Clinical epidemiological characterization of laryngeal cancer, hospital: Abel Santamaría Cuadrado

doi: 10.56294/shp202380

ORIGINAL

Clinical epidemiological characterization of laryngeal cancer, hospital: Abel Santamaría Cuadrado

Caracterización clínico epidemiológica del cáncer de laringe, hospital: Abel Santamaría Cuadrado

Ileana Pacheco Valdés¹ *, Modesto Cordovés Jerez¹ *, Raúl Rodríguez González¹ *, José Roberto Fernández Barrera¹ *, Humberto López Benítez¹ *

¹Hospital General Docente Abel Santamaría Cuadrado, Departamento Otorrinolaringología. Pinar del Rio, Cuba.

Cite as: Pacheco Valdés I, Cordovés Jerez M, Rodríguez González R, Fernández Barrera JR, López Benítez H. Clinical epidemiological characterization of laryngeal cancer, hospital: Abel Santamaría Cuadrado. South Health and Policy. 2023; 2:80. https://doi.org/10.56294/shp202380

Submitted: 02-11-2022 Revised: 12-05-2023 Accepted: 28-10-2023 Published: 29-10-2023

Editor: Dr. Telmo Raúl Aveiro-Róbalo

Corresponding Author: Ileana Pacheco Valdés *

ABSTRACT

An observational, descriptive, retroprospective study was conducted in patients diagnosed with laryngeal cancer who attended the central consultation for head and neck cancer in the Pinar del Río Province, in the period 2018 - 2021, with the aim of clinically and epidemiologically characterizing this disease in the province. The universe and sample consisted of 128 patients diagnosed with laryngeal cancer who met certain criteria. For information processing, a database was created in SPSS version 11.5 of Windows, with the primary data obtained from the medical records. The results were expressed in number of frequencies and percentages and were represented in tables and graphs for their understanding and presentation. Results: The age group that predominated was 50 to 59 years with 62 patients, (48,4 %), with the male sex being the most representative (76,6 %) with 98 patients. The skin color that predominated was white (44 %). The clinical stage that prevailed most was the relatively late one with 83 patients, (64,8 %). The combined treatment was the most used in 60 % with 77 patients. The risk factor that was most present in 122 patients was smoking, (95,3 %), followed by alcoholism with 97 patients (75,7 %). The Municipality that contributed the most cases of this disease was Pinar del Rio with 32 patients, (25 %). Consolación del Sur is the second area that contributed the most admissions with 16,4 % with 21 patients.

Keywords: Clinical Epidemiological; Cancer; Laryngeal Cancer.

RESUMEN

Se realizó una investigación observacional, descriptiva, retroprospectiva en pacientes diagnosticados con cáncer de laringe que acudieron a la consulta central de cáncer de cabeza y cuello de la Provincia Pinar del Río, en el período comprendido 2018 - 2021, con el objetivo de caracterizar clínica y epidemiológicamente esta enfermedad en la provincia. El universo y muestra estuvo conformado por 128 pacientes con el diagnóstico de cáncer de laringe que cumplieron con determinados criterios de inclusión. Para el procesamiento de la información se conformó una base de datos en SPSS versión 11.5 de Windows, con los datos primarios obtenidos de las historias clínicas. Los resultados se expresaron en número de frecuencias y porcentajes y se representaron en tablas y figuras para su comprensión y exposición. Resultados: El grupo de edades que predominó fue el de 50 a 59 años con 62 pacientes, (48,4 %), siendo el sexo masculino el más representativo (76,6 %) con 98 pacientes. El color de la piel que más predominó fue la blanca (44 %). La etapa clínica que más prevaleció fue la relativamente tardía con 83 pacientes, (64,8 %). El tratamiento combinado fue el más utilizado en un 60 % con 77 pacientes. El factor de riesgo que más estuvo presente en 122 pacientes fue el tabaquismo, (95,3 %), seguido del alcoholismo con 97 pacientes (75,7 %). El Municipio que más casos aportó a esta enfermedad fue Pinar del Rio con 32 pacientes, (25 %). Consolación del Sur es la segunda área que más ingresos aportó en un 16,4 % con 21 pacientes.

Palabras clave: Clínico Epidemiológico; Cáncer; Cáncer de Laringe.

INTRODUCTION

Humanity, from the most intimate corner of its history, has been marked by numerous diseases, among which cancer is one of them. The existence of cancer has been known since ancient times; in the old manuscripts of Egypt, the Edwin Smith Papyrus (3000 BC) already refers to tumors in the breast as an incurable, disfiguring, and fatal disease. Hippocrates also knew about cancer (crab), which he called Larkin's (carcinoma), and described different varieties of malignant tumors, such as those of the uterus, breast, and stomach, among others. He even pointed out the importance of early treatment in the prognosis of cancer. Over the centuries, it was given its present name, "Cancer".⁽¹⁾

Cancer is one of the most important diseases of our time, both because of its high incidence and because of its various consequences. In Western countries, it is considered the second leading cause of mortality. It is a multifactorial disease. Some cancers of the upper limit of the larynx (epilarynx) are not always clearly distinguished from those of the hypopharynx, so some studies on the epidemiology of laryngeal cancer also incorporate hypopharyngeal tumors. In this regard, it has been described that the hypopharynx and epilarynx are more exposed to ingested substances, while the endolarynx is more exposed to inhaled carcinogens.⁽²⁾

Risk factors for laryngeal and hypopharyngeal cancer: a risk factor is anything that affects the likelihood of developing a disease, such as cancer. Different types of cancer carry different risk factors. For example, smoking is a risk factor for many cancers, including lung cancer. On the other hand, exposure to strong sunlight is a risk factor for skin cancer. But risk factors don't tell the whole story. Having one or even several risk factors does not mean that a person will get the disease.

Additionally, many individuals who contract the disease may have no known risk factors. Laryngeal cancer has been considered an essential oncologic entity, representing 2 % of all tumors in the body and, according to international statistics, 25-30 % of all head and neck tumors. There is a variety of malignant laryngeal tumors, among which are epidermoid carcinoma, verrucous carcinoma, lymphoma, minor salivary gland carcinomas, melanoma, and sarcomas. Squamous carcinoma is the most frequent, accounting for 95-98 % of cases. Laryngeal cancer is more common in the male sex with a 4:1 ratio, although this pathology has increased in women in recent years. There is also evidence of a peak incidence of laryngeal cancer in the fifth and seventh decade of life.⁽³⁾

The World Health Organization (WHO) considers cancer as a global health problem. According to the latest estimates published in 2020 by the International Agency for Research on Cancer, 12,7 million new cases of cancer and 7,6 million deaths were reported. It is estimated that by the year 2030, there will be around 20 million new cases, 14 million of which will occur in underdeveloped countries.⁽⁴⁾

For its part, the Pan American Health Organization (PAHO)⁽⁵⁾ reports that from 2017 to 2019 in Latin America, the standardized mortality rate as a result of cancer is 110,7 deaths per 100 thousand inhabitants. The highest rates in the region are found in Uruguay (168,4 per 100 000 inhabitants), Cuba (143,3), and Peru (136,6).

According to estimates by Global Cancer Statistics, the increase in cancer incidence and mortality is due to two fundamental causes: the increase in the world population and the increase in life expectancy, which implies aging, without failing to take into account a real increase due to greater exposure to risk factors, especially tobacco. The increase in the number of cases in developing countries in Latin America and the Caribbean is attributed to the fact that they are witnessing an accelerated process of population aging. Head and neck carcinomas (HNC) constitute approximately 5 % of all neoplasms, being the fourth leading cause of cancer death in men. The vast majority occur in men, although in recent years, there has been an increase in the incidence of these tumors in women, mainly due to their more recent incorporation into risky practices (alcohol and tobacco).⁽⁶⁾

Cancer has become the second leading cause of death in all industrialized countries and most developing countries, which are undergoing an accelerated process of demographic transition. In the United States, in 2019, head and neck squamous cell carcinoma accounted for about 3 % of all newly diagnosed cancers, and 49 260 new ones were diagnosed in 2020; 11 480 patients died from the oral cavity, oropharyngeal, and laryngeal cancers.⁽⁷⁾

Laryngeal cancer is the most common non-cutaneous malignant tumor of the head and neck and is the second most common cancer of the respiratory tract after lung cancer. During the last decade, there was the highest age-adjusted incidence rate in the world population in men, and it was registered in Zaragoza, Spain (17,1/100 000); other areas of high incidence in men are also Northern France, Northern Italy, several areas of Central Europe, Southeastern Brazil, and Uruguay. Low-incidence countries include most regions of Africa and Western Asia, as well as English-speaking countries such as Australia, Canada, and China.⁽⁸⁾

In Cuba, head and neck squamous cell carcinoma accounted for about 3 % of all newly diagnosed cancers in 2020. The Cuban statistical yearbook reports that in 2020, 232 women and 1189 men died as a result of this disease and that the larynx, oral cavity, and oropharynx, in that order, are the locations with the most significant impact; head and neck squamous cell carcinoma ranks fourth in cancer mortality, according to the latest published figures, cancer is the leading cause of death in all age groups between 1 and 64 years old, besides being the cause that produces more years of life potentially lost.^(9,10)

The essential factor in laryngeal oncogenesis is tobacco, often associated with excessive consumption of alcoholic beverages. Specific occupational exposures also appear to be responsible for the development of this type of cancer. Despite signs of early onset, a large number of laryngeal tumors, especially supraglottic, are diagnosed at a relatively advanced stage.^(11,12)

It is estimated that a combination of cigarette smoking and alcohol consumption causes at least 75 % of head and neck cancers. Cigarette smoking, however, is associated with an increased risk of head and neck cancer among non-smokers, especially for laryngeal cancer. Similarly, alcohol consumption is associated with an increased risk of head and neck cancer in non-smokers but primarily in heavy consumers.⁽¹³⁾

Other factors implicated in the development of this type of disease include pharyngolaryngeal reflux (PLR), which is characterized by the retrograde flow of gastric contents into the laryngopharynx, where they come into contact with the tissues of the aerodigestive tract. It has been reported in up to 10 % of patients who go for ENT consultation and in more than 50 % of patients with chronic dysphonia has been linked to this disease, edematous laryngeal tissues have an increased risk of intubation damage, contact ulcers, and granulomas, and may progress to symptomatic subglottic stenosis. Although several names have been suggested for reflux-induced laryngeal disorders, the nomenclature adopted by the American Academy of Otolaryngology-Head and Neck Surgery is pharyngolaryngeal reflux.⁽¹⁴⁾

It has been suggested that pharyngolaryngeal reflux increases the risk of cancer of the pharynx and supraglottic larynx, particularly in the epilarynx (suprahyoid epiglottis and aryepiglottic folds); approximately 54 % of patients with VADS cancer have positive 24-hour test to reflux, however, although this rate is elevated it is not much different from that of people without cancer. When risk-adjusted for age, smoking, alcoholism, gender, and ethnicity, pharyngeal-laryngeal cancer is more common in patients with a history of reflux. Although pharyngolaryngeal reflux is a cause of laryngeal damage in up to 50 % of cases, there is still controversy regarding its proper role. It is very likely that the association between smoking and pharyngolaryngeal reflux (PLR) further increases the risk of laryngeal cáncer.⁽¹⁵⁾

In summary, according to the experiences, it can be risky to say that smoking is a more potent risk factor for laryngeal cancer than pharyngolaryngeal reflux (PLR). However, the latter also represents a risk factor. The importance of carrying out studies in patients with head and neck cancer (HNC) lies in the fact that there are currently several therapeutic alternatives that offer similar results in terms of survival and regional loco control of the disease. Therefore, a better knowledge of the patient's functionality and well-being after treatment can be an essential factor when choosing among the different management options.⁽¹⁶⁾

In the last two decades, significant advances have been made in the medical treatment of head and neck tumors. The hyperfractionation technique has enabled the increase of the total dose of radiotherapy received by the cancer, thereby improving local control of the disease without increasing the incidence of late adverse effects. Chemotherapy schedules for the treatment of laryngeal cancer were introduced during the 1980s, identifying a correlation between chemosensitivity and radiosensitivity. Induction chemotherapy has become a method for identifying patients who are likely to have a good response to radiotherapy.^(11,12)

Considering the complexity of this condition and the multiple etiologies and risk factors, research is justified, especially in light of the country's population aging problem, which increases the likelihood of developing cancer-toxic habits. This understanding is crucial in preparing the groundwork to address this phenomenon.

Given the above, it is proposed as an objective to clinically and epidemiologically characterize the behavior of laryngeal cancer in the province of Pinar del Río in the period from 2018 to 2021.

METHOD

An observational, descriptive, retroprospective, descriptive research was conducted in patients diagnosed with laryngeal cancer who attended the central consultation of head and neck cancer at the Abel Santamaría Cuadrado Hospital in Pinar del Río Province, in the period from January 1, 2018 to December 31, 2021.

The universe and sample consisted of 128 patients with the diagnosis of larynx cancer diagnosed at the Abel Santamaría Cuadrado Hospital in Pinar del Río Province, in the study period.

Method

The following research methods were used:

Theoretical methods allowed reaching conclusions and making generalizations, as well as identifying, interpreting, systematizing and deepening the results. Among them were:

· Historical-logical: for the study of the theoretical references related to the clinical and epidemiological characteristics of laryngeal cancer internationally, nationally and in a particular way in the central consultation of head and neck cancer during the period of 2018-2021, the assessment of the evolution of the patient according to clinical stage of diagnosis.

· Systemic-structural: it allowed determining the clinical and epidemiological relationship of patients with larynx cancer in Pinar del Rio.

· Modeling: it allowed defining the indicators for the correct treatment of larynx cancer.

· Analysis and synthesis: to know the qualities of the object of study and its internal relationships during the research.

· Induction and deduction: to reach generalizations about the object of study and to identify and understand particular phenomena within it.

The empirical methods used to obtain data on the object of study were:

· Document análisis:

o Review of clinical histories in the central consultation of head and neck cancer.

o Search in publications: guidelines, regulations and international publications, in physical or electronic support, referred to the subjects of study.

o Study of archives: it refers to international documents from WHO and PAHO, presentations (regulations, resolutions, regulations, instructions, circulars, reports, statistics and primary data from MINSAP archives, the Regulatory Bureau for the Protection of Public Health, CECMED, among others).

Statistical methods: descriptive statistics with distribution of absolute and relative frequencies were used. The results obtained will be presented in tables and graphs for better understanding.

Data collection technique

The clinical histories were reviewed in the central consultation of head and neck cancer of the patients attended in the period evaluated at the Hospital: Abel Santamaría Cuadrado, where the necessary data were found to give values to the different variables.

Processing and analysis of the information

For the processing of the information, a database was formed in SPSS version 11.5 of Windows, with the primary data obtained from the clinical histories. The results were expressed in number of frequencies and percentages and were represented in tables and graphs for their comprehension and exposition.

Ethical aspects of the study

The ethical values that were taken into account are those that correspond to the most important basic principles in the ethics of research with human beings, which are listed below:

· Respect for the person.

· Beneficence.

· Justice.

· Non-maleficence.

The data were obtained from individual medical records. The results obtained will only be used for presentation at scientific events or for publication in biomedical journals of recognized prestige.

RESULTS

Table 1. Patients with laryngeal cancer according to age group and sex
Age group	Sex				Total
	Female		Male		Total
	No.	%	No.	%	No.	%
50 to 59 years old	17	13,2	45	35,2	62	48,4
60 to 69 years old	11	8,6	36	28,1	47	36,8
70 to 79 years	2	1,6	14	11,1	16	12,6
80 and over	-		3	2,2	3	2,2
Total	30	23,4	98	76,6	128	100

Table 1 shows that the predominant age group was 50 to 59 years with 62 patients, representing 48,4 %, with the male sex being the most representative in 76,6 % with 98 patients.

Figure 1. Distribution of patients with laryngeal cancer according to skin color

Figure 1 shows that the most predominant skin color was white (44 %).

Table 2. Distribution of patients with laryngeal cancer according to clinical stage at diagnosis of the disease
Clinical stage at diagnosis	No.	%
Early	31	24,2
Relatively Late	83	64,8
Very Late	14	11
Total	128	100

The most prevalent clinical stage at diagnosis of the disease was the relatively late stage with 83 patients, representing 64,8 % of the total (table 2).

Table 3. Distribution of patients with laryngeal cancer according to the treatment scheme used
Treatment schedules	No.	%
Radiotherapy.	7	5,3
Chemotherapy.	6	4,7
Surgical treatment.	38	30
Combined Treatment	77	60
Total	128	100

Table 3 shows the different treatment schemes, where the combined treatment was the most used in 60 % with 77 patients.

Figure 2. Distribution of patients with laryngeal cancer according to risk factors

Considering the risk factors, it can be seen in graph 2 that smoking was present in 122 patients, which represented 95,3 % of the total, followed by alcoholism with 97 patients (75,7 %).

Table 4. Stratification of the incidence of patients diagnosed with laryngeal cancer according to municipality
Municipalities	No.	%
Pinar del Río	32	25
Consolación del Sur	21	16,4
San Juan y Martínez	14	11
Viñales	14	11
Los Palacios	11	8,6
San Luis	10	7,8
La Palma	9	7
Guane	6	4,6
Sandino	4	3,1
Mantua	4	3,1
Matahambre Mines	3	2,3
Total	128	100

Table 4 shows that the municipality that contributed the most cases to this disease was Pinar del Rio with 32 patients, for 25 %. Consolación del Sur is the second area that contributed the most admissions to the study with 16,4 % with 21 patients.

DISCUSSION

The results obtained in this work are similar to those of studies carried out in France and Spain⁽¹⁷⁾ and correspond to research conducted at INOR (Institute of Oncology and Radiobiology) by Díaz et al.⁽¹⁸⁾ who state that the disease is more frequent between 50 and 70 years of age. However, cases have been reported in individuals between 20 and 30 years of age, as well as those above 80 years of age. In the same study conducted at INOR, 18 out of 630 patients evaluated showed a male predominance, with 558 patients being male. At the same time, among women, only 71 were found, resulting in a ratio of 7,75 to 1 in favor of the male sex. The high incidence of these tumors, mainly in men, highlights the importance of this disease as a health problem in the literature consulted, with a ratio of 10 to 1 concerning women.^(19,20,21)

Castillo-López et al.⁽²²⁾ state that for malignant tumors of the larynx, there was a general predominance of the male sex (86 %). The average age of presentation was 65 ± 11 years, with a median of 66 years and a mode of 68 years. An analysis by age group showed that the most affected group was those aged 60 to 69 years. The present study also coincides with Yang PC et al.⁽²³⁾ who refer that the higher frequency of laryngeal cancer in men than in women is well recognized.

Several studies have highlighted a high frequency of laryngeal cancer in the male sex, and it has been associated with higher tobacco and alcohol consumption in men.⁽²⁴⁾ In agreement with this approach, we found that, when comparing both sexes, eliminating the tobacco risk factor, laryngeal cancer continues to be more frequent in men.⁽¹³⁾

Male sex is a sufficient risk factor for laryngeal cancer. These findings suggest that there may be sex-related factors that influence the occurrence of these tumors. Consistent with this approach, we found that, when comparing both sexes, eliminating the risk factor of smoking, laryngeal cancer continues to be more frequent in men. These findings suggest that there may be sex-related factors influencing the occurrence of these tumors.⁽²⁴⁾

The results for white skin color are consistent with those reported by other authors.^(18,22) Laryngeal and hypopharyngeal cancers are more common among whites and blacks than among Asians and Hispanic Latinos.⁽²²⁾

The relatively late clinical stage at diagnosis of the disease coincides with results similar to those of Castillo-López et al.⁽²²⁾, who reported that, in their study, the time between the onset of symptoms and the request for medical attention was also relatively late. When the time of evolution is grouped, 22 % of the patients sought medical attention during the first 5 months of symptom onset. However, slightly more than half of the patients (54,5 %) did so before the first year. They also report that the stage of the pathology was early (stage 0-II) in more than half of the cases (58 %), excluding those with incomplete data.

Early laryngeal cancer is generally managed with standard therapy, while in advanced disease, the decision is individualized.^(24,25)

The combined treatment scheme used proved to be the most widely adopted due to the reports of improvement obtained; these results align with some reported in the literature consulted.^(24,25)

In patients with advanced stages, the therapeutic decision is evaluated by the oncologic committee and ENT specialists, taking into account the patient's clinical condition. Regarding the management of advanced cancer, it should be noted that some patients follow the exclusive surgical treatment protocol, and the vast majority of patients follow the combined treatment of surgery and chemotherapy.^(26,27,28)

The risk factors of smoking and alcoholism are related to multiple cancers, including laryngeal cancer; these results are similar to those shown by Castillo-López and collaborators22who report that a history of smoking was present in 78,6 % (136) of the patients, and 80 % continued to smoke at the time of their initial clinical interview. Eighty-nine percent of the men reported a positive smoking history, while this was only reported in 11 % of the women, showing a statistically significant difference.

Some authors agree that environmental, occupational, and endogenous factors may play a role in the carcinogenesis of laryngeal carcinoma; high tobacco and alcohol consumption are considered to be the main risk factors for laryngeal squamous cell carcinoma. In addition, alcohol-tobacco intoxication is synergistic in the genesis of epidermoid carcinoma, which increases the risk by 50 % compared to the non-intoxicated population.^(27,28)

Others suggest that gastroesophageal reflux increases the risk of cancer of the pharynx and supraglottic larynx, particularly in the epi larynx (suprahyoid epiglottis and aryepiglottic folds).^(29,30)

Tobacco consumption is a risk factor related to the development of tumors of epidermal origin, and in our sample, it is nine times higher in men than in women.⁽²³⁾

The presenting symptoms of laryngeal cancer are highly variable and depend on the site and size of the tumor. For example, early-stage glottic tumors manifest clinically with dysphonia, whereas supraglottic tumors tend to manifest with dysphagia, pain, or dysphonia.⁽¹⁷⁾

Dysphonia manifests initially in 80 % of patients, but when it was a supraglottic tumor, dysphagia was the most common presenting symptom; even though the glottic tumor gives very early symptoms, it is frequent that the patient does not request timely medical evaluation before 6 months or one year.^(24,25)

This delay in diagnosis is also referred to by other authors ^(31,32) who describe the presence of other symptoms, such as airway compromise, swallowing difficulty, or even palpable masses in the neck. Early diagnosis of the patient could be related to timely care, which would result in a better prognosis and a more prolonged disease-free survival. Even in treatment strategies for laryngeal preservation. 18 However, the association of smoking (Reinke's edema), associated infections (human papillomavirus), laryngopharyngeal reflux, and other factors may be related to intermittent dysphonia, which makes it difficult to establish with precision the onset of symptoms, and many times the patient refers them of very long evolution with an increase in the last months.^(33,34)

The prevalence of smoking and/or alcohol consumption is essential, being present in the majority of patients.⁽³⁵⁾

Dysphonia was reported as the initial symptom in 81 % (140) of patients, followed by dysphagia; the latter was related to supraglottic tumors with a statistically significant difference (p = 0,003), according to Castillo-López et al.⁽²²⁾.

When analyzing the stratification of the incidence of patients diagnosed with laryngeal cancer according to the municipality, Pinar del Río and Consolación del Sur were identified as municipalities that have a geographical extension and a higher population density than the rest of the municipalities; Pinar del Río, being the head municipality of the province, concentrates more population, so it is justified that these addictions and inadequate lifestyles that affect their health increase.

These results coincide with those reported by Hernández García et al.⁽³⁶⁾ in a study conducted at the Abel Santamaría Hospital in 2014. It was found that the distribution of patients according to their geographical origin showed that the most affected municipality was Pinar del Río, with 32 % (which coincides with the one with the highest population density), followed by Consolación del Sur, with 14 %, and Guane with 11 % of the cases.

These elements are handled in studies carried out for the behavior of the geographic variability of laryngeal cancer; in the investigations carried out in Cuba and other countries, the incidence is analyzed by provinces but not taking into account the distribution by municipalities.⁽³⁷⁾

It was found that patients with laryngeal cancer are admitted to the hospital in advanced stages of the disease, distinguishing the glottic-subglottic location for the three most affected municipalities with the highest percentage increase.⁽³⁸⁾

In sum, laryngeal cancer is a pathology of significant impact in otorhinolaryngology and head and neck surgery with a relatively stable epidemiological profile.^(39,40)

CONCLUSIONS

The predominant age group was 50 to 59 years, male sex and white skin color. The most prevalent clinical stage at diagnosis of the disease was relatively late. Combined treatment was the most frequently used. The risk factor that was most present was smoking, followed by alcoholism. The municipality that contributed most cases to this disease was Pinar del Rio, followed by the municipality of Consolación del Sur.

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FINANCING

The authors did not receive funding for the development of the present research.

CONFLICT OF INTEREST

The authors declare that there is no conflict of interest.

AUTHORSHIP CONTRIBUTION

Conceptualization: Ileana Pacheco Valdés, Modesto Cordovés Jerez, Raúl Rodríguez González, José Roberto Fernández Barrera, Humberto López Benítez.

Data curation: Ileana Pacheco Valdés, Modesto Cordovés Jerez, Raúl Rodríguez González, José Roberto Fernández Barrera, Humberto López Benítez.

Formal analysis: Ileana Pacheco Valdés, Modesto Cordovés Jerez, Raúl Rodríguez González, José Roberto Fernández Barrera, Humberto López Benítez.

Research: Ileana Pacheco Valdés, Modesto Cordovés Jerez, Raúl Rodríguez González, José Roberto Fernández Barrera, Humberto López Benítez.

Methodology: Ileana Pacheco Valdés, Modesto Cordovés Jerez, Raúl Rodríguez González, José Roberto Fernández Barrera, Humberto López Benítez.

Project administration: Ileana Pacheco Valdés, Modesto Cordovés Jerez.

Resources: Ileana Pacheco Valdés, Modesto Cordovés Jerez, Raúl Rodríguez González, José Roberto Fernández Barrera, Humberto López Benítez.

Supervision: Ileana Pacheco Valdés, Modesto Cordovés Jerez, Raúl Rodríguez González, José Roberto Fernández Barrera, Humberto López Benítez.

Validation: Ileana Pacheco Valdés, Modesto Cordovés Jerez, Raúl Rodríguez González, José Roberto Fernández Barrera, Humberto López Benítez.

Visualization: Ileana Pacheco Valdés, Modesto Cordovés Jerez, Raúl Rodríguez González, José Roberto Fernández Barrera, Humberto López Benítez.

Writing - original draft: Ileana Pacheco Valdés, Modesto Cordovés Jerez, Raúl Rodríguez González, José Roberto Fernández Barrera, Humberto López Benítez.

Writing - revision and editing: Ileana Pacheco Valdés, Modesto Cordovés Jerez, Raúl Rodríguez González, José Roberto Fernández Barrera, Humberto López Benítez.