Disparities in Mortality from Larynx Cancer: Implications for Reducing Racial Differences

Assessments of social vulnerability on laryngeal cancer treatment & prognosis in the US

BACKGROUND

Previous social determinants of health (SDoH) studies on laryngeal cancer (LC) have assessed individual factors of socioeconomic status and race/ethnicity but seldom investigate a wider breadth of SDoH-factors for their effects in the real-world. This study aims to delineate how a wider array of SDoH-vulnerabilities interactively associates with LC-disparities.

METHODS

This retrospective cohort study assessed 74,495 LC-patients between 1975 and 2017 from the Surveillance-Epidemiology-End Results (SEER) database using the Social Vulnerability Index (SVI) from the CDC, total SDoH-vulnerability from 15 SDoH variables across specific vulnerabilities of socioeconomic status, minority-language status, household composition, and infrastructure/housing and transportation, which were measured across US counties. Univariate linear and logistic regressions were performed on length of care/follow-up and survival, staging, and treatment across SVI scores.

RESULTS

Survival time dropped significantly by 34.37% (from 72.83 to 47.80 months), and surveillance time decreased by 28.09% (from 80.99 to 58.24 months) with increasing overall social vulnerability, alongside advanced staging (OR 1.15; 95%CI 1.13-1.16), increased chemotherapy (OR 1.13; 95%CI 1.11-1.14), decreased surgical resection (OR 0.91; 95%CI 0.90-0.92), and decreased radiotherapy (OR 0.97; 95%CI 0.96-0.99).

DISCUSSION

In this SDoH-study of LCs, detrimental care and prognostic trends were observed with increasing overall SDoH-vulnerability.

Comprehensive Analysis Reveals No Significant Correlation Between p16/ CDKN2A Expression and Treatment Outcomes in Laryngeal Squamous Cell Carcinoma

BACKGROUND

The p16/CDKN2A protein is being explored as an independent prognostic marker in laryngeal cancer, with studies suggesting that p16-positive patients may have a better prognosis. While its role is well-established in oropharyngeal squamous cell carcinoma (OPSCC) related to HPV, ongoing research indicates its potential prognostic value in laryngeal cancer, even in HPV-negative cases.

METHODS

In this study, we investigated the association between survival outcomes and p16 expression in a cohort of 310 laryngeal cancer patients from the Cancer Genome Atlas (TCGA) Program and the University of Maryland Medical Center (UMMC).

RESULTS

In the TCGA cohort, patients with high p16 protein expression had a significantly higher probability of disease-free survival (DFS) at 89%, compared to 51% in the low p16 protein group (p = 0.0266). Additionally, the mean relative p16 protein expression decreased significantly with advancing TNM stage, measured at 1.116 for stage II, 1.075 for stage III, and 0.6204 for stage IV (p = 0.7871 for stage II vs. stage III, p = 0.0065 for stage III vs. stage IV, p = 0.0031 for stage I vs. stage IV). Protein expression for p16 also correlated with CDKN2A retention/deletion status (p = 0.0077), where the DFS was higher in patients with retained CDKN2A than those with deleted CDKN2A (p = 0.0187). Multivariate analysis of the UMMC and TCGA cohorts revealed that both an increase in the patient's age and higher T stage significantly increased the risk of mortality (p = 0.05, p = 0.01, respectively).

CONCLUSION

While this study observes trends suggesting that low p16 protein expression is associated with longer DFS and advanced TNM stage in laryngeal cancer, the multivariate analysis did not establish p16 as an independent prognostic factor. These findings suggest that while p16 may have a biological role in tumor progression, its utility as a standalone prognostic marker in clinical outcomes requires further validation.

Prevalence of surgery in Indigenous people with cancer: a systematic review and meta-analysis

Background

As cancer incidence increases globally, so does the prevalence of cancer among Indigenous peoples. Indigenous peoples face significant barriers to healthcare, including access to and uptake of surgery. To date, the synthesis of access to and uptake of surgery for Indigenous peoples living with cancer has not yet been reported.

Methods

We conducted a systematic literature review and meta-analysis of access to and uptake of surgery for Indigenous peoples in Canada, Australia, New Zealand, and the United States. Five databases were searched to identify studies of Indigenous adults with cancer and those who received surgery. The Joanna Briggs Institute critical appraisal tools were used to assess the quality and inclusion of articles. Random effect meta-analyses were conducted to estimate the pooled prevalence of surgery in Indigenous people with cancer.

Findings

Of the 52 studies in the systematic review, 38 were included in the meta-analysis. The pooled prevalence of surgery in Indigenous people with cancer was 56.2% (95% confidence interval (CI): 45.4-66.7%), including 42.8% (95% CI: 36.3-49.5%) in the Native Hawaiian population, 44.5% (95% CI: 38.7-50.3%) in the Inuit and 51.5% (95%CI: 36.8-65.9%) in Aboriginal and Torres Strait Islander people. Overall, Indigenous people received marginally less cancer surgery than non-Indigenous people (3%, 95% CI: 0-6%). Indigenous people were 15% (95% CI: 6-23%) less likely to receive surgery than non-Indigenous people for respiratory cancers. Remoteness, travel distance, financial barriers, and long waiting times to receive surgery were factors cited as contributing to lower access to surgery for Indigenous people compared to non-Indigenous people.

Interpretation

Efforts to improve access and use of cancer services and surgery for Indigenous peoples should be multilevel to address individual factors, health services and systems, and structural barriers. These determinants need to be addressed to expedite optimal care for Indigenous peoples, especially those living in outer metropolitan areas.

Funding

The Research Alliance for Urban Goori Health (RAUGH) funded this project. GG was funded by an NHMRC Investigator Grant (#1176651).

Laryngeal Squamous Cell Carcinoma Incidence and Survival Trends in the United States: A Population-Based Analysis of Two Decades

IMPORTANCE

Laryngeal cancer has undergone a complex evolution in incidence, management, and standards of care over the past 20 years. Disease-wide demographic and survival risk factors have yet to be elucidated.

OBJECTIVE

Examine incidence, management, and survival trends in laryngeal cancer from 2000 to 2019.

DESIGN, SETTING, AND PARTICIPANTS

The Surveillance, Epidemiology, and End Results database was utilized to identify age-adjusted incidence rates (AAIRs) of laryngeal squamous cell carcinoma (LSCCa) from 2000 to 2019. Joinpoint regression was conducted to identify annual percentage changes (APCs). Chi-squared analysis was used to find changes in demographic, clinicopathologic, and treatment changes over the study period. Finally, univariate Kaplan-Meier and COX multivariate regressions were conducted to identify survival differences.

RESULTS

There were 46 266 cases of LSCCa identified between 2000 and 2019 with AAIR of 2.7 per 100 000 person-years with APC of -2.6% [95% CI: -2.8% to 2.4%]. These rates have largely been down-trending among demographic substratifications. Age at initial diagnosis has been increasing (64.6 → 66.0, p < 0.001). Higher median household income was associated with lower AAIR (35 000 5.3; > $75 000 2.2) and increased annual percentage decrease (< $35 000, -1.1%*; > $75 000, -3.2%*). There were no other clinically significant differences in demographic and clinicopathologic trends although persistent demographic differences were noted. Late T-stage at diagnosis has increased over the study period (T3, 18% → 23%, p < 0.001). Treatment with primary chemoradiotherapy has increased significantly (20.0% → 27.0%, p < 0.001). On univariate analysis, there were no significant differences in survival; however, on multivariate analysis, there has been a progressive improvement in disease-specific and overall survival over 5-year bins. Late-stage disease had a progressive improvement in survival with each treatment period on both univariate and multivariate analysis.

CONCLUSIONS AND RELEVANCE

There has been a progressively significant decrease in age-adjusted incidence of LSCCa with increased utilization of primary chemoradiotherapy. When adjusted for associated characteristics, there has been a continuing improvement in survival over the study period, primarily in late-stage disease.

Laryngeal Cancer in Women: Unveiling Gender-Specific Risk Factors, Treatment Challenges, and Survival Disparities

Laryngeal cancer is one of the main causes of morbidity and mortality worldwide, with a significantly higher prevalence among men than women. However, the incidence, clinical characteristics, and specific treatment of laryngeal cancer in women have often been overlooked by research. This review aims to examine gender differences in incidence, risk factors, hormonal mechanisms, survival, and therapeutic approaches for laryngeal cancer in women. Although smoking and alcohol remain the main risk factors, evidence suggests that women may be more vulnerable to the harmful effects of these behaviors, with a relative higher risk than men. In addition, hormonal factors such as estrogen may influence women's susceptibility to laryngeal cancer, accelerating tumor growth and complicating treatment. Differences in treatment between the sexes, with women tending to receive less intensive treatment than men, is another crucial aspect that needs more attention. This article also analyses the disparities in survival, highlighting that women often have a better prognosis, although this trend varies according to demographic characteristics and the health system. The increasing incidence of laryngeal cancer in women requires increased research to fully understand risk factors and underlying biological mechanisms in order to develop more personalized treatments and optimize clinical outcomes for patients.

Racial Disparities in 30 Day Outcomes Following Total Laryngectomy

BACKGROUND

Despite the growing literature on racial disparities in the utilization of total laryngectomy (TL), and survival following the treatment of laryngeal cancers, there is a paucity of research in TL cohorts evaluating disparities in the immediate postoperative setting.

METHODS

In a national multi-institutional cohort, TL cases between 2010 and 2021 were identified using relevant Current Procedural Terminology (CPT) codes. Logistic regression analyses investigated the association between race/ethnicity and adverse outcomes within 30 days postoperatively.

RESULTS

This study consisted of 1493 patients who underwent TL with or without radical neck dissection. Black patients underwent free flap and pedicled flap reconstruction more frequently than their counterparts (P = .023) and exhibited a 1.532 times higher odds of surgical complications (P < .001).

CONCLUSIONS

There are increased rates of surgical complications in Black patients undergoing TL. Given the limited oncologic and socioeconomic variables available through National Surgical Quality Improvement Program, future study of disparate postoperative outcomes in this population is recommended.

Factors associated with adherence to swallowing therapy among patients diagnosed with oropharyngeal dysphagia

Objective

The objective of this study is to assess disparities in adherence to swallowing therapy for clinically diagnosed oropharyngeal dysphagia (OD) patients.

Methods

Analysis was conducted on data from 600 patients with OD and confirmed impairments in swallowing safety and/or efficiency on a videofluoroscopic swallow study. Patients were classified based on their adherence to treatment sessions, defined as the number of swallow treatment sessions attended. The outcome of treatment adherence was categorized into two groups: those who attended fewer than 50% of the prescribed treatment sessions and those who attended 50% or more of the sessions. Continuous variables were presented as mean ± standard deviation or median ± interquartile range. Categorical variables were compared using Pearson chi-square tests and Fisher's exact test when appropriate. Univariable and multivariable binary logistic regression models were employed to identify factors associated with successful adherence.

Results

Approximately 79% adhered to swallowing treatment. We found no significant relationship between adherence and age, sex, race, ethnicity, primary language, marital status, insurance status, occupation, median income, distance, education, OD severity, and diagnosis year (p > 0.05). We found no covariables to be significant predictors to swallowing treatment nonadherence in both univariable and multivariable binary regression models (p > 0.05).

Conclusion

The variables analyzed in this study were not significantly associated with nonadherence to swallow therapy. Nevertheless, our study still addressed an important knowledge gap and future studies would benefit from exploring other relevant socioeconomic and disease-related factors.

Level of evidence

Level 4.

Racial Disparities in Surgical Management For Early-Stage Laryngeal Squamous Cell Carcinoma and Recurrent Dysplasia

Objective

The aim of this study is to evaluate the association between race and the treatment of laryngeal dysplasia and early-stage laryngeal squamous cell carcinoma (LSCC).

Study design

Retrospective Cohort Study.

Setting

Large multispecialty academic medical center.

Methods

Patients were treated for laryngeal dysplasia or LSCC between September 2019 and September 2022. A retrospective chart review was conducted to collect demographic and clinical information. Two-sample t tests, chi-square tests, and linear regression models were used to compare characteristics (α = 0.05). Analyses were performed in STATA 17.

Results

Sixty-five patients were identified that underwent potassium titanyl phosphate (KTP) transoral laser microsurgery for management of early-stage LSCC (n = 29) or dysplasia (n = 36). The cohort consisted of 23 Black and 42 White patients. No significant difference was found in age, alcohol or tobacco use, rate of adjuvant radiotherapy, stage of disease, nor insurance status between the 2 groups. White patients underwent more procedures to address initial disease and subsequent recurrent dysplasia on average than Black patients (2.52 vs 1.52, P = .02). This remained true after adjusting for demographic and clinical characteristics and insurance status in a linear regression model. While Black patients were more likely to be lost to follow-up than White patients (30.4% vs 9.5%, P = .03), the average number of procedures between the groups still differed significantly (2.63 vs 1.56, P = .04) when controlling for those lost to follow-up.

Conclusion

The findings presented here highlight potential inequities that exist for racial minorities at early stages of treatment and in addressing premalignant conditions, which may contribute to the known downstream disparities in laryngeal cancer outcomes.

The impact of digital inequities on laryngeal cancer disparities in the US

OBJECTIVES

To develop and implement a novel, comprehensive tool, the Digital Inequity Index (DII), that quantifiably measures modern-technology access in the US to assess the impact of digital inequity on laryngeal cancer (LC) care nationwide.

METHODS

DII was calculated based on 17 census-tract level variables derived from the American Community Survey and Federal Communications Commission. Variables were categorized as infrastructure-access (i.e., electronic device ownership, type of broadband, internet provider availability, income-broadband subscription ratio) or sociodemographic (i.e., education, income, disability status), ranked and then averaged into a composite score. 22,850 patients from 2008 to 2017 in SEER were assessed for regression trends in long-term follow-up, survival, prognosis, and treatment across increasing overall digital inequity, as measured by the DII. This methodology allows for us to assess the independent contribution of digital inequity adjusted for socioeconomic confounders.

RESULTS

With increasing overall digital inequity, length of long-term follow-up (p < 0.001) and survival (p = 0.025) decreased. Compared to LC patients with low DII, high DII was associated with increased odds of advanced preliminary staging (OR 1.06; 95 % CI 1.03-1.08), treatment with chemotherapy (OR 1.06; 95 % CI 1.04-1.08), and radiation therapy (OR 1.02; 95 % CI 1.00-1.04), as well as decreased odds of surgical resection (OR 0.96; 95 % CI 0.94-97).

CONCLUSIONS

Digital inequities are associated with detrimental trends in LC patient outcomes in the US, allowing discourse for targeted means of alleviating disparities while contextualizing national sociodemographic trends of the impact of online access on informed care.

Investigating Disparities in Hypopharyngeal/Laryngeal Cancer Survival in Florida With Geospatial Mapping Analysis

OBJECTIVE

Identify predictors of overall survival (OS) after hypopharyngeal/laryngeal cancer in Florida.

MATERIAL AND METHODS

We conducted a retrospective cohort study using data from the Florida Cancer Data System (FCDS) on patients diagnosed with hypopharyngeal or laryngeal cancer from 2010-2017. Primary outcome was OS. Hazard ratios (HRs) were estimated from univariable and multivariable Cox regression models for OS. Data was analyzed from November 1, 2022, to June 30, 2023.

RESULTS

We analyzed 6771 patients, who were primarily male (81.2%), White non-Hispanic (WNH) (78.2%), publicly insured (70.1%), married (51.8%), and residents of urban counties (73.6%). Black patients were more likely to be younger at diagnosis (38.9%), single (43.4%), to have distant SEER stage disease (25.6%). Median OS were lowest among patients who were uninsured (34 months), with hypopharyngeal site disease (18 months), and a smoking history (current: 34 months, former: 46 months, no smoking: 63 months). Multivariable Cox regression analysis showed worse OS for single/unmarried vs married (HR 1.47 [95%CI: 1.36-1.59], P < .001), history of tobacco use (current: HR 1.62 [95%CI: 1.440-1.817], P < .001; former smokers: (HR 1.28 [95%CI: 1.139-1.437], P < .001) vs no history). Improved OS was observed among White Hispanics (WH) vs WNH (HR .73 [95%CI: .655-.817], P < .001) and women vs men (HR .88 [95%CI: .807-.954], P = .002). Geographical mapping showed that mortality rates were highest in census tracts with low income and education.

CONCLUSION

Our findings suggest that sociodemographic and clinical factors impact OS from hypopharyngeal/laryngeal cancer in Florida and vary geographically within the state. These results will help guide future public health interventions.

Healthcare Disparities in Otolaryngology

Purpose of Review

The purpose of this review is to summarize some of the recent research studies on healthcare disparities across various subspecialties within otolaryngology. This review also highlights the impact of COVID-19 pandemic on disparities and proposes potential interventions to mitigate disparities.

Recent Findings

Significant healthcare disparities in care and treatment outcomes have been reported across all areas of otolaryngology. Notable differences in survival, disease recurrence, and overall mortality have been noted based on race, ethnicity, socioeconomic status (SES), insurance status, etc. This is most well-researched in head and neck cancer (HNC) within otolaryngology.

Summary

Healthcare disparities have been identified by numerous research studies within otolaryngology for many vulnerable groups that include racial and ethnic minority groups, low-income populations, and individuals from rural areas among many others. These populations continue to experience suboptimal access to timely, quality otolaryngologic care that exacerbate disparities in health outcomes.

Healthcare Disparities in Laryngology: A Scoping Review

OBJECTIVES/HYPOTHESIS

This scoping review aims to map out existing disparities research within the subspecialty of laryngology in order to highlight gaps in knowledge and guide future research.

STUDY DESIGN

Scoping Review.

METHODS

We completed a scoping review of PubMed, Ovid Embase, and the Cochrane Library for primary research focused on evaluating the existence and impact of disparities in race/ethnicity, sex/gender, insurance status, education level, income, geography, and LGBTQ identity in the context of various laryngological conditions. Publications of any design and date, performed in the United States, and focusing on the adult population exclusively were included.

RESULTS

Of the 4,999 unique abstracts identified, 51 articles were ultimately included. The most frequently examined condition in relation to disparities was laryngeal cancer (27 of 51), followed by voice disorders (15 of 51), deglutitive disorders (eight of 51), and airway disorders (one of 51). Sources of inequity evaluated from most common to least common were race/ethnicity (43 of 51), sex/gender (39 of 51), insurance status (23 of 51), geography (23 of 51), income (21 of 51), and education level (16 of 51). No study examined the association of LGBTQ identity with inequity.

CONCLUSIONS

This scoping review highlights the limited extent of disparities research in laryngology and establishes the need for further scholarship on the impact of disparities in laryngology care. The pathologies studied were, in decreasing order of frequency: laryngeal cancer, voice disorders, deglutitive disorders, and airway disorders. Race/ethnicity and sex/gender were the most common disparities examined, with no evaluation of LGBTQ-related care inequity.

LEVEL OF EVIDENCE

NA Laryngoscope, 132:375-390, 2022.

Association of race and health care system with disease stage and survival in veterans with larynx cancer

BACKGROUND

Black patients with laryngeal squamous cell carcinoma (LSCC) historically have inferior outcomes in comparison with White patients. The authors investigated these racial disparities within the Veterans Health Administration (VHA), an equal-access system, and within the Surveillance, Epidemiology, and End Results (SEER) program, which is representative of the US hybrid-payer system.

METHODS

Patients with invasive (T1 or greater) LSCC were included from SEER (2004-2015) and the VHA (2000-2017). The primary outcomes of overall survival (OS) and larynx cancer-specific survival (LCS) were evaluated in Cox and Fine-Gray models.

RESULTS

In the SEER cohort (7122 patients: 82.6% White and 17.4% Black), Black patients were more likely to present with advanced disease and had inferior OS (hazard ratio [HR], 1.37; 95% CI, 1.26-1.50; P < .0001) in a multivariable analysis. Black LCS was worse in a univariable analysis (HR, 1.42; 95% CI, 1.27-1.58; P < .0001), but this effect was attenuated by 83% when the authors controlled for the TNM category and was found to be insignificant in a multivariable analysis (HR, 1.05; 95% CI, 0.93-1.18; P = .42). In the VHA cohort (9248 patients: 79.7% White and 20.3% Black), the 2 racial cohorts presented with similar tumor characteristics and similar OS (HR, 0.95; 95% CI, 0.89-1.02; P = .14). Black LCS was similar in univariable (HR, 1.10; 95% CI, 1.00-1.22; P = .05) and multivariable analyses (HR, 1.02; 95% CI, 0.92-1.14; P = .67).

CONCLUSIONS

Black patients with LSCC had a tumor burden at diagnosis and survival outcomes comparable to those of White patients within the VHA; this was counter to what was observed in the SEER analysis and prior national trends. This study's findings point toward the notable role of health care access in contributing to racial health disparities in the realm of larynx cancer.