Impact of Nutritional Status on Survival in Head and Neck Cancer Patients After Total Laryngectomy

circHIPK2 promotes malignant progression of laryngeal squamous cell carcinoma through the miR-889-3p/MCTS1/IL-6 axis

Laryngeal squamous cell carcinoma (LSCC) is a common malignant tumor of the head and neck with a poor prognosis. The role of circRNAs in LSCC remains largely unknown. In this study, quantitative real-time PCR (qRT-PCR), Sanger sequencing and fluorescence in situ hybridization were undertaken to detect the expression, localization, and clinical significance of circHIPK2 in LSCC tissues and TU686 and TU212 cells. The functions of circHIPK2 in LSCC were explored through proliferation analysis, EdU staining, colony formation assay, wound healing assay, and Transwell assay. The regulatory mechanisms underpinning circHIPK2, miR-889-3p, and MCTS1 were investigated using luciferase assay, Western blotting, and qRT-PCR. We found that LSCC tissues and cells demonstrated high expression of circHIPK2 that was closely associated with the malignant progression and poor prognosis of LSCC. Knockdown of circHIPK2 inhibited the proliferation and migration of LSCC cells in vitro. Mechanistic studies showed that circHIPK2 competitively bound to miR-889-3p, elevated MCTS1 level, promoted IL-6 secretion, and ultimately accelerated the malignant progression of LSCC. In conclusion, an axis involving circHIPK2, miR-889-3p, MCTS1 and IL-6 regulates the malignant progression of LSCC. circHIPK2 expression may serve as a novel diagnostic and prognostic biomarker for LSCC.

Geriatric Nutritional Risk Index and Postoperative Outcomes Following Head and Neck Cancer Surgery

BACKGROUND

The geriatric nutritional risk index (GNRI) is a tool to assess preoperative nutritional status that can be calculated simply based on height, weight, and serum albumin. This study assesses the utility of GNRI in predicting postoperative complications in patients undergoing major head and neck cancer (HNC) surgery.

METHODS

Retrospective review of the 2016-2020 National Surgical Quality Improvement Program database. Patients were categorized into GNRI > 98 (normal nutritional status), GNRI 92-98 (moderate malnutrition status), and GNRI < 92 (severe malnutrition status). Univariable and multivariable binary logistic regression analyses were performed.

RESULTS

Sixteen thousand seven hundred eight-nine patients undergoing HNC resection were included. On multivariable analysis, moderate and severe malnourishment based on GNRI remained significantly associated with any surgical complication, any medical complication, any complication, Clavien-Dindo grade IV complications, and 30-day mortality.

CONCLUSIONS

GNRI may have utility as a potentially modifiable preoperative prognostic factor that can be optimized to improve complications and mortality following HNC resection.

LEVEL OF EVIDENCE

Level 4.

Plasma Circulating lncRNAs: MALAT1 and NEAT1 as Biomarkers of Radiation-Induced Adverse Effects in Laryngeal Cancer Patients

Background: The majority of head and neck cancers (HNCs) occur in the larynx. In clinical practice, adverse effects are frequently observed in laryngeal cancer (LC) patients undergoing radiotherapy (RT). Therefore, investigating markers that can predict these unfavorable events is of interest. Long non-coding RNAs (lncRNAs) have emerged as potential biomarkers for the early identification of patients susceptible to post-RT toxicity. MALAT1 and NEAT1 regulate various cellular processes, the inflammatory response, and resistance to anti-cancer treatments; however, their impact on the portability of post-RT adverse effects remains unknown. The aim of this study was to evaluate the clinical value of two plasma-circulating lncRNAs, MALAT1 and NEAT1, as predictive biomarkers for post-RT adverse effects in LC patients. Methods: The expression levels of the studied lncRNAs were determined using real-time quantitative reverse transcription PCR (qRT-PCR) in plasma samples obtained from 70 LC patients before the initiation of RT. These levels were then correlated with patient outcomes. Results: A low expression of MALAT1 was associated with a significantly higher probability of anemia, liver failure, and severe malnutrition (OR = 5.36; p = 0.040, OR = 6.07; p = 0.037, OR = 9.75; p < 0.001, respectively) after the completion of RT. Similarly, patients with low NEAT1 expression had a significantly higher risk of anemia, liver failure, and mild or severe malnutrition (OR = 5.26; p = 0.020, OR = 5.70; p = 0.016, OR = 13.09; p = 0.002, respectively). Simultaneous lower expression levels of both lncRNAs were significantly associated with shorter median overall survival (OS) in RT-treated LC patients (HR = 5.44; p = 0.001). Conclusions: The analysis of MALAT1 and NEAT1 expression indicates clinical utility in predicting toxic events induced by RT-based therapy.

Hypoalbuminemia and Postoperative Outcomes Following Major Salivary Gland Resection

Objective

Hypoalbuminemia (HA) is a proxy for malnutrition that has been associated with postoperative complications in several surgical subspecialties. This study investigates the association between pre-operative HA and complications following major salivary gland (MSG) resection.

Methods

Patients undergoing outpatient, elective MSG resection were extracted from the 2005 to 2020 National Surgical Quality Improvement Program database. Demographics and comorbidities were compared between HA (preoperative serum albumin < 3.5 g/dL) and non-HA cohorts. To determine associations between albumin status and postoperative complications, univariate and multivariable binary logistic regression analyses were performed.

Results

A total of 5774 patients undergoing MSG resection were included, of which 321 (5.6%) had preoperative HA. HA was associated with older age on univariate analysis (65.2 vs. 60.2 years, p < 0.001). Multivariable analysis found HA to be independently associated with any surgical complication (OR 2.03, 95% CI 1.09-3.56, p = 0.019) and length of stay (LOS) ≥ 90th percentile (OR 1.58, 95% CI 1.04-2.38, p = 0.032).

Conclusion

Preoperative HA may be a poor prognostic factor associated with an increased risk of surgical complications and prolonged LOS among patients undergoing MSG resection.

Level of Evidence

4.

Prediction of the need of enteral nutrition during radiation therapy for head and neck cancers

INTRODUCTION

Patients with a head and neck (HN) cancer undergoing radiotherapy risk critical weight loss and oral intake reduction leading to enteral nutrition. We developed a predictive model for the need for enteral nutrition during radiotherapy in this setting. Its performances were reported on a real-world multicentric cohort.

MATERIAL AND METHODS

Two models were trained on a prospective monocentric cohort of 230 patients. The first model predicted an outcome combining severe or early fast weight loss, or severe oral intake impairment (grade 3 anorexia or dysphagia or the prescription of enteral nutrition). The second outcome only combined oral intake impairment criteria. We trained a gradient boosted tree with a nested cross validation for Bayesian optimization on a prospective cohort and predictive performances were reported on the external multicentric real-world cohort of 410 patients from 3 centres. Predictions were explainable for each patient using Shapley values.

RESULTS

For the first and second outcome, the model yielded a ROC curve AUC of 81 % and 80%, an accuracy of 77 % and 77 %, a positive predictive value of 77 % and 72 %, a specificity of 78 % and 79 % and a sensitivity of 75 % and 73 %. The negative predictive value was 80 % and 80 %. For each patient, the underlying Shapley values of each clinical predictor to the prediction could be displayed. Overall, the most contributing predictor was concomitant chemotherapy.

CONCLUSION

Our predictive model yielded good performance on a real life multicentric validation cohort to predict the need for enteral nutrition during radiotherapy for HN cancers.

Prognostic value of serum 25-hydroxyvitamin D levels and malnutrition status on postoperative complications in patients following laryngectomy with neck dissection

BACKGROUND

Postoperative complications (PCs) following total laryngectomy remain a significant challenge, with recent investigations directed toward the impact of nutrition status and vitamin D deficiency.

OBJECTIVES

To elucidate the association between preoperative vitamin D level status, malnutrition risk score, and surgical and survival outcomes in patients with advanced laryngeal cancer following total laryngectomy.

STUDY DESIGN

Prospective cohort study.

METHODS

Sixty-four patients with advanced laryngeal carcinoma treated with total laryngectomy were included in the study. Serum levels of 25(OH) D3 were measured employing a commercial chemiluminescent immunoassay kit, while nutrition status was evaluated using the nutrition risk index (NRI) and Malnutrition universal screening tool (MUST).

RESULTS

The mean serum 25(OH) D level was 37.1 ± 19.4 nmol/L (range 11.0-100.6 nmol/L), with 47% of patients exhibiting vitamin D deficiency and 31% displaying insufficiency. Medium/high MUST score had 53% of patients, and moderate/severe NRI was verified in 48% of patients. Univariate logistic regression analysis identified MUST score, GPS score, neutrophil-to-lymphocyte ratio, and circulating 25(OH) D levels as predictive for the occurrence of PCs. In multivariate analysis, MUST score and circulating 25(OH) D levels remained significantly associated with PCs. Patients with high nutrition risk had significantly lower two-year OS rates compared to the medium and low nutrition risk groups, respectively (30% vs. 62% and 83%, p = 0.010).

CONCLUSION

Early identification of malnourished or patients with vitamin D deficiency and those who would benefit from specific nutritional support could be beneficial for minimizing the risk of development of surgical complications and help improve our clinical outcomes.

Analysis of Risk Factors with Assessment of the Impact of the Microbiome on the Risk of Squamous Cell Carcinoma of the Larynx

Introduction: Head and neck squamous cell carcinoma (HNSCC) ranks sixth among cancers in the world, and the 5-year survival rate ranges from 25% to 60%. The risk factors for HNSCC are primarily smoking, alcohol consumption and human papillomavirus (HPV). Data indicate that 15-20% of cancers are caused by infectious agents, 20-30% by smoking and 30-35% by unhealthy lifestyles, diet, lack of physical activity and obesity. Dysbiosis is a microbiome imbalance, which promotes oncogenesis by intensifying inflammatory processes and affecting the host's metabolism. Profiling the microbiome in various types of cancer is currently the subject of research and analysis. However, there is still little information on the correlation of the microbiome with HNSCC and its impact on oncogenesis, the course of the disease and its treatment. Objective: The aim of the study was to prospectively assess risk factors with assessment of the impact of the microbiome on the risk of squamous cell carcinoma of the larynx. The study included a group of 44 patients diagnosed with squamous cell carcinoma of the larynx and 30 patients from the control group. Results: In the control group, bacteria of the normal microbiome dominated-the genus Streptococcus, Gemella, Neisseria and Kingella. In the group of patients with laryngeal cancer, Prevotella, Clostridiales and Stomatobaculum were found significantly more often. Porphyromonas, Fusobacterium, Lactobacillus, Actinobacteria, Actinomyces and Shaalia odontolytica were also found at a higher percentage in the study group. Analyzing the phylum, Firmicutes dominated in the control group; there were statistically significantly more of them than in patients from the study group. Bacteroides and Bacillota were found significantly more often in patients with laryngeal cancer. Conclusions: The importance of the microbiome in oncology has been confirmed in many studies. Independent risk factors for laryngeal cancer were primarily a lower number of Firmicutes in the microbiome, but also an increased leukocyte level above 6.52 × 103/mm and a decreased total protein level below 6.9 g/dL. Prevotella, Clostridiales, Stomatobaculum, Porphyromonas, Fusobacterium, Lactobacillus, Actinobacteria, Actinomyces and Shaalia were considered to be the bacteria contributing to the development of laryngeal cancer. Streptococcus, Gemella, Neisserie and Kingella were considered to be protective bacteria. Moreover, the study confirmed the significant impact of smoking, alcohol consumption and poor oral hygiene on the development of laryngeal cancer. The microbiome, its identification and manipulation may constitute a breakthrough discovery for improving the diagnosis and oncological therapy of laryngeal cancer, and also of the entire group of HNSCC. Profiling the microbiome may allow for personalized therapy related to its modification. Assessing the microbiome of patients diagnosed with cancer may provide an opportunity to predict treatment response and effectiveness.

The relationship between nutritional status and prognosis in advanced gastrointestinal cancer patients in palliative care: a prospective cohort study

OBJECTIVE

The study aimed to determine the nutritional status and its prognostic effect on the survival of patients with advanced gastrointestinal cancer.

METHODS

A prospective cohort study design was conducted in a tertiary hospital in Shanghai, China. The study consisted of 202 advanced gastrointestinal (GI) cancer patients from a palliative care unit. The following data were collected from the patients: biochemical indicators, i.e., anemia (hemoglobin levels), albumin, pre-albumin, C-reactive protein (CRP), and anthropometric parameters, i.e., body mass index (BMI), nutritional status by Patient-Generated Subjective Global Assessment (PG-SGA), and performance status by Karnofsky Performance Status (KPS). Severe malnutrition was confirmed with the PG-SGA score of ≥ 9. Kaplan-Meier survival analysis and the log-rank test were used to calculate overall survival (OS). The effect of nutritional status on survival was performed by Cox regression analysis.

RESULTS

Severe malnutrition was found in 71.3% of patients according to the cutoff of the PG-SGA. PG-SGA score ≥ 9, albumin level < 35 g/L, and CRP level ≥ 10 mg/L predicted shortened life expectancy. Multivariate Cox regression analysis results showed that the PG-SGA score ≥ 9 and the albumin level < 35 g/L were predictive of OS.

CONCLUSION

Our data support that severe malnutrition is a predictor for OS in patients with advanced GI cancer. Information on nutritional status should be considered to individualize palliative care plan for these patients, and hence improve their quality of life.

Nomogram for predicting survival in T1-T2 stage patients with supraglottic squamous cell carcinoma

BACKGROUND

Supraglottic squamous cell carcinoma (SGSCC) is characterized by low differentiation, rapid growth, and inconspicuous initial manifestations. Early detection and prompt treatment can significantly improve survival rates. The main focus of treatment is to maintain optimal laryngeal function.

METHODS

Using the Surveillance, Epidemiology, and End Results (SEER) database, we conducted univariate and multivariate Cox regression analyses to identify independent prognostic factors for T1-T2 SGSCC. We also enrolled 109 patients with T1-T2 SGSCC from the First Affiliated Hospital of Xinjiang Medical University as an external validation set. In addition, we developed a nomogram to predict the prognosis of T1-T2 SGSCC, assessed the predictive accuracy and discriminatory ability of the nomogram using the area under the curve (AUC), C-index, receiver operating characteristic (ROC) curve and calibration curve, and confirmed the clinical validity of the nomogram using decision curve analysis (DCA).

RESULTS

Our investigation identified nine prognostic indicators for T1-T2 SGSCC: age (≥ 65 years), marital status, American Joint Committee on Cancer (AJCC) stage (II-IV), grade (III-IV), M stage (M1), radiotherapy, chemotherapy, sex (female), and surgery. These variables were used to create accurate nomograms that predict overall and specific survival rates at 1, 3, and 5 years. The nomograms demonstrated superior prognostic value and accuracy compared to AJCC staging. Laryngectomy with partial laryngectomy is the preferred treatment option for T1-T2 SGSCC cases, providing superior overall survival (OS) and cancer-specific survival (CSS). Radiotherapy also improves OS and CSS. Our results were based on a comprehensive analysis of various indicators, including the C-index, ROC curve, calibration curve, and DCA curve.

CONCLUSION

Nomograms provide significant advantages in treatment decision making and diagnosis. Laryngectomy with partial laryngectomy is the most appropriate method for T1-T2 SGSCC cases. However, radiotherapy can also be used. Thus, patients with T1-T2 SGSCC should be evaluated to determine if combination therapy is the optimal treatment approach. Nevertheless, further research is needed to understand the role of chemotherapy. Overall, this study identified nine key predictors of future outcomes, aiding healthcare professionals in assessing risks and making treatment decisions for T1-T2 SGSCC patients.

The Relationship between miR-5682 and Nutritional Status of Radiotherapy-Treated Male Laryngeal Cancer Patients

BACKGROUND

Nutritional deficiencies are frequently observed in patients with head and neck cancer (HNC) undergoing radiation therapy. microRNAs (miRNAs) were found to play an important role in the development of metabolic disorders throughout regulation of genes involved in inflammatory responses. This study aimed to explore the correlation between pre-treatment miR-5682 expression and parameters reflecting nutritional deficits in laryngeal cancer (LC) patients subjected to radiotherapy (RT).

METHODS

Expression of miR-5682 was analyzed in plasma samples of 56 male LC individuals. Nutritional status of LC patients was assessed using anthropometric and laboratory parameters, bioelectrical impedance analysis (BIA) and clinical questionnaires.

RESULTS

A high expression of miR-5682 was associated with significantly lower values of BMI, fat mass, fat-free mass and plasma albumin at selected periods of RT course. miR-5682 allowed us to distinguish between patients classified with both SGA-C and low albumin level from other LC patients with 100% sensitivity and 69.6% specificity (AUC = 0.820; p < 0.0001). Higher expression of studied miRNA was significantly associated with shorter median overall survival (OS) in LC patients (HR = 2.26; p = 0.008).

CONCLUSIONS

analysis of miR-5682 expression demonstrates a potential clinical utility in selection of LC patients suffering from nutritional deficiencies developing as a consequence of RT-based therapy.

Oncological features and outcomes of laryngeal cancer surgery: a multicentric study

BACKGROUND

Laryngeal cancer (LC) is among of the most frequent head and neck cancers, associated to a high social impact and mortality. Unfortunately, the current treatment outcomes of LC are often scant, with different factors affecting patient's prognosis (i.e., advanced age, advanced disease stage, lymph node involvement, tumor pathological features, type of intervention). The aims of the present study were: 1) to evaluate the epidemiological and clinical features of patients affected by LC; and 2) to focus on tumor risk factors affecting patient's overall survival (OS) and recurrences.

METHODS

A retrospective analysis of all patients affected by LC and surgically treated at two different hospital settings has been performed.

RESULTS

Two hundred twenty-five patients were enrolled in the present study; of these 189 were males (84%) and 36 (16%) were females. The most frequently performed surgery was total laryngectomy. Thirty-two (14.2%) patients experienced local recurrence, while 15 patients (6.6%) had regional recurrence and 15 distant metastases. Multivariate analysis showed that locoregional recurrence was associated to the occurrence of distant metastases (P=0.002, HR=25,35). Analyzing OS, the only statistically significant factor that correlated with an increased risk of mortality (P<0.015, HR=2,45) was locoregional recurrence.

CONCLUSIONS

The present study confirms the literature data about age and sex distribution of LC, about tumors localization, lymph nodes metastasis and distant metastasis incidence and OS rate, based on T and N stage. Interestingly, within this series, the presence of locoregional recurrence or distant metastasis is related to a worst prognosis and a lower overall survival rate.

Creation of a machine learning-based prognostic prediction model for various subtypes of laryngeal cancer

Depending on the source of the blastophore, there are various subtypes of laryngeal cancer, each with a unique metastatic risk and prognosis. The forecasting of their prognosis is a pressing issue that needs to be resolved. This study comprised 5953 patients with glottic carcinoma and 4465 individuals with non-glottic type (supraglottic and subglottic). Five clinicopathological characteristics of glottic and non-glottic carcinoma were screened using univariate and multivariate regression for CoxPH (Cox proportional hazards); for other models, 10 (glottic) and 11 (non-glottic) clinicopathological characteristics were selected using least absolute shrinkage and selection operator (LASSO) regression analysis, respectively; the corresponding survival models were established; and the best model was evaluated. We discovered that RSF (Random survival forest) was a superior model for both glottic and non-glottic carcinoma, with a projected concordance index (C-index) of 0.687 for glottic and 0.657 for non-glottic, respectively. The integrated Brier score (IBS) of their 1-year, 3-year, and 5-year time points is, respectively, 0.116, 0.182, 0.195 (glottic), and 0.130, 0.215, 0.220 (non-glottic), demonstrating the model's effective correction. We represented significant variables in a Shapley Additive Explanations (SHAP) plot. The two models are then combined to predict the prognosis for two distinct individuals, which has some effectiveness in predicting prognosis. For our investigation, we established separate models for glottic carcinoma and non-glottic carcinoma that were most effective at predicting survival. RSF is used to evaluate both glottic and non-glottic cancer, and it has a considerable impact on patient prognosis and risk factor prediction.

Comparison of three nutritional assessment methods associated with the prognostic impact of laryngeal cancer

BACKGROUND

Several studies have found that the prognostic nutritional index (PNI), controlling nutritional status (CONUT), and Glasgow Prognostic Score (GPS) of patients with laryngeal cancer accurately predict their prognosis. However, there is no consensus regarding the best assessment tool. Therefore, this study aimed to confirm the predictive value of the three nutritional scoring systems for the prognosis of patients with laryngeal cancer.

METHODS

This study analyzed a cohort of 427 patients with laryngeal cancer who visited our hospital. PNI, CONUT, and GPS were calculated, and the relationship between these indicators and prognosis was examined.

RESULTS

The optimal cut-off levels for overall survival (OS) of laryngeal cancer patients determined by PNI, CONUT, and GPS were 45, 3, and 0, respectively. When patients were stratified based on these thresholds, OS and disease-free survival (DFS) were significantly decreased in the malnutrition group (all three, p < 0.05). The OS rates of patients with laryngeal cancer were significantly affected by the three scores according to multivariate analysis.

CONCLUSIONS

The three scoring methods had a high predictive value for the prognosis of patients with laryngeal cancer, with GPS having the strongest correlation with the prognosis of laryngeal cancer patients.

Prognosis

Prognosis is defined as the likely outcome or course of a disease and is the result of a complex interplay between patient and tumor factors. Unfortunately, the prognosis of patients with laryngeal cancer has not changed significantly over the past several decades. However, as our understanding of these patient and tumor factors becomes more nuanced and the resulting treatment options become more precise, there is the potential to improve the prognosis for these patients.

The Prognostic Utilities of Various Risk Factors for Laryngeal Squamous Cell Carcinoma: A Systematic Review and Meta-Analysis

Objective: To assess the prognostic utilities of various risk factors for laryngeal squamous cell carcinoma. Methods: Six databases were searched to January 2022. Hazard ratios for overall survival and disease-free survival were collected and study characteristics were recorded. The risk of bias was evaluated using the Newcastle–Ottawa scale. Results: Twenty-eight studies involving 32,128 patients were finally included. In terms of overall survival, older age, a history of alcohol consumption, a high Charlson comorbidity index score, a high TNM stage (III and IV), a high tumor stage (III and IV), nodal involvement, poor pathological differentiation, primary chemoradiotherapy and radiotherapy were associated with increased risks of death. In terms of disease-free survival, older age (≥60 years), TNM stages III and IV, tumor stages III and IV, supraglottic tumors, and nodal involvement all increased the risk of death. Conclusions: The TNM stage importantly predicts overall survival, and tumor location predicts the disease-free survival of patients with laryngeal squamous cell carcinoma. Of patients with risk factors, the Charlson comorbidity index usefully predicts overall survival.

Clinical practice guidelines on nutrition management in head and neck cancer: a systematic quality appraisal using the Appraisal of Guidelines for Research and Evaluation 2nd edition instrument

OBJECTIVE

Several guidelines have been produced for the management of nutrition in patients with head and neck cancer. However, no systematic evaluation of the quality of these guidelines has been performed to date.

METHOD

A comprehensive search was conducted up to August 2020. The quality of guidelines was assessed by four independent reviewers using the Appraisal of Guidelines for Research and Evaluation, 2nd edition.

RESULTS

Nine guidelines were assessed for critical evaluation. Only two guidelines were classified as 'high quality'. The 'scope and purpose' domain achieved the highest mean score (75.5 ± 17.0 per cent), and the lowest domain mean score was 'applicability' (37.6 ± 23.0 per cent).

CONCLUSION

These findings highlight the variability in the methodological quality of guidelines for the management of nutrition in head and neck cancer. These results may help to improve the reporting of future guidelines and guide the selection for use in clinical practice.

The global, regional, national burden of laryngeal cancer and its attributable risk factors (1990-2019) and predictions to 2035

OBJECTIVE

We aim to report the incidence, mortality and disability-adjusted life years (DALYs) between 1990 and 2019 and provide predictions to 2035.

METHODS

We use estimates from Global Burden of Disease, Injuries and Risk Factors Study 2019 to analyse the incidence, mortality and DALYs.

RESULTS

In 2019, there were more than 209,149 incidence cases, with age-standardised rates (ASRs) of 2.5. Laryngeal cancer accounted for 123,356 death cases, with ASRs of 1.5. Laryngeal cancer was also responsible for 3.26 million (3,034,634 to 3,511,354) DALYs, with ASRs of 38.8 (36.1 to 41.8). In 2019, Central Europe had the highest age-standardised incidence rate. At the national level, the highest incidence rate was observed in Mongolia. Total number and rate were significantly higher among males than females across all age groups. DALYs were attributable to Alcohol use, Smoking, Occupational exposure to sulfuric acid and asbestos. The age-standardised incidence rates in seven GBD regions and 59 countries are projected to increase between 2019 and 2035.

CONCLUSIONS

Despite the current and predicted decline in age-standardised incidence globally, the absolute number of estimates continue to increase. Prevention programmes should concentrate on modifiable risk factors, especially among the males across all age groups.