Head and neck cancer in the South West of England: influence of socio-economic status on incidence and second primary tumours

Oral tongue squamous cell carcinomas in young patients according to their smoking status: a GETTEC study

BACKGROUND

Incidence of oral tongue squamous cell carcinoma (OTSCC) is increasing, especially in young adults, despite decreasing tobacco and alcohol consumption.

METHODS

This multicentric retrospective study of 185 young adults with OTSCC (median follow-up 43 months), investigated risk factors, tumour characteristics and oncological outcomes according to the smoking status.

RESULTS

Overall, 38% of patients were smokers (S). Non-smokers (NS) were significantly younger than S. Sex ratios were 1.1 for N and 1.8 for S. NS patients were less frequently cannabis or alcohol users than S, but were more likely to have a history of leukoplakia. Second primaries were observed in NS (4.4%) and in S (12.7%). Despite more frequent local relapse in NS (p = 0.018), there was no difference in diagnostic stage and overall survival between groups.

CONCLUSION

OTSCC affects differently young S and NS patients suggesting the existence of a specific clinical entity of OTSCC in non-smoking young adults.

Comparison of the diagnostic yield of medical and dental referrals an oral and maxillofacial 2 weeks rule clinic

BACKGROUND

The 2 weeks wait clinic initiative is used as a fast track referral process, to assess patients with suspected cancer. The United Kingdom's National Institute of Clinical Excellence has issued guidelines for which patients should be referred to this service for suspected oral, head and neck cancers. Both general medical practitioners (GMPs) and general dental practitioners (GDPs) can refer to this service.

OBJECTIVE

To ascertain how many of the 2 weeks rule referrals resulted in positive oncology cases. Also, to compare the diagnostic yield of cancer diagnoses between referrals from GMPs and GDPs.

METHODS

Collection and analysis of 2 weeks rule referrals and the clinical outcome for these patients, to an oral and maxillofacial surgery unit for a 6 months period.

RESULTS

Overall, 65% of the patients seen in the clinic were referred by a GMP and 12.5% of these had a diagnosis of cancer. The remaining 35% were referred by a GDP and 10% of these had cancer. There was no statistically significant different diagnostic yield between the two groups.

CONCLUSION

A significant number of patients with confirmed cancer are referred from medically qualified practitioners. Further awareness and education of oral, head and neck cancers is warranted in this group, including at an undergraduate level.

Head and neck cancer in South East England between 1995-1999 and 2000-2004: An estimation of incidence and distribution by site, stage and histological type

Population-based data on head and neck cancer (HNC) stage and histological type are poorly described for England; these data are essential for clinical management and research. The aim of this study was to describe the distribution and incidence of all HNC and selected anatomical sites by sex, age, stage and histological type using a population-based cancer registry in South East England, and determine if the incidence changed between 1995-1999 and 2000-2004. We identified all HNC cancer cases registered by the Thames Cancer Registry for 1995-1999 and 2000-2004. Frequency distributions and age-standardised incidence rates were calculated by sex, age, stage and histological type and trends in incidence between the two time periods were described using incidence rate ratios and 95% confidence intervals. A total of 8700 HNC cases were reported in 2000-2004, representing an age-standardised incidence rate of 8.59 per 100000, which did not change significantly from 1995-1999. The three commonest HNC sites were intra-oral cavity, larynx and tonsil. Males were two to six times as likely as females to be diagnosed with HNC and there was a trend toward younger age at diagnosis over time. Significant increases in the incidence rate of intra-oral cavity cancer for both sexes and tonsillar cancer among males were observed. Conversely, laryngeal cancer incidence decreased over time. Staging data was only available for about 40% of HNC cases. Seventy six percent of HNC cases were squamous cell carcinomas. Trends in incidence varied between HNC sites, highlighting the importance of presenting data for individual HNC sites. The high proportion of unstaged cancers may result from incomplete recording in medical records; thus, the reporting of staging data should be made a priority.

Trends in the epidemiology of larynx and lung cancer in south-east England, 1985-2004

We analysed data on 8987 larynx and 174060 lung cancer patients diagnosed between 1985 and 2004, of which 17.3% of larynx and 35.5% of lung cancers were in females. The age-standardised rates for each cancer declined in both sexes, but since the 1990s, the rates in females over 70 years of age have been diverging.

A survey of general dental practitioners in Merseyside regarding urgent appointments and suspected cancer referrals

AIMS

The aims of this study were to investigate the current situation regarding unregistered patients in the Mersey region who seek an urgent dental appointment, and to gather information on suspected oral cancer cases seen by dentists in the previous two years and about how such cases are referred.

METHODS

The survey took the form of a short questionnaire sent in May 2006 to all general dental practitioners (GDPs) in the Mersey region who were registered with the regional postgraduate dental office.

RESULTS

A total of 904 GDPs were identified and 572 (63%) returned completed survey responses. Half (276/572; 48%) reported that they could see new patients urgently under the National Health Service (NHS) and two-thirds (365/571; 64%) that they could see them either under the NHS or privately. Nineteen per cent reported that they would not see any new patients. Those in the most deprived areas were more likely to see a patient on the NHS. The waiting time for an urgent appointment, if it was offered, was over one week for nearly one-third (32%) of the dentists offering NHS care. Most dentists (84%) said that a patient suspected of having oral cancer would be referred the same day as the decision had been made to refer.

CONCLUSION

Access to dental care has been a high-profile issue over the past few years. This survey indicated that in Merseyside, just under half of the dentists who responded were willing to see new patients with urgent problems under the NHS. It is suggested that this difficulty in access, together with some reported delays in obtaining appointments and the methods of onward referral, may cause additional barriers to early detection of oral cancer, especially for those in the most at-risk groups, who are also very frequently hard to reach.

DNA ploidy, proliferative capacity and intratumoral heterogeneity in primary and recurrent head and neck squamous cell carcinomas (HNSCC) – Potential implications for clinical management and treatment decisions

Despite new diagnostic and therapeutic strategies (combined radiochemotherapy, EGFR antibody Cetuximab), the prognosis of head and neck squamous cell carcinoma (HNSCC) is still poor and more information regarding prognosis is essential to establish earlier and better treatment options. To elucidate the role of DNA ploidy and cellular proliferation, resected tumors of 48 patients with primary or recurrent HNSCC were analyzed by flow cytometry and in vitro-5-bromodeoxyuridine incorporation (BrdU). The results were compared with histopathological findings such as tumor size, lymph node involvement and tumor differentiation. To assess the influence of intratumoral heterogeneity of these biological parameters, multiple biopsies (>3) were analyzed by flow cytometry and BrdU-incorporation in 12 larger (>4 cm diameter) tumors. BrdU-labeling index (LI%) was significantly higher in aneuploid HNSCC and correlated significantly with poor histologic differentiation of the analyzed tumor tissues (P<0.001). Furthermore, a trend for higher LI% in nodal positive tumors was observed. Aneuploid HNSCC showed significantly more often tissue dedifferentiation (P=0.049) and in most cases an advanced tumor stage, especially in tumors with biclonal cell lines. Lymph node involvement was also seen more often in aneuploid and undifferentiated tumors. As in aneuploid tumors recurrent HNSCC showed in most cases a higher LI% and poor tissue differentiation, but as a result of the small collection of samples there was no correlation between aneuploidy and tumor recurrence. To proof the robustness of the acquired data and to estimate the influence of intratumoral heterogeneity to ploidy and LI% multiple biopsies were analyzed in larger tumors. Using a specific statistical algorithm a secure estimation of ploidy and LI% was possible by a single biopsy in these tumors. These findings indicate aneuploidy and proliferative activity as important findings for malignant progression in HNSCC. An estimation of these biological parameters may be useful for identification of patients with high risk for lymph node involvement or tumor recurrence and pre-treatment can be performed by a single biopsy. As a conclusion, these patients may benefit from more aggressive treatment.

An assessment of deprivation as a factor in the delays in presentation, diagnosis and treatment in patients with oral and oropharyngeal squamous cell carcinoma

This study explores the relationship between deprivation and patient and professional delays in presentation and treatment of oral and oropharyngeal squamous cell carcinoma. The cohort comprised 559 consecutive previously untreated patients presenting to the Regional Maxillofacial Unit, Liverpool from 1 January 1992 to 31 December 2002. All had primary surgery. The head and neck database was searched together with a review of casenotes. Deprivation was scored using the Index of Multiple Deprivation 2000 (IMD 2000) from patient post codes. PATIENT DELAY: Similar numbers of patients presented to general dental and general medical practitioners. The predominant presenting symptom was either an ulcer or swelling and 38% had symptoms for 3 or more months. Patients with shorter duration of symptoms tended to be smokers, drinkers, with lower gum and floor of mouth tumours, and more advanced disease. Primary health professional, patient age, gender, marital status, and deprivation showed no obvious correlation with patient delay. PROFESSIONAL DELAY: For 78% of patients a referral letter from GPs and GDPs was sent to the MFU on the same day as the primary consultation. There was on average about 3 weeks from referral to definitive diagnosis and about another 3 weeks before having surgery. Professional delay was shorter in patients with more advanced tumours and for patients living in the most deprived of wards. Deprivation did not seem to significantly lengthen presentation or referral however it may be that it is associated with more rapidly growing tumours.

Area deprivation and oral health in Scottish adults: a multilevel study

OBJECTIVES

To explore the association between area deprivation and adult oral health.

METHODS

Multilevel regression analysis of data taken from the 1998 Adult Dental Health Survey in the UK comprising 632 participants living in 346 households located in 31 postcode sectors in Scotland. Three oral health outcomes were investigated: number of sound (including restored) teeth; has one or more unsound teeth; has periodontal pocketing 4 mm or more in one or more teeth.

RESULTS

In the most deprived areas, individuals had a mean of 4.6 fewer sound teeth than those in the least deprived areas. The difference in normalised number of sound teeth between least and most deprived areas was -0.707 (95% CI -1.164, -0.250), P = 0.024. After adjusting for age, sex, qualification status, head of household social class and household income, the estimated difference was -0.238 (-0.591 to 0.115) (P = 0.164). Area deprivation was not associated with having one or more unsound teeth or periodontal pocketing 4 mm or more in one or more teeth.

CONCLUSIONS

There is a univariate association of area deprivation with the number of sound teeth. This association is largely explained by household and individual level socioeconomic variables. A small area deprivation effect cannot be excluded in these data. The findings challenge current understanding of the relationship between area deprivation and oral health. Further multilevel research exploring the relationship between area deprivation and oral health is required using a larger sample and a prospective longitudinal design.

Multiple primary tumors in patients diagnosed with hypopharyngeal cancer

OBJECTIVE

There have been few series to report on the incidence of multiple primary tumors associated with hypopharyngeal cancer. A unique consecutive patient group in a closed community who were treated by a single surgeon was available. The incidence and effect of multiple primary tumors were unknown.

STUDY DESIGN

We sought to assess (1) the incidence of multiple primary tumors among patients with hypopharyngeal cancer who were treated at a tertiary center, (2) the incidence of synchronous and metachronous tumors, and (3) the location of these multiple primary tumors and their effect on patient survival.

METHODS

We conducted a retrospective study of case notes of 150 consecutive patients with hypopharyngeal malignancy treated by a single surgeon between 1983 and 1998. Information was compiled from the patients' medical records and death data from the Family Health Services Authority.

RESULTS

Thirty-four patients had multiple primary tumors (22.6%). There were 22 men and 12 women; piriform fossa tumor was seen in 21 men and 6 women, and postcricoid space tumor was seen in 6 women and 1 man. Second primary tumors were synchronous in 7 patients, subsequent to hypopharyngeal tumor in 5 patients, and antecedent to hypopharyngeal tumor in 14 patients. Eight patients had 2 primary tumors, of which 4 were synchronous, 4 were subsequent, and 8 were antecedent to hypopharyngeal malignancy. On the last review (2001), 3 patients were alive, and 31 had died: 17 had died from primary malignancy, 11 from another malignancy, and 3 from unrelated causes.

CONCLUSION

The presence of second primary tumors in hypopharyngeal cancer is higher than previously reported, and their presence had a significant effect on the patients' survival.

Oral cancer: material deprivation, unemployment and risk factor behaviour--an initial study

Regional variations in the incidence of oral cancer may be related in some cases to material deprivation. The main aim of this study was to identify in cases (and controls matched for age and sex) an index of material deprivation, employment history, smoking and alcohol habits. This prospective study comprised 100 subjects in each group and was questionnaire based. Previous studies in relation to material deprivation in oral cancer have been population based. There was a statistically significant trend for patients to come from the most deprived groups. Sixty-six per cent of the cases had experience of long-term unemployment. Although a high proportion, this was not statistically significant after multi-variable analysis due to the confounding effects of smoking and alcohol use. Such a high proportion of cases with a history of long-term unemployment requires further study to examine in detail if there is a definite link with oral cancer once the confounding effects of smoking and alcohol are removed.

Effect of deprivation on survival of patients with head and neck cancer: a study of 20,131 cases

There is increasing evidence that, for many cancers, the survival of socioeconomically deprived patients is worse compared with those who are more affluent. This study provides additional evidence that this is true for patients with head and neck cancers. However, the detrimental effects of deprivation were not found to be lifelong, and in this study, were confined to the first 12-18 months after diagnosis. After this there were no significant deprivation-associated effects on subsequent survival. The reasons for the initial increased mortality in the deprived are not clear but may be related to more advanced stage, more biologically aggressive cancers, greater co-morbidity or worse treatment.

Head and neck oncology: the UK experience. Who is publishing what?

Using the MEDLINE database (OVID), a retrospective review of the UK literature on head and neck oncology was performed for the period 1994-2000, each publication being categorised by department and first author. Tumours almost exclusively managed by general surgeons, cardiothoracic surgeons and neurosurgeons were excluded. In the years 1994 to 2000, there were a total of 120 UK publications, 72% of which came from non-academic NHS units; 23% of the publications were from ENT units, 23% from oral and maxillofacial (OMF) surgery units and 18% from plastic surgery units. The majority of plastic surgery publications described reconstructive techniques, whereas a wider range of topics was observed in the publications by ENT and OMP surgeons. Several irregularities in the MEDLINE database were discovered and are discussed. The findings of this study may be relevant to the future planning of head and neck oncology services.

Eliciting views of patients with head and neck cancer and carers on professionally derived standards for care

OBJECTIVES

To examine views of patients and carers on the process of care for people with head and neck cancer; to assess whether focus groups are useful in this setting; to compare priorities and standards identified with those published by healthcare professionals; and to incorporate the expressed views into existing national standards.

DESIGN

Multicentre study of nine regional focus groups.

SETTING

Area covered by two regional health authorities.

PARTICIPANTS

40 patients who had had head and neck cancer and 18 carers.

MAIN OUTCOME MEASURES

Views of individuals and groups on standards. Applicability of the method for patients whose appearance and ability to communicate was altered and for recently bereaved carers. Ease of incorporation of views into national and regional standards.

RESULTS

Patients and carers participated in discussions on all the principal questions. Opinions were expressed on waiting times, information available to patients, coordination of care, and crisis management. Professionally derived standards were substantially improved by the incorporation of the views of patients and carers. There were no technical problems in carrying out this study on patients with communication difficulties or altered appearance nor with recently bereaved carers. Occasionally, participants said that the meetings were therapeutic.

CONCLUSIONS

Professionally facilitated and analysed focus groups are effective in assessing views of patients with cancer and carers on professionally derived standards for care and can be applied in settings traditionally viewed as difficult. Views expressed by patients and carers are powerful motivators for change in the delivery of cancer care.

Treatment of upper aerodigestive tract cancers in England and its effect on survival

The evidence base for head and neck cancers is low with relatively few randomized controlled trials of the two main treatments, surgery and radiotherapy. The aim of the study was to investigate the patterns of surgery and radiotherapy treatment for head and neck cancers in three large areas of England and to investigate their effects on survival. This was a retrospective study of 13510 cases of head and neck cancers (ICD10: C00-C14, C30-C32) diagnosed and treated from 1984 to 1992 in England. We undertook multivariate analyses of survival using a step-wise Cox proportional hazard model and Kaplan-Meier analysis. There were regional variations in the treatments given to patients. Four in ten patients did not receive currently recommended treatments. In multivariate analyses treatment content and timing had an independent effect on survival. Better survival was associated with surgery for mouth cancers, radiotherapy for laryngeal cancers and combined treatment for pharyngeal cancers independent of tumour and demographic factors. Further research is needed to investigate the findings of this study through large randomized controlled trials and multi-centre audits.

Incidence of and survival from upper aerodigestive tract cancers in the U.K.: the influence of deprivation

The aim of the study was to investigate the effect of social deprivation on the incidence of and survival from upper aerodigestive tract (UAT) cancers in the U.K. Incidence was calculated on 25,903 cases of malignant upper aerodigestive tract cancers collected from four cancer registries in the U.K. for the period 1984-1993. A Cox proportional hazard model was used to determine the influence of deprivation, measured in Carstairs quintiles for crude and cause-specific survival on 17,393 of these cases. Patients with UAT cancers who were younger, males or of South Asian origin were more likely to live in a deprived area than in an affluent area. The incidence of UAT cancers in a district was correlated with deprivation score for the district for both men (r = 0.78) and for women (r = 0.60). People who lived in deprived areas had a relative risk of 1.25 (95% confidence interval (CI): 1.15-1.35) of dying from their cancer and of 1.24 (95% CI: 1.13-1.35) of dying from all causes compared with people who lived in affluent areas. People living in deprived areas were more likely to get UAT cancer and were more likely to die from their cancer than people living in affluent areas.