Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.
Background: Epidemiologic studies have shown a significant rise in incidence of oropharyngeal cancer among younger patient populations of 20-44 years of age. This concerning trend has prompted thorough and growing inquiry into the clinical and biological correlates behind this rise. However, there have been relatively limited investigations focused on the social and environmental influences. Among these non-clinical factors, the food environment is a growing field of interest that encompasses several aspects of nutrition availability, government-assistance, and traditional social determinants of health (e.g. socioeconomic status, race/ethnicity, etc.) in order to assess their interrelational influence in real-world contexts. Using the Food and Drug Administration’s Food Environment Atlas (FEA) – a novel, geospatial tool that comprehensively assesses over 280 food environment-related sociodemographic factors – this study aims to quantify the summative associations of the food environment on OPC prognosis among younger patients (20-44 years) compared to older ones.
Methods: This retrospective cohort study analyzed OPC patients between 2000 - 2017 from the NCI-Surveillance-Epidemiology-End Results (SEER) program database. FEA scores were based on 282 county-level variables related to grocery store and restaurant proximity, government-assistance programs, food affordability, accessibility, and traditional SDoH-factors. A composite FEA score was calculated and assigned to patients based on county-of-residence. Multivariate logistic regression and cox-proportional hazard models were performed to assess the association between increasing FEA scores (i.e. worsening food environment) and outcomes of tumor staging, overall survival, and number of primary tumors. These models were stratified along younger (20-44 years) and older (45+) age categories, with age categories set per the conventions of national epidemiology and cancer statistics studies.
Results: Among 70,851 OPC patients, worse food environment was independently associated with greater risk of overall mortality amongst younger patients (HR 1.06, 95% CI 1.01 - 1.12) compared to their older counterparts (HR 1.03, 95% CI 1.02 - 1.04). Similar exacerbated associations were found relative to 3-year mortality rates for younger patients (OR 1.09, 95% CI 1.02 - 1.16) compared to older ones (OR 1.03, 95% CI 1.02 - 1.05); as well as risk of advanced-stage diagnosis for younger (OR 1.05 95% CI 1.01 - 1.11) compared to older patients (OR 1.02, 95% CI 1.01 - 1.03). Younger patients with worse food environments were also more likely to present with a greater number of primary tumors (OR 1.11, 95% CI 1.01 - 1.21) compared to older patients (OR 1.00, 95% CI 0.98-1.01).
Conclusion: The associations of the food environment with worse overall & early survival, advanced staging, and greater number of primary tumors on preliminary diagnosis were exacerbated among younger OPC patients relative to their older counterparts. These findings underscore the importance of jointly assessing social and environmental factors as they interact in the real world. Furthermore, they underscore the need to focus prospective initiatives and investigations on multifaceted influences of food environment disparities within younger OPC patients.
Key Words: Food Environment, Social Vulnerability, Health Disparity, Social Determinants of Health, Oropharyngeal Cancer, Oropharyngeal Squamous Cell Carcinoma, Outcomes