Objective: To assess the recurrence and disease-free survival in oral squamous cell carcinoma patients, and to compare them between two age groups.
Method: Data were extracted from Patel hospital cancer registry database of patients admitted from January 1st2008 to December 31st 2018 based on retrospective diagnosed with oral squamous cell carcinoma. Patient stratified in to two groups i.e. patients with less than or more than 40 years. Various etiological factors, staging, treatment, site of the tumor and recurrence and mortality were assessed.
Results: Of the 450 patients, 124(27.5%) were in group A and 327(72.5%) were in group B. There were 101(81%) males in group A and 240(73.4%) males in group B. The overall mean age was 43.63±10.75 years (range: 22-70 years). The most common site of the tumour was cheek 232(51.5%). Recurrence of tumour was 45(36%) in group A and 120(37%) in group B (p=0.653). Overall mortality in group A was 67(54%) compared to 168(51%) in group B (p=0.811).
Conclusion: Mortality and disease recurrence in both age groups was almost the same. Cheek was the most common site of presentation.
Oral squamous cell carcinoma (OSCC) is a major health problem worldwide due to its high prevalence, very high morbidity and mortality. The prevalence of oral cancer presents20-fold variations among different countries, age groups, gender, races, and ethnic groups. South Asian countries, like Pakistan, India and Bangladesh, account for one-third of the global oral cancer burden, and over 90% of these cancers are attributed to tobacco consumption in various forms in theregion.1 Global cancer statistics had forecast in 2018 that about half of the cases and over half of the cancer deaths in the world will occur in Asia.2
Lip and oral cavity cancers in Pakistan are the second most common cancer, with a 5-year prevalence among all age groups to be 36,560.2 The number of new cases of lip and oral cavity cancers tends to be 10.9% in Pakistan, and it is the second most common cancer in females after breast tumour, and the most common cancer in males after excluding non-melanoma skin cancers.2
According to the Karachi Cancer Registry (KCR) data, 33,309 malignant cases were reported from 8 different centres in 2019 which showed that oral cancer was the leading malignancy in Karachi where 36% males and 44% females chew pan or pan with tobacco.3
Studies have suggested that since in the younger population OSCC is present at an advanced stage with local and regional spread compared to the elder population, a high degree of suspicion should be kept for chronic ulcerated lesions with early diagnosis and aggressive treatment options, including definitive curative surgery with chemotherapy, and radiotherapy should be implied in the management of OSCC presenting at a younger age which can decrease mortality and morbidity in the respective population. It has also been suggested that younger OSCC patients have better survival compared to the older population.4-7
The current study was planned to assess the recurrence and survival in OSCC patients, and to compare them between young and old age groups.
Materials and Methods
This is a retrospective cohort study, conducted at Patel hospital in the department of otolaryngology, head and neck surgery. ERC approval has been taken from our institute having ERC#62 dated: April 17th, 2019. We took patients from January 1st, 2008 to December 31st, 2018. Patients of either gender aged 21-80 years with biopsy-proven OSCC affecting lips, tongue, floor of the mouth, hard palate, alveolar ridge, retromolar trigone, or buccal mucosa were included. Patients with non-squamous cell carcinoma on histology or second primaries, cancer at another sub-site, or recurrence or SCC of the site other than oral cavity or carcinoma in situ or having had previous cancer surgery elsewhere and those with follow-up <6 months were excluded.
The data was stratified into patients aged <40 years in group A and those aged >40 years in group B. Patients after surgical treatment of the tumour were sent for radiotherapy and chemotherapy at another tertiary care hospital. The routine registry form was used for data collection. For missing data, medical record files were reviewed and patients were contacted over the telephone as well. Details of histopathology report, including tumour, node and metastasis (TNM) stage, tumour type, tumour size, grade, margin, depth of invasion, perineural invasion, bone involvement, vessel invasion, muscle invasion and extracapsular spread, were noted for each patient. Patients were staged according to the American Joint Committee on Cancer (AJCC) 8th edition TNM staging.8
Demographic, pathological, surgical and clinical factors as well as tumour staging and radiation were analysed. Follow-up details of all the patients were recorded. Surveillance was done in terms of the presence or absence of regional or distant metastasis. Patients were followed up from the date of surgery for more than a year or mortality within that time.
Data was analysed using SPSS 21. Quantitative variables were presented as mean ± standard deviation, while qualitative variables were expressed as percentages and frequencies. Shapiro Kolmogorov was applied to check data normality. Non-parametric Kruskal Wallis test was applied to check the association between factors of different groups. Survival analysis was done using Kaplan Meir analysis. P<0.05 was considered statistically significant.
Of the 450 patients, 124(27.5%) were in group A and 327(72.5%) were in group B. There were 101(81%) males in group A and 240(73.4%) males in group B. The overall mean age was 43.63±10.75 years (range: 22-70 years). The most common site of the tumour was cheek 232(51.5%). Multiple clinical and pathological comparisons were done between the groups (Table-1).
Overall survival (OS) and disease-free survival (DFS) were not significantly different between the two groups (Table-2). Recurrence of tumour was 45(36%) in group A and 120(37%) in group B (p=0.653) (Figure-1). Overall mortality in group A was 67(54%) compared to 168(51%) in group B (p=0.811) (Figure-2).
In the current study, the most common site of the tumour was cheek, followed by anterior two-third of the tongue as opposed to the evidence-based studies.9-13Parikshit Sharma et al. showed that 82.71% cancer patients were in the 5th, 6th and 7thdecades of life, whereas only 17.29% belonged to the 2nd and 3rd decades. A high proportion of cases were males and it was due to high prevalence of smokeless tobacco consumption, like pan, gutka and chalia.14
In recent studies, it was postulated that there are multiple factors, like genetics, nutritional alterations, as well as human papillomavirus (HPV) infection influence the development and behaviour of OSCC.15,16Cancer prevalence is higher in patients who are addicted to alcohol and tobacco,11,17but the current study observed that patients with increased incidence were exposed to multiple carcinogenic agents, and smoking was the less prevalent risk factor in the study population.
OSCC was rare in a younger population previously and because of that diagnosis was delayed in younger patients leading to morbidity and mortality among the young.18 Age should not be set as a criterion for surgical resection and aggressive treatment options for SCCs should be considered on acase-to-case basis15,16,19,20which is the approach noticed in the current study. There has been an increase in the incidence of OSCCs in the younger population with a fairly advanced stage at presentation,4,21but, the current study found ratios being similar for the presentation of cancer in the young and the elderly. Studies have shown a difference in OS of OSCC patients, with higher survival rate in the young.7,22The current study did not find such a difference. Studies showed that SCCs presenting at a younger age were more aggressive compared to presentation at an older age, but despite aggressive management of the tumour, OS and DFS of the patient remained unaffected.23-26
The current study has limitations, like it was conducted at a single centre where the patients mostly represent from mid to low socioeconomic status having limited resources. Besides, data of some patients had to be excluded due to lack of follow-up.
Large-scale, multicentre, prospective studies should be conducted to assess for mortality and recurrences in patients with a lower stage of cancer at the time of presentation.
Mortality and disease recurrence in both age groups was almost the same. Age had no impact on mortality and recurrence of the tumour. Cheek was the most common site of presentation.
Acknowledgement: We are grateful to bio-statistician Ahmed Raheem for providing the administrative and statistical guidance.
Disclaimer: The Abstract was part of a Poster Presentation at the Shaukat Khanum Symposium (2019) and at the Aga Khan Hospital Annual Conference 2020.
Conflict of Interest: None.
Source of Funding: None.
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