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Screening & Early Detection, Karkinos Healthcare Private Limited, B 702, 7th Floor, Neelkanth Business Park, Kirol Village, Near Bus Depot, VidyaVihar West, Mumbai, 400086, India
Department of Women Wellness, Karkinos Healthcare, Karkinos Healthcare Private Limited, B 702, 7th Floor, Neelkanth Business Park, Kirol Village, Near Bus Depot, VidyaVihar West, Mumbai, 400086, India
Department of Women Wellness, Karkinos Healthcare, Karkinos Healthcare Private Limited, B 702, 7th Floor, Neelkanth Business Park, Kirol Village, Near Bus Depot, VidyaVihar West, Mumbai, 400086, India
Department of Women Wellness, Karkinos Healthcare, Karkinos Healthcare Private Limited, B 702, 7th Floor, Neelkanth Business Park, Kirol Village, Near Bus Depot, VidyaVihar West, Mumbai, 400086, India
Medical Director & CEO Karkinos Kerala, Karkinos Healthcare Private Limited, B 702, 7th Floor, Neelkanth Business Park, Kirol Village, Near Bus Depot, VidyaVihar West, Mumbai, 400086, India
CEO, Karkinos Healthcare Private Limited, B 702, 7th Floor, Neelkanth Business Park, Kirol Village, Near Bus Depot, VidyaVihar West, Mumbai, 400086, India
Oral cancer accounts for approximately one-third of all cancers in India with the majority of these cases estimated to be advanced at presentation, due to a higher proportion of the population consuming tobacco or related products. This could be attributed to habits and cultural factors, leading to a higher prevalence of tobacco-related lesions of the oral cavity. Both early screening and surveillance can enable in early detection of oral cancer in such high-risk populations.
Objective
The study aims to estimate the prevalence of Oral Potential Malignant disease (OPMD) among the population and link it with the lifestyles and risk factors for oral cancer. A better understanding of their pattern and behavior practice within the community is a must.
Methodology
Cross-sectional study was performed on 4974 rural women in the 35–60 years age group through community screening camps organized from September 2021 to November 2021 around Chikkaballapur districts of Karnataka, India. Data was recorded through a digital application and with informed user consent.
Results
We attempt to identify the important risk factors associated with an increased risk including habits such as tobacco, smoking and related products. The prevalence of OPMD varied for all talukas, Mandikal (13.45), Nandi (9.68) and Bagepally (5.09). The most commonly encountered OPMD was leukoplakia (59.2) followed by erythroplakia (31.4), oral submucous fibrosis (6.8) and lichen planus (2.6) were also seen.
Conclusion
This study provides strong evidence that tobacco and related products could be a straight line responsible for developing OPMD.
According to World Health Organisation (WHO), more than 70% of all cancer deaths occur in low-and middle-income countries, where resources available for prevention, diagnosis and treatment of cancer are limited or non-existent.
The International Agency for Research on Cancer (IARC) has predicted that India's cancer incidence will increase by more than 1.7 million by 2035, this indicates that the death rate due to cancer will also increase to 2 million in the same period.
J. K. Elango, P. Gangadharan, S. Sumithra, and M. A. Kuriakose, “Trends of head and neck cancers in urban and rural India,” Asian Pac J Cancer Prev APJCP, vol. 7.
The incidence of oral cancer is highest in India, South and Southeast Asian countries.
Over the last few decades, Karnataka is among, the states where high cancer incidence and prevalence are seen, with females being affected more than males. As per the state health authorities, there is 1 in every 6 females is affected by cancer which is higher compared to other states.
The Chikkaballapur district which is located in the north of Bangalore covers 6 talukas despite touching the urban boundaries, there are limited healthcare facilities for cancer care. The cancer prevalence in the district is 1809 and 2270 in males and females respectively.
Government of Karnataka; Kidwai Memorial Institute of Oncology-Bengaluru; Accessed from: https://kmio.karnataka.gov.in/page/Statistics/Cancer+Burden+and+Estimates/en.
due to the lifestyle and other risk factors of smoking, chewing tobacco and alcohol consumption.
According to GATS 2, in 2017 the tobacco users were 28.6% and smokeless tobacco users were 21.4% where the consumption of tobacco was 2 times more in rural areas as compared to urban areas.
However, early detection of precancerous lesions and conditions can prove to be primordial and preventive which can avert major complications and the development of fully differentiated oral malignancies. Early detection of oral precancerous lesions by visual clinical screening will help in timely preventive interventions by stopping tobacco consumption and other risk factors and treatment needed. Close to half of cancer deaths can be avoided by the prevention and control of risk factors. Therefore, there is a need to reduce the burden of cancer by focusing on community awareness and community cancer screening which is a must to reduce out-of-pocket expenditure and timely treatment, eventually resulting in low cancer mortality.
The primary objectives of the study are to estimate the prevalence of Oral Potential Malignant disease (OPMD) in women between the ages of 35–60 years in the Chikkaballapur district through community screening camps, which can be linked with lifestyles and risk factors for oral cancer and to understand the different patterns of habits practiced within the community to plan for a customised intervention in the future.
2. Methodology
A comprehensive community cancer screening program was conducted for women at various locations (Nandi, Mandikal & Bagepally Taluks) in the Chikkaballapur district of Karnataka. The Screening process includes the recording of demographic, lifestyle, risk factors, medical history and followed by oral cancer screening (Checking for early signs & symptoms and conducting an oral visual examination by a trained nurse). Multiple on-ground key stakeholders supporting the screening camps namely non-governmental organisations (NGO), village heads, panchayat officers and frontline workers consisting of Accredited Social Health Activists (ASHA) and Auxiliary Nurse Midwife (ANM) were also involved. The screening took place across 3 talukas (comprising 74 villages) and was conducted in accordance with resource-stratified guidelines (RSGs) from the National Cancer Grid of India.
A cross-sectional study was conducted, where individuals were examined for any lesions in the oral cavity vis a vis white or red patches, any non-scrapable lesion, swelling etc. The study was conducted from September 18, 2021 to November 16, 2021. A detailed clinical visual examination of the oral cavity especially the lesions involving buccal mucosa, hard & soft palate and tongue along with detailed relevant medical and lifestyle history was recorded. The screening was done by trained nurses who were trained through a structured training module on clinical examination for oral cancer. An additional oversight was through a trained general practitioner who would re-examine the cases. There was a provision of teleconsultation as well to all the suspect cases through a trained community oncologist. The community was sensitised using awareness sessions, followed by a prefixed schedule of camps at the nearest health facilities, schools or community halls.
2.1 Inclusion criteria
Women in the age group of 35–60 years who are interested to participate and undertake the consent form. Women have a past history of consuming any form of tobacco products or having any signs & symptoms of oral lesion(s).
2.2 Exclusion criteria
Women with ages more than 60 years or less than 35 years were excluded.
2.3 Ethical considerations
The current program was approved by the independent ethics committee. All the participants were informed about the program, the screening test, and its importance. All data were recorded through a digital application, and a written informed user consent was taken. The consent forms were translated into local languages (Hindi, Telegu, Kannada). The participants had a choice to decline the screening tests and further follow-up. Participation in the screening program was free of cost and care was taken to consider the cultural and psychological issues while undertaking the cancer screening. Privacy was maintained throughout the process. The IEC is composed of a chairperson, secretary, social worker, legal expert, clinician, social worker and basic medical expert. There was no conflict of interest declared by any of the members of the IEC who can influence the study.
3. Results
During the period of community-based cancer screening, a total of 4974 women were screened for oral cancer by Oral Visual Examination (OVE) by trained nurses in the Chikkaballapur district (Nandi/Chikkaballapur – 2147; Mandikal – 1667; Gulur, Bagepally – 1160 women screened). The data suggests that around 50% of women were in the age group of 35–44 years followed by 27% in the age group of 45–54 years and 23% of women in the age under 60 years. More than 50% of women were unemployed followed by 37% of women employed in agricultural work (Table 1). In addition to demographics, it was observed that around 1300 women have a history of chewing tobacco or smokeless tobacco products.
Table 1Demographic data of the participants from the community outreach camp.
All three talukas of the Chikkaballapur districts observed varied prevalence of OPMD (Fig. 1), where Mandikal (13.45%) taluk observed a high prevalence as compared to Nandi (9.68%) and Bagepally (5.09%). Nandi Taluk is near to Bangalore boundaries and individuals have access to the urban health facilities so the prevalence is not high but few villages are contributing more than 20% prevalence of OPMD are major because of tobacco and related product consumption since childhood. It was observed that the prevalence of oral potentially malignant lesions varied significantly from village to village, as prevalence was higher where areca nut, slaked lime, straw powder, tobacco and betel leaves consumption was high.
Fig. 1Chikkaballapur district map indicated talukas with the prevalence of OPMD.
Oral leukoplakia, erythroplakia, oral submucous fibrosis (OSMF), and oral lichen planus (OLP) among other potentially malignant disorders with risk of transition to oral squamous cell carcinoma (OSCC). Moreover, though the lesion perse may not transform to OSCC, it may serve as a surrogate clinical lesion to identify individuals at risk of developing OSCC. The majority of these disorders may be asymptomatic in the early stages of their evolution and can be detected on routine oral examination. It is essential, therefore, that the primary health professionals are knowledgeable about the clinical features and diagnostic aspects of OPMDs to further investigate and, where appropriate, make referrals to specialists for treatment and also suggest habit cessation or lifestyle modifications through participating in screening and early detection program.
The village-level interpretation of the prevalence and consumption of tobacco products gives a clear understanding of the relationship between habit and OPMD (Fig. 2). Out of 74 villages, 25 villages (9 in Nandi, 11 in Mandikal and 4 in Bagepally) shows high prevelance of OPMD (Fig. 3). Based on the screening 469 were found suspicious for a potential oral premalignant lesion in 74 villages where leukoplakia (59%) was observed as the most common OPMD followed by erythroplakia (31%) and in which 162 (34%) were referred for biopsy (127 erythroplakia, 16 OSMF and 19 leukoplakia) and further diagnostics conformation (Table 2). Few other previous studies discussed the proportion of OPMDs getting converted into malignant lesions of the oral cavity varies from 0.13 to 34%.
On analysing risk factors, the majority of included patients had chewing tobacco habits in the form of gutkha (a chewable mixture of tobacco, betel nut and sweeteners in an attractive pack) and betel quid (betel leaf with slaked lime, betel nut and tobacco), In addition, alcohol consumption was a contributing factor in the causation of OPMD. There is a significant association between the use of tobacco & smokeless tobacco with OPMD positive. It was clearly observed that the use of tobacco, areca nut, beetle nut, slaked lime or straw associated with high probability of getting potential malignancies (Table 3).
Table 3Association of OPMD with tobacco, smokeless tobacco and alcohol (*88 individuals refused to share).
The National Cancer Registry Programme of the Indian Council of Medical Research released an alarming report pointing out an increase in cancer rate incidence in India, with over seven lakh people being registered yearly.
The actual burden of oral cancer in India is much greater than reflected through the existing literature and hence can be regarded as a “tip of the iceberg” situation.
It is demonstrated that oral cancer is interrelated with low income. Low socioeconomic class is interrelated with factors like nutrition, health care, living conditions and risk behaviours which contribute to the development of oral cancer.
In many low-income and middle-income countries, including India, most of the population does not have access to a well-organized and well-regulated cancer care system. A diagnosis of cancer often leads to high personal health expenditures. Such expenditures can push entire families below the poverty line and may threaten social stability.
Shalini Gupta, Rajender Singh1, O. P. Gupta2, Anurag Tripathi, "Prevalence of Oral Cancer and Pre-cancerous Lesions and the Association with Numerous Risk Factors in North India: A Hospital Based Study".
No significant advancement in the treatment of oral cancer has been found in recent years, though the present treatments improve the quality of life of oral cancer patients but the overall survival rate of 5 years has not improved in the past decades. The incidence rates of cancer in rural India are increasing at an alarming rate mainly due to changes in lifestyle.
Alka K, Kamini J, Neelma K, et al. “The study of oral cancer symptoms among tobacco consuming rural women in Kanpur region”. World J Pharmaceut Res 017; volume 6, issue 17, 1268-1273.
The consumption of tobacco is closely associated not only with the development of oral cancer but also with the course of disease involving poor prognosis.
Areca nut is commonly used in India. In the traditional form, naturally crude areca nut is used, wrapped in leaves of Piper betel with lime, saffron and additives such as catechu, cinnamon and cloves. This preparation is referred to as betel quid or paan.
The emergence of newer, chewable flavoured forms of tobacco along with several other ingredients, called gutka has changed the trends in the tobacco market. Gutka contains areca nut, slaked lime, catechu, condiments, and powdered tobacco.
Approximately 20% of women are smokers worldwide. Around 250 million women are daily smokers worldwide, among them 22% of women are related to developing countries and 9% of women in developing countries smoke tobacco.
Although the use of tobacco is less common among women, still tobacco consumption among women in a rural setting is getting more consideration since tobacco causes about 1.5 million deaths in women.
In India, tobacco use by women has doubled in the last five years, according to the global adult tobacco survey (GATS).
Early detection has been well documented as having the potential to significantly reduce the rates of cancer mortality. The early diagnosis of OPMD can be helpful in cancer prevention and reducing related mortality and morbidity. Based on our data, the prevalence of OPMD in the district might be linked to a rise in the usage of tobacco in various forms, areca nut and alcohol. The total target population in the age of 35–60 years in all three talukas was 34,328 out of which 4974 (14.5%) were screened.
The most common site of OPMD was buccal mucosa (58.68%), which is similar to what has been reported in previous studies and related to the site used for chewing smokeless tobacco. The cultural habit of the people of Karnataka of using gutkha could be one of the main reasons.
In a study in Belgaum, Karnataka, tobacco chewing was found to be the main risk factor for OPMD with leukoplakia, OSMF and OSCC accounting for the prevalence of 13.4%, 28.3% and 6.3%, respectively.
This is the first study to describe the point prevalence of tobacco habits and lesions within a defined geographic area of a district. The data will be useful to identify intervention strategies for control of tobacco habits through the implementation of tobacco control policy as well as setting up community-based interventions for tobacco cessation. The use of technology in the healthcare setting can enhance the outcomes of cancer screening. Cancer care is on the cusp of a technological revolution that has the potential not only to improve disease outcomes but also the quality of life. Point-of-care diagnostic technology with artificial intelligence has the potential to adopt advanced diagnostic assays for real-time diagnosis in the community. It can down-stage cancer during diagnosis and improve overall cancer care processes.
Our experience suggested that the use of mobile technology for a cancer-screening programme in constrained settings is feasible. The early findings showed that provider related barriers to early diagnosis of oral cancer could be addressed by mobile based technology.
4.1 Limitation
One of the gaps in the current study is under reporting of risk habits or medical history due to fear among the women. The coverage of the study was across three blocks of the Chikkaballapur district.
5. Conclusion
The prevalence of OPMD in India is on the rise with a predilection for younger age groups, due to the increase in consumption of tobacco and related products. People less than 40 years who are habitual smokers, alcohol consumers, and betel quid chewers must undergo oral mucosa screening regularly so that potential malignancies can be identified. Early screening of OPMD and implementing national preventive programmes can reduce impending complications.
Source of funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Authors contribution
Dr. Kunal Oswal: Programme implementation & execution, data analysis, writing & reviewing Mayank Chhabra: Writing & editing, on-ground execution, data collection & analysis Sripriya Rao: Conceptualization, supervision, Programme implementation, methodology, review Bharat Kumar Sarvepalli: Review, supervision, data analysis Dr. Moni Abraham Kuriakose: Conceptualization, supervision, review Venkataramanan Ramachandran: Conceptualization, supervision, methodology, review.
Declaration of competing interest
Authors declare no conflict of interest.
Acknowledgment
The completion of this study could not have been possible without the support of the on-ground team, health workers (ASHA/ANM), health authorities, panchayat, NGOs, nurses and doctors. We would also like to acknowledge our execution partners Healthcube and Public Health Technologies Trust (PHTT).
J. K. Elango, P. Gangadharan, S. Sumithra, and M. A. Kuriakose, “Trends of head and neck cancers in urban and rural India,” Asian Pac J Cancer Prev APJCP, vol. 7.
Government of Karnataka; Kidwai Memorial Institute of Oncology-Bengaluru; Accessed from: https://kmio.karnataka.gov.in/page/Statistics/Cancer+Burden+and+Estimates/en.
Shalini Gupta, Rajender Singh1, O. P. Gupta2, Anurag Tripathi, "Prevalence of Oral Cancer and Pre-cancerous Lesions and the Association with Numerous Risk Factors in North India: A Hospital Based Study".
Alka K, Kamini J, Neelma K, et al. “The study of oral cancer symptoms among tobacco consuming rural women in Kanpur region”. World J Pharmaceut Res 017; volume 6, issue 17, 1268-1273.
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