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Effects of geographic area and socioeconomic status in Taiwan on survival rates of head and neck cancer patients after radiotherapy
Oral Oncology 62 (2016) 136–138
Contents lists available at ScienceDirect
Oral Oncology journal homepage: www.elsevier.com/locate/oraloncology
Letter to the editor Effects of geographic area and socioeconomic status in Taiwan on survival rates of head and neck cancer patients after radiotherapy q
According to Hagedorn’s research, which focused on male patients (aged 40–64 years) with head and neck cancer (HNC) in Belgium, mortality rates were significantly higher in men with a low socioeconomic status (SES) and in men living in deprived areas. There was significant regional variation in HNC survival [1]. In this study, we examined the effects of geographic regions and individual SES on survival rates after radiotherapy (RT) for HNC in Taiwan. We modified the inclusion and exclusion criteria used in our previous research [2]. We reviewed data of 40,988 adult patients with HNC (aged 20– 65 years) who underwent RT from the Registry for Catastrophic Illness Patients of the Taiwan National Health Insurance Research Database (NHIRD). SES was defined as follows: low income, 6US $ 547 per month [New Taiwan Dollar (NT$) 17,500]; moderate income, between US$ 547 and 781 per month (NT$ 17,500– 25,000); and high income, PUS$ 781 per month (NT$ 25,001) [3]. The geographic regions were categorized into northern, central, southern, and eastern Taiwan [4].
The overall survival rate of patients with HNC who underwent RT in Taiwan was 53.2%, and the median survival duration was 6.03 ± 0.10 years [95% confidence interval (CI): 5.831–6.229] (Table 1). We found that patients with low and medium SES in central, southern, and eastern areas had shorter median survival durations than the others and those with low SES in the northern area had longer median survival durations than the others. Kaplan–Meier survival curves were used for SES and geographic region (p < 0.05) (Figs. 1 and 2). Patients with the lowest SES had the worst survival rate (p < 0.01). According to data published by our government, life expectancy, concentration, and accessibility of medical resources are the best in the northern area [5,6]. This could explain why patients with low and medium SES in the northern area had better survival rates than those in the other areas. Indeed, convenient transportation and adequate concentration and accessibility of medical resources enable patients in Taiwan to choose the hospital they want under the National Health Insurance. Patients with high SES had a greater ability to cross regions and access other hospitals as well as choose the optimal medical therapy and medicines for themselves. Overall, a higher SES was associated with a higher survival rate, and the survival rate was significantly affected by
Table 1 Median survival year in each SES level and geographic region. Region
SES (level)
Cases
Survival (years) Median
SD
95% CI
Low Medium High
16,060 4811 5156 6093
8.680 6.360 7.080 11.610
0.218 0.342 0.324 0.436
8.252–9.108 5.690–7.030 6.444–7.716 10.756–12.464
Low Medium High
10,173 2952 4769 2452
5.740 4.450 5.120 9.140
0.198 0.311 0.239 0.572
5.351–6.129 3.841–5.509 4.651–5.589 8.018–10.262
Low Medium High
12,886 4113 5444 3329
4.290 3.070 3.950 7.080
0.123 0.159 0.168 0.380
4.049–4.531 2.758–3.382 3.621–4.279 6.336–7.824
Low Medium High
1879 607 807 465
3.670 2.300 3.080 7.690
0.258 0.345 0.297 0.906
3.165–4.175 1.607–2.993 2.498–3.662 5.914–9.466
40,998
6.030
0.101
5.831–6.229
Northern
Central
Southern
Eastern
Total case
q The authors report no commercial, proprietary, or financial interest in the products or companies described in this article.
http://dx.doi.org/10.1016/j.oraloncology.2016.10.015 1368-8375/Ó 2016 Elsevier Ltd. All rights reserved.
Letter to the editor / Oral Oncology 62 (2016) 136–138
Fig. 1. Kaplan–Meier plot of survival of patients with HNC undergoing radiotherapy.
P<.05
P<.05
P<.05
P<.05
Fig. 2. Kaplan–Meier plot of survival of patients with HNC undergoing radiotherapy (based on regional area & SES).
137
138
Letter to the editor / Oral Oncology 62 (2016) 136–138
variations in SES in each geographic area in Taiwan. There was also significant regional variation in HNC survival on RT. Conflict of interest statement No funds were received to support this study. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subjects of this study. Acknowledgements This study was supported by grants (VGHKS15-EM4-01) from Kaohsiung Veterans General Hospital and the Taiwan Health Promotion Administration. We are grateful for use of the National Health Insurance Research Database provided by Statistic Center of Department of Health and Welfare. We thank Research Center of Medical Informatics, Kaohsiung Veterans General Hospital, for data management. References
[5] Ministry of the Interior, Life Expectancy Table in Taiwan (version 2015). http:// www.moi.gov.tw/stat/life.aspx [assessed September 15, 2016]. [6] Ministry of Health and Welfare, Density of Medical Resources in Taiwan (version 2008). http://www.mohw.gov.tw/cht/DOS/DisplayStatisticFile.aspx?d= 4002 [assessed September 15, 2016].
Tsu-Jen Kuo Department of Stomatology, Kaohsiung Veterans General Hospital, Taiwan Chi-Hsiang Chu Department of Applied Mathematics, National Sun Yat-sen University, Kaohsiung, Taiwan Pei-Ling Tang Research Center of Medical Informatics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan College of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan Department of Nursing, Meiho University, Pingtung, Taiwan
⇑
[1] Hagedoorn P, Vandenheede H, Vanthomme K, Willaert D, Gadeyne S. A cohort study into head and neck cancer mortality in Belgium (2001–11): are individual socioeconomic differences conditional on area deprivation?. Oral Oncol 2016;61:76–82. [2] Kuo TJ, Leung CM, Chang HS, Wu CN, Chen WL, Chen GJ, et al. Jaw osteoradionecrosis and dental extraction after head and neck radiotherapy: a nationwide population-based retrospective study in Taiwan. Oral Oncol 2016;56:71–7. [3] Chen CH, Huang KY, Wang JY, Huang HB, Chou P, Lee CC. Combined effect of individual and neighbourhood socioeconomic status on mortality of rheumatoid arthritis patients under universal health care coverage system. Fam Pract 2015;32:41–8. [4] Hung GY, Horng JL, Yen HJ, Lee CY, Lee YS. Geographic variation in cancer incidence among children and adolescents in Taiwan (1995–2009). PLoS One 2015;10:e0133051.
Yu-Cheng Lai Department of Orthopedics, Kaohsiung Veterans General Hospital, Taiwan ⇑ Corresponding author at: Department of Orthopedics, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Rd., Kaohsiung 81362, Taiwan. E-mail address: [email protected] Available online 27 October 2016
Contents lists available at ScienceDirect
Oral Oncology journal homepage: www.elsevier.com/locate/oraloncology
Letter to the editor Effects of geographic area and socioeconomic status in Taiwan on survival rates of head and neck cancer patients after radiotherapy q
According to Hagedorn’s research, which focused on male patients (aged 40–64 years) with head and neck cancer (HNC) in Belgium, mortality rates were significantly higher in men with a low socioeconomic status (SES) and in men living in deprived areas. There was significant regional variation in HNC survival [1]. In this study, we examined the effects of geographic regions and individual SES on survival rates after radiotherapy (RT) for HNC in Taiwan. We modified the inclusion and exclusion criteria used in our previous research [2]. We reviewed data of 40,988 adult patients with HNC (aged 20– 65 years) who underwent RT from the Registry for Catastrophic Illness Patients of the Taiwan National Health Insurance Research Database (NHIRD). SES was defined as follows: low income, 6US $ 547 per month [New Taiwan Dollar (NT$) 17,500]; moderate income, between US$ 547 and 781 per month (NT$ 17,500– 25,000); and high income, PUS$ 781 per month (NT$ 25,001) [3]. The geographic regions were categorized into northern, central, southern, and eastern Taiwan [4].
The overall survival rate of patients with HNC who underwent RT in Taiwan was 53.2%, and the median survival duration was 6.03 ± 0.10 years [95% confidence interval (CI): 5.831–6.229] (Table 1). We found that patients with low and medium SES in central, southern, and eastern areas had shorter median survival durations than the others and those with low SES in the northern area had longer median survival durations than the others. Kaplan–Meier survival curves were used for SES and geographic region (p < 0.05) (Figs. 1 and 2). Patients with the lowest SES had the worst survival rate (p < 0.01). According to data published by our government, life expectancy, concentration, and accessibility of medical resources are the best in the northern area [5,6]. This could explain why patients with low and medium SES in the northern area had better survival rates than those in the other areas. Indeed, convenient transportation and adequate concentration and accessibility of medical resources enable patients in Taiwan to choose the hospital they want under the National Health Insurance. Patients with high SES had a greater ability to cross regions and access other hospitals as well as choose the optimal medical therapy and medicines for themselves. Overall, a higher SES was associated with a higher survival rate, and the survival rate was significantly affected by
Table 1 Median survival year in each SES level and geographic region. Region
SES (level)
Cases
Survival (years) Median
SD
95% CI
Low Medium High
16,060 4811 5156 6093
8.680 6.360 7.080 11.610
0.218 0.342 0.324 0.436
8.252–9.108 5.690–7.030 6.444–7.716 10.756–12.464
Low Medium High
10,173 2952 4769 2452
5.740 4.450 5.120 9.140
0.198 0.311 0.239 0.572
5.351–6.129 3.841–5.509 4.651–5.589 8.018–10.262
Low Medium High
12,886 4113 5444 3329
4.290 3.070 3.950 7.080
0.123 0.159 0.168 0.380
4.049–4.531 2.758–3.382 3.621–4.279 6.336–7.824
Low Medium High
1879 607 807 465
3.670 2.300 3.080 7.690
0.258 0.345 0.297 0.906
3.165–4.175 1.607–2.993 2.498–3.662 5.914–9.466
40,998
6.030
0.101
5.831–6.229
Northern
Central
Southern
Eastern
Total case
q The authors report no commercial, proprietary, or financial interest in the products or companies described in this article.
http://dx.doi.org/10.1016/j.oraloncology.2016.10.015 1368-8375/Ó 2016 Elsevier Ltd. All rights reserved.
Letter to the editor / Oral Oncology 62 (2016) 136–138
Fig. 1. Kaplan–Meier plot of survival of patients with HNC undergoing radiotherapy.
P<.05
P<.05
P<.05
P<.05
Fig. 2. Kaplan–Meier plot of survival of patients with HNC undergoing radiotherapy (based on regional area & SES).
137
138
Letter to the editor / Oral Oncology 62 (2016) 136–138
variations in SES in each geographic area in Taiwan. There was also significant regional variation in HNC survival on RT. Conflict of interest statement No funds were received to support this study. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subjects of this study. Acknowledgements This study was supported by grants (VGHKS15-EM4-01) from Kaohsiung Veterans General Hospital and the Taiwan Health Promotion Administration. We are grateful for use of the National Health Insurance Research Database provided by Statistic Center of Department of Health and Welfare. We thank Research Center of Medical Informatics, Kaohsiung Veterans General Hospital, for data management. References
[5] Ministry of the Interior, Life Expectancy Table in Taiwan (version 2015). http:// www.moi.gov.tw/stat/life.aspx [assessed September 15, 2016]. [6] Ministry of Health and Welfare, Density of Medical Resources in Taiwan (version 2008). http://www.mohw.gov.tw/cht/DOS/DisplayStatisticFile.aspx?d= 4002 [assessed September 15, 2016].
Tsu-Jen Kuo Department of Stomatology, Kaohsiung Veterans General Hospital, Taiwan Chi-Hsiang Chu Department of Applied Mathematics, National Sun Yat-sen University, Kaohsiung, Taiwan Pei-Ling Tang Research Center of Medical Informatics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan College of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan Department of Nursing, Meiho University, Pingtung, Taiwan
⇑
[1] Hagedoorn P, Vandenheede H, Vanthomme K, Willaert D, Gadeyne S. A cohort study into head and neck cancer mortality in Belgium (2001–11): are individual socioeconomic differences conditional on area deprivation?. Oral Oncol 2016;61:76–82. [2] Kuo TJ, Leung CM, Chang HS, Wu CN, Chen WL, Chen GJ, et al. Jaw osteoradionecrosis and dental extraction after head and neck radiotherapy: a nationwide population-based retrospective study in Taiwan. Oral Oncol 2016;56:71–7. [3] Chen CH, Huang KY, Wang JY, Huang HB, Chou P, Lee CC. Combined effect of individual and neighbourhood socioeconomic status on mortality of rheumatoid arthritis patients under universal health care coverage system. Fam Pract 2015;32:41–8. [4] Hung GY, Horng JL, Yen HJ, Lee CY, Lee YS. Geographic variation in cancer incidence among children and adolescents in Taiwan (1995–2009). PLoS One 2015;10:e0133051.
Yu-Cheng Lai Department of Orthopedics, Kaohsiung Veterans General Hospital, Taiwan ⇑ Corresponding author at: Department of Orthopedics, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Rd., Kaohsiung 81362, Taiwan. E-mail address: [email protected] Available online 27 October 2016