County of residence linked to laryngeal cancer treatment choice: JAMA Study

Guidelines for many head and neck cancers, especially laryngeal cancers, allow for multiple treatment options. Currently, inequitable provision of surgery may contribute to outcome disparities. However, the role of geospatial factors remains understudied.

Hence, Sean T. Massa and colleagues from the Department of Otolaryngology–Head and Neck Surgery, Saint Louis University in St Louis, St Louis, Missouri conducted this study to assess the association between US geospatial factors and treatment selection for patients with laryngeal cancer.

In this retrospective cohort study, the authors diagnosed a total of 21 289 patients (mean [SD] age, 63.6 [11.2] years; 17 214 [80.9%] male) in 598 counties. Most counties had no otolaryngologist (365 [61.0%]) or radiation oncologist (434 [72.6%]). Patient demographic characteristics were associated with treatment selection after controlling for oncologic factors and accounting for county-level clustering.

In addition, patients in counties least likely to provide surgical treatment experienced inferior survival. Those patients diagnosed with laryngeal squamous cell were identified. Adjusted odds ratios (aORs) for surgical treatment were generated from multivariable, hierarchical models to assess associations with oncologic, demographic, and county variables. Outlier US counties with the highest and lowest aORs were described. Data analysis was performed.

The results showed that –

7. Surgery rates varied from 7.1% to 85.7% among counties with at least 10 cases.
8. After oncologic variables were controlled for, factors independently associated with surgical treatment included patient age (aOR [95% CI], 0.94; 0.91-0.98 per 10 years), marital status (single versus married: aOR [95% CI], 0.87 [0.79-0.97]), and county social deprivation index (aOR [95% CI], 0.98 [0.97-1.00 per 5 points]) but not physician number (≥2 otolaryngologists: aOR [95% CI], 0.91 [0.75-1.11] vs ≥1 radiation oncologist: aOR [95% CI], 0.91; 0.75-1.11).
9. The 5% of counties most likely to provide surgery (aOR, >1.23) were nearly all large metropolitan areas (2593 patients [93.3%]) and treated a disproportionately large number of patients (2778 [13.1%]).
10. The 5% of counties least likely to provide surgery (aOR, <0.79) were also mostly large metropolitan areas (1676 patients [91.2%]) and treated a disproportionately large number of patients (1838 [8.6%]).
11. Patients in counties least likely to provide surgery had inferior survival compared with those most likely to provide surgery (adjusted hazard ratio, 1.16; 95% CI, 1.00-1.35).

Therefore, the authors concluded that "sociodemographic factors contribute to the wide variety in surgical treatment practices by county. The largest metropolitan counties were often outliers regarding their adjusted odds of surgical treatment. This finding is concerning for the counties least likely to provide surgery where survival is inferior."