title: Number of positive nodes is superior to the lymph node ratio and American Joint Committee on Cancer N staging for the prognosis of surgically treated head and neck squamous cell carcinomas.
abstract: Recent changes in head and neck cancer epidemiology have created a need for improved lymph node prognostics. This article compares the prognostic value of the number of positive nodes (pN) with the value of the lymph node ratio (LNR) and American Joint Committee on Cancer (AJCC) N staging in surgical patients.
  
  
  
  The Surveillance, Epidemiology, and End Results database was used to identify cases of head and neck squamous cell carcinomas from 2004 to 2012. The sample was grouped by the AJCC N stage, LNR, and pN and was analyzed with Kaplan-Meier and multivariate Cox proportional hazards models. The sample was also analyzed by the site of the primary tumor.
  
  
  
  This study identified 12,437 patients. Kaplan-Meier survival curves showed superior prognostic ability for LNR and pN staging in comparison with AJCC staging. Patients with a pN value > 5 had the worst overall survival (5-year survival rate, 16%). Patients with oropharyngeal tumors had better outcomes for all groupings, and a pN value > 5 for oropharyngeal cancers was associated with decreased survival. Multivariate regressions demonstrated larger hazard ratios (HRs) and a lower Akaike information criterion for the pN model versus the AJCC stage and LNR models. The HRs were 1.78 (95% confidence interval, 1.62-1.95) for a pN value of 1, 2.53 (95% confidence interval, 2.32-2.75) for a pN value of 2 to 5, and 4.64 (95% confidence interval, 4.18-5.14) for a pN value > 5.
  
  
  
  The pN models demonstrated superior prognostic value in comparison with the LNR and AJCC N staging. Future modifications of the nodal staging system should be based on the pN with a separate system for oropharyngeal cancers. Future trials should consider examining adjuvant treatment escalation in patients with >5 lymph nodes. Cancer 2016;122:1388-1397. © 2016 American Cancer Society.
authors.affiliation: Division of Head and Neck Surgery, Department of Otolaryngology, Stanford University School of Medicine, Stanford, California.
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Roberts
authors.affiliation: Department of Medicine-Oncology, Stanford University School of Medicine, Stanford, California.
authors.forename: A Dimitrios
authors.initials: AD
authors.lastname: Colevas
authors.affiliation: Department of Radiation Oncology-Radiation Therapy, Stanford University School of Medicine, Stanford, California.
authors.forename: Wendy
authors.initials: W
authors.lastname: Hara
authors.affiliation: Division of Head and Neck Surgery, Department of Otolaryngology, Stanford University School of Medicine, Stanford, California.
authors.forename: F Christopher
authors.initials: FC
authors.lastname: Holsinger
authors.affiliation: Cancer Prevention Institute of California, Fremont, California.|Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California.|Canary Center at Stanford for Cancer Early Detection, Stanford, California.|Stanford Cancer Institute, Stanford, California.
authors.forename: Ingrid
authors.initials: I
authors.lastname: Oakley-Girvan
authors.affiliation: Division of Head and Neck Surgery, Department of Otolaryngology, Stanford University School of Medicine, Stanford, California.|Stanford Cancer Institute, Stanford, California.
authors.forename: Vasu
authors.initials: V
authors.lastname: Divi
mesh_terms: D002294:Carcinoma, Squamous Cell / Q000401:mortality* / Q000473:pathology* / Q000556:secondary / Q000601:surgery; D016001:Confidence Intervals; D005260:Female; D006258:Head and Neck Neoplasms / Q000401:mortality* / Q000473:pathology* / Q000601:surgery; D006801:Humans; D015994:Incidence; D053208:Kaplan-Meier Estimate; D008198:Lymph Nodes / Q000473:pathology*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009367:Neoplasm Staging / Q000379:methods*; D009959:Oropharyngeal Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery; D011379:Prognosis; D016016:Proportional Hazards Models; D018426:SEER Program; D015996:Survival Rate; D014481:United States / Q000453:epidemiology
keywords: head and neck cancer; lymph nodes; oral cancer; oropharyngeal cancer; squamous cell carcinoma; staging