This resulted in a larger summation of this variable than the sample size, which was adjusted by logistic regression analysis.
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Frequency of chewing any type of SLT or areca nut clustered mostly around 5 times per day while The participants were assessed for the cancer history in the family, Based on the treatment types in which For the site of tumor, Univariate logistic regression analysis of SES with chewing habits indicated the association Table 2.
Males were 2.
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People with basic level education primary to high school were 4. Marital status, smoking habits and frequency , family history of cancer, type of cancer in the family, and kind of occupation did not show any association with the chewing habits. Multivariate analysis was performed for possible confounding factors Table 2 , Model 1.
The model was adjusted for age, gender, patient status, marital status, and monthly income due to the biological importance of the variables. An insignificant p-value of chi-square in Hosmer and Lemeshow Test validated the goodness-of-fit of the model. For chewing habits of OSCC patients, the factors statistically significant included education record; either primary to matric or uneducated adjusted OR 5.
The association of psychosocial factors and SES was analyzed with the site of tumor buccal and non-buccal by univariate and multivariate logistic regression.
Males were again 3 times more likely to have tumor of the buccal cavity than females CI: 1. People with primary to matric education had 3. Amongst the types of chewable substances, only gutka was found to be significantly associated with the buccal cavity [OR: 4. People of blue-collar occupation labor, businessman, and daily wages had the highest odds of having tumor of buccal site than others. In multivariate Table 3 -Model 2, age, patient status, marital status, occupation, and education were kept in the adjusted variables and insignificant p-value for goodness-of-fit validated the model.
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In multivariate analysis, factors statistically significant included being male: adjusted OR 4. Age, patient current condition, occupation status, marital status, smoking, chewing frequency, types of chewing substance apart from gutka , and family history of cancer were shown not to be associated with the tumor of buccal cavity site. People with chewing habits of any substance had 2. Among the types of chewing products, only areca nut consumers came out to be 4. Occupation employed showed OR of 2.
This model also provided goodness-of-fit and multivariate analysis was performed for tumor stage of OSCC patients and the factors statistically significant were age adjusted OR 1. Pakistan particularly Southern Pakistan with its capital Karachi, largest city of Pakistan, and 6 th most populous over 20million population in the world has shown a stunning increase in OSCC over the years that is because of excessive use of different chewing products amongst various age groups. In this study, age showed significant association with chewing habits that concurs with some studies published from Pakistan and India, reporting the mean age of the patients to be between 41—50 years [ 26 — 28 ].
People between 15 and 49 years of age are habitual of using some form of tobacco and According to a collaborative study in South and East Asia, chewing was more prevalent among men This partially holds with this study where the male to female ratio was for chewing habits. Education plays an important role in the overall health of a country in terms of awareness toward the use of hazardous substances.
Considerable regional variation was reported in both the prevalence and the number of chewing substance users with a higher percentage in LICs and LMICs. In the South-Asian region, OSCC is highly associated with low socioeconomic status, where people are less aware of the consequences of carcinogenic compounds because of less education. The main reason is chewing areca nut related products particularly in low SES, where it is believed to increase work capacity, alertness, suppress hunger, and are a cheap source of entertainment [ 31 ].
According to a recent systematic review, tobacco use in low income, caste, and socioeconomic status groups was roughly twice that of high-status groups [ 16 ]. Our research coincides with the studies showing that most of the people having OSCC belonged to low SES and were habitual of chewing mostly blue-collar workers, servicemen, farmers or housewives.
A somewhat similar study in India found that most of the OSCC recruited patients were middle-aged, belonged to low SES, and were habitual of chewing [ 27 ]. In a combined study from India and Bangladesh, chewing was associated with less education and low income [ 32 ]. In Bangladesh, over half of the habitual chewers have no proper education secondary level education with more prevalence in rural areas [ 33 , 34 ]. As reviewed by Keith et al. This applies to our study, where less education was directly proportional to chewing and implies that gender is an independent factor.
However, multiple regression models did not show any association between sex, marital status, and education with the frequency of betel quid use [ 31 ] which holds for our study. The OC subsites represent a variety of trends in the onset of cancer, type of cancer, and association with the consumption of different carcinogenic substances or genetic predispositions. OSCCs are the aggressive malignant lesions that commonly metastasize to local regional lymph nodes and adjoining tissues [ 38 ]. In our population odds of OSCC in buccal mucosa cavity were two times higher in the chewers and it was strongly associated with males and low SES which is supported by different regional studies reporting buccal cavity as the most common site [ 27 , 39 , 40 ].
As reported by Siddiqi and colleagues, the relative risk to develop mouth oral cavity, tongue, and lip cancers was 3. In western countries, tongue is the most common site of OSCC because of excessive smoking and drinking alcohol [ 41 ]. One possible reason is the direct contact of the cigarette with tongue during smoking while rest of the components are inhaled, whereas, the chewing products are kept in the mouth for a longer period. In the descriptive analysis of this study betel quid usage was highest followed by gutka, however, in univariate and multivariate analysis gutka users appeared to have the highest odds of developing buccal mucosa cancer.
Rationally, gutka is placed between the teeth, held against the buccal mucosa for a longer duration, and lightly chewed and sucked occasionally.
Gutka users consume more dry weight of tobacco, areca nut, and slaked lime as compared to betel quid users and betel leaf also has some anticarcinogenic properties lacking in gutka [ 42 ]. The chemical composition of all these chewing substances is shown to have high cytotoxic and genotoxic effects in vitro and in vivo [ 43 ]. Keeping these substances in the mouth for a long time causes mechanical friction in buccal mucosa leading to premalignant lesions or invasive cancer. In this study tumor stages were grouped into two i. Results from this study imply the association of low SES with chewing habits and late stage presentation supported by different studies.
Areca nut is the fourth most common psychoactive substance used in the world [ 45 ] and habitual areca nut chewers present with more aggressive cancer phenotypes, high rates of metastasized cancer, recurrence, and poor patient survival [ 46 ]. Though the association of areca nut chewing with late stage tumor remains largely unexplored, this is just an observation with no definite answers. However, it is speculated that people tend to keep areca nut in the mouth for a longer period simply because it is hard wood-like stuff which does take a long time to chew, and in contrast to other products, its extract is sucked.
As little as microgram quantity of this extract has shown to be needed for any cytotoxic or genotoxic event resulting in disease progression [ 45 , 47 ]. In a recent study from India, A study by Chu et al. In an American study recruiting Afro-Americans stated an association between SES, job status, and marital status on one side and delayed diagnosis on the other [ 51 ]. A multi-ethnic study including Malays, Indians, and Indigenous people showed the presence of late stage tumors to be The Another study from Taiwan showed In Pakistan, unfortunately, however, most cancer patients tend to present at late stages for a variety of reasons like poverty, lack of awareness, inaccessibility to affordable healthcare, fear of social fall out, etc.
Smoking has been presented to have a synergistic effect with chewing and alcohol consumption in different studies, but subsites most commonly affected are oropharynx or larynx than oral cavity [ 55 — 58 ]. Anatomically turbulent respiratory flow exposes larynx and pharynx more to the cigarette smoke as compared to OC [ 57 ]. Some patients were habitual of using multiple chewing products, having a mixture of several ingredients over and above widely variable chewing duration and quantity of every product in our cohort, which could have a synergistic effect.
Other factors, i. This study elaborates on the chewing habits with SES and clinicopathological features of OSCC in recent times in local context; nonetheless, this study had certain limitations, and first is the sample size and duration of the study. Confidence interval in the analysis was broad, implying the associations were not causal rather had confounders, which were though adjusted in the multivariate analysis.
Still, a large sample size would provide more narrow ranges. Studies have been done to check the dose-dependent effect of chewing and smoking with OSCC [ 22 ], more precise details about pack numbers, chew years, and quit years if applicable could be obtained to strengthen the quantification and dose-dependent effects of these substances. We did not determine the survival rate after the first diagnosis and studies report that early stage OSCC has better five-year survival than late stage [ 59 — 61 ]. Chewing habits are the foremost cause of a drastic increase in OSCC from this region consequently changing the normal mucosa of the oral cavity leading to cancer.
This is a comprehensive study conducted on a number of patients, visiting one of the largest tertiary care Hospitals in Pakistan, minimizing selection bias.
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Despite the recent increase in the price of tobacco products, the consumption is overall increasing even in the low socio-economic group with meager income. This study could provide an insight into ongoing evidence and the causes of oral cancers, which would help in taking measures to control this chewing endemic in Pakistan by educating people, spreading awareness about the hazardous effects and severity of the disease.
Browse Subject Areas? Click through the PLOS taxonomy to find articles in your field. Abstract Oral squamous cell carcinoma OSCC has the highest prevalence in head and neck cancers and is the first and second most common cancer in males and females of Pakistan respectively. Introduction Cancer is by far the first and second most common cause of death in developed and developing countries respectively [ 1 ].
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Methodology Study design Cross-sectional study design was used where the population was defined as those who had developed OSCC. Data analysis Data were analyzed using the SPSS package 20 IBM, Rochester, USA for the association and variables included were age, gender, patient current condition, marital status, location, educational level, type of occupation, monthly income, chewing habits, frequency of chewing, type of chewing substance, smoking, frequency of smoking, history of cancer in the family, tumor stage, and tumor site. Results Socio-economic status SES was determined by descriptive analysis and by performing univariate and multivariate logistic regression, odds ratios were calculated to determine the association between dependent variables and other variables.
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Table 3. Table 4. Discussion Pakistan particularly Southern Pakistan with its capital Karachi, largest city of Pakistan, and 6 th most populous over 20million population in the world has shown a stunning increase in OSCC over the years that is because of excessive use of different chewing products amongst various age groups. Limitations This study elaborates on the chewing habits with SES and clinicopathological features of OSCC in recent times in local context; nonetheless, this study had certain limitations, and first is the sample size and duration of the study.
Acknowledgments We acknowledge all the patients who contributed to the study. References 1. Int J Cancer. CA Cancer J Clin. Global epidemiology of head and neck cancers: a continuing challenge.