ORIGINAL ARTICLE

A Comparison of Community-Based
and Hospital-Based Head and Neck
Cancer Screening Campaigns
Identifying High-Risk Individuals and Early Disease
Michael S. Harris, MD; D. Ryan Phillips, MS; Julia L. Sayer, BSN, RN; Michael G. Moore, MD

Importance: An enduring challenge in the care of patients with head and neck cancer is identifying disease
earlier. Appropriately designed screening campaigns are
one proposed strategy.
Objective: To determine whether a hospital-based or a
community-based head and neck cancer (HNC) screening strategy is more effective in identifying high-risk individuals, signs and symptoms, and findings consistent
with head and neck neoplasia.
Design, Setting, and Participants: In this retrospective cohort analysis, data from HNC screening efforts held at a tertiary care medical center and at a local
motorsports event were compared. Participants completed a questionnaire, and a focused physical examination was performed.
Main Outcomes and Measures: Identification rates
of high-risk individuals, signs and symptoms, and findings consistent with head and neck neoplasia.
Results: The hospital-based and community-based efforts yielded 210 and 1380 individuals screened, respec-

Author Affiliations:
Department of
OtolaryngologyHead and Neck
Surgery (Drs Harris and Moore
and Ms Sayer), Indiana
University School of Medicine
(Mr Phillips), Indianapolis.

tively. The community-based screening events attracted

a significantly greater proportion of participants with risk
factors of HNC including male sex (P.001), current tobacco use (P .001), lifetime history of tobacco use
(P=.03), smokeless tobacco use (P =.003), and current
alcohol use (P=.04). The hospital-based screening events,
however, attracted a statistically greater proportion of
people reporting prior head and neck or otolaryngologic treatment (P .001), history of cancer outside the
head and neck (P .001), and a greater median number
of symptoms (P .001) and examination findings
(P .001).
Conclusions and Relevance: These data suggest that
the 2 screening models attract 2 fundamentally different types of participants, and those in both groups may
benefit from screening, albeit for different reasons: one
has a higher rate of risk factors, and early-stage HNC might
be discovered while it is more readily treatable; the other
has a higher rate of concerning signs, symptoms, and
findings, and screening might be used to diagnose or rule
out HNC.

JAMA Otolaryngol Head Neck Surg. 2013;139(6):568-573

EAD AND NECK CANCER

(HNC) accounts for

46 000 new cases or 3% of
all malignant neoplasms
diagnosed in the United
States each year.1 The disease carries a profound degree of functional, cosmetic, and
psychological morbidity and has a significant negative impact on socioeconomic status and quality of life.2,3 Prognosis of HNC
is closely linked to the stage at presentation.4 The majority of HNC comes to clinical attention at a relatively late stage owing to the surreptitious location of lesions,
late onset of symptoms, and health care access and utilization disparities among those
at highest risk for developing disease.5-8
An enduring challenge in the care of patients with HNC has been to detect lesions earlier. Screening campaigns for HNC

JAMA OTOLARYNGOL HEAD NECK SURG/ VOL 139 (NO. 6), JUNE 2013
568

have been suggested as a solution to this

challenge with the goal of detecting lesions earlier when treatment is more effective and raising awareness within a
population unaware of the seriousness of
HNC.9 Models for large-scale screening
programs have been reported in tertiary
care,10 cancer center,7 and primary care settings.11 To out knowledge, no published
account exists comparing hospital-based
screening and community-based screening campaigns.
The current report compares a free hospital-based screening program with a free
community-based screening program in
terms of the percentage of total screened
participants demonstrating risk factors for
HNC and/or symptoms and physical examination findings concerning for HNC.
The specific aim of the study was to deWWW.JAMAOTO.COM

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Author Aff
Departmen
Otolaryngo
Surgery (Dr
and Ms Say
University
(Mr Phillip

termine which HNC screening design was more effective in identifying high-risk individuals, signs and symptoms, and physical examination findings consistent with
early HNC. It was hypothesized that the communitybased screening would yield a higher percentage of total
screened participants demonstrating risk factors for HNC
and/or symptoms or physical examination findings concerning for disease.

what constitutes heavy ethanol consumption, a cutoff point (2

alcoholic beverages/d for men and 1 alcoholic beverages/d for
women) was established, and these data were converted to dichotomous variables (HNC, no [0] or yes [1]). A finding specifically concerning for HNC was defined as the presence of any
masses, mucosal changes, or skin lesions consistent with possible neoplasia; benign physical examination findings (eg, septal deviation, torus mandibularis) were distinguished from more
serious, possibly malignant, findings.

METHODS

STATISTICAL ANALYSES

HOSPITAL-BASED SCREENING EVENTS

Comparison of median values across samples (ie, hospitalbased vs community-based) was performed using t tests for independent samples. Comparison of rates of normally distributed dichotomous variables (ie, frequency of current smokers
among hospital-based HNC screening participants vs frequency of current smokers among community-based HNC
screening participants) was performed using 2 analyses. Statistical significance was set at P .05. Analyses were performed using SigmaStat, version 3.1.1 (Systat Software).

The hospital-based screening occurred between 2010 and 2011

at Indiana University Hospital and Wishard Memorial Hospital in Indianapolis, Indiana. The event was promoted through
a university-affiliated e-mail list service, print newspaper notices, and advertisements posted in the hospitals. The screening event was open to all persons, regardless of age, sex, medical history, and tobacco or ethanol consumption status.
Screening participants completed a questionnaire detailing pertinent medical history, exposure to HNC risk factors, and symptoms of head and neck disease. Screenings were conducted by
board-certified otolaryngologists and resident otolaryngology
physicians (ENTs) under the supervision of faculty members
from Indiana University School of Medicine Department of OtolaryngologyHead and Neck Surgery.
A focused interview and physical examination elicited signs
and findings concerning for disease, which were noted on a standardized examination form (Figure). Examinations were conducted in a private room equipped with headlights and basic examination equipment. Flexible nasopharyngoscopy was not
performed; indirect laryngoscopy was attempted on all patients. Following the interview and physical examination, screeners triaged screened participants to 1 of 4 disposition options:
(1) routine follow-up with primary care physician, (2) further
head and neck evaluation may be necessary, (3) immediate consultation for suspected neoplasm, or (4) non-ENT referral (eg,
dentist, dermatologist). Direct referrals were not made at the time
of the screening. Likewise, the rate of patient follow-up and ultimate patient outcome were not tracked. Education was provided to participants about HNC signs, symptoms, and risk factors. Smoking cessation resources were also available. Because
no identifiable information was collected, this study was exempt from institutional review board review, per institution policy.

COMMUNITY-BASED SCREENING EVENTS

The community-based screening was conducted as a 2-day
screening event at the Indianapolis Motor Speedway on the day
prior to and the day of the Brickyard 400 NASCAR event over
the years 2009 through 2011. The event was promoted through
a university-affiliated e-mail list service, print newspaper notices, the national Head and Neck Cancer Alliance website, and
radio and television advertisements. Participants were screened
in a manner identical to those in the hospital-based effort.

CODING OF SCREENING FORM DATA

The information gathered from screening forms was entered
into a database on either a scale (eg, age, pack-years of tobacco use, number of HNC symptoms reported by participants, number of physical examination findings reported by
screeners) or as dichotomous variables (eg, current smoker, no
[0] or yes [1]; symptoms present specifically concerning for
HNC, no [0] or yes [1]). For qualitative designations such as

RESULTS

Over the course of 2009 to 2011, 1380 individuals were

screened as part of community-based HNC screening
events, and 210 individuals were screened as part of hospital-based events. Table 1 lists the patient characteristics of the community-based HNC screening events and
those of the hospital-based HNC screening events.
Symptoms were selected by participants on the screening from a closed set of options provided on the screening form (Figure). The median number of symptoms
of HNC reported by participants of the communitybased and hospital-based events was 0 and 1 respectively (range, 0-10), with significantly fewer symptoms
being reported by the community-based participants
(P .001). Table 2 lists the number and frequency
of symptoms reported for the community-based sample
and the hospital-based sample.
The locations of abnormal physical examination findings (eg, oral cavity, larynx) in the community-based and
hospital-based screenings are listed in Table 3. The most
commonly reported abnormal finding locations in the hospital-based sample were the oral cavity (14 of 210, 6.67%),
neck (14 of 210, 6.67%), and skin (11 of 210, 5.24%);
in the community-based sample, the most common locations of abnormal findings were the oral cavity (136
of 1380, 9.86%), skin (84 of 1380, 6.09%), and nose
(58 of 1380, 4.20%).
Regarding the distribution of disposition selections
made by screeners, further head and neck evaluation recommended was selected for 12.39% of communitybased participants (n = 171) and for a significantly higher
20.00% (n = 42) of hospital-based participants (P .001).
Immediate consultation for suspected neoplasm was
selected by screeners for 2.21% of the communitybased sample (n = 29), not significantly different than the
hospital-based sample (0.85% [n = 1]) (P = .51).
A total of 928 community-based participants (77.98%)
reported that the HNC screen increased their awareness of HNC, a proportion significantly lower than that
observed in the hospital-based sample (86.47%, n = .147)

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ORAL, HEAD AND NECK CANCER SCREENING

Figure. Screening questionnaire form.

(P = .04). Altogether, 231 participants (21.19%) noted

that they were previously aware of the signs and symptoms of HNC, a proportion significantly lower than that
observed in the hospital-based sample (36.36%, n = .72)
(P .001).
Screeners for the respective hospital-based and community-based populations chose the remaining 2 options at the following rates: routine follow-up with primary care physician, 62% and 71%; and other (eg,
dental, dermatology, smoking cessation), 4% and 10%.
The disposition option was left blank for 13% of the hos-

pital-based participants and 5% of the communitybased participants.

DISCUSSION

An enduring challenge in the care of patients with HNC

has been to detect lesions earlier when treatments are more
effective. Screening campaigns for HNC are one strategy
aimed at educating the public about the signs and symptoms of early disease to encourage earlier presentation.

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Table 1. Characteristics of Participants in Hospital-Based and Community-Based HNC Screening a

Characteristic

Hospital-Based

Years of study
Total participants
Participant age, median (range), y
Male sex
Medical history
Head and neck treatment
Other cancer
Personal HNC
Family HNC
Symptoms reported, median (range), No.
Current tobacco user
Ever tobacco user
Current nonuser of tobacco
Pack-years, median (range)
Former tobacco user
Current heavy EtOH user
Occasional EtOH user
Nondrinker
Smokeless tobacco user
Findings specifically concerning for cancer
Examination findings 100% WNL
Examination findings, median No.
Increased awareness of HNC
Previously aware of HNC signs/symptoms
Further head and neck evaluation recommended
Referral for suspected neoplasm

P Value b

Community-Based

2010-2011
210
50 (18-80)
53 (25.24)

2009-2011
1380
44 (5-90)
784 (57.31)

32 (15.24)
21 (10.00)
14 (6.68)
43 (20.48)
1 (0-10)
30 (14.42)
84 (40.39)
179 (86.06)
15 (0.25-60)
55 (26.70)
10 (5.44)
71 (38.38)
107 (57.22)
5 (2.45)
19 (9.65)
84 (47.73)
0
147 (86.47)
72 (36.36)
42 (20)
1 (0.85)

NA
NA
.001
.001
.001
.001
.26
.30
.001
.001
.03
.001
.42
.17
.04
.04
.02
.003
.001
.001
.63
.04
.001
.001
.51

91 (6.57)
59 (4.28)
63 (4.57)
239 (17.32)
0 (0-7)
387 (28.41)
639 (48.97)
955 (70.58)
15 (0.25-105)
288 (22.14)
132 (11.40)
559 (47.98)
553 (47.55)
116 (8.64)
94 (6.96)
862 (68.69)
0
928 (77.98)
231 (21.19)
171 (12.39)
29 (2.21)

Abbreviations: EtOH, ethanol; HNC, head and neck cancer; NA, not applicable; WNL, within normal limits.
a Unless otherwise indicated, data are reported as number (percentage) of participants.
b Boldface type indicates statistically significant finding.

Table 2. Symptoms Reported by Hospital-Based and Community-Based HNC Screening Participants

Participants, No. (%)
Symptom
Earaches
Tooth/gum problems
Sore throat
Sore in mouth
Change in voice
Denture problems
Growth in neck
Lump in throat
Swallowing difficulty
Red/white patch in mouth
Swelling in neck
Bleeding

Hospital-Based

Community-Based

P Value a

28 (13.33)
35 (16.63)
50 (23.81)
11 (5.24)
25 (11.90)
7 (3.33)
11 (5.25)
19 (9.05)
28 (13.33)
6 (2.86)
10 (4.76)
9 (4.29)

97 (7.03)
163 (11.81)
127 (9.20)
31 (2.25)
70 (5.07)
37 (2.68)
28 (2.03)
27 (1.96)
76 (5.51)
15 (1.09)
31 (2.25)
13 (0.94)

.01
.13
.001
.02
.001
.76
.01
.001
.001
.08
.06
.001

Abbreviation: HNC, head and neck cancer.

a Boldface type indicates statistically significant finding.

Large-scale screening programs have been reported in tertiary care,10 cancer center,7 and primary care settings.11 The
aim of this study was to determine which HNC screening
model, hospital-based or community-based screening, was
more effective in identifying members of the target population and early signs, symptoms, and physical examination findings concerning for HNC.
The central hypothesis of this study was in part confirmed and in part refuted: the community-based screening events did attract a significantly greater proportion of
participants with risk factors for HNC including, male sex,

current tobacco use, lifetime history of tobacco use, smokeless tobacco use, and current heavy alcohol consumption;
however, the hospital-based screening events attracted a
statistically greater proportion of participants reporting a
history of any head and neck or otolaryngologic treatment, any history of cancer outside the head and neck, and
a greater median number of symptoms and physical examination findings concerning for HNC. Likewise, a significantly greater proportion of the hospital-based sample
was given the disposition assignment further head and neck
evaluation recommended.

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Table 3. Abnormal Physical Examination Findings Reported by Screeners for Hospital-Based and Community-Based
HNC Screening Participants
Participants, No. (%)
Finding
100% Within normal limits
Skin
Oral cavity
Ears
Nose
Voice
Thyroid
Oropharynx
Larynx
Salivary
Neck

Hospital-Based

Community-Based

P Value a

84 (47.73)
11 (5.24)
14 (6.67)
5 (2.38)
6 (2.86)
0
5 (2.38)
1 (0.48)
3 (1.43)
1 (0.48)
14 (6.67)

862 (68.69)
84 (6.09)
136 (9.86)
44 (3.19)
58 (4.20)
1 (0.07)
12 (0.87)
33 (2.39)
20 (1.45)
26 (1.88)
7 (0.51)

.001
.74
.18
.76
.46
.28
.10
.13
.32
.31
.001

Abbreviation: HNC, head and neck cancer.

a Boldface type indicates statistically significant finding.

These data suggest a more interesting conclusion than

originally predicted: the 2 HNC screening models attract
fundamentally different types of participants, and those in
both groups may benefit from screening, albeit for different reasons: one has a higher rate of risk factors, and earlystage HNC might be discovered while it is more readily treatable; the other has a higher rate of concerning signs,
symptoms, and findings, and screening might be used to
diagnose or rule out HNC. Targeting screening events toward individuals with risk factors has been identified previously as a goal by those treating other types of cancer such
as melanoma.12 Our work suggests that targeting those at
risk may not necessarily identify the most disease. For this
reason, rather than highlighting the superiority of one
screening model over the other, these data could be used
to support both screening models. The goal for screening
in the community will concentrate on education and increasing public awareness of the risk factors for HNC, while
hospital-based screening may continue to be used to try
to identify disease at an early stage.
The lower proportion of reported risk factors in the
hospital-based sample may be partially explained by differences in the atmosphere of the 2 settings. For the most
part, both screenings were conducted by the same screeners using the same equipment and following the same protocol guided by standardized screening forms, but the hospital-based efforts were held in a clinic at a tertiary care
medical center, a more somber environment. The community-based efforts, in contrast, were held at a major
motor sports event, a festive environment where alcohol and tobacco consumption are a celebrated part of the
culture. Thus, a form of recall bias may have been at work,
with the hospital-based sample underreporting tobacco
and alcohol use, and the community-based sample
possibly overreporting their risk factors. Similarly, when
compared with patrons who are attending an elective
sporting event, individuals who participate in a hospitalbased screening may be more likely to have a specific
symptom or concern that brought them to be evaluated.
This may account for the higher proportion of individuals reporting head and neck signs and symptoms in the
hospital-based cohort.

A number of limitations of the current study should

be kept in mind, which will serve to guide future research in this area. The asymmetry in the number of participants in each sample (ie, 210 in the hospital-based
sample vs 1380 in the community-based sample) limits
the statistical power of comparison of subgroups. As a
result, subset analyses controlling for variables such as
alcohol and tobacco use and cancer history were not possible. This may be the subject of future investigation.
In addition, the current study is limited by a lack of follow-up data. The screening efforts described herein were
designed principally to raise public awareness about the
signs and symptoms of HNC. Since direct referrals were
not made and contact information was not collected, no
data are available linking screeners disposition selections to future treatment, disease outcomes, or smoking
cessation. Such information would also be useful in performing cost-effectiveness analyses comparing hospitalbased and community-based screening models. Costeffectiveness of community-based oral cancer screening
has been demonstrated within a large sample of high-risk
men,13 but to our knowledge, no such analysis has made
a hospital-based vs community-based comparison.
In conclusion, the current study suggests that the community-based and hospital-based screening models attract 2 fundamentally different types of participants, both
of whom may benefit from screening for different reasons: the community cohort by nature of its higher rate
of risk factors; the hospital-based cohort by virtue of its
higher rate of concerning signs, symptoms, and physical examination findings.
Submitted for Publication: November 20, 2012; final revision received February 20, 2013; accepted March 15, 2013.
Correspondence: Michael S. Harris, MD, Department of
OtolaryngologyHead and Neck Surgery, Indiana University School of Medicine, 699 West Dr, Riley Research Wing 044, Indianapolis, IN 46202 (michharr
@iupui.edu).
Author Contributions: Ms Sayer had full access to all the
data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study

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concept and design: Harris. Acquisition of data: Harris, Phillips, Sayer, and Moore. Analysis and interpretation of data:
Harris, Phillips, and Moore. Drafting of the manuscript:
Harris, Phillips, and Moore. Critical revision of the manuscript for important intellectual content: Harris, Phillips,
Sayer, and Moore. Statistical analysis: Harris. Obtained
funding: Phillips and Sayer. Administrative, technical, and
material support: Sayer and Moore. Study supervision: Sayer.
Conflict of Interest Disclosures: None reported.
Funding/Support: Support and direction for this research was provided by the Head and Neck Cancer Alliance (formerly the Yul Brenner Head and Neck Cancer
Foundation). Funding for screening events was provided, in part, by Bristol-Meyers-Squibb and a 2010 Early
Detection and Prevention grant from the American Head
and Neck Society.
Additional Contributions: We would like to acknowledge Tammy Paal and all participating residents, students, staff, and faculty from the Department of OtolaryngologyHead and Neck Surgery, Indiana University
School of Medicine, as well as community volunteers and
screening participants.
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