Some studies showed 2nd hand smoking has more damaging effect. Mu hunch is the more woen suffer from 2nd hand smoking in developing countries. Also, women tend to have better tolerance than men which may postpone their visit to doctors.

I think the fact is common among the ladies who chew battle nuts. So the crude tobacco prepn. may be the offending factor.

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Betel nuts or tocacco chewing maybe a cause but hard to explain since both genders do them in places have with such tradition. Then, we can not explain the phenomenon where betel nuts chewing is not a common practice.

Yes Ru-Jeng. In Jordan we don't have the habit of betel nut. Most smoking ladies practice narghile smoking and less number smoke cigarettes. Oral cancer victims of female gender are noticed to be non-smokers. But can passive smoking increase the risk for them? or there are some genetic factors?

Hi Najla: That is what I thought about. Second-hand smoking is known to be more carcinogenic than primary smoking. I guess in your culture women may have less chance to go outside of the house than Western world that leads to more exposure to concentrated smoke inside of the house. Sure we can not rule out the contribution of genetic factors. However, other than breast cancer, ovarian cancer, and cervical cancer I can not think of any other caner that affect women more than men.

I don't have accurate statistics regarding the prevalence of oral cancer in Jordan according to gender. Last year though, I saw 4 non-smoker women and 2 smoker men with an advanced oral cancer. Diagnosis for the ladies was delayed because no one could believe that the tongue ulcer is actually cancer

So, maybe you need to take cultural issue into account. Maybe in Jordan women are just reluctant, or feel uncomfortable, to be seen by doctors.

On the contrary. All these women were seen by a number of dentists and physicians and no one was keen to do the proper examination so the delay in diagnosis was because of medical negligence not because of reluctance of patients.

Then I have no good explanation.

As far as the genetic factor is concerned, it is equal for both sex. To the best of my knowledge the peoples of Jordan drink less. But that is also equal for the both sex. What about the use of Oral Contraceptive and use of hormonal therapy?

dear najila

in our country in IRAQ the incedance in male is more than in femal and in femal there is no relation to smooking but now we investagate the relation to HPV the high risk group with cases of OSCC enen though the HPV-related OSCC presented with good prognosis

Good question Tatini. Relevant literature reports that the likely potential for oral cancer is higher in leukoplakia affecting non-smokers. As for oral cancer, I notice that ladies who get oral cancer de novo are usually non-smokers. So how can we explain that? and what other factors may be involved? Is it HPV for example?

The points raised by Ikram may be valid concerning the hormonal therapy. I have to point out though that most of these women are middle-aged or elderly. The point raised by Maha is also important. So Maha, have you found any correlation between HPV and OSCC in Iraq?

Is oral hygene practice different between genders in your country? In Taiwan betel chewing is the number one contributing factor for oral cancer and chronic abrasion is consider a risk factor. Is the diet difefernt between genders?

Generally speaking, Jordanian females may have better oral hygiene practices than males. As for the diet there are no differences. Other factors that may play a role include tobacco use habits. Although cigarettes seem to be more popular among males, I believe that there is a good number of females who smoke cigarettes although they don't like to admit that. Being a smoker woman is against tradition especially for single girls!

Do you have strong data to assume this difference in prognosis ?

I agree with Chloe that a few cases is too early to say there is a difference between genders. However, I think a discussion is good for scientists.

In non-tobacco induced cancer, the carcinogenicity is mediated either by Virus (HPV, and most often Oropharynx) or may be the mutation was inherited. If it is inherited, the mean age would be much less. In either case, the prognosis would be poor when compared to a tobacco induced cancer. Probably gender creeps in because, males use tobacco more commonly than females and this is a world wide phenomenon.

In absence of a known carcingenic exposure, the prognosis of a OSCC is often very poor. Delay in reporting/diagnosis may add to this. In my opinion, hormonal influences may help to spread but not be a factor in causation of the cancer

dear najla we do study on 33 OSCC patients 84% were positive for HPV-16 and 33 healthy control with 34% HPV-16 now in our center we collecting data of HPV-16/18 infection in cervix and corrleated to detection of HPV -16/18in the saliva of the HPV positive women to investgat the role of HPV

in another study on lung cancer high % of HPV-16/18-related group was reported

so it is quit abvious this matter could play important role in carcinogensis

dr. Rooban mention that oropharnx OSCC most offen due to HPV this studies most of them done in USA so we need aprecised data in middle east to be sure is it in oral or oropharnx or tonsil

To answer Chloe I would say that I don't have accurate stats for oral cancer in Jordan. Unfortunately OSCC is understudied in Arabian countries as Maha explained, although we have all the risk factors involved of tobacco, alcohol, viruses, etc. The role of genetics and viruses should be investigated further as Rooban and Tatini suggested.

Dear Tatini as many studies has been done on HPV in relation to OSCC lt they find no significant relation to smoking and alcohol consumption so Ithink of non sextual rout HPV -HR infection and because of latent nature of HPV infection make it difficalt to determine the real story behind its role ,but i still think the high % of HPV detection in OSCC could be non-sextual

Hello Najla, A very interesting question,, As mentioned by others malignancies develop by an interaction of genetic and environmental factors...so in a malignancy initiated without an identifiable environmental factor(habitual exposure, infections etc) the cause has to be genetic or may be immune system aberration, in which ever case the chances of poor prognosis is greater since the tumor would have arisen without any external stimulus..which suggests the system is more prone to a produce and support cancerous cells and changes.

Of course a failure to elicit environmental factors should not be equated with their absence.

A very reasonable answer, thank you Mandana.Do you think that we can do specific genetic tests for cancer victims with unknown risk factors?

I am afraid as far as I know so far there are no such tests for oral carcinoma... may be some one else from the discussion will have specific information on this..

good question dear Najla

Thank you Keto.

Dear Najla, the topic being discussed is very interesting. As opined by many, delayed diagnosis might be the reason for poor prognosis among women, as there is negligeance in the initial period, and the cancer being diagnosed in a later stage. To support this statement I did a biopsy on oral growth of a 64 year old lady today, who thought the growth was due to teeth bite. But actually she also had lymph node metastasis, clinically making the cancer of higher stage. However in our experiece, when we compare prognosis of a similar staged cancer in men and women, non smoking women had a better prognosis than men. Many researches inferred that HPV in Oral cancer has a better prognosis, as the case in many females with oral cancer.

Thank you Vadish. Do you have any relevant study that links HPV-associated SCC with the prognosis aspect?

Good morning Najla.. We, at Nitte University, Mangalore have started a study on this aspect. The study is in preliminary stage, in the stage of diagnosis of HPV in Head-Neck Ca. Regarding prognosis, we may need more time to comment. During the process, I had gone through quite a number of studies, and my previous comments are based on them, not my own experience. Will definitely keep you updated whenever we get a conclusion... Thank you

All the best Vadish with your research. One of the contributers on this forum, Maha Al sened, is also working on a similar aspect in Iraq. It would be nice to see the results of both studies.

There is a recent interesting research from Australia (Koo et al, 2013) about this topic. The researchers point out to the increasing proportion of non-smoker non-drinker patients with oral cancer. among this population the male:female ratio is almost 1:1. They also believe that there are certain etiological and genetic differences between this group and the smoker group of oral cancer patients. This leads to a significantly worse disease-specific mortality. Although HPV is implicated, they believe that it may confer a worse prognosis in tumors of oral tongue.

I think That an oral cancer is a more logic finding in smokers than in non smokers patients, if these last develop an oral cancer this may mean that chromosomic aberrations are more important

This is a very good question, that we have debated many times in our department

Thank you Ahmad. I first thought that delayed diagnosis is the reason behind poor prognosis. I asked this question to know if there are other reasons. The article I pointed out to (Koo et al, 2013) supports genetic and other reasons that worsen the prognosis. Contrary to what I used to believe, if HPV is implicated in etiology, it worsens the prognosis! I think that researchers should focus on this type of oral cancer because its victims may increase with time.

But The role of HPV infection in oral oral cancer is steel debated. A systematic review published in the oral and maxillofacial clinic of north America ( 2011) by natarajan et al. sated that alcohol and tobacco steel the principal etiologic factor and that HPV is not an important factor

Thank you Jose. I appreciate your comments and don't be sorry as in muslim countries we have women who smoke and men who drink, so the risk factors for oscc still exist. The thing is that in Jordan like many Arabic countries many women smoke cigarettes but they deny because a smoker woman is still a social taboo. A new smoking epidemic that started approximately in mid 1990's is smoking narghile (waterpipe). This smoking method is not tabooed by society so women and girls of all ages are so into it.

Dear Ahmad there is some research going in many centers to elucidate the role of HPV in oscc. Stil if there is a role, it is believed that it worsens the prognosis as Koo et al (2013) suggested.

Dear Najla, The problem in studies on HPV is the definition of oral cavity, in fact, some researcher include the posterior part ( tonsil...) in the oral cavity. Other researchers consider this posterior part as a region in the neck. As we know the role of HPV in neck cancer is well established, but when including part of the neck in the oral cavity we can state that HPV is an etiological factor of oral cancer. But if we exclude this posterior region the role of HPV seems not to be fonded on solid evidences

Dear Ahmad, do you have any references to support your suggestion?

You can read the systematic review of natarajan et al. Published in the oral and maxillofacial clinic of north America, I think it's published in March 2011

OK thanks

It's published in the dental clinic not in oral and maxillofac clinic. I apologize

in males tobacco from smoking is the main etiology and hence once surgically removed has better prognosis. But females non tobacco cancer has other endocrinal parameters responsible for the disease parameter which makes the disease worse, hence poor prognosis

Thank you Raghavendra. Do you think that certain hormones may be implicated in oscc like some other types of cancer?

Dear Jose, I absolutely agree with you. I believe that smoking cannot be the only factor for developing H&N Ca. We seem to undermine the genetic and etioogical factors.

Dear Jose and Danuta; there are 2 points that I want to stress. The first is the location of cancer which is oral cancer or tongue cancer since it is different from H & N Ca. The second point is thetheory behind the influence of sex hormones; how can this type of hormones promote oral cancer? Is it the same mechanism as uterine, cervical, and ovarian cancer?

What a great elaboration from you Jose! Thank you for all the nice and relevant literature review, it is worth to be considered a valuable lecture. I am no expert in molecular biology, so I may take some time analysing the data you provided. The examples you mentioned are so true, but in relation to tongue cancer, I just need to know why now?? why do we encounter more oral cancer in females nowadays? or should I say: is there an increasing rate of oral cancer in females?? As far as Jordan is concerned, the types of cancer that are considered a national problem among women are colon and breast cancer. For me as an oral medicine specialist, it is important for me to do something to try and establish diagnosis as early as possible, because patients unfortunately may get lost between doctors of different specialties and all this will definitely worsen prognosis.

Me too

ive come in late..but have a very factual and relevant observation.

i have been seeing more cases of oral sq.cell ca in young females with no tobacco usage.

there seems to be a strong suspicion of the Human Papilloma Virus being involved.

most of these cases will give history of oral sexual practices.

we need to always think of the HPV virus, esp when tobacco is not being used by the patient at all.

it is a very interested information Jose i wish if you have the link to the article about PI3K pathway in patients with HPV-positive oropharyngeal carcinoma i will be grateful if you can send it to me

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thanks Jose for this intersting discussion

to me it not easy issue to be answered with certinity . most of the factors mentioned usally evident in both smoker and nonsmoker groups like EGFR or HPV...etc. if the age matter as we all note the worse prognosis in younger patient we may need to know more about the role of tolerase and propably cytochrome P450