Factors Related to Human Papillomavirus Positivity among Oral Cavity and Pharynx Cancers from Surveillance, Epidemiology and End Results (SEER) Program Data

BACKGROUND

As human papillomavirus positive (HPV+) oral cavity and pharynx cancer (OCPC) incidence increases significantly, our objective was to determine whether selected sociodemographic and clinical factors were associated with HPV+ OCPCs overall and by oropharyngeal and non-oropharyngeal sites.

METHODS

Surveillance, Epidemiology and End Results (SEER) Program data were used in this study. Specifically, univariate and logistic regression models were used to examine the relationships between HPV+ and HPV- OCPC cases and age, sex, race, ethnicity, marital status, factors of neighborhood socioeconomic status (i.e., nSES/Yost index) and rurality/urbanity, first malignancy status, histology, reporting source, stage at diagnosis, and OCPC anatomic site. The same approach was used to identify risk factors for HPV positivity for oropharyngeal and non-oropharyngeal OCPCs separately.

RESULTS

In all OCPCs, cases that were male, <80 years old, lived in the four highest nSES categories, diagnosed with a non-"gum and other mouth" OCPC (ref = hypopharynx), not locally staged at diagnosis, and a first malignancy had higher odds of being HPV+. Cases that were American Indian/Alaska Native and Asian or Pacific Islander (ref = White), Spanish-Hispanic-Latino ethnicity, non-married/partnered, and not reported by a hospital/clinic had lower odds of being HPV+. Associations were maintained in oropharyngeal OCPCs and only age and race remained significant for non-oropharyngeal OCPCs.

CONCLUSIONS

Sociodemographic and clinical differences in HPV+ and HPV- OCPC, overall and for (non)oropharyngeal, cases exist.

IMPACT

Identification of OCPC and (non)oropharyngeal risk factors for HPV positivity may assist in discovering high-risk groups that should receive enhanced public health efforts to reduce the U.S. OCPC burden.

Distinct sociodemographic differences in incidence and survival rates for human papillomavirus (HPV)-like, non-HPV-like, and “other”-like oral cavity and pharynx cancers: An analysis of Surveillance, Epidemiology and End Results (SEER) Program data

Purpose

Oral cavity and pharynx cancer (OCPC) cases are traditionally dichotomized into human papillomavirus (HPV) and non-HPV types. Using a proxy for HPV status, the objective was to evaluate differences in incidence and survival rates of OCPC anatomic sub-sites identified as: 1) HPV-like; 2) non-HPV-like (i.e., tobacco/alcohol-related); and 3) “other”-like (i.e., not predominantly HPV-like nor tobacco/alcohol-like) OCPCs.

Methods

Data from the Surveillance, Epidemiology and End Results Program were used to examine incidence and survival rates for OCPC categories over time and according to age, sex, race, ethnicity, stage at diagnosis, neighborhood socioeconomic status (i.e., nSES or Yost Index), and rurality/urbanity (i.e., Rural Urban Commuting Area (RUCA) codes). Although HPV status was unavailable in this dataset, OCPC anatomies and histologies were classified into three sub-categories, based on potential risk factors. Frequencies, average annual, age-adjusted incidence rates, five-year relative survival rates, and 95% confidence intervals were examined across and within OCPC categories.

Results

HPV-like OCPC incidence rates sharply increased from 1975 through 2015 while non-HPV-like and “other”-like OCPC rates decreased, all converging to similar rates from 2016 through 2018. Increasing over time for both categories, survival was highest for HPV-like and lowest for non-HPV-like OCPCs; survival for “other”-like OCPCs remained stable. Generally, across OCPC categories, incidence and survival rates were significantly higher among males vs. females, Whites vs. African Americans, and non-Hispanics vs. Hispanics. “Other”-like OCPC incidence decreased with increasing nSES tertiles, while no nSES differences were observed for HPV-like and non-HPV-like OCPCs. Incidence rates were significantly lower among urban (vs. rural) residents. For all OCPC categories, survival rates were significantly higher with increasing nSES and variable across RUCA categories.

Conclusion/Impact

HPV-like and non-HPV-like OCPC cases had distinct sociodemographic differences; “other”-like OCPC cases were a sociodemographic blend of HPV-like and non-HPV-like OCPC cases, resembling more of the sociodemographic makeup of non-HPV-like OCPC cases. To prevent new OCPCs, additional studies are needed to epidemiologically and clinically differentiate between OCPC categories so that high-risk groups can be better targeted in future public health interventions.

Low Rates of Dual-Site and Concordant Oral-Cervical Human Papillomavirus Infections and Cancers: A Systematic Review

Objective

The oral-cervical human papillomavirus (HPV) infection/cancer relationship is not well established. Oral-cervical HPV studies were reviewed to assess dual-site occurrence, HPV type concordance, and study quality/deficiencies.

Methods

PubMed, EMBASE, Ovid Medline, and Web of Science were searched between 1/1/1990 and 8/10/2021 for studies investigating HPV infections/cancers and type concordance between the oral cavity/oropharynx and cervix. Dual-site and concordant HPV infection rates were summarized as percentages; cancer diagnoses studies were summarized using standardized incidence ratios (SIR). The Quality Assessment Tool for Quantitative Studies (QATQS) evaluated study methodology.

Results

One hundred fourteen papers were identified. Most were cross-sectional (n=79, 69%), involved synchronous dual-site HPV testing (n=80, 70%), did not report HPV type concordance (n=62, 54%), and achieved moderate methodological QATQS ratings (n=81, 71%). The overall dual-site infection rate averaged 16%; the HPV type concordance rate averaged 41%, among those dually-infected women. Most HPV-related cancer diagnoses studies reported increased secondary cancer risk, with SIRs generally ranging from 1.4 to 29.4 for secondary cervical cancer after primary oral cancer and from 1.4 to 6.3 for secondary oral cancer after primary cervical cancer.

Conclusion/Impact

Oral-cervical HPV infections/cancers remain understudied. Future research should use stronger methodologies and HPV concordance analyses to better understand oral-cervical HPV epidemiology.

Body Mass Index and Early Childhood Caries in High Caries Risk Children: A Nested Case-Control Methodological Investigation

Purpose: To evaluate body mass index (BMI) - early childhood caries (ECC) relationships with various BMI expressions.<br/>Methods: Healthy eight- to 18-month children with unerupted molar(s) were conveniently sampled from Uniontown, Ala., USA, a high caries risk community (i. e., rural, poor, racial minority). Staff measured height/weight, dentists conducted oral exams, and parents completed questionnaires annually (from 2008 to 2014) for BMI, ECC (decayed, missing due to caries, filled primary tooth surfaces [dmfs] score), and sociodemographic values, respectively. Nationally recognized standard (underweight-normal-overweight-obese), crude (overweight/obese-not), and continuous BMI variables were evaluated. Logistic regressions (with restricted cubic splines) assessed BMI-ECC relationships, producing odds ratios (ORs) and 95 percent confidence intervals (95% CIs).<br/>Results: Male and female ECC ORs supported positive and negative parabolic functions, respectively, for increasing standard BMI categories; underweight males were associated with ECC (OR=4.59; 95% CI=1.06 to 19.85). Crudely expressed, overweight/obese males and females had lower and slightly increased odds of ECC, respectively. A continuous BMI produced a similar OR across sexes, while spline models suggested nonlinearity for each.<br/>Conclusion: BMI-ECC associations might be nonlinear; being underweight could be a male ECC risk factor. Studies should include extreme BMI values without collapsing BMI categories.

Children's detailed non-water beverage consumption habits and longitudinal early childhood caries experiences

OBJECTIVES

Sugar-sweetened beverages and dental caries are prevalent among children. Measurement choices could explain their inconsistent relationships. This study evaluated associations between detailed baseline non-water beverage consumption (NWBC) behaviors and longitudinal early childhood caries (ECC) experiences in young, high-caries risk children.

METHODS

Researchers followed poor, rural, African Americans, recruited at 8-18 months old from Uniontown, Alabama, through convenience sampling, annually for 5 years (N = 66). Baseline questionnaires obtained demographics, oral hygiene, and daily dietary histories, including beverage types, frequencies, and NWBC behaviors of intake speed (intermittent/rapid), container (bottles/non-bottles), and bedtime beverages (yes/no). Dentists conducted examinations annually to determine decayed, missing, filled (carious) surfaces (dmfs) scores, producing increments (dmfs_final - dmfs_initial ). Age-adjusted logistic regressions estimated odds ratios (OR) and 95% confidence intervals (95% CI) for ECC (carious: incidence >0 versus caries-free: incidence = 0) with NWBC behavior then NWBC frequency, individually and conditional on NWBC behaviors, exposures.

RESULTS

NWBC behaviors were not associated with ECC; juice was significant (OR: 2.0, 95% CI: 1.0, 4.2). Adjusting for intake speed, juice persisted as a risk factor (OR: 2.1, 95% CI: 1.0, 4.3), remaining suggestive after controlling for container or bedtime beverages (OR: 2.0, 95% CI: 0.9, 4.3; OR: 1.9, 95% CI: 0.9, 4.0, respectively). Container could be an effect modifier (OR_bottle : 3.5, 95% CI: 0.8, 16.2 vs. OR_non-bottle : 1.5, 95% CI: 0.6, 3.7). Milk was not associated with ECC.

CONCLUSIONS

Independently, NWBC behaviors are insufficient in evaluating NWBC/ECC relationships; beverage type, frequency, and consumption behaviors, collectively, can better evaluate associations.

Overestimation of Early Childhood Caries Using the dmfs Index

Purpose: The preferred epidemiological caries assessment method is the decayed, missing, and filled surfaces (dmfs) score, which records all crowned/missing primary teeth's surfaces as carious. The purpose of this study was to evaluate the dmfs score's accuracy in capturing caries-affected (versus treated) surfaces of crowned/extracted teeth. Methods: A high-caries risk cohort of children, eight to 18 months old at baseline, were recruited from a nonfluoridated, rural, minority, and low-income community. Oral examinations occurred every 12 months for five years, identifying children with at least one caries-related crown/extraction (N equals 45). Observed scoring counted all crowned/extracted surfaces as carious. Private dentists' clinical records were also reviewed to determine how many surfaces were carious at crown/extraction appointments (53 actual scores for n equals 19). Differences in actual and observed scoring were evaluated (sign test; α equals 0.05 with two-tailed P-values). Results: Most children in the study group had more than one crown/extraction. Actual scoring revealed two to three fewer carious surfaces per tooth than observed scoring; cumulatively, observed scoring added two to 27 more surface counts per participant (P<0.001). Conclusions: Observed scoring exaggerated early childhood caries burdens when crowns/extractions were prevalent. Modified dmfs scoring, individualized or population-corrected crown/extraction counts, could more accurately estimate disease.

Average area under the curve: An alternative method for quantifying the dental caries experience in longitudinal studies

OBJECTIVES

Field-traditional decayed, missing, filled surfaces (dmfs) increments require complete follow-up, only using initial and final visits. Repeated dmfs scores complicate sophisticated statistical models, limiting their utility. Elsewhere, area under the curve (AUC) uses all repeated measures to summarize data. This study applied AUC methodology to caries data, creating average AUCs for dmfs trajectories (dmfs^aAUC ) and comparing increments and dmfs^aAUC values.

METHODS

Longitudinal data were obtained from high-caries risk (i.e. poor, rural, African American community in Perry County, Alabama) infants, 8 to 18 months at baseline. Baseline and five annual visual oral examinations provided dmfs scores. Differences in baseline and final dmfs scores constituted increments. The trapezoidal rule was applied to dmfs trajectories to calculate AUC values which were adjusted for varying follow-up times, producing dmfs^aAUC values. Participants sharing incremental or dmfs^aAUC values had their trajectories and second caries measurements compared. Within-participant increment and dmfs^aAUC differences were evaluated (paired t test, α = 0.05). Comparative analyses required complete follow-up.

RESULTS

The dmfs^aAUC provided forty-eight additional person-years, increasing the potential sample size by 20% (N = 85). Sixty-six children, 5.7 to 6.3 year-olds at study's end, contributed 121 331 person-days to five-year increment and dmfs^aAUC calculations. Trajectories and dmfs^aAUC values varied for participants with equivalent increments; comparable trajectories and different increments resulted from participants with similar dmfs^aAUC values. Within-participant disease amounts were similar.

CONCLUSIONS

When desired, dmfs^aAUC can replace increments as a more data-inclusive summary of longitudinal caries burden, incorporating intermediate visits, incomplete follow-up and time.