Cause-specific excess mortality in patients treated for cancer of the oral cavity and oropharynx: A population-based study

Causes and Ways of Death in Patients With Head and Neck Cancer

Importance

There is limited literature on the exact causes and ways of death in patients with head and neck cancer. To provide optimal care, especially in the palliative phase, more information on this is needed.

Objective

To provide insights into the causes and ways of death among patients with head and neck cancer.

Design, Setting, and Participants

This retrospective cohort study included a consecutive population of patients who received a diagnosis of primary squamous cell carcinoma of the head and neck between January 2006 and December 2013 who were treated in the Erasmus MC. Patient data were merged with nonpublic microdata from Statistics Netherlands. Follow-up time was specified as the date of diagnosis until death or December 3, 2019, whichever came first. The data were checked and reanalyzed in November 2023.

Main outcomes and Measures

Causes (eg, head and neck cancer, other cancer) and ways (eg, natural death, suicide) of death.

Results

A total of 1291 patients (59.2%; 342 women [26.5%]) died during follow-up (median [IQR] follow-up, 2.7 [1.2-5.6] years). The main cause of death was head and neck cancer (557 [43.1%]), followed by the competing cause of other cancers (344 [26.6%]). In total, 240 patients (18.6%) received palliative sedation and 70 patients (5.4%) euthanasia. Compared with patients with head and neck cancer as the underlying cause of death, lower odds ratios (ORs) were observed for receiving palliative sedation (OR, 0.32 vs 0.07; 95% CI, 0.22-0.46 vs 0.03-0.12) and euthanasia (OR, 0.22 vs 0.01; 95% CI, 0.11-0.41 vs 0-0.107) in patients with other causes of death. Patients with a middle and high income had higher ORs for receiving palliative sedation (OR, 1.46 vs 1.86; 95% CI, 1.05-2.04 vs 1.22-2.85) or euthanasia (OR, 2.25 vs 3.37; 95% CI, 1.18-4.3, 1.6-7.12) compared with low-income patients. Retired patients had lower ORs for receiving palliative sedation or euthanasia compared with employed patients (OR, 0.56 vs 0.44; 95% CI, 0.39-0.8 vs 0.24-0.82).

Conclusion and Relevance

The results of this cohort study suggest that more than half of the patients died of competing causes and palliative sedation and euthanasia were more common in patients with head and neck cancer as the underlying cause of death. Patients with a higher socioeconomic status had higher odds of receiving palliative sedation and euthanasia. These insights may support health care professionals in providing patient-centered care, especially for patients in the palliative phase.

Oral squamous cell carcinoma – clinical characteristics, treatment, and outcomes in a single institution retrospective cohort study

<b>Introduction:</b> Squamous cell carcinoma (SCC) is a common malignancy with high morbidity and mortality. </br></br> <b>Aim:</b> The aim of this study was to analyze the data of patients treated for malignant tumours of the oral cavity at the Department of Otolaryngology, Head and Neck Surgery, and Laryngological Oncology Ludwik Rydygier Collegium Medicum in Bydgoszcz between 2003–2011 to asses the influence of risk factors on survival in patients with squamous cell carcinoma of the oral cavity. </br></br> <b> Material and methods:</b> Material was collected from 62 patients treated for oral SCC between 2003–2011. Forty-three were men (69.35%) with a mean age of 56.33 years. The medical records were analysed, especially history, operative reports, histopathology reports, survival, adjuvant treatment and recurrence. </br></br> <b>Results:</b> All patients underwent surgical treatment (33.87% also had partial removal of the lower jaw, 67.74% adjuvant radio-therapy, 11.29% radiochemotherapy). More than half reported to the doctor within 6 to 15 weeks from the onset of symptoms. The majority smoked and drank alcohol (96.32%). Five-year disease specific survival (DSS) was 68.69%. </br></br> <b>Conclusions:</b> The age over 65 did not significantly influence DSS. The location on the anterior two thirds of the tongue gave the best outcome, while the worst outcome was observed in the retromandibular triangle area which was statistically almost significant (p = 0.06843). In the case of higher degrees of local and regional advancement and a higher stadium, a worse out-come was recorded. Positive surgical margins were identified in 11.29% of the cases, but they had no impact on the results of treatment. No worsening of the outcome was proven for the patients who reported to the doctor later than 15 weeks following the occurrence of symptoms.

Trends of Ten Leading Causes of Death in Head and Neck Squamous Cell Carcinoma

OBJECTIVE

An understanding of the leading causes of death in patients with head and neck squamous cell carcinoma (HNSCC) would be helpful to inform doctors, patients, and healthcare providers on disease management. This study aimed to comprehensively study the leading causes of death in these survivors.

METHODS

We investigated the trends of risk factors for major causes of death in patients with HNSCC. Causes of death in HNSCC were obtained from the Surveillance, Epidemiology, and End Results registries. We characterized trends in the 5-year cumulative mortality as well as risk factors associated with the ten leading causes of death.

RESULTS

Among 48 297 deaths identified, the ten leading causes were as follows: HNSCC, heart disease, lung cancer, chronic obstructive pulmonary disease (COPD), cerebrovascular disease, pneumonia & influenza, accidents & adverse effects, esophagus cancer, chronic liver diseases, and septicemia. Non-HNSCC deaths surpassed HNSCC deaths 4 years after cancer diagnosis. There was a significant decline in the 5-year cumulative mortality from HNSCC, heart disease, lung cancer, COPD, cerebrovascular disease, and esophagus cancer. The risks of mortality from the ten leading causes varied with patient characteristics.

CONCLUSION

Our findings provide a useful picture of mortality patterns in HNSCC survivors, which might help when planning personalized HNSCC care.

Prediction of treatment outcome using MRI radiomics and machine learning in oropharyngeal cancer patients after surgical treatment

OBJECTIVES

In this study, we aimed to analyze preoperative MRI images of oropharyngeal cancer patients who underwent surgical treatment, extracted radiomics features, and constructed a disease recurrence and death prediction model using radiomics features and machine-learning techniques.

MATERIALS AND METHODS

A total of 157 patients participated in this study, and 107 stable radiomics features were selected and used for constructing a predictive model.

RESULTS

The performance of the combined model (clinical and radiomics) yielded the following results: AUC of 0.786, accuracy of 0.854, precision of 0.429, recall of 0.500, and f1 score of 0.462. The combined model showed better performance than either the clinical and radiomics only models for predicting disease recurrence. For predicting death, the combined model performance has an AUC of 0.841, accuracy of 0.771, precision of 0.308, recall of 0.667, and f1 score of 0.421. The combined model showed superior performance over the predictive model using only clinical variables. A Cox proportional hazard model using the combined variables for predicting patient death yielded a c-index value that was significantly better than that of the model including only clinical variables.

CONCLUSIONS

A predictive model using clinical variables and MRI radiomics features showed excellent performance in predicting disease recurrence and death in oropharyngeal cancer patients. In the future, a multicenter study is necessary to verify the model's performance and confirm its clinical usefulness.

Revisiting the metallothionein genes polymorphisms and the risk of oral squamous cell carcinoma in a Brazilian population

Background

Metallothioneins (MTs) gene polymorphisms have been associated with the ability of free radical scavenging and detoxification of heavy metals leading to cancer development. Our aim was to revisit, in a Brazilian population, single-nucleotide polymorphisms (SNPs) of the MT gene family previously associated with oral squamous cell carcinoma (OSCC).

Material and Methods

A case-control investigation with 28 OSCC patients and 45 controls was conducted, using conventional risk factors (tobacco use and alcohol consumption) as covariates. SNPs genotyping for rs8052334 (MT1B), rs964372 (MT1B), and rs1610216 (MT2A) was performed by PCR-RFLP, and SNPs for rs11076161 (MT1A) were analyzed by TaqMan assay.

Results

The only SNP associated with increased risk for OSCC was the MT-1A AA genotype (OR = 4.7; p = 0.01). We have also evidenced for the first time a significant linkage disequilibrium between the SNPs of MT-2A and MT-1A in this population with the highest frequency (30%) of the unfavorable haplotype G/A/C/T (rs1610216 / rs11076161 / rs964372 / rs8052334) of MT gene polymorphisms (OR = 6.2; p = 0.04). Interestingly, after removing the effects of conventional risk factors, we have uncovered the significance of the AA genotype of the rs11076161 with increased odds of 19-fold higher towards OSCC development.

Conclusions

This is the first demonstration that a significant linkage disequilibrium among gene polymorphisms of the MT family may affect susceptibility to oral cancer, which is conditioned by the G/A/C/T haplotype (rs1610216/rs11076161/rs964372/ rs8052334) and the MT-1A gene polymorphism has a potential clinical utility for the OSCC risk assessment.

Key words:Oral squamous cell carcinoma, polymorphism, metallothionein, oral cancer.

Improved outcome prediction of oropharyngeal cancer by combining clinical and MRI features in machine learning models

OBJECTIVES

New markers are required to predict chemoradiation response in oropharyngeal squamous cell carcinoma (OPSCC) patients. This study evaluated the ability of magnetic resonance (MR) radiomics to predict locoregional control (LRC) and overall survival (OS) after chemoradiation and aimed to determine whether this has added value to traditional clinical outcome predictors.

METHODS

177 OPSCC patients were eligible for this study. Radiomic features were extracted from the primary tumor region in T1-weighted postcontrast MRI acquired before chemoradiation. Logistic regression models were created using either clinical variables (clinical model), radiomic features (radiomic model) or clinical and radiomic features combined (combined model) to predict LRC and OS 2-years posttreatment. Model performance was evaluated using area under the curve (AUC), 95 % confidence intervals were calculated using 500 iterations of bootstrap. All analyses were performed for the total population and the Human papillomavirus (HPV) negative tumor subgroup.

RESULTS

A combined model predicted treatment outcome with a higher AUC (LRC: 0.745 [0.734-0.757], OS: 0.744 [0.735-0.753]) than the clinical model (LRC: 0.607 [0.594-0.620], OS: 0.708 [0.697-0.719]). Performance of the radiomic model was comparable to the combined model for LRC (AUC: 0.740 [0.729-0.750]), but not for OS prediction (AUC: 0.654 [0.646-0.662]). In HPV negative patients, the performance of all models was not sufficient with AUCs ranging from 0.587 to 0.660 for LRC and 0.559 to 0.600 for OS prediction.

CONCLUSION

Predictive models that include clinical variables and radiomic tumor features derived from MR images of OPSCC better predict LRC after chemoradiation than models based on only clinical variables. Predictive models that include clinical variables perform better than models based on only radiomic features for the prediction of OS.

Human papillomavirus as a driver of head and neck cancers

The human papillomavirus (HPV) family includes more than 170 different types of virus that infect stratified epithelium. High-risk HPV is well established as the primary cause of cervical cancer, but in recent years, a clear role for this virus in other malignancies is also emerging. Indeed, HPV plays a pathogenic role in a subset of head and neck cancers-mostly cancers of the oropharynx-with distinct epidemiological, clinical and molecular characteristics compared with head and neck cancers not caused by HPV. This review summarises our current understanding of HPV in these cancers, specifically detailing HPV infection in head and neck cancers within different racial/ethnic subpopulations, and the differences in various aspects of these diseases between women and men. Finally, we provide an outlook for this disease, in terms of clinical management, and consider the issues of 'diagnostic biomarkers' and targeted therapies.

Burden of treatment: Reported outcomes in a head and neck cancer survivorship clinic

OBJECTIVE

With the intensification and utilization of multimodal treatment, acute toxicities have increased; however, the frequency of treatment sequelae in long-term head and neck cancer (HNC) survivors are poorly described. The purpose of this analysis was to determine the prevalence and predictors of patient-reported late and long-term treatment-related sequelae in HNC survivors.

METHODS

We performed a cross-sectional analysis of patient-reported outcomes from 228 survivors attending a multidisciplinary HNC survivorship clinic. The primary outcomes comprised quality of life (QOL), symptoms of anxiety and depression, and swallowing dysfunction.

RESULTS

Male gender, tumor sites in the oropharynx and larynx, longer time since treatment, and treatment with surgery alone were associated with higher physical QOL (P < .05). Male gender, longer time since treatment, and treatment with surgery alone were associated with higher social-emotional QOL (P < .05). A reduction in anxiety symptoms and a higher QOL were related to longer time since treatment; however, a reduction in swallowing dysfunction symptoms was only related to longer time since treatment until approximately 6 years. After 6 years, survivors reported worse swallowing dysfunction (P < .05). One hundred thirty-two survivors (56%) reported at least three treatment-related effects that impacted their daily life. Finally, advanced stage disease at diagnosis (stage III-IV) was also associated with severe swallowing dysfunction (P = .004).

CONCLUSION

These data indicate the remarkable prevalence of treatment-related effects in HNC survivors. These results highlight the need for de-intensification of therapies, where appropriate, and for a better understanding of pathophysiology and new approaches to mitigating treatment effects.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:E437-E444, 2019.

Oropharyngeal cancer is no longer a disease of younger patients and the prognostic advantage of Human Papillomavirus is attenuated among older patients: Analysis of the National Cancer Database

OBJECTIVES

HPV-positive oropharyngeal cancer (OPC) patients have been observed to be younger than patients with HPV-negative OPC at diagnosis. We evaluated recent trends in age at OPC diagnosis, and whether older age attenuates the survival benefit of HPV-positive tumor status.

MATERIALS AND METHODS

Patients diagnosed with OPC from 2004 to 2014 represented in the National Cancer Database were included. HPV tumor status was available after 2010. Trends in age by calendar year were compared using linear regression. Overall survival was compared using Cox Proportional Hazards models.

RESULTS

The mean age of OPC patients (N = 119,611) increased significantly from 2004 to 2014 (ß = 0.21 years of age per calendar year, 95% confidence interval [CI] = 0.19-0.23). The increase in age from 2010 to 2014 was similar for HPV-positive (N = 21,880; ß = 0.63, 95%CI = 0.53-0.72) and HPV-negative (N = 11,504; ß = 0.59, 95%CI = 0.45-0.74) patients. Between 2010 and 2014, the proportion of OPCs that were HPV-positive increased significantly for all age groups, including for patients ≥70 years old (from 45% to 60%, p_trend < 0.001). Although patients ≥70 years with HPV-OPC had improved survival compared to those with HPV-negative OPC (adjusted hazard ratio [aHR] = 0.65, 95%CI = 0.55-0.76), the survival benefit of HPV-positive tumor status was significantly attenuated compared to younger HPV-OPC patients (50-59 years: aHR = 0.45, 95%CI = 0.39-0.51; p_interaction < 0.001).

CONCLUSION

The age at OPC diagnosis is increasing for both HPV-positive and HPV-negative patients, and a rising proportion of older patients have HPV-positive tumors. These findings dispel the notion that HPV-positive OPC is a disease of younger patients, identify a growing elderly population of HPV-positive OPC patients with reduced survival, and have implications for evolving treatment paradigms.

Cause-specific mortality in HPV+ and HPV- oropharyngeal cancer patients: insights from a population-based cohort

Identifying the causes of death in head and neck cancer patients can optimize follow-up and therapeutic strategies, but studies in oropharyngeal squamous cell carcinoma (OPSCC) patients stratified by HPV status are lacking. We report cause-specific mortality in a population-based cohort of patients with OPSCC. Patients who had been diagnosed with OPSCC (n = 1541) between 2000 and 2014 in eastern Denmark were included in the study. Causes of death were collected through medical files and the Danish National Cause of Death registry. Deaths were grouped as (1) primary oropharyngeal cancer, (2) secondary malignancies, (3) cardiovascular and pulmonary disease, or (4) other/unspecified. The cumulative incidence of death and specific causes of death were determined using risk analysis. At follow-up, 723 (47.5%) patients had died. The median time to and cause of death were determined: oropharyngeal cancer (n = 432; 1.00 year), secondary malignancies (n = 131; 2.37 years), cardiovascular and pulmonary causes (n = 58; 3.48 years), and unspecified causes (n = 102; 3.42 years). HPV/p16 status was the strongest predictor of improved survival across all causes of death. The only cause of death to decrease in incidence over the 2 years after treatment was death from OPSCC. HPV/p16 positivity was an independent factor for improved survival across all causes of death in patients with OPSCC. In addition, both HPV-positive and HPV-negative OPSCC patients faced high 5- and 10-year mortality rates. Implementing secondary screening and prevention strategies for late toxicity and mortality are major goals in managing the treatment of these patients.

Endoscopic screening for synchronous esophageal neoplasia among patients with incident head and neck cancer: Prevalence, risk factors, and outcomes

Esophageal squamous-cell neoplasia (ESCN) is a common second primary neoplasia found in patients with head-and-neck squamous-cell carcinoma (HNSCC). This study sought to identify the risk factors for synchronous ESCN and how they influence survival in HNSCC patient. Eight hundred and fifteen incident HNSCC patients were prospectively recruited for endoscopy screening for ESCN using white-light imaging, narrow-band imaging, Lugol chromoendoscopy, and pathological confirmation. Associated lifestyle and clinicopathological data were collected. The interquartile follow-up period cutoffs were 11.3, 20.5 and 34.9 months. 124 patients (15.2%) were diagnosed as having synchronous ESCN (66 low-grade dysplasia, 29 high-grade dysplasia, and 29 esophageal squamous-cell carcinoma). Consumption of alcohol, but not betel nut or cigarette, was significantly associated with the presence of synchronous ESCN (adjusted odds ratio [aOR] = 7.1 and 10.9 for former and current drinkers, respectively). There was an interaction between cumulative dose of alcohol consumption and alcohol flushing response on the development of ESCN. High-dose drinkers with flush response were 16.9 times more likely to have esophageal high-grade dysplasia/SCC than non-drinkers. Compared with oral cavity cancer patients, those with hypopharyngeal, laryngeal and oropharyngeal cancer were 6.8, 4.6 and 2.8 times more likely to have esophageal high-grade dysplasia/SCC. HNSCC patients with synchronous ESCN had lower overall survival than those without (p < 0.0001). In conclusion, surveillance of ESCN is strongly recommended for the high-risk subpopulation of HNSCC patients, especially drinkers who have a flush response to alcohol, and those with distant metastasis of index cancer and cancers in hypopharynx, oropharynx and larynx.

Role of comorbidity on outcome of head and neck cancer: a population-based study in Thuringia, Germany

To examine the impact of comorbidity on overall survival (OS) in a population-based study of patients with head and neck cancer who were treated between 2009 and 2011. Data of 1094 patients with primary head and neck carcinomas without distant metastasis from the Thuringian cancer registries were evaluated concerning the influence of patient's characteristics and comorbidity on OS. Data on comorbidity prior to head and neck cancer diagnosis was adapted to the Charlson Comorbidity (CCI), age-adjusted CCI (ACCI), head and neck CCI (HNCCI), simplified comorbidity score (SCS), and to the Adult Comorbidity Evaluation-27 (ACE-27). Most patients were male (80%; median age: 60 years; 50% stage IV tumors). Smoking, alcohol abuse, and anemia were registered for 38%, 33%, and 23% of the patients, respectively. Predominant therapy was surgery + radiochemotherapy (30%), surgery (29%), and surgery + radiotherapy (21%). Mean CCI, ACCI, HNCCI, SCS and ACE-27 were 1.0 ± 1.5, 2.6 ± 2.1, 0.6 ± 0.8, 4.4 ± 4.2, and 0.9 ± 0.9, respectively. Median follow-up was 25.7 months. Multivariable analyses showed that higher age, higher UICC stage, no therapy, including surgery or radiotherapy, alcohol abuse, and anemia, higher comorbidity were independent risk factors for worse OS (all P < 0.05). According to the discriminatory power analysis none of the five comorbidity scores was superior to the other scores to prognosticate OS. This population-based study showed that comorbidity is frequent in German patients with head and neck cancer and is an important risk factor for poor OS. Comorbidity should be routinely assessed and taken into account in prospective clinical trials.