The first discussion about the demographics of marijuana use in HNC patients was by Donald in 1986 [17]. In a case series of six advanced head and neck squamous cell carcinoma cases, which were regular marijuana users, he commented on the exceptionally young age of the group, at a mean age of 27.1, as well as the fact that 2 out of 6 patients had never smoked tobacco [17]. This case series was the first to hint at a possible epidemiological variant in marijuana smoking HNCs. Since then case-control studies have examined the demographics of their respective cases and controls, although they have presented limited specific epidemiological data on the marijuana user cases.

The INHANCE pooled analysis combined five case control studies with 4029 HNC cases from sites in United States and South America, but did not include data from Canada [18]. The prevalence of marijuana use was found to be 10.1% amongst cases and there was a high proportion of males at 85.2%, comparable to the 8.4% prevalence and 85.1% male percentage observed in our study. Marijuana users also similarly reported less tobacco and alcohol use compared to controls. The INHANCE study also found cancers at the oropharyngeal subsite most associated with marijuana, reflective of the subsite distribution observed in our data [18]. The population was more ethnically diverse compared to our study group with only 18.3% of HNC cases being Caucasian, yet similar trends were observed [18]. A follow-up INHANCE analysis of an oropharyngeal subsite reiterated the relationship of this subsite with marijuana which increased with frequency and duration of use. Unfortunately, demographic and socioeconomic data was not compared between the marijuana users and non-users in the group. Marijuana’s relationship with the oropharynx subsite was similarly found to be marginally associate with low smoking/alcohol use but potentially confounded by HPV exposure [16]. However, the primary goal of the INHANCE analyses were not to examine epidemiological variation and only limited comparisons can be made to our data with regards to p16 status, marriage, income, employment, clinical stage, and treatment regime as they were not examined.

Based on 2012 Canada census data, there are a few demographic patterns seen in marijuana users that are part of the general Canadian population [1]. They tend to be younger with 33% being 18–24 and only 0.8% aged 65 or older [1]. There is a male predominance in consistent users with 4.6% of males vs 1.7% of females reporting weekly use and 2.4% of males and 1.2% of females reporting daily use [1]. Lifetime marijuana use and marijuana use within the past year were also higher in males compared to females at 49.4% vs 35.8 and 16.1% vs 8.3%, respectively [1]. In contrast to the young age of marijuana smokers in the general population, our study’s marijuana users were older with a mean age of 62.26. Based on at least weekly marijuana usage, our study observed a 5.7:1 male predominance in the marijuana user group; this is higher than the male predominance observed in the general population both in weekly users (3:1) and daily users (2:1) [1]. The differences in gender and mean age between our population subset compared to that of Canada census data could be related to the epidemiology of HNC where the mean age often range from 55 to 65 years old depending on the disease site and are often predominantly male [19]. While Canada census data provides an overview of the general population, our cross sectional sample of HNC cannot be discounted.

The epidemiology of HNCs related to tobacco smoke and alcohol have also been well studied. Patients have been shown to have peak incidence in late-middle age at 55–59 with a significant 5:1 male predominance [20, 21]. The proportion of patients having an educational attainment higher than a high school diploma are similar between the tobacco and alcohol related HNCs at 29.2 and 31%, respectively [20, 21]. This is similar to patients within our non-marijuana user population where the mean age was 56.6 with a predominantly male population. Our study’s marijuana group however, presented slightly later in late-middle age at 62.26 but with a similar 5.7:1 male predominance. Moreover, the marijuana group had higher educational attainment with 41.9% of patients having higher than a high school diploma. It is still unclear whether these subtle demographic variations within the marijuana user HNC population have any significant effect on the treatment or survivorship outcomes. Certainly more knowledge on this subgroup of patients is needed in the future and could provide interesting insights.

The only variation in socioeconomic characteristics identified from our data set was that HNC patients that reported marijuana use are less likely to be married/common law compared to those that did not (55.4% vs 63.2%; p = 0.048). Marital status has been shown to be an independent prognostic factor in HNCs; however, given the other differences in this population, the significance or impact of marital status among marijuana smoking HNC patients remains undetermined [22]. It is interesting that the marijuana user group were not only more likely to be single but also had higher rates of HPV positive oropharynx cancer, a factor associated with increased sexual practices and partners [15]. While quantification of the amount of partners within this subsite group of patients was beyond the scope of this study future studies is warranted to delineate any potential relationships. The remaining socioeconomic characteristics including educational attainment, income, and employment status were not different between the HNC patients in the marijuana and non-marijuana groups.

HPV positive oropharyngeal cancer was the site of the highest prevalence in the marijuana user group compared to the non-user group (oropharyngeal cancer 63.5% vs 19.9%, p < 0.0001; p16 positive 95.7% vs 82.5%; p = 0.002). This is reflective of the shift to HPV positive oropharynx cancers as the predominant head and neck disease site in Ontario and North America [23–25]. The difference in treatment modality between the two groups supports this as the marijuana user group had statistically higher chemoradiation (p < 0.0001) as the primary therapy, which is the standard treatment option for this disease site within our cancer center. Interestingly, patients who were marijuana users were also found to have statistically lower incidence of tobacco use (p = 0.001). This coupled with the higher incidence of HPV positive oropharynx cancer within the marijuana user group suggest that patients with recreational marijuana use are reflective of the trends in epidemiological variation of HNC patients. These variations could suggest differences in sexual practices between marijuana users and non-users, the potential direct oncogenic effects of marijuana use, or something entirely different that is not yet defined. While the establishment of a true cause and effect relationship is beyond the scope of this study, it is intriguing and would certainly warrant further research.

This is a population-based study with prospectively collected data but is subject to limitations. The primary limitation of this study is the small sample size of HNC patients that reported marijuana use. We were also unable to sub-stratify the marijuana user group based on the quantity of use. Unlike smoking and alcohol, marijuana has not been concretely established as a risk factor for HNC and there is no validated clinically significant cut-off for marijuana frequency/use. We elected to use the definition of at least weekly use based on extrapolation of findings in the literature. Within the setting of HNC, there is data to show marijuana use at a frequency of less than three times per week or at least once monthly is associated with oropharyngeal and HPV-related cancers [15, 16]. Beyond oncology, at least weekly cannabis use has been found to be predictive of adverse events in the context of psychosis, neuropsychological function, and stroke/TIA [26–29]. In addition, since cannabis remains classified as Schedule II substance under the Canadian Controlled Drugs and Substances Act, there may be an under-reporting of marijuana use in the study population which may affect the subsequent break down of patient as well as socioeconomic characteristics of patients [30]. Patient income quintiles were extrapolated from neighbourhood level income and thus the interpretation may be susceptible to ecological fallacy. Despite potential discordance, neighbourhood and individual level income have been shown to produce comparable observations [31, 32]. Due to the inadequate follow-up data, we also were not able to discover the potential effects of marijuana on HNC patients. Future long-t erm prospectively based studies would help mitigate and answer more questions on the relationship of marijuana on HNC patients.

To our knowledge this is the first study to look at the epidemiological variances within HNC patients who are marijuana users. Patients were found to have predominantly HPV positive oropharynx cancer and more likely to be single with statistically significant less tobacco use. There was no statistically significant difference between the two groups in cT and cN Stage as well as age at diagnosis, alcohol use, Karnofsky score, education level, ethnicity, employment status, and income quintiles. This study has also highlighted variations in epidemiology compared to marijuana users in general and HNC patients that smoke and use alcohol.