Survival of Patients With Head and Neck Squamous Cell Carcinoma by Housing Subsidy in a Tiered Public Housing System

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BACKGROUND:Socioeconomic status affects survival in patients diagnosed with head and neck squamous cell carcinoma (HNSCC), even in health systems with universal health care. Singapore has a tiered subsidized housing system, in which income determines eligibility for subsidies by size of apartment. The objective of this study was to assess whether a patient's residential type (small/heavily subsidized, medium/moderate subsidy, large/minimal or no subsidy) influenced mortality. A secondary analysis examined whether patients in smaller subsidized apartments were more likely to present with advanced disease.METHODS:An historical cohort study of patients in a tertiary referral center with HNSCC was identified in the multidisciplinary cancer database from 1992 to 2014. Clinicopathologic data were extracted for analysis. Patient residential postal codes were matched to type of housing. Logistic regression was performed to evaluate the relationship between all-cause mortality and the predictors of interest as well as the association between housing type and disease stage at presentation.RESULTS:Of the 758 patients identified, most were men (73.4%), the median age was 64 years, 30.5% and 15.2% were smokers and former smokers, respectively. Over one-half (56.8%) of patients presented with advanced disease. Male gender, age, stage at presentation, survival time from diagnosis, and smoker status were significant predictors of mortality. Patients living in the smaller, higher subsidy apartments had poorer survival, although they were not more likely to present with advanced disease, suggesting that the survival difference was not because of delayed presentation.CONCLUSIONS:Patients with HNSCC living in smaller, higher-subsidy apartments have poorer survival despite no apparent delays in presentation.Socioeconomic status affects survival in patients with head and neck cancer, even in health systems with universal health care. By using the tiered, subsidized housing system in Singapore as a proxy for socioeconomic status, the results from this study indicate that patients who reside in smaller, higher subsidy apartments have worse survival despite similar disease stage at presentation.

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