Original Article

Association of oral cancer site with addiction and

sociodemographic characteristics: A cross‑sectional study
conducted at a tertiary health centre
Praful Maroti Hulke1, Jalindhar Pandurang Baravakar2, Vinod Genu Bagade3, Alka Modi Asati4, Sonali Tripathi5
Department of Public Health, Taluka Health Officer, Chamorshi, Gadchiroli, Maharashtra, 2Department of Community Medicine,
1

Dr Vitthalrao Vikhe Patil Foundation’s Medical College and Hospital, Ahmednagar, Maharashtra, 3Department of Community
Medicine, Govt. Medical College, Miraj, Maharashtra, 4Department of Community Medicine, Sunderlal Patwa Government Medical
College, Mandsaur, Madhya Pradesh, 5Department of Research and Development, Kalpataru Gramodyog Samiti (NGO), Bhopal,
Madhya Pradesh, India

Abstract Introduction: In contemporary epidemic scenarios, oral cancer ranks the top 3 cancer types afflicting the
Indian population. The primary risk factors include alcohol consumption, tobacco usage in various forms,
such as cigarettes and smokeless tobacco, betelnut chewing, and infection with the human papillomavirus.
This article submitted in preprint in medRxiv on 20 February 2024.
Materials and Methods: This study, conducted at a tertiary healthcare center, adopted a hospital‑based
cross‑sectional approach involving 233 oral cancer patients who sought medical care from January 1 to
December 31, 2017.
Results: The findings indicate that males above the age of 60 (40.11%) and females aged between 41 and
50 years (45.45%) were the most affected groups. A statistically significant association (P < 0.05) was found.
The primary sites for oral cancer were the cheek (40.36%) and tongue (31.78%). Remarkably, the majority
of male patients exhibited a combination of addictions, including tobacco chewing, smoking, and alcohol
use, whereas most female patients were exclusively involved in tobacco chewing.
Conclusion: To curb the increasing prevalence of oral cancer in India, it is imperative to implement
comprehensive public education initiatives and health promotion strategies aimed at reducing both smoking
and alcohol consumption.

Keywords: Alcohol use, health promotion, prevention, smoking, tobacco use

Address for correspondence: Dr. Alka Modi Asati, 201, Second Floor, F2 Block, Faculty Quarter, SPGMC, Mandsaur - 458 001, Madhya Pradesh, India.
E‑mail: asati.dr@gmail.com
Submitted: 01‑Mar‑2024, Revised: 02‑Sep‑2024, Accepted: 04‑Sep‑2024, Published: 15-Oct-2024

INTRODUCTION death in developed nations, plays a significant role in

this trend.[1] Oral cancer, an ancient ailment documented
In today’s world, noncommunicable diseases, often called in texts such as the Sushruta Samhita, is a malignant
modern epidemics, are on the rise. Among the top 10 neoplasm affecting various oral structures, including
causes of mortality, cancer, the second leading cause of
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How to cite this article: Hulke PM, Baravakar JP, Bagade VG, Asati AM,
DOI: Tripathi S. Association of oral cancer site with addiction and sociodemographic
10.4103/jomfp.jomfp_62_24 characteristics: A cross‑sectional study conducted at a tertiary health centre.
J Oral Maxillofac Pathol 2024;28:422-7.

422 © 2024 Journal of Oral and Maxillofacial Pathology | Published by Wolters Kluwer - Medknow
 Hulke, et al.: Association of oral cancer with addiction and sociodemographic characteristics

the lips, mouth floor, cheek lining, gingiva, palate, and MATERIALS AND METHODS
tongue. Its local aggressiveness leads to disfigurement,
functional impairment, and physical and psychosocial Study design
distress, ultimately affecting an individual’s quality of This hospital‑based descriptive study, employing a
life.[2] Oral cancer ranks as the 6th most prevalent cancer cross‑sectional design, was conducted with oral cancer patients.
worldwide, with notable geographical variations.[3] In
Place and duration of study
India, it constitutes nearly 40% of all cancer cases and
Patients were attending a tertiary healthcare center over a
remains among the top three cancer types.[4] Alarmingly,
one‑year period from January 1, 2017, to December 31, 2017.
more than five individuals in India succumb to oral
cancer every hour. [5] Common risk factors for oral Inclusion and exclusion criteria
cancer include tobacco product usage, such as cigarettes, All patients who were diagnosed with oral cancer at the Tertiary
smokeless tobacco, betel nut chewing, excessive alcohol Health Care Centre during the study period and who consented
consumption, and human papillomavir us (HPV) to participate were included. Among the 241 patients diagnosed
infection. Low socioeconomic status, often linked to with oral cancer, 233 met the inclusion criteria.
factors such as nutrition and personal habits, is also
associated with increased risk.[2] Sampling size and sampling
Patients who attended a tertiary healthcare center over a
India, a developing nation, faces a unique challenge: one‑year period and met the inclusion criteria were included
22% of its population lives below the poverty line. in the study. Therefore, the tenure sampling method was
A cancer diagnosis often exacerbates the economic used because the study was conducted for 1 year of tenure.
struggles of affected families. [6,7] To monitor cancer
incidence, survival, and mortality, the Indian Council of Data collection
Medical Research initiated the National Cancer Registry Permission was obtained from the surgery and ENT
Programme (NCRP) in 1982. This program includes departments, and individuals were informed about the study.
population‑based cancer registration (PBCR), with Informed written consent in the local language was obtained
“Barshi” as the primary registry for rural areas in western before participation. A separate proforma was completed for
Maharashtra and the Marathwada region. The incidence each patient and their relatives, ensuring that patient identity
of cancer varies significantly across Indian cities, with remained confidential. A predesigned, pretested proforma was
rates ranging from 37.3 per 100,000 in Barshi to 86.7 per used to gather information on sociodemographic characteristics;
100,000 in Chennai among males and 44.1 per 100,000 in personal habits such as tobacco consumption (including
Barshi to 101.2 per 100,000 in Chennai among females, chewing, betel quid, smoking, gutkha, khaini, or other forms);
according to population‑based cancer registries (PBCRs). alcohol consumption (including duration, frequency, and
amount); and the impact of these habits on living standards.
The estimated overall cancer incidence in India ranges
Proforma was validated for the language by the language
from 70‑90 cases per 100,000 people, resulting in
experts and face validation was done by researchers and subject
approximately 79 lakh new cancer cases annually. In
experts of institute, and it was pretested on 25 patients outside
the year 2000, cancer was responsible for 5.5 lakh
the study setting area.
deaths in India, with Maharashtra accounting for 9% of
these cases.[8] It is crucial to dispel two misconceptions Data analysis
about cancer: First, that it is inevitable, and second, Data was collected, compiled, and analyzed using MS Excel.
that it affects only industrialized nations. In reality, Percentages for qualitative variables and mean and Standard
approximately 80% of cancer cases are preventable and Deviation (SD) for quantitative variables was obtained.
linked to environmental factors.[9] Early detection of oral Chi‑square test was applied wherever necessary to know
cancer and mitigating risk factors offer the best chance the association between variables. The value of P < 0.05
of long‑term survival, improved treatment outcomes, and was considered statistically significant. Data analysis was
more cost‑effective healthcare. carried out via SPSS software version 16.

With this perspective in mind, we studied oral cancer Ethical approval

patients at a tertiary healthcare center to investigate the This study was ethically approved by institutional ethics
relationships between risk factors and oral cancer patients committee as per standards. P. G. Coordination committee,
seeking care. This article was submitted in preprint in Dr V. M. Govt. Medical College, Solapur, number 535, dated
medRxiv on 20 February 2024. 06/09/2016 had approved this protocol.
Journal of Oral and Maxillofacial Pathology | Volume 28 | Issue 3 | July-September 2024 423
 Hulke, et al.: Association of oral cancer with addiction and sociodemographic characteristics

RESULTS Table 2 illustrates the age and site‑wise distribution of oral

cancer patients. Cheek (40.36%) was the most common
This cross‑sectional study, which was conducted over one site of oral cancer, followed by the tongue (31.78%)
year from January 1, 2017, to December 31, 2017, included and gum (8.17%), whereas the lip (3.88%) was the least
233 diagnosed oral cancer patients attending a tertiary care affected site. The floor of the mouth and other mouth
center. The key findings are summarized below. parts (oropharyngeal isthmus and palatoglossal fold)
were equally affected (4.29%). No statistically significant
Table 1 displays the age and site wise distribution of oral association was found between cancer site and age at
cancer patients by sex. The age range of affected individuals diagnosis (P > 0.05).
was 26‑81 years, with the highest number of oral cancer
patients in the above 60 years age group, accounting for Table 3 presents the distribution of patients by their
32.61%, followed by 32.19% in the 51–60 years age group. habit patterns in terms of sex and cancer site. The
majority of oral cancer patients reported tobacco
The least affected age group was those under 30 years, at
chewing alone (32.18%), followed by tobacco chewing
1.29%. The sex distribution revealed that 71.67% of the
combined with smoking (18.88%). Among males, the
patients were males, whereas 28.32% were females, resulting most common habit was tobacco chewing combined
in a male‑to‑female ratio of 2.5:1. The most affected age group with alcohol and smoking (22.16%), followed by
among males was above 60 years (40.11%), whereas among tobacco chewing combined with smoking (21.56%).
females, it was 41–50 years (45.45%). The differences in age Among females, tobacco chewing alone was more
and sex distributions were statistically significant (P < 0.05). common (63.64%) than among males (19.76%). This
association between sex and habit patterns was highly
Figure 1 shows the distribution of patients according to significant (P < 0.01). In terms of the distribution of
their place of residence. Among 233 oral cancer patients, patients according to their habit patterns and cancer
Majority, (54.94%) lived in urban areas, and 45.06% lived in rural site, the tongue was the common site of cancer when
areas. This difference was not statistically significant (P > 0.05). a single habit, such as chewing, smoking, or alcohol
consumption, was present (56%). The cheek was the
Chart 1 shows that the majority of patients (33.79% had a common site. in cases with a combination of more
class III socioeconomic status (according to the modified than one habit. Patients with no habits were more likely
B.G. Prasad’s classification), followed by 28.32% with a to develop cancer in other mouth parts, such as the
class IV socioeconomic status. The least affected patients oropharyngeal isthmus and palatoglossal fold (40%).
had a class I socioeconomic status. This difference was This association between cancer site and habit pattern
highly significant (P < 0.01). was highly significant (P = 0.00). Moreover, 54.94%
of the oral cancer patients had lived for more than
Table 1: Distribution of patients age and site of cancer with 10 years, whereas 36.05% had lived for 5–10 years, and
relation to gender this difference was highly significant (P < 0.01).
Gender Total n (%) Characteristics
Male Female Figure 2 shows the distribution of patients according to their
Age duration of addiction. In the present study, 54.94% of oral
<30# 3 (100%) 0 (0%) 3 (1.29%) Chi square ‑ 30.3
31–40# 15 (100%) 0 (0%) 15 (6.44%) P<0.05 cancer patients had habits for more than 10 years, followed
41–50 34 (53.12%) 30 (46.88%) 64 (27.47%)
51–60 48 (64%) 27 (36%) 75 (32.19%)
>60 67 (88.16%) 9 (11.84%) 76 (32.61%)
Total 167 (71.67%) 66 (28.32%) 233 (100%)
Cancer site
Lip 6 (75%) 3 (25%) 9 (3.88%) Chi square ‑ 3.87
Tongue 59 (79.73%) 15 (20.27%) 74 (31.78%) P>0.05
Gum 13 (68.42%) 6 (31.58%) 19 (8.17%)
Floor of 6 (60%) 4 (40%) 10 (4.29%)
mouth
Cheek 64 (68.09%) 30 (31.91%) 94 (40.36)
Palate 12 (79.73%) 5 (79.73%) 17 (7.23%)
Other mouth 7 (79.73%) 3 (79.73%) 10 (4.29%)
parts*
Total 167 (71.67%) 66 (28.32%) 233 (100%)
[Rows with #were clubbed together for statistical calculation] *Other Figure 1: Distribution of patients according to residence: [Chi‑square
mouth parts include the oropharyngeal isthmus and palatoglossal fold value for goodness of fit is 2.27, P > 0.05, not significant]

424 Journal of Oral and Maxillofacial Pathology | Volume 28 | Issue 3 | July-September 2024
 Hulke, et al.: Association of oral cancer with addiction and sociodemographic characteristics

by 36.05% of patients who had habits for 5–10 years, and DISCUSSION
this difference was highly significant (P < 0.01).
In this study, of 233 oral cancer patients, the highest
The study revealed that most patients were diagnosed proportion of cases were individuals above 60 years of age,
with stage III disease (69.96%), followed by stage II with the least affected group being those under 30 years of
disease (21.03%). No cases of stage I disease were reported age. Most patients were male, resulting in a male‑to‑female
in the study population. Stage III and stage IV cancers ratio of 2.5:1. Among males, the most affected age group
were more common in males, accounting for 78.53% was above 60 years, whereas among females, it was 41–
and 80.95%, respectively, whereas stage II cancers were 50 years, with no female patients younger than 40 years.
more prevalent in females (55.1%). Table 4 shows that the
These findings align with those of previous studies.[4,10,11]
association between sex and stage at diagnosis was highly
In a study done by Akhilesh Krishna et al.[12] in northern
significant (P < 0.01). Furthermore, there was a strong
part of India shows that age group 41‑50 affected most.
association between stage and age at diagnosis, with 69.96%
of patients having stage III cancer, most of whom were in
the 40–60 years age group.

Figure 2: Distribution of patients according to the duration of

Chart 1: Distribution of patients according to socioeconomic status: habit (Addiction): [Chi‑square value for goodness of fit is 74.495, df = 2,
Chi‑square = 77.794. P < 0.01 P < 0.01, highly significant]

Table 2: Age and cancer site distribution of patients

Cancer site Age at diagnosis (years) Total No (%) Chi sqare test
<40 40–60 >60
Lip 00 07 (77.78%) 02 (22.22%) 9 (3.88%) Chi‑square ‑ 6.54
Tongue 5 (6.76%) 43 (58.11%) 26 (35.13%) 74 (31.78%) P>0.05
Gum 02 (10.53%) 13 (68.42%) 04 (21.05%) 19 (8.17%)
Floor of mouth 00 06 (60%) 04 (40%) 10 (4.29%)
Cheek 7 (11.45%) 55 (58.51%) 32 (30.04%) 94 (40.36%)
Palate 02 (11.76%) 10 (58.82%) 05 (29.41%) 17 (7.23%)
Other mouth parts# 2 (20%) 5 (50%) 3 (30%) 10 (4.29%)
Total 18 (7.73%) 139 (59.75%) 76 (32.61%) 233 (100%)
#
Other mouth parts include the oropharyngeal isthmus and palatoglossal fold

Table 3: Distribution of patients addiction habit with gender and cancer site
Addiction Tobacco Smoking Alcohol Tobacco Tobacco Smoking + Tobacco No Total
chewing alone alone chewing chewing Alcohol chewing Addiction
Male 33 (19.76%) 16 (9.58%) 11 (6.59%) 36 (21.56%) 10 (5.99%) 21 (12.57%) 37 (22.16%) 3 (1.8%) 167 (71.67%)
Female 42 (63.64%) 3 (4.55%) 1 (1.52%) 8 (12.12%) 4 (6.06%) 2 (3.03%) 0 6 (9.09%) 66 (28.32%)
P<0.01
Cancer site
Lip 9 (100%) 0 0 0 0 0 0 0 9 (3.88%)
Tongue 42 (56%) 16 (21.6%) 10 (13.51%) 5 (6.75%) 0 0 0 1 (1.35%) 74 (31.78%)
Gum 6 (31.57%) 0 0 12 (63.15%) 0 0 0 1 (5.26%) 19 (8.17%)
Mouth 4 (40%) 0 0 6 (60%) 0 0 0 0 10 (4.29%)
Cheek 14 (14.89%) 3 (3.19%) 2 (2.12%) 21 (22.34%) 14 (14.89%) 21 (22.34%) 19 (20.21%) 0 94 (40.36%)
Palate 0 0 0 0 0 2 (11.76%) 12 (70.58%) 3 (17.64%) 17 (7.23%)
Other* 0 0 0 0 0 0 6 (60%) 4 (40%) 10 (4.29%)
Total 75 (32.18%) 19 (8.15%) 12 (5.15%) 44 (18.88%) 14 (6.04%) 23 (9.87%) 37 (15.87%) 9 (3.86%) 233 (100%)
P=0.00. *Other mouth parts include the oropharyngeal isthmus and palatoglossal fold

Journal of Oral and Maxillofacial Pathology | Volume 28 | Issue 3 | July-September 2024 425
 Hulke, et al.: Association of oral cancer with addiction and sociodemographic characteristics

Table 4: Association of stage of oral cancer with sex and age at diagnosis
Stage at Diagnosis Total P
Stage I# Stage II# Stage III Stage IV
Gender
Male 0 22 (44.9%) 128 (78.53%) 17 (80.95%) 167 (71.67%) <0.01
Female 0 27 (55.1%) 35 (21.47%) 4 (19.05%) 66 (28.32%)
Total 0 49 (21.03%) 163 (69.96%) 21 (9.01%) 233 (100%)
Age at diagnosis (years)
<40 0 14 (28.57%) 4 (2.45%) 0 18 (7.73%) <0.01
40–60 0 32 (65.30%) 102 (62.57%) 5 (23.80%) 139 (59.75%)
> 60 0 3 (6.12%) 57 (34.97%) 16 (76.19%) 76 (32.61%)
Total 0 49 (21.03%) 163 (69.96%) 21 (9.01%) 233 (100%)

However, Durgadevi Pancharethinam et al.,[13] a Study in sexes.[10] The distribution of patients by habit patterns
southern part of India, reported a different pattern, with revealed that the tongue was the common site where
most patients being younger than 30 years and the minimum a single habit, whether chewing, smoking, or alcohol
affected being older than 50 years. This difference may be consumption, was present. The cheek was the common
because of different sociodemographic and behavioral site in patients with a combination of more than one
characteristics of the population in different geographical habit, and patients with no habits/addictions were more
region of India. As present study was done in western part likely to develop cancer in other mouthparts. These
of India. With respect to education, most oral cancer patients results align with those of Addala L et al.[10] However,
in our study were graduates, with 15.02% being illiterate, a Taban R J et al.[21] reported that nontobacco users had
finding that is consistent with Durgadevi Pancharethinam more tumors of the buccal mucosa, tongue, and hard
et al.’s[13] study, however Madani et al.[14] reported majority of palate.
patients from illiterate background. Our results contrast with
those of another study in which half of the patients had no In this study, the majority of oral cancer patients chewed
schooling and one‑fourth had only primary education.[4,5] The tobacco alone, followed by tobacco chewing combined
distribution of oral cancer patients by occupation revealed with smoking, in a study from northern India done by
that the majority were clerical and skilled workers, with only Akhilesh Krishna et al.[12] reported the same findings.
8.15% unemployed, in contrast to Ganesh R et al.’s[4] findings, Among males, multiple addictive habits were more
where a greater proportion of patients were unemployed and common, whereas females predominantly chew tobacco
less skilled. The modified B.G. Prasad classification revealed alone. These findings are similar to those of other
that most patients belonged to the lower‑middle class, studies.[5,22,23] The duration of habits revealed that most
followed by the upper‑lower class, with the least affected patients had lived for more than 10 years, with a significant
belonging to the upper class. These results are consistent with difference observed (P < 0.01). The study also revealed
the findings of Akhilesh Krishna et al. and S P Khandekar that most patients were diagnosed with stage III disease,
et al.,[11,15] but Ganesh R et al. reported a greater proportion followed by stage II disease, and no patients with stage I
of upper to lower‑class patients.[4,12] disease were reported. This distribution differed by sex,
with stage III and IV being more common in males and
The cheek was the most common site of oral cancer, stage II being more prevalent in females. These findings
followed by the tongue, whereas the lip was the least were highly significant (P < 0.01). There was also a strong
affected site. Both the floor of the mouth and other association between stage and age at diagnosis, with most
mouth parts were equally affected. These findings are stage III patients falling into the 40–60 years age group
consistent with those of previous studies[15–18] but in and stage IV patients primarily above 60 years.
a study from north part of India done by Sahu PK
et al.[19] most common site of involvement was the buccal CONCLUSION
mucosa followed by the tongue. The sex distribution
of cancer sites revealed that cheek and tongue were the In this study, male sex, rural location, and additive habits,
most common sites in both males and females, with no mainly tobacco and alcohol, were major risk factors for
significant associations found between them, which is oral cancer. Males above 60 years of age and females in the
in agreement with the findings of a study conducted 41–50 years age group were most affected by oral cancer.
at a cancer hospital in Kolhapur.[20] However, another The cheek is the most common site for cancer and is often
study reported different results, with the tongue and associated with a single addictive habit, followed by the
buccal mucosa being the most common sites in both tongue, which is more commonly affected by a combination
426 Journal of Oral and Maxillofacial Pathology | Volume 28 | Issue 3 | July-September 2024
 Hulke, et al.: Association of oral cancer with addiction and sociodemographic characteristics

of two or more habits. The main focus on deaddiction November, 2005. Available from: http://www.searo.who.int/india/
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