title: Race and competing mortality in advanced head and neck cancer.
abstract: OBJECTIVE
  Black patients with head and neck cancer (HNC) have poorer survival and disease control compared to non-black patients, but disparities in death from non-cancer causes (i.e., competing mortality) are less well-studied.
  
  
  METHODS
  We conducted an analysis of 538 patients (169 black, 369 non-black) with stage III-IV HNC treated on one of six multi-institutional protocols between 1993 and 2004 involving multi-agent chemoradiotherapy with or without surgery. Competing mortality was defined as death due to intercurrent comorbid disease, treatment-related morbidity, or unknown cause in the absence of disease recurrence, progression, or second malignancy. Cox proportional hazards and competing risks regression were used to estimate the effect of black race on competing mortality.
  
  
  RESULTS
  Black race was associated with increased rates of comorbidity, smoking, heavy alcohol use, advanced tumor stage, and poorer performance status (p<.001 for all). Compared to non-black patients, black HNC patients had a higher 5 year cumulative incidence of disease progression (31.4%; 95% CI, 24.4-38.5% vs 23.4%; 95% CI, 19.1-28.1%) and competing mortality (28.1%; 95% CI, 21.2-35.3% vs 14.5%; 95% CI, 11.0-18.5%). When adjusting for age, male sex, body mass index, distance traveled, smoking and alcohol use, performance status, comorbidity, and tumor stage, the black race was associated with death from comorbid disease (Cox hazard ratio 2.13; 95% CI, 1.06-4.28, p=0.033).
  
  
  CONCLUSIONS
  Black patients with advanced HNC are at increased risk of both disease progression and death from competing non-cancer mortality, particularly death from comorbid disease. Improved strategies to manage comorbid disease may increase the benefit of treatment intensification in black patients.
authors.affiliation: Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, CA, United States.
authors.forename: Kaveh
authors.initials: K
authors.lastname: Zakeri
authors.affiliation: Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, CA, United States.
authors.forename: Iain
authors.initials: I
authors.lastname: MacEwan
authors.affiliation: Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, CA, United States.
authors.forename: Aria
authors.initials: A
authors.lastname: Vazirnia
authors.affiliation: Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, United States.
authors.forename: Ezra E W
authors.initials: EE
authors.lastname: Cohen
authors.affiliation: Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL, United States.
authors.forename: Michael T
authors.initials: MT
authors.lastname: Spiotto
authors.affiliation: Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL, United States.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Haraf
authors.affiliation: Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, United States.
authors.forename: Everett E
authors.initials: EE
authors.lastname: Vokes
authors.affiliation: Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL, United States.
authors.forename: Ralph R
authors.initials: RR
authors.lastname: Weichselbaum
authors.affiliation: Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, CA, United States. Electronic address: lmell@ucsd.edu.
authors.forename: Loren K
authors.initials: LK
authors.lastname: Mell
mesh_terms: D003131:Combined Modality Therapy; D006258:Head and Neck Neoplasms / Q000188:drug therapy / Q000401:mortality* / Q000532:radiotherapy; D006801:Humans; D044382:Population Groups
keywords: Competing mortality; Head and neck cancer; Race