Racial disparities in being recommended to surgery for oral and oropharyngeal cancer in the United States

Retrospective Cohort Study on the Impact of Travel Distance on Late-Stage Oral Cancer Treatment and Outcomes: An NCDB Analysis

The National Comprehensive Cancer Network guidelines provide evidence-based consensus for optimal individual site- and stage-specific treatments. This is a cohort study of 11,121 late-stage oral cancer patients in the National Cancer Database from 2010 to 2016. We hypothesized that patient travel distance may affect treatment choices and impact outcome. We split travel distance (miles) into quartiles (D1-4) and assessed treatment choices, type of facility, and survival outcome in relation to distance traveled. Univariate and multivariate analyses addressed contributions of specific variables. White patients were most likely to travel farthest (D4) for treatment compared to Black patients (D1). Urban area patients traveled shorter distances than those from rural areas. Greater travel distance was associated with patients undergoing surgical-based therapies and treatment at academic centers. Patients in D1 had the lowest median survival of all distance quartiles. Surgery-based multimodality treatment (surgery and radiation) had a median survival significantly greater than for non-surgical therapy. Several factors including travel distance and treatment facility were associated with survival outcomes for late-stage oral cavity cancers. Consideration of these factors may help improve the outcome for this patient population.

Persistent poverty disparities in incidence and outcomes among oral and pharynx cancer patients

PURPOSE

Disparities in oral cavity and pharyngeal cancer based on race/ethnicity and socioeconomic status have been reported, but the impact of living within areas that are persistently poor at the time of diagnosis and outcome is unknown. This study aimed to investigate whether the incidence, 5-year relative survival, stage at diagnosis, and mortality among patients with oral cavity and pharyngeal cancers varied by persistent poverty.

METHODS

Data were drawn from the SEER database (2006-2017) and included individuals diagnosed with oral cavity and pharyngeal cancers. Persistent poverty (at census tract) is defined as areas where ≥ 20% of the population has lived below the poverty level for ~ 30 years. Age-adjusted incidence and 5-year survival rates were calculated. Multivariable logistic regression was used to estimate the association between persistent poverty and advanced stage cancer. Cumulative incidence and multivariable subdistribution hazard models were used to evaluate mortality risk. In addition, results were stratified by cancer primary site, sex, race/ethnicity, and rurality.

RESULTS

Of the 90,631 patients included in the analysis (61.7% < 65 years old, 71.6% males), 8.8% lived in persistent poverty. Compared to non-persistent poverty, patients in persistent poverty had higher incidence and lower 5-year survival rates. Throughout 10 years, the cumulative incidence of cancer death was greater in patients from persistent poverty and were more likely to present with advanced-stage cancer and higher mortality risk. In the stratified analysis by primary site, patients in persistent poverty with oropharyngeal, oral cavity, and nasopharyngeal cancers had an increased risk of mortality compared to the patients in non-persistent poverty.

CONCLUSION

This study found an association between oral cavity and pharyngeal cancer outcomes among patients in persistent poverty indicating a multidimensional strategy to improve survival.

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

OBJECTIVE

Medical literature identifies stark racial disparities in head and neck cancer (HNC) in the United States, primarily between non-Hispanic white (NHW) and non-Hispanic black (NHB) populations. The etiology of this disparity is often attributed to inequitable access to health care and socioeconomic status (SES). However, other contributors have been reported. We performed a systematic review to better understand the multifactorial landscape driving racial disparities in HNC.

DATA SOURCES

A systematic review was conducted in Covidence following Preferred Reporting Items for Systematic Reviews and Meta-analyses Guidelines. A search of PubMed, SCOPUS, and CINAHL for literature published through November 2022 evaluating racial disparities in HNC identified 2309 publications.

REVIEW METHODS

Full texts were screened by 2 authors independently, and inconsistencies were resolved by consensus. Three hundred forty publications were ultimately selected and categorized into themes including disparities in access/SES, treatment, lifestyle, and biology. Racial groups examined included NHB and NHW patients but also included Hispanic, Native American, and Asian/Pacific Islander patients to a lesser extent.

RESULTS

Of the 340 articles, 192 focused on themes of access/SES, including access to high-quality hospitals, insurance coverage, and transportation contributing to disparate HNC outcomes. Additional themes discussed in 148 articles included incongruities in surgical recommendations, tobacco/alcohol use, human papillomavirus-associated malignancies, and race-informed silencing of tumor suppressor genes.

CONCLUSION

Differential access to care plays a significant role in racial disparities in HNC, disproportionately affecting NHB populations. However, there are other significant themes driving racial disparities. Future studies should focus on providing equitable access to care while also addressing these additional sources of disparities in HNC.

Differences in Survival between Black and White Patients with Head and Neck Squamous Cell Carcinoma: Comparison of Data from the DOD Central Cancer Registry and SEER

BACKGROUND

Barriers to health care access may contribute to the poorer survival of Black patients with head and neck squamous cell carcinoma (HNSCC) than their White counterparts in the U.S. general population. The Department of Defense's (DOD) Military Health System (MHS) provides universal health care access to all beneficiaries with various racial backgrounds.

METHODS

We compared overall survival of patients with HNSCC by race in the MHS and the general population, respectively, to assess whether there were differences in racial disparity between the two populations. The MHS patients were identified from the DOD's Central Cancer Registry (CCR) and the patients from the U.S. general population were identified from the NCI's Surveillance, Epidemiology and End Results (SEER) program. For each cohort, a retrospective study was conducted comparing survival by race.

RESULTS

Black and White patients in the CCR cohort had similar survival in multivariable Cox regression models with a HR of 1.04 and 95% confidence interval (95% CI) of 0.81 to 1.33 after adjustment for the potential confounders. In contrast, Black patients in the SEER cohort exhibited significantly worse survival than White patients with an adjusted HR of 1.47 (95% CI = 1.43-1.51). These results remained similar in the subgroup analyses for oropharyngeal and non-oropharyngeal sites, respectively.

CONCLUSIONS

There was no racial difference in survival among patients with HNSCC in the MHS system, while Black patients had significantly poorer survival than White patients in the general population.

IMPACT

Equal access to health care could reduce racial disparity in overall survival among patients with HNSCC.

Temporal trends of women with oral cavity, base of tongue and lip cancers in Brazil: An ecological study covering mortality data from 1980 to 2018

OBJECTIVES

Obtaining robust evidence about the local mortality levels, trends and impact of oral cavity/base of tongue cancers and lip cancer, especially for women, is imperative in the fight against cancer. This descriptive retrospective ecological time-series study explored trends in oral cavity/base of tongue cancers and lip cancer mortality rates for women in Brazil from 1980 to 2018, by geographic region and anatomical location.

METHODS

The crude and age-adjusted annual mortality rates were obtained by sex, anatomical location and macro-regions of Brazil. The number of deaths from oral cavity/base of tongue cancers and lip cancers in Brazil was based on official population counts and estimates. The annual percentage change was calculated based on age-adjusted rates. Data set were analysed using the Joinpoint Regression program.

RESULTS

A total of 81,918 individuals died of oral cavity/base of tongue cancers and lip cancer between 1980 and 2018 in Brazil. The age-adjusted mortality rate for women was 0.47 and 0.57 per 100,000 in 1980 and 2018, respectively. The cumulative female mortality rates standardized by age were 0.01/100,000 for lip cancer and 0.5/100,000 for oral cavity and base of tongue cancers. A decrease in deaths related to oral cavity and base of tongue cancers was identified in the 1980s; however, over the last two decades, there has been an increase in the number of deaths of women with cancer at the base of tongue and neighbouring areas and on the floor of mouth. Importantly, Brazilian regions showed wide variability in trends of oral cavity, base of tongue and lip cancers rate and, in 2018, the regions with the highest rates were the Southeast, South and Northeast for both sexes and specifically for women. The North region showed the greatest recent significant upward trend.

CONCLUSIONS

During the last 38 years, Brazil has shown a significant increase in the trend of the mortality rate due to oral cavity/base of tongue and lip cancers in women. Preventive strategies with control of risk factors should be strongly emphasized in order to improve the survival rates of individuals with oral cavity/base of tongue and lip cancers.

Race and socioeconomic status interact with HPV to influence survival disparities in oropharyngeal squamous cell carcinoma

BACKGROUND

HPV-related oropharyngeal squamous cell carcinoma (OPSCC) is associated with a favorable prognosis, yet patients of color and low socioeconomic status (SES) continue to experience inferior outcomes. We aim to understand how the emergence of HPV has impacted race and SES survival disparities in OPSCC.

METHODS

A retrospective cohort of 18,362 OPSCC cases from 2010 to 2017 was assembled using the SEER (Surveillance, Epidemiology, and End Results) database. Cox proportional regression and Fine and Gray regression models were used to calculate hazard ratios (HRs) adjusting for race, SES, age, subsite, stage, and treatment.

RESULTS

Black patients had lower overall survival than patients of other races in HPV-positive and HPV-negative OPSCC (HR 1.31, 95% CI 1.13-1.53 and HR 1.23, 95% CI 1.09-1.39, respectively). Higher SES was associated with improved survival in all patients. Race had a diminished association with survival among high SES patients. Low SES Black patients had considerably worse survival than low SES patients of other races.

CONCLUSION

Race and SES interact variably across cohorts. High SES was protective of the negative effects of race, although there remains a disparity in outcomes among Black and non-Black patients, even in high SES populations. The persistence of survival disparities suggests that the HPV epidemic has not improved outcomes equally across all demographic groups.

A Systematic Review of Head and Neck Cancer Health Disparities: A Call for Innovative Research

OBJECTIVE

(1) Describe the existing head and neck cancer health disparities literature. (2) Contextualize these studies by using the NIMHD research framework (National Institute on Minority Health and Health Disparities). (3) Explore innovative ideas for further study and intervention.

DATA SOURCES

Ovid MEDLINE, Embase, Web of Science, and Google Scholar.

REVIEW METHODS

Databases were systematically searched from inception to April 20, 2020. The PRISMA checklist was followed (Preferred Reporting Items for Systematic Reviews and Meta-analyses). Two authors reviewed all articles for inclusion. Extracted data included health disparity population and outcomes, study details, and main findings and recommendations. Articles were also classified per the NIMHD research framework.

RESULTS

There were 148 articles included for final review. The majority (n = 104) focused on health disparities related to at least race/ethnicity. Greater than two-thirds of studies (n = 105) identified health disparities specific to health behaviors or clinical outcomes. Interaction between the individual domain of influence and the health system level of influence was most discussed (n = 99, 66.9%). Less than half of studies (n = 61) offered specific recommendations or interventions.

CONCLUSIONS

There has been extensive study of health disparities for head and neck cancer, largely focusing on individual patient factors or health care access and quality. This review identifies gaps in this research, with large numbers of retrospective database studies and little discussion of potential contributors and explanations for these disparities. We recommend shifting research on disparities upstream toward a focus on community and societal factors, rather than individual, and an evaluation of interventions to promote health equity.

Nomograms-based prediction of overall and cancer-specific survivals for patients diagnosed with major salivary gland carcinoma

Background

Major salivary glands carcinoma (MSGC) is a relatively rare cancer with diverse histological types and biological behavior. The treatment planning and prognosis prediction are challenging for clinicians. The aim of the current study was to establish a reliable and effective nomogram to predict the overall survival (OS) and cancer-specific survival (CSS) for MSGC patients.

Methods

Patients pathologically diagnosed with MSGC were recruited from Surveillance, Epidemiology, and End Results (SEER) database and randomly divided into training and validation groups (7:3 ratio). Univariate, multivariate Cox proportional hazard models, and least absolute shrinkage and selection operator (LASSO) regression were adopted for the selection of risk factors. Nomograms were developed using R software. The model performance was evaluated by drawing receiver operating characteristic (ROC), overtime C-index curves, and calibration curves. Harrell C-index, areas under the curves (AUC), and Brier score were also calculated. The decision curve analysis (DCA) was conducted to measure the net clinical benefit.

Results

A total of 11,362 patients were identified and divided into training (n=7,953) and validation (n=3,409) dataset. Sex, age, race, marital status, site, differentiation grade, American Joint Committee on Cancer (AJCC) stage, T/N/M stage, tumor size, surgery, and histological type were incorporated into the Cox hazard model for OS prediction after variable selection, while all predictors, except for marital status and site, were selected for CSS prediction. For 5-year prediction, the AUC of the nomogram for OS and CSS was 83.5 and 82.7 in the training and validation dataset, respectively. The C-index was 0.787 for OS and 0.798 for CSS in the validation group. The Brier score was 0.0153 and 0.0130 for OS and CSS, respectively. The calibration curves showed that the nomogram had well prediction accuracy. From the perspective of DCA, a nomogram was superior to the AJCC stage and TNM stage in net benefit. In general, the performance of the nomogram was consistently better compared to the AJCC stage and TNM stage across all settings.

Conclusions

The performance of the novel nomogram for predicting OS and CSS of MSGC patients was further verified, revealing that it could be used as a valuable tool in assisting clinical decision-making.

Travel distance is associated with stage at presentation and laryngectomy rates among patients with laryngeal cancer

BACKGROUND

The impact of travel distance on stage at presentation and management strategies of laryngeal squamous cell carcinoma (SCC) is unknown. We investigated this relationship.

METHODS

Retrospective review of patients with laryngeal SCC in the National Cancer Data Base from 2004 to 2016. Multivariate analysis determined relationships between travel distance, sociodemographic, geographic, and hospital factors. Logistic regression determined the influence of travel distance on T-stage and overall stage at presentation, and receipt of total laryngectomy.

RESULTS

Sixty thousand four hundred and thirty-nine patients were divided into groups based on distance to treatment: short (<12.5 miles); intermediate (12.5-49.9 miles); and long (>50 miles). Increased travel was associated with T4-stage (intermediate vs. short OR 1.11, CI 1.04-1.18, p = 0.001; long vs. short OR 1.5, CI 1.36-1.65, p < 0.001), and total laryngectomy (intermediate vs. short OR 1.40, CI 1.3-1.5, p ≤ 0.001; long vs. short OR 2.52, CI 2.28-2.79, p ≤ 0.001). In T4 disease, total laryngectomy was associated with improved survival compared to nonsurgical treatment (HR 0.75, CI 0.70-0.80, p < 0.001) regardless of travel distance.

CONCLUSION

Longer travel distance to care is associated with increased stage at presentation, rate of laryngectomy, and improved survival in advanced laryngeal SCC. Health policy efforts should be directed towards improving early access to diagnosis and care.

Third-Year Medical Students' Self-perceived Knowledge About Health Disparities and Community Medicine

INTRODUCTION

Medical providers' attitudes about caring for vulnerable populations have significant implications for persistent health disparities. Therefore, assessing medical students' self-perceived knowledge about community-based medicine and care for underserved populations can provide insights for improving health care delivery to achieve health equity. We evaluated third-year medical students' perceptions of their knowledge and attitudes about community medicine, and addressing health care needs of vulnerable populations.

METHODS

From October 2, 2017 to July 12, 2019, third-year medical students at a private, urban medical school were asked to complete an assessment survey during their family medicine clerkship orientation. The anonymous survey assessed students' self-perceived knowledge and attitudes regarding community medicine and care of vulnerable populations. We examined differences in survey responses by student demographics.

RESULTS

A total of 401 students participated in the survey; 50.5% of respondents agreed that they had knowledge to assess health literacy of the patient, while only 22.2% of students agreed that they had knowledge about how to identify a community and conduct a community health needs assessment. Additionally, students agreed with being most comfortable providing care to adolescents (73.0%) and the elderly (69.5%), and that they were least comfortable caring for incarcerated individuals (31.7%) and immigrants/refugees (44.1%).

CONCLUSION

Assessment of learners' self-perceived knowledge can help highlight areas for educational interventions. Our findings suggest the need for improving medical student knowledge in areas of community health and health care for specific vulnerable populations.

A competing risk nomogram for predicting cancer-specific death of patients with buccal mucosa cancer

OBJECTIVES

Our aim was to develop and validate a competing risk nomogram to determine the probability of cancer-specific death in buccal mucosa cancer (BMC) patients.

MATERIALS AND METHODS

We examined the records of BMC patients in the Surveillance, Epidemiology, and End Results (SEER) Program and First Affiliated Hospital of Nanchang University (China). We adopted the cumulative incidence function and Fine-Gray proportional hazards model based on univariate and multivariate analyses by R-software to identify the risk factors associated with cancer-specific death. Subsequently, a nomogram was developed and validated to predict the 3- and 5-year probability of cancer-specific death.

RESULTS

In 1,286 BMC patients identified from SEER database, cumulative incidences of cancer-specific death after diagnosis were 33.4% and 35.5% for 3 and 5 years, respectively. In the training cohort (n = 902) from SEER database, the Fine-Gray model indicated that age, Tumor Node Metastasis (TNM) stages, grade, surgery, and histological type were independent risk factors associated with cancer-specific death, based on which a prognostic nomogram was developed. In the internal validation cohort from SEER database (n = 384) and the external validation cohort from our medical center (n = 174), the nomogram was well calibrated and showed remarkable prediction performance.

CONCLUSION

The nomogram created herein may prove to be a good assistant tool for assessing the prognosis of BMC patients.

Racial Disparity in the Clinical Risk Assessment

Implicit bias has been shown to impact care in many medical specialties. However, few studies examine its impact on psychiatry. Psychiatrists, especially in the Emergency Room, must assess patients' level of dangerousness when determining an appropriate disposition. For a variety of reasons, clinical understanding of dangerousness may be highly vulnerable to implicit bias. This study aims to determine if there is implicit bias in a psychiatric emergency room setting when determining disposition. Patients were included if their race was recorded as White or Black and if their disposition was either admitted to the inpatient psychiatric unit or discharged to the community (N = 743). Analyses were performed to evaluate associations between race, age, gender and disposition. No statistically significant difference in admission rates between races was found. While this could indicate genuine racial parity, there are many factors that may have masked racial disparity and could warrant further study.

Distance Traveled to Head and Neck Cancer Provider: A Measure of Socioeconomic Status and Access

Objective

Improved head and neck cancer survival has been associated with traveling farther distances for treatment, potentially due to patients seeking higher-quality facilities. This study investigates the role of both facility and confounding patient factors on this relationship.

Study Design

Review of national registry data.

Setting

National Cancer Database.

Subjects and Methods

Adults with head and neck cancer diagnosed from 2004 to 2014 were identified. Overall survival was compared among distance-to-facility quartiles via univariate and multivariate survival models. Then, the analysis was stratified by facility and patient factors, and the association between distance and survival was compared among strata.

Results

Overall survival was worst in the shortest-distance quartile (<5 miles; median survival, 80.7 months; 95% CI, 79.2-82.3), while other distance groups showed similar survival (range, 96.4-104 months). This finding remained in the multivariate model (adjusted hazard ratio vs first distance quartile: 0.88; 95% CI, 0.87-0.89). The association between survival and distance persisted in all subgroups when stratified by facility volume and type (adjusted hazard ratio range, 0.82-0.91), suggesting that facility quality does not fully account for this association. When stratified by income, distance remained statistically associated with survival but with a smaller effect size than that of income.

Conclusion

The association between distance to treating facility and head and neck cancer survival is limited to patients with worse survival outcomes living within 5 miles of the facility and is not fully explained by measures of facility quality.

A contemporary analysis of racial disparities in recommended and received treatment for head and neck cancer

BACKGROUND

Racial disparities in squamous cell carcinoma of the head and neck (HNSCC) negatively affect non-Hispanic black (NHB) patients. This study was aimed at understanding how treatment is prescribed and received across all HNSCC subsites.

METHODS

With the National Cancer Database, patients from 2004 to 2014 with surgically resectable HNSCCs, including tumors of the oral cavity (OC), oropharynx (OP), hypopharynx (HP), and larynx (LX), were studied. The treatment received was either upfront surgery or nonsurgical treatment. Treatment patterns were compared according to race and subsite, and how these differences changed over time was evaluated.

RESULTS

NHB patients were less likely than non-Hispanic white (NHW) patients to receive surgery across all subsites (relative risk [RR] for OC, 0.87; RR for OP, 0.75; RR for HP, 0.73; RR for LX, 0.87; all P values <.05). They were also more likely to refuse a recommended surgery (RR for OC, 1.50; RR for OP, 1.23; RR for HP, 1.23; RR for LX, 1.34), and this difference was significant except for HP. NHB patients were more likely to not be offered surgery across all subsites (RR for OC, 1.38; RR for OP, 1.07; RR for HP, 1.05; RR for LX, 1.03; all P values <.05). Rates of surgery increased and rates of not being offered surgery declined for both NHB and NHW patients from 2004 to 2014, but the absolute disparities persisted in 2014.

CONCLUSIONS

Across all HNSCC subsites, NHB patients were less likely than NHW patients to be recommended for and receive surgery and were more likely to refuse surgery. These differences have closed over time but persist. Enhanced shared decision making may improve these disparities.

Socioeconomic Predictors of Pituitary Surgery

Background: There exists a lack of data on the effect of socioeconomic status (SES) on outcomes for pituitary tumors, which have been associated with significant morbidity. The goal of this population-level study is to investigate the role of SES on receiving treatment and survival in patients with pituitary tumors.

Methods: The Surveillance, Epidemiology, and End Results (SEER) program database from the National Cancer Institute was used to identify patients diagnosed with pituitary tumors between 2003 and 2012. SES was determined using a validated composite index. Race was categorized as Caucasian and non-Caucasian. Treatment received included surgery, radiation, and radiation with surgery. Odds of receiving surgery and survival probability were analyzed using multivariate logistic regression and Cox proportional hazards model, respectively.

Results: A total of 25,802 patients with pituitary tumors were identified for analysis. High SES tertile (odds ratio (OR) = 1.095; 95% confidence interval (CI) [1.059, 1.132]) and quintile (OR = 1.052; 95% CI [1.031, 1.072]) were associated with higher odds of receiving surgery (p<0.0001). Caucasian patients had higher odds of receiving surgery when compared to non-Caucasian patients (OR = 1.064; 95% CI [1.000, 1.133]; p<0.05). Neither SES nor race were significant predictors of survival probability.

Conclusion: Socioeconomic status and race were found to be associated with higher odds of receiving surgery for pituitary tumors, and thus serve as independent predictors of surgical management. Further studies are required to investigate possible causes for these findings.

Racial disparities in the choice of definitive treatment for squamous cell carcinoma of the oral cavity

BACKGROUND

Definitive surgery is recommended for oral cavity squamous cell carcinoma (SCC). The purpose of this study was to present our assessment of the disparities in treatment selection for oral cavity SCC.

METHODS

Non-Hispanic white and non-Hispanic black patients with oral cavity SCC were identified in the National Cancer Database (NCDB). Regression models were used to estimate relative risk (RR) of receiving surgery and absolute difference between non-Hispanic white and non-Hispanic black patients.

RESULTS

There were 82.3% of non-Hispanic white patients who received surgery, compared to 64.2% of non-Hispanic black patients (P < .001). The non-Hispanic black patients were less likely to receive surgery than non-Hispanic white patients (RR 0.87) with an absolute difference of 10.9%. The non-Hispanic black patients were significantly more likely to not be offered surgery (RR 1.42) and to refuse recommended surgery (RR 1.38) but not have a contraindication to surgery (RR 1.17).

CONCLUSION

The non-Hispanic black patients are less likely to receive or be recommended surgery for oral cavity SCC and are more likely to refuse surgery. Further study is needed to identify strategies to close this disparity.

The Health System and Policy Implications of Changing Epidemiology for Oral Cavity and Oropharyngeal Cancers in the United States From 1995 to 2016

Oral cavity and oropharyngeal cancers are typically grouped under the general term, "oral cancer." Yet, the incidence of oropharyngeal cancers is increasing in the United States, while the incidence of oral cavity cancers has declined. These 2 distinct but conflated groups of oral cancers are attributed to different risk factors. Incidence and survival trends were examined across US population groups and by anatomical subsite. Disparities in incidence and survival by sex, race/ethnicity, and subsite were identified. Risk factors are complex, interactive, and not fully identified. Cancer control research illustrates health disparities in access to care and patient outcomes. Database and supplemental searches yielded 433 articles published between 1995 and 2016 characterizing aspects of oral cancer epidemiology relating to incidence, survival, risk, disparities, and cancer control. Oral cavity cancer survival in black men remains the most intractable burden. Although understanding of oral cancer etiology is improving, application to policy is limited. Cancer control efforts are diverse, sporadic, limited in scope, and generally lacking in success, and they need stratification by oral cavity cancers/oropharyngeal cancers. Further intervention and epidemiologic research, improved workforce capacity, and integrated care delivery are identified as important directions for public health policy. Sustained, multilevel campaigns modeled on tobacco control success are suggested.

Patient and surgeon factors explain variation in the frequency of frontal sinus surgery

OBJECTIVES/HYPOTHESIS

Ethmoidectomy may be sufficient to address frontal sinus disease, but some surgeons may perform frontal recess dissection initially. Our objectives were to describe patient-associated factors with frequency of frontal sinus surgery and analyze the association with provider volume.

STUDY DESIGN

Retrospective cohort analysis.

METHODS

The 2013 State Ambulatory Surgery Databases of New Jersey, Florida, and Kentucky were queried to identify adults who underwent anterior ethmoidectomy or total ethmoidectomy using standard Current Procedural Terminology codes. Univariate and multivariate logistic regression was performed to determine the odds of undergoing concurrent frontal sinus exploration along with ethmoidectomy, adjusting for age, gender, race, insurance type, median income, and the metropolitan designation by zip code. We also examined provider and center volume, use of image guidance, and total charges.

RESULTS

There were 10,564 ethmoidectomies, of which 4,726 had concurrent frontal sinus surgery. Women were less likely to have frontal sinus surgery (P = .0011), as were patients with Medicare (P = .007). Hispanics were more likely to have frontal sinus surgery (P = .0003). Surgeons with higher surgical volumes were more likely to perform frontal sinus surgery; it was also more likely to be performed in centers where more sinus procedures occurred (P < .0001, both).

CONCLUSIONS

Variation in the utilization of frontal sinus surgery is associated with patient sex, ethnicity, insurance status, geography, as well as provider and hospital volumes. These data support the idea that nonclinical factors may influence the treatment of frontal sinus disease.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:2008-2014, 2018.

Impact of socioeconomic status on survival of colorectal cancer patients

Socioeconomic status (SES) has an impact on the survival of various cancers, but it has not been fully understood in colorectal cancer (CRC). The Surveillance, Epidemiology and End Results database was adopted to detect the role of SES in the survival outcomes of CRC. A total of 184,322 eligible patients were included and SES status was analyzed. The multivariable analysis showed that Non-Hispanic Black (HR, 1.20; 95% CI, 1.15-1.24), being widowed (HR, 1.04; 95% CI, 1.01-1.07), any Medicaid (HR, 1.36; 95% CI, 1.33-1.39) and the lowest education level group patients had relative poorer prognosis. Besides, sex, tumor location, age, differentiation level and American Joint Committee on Cancer stage also had significant effects on overall survival of CRC. The individuals were further divided into five groups according to the number of survival-adverse factors. All of the four groups containing adverse factors showed impaired survival outcomes compared with the group containing no adverse factor.

Trends and the utilization of transoral robotic surgery with neck dissection in New York State

OBJECTIVES

The timing of neck dissection (ND) in relation to transoral robotic surgery (TORS) is controversial. This study identifies local practice patterns and economic and social access disparities during adoption of TORS.

STUDY DESIGN

We analyzed utilization patterns of TORS and ND using the New York Statewide Planning and Research Cooperative System all-payer administrative database. Statewide head and neck cancer incidence from the Centers for Disease Control and Prevention (Bethesda, MD) was used to control for overall cancer incidence.

METHODS

Patient demographic, insurer, and institutional information of patients aged ≥ 18 (n = 225) years from 2008 to 2012 were evaluated. Temporal trends were analyzed with Poisson regression models for counts.

RESULTS

Transoral robotic surgery was used in 386 procedures, and 58.3% involved ND (n = 225). Concurrent ND was most frequent (n = 173), followed by staged TORS then ND (n = 44) and staged ND preceding TORS (n = 8). Caucasians were more likely than Blacks/Hispanics to undergo TORS (P = 0.03). Medicare (26.2%) and Medicaid (2.7%) payers comprised a minority of patients compared to those commercially insured (70.2%). Only 20% of patients received care outside a major urban center, and these patients were more likely to undergo staged procedures, P = 0.02. Staged procedures resulted in higher mean hospital charges (P = 0.02).

CONCLUSION

Concurrent TORS + ND, the most common practice in New York, is more cost-effective. Patients without commercial insurance, patients in racial minorities, or patients residing outside major urban centers may be targeted to improve care access disparities with respect to minimally invasive TORS technology.

LEVEL OF EVIDENCE

2c. Laryngoscope, 127:1571-1576, 2017.

Estudio epidemiológico del cáncer bucal en Colombia 1989-2008

<p>Antecedentes. El incremento del tabaquismo, considerado como un factor de riesgo en la carcinogénesis bucal, ha impedido la disminución de la incidencia del cáncer y precáncer bucal en las últimas décadas. Objetivo. Estudiar la incidencia del cáncer bucal por demanda de atención en Colombia entre los años 1989 y 2008. Materiales y métodos. Estudio descriptivo-retrospectivo que compila los datos de incidencia por demanda de atención en el registro epidemiológico del Instituto Nacional de Cancerología. Se categorizó la información referente a cáncer bucal de acuerdo al género. Resultados. En el año 1999 hubo un notable incremento de cáncer bucal, alcanzando 3.05% en ambos sexos. El sexo masculino resultó el más afectado. Conclusión. Se requiere un mayor compromiso de los odontólogos en el diagnóstico precoz de lesiones a través de un minucioso examen físico.</p>

When a patient's ethnicity is declared, medical students' decision-making processes are affected

BACKGROUND

Disparity in health status and healthcare outcomes is widespread and well known. This holds true for Indigenous peoples in many settings including Australia and Hawaii. While multi-factorial, there is increasing evidence of health practitioner contribution to this disparity. This research explored senior medical students' clinical decision-making processes.

METHODS

A qualitative study was conducted in 2014 with 30 final year medical students from The University of Melbourne, Australia, and The John Burns Medical School, Hawaii, USA. Each student responded to questions about a paper-based case, first in writing and elaborated further in an interview. Half the students were given a case of a patient whose ethnicity was not declared; the other half considered the patient who was Native Hawaiian or Australian Aboriginal. A systematic thematic analysis of the interview transcripts was conducted.

RESULTS

The study detected subtle biases in students' ways of talking about the Indigenous person and their anticipation of interacting with her as a patient. Four main themes emerged from the interview transcripts: the patient as a person; constructions of the person as patient; patient-student/doctor interactions; and the value of various education settings. There was a strong commitment to the patient's agenda and to the element of trust in the doctor-patient interaction.

CONCLUSION

These findings will help to advance medical curricula so that institutions graduate physicians who are increasingly able to contribute to equitable outcomes for all patients in their care. The study also draws attention to subtle biases based on ethnicity that may be currently at play in physicians' practices.

A Contemporary Analysis of Surgical Trends in the Treatment of Squamous Cell Carcinoma of the Oropharynx from 1998 to 2012: A Report from the National Cancer Database

BACKGROUND

This study examined surgical trends for oropharynx squamous cell carcinoma (OPC) from 1998 to 2012, with a post-2009 focus coinciding with the Food and Drug Administration (FDA) approval of transoral robotic surgery (TORS).

METHODS

Using the National Cancer Data Base, the study analyzed 84,449 patients with stage I-IVB OPC. χ (2) tests and logistic regression models were used to examine surgical trends.

RESULTS

The use of surgery decreased from 41.4 % in 1998 to 30.4 % in 2009 (p < 0.001). The surgical trends reversed and in 2012 increased to 34.8 % (p < 0.001). There was much variation in surgery in 2012 between American Joint Committee on Cancer stages, with 80.2 % of stage I patients receiving surgery compared with 54.0 % of stage II patients, 36.8 % of stage III patients, and 28.5 % of stage IV patients (p < 0.001). Black patients with high socioeconomic status (SES) showed lower use of surgery (25.3 %) compared to low SES white (32.3 %) and low SES Hispanic patients (27.3 %) (p < 0.001). The highest surgical rates were noted in the West North Central region and lowest rates were observed in the New England and South Atlantic regions. Between 2009 and 2012, independent predictors of surgical treatment included young age, female gender, white or Hispanic race, high SES, private insurance, academic hospitals, hospitals in the West North Central region, residence more than 75 miles from the hospital, increasing comorbidities, stage I disease, and tonsil origin (all p < 0.05).

CONCLUSION

Since FDA approval of TORS in 2009, surgical rates have increased with multiple socioeconomic and regional factors affecting patient selection. This study provides a basis for further investigation into factors involved in decision making for OPC patients.

Impact of African-American race on presentation, treatment, and survival of head and neck cancer

OBJECTIVES

To determine the associations between African American race and stage at diagnosis, receipt of definitive therapy, and cancer-specific mortality among patients with head and neck cancer.

MATERIALS AND METHODS

The Surveillance, Epidemiology and End Results (SEER) database was used to conduct a retrospective study on 34,437 patients diagnosed with head and neck cancer from 2007 to 2010. Multivariable logistic regression analyses were applied to determine the impact of race on cancer stage at presentation (metastatic vs. non-metastatic) and receipt of definitive treatment. Fine and Gray competing-risks regression modeled the association between race and head and neck cancer-specific mortality.

RESULTS

African Americans were more likely to present with metastatic cancer compared to non-African Americans (Adjusted Odds Ratio [AOR] 1.76; CI 1.50-2.07; P<0.001). Among patients with non-metastatic disease, African Americans were less likely to receive definitive treatment (AOR 0.63; CI 0.55-0.72; P<0.001). After a median follow-up of 19months, African Americans with non-metastatic disease were found to have a higher risk of head and neck cancer specific mortality (AHR 1.19; 95% CI 1.09-1.29; P<0.001).

CONCLUSION

African Americans with head and neck cancer are more likely to present with metastatic disease, less likely to be treated definitively, and are more likely to die from head and neck cancer. The unacceptably high rates of disparity found in this study should serve as immediate targets for urgent healthcare policy intervention.

Incidence and risk factors for and the effect of a program to reduce the incidence of surgical site infection after cardiac surgery

BACKGROUND

Surgical site infection (SSI) after cardiac surgery (CS) is a serious complication that increases hospital length of stay (LOS), has a substantial financial impact, and increases mortality. The study described here was done to evaluate the effect of a program to reduce SSI after CS.

METHODS

In January 2007, a multi-disciplinary CS infection-prevention team developed guidelines and implemented bundled tactics for reducing SSI. Data for all patients who underwent CS from 2006-2008 were used to determine whether there was: 1) A difference in the incidence of SSI in white patients and those belonging to minority groups; 2) a reduction in SSI after intervention; and 3) a statistically significant difference in the incidence of SSI in the third quarter of each year as compared with the other quarters of the year.

RESULTS

Of 3,418 patients who underwent CS; 1,125 (32.9%) were members of minority groups and 2,293 (67.1%) were white. Eighty (2.3%) patients developed SSI. There was no significant difference in the incidence of SSI in non-Hispanic white patients and all others (2.1% vs. 2.8%, p=0. 42). The incidence of SSI decreased significantly from 2006 (3.0%) to 2007 (2.5%) and 2008 (1.4%), (p=0.03). Surgical site infection occurred more often in the third quarter of each of the years of the study than in other quarters of each year (3.3 vs. 2.0%, p=0.038).

CONCLUSIONS

Implementation of a program to reduce SSI after CS was associated with a lower incidence of SSI across all racial and ethnic groups and over time, but was not associated with a lower incidence of SSI in the third quarter of each year than in the other quarters.

Gender and racial inequalities in trends of oral cancer mortality in Sao Paulo, Brazil

OBJECTIVE:To analyse recent trends in oral cancer mortality, focusing specifically on differences concerning gender and race.METHODS:Official information on deaths and population in the city of Sao Paulo, 2003 to 2009, were used to estimate mortality rates from oral cancer (C00 to C10, International Classification of Diseases, 10th Revision), adjusted for age and stratified by gender (females and males) and race (blacks and whites). The Prais-Winsten auto-regression procedure was used to analyse the time series.RESULTS:During the study period, 8,505 individuals living in the city of Sao Paulo died of oral cancer. Rates increased for females (rate of yearly increase = 4.4%, 95%CI 1.4;7.5), and levelled off for men, which represents an inversion of previous trends among genders in the city. Increases were identified for blacks, with a high rate of yearly increase of 9.1% (95%CI 5.5;12.9), and levelled off for whites. Oral cancer mortality in blacks almost doubled during the study period, and surpassed mortality in whites for almost all categories.CONCLUSIONS:Mortality presented a higher increase among women than in men, and it doubled among backs. The surveillance of trends of oral cancer mortality across gender and racial groups may contribute to implementing socially appropriate health policies, which concurrently reduce the burden of disease and the attenuation of unfair, avoidable and unnecessary inequalities in health.

Under the radar: how unexamined biases in decision-making processes in clinical interactions can contribute to health care disparities

Several aspects of social psychological science shed light on how unexamined racial/ethnic biases contribute to health care disparities. Biases are complex but systematic, differing by racial/ethnic group and not limited to love-hate polarities. Group images on the universal social cognitive dimensions of competence and warmth determine the content of each group's overall stereotype, distinct emotional prejudices (pity, envy, disgust, pride), and discriminatory tendencies. These biases are often unconscious and occur despite the best intentions. Such ambivalent and automatic biases can influence medical decisions and interactions, systematically producing discrimination in health care and ultimately disparities in health. Understanding how these processes may contribute to bias in health care can help guide interventions to address racial and ethnic disparities in health.