Analysis of Risk Factors Associated with Squamous Cell Carcinoma in the Indian Population.

BACKGROUND: Squamous cell carcinoma (SCC) describes the carcinomatous growth in the oral cavity. Recently, various authors have described increased SCC incidence in the young population. The distribution of SCC shows varied geographic spread, with the highest distribution in Asian countries. AIMS: The present trial was carried out to assess the associated factors that could lead to increased risk of developing oral cancer.
MATERIALS AND METHODS: Oral examination was carried out for 21 participants by a dentist and any significant oral lesion or deleterious habit if present, was recorded. The data collected were analyzed.
RESULTS: Areca nut was chewed by 47.61% participants (n = 10), smoking tobacco by 76.19% (n = 16), chewing tobacco by 38.09% (n = 8), and consuming alcohol in 9 participants (42.85%). No significant difference was seen concerning age for any factor except alcohol which showed higher intake in the older group where six participants depicted alcohol intake as compared to three participants in the younger group. In participants who chewed areca nuts, 6 participants also smoked tobacco and 1 consumed alcohol. For tobacco chewing, 5 consumed alcohol and 6 also took tobacco as smoke.
CONCLUSION: The present study showed that areca nut and tobacco chewing along with alcohol consumption and tobacco smoking increase the risk of developing SCC in the Indian population. Copyright:

INTRODUCTION

The carcinomas affecting the head-and-neck region are found in both genders and are the third most common malignancy encountered in the human species. Squamous cell carcinoma (SCC) among all head-and-neck carcinomas is the most common type found in India. SCC describes the carcinomatous growth in the oral cavity.[1] Recently, various authors have described increased SCC incidence in the young population. The distribution of SCC shows varied geographic spread, with the highest distribution in Asian countries.[2]

Oral cancers comprise a huge variety of cancers most common being SCC. Oral cancers also include nasopharyngeal carcinomas, basal cell carcinomas, ameloblastomas, and various others affecting the tongue, lip, and buccal mucosa, lip, and/or mouth linings.[3] In India, approximately 48 thousand people die of oral cancer. However, the actual data are higher than the reported, especially in places with limited access to the health-care sector. SCC in India is the fourth most common cancer in females and the second most common in males.[4]

Tobacco in chewable form or smoking makes is the most common etiological and risk factor for SCC along with consumption of alcohol. In India, areca nut chewing is also a commonly encountered risk factor for SCC along with various viral infections caused by the human papillomavirus family.[5] Smokeless tobacco consumption in India also remains a major risk factor for oral cancer. Genetic predisposition and heredity also play a role in SCC pathogenesis via altering host immunity, impairing neoangiogenesis, and causing DNA damage.[6]

SCC in the majority of cases of India remains undetected until advanced, due to lack of proper screening tools and lack of public awareness. Varying clinical presentation with various signs and symptoms also makes the diagnosis difficult as it can present as an area of hyperpigmentation, depigmentation, skin lesion, the lump of oral cavity/neck, and/or mucosal changes.[7] Two precancerous lesions in the oral cavity including leukoplakia and erythroplakia are the definitive precursors of oral malignancies. They initially present as painless white or red areas of the oral cavity which proceeds to dysphagia and burning sensation as they advance. Owing to the varying presentation, lack of screening tools, and lack of public awareness toward SCC in India, identification of risk factors associated remains an important goal for timely diagnosis and treatment.[8] Hence, the present trial was carried out to identify various risk factors associated with an increase in the risk for developing oral cancer.

MATERIALS AND METHODS

The present trial was carried out to assess associated factors that could lead to increased risk of developing oral cancer. A total of 21 participants were included in the study who presented with one or more risk factors of oral cancer. The study included both males and females with the age group of 20 years to 78 years. The mean age of study participants is 48.76 years.

Recruited participants were then divided into two groups, Group I included subjects with minimum one of the defined premalignant and/or malignant lesions in the oral region and the other group with no suspicious lesion. The inclusion criteria were the presence of one or more risk factors for oral cancer. The exclusion criteria were noncompliance and non-willingness to be a part of the trial. Institutional Ethical committee provided the needed ethical clearance.

Before taking informed consent, the participants were clearly explained about the study design and any queries, if there were answered. Following the consent, the participants were made to fill a structured questionnaire about demographic characteristics and personal habits such as smoking, alcohol, and others. The consent and questionnaire were explained in Hindi by a witness. Following this, an oral examination was carried out for all the participants by a dentist expert in the field, and any significant finding, if present, was recorded. The data collected were analyzed statistically.

RESULTS

The present trial was carried out to identify various risk factors associated with an increase in the risk for developing oral cancer. Twenty-one participants with one or more risk factors for developing oral cancers were recruited and participated in the study. The study included both males and females with the age group of 20–78 years with a mean age of 48.76 years. Of the included 21 participants, 17 (80.95%) were males and 4 (19.04%) were females. Among 21 participants, 8 (38.09%) visited the dental department for chief complaints related to teeth and had no lesion in the oral cavity. Nonmalignant lesions on oral examination were seen in 4 (19.04%) participants, no lesion in the oral cavity was seen in 7 (33.3%) participants, 6 (28.57%) study participants had clear premalignant lesions, and appreciable carcinomas were seen in 4 (19.04%) participants. The male participants had nonmalignant lesions, premalignant lesions, and carcinomas in equal distribution, whereas the female population of the study had malignant or premalignant lesions. These characteristics are explained in Table 1.

Table 1

Characteristics of the study participants

Characteristic	n (%)
Total population	21 (100)
Mean age (years)	48.76
Age range	20-78
Sex
Male	17 (80.95)
Female	4 (19.04)
Reason for visiting dentist
For oral lesions	8 (38.09)
Other dental causes	13 (61.90)
Lesion identified on oral examination
No lesion	7 (33.3)
Premalignant lesion	6 (28.57)
Nonmalignant lesion	4 (19.04)
Malignancies	4 (19.04)

The study assessed the various deleterious habits which can lead to increased risk for developing oral cancer. The causes listed by study participants were chewing of areca nuts in 47.61% of participants (n = 10), smoking tobacco in 76.19% (n = 16), chewing tobacco in 38.09% (n = 8), and consuming alcohol in 9 participants (42.85%) [Table 2]. On evaluating these habits based on the reference mean study age (48.76), the results showed no significant difference was seen concerning any factor except alcohol which showed higher intake in the older group where six participants depicted alcohol intake compared to three participants in the younger group. The combination of habits was seen in study participants commonly areca nut and tobacco chewing.

Table 2

Factors and habits increasing the risk for squamous cell carcinoma with age distribution

Characteristic	n=19, n (%)	More than the mean age		Less than mean age
		Positive	Negative	Positive	Negative
Areca nut chewing	10 (47.61)	4	6	6	5
Tobacco chewing	8 (38.09)	4	6	4	7
Alcohol consumption	9 (42.85)	6	7	3	5
Tobacco smoking	16 (76.19)	8	3	8	2

On assessing the combination of habits as seen in individual participants, it was seen that all the participants that chewed tobacco also took area nut (n = 8) [Table 3]. In participants who chewed areca nuts, 6 participants also smoked tobacco, and 1 consumed alcohol. For tobacco chewing, 5 consumed alcohol, and 6 also took tobacco as smoke.

Table 3

Individual habits of the study subjects

Characteristic	n	Areca nut chewing, n (%)		Tobacco chewing, n (%)		Alcohol consumption, n (%)		Tobacco smoking, n (%)
		Positive	Negative	Positive	Negative	Positive	Negative	Positive	Negative
Areca nut chewing	10	-	-	8 (80)	2 (20)	1 (10)	9 (90)	6 (60)	4 (40)
Tobacco chewing	8	8 (100)	-	-	-	5 (62.5)	3 (37.5)	6 (75)	2 (25)
Alcohol consumption	9	1 (11.1)	8 (88.8)	5 (55.5)	4 (44.4)	-	-	5 (55.5)	4 (44.4)
Tobacco smoking	16	6 (37.5)	10 (62.5)	6 (37.5)	10 (62.5)	5 (31.25)	11 (68.75)	-	-

DISCUSSION

The present trial was carried out to identify various risk factors associated with an increase in the risk for developing SCC in India. The results of the present study are less reliable in establishing significance regarding risk factors for SCC owing to the smaller sample size. However, the findings of the present study were consistent with the findings of the various previous studies.

The present study showed that participants who take areca nuts and tobacco in chewable forms have an increased risk of developing SCC and pre-malignant lesions of the oral region. These findings were in agreement with the studies by Galbiatti et al.[9] in 2013 and Al-Swiahb et al.[10] in 2010 where authors have reported the association of areca nut and tobacco chewing with oral cancer.

In the present study, it was seen that all participants who chewed areca nut also take chewable tobacco. In participants who chewed areca nuts, 6 participants also smoked tobacco and 1 consumed alcohol. For tobacco chewing, 5 consumed alcohol, and 6 also took tobacco as smoke. These findings can be attributed to the fact that these two compounds are sold in combination and show synergistic effects. Similar results showing synergistic effects of areca nut and tobacco chewing were also reported by the study of Garg et al.[11] in 2015.

The factors identified in the present study were chewing of areca nuts in 47.61% of participants (n = 10), smoking tobacco in 76.19% (n = 16), chewing tobacco in 38.09% (n = 8), and consuming alcohol in 9 participants (42.85%). The results showed no significant difference concerning mean age for any factor except alcohol which showed higher intake in the older group where 6 participants depicted alcohol intake compared to 3 participants in the younger group. The combination of habits was seen in study participants commonly areca nut and tobacco chewing. Areca nut and tobacco showed even distribution, whereas alcohol consumption did not. These findings were in agreement with the studies of the Indian population conducted by Sinha et al.[12] in 2016 and WHO[13] in 2014 where the same findings were seen for alcohol, tobacco, and areca nuts.

In 21 participants, 8 (38.09%) visited the dental department for chief complaints related to teeth and had no lesion in the oral cavity. Nonmalignant lesions on oral examination were seen in 4 (19.04%) participants, no lesion in the oral cavity was seen in 7 (33.3%) participants, 6 (28.57%) study participants had clear premalignant lesions, and appreciable carcinomas were seen in 4 (19.04%) subjects. The male subjects had nonmalignant lesions, premalignant lesions, and carcinomas in equal distribution, whereas the female population of the study had malignant or premalignant lesions. This can be contributed to the chewing of areca nut and tobacco combination by Indian women which is the main causative factor for developing premalignant lesions such as leukoplakia and SCC which was also confirmed by the study of Kademani[14] in 2007.

CONCLUSION

The present study showed that areca nut and tobacco chewing along with alcohol consumption and tobacco smoking increase the risk of developing SCC in the Indian population. Hence, reduction of using these products should be implemented with simultaneous employment opportunities to people working in sectors associated with their production. More social programs with influencing personalities need to be employed for motivating people to quit these deleterious habits.

The study had few limitations including the small sample size, geographical area bias, no monitoring of the premalignant lesions, and questionnaire form which was in the language which was not native to the place. Hence, studies with larger sample size and from different geographical areas are required to reach definitive conclusions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.