Geographic Variation in the Utilization of Esophagoscopy and Bronchoscopy in Head and Neck Cancer

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Abstract
Objective: To determine the extent to which esophagoscopy and bronchoscopy are being used in various regions of the United States in the initial examination of patients with head and neck cancer. Design: Population-based study derived from Medicare claims data and information from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program. Setting: Five SEER areas (San Francisco, Calif; Connecticut; Seattle, Wash; Iowa; and Detroit, Mich). Participants: The cohort included 1410 Medicare patients with squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx, or larynx diagnosed between March 1, 1991, and December 31, 1993, in the 5 SEER areas. Main Outcome Measure: Rates of esophagoscopy and bronchoscopy according to SEER area. Results: The proportion of patients who underwent esophagoscopy ranged from 12.9% (San Francisco) to 39.8% (Detroit) for patients with local cancer and from 22.2% (San Francisco) to 59.7% (Detroit) for patients with regional cancer. The proportion of patients who underwent bronchoscopy ranged from 6.9% (San Francisco) to 32.6% (Detroit) for patients with local cancer and from 12.8% (San Francisco) to 50.7% (Detroit) for patients with regional cancer. After controlling for differences in age, sex, race, tumor site, tumor grade, comorbidity, and socioeconomic status, SEER area remained independently associated with esophagoscopy and bronchoscopy (both P<.001). Conclusions: There is substantial geographic variation in the use of esophagoscopy and bronchoscopy as part of the initial examination of patients diagnosed as having head and neck cancer that cannot be explained by differences in patient or tumor characteristics. This variation likely underscores uncertainty and disagreement about the value of endoscopic screening for synchronous tumors. Additional research is required to determine whether routine endoscopic screening increases survival rates or improves quality of life. Arch Otolaryngol Head Neck Surg. 1997;123:1203-1210