Opportunistic screening of suspected oral precancerous lesions among patients attending outpatient department of primary health centres, Puducherry

INTRODUCTION

According to the world cancer report, oral cancer is the seventh most common cancer, and the prevalence of oral cancer is higher among men.¹ In South-Central Asia, cancer of the oral cavity is the 3^rd most common type of cancer.² In India, the age-standardized incidence rate of oral cancer is 12.6 per 1,00,000 populations.² Oral cancers are preceded mainly by clinically visible precancerous or premalignant lesions.³ The most common premalignant lesions/precancerous lesions are erythroplakia, leukoplakia, lichen-planus, and oral submucous fibrosis.⁴ The prevalence of leukoplakia in India ranges from 0.2% to 5.2%.⁵ The prevalence of oral submucous fibrosis (OSMF) in India varies between 0.03% and 3.2%.⁵ A cohort study in the Ernakulam district of Kerala showed that 79% of oral cancers arise from pre-existing precancerous lesions/conditions.⁶

In India, the prevalence of premalignant lesions varies with the screening setting, such as hospitals, communities, and primary care facilities. This variation in the prevalence of premalignant lesions can be attributed to regional, life style practices, cultural differences and the prevalence of tobacco or alcohol use.^7-9 The prevalence of precancerous lesions among patients attending hospitals in certain places of India varies from 2.5% to 8. 4%.⁵ A study done in rural Puducherry found that the prevalence of oral precancerous lesions to be 10% among tobacco users aged above 60 years. ¹⁰

Screening the population in the community setting has the disadvantage of missing out on a working population. A similar disadvantage occurs during camp-based screening.¹¹ Opportunistic screening at PHC served as an alternative to camp-based screening and circumvented the underrepresentation of the working population. Oral examination and identification of premalignant lesions by screening at the primary health centre gave an opportunity for providing de-addiction and counseling. It also facilitates appropriate treatment at the earliest. Hence, the study was planned to do an opportunistic screening of suspected oral lesions among the individuals who attend the outpatient Department of Primary Health Centers of Puducherry, intending to determine the proportion of people with suspected precancerous lesions in the oral cavity through visual inspection.

METHODS

This study was a facility-based cross-sectional study carried out in selected urban (Mettupalayam) and rural (Bahour) Primary Health Centres (PHC) of Puducherry from 1^st August 2016 to 30^th September 2016. Individuals above 18 years of age, seeking health care services from outpatient department of two feasibly selected Primary health centers in Puducherry were selected. The Urban Health Center at Mettupalayam caters to a population of around 69,000. The Rural Health Center Bahour caters to a population of nearly 31,000. The daily OPD attendance in each of the PHC varies from 100-200. Twelve hundred participants aged 18 years and above, seeking health care service from the outpatient department of selected PHC was screened opportunistically for suspected precancerous lesions after obtaining a written informed consent Known cases of oral cancer were excluded from the study. Patients were selected by applying the systematic random sampling technique. Data was collected over one month from each PHC. Every tenth patient seeking care from the Primary Health Centre (PHC) was interviewed and examined for suspected oral precancerous lesions during the study period.

The sample size was calculated using OpenEpi Version 3.0. The minimum sample size was estimated to be 1200, assuming the proportion of oral precancerous lesion to be around 2.6%, absolute precision of 0.9% at a confidence interval of 95%.⁴ After obtaining written informed consent, data were collected using a pre-tested semi-structured questionnaire for socio-demographic details, tobacco use, and alcohol use. This was followed by clinical examination by visual inspection of the oral cavity for erythroplakia, leukoplakia, lichen planus, and oral sub mucous fibrosis (OSMF).

Training of the investigator

The screening was done by the 1^st author, who is a trained nurse. She was trained for oral examination under an experienced otolaryngologist and dentist for five days to identify the oral precancerous conditions (erythroplakia, leukoplakia, lichen planus, and oral sub mucus fibrosis). Those participants' findings were cross-verified by a dentist from State Mobile Dental Clinic, Puducherry. The intraoral cavity (buccal mucosa, tongue, the floor of the mouth, hard and soft palate, tonsils) was thoroughly examined using a tongue depressor/wooden spatula, torchlight, and mouth mirror. An operational definition for suspected oral precancerous lesion. A positive suspicious oral lesion was defined as a white patch or a red patch during the visual, oral examination.⁴ The investigator looked for red and white lesions of the oral mucosa and indurated and fixed masses through palpation. All those with oral lesions were counseled and referred to the mobile dental unit for further management.

Data were analysed using EpiData Analysis version 2.2. Prevalence of suspicious lesions was expressed as proportion with 95% Confidence Interval (CI). Association between socio-demographic and clinical characteristics; and tobacco use and oral lesions was expressed as the prevalence ratio with 95% confidence intervals. Log binomial regression were performed by including the risk factors for oral premalignant lesions among tobacco and alcohol users and calculated CI. The measure of association used for identifying possible risk factors for precancerous lesions was PR with 95% CI. Written informed consent was obtained from the study participants before enrolment into the study.

RESULTS

We present here analysis of the 1200 patients attending the OPD of urban (n =600, 50%) and rural (n=600, 50 %) Primary Health Centre of Puducherry underwent opportunistic screening for suspected oral precancerous lesions. The mean age of the study subjects was 51±17 years. Approximately two-third (n=760, 63.3%) of the participants were women and one-third (n=385, 32.1%) were in the age group 46-60 years. More than one-third of the population (35.3%) was illiterate with illiteracy being higher in rural areas as compared to urban (44.2 % vs 26.3%). Nearly, three fourth of the (70.1%) of the participants belonged to the below poverty line, which was higher in rural areas (82.5%). The current users of smokeless tobacco were higher in rural area (22.1%), whereas alcohol users were higher in the urban area (18.8%) (Table 1).

*Classified based on the card used by Public Distribution System. Red Card indicates Below Poverty Line; Yellow card indicates

Above Poverty Line. # Modified Kuppuswamy Classification

**Current users: those who smoke/drink at the time of data collection are current users **Past users: those who were ever users but quit for at least 6 months were considered as past users.

The prevalence of suspected oral precancerous lesions among the study participants was 14.3% (95% CI=12.3, 16.2). Prevalence was higher in rural area (18.5%; 95% CI=15.6, 21.8)) compared to urban area (10.0 %; 95% CI=7.8-12.6) (Table 2).

Sub group analysis of prevalence of suspected oral precancerous lesions in rural and urban area is depicted in Table 3. In the rural and urban areas, participants with higher age, male gender, and substance abuse had a higher prevalence of suspected oral precancerous lesions. The prevalence ratio of suspected oral precancerous lesions for current smokers and alcohol users was higher in urban area. The higher prevalence ratio for a smokeless form of tobacco was observed in rural area. Prevalence of oral precancerous lesions in rural area was high compared to urban among current smokeless tobacco (41.4%) and smokers (44.0%).

Adjusted prevalence ratio by multivariable analysis showed that the participants from the rural PHC had a 1.9 times higher prevalence of suspected oral precancerous lesions than those from the urban PHC. In multivariable analysis, it was also observed that males, those aged above 30 years and tobacco users (smoke or smokeless form) have a higher prevalence of suspected oral precancerous lesions. (Table 4).

#p<0.05, *p<0.01, $p<0.001.

#p<0.05, *p<0.01, $p<0.001. +Calculated using Log-binomial Regression; P value significant at the level of <0.05.

DISCUSSION

We undertook an opportunistic screening for suspected oral precancerous lesions at the outpatient department of an urban and a rural Primary Health Center of Puducherry. The prevalence of suspected oral precancerous lesions was 14.3% (95% CI: 12.3, 16.2), which was similar to that observed in a population-based survey conducted in Indore (13.7%) India.⁸ However, the prevalence varied from 2.3% to 51.1% in India which could be attributed to variations in tobacco/betel quid chewing habits, culture and environmental factors.^6-9 It is also due to the differences in operational definition, study population, and study setting.^5,7-10,12-14 In our study, the most common precancerous lesion was leukoplakia (71%), followed by lichen planus (8%) similar to that noticed in other research works.^7,10,15-19 However, a screening programme in dental hospital noted that oral submucosal fibrosis were the most common precancerous lesion.⁷

The prevalence of suspected oral precancerous lesions was higher in the rural area (18.3%) as compared to an urban area (10.3%). Another study done among tobacco users of age more than 60 years, residing in a rural area in Puducherry reported a prevalence of 10.2%. The higher prevalence in rural areas could be partly attributed to the practice of chewing tobacco/betel quid, which was (28%) in rural area as compared to (16%) in urban areas. However, rural residence had a relatively significant association with suspected oral precancerous lesions in the multivariate analysis also. The yield of the opportunistic screening programme would be higher when implemented in primary health centers in rural areas.

The prevalence of suspected oral lesions was higher in rural women (16.7%) as compared to women in urban PHC (5.4%). Higher prevalence of smokeless tobacco use in rural area may be the possible reason for this. In India, the smokeless form of tobacco use is common among women.^10,20 Males had a higher prevalence ratio (PR) of suspected oral lesions after adjusting for substance use.

Similar male preponderance was noted in studies done at the Indore district of Madhya Pradesh.⁸

The prevalence of suspected oral mucosal lesions increases with age and is 12.2 times higher among people aged more than 60 years.¹⁰ Similar trends were observed in our study and only three subjects (1.8%) were of age less than 30 years. In National Programme for Prevention and Control of Cancer Diabetes, Cardiovascular Disease and Stroke (NPCDCS) programme the screening for oral cancers is recommended for those above 30 years of age. This is an efficient strategy leading to better yield during the screening.²¹

In our study, smokers had a higher prevalence of suspected oral precancerous lesions than never smokers. Similar findings were reported from studies done in northern India, where smokers and tobacco/betel quid chewers had three to four times higher prevalence of precancerous lesions as compared to non-users.⁸

Substance use is an independent risk factor for oral suspicious lesions. Screening tobacco/alcohol users would increase the yield of screening. However, eliciting the correct history of substance use in outpatient department is challenging due to social desirability bias. Hence, screening all those who are aged more than 30 years would be an operationally feasible option. For diagnosis of positive oral lesion, a detailed substance abuse history could be taken and could be redirected to appropriate medical treatment and social interventions such as counselling and tobacco cessation program.

Opportunistic screening of patients attending outpatient department of the primary health centre is less resource-intensive and feasible with minimal training. Screening can be done easily through the visual inspection of the oral cavity using torchlight and disposable tongue depressors. Staining of the participant's mucus membrane by tobacco and Areca nut posed a challenge in the diagnosis of the lesions. Non-availability of confirmatory diagnosis was the limitation of this study. As the study was carried out in OPD settings of PHC, there is a possibility of self-selection bias due to the health seeking behaviour.

CONCLUSION

Opportunistic screening for all individuals above 30 years of age for suspected oral precancerous lesions is feasible in primary healthcare settings. This could help in early identification, appropriate treatment, de-addiction services and follow up.

ACKNOWLEDGEMENTS

We would like to thank Medical officers of Urban (Mettupalayam) and Rural (Bahour) Primary Health Centers of Puducherry and all faculty of the Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry for their contribution in improving protocol and analysis of data.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institute Ethics Committee Human studies (IEC No: JIP/IEC/SC/2016/29/906

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