Survival and quality of life for Sudanese oral cancer patients

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El Sheikh, Mariam
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University College Cork
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Background: Cancer is a growing problem in Sudan. Despite being among the top ten cancers in the country, little attention has been paid to oral cancer by policy makers. There is no national screening program, no national registry, and a paucity of well-designed studies, deficiency in medical facilities, together with the lack of awareness among both the public and health professionals. Thus, updated information on the epidemiology and pattern of oral cancer is needed to draw the attention of the local authorities and improve intervention. The majority of oral cancer cases are diagnosed at advanced stages mainly due to lack of awareness and poverty, leading to high rates of morbidity and mortality. Aim: The principle objective of this project was to provide baseline data on survival rates and quality of life for Sudanese oral cancer patients. The Methods: This research is based on two studies. The first was a retrospective study from 2007-2012 in which the medical records of 940 eligible patients obtained from the archives of Khartoum Teaching Dental Hospital were reviewed. The second study was a longitudinal prospective study from January 2013 to December 2015, in which 360 eligible patients were enrolled. The Functional Assessment of Cancer Therapy – Head and Neck Cancer Questionnaire was translated to Arabic, and a pilot study was conducted to assess feasibility and reliability of the FACT Head and Neck scale. Out of the 360 patients, 130 patients agreed to participate in the QOL study. Survival was calculated using Kaplan – Meier method. Analysis of Variance (ANOVA) was used to compare summary and subscale mean scores. The correlations between the variables (socio-demographic and clinical variables) and the FACT summary scales were analysed with general linear modelling (GLM) using multivariate analysis of variance (MANOVA). Results of the retrospective study: The overall male to female ratio of oral cancer patients was 1.8 to 1 (567 males and 373 females) and the mean age was 56.5 years. On average, patients presented to the hospital seeking treatment 8.5±12.7SD months following the onset of symptoms (range 0.5 to 120 months). Over 50% of patients exhibited considerable delay in presentation, with 29.3% waiting more than 6 months. In 72.9% of the delayed cases, the cause of delay was reported to be patient related. The vast majority (67.1%) presented with stage IV, and two-thirds of patients (63.2%) had evidence of nodal disease on presentation. Among the study sample, 43.6% used tobacco, mainly the local smokeless toombak, especially among males. Over half the patients presented with large lesions extending beyond a specific sub-site. The most common sites were gum (17.2%) and tongue (11.3%). Squamous Cell Carcinoma was the dominant histological type (78.5%). The overall 1, 2, 3 and 5-year overall survival rates were 51%, 39.9%, 36.7% and 34% (CI 30.4-37.7%), respectively. Age was found to be an independent predictor for survival (p=0.001), while histological diagnosis, tumour size (early vs. advanced cancer) and nodal involvement (N0 versus N+ ) were found to be the most important independent prognostic factors (p=0.0001). Results of the prospective study: The FACT-H&N questionnaire exhibited high reliability and demonstrated high internal consistency. Patients with advanced disease stages exhibited significantly lower HRQOL. Likewise, patients who received combined chemotherapy and radiotherapy displayed significantly worse QOL scores; patients who were treated surgically reported better scores. The only exception was the emotional well-being domain. In terms of the prospective changes in QOL, the scores at diagnosis showed mild to moderate impairment. However, one month later there was a rapid deterioration. At 3 months and 12 months the QOL scores showed an improvement with the highest HRQOL scores noted at one year. For the social well-being subscale, the mean HRQOL scores showed a clear trend of increasing from baseline to the subsequent points. Conclusion: This study showed that the majority of patients seek treatment in advanced stages of disease, which impacts negatively on prognosis and decreases overall QOL. The QOL generally improved over time with the highest scores reported in those treated surgically. Thus, more public health efforts are needed for education, prevention and early detection of cases. The findings of this research may contribute to a better understanding of the impact of oral cancer in Sudan.
Oral cancer in Sudan , Toombak , Survival rate , Quality of life
El Sheikh, M. 2018. Survival and quality of life for Sudanese oral cancer patients. PhD Thesis, University College Cork.