Multiple mouth-throat cancer

Multiple CONDICT

Mouth-Throat MOORE,

M.D., Louisville, Kentucky

From the Department of Surgery, University of Louisville &hoot of Medicine, Louisville, Kentucky.

NTEREST in the occurrence, incidence, and I location of multiple cancers has increased in

recent years because such studies are coming to provide new insights of both theoretic and practical importance. One example of their value is the finding that multiple primary cancers in the same organ or tissue occur commonly, whereas the incidence of such cancers in different organs in the same patient probably does not exceed chance expectancy [l]. The vague concept of the innate susceptibility of a particular tissue may be invoked to explain this, but a more convincing and important reason for the differences probably lies in the inadvertent, continuing exposure of the tissue to external carcinogenic substances [I]. Such a situation applies in the upper digestive and respiratory tract, where new cancer develops in the nonkeratinizing, squamous, and respiratory epithelium with greater frequency than any in other tissue, except the skin [I], and where exposure is frequent to external agents which cause cancer in animals

PI.

Cancer

Another use of multiple cancer data was recently demonstrated by a study of multiple, nonsimultaneous cancers as a method for identifying external substances that are carcinogenic for humans [3]. By documenting patients’ exposure to an agent prior to their first cancer and then dividing the patients into two groups, after their curative treatment, according to whether or not they continue exposing themselves to the agent, one can gain direct evidence about the carcinogenicity of the particular substance. This is done simply by observing over the years any difference in the incidence of second, similar cancers between the two groups. Tobacco has been identified

by this method as a necessary component of the cancer-causing complex in most cancers of the mouth, pharynx, and larynx [3]. The true incidence of new, second cancers in any tissue probably will run higher than presently reported when long term studies emerge on the health of entire, local populations. Also, as Moertel states, “if future advances in cancer therapy bring about a progressively larger percentage of long-term survivors, then the proportion of cancer patients who fall victim to a second primary doubtless will increase.” [4] In the following report we make no attempt to authenticate the true incidence of second cancers in the mouth and throat area. The numbers are too small and the criteria for second cancers too strict for this purpose. We do wish, however, to emphasize that second cancers of this tissue occur in sufficient numbers to warrant our taking strict precautionary measures against them. MATERIALS AND RESULTS One hundred forty patients with cancer of the mouth, pharynx, or larynx survived treatment without recurrence for three years or more; these patients were the successfully treated ones from a group of nearly 600 patients with similar cancers seen over a nine year period in two University of Louisville Hospitals* and in a private office. Using strict criteria to identify second, new cancers [3], we found thirty-one patients (22 per cent) who developed new cancers in the same tissues within an average period of roughly six years after their first one. (It is interesting that Wilkins [5] found a 22 per cent incidence of second mouth primaries and Moertel [4] found 16 per cent.) Esophageal and lung cancer has been

* Louisville General Hospital; Veterans Administration Hospital, Louisville, Kentucky. 534

American

Journal

of Surgery

Multiple

Mouth-Throat

Cancer

X-25

TABLE I LOCATIONSOF CASCERS

Floor of mouth Tongue...... ..__._......._____ Palate. Gum........ Buccal mucosa. Larynx (glottic), Larynx (extraglottic). Tonsil. Pharynx. Esophagus. Lung.

First

Second

12

2

8 4 4

4 4 2

1

3 3 1 1 3

1 1

0 0 0 0

1 4 SECOND’

CANCERS

FIG. 1.

included in this tabulation of second cancers because these tissues share a general similarity of epithelial lining; furthermore, for purposes of studying possible external carcinogenic agents, all of these tissues are reached by some of the agents likely to be studied. The mean age of the thirty-one patients with second cancers was approximately fiftyfive years at the time of first cancer diagnosis; this is three years younger than the mean age of the larger group. One quarter of this small group was under the age of fifty, while one third of the group were women. Nearly all of the first cancers occurred in the mouth, while only half of the second cancers developed in the mouth structures, the other half coming in less accessible and less curable regions posteriorly (pharynx, larynx, esophagus, and lung (Fig. 1, Table I). Three or more cancers developed in six patients: three in the buccol mucosa; two in the esophagus ; one in the palate. One hundred twenty-four patients furnished adequate smoking data before and after their first cancer treatment. Since we are interested in the effect of tobacco on the development of mouth and throat cancer, we excluded, for the purpose of a tobacco-cancer analysis, seven patients who had never used tobacco at all. Obviously cancer can occur without tobacco, although rarely does so. Therefore, 117 smokers remained with smoking data suitable for analysis of the tobacco relationship. The distribution of second cancers between smokers who quit tobacco and those who continued its use is as follows: four of forty-three who quit had second cancers; and second cancers developed in twenty-seven of seventy-four Vol. 110. OC~O~PI. 1965

patients who continued to smoke. The difference In distribution is highly significant. (P<.Ol) A comparatively large number of the thirtyone patients with second cancers have died (nineteen of thirty-one), all but two dying from their second cancers. Only one patient died of causes other than cancer. Two patients are living with uncontrolled second cancers. Ten of the group are living and well five years or more. The numbers are small, but they indicate the surprising and overwhelming importance of second cancers as a threat to the patient who has been successfully treated for his first cancer. SUMMARY

AND CONCLUSIONS

Second cancers will develop in more than 20 per cent of “cured” mouth or throat cancer patients in the same organ system in an average of six years. Nearly all of these will be patients who continue to use tobacco. _Vost of the patients in whom second cancers develop will not be cured and will die of these second cancers. The clinical implications and conclusions that are obvious from the above are well stated by Yfoertel [4]: “Possible etiologic factors should be eliminated from the patient’s environment, premalignant lesions should be eradicated promptly, and in the absence of distant metastases, so-called recurrences should be treated with the same vigor as the initial lesion. ” REFERENCES

1. MOERTEL, C. G., DOCKERTY,M. B., and BAGENSTOSS, A. H. Multiple primary malignant neoplasms. I Introduction and presentation of data. II. Tumors of different organs. III. Tumors of multicentric origin. Cancer, 144: 221, 1961.

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Moore

2. WYNDER, E. L., GRAHAM, E. A., and CRONINGER, A. B. Experimental production of carcinoma with cigarette tar. Cancer Res., 13: 855, 1953. 3. MOORE, C. Smoking and cancer of the mouth, pharynx and larynx. J.A .M.A ., 191: 107, 1965.

4. MOERTEL, C. G. Incidence and significance of multiple primary malignant neoplasms. Ann. New York Acad. SC., 114: 886, 1964. 5. WILKINS, S. and VOGELER, W. Carcinoma of the gingiva. Surg. Gynec. & Obst., 105: 145, 1957.

American Journal

of Surgery