Oropharyngeal Cancer , Race , and the Human Papillomavirus Perspective on Settle et al . , p . 776

This perspective on Settle et al. (beginning on p. 776 in this issue of the journal) discusses the racial disparity in oropharyngeal cancer survival in relation to the biological factor human papillomavirus and its association with sexual behavior. This discussion is expanded to a more general consideration of biological and nonbiological (e.g., socioeconomic and cultural) factors affecting racial disparities in disease. Head and neck cancer is a group of diseases that have a higher incidence and cause higher mortality in blacks or African-Americans. Compared with whites, blacks are more likely to have an advanced stage of disease at diagnosis and to have inferior outcomes (shorter survival) within the same stage. The higher incidence of head and neck cancer among blacks has been attributed to a variety of factors, including differences in diet, alcoholic beverages, and tobacco use. Head and neck cancer occurs more frequently in men than in women (1, 2). In this issue of the journal, Settle et al. (3) report a significant study of black-white outcomes in head and neck cancer, which, like any significant article, asks perhaps as many questions as it answers. This article makes one think about what race really means in the medical literature, population categorizations, gene-environment interactions, and disparities in cancer incidence and outcome. Settle et al. show that, despite having disparate outcomes in head and neck cancer overall, black and white patients have similar outcomes for most head and neck cancer sites when they receive the same high-quality care. This finding confirms the premise that a major reason for black-white disparities in head and neck cancer outcomes in the United States is disparities in the quality and timeliness of cancer care, which have been documented in numerous studies (4). This difference in care is especially true of head and neck cancer (5). The key to solving most racial health disparities in the United States is for us to understand that equal treatment yields equal outcome among equal patients, and equal treatment has not been achieved. Much to their credit, these investigators took the important step of searching for the reason for the overall head and neck difference they observed, finding that it was entirely due to differences in oropharyngeal cancer outcomes. Searching further, they found that the oropharyngeal difference was attributable to racial differences in the prevalence of human papillomavirus (HPV)–positive tumors. Black and white patients with HPVnegative oropharyngeal tumors had similar outcomes. These findings are complemented by and consistent with the results of another study reported in this issue of the journal [Chen et al. (6)]. These investigators performed very detailed matching of African-American or Hispanic American head and neck cancer patients with non-Hispanic white patients by age, sex, smoking status, site, tumor stage, nodal status, and treatment. African-American patients had a significantly worse survival from cancer of the oropharynx but not of other head and neck sites. Therefore, two independent research groups using different methods found the same pronounced racial disparity in outcomes of oropharyngeal cancer (but not of other head and neck cancers) among patients receiving the same high-quality care. The role of HPV, specifically HPV-16, in oropharyngeal cancer is well established (7–9). Patients with HPV-positive oropharyngeal tumors have a better prognosis compared with HPV-negative oropharyngeal patients (10). The reasons for this better prognosis are not understood. At first glance, it seems surprising that the white population of oropharyngeal patients would have such a higher rate (∼9-fold) of HPV-positive cancers (3). Could there have been a selection or sampling bias in the trial population of HPVtested patients? No such bias was apparent, however, because these patients were prospectively accrued to a well-designed clinical trial. Therefore, could a race-related biological difference make whites more susceptible than blacks to HPV infection? The subject of biological differences among races is politically charged, harking back to the “biological difference” justification for slavery and segregation. The issue of biological differences, race, and infectious disease is especially sensitive. The atrocity known as the Tuskegee syphilis study was founded on the now discredited principle that an infectious disease (e.g., syphilis) behaves differently in blacks versus whites (11). Author's Affiliation: American Cancer Society; Departments of Hematology and Oncology (Emory University School of Medicine) and Epidemiology (Rollins School of Public Health), Emory University, Atlanta, Georgia Received 9/13/09; accepted 9/16/09; published OnlineFirst 7/29/09. Requests for reprints: Otis W. Brawley, American Cancer Society, 250 Williams Street, Atlanta, GA 30303. Phone: 404-329-7740; Fax: 404-3297530; E-mail: [email protected]. ©2009 American Association for Cancer Research. doi:10.1158/1940-6207.CAPR-09-0150 769 Cancer Prev Res 2009;2(9) September 2009 www.aacrjournals.org Cancer Research. on June 15, 2017. © 2009 American Association for cancerpreventionresearch.aacrjournals.org Downloaded from Published OnlineFirst July 29, 2009; DOI: 10.1158/1940-6207.CAPR-09-0150