Epidemiology of head and neck cancer in ... - Wiley Online Library

Received: 6 June 2017

Revised: 5 July 2017

Accepted: 5 July 2017

DOI: 10.1111/ajco.12757

REVIEW

Epidemiology of head and neck cancer in Thailand Napadon Tangjaturonrasme1 1 Department of Otolaryngology, Faculty of

Medicine, Chulalongkorn University, Bangkok, Thailand

Patravoot Vatanasapt2

Andrey Bychkov3

Abstract Cancer is the most common cause of death in Thailand, with the mortality almost doubled dur-

2 Department of Otorhinolaryngology, Faculty

ing 1998–2011 (from 48.4 to 95.2 per 100 000). The estimated number of new cancer cases in

of Medicine, Khon Kaen University, Khon Kaen, Thailand

2011 was 112 392. Our review provides baseline data on the current epidemiological situation

3 Department of Pathology, Faculty of Medicine,

Chulalongkorn University, Bangkok, Thailand Correspondence Andrey Bychkov, Department of Pathology, Faculty of Medicine, Chulalongkorn University, Rama IV Rd., Pathumwan, Bangkok 10330, Thailand. Email: [email protected]

with head and neck (HN) cancer in Thailand based on reports of the National Cancer Registry and findings from local and international publications. Collectively, HN cancer approaches agestandardized rate (ASR) incidence of 15.7 and 10.7 per 100 000 males and females, respectively, and is ranked among the top five dominant cancers in Thailand. The leading HN malignancies in men are oral (ASR incidence 4.6 per 100 000), nasopharyngeal (ASR 2.8) and laryngeal (ASR 2.7) cancers, while the most common cancers in women are thyroid (ASR 5.1) and oral (ASR 3.2) carcinomas. Some local habits (betel quid chewing, traditional cigarette smoking and alcohol intake) are associated with the high incidence of oral cancer in Northeast Thailand. Despite important prognostic significance, the role of human papillomavirus infection in various HN cancers from Thailand has been scarcely addressed. There is a growing incidence of thyroid cancer over the last two decades. The Thai population overall, compared to worldwide rates of HN malignancies, has a lower incidence of laryngeal and thyroid cancers but higher incidence of nasopharyngeal cancer. KEYWORDS

cancer, epidemiology, head and neck, laryngeal cancer, nasopharyngeal cancer, oral cancer, oropharyngeal cancer, Thailand, thyroid cancer

1

INTRODUCTION

The estimated number of new cancer cases in Thailand increased with population growth.4,5 There were 54 586 male and 57 806 female

Thailand is a country in Southeast Asia, which is located at the center

cancers recorded in 2011, which corresponded to age-standardized

of the Greater Mekong Subregion. The country is populated by almost

rates (ASRs) of 143.3 and 131.9 per 100 000 population, respectively.

66 million people ranking it among the top 20 most populated coun-

The leading cancer site is liver and biliary tree in men, and breast in

tries in the world.1 There are 76 provinces arranged in four geograph-

women. The top 10 leading types of cancer in Thai population are

ical regions, including Northern, Northeastern, Central and Southern

shown in Figure 1.

Thailand. Rapid socioeconomic development of the country in the last

Head and neck (HN) cancer is one of the most common cancers

decades and effective control of communicable diseases resulted in

worldwide.6 Epidemiology of HN cancer often remains partially hid-

the emergence of cancer as the leading cause of death in Thailand.2

den, because many reports present the data according to specific

The most recent estimates indicate that cancer was the most common

sites of cancer instead of the HN cancer as a group. There is a sig-

cause of death in Thailand in 2011, with the mortality almost doubled

nificant variability in the definition of HN cancer. Basically, cancers

since 1998 (from 48.4 to 95.2 per 100 000).3 The population-based

of the HN are considered to include the upper aerodigestive tract,

cancer registry is a vital tool for public health needs, being the core of

that is all lesions of the mucosal surfaces from nasal cavity, oral cav-

any cancer control program. There are 16 province- and region-based

ity, nasopharynx down to larynx, hypopharynx and trachea, with rou-

cancer registries in Thailand responsible for cancer statistics, which

tinely added major salivary glands, and more rarely included thyroid

covers about 33.1% of total population.4 Every 5 years, the Ministry

and parathyroid.7 We considered the thyroid gland as one of the major

of Public Health and the Ministry of Education release a special vol-

representatives of HN malignancy due to the immense role of HN spe-

ume “Cancer in Thailand,” which contains available data on incidence

cialists in the management of thyroid cancer patients. Epidemiology of

and distribution of different malignancies. The latest edition was pub-

HN cancer in Thailand is scarcely addressed in the literature.8 Most of

lished in 2015, and it provided cancer statistics that were collected

the publications are based on data from hospital registries, which could

from 2010 to 2012.4

not provide an inclusive depiction of HN cancer on a nationwide level

Asia-Pac J Clin Oncol. 2017;1–7.

wileyonlinelibrary.com/journal/ajco

c 2017 John Wiley & Sons Australia, Ltd 

1

2

TANGJATURONRASME ET AL .

F I G U R E 1 Leading cancers in Thailand, mean annual ASR 2010–2012 (per 100 000 population). Collective incidence of all head and neck cancers shown in white bars. Oral cavity cancer is combined with salivary gland malignancies. NHL = non-Hodgkin lymphoma

due to considerable variations of some HN cancer entities among the

The age-specific incidence rate was calculated by dividing the num-

provinces. Local cancer statistics are made available from the national

ber of cancer cases in each 5 years age and sex structure of popula-

database; however, access for the international medical and scientific

tion in the age group by estimated population as a person-year, and

community is limited.

then multiplied by 100 000 (expressed per 100 000 population). The

Here, we present an overview of the current epidemiological pro-

age-standardized incidence rate was calculated by estimating the age-

file of HN cancer in Thailand based on the report from the population-

specific incidence rates and applying these rates to the standard pop-

based cancer registries with additional support by findings from avail-

ulation (per 100 000). The data from the “Cancer in Thailand, 2010–

able local and international publications.

2012” were utilized in the analysis and presentation.4 The HN cancer in this review is defined as the cancer sites of the International Classification of Diseases for Oncology (ICD-O) codes C00–C14, C30– C32 and C73, which are oral cavity, major salivary glands, orophar-

2

METHODOLOGY

ynx, nasopharynx, hypopharynx, nasal cavity, paranasal sinuses, larynx, trachea and thyroid.9 Since the population-based registry mainly uses

The first population-based cancer registry started in 1986 in Chiang

extent of cancer instead of stage in the report, we describe the staging

Mai province, and currently the whole network is expanded to the 16

in a term of extent, that is local, regional and distant.

most populated provinces and regions of the Kingdom. The population-

PubMed, Scopus and Google Scholar were queried for a combina-

based cancer registries in Thailand carried out the data by standard

tion of keywords “Thailand” and “head-neck cancer/carcinoma,” includ-

procedure according to the International Association for Research

ing single site entities (e.g. oropharyngeal/oropharynx, thyroid, etc.)

on Cancer (IARC). The data on cancer cases were collected from all

Additional search was performed for the same cancer locations cou-

hospitals, laboratories and death certificates, mainly by active data

pled with Thailand as a country of affiliation of the authors. All avail-

collection.4 All registered cases were followed up by both passive pro-

able publications released since 1990 were reviewed to obtain addi-

cedures with death certificate matching and active procedures with

tional information on epidemiologically relevant data, such as risk fac-

scrutiny of hospital records, postal enquiries and through the network

tors, cancer incidence, survival and more.

of health care system. Quality control was assured through percentage of morphologically verified cases and percentage of death certificate only cases. The population denominators used for the calculation of incidence rates were taken from the Population Projections report

3

HEAD AND NECK CANCER IN THAILAND

for Thailand 2010–2040 by the Population Projection Working Group, Office of the National Economic and Social Development Board.4 It

There were 10 707 new cases of HN cancer (men – 56.6% and

should be noted that at the current stage, a database of the National

women – 43.4%) recorded in Thailand in 2011.4 Collectively, HN can-

Cancer Registry has several limitations. These include variability of the

cer approaches ASR incidence of 15.7 and 10.7 per 100 000 males and

participating regions across the years, which makes difficult to esti-

females, respectively (Figure 1). The leading HN malignancies in men

mate time trends, and absence of data on mortality and survival. How-

are oral, nasopharyngeal and laryngeal cancers, while the most com-

ever, continuing evolution and improvement of the cancer registry over

mon cancers in women are thyroid and oral carcinomas (Table 1). Com-

the last 40 years is aimed to achieve homogenous standards across the

pared to the previous decade, there was a rise of HN cancer, in contrast

country.

with the overall slight decrease of cancer incidence in Thailand.4,5 This

3

TANGJATURONRASME ET AL .

TA B L E 1 ASR incidence of major head and neck malignancies in Thailand, 2011 (per 100 000 population)

and Asian estimates (usually 1.9–2.0).2,4,12 This remarkable finding is largely contributed by the high incidence of oral cancer in women from

Organ/site

ICD-O code

Male

Female

the Northeast region, with sex ratio 0.5–0.7.4 Studies from Khon Kaen,

Oral

C00–06

4.6

3.2

a Northeastern province in Thailand, linked this female preponderance

Lip

C00

0.2

0.7

with local habits of betel quid chewing, traditional cigarette smoking

Tongue

C01–02

2.2

1.0

and alcohol drinking,13–15 with betel quid chewing being the strongest

Mouth

C03–06

2.2

1.5

Oropharynx

C09–10

1.4

0.4

risk factor for oral cancer.13,16 Oral human papillomavirus (HPV) infection is the putative precursor to HPV-related HN cancer, which is the best illustrated by oropha-

Tonsil

C09

1.1

0.3

Other oropharynx

C10

0.3

0.1

Nasopharynx

C11

2.8

0.9

Hypopharynx

C12–13

1.5

0.1

ing on the technique employed.18–20 A recent study from Khon Kaen

ryngeal carcinoma (see below). Association with oral cancer is not so strong.6,17 Several local studies addressed the prevalence of HPV in oral squamous cell carcinoma, and found HPV rate 3–30%, depend-

Larynx

C32

2.7

0.2

found increasing trend of HPV prevalence in oral cancer patients dur-

Thyroid

C73

1.5

5.1

ing 2005–2011.20 Tongue cancer: Tongue was the most common single site of oral cancer in Thai population in 2011, with ASR incidence of 2.2 and 1.0 per

rise was contributed by the substantial growth of incidence of thyroid

100 000 in males and females, respectively.4

cancer in both genders, and also growth of all the HN cancers except-

Mouth cancer: Major locations of this multisite entity were floor

ing nasopharyngeal in male population. At variance, the incidence of

of mouth and buccal mucosa.11 ASR incidence was 2.2 and 1.5 per

several HN malignancies including oral, nasopharyngeal, laryngeal and

100 000 of Thai men and women, respectively.4 The peak incidence in

hypopharyngeal in women decreased.

2011 was in the age group of 50–55 years old, which had been shifted

According to the database from the National Health Security Office

from 45 to 50 years in 2002.4,5

and the Social Security Office of Thailand in 2010, the HN cancer

Lip cancer: The incidence of lip carcinoma was lower than that of

patients required totally 233 525 days of hospitalization (mean, 9 days)

mouth and tongue malignancies, with ASR incidence of 0.2 and 0.7 per

in 2010.8 The amount of hospital charges for HN cancer in the fiscal

100 000 in men and women, respectively.4 Out of 414 new cases diag-

year 2010 was 691 million Baht (USD 21.8 million), with a mean of

nosed in 2011, the vast majority (82.2%) were in females.4 Lip can-

Recent studies reported that

cer is a main entity contributing to the described above low sex ratio

in addition to the growing incidence, survival rates of HN in Thailand

of oral cancer in Thailand. Lip cancer had the best survival rate (with

are not improving.10

5-year survival greater than 70%) among all oral cancer sites based on

26 556 Baht (USD 838) per

admission.8

An issue of urgent need to recruit sufficient num-

bers of specialists involved in the treatment of HN cancer, especially HN surgeons and radiotherapists, has been addressed at the national

the study from endemic province in the Northeast Thailand.15 Recently, the changing pattern of the oral cancer subsites has been reported, for example growth of tongue cancer and declining of car-

level.8

cinoma of the buccal mucosa during the last 30 years.10 The latter

3.1

was likely associated with a cessation of betel quid chewing in certain

Oral cavity cancer

regions, while continuing habits of smoking and alcohol drinking could

Out of 3293 new cases of oral cancer in 2011, 54.4% were diagnosed in

contribute to tongue cancer rates.

men and 45.6% in women, which correspond with ASR incidence of 4.6

Oral cancer incidence in Thailand is different from worldwide pro-

and 3.2 per 100 000 male and female population, respectively (Table

jections (5.5 in men and 2.5 in women, per 100 000 population), hav-

1).4 Oral cancer is one of the most common malignancies in Thai men,

ing lower rates in males and higher rates in females.12 Estimates from

ranked seventh by incidence. Tongue and mouth are the main locations

GLOBOCAN 2012 suggested that cancer of oral cavity had the high-

(Table 1). The incidence increases sharply from 65 years of age in both

est ASR mortality (2.6 and 1.6 per 100 000 males and females, respec-

genders. Among the HN cancers, cancer of the oral cavity caused the

tively) among all HN malignancies in Thailand.12 A study from the

highest number of out-patient visits (28.2%) and in-patient admissions

South Thailand found that 5-year overall survival for the oral cancer

(25%) in 2011.8

was 25.9%.21 Usually, tongue cancer has the worst and lip cancer has

The most common extent of disease at presentation is

regional followed by the local stage.4

Squamous cell carcinoma, usually

the best relative survival rates.15 According to the region-based stud-

well or moderately differentiated, accounts for more than 95% of all

ies, early diagnosis was improved during the last decades, but no signif-

cases.11

icant gain in survival for oral cancer patients was achieved.10

The cancer of oral cavity was ranked as the sixth most common malignancy in Thai females in 1990, but it had been dropped out from the top 10 cancers list by 2011. At the same time, oral cancer is con-

3.2

Oropharyngeal cancer

sistently placed among 6–8 most common malignancies in male popu-

The ASR incidence of oropharyngeal cancer in Thailand in 2011 was

lation for the last 40 years.2,4,5

A male-to-female ratio of oral cancer in

1.4 per 100 000 in men and 0.4 per 100 000 in women (Table 1),

Thailand is within 1.1–1.2 range, which is different from the worldwide

slightly higher than a decade ago (1.1 and 0.2 for males and females,

4

TANGJATURONRASME ET AL .

respectively).4,5 The incidence is growing from age 45 years and

in local population.30,31 Additional studies focused on noninfectious

approaches peak level in the over 75 age group. The main anatomical

causes found that tobacco smoking is another important risk factor.32

location is the tonsil. Most patients are diagnosed with advanced

The case–control study in the northeast of Thailand found that con-

stage.15,21

sumption of sea-salted fish at least once a week was a significant risk

HPV, particularly high-risk types 16 and 18, is the major infectious

factor, as well as working in agriculture or as a woodcutter.33

cause of oropharyngeal cancer, especially of tonsil and tongue base primaries.22,23 The proportion of HPV-associated oropharyngeal can-

3.4

Laryngeal cancer

cers is currently growing in the Western world, with prevalence estimates in the United States approaching 80%.6 As a result, the ratio of oropharyngeal cancer to other HN cancers is around 30% in Western practice, which is substantially different from Asian population (12%) and Thailand (
75% for the former and latter locations, respectively).37 Laryngeal cancer has the highest 2- and 5-year overall survival compared to oral, oropharyngeal and hypopharyngeal cancers.21 Worldwide ASR incidence of laryngeal carcinoma is 3.9 per 100 000 in males and 0.5 per 100 000 in females, which is higher than in Thailand.12 At the same time, Thai rate of laryngeal cancer is comparable with the Southeast Asian estimates provided by GLOBOCAN (2.7 and 0.5 per 100 000 male and female population, respectively). Low incidence in Thai women can be attributed to the cultural predilection of not smoking and drinking.35

Nasopharyngeal cancer is endemic in Southeast Asia (mainly Southern China) due to the local diet saturated with salty preserved fish and also genetic

traits.27

GLOBOCAN database estimates ASR inci-

dence (per 100 000 population) of nasopharyngeal carcinoma in Southeast Asia as 6.4 in males and 2.4 in females, much higher than worldwide incidence – 1.7 in men and 0.7 in women.12 The rate in Thailand is higher than worldwide incidence; however, it is significantly lower than in neighboring endemic Southeast Asia, owing to the different diet styles.28 In the same fashion, mortality rate of nasopharyngeal carcinoma in Thailand (1.3 per 100 000 population) is in between the worldwide mortality (0.7) and the Southeast Asian (2.5) mortality.12 Epstein–Barr virus (EBV) plays a crucial role in carcinogenesis, diagnosis and prognosis of nasopharyngeal cancer, also having clinical use

3.5

Hypopharyngeal cancer

Hypopharyngeal cancer in Thailand has an incidence similar to that of the oropharyngeal carcinoma (Table 1). There were 651 new cases diagnosed in 2011 in Thailand, with a male-to-female ratio 9:1.4 Approximately 90% of patients were more than 50 years old, and around half of all the patients were older than 65 years old.4 Hypopharyngeal cancer has the highest proportion of advanced stage disease at the time of diagnosis, which results in the worst survival rate among all HN cancers in Thailand.15,21

3.6

Thyroid cancer

in posttreatment surveillance.29 There are small-series studies from

Thyroid cancer is the most common malignancy of the endocrine

Thailand, which confirm EBV etiology of nasopharyngeal carcinoma

system. Anatomical position of the thyroid gland determines its

5

TANGJATURONRASME ET AL .

placement under responsibility of HN multidisciplinary team. There

Asia (4.5 – female, 1.8 – male), Asia (5 – female, 1.5 – male) and world

were 2665 new cases of thyroid cancer recorded in 2011 in Thailand.4

(6.1 – female, 1.9 – male).12

Thyroid carcinoma has a prominent gender disparity with a female-

To conclude, according to the recent estimates, thyroid cancer is

to-male ratio exceeding 3:1.38 In 2011, the mean annual incidence of

one of the most common malignancies in Thai women, occupying

thyroid malignancies in Thailand was 1.5 and 5.1 per 100 000 of male

fourth rank by prevalence and seventh rank by incidence. There is slow

and female population, respectively (Table 1).4 Thyroid carcinoma is in

but steady growth of thyroid cancer incidence in both sexes over the

the top 10 of the leading cancer sites in Thai women, slowly climbing

last two decades. The rate of thyroid cancer in Thailand is similar to

from ninth position in 2002 to seventh position in 2011.4,5 There

average Asian and worldwide rates.

was minor variability of incidence among different provinces with the lower rates in the rural North and Northeast regions, more likely due to limited access to diagnostic imaging.

4

CONCLUSION

The majority of male patients (55.8%) were over 60 years old, while the similar proportion of female patients (56.6%) were 30–65

HN cancer is among the top five leading cancers in Thailand. Com-

years old. The peak incidence irrespective of sex was in the 65–75 age

pared to the worldwide rates of HN malignancies, Thai population has

group. It is different from the previous decade (2002), when the peak

lower incidence of laryngeal and thyroid cancers, and higher incidence

incidence in women was recorded in the 50–60 age group.5 A recent

of nasopharyngeal cancer. Despite important prognostic significance,

study from a single cancer center found that thyroid cancer in elderly

the role of HPV infection in various HN cancers from Thailand has been

women showed the highest increase among all the sites between 1993

rarely addressed to date. It should be noted that some GLOBOCAN

and 2012.39 Thyroid cancer in children and adolescents was extremely

estimates (e.g., incidence of oral, nasopharyngeal and thyroid cancer in

rare, accounting for 2.7% in both sexes.4 Histological types of thyroid

male population) are discordant with the more precise data provided

cancer are rarely recorded in regional cancer registries. The most

by the Thai National Cancer Registry. Moreover, some distinct sites

consistent data were available from Eastern Thailand and showed

such as larynx and hypopharynx are not represented in GLOBOCAN

predominance of papillary thyroid carcinoma (over 70%) among all

2012. We believe that our summary presents baseline data on the cur-

thyroid cancers. Recent reports found that papillary carcinoma inci-

rent epidemiological situation and trends of HN cancer in Thailand and

dence increased and follicular carcinoma incidence decreased due to

will offer insight to international and local communities involved in HN

iodination policy, higher recognition of microcarcinomas and changes

cancer research.

in histological classification.40–42 In a line with other Asian countries, and at variance with Western practice, Thailand has very low rate of follicular variant of papillary thyroid carcinoma.42 Molecular profile

ACKNOWLEDGMENT

of thyroid cancer in Thailand appears similar to the neighboring

We thank Ms. Pakaporn Tosirisuk for assistance with data preparation

countries; however, the evidence is limited.43 More studies necessary

and initial draft in section of oral cavity cancer.

to advocate and promote clinical molecular testing of thyroid nodules are anticipated.44

CONFLICT OF INTEREST

Cancer prevalence and mortality are not reported in the major

The authors declare that they have no conflict of interest.

local source.4 Estimates from GLOBOCAN show that thyroid cancer is the fourth most prevalent malignancy in the Thai female population.12 It should be noted that this rate is based on the data from the limited number of Thai regional population-based registries contributing to GLOBOCAN database, and may not represent actual prevalence across the whole country. High prevalence of thyroid cancer is contributed by the relatively low mortality rate (0.6 per 100 000 by GLOBOCAN) compared to other malignancies.12 The incidence of thyroid cancer is on steady rise worldwide.45 The major reason behind this is a widespread use of high-resolution imaging able to detect small-sized low-risk cancers. The IARC experts claimed that enormous increase in thyroid cancer incidence in developed countries is subsequent to opportunistic and often unnecessary ultrasonography.46

A similar trend of growing rate of thyroid microcar-

cinoma was recently reported from a single center in Bangkok, where incidence of subcentimeter cancers among thyroid surgical specimens doubled (from 15% to 32%) between 2005 and 2015.41 GLOBOCAN 2012 data show that ASR per 100 000 population of thyroid cancer in Thailand is not much different from the projected rates in Southeast

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How to cite this article:

Tangjaturonrasme N, Vatanas-

apt P, Bychkov A. Epidemiology of head and neck cancer in Thailand. Asia-Pac J Clin Oncol. 2017;1–7. https://doi.org/10.1111/ajco.12757