Effect of socioeconomic status on survival in patients with head and neck cancer

Machine learning explainability for survival outcome in head and neck squamous cell carcinoma

BACKGROUND

Diagnosis and treatment of head and neck squamous cell carcinoma (HNSCC) induces psychological variables and treatment-related toxicity in patients. The evaluation of outcomes is warranted for effective treatment planning and improved disease management.

OBJECTIVES

This study aimed to build a prognostic system by combining clinicopathological parameters, treatment-related factors, and sociodemographic factors as integrative inputs to build a machine learning (ML) model to estimate the overall survival (OS) of patients with HNSCC. Furthermore, we explored the complementary prognostic potentials of these input parameters. We provide explainability and interpretability using Local Interpretable Model-agnostic Explanations (LIME) and SHapley Additive exPlanations (SHAP) techniques.

METHODS

A total of 419 patients with HNSCC were recruited from three University Hospitals in Sweden. We compared the performance of TabNet, a state-of-the-art deep learning algorithm for tabular data, with extreme gradient boosting (XGBoost) and voting ensemble to predict OS in patients with HNSCC.

RESULTS

Both TabNet and XGBoost showed comparable performance accuracies, with TabNet and XGBoost showing a performance accuracy of 88.1% each and voting ensemble showing an accuracy of 88.7%. The aggregate feature importance showed that p16 (a tumor suppressor protein that plays a crucial role in cell cycle regulation), cancer stage, hemoglobin, age at diagnosis, T class, N class, smoking pack-years, body mass index (BMI), treatment modality, erythrocyte count, and human papillomavirus (HPV) status were the most important parameters for the predictive ability of the model for OS. Furthermore, we found survival trends in this cohort by individually considering parameters such as p16, cancer stage, hemoglobin, age at diagnosis, HPV status, Tumor Nodal Metastasis staging, and socioeconomic factors (marital status, housing, and level of education). In addition, both the LIME and SHAP techniques showed the contribution of each feature to the prediction made by the model.

CONCLUSIONS

The clinical implementation of an ML model can lead to individualized risk-based therapeutic decision-making. Therefore, validating these models with multi-institutional datasets and testing them in the context of clinical trials is warranted for safe clinical implementation.

Rurality, Health Care Resource Use, and Care Trajectories in Patients With Head and Neck Cancer

Importance

Head and neck cancer (HNC) epidemiology varies geographically, and rural populations (typically less affluent) may face barriers accessing cancer care, which could lead to worse outcomes.

Objective

To compare health care resource use between patients with HNC living in urban and rural areas.

Design, Setting, and Participants

Retrospective cohort study in Alberta, Canada. Participants were adult patients (aged ≥18 years) diagnosed with HNC with at least 1 year of posttreatment follow-up between January 2012 and September 2020. Data were analyzed from August to September 2024.

Exposure

Rural location of residence at HNC diagnosis, defined using the forward sortation area of the patients' postal code.

Main Outcomes and Measures

The primary outcomes were health care resource use and patient care trajectories, including hospital length of stay, 30-day hospital readmissions, emergency department visits, time from diagnosis to first treatment, first type of practitioner seen after hospital discharge, and most common practitioner-to-practitioner transitions.

Results

The cohort included 2189 patients with a median (IQR) age of 63 (55-71) years, who were mostly men (1557 patients [71.1%]) with stage IV cancer (1149 patients [52.5%]) of the tongue (640 patients [29.2%]), of which 375 (17.1%) lived in a rural area. There was no difference in cumulative hospital length of stay between urban and rural patients; however, male patients living in rural areas had a longer surgical hospital length of stay than male patients living in urban areas (incidence rate ratio, 1.24; 95% CI, 1.03-1.50). Patients living in rural areas had more 30-day hospital readmissions (63 patients [16.8%] vs 183 patients [10.1%]) and emergency department visits (median [IQR], 8 [3-17] vs 4 [2-9]) than their urban counterparts. Time to first treatment was longer in patients living in rural areas compared with patients living in urban areas (median [IQR], 64 [46-95] days vs 57 [40-84] days). Patients living in rural areas without comorbid conditions had greater odds of being discharged directly to the care of a general practitioner after a hospital stay than urban patients (odds ratio, 1.97; 95% CI, 1.23-3.15).

Conclusions and Relevance

In this cohort study of patients with HNC, living in rural areas was associated with higher health care resource use than patients living in urban areas. Recommendations specific to patients with HNC living in rural areas may be warranted given these differences.

Psychological Factors Related to Treatment Outcomes in Head and Neck Cancer

BACKGROUND

Patients with head and neck cancer (HNC) often demonstrate stress, distress, anxiety, depression, and are at risk for suicide. These affect their quality of life (QoL) but less attention has been given to psychological variables that may impact response to treatment.

OBJECTIVES

This study aims to systematically review publications during 2013-2023 to collate evidence on the effects of psychological variables on HNC treatment outcomes.

METHODS

We searched Ovid Medline, PubMed, Scopus, and Web of Science for articles that examined psychological factors related to treatment outcomes in patients with HNC.

RESULTS

There were 29 studies (5 before treatment, 2 during, 17 after, and 5 covering the whole management trajectory) including 362,766 patients. The psychological factors were either behavioral (adjustment and coping strategy, unrealistic ideas, self-blame), cognitive (elevated risk of psychiatric co-comorbidity), or emotional (distress, depression, anxiety, nervousness, and fear of disfigurement and complications). It was found that there was a relationship between depression and decreased survival in patients with HNC. Pretreatment pain was an independent predictor of decreased survival in a large sample of patients. The distress level was approximately  54%, emotional problems ranged between 10 and 44%, while financial difficulties were identified in 54% of the patients. Sixty-nine percent of patients were reported to have used at least one cost-coping strategy within 6 months after treatment initiation. During post-treatment period, depression increased from 15% at the baseline to 29%, while the fear of recurrence was found among at least 35% of patients.

DISCUSSION AND CONCLUSION

Several psychological factors predict QoL and survival among HNC survivors. Distress encompasses depression and anxiety, and physical burden from HNC diagnosis and treatment. Routine screening and early interventions that target distress could improve HNC survivors' QoL. A systematic and standardized measurement approach for QoL is warranted to homogenize these findings and to understand the underlying relationships.

Tumor Cell Stemness and Stromal Cell Features Contribute to Oral Cancer Outcome Disparity in Black Americans

Black Americans (BAs) with head and neck cancer (HNC) have worse survival outcomes compared to the White patients. While HNC disparities in patient outcomes for BAs have been well recognized, the specific drivers of the inferior outcomes remain poorly understood. Here, we investigated the biologic features of patient tumor specimens obtained during the surgical treatment of oral cancers and performed a follow-up study of the patients' post-surgery recurrences and metastases with the aim to explore whether tumor biologic features could be associated with the poorer outcomes among BA patients compared with White American (WA) patients. We examined the tumor stemness traits and stromal properties as well as the post-surgery recurrence and metastasis of oral cancers among BA and WA patients. It was found that high levels of tumor self-renewal, invasion, tumorigenesis, metastasis, and tumor-promoting stromal characteristics were linked to post-surgery recurrence and metastasis. There were more BA than WA patients demonstrating high stemness traits and strong tumor-promoting stromal features in association with post-surgery tumor recurrences and metastases, although the investigated cases displayed clinically comparable TNM stages and histological grades. These findings demonstrated that the differences in tumor stemness and stromal property among cancers with comparable clinical diagnoses contribute to the outcome disparity in HNCs. More research is needed to understand the genetic and molecular basis of the biologic characteristics underlying the inferior outcomes among BA patients, so that targeting strategies can be developed to reduce HNC disparity.

Psychosocial factors and patient and healthcare delays in large (class T3-T4) oral, oropharyngeal, and laryngeal carcinomas

BACKGROUND

Psychosocial factors and socioeconomic status have been associated with incidence, survival, and quality of life among patients with head and neck cancer. We investigated the association between different psychosocial factors, socioeconomic status, and patient delays in T3-T4 oral, oropharyngeal, and laryngeal cancer.

PATIENTS AND METHODS

We conducted a nationwide prospective questionnaire-based study (n = 203) over a 3-year period.

RESULTS

We found no association between psychosocial factors (depression, social isolation, loneliness, and cynical hostility) and patient delay. Depression was three times more common among head and neck cancer patients compared with the general Finnish population. Head and neck cancer patients had lower educational levels and employment status, and were more often current smokers and heavy drinkers.

CONCLUSIONS

Although we found no association between patient delay and psychosocial factors, patients diagnosed with a large head and neck cancer appeared to have a lower socioeconomic status and higher risk for developing depression, which should be considered in clinical practice.

Socioeconomic Disparities in Postoperative Outcomes of Osteocutaneous Fibula Free Flaps for Head and Neck Reconstruction

BACKGROUND

Osteocutaneous fibula free flaps (FFFs) are a fundamental component of reconstructive surgery in the head and neck region, particularly after traumatic injuries or oncologic resections. Despite their utility, FFFs are associated with various postoperative complications, such as infection, flap failure, and donor site morbidity, impacting up to 54% of cases. This study aimed to investigate the influence of socioeconomic variables, with a particular focus on median household income (MHI), on the incidence of postoperative complications in FFF reconstruction for head and neck cancer.

METHODS

A retrospective analysis of 80 patients who underwent FFF reconstruction for head and neck cancer at a single center from 2016 to 2022 was conducted. Demographic and patient characteristics, including race, MHI, insurance type, history of radiation therapy, and TNM (tumor, node, metastasis) cancer stage, were evaluated. Logistic regression, controlling for comorbidities, was used to assess the impact of MHI on 30-, 90-, and 180-day postoperative complications.

RESULTS

The patient population was predominantly male (n = 51, 63.8%) and White (n = 63, 78.8%), with the majority falling within the $55,000 to $100,000 range of MHI (n = 51, 63.8%). Nearly half of the patients had received neoadjuvant radiation treatment (n = 39, 48.75%), and 36.25% (n = 29) presented with osteoradionecrosis. Logistic regression analysis revealed that the $55,000-$100,000 MHI group had significantly lower odds of developing complications in the 0- to 30-day postoperative period when compared with those in the <$55,000 group (odds ratio [OR], 0.440; 95% confidence interval [CI], 0.205-0.943; P = 0.035). This trend persisted in the 31- to 90-day period (OR, 0.136; 95% CI, 0.050-0.368; P < 0.001) and was also observed in the likelihood of flap takeback. In addition, the $100,000-$150,000 group had significantly lower odds of developing complications in the 31- to 90-day period (OR, 0.182; 95% CI, 0.035-0.940; P = 0.042). No significant difference was found in the >$150,000 group.

CONCLUSIONS

Median household income is a significant determinant and potentially a more influential factor than neoadjuvant radiation in predicting postoperative complications after FFF reconstruction. Disparities in postoperative outcomes based on income highlight the need for substantial health care policy shifts and the development of targeted support strategies for patients with lower MHI.

Correlating area deprivation index with initial stage at presentation and with follow up and recurrence within an advanced practice provider-led survivorship clinic

INTRODUCTION

Living in disadvantaged neighborhoods has been shown to result in worse healthcare outcomes. The Area Deprivation Index (ADI) is a metric that ranks neighborhoods by socioeconomic disadvantage utilizing numerous factors including income, education, employment, and housing quality.

METHODS

A retrospective review of all patients who underwent surveillance in an APP-led head and neck cancer survivorship clinic from Dec 2016 to Oct 2020 at an academic tertiary care center were included. Tumor characteristics, visit frequency, recurrence, number of missed appointments, loss of follow up, and ADI scores were collected.

RESULTS

543 patients were included in the study. A majority were male (69.9 %) and white race (84.9 %) with an average age of 64.6 years old. Average ADI national percentile score was 71.6(range: 17 to 100). ADI national percentile score was not predictive of tumor characteristics at initial presentation: lymphovascular invasion (p = 0.940; OR 1.0 [95 % CI: 0.9 to 1.1]), extranodal extension (p = 0.576; OR 1.0 [95 % CI: 0.9 to 1.2]), positive margins (p = 0.069; OR 0.9 [95 % CI: 0.9 to 1.0]). ADI national percentile score was not significantly correlated with loss to follow up (p = 0.153; OR 1.2 [95 % CI: 0.9 to 1.7] or cancer recurrence (p = 0.594; OR 1.0 [95 % CI: 0.9 to 1.1]). Missing one or more clinic visits was correlated with loss to follow up (p = 0.029; OR 13.1 [95 % CI: 1.3 to 131.7].

CONCLUSION

Living in a disadvantaged neighborhood did not correlate with negative tumor characteristics, loss to follow up, or recurrence within an APP-led survivorship head and neck cancer clinic.

Obstacles for patients with a low socio-economic status treated within the head and neck cancer pathway: A multiple case study

AIMS AND OBJECTIVES

Drawing on ethnographic fieldwork exploring various head and neck cancer treatment pathways of patients with low socio-economic status being treated with radiation therapy in Denmark, our aim was to explore how and why inequality in this treatment pathway might occur in the encounter between these patients and Danish healthcare.

BACKGROUND

In recent years, inequality in cancer treatment of patients with a low socio-economic status has been a growing concern worldwide. The majority of patients with head and neck cancer have a relatively low socio-economic status and are at risk of experiencing inequality in their cancer treatment.

DESIGN/METHODS

Using a method proposed by Robert Yin, we performed a multiple case study of five treatment pathways of patients with a low socio-economic status. The case studies consisted of participant observations and interviews with patients, relatives and health professionals. We applied Herbert Blumer's theory of symbolic interaction as a framework for our analysis.

RESULTS

We identified three concepts that all blocked joint action because patients and health professionals had different perceptions of what interaction required of them in terms of (1) Understanding information; (2) Assuming responsibility for managing practical tasks; and (3) Coordinating one's own treatment pathway.

CONCLUSIONS

We identified how different situations challenged the patients' abilities to assume participation in their own treatment pathway. In their encounter with patients, healthcare professionals did not know which situational impediments to joint action patients were facing.

RELEVANCE TO CLINICAL PRACTICE

We argue that being aware of how challenges unfold in the interaction with patients with low socio-economic status may serve as a starting point for changing practice to reduce inequality in the treatment of these patients.

REPORTING METHOD

This study is reported using consolidated criteria for reporting Qualitative research (SRQR). We used the theory and method of Robert Yin of performing a multi-case study and we applied Herbert Blumer's theory of Symbolic interactionism as a framework for understanding data.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Pharmacological impact of microRNAs in head and neck squamous cell carcinoma: Prevailing insights on molecular pathways, diagnosis, and nanomedicine treatment

Head and neck squamous cell carcinoma is a disease that most commonly produce tumours from the lining of the epithelial cells of the lips, larynx, nasopharynx, mouth, or oro-pharynx. It is one of the most deadly forms of cancer. About one to two percent of all neo-plasm-related deaths are attributed to head and neck squamous cell carcinoma, which is responsible for about six percent of all cancers. MicroRNAs play a critical role in cell proliferation, differentiation, tumorigenesis, stress response, triggering apoptosis, and other physiological process. MicroRNAs regulate gene expression and provide new diagnostic, prognostic, and therapeutic options for head and neck squamous cell carcinoma. In this work, the role of molecular signaling pathways related to head and neck squamous cell carcinoma is emphasized. We also provide an overview of MicroRNA downregulation and overexpression and its role as a diagnostic and prognostic marker in head and neck squamous cell carcinoma. In recent years, MicroRNA nano-based therapies for head and neck squamous cell carcinoma have been explored. In addition, nanotechnology-based alternatives have been discussed as a promising strategy in exploring therapeutic paradigms aimed at improving the efficacy of conventional cytotoxic chemotherapeutic agents against head and neck squamous cell carcinoma and attenuating their cytotoxicity. This article also provides information on ongoing and recently completed clinical trials for therapies based on nanotechnology.

Survival outcomes for patients with T3N0M0 squamous cell carcinoma of the glottis treated with definitive radiation alone versus chemoradiation

BACKGROUND

Given the poor lymphatics of the glottis, we evaluated omission of chemotherapy in patients treated definitely for T3N0M0 squamous cell carcinoma (SCC) of the glottis.

METHODS

We performed survival analysis of patients with T3N0M0 SCC of the glottis identified in the National Cancer Database treated with radiation alone versus chemoradiation.

RESULTS

A total of 3785 patients were identified. Patients age ≥70 and those with comorbidities were less likely to receive chemotherapy (odds ratio [OR] 0.30, 95% CI [0.25-0.37] and 0.48 [0.31-0.76], respectively). Five-year OS was lower in patients treated with radiation versus chemoradiation (33.8% [30.3%-37.2%] vs. 58.0% [55.8%-60.0%]). In patients <70 with no comorbidities this difference persisted (51.0% [44.5%-57.0%] versus 66.7% [64.0%-69.3%]).

CONCLUSION

Overall survival was higher in patients treated with chemoradiation compared to radiation alone, even when controlling for age and comorbidities. Radiotherapy with chemotherapy omission is not appropriate in patients with T3N0M0 SCC of the glottis.

Insights into Nanomedicine for Head and Neck Cancer Diagnosis and Treatment

Head and neck cancers rank sixth among the most common cancers today, and the survival rate has remained virtually unchanged over the past 25 years, due to late diagnosis and ineffective treatments. They have two main risk factors, tobacco and alcohol, and human papillomavirus infection is a secondary risk factor. These cancers affect areas of the body that are fundamental for the five senses. Therefore, it is necessary to treat them effectively and non-invasively as early as possible, in order to do not compromise vital functions, which is not always possible with conventional treatments (chemotherapy or radiotherapy). In this sense, nanomedicine plays a key role in the treatment and diagnosis of head and neck cancers. Nanomedicine involves using nanocarriers to deliver drugs to sites of action and reducing the necessary doses and possible side effects. The main purpose of this review is to give an overview of the applications of nanocarrier systems to the diagnosis and treatment of head and neck cancer. Herein, several types of delivery strategies, radiation enhancement, inside-out hyperthermia, and theragnostic approaches are addressed.

Geographic disparities in head and neck cancer survival in Upstate New York 2011-2019

PURPOSE

To examine the association between distance to care-center and urban-rural residence on 5-year overall survival (OS) from head and neck cancer (HNC).

MATERIALS AND METHODS

Five-year OS was retrospectively measured from date of initial diagnosis for patients with HNC treated at a single tertiary care center. Distances were calculated based on ZIP code of patient's residence and care center. Multilevel Weibull regression was used to adjust for confounders and identify disparities in 5-year all-cause mortality.

RESULTS

A total of 670 patients included in study. Multivariable analysis revealed older age or late-stage cancer at diagnosis, and HPV negative status were associated with poorer OS. Patients residing in isolated small rural town (HR = 2.20, p = 0.015) or small rural town (HR = 2.07, p = 0.015) had lower OS. Distance to care center was not associated with OS (HR = 0.996, p = 0.11).

CONCLUSIONS

Greater rurality was associated with poorer OS among HNC patients in Upstate New York.

Quality of life, HPV-status and phase angle predict survival in head and neck cancer patients under (chemo)radiotherapy undergoing nutritional intervention: Results from the prospective randomized HEADNUT-trial

PURPOSE

To analyze the impact of quality of life (QoL), nutritional and clinical indicators on overall survival in patients with head and neck squamous cell cancer (HNSCC) undergoing (chemo)radiotherapy.

MATERIALS AND METHODS

At the beginning, at the end of (chemo)radiotherapy and during follow-up, QoL was prospectively assessed using the EORTC-QLQ-C30 and -QLQ-H&N35 questionnaires. Data were analyzed in 58 out of 220 screened patients, who were randomized into a control and intervention group. All patients received a nutritional assessment including bioelectrical impedance analysis (BIA), laboratory testing, and a screening for malnutrition based on the questionnaires MUST, NRS-2002 and Nutriscore at baseline and at the end of therapy. The intervention consisted of an individualized nutritional counseling every 2 weeks.

RESULTS

Except for emotional functioning, dyspnea, financial difficulties, dental problems and weight gain, all other scales from the EORTC-QLQ-C30 and -H&N35 deteriorated during (chemo)radiotherapy. At first follow-up, patients of the control group experienced more nausea and vomiting compared to those of the intervention group (p = 0.02). After performing a multivariable model, dental problems at the end of therapy (HR: 1.03; 95% CI: 1-1.06; p = 0.03), HPV negativity (HR: 18.19, 95% CI: 1.61-204.17; p = 0.02), and baseline phase angle (HR: 0.09; 95% CI: 0.01-0.82; p = 0.03) were identified as predictors for overall survival.

CONCLUSIONS

Factors influencing overall survival in patients with HNSCC undergoing (chemo)radiotherapy are complex and multifactorial. We were able to identify QoL-related (dental problems), clinical (HPV status) and nutritional (phase angle) factors as negative predictors for survival. This study was registered within the German Clinical Trials Register (DRKS00016862).