Delays from diagnosis to treatment may account in part for poor head and neck cancer outcomes among patients of low socioeconomic status, minority patients, and the uninsured. The purpose of this study is to evaluate factors associated with treatment delay in an urban county hospital system. METHOD: Retrospective review of consecutive head and neck cancer patients treated at a county hospital serving an indigent urban population and uninsured county residents. Multivariate analysis was performed using the Cox regression model. RESULTS: Ninety consecutive patients were evaluated. The average time from diagnosis to initiation of treatment was 49 days. On univariate analysis, age Ͻ55 years, oropharyngeal primary tumor site, and primary treatment with chemotherapy and radiation were associated with a statistically significant longer delay to treatment. On multivariate analysis, male gender (HR 2.5, 95% CI 1.3-4.9, pϭ0.008), nonsurgical primary treatment modality (HR 0.8, 95% CI 0.3-0.6, pϭ0.003), and positive nodal status (HRϭ0.4, 95% CI 0.2-0.9, pϭ0.018) were associated with a significantly longer delay in treatment, while an association with oropharyngeal primary tumor site approached statistical significance (HRϭ2.2, 95% CI 1.0-4.8, pϭ0.052). CONCLUSION: Alarming delays in head and neck cancer care exist among indigent patients and the uninsured, with young adult males, patients with positive nodal disease, and those receiving primary chemoradiation at highest risk. Possible reasons for the delay include difficulty navigating multidisciplinary cancer care, poor patient compliance, and a lack of resources. Improved patient outreach and more efficient allocation of treatment resources are needed.