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Women less likely than men to receive intensive treatment for head, neck cancers
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CHICAGO — Women appeared less likely than men to receive intensive treatment for head and neck cancer, according to study results presented at ASCO Annual Meeting.
When researchers controlled for factors such as age and serious medical conditions, their analysis showed the ratio of cancer mortality to noncancer mortality was twice as high among women than men.
The findings suggest women with head and neck cancer may be undertreated. However, due to confounding factors, additional prospective study is needed to confirm this possibility.
Head and neck cancers are more than twice as common among men than women.
Patients who have good performance status may receive more intense treatments, such as platinum-based chemotherapy with radiation therapy. Less intensive treatments — such as cetuximab (Erbitux, Eli Lilly) with radiation, or radiation alone — may be offered to patients who cannot tolerate intensive chemotherapy. Others receive no cancer treatment.
Jed A. Katzel, MD, medical oncologist at Kaiser Permanente in Santa Clara, Calif., and colleagues used registry data to evaluate outcomes of 884 patients (661 men) diagnosed with stage II to stage IVB head and neck cancer between 2000 and 2015. All patients underwent treatment at Kaiser Permanente Northern California.
“Our goal was ... to determine which patients were most likely to benefit from aggressive therapy, while minimizing toxicity for those likely to die from competing events,” Katzel said during a press conference.
Investigators used logistic regression models to estimate the odds that patients received intensive cancer treatment. They adjusted for factors such as sex, age, tumor stage, Charlson Comorbidity Index, and history of alcohol or smoking use.
Results showed men were considerably more likely than women to receive intensive chemotherapy (46% vs. 35%) or radiation (70% vs. 60%). Rates of surgery appeared similar between groups.
“This may be a reflection of differences in primary tumor location in our cohort, with relatively more oral cavity cancers in women compared with men, and relatively fewer oropharynx cancers in women,” Katzel said.
Researchers used a generalized competing event model to compare a patient’s risk for dying of cancer with the risk for dying of other causes. This mathematical tool controlled for differences in sex, age, tumor site and Charlson score, but it did not control for HPV status.
After median follow-up of 2.9 years, 364 patients had died; of these, 271 died of cancer and 93 died of other causes.
The generalized competing event model analysis yielded + scores — calculated by dividing the HR for cancer mortality by the HR for noncancer mortality — that showed both women (average + = 7) and men (average + = 3.8) were more likely to die of cancer than other causes.
“For women, the ratio of head and neck cancer death to noncancer death was approximately double the ratio for men, despite controlling for other factors like age and other comorbidities,” Katzel said.
Researchers are evaluating whether differences in the rate of HPV-related head and neck cancers between women and men may play a role in the observed mortality disparities.
HPV-related cancers — which are more responsive to treatment — occur most frequently in the oropharynx. However, in this analysis, fewer women than men had oropharyngeal cancers (38% vs. 55%).
Katzel acknowledged other confounders, including a small number of noncancer deaths (n = 19) among women, and the fact women may have been healthier than men in the cohort.
“Further investigation is needed to determine if there is an actual difference in treatment and outcomes for women compared with men,” Katzel said. “To this end, we have planned a chart-by-chart review, as well as prospective analysis that will be performed in the currently enrolling NRG-HN004 clinical trial.” – by Mark Leiser
For more information:
Park A, et al. Abstract LBA6002. Presented at: ASCO Annual Meeting; June 1-5, 2018; Chicago.
Disclosures: The researchers report funding from Kaiser Permanente Northern California Graduate Medical Education Department. Park reports no relevant financial disclosures. Please see the abstract for all other authors’ relevant financial disclosures.
Perspective
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Jorge Nieva, MD
We are always interested in disparities across gender or across ethnicities, and I think there’s always something we can learn whenever we see disparities like these. My initial reaction was, how do we put this in context in terms of what we already know about disparities in head and neck cancer, and what should it lead us to do next?
We already know head and neck cancer among men and women is very different. Men are much more prone to HPV-positive cancer of the oropharynx, and women much more commonly have cancer at other sites. The first thing we want to know is, was there a correction for cancer site? As the authors correctly point out, that is one of the variables that could be confounding their results.
The literature would suggest we tend to overtreat women on the basis of their performance status. Studies looking at performance status have previously recognized that there’s more discrepancy in performance status when physicians evaluate women than when they evaluate men, typically with physicians giving a higher score to women. This study was very interesting because the finding was the exact opposite. We were undertreating women relative to the amount of treatment administered to men.
It may come down to other clinical variables. I would really like to know more about the differences in location of the cancer, because head and neck cancer isn’t one disease. It’s really a mixture of diseases of very unique anatomic sites, and cancer of the oral cavity and cancer of the oropharynx are treated very differently. Something like an imbalance between the percentage of patients who had oral cavity versus oropharynx cancer could be something that explains the result. I’m sure the authors will be doing that sort of analysis moving forward. That may give us some further insights as to the direction we should take these findings.
Another point that needs to be analyzed are surgical factors. How often were margins positive in men versus women? One could imagine women having less disfiguring surgery; hence, the margin status could be different, on average, for men versus women. Could the importance of cosmesis be different in the two groups, affecting surgical decision-making? The decision to use a free flap as part of the reconstructive process could be different in the two groups.
All these factors are really very important in head and neck cancer, and they need to be evaluated independently. That analysis will be very interesting when this study ultimately appears in published form.
It also is important for all clinicians to recognize their own implicit biases in terms of how they take care of patients, and to be sure no one is being undertreated. A study like this reminds us that there are some very solid and well-established indications for who should get chemotherapy and radiation postoperatively, who should get it as definitive therapy, and when it is appropriate to add chemotherapy to radiation. It is important that those criteria are applied equally among men and women. Perhaps a study like this is an invitation for us to all go back and look at our own treatment patterns and be sure there is no discrepancy that shouldn’t be there.
Perspective
Back to TopJoshua Jones, MD, MA
This is a really striking study. This mathematical model helps us define which patients should get intensive treatment for head and neck cancer, and that treatment can be very intensive. Radiation and chemotherapy can have significant side effects. The outcomes of this study — both the disparities in treatment women receive compared with men, and the disparities in rate of death from head and neck cancer — were very surprising. We don’t know why those differences exist, but it’s really important that we continue this research so we can figure out what those differences are and why they are happening. This will help ensure, as we are talking to patients with head and neck cancer, that we are providing the right treatment for the right patient at the right time.
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