From UK Thames Cancer Registry data, after controlling for socioeconomic deprivation of area of residence, South Asian males showed a higher relative risk of oral (1.36; 95% CI: 1.11, 1.67), but not of pharyngeal cancer than non-South Asian males, whereas South Asian females had much higher risks of these cancers (3.67; 95% CI: 2.97, 4.53 and 2.06; 95% CI: 1.44, 2.93), respectively, than non-South Asians

AE Grulich

AJ Swerdlow

C La Vecchia

D R Moles

H Winter

I dos Santos Silva

I Hindle

J Ferlay

K Nanchahal

KM Lay

MC Chang

N Breslow

N Ikeda

P Balaram

P M Speight

PC Gupta

R Bedi

RP Dikshit

RV Jain

S Fedele

S Franceschi

S R Porter

V Carstairs

WJ Blot

British Journal of Cancer

PubMed

Moles, DR

Fedele, S

Speight, PM

Porter, SR

dos Santos Silva, I

LSHTM Research Online

Moles, DR; Fedele, S; Speight, PM; Porter, SR; dos Santos Silva, I(2008) Oral and pharyngeal cancer in South Asians and non-SouthAsians in relation to socioeconomic deprivation in South East Eng-land. British journal of cancer, 98 (3). pp. 633-5. ISSN 0007-0920Downloaded from: http://researchonline.lshtm.ac.uk/8062/Usage GuidelinesPlease refer to usage guidelines at http://researchonline.lshtm.ac.uk/policies.html or alterna-tively contact researchonline@lshtm.ac.uk.Available under license: Creative Commons Attribution Non-commercial No Derivativeshttp://creativecommons.org/licenses/by-nc-nd/2.5/Short CommunicationOral and pharyngeal cancer in South Asians and non-South Asiansin relation to socioeconomic deprivation in South East EnglandDR Moles*,1, S Fedele2, PM Speight3, SR Porter2 and I dos Santos Silva41Health Services Research, UCL Eastman Dental Institute, 256 Grays Inn Road, London WC1X 8LD, UK; 2Department of Oral Medicine, UCL EastmanDental Institute, 256 Grays Inn Road, London WC1X 8LD, UK; 3Department of Oral and Maxillofacial Pathology, The School of Clinical Dentistry, TheUniversity of Sheff ield, Claremont Crescent, Sheff ield S10 2TA, UK; 4Cancer Research UK Epidemiology and Genetic Group, London School of Hygieneand Tropical Medicine, Keppel Street, London WC1E 7HT, UKFrom UK Thames Cancer Registry data, after controlling for socioeconomic deprivation of area of residence, South Asian malesshowed a higher relative risk of oral (1.36; 95% CI: 1.11, 1.67), but not of pharyngeal cancer than non-South Asian males, whereasSouth Asian females had much higher risks of these cancers (3.67; 95% CI: 2.97, 4.53 and 2.06; 95% CI: 1.44, 2.93), respectively, thannon-South Asians.British Journal of Cancer (2008) 98, 633–635. doi:10.1038/sj.bjc.6604191 www.bjcancer.comPublished online 22 January 2008& 2008 Cancer Research UKKeywords: oral cancer; incidence; ethnicity; relative deprivation; EnglandSouth Asians with origins in India, Pakistan and Bangladeshconstitute the largest minority ethnic group in Britain, representing4% of the 2001 English population (Office for National Statistics,2003). At lower risk of most cancers, they have increased risks oforal and pharyngeal cancers relative to the general Britishpopulation (Winter et al, 1999). Variations in the risk of cancersare strongly related to the prevalence of chewing of tobacco, arecanut and betel quid in developing countries (Lay et al, 1982; Ikedaet al, 1995; Gupta and Nadakumar, 2000) and of tobacco smokingand high alcohol consumption in developed countries (Blot et al,1988; La Vecchia et al, 1997; Hindle et al, 2000a, b). Ethnicdifferences in the incidence of these cancers are little studied inBritain, mainly because of the lack of reliable ethnicity data incancer registries. We investigated differences in the incidence oforal and pharyngeal cancers between South Asians and non-SouthAsians in England, taking into account their socioeconomic statusand population-based data on ethnic differences in tobacco useand alcohol intake.MATERIALS AND METHODSWith ethical approval from the London School of Hygiene andTropical Medicine ethics committee, data for all oral andpharyngeal incident cancers diagnosed in the south east ofEngland in 1985– 1995 were obtained from the Thames CancerRegistry (TCR). As ethnicity data were incomplete in TCR files, acomputer algorithm, SANGRA (South Asian Names and GroupRecognition Algorithm) of high sensitivity and specificity(Nanchahal et al, 2001), was used to identify persons of SouthAsian origin on the basis of their names. Socioeconomic status atdiagnosis was ascertained by the Carstairs index (Carstairs andMorris, 1989). Each of the 1999 census wards in England andWales was assigned a deprivation score and the resultingdistribution categorised into five groups (1¼ least deprived to5¼most deprived). Postcode of usual residence at diagnosis wasused to allocate each subject to a ward and, hence, to a deprivationcategory.Analyses were conducted separately for oral (ICD-10: C01–C06)and pharyngeal (ICD-10: C09, C10, C12– C14) cancers. The relativeimportance of tobacco products and alcohol intake has been foundto differ for these cancers (Franceschi et al, 1999; Hindle et al,2000a, b). Age-standardised incidence rates (per 100 000 person-years) were calculated by the direct method, in 5-year age bands, tothe World Standard Population. Population denominators byethnicity were obtained from the 1991 census; people who definedthemselves as ‘Indian’, ‘Pakistani’ and ‘Bangladeshi’ were regardedas South Asians. Poisson regression models were fitted to estimateage-adjusted and age-deprivation-adjusted incidence rate ratios(Breslow and Day, 1993). Models were compared that included andexcluded the deprivation quintiles, respectively; these weremodelled both as a series of dummy variables and as a lineartrend (nested models), with their relative fit compared usinglikelihood ratio tests.In the late 1990s, the government commissioned the firstnationally representative survey into health-related behavioursamong minority ethnic groups in England. More than 1000 adultsin each of the main three South Asian groups (Indian, Pakistaniand Bangladeshi) were interviewed (Department of Health,2001). Data on tobacco use and alcohol intake, by ethnicity,were extracted from the Survey’s report (http://www.archive.official-documents.co.uk/document/doh/survey99/hse99.htm).Received 19 October 2007; revised 7 December 2007; accepted 10December 2007; published online 22 January 2008*Correspondence: Dr DR Moles; E-mail: d.moles@eastman.ucl.ac.ukBritish Journal of Cancer (2008) 98, 633 – 635& 2008 Cancer Research UK All rights reserved 0007 – 0920/08 $30.00www.bjcancer.comEpidemiologyRESULTSThe TCR held 6658 registrations of incident oral and pharyngealcancers in 1985–1995, with 6355 (95.4%) having data on age, genderand postcode situated within its catchment area. SANGRA identified282 (4.4%) registrations as being of South Asian origin. SouthAsians had higher age-adjusted incidence rates of these cancers thannon-South Asians (Table 1), particularly among females. Amongnon-South Asians, males had over twice the risk of females. Incontrast, South Asian males had a 15% lower risk of oral but a 63%higher risk of pharyngeal cancer than South Asian females.The incidence of both oral and pharyngeal cancers increasedwith increasing socioeconomic deprivation of area of residenceamong non-South Asian males, the most deprived having overtwice the risks of those in the least deprived quintile (Table 2).Among non-South Asian females, there was also a positive trend inpharyngeal cancer risk with deprivation, although less markedthan in males, but no clear trend in oral cancer risk. Neither cancerwas associated with deprivation among South Asians. Afteradjustment for both age and deprivation of area of residence(Table 3), there was only a small ethnic difference in oral cancerincidence in males, and none in pharyngeal cancer. In contrast,South Asian females had substantially greater risks of thesecancers than non-South Asian females (Table 3).These ethnic differences do not parallel the ethnic variations inalcohol intake reported by the 1999 Health Survey for England.Mean weekly consumption of alcohol units by South Asians(range: 0.0– 8.6) and proportion of heavy drinkers (range: 0 –14%)were substantially lower than among the general population (7.2–17.5 and 16– 30%, respectively). After adjustment for under-reporting as ascertained by saliva cotinine levels, current use ofany form of tobacco product was substantially higher amongBangladeshi males (relative risk (RR)¼ 1.52) and females(RR¼ 1.75), mainly due to tobacco chewing, than in the generalpopulation (RR¼ 1.00). Prevalence in Pakistani males (RR¼ 0.97)was similar to that in the general population, but much lower inIndian (RR¼ 0.38) and Pakistani (RR¼ 0.31) females. Socio-economic status was negatively associated with tobacco consump-tion, but positively associated with alcohol intake in the generalpopulation; there were no clear trends among South Asians.Table 1 Oral and pharyngeal cancer incidence by ethnicity, gender and relative deprivation, South East England, 1985–1995Non-South Asians South AsiansAnatomical site Deprivation quintileMales Females Males Females(ICD-10) (Carstairs) N Rate (95% CI)a N Rate (95% CI)a N Rate (95% CI)a N Rate (95% CI)aOral cavity (C01–C06) 1 (least deprived) 246 1.44 (1.25, 1.63) 248 1.18 (1.01, 1.34) 6 5.68 (0.54, 10.85) 8 8.49 (2.10, 14.89)2 311 1.77 (1.56, 1.97) 247 0.98 (0.84, 1.12) 8 3.56 (0.83, 6.29) 5 3.29 (0.29, 6.29)3 380 2.06 (1.84, 2.27) 299 1.21 (1.05, 1.36) 8 2.74 (0.66, 4.82) 8 3.46 (0.94, 5.97)4 499 2.38 (2.16, 2.60) 361 1.25 (1.10, 1.40) 25 4.70 (2.76, 6.64) 27 4.70 (2.83, 6.56)5 (most deprived) 801 3.46 (3.21, 3.70) 412 1.23 (1.10, 1.37) 54 3.80 (2.71, 4.89) 50 4.70 (3.34, 6.07)All quintiles 2237 2.31 (2.21, 2.40) 1567 1.17 (1.11, 1.24) 101 3.97 (3.14, 4.80) 98 4.65 (3.68, 5.62)Pharynx (C09, C10, C12–C14) 1 (least deprived) 157 0.93 (0.78, 1.07) 104 0.47 (0.37, 0.57) 1 0.45 (0.00, 1.32) 3 3.40 (0.00, 7.34)2 198 1.07 (0.91, 1.22) 111 0.47 (0.37, 0.57) 5 3.64 (0.31, 6.98) 2 0.92 (0.00, 2.20)3 237 1.21 (1.05, 1.37) 133 0.51 (0.41, 0.61) 3 2.02 (0.00, 4.30) 2 0.66 (0.00, 1.57)4 330 1.60 (1.41, 1.78) 197 0.76 (0.64, 0.87) 11 2.45 (0.95, 3.95) 8 1.49 (0.41, 2.56)5 (most deprived) 547 2.39 (2.18, 2.60) 255 0.86 (0.74, 0.97) 30 2.16 (1.33, 3.00) 18 1.36 (0.69, 2.03)All quintiles 1469 1.51 (1.43, 1.59) 800 0.63 (0.58, 0.68) 50 2.24 (1.57, 2.90) 33 1.37 (0.87, 1.86)CI¼ confidence interval. aIncidence rate (with 95% confidence interval) per 100 000 person-years, age standardised in 5-year age bands to the World Standard Population.Table 2 Risk of oral and pharyngeal cancers by relative deprivation of area of residence in South Asians and non-South Asians resident in South EastEngland, 1985–1995Males FemalesAnatomical site Deprivation quintile Non-South Asian South Asian Non-South Asian South Asian(ICD-10) (Carstairs) IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI)Oral cavity (C01–C06) 1 (least deprived; reference) 1 1 1 12 1.18 (1.00, 1.40) 0.84 (0.29, 2.43) 0.89 (0.75, 1.07) 0.38 (0.12, 1.15)3 1.35 (1.15, 1.58) 0.58 (0.20, 1.67) 0.98 (0.83, 1.16) 0.41 (0.15, 1.10)4 1.60 (1.37, 1.86) 0.85 (0.35, 2.07) 1.04 (0.89, 1.23) 0.63 (0.29, 1.39)5 (most deprived) 2.20 (1.91, 2.54) 0.77 (0.33, 1.79) 1.05 (0.90, 1.23) 0.54 (0.25, 1.13)Trend per quintile 1.22 (1.18, 1.26) 0.98 (0.83, 1.15) 1.03 (0.99, 1.07) 0.96 (0.82, 1.14)P-value from likelihood ratio test 0.105 0.736 0.436 0.234Pharynx (C09, C10, C12–C14) 1 (least deprived; reference) 1 1 1 12 1.18 (0.96, 1.46) 3.02 (0.35, 25.84) 0.96 (0.74, 1.26) 0.40 (0.07, 2.42)3 1.32 (1.08, 1.62) 1.24 (0.13, 11.86) 1.05 (0.81, 1.36) 0.28 (0.05, 1.65)4 1.67 (1.38, 2.02) 2.06 (0.27, 15.96) 1.38 (1.08, 1.74) 0.50 (0.13, 1.90)5 (most deprived) 2.38 (1.99, 2.84) 2.30 (0.31, 16.85) 1.57 (1.25, 1.97) 0.51 (0.15, 1.74)Trend per quintile 1.25 (1.20, 1.30) 1.08 (0.83, 1.40) 1.15 (1.09, 1.20) 0.97 (0.73, 1.29)P-value from likelihood ratio test 0.093 0.541 0.310 0.55395% CI¼ 95% confidence interval; IRR¼ age- and deprivation-adjusted incidence rate ratio.Oral and pharyngeal cancer in English South AsiansDR Moles et al634British Journal of Cancer (2008) 98(3), 633 – 635 & 2008 Cancer Research UKEpidemiologyDISCUSSIONThe oral and pharyngeal cancer rates observed here are of similarmagnitude to those previously estimated among English SouthAsians (Winter et al, 1999), but much lower than in the Indiansubcontinent (Ferlay et al, 2004). Others have also found that thesecancer risks in migrants are intermediate between those of the hostand the countries of origin (Grulich et al, 1995; Swerdlow et al,1995; Jain et al, 2005), probably reflecting changes in behaviour.The positive trend in oral and pharyngeal cancer risks withsocioeconomic status in non-South Asians is consistent with thesocioeconomic differences in the consumption of tobacco, but notalcohol, reported by the 1999 Health Survey. Similarly, the ethnicdifferences in risk in females in our study do not paralleldifferences in their alcohol consumption but are, to a certainextent, consistent with their higher prevalence of tobacco chewing,particularly among Bangladeshi women. This would accord withtobacco chewing being associated with higher risks of oral thanpharyngeal cancers (Dikshit and Kanhere, 2000), the former effectbeing stronger in females (Balaram et al, 2002). A substantiallimitation of the Health Survey is its not covering the use of betelalone, a well-established carcinogen (Chang et al, 2005); its use iscommon in some South Asian (and other) minority ethnic groups(Bedi and Gilthorpe, 1995).Our study, like similar investigations, was limited by misclassi-fication in assigning of ethnicity on the basis of names and by itsinability to distinguish subethnic groups within the South Asianpopulation, despite evidence that risk behaviours vary greatlyaccording to religion and region of origin. Nevertheless, the highrisks of oral and pharyngeal cancers presumably reflect theirhigher consumption of tobacco products and betel quid alone.ACKNOWLEDGEMENTSDr Moles gratefully acknowledges the financial assistance of theMedical Research Council (MRC) UK. This study was undertakenas part of an MRC Special Training Fellowship in Health ServicesResearch.REFERENCESBalaram P, Sridhar H, Rajkumar T, Vaccarella S, Herrero R, NandakumarA, Ravichandran K, Ramdas K, Sankaranarayanan R, Gajalakshmi V,Munoz N, Franceschi S (2002) Oral cancer in southern India: theinfluence of smoking, drinking, paan-chewing and oral hygiene. Int JCancer 98: 440 – 445Bedi R, Gilthorpe MS (1995) The prevalence of betel-quid and tobaccochewing among the Bangladeshi community resident in a UnitedKingdom area of multiple deprivation. Prim Dent Care 2: 39 – 42Blot WJ, McLaughlin JK, Winn D, Austin DF, Greenberg RS, Preston-Martin S, Bernstein L, Schoenberg JB, Stemhagen A, Fraumeni JF (1988)Smoking and drinking in relation to oral and pharyngeal cancer. CancerRes 48: 3282 – 3287Breslow N, Day NE (1993) Statistical Methods in Cancer Research: The Designand Analysis of Cohort Studies. Lyon: IARC Scientific PublicationsCarstairs V, Morris R (1989) Deprivation and mortality: an alternative tosocial class? Community Med 11: 210 – 219Chang MC, Chiang CP, Lin CL, Lee JJ, Hahn LJ, Jeng JH (2005) Cell-mediated immunity and head and neck cancer: with special emphasis onbetel quid chewing habit. Oral Oncol 41: 757 – 775Department of Health (2001) Health Survey for England 1999: MinorityEthnic Groups. London: The Stationery Office. Available online at http://www.archive.official-documents.co.uk/document/doh/survey99/hse99.htm.Access verified 10 October 2007Dikshit RP, Kanhere S (2000) Tobacco habits and risk of lung,oropharyngeal and oral cavity cancer: a population-based case – controlstudy in Bhopal, India. Int J Epidemiol 29: 609 – 614Ferlay J, Bray F, Pisani P, Parkin DM (2004) GLOBOCAN 2002: CancerIncidence, Mortality and Prevalence Worldwide. IARC CancerBase no. 5,version 2.0. Lyon: IARC PressFranceschi S, Levi F, La Vecchia C, Conti E, Dal Maso L, Barzan L, TalaminiR (1999) Comparison of the effect of smoking and alcohol drinkingbetween oral and pharyngeal cancer. Int J Cancer 83: 1 – 4Grulich AE, McCredie M, Coates M (1995) Cancer incidence in Asianmigrants to New South Wales, Australia. Br J Cancer 71: 400 – 408Gupta PC, Nadakumar A (2000) Oral cancer scene in India. Oral Dis 5:1 – 2Hindle I, Downer MC, Moles DR, Speight PM (2000a) Is alcohol responsiblefor more intra-oral cancer? Oral Oncol 36: 328 – 333Hindle I, Downer MC, Speight PM (2000b) The association between intra-oral cancer and surrogate markers of smoking and alcohol consumption.Community Dent Health 17: 2 – 13Ikeda N, Handa Y, Khim SP, Durward C, Axell T, Mizuno T, Fukano H,Kawai T (1995) Prevalence study of oral lesions in selected Cambodianpopulation. Community Dent Oral Epidemiol 25: 49 – 54Jain RV, Mills PK, Parikh-Patel A (2005) Cancer incidence in the southAsian population of California, 1988 – 2000. J Carcinog 4: 21La Vecchia C, Tavani A, Franceschi S, Levi F, Corrao G, Negri E(1997) Epidemiology and prevention of oral cancer. Oral Oncol 33:302 – 312Lay KM, Sein K, Myint A, Ko KOS, Pindborg JJ (1982) Epidemiologic studyof 6000 villagers of oral precancerous lesions in Bilugyun: preliminaryreport. Community Dent Oral 10: 152 – 155Nanchahal K, Mangtani P, Alston M, dos Santos Silva I (2001) Developmentand validation of a computerized South Asian Names and GroupRecognition Algorithm (SANGRA) for use in British health-relatedstudies. J Public Health Med 23: 278 – 285Office for National Statistics (2003) Census 2001: Key Statistics for LocalAuthorities in England and Wales. London: The Stationery OfficeSwerdlow AJ, Marmot MG, Grulich AE, Head J (1995) Cancer mortality inIndian and British ethnic immigrants from the Indian subcontinent toEngland and Wales. Br J Cancer 72: 1312 – 1319Winter H, Cheng KK, Cummins C, Maric R, Silcocks P, Varghese C (1999)Cancer incidence in the south Asian population of England (1990 – 92).Br J Cancer 79: 645 – 654Table 3 Risk of developing oral and pharyngeal cancer in South Asians relative to non-South Asians (reference), South East England, 1985–1995, adjustedfor age and deprivationAnatomical siteMales Females(ICD-10) IRR (95% CI) P-value IRR (95% CI) P-valueOral cavity (C01–C06) 1.36 (1.11, 1.67) 0.003 3.67 (2.97, 4.53) o0.001Pharynx (C09, C10, C12–C14) 1.00 (0.75, 1.34) 0.978 2.06 (1.44, 2.93) o0.001Oral and pharynx combined 1.22 (1.03, 1.44) 0.019 3.07 (2.56, 3.68) o0.00195% CI¼ 95% confidence interval; IRR¼ age- and deprivation adjusted incidence rate ratio.Oral and pharyngeal cancer in English South AsiansDR Moles et al635British Journal of Cancer (2008) 98(3), 633 – 635& 2008 Cancer Research UKEpidemiology

English

Oral cancer in southern India: the influence of smoking, drinking, paan-chewing and oral hygiene.

Prevalence study of oral lesions in selected Cambodian population. Community Dent Oral Epidemiol 25: 49–54 Jain RV, Mills PK, Parikh-Patel A

Tobacco habits and risk of lung, oropharyngeal and oral cavity cancer: a population-based case–control study in Bhopal, India.

Oral and pharyngeal cancer in South Asians and non-South Asians in relation to socioeconomic deprivation in South East England.

Crossref

Oral and pharyngeal cancer in South Asians and non-South Asians in relation to socioeconomic deprivation in South East England

Silva, IDS

PEARL (Univ. of Plymouth)

University of PlymouthPEARL https://pearl.plymouth.ac.ukFaculty of Health: Medicine, Dentistry and Human Sciences Peninsula Dental School2008-02Oral and pharyngeal cancer in SouthAsians and non-South Asians in relationto socioeconomic deprivation in SouthEast EnglandMoles, DRhttp://hdl.handle.net/10026.1/338210.1038/sj.bjc.6604191British Journal of CancerSpringer Science and Business Media LLCAll content in PEARL is protected by copyright law. Author manuscripts are made available in accordance withpublisher policies. Please cite only the published version using the details provided on the item record ordocument. In the absence of an open licence (e.g. Creative Commons), permissions for further reuse of contentshould be sought from the publisher or author.Version 1 08.05.12  PLYMOUTH UNIVERSITY  DEPOSIT LICENCE AGREEMENT FOR RESEARCH     PEARL supports the long-term preservation of research outputs, and open access to them. 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Moles, D.R.

Fedele, S.

Speight, P.M.

Porter, S.R.

Silva, I.D.

White Rose Research Online

Short CommunicationOral and pharyngeal cancer in South Asians and non-South Asiansin relation to socioeconomic deprivation in South East EnglandDR Moles*,1, S Fedele2, PM Speight3, SR Porter2 and I dos Santos Silva41Health Services Research, UCL Eastman Dental Institute, 256 Grays Inn Road, London WC1X 8LD, UK; 2Department of Oral Medicine, UCL EastmanDental Institute, 256 Grays Inn Road, London WC1X 8LD, UK; 3Department of Oral and Maxillofacial Pathology, The School of Clinical Dentistry, TheUniversity of Sheff ield, Claremont Crescent, Sheff ield S10 2TA, UK; 4Cancer Research UK Epidemiology and Genetic Group, London School of Hygieneand Tropical Medicine, Keppel Street, London WC1E 7HT, UKFrom UK Thames Cancer Registry data, after controlling for socioeconomic deprivation of area of residence, South Asian malesshowed a higher relative risk of oral (1.36; 95% CI: 1.11, 1.67), but not of pharyngeal cancer than non-South Asian males, whereasSouth Asian females had much higher risks of these cancers (3.67; 95% CI: 2.97, 4.53 and 2.06; 95% CI: 1.44, 2.93), respectively, thannon-South Asians.British Journal of Cancer (2008) 98, 633–635. doi:10.1038/sj.bjc.6604191 www.bjcancer.comPublished online 22 January 2008& 2008 Cancer Research UKKeywords: oral cancer; incidence; ethnicity; relative deprivation; EnglandSouth Asians with origins in India, Pakistan and Bangladeshconstitute the largest minority ethnic group in Britain, representing4% of the 2001 English population (Office for National Statistics,2003). At lower risk of most cancers, they have increased risks oforal and pharyngeal cancers relative to the general Britishpopulation (Winter et al, 1999). Variations in the risk of cancersare strongly related to the prevalence of chewing of tobacco, arecanut and betel quid in developing countries (Lay et al, 1982; Ikedaet al, 1995; Gupta and Nadakumar, 2000) and of tobacco smokingand high alcohol consumption in developed countries (Blot et al,1988; La Vecchia et al, 1997; Hindle et al, 2000a, b). Ethnicdifferences in the incidence of these cancers are little studied inBritain, mainly because of the lack of reliable ethnicity data incancer registries. We investigated differences in the incidence oforal and pharyngeal cancers between South Asians and non-SouthAsians in England, taking into account their socioeconomic statusand population-based data on ethnic differences in tobacco useand alcohol intake.MATERIALS AND METHODSWith ethical approval from the London School of Hygiene andTropical Medicine ethics committee, data for all oral andpharyngeal incident cancers diagnosed in the south east ofEngland in 1985– 1995 were obtained from the Thames CancerRegistry (TCR). As ethnicity data were incomplete in TCR files, acomputer algorithm, SANGRA (South Asian Names and GroupRecognition Algorithm) of high sensitivity and specificity(Nanchahal et al, 2001), was used to identify persons of SouthAsian origin on the basis of their names. Socioeconomic status atdiagnosis was ascertained by the Carstairs index (Carstairs andMorris, 1989). Each of the 1999 census wards in England andWales was assigned a deprivation score and the resultingdistribution categorised into five groups (1¼ least deprived to5¼most deprived). Postcode of usual residence at diagnosis wasused to allocate each subject to a ward and, hence, to a deprivationcategory.Analyses were conducted separately for oral (ICD-10: C01–C06)and pharyngeal (ICD-10: C09, C10, C12– C14) cancers. The relativeimportance of tobacco products and alcohol intake has been foundto differ for these cancers (Franceschi et al, 1999; Hindle et al,2000a, b). Age-standardised incidence rates (per 100 000 person-years) were calculated by the direct method, in 5-year age bands, tothe World Standard Population. Population denominators byethnicity were obtained from the 1991 census; people who definedthemselves as ‘Indian’, ‘Pakistani’ and ‘Bangladeshi’ were regardedas South Asians. Poisson regression models were fitted to estimateage-adjusted and age-deprivation-adjusted incidence rate ratios(Breslow and Day, 1993). Models were compared that included andexcluded the deprivation quintiles, respectively; these weremodelled both as a series of dummy variables and as a lineartrend (nested models), with their relative fit compared usinglikelihood ratio tests.In the late 1990s, the government commissioned the firstnationally representative survey into health-related behavioursamong minority ethnic groups in England. More than 1000 adultsin each of the main three South Asian groups (Indian, Pakistaniand Bangladeshi) were interviewed (Department of Health,2001). Data on tobacco use and alcohol intake, by ethnicity,were extracted from the Survey’s report (http://www.archive.official-documents.co.uk/document/doh/survey99/hse99.htm).Received 19 October 2007; revised 7 December 2007; accepted 10December 2007; published online 22 January 2008*Correspondence: Dr DR Moles; E-mail: d.moles@eastman.ucl.ac.ukBritish Journal of Cancer (2008) 98, 633 – 635& 2008 Cancer Research UK All rights reserved 0007 – 0920/08 $30.00www.bjcancer.comEpidemiologyRESULTSThe TCR held 6658 registrations of incident oral and pharyngealcancers in 1985–1995, with 6355 (95.4%) having data on age, genderand postcode situated within its catchment area. SANGRA identified282 (4.4%) registrations as being of South Asian origin. SouthAsians had higher age-adjusted incidence rates of these cancers thannon-South Asians (Table 1), particularly among females. Amongnon-South Asians, males had over twice the risk of females. Incontrast, South Asian males had a 15% lower risk of oral but a 63%higher risk of pharyngeal cancer than South Asian females.The incidence of both oral and pharyngeal cancers increasedwith increasing socioeconomic deprivation of area of residenceamong non-South Asian males, the most deprived having overtwice the risks of those in the least deprived quintile (Table 2).Among non-South Asian females, there was also a positive trend inpharyngeal cancer risk with deprivation, although less markedthan in males, but no clear trend in oral cancer risk. Neither cancerwas associated with deprivation among South Asians. Afteradjustment for both age and deprivation of area of residence(Table 3), there was only a small ethnic difference in oral cancerincidence in males, and none in pharyngeal cancer. In contrast,South Asian females had substantially greater risks of thesecancers than non-South Asian females (Table 3).These ethnic differences do not parallel the ethnic variations inalcohol intake reported by the 1999 Health Survey for England.Mean weekly consumption of alcohol units by South Asians(range: 0.0– 8.6) and proportion of heavy drinkers (range: 0 –14%)were substantially lower than among the general population (7.2–17.5 and 16– 30%, respectively). After adjustment for under-reporting as ascertained by saliva cotinine levels, current use ofany form of tobacco product was substantially higher amongBangladeshi males (relative risk (RR)¼ 1.52) and females(RR¼ 1.75), mainly due to tobacco chewing, than in the generalpopulation (RR¼ 1.00). Prevalence in Pakistani males (RR¼ 0.97)was similar to that in the general population, but much lower inIndian (RR¼ 0.38) and Pakistani (RR¼ 0.31) females. Socio-economic status was negatively associated with tobacco consump-tion, but positively associated with alcohol intake in the generalpopulation; there were no clear trends among South Asians.Table 1 Oral and pharyngeal cancer incidence by ethnicity, gender and relative deprivation, South East England, 1985–1995Non-South Asians South AsiansAnatomical site Deprivation quintileMales Females Males Females(ICD-10) (Carstairs) N Rate (95% CI)a N Rate (95% CI)a N Rate (95% CI)a N Rate (95% CI)aOral cavity (C01–C06) 1 (least deprived) 246 1.44 (1.25, 1.63) 248 1.18 (1.01, 1.34) 6 5.68 (0.54, 10.85) 8 8.49 (2.10, 14.89)2 311 1.77 (1.56, 1.97) 247 0.98 (0.84, 1.12) 8 3.56 (0.83, 6.29) 5 3.29 (0.29, 6.29)3 380 2.06 (1.84, 2.27) 299 1.21 (1.05, 1.36) 8 2.74 (0.66, 4.82) 8 3.46 (0.94, 5.97)4 499 2.38 (2.16, 2.60) 361 1.25 (1.10, 1.40) 25 4.70 (2.76, 6.64) 27 4.70 (2.83, 6.56)5 (most deprived) 801 3.46 (3.21, 3.70) 412 1.23 (1.10, 1.37) 54 3.80 (2.71, 4.89) 50 4.70 (3.34, 6.07)All quintiles 2237 2.31 (2.21, 2.40) 1567 1.17 (1.11, 1.24) 101 3.97 (3.14, 4.80) 98 4.65 (3.68, 5.62)Pharynx (C09, C10, C12–C14) 1 (least deprived) 157 0.93 (0.78, 1.07) 104 0.47 (0.37, 0.57) 1 0.45 (0.00, 1.32) 3 3.40 (0.00, 7.34)2 198 1.07 (0.91, 1.22) 111 0.47 (0.37, 0.57) 5 3.64 (0.31, 6.98) 2 0.92 (0.00, 2.20)3 237 1.21 (1.05, 1.37) 133 0.51 (0.41, 0.61) 3 2.02 (0.00, 4.30) 2 0.66 (0.00, 1.57)4 330 1.60 (1.41, 1.78) 197 0.76 (0.64, 0.87) 11 2.45 (0.95, 3.95) 8 1.49 (0.41, 2.56)5 (most deprived) 547 2.39 (2.18, 2.60) 255 0.86 (0.74, 0.97) 30 2.16 (1.33, 3.00) 18 1.36 (0.69, 2.03)All quintiles 1469 1.51 (1.43, 1.59) 800 0.63 (0.58, 0.68) 50 2.24 (1.57, 2.90) 33 1.37 (0.87, 1.86)CI¼ confidence interval. aIncidence rate (with 95% confidence interval) per 100 000 person-years, age standardised in 5-year age bands to the World Standard Population.Table 2 Risk of oral and pharyngeal cancers by relative deprivation of area of residence in South Asians and non-South Asians resident in South EastEngland, 1985–1995Males FemalesAnatomical site Deprivation quintile Non-South Asian South Asian Non-South Asian South Asian(ICD-10) (Carstairs) IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI)Oral cavity (C01–C06) 1 (least deprived; reference) 1 1 1 12 1.18 (1.00, 1.40) 0.84 (0.29, 2.43) 0.89 (0.75, 1.07) 0.38 (0.12, 1.15)3 1.35 (1.15, 1.58) 0.58 (0.20, 1.67) 0.98 (0.83, 1.16) 0.41 (0.15, 1.10)4 1.60 (1.37, 1.86) 0.85 (0.35, 2.07) 1.04 (0.89, 1.23) 0.63 (0.29, 1.39)5 (most deprived) 2.20 (1.91, 2.54) 0.77 (0.33, 1.79) 1.05 (0.90, 1.23) 0.54 (0.25, 1.13)Trend per quintile 1.22 (1.18, 1.26) 0.98 (0.83, 1.15) 1.03 (0.99, 1.07) 0.96 (0.82, 1.14)P-value from likelihood ratio test 0.105 0.736 0.436 0.234Pharynx (C09, C10, C12–C14) 1 (least deprived; reference) 1 1 1 12 1.18 (0.96, 1.46) 3.02 (0.35, 25.84) 0.96 (0.74, 1.26) 0.40 (0.07, 2.42)3 1.32 (1.08, 1.62) 1.24 (0.13, 11.86) 1.05 (0.81, 1.36) 0.28 (0.05, 1.65)4 1.67 (1.38, 2.02) 2.06 (0.27, 15.96) 1.38 (1.08, 1.74) 0.50 (0.13, 1.90)5 (most deprived) 2.38 (1.99, 2.84) 2.30 (0.31, 16.85) 1.57 (1.25, 1.97) 0.51 (0.15, 1.74)Trend per quintile 1.25 (1.20, 1.30) 1.08 (0.83, 1.40) 1.15 (1.09, 1.20) 0.97 (0.73, 1.29)P-value from likelihood ratio test 0.093 0.541 0.310 0.55395% CI¼ 95% confidence interval; IRR¼ age- and deprivation-adjusted incidence rate ratio.Oral and pharyngeal cancer in English South AsiansDR Moles et al634British Journal of Cancer (2008) 98(3), 633 – 635 & 2008 Cancer Research UKEpidemiologyDISCUSSIONThe oral and pharyngeal cancer rates observed here are of similarmagnitude to those previously estimated among English SouthAsians (Winter et al, 1999), but much lower than in the Indiansubcontinent (Ferlay et al, 2004). Others have also found that thesecancer risks in migrants are intermediate between those of the hostand the countries of origin (Grulich et al, 1995; Swerdlow et al,1995; Jain et al, 2005), probably reflecting changes in behaviour.The positive trend in oral and pharyngeal cancer risks withsocioeconomic status in non-South Asians is consistent with thesocioeconomic differences in the consumption of tobacco, but notalcohol, reported by the 1999 Health Survey. Similarly, the ethnicdifferences in risk in females in our study do not paralleldifferences in their alcohol consumption but are, to a certainextent, consistent with their higher prevalence of tobacco chewing,particularly among Bangladeshi women. This would accord withtobacco chewing being associated with higher risks of oral thanpharyngeal cancers (Dikshit and Kanhere, 2000), the former effectbeing stronger in females (Balaram et al, 2002). A substantiallimitation of the Health Survey is its not covering the use of betelalone, a well-established carcinogen (Chang et al, 2005); its use iscommon in some South Asian (and other) minority ethnic groups(Bedi and Gilthorpe, 1995).Our study, like similar investigations, was limited by misclassi-fication in assigning of ethnicity on the basis of names and by itsinability to distinguish subethnic groups within the South Asianpopulation, despite evidence that risk behaviours vary greatlyaccording to religion and region of origin. Nevertheless, the highrisks of oral and pharyngeal cancers presumably reflect theirhigher consumption of tobacco products and betel quid alone.ACKNOWLEDGEMENTSDr Moles gratefully acknowledges the financial assistance of theMedical Research Council (MRC) UK. This study was undertakenas part of an MRC Special Training Fellowship in Health ServicesResearch.REFERENCESBalaram P, Sridhar H, Rajkumar T, Vaccarella S, Herrero R, NandakumarA, Ravichandran K, Ramdas K, Sankaranarayanan R, Gajalakshmi V,Munoz N, Franceschi S (2002) Oral cancer in southern India: theinfluence of smoking, drinking, paan-chewing and oral hygiene. Int JCancer 98: 440 – 445Bedi R, Gilthorpe MS (1995) The prevalence of betel-quid and tobaccochewing among the Bangladeshi community resident in a UnitedKingdom area of multiple deprivation. Prim Dent Care 2: 39 – 42Blot WJ, McLaughlin JK, Winn D, Austin DF, Greenberg RS, Preston-Martin S, Bernstein L, Schoenberg JB, Stemhagen A, Fraumeni JF (1988)Smoking and drinking in relation to oral and pharyngeal cancer. CancerRes 48: 3282 – 3287Breslow N, Day NE (1993) Statistical Methods in Cancer Research: The Designand Analysis of Cohort Studies. 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Br J Cancer 72: 1312 – 1319Winter H, Cheng KK, Cummins C, Maric R, Silcocks P, Varghese C (1999)Cancer incidence in the south Asian population of England (1990 – 92).Br J Cancer 79: 645 – 654Table 3 Risk of developing oral and pharyngeal cancer in South Asians relative to non-South Asians (reference), South East England, 1985–1995, adjustedfor age and deprivationAnatomical siteMales Females(ICD-10) IRR (95% CI) P-value IRR (95% CI) P-valueOral cavity (C01–C06) 1.36 (1.11, 1.67) 0.003 3.67 (2.97, 4.53) o0.001Pharynx (C09, C10, C12–C14) 1.00 (0.75, 1.34) 0.978 2.06 (1.44, 2.93) o0.001Oral and pharynx combined 1.22 (1.03, 1.44) 0.019 3.07 (2.56, 3.68) o0.00195% CI¼ 95% confidence interval; IRR¼ age- and deprivation adjusted incidence rate ratio.Oral and pharyngeal cancer in English South AsiansDR Moles et al635British Journal of Cancer (2008) 98(3), 633 – 635& 2008 Cancer Research UKEpidemiology

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Oral and pharyngeal cancer in South Asians and non-South Asians in relation to socioeconomic deprivation in South East England.

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