Prognostic significance of smoking and alcohol history in young age oral cavity cancer

Novel prognostic nomograms for postoperative patients with oral cavity squamous cell carcinoma in the central region of China

BACKGROUND

Oral cavity squamous cell carcinoma (OCSCC) is the most common pathological type in oral tumors. This study intends to construct a novel prognostic nomogram model based on China populations for these resectable OCSCC patients, and then validate these nomograms.

METHODS

A total of 607 postoperative patients with OCSCC diagnosed between June 2012 and June 2018 were obtained from two tertiary medical institutions in Xinxiang and Zhengzhou. Then, 70% of all the cases were randomly assigned to the training group and the rest to the validation group. The endpoint time was defined as overall survival (OS) and disease-free survival (DFS). The nomograms for predicting the 3-, and 5-year OS and DFS in postoperative OCSCC patients were established based on the independent prognostic factors, which were identified by the univariate analysis and multivariate analysis. A series of indexes were utilized to assess the performance and net benefit of these two newly constructed nomograms. Finally, the discrimination capability of OS and DFS was compared between the new risk stratification and the American Joint Committee on Cancer (AJCC) stage by Kaplan-Meier curves.

RESULTS

607 postoperative patients with OCSCC were selected and randomly assigned to the training cohort (n = 425) and validation cohort (n = 182). The nomograms for predicting OS and DFS in postoperative OCSCC patients had been established based on the independent prognostic factors. Moreover, dynamic nomograms were also established for more convenient clinical application. The C-index for predicting OS and DFS were 0.691, 0.674 in the training group, and 0.722, 0.680 in the validation group, respectively. Besides, the calibration curve displayed good consistency between the predicted survival probability and actual observations. Finally, the excellent performance of these two nomograms was verified by the NRI, IDI, and DCA curves in comparison to the AJCC stage system.

CONCLUSION

The newly established and validated nomograms for predicting OS and DFS in postoperative patients with OCSCC perform well, which can be helpful for clinicians and contribute to clinical decision-making.

Oral cancer in young adults: should we approach these patients differently?

Objective

The influence of age on treatment outcomes in oral cancer is unclear. We aimed to determine the prevalence of oral cancer in adults under age 45 and to compare treatment outcomes by age.

Methods

Retrospective study of 284 patients treated for oral cancer from 2010 to 2021. The primary analysis involved the full cohort stratified by age (< vs. ≥ 45y). The second analysis included all patients under age 45 (n=44) matched 1:1 by sex and stage to older patients (age 55-70).

Results

In the primary analysis, the only significant difference was more comorbidities in the older group (p<0.001). In the matched-pair analysis, older patients were more likely to be smokers (75% vs. 54%; p=0.045) and had more comorbidities (p=0.007). The mean PLR and NLR values were significantly higher in the younger group.

Conclusions

No significant differences were observed between age groups in disease stage or outcomes, suggesting that other variables are more important.

Prospective cohort of pre- and post-diagnosis alcohol consumption and cigarette smoking on survival outcomes: an Alberta Endometrial Cancer Cohort Study

PURPOSE

To examine the independent and joint relationships between cigarette smoking and alcohol consumption with survival outcomes after endometrial cancer diagnosis.

METHODS

Pre- and post-diagnosis smoking and drinking histories were obtained from endometrial cancer survivors diagnosed between 2002 and 2006 during in-person interviews at-diagnosis and at ~ 3 years post-diagnosis. Participants were followed until death or January 2022. Multivariable-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated with Cox proportional hazards regression for associations with disease-free survival (DFS) and overall survival (OS).

RESULTS

During a median 16.9 years of follow-up (IQR = 15.5-18.1 years), 152 of the 540 participants had a DFS event (recurrence: n = 73; deaths: n = 79) and 134 died overall. Most participants in this cohort were current drinkers (pre = 61.3%; post = 64.7%) while few were current cigarette smokers (pre = 12.8%; post = 11.5%). Pre-diagnosis alcohol consumption was not associated with survival, yet post-diagnosis alcohol intake ≥ 2 drinks/week was associated with worse OS compared with lifetime abstention (HR = 2.36, 95%CI = 1.00-5.54) as well as light intake (HR = 3.87, 95% CI = 1.67-8.96). Increased/consistently high alcohol intake patterns were associated with worse OS (HR = 2.91, 95% CI = 1.15-7.37) compared with patterns of decreased/ceased intake patterns after diagnosis. A harmful dose-response relationship per each additional pre-diagnosis smoking pack-year with OS was noted among ever smokers. In this cohort, smoking and alcohol individually were not associated with DFS and combined pre-diagnosis smoking and alcohol intakes were not associated with either outcome.

CONCLUSION

Endometrial cancer survivors with higher alcohol intakes after diagnosis had poorer OS compared with women who had limited exposure. Larger studies powered to investigate the individual and joint impacts of cigarette smoking and alcohol use patterns are warranted to provide additional clarity on these modifiable prognostic factors.

Analysis of H-ras Mutations and Immunohistochemistry in Recurrence Cases of High-Grade Oral Squamous Cell Carcinoma

BACKGROUND

This study is focused on the identification of gene mutations in H-ras which are probably associated with tumor recurrence in oral squamous cell carcinoma (OSCC) following conventional therapy.

METHODS

Surgically removed biopsies from OSCC patients without recurrence (n = 43) and biopsies from recurrent cases (n = 19) were analyzed. Also, gingival tissues (n = 5) from normal individuals were processed and considered as control. DNA was extracted and amplified using primers for exons 1 and 2 for the H-ras gene, and then DNA products were analyzed using Sanger's sequencing technique. Besides, H-ras expression was compared in samples by immunostaining (IHC), using anti-ras antibody.

RESULTS

Demographic data show that smoking habit in patients and recurrent tumors was ~ 44.1 and 78%, respectively. The major site of malignancy was tongue tissue (40-60%). The rate of pathological stage III/IV were 41.8 and 100% in primary tumors and recurrence malignancy respectively. The sequencing data showed that a specific mutation in H-ras gene, Gly12Ala (G6266A) in recurrence samples and primary cases was detected in ~ 66.6% and 10% respectively. Accumulation of H-ras protein in tissues was relatively high scores (> 5) in both primary and recurrence tumors. The H-ras mutation detected was associated with increased level of H-ras protein accumulated in the malignant cells (IHC data).

CONCLUSION

These data may suggest that regardless of the causes and factors involved, Gly12Ala (G6266A) is associated with recurrence in high-grade OSCC tumors.

The characteristics of head and neck squamous cell cancer in young adults: A retrospective single-center study

We aimed to characterize clinical and prognostical factors of primary head and neck squamous cell carcinoma (HNSCC) in 85 young patients (≤39 years, median age: 37 years; between 2000-2018) in comparison with 140 institutional general HNSCC patients (median age: 61.5 years). The patient's medical records were collected from the institutional database. The prevalence of smoking and alcohol consumption (65.8% and 48.1%) in the young group exceeded the regional population average but was below the institutional (86.4% and 55%) general HNSCC patient population. Primary tumor sites in the group of young patients were as follows: oral cavity (56.4%), oropharynx (17.6%), hypopharynx (11.7%), and larynx (14.1%). Cumulative five-year overall survival was 44.2% in the young group, but significantly better with early T (T1-2 vs. T3-4: 52.6% vs. 26.7%; p = 0.0058) and N0 status (N0 vs. N+: 65.2% vs. 32.3%; p = 0.0013). Young age, abstinence, earlier stage and laryngeal tumor site might predict a better prognosis. The age distribution and the high prevalence of traditional risk factors among the young patients as well as the predominance of oral cavity tumor localization suggest that the early onset of tumor development could be originated from the premature failure of the intrinsic protective mechanisms.

The impact of tobacco smoking on survival of patients with oral squamous cell carcinoma: a population-based retrospective study

BACKGROUND

This article aims to evaluate the impact of smoking status, accumulated tobacco exposure (ATE), and smoking cessation on overall- and disease-free survival (OS and DFS) of patients with oral squamous cell carcinoma (OSCC).

MATERIAL AND METHODS

Patients with primary OSCC treated with curative intent between 2000 and 2019 in Copenhagen were included (n = 1808). Kaplan-Meier curves and multivariable Cox regression analyses were performed to compare the survival of patients with different smoking history. Interactions between ATE and (A) tumor subsite and (B) excessive alcohol consumption (EAC) on the survival were evaluated using multivariable Cox regression analyses with interaction terms.

RESULTS

We included 1717 patients with known smoking status (62.8% males, median age: 64 years (IQR: 57-71 years)), who had a 5-year OS of 53.7% (95%CI: 49.8%-57.9%). Based on fully adjusted multivariable Cox regression analyses, significantly elevated hazard ratios (HRs) for OS and DFS were identified for current, but not former smokers, compared to never-smokers. An approximately linear relationship between continuous ATE and survival estimates was identified. ATE analyzed as a categorical variable showed significantly elevated HRs for OS of patients with all categories (0<x ≤ 30, 30<x ≤ 60, and >60 PYs), however only for DFS of patients with >60 PYs, compared to 0 PYs. Furthermore, an unfavorable long-term prognosis was evident after >3.5 (OS) and >2.5 (DFS) years from diagnosis for patients who continued smoking compared to patients with smoking cessation at diagnosis. The survival estimates of patients with different tumor subsite and alcohol consumption differed with increasing ATE.

CONCLUSION

Tobacco smoking (assessed as smoking status and ATE) was associated with inferior survival (OS and DFS) among patients with OSCC. Unfavorable long-term prognosis was significant for patients who continued smoking compared to patients with smoking cessation at diagnosis. The impact of ATE on survival of patients with OSCC may depend on the tumor subsite and/or alcohol consumption.

"Fact or fiction?": Oral cavity cancer in nonsmoking, nonalcohol drinking patients as a distinct entity-Scoping review

Oral cavity cancer is often described as a lifestyle-related malignancy due to its strong associations with habitual factors, including tobacco use, heavy alcohol consumption, and betel nut chewing. However, patients with no genetically predisposing conditions who do not indulge in these risk habits are still being encountered, albeit less commonly. The aim of this review is to summarize contemporaneous reports on these nonsmoking, nonalcohol drinking (NSND) patients. We performed database searching to identify relevant studies from January 1, 2000 to March 31, 2021. Twenty-six articles from 20 studies were included in this study. We found that these individuals were mostly females in their eighth decade with tumors involving the tongue and gingivobuccal mucosa. This review also observed that these patients were likely diagnosed with early stage tumors with overexpression of programmed death-ligand 1 (PD-L1) and increased intensity of tumor infiltrating lymphocytes. Treatment response and disease-specific prognosis were largely comparable between NSND and smoking/drinking patients.

Prognostic value of non-smoking, non-alcohol drinking status in oral cavity cancer

OBJECTIVES

To compare the treatment response and prognosis of oral cavity cancer between non-smoking and non-alcohol-drinking (NSND) patients and smoking and alcohol-drinking (SD) patients.

METHODS

A total of 313 consecutively treated patients from 2000 to 2019 were included. Demographic, clinicopathologic, treatment, and prognosis information were obtained. Relapse-free survival (RFS), disease-specific survival (DSS), and overall survival (OS) were compared between NSND and SD groups using Kaplan-Meier plots, log-rank test, and multivariate Cox regression analysis.

RESULTS

Sample prevalence of NSND patients was 54.6%. These patients were predominantly females in their eighth decade with lower prevalence of floor of the mouth cancers compared to SD patients (1.8% vs 14.8%). No difference in the RFS and DSS between both groups was found following multivariable analysis; however, NSND patients had better OS (HR (95% CI) - 0.47 (0.29-0.75); p = 0.002). Extracapsular extension was associated with significantly poorer OS, DSS, and RFS in this oral cavity cancer cohort.

CONCLUSION

Treatment response and disease-specific prognosis are comparable between NSND and SD patients with oral cavity cancer. However, NSND patients have better OS.

CLINICAL RELEVANCE

This study shows that oral cavity cancer in NSND is not less or more aggressive compared to SD patients. Although better survival is expected for NSND than SD patients, this is likely due to the reduced incidence of other chronic diseases in the NSND group.

Effect of smoking status and programmed death-ligand 1 expression on the microenvironment and malignant transformation of oral leukoplakia: A retrospective cohort study

Tobacco smoking is associated with an increased risk of oral leukoplakia and head and neck cancer. Although it has recently been reported that the establishment of an immunosuppressive microenvironment in oral potentially malignant disorders may lead to malignant transformation, it is unclear whether the microenvironments of oral potentially malignant disorders differ according to smoking status. We examined differences in programmed death-ligand 1 (PD-L1) expression and subepithelial CD163+ TAM and CD8+ cell/lymphocyte counts in the microenvironment of oral leukoplakia of smoking and non-smoking patients and investigated their associations with malignant transformation. Pathology reports and original biopsy request forms from 1995–2015 were retrospectively reviewed. Lesions clinically characterized as white plaques/lesions of the oral mucosa and pathologically diagnosed as oral epithelial dysplasia were included. Immunohistochemistry was performed to evaluate PD-L1 expression and subepithelial CD163+/CD8+ cell counts. The significance of prognostic factors in predicting malignant transformation was determined using Cox regression analysis. Statistical significance was defined as P<0.05. In total, 200 patients with oral leukoplakia were selected. The mean age at diagnosis was higher in non-smoking patients (n = 141; 66.9 years) than in smoking patients (n = 59; 60.5 years). The 5-year cumulative malignant transformation rate was higher in non-smoking patients than in smoking patients (9.3% vs. 3.0%, respectively). Oral leukoplakia was associated with significantly higher PD-L1 expression and increased numbers of subepithelial CD163+ cells in the non-smoking group compared with the smoking group. Non-smoking-related oral leukoplakia with positive PD-L1 expression was associated with a 6.97-fold (95% confidence interval: 2.14–22.7) increased risk of malignant transformation. The microenvironment of oral leukoplakia differed according to smoking status. A combination of smoking status and PD-L1 expression may predict malignant transformation in oral leukoplakia patients. This study highlights the importance of understanding the interaction between smoking and the microenvironment in oral leukoplakia.

Excision repair cross-complementing group 2 upregulation is a potential predictive biomarker for oral squamous cell carcinoma recurrence

Oral cancer is the fourth most common type of cancer among males in Taiwan, and the prognosis for patients with advanced-stage oral squamous cell carcinoma (OSCC) remains poor. The present study investigated the prognostic value of three DNA repair genes, namely excision repair cross-complementing group 1 (ERCC1), ERCC2 and X-ray repair cross-complementing group 1 (XRCC1) in OSCC. The protein expression levels of XRCC1, ERCC1 and ERCC2 in oral cell lines were analyzed via western blotting and immunohistochemistry using samples from 98 patients with biopsy-proven OSCC, while the χ² test was used to analyze the clinicopathological association. Kaplan-Meier estimates were used to determine the prognostic value of XRCC1, ERCC1 and ERCC2 for overall survival, and the log-rank test was used to evaluate the significance of differences. Multivariate analysis revealed a positive association between ERCC2 expression and OSCC recurrence (19.64-fold; 95% CI, 5.00-77.1; P<0.001). In addition, the high protein expression levels of XRCC1, ERCC1 and ERCC2 were associated with poor disease-free and overall survival rates. Therefore, the present study suggested that high ERCC2 expression may be a risk factor for OSCC recurrence.