Financial Burden of Dental Care Among Patients With Head and Neck Cancer

This survey study examines oral and dental complications of cancer treatment among patients with head and neck cancer, the association of cancer treatment with dental care use, and costs of associated dental treatment.

Key Points

Question

What are the financial implications of preventive and treatment oral care regimens among patients with head and neck cancer (HNC)?

Findings

In this survey study of 85 patients with HNC, 39% of patients accrued a substantial financial burden from the prevention and management of cancer treatment–related dental complications. Financial hardship was significantly associated with educational attainment, income level, dental visit frequency, out-of-pocket dental expenses, and self-reported oral health.

Meaning

The findings suggest that a marked financial burden may be experienced by many patients with HNC and HNC survivors with cancer treatment–related dental complications.

Abstract

Importance

Patients undergoing treatment for head and neck cancer (HNC) experience oral complications requiring substantial dental treatment. This treatment is commonly not reimbursed by medical insurers, presenting a potential financial burden for patients.

Objective

To characterize the dental care needs and associated cost burden for patients with HNC.

Design, Setting, and Participants

This survey study included Head and Neck Cancer Alliance (HNCA) members who were surveyed from March 23 to October 27, 2023, using Qualtrics. The survey was promoted using the HNCA’s social media and email list. Data analysis was performed between October 2023 and May 2024.

Main Outcomes and Measures

Main outcomes were oral and dental complications of cancer treatment among patients with HNC, the association of cancer treatment with dental care use, and costs of associated dental treatment.

Results

Of 100 individuals administered the survey, 85 (85%) completed all required questions and were included in the analysis. Of 84 participants with age and sex data, 51 (61%) were aged 65 years or older and 45 (54%) were female. Of 85 respondents, 59 (70%) indicated that their current oral health was worse than before cancer treatment. Most respondents (73 of 85 [86%]) endorsed oral complications from cancer treatment, including xerostomia (66 of 73 [90%]), caries (35 of 73 [48%]), and oral mucositis (29 of 73 [40%]); 64 of 73 respondents (88%) required follow-up dental treatment. Overall, 4 of 28 (14%) before HNC treatment and 17 of 53 (32%) after treatment reported finances as the reason that not all recommended dental care was received. A total of 33 of the 85 respondents (39%) said that their postcancer dental care had caused them financial hardship. Individuals who were less likely to endorse financial hardship were more likely to have greater educational attainment (odds ratio [OR], 0.20; 95% CI, 0.06-0.58), higher income (OR, 0.33; 95% CI, 0.11-0.94), increased pre-HNC dental visit frequency (OR, 0.30; 95% CI, 0.10-0.86), same or better oral health after HNC (OR, 0.13; 95% CI, 0.02-0.50), and lower out-of-pocket dental expenses after HNC (OR, 0.09; 95% CI, 0.03-0.29).

Conclusions and Relevance

In this survey study, most patients undergoing treatment for HNC required extensive dental treatment throughout cancer treatment; this treatment presented a financial burden for 39% of patients that was a limiting barrier to care. Since most private medical insurers do not reimburse for dental treatment, more comprehensive coverage deserves policy attention.

Introduction

The financial toxicities associated with head and neck cancer (HNC) therapies are increasingly recognized.¹ As HNC treatment regimens favorably impact outcomes, the at-risk period of financial vulnerability is increasing since costs associated with survivorship are elevated above baseline levels for at least 5 years after diagnosis.² For patients treated for HNC, median medical costs, including inpatient and outpatient services and out-of-pocket expenses associated with care, make up a larger percentage of their incomes than for patients with all other cancers.^2,3 A recent study assessed the specific activators of out-of-pocket costs for HNC survivors.² While the study provided a comprehensive description of many of the components contributing to expenses in the study patient cohort, it did not specifically consider issues around oral health and the financial burden of dental care for which HNC survivors are particularly at risk.⁴ While the clinical and economic burden of acute toxic effects associated with concomitant chemoradiotherapy regimens used to treat HNC has been the subject of many studies and reviews,^5,6,7 the long-term adverse consequences of oral complications from therapy are less well documented, especially in the context of their potential to substantially add to the financial weight of survivorship. This burden has been exacerbated by the historical failure of medical insurers to cover the management of dental diseases, even when they are directly associated with primary cancer therapy.⁴

Given the risk of opportunistic infections and development of severe oral complications, such as extensive dental caries, oral mucositis, and osteoradionecrosis of the jaw, it is recommended to treat any underlying dental pathology before commencing an antineoplastic treatment regimen.^8,9 After cancer therapy, the prevalence of dental caries has been found to be 28%, and patients had greater plaque and gingival indexes compared with healthy control individuals.¹⁰ Traditionally, treatments for dental complications have not been covered by medical insurers, and patients pay for this care using either dental insurance (either public or private) or out-of-pocket payment.¹¹ Medicare has only recently authorized payment for dental treatment for the elimination of oral infection prior to cancer therapy and following HNC treatment.¹²

Recently, a longitudinal National Institutes of Health (NIH)–sponsored observational study reported the extent and burden of oral complications in patients with HNC managed comprehensively at 6 academic medical and cancer centers, a best case scenario.¹³ Our study focused on a representative population of patients with HNC and sought to document and understand the associations between adherence to pretreatment oral health assessment and preventive dental treatment, the extent of posttreatment dental disease, and the consequences of the financial burdens of survivorship in this population.

Methods

This survey study was approved by the Harvard Longwood Medical Area Office of Human Research and Administration institutional review board. All study participants provided electronic consent and were not compensated.

A 20-item survey was developed by the study team and administered from March 23 to October 27, 2023, using Qualtrics (eAppendix in Supplement 1). The survey was distributed to members of the Head and Neck Cancer Alliance (HNCA), a national group that provides support and educational resources to patients with HNC and their families. Members who had undergone treatment for HNC were asked to complete the survey.¹⁴ The HNCA has 11 000 active members, and 3000 (mostly survivors) attended one of its webinars (August 29, 2023). Information regarding the survey was distributed via email to the HNCA’s members and was promoted on the HNCA’s social media pages. Four weekly reminders about survey completion were distributed using all platforms. Patients who attended the HNCA’s 2023 Survivorship Symposium were also asked to complete the survey.

Information collected first included cancer history, cancer diagnosis, pre-HNC treatment employment status, frequency of visiting a dentist before treatment, whether an oncologist recommended that a dentist be seen, and what dental care was performed if a dentist was seen prior to initiating cancer therapy. Participants were also asked about the payment type (eg, private insurance, public insurance, or self-pay) used for pre–cancer treatment and post–cancer treatment dental care.

The next section of the survey asked about cancer treatment, current oral health status, and dental appointment frequency. Survey questions addressed the presence of oral or dental complications associated with HNC care and, if they occurred, the dental treatment that was recommended as follow-up and the duration of this treatment. There was an additional set of questions about post–cancer care dental treatment payment types, total out-of-pocket expenses, and reported financial hardship associated with post-HNC treatment dental care.

The survey concluded with demographic questions, including age, sex at birth, race, ethnicity, area of residence, educational attainment, and income level (eAppendix in Supplement 1). Race and ethnicity were ascertained by self-report and included in an effort to better understand if health disparities played a role in accessing dental care for patients with HNC. Race and ethnicity categories included African American or Black, American Indian or Alaska Native, Asian, Hispanic or Latino, Native Hawaiian or Pacific Islander, White (non-Hispanic), and other. Key questions were mandatory to complete the survey (eg, cancer site and treatment modality, whether a dentist was seen prior to initiation of cancer therapy, current oral health compared with precancer treatment, presence of any oral or dental complications associated with cancer treatment, and self-reported financial hardship attributed to dental care after HNC therapy).

Statistical Analysis

Data were first examined through descriptive statistics. Item nonresponses were excluded from analyses. Odds ratios (ORs) and associated 95% CIs were calculated to determine strength of association between factors and self-reported financial hardship due to HNC-associated dental treatment. Statistical analysis was performed with the use of R, version 4.2.1 (R Project for Statistical Computing) between October 2023 and May 2024.

Results

Sociodemographics

A total of 100 individuals consented to participate in the survey. Of these individuals, 85 (85%) answered all the required questions and were included in the analysis.

Of the 84 survey respondents with data on age and sex, 51 (61%) were aged 65 years or older, 45 (54%) were female, and 39 (46%) were male. Most respondents were White (77 of 83 [93%]), a higher share than the US population (59%), and approximately half (44 of 84 [52%]) lived in a suburban area (Table 1).¹⁵ Of 83 respondents, 3 (4%) were African American or Black; 1 (1%), American Indian or Alaska Native; 1 (1%), Asian; and 3 (4%), Hispanic or Latino. None were Native Hawaiian or Pacific Islander or other race and ethnicity. Respondents had a high educational level: 75 of 82 (91%) attended at least some college, 33 of 82 (40%) reported completion of a bachelor’s degree, and 21 of 82 (26%) reported at least starting an advanced degree. Respondents’ median educational level (bachelor’s degree) and household income ($80 001-$100 000) exceeded those of the US population (some college and $75 000, respectively).^16,17

Table 1. Characteristics of 85 Survey Respondents With Head and Neck Cancer.

Characteristic	Patients, No. (%) [% of US population]a
Age, y (n = 84)
18-25	1 (1)
26-35	2 (2)
36-50	10 (12)
51-64	20 (24)
≥65	51 (61)
Sex assigned at birth (n = 84)
Female	45 (54)
Male	39 (46)
Race or ethnicity (n = 83)b
African American or Black	3 (4) [14]
American Indian or Alaska Native	1 (1) [1]
Asian	1 (1) [6]
Hispanic or Latino	3 (4) [19]
Native Hawaiian or Pacific Islander	0 [<1]
White (non-Hispanic)	77 (93) [59]
Otherc	0 [3]
Area of residence (n = 84)
Rural	28 (33)
Suburban	44 (52)
Urban	12 (14)
Highest level of education attained (n = 82)d
Less than high school diploma	1 (1) [9]
High school diploma or GED	6 (7) [28]
Some college	11 (13) [15]
Associate’s degree	10 (12) [10]
Bachelor’s degree	33 (40) [23]
Master’s degree	16 (20) [11]
PhD or other doctoral degree	5 (5) [3]
Prefer not to say	0
Total household income, $ (n = 81)
≤30 000	7 (9) [20]
30 001-45 000	7 (9) [11]
45 001-65 000	15 (19) [13]
65 001-80 000	11 (14) [10]
80 001-100 000	10 (12) [10]
100 001-150 000	15 (19) [16]
150 001-200 000	7 (9) [9]
>200 000	9 (11) [12]

Abbreviation: GED, General Educational Development.

^a Data from the US census.^15,16,17

^b Respondents could select all that applied.

^c Other was given as an option so that individuals had another option to select if they felt that they were not well categorized by the other options provided.

^d Among persons aged 25 years or older; the top census educational category was prorated between the top 2 survey categories for comparability.

Of 84 respondents, 53 (63%) were not employed at the time of the survey. Of those not employed at the time of initiation of their cancer therapy (36 of 85 [42%]), 25 (69%) were retired (eTable 1 in Supplement 1).

Primary Tumor Location and Cancer Treatment(s) Received

Primary tumor site identification and treatment descriptions were based on self-reported information. As noted in Table 2, tumor sites including the mouth, base of tongue, and oropharynx were reported by 62% (53 of 85) of the study cohort. Several patients did not identify a primary site and reported “other.” Several of these sites were recategorized based on the similarity of the patients’ responses to the available answer choices, but 13% of patients (11 of 85) had different sites from those provided as survey options.

Table 2. Cancer and Treatment Characteristics.

Characteristic	Patients, No. (%) (N = 85)
Sites of primary cancer diagnosis
Mouth, oral cavity	20 (24)
Base of tongue	20 (24)
Neck	3 (4)
Oropharynx	13 (15)
Larynx	4 (5)
Hypopharynx	1 (1)
Nasopharynx	5 (6)
Salivary gland	8 (9)
Other	11 (13)
Forms of treatment received for cancera
Chemotherapy	44 (52)
Surgery	54 (64)
Radiotherapy	75 (88)
Immunotherapy	4 (5)
None	0

^a Respondents could select all that applied.

Pre-HNC Dental Care

Most patients reported that their oncologist recommended dental screening at the start of cancer care (67 of 85 [79%]). Patient adherence to that recommendation was high (71 of 85 [84%]), and of those seeing a dentist, treatment was recommended for 33 (46%). Most individuals required some amount of procedural treatment before cancer care, with only 5 of 33 (15%) receiving solely a cleaning and fluoride varnish application. Among those who reported not receiving the recommended treatment course, finances or cost of treatment was the single most common reason (4 of 28 [14%]) (Table 3).

Table 3. Dental Care Among Survey Respondents With Head and Neck Cancer.

Variable	Patients, No. (%)
Pre–cancer treatment dental care
Frequency of dental visits prior to receiving cancer treatment (n = 85)
Emergency treatment only	1 (1)
<Once every 3 y	5 (6)
Once every 2-3 y	4 (5)
Once per year	15 (18)
Twice per year	48 (57)
>Twice per year	11 (13)
Did oncologist recommend that a dentist be seen prior to starting cancer treatment? (n = 85)
No	18 (21)
Yes	67 (79)
Was a dentist seen prior to starting cancer treatment? (n = 85)
No	14 (16)
Yes	71 (84)
Was any dental care required in preparation for receiving cancer treatment? (n = 71)a
No	38 (54)
Yes	33 (46)
Treatment recommended (n = 33)a,b
Extraction of ≥1 tooth	16 (48)
Root canal treatment	2 (6)
Filling(s)	11 (33)
Prosthetics (eg, dentures)	2 (6)
Implant(s)	1 (3)
Teeth cleaning	17 (52)
Other	12 (36)
Treatment received (n = 33)a,b
Extraction of ≥1 tooth	17 (52)
Root canal treatment	1 (3)
Filling(s)	9 (27)
Prosthetics (eg, dentures)	3 (9)
Implant(s)	2 (6)
Teeth cleaning	18 (55)
Other	10 (30)
Reason why not all of dental treatment recommended was received (n = 28)b,c
Finances or cost of treatment	4 (14)
Mouth discomfort	0
Time	3 (11)
Treatment was not medically necessary	0
Did not agree with treatment plan	0
Other	0
All recommended treatment was received	24 (86)
Post–cancer treatment dental care
Current oral health compared with before receiving cancer treatment (n = 85)
Significantly worse	26 (31)
Worse	33 (39)
Same	16 (19)
Better	8 (9)
Significantly better	2 (2)
Frequency of dental visits after receiving cancer treatment (n = 84)
Emergency treatment only	2 (2)
<Once every 3 y	3 (4)
Once every 2-3 y	1 (1)
Once per year	7 (8)
Twice per year	17 (20)
>Twice per year	54 (64)
Have there been oral or dental complications from cancer treatment? (n = 85)
No	12 (14)
Yes	73 (86)
Oral or dental complications (n = 73)b
Oral mucositis	29 (40)
Xerostomia	66 (90)
Osteoradionecrosis of the jaw	12 (16)
Dental caries	35 (48)
Gingival and periodontal disease	16 (22)
Candidiasis	25 (34)
Infection	13 (18)
Glossodynia, mouth pain, or burning mouth syndrome	29 (40)
Other	34 (47)
Was follow-up dental treatment required? (n = 73)
No	9 (12)
Yes	64 (88)
Treatment recommended (n = 64)a,b
Extraction of ≥1 tooth	29 (45)
Root canal treatment	23 (36)
Filling(s)	24 (38)
Prosthetics (eg, dentures)	20 (31)
Implant(s)	13 (20)
Teeth cleaning	47 (73)
Over-the-counter medication use	23 (36)
Other	28 (44)
Treatment received (n = 63)a,b
Extraction of ≥1 tooth	32 (51)
Root canal treatment	18 (29)
Filling(s)	25 (40)
Prosthetics (eg, dentures)	10 (16)
Implant(s)	6 (10)
Teeth cleaning	49 (78)
Over-the-counter medication use	18 (29)
Other	25 (40)
Reason why not all of dental treatment recommended was received (n = 53)a,c
Finances or cost of treatment	17 (32)
Mouth discomfort	8 (15)
Time	3 (6)
Treatment was not medically necessary	0
Did not agree with treatment plan	1 (2)
Other	4 (8)
All recommended treatment was received	32 (60)
Period of post–cancer treatment dental care, mo (n = 64)
<1	6 (9)
2-4	3 (5)
5-9	11 (17)
>9	44 (69)

^a Respondents were asked to respond to these questions depending on their responses to previous questions in the survey; thus, frequencies do not add to the total number.

^b Respondents could select all that applied.

^c Respondents could select multiple reasons for why not all recommended dental treatment was received; thus, frequencies do not add to the total number.

Of charges for pre–cancer treatment dental services, 23 individuals reported that 56% of their treatment was paid for directly as an out-of-pocket expense, which is comparable to the distribution of dental expenditures in the general population.¹⁸ This was supplemented with private insurance (19 [57%]), public insurance (8 [19%]), and free care (3 [30%]) (eTable 2 in Supplement 1).

Post-HNC Dental Care

Of 85 respondents, 59 (69%) indicated that their perceived current (post–HNC treatment) oral health was worse or significantly worse compared with before cancer treatment. While only 11 individuals (13%) reported going to the dentist more than twice a year before cancer care, 54 (64%) said that they did so after their cancer treatment. Most respondents (73 of 85 [86%]) reported that they had experienced some oral or dental complications from their cancer treatment, including xerostomia (66 of 73 [90%]), dental caries (35 of 73 [48%]), and oral mucositis (29 of 73 [40%]). Of the patients who reported having complications, 64 (88%) required follow-up dental treatment, which included professional cleaning (47 [73%]), extractions (29 [45%]), and fillings (24 [38%]) (Table 3).

Post–Cancer Treatment Dental Needs and Cost Implications

The median elapsed time from cancer diagnosis to completion of cancer treatment for study respondents was 1 year (range, 0-22 years; mean [SD], 1.5 [3.2] years). Of the 64 patients (88%) for whom post–cancer treatment dental care was necessary, 63 (98%) received at least some care (Table 3).

Of charges for cancer treatment–related dental care, 60% were paid by the patient as an out-of-pocket expense. As was the case with pre–cancer treatment dental services, this payment was supplemented with private (51%) and public (29%) insurance (eTable 2 in Supplement 1). Thirty-three patients (63%) reported not completing the recommended dental treatment plan, and the reasons most noted for this noncompletion were finances and cost of treatment (17 [32%]) (Table 3).

Patient Estimates of Costs of Pretreatment and Posttreatment Dental Services

Of 84 patients, 30 (36%) reported aggregate out-of-pocket expenses of less than $1000 for costs associated with pretreatment and posttreatment dental care. In contrast, 33 of 84 (39%) reported self-pay costs for precancer and postcancer treatment dental care of $5000 or more. Of the 85 respondents, 33 (39%) said that their postcancer dental care had caused them financial hardship (Table 4).

Table 4. Self-Reported Financial Burden of Dental Care for Patients With Head and Neck Cancer.

Variable	Patients, No. (%)
Estimated total out-of-pocket dental treatment expenses both in preparation for cancer treatment and after receiving cancer care (median, $2000), $ (n = 84)
<500	20 (24)
500-999	10 (12)
1000-2999	15 (18)
3000-4999	6 (7)
≥5000	33 (39)
Postcancer dental care has caused financial hardship (n = 85)
No	52 (61)
Yes	33 (39)

Variable Association With Financial Hardship

The OR of 0.20 (95% CI, 0.06-0.58) indicated a decreased odds of financial toxicity among individuals with a bachelor’s degree or a higher level of education compared with those with lower levels of education (Table 5). However, the wide 95% CI suggests there was variability and instability of the OR. Additionally, those with higher incomes (>$65 000) had a moderate reduction in the odds of experiencing financial toxicity (OR, 0.33; 95% CI, 0.11-0.94) compared with those with lower income levels. The wide 95% CI suggests there was uncertainty regarding the true value of the association between income and financial toxicity.

Table 5. Variables of Self-Reported Financial Hardship Associated With HNC-Associated Dental Treatment.

Characteristic	OR (95% CI)
Age (n = 84)
<65 y	1.87 (0.70-5.07)
≥65 y	1 [Reference]
Sex at birth (n = 84)
Female	1 [Reference]
Male	0.63 (0.23-1.66)
Race and ethnicity (n = 83)
Racial and ethnic minority groupsa	1 [Reference]
Non-Hispanic White	0.24 (0.02-1.57)
Location (n = 84)
Urban or suburban	1.00 (0.36-2.84)
Rural	1 [Reference]
Educational level (n = 82)
Less than a bachelor’s degree	1 [Reference]
Bachelor’s degree or greater	0.20 (0.06-0.58)
Income (n = 81)
≤$65 000	1 [Reference]
>$65 000	0.33 (0.11-0.94)
Employment status at HNC diagnosis (n = 85)
Employed	1.00 (0.38-2.65)
Unemployed	1 [Reference]
Pre-HNC annual dental visit frequency (n = 84)
≤1	1 [Reference]
≥2	0.30 (0.10-0.86)
Post-HNC annual dental visit frequency (n = 84)
≤1	1 [Reference]
≥2	0.32 (0.07-1.26)
Oral health after HNC vs before (n = 85)
Worse	1 [Reference]
Same or better	0.13 (0.02-0.50)
Post-HNC out-of-pocket dental expenses (n = 84)
<$3000	0.09 (0.03-0.29)
≥$3000	1 [Reference]

Abbreviations: HNC, head and neck cancer; OR, odds ratio.

^a African American or Black, American Indian or Alaska Native, Asian, Hispanic or Latino, and/or Native Hawaiian or Pacific Islander.

The OR of 0.30 (95% CI, 0.10-0.86) suggested a moderate reduction in the odds of financial toxicity among individuals who had a pre-HNC annual dental visit frequency of 2 or more compared with those with a lower frequency. However, the 95% CI for this association was relatively wide, suggesting a significant level of uncertainty associated with the true value of the association between pre-HNC annual dental visit frequency and financial toxicity. Furthermore, those who reported that their oral health after HNC treatment was either the same or better than before HNC had a decreased risk of financial hardship (OR, 0.13; 95% CI, 0.02-0.50) compared with respondents who experienced a worsening of their oral health. Again, the 95% CI was fairly wide, suggesting uncertainty regarding the true value of this association.

Among those who reported no oral or dental complications, none mentioned experiencing post-HNC financial hardship due to dental expenses. Of 73 individuals with such complications, 33 (45%) reported financial difficulty. Patients who said that their out-of-pocket expenses for dental care associated with HNC treatment amounted to less than $3000 had a decrease in the odds of experiencing financial toxicity (OR, 0.09; 95% CI, 0.03-0.29) compared with those with expenses totaling $3000 or more.

Discussion

In this survey study, both acute and late oral complications were reported in patients treated for HNC. In particular, pathologies specifically affecting the teeth and periodontium were almost universal in this population, largely as a consequence of radiotherapy-associated xerostomia. While these complications may have been associated with cancer treatment, medical third-party payers typically do not cover costs associated with their treatment, which results in substantial financial burdens for some patients and their families.¹⁹ The objective of this study was to assess the reality of this hypothesis. We found that patients undergoing treatment for HNC experienced marked oral and dental complications that required extensive dental care. Survey respondents indicated a decline in perceived oral health following HNC treatment, and many reported that costs for the related dental care amounted to over $5000. These costs presented not only a financial hardship for patients but also a limiting barrier to care.

In 2023, results were published from the Clinical Registry of Dental Outcomes in Head and Neck Cancer Patients (OraRad) study, a multicenter, NIH-funded observational study designed to assess and document the impact of radiotherapy in patients with HNC and during their survivorship.¹³ Conducted at academic health centers, the OraRad study differed from this study in its population and methods. There were also notable differences in outcomes and conclusions.

The OraRad study was prospective and followed up patients through their HNC treatment, including a survey at 4 years after radiotherapy, to assess barriers to dental care and ongoing presence of oral complications.¹³ The OraRad study population consisted of more males than did the current study (77% compared with 46% in our study) but had a similar distribution in terms of ethnicity.¹³ Respondents to the OraRad survey had a mean age of 59 years, while most of the participants in our study were older than 65 years.¹³ In contrast, our study used a cross-sectional design. A clinical patient population was queried at a point in time following completion of their cancer treatment, typically 7 years.

In contrast to the 95% of patients in the OraRad study for whom a pretreatment dental screening was recommended,¹³ 79% of respondents in our study reported receiving similar advice. This difference could be attributable to the multidisciplinary care models that characterize academic health centers in which oral medicine and dentistry are more readily accessible.

Dental care use increases substantially with a diagnosis of HNC.²⁰ This was supported by the present study in that while 13% of survey respondents said that they visited a dentist more than twice a year before cancer treatment, this percentage increased to 64% after cancer care. This finding coincides with the OraRad study, in which most patients with HNC placed a high priority on oral hygiene and dental treatment after cancer care.¹³

Acute and late oral complications are established sequelae of HNC treatment, and previous research has also found oral complications in patients with HNC to be not only prevalent but also expensive.^13,21,22 The present study population differed dramatically from the OraRad cohort in reporting the financial burden of post–cancer treatment dental care among patients who did not receive recommended dental care.¹³ In the present cohort, finances were cited as an inhibiting factor for care by 14% of patients before cancer treatment and by 32% for after treatment. In comparison, only 7% of OraRad participants did not receive postcancer dental care due to the cost, and just 25% of patients were concerned about paying for postcancer dental treatment.¹³ As previously noted, this difference likely reflects 2 potential features of the OraRad study population compared with the present clinical cohort. First, the OraRad study population included participants in an NIH-sponsored study and, thus, had certain components of care covered by grant funds; second, the medical centers may have had free care options.²³ Interestingly, the distribution of dental expenditures among survey respondents in the current study was comparable to that in the general population.¹⁸ This is important given that a high percentage of dental expenditures were out of pocket for those experiencing financial toxicity related to cancer care, leading to the necessity for additional financial support from private and public insurance providers.

In the current study, 45% of those who reported having oral complications noted that dental care attributable to their cancer therapy caused them financial hardship. Respondents who reported that their oral health was significantly worse after than before cancer treatment were more likely to experience financial hardship from dental expenses. Oral and dental complications of cancer treatment have been previously shown to negatively affect patient health and lead to higher costs of care.²⁴ A total of 39% of patients who reported seeing a dentist more than twice a year after cancer treatment reported financial difficulty compared with 18% of those who went to a dentist twice yearly before cancer treatment. A previous study found that involving dentists in the care of patients with HNC was associated with decreased costs and shorter treatment times, emphasizing the role of dentists in HNC care teams.²⁴

Many of the studies that have examined costs associated with HNC treatment have not included an analysis of dental expenses.^2,3,21 However, dental visits have been found to be the most common ancillary care expense among out-of-pocket costs for patients with HNC.²²

Despite pathobiological, clinical, and causal evidence to support the association between oral health and HNC treatment,^25,26,27 both private and public medical payers largely do not provide reimbursement based on distinctions in which medical and dental services are subject to an imposed firewall.¹⁹ As a consequence, a notable share of the burden for payment of treatment of cancer care–related dental diseases falls directly on the patient, especially during the survivorship period.

Increasing evidence^{28,29,30,31,32} has underscored the association between oral and systemic health. Separation of the 2 makes little sense physiologically or fiscally.^24,33 Mitigation of oral disease is associated with improved overall health and cost-savings for many conditions.²⁴ A better understanding of oral health, including systemic health outcomes and fiscal associations, should be a critical component to shaping public policy and reimbursement decisions. Given the association of HNC treatment with oral health and the subsequent necessity of dental care that is traditionally not paid for by medical insurers, more work appears to be needed to increase coverage for these patients to afford them access to this care.

Limitations

The main limitation of our study relates to generalizability to the broader population with HNC, considering the demographics of the survey population and relatively small sample size. The survey was distributed via email and social media platforms specifically to members of the HNCA, which represents a subset of patients diagnosed with HNC. The HNCA patients remain connected to resources related to their cancer treatment and, as such, may have different needs and experiences with the health care system. Furthermore, while the survey population may be more representative of a clinical patient population with HNC than those included in the OraRad study,¹³ our survey was entirely voluntary; as such, we cannot neglect the possibility that those who elected to participate could also be those for whom financial issues were most impactful. The study population also had a high educational level and relatively high income. It is expected that the financial burden for patients with lower income would be greater and, therefore, the need for coverage of dental care would be greater. Given the relatively small sample size and wide 95% CIs in some instances, these results may not be robust; therefore, further research and a larger sample size is required for more precise estimates of the true association between these variables.

Conclusions

In this survey study, most patients undergoing treatment for HNC had extensive dental needs throughout cancer care; this treatment presented a financial burden for 39% of patients. Since most private medical insurers do not reimburse for dental treatment, more comprehensive coverage deserves policy attention.

Supplement 1.

eAppendix. Survey Instrument

eTable 1. Employment Status Pre- and Post-Cancer Diagnosis

eTable 2. Payment Types Used for Dental Care in Head and Neck Cancer Patients

Supplement 2.

Data Sharing Statement