Head and Neck Cancer Survival Disparities by Race and Rural-Urban Context

Effects of Rurality, Socioeconomic Status, and Race on Head and Neck Squamous Cell Carcinoma Outcomes

OBJECTIVE

To examine how rural residence interacts with SES and race/ethnicity relative to Head and neck squamous cell carcinoma (HNSCC) treatment delay and outcomes.

METHODS

The SEER database was queried for patients aged ≥18 with HNSCC. Out of 164,337 cases, 126,052 remained after exclusions for missing data. Statistical tests performed included Chi-squared tests, log-binomial regression models, and parametric accelerated failure time (AFT) models, with a significance level of α < 0.05.

RESULTS

About 38% of patients residing in lowest SES census tracts were rural, whereas over 98% of patients from highest SES tracts were urban. Delayed treatment was associated with shorter median survival [aTR = 0.968, 95% confidence interval (CI): 0.939, 0.999]. Risk for treatment delay increased with decreasing SES and was greater for those with minoritized race/ethnicity status. Rurality was associated with a lower risk [aRR: 0.917, 95% CI: 0.892, 0.946] of treatment delays but was not predictive for patient survival (aTR: 1.019 [0.978, 1.061]). Cancer-specific mortality increased with decreasing SES and was higher in patients with minoritized race/ethnicity status.

CONCLUSION

Rurality was associated with decreased risk for treatment delay but not with worse survival relative to urban residence, whereas low SES and minority status remained predictive for poor outcome regardless of geographic context (level of evidence: 4). Although these findings argue against HNSCC survival deficits specific to rural populations, there remains concern regarding potential care shortfalls in rural populations not detected in this sample. Confirmatory patient-level analysis should be prioritized to optimize support along the rural/urban divide.

LEVEL OF EVIDENCE

4 Laryngoscope, 135:1715-1723, 2025.

Demographics and Trends in Outpatient Surgery for Laryngeal Cancer: 2016-2021

OBJECTIVE

To analyze the utilization patterns of outpatient laryngoscopic excision procedures for laryngeal cancer in the United States, examining procedural costs and patient demographics to identify disparities in healthcare access.

STUDY DESIGN

Retrospective cohort study.

SETTING

National Ambulatory Surgery Sample database of major ambulatory surgeries in the United States, 2016-2021.

METHODS

Encounters for endoscopic resection of laryngeal cancers were identified focusing on patient demographics and procedural costs. Analysis was performed regarding trends over time.

RESULTS

Of 11,371 encounters in 2016-2021, patients were mostly male (82.6%), White (75.3%), and living in metropolitan areas with greater than 1 million residents (54.1%), with an even distribution between income quartiles. Predictors of utilization at urban teaching hospitals progressively decreased in patients residing in smaller metropolitan areas (250-999,000 residents (odds ratio [OR] = 0.451, P ≤ .0001) and 50-249,000 residents (OR = 0.193, P ≤ .0001). Higher utilization was found in non-White patients (Black [OR = 1.673, P = .0075], Hispanic [OR = 1.752, P = .0118]), and those with patients with higher income (2nd quartile [OR = 1.411, P = .0058], 3rd quartile [OR = 2.017, P ≤ .0001], and 4th quartile [OR = 4.422, P < .0001]). These findings were consistent on multivariate analysis, however belonging to a racial minority lost significance (Black patients [P = .0508], Hispanic [P = .3008]).

CONCLUSION

There are existing disparities in endoscopic resection of laryngeal cancers. Our findings add to the literature underscoring the importance of expanding access to minimally invasive laryngeal preserving surgical treatment.

Geospatial Mapping of Head and Neck Cancer Research: Assessing Access, Disparities, and Characteristics of Head and Neck Cancer Clinical Trials Across the United States

OBJECTIVE

To report geographic distribution and characteristics of head and neck cancer (HNC) clinical trials in the United States.

METHODS

We conducted a retrospective analysis of U.S. HNC clinical trials searching ClinicalTrials.gov from January 1, 2017 to December 31, 2021 using the terms "head and neck cancer" or "head and neck neoplasms."

RESULTS

A total of 381 clinical trials met inclusion criteria with 2181 trial opportunities, which were correlated with population density. Of the U.S. population, 72% live within a 25-mile radius of trials. California, Pennsylvania, and New York had the greatest number of clinical trial entries. The majority of patients living more than 25 miles from an HNC clinical trial site are located in rural areas. One hundred sixty-five (43.3%) trials were about systemic therapy, of which 138 (83.6%) involved targeted immunotherapy. There were 286 unique principal investigators. One hundred six (37.1%) were females and 180 (62.9%) were males.

CONCLUSIONS

We demonstrate disparity in the geographic distribution of HNC trials favoring densely populated urban areas, which may limit patient access due to travel burden. Studies are skewed towards immunotherapy drug trials, with fewer radiation and surgery investigations.

LEVEL OF EVIDENCE

Level III.

Socioeconomic disparities: a more important risk factor for advanced-stage oral cancer in Florida than smoking?

PURPOSE

To explore the associations between sociodemographic factors with advanced-stage oral cavity cancer (OCC) presentation among Floridians.

METHODS

Demographic and cancer data on OCC patients (n = 7,826) diagnosed between 2010 and 2017 were retrieved from the Florida Cancer Data System (FCDS). Census tract median income and percentage of population with a bachelor's degree or higher were used to infer income and education. Pearson's chi-square tests of independence were used to compare sociodemographic factors between racial/ethnic groups and staging groups. Multinomial logistic regression analyzed predictors of advanced disease. Incidence and percent late-stage diagnosis versus income were mapped using ArcGIS Pro.

RESULTS

Among 5,252 cases analyzed: 5.7% were Black, 82.4% White Non-Hispanic, 61.5% male, 63.3% publicly insured, 6.5% uninsured, 58.7% current or former smokers, and 73.0% urban residents. Black patients were more likely to present with advanced disease, be single/unmarried, uninsured, and less likely to be former smokers. Male sex, Black race, non-married status, no insurance, Medicaid, VA/military insurance, and lower educational status were associated with increased risk of regional vs. early disease in multivariable analysis (MVA) (p < 0.05). These factors, in addition to Medicare, were associated with distant disease in MVA. Geospatial mapping revealed higher rates of regional and distant disease presentation in the Tampa Bay and Orlando areas.

CONCLUSION

Black race, male sex, non-married status, lower education, Medicaid, VA/Military insurance and no insurance were associated with advanced OCC in Florida. Smoking status was not associated with advanced disease presentation after adjusting for sociodemographic variables.

Addressing oral cancer inequalities: a multifaceted approach to equitable healthcare

Oral cancer remains a persistent health challenge globally, with rising incidence and flat survival rates, particularly among disadvantaged populations. This paper explores the socioeconomic, ethnic and cultural factors contributing to inequalities in oral cancer care, such as limited access to healthcare, lower education levels, financial constraints and systemic disadvantages based on ethnicity and cultural practices. Addressing these inequalities requires a multi-faceted approach, including community outreach, patient education and policy advocacy.Effective strategies include mobile clinics, free screening events, culturally sensitive educational materials, digital tools and social media outreach. Integrating telehealth services, artificial intelligence for early diagnosis, community-based participatory research and microfinance initiatives are also crucial. Furthermore, improving health literacy and promoting preventive behaviours are essential steps towards mitigating these inequalities.Public health education and social services must collaborate to enhance access to dental care, ensuring better outcomes across all populations, regardless of socioeconomic or ethnic background. This paper highlights the role of dental professionals in reducing inequalities and promoting oral health equity through innovative and comprehensive strategies.

Head and neck cancer mortality in the United States: Regional differences in hospice use and place of death

BACKGROUND

With more than 15,000 annual deaths from head and neck cancer (HNC), an important aspect of end-of-life care for these patients is place of death. Recent evidence suggests an increasing preference for home/hospice at end of life; however, it is unclear whether there is variation in home/hospice use based on region or urban status. We described differences in the place of death of HNC patients based on their region and urban status.

METHODS

Using the CDC WONDER (Wide-Ranging Online Data for Epidemiologic Research) database for HNC mortality (1999 to 2019), place of death was dichotomized as home/hospice vs. other, by Health and Human Services (HHS) region (Regions 1-10), and by urbanization status. Multivariable logistic regression analyses estimated odds of place of death being home/hospice, and being urban/metro, adjusting for both clinical and nonclinical variables.

RESULTS

Over the study period, there were 260,630 deaths, 47.4% of which were at home or hospice. Compared to patients in New England/Region 1 (CT, ME, MA, NH, RI, and VT), HNC patients were more likely to die at home/hospice in the Pacific Northwest/Region 10 (AK, ID, OR, WA) (aOR (1.73; 95% CI: 1.64, 1.83) and less likely in the Eastern Section/Region 2 (NJ, NY, PR, VI) (aOR 0.93; 95% CI: 0.89, 0.97). Further, large central metro areas had significantly lower rates of dying at home/hospice than did all other settings.

CONCLUSION

Patients in moderately urban areas were reported to have the greatest use of hospice services and at-home death; patients in the HHS Region representing Alaska, Idaho, Oregon, and Washington were also found to have the highest rates of use. These differences in hospice care should be considered when clinicians counsel patients on their end-of-life options.

An Analysis of the Otolaryngology Workforce in Pennsylvania

Objective

This study aims to analyze the distribution of otolaryngologists between urban and rural counties in Pennsylvania.

Study Design

Retrospective database.

Setting

American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) database and Centers for Medicare and Medicaid Services (CMS) Database.

Methods

The AAO-HNS database (Entnet.org) and the CMS Database were used to identify otolaryngologists, their primary location, and their state of training. The 2023 Rural-Urban Continuum Codes were used to classify metropolitan (codes 1-3) and nonmetropolitan counties (codes 4-9) and determine county populations.

Results

A total of 388 otolaryngologists were identified across 67 Pennsylvania counties (33 metropolitan, 34 nonmetropolitan), 80% of which were male. There were 354 otolaryngologists in metropolitan counties serving 11.2 million people, with an average of 2.4 otolaryngologists per 100,000 people (/100 k). The majority of otolaryngologists (n = 235, 60.6%) are located in counties designated by code 1. There were 34 otolaryngologists in nonmetropolitan counties serving 1.8 million people, with an average of 2.4 otolaryngologists/100 k. Montour County (code 6) is home to a large academic center and accounts for 14/34 otolaryngologists in the nonmetropolitan counties. With the exception of Montour County, the remaining nonmetropolitan counties averaged 1.0 otolaryngologist/100 k. Only 3 metropolitan counties did not have otolaryngologists compared to 19 nonmetropolitan counties without otolaryngologists. Most otolaryngologists received their residency training in Pennsylvania (n = 177). New York (n = 35) and Maryland (n = 24) were the second most common states for training.

Conclusion

There is a lack of otolaryngologists in rural counties of Pennsylvania, except in counties home to large academic centers.

Impact of Adjuvant Radiotherapy Setting on Quality-of-Life in Head and Neck Squamous Cell Carcinoma

OBJECTIVE

To determine differences in post-treatment QoL across treatment settings in patients receiving adjuvant radiation therapy for head and neck squamous cell carcinoma (HNSCC).

METHODS

This was a prospective observational cohort study of patients with HNSCC initially evaluated in a head and neck surgical oncologic and reconstructive clinic at an academic medical center (AMC). Participants were enrolled prior to treatment in a prospective registry collecting demographic, social, and clinical data. Physical and social-emotional QoL (phys-QoL and soc-QoL, respectively) was measured using the University of Washington-QoL questionnaire at pre-treatment and post-treatment visits.

RESULTS

A cohort of 177 patients, primarily male and White with an average age of 61.2 ± 11.2 years, met inclusion criteria. Most patients presented with oral cavity tumors (n = 132, 74.6%), had non-HPV-mediated disease (n = 97, 61.8%), and were classified as Stage IVa (n = 72, 42.8%). After controlling for covariates, patients treated at community medical centers (CMCs) reported a 7.15-point lower phys-QoL compared with those treated at AMCs (95% CI: -13.96 to -0.35, p = 0.040) up to 12 months post-treatment. Additionally, patients who were treated at CMCs had a 5.77-point (-11.86-0.31, p = 0.063) lower soc-QoL score compared with those treated at an AMC, which was not statistically significant.

CONCLUSION

This study revealed that HNSCC patients treated with radiation at AMCs reported significantly greater phys-QoL in their first-year post-treatment compared to those treated at CMCs, but soc-QoL did not differ significantly. Further observational studies are needed to explore potential factors, including treatment planning and cancer resource engagement, behind disparities between AMCs and CMCs.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:3645-3655, 2024.

Characterization of a Diverse Set of Conditionally Reprogrammed Head and Neck Cancer Cell Cultures

OBJECTIVE

To establish and characterize a diverse library of head and neck squamous cell cancer (HNSCC) cultures using conditional reprogramming (CR).

METHODS

Patients enrolled on an IRB-approved protocol to generate tumor cell cultures using CR methods. Tumor and blood samples were collected and clinical information was recorded. Successful CR cultures were validated against banked reference tumors with short tandem repeat genotyping. Cell morphology was archived with photodocumentation. Clinical and demographic factors were evaluated for associations with successful establishment of CR culture. Human papilloma virus (HPV) genotyping, clonogenic survival, MTT assays, spheroid growth, and whole exome sequencing were carried out in selected cultures.

RESULTS

Forty four patients were enrolled, with 31 (70%) successful CR cultures, 32% derived from patients who identified as Black and 61% as Hispanic. All major head and neck disease sites were represented, including 15 (48%) oral cavity and 8 (26%) p16-positive oropharynx cancers. Hispanic ethnicity and first primary tumors (vs. second primary or recurrent tumors) were significantly associated with successful CR culture. HPV expression was conserved in CR cultures, including CR-024, which carried a novel HPV-69 serotype. CR cultures were used to test cisplatin responses using MTT assays. Previous work has also demonstrated these models can be used to assess response to radiation and can be engrafted in mouse models. Whole exome sequencing demonstrated that CR cultures preserved tumor mutation burden and driver mutations.

CONCLUSION

CR culture is highly successful in propagating HNSCC cells. This study included a high proportion of patients from underrepresented minority groups.

LEVEL OF EVIDENCE

Not Applicable Laryngoscope, 134:2748-2756, 2024.

Population-Based Prognostic Models for Head and Neck Cancers Using National Cancer Registry Data from Taiwan

PURPOSE

This study aims to raise awareness of the disparities in survival predictions among races in head and neck cancer (HNC) patients by developing and validating population-based prognostic models specifically tailored for Taiwanese and Asian populations.

METHODS

A total of 49,137 patients diagnosed with HNCs were included from the Taiwan Cancer Registry (TCR). Six prognostic models, divided into three categories based on surgical status, were developed to predict both overall survival (OS) and cancer-specific survival using the registered demographic and clinicopathological characteristics in the Cox proportional hazards model. The prognostic models underwent internal evaluation through a tenfold cross-validation among the TCR Taiwanese datasets and external validation across three primary racial populations using the Surveillance, Epidemiology, and End Results database. Predictive performance was assessed using discrimination analysis employing Harrell's c-index and calibration analysis with proportion tests.

RESULTS

The TCR training and testing datasets demonstrated stable and favorable predictive performance, with all Harrell's c-index values ≥ 0.7 and almost all differences in proportion between the predicted and observed mortality being < 5%. In external validation, Asians exhibited the best performance compared with white and black populations, particularly in predicting OS, with all Harrell's c-index values > 0.7.

CONCLUSIONS

Survival predictive disparities exist among different racial groups in HNCs. We have developed population-based prognostic models for Asians that can enhance clinical practice and treatment plans.

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.

Association Between Social Determinants of Health, Distance from Treatment Center, and Treatment Type with Outcomes in Human Papillomavirus Associated Oropharyngeal cancer

OBJECTIVES

Social determinants of health (SDOH) can influence access to cancer care, clinical trials, and oncologic outcomes. We investigated the association between SDOH, distance from treatment center, and treatment type with outcomes in human papillomavirus associated oropharyngeal squamous cell carcinoma [HPV(+)OPSCC] patients treated at a tertiary care center.

STUDY DESIGN

Retrospective review.

METHODS

HPV(+)OPSCC patients treated surgically from 2006 to 2021 were selected from our departmental Oropharyngeal Cancer RedCap database. Demographic data, treatment, and oncologic outcomes were extracted. Distance was calculated in miles between the centroid of each patient zip code and our hospital zip code (zipdistance).

RESULTS

874 patients (89 % male; mean age: 58 years) were identified. Most patients (96 %) reported Non-Hispanic White as their primary race. 204 patients (23 %) had a high-school degree or less, 217 patients (25 %) reported some college education or a 2-year degree, 153 patients (18 %) completed a four-year college degree, and 155 patients (18 %) had post-graduate degrees. Relative to those with a high-school degree, patients with higher levels of education were more likely to live further away from our institution (p < 0.0001). Patients who received adjuvant radiation therapy elsewhere lived, on average, 104 miles further away than patients receiving radiation at our institution (Estimate 104.3, 95 % CI 14.2-194.4, p-value = 0.02). In univariable Cox PH models, oncologic outcomes did not significantly differ by zipdistance.

CONCLUSIONS

Education level-and access to resources-varied proportionally to a patient's distance from our center. Patients travelling further distances for surgical management of OPSCC were more likely to pursue adjuvant radiation therapy at an outside institution. Distance traveled was not associated with oncologic outcomes. Breaking down barriers to currently excluded populations may improve access to clinical trials and improve oncologic outcomes for diverse patient populations.

Poor oral health influences head and neck cancer patient survival: an International Head and Neck Cancer Epidemiology Consortium pooled analysis

BACKGROUND

Poor oral health has been identified as a prognostic factor potentially affecting the survival of patients with head and neck squamous cell carcinoma. However, evidence to date supporting this association has emanated from studies based on single cohorts with small-to-modest sample sizes.

METHODS

Pooled analysis of 2449 head and neck squamous cell carcinoma participants from 4 studies of the International Head and Neck Cancer Epidemiology Consortium included data on periodontal disease, tooth brushing frequency, mouthwash use, numbers of natural teeth, and dental visits over the 10 years prior to diagnosis. Multivariable generalized linear regression models were used and adjusted for age, sex, race, geographic region, tumor site, tumor-node-metastasis stage, treatment modality, education, and smoking to estimate risk ratios (RR) of associations between measures of oral health and overall survival.

RESULTS

Remaining natural teeth (10-19 teeth: RR = 0.81, 95% confidence interval [CI] = 0.69 to 0.95; ≥20 teeth: RR = 0.88, 95% CI = 0.78 to 0.99) and frequent dental visits (>5 visits: RR = 0.77, 95% CI = 0.66 to 0.91) were associated with better overall survival. The inverse association with natural teeth was most pronounced among patients with hypopharyngeal and/or laryngeal, and not otherwise specified head and neck squamous cell carcinoma. The association with dental visits was most pronounced among patients with oropharyngeal head and neck squamous cell carcinoma. Patient-reported gingival bleeding, tooth brushing, and report of ever use of mouthwash were not associated with overall survival.

CONCLUSIONS

Good oral health as defined by maintenance of the natural dentition and frequent dental visits appears to be associated with improved overall survival among head and neck squamous cell carcinoma patients.

Racial and Ethnic Disparities in Cancer Occurrence and Outcomes in Rural United States: A Scoping Review

BACKGROUND

Cancer is the second-leading cause of death in the United States. Most studies have reported rural versus urban and Black versus White cancer disparities. However, few studies have investigated racial disparities in rural areas.

OBJECTIVE

We conducted a literature review to explore the current state of knowledge on racial and ethnic disparities in cancer attitudes, knowledge, occurrence, and outcomes in rural United States.

METHODS

A systematic search of PubMed and Embase was performed. Peer-reviewed articles published in English from 2004-2023 were included. Three authors independently reviewed the articles and reached a consensus.

RESULTS

After reviewing 993 articles, a total of 30 articles met the inclusion criteria and were included in the present review. Studies revealed that underrepresented racial and ethnic groups in rural areas were more likely to have low cancer-related knowledge, low screening, high incidence, less access to treatment, and high mortality compared to their White counterparts.

CONCLUSION

Underrepresented racial and ethnic groups in rural areas experienced a high burden of cancer. Improving social determinants of health may help reduce cancer disparities and promote health.

Demographics and access to head and neck cancer care in rural areas compared to urban areas in Germany

BACKGROUND

Demographic development in rural and urban areas differs substantially. Demographics and access to specialized head and neck cancer centers may affect head and neck cancer patients' (HNCP) outcomes. Here, we compare epidemiological indicators and outcomes of HNCP in rural and urban Germany.

PATIENTS AND METHODS

In a retrospective analysis of data from the Center for Cancer Registry Data (ZfKD) between 2002 and 2017, 212,920 HNCP were included. Incidence, demographics, travel distance to specialized centers, and ground values were compared between rural and urban areas with a focus on their association with patient outcomes.

RESULTS

The mean age of HNCP was significantly higher in urban areas (mean difference = 1.4 years; p < 0.0001), but increased at a comparable rate (p = 0.26) in rural and urban areas during the observation period. Gender imbalance was higher in rural areas (mean ratio of men/women: 4.1 vs. 3.1; p < 0.0001), but showed a comparable trend toward equilibration in both, rural and urban districts (p = 0.46). The portion of HNCP of the entire HNCP population living in urban areas increased from 55.9% in the year 2002 to 76.4% in the year 2017. There was no significant difference or change in the ratio of advanced to low UICC stage during the observation period (p = 0.26). However, travel distances to medical centers were higher in rural areas, especially (p < 0.0001) in East Germany. Median survival of HNCP in rural areas was significantly lower than in urban areas (42 months [SEM = 0.7; CI: 40.5-43.5] vs. 54 months [SEM = 1.2; CI: 51.7-56.3]; p < 0.0001) in East Germany, whereas in West Germany no significant difference was observed (59 months [SEM = 0.8; CI: 57.4-60.6] vs. 60 months [SEM = 0.5; CI: 59.0-61.0]; p = 0.15).

CONCLUSIONS

Place of residence contributes to survival outcome of HNCP. Access to specialized care and socioeconomic factors could be improved in East Germany.

Disentangling Social Determinants of Health and Rurality in Head and Neck Cancer 2-Year Mortality

Social determinants of health (SDoH) and rurality are known factors that may influence outcomes in head and neck squamous cell carcinoma (HNSCC). Patients residing in remote locations or those with multiple SDoH may encounter barriers to initial diagnosis, adherence to multidisciplinary treatments, and posttreatment surveillance, which may impact their overall survival. However, previous studies have shown mixed results associated with rural residence. The aim of this study is to identify the impact of rurality and SDoH on 2-year survival in HNSCC. The study was conducted using a Head and Neck Cancer Registry at a single institution from June 2018 through July 2022. Rurality, defined by US census scores, and individual measures of SDoH were used. Our results indicate that each additional adverse SDoH factor results in 1.5 times the odds of mortality at 2 years. Individualized measures of SDoH, rather than rurality alone, better reflect patient prognosis in HNSCC.

Aging in Rural Communities

Purpose of Review

Population aging is occurring worldwide, particularly in developed countries such as the United States (US). However, in the US, the population is aging more rapidly in rural areas than in urban areas. Healthy aging in rural areas presents unique challenges. Understanding and addressing those challenges is essential to ensure healthy aging and promote health equity across the lifespan and all geographies. This review aims to present findings and evaluate recent literature (2019-2022) on rural aging and highlight future directions and opportunities to improve population health in rural communities.

Recent Findings

The review first addresses several methodological considerations in measuring rurality, including the choice of measure used, the composition of each measure, and the limitations and drawbacks of each measure. Next, the review considers important concepts and context when describing what it means to be rural, including social, cultural, economic, and environmental conditions. The review assesses several key epidemiologic studies addressing rural-urban differences in population health among older adults. Health and social services in rural areas are then discussed in the context of healthy aging in rural areas. Racial and ethnic minorities, indigenous peoples, and informal caregivers are considered as special populations in the discussion of rural older adults and healthy aging. Lastly, the review provides evidence to support critical longitudinal, place-based research to promote healthy aging across the rural-urban divide is highlighted.

Summary

Policies, programs, and interventions to reduce rural-urban differences in population health and to promote health equity and healthy aging necessitate a context-specific approach. Considering the cultural context and root causes of rural-urban differences in population health and healthy aging is essential to support the real-world effectiveness of such programs, policies, and interventions.

Excess Mortality Among Solid Organ Transplant Recipients in the United States During the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic is the first sustained respiratory disease pandemic to arise since the start of solid organ transplantation (SOT). Prior studies have demonstrated that SOT recipients are at greater risk for severe complications of infection and are less likely to respond to vaccination.

METHODS

The Scientific Registry of Transplant Recipients Standard Analysis Files was used to assess the cumulative excess mortality in SOT recipients during the first 20 mo of the pandemic.

RESULTS

Compared with excess mortality rates in the US population (25.9 deaths/10 000; confidence interval [CI], 10.9-41.1), the excess mortality per 10 000 was higher in all SOT groups: kidney (188.5; CI, 150.7-225.6), lung (173.6; CI, 17-334.7), heart (123.7; CI, 56-191.4), and liver (105.1; CI, 64.6-146). The higher rates persisted even with attempts to control for population age structure and renal allograft failure. Excess mortality was also higher in Black (236.8; CI, 186.1-287) and Hispanic (256.9; CI, 208.1-305.2) organ recipients compared with other racial and ethnic groups in the Scientific Registry of Transplant Recipients and compared with the Black and Hispanic populations in the United States.

CONCLUSIONS

Studies of excess mortality provide insight into the health and survival of specialized populations like SOT recipients during major health events like the COVID-19 pandemic.

Racial Disparities in Charges, Length of Stay, and Complications Following Adult Inpatient Epistaxis Treatment

BACKGROUND

Although recent studies have identified an association between race and adverse outcomes in head and neck surgeries, there are limited data examining the impact of racial disparities on adult inpatient outcomes following epistaxis management procedures.

OBJECTIVE

To analyze the association between race and adverse outcomes in hospitalized patients undergoing epistaxis treatment.

METHODS

This retrospective cohort analysis utilized the 2003 to 2014 National Inpatient Sample. International Classification of Diseases, Ninth Revision codes were used to identify cases with a primary diagnosis of epistaxis that underwent a procedure for epistaxis control. Cases with missing data were excluded. Higher total charges and prolonged length of stay (LOS) were indicated by values greater than the 75th percentile. Demographics, hospital characteristics, Elixhauser comorbidity score, and complications were compared among race cohorts using univariate chi-square analysis and one-way analysis of variance (ANOVA). The independent effect of race on adverse outcomes was analyzed using multivariate binary logistic regression while adjusting for the aforementioned variables.

RESULTS

Of the 83 356 cases of epistaxis included, 80.3% were White, 12.5% Black, and 7.2% Hispanic. Black patients had increased odds of urinary/renal complications (odds ratio [OR] 2.148, 95% confidence interval [CI] 1.797-2.569, P < .001) compared to White patients. Additionally, Black patients experienced higher odds of prolonged LOS (OR 1.227, 95% CI 1.101-1.367, P < .001) and higher total charges (OR 1.257, 95% CI 1.109-1.426, P < .001) compared to White patients. Similarly, Hispanic patients were more likely to experience urinary/renal complications (OR 1.605, 95% CI 1.244-2.071, P < .001), higher total charges (OR 1.519, 95% CI 1.302-1.772, P < .001), and prolonged LOS (OR 1.157, 95% CI 1.007-1.331, P = .040) compared to White patients.

CONCLUSION

Race is an important factor associated with an increased incidence of complications in hospitalized patients treated for epistaxis.

Oral Cancer Prevalence, Mortality, and Costs in Medicaid and Commercial Insurance Claims Data

BACKGROUND

This study compared prevalence, incidence, mortality rates, treatment costs, and risk factors for oral and oropharyngeal cancer (OC/OPC) between two large United States adult cohorts in 2012-2019.

METHODS

Medicaid and commercial claims data came from the IBM Watson Health MarketScan Database. Logistic regression analyses estimated incidence and risk factors for OC/OPC. Mortality was calculated by merging deceased individuals' files with those of the existing cancer cohort. Summing costs of outpatient and inpatient services determined costs.

RESULTS

Prevalence of OC/OPC in Medicaid enrollees decreased each year (129.8 cases per 100,000 enrollees in 2012 to 88.5 in 2019); commercial enrollees showed a lower, more stable prevalence (64.7 per 100,000 in 2012 and 2019). Incidence trended downward in both cohorts, with higher incidence in the Medicaid (51.4-37.6 cases per 100,000) than the commercial cohort (31.9-31.0 per 100,000). Mortality rates decreased for Medicaid enrollees during 2012-2014 but increased in the commercial cohort. OC/OPC treatment costs were higher for commercial enrollees by $8.6 million during 2016-2019. OC/OPC incidence was higher among adults who were older, male, and white; used tobacco or alcohol; or had prior human immunodeficiency virus/acquired immune deficiency syndrome diagnosis and lower among those who had seen a dentist the prior year.

CONCLUSIONS

Medicaid enrollees experienced higher OC/OPC incidence, prevalence, and mortality compared with commercially insured adults. Having seen a dentist within the prior year was associated with a lower risk of OC/OPC diagnosis.

IMPACT

Expanding Medicaid dental benefits may allow OC/OPC to be diagnosed at earlier stages through regular dental visits.

Persistent ethnicity-associated disparity in anti-tumor effectiveness of immune checkpoint inhibitors despite equal access

We reviewed response to immune checkpoint inhibitors (ICI) of 207 patients with diagnoses of lung or head and neck cancer treated with chemotherapy/ICI combination therapy and ICI monotherapy between 2015 and 2020 at one of three clinical pavilions associated with the Dan L. Duncan Comprehensive Cancer Center at Baylor College of Medicine. Two of these pavilions (Harris Health System and the Michael E. DeBakey Veterans Affairs Medical Center) serve large minority populations and provide equal access to care regardless of means. 174 patients had a diagnosis of lung cancer (non-small cell or small cell) and 33 had a diagnosis of head and neck squamous cell carcinoma (HNSCC). 38% self-identified as Black, 45% as non-Hispanic White, and 18% as Hispanic. The objective response rate (ORR) was similar for lung cancer (35.057%) and HNSCC patients (30.3%) (p=0.894). The ORR for Hispanic and Black patients was lower compared to non-Hispanic White patients (H 27.0%, B 32.5%, W 38.7%; H vs. W p=0.209; B vs. W p=0.398). When considering only patients treated with ICI monotherapy, the ORR for Hispanic patients dropped further to 20.7% while the ORR of Black and non-Hispanic White patients remained about the same (B 29.3% and W 35.9%, H vs. W p=0.133; B vs. W p=0.419). Immune related adverse events were the lowest in the Hispanic population occurring in only 30% of patients compared to 40% of patients in the Black cohort and 50% of the non-Hispanic White cohorts.

Rural-Urban Disparities in Cancer Outcomes: Opportunities for Future Research

Cancer care disparities among rural populations are increasingly documented and may be worsening, likely because of the impact of rurality on access to state-of-the-art cancer prevention, diagnosis, and treatment services, as well as higher rates of risk factors such as smoking and obesity. In 2018, the American Society of Clinical Oncology undertook an initiative to understand and address factors contributing to rural cancer care disparities. A key pillar of this initiative was to identify knowledge gaps and promote the research needed to understand the magnitude of difference in outcomes in rural vs nonrural settings, the drivers of those differences, and interventions to address them. The purpose of this review is to describe continued knowledge gaps and areas of priority research to address them. We conducted a comprehensive literature review by searching the PubMed (Medline), Embase, Web of Science, and Cochrane Library databases for studies published in English between 1971 and 2021 and restricted to primary reports from populations in the United States and abstracted data to synthesize current evidence and identify continued gaps in knowledge. Our review identified continuing gaps in the literature regarding the underlying causes of rural-urban disparities in cancer outcomes. Rapid advances in cancer care will worsen existing disparities in outcomes for rural patients without directed effort to understand and address barriers to high-quality care in these areas. Research should be prioritized to address ongoing knowledge gaps about the drivers of rurality-based disparities and preventative and corrective interventions.

Rural Otolaryngology Care Disparities: A Scoping Review

OBJECTIVE

To broadly synthesize the literature regarding rural health disparities in otolaryngology, categorize findings, and identify research gaps to stimulate future work.

STUDY DESIGN

Scoping review.

DATA SOURCES

A comprehensive literature search was performed in the following databases: PubMed/MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, Google Scholar, and CINAHL.

REVIEW METHODS

The methods were developed in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. Peer-reviewed, English-language, US-based studies examining a rural disparity in otolaryngology-related disease incidence, prevalence, diagnosis, treatment, or outcome were included. Descriptive studies, commentaries, reviews, and letters to the editor were excluded. Studies published prior to 1980 were excluded.

RESULTS

The literature search resulted in 1536 unique abstracts and yielded 79 studies that met final criteria for inclusion. Seventy-five percent were published after 2010. The distribution of literature was as follows: otology (34.2%), head and neck cancer (20.3%), endocrine surgery (13.9%), rhinology and allergy (8.9%), trauma (5.1%), laryngology (3.8%), other pediatrics (2.5%), and adult sleep (1.3%). Studies on otolaryngology health care systems also accounted for 10.1%. The most common topics studied were practice patterns (41%) and epidemiology (27%), while the Southeast (47%) was the most common US region represented, and database study (42%) was the most common study design.

CONCLUSION

Overall, there was low-quality evidence with large gaps in the literature in all subspecialties, most notably facial plastic surgery, laryngology, adult sleep, and pediatrics. Importantly, there were few studies on intervention and zero studies on resident exposure to rural populations, which will be critical to making rural otolaryngology care more equitable in the future.

Rural disparities in head and neck cancer from 2017 to 2021: a single institution analysis

Introduction:

This study aims to look at the trends in our head and neck cancer patient population over the past 5 years with an emphasis on the past 2 years to evaluate how the coronavirus disease 2019 (COVID-19) pandemic has impacted our disparities and availability of care for patients, especially those living in rural areas. An additional aim is to identify existing disparities at our institution in the treatment of head and neck patients and determine solutions to improve patient care.

Materials and Methods:

A retrospective chart review was performed to identify patients who were consulted and subsequently treated with at least one fraction of radiation therapy at our institution with palliative or curative intent. Patient demographic information was collected including hometown, distance from the cancer centre based on zip-codes and insurance information and type of appointment (in-person or telehealth). Rural–urban continuum codes were used to determine rurality.

Results:

A total of 490 head and neck cancer patients (n = 490) were treated from 2017 to 2021. When broken down by year, there were no significant trends in patient population regarding travel distance or rurality. Roughly 20–30% of our patients live in rural areas and about 30% have a commute > 50 miles for radiation treatment. A majority of our patients rely on public insurance (68%) with a small percentage of those uninsured (4%). Telehealth visits were rare prior to 2019 and rose to 5 and 2 visits in 2020 and 2021, respectively.

Conclusions:

Head and neck cancer patients, despite rurality or distance from a cancer centre, may present with alarmingly enough symptoms despite limitations and difficulties with seeking medical attention even during the COVID-19 pandemic in 2020. However, providers must be aware of these potential disparities that exist in the rural population and seek to address these.

Use of telemedicine consultations in head and neck cancer: patient perceptions, acceptability and accessibility

BACKGROUNDS

Telemedicine has been effective in the management of various medical conditions, however, there is limited knowledge of its use in head and neck oncosurveillance. This is of importance currently while trying to mitigate the risk of transmission during the COVID-19 pandemic. This study aims to evaluate acceptability, satisfaction and perceptions of telemedicine technology among outpatients for head and neck oncologic surveillance.

METHODS

A cross-sectional study was conducted for head and neck surgical oncology patients who attended telemedicine consultations between March and October 2020 at the Peter MacCallum Cancer Centre. Data on demographic, socioeconomic and acceptability variables was collected, utilizing Likert scale questions. The primary outcome measures were patient satisfaction and perceptions, while the secondary outcome was access to technology.

RESULTS

One hundred and fifteen patients were invited to participate, and 100 were included in the final analysis; 95% of patient's had a positive experience with telemedicine appointments and were willing to have future telemedicine appointments. Regional and rural patients were more accepting of telemedicine consultations, citing savings in travel time and the minimal disruption to normal day-to-day activities. All participants had access to telecommunication devices, with 63% having three or more devices. Issues identified include a lack of physical examination by clinician for 65% of participants and the inability to self-examine for 88% of participants.

CONCLUSION

The study demonstrates patients' acceptance of telemedicine appointments as a component of outpatient surveillance for head and neck surgical oncology. This has benefits during the COVID-19 pandemic in addition to increasing accessibility for rural patients.

Emerging Disparities in Prevention and Survival Outcomes for Patients with Head and Neck Cancer and Recommendations for Health Equity

Purpose of Review

The aim of this review is to describe less known and emerging disparities found in the prevention and survival outcomes for patients with head and neck cancer (HNC) that are likely to play an increasingly important role in HNC outcomes and health inequities.

Recent Findings

The following factors contribute to HNC incidence and outcomes: (1) the effect of rurality on prevention and treatment of HNC, (2) dietary behavior and nutritional factors influencing the development of and survival from HNC, and (3) barriers and benefits of telehealth for patients with HNC.

Summary

Rurality, nutrition and diet, and telehealth usage and access are significant contributors to the existing health disparities associated with HNC. Population and culturally specific interventions are urgently needed as well as more research to further define the issues and develop appropriate population and individual level solutions.

A Tale of Two Centers: Visual Exploration of Health Disparities in Cancer Care

The annual incidence of head and neck cancers (HNC) worldwide is more than 550,000 cases, with around 300,000 deaths each year. However, the incidence rates and disease-characteristics of HNC differ between treatment centers and different populations, due to undetermined reasons, which may or not include socioeconomic factors. The multi-faceted and multi-variate nature of the data in the context of the emerging field of health disparities research makes automated analysis impractical. Hence, we present a visual analysis approach to explore the health disparities in the data of HNC patients from two different cohorts at two cancer care centers. Our approach integrates data from multiple sources, including census data and city data, with custom visual encodings and with a nearest neighbor approach. Our design, created in collaboration with oncology experts, makes it possible to analyze the patients' demographic, disease characteristics, treatments and outcomes, and to make significant comparisons of these two cohorts and of individual patients. We evaluate this approach through two case studies performed with domain experts. The results demonstrate that this visual analysis approach successfully accomplishes the goal of comparing two cohorts in terms of different significant factors, and can provide insights into the main source of health disparities between the two centers.

Race and Ethnicity in Otolaryngology Academic Publications

OBJECTIVE

Within otolaryngology, race is commonly included as a study covariate; however, its value in clinical practice is unclear. This study sought to explore how race and ethnicity have been used and applied over time in otolaryngology publications.

DATA SOURCES

PubMed database.

REVIEW METHODS

A systematic review was done to identify original otolaryngology studies between January 1, 1946, and June 25, 2020, with the following search terms: "otolaryngology" AND "race" OR "ethnicity."

RESULTS

Of the 1984 yielded studies, 932 were included in the final analysis. Only 2 studies (0.2%) defined race, and 172 (18.5%) gave participants the opportunity to self-identify race. Less than half (n = 322, 43.8%) of studies controlled for confounders. One hundred studies (10.7%) linked race to genetic factors. An overall 564 (60.5%) made conclusions about race, and 232 (24.9%) mentioned that race is relevant for clinical decision making. The majority of studies had first and senior authors from high-income countries (93.9% and 93.8%, respectively). Over time, there was a significant increase in publications that controlled for confounders, the number of race categories used, and studies that highlighted disparities.

CONCLUSION

Race and ethnicity are often poorly defined in otolaryngology publications. Furthermore, publications do not always control for confounding variables or allow participants to self-identify race. On the basis of our findings, we suggest 7 foundational principles that can be used to promote equitable research in otolaryngology publications. Future efforts should focus on incorporating research guidelines for race and ethnicity into journal publication standards.

Health-related quality of life in head and neck cancer survivors: Evaluating the rural disadvantage

PURPOSE

Head and neck cancer (HNC) survivors often experience distress and health-related quality of life (HRQOL) impairment. Research suggests that rural cancer patients may have poorer outcomes than urban patients. This study examined whether HNC patient emotional and HRQOL outcomes differ in those living in a rural versus urban location at 6 and 12 months postdiagnosis.

METHODS

A total of 261 HNC patients were included from a longitudinal study of HNC outcomes. The majority were diagnosed with advanced stage cancer (51.3%); the most common cancer site was oral cavity (41.0%). Rurality was measured using the US Department of Agriculture Rural Urban Commuting Area codes. Depression was measured using the Beck Depression Inventory (BDI), general HRQOL using the Short Form-36 (SF-36), and HNC-specific HRQOL using the Head and Neck Cancer Inventory (HNCI). Analyses were 2 (group) × 3 (assessment) repeated measures ANCOVAs, controlling for demographic and clinical characteristics.

FINDINGS

Approximately 45% of the sample lived in a rural location. Follow-up comparisons of significant overall models indicated that rural patients reported significantly more nonsomatic depression symptoms at 6-month follow-up. Rural patients were also more likely to report significantly poorer general mental HRQOL at 12-month follow-up, significantly poorer HNC-specific HRQOL related to eating at 6- and 12-month follow-up, and marginally worse aesthetics at 12-month follow-up.

CONCLUSIONS

These findings are consistent with suggestions that rural HNC patients may be at heightened risk for depression symptoms and decrements in HRQOL. Patients should be screened and regularly monitored for issues with depression and HNC-specific HRQOL throughout the survivorship period.

Incidence and Risk of Suicide Among Patients With Head and Neck Cancer in Rural, Urban, and Metropolitan Areas

Importance

Patients with head and neck cancer (HNC) are known to be at increased risk of suicide compared with the general population, but there has been insufficient research on whether this risk differs based on patients' rural, urban, or metropolitan residence status.

Objective

To evaluate whether the risk of suicide among patients with HNC differs by rural vs urban or metropolitan residence status.

Design, Setting, and Participants

This cross-sectional study uses data from the Surveillance, Epidemiology, and End Results database on patients aged 18 to 74 years who received a diagnosis of HNC from January 1, 2000, to December 31, 2016. Statistical analysis was conducted from November 27, 2020, to June 3, 2021.

Exposures

Residence status, assessed using 2013 Rural Urban Continuum Codes.

Main Outcomes and Measures

Death due to suicide was assessed by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes (U03, X60-X84, and Y87.0) and the cause of death recode (50220). Standardized mortality ratios (SMRs) of suicide, assessing the suicide risk among patients with HNC compared with the general population, were calculated. Suicide risk by residence status was compared using Fine-Gray proportional hazards regression models.

Results

Data from 134 510 patients with HNC (101 142 men [75.2%]; mean [SE] age, 57.7 [10.3] years) were analyzed, and 405 suicides were identified. Metropolitan residents composed 86.6% of the sample, urban residents composed 11.7%, and rural residents composed 1.7%. The mortality rate of suicide was 59.2 per 100 000 person-years in metropolitan counties, 64.0 per 100 000 person-years in urban counties, and 126.7 per 100 000 person-years in rural counties. Compared with the general population, the risk of suicide was markedly higher among patients with HNC in metropolitan (SMR, 2.78; 95% CI, 2.49-3.09), urban (SMR, 2.84; 95% CI, 2.13-3.71), and rural (SMR, 5.47; 95% CI, 3.06-9.02) areas. In Fine-Gray competing-risk analyses that adjusted for other covariates, there was no meaningful difference in suicide risk among urban vs metropolitan residents. However, compared with rural residents, residents of urban (subdistribution hazard ratio, 0.52; 95% CI, 0.29-0.94) and metropolitan counties (subdistribution hazard ratio, 0.55; 95% CI, 0.32-0.94) had greatly lower risk of suicide.

Conclusions and Relevance

The findings of this cross-sectional study suggest that suicide risk is elevated in general among patients with HNC but is significantly higher for patients residing in rural areas. Effective suicide prevention strategies in the population of patients with HNC need to account for rural health owing to the high risk of suicide among residents with HNC in rural areas.

Geographic disparities in head and neck cancer survival in Upstate New York 2011-2019

PURPOSE

To examine the association between distance to care-center and urban-rural residence on 5-year overall survival (OS) from head and neck cancer (HNC).

MATERIALS AND METHODS

Five-year OS was retrospectively measured from date of initial diagnosis for patients with HNC treated at a single tertiary care center. Distances were calculated based on ZIP code of patient's residence and care center. Multilevel Weibull regression was used to adjust for confounders and identify disparities in 5-year all-cause mortality.

RESULTS

A total of 670 patients included in study. Multivariable analysis revealed older age or late-stage cancer at diagnosis, and HPV negative status were associated with poorer OS. Patients residing in isolated small rural town (HR = 2.20, p = 0.015) or small rural town (HR = 2.07, p = 0.015) had lower OS. Distance to care center was not associated with OS (HR = 0.996, p = 0.11).

CONCLUSIONS

Greater rurality was associated with poorer OS among HNC patients in Upstate New York.

The impact of travel distance to treatment centre on oral tongue squamous cell carcinoma survival and recurrence

There have been no prior studies examining the effect of distance to the treatment centre on oral squamous cell carcinoma outcomes in Australia. The purpose of this study was to analyse the impact of travel distance on oral tongue squamous cell carcinoma (OTSCC) outcomes. This was a retrospective analysis of 243 patients who received surgical treatment ± adjuvant therapy between 2007 and 2016. The overall survival (OS), disease-specific survival (DSS), and freedom from loco-regional failure (FFLRF) survival analyses were conducted using Kaplan-Meier curves and a multivariate Cox proportional hazards model. A competing risk (CR) analysis was conducted. Patients living ≥200 km from the treatment centre, when compared with those living within 40 km, had worse OS (hazard ratio (HR) 3.11, 95% confidence interval (CI) 1.74-5.54), DSS (HR 2.58, 95% CI 1.30-5.12), and FFLRF (HR 2.47, 95% CI 1.22-5.01). These discrepancies were significant when adjusted for socioeconomic status (OS P < 0.001, DSS P  0.004, FFLRF P = 0.005) and in the presence of CR (OTSCC-specific death with CR 'non-disease-related death' P =0.030, FFLRF with CR 'any cause death' P = 0.013, FFLRF with CR 'OTSCC-specific death' P = 0.004). Patients with OTSCC living ≥200 km from the treatment centre were found to have worse outcomes than those living within 40 km.

Geographic Distribution of Otolaryngology Advance Practice Providers and Physicians

OBJECTIVES

Advanced practice providers (APPs), namely physician assistants (PAs) and nurse practitioners (NPs), play an increasing role in meeting growing demands for otolaryngologic services, particularly in rural communities. This study analyzes the geographic distribution of otolaryngology providers, which is essential to addressing future demands.

STUDY DESIGN

Cross-sectional study.

SETTING

Medicare Provider Utilization and Payment Data for 2017.

METHODS

Current Procedural Terminology codes were used to identify APPs providing 10 common otolaryngologic services. Geographic distribution was evaluated by calculating densities of APPs and otolaryngologists per 100,000 persons in urban versus rural counties as defined by the National Center for Health Statistics Urban-Rural Classification Scheme.

RESULTS

We identified cohorts of 8573 otolaryngologists, 1148 NPs, and 895 PAs. There were significantly higher population-controlled densities of otolaryngologists and APPs in urban counties as compared with rural counties. The majority of otolaryngologists (92.1%) and APPs (83.3%) were in urban counties. However, the proportion of APPs (16.7%) in rural counties was significantly higher than the proportion of otolaryngologists (7.9%) in rural counties (P < .01). A significant majority of rural counties (72.2%) had zero identified providers, and a greater proportion of rural counties (5.0%) were served exclusively by APPs as compared with urban counties (3.2%).

CONCLUSIONS

Although otolaryngologists and APPs mostly practiced in urban counties, a relatively higher proportion of APPs practiced in rural counties when compared with otolaryngology physicians. The majority of rural counties did not have any otolaryngologic providers. Given the expected shortages of otolaryngology physicians, APPs may play a critical role in addressing these gaps in access.

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.

Socioeconomic Status and Rurality Among Patients With Head and Neck Cancer

OBJECTIVE

Describe the relationship among rurality, socioeconomic status (SES), and patient/tumor characteristics in patients presenting with head and neck cancer.

STUDY DESIGN

Retrospective single-institution study.

SETTING

Academic tertiary-level medical center.

METHODS

Patients with head and neck cancer presenting between 2011 and 2015 were included. Stage at presentation, insurance status, and demographic characteristics were collected. Rurality was measured through Rural-Urban Continuum Codes. SES was measured by SES index scores of the Agency for Healthcare Research and Quality, which incorporate multiple components of SES. Associations among rurality, SES, and patient/tumor characteristics were assessed with univariate and multivariable statistics. All P values were calculated via 2-sided hypotheses. The threshold for statistical significance was set at P < .05. Statistical analyses were conducted with Stata/SE 14 (StataCorp).

RESULTS

The study included 266 patients diagnosed with head and neck cancer between 2011 and 2015. Rural residence was associated with lower SES (P < .001). T and N stages were associated with rurality (P = .036 and .050, respectively). Higher educational status was associated with oropharyngeal cancer (P = .005).

CONCLUSIONS

Rurality and SES have distinct impacts on patients with head and neck cancer. Specifically, rurality is associated with tumor stage among patients with head and neck cancer. Knowledge of disparities among patients with rural residency may help target interventions to facilitate earlier diagnosis.

Head and Neck Cancer in a Rural U.S. Population: Quality of Life, Coping, Health Care Literacy, and Access to Services

Purpose The aim of this study was to explore the beliefs, access, and motivations of individuals with head and neck cancer (HNC) living in a rural community in the United States, regarding their speech and swallowing deficits. Method A convenience sample of nine patient participants with HNC and nine caregiver participants completed in-depth, semistructured interviews regarding their experiences with HNC diagnosis and treatment. The researchers utilized a thematic networks approach to analyze the qualitative data obtained. Results Primary results of the study were a set of common themes emerging from 735 units for analysis, arranged into 34 basic themes, nine organizing themes, and four global themes. The resulting networks centered around quality of life impact, coping, health literacy, and access. Direct quotes from the participants are utilized to illustrate response categories. Conclusions Individuals with HNC and their caregivers living in rural communities in the United States appear to represent a unique subset of the HNC population. While they present similarly in most areas, they display unique tendencies in the areas of psychological coping, health literacy, and access. Provision of practical, pertinent information that can be accessed by patients and caregivers alike outside the hospital is suggested to better serve this community.

Racial and Ethnic Disparities in Laryngeal Cancer Care

There is a long history of racial and ethnic disparities in healthcare and they continue to persist in contemporary society. These disparities have the potential to negatively affect morbidity and mortality in racial and ethnic minorities diagnosed with laryngeal cancer. Diagnosis, medical treatment, and rehabilitation for laryngeal cancer have improved considerably, leading to improvements in overall survival rates and physical, social, and psychological functioning. Yet members of minority and underrepresented groups are at an increased risk for experiencing reduced access to quality care and delays between diagnosis and treatment, and as a result have lower survival rates. Increasing health providers' awareness of racial and ethnic disparities in laryngeal cancer is necessary to facilitate changes in patient and provider education, clinical practice, and health policies. The purpose of this review is to summarize current literature on disparities in laryngeal cancer diagnosis, treatment, and rehabilitation among Black and Hispanic patients. We present recent data from the Surveillance, Epidemiology, and End Results database to examine trends in laryngeal cancer and patient, provider, and health systems factors that may perpetuate these disparities. In addition, we offer interventions to address racism and other racial and ethnic biases in laryngeal cancer care and describe research and legislative actions that are needed to reduce disparities in this area.

The Intersection of Rural Residence and Minority Race/Ethnicity in Cancer Disparities in the United States

One in every twenty-five persons in America is a racial/ethnic minority who lives in a rural area. Our objective was to summarize how racism and, subsequently, the social determinants of health disproportionately affect rural racial/ethnic minority populations, provide a review of the cancer disparities experienced by rural racial/ethnic minority groups, and recommend policy, research, and intervention approaches to reduce these disparities. We found that rural Black and American Indian/Alaska Native populations experience greater poverty and lack of access to care, which expose them to greater risk of developing cancer and experiencing poorer cancer outcomes in treatment and ultimately survival. There is a critical need for additional research to understand the disparities experienced by all rural racial/ethnic minority populations. We propose that policies aim to increase access to care and healthcare resources for these communities. Further, that observational and interventional research should more effectively address the intersections of rurality and race/ethnicity through reduced structural and interpersonal biases in cancer care, increased data access, more research on newer cancer screening and treatment modalities, and continued intervention and implementation research to understand how evidence-based practices can most effectively reduce disparities among these populations.