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Factors Associated with Non-cancer Mortality in Advanced Head and Neck Cancer: A Competing Risks Analysis
I. J. Radiation Oncology d Biology d Physics
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Volume 72, Number 1, Supplement, 2008
Factors Associated with Non-cancer Mortality in Advanced Head and Neck Cancer: A Competing Risks Analysis
L. K. Mell1, J. J. Dignam2, J. K. Salama1, E. E. Cohen3, B. N. Polite3, A. D. Bhate4, D. J. Haraf1, B. B. Mittal4, E. E. Vokes3, R. R. Weichselbaum1, et al. 1 University of Chicago Department of Radiation & Cellular Oncology, Chicago, IL, 2University of Chicago Department of Health Studies, Chicago, IL, 3University of Chicago, Department of Medicine, Section of Hematology/Oncology, Chicago, IL, 4 Northwestern University Department of Radiation Oncology, Chicago, IL
Purpose/Objective(s): To analyze risk factors for competing mortality (CM) in advanced head and neck cancer (HNC). Materials/Methods: We analyzed 479 patients with non-metastatic stage III-IV HNC diagnosed between 1993 and 2004. Patients were treated on any of five consecutive multi-institutional protocols involving organ-preserving concurrent chemotherapy and hyperfractionated radiotherapy with limited surgery. We used Fine-Gray competing risks regression models to analyze factors associated with the cumulative incidence of CM, locoregional (LRF), distant (DF) failure, and second malignancies (SM) as first events. Based on factors found to be associated with CM, a risk score was developed to stratify patients according to risk of CM. Results: Median follow-up was 52 months and 400 patients were available for analysis. Five-year disease-free survival (DFS) was 52.3% (95% CI, 47.2-57.9%). The 5-year cumulative incidence of CM, LRF, DF, and SM was 19.1% (95% CI, 15.0-23.2%), 9.7% (95% CI, 6.7-12.7%), 12.1% (95% CI, 8.8-15.4%), and 6.4% (95% CI, 3.6-9.2%), respectively. On multivariate analysis, increasing age (HR = 1.36, p = 0.010), female gender (HR = 2.05, p = 0.002), decreasing body mass index (BMI) (HR = 0.95, p = 0.031), and increasing Charlson comorbidity index (HR = 1.31, p = 0.004) were associated with CM. Using the mean risk score as a cutoff, patients with a low (n = 217) versus high (n = 183) score had a DFS of 66% vs. 38%, respectively (HR 2.10, 95% CI, 1.57-2.82, p \ 0.001). Five-year cumulative incidence of CM, LRF, DF, and SM was 10.1% vs. 29.5% (p \ 0.001), 8.8% vs. 10.8% (p = 0.40), 10.2% vs. 14.2% (p = 0.31), and 5.3% vs. 7.4% (p = 0.43), for low vs. high-risk patients, respectively. Conclusions: Non-cancer mortality is a common event influencing DFS in advanced head and neck cancer and is associated with age, gender, BMI, and comorbid disease. Competing risk models are useful to identify patients at high risk for CM, who may benefit from interventions directed at reducing this risk. Author Disclosure: L.K. Mell, None; J.J. Dignam, None; J.K. Salama, None; E.E. Cohen, None; B.N. Polite, None; A.D. Bhate, None; D.J. Haraf, None; B.B. Mittal, None; E.E. Vokes, None; R.R. Weichselbaum, None.
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The Effect of Race on Combining Surgery and Radiation in Locally Advanced Non-small Cell Lung Cancer
B. E. Lally1, A. Blackstock2, M. K. Buyyounouski1, S. J. Feigenberg1, W. J. Scott1, C. R. Thomas3, A. A. Konski1 1 Fox Chase Cancer Center, Philadelphia, PA, 2Wake Forest University School of Medicine, Winston Salem, NC, 3Oregon Health Sciences University, Portland, OR
Purpose/Objective(s): African American (AA) patients with locally advanced non-small cell lung cancer (NSCLC) have worse overall survival than Caucasian (C) patients. The physician-patient encounter has been implicated as a potential source of racial disparities. Our specific aims was to isolate the effect of decision making. We used radiotherapy (RT) utilization as a proxy for different care plans patients maybe offered, and examined treatment employed by race/ethnicity. Materials/Methods: Using data from the Surveillance, Epidemiology, and End Results (SEER) Program, we identified 29,208 patients with pathologically confirmed NSCLC diagnosed between 1998 and 2004 coded as having N2 involvement. Categorical variables investigated included age (\60, 60-69, and $70 yrs.), sex, histology (large cell carcinoma, squamous cell carcinoma, or adenocarcinoma) tumor location, laterality, and race/ethnicity (C, AA, and other). As a measure of access to healthcare delivery, we obtained information from the 2000 census on income including the median 1999 household income averaged per county and stratified by the median (MEDINC). Results: Our cohort included 24332 C, 3156 AA, and 1720 others. 8864 patients underwent either a lobectomy or pneumonectomy; of these 573 were treated with pre-operative RT and 3512 were treated only with post-operative RT. In multivariate analysis of all patients, variables associated with surgery being performed included younger age, female sex, adenocarcinoma histology, and left lower lobe location. AA race/ethnicity (odds ratio [OR] = 1.6; 95% confidence interval [CI] 1.5-1.8) and lower MEDINC (OR= 1.2; CI 1.1-1.2) both predicted decreased probability of undergoing surgery. We then performed a subset analysis including only the patients who underwent surgery. AA race/ethnicity (OR = 1.7; CI 1.2-2.5) but not lower MEDINC (OR= 0.9; CI 0.7-1.0) predicted decreased probability of receiving preoperative RT. In contrast, neither AA race/ethnicity (OR = 1.0; CI 0.9-1.2) nor MEDINC (OR = 1.0; CI 0.9-1.1) predicted for decreased probability of receiving post-operative RT within this same subset. Conclusions: The optimal combination of surgery and RT is controversial, but the treatment patients receive appears to be impacted by both race/ethnicity and access to care. Additional research should focus on the physician-patient encounter, how it pertains to the different oncology specialties, as well as the team approach used to deliver care. Author Disclosure: B.E. Lally, None; A. Blackstock, None; M.K. Buyyounouski, None; S.J. Feigenberg, None; W.J. Scott, None; C.R. Thomas, None; A.A. Konski, None.
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Does Marital Status Influence Survival among Women with Invasive Cervical Cancer? Analysis of Population-based Surveillance, Epidemiology and End Results (SEER) Data
M. K. Patel1, D. A. Patel2, M. Lu1, M. Elshaikh1, B. Movsas1 1 Henry Ford Health System, Detroit, MI, 2University of Michigan Medical School, Ann Arbor, MI Purpose/Objective(s): For several types of cancer, studies have demonstrated that married individuals present with less advanced stage of disease, are more likely to receive aggressive treatment, and live longer compared to unmarried individuals. To our knowledge, marital status has not yet been explored as a predictor of survival in patients with cervical cancer. The objective of this study is
S42
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Volume 72, Number 1, Supplement, 2008
Factors Associated with Non-cancer Mortality in Advanced Head and Neck Cancer: A Competing Risks Analysis
L. K. Mell1, J. J. Dignam2, J. K. Salama1, E. E. Cohen3, B. N. Polite3, A. D. Bhate4, D. J. Haraf1, B. B. Mittal4, E. E. Vokes3, R. R. Weichselbaum1, et al. 1 University of Chicago Department of Radiation & Cellular Oncology, Chicago, IL, 2University of Chicago Department of Health Studies, Chicago, IL, 3University of Chicago, Department of Medicine, Section of Hematology/Oncology, Chicago, IL, 4 Northwestern University Department of Radiation Oncology, Chicago, IL
Purpose/Objective(s): To analyze risk factors for competing mortality (CM) in advanced head and neck cancer (HNC). Materials/Methods: We analyzed 479 patients with non-metastatic stage III-IV HNC diagnosed between 1993 and 2004. Patients were treated on any of five consecutive multi-institutional protocols involving organ-preserving concurrent chemotherapy and hyperfractionated radiotherapy with limited surgery. We used Fine-Gray competing risks regression models to analyze factors associated with the cumulative incidence of CM, locoregional (LRF), distant (DF) failure, and second malignancies (SM) as first events. Based on factors found to be associated with CM, a risk score was developed to stratify patients according to risk of CM. Results: Median follow-up was 52 months and 400 patients were available for analysis. Five-year disease-free survival (DFS) was 52.3% (95% CI, 47.2-57.9%). The 5-year cumulative incidence of CM, LRF, DF, and SM was 19.1% (95% CI, 15.0-23.2%), 9.7% (95% CI, 6.7-12.7%), 12.1% (95% CI, 8.8-15.4%), and 6.4% (95% CI, 3.6-9.2%), respectively. On multivariate analysis, increasing age (HR = 1.36, p = 0.010), female gender (HR = 2.05, p = 0.002), decreasing body mass index (BMI) (HR = 0.95, p = 0.031), and increasing Charlson comorbidity index (HR = 1.31, p = 0.004) were associated with CM. Using the mean risk score as a cutoff, patients with a low (n = 217) versus high (n = 183) score had a DFS of 66% vs. 38%, respectively (HR 2.10, 95% CI, 1.57-2.82, p \ 0.001). Five-year cumulative incidence of CM, LRF, DF, and SM was 10.1% vs. 29.5% (p \ 0.001), 8.8% vs. 10.8% (p = 0.40), 10.2% vs. 14.2% (p = 0.31), and 5.3% vs. 7.4% (p = 0.43), for low vs. high-risk patients, respectively. Conclusions: Non-cancer mortality is a common event influencing DFS in advanced head and neck cancer and is associated with age, gender, BMI, and comorbid disease. Competing risk models are useful to identify patients at high risk for CM, who may benefit from interventions directed at reducing this risk. Author Disclosure: L.K. Mell, None; J.J. Dignam, None; J.K. Salama, None; E.E. Cohen, None; B.N. Polite, None; A.D. Bhate, None; D.J. Haraf, None; B.B. Mittal, None; E.E. Vokes, None; R.R. Weichselbaum, None.
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The Effect of Race on Combining Surgery and Radiation in Locally Advanced Non-small Cell Lung Cancer
B. E. Lally1, A. Blackstock2, M. K. Buyyounouski1, S. J. Feigenberg1, W. J. Scott1, C. R. Thomas3, A. A. Konski1 1 Fox Chase Cancer Center, Philadelphia, PA, 2Wake Forest University School of Medicine, Winston Salem, NC, 3Oregon Health Sciences University, Portland, OR
Purpose/Objective(s): African American (AA) patients with locally advanced non-small cell lung cancer (NSCLC) have worse overall survival than Caucasian (C) patients. The physician-patient encounter has been implicated as a potential source of racial disparities. Our specific aims was to isolate the effect of decision making. We used radiotherapy (RT) utilization as a proxy for different care plans patients maybe offered, and examined treatment employed by race/ethnicity. Materials/Methods: Using data from the Surveillance, Epidemiology, and End Results (SEER) Program, we identified 29,208 patients with pathologically confirmed NSCLC diagnosed between 1998 and 2004 coded as having N2 involvement. Categorical variables investigated included age (\60, 60-69, and $70 yrs.), sex, histology (large cell carcinoma, squamous cell carcinoma, or adenocarcinoma) tumor location, laterality, and race/ethnicity (C, AA, and other). As a measure of access to healthcare delivery, we obtained information from the 2000 census on income including the median 1999 household income averaged per county and stratified by the median (MEDINC). Results: Our cohort included 24332 C, 3156 AA, and 1720 others. 8864 patients underwent either a lobectomy or pneumonectomy; of these 573 were treated with pre-operative RT and 3512 were treated only with post-operative RT. In multivariate analysis of all patients, variables associated with surgery being performed included younger age, female sex, adenocarcinoma histology, and left lower lobe location. AA race/ethnicity (odds ratio [OR] = 1.6; 95% confidence interval [CI] 1.5-1.8) and lower MEDINC (OR= 1.2; CI 1.1-1.2) both predicted decreased probability of undergoing surgery. We then performed a subset analysis including only the patients who underwent surgery. AA race/ethnicity (OR = 1.7; CI 1.2-2.5) but not lower MEDINC (OR= 0.9; CI 0.7-1.0) predicted decreased probability of receiving preoperative RT. In contrast, neither AA race/ethnicity (OR = 1.0; CI 0.9-1.2) nor MEDINC (OR = 1.0; CI 0.9-1.1) predicted for decreased probability of receiving post-operative RT within this same subset. Conclusions: The optimal combination of surgery and RT is controversial, but the treatment patients receive appears to be impacted by both race/ethnicity and access to care. Additional research should focus on the physician-patient encounter, how it pertains to the different oncology specialties, as well as the team approach used to deliver care. Author Disclosure: B.E. Lally, None; A. Blackstock, None; M.K. Buyyounouski, None; S.J. Feigenberg, None; W.J. Scott, None; C.R. Thomas, None; A.A. Konski, None.
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Does Marital Status Influence Survival among Women with Invasive Cervical Cancer? Analysis of Population-based Surveillance, Epidemiology and End Results (SEER) Data
M. K. Patel1, D. A. Patel2, M. Lu1, M. Elshaikh1, B. Movsas1 1 Henry Ford Health System, Detroit, MI, 2University of Michigan Medical School, Ann Arbor, MI Purpose/Objective(s): For several types of cancer, studies have demonstrated that married individuals present with less advanced stage of disease, are more likely to receive aggressive treatment, and live longer compared to unmarried individuals. To our knowledge, marital status has not yet been explored as a predictor of survival in patients with cervical cancer. The objective of this study is