Socioeconomic position and stage at diagnosis of head and neck cancer – a nationwide study from DAHANCA

Abstract

AbstrActbackground. Socioeconomic differences in survival after head and neck squamous cell carcinoma (HNSCC) are among the greatest for any malignancy. To improve our understanding of the mechanisms by which socioeconomic position influences HNSCC survival, we investigated the association between socioeconomic position and advanced stage HNSCC at diagnosis. Material and methods. Men and women with HNSCC diagnosed between 1992 and 2008 were identified in the Danish Head and Neck Cancer Group (DAHANCA) database, which contains detailed information on all cases of HNSCC treated in Denmark. Individual information on the following four socioeconomic indicators: highest attained educational level, cohabitation status, disposable income and degree of urbanisation were obtained from Statistics Denmark. For the 9683 cases on which there was full information, we estimated odds ratios (ORs) for a diagnosis of advanced stage (TNM III-IV) HNSCC in multivariate logistic regression models by site (glottic, non-glottic larynx, oropharynx, hypopharynx and oral cancer), with adjustment for age, gender, period of diagnosis, education, income, cohabitation status, degree of urbanisation and comorbidity in accordance with a causal diagram. results. For all HNSCC sites, the ORs for advanced stage at diagnosis were increased for patients with low income and for men living alone. For glottic and oral cancers, the ORs for advanced stage HNSCC increased systematically by decreasing length of education. Increased ORs were found for hypopharynx cancer patients living in rural areas or provincial cities. Having one or more comorbid conditions was associated with an increased OR for advanced stage oral cancer but with a decreased OR for oropharynx cancer. conclusion. In this nationwide population-based study, socioeconomic differences in stage at diagnosis were found for all HNSCC subsites. Focus on the high risk for advanced stage HNSCC among vulnerable patients may be beneficial during referral and diagnosis in order to improve HNSCC outcomes.

Impact of socio‐economic position on cancer stage at presentation: Findings from a large hospital‐based study in Germany

“…Income is more likely to change during the life-course than education and therefore represents a more accurate indicator of current SEP. 23,24 Our study supports evidence from other countries such as the USA, 14 Australia 25 and Denmark 26 showing that individuals with low income are at higher risk of late-stage cancer than wealthy people. In Iran, in contrast, breast cancer patients with poor economic resources did not differ from wealthier ones in terms of tumor stage.…”

“…14 In Denmark, men living alone had increased odds of advanced tumors, whereas this effect was not found in women. 26 Other studies did not find an association between cohabitation and stage. 21,22 We found that patients who lived alone had increased odds of advanced disease, adjusted for age and gender.…”

“…For example, colorectal cancer patients who had never married had 2.7 times the odds of presenting with late‐stage cancer in the USA . In Denmark, men living alone had increased odds of advanced tumors, whereas this effect was not found in women . Other studies did not find an association between cohabitation and stage .…”

Urban and rural differences in outcomes of head and neck cancer

“…Because of provincial privacy standards during the study timeframe, we only had approval to access the first three characters of a patient's six‐digit postal code. This allowed reliable ascertainment of community size, but not other important census‐based information related to socioeconomic status, which have been shown to correlate with both urban–rural residence and cancer survival . A case‐control study in Ontario demonstrated that lower socioeconomic status groups had a significantly higher risk of HNC, and they were also more susceptible to a late cancer diagnosis .…”

The Danish Head and Neck Cancer database

“…The database has not only been strengthened by linkage to other registries6,7 but has also shown its value by being a supportive basis for studies of comorbidity,6 value of follow-up,14 or socioeconomical relationship in patients with head and neck cancer 15,16. In the foreseen future, it will be part of international comparisons of treatment strategies, and for such purpose, a clinical database is far superior than using cancer registry comparisons (such as the Nordic NORDCAN study), since such databases are incomplete and inaccurate regarding clinical information.…”