The development and validation of oral cancer staging using administrative health data

Oral cancer is a major health problem, the worldwide annual incidence being 274,300 cases with 128,000 deaths; two-thirds of this burden is in developing countries [1]. Despite considerable advances in diagnostic and therapeutic techniques, oral cancer continues to portend a poor prognosis. We surveyed available published reports and found that the effect of treatment regimen or other prognosis-related factors is often uncertain and controversial [2–5]. The complexity of histological prognosticators in oral cancer likely partly accounts for this because it makes it difficult to compare the benefits of different treatment regimens; small samples are another limitation of previous studies [6–8].

The Taiwan National Health Insurance program, which has operated since 1995, enrolls almost 99% of the inhabitants of Taiwan and is contracted with 97% of hospitals and clinics throughout the nation [9]. It therefore provides an opportunity to assess correlations between outcome and treatment protocol and thus compare the effectiveness of different treatment regimens. However, the major purpose of this program concerns costs of medical services. In general, lack of information about disease severity is a critical problem when analyzing a population database. Anatomic site and disease stage are the most important tumor-related predictors of the prognosis of oral cancer after various treatment regimens [10–13]. The aim of this study was to try to assess how accurately the severity of oral cancer at the time of first diagnosis can be assessed on the basis of variables commonly available in national databases.

Knowledge of the anatomy and disease staging is essential to optimal treatment planning [15]. Some anatomic sites, such as the superior gingivolabial sulcus, are linked with poor outcomes because of their rich lymphatic drainage and difficulty in evaluating the extent of local invasion, and therefore in selecting an appropriate management strategy [16]. Vascular and lymphatic networks, which vary between different anatomic sites, may influence tumor evolution and hence the outcome; thus, SCCs at the base rather than the oral part of the tongue have a higher rate of metastasis [17]. Cancer staging reflects both homogeneous survival data and important variations in disease characteristics that affect treatment options. Differentiation between stages I or II and stages III or IV of oral SCCs is most important for treatment planning, because early-stage tumors (stages I and II) typically require only single-modality therapy (mostly surgical resection), whereas stage III and IV tumors may require multimodality therapy with a combination of chemotherapy, radiation, and surgical resection. The appropriate therapeutic modalities depend on the site of origin of the primary tumor [18]. Population-based administrative data are an effective source of information about chronic disease or for cancer surveillance. However, the ways in which data can be extracted from such databases differ; in practice certain categories of clinical information may be unavailable.

This study provides a method for adjusting for cancer severity when staging information is not available. We found that the severity of oral cancer can be assessed based on sex, age at first diagnosis, oral cancer subsite, and therapy regimen with an accuracy of 84% in male subjects and more than 96% in female subjects. In Taiwan, oral cancer is a male-dominant cancer, the male:female ratio being 9:1 [19]. More than 70% of men with oral cancer have the habits of both chewing and smoking tobacco, whereas only approximately 10% of female patients have these habits [20]. Although some studies have failed to find an association between prognosis and smoking tobacco or consuming alcohol [21], most authors have reported higher mortality in smokers and alcohol drinkers [22, 23]. In a study from Taiwan [21], Lo et al. reported that areca quid chewing is also correlated with a poor prognosis. Smokers and alcohol drinkers seem to be at higher risk of developing second primary oral cancers than nonsmokers and nondrinkers; thus, they face worse outcomes [24, 25]. In our study, we found that the sex of the patient seemed to affect the choice of treatment plan: a higher proportion of male than female patients had undergone combined multimodality therapy, especially those with early-stage disease. This finding may be related to the sexes having different habits; it requires further study.

Previous studies have suggested that sex differences in oral cancer prognosis are attributable to a delay in seeking medical care and differences in rate of compliance with recommended treatment. Some studies have reported lower survival rates in female subjects [22, 26], whereas others have found no sex-based difference in prognosis [21, 27, 28]. A correlation between prognosis and age is controversial; some authors reporting they are unrelated and others having found that older patients have worse prognoses [22, 23]. Most researchers accept that disease staging has a crucial influence on outcome [21, 28–30].

This study has some limitations. Patients were included on the basis of a previous diagnosis of oral cancer. The training and expertise of the personnel who performed the pathological assessments is unknown; therefore, we are unable to determine the reliability of their findings. Measurement methods and diagnostic criteria were also likely variable. However, because the database used was from a medical center, its accuracy is reliable.

The main conclusion of this study is that adjusting for sex, first diagnosed age, oral cancer subsite, and therapy regime facilitates accurate assessment of the severity of oral cancer. Our findings provide a method for adjusting for cancer severity when staging information is not available from national health-related databases.