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 age-adjusted 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.
Highlights
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
We have evaluated the relative survival (RS) of all HNSCC in the majority of Appalachian states from 2007–2013 and have identified an outcome disparity in white males with oropharynx cancers that corresponds with elevated smoking and smokeless tobacco use in the region
No significant difference was found in CRS between non-human papillomavirus (HPV)-associated patients in Appalachian counties (n = 1,577/33,281; CRS = 29.5%) compared to non-HPV-associated patients in non-Appalachian states (n = 7,856/33,281; CRS = 30.9%). These results suggest that the stage IV white Appalachian male OC/P survival disparity is driven by lower survival of HPV-associated oropharyngeal patients
Summary
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. The survival disparity was confined to human papillomavirus (HPV)-associated oropharyngeal cancers, 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. The region is over 80% white, with several states having higher percentages of oral and other HPV-associated cancers, and higher smoking and smokeless tobacco use[17,18,19]. We have evaluated the RS of all HNSCC in the majority of Appalachian states from 2007–2013 and have identified an outcome disparity in white males with oropharynx cancers that corresponds with elevated smoking and smokeless tobacco use in the region
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