Area Deprivation Index Is Associated With Extent of Disease at Presentation in Inverted Papilloma

Abstract

Sinonasal inverted papilloma (IP) is the most common benign tumor found in the nasal cavity and has the potential for locally destructive effects and malignant transformation [1-3]. Birkenbeuel et al. demonstrate that in 565 patients with squamous cell carcinoma transformation of their IP, the 5-year overall survival rate was 62% and a mean recurrence time of 24.3 months [4]. Therefore, follow-up is crucial in detection of recurrence and preemptive revision resection prior to malignant transformation. While postulated, it has not yet been examined how socioeconomic factors may affect the disease presentation in IP patients. In the present study, we hypothesize that the area deprivation index (ADI), a geographic-level metric of socioeconomic disadvantage at the “neighborhood level,” may be higher in patients with more advanced diseases.

Approval was obtained from the University of Pennsylvania and Zucker School of Medicine at Hofstra/Northwell Institutional Review Boards.

This is a multi-institutional retrospective analysis of all patients who underwent resection of IP at two tertiary care centers over a 10-year period from 2008 to 2018. Chart review was conducted to gather data on demographics, disease presentation, and operative management. All factors were analyzed based on the ADI, which was provided by the University of Wisconsin Neighborhood Atlas and assigns discrete ordinal rankings of a census block group's deprivation relative to national data. ADI scores were assigned to patients based on their most recent documented residential address at the time of their rhinology care, and patients with higher ADI scores reside in a relatively more disadvantaged community.

The difference in mean ADI was compared using the Student's t-test. The significance level was set at an alpha (p-value) < 0.05 and was two-tailed. All statistical analysis was done using STATA version 13 (StataCorp, College Station, TX).

The correlation between ADI and disease presentation in IP patients raises concerns about disparities in disease burden and multiple sinus involvement that may lead to more extensive surgery and complications such as recurrence. Tong et al. previously demonstrated that multiple sinus attachment is significantly associated with increased odds of recurrence; moreover, multiple sinus attachment was also associated with increased rates of primary open surgical approach as opposed to endoscopic or combined approaches [5].

More broadly, this study's findings also align with a growing body of research indicating that patients residing in socially disadvantaged communities composed of lower income, educational attainment, and employment opportunities face significant challenges in accessing timely and quality surgical services [6]. The use of geographic indices to operationalize community and socioeconomic disadvantage continues to accumulate, with higher ADI previously being associated with increased likelihood of baseline severity of disease and revision surgery rates in the setting of chronic rhinosinusitis with nasal polyps (CRSwNP) [7, 8]. In the context of IP, delayed diagnoses can result in disease progression, rendering management more complex and increasing the risk of complications [4, 5]. More extensive surgical resections and adjuvant therapy necessitate more specialized support and follow-up care, which might not be readily available or accessible for patients from socioeconomically disadvantaged communities. Indeed, Samuelson et al. and Poetker et al. both established that rhinology care utilization at their institutions amongst patients with chronic rhinosinusitis with nasal polyps was dominated by white, female, and privately insured patients [9, 10].

This study is limited to a two-institution retrospective preliminary investigation; therefore, multi-institutional longitudinal studies tracking the long-term impact of socioeconomic status on treatment adherence, disease recurrence, and overall survival rates can provide valuable insights into the effectiveness of interventions over time and across populations in IP. Additionally, this study did not evaluate for other potentially confounding environmental factors intimately tied to health care disparities such as air quality, heat stress, and particulate matter. Future studies should aim to better incorporate these factors by operationalizing a metric which capture cumulative exposure to these environmental risk factors.

This study demonstrates that patients from socioeconomically disadvantaged communities exhibited higher rates of multiple sinus involvement and extra-sinus extension which required correspondingly higher rates of open surgical approaches. These findings align with existing research on disparities in accessing surgical services and highlight potential barriers to timely and quality care for IP patients from resource-deprived areas. This study emphasizes the need for further investigation into the intricate relationship between socioenvironmental factors and timely diagnosis, management, and outcomes of IP.

The authors declare no conflicts of interest.