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ISSN 2007-3178 (Print)
Asociación Mexicana de Cirugía Bucal y Maxilofacial, Colegio Mexicano de Cirugía Bucal y Maxilofacial, A.C.

2021, Number 3

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Rev Mex Cir Bucal Maxilofac 2021; 17 (3)

Incidence and management experience of oral cavity cancer at the Instituto Nacional de Cancerología de México

Prada Vidarte, Oskar Eduardo1; Trinidad de Jesús, Imelda2; Granados García, Martín3

Language: English
References: 33
Page: 111-121
PDF size: 232.78 Kb.


ABSTRACT

Objective: The objective of this study is to present the incidence and management experience of oral cavity cancer (OCC) at the Instituto Nacional de Cancerología de México (INCan) during March 2018 and October 2020. Study design: It is descriptive, retrospective and cross-sectional. The database of 1,440 clinical records of the Head and Neck Surgery Department of the INCan was used, using the statistical software IBM® SPSS® Statistics, version 21 for Windows. Only 221 met the inclusion criteria, categorizing them according to age group, state of residence, predisposing factors, anatomical region, type of treatment, disease state, clinical stage (CS), and type of surgery performed with and without reconstruction. Results: The highest incidence of OCC occurred in the age group of 51 to 55 years (n = 31, 14.1%, SD = 1.47), in those who reside in the Estado de México (n = 66, 29.9%), the alcoholism and smoking were the main predisposing factors (n = 49, 22.1%), the most frequent anatomical region was the mobile tongue (n = 98, 44.1%), a high percentage of patients abandoned treatment (n = 44, 19.9%), the main treatment was surgery (n = 41, 18.6%), there was a high percentage of patients alive during the analysis (n =189, 85.5%), the CS most incident was IV B (n = 80, 36.2%), hemiglossectomy was the main surgery performed (n = 31, 34.1%) and postoperative reconstruction was only performed in four patients (4.4%). Conclusions: The incidence of OCC in INCan is 15.3% and its management depends on the CS at the time of diagnosis.



INTRODUCTION

Oral cavity cancer (OCC) represents a serious health problem, particularly in underdeveloped countries, with an estimated 484,628 cases in 20021 and a global gender ratio (men:women) of 2:1.2

There is great geographic variation in mortality from OCC. In 2000, mortality rates were excessively high in some countries in Central and Southern Asia and Melanesia, where rates were between 19 and 22 per 100,000 population.1 In Africa, mortality rates have reached 14 per 100,000. In Europe, Slovakia and Hungary were the countries with the highest death rates (7 and 11 per 100,000). For 2020 in Latin America, mortality rates were high in Cuba, Brazil, and Uruguay, with mortality rates of 1.8, 1.5, and 1.4 per 100,000 population respectively, while the countries with the lowest mortality were Bolivia, Nicaragua, and Honduras, with mortality rates of 0.3, 0.33 and 0.38 per 100,000 population, respectively. In Mexico, the mortality rate for 2020 was 4.1 per 100,000 population.1,3

The campaign to fight cancer in Mexico originated in 1940 as an initiative promoted by the Ministry of Health and Assistance. The need to have an information system that would allow knowing the frequency and distribution of the different malignant neoplasms led to the creation, in 1982, of the National Cancer Registry (NCR) as a basis for evaluating the various health programs related to this disease and focused on the benefit of the population.4

In Mexico, for 1989, neoplasms of the oral cavity represented the 15th position for men and the 19th position for women with a ratio of 1.7 to 1; the average age of appearance corresponded to 60 years; the mobile tongue was the most frequent anatomical region (75%), followed by the base of the tongue (6%). The histopathological registry of malignant neoplasms (HRMN) also reported that during the 1993-1997 period, the oral cavity ranked 22nd with respect to the location of cancer in both sexes, corresponding to 1% of all registered cases. Like other reports, squamous cell carcinoma ranked first among the various histological types.5

There are few data on malignant lesions in the oral cavity in Mexico. During the year 2000, 1,389 cases of neoplasms located in the lip, oral cavity and oropharynx were reported, which represents 1.51% of the 91,913 cases of malignant neoplasms registered in that year.5

Malignant lesions located in the head and neck represent 17.6% of all (108,064) malignant neoplasms reported to the HRMN in 2002. Of these neoplasms, the most important group due to its frequency are non-melanocytic carcinomas of the skin, with 11,803 cases, which means 62% of the malignant tumors of this region in question. The next group is made up of malignant neoplasms of the upper aerodigestive tract, which represent 12% of malignant lesions in the head and neck, with 2,269 cases. Specific sites are distributed as follows: laryngeal cancer, 42%; oral cancer, 37%; nasal cavity and paranasal sinus cancer, 9%; oropharyngeal cancer, 6%; nasopharyngeal cancer, 3%, and hypopharyngeal cancer also with 3%. Likewise, the estimated lethality for OCC is 62.4%.6

Among the epidemiological factors for Latin America are considered age, sex, race, smoking and alcohol consumption, the latter being the most important risk factor for the development of this neoplasm, as well as recurrences after treatment. The human papilloma virus (HPV) in the Mexican population occupies a special place in the pathogenesis of oral squamous cell carcinoma, since the prevalence in men and women is 43 and 17.5%, respectively, being the most frequently associated serotype 16.7,8

In relation to cancer of the upper aerodigestive tract, presentation in advanced stages is a constant. 65% of cases present in locally and regionally advanced stages. This is due to indolence on the part of the patients, but also to a lack of suspicion on the part of the first contact physician, so that the diagnosis is delayed, significantly deteriorating the prognosis. It is not uncommon for many patients to have been treated as infectious processes for months with no response and to have seen multiple dentists and physicians before the diagnosis is established.9

Histopathological prognostic factors include location, since tumors in the posterior region of the oral cavity are associated with a higher incidence of lymph node metastasis, tumor size, perineural lymphovascular invasion, bone involvement, sialoadenotropism (the latter associated with a higher risk of recurrences). Metastases of oral squamous cell carcinoma to the skin are also associated with low survival rates; the histological type, from well differentiated (grade I), moderately differentiated (grade II) to poorly differentiated (grade III), of which the latter has a worse prognosis; the presence of metastatic lymph nodes and desmoplasia, among others. Of these factors, the one with the greatest prognostic importance is tumor thickness; it was observed that patients with tumors > 5 mm have lower survival.10

The objective of this study was to identify the frequency and risk factors of OCC in a Mexican population, as well as to present the type of opportune treatment and multidisciplinary management that is given to this type of patients in the Instituto Nacional de Cancerología de Mexico (INCan).



MATERIAL AND METHODS

A retrospective and cross-sectional study of the new detected cases of OCC was carried out using the database of 1,440 clinical files of patients who attended the Head and Neck Surgery Department of the INCan during March 2018 and October 2020, of which 345 corresponded to patients diagnosed with oral cavity cancer, with only 221 meeting our inclusion criteria. 118 were excluded because they had incomplete files (they did not specify the anatomical region or the type of treatment offered) and six because it was corroborated after the biopsy that it was not a malignant neoplasm of the oral cavity. The statistical software IBM® SPSS® Statistics, version 21 for Windows, was used, as well as the statistical methods of: frequency distribution, arithmetic mean, standard deviation and 95% confidence intervals. They were categorized taking into account the following variables of interest: age group, state of residence, predisposing factors, anatomical region of the neoplasm, type of treatment, state of the disease during analysis, clinical stage (CS) according to the American Joint Committee on Cancer (AJCC) of 2017, and type of surgery performed with and without reconstruction.

The CS was categorized into groups as follows:

  • 1. CS I: T1 + N0 + M0
  • 2. CS II: T2 + N0 + M0
  • 3. CS III: T1,2,3 + N1 + M0 or also T3 + N0 +M0
  • 4. CS IVA: T1,2,3,4a + N2 + M0 or also T4a + N0,1 + M0
  • 5. CS IVB: any T + N3 + M0 or also T4b + any N + M0
  • 6. CS IVC: any T + any N + M1

Taking into account that "T" represents the size of the primary tumor, "N" the metastasis in regional lymph nodes and "M" the distant metastasis.

The inclusion criteria were: all clinical files of patients diagnosed with oral cavity cancer without previous treatment registered in the database of the Head and Neck Surgery Department of the INCan from March 2018 to October 2020, clinical files of patients older than 18 years and of both sexes.

The exclusion criteria were the clinical files of patients that were incomplete and the elimination criteria were those clinical files where it was confirmed after the biopsy that it was not a malignant neoplasm of the oral cavity.

Within the types of treatment offered at INCan, we will mention their operational definitions:

  • 1. Abandonment of treatment: those patients who stop attending the INCan at any stage of treatment after performing a biopsy to determine the diagnosis of the neoplasm.
  • 2. Does not accept treatment: those patients who decide to drop out of any type of treatment at the INCan immediately have their oncological diagnosis corroborated through biopsy.
  • 3. Surgery: patients who undergo surgical resection of a certain anatomical region of the oral cavity compromised by the malignant neoplasm.
  • 4. Radiotherapy: uses high-energy particles or waves, such as X-rays, gamma rays, electron beams or protons, to kill or damage cancer cells.
  • 5. Concomitant radiotherapy: it is administered at the same time as another treatment, such as chemotherapy, in order to carry out local and systemic treatment at the same time, thus improving the results of each therapy separately.
  • 6. Chemotherapy: Treatment with drugs given orally or intravenously that stop the growth of cancer cells, either by killing the cells or by stopping them from dividing.
  • 7. Pain clinic: is the service that is responsible for the evaluation and adequate management of pain caused by cancer in any of its phases and that is based on the application of the treatment algorithm proposed by the World Health Organization (WHO).
  • 8. Palliative care: is the service that is responsible for providing care to patients with advanced and incurable oncological disease and their families, in order to provide quality of life and quality of death until the last moment.

The Head and Neck Surgery Department of the INCan has a treatment protocol according to the CS in which the patients are at the time of diagnosis, which is as follows:

  • 1. Early (CS I and II) squamous carcinomas of the upper aerodigestive tract (SC-UADT) are usually treated with a single therapeutic modality, either surgery (QX) or definitive radiotherapy (RT), although adjuvant treatment is added if necessary detect adverse prognostic factors.
  • 2. In early clinical stages, although RT produces oncological results comparable to QX, immediate morbidity and sequelae generally advise QX, since this is an expeditious treatment that provides valuable prognostic information, therefore RT is usually reserved for the patient eligible or refusing to undergo surgery.
  • 3. The treatment of choice for moderately advanced or advanced resectable (CS III and IVa) SC-UADT is surgical resection plus adjuvant treatment. Surgical resection is chosen if the resection sequelae are acceptable, otherwise, induction chemotherapy (QTi) is considered; but if at least a partial response is not obtained, the QX is resumed. But if a partial or complete clinical response is obtained, chemotherapy and concomitant radiotherapy (QT-RTc) are considered.
  • 4. Patients with very advanced or unresectable (CS IVb) SC-UADT, if the patient is suitable, the treatment of choice is definitive QT-RTc, however, in some cases QTi is considered prior to QT-RTc if this implies some advantage, such as the possibility of resection or rapid palliation. After medical treatment, resection may be considered if the neoplasm has responded favorably and becomes resectable.
  • 5. Both in early and advanced stages, the primary tumor and the regional nodes are treated in a coordinated manner seeking to match the best therapy for both the primary tumor and the regional nodes.
  • 6. Finally, metastatic (CS IVc) SC-UADT, although they are considered incurable, and therefore the treatment has a palliative objective, a long-lasting palliation and good quality of life can still be obtained through the administration of a biological agent or immunotherapy, both with or without QTi.

All the information provided in the database by the patients who attended in this period of time belongs to the Head and Neck Surgery Department of the INCan.

The data collection protocol and the permission to use the information collected that allowed this research to be carried out had the approval of the INCan Institutional Research Committee.



RESULTS

All results were obtained taking into account a confidence level of 95% (p < 0.05).

The number of admissions of patients with OCC to the INCan from March to December 2018 was 84 patients (38%), from January to December 2019 it was 88 patients (39.8%) and from January to October 2020 it was 49 patients (22.2%), decreasing notably from the previous year in relation to the lower number of hospital inflows due to the SARS-CoV-2 virus pandemic (Table 1).

The highest incidence of OCC was in the age group 51 to 55 years (n = 31, 14.1%, SD = 1.47), followed by the age group 56 to 60 years (n = 27, 12.2%, SD = 1.36). OCC was more prevalent in men (n = 126, 57.01%) than in women (n = 95, 42.9%) with a male/female ratio of 1.32/1 (Table 2).

The patients come from a total of 19 states of the Mexican Republic, where those who had a higher incidence of OCC (n = 66, 29.9%) were residents of the State of Mexico, followed by those who reside in Mexico City (n = 58, 26.2%) (Table 3).

Alcohol consumption along with tobacco ranks first among the main predisposing factors for OCC (n = 49, 22.1%), with men being the most affected. The second predisposing factor with greater prevalence also in men was the consumption of tobacco, alcohol and cooking with firewood (n = 45, 20.3%). The third predisposing factor was cooking with firewood (n = 38, 17.1%), this time with a greater predominance in women. It can also be seen that tobacco consumption in women (n = 13, 13.5%) compared to men (n = 4, 3.2%) has been increasing in recent years (Table 4).

The most frequent anatomical region of neoplasia was the mobile tongue (n = 98, 44.1%), affecting slightly more women than men, followed by the gingiva (n = 32, 14.4%) in second place and the hard palate (n = 22, 10%) in third place (Figure 1).

There is a high percentage of patients who abandoned treatment (n = 44, 19.9%). The main treatment performed at the INCan to its patients was surgery (n = 41, 18.6%), followed by surgery together with radiotherapy (n = 35, 15.8%) in second place and only radiotherapy (n = 31, 14%) in third place (Table 5).

There was a high percentage of patients alive during the analysis (n = 189, 85.5%) compared to the dead (n = 32, 14.5%) (Table 6).

The most incident CS with which patients were diagnosed upon arrival at the INCan was IVB (n = 80, 36.2%), followed by stage III (n = 41, 18.6%) in second place and stage IVA (n = 38, 17.2%) in third place (Table 7).

Hemiglossectomy was the most performed surgery (n = 31, 34.1%), followed by hemimaxillectomy (n = 16, 18.7%) in second place and hemimandibulectomy (n = 12, 13.2%) in third place. In addition, it is important to highlight that postsurgical reconstruction was only performed in four patients (4.4%), of which two were microvascular fibular grafts and two were rotational flaps (Figure 2).



DISCUSSION

There are few data on malignant lesions in the oral cavity in Mexico. During the year 2000, 1,389 cases of neoplasms located in the lip, oral cavity and oropharynx were reported, which represents 1.51% of the 91,913 cases of malignant neoplasms registered in that year.5 In our study we were able to determine that the admission of patients to the INCan was stable during 2018 and 2019, while during 2020 it decreased notably due to the high hospital occupancy due to the SARS-CoV-2 virus pandemic. Unlike some authors,11,12 the majority of our patients They were referred by general practitioners.

In our study, the highest incidence of OCC was found in the age group of 51 to 55 years, these results being similar to those reported by Canto and Parkin2,13 where more than 90% of malignant neoplasms in the oral cavity occur in people over 40 years of age and the average age at which this condition is diagnosed is around 63 years, with a high probability of death from the sixth decade of life.

It is recognized that OCC is more frequent in men, which has to do with a greater expression in these people of the main risk factors for the disease, in this case smoking and alcoholism, which are health problems, where men have not ceased to have the leading role.14,15 This study shows that this frequency of the disease is still maintained in male patients who represented 57.01% of the total.

Carrillo et al.16 in 2011, as well as Llewellyn et al.17 in 2004 mention that smoking and alcoholism are determining factors for the development of OCC, which is consistent with what was found in our study where the consumption of both predisposes further to the appearance of the disease. Herity18 reported an association between the amount of alcohol consumed and the risk of tongue cancer. Various theories of the mechanisms of this relationship invoke alcohol's dissolving effects on mucous membranes, negative effects on hepatic detoxification processes, and nutritional deficiencies common in alcoholics.19

Ramirez, Trinidade, Malone, Hendershot and Matovina7,20-23 in their different studies mention that there is a high rate of abandonment of treatment in patients with OCC, which correlates with what was found in our study where the dropout represents a significant proportion of our cases.

Elango and Liang,24,25 report that the tongue is the most frequently affected subsite. In our study, it was also determined that the mobile tongue was the main anatomical region of neoplasia with 44.3%.

In most developed countries, cancer mortality shows a reduction in the magnitude of its increasing trends; however, the profile of mortality from this type of cancer in less developed nations still shows a clear upward pattern.26,27 Our study reported a mortality of 14.5% in 2020 of patients treated at the INCan.

It is important to note that in Mexico most patients are diagnosed with late CS (III and IV),7,28 as shown by our results, where the diagnosis of the disease was made in most cases in stage IVB.

The prognosis is better for patients with early lesions compared to those with advanced CS of the disease.29 Treatment in late stages is complex, costly and with poor results;30 when it is surgical it becomes mutilating and deleterious, producing in the patients with harmful physical, nutritional, social and psychological consequences, in addition to affecting their quality of life.31,32 This is consistent with the main treatment performed at the INCan, which was surgery, the main ones being hemiglossectomy, hemimaxillectomy and hemimandibulectomy.

The Department of Oral Pathology of the Universidad Nacional Autónoma de México (UNAM) together with the INCan have been working on a National Registry of Oral Injuries (NROI) that by 2021 registers a total of 2090 oral cavity lesions detected, of which 137 were malignant in nature so they were referred to the INCan for specialized cancer treatment. In addition, this database places oral squamous cell carcinoma in 7th place, representing 2.3% of the total number of lesions detected to date.33 This reveals the important work that UNAM has been carrying out to obtain a database of data of the cases detected in its Department of Oral Pathology and which in turn are sent in time for specialized treatment to the INCan.

Due to the fact that post-surgical reconstruction was performed in only four patients, it is important to place more emphasis on protocolizing the cases in a multidisciplinary manner with the Departments of Plastic Surgery, Maxillofacial Prosthesis, Medical Oncology and Radiotherapy of our institute in order to restore the functionality and aesthetics lost by surgery and that allows them in the not too distant future to reintegrate them into society.



CONCLUSIONS

The incidence of OCC in the INCan during March 2018 and October 2020 is 15.3% (221 of 1,440 patients in total), being managed at the institute taking into account the CS at the time of diagnosis, as explained in the protocol of treatment of the Head and Neck Surgery Department for this type of patients.

Today, OCC continues to be a public health problem in Mexico, where the greatest predisposing factors for the disease are tobacco and alcohol consumption, so much more resources should be invested in prevention and not just in treatment, which in most cases, due to its detection in late CS, it becomes unsatisfactory for patients.

The importance of early diagnosis of the disease is essential, so health personnel (dentists and physicians with or without specialties) must have better training and awareness since their formation, in this way to prevent patients from going to highly specialized establishments seeking help to resolve their ailments in late CS, leading to a poor prognosis due to the few treatment options that can be offered.

The high percentage of abandonment of treatment of patients diagnosed with OCC leads us to carry out a constructive self-analysis that allows modifying health policies and the direction of resources, so that the medical specialties that have the capacity to dedicate themselves to the reconstruction of the defects that the surgery entails, can work and function efficiently.

This study has the limitations of not knowing the reason why patients chose to drop out of treatment, not knowing the reason for performing so little reconstructive surgery in our institute, as well as not knowing the definitive histopathological diagnoses of each of the malignant neoplasms of the oral cavity, which leads to the need for future studies that allow us to identify these shortcomings and provide more accurate results to establish policies that improve the follow-up and protocol of our patients.



ACKNOWLEDGEMENTS

To all the personnel that make up the Head and Neck Surgery Department of the INCan.


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AFFILIATIONS

1 Third-year resident of the Oral and Maxillofacial Surgery Specialty at the Universidad Nacional Autónoma de México, CDMX, Mexico.

2 Dental Surgeon of the Benemérita Universidad Autónoma de Puebla, México.

3 Physician specialist in Oncological Surgery of the Head and Neck of the Instituto Nacional de Cancerología de México.



Conflict of interest: The authors state that they have no conflict of interest.



CORRESPONDENCE

Oskar Eduardo Prada Vidarte. E-mail: eduline22@hotmail.com




Received: November 2021. Accepted: March 2022.

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