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Study Finds All Myanmar Mouth Cancer Patients Chew Betel Quid

17 Nov 2017
Head and Neck Cancers

LUGANO, Switzerland – A study in Myanmar has found that all mouth cancer patients use smokeless tobacco, researchers report at the ESMO Asia 2017 Congress. (1) Betel quid chewing often starts in adolescence and is associated with smoking and drinking alcohol, which are also risk factors for oral cancer. (2,3)

According to GLOBOCAN 2012, more than half of oral cancers in the world occur in Asia where an estimated 168,850 new cases were diagnosed in 2012. Of these, approximately 11% of patients were from Southeast Asia. (4)

Lead author Dr Khin Khin Nwe, medical oncologist, Toungoo General Hospital, Toungoo, Myanmar said: “According to previous studies the incidence of oral cancer, also called mouth cancer, in Southeast Asia has been disturbingly high for many years. It has also been shown that smokeless tobacco use is common in this region – for example in Myanmar more than 50% of men use betel quid.” (4)

This observational study investigated the lifestyle behaviours of head and neck cancer patients that may have contributed to their disease. The cross-sectional study was conducted in the medical oncology unit of Toungoo General Hospital in 2016. All head and neck squamous cell cancer (HNSCC) patients who came to the hospital were included in the study. Participants were asked about betel quid chewing, smoking, and alcohol.

Of the 307 cancer patients who visited Toungoo Hospital that year, 67 (22%) had HNSCC and were included in the study. Out of the 67 patients, 41 were male and 26 were female. The mean age was 59.2 years (range 36 to 81) for men and 58.7 years (range 19 to 86) for women. The most common cancer site was oral cavity (34.3%), followed by larynx (25.4%), oropharynx (11.9%), nasopharynx (11.9%), hypopharynx (10.4%), lip (4.5%), and nose (1.5%).

Regarding lifestyle habits of the entire study population, 20 patients (30%) chewed betel only; 19 patients (28%) chewed betel and smoked tobacco; 19 patients (28%) chewed betel, smoked tobacco, and consumed alcohol. Two patients smoked tobacco and drank alcohol, two smoked tobacco only, two had none of the risk factors, and information was unavailable for three patients.

All oral cavity (mouth) cancer patients were betel quid chewers. In addition, 48% smoked tobacco and 44% consumed alcohol. The majority (87%) of mouth cancer patients said they kept betel quid in the buccal cavity (cheek) most of the time.


Nwe said: “We found that all patients with mouth cancer chewed betel quid. Most had started the habit as teenagers and had found it too difficult to quit. Betel quid chewing appeared to interact with tobacco smoking and alcohol drinking in an additive way in this population.”

Nwe concluded: “Chewing of betel quid has been common in Southeast Asia, including Myanmar, for a long time and our study shows that it is a public health problem. Efforts are needed to increase awareness of the risks of betel quid chewing so that adolescents do not start the habit and adults are encouraged to quit. This may help to prevent head and neck cancer.”

Commenting on the topic, Dr Makoto Tahara, Chief, Department of Head and Neck Medical Oncology, National Cancer Centre Hospital East, Chiba, Japan, said: “Given the number of health issues associated with chewing betel quid, particularly oral cancer and precancerous conditions such as leukoplakia and oral submucous fibrosis, understanding ways to reduce betel quid chewing is of global public health importance. In the last decade, betel quid has been classified as a group 1 carcinogen by the International Agency for Research on Cancer (IARC).”

“Limited research has been conducted to understand the behavioural and psychosocial factors that lead individuals to initiate and/or maintain betel quid chewing,” he continued. “Determining such psychosocial and behavioural risk factors would help design prevention and treatment programmes aiming to reduce the prevalence of betel quid chewing. In many countries within the Western Pacific region, the long-established behaviour of betel quid use is integral to community life, from routine aspects of daily life to ceremonial celebrations. Given the social importance of chewing betel quid, chewers might fear the negative social repercussions associated with quitting. For instance, for an individual attending a social or cultural event where betel quid is offered, refusing it could be construed as an insult by the host.”

Tahara said: “Interventions designed to treat or prevent betel quid chewing may need to include a strong social/cultural component. For example, such interventions may provide chewers trying to quit with skills regarding how to deal with the social/cultural pressures to chew. With regards to prevention, if social influence is found to play an important role in chewing initiation among youths and young adults, perhaps social influence-based smoking cessation interventions that have been found to be effective in this age group may be adapted to prevent betel quid initiation.”


Notes to Editors

Please make sure to use the official name of the meeting in your reports: ESMO Asia 2017 Congress

  1. Abstract 372P_PR ‘Head and neck cancer occurrences and Lifestyle habits in Toungoo, Myanmar‘ will be presented by Khin Khin Nwe during the Poster Display session on Saturday, 18 November 2017, 13:00 to 14:00 (SGT) in the Exhibition area. Annals of Oncology, Volume 28, 2017 Supplement 10.
  2. Betel quid consists of betel leaf, slaked lime and areca nuts, with or without tobacco. Other ingredients may be added according to regional traditions and personal tastes. These include catechu, spices (aniseed, cardamom, nutmeg, cinnamon, cloves), sweeteners(coconut, dried dates, liquorice), and essences (rose essence, menthol, mint, rose petals). The mixture is chewed and may be kept in the mouth for many hours.
  3. IARC Working Group on the Evaluation of Carcinogenic Risk to Humans. Betel-quid and Areca-nut Chewing and Some Areca-nut-derived Nitrosamines. Lyon (FR): International Agency for Research on Cancer; 2004. (IARC Monographs on the Evaluation of Carcinogenic Risks to Humans, No. 85.)
  4. Cheong SC, et al. Oral cancer in South East Asia: Current status and future directions. Translational Research in Oral Oncology. 2017. DOI: 10.1177/2057178X17702921
About the European Society for Medical Oncology (ESMO)

ESMO is the leading professional organisation for medical oncology. With 17,000 members representing oncology professionals from 150 countries worldwide, ESMO is the society of reference for oncology education and information. We are committed to supporting our members to develop and advance in a fast-evolving professional environment.

Abstract 372P_PR

Head and neck cancer occurrences and lifestyle habits in Toungoo, Myanmar

K.K. Nwe1, S. Aung2, S. Thaung3, Y. Mon4, H. Thazin1
1Medical Oncology Unit, Toungoo General Hospital, Taungoo, Myanmar, 2Medical Oncology Unit, Yangon General Hospital, Yangon, Myanmar, 3Medical Oncology Unit, Naypyitaw General Hospital, Naypyitaw, Myanmar, 4Medical Oncology Unit, Taunggyi General Hospital, Taunggyi, Myanmar

Background: Head & neck cancer was the first most common in Toungoo Hospital, the second in Mandalay Hospital in 2016 and the third in Yangon Hospital, Myanmar in 2012. Betel quid chewing, smoking and alcohol consumption are the main risk factors for head and neck cancer. Most Myanmar people are used to betel quid chewing and keeping it in their mouth for long hours. Each wrapped betel leaf contains areca nut, tobacco, slaked lime and some other ingredients. We try to find out the life style of head and neck cancer patients, such as smoking, alcohol consumption and betel quid chewing in our region, Toungoo.

Methods: A descriptive study was conducted by retrieving and analyzing data for the year 2016 at Toungoo General Hospital.

Results: Among 307 cancer patients registered, 67 (21.8%) patients were head and neck squamous cell cancer. Male to female ratio was 1.6:1. The mean age of male patients was 59.2 (range 36-81 years) and that for female was 58.7 (range 19-86). The most common sites were oral cavity (34.3%, mean age 75.9) followed by larynx (25.4%, mean age 68.9), oropharynx (11.9%, mean age 63.5) and nasopharynx (11.9%, mean age 62.5), hypopharynx (10.4%, mean age 62.1), lip (4.5%, mean age 59.3) and nose (1.5%, mean age 68). Regarding to their habits, betel only patients were 20 (29.8%); smoking and betel, 19 (28.3%); smoking, alcohol and betel, 19 (28.3%); without documentation, 3 (4.5%); alcohol and betel 2(3%); smoking only, 2 (3%); without habit, 2 (3 %); no alcohol only and no alcohol and smoking patients. All oral cavity cancer patients were betel quid chewers, mostly smokers (47.8%) and alcoholics (43.5%). The majority (87%) of oral cancer patients had history of habitual betel quid chewing and keeping it in buccal cavity most of the time. In most cases, they started this habit at their teenage and found it very difficult to quit until they came across sinister health consequences

Conclusions: Betel chewing was the primary contributor in head and neck cancer occurrences and it also interacts with smoking and alcohol drinking in an additive way in this population. This issue can be noticed for public awareness of risk habits in head and neck cancer patients and that may be a great help in cancer prevention through life style modification.

Legal entity responsible for the study: Toungoo General Hospital

Funding: None

Disclosure: All authors have declared no conflicts of interest.

Keywords: life style, betel quid chewing, head and neck cancer, Myanmar

Last update: 17 Nov 2017

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