A risk factor‐based model for upper aerodigestive tract cancers in India: predicting and validating the receiver operating characteristic curve

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Cancers of the upper aerodigestive tract (UADT: including lip and oral cavity, pharynx, larynx, and esophagus) are the fifth commonest cancer in the world and a leading cause of cancer mortality with an estimated 1 055 000 new cases and 725 000 deaths worldwide in 2012 1. The absolute numbers of UADT cancers and cancer‐related deaths are notably high in India. By the year 2020 in India, according to the international classification of diseases (ICD‐10), cancer of mouth (C03‐06; 68 977 expected cases) is anticipated to be the most common cancer among males and cancer of tongue (C01‐02) is plausible to be the fourth most common. Similarly, among females, cancer of mouth (C03‐06; 21 366 expected cases) is likely to be the sixth most common cancer 2.
Upper aerodigestive tract cancers usually progress rapidly, resulting in death within a few years of initial diagnosis, as achieving local control at the cancer site is difficult with late presentation 3. Furthermore, stress and social stigma associated with cancer, blind faith in religious leaders, alternate forms of medicine, poor availability and limited access to healthcare services, in addition to expensive cancer treatment leads to 60–80% of patients reporting at the hospital with advanced stages of disease 4. Occasionally, delay in diagnostic tests and treatment plans can also be due to issues within the healthcare system 4.
Tobacco consumption in all its forms and alcohol drinking remain the most established modifiable risk factors 5. Socio‐economic determinants like income, education, occupation, and type of housing (kutcha: made of inferior materials like wood, mud, straw, and dry leaves or the pucca: made of concrete material) have also been considered markers for UADT cancers as lower status in one or more of these determinants is a possible surrogate for higher consumption of tobacco, alcohol, relatively inadequate diet in fruits and vegetables, and exposure to secondhand tobacco smoke (SHS) since childhood 9.
Effective screening program, notably for oral cancer, can identify incident cases and prevent deaths in an effectively targeted high‐risk population groups 8. As most healthcare workers involved in such screening programs, especially in low and middle‐income countries, are multipurpose workers with responsibilities in immunization, maternal and child health care, and other preventive health programs, it would not be possible for such screening to be conducted in the whole community in view of excessive workload. A screening program is likely to be sustainable and cost‐effective only when healthcare workers conducting the screening target well‐identified high‐risk groups. To improve screening compliance by healthcare workers, these high‐risk groups can be identified using risk assessment tools commonly used to estimate a patient's relative risk of disease on the basis of well‐established risk factors. Although risk assessment tools for other common cancers like breast and colorectal cancer have been helpful in clinical decision making regarding screening and prevention strategies 10, few prediction tools for the incidence of UADT cancers have been developed.
Therefore, as a possible solution, we have developed a risk factor‐based screening model designed to identify individuals at high risk for UADT cancers who can then be targeted for clinical examination and for focused preventive/treatment measures at the healthcare centers.
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