Economic burden of managing oral cancer patients in Sri Lanka: a cross-sectional hospital -based costing study

Cost-effectiveness analysis of (accelerated) pre-operative versus (conventional) post-operative radiotherapy for patients with oral cavity cancer in Sweden

BACKGROUND

Treatment for resectable oral cavity cancer (OCC) often includes combinations of surgery and radiotherapy (RT), but there is no conclusive information on the preferred treatment order. The aim of this study was to assess the costs and cost-effectiveness of two alternative treatment regimens for patients with OCC, reflecting pre- and post-operative RT, from a societal perspective.

METHODS

The study used data from the ARTSCAN 2 randomised controlled trial, which compares pre-operative accelerated RT with post-operative conventionally fractionated RT. Two-hundred-forty patients were included in the analysis of treatment outcomes. Direct costs were retrieved from the hospital's economic systems, while indirect costs were obtained from national registries. Cost-effectiveness was assessed and a sensitivity analysis was performed. Overall survival (OS) at 5 years, was used as effect measure in the analysis.

RESULTS

Two-hundred-nine patients completed the treatments and had retrievable data on costs. Mean direct costs (inpatient and outpatient care) were € 47,377 for pre-operative RT and € 39,841 for post-operative RT (p = 0.001), while corresponding indirect costs were € 19,854 and € 20,531 (p = 0.89). The incremental cost, i.e., the mean difference in total cost between the treatment regimens, was € 6859 paralleled with a 14-percentage point lower OS-rate at 5 years for pre-operative RT (i.e., 58 vs. 72%). Thus, pre-operative RT was dominated by post-operative RT.

CONCLUSIONS

From a societal perspective, post-operative RT for patients with resectable OCC is the dominant strategy compared to pre-operative RT.

Measuring financial toxicity in head and neck cancer: a systematic review

Objective

The current study systematically reviews the literature about financial toxicity (FT) in head and neck cancer patients. Three databases were reviewed: PubMed, Scopus and Web of Science.

Methods

Full text English papers published from 2000 to 2022 reporting on quantitative results about FT in head and neck cancer survivors collected through structured questionnaires or interviews were included.

Results

Twenty-seven articles were included. Most of the articles were published after 2015 and from United States. There was a slight prevalence of papers dealing with oropharyngeal cancer, squamous-cell carcinoma and locally advanced head and neck cancer. Measures of FT were obtained through validated questionnaires like COST, FIT and FDQ. Collected data were mostly referrable to financial spending, financial resources, psychosocial aspect, support seeking, coping care and coping lifestyle subdomain. FT scores by COST were found to be worse in the COVID era. Financial counseling and adequate information about the costs of treatment were two effective strategies to mitigate FT.

Conclusions

FT is a relatively new challenge in head and neck cancer treatment, whose expenses are higher than therapies for other cancers. A universal method to assess FT and a unified guideline for the administration of questionnaires are needed to mitigate FT and to improve patient outcomes.

Oral cavity cancer incidence and survival trends: A population-based study

INTRODUCTION

The present study aimed to calculate the burden of oral cavity cancer (OCC) including incidence, mortality rate, survival rate, and influence of predictive factors such as clinicopathological, demographic findings, and treatment modalities.

MATERIALS AND METHODS

Data in this retrospective study were collected from India's population-based cancer registry (PBCR) from 2010 to 2016. A total of 1051 cases of OCC were noted. Incidence and mortality rates were calculated. The cumulative survival outcome was calculated using Kaplan-Meier (KM) method. Prognostic factors were estimated using the Cox proportional hazard regression model.

RESULTS

The age-standardized incidence rates (ASR), and mortality rate (ASMR), of overall OCC cases were 10.1 and 8.4 per 100 thousand population, respectively. Five-year overall survival (OS) was 32.3%. Survival outcome was significantly associated with the given treatment (Chi-square value = 58.17, P = 0.0001) and anatomical site (Chi-square value = 26.70, P = 0.0001). 17.6% of cases in males were <39-year age group. The hazard ratio (HR) in the age group of >50 years was 2.065 (95% CI 1.34-3.18, P = 0.001). Combination therapy had an HR of 2.630 (95% CI 1.91-3.63, P value 0.000). Tonsillar carcinoma (C09) (95% CI 1.04-3.12) had 1.8 times more chances of death than lip carcinoma (C00).

CONCLUSION

OCC cases are increasing in the younger population, and overall, cases show higher mortality rates with reduced survival outcomes. Prognostic factors such as age >50 years, single modality treatment, and alveolar and tonsillar malignancy are associated with poor survival. OCC robust screening by a trained health professional can improve early detection and increases awareness and lower mortality of the disease.

Antitumoral properties of the pomegranate peel and blueberry extracts against tongue carcinoma (in vitro study)

Background

Oral squamous cell carcinoma (OSCC) is one of the most common cancers globally. Considering the drawbacks of the traditional treatment phytochemicals have been introduced to the research field with consideration of their minimal, or no side effects and good efficacy against cancer cells. Pomegranate peel and blueberries are very well-known phytochemicals in this context.

Material and methods

Methanolic extracts are prepared from both pomegranate peel (PPE) and blueberry (BE) dried powders. The antioxidant content was determined by ORAC assay for both extracts. The cytotoxic levels of the extracts and IC50 on the HNO-97 cell line were defined using the colorimetric SRB assay. Then flow cytometric apoptosis analysis of the IC50 of both extracts was performed. Finally, an investigation of the metastasis through the wound healing assay was performed for both extracts.

Results

A significant difference in the antioxidant content was found between PPE and BE ethanolic extracts. The Ic50 for the PPE-treated cell line was 73.35 µg/ml while the BE showed it at 525.38 µg/ml with a significant difference between them. Both PPE and BE showed significant induction of cancer cell apoptosis with much better results with PPE treatment. The wound healing assay showed significant inhibition of cell migration when treated with PPE while there was not any significant effect on cell migration when treated with BE.

Conclusion

With the consideration that, the Phytochemicals used are well-known fruits with no harm on normal tissues. Low doses of PPE exert incredibly significant alteration in the HNO-97 tongue cancer cell proliferation, inducing apoptosis and inhibition of cancer cell migration. Meanwhile, treatment with BE needs much higher doses for showing anti-proliferative properties of cancer cells and induce cancer cell apoptosis. This gives promising results for further investigations about using them as a treatment or adjunctive treatment for oral cancer cases.

Estimating the direct costs of oral cancer in Spain: a retrospective hospital data analysis

BACKGROUND

Studies on the costs incurred from cancer in Spain are scarce and have focused on the most prevalent types such as colorectal, breast, and lung cancer. The aim of this study was to calculate the direct costs associated with the diagnostic, treatment and follow-up procedures for oral cancer in Spain.

MATERIAL AND METHODS

Applying a bottom-up approach, we retrospectively analyzed the medical records of a cohort of 200 patients with oral cancer (C00-C10), diagnosed and treated in Spain between 2015 and 2017. For each patient, we collected their age, sex, degree of medical impairment (American Society of Anesthesiologists [ASA] classification), tumor extent (TNM classification), relapses and survival during the first 2 years of follow-up. The final calculation of the costs is expressed in absolute values in euros as the percentage of the gross domestic product per capita and in international dollars (I$).

RESULTS

The total cost per patient rose to €16,620 (IQR, €13,726; I$11,634), and the total direct cost at the national level was €136,084,560 (I$95,259,192). The mean cost for oral cancer represented 65.1% of the gross domestic product per capita. The costs for the diagnostic and therapeutic procedures were determined by the ASA grade, tumor size, lymph node infiltration and presence of metastases.

CONCLUSIONS

The direct costs for oral cancer are considerable compared with other types of cancer. In terms of gross domestic product, the costs were similar to those of countries neighboring Spain, such as Italy and Greece. The main determinants of this economic burden were the patient's degree of medical impairment and tumor extent.

An overview of the burden of oral cancer in Sri Lanka and its inequalities in the face of contemporary economic and social malaise

OBJECTIVES

Over the past several decades, oral cancer has been the most common malignancy among Sri Lankan males and the top 10 cancer among females, disproportionately affecting low socio-economic groups. Sri Lanka is a lower-middle-income developing country (LMIC), currently striking through an economic crisis, and social and political unrest. Occurring at an accessible body site and predominantly attributed to potentially modifiable health-related behaviours, oral cancer should be preventable and controllable. Unfortunately, broader contextual factors that are socio-cultural, environmental, economic, and political and mediated through social determinants of people's lives consistently hinder progress. Many LMICs with a high burden of oral cancer are now gripped by economic crises, consequent social and political unrest, all compounded by reduced public health investments. The aim of this review is to provide a critical commentary on key aspects of oral cancer epidemiology including inequalities, using Sri Lanka as a case study.

METHODS

The review synthesizes evidence from multiple data sources, such as published studies, web-based national cancer incidence data, national surveys on smokeless tobacco (ST) and areca nut use, smoking and alcohol consumption, poverty headcount ratios, economic growth, and Gross Domestic Product (GDP) health expenditure. National trends in the oral cancer, ST use, smoking and alcohol consumption in Sri Lanka are identified alongside inequalities.

RESULTS

Using these evidence sources, we discuss 'where are we now?', together with the availability, accessibility and affordability of oral cancer treatment services, oral cancer prevention and control programmes, tobacco and alcohol control policies, and finally, outline macroeconomic perspectives of Sri Lanka.

CONCLUSIONS

Finally, we speculate, 'where to next?' Our overarching goal of this review is to initiate a critical discourse on bridging the gaps and crossing the divides to tackle oral cancer inequalities in LMIC such as Sri Lanka.

Exploring the microbiome of oral epithelial dysplasia as a predictor of malignant progression

A growing body of research associates the oral microbiome and oral cancer. Well-characterized clinical samples with outcome data are required to establish relevant associations between the microbiota and disease. The objective of this study was to characterize the community variations and the functional implications of the microbiome in low-grade oral epithelial dysplasia (OED) using 16S rRNA gene sequencing from annotated archival swabs in progressing (P) and non-progressing (NP) OED. We characterised the microbial community in 90 OED samples - 30 swabs from low-grade OED that progressed to cancer (cases) and 60 swabs from low-grade OED that did not progress after a minimum of 5 years of follow up (matched control subjects). There were small but significant differences between P and NP samples in terms of alpha diversity as well as beta diversity in conjunction with other clinical factors such as age and smoking status for both taxa and functional predictions. Across all samples, the most abundant genus was Streptococcus, followed by Haemophilus, Rothia, and Neisseria. Taxa and predicted functions were identified that were significantly differentially abundant with progression status (all Ps and NPs), when samples were grouped broadly by the number of years between sampling and progression or in specific time to progression for Ps only. However, these differentially abundant features were typically present only at low abundances. For example, Campylobacter was present in slightly higher abundance in Ps (1.72%) than NPs (1.41%) and this difference was significant when Ps were grouped by time to progression. Furthermore, several of the significantly differentially abundant functions were linked to the Campylobacteraceae family in Ps and may justify further investigation. Larger cohort studies to further explore the microbiome as a potential biomarker of risk in OED are warranted.

Prevalence, Habit Pattern, and Awareness on Harmful Effects of Tobacco/Areca Nut Use among Patients Visiting a Tertiary Care Center in Sri Lanka

Background The carcinogenicity of tobacco and areca nut is well established worldwide. Areca nut is the fourth most common psychoactive substance identified recently. The effects of areca nut on the autonomic nervous system make the users dependent on the habit which has been an emerging health issue among Sri Lankan adults and adolescents. This study aimed to evaluate the prevalence and patterns of these risk habits among the patients attending a tertiary care center in Sri Lanka, and their awareness of the harmful effects of the habit.

Method A hospital-based cross-sectional study was conducted among 512 patients using an interviewer-administered questionnaire.

Results The sample consisted of 167 (33%) tobacco consumers. The average age of the initiation of tobacco consumption was 23.66 years (standard deviation ± 8.04). Age (p = 0.001), gender (p = 0.001), income (p = 0.005), and educational level (p = 0.001) are significantly associated with tobacco consumption. There is a strong likelihood for tobacco consumers to consume areca nut (odds ratio [OR] 30.58, 95% confidence interval [CI] 17.05–54.88) and alcohol (OR 11.16, 95% CI 6.91–17.98) at any stage in their lives. The majority of the tobacco consumers (61%) were smokeless tobacco users. Areca nut consumers are 0.44 times more likely to know its carcinogenic effects than nonconsumers (95% CI 0.28–0.69). Tobacco consumers are more likely to be aware of the harmful effects of tobacco consumption than nonconsumers (OR 1.11, 95% CI 0.45–2.74). Sixty percent have made at least one attempt to quit the habit. Sixty-two percent of the unsuccessful quitters reported the reason as “addiction.”

Conclusion Prevalence of smokeless tobacco consumption prevails at a high level among Sri Lankans. Tobacco and areca nut users are more likely to be aware of its harmful effects than the nonconsumers but unable to quit the habit due to the psychoactive properties of tobacco and areca nut.

Salivary Interleukin Levels in Oral Squamous Cell Carcinoma and Oral Epithelial Dysplasia: Findings from a Sri Lankan Study

The incidence of oral squamous cell carcinoma (OSCC), and its precursor, oral epithelial dysplasia (OED), is on the rise, especially in South Asia. OSCC is the leading cancer in males in Sri Lanka, with >80% diagnosed at advanced clinical stages. Early detection is paramount to improve patient outcome, and saliva testing is a promising non-invasive tool. The aim of this study was to assess salivary interleukins (lL1β, IL6, and IL8) in OSCC, OED and disease-free controls in a Sri Lankan study cohort. A case-control study with OSCC (n = 37), OED (n = 30) patients and disease-free controls (n = 30) was conducted. Salivary lL1β, IL6, and IL8 were quantified using enzyme-linked immuno-sorbent assay. Comparisons between different diagnostic groups and potential correlations to risk factors were assessed. Salivary levels for the three tested interleukins increased from disease-free controls through OED, and were highest in OSCC samples. Furthermore, the levels of IL1β, IL6, and IL8 increased progressively with OED grade. The discrimination between patients (OSCC and OED) and controls, as assessed by AUC of receiver operating characteristic curves, was 0.9 for IL8 (p = 0.0001) and 0.8 for IL6 (p = 0.0001), while IL1β differentiated OSCC from controls (AUC 0.7, p = 0.006). No significant associations were found between salivary interleukin levels and smoking, alcohol, and betel quid risk factors. Our findings suggest that salivary IL1β, IL6, and IL8 are associated with disease severity of OED, and are potential biomarkers for predicting disease progression in OED, and the screening of OSCC.

Difference in clinical presentation and their significance in oral squamous cell carcinoma: A retrospective analysis

BACKGROUND

Oral squamous cell carcinoma (OSCC) remains the most common cancer among Indian men. OSCC involving the tongue and bucco alveolar complex (BAC) behaves differently. Nevertheless, the differences in clinical features and symptoms between the two subsites and their relation to pathology remain largely unexplored.

STUDY DESIGN

The study compared various clinical parameters and pathological factors between tongue cancer patients and patients with BAC cancer.

RESULTS

Among 474 patients, 232 had tongue cancer and 242 had BAC cancer. Except for the ulcer, 30% of patients with OSCC were asymptomatic at presentation. Compared to tongue cancers, lesions confined to BAC present at an advanced stage (P = 0.006). Multivariate analysis showed that dysphagia in tongue cancer (P = 0.020) and external swelling or lesion in BAC cancers (P = 0.002) were significant predictors of an advanced stage of the disease. On histopathology, perineural invasion (PNI) was significantly associated with tongue (P = 0.008) compared to BAC cancers (P = 0.015). Cancers of the tongue with pain and referred otalgia had a significantly higher depth of invasion (DOI), compared to those without pain (DOI - no pain 6.9 mm, pain 9.9 mm, and referred otalgia 11.4 mm).

CONCLUSIONS

Patients with OSCC present late and in an advanced stage of the disease. Among tongue cancers, clinical history of pain was significantly associated with DOI and PNI, the significance of which needs to be prospectively analyzed. Clinical history in OSCC can be used as predicting factor for an advanced pathological stage of the disease. It also had an influence on various pathological characters, which is subsite specific.

Conventional Therapies of Oral Cancers: Highlights on Chemotherapeutic Agents and Radiotherapy, Their Adverse Effects, and the Cost Burden of Conventional Therapies

Oral cancer (OC) is increasing worldwide, and it is mostly present to clinic in the late-stage of disease. Cancer of the lips, tongue, hard palate, upper and lower gingiva, buccal mucosa, and retromolar trigone are all included in the category of oral cavity cancer. Disease symptomatology and pathological grading decides the course of treatment. Several treatment modalities either alone in combinations may be utilized for oral squamous cell carcinoma (OSCC), including surgery, radiotherapy (external beam radiotherapy/brachytherapy), and adjuvant systemic therapy (chemotherapy or immunotherapy). Cancer patients also face a greater risk of oral side effects from chemotherapy, such as slowed tissue healing, bone, and salivary gland damage and disintegration, and disruption of the normal bacterial balance in the mouth. Consequently, the economic burden of the salivary gland, oral cavity, and oropharyngeal cancers must be also known for budget allocation, designing different programs and management strategies targeting oral cancers by any healthcare institutes. This article provides a summary of the most recent research that supports the use of chemotherapy for patients with advanced illness both alone and in conjunction with radiation including its adverse events and cost burden for oral cancers.

Disparities in end-of-life outcomes among advanced cancer patients in Sri Lanka: Results from the APPROACH study

OBJECTIVE

A Universal Health Coverage goal is to provide access to affordable palliative care to reduce disparities in end-of-life (EOL) outcomes. To assess progress toward this goal in Sri Lanka, our primary aim was to systematically assess differences in patients' physical, psychological, social and spiritual outcomes, and their perceived quality of care by their socioeconomic status (SES).

METHODS

As part of the multi-country APPROACH (Asian Patient Perspectives Regarding Oncology Awareness, Care and Health) study, we surveyed 199 patients with a stage IV solid malignant tumor and aged >21 years from the largest government cancer hospital in Sri Lanka. We assessed their physical (physical and functional well-being, symptom burden), psychological (anxiety, depression, emotional well-being), social (social well-being), and spiritual outcomes and perceived quality of care (physician communication, nursing care, and coordination/responsiveness).

RESULTS

Low SES patients reported significantly lower physical and functional well-being, emotional well-being, spiritual well-being including meaning/peace and faith; and significantly higher symptom burden, anxiety and depressive symptoms compared with patients from high SES (p < 0.05 for all outcomes).

SIGNIFICANCE OF RESULTS

Results have implications regarding reducing barriers in access to appropriate palliative care and EOL care services to stage IV cancer patients from low SES in Sri Lanka.

Burden of oral cancer in Asia from 1990 to 2019: Estimates from the Global Burden of Disease 2019 study

Background

Oral cancer (OC) poses a threat to human health and imposes a heavy burden on countries. We assessed the burden imposed by OC on Asian nations from 1990 to 2019 based on gender and age.

Methods

We collected oral cancer data from the 2019 Global Burden of Disease study from 1990 to 2019 in 45 Asian countries and territories. Annual case data and age-standardised rates (ASRs) were used to investigate the incidence, mortality, and disability-adjusted life-years (DALYs) of OC based on age and gender from 1990 to 2019 in 45 Asian countries and territories. Estimated annual percentage changes (EAPCs) were used to assess incidence rate, mortality, and trends in DALYs.

Results

The age-standardised incidence rate (ASIR) of OC increased from 1990 to 2019 with an EAPC of 0.32 (95% CI, 0.19–0.46), and the age-standardised death rate of OC remained stable at an EAPC of 0.08 (95%CI, from -0.06 to 0.21). The age-standardised DALYs of OC decreased at an EAPC of -0.16 (95%CI, from -0.30 to -0.02). The proportion of patients older than 70 years increased yearly in terms of incidence, mortality, and DALYs from 1990 to 2019. Of the DALYs, smoking was the main contributor in the Asian regions, and the largest contributor to DALYs in most Asian regions. Other contributors were alcohol use and chewing tobacco.

Conclusion

Although the burden of OC was declining in Asia, South Asia remained the region with the highest burden. OC caused the greatest burden in Pakistan, Taiwan China, and India. Therefore, measures should be taken to reduce the burden of oral cancer in high-risk regions and countries with attributable risk factors.

The cost of oral cancer: A systematic review

Although clinical and epidemiological aspects of oral cancers (OC) are well-documented in the literature, there is a lack of evidence on the economic burden of OC. This study aims to provide a comprehensive systematic assessment on the economic burden of OC based on available evidence worldwide. A systematic review was conducted. The population was any individual, who were exposed to OC, considered here as lip (LC), oral cavity (OCC), or oropharynx (OPC) cancer. The outcome was information on direct (medical and non-medical) and indirect (productivity loss and early death) costs. The data sources included Scopus, Web of Science, Cochrane, BVS, and NHS EED. A search of grey literature (ISPOR and INAHTA proceedings) and a manual search in the reference lists of the included publications were performed (PROSPERO no. CRD42020172471). We identified 24 studies from 2001 to 2021, distributed by 15 countries, in 4 continents. In some developed western countries, the costs of LC, OCC, and OPC reached an average of Gross Domestic Product per capita of 18%, 75%, and 127%, respectively. Inpatient costs for OC and LC were 968% and 384% higher than those for outpatients, respectively. Advanced cancer staging was more costly (from ~22% to 373%) than the early cancer staging. The economic burden of oral cancer is substantial, though underestimated.

The economic impact of cancer diagnosis to individuals and their families: a systematic review

Background

The effect of a cancer diagnosis is wide-ranging with the potential to affect income, employment and risk of poverty. The aim of this systematic review is to identify the economic impact of a cancer diagnosis for patients and their families/caregivers.

Methods

The search covered peer-reviewed journals using MEDLINE, EMBASE, CINAHL, Cochrane Library, Epistemonikos and PsycINFO databases. Quality appraisal was undertaken using CASP tools. Monetary values were converted to US Dollars/2019 using a purchasing power parities (PPP) conversion factor. The review included articles up to and including January 2020, written in English language, for patients with cancer aged ≥ 18 years and focused on the costs up to 5 years following a cancer diagnosis.

Results

The search was run in January 2020 and updated in November 2021. Of the 7973 articles identified, 18 met the inclusion criteria. Studies were undertaken in the USA, Ireland, Canada, Australia, France, UK, Malaysia, Pakistan, China and Sri Lanka. The majority were cohort studies. Twelve reported out-of-pocket costs (range US$16–US$2523/month per patient/caregiver) consisting of medical expenses (e.g. surgery, radiotherapy and chemotherapy) and non-medical expenses (e.g. travel, food and childcare). Fourteen studies reported patient/caregiver loss of income and lost productivity (range 14–57.8%).

Conclusions

A high percentage of cancer patients and their families/caregivers experience out-of-pocket expenditure, loss of income and lost productivity. Future research is needed to observe the effects of continuing changes to healthcare policies and social protections on the economic burden among cancer patients and their families/caregivers.

Outpatient Dental Treatment Expenditure for Patients with Oromaxillofacial Cancer: A Cohort Study in Taiwan

The information on the outpatient expenditure of patients with oromaxillofacial cancer is minimal. This study aimed to compare the average annual expenditure on dental treatment for these patients 5 years before and 5 years after oromaxillofacial cancer diagnosis. In this study, 7731 patients who received oromaxillofacial cancer diagnosis in 2005 were selected from the Registry of Catastrophic Illness Database as the case-cohort. In the control cohort, 38,655 people without cancer were selected from the National Health Insurance Research Database, with the case–control ratio being 1:5. All participants were observed for 5 years before diagnosis and 5 years after diagnosis. The conditional logistic regression model was used to determine the odds ratios of annual expenditures incurred by participants in the case-cohort. The measurement results indicated that in the oromaxillofacial cancer cohort, the average annual dental expenditure levels at 1, 2, 3, 4, and 5 years after diagnosis were US $97.34, US $77.23, US $109.65, US $128.43, and US $128.03 and those at these years before diagnosis were US $37.52, US $32.10, US $31.86, US $29.14, and US $29.35, respectively. In conclusion, the average annual expenditure on the dental treatment of oromaxillofacial cancer patients after five years of diagnosis was increased compared to five years before diagnosis.

Burden of Oral Cancer on the 10 Most Populous Countries from 1990 to 2019: Estimates from the Global Burden of Disease Study 2019

Background: Oral cancer (OC) is a common tumour that poses a threat to human health and imposes a heavy burden on countries. This study assessed the burden imposed by OC on the 10 most populous countries from 1990 to 2019 on the basis of gender, age and socio-demographic index. Methods: Data on incidence, mortality, disability-adjusted life years (DALY) and corresponding age-standardised rates (ASR) for OC in the 10 most populous countries from 1990 to 2019 were derived from the Global Burden of Disease Study 2019. Estimated annual percentage changes were calculated to assess the trends of morbidity, mortality and DALY. The indicator that served as a proxy for survival rate was the supplement of mortality-to-incidence ratio (SMIR) (1 − (M/I)). Results: The number of new cases, deaths and DALY have increased in all 10 countries in the past 30 years. Trends in age-standardised incidence rates (ASIR), age-standardised mortality rate (ASMR) and age-standardised DALY for OC in the 10 most populous countries varied. The SMIR increased in all countries, with most countries having an SMIR between 30% and 50%. In 2019, the United States had the highest SMIR at 76%, whereas Russia had the lowest at 21.7%. Incidence and mortality were close between male and female subjects in Japan, Indonesia, Mexico, India, Bangladesh and Pakistan. The incidence and mortality in male subjects in the United States, Russia, China and Brazil were two or more times those of female subjects. Gender difference was highest among patients aged 40–69 years. Conclusion: Trends and gender differences in ASIR, ASMR and age-standardised DALY for OC vary in the 10 most populous countries. Government cancer programs are often expensive to run, especially in countries with large populations. Policy makers need to take these differences into account when formulating policies.

Prognostic value of lymphovascular and perineural invasion in squamous cell carcinoma of the tongue

OBJECTIVE

The objective of this study was to investigate the association between survival rate and lymphovascular invasion (LVI) and perineural invasion (PNI) in the tumor invasive front (TIF) of squamous cell carcinoma of the tongue (TSCC).

STUDY DESIGN

Seventy patients with TSCC were included. The retrospective analysis included demographic, clinical, and histopathologic data. Tissue blocks containing the TIF were stained with anti-α-smooth muscle actin and anti-S100 to detect LVI and PNI, respectively. Overall survival (OS) and disease-specific survival (DSS) were assessed using Pearson's chi-square test, Kaplan-Meier method, and Cox regression.

RESULTS

LVI and PNI were detected in 61.4% and 78.6% of the TSCC samples at the TIF, respectively. LVI and PNI were present in 54.3% of the cases and were associated with advanced clinical stage, lymph node resection, metastatic nodes, and lower survival (P < .05). The 5-year OS and DSS rates were 44% and 52%, respectively. Multivariate analysis showed that primary tumors >3.0 cm (hazard ratio = 4.29; P = .004) and a concomitant presence of LVI and PNI at the TIF (hazard ratio = 4.0; P = .012) were independent predictors for worse DSS.

CONCLUSION

LVI and PNI, identified by immunostaining at the TIF, are potential prognostic markers of TSCC.

A prospective study to determine the cost of illness for oral cancer in India

India accounts for almost a third of the global burden of oral cancer, a situation worsened by the inability to afford care. When available, aid is often insufficient, and costing is based on informal estimations. This study objectively determines direct healthcare costs of oral cancer in India. The study was performed from a healthcare provider's perspective using a validated bottom-up method. Care pathways were determined by prospectively observing the natural management of 100 oral cancer patients treated between October 2019 and March 2020. Specific costing categories were built across services, and apportioned values for each interaction was averaged. Costs of treatment and service utilisation were obtained using probabilistic sensitivity analyses. The unit cost of treating advanced stages (United States Dollar (USD) 2,717) was found to be 42% greater than early stages (USD1,568). There was an 11% reduction in unit costs with increases in socioeconomic status. Medical equipment accounted for 97.8% of capital costs, with the highest contributor being imaging services. Variable costs for surgery in advanced stages were 1.4 times higher than early stages. Compared to surgery alone, the average cost of treatment increased by 44.6% with adjuvant therapy. These results show that over the next decade, India will incur an economic burden of USD 3 billion towards the direct healthcare of oral cancer. Early detection and prevention strategies leading to 20% reduction in advanced stage disease could save USD 30 million annually. These results are critical to deliver a disease-driven and objective reform for oral cancer care.

Provider cost of treating oral potentially malignant disorders and oral cancer in Malaysian public hospitals

Oral cancer has been recognized as a significant challenge to healthcare. In Malaysia, numerous patients frequently present with later stages of cancers to the highly subsidized public healthcare facilities. Such a trend contributes to a substantial social and economic burden. This study aims to determine the cost of treating oral potentially malignant disorders (OPMD) and oral cancer from a public healthcare provider’s perspective. Medical records from two tertiary public hospitals were systematically abstracted to identify events and resources consumed retrospectively from August 2019 to January 2020. The cost accrued was used to estimate annual initial and maintenance costs via two different methods- inverse probability weighting (IPW) and unweighted average. A total of 86 OPMD and 148 oral cancer cases were included. The initial phase mean unadjusted cost was USD 2,861 (SD = 2,548) in OPMD and USD 38,762 (SD = 12,770) for the treatment of cancer. Further annual estimate of initial phase cost based on IPW method for OPMD, early and late-stage cancer was USD 3,561 (SD = 4,154), USD 32,530 (SD = 12,658) and USD 44,304 (SD = 16,240) respectively. Overall cost of late-stage cancer was significantly higher than early-stage by USD 11,740; 95% CI [6,853 to 16,695]; p< 0.001. Higher surgical care and personnel cost predominantly contributed to the larger expenditure. In contrast, no significant difference was identified between both cancer stages in the maintenance phase, USD 700; 95% CI [-1,142 to 2,541]; p = 0.457. A crude comparison of IPW estimate with unweighted average displayed a significant difference in the initial phase, with the latter being continuously higher across all groups. IPW method was shown to be able to use data more efficiently by adjusting cost according to survival and follow-up. While cost is not a primary consideration in treatment recommendations, our analysis demonstrates the potential economic benefit of investing in preventive medicine and early detection.

Economic cost of managing patients with oral potentially malignant disorders in Sri Lanka

OBJECTIVES

Cancer of the oral cavity is the leading malignancy amongst males in Sri Lanka, and eighth amongst women. Almost all malignancies are developed from a clinically visible precursor stage called an oral potentially malignant disorder (OPMD). The objective of this study was to estimate costs of managing patients with OPMD in Sri Lanka for a 12-month period from diagnosis.

METHODS

A hospital-based costing study was conducted in Sri Lanka in the years 2016-2017. Three selected treatment centres participated. For societal perspectives, healthcare, household and indirect costs were used. Costs to the healthcare system included clinic visits, diagnostic biopsy, consumables and drug costs. Capital costs included apportioned value of land, buildings, equipment and furniture. Household costs consisted of out-of-pocket expenditure and indirect costs of lost income.

RESULTS

Sixty-two patients were recruited (39 male and 23 female). The majority had awareness of oral potentially malignant disorders (OPMDs). Total average cost of managing a single patient with an OPMD for 1 year was SLR 19 547 (US$ 140) which includes a health system cost of SLR 7320 (US$ 52) and household cost of SLR 12 227 (US$ 87). Travel loss and income loss were a substantial burden to patients and their families.

CONCLUSIONS

Managing patients with an OPMD, even with annual monitoring, is less costly than managing patients with oral cancer. Out-of-pocket costs are very high, and these could be reduced by revising the National Management Guidelines to allow care closer to home.

Economic Burden of Cancer on Cancer Patients Treated at Hawassa University Comprehensive Specialized Hospital

Cancer causes the highest economic loss of all of the leading 15 causes of death worldwide. The economic loss includes the loss of income and the expenses associated with health care costs. The Low awareness of the community toward cancer, the inadequacy of professionals and service providers, and the high budget consuming nature of the treatments are creating a great burden on the cancer patients. The objective of this study was to calculate patient side cancer treatment cost and to assess the contributing factors, among the cancer patients who were treated at Hawassa University Comprehensive Specialized Hospital. The health facility based cross-sectional study design was employed using a consecutive sampling technique. Questionnaires was used to collect primary data; while chart was used to collect the secondary data. Indirect costs incurred on these patients due to off job days were checked. Descriptive and inferential statistics were applied to illustrate the data. On average, $209.99 was spent on treatment by each cancer patients. Of these, medication cost is the highest ($20.77, IQR = 0.53-112.56) from the direct medical costs, and transportation cost is the highest ($58.33, IQR = 22.0-131.67) from the indirect medical costs. Inpatients paid $245.16 (IQR = 147.64-439.20); while outpatients paid $147.37 (IQR = 81.42-240.50). The patients lose about 55.99% of their average annual income. Outpatients pay $0, 92 less than in patients (P = 0.00, CI -0.72-0.34), and the cost increases by $0.2 for the patients who came from Oromia. The cost of transportation and medication were the one which were significantly affecting the burden; but the total cost of treatment was lesser when compared to similar studies done in different areas. The cost balances toward the patients who came from the Oromiya region. Treatment service has to be extended to West Arsi Zone to minimize the cost of transportation and awareness about cancer is needed in the first place and due attention has to be given to thyroid cancer. Furthermore, facility side study should be done to see the complete picture of the burden.

Betel Quid Addiction: A Review of Its Addiction Mechanisms and Pharmacological Management as an Emerging Modality for Habit Cessation

Areca-nut (AN) and added smokeless-tobacco (SLT) are considered agents that may cause addiction to betel-quid (BQ). However, the primary addictive substance in AN is not clearly understood. Objective: The present review evaluates possible addictive chemicals in AN with their mechanisms of action for progression to BQ dependence, as it is essential to overcome barriers in BQ cessation. It also identifies innovative treatment modalities in BQ cessation including the scope for research on pharmacotherapy using Monoamine-oxidase Inhibitors, Selective Serotonin Re-uptake Inhibitors and Norepinephrine Dopamine Reuptake Inhibitors. Methods: This is a narrative review on addictive properties of BQ and trials undertaken to promote cessation of SLT or AN use. Results: Twenty interventional studies, three by behavioral therapy and seventeen using pharmacotherapy were reviewed. There was heterogeneity in reported follow up times, most studies reporting data at 12 weeks with abstinence rates of 45-55% for SLT cessation and at 8 weeks with abstinence rates around 35% for AN cessation. Conclusion: Even though literature reveals a few cessation programs through behavioral support for BQ addiction, its success has been limited in certain instances mainly due to addictive properties of AN, resulting in withdrawal and relapse. Hence, in line with pharmacotherapy in tobacco smoking cessation, potential pharmacological agents to assist in cessation of SLT and AN require more attention. Several clinical trials for SLT cessation have been carried out with varying levels of success using Nicotine Replacement Therapy and Varenicline while trials on antidepressants for SLT and AN cessation are also emerging.

Oral cancer in Papua New Guinea: looking back and looking forward

Oral diseases, including cancers, affect 3.5 billion people globally and remain largely untreated in low- to middle-income countries because of lack of resources. In Papua New Guinea (PNG), oral cancer has, for many decades, been identified as the most common cancer in men, but as the GLOBOCAN 2018 data are estimates extrapolated from surrounding countries, the real prevalence of this disease is not known. The PNG National Health Plan (2011-2020) highlights the need to improve health care, but oral health is not identified as a priority. Alcohol, tobacco, and areca nut/betel quid, which are the social and commercial determinants of oral cancer, are common risk factors, and there are robust data linking these risk factors to oral cancer in PNG. Our recent Global Challenges Research Fund Workshop on Oral Cancer, held in Port Moresby, PNG, brought together a number of researchers in oral cancer epidemiology and translational science with clinicians from PNG to assess the current situation and plan ways to move forward. In this article, we will review the literature on oral cancer in PNG, and make suggestions as to how, collaboratively, we can address the issues identified, ultimately, for the benefit of the people of PNG.