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Table of Contents
ORIGINAL ARTICLE
Year : 2017  |  Volume : 19  |  Issue : 2  |  Page : 47-50

Incidence of head and neck cancers in jazan province, Saudi Arabia


Department of Otorhinolaryngology Head and Neck Surgery Faculty of Medicine Jazan University; Department of Otorhinolaryngology Head and Neck Surgery Prince Mohammed bin Nasser Hospital; Department of Otorhinolaryngology Head and Neck Surgery King Fahd Central Hospital, Jazan, Saudi Arabia

Date of Web Publication7-Jan-2020

Correspondence Address:
Fahd Alharbi
P.O. Box: 2585, Jazan 45142
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-8491.275315

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  Abstract 


Objectives: The objective of this study was to evaluate the incidence of various types of head and neck cancer in Jazan province, Saudi Arabia.
Material and Methods: This was a prospective study of histologically confirmed cancer cases in Jizan, Saudi Arabia. One hundred and thirty two cases were histologically confirmed to have cancer in the head and neck region. Type of management for each case was also included.
Results: The type of cancer which was more frequently seen among the studied sample was squamous cell carcinoma (SCC). Almost 61.3% of the patients were seen to be affected with SCC followed by thyroid cancer (21.2%). Non-Hodgkin’s lymphoma was seen in (12.3%) of the cases, which was the most common site in the recorded data.
Conclusion: Head and neck cancers are increasing in Jazan region. Oral and oropharyngeal cancers show the most significant rise due to smokless tobacoo, with implications for public health action and service provision.

Keywords: Head and neck cancer, shamma, Jazan region, oral cancer, thyroid cancer


How to cite this article:
Alharbi F. Incidence of head and neck cancers in jazan province, Saudi Arabia. Saudi J Otorhinolaryngol Head Neck Surg 2017;19:47-50

How to cite this URL:
Alharbi F. Incidence of head and neck cancers in jazan province, Saudi Arabia. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2017 [cited 2020 Oct 31];19:47-50. Available from: https://www.sjohns.org/text.asp?2017/19/2/47/275315




  Introduction Top


Head and neck cancers are biologically heterogeneous tumors. Alcohol drinking and tobacco smoking are the major risk factors for upper aerodigestive tract cancers. Oral cancer has been a public health concern for quite some time. Various government and non- government organizations are involving the community and stakeholders in order to tackle this dreadful disease. Previous studies suggest that tobacco, alcohol and human papilloma virus (HPV) are all risk factors for developing oral cancer [1]. Smokeless tobacco is also considered to be responsible for oral cancer [2]. There is a high prevalence of shamma use in between inhibitant of Jazan region. Shamma is a form of smokeless tobacco in a powdered form mixed with lime, pepper, ash, and flavoring oils. The user places it in the buccal cavity till the flavor of it lasts [3].

Thyroid cancer is the most frequent endocrine malignancy. It is the fifth most common cancer in women in the United State of America. The incidence continues to rise worldwide. Differentiated thyroid cancer is the most frequent subtype of thyroid cancer. Its prognosis is generally favorable in cases of well- differentiated thyroid cancers, such as papillary and follicular cancers, which have survival rates of approximately 95% at 40 years [4],[5].

Currently, the literature available to demonstrate the incidence of head and neck cancer in Jazan region is scarce. This study was designed to explore the incidence of different types of head and neck cancer and our experience in Jazan region of the Kingdom of Saudi Arabia.


  Materials and Methods Top


Ethical approval:

A departmental ethical approval was obtained from King Fahd Central Hospital as well as Prince Mohammed bin Nasser Hospital Jazan, Saudi Arabia.

Type and duration of study:

A cross-sectional descriptive type of study was designed for the patients visiting King Fahd Hospital and Prince Mohammed Bin Naser Hospital, Jazan, Saudi Arabia. The data collected was during the period from 2012 till April 2016.

Informed consent:

Informed consent was obtained from all individual participants included in the study.

Data collection:

All data were recorded prospectively during the patient initial admission, and all follow up data were recorded during their out-patient clinic follow up. All patients treated with external beam radiotherapy as a single modality, or adjunctive radiotherapy, or post operatively were referred to different oncology centers outside the region. All the patients with cancer involving head and neck were included in the study. Variables such as age, gender, type of cancer, site, stage of cancer, risk factors involved, treatment performed as well as prognosis were recorded.

Statistical analysis:

All the data was entered and analyzed using SPSS version 20 (IBM, USA). Age was kept as a continuous variable, staging of cancer was recorded as an ordinal variable while all other variables were entered as categorical variables. Descriptive statistics were performed and the values were written as percentages or Mean +S.D (standard deviation) as necessary. Spread of cancer within different ages and gender was also calculated.


  Results Top


Altogether 132 (N) patient’s data was recorded in the intended time period of which 76 patients (57.5%) were females and 56 (42.5%) were males. The mean age was 56.74 +18.90 (mean +S.D). The distribution of cancer is shown in [Table 1]. The common type of head and neck cancers seen was oral cancer, which makes 44.7% of the cases. Almost 61.3% of the patients were seen to be affected with squamous cell carcinoma (SCC). The second common type of cancer was thyroid cancer (21.2%) followed by non Hodgkin’s lymphomas in (12.3%) of the cases
Table 1: Descriptive analysis of different sites of cancer

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Carcinoma in many cases was detected at late stages (stage III or stage IV) as shown in [Figure 1]. Stage III was seen and recorded in 45 (34.9%) cases while stage IV was seen in 42 (32.1%) of the cases. Out of the 28 patients who had total thyroidectomy, 5 patients (17.8%) developed transient hypocalcemia and hypo-parathyroidsm. Of which, none developed permanent hypo-parathyroidsm. No patient developed recurrent laryngeal nerve injury.
Figure 1: Graph displaying the percentage of carcinoma seen in various stages

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Regarding surgical complications, out of the 25 patients who had composite resection, reconstruction and/or neck dissection, 2 patients (8%) had post-operative wound infection, 3 patients (12%) had dysphagia, and 2 patients (8%) had exposure of the reconstruction plate skin. Around 5% of the patients had experienced death within 5 years of the diagnosis and 88 (83%) of the patients did not bother to follow up for their further check up and treatment.


  Discussion Top


Head and neck cancers are common in several regions of the world where tobacco use and alcohol consumption is high. The mean age of the patients in our study was 56.74 + 18.90, of which 57.5% (76) were females and 42.5% (56) were males. This agrees with Issing et al, who found that in 107 patients with advanced head and neck cancer, the average age was 59.4 years [6]. The sex ratio was 76 females to 56 males. This could be explained by the fact that more female patients were using smokeless tobacco than male patients in Jazan regions.

In discussing the results we observe that most of our patient were suffering from oral cancer. The most common type of malignancy was squamous cell carcinoma. Jazan region is reported to have the highest incidence of oral cancer cases in the Saudi Arabia. Shamma (smokeless tobacco) was seen to be a major risk factor for the development of oral cancer in addition to cigarette smoking. The most common site of oral cancer was the tongue (17%) followed by the buccal area (11.3%) and floor of the mouth (7.5%). It was observed that oral cancers were more common in males (77.7%) than females (52.5%). Smokeless tobacco habit was also seen in younger males. A study performed by Allard et all and Al Sanosy in the Kingdom of Saudi Arabia have revealed frequent use of smokeless tobacco among the people living in the Jazan province, which is situated in the southern region of the Arabian Peninsula [7],[8].

A literature review performed by Al-Jaber et al in the epidemiology of oral cancer in the Arab World found that eight prevalence studies found oral cancer prevalence ranging from 1.8 to 2.13 per 100,000 persons. Oral cancer cases occur most commonly in the fifth to sixth decade of life, and the incidence in younger age was reported in some Arab countries. Yemenis have a high prevalence of oral cancer among people younger than 45 years. Behavioral determinants such as smokeless tobacco, qhat, and cigarette smoking were strongly associated with oral cancer. Alcohol drinking and solar radiation exposures were cited as possible risk factors. The most affected sites were the tongue, floor of the mouth, and lower lip. Squamous cell carcinoma was the most detected type of cancer (61.3%). Most of the patients usually presented in late stages (III and IV) at the time of diagnosis [9]. Regarding surgical complications, out of the 25 patients who had composite resection, reconstruction and/or neck dissection, 2 patients (8%) had post-operative wound infection, 3 patients (12%) had dysphagia, and 2 patients (8%) had exposure of the reconstruction plate skin. It is clear that reconstruction with plates only is not effective in bridging large defects of the resected mandible, and should be covered by a free flap, or a myocutaneous flap [10].

The second common malignancy observed in the Jazan region was thyroid cancer (21.7%) and most of them were papillary thyroid cancer. All patient underwent fine needle aspiration cytology preoperatively. The standard treatment for most thyroid cancer patients was surgery followed by either radioactive iodine or observation is effective. Out of the 28 patients who had total thyroidectomy, 5 patients (17.8%) developed transient hypocalcemia and hypoparathyroidsm. Of which, none developed permanent hypoparathyroidsm. No patient developed recurrent laryngeal nerve injury. Lymphomas make (12.3%) of the cases. The most common types of lymphomas seen in our cases were non-Hodgkin’s lymphoma (12.3%). Lymphoma is a well-known pathology in the head and neck region. Extra nodal lymphoma constitutes about 33 % of all non-Hodgkin’s lymphoma. 18-28% develops in the head and neck region. A multimodality treatment with multi-agent chemotherapy (CT) and radiotherapy (RT) is considered optimum [11]. 25% of extra nodal lymphomas occur in the head and neck region [12]. Lymphomas management required an interdisciplinary collaboration between the otolaryngologist, the hema- tologist, the anatomical pathologist, and the oncologist. Nasopharyngeal carcinoma makes (9.1%) of the cases. The most common type was undifferentiated carcinoma, which is consistent with literature [13]. The salivary gland cancer make about (5%). The most common types were mucoepidermoid carcinoma, followed by squamous cell carcinoma and adenoid cystic carcinoma. The most affected salivary gland is the parotid gland followed by the submandibular gland. Hypopharynx and larynx make also about (5%) of the cases. The most common histopathological type is squamous cell carcinoma. Nose and paranasal sinuses carcinoma account for (3.8%) of the cases. The most common types seen are squamous cell carcinoma. Temporal bone cancer makes (1.5%) of the cases and the all cases were squamous cell carcinoma.

It is observed that 87 (67%) of the cases presented at late stages (stage III or stage IV). Stage III was seen and recorded in 45 (34.9%) cases while stage IV was seen in 42 (32.1%) of the cases versus 43 (32%) of the cases presented at early stage (I and II). This is because of the weakness of the educational and prevention program applied by the general physician in the peripheral hospitals. An important reason is that patients presented to the tertiary center in advanced stage of the disease due to the ineffective referral system to the tertiary specialized medical center in the region. Unfortunately, many of the patients did not bother to follow up for their further check up and treatment. The management of head and neck cancer requires most often radical resection of the tumor with not only severe impairment of important functions like swallowing and speech, but also aesthetic issues. Therefore the rehabilitation from a functional and cosmetic standpoint is an essential goal of treatment in addition to control of the malignant disease.

Addressing the issue of perioperative mortality, we had 6 patients (4.5%) who died in the perioperative period due to bleeding from tumor site, tracheostomy, and pulmonary complications.

Because the service of head and neck surgical oncology was not available in the region for many years and most of the patients who diagnosed with malignancy of the head and neck were referred to higher medical center outside the region, the acceptance of the society to have such practice in the region was difficult at the beginning of the service in the region.

Another issue in the management of malignancy of head and neck region is the limitation of trained head and neck oncology surgeons. The lack of radiation therapy in the region resulted in that many patients were referred to higher center outside the region for radiation therapy. This also added to the problem of management of head and neck cancer in Jazan region. The referral of patients to receive radiation therapy in another center, contribute to the loss of follow up of many of our patients, as many of them continued their follow up in the other center.

While primary prevention is the potential strategy for long term disease control, early detection and treatment may have limited potential to improve mortality in the short term. Because of incidence of head and neck cancer in the region, it was necessary to conduct this study in order to show how serious is this problem and how it affects the health system in Jazan region.

Unfortunately no solid evidence exists regarding the true head and neck prevalence in the Kingdom of Saudi Arabia due to the lack of national cancer registries and population-based studies.

This study is the first of its kind that combines different types of head and neck cancers in Jazan region. In conclusion, the study showed that shamma is a major risk factor for oral cancer in Jazan region. The otolaryngologist, dentist and public health practitioners should be actively involved in conducting and implementing various diagnostic and prevention policies in the region. All the multidisciplinary services of head and neck cancer including surgery, radiotherapy, and chemotherapy should be provided in one oncology center. The management should be provided through a standard head and neck Oncology Board, to achieve standard patient care, adequate follow up, and surveillance.

Acknowledgment

The author gratefully acknowledges Dr. Mir Faeq Quadri for his help in the statistical analysis.



 
  References Top

1.
Lin W, Jiang RS, Wu SH, et al Smoking, alcohol, and betel quid and oral cancer: a prospective cohort study. J Oncol. 2011a;11:525-6.  Back to cited text no. 1
    
2.
Lin WJ, Jiang RS, Wu SH, et al (2011b). Smoking, alcohol, and betel quid and oral cancer: a prospective cohort study. J Oncol. 2011b; 11:1-5.  Back to cited text no. 2
    
3.
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Issing PR, Kempf HG, Heppt W, Schönermark M, Lenarz T. [Reconstructive surgery in the head-neck area with regional and free tissue transfer] Laryngorhinootologie. 1996;75:476-482. German.  Back to cited text no. 6
    
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Allard WF, De Vol EB, Te OB .Smokeless tobacco (shamma) and oral cancer in Saudi Arabia. Community Dent Oral Epidemiol.1999; 27: 398-5.  Back to cited text no. 7
    
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Al-Sanosy RM (2014). Smokeless tobacco (shammah) in Saudi Arabia: a review of its pattern of use, prevalence, and potential role in oral cancer, Asian Pac J Cancer Prev. 2014;15:6477-3.  Back to cited text no. 8
    
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Giridhar P, Mallick S, Bhasker S, Pathy S, Mohanti BK, Biswas A, Sharma A. Head and neck extra nodal NHL (HNENL) Treatment Outcome and Pattern of failure – A Single Institution Experience. Asian Pac J Cancer Prev. 2015;16 (15):6267-72.  Back to cited text no. 11
    
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Tuşaliu M, Mogoanta CA, Dobrea CM, Zainea V. Clinical and histological aspects with therapeutic implications in head and neck lymphomas. Rom J Morphol Embryol. 2015;56(2):499-504.  Back to cited text no. 12
    
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