Trends in Place of Death for Head and Neck Cancer Patients in the US from 1999 to 2016 Using the CDC WONDER Database

Abstract

What constitutes a “good” death is open to interpretation, but most agree that death at home or hospice is optimal and contributes to achieving this goal. Head and neck cancer (HNC) patients often experience significant morbidity and mortality related to their disease and/or cancer therapies, but little is known about trends and disparities in their place of death. The CDC WONDER (Wide-ranging Online Data for Epidemiologic Research) database contains national US death certificate data, including place/cause of death and patient-specific characteristics. Trends in place of death were evaluated from 1999 to 2016 for patients who died from HNC and correlated to aggregate patient-specific data including age, sex, race, census region, and primary tumor subsite. Deaths in hospice facilities were not specifically reported until 2003. Using individual data from 2015, univariate (UVA) and multivariate (MVA) logistic regression analyses were used to evaluate disparities in place of death based on demographic factors. From 1999 to 2016, 130,466 patients died from HNC in the US (28.8% oral cavity, 27.2% oropharynx, 1.7% nasopharynx, 42.2% hypopharynx/larynx). Most patients were white (91.4%) and male (80.1%). Forty-four percent of deaths occurred at home or hospice. Total number of HNC-related deaths increased from 6,493 in 1999 to 8,693 in 2016. Percent of deaths at home or hospice increased significantly over the study period for all patients (R2 = 0.97, p<0.0001), rising from 31.4% in 1999 to 40% in 2006 to 59% in 2016. Percent of deaths at home or hospice increased significantly in white (33% in 1999 vs 42% in 2006 vs 59% in 2016), black (21% vs 22% vs 51%), age 35-64 (35% vs 43% vs 62%), age ≥65 (29% vs 38% vs 57%), male (33% vs 41% vs 58%) and female patients (27% vs 37% vs 61%), as well as for all disease subsites and census regions. Prior work for all cancer types demonstrated that age ≥40, marital status, education level, and white race were associated with death at home or hospice on UVA. For deaths from HNC, patients with hypopharynx/larynx cancer were less likely to die at home or hospice (OR 0.80, 95% CI 0.73-0.87, p<0.000001). On MVA, HNC patients who were single, black, or Asian/Pacific Islanders were less likely to die at home or hospice. Patient sex and education level were not significantly associated with place of death. Similar to the UVA, patients with cancers of the hypopharynx/larynx were less likely to die at home or hospice on MVA (OR 0.83, 95% CI 0.76-0.92, p=0.0002). Percent of HNC-related deaths at home or hospice increased by 1.9-fold between 1999 and 2016. Non-white patients and those with hypopharynx/larynx cancers were significantly less likely to die at home or hospice. Continued emphasis on palliative care and provider/patient education may help to narrow these apparent disparities and contribute to more HNC patients experiencing a “good” death.