Malignant Tumors of the Oral Cavity among Jordanians

ABSTRACT

Objective: To determine the incidence of primary malignant tumors of the oral cavity in Jordan and to compare the incidence rates among Jordanian population with world standard population.

Methods: A retrospective study was conducted during the period 2000 and 2007, on 156 cases with histological diagnosis of primary malignant tumors of the oral cavity. The cases were registered and received by active case finding from the maxillofacial departments at the Royal Medical Services Hospitals, Hospitals of the Ministry of Health, Hospitals of Jordan University and Jordan University of Science and Technology and private hospitals. The records included the age, sex and primary site. The age-adjusted standardized rates were calculated and the incidence rates among Jordanian population were compared with the other world standard population. 

Results: Over seven years, the primary malignant tumors of the oral cavity in Jordan accounted for 156 cases, of these 96 (61.5%) were males and 60 (38.5%) were females, with a male to female ratio of 1.6: 1. The overall age-adjusted standardized rate was 5.26 per 100,000 (standard world population), and the age-adjusted standardized rates was 6.60 per 100,000 males and 3.87 per 100,000 females. The squamous cell carcinoma was the most common accounting for 67.3% of all oral cavity malignant tumors. On the other hand the most frequent site of oral malignant tumors in Jordan was lips for males, accounting for 23.7%  while the tongue was the most common site of oral cavity tumor in Jordan for both sexes accounting for 18.6%, and the age-adjusted standardized rate was somewhat equal in both sexes: 1.01/100,000 versus 0.96/100 000, respectively.

Conclusion: The age-adjusted rate of primary malignant tumors in Jordan was 5.26 per 100,000 (standard world population). The frequency rate increased with increasing age and was more common in males. The squamous cell carcinoma was the most common type with a tendency for a tongue cancer in both sexes and lip cancer becoming more frequent in males. 

Keywords: Jordanians, Malignant oral tumors, Mouth, Tongue, Lip.

JRMS September 2014; 21(3): 6-13 / DOI: 10.12816/0005521 

Introduction

Oral cancer is an important public health problem.(1,2) It is the 6th most common cancer in men. (3) Most of oral cancers are preventable, as 75% of oral cancers are related to use of tobacco, alcohol, or both substances. It mainly affects individuals in the 6th and 7th decades of the life with history of smoking and or alcohol consumption.(4-6)  Dietary deficiency of vitamin A and iron have their impact on oral mucosa and have been associated with high risk of oral malignancy.(7) In Jordan, 21% of the population were reported to have vitamin A deficiency,(8) 30%  of women were anemic and 55% of these anemic had iron deficiency.(9) There were 615,000 new cases of oral cavity tumors reported worldwide in 2000, and 300,000 were primary squamous cell carcinomas (SCC) of the oral cavity.(10) The SCC was reported as the most common oral malignancy representing about 66.5%.(11,12) The most frequent oral cancer sites are the tongue, floor of the mouth, soft palate tissue areas in back of the tongue, lips and gums.(13-17) 

The aim of this study was to determine the incidence of primary malignant tumors of the oral cavity in Jordan and to compare the incidence rates among Jordanian population with world standard population and to review the epidemiology and clinical features of primary malignant tumors of the oral cavity.

Methods

This study was conducted retrospectively on 156 cases of histologically diagnosed primary malignant tumors of the oral cavity that were registered and received by active case finding in the period of 2000 – 2007. The cases were registered and received by active case finding from the maxillofacial departments at the hospitals of the Royal Medical Services, Ministry of Health, Jordan University and Jordan University of Science and Technology and private sector. The retrieved data included the age, sex and primary site. 

The International Classification of Disease (ICD9) was used for coding of the primary site of the oral cavity malignant tumors as shown in Table I. This is a population-based cancer registry study based on the 2004 Jordan population census (Fig.1 and 2). The age and sex specific rates of primary malignant tumors of the oral cavity were calculated using the 5-years divisions of age groups. The rate refers to the number of the newly diagnosed cases of primary malignant oral tumors and it is calculated as the number of new cases diagnosed in Jordan over 7-years divided by the number of residents. The age-adjusted standardized rates (ASR) were calculated by the use of direct method and world standard population expressed per  100,000  inhabitants, allowing  comparison  of  our  rates  among  the 

Jordanian   population   with   world standard population (Fig. 3).  The different age distributions with ten age categories (0-35, 35-39, 40-44, 45-49, 50-54, 55-59, 60-64, 65-69, 70-74, 75+)  were standardized using the age-specific rates in each population to one standard population. 

Results

Of 156 cases of primary malignant tumors of the oral cavity, 96 cases (61.5%) were men and 60 cases (38.5%) were women. The male-to-female ratio was 1.6:1. The mean age of the patients for both sexes was 57.6 ± 18.3 SD (range 6-100 years). The overall ASR was 5.26 per 100 000 (standard world population), the ASR was 6.60 per 100,000 males and 3.87 per 100,000 females. The highest rate was in elderly patients over 75 years of age and about 75.7% of the oral cavity tumors were found in patients who are 45 years or older. Over the age of 50, both sexes showed rise in the rate of tumour occurrence among the different age groups, which was higher among males compared to females as shown in Table II. 

The SCC was the most frequent histological type accounting for 67.3% of all diagnosed oral cavity malignant tumors with an ASR of 3.75 per 100,000 and for males it constituted 4.65 per 100,000 and for females 2.81 per 100,000. The non-squamous cell carcinomas accounted for 32.7% with an ASR of 1.51 per 100,000 residents and for males it constituted 1.95 per 100,000 and for females it was 1.06 per 100,000 (Table III). 

Other histological types of malignant tumours included: lymphoma (9%), sarcoma (5.8%), basal cell carcinoma (4.5%), adenoid cystic carcinoma (4.5%), mucoepidermoid carcinoma (4.5%), adenocarcinoma (2.6%), melanoma (1.3%) and Langerhan’s histocytosis (0.6%) as shown in Table IV.

Table V shows the number of cases, percentages and ASR of primary malignant tumors of the oral cavity recorded in different anatomical sites in our study. It also shows percentages for males, females and total population  along with ASR for all three groups. 

Table I: International Classification of Disease (ICD9) codes for Oncology (Malignant Neoplasm of Lip, Oral Cavity) 

Fig. 1:  Age distribution of Jordan population in 2004

Fig. 2: Age distribution of Jordan population by gender in 2004

Fig. 3: World Standard population used for age adjustment

Table II: Primary malignant tumors of the oral cavity age-specific rate (ASR) per 100,000 population, by gender-Jordan 2000-2007

Standard world population  --Not applicable   *ASR: World Age-Standardized Rate.

Table III: Rates of intra-oral squamous cell carcinoma (SCC) versus non- squamous cell carcinoma (Non-SCC) per 100,000 of Jordan population 2000-2007

Table IV: Distribution of primary malignant tumors of oral cavity by histological types per 100,000 of Jordan populations 2000-2007

Table V: Numbers, percentages and age-adjusted rates of primary malignant tumors of the oral cavity recorded at different anatomic sites, in Jordan: 2000-2007.

Discussion

This is a population-based cancer registry study based on the 2004 Jordan population census that determines the incidence of primary malignant tumors of the oral cavity in Jordanians. The world age-standardized Ratio (ASR) of primary malignant tumors in Jordan was 6.60 per 100,000 males and 3.87 per 100,000 females. Globally the ASR of primary malignant tumors is 6.3 per 100,000 males and 3.2 per 100,000 females. There are notable differences between oral cavity tumors incidence rates in developed and developing countries. In the developed parts of the world, the ASR is 6.5 in males and 2.6 in females; in less developed areas, the rates are 11.1 and 7.2, respectively. 

Review of literature revealed that Melanesia had the highest incidence (31.5 per 100,000 in men and 20.2 per 100,000 in women) and this was attributed to the chewing of betel leaf (paan) in that country. Rates in men were high in the following regions with decreasing frequency:    South   Asia  (12.7  per  100,000), 

Western Europe (11.3 per 100,000), Southern Africa (11.1 per 100,000), Australia/New Zealand (10.2 per 100,000), and Southern Europe (9.2 per 100,000) which reflects prevalence of specific risk factors, such as tobacco and/or alcohol use. On the contrary, females were affected more frequently in Southern Asia with a rate of (8.3 per 100,000).

 In Jordan 46% of males and 10% of females were reported to be smokers.(18) All forms of smoking are socially acceptable while alcohol consumption in this Muslim community is prohibited and not socially acceptable. 

The high rate of oral cancer in Australia is due to lip cancer related to solar irradiation.(19,20,21) In Jordan the average daily sun exposure is nine hours around the year, most of men are outdoor workers, this increases exposure to UV light and increases risk for lip cancer.(22) The oral cavity malignant tumors incidence in this study was higher than that reported by national cancer registry in Jordan (ASR 6.60 versus reported 5.26 per 100,000),(23) and than that reported in another study in the North of Jordan (ASR 6.60 

versus 2.14 per 100,000).(22) The epidemiology of oral cavity malignant tumors in this study was characterized by the higher rate in patients over 50 years of age and the incidence rate by age group increased with age,  this is consistent with a study conducted in the North of Jordan that reported  more prevalent malignant tumors of the oral cavity with increase of age.(22) Other studies reported that about one and half to four-fold increase in prevalence of oral cavity cancer was observed in patients above the age of 50 years compared with those below the age of 50, and it is a disease that affects men in the 5th and  6th  decades  of  life  and  is  associated with  habits  of   smoking,  alcohol consumption, different  geographic areas and gender.(4-6,22,24,25-30) 

The male-to-female ratio of 1.6:1 was another characteristic of oral cavity malignant tumors pattern in this study. In developed countries, the male-to-female ratio is 2.5:1, and in less developed countries it is about 1.5:1.(19) Indeed, gender was not found to be a risk factor for oral cavity cancer; this difference in prevalence reflects the existence of other risk factors associated with the male gender, such as tobacco and alcohol consumption habits.(31) Other studies showed different male: female ratios for example, in North of Jordan the male-to-female ratio was 1.8:1,(22) in USA 2.4:1,(32) UK 2.3:1, France 5.5:1, Spain 4.9:1 and Germany 4:1,(1) Hungary 4:1, (24) Iraq 2:1,(33) Nigeria 1.4:1,(34) and in North India it was 1.6:1.(21)

The SCC was more common than other histological types of oral cavity tumors, and it accounted for 67.3% of the cases. Other studies reported that SCC was the most frequent histological type, accounting for 95% of the oral cancer tumors, and the lip was the most commonly affected site followed by the tongue. This could be explained by a lesser exposure to alcohol and tobacco in women.(1,27,35-40,41) Other study showed that the most common sites of tumors were tongue and floor of the mouth, but in the women group the incidence of tumors in these sites were 43% compared with 61% in the men.(27) The second most common tumor of the head and neck was Lymphoma and about 3% to 5% of non-Hodgkin were primarily located in the oral cavity with the Waldeyer ring being the most frequently involved site.(42,43) 

Sarcomas represent a minority of these neoplasms, accounting for only 3–10% of all head and neck soft tissue tumors.(44) Salivary glands are remarkable for their histological diversity. These neoplasms can be of epithelial, mesenchymal and lymphoid origin. Carcinoma of the salivary glands accounts for less than 1% of all oral cavity neoplasms.(38)  Review of literature revealed that basal cell carcinoma affects the head and neck in 97.5%, distributed over the following sites: nasal accounting for 27.0%, frontal 21.4%, cheek 15.3%, eyelids 12.1%, ears 7.5%, neck 7.5%, lips 5.3%, scalp 2.5%, and chin 1.4%. Histologically, 66.2% basal cell carcinomas were solid, 17.1% infiltrative and 7.1% combined.(45) 

Limitations of the Study

The study was carried out for the purpose of the best estimation of the incidence of oral cavity tumors in Jordan. Patients with early cancer stages or pre-cancerous changes were not included. Moreover, risk factors of lifestyle, cigarette smoking, alcohol consumption, dietary habits, and family history were not studied. 

Conclusion

The age-adjusted rate of primary malignant tumors in Jordan was 5.26 per 100,000 (standard world population). The frequency rate increased with increasing age and was more common in males. The squamous cell carcinoma was the most common type with a tendency for a tongue cancer in both sexes and lip cancer becoming more frequent in males.

Recommendations

There is a need for a national program focusing on educational information addressing the oral health and its importance in preventing oral cavity malignant tumors. Many studies suggest that tobacco use and alcohol drinking play the greatest role in carcinogenesis of oral cavity malignant tumors. The documentation of oral cancer cases nationwide is far deficient from optimum, and more collaboration is needed between the different health care organizations and the national cancer registry in Jordan.

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