The survival outcome and gender difference of elderly females with laryngeal cancer

doi:10.21203/rs.3.rs-2455920/v1

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The survival outcome and gender difference of elderly females with laryngeal cancer

https://doi.org/10.21203/rs.3.rs-2455920/v1

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Background

To analyze the gender differences in epidemiology and survival of elderly females with laryngeal cancer, and possible clinical countermeasures to reduce the differences.

Methods

Patients aged ≥ 65 years with laryngeal cancer in the Surveillance, Epidemiology, and End Results database from 2010–2018 were collected. The Kaplan-Meier method was performed to calculate overall survival (OS) and evaluate univariate factors affecting OS. Multivariate Cox regression analysis was conducted on variables with P-value < 0.05. Propensity score matching was applied to reduce the effects of confounding factors. Gender differences were analyzed by the chi-squared test.

Results

The gender difference was significant in survival prognosis in the elderly population, with males having significantly better OS than females. The gender difference was mainly manifested in stage I. Gender, age at diagnosis, marital status, tumor site, and treatment modality were prognostic factors affecting the OS of stage I patients. Compared to male patients, females were diagnosed at an older age, with more singles, more supraglottic types, and more likely to undergo lymph node dissection (LND). The gender difference of OS in radiotherapy (RT) group was the most obvious, and the prognosis of organ preservation surgery (OPS) group was comparable to that of the OPS + RT group, but both better than that of the RT group.

Conclusion

The gender difference in survival was significant in elderly patients with stage I laryngeal cancer. To narrow gender differences: LND should be emphasized in females with supraglottic laryngeal cancer; OPS should be considered for females for a better prognosis and combination therapy was not advocated; Age at diagnosis ≥ 85 years and single females should receive more attention.

elderly

gender difference

stage I laryngeal cancer

organ preservation surgery

radiation therapy

Laryngeal cancer is one of the cancers with the highest male-to-female ratio difference of all malignancies, and the ratio of male-to-female incidence can reach 6.4:1 [1]. It is generally accepted that females have lower risk and better prognosis than males in a wide range of cancer types unrelated to reproductive function, such as colon, liver, and head and neck cancers [2, 3]. The larynx is a secondary sexual organ and sex hormones may play a key role in carcinogenesis, with androgen associated with higher prevalence and poor prognosis in males and estrogen having a protective effect in females [4, 5]. Due to the protective effect of estrogen [3, 6], female and younger patients show greater immune protection in their tumors compared to male and older patients [7, 8]. These opinions were confirmed in several retrospective studies: gender is an independent prognostic indicator for laryngeal squamous cell carcinoma and females have a better 5-year survival rate compared to male patients [9, 10].

However, female patients with laryngeal cancer may no longer have unique survival advantages due to the marked decrease in estrogen levels in the older population. Majszyk D et al [1] found that although female patients were diagnosed with laryngeal cancer in a shorter period of time, the tumors tended to be more advanced. Supraglottic laryngeal cancer is more common in women, which may be one of the reasons why more advanced cases are seen at the time of tumor diagnosis [1, 11, 12]. Moreover, studies have shown that: Health-related quality-of-life (HRQoL) of females with laryngeal cancer is significantly lower than that of male patients [13]; One-third of the laryngeal cancer population suffers from depression, and the probability of depression in the elderly and female patients is significantly higher than that in male and young patients [14]; Alcohol and tobacco consumption are high-risk factors for the development of laryngeal cancer, with a significant increase in female patients in recent years due to a marked increase of tobacco consumption [3, 15, 16]. The increased incidence, poor prognosis and quality of life indicate that elderly women are a special group of laryngeal cancer patients.

With the global aging of the population, elderly patients with head and neck tumors have significantly increased [17], and elderly female patients should receive more attention. However, there is a near gap in research for this group, so we made a first attempt to analyze the epidemiological differences, survival differences, and possible clinical countermeasures for this special population compared with male patients using the Surveillance, Epidemiology, and End Results (SEER) database.

2.1 Patients

Patients with a clear diagnosis of laryngeal cancer in the SEER database from 2010–2018 were collected. Inclusion criteria: age at diagnosis ≥ 65 years; histopathological type of squamous cell carcinoma; Exclusion criteria: 1) unknown survival time/incomplete follow-up time; 2) unclear diagnosis of death/diagnosed autopsy (death certificate) only; 3) incomplete record of surgical procedure/unknown registration of chemoradiotherapy. Variables included in the analysis included age at diagnosis, gender, race, marital status, tumor site (ICD-O-3 site code), pathological grade, tumor size, TNM stage (AJCC, 7th edition, 2010), surgical modality (primary lesion surgery and cervical lymph node dissection), and chemoradiotherapy information.

We classified the aging population into “young old” (65–74), “older old” (75–84) and “oldest old” (85 and beyond). The tumor site was divided into four groups: “Glottis (C32.0)”, “Supraglottis (C32.1)”, “Subglottis (C32.2)”, and “Other (C32.3, C32.8, and C32.9). According to the surgery code from SEER (Larynx C320–C329), organ preservation surgery (OPS) included transoral surgical approaches (C10 and C20) and partial laryngectomy (C30).

2.2 Statistical analysis

The Kaplan-Meier (K-M) method was performed to calculate the overall survival (OS) of elderly patients with laryngeal cancer and evaluate the epidemiological features and clinicopathological factors affecting OS. Variables with statistical significance were introduced into multivariate analysis using Cox proportional hazards regression model. Log-rank test was used for comparisons between groups, and the results are presented as survival curves. Gender differences were analyzed by the chi-squared test (Fish exact probability method, Bilateral test). The propensity score matching (PSM) was applied to reduce the effects of data and confounding variables. The above data were statistically analyzed using SPSS version 24.0 software (IBM Corporation, Armonk, NY, USA) and a P-value < 0.05 was considered statistically significant.

3.1 Gender differences in terms of overall survival in elderly patients with laryngeal cancer were shown in stage I

There were 20,167 cases of laryngeal squamous cell carcinoma in the SEER database from 2010–2018, excluding 358 cases with unknown cause of death, unclear information on surgical modality and radiotherapy, and 9650 cases aged < 65 years, and finally, 10,159 cases met the inclusion criteria (Fig. 1). K-M analysis showed that there was a significant gender difference in survival prognosis in the laryngeal cancer patients aged ≥ 65 years, with males having significantly better OS than females (P < 0.001) (Fig. 2a). To further explore the gender difference in laryngeal cancer patients, K-M analysis was performed on patients diagnosed with stage I, stage II, stage III, and stage IV, respectively. It was found that the gender difference of elderly laryngeal cancer was mainly manifested in patients diagnosed with stage I (P = 0.024), while the gender differences in patients diagnosed with stage II, stage III, and stage IV were not significant (P = 0.564, P = 0.938, P = 0.240, respectively) (Fig. 2b-2e).

After screening out patients with stage II (N = 1588), stage III (N = 1616), stage IV (N = 2378), and stage unknown (N = 579), there were 3998 patients with stage I remaining. In the guidelines of the National Comprehensive Cancer Network (NCCN), the main treatment methods for early laryngeal cancer are laryngeal preservation surgery and radiation therapy (RT) [18]. To better investigate the epidemiological characteristics of stage I patients and the gender differences between treatment modalities, we further screened out patients treated with chemotherapy or (and) total/radical laryngectomy (N = 168), leaving 3830 patients remaining.

3.2 Prognosis analysis of elderly patients with stage I laryngeal cancer

Variables such as patients' general clinical information and treatment modality were analyzed univariately by the K-M method and Log-rank test, and variables with P < 0.05 were screened into Cox proportional hazards regression model to analyze independent risk factors affecting OS in patients. The variables included in the multifactorial analysis were: gender (P = 0.045), age at diagnosis (P < 0.001), race (P = 0.001), marital status (P < 0.001), tumor size (P = 0.005), tumor site (P < 0.001), pathological grade (P = 0.004) and treatment modality (P < 0.001).

Multifactorial Cox analysis showed that gender (P = 0.008), age at diagnosis (P < 0.001), marital status (P < 0.001), tumor site (P < 0.001), and treatment modality (P < 0.001) were prognostic factors affecting patients' OS. In further stratified analysis: Female and marital status were protective factor, female (vs male, hazard ratio (HR) = 0.797, 95% CI = 0.675–0.941, P = 0.008), married (vs single, HR = 0.702, 95% CI = 0.619–0.795, P < 0.001); Advanced age was a risk factor, oldest old (vs young old, HR = 3.257, 95%CI = 2.768–3.833, P < 0.001), older old (vs young old, HR = 1.699, 95%CI = 1.493–1.934, P < 0.001); Supraglottis and subglottis were risk factors, supraglottis (vs glottis, HR = 2.828, 95% CI = 1.594–5.017, P < 0.001), subglottis (vs glottis, HR = 2.741, 95% CI = 2.290–3.282, P < 0.001); All treatment modalities significantly improved prognosis (vs. none, HR < 0.05, P < 0.001). (Table 1)

Table 1

Univariate analysis and multivariate Cox regression analysis (Forward:LR) of prognostic factors influencing overall survival of elderly patients with stage Ⅰ laryngeal cancer.
Variable	Mean survival (95%CI ^a) months	Univariate analysis		Multivariate analysis
Variable	Mean survival (95%CI ^a) months	Log-rank(χ²)	P-value	HR^b (95% CI)	P-value
Gender		4.01	0.045		0.008
Male	74.89(73.33–76.45)			Reference
Female	70.95(67.13–74.78)			0.797(0.675–0.941)	0.008
Age at diagnosis, years		202.56	< 0.001		< 0.001
65–74	81.57(79.70-83.43)			Reference
75–84	70.53(68.08–72.98)			1.699(1.493–1.934)	< 0.001
≥ 85	51.31(47.21–55.41)			3.257(2.768–3.833)	< 0.001
Race		13.78	0.001		0.001
White	74.06(72.48–75.63)			Reference
Black	71.61(67.30-75.91)			1.132(0.950–1.348)	0.166
Other^c	86.75(80.59–92.91)			0.698(0.538–0.907)	0.007
Marital status		64.27	< 0.001		< 0.001
Single^d	66.42(63.84-69.00)			Reference
Married	78.38(76.57–80.19)			0.702(0.619–0.795)	< 0.001
Unknown	77.27(71.80-82.74)			0.698(0.538–0.907)	0.007
Tumor Size, cm		12.82	0.005		0.017
< 3	75.10(72.15–78.06)			Reference
3–5	55.95(38.01–73.89)			2.077(1.231–3.505)	0.006
> 5	87.23(72.82-101.64)			0.487(0.121–1.960)	0.311
Unknown	74.18(72.51–75.85)			1.140(0.991–1.312)	0.066
Tumor Site		148.81	< 0.001		< 0.001
Glottis	77.04(75.54–78.55)			Reference
Subglottis	46.12(26.19–66.05)			2.828(1.594–5.017)	< 0.001
Supraglottis	52.89(47.73–58.05)			2.741(2.290–3.282)	< 0.001
Other	57.44(48.15–66.72)			1.797(1.340–2.411)	< 0.001
Grade		13.08	0.004		0.124
Glottis	75.19(71.99–78.40)			Reference
Subglottis	73.99(71.81–76.17)			NA	NA
Supraglottis	67.19(62.28–72.10)			NA	NA
Unknown	76.71(72.85–75.74)			NA	NA
Therapy		111.06	< 0.001		< 0.001
None	50.74(44.50-56.98)			Reference
RT^e	73.67(71.60-75.75)			0.455(0.375–0.553)	< 0.001
OPS^f	79.01(75.91–82.11)			0.379(0.303–0.474)	< 0.001
OPS + RT	77.43(74.64–80.23)			0.400(0.322–0.495)	< 0.001
^a 95%CI: 95% Confidence Interval; ^b HR: Hazard Ratio; ^c Other: American Indian/AK Native, Asian/Pacific Islander and other races; ^dSingle: Never married, Domestic Partner, Widowed, Separated or Divorced; ^eRT: Radiation Therapy; ^fOPS: Organ Preservation Surgery

3.3 Gender differences among elderly patients with stage I laryngeal cancer

The stage I population included 3266 male patients (85.3%) and 564 female patients (14.7%). In the K-M analysis, the average survival time (AST) of OS was 74 months for male patients compared with 70 months for females. Similarly, the AST was 94 months for male patients compared with 90 months for female patients in cancer specific survival (CSS) comparison. The differences were statistically significant (P < 0.05). We analyzed the composition of male and female patients using chi-square tests and found statistically significant differences in the variables of age at diagnosis, marital status, tumor site and lymph node dissection (LND). Compared to male patients, females were diagnosed at an older age (age of diagnosis ≥ 85 years: 15.1% vs. 11.2%), with more singles (56.7% vs. 29.8%), more supraglottic types (21.8% vs. 6.4%) and more likely to undergo LND (2.0% vs. 0.6%).

To reduce data bias and confounding factors, we performed propensity score matching (PSM) on general epidemiological and clinicopathological data except for "treatment modality". After matching with a propensity score of 1:2 and a caliper value of 0.02, the distribution of propensity scores (Fig. 3a) and univariate SD scatter plots (Fig. 3b) indicated a good matching effect. After matching, there was no longer a significant difference in the composition ratio various variables for male and female patients. Meanwhile, the survival difference between male and female patients disappeared. (Table 2)

Table 2

The portion and distribution of clinical characteristics in elderly patients with stage Ⅰ laryngeal cancer before and after propensity score matching.
Variable	Before PSM^a(n = 3830)			After PSM(n = 1542)
Variable	Male (n = 3266, 85.3%)	Female (n = 564, 14.7%)	P-value	Male (n = 1011, 65.6%)	Female (n = 531, 34.4%)	P-value
Age of diagnosis, years	74.73 ± 7.11	75.43 ± 7.60	0.032	75.07 ± 7.51	75.16 ± 7.48	0.833
Age of diagnosis, years			0.025			0.714
65–74	1774(54.3%)	301(53.4%)		549(54.3%)	294(55.4%)
75–84	1126(34.5%)	178(31.6%)		330(3.6%)	163(30.7%)
≥ 85	366(11.2%)	85(15.1%)		132(13.1%)	74(13.9%)
Race			0.563			0.240
White	2749(84.2%)	468(83.0%)		850(84.1%)	441(83.1%)
Black	384(11.8%)	75(13.3%)		114(11.3%)	72(13.6%)
Other^b	133(4.1%)	21(3.7%)		47(4.6%)	18(3.4%)
Marital status			< 0.001			0.075
Single^c	974(29.8%)	320(56.7%)		501(49.6%)	293(55.2%)
Married	2092(64.1%)	208(36.9%)		447(44.2%)	203(38.2%)
Unknown	200(6.1%)	36(6.4%)		63(6.2%)	35(6.6%)
Site			< 0.001			0.172
Glottis	2966(90.8%)	416(73.8%)		825(81.6%)	416(78.3%)
Subgiottis	18(0.6%)	5(0.9%)		4(0.4%)	0(0.0%)
Supraglottis	208(6.4%)	123(21.8%)		157(15.5%)	101(19.0%)
Other	74(2.3%)	20(3.5%)		25(2.5%)	14(2.6%)
Grade			0.176			0.634
Grade 1	659(20.2%)	104(18.4%)		190(19.7%)	100(18.8%)
Grade 2	1422(43.5%)	266(47.2%)		467(46.2%)	249(46.9%)
Grade 3	281(8.6%)	56(9.9%)		85(8.4%)	54(10.2%)
Unknown	904(27.7%)	138(24.5%)		260(25.7%)	128(24.1%)
Tumor Size, cm			0.964			0.964
< 3 cm	800(24.5%)	138(24.5%)		221(21.9%)	124(23.4%)
3–5 cm	33(1.0%)	6(1.1%)		9(0.9%)	5(0.9%)
> 5 cm	10(0.3%)	2(0.4%)		4(0.4%)	2(0.4%)
Unknown	2423(74.2%)	418(74.1%)		777(76.9%)	400(75.3%)
Therapy			0.451			0.761
None	200(6.1%)	42(7.0%)		70(6.9%)	33(6.2%)
RT^d	1595(48.8%)	279(46.8%)		490(48.5%)	248(46.7%)
OPS^e	708(21.7%)	226(37.9%)		221(21.9%)	127(23.9%)
OPS + RT	763(23.4%)	37(6.2%)		230(22.7%)	123(23.2%)
OPS			0.647			0.191
None	1795(55.0%)	304(53.9%)		560(55.4%)	281(52.9%)
Yes	1471(45.0%)	260(46.1%)		451(44.6%)	250(47.1%)
LND^f			0.003			0.114
None	3242(99.3%)	551(97.7%)		1001(99.0%)	519(97.7%)
Yes	18(0.6%)	11(2.0%)		7(0.7%)	10(1.9%)
Unknown	6(0.2%)	2(0.4%)		3(0.3%)	2(0.4%)
RT			0.076			0.310
None/unknown	908(27.8%)	174(30.9%)		291(28.8%)	160(30.1%)
Yes	2358(72.2%)	390(69.1%)		720(71.2%)	371(69.9%)
OS^g, AST^h, Months (95%CIⁱ)	74.89 (73.33, 76.45)	70.95 (67.13, 74.78)	0.045	71.55 (68.70, 74.40)	72.25 (68.35, 76.15)	0.726
CSS^j, AST, months (95%CI)	94.48 (93.24, 95.73)	90.38 (87.05, 93.70)	0.005	91.86 (89.44, 94.27)	91.43 (88.08, 94.78)	0.780
^aPSM: Propensity Score Matching; ^bOther: American Indian/Alaska Native, Asian/Pacific Islander and other races; ^cSingle: Never married, Domestic Partner, Widowed, Separated or Divorced; ^dRT: Radiation Therapy; ^eOPS: Organ Preservation Surgery; ^fLND: Lymph Node Dissection; ^gOS: Overall Survival; ^hAST: Average Survival Time; ⁱ95%CI: 95% Confidence Interval; ^jCSS: Cancer Specific Survival

3.4 Gender differences in survival of elderly patients with stage I laryngeal cancer under different treatment modalities

In the univariate analysis of the survival prognosis of male and female patients with different treatment modalities, we found that in RT group, OPS group and OPS + RT group, male patients had better OS and CSS than females, among which the gender difference of OS in the RT group was the most obvious, but the difference was not statistically significant (Fig. 4). The prognosis of the OPS group was comparable to that of the OPS + RT group (OS: 75.17 months vs. 75.32 months; CSS: 91.87 months vs. 90.51 months), but both better than that of the RT group (OS: 69.30 months; CSS: 90.38 months) in elderly women. (Table 3)

Table 3

Survival comparison between different treatments in elderly patients with stage I laryngeal cancer
Variable	Overall Survival, AST^a, months (95%CI)^b		P-value	Cancer Specific Survival, AST, months (95%CI)		P-value
Variable	Male	Female	P-value	Male	Female	P-value
Therapy
None	51.05(44.19–57.91)	48.90(33.90–63.90)	0.733	75.64(68.36–82.93)	67.84(51.90-83.78)	0.204
RT^c	74.45(72.21–76.69)	69.30(63.76–74.85)	0.063	94.22(92.41–96.03)	90.38(85.51–95.25)	0.077
OPS^d	79.56(76.18–82.94)	75.17(68.37–81.97)	0.701	96.46(93.91–99.01)	91.87(86.75–96.99)	0.940
OPS + RT	77.85(74.87–80.82)	75.32(67.40-83.24)	0.439	97.32(95.10-99.54)	90.51(83.59–97.44)	0.022
^aAST: Average Survival Time; ^b95%CI: 95% Confidence Interval; ^cRT: Radiation Therapy; ^cRT: Radiation Therapy; ^dOPS: Organ Preservation Surgery

Gender differences are associated with cancer incidence and survival, and there may be complex interactions in the intrinsic control of the tumor microenvironment (hormones) and the systemic determinants of cancer progression, such as the immune system and metabolism [5]. It is generally accepted that estrogen is a protective factor for tumor progression [3, 5, 6] and that women with head and neck cancers, including laryngeal cancers, tend to have better survival outcomes [4, 5], but lower estrogen and estrogen receptor levels in elderly females [19] make laryngeal cancers more likely to develop and be aggressive [5]. These ideas were confirmed in our study, where there was a significant difference in survival between male and female patients in a cohort of elderly laryngeal cancer, with male patients having significantly higher OS than female patients. Surprisingly, however, the gender differences in survival were mainly concentrated in stage I rather than advanced patients, and we considered that this might be related to the large gender differences in the epidemiology of T1N0M0 patients and the different effects on standardized treatment. Therefore, we focused on stage I patients, and the survival difference between men and women disappeared after PSM of general epidemiological data and clinicopathological data.

In our study, the supraglottic type was found to be a risk factor affecting the prognosis of elderly patients with stage I laryngeal cancer, and the death risk was 2.8 times higher in patients diagnosed with supraglottic type than in patients with glottic type. Meanwhile, the tumor site was an important factor contributing to the gender difference, with a higher proportion of female patients having supraglottic laryngeal cancer. Differences in clinicopathological and immunohistochemical staining characteristics suggest that T1-T2 glottic and supraglottic squamous cell carcinoma should be treated as distinct entities [20]. Although the guidelines indicate that LND is required even for early supraglottic laryngeal cancer [18, 21], we observed a low rate of LND in elderly patients with stage I laryngeal cancer. Even in females with a high prevalence of supraglottic type, only 2% of patients had LND, which may be related to the worse prognosis of females. Many studies have confirmed that early supraglottic laryngeal cancer is also prone to lymph node metastasis, which is an important factor affecting patient prognosis. The clinical staging of many N0 patients is often inaccurate due to occult metastasis, which is an important factor for recurrence and poor prognosis of laryngeal cancer [22–24]. Therefore, to narrow gender differences, more emphasis should be placed on neck selective treatment in female patients with supraglottic laryngeal cancer.

According to the NCCN guidelines, a single treatment modality, OPS alone or RT alone, should be chosen for early-stage laryngeal cancer, with the choice of treatment modality depending on the expected functional outcome, reliability of follow-up, general medical status, and the patient's wishes [18]. In stage I laryngeal cancer, an equal proportion of male and female patients chose OPS and RT, with nearly half of them choosing RT. Although the survival difference between men and women was not statistically significant by comparison of the two treatments, female patients in the RT group had significantly worse OS than males compared with the OPS group, and the OPS group also showed better OS and CSS compared with the RT group in females. Al-Qurayshi Z et al [25] found that T stage was underestimated preoperatively in 23% of patients undergoing surgery and that surgery had the advantage of accurate staging over RT [26–28]. Patients treated with RT have a higher rate of local recurrence and can only be salvaged surgically after recurrence mostly only by total laryngectomy [29, 30]. Therefore, it is reasonable to suggest that OPS should be chosen more often for elderly females with stage I laryngeal cancer for a better prognosis when circumstances permit. In addition to OPS or RT alone, we also observed a treatment pattern of OPS combined with RT in stage I laryngeal cancer that did not show a better prognosis or improved gender differences than OPS alone. Therefore, considering the specificities of the elderly population (worse Karnofsky score and immunity, etc.), we do not advocate combination therapy to avoid compromising function and prognosis [31].

In stage I elderly laryngeal cancer population, females were more likely to be diagnosed with an advanced age (≥ 85 years) or single status compared with male patients. In multivariate analysis, age at diagnosis and single status were also risk factors affecting prognosis, which may be associated with poorer survival in female patients compared to males. Advanced age means patients are more likely to have comorbidities, which is a strong independent predictor of mortality for head and neck cancer patients, and also affects the cost of the care and quality of life, as well as treatment options [32, 33]. Because of poorer HRQoL [13] and more likely to be single, female patients with laryngeal cancer may face greater psychological stress, more fragile emotions and social functioning, and thus females are significantly more likely to acquire depression than male patients [14]. Elderly females with laryngeal cancer, especially the oldest old (≥ 85 years) and single patients should receive more attention including individualized treatment and psychological support to improve prognosis and reduce gender differences.

Due to the nature of retrospective studies and the limitations of the SEER database, our study inevitably has some limitations. Information on disease recurrence as well as comorbidities is not available in the database. Patients with comorbidities may not be considered suitable candidates for surgery, and are only offered radiotherapy, which may result in some selection bias. Also, as a retrospective study, it is inevitable to introduce some confounding factors into the study, which may cause the conclusion to be biased. However, it is undeniable that there is a gap in research on this group, and our first comprehensive and systematic analysis of laryngeal cancer in elderly women with the help of big data still has great clinical value, and we expect more prospective studies in the future to provide more accurate guidance.

HRQoL: Health-related quality-of-life

K-M: Kaplan-Meier

NCCN: National Comprehensive Cancer Network

AST: Average survival time

LND: Lymph node dissection

RT: Radiation therapy

SEER: Surveillance, Epidemiology, and End Results

OS: Overall survival

HR: Hazard ratio

CSS: Cancer specific survival

PSM: Propensity score matching

OPS: Organ preservation surgery

Ethics approval and consent to participate: Ethics approval and patient informed consent is not required to extract data from the SEER database. We obtained the authorization to access the SEER database, with the number 14755-Nov2020. All methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication: Not applicable

Availability of data and materials: All data generated or analysed during this study are included in this published article and its supplementary information files.

Competing interests: The authors declare that they have no competing interests.

Funding: Not applicable

Authors' contributions:

YP: designed of the work, analyzed the data and drafted the work

YH: contributions to the conception and drafted the work

EQ: the acquisition and interpretation of data and analyzed the data

SR: designed of the work and substantively revised the work

Acknowledgements: The authors would like to thank the SEER program for public access to the database.

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The survival outcome and gender difference of elderly females with laryngeal cancer

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Abstract

Background

Methods

Results

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Introduction

Methods

2.1 Patients

2.2 Statistical analysis

Results

3.2 Prognosis analysis of elderly patients with stage I laryngeal cancer

3.3 Gender differences among elderly patients with stage I laryngeal cancer

Discussion

Abbreviations

Declarations

References

Additional Declarations

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