The prognostic significance of age in oropharyngeal squamous cell carcinoma

Increasing HPV vaccination coverage to prevent oropharyngeal cancer: A cost-effectiveness analysis

The incidence of oropharyngeal cancer (OPC) has been rising, especially among middle-aged men. While Human Papillomavirus (HPV) has been irrevocably implicated in the pathogenesis of oropharyngeal cancer (OPC), the current HPV vaccination uptake rate remains low in the US. The aim of our study was to evaluate the impact of increased HPV vaccination coverage on HPV-associated OPC incidence and costs. A decision analytic model was constructed for hypothetical cohorts of 9-year-old boys and girls. Two strategies were compared: 1) Maintaining the current vaccination uptake rates; 2) Increasing HPV vaccination uptake rates to the Healthy People 2030 target (80%) for both sexes. Increasing HPV vaccination coverage rates to 80% would be expected to prevent 5,339 OPC cases at a cost of $0.57 billion USD. Increased HPV vaccination coverage would result in 7,430 quality-adjusted life year (QALY) gains in the overall population, and it is estimated to be cost-effective for males with an incremental cost-effectiveness ratio of $86,940 per QALY gained under certain conditions. Expanding HPV vaccination rates would likely provide a cost-effective way to reduce the OPC incidence, particularly among males.

Time-varying survival effects for squamous cell carcinomas at oropharyngeal and nonoropharyngeal head and neck sites in the United States, 1973-2015

BACKGROUND

Anatomical site is strongly associated with head and neck cancer etiology, and etiology and patient sociodemographic characteristics are prognostic factors for survival. It is not known whether the effects of these predictors persist over the postdiagnosis period or are strongest proximal to the time of diagnosis.

METHODS

Using survival times and causes of death for 180,434 patients with head and neck cancer in the Surveillance, Epidemiology, and End Results cancer registry (1973-2015), the empirical cumulative incidences of cancer-specific death and other-cause death were calculated with a competing risks framework, and the time-dependent effects (hazard ratios) of anatomical tumor site (oropharynx, oral cavity, or hypopharynx/larynx), age, sex, race, and year of diagnosis on cancer-specific death and other-cause death, stratified by tumor stage, were estimated.

RESULTS

All effects were significantly time-varying (P < .001). Patients with nonoropharyngeal cancer had a higher hazard of cancer-specific death but a similar cumulative fraction of deaths because of a higher rate of death from other causes. Cancer-specific survival has not changed for patients with nonoropharyngeal cancer over the past decades but has improved since 2000 for patients with oropharyngeal cancer. The effects of age and sex on cancer survival were strongest proximal to the diagnosis, whereas the effect of race persisted over time.

CONCLUSIONS

Recent improvements in survival for patients with oropharyngeal cancer may be due more to an increasing fraction of cancers attributable to human papillomavirus than to increasing treatment effectiveness. The prognostic strength of anatomical site and other predictors changes over the postdiagnosis period.

LAY SUMMARY

It is generally assumed that the effects of tumor and personal characteristics on the survival of patients with head and neck cancer are fixed over time, but this study shows that many factors are most important only in the first few years after diagnosis. Also, recent improvements in the survival of patients with head and neck cancer appear to benefit only patients with cancers of the oropharynx. The improvements may be due more to an increasing fraction of cancers caused by human papillomavirus (which generally have better outcomes) than to advances in head and neck cancer treatment overall.

Head and neck squamous cell carcinoma in young patients: a 26-year clinicopathologic retrospective study in a Brazilian specialized center

BACKGROUND

To describe the clinicopathologic profile of young patients with head and neck squamous cell carcinoma (HNSCC) and compare to middle-aged and elderly adults.

MATERIAL AND METHODS

Patients' individual records were reviewed for clinicopathologic data. Eighty-nine patients with age 18-45 years old met the inclusion criteria of the study. Two additional groups of middle-aged (n=89) and old (n=89) adults were set to comparative analysis.

RESULTS

Young patients represented 11.9% of all patients diagnosed with HNSCC. Women were more affected by HNSCC in the young and elder groups (p= 0.04), and young patients were more prone to be non-smokers (p= 0.01) and have lymph node metastasis at the time of diagnosis (p=0.04). In the young group, patients diagnosed with the disease in advanced stages were more prone to have a positive familial history of cancer (p= 0.04), a positive status of alcohol consumption (p= 0.03), and to be heavy drinkers (p= 0.01). Survival was not different for the young group in comparison to the other groups.

CONCLUSIONS

HNSCC in young patients had a different profile when compared to older patients, especially regarding sex and exposure to the classic risk factors for this disease. The survival of the young group is similar to the older groups and advanced clinical stage is predictor of worse survival.

Differential impact of age on survival in head and neck cancer according to classic Cox regression and decision tree analysis

OBJECTIVES

To assess the impact of age on the survival of patients with head and neck squamous cell carcinoma (HNSCC) using different statistical methods.

DESIGN

A retrospective population-based study.

SETTING

Surveillance, Epidemiology, and End Results database.

SUBJECTS AND METHODS

A total of 28 639 patients with newly diagnosed HNSCC were enrolled between 1 January 2007 and 31 December 2013. The effect of age on 5-year disease-specific survival was calculated using a Kaplan-Meier method and compared using log-rank tests. A Cox proportional hazards model was used for a multivariate analysis. A classification and regression tree (CART) analysis that partitioned patients with significantly different Kaplan-Meier curves was introduced to identify the important cancer-related parameters influencing survival.

RESULTS

Uni- and multivariate analyses indicated that patients who were older than 60 years had poorer 5-year disease-specific survival regardless of tumour subsite and tumor-node-metastasis (TNM) stage. However, the CART analysis determined that age played only a minor role in survival after comparing with other prognosticators. The relative importance of age using the Gini index was as follows: 3.21% for oral cancer, 8.32% for oropharyngeal cancer, 2.56% for hypopharyngeal cancer and 16.51% for laryngeal cancer.

CONCLUSIONS

Different to traditional statistical methods, the CART analysis which was used to identify homogeneous populations revealed that the impact of age varied for different patient groups according to the presence or absence of other prognosticators. This important information could help to guide our clinical decisions and future researches.

Association of impaired renal function and poor prognosis in oropharyngeal squamous cell carcinoma

BACKGROUND

Renal function influences decisions regarding treatment for patients with oropharyngeal squamous cell carcinoma (SCC). However, the importance of renal function in oropharyngeal SCC has not yet been reported.

METHODS

Four hundred sixty patients with oropharyngeal SCC treated with curative intent between April 2005 and March 2007 in 12 institutions in Japan were analyzed retrospectively.

RESULTS

Four hundred three patients (87.6%) showed a creatinine clearance (CrCl) ≥50 mL/min and 57 (12.4%) with a CrCl <50 mL/min. Age was associated with worse overall survival (OS), whereas stage IVB, radiotherapy (RT), and CrCl <50 were associated with worse OS on univariate analyses. Surgery and hypertension were associated with better OS on univariate analyses. On multivariate analysis, age, stage, hypertension, and CrCl were also found to be significantly associated with OS.

CONCLUSION

Based on this retrospective study, impaired renal function is an independent predictor of increased risk of death in patients with oropharyngeal SCC. © 2016 Wiley Periodicals, Inc. Head Neck 38: First-1500, 2016.

Socioeconomic and Other Demographic Disparities Predicting Survival among Head and Neck Cancer Patients

BACKGROUND

The Institute of Medicine (IOM) report, "Unequal Treatment," which defines disparities as racially based, indicates that disparities in cancer diagnosis and treatment are less clear. While a number of studies have acknowledged cancer disparities, they have limitations of retrospective nature, small sample sizes, inability to control for covariates, and measurement errors.

OBJECTIVE

The purpose of this study was to examine disparities as predictors of survival among newly diagnosed head and neck cancer patients recruited from 3 hospitals in Michigan, USA, while controlling for a number of covariates (health behaviors, medical comorbidities, and treatment modality).

METHODS

Longitudinal data were collected from newly diagnosed head and neck cancer patients (N = 634). The independent variables were median household income, education, race, age, sex, and marital status. The outcome variables were overall, cancer-specific, and disease-free survival censored at 5 years. Kaplan-Meier curves and univariate and multivariate Cox proportional hazards models were performed to examine demographic disparities in relation to survival.

RESULTS

Five-year overall, cancer-specific, and disease-free survival were 65.4% (407/622), 76.4% (487/622), and 67.0% (427/622), respectively. Lower income (HR, 1.5; 95% CI, 1.1-2.0 for overall survival; HR, 1.4; 95% CI, 1.0-1.9 for cancer-specific survival), high school education or less (HR, 1.4; 95% CI, 1.1-1.9 for overall survival; HR, 1.4; 95% CI, 1.1-1.9 for cancer-specific survival), and older age in decades (HR, 1.4; 95% CI, 1.2-1.7 for overall survival; HR, 1.2; 95% CI, 1.1-1.4 for cancer-specific survival) decreased both overall and disease-free survival rates. A high school education or less (HR, 1.4; 95% CI, 1.0-2.1) and advanced age (HR, 1.3; 95% CI, 1.1-1.6) were significant independent predictors of poor cancer-specific survival.

CONCLUSION

Low income, low education, and advanced age predicted poor survival while controlling for a number of covariates (health behaviors, medical comorbidities, and treatment modality). Recommendations from the Institute of Medicine's Report to reduce disparities need to be implemented in treating head and neck cancer patients.

Trends in the Incidence of Oropharyngeal Cancers in the United States

Objective

The incidence of oropharyngeal squamous cell carcinoma (SCCa) has increased in the United States despite a decrease in tobacco usage, and it may be driven by an increase in oral human papilloma virus (HPV) infection. We studied the incidence of tongue base and tonsillar SCCa over time to understand the changing epidemiology of oropharyngeal SCCa.

Setting

Large national tumor registry.

Subjects and Methods

We studied patients diagnosed with oropharyngeal SCCa in SEER data (Surveillance, Epidemiology, and End Results) from 1973 to 2009. Age-adjusted incidence rates standardized to the 2000 US population were computed, with stratifications for age, sex, race, and stage.

Results

The sample included 10,061 tongue base and 11,515 tonsillar oropharyngeal cancers. When stratified by age, the incidence of oropharyngeal SCCa in patients ≤55 years of age more than doubled over 30 years. While the incidence rate in females remained stable, the rate in males more than doubled, from 2 per 100,000 persons in 1973 to >4 per 100,000 persons in 2009. The age-adjusted incidence of oropharyngeal SCCa in patients of black race/ethnicity remained consistently elevated, but the incidence in patients of white race/ethnicity rose from 1.3 per 100,000 persons to >2.5 per 100,000 persons, surpassing the incidence in black patients starting in 2002.

Conclusion

The observation that the incidence of oropharyngeal SCCa is increasing among younger white males, despite a reduction in tobacco usage in the United States, is consistent with HPV as the source. Primary and secondary prevention strategies may be warranted in this population.

Clinical outcomes in elderly patients with human papillomavirus-positive squamous cell carcinoma of the oropharynx treated with definitive chemoradiation therapy

BACKGROUND

The benefit of combined chemoradiation in elderly patients with human papillomavirus (HPV)-positive locally advanced oropharyngeal squamous cell carcinoma (SCC) must be balanced with the potential for higher toxicity rates. We performed a retrospective review of our institutional experience.

METHODS

Patients 70 years or older with p16-positive oropharyngeal SCC treated with definitive chemoradiation from 2005 to 2013 were evaluated. Overall survival (OS), disease-free survival (DFS), and locoregional failure-free survival were calculated.

RESULTS

Twenty-one eligible patients had a follow-up of 22.4 months. Estimated 5-year OS, DFS, and locoregional failure-free survival were 76.0%, 40%, and 95%, respectively. There was 1 death from acute toxicity, and 50% had unplanned hospitalizations. Sixty percent had late toxicity, and 6-month feeding tube dependence was 25%.

CONCLUSION

Elderly patients with HPV-positive locally advanced SCC of the oropharynx treated with definitive chemoradiation had good OS but high rates of acute and long-term toxicity. © 2015 Wiley Periodicals, Inc. Head Neck 38: 846-851, 2015.

The impact of HPV infection, smoking history, age and operability of the patient on disease-specific survival in a geographically defined cohort of patients with oropharyngeal squamous cell carcinoma

CONCLUSIONS

Patients with human papillomavirus (HPV)-positive tumours had better 5-year disease-specific survival (DSS) than HPV-negative patients. TNM score only predicted prognosis among HPV-negative patients. A previous history of smoking and age at diagnosis predicted DSS among HPV-positive patients whereas operability at diagnosis predicted DSS among both HPV-positive and HPV-negative patients.

OBJECTIVES

HPV is a risk factor for oropharyngeal squamous cell carcinoma (OPSCC). The extent to which smoking, age and operability could play a role in HPV-positive surgically treated head and neck SCCs has not been extensively addressed previously and this study aimed to evaluate these factors.

METHODS

We identified 232 patients with OPSCC, of which 186 from the tonsil or base of the tongue region were treated in the period 1992-2008 in Western Norway. The 5-year DSS was recorded. Details on smoking history and whether the lesion was operable or not, as well as clinical information, were obtained retrospectively from the hospital records.

RESULTS

TNM stage predicted survival only among HPV-negative patients. A previous smoking affected prognosis only among HPV-positive patients (relative risk (RR) = 2.5; confidence interval (CI) = 1.0-6.2; p = 0.05). Increasing age of the patient had a negative effect on survival in HPV-positive patients only, especially among the oldest quartile (RR = 4.4; CI = 2.0-9.0; p < 0.001). Whether the tumour was operable or not uniquely predicted DSS both among HPV-positive (RR = 0.34; CI = 0.13-0.93; p < 0.05) and HPV-negative (RR = 0.25; CI = 0.10-0.66; p < 0.01) patients with tonsil/base of the tongue SCC.

Age and stage as determinants of treatment for oral cavity and oropharyngeal cancers in the elderly

BACKGROUND

We investigate treatment selection for oral cavity and oropharyngeal (OC&OP) cancers to understand factors that influence treatment selection.

METHODS

We studied 7023 patients, ⩾66 years, diagnosed with a first primary OC&OP cancer using SEER-Medicare data. Multinomial logistic regression was to model treatment selection, controlling for other factors.

RESULTS

Most patients with OC cancer were treated with surgery alone (56.5%); most patients with OP cancer were treated with chemotherapy and radiation (28.9%). Age, stage and site were the most important predictors of treatment selection. As age increased from 70 to 81 (the interquartile range), treatment shifted toward surgery alone (OR=1.26; CI: 1.08-1.46) and no treatment (OR=1.5, 95% CI: 1.25-1.80), and away from combined surgery, radiation and treatments involving chemotherapy.

CONCLUSIONS

Age, stage, and site are the most important determinants of treatment selection for patients with OC&OP cancers. Increasing age and stage drive treatment toward non-surgical options and no treatment at all.