INTRODUCTION – Oral and pharyngeal cancers are considered an important part of the global burden of cancer. With about 500,000 new oral and pharyngeal cancers being diagnosed annually, three-quarters of these are from the developing world with about 65,000 cases from India. Squamous cell carcinoma (SCC) arises in up to 90% of the cases.
AIM – To review the difference in the patterns of presentations, outcomes, patterns of failure and etiological factors of the disease in India as compared to that in the western world and to determine the prognostic significance of treatments rendered to Indian patients.
When we discuss about how oral cancer affects in Western population and India. Then we can say that in western population where tongue cancer mainly effects Tongue & Foam and the main reason is Smoking and alcohol, Where 65% cases comes under T1-T2 and its effects mainly 40 to 50 years age of people, where SMF has rare but affordable and least burden comes on treating hospital.
But in India Gutkha and khaini are main causes of Oral cancer. Buccal Mucosa & Alveolus mainly affected Mouth. Where 80% case comes under T3-T4 type of lesion, And it affects young people. In India SMF is too common and continue increasing. And then Oral cancer is become costly and heavy burden comes on patient.
1. Lack of awareness and Low socioeconomic status: Due to lack of awareness and low socioeconomic status mainly in rural Indians, the patients try to bypass the complicated and expensive treatment indicated for cancer. Opting for such claptrap, even patients in whom the diagnosis is made in the initial stages come back only after the tumor grows to a T4 lesion.
2. Personal habits: Endemic use of oral tobacco available in India in more than 6 forms. Ghoshal S in a study on carcinoma of buccal mucosa observed that out of 100 patients 96 had a history of oral tobacco intake.
3. Myths related to cancer surgery: lead to indulgence in alternative treatments prevalent in India which claim to treat cancer like yoga, ayurveda, babas and tantriks.
1. Age Predilection: The mean age group of Indian patients reporting with squamous cell carcinoma of buccal mucosa in a study by S. Ghoshal et al was less than 40 years of age. This difference in age predilection might be due to the difference in etiological causes and the over expression of P53 gene found in India.
2. Site distribution: In Indian patients the most common affected area are buccal mucosa, retro molar triangle and mandibular gingiva. In western countries the most predominant risk factor has been considered to be smoking and alcohol consumption and the most affected regions of the oral cavity to be tongue and floor of mouth. In India where oral cavity to be tongue and floor of mouth is 58.30% and 28% respectively as compare to west where this ratio is 67% and 22% respectively.
3. Tumour size and clinical presentation: Indian patients though reporting at an advanced stage, they are rarely associated with distant metastasis. Hence the disease can be managed efficiently surgically followed by adjuvant treatment. Locoregional recurrence is rare. Patients die of second primary or metastatic lesions in lungs and liver which is unusual in cases of head and neck cancer.
4. P53 over expression: Mutations of the p53 tumour suppressor gene play an important role. P53 over expression is more common in Indian patients.
5. Oral submucous fibrosis: Trismus is one of the main symptoms of OSMF. We observed that due to limited mouth opening it was difficult to evaluate the oral cavity by the clinicians. Also self evaluation is not possible leading to increased chances of missing out lesions in its initial stages. These patients usually present with either T3 or T4 lesions. Due to the immense fibrosis in the oral mucosa caused by this disease the incidence of hematogenous and lymphatic metastasis is low. Thus increasing the importance of locoregional control.
Due to the absence of metastasis in patient with T3 and T4 lesions in India, loco-regional control of the disease plays a very important role in its prognosis. Patients suffering from OSMF with restricted mouth opening pose difficulty in circumstantiating the diagnosis by a biopsy due to inadequate access to the lesion. It has been observed that on resection there is shrinkage in the tissues which were initially fibrosis. Thus it is difficult to assess the extra surgical margin which is to be resected. Further the reduction in laxity of oral mucosa causes an increase in the proximity of anatomical structures to each other thus generating intraoperative difficulties for the surgeon. It has been reported that shrinkage can reduce the width of the surgical margin by as much as 46%, a vagary that is not accounted for in standardized guidelines.
Greater emphasis should be laid on primary prevention and early detection of cases. There should be more studies on the reasons behind this unusual clinical presentation of head and neck cancer in India which is much different than that in western population. This might involve genetic basis. Aggressive counseling in tobacco cessation have to be implemented. Need for a body to control the prevalence of alternative treatments like ayurveda and yoga.
Requirement of customized protocol for management of head and neck cancer in Indian population.