Article

Translational Research in Oral Oncology

1–9
Oral cancer in South East Asia: ª The Author(s) 2017
Reprints and permission:

Current status and future directions sagepub.co.uk/journalsPermissions.nav

DOI: 10.1177/2057178X17702921
journals.sagepub.com/home/too

Sok Ching Cheong1,2, Patravoot Vatanasapt3,4, Yang Yi-Hsin5,

Rosnah B Zain2,6, Alexander Ross Kerr7 and Newell W Johnson8

Abstract
Objectives: To document the burden of oral cancer in South East Asia (SEA) and to examine the gaps in acquiring accurate data
within these countries.
Methods: Epidemiological data on oral cancer from countries in SEA were obtained and reviewed from public population-based
databases. Descriptions on the incidence and mortality of oral cancer were based on data obtained from GLOBOCAN 2012, and
prediction of the number of cases and deaths due to oral cancer were also taken from the same database. The availability of and
accessibility to population-based cancer registry were also documented.
Results: Five of the eleven countries in SEA have national cancer registries, but the reporting periods varied from 2002 to 2014
across these countries. Whilst incidence and mortality data were obtainable for all SEA countries from GLOBOCAN 2012, data
quality varied substantially across the countries. Estimated incidences of oral cancer ranged from 1.6 to 8.6/100,000 per annum
with similar rates in males and females for most countries. The incidence was the highest in Myanmar and Brunei for males and
females, respectively. Mortality due to oral cancer was reported to be 0.4 to 5.3/100,000, with the highest mortality in Myanmar
and Timor-Leste among males and females, respectively. Based on the predicted number of cases and deaths for 2020, oral cancer
incidence and mortality is expected to increase and the trends are similar between males and females, which is not surprising as
with population growth, the disease burden will rise further.
Conclusion: This study demonstrates a severe lack of accurate epidemiological data on oral cancer and underscores the urgent
need to develop expertise within this region that can address this issue. While there is a clear need for improved primary
prevention, for increased skilled workforce and for improved diagnostic and treatment facilities, an essential first step is to
establish robust cancer registries so that progress or lack thereof can be monitored accurately, and appropriate action planned.

Keywords
Oral cancer, epidemiology, South East Asia, ASEAN, cancer incidence, cancer death

Date received: 03 January, 2017; accepted: 09 February, 2017

1
Head and Neck Cancer Research Team, Cancer Research Malaysia, Subang Jaya, Malaysia
2
Department of Oral & Maxillofacial Clinical Sciences, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia
3
Department of Otorhinolaryngology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
4
Cancer Unit, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
5
Statistical Analysis Laboratory, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
6
Oral Cancer Research and Co-ordinating Centre (OCRCC), Faculty of Dentistry, University of Malaya, Subang Jaya, Malaysia
7
Department of Oral and Maxillofacial Pathology, Radiology and Medicine, New York University College of Dentistry, New York, NY, USA
8
Menzies Health Institute Queensland and School of Dentistry and Oral Health, Griffith University, Queensland, Australia

Corresponding author:
Sok Ching Cheong, Cancer Research Malaysia, No. 1, Jalan SS12/1A, 47500 Subang Jaya, Selangor, Malaysia.
Email: sokching.cheong@cancerresearch.my

Creative Commons CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 3.0 License
(http://www.creativecommons.org/licenses/by-nc/3.0/) which permits non-commercial use, reproduction and distribution of the work without further
permission provided the original work is attributed as specified on the SAGE and Open Access pages (http://www.uk.sagepub.com/aboutus/openaccess.htm).
2 Translational Research in Oral Oncology

Figure 1. Sub-regions within Asia as defined by the United Nation. Countries highlighted in blue are those included within South East Asia.

Table 1. Status of cancer registries in countries in SEA.

GLOBOCAN data
National cancer registries source1 CI5: Vol 92 CI5: Vol 103

Active cancer Data Last accessible Last reported

Countries registry4 online report period Use of ICD 10 Incidencea Mortalityb Data availability Data availability

Brunei Yes No Not known Not known Not known F 5 NA NA

Cambodia No NA NA NA NA G 6 NA NA
Indonesia Yes No Not known Not known Not known F 6 NA NA
Lao PDR No NA NA NA NA G 6 NA NA
Malaysia Yes Yes 2007 2007 Yes C 2 Yes Yes
Myanmar No NA NA NA NA G 6 NA NA
Philippines Yes Yes 2008 1998–2002 Yes B 2 Yes Yes
Singapore Yes Yes 2015 2010–2014 Yes A 1 Yes Yes
Thailand Yes Yes 2015 2010–2012 Yes B 3 Yes Yes
Timor-Leste No NA NA NA NA G 6 NA NA
Vietnam Yes No Not known Not known Not known E 4 NA NA

NA: not available; not known: data is not accessible.

a
Incidence data source: A. High quality  national data or high-quality regional (coverage greater than 50%); B. High quality  regional (coverage between 10% and
50%); C. High quality  regional (coverage lower than 10%); D. National data (rates); E. Regional data (rates); F. Frequency data; G. No data.
b
Mortality data source: National statistics are collated and made available by the WHO for countries with vital registration. 1, High quality  complete vital
registration; 2, medium quality  complete vital registration; 3, low quality  complete vital registration; 4, incomplete or sample vital registration; 5, other
sources (cancer registries, verbal autopsy surveys, etc.); 6, no data.

Introduction defined by United Nations; Figure 1 and Table 1) where the

incidence of oral cancer has been regarded as disturbingly
Globally, oral cancers (ICD, 10th edition C00-08) accounted
high for many years. 5 Globally, while oral cancer is
for 300,373 new cancer cases and 145,353 cancer deaths in
predominantly diagnosed among males, it can be as common
2012.1 More than half of oral cancers in the world occur
or even more common in females than in males, in many SEA
in Asia where an estimated 168,850 new cases were diagnosed
populations.1,6 The mortality to incidence ratio in SEA is
in this geographical region alone. Of these, approximately 11%
among the highest in Asia,7,8 and in 2012, the mortality due
were from South East Asia (SEA; comprising 11 countries as
to oral cancer in SEA has been estimated as 8508 cases, where
Cheong et al 3

Table 2. Oral cancer incidence and mortality in SEA countries in 2012.

Incidence Mortality

Male Female Both sexes Male Female Both sexes

Population Numbers ASR (W) Numbers ASR (W) Numbers ASR (W) Numbers ASR (W) Numbers ASR (W) Numbers ASR (W)

Lao PDR 49 2.5 91 4.2 140 3.5 26 1.4 48 2.3 74 1.9

Indonesia 3002 2.8 2327 1.9 5329 2.3 1263 1.2 987 0.8 2250 1.0
Malaysia 413 3.3 363 2.8 776 3.0 156 1.2 97 0.8 253 1.0
Vietnam 1392 3.3 755 1.6 2147 2.4 632 1.5 339 0.7 971 1.1
Singapore 125 3.4 65 1.7 190 2.5 41 1.1 17 0.4 58 0.7
Philippines 1258 4.1 1105 3.2 2363 3.6 527 1.9 451 1.4 978 1.6
Brunei 9 4.5 9 9.0 18 6.0 2 1.1 2 2.0 4 1.4
Thailand 2158 5.1 1551 3.0 3709 4.0 1114 2.6 799 1.6 1913 2.1
Timor-Leste 21 5.9 19 5.3 40 5.6 12 3.8 11 3.4 23 3.6
Cambodia 280 7.1 304 5.2 584 3.8 151 4.1 165 2.9 316 3.4
Myanmar 1810 8.6 965 4.1 2775 6.2 1090 5.3 578 2.5 1668 3.8
Total 10517 7554 18071 5014 3494 8508
SEA: South East Asia; ASR: age-standard rate.

5014 and 3494 were men and women, respectively (Table 2)1;
however, because cause-specific recording of mortality is
poor in most countries in SEA, the numbers here are likely
under-reported.
Globally, the most common risk habit associated with oral
cancer is the use of tobacco, both smoked and smokeless, the
latter often in combination with areca nut in numerous forms.
Demographics and health surveys report that tobacco use in all
countries of SEA exceeded 50% among men aged 15–49,9 and
some of these countries, notably Indonesia and Timor-Leste,
are among those with the highest smoking rates among males in
the world, where more than 70% of men smoke (72.3% and
96.5%, respectively).10,11 Among the populations within the
SEA region, the use of smokeless tobacco is very high, where,
for example, in Myanmar, more than 50% of the male popula-
tion indulge.12 In contrast to smoking, where rates remain
relatively low among women in SEA, the highest use of
smokeless tobacco among women globally is in South and
SEA.11,13 In South and SEA, smokeless tobacco is often used
as one of the ingredients of betel quid, a mixture of sub-
stances that contain areca nut (the fourth most consumed
psychoactive substance in the world), slaked lime and other
condiments.14 The chewing of betel quid is practised by more
than 600 million people (approximately 10% of the world’s
population), many of whom reside in the geographical areas
of South and SEA.15,16 Wrapped in a betel leaf, the betel quid
is often kept in contact with the oral mucosa for extended
periods, even overnight.17 As areca nut itself is a carcinogen,18
the use of betel quid with or without smokeless tobacco is
highly associated with oral potentially malignant disorders and
oral cancer of the population in this region.19,20 In a recent
prevalence study in Cambodia, 19.7% of women were found
to indulge in betel quid chewing and this was the strongest risk
factor associated with oral potentially malignant disorders with
a relative risk of 6.7.21
There are huge disparities in the percentage of population
covered by population-based registries between high- and low-
income countries. While a large proportion of the population
is covered by population-based cancer registries in Europe
(42%), Oceania (78%) and North America (95%), only about
6% of the entire Asian population is covered.1,2 Therefore,
the true burden of oral cancer in this region is unknown and
almost certainly significantly underestimated, and in SEA
countries, many lack efficient methods of storing and disse-
minating information that are necessary to understand pat-
terns in incidence and mortality associated with this
disease. Therefore, the aim of this study was to document
the burden of oral cancer in SEA through the review of cur-
rent available data and to examine the gaps in acquiring
accurate data within these countries. In addition, we discuss
the challenges that are associated with the management of
oral cancer and discuss possible collective approaches that
will be important for countries within this region to take
forward, in order to progress towards improving oral cancer
prevention, management and survival.
Materials and methods
Epidemiological data on oral cancer from countries in SEA
were obtained and reviewed from several sources including the
population-based data from the public databases of Cancer
Incidence in Five Continents (CI5 Vols IX and X)2,3 and GLO-
BOCAN 2012 (http://globocan.iarc.fr/).1 Further, data from
cancer registries were reviewed for the individual countries
where available, and for countries where the data are not acces-
sible, the authors contacted head and neck cancer surgeons in
the respective countries where possible, to determine the avail-
ability of data. Having reviewed these, data from GLOBOCAN
2012 were found to be the most comprehensive; therefore,
detailed descriptions of the incidence and mortality due to oral
4 Translational Research in Oral Oncology

cancer in SEA are derived therefrom. Age-standard rates

(ASR) against the world standard population were used.
Furthermore, prediction of the number of cases and deaths due
to oral cancer was also obtained from GLOBOCAN 2012.

Results
Of the 11 countries within the SEA region, Singapore, Thai-
land, Philippines, Vietnam and Malaysia are the only coun-
tries that have population-based cancer registries. Reports
from Singapore and Thailand’s registries were the most up-
to-date with the last report dated 2015, with reporting periods
till 2014 and 2012, respectively.22,23 The most recent reports
for Malaysia and the Philippines were in 2011 and 2008, with
reporting periods up to 2007 and 2002, respectively.24,25 Data
on Vietnam were not accessible and, therefore, the last report-
ing period is not known. Looking at data on oral cancer spe-
cifically, these data were available from the Thailand,
Philippines and Malaysia registries in the last reporting peri-
ods, the latest data for Singapore were not available and data
on oral cancer were last reported for 2003–2007 (Table 1). As
the majority of the SEA countries do not have national regis-
tries and only a minority contributed data to the CI5 Vols IX
and X (Table 1), we relied on data from GLOBOCAN 2012
which appeared to be the most comprehensive for all coun-
tries within SEA.1
Data quality in GLOBOCAN 2012 varied substantially
across the different SEA countries with Singapore, Thailand
and the Philippines having high-quality national or regional
coverage of more than 10% (Table 1). Notably, while we look
at the incidence of oral cancer across the world, three of the
SEA countries were among the top 20 countries with the
highest incidence of oral cancer, including Myanmar, Brunei
and Cambodia for both genders. Among females, Brunei,
Timor-Leste, Cambodia, Lao PDR and Myanmar were the
countries with the highest incidence of oral cancer (Figure 2)
with ASRs of up to 9.0/100,000. Focusing on the data for
SEA countries more closely, 10,517 males and 7554 females
were diagnosed with oral cancer in SEA per year, with a
male-to-female ratio of 1.4:1. There is a marked variation
in the ASR across the different countries in SEA ranging
from 2.5 to 8.6/100,000 per annum for males, with Myanmar
having the highest incidence; and 1.6–9.0/100,000 per
annum for females, with Brunei being the highest (Table 2
and Figure 3). While in most countries oral cancer is more
commonly diagnosed among males, there appears to be a
predilection towards females in Brunei and Lao PDR, with
ASR almost doubling that of males (Figure 3). Based on the
estimated deaths due to oral cancer, a wide range is observed
across the different countries in SEA. Among males, the
mortality rates were 1.1–5.3/100,000 per annum, with Myan- Figure 2. Incidence and mortality of oral cancer across the world
for males (a), females (b) and overall (c). Several SEA countries
mar having the highest rates. Among females, the ASR were
were among the top 20 countries with the highest incidence of
0.4–3.4/100,000 per annum, with Timor-Leste having the oral cancer (*).
highest mortality rates. Consistent with the higher incidence
Cheong et al 5

% Increase
(a)

75.0
74.7
22.8
25.7
32.8
31.2
34.9
37.9
23.3
4.3
31.8
10
Male Female

Both sexes
8
ASR/100,000

2020

7
552
2764
93
336
2189
1319
80
2359
24
1280
4
2

2012

4
316
2250
74
253
1668
978
58
1913
23
971
0

% Increase

150.0
70.3
21.1
25.0
40.2
35.6
37.5
35.3
22.8
0.0
38.3
(b)

Mortality

Female
10
Male Female

2020

5
281
1195
60
136
784
620
23
981
11
469
8
ASR/100,000

2012
4

2
165
987
48
97
578
451
17
799
11
339
2

% Increase
0

0.0
79.5
24.2
26.9
28.2
28.9
32.6
39.0
23.7
8.3
28.3
Male

2020

2
271
1569
33
200
1405
699
57
1378
13
811
Figure 3. Incidence (a) and mortality (b) of oral cancer across the
countries in SEA in males and females.

2012

2
151
1263
26
156
1090
527
41
1114
12
632
in Brunei and Lao PDR among females, the mortality rates

% Increase
due to oral cancer were also higher among females in these

83.3
63.9
21.5
24.3
31.1
30.1
32.8
34.7
23.6
0.0
28.4
countries compared to males (Table 2 and Figure 3).
Both sexes

We also examined the predicted incidence and mortality

trends in GLOBOCAN 2012 for 2020. Comparing the inci-
2020

33
957
6473
174
1017
3611
3137
256
4586
40
2757
dence and mortality projected in 2020 to those reported in
2012, the data suggest that oral cancer incidence would con-
tinue to rise in every one of the SEA countries, with increases
18

40
2012

584
5329
140
776
2775
2363
190
3709

2147
Table 3. Projected oral cancer incidence and mortality in SEA countries.

of up to 83.3% and 63.9% by 2020 in Brunei and Cambodia,

respectively (Table 3). Consistently, the mortality rates are also
% Increase

predicted to increase in all SEA countries, again with Brunei

155.6
60.5
19.3
25.3
36.6
34.0
35.0
33.8
23.9
0.0
33.4
and Cambodia predicted to have the steepest increase of up to
Incidence

75.0%. These trends are consistent across both sexes with sim-
Female

ilar rates of increase (Table 3).

2020

23
488
2775
114
496
1293
1492
87
1921
19
1007

Discussion
2012

9
304
2327
91
363
965
1105
65
1551
19
755

This study examined the status of cancer registries, the inci-

dence and mortality due to oral cancer in countries within SEA,
% Increase

with the aim to provide evidence that there is an urgent need to

11.1
67.5
23.2
22.4
26.2
28.1
30.8
35.2
23.5
0.0
25.7

prioritize resources to put in place structured programs that

would benefit the region to reduce oral cancer burden here.
Male

While this report discusses the extent of the oral cancer burden
10

60

21
2020

469
3698

521
2318
1645
169
2665

1750

in SEA, the main limitation is the lack of systematic documen-

tation of the disease, where most of the countries in SEA do not
9
280

49
413

125

21
2012

3002

1810
1258

2158

1392

have an official cancer registry.4 While the data were available

for all SEA countries from GLOBOCAN 2012, many were
Timor-Leste

either obtained from regional registries or estimated from rates

Philippines
Cambodia

Singapore
Indonesia

Myanmar
Lao PDR

of neighbouring countries and, therefore, may not be entirely

Thailand

Vietnam
Malaysia
Brunei

representative of the respective countries. This is perhaps not

surprising as only 2% of Asia’s population is covered by
6 Translational Research in Oral Oncology
population-based registries and, subsequently, coverage in
GLOBCAN for Asia is sparse.1 This is not to say that epide-
miological studies are not conducted in SEA countries: in fact,
in many of the countries, regional or hospital-based cancer
registries exist,26–28 while for other countries such as Lao PDR,
wider data collection has recently been initiated (see below). It
is evident that data collection in many of the SEA countries is
very much driven by a bottom-up approach and largely
supported through external regional and/or international
collaborations. 29–31 Without the presence of robust
population-based cancer registries, data on the mortality due
to cancer are also difficult to ascertain. Furthermore, many
SEA countries do not have comprehensive death registration
systems and even when such a system exists, the quality of the
cause of death information is very often poor.7 Political con-
flicts, internally displaced persons and struggles with weak
economies compound the challenges in data collection. Devel-
opment of robust population-based registries will require
strong support from governments as this relies heavily on
strong networks with flow of accurate information among pub-
lic and private healthcare service units, registries of births and
deaths, and population census data. While cancer registries in
lower resource settings may find it difficult to match the strict
criteria of a quality data set for inclusion into international
databases such as CI5, population-based registries are critical
to cancer control and therefore should remain a priority. Recog-
nizing the critical need for regional and national support, the
International Agency for Research on Cancer (IARC) has
developed regional hubs through the Global Initiative for
Cancer Registry Development to empower low- and middle-
income countries to produce high-quality information on the
burden of cancer through educational support and collabora-
tive research. In 2011, a hub for Asia was launched in the Tata
Memorial Hospital in Mumbai, India. While it is currently
unclear how and whether or not this initiative will impact coun-
tries in SEA, one approach by which SEA countries can improve
the state of cancer registries is through regional collaborations.
Meetings to set up an Asian Network on Cancer Registries were
held in Korea in 2008 and Thailand in 2009 with objectives to
include training for standardization of records, networking, plan-
ning and execution of collaborative research and evaluation of
cancer control and treatment outcomes. Encouragingly, the
National Cancer Institute of Thailand have collaborated with the
International Agency for Cancer Registries (IACR) to help the
Association of South East Asian Nations (ASEAN) countries,
including Lao PDR, Myanmar, Cambodia, Malaysia and Indo-
nesia, to provide training that will enhance their capacity to
develop or strengthen their population-based cancer registries.
Notably, this collaborative effort has led to the initiative to doc-
ument oral cancer cases in Lao PDR (Patravoot Vatanasapt,
personal communication, 18 October 2016), but more efforts
in regional and global support should be strongly encouraged
and systematically facilitated.
Decreasing trends of oral cancer have been reported in
Singapore, Thailand and Philippines, while32–34 from GLOBO-
CAN 2012, it appears that both incidence and mortality of oral
cancer will continue to increase. The data from the cancer
registry from Khon Kaen, Thailand, also showed an increasing
trend of oral cancer, especially among females.6 Some of these
apparent discrepancies could be due to regional differences
within countries, for example, while oral cancer cases are
reportedly declining in Chiang Mai in the north of Thailand,
the rates are increasing in north-eastern Thailand in Khon
Kaen.6,34 The overall increase in incidence and mortality due
to oral cancer is perhaps not surprising as the use of tobacco,
both smoked and smokeless, is high in SEA countries. SEA
countries including Indonesia, Vietnam and Timor-Leste are
among the top consumers of cigarettes.9,10 Among females in
SEA countries, Lao PDR and Brunei have the highest percent-
age of women smokers (11.4% and 8.4%, respectively),10 and
this could in part explain the high incidence rates among
females in these countries, and this observation should be stud-
ied more carefully for effective cancer control planning. The
rampant use of tobacco both smoked and smokeless is attrib-
uted primarily by the fact that the tobacco industry and tobacco
marketing are not regulated well in most of SEA even though
all of these countries, apart from Indonesia, have signed the
World Health Organization’s Framework Convention of
Tobacco Control and direct advertising is supposedly banned
in Brunei, Cambodia, Lao PDR, Malaysia, Philippines, Singa-
pore and Thailand.35,36 In fact with the tobacco industry con-
tributing significantly to the economics of the country, conflict
of interest in the revenue taxes generated from the tobacco
industry must be consciously examined in accordance with
guidelines stipulated in Article 5.3. Betel quid chewing which
is also closely linked with oral cancer and widely practiced in
SEA countries compounds the issue of tobacco control.24,28,37–39
In some areas, for example in the north-eastern region of
Thailand, betel quid chewing is the strongest risk factor for oral
cancer with odds ratio of 9.01, and the habit continues to be
popular among youths.19,20,28,38,40 The betel quid chewing habit
is practised both among the men and women and therefore, in
contrast to many other parts of the world where there is a pre-
ponderance of oral cancer among males, the number of oral
cancer diagnosed in women rival that in the men and this is in
major part because of the betel quid chewing habit that is also
widely practiced among the women.41,42 While efforts to control
the use of betel quid have been somewhat successful in India,
there are currently no regulations in place to control betel quid
chewing within any SEA country and educational programmes
to highlight the risks are limited or non-existent. Although emer-
ging studies in some pockets of society indicate that betel quid
use may be on the decline,30,43 we must not be complacent as
large migratory waves across SEA have occurred in recent years,
and such habits could be reintroduced into the host countries
resulting in future increase in oral cancer risk. For example,
while betel quid chewing was commonly observed in rubber
estates among the Indian population 2–3 decades ago in
Malaysia, this habit is prevalent in the cities at present time,
albeit among migrant communities (authors’ observations).
With the challenges outlined for all the SEA countries in
this study, it is apparent that many have overlapping issues
Cheong et al
which could be more effectively addressed if there is com-
mitted collaboration within the region. As the SEA countries
come together as the ASEAN, this affords an opportunity to
address some of these issues under the objectives of ASEAN
to promote active collaboration and mutual assistance on
matters of common interest including those pertaining to
social, technical and scientific fields and to provide assis-
tance to each other in the form of training and research facil-
ities in the educational, professional, technical and
administrative spheres. The importance of oral cancer was
underscored in a recent publication on the burden of cancer
on member countries where oral cancer was reported to be
the fifth most common cancer among ASEAN member coun-
tries contributing to 50% of all new cancer cases.44 Further-
more, the need for programmes that would promote
prevention and early detection of oral cancer was highlighted
at a 2013 Chief Dental Officers’ meeting among ASEAN
countries in Chiang Mai. Such collaborations within ASEAN
are emerging45 and an opportunity to form an organization
for Asian co-operation on cancer registration could be the
next step forward so that collaborative and comparative epi-
demiological studies across the different countries can be
conducted. Clear guidelines were put forward within the Res-
olution of the WHO Regional Committee for SEA and further
discussed under the Disease Control Priorities in Developing
countries. 46 To address these, several other challenges
urgently need addressing in relation to the development of
robust cancer registries. There is an urgent need to build
human resource capacities in epidemiology and medical
sciences to provide global standards of reporting. The need
for basic and specialised training is real and critical to
improve diagnosis and treatment of oral cancer in SEA
countries. Data on oral cancer should be based on
histologically confirmed cases, which are currently not
possible without adequately trained specialists in some of
these countries. As previously suggested, global and perhaps
more practically, regional collaborations could be a way
forward in developing expertise to address these issues.
While much of this requires commitment from the respective
governments, assistance to map a national cancer control plan
from international governing bodies including the World
Health Organization (WHO), IARC15, IACR and the Union
for International Cancer Control would go a long way in
addressing the challenges discussed in this study.
Authors’ Note
This study was presented in the Global Oral Cancer Forum (GOCF)
2016 held in New York, USA, in March 2016. We are committed to an
understanding of cancer prevention, diagnosis and treatment through a
fundamental research program.
Acknowledgements
The authors thank Nur Syafinaz Zainal and Abhinav Sardana for
assistance in the preparation of the material for this study. The authors
are grateful to Mei Fong Ng for preparing Figure 1.
7
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: This study
is funded by sponsors and donors of Cancer Research Malaysia. Can-
cer Research Malaysia is a non-profit research organization. The Glo-
bal Oral Cancer Forum (GOCF) 2016 was funded by the Henry Schein
Cares Foundation. SCC received financial support from the same
foundation to present this data at the GOCF.
References
1. Ferlay J, Soerjomataram I, Dikshit R, et al. Cancer incidence and
mortality worldwide: sources, methods and major patterns in
GLOBOCAN 2012. Int J Cancer 2015; 136: E359–386.
2. Curado M-P, Edwards B, Shin HR, et al. Cancer incidence in
five continents, Vol. IX. Lyon: IARC Scientific Publications
(WHO) and International Association of Cancer Registries,
2007.
3. Forman D, Bray F, Brewster DH, et al. Cancer incidence in five
continents, Vol. X. Lyon: IARC Scientific Publications (WHO)
and International Association of Cancer Registries, 2014.
4. Sobue T, Inoue M and Tanaka H. Cancer registry and epidemio-
logical study working group report. Jpn J Clin Oncol 2010; 40
Suppl 1: i76–81.
5. Warnakulasuriya S. Global epidemiology of oral and oropharyn-
geal cancer. Oral Oncol 2009; 45: 309–316.
6. Vatanasapt P, Suwanrungruang K, Kamsa-Ard S, et al.
Epidemiology of oral and pharyngeal cancers in Khon Kaen,
Thailand: a high incidence in females. APJCP 2011; 12:
2505–2508.
7. Alwan A, Maclean DR, Riley LM, et al. Monitoring and
surveillance of chronic non-communicable diseases: progress
and capacity in high-burden countries. Lancet 2010; 376:
1861–1868.
8. Ng CJ, Teo CH, Abdullah N, et al. Relationships between cancer
pattern, country income and geographical region in Asia. BMC
Cancer 2015; 15: 613.
9. Ansara DL, Arnold F, Kishor S, et al. Tobacco use by men and
women in 49 countries with demographic health surveys. Mary-
land: ICF International, 2013, p. 65 (accessed 12 December
2016).
10. Eriksen M, Mackay J, Schluger NW, et al. The tobacco atlas, 5th
ed. Georgia: American Cancer Society, 2015.
11. Sreeramareddy CT, Pradhan PM, Mir IA, et al. Smoking and
smokeless tobacco use in nine South and Southeast Asian
countries: prevalence estimates and social determinants from
Demographic and Health Surveys. Popul Health Metr 2014;
12: 22.
12. Regional Office for South-East Asia. 90% of smokeless tobacco
users live in South-East Asia. New Delhi, India: World Health
Organization, 2013. http://www.searo.who.int/mediacentre/
releases/2013/pr1563/en/
8 Translational Research in Oral Oncology
13. International Agency for Research on Cancer. IARC monographs
on the evaluation of carcinogenic risks to humans, volume 83.
Tobacco Smoke and Involuntary Smoking. Lyon, France: IARC
Scientific Publications (WHO), 2004. http://monographs.iarc.fr/
ENG/Monographs/vol83/mono83.pdf
14. Boucher BJ and Mannan N. Metabolic effects of the consumption
of Areca catechu. Addict Biol 2002; 7: 103–110.
15. Gupta PC and Ray CS. Epidemiology of betel quid usage. Ann
Acad Med Singapore 2004; 33: 31–36.
16. Gupta PC and Warnakulasuriya S. Global epidemiology of areca
nut usage. Addict Biol 2002; 7: 77–83.
17. Zain RB, Ikeda N, Gupta PC, et al. Oral mucosal lesions
associated with betel quid, areca nut and tobacco chewing
habits: consensus from a workshop held in Kuala Lumpur,
Malaysia, November 25–27, 1996. J Oral Pathol Med 1999;
28: 1–4.
18. International Agency for Research on Cancer. IARC monographs
on the evaluation of carcinogenic risks to humans, volume 85.
Betel-quid and areca-nut chewing and some areca-nut-derived
nitrosamines. Lyon, France: IARC Scientific Publications (WHO),
2004. http://monographs.iarc.fr/ENG/Monographs/vol85/
mono85.pdf.
19. Loyha K, Vatanasapt P, Promthet S, et al. Risk factors
for oral cancer in northeast Thailand. APJCP 2012; 13:
5087–5090.
20. Kampangsri W, Vatanasapt P, Kamsa-Ard S, et al. Betel quid
chewing and upper aerodigestive tract cancers: a prospective
cohort study in Khon Kaen, Thailand. APJCP 2013; 14:
4335–4338.
21. Chher T, Hak S, Kallarakkal TG, et al. Prevalence of oral cancer,
oral potentially malignant disorders and other oral mucosal
lesions in Cambodia. Ethn Health 2016; Oct 26: 1–15.
22. Imsamran W, Chaiwerawattana A, Wiangnon S, et al. Cancer in
Thailand, Volume VIII, 2010-2012. Bangkok: Ministry of Public
Health, Ministry of Education, 2015, p.178.
23. Lee HP, Chew LL, Chow KY, et al. Singapore cancer registry
interim annual report trends in cancer incidence in Singapore
2010–2014. Singapore: Singapore National Registry of Disease
Office (NRDO), 2015, p. 56.
24. Redaniel MTM, Laudico AV, Lumague MRM, et al. Cancer in
the Philippines Volume IV. Manila: Philippine Cancer Society &
Manila Cancer Registry, 2008.
25. Zainal Ariffin O and Nor Saleha IT. National Cancer Registry
report 2007; Malaysia cancer statistics-data and figure. Putra-
jaya: Non-Communicable Disease Section (NCD), Ministry of
Health Malaysia, 2011, p. 126.
26. Aung S. Epidemiology of cancer in Myanmar. Yangon: Forum on
Cancer in Myanmar 2002, pp. 33–60.
27. Parkin MD, Whelan SL, Ferlay J, et al. Cancer incidence in five
continents Volume VIII. Lyon: IARC Scientific Publications
(WHO) and International Association of Cancer Registries,
2002, pp. 306–309.
28. Reichart PA and Way TH. Oral cancer and pre-cancer in
Myanmar: a short review. J Oral Pathol Med 2006; 35:
193–196.
29. Ikeda N, Handa Y, Khim SP, et al. Prevalence study of oral
mucosal lesions in a selected Cambodian population. Comm Dent
Oral Epidemiol 1995; 23: 49–54.
30. Reichart PA and Nguyen XH. Betel quid chewing, oral cancer and
other oral mucosal diseases in Vietnam: a review. J Oral Pathol
Med 2008; 37: 511–514.
31. Soares LF, Crocombe L and Stevens S. Oral health in Timor
Leste (east Timor). Dili: Timor Leste Dentist Community,
2013.
32. Lee HP, Ang PT, Chow KY, et al. Singapore cancer registry
report: trends in cancer incidence in Singapore 1968–2007. Sin-
gapore: Singapore National Registry of Disease Office (NRDO),
2015, p. 185.
33. Laudico AV, Mirasol-Lumague MR, Mapua CA, et al. Cancer
incidence and survival in metro Manila and Rizal province, Phi-
lippines. Jpn J Clin Oncol 2010; 40: 603–612.
34. Reichart PA, Dietrich T, Khongkhunthian P, et al. Decline of
oropharyngeal cancer in Chiangmai province, Thailand, between
1988 and 1999. Oral Oncol 2003; 39: 569–573.
35. The ASEAN Tobacco Control Report, 2012. Vietnam: Associ-
ation of Southeast Asian Nation & Southeast Asia Tobacco
Control Alliance; 2012. http://www.asean.org/storage/images/
rotating_banner/the%20asean%20tobacco%20control%20re
port.pdf (accessed 12 December 2016).
36. Southeast Asia Tobacco Control Alliance (SEATCA). Tobacco
Advertising, Promotion and Sponsorship Index: 2016 ASEAN
Report on Implementation of WHO Framework Convention on
Tobacco Control. Bangkok: FCTC, 2016.
37. Lee CH, Ko AM, Warnakulasuriya S, et al. Intercountry pre-
valences and practices of betel-quid use in south, southeast and
eastern Asia regions and associated oral preneoplastic disor-
ders: an international collaborative study by Asian betel-quid
consortium of south and east Asia. Int J Cancer 2011; 129:
1741–1751.
38. Oo HN, Myint YY, Maung CN, et al. Oral cancer in Myanmar: a
preliminary survey based on hospital-based cancer registries.
J Oral Pathol Med 2011; 40: 20–26.
39. Tran TKC, Nguyen TBN, Nguyen TH, et al. Betel chewing and
oral mucosal lesions in Vietnamese population sample. In: Pro-
ceedings, Oral Cancer in the Asia Pacific- A Regional Update
and Networking, Faculty of Dentistry, University Malaya, Kuala
Lumpur. 2006, p. 71 (accessed 18 February 2016).
40. Taylor P. The country where nearly two-thirds of men smoke.
BBC News; 2014. http://www.bbc.com/news/magazine-
27677882 (accessed 12 December 2016).
41. Durward C, Todd R, So PK, et al. The national oral health survey
in Cambodia, 1990-1991. Geneva, Switzerland: World Health
Organization; 1990–1991.
42. Nguyen TH and Ngo TPT. Oral cancer in Vietnamese adults
under 45-years old. Oral Cancer in the Asia Pacific- A
Regional Update and Networking, Kuala Lumpur: Faculty of
Dentistry, University Malaya, 2006, p. 71 (accessed 18 Feb-
ruary 2016).
43. Sriamporn S, Parkin DM, Pisani P, et al. A prospective study of
diet, lifestyle, and genetic factors and the risk of cancer in Khon
Cheong et al 9

Kaen Province, northeast Thailand: description of the cohort.

Asian Pac J Cancer Prev 2005; 6: 295–303. Translational value
44. Kimman M, Norman R, Jan S, et al. The burden of cancer in
member countries of the Association of Southeast Asian Nations
The incidence of oral cancer in South East Asia coun-
(ASEAN). Asian Pac J Cancer Prev 2012; 13: 411–420.
tries are among the highest in the world. This study
45. Jan S, Kimman M, Kingston D, et al. The socioeconomic burden
highlights the lack of systematic documentation of the
of cancer in member countries of the Association of Southeast
cancer burden in these countries and underscores the
Asian Nations (ASEAN) – stakeholder meeting report. Asian Pac
urgent need to address this so that effective policies for
J Cancer Prev 2012; 13: 407–409.
cancer control can be developed, implemented and
46. Sankaranarayanan R, Ramadas K, Amarasinghe H, et al. Oral
evaluated. Based on the data from this study, positive
cancer: prevention, early detection, and treatment. Disease Con-
steps that could be taken to address the challenges faced
trol Priorities: Cancer. 3rd ed. Washington DC, USA: The World
by the region are discussed, particularly the establish-
Bank; 2015. http://dcp-3.org/sites/default/files/chapters/
ment of robust cancer registries through strong regional
DCP3%20Cancer_Ch%205.pdf (accessed 12 December 2016).
(ASEAN) and international collaborations.