LAUSR

that found a statistically significant survival benefit for patients undergoing an elective neck dissection for early-stage oral cavity carcinoma compared with patients randomized to a watchful waiting group. The study was performed in India, the world’s largest producer and consumer of betel nut, and it did not assess, nor control for this variable.2 If betel nut consumption is indeed an independent prognosticator, the generalizability of these results to non–betel nut regions may be mitigated. Conversely,numerousotheroralcavitystudiesfrombetelnut regions have shown higher proportions of verrucous carcinomas, a remarkably indolent variety of oral cancer with minimal metastatic potential. Over a 10-year period, Vidyasagar et al5 reported 438 institutional oral cancer diagnoses, of which 107 were verrucous carcinomas (24%). Such proportions of verrucous disease have never been reported in non–betel nut regions. When taken in conjunction with conclusions by Yang et al,3 these findings maysuggestasubstantiallydifferentspectrumoforalcancerphenotypes in betel regions relative to non–betel nut regions.