title: Survival of patients with head and neck squamous cell carcinoma by housing subsidy in a tiered public housing system.
abstract: 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.
  
  
  
  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.
  
  
  
  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.
  
  
  
  Patients with HNSCC living in smaller, higher-subsidy apartments have poorer survival despite no apparent delays in presentation. Cancer 2017;123:1998-2005. © 2017 American Cancer Society.
authors.affiliation: Department of General Surgery, Singapore General Hospital, Singapore.|Duke-National University of Singapore Medical School, Singapore.
authors.forename: Ting Hway
authors.identifier: 0000-0001-9234-4529
authors.initials: TH
authors.lastname: Wong
authors.affiliation: Division of Surgical Oncology, National Cancer Center Singapore, Singapore.
authors.forename: Thakshayeni
authors.initials: T
authors.lastname: Skanthakumar
authors.affiliation: Duke-National University of Singapore Medical School, Singapore.
authors.forename: Nivedita
authors.initials: N
authors.lastname: Nadkarni
authors.affiliation: School of Pharmacy, Memorial University of Newfoundland, Canada.
authors.forename: Hai Van
authors.initials: HV
authors.lastname: Nguyen
authors.affiliation: Duke-National University of Singapore Medical School, Singapore.|Division of Surgical Oncology, National Cancer Center Singapore, Singapore.
authors.forename: N Gopalakrishna
authors.initials: NG
authors.lastname: Iyer
mesh_terms: D000368:Aged; D002294:Carcinoma, Squamous Cell / Q000401:mortality* / Q000628:therapy; D005260:Female; D005380:Financing, Government / Q000706:statistics & numerical data*; D006258:Head and Neck Neoplasms / Q000401:mortality* / Q000628:therapy; D054624:Health Status Disparities; D006801:Humans; D007182:Income; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011638:Public Housing / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012307:Risk Factors; D012846:Singapore; D012923:Social Class; D000077195:Squamous Cell Carcinoma of Head and Neck; D015996:Survival Rate
keywords: head and neck; inequalities; residence characteristics; social determinants of health; socioeconomic; squamous cell carcinoma