Date of Award

January 2025

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Benajmin Judson

Abstract

Head and neck cancer (HNC) affects over 340,000 individuals worldwide annually and isassociated with significant physical, psychological, and financial burdens. Although palliative care (PC) can alleviate many of these challenges, less than 2% of patients with HNC receive PC services. This thesis examines palliative care utilization among HNC patients from multiple perspectives: patient-level, policy-level, cost-level, and provider viewpoints. Four complementary investigations were conducted. (1) Using the National Cancer Database (NCDB) from 2004–2019, we applied Andersen’s Behavioral Model (predisposing, enabling, and need factors) to identify patient- and system-level determinants of PC. (2) A separate NCDB analysis (2015–2020) explored the impact of Medicaid expansion and state-level palliative care policies on PC uptake. (3) The National Inpatient Sample (NIS, 2017–2020) was queried to compare hospital costs and aggressive end-of-life interventions versus PC in terminal HNC patients. (4) A 16-item survey of otolaryngologists, distributed via the American Head and Neck Society, assessed provider perspectives on PC referral timing and barriers. Overall, 5% of HNC patients in the NCDB received PC. Multivariable analyses revealed that younger age, advanced disease, and higher comorbidity scores predicted PC use, while private insurance and higher income had mixed associations across datasets. Medicaid expansion was associated with a modest but significant increase in PC utilization. In the NIS, PC was linked to fewer ICU admissions, less use of invasive therapies, and lower overall hospital costs. Survey responses highlighted late-stage referrals and multiple provider- and institution-level barriers, including discomfort discussing poor prognosis, lack of PC training, and limited integration of PC teams in tumor boards. Despite the substantial symptom burden in HNC, PC is underutilized. Equitable access and timely PC referrals are shaped by patient sociodemographic, health policies, and provider practices. Strengthening insurance coverage of PC, integrating PC teams into standard oncology workflows, and improving provider training and awareness are critical steps to optimizing palliative care for patients with HNC.

Comments

This thesis is restricted to Yale network users only. It will be made publicly available on 05/14/2027

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