ORIGINAL ARTICLE
Does Rurality Influence Treatment Decisions in Early Stage Laryngeal Cancer? Heath B. Mackley, MD;1 Tatiana Teslova, BS;1 Fabian Camacho, MS;2 Pamela F. Short, PhD;3 & Roger T. Anderson, PhD2 1 Department of Radiation Oncology, Penn State Hershey Cancer Institute, Penn State College of Medicine, Hershey, Pennsylvania 2 Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania 3 Department of Health Policy and Administration, Penn State University, University Park, Pennsylvania
Abstract Purpose: The mortality rate of laryngeal cancer has been trending downward Acknowledgments: The authors acknowledge the assistance of the Community Sciences and Health Outcomes Core of the Penn State Hershey Cancer Institute in this research. For further information, contact: Heath Mackley, MD, Department of Radiation Oncology, Penn State Cancer Institute, 500 University Drive, Hershey, PA 17033; e-mail: [email protected]. doi: 10.1111/jrh.12069
with the use of more effective surgical, radiation, and systemic therapies. Although the best treatment for this disease is not entirely clear, there is a growing consensus on the value of primary radiotherapy as an organ preservation strategy. This study examines urban-rural differences in the use of radiotherapy as the primary treatment for early stage laryngeal cancer in Pennsylvania. Experimental Design: The sample was drawn from the Pennsylvania tumor registry, which lists 2,437 laryngeal cancer patients diagnosed from 2001 to 2005. We selected 1,705 adults with early stage squamous cell carcinoma of the larynx for our analysis. Demographic data and tumor characteristics were included as control variables in multivariate analyses. Rurality was assigned by ZIP code of patient residence. Results: Controlling for demographic and clinical factors, rural patients were less likely than urban patients to receive radiotherapy as the primary treatment modality for early stage larynx cancer (OR 0.740, 95% CI 0.577-0.949, P = .0087). No other associations between rural status and treatment choice were statistically significant. Conclusions: Relatively fewer rural patients with larynx cancer are treated primarily with radiation therapy. Further investigations to describe this interaction more thoroughly, and to see if this observation is found in larger population data sets, are warranted.
Key words early stage, laryngeal cancer, organ preservation, radiotherapy, rurality.
Cancers of the larynx accounted for 12,360 new cases and 3,650 deaths in the United States in 2012.1 Alcohol and tobacco are the 2 leading causes of laryngeal carcinoma.2,3 The mortality rate of laryngeal cancer has been trending downward with the use of more effective diagnostics and therapies. Improved diagnostic techniques, such as positron emission tomography, endoscopic imaging,4 and tissue autofluorescence,5 more accurately stage patients and allow the detection of asymptomatic tumors at earlier stages. Over the past decade, there has been a growing consensus on the importance of organ preservation in la406
ryngeal cancer. Several treatment strategies have been developed to achieve this goal, such as transoral endoscopic microsurgery,6,7 photodynamic therapy,8 radiation therapy,9,10 and combining chemotherapy with radiotherapy.11 Recent guidelines recommend laryngeal preservation in the initial treatment of all patients with T1 or T2 larynx malignancies.12 This can be achieved with radiotherapy for early stage (Stage I-II) malignancies,13,14 an approach shown to have similar long-term overall survival in patients compared to total laryngectomy.15 The toxicity of radiotherapy has improved over time as well, without compromising efficacy, with the c 2014 National Rural Health Association The Journal of Rural Health 30 (2014) 406–411
Mackley et al.
implementation of more focal radiation delivery methods such as intensity-modulated radiation therapy.16,17 Organ preservation in locally advanced (Stage III-IVb) laryngeal cancer is also a standard option, where the combination of radiotherapy and chemotherapy has been demonstrated to provide a better long-term quality of life and less respiratory, speech, and sleep disturbances without compromising survival.18 Even when radiation therapy is considered the standard of care, or at least an accepted treatment option, there is no ensurance that rural populations will have equal access to this mode of treatment. For example, there is growing evidence that rural populations are less likely to receive radiation after breast conservation surgery for breast cancer, even though it is widely considered the standard of care based upon randomized trials.19-21 There is also evidence that rurality influences patients’ choices of treatments involving radiotherapy, with breast cancer patients living far from a radiation facility less likely to choose breast conservation therapy.22-24 Medical and radiation oncology services have been shown to be less accessible to rural colorectal cancer patients, who confront a greater potential burden of time, cost, and discomfort in traveling to treatment facilities.25 There is limited evidence that rural populations receive less radiotherapy across all disease sites when it is indicated,26 but there are currently no data specifically regarding the treatment of laryngeal cancer for patients in rural areas. The purpose of this investigation is to examine urbanrural differences in treatment choices for laryngeal malignancies in Pennsylvania residents. Pennsylvania was chosen for this exploratory study because the state cancer registry offers large samples of both rural and urban laryngeal cancer patients, and there is no reason to think that the treatment of laryngeal cancer is atypical in Pennsylvania.
Materials and Methods A total of 2,437 larynx cancer cases (C101, C320-C329) diagnosed from 2001 to 2005 were identified from the Pennsylvania Central Cancer Registry database (PCR). The PCR is a statewide effort to collect cancer incidence data that has been operating since 1982. Hospitals and health care providers are mandated by law to report incident cancer cases to the registry. Through case finding and abstraction efforts, the registry summarizes information for each case regarding the type, site, and extent of the cancer and the types of treatment received. In 2005, the registry received the highest possible certification awarded to statewide registries from the North
c 2014 National Rural Health Association The Journal of Rural Health 30 (2014) 406–411
Rurality’s Influence on Laryngeal Cancer Treatment
American Association of Central Cancer Registrars for completeness, quality, and accuracy of the data. Cases were restricted to those exhibiting histology and behavior pertaining to squamous cell carcinoma identified through ICD-O-3 codes (ICD-O-3 histology 8051 and behavior 3, 8052:2, 8052:3, 8070:3, 8071:3, 8072:3, 8073:3, 8074:3, 8075:3, 8076:3, 8077:2, 8077:3, 8078:3, 8083:3, 8084:3, 8094:3, 8560:3). Second, cases with indeterminate treatment choice, as defined in the next paragraph, were excluded from the sample. Finally, cases were selected if they had a local- (N = 1,705) or regionalstage (N = 732) tumor defined according to the 2000 Surveillance, Epidemiology, and End Results (SEER) summary-stage classification method (codes 1 for local, and codes 2 through 5 for regional). Both local- and regional-stage patients are potentially curable, and they can receive organ preservation as a primary treatment choice. In general, local corresponds with early stage (III) and regional stage corresponds to locally advanced stages (III-IVb). Treatment choice was defined as having surgery as the primary modality, radiation as the primary modality, or no treatment received. Receipt of radiation during the first course of treatment was based on the SEER/Commission on Cancer Consortium regional radiation treatment modality variable available from the registry. Receipt of surgery was based on SEER site-specific surgery codes for larynx.27 Wide/radical excisions and laryngectomies were considered indications of definitive primary surgery. A patient was also coded as receiving primary surgery if local tumor destruction/excision was provided and no radiotherapy was given. Otherwise, a patient was coded as receiving primary radiation if radiation was confirmed and surgery was not definitive, not provided, or unknown. Rural status was determined by using Rural-Urban Commuting Area codes (RUCA) adapted to ZIP codes. The codes are a census tract-based urban/rural classification scheme that uses Bureau of Census urbanized area and urban cluster definitions in combination with work commuting information. For purposes of this project, RUCA urban status was defined as all ZIP codes that have 30% or more of their workers going to a Census Bureaudefined urbanized area.28 Otherwise, the case was classified as rural. The association of rurality with primary surgery and primary radiation was examined by fitting logistic regressions predicting treatment choice as the dependent outcome variable. Rural/urban status was included as a predictor together with additional covariates encompassing local versus regional SEER summary stage, gender, age at time of diagnosis, race, and presence of positive lymph nodes. The SAS v9.3 system (SAS Institute Inc., Cary, North Carolina) was used to report and analyze the data.
407
Rurality’s Influence on Laryngeal Cancer Treatment
Mackley et al.
Table 1 Patient Characteristics
Age White Females Stage local (vs regional) Treatment Primary surgery Primary radiation None No chemotherapy
All (N = 2,437)
Rural (N = 532) 21.8%
Urban (N = 1,905) 78.2%
P Value
65.8 (11.3) 87.7% 21.1% 70.0%
65.7 (11.6) 96.6 18.1 72.4
65.8 (11.3) 85.2 22.0 69.3
.6073
Does Rurality Influence Treatment Decisions in Early Stage Laryngeal Cancer? Heath B. Mackley, MD;1 Tatiana Teslova, BS;1 Fabian Camacho, MS;2 Pamela F. Short, PhD;3 & Roger T. Anderson, PhD2 1 Department of Radiation Oncology, Penn State Hershey Cancer Institute, Penn State College of Medicine, Hershey, Pennsylvania 2 Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania 3 Department of Health Policy and Administration, Penn State University, University Park, Pennsylvania
Abstract Purpose: The mortality rate of laryngeal cancer has been trending downward Acknowledgments: The authors acknowledge the assistance of the Community Sciences and Health Outcomes Core of the Penn State Hershey Cancer Institute in this research. For further information, contact: Heath Mackley, MD, Department of Radiation Oncology, Penn State Cancer Institute, 500 University Drive, Hershey, PA 17033; e-mail: [email protected]. doi: 10.1111/jrh.12069
with the use of more effective surgical, radiation, and systemic therapies. Although the best treatment for this disease is not entirely clear, there is a growing consensus on the value of primary radiotherapy as an organ preservation strategy. This study examines urban-rural differences in the use of radiotherapy as the primary treatment for early stage laryngeal cancer in Pennsylvania. Experimental Design: The sample was drawn from the Pennsylvania tumor registry, which lists 2,437 laryngeal cancer patients diagnosed from 2001 to 2005. We selected 1,705 adults with early stage squamous cell carcinoma of the larynx for our analysis. Demographic data and tumor characteristics were included as control variables in multivariate analyses. Rurality was assigned by ZIP code of patient residence. Results: Controlling for demographic and clinical factors, rural patients were less likely than urban patients to receive radiotherapy as the primary treatment modality for early stage larynx cancer (OR 0.740, 95% CI 0.577-0.949, P = .0087). No other associations between rural status and treatment choice were statistically significant. Conclusions: Relatively fewer rural patients with larynx cancer are treated primarily with radiation therapy. Further investigations to describe this interaction more thoroughly, and to see if this observation is found in larger population data sets, are warranted.
Key words early stage, laryngeal cancer, organ preservation, radiotherapy, rurality.
Cancers of the larynx accounted for 12,360 new cases and 3,650 deaths in the United States in 2012.1 Alcohol and tobacco are the 2 leading causes of laryngeal carcinoma.2,3 The mortality rate of laryngeal cancer has been trending downward with the use of more effective diagnostics and therapies. Improved diagnostic techniques, such as positron emission tomography, endoscopic imaging,4 and tissue autofluorescence,5 more accurately stage patients and allow the detection of asymptomatic tumors at earlier stages. Over the past decade, there has been a growing consensus on the importance of organ preservation in la406
ryngeal cancer. Several treatment strategies have been developed to achieve this goal, such as transoral endoscopic microsurgery,6,7 photodynamic therapy,8 radiation therapy,9,10 and combining chemotherapy with radiotherapy.11 Recent guidelines recommend laryngeal preservation in the initial treatment of all patients with T1 or T2 larynx malignancies.12 This can be achieved with radiotherapy for early stage (Stage I-II) malignancies,13,14 an approach shown to have similar long-term overall survival in patients compared to total laryngectomy.15 The toxicity of radiotherapy has improved over time as well, without compromising efficacy, with the c 2014 National Rural Health Association The Journal of Rural Health 30 (2014) 406–411
Mackley et al.
implementation of more focal radiation delivery methods such as intensity-modulated radiation therapy.16,17 Organ preservation in locally advanced (Stage III-IVb) laryngeal cancer is also a standard option, where the combination of radiotherapy and chemotherapy has been demonstrated to provide a better long-term quality of life and less respiratory, speech, and sleep disturbances without compromising survival.18 Even when radiation therapy is considered the standard of care, or at least an accepted treatment option, there is no ensurance that rural populations will have equal access to this mode of treatment. For example, there is growing evidence that rural populations are less likely to receive radiation after breast conservation surgery for breast cancer, even though it is widely considered the standard of care based upon randomized trials.19-21 There is also evidence that rurality influences patients’ choices of treatments involving radiotherapy, with breast cancer patients living far from a radiation facility less likely to choose breast conservation therapy.22-24 Medical and radiation oncology services have been shown to be less accessible to rural colorectal cancer patients, who confront a greater potential burden of time, cost, and discomfort in traveling to treatment facilities.25 There is limited evidence that rural populations receive less radiotherapy across all disease sites when it is indicated,26 but there are currently no data specifically regarding the treatment of laryngeal cancer for patients in rural areas. The purpose of this investigation is to examine urbanrural differences in treatment choices for laryngeal malignancies in Pennsylvania residents. Pennsylvania was chosen for this exploratory study because the state cancer registry offers large samples of both rural and urban laryngeal cancer patients, and there is no reason to think that the treatment of laryngeal cancer is atypical in Pennsylvania.
Materials and Methods A total of 2,437 larynx cancer cases (C101, C320-C329) diagnosed from 2001 to 2005 were identified from the Pennsylvania Central Cancer Registry database (PCR). The PCR is a statewide effort to collect cancer incidence data that has been operating since 1982. Hospitals and health care providers are mandated by law to report incident cancer cases to the registry. Through case finding and abstraction efforts, the registry summarizes information for each case regarding the type, site, and extent of the cancer and the types of treatment received. In 2005, the registry received the highest possible certification awarded to statewide registries from the North
c 2014 National Rural Health Association The Journal of Rural Health 30 (2014) 406–411
Rurality’s Influence on Laryngeal Cancer Treatment
American Association of Central Cancer Registrars for completeness, quality, and accuracy of the data. Cases were restricted to those exhibiting histology and behavior pertaining to squamous cell carcinoma identified through ICD-O-3 codes (ICD-O-3 histology 8051 and behavior 3, 8052:2, 8052:3, 8070:3, 8071:3, 8072:3, 8073:3, 8074:3, 8075:3, 8076:3, 8077:2, 8077:3, 8078:3, 8083:3, 8084:3, 8094:3, 8560:3). Second, cases with indeterminate treatment choice, as defined in the next paragraph, were excluded from the sample. Finally, cases were selected if they had a local- (N = 1,705) or regionalstage (N = 732) tumor defined according to the 2000 Surveillance, Epidemiology, and End Results (SEER) summary-stage classification method (codes 1 for local, and codes 2 through 5 for regional). Both local- and regional-stage patients are potentially curable, and they can receive organ preservation as a primary treatment choice. In general, local corresponds with early stage (III) and regional stage corresponds to locally advanced stages (III-IVb). Treatment choice was defined as having surgery as the primary modality, radiation as the primary modality, or no treatment received. Receipt of radiation during the first course of treatment was based on the SEER/Commission on Cancer Consortium regional radiation treatment modality variable available from the registry. Receipt of surgery was based on SEER site-specific surgery codes for larynx.27 Wide/radical excisions and laryngectomies were considered indications of definitive primary surgery. A patient was also coded as receiving primary surgery if local tumor destruction/excision was provided and no radiotherapy was given. Otherwise, a patient was coded as receiving primary radiation if radiation was confirmed and surgery was not definitive, not provided, or unknown. Rural status was determined by using Rural-Urban Commuting Area codes (RUCA) adapted to ZIP codes. The codes are a census tract-based urban/rural classification scheme that uses Bureau of Census urbanized area and urban cluster definitions in combination with work commuting information. For purposes of this project, RUCA urban status was defined as all ZIP codes that have 30% or more of their workers going to a Census Bureaudefined urbanized area.28 Otherwise, the case was classified as rural. The association of rurality with primary surgery and primary radiation was examined by fitting logistic regressions predicting treatment choice as the dependent outcome variable. Rural/urban status was included as a predictor together with additional covariates encompassing local versus regional SEER summary stage, gender, age at time of diagnosis, race, and presence of positive lymph nodes. The SAS v9.3 system (SAS Institute Inc., Cary, North Carolina) was used to report and analyze the data.
407
Rurality’s Influence on Laryngeal Cancer Treatment
Mackley et al.
Table 1 Patient Characteristics
Age White Females Stage local (vs regional) Treatment Primary surgery Primary radiation None No chemotherapy
All (N = 2,437)
Rural (N = 532) 21.8%
Urban (N = 1,905) 78.2%
P Value
65.8 (11.3) 87.7% 21.1% 70.0%
65.7 (11.6) 96.6 18.1 72.4
65.8 (11.3) 85.2 22.0 69.3
.6073
