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.
Submitted February 18, 2019; accepted for publication September 3, 2019.
Author contributions:Study concept, data curation, and formal data analysis: Pike, B.A. Mahal, Sanford. Manuscript preparation–writing of original draft, review, and editing: All authors.
Disclosures: Dr. Pike has disclosed that he receives consulting fees from Third Rock Ventures. All remaining authors have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article.
Correspondence: Luke R.G. Pike, MD, DPhil, Department of Radiation Oncology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114. Email: email@example.com
JemalA, SimardEP, DorellC, . Annual report to the nation on the status of cancer, 1975-2009, featuring the burden and trends in human papillomavirus (HPV)-associated cancers and HPV vaccination coverage levels. J Natl Cancer Inst2013;105:175–201.
JemalA, SimardEP, DorellC, . Annual report to the nation on the status of cancer, 1975-2009, featuring the burden and trends in human papillomavirus (HPV)-associated cancers and HPV vaccination coverage levels. J Natl Cancer Inst 2013;105:175–201.2329703910.1093/jnci/djs491)| false
GillisonML, ZhangQ, JordanR, . Tobacco smoking and increased risk of death and progression for patients with p16-positive and p16-negative oropharyngeal cancer. J Clin Oncol 2012;30:2102–2111.2256500310.1200/JCO.2011.38.4099)| false
SchacheAG, PowellNG, CuschieriKS, . HPV-related oropharynx cancer in the United Kingdom: an evolution in the understanding of disease etiology. Cancer Res 2016;76:6598–6606.10.1158/0008-5472.CAN-16-063327569214)| false
SettleK, PosnerMR, SchumakerLM, . Racial survival disparity in head and neck cancer results from low prevalence of human papillomavirus infection in black oropharyngeal cancer patients. Cancer Prev Res (Phila)2009;2:776–781.
SettleK, PosnerMR, SchumakerLM, . Racial survival disparity in head and neck cancer results from low prevalence of human papillomavirus infection in black oropharyngeal cancer patients. Cancer Prev Res (Phila) 2009;2:776–781.1964104210.1158/1940-6207.CAPR-09-0149)| false
FakhryC, WestraWH, WangSJ, . The prognostic role of sex, race, and human papillomavirus in oropharyngeal and nonoropharyngeal head and neck squamous cell cancer. Cancer 2017;123:1566–1575.2824109610.1002/cncr.30353)| false
ChaturvediAK, EngelsEA, AndersonWF, . Incidence trends for human papillomavirus-related and -unrelated oral squamous cell carcinomas in the United States. J Clin Oncol 2008;26:612–619.10.1200/JCO.2007.14.171318235120)| false
GillisonML, D’SouzaG, WestraW, . Distinct risk factor profiles for human papillomavirus type 16-positive and human papillomavirus type 16-negative head and neck cancers. J Natl Cancer Inst2008;100:407–420.
GillisonML, D’SouzaG, WestraW, . Distinct risk factor profiles for human papillomavirus type 16-positive and human papillomavirus type 16-negative head and neck cancers. J Natl Cancer Inst 2008;100:407–420.10.1093/jnci/djn02518334711)| false
FrischM, GoodmanMT. Human papillomavirus-associated carcinomas in Hawaii and the mainland U.S. Cancer 2000;88:1464–1469.1071763110.1002/(SICI)1097-0142(20000315)88:6<1464::AID-CNCR26>3.0.CO;2-O)| false
StenmarkMH, ShumwayD, GuoC, . Influence of human papillomavirus on the clinical presentation of oropharyngeal carcinoma in the United States. Laryngoscope 2017;127:2270–2278.2830408310.1002/lary.26566)| false
RubinSJ, KirkeDN, EzzatWH, . Marital status as a predictor of survival in patients with human papilloma virus-positive oropharyngeal cancer. Am J Otolaryngol 2017;38:654–659.2894734410.1016/j.amjoto.2017.09.003)| false
ChuKP, HabbousS, KuangQ, . Socioeconomic status, human papillomavirus, and overall survival in head and neck squamous cell carcinomas in Toronto, Canada. Cancer Epidemiol 2016;40:102–112.2670636510.1016/j.canep.2015.11.010)| false
MahalBA, InversoG, AizerAA, . Impact of African-American race on presentation, treatment, and survival of head and neck cancer. Oral Oncol 2014;50:1177–1181.10.1016/j.oraloncology.2014.09.00425261298)| false
PosnerMR, LorchJH, GoloubevaO, . Survival and human papillomavirus in oropharynx cancer in TAX 324: a subset analysis from an international phase III trial. Ann Oncol 2011;22:1071–1077.2131722310.1093/annonc/mdr006)| false