Eric Adjei Boakye

Suicide: A Major Threat to Head and Neck Cancer Survivorship

TO THE EDITOR: The article by Ringash that was recently published in Journal of Clinical Oncology provided a compelling narrative of both the improvements made in head and neck cancer survivorship, as well as the challenges created by longer-term treatment and associated toxicities. There are currently at least 280,000 head and neck cancer survivors in the United States. As the article by Ringash stated, the upturn in head and neck cancer survivorship in the last three decades has coincided with the emergence of human papilloma virus-positive oropharyngeal cancer, as well as a decrease in tobacco use in the general population. These make it a challenge to isolate survival gains as a function of improved therapy from the natural prognostic value of a diagnosis of human papilloma virus-positive oropharyngeal cancer. Whatever the case, the fact that more than one-quarter million Americans are currently alive after a diagnosis of head and neck cancer means there needs to be a more deliberate effort in longer-term management of treatment-related toxicities, some of which are lifelong. We agree with Ringash’s conclusion that new models of care need to be developed in response to the significant quality-of-life issues faced by patients with head and neck cancer. The Institute of Medicine publication From Cancer Patient to Cancer Survivor: Lost in Transition, also cited by Ringash, called for a clear individualized survivorship plan for cancer patients. There is a serious need for this model to be implemented universally in head and neck cancer management. Although we agree with Ringash that patients with head and neck cancer face competing mortality risks from second primary cancers and other noncancers, what we found lacking was recognition of an important competing cause of mortality in head and neck cancer survivors: suicide. Suicide associated with head and neck cancer is not just a competing cause of death; it is also a quality-of-life issue. Many authors agree that head and neck cancer is among the top cancer sites associated with suicide. One national study of 1.3 million cancer patients even found that head and neck cancer carried the highest risk of suicide among cancer survivors. As a quality-of-life issue as well as a competing cause of death, the elevated risk of head and neck cancer-related suicide, although it peaks during the first few years after diagnosis, remains virtually throughout the course of the cancer survivor’s life. Additionally, some other wellknown quality-of-life issues associated with head and neck cancer (eg, pain, disability, esthetic compromise and body image issues, psychosocial function, anxiety, emotional distress, and depression) are all associated with suicide. Therefore, it is difficult to have a discussion of quality-of-life interventions in head and neck cancer without addressing the issue of suicide. Thus, we believe that suicide in patients with head and neck cancer should be addressed as a major threat to cancer survivorship. Cardiovascular disease, for example, is a known competing cause of death among patients with head and neck cancer, and is listed in Figure 4 of Ringash’s article. Cardiovascular disease may be managed for a long time; however, when a cancer patient decides that he/she is “better off dead,” a finality, or terminality, is invoked. This is quite unique to suicide compared with other competing causes of death. Thus, in the urgent call for “new strategies and models of care to better address quality-of-life issues and meet the needs of survivors of head and neck cancer,” we believe it is pertinent that suicide is recognized as an important threat to head and neck cancer survivorship.

Not just a woman's business! Understanding men and women's knowledge of HPV, the HPV vaccine, and HPV-associated cancers

Few studies have included men when assessing differences in knowledge about HPV, and HPV-associated cancers. We examined gender differences in knowledge about HPV, HPV vaccine, and HPV-associated cancers. Multivariable logistic regression models were used to analyze data of 3,677 survey respondents aged 18 years and older from the 2014 Health Information National Trends Survey. Covariates included age, race/ethnicity, marital status, education, income level, regular provider, general health, internet use, and family structure aged 9 to 27 years. Analyses were conducted in 2015. Sixty-four percent of respondents had heard of HPV and the HPV vaccine. Seventy-eight percent of respondents knew HPV causes cervical cancer, but only 29% knew it causes penile cancer, 26% knew it causes anal cancer, and 30% knew it causes oral cancer. In multivariable analyses, males were less likely to have heard of HPV (aOR: 0.33; 95% CI: 0.25-0.45), and less likely to have heard of the HPV vaccine (aOR: 0.24; 95% CI: 0.18-0.32) compared to females. No differences existed between males and females regarding knowledge about HPV-associated cancers. In conclusion, knowledge of HPV, the vaccine, and HPV-associated cancers in both males and females in the United States remains very low, especially among men.

40-year incidence trends for oropharyngeal squamous cell carcinoma in the United States

OBJECTIVES To determine differences in oropharyngeal squamous cell carcinoma (OPSCC) incidence between 1975 and 2014 stratified by race, sex, and age. MATERIALS AND METHODS We obtained age-adjusted OPSCC incidence rates for race and sex groups from 1975 to 2014 using the Surveillance, Epidemiology, and End Results 9 database. We defined OPSCC as cancers of the base of tongue, lingual/palatine tonsil, oropharynx, soft palate, uvula, and Waldeyers ring. We used Joinpoint analyses to determine incidence trends for race/sex/age groupings. RESULTS There were 38,624 oropharyngeal primary tumors in the analyses. Males accounted for 74% of sample population, and whites accounted for 84% of tumors. Overall, there was a 57.3% increase in incidence of oropharyngeal between 1975 and 2014. For blacks and whites, average incidence was lower for females than males. Rates for black males aged ≥50years was highest for most of the follow-up time but decreased sharply around 1988 and were surpassed by the significant increase in incidence in white males aged 50-59 (1995-2014 APC=4.07, p<0.001) and ≥60years (2002-2014 APC=4.25, p<0.001). For males aged ≥60, whites had higher rates than blacks starting in 2010. OPSCC incidence in White males (10.99 per 100,000 person-years) surpassed rates in Blacks (10.14 per 100,000 person-years) beginning in 2008. CONCLUSION OPSCC has significantly increased in the United States in the last 40 years. This overall increase in OPSCC can primarily be attributed to white males. OPSCC prevention and early detection efforts could target these demographic factors to decrease rising OPSCC incidence.

A Comparison of Parent- and Provider-Reported Human Papillomavirus Vaccination of Adolescents

INTRODUCTION There is considerable effort at the state and national levels to monitor human papillomavirus (HPV) vaccine uptake and understand the factors that influence who gets vaccinated. Accurate measurement of vaccination coverage is critical for monitoring HPV vaccination. This study aimed to determine comparability between parent- and provider-reported HPV vaccination status for a sample of adolescents in the U.S. METHODS Data from the 2014 National Immunization Survey-Teen were analyzed in 2016 for 20,827 adolescents. Information on HPV vaccine uptake (initiation [one or more dose] and completion [three or more doses]) was obtained using parental (recall) and provider reports (electronic medical records). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and κ-coefficient were computed to determine how comparable parental and provider (ref group) reports were for HPV vaccination. RESULTS Prevalence of HPV vaccine initiation was comparable between parental and provider report (51.3% vs 50.0%) and for completion (30.7% vs 27.3%). Compared with provider report, parent-reported HPV vaccine initiation had high sensitivity (86.0%), specificity (87.4%), PPV (87.5%), NPV (85.9%), and acceptable κ-coefficient (0.73). Compared with provider report, parent-reported HPV vaccine completion had a sensitivity of 71.5%, specificity of 91.1%, PPV of 78.5%, NPV of 87.6%, and κ-coefficient of 0.64. Similar characteristics-adolescent age, sex, number of doctor visits, and region-were associated with HPV vaccine uptake using parental and provider reports. CONCLUSIONS Parental recall is comparable to provider report in monitoring HPV vaccine uptake for adolescents, although parental recall is less comparable for HPV vaccine completion.

Association Between Head and Neck Squamous Cell Carcinoma Survival, Smoking at Diagnosis, and Marital Status

Importance While the adverse association between smoking and head and neck squamous cell carcinoma (HNSCC) survival has been well described, there are also inconclusive studies and those that report no significant changes in HNSCC survival and overall mortality due to smoking. There is also a lack of studies investigating the association of marital status on smoking status at diagnosis for patients with HNSCC. Objective To examine the association between patient smoking status at HNSCC diagnosis and survival and the association between marital status and smoking in these patients. Design, Setting, and Participants This retrospective cohort study was conducted by querying the Saint Louis University Hospital Tumor Registry for adults with a diagnosis of HNSCC and treated at the university academic medical center between 1997 and 2012; 463 confirmed cases were analyzed. Main Outcomes and Measures Cox proportional hazards regression analysis was used to evaluate association of survival with smoking status at diagnosis and covariates. A multivariate logistic regression model was used to assess whether marital status was associated with smoking at diagnosis adjusting for covariates. Results Of the 463 total patients (338 men, 125 women), 92 (19.9%) were aged 18 to 49 years; 233 (50.3%) were aged 50 to 65 years; and 138 (29.8%) were older than 65 years. Overall, 56.2% of patients were smokers at diagnosis (n = 260); 49.6% were married (n = 228); and the mortality rate was 54.9% (254 died). A majority of patients were white (81.0%; n = 375). Smokers at diagnosis were more likely to be younger (ie, <65 years), unmarried, and to drink alcohol. We found a statistically significant difference in median survival time between smokers (89 months; 95% CI, 65-123 months) and nonsmokers at diagnosis (208 months; 95% CI, 129-235 months). In the adjusted Cox proportional hazards model, patients who were smokers at diagnosis were almost twice as likely to die during the study period as nonsmokers (hazard ratio, 1.98; 95% CI, 1.42-2.77). In the multivariate logistic regression analysis, unmarried patients were 76% more likely to use tobacco than married patients (adjusted odds ratio, 1.76; 95% CI, 1.08-2.84). Conclusions and Relevance Smokers were almost twice as likely as nonsmokers to die during the study period. We also found that those who were married were less likely to be smokers at diagnosis. Our study suggests that individualized cancer care should incorporate social support and management of cancer risk behaviors.

Sociodemographic Factors Associated With Knowledge and Risk Perception of Human Papillomavirus and Human Papillomavirus-Associated Oropharyngeal Squamous Cell Carcinoma Among a Predominantly Black Population.

Importance The incidence of human papillomavirus (HPV)–associated oropharyngeal squamous cell carcinoma (OPSCC) is increasing in the United States and may be underestimated among black individuals. Characterizing the current knowledge level among black individuals is critical to developing interventions to increase awareness. Objective To describe the sociodemographic correlates of knowledge and risk perception of HPV and HPV-associated OPSCC among a predominantly black population. Design, Setting, and Participants A cross-sectional survey was conducted at a drag racing event on September 12 and 13, 2015, in Madison, Illinois. The setting was a community-based oral head and neck cancer screening and education initiative. Participants were 301 drag race attendees 18 years or older who were conveniently sampled from attendees at an annual drag racing event predominantly patronized by black individuals. Main Outcomes and Measures The primary outcome was knowledge and risk perception of HPV and HPV-associated OPSCC. An electronic-based questionnaire elicited sociodemographic information and contained oral cancer knowledge and risk perception items, which were combined to form knowledge and risk perception scores. Multivariable linear regression analysis assessed estimates of knowledge and risk perception of HPV and HPV-associated OPSCC. Results Of the 301 participants (111 female and 190 male) completing the questionnaire, 194 (64.5%) were black. Overall, respondents ranged in age from 18 to 78 years, with a mean (SD) age of 48.0 (13.0) years. The mean (SD) knowledge score was 5.7 (4.6) of 15, and the mean (SD) risk perception score was 2.2 (1.4) of 6. Using multivariable linear regression, we found that, for every 1-year increase in age, knowledge of HPV-associated OPSCC decreased by 5.0% and was worse in men (&bgr; = −1.26; 95% CI, −2.33 to −0.18), black vs white individuals (&bgr; = −1.29; 95% CI, −2.35 to −0.23), and those with a high school diploma or less vs college graduates (&bgr; = −3.23; 95% CI, −4.67 to −1.80). Black individuals also had lower perceived risk of developing HPV-associated OPSCC (&bgr; = −0.36; 95% CI, −0.69 to −0.02) compared with white individuals, and participants with a high school diploma or less had lower perceived risk of developing HPV-associated OPSCC compared with those with a college degree or higher (&bgr; = −0.59; 95% CI, −1.04 to −0.14). Conclusions and Relevance Age and sex were independent correlates of knowledge of HPV-associated OPSCC, while race and education level were correlates of both knowledge and risk perception of HPV-associated OPSCC. These findings should inform future interventions targeted at increasing knowledge of HPV-associated OPSCC in black communities.

Correlates of health information seeking between adults diagnosed with and without cancer

Purpose To examine predictors of information seeking behavior among individuals diagnosed with cancer versus those without. Methods Cross-sectional data from the Health Information National Trends Survey 4 Cycles 1–3 (October 2011 to November 2013) were analyzed for 10,774 survey respondents aged ≥18 years. Binary logistic regression was used to examine the effect of socio-demographic and behavioral factors on health information seeking. Results Cancer diagnosis did not predict health information seeking. However, respondents diagnosed with cancer were more likely to seek health information from a healthcare practitioner. Compared to males, females were more likely to seek health information irrespective of cancer diagnosis. Regardless of cancer diagnosis, those without a regular healthcare provider were less likely to seek health information. Likelihood of seeking health information declined across education strata, and significantly worsened among respondents without high school diplomas irrespective of cancer diagnosis. Conclusions Respondents sought health information irrespective of cancer diagnosis. However, the source of health information sought differed by cancer diagnosis. Gender, education, and having a regular healthcare provider were predictors of health information seeking. Future health communication interventions targeting cancer patients and the general public should consider these findings for tailored interventions to achieve optimal results.

Characteristics and predictors of oral cancer knowledge in a predominantly African American community

Purpose To characterize smoking and alcohol use, and to describe predictors of oral cancer knowledge among a predominantly African-American population. Methods A cross-sectional study was conducted between September, 2013 among drag racers and fans in East St. Louis. Oral cancer knowledge was derived from combining questionnaire items to form knowledge score. Covariates examined included age, sex, race, marital status, education status, income level, insurance status, tobacco and alcohol use. Adjusted linear regression analysis measured predictors of oral cancer knowledge. Results Three hundred and four participants completed questionnaire; 72.7% were African Americans. Smoking rate was 26.7%, alcohol use was 58.3%, and mean knowledge score was 4.60 ± 2.52 out of 17. In final adjusted regression model, oral cancer knowledge was associated with race and education status. Compared with Caucasians, African Americans were 29% less likely to have high oral cancer knowledge (β = -0.71; 95% CI: -1.35, -0.07); and participants with a high school diploma or less were 124% less likely to have high oral cancer knowledge compared with college graduates (β = -1.24; 95% CI: -2.44, -0.41). Conclusions There was lower oral cancer knowledge among African Americans and those with low education. The prevalence of smoking was also very high. Understanding predictors of oral cancer knowledge is important in future design of educational interventions specifically targeted towards high-risk group for oral cancer.

Self-Reported Lifetime Depression and Current Mental Distress Among Veterans Across Service Eras

INTRODUCTION Limited research exists comparing the prevalence of lifetime depression and current mental distress between veterans and nonveterans by military service era. We compared the prevalence of self-reported lifetime depression and current mental distress between veterans and nonveterans of the World War II, Korea, Vietnam, and Gulf War eras. METHODS Data from the 2012 Behavior Risk Factor Surveillance System were analyzed for 243,561 survey participants aged 18 years and older. Separate multivariable logistic regression models were computed for each service era to estimate the association between veteran status and lifetime depression and current mental distress. RESULTS Lifetime depression was lower among veterans vs. nonveterans who served in the military during World War II era (adjusted odds ratio [aOR] = 0.54; 95% confidence interval [CI] = 0.43-0.66) and the Korean War era (aOR = 0.50; 95% CI = 0.42-0.59) but higher among veterans vs. nonveterans of the Vietnam War era (aOR = 1.39; 95% CI = 1.43-1.73). Similarly, current mental distress was lower among veterans vs. nonveterans of the World War II era (aOR = 0.56; 95% CI = 0.44-0.71) and the Korean War era (aOR = 0.47; 95% CI = 0.37-0.60) but higher among veterans vs. nonveterans of the Vietnam War era (aOR = 1.14; 95% CI = 1.02-1.28). CONCLUSION Both lifetime depression rates and current mental distress differed among veterans compared to nonveterans within each service era. Understanding the burden of depressive disorder among veterans of all eras may facilitate efficient and effective treatment and allocation of mental health care resources.

Primary Cancer vs Competing Causes of Death in Survivors of Head and Neck Cancer

that by releasing panelists’ names they would be subject to lobbying by numerous entities. This proposed legislation and the California Association of Health Plans’ response highlight the concern and complexity around OCP transparency. Collaboration with industry is key to innovation; however, to ensure patient and clinician trust and maintain their momentum in the value space, pathway developers will need to be transparent about FCOI and how those interests are managed. Many vendors have begun this process, and 1 suggestion would be to take guidance from the Institute of Medicine’s recommendations for groups charged with clinical practice guideline development.6