Association of Smoking, Comorbidity, Clinical Stage, and Treatment Intent With Socioeconomic Differences in Survival After Oropharyngeal Squamous Cell Carcinoma in Denmark

Abstract

ImportanceThe socioeconomic gap in survival after cancer is pronounced among patients with head and neck cancer. Understanding the mechanisms of this gap is crucial to target intervention strategies.ObjectiveTo investigate socioeconomic differences in survival after oropharyngeal squamous cell carcinoma (OPSCC) according to human papillomavirus (HPV) status and the extent to which smoking, comorbidity, clinical stage, and treatment intent explain the survival gap.Design, Setting, and ParticipantsThis nationwide, population-based cohort study was based on prospectively collected information on all patients with a diagnosis of OPSCC from the Danish Head and Neck Cancer Group database and administrative registries. The study included 4600 patients born in 1921 or later, aged 30 years or older, and residing in Denmark 1 year prior to OPSCC diagnosis. Patients with missing information (547 [12%]) were excluded. Patients were diagnosed between January 1, 2008, and December 31, 2019, and followed up until December 31, 2021. Data were analyzed from June 6 to October 4, 2022.ExposureSocioeconomic position (educational level, disposable income, or cohabiting status).Main Outcomes and MeasuresSocioeconomic differences in 5-year overall survival were estimated in Cox proportional hazards regression models by HPV status. The indirect effect and proportion mediated by smoking, comorbidity, clinical stage, and treatment intent were estimated based on a counterfactual approach.ResultsThe analyzed cohort comprised 4053 patients (1045 women [26%] and 3008 men [74%]). The median age was 61 years (IQR, 55-68 years), and 2563 patients (63%) had HPV-positive OPSCC while 1490 patients (37%) had HPV-negative OPSCC. The 5-year standardized overall survival was 10% to 15% lower among patients with a lower educational level, with low disposable income, or who were living alone (patients with HPV-positive OPSCC, 68%-71%; patients with HPV-negative OPSCC, 31%-34%) than patients with a higher educational level, high disposable income, or a cohabiting partner (patients with HPV-positive OPSCC, 81%-86%; patients with HPV-negative OPSCC, 43%-46%). Among patients with HPV-positive OPSCC, a considerable part of this survival gap was estimated to be associated with differences in smoking (27%-48%), comorbidity (10%-19%), clinical stage (8%-19%), and treatment intent (16%-28%). Among those with HPV-negative OPSCC, comorbidity (12%-22%) and treatment intent (16%-42%) were the primary potential mediators.Conclusions and RelevanceThis cohort study suggests that, regardless of HPV status, patients with low socioeconomic position had 10% to 15% lower 5-year overall survival than patients with high socioeconomic position. A substantial part of this survival gap was associated with differences in smoking, comorbidity, clinical stage, or treatment intent at diagnosis.

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

“…These lifestyle choices also characterise people with a low SES who also often have low educational level, income, social status and occupational status (Halgren Olsen et al, 2019). Thus, it is well documented that the majority of patients with head and neck cancer have a low SES (Choi et al, 2016;Jakobsen et al, 2018); this increases the risk of inequality in the treatment of head and neck cancer, which has also been documented in several other studies (Andersen et al, 2008;Choi et al, 2016;Halgren Olsen et al, 2022). Lineback et al (2017) found that patients with oesophageal cancer with a low SES status were more likely to be offered less surgery than patients with a high SES (Lineback et al, 2017), which was also found for patients with head and neck cancer being offered radiation therapy as documented by Park and Decker (Park & Decker, 2016).…”

“…These lifestyle choices also characterise people with a low SES who also often have low educational level, income, social status and occupational status (Halgren Olsen et al, 2019). Thus, it is well documented that the majority of patients with head and neck cancer have a low SES (Choi et al, 2016; Jakobsen et al, 2018); this increases the risk of inequality in the treatment of head and neck cancer, which has also been documented in several other studies (Andersen et al, 2008; Choi et al, 2016; Halgren Olsen et al, 2022).…”

A meta-validated immune infiltration-related gene model predicts prognosis and immunotherapy sensitivity in HNSCC

“…However, due to the complex anatomy of head and neck, it is difficult to perform surgery. When patients are diagnosed with head and neck cancer, more than 50% of them are in clinical stage III or IV and lose their best chance of operation [2]. This is one of the reasons why the total global survival rate of HNSCC is only 50%.…”

Mendelian randomization eradicates the causal relationship between educational attainment, household income, and oropharyngeal cancer

“…Besides, rural residents and people of black ethnicity have a higher incidence rate and a worse prognosis, which might be attributed to socioeconomic barriers such as insurance and income (5,6). As for educational attainment, a Danish study found that the incidence of oropharyngeal cancer increased in individuals with a short education (7), and a recent cohort study discovered that those with a lower educational level usually had a lower survival rate (8). However, these traditional observational results tend to be biased by undetectable potential confounders and should be explained with caution (9).…”