Elsevier

Oral Oncology

Volume 47, Issue 7, July 2011, Pages 642-647
Oral Oncology

A population-based study of factors associated with early versus late stage oral cavity cancer diagnoses

https://doi.org/10.1016/j.oraloncology.2011.04.018Get rights and content

Summary

Oral cavity cancers can be detected early yet many are diagnosed with advanced disease. We assessed risk factors for advanced stage disease in a population-based study. Study population was all Ontario patients with anterior tongue or floor of mouth cancers diagnosed between 1991 and 2000 (n = 2033). Data are from a retrospective chart review. Risk factors included: demographic characteristics, co-morbidity, precancerous lesions, dental status, smoking, alcohol use, and social marginalization. Multivariate regression analyses assessed independent associations while controlling for disease grade and site. Forty percent had advanced disease. Eighty-nine percent presented with symptoms and 66% were referred by a family physician. Risk factors in the tongue group were being: age ⩾80 (RR 1.47), widowed (RR 1.34), social marginalized (RR 1.69), a current smoker (RR 1.26), or a smoker-heavy drinker (RR 1.73). Risk factors in the floor of mouth group were being: age ⩾70 (70–79: RR 1.24 and ⩾80: RR 1.43), and socially marginalized (RR 1.22). Having a pre-cancerous lesion (RR 0.44) or a regular dentist (RR 0.84) was protective in the floor of mouth group. Risk factors for those with co-morbid illnesses were being: age ⩾70 (70–79: RR 1.28 and ⩾80: RR 1.55), separated/divorced (RR 1.26), socially marginalized (RR 1.37), or a smoker-heavy drinker (RR 1.44); while having a regular dentist was protective (RR 0.83). Targeted education to alert those at risk about oral cancer warning signs and better training coupled with opportunistic oral cavity exams by family physicians could reduce the burden of this disease.

Introduction

Oral cavity cancers can be detected early with a simple oral examination, but compared to cancers that involve more elaborate screening tests (i.e., breast, prostate and colon), the rate of early diagnosis of oral cavity cancers has not improved over time1 with advanced disease at presentation ranging from 27% to 77%.2, 3, 4, 5, 6, 7 Also, some oral cavity cancers may be preventable through treatment of pre-malignant lesions, but many dentists and family physicians are not performing the opportunistic oral cavity screening exams in at-risk patients that could detect such lesions.8 Unlike breast, prostate and colon where overall survival is improving partly due to early detection, survival in oral cavity cancer is stagnant at about 50% and as with most other cancers, survival varies greatly based on the stage of the disease at presentation.3 Along with a survival advantage, patients presenting with earlier stage disease have a significantly better functional result with respect to speech and swallowing function and treatment is much less disfiguring.

Most studies investigating late stage diagnosis in oral cavity cancer have described the duration and sources of diagnostic delay.9, 10, 11 Patient-related delay is usually the longest source varying from 19 to 90 days.3, 4, 7, 12, 13, 14 We need to better understand how late stage oral cavity cancer diagnoses occur. Our objective was to assess the associations between disease stage and factors that may compromise an early diagnosis including: patient and disease characteristics, living circumstances and access to care. This work provides evidence about who should be targeted for education campaigns about the early warning signs of oral cancer and contrasts how early staged and late staged patients come to be diagnosed.

Section snippets

Patients and methods

We conducted a population-based retrospective cohort study of all patients diagnosed with invasive squamous cell carcinomas of the anterior tongue and floor of mouth in Ontario, Canada from 1991 through 2000. We used the Ontario Cancer Registry to identify study subjects and the linked Cancer Care Database housed at our research unit to identify patient charts for data abstraction and to provide some data elements.15, 16, 17 The principal data were collected through a province-wide chart review.

Results

There were 2311 patients with a cancer of the anterior tongue (ICD-O C02.0, C02.1) or floor of mouth (ICD-O C04) diagnosed from 1991 through 2000 in the Ontario Cancer Registry. We reviewed pathology reports on 393 cancers of the gum (ICD-O C03) looking for misclassified cases, yielding 18 more cases. Reasons for exclusion included: anatomic site coding error (n = 69), not squamous cell carcinoma (n = 57), not an Ontario resident (n = 48), non-invasive (n = 10), diagnosis outside the study period (n = 

Discussion

We identified characteristics about a person, his/her health status and lifestyle, degree of social isolation, and access to dental and precancerous lesion care that affect the chance of being diagnosed with an advanced oral cavity cancer. Our findings varied across the two disease site groups, possibly due to the variations in symptoms at presentation. Older age and social marginalization were risk factors for advanced disease in both sites while being widowed and smoking with or without heavy

Conflict of interest statement

None declared.

Acknowledgments

We would like to thank Marlo Whitehead and Zhi Song for programming and statistical support and Suzanna Keller for her many and varied contributions to the successful conduct of the study. We wish to acknowledge the Ontario Cancer Registry and Cancer Care Ontario for providing us with the Ontario registry data. This work was supported by the Canadian Institutes of Health Research (Grant No. MOP 67096) and by the Canada Research Chairs Program (PG).

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