Association of Human Papillomavirus Status With Suicide Risk Among Patients With Head and Neck Cancer

Abstract

ImportanceHuman papillomavirus (HPV) is strongly associated with head and neck cancer, and HPV status is considered a prognostic factor. Being a sexually transmitted infection, HPV-related cancers may have greater risk of stigma and psychological distress; however, the potential association of HPV-positive status with psychosocial outcomes, such as suicide, is understudied in head and neck cancer.ObjectiveTo investigate the association between HPV tumor status and suicide risk among patients with head and neck cancer.Design, Setting, and ParticipantsThis population-based retrospective cohort study included adult patients with clinically confirmed cases of head and neck cancer based on HPV tumor status from the Surveillance, Epidemiology, and End Results database from January 1, 2000, to December 31, 2018. Data analysis was conducted from February 1 to July 22, 2022.Main Outcomes and MeasuresThe outcome of interest was death by suicide. Primary measure was HPV status of tumor site, dichotomized as positive or negative. Covariates included age, race, ethnicity, marital status, cancer stage at presentation, treatment modality, and type of residence. Cumulative risk of suicide among patients with HPV-positive and HPV-negative head and neck cancer was assessed using Fine and Gray competing risk models.ResultsOf 60 361 participants, the mean (SD) age was 61.2 (13.65) years, and 17 036 (28.2%) were women; there were 347 (0.6%) American Indian, 4369 (7.2%) Asian, 5226 (8.7%) Black, 414 (0.7%) Native Hawaiian or Other Pacific Islander, and 49 187 (81.5%) White individuals. A competing risk analysis showed a significant difference in the cumulative incidence of suicide between HPV-positive cancers (5-year suicide-specific mortality, 0.43%; 95% CI, 0.33%-0.55%) and HPV-negative cancers (5-year suicide-specific mortality, 0.24%; 95% CI, 0.19%-0.29%). Tumor status that was HPV positive was associated with increased suicide risk in the unadjusted model (hazard ratio [HR], 1.76; 95% CI, 1.28-2.40), but not the fully adjusted model (adjusted HR, 1.18; 95% CI, 0.79-1.79). Among people with oropharyngeal cancer only, HPV status was associated with increased suicide risk, but the width of the confidence interval prevented definitive conclusion (adjusted HR, 1.61; 95% CI 0.88-2.94).Conclusions and RelevanceThe results of this cohort study suggest that patients with HPV-positive head and neck cancer have similar risk of suicide as patients with HPV-negative cancer, despite differences in overall prognosis. Early mental health interventions may be associated with reduced suicide risk in all patients with head and neck cancer and should be assessed in future work.

Sex and Marital-Status Differences in Delayed Initiation for Pharyngeal Cancer Treatment, Before and After Medicaid Expansion

“…Missing HPV data was imputed through Multiple Imputation Chained Equations 23 (50x) Logistic Regressions with histology, grade, schema as predictors 17,24,25 . Given that the level of missingness varies over time (∼70% in 2010 and 20% in 2017) 22 , and high proportion of estimated HPVa OPC (>70%), we do not restrict the sample to HPV positive cases but instead add imputed HPV codes to all models.…”

Examining the effect of Medicaid expansion on early detection of head and neck cancer of the oral cavity and pharynx by HPV‐type and generosity of dental benefits

“…The specialized data file includes a clinically validated variable indicating the HPV etiology (HPV in situ hybridization, tissue polymerase chain reaction, in situ hybridization for E6/7 RNA, real‐time polymerase chain reaction for E6/7 RNA) of each HNC tumor within the following HNC sites: Lip, Hypopharynx, Nasopharynx, Oropharynx, Pharyngeal Tonsil, Pharynx Other, Palate Soft, Tongue Base, Gum and Other Mouth, and Other Oral Cavity 30 . Following established practice, missing HPV‐status was imputed with data on tumor grade, histology, site, behavior, and encrypted census tract‐level socioeconomic indicators via a logistic regression model through Multiple Imputation Chained Equations 31–38 . This specialized data includes cancer diagnoses for year 2010–2016.…”

“…30 Following established practice, missing HPV‐status was imputed with data on tumor grade, histology, site, behavior, and encrypted census tract‐level socioeconomic indicators via a logistic regression model through Multiple Imputation Chained Equations. 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 This specialized data includes cancer diagnoses for year 2010–2016. Because adults over age 65 could benefit from access to Medicaid dental coverage, the analytical sample includes adults between ages 30–84.…”

A disturbing link between cancer and suicide

“…Smaller studies have backed many of the associations while adding further nuance to the overall findings. One recent report, for example, found that the risk of suicide is roughly equivalent with human papillomavirus (HPV)–independent and HPV‐associated head and neck tumors 6 . Dr Richmon, however, warns that different factors may be contributing to the risk for each group.…”

“…One recent report, for example, found that the risk of suicide is roughly equivalent with human papillomavirus (HPV)independent and HPV-associated head and neck tumors. 6 Dr Richmon, however, warns that different factors may be contributing to the risk for each group. The traditional group of patients with HPV-independent head and neck cancers tends to be older, have higher rates of tobacco and alcohol use, and carry other comorbidities.…”