Compared With Men, Women With Head and Neck Cancer Undertreated

Jed A. Katzel, MDt

Women with head and neck cancer (HNC) may be severely undertreated compared with their male counterparts, according to study results presented at the 2018 ASCO Annual Meeting.

Although HNCs account for approximately 4% of all cancers in the United States, the disease occurs twice as often among men than women. Yet, in this study, women appeared to be less likely to receive intensive chemotherapy and radiation. Women also had higher death rates compared with men.

The treatment of HNC often requires intensive treatment, such as platinum-based chemotherapy with radiation therapy, that can have lasting side effects, explained senior author Jed A. Katzel, MD, medical oncologist, Kaiser Permanente.

Therefore, the researchers evaluated health outcomes in 884 patients (female, n = 223; male, n = 661) diagnosed between 2000 and 2015 at Kaiser Permanente Northern California based on demographic data and comorbidities using a generalized competing event (GCE) model.

“The GCE model is a mathematical model that can be used to calculate an omega-plus [ω+] score for a patient,” said Katzel. “The ω+ score is the hazard for cancer mortality over the hazard for noncancer mortality.” It essentially describes the degree to which cancer is the cause of death for the patient.

Using the GCE model, the researchers controlled for age, sex, tumor site and Charlson comorbidity index (CCI) to identify associations between these factors and the relative hazard for HNC-specific mortality. Logistic regression models then estimated the odds of receiving intensive treatment, (platinum-based chemotherapy with radiation), adjusting for the same covariates plus cancer stage, smoking, and alcohol abuse history.

The primary objective of the study was to determine those patients most likely to benefit from aggressive therapy, and to minimize toxicity for patients likely to die from competing events.

Women exhibited lower odds of receiving intensive chemotherapy (35% vs 46%; P = .006) and radiation (60% vs 70%; P = .008) compared with men. However, rates for surgery appeared to be similar among both groups. Katzel attributed these findings to a potential reflection in the different primary tumor locations within the cohortthere were relatively more oral cavity cancers and fewer oropharyngeal cancers among women.

After a median follow-up of 2.9 years, 271 patients died of cancer, including 93 of noncancer causes. Both men (average ω+ of 3.8) and women (average ω+ of 7) were more likely to die from cancer than from other causes.

However, the ratio of cancer deaths compared with noncancer deaths was 1.92 times higher in women compared with men (95% CI, 1.07-3.43), indicating they may be relatively undertreated, the researchers wrote. Katzel noted that confounding factors to explain this could include a lower percentage of oropharyngeal HNC in women; the smaller number of non-cancer deaths in women (n = 19); and that the women in this cohort may have been healthier than the men.

Lastly, regarding HPV-related cancer, fewer women had oropharyngeal cancers than men (38% vs 55%). “While further analysis is ongoing, this may also be a factor driving higher cancer-related mortality rates in women, as HPV-related cancers occur most frequently in the oropharynx,” the researchers wrote. HPV status is important because HPV-related head and neck tumors are more responsive to treatment; these patients usually demonstrate a better prognosis.

Katzel added additional trials are necessary to “determine if there is an actual difference in treatment and outcomes for women compared with men.”

“To this end, we have planned a chart-by-chart review and prospective trials using GCE in the NRG-HN004 clinical trial,” he added.

ASCO expert Joshua A. Jones, MD, MA, assistant professor of clinical radiation oncology, Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, agreed that further research is warranted considering these findings were not only striking, but a surprise.

“The idea that there are disparities in the treatment women receive compared with men, but also disparities in the rate of death in head and neck cancer in women compared with men, and we don’t know why those differences exist,” he said.

“It is really important that we continue this research, that we continue to figure out what those differences are, why they are happening so that we can make sure that as we are talking with patients with head and neck cancer that we are providing the right treatment for the right patient at the right time,” Jones added. “And (it is important) that everyone has the appropriate access to outstanding clinical care for head and neck cancer.”

Park A, Alabaster A, Shen H, Mell LK, Katzel JA. Are women with head and neck cancer undertreated? Presented at: 2018 ASCO Annual Meeting; June 1-5, 2018; Chicago. Abstract LBA6002.

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