Original PaperVariation in survival of patients with head and neck cancer in Europe by the site of origin of the tumours
Introduction
Head and neck cancers are the fourth most common cancer in men in the European Union[1], after cancer of the lung, colorectal and prostate cancers. The epidemiology is characterised by a strong incidence gradient, with rates increasing from Northern to Mediterranean countries; Eastern countries have shown intermediate incidence rates[2]. The highest incidence was registered in France, where it is as high as lung cancer (approximately 50/100 000 men-year, World standardised rate), the lowest in Sweden and U.K. (9 and 10 per 100 000, respectively). Such large geographical variability reflects a different prevalence of lifestyle risk factors, such as alcohol drinking, tobacco smoking, the type of tobacco[3]and dietary habits[4], which may have independent influence on prognosis[5]. The incidence of head and neck cancers in women is lower than in men (the overall annual age standardised incidence rate in the EU has been estimated at 26 per 100 000 in men and 3.1 per 100 000 women)[1]and the geographical pattern is quite different, with lower variability than in men but with fairly high rates (3–4/100 000) in France, Switzerland, Scotland and Denmark and lower rates in Spain and Southern Italy, Finland and Eastern Countries (around 2/100 000 or less).
The anatomy of the upper respiratory and digestive tract is very complex for the non specialist. Even specialists use rather subjective criteria for the definition of the borders between contiguous organs and the oncological classifications for this anatomical region are not consistent. The base of the tongue, for instance, is classified with tongue in ICD-IX (International Classification of Diseases, ninth revision)[6]and with oropharynx in the UICC-TNM Classification of Malignant Tumours[7]. The classification of tumours arising at the border between larynx and pharynx, sometimes called epilarynx, is also inconsistent. According to the ICD, for instance, the anterior surface and free border of the epiglottis, as well as the carrefour between the epiglottic border, the ari-epiglottic and the pharyngo-epiglottic fold, belong to the oropharynx (ICD 146) and the border of the ari-epiglottic fold to the hypopharynx (ICD 148), but in TNM classification tumours arising in these sites are included in supraglottic laryngeal cancer. The term extrinsic larynx is still used, which sometimes refers to supraglottic larynx (ICD 161.1) and sometimes to lesions overlapping the larynx and pharynx which should be coded either to oro- or hypopharynx or to pharynx NOS (ICD 149).
There is ample clinical evidence that the site of origin of head and neck cancer is a major determinant of prognosis, both because of the different stage at diagnosis and because of the different possibilities of surgical treatment. The sub-site within the oral cavity, larynx and pharynx is also a major factor. Cancer of the base of tongue, for instance, has a worse prognosis than those arising in the rest of the oral cavity; cancer of the tonsil has a better prognosis than cancers arising in other parts of the oropharynx; supraglottic cancer has a worse prognosis than glottic cancer; and the prognosis of cancer arising in the epilarynx is worse than supraglottic but better than hypopharyngeal cancer8, 9, 10, 11.
Unfortunately, only a few registries have collected detailed information on the fourth digit sub-site of head and neck cancers. They are sufficient, however, to clarify that the case mix within 3-digit categories of head and neck cancers varies considerably between different European populations. As a general pattern Southern European countries tend to have a higher incidence of cancer of the pyriform sinus (particularly in France), supraglottic larynx (particularly in Spain) and the base of the tongue, which have a worse prognosis with respect to other sub-sites within the pharynx, larynx and oral cavity. Notable exceptions are Southern Italy (showing a lower incidence of all head and neck cancers and also a lower proportion of sub-sites with poor prognosis), British women (with a relatively high incidence of retrocricoid cancer, which also has a poor prognosis) and larynx cancer among women (characterised by a higher proportion of supraglottic sites in Northern and Central Europe and of glottic cancer in Mediterranean and Eastern countries)[12].
The aim of this study was to describe the prognosis of head and neck cancers in Europe on the basis of the information available to cancer registries collaborating in the EUROCARE II project, taking into account, whenever possible, the anatomical sub-site of origin of the tumours.
Section snippets
Patients and methods
Survival analysis was carried out on 35 004 head and neck (ICD 141, 143–148 and 161) cancer cases diagnosed between 1985 and 1989 in 17 countries as recorded by 44 population-based cancer registries. Some of these cover the whole country (Iceland, Finland, Denmark, Scotland, Slovenia, Slovakia, Estonia) or a large proportion of the country (England) whilst others cover up to 20% of the national population (those indicated with an asterisk in the relevant tables). Table 1 provides a breakdown of
Results
Table 2 provides the number of cases by ICD 3-digit site and, as a further indicator of data quality, the proportion of cases with unspecified fourth digit sub-site. It also gives the proportion of cases coded to relevant sub-sites: base of tongue, tonsil, pyriform sinus and supraglottis. The proportion of unspecified sub-sites was fairly low for The Netherlands, France, Slovakia and Slovenia. U.K. data did not have sufficient detail for a proper analysis of cancer of the tongue but were fairly
Discussion
Survival of patients with head and neck cancers is difficult to study for several reasons. Firstly, the prognosis varies considerably according to the precise anatomical site of origin of the tumours, which affects the early appearance of symptoms and, therefore, the stage at diagnosis and the possibility of radical surgical resection. The distribution of such sites and sub-sites in European populations is far from uniform, so that geographical differences in survival may be largely due to a
Acknowledgements
The EUROCARE study was financed through the BIOMED programme of the European Union.
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The EUROCARE Working Group for this study is listed in the Appendix A.