Propensity-score Matching Analysis for Marital Status and Survival of Oral and Oropharyngeal Squamous Cell Carcinoma Based on SEER Database

doi:10.21203/rs.3.rs-1071238/v1

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Propensity-score Matching Analysis for Marital Status and Survival of Oral and Oropharyngeal Squamous Cell Carcinoma Based on SEER Database

https://doi.org/10.21203/rs.3.rs-1071238/v1

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Object

Marital status plays different roles as a risk factor on survival in various cancers . The study is aimed to analyze the impact of marital status on survival of oral and oropharyngeal squamous cell carcinoma(OPSCC) at population level based on SEER database using propensity-score matching method(PSM).

Methods

37,023 eligible patients were extracted from the Surveillance, Epidemiology, and End Results(SEER) database, and analyzed the impact of various marital status on cancer-specific survival(CSS) of OPSCC by Kaplan-Meier method and Cox regression model. Then we used propensity-score matching analysis to balance baseline characteristics between married, single, divorced and widowed patients. The impact of various marital status after pairwise matching using p-value adjusted and PSM on CSS was re-analyzed by Kaplan-Meier method.

Results

The age, sex, race, tumor location, pathologic grades, SEER stages, treatments, composite socioeconomic status(C-SES), insurance, and marital status were identified as independent prognostic factors for CSS of OPSCC. Widowed patients presented the worst CSS, compared with married, single, and divorced patients(P<0.001). Subgroup analysis indicated that widowed patients always presented with the significantly decreasing risk of CSS compared with other marital status in different SEER stages(P<0.001), and different C-SES(P<0.001). After propensity-score matching, widowed patients were still found to be associated with significantly decreased CSS compared with other marital groups(P<0.001).

Conclusion

Marital status was first analyzed after using PSM to balance clinicopathological and socioeconomic confounding factors and identified as an independent prognostic factor for CSS of OPSCC. Widowed patients was significantly associated with a decreasing CSS, which indicated that absence of spousal support and optimal psychosocial coping strategies may explain the phenomenons.

Otorhinolaryngology

oral and opopharynx

squamous cell carcinoma

marital status

survival

SEER program

Oral and oropharyngeal squamous cell carcinoma(OPSCC) was one of the common malignant tumor in head neck. The incidence of OPSCC continued to increase, due to excessive tobacco, alcohol consumption and HPV infection[1,2]. Furthermore, mortality rates were relentlessly increasing overall by 0.5% per year from 2009 to 2018, although optimized multidisciplinary treatments improved local control[3,4].

As we know that the anatomy of oral and oropharyn is not deeply hidden, primary tumor should been easier to be examined in early stage, and have more opportunities to be cure and better survival. However, the reality of survival of OPSCC was opposite. Therefore, we need to further analyze the predictive factors to establish comprehensive treatment strategies and improve survival of patients with OPSCC.

Prior studies suggested that the confounding risk factors, including age, sex, race, tumor site, pathologic grade, treatment, socioeconomic status, alcohol and tobacco consumption, HPV infection and marital status, played controversial roles in survival of patients with OPSCC[5-10]. Many studies also indicated that unmarried status was an increasing risk of mortality in oral cavity or oropharyngeal cancer, compared with married status based on a population studies[11-14]. However, the impact of more detailed unmarried status on survival has not been previously reported. The effect of socioeconomic and marital status on survival of OPSCC had been reported in seldom. Therefore, it is important to explore the effect of different marital status on survival of OPSCC patients and formulate more reasonable strategies.

In the present study, we extracted data from the Surveillance, Epidemiology, and End Results cancer registry database to assess and compare the effects of married, single, divorced and widowed status on cancer-specific survival using PSM and explored the possible mechanisms.

Patient population

All eligible patients with OPSCC diagnosed from 1975 to 2016 were identified in the SEER database (version 8.3.9,updated at Sep 20th, 2021). The current database we used was Incidence-SEER 18 Regs Custom Data (with additional treatment fields), Nov 2018 Sub (1975-2016 varying). Patients over the age of 20-year old and who received a pathological diagnosis of OPSCC (ICD-O-3 histology code: 8052, 8053, 8070, 8071, 8072, 8073, 8074, 8075, 8076, 8078, 8083, 8084) were included in our studies. The criteria of tumor stage was based on SEER combined summary stage 2000. Patients with more than one primary tumor, incomplete follow-up information, and incomplete clinicopathological characteristics (age, sex, race, pathologic grade, SEER stages, treatments) and socioeconomic characteristics(insurance, composite SES, marital status) were excluded.

Study variables

Variables about clinicopathological and composite socioeconomic characteristics were shown in Table 1. The tumor location was divided into tongue(anterior and basal), oroharynx(tonsils) and others(mucous of buccal, mouth floor, lip, palate and others). Pathological grades were divided into 2 categories: low grade (well and moderately differentiated) and high grade (poorly and undifferentiated). In our study, we merged seperated and divorced patients into divorced group.

Three standard 2000 US Census variables from SEER database, including median family income, the percentage of persons who have less than high school education, and the percentage of persons with income below the poverty level, were extracted. A composite SES variable was set up according to the three SES variables as described in previous studies [15-17]. The composite SES variables was further classified as low C-SES (C-SES score <5) and high C-SES (C-SES score ≥5)[18].

Propensity‑score matching:

Marital status was divided into married, single, divorced, and widowed groups from SEER database. To precisely assess the roles of marital status in prognosis of OPSCC patients, propensity-score matching method was performed to balance clinicopathological and socioeconomic characteristics between different marital pairwise groups. After p-value adjusted and pairwise matching, the prognostic importance of marital status on CSS were re-analyzed within the matching pair of groups.

Statistical analysis

Pearson’s Chi-squared test was performed to analyze relationship of different clinicopathological and socioeconomic characteristics between various marital groups. CSS was estimated by Kaplan–Meier methods. Log rank test was performed to evaluate the statistical significance of differences between survival curves of various marital groups. Multivariable Cox proportional-hazards regression model was performed to analyze the hazard ratios of risk factors. All statistical tests were two-tailed. Statistical significance was identified as p value less than 0.05. The statistical analysis was conducted using SPSS(version 20.0) and R(version4.1.1).

Baseline clinicopathological and socioeconomic characteristics

A total of 37,023 eligible patients (27,776 males and 9,247 females) were included in our studies from the SEER database. Of these patients, there were 21,049(56.9%) married patients, 7,554(20.4%) single, 5,428(14.7%) divorced and 2,992(8.1%) widowed patients. Detailed clinicopathological and composite socioeconomic characteristics were shown in Table 1. Statistically significant differences were identified in age, sex, race, tumor location, pathological grades, SEER stages, treatments, insurance, C-SES between different marital groups(P<0.001). Among the comparisons of risk factors, widowed patients had twice or three times higher proportion in the group of age ≥60-year old(87.9%), and female(62.6%), than that of other corresponding marital groups.

The roles of marital status on CSS of OPSCC

The detailed univariate and Cox-regression multivariate analysis were shown in Table 2. The groups of age ≥60-year old, female, black race, other tumor location, low pathological grade group, the distant SEER stage, low C-SES, non-insurance, and non-treatment had significant worse 5-year CSS (P<0.001). Furthermore, these variables were also determined as independent risk factors for CSS of OPSCC by multivariate analysis. Forest plot was showed in Figure 1 according to multivariate Cox-proportional hazard analysis.

Univariate analysis by Kaplan-Meier method showed that significant differences were observed in CSS among different marital groups. In a crude survival analysis, the widowed group was associated with a significant decreasing risk of CSS( P>0.001), as shown in Figure 2A. The 5-year CSS of widowed group was significantly worse than that of married, single and divorced groups. Furthermore, the widowed patients had a significant lower risk of cancer-specific survival compared with married, single and divorced patients after controlling for the confounding risk factors(P<0.001), as showed in Figure 2B.

Subgroup analysis of the roles of marital status by SEER stage

The effects of marital status on CSS were evaluated regarding the SEER stage, as shown in Table 3. We found that widowed patients invariably had the worse 5-year CSS compared with married, single and divorced patients in the localized, regional and distant groups(Figure 3). In the subgroup of different SEER stages , multivariate Cox-regression analysis indicated that widowhood was invariably significant decreasing risk of CSS compared with married patients (local, HR 1.607, 95%CI: 1.372-1.882, P<0.001; region, HR 1.887, 95%CI: 1.703-2.090, P<0.001; distant, HR 1.499, 95%CI: 1.307-1.719, P<0.001).

Subgroup analysis the role of marital status by C-SES

The effects of marital status on CSS at different C-SES were assessed, as shown Table 4. Subgroup ananlysis showed that marital status was invariably determined to be an independent risk factors of CSS among OPSCC patients with low and high C-SES according to the log-rank tests and Cox-regression multivariate analysis (Figure 4, P<0.001). In low and high C-SES group, widowed patients invariably had the worse CSS, compared with married patients.(HR 1.685,95%CI:1.446-1.963, P<0.001; HR 1.762, 95%CI: 1.623-1.914, P<0.001).

Propensity -score matching for different pairwise marital groups

P-values adjusted method(BH) was used to test the statistically differences between pairwise marital groups. Then we found that there were significant differences between widowed and other marital groups(P<0.001), between married and other marital groups(P<0.001) respectively. Since the several baseline characteristics among different marital groups were significantly different, we performed propensity-score matching analysis to balance the confounding factors. If there was statistically significant differences of survival analysis between different marital status using Kaplan-mier methods, each group was matched a 1:1 ratio. The detailed variables after propensity-score matching were shown in Table 5.

Survival analysis after propensity-score matching

Figure 5A and 5B showed that before and after PSM, CSS of widowed patients was always significantly worse than that of married patients (P<0.001). After adjusting for confounding factors (age, sex, race, pathological grade, tumor location, treatments, insurance, C-SES), widowhood was still statistically significant increasing risk of mortality (HR 1.366, 95%CI:1.246-1.497, P<0.001).

Figure 5C and 5D showed before and after PSM of widowed and divorced patients, CSS of widowed patients was also significantly worse than that of divorced patients (P<0.001). After adjusting for confounding factors, widowed status was statistically significant risk factor of CSS (HR 1.255, 95%CI:1.145-1.376, P<0.001).

Pairwise comparison of different marital status effect on CSS before and after PSM, as such married and divorced (HR 1.348, 95%CI:1.255-1.449, P<0.001)), single and widowed(HR 1.291, 95%CI:1.174-1.419, P<0.001), married and single patients(HR 1.384, 95%CI:1.301-1.473, P<0.001), were shown in from Figure 5E to Figure 5J. After balancing the confounding prognostic factors, marital status was statistically significant risk factor for CSS of OPSCC patients.

The effect of marital status on prognostic of various diseases was inconsistent. Some studies indicated married status had a better life expectancy and quality in cardiovascular disease and carcinomas[19,20,21], while no significant effects on survival of cancer patients were suggested in other studies[22,23]. Prior studies on marital status on survival of oral or oropharyngeal squamous cell carcinoma showed that marital status was an independent prognostic factor, and marriage had an protective effect on survival for for oral or oropharyngeal cancer[11,24]. However, these studies had not been combined clinicalpathological characteristics with socioeconomic characteristics of OPSCC, and analyzed survival of the pairwise marital patients after using prospensity-score matching without p adjusted method. Therefore, it is necessary to clarity the holistic impact of marital status on survival.

Based on clinicopathological and socioeconomic characteristics of OPSCC, marital status is definitely identified as an independent prognostic risk factor for CSS after balancing age, sex, race,pathologic grade, SEER stage, tumor location, treatment modalities, insurance, C-SES using PSM and p-values adjusted method. Furthermore, we found that in both in multivariate survival analysis and pairwise matching survival after p-value adjusted method and propensity-scores matching, widowed patients invariably had the worst cancer-specific survival compared with married, single and divorced patients. Our studies also indicated that prognostic factors of non-insurance and low composite socioeconomic status were determined to be decreasing risk factors of survival. Therefore, evaluating the socioeconomic status was necessary for the prognosis of OPSCC patients.

Marital status has been indicated to be associated with the prognosis in various malignant tumors. Prior studies have demonstrated that marriage had an independent protective effects on survival, and married patients had lower risk for metastatic caners, and were more inclined to receive definite treatment. Perhaps, there were the strong social support and insurance coverage, better living habits and psychology state in the married populations[11,23,25,26,27]. Our findings also confirmed the protective roles of marriage in OPSCC. Furthermore, the detailed classification of marital status indicated that widowed patients had the worst CSS compared with married, single and divorced patients.

Some studies found that the worse prognosis in widowed patients was due to delayed diagnosis and insufficient treatments. Lack of spousal support and financial assistance were mainly disadvantages in widowed patients[28,29,30]. Our studies also showed that the higher percentage of low composite socioeconomic status was in widowed patients, compared with married and divorced patients. Moreover, subgroup analysis in low and high C-SES indicated that widowed patients always had the worst CSS, compared with other marital status. Even if balancing the confounding factors using PSM, widowed patients still had the worst CSS, compared with others. The association between widowhood and poor survival may be attributed to the psychosocial factors[31]. The spousal death and the need of adaption to new social roles were very depressed and stressful for the surviving companion. Psychological depression could lead to poor medical compliance, and increasing the mortality risk of malignant tumor.[32]

Marriage had protective roles for survival of oral cancer. However, widowed status was faced by almost everyone in the course of life. To explore the disadvantaged prognostic factors for survival seemed to be more pressing.Our studies also indicated that the importance of marital status in survival of OPSCC patients. Marriage had an advantage on cancer prognosis, and more compliant to proper treatments under their spousal support and encouragements. However, widowed patients seemed to be particularly prone to depression[33], and widowhood had a negative impact on immune status and hormone level.

However, a few researchers suggested that there were no significant differences in prognosis between malignant tumor and marital status. These authors suggested that the phenomenons may be originated from the limitations of the database, including the number of confounding prognostic factors, different clinicopathological and socioeconomic characteristics, and study design type[23,29]. In our studies, we extracted 3 standard 2000 US Census variables to set up a composite socioeconomic status variable, and explored the association between marital status and CSS after controlling socioeconomic and clinicopathologic variables using propensity-score matching method.

There are some limitations in our studies. First, the information of marital status in SEER databse was acquired only at the time of tumor diagnosis, and there were no changes during the course of therapy, even till death. Second, psychosocial factors, tobacco and alcohol consumption, and HPV infection were not including in SEER database, the association of psychosocial and survival should be further performed and validated. Third, although we utilized the PSM methods to reduce the bias, there were inherent bias of retrospective research. The evaluation of life quality was also an important goal missing from the SEER database.

Based on population level of SEER database, widowed patients with oral and oropharyngeal carcinoma were first identified to have the worst cancer-specific survival compared with married, single and divorced patients, and marital status was shown as an independent prognostic risk factor for survival after balancing the confounding prognositic factors using p-value adjusted method and propensity-score matching method. Psychosocial depression and loss of spousal support leading to the negative effects on the widowed patients should be further studied in multicenter, large samples, randomized control study.

Acknowledgements

Not applicable

Funding

The study was supported by Hubei Provincial Naturral Science Foundation (No.2011CBD484).

Availability data and materials

The datasets used and/or analyzed during the current study are available from the Surveillance, Epidemiology, and End Results(SEER) database.

Authors information

Affiliations

Department of Otolaryngology Head an Neck, Institute of Otorhinolaryngology, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei, China

Wei Ming, Jingjing Zuo, Jibo Han, Yan Wang, Jinhui Chen

Contributions

All persons designated as the authors have participated sufficiently in the work to take public responsibility for the content of the manuscript.

Corresponding author

Correspondence to Wei Ming

Ethics declarations

Ethics appoval and consent to participate

The study was approved by the Renmin hospital of Wuhan University Ethics Committee and conducted in accordance with the ethical standards of the declaration of Helsinki. Based on the public data of SEER programs, signing an informed consent was not required.

Consent for publication

Not applicable

Competing interests

The authors declare that there is no conflict of interest.

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Table 1. Baseline clinicopathological and socieconomic characteristics of OPSCC patients

Characteristics	Total	Married	Single	Divorced	Widowed	P value
Characteristics	n=37023	n=21049(%)	n=7554(%)	n=5428(%)	n=2992(%)	P value
Age						<0.001
<60	17745	10082(47.9%)	4694(62.1%)	2607(48.0%)	362(12.1%)
≥60	19278	10967(52.1%)	2860(37.9%)	2821(52.0%)	2630(87.9%)
Sex						<0.001
Female	9247	4342(20.6%)	1685(22.3%)	1347(24.8%)	1873(62.6%)
Male	27776	16707(79.4%)	5869(77.7%)	4081(75.2%)	1119(37.4%)
Race						<0.001
Black	2976	964(4.6%)	1263(16.7%)	505(9.3%)	244(8.1%)
White	32064	18773(89.2%)	5989(79.3%)	4745(87.4%)	2557(85.5%)
Other	1983	1312(6.2%)	302(4.0%)	178(3.3%)	191(6.4%)
Location						<0.001
Tongue	16719	9778(46.4%)	3329(44.1%)	2309(42.5%)	1303(43.5%)
Oropharyn	12582	7301(34.7%)	2651(35.1%)	1988(36.6%)	642(21.5%)
Others	7722	3970(18.9%)	1574(20.8%)	1131(20.8%)	1047(35.0%)
Grade						<0.001
Low	22852	12588(59.8%)	4791(63.4%)	3355(61.8%)	2118(70.8%)
High	14171	8461(40.2%)	2763(36.6%)	2073(38.2%)	874(29.2%)
SEER stage						<0.001
Local	11007	6546(31.1%)	1936(25.6%)	1301(24.0%)	1224(40.9%)
Regional	20005	11577(55.0%)	4094(54.2%)	3042(56.0%)	1292(43.2%)
Distant	6011	2926(13.9%)	1524(20.2%)	1085(20.0%)	476(15.9%)
Composite SES						<0.001
Low	7398	3886(18.5%)	1757(23.3%)	1117(20.6%)	638(21.3%)
High	29625	17163(81.5%)	5797(76.7%)	4311(79.4%)	2354(78.7%)
Insurance						<0.001
None	1684	575(2.7%)	677(9.0%)	359(6.6%)	73(2.4%)
Insurance(medicaid)	35339	20474(97.3%)	6877(91.0%)	5069(93.4%)	2919(97.6%)
Treatment						<0.001
None	2526	929(4.4%)	774(10.3%)	473(8.7%)	350(11.7%)
Surgery alone	10082	5865(27.9%)	1887(25.0%)	1220(22.5%)	1110(37.1%)
Radiation alone	12796	7182(34.1%)	2693(35.6%)	2093(38.6%)	828(27.7%)
Surgery with radiation	11619	7073(33.6%)	2200(29.1%)	1642(30.2%)	704(23.5%)
Cancer-specific death						<0.001
Events	9130	4093(19.4%)	2306(30.5%)	1662(30.6%)	1069(35.7%)
Censored	27893	16956(80.6%)	5248(69.5%)	3766(69.4%)	1923(64.3%)

Table 2. Univariate and multivariate survival analysis for marital status on CSS of patients with OPSCC

Vaviables	5-year CSS	Univariate analysis		Multivariate analysis
Vaviables	5-year CSS	Log rank χ² test	P	HR(95Z%CI)	P
Age		272.436	<0.001
<60	72%			Reference
≥60	63%			1.401(1.340-1.464)	<0.001
Sex		73.511	<0.001
Female	65%			Reference
Male	69%			0.825(0.785-0.866)	<0.001
Race		610.992	<0.001
Black	48%			Reference
White	70%			0.684(0.642-0.728)	<0.001
Other	66%			0.844(0.759-0.939)	<0.05
Location		174.319	<0.001
Tongue	66%			Reference
Oropharynx	73%			0.703(0.669-0.738)	<0.001
Other	64%			1.238(1.172-1.308)	<0.001
Grade		26.698	<0.001
Low	67%			Reference
High	69%			0.802(0.767-0.839)	<0.001
Seer stage		2992.176	<0.001
Local	81%			Reference
Regional	68%			2.152(2.006-2.309)	<0.001
Distant	42%			4.304(3.993-4.639)	<0.001
Composite SES		109.128	<0.001
Low	63%			Reference
High	69%			0.889(0.846-0.933)	<0.001
Insurance		134.827	<0.001
None	55%			Reference
Insurance(medicaid)	68%			0.787(0.724-0.856)	<0.001
Treatment		5375.402	<0.001
None	28%			Reference
Surgery alone	80%			0.179(0.165-0.194)	<0.001
Radiation alone	64%			0.263(0.247-0.279)	<0.001
Surgery with Radiation	71%			0.214(0.201-0.229)	<0.001
Marital status		1037.044	<0.001
Married	74%			Reference
Single	60%			1.522(1.443-1.605)	<0.001
Divorced	60%			1.487(1.404-1.575)	<0.001
Widowed	54%			1.736(1.615-1.867)	<0.001

Table 3. Subgroup survival analysis for marital status on CSS of OPSCC according to SEER stages

SEER stages	5-year CSS	Univariate analysis		Multivariate analysis
SEER stages	5-year CSS	Log rank χ² test	P	HR(95Z%CI)	P
Localized		126.885	<0.001
Married	85%			Reference
Single	79%			1.397(1.213-1.609)	<0.001
Divorced	76%			1.599(1.378-1.856)	<0.001
Widowed	74%			1.607(1.372-1.882)	<0.001
Regioned		689.966	<0.001
Married	76%			Reference
Single	61%			1.570(1.460-1.689)	<0.001
Divorced	63%			1.457(1.345-1.577)	<0.001
Widowed	48%			1.887(1.703-2.090)	<0.001
Distant		233.965	<0.001
Married	52%			Reference
Single	36%			1.407(1.279-1.547)	<0.001
Divorced	37%			1.409(1.273-1.560)	<0.001
Widowed	24%			1.499(1.307-1.719)	<0.001

Table 4. Subgroup survival analysis for marital status on CSS of OPSCC based on C-SES

Composite socioeconomic status	5-year CSS	Univariate analysis		Multivariate analysis
Composite socioeconomic status	5-year CSS	Log rank χ² test	P	HR(95Z%CI)	P
Low		267.150	<0.001
Married	72%			Reference
Single	53%			1.584(1.423-1.763)	<0.001
Divorced	56%			1.513(1.342-1.707)	<0.001
Widowed	51%			1.685(1.446-1.963)	<0.001
High		760.968	<0.001
Married	76%			Reference
Single	63%			1.494(1.404-1.588)	<0.001
Divorced	62%			1.475(1.381-1.575)	<0.001
Widowed	56%			1.762(1.623-1.914)	<0.001

Table 5 The baseline characteristics of patients with OPSCC after PSM
Variables	Married n=2992	Widowed n=2992	P	Divorced n=2992	Widowed n=2992	P	Single n=2992	Widowed n=2992	P
Age,years			0.874			<0.001			0.020
<60	357	362		540	362		424	362
≥60	2635	2630		2452	2630		2568	2630
Sex			0.831			<0.001			<0.001
Female	1864	1873		1091	1873		910	1893
Male	1128	1119		1901	1119		2082	1119
Race			0.247			<0.001			0.020
Black	223	244		250	244		271	244
White	2601	2557		2635	2557		2576	2557
Others	168	191		107	298		145	191
Location			0.027			<0.001			<0.001
Tongue	1271	1303		1216	1303		1296	1303
Oropharyn	728	642		1012	642		951	642
Others	993	1047		764	1047		745	1047
Grade			0.669			0.020			<0.001
Low	2134	2118		2034	2118		1944	2118
High	858	874		958	874		1048	874
Stage			0.943			<0.001			<0.001
Localized	1237	1224		929	1224		877	1224
Regional	1283	1292		1576	1292		1596	1292
Distant	472	476		487	476		519	476
Treatment			<0.001			<0.001			<0.001
None	244	350		339	350		325	350
Surgery alone	1147	1110		866	1110		855	1110
Radiation alone	837	828		1073	828		1056	828
Surgery with Radiation	764	704		714	704		756	704
Insurance			0.568			0.934			0.335
None	80	73		75	73		85	73
Insurance(medicaid)	2912	5831		2917	2919		2907	2919
Composite SES			0.728			0.925			0.950
Low	626	638		635	638		641	638
High	2366	2354		2357	2354		2351	2354

Continue Table 5 The baseline characteristics of patients with OPSCC after PSM
Variables	Married n=5428	Divorced n=5428	P	Married n=7554	Single n=7554	P
Age,years			0.833			0.091
<60	2595	2607		4593	4694
≥60	2833	2821		2961	2860
Sex			0.608			0.938
Female	1323	1347		1680	1685
Male	4105	4081		5874	5869
Race			0.777			<0.001
Black	498	505		923	1263
White	4764	4745		6352	5989
Others	166	178		279	302
Location			0.931			0.484
Tongue	2297	2309		3264	3329
Oropharyn	2007	1988		2717	2651
Others	1124	1131		1573	1574
Grade			0.828			0.531
Low	3367	3355		4829	4791
High	2061	2073		2725	2763
Stage			0.756			0.907
Localized	1283	1301		1957	1936
Regional	3030	3042		4069	4094
Distant	1115	1085		1528	1524
Treatment			0.581			<0.001
None	437	473		636	774
Surgery alone	1241	1220		2036	1887
Radiation alone	2126	2093		2653	2693
Surgery with Radiation	1624	1642		2229	2200
Insurance			0.532			<0.001
None	342	359		542	677
Insurance(medicaid)	5086	5069		7012	6877
Composite SES			0.636			0.384
Low	1137	1117		1711	1757
High	4291	4311		5843	5797

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Propensity-score Matching Analysis for Marital Status and Survival of Oral and Oropharyngeal Squamous Cell Carcinoma Based on SEER Database

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