Socioeconomic status, human papillomavirus, and overall survival in head and neck squamous cell carcinomas in Toronto, Canada

Adaptive Universal Principles for Real-world Observational Studies (AUPROS): an approach to designing real-world observational studies for clinical, epidemiologic, and precision oncology research

The field of precision oncology has witnessed several advances that stimulated the development of new clinical trial designs and the emergence of real-world data (RWD) as an important resource for evidence generation in healthcare decision-making. Here, we highlight our experience with an innovative approach to a set of Adaptive, Universal Principles for Real-world Observational Studies (AUPROS). To demonstrate the utility of these principles, we used a mixed-methods approach to assess three studies that follow AUPROS at Princess Margaret Cancer Centre: (1) Molecular Epidemiology of ThorAcic Lesions (METAL), (2) Translational Head And NecK Study (THANKS), and (3) CAnadian CAncers With Rare Molecular Alterations (CARMA; NCT04151342). We performed resource assessments, stakeholder-directed surveys and discussions, analysis of funding, research output, collaborations, and a Strengths-Weaknesses-Opportunities-Threats (SWOT) analysis. Based on these analyses, AUPROS is an approach that is applicable to a wide range of observational study designs. The universality of AUPROS allows for multi-purpose analyses of various RWD, and the adaptive nature creates opportunities for multi-source funding and collaborations. Following AUPROS can offer cost and logistical benefits and may lead to increased research productivity. Several challenges were identified pertinent to ethics approvals, sustainability, complex coordination, and data quality that require local adaptation of these principles.

Socioeconomic Status, Length of Stay, and Postoperative Complications in Oral Cavity Squamous Cell Carcinoma

Background: Despite universal healthcare in Canada, low socioeconomic status (SES) has been associated with worse survival in oral cavity squamous cell carcinoma (OCSCC) patients. However, the relationship between SES and outcomes during the acute postoperative period is poorly defined. Hamilton, Ontario, presents a unique population with widely varying SES within the same geography. The objective of this study was to examine the relationship between SES, length of hospital stay (LOHS), and postoperative complications in OCSCC. Methods: Newly diagnosed OCSCC patients receiving primary surgical treatment from 2010 to 2014 were identified within a prospectively collected database. Inclusion criteria included age >18 years old, pathological diagnosis of oral cavity cancer, and primary surgical treatment with curative intent. Patients were excluded if they were undergoing palliative treatment or had previous head and neck surgery/radiotherapy. Postal codes were used to identify neighborhood-level socioeconomic variables via 2011 Canada Census data. Income quartiles were defined from groups of neighboring municipalities based on Canada Census definitions. Demographic, social, pathological, staging, and treatment data were collected through chart review. Results: One hundred and seventy-four patients were included in the final analysis. OCSCC patients with lower SES were more likely to be younger (P = .041), male (P = .040), have significant tobacco and alcohol use (P = .001), higher Charlson Comorbidity Index (CCI; P = .014), lower levels of education (P = .001), and have lower employment levels (P = .001). Lower SES patients had higher clinical tumor (P = .006) and clinical nodal (P = .004) staging and were more likely to receive adjuvant therapy (P = .001) and G-tubes (P = .001). Multivariable regression analysis showed that low SES was a statistically significant predictor of postoperative complications [β 2.50 (95% confidence interval (CI) 0.200, 3.17); P = .014] and LOHS [β 2.03 (95% CI 1.06, 2.99); P = .0001]. Tobacco and alcohol use, clinical tumor, and nodal stage, CCI, and planned adjuvant therapy were also statistically significant predictors of postoperative complications and LOHS (P < .05). Conclusion: Patients with lower SES have more advanced OCSCC disease with increased comorbidities that owes itself to more acute postoperative complications and LOHS within this study population. Patients with low SES should be identified as patients that require more support during their cancer treatment.

Survival inequalities in head and neck cancers: A hospital-based cohort study

BACKGROUND

We investigated whether the socioeconomic status (SES) influenced survival rates in oropharynx cancers (OPC), oral cavity cancers (OCC), and larynx cancers (LC) in Brazilian patients.

METHODS

This hospital-based cohort study assessed the age-standardized 5-year relative survival (RS) using the Pohar Perme estimator.

RESULTS

Overall, we identified 37 191 cases, and 5-year RS were 24.4%, 34.1%, and 44.9% in OPC, OCC, and LC, respectively. In multiple Cox regression, the highest risk of death occurred in the most vulnerable social strata for all subsites-that is, illiterates or patients relying on publicly funded healthcare services. Disparities increased over time by 34.9% in OPC due to the rising of survival rates in the highest SES, whereas they reduced by 10.2% and 29.6% in OCC and LC.

CONCLUSIONS

The potential inequities were more significant for OPC than for OCC and LC. It is urgent to tackle social disparities to improve prognoses in highly unequal countries.

Association of Smoking, Comorbidity, Clinical Stage, and Treatment Intent With Socioeconomic Differences in Survival After Oropharyngeal Squamous Cell Carcinoma in Denmark

IMPORTANCE

The socioeconomic gap in survival after cancer is pronounced among patients with head and neck cancer. Understanding the mechanisms of this gap is crucial to target intervention strategies.

OBJECTIVE

To investigate socioeconomic differences in survival after oropharyngeal squamous cell carcinoma (OPSCC) according to human papillomavirus (HPV) status and the extent to which smoking, comorbidity, clinical stage, and treatment intent explain the survival gap.

DESIGN, SETTING, AND PARTICIPANTS

This nationwide, population-based cohort study was based on prospectively collected information on all patients with a diagnosis of OPSCC from the Danish Head and Neck Cancer Group database and administrative registries. The study included 4600 patients born in 1921 or later, aged 30 years or older, and residing in Denmark 1 year prior to OPSCC diagnosis. Patients with missing information (547 [12%]) were excluded. Patients were diagnosed between January 1, 2008, and December 31, 2019, and followed up until December 31, 2021. Data were analyzed from June 6 to October 4, 2022.

EXPOSURE

Socioeconomic position (educational level, disposable income, or cohabiting status).

MAIN OUTCOMES AND MEASURES

Socioeconomic differences in 5-year overall survival were estimated in Cox proportional hazards regression models by HPV status. The indirect effect and proportion mediated by smoking, comorbidity, clinical stage, and treatment intent were estimated based on a counterfactual approach.

RESULTS

The analyzed cohort comprised 4053 patients (1045 women [26%] and 3008 men [74%]). The median age was 61 years (IQR, 55-68 years), and 2563 patients (63%) had HPV-positive OPSCC while 1490 patients (37%) had HPV-negative OPSCC. The 5-year standardized overall survival was 10% to 15% lower among patients with a lower educational level, with low disposable income, or who were living alone (patients with HPV-positive OPSCC, 68%-71%; patients with HPV-negative OPSCC, 31%-34%) than patients with a higher educational level, high disposable income, or a cohabiting partner (patients with HPV-positive OPSCC, 81%-86%; patients with HPV-negative OPSCC, 43%-46%). Among patients with HPV-positive OPSCC, a considerable part of this survival gap was estimated to be associated with differences in smoking (27%-48%), comorbidity (10%-19%), clinical stage (8%-19%), and treatment intent (16%-28%). Among those with HPV-negative OPSCC, comorbidity (12%-22%) and treatment intent (16%-42%) were the primary potential mediators.

CONCLUSIONS AND RELEVANCE

This cohort study suggests that, regardless of HPV status, patients with low socioeconomic position had 10% to 15% lower 5-year overall survival than patients with high socioeconomic position. A substantial part of this survival gap was associated with differences in smoking, comorbidity, clinical stage, or treatment intent at diagnosis.

Prognostic impact of socioeconomic status compared to overall stage for HPV-negative head and neck squamous cell carcinoma

OBJECTIVE

To estimate the relative prognostic ability of socioeconomic status (SES) compared to overall stage for HPV-negative head and neck squamous cell carcinoma (HNSCC) MATERIALS AND METHODS: Data were obtained from the Carolina Head and Neck Cancer Epidemiology Study (CHANCE). An empirical 4-category SES classification system was created. Cox proportional hazards models, survival gradients, Bayesian information criterion (BIC), and Harrell's C index were used to estimate the prognostic ability of SES compared to stage on overall survival (OS).

RESULTS

The sample consisted of 1229 patients with HPV-negative HNSCC. Patients with low SES had significantly increased risk of mortality at 5 years compared to patients with high SES (HR 3.11, 95% CI 2.07-4.67; p < 0.001), and the magnitude of effect was similar to overall stage (HR 3.01, 95% CI 2.35-3.86; p < 0.001 for stage IV versus I). Compared to overall stage, the SES classification system had a larger total survival gradient (35.8% vs. 29.1%), similar model fit (BIC statistic of 7412 and 7388, respectively), and similar model discriminatory ability (Harrell's C index of 0.61 and 0.64, respectively). The association between low SES and OS persisted after adjusting for age, sex, race, alcohol, smoking, overall stage, tumor site, and treatment in a multivariable model (HR 2.96, 95% CI 1.92-4.56; p < 0.001).

CONCLUSION

SES may have a similar prognostic ability to overall stage for patients with HPV-negative HNSCC. Future research is warranted to validate these findings and identify evidence-based interventions for addressing barriers to care for patients with HNSCC.

Socioeconomic Status Drives Racial Disparities in HPV-negative Head and Neck Cancer Outcomes

OBJECTIVES/HYPOTHESIS

To determine drivers of the racial disparity in stage at diagnosis and overall survival (OS) between black and white patients with HPV-negative head and neck squamous cell carcinoma (HNSCC).

STUDY DESIGN

Retrospective cohort study.

METHODS

Data were examined from of a population-based HNSCC study in North Carolina. Multivariable logistic regression and Cox proportional hazards models were used to assess racial disparities in stage at diagnosis and OS with sequential adjustment sets.

RESULTS

A total of 340 black patients and 864 white patients diagnosed with HPV-negative HNSCC were included. In the unadjusted model, black patients had increased odds of advanced T stage at diagnosis (OR 2.0; 95% CI [1.5-2.5]) and worse OS (HR 1.3, 95% CI 1.1-1.6) compared to white patients. After adjusting for age, sex, tumor site, tobacco use, and alcohol use, the racial disparity persisted for advanced T-stage at diagnosis (OR 1.7; 95% CI [1.3-2.3]) and showed a non-significant trend for worse OS (HR 1.1, 95% CI 0.9-1.3). After adding SES to the adjustment set, the association between race and stage at diagnosis was lost (OR: 1.0; 95% CI [0.8-1.5]). Further, black patients had slightly favorable OS compared to white patients (HR 0.8, 95% CI [0.6-1.0]; P = .024).

CONCLUSIONS

SES has an important contribution to the racial disparity in stage at diagnosis and OS for HPV-negative HNSCC. Low SES can serve as a target for interventions aimed at mitigating the racial disparities in head and neck cancer.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1301-1309, 2021.

Development and validation of nomogram to predict risk of survival in patients with laryngeal squamous cell carcinoma

To the best of our knowledge, this is the first study established a nomogram to predict survival probability in Asian patients with LSCC. A risk prediction nomogram for patients with LSCC, incorporating easily assessable clinicopathologic factors, generates more precise estimations of the survival probability when compared TNM stage alone, but still need additional data before being used in clinical application.

Background: Due to a wide variation of tumor behavior, prediction of survival in laryngeal squamous cell carcinoma (LSCC) patients received curative-intent surgery is an important but formidable challenge. We attempted to establish a nomogram to precisely predict survival probability in LSCC patients.

Methods: A total of 369 consecutive LSCC patients underwent curative resection between 2008 and 2012 at Hunan Province Cancer Hospital were included in the present study. Subsequently, 369 LSCC patients were assigned to a training set (N=261) and a validation set (N=108) at random. On the basis of multivariable Cox regression analysis results, we developed a nomogram. The predictive accuracy and discriminative ability of the nomogram were confirmed by calibration curve and a concordance index (C-index), and compared with TNM stage system by C-index, receiver operating characteristic (ROC) analysis.

Results: Six independent parameters to predict prognosis were age, pack years, N-stage, lymph node ratio (LNR), anemia and albumin, which were all assembled into the nomogram. The calibration curve verified excellent models’ concordance. The C-index of the nomogram was 0.73 (0.68–0.78), and the area under curve (AUC) of nomogram in predicting overall survival (OS) was 0.766, which were significantly higher than traditional TNM stage. Decision curve analysis further demonstrated that our nomogram had a larger net benefit than the TNM stage.

Conclusion: A risk prediction nomogram for patients with LSCC, incorporating easily assessable clinicopathologic factors, generates more precise estimations of the survival probability when compared TNM stage alone, but still need additional data before being used in clinical application.

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

PURPOSE

Privately insured patients with head and neck cancer (HNC) typically have better outcomes; however, differential outcome among Medicaid versus the uninsured is unclear. We aimed to describe outcome disparities among HNC patients uninsured versus on Medicaid.

METHODS

A cohort of 18-64-year-old adults (n = 57 920) with index HNC from the Surveillance, Epidemiology, and End Results 18 database (2007-2015) was analyzed using Fine and Gray multivariable competing risks proportional hazards models for HNC-specific mortality.

RESULTS

Medicaid (sdHR = 1.65, 95% CI 1.58, 1.72) and uninsured patients (sdHR = 1.55, 95% CI 1.46, 1.65) had significantly greater mortality hazard than non-Medicaid patients. Medicaid patients had increased HNC mortality hazard than those uninsured.

CONCLUSION

Compared with those uninsured, HNC patients on Medicaid did not have superior survival, suggesting that there may be underlying mechanisms/factors inherent in this patient population that could undermine access to care benefits from being on Medicaid.

Outcomes of HPV-Associated Squamous Cell Carcinoma of the Head and Neck: Impact of Race and Socioeconomic Status

BACKGROUND

Socioeconomic factors affecting outcomes of HPV-associated squamous cell carcinoma of the head and neck (SCCHN) are poorly characterized.

METHODS

A custom SEER database identified adult patients with primary nonmetastatic SCCHN and known HPV status diagnosed in 2013 through 2014. Multivariable logistic regression defined associations between patient characteristics and HPV status, with adjusted odds ratios (aORs) and 95% confidence intervals reported. Fine-Gray competing risks regression estimated adjusted hazard ratios (aHRs) and 95% confidence intervals for cancer-specific mortality (CSM), including a disease subsite * HPV status * race interaction term.

RESULTS

A total of 4,735 patients with nonmetastatic SCCHN and known HPV status were identified. HPV-associated SCCHN was positively associated with an oropharyngeal primary, male sex, and higher education, and negatively associated with uninsured status, single marital status, and nonwhite race (P≤.01 for all). For HPV-positive oropharyngeal SCCHN, white race was associated with lower CSM (aHR, 0.55; 95% CI, 0.34-0.88; P=.01) and uninsured status was associated with higher CSM (aHR, 3.12; 95% CI, 1.19-8.13; P=.02). These associations were not observed in HPV-negative or nonoropharynx SCCHN. Accordingly, there was a statistically significant disease subsite * HPV status * race interaction (Pinteraction<.001).

CONCLUSIONS

Nonwhite race and uninsured status were associated with worse CSM in HPV-positive oropharyngeal SCCHN, whereas no such associations were observed in HPV-negative or nonoropharyngeal SCCHN. These results suggest that despite having clinically favorable disease, nonwhite patients with HPV-positive oropharyngeal SCCHN have worse outcomes than their white peers. Further work is needed to understand and reduce socioeconomic disparities in SCCHN.

Inequality in survival of people with head and neck cancer: Head and Neck 5000 cohort study

BACKGROUND

Explanations for socioeconomic inequalities in survival of head and neck cancer (HNC) patients have had limited attention and are not well understood.

METHODS

The UK Head and Neck 5000 prospective clinical cohort study was analyzed. Survival relating to measures of socioeconomic status was explored including area-based and individual factors. Three-year overall survival was determined using the Kaplan-Meier method. All-cause mortality was investigated via adjusted Cox Proportional Hazard models.

RESULTS

A total of 3440 people were included. Three-year overall survival was 76.3% (95% CI 74.9, 77.7). Inequality in survival by deprivation category, highest education level, and financial concerns was explained by age, sex, health, and behavioral factors. None of the potential explanatory factors fully explained the inequality associated with annual household income or the proportion of income of benefits.

CONCLUSION

These results support the interventions to address the financial issues within the wider care and support provided to HNC patients.

Race, not socioeconomic disparities, correlates with survival in human papillomavirus-negative oropharyngeal cancer: A retrospective study

PURPOSE

Investigate the impact of black versus white race, socioeconomic status (SES), and comorbidity burden on oropharyngeal cancer (OPC) survival.

MATERIALS AND METHODS

This study retrospectively analyzed patients diagnosed between 1991 and 2012 at an urban tertiary care center with a high volume of head and neck cancer referrals. Data gathered included demographics, human papilloma virus (HPV) status, follow-up time, comorbidities, smoking history, and overall survival. SES was extrapolated from the 2000 and 2010 censuses. Analysis of variance, chi-square tests, multivariable Cox proportional hazards models, Cox proportional hazards regression, Kaplan Meier curves and the log-rank test were utilized.

RESULTS

Of 208 charts reviewed, 192 patients met inclusion criteria. Black patients had significantly (p < 0.001) poorer survival at 1, 2, and 5 years than white patients (5-year survival: 32% vs 64%); this discrepancy persisted in only HPV-negative disease (20% vs 50%). In the HPV-negative subgroup, there was no racial difference in treatment modality received, Charlson Comorbidity Index, and proportion receiving inadequate, noncurative or no treatment. Univariate analysis identified significant differences in median household income, education level, and stage at presentation between black and white subgroups. Multivariate analysis identified white race and HPV-positive status as independent predictors of overall survival, but SES and stage at presentation were not.

CONCLUSION

SES did not explain the greater survival in HPV-negative white versus black patients. This indicates that race is an independent predictor of survival; future studies should examine more accurate indicators of SES and genetic differences in tumors of black and white patients.

Decreased overall survival in black patients with HPV-associated oropharyngeal cancer

PURPOSE

Racial disparities for overall survival (OS) in head and neck cancer have been well described. However, the extent to which these disparities exist for HPV-associated oropharyngeal squamous cell carcinoma (OPSCC), and the contribution of demographic, clinical, and socioeconomic status (SES) variables, is unknown.

MATERIALS AND METHODS

Patients were identified from the Carolina Head and Neck Cancer Epidemiology Study (CHANCE), a population-based study in North Carolina. Cox proportional hazards regression models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for OS in black versus white patients with sequential adjustment sets.

RESULTS

A total of 157 HPV-associated OPSCC patients were identified. Of these, 93% were white and 7% were black. Black patients with HPV-associated OPSCC were more likely to be younger, have an income <$20,000, live farther away from clinic where biopsy was performed, and have advanced T stage at diagnosis. Black patients had worse OS in the unadjusted analysis (HR 4.9, 95% CI 2.2-11.1, p < 0.0001). The racial disparity in OS slightly decreased when sequentially adjusting for demographic, clinical, and SES variables. However, HR for black race remained statistically elevated in the final adjustment set which controlled for age, sex, stage, smoking, alcohol use, and individual-level household income, insurance, and education level (HR 3.4, 95% CI 1.1-10.1, p = 0.028).

CONCLUSION

This is the first population-based study that confirms persistence of racial disparities in HPV-associated OPSCC after controlling for demographic, clinical, and individual-level socioeconomic factors.

Factors Explaining Socio-Economic Inequalities in Cancer Survival: A Systematic Review

BACKGROUND

There is strong and well-documented evidence that socio-economic inequality in cancer survival exists within and between countries, but the underlying causes of these differences are not well understood.

METHODS

We systematically searched the Ovid Medline, EMBASE, and CINAHL databases up to 31 May 2020. Observational studies exploring pathways by which socio-economic position (SEP) might causally influence cancer survival were included.

RESULTS

We found 74 eligible articles published between 2005 and 2020. Cancer stage, other tumor characteristics, health-related lifestyle behaviors, co-morbidities and treatment were reported as key contributing factors, although the potential mediating effect of these factors varied across cancer sites. For common cancers such as breast and prostate cancer, stage of disease was generally cited as the primary explanatory factor, while co-morbid conditions and treatment were also reported to contribute to lower survival for more disadvantaged cases. In contrast, for colorectal cancer, most studies found that stage did not explain the observed differences in survival by SEP. For lung cancer, inequalities in survival appear to be partly explained by receipt of treatment and co-morbidities.

CONCLUSIONS

Most studies compared regression models with and without adjusting for potential mediators; this method has several limitations in the presence of multiple mediators that could result in biased estimates of mediating effects and invalid conclusions. It is therefore essential that future studies apply modern methods of causal mediation analysis to accurately estimate the contribution of potential explanatory factors for these inequalities, which may translate into effective interventions to improve survival for disadvantaged cancer patients.

Oral squamous cell carcinoma: epidemiological study and risk factor assessment based on a 39-year series

Oral squamous cell carcinoma (OSCC) remains a challenge for head and neck surgeons, with low 5-year survival rates despite improvements in diagnostic techniques and therapies. This retrospective observational study was performed to evaluate the epidemiology and risk factors in a cohort of 666 patients with invasive OSCC over a 39-year period. Risk factors assessed were age, sex, toxic habits, premalignant lesions, tumour location and size, and neck involvement, and pathological factors such as surgical margins, tumour thickness, perineural invasion, and bone invasion. These factors were analysed over time, and their influence on recurrence and survival rates examined. Results were compared with those of current epidemiological studies in the literature. This series showed a tendency to diagnosis at older ages (P<0.001) and decreased differences in sex distribution (P<0.001) over time. Regarding risk factors, tobacco and alcohol drinking increased significantly in females, but remained stable in males. Forty percent of the patients developed recurrences during follow-up; the relapse rate did not improve over time (45.6% in the 1980s to 36.1% in 2010-2017). The 5-year survival rate also remained stable over time, ranging from 62.7% (1980s) to 71.7% (2010-2017). This epidemiological study analysed trends across four decades in a stable cohort, with results that may be extrapolated to the populations of European countries. The results confirmed that recurrence rates and survival rates have not improved over time, despite better surgical treatments and new therapies. Further studies are needed to improve knowledge about genetics and tumour behaviour in oral cancer.

Laryngeal Cancer Attributable Factors and the Influence on Survival Rates: A Single Brazilian Institution Experience

Introduction  Epidemiological studies focused on prognostic factors associated with laryngeal cancer in the Brazilian population are poorly reported in the literature.

Objective  To evaluate the influence of certain risk factors on the survival rates of patients with squamous cell carcinoma (SCC) of the larynx.

Methods  This retrospective study was conducted on adult patients who were admitted to the outpatient clinic of the head and neck department in a tertiary care hospital. Evaluation of the influence of risk factors on the survival rates of patients registered in the hospital with laryngeal SCC was performed based on age, sex, initial stage, time of evolution, habits, educational levels and relapse and death. Overall survival (OS), disease-free survival (DFS) and clinical-demographic data were analyzed using the Kaplan-Meier method, Log-rank test and Cox regression.

Results  A total of 107 patients with a mean age of 59.8 years (range 19–81) were included in this study. Stages III and IV were associated with decreased DFS ( p  = 0.02) and OS ( p  = 0.02). Smoking patients had a greater period of disease evolution than non-smoking patients ( p  = 0.003). Alcohol consumption in smokers increased the risk of death by 2.8 ( p  = 0.002) compared with non-drinking smokers. Male patients presented lower DFS average when compared with female patients ( p  = 0.04).

Conclusion  Our study confirms that male gender, smoking habit combined with alcohol consumption, and advanced stages were strongly associated with poor prognosis.

Impact of socioeconomic inequalities on quality of life in oral submucous fibrosis patients

AIM

The purpose of this study was to analyze the impact of socioeconomic characteristics on oral health-related quality of life (OHRQoL) in patients with oral submucous fibrosis (OSF).

METHODS

 A total of 300 OSF patients' quality of life (QoL) data were obtained using OHRQoL-OSF and global self ratings of oral health and overall wellbeing. The socioeconomic status (SES) of participants was analyzed by using modified Kuppuswamy scale.

RESULTS

OSF patients with lower SES had worse OHRQoL as compared with those with middle and upper SES (p < 0.001). The household income of the family was found to be strongly associated with poor OHRQoL.

CONCLUSION

Socioeconomic characteristics should be considered in the holistic management of OSF as it has been strongly associated with the OHRQoL of these patients.

Effects of income and residential area on survival of patients with head and neck cancers following radiotherapy: working age individuals in Taiwan

Objectives

The five-year survival rate of head and neck cancer (HNC) after radiotherapy (RT) varies widely from 35% to 89%. Many studies have addressed the effect of socioeconomic status and urban dwelling on the survival of HNC, but a limited number of studies have focused on the survival rate of HNC patients after RT.

Materials and methods

During the period of 2000–2013, 40,985 working age individuals (20 < age < 65 years) with HNC patients treated with RT were included in this study from a registry of patients with catastrophic illnesses maintained by the Taiwan National Health Insurance Research Database (NHIRD).

Results

The cumulative survival rate of HNC following RT in Taiwan was 53.2% (mean follow-up period, 3.75 ± 3.31 years). The combined effects of income and geographic effect on cumulative survival rates were as follows: high income group > medium income group > low income group and northern > central > southern > eastern Taiwan. Patients with moderate income levels had a 36.9% higher risk of mortality as compared with patients with high income levels (hazard ratio (HR) = 1.369; p < 0.001). Patients with low income levels had a 51.4% greater risk of mortality than patients with high income levels (HR = 1.514, p < 0.001).

Conclusion

In Taiwan, income and residential area significantly affected the survival rate of HNC patients receiving RT. The highest income level group had the best survival rate, regardless of the geographic area. The difference in survival between the low and high income groups was still pronounced in more deprived areas.

Socioeconomic status and quality of life in patients with locally advanced head and neck cancer

PURPOSE

Socioeconomic aspects play an important role in health care. Patients with locally advanced head and neck cancer (LAHNC) experience detrimental effects on their quality of life (QoL). This prospective study examines QoL differences between patients with different socioeconomic status (SES) after intensity-modulated radiation therapy (IMRT).

PATIENTS AND METHODS

In all, 161 patients were questioned at the end of IMRT and at 12 and 24 months follow-up using the questionnaires of the European Organization for Research and Treatment of Cancer (EORTC) QLQ-30 and QLQ-HN35. Patients' QoL 2 years after IMRT was compared to a population reference sample and QoL of patients from lower, middle, and higher social class 2 years after IMRT was analyzed by ANCOVA using baseline QoL (end of radiation treatment) as a covariate.

RESULTS

Patients with high SES report worse QoL at the end of IMRT in the domains global health status (-15.2; p = 0.005), role function (-23.8; p = 0.002), and social function (-19.4; p = 0.023) compared to patients with middle and low SES. QoL improved during the first 12 and 24 months. However, 2 years after IMRT, middle and low SES patients report lower QoL in the domains global health status, physical function, and role function, and report a higher general (fatigue, pain, dyspnea) and head and neck cancer-specific symptom burden (pain, swallowing, senses, speech, social eating, opening mouth, and felt ill) than patients with high SES.

CONCLUSION

After IMRT for LAHNC, patients with high SES report worse QoL compared to patients with middle or low SES. There is a marked improvement within the first 24 months in many domains. However, the magnitude of improvement in patients with middle or low SES is significantly smaller compared to patients with high SES.

Understanding Interactions of Smoking on Prognosis of HPV-Associated Oropharyngeal Cancers

The new 8th edition AJCC/UICC staging system for human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC), developed to account for improved survival outcomes over HPV-negative cancers, includes anatomic features strictly associated with tumor-node-metastasis (TNM) and does not account for patient-specific characteristics that may impact prognosis. This commentary evaluates the evidence of smoking as an adverse prognostic factor in HPV-associated OPSCC. We review the multifactorial biological, clinical, and social/behavioral characteristics of smokers with OPSCC that impact outcomes, discuss current challenges with incorporating smoking history in prognostic classifications, and consider opportunities for future investigation.

Facial Plastic Surgery Patient Resources Exceed National Institute Recommendations

Patient education is essential in enhancing the physician-patient therapeutic alliance, patient satisfaction, and clinical outcomes. The American Medical Association and National Institute of Health recommend that information be written at a 6th-grade reading level, but online resources often exceed patient literacy. The purpose of this study is to assess readability of online material for facial plastics procedures presented on academic plastic surgery and otolaryngology websites.An Internet search was performed of all academic institutions that had both plastic surgery and otolaryngology training programs who offered patient information on facial plastic surgery procedures. National society websites for both plastic surgery and otolaryngology were also analyzed. All procedural information was compiled and readability analyses were performed. A 2-tailed Z-test was used to compare scores, and statistical significance was set at P < 0.05.Sixty-three programs were identified; 42 had educational material. The overall average readability for all information was at a 10th-grade reading level. The national plastic surgery website had a significantly higher word count and number of syllables per word compared to the national otolaryngology website (P < 0.001, P = 0.04).The complexity of written resources represents an obstacle to online patient education and efforts to improve readability could benefit patients seeking medical information online. Current online education materials are a potential hindrance to patient education, satisfaction, and decision making. Healthcare institutions should consider writing new materials with simpler language that would be accessible to patients.

Alcohol and cigarette consumption predict mortality in patients with head and neck cancer: a pooled analysis within the International Head and Neck Cancer Epidemiology (INHANCE) Consortium

BACKGROUND

This study evaluated whether demographics, pre-diagnosis lifestyle habits and clinical data are associated with the overall survival (OS) and head and neck cancer (HNC)-specific survival in patients with HNC.

PATIENTS AND METHODS

We conducted a pooled analysis, including 4759 HNC patients from five studies within the International Head and Neck Cancer Epidemiology (INHANCE) Consortium. Cox proportional hazard ratios (HRs) and the corresponding 95% confidence intervals (CIs) were estimated including terms reported significantly associated with the survival in the univariate analysis.

RESULTS

Five-year OS was 51.4% for all HNC sites combined: 50.3% for oral cavity, 41.1% for oropharynx, 35.0% for hypopharynx and 63.9% for larynx. When we considered HNC-specific survival, 5-year survival rates were 57.4% for all HNC combined: 54.6% for oral cavity, 45.4% for oropharynx, 37.1% for hypopharynx and 72.3% for larynx. Older ages at diagnosis and advanced tumour staging were unfavourable predictors of OS and HNC-specific survival. In laryngeal cancer, low educational level was an unfavourable prognostic factor for OS (HR = 2.54, 95% CI 1.01-6.38, for high school or lower versus college graduate), and status and intensity of alcohol drinking were prognostic factors both of the OS (current drinkers HR = 1.73, 95% CI 1.16-2.58) and HNC-specific survival (current drinkers HR = 2.11, 95% CI 1.22-3.66). In oropharyngeal cancer, smoking status was an independent prognostic factors for OS. Smoking intensity (>20 cigarettes/day HR = 1.41, 95% CI 1.03-1.92) was also an independent prognostic factor for OS in patients with cancer of the oral cavity.

CONCLUSIONS

OS and HNC-specific survival differ among HNC sites. Pre-diagnosis cigarette smoking is a prognostic factor of the OS for patients with cancer of the oral cavity and oropharynx, whereas pre-diagnosis alcohol drinking is a prognostic factor of OS and HNC-specific survival for patients with cancer of the larynx. Low educational level is an unfavourable prognostic factor for OS in laryngeal cancer patients.

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.