Influence of Socio-economic Factors on the Late Presentation of Head and Neck Cancers

Head and neck cancers are some of the most common cancers in the Indian subcontinent. A significant issue that confronts the otolaryngologists is many of these cancers present in the late stage. This is in contrast to western countries where head and neck cancers present in early stages. A major factor responsible for the difference in presentation could be due to inequalities in the standard of living in developed and developing countries.

Standard of Living (SOL) [1,2] in a country depends upon:
1) Level of national income
2) The total amount of goods and services a country is able to produce
3) Size of population
4) Level of education
5) General price level
6) Distribution of national income

Staging of cancer depends on the size of primary lesion, its extent of spread to regional lymph nodes and the presence or absence of blood borne metastasis. A stage also refers to a point in time in an essentially dynamic situation where the tumor and patient are changing in relation to each other.

Knowledge of extent of tumor affects the choice of treatment and that “small” or early cancers do better than more advances once. The morphological extent of cancer does not tell the whole story and it may be better to integrate tumor and host related factors with anatomical extent to produce prognostic indices with which to make treatment decisions and compare outcomes. Most of these cancers when staged as III or IV do not have a 5yr survival exceeding 40% worldwide.

Many factors in India could influence the late presentation of head and neck cancers for treatment. In traditional societies gender could influence the time of consultation with a doctor.

Illiteracy and standard of living [1,2] are obvious factors which could exert their influence as these could be governed by per capita income of the family.

Education and socio-economic status may affect an individual’s knowledge of the health care system, access to services and potential level of involvement in care. As a result those who are more educated may have more positive outcomes because of more active involvement in treatment decisions. Additionally, level of social support among better educated and more economically stable individuals may play a role in the rehabilitation process.

India is a country with multiple systems of alternate medicine and many head and neck cancers seek their help fearing the mutilating effects of surgery and radiation.

Another interesting facet that has to be researched is the number of doctors the patient has seen before being diagnosed as having cancer. This could also throw some light on the quality of medical education in our country.

All the patients In total of 62 patients were enrolled in the study.

were first confirmed histopatologically and then were later staged on the basis of standard TNM staging system of head and neck malignancy [3].

Patients were divided into 2 groups
A: I^st and II^nd stage (Early stage)
B: III^rd and IV^th stage (Late stage)

We performed a logistic regression analysis for variables of socioeconomic status (marital status, family income, highest level of education achieved) and potential confounding variables (age, gender, religion smoking status and alcohol consumption). 

So, a detailed performa including fore-mentioned variables along with other factors such as number of consultations before achieving definitive diagnosis, treatment of alternate medicine and distance of tertiary centre from home was filled at the first visit of the patient to our tertiary hospital.

The effects of these socioeconomic variables on head and neck cancer were compared with their effects on cancers overall. We compared these variables between the respective 2 groups and tabulated the data using “chi square” method. A ‘p’ value of <0.05 was consider significant.

Head and neck cancer shares about 1.8% of all cancers worldwide in terms of incidence and having a high mortality rate of about 72% on incidence [2]. The mortality rate is higher in our country as compared to other developed countries just because of their late presentation and delay in their early diagnosis. Various host related factors determine not only the stage of presentation of cancer but also treatment decision and outcome of disease [4].

The association between head and neck cancers and socio-economic factors remains under-researched and poorly understood, and therefore, this study is very relevant.

Some attempts have been made previously to determine the affect of socio-economic indices on quality of life after definitive treatment in head and neck cancer [5], but no such Indian study has been conducted to determine their role in diagnosis of cancer.

Presentation of cancer varies largely as a result of lifestyle and thus a consequence of the conditions in which individuals live and work. This lifestyle has been highly influenced by the person’s annual income which has come to be highly significant in our study (p=0.003). As far as education of patient is concerned; it had a statistically significant elevated risk of head and neck cancer among the uneducated and school dropouts. The effect of education may be attributed to its influence on risky behaviours and lifestyle choices. Similar type of result was concluded by various studies conducted at other geographic area populations [6,7].

Our study showed that incidence of head and neck cancer is more in males (40s and 50s) as compared to females irrespective of stage. Our finding is in agreement with the study conducted by WHO [2] and University of Texas [6].

Majority of patients of early stage cancers belong to a younger age group in comparison to patients of late stage who belong to an older age group. Various socio-economic indices (such as occupation, marital status, ethnicity and education of their children) have no direct influence on the late presentation of head and neck cancers. Some western studies do not support our result stating statistically significant increase in head and neck cancer incidence for adult men with status as single or never married and unemployed or unskilled employment life time [7,8].

Along with these indices, we have also tried to investigate certain other aspects corresponding to the same but these have no previous literature to correlate upon. In the field of previous medical consultations before being diagnosed as to have cancer, majority of patients have gone for 1-2 previous consultations. This suggest that the patient first prefers to go to a local nearby doctor and later if not satisfied or cured then finally goes to a tertiary centre.

Most of the cancers were detected by doctors at the post-graduate level in both early and late stages but still some of the graduates have succeeded in early detection of cancers. These are the few graduates sitting at primary or secondary centres and have diagnosed the case histopathologically. The patient is then referred to tertiary hospital for further evaluation. Similar study was conducted in Canada for oral cancers and they concluded that dentists also play a significant role in disease identification [9].

In case of alternate medicine, 26% of patients took ayurveda predominately compared to homeopathy. This suggests that other medical treatments for cancer are still popular among our people.

Major percentage of patients in early stage resides within the 25km range from the nearby tertiary hospital while greater percentage in late stage is outside this limit. People living in areas with limited access to health care services have poorer health/prognosis then people living in metropolitan areas. Geographical isolation, poorer transport links, shortage of health care providers and more difficult access to health care are probably contributing factors along with a high proportion of indigenous people and generally lower socio-economic status of residents of remote areas. This shows that distance is a significant negative factor for causing delay in presentation in our patients and goes in coordination with various other reference studies [7,8,10]. All these above mentioned factors are also contributing to the delay in early diagnosis of cancer.