Association of Socioeconomic Factors and Immunotherapy Use in Head and Neck Cutaneous Squamous Cell Carcinoma

Introduction: Immunotherapy is being increasingly utilized for treatment of cutaneous squamous cell carcinoma of the head and neck (cSCCHN). There are limited studies on social factors and their association with immunotherapy receipt in cSCCHN.

Methods: This is a population-based, cross-sectional study using Epic Cosmos, a database that includes >289 million patients from >1600 hospitals and clinics across the United States, Saudi Arabia and Lebanon. ICD-10 codes and cancer staging information entered by the clinician were used to identify patients with advanced stage (III and IV) cSCCHN between December 2015 and December 2024. Data extracted include the CDC Social Vulnerability Index (SVI) at the ZIP-code level (higher SVI indicates higher social vulnerability), census region, Medicaid versus non-Medicaid insurance, minority race, sex, and smoking history. Outcomes studied include receipt of immunotherapy (pembrolizumab, nivolumab, ipilimumab, and cemiplimab). Statistical significance was determined using chi-squared tests.

Results: 16,754 patients with advanced stage cSCCHN were identified. 74.0% (12,413) were male and 85.9% (14,407) were white. 2,944 (17.6%) and 5,445 (32.5%) were in the 1st and 4th SVI quartiles, respectively. 11.9% (2,000) of patients received immunotherapy. Increased SVI was significantly associated with decreased receipt of immunotherapy (13.6% in the least socially vulnerable quartile compared to 11.1% in the most socially vulnerable quartile, p=0.00005). Patients in the Northeast and non-smokers were significantly more likely to receive immunotherapy (p=0.00004 and 0.00002, respectively). Race, sex, and Medicaid insurance were not associated with immunotherapy receipt.

Conclusions: Receipt of immunotherapy in advanced cSCCHN is associated with a lower SVI, Northeast region, and non-smoking status. As immunotherapy use is established as standard of care treatment, targeted strategies to improve equity in immunotherapy usage and increase patient access may help reduce disparities. Future research should further elucidate barriers to access and impact on patient outcomes.