Race and Insurance Status Affect Survival Outcomes for HPV-Associated Cancer

A new study observed that race and insurance status impact the cure rate in HPV-associated squamous cell carcinoma of the head and neck (SCCHN).

Previous data on the subject have been limited to retrospective studies and analyses, the study authors note in their report.

“It has been suggested that HPV-negative SCCHN is more common among nonwhite, urban, and poorly insured individuals due to higher smoking rates in these populations. Furthermore, the inferior outcomes observed in patients of lower socioeconomic status (SES) with SCCHN have largely been attributed to a predominance of HPV-negative disease,” they continue. “However, these hypotheses have not been tested in the prospective setting, given that clinical trials tend to include a disproportionate number of patients who are white and of higher SES. Furthermore, no large population-based studies have examined the burden of HPV-associated disease and cancer-related survival as affected by socioeconomic factors.”

The researchers used a custom SEER database to identify adults primary nonmetastatic SCCHN patients whose HPV status was known and diagnosed between 2013 and 2014. The outcome was cancer-specific mortality (CSM).

The study was published in Journal of the National Comprehensive Cancer Network.

Race, Insurance Status Impact Survival

Final analysis included 4,735 patients with nonmetastatic SCCHN whose HPV status was known. The following factors were positively correlated with HPV-associated SCCHN: an oropharyngeal primary, male sex, and higher education. Factors negatively associated with HPV-associated SCCHN were uninsured status, single marital status, and nonwhite race. In HPV-positive oropharyngeal SCCHN, white race was correlated with lower CSM (adjusted hazard ratio [aHR]=0.55; 95% confidence interval [CI], 0.34–0.88; P=0.01), while uninsured patients had higher CSM (aHR=3.12; 95% CI, 1.19–8.13; P=0.02). These correlations did not persist in HPV-negative or nonoropharynx SCCHN.

“When we examined outcomes by race and insurance status, adjusting for all clinical factors, those patients who were non-white or uninsured or poorly insured had much reduced cancer-specific survival compared to their white and well-insured peers,” said study author Luke R. G. Pike, MD, DPhil, of the Department of Radiation Oncology, Massachusetts General Hospital, in a press release. “It’s unsettling that black and Hispanic men and women with HPV-positive oropharyngeal carcinoma—a disease we now recognize to be curable in many patients with even very advanced disease—appear to do disproportionately poorly as compared to their white peers. We also speculate that patients with insufficient insurance were unable to access high-quality radiotherapy, surgery, and chemotherapy, which is crucial to the successful treatment of locally advanced HPV-positive oropharyngeal cancer. We must strive to ensure that all men and women, no matter their insurance status or race, can get access to high-quality treatment for head and neck cancers.”

Francis Worden, MD, University of Michigan Rogel Cancer Center, and Member of the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Panel for Head and Neck Cancers, who was not involved in the present study, said of its findings, “While the exact reasons for these findings are speculative given the retrospective nature of this work, their data bring to light the importance for early diagnosis and treatment of all patients with HPV-positive oropharyngeal cancers and the importance of identifying and eliminating barriers to care. HPV-positive cancers are highly curable, but data does show that patients who present with higher stage disease (due primarily to delays in diagnosis and thus delays in treatment) have lower overall survival rates. Additionally, lower income, non-white populations may be less likely to obtain care at larger, more experienced cancer centers that treat higher volumes of head and neck cancers. Published data suggest that patient care at such centers of excellence leads to improved outcomes due to expertise in administering complex treatment plans and the high level of support that is provided during medical care.”