ABSTRACT
Background
The American Society of Clinical Oncology recommends routine influenza vaccination for cancer patients. Lack of influenza vaccination may lead to increased infection incidence, increased infection severity, and delays in cancer care. Vaccine uptake among head and neck patients is unknown.
Methods
We performed a retrospective cohort analysis using the SEER‐Medicare database for patients above age 65 with head and neck cancer diagnosed between 2013 and 2018.
Results
Among 32,155 patients, 32.5% received vaccination in the year before diagnosis and 32.1% in the year after diagnosis. Analyses revealed a significant increase in vaccination at the time of diagnosis and fewer vaccinations in the 3 months afterward. Various factors were associated with decreased odds of receiving vaccination, including Black and AAPI race/ethnicity, male gender, and regional and distant metastasis.
Conclusions
Vaccination uptake is suboptimal in patients with head and neck cancer, underscoring the need for targeted interventions to enhance preventive care to improve outcomes in high‐risk patients.
Keywords: head and neck cancer, influenza immunization, influenza vaccination
1. Introduction
In 2024, the American Society of Clinical Oncology (ASCO) published guidelines regarding vaccination of adults with cancer and strongly recommends that all adults with cancer remain up to date on seasonal vaccines [1]. Specifically, ASCO recommends annual influenza vaccination with an inactivated quadrivalent vaccine for all patients, and use of a high dose or adjuvanted formulation for patients aged 65 or older. Because patients with cancer have heightened risk for infection and varying degrees of immunocompromise, vaccines are an important part of standard preventative care [2, 3]. The purpose of vaccination is to protect against or decrease severity of infection when infection cannot be avoided [4, 5, 6]. Hospitalized patients with influenza experience higher mortality, longer hospital stays, and increased rates of complications [5, 7]. Influenza can also cause delays or interruptions in chemotherapy and other cancer treatments [8, 9].
Many factors including lack of access to primary care, patient understanding, and ease of access to vaccination may lead to lower vaccination rates than optimal. ASCO has engaged with the Centers for Disease Control and Prevention (CDC), Council of Medical Specialty Societies, and other specialty societies in a 5 year cooperative agreement to improve vaccination among high‐risk adults [10]. In the United States, there is limited information regarding the uptake of influenza immunization in cancer, and there are no published studies about the incidence of vaccination in head and neck cancer patients.
The purpose of the current study is to provide information on the incidence of influenza vaccination in patients with head and neck cancer in the United States (US). We leveraged the SEER‐Medicare database, which covers approximately one‐third of the US population, to gain information on vaccination patterns in the US in patients above age 65. The SEER‐Medicare database is uniquely positioned for this study because of the high proportion of coverage of patients over age 65 and the inclusion of non‐hospital vaccination sites such as mass vaccination sites (e.g., pharmacies) and urgent care clinics.
2. Methods
2.1. Data Source and Study Cohort
The SEER‐Medicare database was used in this study and is a collaboration between the National Cancer Institute (NCI) and the Centers for Medicare and Medicaid Services (CMS). The Surveillance, Epidemiology, and End Results (SEER) cancer registry data was linked with Medicare enrollment and claims data to create the SEER‐Medicare database. The SEER‐Medicare database is a robust resource to investigate patterns and outcomes of cancer care within the United States and covers approximately one‐third of the population [11].
For our study, we included all patients aged 65 and above who were diagnosed in the years of 2013–2018 with head and neck cancer as defined by the following ICD‐O‐3 site codes: C00‐C06.9 except C02.4 (oral cavity); C07‐C08.9 (salivary); C09‐C10.9 and C02.4 (oropharynx); C11‐C11.9 (nasopharynx); C12.9‐C14 (pharynx); C32‐C32.9 (larynx). Included patients had at least 1 year follow up after time of diagnosis. Patients with cancer diagnosed on autopsy or by death certificate were excluded. Patients were required to have Medicare part A and B coverage for at least 12 months before and after the date of diagnosis given influenza vaccines are always covered by Medicare part B.
2.2. Determination of Vaccination
Information regarding influenza vaccination was obtained from Medicare claims data for all patients included in the study. To be complete, insurance claims from both inpatient and outpatient sources were queried. The National Claims History (NCH) files and Medicare Outpatient files were queried using the HCPCS code “G0008” indicating administration of the influenza vaccine. The Medicare Provider Analysis and Review (MedPAR) file was queried for procedure code “9952” (before 2015) or “3E0234Z” (after 2015) for administration of the influenza vaccine. Location of immunization was determined by the Line Place of Service variable for claims within the NCH files. Location of immunization was determined to be outpatient clinic for claims within the Outpatient file and hospital inpatient for claims within the MedPAR file.
2.3. Statistical Methods
Analyses were performed using R statistical software (version 4.2.2, R Foundation for Statistical Computing). A level of p < 0.05 was chosen for statistical significance. Continuous variables are presented as means with standard deviations. Tests between two groups were performed using Student's t‐test or Kruskal–Wallis rank sum test and p‐values are displayed. Categorical data were represented as counts with percentages and tested with Chi‐squared test. Cells with N < 11 were combined with other cells as appropriate per SEER‐Medicare data use regulations.
Logistical regression analysis was performed to identify variables associated with receiving at least one vaccine in the year before or after diagnosis. The variables included in the model included age, race/ethnicity, sex, primary site, treatment modality, and SEER Summary Stage. Results are displayed as odds ratios with 95% confidence intervals.
2.4. Temporal Analysis
A month offset was computed by dividing the difference (in days) between date of vaccine and date of diagnosis by 30, then categorized claims as “Before Diagnosis” (offset < 0), “Month of Diagnosis” (offset = 0), or “After Diagnosis” (offset > 0). Monthly counts were summarized by period and plotted. To test for differences over 24 months, we constructed a contingency table by month offset and ran a chi‐square test, then modeled counts using a Poisson regression with month offset as a factor; the overall effect was assessed by a likelihood ratio chi‐square test and individual month p‐values were adjusted using Benjamini–Hochberg (BH) False Discovery Rate (FDR) Control.
3. Results
A total of 32,155 patients met inclusion criteria for this study (Table 1). The mean age was 73.41 (SD 8.91), 32.58% of patients were female, and 88.02% of patients were white. The most common primary site was oral cavity, followed by oropharynx and salivary. In the year prior to cancer diagnosis, 32.5% of patients received one or more influenza vaccinations. In the year after cancer diagnosis, 32.1% of patients received one or more influenza vaccinations. In the year before or after diagnosis, 17.17% of patients received one and 24.57% of patients received two or more influenza vaccinations.
TABLE 1.
Demographic and cancer characteristics for all patients included in the study.
| Variable | N | SD or % |
|---|---|---|
| 32,155 | ||
| Age | 73.41 | 8.91 |
| Sex | ||
| Female | 10,477 | 32.58% |
| Race/ethnicity | ||
| White | 28,302 | 88.02% |
| Black | 2129 | 6.62% |
| AAPI | 1378 | 4.29% |
| Other | 346 | 1.08% |
| SEER summary stage | ||
| In situ | 1536 | 4.78% |
| Localized | 12,358 | 38.43% |
| Regional metastasis | 12,749 | 39.65% |
| Distant metastasis | 3366 | 10.47% |
| Unknown | 2146 | 6.67% |
| Primary site | ||
| Larynx | 704 | 2.19% |
| Nasopharynx | 784 | 2.44% |
| Oral cavity | 17,377 | 54.04% |
| Oropharynx | 5197 | 16.16% |
| Hypopharynx | 883 | 2.75% |
| Salivary | 3761 | 11.70% |
| Overlapping sites | 289 | 0.90% |
| Unspecified | 3160 | 9.83% |
| Vaccines in the year before diagnosis | ||
| 0 | 21,677 | 67.41% |
| 1 | 9953 | 30.95% |
| 2+ | 525 | 1.63% |
| Vaccines in the year after diagnosis | ||
| 0 | 21,834 | 67.90% |
| 1 | 9745 | 30.31% |
| 2+ | 576 | 1.79% |
| Total vaccines in the year before or after diagnosis | ||
| 0 | 18,733 | 58.26% |
| 1 | 5522 | 17.17% |
| 2+ | 7900 | 24.57% |
Note: Counts data is presented as counts with percentages whereas age is presented as mean with standard deviation (SD).
There was a slight trend toward decreased vaccination over time (Table 2, Figure 1). In 2013, 54.9% of patients did not receive any influenza vaccination in the year before or after diagnosis, compared to 59.96% of patients in 2018.
TABLE 2.
Counts and percentages of number of vaccines administered in the year before, after, or combined before or after based on year of cancer diagnosis.
| Year of diagnosis | N | 0 | 1 | 2+ | |||
|---|---|---|---|---|---|---|---|
| Vaccines in the year before diagnosis | |||||||
| 2013 | 5287 | 3423 | 64.74% | 1771 | 33.50% | 93 | 1.76% |
| 2014 | 5297 | 3422 | 64.60% | 1778 | 33.57% | 97 | 1.83% |
| 2015 | 5404 | 3647 | 67.49% | 1688 | 31.24% | 69 | 1.28% |
| 2016 | 5544 | 3940 | 71.07% | 1517 | 27.36% | 87 | 1.57% |
| 2017 | 5086 | 3469 | 68.21% | 1519 | 29.87% | 98 | 1.93% |
| 2018 | 5537 | 3776 | 68.20% | 1680 | 30.34% | 81 | 1.46% |
| Vaccines in the year after diagnosis | |||||||
| 2013 | 5287 | 3446 | 65.18% | 1734 | 32.80% | 107 | 2.02% |
| 2014 | 5297 | 3529 | 66.62% | 1677 | 31.66% | 91 | 1.72% |
| 2015 | 5404 | 3818 | 70.65% | 1493 | 27.63% | 93 | 1.72% |
| 2016 | 5544 | 3798 | 68.51% | 1665 | 30.03% | 81 | 1.46% |
| 2017 | 5086 | 3455 | 67.93% | 1524 | 29.96% | 107 | 2.10% |
| 2018 | 5537 | 3788 | 68.41% | 1652 | 29.84% | 97 | 1.75% |
| Total vaccines (before or after diagnosis) | |||||||
| 2013 | 5287 | 2904 | 54.93% | 956 | 18.08% | 1427 | 26.99% |
| 2014 | 5297 | 2970 | 56.07% | 924 | 17.44% | 1403 | 26.49% |
| 2015 | 5404 | 3181 | 58.86% | 1015 | 18.78% | 1208 | 22.35% |
| 2016 | 5544 | 3327 | 60.01% | 1011 | 18.24% | 1206 | 21.75% |
| 2017 | 5086 | 3031 | 59.59% | 780 | 15.34% | 1275 | 25.07% |
| 2018 | 5537 | 3320 | 59.96% | 836 | 15.10% | 1381 | 24.94% |
FIGURE 1.
A line graph of the percentage of patients receiving vaccines in the year before and after diagnosis. The number of vaccines is stratified by color. The x‐axis represents the year of cancer diagnosis whereas the y‐axis represents the percentage of patients in each category.
The most common setting for influenza immunization was at an outpatient clinic (61.97%, Table 3). The second most common setting was mass immunization centers (35.86%), which are defined by Medicare to be locations such as malls or pharmacies where providers administer vaccines and can submit associated claims. Approximately 2% of patients received vaccines in other settings such as while as a hospital inpatient, at a public health clinic, at a private residence, or at Urgent Care.
TABLE 3.
Counts and percentages of location of vaccine administration.
| Location of immunization | N | % |
|---|---|---|
| Outpatient clinic | 13,938 | 61.97% |
| Mass immunization center | 8066 | 35.86% |
| Hospital inpatient | 228 | 1.01% |
| Public health clinic | 63 | 0.28% |
| Private residence | 50 | 0.22% |
| Urgent care | 43 | 0.19% |
| Other | 105 | 0.47% |
Regarding time of administration, the number of vaccines administered was relatively constant during the 12 months prior to cancer diagnosis (Figure 2). The month of diagnosis had significantly more vaccines administered (Poisson regression adjusted p‐value = 0.012), whereas the 3 months after diagnosis had significantly fewer vaccines administered (Poisson regression adjusted p‐values for 1 month after diagnosis = 0.029, 2 months = 0.012, 3 months = 0.007). All other months were not statistically significant after adjusting for multiple comparisons.
FIGURE 2.
Line graph depicting the number of total vaccine claims (y‐axis) compared to the month offset relative to date of diagnosis (x‐axis). For example, a vaccine received 2 months before cancer diagnosis would be assigned a month offset of −2. Statistically significant months are indicated with an asterisk (BH‐FDR adjusted p‐value < 0.05).
The states with the highest percent of patients receiving at least 1 influenza vaccine in the year before or after diagnosis were Iowa (56%), New Jersey (55.8%), and Connecticut (48.9%, Figure 3). In contrast, the registries with the lowest percent of patients receiving at least 1 influenza vaccine in the year before or after diagnosis were Hawaii (29.4%), New Mexico (33.5%), and California (34.7%).
FIGURE 3.
Histogram of percent of patients receiving at least one vaccination in the year before or after head and neck cancer diagnosis with state of residence on the x‐axis. Each bar is labeled with the percentage of patients in each bin for ease of reading.
A logistic regression was used to determine factors associated with higher or lower odds of receiving at least one influenza vaccine in the year before or after diagnosis (Table 4). Factors associated with higher odds included age (OR = 1.02 [1.02–1.03]), female sex (1.11 [1.05–1.16]), salivary primary (1.14 [1.06–1.22]) and unspecified primary site (1.1 [1.02–1.19]). Factors associated with lower odds included Black race/ethnicity (0.531 [0.48–0.58]), Asian American and Pacific Islander (AAPI) race/ethnicity (0.80 [0.71–0.89]), regional metastasis (0.87 [0.82–0.93]), and distant metastasis (0.87 [0.80–0.94]). Treatment modality used was not significantly associated with higher or lower odds of vaccination (chemotherapy OR 1.03 [0.96–1.09], radiation OR 1.03 [0.96–1.09], surgery OR 0.98 [0.93–1.04]).
TABLE 4.
The results of a logistic regression are presented where the outcome of interest is receiving at least one influenza vaccine in the year before or after diagnosis.
| Variable | Odds ratio | 95% confidence interval |
|---|---|---|
| Age | 1.03 | 1.03–1.03 |
| Sex | ||
| Male | ref | |
| Female | 1.11 | 1.06–1.17 |
| Race/ethnicity | ||
| White | ref | |
| Black | 0.426 | 0.38–0.47 |
| AAPI | 0.81 | 0.72–0.92 |
| Other | 0.86 | 0.69–1.09 |
| SEER summary stage | ||
| Localized | ref | |
| In situ | 1.05 | 0.94–1.18 |
| Regional metastasis | 0.85 | 0.81–0.91 |
| Distant metastasis | 0.84 | 0.77–0.92 |
| Unknown | 1.04 | 0.94–1/15 |
| Primary site | ||
| Oral cavity | ref | |
| Larynx | 1.06 | 0.89–1.24 |
| Nasopharynx | 1.01 | 0.85–1.18 |
| Oropharynx | 1 | 0.93–1.08 |
| Hypopharynx | 0.98 | 0.84–1.14 |
| Salivary | 1.13 | 1.05–1.22 |
| Overlapping sites | 0.94 | 0.73–1.21 |
| Unspecified | 1.09 | 1.00–1.18 |
| Chemotherapy | 1.03 | 0.96–1.09 |
| Radiation | 1.03 | 0.96–1.09 |
| Surgery | 0.98 | 0.93–1.04 |
| Housing context | ||
| Metro > 1 million | ref | |
| Metro < 1 million | 1.18 | 1.12–1.24 |
| Adjacent to metro area | 1.11 | 1.02–1.21 |
| Not adjacent to metro area | 0.99 | 0.89–1.10 |
Note: Results are presented as odds ratios with confidence intervals.
Lastly, based on analyses of the Medicare Current Beneficiary Survey and studies of insurance patterns, approximately 25% of patients over 65 either supplement their Medicare coverage with private insurance or have no insurance coverage [12, 13, 14, 15]. We furthermore estimate that the number of patients who have Medicare coverage but choose to pay out of pocket for influenza vaccination is low and negligible given Medicare covers the full cost of influenza vaccination with no copayment. We therefore extrapolated a “best‐case scenario” vaccine coverage by assuming our current data is representative for 75% of the population, and that all the remaining 25% of patients with alternative insurance coverage received yearly influenza vaccines. In the best‐case scenario, the number of patients receiving at least one vaccine in the year before diagnosis is 49.44%, in the year after diagnosis is 49.07%, and in the year before or after diagnosis is 56.31%.
4. Discussion
Influenza vaccinations are recommended for patients with solid cancers [1]. Lack of influenza vaccination may lead to increased infection incidence, increased infection severity, and delays in cancer care [2, 3, 4]. At present, there is little information about the uptake of influenza vaccination in patients with head and neck cancer. Information regarding vaccination uptake is important to establish a baseline and raise awareness about barriers to access.
An analysis of the 2012–2013 National Health Interview Survey (NHIS) showed that influenza vaccination coverage among patients with cancer was 56.4% [16]. A separate study conducted in Denmark showed that the incidence of influenza vaccine use in patients with head and neck cancer was 38% [17]. In our study, we found that influenza vaccine use in patients with head and neck cancer was 32.5% in the year prior to diagnosis and 32.1% in the year after diagnosis, with 41.7% of patients receiving at least one vaccine in the year before or after diagnosis. The discrepancy between our findings and the NHIS study may be explained by a younger patient population in the NHIS study (ages 18–64) and selection and recall bias inherent to the survey study design (61.2% response rate).
Since not all patients age 65 or older use Medicare as their primary insurance, we attempted to extrapolate our findings and provide “best‐case scenario” estimates by assuming all patients with alternative insurance receive annual influenza vaccines. In this “best‐case scenario” which is likely an overestimate, vaccination rates were approximately 50%. Given the current goal set forth by Healthy People 2030 for influenza vaccination in the general population in the United States is 70% [18], and numerous governing bodies recommend focusing efforts on individuals with high‐risk conditions including cancer [10, 19], our results highlight that greater efforts are needed to increase vaccination uptake in patients with head and neck cancer.
We found that patients tend to receive more vaccinations during the month when they were diagnosed with cancer. This may be due to increased contact with the healthcare system during this time. We also found that patients tend to receive fewer vaccinations in the 3 months following their diagnosis with cancer, possibly due to prioritization of other care or lack of immediate knowledge about vaccination recommendations in the setting of a new cancer diagnosis. Additionally, we found that many other factors were associated with decreased odds of receiving vaccination. Black and AAPI patients were significantly less likely to receive vaccination compared to White patients and males were less likely to receive vaccination compared to females, indicating a need to prioritize these populations. Interestingly, patients with regional or distant metastasis had lower odds of receiving vaccination but there was no association between treatment modality and vaccination, indicating this trend is likely not due to increased use of systemic therapy in patients with higher stage disease. Possible explanations for this trend include increased complexity of care leading to vaccinations being deferred or decreased perceived benefit in this population. These findings indicate this is also a population that should be prioritized. Lastly, significant variation in vaccination rates based on geographical location may be secondary to differences in socioeconomic status, healthcare access, or healthcare infrastructure. Locations with high vaccination rates may be viewed as examples for how to increase vaccine uptake.
Our study has notable limitations. Notably, we acknowledge that it is not possible to capture every single influenza vaccination record for every patient. It is likely that there are missing records from patients who paid out of pocket, received vaccinations at alternative venues, or utilized different insurance to pay for their vaccinations. We have attempted to address this by being comprehensive with the data provided, and providing a “best‐case scenario” extrapolation of our data to account for these other factors. Additionally, we acknowledge that there are limitations of treatment data in the SEER‐Medicare database such as missing information about neoadjuvant treatment, notable bias in which patients receive treatment, and possible incompleteness of variables.
5. Conclusions
Influenza vaccination uptake in head and neck cancer patients aged 65 and over is suboptimal; the vaccination rate in this population is approximately 32% in the year before and the year after diagnosis. These rates remain well below national targets and Healthy People 2030 goals. Racial disparities, geographic variations, and the lower likelihood of vaccination among patients with advanced disease underscore the need for tailored, population‐specific strategies. Our findings illustrate the importance of enhancing vaccination outreach and access within this vulnerable population, potentially informing efforts to improve preventive care practices for head and neck cancer patients.
Funding
The collection of cancer incidence data used in this study was supported by the California Department of Public Health pursuant to California Health and Safety Code Section 103885; Centers for Disease Control and Prevention's (CDC) National Program of Cancer Registries, under cooperative agreement 1NU58DP007156; the National Cancer Institute's Surveillance, Epidemiology and End Results Program under contract HHSN261201800032I awarded to the University of California, San Francisco, contract HHSN261201800015I awarded to the University of Southern California, and contract HHSN261201800009I awarded to the Public Health Institute.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgments
This study used the linked SEER‐Medicare database. The interpretation and reporting of these data are the sole responsibility of the authors. The authors acknowledge the efforts of the National Cancer Institute; Information Management Services (IMS) Inc.; and the Surveillance, Epidemiology, and End Results (SEER) Program tumor registries in the creation of the SEER‐Medicare database. The collection of cancer incidence data used in this study was supported by the California Department of Public Health pursuant to California Health and Safety Code Section 103885; Centers for Disease Control and Prevention's (CDC) National Program of Cancer Registries, under cooperative agreement 1NU58DP007156; the National Cancer Institute's Surveillance, Epidemiology and End Results Program under contract HHSN261201800032I awarded to the University of California, San Francisco, contract HHSN261201800015I awarded to the University of Southern California, and contract HHSN261201800009I awarded to the Public Health Institute. The ideas and opinions expressed herein are those of the author(s) and do not necessarily reflect the opinions of the State of California, Department of Public Health, the National Cancer Institute, and the Centers for Disease Control and Prevention or their Contractors and Subcontractors.
Lee M. Y., Sunwoo J. B., and Chen M. M., “Patterns of Influenza Vaccination in Head and Neck Cancer Patients in the United States,” Laryngoscope Investigative Otolaryngology 11, no. 1 (2026): e70358, 10.1002/lio2.70358.
Preliminary results from this project were presented at the 2025 American Head and Neck Society Meeting in New Orleans, LA.
Data Availability Statement
The data that support the findings of this study are available from NIH SEER. Restrictions apply to the availability of these data, which were used under license for this study. Data are available from https://healthcaredelivery.cancer.gov/seermedicare/ with the permission of NIH SEER.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from NIH SEER. Restrictions apply to the availability of these data, which were used under license for this study. Data are available from https://healthcaredelivery.cancer.gov/seermedicare/ with the permission of NIH SEER.