Assessing the impact of institutional and sociodemographic factors on treatment and outcomes in head and neck cancer
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Abstract
Disparities in head and neck cancer (HNC) outcomes reflect the complex interplay of social, institutional, and biological factors that influence access to care, treatment delivery, and survival. This dissertation examines structural and clinical determinants of inequities in cancer care through three population-based studies using data from the National Cancer Database (NCDB). Collectively, these studies evaluate the effects of healthcare system characteristics, global crises, and evolving treatment paradigms on outcomes among HNC patients. The first study assessed the association between hospital safety-net burden and survival among patients with head, neck, and thyroid cancers. Although crude analyses showed worse survival in hospitals with higher safety-net burden, the association was largely explained by patient and treatment characteristics. Using propensity score–based methods, safety-net burden was not independently associated with overall survival, indicating that differences in outcomes reflect patient mix and access-related disparities rather than hospital performance itself.
The second study evaluated the impact of the COVID-19 pandemic on diagnosis, treatment, and care delivery for HNC patients in the United States. The pandemic year (2020) showed a 17% relative decline in new cancer diagnoses. Among treated patients, there was a small increase in advanced-stage presentation and a shorter time from diagnosis to treatment initiation, while treatment utilization (surgery, radiation, chemotherapy) and radiation discontinuation were essentially unchanged compared with the pre-pandemic period. While baseline disparities by race, income, and hospital type persisted, the pandemic did not substantially exacerbate these inequities.
The third study assessed reduced-dose radiation (50–<66 Gy) versus standard dose (66–70 Gy) for HPV-positive oropharyngeal cancer. After inverse probability weighting and quantitative bias analysis for smoking, overall survival was comparable across dose groups. Survival patterns varied by treatment modality: reduced dose appeared beneficial in surgical/adjuvant settings and less favorable in definitive chemoradiation. No survival disparities were detected by race or income.
Together, these studies provide evidence that institutional context, systemic disruptions, and treatment innovations intersect to shape cancer care outcomes. The findings emphasize the need for equity-centered policies that strengthen safety-net infrastructure, ensure resilience during public health crises, and judicious implementation of emerging treatment innovations such as de-escalation therapies within an appropriate clinical context.
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2026