Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.
Background: Options for definitive treatment of early-stage laryngeal cancer are often dictated by patient preference, including minimally invasive surgery and radiation. A trend has emerged towards increased surgical utilization, particularly among patients with higher income and greater socioeconomic status (SES).1 However, the impact of SES and other factors on treatment decisions for early-stage laryngeal cancer remains underexplored.
Objective: This study investigates the effect of demographic and SES factors on treatment decisions, and secondarily on treatment delays, for early-stage laryngeal cancer.
Methods: We conducted a retrospective analysis of patients with early-stage laryngeal cancer (T1-T2, N0) from the Surveillance, Epidemiology, and End Results (SEER) database from 2011 to 2020. Demographic variables included age, sex, race/ethnicity, insurance status, and a county-level SES measure known as the social vulnerability index (SVI). Treatment-related variables included time from diagnosis to treatment and treatment type (surgery alone, radiation alone, combination, no treatment, unknown). Treatment delay was defined as 2 or more months from diagnosis to treatment initiation. Chi-squared tests were used to determine statistical significance, with a minimum p-value of 0.05.
Results: Our analysis included 8,801 patients. Treatment types were surgery alone (32.8%), radiation alone (39.0%), combination therapy (16.7%), and no/unknown treatment (11.6%.) Treatment choice significantly correlated with insurance status (p=0.001), SVI (p<0.001), age (p<0.001) and race (p<0.001). Higher surgery rates were observed in patients with private insurance, other non-Hispanic race, and older age; the lowest rates were among Black non-Hispanic, uninsured, and those in the highest SVI quartile. Radiation alone was more common among uninsured, Black non-Hispanic, and younger patients, while it was least common in older patients, those of Other non-Hispanic race, and individuals with public insurance. Meanwhile, no treatment was prevalent in those without insurance, in the highest SVI quartile, older patients, and Black non-Hispanic individuals. Treatment was timely in 69.3% of patients, delayed for 20.3%, and unknown for 10.4%. Delays correlated with insurance status (p=0.02), SVI (p=0.01), age (p<0.001) and race (p<0.001). Delays were most common in uninsured patients, those in higher SVI quartiles, younger individuals, and Black non-Hispanic and Hispanic patients.
Conclusion: Factors unrelated to tumor biology significantly influence treatment choices and timing of treatment in early-stage laryngeal cancer. Our findings indicate that surgery is more frequently chosen by older and privately insured patients, while Black, uninsured, and socially vulnerable populations often under-utilize surgery and instead opt for radiation or no treatment, ultimately experiencing the greatest delays. Further research is needed to clarify how insurance, social vulnerability, age, and race affect treatment decisions.
Citations:
1. Chen AY, Fedewa S, Zhu J. Temporal trends in the treatment of early- and advanced-stage laryngeal cancer in the United States, 1985-2007. Arch Otolaryngol Head Neck Surg. 2011;137(10):1017-1024. doi:10.1001/archoto.2011.171