The "Sweet Spot" Revisited: Optimal Recall Rates for Cancer Detection With 2D and 3D Digital Screening Mammography in the Metro Chicago Breast Cancer Registry.

OBJECTIVE. One central question pertaining to mammography quality relates to discerning the optimal recall rate to maximize cancer detection while minimizing unnecessary downstream diagnostic imaging and breast biopsies. We examined the trade-offs for higher recall rates in terms of biopsy recommendations and cancer detection in a single large health care organization. MATERIALS AND METHODS. We included 2D analog, 2D digital, and 3D digital (tomosynthesis) screening mammography examinations among women 40-79 years old performed between January 1, 2005, and December 31, 2017, with cancer follow-up through 2018. There were 36, 67, and 38 radiologists who read at least 1000 2D analog examinations, 2D digital examinations, and 3D tomosynthesis examinations, respectively, who were included in these analyses. Using logistic regression with marginal standardization, we estimated radiologist-specific mean recall (abnormal interpretations/1000 mammograms), biopsy recommendation, cancer detection (screening-detected in situ and invasive cancers/1000 mammograms), and minimally invasive cancer detection rates while adjusting for differences in patient characteristics. RESULTS. Among 1,060,655 screening mammograms, the mean recall rate was 10.7%, the cancer detection rate was 4.0/1000 mammograms, and the biopsy recommendation rate was 1.60%. Recall rates between 7% and 9% appeared to maximize cancer detection while minimizing unnecessary biopsies. CONCLUSION. The results of this investigation are in contrast to those of a recent study suggesting appropriateness of higher recall rates. The "sweet spot" for optimal cancer detection appears to be in the recall rate range of 7-9% for both 2D digital mammography and 3D tomosynthesis. Too many women are being called back for diagnostic imaging, and new benchmarks could be set to reduce this burden.

Primary central nervous system tumor treatment and survival in the United States, 2004-2015.

INTRODUCTION: Brain tumor treatment and survival information is generally limited in large-scale cancer datasets. We provide a clinical investigation of current patterns of care and survival estimates for central nervous system (CNS) tumors treated in the United States. METHODS: We analyzed the National Cancer Database from 2004-2015 for all patients with diagnosis of primary CNS tumors. We describe patient demographics, treatment modality, and analyzed survival estimates. RESULTS: 512,168 patient tumor records were examined. The most common histology was meningioma (43.6%), followed by glioblastoma (22.0%), and nerve sheath tumors (10.6%). Patients had a median age of 60 years, with a female (57.9%), white (85.0%), and non-Hispanic (87.8%) predominance. Tumors were reported as World Health Organization (WHO) grade I for 55.9% of the patients, grade II for 5.9%, grade III for 4.4%, grade IV for 24.3%, and grade unknown or not applicable for 9.4%. Overall, 56% underwent surgical procedures, 30.4% received radiation, and 20.6% received chemotherapy. Radiation plus chemotherapy and surgery was the most common treatment modality in high-grade tumors (40.5% in WHO grade III and 49.3% in WHO grade IV), while surgery only or watchful waiting was preferred in low-grade tumors. Older age, male gender, non-Hispanic origin, higher number of comorbidities, and lower socioeconomic status were identified as risk factors for mortality. CONCLUSIONS: Our analysis provides long-term survival estimates and initial treatment decisions for patients with CNS tumors in hospitals throughout the United States. Age, comorbidities, gender, ethnicity, and socioeconomic characteristics were determinants of survival.

Performance characteristics of digital vs film screen mammography in community practice.

We compared the performance characteristics of 297 629 full field digital (FFDM) and 416 791 screen film mammograms (SFM). Sensitivity increased with age, decreased with breast density, and was lower for more aggressive and lobular tumors. While sensitivity did not differ significantly by modality, specificity was generally 1%-2% points higher for FFDM than for SFM across age and breast density categories. The lower recall rate for FFDM vs SFM in our study may partially explain performance differences by modality. In this large health care organization, modest gains in performance were achieved with the introduction of FFDM as a replacement for SFM.

Demographics, patterns of care, and survival in pediatric medulloblastoma.

We evaluated the American College of Surgeon's National Cancer Data Base (NCDB) to describe current hospital-based epidemiologic frequency, survival, and patterns of care of pediatric medulloblastoma. We analyzed NCDB 1998-2011 data on medulloblastoma for children ages 0-19 years using logistic and poisson regression, Kaplan-Meier survival estimates, and Cox proportional hazards models. 3647 cases of medulloblastoma in those aged 0-19 years were identified. Chemotherapy was received by 79 and 74% received radiation, with 65% receiving both therapies. Those who received radiation were more likely to be older than four, while those who received chemotherapy were more likely to be age four and younger. Variables associated with receipt of neither radiation nor chemotherapy included age at diagnosis of <1 year, female gender, being of race other than black or white, having no insurance, and living in a residential area with a low level of high school graduates. Better overall survival was observed as age at diagnosis increased, in females, and having received radiation. Compared to medulloblastoma, NOS, better survival was observed for those with demoplastic medulloblastoma, with worse survival in those with large cell medulloblastoma. Majority received multi- disciplinary therapy and radiation had the greatest effect on survival. Ages four and under were most likely to receive chemotherapy and least likely to receive radiation. Suboptimal treatment included 17.8% that did not receive chemotherapy, of which 11.8% received neither chemotherapy nor radiation. Disparities associated with medical access were characteristics for not receiving standard treatment, which resulted in poor outcome.

Epidemiology of meningiomas post-Public Law 107-206: The Benign Brain Tumor Cancer Registries Amendment Act.

BACKGROUND: The current analysis follows the implementation of Public Law 107-260, the Benign Brain Tumor Cancer Registries Amendment Act, which mandated the collection of nonmalignant brain tumors. METHODS: Meningiomas were selected from the Surveillance, Epidemiology, and End Results (SEER) Program database for the years 2004 to 2011. Demographic and clinical characteristics, initial treatment patterns, and survival outcomes were evaluated using surveillance epidemiology statistical methods. RESULTS: The average annual age-adjusted incidence rate per 100,000 population was 7.62 (95 % confidence interval [CI], 7.55-7.68) for all meningiomas, 7.18 (95% CI, 7.12-7.25) for benign meningiomas, 0.32 (95% CI, 0.31-0.33) for borderline malignant meningiomas, and 0.12 (95% CI, 0.11-0.12) for malignant meningiomas. The annual rates increased for benign and borderline malignant tumors but decreased for malignant tumors. The rates for women exceeded those for men, especially for those with benign meningiomas. Black race was associated with significantly higher rates as was advancing age. Greater than 80% of tumors were located in cerebral meninges. Diagnostic confirmation through pathology occurred for approximately 50% of benign tumors, 90% of borderline malignant tumors, and 80% of malignant tumors. No initial treatment was reported for greater than 60% of benign tumors, 29% of borderline malignant tumors, or 31% of malignant tumors. The 5-year relative survival estimates for benign tumors, borderline malignant tumors, and malignant tumors were 85.6% (95% confidence interval [CI], 85%-86.2%), 82.3% (95% CI, 79.3%-84.8%), and 66% (95% CI, 60.6%-70.9%), respectively. Predictors of poorer survival were advanced age, being male gender, black race, no initial treatment, and malignant tumor behavior. CONCLUSIONS: The current analysis demonstrates that there is an increasing incidence of nonmalignant meningiomas, probably because of reporting learning curves associated with the implementation of Public Law 107-260. The high proportion of cases who receive no initial treatment is a survival outcome concern, especially for patients with malignant meningiomas.

Descriptive epidemiology of malignant and nonmalignant primary spinal cord, spinal meninges, and cauda equina tumors, United States, 2004-2007.

BACKGROUND: Primary tumors of the spinal cord, spinal meninges, and cauda equina are relatively rare, and a paucity of population-based data exist on tumors in these sites. This study intends to augment the current literature by examining incidence of these tumors on a national level. METHODS: Data from central cancer registries in the National Program of Cancer Registries (NPCR) and Surveillance, Epidemiology, and End Results (SEER) programs for 2004-2007 (covering 99.2% of US population) and 1999-2007 (covering 89.4% of US population) were analyzed. Analyses for diagnosis years 2004-2007 included cases of malignant and nonmalignant primary spinal cord, spinal meninges, and cauda equina tumors. Descriptive statistics including estimated age-adjusted incidence rates standardized to the 2000 US standard population were conducted for both malignant and nonmalignant primary spinal tumors from cases diagnosed during 2004-2007 as well as trend analyses on malignant cases of primary spinal tumors (n = 5103) for cases diagnosed during 1999-2007 using SEER Stat 6.6.2 software. RESULTS: There were 2576 cases of malignant primary spinal tumors and 9136 cases of nonmalignant primary spinal tumors in 2004-2007. The incidence of malignant and nonmalignant primary spinal tumors combined differed by age, sex, race, and ethnicity. Results of trend analyses indicated that malignant primary spinal tumors have been stable throughout the 1999-2007 period. CONCLUSIONS: This large population-based study adds new insights into the descriptive epidemiology of primary spinal cord, spinal meninges, and cauda equina tumors by providing in-depth analyses of the incidence of these tumors on a national level.

Improved survival time trends for glioblastoma using the SEER 17 population-based registries.

The EORTC/NCIC 22981/26981 study demonstrated an improvement in median overall survival (OS) from 12.1 to 14.6 months in patients with glioblastoma (GBM) who received temozolomide with post-operative radiotherapy (RT). The current study was performed to determine if those results translated into a survival benefit in a population-based cohort. Patients diagnosed between 2000 and 2006 with a GBM who underwent surgery and post-operative RT were selected from the Surveillance, Epidemiology and End Results database. Patients were grouped into time periods: 2000-2001, 2002-2003, 2004 and 2005-2006 (which represented those treated after the EORTC/NCIC trial presentation in 2004). Relative survival (RS) was estimated by the Kaplan-Meier method, and Cox multivariable regression modeling was used to estimate proportional hazard ratios (HR). Over time, there was improvement in the median and 2-year RS of 12 months and 15% for 2000-2001, 13 months and 19% for 2002-2003, 14 months and 24% for 2004, and 15 months and 26% for 2005-2006 (P < 0.0001 compared to 2000-2001 and 2002-2003; P = 0.07 compared to 2004). The estimated adjusted HR showed that patients diagnosed in 2005-2006 had significantly improved survival when compared to patients diagnosed in 2000-2001 (HR = 0.648, 95% CI 0.604-0.696). The median and 2 year RS of 15 months and 26% in 2005-2006 was similar to the median and 2 year OS of 14.6 months and 26% seen in the EORTC/NCIC phase III study. These results are encouraging and suggest that the current treatment of glioblastoma nationwide is now associated with an improved survival compared to previous time cohorts.

Descriptive epidemiology of selected olfactory tumors.

Olfactory tumors, especially olfactory neuroblastomas (ON) and carcinomas with neuroendocrine differentiation (CND), are extremely rare, and little descriptive epidemiologic information is available. The objective of this study was to more fully describe selected olfactory tumors using a large population-based cancer incidence database. The Surveillance, Epidemiology and End Results (SEER) 9 registries limited-use data were reviewed from 1973 to 2006 for selected nasal cavity (C30.0) and accessory sinus (C31.0-31.9) tumors. Frequencies, incidence rates, and relative survival rates were estimated using SEER*Stat, v6.5.2. The majority of cases were squamous cell carcinoma (SCC), while the incidence of ON was greater than CND. For ON, the incidence was highest in the 60-79 year age group, while for SCC, the incidence was highest in the 80+ year age group. For CND, the incidence leveled off in the oldest age groups. Survival rates were highest for ON (>70% alive at 5 years after diagnosis) and poorest for CND (44% alive at 5 years). Adjuvant radiation therapy did not improve survival over surgery alone in ON. In SCC, survival was worse in patients who received adjuvant radiation compared to patients who had surgery alone. Our analysis confirms some previously published information, and adds new information about the incidence and demographics of ON and CND. In addition, our analysis documents the lack of benefit of adjuvant radiation in ON. It is not feasible to conduct prospective trials in patients with these rare diseases, and the importance of registry data in learning about olfactory tumors is emphasized.

Economic, racial and ethnic disparities in breast cancer in the US: towards a more comprehensive model.

Using cancer registry data, we focus on racial and ethnic disparities in stage of breast cancer diagnosis in Cook County, IL. The county health system is the "last resort" health-care provider for low-income persons. Socioeconomic status is measured using empirical Bayes estimates of tract-level poverty, specific to non-Hispanic whites, non-Hispanic blacks or Hispanics in one of three age groups. We use ordinal logistic regression with non-proportional odds to model stage. Blacks and Hispanics are at greater risk for regional and distant stage diagnosis, but the disparity declines with age. Women in high-poverty areas are at substantially greater risk for late-stage diagnosis. The effects of poverty do not differ by age or across racial and ethnic groups.

The Impact of the Benign Brain Tumor Cancer Registries Amendment Act (Public Law 107-260) on Non-malignant Brain and Central Nervous System Tumor Incidence Trends.

The study objective was to investigate patterns of reported non-malignant brain and CNS tumor incidence over a time period encompassing 1997-2008 during which time the Benign Brain Tumor Cancer Registries Amendment Act (PL 107-260) was passed and implemented. Analyses of 75,350 incident non-malignant brain and CNS tumors from eleven population-based central registries revealed that there were statistically significant increases in the age-adjusted incidence rate for non-malignant tumors for those diagnosed prior to 2002 and over the time period from 2002 until 2005. However, no significant change in the age-adjusted incidence rate for non-malignant tumors was observed over the time period 2005 to 2008 indicating that the incidence from this time period may quantify the "true" incidence of non-malignant brain and CNS tumors in the United States.

Patterns and disparities of care in glioblastoma.

BACKGROUND: Glioblastoma is an aggressive disease with a defined standard of care offering crucial survival benefits. Disparities in care may influence treatment decisions. This study seeks to evaluate potential patterns in care delivery using the National Cancer Database (NCDB). METHODS: We evaluated the NCDB from 1998 to 2011 for patients diagnosed with glioblastoma older than 20 years of age in order to describe current hospital-based demographics, rates of treatment modality by age, race, gender, likelihood of receiving treatment, and survival probabilities. RESULTS: From 1998 to 2011, 100672 patients were diagnosed with glioblastoma in the United States. Of these, 54% were younger than 65 years of age, while 20% were 75 years of age or older. The most common type of treatment was surgery (73%), followed by radiation (69%) and chemotherapy (50%). Eleven percent of patients did not receive any form of therapy. Patients receiving no form of treatment were more likely to be older, female, black, or Hispanic. Tumors that did not involve brainstem, ventricles, or the cerebellum were associated with more aggressive treatment and better overall survival. The median survival was 7.5 months. The use of concomitant surgical resection, chemotherapy, and radiation demonstrated greater survival benefit. CONCLUSIONS: Median survival for glioblastoma is significantly less than reported in clinical trials. Sociodemographic factors such as age, gender, race, and socioeconomic status affect treatment decisions for glioblastoma. The elderly are greatly undertreated, as many elderly patients receive no treatment or significantly less than standard of care.

Neighborhood change and distant metastasis at diagnosis of breast cancer.

PURPOSE: To test whether upward socioeconomic neighborhood change has an effect on probability of distant metastasis at diagnosis of breast cancer among women who live there. METHODS: Census tract data (N = 1,137) from Cook County. IL, from 1990 and 2000 and cancer registry data for female breast cancer cases for these census tracts from 1994-2000 (N = 21,516) were used. A multilevel model of 1990 baseline socioeconomic status (SES) of neighborhoods and degree of neighborhood change 1990-2000 (compositional characteristics) and patient's age and race/Hispanic status (individual characteristics) was constructed to predict distant metastasis (vs. local and regional stage) at diagnosis. RESULTS: While residence in a census tract with lower baseline SES in 1990 (higher concentrated disadvantage and immigration and lower concentrated affluence) and being African American were associated with increased odds of distant metastasis at diagnosis, residence in an improving census tract was also associated with increased odds of distant metastasis at diagnosis. CONCLUSIONS: Paradoxically, both measures of initial neighborhood disadvantage and upward neighborhood socioeconomic change were independently associated with greater odds of distant metastasis at diagnosis of breast cancer. Neighborhood social and economic change can affect health.

Characteristics and survival outcomes associated with the lack of radiation in the treatment of glioblastoma.

Radiation increases survival in glioblastoma (GBM); however, 30% do not receive this treatment. We sought to identify characteristics associated with not receiving radiation and the impact on outcomes. We analyzed the Surveillance, Epidemiology, and End Results program (SEER) 18 registries 2000-2013 research database on 30,479 GBM cases that were aged 20 years and older. In total, 21,179 received radiation as first course of therapy, while 8218 did not with 5178 (63%) being 65 years and older. Early decisions on surgery often predicted radiation therapy with 61% having only a biopsy or no surgery at diagnosis. Radiation use as upfront therapy has slowly increased over time at a rate of 0.4% per year; still 25% did not receive radiation in 2013. Cases treated with radiation were more likely to be younger, underwent surgery, lived in a metropolitan area, had higher socioeconomic status, and were in a couple-based relationship. An increased survival in GBM was associated with the use of upfront radiation along with younger age, being of race other than white, undergoing surgery, and a more recent diagnosis. Not receiving radiation therapy adversely affects survival. A trend toward an increased use of radiation was observed although many young adults still do not receive this treatment. Decreased usage of radiation in the elderly and in biopsy-only surgeries was anticipated, but race, gender, and poverty were also statistically significant. Clinicians should be aware of this underutilization, and an increased usage of radiation should improve outcomes for glioblastoma.

National cancer database analysis of outcomes in pediatric glioblastoma.

Glioblastoma in children is an aggressive disease with no defined standard therapy. We evaluated hospital-based demographic and survival patterns obtained through the National Cancer Database to better characterize children with glioblastoma. Our study identified 1173 patients from 0 to 19 years of age between 1998 and 2011. Comparisons were made among demographics, clinical characteristics, treatment, and survival variables. Fifty-four percent of patients were over 10 years of age. Approximately 80% of patients underwent either partial or complete resection. Adjuvant therapy was used variably, and its use increased with patient age. Forty-eight percent of patients received the combination of surgery, radiation, and chemotherapy, and 4% did not receive any treatment. As expected, patients ≤5 years of age had better 5-year survival than those ages 6-10 (P = 0.01) or 11-19 years (P = 0.0077). Other factors associated with poor survival included black race and central tumor location. Better outcomes were associated with treatment that included surgery, radiotherapy, and chemotherapy compared to any other treatment combinations. Radiotherapy had no impact on survival in the 0 to 10-year-old age group, but was associated with improved survival for patients 11-19 years. We report an extensive demographic and survival analysis of pediatric glioblastoma. The observed differences likely reflect variances in tumor biology and likelihood of treatment receipt. Improved survival was associated with the use of surgery, radiotherapy, and chemotherapy. Radiation therapy was not associated with survival in patients younger than 10 years of age.

Smoking cessation processes in low-SES women: the impact of time-varying pregnancy status, health care messages, stress, and health concerns.

UNLABELLED: We tracked smoking outcomes - quitting, stage of readiness, action, motivation, self-efficacy, and confidence - over time among 943 low-SES women smokers accrued in an earlier smoking cessation intervention trial conducted in public health clinics. We assessed outcomes at 2, 6, 12 and 18 months post-initial clinic visit. Controlling for baseline characteristics and earlier program participation, we used hierarchical linear modeling to assess how intervening life events - pregnancy and exposure to subsequent clinic smoking interventions - affected smoking outcomes directly and indirectly, through the mediators, perceived stress and health concerns. RESULTS: All longitudinal smoking outcomes were positively related to health concerns and negatively related to perceived stress. Pregnancy favorably influenced all smoking outcomes but confidence, but exposure to additional interventions affected only motivation. Health concerns and stress partially mediated the positive impact of pregnancy. CONCLUSION: Public health efforts targeted to low-SES women smokers should continue to emphasize the benefits of quitting smoking for health maintenance and incorporate more effective stress-coping mechanisms. Pregnancy increases abstinence, but preventing post-delivery relapse may require stress management and re-focusing of health concerns.

Impact of a False-Positive Screening Mammogram on Subsequent Screening Behavior and Stage at Breast Cancer Diagnosis.

Background: Experiencing a false positive (FP) screening mammogram is economically, physically, and emotionally burdensome, which may affect future screening behavior by delaying the next scheduled mammogram or by avoiding screening altogether. We sought to examine the impact of a FP screening mammogram on the subsequent screening mammography behavior.Methods: Delay in obtaining subsequent screening was defined as any mammogram performed more than 12 months from index mammogram. The Kaplan-Meier (product limit) estimator and Cox proportional hazards model were used to estimate the unadjusted delay and the hazard ratio (HR) of delay of the subsequent screening mammogram within the next 36 months from the index mammogram date.Results: A total of 650,232 true negative (TN) and 90,918 FP mammograms from 261,767 women were included. The likelihood of a subsequent mammogram was higher in women experiencing a TN result than women experiencing a FP result (85.0% vs. 77.9%, P < 0.001). The median delay in returning to screening was higher for FP versus TN (13 months vs. 3 months, P < 0.001). Women with TN result were 36% more likely to return to screening in the next 36 months compared with women with a FP result HR = 1.36 (95% CI, 1.35-1.37). Experiencing a FP mammogram increases the risk of late stage at diagnosis compared with prior TN mammogram (P < 0.001).Conclusions: Women with a FP mammogram were more likely to delay their subsequent screening compared with women with a TN mammogram.Impact: A prior FP experience may subsequently increase the 4-year cumulative risk of late stage at diagnosis. Cancer Epidemiol Biomarkers Prev; 26(3); 397-403. ©2017 AACR.

Absence of an anticipated racial disparity in interval breast cancer within a large health care organization.

PURPOSE: Compared to non-Latina (nL) white women, nL black women are diagnosed with more aggressive breast cancers, which in turn should be more likely to go undetected on screening mammography and subsequently arise as interval breast cancer (IBC). We sought to estimate the extent of an anticipated racial disparity in IBC within a single, large health care organization. METHODS: The present analysis focuses on 4357 breast cancers diagnosed between 2001 and 2012 and within 18 months of a screening mammogram (N = 714,218). We used logistic regression with model-based standardization (predictive margins) to estimate adjusted prevalence differences corresponding to a racial disparity in IBC. RESULTS: Overall, prevalence of IBC within 18 months was 20.7%. Contrary to expectation, in patient-adjusted models, there was no IBC racial disparity (percentage point disparity = -2.1, 95% confidence interval: -4.7, 2.6). However, when controlling for facility characteristics, including proportion of nL black patients, the model coefficient for the IBC disparity reversed sign and changed substantially (P < .0001) and a racial disparity emerged (percentage point disparity = +5.1, 95% confidence interval: -0.3, 9.9). CONCLUSIONS: The sorting of patients by race across facilities appears to have mitigated an otherwise anticipated disparity in IBC. Possible explanations are discussed.

Epidemiologic and molecular prognostic review of glioblastoma.

Glioblastoma multiforme (GBM) is the most common and aggressive primary central nervous system malignancy with a median survival of 15 months. The average incidence rate of GBM is 3.19/100,000 population, and the median age of diagnosis is 64 years. Incidence is higher in men and individuals of white race and non-Hispanic ethnicity. Many genetic and environmental factors have been studied in GBM, but the majority are sporadic, and no risk factor accounting for a large proportion of GBMs has been identified. However, several favorable clinical prognostic factors are identified, including younger age at diagnosis, cerebellar location, high performance status, and maximal tumor resection. GBMs comprise of primary and secondary subtypes, which evolve through different genetic pathways, affect patients at different ages, and have differences in outcomes. We report the current epidemiology of GBM with new data from the Central Brain Tumor Registry of the United States 2006 to 2010 as well as demonstrate and discuss trends in incidence and survival. We also provide a concise review on molecular markers in GBM that have helped distinguish biologically similar subtypes of GBM and have prognostic and predictive value.

The impact of the Benign Brain Tumor Cancer Registries Amendment Act (Public Law 107-260) on non-malignant brain and central nervous system tumor incidence trends.

The study objective was to investigate patterns of reported non-malignant brain and CNS tumor incidence over a time period encompassing 1997-2008 during which time the Benign Brain Tumor Cancer Registries Amendment Act (PL 107-260) was passed and implemented. Analyses of 75,350 incident non-malignant brain and CNS tumors from eleven population-based central registries revealed that there were statistically significant increases in the age-adjusted incidence rate for non-malignant tumors for those diagnosed prior to 2002 and over the time period from 2002 until 2005. However, no significant change in the age-adjusted incidence rate for non-malignant tumors was observed over the time period 2005 to 2008 indicating that the incidence from this time period may quantify the "true" incidence of non-malignant brain and CNS tumors in the United States.

Oral and pharyngeal cancer in women.

Although in the United States the incidence of oral and pharyngeal cancer (OPC) has been significantly higher in men than in women, the identification of human papilloma virus as a risk factor for OPC has focused new scrutiny on who may develop OPC. One surprising element is that non-Hispanic white women have a higher incidence of OPC than of cervical cancer. OPC is thus a woman's disease, and diligence is needed to ensure that the occurrence of OPC in women does not go undetected by their oral health care providers.