# The Impact of Digital Inequities on Nasal and Paranasal-Sinus Cancer Disparities in the United States: A Cohort Study

## TL;DR

This study finds that unequal access to digital resources worsens cancer care outcomes for nasal and paranasal sinus cancers in the U.S.

## Contribution

The study introduces the Digital Inequity Index to quantify how digital access disparities affect cancer care outcomes.

## Key findings

- Higher digital inequity is linked to shorter follow-up times and reduced odds of receiving surgery or radiation for nasal and paranasal sinus cancers.
- Electronic device and service availability had stronger impacts on care disparities than income-broadband ratios.
- Digital inequities affect cancer care even after accounting for traditional social determinants of health.

## Abstract

In the modern era, the use of technology can substantially impact care access. Despite the extent of its influence on several chronic medical conditions related to the heart, lungs, and others, the relationship between one’s access to digital resources and oncologic conditions has been seldom investigated in select pathologies among gastrointestinal and head-neck regions. However, studies on the influence of this “digital inequity” on other cancers pertaining to nasal and paranasal sinus cancer (NPSC) have yet to be performed. This remains in stark contrast to the extent of large data approaches assessing the impact of traditional social determinants/drivers of health (SDoH), such as factors related to one’s socioeconomic status, minoritized race or ethnicity, and housing-transportation status, on prognostic and treatment outcomes.

This study aims to use the Digital Inequity Index (DII), a novel, comprehensive tool that quantifies digital resource access on an area- or community-based level, to assess the relationship between inequities in digital accessibility with NPSC disparities in prognosis and care in the United States.

Patients with NPSC from 2008 to 2017 in the Surveillance, Epidemiology, and End Results Program were assessed for significant regression trends in the long-term follow-up period and treatment receipt across NPSCs with increasing overall digital inequity, as measured by DII. DII was based on 17 census-tract level variables derived from the summarized values overlapping that same time period from the US Census/American Community Survey and Federal Communications Commission Annual Broadband Report. Variables were categorized as infrastructure-access (ie, electronic device ownership, internet provider availability, and income-broadband subscription ratio) or sociodemographic (education, income, age, and disability), ranked, and then averaged into a composite score to encompass direct and indirect factors related to digital inequity.

Across 8012 adult patients with NPSC, males (n=5416, 67.6%) and White race (n=4293, 53.6%) were the most represented demographics. With increasing digital inequity, as measured by increasing total DII scores, significant decreases in the length of long-term follow-up were observed with nasopharyngeal (P<.01) and maxillary sinus cancers (P=.02), with decreases as high as 19% (35.2 to 28.5 months, nasopharynx). Electronic device and service availability inequities showcased higher-magnitude contributions to observed associated regression trends, while the income-broadband ratio contributed less. Significantly decreased odds of receiving indicated surgery (lowest odds ratio 0.87, 95% CI 0.80-0.95, maxillary) and radiation (lowest odds ratio 0.78, 95% CI 0.63-0.95, ethmoid) for several NPSCs were also observed.

Digital inequities are associated with detrimental NPSC care and surveillance trends in the United States, even when accounting for traditional SDoH factors. These results prompt the need to include digital factors into the discussion of contextualizing SDoH-based analyses of cancer care disparities, as well as the specific factors from which prospective implementations and initiatives can invest limited public health resources to alleviate the most pertinent drivers of disparities.