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.