How will I be after my operation for oral cancer?

Validated health-related quality of life measures for patients with oral cancer have been available for over a decade. We used the Liverpool head and neck cancer database to identify 1060 patients who had curative operations for primary squamous cell carcinoma of the head and neck at the regional maxillofacial unit between 1995 and 2010. We then produced one-page summary tables for subsites of oral cancer by stage and common treatments based on patient-reported outcomes from the University of Washington quality of life (UWQoL) head and neck cancer questionnaire. Data had been collected in a series of annual surveys. Sites included were buccal and retromolar (n=189), oral tongue (n=358), floor of the mouth (n=321), and other oral sites (n=192). A total of 633 patients completed at least one questionnaire (total 1931) between 9 and 60 months after treatment (71% of those alive at 9 months). Only questionnaires completed around 2 years from diagnosis or operation were analysed. Data include crude survival at 1, 2, and 5 years, the 12 UWQoL domains, which comprise the number of patients who chose the best 2 responses for each, overall health-related QoL, and the number who chose the worst responses (based on an algorithm). The data are sufficiently detailed to be used in discussions with patients about likely outcomes. They can help patients to make decisions about the type of treatment, provide a reference for realistic expectations, and enable them to be better informed when they give their consent.

Meeting report: 3rd international transplant conference: how much risk can you take?

The 3rd International Transplant Conference took place on 31st October and 1st November 2014 at the University of Warwick, Coventry, UK. Key focal points of the meeting were the exploration of the molecular basis of antibody-antigen interactions and their relation to clinical practice and to share experiences and knowledge regarding strategies to transplant the 'high-risk' patient. In addition, lively debate sessions were hosted where controversial clinical and immunological themes were discussed by leading experts in the field.

Frequency and outcomes of submandibular gland obstruction following resection of squamous cell carcinomas in the vicinity of the submandibular duct

INTRODUCTION

The aim of this study was to report rates, associated factors and outcomes of submandibular gland obstruction following surgery for squamous cell carcinoma in the anterior floor of the mouth (FOM) or ventral tongue without a neck dissection where resection has involved (or has been in very close proximity to) the submandibular duct.

METHODS

A retrospective case note review was carried out for the period January 2007 to December 2011. Only patients who received primary local surgical resection for squamous cell carcinoma of the anterior FOM or ventral tongue were included.

RESULTS

Fifty-two patients were analysed. Fifteen (29%) developed submandibular gland symptoms following surgery. Symptoms resolved spontaneously for 14 (93%) and 1 patient required the submandibular duct to be repositioned. Comparatively, 2 patients (13%) developed symptoms when the duct was repositioned during primary surgery. No patients had their submandibular gland removed.

CONCLUSIONS

Resection of small tumours associated with the FOM and ventral tongue in proximity to the submandibular duct is associated with obstructive symptoms in about a quarter of patients; this is reduced by half when redirecting the duct. Symptoms are self-limiting and self-resolving. A prospective clinical trial comparing duct repositioning with subcapsular gland excision would help clarify potential benefits and best treatment modalities.

Do head and neck cancer survivors attend a high street dentist on a regular basis?

Head and neck cancer (HNC) patients face complex oral health issues following treatment. The aims of this study were to determine the proportion of HNC patients attending their dentist regularly and investigate clinicodemographic characteristics associated with attendance. Two surveys asked about patient attendance patterns and dentition. Pre-treatment orthopantomographs were evaluated for those treated between 2007-2009. The response rate was 66% (444/672). 69% (305/444) saw a high street dentist regularly. 28% of edentulous patients attended regularly compared with 84% with natural teeth, p < 0.001. Associations at p < 0.001 with regular attendance were the leaving of formal education (> 16 years) and earlier clinical staging. HNC patients should be encouraged to see a dentist regularly for routine dental care and cancer surveillance in partnership with the cancer service.

Place and time of death in patients treated with palliative intent for oral cancer

Information about place and time of death can help patients, carers, general medical practitioners, and multi-professional teams to put palliation for oral cancer into context, particularly the aspirations of patients about where they die. Aintree Regional Maxillofacial Unit treated 487 consecutive patients for primary oral squamous cell carcinoma between 2006 and 2010. Mortality was ascertained from the Office for National Statistics. A total of 65 (13%) patients were treated with palliative intent, and median (IQR) survival was 4.3 months (2.1-8.0). The most common reasons for palliation were inoperability (33%) and extensive disease associated with serious comorbidity (18%). A total of 22 died in hospital, 14 in a hospice, 14 in their own home, 14 in a nursing, residential, or old people's home, and one elsewhere. Most patients given palliative care do not die in hospital and survival is short. Their needs and those of their carers can be better met through integrated care that is linked to the primary sector.

How often do head and neck cancer patients raise concerns related to intimacy and sexuality in routine follow-up clinics?

Intimacy and sexuality problems are underreported in head and neck cancer patients. The aim of this study was to collate the various prompts available in a routine follow-up clinic through the use of an intimacy screening question and Patient's Concerns Inventory (PCI), and to identify how often these problems were raised by patients and what possible actions took place as a consequence. 177 patients completed the intimacy screening question, PCI and UW-QOLv.4 at follow-up clinics, from October 2008 to January 2011. Case note review identified if intimacy was mentioned in clinic letters and if referral for support was made. On the intimacy screening question, 15 % (26) reported problems of considerable/some concern (24) or selected intimacy/sexuality on the PCI (2). The PCI identified that 9 of the 24 reporting the worst problems wanted the topic discussed in clinic, and clinic letters suggested that 5 of these discussed the issue in clinic with 4 being referred on, 3 to a clinical psychologist and 1 to a clinical nurse specialist. Intimacy problems are underreported in clinic reviews. It is a difficult subject to discuss. It will remain a potential unmet need unless attempts are made to advance the opportunities for patient screening, information leaflets, staff training on how to talk about such sensitive issues and referral for counselling.

Analysis of time taken to discuss new patients with head and neck cancer in multidisciplinary team meetings

Multidisciplinary team (MDT) meetings have an important role in the management of head and neck cancer. Increasing incidence of the disease and a drive towards centralised meetings on large numbers of patients mean that effective discussions are pertinent. We aimed to evaluate new cases within a single high volume head and neck cancer MDT and to explore the relation between the time taken to discuss each case, the number of discussants, and type of case. A total of 105 patients with a new diagnosis of head and neck malignancy or complex benign tumour were discussed at 10 head and neck cancer MDT meetings. A single observer timed each discussion using a stopwatch, and recorded the number of discussants and the diagnosis and characteristics of each patient. Timings ranged from 15 to 480 s (8 min) with a mean of 119 s (2 min), and the duration of discussion correlated closely with the number of discussants (rs=0.63, p<0.001). The longest discussions concerned patients with advanced T stage (p=0.006) and advanced N stage (p=0.009) disease, the elderly (p=0.02) and male patients (p=0.05). Tumour site and histological findings were not significant factors in the duration of discussion. Most discussions on patients with early stage tumours were short (T1: 58% less than 60s, mean 90) and fewer people contributed. Many patients, particularly those with early stage disease, require little discussion, and their treatment might reasonably be planned according to an agreed protocol, which would leave more time and resources for those that require greater multidisciplinary input. Further studies may highlight extended discussions on patients with head and neck cancer, which may prompt a review of protocols and current evidence.

Outcomes of rescue therapy in acute severe ulcerative colitis: data from the United Kingdom inflammatory bowel disease audit

BACKGROUND

Approximately one third of patients with acute severe ulcerative colitis (ASUC) fail response to steroids. Ciclosporin and anti-TNFα are proven second-line therapies, but evidence of their efficacy has come mainly from tertiary centres and/or selective clinical trial recruitment.

AIM

To assess ASUC outcomes in a large unselected cohort.

METHODS

UK-wide audits of IBD care were conducted in 2008 (209 hospital sites) and 2010 (198 hospital sites), covering >87% of admitting hospitals. Each site entered data from 20 consecutive UC admissions onto a web-based proforma. Admissions included 852 (2008) and 984 (2010) with ASUC, accounting for 35% and 39% of UC admissions, respectively.

RESULTS

ASUC in-hospital mortality was 1.2% in 2008; 0.7% in 2010 (P = 0.22). Response to first-line steroid therapy was 61% (2008); 58% (2010) and mortality was higher in non-responders: 2008: 2.9% (9/315) vs. 0.19% (1/537; P < 0.001); 2010: 1.8% (7/391) vs. 0.0% (0/593; P = 0.002). In 2010, more patients (56%) received second-line medical therapy than in 2008 (47%, P = 0.02). In-hospital mortality was similar to second-line medical therapy vs. surgery without further medical therapy; 2008: 2.7% vs. 2.8%, P = 0.99; 2010: 0.9% vs. 3.1%, P = 0.17. Second-line therapy response was more frequently observed with anti-TNFα than ciclosporin: (2008: 76% vs. 46%, P < 0.001; 2010: 80% vs. 58%, P < 0.001).

CONCLUSIONS

Mortality in acute severe ulcerative colitis was low, but higher in steroid non-responders. Patients treated with second-line medical therapies had no higher risk of in-hospital mortality than those undergoing surgery. Second-line 'rescue' medical therapy usage is increasing; however, ciclosporin response rates were relatively low.