ORIGINAL ARTICLE NATIONAL CANCER DATABASE REPORT ON CANCER OF THE HEAD AND NECK: 10-YEAR UPDATE

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1 ORIGINAL ARTICLE NATIONAL CANCER DATABASE REPORT ON CANCER OF THE HEAD AND NECK: 10-YEAR UPDATE Jay S. Cooper, MD, 1 Kim Porter, MPH, 2 Katherine Mallin, PhD, 2 Henry T. Hoffman, MD, 3 Randal S. Weber, MD, 4 Kian K. Ang, MD, PhD, 5 E. Greer Gay, RN, PhD, MPH, 2 Corey J. Langer, MD 6 1 Department of Radiation Oncology, Maimonides Medical Center, Brooklyn, New York. jcooper@maimonidesmed.org 2 American College of Surgeons, Chicago, Illinois 3 Department of Otolaryngology Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa 4 Department of Head and Neck Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 5 Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 6 Fox Chase Cancer Center, Philadelphia, Pennsylvania Accepted 8 September 2008 Published online 2 February 2009 in Wiley InterScience ( DOI: /hed Abstract: Background. We sought to examine the current state of cancer care for head and neck tumors in the United States. We therefore performed a retrospective, longitudinal study of the approximately 822,000 head and neck cancer cases included in the National Cancer Data Base (NCDB) for 1990 through 2004, representing approximately 75% of the estimated incident diagnoses in the United States. Methods. All cases of head and neck cancer diagnosed and reported to the NCDB during this interval were reviewed, and descriptive statistics, grouped by disease and host factors, were analyzed over time and compared with a prior similar analysis done 10 years ago. Results. Although many similarities persist, several major changes in head and neck cancer have occurred, most notably (1) a decrease in the number of the older-aged patients who have mucosally derived squamous cell carcinomas coupled with an increase in the number of younger-aged Correspondence to: J. S. Cooper VC 2009 Wiley Periodicals, Inc. patients who have thyroid-origin adenocarcinomas and (2) a decrease in the use of radiation therapy alone for treatment in favor of chemotherapy enhanced radiation therapy. Conclusion. Head and neck cancers include a heterogeneous group of tumors whose precise composition changes over time and whose therapy evolves as well. The NCDB is well suited to capture this information and provide both an analysis of the current state of cancer care for head and neck tumors and a longitudinal view over time. VC 2009 Wiley Periodicals, Inc. Head Neck 31: , 2009 Keywords: national cancer database; head and neck cancer; cancer; demographics; nationwide The National Cancer Data Base (NCDB) was established in 1989 by the American College of Surgeons Commission on Cancer (CoC) and the American Cancer Society. 1,2 Every year, the NCDB collects information submitted from hospital-based cancer registries detailing the state of cancer care throughout the United States. 748 National Cancer Database Report on Cancer: 10-Year Update HEAD & NECK DOI /hed June 2009

2 Analysis of these data provides a snapshot of the current status of care and permits longitudinal analyses of changes in care over time. To interpret the database accurately, it is necessary to know that the instructions given to tumor registrars (ie, the rules used to identify, categorize, and report findings) have changed within the past decade; the instructions have evolved from those in the Data Acquisition manual, to those in the Registry Operations and Data Standards, and then to the Facility Oncology Registry Data Standards manual. Although these changes have upgraded the quality of the information reported to the NCDB, the information now collected is not precisely congruent with the data collected over all years of study. Similar limitations have been imposed by changes associated with the incorporation of new staging rules in new editions of the American Joint Committee on Cancer (AJCC) staging manuals. As a result, some nuances in data interpretation prevent precise comparability of our current findings with previous findings throughout this report. The 1998 NCDB report by Hoffman et al 3 provided information grouped by earlier ( ) and later ( ) years of accrual. To facilitate comparison, this report intentionally overlaps the later group ( ) and adds 2 newer groups ( and ). The purpose of this study was to provide a modern overview of head and neck cancer by providing a snapshot of the current status of disease and care which simultaneously permits longitudinal analyses of changes in disease presentation and care over time. PATIENTS AND METHODS The NCDB collects data from hospital-based cancer registries during the annual call for data. This manuscript reflects the data collected for 1990 through The NCDB serves as a comprehensive clinical surveillance resource for cancer care in the United States with the intention of improving the quality of cancer care by providing physicians, cancer registrars, and others with the means to compare their management with that of other cancer centers around the country. Institutional cancer case series were voluntarily reported to the NCDB by any hospital with an active cancer registry until the end of Beginning in 1996, case reporting became a standing requirement of, and starting in 2001, was limited to, CoC-approved cancer programs. Newly approved CoC-accredited members report not only their current data, but may also report data from prior years if the registry data conform to the current NCDB standards. Consequently, the number of head and neck cancer cases accrued between 1990 and 1994 in this report is larger (n ¼ 254,256) than the number in the same interval described in the prior report (n ¼ 176,730). The NCDB collects data from over 1440 CoC-approved cancer program registries, accounting for approximately 75% of the estimated incident cancer diagnosed in the United States. The NCDB includes approximately 19 million cases of reported cancer diagnosed between 1985 and Tumors were defined using the topography and morphology codes from the International Classification of Disease for Oncology (ICD-O 2 and 3). Tumors were included in this analysis if the reported primary site was lip, oral cavity, oropharynx, nasopharynx, hypopharynx, and major salivary glands (C ), sinonasal tract (C30.0, ), larynx (C ), middle ear (C30.1), trachea (C33.9), eye and ocular adnexa (C ), olfactory nerve (C72.2), thyroid gland (C73.9), parathyroid gland (C75.0), other endocrine-related structures (C75.2, C ) [excluding pineal and pituitary glands], bones, joints, and articular cartilages isolated to the head/neck (C ), peripheral nerves (C47.0), connective, subcutaneous, and other soft tissues (C49.0), lymph nodes (77.0), or other and ill-defined (C76.0). Histologic diagnoses were grouped as carcinoma NOS (M8010, M ), squamous cell carcinoma (M ), verrucous carcinoma (M8051), adenocarcinoma (M ), and lymphoma (M ). All other histological codes were combined into a category labeled other. A case was included if the tumor was the only primary or the first of multiple primaries. The race/ethnicity categories used by NCDB have been modified from the previous report to comply with the standards of classification of federal data on race and ethnicity. 4 For purposes of this report, race and ethnicity were grouped as White non-hispanic, Black non-hispanic, Hispanic, other, and unknown. U.S. Census median income data 5 were linked to each patient s zip code. Median National Cancer Database Report on Cancer: 10-Year Update HEAD & NECK DOI /hed June

3 Table 1. Demographic characteristics, percent distribution, and means by diagnosis years. Year of diagnosis Sex Male Female Age group < þ Unknown Mean age Race/ethnicity White non-hispanic Black non-hispanic Hispanic Other Unknown Median household income percentile* Lowest 20% % % Unknown Total N 254, , ,786 *Based on 1990, 2000 Census Median Income at zip code level (1990), zip code tabulation areas (ZCTA) household incomes were calculated for each zip code (1990) or ZCTA 1 (2000). (ZCTAs are generalized area representations of U.S. Postal Service [USPS] ZIP Code service areas, built by aggregating Census 2000 blocks.) Patients diagnosed from 1990 to 1994 were assigned census values from 1990, and patients diagnosed from 1995 to 2004 were assigned census values from The income value is a proxy measure of the socioeconomic milieu in which the patient lives. Because of changes made to the AJCC staging system over time, 3 different staging models were applied to cancers included in this report. The AJCC third edition staging system was in place for cases diagnosed between 1990 and 1992, the fourth edition was used for cases diagnosed between 1993 and 1997, the fifth edition was applied to cases diagnosed between 1998 and 2002, and the sixth edition was used for cases diagnosed between 2003 and RESULTS Between 1990 and 2004, 821,779 head and neck tumors (approximately 55,000 per year) were reported to the NCDB and accounted for 6.5% of all tumors (range, 6.2% to 6.9% per year). Patient Characteristics. Between 1990 and 1999, patients were more likely to be in the 60- to 69- year-old cohort; however, between 2000 and 2004, patients were more likely to be between the ages of 50 and 59 (Table 1). Men were more commonly affected than women (57.4% vs 42.6%), but the proportion of women who developed head and neck cancers rose somewhat from 40.2% to 45.3%. The distribution of tumors within race/ethnicity groups was relatively stable across the years of study, with the percentage of Hispanic and other race/ethnicity groups increasing slightly. The majority of patients lived in zip codes that had median household family incomes in the 20th to 80th percentile. The income distribution was relatively stable over time. The mucosally derived head and neck cancers were more commonly associated with lower income (greatest percentage of low-income group and least percentage of high-income group), whereas thyroid gland carcinomas had the opposite associations (Table 2). Median household income percentile Table 2. Median household income percent distribution by head and neck sites. Major head and neck sites* Major salivary gland Head and neck tumor sites Thyroid gland Sinonasal Eye and adnexa Bottom 20% % % Missing Total N 437,251 36, ,875 23,984 28, ,211 *Lip, oral cavity, oropharynx, nasopharynx, hypopharynx, pharynx NOS, larynx. Other 750 National Cancer Database Report on Cancer: 10-Year Update HEAD & NECK DOI /hed June 2009

4 Table 3. Primary site, cell type, differentiation: percent distribution by year of diagnosis. Year of diagnosis Primary site N Lip ,137 Oral cavity ,880 Oropharynx ,205 Nasopharynx ,436 Hypopharynx ,768 Pharynx, NOS ,892 Larynx ,993 Major salivary gland ,857 Thyroid gland ,875 Sinonasal ,984 Eye and adnexa ,601 Other ,211 Cell type Squamous cell carcinoma ,289 Adenocarcinoma ,562 Verrucous carcinoma ,546 Carcinoma, NOS ,429 Lymphoma ,523 Other ,430 Grade/differentiation Well differentiated ,342 Moderately differentiated ,877 Poorly differentiated ,938 Undifferentiated ,805 Subtotal known grade 141, , , ,962 Missing/unknown* ,817 N 254, , , ,779 *As percent of all cases. Disease Characteristics. A major shift in the distribution of anatomic sites has occurred over the years such that carcinomas arising in the thyroid gland now constitute the largest group of tumors (Table 3) increasing from 17% to 30% over the 3 time periods. As in the previous report, carcinomas of the larynx remain the most common type of squamous malignancy. However, the relative proportion of nonthyroid malignancies has decreased for every anatomic subsite except carcinomas of the oropharynx (which have increased) and carcinomas of the major salivary glands (which have remained stable). Squamous cell carcinoma constitutes (as it did previously) the largest histologic-type group (Table 3), but the proportion of this histologictype relative to others has decreased over time. This decrease in squamous cell carcinoma correlated with an increase in adenocarcinoma. As would be expected, the vast majority (89%) of cancers arising from mucosal surfaces of the upper aerodigestive tract (lip, oral cavity, pharynx, and larynx) were squamous cell carcinomas. Squamous cell carcinomas accounted for 90.8% of the common head and neck cancers in men and 83.6% in women (Table 4). Adenocarcinoma was the most common histologic type seen in the thyroid gland (93.5% of men; 95.2% of women) and major salivary glands (53.1% of men; 60.4% of women). Lymphoma constituted 82.5% of the cases (80.3% in men; 85.1% in women) originating in the primary site group labeled Other, which includes lymph nodes of the head, face, and neck. Similar to the findings in the 1998 report, the proportion of lymphoma cases arising at designated sites was greatest for the eye and ocular adnexa (20.9%), major salivary glands (15.5%), sinonasal (13.5%), and nasopharynx (10.7%). Unlike the findings in the 1998 report, the proportion of tumors classified as carcinoma, NOS was greatest in the nasopharynx, sinonasal regions, and major salivary gland. Despite changes in the staging system rules, there has been little change in the percentages National Cancer Database Report on Cancer: 10-Year Update HEAD & NECK DOI /hed June

5 Site Squamous cell carcinoma Table 4. Percent distribution of histologic type by anatomical site and sex. Adenocarcinoma Histologic type Verrucous carcinoma Carcinoma NOS Lymphoma Other Major head and neck sites* Male ,464 Female ,787 Major salivary gland Male ,979 Female ,878 Thyroid gland Male ,592 Female ,283 Sinonasal Male ,166 Female ,818 Eye and adnexa Male ,330 Female ,271 Other Male ,806 Female ,405 *Lip, oral cavity, oropharynx, nasopharynx, hypopharynx, pharynx NOS, larynx. N of stage III or stage IV tumors. Stage I tumors have become more common over time and stage II tumors decreased in the most recent ( ) grouping (Table 5). Associations between the degree of histologic differentiation, histologic type, and stage are suggested by our data (Tables 6 and 7). Undifferentiated carcinomas and poorly differentiated carcinomas more commonly presented as stage IV disease, whereas well-differentiated carcinomas were most frequently associated with stage Table 5. Percent distribution of AJCC stage by edition years. AJCC stage (fourth edition) AJCC edition year groups (fifth edition) (sixth edition) 0, In situ I II III IV Subtotal 338, , ,277 known stage Percent unknown stage Total 415, , ,874 I disease. Similarly, carcinomas that were not otherwise classified were associated with stage IV disease, whereas adenocarcinomas and verrucous carcinomas were most often associated with stage I. Table 6. Percent distribution of degree of differentiation by stage and AJCC edition. Degree of differentiation AJCC stage, edition Well Moderate Poor Undifferentiated Fourth edition, I II III IV N 48,492 92,635 50, Fifth edition, I II III IV N 32,051 60,197 34, Sixth edition, I II III IV N 11,622 22,563 13, National Cancer Database Report on Cancer: 10-Year Update HEAD & NECK DOI /hed June 2009

6 Squamous cell carcinoma Table 7. Percent distribution of histologic type by stage and AJCC edition. Adenocarcinoma Histologic type, AJCC edition Verrucous carcinoma Carcinoma, NOS Lymphoma Other AJCC fourth edition, I II III IV N 195,016 81, , AJCC fifth edition, I II III IV N 126,413 77, , AJCC sixth edition, I II III IV N 48,653 36, , Similar to the findings in the 1998 report, 3 the most common initial management strategies used over all years (Table 8) were surgery alone (28.3%, relatively unchanged over time), surgery combined with irradiation (22.0%, relatively unchanged over time), and irradiation alone (15.2%, decreasing over time). Modest changes in the types of treatments occurred between 1990 and 2004 with a continuing trend toward an increasing use of combined radiotherapy and chemotherapy as was previously detected by Hoffman et al. 3 Use of combined chemotherapy with radiation as initial management increased from 6.1% of patients treated between 1990 and 1994 to 11.7% of patients treated between 2000 and A corresponding decrease, from 18.5% to 11.7% in the use of radiation therapy alone for initial management, occurred over the same time periods. This trend is clearly evident for laryngeal tumors (Table 9) as part of organ preservation: the use of surgery alone dropped from 21.4% to 17.5%, the use of surgery and radiation therapy dropped from 28.9% to 20.2%, while the use of radiation therapy with chemotherapy increased from 4.4% to 15.0%. Outcome. Five-year relative survival for patients whose tumors were diagnosed between 1990 and 1999, grouped by the more and less common tumor types, is shown in Figures 1A Table 8. Percent distribution of treatment by diagnosis year, all head and neck tumors. Treatment All years N Surgery only ,830 Radiation only ,024 Chemotherapy only ,842 Surgery and radiation ,143 Surgery and chemotherapy ,464 Radiation and chemotherapy ,017 Surgery, radiation, chemotherapy ,765 Other treatment ,815 Unknown or no treatment ,879 N ,779 National Cancer Database Report on Cancer: 10-Year Update HEAD & NECK DOI /hed June

7 Table 9. Percent distribution of treatment by diagnosis year, laryngeal tumors only. Treatment N Surgery only ,378 Radiation only ,444 Chemotherapy only Surgery and radiation ,100 Surgery and chemotherapy Radiation and chemotherapy ,442 Surgery, radiation, chemotherapy No surgery, radiation, chemotherapy ,163 or unknown treatment Other treatments N 52,410 53,206 45, ,933 and 1B, respectively. As a group, carcinomas of the lip have the best survival at every time point, whereas carcinomas of the hypopharynx have the worst. Carcinomas of the oral cavity, nasopharynx, and oropharynx have relatively similar outcome. Over time (see Figure 2), changes in 5-year survival are modest when comparing the years 1990 to 1994 to the years 1995 to 1999; no site changes by more than 6%. However, the large numbers of patients included in the NCDB allow us to detect statistically significant improvements in carcinomas of the oral cavity, oropharynx, and nasopharynx, as well as a statistically significant decrease in carcinomas of the larynx. Survival data grouped by histology are shown in Figure 3 for 1990 to 1999 cases. At all points in time, adenocarcinomas are associated with the best survival rates (93% at 5 years), squamous cell carcinomas and carcinomas NOS with the worst survival rates (approximately 55% at 5 years), and verrucous carcinomas and lymphomas with intermediate survival rates (83% and 75%, respectively, at 5 years). Conditional survival, defined as the probability of additional survival once the patient has survived to that point (eg, the probability of surviving for 3 years if the patient already has survived for 2 years), is detailed in Figures 4A and FIGURE 1. Five-year survival by site: (A) mucosal surfaces of the aerodigestive tract and (B) other, for 1990 to 1999 cases of head and neck cancers. FIGURE 2. Five-year survival by site: 1990 to 1994 versus 1995 to National Cancer Database Report on Cancer: 10-Year Update HEAD & NECK DOI /hed June 2009

8 FIGURE 3. Five-year survival by histologic type for 1990 to 1999 cases of head and neck cancers. 4B. Although there is a nearly 30% difference in the probability of survival for the first year (69.4% for the hypopharynx to 98.6% for the lip), 5-year conditional survival (predicated on living at least to year 4) shows less than a 10% range. Clearly, for head and neck cancers as a group, surviving for a year improves the patient s chances of surviving for another year. DISCUSSION Examination of the NCDB at any point in time provides both an assessment of the nationwide state of cancer care and allows changes over time to be assessed. By adding 10 years of data ( ) to those in the previous evaluation, 3 the current report augments and contemporizes the previous publication. Although the number of cancer cases per year reported to the NCDB varied between 649,574 and 971,661 over the 15-year span, the proportion of head and neck tumors varied by less than 1%, between 6.2% and 6.9%. This consistency seems remarkable considering the changes in culture (smoking became less popular and socially acceptable), improvements in detection, and changes in the relative proportions of types of head and neck tumors (discussed below). FIGURE 4. (A) Conditional 5-year survival of (mucosal surface of the aerodigestive tract) head and neck cancers. (B) Conditional 5-year survival of (other) head and neck cancers. Patient Characteristics. Overall, head and neck cancer remains a disease that typically affects elderly (60 69 years old), poor, white men. However, shifts in patient characteristics appear to be occurring. In the 2000 to 2004 cohort, the prototype patient was not quite as old (most commonly 50 to 59 years old), wealthier, slightly less likely to be white, and less likely to be a man. The clustered association of relatively elderly, poor men who have squamous cell cancers arising in the common head and neck sites (oral cavity, nasopharynx, oropharynx, hypopharynx, and larynx; see below) is being replaced by the cluster of younger, wealthier women who are developing adenocarcinomas of the thyroid gland. Disease Characteristics. In the 1998 report, an 11.5% proportionate increase in the number of reported cases of adenocarcinoma occurred between the years 1985 to 1989 and the years 1990 to This trend has further increased over time, increasing approximately 33% between the years 1990 to 1994 and the years 1995 to 1999 and still another 32% between the years 1995 to 1999 and the years 2000 to 2004 such that 1 of every 3 cancers reported between 2000 and 2004 was an adenocarcinoma. Although the decrease in tobacco use and consequent tobacco-related cancers could explain a relative increase in tobacco-independent adenocarcinomas, it does not explain the absolute increase (from 54,131 cases between 1990 and National Cancer Database Report on Cancer: 10-Year Update HEAD & NECK DOI /hed June

9 1994 to 95,367 cases between 2000 and 2004). Furthermore, essentially all of these additional adenocarcinomas arose in the thyroid gland, reflecting a nearly parallel increase from 17.5% to 22.2% to 30.0% over the same intervals. The 1998 report discussed possible explanations for this including artifacts of improved record keeping, the now discredited practice of using radiotherapy for acne and/or adenoid enlargement, the development of more advanced diagnostic methods, and the increased use of imaging and needle aspirate biopsies that may identify small, previously undetectable cancers. Analyses of SEER data similarly showed an increase in thyroid cancer and suggested that almost all of the increased incidence in that database was due to increased detection of small papillary cancers less than 2 cm. 6,7 It seems reasonable to assume that the explanation of the increase we see in the NCDB is the same. In 1998, Hoffman et al 3 also reported that the diagnosis of lymphoma in the head and neck database had shown a proportionate increase, from 14.7% in 1985 to 1989 to 15.4% in 1990 to 1994, and speculated that this increase might reflect a greater prevalence of immunodeficiency (from human immunodeficiency virus [HIV] infection, transplant operations, and the use of medical treatments [eg, chemotherapy] that affect the immune system) and the effects of an aging population (the risk of developing lymphoma increases with age). The current database reveals both an absolute and proportional decrease from the years 1990 to 1994 to the years 2000 to This suggests that the use of modern antiretroviral therapy for HIV has had an important impact, because all of the other factors have not changed substantially. In support of this concept, a study of patients with acquired immunodeficiency syndrome (AIDS), using AIDS and population based cancer registry data from 11 U.S. regions, detected a decline in the incidence of non-hodgkin s lymphoma between the years 1990 to 1995 and the years 1996 to 2002, similar to the time periods in this study. 8 Hoffman et al 3 also commented on the 16.3% incidence of squamous cell histology recorded in the major salivary glands. They speculated that this may represent an artificially high number, inflated by erroneously including the metastases to the glands. In the current update, squamous tumors account for 14.4% of neoplasms. Perhaps better diagnostic tools have decreased the rate of incorrect attribution. Except for an increase in carcinomas arising in the oropharynx (data not shown), the decrease in squamous cell reflects an across the board decline in alcohol- and smoking-related cancers. (The observed increase in cancers of the oropharynx supports other research which shows an increased incidence of oropharyngeal cancer attributed to human papillomavirus (HPV) infection 9 11 secondary to orogenital transmission among young adults.) Patient and Disease Characteristics. A relatively greater percentage (12.7%) of patients who had tumors arising in the common head and neck sites had household incomes in the lowest group. In contrast, only 7.4% of patients who had thyroid cancers belonged to the same group. The other cancer types fell in between these values. To the extent that squamous carcinomas of the common sites are associated with different etiologic agents (tobacco, alcohol) than adenocarcinomas of the thyroid (ionizing radiation), the data are consistent with the idea that relative poverty is often associated with unhealthy lifestyles Treatment. As was evident in the previous report, a wide spectrum of treatments continues to be used for cancers arising in the head and neck region. However, the current analysis demonstrates clear shifts over time in the frequency of some treatment regimens. Although there has been relatively little change in the frequency of surgery alone, the use of radiation therapy alone has decreased, while the frequency of radiation enhanced by chemotherapy has increased. Although a more precise characterization of the magnitude of change in these treatment paradigms in individual anatomic sites will be the subject of future analyses, it seems reasonable to assume that this overall change reflects the emergence of data from phase III protocols showing the addition of chemotherapy to radiation therapy (1) enhancing the rate of locoregional control of advanced tumors, such as in the nasopharynx, and (2) increasing the rate of larynx preservation. Outcome. The rank-order likelihood of 5-year survival after treatment for a cancer arising in one of the subsites of the head and neck region remained consistent with the order described in the 1998 report. However, it appears that the greatest improvement in outcome over the National Cancer Database Report on Cancer: 10-Year Update HEAD & NECK DOI /hed June 2009

10 to 1999 time span has occurred in the common mucosally derived tumors associated with the worst prognosis. During the intervals 1985 to 1989, 1990 to 1994, and 1995 to 1999, 5-year survival for carcinomas of the nasopharynx has improved from 47.0% to 51.3% to 56.2% and for carcinomas of the oropharynx from 46.1% to 47.5% to 54.2%. If many of the additional oropharyngeal cancers are HPV related, the improvement seen may reflect previously observed improved survival associated with HPV-positive tumors when compared with HPVnegative tumors In contrast, 5-year survivals of carcinomas of the lip have gone from 91.1% to 91.5% to 89.7% and carcinomas of the larynx have gone from 68.6% to 67.5% to 66.1%. It is tempting to speculate that the relatively good expected outcome for lip and/or larynx cancers has promoted a desire to preserve function at these sites (perhaps at the cost of cure in some cases) to a greater degree than at sites associated with more dire outcomes. For tumors arising at other sites, improvement was observed at all sites: sinonasal tumors yielding the least gain (3.4% from to ), other sites leading to the greatest gain (12.4%), and thyroid/eye and adnexa/major salivary glands yielding intermediate gains (6.4% to 7.4%). Our conditional survival analysis shows that (1) most patients with squamous cell carcinoma who died within the 5-year follow-up period did so within 2 years of diagnosis and (2) the rate at which patients died differed substantially by site. The conditional likelihood of surviving to year 3 (assuming survival to at least year 2) exceeds 90% for all but carcinomas arising in the hypopharynx (81.1%). And, by year 5, conditional survival for carcinomas of the hypopharynx comes extremely close to the 90% mark (89.8%). Thus the major difference in outcome occurs in the first or second year. CONCLUSION This update of the 1998 NCDB head and neck cancer report both confirms some previous findings and reveals new trends. Carcinomas of the head and neck have consistently accounted for approximately 6.5% of all cancers in the NCDB, but in more recent years the prototypic poor, older, male victim has been less evident. The typical tobacco-associated mucosal-origin squamous cell carcinoma has decreased in frequency only to be replaced by an adenocarcinoma arising in the thyroid. Largely in association with this change, morphologic grading of tumors has become less common. Treatment by radiation therapy alone has decreased, while the use of chemotherapy-enhanced radiation therapy has increased. Survival continues to vary according to the site of origin of the tumor, but there are signs that progress is occurring. REFERENCES 1. Jesup JM, Menck HR, Winchester DP, Hundhal SA, Murphy JP. The National Cancer Data Base report on hospital reporting. Cancer 1996;78: Steele GD, Jessup HM, Winchester DP, Menck HR, Murphy JP, editors. 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