Abstract

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Objective: To assess the coverage and quality of oral cancer information in newspapers circulated in Hyderabad for 15 years (1996-2011).
Methods: Articles on oral cancer in news papers were retrieved from old newspaper archives in internet and from newspaper libraries published between years 1996 and August 2011. The articles were analyzed both for quality and accuracy of information using criteria suggested by Maria T. Canto et al, 1998.
Results: A total of 72 articles and news items on oral cancer were identified and assessed for quality of information. 91.6 % of the articles mentioned at least one risk factor and all of them identified tobacco as risk factor. 19.4% of the articles mentioned at least one warning signs. 11.1% articles mentioned symptoms of oral cancer. Information about location of oral cancer lesion was mentioned in 15.2% articles. Based on accuracy scale, 1 among 72 articles was inaccurate, 71 had combination of accurate and inaccurate information and none of them were accurate. CONCLUSION: The coverage of oral cancer information is scanty and the quality of information provided is poor.

Introduction

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Oropharyngeal cancer is the eleventh most common cancer worldwide and it constitutes the most life threatening of all dental conditions. The five year oral cancer survival rate of 50 percent is one of the lowest among all major cancers, and it has not improved in decades1. Oral cancers are highly prevalent in regions such as India and Southeast Asia as a result of widespread betel nut and tobacco chewing practices. The causes and types of cancer vary globally. The reasons for differences in the incidence, pathology, mortality, and clinical characteristics of cancers in different geographical regions are manifold and complex. Historical background, genetics, environment, lifestyles, socio-cultural and behavioral factors, as well as economics may all play a role, and these elements may interact to contribute to higher or lower risk for specific cancers. The primary risk factors for oral cancers include all kinds of tobacco and alcohol use, unprotected exposure to sun (lip cancer), some viruses, lack of eating fruits and vegetables and marijuana use. Of all the environmental factors, the use of tobacco poses the greatest threat and contributes considerably to cancer prevalence and mortality in developing countries. Tobacco use, including smokeless tobacco, and excessive alcohol consumption are estimated to account for about 90% of oral cancers. This risk is on the rise in developing countries2. India, the third largest grower of tobacco in the world, amassed 1.7 million disability-adjusted life years (DALYs) in 1990 due to disease and injury attributable to tobacco use in a population where 65% of the men and 38% of the women consume tobacco2. Oral cancer, continue to have a high incidence and mortality in less- developed countries in spite of being amenable to early detection. Screening programs and pathologic expertise for rapid and accurate diagnosing and staging are lacking. Detecting oral cancer in its early stages dramatically affects survival rates compared with detecting it in later stages3. Health communication specialists can contribute by promoting cancer screening and preventive behaviors. In particular, health communication that is perceived as personally relevant to an individual or group can motivate cancer prevention and early detection behavior. Recent research has focused on identifying effective channels for delivering cancer information, and the extent to which cancer information-seeking behavior may be explained by individuals’ media preferences and the environments in which they reside. Adelman and Verbrugge (2000) argue that newspapers provide “an accessible, non-transient form of media. They are inexpensive, have broad public use, and can be read and reread. By contrast, periodicals often cost more, websites have narrower access, and broadcast news evaporates”3. In Indian newspapers, the maximum amount of coverage had been given to political news reports. This category leads others by a wide margin both in terms of numbers as well as the space covered by it. Advertisements do cover a lot of space as they were either full page or half page advertisements on some health related issues. Indian public seems to show no interest as very few letters related to health were published in the newspapers. This lack of participation could be a result of low awareness levels or perhaps the seriousness of the issue has not sunk in the public psyche. It is possible that the general public is still under the ‘denial stage’ as they believe that problem cannot happen to them. Considering that little media attention has been given to educating the public on oral cancer, it is not surprising that the most Indian adults have little accurate knowledge about oral cancer4. The purpose of this study was to asses the coverage and quality of oral cancer information in newspapers circulated in Hyderabad during the period of 1996-2011.

Methods

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Study Design: A retrospective observational study was conducted to assess the coverage and quality of oral cancer information in newspapers that are circulated in Hyderabad.

Article search: Two methods used for searching the articles were computer search and hand search. List of newspapers available in Hyderabad was obtained from internet. The old e-news paper archives were searched for articles published on oral cancer using the key words “oral cancer”, “mouth cancer” and “tobacco” and all the articles obtained were collected. The news paper Libraries were searched for the articles filed under the categories “Tobacco” and “cancer”. 220 articles thus retrieved from the internet and libraries were in the time period of 1996-2011. Articles thus obtained were assessed for the quality of the information published.

Quality Assessment:
To determine the quality of the oral cancer information, articles were analyzed using the scale developed by Maria T. Canto et al, 1998, which measures adequacy and accuracy of the oral cancer information.  The adequacy scale consists of the following topics and sub topics,
1. Risk factors
   (i)Tobacco
   (ii)Alcohol
   (iii)Sun
   (iv)Lack of fruit and vegetables
   (v)Virus
   (vi)Early warning signs:
        (i)No pain
        (ii)Ulcer/sore
        (iii)Thickening/swelling
        (iv)Red/white patch
1. Location:
   (i)Lip
   (ii)Tongue
   (iii)Cheek
   (iv)Palate
   (v)Gums
   (vi)Floor of the mouth
   (vii)Throat
   (viii)Symptoms
         (i)Numbness
         (ii)Burning/altered taste
         (iii)Discomfort with dentures
         (iv)Discomfort in the throat
         (v)Lump
         (vi)Prevention
             (i)Diet
             (ii)Tobacco cessation
             (iii)Decrease in alcohol use
             (iv)Sun protection
             (v)Oral cancer examination
                 (i)Clinical
                 (ii)Self
                 (iii)Use of toluidine blue

The following adequacy scale was used to score each topic:
0: Not mentioned
1: Mentioned 1 subtopic
2: Mentioned two or more subtopics
3: Mentioned all subtopics.

Other information obtained from articles included morbidity/mortality statistics, treatment for oral cancers. To determine the quality of the content of each item based on current scientific literature, the following scale was used: 0= inaccurate or misleading; 1= mix of accurate and inaccurate information; and 2= accurate.

Results

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Risk Factors:  91.6 % of the articles mentioned at least one risk factor and all of them identified tobacco. Chewing and smoking tobacco were mentioned equally, i.e., 51.3% each. Alcohol was mentioned as a risk factor by 5.5% articles. Diet was mentioned only in 1.3% of the articles. 6.9% articles mentioned betel nut. Early warning signs: 19.4% of the articles mentioned at least one warning signs. The most common warning signs mentioned were oral submucous fibrosis (57%) and red/white patch (35.7%). 21.4% of the articles mentioned ulcer/unhealed sore. Symptoms: 11.1 % articles mentioned symptoms of oral cancer. Most common symptom mentioned was stiffening/ reduced mouth opening. Location of the lesion: Information about location of oral cancer lesion was mentioned in 15.2% articles which included lip (15.2%), tongue (9.7%), throat (1.3%), cheek (1.3%), and gums (1.3%).

Prevention: Not even half of the articles mentioned about preventive measures. 22.2% recommended tobacco cessation which was the most common preventive method mentioned. The topic of consumption of fruit and vegetable was scarce (2.7%).

Examination: Only one article mentioned the examination and method mentioned was biopsy.

Accuracy score:
One article received an accuracy score 0. 71 articles had a score 1.

Health status outcomes and objectives:
30% articles presented information about morbidity and mortality for oral cancers. 5.5% mentioned various treatment procedures available for oral cancers (surgery, radiation, chemo therapy and targeted therapy)

Discussion

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Cancer remains one of the leading causes of morbidity and mortality worldwide. It is predicted that by 2020, the number of new cases of cancer in the world will increase to more than 15 million, with deaths increasing to 12 million. Disparities in cancer risk combined with poor access to epidemiological data, research, treatment, and cancer control and prevention combine to result in significantly poorer survival rates in developing countries for a range of specific malignancies. Mass media plays an important role in creating awareness among public by providing information on epidemiology, prevention and treatment, research on any disease. This study assessed the quality and quantity of oral cancer information provided by newspapers to their readers between the years 1996 to August 2011. Overall, the coverage of oral cancer in newspapers was disproportionately low considering the explosion of health information available in newspapers. 220 articles were related to cancer and tobacco, but only 72 mentioned oral cancer. In a similar study conducted by Mario T Canto et al5, 10,066 articles were related to cancer but only 32 focused on oral cancer. In another study by Jalaima A. Graham et al6, 39 articles were on oral cancer during a period of 5 years. Among the cancer articles, importance was given to cervical and breast cancers.
The scale used in this study was developed by Maria T. Canto et al, which consisted of 6 topics and few subtopics under each topic, based on which the quality of oral cancer information was assessed. Not even 1 article mentioned all the topics and subtopics. Dearth of articles on oral cancer may be because newspapers give maximum coverage to political news reports and advertisements occupying most of the space in the health columns. Though the incidence of oral cancer increased in past few years, it has not caught enough media attention. This may be due to lack of reliable oral cancer prevalence and mortality data available for India7. The articles reviewed in the present study contained information analogous to the results of a study conducted by Maria T. Canto et al on coverage and quality of oral cancer information in the popular press, in that oral cancer was depicted as mainly associated with spit tobacco, while lung cancer was linked with smoking. Many articles mentioned cigarette use as a risk factor for lung cancer, but failed to mention that it is the major risk factor for oral cancer. 91.6 % of the articles mentioned at least one risk factor and the most common risk factor mentioned was tobacco.5.5% of the articles mentioned alcohol as a risk factor. In a study conducted by Maria T. Canto et al, 94% of the articles mentioned at least one risk factor, among which 86% identified tobacco and 26% identified alcohol. In a study done by Jalaima A. Graham et al, 72% of the articles mentioned atleast one risk factor the three most common products mentioned were snuff (48%), chewing/spit tobacco (44%), and cigarettes (41%) and alcohol was mentioned by 4 articles. Importance was given to tobacco, which may be because the overall tobacco consumption in India continues to grow at 2% to 3% annually and currently, approximately 65% of Indian men and one third of Indian women use some form of tobacco. And also, the strength and consistency of the association between tobacco and oral cancer has been demonstrated in numerous case-control and cohort studies with significant relative risks or odds ratios in the threefold to 12-fold range. Other potential risk factors for oral cancer such as poor nutrition, laryngo-pharyngeal reflux, human papilloma virus, air pollution, and genetics have been greatly studied recently in the Western literature but, as of yet, have received little attention in the Indian population. Tobacco articles depicted it as a risk factor for lung cancer and other colorectal cancers, but very few mentioned its association with occurrence of oral cancer. The sites which were mostly mentioned as locations for oral cancer were, lip (15.2%), tongue (9.7%). Findings are in consistency with a study conducted by Maria T. canto et al that, most common locations mentioned were, tongue (26%), lip (16%) and gums (14%). In a similar study by Jalima A. graham et al, location of oral cancer lesions mentioned were, mouth (46%), throat (21%), and tongue (18%). Cheeks, lips and gums were mentioned because users of spit tobacco, pan and betel nut place them in contact with the oral mucosa mainly in these areas. For self protection, the public should know that in most cases pain is not present with early stages of oral cancer. 19.4% of the articles mentioned at least one warning signs and commonly mentioned were  oral submucous fibrosis and red/white patch, while in a study by Maria T. Canto et al, 26% articles mentioned at least one warning sign but the common warning sign mentioned was red or white sore and ulcer. In a study done by Jalaima A. graham et al, only 8 articles mentioned one early warning sign and the most commonly mentioned were a white patch (13%), ulcer/sore (10%), and a sustained sign (13%). The general public’s awareness of these early warning signs could help with their self examination and help prompt them to seek follow up care by health professionals. In general, the articles and news items failed to address the evidence available to support oral cancer examination as a tool for early detection of these cancers.
11.1% of the articles mentioned symptoms of oral cancer. Most common symptom mentioned was stiffening/ reduced mouth opening. This may be because reduced mouth opening is a subjective symptom. In a study done by Jalaima A. Graham et al, asymptomatic, discomfort in throat, and hoarseness were identified in 3 articles.22.2 % articles recommended tobacco cessation as the major preventive measure for oral cancer. This may be because the adverse effects of tobacco on oral health are well documented, so behavior modification through health education is important to reduce tobacco use and prevent oral cancer. Where general knowledge of the etiology and presentation of oral cancer is lacking, strengthening the public about the association with tobacco and about the nature of presentation may be effective in reducing oral cancer incidence and mortality. Alcohol seems to have an effect on risk of oral cancer independent of tobacco smoking, but these effects are consistently significant only at the highest level of alcohol consumption, this may be the reason for not focusing it as a risk factor for oral cancer. The principal measure of early detection for oral cancers is a comprehensive oral examination. Only one article mentioned the need for oral cancer examination by a health professional. The findings were in consistency with that of a similar study conducted by Maria T. Canto et al. The survival rate in oral cancer patients were very poor in India, the chief reason for these poor survival rates is the late presentation for treatment. It is important to remember that the oral cavity provides relatively easy access for a provider to determine changes in the tissue. None of the articles mentioned the importance of self examination.Although this study provides a comprehensive analysis of articles and news items about oral cancer in the newspapers of Hyderabad, it has limitations. One limitation is that the study relied on newspaper libraries to identify articles on oral cancer. Second, the public is exposed to other types of mass media not included in this study, such as television and radio. Therefore, this study is not a complete description of the information the public has been exposed to on the topic of oral cancer. Nevertheless, the results show the lack of participation of public health professionals and low level of interest of media in educating public on oral cancer. The use of mass media is pivotal to inform the public about the availability of an oral cancer examination, and to accurately inform them on the early warning signs for, symptoms of, and risk factors for oral cancer.

Conclusion(s)

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Conclusions and Recommendations:

1. In summary, this study demonstrates not only a lack of coverage of oral cancer in the newspapers, but also inaccuracies.
2. Writers of health-related issues in newspapers should have access to scientists, federal agencies, and other key organizations
3. Public health dentists should effectively utilize the mass media i.e., newspapers to educate the people.
4. They should educate and motivate newspaper health column writers to approach them for accurate information.

Reference(s)

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1. Global data on incidence of oral cancer, 2005. Available on www.who.int/oral_health. Accessed on 9/9/2011.
2. P. Kanavos. The rising burden of cancer in the developing world. Annals of Oncology, 2006,15–23,
3. Elisia L. Cohen. Cancer coverage in general-audience and black newspapers. Health Communication, 2008, 23: 427–435
4. Gupta. A, A. K. Sinha. Health Coverage in Mass Media: A Content Analysis. J Communication, 2010; 1(1): 19-25
5. Maria T. Canto, Yoko Kawaguchi, Alice M. Horowitz. Coverage and Quality of Oral cancer Information in the Popular Press: 1987-98. Journal of Public health Dentistry, 1998; 58(3):241-247.
6. Coverage and Quality of Oral cancer Information in selected Popular Press: May 1998 to July 2003. Journal of Public health Dentistry, 2004;64(4): 231-236
7. Erich M. Sturgis. A review of social and behavioral efforts at oral cancer preventions in India. Head & Neck, 2004; 26:937-944.

Source(s) of Funding

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None

Competing Interests

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None

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