Analysis of Clinicopathological Parameters of Oral Squamous Cell Carcinoma in Different Age Groups

Abstract

Context: 

Oral squamous cell carcinoma (OSCC) is the most common malignancy of oral cavity. OSCC shows geographical variation with respect to the age, sex, site, and habits of the population. In general, OSCC is most commonly seen in men in the 6^th to 8^th decades of life and is rare in patients younger than 40 years. In recent years, it have been observed an increased incidence of OSCC in young individuals.

Aims: 

To compare and correlate the clinical parameters of OSCC in different age groups.

Settings and Design: 

Ninety histopathologically diagnosed cases with OSCC were included in our prospective study. These patients were divided into three groups: Group I: 30 patients below 40 years of age; Group II: 30 patients who were between 41 and 60 years of age; and Group III: 30 patients who were above 60 years of age.

Subjects and Methods: 

The relevant information regarding clinical parameters, i.e., age, sex, site of lesion, risk factors, duration of habit, tumor, node, metastasis (TNM) staging, and clinical diagnosis were collected and tabulated.

Statistical Analysis Used: 

The Chi-square test was applied to evaluate the significant difference among different age groups.

Results: 

There was a statistically significant difference in the duration of habit and TNM staging among different age groups.

Conclusions: 

OSCC in different age groups shows some differences as well as similarities in the parameters that were analyzed.

INTRODUCTION

Oral squamous cell carcinoma (OSCC) is the common type of head and neck cancer.[¹] In India, OSCC represents more than 45% of all malignancies reported.[²] OSCC is among the most common malignancy worldwide, with a peak incidence between the fifth and seventh decade of life.[²] Recent data have indicated that the increase of head and neck squamous cell carcinoma (SCC) incidence in a younger age group (younger than 45 years old) compared to patients above 45 years. Males are affected twice as frequently as females and the majority of patients are more than 45 years old.[³]

OSCC in young patients may be a distinct disease entity on the basis of different biological behaviour and etiological factors.[⁴] This has generally been attributed to the indiscriminate substance abuse particularly the use of tobacco, smoking, betel quid chewing, and alcohol consumption over a considerable period of time. However, in many cases, a lack of significant habits in some young patients provoked many authors to postulate factors such as genetic factors, immune deficiency, dietary factors, viruses like herpes simplex virus and human papilloma virus (HPV) in the aetiology of these cancers.[⁵] The lag time period between the exposure to carcinogen and OSCC development in young patients may be short compared to the classical lag time period in older OSCC patients.[⁶]

The risk factors of OSCC are complex and multifactorial. It has been observed that oral cancer in young people is increasing in India due to chewing pan masala products containing tobacco.[⁴] Despite the demonstration by some studies,[⁴] that the same etiological factors are present in younger and older patients, the possibility of the existence of a carcinogenic action of tobacco and alcohol in the young patient is low, given that in this group exposure time would be relatively short for the establishment of a cause-effect relation.[⁴]

Literature shows biased data regarding the aggression and prognosis of OSCC in young patients and the general view is that it is more aggressive and has a worse prognosis than older patients.[⁷] However, in a few studies, it has been found that the survival rate of patients below 40 years of age is better than that of patients above 40 years of age.[⁸] Whereas other authors have suggested that young patients have a similar clinical course and their survival rate is no different from other age groups.[⁹¹⁰] Very few studies have analyzed the demographic, etiological, and histopathological data of OSCC among different age groups. Thus, the purpose of this study to evaluate the demographics, risk profile, and clinicopathological features of OSCC in different age groups.

SUBJECTS AND METHODS

Ethical approval from the Institutional Ethical Committee was obtained. Informed consent from all the patients was obtained for the present study. The study group consisted of patients with OSCC among different age groups who reported to the outpatient department of Institute Hospital and Regional Cancer Hospital whose demographic data could be procured provided along with complete records providing relevant clinical details.

The total number of patients in our prospective study was 90. Patients histopathologically diagnosed with OSCC were included in the study. These patients were divided into three groups: Group I: 30 patients below 40 years of age; Group II: 30 patients who were between 41 and 60 years of age; and Group III: 30 patients who were above 60 years of age. Patients below 40 years of age were considered as “Young patients,” patients aged between 41 and 60 years considered as “Middle aged patients” and patients who were above 60 years of age were considered as “Old patients.” The inclusion criteria include patients whose complete records were available providing relevant clinical details and only primary tumors diagnosed with OSCC were included.

The relevant information regarding clinical parameters, i.e., age, sex, site of lesion, risk factors, duration of habit, tumor, node, metastasis (TNM) staging, and clinical diagnosis was collected and tabulated. Staging of OSCC was done according to the staging system suggested by American Joint Committee for Cancer Staging (AJCCS) and End Results Reporting known as the TNM system.[¹¹] All the data were tabulated in an Excel sheet and the statistical analysis was done using statistical software SPSS version 24.0 (IBM Corp., Armonk, USA). The Chi-square test was applied to evaluate the significant difference of clinical parameters among different age groups. Results with “P < 0.05” were observed to be statistically significant at 95% of confidence interval.

RESULTS

The clinical parameters, i.e., age, sex, site of lesion, risk factors, duration of habit, TNM staging, and clinical diagnosis were collected and tabulated, as shown in [Tables 1-7]. The present study comprised of total 90 cases, 70 (77.77%) were male and 20 (22.22%) were female. In this study, we observed that there was a statistically significant difference in the duration of habit and TNM staging among different age groups. Maximum number of patients (63.33%) of Group III individuals had duration of habit above 10 years. The percentage of the patients in Group I developing cancer after a shorter duration (6–10 years) of exposure to risky habits was higher compared to the Group III (53% in young group and 30% in older group) which shows statistically significant difference in different age groups [P = 0.001, Table 3]. On comparison of staging among different age groups, Group I patients shows (86.66%) in Stage III followed by (10%) in Stage I and (3.33%) in Stage II which was statistically significant [P = 0.035, Table 7]. Furthermore, we did not found a statistically significant difference between other parameters (P > 0.05).

Table 1: Gender distribution in different age groups

Table 2: Comparison of risk factors between different age groups

Table 3: Duration of habits in different age groups

Table 4: Site distribution in different age groups

Table 5: Comparison of T stage in different age groups

Table 6: Comparison of N stage in different age groups

Table 7: Tumor, node, metastasis staging in different age groups

DISCUSSION

Head and neck cancer, comprising OSCC, is the sixth leading cancer worldwide. SCC is a well-recognized malignant neoplasm that is responsible for more than 90% of oral malignancies.[¹²] According to the World Health Organization, around 657,000 new cases of cancers of the oral cavity and pharynx each year, and more than 330,000 deaths.[¹³] The clinical presentation of OSCC can vary extensively and the initial tumors can often be subtle and asymptomatic, which may characterize a diagnostic challenge in this early clinical stage.[¹⁴] Various studies showed a rising incidence of OSCC in younger patients with a different etiological association for the progression of cancer.[¹⁵] Hence, the present study had an objective to conduct a comparative analysis on the clinicopathological aspects OSCC in different age group patients to provide more in-depth knowledge of the disease at the younger population.

OSCC usually occurs in the elderly men over 50 years of age. It is seldom occurs in patients who are <40 years old (0.4%–5.5%).[¹⁶] A high prevalence of smokeless tobacco use has led to an increasing incidence of OSCC in younger patients with combination of delayed presentation has made oral cancer a major mortality rate in India.[¹⁷] However, many cases are often misdiagnosed and inappropriately treated leading to delay in definitive treatment.[¹⁸]

The clinical parameters, i.e., age, sex, site of lesion, risk factors, duration of habit, and TNM staging were recorded. Out of 90 cases of OSCC included in the study among different age groups, we observed a definite male predominance (83.33%) among Group III followed by (80%) in Group I and (70%) in Group II. The youngest patient in our study was 23 years old and the oldest was 82 years old. We did not find a statistically significant difference between different age groups [P = 0.434, Table 1].

The preponderance of males in all the age groups is primarily due to the predominance of adverse habits such as tobacco, smoking, tobacco in combination with gutkha and alcohol consumption among males. These results are in accordance with Iype et al.,[⁵] Iamaroon et al.,[¹⁹] Sasaki et al.[²⁰] and Acharya and Tayaar[³] who observed that males were more commonly affected than females in younger age group. It is well known that adult people with smoking history are at a great risk for OSCC development. This demographic changing in the tumor incidence is not well apparent because the long period of smoking habit (that has been seen in adult patients) is uncommon in young individuals. So, tobacco smoking may not be an important factor in the tumor development in young patients or it may be reflected as a cofactor with other parameters such as viruses including HPV16.[²¹] Most of the studies showed a male predominance which can be recognised to the socioeconomic norms favouring the easy accessibility of tobacco products to the male population along with the easy acceptance of habits by the same.[¹³] In contrast, Kuriakose et al.[⁷] reported a slight predominance in females i.e., 20 (54%) out of 37 patients in the younger age group. These variations may be due to differences in geographic locations and social lifestyles between populations. The possible risk factors in young patients with OSCC seem to present a different pattern from that of older patients. In the present study, we found that tobacco chewing habit was most common in Group II and Group I accounting for (50%) and (43.33%) respectively. However, in the Group III tobacco in combination with gutkha chewing habit was most common with (33.33%) followed by (23.33%) in Group I and (16%) in Group II. In Group II and Group III, only (10%) had tobacco and alcohol habit. However, the dissimilarity in the risk factors was not found to be statistically significant among different age groups [P = 0.456, Table 2].

In the present study, the duration of habit varied from no deleterious habit, minimum of 1–5 years, 6–10 years and above 10 years. We observed that the maximum number of patients in Group III (63.33%) and (50%) in Group II had duration of habit above 10 years. The percentage of the patients in Group I developing cancer after a shorter duration (6–10 years) of exposure to risky habits was higher compared to the Group III (53% in Group I and 30% in Group III respectively) which was found to be statistically significant [P = 0.001, Table 3]. This finding was in accordance with the study performed by Acharya and Tayaar[³] who stated that younger patients develop oral cancer after a shorter duration of exposure to carcinogen (1–10 years) compared to older patients (61% vs. 21% respectively) which has led to the assumption that young patients may have other factors which make them susceptible to developing cancer.

On analyzing the site of the lesion, buccal mucosa (58.88%) was found to be the predominant site for the occurrence of OSCC followed by alveolar mucosa (18.88%), tongue (17.77%) in different age groups. We observed that buccal mucosa was involved in (63.33%) of both Group I and Group III followed by (50%) in Group II [Table 4]. This site specific occurrence can be attributed to the prevalent habit of tobacco and quid chewing which is placed in the buccal commissure. This causes constant irritation of buccal mucosa by the quid ingredients along with the release of detrimental carcinogens. Our results were in accordance with the study conducted by Acharya and Tayaar[³] who stated that buccal mucosa (47%) was the most commonly affected site followed by the tongue (22.78%) in younger patients. Gupta and Nandakumar[²²] reported that oral cancers in India are due to the use of smokeless tobacco and are site specific that is cancer is common at the site of placement of tobacco containing quid. High incidence of the cancers of buccal mucosa and alveolar mucosa in our patients may be due to the habit of quid placement in the gingivobuccal sulcus. Buccal mucosa was the most common site involved which was consistent with many other studies.[²²²³²⁴] This was followed by gingiva, tongue, palate, labial mucosa, and floor of the mouth.[¹³]

All the cases of OSCC were clinically staged according to the criteria given by AJCCS known as the TNM system.[¹¹] The TNM system has been used for decades in an attempt to predict clinical behaviour and appropriate therapy for OSCCs. On comparison of primary tumor size in different age groups, we found that T2 tumor size was more commonly seen in Group II and Group III (63.33% and 56.66% respectively) and (30%) in Group I whereas T3 tumor size (40%) was found more commonly in Group I as compared to only (30%) and (20%) in Group III and Group II respectively. This revealed that younger patients had a tendency for larger lesions in the oral cavity at initial presentation. However, there was no significant difference [P = 0.089, Table 5]. Similarly, Acharya and Tayaar[³] also found no significant difference with respect to tumor size between younger and older group of patients. Saeed and Abdullah[²¹] also revealed that advanced tumor stage was highly recorded for young patients in comparison to adult patients but it was statistically nonsignificant. Some studies recommended that the OSCC in young patients have more aggressive behaviour. Considering the important role of immune response in control to tumor cell proliferation, lower immune response in younger patient's possibly reason for more aggressive behaviour in this age group.[²¹²³]

When the nodal status was compared among different age groups, maximum number of cases were in N1 stage (96.66%) among Group II, followed by (86.66%) in Group I and (80%) in Group III which was not statistically significant [P = 0.140, Table 6]. Furthermore, stage wise comparison noted that in Group II maximum number of patients with Stage III (96.66%) followed by (3.33%) in Stage II, whereas the number of patients in Group III were distributed between Stage III (80%), Stage II (16%) and Stage I (3.33%). Group I patients showed (86.66%) in Stage III followed by (10%) in Stage I and (3.33%) in Stage II. When these three groups were compared statistically, we found a statistically significant difference [P = 0.035, Table 7]. Our results were in accordance with the study conducted by Kuriakose et al.[⁷] who noted that majority of the tumors in younger and older age groups were in Stage III. Advanced stage tumors (Stage III and Stage IV) were the most frequent presentation in both young and old group of patients, with an average percentage of 54% and 52%, respectively. The little rise of advanced tumors in the young group may be due to delay in consultation or late diagnosis since the expectation of OSCC was not as much in nonsmoker of the younger group in general.[²⁵²⁶] However, the clinicalstage distribution difference was not statistically significant in the selected groups (P > 0.05).

This study revealed that OSCC in different age groups shows some differences as well as similarities in the parameters that were analysed. Although exposure to behavioural risk factors was similar, in younger persons these deleterious habits evoked an immediate response causing the disease. In this study, the duration of habit and TNM stage was found to be statistically significant among different age groups.

CONCLUSIONS

This is a preliminary study, so a study with a large sample size is mandatory. Since the study was carried out at our institute and a few cancer centres, it represents a specific patient population and not a community as a whole therefore, it constituted a relatively smaller sample size. In future, multicentric studies with a larger sample size are required to investigate possible potentiating and confounding factors including genetic factors, nutritional deficiencies and immune status to predict the prognosis and survival rate among patients of different age groups.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.