Shamma Usage and Oral Cancer in Saudi Arabia
1985; King Faisal Specialist Hospital and Research Centre; Volume: 5; Issue: 3 Linguagem: Inglês
10.5144/0256-4947.1985.135
ISSN0975-4466
AutoresMagid H. Amer, Colin A. Bull, M. Nabil Daouk, Peter McArthur, Gregory Lundmark, Mohamed El Senoussi,
Tópico(s)Oral health in cancer treatment
ResumoOriginal ArticlesShamma Usage and Oral Cancer in Saudi Arabia Magid Amer, MD, FRCS(Ed), FRCP(C), FACP Colin A. Bull, MBBS, FRCR, FRACR M. Nabil Daouk, MD, FACS Peter D. McArthur, MD, FRCS(C), FACS Gregory J. Lundmark, and MD, FACS Mohamed El SenoussiMB, BCh, DMRE, CES Magid Amer Head, Division of Medical Oncology, Department of Oncology, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia , Colin A. Bull Staff Radiotherapist, Division of Radiation Oncology, Department of Oncology, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia , M. Nabil Daouk Staff Otolaryngologist, Department of Surgery, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia , Peter D. McArthur Head, Division of Otolaryngology, Department of Surgery, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia , Gregory J. Lundmark Staff Otolaryngologist, Department of Surgery, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia , and Mohamed El Senoussi Staff Radiation Oncologist, Division of Radiation Therapy, Department of Oncology, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia Published Online::1 Jul 1985https://doi.org/10.5144/0256-4947.1985.135SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutABSTRACTABSTRACTBetween June 1981 and July 1984, 33 (49%) of 68 patients with intraoral cancer referred to the King Faisal Specialist Hospital admitted to using shamma, which is a mixture of tobacco, black pepper, slaked lime, oils, and other materials. Eighty-five percent of these shamma users were referred from the Southern Province, particularly from the Gizan area (73%). The habit usually began at age 13 to 40 years (mean of 24.3 years) and continued for 10 to 50 years (average 27.1 years). Primary disease was usually located at the buccal mucosa, lower alveolus, and retromolar trigone (66%), particularly on the right side (58%). At the time of initial diagnosis, the majority of patients had advanced Stage III and IV disease (76%). Many patients had poorly differentiated cells (45%) in addition to extensive intraoral leukoplakia. Twenty-seven patients (82%) were treated aggressively with radical surgery, radiation, and chemotherapy, either singly or in combination. Despite such intensive treatment, the mean survival of all patients was nine months, and the one-year disease-free survival was only 21%. The hazard of carcinogenicity of shamma is of great concern in view of its widespread use among certain populations, especially in the southern part of Saudi Arabia.INTRODUCTIONIntraoral cancer accounts for about 4% to 5% of all cancers in the United States.1,2 Major risk factors are heavy smoking and alcohol abuse.3 The risk of death from oral cancer is among the highest in the world in India, China, Thailand, Ceylon, and the Central Republic of the Soviet Union; it has been attributed to the habitual use of snuff and chewing tobacco alone or in combination with the betel nut.4Oral cancer accounts for 5.2% of all cancer patients referred to the King Faisal Specialist Hospital and Research Centre (KFSH) and is ranked the fourth commonest tumor in both males and females, falling behind malignant lymphoma (11.4%), breast carcinoma (7.4%), and esophageal cancer (5.3%).* Recently it was noticed that a high percentage of these patients were referred from the Southern Province5 and that the majority admitted the habitual use of shamma. Shamma is locally produced or imported from Yemen and is a mixture of tobacco, slaked lime, black pepper, oils, flavoring, and other ingredients. It is chewed first, then allowed to rest in the gingivobuccal sulcus. A study was undertaken to assess the clinical impact of shamma usage and the possible development of oral cancer.MATERIALS AND METHODSAll patients with squamous cell carcinoma of the intraoral cavity referred to KFSH between June 1981 and July 1983 were entered into the study. All cases had detailed history and clinical examination with special emphasis on occupational history, residential location, nutritional status, and social habits, particularly shamma usage, alcohol consumption, and smoking. Initial laboratory and radiologic studies included a complete blood cell count and hemogram, multiphasic blood chemistry screen, and chest radiograph. Most patients had radionuclide liver and bone scanning, and a few had computerized tomographic (CT) head and neck scanning. Histologic confirmation of malignancy was obtained in all patients through tumor biopsy during the initial hospital visit.Age in years was defined at the time of initial diagnosis. Residency location referred to one of the five main provinces in Saudi Arabia. Socioeconomic status was determined based on the patient's living conditions. Those who lived in a small house or tent, without electricity, clean running water, or properly established sewage system, were considered in the low socioeconomic class regardless of income. They included some Bedouin and farmers. Other Patients were considered as middle or upper class depending on whether their gross yearly income was less than or over 100,000 Saudi riyals (approximately U.S. $28,000).Tobacco consumption was analyzed both in terms of presence or absence of smoking history and the number of cigarettes consumed a day. Patients who smoked fewer than 20 cigarettes a day or the equivalent for 30 years were considered light smokers, while those who smoked more than this were considered heavy smokers.Clinical staging of initial cancer employs the TNM system classification as adopted by the American Joint Committee on Cancer.6 Time to diagnosis in months was counted from initial symptoms to clinicopathologic diagnosis of malignancy.Patients with oral cancer were treated with radical surgery if they had a localized Stage I or II disease or if the tumor had recurred following radiation. Radiation therapy was used for patients with higher stages of disease. Radiation doses varied depending on the patient's general condition and performance status. Radical radiation therapy (6500 rads for 6.5 weeks) was considered in ambulatory patients, while palliative treatment (1800 rads for three days) was used in terminal cases. Chemotherapy was administered to patients with distant metastases or to those with recurrent disease following surgery or radiation therapy. Agents used were methotrexate, bleomycin, 5-fluorouracil, vincristine, and cis platin, either as single agents or in combination. All patients were followed closely for at least a year, with frequent hospital visits every 3 to 12 weeks. Survival in months was calculated from the initial therapy to the last hospital visit.The chi-square statistical test with one degree of freedom was used to differentiate between two or more variables, while the Student's t test (in two tails of the t distribution, and two less than the total number as a degree of freedom) was used to differentiate between the various means. Survival statistics were calculated based on the actuarial (life-table) method.6RESULTSBetween 1 June 1981 and 30 July 1983, 68 patients with histologically confirmed squamous cell carcinoma, as a primary intraoral cancer, were entered into the study. Patient characteristics are depicted in Table 1 and 2.Table 1. Demographic characteristics of 68 patients with intraoral squamous cell carcinomaTable 1. Demographic characteristics of 68 patients with intraoral squamous cell carcinomaTable 2. Intraoral squamous cell carcinoma: Tumor characteristics and initial stageTable 2. Intraoral squamous cell carcinoma: Tumor characteristics and initial stageThirty-three patients (49%) admitted the habitual use of shamma. The actual incidence may have been even higher, as many shamma users denied the habit. The average age these patients began to use shamma was 24.3 years (varying from 13 to 40 years), and they continued the habit for 10 to 50 years (average 27.1 years). Half of these patients began using shamma at 20 years old or younger and continued even after the appearance of malignancy. The mean interval between the beginning of the habit and the development of cancer was 30 years. Eight patients were smokers, and two of them had used shamma. None of these patients with intraoral cancer admitted to the consumption of alcohol. Alcohol-related hepatitis, pancreatitis, gastritis, and neuropsychiatric problems likewise were not seen.The patients who used shamma, when compared to other patients with oral cancer, were mostly farmers and Bedouins of low socioeconomic class (73% vs 37%, P = 0.006), and were referred mainly from the Southern Province (85% vs 23%, P < 0.001) particularly from the Gizan area (73%), Al-Baha (6%), Abha (3%), and Najran (3%). Their disease usually arose from the buccal mucosa, lower alveolus, and retromolar trigone; it had a poorly differentiated histology and less tendency to spread to regional lymph nodes or to distant organ sites. Extensive intraoral leukoplakia was seen more often in shamma users (21%) than in other patients (3%) (P < 0.05).Figure 1: Survival of oral cancer patients from time of initial therapy.Download FigureDISCUSSIONMany investigators have indicated that as many as 90% of all head and neck cancers arise in susceptible persons after prolonged exposure to carcinogenic environmental factors.1,3 This consensus derives from clinical experience supported by epidemiologic analysis. For example, in the United States, oral cancers account for 4% of all cancer in males and 2% in females. Most of these patients have a history of heavy smoking and alcohol abuse, and the majority practice poor oral hygiene.4 The relative risk of this cancer increased four-fold in women who were long-term users of snuff.7 Snuff dipping consists of the placement and retention of finely ground or powdered tobacco in the oral vestibule, between the gum and cheek. The habit has been particularly common among rural women in the Southeastern United States. Conversely, among practicing Mormons who neither smoke nor drink, cancer of the oral cavity is rare.3Similar geographic and regional variations in the incidence of oral cancer have been reported world-wide. Carcinoma of the hard palate, a relatively rare disease, is endemic among the women of Andhra Pradesh, India, as well as in Venezuela and Panama. This correlates with the local custom of reverse chutta smoking, in which the lit end of a slow-burning cheroot is held in the mouth and seldom removed.3 In some parts of India as well as in Southeast Asia, tobacco is often smoked in the form of beedi. This is a variety of cigarette in which uncured tobacco is wrapped in a dried leaf. Beedi smoke has been associated with cancer of the base of the tongue as well as tonsil, hypopharynx, and esophagus. The highest reported incidence was at Bombay, India, where oral cancer accounts for half of all malignancies. This was attributed to the custom of chewing betel quid or pan. Such a quid consists basically of the leaf of the betel vine smeared with stone lime and wrapped around cured or uncured areca nut, the fruit of the betel palm.8 Tobacco is commonly added to the quid. This material is held in the user's cheek as a quid often even during sleep.The excess risk of oral cancer among shamma users in the Southern Province, Saudi Arabia, resembles that observed after heavy exposure to tobacco chewing and snuff dipping in certain parts of the United States, habitual use of powdered material such as pan in India, khaini in Southeast Asia, and nass in certain Soviet republics. These products have in common tobacco and other ingredients such as lime and oil.7The carcinogenic factor(s) in shamma is still undetermined. Because the contents of shamma vary from one region to another, it is difficult to identify the carcinogenic agent(s) positively. Tobacco is the most obvious ingredient, but the lime mixture and the mechanical trauma of chewing are contributing factors. The carcinogenic elements in tobacco have not been clearly identified. The polycyclic hydrocarbons found in cigarette smoke have been shown to produce squamous cell cancers in the respiratory tract of laboratory animals.8 Tobacco-specific nitrosamine complexes formed during fermentation are important initiators of of malignancy.4 Many of these carcinogens—present in condensate during cigarette smoking, tobacco chewing, snuff dipping, the use of betel nut, pan, khaini, nass (and possibly shamma)—are dissolved in saliva. Persistent pooling of this saliva with its high content of concentrated carcinogens at the anterior floor of the mouth and gingivobuccal sulcus may be responsible for the development of malignancies at these regions.9The habitual use of shamma is a folkway that provides immediate pleasure and distraction and flourishes because of ignorance and indifference toward possible future adverse consequences for health. Fortunately, the Saudi Arabian government has banned the use of shamma in the Kingdom and has imposed stiff penalties for those who trade or use it. Multimedia campaigns have been organized to educate and protect the public. We do hope that these and other measures will ultimately lead to a substantial decrease in the incidence of and mortality from oral cancer in the Kingdom.* Based on 1983 cancer statistics, King Faisal Specialist Hospital and Research Centre.ARTICLE REFERENCES:1. Silverberg E: "Cancer statistics" . CA 31(1): 13–281981. Google Scholar2. Silverberg E: "Cancer statistics, 1984" . CA 34(1): 7–231984. Google Scholar3. Decker J, Goldstein JC: "Risk factors in head and neck cancer" . N Engl J Med 306(19): 1151–51982. Google Scholar4. Schottenfeld S: "Snuff dipper's cancer [editorial]" . N Engl J Med 304(13): 778–91981. Google Scholar5. Amer MH: "Pattern of cancer in Saudi Arabia: a personal experience based on the management of 1000 patients. Part 1" . The King Faisal Specialist Hospital Medical Journal 2(4): 203–151982. Google Scholar6. Beahrs OH, Myers MH (eds): "Manual for Staging of Cancer" ., ed. 2. American Joint Committee on Cancer. Philadelphia, J.B. Lippincott, 1983. Google Scholar7. Winn DM, Blot WJ, Shy CM, et al.: "Snuff dipping and oral cancer among women in the Southern United States" . N Engl J Med 304(13): 745–91981. Google Scholar8. Keane WM, Atkins JP, Wetmore R, et al.: "Epidemiology of head and neck cancer" . Laryngoscope 91(12): 2037–451981. Google Scholar9. Moore C, Catlin D: "Anatomic origins and locations of oral cancer" . Amer J Surg 114: 510–31967. 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Volume 5, Issue 3July 1985 Metrics History Published online1 July 1985 KeywordsMouth neoplasms – Saudi ArabiaShamma – Saudi ArabiaInformationCopyright © 1985, Annals of Saudi MedicinePDF download
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