Association of Household Income at Diagnosis With Financial Toxicity, Health Utility, and Survival in Patients With Head and Neck Cancer

Abstract

ImportanceWhile several studies have documented a link between socioeconomic status and survival in head and neck cancer, nearly all have used ecologic, community-based measures. Studies using more granular patient-level data are lacking.ObjectiveTo determine the association of baseline annual household income with financial toxicity, health utility, and survival.Design, Setting, and ParticipantsThis was a prospective cohort of adult patients with head and neck cancer treated at a tertiary cancer center in Toronto, Ontario, between September 17, 2015, and December 19, 2019. Data analysis was performed from April to December 2021.ExposuresAnnual household income at time of diagnosis.Main Outcome and MeasuresThe primary outcome of interest was disease-free survival. Secondary outcomes included subjective financial toxicity, measured using the Financial Index of Toxicity (FIT) tool, and health utility, measured using the Health Utilities Index Mark 3. Cox proportional hazards models were used to estimate the association between household income and survival. Income was regressed onto log-transformed FIT scores using linear models. The association between income and health utility was explored using generalized linear models. Generalized estimating equations were used to account for patient-level clustering.ResultsThere were 555 patients (mean [SD] age, 62.7 [10.7] years; 109 [20%] women and 446 [80%] men) included in this cohort. Two-year disease-free survival was worse for patients in the bottom income quartile (<$30 000: 67%; 95% CI, 58%-78%) compared with the top quartile (≥$90 000: 88%; 95% CI, 83%-93%). In risk-adjusted models, patients in the bottom income quartile had inferior disease-free survival (adjusted hazard ratio, 2.13; 95% CI, 1.22-3.71) and overall survival (adjusted hazard ratio, 2.01; 95% CI, 0.94-4.29), when compared with patients in the highest quartile. The average FIT score was 22.6 in the lowest income quartile vs 11.7 in the highest quartile. In adjusted analysis, low-income patients had 12-month FIT scores that were, on average, 134% higher (worse) (95% CI, 16%-253%) than high-income patients. Similarly, health utility scores were, on average, 0.104 points lower (95% CI, 0.026-0.182) for low-income patients in adjusted analysis.Conclusions and RelevanceIn this cohort study, patients with head and neck cancer with a household income less than CAD$30 000 experienced worse financial toxicity, health status, and disease-free survival. Significant disparities exist for Ontario’s patients with head and neck cancer.

Oncologic Significance of Therapeutic Delays in Patients With Oral Cavity Cancer

“…Indeed, National Cancer Database studies have highlighted that, for patients with HNC, insurance status is associated with treatment delays and oncologic outcomes. 5,7,18 While universal health care coverage mitigates some barriers, socioeconomic factors can still influence HNC outcomes in Canadian patients. In a Canadian HNC cohort, Noel et al 19 revealed that lower household income was associated with worse oncologic outcomes and health status.…”

“…While universal health care coverage mitigates some barriers, socioeconomic factors can still influence HNC outcomes in Canadian patients. In a Canadian HNC cohort, Noel et al revealed that lower household income was associated with worse oncologic outcomes and health status. Regarding dental insurance, coverage in Canada varies by province.…”

Neighborhood Deprivation and Symptoms, Psychological Distress, and Quality of Life Among Head and Neck Cancer Survivors

“…Particularly among survivors of head and neck cancer (HNC), patient-level factors, such as race, income, and education, have emerged as factors associated with survival and QOL outcomes. Black race, lower income, and limited educational attainment (ie, high school or less) are factors associated with worse survival among patients treated for HNC . Furthermore, financial toxicity has been associated with reduced health-related QOL and overall survival .…”

“…Black race, lower income, and limited educational attainment (ie, high school or less) are factors associated with worse survival among patients treated for HNC. [4][5][6][7][8][9] Furthermore, financial toxicity has been associated with reduced health-related QOL and overall survival. 10,11 Similarly, HNC survivors unable to return to work after treatment completion frequently report diminished QOL along with an increase in symptoms of anxiety and depression.…”

Insurance Status is Associated With Recurrence in Cutaneous Head and Neck Squamous Cell Carcinoma

“…11 Moreover, a prospective study from Canada showed that lower-income mucosal HNSCC patients experience worse 2-year survival, financial toxicity, and poorer overall health. 12,13 In breast cancer, being African American, having low income, nonprivate health insurance, never having been married, and lack of transportation are all predictors of advanced-stage disease. 14 Similar disparities based on socioeconomic status and race have been observed in colorectal and prostate cancers.…”