Geographic disparities in head and neck cancer mortality and place of death in the United States from 2003 to 2019.
Authors: Balanchivadze Nino , Blackford Amanda L. , Huang Ling , Altiery De Jesus Vivian V. Altiery , Hwang Michael , Sedhom Ramy , Gupta Arjun , Hussaini S. M. Qasim 
Published: September 2022

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Background: Survival has significantly improved for patients with head and neck cancer (HNC) in the last decade in the US. Unfortunately, social determinants of health continue to impact patient outcomes. HPV vaccine uptake and access to quality end-of-life care vary notably between geographic areas. We investigated potential disparities in rural-urban age-adjusted mortality rates (AAMRs) and place of death for individuals with head and neck cancer (HNC). Methods: We used the CDC WONDER database to identify patients who died from HNC between 2003 and 2019 within the following 2013 US Census population classifications: large metropolitan (≥1 million), medium/small metropolitan (50,000-999,999), and rural areas (< 50,000). AAMR (per 100,000 individuals) was stratified by geographic area, age, and race/ethnicity. Annual percentage changes (APC) in AAMR were estimated with linear regression models of the log-scale AAMR (including population size as weights) and differential changes over time by geographic area were assessed with interaction tests. Odds ratios (OR) for the association between each place of death and individual-level characteristics were calculated using logistic regression, adjusting for year of death. Results: From 2003 to 2019, 221,861 deaths related to HNC occurred (48.5% large metropolitan, 31.9% medium/small metropolitan, 19.7% rural). Total AAMR declined from 6.7 to 5.8 during this period. Rural areas consistently had a higher AAMR and also slower annual improvement over time (APC –0.11; 95% CI, –0.36 to 0.13; p < 0.001) than medium/small metropolitan (APC –0.51; 95% CI, –0.78 to 0.24) and large metropolitan areas (APC –1.19; 95% CI, –1.39 to –1.0; p < 0.001). Non-Hispanic (NH) Black patients had the highest overall AAMR, but quickest annual improvement (APC –2.91; 95% CI, –3.28 to –2.55; p < 0.001) compared to Hispanic (APC -1.42, 95% CI, -1.9 to -0.93) and NH White patients (APC –0.26, 95% CI, –0.44 to 0.07). Individuals in rural areas died less often in a hospice facility (5.6% rural vs 10.8% large metropolitan vs 12% medium/small metropolitan) and slightly more often at home (46.3% rural vs 40.1% large metropolitan vs 43.7% medium/small metropolitan). Relative to patients in rural areas, patients in large metropolitan (OR 1.77; 95% CI, 1.74 to 1.81) and medium/small metropolitan areas (OR 2.27; 95% CI, 2.23 to 2.31) had higher odds of dying in a hospice facility compared to a medical facility. Conclusions: Rural residents with HNC experienced higher mortality rates and had lesser improvement compared to urban areas, with notable sociodemographic differences, and disparities in place of death. Public health interventions to combat health inequities for patients with HNC are required. Further, as EOL care is increasingly complex and the role of unpaid caregiving burdensome, policy interventions targeted to support disadvantaged populations and communities are urgent and necessary.