Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.
Background: Head and neck squamous cell carcinoma (HNSCC) has significant morbidity and mortality. Immunotherapies are emerging as an important treatment modality for certain head and neck cancers. We aim to evaluate trends in immunotherapy usage and how they relate to social determinants of health across the United States.
Methods: In this population-based, retrospective cross-sectional study, Epic Cosmos, an aggregated electronic health record dataset that includes >277 million patients from >1500 hospitals and clinics across the United States was used to identify patients with stage IV HNSCC between October 2015 and October 2024. The patient cohort was identified by patients with cancers of the lip and oral cavity, nasal cavity, pharynx, and larynx and with cancer staging information (stages I, II, III, IV) entered by the clinician. Patients receiving immunotherapy were identified as patients receiving pembrolizumab, nivolumab, ipilimumab, cemiplimab, toripalimab-tpzi, and avelumab. The CDC Social Vulnerability Index (SVI) was used to represent social determinants of health at the ZIP-code level, based on the patient’s most recent recorded address. SVI reflects demographic and socioeconomic factors that affect communities that encounter neighborhood-level stressors, where lower SVI indicates lower social vulnerability. Statistical significance was determined using chi-squared tests at p<0.05.
Results: 23,934 patients with stage IV HNSCC were identified. 72.1% were male and 81.3% were white. 19.6% of patients received immunotherapy, with the most common immunotherapy received as pembrolizumab (17% of patients). The least socially vulnerable quartile was significantly associated with increased receipt of immunotherapy compared to the other SVI quartiles (21.6% versus 19.3%, p=0.0009). Of the individual SVI themes, only household characteristics (e.g., aged 65 and older, aged 17 and younger, civilian with a disability, single-parent households, and English language proficiency) were significantly associated with immunotherapy receipt (p=0.02679), while housing/transport, racial and ethnic minority status, and socioeconomic percentiles were not (p=0.279, 0.507, 0.09, respectively). White race was significantly associated with lower immunotherapy receipt compared to other minority races in patients (19.5% versus 21.3%, p=0.0023). Males with stage IV HNSCC were significantly associated with higher immunotherapy usage compared to females (20.1% versus 18.4%, p=0.0002). Patients in the Northeast were significantly associated with a higher percentage of usage of immunotherapy compared to other census regions (23% versus 18.8%, p<0.00001).
Conclusion: Higher immunotherapy receipt in stage IV HNSCC is associated with a lower social vulnerability index, particularly based on household characteristics. Males and the northeast region were also associated with higher immunotherapy usage. While minority races were associated with higher usage, studies should further understand the reasons for these differences in immunotherapy usage. As immunotherapy use increases across the country, targeted strategies to improve equity in immunotherapy usage and increase patient enrollment in clinical trials and access to academic centers may bridge disparities. Future research should further elucidate barriers to access and impact on patient outcomes.