The Epidemiological Trend of Oral Carcinoma in Eastern Europe

Oral and pharyngeal cancer is estimated by World Health Organization (WHO) to be the eighth most common cancer worldwide with signiûcant regional variation with increasing and decreasing incidence trend. The aim of the study was to evaluate the oral cancer epidemiological trend, incidence and mortality in Central and East Europe (CEE), and to compare the incidence of oral cancer with other regions from the world. The analyzed data was from NORDCAN and GLOBOCAN, using ASR (age- standardize rate) incidence and mortality overall and by sexes. The incidence of oral and pharyngeal cancer is higher in CEE than the global incidence. This is in accord with specific mortality from oral and pharyngeal cancer that is higher in CEE than the regions other submitted to the current evaluation. The incidence of oral cancer is very high at man, especially in Hungary, which is the most affected from oral cancer from CEE.


Results and discussions
The results of the current epidemiological study of oral cavity cancer are separately presented according to their localization, for evaluating which types have higher incidence or mortality according to regions from CEE and also a comparative evaluation between men and women.
Oral cavity, laryngeal and pharyngeal cancer Oral cavity, laryngeal and pharyngeal cancer accounted 686328 new cases in 2012 and caused 375665 deaths in the same year. The highest incidence was in West of Europe where ASR incidence/100000 people was 13, and in more developed countries as we see from table I that the incidence was higher than in the less developed countries, but the mortality was higher in the less developed countries 5.4 than in the more developed countries 3.9, (table 1). The incidence of oral, laryngeal and pharyngeal cancer of 11.5 is higher in CEE than the global incidence 9 or than incidence for the more developed countries 10.4. The mortality from oral and pharyngeal cancer is higher in CEE than the other studied regions, (table 1).
From CEE, we observe in table II the highest incidence at 100.000 people in Hungary 23.8 and on the second place is Romania 16.6. The lowest incidence was observed in Russian Federation. The mortality was highest in Hungary 12.3 and on the second place Slovakia with 9.9. The incidence of oral and pharyngeal cancer in CEE was higher at men 22.8 that the woman 3.2, with a rate than 7:1 (men: woman), ( fig.1). The incidence at men in Hungary was 42.2 which is the highest ASR incidence from the world, were the second ASR man incidence is in Papua New Guinea 38.3, the third is in Bangladesh 33.1 and the forth in Romania 32.4. (table 2). The highest changes rates between mortality at men from 2012 and mortality from 2000-2004 were found in Bulgaria 181.91%, Romania 94.19% and Poland 90.63%. The mortality rate of changes at woman was very high at all ten countries over 100%, but the highest was found at woman from Czech Republic 471.69%, Bulgaria 307.44% and 275% Poland, (table 3).
Lip and oral cavity cancer 300373 (4) of new lip and oral cavity cancer was diagnosed in the world, 199550 (3.7) in the less developed countries, 100823 (4.7) in more developed countries and 23765 and incidence 5 from CEE.(table 2). The global incidence of lip and oral cavity at men 5.5 is higher than the woman 2.5. (table 2). In CEE the incidence at men is 9.1 and is the third highest incidence from the regions on the world after Melanesia 22.9 and South-Central Asia 9.9. At woman in CEE the incidence is 2, that is the fourteen places from the world regions, and is smaller than West of Europe 3.2, more than in developed regions 2.8 or than less developed regions 2.5. From the countries of CEE, the highest incidence is in Hungary 9.7, followed by Slovakia 145323 people died worldwide because of lip and oral cancer that represent a mortality/100000 people of 1.9, in CEE died 12516 people (2.6). (table 1). The mortality was also higher in men that the woman, in the world 2.7:1.2, in CEE 5.1: 0.7. The highest mortality/100000 people in countries from CEE was found in Hungary 4.4, followed by Slovakia and Belarus 3.2. Hungary has the highest mortality rate from the CEE countries 23.2, followed by Romanian men 19.4 people and Slovakia men 18.4 people ( fig. 3). For woman, also the highest mortality was found in Hungary 8.4 people, followed by woman from Poland 4.2 people and Slovakia 3.9 people, (table 3).
Pharyngeal cancer 229078 (3.1) new pharyngeal cancer was diagnosed in the world in 2012 and 146936 (1.9) died because of it. In CEE were diagnosed 13216 (3) people and died 9159 (2). The incidence of pharyngeal cancer in CEE, (figure 2) was lower than the incidence found in West of Europe 4.8, more developed regions incidence 3.1 and less developed regions incidence 3.2, but the mortality was higher than West of Europe 1.7, more developed regions 1.3 and lower than less developed regions 2.2, (fig. 3). The same as in lips and From the CEE countries, the highest incidence was found in Hungary 7.8, followed by Romania 6.1 and Slovakia 5.5. The highest incidence of pharyngeal cancer was found at Hungarian men 14.1, followed by Romanian men 12.1 and Slovakian men 10.7, (table 2). At woman, the highest incidence was found at Hungarian woman 2.4, followed by Czech woman 1.5 and Moldavian woman, (table 2). The mortality from pharyngeal cancer in CEE countries was found in Hungary 4.9, followed by Slovakia 4.1people and Romania 3.8. The mortality was highest at the Hungarian men 9.2, followed by Slovakian men 8.3 and Romanian man 7.4. The mortality at women in the studied countries was low, but the highest was found in Hungary 1.3, Bulgaria 0.8, Romania 0.6 and Slovakia 0.6, (   3). For woman, the second affected country is Poland 0.9, and third is Czech Republic 0.5. The mortality/100000 people are highest and Moldavian men 7.6 followed by Bulgarian men 6.7, Hungarian and Romanian men 6.2, (table 3).
The present study highlighted the variability of OSCC incidence and mortality rates across country of Central and East of Europe are in Hungary, Romania and Slovakia.
Oral cancer incidence CEE is lower than the incidence from Vest of Europe, but the mortality is much higher, and these can be possible from diagnostic method, with diagnosis OSCC in a higher stage, late submission of the patients to the doctor although the existence symptoms, or because of the prognosis and the treatment. This can be observed for the pharyngeal cancer at man, where the men from Bulgaria and Republic of Moldova, which has a lower incidence than the Hungarian men, has a higher mortality.
The incidence for oral cancer in CEE is higher at man that the woman and the rate incidence man: woman is higher than other parts of the world, although the environmental and living conditions are similar but the life style, behaviors and the work place is different. The incidence of OSCC is higher in CEE at man because of their habits, the most of them use to combine alcohol consumption with tobacco smoking, bad oral hygiene and smaller amounts of fruits and vegetables consumption [8,21,22].
The alcohol consumption in CEE has some characteristics like: beer is currently the most consumed type of alcohol, but the spirts from home production and from the markets (like vodka) are also very frequently consumed. The Hungarian woman have the highest incidence and mortality for all type of OSCC across countries of CEE, but they are also known that they have the highest alcohol consumption [23].
Although some of the risk factors are known and there are differences in the geographical distribution of oral cavity and lip, pharyngeal and laryngeal cancer, globally, Hungary is all five in all these cancers, which may imply a genetic predisposition [24] combined with known risk factors for this country, high alcohol consumption, smoking and low fruit consumption.
The highest incidence and mortality of oral cancer in CEE, presented in table II is at Hungarian men and women, and the Hungarian man has the highest incidence from the entire world, which can be explained by the lifestyle, where the tobacco and alcohol consumption is very high and they are incriminated for the high incidence of oral cancer in this country [25]. The incidence of pharynx cancer and lip and oral cavity at Hungarian man is the second highest incidence from the world and at the larynx cancer is the third incidence from the world. The HPV infection and the OSCC incidence is higher at Hungarian man than the Hungarian woman [26,27].
The woman OSCC incidence and mortality rates is not very high across CEE, but the trend of mortality rate in much higher in the last decade than the other decades, comparing with the penultimate decade, this can be explained by increasing the incidence of HPV+ [28]. Bulgaria and Romanian man has the highest rate of changes of mortality in the last decade; this may be possible because of a better monitoring of morbidity in these two countries.
Our study showed that incidence of laryngeal cancer is in decrease on the world and in Europe, which is the same with the trend from US [29], but the pharyngeal cancer is increasing also in Europe and US [29].
We have limited data about the prevalence of HPV+ people in Central and East Europe, but in the last decade, all the CEE countries have introduced the immunization for HPV in the national vaccination program [30,31], so we can't define the influence of decreasing the OSCC later.
Although the risk factors for oral cancer are well known, premalignant lesions are known, oral and pharyngeal cancer appears to be easily prevented by screening [31] at regular medical checkups and preventive measures have been taken, oral cancer remains a major public health issue in CEE, were the mortality from OSCC is high.
The present study has limitation. We aimed to describe the epidemiological trend of OSCC in CEE but, we used data from GLOBOCAN, not from national registry, so is possible to have lack of information, because the used registry to not been complete. We also used data for the ten of the most affected for OSCC countries from CEE, not all of them.

Conclusions
The incidence of OSCC has an increasing trend for pharynx cancer, plate of mouth and a decreasing for larynx cancer and lip cancer. OSCC incidence and mortality in Central and East Europe has variable differences between countries, Hungary, Romania and Slovakia experiencing the highest rates from this region. The differences between sexes are also very high, males from CEE are very affected, being the third most affected males from the world, but the women are on the fourteen places. The most affected people from this region are Hungarians, especially men as shown in table 2.
The alcohol consumption and tobacco is still the mean risk factors for OSCC in this region, and most of the countries implemented the WHO recommendation for public anti-tobacco strategy and anti-alcohol consuming [32]. The very high mortality because of the OSCC in CEE can be reduce by a preventive national or regional strategy with health education for population with informed by the OSCC early symptoms, and by screening on the dentistry, or improve the diagnosis methods.