INTRODUCTION

Mouth and neck cancer is normally represented by epithelial neoplasm of squamous cell carcinoma (SCC) type, which affect the upper digestive tract. It is one of the most frequent neoplasms in Brazil 1. The rates of local control and survival increase with the local-regional treatments that have advanced in the past 30 years, but they have not significantly changed in the past few years 2.

Mouth and oropharynx cancer is directly associated with alcohol abuse and smoking. Both affect mainly male subjects that are over the age of 50 years. Over 90% of the cases are SCC. The behavior is very aggressive and there is early neck metastasis that is frequently bilateral and, especially in oropharynx cases, lymphatic regions cross the midline 3.

The oropharynx cancer has the aggravation of being olygosymptomatic at first, owing to the sensitive innervation pattern by the glossopharyngeus and the irregular surface of the mucosa, especially of the palatine tonsils, with ridges in which a small carcinoma can hide in a clinical examination, or because of the investigation pattern of the patients, which is not always very attentive 3.

In Brazil, the incidence of oral cancer is considered one of the highest in the world, among the 6 most common types of cancer that affect males and among the top 8 that affect women. It may be considered the most common head and neck type of cancer, except for skin cancer.

We analyzed the medical charts of cases of mouth and oropharynx squamous cell carcinoma seen by the Head and Neck Surgery Service of Hospital Ana Costa and Head and Neck Surgery Division, Irmandade da Santa Casa de Misericórdia de Santos, between 1997 and 2000, in order to characterize patients that were submitted to surgical treatment with and without radiotherapy, to define the most significant factors for early diagnosis.

MATERIAL AND METHOD

The research project under number 066/02 dated 27/08/2202 was approved by the Research Ethics Committee, Universidade Metropolitana de Santos, responding to CONEP. Data in the study were collected from the medical chart analysis of the Division of Head and Neck Surgery, Santa Casa de Misericórdia de Santos and Hospital Ana Costa, between 1997 and 2000. We included 43 cases of mouth SCC and 25 cases of oropharynx SCC. In addition, we also excluded 7 cases of mouth and 5 cases of oropharynx SCC since medical charts were not completed. All surgeries had been conducted by the two authors who are surgeons. We also excluded patients whose treatment was radiotherapy associated or not with chemotherapy.

Information on gender, age, profession, ethnic background, smoking habits and alcohol abuse, site of lesion, clinical staging, treatment, grade of histological differentiation, survival, origin of referral to treatment (ENT, other physicians, dentists or the patient), use of total dental prosthesis, and presence of a second primary tumor was analyzed and compiled in a specific form.

Later on, data were analyzed and statistically studied using Fisher's exact test. We correlated clinical staging with alcohol abuse and smoking with mouth and oropharynx; primary site with use of dental prosthesis, age with histological grade; referral with tumor staging, and survival with staging. We also characterized the treatment modalities that were employed.

Sample Characterization

Out of the total number of patients with SCC, there were 33 male (77%) and 10 female patients (23%), whereas among patients with oropharynx lesion, there were 23 male (92%) and 2 female subjects (8%) (Table 1).

The age of mouth SCC ranged from 46 to 91 years (median of 62 years). The most affected age range varied from 60 to 69 years. Subjects with oropharynx SCC presented ages between 40 and 81 years (median of 58 years), being that the most affected age range was 50 to 59 years (Table 2).

As to professions, both groups had retirees and housewives, which amounted to 65.1% of the patients with mouth SCC (n=28) and 68% of oropharynx SCC patients (n=17).

In the mouth SCC group, there were only 4 non-Caucasian patients (9.3%), whereas in the oropharynx SCC, two were not Caucasian (8%).

Patients with mouth SCC were referred to the Head and Neck division predominantly by physicians (n=36 - 81%), followed by dentists (n=6 -14%) and two patients had come independently (5%). As to patients with oropharynx SCC, 92% were referred by physicians (n=23), 4% by dentists (n=1) and 4% came spontaneously (n=1) (Table 3).

As to smoking, 15 patients (35%) in the mouth SCC group smoked 40 cigarettes a day and 10 subjects (23.2%) did not smoke. Among the patients with oropharynx SCC, 12 patients (48%) smoked up to 40 cigarettes a day and 4 patients (16%) did not smoke (Table 4). Alcohol abuse was reported in 32 cases (74%) of mouth SCC and the remaining patients did not report alcohol abuse. Among oropharynx SCC, there were 20 cases (80%) of alcohol abuse and 5 subjects (20%) did not report it (Table 5).

As to use of dental prosthesis, 34 patients (79%) with mouth SCC did not use them, 8 (19%) had upper and lower arches and 1 (2%) had upper prosthesis only. As per oropharynx SCC patients, 13 (52%) did not wear it, 9 (36%) had upper and lower prostheses and 3 (12%) had only upper prosthesis (Table 6).

In the group with mouth SCC, tongue was the most frequent site, with 22 registered cases (51.1%), followed by floor of the mouth in 11 cases (25.5%); retromolar area in 4 (9.3%); anterior tonsil pillar in 3 cases (6.9%), jugal mucosa in 2 (4.6%), and 1 in the alveolar rim (2.3%). In the oropharynx group, 19 patients had palatine tonsil SCC (76%), 5 had tongue base (20%) and 1 patient had soft palate SCC (4%) (Table 7).

Tumor staging in the mouth SCC presented: 1 (2.3%) carcinoma in situ; 5 (11.6%) stage I; 14 (32.5%) stage II; 12 (27.9%) stage III, and 11 (25.5%) stage IV. The group of oropharynx SCC presented 1 case (4%) of stage II, 10 patients of stage III (40%) and 14 (56%) stage IV (Table 8).

As to histology differentiation in patients with mouth SCC we found 2 patients (4.7%) with in situ neoplasm, 9 patients (20.9%) with grade I (well differentiated), 31 patients (72.1%) with grade II (moderately differentiated) and 1 patient (2.3%) with grade III (little differentiated). For oropharynx SCC patients, we found 2 cases (8%) of patients with grade I (well differentiated), 21 patients (84%) with grade II (moderately differentiated) and 1 patient (8%) with grade III (little differentiated) (Table 9).

RESULTS

Considering the mouth, when we correlated clinical staging and smoking, we detected a non-significant difference between smoker and non-smoker groups (descriptive level = 0.8567). The same applied to alcohol abuse and staging, in which there was no statistically significant difference between those who drank and those who did not (descriptive level = 0.9189). As to oropharynx, we correlated staging and smoking and there was no statistically significant difference between smokers and non-smokers, nor between the groups compared one to the other (descriptive level = 0.9999). When we related it to alcohol abuse, we detected a trend of patients that did not abuse of alcohol and had stage III and the ones that had alcohol abuse had stage IV, but there was no statistically significant difference between the two groups (descriptive level = 0.6917).

We analyzed primary sites on the mouth and oropharynx and use of dental prosthesis and we did not find statistically significant differences between them (descriptive level = 0.0749 for the mouth and 0.9999 for the oropharynx).

We analyzed primary site and age. In mouth tumors, the higher incidence was in the age range 50 to 59 years, especially on the tongue and floor of the mouth. There was no statistically significant difference between the groups (descriptive level =0.2102). In oropharynx tumors, we considered that palatine tonsil tumors encompassed a broader range, which did no happen with soft palate and tongue base. There was no statistically significant difference between tonsils and the other two groups (descriptive level = 0.4413).

We correlated tumor site and histology grade. In mouth tumors, we detected predominance of grades I and II on the tongue and floor of the mouth. Retromolar tumors were classified as grades II and III. In oropharynx tumors we observed only grade II on tongue base and soft palate. The same grade was prevalent in tonsil tumors.

By correlating the professional who made the referral and tumor staging, we observed that both in oral tumors and oropharynx tumors, physicians were professionals that did most of the referrals, and dentists referred only 10% of them, usually stages II or IV. In month tumors, general physicians (53.5%) and ENT (27.9%) were the professionals that referred the most and dentists referred only 14% of the patients, which were staged II or IV, which means that there is a possibility of having statistically significant difference between the referral patterns in the two groups. In oropharynx tumors, physicians in general (40%) and ENT (52%) made most of the referrals, whereas dentists referred only 1 patient (4%). The only case of stage II was referred by the ENT. There was no statistically significant difference considering staging (Table 10).

The association between surgery and postoperative adjuvant radiotherapy was conducted in 20 (47%) patients with mouth SCC, whereas the others were submitted only to surgery. For oropharynx tumors, 80% were treated with surgery and radiotherapy, 16% to salvage surgery after radiotherapy and 4% only to surgery. There was no statistically significant difference between treatment approach and survival rate.

The minimum follow-up was 26 months. Patient's survival with SCC of the mouth ranged from 2 to 92 months, whereas patients with oropharynx SCC had shorter survival rates, ranging from 1 to 40 months. Most of the patients with SCC of the mouth were asymptomatic, that is, they were alive and had no evidence of the disease - 30 patients (69.7%), and the opposite happened in the oropharynx SCC group, in which 17 (68%) of the subjects died of the disease. We noticed that oropharynx tumors caused more deaths than mouth tumors, that is, patients with oropharynx tumors have 2.4 times more likelihood of dying of cancer than patients with mouth tumors. We concluded that there is statistically significant difference between both groups (descriptive level = 0.0021). As a result of the breakdown of the sample into stages in situ, I and II in one group and stages III and IV in the other, there was statistically significant difference in survival, which was much better for the former group (Graph 1).

Four patients (9.3%) with mouth SCC had a second primary tumor, one in the lung and two in the larynx, whereas 2 patients with oropharynx SCC (8%) had a second primary focus, one in the larynx and the other in the pyriform sinus.

DISCUSSION

As to age, we did not detect the occurrence of mouth SCC in patients aged younger than 40 years, differently from the findings reported by other authors 4, 5. The most affected age range corresponded to the references described above, showing that the preferential age range was 50 to 70 years. In a study conducted with 264 patients with mouth cancer aged less than 35 years, 59.4% of the patients smoked, indicating that other etiological factors should be assessed 6. In our sample, patients had significant exposure to smoking and alcohol abuse and they were aged over 40 years.

Considering gender, data found in our study were in accordance with the literature 7, showing that in cases of mouth SCC there was higher incidence of male gender in a proportion of 3:1. In Brazil, a study was conducted comparing 228 female patients and 849 male patients and in the first group, the advanced age range - 60.7 years against 55.6 years, with statistical difference 8. The authors believed it was due to less exposure to smoking and alcohol abuse among women.

In a study conducted in Australia, there were 2,173 new cases of mouth cancer in one year, with 400 deaths. Most of the patients were aged over 60 years and there was male-female prevalence of 2:1. However, over 50% of the cases were lip tumors 9. In Brazil, there was prevalence of tongue cancer. The characteristics of the Australian population and exposure to sun seem to have an important role in these figures. We should consider that most lip tumors, especially in early stages, are seen by plastic surgeons, reason why they are not very common in a oncology center.

The most common findings were located on the tongue (50%), followed by floor of the mouth (26%), differently from other findings 4, in which the most frequent site was floor of the mouth (25%) followed by tongue (21.87%). In a stratification of the many affected sites in the mouth and oropharynx and exposure to the main risk factors, smoking had more impact on the jugal region, alveoli, tonsil and floor of the mouth. Alcohol abuse was more significant on jugal region and floor of the mouth. Curiously, for the tongue, palate and lip these factors were not correlated with risk 10.

The use of dental prostheses was not associated with increased risk of upper aerodigestive tract cancer, but history of oral ulcers secondary to poor adjustments was associated with mouth and pharynx cancer. Poor oral hygiene with few tooth brushings everyday was a risk factors 11. In a retrospective study about the risk of cancer in the upper aerodigestive tract, the use of dental prostheses was not associated with increased risk, but the history of oral ulcers secondary to poor adjustment and poor oral hygiene were risk factors 11. Maybe poor hygiene allows the carcinogenous - alcohol and tobacco, to remain longer in contact with the mucosa, and in our opinion, there are few consistent studies in the literature to confirm these hypotheses.

Stage II was the most frequently found (32%). In a correlated study, stage II was the most frequent one (45.79%)4. The degree of histological differentiation most frequently found in patients with SCC of the mouth was grade II, that is, moderately differentiated (72%), differently from other findings2 that described grade II as being the most frequent in maxillary sinus and floor of the mouth tumors.

According to the Dental Sciences Regional Board, the city of Santos, on the coast of the state of Sao Paulo, is a port city with 417,983 inhabitants, a well-structure healthcare system that counts on health prevention actions. There are 1,800 dentists in the city and only 110 are city administration employees. Half of the population of Santos has dental health covered by the public healthcare system. It generates two specific situations. On the one hand, more privileged social groups in which the professional/inhabitant ratio is 1/122, whereas on the other hand, the other half of the population has a professional-inhabitant ratio of 1/1,895.

Oral cavity lesions, more accessible through clinical examination, are generally referred by the general practitioner. The oropharynx lesions, not easily accessed, are normally referred by the ENT physician. Our results showed the poor performance of dentists in diagnosing and referring for treatment patients with mouth and oropharynx cancer. In addition to the difficulties that late diagnosis can bring to the patients and the institutions that cover treatment costs, another aspect should be considered. In a retrospective analysis conducted in the United States, comprising a period from 1984 to 2000, there were 50 cases in which judges sentenced malpractice in cases of mouth cancer, involving 21 American states 12. The main allegation in the lawsuits was delay in diagnosis 12, 13. In a study conducted with dentists in Canada, 670 professionals answered a questionnaire and 56.7% said they had updated knowledge on mouth and oropharynx cancer. Most identified smoking (99.4%) and alcohol abuse (90.4%) as risk factors, but few correctly identified the intake of foods such as pepper (57%), and poor oral hygiene status (46.3%) as being risk factors 14.

Strategies for prevention and education of the population and more appropriate professional training can improve the approach of these patients. These data indicate the need to have more effective early diagnosis of mouth and oropharynx cancer. The main concern, in our opinion, involves structuring of university courses, both in the medical and dental areas.

CONCLUSION

The present study emphasizes the importance of having primary care physicians and dentists that are able to recognize lesions so that they can help defining early diagnosis.




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1 Ph.D. in Otorhinolaryngology and Head and Neck Surgery, UNIFESP - Escola Paulista de Medicina.
2 Ph.D. in Oral Pathology, University of Sao Paulo.
3 Former undergraduate, Dental School, Universidade Metropolitana de Santos (UNIMES).
4 Master in Head and Neck Surgery, Post-Graduation in Head and Neck Surgery, Hospitalar Heliópolis, Sao Paulo.
Affiliation: Discipline of Otorhinolaryngology and Head and Neck Surgery, Discipline of General and Oral Pathology, Dental School, Universidade Metropolitana de Santos "Unimes".
Address correspondence to: Rogério A. Dedivitis - Rua Olinto Rodrigues Dantas, 343 conjunto 92 Santos SP11050-220.
Tel (5513) 3223-5550 /3221-1514 - E-mail: dedivitis.hns@uol.com.br