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Targeting the Betel Quid & Areca Nut Users

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Targeting the Betel Quid & Areca Nut Users Prioritizing research and policy interventions to prevent oral cancers – Targeting the Betel Quid & Areca Nut Users Epidemiology of areca nut use - the rising burden in the South East Asia and Taiwan Yi-Hsin (Connie) Yang Kaohsiung Medical University, Taiwan Track 1 - Motivating prevention and healthy behaviours National Cancer Institute (United States) National Institute of Cancer Prevention and Research (NICPR) (India) Disclosure of interest: None declared Betel-quid & Areca-nut (BQ/AN) chewing is popular in this region! It is chewed or placed in mouth for many reasons, including its psycho- stimulating effect, as well as a social and cultural practice. BQ/AN with & without tobacco are considered as BQ/AN generally consists of: carcinogenicity by IARC Monographs The 4th most universally consumed substance after tobacco, alcohol and caffeine At least 10% of the worlds’ population (600 million persons) globally. Areca nut (from the Areca catechu tree) unripe/ripe, Slaked lime whole/sliced (calcium hydroxide) /chopped, sea raw/roasted/ shells, sun dried, corals, boiled/soake limestone. d & fermented. Betel leaf (from the Piper betle L. vine) IARC mono #85 Zhang, et al. Oral oncology 2007 Other ingredients inflorescence (also called flower or pods), stem or catkins. inflorescence is common in Melanesia and in parts of Taiwan, and it is often added to the quid for its aromatic flavor. Tobacco Catechu, spices, sweeteners and essences. Industrial packaged products Pan masala (IARC mono #85) Gutka (IARC mono #85) Hunan, China with tobacco without tobacco Pan masala (IARC mono #85) Gutka (IARC mono #85) Data not reported Betel quid without added tobacco China Betel quid with & without added tobacco Pakistan Nepal Betel quid with added Taiwan Bangladesh tobacco India Philippines Burma Laos Palau Guam Thailand Vietnam Micronesia Cambodia Maldives Brunei Sri Lanka Malaysia Singapore Papua New Guinea Indonesia Solomon islands Disease Burden and Health Effects • Oral cancer • Periodontal diseases Half of oral cancers • OPMD (oral potentially • Cardiovascular could be prevented if malignant disorders) • Nervous people stopped their chewing habits • Leukoplakia • Gastrointestinal • OSF population attributable • Metabolic • Erythroplakia fraction: • Respiratory • Oral lichenoid lesions PAF%=53.7% in • Reproductive Taiwan; • Other cancers PAF%=49.5% in India subcontinent Mehrtash et al., Lancet oncology 2017 Guha et al. IJC 2014 IARC mono #85 Male incidence POPULATION Numbers Crude Rate ASR (W) Lip and oral cavity cancer World 198975 5.6 5.5 (C00-C08): Estimated 300,373 Asia 111994 5.2 5.2 new cases and 145,353 deaths. Melanesia 578 12.4 22.9 Sri Lanka 1845 17.6 15.4 Among them, 126,722 (42.2%) Bangladesh 7120 9.2 13.0 cases and 77,469 (53.3%) death Kazakhstan 788 10.0 11.6 Pakistan 7068 7.7 10.5 from South-Central and -East Asia. India 53842 8.3 10.1 Taiwan 4807 41.2 31.2 mortality POPULATION Numbers Crude Rate ASR (W) World 97940 2.8 2.7 Asia 65045 3.0 3.0 Bangladesh 4094 5.3 7.7 India 36436 5.6 6.7 Pakistan 4046 4.4 6.3 Afghanistan 453 2.6 5.8 Myanmar 1090 4.5 5.3 GLOBOCAN 2012 & Sri Lanka 634 6.1 5.2 Taiwan Cancer Registry 2012 Taiwan 1596 13.7 10.3 Betel quid & areca nut chewing prevalence and characteristics men women 50 46.8 45 43.6 psycho-stimulating effect 40 34.9 35 social and cultural practice 29.5 30 23.9 25 BQ & AN users, so call 20 18 13.5 15 12 high-risk groups 10.7 9.8 10 Taiwan: 5 2.5 1.8 0 Indigenous communities (~56%) Taiwan Hunan, Malaysia Indonesia Nepal Sri Lanka Certain occupations (~41%) [e-pod poster] mainland China India: rural adults ( 20%~51%) IARC mono #85 urban adults (5%~38%), higher in men Lee et al. IJC 2011 then in women Yap et al. BMC public health 2008 Taiwan’s actions on BQ/AN control Environmental Ministry of National Partnership Council of Protection Defense (BQ free & Ministry of across Agriculture Administration cessation classes Education (health (subsidize areca government (spitting free and in all military education) tree by other crops) agencies fine) personals) high-risk group (BQ dentists, ENTs and Organized oral each year chewers or trained physicians cancer screening cost-effectiveness smokers w/ 30+ in health centers & approximately 100 evaluation screening years old or 18+ for outreach to million program indigenous) communities health education BQ and smoking Public materials for cessation service in warning signs on documentary on schools, hospitals, awareness BQ packages oral cancer patients campaigns communities and communities & high-risk groups work places BQ free supporting Chuang et al., Cancer 2017: 26% mortality reduction. Working with environment in BQ cessation: Lee CH et al., JAMA Psychiatry 2018; Lee CY et al., organizations to Plos One 2018; Lin et al., Subst Use Misuse 2017; Lo et al., Plos high-risk promote BQ free One 2016; Tsai et al., J R Army Med Corps 2018; Yang et al., J Clin communities Nurs 2017; Yen et al. Subst Use Misuse 2017 Courtesy of Health Promotion Administration, Ministry of Health and Welfare, Taiwan 60 Crude incidences increase due to aging population 50 Age standardized incidences 40 decrease slowly BQ 30 prevalence start to Crude mortalities 20 decline Age standardized mortalities 10 0 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 CRIS online system (https://cris.hpa.gov.tw) Incidence(crude) Incidence(ASR) Death rate(crude) Death rate(ASR) Conclusion: BQ/AN control actions It is all about high-risk groups! Challenge! Require research! How to identify & to understand! Real world evidences Qualitative studies Plans thereafter: Intervention studies ... • Oral cancer awareness • Intervention of cessation High-risk individuals usually do not or less frequently attend • Oral cancer screening health services! Netuveli et al., J Med Screen 2006 Effectiveness is important! Thank You for Your Attention! Comments or Questions? Contact email: [email protected] Areca nut and Associated Oral Lesions Rimal Jyotsna, MDS, FAIMER Fellow Professor and Head, Oral Medicine and Radiology, B.P. Koirala Institute of Health Sciences Track 3: Motivating prevention and healthy behaviors Disclosure of interest: None declared Areca nut • Fruit drupe of Areca palm • Tropical fruit from Asian & Pacific areas • The fourth psychoactive substance • Types: White, Red, Husks, combined with other carcinogenic products • Symbolized as pleasure-giving, stimulant, psychotic substance, betelmania, Meige’s syndrome Areca nut: Content and types Content: Types: (based on type of curing) • Tannins • Unripe/ripe • Polyphenols • Whole/sliced • Alkaloids (Arecaidine, • Raw/roasted/sun dried Arecoline, guvacoline, • Boiled/soaked in water Guvacine etc) • Fermented (under mud) Oral Mucosal Lesions associated with Areca nut Mucosal changes without malignant potential • Keratosis, staining, gingival, periodontal diseases Mucosal changes with malignant potential • Oral Submucous Fibrosis • Betel-quid lichenoid lesion • quid retained sites ORAL SUBMUCOUS FIBROSIS Chronic, insidious, progressive disease that is associated with significant functional morbidity and an increased risk for malignancy Clinical Presentations of OSF • Burning sensation to spicy food • Progressive inability to open the mouth • vesicles, particularly on the palate • Dryness of the mouth • Nasal tonality to the voice • Blanching of mucosa followed by fibrosis • mottled, marble like appearance of mucosa • Dysphagia to solid food • Impaired mouth movements (eg, eating, whistling, blowing,) Clinical Presentations of OSF Stiff and small tongue Blanched and leathery floor of the mouth Fibrotic and depigmented gingiva Rubbery soft palate with decreased mobility Blanched and atrophic tonsils Shrunken budlike uvula Sinking of the cheeks, not commensurate with age or nutritional status Change of gustatory sensation Hearing loss due to stenosis of the Eustachian tubes Leukoplakia is found in more than 25% of individuals with OSF Diagnosis History, clinical features Chair side tests: Non-invasive Clinical Diagnostic Tools • Chemo-luminiscence: Toluidine blue, Acetic Acid • Vizilite • Identifi • Microlux • Diagnostic Accuracy ( Sensitivity, Specificity And Accuracy) Diagnosis Laboratory testing: • Decreased serum iron level • Serum copper levels directly proportional to clinical stage • Reduced level of zinc in serum Histopathology Molecular Markers • c-Myc and HIF-1α –screening markers • VEGFRII and CD105 - prognostic markers Concerns Resuming Normal Eating, Chewing, Speech Restoring The Normal Mouth Opening Reducing Pain And Burning Sensation Improving Tissue Blood Flow Preventing Disease Progression Preventing Malignant Transformation Improving The Quality Of Life Way Forward Collaborative/multidisciplinary research Consortium for making strategies to improve public policy and treatment outcome Mark OSF day /Anti OSF/ betel quid day for public awareness and advocacy Email: [email protected] Thank you Prioritizing research and policy interventions to curb Areca nut induced cancers in South East Asia Targeted Interventions for betel quid and areca nut users Professor Dr. Rosnah Binti Zain Associate Professor Dr. Shilpa Gunjal MAHSA University, MALAYSIA Track 3: Motivating prevention and healthy behaviors Disclosure of interest: None declared Targeted intervention Intervention: any activity undertaken with the objective of improving human health by preventing disease, by curing or reducing the severity or duration of an existing disease, or by restoring function lost through disease or injury. Targeted interventions:
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