This manuscript characterizes the demographics, presenting symptoms and risk factors of patients diagnosed with head and neck cancer at Hopital de L’Universite d’Etat d’Haiti (HUEH), Haiti’s single largest healthcare facility. We conducted a prospective study of patients who presented to HUEH between January and March of 2016 with a lesion of the head or neck suspicious for cancer. All patients who met eligibility criteria received a biopsy, which was interpreted by a Haitian pathologist and when the specimen was available was confirmed by a team of pathologists from Stanford University. A total of 34 participants were identified. The biopsy-confirmed diagnoses were squamous cell carcinoma (n=7), benign (n=7), large cell lymphoma (n=2), ameloblastoma (n=2), pleomorphic adenoma (n=1), and adenocarcinoma (n=1). Fourteen patients were unavailable for biopsy. Patients with head and neck cancer had a mean age of 63.4 years, were majority male (62.5%), waited on average 10.9 months to seek medical attention, and most commonly presented with T-stage 3 or higher disease (87.5%). By characterizing patterns of head and neck cancer at HUEH we hope to facilitate efforts to improve early detection, diagnosis, and management of this important public health condition.
The majority of global cancer deaths now occur in low and middle-income countries, where patients present at later stages of disease and have less access to curative treatment [
In Haiti, the western hemisphere’s poorest country, little is known regarding the burden of head and neck cancer or the prevalence of traditional risk factors. New research, however, has demonstrated that Haiti has the highest incidence of esophageal, stomach, and liver cancer in the Caribbean, and one of the highest rates of Human Papilloma Virus (HPV) induced cervical cancer in the world [
Participants were prospectively recruited at HUEH in Port-au-Prince, Haiti between January and March 2016. Patients 18 years of age or older with a clinically suspicious lesion of the oral cavity, oropharynx, hypopharynx, larynx, mandible, or neck that met at least three of the following four criteria were eligible to participate: (1) at least 2 cm in diameter, (2) increasing in size over time, (3) present for at least 30 days, and (4) nonpainful. Eligible participants provided written informed consent in Creole and completed a verbal interview modeled from the HOTSPOT survey that was administered by a Haitian physician [
Data manipulation and analysis was performed using STATA v.14.0 (StataCorp, College Station, TX). Differences in proportions were assessed using Fisher’s Exact Test and differences in the average level of continuous measures were assessed with the Wilcoxan Rank-Sum Test. Statistical significance was determined by a two-sided type I error threshold of 0.05. Diagnoses of SCC and adenocarcinoma were grouped together as ‘cancer,’ and diagnoses of benign, pleomorphic adenoma, and ameloblastoma were grouped together as ‘benign.’ This study was approved by the Stanford University IRB, Family Health Ministries, 501-C3 IRB, and the HUEH ethics committee.
Table
Patient presentation and demographics.
| | | | |
---|---|---|---|---|
Age (mean) | 63.4 | 44.3 | 47.9 | 0.02 |
Male | 5 (62.5%) | 5 (50%) | 15 (44.1%) | 0.48 |
Literate | 3 (37.5%) | 8 (80%) | 24 (70.6%) | 0.09 |
Months to Presentation (mean) | 10.9 | 13.7 | 11.43 | 0.77 |
Hx of HIV/AIDS | 1 (12.5%) | 0 | 2 (5.9%) | 0.44 |
Symptoms: | ||||
Fever | 2 (25%) | 1 (10%) | 5 (14.7%) | 0.56 |
Weight Loss | 4 (50%) | 5 (50%) | 17 (50%) | 0.68 |
Dysphagia | 2 (25%) | 5 (50%) | 14 (41.2%) | 0.28 |
Lesion Location: | ||||
oral cavity | 3 (37.5%) | 3 (30%) | 8 (23.5%) | 0.56 |
oropharynx | 3 (37.5%) | 3 (30%) | 9 (26.5%) | 0.56 |
mandible | 0 | 1 (10%) | 2 (5.9%) | 0.56 |
neck | 1 (12.5%) | 2 (20%) | 10 (29.4%) | 0.59 |
larynx | 1 (12.5%) | 1 (10%) | 5 (14.7%) | 0.71 |
A total of 20 biopsies were performed: 8 were epithelial cancers (7 SCC and 1 adenocarcinoma), 10 were benign (7 general benign, 2 ameloblastoma, and 1 pleomorphic adenoma), and 2 were large cell lymphoma. Fourteen patients (41.2%) were unavailable for biopsy and remained undiagnosed. Table
Head and neck cancer cases.
| | | | | | | |
---|---|---|---|---|---|---|---|
SCC | F | 71 | 24 | oropharynx | 6 | 3 | Negative |
SCC | M | 55 | 4 | oropharynx | 5 | 4 | Negative |
SCC | M | 44 | 3 | oral cavity | 3 | 2 | Negative |
SCC | F | 51 | 24 | oral cavity | 4.5 | 3 | Negative |
SCC | M | 81 | 6 | oral cavity | 16 | 4 | Negative |
SCC | M | 63 | - | larynx | 2 | 3 | Negative |
SCC | M | 59 | 12 | neck | 6 | 4 | - |
Adeno | F | 83 | 3 | oropharynx | 5 | 3 | - |
Figure
Sexual practices revealed no statistically significant differences between the head and neck cancer and benign groups. The number of vaginal sex partners for all 34 participants were as follows: 5.9% no lifetime vaginal sex partners (n=2), 47.1% one lifetime partner (n=16), 35.3% two to five lifetime partners (n=12), 8.8% six to ten lifetime partners (n=3), and 2.9% ten or greater lifetime partners (n=1). The number of lifetime oral sex partners for all 34 participants were as follows: 47.1% no lifetime oral sex partners (n=16), 26.5% one lifetime partner (n=9), 17.7% two to five lifetime partners (n=6), 5.9% six to ten lifetime partners (n=2), and 2.9% ten or greater lifetime partners (n=1).
Head and neck cancer in low and middle-income countries remains a poorly understood public health concern. In this study we describe the epidemiology of head and neck cancer at HUEH, Haiti’s largest healthcare facility, by prospectively identifying patients with head and neck cancer over a three-month period. During this time a total of eight patients with a new diagnosis of head and neck cancer were identified. Patients with head and neck cancer at HUEH had a mean age of 63.4 years, were majority male (62.5%), waited on average 10.9 months to seek medical attention, and most commonly presented with T-stage 3 or higher disease. Patient demographics are similar to those in high-income countries where males are two to four times more likely than females to develop head and neck cancer and the typical age of presentation is between 50 and 70 years [
Head and neck cancer risk factors at HUEH appear consistent with those in high-income countries. In high-income countries, nearly 75% of head and neck cancer (with the exception of oropharyngeal cancer) is attributable to tobacco or alcohol use [
Whether HPV is a risk factor for oropharyngeal cancer in Haiti, however, remains unclear. In high-income countries, greater than 50% of oropharyngeal cancers are now associated with HPV [
While determining long-term outcomes of patients with head and neck cancer at HUEH is beyond the scope of this study, it does appear that a relatively small percentage of these patients go on to receive surgical treatment. For the year of 2014, for instance, a total of 4 operations at HUEH were performed to treat head and neck cancer [
Another important finding of this study was the discrepancy in diagnoses between the Haitian and Stanford-based pathologists. We attribute this discrepancy to a lack of immunohistochemistry and other specialized staining techniques in Haiti, and absence of a mechanism for obtaining second opinions on cases where there is known high interobserver variability (e.g., diagnosis of epithelial dysplasia). Future efforts to bolster pathologic infrastructure may improve the accuracy of head and neck cancer diagnoses and in turn benefit all patients receiving biopsies.
This study has several limitations. First, the small study size results in low statistical power, making comparisons between patients with benign and cancerous diagnoses challenging. There was also a high rate of patients who were lost to follow-up, which may have distorted the types and rates of diagnoses. As with any survey that asks sensitive questions, it is also possible that respondents may have been reserved in their answers. Extrapolating these results to the general population of Haiti is challenging given the confounders that all participants had lesions suspicious of head and neck cancer and were recruited from the same hospital. One of the inclusion criteria (that the suspected lesion be at least 2 cm in diameter) may also have resulted in selection bias by predisposing enrolled patients to later stage disease. To the best knowledge of the authorship team, however, no potential participants were excluded for a lesion that was less than 2 cm in size.
It is also important to note that this study ended earlier than anticipated due to a medical staff strike at HUEH that started in March 2016 and resulted in the closure of the hospital for a four-month period [
Head and neck cancer in low and middle-income countries like Haiti remains a poorly understood public health concern. We find that patients with head and neck cancer at HUEH, Haiti’s largest healthcare facility, tend to present with late T-stage disease associated in large part with smoking and alcohol consumption. The rate of HPV induced head and neck cancer at HUEH remains unclear and is an important subject for future research. Efforts to improve head and neck cancer treatment at HUEH may focus on facilitating hospital access, bolstering surgical training and capacity, improving diagnostic and pathologic infrastructure, and educating the general public about cancer risk factors and symptoms that require prompt hospital presentation.
The data used to support the findings of this study are available from the corresponding author upon request.
The authors declare that they have no conflicts of interest.
This project was funded by the Stanford University Translational Research and Medicine (TRAM) grant and by the Stanford University Medical Scholars Research Grant. This project was also conducted in collaboration with Family Health Ministries.