Factors Associated With a Prolonged Diagnosis‐to‐Treatment Interval in Laryngeal Squamous Cell Carcinoma

Abstract

Objective Evaluate factors associated with treatment delays and their effect on survival in laryngeal squamous cell carcinoma. Study Design Retrospective cohort study. Setting National Cancer Database. Methods Patients receiving primary radiation or surgery for laryngeal squamous cell carcinoma were included from 2004 to 2017. The primary outcomes were the diagnosis-to-treatment interval (DTI) and 5-year survival. Variables of prolonged DTI (>30 days) were assessed via logistic regression models. Survival was then assessed through Cox proportional hazards models. Candidate variables for both outcomes included age, sex, race, ethnicity, distance to treatment facility, insurance coverage, treatment facility type, TNM T stage, nodal status, and DTI (in models estimating survival). Results An overall 136,203 patients with laryngeal cancer were identified, from which 51,747 remained after exclusions were applied: 18,499 received primary surgery and 33,248 received primary radiation. Being a member of a racial or ethnic minority, advanced age, female sex, ≥30 miles from treatment facility, lack of insurance, treatment at an academic cancer center, and primary radiation were associated with a prolonged DTI. However, in spite of a faster DTI, treatment at a community cancer center was independently associated with higher mortality (hazard ratio, 1.2; P < .0001). Conclusions Despite being associated with prolonged DTI, receiving treatment at a high-volume academic facility was associated with significantly improved survival. Our results indicate that improved referral pathways or outreach may help improve survival in laryngeal cancer, especially in high-risk populations.

Racial Disparities in Head and Neck Cancer: It's Not Just About Access

“…Distance from the treating hospital was found to be negatively associated with adherence to follow‐up for HNC care, longer treatment package time, and higher mortality rates 35,42,53,65‐67 . It is important to note that variables such as drive time and travel distance were defined differently among studies and thus, may not be directly comparable.…”

“…In the United States, NHB patients were more likely than NHW patients to utilize Medicaid or present as uninsured 6 . Uninsured NHB patients were more likely to be diagnosed with advanced stage HNC, and they had poorer OS compared to NHB patients with private insurance coverage 7,53 54 .…”

“…Those with private insurance had significantly higher OS than uninsured patients (HR, 1.72; 95% CI, 1.59‐1.87), patients with Medicaid (HR, 1.99; 95% CI, 1.88‐2.12), and patients with Medicare (HR, 2.07; 95% CI, 1.99‐2.16) 40 . Multiple studies reported that insurance status remained an independent prognostic factor for OS even after accounting for educational attainment, race, disease site, and tumor, node, and metastasis stage of the disease 7,16,20,40,52,53,55‐61 …”

“…Farther travel distance to the treating hospital was associated with increased 90‐day mortality in low SES patients 42 . NHB and Hispanic patients, as well as patients with Medicaid insurance, were more likely to live far from treating hospital and less likely to travel long distances for HNC treatment, thus they were more likely to be lost to follow up and experience inferior outcomes 35,42,53,66,68,69 . However, patients with the means to travel long distances for treatment at higher‐quality hospitals experienced improved OS 66,69 …”

“…Additionally, NHB patients were significantly less likely to receive any cancer‐directed treatment 76 and were more likely to refuse recommended surgery despite having no contraindications compared to NHW and Hispanic patients 77‐79 . When NHB patients did receive cancer‐directed treatment, compared to NHW patients, they were significantly more likely to elect for primary chemoradiotherapy in lieu of surgical intervention 80 despite presenting with higher stage cancers at initial diagnosis 53,81 . Thus, NHB patients with HNC realized a 19% higher mortality rate than NHW patients 14,66,70 …”