Effects of Socioeconomic Factors and Health Disparities on Oral Cancer Management among Elderly: A Systematic Review

1. Background

1.1 Prevalence of Oral Cancer among Elderly Population

            The size of the oral cancer problem has significantly increased among the elderly population across the globe. According to Chan et al. (2023), oral cancer is ranked as one of the most common cancer in Malaysia. It is reported in the Malaysian National Cancer Registry that the five year survival rate of oral cancer is approximately 50% if treated with surgery. Furthermore, it is stated that the rate of oral cancer in Malaysia is projected to increase twice by the year 2040 following the population growth and age-specific incidence (Ahmad et al., 2021). It is also estimated that higher percentage of oral cancer may be subjected to poor awareness regarding oral health management , particularly in lower socio-economic regions in the Malaysia (Raman et al., 2022).

1.2 Socioeconomic Factors and Health Disparities among Oral Cancer Patients

            This section intends to determine the socioeconomic factors and health disparities that may influence oral cancer management. Mihor et al. (2020) stated that there is increasing evidence that socioeconomic disparities and parameters are correlated with oral cancer prevalence and management. The prevalence and mortality rate of oral cancer is found higher in underdeveloped countries (Shrestha et al., 2020). This reflects that oral cancer can be impacted by socioeconomic factors and health disparities as well.

Socioeconomic Status

Some studies suggest a significant association between oral cancers and socioeconomic factors. For example, a study conducted by Macpherson (2018) demonstrates that medical care for oral cancer management is only accessible to those patients who have higher socioeconomic status. Discrimination based on the socioeconomic status of patients results in differences in treatment and survival rates among elderly patients with oral cancer. The accessibility of oral cancer patients is dependent on socioeconomic factors, including education, income, and age. A study conducted by Heikkilä et al. (2018) evaluates that the mortality and treatment of patients with oral cancer must be equal in different social settings. As per Akinkugbe et al. (2020), there is an evident need for consistent data to link socioeconomic status with oral cancer management of elderly patients in a comprehensive way, which at present is limited. However, Azimi et al. (2020) state that the correlation between health outcomes and socioeconomic factors has been well documented. Evidence of health inequalities in oral cancer management has extensively been reported in the Western Asia region. Age-standardised lip and oral cavity cancer were also found associated with poor management of oral cancer due to health disparities and socioeconomic status.

Racial and Ethnic Discrimination

Racial and ethnic discrimination are also major socioeconomic factors that reduce the management of oral cancer patients. Patients with Asian and Black ethnicity are likely to experience poor management of oral cancer (Yu et al., 2019). Their ethnicity makes them less valued in the healthcare system which eventually results in poor management of oral cancer.

Health Insurance Status

Northridge et al. (2020) stated that the insurance status of the elderly population also makes them experience discrimination in the healthcare system while receiving care for oral cancer management. The older population usually has low insurance status which makes them vulnerable to the increased prevalence of oral cancer and poor oral health management. According to Northridge et al. (2020), oral healthcare disparities demonstrate unequal opportunities for people to remain healthy and experience discrimination about their oral health management.

Solutions to address Socioeconomic Status

 The elimination of disparities in oral health management is required to ensure proper management of oral cancer. This could be done by providing equal accessibility to high-quality care for oral health or oral cancer management. Moreover, Henshaw et al. (2018) evaluate that healthcare disparities in all aspects of oral health management need to be addressed. The strategies that may be used include the allocation of sufficient resources for oral health management and the improving quality of services for oral health management. Expenses to maintain oral health management are a major factor that reduces the accessibility of patients to receive quality care for oral health management. Thus, free oral healthcare services can be provided to patients, particularly the elderly population to reduce the burden of finances on patients. In addition, free and equal oral healthcare services and allocation of healthcare resources should be provided to ethnic patients to make them valued equally in the healthcare system (Lauritano et al., 2019).

1.3 Impact of Socioeconomic Factors and Health Disparities on Oral Cancer Management

            This section demonstrates the impact of socioeconomic factors on oral cancer management. According to Brand et al. (2019), low levels of awareness and knowledge regarding oral cancer management contribute to delayed diagnosis and management of oral cancer management. Health disparities are the major reasons for poor oral cancer management (Northridge et al., 2020). In support, Dhanuthai et al. (2018) highlight communication and affordability as two major disparities that develop barriers for patients to access quality treatment and management of oral cancer. A study conducted by Ren et al. (2020) identifies that a significant reduction in mortality rate was observed among elderly patients with high-income status. In support, Smith et al. (2018) stated that socioeconomic disparities can affect oral cancer management and enhance the mortality rate for elderly patients with oral cancer. On the other hand, the findings of the study identified that stigmatization as a socioeconomic factor made oral cancer patients unable to receive quality care for oral cancer management. Lack of social network and support from family, availability and accessibility to medical care, and acceptance of new identity in society are the major socioeconomic factors that affect negatively oral cancer management. Moreover, Smith et al. (2018) demonstrate that ethnicity is a major socioeconomic factor that affects negatively on management of oral cancer. The factors of ethnic and racial discrimination make patients unable to acquire equal care in the healthcare system which eventually results in poor management of oral cancer. The low socioeconomic levels or insurance status of the elderly population also make them unable to receive quality care in the healthcare system while receiving care for oral health management. In this way, it is asserted that health disparities and low socioeconomic status of patients harm the treatment and management of oral cancer.

Additionally, the findings of the study conducted by Agarwal et al. (2020) demonstrate that oral cancer management can be affected by socioeconomic factors and make patients with low socioeconomic status unable to receive proper care and knowledge about oral cancer management. The health disparities in terms of socioeconomic status develop in differences in treatment and management among elderly patients with oral cancer. The accessibility of oral cancer patients can be improved by addressing socioeconomic factors, including education, income, and age. However, it is also evaluated that mortality and treatment of patients with oral cancer must be equal in different social settings (Mao et al., 2022). It is reported that there is an inconsistent data that could not determine a considerable association between socioeconomic status and oral cancer management of elderly patients (Singh et al., 2019).

1.4 Gap in the Literature

            Existing literature demonstrates that socioeconomic disparities and parameters are correlated with oral cancer prevalence and management and the prevalence and mortality rate of oral cancer is found higher in underdeveloped countries  (Herrera-Serna et al., 2019). However, some studies evaluate that the mortality and treatment of patients with oral cancer must be equal in different social settings. Several studies have evaluated the levels of awareness regarding oral cancer management and knowledge regarding risk factors and symptoms of oral cancer (Conway et al., 2018). Furthermore, a review of existing studies and literature reported that evidence reporting awareness of oral cancer management in elderly patients is rare with inconsistent findings regarding the association between age as a socioeconomic factor and oral cancer management. In support, (De Cicco et al.) stated that the inconsistent findings contribute to limiting the knowledge and understanding about the effects of socioeconomic status and health disparities on oral cancer management among elderly patients. This gap in the literature raises the need to conduct a study focusing on providing consistent findings regarding the association between socioeconomic factors and oral cancer management. Hence, this study intends to conduct a systematic review to evaluate studies focused on socioeconomic status and health disparities and their impact on oral cancer patients, particularly in the context of the elderly population. The rationale behind conducting this study is to address the gap by analyzing the association between socioeconomic status and oral cancer management based on findings of existing studies and literature particularly focused on the effects of socioeconomic status and health disparities on oral cancer management among elderly patients.

2. Systematic Review Question and Objectives

2.1 Research Question

            To formulate a question for this study, the PEO framework is used which stands for P= Population, E= Exposure, and O= Outcomes.

Table 1: PEO Framework

Source: (Author, 2023)

The question that this study will address is:

“Are elderly patients with oral cancer experience health disparities and poor oral cancer management due to low socioeconomic status?”

            The above stated research question will be addressed in order to fil gap in the existing literature.

2.2 Research Aim and Objectives

            The aim of the study is to evaluate the impact of the socioecomic factors and health disparities on oral health management among elderly patients.  The research objectives that are intended to be achieved in this research are:

• To analyse the prevalence of oral cancer among elderly population
• To determine the socioecomic factors affecting oral health management among elderly patients
• To evaluate the impact of the socioecomic factors and health disparities on oral health management among elderly patients

3. Methods of the Review

3.1 Search Strategy

In this study, the researcher intends to adopt qualitative research design as the review is based on the analysis of issue of socioeconomic factors and its impact on oral cancer management. According to Merriam and Grenier (2019), qualitative design enable researcher to acquire an insight regarding specific issue and its impact on outcomes in a wider population base. Hence, the rationale behind using qualitative research design in this systematic review is that it will enable researcher to analyse the association between socioeconomic status and oral cancer management the basis of findings of existing studies and literature particularly focused on the effects of socioeconomic status and health disparities on oral cancer management among elderly patients.

            As the nature of the study is qualitative, the search strategy that will be followed in this study includes databases, keywords, Boolean operators, and a PRISMA flowchart. Databases such as PubMed, Google Scholar and CINAHL will be used to retrieve studies and literature relevant to socioeconomic factors and health disparities and their impact on oral cancer management among elderly patients. These databases are considered suitable during the retrieval of studies due to the reason that these provide the highest level of evidence and reliable findings in the medical field (Gusenbauer and Haddaway, 2020). These also help to retrieve the most reliable and up-to-date studies on scientific issues. Additionally, this study demonstrates that  key terms, Boolean Operators, and MeSH terms that will be used in this study are illustrated in the below mentioned table:

Table 2: Search Strategy

Source: (Author, 2023)

            In addition, PRISMA flowchart will be used for retrieving relevant studies through mapping out the records identified, excluded and included, and exclusions’ reasons. The PRISMA flowchart that maps out the overall search strategy of this study is demonstrated in below mentioned figure:

3.2 Study Selection Criteria and Procedure

            In this research, study selection criteria that will be used help to decide what type of studies, participants, and outcome measures are intended to focus. The rationale behind using inclusion and exclusion criteria in the study is to retrieve relevant and up-to-date articles that help to address research question of the study and will fill gap in the literature significantly. The inclusion and exclusion criteria set for this study are:

Table 3: Study Selection Criteria

Source: (Author, 2023)

3.2.1 Types of Participants

            The participants that will be focused in this systematic review are elderly patients with oral cancer.

3.2.2 Types of Outcome Measures

            The outcome measures that this study will consider include primary outcomes such as lack of awareness and management of oral cancer, while secondary outcomes include reduced quality of life, survival rate, and adverse effects of health disparities on oral cancer management.

3.2.3 Types of Studies

            The type of studies that this systematic review will include primary qualitative studies, studies published in the last 5 years, published evidence-based studies, and studies published in the English language emphasizing findings related to socioeconomic factors and their impact on oral cancer management. Studies focused on socioeconomic factors such as lack of social network and support from family, availability and accessibility to medical care, and acceptance of new identity in the society will be included in this study.

3.3 Study Quality and Assessment Checks

            Since this study meets the scope of PEO, it is essential to outline the quality and assessment processes that the study will use to identify the quality of the methodology used in the primary studies (Johnson et al., 2020). In this study, CASP checklists will be used to determine the quality of the studies’ methodology. CASP will help the researcher determine the quality of the methodology used in the selected studies based on reliability, validity, clinical relevance, and outcomes of the studies. The CASP checklist will consist of 10 questions and each study will be assessed based on those 10 questions to evaluate the quality and reliability of the methods used in the selected studies. The reason for using CASP checklist in this study is that it is found suitable for the study to assess methodology quality of each article included in the study.

4. Data Extraction

            The synthesis of data is based on collecting and summarising the outcomes of the studies. In this systematic review, the findings of the selected studies are presented in below mentioned table:

Table 4: Findings of the Selected Studies

5. Data Synthesis

            To synthesise the findings of the selected studies, a thematic analysis will be used as this study is based on the evaluation of qualitative primary studies. Themes that will be used to synthesise and analyse the data collected from past studies include “Prevalence of Oral Cancer among Elderly”, “Socioeconomic Factors and Health Disparities among Oral Cancer Patients”, and “Impact of Socioeconomic Factors and Health Disparities on Oral Cancer Management”. Based on data synthesis of these themes, the following study will help to advance the knowledge and understanding of the effects of socioeconomic status and health disparities on oral cancer management among elderly patients. The gap in the literature identified above will be fulfilled by providing consistent findings regarding the association between socioeconomic factors and oral cancer management. It could be asserted that this study will help extend the scope of the studies focusing on socioeconomic status and health disparities and their impact on oral cancer patients, particularly in the context of the elderly population.

The results of this study will allow healthcare practitioners to manage the socioeconomic factors that can affect the management of oral cancer among elderly patients. These factors may include social networks and support from family, availability and accessibility to medical care, and acceptance of a new identity. Proper consultation allows elderly patients to receive treatment to early diagnosis and management of oral cancer. The elimination of disparities in oral health management is required to be maintained by healthcare practitioners to ensure proper management of oral cancer. This could be done by providing equal accessibility to high-quality care for oral health or oral cancer management. Free oral healthcare services provisions by healthcare practitioners could allow patients, particularly the elderly population to reduce the burden of finances on patients and contribute actively in the management and treatment of oral cancer.

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