Spectrum of oral cancers in a tertiary care hospital in industrial belt of Haryana, India

Oral cancer is amongst the three top cancers in India, accounting for more than 30% of all cancers reported in the country. It is also the leading cause of cancers in males in India. Faridabad district in Haryana is the 9th largest Industrial estate in Asia. Objective: To study the spectrum of oral cancers in the Industrial belt of Haryana, Faridabad. Materials and Methods: A descriptive analysis was conducted on biopsies of oral cancers at ESIC Medical College and Hospital, Faridabad. The hospital based cancer registry data for oral cancers have been presented over a period of 30 months (2016-19). This centre caters to patients working in factories, who are covered under ESI scheme and have monthly income of less than 21,000 INR. The data was collected based on patient record. Result: A total of 130 cases of oral cancers were studied and tongue was the commonest site (40.5%) with ulcero-proliferative growth. Male: female ratio was 5.5:1. The highest presentation was noted in the 4th decade (30.7%) with male predominance of 85%. Ulcer was the most common presentation in 57% (75/130). Moderately differentiated tumours were noted in 53% (70/130) of cases. Majority of the cases presented with history of smoking. Conclusion: This lower age of presentation of oral cancers with tongue as the commonest site and high incidence of tobacco smoking among patients who represent the lower middle socioeconomic strata of society and mostly are factory workers alarm us to focus on predisposing factors. © 2020 Published by Innovative Publication. This is an open access article under the CC BY-NC-ND license (https://creativecommons.org/licenses/by/4.0/)


Introduction
The oral cancer which poses huge health burden is one of the most common cancers in Indian subcontinent. It involves the head and neck primarily arising in the oral cavity and oropharynx. The tumour may be locally confined or extend to the neighbouring organs. 1 It is the 6 th most common malignancy globally with annual incidence of over 30,000 cases. About 62% cases are reported from developing countries. 2 The oral cavity is the most common site of cancer in the Indian subcontinent contributing to one third of all cancers. 3 It is among top three cancers in India. 4 Almost 90 to 95% oral cancers in India are Squamous cell carcinoma. 5 Accounts for 30% of all cancers in India and age adjusted rate is 20 per 100000. 3 The most important risk factors are alcohol and tobacco. Tobacco includes smoking of cigarettes, bidi and hookah. And use of smokeless tobacco which includes betel quid and areca nuts. Also implicated are HPV infection, poor dental care and poor nutrition. 5 Immunosuppression, poor oral hygiene, ill-fitting dentures are other factors contributing to the oral cancer. 1 In regions near the equator there is high frequency of squamous cell carcinomas. The mean age of presentation in Asian Countries is 5 to 6 th decade compared to the https://doi.org/10.18231/j.ijpo.2020.048 2394-6784/© 2020 Innovative Publication, All rights reserved. 253 7 th to 8 th decade in North American population. 6 There is an increasing trend of Oral cancers among younger population globally. About 4 to 6% cases are noted below the 4 th decade. This probably is due to the increasing use of smokeless tobacco in form of Pan Parag, Gutka and Cigarette smoking in young adults in countries like India, Pakistan and Bangladesh. 1 Low socioeconomic class are associated with factors like poor nutrition, health care, living condition and greater exposure to risk factors. The detection of and prevention of disease is also compromised, all of which together contributes to the development of oral cancers. 5 Geographical variations in different populations and regions arise due to difference in the type, pattern of tobacco use, lifestyle and ethnicity. Variations in the epidemicity of the cancer are related to age of the population and regional difference in the risk factors. 7 Burden of Oral cancer in India is related to several factors ( Figure 1).
Social media and television plays an important role to create awareness about the harmful effects of tobacco. Western influence on the Indian lifestyle and pattern of tobacco use also plays an important role in the site specific incidence of oral cancers.
The present study was carried to study the spectrum of oral cancers among the factory workers in Industrial belt of Haryana, Faridabad district, India. Haryana ranks 9 th among the industrial estates in Asia. The study depicts an increasing trend of cancer of tongue among the young factory workers belonging to low socioeconomic strata.
To the best of our knowledge it is the first study of oral cancers among the industrial workers globally.

Materials and Methods
A retrospective descriptive analysis of all biopsies of oral cancers were conducted in the department of Pathology at ESIC Medical College and Hospital, Faridabad. The hospital based cancer registry data for oral cancers was presented over a period of 30 months (2016-19) since the inception. The subjects included factory workers covered under ESI scheme attending the tertiary care centre. The data was collected based on the hospital patient record.
The data was presented in the XL sheet and calculated as ratio and proportions. Chi square test and t test were applied. The significance level was set at 5%.

Results
In the present cross sectional analysis it was seen that out of 130 cases of Oral cancers, 110 were males and 20 were females which shows a predominance of males, with male to female ratio of 5.5:1.
The age distribution is from 23 to 80 years. The mean age of cancer was 54.01yrs. The age wise distribution showed maximum number of cases (40/130) were in the age group of 40 to 50 years followed by age group 50 to 60 years (33/130) and minimum numbers (5/130) were recorded below 30 years ( Figure 3).
Sex wise distribution showed most common age group in males was 41-50 years while in females it is 50-60 years.
The number of cases with no history of alcohol and smoking is 15% (22/130).
A significant association was found between sex and habits. (p<0.001) The highest proportion of cancer was noted in the tongue which was 40.5% followed by cancer of buccal mucosa (18.5%) and lowest being the lip 1.5%. (Figure 4).
Tongue was the commonest site in both males and females with maximum number of cases being moderately differentiated carcinoma ( Table 2).
The association between sites and habits was found to be significant (p<0.001) The commonest subtype was Squamous cell carcinoma of which 53% were moderately differentiated (70/130) carcinoma followed by 35% (40/130) which were well differentiated and 10% (13/130) were poorly differentiated. Association between the grade of the tumour and habits were found to be statistically significant. (p < 0.001) Other subtypes noted were Basosquamous Ca, Carcinoma In Situ, Mucoepidermoid carcinoma each contributing 2 cases and a single case of Spindle cell ca.

Discussion
Oral cancers are malignant neoplasm of oral cavity which includes the lip, floor of the mouth, cheek lining, gingiva, palate and tongue. 5 40% of all cancers in the South Asian countries and 30% of cancers in India are Oral cancer. It is the commonest cancer in males and 4 th most     14 11 both chewable and non-chewable products. Tobacco alone contributes to 75% of the cases. 9 According to Global Adult Tobacco Survey, 34.6% of adults in India; including 47.9% of males and 20.3% of females consume tobacco. As per the data 14% of adults smoke tobacco while 25.9% consume smokeless tobacco. 10 Smokeless tobacco in the form of Gutka, Pan etc are increasing among young adults in the Indian subcontinent.
Tobacco, areca nut, betel quid chewing, alcoholism are the predominant risk factors. Alone or in combination these are major predisposing factors for oral potential malignant disorders (OPMD or oral cancers. 1 The incidence of OPMD is 1-5%. 11 These include leukoplakia, erythroplakia, submucosal fibrosis, lichen planus, actinic keratosis, palatal lesions in smokers. 12 Alcohol and tobacco products are known carcinogenic agents. Alcohol and tobacco were the most important risk factor in our present study and both are more common in males while 15% cases gave no history. Tobacco and alcohol consumption at present and in the past are considered the most important risk factors in other studies for OSCC. 13 Several studies showed males showed greater association with these risk factors. [14][15][16] Tobacco Smoking contributed to 67% (85/130) while chewing contributed to 50% (65/130). However, Only 20% of these cases gave history of alcohol consumption. This is in concordance to a study by Raveendran et al. 1 in which Alcohol and tobacco was implicated in three fourth of the cases while in remaining one fourth of the cases no definite etiological factor could be identified.
At times no history of alcohol and smoking could be elicited in younger patients as the most common risk factors. In the younger age group dietary or nutritional factors and genetic predisposition, and high-risk HPV types (especially HPV type 16) have been demonstrated as causative factors in OSCC more than the adults or elderly group. 17 HPV type 16 is an independent major risk factor for oral Cancer. In developing countries up to 23% of malignancies are caused by infectious agents, including HPV. 18 The demonstration of HPV mediated oropharyngeal cancer is an important development in the pathogenesis of oral cancers. However, HPV detection was not undertaken in the present study as the test is not routinely performed in the given setup.
Tongue is the most common site in the western world as smoking is more prevalent while carcinoma of the buccal mucosa are more common in the Asian Countries due to the habit of chewing and keeping the tobacco or the betel quid in the gum. 19 However, present study shows Tongue as most common site (40.5%) followed by the buccal mucosa (18.5%). Tongue is also the commonest site noted in several other Indian studies namely by Patel et al (23.02%), Mehrotra et al (42.5%) and IYPE et al (52%). Agarwal and Rajderkar also noted Tongue as the most common site. [20][21][22] Studies from Mexico (44.7%) and Brazil (34.9%) also showed tongue as the commonest site. 17,19 Buccal mucosa was noted as the commonest site by Giri et al (37.1%). 23 Few Indian studies by Anjali Narwal (37.9%), Shenoi et al (45.7%) and Khanderkar et al (55%) reported alveolus as the most common site. 24,25 The mean age of presentation in the Asian populations is 5 th and 6 th decade compared to the 7 th and 8 th decade in North America. 26 The present study shows the highest number of cases were in the 4 th and 5 th decade, a decade earlier than that noted in most Indian studies. This is in concordance with study by Sharma and Krishna where majority of cases were seen in 4 th and 5 th decade. Also, Krisnanmurthy and Ram Shankar noted majority of patients were in age group of 51 to 60 years with mean age of 53.4 years. 27 Also, Giri et al noted majority of cases were above 60 years of age and only a few cases were below 30 years similar to the present study. 23 Only 5% of the patients reported in the present study were under 30 years of age, as presented by Jainkittivong, et al. 28 Literature reveals the means usually ranging from 4 to 6%. 13 The present study highlights the age group affected in males is 41 to 50 years which is a decade lower than females. This is in concordance with several other studies were the age group of females are higher than males in oral squamous cell carcinoma(OSCC). 15,29 Male to female ratio is higher 5.5:1, as the habits of tobacco smoking and chewing both are more among males. This is in concordance with studies by Patel  The factory workers belong to the lower and middle socioeconomic group and are predominantly males. Studies have shown lower socio economic group have inadequate access to health care facilities and poor health services. Poor dental hygiene contributes to 85% of cases. Those having dentures for more than 15 years and not visiting dentists regularly are also at higher risk. 5 Lack of awareness of the harmful effects of tobacco and delay in the diagnosis at early stage is an important factor for increased incidence of Oral cancers among this population.
However, several recent studies have shown an increase in the number of affected females, with male to female ratio lower than 2:1, which can be attributed to the social changes and the life style pattern of the present day women exposing them to more use of alcohol and smoking in regular life and high risk strains of HPV subtypes. 17 In the present study, Ulcero proliferative (UC) lesion is the most frequent presentation (75%) followed by dysphagia (33%). Similar to this study, UC growth was also noted in 74.5% cases by Anjali Narwal et al while Mathur et al reported UC lesions in 52.9% cases. Similar findings were also noted by Shyam Sunder et al, by lshiyama et al and Wahiel et al. 25 Majority of oral cancers are squamous cell carcinomas. The present study shows moderately differentiated cacinoma was the most common histological subtype in both the males and females. This is similar to other studies which also showed moderately differentiated and well differentiated OSCC as the most common subtypes. 17 On the contrary, Effiom, et al. have shown that 47.6% of their cases were poorly differentiated tumors, while well differentiated tumors represented 32.6%. 29 With the introduction of the cigarettes and other Tobacco products act (COPTA) in 2003, smoking was banned in public places in India and also sale of tobacco products to children below 18 yrs. Significant awareness was created in social media and television along with pictorial and textual warning on these products. 30 This might be contributing to the changes in the presentations of oral cancer in India.
To summarise this is the first pilot study on Oral cancers among industrial workers in the India. It gives for an insight to look for etiological factors that predispose to early age of presentation in males with tongue as the commonest site followed by buccal mucosa. The higher male incidence may be explained by increased number of male workers and more indulgence in smoking and alcohol during the long working hours in factories. Factory workers generally belong to low socioeconomic group with low income which contributes to lack of proper diet, nutrients and dental hygiene.

Limitations
It is a hospital based cross sectional study which caters to specific patient population working in Industries and their families. Specific dietary and tobacco consumption habits could not be correlated much with the sites of predilection of Oral cancers and being retrospective, history of oral hygiene also could not be elicited.

Conclusion
No centralised hospital based Oral Cancer registry or population based cancer registry is available in most Indian States. Haryana is small agricultural state with predominance of rural population. Such studies will give an insight to the health authorities to raise the public awareness of the risk factors as well as early diagnosis and treatment of oral cancers in India where it has high prevalence.

Source of Funding
None.

Conflict of Interest
None.