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Head and neck cancer in Saudi Arabia; Mini review and update.

Introduction:

Head and neck cancer (HNC) is a group of malignancies affecting the oral cavity, throat, ear/nose, and larynx 1. More than 500,000 deaths due to  HNC with approximately 300,000 new cases per annum 2. The highest incidences of HNC in the world are found in South Asia, and parts of central and southern Europe2. In addition, the most common risk factors associated with HNC are tobacco and alcohol use with significant interaction observed between them 3. Other observed risk factors are poor oral hygiene4 and the human papillomavirus (HPV) 16 in tongue, tonsil and orpharyngeal HNC and, in particular, nonsmoking cases of HNC5. In South Asian countries the risk of HNC is further aggravated by smoking of bidis which increases the incidence of cancer of the hypopharynx and larynx6, and chewing tobacco, betel quid and areca nut7. Oral cancer is a significant health problem, being the sixth most common cause of malignant neoplastic disease-related deaths worldwide 8. The incidence and mortality rates as a result of oral cancer are higher in developing countries as compared to the developed world8,9. Oral cancer is reported to be a prevalent malignancy in Saudi Arabia, like lymphoma and leukemia10. Malignant oral cavity tumors represent approximately 26% of all head and neck cancers detected yearly in KSA11. High prevalence of oral cancer was reported in the southwestern region of Saudi Arabia12.

The majority of studies conducted to assess the association between oral cancer and chewing tobacco. In Saudi Arabia, few written reports have looked into the incidence of HNC. Published literature has shown that a lack of public awareness about signs and risk factors for OC can contribute to the late diagnosis and poor prognosis 13, 14. When intensify efforts to raise awareness of signs and symptoms of OC among the members of the Society can therefore aid in prevention, early detection, and better prognosis of the disease. In Saudi Arabia, data regarding public knowledge of oral cancer are scarce 15, 16. Therefore, we conducted this review to assess any updated published data in  regards to the incididence and associated risk factors of HNC in Saudi Arabia.

Material and methods:

A review of English literature was performed using PubMed/MEDLINE for head and neck cancer studies, and for reports that focused on the incidence of head and neck cancer between Saudis and Non-Saudis populations. Keywords used include a combination of the following: "head and neck cancer", "oral cancer",  and "Saudi Arabia".  Reference searches were performed manually for all retrieved articles to ensure that all available studies and data were reviewed. No human subjects or animals participated in this review of the literature.

Results:  

Few studies about Head and neck cancer / Oral cancer in Saudi Arabia. Also few reports (Annual reports) related to the the incidence of head and neck cancer by  Saudi Health Council  and King Faisal Specialist Hospital & Research Centre's Oncology Centre in Riyadh were identified in the English literature.

Discussion:   

Head and neck cancer (HNC) is a public health problem for both in developing as well as developed countries 8. The prevalence of HNC in general, and oral cancer in specific is higher in Asian countries, especially Southeast Asia 17. HNC is ranked the 6th  most common malignancies in Asia 9. Approximately 274,300 new OC cases occur per annum. High incidence rates are reported from developing nations situated in South-Central and South -East regions of Asia 9. While in Saudi Arabia, OC represent common malignancy in Saudi Arabia like lymphoma and leukemia, the highest incidence of which is reported from Jazan province 10, 12.  

In the last report discuss the incidence of cancer in Saudi Arabia, between January and December 2011, the total number of adult cancer incidence cases reported was 14011, the total number of analyzed cases were13, 505. Overall cancer was more in females than in males. Cancer affected  6,459 (46.1%) males and 7,552 (53.9%) female with male to female a ratio of 86:100. Of all cases, 10,438 out of them were Saudis. They found 87 cases of OC accounting for 0.8% of all newly diagnosed cases (41, 0.8% males and 46, 0.8% females) among Saudis in the year 201118. This is lower than reported by Sunny et al. ; Bhurgri  19,20, who found a prevalence of 8-10% of all cancers occur in the oral cavity among  Indians and Pakistanis with an incidence rate of more than 10 per 100,000 21,22. These results  showed significant differences in incidence rate of  OC among Saudis, Indians, and Pakistanis. In a sample of 124 adult patients with cancer at the palliative care (PC) outpatient setting in a major tertiary hospital in Saudi Arabia, The majority of patients (85.5%) reported they have pain. Roughly 15.3% had head and neck cancer compared with 27.4% had breast cancer 23. In contrast, other surveys of oral cancer conducted on Oral Maxillofacial Surgery Unit of the Armed Forces Hospital, Riyadh, KSA 24 reported to be 13% of all cancers and 72% of HNC diagnosed each year in Jazan region of KSA. The sources claimed that this high incidence of OC is attributed to "Shammah" using habit  24. Oral cancer is the 6th most common cancer among women and 12th most common cancer among men at KFSH&RC. During 2011, 97 new cases (38 males and 59 females) of OC were registered at KFSH&RC by the end of 2011. Oral cancer accounts for 4.2% of all cancers in KFSH&RC; 4.4% of all female malignant cases compared to all male malignant cases by 3.9%  25. While in united states, 45,780 new cases of cancer of the oral cavity and pharynx (throat) are expected in 2015 26. These data from the Saudi Cancer Registry (SCR) showed significant differences in trends from those of the U.S.A when compared to the data published in Cancer Facts & Figures 2015, by the American Cancer Society.

Tobacco smoking and chewing and alcohol consumption are the main risk factors for HNSCC and have been estimated to account for the vast majority of the disease burden worldwide  27. Tobacco use is widespread in Asian countries. More than 90% of OC cases report using tobacco products 28, 29. Tobacco is an independent risk factor, the relative risk of occurrence of OC in tobacco users is 11 times that of people who never used tobacco 29. In North America, it was noted that, although there has been a significant reduction of the incidence of head and neck cancers as a result of the anti-smoking campaigns since the late 80s, there was a significant increase in the incidence of oropharyngeal squamous cell carcinomas in young (40'55 years) specifically in the tonsils and the base of the tongue where most of these patients are not alcohol or tobacco consumers 30. Within the Middle East, rates of smoking are high 31, 32 although alcohol consumption is restricted. This is especially true for Saudi Arabia, where smoking rates are increasing for both cigarettes and Shisha 33. However, there have been very few studies depicting the magnitude or etiologic factors of HNC in the Middle East and Saudi Arabia. Previous hospital based studies from Saudi Arabia showed that Malignant oral cavity tumors constitute approximately 26% of all head and neck cancers detected yearly in KSA 11.  Also in study for Al-Attas et al., 34 found  the most common variety of tobacco used was cigarette smoking followed by Shisha, smokeless tobacco (ST), betel nuts and Khat, respectively.They reasoned out that ST was associated with a wide range of oral mucosal lesions.  In another study, Sawair et al., 35 studied the association of khat chewing and tobacco consumption with the occurrence of oral cancer in Sana'a, Yemen. A total of 649 cases of primary malignant tumors (348, 53.6% males and 301, 46.4% females) were extracted. Oral cancer was the most frequent body cancer in both males (17.2%) and females (19.6%). Squamous cell carcinoma (SCC) was the most frequent oral cancer (84%), and the tongue (42%), gingiva (23%) and buccal mucosa (20%) were the most common sites. Simultaneous chewing of tobacco and khat was found in 48 cases (52.2%). That survey has disclosed that oral SCC is the most frequent cancer in Yemen, and that higher relative frequency of oral SCC may be related to the habits of chewing tobacco and khat. These results were in agreement with the findings of El- Halboub et al.36, who found the prevalence for Characterization of Yemeni patients treated for oral and pharyngeal cancers in Saudi Arabia to be approximately 49%.

Human papillomavirus (HPV) is today shown as the principal cause of an increase in incidence of a subset of head and neck squamous cell cancers (HNCs) in numerous geographic regions around the world  37. The strongest association is between HPV and squamous cell carcinoma of the oral cavity and more so in the oropharynx causal role of HPV-16 in this context but it is limited for HPV-18  38. HPV can cause cancers at the back of the throat, most commonly in the base of the tongue and tonsils, in an area known as the"oropharynx". These cancers are called "oropharyngeal cancers" 39. Approximately 10% of men and 3.6 % of women in the U.S. have HPV in their mouths, and HPV infection is more commonly found with older age 40. More than 50,000 cases of head and neck (HN) cancers, mostly SCC, are estimated to have occurred in the United States in 2012, with about 13,000 deaths 41. HN cancers represents about 3.5% of all malignant tumors in the United States 41 and Europe 42, 43, but in many other regions of the world, such as India, Southeast Asia and Brazil, they are much more prevalent, being altogether the 5th/6th most common malignancy worldwide 41 44 45. Other studies in the U.S., 39 have found that about 7% of people have oral HPV. But only 1% of people have the type of oral HPV that is found in oropharyngeal cancers (HPV type 16). Oral HPV is about three times more common in men than in women. Each year, in the U.S., approximately 9,000 people are diagnosed with cancers of the oropharynx that may be caused by HPV. Cancers of the oropharynx are about four times more common in men than women 39. In a systematic meta-analysis, Kreimer et al. have reviewed 60 eligible studies that included 5,046 cases of squamous cell carci- nomas of the head and neck 5 . HPV was prevalent in 35.6% of oropharyngeal, in 23.5% of oral, and in 24% of laryngeal cancers. HPV-16 was by far the commonest subtype in all HPV-positive cancers (87% of oropharyngeal, 68% of oral, and 69% of laryngeal cancers). HPV-18 was the next most common subtype.  This is lower than reported by Alsbeih G 46, who found a prevalence of HPV infection in anal, penile, vaginal, vulvar, and oropharyngeal cancers has not yet been explored in Saudi Arabia. In fact, the extrapolation of these rough estimated percentages of HPV-positive anogenital (96%) and head and neck (30%) cancers in Saudi Arabia. However; these studies remain inconclusive, especially that some experts in the field still do not support such a role in view of the inadequate evidence. Acknowledging that detection of HPV infection in head and neck cancers remains lacking with no published report to date from Saudi Arabia, few studies had looked at this potential in some other types of tumors such as ocular and prostatic cancers.

Conclusion:

Oral cancer is common malignancy in Saudi Arabia, with an exponential increase in the incidence rates over the last few years. Nonetheless, cancer of the oral cavity is a significant public health problem in Saudi Arabia. While there are some common factors like cigarette smoking, Shisha, smokeless tobacco, betel nuts and Khat there are some differences in the prevalence of habits, in addition to some still unknown or unexplained factors in this country. Tobacco chewing along with smoking and Shisha are the main reasons for the increasing incidence rate of OC. More studies are required to determine the etiology, Risk factors and local characteristics of the disease in this country to determine the significance of the changing trends at different levels. Further clinical and epidemiological researches are needed to determine successful strategies for increasing awareness, screening, early detection, diagnosis and management in Saudi Arabia with unique cultural, racial and ethnic makeup as compared to the West. This review paper is an initial step in a funded research project to understand the pattern of head and neck cancer and provide adequate epidemiological data. One goal of this review is to generate further data and used it as a reference for defining public health initiatives in cancer control in Saudi Arabia.

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