Photo Credit: ZayWin Htal

Extensive racial and ethnic disparities in head and neck cancer influence everything from stage at diagnosis, time to treatment, and treatments offered.

“Although head and neck cancers primarily affect White patients, one in five patients with head and neck cancer are from racial and ethnic minority groups. Some cancers of the head and neck, such as nasopharyngeal cancer, primarily affect minority patients,” Matthew Lin, MS4, and Niels Kokot, MD, note. “While disparities in presentation and outcomes between White and non-White patients with head and neck cancer have been found at the national level, few have explored the differences among individual minority groups, and none have done so at the county level.”

Further, previous research has shown differences between head and neck cancer trends at the national and county level. The researchers wanted “to understand whether the same disparities in head and neck cancer found nationally persisted within Los Angeles County,” Lin and Dr. Kokot explain. “This population represents a highly diverse and predominantly minority population residing in a relatively urban area with a robust healthcare infrastructure.”

For a study published in the American Journal of Otolaryngology, Lin, Dr. Kokot, and colleagues conducted a retrospective cohort analysis of the Los Angeles County SEER database. The cohort included 18,510 patients (average age, 62.84) who were mostly men (64.35%) and primarily White (69.57%).

The researchers observed significant differences in average age at diagnosis, sex, socioeconomic quintile, insurance status, stage at diagnosis, treatments used, and time to first treatment (all P<0.001) when patients were stratified by race and ethnicity. Minority groups included fewer men and were significantly younger, less likely to pursue surgery, more likely to pursue chemotherapy or radiation, and endorsed longer time to first treatment (all P<0.001).

Physician’s Weekly (PW) spoke with Lin and Dr. Kokot to learn more about the study results.

PW: Which study findings are most important to emphasize?

Lin & Dr. Kokot: We would like to emphasize just how pervasive and intimately connected the disparities are among minority patients, even in a county as diverse, culturally sensitive, and urban as Los Angeles County. Disparate health access stemming from lower income and variable insurance status can impact every level of the diagnosis and management of head and neck cancer.

The significant differences in treatment modality seen among racial and ethnic groups may stem from two reasons. Late-stage cancers, which our data show are more common at presentation among minority patients, are often treated without surgery. However, prior literature has suggested that publicly or uninsured patients with head and neck cancer are more likely to seek treatment from institutions that may lack the subspecialty surgical expertise and interdisciplinary treatment capabilities to offer standard-of-care treatment. As such, minority patients in our cohort may also be pursuing nonsurgical management due to issues with healthcare access. As both reasons likely contributed to our findings, our work also demonstrates the unfortunate multilevel issues minorities face when seeking treatment for head and neck cancer.

Our findings also highlight the significant financial barriers to head and neck cancer treatment minority patients face. Public insurance or lack of insurance precludes patients from timely care. Further, the high cost of treatment for head and neck cancer and its unfortunate association with patient bankruptcy may cause economically disadvantaged patients to consider the financial implications of potentially life-saving treatment—and may at least bring some pause before fully committing to cancer treatment.

What are the implications of your results?

While head and neck cancers traditionally affect older White patients, we hope our work reminds clinicians that it undeniably still occurs, and should be considered, among individuals of all ages and racial and ethnic backgrounds who present with symptoms such as persistent neck masses, ear or dental pain, and trouble with or pain while swallowing.

Furthermore, while otolaryngologists and oncologists are primarily responsible for managing head and neck cancer, all physicians are responsible for preventing and identifying these malignancies. Physicians should also continue using their status as trusted health professionals to promote healthy habits, risk factor reduction, and awareness of such malignancies among racial and ethnic minority groups that may suffer from disparate healthcare access and literacy. This can include free screenings, working with community leaders to create culturally sensitive interventions, and combating online disinformation through concise and digestible physician-featuring content. Ultimately, many protective measures against head and neck cancers confer health-related benefits across many organ systems and against many pathologies, so considering how head and neck cancer aligns with physicians’ current clinical foci can help seamlessly integrate such efforts into their existing practices.

As the treatment and management of head and neck cancer becomes increasingly complex, interdisciplinary, and centralized at centers of excellence, the disparities minority patients face may only be further magnified. As such, concerted efforts to ensure underserved minority patients receive timely diagnosis and standard-of-care treatment must continue to further improve the outcomes and quality of life of all patients with head and neck cancer.

What would you like to see future research focus on?

We hope our work inspires other institutions to similarly examine the populations they serve to understand what gaps in presentation, access to care, and clinical outcomes exist among their patients. It would also be useful to perform this type of analysis among individual head and neck cancer subtypes, such as thyroid cancer, facial cutaneous melanoma, and HPV-positive oropharyngeal cancer. Better understanding why these disparities exist—whether it be due to insurance status, health literacy, cultural norms, or another fact—and creating culturally sensitive public health interventions to combat these barriers may help increase awareness of head and neck cancer and the need to present to healthcare professionals in a timely manner for traditionally underserved minority populations. Given the increasing prevalence of HPV-positive oropharyngeal cancer, ensuring adequate HPV vaccination knowledge and vaccination rates among minorities, who are traditionally under-vaccinated relative to their White counterparts, is another key area that needs to be acted upon.