Knowledge and Screening of Head and Neck Cancer Among American Indians in South Dakota

Objectives. We established the level of awareness of risk factors and early symptoms of head and neck cancer among American Indians in South Dakota and determined whether head and neck cancer screening detected clinical findings in this population.Methods. We used the European About Face survey. We added questions about human papillomavirus, a risk factor for head and neck cancer, and demographics. Surveys were administered at 2 public events in 2011. Participants could partake in a head and neck cancer screening at the time of survey administration.Results. Of the 205 American Indians who completed the survey, 114 participated in the screening. Mean head and neck cancer knowledge scores were 26 out of 44. Level of education was the only factor that predicted higher head and neck cancer knowledge (b = 0.90; P = .01). Nine (8%) people had positive head and neck cancer screening examination results. All abnormal clinical findings were in current or past smokers (P = .06).Conclusions. There are gaps in American Indian knowledge of head and neck cancer risk factors and symptoms. Community-based head and neck cancer screening in this population is feasible and may be a way to identify early abnormal clinical findings in smokers.Head and neck cancer, including cancers of the oral and nasal cavities, oropharynx, hypopharynx, and larynx, affects approximately 50 000 Americans a year.1 American Indians in the Northern Plains (North and South Dakota, Nebraska, Iowa) have significantly elevated incidence rates of head and neck cancer when compared with the US White population. Age-adjusted incidence rates for all head and neck cancer combined are 30% higher in this population, and for some subsites of head and neck cancer, such as tonsil (2.3 vs 1.3), floor of mouth (2.1 vs 1.5), and hypopharynx (1.5 vs 0.7), the rates per 100 000 persons are dramatically higher. These head and neck cancer rates are the second highest among all American Indians in the United States, second only to the Alaska Native population.2The most common risk factors for these cancers are tobacco and alcohol use. Exposure to the human papillomavirus (HPV) is an additional risk factor for oropharyngeal cancer, which includes cancer of the tonsil.3 Smoking is ubiquitous in this community, with 40% of people reporting current smoking compared with 23% for the general US population. Rates of binge drinking for this population are 20% compared with 17% for the general population.4 Studies of HPV infection rates taken from cervical samples of American Indian women in the Northern Plains have shown similar infection rates to those in the general US population.5 However, the rates of infection with high-risk, oncogenic strains of HPV are significantly higher (67% vs 15%).5,6 These high rates of smoking, heavy alcohol consumption, and virulent HPV infection place American Indians in the Northern Plains at marked risk for head and neck cancer.American Indians diagnosed with head and neck cancer also experience poorer survival compared with the general US population. Analysis of the Surveillance Epidemiology and End Result database and tumor registries in South Dakota indicated worse overall survival for American Indian patients with head and neck cancer (hazard ratio = 0.59), even after the study controlled for demographic variables and disease stage.7,8 A significant contributing factor to this disparity is late-stage presentation. Stage at presentation is the most important prognostic factor for head and neck cancer. Early-stage cancer is very curable, with 5-year survival rates around 91%. These survival rates decline dramatically for late-stage cancers to 30%.1Lack of public awareness of early signs and symptoms of certain cancers has been linked to later stage at presentation.9 Therefore, public health campaigns to increase awareness of early signs and symptoms of head and neck cancer may have a role in decreasing late-stage presentation. Critical to implementing successful educational efforts is defining a baseline knowledge level. The About Face survey was conducted by the European Head and Neck Society to gauge public awareness of head and neck cancer in Europe.10 It found that the general public has poor overall awareness of head and neck cancer and its early signs and symptoms. Telephone surveys conducted in the United States also have documented low awareness of head and neck cancer among rural Floridians.11,12 No comparable studies have been done among the American Indian population within the United States.Another potential avenue to decrease late-stage presentation is screening programs. Because of the relatively low incidence of head and neck cancer in the general population, no official recommendations exist for population-based screenings.13 However, community-based screening programs in Maryland and Kerala, India, have shown success in decreasing the rates of some types of head and neck cancer, such as oral cavity cancer.14,15 Furthermore, community-based screenings have been found to be cost-effective and have been successful in identifying positive clinical findings associated with head and neck cancer in at-risk individuals.16–18Given the high incidence of head and neck cancer among American Indians in the Northern Plains and demonstrated patterns of late-stage presentation among this population, our study had 2 goals. The first goal was to establish the level of awareness of risk factors and early symptoms of head and neck cancer among American Indians. The second goal was to determine whether a community-based head and neck cancer screening is a feasible and potentially effective method to detect positive clinical findings associated with head and neck cancer in this population.