Population analysis of socioeconomic status and otolaryngologist distribution on head and neck cancer outcomes

Disparities in Care for Patients with Head and Neck Cancer

This article examines disparities in head and neck cancer across the cancer care continuum. It provides a public health lens to understand multilevel determinants of health behavior and the importance of social determinants of health. This article reviews the evidence base showing profound differences in incidence, treatment, and survival for patients with head and neck cancer by race, ethnicity, socioeconomic status, and geography. Continued research is needed to understand and address disparities for patients with head and neck cancer.

Choice of Adjuvant Radiotherapy Facility in Sinonasal Squamous Cell Carcinoma

OBJECTIVE

Undergoing surgery and adjuvant radiotherapy (aRT) at the same facility has been associated with higher overall survival (OS) in head and neck squamous cell carcinoma. Our study investigates whether undergoing surgery and aRT at the same academic facility is associated with higher OS compared with separate facilities in sinonasal squamous cell carcinoma (SNSCC).

METHODS

The 2006 to 2017 National Cancer Database was queried for patients with SNSCC undergoing surgery at an academic facility followed by aRT with or without adjuvant chemotherapy. Multivariable binary logistic and Cox proportional hazards regression models were implemented.

RESULTS

Of 419 patients satisfying inclusion criteria, 299 (71.4%) underwent surgery and aRT at the same academic facility. Residence in a less populated area (adjusted odds ratio [aOR] 1.75, 95% confidence interval [CI] 1.02-2.99, p = 0.042) and surgical facility case volume (aOR 2.51, 95% CI 1.21-5.21, p = 0.014) were associated with undergoing surgery and aRT at different facilities on multivariable logistic regression adjusting for patient demographics, clinicopathologic features, and adjuvant therapy (p < 0.05). Five-year OS was higher among patients undergoing surgery and aRT at the same academic facility (64% vs. 55%, p = 0.039). Undergoing surgery and aRT at different facilities remained associated with worse OS on multivariable Cox regression (aHR 1.90, 95% CI 1.09-3.32, p = 0.023).

CONCLUSION

Undergoing surgery and aRT at the same academic facility is associated with higher OS in SNSCC. Academic physicians should carefully consider the recommendation of aRT treatment facility based on the level of benefit that the patient may derive from coordinated multidisciplinary care.

LEVEL OF EVIDENCE

3 Laryngoscope, 2024.

Patient Factors Associated with Missed Otolaryngology Appointments at an Urban Safety-Net Hospital

OBJECTIVE

To determine if patient factors related to ethnicity, socioeconomic status (SES), medical comorbidities, or appointment characteristics increase the risk of missing an initial adult otolaryngology appointment.

METHODS

This study is a retrospective case control study at Boston Medical Center (BMC) in Boston, Massachusetts, that took place in 2019. Patient demographic and medical comorbidity data as well as appointment characteristic data were collected and compared between those that attended their initial otolaryngology appointment versus those who missed their initial appointment. Chi-square and ANOVA tests were used to calculate differences between attendance outcomes. Multivariate analysis was used to compare the odds of missing an appointment based on various patient- and appointment-related factors.

RESULTS

Patients who were more likely to miss their appointments were more often female, of lower education, disabled, not employed, Black or Hispanic, and Spanish-speaking. Spring and Fall appointments were more likely to be missed. When a multivariate regression was conducted to control for social determinants of health (SDOH) such as race, insurance status, employment, and education status, the odds of females, Spanish-speaking, students, and disabled patients missing their appointment were no longer statistically significant.

CONCLUSION

A majority of patients at BMC come from lower SES backgrounds and have multiple medical comorbidities. Those who reside closer to BMC, often areas of lower average income, had higher rates of missed appointments. Interventions such as decreasing lag time, providing handicap-accessible free transportation, and increasing accessibility of telemedicine for patients could help improve attendance rates at BMC.

LEVEL OF EVIDENCE

IV Laryngoscope, 134:4003-4010, 2024.

Choice of Adjuvant Radiotherapy Facility in Major Salivary Gland Cancer

OBJECTIVE

Undergoing surgery and adjuvant radiotherapy (aRT) at the same facility has been associated with higher overall survival (OS) in head and neck squamous cell carcinoma. Our study investigates whether undergoing surgery and aRT at the same academic facility is associated with higher OS in major salivary gland cancer (MSGC).

METHODS

The 2006-2018 National Cancer Database was queried for patients with MSGC undergoing surgery at an academic facility and then aRT. Multivariable binary logistic and Cox proportional hazards regression models were implemented.

RESULTS

Of 2801 patients satisfying inclusion criteria, 2130 (76.0%) underwent surgery and aRT at the same academic facility. Residence in a less populated area (adjusted odds ratio [aOR] 1.69, 95% confidence interval [CI] 1.16-2.45), treatment without adjuvant chemotherapy (aOR 1.97, 95% CI 1.41-2.76), and aRT duration (aOR 1.02, 95% CI 1.01-1.04) were associated with undergoing surgery and aRT at different facilities on multivariable logistic regression adjusting for patient demographics, clinicopathologic features, and adjuvant therapy (p < 0.01). Five-year OS was higher in patients undergoing surgery and aRT at the same academic facility (68.8% vs. 61.9%, p < 0.001). Undergoing surgery and aRT at different facilities remained associated with worse OS on multivariable Cox regression (aHR 1.41, 95% CI 1.10-1.81, p = 0.007).

CONCLUSION

Undergoing surgery and aRT at the same academic facility is associated with higher OS in MSGC. Although undergoing surgery and aRT at the same academic facility is impractical for all patients, academic physicians should consider same-facility treatment for complex patients who would most benefit from clear multidisciplinary communication.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:3620-3632, 2024.

Soluble CD44 in oral rinses for the early detection of cancer: a prospective cohort study in high-risk individuals

BACKGROUND

There are 54,000 new cases of oral cavity and oropharyngeal cancer in the United States and more than 476,000 worldwide each year. Oral cavity and oropharyngeal squamous cell carcinoma make up most tumors with five-year survival rates of 50% due to prevalence of late-stage diagnoses. Improved methods of early detection in high-risk individuals are urgently needed. We aimed to assess the tumorigenic biomarkers soluble CD44 (solCD44) and total protein (TP) measured using oral rinses as affordable convenient screening tools for cancer detection.

METHODS

In this prospective cohort study, we recruited 150 healthy current or former smokers through a community screening program. Baseline and four annual visits were conducted from March 2011-January 2016 with records followed until August 2020. Participants provided oral rinses, received head and neck exams, and completed questionnaires. SolCD44 and TP levels were measured and compared across groups and time. Participants were placed in the cancer group if malignancy developed in the study period, the suspicious group if physical exams were concerning for premalignant disease or cancer in the head and neck, and the healthy group if there were no suspicious findings. This analysis used two-sample t-test for comparison of means and two-sample Wilcoxon Test for comparison of medians. For subjects with follow-ups, estimated means of biomarkers were obtained from a fitted Repeated Measures Analysis of Variance (RANOVA) model including group, visit, and their interaction. Pairwise comparisons of mean solCD44 were made, including intergroup and intragroup comparison of values at different years.

RESULTS

Most participants were males (58.7%), < 60 years of age. (90.7%), and Black (100%). Baseline mean solCD44 was elevated (2.781 ng/ml) in the cancer group compared to the suspicious group (1.849 ng/ml) and healthy group (1.779 ng/ml).

CONCLUSION

This study supports the feasibility of a CD44-based oral rinse test as an affordable and convenient adjunctive tool for early detection of aerodigestive tract and other cancers in high-risk populations.

Perspectives on Referral Pathways for Timely Head and Neck Cancer Care

Importance

Timely diagnosis and treatment are of paramount importance for patients with head and neck cancer (HNC) because delays are associated with reduced survival rates and increased recurrence risk. Prompt referral to HNC specialists is crucial for the timeliness of care, yet the factors that affect the referral and triage pathway remain relatively unexplored. Therefore, to identify barriers and facilitators of timely care, it is important to understand the complex journey that patients undertake from the onset of HNC symptoms to referral for diagnosis and treatment.

Objective

To investigate the referral and triage process for patients with HNC and identify barriers to and facilitators of care from the perspectives of patients and health care workers.

Design, Participants, and Setting

This was a qualitative study using semistructured interviews of patients with HNC and health care workers who care for them. Participants were recruited from June 2022 to July 2023 from HNC clinics at 2 tertiary care academic medical centers in Boston, Massachusetts. Data were analyzed from July 2022 to December 2023.

Main Outcomes and Measures

Themes identified from the perspectives of both patients and health care workers on factors that hinder or facilitate the HNC referral and triage process.

Results

In total, 72 participants were interviewed including 42 patients with HNC (median [range] age, 60.5 [19.0-81.0] years; 27 [64%] females) and 30 health care workers (median [range] age, 38.5 [20.0-68.0] years; 23 [77%] females). Using thematic analysis, 4 major themes were identified: the HNC referral and triage pathway is fragmented; primary and dental care are critical for timely referrals; efficient interclinician coordination expedites care; and consistent patient-practitioner engagement alleviates patient fear.

Conclusions and Relevance

These findings describe the complex HNC referral and triage pathway, emphasizing the critical role of initial symptom recognition, primary and dental care, patient information flow, and interclinician and patient-practitioner communication, all of which facilitate prompt HNC referrals.

Geospatial evaluation of access to otolaryngology care in the United States

Objectives

This county-level epidemiological study evaluated the travel distance to the nearest otolaryngologist for continental US communities and identified socioeconomic differences between low- and high-access regions.

Methods

Geospatial analysis of publicly available 2015-2022 NPI records was combined with US census data to identify geospatial gaps in otolaryngologist distribution. Moran's index geospatial clustering in distance to the nearest county with an otolaryngologist was used as the core metric for differential access determination. Univariate logistic analysis was conducted between low- and high-access counties for 20 socioeconomic and demographic variables.

Results

Nationally, the average person was 22 miles from an otolaryngologist. 444 counties were identified as geospatially "low access" with increased travel distance in the Midwest, Great Planes, and Nevada with a median of 47 miles. 1231 counties in the Eastern United States and Western Coast were identified as "high access" with a 3-mile median travel distance. Areas of low access to otolaryngological care had smaller median populations (12,963 vs. 558,306), had smaller percent Black and Asian populations (2% vs. 11%, 1% vs. 5%, respectively), had a greater percent American Indian population (2% vs. 1%), were less densely populated (8 vs. 907 people per square mile), had fewer percent college graduates (20% vs. 34%), and fewer otolaryngologists per county (median: 0.01-20).

Conclusion

These findings highlight disparity in otolaryngology care in the United States and the need for otolaryngology funding initiatives in the Midwest and Great Plains regions.

Level of Evidence

Level 3.

Racial Disparities in Head and Neck Cancer: It's Not Just About Access

OBJECTIVE

Medical literature identifies stark racial disparities in head and neck cancer (HNC) in the United States, primarily between non-Hispanic white (NHW) and non-Hispanic black (NHB) populations. The etiology of this disparity is often attributed to inequitable access to health care and socioeconomic status (SES). However, other contributors have been reported. We performed a systematic review to better understand the multifactorial landscape driving racial disparities in HNC.

DATA SOURCES

A systematic review was conducted in Covidence following Preferred Reporting Items for Systematic Reviews and Meta-analyses Guidelines. A search of PubMed, SCOPUS, and CINAHL for literature published through November 2022 evaluating racial disparities in HNC identified 2309 publications.

REVIEW METHODS

Full texts were screened by 2 authors independently, and inconsistencies were resolved by consensus. Three hundred forty publications were ultimately selected and categorized into themes including disparities in access/SES, treatment, lifestyle, and biology. Racial groups examined included NHB and NHW patients but also included Hispanic, Native American, and Asian/Pacific Islander patients to a lesser extent.

RESULTS

Of the 340 articles, 192 focused on themes of access/SES, including access to high-quality hospitals, insurance coverage, and transportation contributing to disparate HNC outcomes. Additional themes discussed in 148 articles included incongruities in surgical recommendations, tobacco/alcohol use, human papillomavirus-associated malignancies, and race-informed silencing of tumor suppressor genes.

CONCLUSION

Differential access to care plays a significant role in racial disparities in HNC, disproportionately affecting NHB populations. However, there are other significant themes driving racial disparities. Future studies should focus on providing equitable access to care while also addressing these additional sources of disparities in HNC.

Forecasting Rural and Urban Otolaryngologists, Radiation Oncologists, and Oropharyngeal Carcinoma

OBJECTIVE

To forecast oropharyngeal carcinoma (OPC) incidence with otolaryngologist and radiation oncologist numbers per population by rural and urban counties through 2030.

METHODS

Incident OPC cases were abstracted from the Surveillance, Epidemiology, and End Results 19 database, and otolaryngologists and radiation oncologists from the Area Health Resources File by county from 2000 to 2018. Variables were analyzed by metropolitan counties with over 1,000,000 people (large metros), rural counties adjacent to a metro (rural adjacent), and rural counties not adjacent to a metro (rural not adjacent). Data were forecasted via an unobserved components model with regression slope comparisons.

RESULTS

Per 100,000 population, forecasted OPC incidence increased from 2000 to 2030 (large metro: 3.6 to 10.6 cases; rural adjacent: 4.2 to 11.9; rural not adjacent: 4.3 to 10.1). Otolaryngologists remained stable for large metros (2.9 to 2.9) but declined in rural adjacent (0.7 to 0.2) and rural not adjacent (0.8 to 0.7). Radiation oncologists increased from 1.0 to 1.3 in large metros, while rural adjacent remained similar (0.2 to 0.2) and rural not adjacent increased (0.2 to 0.6). Compared to large metros, regression slope comparisons indicated similar forecasted OPC incidence for rural not adjacent (p = 0.58), but greater for rural adjacent (p < 0.001, r = 0.96). Otolaryngologists declined for rural regions (p < 0.001 and p < 0.001, r = -0.56, and r = -0.58 for rural adjacent and not adjacent, respectively). Radiation oncologists declined in rural adjacent (p < 0.001, r = -0.61), while increasing at a lesser rate for rural not adjacent (p = 0.002, r = 0.96).

CONCLUSIONS

Rural OPC incidence disparities will grow while the relevant, rural health care workforce declines.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:136-142, 2024.

Two web-based dynamically interactive nomograms and risk stratification systems for predicting survival outcomes and guiding treatment in non-metastatic nasopharyngeal carcinoma

BACKGROUND

A nomogram is a valuable and easily accessible tool for individualizing cancer prognosis. This study aims to establish and validate two prognostic nomograms for long-term overall survival (OS) and cancer-specific survival (CSS) in non-metastatic nasopharyngeal carcinoma (NPC) patients and to investigate the treatment options for the nomogram-based risk stratification subgroups.

METHODS

A total of 3959 patients with non-metastatic NPC between 2004 and 2015 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. The patients were randomly allocated to the training and validation cohorts in a 7:3 ratio. Prognostic nomograms were constructed to estimate OS and CSS by integrating significant variables from multivariate Cox regression employing a backward stepwise method. We examined the correlation indices (C-index) and areas under the curves (AUC) of time-dependent receiver operating characteristic curves to assess the discriminative ability of our survival models. The comprehensive enhancements of predictive performance were evaluated with net reclassification operating improvement (NRI) and integrated discrimination improvement (IDI). Reliability was validated using calibration plots. Decision curve analysis (DCA) was used to estimate clinical efficacy and capability. Finally, the nomogram-based risk stratification system used Kaplan-Meier survival analysis and log-rank tests to examine differences between subgroups.

RESULTS

The following independent parameters were significant predictors for OS: sex, age, race, marital status, histological type, median household income, AJCC stage tumor size, and lymph node size. Except for the race variables mentioned above, the rest were independent prognostic factors for CSS. The C-index, AUC, NRI, and IDI indicated satisfactory discriminating properties. The calibration curves exhibited high concordance with the exact outcomes. Moreover, the DCA demonstrated performed well for net benefits. The prognosis significantly differed between low- and high-risk patients (p < 0.001). In a treatment-based stratified survival analysis in risk-stratified subgroups, chemotherapy benefited patients in the high-risk group compared to radiotherapy alone. Radiotherapy only was recommended in the low-risk group.

CONCLUSIONS

Our nomograms have satisfactory performance and have been validated. It can assist clinicians in prognosis assessment and individualized treatment of non-metastatic NPC patients.

Association between depressive symptoms and socioeconomic status in head and neck cancer patients attending rural tertiary health care center

AIM

To study the association between depressive symptoms and socio-economic status (SES) in patients with head and neck cancer (HNC).

MATERIALS AND METHODS

Histopathology-proven non-metastatic and non-recurrent HNC patients attending radiation oncology services in February and June 2021 who consented to the study were evaluated with an interview. Hamilton Depression Rating Scale (HDRS) and modified BG Prasad classification were used to assess depressive symptoms and SES, respectively. Statistical analysis was done using SYSTAT version 12 (by Crane's software, Bangalore).

RESULTS

The study cohort comprised 100 patients. The median age was 55 years (minimum: 28, maximum: 86) with a male-to-female ratio of 2.57:1. The majority of patients were educated beyond middle-school level (44%), of middle SES (47%), oral cavity subsite (68%), stage IVA (36%) disease, and were on treatment (79%). HDRS scores showed absent, moderate, and severe depressive symptoms in 21, 63, and 16 patients, respectively, that is, the prevalence of depressive symptoms was 79%. Lower socioeconomic strata showed a significantly higher prevalence of severe depressive symptoms (P-value = 0.01). HDRS score was significantly higher in females (P-value = 0.024) and in patients who were illiterate or were educated less than middle-school level (P-value = 0.010). No statistically significant difference was found between HDRS score and age of patient, stage and site of disease, and on treatment or follow-up status.

CONCLUSION

Depressive symptoms are common in patients with head and neck cancer. Low socioeconomic status (SES), female gender, and education less than middle school are associated with severe depressive symptoms. Psycho-oncological and psychotherapeutic interventions are the need of the hour.

Healthcare Disparities in Otolaryngology

Purpose of Review

The purpose of this review is to summarize some of the recent research studies on healthcare disparities across various subspecialties within otolaryngology. This review also highlights the impact of COVID-19 pandemic on disparities and proposes potential interventions to mitigate disparities.

Recent Findings

Significant healthcare disparities in care and treatment outcomes have been reported across all areas of otolaryngology. Notable differences in survival, disease recurrence, and overall mortality have been noted based on race, ethnicity, socioeconomic status (SES), insurance status, etc. This is most well-researched in head and neck cancer (HNC) within otolaryngology.

Summary

Healthcare disparities have been identified by numerous research studies within otolaryngology for many vulnerable groups that include racial and ethnic minority groups, low-income populations, and individuals from rural areas among many others. These populations continue to experience suboptimal access to timely, quality otolaryngologic care that exacerbate disparities in health outcomes.

Racial survival disparities in head and neck cancer clinical trials

BACKGROUND

Survival disparities between Black and White head and neck cancer patients are well documented, with access to care and socioeconomic status as major contributors. We set out to assess the role of self-reported race in head and neck cancer by evaluating treatment outcomes of patients enrolled in clinical trials, where access to care and socioeconomic status confounders are minimized.

METHODS

Clinical trial data from the Radiation Therapy Oncology Group studies were obtained. Studies were included if they were therapeutic trials that employed survival as an endpoint. Studies that did not report survival as an endpoint were excluded; 7 Radiation Therapy Oncology Group Studies were included for study. For each Black patient enrolled in a clinical trial, a study arm-matched White patient was used as a control.

RESULTS

A total of 468 Black participants were identified and matched with 468 White study arm-specific controls. White participants had better outcomes than Black participants in 60% of matched pairs (P < .001). Black participants were consistently more likely to have worse outcomes. When outcomes were measured by progression-free survival or disease-free survival, the failure rate was statistically significantly higher in Black participants (hazard ratio [HR] = 1.50, P < .001). Failure was largely due to locoregional failure, and Black participants were at higher risk (subdistribution HR =1.51, P = .002). The development of distant metastasis within the paired cohorts was not statistically significantly different.

CONCLUSION

In this study of clinical trial participants using self-reported race, Black participants consistently had worse outcomes in comparison to study arm-specific White controls. Further study is needed to confirm these findings and to explore causes underlying this disparity.

Individuals Experiencing Homelessness: A Systematic Review of Otolaryngology-Related Health Needs and Community-Based Interventions

OBJECTIVE

Access to and use of physician services is limited for those experiencing homelessness. Homelessness may predispose patients to several Otolaryngology-Head and Neck Surgery (OHNS) health conditions and barriers to care may leave these unaddressed. The aim of this review was to synthesize the literature on OHNS health needs and community-based interventions for patients experiencing homelessness.

DATA SOURCES

English literature was searched in MEDLINE, EMBASE, and CINAHL.

REVIEW METHODS

Studies were included if they reported on OHNS-related conditions in patients experiencing homelessness and/or interventions related to providing OHNS care to this patient population.

RESULTS

Twelve hundred and one articles were screened, and 12 articles were included. Most studies reported on otologic conditions (n = 8) and head and neck-related conditions (n = 6). Nasal trauma, chronic rhinosinusitis, dysphonia, hearing loss, and cancerous/precancerous head and neck lesions were common OHNS conditions reported in this patient population. Identified barriers to care included lack of transportation, financial considerations, and lower health literacy. Three articles on community-based interventions were included. Most of these interventions were single visits to shelters, and ensuring adequate follow-up was identified as a challenge.

CONCLUSION

The current literature brings attention to certain OHNS diseases that are prevalent in this unique patient population and identifies unique barriers these patients experience when accessing care. Future studies should focus on further delineating the impact of OHNS diseases in patients experiencing homelessness and screening interventions that can be employed to mitigate the impact of diseases of the head and neck.

Practice Patterns and Career Satisfaction in Recent Head and Neck Oncology Fellowship Graduates

Objective

Examine the characteristics of recent head and neck (H&N) oncology fellowship graduates and assess their current perceptions of career alignment and satisfaction.

Methods

H&N fellowship graduates from American Head and Neck Society–accredited programs between 2015 to 2020 were surveyed. Two-sample t tests and analysis of variance tests were used to determine the effect of respondents’ demographics, fellowship characteristics, career preferences, and current practice on their degree of career alignment with expectations and overall job satisfaction.

Results

Fifty-eight fellowship graduates completed the cross-sectional survey. Of all respondents, 52 (89.7%) primarily preferred an academic job, of whom 5 (9.6%) went into private practice. Respondents in private practice, those treating general otolaryngology patients, and those who do not work with residents demonstrated significantly poorer job alignment and career satisfaction as compared with those in academic medicine, those treating only H&N patients, and those working with residents, respectively.

Discussion

The majority of graduating H&N fellows prefer a job in academic medicine; however, there may be an insufficient number of desirable academic positions available each year to meet such demand.

Implications for Practice

By setting realistic career expectations, preparing for a mixed scope of practice, and integrating resident involvement into private practice groups, H&N providers may ultimately find more fulfillment in their work. These findings could also be valuable to the American Head and Neck Society and fellowship programs in designing training and in planning for the number of available fellowship positions each year.

A Systematic Review of Head and Neck Cancer Health Disparities: A Call for Innovative Research

OBJECTIVE

(1) Describe the existing head and neck cancer health disparities literature. (2) Contextualize these studies by using the NIMHD research framework (National Institute on Minority Health and Health Disparities). (3) Explore innovative ideas for further study and intervention.

DATA SOURCES

Ovid MEDLINE, Embase, Web of Science, and Google Scholar.

REVIEW METHODS

Databases were systematically searched from inception to April 20, 2020. The PRISMA checklist was followed (Preferred Reporting Items for Systematic Reviews and Meta-analyses). Two authors reviewed all articles for inclusion. Extracted data included health disparity population and outcomes, study details, and main findings and recommendations. Articles were also classified per the NIMHD research framework.

RESULTS

There were 148 articles included for final review. The majority (n = 104) focused on health disparities related to at least race/ethnicity. Greater than two-thirds of studies (n = 105) identified health disparities specific to health behaviors or clinical outcomes. Interaction between the individual domain of influence and the health system level of influence was most discussed (n = 99, 66.9%). Less than half of studies (n = 61) offered specific recommendations or interventions.

CONCLUSIONS

There has been extensive study of health disparities for head and neck cancer, largely focusing on individual patient factors or health care access and quality. This review identifies gaps in this research, with large numbers of retrospective database studies and little discussion of potential contributors and explanations for these disparities. We recommend shifting research on disparities upstream toward a focus on community and societal factors, rather than individual, and an evaluation of interventions to promote health equity.

Rural Otolaryngology Care Disparities: A Scoping Review

OBJECTIVE

To broadly synthesize the literature regarding rural health disparities in otolaryngology, categorize findings, and identify research gaps to stimulate future work.

STUDY DESIGN

Scoping review.

DATA SOURCES

A comprehensive literature search was performed in the following databases: PubMed/MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, Google Scholar, and CINAHL.

REVIEW METHODS

The methods were developed in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. Peer-reviewed, English-language, US-based studies examining a rural disparity in otolaryngology-related disease incidence, prevalence, diagnosis, treatment, or outcome were included. Descriptive studies, commentaries, reviews, and letters to the editor were excluded. Studies published prior to 1980 were excluded.

RESULTS

The literature search resulted in 1536 unique abstracts and yielded 79 studies that met final criteria for inclusion. Seventy-five percent were published after 2010. The distribution of literature was as follows: otology (34.2%), head and neck cancer (20.3%), endocrine surgery (13.9%), rhinology and allergy (8.9%), trauma (5.1%), laryngology (3.8%), other pediatrics (2.5%), and adult sleep (1.3%). Studies on otolaryngology health care systems also accounted for 10.1%. The most common topics studied were practice patterns (41%) and epidemiology (27%), while the Southeast (47%) was the most common US region represented, and database study (42%) was the most common study design.

CONCLUSION

Overall, there was low-quality evidence with large gaps in the literature in all subspecialties, most notably facial plastic surgery, laryngology, adult sleep, and pediatrics. Importantly, there were few studies on intervention and zero studies on resident exposure to rural populations, which will be critical to making rural otolaryngology care more equitable in the future.

Geographic disparities in head and neck cancer survival in Upstate New York 2011-2019

PURPOSE

To examine the association between distance to care-center and urban-rural residence on 5-year overall survival (OS) from head and neck cancer (HNC).

MATERIALS AND METHODS

Five-year OS was retrospectively measured from date of initial diagnosis for patients with HNC treated at a single tertiary care center. Distances were calculated based on ZIP code of patient's residence and care center. Multilevel Weibull regression was used to adjust for confounders and identify disparities in 5-year all-cause mortality.

RESULTS

A total of 670 patients included in study. Multivariable analysis revealed older age or late-stage cancer at diagnosis, and HPV negative status were associated with poorer OS. Patients residing in isolated small rural town (HR = 2.20, p = 0.015) or small rural town (HR = 2.07, p = 0.015) had lower OS. Distance to care center was not associated with OS (HR = 0.996, p = 0.11).

CONCLUSIONS

Greater rurality was associated with poorer OS among HNC patients in Upstate New York.

Socioeconomic Status and Survival in Nasopharyngeal Carcinoma: A Population-Based Study

OBJECTIVES/HYPOTHESIS

To evaluate survival for nasopharyngeal carcinoma in relation to socioeconomic status.

STUDY DESIGN

Retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER) Census Tract-level Socioeconomic Status Database (2000-2016).

METHODS

Patients with nasopharyngeal carcinoma diagnosed between 2000 and 2016 were identified. Data were stratified based on socioeconomic status, divided into three groups: group 1 being the poorest and group 3 the wealthiest. Univariate analysis as well as multivariate Cox regression analysis adjusted for individual variables was performed.

RESULTS

A total of 5,527 patients were included in the study, with 33% in group 1, 34% in group 2, and 33% in group 3. There was a significant difference between groups in regard to age at diagnosis, race, histologic subtype, overall stage, tumor stage, nodal stage, and whether or not they received radiation. Patients in group 1, the poorest socioeconomic status, were more likely to be young (P = .003), black (P < .0001), present with higher overall stage (P = .009), tumor stage (P = .01), and nodal stage (P = .02), and less likely to receive radiation (P = .005). In multivariate analysis, there was a significant difference in survival between the groups, with group 1 patients less likely to survive compared to group 3 (hazard ratio = 1.28; 95% CI 1.07-1.57).

CONCLUSIONS

Patients in the poorest socioeconomic status presented with more advanced nasopharyngeal cancer and were less likely to receive radiation when compared with individuals of higher socioeconomic status. The poorest socioeconomic status groups were less likely to survive from their disease when controlling for other variables.

LEVEL OF EVIDENCE

NA Laryngoscope, 2021.

Socioeconomic Status and Rurality Among Patients With Head and Neck Cancer

OBJECTIVE

Describe the relationship among rurality, socioeconomic status (SES), and patient/tumor characteristics in patients presenting with head and neck cancer.

STUDY DESIGN

Retrospective single-institution study.

SETTING

Academic tertiary-level medical center.

METHODS

Patients with head and neck cancer presenting between 2011 and 2015 were included. Stage at presentation, insurance status, and demographic characteristics were collected. Rurality was measured through Rural-Urban Continuum Codes. SES was measured by SES index scores of the Agency for Healthcare Research and Quality, which incorporate multiple components of SES. Associations among rurality, SES, and patient/tumor characteristics were assessed with univariate and multivariable statistics. All P values were calculated via 2-sided hypotheses. The threshold for statistical significance was set at P < .05. Statistical analyses were conducted with Stata/SE 14 (StataCorp).

RESULTS

The study included 266 patients diagnosed with head and neck cancer between 2011 and 2015. Rural residence was associated with lower SES (P < .001). T and N stages were associated with rurality (P = .036 and .050, respectively). Higher educational status was associated with oropharyngeal cancer (P = .005).

CONCLUSIONS

Rurality and SES have distinct impacts on patients with head and neck cancer. Specifically, rurality is associated with tumor stage among patients with head and neck cancer. Knowledge of disparities among patients with rural residency may help target interventions to facilitate earlier diagnosis.

Machine learning models to predict length of stay and discharge destination in complex head and neck surgery

BACKGROUND

This study develops machine learning (ML) algorithms that use preoperative-only features to predict discharge-to-nonhome-facility (DNHF) and length-of-stay (LOS) following complex head and neck surgeries.

METHODS

Patients undergoing laryngectomy or composite tissue excision followed by free tissue transfer were extracted from the 2005 to 2017 NSQIP database.

RESULTS

Among the 2786 included patients, DNHF and mean LOS were 421 (15.1%) and 11.7 ± 8.8 days. Four classification models for predicting DNHF with high specificities (range, 0.80-0.84) were developed. The generalized linear and gradient boosting machine models performed best with receiver operating characteristic (ROC), accuracy, and negative predictive value (NPV) of 0.72-0.73, 0.75-0.76, and 0.88-0.89. Four regression models for predicting LOS in days were developed, where all performed similarly with mean absolute error and root mean-squared errors of 3.95-3.98 and 5.14-5.16. Both models were developed into an encrypted web-based interface: https://uci-ent.shinyapps.io/head-neck/.

CONCLUSION

Novel and proof-of-concept ML models to predict DNHF and LOS were developed and published as web-based interfaces.

Factors Associated With the Choice of Radiation Therapy Treatment Facility in Head and Neck Cancer

OBJECTIVE

To analyze the clinicodemographic characteristics and treatment outcomes of patients receiving postoperative radiation therapy (PORT) at a different treatment facility rather than the initial surgical facility for head and neck cancer.

STUDY DESIGN

Retrospective cohort analysis.

METHODS

Utilizing the National Cancer Data Base, 2004 to 2015, patients with a diagnosis of oral cavity/oropharyngeal, hypopharyngeal, and laryngeal squamous cell carcinoma were studied. Multivariate analysis was completed with multivariate regression and Cox proportional hazard model, and survival outcomes were examined using Kaplan-Meier analysis.

RESULTS

A total of 15,181 patients who had surgery for a head and neck cancer at an academic/research center were included in the study population. Of the study population, 4,890 (32.2%) patients completed PORT at a different treatment facility. Treatment at a different facility was more common among patients who were ≥65 years old, white, Medicare recipients, those with a greater distance between residence and surgical treatment facility, and with lower income within area of residence (each P < .05). Overall survival was worse in patients completing PORT at a different treatment facility versus at the institution where surgery was completed (61.9% vs. 66.4%; P = .002).

CONCLUSIONS

PORT at a different facility was more common in older individuals, Medicare recipients, those with greater distance to travel, and lower-income individuals. Completing PORT outside the hospital where surgery was performed was associated with inferior survival outcomes among head and neck cancer patients.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:1019-1025, 2021.

The Current State of the Otolaryngology Workforce

A shortage of otolaryngologists is predicted for the coming decades, primarily because of an aging population and aging workforce. However, many factors affect the agility of the workforce to expand or contract. This article discusses what is known about factors of the current otolaryngology workforce, including trends in residency and fellowship training, diversity of the specialty, its geographic distribution, and the challenges of caring for an aging population. Predicting the shortage and possible solutions through modeling is complex and prone to errors caused by incomplete data and assumptions about otolaryngology's similarity to other specialties of medicine at large.

Geographic Heterogeneity in Otolaryngology Medicare New Patient Visits

Objective

To analyze the spatial variation of sociodemographic factors associated with the geographic distribution of new patient visits to otolaryngologists.

Study Design

Retrospective cross-sectional analysis.

Setting

United States.

Subject and Methods

Medicare new patient visits pooled from 2012 to 2016 to otolaryngology providers were obtained from the Centers for Medicare and Medicaid Services, and county-level sociodemographic data were obtained from the 2012-2016 American Community Survey. The mean number of new patient visits per otolaryngology provider by county was calculated. The spatial variation was analyzed with negative binomial and geographically weighted regression. Predictors included various neighborhood characteristics.

Results

There were 7,199,129 Medicare new patient visits to otolaryngology providers from 2012 to 2016. A 41.7-fold difference in new patient evaluation rates was observed across US counties (range, 11-458.8 per otolaryngology provider). On multivariable regression analysis, median age, sex, work commute time, percentage insured, and the advantage index of a county were predictors for the rate of new patient visits to otolaryngology providers. However, geographically weighted regression demonstrated that the association of a county’s disadvantage index, advantage index, percentage insured, and work commute times with new patient visits per provider varied across space.

Conclusions

There are wide geographic differences in the number of new Medicare patients seen by otolaryngologists, and the influence of county sociodemographic factors varied regionally. Further research to analyze the variations in practice patterns of otolaryngologists is warranted to predict future public health needs.

Geographical and Racial Disparities in Head and Neck Cancer Diagnosis in South-Eastern United States: Using Real-World Electronic Medical Records Data

Background: Rurality, race, and age at diagnosis are important predictors in head and neck cancer (HNC) prognosis. However, literature on the associations of rurality and race with age at HNC diagnosis is limited. Data on geographical, racial, and gender disparities in young HNC patients (diagnosed ≤45 years) are also scarce.

Materials and Methods: This retrospective study assesses rural–urban, racial, and gender disparities in age at HNC diagnosis, using electronic medical records (Cerner) data of 4258 HNC patients (1538 residing in rural counties and 2720 in urban counties) from National Cancer Institute-designated cancer center in Alabama. Rurality was defined based on 2010 U.S. Census Bureau's rural–urban classification. Logistic regression was used to assess the association of young HNC diagnosis with demographical, behavioral, and clinical variables. ArcGIS 10.2 was used to map geospatial distribution of age and population-adjusted HNC case across rural and urban counties.

Results: Patients from rural counties were less likely to be diagnosed at younger age (≤45 years) compared with urban counties (odds ratio [OR] [95% confidence interval (CI)]: 0.74 [0.58–0.93]). Most patients present at stage III/IV (64.9% in rural and 60.2% in urban). Compared with white patients, black patients were 70% more likely to get diagnosed at a young age (95% CI: 1.23–2.35). Young patients were more likely to be females and blacks compared with older patients (p<0.0001). Among oral cavity cancer patients, rural patients were 51% less likely to get diagnosed at young age compared with urban patients (95% CI: 0.27–0.89).

Conclusions: Head and neck cancer screening is not routinely conducted so most show up at later stage of cancer. There is also evidence of disparities in age at HNC diagnosis based on rurality, race, and gender; targeted screening can help in reducing these disparities.

Evaluation of the quality of the information received during head and neck cancer announcement: Prospective two-center study

BACKGROUND

Providing patient with cancer with appropriate information following the disclosure of a cancer diagnosis has multiple benefits. The objective was to evaluate the quality of the information received during an announcement for head and neck cancer and to determine predictive factors.

METHODS

We conducted a prospective two-center study using self-questionnaires to assess the patient's perception of the quality of the announcement.

RESULTS

Satisfaction scores on the information provided about the overall disease were 7.7/10. The main positive predictors of quality were a satisfactory consultation setting (P = .004), assessment of pain by a physician (P = .04), physician availability (P = .003), accurate information about tumor stage, quality of information regarding the type (P < .0001) and purpose (P = .001) of treatment and its side effects (P = .006), and the interview with the oncology nurse coordinator (P < .05).

CONCLUSIONS

Patients who received the announcement of head and neck cancer perceived the information received during the pretherapeutic period as satisfactory.