- Email: [email protected]
Oral cancer survival in young people in South East England
Oral Oncology (2007) 43, 982– 986
available at www.sciencedirect.com
journal homepage: http://intl.elsevierhealth.com/journals/oron/
Oral cancer survival in young people in South East England Saman Warnakulasuriya
a,*
¨ller , Vivian Mak b, Henrik Mo
b
a Department of Oral Medicine, King’s College Dental Institute at Guy’s, King’s and St Thomas’ Hospitals, WHO Collaborating Centre for Oral Cancer and Precancer, Denmark Hill Campus, Caldecot Road, London SE5 9RW, UK b Thames Cancer Registry, King’s College London, UK
Received 9 October 2006; accepted 26 November 2006 Available online 12 March 2007
KEYWORDS
Summary The incidence rate of oral cancer among young people in the UK has been increasing since 1970s. The objective of this study was to compare relative survival of young people (under 45 years of age) diagnosed with oral cancer with that of older people (45 years and older) resident in South East England. Between 1986 and 2002, 5 year relative survival was higher among young people compared with the older group, suggesting age was a strong independent predictor of survival. Apart from age other independent predictors of survival included stage, treatment and affluence but residence was not a significant predictor of survival in either age group. For the young age group (0–44 years) mean relative survival for the period under study was relatively constant but consistently higher in younger women than in younger men. c 2006 Elsevier Ltd. All rights reserved.
Oral cancer; Young people; Survival
Introduction
Squamous cell carcinoma of the oral cavity and oropharynx is rare in patients under the age of 45 years being primarily a disease that occurs in males in their sixth and seventh decade.1 Younger patients account for approximately 6% of all oral cancers in the UK.2 An alarming rise in the incidence of oral cancer among younger adults has been reported in Europe3–6 in the USA7,8 and in rest of the world.9 From US it was reported that between 1960 and mid 1980s male patients * Corresponding author. Tel.: +44 20 7 346 3608/+44 20 7 737 4000x2430; fax: +44 20 7 346 3624. E-mail address: [email protected] (S. Warnakulasuriya).
30–39 years of age exhibited a nearly fourfold increase in oral cancer incidence.7 This trend continued to 1990s for tongue cancer as the incidence increased fivefold among young men and sixfold among young women compared with only a twofold increase in older age groups.10 It is not clear whether young people have a significantly better or worse prognosis as compared with older patients. A review of published research provided conflicting views2 and some authors have commented on genetic factors contributing to the disease11 and furthermore poorer survival among young people.12 We aimed to examine the trends in relative survival in South East England among young and older patients diagnosed with oral or oropharyngeal cancer and variations in
1368-8375/$ - see front matter c 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.oraloncology.2006.11.021
Oral cancer survival in young people in South East England
983
mortality and survival across two broad age groups (0–44 vs 45+), in addition to treatment groups, socio-economic groups and the cancer network of residence.
carried out to mutually adjust the estimated parameters. Period analysis was used to estimate relative survival. Death certificate only (DCO) cases were excluded from the survival analysis.
Materials and methods Results Subjects with oral and oropharyngeal cancer (ICD-10 C00-06, C09-C10 and C14) with a period of follow up between1986 and 2002 were identified from the Thames Cancer Registry (TCR) database. Trends in survival were examined for the whole period 1986–2002 and variations in survival were examined for the more recent years 1995–2002. TCR covers a residential population of 14 million and 13 cancer networks, four of which are shared with neighbouring cancer registries. To examine trends in survival following oral cancer a total of 7937 men and 4854 women resident in the SE England at the time of cancer diagnosis were identified. To examine variations in survival analysis 4836 subjects 45 years and older and 483 subjects under 45 years were included. Their postcodes were used to assign them into cancer network of residence. The income domain coded by Indices of Deprivation13 was used to classify the subjects into five socio-economic groups. These ranged from most affluent (quintile 1) to the most deprived (quintile 5). Cox proportional hazards regression was used to estimate predictive factors of crude survival. The factors examined were those recorded at the time of diagnosis and initial treatment. These included age, stage, year of diagnosis, type of surgery and any radiotherapy received, their cancer network by residence and socio-economic status. Univariate analysis was used to describe the impact of each single factor on survival. Multivariate analysis was
Figure 1 shows the trends in relative survival of oral cancer patients by sex and by age groups (0–44; 45+ years) between 1986 and 2002. For the young age group (0–44 years) mean relative survival was relatively constant for the period but consistently higher in women than in men. Five-year relative survival was higher among young people compared with the older group throughout the period of analysis. The age was a strong independent predictor of crude survival (Table 1). Among both young and older age groups the proportion of oral and oropharyngeal cancers diagnosed at a localised stage (37% and 36%) was similar. Tables 2 and 3 show the hazards ratios with 95% confidence and p-values for age, stage and therapies received, by the two age groups. The stage at diagnosis, type of surgical therapy (investigative and no therapy recorded vs radical surgery) and whether radiotherapy was given or not, were all strong independent predictors of survival in both age groups. The multivariate analysis showed that these effects were not greatly influenced by other factors. Cancer network of residence (n = 13) was not a significant predictor of survival in either age group (data not shown). Socio-economic group was a significant predictor of survival (Table 4). Among young cases the trend was substantially attenuated by adjustment for stage and treatment.
Females
80
80
70
70
60
60
% Relative survival
% Relative survival
Males
50 40 30
0-44y
50 40 30
0-44y
45+y
20
20
10
10
0
45+y
0
1986-1990
1991-1995
1996-2000
2001-2002
1986-1990
Period of follow-up
1991-1995
1996-2000
2001-2002
Period of follow-up
Figure 1 Trends in 10 year relative survival in South East England, estimated with period analysis. Oral and pharyngeal cancer (ICD-10 C00-C06, C09-C10 and C14).
Table 1 Cox proportional hazards regression of oral and pharangeal cancer (ICD-10 C00-C06, C09-C10 anf C14) survival in South East England 1995–2002 variable: age Age group at diagnosis
Number
% Cases
Hazard ratio
Univariate
Hazard ratio
Multivariate
45 Plus 0–44
4836 483
91 9
1.00 0.47
– 0.40
1.00 0.50
– 0.42
p For trend
X2 = 427.7, p < 0.001
– 0.56
X2 = 415.9, p < 0.001
– 0.59
984
S. Warnakulasuriya et al.
Table 2 Cox proportional hazards regression of oral and pharyngeal cancer (ICD-10 C00-C06, C09-C10 and C14) survival in South East England, 1995–2002 variable: disease stage Disease stage
Cases
% Of cases
Univariate
Multivariate
Hazards ratio
LL
UL
Hazards ratio
LL
UL
Patients aged 0–44 years Local Extension beyond organ of origin Regional lymph node involvement Metastasis Not known Test for trend
181 46 88 28 140
37 10 18 6 29
1.00 – 2.23 1.26 1.98 1.22 2.57 1.30 1.96 1.25 x2 = 11.3, p < .001
– 3.95 3.22 5.08 3.06
1.00 – 1.86 1.00 1.79 1.05 1.89 0.91 1.61 0.99 x2 = 6.3, p = 0.012
– 3.44 3.01 3.91 2.64
Patients aged 45 years and over Local Extension beyond organ of origin Regional lymph node involvement Metastasis Not known Test for trend
1746 606 765 385 1334
36 13 16 8 28
1.00 – 1.98 1.75 1.50 1.33 2.96 2.57 1.85 1.67 X2 = 189.42, p < 0.001
– 2.25 1.71 3.41 2.05
1.00 – 1.92 1.69 2.10 1.84 3.15 2.72 1.72 1.53 X2 = 266.01, p < 0.001
– 2.19 2.40 3.64 1.92
Table 3 Cox proportional hazards regression of oral and pharyngeal cancer (ICD-10 C00-C06, C09-C10 and C14) survival in South East England 1995–2002 variable: types of treatment Types of treatment
Cases
% Of cases
Univariate Hazards ratio
Patients aged 0–44 years Surgery Radical surgery Investigative surgery only Other surgery No surgery recorded Test for heterogeneity Radiotherapy Radiotherapy No radiotherapy recorded Test for trend Patients aged 45 years and over Surgery Radical surgery Investigative surgery only Other surgery No surgery recorded Test for heterogeneity Radiotherapy Radiotherapy No radiotherapy recorded Test for trend
Multivariate LL
UL
Hazards ratio
LL
UL
75 77 270 61
16 16 56 13
1.00 – 1.61 0.92 0.85 0.52 1.58 0.88 X2 = 11.41, p = 0.003
– 2.81 1.38 2.81
1.00 – 1.97 1.07 1.18 0.71 1.98 1.01 x2 = 6.22, p = 0.45
– 3.64 1.97 3.88
231 252
48 52
1.00 – 1.75 1.23 X2 = 9.85, p = 0.002
– 2.47
1.00 – 1.43 0.97 x2 = 3.26, p = 0.071
– 2.09
507 1312 2301 716
10 27 48 15
1.00 – 2.16 1.85 1.12 0.96 1.91 1.61 x2 = 2.12, p < 0.001
– 2.53 1.31 2.26
1.00 – 2.20 1.87 1.11 0.95 1.41 1.16 x2 = 180.75, p < 0.001
– 2.59 1.31 1.70
2199 2637
45 55
1.00 – 1.00 0.93 x2 = 0.01, p = 0.923
– 1.09
1.00 – 0.85 0.77 x2 = 14.22, p < 0.001
– 0.92
Discussion Rising trends in oral cancer incidence in young people has been observed in western Europe.3,4,6,14 Much of the controversy regarding whether young patients fare better or worse than older patients has not been addressed. In a recent review of the Surveillance, Epidemiology and End Results (SEER) data
base, US authors10 reported that the overall 5-year survival was consistently higher among young adults for specific sites (tongue and tonsil) compared with adults P45 years (51% and 43%, respectively). Young patients with lung cancer are also reported to have better performance status.15 Our study based on a UK cancer registry confirms these findings that young people under 45 years of age have significantly
Oral cancer survival in young people in South East England
985
Table 4 Cox proportional hazards regression of oral and pharyngeal cancer (ICD-10 C00-C06, C09-C10 and C14) survival in South East England 1995–2002 variable: socio-economic status Socio-economic status
Cases
% Of cases
Multivariatea
Univariate Hazards ratio
Patients aged 0–44 years Affluent 2 3 4 Deprived Test for trend
LL
UL
Hazards ratio
LL
UL
83 74 85 111 130
17 15 18 23 27
1.00 – 1.19 0.62 1.16 0.62 1.53 0.87 2.12 1.23 x2 = 9.38, p < 0.002
– 2.27 2.17 2.71 3.66
1.00 – 1.04 0.51 1.11 0.56 1.38 0.72 1.74 0.88 x2 = 3.60, p = 0.058
– 2.10 2.21 2.62 3.44
Patients aged 45 years and over Affluent 1746 2 606 3 765 4 385 Deprived Not known 1334 Test for trend
36 13 16 8 28
1.00 – 1.98 1.75 1.50 1.33 2.96 2.57 1.85 1.67 X2 = 31.28, p < 0.001
– 2.25 1.71 3.41 2.05
1.00 – 1.92 1.69 2.10 1.84 3.15 2.72 1.72 1.53 X2 = 24.16, p < 0.001
– 2.19 2.40 3.64 1.92
a
Adjusted for disease stage and type of treatment.
higher survival rates. As the relative survival analyses corrects for other causes of deaths, these being expected to be higher in the older population, the finding appears to suggest that oral cancer is not more aggressive in young people than older people. An earlier meta-analysis16 of patients less than 40 years old and a selected older cohort of patients (matched for disease stage) indicated disease-specific outcomes were similar. The survival of oral SCC among young adults was constant over time. Lack of improvement on survival from this disease has been commented on previously.1 Treatment of early stage oral cancers achieves significantly higher survival. This may be reflected in our data that those receiving surgery as the form of treatment against those who had no surgery had better outcome. The group receiving radiotherapy alone, albeit advanced cases, also had significantly poorer outcomes. Others have previously concluded that young patients treated primarily with operative therapy do somewhat better than those treated with radiotherapy.17 Early diagnosis and referral is a key to achieve improved survival. A study identified three variables that account for delay in presentation among young people: lack of further education, perception of being under stress in the period prior to diagnosis and absence of risk factors.18 Recent UK Guidelines for referral and management of Head and Neck cancers for those suspected of mouth cancer could help to streamline patient’s cancer journeys particularly in the pre-treatment assessment period and help in earlier diagnosis as patients referred to hospitals from primary care would be seen within 2 weeks of referral.19 Cancer Centres were established across the UK to provide critical mass of cases and the necessary skill mix for care. It has been proposed that the outcome for some site-specific cancers (e.g. prostate cancer) could vary between cancer networks.20 Our study that explored regional variation in the performance (by patient survival) of Cancer Networks, does not suggest that the postcode of residence influences treatment outcomes in oral cancer within South East England.
We have found a significant difference in survival rates between affluent and non affluent groups among the young people (Table 4). This discrepant trend in survival may reflect less patient delay in seeking care or better nutrition among the affluent group. A gap between survival from cancer of most affluent and most deprived has been reported.21 and this may reflect several barriers to consult a physician, including lack of awareness of early symptoms and access to care. We proposed to examine patient journeys from the time of the first symptom to seeing a specialist to explore what deficiencies exist in care pathways within the National Health Service for providing care for young people with oral cancer.
Conclusion From an analysis of secondary data based on the population resident in Southern England it does not appear that developing oral cancer at a younger age necessarily carries a poorer prognosis. Delay and extent (stage) of the tumour at presentation which perhaps determines treatment and host’s affluence rather than chronological age appear to determine the outcome.
References 1. Cancer Research UK. Oral Cancer UK, 2005. 2. Llewellyn CD, Johnson NW, Warnakulasuriya KAAS. Risk factors for squamous cell carcinoma of the oral cavity in young people – a comprehensive literature review. Oral Oncology 2001;37: 401–18. 3. Moller H. Changing incidence of cancer of the tongue, oral cavity, and pharynx in Denmark. J Oral Pathol Med 1989;18: 224–9. 4. Macfarlane GJ, Boyle P, Scully C. Rising mortality from cancer of the tongue in young Scottish males. Lancet 1987;2:912. 5. Macfarlane GJ, Boyle P, Scully C. Oral cancer in Scotland: changing incidence and mortality. BMJ 1992;305:1121–3. 6. Annertz K, Anderson H, Biorklund A, et al. Incidence and survival of squamous cell carcinoma of the tongue in Scandi-
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13.
S. Warnakulasuriya et al. navia, with special reference to young adults. Int J Cancer 2002;101:95–9. Chen J, Eisenberg E, Krutchkoff DJ, Katz RV. Changing trends in oral cancer in the United States, 1935–1985: A Connecticut study. J Oral Maxillofac Surg 1991;49:1152–58. Schantz SP, Yu GP. Head and neck cancer incidence trends in young Americans, 1973–1997, with a special analysis for tongue cancer. Arch Otolaryngol Head Neck Surg 2002; 128:268–74. Macfarlane GJ, Boyle P, Evstifeeva TV, et al. Rising trends of oral cancer mortality among males worldwide: the return of an old public health problem. Cancer Causes Control 1994;5: 259–65. Shiboski CH, Schmidt BL, Jordon RCK. Tongue and tonsil carcinoma; increasing trends in the US population ages 20–44 years. Cancer 2005;103:1843–9. Mackenzie J, Ah-See K, Thakker N, Sloan P, Maran AG, Birch J, Macfarlane GF. Increasing incidente of oral cancer amongst young persons: what is the aetiology? Oral Oncology 2000;36: 387–9. Schantz SP, Byers RM, Goepfert H, Shallenberger RC, Beddingfield N. The implications of tobacco use in the young adult with head and neck cancer. Cancer 1988;62:1374–80. Department for Communities and Local Government (UK); 2000. http://www.communities.gov.uk/index.asp?id=1128452.
14. Levi F, La Vecchia C, Randimbson L, Te V-C. Cancer incidence and mortality in young adults in Vaud, Switzerland, 1974–1992. Int J Cancer 1995;61:606–610. 15. Radzikowska E, Roszkowski K, Glaz P. Lung cancer patients under 50 years old. Lung cancer 2001;33:203–11. 16. Pitman KT, Johnson JT, Wagner RL, Myers EN. Cancer of the tongue in patients less than forty. Head and Neck 2000;22: 297–302. 17. Newman AN, Rice DH, Ossoff RH, Sisson GA. Carcinoma of the tongue in persons younger than 30 years of age. Arch Otolaryngol 1983;109:302–4. 18. Llewellyn CD, Johnson NW, Warnakulasuriya S. Factors associated with delay in presentation among younger patients with oral cancer. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97:707–13. 19. National institute for clinical excellence. Improving outcomes in head and neck cancers. NICE, 2004. 20. Thames cancer registry. Prostate cancer in South East England: Cancer network perspective. Cancer in South East England 2002. London: Thames Cancer Registry 2005. pp. 69–80. 21. Coleman M, Babb P, Damiecki P. Cancer survival trends in England and Wales 1971–1995 Deprivation and NHS region. Studies on Medical and Population Subjects No 61. Stationery Office Books 1999.
available at www.sciencedirect.com
journal homepage: http://intl.elsevierhealth.com/journals/oron/
Oral cancer survival in young people in South East England Saman Warnakulasuriya
a,*
¨ller , Vivian Mak b, Henrik Mo
b
a Department of Oral Medicine, King’s College Dental Institute at Guy’s, King’s and St Thomas’ Hospitals, WHO Collaborating Centre for Oral Cancer and Precancer, Denmark Hill Campus, Caldecot Road, London SE5 9RW, UK b Thames Cancer Registry, King’s College London, UK
Received 9 October 2006; accepted 26 November 2006 Available online 12 March 2007
KEYWORDS
Summary The incidence rate of oral cancer among young people in the UK has been increasing since 1970s. The objective of this study was to compare relative survival of young people (under 45 years of age) diagnosed with oral cancer with that of older people (45 years and older) resident in South East England. Between 1986 and 2002, 5 year relative survival was higher among young people compared with the older group, suggesting age was a strong independent predictor of survival. Apart from age other independent predictors of survival included stage, treatment and affluence but residence was not a significant predictor of survival in either age group. For the young age group (0–44 years) mean relative survival for the period under study was relatively constant but consistently higher in younger women than in younger men. c 2006 Elsevier Ltd. All rights reserved.
Oral cancer; Young people; Survival
Introduction
Squamous cell carcinoma of the oral cavity and oropharynx is rare in patients under the age of 45 years being primarily a disease that occurs in males in their sixth and seventh decade.1 Younger patients account for approximately 6% of all oral cancers in the UK.2 An alarming rise in the incidence of oral cancer among younger adults has been reported in Europe3–6 in the USA7,8 and in rest of the world.9 From US it was reported that between 1960 and mid 1980s male patients * Corresponding author. Tel.: +44 20 7 346 3608/+44 20 7 737 4000x2430; fax: +44 20 7 346 3624. E-mail address: [email protected] (S. Warnakulasuriya).
30–39 years of age exhibited a nearly fourfold increase in oral cancer incidence.7 This trend continued to 1990s for tongue cancer as the incidence increased fivefold among young men and sixfold among young women compared with only a twofold increase in older age groups.10 It is not clear whether young people have a significantly better or worse prognosis as compared with older patients. A review of published research provided conflicting views2 and some authors have commented on genetic factors contributing to the disease11 and furthermore poorer survival among young people.12 We aimed to examine the trends in relative survival in South East England among young and older patients diagnosed with oral or oropharyngeal cancer and variations in
1368-8375/$ - see front matter c 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.oraloncology.2006.11.021
Oral cancer survival in young people in South East England
983
mortality and survival across two broad age groups (0–44 vs 45+), in addition to treatment groups, socio-economic groups and the cancer network of residence.
carried out to mutually adjust the estimated parameters. Period analysis was used to estimate relative survival. Death certificate only (DCO) cases were excluded from the survival analysis.
Materials and methods Results Subjects with oral and oropharyngeal cancer (ICD-10 C00-06, C09-C10 and C14) with a period of follow up between1986 and 2002 were identified from the Thames Cancer Registry (TCR) database. Trends in survival were examined for the whole period 1986–2002 and variations in survival were examined for the more recent years 1995–2002. TCR covers a residential population of 14 million and 13 cancer networks, four of which are shared with neighbouring cancer registries. To examine trends in survival following oral cancer a total of 7937 men and 4854 women resident in the SE England at the time of cancer diagnosis were identified. To examine variations in survival analysis 4836 subjects 45 years and older and 483 subjects under 45 years were included. Their postcodes were used to assign them into cancer network of residence. The income domain coded by Indices of Deprivation13 was used to classify the subjects into five socio-economic groups. These ranged from most affluent (quintile 1) to the most deprived (quintile 5). Cox proportional hazards regression was used to estimate predictive factors of crude survival. The factors examined were those recorded at the time of diagnosis and initial treatment. These included age, stage, year of diagnosis, type of surgery and any radiotherapy received, their cancer network by residence and socio-economic status. Univariate analysis was used to describe the impact of each single factor on survival. Multivariate analysis was
Figure 1 shows the trends in relative survival of oral cancer patients by sex and by age groups (0–44; 45+ years) between 1986 and 2002. For the young age group (0–44 years) mean relative survival was relatively constant for the period but consistently higher in women than in men. Five-year relative survival was higher among young people compared with the older group throughout the period of analysis. The age was a strong independent predictor of crude survival (Table 1). Among both young and older age groups the proportion of oral and oropharyngeal cancers diagnosed at a localised stage (37% and 36%) was similar. Tables 2 and 3 show the hazards ratios with 95% confidence and p-values for age, stage and therapies received, by the two age groups. The stage at diagnosis, type of surgical therapy (investigative and no therapy recorded vs radical surgery) and whether radiotherapy was given or not, were all strong independent predictors of survival in both age groups. The multivariate analysis showed that these effects were not greatly influenced by other factors. Cancer network of residence (n = 13) was not a significant predictor of survival in either age group (data not shown). Socio-economic group was a significant predictor of survival (Table 4). Among young cases the trend was substantially attenuated by adjustment for stage and treatment.
Females
80
80
70
70
60
60
% Relative survival
% Relative survival
Males
50 40 30
0-44y
50 40 30
0-44y
45+y
20
20
10
10
0
45+y
0
1986-1990
1991-1995
1996-2000
2001-2002
1986-1990
Period of follow-up
1991-1995
1996-2000
2001-2002
Period of follow-up
Figure 1 Trends in 10 year relative survival in South East England, estimated with period analysis. Oral and pharyngeal cancer (ICD-10 C00-C06, C09-C10 and C14).
Table 1 Cox proportional hazards regression of oral and pharangeal cancer (ICD-10 C00-C06, C09-C10 anf C14) survival in South East England 1995–2002 variable: age Age group at diagnosis
Number
% Cases
Hazard ratio
Univariate
Hazard ratio
Multivariate
45 Plus 0–44
4836 483
91 9
1.00 0.47
– 0.40
1.00 0.50
– 0.42
p For trend
X2 = 427.7, p < 0.001
– 0.56
X2 = 415.9, p < 0.001
– 0.59
984
S. Warnakulasuriya et al.
Table 2 Cox proportional hazards regression of oral and pharyngeal cancer (ICD-10 C00-C06, C09-C10 and C14) survival in South East England, 1995–2002 variable: disease stage Disease stage
Cases
% Of cases
Univariate
Multivariate
Hazards ratio
LL
UL
Hazards ratio
LL
UL
Patients aged 0–44 years Local Extension beyond organ of origin Regional lymph node involvement Metastasis Not known Test for trend
181 46 88 28 140
37 10 18 6 29
1.00 – 2.23 1.26 1.98 1.22 2.57 1.30 1.96 1.25 x2 = 11.3, p < .001
– 3.95 3.22 5.08 3.06
1.00 – 1.86 1.00 1.79 1.05 1.89 0.91 1.61 0.99 x2 = 6.3, p = 0.012
– 3.44 3.01 3.91 2.64
Patients aged 45 years and over Local Extension beyond organ of origin Regional lymph node involvement Metastasis Not known Test for trend
1746 606 765 385 1334
36 13 16 8 28
1.00 – 1.98 1.75 1.50 1.33 2.96 2.57 1.85 1.67 X2 = 189.42, p < 0.001
– 2.25 1.71 3.41 2.05
1.00 – 1.92 1.69 2.10 1.84 3.15 2.72 1.72 1.53 X2 = 266.01, p < 0.001
– 2.19 2.40 3.64 1.92
Table 3 Cox proportional hazards regression of oral and pharyngeal cancer (ICD-10 C00-C06, C09-C10 and C14) survival in South East England 1995–2002 variable: types of treatment Types of treatment
Cases
% Of cases
Univariate Hazards ratio
Patients aged 0–44 years Surgery Radical surgery Investigative surgery only Other surgery No surgery recorded Test for heterogeneity Radiotherapy Radiotherapy No radiotherapy recorded Test for trend Patients aged 45 years and over Surgery Radical surgery Investigative surgery only Other surgery No surgery recorded Test for heterogeneity Radiotherapy Radiotherapy No radiotherapy recorded Test for trend
Multivariate LL
UL
Hazards ratio
LL
UL
75 77 270 61
16 16 56 13
1.00 – 1.61 0.92 0.85 0.52 1.58 0.88 X2 = 11.41, p = 0.003
– 2.81 1.38 2.81
1.00 – 1.97 1.07 1.18 0.71 1.98 1.01 x2 = 6.22, p = 0.45
– 3.64 1.97 3.88
231 252
48 52
1.00 – 1.75 1.23 X2 = 9.85, p = 0.002
– 2.47
1.00 – 1.43 0.97 x2 = 3.26, p = 0.071
– 2.09
507 1312 2301 716
10 27 48 15
1.00 – 2.16 1.85 1.12 0.96 1.91 1.61 x2 = 2.12, p < 0.001
– 2.53 1.31 2.26
1.00 – 2.20 1.87 1.11 0.95 1.41 1.16 x2 = 180.75, p < 0.001
– 2.59 1.31 1.70
2199 2637
45 55
1.00 – 1.00 0.93 x2 = 0.01, p = 0.923
– 1.09
1.00 – 0.85 0.77 x2 = 14.22, p < 0.001
– 0.92
Discussion Rising trends in oral cancer incidence in young people has been observed in western Europe.3,4,6,14 Much of the controversy regarding whether young patients fare better or worse than older patients has not been addressed. In a recent review of the Surveillance, Epidemiology and End Results (SEER) data
base, US authors10 reported that the overall 5-year survival was consistently higher among young adults for specific sites (tongue and tonsil) compared with adults P45 years (51% and 43%, respectively). Young patients with lung cancer are also reported to have better performance status.15 Our study based on a UK cancer registry confirms these findings that young people under 45 years of age have significantly
Oral cancer survival in young people in South East England
985
Table 4 Cox proportional hazards regression of oral and pharyngeal cancer (ICD-10 C00-C06, C09-C10 and C14) survival in South East England 1995–2002 variable: socio-economic status Socio-economic status
Cases
% Of cases
Multivariatea
Univariate Hazards ratio
Patients aged 0–44 years Affluent 2 3 4 Deprived Test for trend
LL
UL
Hazards ratio
LL
UL
83 74 85 111 130
17 15 18 23 27
1.00 – 1.19 0.62 1.16 0.62 1.53 0.87 2.12 1.23 x2 = 9.38, p < 0.002
– 2.27 2.17 2.71 3.66
1.00 – 1.04 0.51 1.11 0.56 1.38 0.72 1.74 0.88 x2 = 3.60, p = 0.058
– 2.10 2.21 2.62 3.44
Patients aged 45 years and over Affluent 1746 2 606 3 765 4 385 Deprived Not known 1334 Test for trend
36 13 16 8 28
1.00 – 1.98 1.75 1.50 1.33 2.96 2.57 1.85 1.67 X2 = 31.28, p < 0.001
– 2.25 1.71 3.41 2.05
1.00 – 1.92 1.69 2.10 1.84 3.15 2.72 1.72 1.53 X2 = 24.16, p < 0.001
– 2.19 2.40 3.64 1.92
a
Adjusted for disease stage and type of treatment.
higher survival rates. As the relative survival analyses corrects for other causes of deaths, these being expected to be higher in the older population, the finding appears to suggest that oral cancer is not more aggressive in young people than older people. An earlier meta-analysis16 of patients less than 40 years old and a selected older cohort of patients (matched for disease stage) indicated disease-specific outcomes were similar. The survival of oral SCC among young adults was constant over time. Lack of improvement on survival from this disease has been commented on previously.1 Treatment of early stage oral cancers achieves significantly higher survival. This may be reflected in our data that those receiving surgery as the form of treatment against those who had no surgery had better outcome. The group receiving radiotherapy alone, albeit advanced cases, also had significantly poorer outcomes. Others have previously concluded that young patients treated primarily with operative therapy do somewhat better than those treated with radiotherapy.17 Early diagnosis and referral is a key to achieve improved survival. A study identified three variables that account for delay in presentation among young people: lack of further education, perception of being under stress in the period prior to diagnosis and absence of risk factors.18 Recent UK Guidelines for referral and management of Head and Neck cancers for those suspected of mouth cancer could help to streamline patient’s cancer journeys particularly in the pre-treatment assessment period and help in earlier diagnosis as patients referred to hospitals from primary care would be seen within 2 weeks of referral.19 Cancer Centres were established across the UK to provide critical mass of cases and the necessary skill mix for care. It has been proposed that the outcome for some site-specific cancers (e.g. prostate cancer) could vary between cancer networks.20 Our study that explored regional variation in the performance (by patient survival) of Cancer Networks, does not suggest that the postcode of residence influences treatment outcomes in oral cancer within South East England.
We have found a significant difference in survival rates between affluent and non affluent groups among the young people (Table 4). This discrepant trend in survival may reflect less patient delay in seeking care or better nutrition among the affluent group. A gap between survival from cancer of most affluent and most deprived has been reported.21 and this may reflect several barriers to consult a physician, including lack of awareness of early symptoms and access to care. We proposed to examine patient journeys from the time of the first symptom to seeing a specialist to explore what deficiencies exist in care pathways within the National Health Service for providing care for young people with oral cancer.
Conclusion From an analysis of secondary data based on the population resident in Southern England it does not appear that developing oral cancer at a younger age necessarily carries a poorer prognosis. Delay and extent (stage) of the tumour at presentation which perhaps determines treatment and host’s affluence rather than chronological age appear to determine the outcome.
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