A 2020 Update on Public Awareness of Head and Neck Cancers

OBJECTIVE

To assess knowledge regarding head and neck cancers (HNCs) in 2020, factors associated with knowledge of the role of human papillomavirus (HPV) in HNCs, and factors associated with exposure to Oral, Head and Neck Cancer Awareness Week (OHANCAW).

STUDY DESIGN

Cross-sectional survey.

SETTING

Online.

METHODS

The survey was distributed to 517 participants via a paid panel and utilized US Census-built quotas to represent the US population.

RESULTS

Participants surpassed 50% awareness rates in only 5 of 10 (50.0%), 2 of 6 (33.3%), and 5 of 9 (55.5%) preselected answer choices for subsites, risk factors, and signs/symptoms of HNCs, respectively. Knowledge of HPV's role in oropharyngeal cancer was also low, at 30.6%. However, of the controlled variables, exposure to OHANCAW was closely associated with knowledge of HPV's role in HNC (odds ratio, 10.25; 95% CI, 5.36-19.62). Women and elderly individuals were less likely to be exposed to OHANCAW, while those with higher education, those who drink heavily (>4 drinks/d), and current but not former tobacco users were more likely to be exposed.

CONCLUSIONS

Knowledge of HNCs and the causal role of HPV remains suboptimal, though our results suggest that OHANCAW remains a viable educational pathway. However, certain at-risk populations, such as former smokers and older individuals, whom we may not be effectively reaching and screening, represent a priority for future outreach efforts.

Superselective intranidal delivery of platinum-based high-density packing coils for treatment of arteriovenous malformations

Arteriovenous malformations (AVMs) classically feature an intervening nidus of poorly differentiated endothelium. The pillar of modern AVM treatment is intranidal delivery and deposition of various liquid embolic agents such as n-butyl cyanoacrylate, ethylene vinyl alcohol copolymer, and ethanol. These agents are cumbersome to prepare, deliver, and deploy and have been associated with complications related to limited delivery control, nonretrievability, frequent microcatheter exchanges, and nontarget embolization. Coils and other proximal occlusive agents have not been traditionally recommended as sole embolic agents for AVM treatment given the inherent lack of adequate AVM nidus penetration with previous coil technologies. In the present report, we have described a series of three patients with AVMs in whom newer generation, platinum-based, packing coils were used safely and effectively as the primary agent for superselective nidal penetration and embolization.

Changes in Population-Level and Institutional-Level Prescribing Habits of Radioiodine Therapy for Papillary Thyroid Cancer

Background: In the past two decades, new evidence and guidelines have emerged to refine recommendations for the use of radioactive iodine (RAI) therapy after thyroidectomy for cancer. We aim to describe national trends in RAI utilization, assess the impact of individual hospitals on RAI utilization, and examine whether variation in prescribing habits has declined over time. Methods: The National Cancer Database (NCDB) was queried from 2004 to 2016 for patients with papillary thyroid cancer (PTC) who received total thyroidectomy. Trends were analyzed using Joinpoint analysis. Hospital-specific effects and variation in prescribing habits were assessed through a hierarchical, mixed regression model. Results: RAI utilization declined from 61.0% in 2004 to 43.9% in 2016. RAI use declined most profoundly in patients with T1a, N0/X, M0 PTC without extrathyroidal extension (34.8% in 2004 to 9.5% in 2015), but continues to be used commonly in patients with advanced disease for whom it is routinely recommended (73.4% in 2004 to 72.0% in 2015). Furthermore, ∼80% of hospitals in 2016 utilized at or below the median utilization rate in 2006. Variation in RAI utilization across hospitals decreased by ∼50% from 2004 to 2016 (Levene's test p < 0.001), with a significant decline (p = 0.002) in the variation after 2012 (confidence interval: 2010 to 2014). Conclusions: Recommendations for whom to prescribe RAI appear to have impacted both the number of patients receiving RAI and the variation in prescribing habits across hospitals. Hospital selection has contributed less to the probability of receiving RAI over time.

Prolonged inpatient stay after upfront total laryngectomy is associated with overall survival

OBJECTIVES

To investigate factors and complications associated with prolonged inpatient length of stay (LOS) in patients who receive total laryngectomy (TL), and to analyze its effect on short-term and long-term overall survival (OS).

METHODS

The National Cancer Database (NCDB) was queried from 2004 to 2016 for patients with laryngeal cancer, who received TL within 60 days of diagnosis, and who had an inpatient LOS ≥1 night. Multivariable binary logistic regression and survival analyses on propensity score matched cohorts with Kaplan-Meier analysis and extended Cox regression were utilized.

RESULTS

Eight thousand two hundred and ninety-eight patients from the NCDB were included. Median inpatient LOS was 8 days after TL (IQR: 7, 12). Prolonged LOS was defined as above the 75th percentile or 13 days or greater. On multivariable analysis, increasing patient age (OR 1.14 per 10 years, P = .003), female sex (OR 1.35, P < .001), and Charlson-Deyo comorbidity score of ≥2 compared to a score of 0 (OR 1.43, P < .001) were associated with prolonged LOS. Patients treated at high surgical case volume centers had a decreased likelihood for prolonged LOS (OR 0.67, P < .001). Ninety-day mortality increased over time in patients who stayed ≥13 days. Prolonged LOS was independently associated with worse OS on multivariable analysis (HR 1.40, 95% CI: 1.22, 1.61) in a matched cohort.

CONCLUSIONS

Prolonged LOS after TL serves as a strong indicator for postoperative long-term mortality and may help identify patients who warrant closer surveillance.

LEVEL OF EVIDENCE

3.

The role of vitamin D in head and neck cancer

OBJECTIVE

Head and neck squamous cell carcinoma (HNSCC) describes a set of malignancies of the head and neck that continue to inflict considerable morbidity and mortality. Because HNSCC often presents at an advanced stage, patients frequently undergo intensive multi-modal therapy with an intent to cure. Vitamin D is a precursor to the biologically active hormone calcitriol which governs bone and calcium physiology that is obtained from diet and UV-B exposure. Vitamin D is known to have pleiotropic effects on health and disease. In this review, we examine the role of vitamin D in cancer with emphasis on HNSCC and discuss potential avenues for further research that might better elucidate the role of vitamin D in the management of HNSCC.

REVIEW METHODS

A review of MEDLINE database indexed literature concerning the role and biology of vitamin D in HNSCC was conducted, with special consideration of recently published work and research involving immunobiology and HNSCC.

CONCLUSIONS

The available evidence suggests that vitamin D may play a role in protecting against HNSCC, particularly in persons who smoke, although conflicting and limited data exists. Promising initial work encourages the pursuit of further study.

IMPLICATIONS FOR PRACTICE

The significant morbidity and mortality that HNSCC brings warrants continued research in available and safe interventions that improve patient outcomes. With the rise of immunotherapy as an effective modality for treatment, continued research of vitamin D as an adjunct in the treatment of HNSCC is supported.

Revisiting the Radiation Therapy Oncology Group 1221 Hypothesis: Treatment for Stage III/IV HPV-Negative Oropharyngeal Cancer

OBJECTIVE

In 2014, the Radiation Therapy Oncology Group 1221 trial was initiated to analyze whether surgery with risk-based radiation therapy or chemoradiation therapy was superior to chemoradiation therapy alone in patients with clinically staged T1-2N1-2bM0 HPV-negative oropharyngeal squamous cell carcinoma. However, the study was prematurely terminated. Given the lack of a randomized controlled trial, we retrospectively approached the same question using large national cancer databases.

STUDY DESIGN

Retrospective cohort study.

SETTING

The National Cancer Database and Surveillance, Epidemiology, and End Results (SEER) program from 2010 to 2016.

METHODS

We identified 3004 patients in the National Cancer Database and 670 patients in the SEER database. Statistical techniques included Kaplan-Meier survival analysis, binary and multinomial logistic regressions, Cox proportional hazard regressions, and inverse propensity score weighting.

RESULTS

On weighted multivariable Cox regression, patients recommended to receive frontline surgery had improved overall survival as compared with those recommended to receive chemoradiation therapy alone (hazard ratio [HR], 0.77; 95% CI, 0.68-0.86). On post hoc multivariable analysis based on therapy actually received, frontline surgery with adjuvant chemoradiation therapy was associated with improved overall survival (HR, 0.59; 95% CI, 0.50-0.71) as compared with chemoradiation therapy without surgery. Analysis of the SEER cohort revealed improved overall survival (HR, 0.69; 95% CI, 0.54-0.87) and head and neck cancer-specific survival (HR, 0.59; 95% CI, 0.41-0.84) in patients recommended to receive frontline surgery over chemoradiation therapy alone.

CONCLUSION

Our findings support the use of surgery with risk-based addition of adjuvant therapy in patients with cT1-2N1-2bM0 HPV-negative oropharyngeal cancer.

Sequencing of Sclerosing Microcystic Adenocarcinoma Identifies Mutational Burden and Somatic Variants Associated With Tumorigenesis

BACKGROUND/AIM

Sclerosing microcystic adenocarcinoma (SMA) is a rare oral cavity neoplasia, histologically resembling microcystic adnexal carcinoma (MAC) of the skin. Only nine SMA cases have been reported in the literature, frequently in the context of immunosuppression; SMA has not been recognized in the most recent WHO tumor classification. We sought to identify potential molecular mechanisms of tumorigenesis in a case of SMA relative to those known for MAC.

CASE REPORT

A 41-year-old female with psoriatic arthritis undergoing immunosuppression therapy presented with a tongue mass. Biopsy revealed a diagnosis of SMA. Partial glossectomy and neck dissection showed no residual tumor or nodal disease.

RESULTS

whole exome sequencing revealed moderate mutational burden and putative loss of function mutations in CDK11B but no overlap with known MAC mutations.

CONCLUSION

We characterized the genomic profile of SMA for the first time, identifying both mutational burden and unique somatic variants associated with tumorigenesis.

The epidemiology, surgical management, and impact of margins in skull and mandibular osseous-site tumors

OBJECTIVE

The aim of the study was to characterize the epidemiology and treatment outcomes of head and neck (HN) osseous-site tumors.

METHODS

Descriptive analyses and multivariate Cox regressions were performed to analyze the effect of surgery on overall survival (OS) utilizing the National Cancer Database (2004-2016).

RESULTS

Of 2449 tumors, surgery was utilized in 84.5% of cases. OS was worse in osteosarcoma (5-year OS: 53.4% [SE: 2.5%]) compared with cartilage tumors (5-year OS: 84.6% [SE: 1.8%]) (log-rank P < .001). Treatment regimens that included surgery were associated with improved OS on multivariate analysis (hazard ratio [HR] 0.495 [95% CI: 0.366-0.670]). Positive margins were found in 40.8% of cases, and associated with decreased OS in osteosarcomas (HR 1.304 [0.697-2.438]).

CONCLUSION

Treatment that included surgery was associated with an increased OS within our cohort of HN osseous-site tumors, although the rates of positive margins were >40%. These findings may be limited by inherent selection bias in the database.

An Analysis of Otolaryngology Medical Malpractice Payments From the National Practitioner Data Bank

OBJECTIVE

To describe malpractice payments made on behalf of otolaryngologists, analyze trends over time, and test the association of payment amount with severity of alleged malpractice and patient age.

STUDY DESIGN

Retrospective cross-sectional analysis.

SETTING

National Practitioner Data Bank.

SUBJECTS AND METHODS

This study comprised all payments made on behalf of otolaryngologists from 1991 to 2018 that were reported to the National Practitioner Data Bank. Descriptive statistics were calculated within and across years. Trends in payments were analyzed with the Mann-Kendall test. Generalized linear regression was utilized to test for association of payment amount with severity of the alleged injury and patient age.

RESULTS

From 1991 to 2018, there was a significant decrease in the number of payments (272 to 81) and number of otolaryngologists on whose behalf payments were made (250 to 77). Mean and median payments increased significantly from $248,848 to $420,386 and from $96,813 to $275,000, respectively. By severity of alleged injury, mean payments ranged from $39,755 (95% CI, $20,957-$75,412) for insignificant injury to $754,349 (95% CI, $624,847-$910,692) for patients who were left quadriplegic, sustained brain damage, or required lifelong care. By patient age, mean payments for patients ≥60 years old were $191,465 (95% CI, $159,880-$229,292) versus $247,878 (95% CI, $209,416-$293,402) for patients aged 20 to 39 years and $232,225 (95% CI, $197,691-$272,793) for patients aged 40 to 59 years.

CONCLUSION

The annual number and total value of malpractice payments decreased, while the annual mean and median payments increased. Payment amount was associated with severity of alleged malpractice and patient age.

Assessing National Utilization Trends and Outcomes of Robotic and Endoscopic Thyroidectomy in the United States

OBJECTIVE

We aimed to evaluate trends and outcomes of surgical approaches to thyroid surgery. We hypothesized that there have been changes over time in the utilization of approaches to thyroidectomy, including endoscopic, robotic, and open approaches, and that patient outcomes may differ between open surgery and endoscopic or robotic approaches.

STUDY DESIGN

Retrospective analysis.

SETTING

The National Cancer Database (NCDB) was queried between 2010 and 2016.

SUBJECTS AND METHODS

National cohort of patients. Descriptive statistics were performed using χ² test, Mann-Whitney U test, t test and analysis of variance. To investigate complication rates, patient matching was performed with subsequent analysis using simple and multivariable logistic regressions.

RESULTS

We identified 217,938 patients within the NCDB. While endoscopic thyroid surgery increased, relatively, in use over time (0.93% to 2.34% of cases in 2010 and 2016, respectively), robotic thyroid surgery started to decline relatively to other approaches from 2013 to 2016 (0.39% to 0.25% of cases, respectively). The endoscopic approach was performed more commonly than the robotic approach within individual facilities that have reported both procedures (P = .025). Robotic thyroid surgery was associated with increased risk of positive margins (P = .046), while endoscopic thyroid surgery was associated with a higher rate of unplanned hospital readmission (OR, 1.55; 95% CI, 1.09-2.22), longer inpatient stays (OR, 1.55; 95% CI, 1.19-2.02), and higher 90-day postoperative mortality (OR, 4.45; 95% CI, 1.58-12.6).

CONCLUSION

Endoscopic thyroid surgery has increased in utilization since 2004 but may have worse morbidity and mortality outcomes compared to open surgery.

Adjuvant external beam radiotherapy for surgically resected, nonmetastatic anaplastic thyroid cancer

BACKGROUND

EBRT in resected, nonmetastatic anaplastic thyroid cancer (ATC) remains undefined. We evaluated patterns/outcomes with EBRT and chemotherapy in this setting.

METHODS

This retrospective analysis included patients identified from the National Cancer Database with nonmetastatic ATC from 2004 to 2014 who underwent non-palliative resection.

RESULTS

Our analysis included 496 patients, including 375 who underwent adjuvant EBRT (among whom 198 received concurrent chemotherapy). The median age was 68 years. On MVA, EBRT was associated with sex (OR 0.5, 95% CI 0.3-0.8, P = .002) and income (OR 2.2, 95% CI 1.4-3.3, P < .001). EBRT was associated with longer OS on UVA (12.3 vs 9.1 months, P = .004) and MVA (HR 0.7 [CI 0.6-0.9], P = .004). Concurrent chemoradiation was associated with longer OS on UVA (14.0 vs 9.1 months, P = .003) and MVA (HR 0.6 [CI 0.5-0.8], P < .001).

CONCLUSION

Adjuvant EBRT is associated with longer OS in resected, nonmetastatic ATC, with additional improved survival with concurrent chemotherapy.

Epidemiological analysis of croup in the emergency department using two national datasets

OBJECTIVES

To characterize cases of croup presenting to emergency departments (EDs) nationwide, analyze trends, and determine readmission rates.

METHODS

Retrospective review of the Nationwide Emergency Department Sample (2007-2014) and the National Hospital Ambulatory Medical Care Survey (2008-2015).

RESULTS

Both databases provided similar descriptive statistics. Annual mean of 352,388 (weighted) cases in the National Emergency Department Sample (1.35% of ED cases). Average age and male:female ratio 2.50 years and 1.95:1, respectively. Peak incidence was in autumn (October = 13.7%) with troughs in the summer (July = 3.7%). 21.3% received nebulizers, <1% laryngoscopic or airway procedures, 75.1% steroids, and 13.3% antibiotics. Of the patients receiving antibiotics, 16.0% had isolated croup. 3.0% of cases were admitted to the hospital. No trend was identified in the incidence of croup, mean age, or antibiotic and steroid usage. Hospital admission rates decreased (4.0%-2.3%) and nebulizer usage increased (14.6%-27.5%; p < 0.05). 5% of patients represented repeat admissions (were seen within 72 h prior).

CONCLUSIONS

Croup imposes a significant burden on the ED. Although hospital admissions decreased, annual incidence in the ED remained stable. The majority of cases are in males less than three years old, and 5.0% of patients represented readmissions. Only three-quarters received glucocorticoids despite the proven benefits, including reducing readmission rates. Antibiotic usage was high, with a large number representing potential cases of inappropriate antibiotic use.

The Association between Industry Payments and Brand-Name Prescriptions in Otolaryngologists

OBJECTIVE

To associate pharmaceutical industry payments to brand-name prescriptions by otolaryngologists.

STUDY DESIGN

Retrospective cross-sectional analysis.

SETTING

Open Payments Database and the Medicare Part D Participant User File 2013-2016.

SUBJECTS AND METHODS

We identified otolaryngologists receiving nonresearch industry payments and prescribing to Medicare Part D recipients. Records were linked by physician name and state. The value of industry payments and the percentage of brand-name drugs prescribed per hospital referral region (HRR) were characterized as medians. Industry payments were correlated to the rate of brand-name prescription by Kendall's τ correlation. This was repeated at the individual physician level and stratified by payment type.

RESULTS

In total, 8167 otolaryngologists received a median of $434 (interquartile range, $138-$1278) in industry compensation over 11 (3-26) payments. Brand-name drugs made up a median of 12.9% (8.6%-18-4%) of each physician's drug claims. The number (τ = 0.05, P < .001) and dollar amount (τ = 0.04, P < .001) of industry payments were correlated with the rate of brand-name drug prescription at the individual physician level. The number of industry payments was also associated with the rate of brand-name prescription by HRR (τ = 0.14, P < .001), but the dollar amount was not. By HRR, food and beverage payments received by physicians were associated with the rate of brand-name drug prescription (τ = 0.04, P < .001), but travel and lodging payments were not.

CONCLUSIONS

Industry financial transactions are associated with brand-name drug prescriptions in otolaryngologists, and these associations are stronger at the regional level than at the individual physician level. These correlations are of modest strength and should be interpreted cautiously by readers.

Association of Human Papillomavirus Status at Head and Neck Carcinoma Subsites With Overall Survival

Importance

Data are limited on the prognostic value of human papillomavirus (HPV) status for head and neck carcinoma subsites.

Objective

To determine whether HPV positivity at each head and neck subsite is associated with improved overall survival.

Design, Setting, and Participants

This retrospective population-based cohort study used the National Cancer Database to identify patients diagnosed with head and neck squamous cell carcinomas from January 1, 2010, to December 31, 2014. Patients were classified according to the location of their primary malignancy into 1 of the 6 main subsites of the upper aerodigestive tract: oral cavity, oropharynx, nasopharynx, hypopharynx, larynx, and sinonasal tract. Patients were also classified by their HPV status. Data collection for this study took place from January 1, 2010, to December 31, 2014. Data analysis was conducted from August 1, 2017, to September 30, 2017.

Main Outcomes and Measures

The difference in 5-year overall survival between patients with HPV-positive status and those with HPV-negative status in various head and neck carcinoma subsites; the role of HPV status in an unadjusted Cox multivariate regression model.

Results

Of the 175 223 total number of patients identified (129 634 [74.0%] male; 45 589 [26.0%] female; mean [SD] age, 63.1 [11.9] years), 133 273 (76.1%) were ineligible and 41 950 (23.9%) were included in the sample. This sample included 16 644 patients (39.7%) with HPV-positive tumors and 25 306 (60.3%) with HPV-negative tumors. Patients with an HPV-positive status were more likely to be younger, be white, be male, present with local T category tumors, and have poor differentiation on histologic examination. HPV-positive status was associated with survival at 4 tumor subsites: oral cavity (hazard ratio [HR], 0.76; 95% CI, 0.66-0.87), oropharynx (HR, 0.44; 95% CI, 0.41-0.47), hypopharynx (HR, 0.59; 95% CI, 0.45-0.77), and larynx (HR, 0.71; 95% CI, 0.59-0.85). The HPV status was the greatest factor in survival outcome between the HPV-positive and -negative cohorts at the oropharynx subsite (77.6% vs 50.7%; survival difference, 26.9%; 95% CI, 25.6%-28.2%) and hypopharynx subsites (52.2% vs 28.8%; survival difference, 23.4%; 95% CI, 17.5%-29.3%). For the nasopharynx (HR, 1.03; 95% CI, 0.75-1.42) and sinonasal tract (HR, 0.63; 95% CI, 0.39-1.01) subsites, HPV-positive status was not an independent prognostic factor.

Conclusions and Relevance

Human papillomavirus positivity was associated with improved survival in 4 subsites (oropharynx, hypopharynx, oral cavity, and larynx), and the largest survival difference was noted in the oropharynx and hypopharynx subsites. In the nasopharynx and sinonasal tract subsites, HPV positivity had no association with overall survival. Given these results, routine testing for HPV at the oropharynx, hypopharynx, oral cavity, and larynx subsites may be warranted.

Margins in Laryngeal Squamous Cell Carcinoma Treated with Transoral Laser Microsurgery: A National Database Study

Objectives

To determine national positive margin rates in transoral laser microsurgery, to compare patients with positive and negative margins, and to identify factors associated with positive margins.

Study Design

Retrospective review of the National Cancer Database.

Setting

Population based.

Subjects/Methods

Patients included those with TIS-T3 laryngeal squamous cell carcinoma (2004-2014). Univariable and multivariable logistic regression were used to identify predictors.

Results

A total of 1959 patients met inclusion criteria. The national positive margin rate was 22.3%. Sixty-five percent of patients had T1 disease; 94.3% were N-negative; and 74.0% had glottic tumors. Fifty-eight percent of patients were treated at academic centers, and 60.6% were treated at facilities performing <2 cases per year. On multivariable analysis, factors associated with margin status included facility volume (odds ratio [95% CI]; in cases per year: 0.93 [0.89-0.97], P = .001), academic status (vs nonacademic; academic: 0.70 [0.54-0.90], P = .008), T-stage (vs T1; T2: 2.74 [2.05-3.65], T3: 5.53 [3.55-8.63], TIS: 0.59 [0.38-0.92], P < .001), and N-stage (vs N0; N1: 3.42 [1.79-6.54], N2: 2.01 [1.09-3.69], P < .001). Tumor subsite was not associated with margin status.

Conclusion

The national positive margin rate for laryngeal laser surgery is 22%, which is concerning given the equivalent survival benefit offered by surgery and primary radiation and the increased likelihood of bimodal therapy in the situation of positive margins. Cases treated at nonacademic centers and those with lower caseloads had a higher likelihood of positive margins. There was a linear association between T-stage and likelihood of positive margins, with T3 tumors being 5 times as likely as T1 to yield positive margins. This study highlights the importance of proper patient selection for transoral laser microsurgery resections.

Preoperative biopsy in parotid malignancies: Variation in use and impact on surgical margins

OBJECTIVES

Determine rate of preoperative biopsy in parotid malignancies, identify factors associated with its use, and its association with surgical margins.

STUDY DESIGN

Retrospective cohort.

SETTING

Commission on Cancer-Accredited Institutions.

SUBJECTS AND METHODS

We included 5533 patients treated surgically for a parotid malignancy 2004-2014 in the National Cancer Database. Chi-squared tests, univariable, and multivariable logistic regressions were used to evaluate predictors of preoperative biopsy (defined as needle, aspiration, or incisional), and associate biopsy with surgical margins.

RESULTS

Preoperative biopsy was utilized in 26.0% of patients. Biopsy was more likely in patients >60 years (odds ratio [OR]: 1.19, P = .035), advanced clinical T stage (vs. T1,T2 OR: 1.23, P = .009; T3 OR: 1.26, P = .026; T4A OR: 2.05, P < .001), advanced clinical N stage (vs. N0, N1: OR: 1.39, P = .013; N2/3: OR: 1.63, P < .001), in academic centers (OR: 1.18, P < .024), and in higher volume centers (vs. low, medium OR: 1.28, P = .002; high OR: 2.16, P < .001). Biopsy use increased over time (vs. 2004-2006, 2007-2010 OR: 1.20, P = .047; 2011-2014 OR: 1.39, P < .001). Biopsy was associated with a reduced risk of positive margins in patients with clinical T1 stage (OR: 0.70, P = .012), and younger than 61 (OR: 0.79, P = .036).

CONCLUSION

The national rate of preoperative biopsy in parotid malignancy is low at 26.0%, but has increased over time. Preoperative biopsy is associated with a reduced risk of positive margins in younger patients and those with early clinical stage, suggesting its increased use may improve surgical outcomes and decrease reoperation or adjuvant therapy in these subgroups of patients.

LEVEL OF EVIDENCE

3 Laryngoscope, 130:1450-1458, 2020.

Positive Surgical Margins in Submandibular Malignancies: Facility and Practice Variation

OBJECTIVES

Identify positive margin rate in a national cohort of patients with submandibular carcinoma, identify predictors of positive margins, and associate margins with overall survival.

STUDY DESIGN

Retrospective cohort.

SETTING

Commission on Cancer-accredited hospitals.

SUBJECTS AND METHODS

We included patients in the National Cancer Database from 2004 to 2014 who were diagnosed with submandibular carcinoma and underwent primary surgical resection. We determined the rate of positive surgical margins and associated patient, tumor, and treatment factors with positive margins via univariable and multivariable logistic regression analysis. We associated margin status with overall survival by Kaplan-Meier curve and Cox proportional hazards regression.

RESULTS

We identified 1150 patients with submandibular malignancy undergoing surgical resection. Positive margin rate was 41.0%. Increased odds of positive margins were seen in patients with advanced T stage (vs T1, T3: odds ratio [OR] = 3.04, P < .001; T4a: OR = 2.89, P < .001), adenoid cystic carcinoma histology (OR = 1.54, P = .020), and those treated at nonacademic facilities (OR = 1.41, P = .008). Patients who underwent a preoperative diagnostic biopsy had decreased odds of positive margins (OR = 0.72, P = .014). Positive margins were associated with reduced overall survival (58% vs 69% 5-year overall survival, P < .001; hazard ratio = 1.49, P = .001) when controlling for patient, tumor, and management factors.

CONCLUSIONS

The national positive margin rate of submandibular carcinoma is 41.0%. Preoperative biopsy and treatment at academic institutions independently decreased the risk of positive margins, and positive margins were independently associated with diminished overall survival. Positive margin rate for submandibular carcinoma may be considered a benchmark for quality of care.

Gender disparities in head and neck cancer chemotherapy clinical trials participation and treatment

OBJECTIVES

To characterize the representation of women in clinical trials directing the National Comprehensive Cancer Network (NCCN) guidelines for chemotherapy use in head and neck squamous cell carcinoma (HNSCC), as well as the relationship between gender and chemotherapy administration in the definitive treatment of HNSCC in the United States.

METHODS

A review of all HNSCC chemotherapy clinical trials cited by the 2018 NCCN guidelines was performed. Sex-based proportions were compared with the corresponding proportions in the general U.S. population of patients with HNSCC between 1985 and 2015, derived from the Surveillance, Epidemiology, and End Results (SEER) program. A second analysis using the National Cancer Database (NCDB), identified 63,544 adult patients diagnosed with stages III-IVB HNSCC between 2004 and 2014 and treated with definitive radiotherapy or chemoradiotherapy. Univariable and multivariable logistic regression analyses were used to identify predictors of chemotherapy administration.

RESULTS

While women comprised 26.2% of U.S. patients with HNSCC between 1985 and 2015, they comprised only 17.0% of patients analyzed in U.S. NCCN-cited chemotherapy clinical trials between 1985 and 2017. On multivariable analysis, women had decreased odds of receiving chemotherapy (Odds Ratio [OR]: 0.875; 95% Confidence Interval [CI]: 0.821-0.931; p < 0.001).

CONCLUSION

Women are underrepresented in HNSCC chemotherapy clinical trials cited by the national guidelines. Additionally, women are less likely than men to receive definitive chemoradiotherapy as oppose to definitive radiotherapy. Reasons for these disparities warrant further investigation as well as re-evaluation of eligibility criteria and enrollment strategies, in order to improve relevance of clinical trials to women with HNSCC.