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British Journal of Oral and Maxillofacial Surgery 46 (2008) 187191

Survival after diagnosis of cancer of the oral cavity

Katayoun Sargeran a,b,c, , Heikki Murtomaa a , Seyed Mohammad Reza Safavi c ,
Miira M. Vehkalahti a , Olli Teronen d
a

Department of Oral Public Health, Institute of Dentistry, University of Helsinki, P.O. Box 41, FI-00014, Helsinki, Finland
Department of Community Oral Health, School of Dentistry, Shaheed Beheshti Medical University (SBMU), Tehran, Iran
c Iran Centre for Dental Research (ICDR), School of Dentistry, Shaheed Beheshti Medical University (SBMU), Tehran, Iran
d Institute of Dentistry, University of Helsinki, P.O. Box 41, FI-00014, Helsinki, Finland
b

Accepted 7 November 2007

Available online 21 December 2007

Abstract
In this retrospective study we analysed the survival in 470 patients with oral cancer. Patients who attended five university hospitals in
Tehran, Iran, during the period 19962002 were included. Data were obtained from a combination of sources including patients records,
telephone calls, and deaths registered by the Ministry of Health. Survival curves were generated using Kaplan-Maier curves. Univariate and
multivariate analyses of the relations between survival and age, sex, site of primary tumour, stage, and histopathological type were made
using the log-rank test and Coxs regression analysis. Sex and age were not associated with survival. Treatment and stage of tumour at
the time of diagnosis were related to survival. The overall survival rates were higher in patients with stages I or II cancer than those in
stages III (OR = 2.8, 95% CI = 1.8 to 4.4) or IV (OR = 4.6, 95% CI = 3.1 to 6.8) at the time of diagnosis. Patients treated with radiotherapy
had lower survival than those who had been operated on and had radiotherapy or operation alone (OR = 2.8, 95% CI = 1.7 to 4.5). There
was no difference in survival depending on the histological type of tumour. To achieve higher survival, early detection and diagnosis of
oral cancers should be emphasised in oral health programmes to improve public awareness and preventive activities among dentists in
Iran.
2007 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Oral cancer; Survival; Iran

Introduction
Cancers of the oral cavity have high mortality and, despite
the current progress in treatment, have not improved
dramatically.14 Five-year survival ranging from 30% to 80%
has been reported from several parts of the world.2,3,510
The rates are low for developing countries,2,3,1113 mainly
because the tumour had reached a late stage by the time of
diagnosis.2,3,13

Corresponding author. Tel.: +358 9 19127301; fax: +358 9 19127346.

E-mail addresses: katayoun.sargeran@helsinki.fi (K. Sargeran),
heikki.murtomaa@helsinki.fi (H. Murtomaa), safavismr@icdr.ac.ir
(S.M.R. Safavi), miira.vehkalahti@helsinki.fi (M.M. Vehkalahti),
olli.teronen@helsinki.fi (O. Teronen).

Various factors that affect survival of patients with oral

cancer have been investigated, including age, sex, stage of
disease at the time of diagnosis, site of tumour, and histological type.7,9,14,15 These factors also influence the options
for treatment. Patients with cancers of the oral cavity are
commonly treated surgically; in most cases postoperative
radiotherapy or chemotherapy, or both are also required.
These treatments may result in severe deformities of the orofacial structures, as well as pain, and difficulty in speaking,
eating, chewing, and swallowing, all decreasing the patients
quality of life.16
In the present study we calculated 1-5-year survival for
patients with cancer of the oral cavity for age, sex, stage of
tumour, histological type, and treatment during 1996-2002 in
five university hospitals in Tehran, Iran.

0266-4356/$ see front matter 2007 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.bjoms.2007.11.004

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K. Sargeran et al. / British Journal of Oral and Maxillofacial Surgery 46 (2008) 187191

Methods
The study comprised a retrospective cohort of patients with
primary cancer of the oral cavity diagnosed at five university hospitals in Tehran during the period 1996-2002. These
hospitals are the main referral centres for the treatment of
patients with oral cancer from all over the country. For survival analysis, the patients were followed from the date of
diagnosis to late 2005. We defined survival as the time from
diagnosis until 31 December 2005 or until death from cancer,
whichever occurred first. Survival was censored if a patient
was alive at the end of follow-up, lost to follow-up, or died of
a cause other than cancer. Ethical approval for the study was
given by the Ethics Committee of the School of Dentistry,
Shaheed Beheshti Medical University.
The study included the medical records of 470 patients
diagnosed with invasive primary tumours of the oral cavity (ICD-10 codes C01-C06 and C09-C10)17 who were
admitted to five university hospitals in Tehran, Iran between
January 1996 and April 2002. Patients with incomplete medical records or who lacked histological results; and those
with haematological tumours, carcinoma in situ, recurrent
tumours, metastases, or with a previous history of any cancer,
were excluded from the study.
Data collection
All eligible patients were identified from the patient attendance list and information files held in the records department
of each hospital. No patient can be admitted to the hospital
or treated in these five hospitals without previously filling
in the required forms and documents. Data collection forms
and records files were cross checked to ensure inclusion of
all eligible cases.
Information abstracted from patient records included birth
date, sex, and the date of diagnosis. The TNM (tumour, node,
metastases) stage,18 primary tumour site, and histopathological type were retrieved from histopathological reports. Methods of treatment, (resection, preoperative or postoperative
radiotherapy) and the final dates of admission to the hospital
were also recorded, as were the date and the cause of death,
if it happened in hospital. The distribution of our patients by
age (mean (SD) 61 (15)) and sex (54% men) was similar to
our previous study of oral cancers in Tehran, Iran.19 Data on
the stage of tumour were unavailable for 15% of all patients.
Patients condition was ascertained using a combination of
information from records, telephone calls, and death registration files in the Iran Ministry of Health, and was considered
as uncensored if the death had been caused by cancer and
censored if the patient was alive at the end of follow-up or
had died of another cause. Of all cases of oral cancer, 37 (8%)
were lost to follow-up (at any time after diagnosis), and this
was recorded for the following conditions: no record in the
death certificate; no data available on survival in the medical
record; the person who answered the telephone did not know
the patient or the date of death, or there was no answer to

five telephone calls at different times of the day during one

week. Any change in the phone numbers was checked from
the telephone information centre.
The time of death and final follow-up were recorded to an
accuracy of one month.
Statistical analysis
Survival curves were generated by Kaplan-Meier methods.
After initial descriptive statistics, univariate analyses of the
relations between survival and age, sex, primary site, stage,
and histopathological type were evaluated, using the log-rank
test. Multivariate analysis was by Coxs regression model to
calculate the hazard ratios. Probabilities of less than 0.05,
were accepted as significant.

Results
Of the 470 tumours of the oral cavity 167 (35%) were stage
IV, 70 (15%) stage III, 73 (16%) stage II, and 92 (20%) stage
I at the time of diagnosis, whereas the stage of tumours was
unknown in 68 (14%).
Of all 416 patients whose treatment status was known,
344 (83%) were operated on, (70 (17%) had operation alone,
and 274 (66%) operation with adjuvant radiotherapy) and
72 (17%) were treated with radiotherapy alone. The reason
for treating patients by radiotherapy alone, as noted in the
records, was the patients general health, an advanced stage
of cancer at the time of diagnosis, or a tumour sited in close
proximity to vital organs.
In the survival analysis, the cases were followed for a maximum of 116 months (mean (SD) 32 (26), range 0116). Of
the total of 470 patients, 335 (71%) died of their oral cancer, and 80 (17%) survived. Eighteen patients died of other
causes (4%), and 37 (8%) were lost to follow up. The overall 5-year survival was 30%. The results of the univariate
analysis between survival and independent variables of age,
sex, stage of tumour at the time of diagnosis, histological
type, and treatment are shown in Table 1. Sex and age were
not associated with survival. Treatment and stage of tumour
at the time of diagnosis were, however, related to survival.
Patients treated with radiotherapy alone were more likely to
die sooner (P < 0.05).
Fig. 1 shows survival and stage of tumour at the time of
diagnosis. Patients with stages III or IV had shorter survival than those with stages I or II (P < 0.05). There was
no difference in survival according to the histological type
of tumour. Tumours other than squamous cell carcinoma
included: adenoid cystic carcinoma (5%), verrucous carcinoma (3%), mucoepidermoid carcinoma (2%), and other
histological types (including undifferentiated carcinoma and
melanoma) 4%.
The Coxs multivariate analysis showed that treatment and
stage of tumour were the most important determinants of
survival compared with age, sex, and histological type of

K. Sargeran et al. / British Journal of Oral and Maxillofacial Surgery 46 (2008) 187191

189

Table 1
Survival rates for patients with cancer of the oral cavity (n = 470) by age, sex, stage of tumour at diagnosis, treatment, and histological type
Variable

No (%)

Survival rates (%)

12 months

P-value
24 months

60 months

Sex
Female
Male

213 (45)
257 (55)

(74)
(80)

(57)
(55)

(25)
(31)

Age (years)
<40
4164
65 or more

57 (12)
193 (41)
220 (47)

(71)
(79)
(77)

(56)
(60)
(52)

(33)
(32)
(25)

Stage of tumour
I
II
III
IV
Missing

92 (20)
73 (16)
70 (15)
167 (35)
68 (14)

(93)
(91)
(77)
(45)

(80)
(80)
(50)
(22)

(51)
(44)
(13)
(12)

Treatment
Surgery
Surgery + radiotherapy
Radiotherapy
Missing

70 (15)
274 (58)
72 (15)
54 (12)

(93)
(81)
(53)

(84)
(61)
(18)

(54)
(27)
(08)

Histology
SCC
Non-SCC
Total

404 (86)
66 (14)
470 (100)

(76)
(82)
(77)

(55)
(64)
(57)

(29)
(33)
(30)

Fig. 1. Survival of patients with cancer of the oral cavity by stage of tumour
(n = 470).

tumour (Table 2). The overall survival was longer in patients

with cancer in the stages I or II than in those with stages III
(OR = 2.8, 95% CI = 1.8 to 4.4) or IV (OR = 4.6, 95% CI = 3.1
to 6.8) at the time of diagnosis. Patients treated operatively
also had longer survival than those who had been operated
on with radiotherapy, or with radiotherapy alone (OR = 2.8,
95% CI = 1.7 to 4.5).

Discussion
Primary malignancy of the oral cavity remains a cancer with
a poor prognosis regardless of the current improvements in

0.68

0.33

<0.001

<0.001

0.47

treatment, because it is usually diagnosed late.2,3 We have

examined survival of patients with cancers of the oral cavity
between 1996 and 2002. Available reports rarely deal with
this topic in developing countries and particularly those in
the Middle East.
The overall outcome for oral cancer is dismal, with the
5-year survival being 30%80%.2,3,510 Our findings show
that the 5-year survival in our series are comparable with
those reported from developing countries.3,11,12 Subset analysis showed that patients with stage I or II tumours had the
longest survival, while the lowest was in later stages (Table 1).
This illustrates the minimal impact that treatment has had on
the advanced stages of this disease.
Previous reports have shown between 22% and 90% 5year survival for stages I and II oral cancer after simple or
extended resection and radiotherapy,2,9,10,12,15 and 2% and
80% for stage III and IV carcinoma after extended resection,
with or without adjuvant treatment.2,3,9,10,12,15 The survival
of our patients was certainly longer during the earlier stages
than the advanced stages (Fig. 1), but was shorter than that
reported in western countries.7,9,10,15,20
Patients treated with radiotherapy alone had shorter survival than those who were treated surgically or who had been
operated on and had had adjuvant radiotherapy. Patients given
radiotherapy alone had more advanced disease (71% at stages
III or IV at the time of diagnosis) and were probably of poor
general health. Our findings support earlier reports regarding the relation between treatment and survival in patients
with oral cancer.2,12,21 Primary surgical management with
adjuvant radiotherapy has been associated with high rates of

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K. Sargeran et al. / British Journal of Oral and Maxillofacial Surgery 46 (2008) 187191

Table 2
Determinants of length of survival assessed by Coxs regression analysis in patients with cancer of the oral cavity (n = 470).
Variable

ES1

SE2

OR3

95% CI4

P-value

Sex
(Malea , Female)

0.2

0.1

1.2

0.9 to 1.6

0.11

Age group (years)

<40a
4164
65 or more

0.4
0.4

0.2
0.2

1.5
1.5

0.9 to 2.3
1.0 to 2.3

0.08
0.07

Stage
Ia
II
III
IV

0.3
1.0
1.5

0.2
0.2
0.2

1.3
2.8
4.6

0.9 to 2.1
1.8 to 4.4
3.1 to 6.8

0.17
<0.001
<0.001

Treatment
Surgerya
Surgery + radiotherapy
Radiotherapy

0.7
1.0

0.2
0.2

1.1
2.8

0.7 to 1.6
1.7 to 4.5

0.73
<0.001

Histology
(SCCa , non-SCC)

0.1

0.2

1.1

0.7 to 1.5

0.73

Estimate of strength 2 Standard error 3 Odds ratio 4 Confidence interval.

a Reference category.

local control in previous reports.2,9,12,14 However, the longer

survival found here for patients treated by operation alone
may be mainly because this method is used for the treatment
of earlier tumours.
Our findings are in line with previous reports that the
advanced stages of oral cavity cancers at the time of diagnosis are associated with shorter survival. It is particularly
important when we consider our findings in this and the previous study,19 that in Iran, most oral cancers are diagnosed
when they are advanced.
The decision to treat is based not only on the stage of
tumour but also on several other factors such as the general health of the patient, state of surgical margins and in
some cases by the patients decision about treatment. These
all may have an impact on the outcome of the treatment and
on survival.
We recommend the planning of prevention campaigns that
target the improvement of public awareness of oral cancer and
continuing education for oral health professionals about its
early detection and diagnosis.

Acknowledgements
We thank the Iran Cancer Institute and all hospital personnel
for their cooperation. This work was partially supported by a
grant from the Iran Centre for Dental Research.

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