Research

Original Investigation

Factors Associated With Mortality in Pediatric

vs Adult Nasopharyngeal Carcinoma
Morgan K. Richards, MD, MPH; John P. Dahl, MD, PhD, MBA; Kenneth Gow, MD; Adam B. Goldin, MD, MPH;
John Doski, MD; Melanie Goldfarb, MD; Jed Nuchtern, MD; Monica Langer, MD; Elizabeth A. Beierle, MD;
Sanjeev Vasudevan, MD; Douglas S. Hawkins, MD; Sanjay R. Parikh, MD

CME Quiz at
IMPORTANCE Nasopharyngeal carcinoma (NPC) is endemic in some Asian regions but is jamanetworkcme.com and
CME Questions page 304
uncommon in the United States. Little is known about the racial, demographic, and biological
characteristics of the disease in pediatric patients.

OBJECTIVES To improve understanding of the differences between pediatric and adult NPC
and to determine whether race conferred a survival difference among pediatric patients
with NPC.

DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included all 17 317
patients with a primary diagnosis of NCP in the National Cancer Data Base from January 1,
1998, to December 31, 2011. Of these, 699 patients were 21 years or younger (pediatric);
16 618 patients, older than 21 years (adult). Data were analyzed after data collection.

EXPOSURE Pediatric age at diagnosis of NPC.

MAIN OUTCOMES AND MEASURES Demographic, tumor, and treatment characteristics of

pediatric patients with NPC were compared with those of adults using the χ2 test for
categorical variables. An adjusted Cox proportional hazards regression model was used to
examine survival differences in pediatric patients relative to adult patients. In addition, the
risk for pediatric mortality by race was estimated.

RESULTS Of the 17 317 patients, a total of 699 pediatric and 16 618 adult patients were
identified with a primary diagnosis of NPC (female, 239 pediatric patients [34.2%] and 5153
adult patients [32.4%]). Pediatric patients were most commonly black (299 of 686 [43.6%]),
whereas adults were most likely to be non-Hispanic white (9839 of 16 504 [60.0%];
P < .001). Pediatric patients were less likely to be Asian (39 of 686 [5.7%]) than were adults
(3226 of 16 405 [19.7%]; P < .001). Pediatric patients were more likely to have regional nodal
evaluation and to present with stage IV disease (227 of 643 [35.3%] and 330 of 565 [58.4%],
respectively) than were adult patients (3748 of 15 631 [24.0%] and 6553 of 13 721 [47.8%],
respectively; P < .001 for both comparisons). Pediatric patients had a lower risk for mortality
relative to adults (hazard ratio, 0.37; 95% CI, 0.25-0.56). No difference in mortality by racial
group was found among pediatric patients (hazard ratio, 1.10; 95% CI, 0.82-1.40).

CONCLUSIONS AND RELEVANCE Pediatric patients with NPC were more commonly black and
presented more frequently with stage IV disease. Pediatric patients had a decreased mortality
risk relative to adults, even after adjusting for covariables. Asian race was not associated with
increased mortality in pediatric patients with NPC. Racial differences are not associated with
an increased risk for mortality among pediatric patients.

Author Affiliations: Author

affiliations are listed at the end of this
article.
Corresponding Author: Morgan K.
Richards, MD, MPH, Division of
Pediatric General and Thoracic
Surgery, Department of General and
Thoracic Surgery, Seattle Children’s
JAMA Otolaryngol Head Neck Surg. 2016;142(3):217-222. doi:10.1001/jamaoto.2015.3217 Hospital, 4800 Sand Point Way NE,
Published online January 14, 2016. PO Box OA.9.220, Seattle, WA 98105.

217

Copyright 2016 American Medical Association. All rights reserved.

 Research Original Investigation
N
asopharyngeal carcinoma (NPC) is a rare malignant tu-
mor derived from the epithelium lining the nasophar-
ynx. The World Health Organization (WHO) classifi-
cation system for NPC characterizes the tumors based on the
following 3 primary histopathologic subtypes: keratinizing
squamous cell carcinoma (type I), nonkeratinizing differenti-
ated carcinoma (type II), and nonkeratinizing undifferenti-
ated carcinoma (type III).1
The pathogenesis of NPC is related to a number of genetic
and environmental factors. Subtypes of HLA antigens, chro-
mosomal deletions affecting tumor suppressor genes, and a
polymorphism of the CYP2E1 gene have all been associated with
an increased risk for developing NPC. 2 Infection with the Ep-
stein-Barr virus is the most common environmental factor as-
sociated with the pathogenesis of types II and III NPC.2 Addi-
tional environmental risk factors include tobacco smoking and
exposure to preserved foods, formaldehyde, and wood dust.2
Nasopharyngeal carcinoma is endemic to southern China,
Southeast Asia, northern Africa, and the Arctic region; NPC is
much less common in Japan and the western hemisphere. In
endemic areas, the incidence of NPC has a unimodal age dis-
tribution with a peak from 50 to 60 years of age.3 In the Medi-
terranean countries and in select North American popula-
tions, a bimodal age distribution has a minor peak from 10 to
20 years of age and a second peak from 40 to 60 years of age.3
In the United States, adults of Chinese descent have the high-
est rates of NPC, followed distantly by other ethnic groups, with
persons of European descent at the lowest rates of NPC.4 Na-
sopharyngeal cancer is 2 to 3 times more common in males than
females, irrespective of race/ethnicity.5 In endemic areas, lower
socioeconomic status is associated with a higher risk for NPC.6-8
In the western hemisphere, NPC is exceedingly rare in chil-
dren and adolescents; the annual incidence of NPC inthe United
States has been estimated to be 0.5 per 1 million children. 9 The
WHO type III is the most common pathologic subtype of NPC
in children, irrespective of geographic location or race/
ethnicity, and the median age at NPC diagnosis in children is
13 years.4,10 As with adults, the incidence of NPC in children is
highest in boys; however, the highest rates of NPC in persons
younger than 20 years are in the black population. 4,10,11
Although the demographic distribution and outcomes re-
lated to NPC in children and adolescents younger than 20 years
in the United States are known, the characteristics of NPC and
associated socioeconomic factors are less well described.11 The
purpose of the present study was to use the National Cancer
Data Base (NCDB) to examine such characteristics of NPC
among pediatric patients. Our primary hypothesis was that, as
with endemic areas, NPC in persons 21 years or younger in the
Unites States would be associated with factors implying a lower
socioeconomic status.
Methods
Study Population
We used the NCDB to perform a retrospective cohort study
of pediatric and adult patients with NPC in the United States.
Pediatric patients from birth to 21 years of age were com-
218 JAMA Otolaryngology–Head & Neck Surgery March 2016 Volume 142, Number 3
Copyright 2016 American Medical Association. All rights reserved.
Factors Associated With Mortality in Pediatric Nasopharyngeal Carcinoma
pared with adults older than 21 years. All of the data made
available to us by the NCDB ranged from January 1, 1998, to
December 31, 2011. No duplicate cases were included in the
analysis. This study was approved by the institutional
review board of the Seattle Children’s Hospital. Because data
were deidentifed, informed consent was waived.
Clinical Covariates and Measures
Patient demographics included sex, race, insurance status,
household income, educational level, and rural vs urban
place of residence (Table 1). Race was documented by the
trained abstractors based on the medical record and based on
standardized classifications within the NCDB data dictionary
(http://ncdbpuf.facs.org/node/259). Race was assessed in this
study because previous reports of unequal racial distribu-
tions of NPC among adult patients have been made. 12-14
Whether this racial distribution is the same or different in
children has yet to be determined. Insurance status was
defined as private, governmental, or uninsured. Household
income was divided into quartiles based on the patient’s
home zip code. Educational level was based on the percent-
age of high school graduates in the patient’s home zip code.
Rural vs urban place of residence was based on population
density and proximity to a metropolitan area.
Tumor features included stage of disease, tumor behav-
ior, tumor grade, and the presence of positive or negative
margins at surgical resection. Disease staging was based on
the National Comprehensive Cancer Network TNM classi-
fication.15 Tumor behavior was described as in situ or inva-
sive, whereas tumor grade was categorized as well differenti-
ated, moderately differentiated, poorly differentiated, or
undifferentiated.15
Treatment factors included nodal evaluation and margin
status. Nodal evaluation was categorized as performed or not
performed. Margin status was defined as positive or negative.
In addition, the types of treatment received, including radio-
therapy, chemotherapy, and operative intervention, were
compared between pediatric and adult patients with NPC.
Statistical Analysis
Data were analyzed after data collection. To perform the
analyses, pediatric patients 21 years or younger were com-
pared with the adult population using univariate statistics
with the χ2 test for categorical data (P < .05). An adjusted Cox
proportional hazards regression model was used to estimate
survival differences between the 2 groups. To account for the
increased risk for mortality due to non-NPC causes among
older patients, estimated survival was compared between the
2 groups with the adult patient group restricted to patients
younger than 60 years. Finally, we stratified the pediatric
group by race, and survival was again estimated using an
adjusted Cox proportional hazards regression model. Adjust-
ment factors were determined a priori and included sex,
income, education, race, insurance status, urban vs rural
place of residence, Charlson/Deyo comorbidity index (http:
//ncdbpuf.facs.org/content/charlsondeyo-comorbidity-index),
tumor grade, and disease stage. Statistical analysis was com-
pleted using STATA software (version 12; StataCorp LP).
jamaotolaryngology.com
Factors Associated With Mortality in Pediatric Nasopharyngeal Carcinoma Original Investigation Research

Table 1. Demographic, Tumor, and Treatment Characteristics for Patients With NPC

Patient Group, No./Total No. (%)a

Pediatric Adult
Characteristic (n = 699) (n = 16 618) P Value
Demographic and health
Female 239/699 (34.2) 5153 (31.0) .08
Race
White 265/686 (38.6) 9839/16 405 (60.0)
Black 299/686 (43.6) 2249/16 405 (13.7)
<.001
Asian 39/686 (5.7) 3226/16 405 (19.7)
Other 83/686 (12.1) 1091/16 405 (6.7)
Insurance status
Private 336/664 (50.6) 7960/15 751 (50.5)
Government 278/664 (41.9) 6641/15 751 (42.2) .97
Uninsured 50/664 (7.5) 1150/15 751 (7.3)
Median household income, $
<30 000 209/665 (31.4) 2552/15 692 (16.3)
30 000-35 000 133/665 (20.0) 2985/15 692 (19.0)
<.001
35 000-45 999 155/665 (23.3) 4328/15 692 (27.6)
≥46 000 168/665 (25.3) 5827/15 692 (37.1)
Adults in patient’s zip code with no high school diploma, %
≥29 240/665 (36.1) 3628/15 691 (23.1)
20.0-28.9 165/665 (24.8) 3935/15 691 (25.2)
<.001
14.0-19.9 121/665 (18.2) 3441/15 691 (21.9)
<14.0 139/665 (20.9) 4687/15 691 (30.0)
Place of residence by population
Metro ≥1 million 374/666 (56.2) 9116/15 627 (58.3)
Metro 250 000 to 1 million 116/666 (17.4) 2760/15 627 (17.7)
.01
Metro <250 000 or adjacent to metro 128/666 (19.2) 3059/15 627 (19.6)
Urban or rural <20 000 and not adjacent to metro 48/666 (7.2) 692/15 627 (4.4)
Charlson/Deyo comorbidity index
0 445/462 (96.3) 9325/10 900 (85.6)
1 17/462 (3.7) 1235/10 900 (11.3) <.001
≥2 0 340/10 900 (3.1)
Tumor
Invasive 699 (100) 16 557/16 618 (99.6) .11
Grade
Well differentiated 6/528 (1.1) 513/12 192 (4.2)
Moderately differentiated 12/528 (2.3) 2229/12 192 (18.2)
<.001
Poorly differentiated 146/528 (27.7) 5941/12 192 (48.7)
Undifferentiated 364/528 (68.9) 3509/12 192 (28.8)
Stage
0 1/565 (0.2) 76/13 721 (0.6)
I 20/565 (3.5) 1335/13 721 (9.7)
II 41/565 (7.3) 1753/13 721 (12.8) <.001
III 173/565 (30.6) 4004/13 721 (29.2)
IV 330/565 (58.4) 6553/13 721 (47.8)
WHO classification
Abbreviations: metro, metropolitan;
Keratinizing SCC (type I) 81/435 (18.6) 7838/12 170 (64.4)
NPC, nasopharyngeal carcinoma;
Nonkeratinizing SCC (type II) 83/435 (19.1) 2020/12 170 (16.6) <.001 SCC, squamous cell carcinoma;
Undifferentiated SCC (type III) 271/435 (62.3) 2312/12 170 (19.0) WHO, World Health Organization.
a
Treatment Denominators do not sum to
column totals because of missing
Re gional node examination
data. Percentages have been
Not performed 416/643 (64.7) 11 883/15 631 (76.0) rounded and may not total 100.
<.001
Performed 227/643 (35.3) 3748/15 631(24.0) Pediatric patients are 21 years or
Positive surgical margin 22/699 (3.1) 556/16 618 (3.3) .21 younger; adult patients, older than
21 years.

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Copyright 2016 American Medical Association. All rights reserved.

 Research Original Investigation
Table 2. Differences in Treatment Modalities for Pediatric and Adult Patients With NPC
Patient Group, No./Total No. (%)a
Pediatric
Treatment Modality (n = 699)
Type of treatment
None 26/691 (3.8)
Radiotherapy alone 19/691 (2.7)
Chemotherapy alone 3/691 (0.4)
Radiotherapy + chemotherapy (any type) 562/691 (81.3)
Surgical excision or resection 81/691 (11.7)
Chemotherapy regimen
Radiotherapy + single-agent chemotherapy 98/514 (19.1)
Radiotherapy + multiple-agent chemotherapy 416/514 (80.9)
Results
We identified a total of 17 317 patients as having a primary di-
agnosis of NPC, including 699 pediatric patients and 16 618 adult
patients. We found no difference between pediatric and adult
patients in terms of their sex distribution (239 female pediat-
ric patients [34.2%] 5153 female adult patients [31.0%]; P = .08).
In addition, we found no difference with regard to insurance
status between groups (P = .97). Pediatric patients had a sig-
nificantly different racial profile relative to adult patients, with
a predominance of black patients (299 of 686 [43.6%]) com-
pared with adults, among whom white race was more com-
mon (9839 of 16 405 patients [60.0%]; P < .001). Pediatric pa-
tients were significantly less likely to be of Asian race (39 of 686
[5.7%]) than were adults (3226 of 16 405 [19.7%]; P < .001)
(Table 1). Pediatric patients were more likely to live in a rural
area, in an area with lower median household income, and in
an area of lower educational achievement relative to adult pa-
tients (P = .01, P < .001, and P < .001, respectively) (Table 1).
Pediatric patients were more likely to present with an un-
differentiated tumor (364 of 528 [68.9%]) than adult patients
(3509 of 12 192 [28.8%]; P < .001). Pediatric patients were also
more likely to present with stage IV disease (330 of 565 [58.4%])
than adult patients (6553 of 13 721 [47.8%]; P < .001), although
there was no difference in positive margin status at resection.
Pediatric patients had more undifferentiated squamous cell tu-
mors (WHO type III) (271 of 435 [62.3%]) relative to adult pa-
tients (2312 of 12 170 [19.0%]; P < .001). Pediatric patients were
more likely to undergo nodal sampling at the time of resection
(227 of 643 [35.3%]) relative to adult patients (3748 of 15 631
[24.0%]; P < .001) (Table 1). In addition, pediatric patients were
more likely to undergo radiotherapy and chemotherapy than
adult patients. Pediatric patients more frequently received mul-
tiple-agent chemotherapy than did adult patients, who more of-
ten received single-agent therapy (P < .001) (Table 2).
Compared with adults, NPC-related mortality was de-
creased more than 60% among pediatric patients, based on Cox
proportional hazards regression analysis (hazard ratio, 0.37;
95% CI 0.25-0.56) (Table 3 and Figure 1). When the adult popu-
lation was restricted to patients younger than 60 years, again
NPC-related mortality was nearly 60% less likely among pe-
diatric patients (hazard ratio, 0.41; 95% CI 0.27-0.63). When
220 JAMA Otolaryngology–Head & Neck Surgery March 2016 Volume 142, Number 3
Copyright 2016 American Medical Association. All rights reserved.
Factors Associated With Mortality in Pediatric Nasopharyngeal Carcinoma
Adult
(n = 16 618) P Value
1513/16 258 (9.3)
1945/16 258 (12.0) Abbreviation: NPC, nasopharyngeal
110/16 258 (0.7) <.001 carcinoma.
a
10 444/16 258 (64.2) Denominators do not sum to
2246/16 258 (13.8) column totals because of missing
data. Percentages have been
rounded and may not total 100.
3578/9521 (37.6) Pediatric patients are 21 years or
<.001
5943/9521 (62.4) younger; adult patients, older than
21 years.
pediatric patients were stratified by race, no difference was seen
in mortality by race (hazard ratio, 1.10; 95% CI 0.82-1.40)
(Table 3 and Figure 2).
Discussion
The present study confirms that in the United States, the demo-
graphic distribution of NPC differs between the pediatric and
adult populations. Using the NCDB population of 699 persons
21 years and younger with a diagnosis of NPC, we found that
relative to adults, NPC in pediatric patients is more common
in black patients and relatively rare in Asians. Richey et al11 and
Sultan et al9 previously used a different data source, the Na-
tional Cancer Institute Surveillance, Epidemiology, and End Re-
sults (SEER) tumor registry, to examine the population demo-
graphics for persons with NPC in the United States. The study
by Richey et al11 identified 160 patients younger than 20 years
with a diagnosis of NPC and demonstrated that the incidence
of NPC was 1.61 per 1 million for black individuals and 0.95 per
1 million for Asian and other races. The study by Sultan et al9
of 129 pediatric patients younger than 20 years and 5885 adults
found an incidence of 0.5 per 1 million person-years in pedi-
atric patients and 8.4 per 1 million person-years in adults. The
present study uses different statistical methods and agrees with
the results presented by Richey et al,11 but it includes a much
larger population of children with a diagnosis of NPC. Both pre-
vious studies failed to demonstrate any differences in NPC-
related mortality among the different ethnic populations.
Data from the NCDB also demonstrate that pediatric pa-
tients presenting with NPC tend to live in a rural area, in an
area with a lower median income, or in an area with lower edu-
cational achievement. These findings are consistent with pre-
vious findings indicating that NPC is more common in adults
of lower socioeconomic status.12 Given these findings, we can
hypothesize that pediatric patients with NPC in such areas may
be at increased risk for developing NPC owing to environmen-
tal exposures, such as tobacco smoke or preserved foods. How-
ever, tobacco exposure is most commonly associated with type
I NPC, which is the least common type of NPC in children. In
addition, the method of food preservation closely associated
with the development of NPC is most commonly used in tra-
ditional southern Chinese culture.12 The development of NPC
jamaotolaryngology.com
 Factors Associated With Mortality in Pediatric Nasopharyngeal Carcinoma Original Investigation Research

Table 3. Adjusted Mortality Risk Comparing Pediatric and Adult Patients Figure 2. Kaplan-Meier Survival Estimates for Pediatric Patients With
With NPC Nasopharyngeal Carcinoma by Race
Pediatric Patient Group Comparisona Risk for Mortality, HR (95% CI)b 100
All adults aged >21 y 0.37 (0.25-0.56)
Adults aged 21-60 y 0.41 (0.27-0.63)

Surviving Patients, %
75
Stratified by race 1.10 (0.82-1.40)

Abbreviations: HR, hazard ratio; NPC, nasopharyngeal carcinoma. 50

a White
Pediatric patients are 21 years or younger; adult patients, older than 21 years. Black
b
Adjusted for sex, income, educational level, race, insurance, urban vs rural 25 Asian
place of residence, Charlson/Deyo comorbidity index, tumor grade, and tumor Other
stage, described in Table 1. 0
0 5 10 15
Time Since Diagnosis, y
No. at risk
Figure 1. Kaplan-Meier Survival Estimates for Pediatric and Adult
White 168 119 25 0
Patients With Nasopharyngeal Carcinoma Black 183 100 29 0
Asian 26 16 4 0
100 Other 48 30 7 0

Pediatric patients Pediatric patients include those 21 years or younger.

75
Surviving Patients, %

significantly more likely to undergo radiotherapy and chemo-

50
25
Adult patients
0
0 5 10
Time Since Diagnosis, y
No. at risk
Pediatric patients 432 268 66
Adult patients 10466 4399 984
Pediatric patients include those 21 years or younger; adult patients, older than
21 years.
in the pediatric population in the United States may be re-
lated to Epstein-Barr virus infection or a specific genetic pre-
disposition found more commonly in the black population.
Our results indicate that persons 21 years or younger with
NPC in the United States more frequently present with undif-
ferentiated tumors and more advanced disease. This finding
is consistent with those of previous studies focusing on the
population characteristics of NPC in the United States and in
endemic areas. Sultan et al9 noted in the SEER database that
children were more likely to present with advanced disease.
One recent study by Yan et al13 examined the characteristics
of NPC in children and adolescents at a large cancer center in
southern China and found that more than 90% of patients with
NPC who were younger than 21 years had stage III or stage IV
disease at presentation. Despite the fact that children with NPC
tend to have less differentiated, more advanced tumors, these
patients have a lower risk for all-cause mortality relative to
adults with NPC. The improved survival may have been re-
lated to the presence of less morbidity in the pediatric popu-
lation relative to the adults; however, pediatric patients were
therapy. The more aggressive treatment regimens may have
contributed to an overall improved survival.
An important strength of this study is the large number of
pediatric patients. The NCDB is a hospital-based registry that
15
captures approximately 70% of all new cancer cases, includ-
ing 42% of childhood cancers in the United States.16 Data cap-
ture began in 1989 and now includes more than 30 million
0
0 records.16 However, some limitations to this study must be
noted. First, owing to limitations in database coding, we are
unable to distinguish between disease-specific and all-cause
mortality, which is important when comparing adult and pe-
diatric patient populations. We attempted to mitigate this limi-
tation byrestricting that analysis to younger adult patients (<60
years) and by controlling for adult comorbidities. Second, dis-
ease incidence could not be calculated because the NCDB does
not capture a representative sample of the population. Fi-
nally, facility identification information was not available, so
we could not determine whether patients were treated at adult
or pediatric institutions. These data may have been useful in
evaluating for differences in treatment practices. Long-term
follow-up data regarding second malignant neoplasms after ra-
diotherapy may be limited in this data set.
Conclusions
Although uncommon, pediatric NPC appears to affect a dif-
ferent patient demographic relative to adult NPC. Nasopha-
ryngeal carcinoma in children is associated with rural loca-
tion, low socioeconomic status, and more advanced disease
at presentation. Despite these differences, pediatric NPC is as-
sociated with a lower mortality rate than adult disease.

ARTICLE INFORMATION Published Online: January 14, 2016.
Submitted for Publication: August 19, 2015; final doi:10.1001/jamaoto.2015.3217.
revision received October 31, 2015; accepted Author Affiliations: Department of Surgery,
November 11, 2015. University of Washington, Seattle (Richards);
Division of Pediatric General and Thoracic Surgery,
Department of General and Thoracic Surgery,
Seattle Children’s Hospital, Seattle, Washington
(Richards, Gow, Goldin); Department of
Otolaryngology—Head and Neck Surgery,
University of Washington, Seattle (Dahl, Parikh);

jamaotolaryngology.com JAMA Otolaryngology–Head & Neck Surgery March 2016 Volume 142, Number 3 221

Copyright 2016 American Medical Association. All rights reserved.

 Research Original Investigation
Division of Pediatric Surgery, Methodist Children’s
Hospital of South Texas, San Antonio (Doski);
Department of Surgery, John Wayne Cancer
Institute, Santa Monica, California (Goldfarb);
Division of Pediatric Surgery, Baylor College of
Medicine, Houston, Texas (Nuchtern, Vasudevan);
Department of Pediatric General Surgery, Maine
Children’s Cancer Program, Portland (Langer);
Department of Pediatric General Surgery,
University of Alabama, Birmingham (Beierle); Fred
Hutchinson Cancer Research Center, Department of
Pediatrics, Seattle Children’s Hospital, University of
Washington, Seattle (Hawkins).
Author Contributions: Drs Richards and Gow had
full access to all the data in the study and take
responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: Richards, Gow, Goldin,
Nuchtern, Langer, Vasudevan, Parikh.
Acquisition, analysis, or interpretation of data:
Richards, Dahl, Gow, Doski, Goldfarb, Beierle,
Hawkins, Parikh.
Drafting of the manuscript: Richards, Dahl, Gow,
Goldin, Hawkins, Parikh.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: Richards, Goldin.
Administrative, technical, or material support: Gow,
Goldin, Nuchtern.
Study supervision: Gow, Goldin, Goldfarb,
Vasudevan, Hawkins, Parikh.
Conflict of Interest Disclosures: None reported.
222 JAMA Otolaryngology–Head & Neck Surgery March 2016 Volume 142, Number 3
Copyright 2016 American Medical Association. All rights reserved.
Factors Associated With Mortality in Pediatric Nasopharyngeal Carcinoma
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