{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,11]],"date-time":"2026-06-11T15:22:56Z","timestamp":1781191376721,"version":"3.54.1"},"reference-count":43,"publisher":"American Medical Association (AMA)","issue":"12","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Netw Open"],"abstract":"Importance<\/jats:title>The socioeconomic gap in survival after cancer is pronounced among patients with head and neck cancer. Understanding the mechanisms of this gap is crucial to target intervention strategies.<\/jats:p><\/jats:sec>Objective<\/jats:title>To investigate socioeconomic differences in survival after oropharyngeal squamous cell carcinoma (OPSCC) according to human papillomavirus (HPV) status and the extent to which smoking, comorbidity, clinical stage, and treatment intent explain the survival gap.<\/jats:p><\/jats:sec>Design, Setting, and Participants<\/jats:title>This nationwide, population-based cohort study was based on prospectively collected information on all patients with a diagnosis of OPSCC from the Danish Head and Neck Cancer Group database and administrative registries. The study included 4600 patients born in 1921 or later, aged 30 years or older, and residing in Denmark 1 year prior to OPSCC diagnosis. Patients with missing information (547 [12%]) were excluded. Patients were diagnosed between January 1, 2008, and December 31, 2019, and followed up until December 31, 2021. Data were analyzed from June 6 to October 4, 2022.<\/jats:p><\/jats:sec>Exposure<\/jats:title>Socioeconomic position (educational level, disposable income, or cohabiting status).<\/jats:p><\/jats:sec>Main Outcomes and Measures<\/jats:title>Socioeconomic differences in 5-year overall survival were estimated in Cox proportional hazards regression models by HPV status. The indirect effect and proportion mediated by smoking, comorbidity, clinical stage, and treatment intent were estimated based on a counterfactual approach.<\/jats:p><\/jats:sec>Results<\/jats:title>The analyzed cohort comprised 4053 patients (1045 women [26%] and 3008 men [74%]). The median age was 61 years (IQR, 55-68 years), and 2563 patients (63%) had HPV-positive OPSCC while 1490 patients (37%) had HPV-negative OPSCC. The 5-year standardized overall survival was 10% to 15% lower among patients with a lower educational level, with low disposable income, or who were living alone (patients with HPV-positive OPSCC, 68%-71%; patients with HPV-negative OPSCC, 31%-34%) than patients with a higher educational level, high disposable income, or a cohabiting partner (patients with HPV-positive OPSCC, 81%-86%; patients with HPV-negative OPSCC, 43%-46%). Among patients with HPV-positive OPSCC, a considerable part of this survival gap was estimated to be associated with differences in smoking (27%-48%), comorbidity (10%-19%), clinical stage (8%-19%), and treatment intent (16%-28%). Among those with HPV-negative OPSCC, comorbidity (12%-22%) and treatment intent (16%-42%) were the primary potential mediators.<\/jats:p><\/jats:sec>Conclusions and Relevance<\/jats:title>This cohort study suggests that, regardless of HPV status, patients with low socioeconomic position had 10% to 15% lower 5-year overall survival than patients with high socioeconomic position. A substantial part of this survival gap was associated with differences in smoking, comorbidity, clinical stage, or treatment intent at diagnosis.<\/jats:p><\/jats:sec>","DOI":"10.1001\/jamanetworkopen.2022.45510","type":"journal-article","created":{"date-parts":[[2022,12,7]],"date-time":"2022-12-07T16:01:56Z","timestamp":1670428916000},"page":"e2245510","source":"Crossref","is-referenced-by-count":21,"title":["Association of Smoking, Comorbidity, Clinical Stage, and Treatment Intent With Socioeconomic Differences in Survival After Oropharyngeal Squamous Cell Carcinoma in Denmark"],"prefix":"10.1001","volume":"5","author":[{"given":"Maja Halgren","family":"Olsen","sequence":"first","affiliation":[{"name":"Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark"},{"name":"Survivorship and Inequality in Cancer, Danish Cancer Society Research Center, Copenhagen, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kirsten","family":"Frederiksen","sequence":"additional","affiliation":[{"name":"Statistics and Data Analysis, Danish Cancer Society Research Center, Copenhagen, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pernille","family":"Lassen","sequence":"additional","affiliation":[{"name":"Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Charlotte","family":"Rotb\u00f8l","sequence":"additional","affiliation":[{"name":"Department of Oncology, Aalborg University Hospital, Aalborg, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Trille Kristina","family":"Kjaer","sequence":"additional","affiliation":[{"name":"Survivorship and Inequality in Cancer, Danish Cancer Society Research Center, Copenhagen, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"J\u00f8rgen","family":"Johansen","sequence":"additional","affiliation":[{"name":"Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark"},{"name":"Department of Oncology, Odense University Hospital, Odense, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hanne","family":"Primdahl","sequence":"additional","affiliation":[{"name":"Department of Oncology, Aarhus University Hospital, Aarhus, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elo","family":"Andersen","sequence":"additional","affiliation":[{"name":"Department of Oncology, Herlev University Hospital, Herlev, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Claus Andrup","family":"Kristensen","sequence":"additional","affiliation":[{"name":"Department of Oncology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maria","family":"Andersen","sequence":"additional","affiliation":[{"name":"Department of Oncology, Aalborg University Hospital, Aalborg, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohammad","family":"Farhadi","sequence":"additional","affiliation":[{"name":"Department of Clinical Oncology and Palliative Care, Zealand University Hospital, N\u00e6stved, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jens","family":"Overgaard","sequence":"additional","affiliation":[{"name":"Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Susanne Oksbjerg","family":"Dalton","sequence":"additional","affiliation":[{"name":"Survivorship and Inequality in Cancer, Danish Cancer Society Research Center, Copenhagen, Denmark"},{"name":"Department of Clinical Oncology and Palliative Care, Zealand University Hospital, N\u00e6stved, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"name":"Danish Head and Neck Cancer Group (DAHANCA)","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"10","published-online":{"date-parts":[[2022,12,7]]},"reference":[{"issue":"2","key":"zoi221286r1","doi-asserted-by":"publisher","first-page":"337","DOI":"10.3390\/cancers13020357","article-title":"Estimation of the potentially avoidable excess deaths associated with socioeconomic inequalities in cancer survival in Germany.","volume":"13","author":"Jansen","year":"2021","journal-title":"Cancers (Basel)"},{"issue":"1","key":"zoi221286r2","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0228551","article-title":"Differences in cancer survival by area-level socio-economic disadvantage: a population-based study using cancer registry data.","volume":"15","author":"Afshar","year":"2020","journal-title":"PLoS One"},{"issue":"5","key":"zoi221286r3","doi-asserted-by":"publisher","first-page":"737","DOI":"10.1080\/0284186X.2019.1566772","article-title":"Socioeconomic inequality in cancer survival\u2014changes over time: a population-based study, Denmark, 1987-2013.","volume":"58","author":"Dalton","year":"2019","journal-title":"Acta Oncol"},{"key":"zoi221286r4","doi-asserted-by":"publisher","DOI":"10.1093\/ije\/dyy167","article-title":"Differential vulnerability and susceptibility: how to make use of recent development in our understanding of mediation and interaction to tackle health inequalities.","author":"Diderichsen","year":"2019","journal-title":"Int J Epidemiol"},{"issue":"1","key":"zoi221286r5","doi-asserted-by":"publisher","first-page":"7","DOI":"10.1136\/jech.2004.023531","article-title":"Indicators of socioeconomic position (part 1).","volume":"60","author":"Galobardes","year":"2006","journal-title":"J Epidemiol Community Health"},{"issue":"5","key":"zoi221286r6","doi-asserted-by":"publisher","first-page":"e1","DOI":"10.1093\/heapro\/day062","article-title":"Does health literacy mediate the relationship between socioeconomic status and health disparities? integrative review.","volume":"34","author":"Stormacq","year":"2019","journal-title":"Health Promot Int"},{"issue":"6","key":"zoi221286r7","doi-asserted-by":"publisher","DOI":"10.1111\/ecc.v28.6","article-title":"Characteristics of customary non-attenders in general practice who are diagnosed with cancer: a cross-sectional study in Denmark.","volume":"28","author":"Jensen","year":"2019","journal-title":"Eur J Cancer Care (Engl)"},{"issue":"1","key":"zoi221286r8","doi-asserted-by":"publisher","first-page":"140","DOI":"10.1111\/hex.v24.1","article-title":"What are the underlying reasons behind socioeconomic differences in doctor-patient communication in head and neck oncology review clinics?","volume":"24","author":"Allen","year":"2021","journal-title":"Health Expect"},{"key":"zoi221286r9","doi-asserted-by":"publisher","DOI":"10.1177\/10732748211011956","article-title":"Factors explaining socio-economic inequalities in cancer survival: a systematic review.","volume":"28","author":"Afshar","year":"2021","journal-title":"Cancer Control"},{"issue":"5","key":"zoi221286r10","doi-asserted-by":"publisher","first-page":"685","DOI":"10.3109\/0284186X.2014.996665","article-title":"Predictors of continuous tobacco smoking in a clinical cohort study of Danish laryngeal cancer patients smoking before treated with radiotherapy.","volume":"54","author":"M\u00f8ller","year":"2015","journal-title":"Acta Oncol"},{"issue":"5","key":"zoi221286r11","doi-asserted-by":"publisher","first-page":"759","DOI":"10.3109\/0284186X.2014.998279","article-title":"Socioeconomic position and stage at diagnosis of head and neck cancer\u2014a nationwide study from DAHANCA.","volume":"54","author":"Olsen","year":"2015","journal-title":"Acta Oncol"},{"key":"zoi221286r12","doi-asserted-by":"publisher","first-page":"491","DOI":"10.2147\/CLEP","article-title":"The Danish Head and Neck Cancer database.","volume":"8","author":"Overgaard","year":"2016","journal-title":"Clin Epidemiol"},{"key":"zoi221286r13","doi-asserted-by":"publisher","first-page":"102","DOI":"10.1016\/j.canep.2015.11.010","article-title":"Socioeconomic status, human papillomavirus, and overall survival in head and neck squamous cell carcinomas in Toronto, Canada.","volume":"40","author":"Chu","year":"2016","journal-title":"Cancer Epidemiol"},{"issue":"3","key":"zoi221286r14","doi-asserted-by":"publisher","first-page":"e313","DOI":"10.1200\/OP.20.00671","article-title":"Socioeconomic factors influence the impact of tumor HPV status on outcome of patients with oropharyngeal squamous cell carcinoma.","volume":"17","author":"Marks","year":"2021","journal-title":"JCO Oncol Pract"},{"issue":"1","key":"zoi221286r15","doi-asserted-by":"publisher","first-page":"131","DOI":"10.1177\/0194599820935853","article-title":"Socioeconomic and racial disparities and survival of human papillomavirus\u2013associated oropharyngeal squamous cell carcinoma.","volume":"164","author":"Rotsides","year":"2021","journal-title":"Otolaryngol Head Neck Surg"},{"issue":"1","key":"zoi221286r16","doi-asserted-by":"publisher","first-page":"107","DOI":"10.1016\/j.radonc.2017.10.018","article-title":"Prognostic impact of HPV-associated p16-expression and smoking status on outcomes following radiotherapy for oropharyngeal cancer: the MARCH-HPV project.","volume":"126","author":"Lassen","year":"2018","journal-title":"Radiother Oncol"},{"issue":"2","key":"zoi221286r17","doi-asserted-by":"publisher","first-page":"269","DOI":"10.1016\/j.radonc.2012.09.017","article-title":"Scoring and classification of oropharyngeal carcinoma based on HPV-related p16-expression.","volume":"105","author":"Lassen","year":"2012","journal-title":"Radiother Oncol"},{"issue":"1","key":"zoi221286r18","doi-asserted-by":"publisher","first-page":"24","DOI":"10.1056\/NEJMoa0912217","article-title":"Human papillomavirus and survival of patients with oropharyngeal cancer.","volume":"363","author":"Ang","year":"2010","journal-title":"N Engl J Med"},{"issue":"12","key":"zoi221286r19","doi-asserted-by":"publisher","first-page":"1992","DOI":"10.1200\/JCO.2008.20.2853","article-title":"Effect of HPV-associated p16INK4A expression on response to radiotherapy and survival in squamous cell carcinoma of the head and neck.","volume":"27","author":"Lassen","year":"2009","journal-title":"J Clin Oncol"},{"issue":"1","key":"zoi221286r21","doi-asserted-by":"publisher","DOI":"10.1016\/j.amjoto.2020.102780","article-title":"Decreased overall survival in Black patients with HPV-associated oropharyngeal cancer.","volume":"42","author":"Sheth","year":"2021","journal-title":"Am J Otolaryngol"},{"issue":"1","key":"zoi221286r22","doi-asserted-by":"publisher","DOI":"10.1016\/j.amjoto.2020.102816","article-title":"Race, not socioeconomic disparities, correlates with survival in human papillomavirus\u2013negative oropharyngeal cancer: a retrospective study.","volume":"42","author":"Freedman","year":"2021","journal-title":"Am J Otolaryngol"},{"issue":"2","key":"zoi221286r23","first-page":"177","article-title":"Outcomes of HPV-associated squamous cell carcinoma of the head and neck: impact of race and socioeconomic status.","volume":"18","author":"Pike","year":"2020","journal-title":"J Natl Compr Canc Netw"},{"issue":"6","key":"zoi221286r24","doi-asserted-by":"publisher","first-page":"654","DOI":"10.1016\/j.amjoto.2017.09.003","article-title":"Marital status as a predictor of survival in patients with human papilloma virus\u2013positive oropharyngeal cancer.","volume":"38","author":"Rubin","year":"2017","journal-title":"Am J Otolaryngol"},{"key":"zoi221286r25","doi-asserted-by":"publisher","first-page":"563","DOI":"10.2147\/CLEP","article-title":"The Danish health care system and epidemiological research: from health care contacts to database records.","volume":"11","author":"Schmidt","year":"2019","journal-title":"Clin Epidemiol"},{"key":"zoi221286r26","doi-asserted-by":"publisher","first-page":"149","DOI":"10.1016\/j.radonc.2020.07.037","article-title":"The Danish Head and Neck Cancer Group (DAHANCA) 2020 radiotherapy guidelines.","volume":"151","author":"Jensen","year":"2020","journal-title":"Radiother Oncol"},{"issue":"8","key":"zoi221286r27","doi-asserted-by":"publisher","first-page":"1329","DOI":"10.1002\/ijc.v150.8","article-title":"Treatment outcomes and survival following definitive (chemo)radiotherapy in HPV-positive oropharynx cancer: large-scale comparison of DAHANCA vs PMH cohorts.","volume":"150","author":"Lassen","year":"2022","journal-title":"Int J Cancer"},{"issue":"7","key":"zoi221286r28","doi-asserted-by":"publisher","first-page":"91","DOI":"10.1177\/1403494810394715","article-title":"Danish Education Registers.","volume":"39","author":"Jensen","year":"2011","journal-title":"Scand J Public Health"},{"issue":"7","key":"zoi221286r29","doi-asserted-by":"publisher","first-page":"103","DOI":"10.1177\/1403494811405098","article-title":"Danish registers on personal income and transfer payments.","volume":"39","author":"Baadsgaard","year":"2011","journal-title":"Scand J Public Health"},{"issue":"7","key":"zoi221286r30","doi-asserted-by":"publisher","first-page":"22","DOI":"10.1177\/1403494810387965","article-title":"The Danish Civil Registration System.","volume":"39","author":"Pedersen","year":"2011","journal-title":"Scand J Public Health"},{"issue":"7","key":"zoi221286r31","doi-asserted-by":"publisher","first-page":"30","DOI":"10.1177\/1403494811401482","article-title":"The Danish National Patient Register.","volume":"39","author":"Lynge","year":"2011","journal-title":"Scand J Public Health"},{"issue":"1","key":"zoi221286r34","doi-asserted-by":"publisher","first-page":"38","DOI":"10.1016\/j.radonc.2012.01.011","article-title":"Effect of smoking on oxygen delivery and outcome in patients treated with radiotherapy for head and neck squamous cell carcinoma\u2014a prospective study.","volume":"103","author":"Hoff","year":"2012","journal-title":"Radiother Oncol"},{"issue":"1","key":"zoi221286r35","doi-asserted-by":"publisher","first-page":"91","DOI":"10.1016\/j.radonc.2013.11.009","article-title":"Evaluation of comorbidity in 9388 head and neck cancer patients: a national cohort study from the DAHANCA database.","volume":"110","author":"B\u00f8je","year":"2014","journal-title":"Radiother Oncol"},{"issue":"9","key":"zoi221286r37","doi-asserted-by":"publisher","first-page":"847","DOI":"10.1007\/s10654-018-0375-y","article-title":"Estimation of causal effect measures with the R-package stdReg.","volume":"33","author":"Sj\u00f6lander","year":"2018","journal-title":"Eur J Epidemiol"},{"issue":"3","key":"zoi221286r39","doi-asserted-by":"publisher","first-page":"838","DOI":"10.1093\/ije\/dyn372","article-title":"Opening the black box: a motivation for the assessment of mediation.","volume":"38","author":"Hafeman","year":"2009","journal-title":"Int J Epidemiol"},{"issue":"4","key":"zoi221286r40","doi-asserted-by":"publisher","first-page":"426","DOI":"10.1007\/s11121-011-0270-1","article-title":"The causal mediation formula\u2014a guide to the assessment of pathways and mechanisms.","volume":"13","author":"Pearl","year":"2012","journal-title":"Prev Sci"},{"issue":"4","key":"zoi221286r41","doi-asserted-by":"publisher","first-page":"440","DOI":"10.1016\/S1470-2045(15)00560-4","article-title":"Development and validation of a staging system for HPV-related oropharyngeal cancer by the International Collaboration on Oropharyngeal Cancer Network for Staging (ICON-S): a multicentre cohort study.","volume":"17","author":"O\u2019Sullivan","year":"2016","journal-title":"Lancet Oncol"},{"issue":"10","key":"zoi221286r42","doi-asserted-by":"publisher","first-page":"1612","DOI":"10.1002\/cam4.2015.4.issue-10","article-title":"The relationships among individual and regional smoking, socioeconomic status, and oral and pharyngeal cancer survival: a mediation analysis.","volume":"4","author":"Guo","year":"2015","journal-title":"Cancer Med"},{"issue":"4","key":"zoi221286r43","doi-asserted-by":"publisher","first-page":"1252","DOI":"10.1002\/hed.v43.4","article-title":"Inequality in survival of people with head and neck cancer: Head and Neck 5000 cohort study.","volume":"43","author":"Ingarfield","year":"2021","journal-title":"Head Neck"},{"key":"zoi221286r20"},{"key":"zoi221286r36"},{"key":"zoi221286r32","unstructured":"Statistics Denmark. DISPON_13. Accessed October 31, 2022. https:\/\/www.dst.dk\/da\/Statistik\/dokumentation\/Times\/moduldata-for-sociale-forhold\u2013sundhedsvaesen\u2013retsvaesen\/livskvalitet\/dispon-13"},{"key":"zoi221286r33","unstructured":"Statistics Denmark. Households and families. Accessed October 2, 2022. https:\/\/www.dst.dk\/en\/Statistik\/emner\/borgere\/husstande-familier-og-boern\/husstande-og-familier"},{"key":"zoi221286r38","unstructured":"SAS Help Center. SAS\/STAT user\u2019s guide: the PHREG procedure. Accessed August 4, 2022. https:\/\/documentation.sas.com\/doc\/en\/pgmsascdc\/9.4_3.3\/statug\/statug_phreg_examples08.htm"}],"container-title":["JAMA Network Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/articlepdf\/2799261\/olsen_2022_oi_221286_1669818299.77682.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2022,12,7]],"date-time":"2022-12-07T16:02:02Z","timestamp":1670428922000},"score":1,"resource":{"primary":{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/fullarticle\/2799261"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,12,7]]},"references-count":43,"journal-issue":{"issue":"12","published-print":{"date-parts":[[2022,12,1]]}},"URL":"https:\/\/doi.org\/10.1001\/jamanetworkopen.2022.45510","relation":{},"ISSN":["2574-3805"],"issn-type":[{"value":"2574-3805","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,12,7]]}}}