Impact of race on outcome after definitive radiotherapy for squamous cell carcinoma of the head and neck

Exploring the impact of GSTM1 as a novel molecular determinant of survival in head and neck cancer patients of African descent

BACKGROUND

Blacks/African American (BAA) patients diagnosed with head and neck squamous cell carcinoma (HNSCC) have worse survival outcomes than White patients. However, the mechanisms underlying racial disparities in HNSCC have not been thoroughly characterized.

METHODS

Data on gene expression, copy number variants (CNVs), gene mutations, and methylation were obtained from 6 head and neck cancer datasets. Comparative bioinformatics analysis of the above genomic features was performed between BAAs and Whites. The expression pattern of GSTM1 was validated by immunohistochemistry using tumor tissue microarray (TMA). Effect of GSTM1 knockdown were assessed by cell proliferation, colony formation, and tumor development in an orthotopic mouse model. The changes in protein kinases were determined using the Proteome Profiler Human Phospho-Kinase Array Kit in HNSCC cells with or without GSTM1 knockdown.

RESULTS

We identified ancestry-related differential genomic profiles in HNSCC. Specifically, in BAA HNSCC, FAT1 mutations were associated with its gene expression, SALL3 gene expression correlated with its gene CNVs, and RTP4 gene expression showed an inverse correlation with its methylation. Notably, GSTM1 emerged as a prognostic risk factor for BAA HNSCC, with high gene CNVs and expression levels correlating with poor overall survival in BAA patients. Immunohistochemistry results from newly developed in-house TMA validated the expression pattern of GSTM1 between BAA HNSCC and White HNSCC. In an orthotopic mouse model, GSTM1 knockdown significantly inhibited malignant progression in tumors derived from BAAs. In contrast, loss of GSTM1 did not affect the development of HNSCC originating in Whites. Mechanistically, GSTM1 knockdown suppressed HSP27 phosphorylation and β-catenin in BAA HNSCC cells, but not in White HNSCC cells. This differential effect at least partially contributes to tumor development in BAA patients.

CONCLUSION

This study identifies GSTM1 as a novel molecular determinant of survival in HNSCC patients of African descent. It also provides a molecular basis for future research focused on identifying molecular determinants and developing therapeutic interventions to improve outcomes for BAA patients with HNSCC.

Lower disease control rates and survival outcomes among Blacks with pharyngeal squamous cell carcinomas compared with Whites: a retrospective analysis at the University of Florida

Disparate clinical outcomes for pharyngeal squamous cell carcinoma (PSCC) of the oropharynx (OPSCC) and hypopharynx (HPSCC) have been observed in Black compared with White patients. Higher tobacco and alcohol use has been associated with decreased survival in Black patients with PSCC. Higher human papilloma virus (HPV) infection rates, associated with specific subsites of the oropharynx, are linked to improved overall survival (OS). Using an institutional cohort of Black and White patients with PSCC, we performed a retrospective analysis using multiple disease endpoints including local control (LC), local-regional control (LRC), freedom from distant metastases (DMFS), OS, cause-specific survival (CSS), and recorded tobacco and alcohol use. 1419 patients [Black (n = 111) and White (n = 1,308)] treated for PSCC from 1973 to 2013 were evaluated. PSCC 5- and 10-year LC, LRC, and DMFS and CSS rates were lower for Blacks. Notably, Black patients with OPSCC had higher stage cancers, higher percentage of soft palate tumors, and lower percentage of base of tongue cancers, were more likely to receive radiotherapy, and had higher tobacco and alcohol use. OS was significantly lower in Black patients at both anatomic sites, with the greatest difference observed for OPSCC. Multivariate analysis showed race and tobacco independently predicted DMFS, OS, and CSS; however, tobacco use had a greater impact on DMFS (HR 2.5, p = 0.021) than race (HR 1.9, p = 0.027). Overall, we propose that the higher burden of tobacco use along with a lower rate of tumors arising from traditional HPV-related subsites were important contributors to disparate disease outcomes seen in our Black patients.

Radiotherapy Remains Underused in the Treatment of Soft-Tissue Sarcomas: Disparities in Practice Patterns in the United States

BACKGROUND

Practice patterns of radiation therapy (RT) use for soft-tissue sarcoma (STS) remain quite variable, despite clinical practice guidelines recommending the addition of RT to surgery for patients with high-grade STS, particularly for larger tumors. Using the National Cancer Database (NCDB), we assessed patterns of overall RT use, neoadjuvant versus adjuvant treatment, and specific RT modalities in this population.

PATIENTS AND METHODS

Patients aged ≥18 years with stage II/III STS in 2004 through 2015 were identified from the NCDB. Patterns of care were assessed using multivariable logistic regression analysis.

RESULTS

Of 27,426 total patients, 11,654 (42%) were treated with surgery alone versus 15,772 (58%) with RT in addition to surgery, with no overall increase in RT use over the study period. Notable clinical predictors of receipt of RT included tumor size (>5 cm), grade III, and tumors arising in the extremities. Conversely, female sex, older age (≥70 years), Black race, noncommercial insurance coverage, farther distance to treatment, and poor performance status were negative predictors of RT use. Of those receiving RT, 27% were treated with neoadjuvant RT and 73% with adjuvant RT. The proportion of those receiving neoadjuvant RT increased over time. Relevant factors associated with neoadjuvant RT included treatment at academic centers, larger tumor size, and extremity tumors. Of those who received RT with a modality specified as either intensity-modulated RT (IMRT) or 3D conformal RT (3DCRT), 61% were treated with IMRT and 39% with 3DCRT. The proportion of patients treated with IMRT increased over time. Relevant factors associated with IMRT use included treatment at academic centers, commercial insurance coverage, and larger and nonextremity tumors.

CONCLUSIONS

Although use of neoadjuvant RT and IMRT has increased over time, a significant number of patients with STS are not receiving adjuvant or neoadjuvant RT. Our findings also note potential sociodemographic disparities and highlight the concern that not all patients with STS are being equally considered for RT.

Differential mutation spectrum and immune landscape in African Americans versus Whites: A possible determinant to health disparity in head and neck cancer

African Americans (AA) with Head and Neck Squamous Cell Carcinoma (HNSCC) have a worse disease prognosis than White patients despite adjusting for socio-economic factors, suggesting the potential biological contribution. Therefore, we investigated the genomic and immunological components that drive the differential tumor biology among race. We utilized the cancer genome atlas and cancer digital archive of HNSCC patients (1992-2013) for our study. We found that AA patients with HNSCC had a higher frequency of mutation compared to Whites in the key driver genes-P53, FAT1, CASP8 and HRAS. AA tumors also exhibited lower intratumoral infiltration of effector immune cells (CD8+, γδT, resting memory CD4+ and activated memory CD4+ T cells) with shorter survival than Whites. Unsupervised hierarchical clustering of differentially expressed genes demonstrated distinct gene clusters between AA and White patients with unique signaling pathway enrichments. Connectivity map analysis identified drugs (Neratinib and Selumetinib) that target aberrant PI3K/RAS/MEK signaling and may reduce racial disparity in therapy response.

Disparities in Head and Neck Cancer: A Case for Chemoprevention with Vitamin D

Blacks experience disproportionate head and neck cancer (HNC) recurrence and mortality compared to Whites. Overall, vitamin D status is inversely associated to HNC pointing to a potential protective linkage. Although hypovitaminosis D in Blacks is well documented it has not been investigated in Black HNC patients. Thus, we conducted a prospective pilot study accessing vitamin D status in newly diagnosed HNC patients stratified by race and conducted in vitro studies to investigate mechanisms associated with potential cancer inhibitory effects of vitamin D. Outcome measures included circulating levels of vitamin D, related nutrients, and risk factor characterization as well as dietary and supplemental estimates. Vitamin D-based in vitro assays utilized proteome and microRNA (miR) profiling. Nineteen patients were enrolled, mean circulating vitamin D levels were significantly reduced in Black compared to White HNC patients, 27.3 and 20.0 ng/mL, respectively. Whites also supplemented vitamin D more frequently than Blacks who had non-significantly higher vitamin D from dietary sources. Vitamin D treatment of HNC cell lines revealed five significantly altered miRs regulating genes targeting multiple pathways in cancer based on enrichment analysis (i.e., negative regulation of cell proliferation, angiogenesis, chemokine, MAPK, and WNT signaling). Vitamin D further altered proteins involved in cancer progression, metastasis and survival supporting a potential role for vitamin D in targeted cancer prevention.

Timing of Postoperative Radiotherapy in Surgically Treated HPV-Positive Oropharyngeal Squamous Cell Carcinoma

OBJECTIVE

Optimal timing of postoperative radiotherapy (PORT) remains understudied in human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma. Objectives are to determine if delays between surgery and radiotherapy, breaks during radiotherapy, disease, or patient factors are associated with recurrence or survival decrements in HPV-related disease.

DESIGN

Retrospective review.

SETTING

Academic medical center.

SUBJECTS

A total of 240 cases of HPV-positive oropharyngeal squamous cell carcinoma from 2000 to 2016.

METHODS

Patient and tumor characteristics (American Joint Committee on Cancer, eighth edition), delays to radiation initiation, and breaks during radiation were recorded. Overall survival (OS) and recurrence-free survival (RFS) were analyzed.

RESULTS

RFS and OS were not significantly affected by delays to PORT >6 weeks or by treatment intervals >100 days (surgery to PORT completion). Breaks during PORT significantly imparted an OS detriment (hazard ratio [HR], 2.4; 95% CI, 1.2-4.8). Advanced-stage disease was significantly associated with reduced RFS and OS. Subgroup analysis of stage I versus stage II/III disease found that >6 weeks to PORT initiation and treatment intervals >100 days did not significantly decrease RFS or OS in either stage group. Advanced-stage disease was significantly associated with worsened OS (HR, 6.6; 95% CI, 2.3-19.1) and RFS (HR, 5.3; 95% CI, 1.5-18.4). Breaks during PORT significantly reduced RFS (HR, 3.6; 95% CI, 1.2-10.8) and OS (HR, 3.2; 95% CI, 1.2-9.0) in the stage II/III subset.

CONCLUSION

Delays to radiotherapy initiation and prolonged treatment time did not affect recurrence or survival in HPV-related oropharyngeal disease. Locoregionally advanced disease was consistently associated with worse outcomes. Breaks during PORT may affect recurrence and survival, although larger studies are needed to confirm this finding.

Immunometabolic Alterations by HPV Infection: New Dimensions to Head and Neck Cancer Disparity

Head and neck squamous cell carcinoma (HNSCC) is the sixth most common cancer, with high morbidity and mortality. Racial disparity in HNSCC is observed between African Americans (AAs) and whites, effecting both overall and 5-year survival, with worse prognosis for AAs. In addition to socio-economic status and demographic factors, many epidemiological studies have also identified factors including coexisting human papillomavirus (HPV) infection, primary tumor location, and a variety of somatic mutations that contribute to the prognostic incongruities in HNSCC patients among AAs and whites. Recent research also suggests HPV-induced dysregulation of tumor metabolism and immune microenvironment as the major regulators of HNSCC patient prognosis. Outcomes of several preclinical and clinical studies on targeted therapeutics warrant the need to elucidate the inherent mechanistic and population-based disparities underlying patient responses. This review systematically reports the underlying reasons for inconsistency in disease prognosis and therapy responses among HNSCC patients from different racial populations. The focus of this review is twofold: aside from discussing the causes of racial disparity, we also seek to identify the consequences of such disparity in terms of HPV infection and its associated mutational, metabolic, and immune landscapes. Considering the clinical impact of differential patient outcomes among AA and white populations, understanding the underlying cause of this disparity may pave the way for novel precision therapy for HNSCC.

Racial Disparity Among the Head and Neck Cancer Population

Head and neck cancer is the ninth most common cancer in the USA, accounting for 3.3 % of all cancers. The incidence of head and neck cancer has plateaued recently; however, morbidity and mortality continue to remain high. Moreover, racial disparity between African-American and White patients has been studied in the head and neck community, and a vast difference still remains in mortality rate and late stage at presentation. A review of the English literature was performed using PubMed/MEDLINE for demographics, epidemiology, and studies that focused on the disparity in head and neck cancer between African-American and White patients. Age-adjusted incidence of head and neck cancer is increased in African-Americans, while the 5-year survival is decreased compared to Whites. African-American patients present with more advanced disease. When receiving similar multidisciplinary care, the overall survival was not significantly different, but racial disparity often persists in treatment regimens. Socioeconomic determinants such as insurance status play a critical role in racial disparity, along with low levels of public awareness, a lack of knowledge of specific risk factors, and a sense of mistrust that is seen in the African-American population. Disparity in the head and neck cancer community is worrisome, and although efforts have been taken to decrease the disparity, a significant difference exists. Fortunately, the disparity is reversible and can be eliminated. To do so, it is critical to extend to underserved community programs that provide appropriate screening and diagnosis, with subsequent follow-up and treatment following the standards of care.

Oropharyngeal cancer as a driver of racial outcome disparities in squamous cell carcinoma of the head and neck: 10-year experience at the University of Maryland Greenebaum Cancer Center

BACKGROUND

Racial outcome disparities have been observed in head and neck squamous cell carcinoma (HNSCC) with diminished survival for black patients compared with white patients.

METHODS

We retrospectively analyzed 1318 patients with primary HNSCC treated at the University of Maryland Greenebaum Cancer Center (UMGCC) from 2000 to 2010.

RESULTS

Of all the patients, 65.9% were white, 30.7% were black, and 3.3% were of other races. Black patients were less likely to present with oral cavity cancer, and more likely to present with laryngeal or hypopharyngeal cancers. White patients were more likely to have early stage disease, especially in the oral cavity. Black race was independently associated with worse overall survival (OS) in the entire cohort. Black patients had a significantly worse OS among oral cavity and oropharyngeal cancers, with the largest disparity in oropharyngeal cancer. However, in multivariate analysis, race was only still significant in oropharyngeal cancer.

CONCLUSION

We observed differences by race in distribution of disease site, stage, and OS. Survival disparity in the entire cohort was driven mostly by differences among oropharyngeal cancer.

Determinants of First-Time Cancer Examinations in a Rural Community: A Mechanism for Behavior Change

OBJECTIVES

After conducting a media campaign focusing on the importance of oral and pharyngeal cancer (OPC) examinations, we assessed mechanisms of behavior change among individuals receiving an OPC examination for the first time.

METHODS

We used data from 2 waves of telephone surveys of individuals residing in 36 rural census tracts in northern Florida (n = 806). The second survey occurred after our media intervention. We developed media messages and modes of message delivery with community members via focus groups and intercept interviews. We performed a mediation analysis to examine behavior change mechanisms.

RESULTS

Greater exposure to media messages corresponded with heightened concern about OPC. Heightened concern, in turn, predicted receipt of a first-time OPC examination, but only among men.

CONCLUSIONS

We extended earlier studies by measuring an outcome behavior (receipt of an OPC examination) and demonstrating that the putative mechanism of action (concern about the disease) explained the link between a media intervention and engaging in the target behavior. Improving the quality of media campaigns by engaging community stakeholders in selecting messages and delivery methods is an effective strategy in building public health interventions aimed at changing behaviors.

Impact of African-American race on presentation, treatment, and survival of head and neck cancer

OBJECTIVES

To determine the associations between African American race and stage at diagnosis, receipt of definitive therapy, and cancer-specific mortality among patients with head and neck cancer.

MATERIALS AND METHODS

The Surveillance, Epidemiology and End Results (SEER) database was used to conduct a retrospective study on 34,437 patients diagnosed with head and neck cancer from 2007 to 2010. Multivariable logistic regression analyses were applied to determine the impact of race on cancer stage at presentation (metastatic vs. non-metastatic) and receipt of definitive treatment. Fine and Gray competing-risks regression modeled the association between race and head and neck cancer-specific mortality.

RESULTS

African Americans were more likely to present with metastatic cancer compared to non-African Americans (Adjusted Odds Ratio [AOR] 1.76; CI 1.50-2.07; P<0.001). Among patients with non-metastatic disease, African Americans were less likely to receive definitive treatment (AOR 0.63; CI 0.55-0.72; P<0.001). After a median follow-up of 19months, African Americans with non-metastatic disease were found to have a higher risk of head and neck cancer specific mortality (AHR 1.19; 95% CI 1.09-1.29; P<0.001).

CONCLUSION

African Americans with head and neck cancer are more likely to present with metastatic disease, less likely to be treated definitively, and are more likely to die from head and neck cancer. The unacceptably high rates of disparity found in this study should serve as immediate targets for urgent healthcare policy intervention.

Race disparities attributed to volumetric tumor burden in patients with head and neck cancer treated with radiotherapy

BACKGROUND

The purpose of this study was to evaluate how gross tumor volume (GTV) affects treatment outcome among different race/ethnic groups in patients with head and neck cancer receiving definitive radiotherapy (RT).

METHODS

Ninety-one patients with head and neck cancer were treated to a median RT dose of 69.96 Gy in 33 fractions. The patient's self-reported race/ethnicity, primary tumor, and nodal GTV were obtained. Two-year actuarial local, nodal, and distant control, and overall and disease-free survival were calculated.

RESULTS

The patients were categorized as white (n = 43) or non-white (n = 48), which included 29 African Americans, 11 Hispanics, 5 Asians, and 3 others. The mean primary GTV was 21.0 cc and 39.9 cc for whites and non-whites, respectively (p = .011). White patients reported improved overall survival of 85.4% compared to non-whites (65.8%; p = .006). Improvements in local and nodal control and disease-free survival rates were also observed.

CONCLUSION

White patients demonstrated improved treatment outcomes compared with non-whites, which may be reflective of tumor volume.

Racial parities in outcomes after radiotherapy for head and neck cancer

BACKGROUND

Although black patients experience worse outcomes after treatment for squamous cell carcinoma of the head and neck (HNSCC), these conclusions were based on populations in which blacks comprised a minority of patients. The objective of the current study was to determine the impact of race on outcomes in patients with HNSCC who received radiotherapy at an institution in which blacks comprised the majority of patients.

METHODS

In this retrospective cohort study, the authors reviewed 366 black patients and 236 white patients who had nonmetastatic HNSCC for which they received radiotherapy between 1990 and 2012. The primary study outcome measures were locoregional control, freedom from distant metastasis, progression-free survival, and overall survival.

RESULTS

The median follow-up was 18.3 months for all patients. The 2-year locoregional control rate was 71.9% for black patients compared with 64.2% for white patients (hazard ratio, 0.72; P=.03). There was no difference between blacks and whites regarding 2-year freedom from distant metastasis, progression-free survival, or overall survival. Among the patients who had stage III through IVB disease, blacks and whites had similar outcomes. On multivariate analysis, race was not statistically significant for locoregional control, freedom from distant metastasis, progression-free survival, or overall survival. Despite these similar outcomes, black patients had worse socioeconomic factors and increased comorbidities but had similar treatment compliance compared with white patients.

CONCLUSIONS

With more adverse prognostic factors, black patients experienced oncologic outcomes similar to the outcomes of white patients after receiving radiotherapy for HNSCC. The current data suggest that centers that treat large percentages of minority patients who receive radiotherapy for HNSCCs may overcome existing health care disparities through improved treatment compliance.

Human papillomavirus-related squamous cell carcinoma of the oropharynx: a comparative study in whites and African Americans

OBJECTIVES

To evaluate the frequency of human papillomavirus-related oropharyngeal squamous cell carcinoma in African Americans and whites and to examine patient outcomes in these 2 groups.

DESIGN

Retrospective study.

SETTING

One tertiary care, university medical center.

PATIENTS

Information on patients with stage III/IV oropharyngeal squamous cell carcinoma diagnosed between 1998 and 2007, and with primary surgical samples available for review, were selected from a radiotherapy database. One patient was Native American and was excluded from analysis; data on 174 patients were analyzed.

RESULTS

One hundred forty-eight patients (85.1%) were white and 26 (14.9%) were African American. Human papillomavirus in situ hybridization-positive and p16-positive tumors were much more common in whites (63.5% and 83.1% of tumors, respectively) than in African Americans (11.5% and 34.6% of tumors, respectively) (P < .001). African Americans were also more likely to have received definitive (nonsurgical) rather than postoperative radiation therapy (P = .001) and had a higher frequency of T3/T4-stage tumors (P = .03) compared with whites. Disease-free survival was significantly shorter for African Americans (P = .02). In multivariate analysis, viral status (P = .006), T stage (P = .02), and treatment type (P = .002), but not race (P = .98), were significant factors contributing to disease-free survival.

CONCLUSIONS

In high-stage oropharyngeal squamous cell carcinoma, the proportion of human papillomavirus-related tumors is much higher in whites than in African Americans. African Americans also appear to develop higher T-stage tumors and are more likely to receive definitive therapy. The shorter disease-free survival observed in African Americans may be due to viral status, treatment type, and higher T stage, but does not appear to be due to race.

Human papillomavirus-active head and neck cancer and ethnic health disparities

OBJECTIVES/HYPOTHESIS

Mortality for black males with head and neck squamous cell carcinoma (HNSCC) is twice that of white males or females. Human papillomavirus (HPV)-active HNSCC, defined by the concurrent presence of high-risk type HPV DNA and host cell p16(INK4a) expression, is associated with decreased mortality. We hypothesized that prevalence of this HPV-active disease class would be lower in black HNSCC patients compared to white patients.

STUDY DESIGN

Multi-institutional retrospective cohort analysis.

METHODS

Real-time polymerase chain reaction was used to evaluate for high-risk HPV DNA presence. Immunohistochemistry for p16(INK4a) protein was used as a surrogate marker for HPV oncoprotein activity. Patients were classified as HPV-negative (HPV DNA-negative, p16(INK4a) low), HPV-inactive (HPV DNA-positive, p16(INK4a) low), and HPV-active (HPV DNA-positive, p16(INK4a) high). Overall survival and recurrence rates were compared by Fisher exact test and Kaplan-Meier analysis.

RESULTS

There were 140 patients with HNSCC who met inclusion criteria. Self-reported ethnicity was white (115), black (25), and other (0). Amplifiable DNA was recovered from 102/140 patients. The presence of HPV DNA and the level of p16(INK4a) expression were determined, and the results were used to classify these patients as HPV-negative (44), HPV-inactive (33), and HPV-active (25). Patients with HPV-active HNSCC had improved overall 5-year survival (59.7%) compared to HPV-negative and HPV-inactive patients (16.9%) (P = .003). Black patients were less likely to have HPV-active disease (0%) compared to white patients (21%) (P = .017).

CONCLUSIONS

The favorable HPV-active disease class is less common in black than in white patients with HNSCC, which appears to partially explain observed ethnic health disparities.

Matched-pair analysis of race or ethnicity in outcomes of head and neck cancer patients receiving similar multidisciplinary care

It is unknown whether population-level racial or ethnic disparities in mortality from squamous cell carcinoma of the head and neck (SCCHN) also occur in the setting of standardized multidisciplinary-team directed care. Therefore, we conducted a matched-pair study that controlled for several potentially confounding prognostic variables to assess whether a difference in survival exists for African American or Hispanic American compared with non-Hispanic white American SCCHN patients receiving similar care. Matched pairs were 81 African American case and 81 non-Hispanic white control patients and 100 Hispanic American cases and 100 matched non-Hispanic white controls selected from 1,833 patients of a prospective epidemiologic study of incident SCCHN within a single, large multidisciplinary cancer center. Matching variables included age (+/-10 years), sex, smoking status (never versus ever), site, tumor stage (T(1-2) versus T(3-4)), nodal status (negative versus positive), and treatment. Cases and controls were not significantly different in proportions of comorbidity score, alcohol use, subsite distribution, overall stage, or tumor grade. Matched-pair and log-rank analyses showed no significant differences between cases and controls in recurrence-free, disease-specific, or overall survival. Site-specific analyses suggested that more aggressive oropharyngeal cancers occurred more frequently in minority than in non-Hispanic white patients. We conclude that minority and non-Hispanic white SCCHN patients receiving similar multidisciplinary-team directed care at a tertiary cancer center have similar survival results overall. These results encourage reducing health disparities in SCCHN through public-health efforts to improve access to multidisciplinary oncologic care (and to preventive measures) and through individual clinician efforts to make the best multidisciplinary cancer treatment choices available for their minority patients. The subgroup finding suggests a biologically based racial/ethnic disparity among oropharyngeal patients and that prevention and treatment strategies should be tailored to different populations of these patients.

Toxicity profile and efficacy of oral capecitabine as adjuvant chemotherapy for Chinese patients with Stage III colon cancer

PURPOSE

The Xeloda in Adjuvant Cancer Therapy trial, conducted in a white population of patients, established capecitabine (Xeloda) as adjuvant chemotherapy for Stage III colon cancer. Given the ethnical difference in toxicity of adjuvant chemotherapy in colon cancer, this study was designed to evaluate the safety and efficacy of adjuvant capecitabine in Chinese patients with colon cancer.

METHODS

Chinese patients with curatively resected Stage III colon adenocarcinoma, who received adjuvant capecitabine, were entered into a prospective database. Oral capecitabine was given at 1,250 mg/m(2) twice daily, Days 1 to 14, every 21 days, for 8 cycles. Toxicities, laboratory abnormalities, and survival outcomes were evaluated.

RESULTS

Fifty-eight patients were entered into the database between August 2004 and October 2005. The median age was 63.9 years with a male-to-female ratio of 1.15:1. With a median follow-up duration of 20.9 months, 14 patients relapsed and 3 patients died. Disease-free and overall survival at two years was 69 and 97 percent, respectively. Grade 3 toxicities occurred as follows: stomatitis (1.7 percent), diarrhea (0 percent), hand-foot syndrome (41.4 percent), leucopenia (1.7 percent), neutropenia (3.4 percent), and hyperbilirubinemia (1.7 percent). No Grade 4 or 5 toxicity was noted. Compared with the Xeloda in the Adjuvant Cancer Therapy trial, a much higher incidence of serious hand-foot syndrome and a lower rate of severe diarrhea were found in this study.

CONCLUSIONS

A different toxicity profile of adjuvant capecitabine was noted in this study on Chinese patients with colon cancer compared with that reported in the Xeloda in Adjuvant Cancer Therapy trial, whereas the efficacy outcomes were comparable.

Racial disparity in stage at diagnosis and survival among adults with oral cancer in the US

OBJECTIVES

To explore distribution of stage at diagnosis and relative survival rates among US adults with oral cavity cancer in relation to race, and over time.

METHODS

We obtained 1973-2002 oral cancer incidence data from the Surveillance, Epidemiology, and End Results (SEER) Program, and computed proportions for each oral cavity site by stage at diagnosis, tumor size, and 5-year relative survival rates among Whites and Blacks.

RESULTS

A total of 46 855 cases of oral cavity cancer were reported to the SEER registry among adults > or =20 years between 1973 and 2002. African-Americans had a significantly higher proportion of cancer, mainly in the tongue, that had spread to a regional node or to a distant site at diagnosis than Whites: 67% versus 49% of tongue cancers reported from 1973 to 1987 (P < 0.001), and 70% versus 53% of those reported from 1988 to 2002 (P < 0.001). They had a significantly higher proportion of tongue cancer that were >4 cm in diameter at time of diagnosis (59% versus 44%; P < 0.001), and black men in particular experienced lower 5-year relative survival rates than white men, in particular, for tongue cancer (25% versus 43% from 1973 to 1987, and 31% versus 53% from 1988 to 2002).

CONCLUSION

There are significant racial disparities with respect to stage at diagnosis and survival among adults with oral cancer reported to the SEER registry from 1973 to 2002. One possible explanation for the lower survival among Blacks may be a difference in access to, and utilization of, healthcare services.

Racial disparities in patients with head and neck squamous cell carcinoma

OBJECTIVES/HYPOTHESIS

Black patients are reported to have a higher incidence of advanced disease and increased mortality from head and neck squamous cell carcinoma (HNSCC) but constitute the minority of patients in large-scale studies investigating the effect of race on outcome. This study sought to determine if racial disparities exist between black and white patients with HNSCC treated at a single large institution in the South with a high proportion of black patients.

STUDY DESIGN

The authors conducted a nonrandomized retrospective cohort analysis.

METHODS

The tumor registry was used to identify patients diagnosed with HNSCC from 1985 to 2002. The medical records of non-Hispanic white and black adult patients were retrospectively reviewed. Median household income, percentage of population below poverty level, and education level based on census tract and block information were obtained from U.S. Census 2000 data. Standard statistical analysis, including Kaplan-Meier survival curve analysis and Cox proportional hazards models, was used to analyze the effects of covariables on survival.

RESULTS

A total of 1,128 patients met study criteria (478 black, 650 white). Compared with white patients, black patients were significantly younger (mean age, 53.9 vs. 56.4 years, P<.0001), male (81.2% vs. 72.3%, P=.0005), more commonly abused alcohol (88.0% vs. 74.3%, P<.0001), and were significantly less likely to have insurance (8.6% vs. 21.7%, P<.0001). There was no difference in the incidence of tobacco use (91.7%), advanced comorbidity (35.9%), or primary tumor site. Black patients had a significantly greater incidence of stage IV disease (65.7% vs. 46.6%, P<.0001) and nonoperative treatment (48.7% vs. 30.8%, P<.0001), which was performed for inoperable disease in 57.1% of black compared with 31.0% of white patients (P<.0001). Black patients resided in census block groups with significantly lower mean education level, median income, and a higher percentage of population below poverty compared with white patients. The 5-year disease-specific survival differed significantly between black (29.3%) and white (54.7%) patients (P<.0001). Cox proportional hazards models revealed that alcohol abuse, advanced TNM stage, high tumor grade, nodal disease, extracapsular spread, advanced comorbidity, and regional or distant metastatic disease were associated with poorer survival for all patients. An interaction with race was found for insurance status, nonoperative treatment, and extracapsular spread. Stepwise variable selection adjusting for patient, tumor, and treatment characteristics showed a significant effect only for race by payor status on disease-specific survival (P=.0228).

CONCLUSIONS

Insurance status, treatment, and extracapsular spread differentially affected the survival of black patients compared with white patients. Only insurance status had a significant effect on survival in black patients after controlling for other variables. These data suggest that racial differences in HNSCC outcomes are primarily related to differences in access to health care.

Florida adults' oral cancer knowledge and examination experiences

OBJECTIVE

This study assessed awareness of oral cancer, knowledge of its major risk factors and clinical signs, and oral cancer examination experiences among Florida adults aged 40 years and older.

METHODS

A statewide random digit dial, computer assisted telephone survey was conducted in 2002. Data from 1,773 respondents were weighted to permit statewide estimates. Bivariate analyses were used to examine awareness and knowledge of oral cancer. Multiple logistic regression analysis was used to model past-year oral cancer examination experiences of Florida's adults.

RESULTS

In Florida, 15.5% of adults aged 40 years and older had never heard of oral cancer and another 40.3% reportedly knew little or nothing about it. About one-half of adults did not think oral white or red patches or bleeding could indicate oral cancer and 27.6% correctly identified three of oral cancer's major risk factors. After hearing an oral cancer exam described, just 19.5% of adults reported receiving one within the preceding 12 months. Blacks and Hispanics were significantly less likely than non-Hispanic whites to have received a recent oral cancer examination. Persons with low levels of education, those who lacked a regular dentist or source of preventive medical care, and adults who knew few or none of the clinical signs of oral cancer also were less likely to have received a recent oral cancer exam.

CONCLUSIONS

There is widespread lack of awareness and knowledge in Florida regarding oral cancer and low levels of reported examination, particularly among groups experiencing disproportionately high incidence and late stage diagnosis. Increasing awareness of this disease and promoting primary and secondary prevention may help lessen the disease burden in Florida and reduce racial disparities in its outcomes.

Definitive radiotherapy for squamous cell carcinoma of the base of tongue

OBJECTIVE

To evaluate definitive radiotherapy (RT) for treatment of base of tongue cancer.

METHODS

There were 333 patients with squamous cell carcinoma of the base of tongue treated with definitive RT and had follow-up from 0.2 to 26.2 years. Follow-up on living patients ranged from 1.2 to 26.2 years (median, 6.6 years).

RESULTS

Local control rates at 5 years were: T1, 98%; T2, 92%; T3, 82%; and T4, 53%. The 5-year rates of local-regional control rates were: I-II, 100%; III, 82%; IVA, 87%; and IVB, 58%. The rates of absolute and cause-specific survival at 5 years were as follows: I-II, 67% and 91%; III, 66% and 77%; IVA, 67% and 84%; and IVB, 33% and 45%. Severe complications developed in 52 patients (16%).

CONCLUSION

Our data and review of the pertinent literature reveal that the local-regional control rates and survival rates after RT were comparable to those after surgery, and the morbidity associated with RT was less.

Retromolar trigone squamous cell carcinoma treated with radiotherapy alone or combined with surgery

BACKGROUND

Treatment outcomes were analyzed for retromolar trigone squamous cell carcinoma.

METHODS

Between June 1966 and August 2003, 99 patients were treated with radiotherapy alone (35 patients) or radiotherapy combined with surgery (64 patients). Followup ranged from 0.2 to 23.8 years (median, 3.3 yrs). All living patients had followup for at least 1 year.

RESULTS

The 5-year local-regional control rates after definitive radiotherapy versus surgery and radiotherapy were as follows: Stages I-III, 51% and 87%; Stage IV, 42% and 62%; and overall, 48% and 71%, respectively. The 5-year cause-specific survival rates after definitive radiotherapy compared with surgery and radiotherapy were as follows: Stages I-III, 56% and 83%; Stage IV, 50% and 61%; and overall, 52% and 69%, respectively. Multivariate analyses revealed that the likelihood of cure was better with surgery and radiotherapy compared with definitive radiotherapy.

CONCLUSIONS

The likelihood of cure after treatment for retromolar trigone squamous cell carcinoma was influenced by the extent of disease and treatment. Patients treated with surgery and radiotherapy had a better outcome than those treated with radiotherapy alone.