Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.
Background: Sociodemographic factors, such as insurance status, geographic location, and ethnicity, influence access to and timeliness of medical care. Research from other fields suggest that the social vulnerability index, a comprehensive measure capturing factors like socioeconomic status, household composition, and healthcare access, may help predict populations at high-risk for barriers to quality healthcare. In head and neck cancer, delays in treatment are known to impact clinical outcomes, but it is unclear how this is related to sociodemographic factors. Thus, this study examines the impact of social vulnerability on treatment timing/completion and postoperative outcomes in head and neck cancer patients at a high-volume, tertiary-care institution.
Methods: Head and neck surgical cancer cases at a single institution from 2019-2022 were reviewed. Demographic data (age, gender, insurance status, comorbidities), oncologic information (tumor site, staging, treatment modalities, treatment timing), surgical complications, and follow-up time were collected. Patient addresses were mapped to U.S. Census tracts to determine their Social Vulnerability Index (SVI), as assigned by the Center for Disease Control and Prevention (2022). Possible SVI values range from 0-1, where 1 indicates greater social vulnerability. Pearson correlation, T-test, and ANOVA was used for continuous and categorical (2 or ³2 levels), respectively, to test associations of SVI with other patient variables. Univariate logistic and Cox regression approaches were used to examine the association between SVI and treatment timelines (time to initial treatment and total treatment package time) and postoperative outcomes.
Results: The cohort consisted of 151 adults (60% male, 94% White) treated surgically for head and neck cancer (31% oral cavity, 15% larynx, 14% oropharynx, 11% salivary, 11% cutaneous, 11% sinonasal/skull base, 7% other). Mean age at diagnosis of 64.7 years (SD 13.9 years). The majority had governmental insurance (65%, private 34%, both 1%). Adjuvant therapy (32% radiation, 19% chemoradiation) was administered in the majority of cases. Median follow-up, time to treatment initiation, and total treatment package time were 373 days, 29 days and 105 days (15 weeks), respectively. Average SVI was 0.43 (SD 0.28). SVI was associated with insurance status (F(2,142) = 3.74, p = 0.026), but not with age, gender, or primary tumor site. Univariate logistic regression for total treatment package delay (>14 weeks) showed a significant association with SVI (OR = 0.27, 95% CI: 0.07 - 0.9, p = 0.036). There was no association with other variables hypothesized to be contributory (age, gender, insurance, comorbidities, complications, disposition status, stage, or primary tumor site). The SVI was not associated with time to initial treatment, complication rate, or overall survival on univariate analysis. Multivariate analysis was not performed due to lack of multiple univariate significant associations.
Conclusion: Head and neck cancers require prompt diagnosis and treatment to optimize survival outcomes. Our analysis suggests that increased social vulnerability may be predictive of a longer total treatment package time. Early identification and addressing these disparities may improve equity in cancer care.