Differences in Survival Outcomes among Racial Minorities with Head and Neck Cancer

Abstract

<h3>Purpose/Objective(s)</h3> While disparities in patient outcomes for head and neck squamous cell carcinoma (HNSCC) have been documented, the specific drivers of inferior outcomes among racial/ethnic (R/E) minorities remain poorly understood. Our objective was to identify the defining prognostic factors for survival outcomes among R/E minority HNSCC patients in the United States. <h3>Materials/Methods</h3> We identified HNSCC patients of all the major mucosal head and neck subsites treated with surgery, radiation, chemotherapy or a combination of modalities between 2004-2016 using the National Cancer Database (NCDB). Patient outcomes were stratified by R/E groups including White, Black, Hispanic, Native American/Other, and Asian. Covariates analyzed include ethnicity, race, insurance type, income, age, sex, stage, cancer site, co-morbidity status, treatment modality, and HPV status. Kaplan Meier analysis and log-rank test were used to estimate overall survival (OS) outcomes between strata. Cox proportional hazard regression models were used to assess the association between co-variates and risk of death. <h3>Results</h3> 311,032 HNSCC patients were treated between 2004-2016, of which 269,166 (86.5%) were White, 32,871 (10.5%) were Black, 6,285 (2%) were Asian, and 2,710 (0.8%) were Native American. By ethnicity, 12,379 (4%) were Hispanic. Compared to White HNSCC patients, Black patients were more likely to have Medicaid insurance (22% vs 8%, p<0.001), lower income (<30,000, 42% vs 13%, p<0.0001), Stage IV disease (39% vs 29%, p<0.0001), less likely to be treated with surgery (26% vs 15%, p<0.0001), and had a higher proportion of HPV negative oropharyngeal carcinoma (18% vs 21%, p<0.0001). Among patients treated with surgery, Black patients had a longer time to initiation of adjuvant RT compared to White patients (mean 58 vs 53 days, p<0.0001). Among all patients, 5-year OS for White, Black, Hispanic, Native American/Other, and Asian was 50.8%, 38.5%, 51.5%, 51.2%, and 57.2%, respectively (log rank, p<0.0001). Black patients had an inferior 5-year OS for the majority of HNSCC subsites, including the oral cavity, hypopharynx, larynx, nasal cavity, and oropharynx (all log-rank p<0.0001). Even among favorable HPV positive oropharynx cancer patients, Black patients had a significantly inferior OS compared to White patients (log-rank, p<0.0001). On multivariable analysis, Black patients had a higher mortality (HR:1.09, 95% CI, 1.02-1.155, P=0.003) after adjusting for income, insurance type, co-morbidity status, treatment modality, clinical stage, and HPV status. <h3>Conclusion</h3> This large cohort of HNSCC patients demonstrates that Black race is independently associated with worse OS. Efforts should be made to reduce clinical and non-clinical factors in racial minorities to further narrow the survival gaps in HNSCC. Further work is needed to better understand the biological basis for the worse outcomes seen after accounting for social determinants of health.