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Prognostic effect of tobacco and alcohol use in patients with oral tongue cancer
SCIENTIFIC PAPERS
Prognostic Effect of Tobacco and Alcohol Use in Patients with Oral Tongue Cancer William D. Johnston, MD, Columbia, Missouri A. J. Ballantyne, MD, Houston, Texas
Chronic users of tobacco and alcohol have a greater incidence of cancer of the mucosa exposed to these agents than nonusers of tobacco and alcohol. The present retrospective case analysis of patients with oral tongue cancer was done to compare the outcome of the users and nonusers of tobacco and alcohol.
per cent of males and only 41 per cent of females were chronic users of alcohol. Of the 308 patients who used either tobacco or alcohol or both, 96 (31.2 per cent) were dead due to tumor in five years. Only 6 of the 43 nonusers (13.9 per cent) died due to tumor within five years.
Material and Methods The charts of 351 patients treated for oral tongue cancer at the M.D. Anderson Hospital, Houston, Texas, between January 1,1948 and December 31,1967 were reviewed. A history of habits, including tobacco and alcohol use, has always been required on the initial history and physical form at the M.D. Anderson Hospital. The information on tobacco and alcohol usage in this review is mainly from this initial interview and from other available comments of follow-up examiners. Of these 351 patients, 52 (13 male, 39 female) claimed no use of tobacco, 105 (49 male, 56 female) claimed no use of alcohol, and only 43 claimed no use of either tobacco or alcohol.
Percent who developed a second primary cancer Percent who died due to second primary cancer
Results
Comparing tobacco and alcohol use according to sex, 94 per cent of males and only 61 per cent of females with oral tongue cancer used tobacco, and 76
From the Department of Surgery, Ellis Fischel State Cancer Hospital, and the Cancer Research Center, Columbia, Missouri, and the Head and Neck Service, M. D. Ardemon Hospital, f-buston, Texas. This work was supported in part by Clinical Cancer Education Program grant CA17946 from the National Cancer Institute. Reprint requests should be addressed to William Johnston, MD, Ellis Fischel State Cancer Hospital, Business 70 & Garth Avenue, Columbia, Missouri 65201. Presented at the Twenty-Third Annual Meeting of the Society of Head and Neck Surgeons, Hilton Head Island, South Carolina, May 4-7, 1977.
444
Users of Tobacco and Alcohol
Non-users of Tobacco and Alcohol
Figure 1. Incidence of second primary cancer in five fo twenty year follow-up after treatment of primary cancer. There was a greater incidence of second primary cancer and deaths due to second primary cancer in users of tobacco and alcohol than in nonusers.
The American Journal of Surgery
Tobacco and Alcohol and Oral Tongue Cancer NO-
1007 90 -
90.
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0
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0 Nonusers (Male)
Users (Male)
Nonusers Users (Female) (Female)
OfTobacco Figure 2. Percentage otusers andnonusers of tobacco who develop oral tongue cancer at age seventy years or older.
Of the 351 patients, 206 (58.7 per cent) lived two years with no evidence of tumor. Of these 206 patients, 106 were chronic users of both tobacco and alcohol, and 29 of these 106 (27.4 per cent) developed a second primary cancer. Twenty-seven of the 206 who were free of tumor at two years were nonusers of tobacco and alcohol. Only five (18.5 per cent) of these developed a second primary cancer. (Figure 1.) Thirty-five of the 308 users of tobacco and/or alcohol (11.4 per cent) died of intercurrent disease within five years of treatment. Four of the 43 nonusers (9.3 per cent) died of intercurrent disease within five years. This does not appear to be significant until we note the percentage of users and nonusers of tobacco and alcohol who develop oral tongue cancer at age seventy years or older; Figures 2 and 3 show that nonusers of tobacco and alcohol are older when they develop oral tongue cancer than users of tobacco and alcohol. Figures 4,5, and 6 show the T and N staging distributions for users compared with nonusers of tobacco and alcohol. There is little difference except for a slightly higher percentage of No staging for nonusers. Figures 7 and 8 show no significant difference in the frequency of surgery and radiotherapy treatment for the two groups.
volume 134. octobof
1977
Nonusers Male)
Users (Male)
Users Nonusers (Female)(Female)
OfAlcohol Figure 3. Percentage of users and nonusers of akohol who develop oral tongue cancer at age seventy years or older.
IiBzi
*T3, 74 50 40. 30. 20. 10. Users ,4&l0I
Figure 4. Tstage distribution between users and nonusers of tobacco or alcohol.
Comments
Tobacco smoke condensate has been proved to be a complete carcinogen-that is, by itself it can experimentally induce carcinomas [I]. The increased incidence of cancer in tobacco and alcohol contact tissues in patients who are chronic users of these two agents is proved and accepted [2-41. Also, Moore [5,6]
Johnston
and Ballantyne
8-J 70
70
60
60
50
50
40 40 30 30 20 LO 0’ ” I
10 .
Users No
Nonusers
Users Nl
NO
Nonusers
Nonusers
Users N2 & N3
Nl
N2 & N3
0 Users No
Figure 5. N stage distribution between tobacco users and nonusers.
Nonusers No
Users
Nonusers
Users
Nl
Nl
N2 & N3
Nonusers N2 & N3
Figure 6. N stage distribution between alcohol users and
68%
Users of Tobacco
Nonusers of Tobacco
Users
Nont+.ers
Figure 7. Frequency of use of surgery alone for treatment between users and nonusers of both tobacco and alcohol.
has proved an increased incidence (40 per cent) of second primary cancers developing in tobacco-contact tissues of those patients who continue to smoke after cure of a cancer of the oral cavity, pharynx, and larynx as compared with those who quit smoking (6 per cent incidence).
446
of Tobacco
of Tobacco
Nonusers of Alcohol
Figure 6. Frequency of use of radiotherapy for treatment between users and nonusers of both tobacco and alcohol.
The present retrospective case analysis was undertaken not to test any of these statistically proved facts but to assess the outcome of patients with a cancer of the oral tongue who are chronic users of tobacco and alcohol compared with those who are nonusers. The review has revealed some interesting
The American Journal of Surgery
Tobacco
contrasts. (1) Those patients listed as nonusers of tobacco who develop oral tongue cancer are predominantly females (75 per cent). (2) Those nonusers who develop an oral tongue cancer do so later in life than do the users of tobacco and alcohol. (3) Despite this fact, more of the users die of intercurrent disease within five years than do the older nonusers. (4) More of the users die due to tumor and due to second primary cancers than do the nonusers. (5) This increased incidence of death due to disease is not secondary to any difference in the pretreatment staging of their primary or neck disease, and it is not explained by any difference in their treatment. A possible explanation is that cancers induced by tobacco and alcohol are biologically more aggressive. Another possible explanation is a decrease in immunocompetence resulting in those patients who have chronically used tobacco and/or alcohol. The data presented here do not allow any statements regarding these possible explanations. A prospective study is indicated to consider the immunocompetence of both groups (users and nonusers) when they present with cancer of tobacco- or alcohol-contact tissues to see if a correlation exists among three factors: chronic alcohol and tobacco use; decreased immunocompetence; and poor prognosis.
Volume 134, October 1977
and Alcohol
and Oral Tongue
Cancer
Summary
A retrospective case analysis shows that patients with oral tongue cancer who have chronically used tobacco and alcohol have an increased incidence of death due to tumor, due to a second primary cancer, and due to intercurrent disease when compared with patients with oral tongue cancer who have never used tobaccoor alcohol,This difference is not explained by a difference in tumor staging, patients’ ages, or type of treatment received.
References 1. Wynder EL, Hoffmann D: Interpretation of experimental findings, p 623. Tobacco and Tobacco Smoke: Studies in Experimental Carcinogenesis. New York, Academic Press, 1967. 2. Vincent RG, Marchetta F: The relationship of the use of tobacco and alcohol to cancer of the oral cavity, pharynx or larynx. Am J Surg 106: 501, 1963. 3. Kissin 8. Kaley MM, Su WH, Lamer R: Head and neck cancer in aicohoiics: The relationship to drinking, smoking, and dietary patterns. JAMA 224: 1174. 1973. 4. Keller AZ, Terris M: The association of alcohol and tobacco with cancer of the mouth and pharynx. Am J Public Health 55: 1576, 1965. 5. Moore G: Smoking and cancer of the mouth, pharynx and larynx. JAMA 191: 283, 1965. 6. Moore C: Cigarette smoking and cancer of the mouth. pharynx and larynx: a continuing study. JAMA 218: 553. 1971.
Prognostic Effect of Tobacco and Alcohol Use in Patients with Oral Tongue Cancer William D. Johnston, MD, Columbia, Missouri A. J. Ballantyne, MD, Houston, Texas
Chronic users of tobacco and alcohol have a greater incidence of cancer of the mucosa exposed to these agents than nonusers of tobacco and alcohol. The present retrospective case analysis of patients with oral tongue cancer was done to compare the outcome of the users and nonusers of tobacco and alcohol.
per cent of males and only 41 per cent of females were chronic users of alcohol. Of the 308 patients who used either tobacco or alcohol or both, 96 (31.2 per cent) were dead due to tumor in five years. Only 6 of the 43 nonusers (13.9 per cent) died due to tumor within five years.
Material and Methods The charts of 351 patients treated for oral tongue cancer at the M.D. Anderson Hospital, Houston, Texas, between January 1,1948 and December 31,1967 were reviewed. A history of habits, including tobacco and alcohol use, has always been required on the initial history and physical form at the M.D. Anderson Hospital. The information on tobacco and alcohol usage in this review is mainly from this initial interview and from other available comments of follow-up examiners. Of these 351 patients, 52 (13 male, 39 female) claimed no use of tobacco, 105 (49 male, 56 female) claimed no use of alcohol, and only 43 claimed no use of either tobacco or alcohol.
Percent who developed a second primary cancer Percent who died due to second primary cancer
Results
Comparing tobacco and alcohol use according to sex, 94 per cent of males and only 61 per cent of females with oral tongue cancer used tobacco, and 76
From the Department of Surgery, Ellis Fischel State Cancer Hospital, and the Cancer Research Center, Columbia, Missouri, and the Head and Neck Service, M. D. Ardemon Hospital, f-buston, Texas. This work was supported in part by Clinical Cancer Education Program grant CA17946 from the National Cancer Institute. Reprint requests should be addressed to William Johnston, MD, Ellis Fischel State Cancer Hospital, Business 70 & Garth Avenue, Columbia, Missouri 65201. Presented at the Twenty-Third Annual Meeting of the Society of Head and Neck Surgeons, Hilton Head Island, South Carolina, May 4-7, 1977.
444
Users of Tobacco and Alcohol
Non-users of Tobacco and Alcohol
Figure 1. Incidence of second primary cancer in five fo twenty year follow-up after treatment of primary cancer. There was a greater incidence of second primary cancer and deaths due to second primary cancer in users of tobacco and alcohol than in nonusers.
The American Journal of Surgery
Tobacco and Alcohol and Oral Tongue Cancer NO-
1007 90 -
90.
&o-
eo-
70-
70. Z60
E60
0
0
z z
50-
g
40-
g
40-
A
?a-
A
30-
$50
ZO-
20-
lo-
lon ”
0 Nonusers (Male)
Users (Male)
Nonusers Users (Female) (Female)
OfTobacco Figure 2. Percentage otusers andnonusers of tobacco who develop oral tongue cancer at age seventy years or older.
Of the 351 patients, 206 (58.7 per cent) lived two years with no evidence of tumor. Of these 206 patients, 106 were chronic users of both tobacco and alcohol, and 29 of these 106 (27.4 per cent) developed a second primary cancer. Twenty-seven of the 206 who were free of tumor at two years were nonusers of tobacco and alcohol. Only five (18.5 per cent) of these developed a second primary cancer. (Figure 1.) Thirty-five of the 308 users of tobacco and/or alcohol (11.4 per cent) died of intercurrent disease within five years of treatment. Four of the 43 nonusers (9.3 per cent) died of intercurrent disease within five years. This does not appear to be significant until we note the percentage of users and nonusers of tobacco and alcohol who develop oral tongue cancer at age seventy years or older; Figures 2 and 3 show that nonusers of tobacco and alcohol are older when they develop oral tongue cancer than users of tobacco and alcohol. Figures 4,5, and 6 show the T and N staging distributions for users compared with nonusers of tobacco and alcohol. There is little difference except for a slightly higher percentage of No staging for nonusers. Figures 7 and 8 show no significant difference in the frequency of surgery and radiotherapy treatment for the two groups.
volume 134. octobof
1977
Nonusers Male)
Users (Male)
Users Nonusers (Female)(Female)
OfAlcohol Figure 3. Percentage of users and nonusers of akohol who develop oral tongue cancer at age seventy years or older.
IiBzi
*T3, 74 50 40. 30. 20. 10. Users ,4&l0I
Figure 4. Tstage distribution between users and nonusers of tobacco or alcohol.
Comments
Tobacco smoke condensate has been proved to be a complete carcinogen-that is, by itself it can experimentally induce carcinomas [I]. The increased incidence of cancer in tobacco and alcohol contact tissues in patients who are chronic users of these two agents is proved and accepted [2-41. Also, Moore [5,6]
Johnston
and Ballantyne
8-J 70
70
60
60
50
50
40 40 30 30 20 LO 0’ ” I
10 .
Users No
Nonusers
Users Nl
NO
Nonusers
Nonusers
Users N2 & N3
Nl
N2 & N3
0 Users No
Figure 5. N stage distribution between tobacco users and nonusers.
Nonusers No
Users
Nonusers
Users
Nl
Nl
N2 & N3
Nonusers N2 & N3
Figure 6. N stage distribution between alcohol users and
68%
Users of Tobacco
Nonusers of Tobacco
Users
Nont+.ers
Figure 7. Frequency of use of surgery alone for treatment between users and nonusers of both tobacco and alcohol.
has proved an increased incidence (40 per cent) of second primary cancers developing in tobacco-contact tissues of those patients who continue to smoke after cure of a cancer of the oral cavity, pharynx, and larynx as compared with those who quit smoking (6 per cent incidence).
446
of Tobacco
of Tobacco
Nonusers of Alcohol
Figure 6. Frequency of use of radiotherapy for treatment between users and nonusers of both tobacco and alcohol.
The present retrospective case analysis was undertaken not to test any of these statistically proved facts but to assess the outcome of patients with a cancer of the oral tongue who are chronic users of tobacco and alcohol compared with those who are nonusers. The review has revealed some interesting
The American Journal of Surgery
Tobacco
contrasts. (1) Those patients listed as nonusers of tobacco who develop oral tongue cancer are predominantly females (75 per cent). (2) Those nonusers who develop an oral tongue cancer do so later in life than do the users of tobacco and alcohol. (3) Despite this fact, more of the users die of intercurrent disease within five years than do the older nonusers. (4) More of the users die due to tumor and due to second primary cancers than do the nonusers. (5) This increased incidence of death due to disease is not secondary to any difference in the pretreatment staging of their primary or neck disease, and it is not explained by any difference in their treatment. A possible explanation is that cancers induced by tobacco and alcohol are biologically more aggressive. Another possible explanation is a decrease in immunocompetence resulting in those patients who have chronically used tobacco and/or alcohol. The data presented here do not allow any statements regarding these possible explanations. A prospective study is indicated to consider the immunocompetence of both groups (users and nonusers) when they present with cancer of tobacco- or alcohol-contact tissues to see if a correlation exists among three factors: chronic alcohol and tobacco use; decreased immunocompetence; and poor prognosis.
Volume 134, October 1977
and Alcohol
and Oral Tongue
Cancer
Summary
A retrospective case analysis shows that patients with oral tongue cancer who have chronically used tobacco and alcohol have an increased incidence of death due to tumor, due to a second primary cancer, and due to intercurrent disease when compared with patients with oral tongue cancer who have never used tobaccoor alcohol,This difference is not explained by a difference in tumor staging, patients’ ages, or type of treatment received.
References 1. Wynder EL, Hoffmann D: Interpretation of experimental findings, p 623. Tobacco and Tobacco Smoke: Studies in Experimental Carcinogenesis. New York, Academic Press, 1967. 2. Vincent RG, Marchetta F: The relationship of the use of tobacco and alcohol to cancer of the oral cavity, pharynx or larynx. Am J Surg 106: 501, 1963. 3. Kissin 8. Kaley MM, Su WH, Lamer R: Head and neck cancer in aicohoiics: The relationship to drinking, smoking, and dietary patterns. JAMA 224: 1174. 1973. 4. Keller AZ, Terris M: The association of alcohol and tobacco with cancer of the mouth and pharynx. Am J Public Health 55: 1576, 1965. 5. Moore G: Smoking and cancer of the mouth, pharynx and larynx. JAMA 191: 283, 1965. 6. Moore C: Cigarette smoking and cancer of the mouth. pharynx and larynx: a continuing study. JAMA 218: 553. 1971.