DISCUSSION:
There have been increasing efforts in recent decades to improve health literacy among various patient populations. Previous studies have shown that the American public is most aware of tobacco as a risk factor for head and neck cancer and marginally aware of other risk factors2. We aimed to identify the level of knowledge of the general otolaryngology clinic population at a tertiary academic medical center. Our patients had a moderately high awareness of cigarettes (83.7%) and chewing tobacco (77.5%) as risk factors for HNC. In an online survey of the adult American public by Luryi et al, only 54.5% and 32.7% of adults correctly identified smoking cigarettes and chewing tobacco as risk factors for HNC, respectively2. The increased awareness of the carcinogenic nature of tobacco observed in our population could be attributed to a general increased health literacy in patients presenting to a specialty clinic or to increased media representation of the harmful effects of tobacco in recent years. Our non-cancer patient population more often correctly identified chewing tobacco as a risk factor for HNC compared to our cancer patients (78.9% vs 68.1%). Chewing tobacco is not as common in the northeast as compared to the Midwest United States9. Our patients were decently informed of the carcinogenic effects of chewing tobacco despite the low prevalence of this practice in our geographic location.
Drinking three or more alcoholic beverages a day increases a person’s risk of developing head and neck cancer 10. This risk is further intensified in patients who smoke tobacco and drink alcohol due to alcohol’s potential solvent properties 10. We have observed a lack of awareness especially among newly diagnosed head and neck cancer patients of the carcinogenic effects of alcohol. This was our driving force to pursue this study and bring attention to this knowledge gap. Our patients had mildly increased knowledge of alcohol as a risk factor for HNC (29.0%) compared to the general population as surveyed by Luryi et al (4.8%) 2.Previous studies at cancer screening events have shown similar results to ours, with 39.5% of patients identifying alcohol as a risk factor4. Our cancer patients were more knowledgeable of alcohol as a risk factor (40.6%) compared to our non-cancer patients (27.2%).However, the awareness level is too low to consider our cancer cohort or general otolaryngology population well informed.Our faculty and house staff have made efforts to educate newly diagnosed cancer patients of the carcinogenic effects of alcohol. As evidenced from this study, more work is needed in addition to expanding our education efforts to the remainder of our clinic population. Overall, the American public and otolaryngology patient population knowledge of alcohol as a risk factor for HNC is poor.
With the rise in Human Papilloma Virus (HPV) related cancers of the head and neck, public awareness of this viral risk factor has increased but is still only at 12 - 28% 2-4. Oral sex, increased number of sexual partners, and early age at first sexual encounter are associated with an increased risk of HNC 11. Similar to previous studies, only 21.8% of our patients identified oral sex as a risk factor for HNC.Public awareness of HPV is increasing, but it’s relation to head and neck cancer is still largely unknown by the general ENT population. Our cancer population was slightly more informed than the general ENT population (33.3% vs 20%). Sexual behaviors and their risk of HPV transmission is always a topic of education for our newly diagnosed HPV positive cancers patients.
It is not unexpected that the remainder of the risk factors for HNC were not commonly known by our patients. Increased risk of HNC with long term frequent use of mouthwash is thought to be related to the alcohol content 12.Poor oral hygiene and infrequent teeth brushing has repeatedly been shown to elevate the risk of HNC13. Betel quid has been associated with HNC regardless of whether tobacco is added to the mixture 14. Knowledge of these risk factors and their relation to head and neck cancer has not been well studied in the American public.
This study is the first to explore the general otolaryngology clinic patient population knowledge of head and neck cancer. We hypothesized that general otolaryngology patients would have improved knowledge compared to the general public. Our patients did show increased knowledge of the carcinogenic risk of smoking cigarettes and chewing tobacco compared to the general population as surveyed by Luryi.Our patients had improved, but still unsatisfactory, knowledge of alcohol as a risk factor for HNC. Our study brings attention to the need for patient education of the risk factors for head and neck cancer especially alcohol – a modifiable risk factor. Patients with a history of head and neck cancer are mildly more informed of the risk factors for HNC likely due to our physician to patient educational efforts, but there is still much needed improvement in this population as well.
Limitations of this study include single academic institution and localized geographic location. Albany county has a small Hispanic population (6%) compared to the United States as a whole (18%).8 However, as a tertiary referral center, we have a wide service area including 25 counties in New York, Vermont, and Massachusetts. Collecting sociodemographic information would have added to our study’s generalizability. Our future efforts will be aimed at improving knowledge of all otolaryngology patients through increased physician to patient efforts and educational campaigns.