Racial differences in nasopharyngeal carcinoma in the United States

Nasopharyngeal cancer mortality in disaggregated Asian and non-Asian Americans

BACKGROUND

Nasopharyngeal carcinoma (NPC) mortality varies based on multiple risk factors. While NPC mortality is higher in Asia, little is known about Asian subgroups in the United States (US).

METHODS

Using the 2005-2020 National Vital Statistics System, we examined NPC mortality by age, race (non-Hispanic black, Hispanic white (HW), non-Hispanic white (NHW), Chinese, Filipino, Asian Indian, Japanese, Korean, Vietnamese), sex, and nativity (Untied States or foreign-born).

RESULTS

Upon disaggregation, Chinese (1.96 [CI: 1.78-2.16]), Filipino (0.68 [0.68-1.11]), and Vietnamese Americans (0.68 [0.52-1.10]) had the top age-adjusted mortality rates (AAMR per 100 000 person-years). Foreign-born Chinese, Vietnamese, Filipinos, Asian Indians, and NHW had higher AAMRs compared to US-born persons. All male groups had higher AAMR compared to females. Stratifying for race, nativity, and sex, foreign-born Chinese males (4.09 [3.79-4.40]) had the highest AAMR.

CONCLUSION

These findings demonstrate the importance of disaggregating NPC mortality data by Asian subgroups, providing valuable insights for targeted public health interventions in the United States.

Nasopharyngeal carcinoma in Sarawak : a 10-year review and update

AIM

Nasopharyngeal carcinoma (NPC) is prevalent in certain regions, particularly Southeast Asia and Southern China. In Malaysia, it is notably frequent among the Bidayuh community. This study presents a comprehensive review of NPC cases diagnosed and treated at Sarawak General Hospital from 2010 to 2020.

METHOD

A retrospective data collection was conducted using the clinical records of patients who were histopathologically diagnosed with NPC at the Otolaryngology-Head & Neck Clinic and the Radiotherapy & Oncology Clinic at Sarawak General Hospital.

RESULT

The study comprised a total of 892 patients from 2010 to 2020. Males outnumbered females 3-to-1, with a mean age of 51 years (standard deviation: 13.9). The largest groups of patients were the Iban (34%) and the Bidayuh (21%), followed by the Chinese (19%) and the Malay (15%). The Bidayuh had the highest incidence rate with 81 cases per 100,000. Only 10% of the study population had a family history of NPC. The most common presentation was a neck lump (64.5%). Distant metastasis was discovered in 20% of patients. 82% of the cases were stage 3 or 4 at the time of presentation. The histological types of the 892 cases were mainly undifferentiated carcinoma (73%). Eighty-six patients developed recurrence, with 83% experiencing local recurrence, 10% developing distant metastasis, and 7% developing regional recurrence. Treatment for recurrence included nasopharyngectomy, neck dissection, and chemotherapy.

CONCLUSION

The study highlights a significant incidence of NPC among the Bidayuh. Emphasis on screening and early detection is crucial for better outcomes, with lifelong follow-up recommended.

Enhancing Nasopharyngeal Carcinoma Survival Prediction: Integrating Pre- and Post-Treatment MRI Radiomics with Clinical Data

Recurrences are frequent in nasopharyngeal carcinoma (NPC) despite high remission rates with treatment, leading to considerable morbidity. This study aimed to develop a prediction model for NPC survival by harnessing both pre- and post-treatment magnetic resonance imaging (MRI) radiomics in conjunction with clinical data, focusing on 3-year progression-free survival (PFS) as the primary outcome. Our comprehensive approach involved retrospective clinical and MRI data collection of 276 eligible NPC patients from three independent hospitals (180 in the training cohort, 46 in the validation cohort, and 50 in the external cohort) who underwent MRI scans twice, once within 2 months prior to treatment and once within 10 months after treatment. From the contrast-enhanced T1-weighted images before and after treatment, 3404 radiomics features were extracted. These features were not only derived from the primary lesion but also from the adjacent lymph nodes surrounding the tumor. We conducted appropriate feature selection pipelines, followed by Cox proportional hazards models for survival analysis. Model evaluation was performed using receiver operating characteristic (ROC) analysis, the Kaplan-Meier method, and nomogram construction. Our study unveiled several crucial predictors of NPC survival, notably highlighting the synergistic combination of pre- and post-treatment data in both clinical and radiomics assessments. Our prediction model demonstrated robust performance, with an accuracy of AUCs of 0.66 (95% CI: 0.536-0.779) in the training cohort, 0.717 (95% CI: 0.536-0.883) in the testing cohort, and 0.827 (95% CI: 0.684-0.948) in validation cohort in prognosticating patient outcomes. Our study presented a novel and effective prediction model for NPC survival, leveraging both pre- and post-treatment clinical data in conjunction with MRI features. Its constructed nomogram provides potentially significant implications for NPC research, offering clinicians a valuable tool for individualized treatment planning and patient counseling.

Short-term OS as a surrogate endpoint for 5-year OS in nasopharyngeal carcinoma in non-endemic area

PURPOSE

To address this evidence gap and validate short-term OS at less than 5 years as a reliable surrogate endpoint for 5-year OS.

METHODS

We analyzed data from the Surveillance, Epidemiology, and End Results (SEER) database, focusing on non-metastatic NPC patients diagnosed between 2010 and 2015. Patients were categorized into radiotherapy and chemoradiotherapy groups.

RESULTS

This retrospective study examined 2,047 non-metastatic NPC patients. Among them, 217 received radiotherapy, and 1,830 received chemoradiotherapy. Our analysis results indicated that the 4-year OS may serve as a reliable surrogate endpoint for patients with AJCC clinical stage I (80 vs. 78%, P = 0.250), regardless of the treatment received. Specifically, in the radiotherapy group, patients with stage I, T0-T1, and N0 NPC showed similar OS rates at 4 and 5 years (83 vs. 82%, P = 1.000; 78 vs. 76%, P = 0.250; 78 vs. 77%, P = 0.500, respectively). Similarly, patients with stage II-IV, T2-T4, and N1-3 NPC showed no significant difference in OS rates between 3 and 5 years (57 vs. 51%, P = 0.063; 52 vs. 46%, P = 0.250; 54 vs. 46%, P = 0.125, respectively) in the radiotherapy group. In the chemoradiotherapy group, only the 3-year OS rate did not significantly differ from that at 5 years in stage I patients (79vs. 72%, P = 0.063).

CONCLUSIONS

Our study suggests that short-term surrogate endpoints may be valuable for evaluating 5-year OS outcomes in NPC patients in non-endemic areas.

Cost-efficiency and budget-neutral expanded access modeling of the novel PD-1 inhibitor toripalimab versus pembrolizumab in recurrent or metastatic nasopharyngeal carcinoma

AIMS

To estimate, in the setting of recurrent or metastatic nasopharyngeal carcinoma (R/M NPC) for an assumed 1,207 incident US cases in 2024, (1) the cost-efficiency of a toripalimab-gemcitabine-cisplatin regimen compared to a similar pembrolizumab regimen; and (2) the budget-neutral expanded access to additional toripalimab cycles and regimens afforded by the accrued savings.

METHODS

Simulation modeling utilized two cost inputs (wholesale acquisition cost (WAC) at market entry and an ex ante toripalimab price point of 80% of pembrolizumab average sales price (ASP)) and drug administration costs over 1 and 2 years of treatment with treatment rates ranging from 45% to 90%. In the absence of trial data for pembrolizumab-gemcitabine-cisplatin in R/M NPC, it is assumed that such a regimen would be comparable to toripalimab-gemcitabine-cisplatin in efficacy and safety.

RESULTS

In the models utilizing the WAC, toripalimab saves $2,223 per patient per cycle and $40,014 over 1 year of treatment ($77,805 over 2 years). Extrapolated to the 1,207-patient panel, estimated 1-year savings range from $21,733,702 (45% treatment rate) to $43,467,404 (90% rate). Reallocating these savings permits budget-neutral expanded access to an additional 2,359 (45% rate) to 4,717 (90% rate) toripalimab maintenance cycles or to an additional 126 (45% rate) to 252 (90%) full 1-year toripalimab regimens with all agents. Two-year savings range from $42,259,976 (45% rate) to $84,519,952 (90% rate). Reallocating these efficiencies provides expanded access, ranging from an additional 4,586 (45% rate) to 9,172 (90% rate) toripalimab cycles or to an additional 128-257 full 2-year toripalimab regimens. The ex ante ASP model showed similar results.

CONCLUSION

This simulation demonstrates that treatment with toripalimab generates savings that enable budget-neutral funding for up to an additional 252 regimens with toripalimab-gemcitabine-cisplatin for one full year, the equivalent of approximately 21% of the 2024 incident cases of R/M NPC in the US.

Toxicity profile of patients treated with proton and carbon-ion therapy for primary nasopharyngeal carcinoma: A systematic review and meta-analysis

BACKGROUND

Proton and carbon-ion therapy may spare normal tissues in regions with many critical structures surrounding the target volume. As toxicity outcome data are emerging, we aimed to synthesize the published data for the toxicity outcomes of proton or carbon-ion therapy (together known as particle beam therapy [PBT]) for primary nasopharyngeal carcinoma (NPC).

MATERIALS AND METHODS

We searched PubMed and Scopus electronic databases to identify original studies reporting toxicity outcomes following PBT of primary NPC. Quality assessment was performed using NIH's Quality Assessment Tool. Reports were extracted for information on demographics, main results, and clinical and dose factors correlates. Meta-analysis was performed using the random-effects model.

RESULTS

Twelve studies were selected (six using mixed particle-photon beams, five performed comparisons to photon-based therapy). The pooled event rates for acute grade ≥2 toxicities mucositis, dermatitis, xerostomia weight loss are 46% (95% confidence interval [95% CI]-29%-64%, I2 = 87%), 47% (95% CI-28%-67%, I2 = 87%), 16% (95% CI-9%-29%, I2 = 76%), and 36% (95% CI-27%-47%, I2 = 45%), respectively. Only one late endpoint (xerostomia grade ≥2) has sufficient data for analysis with pooled event rate of 9% (95% CI-3%-29%, I2 = 77%), lower than intensity-modulated radiotherapy 27% (95% CI-10%-54%, I2 = 95%). For most endpoints with significant differences between the PBT and photon-based therapies, PBT resulted in better outcomes. In two studies where dose distribution was studied, doses to the organs at risk were independent risk factors for toxicities.

CONCLUSION

PBT may reduce the risk of acute toxicities for patients treated for primary NPC, likely due to dose reduction to critical structures. The pooled event rate for toxicities derived in this study can be a guide for patient counseling.

Tumor molecular landscape of Epstein-Barr virus (EBV) related nasopharyngeal carcinoma in EBV-endemic and non-endemic areas: Implications for improving treatment modalities

Epstein-Barr virus (EBV) related- nasopharyngeal carcinoma (NPC) is a squamous carcinoma of the nasopharyngeal mucosal lining. Endemic areas (EA) are east and Southeast Asia, were NPC was recorded with higher incidence and longer estimated survival than in non-endemic area (NEA) such as Europe, We analyzed the gene expression and microenvironment properties of NPC in both areas to identify molecular subtypes and assess biological and clinical correlates that might explain the differences in incidence and outcome between EA- and NEA-NPCs. Six EA-NPC transcriptomic datasets, including tumor and normal samples, were integrated in a meta-analysis to identify molecular subtypes using a ConsensusClusterPlus bioinformatic approach. Based on the biological/functional characterization of four identified clusters were identified: Cl1, Immune-active; Cl2, defense-response; Cl3, proliferation; Cl4, perineural-interaction/EBV-exhaustion. Kaplan-Meier survival analysis, applied to the single dataset with available disease-free survival indicated Cl3 as the cluster with the worst prognosis (P = 0.0476), confirmed when applying four previously published prognostic signatures. A Cl3 classifier signature was generated and its prognostic performance was confirmed (P = 0.0368) on a validation dataset. Prediction of treatment response suggested better responses to: radiotherapy and immune checkpoint inhibitors immune-active and defense-response clusters; chemotherapy proliferation cluster; cisplatin perineural-interaction/EBV-exhaustion cluster. RNA sequencing for gene expression profiling was performed on 50 NEA-NPC Italian samples. In the NEA cohort, Cl1, Cl2 and Cl3 were represented, while perineural-interaction/EBV-exhaustion was almost absent. The immune/biological characterization and treatment-response prediction analyses of NEA-NPC partially replicated the EA-NPC results. Well characterized EA- and NEA-NPC retrospective and prospective cohorts are needed to validate the obtained results and can help designing future clinical studies.

Two web-based dynamically interactive nomograms and risk stratification systems for predicting survival outcomes and guiding treatment in non-metastatic nasopharyngeal carcinoma

BACKGROUND

A nomogram is a valuable and easily accessible tool for individualizing cancer prognosis. This study aims to establish and validate two prognostic nomograms for long-term overall survival (OS) and cancer-specific survival (CSS) in non-metastatic nasopharyngeal carcinoma (NPC) patients and to investigate the treatment options for the nomogram-based risk stratification subgroups.

METHODS

A total of 3959 patients with non-metastatic NPC between 2004 and 2015 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. The patients were randomly allocated to the training and validation cohorts in a 7:3 ratio. Prognostic nomograms were constructed to estimate OS and CSS by integrating significant variables from multivariate Cox regression employing a backward stepwise method. We examined the correlation indices (C-index) and areas under the curves (AUC) of time-dependent receiver operating characteristic curves to assess the discriminative ability of our survival models. The comprehensive enhancements of predictive performance were evaluated with net reclassification operating improvement (NRI) and integrated discrimination improvement (IDI). Reliability was validated using calibration plots. Decision curve analysis (DCA) was used to estimate clinical efficacy and capability. Finally, the nomogram-based risk stratification system used Kaplan-Meier survival analysis and log-rank tests to examine differences between subgroups.

RESULTS

The following independent parameters were significant predictors for OS: sex, age, race, marital status, histological type, median household income, AJCC stage tumor size, and lymph node size. Except for the race variables mentioned above, the rest were independent prognostic factors for CSS. The C-index, AUC, NRI, and IDI indicated satisfactory discriminating properties. The calibration curves exhibited high concordance with the exact outcomes. Moreover, the DCA demonstrated performed well for net benefits. The prognosis significantly differed between low- and high-risk patients (p < 0.001). In a treatment-based stratified survival analysis in risk-stratified subgroups, chemotherapy benefited patients in the high-risk group compared to radiotherapy alone. Radiotherapy only was recommended in the low-risk group.

CONCLUSIONS

Our nomograms have satisfactory performance and have been validated. It can assist clinicians in prognosis assessment and individualized treatment of non-metastatic NPC patients.

The role of interventional radiotherapy (brachytherapy) in nasopharynx tumors: A systematic review

Purpose

Nasopharyngeal cancers (NPC) are very aggressive, and the recurrence rate after radical therapy is high. This study aimed to evaluate the efficacy of brachytherapy (BT) also called interventional radiotherapy (IRT) in primary NPC in comparison with external beam radiotherapy (EBRT) alone.

Material and methods

A systematic search was performed in Scopus, Cochrane, and PubMed databases. Clinical query based on PICO framework was as follows: In patients with NPC (P), is EBRT plus IRT (I) superior to EBRT alone (C) in terms of local control (LC) and toxicity (O)? Full articles evaluating the efficacy of IRT as a boost after EBRT in patients with NPC were considered.

Results

Eight papers, including 1,320 patients fulfilled the inclusion criteria. The median 5-year LC for IRT group and no-IRT group was 98% (range, 95.8-100%) and 86% (range, 80.2-91%), respectively; the median 5-year overall survival (OS) for IRT group and no-IRT group was 93.3% (range, 89.2-97.5%) and 82.9% (range, 74.8-91.1%), respectively; the median 5-year DFS for IRT group and no-IRT group was 94.2% (range, 92.5-96%) and 83.9% (range, 73.3-94.6%), respectively; the median 5-year cancer-specific survival (CSS) for IRT group and no-IRT group was 96% (range, 94.5-97.5%) and 88.2% (range, 83.4-93.1%), respectively. G1-2 and G3-4 toxicities were similar in some articles, or significantly lower in patients treated with IRT in other papers.

Conclusions

Data suggest that IRT may improve results of external beam radiotherapy in primary NPCs, especially when using new technologies.

Early onset of nasopharyngeal cancer in Asian/Pacific Islander Americans revealed by age-specific analysis

PURPOSE

Incidence of nasopharyngeal cancer is substantially higher in Asian/Pacific Islanders (APIs) than other racial groups. Examining age-specific incidence patterns by racial group and histology could inform disease etiology.

METHODS

We analyzed data from 2000 through 2019 from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program to compare age-specific incidence rates of nasopharyngeal cancer in non-Hispanic (NH) Blacks, NH APIs, and Hispanics to NH Whites using incidence rate ratios with 95% confidence intervals (CIs).

RESULTS

NH APIs showed the highest incidence of nasopharyngeal cancer across all histologic subtypes and almost all age groups. The racial differences were most pronounced in the age 30-39 group; relative to NH Whites, NH APIs were 15.24 (95% CI: 11.69-20.05), 17.26 (95% CI: 12.56-24.07), and 8.91 (95% CI: 6.79-11.48) times as likely to have differentiated non-keratinizing, undifferentiated non-keratinizing, and keratinizing squamous cell tumors, respectively.

CONCLUSIONS

These findings suggest an earlier onset of nasopharyngeal cancer among NH APIs, which highlight unique early life exposure to critical nasopharyngeal cancer risk factors as well as genetic predisposition in this high-risk population.

An overall survival predictive nomogram to identify high-risk patients among locoregionally advanced nasopharyngeal carcinoma: Developed based on the SEER database and validated institutionally

Objective

Locoregionally advanced nasopharyngeal carcinoma (LA-NPC) patients, even at the same stage, have different prognoses. We aim to construct a prognostic nomogram for predicting the overall survival (OS) to identify the high-risk LA-NPC patients.

Materials and methods

Histologically diagnosed WHO type II and type III LA-NPC patients in the Surveillance, Epidemiology, and End Results (SEER) database were enrolled as the training cohort (n= 421), and LA-NPC patients from Shantou University Medical College Cancer Hospital (SUMCCH) served as the external validation cohort (n= 763). Variables were determined in the training cohort through Cox regression to form a prognostic OS nomogram, which was verified in the validation cohort, and compared with traditional clinical staging using the concordance index (C-index), Kaplan–Meier curves, calibration curves and decision curve analysis (DCA). Patients with scores higher than the specific cut-off value determined by the nomogram were defined as high-risk patients. Subgroup analyses and high-risk group determinants were explored.

Results

Our nomogram had a higher C-index than the traditional clinical staging method (0.67 vs. 0.60, p&lt;0.001). Good agreement between the nomogram-predicted and actual survival were shown in the calibration curves and DCA, indicating a clinical benefit of the nomogram. High-risk patients identified by our nomogram had worse prognosis than the other groups, with a 5-year overall survival (OS) of 60.4%. Elderly patients at advanced stage and without chemotherapy had a tendency for high risk than the other patients.

Conclusions

Our OS predictive nomogram for LA-NPC patients is reliable to identify high-risk patients.

Causes of Death in Long-Term Nasopharyngeal Carcinoma Survivors

Purpose

To assess the causes of death (COD) and long-term survival after nasopharyngeal carcinoma (NPC) diagnosis.

Methods

Using linked data from the Surveillance, Epidemiology, and End Results program, patients with NPC diagnosed from 1990 to 2010 and followed up >5 years were identified. Chi-squared test, the Kaplan–Meier method, and the Cox proportional hazard model were used for analyses.

Results

Among the 3,036 long-term NPC survivors, 1,432 survived for >5–10 years and 1,604 survived for >10 years. The most common COD was primary NPC (36.9%), followed by other causes (28.7%), other cancers (15.3%), cardiac disease (12.9%), and non-malignant pulmonary disease (6.2%). With a median follow-up of 125 months, deaths from NPC decreased with increasing time from diagnosis, while death because of cardiac disease and other causes increased. In those aged <50 years, death due to NPC remained the main COD over time, while cardiopulmonary disease-related death was the leading COD in patients aged ≥50 years. In White patients, death due to NPC decreased, and death due to cardiac disease increased over time. Death from NPC remained significant in Black and Asian patients even 15 years after the diagnosis of NPC, while death due to cardiac disease significantly increased after 9 years of diagnosis in Black patients. Multivariate analyses showed that the independent factors associated with inferior NPC-specific survival were older age, Asians, American Indian/Alaska Native, regional stage, distant stage, and diagnosis in the early years.

Conclusions

The probability of death from primary NPC remains significant even 15 years after the NPC diagnosis. Our study advocates continued surveillance for NPC survivors beyond the traditional 5 years. Individualized follow-up strategies are required for patients with NPC of different ages and races.

Effects of Self-Care plus Forecasting Nursing on the Treatment Outcomes and Emotions in Patients with Nasopharyngeal Carcinoma after Radiotherapy

Objective

To explore the effects of self-care plus forecasting nursing on the treatment outcomes and emotions in nasopharyngeal carcinoma patients undergoing radiotherapy.

Methods

Eighty nasopharyngeal carcinoma patients after radiotherapy admitted to our hospital from February 2020 to August 2021 were selected. The patients were allocated into an observation group (n = 40) and an experimental group (n = 40) according to different nursing protocols. The observation group received traditional nursing intervention, whereas the experimental group received self-care plus forecasting nursing intervention. The levels of the indexes (quality of life, score on the Zung Self-Rating Anxiety Scale (SAS), score on the Zung Self-Rating Depression Scale (SDS), and adverse reaction) were compared between the two groups.

Results

The score of the experimental group for the quality of life was significantly higher than that of the observation group (P < 0.05); the SAS and SDS scores of the experimental group after nursing intervention were significantly lower than those of the observation group (P < 0.05); the incidence of adverse reactions in the experimental group during radiotherapy was significantly lower than that of the observation group (P < 0.05).

Conclusion

The self-care plus forecasting nursing intervention is effective in postradiotherapy patients with nasopharyngeal carcinoma. The technique is proved effective to improve the quality of life, reduce anxiety and depression, and decrease the incidence of adverse reactions in patients during treatment. These features make the technique worthy of a wider clinical application.

Clinical trial data of Anti-PD-1/PD-L1 therapy for recurrent or metastatic nasopharyngeal Carcinoma: A review

IMPORTANCE

Anti-programmed cell death receptor-1 (PD-1) therapy is standard of care for incurable recurrent or metastatic non-nasopharyngeal head and neck cancer. In contrast, there are no regulatory agency-approved anti-PD-1 agents indicated for the treatment of recurrent or metastatic nasopharyngeal carcinomas (RM-NPC) in the Western hemisphere, and no standard treatment option exists beyond first-line chemotherapy for RM-NPC. The pace of development of novel systemic therapy regimens for RM-NPC has been slow compared to many other advanced tumor types, leaving an unmet clinical need for these patients with a poor prognosis.

OBSERVATIONS

Recent clinical trials have documented the clinical activity of anti-PD-1 therapy in RM-NPC. In particular, randomized clinical trials in the first-line setting have demonstrated significant improvements in progression-free survival (PFS) with the addition of anti-PD-1 therapy to standard chemotherapy. Whether the observed PFS benefits require combination chemoimmunotherapy or can be achieved with chemotherapy followed by crossover to immunotherapy upon progression remains unknown. Ongoing clinical trials are exploring novel anti-PD-1 therapy-based combinations, which may further solidify a role for these agents in RM-NPC.

CONCLUSIONS AND RELEVANCE

Among patients with RM-NPC, anti-PD-1 therapy added to first-line standard-of-care gemcitabine plus cisplatin provides significantly better efficacy outcomes compared to chemotherapy alone, and anti-PD-1 monotherapy appears to have comparable clinical activity and better tolerability than chemotherapy in previously treated disease. Thus, anti-PD-1 therapy is poised to advance standard of care for the treatment of RM-NPC.

Racial and Ethnic Disparities in Nasopharyngeal Cancer with an Emphasis among Asian Americans

Despite the overall decreasing incidence, nasopharyngeal cancer (NPC) continues to cause a significant health burden among Asian Americans (AAs), who are a fast-growing but understudied heterogeneous racial group in the United States. We aimed to examine the racial/ethnic disparities in NPC incidence, treatment, and mortality with a specific focus on AA subgroups. NPC patients aged ≥ 15 years were obtained from the Surveillance, Epidemiology, and End Results (SEER) 18 (1975-2018). AAs were divided into Chinese, Filipino, Vietnamese, Hawaiian, Japanese, Laotian, Korean, Cambodian, Indian/Pakistani and other Asian/Pacific Islanders (APIs). Age-adjusted incidence was calculated using the SEER*Stat software. Cox proportional and Fine-Gray sub-distribution hazard models were used to calculate overall and cause-specific mortalities after adjusting for confounders. Among the total 11,964 NPC cases, 18.4% were Chinese, 7.7% Filipino, 5.0% Vietnamese, 1.2% Hawaiian, 1.0% Japanese, 0.8% Laotian, 0.8% Korean, 0.6% Cambodian, 0.5% Indian/Pakistani and 4.4% other APIs. Laotians had the highest age-adjusted NPC incidence (9.21 per 100,000), which was 18.04 times higher than it in non-Hispanic Whites (NHWs). Chinese and Filipinos observed lower overall mortalities, however, Chinese saw increased NPC-specific mortality than NHWs. Disparities in mortality were also found across different histology subtypes. This is the first and largest study examining the NPC incidence and outcomes in AA subgroups. The significant disparities of NPC within AAs underline the importance of adequate AA-subgroup sample size in future studies to understand the prognostic role of ethnicity in NPC and advocate more ethnically and culturally tailored cancer prevention and care delivery.

Surveillance tools for detection of recurrent nasopharyngeal carcinoma: An evidence-based review and recommendations

Objective

Nasopharyngeal carcinomas (NPC) are tumors arising from epithelium of the nasopharynx. The 5-year survival rate of primary NPC is 80% with significant risks of recurrence. The objective here is to provide an evidence-based systemic review of the diagnostic value of different modalities in detecting local, regional, and distal recurrent NPC, as well as the associated costs with these modalities.

Methods

MEDLINE, EMBASE, and the Cochrane review database were queried. Two hundred and twenty-three abstracts were generated using the inclusion criteria: patients >18 years of age; histopathological reference standard; and modalities pertaining to imaging or microbiology.

Results

Twenty-four manuscripts fulfilled the inclusion criteria and 5 surveillance tools identified: endoscopy, MR, FDG-PET, Tc-99m MIBI and ²⁰¹TI SPECT, and EBV DNA.

Conclusions

For local surveillance, endoscopy is the gold standard recommendation, with increased efficacy if Narrow Band Imaging or contact endoscopy are utilized. MRI and FDG-PET is also recommended to help with local to distal spread; however, Tc-99m MIBI and ²⁰¹TI SPECT are options as well. EBV DNA is recommended as a cheap and accessible adjunct surveillance tool if an available as an option.

Open and endoscopic surgery improve survival for squamous and nonsquamous cell nasopharyngeal carcinomas: An NCDB cohort study

BACKGROUND

Nasopharyngeal tumors (NPTs) are primarily treated with nonsurgical therapy. Recent studies have demonstrated endoscopic salvage surgery for NPT recurrences may improve survival relative to reirradiation. However, there are very limited data on open compared with endoscopic approaches for NPTs. We investigated whether endoscopic and open surgical approaches to the nasopharynx improve overall survival for all histologic subtypes of NPTs.

METHODS

We performed a retrospective cohort study using the National Cancer Database (NCDB). All adult patients with NPTs from 2004 to 2016 without distant metastasis who underwent treatment with curative intent were included. We extracted clinical and treatment variables to assess our primary outcome of overall survival.

RESULTS

On univariate analysis, patients undergoing endoscopic surgery, but not open surgery, had significantly improved overall survival relative to those undergoing nonsurgical treatment. Post hoc analysis demonstrated significantly improved overall survival for surgery in patients with minor salivary gland histology, but not squamous cell carcinoma (SCC) histology or by T or N classification. A Cox proportional hazards model was used for multivariate regression. After adjusting for covariates, both endoscopic and open approaches were associated with improved overall survival relative to nonsurgical treatment for all tumor types. A multivariate regression of SCC found that open surgery, but not endoscopic surgery, was significantly associated with improved overall survival.

CONCLUSION

Both endoscopic and open surgical approaches are associated with improved overall survival of patients with NPT. These findings highlight important oncologic validity as endoscopic and robotic platforms to the nasopharynx become more widely adopted.

Race and Ethnicity in Otolaryngology Academic Publications

OBJECTIVE

Within otolaryngology, race is commonly included as a study covariate; however, its value in clinical practice is unclear. This study sought to explore how race and ethnicity have been used and applied over time in otolaryngology publications.

DATA SOURCES

PubMed database.

REVIEW METHODS

A systematic review was done to identify original otolaryngology studies between January 1, 1946, and June 25, 2020, with the following search terms: "otolaryngology" AND "race" OR "ethnicity."

RESULTS

Of the 1984 yielded studies, 932 were included in the final analysis. Only 2 studies (0.2%) defined race, and 172 (18.5%) gave participants the opportunity to self-identify race. Less than half (n = 322, 43.8%) of studies controlled for confounders. One hundred studies (10.7%) linked race to genetic factors. An overall 564 (60.5%) made conclusions about race, and 232 (24.9%) mentioned that race is relevant for clinical decision making. The majority of studies had first and senior authors from high-income countries (93.9% and 93.8%, respectively). Over time, there was a significant increase in publications that controlled for confounders, the number of race categories used, and studies that highlighted disparities.

CONCLUSION

Race and ethnicity are often poorly defined in otolaryngology publications. Furthermore, publications do not always control for confounding variables or allow participants to self-identify race. On the basis of our findings, we suggest 7 foundational principles that can be used to promote equitable research in otolaryngology publications. Future efforts should focus on incorporating research guidelines for race and ethnicity into journal publication standards.

Impact of Race, Ethnicity, and Socioeconomic Status on Nasopharyngeal Carcinoma Disease-Specific and Conditional Survival

Introduction  Race, ethnicity, and socioeconomic status (SES) are complex, interconnected social determinants of health outcomes. This study uses multivariable analysis on a combination of large national datasets to examine the effects of these factors on 5-year disease-specific survival (DSS) and conditional DSS (CDSS) for nasopharyngeal carcinoma (NPC). Methods  A retrospective study of adults with NPC between 2000 and 2017 from the Surveillance, Epidemiology, End Results (SEER) registry was performed, using the National Cancer Institute Yost Index, a census tract-level composite score of SES to categorize patients. Kaplan-Meier analysis and Cox's regression for DSS and CDSS were stratified by SES. Logistic regression was conducted to identify risk factors for advanced cancer stage at time of diagnosis and receiving multimodal therapy. Results  Our analysis included 5,632 patients. DSS was significantly associated with race and SES ( p  < 0.01). Asian/Pacific Islander patients exhibited increased survival when controlling for other variables (hazard ratio [HR] = 0.73, p  < 0.01). Although Black patients were more likely to be diagnosed with advanced disease (Black odds ratio [OR] = 1.47, p  < 0.01), Black patients were also less likely to receive multimodal therapy; however, this relationship lost statistical significance once SES was incorporated into the multivariable analysis. DSS was decreased among the lowest (first) and middle (second) tertiles of SES (first HR = 1.34, p  < 0.01; second HR = 1.20, p  < 0.01) compared with the highest (third). Conclusion  Our results indicate that race, ethnicity, and SES significantly affect survival, stage at diagnosis, and treatment of NPC. An interplay of tumor biology and inequalities in access to care likely drives these disparities.

Qing Yan Li Ge Tang, a Chinese Herbal Formula, Induces Autophagic Cell Death through the PI3K/Akt/mTOR Pathway in Nasopharyngeal Carcinoma Cells In Vitro

Since a portion of patients with nasopharyngeal carcinoma (NPC) do not benefit much from current standard treatments, it is still needed to discover new therapeutic drugs to improve the prognosis of the patients. Considering that Chinese traditional medicine plays a role in inhibiting tumor progression, in this study, we aimed to investigate whether a Chinese herbal formula, Qing Yan Li Ge Tang (QYLGT), has the anticancer activity in NPC cells and explore the underlying mechanism as well. MTT assay, colony formation assay, immunoblotting assay, and DNA laddering assay were performed to assess cell viability, cell colony formation, protein expression, and DNA fragmentation, respectively. Results show that QYLGT was able to inhibit the cell viability and decrease colony formation ability in NPC cells. QYLGT could also increase the formation of intracellular vacuoles and induce the autophagy-related protein expressions, including Atg3, Atg6, and Atg12-Atg5 conjugate in NPC cells. Treatment with an autophagy inhibitor, 3-methyladenine, could significantly recover QYLGT-inhibited cell viability of NPC cells. In addition, QYLGT did not significantly induce apoptosis in NPC cells. We also found that QYLGT had the ability to activate phosphoinositide 3-kinase (PI3K)/Akt/mammalian target of the rapamycin (mTOR) pathway. Treatment with PI3K inhibitors, LY294002 and wortmannin, or mTOR inhibitors, rapamycin and Torin 1, could not only recover QYLGT-inhibited cell viability of NPC cells but also inhibit Atg3 expression. Taken together, our results demonstrated that QYLGT could induce autophagic cell death in NPC cells through the PI3K/Akt/mTOR pathway.

Mental Disorders in Nasopharyngeal Carcinoma Patients Receiving Radiation Therapy: A Nationwide Population-based Study

BACKGROUND/AIM

Using nationwide data from South Korea, we analyzed the prevalence of mental disorders among patients with nasopharyngeal carcinoma (NPC) who received radiotherapy (RT).

PATIENTS AND METHODS

Data were collected between January 2010 and December 2014, and 1,819 patients diagnosed with NPC who underwent RT were identified. We calculated the prevalence of the five most commonly diagnosed mental disorders and their incidences according to a time sequence based on the time of RT.

RESULTS

Among 1,819 patients, 144 (7.9%) were diagnosed at least once with a mental disorder between one year before the start of RT and the last follow-up. Based on the first diagnosis, 51 (35.4%) patients experienced anxiety, and 46 (31.9%) suffered from depression. The frequency of mental disorders increased up to the beginning of RT and then declined. Before the start of RT, anxiety was most frequent, and depression occurred after the start of RT. The cumulative incidence of mental disorders in the older age group tended to be higher than that of the younger group (≥54 vs. <54 years, log-rank p=0.052).

CONCLUSION

The proportion of mental disorders differed before and after the start of RT in patients with NPC. At the beginning of RT, mental disorders emerged most often during management. Early screenings and interventions for mental disorders were able to improve quality of life (QOL).

Socioeconomic Status and Survival in Nasopharyngeal Carcinoma: A Population-Based Study

OBJECTIVES/HYPOTHESIS

To evaluate survival for nasopharyngeal carcinoma in relation to socioeconomic status.

STUDY DESIGN

Retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER) Census Tract-level Socioeconomic Status Database (2000-2016).

METHODS

Patients with nasopharyngeal carcinoma diagnosed between 2000 and 2016 were identified. Data were stratified based on socioeconomic status, divided into three groups: group 1 being the poorest and group 3 the wealthiest. Univariate analysis as well as multivariate Cox regression analysis adjusted for individual variables was performed.

RESULTS

A total of 5,527 patients were included in the study, with 33% in group 1, 34% in group 2, and 33% in group 3. There was a significant difference between groups in regard to age at diagnosis, race, histologic subtype, overall stage, tumor stage, nodal stage, and whether or not they received radiation. Patients in group 1, the poorest socioeconomic status, were more likely to be young (P = .003), black (P < .0001), present with higher overall stage (P = .009), tumor stage (P = .01), and nodal stage (P = .02), and less likely to receive radiation (P = .005). In multivariate analysis, there was a significant difference in survival between the groups, with group 1 patients less likely to survive compared to group 3 (hazard ratio = 1.28; 95% CI 1.07-1.57).

CONCLUSIONS

Patients in the poorest socioeconomic status presented with more advanced nasopharyngeal cancer and were less likely to receive radiation when compared with individuals of higher socioeconomic status. The poorest socioeconomic status groups were less likely to survive from their disease when controlling for other variables.

LEVEL OF EVIDENCE

NA Laryngoscope, 2021.

The prognostic significance of race in nasopharyngeal carcinoma by histological subtype

BACKGROUND

Race has been shown to have variable prognostic importance in nasopharyngeal carcinoma (NPC). However, previous studies are limited by a lack of comprehensive treatment, epidemiologic, and comorbidity data.

METHODS

This was a retrospective cohort study utilizing the National Cancer Database from 2004 to 2016. Multivariable Cox proportional hazards regressions were used to calculate adjusted hazard ratios (aHR) for overall survival.

RESULTS

A cohort of 9995 patients met inclusion and exclusion criteria. Race, insurance, comorbidity, treatment, stage, age, and histology were independent prognosticators. Among patients with keratinizing NPC, Asians and Hispanics had superior survival (aHR 0.58 [95% confidence interval (CI) 0.48-0.69], aHR 0.76 [95% CI 0.61-0.96]) compared to white patients. Among patients with non-keratinizing differentiated NPC, Asians and black patients had improved survival (aHR 0.71 [95% CI 0.56-0.91], aHR 0.72 [95% CI 0.54-0.95]) compared to white patients. Race was not prognostic in non-keratinizing undifferentiated NPC.

CONCLUSION

The prognostic significance of race varies across histological subtypes of NPC.

A clinical study on the factors associated with nasopharyngeal carcinoma among the Chinese population

Nasopharyngeal carcinoma (NC) arises from the nasopharynx epithelium and the majority of NC cases globally are within China and Southeast Asia. Both short palate lung and nasal epithelium clone 1 (SPLUNC1) and myelodysplasia syndrome 1-ectopic viral integration site 1 (MDS1-EVI1) play an important role in carcinogenesis and have been found to be associated with nasopharyngeal carcinoma. In spite of their role in NC, the association between these genes and their polymorphisms in the development of NC has thus far not been studied. In the present study, the relationship between SPLUNC1 (rs2752903, T>C) and MDS1-EVI1 (rs6774494, G>A) polymorphisms and their role in the development of NC among the Chinese population were investigated. From a Chinese population of 1,059 patients with NC and 891 controls, genotype frequencies and the distribution of SPLUNC1 and MDS1-EVI1 polymorphisms were analyzed for possible susceptibility to NC. It was observed that those with MDS1-EVI1 CC (OR, 2.76; 95% CI, 1.96-3.81) and MDS1-EVI1 CT (OR, 1.51; 95% CI, 1.22-2.14) polymorphisms had an increased risk of developing NC. Those with SPLUNC1 AA genotypes also observed a higher risk for NC compared with SPLUNC1 GG genotypes (OR, 2.15; 95% CI, 1.62-3.15). When observing the gene-gene interaction between SPLUNC1 and MDS1-EVI1 polymorphisms, it was found that the presence of both SPLUNC1 CC and MDS1-EVI1 AA alleles was associated with a higher risk for NC compared with those who did not carry both alleles (OR, 6.75; 95% CI, 3.41-12.11). The present study suggested that the association between SPLUNC1 (rs2752903, T>C) and MDS1-EVI1 (rs6774494, G>A) polymorphisms may be a potent risk factor in the occurrence of NC.

Quality-Adjusted Life Years and Disability-Adjusted Life Years Are Better With Concurrent Chemoradiation Therapy Than Induction Chemotherapy Followed by Chemoradiation Therapy in Nasopharyngeal Carcinoma

Introduction As traditional measures such as overall survival (OS) or disease-free survival (DFS) alone do not give a holistic view of the outcomes of a treatment paradigm, we determine to add the evidence of quality-adjusted life year (QALY) and disability-adjusted life year (DALY) to the outcomes of the nasopharyngeal carcinoma patients (NCP) treated with definitive chemoradiation therapy (chemoRT) with or without induction chemotherapy (induction chemo). Methods This is a retrospective analysis of 85 NCPs treated at an academic state institution. The OS estimated by the Kaplan-Meier method and the multivariate Cox regression model determined the co-variables associated with the OS. The relationship between QALYs gained and DALYs saved were calculated from age of the disease onset, duration of the disease, quality of life (QoL) and disability weights. Results Of the 85 eligible NCPs of this cohort, the disease frequency distribution per the World Health Organization (WHO) classification was 41.2% for Type-I, 42.4% for Type-II, and 16.5% for Type-III. The median follow-up (24 months). The five-year OS of patients treated with concurrent chemoRT vs. induction chemo followed by concurrent chemoRT was 54.7 vs. 14.8% for WHO Type I, 60.1 vs. 58.3% for WHO Type II, and 83.3 vs. 50.0% for WHO Type III (p=0.029). The average DALYs saved with concurrent chemoRT were 12.2 years vs. 5 years for induction chemo followed by concurrent chemoRT. The average QALYs gained with concurrent chemoRT were 6.9 years vs. 3.1 years for induction chemo followed by concurrent chemoRT. Conclusion Patients treated with concurrent chemoRT had an increased QoL when compared to induction chemo followed by concurrent chemoRT. The average DALYs saved were higher in the patients treated with concurrent chemoRT than treated with induction chemo followed by concurrent chemoRT.

Chinese and South Asian ethnicity, immigration status and head and neck cancer outcomes: A population based study

OBJECTIVE

While it is known that certain ethnic and immigrant groups are at increased risk of developing head and neck cancer, the individual effects of immigration status and ethnicity on head and neck cancer outcomes is less clear. We sought examine the independent effects of immigration and Chinese and South Asian ethnicity on overall survival in a head and neck cancer patient population.

METHODS

This was a population-based retrospective matched cohort study using linked Ontario administrative databases between 1994 and 2017. Incident cancer cases were captured in long-standing residents of Chinese and South Asian ethnicity, Chinese and South Asian immigrants, as well as a reference population. Subjects were followed until death. A hard-matching approach was used to adjust for key differences and ensure both groups were balanced with respect to age, sex and cancer site. Cox proportional hazard models were used to estimate the impact of Chinese and South Asian ethnicity on overall survival while further adjusting for baseline covariates.

RESULTS

Among 1639 immigrants with head and neck cancer, matched to 3278 controls, the overall 5-year survival rate was 66% and 59%, respectively. After adjusting for between group-differences, all-cause mortality was lower for immigrants (HR 0.76[95%CI 0.69-0.83]) and individuals of Chinese ethnicity (HR 0.78[95%CI 0.68-0.90]), relative to the general population.

CONCLUSIONS

In Ontario, immigrants experience lower mortality rates following a head and neck cancer diagnosis. Individuals of Chinese ethnicity with head and neck cancer experience a survival advantage, relative to South Asian individuals and the general population.

Subtype Specific Nasopharyngeal Carcinoma Incidence and Survival Trends: Differences between Endemic and Non-Endemic Populations

BACKGROUND

While nasopharyngeal carcinoma (NPC) is rare in non-endemic regions such as the North America, endemic countries, such as Thailand, continue to struggle with high incidence and mortality rates. NPC has a complex etiology that varies by histological subtype.

METHODS

NPC cases (1990-2014) were identified using the International Classification of Diseases for Oncology (ICD-O) code C11 from the Chiang Mai, Khon Kaen, Lampang, and Songkhla cancer registries and compared to Asian/Pacific Islanders (A/PI) from the US SEER program. Age-standardized incidence rates and changes in annual percent change (APC) for overall and subtype specific NPC were assessed using R and Joinpoint. Kaplan Meier curves were generated in SAS to evaluate differences in survival by sex, year of diagnosis and histological subtype. Five-year relative survival estimates were calculated between 2000-2014.

RESULTS

Non-keratinizing NPC predominated across all registries except Songkhla, where the keretinizing subtype made up ~60% of all reported cases. Incidence of keratinizing NPC significantly decreased among Chiang Mai males between 1996 and 2014 (APC:-13.0 [95%CI:-16.2, -9.6]), Songkhla females (APC:-4.0 [95%CI: -7.4, -0.5]) and males between 2006 and 2014 (APC:-15.5 [95%CI:-25.0, -4.7]), as well as A/PI females (APC:-5.1 [95%CI:-6,7, -3.4]) and males (APC: -4.8 [95%CI:-5.9, -3.7]). Non-keratinizing NPC increased among Songkhla males (APC:4.3 [95%CI:1.8, 6.9]). The keratinizing subtype exhibited the worst survival, while the non-keratinizing undifferentiated subtype had the best survival. Although US A/PI had the highest 5-year relative survival estimates, among the Thai registries Chiang Mai had the best and Lampang the worst survival.

CONCLUSION

Although US A/PIs exhibited similar rates of NPC as seen in the endemic Thai population, improved tobacco control has led to a decrease in keratinizing NPC incidence irrespective of geography. Additionally, while challenges associate with access to care may still exist among rural Thais, chemoradiation was shown to confer a survival benefit in non-keratinizing NPC treatment.

Label-free quantitative mass spectrometry from formalin-fixed paraffin-embedded samples of nasopharyngeal carcinoma: Preliminary results from a non-endemic European cohort of patients

Aim

Report our results of biomarker discovery in formalin-fixed paraffin-embedded (FFPE) nasopharyngeal carcinoma (NPC) via proteomic analysis.

Background

Nasopharyngeal carcinoma (NPC) is a rare cancer in Western countries. Proteomic analysis have already been reported as a useful tool to provide biomarkers. Formalin-fixed paraffin-embedded (FFPE) samples, despite largely underused, can provide invaluable information for biomarker research via proteomic analysis.

Methods

FFPE samples of NPC were submitted to protein extraction followed by FASP-digestion and label-free quantitative mass spectrometry (MS). Patients' received concurrent chemoradiation with or without adjuvant chemotherapy as per Intergroup 0099 trial. IMRT was delivered following the RTOG0615 specifications. Toxicity was scored using the CTCAE 4.03 tables. Survival was estimated using Kaplan-Meier curves. Log-rank was used to detect differences. KEGG ontology graphics were generated.

Results

28 FFPE samples from NPC patients were used. Patients were: 79% male, 97% Caucasians, 86% WHO type 3, 40% T1, 10% T2, 25% T3, and 25% T4. With a median follow up of 37 months, local control was 83 (T1, 100% T2, T3 and T4), overall survival was 84%, and six patients developed distant metastases. All five patients that died were due to metastatic disease. Tumor samples contained a median of 75% of tumor material. We found Epstein-Barr (EBV) and Herpes simplex (HSV) viruses' related proteins significantly present in early-stage primary NPC (T1 and T2, p < 0.01). A pool of 10 proteins was statistically up-regulated in the metastatic group of patients (p < 0.01). Median survival from this M1 group was <1 year (p < 0.001).

Conclusions

FFPE samples yielded adequate material for MS analysis. We found EBV and HSV related proteins on early-stage NPC, and proteomic profiling associated with distant metastases, potential candidates of disease biomarkers. Validation is needed.

LncRNA MSC-AS1 aggravates nasopharyngeal carcinoma progression by targeting miR-524-5p/nuclear receptor subfamily 4 group A member 2 (NR4A2)

Background

Nasopharyngeal carcinoma (NPC) is a subtype of head and neck cancer with dismal prognosis and high relapse rate. The role of long non-coding RNAs (lncRNAs) in NPC has become a research hotspot in recent years. This study aimed to interrogate the function and mechanism of lncRNA MSC antisense RNA 1 (MSC-AS1) in NPC.

Methods

MSC-AS1 level in NPC tissues and cells were detected by RT-qPCR. Function of MSC-AS1 in NPC cells was assessed by CCK-8, EdU, TUNEL, caspase-3 activity, and transwell invasion assay. Interaction of microRNA-524-5p (miR-524-5p) with MSC-AS1 and nuclear receptor subfamily 4 group A member 2 (NR4A2) was determined by RIP and luciferase reporter assays.

Results

MSC-AS1 was upregulated in NPC tissues and cells. Functional assays indicated that MSC-AS1 exacerbated cell proliferation, hindered apoptosis, and facilitated invasion and epithelial-to-mesenchymal transition (EMT) in NPC. Mechanistically, MSC-AS1 sequestered miR-524-5p to upregulate NR4A2 expression in NPC cells. Finally, NR4A2 was conformed as an oncogene in NPC, and overexpressed NR4A2 could restore MSC-AS1 knockdown-mediated inhibition on NPC progression.

Conclusions

Our study firstly showed that lncRNA MSC-AS1 aggravated NPC progression by sponging miR-524-5p to increase NR4A2 expression, indicating MSC-AS1 as a novel target for the lncRNA-targeted therapy in NPC.

Geographical and Racial Disparities in Head and Neck Cancer Diagnosis in South-Eastern United States: Using Real-World Electronic Medical Records Data

Background: Rurality, race, and age at diagnosis are important predictors in head and neck cancer (HNC) prognosis. However, literature on the associations of rurality and race with age at HNC diagnosis is limited. Data on geographical, racial, and gender disparities in young HNC patients (diagnosed ≤45 years) are also scarce.

Materials and Methods: This retrospective study assesses rural–urban, racial, and gender disparities in age at HNC diagnosis, using electronic medical records (Cerner) data of 4258 HNC patients (1538 residing in rural counties and 2720 in urban counties) from National Cancer Institute-designated cancer center in Alabama. Rurality was defined based on 2010 U.S. Census Bureau's rural–urban classification. Logistic regression was used to assess the association of young HNC diagnosis with demographical, behavioral, and clinical variables. ArcGIS 10.2 was used to map geospatial distribution of age and population-adjusted HNC case across rural and urban counties.

Results: Patients from rural counties were less likely to be diagnosed at younger age (≤45 years) compared with urban counties (odds ratio [OR] [95% confidence interval (CI)]: 0.74 [0.58–0.93]). Most patients present at stage III/IV (64.9% in rural and 60.2% in urban). Compared with white patients, black patients were 70% more likely to get diagnosed at a young age (95% CI: 1.23–2.35). Young patients were more likely to be females and blacks compared with older patients (p<0.0001). Among oral cavity cancer patients, rural patients were 51% less likely to get diagnosed at young age compared with urban patients (95% CI: 0.27–0.89).

Conclusions: Head and neck cancer screening is not routinely conducted so most show up at later stage of cancer. There is also evidence of disparities in age at HNC diagnosis based on rurality, race, and gender; targeted screening can help in reducing these disparities.

Development and validation of a nomogram for predicting long-term overall survival in nasopharyngeal carcinoma: A population-based study

We aimed to develop a nomogram based on a population-based cohort to estimate the individualized overall survival (OS) for patients with nasopharyngeal carcinoma (NPC) and compare its predictive value with that of the traditional staging system.Data for 3693 patients with NPC were extracted from the Surveillance, Epidemiology, and End Results dataset and randomly divided into two sets: training (n = 2585) and validation (n = 1108). On the basis of multivariate Cox regression analysis, a nomogram was constructed to predict the 3-, 5-, and 10-year survival probability for a patient. The performance of the nomogram was quantified with respect to discrimination, calibration, and clinical utility.In the training set, age, sex, race, marital status, histological type, T stage, N stage, M stage, radiotherapy, and chemotherapy were selected to develop a nomogram for predicting the OS probability based on the multivariate Cox regression model. The nomogram was generally more discriminative compared with the American Joint Committee on Cancer 7th staging system. Calibration plots exhibited an excellent consistency between the observed probability and the nomogram's prediction. Categorical net classification improvement and integrated discrimination improvement suggested that the predictive accuracy of the nomogram exceeded that of the classic staging system. With respect to decision curve analyses, the nomogram exhibited preferable net benefit gains than the staging system across a wide range of threshold probabilities.This proposed nomogram exhibits an excellent performance with regard to its predictive accuracy, discrimination capability, and clinical utility, and thus can be used as a convenient and reliable tool for prognosis prediction in patients with NPC.

Increasing incidence of Epstein-Barr virus-related nasopharyngeal carcinoma in the United States

BACKGROUND

The incidence of nasopharyngeal carcinoma (NPC) has been historically low in the United States. Although etiological factors differ by histological subtype, Epstein-Barr virus is accepted as the primary risk factor for nonkeratinizing NPC. In light of the changing epidemiology of viral-associated cancers, it is important to evaluate the temporal incidence of NPC in the United States.

METHODS

Incidence and survival data from 1973 through 2015 were obtained from the Surveillance, Epidemiology, and End Results program. Stratified analyses were conducted to assess temporal trends in NPC by histological subtype, sex, and race. The data were analyzed using SAS and Joinpoint Regression Software to determine age-adjusted incidence rates, determine trends in the annual percent change, and calculate 5-year relative survival estimates and Kaplan-Meier curves.

RESULTS

Although overall NPC incidence is decreasing in the United States, the nonkeratinizing differentiated subtype is starkly increasing, with an annual percent change of approximately 4% among white males (95% CI, 2.5%-5.2%), white females (95% CI, 1.9%-6.2%), and black males (95% CI, 2.0%, 5.7%); 2.7% among black females (95% CI, 0.8%, 4.6%); and 1.8% among women in the "other" race category (95% CI, 0.4%-3.3%). Racial disparities were noted, with 32% of nonkeratinizing NPC cases among blacks occurring before the age of 40 years. In addition, black males displayed consistently worse survival across all histological subtypes, whereas individuals in the "other" race category, particularly females, experienced the highest 5-year relative survival estimates.

CONCLUSIONS

The current results indicate that the Epstein-Barr virus-related, differentiated NPC subtype is increasing across all sexes and races in the United States, with distinct incidence and survival disparities among blacks.

The racial disparity of nasopharyngeal carcinoma based on the database analysis

OBJECTIVE

To investigate whether the racial/ethnical disparity of nasopharyngeal carcinoma exists among the four major ethical groups in the United States named Asians, Caucasians, African Americans and Hispanics between the years of 1973 to 2013 using the Surveillance, Epidemiology, and End Result (SEER) database.

METHODS

The National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) database from 1973 to 2013 was utilized in this study to calculate survival trends for the four main ethical groups in the United States. The cases of nasopharyngeal carcinoma were extracted based on the SEER code cs0204schema. Death due to the diagnosed nasopharyngeal cancer was considered to be the event of interest, and death due to other causes was treated as the censoring events. Kaplan-Meier model was adopted to estimate survival outcomes; the Cox proportional hazards model was employed to do the hazard ratios (HR) estimation.

RESULTS

A total of 8068 eligible patients of nasopharyngeal carcinoma were identified. The cohort was composed of 40.69% Caucasians, 11.34% African Americans, 40.16% Asians and 7.81% Hispanics. According to the multivariate Cox regression analysis, Asians had a better survival prognosis against Caucasians (HR: 0.74, 95% CI: 0.65-0.84, P < 0.001). African Americans showed marginal worse survival prognosis compared with Caucasians (HR: 1.26, 95% CI: 1.07-1.49, P < 0.005). There was no significant difference between Hispanics and Caucasians (HR: 1.13, 95% CI: 0.92-1.39, P = 0.261).

CONCLUSION

Asians showed a disease specific survival advantage over Caucasians, African Americans and Hispanics, which was independent of sex, age at diagnosis, grade, TNM staging and treatment strategy.

HIGH-RISK INTRAOCULAR RETINOBLASTOMA: Comparison Between Asian Indians and Americans From Two Major Referral Centers

PURPOSE

To identify the differences in the clinical and histopathologic features in eyes with advanced intraocular retinoblastoma in a developing country (India) versus a developed country (USA).

METHODS

Retrospective study.

RESULTS

Of 524 patients with retinoblastoma who underwent primary enucleation, 331 were from India, and 193 were from the USA. Asian Indians were older at presentation (35 months vs. 29 months; P = 0.02), had thicker tumors (13.8 mm vs. 12.4 mm; P = 0.0001) compared with Americans. High-risk intraocular retinoblastoma was more common in Asian Indians with a 2-fold greater risk compared with Americans (35% vs. 23%; odds ratio = 1.83; P = 0.003). Statistically significant differences in the histopathologic features (Asian Indians vs. Americans) included massive (≥3 mm) choroidal infiltration (17% vs. 6%; P = 0.0003) and optic nerve infiltration (48% vs. 15%; P = 0.0001). Asian Indians had a 5-fold greater risk of having optic nerve invasion (odds ratio = 5.45; P < 0.0001) and 3-fold greater risk of massive choroidal invasion (odds ratio = 2.80; P < 0.0001) compared with Americans. With appropriate use of adjuvant systemic chemotherapy, the difference in the rates of systemic metastasis (5% vs. 2%, P = 0.67) and related death in both countries (5% vs. 0%, P = 0.14) were not statistically significant.

CONCLUSION

High-risk intraocular retinoblastoma is more common in Asian Indians compared with Americans.

Does East meet West? Towards a unified vision of the management of Nasopharyngeal carcinoma

Nasopharyngeal cancer (NPC) is notable for its wide geographic variation, with incidences as high as 30 in 100,000 in endemic regions but < 1 in 100,000 worldwide. This review aims to identify areas where there could be differences in prognosis, management or outcomes among countries with high or low incidence of NPC. The incidence has generally declined both in endemic and non-endemic regions throughout the years, which may be attributed to the decrease in exposure to risk factors such as early exposure to salted fish and smoking. Ethnicity has an impact both on incidence and prognosis, with Southeast Asians having the highest incidence but also better survival. Concurrent chemoradiotherapy, with or without adjuvant and/or induction chemotherapy, is the standard of care for locoregionally advanced disease, as reflected in clinical practice guidelines. Despite improvements in management, a proportion of patients relapse. Salvage treatment is associated with significant morbidity due to the critical location of the nasopharynx and the toxicities of initial therapy. Clinical expertise is paramount, but is easier to attain in endemic regions and high volume centers where enrollment of patients in clinical trials is more feasible. Collaboration between low and high incidence countries and between low and high volume facilities is key to improving NPC prognosis worldwide.

Vesicle-bound EBV-BART13-3p miRNA in circulation distinguishes nasopharyngeal from other head and neck cancer and asymptomatic EBV-infections

Cell‐free microRNA (miRNA) in biofluids released by tumors in either protein or vesicle‐bound form, represent promising minimally‐invasive cancer biomarkers. However, a highly abundant non‐tumor background in human plasma and serum complicates the discovery and detection of tumor‐selective circulating miRNAs. We performed small RNA sequencing on serum and plasma RNA from Nasopharyngeal Carcinoma (NPC) patients. Collectively, Epstein Barr virus‐encoded miRNAs, more so than endogenous miRNAs, signify presence of NPC. However, RNAseq‐based EBV miRNA profiles differ between NPC patients, suggesting inter‐tumor heterogeneity or divergent secretory characteristics. We determined with sensitive qRT‐PCR assays that EBV miRNAs BART7‐3p, BART9‐3p and BART13‐3p are actively secreted by C666.1 NPC cells bound to extracellular vesicles (EVs) and soluble ribonucleoprotein complexes. Importantly, these miRNAs are expressed in all primary NPC tumor biopsies and readily detected in nasopharyngeal brushings from both early and late‐stage NPC patients. Increased levels of BART7‐3p, BART9‐3p and particularly BART13‐3p, distinguish NPC patient sera from healthy controls. Receiver operating characteristic curve analysis using sera from endemic NPC patients, other head and neck cancers and individuals with asymptomatic EBV‐infections reveals a superior diagnostic performance of EBV miRNAs over anti‐EBNA1 IgA serology and EBV‐DNA load (AUC 0.87–0.96 vs 0.86 and 0.66 respectively). The high specificity of circulating EBV‐BART13‐3p (97%) for NPC detection is in agreement with active secretion from NPC tumor cells. We conclude EV‐bound BART13‐3p in circulation is a promising, NPC‐selective, biomarker that should be considered as part of a screening strategy to identify NPC in endemic regions.

What's new?

Analysis of DNA from human tumor viruses in patient blood is a non‐invasive screening method for individuals at risk for developing cancer. A drawback is over‐diagnosis as these sensitive methods also detect non‐cancer‐related infections. Here the authors show by RNA sequencing and PCR amplification that a microRNA (BART13‐3p) encoded by the Epstein–Barr Virus (EBV) is associated with circulating vesicles in patients with nasopharyngeal carcinoma, thus distinguishing between cancer and non‐cancer‐related EBV infections.

Long non-coding RNA SNHG20 promotes nasopharyngeal carcinoma cell migration and invasion by upregulating TGF-β1

Small nucleolar RNA host gene 20 (SNHG20) has been reported to serve roles in several types of malignancies, while its role in nasopharyngeal carcinoma remains unknown. In the present study, tumor tissues and adjacent healthy tissues of patient with nasopharyngeal carcinoma, as well as blood samples from patients with nasopharyngeal carcinoma and heathy controls were collected, and expression levels of SNHG20 were detected by reverse transcription-quantitative polymerase chain reaction. Receiver operating characteristic curve and survival curve analyses were performed to evaluate the diagnostic and prognostic values of SNHG20 expression for nasopharyngeal carcinoma, respectively. Associations between serum expression levels of SNHG20 and clinical data of patients with nasopharyngeal carcinoma were analyzed using χ² test. A SNHG20 expression vector was constructed and transfected into nasopharyngeal carcinoma cells, and cell migration and invasion were detected by Transwell assays. Expression of transforming growth factor-β1 (TGF-β1) was detected by western blotting. Results indicated that the expression level of SNHG20 increased in cancer tissues compared with healthy tissues of patients with nasopharyngeal carcinoma. Serum level of SNHG20 increased in patients with nasopharyngeal carcinoma compared with healthy controls. Significant association was identified between serum levels of SNHG20 and distant tumor metastasis. Serum SNHG20 could serve as a potential diagnostic and prognostic marker for nasopharyngeal carcinoma. Overexpression of SNHG20 promoted nasopharyngeal carcinoma cell migration and invasion, and promoted the expression of TGF-β1. TGF-β1 inhibitor reduced the effects of SNHG20 overexpression on nasopharyngeal carcinoma cell migration and invasion, and exhibited no significant effect on SNHG20 expression. Therefore, the results of the present study indicated that lncRNA SNHG20 could promote the migration and invasion of nasopharyngeal carcinoma cells by upregulating TGF-β1.

Impact of age on survival of locoregional nasopharyngeal carcinoma: An analysis of the Surveillance, Epidemiology, and End Results program database, 2004-2013

OBJECTIVES

To determine the impact of age at diagnosis and other factors on survival in nasopharyngeal carcinoma (NPC).

DESIGN, SETTING AND PARTICIPANTS

A retrospective, population-based cohort study of 3103 patients are selected, whose records were submitted to the Surveillance, Epidemiology, and End Results (SEER) database between 2004 and 2013. We evaluated the demographic and clinical characteristics of patients who were 20 years or older with a diagnosis of primary, non-metastatic NPC.

MAIN OUTCOME MEASURES

Overall survival (OS) and risks of OS and NPC-specific survival.

RESULTS

Overall survival rates at 1, 3, and 5 years were 85.8%, 71.0%, and 62.6%, respectively. Older age was a significant predictor of poor OS, as was Chinese ethnicity. We also determined that middle-aged white patients, but not middle-aged black or Chinese patients, were at a higher risk of death than were younger patients of the same race/ethnicity. Nodal (N) stage 0-1 disease was a significant predictor of poor OS when comparing survival of older patients with N0-1 vs N2-3 stage disease. Finally, we found that married patients had a decreased risk of death when compared to those who were single.

CONCLUSIONS

The survival of older patients with NPC is inferior to that of younger patients. Race/ethnicity, marital status, and stage of disease are important modifiers of risk. Collectively, our results indicate that management of older patients requires optimisation.

Identification of fatal outcome in a childhood nasopharyngeal carcinoma patient by protein expression profiling

Nasopharyngeal carcinoma (NPC) is a rare disease in children with good prognosis and high cure rate. Nevertheless, certain patients have an unfavorable prognosis due to development of refractory NPC that is unresponsive to any therapeutic strategies. The current study studies a case of a 17 years-old female with non-keratinizing NPC type IIb (T2N0M0), who passed away as a consequence of resistance to chemo-, radio- and β-interferon therapy, and to an allogenic stem cell transplantation. In order to identify factors that lead to treatment failure and fatal outcome, immunohistochemical analyses of different tumor biomarkers and hierarchical cluster analysis were performed and compared with those of eight other patients with NPC who experienced complete remission following conventional therapy. Hierarchical cluster analysis of the immunohistochemical results clearly demonstrated that staining for immunological factors (CD4, CD8 and CD56) distinguished this patient from the others. To further investigate a potential role of the immune system, lymphocytic infiltration was assessed in tumor tissue by evaluation of hematoxylin and eosin-stained tumor sections. Indeed, no tumor infiltrating lymphocytes (TILs) were observed in this NPC case, while 7 out of 8 of the other NPC samples contained variable TIL amounts. The view that immunodeficiency of the patient may be a factor in the fatal outcome of treatment is supported by the fact that this patient with NPC was not positive for Epstein-Barr virus markers and also infected by several other viruses and fungi (herpes simplex virus, human herpes virus 6, Varicella zoster virus, and Candida). In conclusion, the investigation of rare NPC cases with poor prognosis may provide an improved understanding of the molecular mechanisms involved in refractory tumors and identification of novel potential therapeutic targets for NPC in the future.

Traditional Herbal Formula NPC01 Exerts Antiangiogenic Effects through Inhibiting the PI3K/Akt/mTOR Signaling Pathway in Nasopharyngeal Carcinoma Cells

Antiangiogenic therapy is vital in nasopharyngeal carcinoma (NPC) treatment. NPC01 has already been successfully used in treating patients with NPC in clinical practice and exerted an excellent antiangiogenetic effect. However, the potential molecular mechanism underlying the antitumor effect of NPC01 has not been well explored. The present study demonstrated that NPC01 could significantly inhibit cell proliferation and induce cell apoptosis in a dose-dependent manner in human NPC cell lines. Furthermore, NPC01 exerted antiproliferative and antiangiogenic effects in NPC xenograft mice. Moreover, the study showed that NPC01 could significantly decrease the expression of angiogenesis-associated factors including hypoxia-inducible factor-1α and vascular endothelial growth factor. Additionally, the decreased expression of these angiogenesis-associated factors could be due to the inhibition of the phosphoinositide 3-kinase (PI3K)/protein kinase B (Akt)/mammalian target of rapamycin (mTOR) signaling pathway (PI3K/Akt/mTOR). In conclusion, the results proposed that NPC01 could exert its antitumor effect by suppressing the PI3K/Akt/mTOR signaling pathway. Further studies are warranted to elucidate the molecular mechanism.

Impact of marital status at diagnosis on survival and its change over time between 1973 and 2012 in patients with nasopharyngeal carcinoma: a propensity score-matched analysis

The impact of marital status at diagnosis on survival outcomes and its change over time in patients with nasopharyngeal carcinoma (NPC) are unclear. The Surveillance, Epidemiology, and End Results (SEER) database was used to identify patients diagnosed with NPC in the United States from 1973 to 2012. A primary comparison (married vs. unmarried) was implemented with 1:1 propensity score matching. Secondary comparisons were performed individually between three unmarried subgroups (single, separated/divorced, widowed) and married group. The effect of marital status on cause‐specific survival (CSS) and overall survival (OS) were evaluated using univariate/multivariate analysis. Moreover, we investigated the change over time (1973–2012) in the effect of marital status on NPC survival. Married patients had better 5‐year CSS/OS than unmarried patients (61.1% vs. 52.6%, P < 0.001; 55.6% vs. 45.3%, P < 0.001, respectively). In multivariate analysis, unmarried patients had significantly poorer CSS/OS than married patients (adjusted hazard ratio [aHR] = 1.35, P < 0.001; aHR = 1.40, P < 0.001, respectively). The survival benefit of being married was only detected in non‐Hispanic white and Chinese American patients. Single, separated/divorced, and widowed patients had significantly poorer CSS/OS than married patients (aHR = 1.37 and 1.37; 1.46 and 1.42; 1.43 and 1.48, respectively; all P < 0.001). The change over time in the effect of marital status on survival was more stable in male than female. The strength of the negative effect of separated/divorced and widowed status showed a downward and upward trend, respectively. Gender difference in the adverse effect of single status on NPC survival became smaller over time. Only non‐Hispanic white and Chinese American patients with NPC obtain survival benefits from married status. Single and widowed patients are regarded as high‐risk population

Apogossypolone induces apoptosis and autophagy in nasopharyngeal carcinoma cells in an in vitro and in vivo study

Nasopharyngeal carcinoma (NPC) has a high incidence and mortality rate, particularly in Southern China. Apogossypolone (ApoG2) is a novel derivative of gossypol with antitumor activity and less toxicity. The human NPC CNE-2 cell line was studied in the in vitro model; whilst 4 week-old male nude mice (BALB/c-nu) were inoculated subcutaneously with CNE-2 cells, and xenograft tumors were studied in the in vivo model. Graded concentrations of ApoG2 were used in treatment studies. In ApoG2-treated and control in vitro and in vivo tumor cells, cell apoptosis, and autophagy were evaluated and quantified using fluorescent and transmission electron microscopy and flow cytometry. Hoechst-33258 fluorescence staining was used to evaluate apoptosis in treated and non-treated cell culture and xenograft NPC cells. Western blotting was performed on lysed tumor cells using primary antibodies to B-cell lymphoma-2 (Bcl-2), beclin-1, and β-actin, and flow cytometry results indicated cell apoptosis rates of 3.90±0.34 and 19.52±1.18% in the control and ApoG2-treated cells, respectively (F=485.294, P<0.001). Western blot analysis showed that ApoG2 significantly decreased expression of the Bcl-2 protein in CNE-2 cells, when compared with control cells (F=68.909, P=0.001) and flow cytometry showed cell autophagy rates of 0.92±3.10% of control cells compared with 28.24±7.35% of ApoG2-treated cells (F=31.035, P=0.003). ApoG2 treatment significantly increased beclin-1 protein expression in CNE-2 cells (F=497.906, P<0.001). ApoG2 treatment inhibited NPC xenograft tumor growth by 65.49% (P<0.05). In conclusion, these results support a role for ApoG2 in inhibiting the growth of human NPC cells by inducing apoptosis and autophagy. Future controlled clinical studies could be planned, to define safety, efficacy and dosing regimens for ApoG2 as a potential treatment for patients with NPC.

Socioeconomic factors and survival in patients with non-metastatic head and neck squamous cell carcinoma

The effect of socioeconomic factors on receipt of definitive treatment and survival outcomes in non‐metastatic head and neck squamous cell carcinoma (HNSCC) remains unclear. Eligible patients (n = 37 995) were identified from the United States Surveillance, Epidemiology and End Results (SEER) database between 2007 and 2012. Socioeconomic factors (i.e., median household income, education level, unemployment rate, insurance status, marital status and residence) were included in univariate/multivariate Cox regression analysis; validated factors were used to generate nomograms for cause‐specific survival (CSS) and overall survival (OS), and a prognostic score model for risk stratification. Low‐ and high‐risk groups were compared for all cancer subsites. Impact of race/ethnicity on survival was investigated in each risk group. Marital status, median household income and insurance status were included in the nomograms for CSS and OS, which had higher c‐indexes than the 6th edition TNM staging system (all P < 0.001). Based on three disadvantageous socioeconomic factors (i.e., unmarried status, uninsured status, median household income <US $65 394), the prognostic score model generated four risk subgroups with scores of 0, 1, 2 or 3, which had significantly separated CSS/OS curves (all P < 0.001). Low‐risk patients (score 0–1) were more likely to receive definitive treatment and obtain better CSS/OS than high‐risk patients (score 2–3). Chinese and non‐Hispanic black patients with high‐risk socioeconomic status had best and poorest CSS/OS, respectively. Therefore, marital status, median household income and insurance status have significance for predicting survival outcomes. Low‐risk socioeconomic status and Chinese race/ethnicity confer protective effects in HNSCC.