Profile of Head and Neck Cancer Patients in The Department of. Otorhinolaringology-Head and Neck Surgery Department Faculty

Transcription

1 Profile of Head and Neck Cancer Patients in The Department of Otorhinolaringology-Head and Neck Surgery Department Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital Bandung in The Period Inez Aulia Rakhmawulan 1, Yussy Afriani Dewi 2, Nursiah Nasution 3 1 Faculty of Medicine, 2 Departement of Otorhinolaringology, Head and Neck Surgery, 3 Departement of Cell Biology, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung 1 Inez Aulia Rakhmawulan Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km. 21, Jatinangor, Sumedang. Phone: inez.rakhmawulan@gmail.com 2 Yussy Afriani Dewi, dr., SpTHT-KL(K), M.Kes Department of Otorhinolaringology-Head and Neck Surgery, Faculty of Medicine, Universitas Padjadjaran, Dr. Hasan Sadikin General Hospital, Jalan Pasteur No. 38 Bandung Phone: yussyad@yahoo.com 3 Nursiah Nasution, dr., Department of Cell Biology, Faculty of Medicine, Universitas Padjadjaran/ Dr. Hasan Sadikin General Hospital, Jalan Prof. Eykman No. 38 Bandung Phone:

2 Abstract Background: Head and neck cancer is a health problem with a high mortality rate. Head and neck cancer are increasing and effect many individuals from diverse backgrounds. Usually patients come with terminal stages, until it decreases their quality of life. The point of this study is to ascertain the profile of head and neck cancer patients at the Otorhinolaringology, Head and Neck Surgery Departement, Dr. Hasan Sadikin General Hospital Bandung during Methods: A descriptive cross sectional method from medical records of head neck cancer patients at the Otorhinolaringology, Head and Neck Surgery Departement, Dr. Hasan Sadikin General Hospital Bandung period that used the total sampling method. Results: 665 patients were included in this research, of them 388 were men and 277 were women. Most of them were elementary educated (44.96%), housewives (32.03%), and those aged years old (28.33%). There were nasopharyngeal (38.20%), sinonasal (17.29%), larnyx (13.08%), oropharnyx (6.32%), thyroid gland (6.17%), oral cavity (3.91%), hypopharynx (2.41%), parotid gland (2.26%) cancer, and also found Non Hodgkin Malignant Lymphoma (9.32%). The major histopathological findings were Undifferentiated Carcinoma (45.41%) and Squamous Cell Carcinoma (22.26%). Patients with stage I (7.4%), II (13.5%), III (24.4%), IV (54.7%). Conclusion: Head neck cancer incidences were 6.65%, with nasopharyngeal carcinoma (38.20%) cases being most predominant. There was a higher instance 2

3 in elderly, men, and low education. Housewives are highly effected. Patients came with terminal stages, undifferentiated carcinoma was the major histopathology. Keywords: Head and Neck Cancer, Incidence, Terminal Stages Introduction Currently, head neck cancer ranks sixth after breast cancer, colon, and rectum, lungs, uterus, and cervix, also prostate and bladder. Worldwide incidence of head neck cancer is around 650,000 cases per year with a mortality rate of 350,000 cases per year. 1 It is increasing in incidence over the past three decades. 2 The term head and neck cancer is usually used to describe all carcinoma arising from upper aerodigestive tract such as sinonasal tract, oral cavity, pharynx, and larnyx, usually reffered to squamous cell carcinoma because it is the predominant histopathology. 2 Risk factors for this illness include a history of smoking, exposure to carcinogens, diet, oral hygiene, infectious diseases such as Human Papilloma Virus (HPV), and Epstein Barr Virus (EBV), family history, and alcohol consumption. 3-5 Age, gender, race, and social economic status are also important for determining the risk of head and neck cancer. 6 Head neck cancer is an important health problem. This kind of cancer is usually three to five times more prevalent among men than women. The prognosis for head neck cancer depends on the stage of the illness. 5, 6 Patients suffering from early stages of this cancer have a better quality of life post treatment when compared to terminal stage patients. Cancer patients will never regain a normal standard of health. 7 If this fact doesn t receive appropriate attention, then an 3

4 increase in the incidence of head neck cancer is possible. This study was conducted to determine the profile of head neck cancer patients at the Otorhinolaringology, Head and Neck Surgery Departement, Dr. Hasan Sadikin General Hospital Bandung during Methods This study was carried out from August to October 2013 at the THT-KL Department FK Unpad / RSUP. Dr. Hasan Sadikin Bandung used the cross sectional descriptive method. The population was all the head neck cancer patients that were hospitalized and or received outpatient treatment at the Otorhinolaringology, Head and Neck Surgery Departement, Dr. Hasan Sadikin General Hospital Bandung during Medical records from research subjects served as the secondary data. A total sampling method was used to collect the sample. Head and neck cancer is choosen based on clinical diagnosis, in the tumor subsites such as carcinoma nasopharyngeal, laryngeal carcinoma, sinonasal malignant tumors, oropharynx, hypopharynx, mouth cavity, neck, Hodgkin lymphoma and non-hodgkin lymphoma based on the American Joint Committee on Cancer (AJCC) of The sample taken were all the subjects that had the complete data and encompass all the variables needed such as age, sex, job, education, clinical diagnosis, and stage of cancer. From a total of 1,006 medical records, 665 were examined because they had all the variables needed. Data was derived with 4

5 descriptive statistics, using frequency and percentage calculations; the results of the study are illustrated in tables. Age is grouped by Health Department of Indonesia in 2009 to toddlers (0-5 years old), kids (5-11 years old), early adolscence (12-16 years old), late adolscence (17-25 yerars old), early adult (26-35 years old), late adult (36-45 years old), early elderly (46-55 years old), late elderly (56-65 years old) and seniors (>65 years old). 9 Education is grouped into uneducated, elementary school, middle school, university. Empoleyment is divided to unemployed, laborer, farmer, houswife, government worker, private worker, student, and others. Histopathological findings were classified base on World Health Organization Classification of Tumor in Tumor staging is grouped by the location and TNM criteria based on AJCC 2010 to stage I, II, III, IV. 8 Results During the research period there were 1,006 head and neck cancer patients of the Otorhinolaringology, Head and Neck Surgery Departement, Dr. Hasan Sadikin General Hospital Bandung during , but only 665 were examined due to the completeness of data in medical records. There were more of Male patients than the female patients, with the ratio of 1,4:1. The predominant of head and neck clinical diagnosis were nasopharingeal carcinoma (38.2%), followed by sinonasal (17.29%), and larynx (13.08%) (Table 1). 5

6 Table 1 Head and Neck Cancer Subsites Subsites Males Females n % n % Σ % Nasopharynx Sinonasal and Nasal Cavity Larynx Non Hodgkin Malignant Lymphoma Oropharynx Thyroid Gland Oral Cavity Hipopharynx Parotid Gland Neck Σ The predominant education level were elementary school educated as many as 299 patients (45%), 175 patients of high school educated patients (26,3%) and 111 middle school educated patients (16,7%). Based on the background, housewives were highly affected (32,0%). Patients in the group of years old were predominantly found, as many as 285 patients (28,3%) (Table 2). The major histological findings found in this research were undifferentiated carcinoma in 302 patients (45.4%), Squamous Cell Carcinoma in 6

7 148 patients (22.3%) (Table 3). There were 364 patients (54.7%) on the stage IV, 162 patients (24,4%) on the stage III (Table 4). Table 2 Head and Neck Cancer Patient Profile Variables n % Education Elementary School High School Middle School Uneducated University Employment Housewife Laborer Unemployed Entrepreneur Private Worker Farmer Government Worker Student Retired Other Age > Median age 50 Mode of Age 50 Mean ± std dev age ± Age Range

8 Table 3 Histopathological Finding of Head and Neck Cancer Histopathology n (%) Undifferentiated Carcinoma Squamous Cell Carcinoma Non Hodgkin Malignant Lymphoma Papillary Carcinoma Folicullar Neoplasm Adenoid Cystic Carcinoma Adenoid Cystic Carcinoma Adenocarcinoma Adenocarcinoma Pleomorphic Adenoma Mucoepidermoid Carcinoma Transitional Cell Carcinoma Anaplastic Carcinoma Acinic Cell Carcinoma Angiosarcoma Acinic Cell Ca Adenosquamous Cell Carcinoma Basal Cell Carcinoma Hemangioperisitoma Melanoma Maligna Myxofibrosarcoma rabdomiosarcoma Spindle Cell Carcinoma

9 Table 4 Stage of Head and Neck Cancer Stage n % I II III IV Total Discussion A tumor is an abnormal growth of tissue, where cells multiply excessivly and in an uncontrolled manner. There are two kinds of tumors: benign and malignant. A tumor is classified as malignant when the growth infiltrates the surrounding tissue and starts to metastasize; this is known as a carcinoma. 11 The term head and neck cancer is used to describe all types of cancers stemming from the upper aerodigestive tract, such as sinonasal tract, the oral cavity, the pharynx, or the larynx. It is normally reffered to squamous cell carcinoma, because it is the most common histopathology. 2 Out of the 15,138 patients in Otorhinolaringology, Head and Neck Department, Faculty of Medicine, Universitas Padjadjaran / Dr. Hasan Sadikin General Hospital Bandung, there were 1,006 patients of head and neck cancer from The number of head and neck cancer cases was higher than the 448 cases in Pathology Department of Dr. Kariadi Hospital Semarang from The incidence of head and neck cancer in Otorhinolaringology, Head and 9

10 Neck Department, Faculty of Medicine, Universitas Padjadjaran / Dr. Hasan Sadikin General Hospital Bandung during was 6.65%. Of the 1,006 patients, only 665 patients are included in this research sudy because their medical records had all the variables needed. The ratio of males to females was 1.4 to 1. This is similar to a research study by Leslie Kim that found the incidence of head and neck cancer to be three-fold higher in men than in women. 6 This is probably due to the fact that, compared to women, men have a higher tendency to smoke ciggaretes and drink alcohol. A research study by Kristina R. Dahlstrom also supports that smoking and drinking alcohol, which are risk factors for head and neck cancer, are behaviors observed more frequently in men (79.9%) than in women. 13 In this research, the predominant head and neck cancer type was Nasopharyngeal Carcinoma (38.2%), followed by sinonasal cancer (17.29%), and then laringeal cancer (13.08%). The percentage of nasopharingeal carcinoma cases was significantly higher when compared to the other head and neck cancer types. This is concurrent with a study by Efiaty Arsyad Soepardi, which studied Indonesia, which found almost sixty percent of head and neck cancer to be nasopharyngeal carcinoma; eighteen percent to be sinonasal cancer, and sixteen percent to be laryngeal while other types of cancer had very low percentages. 14 The etiology of this cancer is probably due to the infection of Epstein barr virus and is influenced by lifestyle, bad dietary habits, and genetic factors. Viviana P. Lutzky reported that in 2000, more than 80% of cases of nasopharyngeal carcinoma in Southeast Asia were new. Influencing risk factors 10

11 for pathogenesis of Nasopharingeal cancer include childhood diet, for instance a diet of preserved meats and Cantonese-style salted fish known to contain carcinogenic nitrosamines. Other environmental factors associated with the development of NPC include smoking, alcohol, and Chinese herbal medication. 15 Most of the patients were not highly educated. Two hundred and ninetynine of the patients were elementary school graduates (45%); one hundred and eleven patients were middle school graduates (16,7%). Findings suggest that patients lacking higher education were more likely to be uninformed about head and neck cancer. People without higher education tended to have a lower socioeconomic status, which may affect their lifestyle; for example they might have a bad diet and bad oral hygiene. Previous studies by the 2009 International Head and Neck Cancer Epidemiology (INHANCE) study discovered that 38.7% of the 12,282 total cases had only a middle school education. 16 This cancer is found more commonly in men than in women. The majority of the women studied were housewives (32%) while 14.7% were laborers. This suggests that the women might have acquired the cancer from exposure to carcinogenic agents found on cooking utensils and cookware. It is also possible that they were exposed to cancer-causing agents from consuming salted fish or other preserved food containing dangerous substances such as formalin, which are commonly found in Indonesia. Kim L discovered that of the many studies from high and low income countries, patients with low socioeconomic status and a low level of education had a higher risk of cancer especially oral cancer. 6 11

12 The highest instances of head and neck cancer cases was among middle aged adults (46-55 years old); as many as 285 patients (28.3%) fell in this category; the median age being fifty years old, with a range of two to ninety-one years old. This is concurrent with the research conducted in Egypt by Heba Mohamed Tawfik, where the median age was fifty years old and the cancer was more common among people fifty years old and older. 17 This study showed that a long exposure period to carcinogens, virus, DNA genes, and accumulation of mutation increased the risk factor for cancer. This is concurrent with a research study by Kostas N. Syrigos that found that the eldery may be effected by high exposure to risk factors over a long period of time, or by an accumulation of mutations, decrease in DNA repair efficiency, and a weakening immune system. 1 The majority, 302 patients (45.4%), of histological findings were classified as undifferentiated carcinoma, while 148 patients (22.3%) were classified as having squamous cell carcinoma. This is not concurrent with previous research studies by Goon and Kim L, Syrigos, whose research reported that 90% of head and neck cancer malignancy was squamous cell carcinoma. This 1, 2, finding is commonly linked to the infection of Human Papilloma Virus (HPV). 6, 14 Undifferentiated carcinoma is usually found in Nasopharingeal Carcinoma and Sinonasal cancer, which often relate to an Epstein Barr Virus (EBV) 4, 10, 18 infection, which is characterized by rapid metastasis and cauding death. The majority of patients first came to the hospital with an terminal stage of cancer (stage III and IV). This is probably due to their lack of knowledge about head and neck cancer, as the symptoms were not incapacitating and the hospital 12

13 fee was either too expensive or they chose alternative medicine instead of going to see a doctor. The prognosis of head and neck cancer is based patient s stage of cancer when first diagnosed. During the early stages, patients have a sixty to ninety-five percent chance of being healed by local treatment only, while patients in the terminal stages have over a fifty percent chance of recurrence or metastasisation of the cancer 5, 6 In conclusion, head and neck cancer occurred more commonly in males, in people more than forty-six years old, and in people with a low level of education and a socioeconomic status. Nasopharingeal carcinoma was found to be the most common type of head and neck cancer; the majority of patients were already on the terminal stage of cancer with diagnosed undiffferentiated carcinoma. 13

14 References 1. Syrigos KN, Karachalios D, Karapanagiotou EM, Nutting CM, Manolopoulos L, Harrington KJ. Head and neck cancer in the elderly: An overview on the treatment modalities. Elsevier Cancer Treatment Review Goon PK, Stanley MA, Ebmeyer Jr, Steinsträsser L, Upile T, Jerjes W, et al. HPV & head and neck cancer: a descriptive update. Head & Neck Oncology. 2009;1(36). 3. Hassan MA, Lund VJ, Howard DJ, Sacker AA. Are the demographics for squamous cell cancer in the head and neck changing in the United Kingdom? The Journal of Laryngology & Otology. 2007;121: Robert I. Haddad MD, and Dong M. Shin, M.D. Recent Advances in Head and Neck Cancer. The New England Journal of Medicine. 2008: Bruce Brockstein MD, Gregory Masters MD, editors. Head and Neck Cancer: Kluwer Academic Publisher; Kim L, King T, Agulnik M. Head and Neck Cancer: Changing Epidemiology and Public Health Implications. Oncology. 2010;24(10). 7. Devendra A. Chaukar M, DNB, Rohan R. Walvekar M, DNB, DORL, Ashok K. Das M, Mandar S. Deshpande M, DNB, Prathamesh S. Pai M, DNB, Pankaj Chaturvedi M, et al. Quality of life in head and neck cancer survivors: a cross-sectional survey. American Journal of Otolaryngology Head and Neck Medicine and Surgery. 2009;265: Deschler DG, MD Terry Day M, editors. Pocket Guide to Neck Dissection Classification and TNM Staging Of Head And Neck Cancer And Neck Dissection Classification. Alexandria, VA: American Academy of Otolaryngology Head and Neck Surgery Foundation, Inc.; Indonesia DKR. Klasifikasi Umur. Jakarta: Departemen Kesehatan Republik Indonesia; 2009 [cited 2012]; Available from: Barnes L, Eveson J, Reichart P, Sidransky D. World Health Organization Classification of Tumours-Pathology and Genetics of Head and Neck Tumours. WHO Dorland's Medical Dictionary. Saunders, an imprint of Elsevier; Dorland's Medical Dictionary. 12. Wiliyanto O. Insidensi Kanker Kepala Leher Berdasarkan Diagnosis Patologi Anatomi di RS Dr. Kariadi Semarang Periode 1 Januari Desember 2005: Universitas Diponegoro; Kristina R. Dahlstrom B, Jarrod A. Little M, Mark E. Zafereo M, Margaret Lung R, Qingyi Wei M, PhD,, Erich M. Sturgis M, MPH. Squamous Cell Carcinoma Of The Head And Neck In Never Smoker Never Drinkers: A Descriptive Epidemiologic Study. Wiley interscience. 2007:

15 14. Prof. Dr. Efiaty Arsyad Soepardi STK, Prof. Dr. Nurbaiti Iskandar STK, DR. Dr. Jenny Bashiruddin STK, DR. Dr. Ratna Dwi Restuti STK, editors. Buku Ajar Ilmu Kesehatan Telinga Hidung Tenggorok Kepala & Leher. Edisi Keenam ed. Jakarta: Balai Penerbit FKUI; Viviana P. Lutzky, Denis J. Moss, David Chin, William B. Coman, Parsons PG, Boyle GM. Biomarkers for Cancers of the Head and Neck. Clinical Medicine: Ear, Nose and Throat Hashibe M, Brennan P, Chuang S-c, al e. Interaction between Tobacco and Alcohol Use and the Risk of Head and Neck Cancer: Pooled Analysis in the International Head and Neck Cancer Epidemiology Consortium. Cancer Epidemiology, Biomarkers & Prevention. 2009;18: Heba Mohamed Tawfik M, Nehad M.R. Abd El-Maqsoud M, Balegh H.A. Abdel Hak M, Yasser M. El-Sherbiny M. Head and neck squamous cell carcinoma: mismatch repair immunohistochemistry and promoter hypermethylation of hmlh1 gene. American Journal of Otolaryngology Head and Neck Medicine and Surgery. 2010;32: Powles T, Powles J, Nelson M, Sandison A, Peston D. Head and neck cancer in patients with human immunodeficiency virus infection: incidence, outcome and association with Epstein-Barr virus. The Journal of Laryngology & Otology. 2004;118: