Radiation and Second Primary Thyroid Cancer Following Index Head and Neck Cancer

OBJECTIVES/HYPOTHESIS

Radiation is thought to increase risk of developing second primary thyroid cancer (SPTC). This study estimated the rate of SPTC following index head and neck cancer (HNC) and determined whether radiation treatment among HNC survivors increased SPTC risk.

STUDY DESIGN

Retrospective data analysis.

METHOD

The Surveillance, Epidemiology, and End Results database (1975-2014) was queried for cases of index HNC (N = 127,563) that developed SPTC. Adjusted multivariable competing risk proportional hazards model tested risk of developing a SPTC following index HNC. Sensitivity analyses using proportional hazards models were also performed restricting data to patients who 1) received both radiation and chemotherapy and 2) radiation alone.

RESULTS

Only 0.2% of index HNC survivors (n = 229) developed SPTC, yielding a rate of 26.1 per 100,000 person-years. For every increasing year of age at diagnosis, patients were 3% less likely to develop an SPTC (adjusted hazard ratio [aHR] = 0.97, 95% CI: 0.96-0.98). Males were also less likely to develop an SPTC (aHR = 0.73, 95% CI: 0.55-0.96). Radiation (aHR = 0.92, 95% CI: 0.68-1.25), surgery (aHR = 0.79, 95% CI: 0.56-1.11), and chemotherapy (aHR = 1.13, 95% CI: 0.76-1.69) were not significantly associated with developing SPTC. The sensitivity models also did not find an association between treatment and risk of SPTC.

CONCLUSIONS

Rate of developing SPTC following index HNC was very low, and previous exposure to radiation did not significantly increase risk in our study population. More studies are needed to understand the increasing incidence of thyroid cancer across the United States.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:1014-1020, 2019.

Utility of intraoral ultrasound in managing oral tongue squamous cell carcinoma: Systematic review

OBJECTIVES/HYPOTHESIS

Adequate surgical resection of early stage oral tongue cancer provides the best chance at preventing locoregional disease recurrence. Determination of tumor dimensions and margin location is challenging and can lead to inadequate resections with close/positive margins. Ultrasonography has proven its utility in determining the thickness and extent of tongue tumors. Preoperative tumor dimension measurements carry increased significance with the addition of depth of invasion (DOI) to the eighth edition of the American Joint Committee on Cancer (AJCC) TNM staging system. We report the results of a systematic review of the literature pertaining to the use of ultrasound in the diagnosis and management of oral tongue carcinoma.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-analysis statement checklist was used to inform the design of this systematic review. All studies that utilized ultrasound in the diagnosis/management of primary carcinoma of the oral tongue were included. PubMed, Embase, and Cochrane were reviewed to identify eligible studies.

RESULTS

Nineteen articles were included in our analysis. Six hundred seventy-eight patients were studied in the articles included. Ultrasound tumor thickness measurements correlate well with those on histopathology and show promise as a predictor of cervical lymph node metastasis. Ultrasound can be safely used intraoperatively for deep margin assessment.

CONCLUSIONS

Ultrasound is useful in the evaluation of oral tongue malignancies. More experience is needed to determine if it is reliable in determining preoperative DOI in light of the role this tumor parameter plays in the eighth edition of the AJCC staging manual. Laryngoscope, 129:662-670, 2019.

Bundled Payments in Otolaryngology: Early Lessons from Arkansas

The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 established value-based reimbursement as the new norm in health care. As part of this shift, public and private insurers have adopted bundled payments in an effort to improve quality and control cost. Arkansas recently implemented an otolaryngology-specific bundled payment, which reimburses episodes of care involving adenoidectomy and/or tonsillectomy. In this mandatory model, otolaryngologists have the potential for shared savings or losses based on spending relative to risk-adjusted historical benchmarks and performance on quality metrics. The initiative has resulted in reduced health care costs and rates of postoperative antibiotic prescription and secondary bleeding. However, this experiment also illustrates potential pitfalls with bundled payments, such as emphasis of quality metrics lacking clinical relevance and incentive for increased service volume. The Arkansas initiative offers important lessons for otolaryngologists as ongoing reform under MACRA brings episode-based care to the forefront of our field.

Abstract 4255: Differences in the sociodemographic correlates of HPV-associated cancer survival in the United States

Purpose: Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States. One in every four individuals-nearly 80 million-is infected. More than 38,000 new cases of HPV-associated cancers are diagnosed annually. However, factors related to HPV-associated cancer survivorship, based on primary anatomic site, remain understudied. The aim of this study was to assess sociodemographic factors related to survival following diagnosis of HPV-associated cancers in the United States.

Methods: Patients ≥18 years diagnosed with first-primary HPV-associated cancer between 2007 and 2014 were identified from the Surveillance, Epidemiology, and End Results 18. HPV-associated cancers sites were defined as anal, cervical, oropharyngeal, penile, vaginal, and vulvar per the International Classification of Diseases for Oncology, third edition codes. Kaplan-Meier curves showing cancer-specific survival (CSS) from each HPV-associated cancer site stratified by sex with differences assessed by log-rank tests. Fine and Gray proportional hazards regression models for each HPV-associated site controlled for clinical covariates and estimated sociodemographic predictors of hazard of death from cancer.

Results: A total of 63,329 patients with HPV-associated cancers were included in the analyses. The most common sites were cervix for females (58%) and oropharynx for males (78%). Overall 8-year survival at the end of follow-up was 56%. For males, anal cancer had the lowest CSS (62%) compared to oropharyngeal (69%) and penile (72%) cancer (p<0.01). For females, vaginal cancer had the lowest CSS (46%) compared to anal (71%), cervical (67%), oropharyngeal (57%), and vulvar (72%) cancer. Final adjusted model showed significant CSS differences based on sociodemographic factors, including sex, age, marital status, race/ethnicity, and insurance status. Males were more likely to die from anal cancer compared to females (aHR=1.53, 95% CI 1.39, 1.68), while less likely than females to die from oropharyngeal cancer (aHR=0.91, 95% CI 0.84, 0.98). Blacks were more likely to die from anal (aHR=1.33, 95% CI 1.16, 1.52), cervical (aHR=1.13, 95% CI 1.05, 1.22), and oropharyngeal cancer (aHR=1.54, 95% CI 1.41, 1.68) compared with Whites. Each increasing year of diagnosis was associated with a 1-3% increase in hazard of cancer-specific death for all cancers.

Conclusions: There is marked variability in sociodemographic correlates among HPV-associated cancer survivors in the United States, based on sex, age, insurance and marital status, race/ethnicity, and cancer type. This has important implications for clinical decision making and identification of populations at greater risk of death from HPV-associated cancers.

Citation Format: Nosayaba Osazuwa-Peters, Matthew C. Simpson, Eric Adjei Boakye, Kahee A. Mohammed, Longwen Zhao, Sai D. Challapalli, Rebecca L. Rohde, Vy T. Pham, Sean T. Massa, Mark A. Varvares. Differences in the sociodemographic correlates of HPV-associated cancer survival in the United States [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 4255.

Abstract C54: Survival outcomes for head and neck patients with Medicaid: A health insurance paradox

Introduction: Although there are currently more than 430,000 head and neck cancer (HNC) survivors in the United States, it is accepted that many more patients would have survived longer if they presented at an earlier stage. Less than half of all head and neck cancer patients present with early-stage disease. One of the factors implicated in late stage of presentation for head and neck cancer patients is access to care, driven by health insurance status. While individuals with health insurance are known to present earlier, less is known about outcome differences for patients who are uninsured or who have Medicaid insurance. We have observed many head and neck cancer patients initially present without insurance despite qualifying for Medicaid, and so are assisted with obtaining insurance before discharge. This process blurs the line between uninsured and Medicaid patients. The aim of this study was to determine whether there are disparities in survival outcomes for HNC patients based on whether they are insured, uninsured, or have Medicaid insurance.

Methods: A cohort of 49,524 patients aged 18-64 years with first primary HNC from the Surveillance, Epidemiology, and End Results (SEER) 18 database diagnosed from 2007-2014 was included. Actuarial survival curves stratified by insurance status (insured, Medicaid, and uninsured) were created to determine HNC-specific survival differences between the groups with a log-rank test. Patient characteristics including insurance, race/ethnicity, sex, county-level poverty, surgery, marital status, tumor site, stage, year of diagnosis, and age at diagnosis were utilized in a Fine and Gray competing risk proportional hazard model to compute adjusted hazard ratios (aHR) for cause-specific death from HNC. Multinomial logistic regression was also performed to determine characteristics of patients with each type of insurance by adjusted odds ratios (aOR).

Results: The cohort was mostly male (75.6%) and insured (73.6%), with 18.6% on Medicaid and 7.8% uninsured. At the end of the 7-year follow-up period, HNC-specific survival rate was significantly lower for patients on Medicaid (49.5%) than uninsured (54.8%) and insured patients (74.2%) (log-rank p < 0.001). After controlling for other prognostic demographic and clinical factors, patients on Medicaid (aHR=1.63, 95% CI: 1.54, 1.71) and uninsured patients (aHR=1.33, 95% CI: 1.43, 1.64) had higher hazard of death from HNC compared to insured patients. Compared with non-Hispanic whites, other race/ethnicity groups were more likely to be on Medicaid, with non-Hispanic American Indians/Alaska Natives being the most likely (aOR=3.46, 95% CI: 2.66, 4.51). Medicaid were more likely not have received surgery than insured patients (aOR=1.34, 95% CI: 1.26, 1.42). They were also more likely to present at advanced disease.

Conclusion: While patients with health insurance had better survival outcome in general, our study showed that patients with Medicaid did not have a better survival outcome than those without any insurance after adjusting for all other prognostic factors, including stage of presentation and treatment modality. Medicaid patients, in fact, had worse outcome than uninsured HNC patients. It could be that despite having insurance, Medicaid patients did not have adequate access to care and thus had delayed presentations. Our findings highlight the need to bridge the health insurance gap for HNC patients to increase survivorship.

Citation Format: Nosayaba Osazuwa-Peters, Matthew C. Simpson, Sean T. Massa, Eric Adjei Boakye, Lauren M. Cass, Sai Deepika Challapalli, Rebecca L. Rohde, Mark A. Varvares. Survival outcomes for head and neck patients with Medicaid: A health insurance paradox [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr C54.

Correlates of human papillomavirus (HPV) vaccination initiation and completion among 18-26 year olds in the United States

PURPOSE

To examine correlates of HPV vaccination uptake in a nationally representative sample of 18-26-year-old adults.

METHODS

Young adults aged 18-26 years were identified from the 2014 and 2015 National Health Interview Survey (n = 7588). Survey-weighted multivariable logistic regression models estimated sociodemographic factors associated with HPV vaccine initiation (≥1 dose) and completion (≥3 doses).

RESULTS

Approximately 27% of study participants had initiated the HPV vaccine and 16% had completed the HPV vaccine. Participants were less likely to initiate the vaccine if they were men [(adjusted odds ratio) 0.19; (95% confidence interval) 0.16-0.23], had a high school diploma (0.40; 0.31-0.52) or less (0.46; 0.32-0.64) vs. college graduates, and were born outside the United States (0.52; 0.40-0.69). But, participants were more likely to initiate the HPV vaccine if they visited the doctor's office 1-5 times (2.09; 1.56-2.81), or ≥ 6 times (1.86; 1.48-2.34) within the last 12 months vs. no visits. Odds of completing HPV vaccine uptake followed the same pattern as initiation. And after stratifying the study population by gender and foreign-born status, these variables remained statistically significant.

CONCLUSIONS

In our nationally representative study, only one out of six 18-26 year olds completed the required vaccine doses. Men, individuals with high school or less education, and those born outside the United States were less likely to initiate and complete the HPV vaccination. Our findings suggest that it may be useful to develop targeted interventions to promote HPV vaccination among those in the catch-up age range.

Assessing university students' sexual risk behaviors as predictors of human papillomavirus (HPV) vaccine uptake behavior

OBJECTIVES

There exists a significant gap in vaccine coverage of the human papillomavirus (HPV) among college-aged students. This study assessed sexual risk-taking behavior among university students and analyzed predictors of HPV vaccine initiation and completion in this population.

MATERIALS AND METHODS

Data (n = 746) were from an anonymous online, cross-sectional survey distributed to university students, between the ages of 19-26 years, at a private Midwestern university. Both chi-square and multivariable logistics regression models estimated the association between sociodemographic characteristics and sexual risk factors (including number of vaginal sexual partners, number of oral sexual partners, initiation of oral sex, and initiation of vaginal sex), with HPV vaccine initiation and completion.

RESULTS

A significant number of participants (40%) had not received a single dose of the HPV vaccine series. Of those who initiated the series, more than half (51%) did not achieve completion. Additionally, a greater number of participants have had multiple (4 or more) oral sexual partners than vaginal sexual partners (25.7% vs. 20.3%). After adjusting for covariates, it was found that sexual risk factors were not significantly associated with HPV vaccine initiation or completion.

CONCLUSION

HPV vaccine initiation and completion rates are suboptimal among university students. High levels of sexual-risk taking behaviors associated with HPV infection persist, yet are not significant predictors of HPV vaccine behaviors in this age group. To increase uptake among 18-26-year-old students, future public health interventions should focus on HPV vaccine education and uptake across the entire population, irrespective of sexual risk profile.

The Merit-based Incentive Payment System (MIPS): A Primer for Otolaryngologists

Following passage of the 2015 Medicare Access and CHIP Reauthorization Act, most clinicians caring for Medicare Part B patients were required to participate in a new value-based reimbursement system known as the Merit-based Incentive Payment System (MIPS) beginning in 2017. The MIPS adjusts payment rates to providers based on a composite score of performance across 4 categories: quality, advancing care information, clinical practice improvement activities, and resource use. However, factors such as practice size, setting, informational capabilities, and patient population may pose challenges as otolaryngologists endeavor to adapt to this broad-reaching payment reform. Given potential barriers to adoption, otolaryngologists should be aware of several important initiatives to help optimize their performance, including advocacy efforts by the American Academy of Otolaryngology—Head and Neck Surgery, the development of otolaryngology-specific MIPS quality measures, and the launch of a Centers for Medicare & Medicaid Services–qualified otolaryngology clinical data registry to facilitate reporting.

Preoperative laboratory data are associated with complications and surgical site infection in composite head and neck surgical resections

OBJECTIVES

1) Describe normal/abnormal preoperative laboratory testing incidence in head and neck (H&N) composite resections and 2) determine complication, surgical site infection (SSI), and transfusion predictors by laboratory test.

METHODS

The 2006 to 2013 NSQIP databases were queried for H&N composite resections. Laboratory data was categorized within, under, or above the normal reference range according to NSQIP definitions. Overall complications and SSI were analyzed with multivariable logistic regression analysis.

RESULTS

From 2006 to 2013, there were 1193H&N composite resections, of which 1135 (95.1%) underwent ≥1 preoperative laboratory test. Complete blood counts were obtained in 92.3%, basic metabolic panels in 90.7%, coagulation studies in 56.2%, and liver function tests (LFTs) in 52.6%. Low sodium was found in 11.5%, increasing complication odds by 2.30 (p = 0.005). High AST comprised 10.0% and increased complication odds (OR = 2.93, p = 0.012). Additionally, 9.2% had a high white blood cell (WBC) count and 3.5% had high platelets, increasing complications by 1.92 (p = 0.030) and 3.13 (p = 0.015), respectively. BUN, creatinine, total bilirubin, albumin, alkaline phosphatase, INR, PT, and aPTT abnormal values did not affect postoperative complications. Increased SSI odds were appreciated with low sodium (OR: 2.83, p = 0.002), high AST (OR: 6.85, p < 0.001), and high alkaline phosphatase (OR: 5.46, p = 0.007). Importantly, INR had no effect on transfusion rates. High PT, aPTT, or low platelets did not change transfusion odds.

CONCLUSION

Inflammatory markers are associated with complications but not SSI. High LFTs and low sodium are associated with complications and SSI. Coagulopathies did not increase transfusion rates. These findings identify laboratory studies to focus on during H&N resection preoperative assessments.

SALL1 functions as a tumor suppressor in breast cancer by regulating cancer cell senescence and metastasis through the NuRD complex

Background

SALL1 is a multi-zinc finger transcription factor that regulates organogenesis and stem cell development, but the role of SALL1 in tumor biology and tumorigenesis remains largely unknown.

Methods

We analyzed SALL1 expression levels in human and murine breast cancer cells as well as cancer tissues from different types of breast cancer patients. Using both in vitro co-culture system and in vivo breast tumor models, we investigated how SALL1 expression in breast cancer cells affects tumor cell growth and proliferation, metastasis, and cell fate. Using the gain-of function and loss-of-function strategies, we dissected the molecular mechanism responsible for SALL1 tumor suppressor functions.

Results

We demonstrated that SALL1 functions as a tumor suppressor in breast cancer, which is significantly down-regulated in the basal like breast cancer and in estrogen receptor (ER), progesterone receptor (PR) and epidermal growth factor receptor 2 (HER2) triple negative breast cancer patients. SALL1 expression in human and murine breast cancer cells inhibited cancer cell growth and proliferation, metastasis, and promoted cell cycle arrest. Knockdown of SALL1 in breast cancer cells promoted cancer cell growth, proliferation, and colony formation. Our studies revealed that tumor suppression was mediated by recruitment of the Nucleosome Remodeling and Deacetylase (NuRD) complex by SALL1, which promoted cancer cell senescence. We further demonstrated that the mechanism of inhibition of breast cancer cell growth and invasion by SALL1-NuRD depends on the p38 MAPK, ERK1/2, and mTOR signaling pathways.

Conclusion

Our studies indicate that the developmental control gene SALL1 plays a critical role in tumor suppression by recruiting the NuRD complex and thereby inducing cell senescence in breast cancer cells.

Electronic supplementary material

The online version of this article (10.1186/s12943-018-0824-y) contains supplementary material, which is available to authorized users.

Suicide risk among cancer survivors: Head and neck versus other cancers

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Background: While head and neck cancer (HNC) only accounts for 4% of new cancer cases in the United States, incidence of HNC-associated suicide may be significantly higher due to quality of life issues associated with HNC survivorship. This study estimated incidence of HNC-associated suicide versus other common cancers, and quantified suicide rate among HNC survivors compared with non-HNC. Methods: We queried the Surveillance, Epidemiology and End Results 18 database from 2000-2014 for all cancer deaths confirmed as suicide. Mortality rates from suicide was estimated for the 21 most common cancers in the United States, including HNC. Negative binomial regression estimated mortality rate ratios (MRRs) and 95% confidence intervals (CIs), between HNC and the other 20 other cancers combined, and as individual sites. Models were stratified by sex (when applicable), controlling for race, marital status, age, year and stage of diagnosis. Results: There were 4,769 suicides observed among 4,613,123 cancer survivors from 2000-2014, yielding an incidence rate of 23.6 suicides per 100,000 person-years. Combined, all other cancers had a 45% decreased suicide ratio compared to HNC for both males (MRR = 0.55, 95% CI 0.48, 0.64) and females (MRR = 0.55, 95% CI 0.37, 0.81). For specific cancer sites, only pancreatic cancer had a higher mortality rate due to suicide than HNC (86.4 suicides per 100,000 person-years, versus 63.4 suicides per 100,000 person-years). Stratified by gender, only male pancreatic cancer survivors had a significantly higher suicide MRR compared with HNC (MRR = 1.54, 95% CI 1.23, 1.90). For females, all cancer sites (including pancreas) had either significantly or insignificantly lower suicide MRR compared with HNC. Conclusions: Risk of suicide is significantly higher among HNC survivors compared to all other cancers, except pancreatic cancer. Our findings confirm that HNC survivors are prime candidates for lifelong psychosocial surveillance.

Salvage of recurrence after surgery and adjuvant therapy: A systematic review

PURPOSE

To determine the oncologic and functional outcomes of patients undergoing salvage surgery for recurrent head and neck squamous cell carcinoma after initial management with surgery and adjuvant therapy.

DATA SOURCES

Ovid Medline, Embase, Scopus, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, Cochrane Database of Systematic Reviews, and Clinicaltrials.gov.

REVIEW METHODS

A structured search was performed of the literature to identify studies that included patients undergoing surgical salvage for local, regional, or locoregional recurrent head and neck squamous cell carcinoma without known distant metastases who had been treated with initial surgery and post-operative adjuvant radio- or chemoradiotherapy. Studies were excluded if they did not report at least 1-year survival estimates, included patients who underwent primary non-surgical management, or included those treated with non-surgical salvage therapies or supportive care alone.

RESULTS

The search strategy yielded 3746 abstracts. After applying exclusion and inclusion criteria, 126 full-texts were reviewed and six studies were included with a total of 222 patients. All studies were retrospective in design and included diverse disease subsites and stages. Complications and functional outcomes were inconsistently reported. Five-year survival estimates ranged between 10% and 40% between studies.

CONCLUSIONS

Patients undergoing salvage surgery for recurrent head and neck squamous cell carcinoma after initial surgery and adjuvant therapy may have a particularly poor prognosis. Future studies are needed to determine functional and quality of life outcomes in this patient population and to identify specific prognostic factors for re-recurrence and survival.

Intraoperative Ultrasound in Oral Tongue Cancer Resection: Feasibility Study and Early Outcomes

The current standard of care in oral tongue cancer surgery is complete resection with a target of 5-mm microscopic clearance at all margins on final pathologic review. While current methods of resection are often successful at determining the mucosal margins of the lesion, they may be limited when attempting to achieve an adequate deep margin. A number of previous studies suggested that ultrasound is superior to manual palpation and other imaging modalities (computed tomography, magnetic resonance imaging) at demarcating the margins of tongue lesions. Recent clinical reports of the intraoperative use of this modality have used an invasive method to mark the proposed deep resection margin. In this communication, we report our initial experience with the use of intraoperative ultrasound as an adjunct to oral tongue cancer surgery without the use of an invasive method to mark the deep resection margin.

Association Between Head and Neck Squamous Cell Carcinoma Survival, Smoking at Diagnosis, and Marital Status

Importance

While the adverse association between smoking and head and neck squamous cell carcinoma (HNSCC) survival has been well described, there are also inconclusive studies and those that report no significant changes in HNSCC survival and overall mortality due to smoking. There is also a lack of studies investigating the association of marital status on smoking status at diagnosis for patients with HNSCC.

Objective

To examine the association between patient smoking status at HNSCC diagnosis and survival and the association between marital status and smoking in these patients.

Design, Setting, and Participants

This retrospective cohort study was conducted by querying the Saint Louis University Hospital Tumor Registry for adults with a diagnosis of HNSCC and treated at the university academic medical center between 1997 and 2012; 463 confirmed cases were analyzed.

Main Outcomes and Measures

Cox proportional hazards regression analysis was used to evaluate association of survival with smoking status at diagnosis and covariates. A multivariate logistic regression model was used to assess whether marital status was associated with smoking at diagnosis adjusting for covariates.

Results

Of the 463 total patients (338 men, 125 women), 92 (19.9%) were aged 18 to 49 years; 233 (50.3%) were aged 50 to 65 years; and 138 (29.8%) were older than 65 years. Overall, 56.2% of patients were smokers at diagnosis (n = 260); 49.6% were married (n = 228); and the mortality rate was 54.9% (254 died). A majority of patients were white (81.0%; n = 375). Smokers at diagnosis were more likely to be younger (ie, <65 years), unmarried, and to drink alcohol. We found a statistically significant difference in median survival time between smokers (89 months; 95% CI, 65-123 months) and nonsmokers at diagnosis (208 months; 95% CI, 129-235 months). In the adjusted Cox proportional hazards model, patients who were smokers at diagnosis were almost twice as likely to die during the study period as nonsmokers (hazard ratio, 1.98; 95% CI, 1.42-2.77). In the multivariate logistic regression analysis, unmarried patients were 76% more likely to use tobacco than married patients (adjusted odds ratio, 1.76; 95% CI, 1.08-2.84).

Conclusions and Relevance

Smokers were almost twice as likely as nonsmokers to die during the study period. We also found that those who were married were less likely to be smokers at diagnosis. Our study suggests that individualized cancer care should incorporate social support and management of cancer risk behaviors.

Abstract 4221: Factors associated with HPV vaccination initiation and completion among 18-26 year olds in the United States

Background The HPV vaccine prevents HPV-associated cancers and genital warts, which cause significant morbidity and mortality in the US. While the vaccine is targeted toward 11-12-year-old boys and girls, there is a catch-up vaccination range up to 26 years. However, vaccination rates are very low among eligible young adults, aged 18-26 years, and besides college-related studies, not a lot is known about factors associated with the HPV vaccine uptake in this population. The aim of this study was to assess sociodemographic factors associated with HPV vaccination uptake in a nationally representative sample of 18-26-year-old adults.

Methods The National Health Interview Survey 2014-2015 was examined for young adults, aged 18-26 years (n = 7588). HPV vaccine initiation was defined as receipt of at least one dose of the vaccine and completion as receipt of the three doses. Sociodemographic factors included age, gender, race, marital status, education, health insurance, regular provider, number of doctor visits, and geographic region. Survey-weighted multivariable logistic regression models were used to examine the socio-demographic factors that were associated with HPV vaccine uptake.

Results Approximately 27% of respondents had initiated the HPV vaccine and 16% had completed the HPV vaccine. After adjusting for covariates, compared to females, males were 81% less likely to initiate HPV vaccine [(adjusted odds ratio) 0.19; (95 % confidence interval) 0.16-0.23]. Other factors associated with HPV vaccine initiation included having health insurance (1.70; 1.32-2.18), visiting the doctor’s office 6+ times (1.86; 1.48-2.34) and 1-5 times (2.09; 1.56-2.81) vs. no doctor’s office within the last 12 months, and having no high school diploma (0.46; 0.32-0.64) and having high school diploma (0.40; 0.31-0.52) vs. college degree or higher. The same factors were associated with HPV vaccine completion; but, being black (0.60; 0.44-0.83) vs. white and having no usual place of care (0.74; 0.57-0.96) were also associated with lower odds of completing the vaccine series.

Conclusions Our study shows that there are sociodemographic factors associated with HPV vaccine uptake among young adults in the United States, and males, individuals with a lower education, and those without adequate healthcare access are less likely to initiate and complete the HPV vaccination. Our findings suggest it is necessary to develop targeted interventions to promote HPV vaccination among those in the catch-up age range.

Citation Format: Eric Adjei Boakye, Betelihem B. Tobo, Daphne Lew, Meera Muthukrishnan, Vy T. Pham, Rebecca Rohde, Thomas Burroughs, Mark A. Varvares, Nosayaba Osazuwa-Peters. Factors associated with HPV vaccination initiation and completion among 18-26 year olds in the United States [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 4221. doi:10.1158/1538-7445.AM2017-4221

Decreased cancer-independent life expectancy in the head and neck cancer population

BACKGROUND

Aside from cancer mortality, patients with head and neck cancer have increased mortality risk. Identifying patients with the greatest loss of cancer-independent life expectancy can guide comprehensive survivorship programs.

METHODS

Age-based survival data from the Surveillance, Epidemiology, and End Result (SEER) database for patients with head and neck cancer were censored for mortality from the index cancer. Life expectancy and years of life lost (YLL) referenced to the general population were calculated. Cox proportional regression models produced hazard ratios (HRs).

RESULTS

Cancer-independent life expectancy for patients with head and neck cancer is 6.5 years shorter than expected. The greatest hazard and impact of other-cause mortality was associated with black race (HR 1.23; YLL 8.55), stage IV (HR 1.60; YLL 7.92), Medicaid (HR 1.55; YLL 12.9), and previous marriage (HR 1.49; YLL 11.4).

CONCLUSION

Patients with head and neck cancer lives are foreshortened independent of their cancer diagnosis necessitating management of noncancer mortality to maximize overall survival.

Sociodemographic factors associated with developing head and neck and esophageal cancers following breast cancer

e13063

Background: Breast cancer survivors may develop other primary malignancies due to several factors. However, sociodemographic factors associated with the development of head and neck (HN) and esophageal second primary malignancies (SPMs) following management of primary breast cancer (BC) have not been well studied. This study examined the association between BC patients’ sociodemographic characteristics and the development of an esophageal or HN SPM. Methods: Patients ( n= 505,641) diagnosed with breast cancer between 1973 and 2013 in the Surveillance, Epidemiology, and End Results (SEER) 9 program were used for this analysis. HN SPMs included oral cavity, pharynx, larynx, and sinuses. Cox proportional hazards regression was used to evaluate estimators of survival based on age at diagnosis, race, marital status, treatment type, and year of diagnosis. Results: A total of 284 BC patients developed an esophageal SPM, and 969 developed HN SPM. In the adjusted model, increased age at BC diagnosis was a significant predictor for developing both HN and esophageal SPMs. For every 1-year increase in age at diagnosis, the hazard of developing an esophageal SPM increased (HR: 1.05; 95% CI: 1.04-1.06) and HN SPM increased (HR: 1.02; 95% CI: 1.02 -1.03). Hispanic women had a decreased hazard (HR: 0.63; 95% CI: 0.47-0.85) of developing HN SPM compared to non-Hispanic White women, however there was no significant difference for esophageal SPM. Women that were married had a decreased hazard (HR: 0.70; 95% CI: 0.55-0.90) of developing esophageal SPM compared to unmarried women. Conclusions: Sociodemographic factors may be important in the development of SPMs after treatment for breast cancer. While older women with BC were more likely to develop SPMs of the HN and esophagus, Hispanic breast cancer survivors and married women were less likely to develop SPMs of the HN and esophagus. To optimize survival benefits in the breast cancer population, there is need to further explore these sociodemographic factors associated with developing SPMs.

Incidence of esophageal and head and neck cancers among breast cancer survivors in the United States

e12054

Background: Late sequelae of breast cancer therapies potentially impact morbidity and mortality with increasing numbers of survivors. Radiation exposure has been linked to increased incidence of second primary cancers (SPC). However, to date, there is limited literature describing incidence of head and neck (HN) and esophageal cancers in patients with an index breast cancer (BC). This study aimed to describe the incidence of esophageal and HN cancers following breast cancer diagnosis. Methods: Standardized incidence ratios (SIRs) were calculated using the Surveillance, Epidemiology, and End Results (SEER) 9 database for BC patients diagnosed from 1973-2013. SIRs compared incidence of HN and esophageal cancer after an initial BC diagnosis to the general population. HN included oral cavity, pharynx, and larynx. BC patients were grouped into those who received radiotherapy for their breast cancer (n = 216,045) and those who did not (n = 289,596). SIRs were calculated in 5-year intervals. SEER does not contain information on chemotherapy. Results: Less than 1% of BC patients developed HN (0.3%) or esophageal cancers (0.1%), irrespective of radiation treatment. However, among patients with an index BC who received radiation therapy, there was significant but small increased incidence of HN and esophageal cancers five to nine years following treatment (HN SIR: 1.22; 95% CI, 1.04-1.43 and esophagus SIR: 1.44; 95% CI, 1.09-1.87). Esophageal cancer incidence continued to increase through 15 years of follow-up, however incidence of HN was not significant beyond ten years after the index BC diagnosis and radiation treatment. Conclusions: Compared to the general population, breast cancer patients have elevated incidence of HN and esophageal cancers detected five to nine years after receiving radiation treatment, but only the incidence of second primary esophageal cancer remains elevated at 15 years. These findings warrant further investigations of breast cancer radiation and future malignancies.

Frailty index: Intensive care unit complications in head and neck oncologic regional and free flap reconstruction

BACKGROUND

Head and neck extirpations requiring reconstruction are challenging surgeries with high postoperative complication risk.

METHODS

Regional and free flap reconstructions of head and neck defects were collected from the 2006-2013 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. The modified frailty index was made of 15 variables, with increasing index scores indicative of frailer patients. Intensive care unit (ICU)-level complications were defined by Clavien-Dindo classification IV and analyzed with multivariable logistic regression.

RESULTS

There were 266 flap reconstructions (126 regional and 140 free) with 86 (7.2%) Clavien-Dindo classification IV complications. As modified frailty index increased, a moderate correlation was demonstrated for Clavien-Dindo classification IV complications (R² = 0.30). Increasing modified frailty index score was correlated on linear regression with free versus regional flaps: Clavien-Dindo classification IV (R² = 0.09; 0.60), morbidity (R² = 0.04; 0.59), and mortality (R² = 0.07; 0.46), respectively. On multivariable analysis, the modified frailty index was associated with Clavien-Dindo classification IV complications for all flaps (odds ratio [OR] 4.38; 95% confidence interval [CI] 1.33-14.48) and free flaps (OR 6.60; 95%CI 1.02-42.52), but not regional flaps (OR 9.05; 95%CI 0.60-137.10).

CONCLUSION

The modified frailty index score is predictive of critical care support in head and neck resections necessitating reconstruction, specifically for free flaps.