Social Determinants of Health and Oral Cavity Cancer Treatment and Survival: A Competing Risk Analysis.
OBJECTIVE
Competing risk analysis is a powerful assessment for cancer risk factors and covariates. This method can better elucidate insurance status and other social determinants of health covariates in oral cavity cancer treatment, survival, and disparities.


STUDY DESIGN
Retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER) database.


METHODS
Data regarding patient characteristics, clinical stage at diagnosis, treatment, and survival data for 20,271 patients diagnosed with oral cavity cancer was extracted from the SEER 18 Regs Research Data including Hurricane Katrina Impacted Louisiana Cases from 1973 to 2014. All statistical analyses were performed using SAS 9.5 (SAS Institute Inc., Cary, NC). The Fine-Gray method for assessing impact, risk, and covariates was employed.


RESULTS
Medicaid patients presented with later stage disease, larger tumor size, more distant metastases, and more lymph node involvement at diagnosis compared to insured patients. Medicaid patients were less likely to receive cancer-directed surgery. Medicaid status was also associated with worse cancer-specific survival (subhazard ratios 1.87, 95% confidence interval 1.72-2.04, P < .0001) after adjustment for all covariates.


CONCLUSION
This is the first study examining specifically how Medicaid status and social determinants of health covariates impact oral cavity cancer treatment and outcomes and is the first using methods validated for complex covariates. Patients with Medicaid present with more extensive oral cavity disease burden are less likely to receive definitive therapy and have significantly worse overall survival than those with other forms of insurance. This better identifies disparities and the need for improving health literacy, specifically for the at-risk Medicaid population, and can guide clinicians.


LEVEL OF EVIDENCE
NA Laryngoscope, 130:2160-2165, 2020.
['Agarwal|Pratima|P|0000-0002-6502-9045', 'Agrawal|Ravi R|RR|', 'Jones|Eric A|EA|', 'Devaiah|Anand K|AK|0000-0002-4375-0421']
D000328:Adult D000368:Aged D005260:Female D054624:Health Status Disparities D054625:Healthcare Disparities D006801:Humans D019458:Insurance Coverage D008145:Louisiana D008297:Male D008484:Medicaid D008875:Middle Aged D009062:Mouth Neoplasms D012189:Retrospective Studies D012307:Risk Factors D018426:SEER Program D012720:Severity of Illness Index D064890:Social Determinants of Health D014481:United States
social determinants of health Oral cavity cancer healthcare disparities insurance, socioeconomic