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ImportanceOncologic treatment is costly to the health care system and to individuals, but patients with head and neck cancer (HNC) also have long-term care needs after treatment. Survivors of HNC require specific consideration given their rapidly growing numbers. This subpopulation of cancer survivors often experiences long-term treatment-associated morbidity.ObjectiveTo describe the total and out-of-pocket (OOP) costs associated with HNC survivorship and the risk factors for financial toxicity among this population.Design, Setting, and ParticipantsThis was a retrospective review and economic evaluation of a cohort of US adults with a diagnosis of HNC from 2006 to 2018. The study used data the from IBM MarketScan Commercial Claims Database. Data were analyzed from November 2020 to June 2022.ExposuresTreatment for HNC.Main Outcomes and MeasuresTotal and OOP medical costs were assessed monthly and reported relative to the date of HNC diagnosis. The primary outcome was the difference between a patient’s mean monthly survivorship costs (13-60 months after diagnosis) and mean monthly baseline costs (7-12 months before diagnosis). Univariate and multivariable linear regression models were created for total and OOP costs to generate coefficient estimates with 95% CIs.ResultsThe study cohort of this economic evaluation included 19 098 patients with HNC (median [range] age, 56 [18-64] years; 14 144 [74.1%] men and 4954 [25.9%] women; race and ethnicity were not considered). Throughout the survivorship period, median total and OOP costs were $372 per month and $31 per month higher than baseline costs, respectively, with variation in expenses by demographic information, health plan type, and oncologic variables. In the multivariable model, greater total and OOP excess survivorship costs were associated with female sex ($343/mo; 95% CI, $126 to $560 and $9/mo; 95% CI, $4 to $14). Highest and lowest total excess survivorship costs associated with cancer site were seen for hypopharyngeal ($1908/mo; 95% CI, $1102 to $2714) and oropharyngeal cancers (−$703/mo; 95% CI, −$967 to −$439) vs oral cavity cancers. Compared with surgery or radiation therapy alone, multimodal treatment was generally associated with excess OOP survivorship costs.Conclusions and RelevanceThe findings of this retrospective economic evaluation review suggest that the costs of HNC survivorship remain persistently elevated above baseline costs for at least 5 years after diagnosis. High survivorship costs were associated with female sex, hypopharyngeal tumors, and treatment with multimodal therapy. Practitioners should seek to minimize costs for these patients at higher-risk of financial toxicity after treatment and work to provide directed supportive services.

Objectives/hypothesis Radiation-associated sarcomas of the head and neck (RASHN) are known but rare sequelae after radiation for squamous cell carcinoma. The purpose of this study was to characterize RASHN, estimate the risk of RASHN in head and neck squamous cell patients after therapeutic radiation, and compare their survival to that of patients with de novo sarcomas of the head and neck (dnSHN). Study design Retrospective database analysis. Methods RASHN and dnSHN cases were collected from the Surveillance, Epidemiology, and End Results Database to identify risk factors and calculate incidence and latency. Survival was compared between RASHN and dnSHN. Results The risk of RASHN was 20.0 per 100,000 person-years. The average latency period was 124.2 months (range 38-329). The cumulative incidence of RASHN at 20 years was 0.13%. Oral cavity and oropharynx primaries demonstrate increased risk. Five-year overall survival of RASHN was 22.4% compared to 64.5% for dnSHN. Conclusions RASHN are confirmed to be rare. RASHN have poor overall survival and worse survival compared to dnSHN. The impact of intensity-modulated radiation therapy protocols on this risk is unknown. Modifiable risk factors of smoking and alcohol consumption continue to dwarf radiation therapy as risk factors of second primary head and neck cancers. Level of evidence 3 Laryngoscope, 2021.

The epidemiology of head and neck cancer (HNC) sites differ substantially. This study compares HNC incidence trends by site and demographic subgroups.We used the U.S. Cancer Statistics Public Use Database to calculate HNC incidence rates per 100 000. We assessed trends with annual percent change (APC) longitudinally from 2001 to 2017.The oropharyngeal cancer incidence APC decreased from 4.38% (95% CI: 3.6, 5.1) to 2.93% (2.5, 3.3) in 2008 among White males. Oral cavity cancer incidence rose in Other race males (APC 2.5% [1.6, 3.36]) and White females (APC: 0.96% [0.7, 1.2]). Although decreasing (APC: -1.15% [-1.48, -0.83]), laryngeal cancer incidence remained disproportionately high among Black males.Notable incidence trends occurred in non-White groups at non-oropharyngeal sites. With parity of smoking rates by race, differing sexual behaviors, and shifting demographics by race and sex, future studies of HNC trends should consider stratifying analyses to understand health disparities.

Purpose Privately insured patients with head and neck cancer (HNC) typically have better outcomes; however, differential outcome among Medicaid versus the uninsured is unclear. We aimed to describe outcome disparities among HNC patients uninsured versus on Medicaid. Methods A cohort of 18-64-year-old adults (n = 57 920) with index HNC from the Surveillance, Epidemiology, and End Results 18 database (2007-2015) was analyzed using Fine and Gray multivariable competing risks proportional hazards models for HNC-specific mortality. Results Medicaid (sdHR = 1.65, 95% CI 1.58, 1.72) and uninsured patients (sdHR = 1.55, 95% CI 1.46, 1.65) had significantly greater mortality hazard than non-Medicaid patients. Medicaid patients had increased HNC mortality hazard than those uninsured. Conclusion Compared with those uninsured, HNC patients on Medicaid did not have superior survival, suggesting that there may be underlying mechanisms/factors inherent in this patient population that could undermine access to care benefits from being on Medicaid.

The incidence of oropharyngeal squamous cell carcinoma (OPSCC) is increasing secondary to human papillomavirus (HPV)-related disease. Despite this, outcomes of patients with HPV-negative OPSCC undergoing transoral robotic surgery (TORS) are largely unknown.Analysis of the National Cancer Database (NCDB).Not applicable.The 2015 participant user file from the NCDB was analyzed between 2010 and 2015 for patients with OPSCC who underwent TORS and neck dissection. Kaplan-Meier survival analysis was used to estimate overall survival of the study population. Univariable Cox survival analyses was used to determine significant associations between demographic, tumor, and treatment characteristics and overall survival (OS).There were 164 patients (124 male and 40 female) with a mean age of 58 years (30-89 years). Median follow-up was 34 months. Five-year OS was 78% (95% CI, 70%-86%). Patients with early stage disease (pT1-2, N0-1) had significantly improved OS compared to patients with advanced T- or N-stage disease (log-rank 0.011; 5-year OS: 88% [95% CI, 78%-98%] vs 66% [95% CI, 50%-82%]).Very few patients in the NCDB underwent TORS for HPV-negative OPSCC, but those who did had favorable outcomes, especially in early stage disease. Based on these findings, TORS may be considered in the treatment algorithm for patients with HPV-negative OPSCC.Level IV.

Background Patients with head and neck cancer (HNC) are at risk for limited healthcare access. Methods Individuals reporting a history of cancer were identified from the Medical Expenditure Panel Survey, an annual assessment of the nation's health. Access to care variables were compared between "HNC" and "other cancer" using multivariable methods and stratified by age 65. Results From 1998 to 2015, 420 patients with HNC and 14 468 with other cancers completed the survey. Among patients with HNC, 10.4% (95% confidence interval [CI] 5.0-15.9) lacked a regular provider, compared to 6.1% (95% CI 5.5-6.6) of other cancer survivors. Ten percent of HNC survivors lacked a regular provider and 14.6% report barriers to needed care. For those 65 years and older, HNC was associated with lacking a regular provider (adjusted odds ratio 2.58, 95% CI 1.15-5.80). Conclusion HNC was associated with lack of a regular care provider after age 65, which may result in substandard survivorship care.

Head and neck cancer (HNC) patients frequently require care through emergency departments (ED) due to lack of access or symptom acuity, however, the frequency and implications of this occurrence have not been delineated.To determine the association between emergency department admission of HNC surgery with length of stay (LOS) and total costs (TC).A cohort of 12,920 adult HNC patients admitted to acute care hospitals receiving ablative surgery during index admission was identified using the New York State Inpatient Database from 2006 to 2016. Outcomes included LOS, TC, 90-day complications, and inpatient mortality.Eight percent of the cohort was admitted through the ED, which increased over the study period from 6.52% (95% CI: 5.05-7.99) to 17.0% (95% CI: 14.9-19.1). ED admission was associated with a longer LOS (11 days longer, 95% CI 10.3-11.7) and higher mean TC ($43,197) versus non-ED admission ($19,010), with a mean difference of $24,191 (95% CI 20,713-27,669). After controlling for covariates, ED admission was associated with an 81.6% (95% CI 76.8-86.5) and 80.4% (95% CI 70.5-90.8) increase in LOS and TC, respectively, and decreased survival with a hazard ratio of 1.97 (95% CI 1.60-2.42).Rates of ED admission for HNC diagnoses requiring surgical intervention during index admission are rising and associated with longer LOS higher TC, more postoperative complications, and increased inpatient mortality after accounting for patient and facility differences. Striving for high-quality HNC cancer care demands addressing barriers to care that contribute to patients relying on the ED for access.

Objectives Human papillomavirus (HPV)-associated cancers account for about 9% of the cancer mortality burden in the United States; however, survival differs among sociodemographic factors. We determine sociodemographic and clinical variables associated with HPV-associated cancer survival. Methods Data derived from the Surveillance, Epidemiology, and End Results 18 cancer registry were analyzed for a cohort of adult patients diagnosed with a first primary HPV-associated cancer (anal, cervical, oropharyngeal, penile, vaginal, and vulvar cancers), between 2007 and 2015. Multivariable Fine and Gray proportional hazards regression models stratified by anatomic site estimated the association of sociodemographic and clinical variables and cancer-specific survival. Results A total of 77 774 adults were included (11 216 anal, 27 098 cervical, 30 451 oropharyngeal, 2221 penile, 1176 vaginal, 5612 vulvar; average age = 57.2 years). The most common HPV-associated cancer was cervical carcinoma (58%) for females and oropharyngeal (81%) for male. Among patients diagnosed with anal/rectal squamous cell carcinoma (SCC), males had a higher risk of death than females. NonHispanic (NH) blacks had a higher risk of death from anal/rectal SCC, oropharyngeal SCC, and cervical carcinoma; and Hispanics had a higher risk of death from oropharyngeal SCC than NH whites. Marital status was associated with risk of death for all anatomic sites except vulvar. Compared to nonMedicaid insurance, patients with Medicaid and uninsured had higher risk of death from anal/rectal SCC, oropharyngeal SCC, and cervical carcinoma. Conclusions There exists gender (anal) and racial and insurance (anal, cervical, and oropharyngeal) disparities in relative survival. Concerted efforts are needed to increase and sustain progress made in HPV vaccine uptake among these specific patient subgroups, to reduce cancer incidence.

Improved head and neck cancer survival has been associated with traveling farther distances for treatment, potentially due to patients seeking higher-quality facilities. This study investigates the role of both facility and confounding patient factors on this relationship.Review of national registry data.National Cancer Database.Adults with head and neck cancer diagnosed from 2004 to 2014 were identified. Overall survival was compared among distance-to-facility quartiles via univariate and multivariate survival models. Then, the analysis was stratified by facility and patient factors, and the association between distance and survival was compared among strata.Overall survival was worst in the shortest-distance quartile (5 miles; median survival, 80.7 months; 95% CI, 79.2-82.3), while other distance groups showed similar survival (range, 96.4-104 months). This finding remained in the multivariate model (adjusted hazard ratio vs first distance quartile: 0.88; 95% CI, 0.87-0.89). The association between survival and distance persisted in all subgroups when stratified by facility volume and type (adjusted hazard ratio range, 0.82-0.91), suggesting that facility quality does not fully account for this association. When stratified by income, distance remained statistically associated with survival but with a smaller effect size than that of income.The association between distance to treating facility and head and neck cancer survival is limited to patients with worse survival outcomes living within 5 miles of the facility and is not fully explained by measures of facility quality.

The aim of the study was to estimate hospitalization cost, and factors associated with hospitalization costs and length of stay (LOS) of patients treated for head and neck cancer in the United States.Data on 71,440 weighted hospital admissions from the 2014 National Inpatient Sample with a diagnosis of head and neck cancer were examined. Multivariable linear regression models estimated factors associated with hospitalization costs, and negative binomial regression models were used to identify factors associated with hospital LOS. Factor variables included characteristics of the patient, clinical, and hospital characteristics.The average hospitalization cost was US $18,371 and the average LOS was 6.6 days. LOS was significantly associated with admissions involving bacterial infection, major operating procedures, chemo procedure, and radiation procedure as well as admissions at medium or small bed size hospitals, and rural hospitals. Admissions among black patients, elective admissions, admissions involving bacterial infection, major operating procedures, chemo procedure, radiation procedure, and advance comorbidities were associated with increased hospitalization costs. In contrast, admissions at urban nonteaching or rural had increased hospitalization costs.Admissions that involve higher number of comorbidities, metastasis, bacterial infection, radiation, and chemo procedures had longer hospital stay and higher cost whereas admissions are rural hospitals had shorter hospital stay and lower cost. Understanding these factors associated with increased LOS and hospitalization cost will help efforts to decrease health care cost and improve quality of care.

To determine the frequency and management of short- and long-term complications related to oromandibular free flap reconstruction and identify potentially predictive factors of hardware complications.Retrospective chart review.A retrospective database from chart review was formed consisting of 266 oromandibular free flap reconstructions performed at a single institution over a 15-year period. Data were collected on demographics, surgical treatment, complications, and management of complications. Subgroup univariate and multivariate analyses were performed to compare patients with hardware complications and those without.Eighty-one of 266 patients (30.5%) that underwent oromandibular reconstruction had an early complication (4 weeks after surgery), and the most common complications were cervical wound dehiscence (11.3%) and fistulas (9.40%). Eighty of 266 patients (30.1%) had a long-term complication (4 weeks after surgery) and the most common complication was plate exposure (26.7%). Univariate and multivariate analyses showed no association between whether there was hardware extrusion and fibula versus scapula, smoking history, virtual surgical planning (VSP), and dental implantation (P .05). Only early complications (OR, 3.59, 95% CI, 1.83-7.05, P .01) and patients undergoing oromandibular reconstruction for osteoradionecrosis (OR, 2.26, 95% CI, 1.10-4.64, P = .03) were strongly and independently associated with subsequent hardware extrusion on univariate analysis.Both short- and long-term complications are common after oromandibular reconstruction. The most important predictive factor for a late complication is an early complication and prior radiation. There was no difference of plate complications among the various free flap types. Dental implantation and use of VSP were not associated with hardware complications.4 Laryngoscope, 131:1997-2005, 2021.

Background Race has been shown to have variable prognostic importance in nasopharyngeal carcinoma (NPC). However, previous studies are limited by a lack of comprehensive treatment, epidemiologic, and comorbidity data. Methods This was a retrospective cohort study utilizing the National Cancer Database from 2004 to 2016. Multivariable Cox proportional hazards regressions were used to calculate adjusted hazard ratios (aHR) for overall survival. Results A cohort of 9995 patients met inclusion and exclusion criteria. Race, insurance, comorbidity, treatment, stage, age, and histology were independent prognosticators. Among patients with keratinizing NPC, Asians and Hispanics had superior survival (aHR 0.58 [95% confidence interval (CI) 0.48-0.69], aHR 0.76 [95% CI 0.61-0.96]) compared to white patients. Among patients with non-keratinizing differentiated NPC, Asians and black patients had improved survival (aHR 0.71 [95% CI 0.56-0.91], aHR 0.72 [95% CI 0.54-0.95]) compared to white patients. Race was not prognostic in non-keratinizing undifferentiated NPC. Conclusion The prognostic significance of race varies across histological subtypes of NPC.

To systematically review the literature to determine the prevalence and clinical outcomes of second primary oropharyngeal squamous cell carcinoma (OPSCC).Search strategies created with a medical librarian were implemented using multiple databases in October 2019.The population of interest included adults age18 years with a p16+ or human papillomavirus-positive OPSCC. The outcome was a synchronous or metachronous second primary OPSCC. Inclusion and exclusion criteria were designed to capture all study designs. In total, 685 records were identified by the search strategy. Two reviewers independently performed the review, extracted data, and performed a quality assessment. Primary Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. A random-effects model was used for the meta-analysis.A total of 2470 patients with 35 second primary OPSCCs from 15 studies were identified. The pooled prevalence of second primary OPSCC was 1.4% (range, 0%-14.3%). In the random-effects model, the prevalence was estimated at 1.3% (95% CI, 0.7%-2.3%;Overall, the rate of second primary OPSCC in patients with an index p16+ OPSCC is low, and most patients are successfully treated. Insufficient evidence currently exists to recommend routine elective tonsillectomy during surgical treatment of p16+ OPSCC.

BACKGROUND: Oropharyngeal squamous cell carcinoma (OPSCC) epidemiology has not been examined previously in the nationwide Veterans Affairs (VA) population. METHODS: Joinpoint regression analysis was applied to OPSCC cases identified from VA administrative data from 2000 to 2012. RESULTS: We identified 12 125 OPSCC cases (incidence: 12.2 of 100 000 persons). OPSCC incidence declined between 2000 and 2006 (annual percent change [APC] = −4.27, P < .05), then increased between 2006 and 2012 (APC = 7.02, P < .05). Significant incidence increases occurred among white (APC = 7.19, P < .05) and African American (APC = 4.87, P < .05) Veterans and across all age cohorts. The percentage of never-smokers increased from 8% in 2000 to 15.7% in 2012 (P < .001), and 2-year overall survival improved from 31.2% (95% confidence interval (CI) [30-33.4]) to 55.7% (95% CI [54.4-57.1]). CONCLUSIONS: OPSCC incidence is increasing across all racial and age cohorts in the VA population. Smoking rates remain high among Veterans with OPSCC and gains in survival lag those reported in the general population.

Introduction Delays in radiation are multifactorial, frequent, and associated with poor outcomes. This study investigates the effect of both primary and adjuvant radiation therapy duration and their interaction with other measures of treatment delay on survival in head and neck squamous cell carcinoma (HNSCC). Methods We built a retrospective cohort using the National Cancer Database, consisting of primary oral cavity, hypopharynx, larynx and oropharynx squamous cell carcinoma without distant metastasis and with at least six weeks of radiation. The primary exposure was the duration of radiation therapy (DRT), and the primary outcome was death. We estimated the association between DRT and 5-year overall survival (OS) using Kaplan-Meier curves and hazard ratios (HRs) with Cox proportional hazard regression. Results In both primary (definitive) and adjuvant (post-surgical) radiation settings, increased DRT results in decreased survival. In the primary radiation cohort, 5-year OS was 59.7% [59.1%-60.3%] among those with 47–53 days DRT, which decreased significantly with each subsequent week to completion (81+ days: 38.4% [36.2%-40.7%]). In the surgical cohort, survival decreased 16.5% when DRT extended beyond 75 days (40–46 days: 68.2% [67.3%-69.1%] vs. 75+ days: 53.3% [50.1%-56.7%]). Multivariate analyses showed increased hazard of death with increased DRT (primary radiation: 81+ days HR: 1.69 [1.58–1.81]); surgical: 75+ days HR: 1.61 [1.37–1.88]), with effects intensifying when restricting to those receiving full-dose radiation. Conclusion A prolonged DRT was associated with worse OS in head and neck cancer. Radiation treatment delays of even a week lead to a significant survival disadvantage. DRT had a stronger association with survival than time to initiation of postoperative adjuvant radiotherapy.

Background This study aims to provide modern estimates of survival for untreated head and neck cancer (HNC) and to identify patient- and tumor-specific factors associated with not receiving definitive treatment. Methods Adults with mucosal HNC were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Median overall survival of untreated patients was calculated and stratified by site and stage. Cause-specific survival and factors associated with no treatment were investigated with advanced statistics. Results The study cohort included 6477 patients who received no treatment. Overall, untreated patients had a median survival of 12 months, with significant variability by site and stage. Multivariable analysis identified advanced age, black race, unmarried status, and lack of private insurance as associated with no treatment. Conclusions Survival of HNC without treatment is dismal, yet substantial variation exists by tumor site and stage. Higher rates of no treatment among the poor and racial minorities are potentially driven by disparities in care availability and provision.

Purpose While smoking is linked to worse outcomes for human papillomavirus (HPV)-related oropharyngeal squamous cell cancer (OPSCC), the magnitude of this association and the amount of smoking exposure necessary to confer clinically significant differences in outcomes is unclear. Recent studies suggested that greater tobacco exposure results in higher risk of cancer progression and death. Our study objective was to perform a systematic review of the association between smoking and HPV-related OPSCC outcomes. Materials and methods A literature search was conducted in April 2019 to identify relevant articles using Embase, Medline, Scopus, CENTRAL, and Cochrane databases. All studies were independently screened by two investigators to identify studies that assessed HPV-positive patients as an independent cohort, specified smoking measures, and reported locoregional recurrence (LRR), overall survival (OS), disease-specific survival (DSS), or disease-free survival (DFS) in association with smoking. Results Of 1130 studies identified, 10 met final inclusion criteria with 2321 total patients, mean age 57.5 years. Smoking measures included ever vs never, current vs never/former smokers, ≤10 vs >10 pack-year, and continuous pack-years. Of these studies, 8 (80%) showed a significant effect of smoking on increasing recurrence and mortality. Adjusted HRs for LRR ranged from 0.6 to 5.2, OS from 1.3 to 4.0, DSS from 2.3 to 7.2, and DFS from 1.02 to 4.2 among heavier smokers compared to lighter/non-smokers. Conclusions While there was significant variability in smoking metrics and reported outcomes, all studies reporting statistically significant HRs showed that smoking was associated with worse outcomes. Further studies using uniform smoking measures are necessary to better understand this association.

Objectives/hypothesis Head and neck squamous cell carcinoma (HNSCC) prognosis strongly correlates with demographic factors. This study aimed to determine whether demographic predictors of HNSCC survival differ between age cohorts, with an emphasis on the growing elderly demographic. Study design Outcomes research. Methods Adults with squamous cell carcinoma of the upper aerodigestive tract were identified from the Surveillance, Epidemiology and End Results 18 database. Demographic and oncologic factors were compared between three age groups: 18 to 49, 50 to 74, and >75 years. Factors associated with cancer-specific survival were assessed in each cohort using subdistribution hazard ratio (sHR) and 95% confidence interval (CI) produced by multivariate competing risk models. Results A cohort of 69,098 patients included 10,588 (15.3%) 75 years or older and 9,882 (14.3%) less than 50 years old. Older patients were more often female (35.4% vs. 25.1% aged 18-49 years and 20.4% aged 50-74 years), white (78.7% vs. 69.4% and 75.9%), insured (63.5% vs. 46.5% and 56.8%), and married (56.6% vs. 53% and 51.1%), but received adequate treatment less often (72.0% vs. 86.3% and 82.7%). In the older cohort, male sex was associated with lower mortality (sHR: 0.92, 95% CI: 0.85-1.00), and unlike the younger cohorts, black race was no longer associated with mortality (sHR: 1.07, 95% CI: 0.94-1.22). Marriage was associated with lower mortality in all age groups but with diminishing effects (single sHR: young 1.52, middle 1.31, older 1.14). Conclusions Elderly HNSCC patients have distinct effects from demographic prognostic factors and should be considered a separate subgroup with unique epidemiology, risks, and preferences. Level of evidence 2c Laryngoscope, , 129:146-153, 2018.

Objectives To assess head and neck cancer (HNC) patients’ perspectives on the value and burdens of routine cancer follow-up care. Materials and methods Data was obtained from HNC patients (n = 100) at an urban, tertiary head and neck cancer clinic. A novel 15-question survey tool evaluated the logistic, financial, and psychosocial burdens associated with clinic visits. The clinical characteristics and survey responses of demographic groups were analyzed with comparative statistics. Linear regression modeling was utilized to identify predictors of overall stress. Results A majority of study participants were male (74%), white (83%), and had histories of tobacco (77%) and alcohol (77%) use. Most participants were satisfied with the frequency of their office visits (75%). Patients with laryngeal cancer, advanced stage disease, or who underwent multimodality therapy more often desired increased appointment frequency. These patients also rated the burdens of travel cost and overall stress higher, compared to patients desiring visits less often (41.5% vs 28.4%, p = 0.047 and 46.6% vs 38.3%, p = 0.003, respectively). Travel stress was associated with highest overall stress (beta 0.6, CI: 0.4, 0.7). Conclusion The HNC survivor population is uniquely disenfranchised in several social and economic ways. While most patients are satisfied with their follow-up care, a significant subset of patients – those with limited social support, high financial stress, functional deficits, and those with transportation burdens – desire more frequent care. Survivorship care plans should incorporate the perspectives of current survivors.

Background The number of elderly patients with oral squamous cell carcinoma (OCSCC) is increasing as the elderly population increases. Unfortunately, evidence to guide the management of these patients is lacking. Methods Patients with OCSCC identified from the National Cancer Database (NCDB) were stratified into age-based cohorts. Demographics, comorbidities, and treatment patterns were analyzed. Patients were stratified into early stage (Stage I/II) and advanced stage (Stage III/IV) disease. The likelihood of receiving multimodality therapy by age was calculated using multinomial logistic regression for each stratum while controlling for potential confounders. Cox proportional hazard regression was used to calculate 5-year mortality risk while controlling for potential confounders. Results Surgery alone or palliative options were offered to older patients more frequently. After controlling for confounders, older patients were less likely to receive multimodality therapy for both early stage and advanced stage disease. Patients with advanced disease across all age cohorts had improved 5-year survival with surgery and adjuvant therapy. Conclusion Our analyses suggest that elderly patients have unique demographic and pathologic features. They frequently receive less treatment than similarly staged younger patients, yet they benefit from multimodality therapy when feasible. These data suggest an urgent need to critically appraise the care of elderly OCSCC patients within the broader context of their individual comorbidity burden, functional status, and treatment goals.

IMPORTANCE: Guidelines for many head and neck cancers, especially laryngeal cancers, allow for multiple treatment options. Currently, inequitable provision of surgery may contribute to outcome disparities. However, the role of geospatial factors remains understudied. OBJECTIVE: To assess the association between US geospatial factors and treatment selection for patients with laryngeal cancer. DESIGN, SETTING, AND PARTICIPANTS: In this retrospective cohort study, patients diagnosed with laryngeal squamous cell carcinoma between January 1, 2004, and December 31, 2014, were identified from the Surveillance, Epidemiology, and End Results database. Adjusted odds ratios (aORs) for surgical treatment were generated from multivariable, hierarchical models to assess associations with oncologic, demographic, and county variables. Outlier US counties with the highest and lowest aORs were described. Data analysis was performed from April 29 to September 11, 2020. EXPOSURES: County of residence. MAIN OUTCOMES AND MEASURES: The aORs for surgical treatment were generated from multivariable, hierarchical models. Outlier counties with the highest and lowest aORs are described. RESULTS: The cohort includes 21 289 patients (mean [SD] age, 63.6 [11.2] years; 17 214 [80.9%] male) in 598 counties. Most counties had no otolaryngologist (365 [61.0%]) or radiation oncologist (434 [72.6%]). Surgery rates varied from 7.1% to 85.7% among counties with at least 10 cases. After oncologic variables were controlled for, factors independently associated with surgical treatment included patient age (aOR [95% CI], 0.94; 0.91-0.98 per 10 years), marital status (single versus married: aOR [95% CI], 0.87 [0.79-0.97]), and county social deprivation index (aOR [95% CI], 0.98 [0.97-1.00 per 5 points]) but not physician number (≥2 otolaryngologists: aOR [95% CI], 0.91 [0.75-1.11] vs ≥1 radiation oncologist: aOR [95% CI], 0.91; 0.75-1.11). The 5% of counties most likely to provide surgery (aOR, >1.23) were nearly all large metropolitan areas (2593 patients [93.3%]) and treated a disproportionately large number of patients (2778 [13.1%]). The 5% of counties least likely to provide surgery (aOR

To determine differences in oropharyngeal squamous cell carcinoma (OPSCC) incidence between 1975 and 2014 stratified by race, sex, and age.We obtained age-adjusted OPSCC incidence rates for race and sex groups from 1975 to 2014 using the Surveillance, Epidemiology, and End Results 9 database. We defined OPSCC as cancers of the base of tongue, lingual/palatine tonsil, oropharynx, soft palate, uvula, and Waldeyer's ring. We used Joinpoint analyses to determine incidence trends for race/sex/age groupings.There were 38,624 oropharyngeal primary tumors in the analyses. Males accounted for 74% of sample population, and whites accounted for 84% of tumors. Overall, there was a 57.3% increase in incidence of oropharyngeal between 1975 and 2014. For blacks and whites, average incidence was lower for females than males. Rates for black males aged ≥50years was highest for most of the follow-up time but decreased sharply around 1988 and were surpassed by the significant increase in incidence in white males aged 50-59 (1995-2014 APC=4.07, p0.001) and ≥60years (2002-2014 APC=4.25, p0.001). For males aged ≥60, whites had higher rates than blacks starting in 2010. OPSCC incidence in White males (10.99 per 100,000 person-years) surpassed rates in Blacks (10.14 per 100,000 person-years) beginning in 2008.OPSCC has significantly increased in the United States in the last 40 years. This overall increase in OPSCC can primarily be attributed to white males. OPSCC prevention and early detection efforts could target these demographic factors to decrease rising OPSCC incidence.

Purpose/objectives The increasing survivorship of head and neck squamous cell carcinoma (HNSCC) comes with a risk of death from other causes, known as competing causes. The demographics of HNSCC are also evolving with increasing incidence of Human Papillomavirus (HPV) associated tumors. This study describes competing causes of death for the HNSCC population compared to the general population and identifies associated risk factors. Methods Adult patients with first mucosal HNSCC (2004–2011) were identified from the Surveillance, Epidemiology and End Result database. Competing causes of death were compared to reference populations using proportion of deaths and Standardized Mortality Ratios (SMR). A multivariable competing risk survival analysis yielded subdistribution hazard ratios (HR) for competing mortality. Results Of 64,598 HNSCC patients, 24,602 (38.1%) were deceased including 7142 deaths (29.0%) from competing causes. The most common were cardiovascular disease, lung cancer, and other cancers. All relative mortality rates were elevated, especially liver disease (SMR 38.7; 95% CI: 29.4–49.3), suicide (SMR 37.1; 95% CI: 26.1–48.6), and subsequent primary cancers (SMR 7.5; 95% CI: 6.78–8.32). Demographic and tumor factors independently increased risk of competing mortality, including age (HR per 5 years 1.24; 95% CI: 1.22–1.25), sex (male HR 1.23; 95% CI: 1.16–1.32), race (Black HR 1.17; 95% CI: 1.09–1.26), insurance (uninsured HR 1.28; 95% CI: 1.09–1.50), and marital status (single HR 1.29; 95% CI: 1.21–1.37). Conclusion Nearly one in three HNSCC patients died from competing causes. When developing long term survivorship regimens for HNSCC patients, clinicians should be familiar with this population’s specific risks.

Skin grafts offer a dynamic repair option for nasal defects of appropriate size, depth, and location. Granulation and grafting can successfully be used as stand-alone reconstructive options or in conjunction with flap repair. This article reviews suitable indications for graft and granulation use in nasal repair to achieve optimum functional and esthetic outcomes.

Importance Head and neck cancer (HNC) is more common among socioeconomically disenfranchised individuals, making financial burden particularly relevant. Objective To assess the financial burdens of HNC compared with other cancers. Design, Setting, and Participants In this retrospective review of nationally representative, publicly available survey, data from the Medical Expenditure Panel Survey were extracted from January 1, 1998, to December 31, 2015. A total of 444 867 adults were surveyed, which extrapolates to a population of 221 503 108 based on the weighted survey design. Data analysis was performed from April 18, 2018, to August 20, 2018. Exposures Of 16 771 patients with cancer surveyed (weighted count of 10 083 586 patients), 489 reported HNC (weighted count of 261 631). Main Outcomes and Measures Patients with HNC were compared with patients with other cancers on demographics, income, employment, and health. Within the HNC group, risk factors for total medical expenses and relative out-of-pocket expenses were assessed with regression modeling. Complex sampling methods were accounted for with weighting using balanced repeated replication. Results A total of 16 771 patients (mean [SD] age, 62.3 [18.9] years; 9006 [53.7%] female) with cancer were studied. Compared with patients with other cancers, patients with HNC were more often members of a minority race/ethnicity, male, poor, publicly insured, and less educated, with lower general and mental health status. Median annual medical expenses ($8384 vs $5978; difference, $2406; 95% CI, $795-$4017) and relative out-of-pocket expenses (3.93% vs 3.07%; difference, 0.86%; 95% CI, 0.06%-1.66%) were higher for patients with HNC than for patients with other cancers. Among patients with HNC, median expenses were lower for Asian individuals compared with white individuals ($5359 vs $10 078; difference, $4719; 95% CI, $1481-$7956]), Westerners ($8094) and Midwesterners ($5656) compared with Northwesterners ($10 549), and those with better health status ($16 990 for those with poor health vs $6714 for those with excellent health). Higher relative out-of-pocket expenses were associated with unemployment (5.13% for employed patients vs 2.35% for unemployed patients; difference, 2.78%; 95% CI, 0.6%-4.95%), public insurance (5.35% for those with public insurance vs 2.87% for those with private insurance; difference, 2.48%; 95% CI, −0.6% to 5.55%), poverty (13.07% for poor patients vs 2.06% for high-income patients), and lower health status (10.2% for those with poor health vs 1.58% for those with excellent health). Conclusions and Relevance According to this study, HNC adds a substantial, additional burden to an already financially strained population in the form of higher total and relative expenses. The financial strain on individuals, assessed as relative out-of-pocket expenses, appears to be driven more by income than by health factors, and health insurance does not appear to be protective.

Objective: The last three decades in the United States have seen oropharyngeal cancer emerge as an important human papillomavirus (HPV)-associated cancer, with about three-quarters of cases thought to be positive for HPV. It has dramatically increased in incidence and recently surpassed cervical cancer as the leading HPV-associated cancer. While positive HPV tumor status generally portends better survival probability compared with non-HPV related head and neck cancer, there is a paucity of data describing mortality trends. This study aimed to describe trends in oropharyngeal cancer incidence-based mortality in the United States in the last three decades. Methods: We estimated age-adjusted incidence-based mortality rates (AAMR) from first primary oropharyngeal squamous cell carcinoma (OPSCC), using the Surveillance, Epidemiology, and End Results (SEER) 9 database from 1985-2016. To prevent later years from having a cumulatively larger set of patients diagnosed in the past, we only included OPSCC patients who died within 10 years of diagnosis. AAMRs were stratified by race, sex, and age at death and were presented per 100,000 person-years. Rate ratios (RRs) determined which groups had significantly different AAMRs, and Joinpoint regression calculated which groups had significant increases/decreases in annual AAMRs over time through annual percentage changes (APCs) and average APCs (AAPCs). We used 95% confidence intervals (CIs) to determine significant RRs, APCs, and AAPCs. Results: This study included 12,102 patients who died from first primary OPSCC from 1985-2016 with an AAMR of 1.16 per 100,000 person-years. AAMRs among males were 3.58 times higher than for females (RR = 3.58, 95% CI 3.43, 3.73). AAMRs among blacks were about 2 times higher than for whites (RR = 2.06, 95% CI 1.96, 2.16) but were about 60% lower for other race than whites (RR = 0.37, 95% CI 0.34, 0.42). From 1985-2009, AAMRs for first primary OPSCC decreased approximately 1.92% annually (APC = -1.92, 95% CI -2.27, -1.56) but remained stable from 2009-2016, which resulted in an average annual decrease of -1.31% from 1985-2016 (AAPC = -1.31, 95% CI -1.84, -0.78). When stratified by race or sex, all groups exhibited significant mortality rates decrease, however decrease was significantly greater among whites than blacks (white AAPC1985-2016 = -0.76; 95% CI -1.33, -0.17 vs black AAPC1985-2016 = -3.36; 95% CI -3.85, -2.87). AAMRs significantly decreased among 65+ year olds (AAPC = -0.88, 95% CI -1.63, -0.13), while AAMRs for 15-39 and 40-64-year olds exhibited non-significant decreases. Conclusions: While there has been significant decrease in oropharyngeal cancer mortality in the last three decades in the United States across age groups, races/ethnicity, and gender, there remained a significant mortality gap between blacks and whites, highlighting the persistent cancer-related disparity in the United States. Citation Format: Nosayaba Osazuwa-Peters, Matthew C Simpson, Sean T Massa, Eric Adjei Boakye, Kara M Christopher, Sai D Challapalli, Katherine M Polednik, Haley N Bray, Greg M Ward, Mark A Varvares. Oropharyngeal cancer incidence-based mortality trends in the United States, 1985-2016 [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr D128.

To determine whether the impact of marital status on head and neck cancer (HNC) outcomes vary by gender.The Surveillance, Epidemiology, and End Results 18 database from 2007 to 2014 was queried for eligible cases of HNC (n = 71,799). An interaction term (gender*marital status) was tested for each outcome of interest (cancer-specific survival, stage of presentation, adequate treatment), and when significant (p 0.05), the model was stratified by gender. A competing risks proportional hazards (subdistribution [sd]) model estimated the interaction effect on cancer-specific survival. Logistic regression estimated effect on stage of presentation and treatment type.There was significant gender*marital status interaction for cancer-specific survival and stage of presentation. While married/partnered patients had the highest survival among both genders, males benefitted more: widowed (male sdHR = 1.41, 95% CI 1.31, 1.52; female sdHR = 1.15, 95% CI 1.06, 1.26), divorced/separated (males: sdHR = 1.39, 95% CI 1.32, 1.46; females: sdHR = 1.17, 95% CI 1.06, 1.28), or never married (males: sdHR = 1.42, 95% CI 1.36, 1.49; females: sdHR = 1.15, 95% CI 1.05, 1.26). When stratified by oropharyngeal cancer vs. non-oropharyngeal HNC, unmarried males had 50-60% increased hazard of death, while no difference was found for females. Unmarried males also had greater odds of presenting with late-stage disease compared with females. No gender*marital status interaction was observed for adequate treatment, although married/partnered survivors had greater odds of receiving adequate treatment.While there are survival benefits for married patients with HNC, married/partnered males, especially those with oropharyngeal cancer, may benefit more than females.

Head and neck squamous cell carcinoma (HNSCC) prognosis strongly correlates with demographic factors. This study aimed to determine whether demographic predictors of HNSCC survival differ between age cohorts, with an emphasis on the growing elderly demographic.Outcomes research.Adults with squamous cell carcinoma of the upper aerodigestive tract were identified from the Surveillance, Epidemiology and End Results 18 database. Demographic and oncologic factors were compared between three age groups: 18 to 49, 50 to 74, and75 years. Factors associated with cancer-specific survival were assessed in each cohort using subdistribution hazard ratio (sHR) and 95% confidence interval (CI) produced by multivariate competing risk models.A cohort of 69,098 patients included 10,588 (15.3%) 75 years or older and 9,882 (14.3%) less than 50 years old. Older patients were more often female (35.4% vs. 25.1% aged 18-49 years and 20.4% aged 50-74 years), white (78.7% vs. 69.4% and 75.9%), insured (63.5% vs. 46.5% and 56.8%), and married (56.6% vs. 53% and 51.1%), but received adequate treatment less often (72.0% vs. 86.3% and 82.7%). In the older cohort, male sex was associated with lower mortality (sHR: 0.92, 95% CI: 0.85-1.00), and unlike the younger cohorts, black race was no longer associated with mortality (sHR: 1.07, 95% CI: 0.94-1.22). Marriage was associated with lower mortality in all age groups but with diminishing effects (single sHR: young 1.52, middle 1.31, older 1.14).Elderly HNSCC patients have distinct effects from demographic prognostic factors and should be considered a separate subgroup with unique epidemiology, risks, and preferences.2c Laryngoscope, , 129:146-153, 2018.

Chronic nasal obstruction is common and is often attributable to nasal valve obstruction. Functional rhinoplasty consists of a group of techniques aimed to relieve nasal valve obstruction. Symptom improvement can be reliably achieved using traditional grafting techniques; however, symptoms persist in a subset of patients. Novel evaluation tools strive to improve patient selection for specific treatments. Concurrently, emerging techniques have built on the success of traditional functional rhinoplasty. The overlap between functional and aesthetic rhinoplasty continues to blur. With functional implications of aesthetic surgery now well established, the cosmetic impact of functionally oriented surgery is increasingly recognized.

Background Many studies have demonstrated the advantage of postoperative concurrent chemoradiotherapy (CRT) over radiotherapy (RT) alone in locoregional control, but few have examined overall survival with respect to national databases. Methods The literature was searched for eligible randomized controlled trials. The Surveillance, Epidemiology, and End Results (SEER) Database and National Cancer Data Base (NCDB) were searched for 5-year overall survival data. Results Twenty-eight studies were examined and demonstrated 44% greater locoregional control (relative risk [RR] = 0.56; 95% confidence interval [CI] = 0.46–0.68) and 12% overall survival benefit (RR = 0.88; 95% CI = 0.81–0.98) with postoperative adjuvant CRT compared to adjuvant RT. Overall SEER survival was 45.0% in 1973, rising to 53.2% in 2005. The NCDB documents a similar increase in overall survival from 45.5% in 1994 to 53.4% in 2005. Conclusion The literature shows mortality benefit of adjuvant CRT in patients with advanced head and neck cancer, reflected in SEER and NCDB. © 2015 Wiley Periodicals, Inc. Head Neck 38: 208–215, 2016

Objective To determine whether marital status independently predicts survival in a head and neck cancer (HNC) survivor population. Methods In this retrospective cohort study, we analysed data from 460 adult patients (59.31 ± 11.42) years diagnosed with HNC at an academic tertiary referral centre between 1997 and 2012. Cox proportional hazards model estimated the effect of marital status on survival. Results Our study had 73% men, and 82.2% were Whites. We found an association between marital status and HNC survival. Unmarried HNC patients had a 66% increase in hazard of death compared to married patients (aHR = 1.66, 95% CI = 1.23-2.23). This was after controlling for sociodemographic variables (age, race, sex and health insurance status), social habits (tobacco and alcohol), primary anatomical subsite (oral cavity, oropharyngeal, laryngeal and others), stage at presentation (early vs. late stage) and treatment modality (surgery, surgery with adjuvant therapies, other single modality therapy and palliative care). Conclusions Being married confers survival advantage for HNC survivors. Our finding underscores the need to recognise this aspect of survivorship. Social support should be considered part of standard care for managing HNC. There may also be need to develop other support mechanisms, especially for unmarried HNC survivors.

Objective Survival of advanced laryngeal cancer is declining while the popularity of organ preservation protocols grows. This study assesses the survival impact of refusing surgical treatment for locally advanced, resectable laryngeal cancer. Methods Adult patients with T3 and T4a non-metastatic laryngeal squamous cell carcinoma were identified from the Surveillance, Epidemiology and End Results 18 database from 2004 to 2013. Patients were stratified based on a recommendation for extirpative surgery and the refusal of surgery. Multivariate logistic regression modeling identified variables associated with refusal. A multivariate cox proportional hazard model produced adjusted Kaplan-Meier survival curves. Survival was compared using adjusted hazard ratios (aHR) with 95% confidence intervals (CI). Results Of 5786 patients in the study, 2877 were recommended for surgical treatment and 138 (4.8%) refused. Refusal of surgery was associated with unmarried status (Single, odds ratio (OR) 1.79, CI 1.10–2.92), black race (OR 1.50, CI 1.00–2.22), T3 tumors (OR 1.80, CI 1.26–2.61) and N3 nodal disease (OR 3.50, CI 1.24–8.48). Compared to patients undergoing surgery, those who refused had lower 5-year cancer specific survival and increased hazard of cancer-specific mortality (aHR 1.60, CI 1.24–2.07) which resulted in decreased 5-year survival (50.0 vs 60.1%), after controlling for other factors. Conclusion Refusal of surgery for locally advanced laryngeal cancer is more common in patients without marital support and with T3 tumors. This decision results in a 10% survival decrease at 5-year. Future study is needed to understand patients’ reasoning behind this decision and to investigate additional factors not available in this dataset.

To determine the safety, efficacy, and potential for hearing preservation of an electroacoustic hearing system in patients with severe high-frequency and moderate low-frequency hearing loss.Five patients were included in this study with steeply down-sloping sensorineural hearing loss. All patients had a history of hearing aid use and similar hearing in the contralateral ear. Ages ranged from 48 to 69 years.All participants were implanted with an electro-acoustic stimulation (EAS) device using a hearing preservation technique. This device integrates electric and acoustic stimulation into a single processor for simultaneous ipsilateral bimodal stimulation.Pure-tone audiograms (PTA) and speech reception thresholds (SRTs) during preoperative evaluation; initial cochlear implant (CI) stimulation; initial EAS stimulation; and at 3, 6, and 12 months poststimulation. Consonant-Nucleus-Consonant (CNC) monosyllables preoperatively and at 3, 6, and 12 months poststimulation.All participants showed preserved hearing in the surgical ear after implantation as measured by PTA and SRT. Significant improvement in speech recognition testing over hearing aid was observed at 3 months with EAS versus 6 months with CI-only stimulation. Facial stimulation occurred in 1 patient and resolved after reprogramming.There were no significant complications in this cohort of patients. Adequate hearing preservation was achieved. EAS and CI aided conditions both showed significant improvement over hearing aid with EAS condition achieving significance sooner.

Aside from cancer mortality, patients with head and neck cancer have increased mortality risk. Identifying patients with the greatest loss of cancer-independent life expectancy can guide comprehensive survivorship programs.Age-based survival data from the Surveillance, Epidemiology, and End Result (SEER) database for patients with head and neck cancer were censored for mortality from the index cancer. Life expectancy and years of life lost (YLL) referenced to the general population were calculated. Cox proportional regression models produced hazard ratios (HRs).Cancer-independent life expectancy for patients with head and neck cancer is 6.5 years shorter than expected. The greatest hazard and impact of other-cause mortality was associated with black race (HR 1.23; YLL 8.55), stage IV (HR 1.60; YLL 7.92), Medicaid (HR 1.55; YLL 12.9), and previous marriage (HR 1.49; YLL 11.4).Patients with head and neck cancer lives are foreshortened independent of their cancer diagnosis necessitating management of noncancer mortality to maximize overall survival.

Introduction: Among the known nonclinical prognostic factors for head and neck squamous cell carcinoma (HNSCC) survivorship, there has been recent focus on the potential benefits of being married. Several studies have shown that marriage confers a survival advantage for HNSCC patients. However, anecdotal evidence suggests that there may be marked differences in this survival benefit based on the sex of the patient. To date, no study has described how sex differences influence head and neck cancer survivorship based on marital status. Our study aimed to determine whether marital status at diagnosis impacts survivorship of HNSCC differently based on sex. Methods: In this retrospective study, we utilized a patient cohort of 27,208 confirmed HNSCC cases from the Surveillance, Epidemiology, and End Results (SEER) 18 database (2004–2014) who received chemotherapy and radiotherapy. Actuarial survival curves stratified by marital status at diagnosis (married/partnered, never married, divorced/separated, widowed) indicated cancer-specific survival from HNSCC. Survival differences between marital status groups were first assessed by log-rank tests with Bonferroni adjustments. Second, patients' demographic and clinical characteristics including sex, marital status, race/ethnicity, insurance status, HNSCC site, stage, age at diagnosis, year of diagnosis, and county-level poverty were utilized in Fine and Gray competing risk proportional hazard models to examine the potential interaction between sex and marital status and estimate adjusted hazard ratios (aHR) for death from HNSCC. Results: The cohort was mostly men (80.8%) and married/partnered (56.5%). Married/partnered patients had the best survival of any marital status group (log-rank and Bonferroni p < 0.001). The initial Fine and Gray model controlling for covariates indicated a significant interaction between sex and marital status (p < 0.05), with married women having a 13% increased hazard of death compared to married men (aHR=1.13, 95% CI: 1.04, 1.24). Final Fine and Gray models stratified by sex showed that widowed women had an increased hazard of death compared to married/partnered women (aHR=1.19, 95% CI: 1.03, 1.38), while there was no statistically significant survival difference between married and unmarried women. For men, patients who were unmarried (aHR=1.37, 95% CI: 1.27, 1.46), widowed (aHR=1.36, 95% CI: 1.20, 1.54), or divorced/separated (aHR=1.30, 95% CI: 1.21, 1.39) had an increased hazard of HNSCC death compared to men who were married/partnered at the time of diagnosis. Racial disparities persisted irrespective of marital status; non-Hispanic black women had higher hazards of HNSCC death compared with non-Hispanic white women (aHR=1.29, 95% CI: 1.12, 1.48). Hispanic men (aHR=1.12, 95% CI: 1.02, 1.23) and non-Hispanic black men (aHR =1.27, 95% CI: 1.17, 1.37) had a higher hazard of HNSCC death compared with non-Hispanic white men. Conclusions: Our study has shown for the first time in the head and neck cancer literature that while being married confers survival benefits in general, married men with HNSCC may benefit more than women. Unmarried men seemed to fare the worst compared with every marital status for both men and women. More research is needed to understand this differential marital status benefit based on sex. Additionally, efforts should focus on developing analogous support systems for men and women who are head and neck cancer patients that could improve their survival, especially unmarried men and widowed men and women. Citation Format: Nosayaba Osazuwa-Peters, Matthew C. Simpson, Lauren M. Cass, Sai Deepika Challapalli, Zisansha S. Zahirsha, Eric Adjei Boakye, Sean T. Massa. Which head and neck cancer patient benefits from being married: The man or the woman? [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr A87.

Background: The United States population is aging, and cancer is the second most common cause of death in the elderly. Head and neck squamous cell carcinoma (HNSCC) incidence is increasing and contributes 2.2% of all cancer mortality. HNSCC research often excludes elderly patients due to disqualifying comorbidities, similar to many cancer sites. These patients also may not receive adequate therapy due to age despite evidence of equal survival after controlling for comorbidities. Beyond oncologic variables, demographic factors have been shown to impact HNSCC survival, including age, socioeconomic status, race, sex, poverty, insurance, and marriage. Whether these associations are maintained in elderly patients is unknown. This study aims to compare demographic predictors of HNSCC survival between age cohorts. Methods: Adult patients with squamous cell carcinoma of mucosal head and neck sites were selected from the Surveillance, Epidemiology and End Result database from 2004 to 2013. Patients were excluded with previous malignancies or missing data for follow-up, marital status, and surgical treatment. Demographic and tumor data were collected, including site, stage, treatment, age, race, sex, insurance, and median county-level income. Patients were divided into three age cohorts: younger (18-49 years), middle (50-74 years), and older (>75 years). Cohorts were compared with two-tailed chi-squared and ANOVA tests as appropriate with p < 0.05 considered significant. Previously identified predictors of HNSCC survival were assessed in each cohort using multivariate Fine and Gray competing risk models controlled for oncologic variables. Subdistribution hazard ratios (sHR) with 95% confidence intervals (CI) are reported. Sensitivity analyses were performed by (1) excluding inadequately treated patients, (2) removing adjuvant therapies from the model, and (3) varying the cutoff between age cohorts. Inadequate treatment was considered less than 1 modality for stage I-II or less than 2 modalities for stage III-IV. Results: The study cohort consisted of 69,098 patients with a majority white (75.4%), male (76.7%), married (55.2%), and insured (56.3%). The median age at diagnosis was 61.7 years with 14.3% below 50 years and 15.3% 75 years or above. Compared to the young and middle-aged cohorts, the older cohort was significantly more often female (35% vs 25.1 and 20.4%), white (78.7% vs 69.4 and 75.9%), and insured (63.5% vs 46.5% and 56.8%), but received adequate treatment less often (72.0% vs 86.3% and 82.7%) (p < 0.001 for all). In the survival models, several demographic factors showed different effects on cancer survival between age cohorts. Male sex was associated with lower mortality in the older group (sHR 0.92, CI 0.85-1.00), but not in other cohorts. In the young and middle-aged cohort, Black race was associated with increased mortality (sHR 1.43 and 1.23, CI 1.27-1.60 and 1.17-1.30, respectively), but this is not found in the older cohort (sHR 1.07, CI 0.94-1.22). In all cohorts, single marital status was associated with higher mortality, but the effect was greatest in the younger cohort (sHR 1.52, CI 1.37-1.68) and least in the oldest cohort (sHR 1.14, CI 1.01-1.28). These effects were preserved in the sensitivity analyses and with varying the age cutoff between middle and older cohorts as low as 65 years. Conclusion: A substantial proportion of HNSCC patients are elderly. These patients are less often treated with adequate curative therapy and differ demographically from their younger peers. Uniquely in the older HNSCC patients, female sex is a risk factor for cancer mortality, while the impact of race and marital status was reduced compared to the younger cohorts. While future research investigates the mechanisms by which demographics affect survival, the differences between age cohorts must be considered. Citation Format: Sean T. Massa, Lauren Cass, Sai Challapalli, Zisansha Zahirsha, Matt Simpson, Nosayaba Osazuwa-Peters, Gregory Ward. Age differences in demographic predictors of head and neck cancer survival [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr A88.

Introduction: Although there are currently more than 430,000 head and neck cancer (HNC) survivors in the United States, it is accepted that many more patients would have survived longer if they presented at an earlier stage. Less than half of all head and neck cancer patients present with early-stage disease. One of the factors implicated in late stage of presentation for head and neck cancer patients is access to care, driven by health insurance status. While individuals with health insurance are known to present earlier, less is known about outcome differences for patients who are uninsured or who have Medicaid insurance. We have observed many head and neck cancer patients initially present without insurance despite qualifying for Medicaid, and so are assisted with obtaining insurance before discharge. This process blurs the line between uninsured and Medicaid patients. The aim of this study was to determine whether there are disparities in survival outcomes for HNC patients based on whether they are insured, uninsured, or have Medicaid insurance. Methods: A cohort of 49,524 patients aged 18-64 years with first primary HNC from the Surveillance, Epidemiology, and End Results (SEER) 18 database diagnosed from 2007-2014 was included. Actuarial survival curves stratified by insurance status (insured, Medicaid, and uninsured) were created to determine HNC-specific survival differences between the groups with a log-rank test. Patient characteristics including insurance, race/ethnicity, sex, county-level poverty, surgery, marital status, tumor site, stage, year of diagnosis, and age at diagnosis were utilized in a Fine and Gray competing risk proportional hazard model to compute adjusted hazard ratios (aHR) for cause-specific death from HNC. Multinomial logistic regression was also performed to determine characteristics of patients with each type of insurance by adjusted odds ratios (aOR). Results: The cohort was mostly male (75.6%) and insured (73.6%), with 18.6% on Medicaid and 7.8% uninsured. At the end of the 7-year follow-up period, HNC-specific survival rate was significantly lower for patients on Medicaid (49.5%) than uninsured (54.8%) and insured patients (74.2%) (log-rank p < 0.001). After controlling for other prognostic demographic and clinical factors, patients on Medicaid (aHR=1.63, 95% CI: 1.54, 1.71) and uninsured patients (aHR=1.33, 95% CI: 1.43, 1.64) had higher hazard of death from HNC compared to insured patients. Compared with non-Hispanic whites, other race/ethnicity groups were more likely to be on Medicaid, with non-Hispanic American Indians/Alaska Natives being the most likely (aOR=3.46, 95% CI: 2.66, 4.51). Medicaid were more likely not have received surgery than insured patients (aOR=1.34, 95% CI: 1.26, 1.42). They were also more likely to present at advanced disease. Conclusion: While patients with health insurance had better survival outcome in general, our study showed that patients with Medicaid did not have a better survival outcome than those without any insurance after adjusting for all other prognostic factors, including stage of presentation and treatment modality. Medicaid patients, in fact, had worse outcome than uninsured HNC patients. It could be that despite having insurance, Medicaid patients did not have adequate access to care and thus had delayed presentations. Our findings highlight the need to bridge the health insurance gap for HNC patients to increase survivorship. Citation Format: Nosayaba Osazuwa-Peters, Matthew C. Simpson, Sean T. Massa, Eric Adjei Boakye, Lauren M. Cass, Sai Deepika Challapalli, Rebecca L. Rohde, Mark A. Varvares. Survival outcomes for head and neck patients with Medicaid: A health insurance paradox [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr C54.