Food and social background of Nasopharyngeal cancer patients in Jakarta

Food and Social

Background

of

Nasopharyngeal Cancer Patients in

Jakarta

Averdi Roezin

Abstrak

BerbaEai Jaktot Elah dibuktikan s.baqai _{wnJehab dan ttetlisp.sisi} tihbulhya

ka

_{iiona atofdrinE 6NF)} sepefli Vire Epstei, Batt ( EB _), dakahan, je^b kelanin. _Ecrctik , sosbl ekDno i, likgkugan.lan laia laih. ScIaM t0 bulaa dori Jonwti sahpai Oktobet 1996 di Bagiu THT FKUIRIiUPN Dt. Cipto Mangutkusuno lakrtta diddpatkan 81 kas6 batu katsbma MefatiaE .Lm dibandihS*'n .lenEan E 1 kasus buNnn katsinoM natujarihE yanE datanq berobat yats diahbil secara acdk dalatu waktu ydag sana. Penderita ldki laki lebih baryak dari \|dnita (61,201a : 3 5,6OEa) denEat unut rata-rata 45 tahun padd krlonpok KNF de 34,13 tahs pada kelotsrok han-KN F. Diszlid*i pula pendidikdn, penghasilan sebulm. berat ba.!an, aergi untuk tuen&dk sutuber air ninm, dan Lliddpatkan bahwd kelonpok KNF mmaw betusal dai _{Eolaryan berpaghasilan} tetut& Ditnukan pula bahwa secaft betuk@

ikan asih yahg dikonsumsi sehari hdti okh kelotupok KNF lebih banyak

diba

bskaa pada kelonpok non KNF, juEa kebbsam merokok

du

linskunsan JokE tloluti.f lebih banrak pdda petdetita KNF.

Many _factoB hare been prcr.n as the etinLoqicaL @d pre.lispottus _fadots oJ a6opharrngeat cdrcet sch

6

EB

viw,

diet,

sa

senetics, social economr, earironment and othea. Duting

10

oaths _fron Janrary to Ocnabet 1996 in the Depl hett

ol

OtorhinoldrynEalos, Medicdl Faculry, Unitercirt al hdonesi4 ve _found 8t ne|9 c6es oJ naephartttgedt cancet and coq,arcd rtem eith 8l cases aJ aoh NPC pdtiens in the sane tihe. Male patients vere norc _lrequeat than _feML (61.20Ea : 35.80%): the ayerage aee was 45 yedts in NPC aad J4.13 lears il flon NPC _{Etoup. Edacation,}

na

hl! inco e, bodr weiSht, eneryy _{Jot cookin|} Mr! eatet saurces wete studied. We

fomd

that the NPC patierts cahe _lrom a lower ia@me _8roup. The protninent e"ideace w6 that the cansunption oJ sabed _fsh as a ptut.in sa rce was hiEher ih the NPC .onpated to the ao, NpC gtoup G 3.3 3Ea and I 3.58%), and this dtlfercnc. was stuIisticaLu siBtiJiaat. Polutcd en'iroMeht ds weII as

wkins

habit

wrc

dl:o hisher in the NpC .ohpdted

b

Kelwo ls: salt.dfish, shokinI habit.

It's nearly definilive thal EB-virus (EBV) is rhe

eriol-ogy of nasopharyngeal cancer (NPC). But EBV is not

runnjng alonc: there aresome ext€mal factorsthatplay a role

in

the appearins

of

NPC. Those

factors

are genetics. age, sex, diet, geography, social economy. culture and habit, polution, infection and many others.

Environm€ntal polution is still thought by many. espc

cially in lay Inan. as a major cause of many forms

of

cancer. However. intcnsive research

in

the last 3 decades has shown that lbis concepr is incorrect. Life-style

ot

liiestyle-related behavior can promote and

cause the d€velopment

of

various cancer found in human. Thc etiological factors are ofren complex and need carelul analysis and evaluation.

In nasopharyngeal carcinoma, many authors had m€n,

tioned

EB

virus, genetics and diet

to

be the main

etiological factom. The enviromcntal factors and/or

diet factors can react with genetic malerial. such as DNA and should be rhe rmponanr one

in

causins

NPC,l

Ho2 first proposed that Chirese salted fish, apopular food

in

Southem China, especially favourcd by the

Cantonese. was apossible factor in the devclopm€nt

of

IJPC. This theory was based on rhe+acfthaHhehighcst incidence of NPC occurs in the fisher folk of Hong

Kong, whose di€t contains a high proponion ofsaltcd

fish

and

a

deficient intake

of

vitamin-rich fresh

vegelables and fruhs. In Indonesia, there was no siudy

lo prool thar salred ftsh (onsumprion, social economic

condition, culture and habit, and polution play a role

in rhe NPC. even lhough lndanesian pcople hav€ inre' mediate to high susceptibility to NPC.

De pafl h e n t oJ O ra r hin o I _{arynsolo I y,} F acul _ry.J M e dXine,

'wl

250 _{Me.! J Indones}

Table 1- Age distribunon ofNPC and non-NPC patients (N = 8l)

Therefore, during I 0 months, from January to October

1996

in

the Department

of

Otorhinolaryngology. Medical Faculty, Universjty of Indonesia we studicd 81 new cases of NPC and comparcd thcm to anolher

81 patients of non NPC. This study was focuscd on

food and social background ofthe NPC and non NPC

METHODS

This study was hcld

in

thc Dcparhenl of Otorbino

Iaryngology,

Medical

Faculty.

Univcrsity

of

In

donesia.IDr. Cipto Mangunkusumo Hospilal. Jakarta,

bctween January

I

to October 31, 1996. During that

time were found 81 new cases of nasopharyngeal can-cer-

which

consist of 52 males and 29 females. The diagnosis was based on the anamnesis, clinical ex-amination, radiological examination - CTScan, biopsy

and histopathological finding of nasopharyngeal

can-cer. The control group ofnon NPC patienls wcr€ also

consist

of

52 males and 29 females suffeing from

various diseases and normal one. The conlrol group

cases werc taken randomized on the samc day after each caseofNPC was diagnosed. The criteriato be the

control group were an adult patient and has the same sex with the NPC paiient. The exclusion ofNPC was

colftrmcd by

rhe anamnesis. clinical e\amin0rion. conventional radiological €xamination. biopsy and

bjstopathological examination

if

suspiciously there was atumor

a d

demonstrable signs and symptoms

of

nasopharyngeal cancer. In thi s control group included

any kinds of diseases

of

ihe ear, nose and throat and

neoplasms

of

the

ear,

nose and throat, except

nasopharyngeal cancer.In both groups food and social background were studied including age, sex,

occupa-!ion, education, monthly income, body weight. main food, protein soDrces, other supplemen t lood, smoking babit, energy for cooking, drinking water sources and

housing.

RESULTS

Sex

Bolh groups

of

8l

cases each, consist

of

52 rnalcs

(64.20qa) and 29 females (35 .80ok).

Non'NPC % (N) NPC q, 0',1)

20 -29

30

39 40-49 50-59

60

69

SD

2.4',7 \2) 9.88 (8) 25.92 (2t) 25.92 <21) 19.75 ( l6)

16.06

(l])

112.81

9.88 (8) 38.29 (31) 23.47 (19) 12.35 (t 0) 8.64 (7) 2.47 12)

4.94 (4)

11346

Staging and type of disease

In the NPC group, most ofthe cases were in advanced stage, stagel was nil, stage II two cases or 2.477a, stage

In

17.287o (l4cases) and stage lV 65 cases or 80.25%.

All

of

tbe

cases were undifferentiated

type

of

squamous cell

carcinoma-Various diseases were found in the control group such

Chronic supp. otitis media

Allergic rhinitis

Chronic tonsilitis

Laryngeal tumor

No abnormality detccted Chronic pharyngitis Ceruminal plug Tonsil tumor

Tongue tumor

Submandibular abscess Nasal polyps

Laryngitis

Hypophysis tumor

Tubal oclussion Vasomotor rbinitis

Septal dcflectior

Total t'7

l4

1l 5 3 9 6 5 I 1 l 1 1 l 2 2 I 81 (20.99Eo) (t7.28Eo) ( 13.58eo)

(

6.1'7Co)

(

3.'7OCo)

( 1 r.1 170) '7.4tCo) 6.17Co) t.23Co) |.23Eo) 1.23Eo) 1.23Eo) 1.23Eo) 1.23Eo) 2.41Eo) 2.47co) 1.23Co) Age

In NPC paticnts the age was ranging from 20 lo 64 years and the mean was,15 ycars;

in

the conlrol group

the

age was ranging fronl

i8

to 84 yeals and the moaD was 34.1:l years (Table

l).

Educal:c:r

In

the

NPC group iliteracy cases were

5

(6.17,/.). Primary School 29 (35.807,), Secondary High School

l7

(20.997.), _{High School21} (25.92E

)

and Univcr

siiy

graduates

9

(11.12Ea).

In

_the conlrol group, ili|€racy \N _{erc 2 (2.41 %), Primary School 9} ( I l. I I o/,), [image:2.596.317.552.114.249.2]

Table 2. Education of rhe rwo groDps N = 8 I

Monthly inrome

Most

of

the cases in NPC and

control

group had

monthly income between USD 50 to 150; in the NPC grcup there were 42 cases (58.037d), and

in

the con

trol sroup there were

3l

cases (38.287a) (Table 3).

Table 3. Monthly incohe olftetwo sroups N= 8l

with 42.21% in the NPC group and this difference was

statislically not significant _{(P =} 0.1098).

There are 4 kinds of protein sources taken by most Indonesian

in

their meals. Meat (beef, mutton, pork

and fresh fish),

taofu

or soya bean cu.d, soya bean cake and saltcd fish. Th€ lastthree were earen in daily

meal of most low income people in Indonesia.

In the NPC group meat, taofu, soya bean cake, and salted fish was taken

by

45.69Vo, 95.O67o, a2;72Vo

and

33.3370 of patients respectivcly at least twic€ a week in their menu. In the oth€r _$oup, meat, taofu, soya bean cake was takcn by 6'7.90Eo, 24.O'7qo and ?1-6070

of

patients rcspectively, butsalted fish was rdken by

only

I I 58d. of the cases (Table 4).

Tablc 4. Protcin sour@s in botb group _{of patients}

(N-

81) NPC %

0!)

Non NPC % (N)

Secondary High School High School

6.11 (5) 35.80 (29) 20.99 (t7) 25.92 t2t )

t1.t2(9)

2.41 12) r l.r l (9) 16.05 _{13)

43.21{r5) t7.16122)

Income LUSD) NPC 70

(N)

Non NPC % (N) 0

50

150

> 250

Salted fish*

45.68 (37) 95.06 (77) 82.72 (6t) 3333

(n)

67.90 (55) 74.07 (60) 71.60 (58) 13.58(11) 4.94 (4)

r3.58 (11) 58.03 (47) 17.28 (14) 6.17 (5) 120.78

12.34

(0)

17.28 (t4) 18.28 (3 r)

14.42lt2) 17.28 (t4) 135.21

+ 80:12

Body weisht

Most

of

the NPC group paticnts have body weight below normal (58.027o), while tbe percentage of nor-mal and above normal body weishi was 20,99% and 20.99% respectivcly. Normal body weight ₌ 90% (H - 100) _{kg (H =} height in cenlimeter).

In non NPC group, cascs having below normal. nor mal and above normdl body weight were 50-627r,

l1

1]e, and

Io.oso;

respe,'rvrly. There

wi.

no.ig,

nificant difierence

of

body weight ligures between

both groups (P ₌ 0.0217).

Food

Ricerras themain stapleinboth grorps as wcll as most

of Indonesian pcople.

All

of the NPC group ate rice two or three times aday (1007,) and only one (1.237.) in the non-NPC group are srgo rs mJrn rood

Additional food

Vcgetables an d fru irs are eaten hy '14 _{.01Eo alrd 62.96q.}

of the NPC group, and hy 16.54E, aDd 59.26Ea in the

nor NPC group respcclivcly. However, only 21.161L drank milk every day in the non-NPC group conpared

NPC%(N)

Non-NPC % (N)

*

'flre salred fishjntakeas a prctein source was statislically significdtly diffe.ent between the two groups (P<0.005).

Smoking habit

There were smokers in both groups; 49.38% in NPC

group and only 32.107a in non-NPC group,

but

this

difference was statistically not significant _iOR= 2.06,

P ₌ 0.0251).

Sources of energy

Most of subjects used kerosen€ as the main source

of

cnergy for cooking (Table 5). Table 5. Energy for cooking (N ₌ 81)

NPC %

(N)

Non NPC % (N)

Gas (l.PG)

18.52 (r5) 65.4r (53) 13.58 _{l l) 2.47 _\2)

[image:3.596.45.280.107.195.2] [image:3.596.44.280.309.416.2] [image:3.596.308.538.343.419.2]

252

Ground

water

was the main watcr source

in

most subjects: 70.107"

of

the NPC, and 62.9090

of

lhe

non-NPC group used ground

water.

Clean water

facilities was uscd by 28.4070 of thc NPC and 37.049,

of

the non-NPC gro p. Water deposii collectcd from rain

fall

was used by one palient

of

the NPC group (1.24.7a).

The difference betw€en ground water and clean wxter

facilities Dsed by lhe lwo groups was not slatistically significant (P = 0,1501).

Housing

Most of the subjects lived with their family in a small house, usually out of the city (Table 6).

Table 6. Housirg size of bolh Sroup of parients

Med J Indones

to fifth decadeoflife, andthis is in agreement $/ith this

srudy. However, NPC parienrs $cre aiso found rt

e\tremes oI uge such as 7 to 80 years old "

Almosl all of the NPC cascs came on the late stage, 97.53% came to the hospital in the stage

Itr

and W.

This is the typical figur€

of

NPC patients in Jakarta,

where we found the same figure

in

1988 1992. i.e. stase

I

0.90qo, stage 112.94E . stage

III

18.78% and stase

M7.38Eo,

or 96.167, were at stase

I

and IV

froin the 442 patients.5

Roezin et al6

in

1989 also had the same figure

tion

90

NPC patients.

i.e.

3.'75Ea stage

I,

1.257o stage

l\,

13.337, stage LII and 82.23Ea stage

IV,

or 95.56dl, were at stagc

III

and IV.

Most

of

thc cases

in

the NPC group were Primary

School graduates, but in the non NPC group most

of

them were High School graduates- There were more

University graduates in the non-NPC than intheNPC

groDp. As a

whole,

the non-NPC group was more educared than Ihe

\Pc

group. Th€ monlhly income

revealed that the NPC patients came from the Iower income people compared to the non_NPC patients.

Norrnal

and below normal body weight in the two groups showcd nearly the same figure; 79.01 inthe

NPC and 83.957, in non-NPC group.

Almosr all

oflh€.ubjerls

rn Ihe

l\

o grouts ate rice every day as well as most of Indonesian people, only

one rn lhe non NPC group ale sago as lhe main

(dr-bohydrate source. In some people in east part of In-donesiasagois the main carbohydrate source and some other people in lbat region took com as the main food.

ln Jakarta, the meat price is much higher

(t

8

tinet

than taofu and soya bean cake, and the price

of

salted

fish

is

about 807o

of

meat prico.

In

this study the

.ubjecls com.umed sahcd fish only 50 Lo 75 gram. rn each meal because they ate much more rice than salted

fish.

In thl3 NPC group they ate meat less in frequency and quantily compared tothe ncn NPCgroup(45.68% and

67.9070); in g€ncral, this showed that thc NPC group came from Iower €conomic class comparcd to the non NPC group. However, they ate more satted fish than

the non-NPC group (33.33% and 13.587,),1nd this

diflerence

is

statistically significant supposing lhe

role ofsaltcd 6sh in predisposing NPC in this study

The consumption ofsalted fish in Indonesian was very much diffcrent than people in China or Hong Kong.In

Non - NPC (eo)

20 ,29

30,39 40-49

50

59

60-69

7A -19 80-89

90

99 > 100 SD

3.70 (3i

6. r7 (5) 9.88 (8) 8 64 (?) 8.64 (7) 2.47 \2)

16.0s (13) 4.94 (4) 4.94 (4) 34.57 (28) +27 70

8.64{7) 13.58 ₀₁₎

6. r7 (5) 7.4t 16) 8.64 ('1)

3.70(l)

t7.28 (t4) 2.46 (2) r.70 (3) 29.58 (21) 63.?0mz J 31.?6 The house s rizeotthe two g.ouPs wds not stalistically

significmt (P _{= 0.1109).}

Combined factors

The combinalion ofall factors above showed lhat sex. age. body weight. salted fish consumption, smoking

habit, sources ofcnergy (wood and kcrosene). water sources and housing. in logistic regression test had an

ORof2lS

DISCUSSION

Sex ratio between male and female in this study was 1.8 :

l.

I1's a bit djfferent with the figure nentioned by Shanmugaratnam who sludied the epidemiology

of

NPC (2-3 :

l).r

Thc hrlhe r rncrdence ol NPC r. in lhe 4 h ,lr' _"d"

"

hlc

)

NPC.c, ur.d mo.r lrcqurnrly drou'rJ rhc l.urrh [image:4.596.56.291.334.498.2]

Cbina or Hongkong, they are a lot of salled fish in cach meal, every day for years sinc€ the weaning. A case control study in Hong Kong on cases under 35 years of age found a positive association

of

NPC

with

the

conrumplion ol srlled fi\h ar any lirne. bul lhi\

ds\ocia-tion was particularly strong for the consumplion during childhood. There was a relaiive increase in

risk

of neariy 40 fold for the consumption of saited fish once

or more rime\ a week ar agc

ot

10. rn cnmparison ro rare consumpnon.' somc crfer rmenral

:unpfl

lor rhis

association

was

provided

by

the study

of

Yu

and Henderson

in

which rats f€d salted fish developed

tumors in lhc nasal cavity.8

Vegetables and frDits were consumed by both groups

wirh

abou'

Inc samc pcr(cnrage. Hnwever.

it wr'

much

different

in

drinking rnilk which percentage was higher in the NPC group becausethey believe that

nilk

could increase their body resistance against

cdn-There was difference between smoking habji

in

thc NPC group (49.38%) comparedto thenonNPC group

(32.107.). Even it's not sradstically sigrificanl, but

lhe O.R. showed thatthe smokers have 2 timcs highcr

risk

lt)

have nasopharyngeal cancer than the non

Wood andkcrosene wereusedmorc frequent as energy source in the NPC comparcd with the non-NPC group,

though those figures are statistically not significant. Both energy sources give more

polutior and

are

usuaily used by lower income group. In the non-NPC group they used

more

gas and electricity as energy sources compared to the NPC group. As a whole the

NPC group lived in more poluied environment than

non NPC group.

Ground watcr are used by mosi of IndoDesian people as water sourcc for drink and olher nccessity. But

some people in big city used water from clean water

lacilities provided by the goverment.

Ground water wcrc morc uscd by thc NPC (70.107.) compared to 62.909,

in

Don NPC sroup, bu1 water

supply by govemmcnl wcrc used more in non NPC (3'7.049a) than

in

NPC _sroup (28.4070). Thc clcan

waterfascil;1ies by govclncnt arcDot found iD allparts

ofJakarta.

but

thc ijgures showcd lhat rhc non NPC g.oup was morc wcalthy !haD NPC group.

Hn

r:i

.r/.

r\ Jr.c

Jl

rl,J p.rJmcrer

"l

he

'lrl.\

l 1

rcir.

l.uu.e .r,,e in

NP.

wr'

/

4R

L

.^r1

,.(d

r.

63.70

n2 in

non-NPC group. EvDnthough

il

s

not

statistically significant, il showed that the NPC group

had larger house than the non-NPC group.

Thecombined factors i.e. age, sex, body weight,

smok-ing habit, salled fish consumption, souces of energy (wood and kerosene), water sources and housins

showed that the NPC group had 2.18 times the

risklo

have nasopharyngeal caJcjnoma tban non NPC group. The other factor that was never proved before as an important risk factor

ofNPC

in Indonesiawas salted fish. However, thjs study revealed that salted fish

played a role in increasing the risk ofNPC.

CONCLUSION

Male is more frequent to have nasopharyngeal cancor than female and the age average ofNPC patients was

45 years (between 40 to 50 years). Most of the NPC pilienls (ame lrom lower income srarus, I've rn more

poluted cnvironment caused

by

smoking habit and energy sourc€ in daily used; as a whole tbe quality

of

life

was less wealthy compared

to

the non-NPC

patients.

Males in the 4th decadeoflife who atesalted fish more

than twjce a week, had a smoking habitand with alow social economic condition had 2.18 times the

pos-sibility

to

have nasopharyngeal cancer than other pcoplc with better social economic and do not have salted fish in tbeir meal.

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1.

WeisblrserJH, HornCL. Tne Causes ol Cdcer. tn:Holleb

AI, Fink DB. Murahy cP, Edito6. Clinical Oncolosy Ar flican Cr!er Soc er) Arlanrdl40z.P4-lt,F

2.

Ho JC. An Epidcmiologic and Clinical Study

ol

Nrsopharyngcal Carcinona. In: Vad Ha$eit CA, Gibb AC,

editos. Nasopharyngeal Carcinoma. Hong Kong: The Chinese Unive6ity P.es, l99l123-4.

r.

Sh"rnuCarrrnam

I

Na\ophdryngrdt

.d

, inomd Epidcmiology and Aetiology. Pro.eedings or Nasopharyn

gedl Cdcer Seninar I 988, April 16; Semarang. Sendang: FK IINDIP 1988:1-15

.!.

Roezin A. Managcmcnt of NPC in In.lonesia. Asim J of

Su.gery l99.li l6(4):274'9.

'

\

''.l _{lr.o D.}

tl

./rn

A

RrJ\i N \dopharyngeal _' drL rnom"

in Cipt{r Mangunkusuno Gcneral HosPital, Jakdta, ln ilonesia. AbsLncl

ol

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{

I

:

I 7.

8.

Yu MC, Ho JHC, Lar SH, Hqderson BE. Cantonese stvle salted fish as a cause of NPC: Report of a ca5e control shrdv

ir Hong Kong. Cmce. Res 1986:46:956_61

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as a caNe ofNPC. tn : Tomatis L. Aitio A, Dav NE, Heseltine

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