Elsevier

Oral Oncology

Volume 65, February 2017, Pages 8-15
Oral Oncology

Competing causes of death in the head and neck cancer population

https://doi.org/10.1016/j.oraloncology.2016.12.006Get rights and content

Highlights

  • Analysis of causes of death other than the primary cancer.

  • Mortality rates for all causes are greatly elevated.

  • Demographic and tumor factors modify the risk of death from competing causes.

Abstract

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.

Section snippets

Background

It is estimated that 61,760 individuals will be diagnosed with head and neck squamous cell carcinoma (HNSCC) in the United States in 2016, and 13,190 will die from this disease [1]. In addition to death from HNSCC itself, these patients are at risk of dying from other causes. These alternative etiologies are referred to as competing causes, with associated risk factors termed competing risks, because they compete with the cancer itself to cause death [2], [3], [4]. This has become even more

Data source

Patients were identified from the publicly available Surveillance, Epidemiology, and End Results (SEER) 13 database (http://seer.cancer.gov/data/access.html) [22]. This database is the largest and most comprehensive available in SEER for standardized mortality ratio (SMR) analysis. SEER 13 covered 13.4% of the United States’ population from 1992 to 2011 [23]. HNSCC patients were defined as adults aged ⩾20 years diagnosed from 2004 to 2011 with primary squamous cell carcinoma of upper

Results

A total of 64,598 HNSCC patients met the study criteria. These individuals had a mean age of 62 years (SD: 12.0) and included 24,602 (38.1%) deceased individuals. Median follow up was 2.1 years (SD: 2.4). Deaths included 17,460 (71.0%) attributed to the primary HNSCC and 7142 (29.0%) due to competing causes. The cohort was predominately White (83.0%) and male (76.4%). The majority of tumors were located in the oral cavity (40.9%), larynx (28.9%), and oropharynx (19.3%). Compared to living

Discussion

The purpose of this study was to describe the competing causes of mortality in HNSCC patients, compare them to the general population, and identify risk factors associated with death from these competing causes. Previously, the most common causes of competing mortality for HNSCC patients were reported as cardiovascular, pulmonary and secondary cancers [11], [21]. These previous studies focused on selected competing causes without a detailed analysis of mortality rates. Additionally, Baxi et al.

Conclusion

Traditionally HNSCC care, led by a Head and Neck Surgeon, focuses on cancer treatment and complication management which may neglect patients' comorbid diseases. As HNSCC survival improves, addressing potentially preventable competing causes of death, particularly liver disease and suicide, becomes increasingly important. Increasing comorbidity management and preventive healthcare presents an opportunity to improve overall care and survivorship for HNSCC patients.

Conflictions of interest statement

The authors have no conflicts of interest to disclose.

Disclosures

LD Arnold owns stock in Pfeizer, Inc and Merck & Co, Inc. All remaining authors have declared no conflicts of interest.

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