drinking alone was observed in <1% patient as a risk factor. In oral tongue cancer, smoking and tobacco chewing were equally prevalent. Habit of tobacco chewing and alcohol were significantly higher in carcinoma buccal mucosa than other HNC suggesting synergistic effect specific to this site.
Keywords: Epidemiology, head and neck cancer, prevalence, risk factor, synergistic effect, tobacco use, Uttar Pradesh
|How to cite this article:|
Alam MS, Siddiqui SA, Perween R. Epidemiological profile of head and neck cancer patients in Western Uttar Pradesh and analysis of distributions of risk factors in relation to site of tumor. J Can Res Ther 2017;13:430-5
|How to cite this URL:|
Alam MS, Siddiqui SA, Perween R. Epidemiological profile of head and neck cancer patients in Western Uttar Pradesh and analysis of distributions of risk factors in relation to site of tumor. J Can Res Ther [serial online] 2017 [cited 2020 Jun 4];13:430-5. Available from: http://www.cancerjournal.net/text.asp?2017/13/3/430/180687
| > Introduction|| |
Head and neck cancers (HNCs) are a major form of cancers in India, accounting for 23% of all cancers in males and 6% in females. In India, the disproportionately higher incidence of HNC compared to other common malignancies may be due to excessive consumption of tobacco in various forms with and without alcohol, low socioeconomic status leading to poor oral and dental hygiene, poor diet, and infections of viral origin. The spectrum of HNC varies from place to place within the country because of significant variation in regional risk factors.,,
It is necessary to identify the differences if any in the sites, patterns, and incidences of the disease among various communities living in geographic areas having varying pattern of climate and physical environments to identifying dietary habits, social customs, and such other factors. This study has been done in an attempt to define the demographic and risk profile of HNC patients in Western Uttar Pradesh.
| > Materials and Methods|| |
This cross-sectional study has been designed and approved by the Institute's Ethical Committee.
Catchment area of this study was a major population of Western Uttar Pradesh. Study population consists of 850 patients registered and finally diagnosed with head and neck malignancy in our institute between January 2011 and December 2013. Data pertaining to these patients were entered in standardized questionnaire. These were in context to age, sex, site involved, smoking, alcohol and chewing habits, and other clinical details. Patients on the basis of histopathology were categorized into squamous cell carcinoma and other malignancy. Various malignancies of the head-neck region were classified according to International Classification of Disease (ICD) coding system devised by WHO (10th revision) using ICD codes from C00 to C80.
Statistical analysis was done on the data collected, and result was formulated. Significance (P) values and correlation values were determined by Pearson Chi-square test by correlating two variables at a time from age, gender, risk factor, and site of tumor. P < 0.05 was considered significant and P > 0.05 was considered statistically insignificant.
| > Results|| |
Study population consists of 794 males and 56 female patients of HNC. Male:female ratio was 16:1. More than 97% cases were squamous cell carcinoma. Difference in incidence in males and females was significant in each age group (P < 0.05). Maximum incidence of HNC was found in 51–60 year age group (34%) but in male incidence was almost equal in 51–60 and 41–50 age group (n = 246 and 241, respectively). More than 60% of the patients were 41–60 year of age [Table 1].
Distribution of cases according to age, gender, and site of the tumor
Most common site of HNC was oral cavity (n = 279) followed by oropharynx (n = 271) and larynx (n = 179). Malignancy arising from hypopharynx (n = 36), nose and paranasal sinuses (PNS) (n = 19), and nasopharynx (n = 8) were uncommon. Secondary neck with unknown primary constituted 5% of all HNC. Tumors arising from salivary glands (n = 8), thyroid (n = 4), external auditory canal (n = 1), ear pinna (n = 1), and eyelid (n = 2) all together account for <2% of HNC. Most common subsite of HNC was base of tongue (BOT) (16%) followed by buccal mucosa (14.2%). Oral tongue (13.5%) and supraglottic larynx (13.5%) had equal incidence [Table 2].
Oral cancer was most common HNC in <40 year age groups and ranked second and third, respectively, in 41–50 and above 50 age groups. Oropharynx was most common HNC in more than 40 year age groups. Carcinoma larynx has shown consistent increase in incidence with an increase in age and ranked second common HNC in more than 50 year age groups. Secondary neck with unknown primary presents 5–8% of HNC in all age groups. Cancer arising from salivary glands, nose, and PNS were more common in <50 year age group [Table 3].
|Table 3: Distribution of case according to age group and site of tumor (total=850)|
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Distribution of risk factor according to gender and age
In this study, tobacco smoking was found to be most prevalent risk factor in total (35.8%) as well as in male patients (37.3%). Tobacco chewing only was uncommon (8.7%) in males but in combination with smoking, it accounts second common risk factor (19%). In female patients, most prevalent risk factor was tobacco chewing (34%) followed by smoking (16%) and smoking with tobacco chewing (14.2%). Alcohol addiction was rare (<5%) in females while in males, it was found either with smoking (10%) or with smoking and chewing tobacco (9.3%). Only 30% female and 14% male were free of all these risk factors [Table 4]. In <30 year age group, tobacco chewing (26.7%) was a most common risk factor, smoking (13.3%), smoking with tobacco chewing (15.5%), and smoking with chewing and alcohol consumption (13.3%) had equal prevalence. Above this age group, smoking alone was most prevalent risk factor and found in 34–50% of each age group. Smoking with tobacco chewing and alcohol was much common in below 50 year age groups. Smoking with alcohol habit was present in 10% of patients in each age group. Thirty-three percent of more than 80 year age patients were free of all these risk factors compared to <20% patients in other age groups [Table 4].
|Table 4: Distribution of risk factor in relation to gender in study population (total=850)|
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Distribution of risk factor according to site of tumor
In patients of carcinoma oropharynx, larynx, and hypopharynx and secondary neck with unknown primary, smoking alone was present in 47%, 43%, 52%, and 52% population, respectively, and smoking with other habits was found in 60% population as the most common risk factor. Tobacco chewing alone was rare (<5%) in this group. In patients of oral cancer, tobacco chewing, smoking, tobacco chewing with smoking, and tobacco chewing with smoking and alcohol was present in 25%, 20% 19%, and 12.5% population, respectively. Smoking with alcohol was present in 17% cases of carcinoma nasopharynx and larynx. In cancer arising from nose and PNS, thyroid, and salivary gland, about 50% patients and in carcinoma nasopharynx 35% patients had none of these risk factors. In remaining sites, only 16% of patients were free of all these risk factors [Table 5].
|Table 5: Distribution of risk factors according to site of tumor (total = 850)|
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In patients of carcinoma oral tongue and buccal mucosa, tobacco chewing was present in 22% and 24% population, respectively. Smoking alone was more prevalent in oral tongue (28% vs. 8%) and tobacco chewing with smoking (14% vs. 21%), or with smoking and alcohol (16% vs. 33%) was more prevalent in buccal mucosa.
In patients of carcinoma BOT and tonsillar fossa smoking, tobacco chewing, and tobacco chewing with smoking was present in 48%, 3.5%, and 16% population, respectively. Combined habit of smoking, alcohol, and tobacco chewing was found to be more common in carcinoma BOT (16% vs. 5%). Only 14% cases of carcinoma BOT and 4% cases of carcinoma tonsil were free of all these risk factors [Table 6].
|Table 6: Distribution of common risk factor in common sites of head and neck cancer|
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| > Discussion|| |
This study is retrospective and hospital-based, which includes histologically confirmed cases of HNCs. Study population is mixture of rural, urban, and suburban population. Half of the study population is nonvegetarian. As per various studies published squamous cell carcinoma varying from 88% to 96%,,, is the most common histological subtype. In our study, squamous cell carcinoma was observed in more than 97% cases.
Prevalence of HNC with respect to total body malignancies varies from 9.8% to 42.7%,,,, and it accounts for 30% of all cancer in males and 11–16% in females. Male:female ratio is commonly 1:1–3.1:1.,, In the current study, 4015 cases of confirmed malignancy (1698 male and 2317 female) were registered between January 2011 and December 2013. Out of that 850 (794 males and 56 females) were of HNCs, which represents 21.2% of all cases and 47% of males and 2.5% in female cancer. Male:female ratio was 16:1. According to one of the study in Eastern Uttar Pradesh, HNC burden was reported to be 35.65% in male and 7.44% in female. From this study, we can conclude that state of Uttar Pradesh has very high burden of HNC only second to the highest (54.48%), reported in Northeast, in males and very low burden in females in this region.
Geographical variations in the incidence of HNC in different part of world and within the country are indicative of differences in the prevalence of regional risk factors. This variation in different regions of India is supported by various studies.,,,,, According to recent studies in different region of India on HNC patients, larynx was most common site of HNC in South India (38.37%) and Bihar, oral cavity in Uttar Pradesh, and Ahmednagar (41.28%), and oropharynx in Northeast and Meghalaya (24%). In this study, oral cancer (32.8%) was found to be most common HNC and BOT was most common subsite followed by buccal mucosa. Carcinoma hypopharynx (<5%) was uncommon in this population.
In India, tobacco consumption is responsible for half of all the cancers in men and a quarter of all cancers in women. Variations in the incidence of HNC by site are mostly related to the relative distribution of major risk factors such as tobacco or betel quid chewing, cigarette or bidi smoking, alcohol consumption, and viral infections.
India has one of the highest rates of oral cancer in the world, partly attributed to high prevalence of tobacco chewing.,,, The prevalence of both smoking and chewing tobacco in various forms varies significantly among different states in India. Some regional patterns have been observed for chewing tobacco. Chewing of tobacco is relatively more common in the Central, Eastern, Western (except Goa), and Northeastern states (except Meghalaya) compared to Northern and Southern states. However, in the Northern states, where chewing is relatively less common, smoking of tobacco is relatively higher (except in Punjab where tobacco prevalence is one of the lowest as majority of its population (58%) practice Sikh religion, which prohibits tobacco consumption). Tobacco consumption is highest in the least educated, poorest, and scheduled castes and scheduled tribe.
Prevalence of tobacco consumption increases up to the age of 50 years and then there is decline in Indian population. In this study, maximum number of HNCs are present in 50–60 year of age and >60% of HNC were found in 40–60 year of age. Prevalence was equal in 41–50 year and 51–60 year age group in males.
Smoking is relatively more pronounced factor for cancer of pharynx (relative risk [RR] =8.5) and larynx (RR = 7.5) than cancer of oral cavity (RR = 4.9). In this study, smoking was present in >80% cases of cancer of oropharynx, larynx, and hypopharynx and only 50% cases of oral cancer. There is 6-fold higher risk of oral cancer among the people having habit of betel nut and tobacco (gutkha). In this study, tobacco chewing including betel nut was present in >60% cases of oral cancer and only 30% of pharynx and larynx cancer. This habit was found to be more common in younger age group and female patients that may be the reason for oral cancer as most common cancer in this group.
In this study, out of 850, only one case of HNC with alcohol only as a risk factor was found. Although RR of modest amount of alcohol consumption on a different site of HNC in nonsmoker is controversial. This study supports the result that there is little or no risk of HNC with moderate alcohol intake in ex-smokers or who never smoked.,
High alcohol consumption has RR >5 mainly for oral cavity, oropharynx, and esophagus. When tobacco smoking and alcohol consumption are combined, they may increase the risk by more than 15-fold. This effect is possibly because alcohol may act as a solvent and enhance the penetration of carcinogens into target tissues. Acetaldehyde, which is the alcohol metabolite, has been identified recently as a tumor promoter.,, In this study, combined habit of tobacco chewing and alcohol consumption was most prevalent predisposing factor for oral cancer.
Comparing risk factors of cases of carcinoma oral tongue and buccal mucosa, there was a significant difference (P < 0.001). Tobacco chewing was equally prevalent in both (22% vs. 24%). Smoking was more prevalent in oral tongue (28% vs. 8%) but tobacco chewing and smoking or tobacco chewing along with smoking and alcohol is more prevalent in buccal mucosa which suggests synergistic effect of tobacco and alcohol on buccal mucosa but no similar effect on oral tongue (odds ratio = 2).
In this study, secondary neck with unknown primary constituted 5% of all HNC. Habit of smoking or smoking with alcohol was present in 60% cases. Primary can be detected in more than 50% of these patients after pan-endoscopy guided biopsy and PET scan. Primary commonly lies in nasopharynx, oropharynx, or pyriform fosse. These sites have a strong association with smoking which could explain habit of smoking in more than half of these patients. In carcinoma nasopharynx, habit of smoking and smoking with alcohol was present in around 70% cases shows strong association between them.
In study population, HNC prevalence was very low in females and male:female ratio was exceptionally high. A detailed study on this population can find associated factor responsible for this difference which could be used for prevention of HNC in other population.
| > Conclusion|| |
HNCs are one of the most common malignancies prevalent in India with wide variations in risk factors, sites of involvement, geographical, and demographic characteristics. Heterogeneity in risk factors and differences in the prevalence of HNC at different sites of head and neck region may be because of differences in surface area, microanatomy, tissue microenvironment, and duration of exposure to carcinogens which need to be explored.
I am thankful and would like to acknowledge the contributions of the doctors and staffs of the Department of Radiotherapy and Otorhinolaryngology, J.N. Medical College and Hospital, Aligarh, Uttar Pradesh, India.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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