CANCER – The one single word that is dreaded alike by almost every human being on earth. Unfortunately, the fear of the disease, often leads to fear of knowing about the disease as well. This is extremely tragic since most cancers can be treated effectively especially if diagnosed early.
In this article, we will throw some light on the most common form of Cancer in India, which are the Head & Neck cancers (HNC: cancers affecting mouth, throat, larynx, nose and sinus). Also one of those cancers, that is considered to be preventable.

Did you know?

• HNC is not just common in India but also the 6th most common cancer in the world.
• While HNC is the most common cancer in South & South east Asia, it is only about 1%-4% of the western world cancer cases.1
• Some trends, that dominate HNC worldwide are also seen in India1 :
  • HNC are more common in men compared to women.
    About 40% of cancers in men are HNC while its only about 8% in case of women
  • There has been an upward trend in case of young adults getting affected with the disease. According to a study conducted in 2016, HNC was found to be the most common cancer in adolescents & young adults (AYA)2
• The single most important risk factor for cancer is TOBACCO (responsible for approximately 22% of cancer-related deaths globally).3
  It is also important to define tobacco consumption as smoke and smoke less (that comprises of betel nut, pan, gutkha, khaini etc)
• Also in India :
  • HNC account for 30% of all cancers in the country4
  • Over 200,000 cases of HNC occur each year, about 40% of these are oral cancers
  • Typically north and the north eastern belt of the country harbour most of these cancers, due to higher consumption of tobacco products along with lack of awareness and low literacy rates5

Risk Factors

It is very often said and truthfully so that Cancer is a disease that impacts not only the patient but the entire family. Considering the socio-economic burden of the disease it is important to understand these trends and guard all those who are at a higher risk of the disease. Typically, modifying or avoiding key risk factors can significantly reduce the burden of cancer. These risk factors include:

1. tobacco use (including smokeless tobacco)
2. alcohol consumption
3. human papillomavirus (HPV) infection
4. poor oral hygiene.

People who consume both tobacco and alcohol are at a much higher risk of developing these cancers.
Other risk factors associated with the prevalence of HNSCC are poor dental hygiene, poor diet, immunosuppressant, submucous fibrosis, gastrointestinal reflux, different inherited syndrome, and chronic iron deficiency anaemia.4

Presentation & Diagnosis

Oral cancers though one of the most preventable cancer has not yet been able to meet the success that the clinician community would desire. The ever-increasing numbers due to continued tobacco consumption

patterns and lack of awareness, only bring in the patient to the medical facility at an advanced stage. That is a significant part of the battle lost as the key is always to catch cancer early, as early as possible. This is precisely the reason why there are so many cancer awareness initiatives that are undertaken, but there is a long way to go, especially in our country.
Oral cancers were found to be the most common HNC in patients below 40 year age group, whereas carcinoma oropharynx and larynx were more common in patients above 40 year age group. Also there have been studies that correlate tobacco chewing (smokeless) to mouth cancers (40%) while in case of smokers the most common site was found to be the larynx and hypopharynx.
According to the National Cancer Institute, the five-year survival rates for oral cavity and pharynx cancers are as follows:

• 83 percent, for localized cancer (that hasn’t spread)
• 64 percent, for cancer that’s spread to nearby lymph nodes
• Overall, 60 percent of all people with oral cancer will survive for five years or more. The earlier the stage at diagnosis, the higher the chance of survival after treatment. In fact, the five-year overall survival rate in those with stage 1 and 2 oral cancers is typically 70 to 90 percent. This makes timely diagnosis and treatment all the more important

Challenges

It is obvious that a country with the sheer vastness of size, population & complexities that India has, the challenges of HNC treatment in India7 would be manifold, some of which are outlined here:
The vast numbers and diversity of HNC cases in India, makes it a potential hub for developing clinical protocols and awareness programs that would enable lessening the burden of the disease thereby improving economic growth for a fast developing nation, such as India. This entails consolidation of efforts on epidemiological and clinical data reviews but the fraternity faces a huge challenge when it comes to:

1. Availability of resources, funding and infrastructure not just for screening and treatment but also for prevention and rehabilitation.
2. Availability of medical workforce, physicians, health workers, technical staff and pathologists in semi urban and rural areas.
3. Reliability of data due to missing cases from registry, small sample size, short study period and insufficient geographic coverage.
4. Tobacco & alcohol consumption patterns in certain states, where it is associated with Indian culture.
5. Lifestyle patterns of tobacco consumption in backward states with low economic and literacy rates.

The way forward

With the context of prevalence, emerging trends and significant socio-economic impact, HNC needs attention from all, tobacco and alcohol users, high risk groups, clinicians, government, policy makers, healthcare communities and NGOs. The disease calls for prevention and cure as a community. Here are a few broad steps that should be taken more aggressively8 :

• Proactive and pre-emptive measures for the high risk group that entails awareness building, psychological therapy and access to screening camps for early diagnosis and treatment. HNC awareness and screening not only result in early diagnosis and improved outcomes but would safeguard resources and infrastructure for those in need of treatment and rehabilitation. This would further enhance productivity of the patient/effected for economic activities.
• Development on consensus guidelines for key HNC, that would positively impact treatment timelines, better utilization of scare resources and significant effect on patient health and recovery.
• An active collaboration between investigators, research institutes, funding agencies, industry and regulatory bodies to prioritize the research domains and consolidate efforts.

It would be unfair and unrealistic to even imagine that taking these measures would lead to an immediate & drastic reduction in the number of HNC cases but taking these actions and most importantly continuing with them would certainly ensure a good start in the right direction.

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4011474/
2. http://www.indianjcancer.com/article.asp?issn=0019-509X;year=2016;volume=53;issue=3;spage=457;epage=459;aulast=Sharma
3. https://www.who.int/news-room/fact-sheets/detail/cancer
4. http://www.cancerjournal.net/article.asp?issn=0973-1482;year=2017;volume=13;issue=3;spage=430;epage=435;aulast=Alam
5. http://www.ijmpo.org/article.asp?issn=0971-5851;year=2019;volume=40;issue=5;spage=18;epage=22;aulast=Sharma
6. https://www.healthline.com/health/oral-cancer#rehabilitation
7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6362726/
8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6362726/