Social Determinants of Health and Oral Cavity Cancer Treatment and Survival: A Competing Risk Analysis

Abstract

ObjectiveCompeting risk analysis is a powerful assessment for cancer risk factors and covariates. This method can better elucidate insurance status and other social determinants of health covariates in oral cavity cancer treatment, survival, and disparities.Study DesignRetrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER) database.MethodsData regarding patient characteristics, clinical stage at diagnosis, treatment, and survival data for 20,271 patients diagnosed with oral cavity cancer was extracted from the SEER 18 Regs Research Data including Hurricane Katrina Impacted Louisiana Cases from 1973 to 2014. All statistical analyses were performed using SAS 9.5 (SAS Institute Inc., Cary, NC). The Fine‐Gray method for assessing impact, risk, and covariates was employed.ResultsMedicaid patients presented with later stage disease, larger tumor size, more distant metastases, and more lymph node involvement at diagnosis compared to insured patients. Medicaid patients were less likely to receive cancer‐directed surgery. Medicaid status was also associated with worse cancer‐specific survival (subhazard ratios 1.87, 95% confidence interval 1.72–2.04, P < .0001) after adjustment for all covariates.ConclusionThis is the first study examining specifically how Medicaid status and social determinants of health covariates impact oral cavity cancer treatment and outcomes and is the first using methods validated for complex covariates. Patients with Medicaid present with more extensive oral cavity disease burden are less likely to receive definitive therapy and have significantly worse overall survival than those with other forms of insurance. This better identifies disparities and the need for improving health literacy, specifically for the at‐risk Medicaid population, and can guide clinicians.Level of EvidenceNA Laryngoscope, 130:2160–2165, 2020

Favorable Lip and Oral Cancer Mortality-to-Incidence Ratios in Countries with High Human Development Index and Expenditures on Health

“…Prognosis varies with disparities in socioeconomic status [ 15 ]. People with limited income and heavier oral cancer disease burden may receive less definitive therapy and have lower overall survival rates than others [ 16 , 17 ]. As the early detection of oral cancer is one of the most important factors that affect overall survival and prognosis [ 18 ], an affordable oral cancer examination could help early diagnosis, improve prognosis, and increase survival rates [ 19 ].…”

Targets for improving disparate head and neck cancer outcomes in the low‐income population

“…The head and neck cancer outcomes in low‐income populations lag behind those of the more affluent—and the degree is dramatic. The degree of disparity is in the range of 20%–90% worse overall survival across most subtypes 5–13 . Yet the necessary solutions advocated in this review have already been proven to work—as drastically better outcomes have already been achieved in more affluent populations.…”

“…Thirty years later, survival rates in low‐income patients with head and neck cancer have proven to be worse than the 1990 estimates as illustrated by our nation's two largest populations databases. Surveillance, epidemiology, and end results (SEER) studies show that Medicaid patients with salivary cancer have 70% worse overall survival and those with oral cancer have nearly 90% worse cancer‐specific survival 5,6 . Studies from the National Cancer Database demonstrate that Medicaid patients have 80% worse overall survival and those with median income under $30 000 have 20% worse overall survival 7 .…”

“…Surveillance, epidemiology, and end results (SEER) studies show that Medicaid patients with salivary cancer have 70% worse overall survival and those with oral cancer have nearly 90% worse cancer‐specific survival. 5 , 6 Studies from the National Cancer Database demonstrate that Medicaid patients have 80% worse overall survival and those with median income under $30 000 have 20% worse overall survival. 7 Institutional data by Choi et al found that lower income was associated with 50% worse overall survival and 40% worse disease‐specific survival for all head and neck subsites.…”

Favorable Lip and Oral Cancer Mortality-To-Incidence Ratios in Countries With High Human Development Index and Expenditures On Health

“…Moreover, the early detection of oral cancer is one of the most important factors that affect the overall survival and prognosis [13], since an affordable examination target to oral cancer can help early diagnosis and improve the prognosis and survival rate [14], and the prognosis has disparities in socioeconomic status [15]. People with limited income may receive much less de nitive therapy and have much more burden from oral cancer and worse overall survival rates [16,17].…”