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Movaghari A, Khademalhosseini M, Jalali N, Yazdi Mirmokhalesouni S H, Sheikh Fathollahi M. The frequency of head and neck cancers among samples received by Ali-ibn Abi Talib Hospital Pathology Centre from 2005 to 2016, Rafsanjan, Iran . JOHE. 2019; 8 (1) :1-5
URL: http://johe.rums.ac.ir/article-1-294-en.html
1- Department of Oral Medicine, Dental School, Rafsanjan University of Medical Sciences, Rafsanjan, Iran.
2- Department of Pathology, Medical School, Rafsanjan University of Medical Sciences, Rafsanjan, Iran. , Mortezakhademalhosseini@gmail.com
3- Department of Neurology, Medical School, Rafsanjan University of Medical Sciences, Rafsanjan, Iran.
4- Dental School, Rafsanjan University of Medical Sciences, Rafsanjan, Iran.
5- Department of Epidemiology and Biostatistics, Medical School, Rafsanjan University of Medical Sciences, Rafsanjan, Iran.
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The frequency of head and neck cancers among samples received by Ali-ibn Abi Talib Hospital Pathology Centre from 2005 to 2016, Rafsanjan, Iran

Ateke Movaghari1, Morteza Khademalhosseini2*, Nazanin Jalali3, Seyed Hossein Yazdi Mirmokhalesouni4, Mahmood Sheikh Fathollahi5
 
1. Assistant Prof., Department of Oral Medicine, Dental School, Rafsanjan University of Medical Sciences, Rafsanjan, Iran.
2. Assistant Prof., Department of Pathology, Medical School, Rafsanjan University of Medical Sciences, Rafsanjan, Iran.
3. Assistant Prof., Department of Neurology, Medical School, Rafsanjan University of Medical Sciences, Rafsanjan, Iran.
4. Dental Student, Dental School, Rafsanjan University of Medical Sciences, Rafsanjan, Iran.
5. Assistant Prof., Department of Epidemiology and Biostatistics, Medical School, Rafsanjan University of Medical Sciences, Rafsanjan, Iran.

* Corresponding author: Morteza Khademalhosseini,     E-mail: Mortezakhademalhosseini@gmail.com


Abstract
Background:
Head and neck cancer is the sixth most common cancer in the world, with 690,000 new cases identified in 2012. There are some arguments over an increase or a decrease in the incidence rate of head and neck cancers in different locations. This study is conducted aimed at determining the frequency of head and neck cancers in patients referring to Rafsanjan Ali-ibn Abi Talib hospital pathology lab from 2005 to 2016 and comparing frequencies in different years.
Materials and Methods: In this descriptive study, a datasheet was prepared from medical files from 2005 to 2016, containing the date, age, sex, type, and site of tumors in patients admitted to Ali-ibn Abi Talib hospital pathology lab, Rafsanjan, Iran. Data were analyzed using chi-square or Fisher’s exact tests. 
Results: In this study, 343 cancer cases were obtained from 27414 files (1.25%). Out of these cases, 33.2% (114 cases) and 66.8% (229 cases) occurred in women and men (P < 0.001), respectively. The most common site of the tumor was skin, and the most common cancer was basal cell carcinoma. There was no evidence of a significant linear trend for the incidence of malignancies from March 21, 2005 to September 22, 2015.
Conclusions: The present study did not show any significant changes in the frequency of head and neck cancers in different years. We need to study the incidence rates of more prevalent risk factors, such as tobacco and alcohol in these patients simultaneously.
 
Keywords: Head and Neck, Cancer, Incidence, Epidemiology, Frequency

Introduction
Head and neck cancer is the sixth most common cancer in the world, with 690,000 new cases identified in 2012, and 375,000 individuals died of head and neck cancers, having been approximately 4.6% of the total mortality of cancers (1); however, head and neck cancer is the third leading cause of deaths in Iran (2). Anatomic sites involved in head and neck cancers include the oral cavity, nose, nasopharynx, oropharynx, hypopharynx, larynx, thyroid, and salivary glands (3).
Alcohol consumption, heavy tobacco smoking, and the special strains of Human Papilloma Virus (HPV) are environmental and lifestyle risk factors known to be closely associated with head and neck cancers (4). Tobacco smoking is the leading preventable cause of morbidity and mortality worldwide. Approximately 5,000,000 deaths occur every year worldwide due to direct tobacco smoking, with the effects of secondhand smoke leading to additional 600,000 deaths. Furthermore, mortalities attributed to tobacco use have been increasing at a higher rate in developing countries, with higher prevalence rates having been observed among men than women (5).
Squamous cell carcinomas (HNSCC) is the most common type of head and neck cancer (more than 90%) that arises from the mucosal surfaces of the oral cavity (OSCC, ICD-10 code: C00-08), oropharynx (OPSCC, ICD-10 code: C09-10 and C12-14), and larynx (ICD-10 code C32-9)(6). Head and neck cancers have a distinct geographical distribution with this difference being due to the different risk habits of populations (7).
There are some arguments over an increase or a decrease in the incidence rates of head and neck cancers in different locations. To find an answer to such arguments, there is a need for the careful statistical analysis of the incidence rate of head and neck cancers in the Iranian society and comparing it with other regions.
The present study was conducted to determine the incidence rate of head and neck cancers in patients referring to Rafsanjan Ali-ibn Abi Talib hospital pathology lab from 2005 to 2016.
 
Materials and Methods
This is a descriptive study in which a datasheet, including the date, age, sex, type, and site of the tumor, was prepared from medical files. The data set consisted of patients’ information on head and neck cancers, admitted to the Abi Talib hospital pathology lab, Rafsanjan, Iran. The data were extracted from 27414 files of patients from 2005 and 2016. The cases of head and neck sites were identified by the standard ‘International Statistical Classification for Diseases’, the 10th revision (ICD-10) coding (8).
The ICD-10 coding for head and neck sites is comprised of C00 (lip), C01-06 (oral cavity), C07 (parotid), C09 (tonsil), C10 (oropharynx), C11 (nasopharynx), C12-14 (hypopharynx), C30-31 (nose and paranasal sinus), C32 (larynx), skin C43.0-43.4, C44.0-44.4, and C73 (thyroid glands). Malignancies, including squamous cell carcinoma, melanoma, undifferentiated carcinoma, papillary cell carcinoma, follicular cell carcinoma, mucoepidermoid carcinoma, acinic cell carcinoma, adenoid cystic carcinoma, parathyroid carcinoma, lymphoma, and basosquamous cell carcinoma were studied.
The privacy of patient information was preserved while handling the data set. Data were analyzed using SPSS 15.0. The chi-square test for trend was utilized to assess a linear trend for the incidence of malignancies over the study period. In addition, the significance level was considered at 0.05.
 
Results
In this study, all cases of head and neck cancers were examined based on the registration data obtained from Ali-ibn Abi Talib hospital pathology lab, with 343 cases extracted from 27,414 files (1.25%). From among these cases of cancers, 33.2% (114 cases) and 66.8% (229 cases) occurred in women and men, respectively, with the difference between males and females having been statistically significant (P < 0.001). The total male-to-female ratio was 2.01, and the mean ± standard age of the patients was 63.90± 14.88 years, ranging from 10 to 96 years. The mean ages of the males and females were 64.15± 14.74 years and 63.39± 15.21 years, respectively.
Table 1 shows the frequency distribution of the cases according to the site of the lesion and sex. The difference of thyroid carcinoma between males and females was statistically significant (P = 0.004). Out of 144 females, 2 individuals (1.8%) were aged under 30, 41 individuals (36%) from 31 to 60, and 71 individuals (62.3%) over 61.
Table 1: The frequency distribution of head and neck cancers by the site and gender over the period of 2005 to 2016
Sites of head & neck cancers Females Males P-value
Lips 10 (8.8%) 17 (7.4%) 0.662*
Oral cavity 7 (6.1%) 21 (9.2%) 0.334*
Pharynx 2 (1.8%) 8 (3.5%) 0.506#
Larynx 8 (7.0%) 6 (2.6%) 0.079*
Esophagus 3 (2.6%) 14 (6.1%) 0.162*
Nasal cavity 2 (1.8%) 7 (3.1%) 0.723#
Cervical lymph nodes 1 (0.9%) 11 (4.8%) 0.068#
Paranasal sinuses 0 (0%) 1 (0.4%) 0.999#
Salivary glands 1 (0.9%) 5 (2.2%) 0.668#
Thyroid 20 (17.5%) 17 (7.4%) 0.004*€
Parathyroid 1 (0.9%) 1 (0.4%) 0.555#
Skin 59 (51.8%) 121 (52.8%) 0.850*
Total 114 (100%) 229 (100%) <0.001*€
- Data are expressed as n (%). *The chi-square test or #the Fisher’s exact test were used, with €P < 0.05 considered statistically significant for both genders. 
In the same vein, out of 229 males, 4 individuals (1.7%) were aged under 30, 92 individuals (40.2%) from 31 to 60, and 133 individuals (58.1%) over 61. No statistically significant difference was observed between males and females (P = 0.778).
Six cases of malignant tumors which occurred to individuals aged under 30 included squamous cell carcinoma (two cases), lymphoma (two cases), and papillary thyroid carcinoma (two cases). Basal cell carcinoma and squamous cell carcinoma were the most common and second common cancers in both genders.
Table 2 shows the gender-based frequency of each type of cancer. There was no statistically significant difference between males and females except for papillary thyroid carcinoma having been more prevalent in females (P=0.009), and lymphoma having been more common in men (P=0.034).
 
Table 2: The frequency of head and neck cancers based on tumor types and gender 
Tumor types Female Male P-value
BCC 59 (51.8%) 112 (48.9%) 0.619*
SCC 24 (21.1%) 65 (28.4%) 0.145*
Melanoma 4 (3.5%) 7 (3.1%) 0.999
Undifferentiated carcinoma 2 (1.8%) 5 (2.2%) 0.999#
Papillary cell carcinoma 19 (16.7%) 17 (7.4%) 0.009*
Medullary carcinoma 2 (1.8%) 1 (0.4%) 0.257#
Acinic cell carcinoma 0 (0%) 1 (0.4%) 0.999#
Adenoid cystic carcinoma 2 (1.8%) 5 (2.2%) 0.999#
Parathyroid carcinoma 1 (0.9%) 3 (1.3%) 0.999#
Basosquamous carcinoma 1 (0.9%) 3 (1.3%) 0.999#
Lymphoma 0 (0%) 10 (4.4%) 0.034€*
Total 114 (100%) 229 (100%) <0.001*
Data are expressed as n (%).














*The chi-square test or #the Fisher’s exact test was used, with €P < 0.05 considered statistically significant for both genders.
 
Table 3 shows the frequency of cancers for each year. According to this table, the highest percentage of malignancies has been related to the period from March 21, 2005 to March 20, 2006, with the lowest percentage of malignancies having been related to the period from March 21, 2009 to March 20, 2010. The chi-square test for trend shows that there is no evidence of a significant linear trend for the frequency of malignancies from March 21, 2005 to September 22, 2015 (P=0.369).

Table 3: The frequency distribution of head and neck cancers over the period of the study (2005-2016)
Variable 2005-2006 2006-2007 2007-2008 2008-2009 2009-2010 2010-2011 2011-2012 2012-2013 2013-2014 2014-2015 2015-
22 Sep 2015
Total
Cancers 36
1.41%
46
1.35%
40
1.29%
38
1.34%
24
1.01%
27
1.12%
31
1.25%
31
1.40%
29
1.13%
31
1.16%
10
1.23%
343
1.25%
Cases 2523
98.6%
3354
98.6%
3050
98.7%
2805
98.7%
2347
99.0%
2385
98.9%
2448
98.7
2188
98.6%
2534
98.9%
2633
98.8%
804
98.8
27071
98.7%
Total 2559
100%
3400
100%
3090
100%
2843
100%
2371
100%
2412
100%
2479
100%
2219
100%
2563
100%
2664
100%
814
100%
27414
100%
Data were analyzed using the chi-square test for trend, with P=0.369.
 

Discussion
Facts and figures about the epidemiological characteristics of head and neck cancers are quite different. In the present study, we included the skin cancers of head and neck, with these cancers (for example BCC and SCC) being obviously the most common cancers. Hence, about 52% of the cancers in the present study were skin cancers. In addition, the most common site of involvement was the skin of the head and neck in the southeast of Iran (9). In most articles, skin cancers are not considered in the category of head and neck cancers, so the larynx was reported as the most common site of involvement in Kerman (46.76%) (10); in the same vein, Mafi et al reported laryngeal cancer as the most common type of head and neck cancers in both sexes in Iran (11). In the present study, the second most common site of involvement was thyroid after skin, probably due to the referral of laryngeal cancer to another medical center.
The significant point in the present study was the changes in the frequency of cancers in different years. In addition, the male-to-female ratio was about 2.0, which was rational because the most common tumors in this study were skin tumors, with the major risk factor for these tumors having been sunlight. Furthermore, men are more exposed to sunlight than women in this region. In Zahedan, Kadeh et al reported that head and neck cancers were more prevalent in woman (53%) than in men (47%), but SCC, being the most common head and neck cancer, was more common in men (9). In the present study, papillary thyroid carcinoma was the only tumor which was more prevalent in women than in men. Based on the cancer registry data, Mirzaei et al reported that the sex ratio was greater in men for various types of head and neck cancers than in women, except for thyroid cancer, from 2003 to 2009 (12).
The present study did not show a significant increase or decrease in the frequency of head and neck cancers from March 21, 2005 to September 22, 2016 in both sexes, but several studies have shown an increase or a decrease in the incidence rate of head and neck cancers; for example, Rama Jayaraj et al (1) demonstrated that the incidence rate of head and neck cancer decreased in the Northern Territory males of Australia but remained unchanged in Australian females; in contrast, Mirzaei et al (12) reported an increasing trend in the age-standardized rate of head and neck cancers in Iran. A study in Denmark reported a marked increase in head and neck cancers, with the highest incidence rate having been reported in patients aged over 60 (13).
Using population–based registry data over the periods of 1983-1987 and 1998-2002, Simard et al reported a change in the incidence rate of head and neck cancers in different countries, perhaps due to the prevalence of different head and neck risk factors. The fixedness of the frequency of head and neck cancers in our patients implied that no change occurred in exposure to carcinogens, such as sun exposure and smoking (14).
Elango et al concluded that the overall incidence rate of head and neck squamous cell carcinoma (HNSCC) decreased, with this could have been due to the decreased prevalence of tobacco use. However, the incidence rate of tongue cancer increased in the present study, implying that factors other than tobacco and alcohol might have played a role in tumorigenesis (7).
Sarcomas is one of the tumors expected to be diagnosed in the head and neck region. In this study, no case of sarcoma was observed, so the measuring of its frequency was not possible. One of the reasons for the low frequency of sarcoma in the region studied is that this cancer is observed in larger areas. Alishahi et al studied 105 patients with head and neck sarcoma in Isfahan, Iran, with the most prevalent cases of sarcomas having been reported to be Osteosarcoma (30.47%), Chondrosarcoma (13.33%), and Ewing sarcoma{Alishahi, 2015 #10} (10.47%) (15).
Cancer incidence rates are connected with cancer risk factors, with some of the most common risk factors for head and neck cancers being sunlight exposure, cigarette smoking, and alcohol consumption (16); hence, any changes in these habits can change the incidence rates of head and neck cancers in the next decades. One of the major limitations of the present study was that it was conducted on patients referred to a specialized hospital, so the entire population was not considered. Hence, conducting more extensive studies containing all patients with head and neck cancers in the Rafsanjan city could yield better results.
 
Conclusion
The present study showed no significant increase or decrease in the frequency rates of head and neck cancers over the period of the study. Determining an increase or a decrease in the frequency of head and neck cancers is not easy; thus, to establish a causal relationship, the effects of more prevalent risk factors, such as tobacco and alcohol must be assessed in patients, concurrently.
 
Acknowledgement
The authors would like to express their sincere gratitude to all pathologists and staff of the Pathology Department at Rafsanjan Ali-ibn Abi Talib hospital who participated in this study.

Conflict of interest: None declared.
 
References
  1. Jayaraj R, Singh J, Baxi S, Ramamoorthi R, Thomas M. Trends in incidence of head and neck cancer in the northern territory, Australia, between 2007 and 2010. Asian Pac J Cancer Prev 2014; 15(18):7753-6.
  2. Keyghobadi N, Rafiemanesh H, Mohammadian-Hafshejani A, Enayatrad M, Salehiniya H. Epidemiology and trend of cancers in the province of Kerman: southeast of Iran. Asian Pac J Cancer Prev 2015;16(4):1409-13.
  3. Krishnatreya M, Rahman T, Kataki AC, Sharma JD, Nandy P, Baishya N. Pre-treatment performance status and stage at diagnosis in patients with head and neck cancers. Asian Pac J Cancer Prev 2014; 15(19):8479-82.
  4. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA Cancer J Clin 2013; 63(1):11-30.
  5. Farazi P, Lander L, Pavlou P, Watkins K, Le L, Soliman A. Geographic trends of tobacco-related cancers in Cyprus. Tob Induc Dis 2015; 13(1):21.
  6. Vigneswaran N, Williams MD. Epidemiologic trends in head and neck cancer and aids in diagnosis. Oral Maxillofac Surg Clin North Am 2014; 26(2):123-41.
  7. Elango JK, Gangadharan P, Sumithra S, Kuriakose MA. Trends of head and neck cancers in urban and rural India. Asian Pac J Cancer Prev 2006; 7(1):108-12.
  8. World Health Organization. ICD-10 : International statistical classification of diseases and related health problems. Tenth Revision, 2nd ed. Geneva: World Health Organization; 2004. Avaiable from: http://www.who.int/iris/handle/10665/42980
  9. Kadeh H, Saravani Sh, Moradbeiki B. Epidemiological aspects of head and neck cancers in a population of south east region of Iran. Caspian Journal of Dental Research 2015; 4(2):33-9.
  10. Larizadeh MH, Damghani MA, Shabani M. Epidemiological characteristics of head and neck cancers in southeast of Iran. Iran J Cancer Prev 2014; 7(2):80-6.
  11. Mafi N, Kadivar M, Hosseini N, Ahmadi S, Zare-Mirzaie A. Head and neck squamous cell carcinoma in Iranian patients and risk factors in young adults: a fifteen-year study. Asian Pac J Cancer Prev 2012; 13(7):3373-8.
  12. Mirzaei M, Hosseini SA, Ghoncheh M, Soheilipour F, Soltani S, Soheilipour F, et al. Epidemiology and trend of head and neck cancers in Iran. Glob J Health Sci 2015; 8(1):189-93.
  13. Blomberg M, Nielsen A, Munk C, Kjaer SK. Trends in head and neck cancer incidence in Denmark, 1978-2007: focus on human papillomavirus associated sites. Int J Cancer 2011; 129(3):733-41.
  14. Simard EP, Torre LA, Jemal A. International trends in head and neck cancer incidence rates: differences by country, sex and anatomic site. Oral Oncol 2014; 50(5):387-403.
  15. Alishahi B, Kargahi N, Homayouni S. Epidemiological evaluation of head and neck sarcomas in Iran (the study of 105 cases over 13 years). Iran J Cancer Prev 2015; 8(4):e3432
  16. Shaw R, Beasley N. Aetiology and risk factors for head and neck cancer: United Kingdom National Multidisciplinary Guidelines. J Laryngol Otol 2016; 130(S2):S9-S12.

© The Author(s) 2019; All rights reserved. Published by Rafsanjan University of Medical Sciences Press.   
Type of Study: original article | Subject: Epidemiology
Received: 2018/02/17 | Accepted: 2019/01/20 | ePublished: 2019/04/29

References
1. Jayaraj R, Singh J, Baxi S, Ramamoorthi R, Thomas M. Trends in incidence of head and neck cancer in the northern territory, Australia, between 2007 and 2010. Asian Pac J Cancer Prev 2013; 15(18):7753-6. [DOI] [PMID]
2. Keyghobadi N, Rafiemanesh H, Mohammadian-Hafshejani A, Enayatrad M, Salehiniya H. Epidemiology and trend of cancers in the province of Kerman: southeast of Iran. Asian Pac J Cancer Prev 2015;16(4):1409-13. [DOI] [PMID]
3. Krishnatreya M, Rahman T, Kataki AC, Sharma JD, Nandy P, Baishya N. Pre-treatment performance status and stage at diagnosis in patients with head and neck cancers. Asian Pac J Cancer Prev 2014; 15(19):8479-82. [DOI] [PMID]
4. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA Cancer J Clin 2013; 63(1):11-30. [DOI] [PMID]
5. Farazi P, Lander L, Pavlou P, Watkins K, Le L, Soliman A. Geographic trends of tobacco-related cancers in Cyprus. Tob Induc Dis 2015; 13(1):21. [DOI] [PMID] [PMCID]
6. Vigneswaran N, Williams MD. Epidemiologic trends in head and neck cancer and aids in diagnosis. Oral Maxillofac Surg Clin North Am 2014; 26(2):123-41. [DOI] [PMID] [PMCID]
7. Elango JK, Gangadharan P, Sumithra S, Kuriakose MA. Trends of head and neck cancers in urban and rural India. Asian Pac J Cancer Prev 2006; 7(1):108-12. [PMID]
8. World Health Organization. ICD-10 : International statistical classification of diseases and related health problems. Tenth Revision, 2nd ed. Geneva: World Health Organization; 2004. Avaiable from: http://www.who.int/iris/handle/10665/42980 [Report]
9. Kadeh H, Saravani Sh, Moradbeiki B. Epidemiological aspects of head and neck cancers in a population of south east region of Iran. Caspian Journal of Dental Research 2015; 4(2):33-9. [Article] [DOI]
10. Larizadeh MH, Damghani MA, Shabani M. Epidemiological characteristics of head and neck cancers in southeast of Iran. Iran J Cancer Prev 2014; 7(2):80-6. [PMID] [PMCID]
11. Mafi N, Kadivar M, Hosseini N, Ahmadi S, Zare-Mirzaie A. Head and neck squamous cell carcinoma in Iranian patients and risk factors in young adults: a fifteen-year study. Asian Pac J Cancer Prev 2012; 13(7):3373-8. [DOI] [PMID]
12. Mirzaei M, Hosseini SA, Ghoncheh M, Soheilipour F, Soltani S, Soheilipour F, et al. Epidemiology and trend of head and neck cancers in Iran. Glob J Health Sci 2015; 8(1):189-93. [DOI] [PMID] [PMCID]
13. Blomberg M, Nielsen A, Munk C, Kjaer SK. Trends in head and neck cancer incidence in Denmark, 1978-2007: focus on human papillomavirus associated sites. Int J Cancer 2011; 129(3):733-41. [DOI] [PMID]
14. Simard EP, Torre LA, Jemal A. International trends in head and neck cancer incidence rates: differences by country, sex and anatomic site. Oral Oncol 2014; 50(5):387-403. [DOI] [PMID]
15. Alishahi B, Kargahi N, Homayouni S. Epidemiological evaluation of head and neck sarcomas in Iran (the study of 105 cases over 13 years). Iran J Cancer Prev 2015; 8(4):e3432 [DOI] [PMID] [PMCID]
16. Shaw R, Beasley N. Aetiology and risk factors for head and neck cancer: United Kingdom National Multidisciplinary Guidelines. J Laryngol Otol 2016; 130(S2):S9-S12. [DOI] [PMID] [PMCID]

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