Rural–urban and educational gradients in head and neck cancer incidence in Finland from 1977 to 2021
DOI:
https://doi.org/10.2340/1651-226X.2025.43391Keywords:
head and neck neoplasms, urban health, socioeconomic factors, incidence, human papillomavirus infectionsAbstract
Background and purpose: Rural–urban differences in head and neck cancer (HNC) incidence remain understudied, especially in Europe. Changes over time in risk factors, such as smoking and human papillomavirus status, may be reflected in alterations of HNC incidence by subsite, educational level, and urbanity.
Material and methods: Incidence rate ratios (IRR) – adjusted for age, calendar period, educational and urbanization level, and region – and age-standardized HNC incidence per 100,000 person-years were estimated by sex, subsite, levels of education and urbanization over 5-year periods from 1977 to 2021. We estimated the average annual percent change in incidence and IRRs between levels of urbanization and education using Poisson regression.
Results: A lower incidence of oral cavity (IRR 0.82, 95% confidence interval [CI]: 0.73–0.93 for 2007–2021), oropharyngeal (0.75, 0.65–0.87), and nasopharyngeal cancer (0.43, 0.25–0.75) was noted among rural men when compared with urban men. Semi-urban men also showed lower incidences than urban men. Similarly, a lower incidence of oropharyngeal cancer (OPC) was observed among rural (IRR 0.62, 95% CI: 0.47–0.80) and semi-urban women (0.79, 0.63–0.99). Additionally, our study indicates that the rates of OPC and oral cavity cancer are increasing across all educational and urbanization levels. The rise in OPC is particularly notable since 1997–2001, especially among urban populations, in both men and women.
Interpretation: While a higher prevalence of risk factors among urban populations may explain the differences noted across the different urbanization levels, the reasons for the increasing trends across all strata remain unclear.
Downloads
References
Gormley M, Creaney G, Schache A, Ingarfield K, Conway DI. Reviewing the epidemiology of head and neck cancer: definitions, trends and risk factors. Br Dent J. 2022;233:780–6.
https://doi.org/10.1038/S41415-022-5166-x DOI: https://doi.org/10.1038/s41415-022-5166-x
Lechner M, Liu J, Masterson L, Fenton TR. HPV-associated oropharyngeal cancer: epidemiology, molecular biology and clinical management. Nat Rev Clin Oncol. 2022;19:306–27.
https://doi.org/10.1038/s41571-022-00603-7 DOI: https://doi.org/10.1038/s41571-022-00603-7
Hussein AA, Helder MN, de Visscher JG, Leemans CR, Braakhuis BJ, de Vet HCW, et al. Global incidence of oral and oropharynx cancer in patients younger than 45 years versus older patients: a systematic review. Eur J Cancer. 2017;82:115–27.
https://doi.org/10.1016/j.ejca.2017.05.026 DOI: https://doi.org/10.1016/j.ejca.2017.05.026
Reitsma MB, Fullman N, Ng M, Salama JS, Abajobir A, Abate KH, et al. Smoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015: a systematic analysis from the global burden of disease study 2015. Lancet. 2017;389(10082):1885–906.
https://doi.org/10.1016/s0140-6736(17)30819-x DOI: https://doi.org/10.1016/S0140-6736(17)30819-X
Koleśnik M, Stępień E, Polz-Dacewicz M. Prevalence of human papillomavirus (HPV) in the oral cavity of a healthy population in South-Eastern Poland. Int J Environ Res Public Health. 2022;19:7213.
https://doi.org/10.3390/ijerph19127213 DOI: https://doi.org/10.3390/ijerph19127213
Roura E, Iftner T, Vidart JA, Kjaer SK, Bosch FX, Muñoz N, et al. Predictors of human papillomavirus infection in women undergoing routine cervical cancer screening in Spain: the CLEOPATRE study. BMC Infect Dis. 2012;12:145.
https://doi.org/10.1186/1471-2334-12-145 DOI: https://doi.org/10.1186/1471-2334-12-145
Liederbach E, Kyrillos A, Wang CH, Liu JC, Sturgis EM, Bhayani MK. The national landscape of human papillomavirus-associated oropharynx squamous cell carcinoma. Int J Cancer. 2017;140:504–12.
https://doi.org/10.1002/ijc.30442 DOI: https://doi.org/10.1002/ijc.30442
Weiss J, Heinz-Fischer C. The more rural the less educated? An analysis of national policy strategies for enhancing young adults’ participation in formal and informal training in European rural areas. Youth. 2022;2:405–21.
https://doi.org/10.3390/youth2030030 DOI: https://doi.org/10.3390/youth2030030
Conway DI, Brenner DR, McMahon AD, Macpherson LMD, Agudo A, Ahrens W, et al. Estimating and explaining the effect of education and income on head and neck cancer risk: INHANCE consortium pooled analysis of 31 case-control studies from 27 countries. Int J Cancer. 2015;136:1125–39.
https://doi.org/10.1002/ijc.29063 DOI: https://doi.org/10.1002/ijc.29063
Zahnd WE, James AS, Jenkins WD, Izadi SR, Fogleman AJ, Steward DE, et al. Rural-urban differences in cancer incidence and trends in the United States. Cancer Epidemiol Biomarkers Prev. 2018;27:1265–74.
https://doi.org/10.1158/1055-9965.epi-17-0430 DOI: https://doi.org/10.1158/1055-9965.EPI-17-0430
Friis S, Storm HH. Urban-rural variation in cancer incidence in Denmark 1943–1987. Eur J Cancer. 1993;29:538–44.
https://doi.org/10.1016/s0959-8049(05)80147-9 DOI: https://doi.org/10.1016/S0959-8049(05)80147-9
Sharp L, Donnelly D, Hegarty A, Carsin AE, Deady S, McCluskey N, et al. Risk of several cancers is higher in urban areas after adjusting for socioeconomic status. Results from a two-country population-based study of 18 common cancers. J Urban Health. 2014;91(3):510–25.
https://doi.org/10.1007/s11524-013-9846-3 DOI: https://doi.org/10.1007/s11524-013-9846-3
Wilkinson D, Cameron K. Cancer and cancer risk in South Australia: what evidence for a rural-urban health differential? Aust J Rural Health. 2004;12:61–6. DOI: https://doi.org/10.1111/j.1440-1584.2004.tb00570.x
https://doi.org/10.1111/j.1038-5282.2004.00555.x DOI: https://doi.org/10.1111/j.1038-5282.2004.00555.x
Smailyte G, Kurtinaitis J. Cancer mortality differences among urban and rural residents in Lithuania. BMC Public Health. 2008;8:56.
https://doi.org/10.1186/1471-2458-8-56 DOI: https://doi.org/10.1186/1471-2458-8-56
Siesling S, Van Der Aa MA, Coebergh JWW, Pukkala E. Time-space trends in cancer incidence in the Netherlands in 1989–2003. Int J Cancer. 2008;122:2106–14.
https://doi.org/10.1002/ijc.23358 DOI: https://doi.org/10.1002/ijc.23358
Stein AP, Saha S, Kraninger JL, Swick AD, Yu M, Lambert PF, et al. Prevalence of human papillomavirus in oropharyngeal cancer: a systematic review. Cancer J. 2015;21:138–46.
https://doi.org/10.1097/ppo.0000000000000115 DOI: https://doi.org/10.1097/PPO.0000000000000115
Vartiainen VA, jousilahti P, Laatikainen T, Vartiainen E. Contribution of smoking change to 45-year trend in prevalence of chronic bronchitis in Finland. Scand J Public Health. 2023;51:1189–95.
https://doi.org/10.1177/14034948221104351 DOI: https://doi.org/10.1177/14034948221104351
Finnish Institute for Health and Welfare. Smoking statistics 2023. Statistical Report 55/2024. Helsinki: Finnish Institute for Health and Welfare; 2024.
Ruokolainen O, Heloma A, Jousilahti P, Lahti J, Pentala-Nikulainen O, Rahkonen O, et al. Thirty-eight-year trends of educational differences in smoking in Finland. Int J Public Health. 2019;64:853–60.
https://doi.org/10.1007/s00038-019-01228-x DOI: https://doi.org/10.1007/s00038-019-01228-x
Harkonen J, Savonen J, Virtala E, Suomalaisten PM. Finnish drinking habits survey 1968–2016 (In Finnish). Helsinki: Finnish Institute of Health and Welfarei; 2017.
Madathil S, Rousseau MC, Joseph L, Coutlée F, Schlecht NF, Franco E, et al. Latency of tobacco smoking for head and neck cancer among HPV-positive and HPV-negative individuals. Int J Cancer. 2020;147:56–64.
https://doi.org/10.1002/ijc.32708 DOI: https://doi.org/10.1002/ijc.32708
Murto J, Kaikkonen R, Pentala-Nikulainen O, Koskela T, Virtala E, Harkanen T, et al. Results of the adult health, wellbeing, and services survey 2010–2016 (In Finnish) [Internet]. Helsinki: Finnish Institute of Health and Welfare; 2014. Available from: www.thl.fi/ath
Halme JT, Seppä K, Alho H, Pirkola S, Poikolainen K, Lönnqvist J, et al. Hazardous drinking: prevalence and associations in the Finnish general population. Alcohol Clin Exp Res. 2008;32:1615–22.
https://doi.org/10.1111/j.1530-0277.2008.00740.x DOI: https://doi.org/10.1111/j.1530-0277.2008.00740.x
Miranda-Filho A, Bray F. Global patterns and trends in cancers of the lip, tongue and mouth. Oral Oncol. 2020;102:104551.
https://doi.org/10.1016/j.oraloncology.2019.104551 DOI: https://doi.org/10.1016/j.oraloncology.2019.104551
Katirachi SK, Grønlund MP, Jakobsen KK, Grønhøj C, von Buchwald C. The prevalence of HPV in oral cavity squamous cell carcinoma. Viruses. 2023;15(2):451.
https://doi.org/10.3390/v15020451 DOI: https://doi.org/10.3390/v15020451
Pavia M, Pileggi C, Nobile CGA, Angelillo IF. Association between fruit and vegetable consumption and oral cancer: a meta-analysis of observational studies. Am J Clin Nutr. 2006;83:1126–34.
https://doi.org/10.1093/ajcn/83.5.1126 DOI: https://doi.org/10.1093/ajcn/83.5.1126
Xu J, Yang XX, Wu YG, Li XY, Bai B. Meat consumption and risk of oral cavity and oropharynx cancer: a meta-analysis of observational studies. PLoS One. 2014;9:e95048.
https://doi.org/10.1371/journal.pone.0095048 DOI: https://doi.org/10.1371/journal.pone.0095048
Stuckler D, McKee M, Ebrahim S, Basu S. Manufacturing epidemics: the role of global producers in increased consumption of unhealthy commodities including processed foods, alcohol, and tobacco. PLoS Med. 2012;9:e1001235.
https://doi.org/10.1371/journal.pmed.1001235 DOI: https://doi.org/10.1371/journal.pmed.1001235
Bosetti C, Carioli G, Santucci C, Bertuccio P, Gallus S, Garavello W, et al. Global trends in oral and pharyngeal cancer incidence and mortality. Int J Cancer. 2020;147:1040–9.
https://doi.org/10.1002/ijc.32871 DOI: https://doi.org/10.1002/ijc.32871
Mehanna H, Beech T, Nicholson T, El-Hariry I, McConkey C, Paleri V, et al. Prevalence of human papillomavirus in oropharyngeal and nonoropharyngeal head and neck cancer – systematic review and meta-analysis of trends by time and region. Head Neck. 2013;35:747–55.
https://doi.org/10.1002/hed.22015 DOI: https://doi.org/10.1002/hed.22015
Lundberg M, Leivo I, Saarilahti K, Måkitie AA, Mattila PS. Increased incidence of oropharyngeal cancer and p16 expression. Acta Otolaryngol. 2011;131:1008–11.
https://doi.org/10.3109/00016489.2011.575796 DOI: https://doi.org/10.3109/00016489.2011.575796
Ochoa Scussiatto H, Stenson KM, Al-Khudari S, Jelinek MJ, Pinto JM, Bhayani MK. Air pollution is associated with increased incidence-rate of head and neck cancers: a nationally representative ecological study. Oral Oncol. 2024;150:106691.
https://doi.org/10.1016/j.oraloncology.2024.106691 DOI: https://doi.org/10.1016/j.oraloncology.2024.106691
Sillanpää S, Fung PL, Niemi J V., Kousa A, Kangas L, Zaidan MA, et al. Long-term air quality trends of regulated pollutants in the Helsinki metropolitan area from 1994–2019 and its implications to the Air Quality Index. Boreal Environ Res. 2022;27:61–79.
https://doi.org/10.1547/porel.1254.238
Lehtinen T, Elfström KM, Mäkitie A, Nygård M, Vänskä S, Pawlita M,
et al. Elimination of HPV-associated oropharyngeal cancers in Nordic countries. Prev Med (Baltim). 2021;144:106445.
https://doi.org/10.1016/j.ypmed.2021.106445 DOI: https://doi.org/10.1016/j.ypmed.2021.106445
Lindqvist C. Risk factors in lip cancer: a questionnaire survey. Am J Epidemiol. 1979;109:521–30.
https://doi.org/10.1093/oxfordjournals.aje.a112710 DOI: https://doi.org/10.1093/oxfordjournals.aje.a112710
Pogoda JM, Preston-Martin S. Solar radiation, lip protection, and lip cancer risk in Los Angeles County women (California, United States). Cancer Causes Control. 1996;7:458–63.
https://doi.org/10.1007/BF00052672 DOI: https://doi.org/10.1007/BF00052672
Ryser MD, Gulati R, Eisenberg MC, Shen Y, Hwang ES, Etzioni RB. Identification of the fraction of indolent tumors and associated overdiagnosis in breast cancer screening trials. Am J Epidemiol. 2018;188:197–205.
https://doi.org/10.1093/aje/kwy214 DOI: https://doi.org/10.1093/aje/kwy214
D’Souza G, Cullen K, Bowie J, Thorpe R, Fakhry C. Differences in oral sexual behaviors by gender, age, and race explain observed differences in prevalence of oral human papillomavirus infection. PLoS One. 2014;9:e86023.
https://doi.org/10.1371/journal.pone.0086023 DOI: https://doi.org/10.1371/journal.pone.0086023
Leinonen MK, Miettinen J, Heikkinen S, Pitkäniemi J, Malila N. Quality measures of the population-based Finnish Cancer Registry indicate sound data quality for solid malignant tumours. Eur J Cancer. 2017;77:31–9.
https://doi.org/10.1016/j.ejca.2017.02.017 DOI: https://doi.org/10.1016/j.ejca.2017.02.017
Additional Files
Published
How to Cite
License
Copyright (c) 2025 Rayan Nikkilä, Heidi Ryynänen, Aaro Haapaniemi, Nea Malila, Janne Pitkäniemi, Karri Seppä, Antti Mäkitie
This work is licensed under a Creative Commons Attribution 4.0 International License.
