Oral Cancer is mostly a man made disease associated with tobacco since centuries. In early part of 17th century few original documents do suggest large tumor masses in oral cavity following tobacco ingestion, initially used to be taken as medicine for some oral ailments. Among the epidemiological factor causing Oral Cancer, tobacco is the most important culprit along with alcohol. Both together are responsible for 40% of Cancer and 60% of Cancer related death all over the world. Oral Cancer is 8th most common Cancer in USA, 13th in U.K. and first or second in most of South and South East Asia. It forms 2% of all Cancer in Western Countries but accounts for 30-40% in Indian and neighboring countries. China consumes 39% of tobacco followed by 5 to 8% in U.S.A. and 3% India in various forms. In China and West it is smoking and alcohol but in South Asia it is oral tobacco is important cause of Oral Cancer.
Male and Female ratio is 1.7 to 1.0 in most of the countries. Mean age is 45 years in West with peak at 60-69 years. In India mean age is 36 years and peak 55-60 years. It is a disaster to learn that 10 to 20% of High School students in USA do take tobacco orally in various forms occasionally or regularly and get Oral Cancer in 4% of this population. This is true for most of the western countries. In South Asia the figure is still high, 30-40% in 15 to 30 years age group, with 40 – 50% developing oral cancer and 42% of all
deaths due to tobacco related diseases. In U.S.A. 6.5–8 per 1,00,000, France 8–9 per 1,00,000 and 20 per 1,00,000 in India; get Oral Cancer. In China – 1.2 million death due to tobacco related disorder including Oral Cancer annually.
Few important statistics are eye opener.
$35 billion is the tobacco industry profit at the cost of 6 million deaths. In India Tobacco related products industry for oral consumption is more than Rs. 1000 crore with profit of 50% at the cost of 1.6 lacs to 2 lacs reported deaths, while unreported are much more. In USA – Cigarette sold worth $71 billion/year and is responsible for an estimated $193 billion in its health related expenditure. One Cane of Marlboro Cigarette ($12 – 20 sticks) can purchase 29 cans of rice to feed 8 people, and part of its sale can save millions of life from hunger deaths. If proper steps are not taken, there will be 3,00,000 cases/year – In USA, by 2020 and 15 million new cases every year in the world, of which 2/3 in developing countries with poor survival. Risk factor is 0.86% in Man/Women born today in their life time. In USA 80% of Oral Cancer are diagnosed in early stage but 5 years – survival is 60% while in Indian and South East Asia countries late diagnosis (III & IV stage) is more than 70%, with 5 years survival of 35%, Arab countries 5 years – 32%. Overall survival in young age group of patients is still low. Low socio economic group patients farm a large percentage of group and found to be of genetic P53 dissociation, and still poor survival. Last 3 decades has seen improved management and total care system all over the world but total survival rate is not much improved.
PreCarcinoma Conditions and Carcinogens –
There are many known such condition, like sun exposures with lip lesions, cigar smoking with local marks over lip, marijuana smoking, snuff tobacco, betal quid (PAAN) giving rise to local stomatitis or submucous fibrosis, gradually leading to Cancer.
Low intake of fruits and vegetables, poor oral hygiene with bacterial infection of gums and teeth, many harbors HPV virus, lichenplanus, leukoplakia, Erythroplasia, nicotine stomatitis and Keratosis are common precancerous condition and needs proper evaluation and care. Immuno Suppressor patients are likely to develop oral cancer twice more than a normal population and needs proper advise.
Tobacco specific nitrosamines are a group of Carcinogens – NHK and NHH, causing oral cancer in animal model. Onco proteins like RB, D-type cycline expression, are active in G-1 regulation in oral cancer. This also leads in few onco proteins reversing the process in G-1 cycle. Human Papilloma Virus found in large cases of oral cancer, where tobacco is not a cofactor, plays active role at genetic level and needs further evaluation and study, not only for prevention but from treatment point of view also. Many such studies are ongoing related to gene expression, tumor suppression, transcription factor, Xenobiotics, enzymes, metastatic proteins etc., and giving hope for better management in future.
Management guideline and its application –
Surgery remains the main stay for oral cancer except for few sites (Post tongue, Naso pharynx). Extent of Surgery depends on primary site, location, size, proximity to bone and depth of infiltration. These factors guide to bone saving, extend of wide excision to radical surgery and reconstruction. No compromise on extend of Surgery as per factor guiding, for cure. Defects left, to be reconstructed by myocutaneous or free flaps with far improved result/survival. Better understanding of molecular biology and local progression, early detection, and proper nodal management with adjuvant chemo, radiation or its combination, lead to multimodality, coordinated efforts to give high survival and better life.
The above guideline is to be applied judiciously after assessing clinically, radio logically and histopathologically to stage and grade it in relation to other existing conditions and plan it carefully. Once plan is framed, execute it with the help of other colleagues Chemotherapist and Radiotherapist to get best of results and better survival with livable life. General Surgeons should understand their limitations and get experience, associated with trained group of specialist and develop skill for correct independent decisions, and take help of other Onco specialists if necessary.
Oral Cancer Awareness Programme –
American Cancer Society report of March 2012, shows magnitude of the problem with 6 million (20% Cancer – 12% Oral Cancer) deaths due to tobacco related diseases, which is likely to be one billion by the end of 21st century, one person death every 6 seconds. No National health programme in any country can check incidence of oral cancer till an active participation by social organizations, religious institutions, Political parties, Medical Association of all specialities and Government organizations come together with a pledge to enact programme with dedication. A large scale awareness programme involving educational institution, media, entertainment houses and strict law to enforce ban on tobacco production and sale will check the problem in years to come.
WHO in a global treaty endorsed by more than 174 countries gave a clear mandate for public awareness programme and ban tobacco sale. Revenue involved is so high, that no country has banned this legally. In India 6 states have legally banned tobacco related GUTKA POUCH, sale. How for it is effective, time will show. A programme has been charted to guide, Nations to protect their citizen is named as M POWER, M-Monitor, P-Protect, O-Offer help to quit, W- Warn of danger, E-Enforce ban on Adds, promotion and sponsorship, R – Raise Taxes. This needs national conscientious and political will. Young generation is bright and focused to make a composite effort for thoughtful awareness programme and early detection to keep population away from tobacco evil and treatment at an early stage.
SEER – (Surveillance, Epidemiology and End Result)
Programme of National Cancer Institute USA, framed a programme aimed at mass education, public awareness regarding tobacco ill effects and other epidemiological factor and proper management guidance to get expected end result. Programmes are made to work but expected results still elude, and needs evaluation. Last 30 years study (1975-2007) – has shown no improvement in end result.
Doctors Responsibility –
No law, no national programme and no efforts through any organization including Government departments and its related agencies can be successful in public awareness and early detection without involvement of Doctors and paramedical staff. Everyone needs medical help few times a year for various problems, has to go through a Medical System involving Doctors and paramedical staff. Programmes for Breast Cancer, AIDS, Tuberculosis, PAP Smear for Ca Cervix and PSA (Prostate) are successful. Similarly early detection programme like oral examination and finger palpation, brush cytology/biopsy – involving General Practioners, Dentists, Physician, Surgeons and Para Medical Staff in clinics/Camps and educational institution will save population specially youth from tobacco disaster.
Oral Cancer and tobacco – charts and pamphlets in all the hospitals including primary health centres and Government Offices, prominent places in town and cities will boost awareness programme. We as a Surgeon do examine patients for various problems, and needs to examine oral cavity irrespective of disease, will help such programme and save millions of lives.
Can Oral Cancer have a theme mark like PINK RIBBON (Breast Cancer)? Which can be displayed at important places in towns and cities, Hospitals and Clinics to make people aware of the oral cancer and early diagnosis. Self examinant by public himself, particularly in high risk group will prove the most beneficial awareness programme to detect early oral cancer. The efforts towards this direction jointly by Government and Public will improve Nation’s Health.
FUTURE –
Clear understanding of oral cancer cell biology has developed Laser Capture Micro dissection, comparative genome hybridizations and micro protein chips, and few more ionic procedures to give a cure with minimal morbidity and better results, though in early stages. Pharmacological targeted treatment with advance radiation techniques have changed the scenario in late stages also with or without surgery and improved survival. Improved technology cannot replace basic approach of awareness programme and consorted efforts of Governments and public together. Theme mark like “TWO GREEN LEAVES” suggesting – make life bright by oral self examination, or any other theme, which attracts attention with a message, endorsed by Doctors, Public Leaders, Sports person, T.V. movie stars and Educationists will definitely help in controlling national menace.
