Disparate survival of late-stage male oropharyngeal cancer in Appalachia

Abstract

the United States Appalachian region harbors a higher cancer burden than the rest of the nation, with disparate incidence of head and neck squamous cell carcinomas (HnScc), including oral cavity and pharynx (oc/p) cancers. Whether elevated HnScc incidence generates survival disparities within Appalachia is unknown. To address this, HNSCC survival data for 259,737 tumors from the North American Association for Central Cancer Registries 2007-2013 cohort were evaluated, with ageadjusted relative survival (RS) calculated based on staging, race, sex, and Appalachian residence. tobacco use, a primary HnScc risk factor, was evaluated through the Behavioral Risk factor Surveillance System from Appalachian states. Decreased oc/p RS was found in stage iV Appalachian white males within a subset of states. The survival disparity was confined to human papillomavirus (HPV)-associated oropharyngeal cancers, specifically the oropharynx subsite. This correlated with significantly higher smoking and male smokeless tobacco use in most Appalachian disparity states. Lower survival of Appalachian males with advanced-stage HpV-associated oropharyngeal cancers suggests pervasive tobacco consumption likely generates more aggressive tumors at HpV-associated oropharynx subsites than national averages. comprehensive tobacco and HpV status should therefore be evaluated prior to considering treatment de-intensification regimens for HPV-associated oropharyngeal cancers in populations with high tobacco consumption. HNSCC involves the epithelium of the oral cavity, pharynx and larynx. OC/P cancers are a major HNSCC subset, with nearly 11,000 deaths predicted in the US in 2020 1. Risk factors include tobacco and alcohol use, and highrisk human papillomavirus (HPV) infection 2,3. OC/P cancers are subdivided into HPV-associated oropharynx (HPV-associated) and non-HPV-associated oral cavity, hypopharynx, and nasopharynx (non-HPV-associated) cancers 4. These designations are supported by studies indicating that non-HPV-associated cancers are primarily tobacco/alcohol induced, whereas HPV-associated cancers are predominantly caused by HPV infection 5. Furthermore, HPV-negative or non-HPV-associated cancers consistently have poorer outcomes than HPV-positive or HPV-associated cancers, segregating these cancers as distinct diseases with differential clinical management 6,7. While national incidence of non-HPV-associated cancers is decreasing due to tobacco cessation, HPV-associated cancers are increasing due to rising infection rates 8. Regarding race, blacks with HNSCC present with more advanced disease, are older and have worse survival than whites, denoting a racial disparity 9-11. Increased screening for HPV coupled with subsite analysis indicates that blacks with HNSCC have less HPV-positive cancer than whites, explaining differences in survival 12,13. Consistent with this, HPV-associated cancers continue to increase in white males and in rural areas 4,14,15. The Appalachian region encompasses 205,000 square miles across 420 counties in 13 contiguo...

Assessing the Applicability of the TALK Score: A Modification for Concurrent Tobacco Use During Treatment

“…Despite national efforts to decrease smoking rates, tobacco consumption in the Appalachian region is the highest in the country and subsequently has resulted in the highest numbers of larynx cancer. [12][13][14] Roughly 24% of Appalachian Kentuckians live below the poverty level, 37% have not completed high school, and these issues coupled with economic dependence and cultural norms have led to persistent smoking behaviors. 15 The adult smoking rate in Appalachia is 24.2% as compared with 13.7% nationally.…”

Rural Otolaryngology Care Disparities: A Scoping Review

“…While practice patterns were most commonly studied in otology, outcomes (8) were most commonly studied in head and neck cancer. Five of these studies presented disparities in survival, [55][56][57] with 3 studies finding worse survival outcomes for rural patients with head and neck cancer, 1 study finding no significant difference in survival, 58 and 1 study finding the opposite trend. 59 Three studies were published on disparities in rural cancer treatment, [60][61][62] and 2 examined disparities in screening.…”

Extranodal Extension Improves AJCC‐8 Accuracy in HPV+ Oropharyngeal Cancer in a High‐Risk Population

“…Head and neck cancers are particularly prevalent in the Appalachian region of the United States 6 with Kentucky reporting the highest rates of HPV+ tumors (15.3 per 100,000) and HPV+ OPSCCs (6.2 per 100,000) in the nation 7 . Appalachia comprises 423 counties and a population of 25.7 million people 8 .…”

“…4 Due to the improved prognosis of HPV+ OPSCCs, the eighth edition of the American Joint Committee on Cancer staging criteria (AJCC-8) now stages HPV+ and HPVÀ OPSCCs separately. 5 Head and neck cancers are particularly prevalent in the Appalachian region of the United States 6 with Kentucky reporting the highest rates of HPV+ tumors (15.3 per 100,000) and HPV+ OPSCCs (6.2 per 100,000) in the nation. 7 Appalachia comprises 423 counties and a population of 25.7 million people.…”