A Comparison of Community-Based and Hospital-Based Head and Neck Cancer Screening Campaigns: Identifying High-Risk Individuals and Early Disease

Importance An enduring challenge in the care of patients with head and neck cancer is identifying disease earlier. Appropriately designed screening campaigns are one proposed strategy.

Objective To determine whether a hospital-based or a community-based head and neck cancer (HNC) screening strategy is more effective in identifying high-risk individuals, signs and symptoms, and findings consistent with head and neck neoplasia.

Design, Setting, and Participants In this retrospective cohort analysis, data from HNC screening efforts held at a tertiary care medical center and at a local motorsports event were compared. Participants completed a questionnaire, and a focused physical examination was performed.

Main Outcomes and Measures Identification rates of high-risk individuals, signs and symptoms, and findings consistent with head and neck neoplasia.

Results The hospital-based and community-based efforts yielded 210 and 1380 individuals screened, respectively. The community-based screening events attracted a significantly greater proportion of participants with risk factors of HNC including male sex (P < .001), current tobacco use (P < .001), lifetime history of tobacco use (P = .03), smokeless tobacco use (P = .003), and current alcohol use (P = .04). The hospital-based screening events, however, attracted a statistically greater proportion of people reporting prior head and neck or otolaryngologic treatment (P < .001), history of cancer outside the head and neck (P < .001), and a greater median number of symptoms (P < .001) and examination findings (P < .001).

Conclusions and Relevance These data suggest that the 2 screening models attract 2 fundamentally different types of participants, and those in both groups may benefit from screening, albeit for different reasons: one has a higher rate of risk factors, and early-stage HNC might be discovered while it is more readily treatable; the other has a higher rate of concerning signs, symptoms, and findings, and screening might be used to diagnose or rule out HNC.

Head and neck cancer (HNC) accounts for 46 000 new cases or 3% of all malignant neoplasms diagnosed in the United States each year.¹ The disease carries a profound degree of functional, cosmetic, and psychological morbidity and has a significant negative impact on socioeconomic status and quality of life.^2,3 Prognosis of HNC is closely linked to the stage at presentation.⁴ The majority of HNC comes to clinical attention at a relatively late stage owing to the surreptitious location of lesions, late onset of symptoms, and health care access and utilization disparities among those at highest risk for developing disease.^5-8

An enduring challenge in the care of patients with HNC has been to detect lesions earlier. Screening campaigns for HNC have been suggested as a solution to this challenge with the goal of detecting lesions earlier when treatment is more effective and raising awareness within a population unaware of the seriousness of HNC.⁹ Models for large-scale screening programs have been reported in tertiary care,¹⁰ cancer center,⁷ and primary care settings.¹¹ To out knowledge, no published account exists comparing hospital-based screening and community-based screening campaigns.

The current report compares a free hospital-based screening program with a free community-based screening program in terms of the percentage of total screened participants demonstrating risk factors for HNC and/or symptoms and physical examination findings concerning for HNC. The specific aim of the study was to determine which HNC screening design was more effective in identifying high-risk individuals, signs and symptoms, and physical examination findings consistent with early HNC. It was hypothesized that the community-based screening would yield a higher percentage of total screened participants demonstrating risk factors for HNC and/or symptoms or physical examination findings concerning for disease.

The hospital-based screening occurred between 2010 and 2011 at Indiana University Hospital and Wishard Memorial Hospital in Indianapolis, Indiana. The event was promoted through a university-affiliated e-mail list service, print newspaper notices, and advertisements posted in the hospitals. The screening event was open to all persons, regardless of age, sex, medical history, and tobacco or ethanol consumption status. Screening participants completed a questionnaire detailing pertinent medical history, exposure to HNC risk factors, and symptoms of head and neck disease. Screenings were conducted by board-certified otolaryngologists and resident otolaryngology physicians (ENTs) under the supervision of faculty members from Indiana University School of Medicine Department of Otolaryngology–Head and Neck Surgery.

A focused interview and physical examination elicited signs and findings concerning for disease, which were noted on a standardized examination form (Figure). Examinations were conducted in a private room equipped with headlights and basic examination equipment. Flexible nasopharyngoscopy was not performed; indirect laryngoscopy was attempted on all patients. Following the interview and physical examination, screeners triaged screened participants to 1 of 4 disposition options: (1) routine follow-up with primary care physician, (2) further head and neck evaluation may be necessary, (3) immediate consultation for suspected neoplasm, or (4) non-ENT referral (eg, dentist, dermatologist). Direct referrals were not made at the time of the screening. Likewise, the rate of patient follow-up and ultimate patient outcome were not tracked. Education was provided to participants about HNC signs, symptoms, and risk factors. Smoking cessation resources were also available. Because no identifiable information was collected, this study was exempt from institutional review board review, per institution policy.

The community-based screening was conducted as a 2-day screening event at the Indianapolis Motor Speedway on the day prior to and the day of the Brickyard 400 NASCAR event over the years 2009 through 2011. The event was promoted through a university-affiliated e-mail list service, print newspaper notices, the national Head and Neck Cancer Alliance website, and radio and television advertisements. Participants were screened in a manner identical to those in the hospital-based effort.

The information gathered from screening forms was entered into a database on either a scale (eg, age, pack-years of tobacco use, number of HNC symptoms reported by participants, number of physical examination findings reported by screeners) or as dichotomous variables (eg, current smoker, no [0] or yes [1]; symptoms present specifically concerning for HNC, no [0] or yes [1]). For qualitative designations such as what constitutes heavy ethanol consumption, a cutoff point (≥2 alcoholic beverages/d for men and ≥1 alcoholic beverages/d for women) was established, and these data were converted to dichotomous variables (HNC, no [0] or yes [1]). A finding specifically concerning for HNC was defined as the presence of any masses, mucosal changes, or skin lesions consistent with possible neoplasia; benign physical examination findings (eg, septal deviation, torus mandibularis) were distinguished from more serious, possibly malignant, findings.

Comparison of median values across samples (ie, hospital-based vs community-based) was performed using t tests for independent samples. Comparison of rates of normally distributed dichotomous variables (ie, frequency of current smokers among hospital-based HNC screening participants vs frequency of current smokers among community-based HNC screening participants) was performed using χ² analyses. Statistical significance was set at P < .05. Analyses were performed using SigmaStat, version 3.1.1 (Systat Software).

Over the course of 2009 to 2011, 1380 individuals were screened as part of community-based HNC screening events, and 210 individuals were screened as part of hospital-based events. Table 1 lists the patient characteristics of the community-based HNC screening events and those of the hospital-based HNC screening events.

Symptoms were selected by participants on the screening from a closed set of options provided on the screening form (Figure). The median number of symptoms of HNC reported by participants of the community-based and hospital-based events was 0 and 1 respectively (range, 0-10), with significantly fewer symptoms being reported by the community-based participants (P < .001). Table 2 lists the number and frequency of symptoms reported for the community-based sample and the hospital-based sample.

The locations of abnormal physical examination findings (eg, oral cavity, larynx) in the community-based and hospital-based screenings are listed in Table 3. The most commonly reported abnormal finding locations in the hospital-based sample were the oral cavity (14 of 210, 6.67%), neck (14 of 210, 6.67%), and skin (11 of 210, 5.24%); in the community-based sample, the most common locations of abnormal findings were the oral cavity (136 of 1380, 9.86%), skin (84 of 1380, 6.09%), and nose (58 of 1380, 4.20%).

Regarding the distribution of disposition selections made by screeners, “further head and neck evaluation recommended” was selected for 12.39% of community-based participants (n = 171) and for a significantly higher 20.00% (n = 42) of hospital-based participants (P < .001). “Immediate consultation for suspected neoplasm” was selected by screeners for 2.21% of the community-based sample (n = 29), not significantly different than the hospital-based sample (0.85% [n = 1]) (P = .51).

A total of 928 community-based participants (77.98%) reported that the HNC screen increased their “awareness of HNC,” a proportion significantly lower than that observed in the hospital-based sample (86.47%, n = .147) (P = .04). Altogether, 231 participants (21.19%) noted that they were previously “aware of the signs and symptoms of HNC,” a proportion significantly lower than that observed in the hospital-based sample (36.36%, n = .72) (P < .001).

Screeners for the respective hospital-based and community-based populations chose the remaining 2 options at the following rates: “routine follow-up with primary care physician,” 62% and 71%; and “other (eg, dental, dermatology, smoking cessation),” 4% and 10%. The disposition option was left blank for 13% of the hospital-based participants and 5% of the community-based participants.

An enduring challenge in the care of patients with HNC has been to detect lesions earlier when treatments are more effective. Screening campaigns for HNC are one strategy aimed at educating the public about the signs and symptoms of early disease to encourage earlier presentation. Large-scale screening programs have been reported in tertiary care,¹⁰ cancer center,⁷ and primary care settings.¹¹ The aim of this study was to determine which HNC screening model, hospital-based or community-based screening, was more effective in identifying members of the target population and early signs, symptoms, and physical examination findings concerning for HNC.

The central hypothesis of this study was in part confirmed and in part refuted: the community-based screening events did attract a significantly greater proportion of participants with risk factors for HNC including, male sex, current tobacco use, lifetime history of tobacco use, smokeless tobacco use, and current heavy alcohol consumption; however, the hospital-based screening events attracted a statistically greater proportion of participants reporting a history of any head and neck or otolaryngologic treatment, any history of cancer outside the head and neck, and a greater median number of symptoms and physical examination findings concerning for HNC. Likewise, a significantly greater proportion of the hospital-based sample was given the disposition assignment “further head and neck evaluation recommended.”

These data suggest a more interesting conclusion than originally predicted: the 2 HNC screening models attract fundamentally different types of participants, and those in both groups may benefit from screening, albeit for different reasons: one has a higher rate of risk factors, and early-stage HNC might be discovered while it is more readily treatable; the other has a higher rate of concerning signs, symptoms, and findings, and screening might be used to diagnose or rule out HNC. Targeting screening events toward individuals with risk factors has been identified previously as a goal by those treating other types of cancer such as melanoma.¹² Our work suggests that targeting those at risk may not necessarily identify the most disease. For this reason, rather than highlighting the superiority of one screening model over the other, these data could be used to support both screening models. The goal for screening in the community will concentrate on education and increasing public awareness of the risk factors for HNC, while hospital-based screening may continue to be used to try to identify disease at an early stage.

The lower proportion of reported risk factors in the hospital-based sample may be partially explained by differences in the atmosphere of the 2 settings. For the most part, both screenings were conducted by the same screeners using the same equipment and following the same protocol guided by standardized screening forms, but the hospital-based efforts were held in a clinic at a tertiary care medical center, a more somber environment. The community-based efforts, in contrast, were held at a major motor sports event, a festive environment where alcohol and tobacco consumption are a celebrated part of the culture. Thus, a form of recall bias may have been at work, with the hospital-based sample underreporting tobacco and alcohol use, and the community-based sample possibly overreporting their risk factors. Similarly, when compared with patrons who are attending an elective sporting event, individuals who participate in a hospital-based screening may be more likely to have a specific symptom or concern that brought them to be evaluated. This may account for the higher proportion of individuals reporting head and neck signs and symptoms in the hospital-based cohort.

A number of limitations of the current study should be kept in mind, which will serve to guide future research in this area. The asymmetry in the number of participants in each sample (ie, 210 in the hospital-based sample vs 1380 in the community-based sample) limits the statistical power of comparison of subgroups. As a result, subset analyses controlling for variables such as alcohol and tobacco use and cancer history were not possible. This may be the subject of future investigation.

In addition, the current study is limited by a lack of follow-up data. The screening efforts described herein were designed principally to raise public awareness about the signs and symptoms of HNC. Since direct referrals were not made and contact information was not collected, no data are available linking screeners' disposition selections to future treatment, disease outcomes, or smoking cessation. Such information would also be useful in performing cost-effectiveness analyses comparing hospital-based and community-based screening models. Cost-effectiveness of community-based oral cancer screening has been demonstrated within a large sample of high-risk men,¹³ but to our knowledge, no such analysis has made a hospital-based vs community-based comparison.

In conclusion, the current study suggests that the community-based and hospital-based screening models attract 2 fundamentally different types of participants, both of whom may benefit from screening for different reasons: the community cohort by nature of its higher rate of risk factors; the hospital-based cohort by virtue of its higher rate of concerning signs, symptoms, and physical examination findings.

Correspondence: Michael S. Harris, MD, Department of Otolaryngology–Head and Neck Surgery, Indiana University School of Medicine, 699 West Dr, Riley Research Wing 044, Indianapolis, IN 46202 (michharr@iupui.edu).

Submitted for Publication: November 20, 2012; final revision received February 20, 2013; accepted March 15, 2013.

Author Contributions: Ms Sayer had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Harris. Acquisition of data: Harris, Phillips, Sayer, and Moore. Analysis and interpretation of data: Harris, Phillips, and Moore. Drafting of the manuscript: Harris, Phillips, and Moore. Critical revision of the manuscript for important intellectual content: Harris, Phillips, Sayer, and Moore. Statistical analysis: Harris. Obtained funding: Phillips and Sayer. Administrative, technical, and material support: Sayer and Moore. Study supervision: Sayer.

Funding/Support: Support and direction for this research was provided by the Head and Neck Cancer Alliance (formerly the Yul Brenner Head and Neck Cancer Foundation). Funding for screening events was provided, in part, by Bristol-Meyers-Squibb and a 2010 Early Detection and Prevention grant from the American Head and Neck Society.

Additional Contributions: We would like to acknowledge Tammy Paal and all participating residents, students, staff, and faculty from the Department of Otolaryngology–Head and Neck Surgery, Indiana University School of Medicine, as well as community volunteers and screening participants.