1
|
Shah HP, Cohen O, Bourdillon AT, Burtness BA, Boffa DJ, Young M, Judson BL, Mehra S. Identifying Opportunities to Deliver High-Quality Cancer Care Across a Health System: A Clinical Responsibility. Otolaryngol Head Neck Surg 2024; 171:445-456. [PMID: 38606669 DOI: 10.1002/ohn.755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 02/29/2024] [Accepted: 03/15/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVE We examined process-related quality metrics for oral squamous cell carcinoma (OSCC) depending on treating facility type across a health system and region. STUDY DESIGN Retrospective in accordance with Strengthening the Reporting of Observational Studies in Epidemiology guidelines. SETTING Single health system and region. METHODS Patients with OSCC diagnosed between 2012 and 2018 were identified from tumor registries of 6 hospitals (1 academic and 5 community) within a single health system. Patients were categorized into 3 care groups: (1) solely at the academic center, (2) solely at community facilities, and (3) combined care at academic and community facilities. Primary outcome measures were process-related quality metrics: positive surgical margin rate, lymph node yield (LNY), adjuvant treatment initiation ≤6 weeks, National Comprehensive Cancer Network (NCCN)-guideline adherence. RESULTS A total of 499 patients were included: 307 (61.5%) patients in the academic-only group, 101 (20.2%) in the community-only group, and 91 (18.2%) in the combined group. Surgery at community hospitals was associated with increased odds of positive surgical margins (11.9% vs 2.5%, odds ratio [OR]: 47.73, 95% confidence interval [CI]: 11.2-275.86, P < .001) and lower odds of LNY ≥ 18 (52.8% vs 85.9%, OR: 0.15, 95% CI: 0.07-0.33, P < .001) relative to the academic center. Compared with the academic-only group, odds of adjuvant treatment initiation ≤6 weeks were lower for the combined group (OR: 0.30, 95% CI: 0.13-0.64, P = .002) and odds of NCCN guideline-adherent treatment were lower in the community only group (OR: 0.35, 95% CI: 0.18-0.70, P = .003). CONCLUSION Quality of oral cancer care across the health system and region is comparable to or better-than national standards, indicating good baseline quality of care. Differences by facility type and fragmentation of care present an opportunity for bringing best in-class cancer care across an entire region.
Collapse
Affiliation(s)
- Hemali P Shah
- Department of Otolaryngology-Head and Neck Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
- Division of Otolaryngology-Head and Neck Surgery, Yale Department of Surgery, New Haven, Connecticut, USA
| | - Oded Cohen
- Division of Otolaryngology-Head and Neck Surgery, Yale Department of Surgery, New Haven, Connecticut, USA
- Yale Cancer Center, New Haven, Connecticut, USA
- Department of Otolaryngology-Head and Neck Surgery, Ben Gurion University of the Negev Samson Assuta Ashdod University Hospital, Ashdod, Israel
| | - Alexandra T Bourdillon
- Division of Otolaryngology-Head and Neck Surgery, Yale Department of Surgery, New Haven, Connecticut, USA
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco School of Medicine, San Francisco, California, USA
| | - Barbara A Burtness
- Yale Cancer Center, New Haven, Connecticut, USA
- Division of Medical Oncology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Daniel J Boffa
- Yale Cancer Center, New Haven, Connecticut, USA
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Melissa Young
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Benjamin L Judson
- Division of Otolaryngology-Head and Neck Surgery, Yale Department of Surgery, New Haven, Connecticut, USA
- Yale Cancer Center, New Haven, Connecticut, USA
| | - Saral Mehra
- Division of Otolaryngology-Head and Neck Surgery, Yale Department of Surgery, New Haven, Connecticut, USA
- Yale Cancer Center, New Haven, Connecticut, USA
| |
Collapse
|
2
|
Vasudev M, Martin E, Frank MI, Meller LLT, Haidar YM. Treatment Delay and HPV Status on OPSCC With Upfront Surgery: Analysis of National Cancer Database. Otolaryngol Head Neck Surg 2024; 171:124-137. [PMID: 38532532 DOI: 10.1002/ohn.699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 01/12/2024] [Accepted: 02/05/2024] [Indexed: 03/28/2024]
Abstract
OBJECTIVE Evaluate the effect of treatment delay on survival in human papillomavirus (HPV)-positive and HPV-negative oropharyngeal squamous cell carcinoma (OPSCC) patients undergoing primary surgical resection. STUDY DESIGN Retrospective cohort study using the 2010-2017 National Cancer Database. SETTING Multicenter database study. METHODS Patients >18 years old with OPSCC and known HPV status, treated surgically with or without postoperative radiation/chemotherapy were included. Two cohorts based on HPV status were grouped by time to treatment initiation (TD-TI, ≤30, 31-60, ≥61 days) and surgery to radiotherapy (TS-RT, ≤42, 43-66, ≥67 days). Univariate, Kaplan-Meier, and multivariate analyses assessed correlations between demographic and clinical factors with overall survival in treatment delay groups. RESULTS Included were 1643 HPV-positive OPSCC patients and 391 HPV-negative OPSCC patients. No associations between survival and gender, age, race, insurance, or radiotherapy length were observed. Regardless of HPV status, larger tumor size (>2 cm) and lymphovascular invasion predicted worse survival. HPV negative patients with >4 lymph nodes involved had 2.5× greater mortality risk (P = .039). Robotic surgery was associated with improved survival only in HPV positive patients (hazard ratio [HR]: 0.41, P < .001). In HPV positive patients, higher TD-TI related to lower mean survival, although this was not significant on multivariate analysis. HPV negative patients with >42 days of TS-RT had decreased survival (43-66 days, HR 1.63, P = .049; ≥67 days, HR 2.10, P = .032). CONCLUSION Longer TS-RT was associated with lower overall survival in HPV negative patients. Treatment delay was not associated with survival in HPV positive OPSCC according to multivariate analysis. These findings enhance knowledge about treatment delay effects in OPSCC, aiding providers in decisions and patient communication.
Collapse
Affiliation(s)
- Milind Vasudev
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Elaine Martin
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Madelyn I Frank
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Leo L T Meller
- School of Medicine, University of California, San Diego, La Jolla, California, USA
| | - Yarah M Haidar
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| |
Collapse
|
3
|
Petery T, Frankart AJ, Esslinger H, Wu X, Rai SN, Takiar V. The effect of treatment package time on locally advanced oral cavity cancer outcomes. Oral Oncol 2024; 154:106870. [PMID: 38823171 DOI: 10.1016/j.oraloncology.2024.106870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 05/18/2024] [Accepted: 05/25/2024] [Indexed: 06/03/2024]
Abstract
OBJECTIVE(S) To assess the influence of treatment package time (TPT) on overall survival (OS) and event free survival (EFS) in oral cavity cancer (OCC) patients treated with surgery and adjuvant radiation therapy (RT) with or without concurrent chemotherapy (CHT). MATERIALS/METHODS 354 adult OCC patients treated at a single, high-volume center between 2012-2022 with various pathologic risk features were included. TPT was defined as days from surgery to RT completion. Kaplan-Meier estimates, log-rank p-values, univariable (UVA) and multivariable (MVA) Cox regression analyses were performed to determine the impact of TPT on OS and EFS, and the optimal TPT cutoff. RESULTS The optimal TPT cutoff was 105 days. TPT < 105 days was significantly associated with improved OS and EFS (p = 0.002 and p = 0.027, respectively) compared to TPT ≥ 105 days. On UVA, factors significantly associated with OS were TPT < 105 days, former/current smoker status, pathologic stage IV, positive perineural invasion (PNI), and extranodal extension (ENE) (all p < 0.05). On MVA for OS, TPT < 105 days, former/current smoker status, pathologic stage IV, and positive PNI (all p < 0.05) remained significant. Factors significantly associated with EFS on UVA were TPT < 105 days, former/current smoker status, pathologic stage IV, positive PNI or ENE, and concurrent CHT (all p < 0.05). On MVA, TPT < 105 days, pathologic stage IV, and positive PNI (all p < 0.05) remained significant. CONCLUSIONS In a large, homogenous cohort of OCCs, optimal TPT was <105 days, with TPT ≥ 105 days significantly associated with worse OS and EFS. Multidisciplinary coordination should analyze factors potentially contributing to treatment delay.
Collapse
Affiliation(s)
- Taylor Petery
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrew J Frankart
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - Hope Esslinger
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - Xiaoyong Wu
- Division of Biostatistics and Bioinformatics & Cancer Data Science Center, Department of Environmental and Public Health Sciences, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Shesh N Rai
- Division of Biostatistics and Bioinformatics & Cancer Data Science Center, Department of Environmental and Public Health Sciences, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Biostatistics and Bioinformatics Shared Resources, University of Cincinnati Cancer Center, Cincinnati, OH, USA
| | - Vinita Takiar
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, USA; Cincinnati VA Medical Center, Cincinnati, OH, USA.
| |
Collapse
|
4
|
Duckett KA, Kassir MF, Nguyen SA, Brennan EA, Chera BS, Sterba KR, Halbert CH, Hill EG, McCay J, Puram SV, Jackson RS, Sandulache VC, Kahmke R, Osazuwa-Peters N, Ramadan S, Nussenbaum B, Alberg AJ, Graboyes EM. Factors Associated with Head and Neck Cancer Postoperative Radiotherapy Delays: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg 2024. [PMID: 38842034 DOI: 10.1002/ohn.835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 05/02/2024] [Accepted: 05/12/2024] [Indexed: 06/07/2024]
Abstract
OBJECTIVE Initiating postoperative radiotherapy (PORT) within 6 weeks of surgery for head and neck squamous cell carcinoma (HNSCC) is included in the National Comprehensive Cancer Network Clincal Practice Guidelines and is a Commission on Cancer quality metric. Factors associated with delays in starting PORT have not been systematically described nor synthesized. DATA SOURCES PubMed, Scopus, and CINAHL. REVIEW METHODS We included studies describing demographic characteristics, clinical factors, or social determinants of health associated with PORT delay (>6 weeks) in patients with HNSCC treated in the United States after 2003. Meta-analysis of odds ratios (ORs) was performed on nonoverlapping datasets. RESULTS Of 716 unique abstracts reviewed, 21 studies were included in the systematic review and 15 in the meta-analysis. Study sample size ranged from 19 to 60,776 patients. In the meta-analysis, factors associated with PORT delay included black race (OR, 1.46, 95% confidence interval [CI]: 1.28-1.67), Hispanic ethnicity (OR, 1.37, 95% CI, 1.17-1.60), Medicaid or no health insurance (OR, 2.01, 95% CI, 1.90-2.13), lower income (OR, 1.38, 95% CI, 1.20-1.59), postoperative admission >7 days (OR, 2.92, 95% CI, 2.31-3.67), and 30-day hospital readmission (OR, 1.37, 95% CI, 1.29-1.47). CONCLUSION Patients at greatest risk for a delay in initiating guideline-adherent PORT include those who are from minoritized communities, of lower socioeconomic status, and experience postoperative challenges. These findings provide the foundational evidence needed to deliver targeted interventions to enhance equity and quality in HNSCC care delivery.
Collapse
Affiliation(s)
- Kelsey A Duckett
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mohamed Faisal Kassir
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Shaun A Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Emily A Brennan
- MUSC Libraries, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Bhisham S Chera
- Department of Radiation Oncology, Hollings Cancer Center, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Katherine R Sterba
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Chanita Hughes Halbert
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
| | - Elizabeth G Hill
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jessica McCay
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Sidharth V Puram
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
- Department of Genetics, Washington University School of Medicine, St Louis, Missouri, USA
| | - Ryan S Jackson
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Vlad C Sandulache
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
- ENT Section, Operative CareLine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Russel Kahmke
- Department of Head and Neck Surgery and Communication Sciences, Duke University, Durham, North Carolina, USA
| | - Nosayaba Osazuwa-Peters
- Department of Head and Neck Surgery and Communication Sciences, Duke University, Durham, North Carolina, USA
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina, USA
| | - Salma Ramadan
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Brian Nussenbaum
- American Board of Otolaryngology-Head and Neck Surgery, Houston, Texas, USA
| | - Anthony J Alberg
- Department of Epidemiology and Biostatistics, University of South Carolina Arnold School of Public Health, Columbia, South Carolina, USA
| | - Evan M Graboyes
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| |
Collapse
|
5
|
Graboyes EM, Cagle JL, Ramadan S, Prasad K, Yan F, Pearce J, Mazul AL, Anoma JS, Hill EG, Chera BS, Puram SV, Jackson R, Sandulache VC, Tam S, Topf MC, Kahmke R, Osazuwa-Peters N, Nussenbaum B, Alberg AJ, Sterba KR, Halbert CH. Neighborhood-Level Disadvantage and Delayed Adjuvant Therapy in Head and Neck Cancer. JAMA Otolaryngol Head Neck Surg 2024; 150:472-482. [PMID: 38662392 PMCID: PMC11046410 DOI: 10.1001/jamaoto.2024.0424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 03/07/2024] [Indexed: 04/26/2024]
Abstract
Importance For patients with head and neck squamous cell carcinoma (HNSCC), initiation of postoperative radiation therapy (PORT) within 6 weeks of surgery is recommended by the National Comprehensive Cancer Network Guidelines and the Commission on Cancer. Although individual-level measures of socioeconomic status are associated with receipt of timely, guideline-adherent PORT, the role of neighborhood-level disadvantage has not been examined. Objective To characterize the association of neighborhood-level disadvantage with delays in receiving PORT. Design, Setting, and Participants This retrospective cohort study included 681 adult patients with HNSCC undergoing curative-intent surgery and PORT from 2018 to 2020 at 4 US academic medical centers. The data were analyzed between June 21, 2023, and March 5, 2024. Main Outcome Measures and Measures The primary outcome was delay in initiating guideline-adherent PORT (ie, >6 weeks after surgery). Time-to-PORT (TTP) was a secondary outcome. Census block-level Area Deprivation Index (ADI) scores were calculated and reported as national percentiles (0-100); higher scores indicate greater deprivation. The association of ADI scores with PORT delay was assessed using multivariable logistic regression adjusted for demographic, clinical, and institutional characteristics. PORT initiation across ADI score population quartiles was evaluated with cumulative incidence plots and Cox models. Results Among 681 patients with HNSCC undergoing surgery and PORT (mean [SD] age, 61.5 [11.2] years; 487 [71.5%] men, 194 [29.5%] women) the PORT delay rate was 60.8% (414/681) and median (IQR) TTP was 46 (40-56) days. The median (IQR) ADI score was 62.0 (44.0-83.0). Each 25-point increase in ADI score was associated with a corresponding 32% increase in the adjusted odds ratio (aOR) of PORT delay (aOR, 1.32; 95% CI, 1.07-1.63) on multivariable regression adjusted for institution, age, race and ethnicity, insurance, comorbidity, cancer subsite, stage, postoperative complications, care fragmentation, travel distance, and rurality. Increasing ADI score population quartiles were associated with increasing TTP (hazard ratio of PORT initiation, 0.71; 95% CI, 0.53-0.96; 0.59; 95% CI, 0.44-0.77; and 0.54; 95% CI, 0.41-0.72; for ADI quartiles 2, 3, and 4 vs ADI quartile 1, respectively). Conclusions and Relevance Increasing neighborhood-level disadvantage was independently associated with a greater likelihood of PORT delay and longer TTP in a dose-dependent manner. These findings indicate a critical need for the development of multilevel strategies to improve the equitable delivery of timely, guideline-adherent PORT.
Collapse
Affiliation(s)
- Evan M. Graboyes
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | - Joshua Lee Cagle
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston
| | - Salma Ramadan
- Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Kavita Prasad
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Flora Yan
- Department of Otolaryngology–Head and Neck Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - John Pearce
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | - Angela L. Mazul
- Department of Otolaryngology–Head and Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jean-Sebastien Anoma
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | - Elizabeth G. Hill
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | - Bhisham S. Chera
- Hollings Cancer Center, Department of Radiation Oncology, Medical University of South Carolina, Charleston
| | - Sidharth V. Puram
- Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri
- Department of Genetics, Washington University School of Medicine, St Louis, Missouri
| | - Ryan Jackson
- Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Vlad C. Sandulache
- Bobby R. Alford Department of Otolaryngology Head and Neck Surgery, Baylor College of Medicine, Houston, Texas
- ENT Section, Operative CareLine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Samantha Tam
- Department of Otolaryngology–Head and Neck Surgery, Henry Ford Health, Detroit, Michigan
| | - Michael C. Topf
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Russel Kahmke
- Department of Head and Neck Surgery and Communication Sciences, Duke University, Durham, North Carolina
| | - Nosayaba Osazuwa-Peters
- Department of Head and Neck Surgery and Communication Sciences, Duke University, Durham, North Carolina
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina
- Deputy Editor, Diversity, Equity, and Inclusion, JAMA Otolaryngology–Head & Neck Surgery
| | - Brian Nussenbaum
- American Board of Otolaryngology–Head and Neck Surgery, Houston, Texas
| | - Anthony J. Alberg
- Department of Epidemiology and Biostatistics, University of South Carolina Arnold School of Public Health, Columbia
| | - Katherine R. Sterba
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | - Chanita Hughes Halbert
- Department of Population and Public Health Sciences and Norris Comprehensive Cancer Center, University of Southern California, Los Angeles
| |
Collapse
|
6
|
Mrosk F, Absah M, Richter M, Sprünken E, Doll C, Kreutzer K, Rendenbach C, Beck M, Klinghammer K, Heiland M, Koerdt S. The impact of time between surgery and adjuvant chemoradiotherapy in advanced oral cavity squamous cell carcinoma. Front Oncol 2024; 14:1393910. [PMID: 38774413 PMCID: PMC11106360 DOI: 10.3389/fonc.2024.1393910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 04/23/2024] [Indexed: 05/24/2024] Open
Abstract
Objective In advanced oral squamous cell carcinoma (OSCC), adjuvant therapy (AT) is an important part of the treatment to ensure extended locoregional control after primary surgical resection. The impact of the time interval between surgery and AT on the oncological prognosis remains unclear, particularly in high-risk constellations. The aim of this study is to categorize treatment delays and to determine their impact on the oncological prognosis within the context of the histopathological risk parameters of patients with advanced OSCC. Methods In this single-institutional retrospective cohort study, all patients treated for OSCC between 2016 and 2021 and who received postoperative chemoradiation (POCRT) were included. Patients were divided into two groups: Group I: ≤ 6 weeks between surgery and POCRT; and Group II: > 6 weeks between surgery and POCRT. Results Overall, 202 patients were included (Group I: 156 (77.2%) vs. Group II: 46 (22.8%)). There were no statistically significant differences in epidemiological aspects and histopathological risk factors between the two groups. The maximum time to initiation of POCRT was 11 weeks. Delayed POCRT initiation had no statistically significant influence on the 5-year OS (61.6% vs. 57.3%, p = 0.89), locoregional control rate (38.6% vs. 43.3%, p = 0.57), and RFS (32.3% vs. 30.4%, p = 0.21). On multivariate analysis, extracapsular spread (HR: 2.21, 95% CI: 1.21 - 4.04, p = 0.01) and incomplete surgical resection (HR: 2.01, 95% CI: 1.10 - 3.69, p = 0.02) were significantly correlated with OS. For RFS, ECS (HR: 1.82, 95% CI: 1.15 - 2.86, p = 0.01), incomplete resection (HR: 1.67, 95% CI: 1.04 - 2.71, p = 0.04), and vascular infiltration of the tumor (V-stage; HR: 2.15, 95% CI: 1.08 - 4.27, p = 0.03) were significant risk predictors. Conclusion Delays in POCRT initiation up to 11 weeks after surgical resection for advanced OSCC were not statistically significantly associated with impaired survival. In cases of prolonged surgical treatment due to management of complications, a small delay in AT beyond the recommended time limit may be justified and AT should still be pursued.
Collapse
Affiliation(s)
- Friedrich Mrosk
- Department of Oral and Maxillofacial Surgery, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Majd Absah
- Department of Oral and Maxillofacial Surgery, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Maximilian Richter
- Department of Oral and Maxillofacial Surgery, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Erin Sprünken
- Institute of Biometry and Clinical Epidemiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Christian Doll
- Department of Oral and Maxillofacial Surgery, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Kilian Kreutzer
- Department of Oral and Maxillofacial Surgery, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Carsten Rendenbach
- Department of Oral and Maxillofacial Surgery, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Marcus Beck
- Department of Radiation Oncology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Konrad Klinghammer
- Department of Hematology, Oncology and Cancer Immunology, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Max Heiland
- Department of Oral and Maxillofacial Surgery, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Steffen Koerdt
- Department of Oral and Maxillofacial Surgery, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| |
Collapse
|
7
|
Barry B, Dolivet G, Clatot F, Huguet F, Abdeddaim C, Baujat B, Blanchard N, Calais G, Carrat X, Chatellier A, Coste F, Cupissol D, Cuvelier P, De Mones Del Pujol E, Deneuve S, Duffas O, Dupret-Bories A, Even C, Evrard C, Evrard D, Faivre S, Fakhry N, Garrel R, Gorphe P, Houliat T, Kaminsky MC, Krebs L, Lapeyre M, Lindas P, Malard O, Mirghani H, Mondina M, Moriniere S, Mouawad F, Pestre-Munier J, Pham Dang N, Picard A, Ramin L, Renard S, Salvan D, Schernberg A, Sire C, Thariat J, Vanbockstael J, Vo Tan D, Wojcik T, Klein I, Block V, Baumann-Bouscaud L, De Raucourt D. [French national standard for the treatment of squamous cell carcinoma of upper aero-digestive tract - General principles of treatment]. Bull Cancer 2024; 111:393-415. [PMID: 38418334 DOI: 10.1016/j.bulcan.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 12/14/2023] [Accepted: 12/31/2023] [Indexed: 03/01/2024]
Abstract
OBJECTIVES The management of upper aerodigestive tract cancers is a complex specialty. It is essential to provide an update to establish optimal care. At the initiative of the INCa and under the auspices of the SFORL, the scientific committee, led by Professor Béatrix Barry, Dr. Gilles Dolivet, and Dr. Dominique De Raucourt, decided to develop a reference framework aimed at defining, in a scientific and consensus-based manner, the general principles of treatment for upper aerodigestive tract cancers applicable to all sub-locations. METHODOLOGY To develop this framework, a multidisciplinary team of practitioners was formed. A systematic analysis of the literature was conducted to produce recommendations classified by grades, in accordance with the standards of the French National Authority for Health (HAS). RESULTS The grading of recommendations according to HAS standards has allowed the establishment of a reference for patient care based on several criteria. In this framework, patients benefit from differentiated care based on prognostic factors they present (age, comorbidities, TNM status, HPV status, etc.), conditions of implementation, and quality criteria for indicated surgery (operability, resectability, margin quality, mutilation, salvage surgery), as well as quality criteria for radiotherapy (target volume, implementation time, etc.). The role of medical and postoperative treatments was also evaluated based on specific criteria. Finally, supportive care must be organized from the beginning and throughout the patients' care journey. CONCLUSION All collected data have led to the development of a comprehensive framework aimed at harmonizing practices nationally, facilitating decision-making in multidisciplinary consultation meetings, promoting equality in practices, and providing a state-of-the-art and reference practices for assessing the quality of care. This new framework is intended to be updated every 5 years to best reflect the latest advances in the field.
Collapse
Affiliation(s)
- Béatrix Barry
- AP-HP, hôpital Bichat-Claude-Bernard, ORL et CCF, Paris (75), France
| | - Gilles Dolivet
- Institut de cancérologie de Lorraine, ORL et CCF, Nancy (54), France.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Olivier Duffas
- Centre hospitalier de Libourne, ORL et CMF, Libourne, France
| | | | | | | | - Diane Evrard
- AP-HP, hôpital Bichat-Claude-Bernard, ORL et CCF, Paris (75), France
| | | | - Nicolas Fakhry
- Assistance publique-Hôpitaux de Marseille, ORL et CCF, Marseille, France
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Didier Salvan
- Centre hospitalier Sud Francilien, ORL et CCF, Corbeil-Essonnes, France
| | | | | | | | | | | | | | - Isabelle Klein
- Dispositif Spécifique Régional du Cancer Grand Est - NEON, Nancy (54), France
| | - Véronique Block
- Dispositif Spécifique Régional du Cancer Grand Est - NEON, Nancy (54), France
| | | | | |
Collapse
|
8
|
Matos LL, Kowalski LP, Chaves ALF, de Oliveira TB, Marta GN, Curado MP, de Castro Junior G, Farias TP, Bardales GS, Cabrera MA, Capuzzo RDC, de Carvalho GB, Cernea CR, Dedivitis RA, Dias FL, Estefan AM, Falco AH, Ferraris GA, Gonzalez-Motta A, Gouveia AG, Jacinto AA, Kulcsar MAV, Leite AK, Lira RB, Mak MP, De Marchi P, de Mello ES, de Matos FCM, Montero PH, de Moraes ED, de Moraes FY, Morais DCR, Poenitz FM, Poitevin A, Riveros HO, Sanabria Á, Ticona-Castro M, Vartanian JG, Viani G, Vines EF, William Junior WN, Conway D, Virani S, Brennan P. Latin American Consensus on the Treatment of Head and Neck Cancer. JCO Glob Oncol 2024; 10:e2300343. [PMID: 38603656 DOI: 10.1200/go.23.00343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/19/2023] [Accepted: 02/07/2024] [Indexed: 04/13/2024] Open
Abstract
Head and neck squamous cell carcinoma (HNSCC) is well known as a serious health problem worldwide, especially in low-income countries or those with limited resources, such as most countries in Latin America. International guidelines cannot always be applied to a population from a large region with specific conditions. This study established a Latin American guideline for care of patients with head and neck cancer and presented evidence of HNSCC management considering availability and oncologic benefit. A panel composed of 41 head and neck cancer experts systematically worked according to a modified Delphi process on (1) document compilation of evidence-based answers to different questions contextualized by resource availability and oncologic benefit regarding Latin America (region of limited resources and/or without access to all necessary health care system infrastructure), (2) revision of the answers and the classification of levels of evidence and degrees of recommendations of all recommendations, (3) validation of the consensus through two rounds of online surveys, and (4) manuscript composition. The consensus consists of 12 sections: Head and neck cancer staging, Histopathologic evaluation of head and neck cancer, Head and neck surgery-oral cavity, Clinical oncology-oral cavity, Head and neck surgery-oropharynx, Clinical oncology-oropharynx, Head and neck surgery-larynx, Head and neck surgery-larynx/hypopharynx, Clinical oncology-larynx/hypopharynx, Clinical oncology-recurrent and metastatic head and neck cancer, Head and neck surgery-reconstruction and rehabilitation, and Radiation therapy. The present consensus established 48 recommendations on HNSCC patient care considering the availability of resources and focusing on oncologic benefit. These recommendations could also be used to formulate strategies in other regions like Latin America countries.
Collapse
Affiliation(s)
- Leandro Luongo Matos
- Head and Neck Surgery, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas, Universidade de São Paulo (Icesp HCFMUSP), São Paulo, Brazil
- Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo, Brazil
| | | | | | | | | | | | - Gilberto de Castro Junior
- Clinical Oncology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas, Universidade de São Paulo (Icesp HCFMUSP), São Paulo, Brazil
| | | | | | | | | | | | | | | | | | - Andrés Munyo Estefan
- Profesor Adjunto Catedra de Otorrinolaringologia del Hospital de Clínicas, Montevidéu, Uruguay
| | | | | | | | - Andre Guimarães Gouveia
- Juravinski Cancer Centre, Department of Oncology, Division of Radiation Oncology, McMaster University, Hamilton, ON, Canada
| | | | - Marco Aurelio Vamondes Kulcsar
- Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas, Universidade de São Paulo (Icesp HCFMUSP), São Paulo, Brazil
| | - Ana Kober Leite
- Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas, Universidade de São Paulo (Icesp HCFMUSP), São Paulo, Brazil
| | - Renan Bezerra Lira
- AC Camargo Cancer Center and Hospital Albert Einstein, São Paulo, Brazil
| | - Milena Perez Mak
- 3Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, Brazil
| | | | | | | | - Pablo H Montero
- Department of Surgical Oncology and Head and Neck Surgery, Division of Surgery, P. Universidad Católica de Chile, Santiago, Chile
| | | | | | | | | | | | | | - Álvaro Sanabria
- 4Department of Surgery, Universidad de Antioquia, Hospital Alma Mater, Medellin, Colombia
| | - Miguel Ticona-Castro
- 5ESMO Member, Peruvian Society of Medical Oncology (S.P.O.M.) Member, La Molina, Peru
| | - José Guilherme Vartanian
- 6Head and Neck Surgery and Otorhinolaryngology Department, A. C. Camargo Cancer Center, São Paulo, Brazil
| | - Gustavo Viani
- 7Ribeirao Preto Medical School, University of Sao Paulo, Ribeirão Preto, Brazil
| | - Eugenio F Vines
- Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | | | | | - Shama Virani
- International Agency for Research on Cancer (IARC/WHO), Genomic Epidemiology Branch, Lyon, France
| | - Paul Brennan
- International Agency for Research on Cancer (IARC/WHO), Genomic Epidemiology Branch, Lyon, France
| |
Collapse
|
9
|
Bernicker E, Averbuch SD, Edge S, Kamboj J, Khuri FR, Pierce JY, Schiller J, Sirohi B, Thomas A, Moushey A, Phillips J, Hendricks C. Climate Change and Cancer Care: A Policy Statement From ASCO. JCO Oncol Pract 2024; 20:178-186. [PMID: 38011607 DOI: 10.1200/op.23.00637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/20/2023] [Accepted: 10/26/2023] [Indexed: 11/29/2023] Open
Affiliation(s)
| | | | - Stephen Edge
- Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | | | | | | | | | | | | | - Allyn Moushey
- American Society of Clinical Oncology, Alexandria, VA
| | | | | |
Collapse
|
10
|
Choi KY, Patel SD, Lane C, Tucker J, Chan K, Pradhan S, Mahase SS, Tam SH, King TS. Elucidating survival and functional outcomes in patients with primary head and neck malignancies treated in academic versus community settings. Head Neck 2024; 46:398-407. [PMID: 38087455 DOI: 10.1002/hed.27588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 10/19/2023] [Accepted: 11/19/2023] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Differences in treatment outcomes between community or academic centers are incompletely understood. METHODS Retrospective review of head and neck cancer patients between 2010 and 2020 in a rural health region. Kaplan-Meier curves and log-rank tests were used to evaluate survival outcomes, along with bivariate and multivariable Cox proportional hazards models. Linear regression was used for functional outcomes of tracheotomy and gastrostomy tube dependence. RESULTS Two hundred and forty-eight patients treated at an academic center were compared with 94 patients treated in community centers. In multivariable analysis, the risk of death (HR = 0.60, p = 0.019), and risk of recurrence were lower (HR = 0.29, p < 0.001) for patients treated in academic centers. Patients treated in community centers had longer gastrostomy tube dependence (p = 0.002). CONCLUSION Our findings suggest that treatment at an academic center was associated with a lower risk of recurrence and shorter gastrostomy tube dependence compared to treatment in the community.
Collapse
Affiliation(s)
- Karen Y Choi
- Department of Otolaryngology-Head and Neck Surgery, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Shivam D Patel
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ciaran Lane
- Department of Otolaryngology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Jacqueline Tucker
- Department of Otolaryngology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kimberly Chan
- Department of Otolaryngology-Head and Neck Surgery, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Sandeep Pradhan
- Department of Public Health Sciences, Division of Biostatistics and Bioinformatics, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Sean S Mahase
- Department of Radiation Oncology, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Samantha H Tam
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Medical Center, Detroit, Michigan, USA
| | - Tonya S King
- Department of Public Health Sciences, Division of Biostatistics and Bioinformatics, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| |
Collapse
|
11
|
Duckett KA, Kassir MF, Nguyen SA, Brennan EA, Chera BS, Sterba KR, Hughes Halbert C, Hill EG, McCay J, Puram SV, Sandulache VC, Kahmke R, Ramadan S, Nussenbaum B, Alberg AJ, Graboyes EM. Delays Starting Postoperative Radiotherapy Among Head and Neck Cancer Patients: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg 2024; 170:320-334. [PMID: 37731255 PMCID: PMC10840985 DOI: 10.1002/ohn.538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/10/2023] [Accepted: 09/02/2023] [Indexed: 09/22/2023]
Abstract
OBJECTIVE Initiating postoperative radiotherapy (PORT) within 6 weeks (42 days) of surgery is the first and only Commission on Cancer (CoC) approved quality metric for head and neck squamous cell carcinoma (HNSCC). No study has systematically reviewed nor synthesized the literature to establish national benchmarks for delays in starting PORT. DATA SOURCES Following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, we performed a systematic review of PubMed, Scopus, and CINAHL. REVIEW METHODS Studies that described time-to-PORT or PORT delays in patients with HNSCC treated in the United States after 2003 were included. Meta-analysis of proportions and continuous measures was performed on nonoverlapping datasets to examine the pooled frequency of PORT delays and time-to-PORT. RESULTS Thirty-six studies were included in the systematic review and 14 in the meta-analysis. Most studies utilized single-institution (n = 17; 47.2%) or cancer registry (n = 16; 44.4%) data. Twenty-five studies (69.4%) defined PORT delay as >6 weeks after surgery (the definition utilized by the CoC and National Comprehensive Cancer Network Guidelines), whereas 4 (11.1%) defined PORT delay as a time interval other than >6 weeks, and 7 (19.4%) characterized time-to-PORT without defining delay. Meta-analysis revealed that 48.6% (95% confidence interval [CI], 41.4-55.9) of patients started PORT > 6 weeks after surgery. Median and mean time-to-PORT were 45.8 (95% CI, 42.4-51.4 days) and 47.4 days (95% CI, 43.4-51.4 days), respectively. CONCLUSION Delays in initiating guideline-adherent PORT occur in approximately half of patients with HNSCC. These meta-analytic data can be used to set national benchmarks and assess progress in reducing delays.
Collapse
Affiliation(s)
- Kelsey A Duckett
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mohamed Faisal Kassir
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Shaun A Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Emily A Brennan
- MUSC Libraries, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Bhishamjit S Chera
- Department of Radiation Oncology, Hollings Cancer Center, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Katherine R Sterba
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Chanita Hughes Halbert
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
| | - Elizabeth G Hill
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jessica McCay
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Sidharth V Puram
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
- Department of Genetics, Washington University School of Medicine, St Louis, Missouri, USA
| | - Vlad C Sandulache
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
- ENT Section, Operative CareLine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Russel Kahmke
- Department of Head and Neck Surgery and Communication Sciences, Duke University, Durham, North Carolina, USA
| | - Salma Ramadan
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Brian Nussenbaum
- American Board of Otolaryngology-Head and Neck Surgery, Houston, Texas, USA
| | - Anthony J Alberg
- Department of Epidemiology and Biostatistics, University of South Carolina Arnold School of Public Health, Columbia, South Carolina, USA
| | - Evan M Graboyes
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| |
Collapse
|
12
|
Rosas Herrera AM, Haskins AD, Hanania AN, Jhaveri PM, Chapman CH, Huang Q, Hernandez DJ. Timely delivery of PORT for head and neck squamous cell carcinoma in a county hospital. Laryngoscope Investig Otolaryngol 2024; 9:e1211. [PMID: 38362185 PMCID: PMC10866599 DOI: 10.1002/lio2.1211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 12/11/2023] [Accepted: 12/21/2023] [Indexed: 02/17/2024] Open
Abstract
Objectives The objective of this study was to compare the rate of post-operative radiation therapy (PORT) initiation within 6 weeks for head and neck squamous cell carcinoma patients treated at a safety net, academic institutio between 2019 and 2021 versus those treated in 2022 after implementation of a new clinical pathway. Methods A retrospective case-control study was performed at a single tertiary care, safety-net, academic institution. Patient demographics, tumor characteristics, dates of surgery, and other treatment dates were collected from the electronic medical record. The time from surgery to PORT was calculated. Patients who started radiation treatment within 42 days of surgery were regarded as having started PORT on time. The demographics, tumor characteristics, and rate of timely PORT for the two cohorts of patients were compared. Results From 2018 to 2021, our rate of PORT initiation within 6 weeks of surgery was 12% (n = 57). In 2022, our rate of timely PORT was 88% (n = 16), p < 0.5. Patient demographics and characteristics were similar with the exception of marital status and use of free-flap reconstruction. The 2022 cohort was more likely to be single (p < 0.5), and all patients underwent free-flap reconstruction in 2022 (p < 0.05). Conclusion Early referrals, frequent communication, and use of a secure registry were the key to the success found by our group despite the socioeconomic challenges of our underserved, safety-net hospital patient population. The changes made at our institution should serve as a template for other institutions seeking to improve the quality of care for their HNSCC patients.
Collapse
Affiliation(s)
- Ana Maria Rosas Herrera
- Bobby R. Alford Department of Otolaryngology – Head and Neck SurgeryBaylor College of MedicineHoustonTexasUSA
| | - Angela D. Haskins
- Bobby R. Alford Department of Otolaryngology – Head and Neck SurgeryBaylor College of MedicineHoustonTexasUSA
| | - Alexander N. Hanania
- Department of Radiation Oncology, Dan L. Duncan Cancer CenterBaylor College of MedicineHoustonTexasUSA
| | - Pavan M. Jhaveri
- Department of Radiation Oncology, Dan L. Duncan Cancer CenterBaylor College of MedicineHoustonTexasUSA
| | - Christina H. Chapman
- Department of Radiation Oncology, Dan L. Duncan Cancer CenterBaylor College of MedicineHoustonTexasUSA
| | - Quillan Huang
- Section of Hematology and Oncology, Department of MedicineBaylor College of MedicineHoustonTexasUSA
| | - David J. Hernandez
- Bobby R. Alford Department of Otolaryngology – Head and Neck SurgeryBaylor College of MedicineHoustonTexasUSA
| |
Collapse
|
13
|
Rich BJ, Samuels SE, Azzam GA, Kubicek G, Freedman L. Oral Cavity Squamous Cell Carcinoma: Review of Pathology, Diagnosis, and Management. Crit Rev Oncog 2024; 29:5-24. [PMID: 38683151 DOI: 10.1615/critrevoncog.2023050055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Abstract
Squamous cell carcinoma of the oral cavity presents a significant global health burden, primarily due to risk factors such as tobacco smoking, smokeless tobacco use, heavy alcohol consumption, and betel quid chewing. Common clinical manifestations of oral cavity cancer include visible lesions and sores, often accompanied by pain in advanced stages. Diagnosis relies on a comprehensive assessment involving detailed history, physical examination, and biopsy. Ancillary imaging studies and functional evaluations aid in accurate staging and facilitate treatment planning. Prognostic information is obtained from histopathological factors, such as tumor grade, depth of invasion, lymphovascular invasion, and perineural invasion. Notably, lymph node metastasis, found in approximately half of the patients, carries significant prognostic implications. Effective management necessitates a multidisciplinary approach to optimize patient outcomes. Surgical resection is the backbone of treatment, aimed at complete tumor removal while preserving functional outcomes. Adjuvant therapies, including radiation and chemotherapy, are tailored according to pathological factors. Further work in risk stratification and treatment is necessary to optimize outcomes in squamous cell carcinoma of the oral cavity.
Collapse
Affiliation(s)
| | | | - Gregory A Azzam
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine
| | - Gregory Kubicek
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine
| | - Laura Freedman
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine
| |
Collapse
|
14
|
Chen AM, Harris JP, Tjoa T, Haidar Y, Armstrong WB. Racial disparities in the timely receipt of adjuvant radiotherapy for head and neck cancer. Oral Oncol 2023; 147:106611. [PMID: 37956484 DOI: 10.1016/j.oraloncology.2023.106611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/11/2023] [Accepted: 10/29/2023] [Indexed: 11/15/2023]
Abstract
PURPOSE To evaluate the influence of socioeconomic and demographic factors which might predict for excessive delays in the receipt of adjuvant radiotherapy for head and neck cancer. METHODS AND MATERIALS The medical records of 430 consecutive patients referred for adjuvant radiation after surgical resection for squamous cell carcinoma of the head and neck were reviewed. The number of days from surgery to initiation of radiation was recorded. To study the variability in which adjuvant radiation was delivered, descriptive statistics were used to determine the percentage of patients who deviated from starting treatment beyond the recommended benchmark of 42 days. The chi-square statistic was used to compare differences in proportion among subsets. A Cox proportional hazards model was constructed to perform a multi-variate analysis to identify factors which independently influenced the likelihood for non-adherence. RESULTS The interval between surgery and the start of radiation therapy ranged from 5 to 128 days (mean, 36 days). The mean number of days from surgery to radiation therapy was 31 days, 35 days, 40 days, and 42 days for Caucasians, Asians, Latino, and Black patients (p = 0.01). In all, 359 of 430 patients (83 %) started adjuvant radiation within 42 days. The proportion of patients who initiated radiation therapy within 42 days of surgery was 91 %, 86 %, 71 %, 65 %, and 80 % for Caucasians, Asians, Latinos, Blacks, and Native Hawaiian/Pacific Islanders, respectively (p < 0.001). Patient characteristics associated with higher odds of non-adherence to the timely receipt of adjuvant radiation therapy within then 42-day benchmark from surgery to radiation included race ([OR] = 4.23 95 % CI (1.30-7.97), non-English speaking status ([OR] = 2.38, 95 % CI: 0.61-4.50), and low socioeconomic status ([OR] = 1.21, 95 % CI: 1.01-1.86). CONCLUSION Underrepresented minorities are more likely to experience delays in the receipt of adjuvant radiation for head and neck cancer. The potential underlying reasons are discussed.
Collapse
Affiliation(s)
- Allen M Chen
- Departments of Radiation Oncology, University of California, Irvine, Chao Family Comprehensive Cancer Center, Orange, CA 92868, USA.
| | - Jeremy P Harris
- Departments of Radiation Oncology, University of California, Irvine, Chao Family Comprehensive Cancer Center, Orange, CA 92868, USA
| | - Tjoson Tjoa
- Departments of Otolaryngology, University of California, Irvine, Chao Family Comprehensive Cancer Center, Orange, CA 92868, USA
| | - Yarah Haidar
- Departments of Otolaryngology, University of California, Irvine, Chao Family Comprehensive Cancer Center, Orange, CA 92868, USA
| | - William B Armstrong
- Departments of Otolaryngology, University of California, Irvine, Chao Family Comprehensive Cancer Center, Orange, CA 92868, USA
| |
Collapse
|
15
|
Nguyen J, Patel R, Eloy JA, Baredes S, Park RCW. Assessing the Association Between Time to Surgery and Survival in Sinonasal Squamous Cell Carcinoma. Laryngoscope 2023; 133:3389-3395. [PMID: 37194665 DOI: 10.1002/lary.30738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/13/2023] [Accepted: 04/28/2023] [Indexed: 05/18/2023]
Abstract
INTRODUCTION To assess the association between time to surgery (TTS) and survival in sinonasal squamous cell carcinoma patients (SSCC). METHODS We queried the 2004-2016 National Cancer Database for all cases of adult SSCC undergoing primary surgical treatment. Patients with missing TTS information were excluded. We conducted a multivariate analysis of patient demographic and clinicopathological characteristics' effect on overall survival (OS) using a Cox proportional hazards model enhanced with cubic spline non-linear approximation. Bootstrapping methods were utilized to detect the aggregate risk of TTS delay on patient OS. RESULTS A total of 2,881 patients met the inclusion criteria. The majority of patients were male (63.5%), White (86.3%), and over the age of 60 (58.4%). Parametric cubic spline approximation Cox hazard model detected a non-linear association between patient OS and TTS below 30 days with the lowest risk occurring at 18 days and steadily increasing subsequently. To analyze the aggregate risk and identify the optimal TTS cut-off after 30 days of surgical delay, the cohort sample was bootstrapped and dichotomized. The largest increase in aggregated risk was identified at 59 days (Hazards Ratio [HR] = 1.006 [0.839-1.084], p = 0.003). 60 days were used as the optimal TTS cut-off for analyzing the survival rate using the Cox proportional hazard model. Undergoing surgery within 60 days translated to a 14.6% decreased chance of death (HR: 0.854 [0.83-0.96]). CONCLUSIONS Increasing TTS is associated with worse overall survival in patients with SSCC. Our study suggests that surgery should be done within 60 days to achieve optimal survival results. LEVEL OF EVIDENCE 4 Laryngoscope, 133:3389-3395, 2023.
Collapse
Affiliation(s)
- Julia Nguyen
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Rushi Patel
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Jean Anderson Eloy
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Department of Otolaryngology and Facial Plastic Surgery, Saint Barnabas Medical Center - RWJ Barnabas Health, Livingston, New Jersey, USA
| | - Soly Baredes
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Richard Chan Woo Park
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| |
Collapse
|
16
|
Tirelli G, Boscolo-Rizzo P, Pelloso L, Gardenal N, Giudici F, Marcuzzo AV, Tofanelli M. Impact of time-to-surgery on survival and quality of life in oral cancer. Am J Otolaryngol 2023; 44:103984. [PMID: 37437337 DOI: 10.1016/j.amjoto.2023.103984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 06/30/2023] [Accepted: 07/04/2023] [Indexed: 07/14/2023]
Abstract
PURPOSE To investigate the association between time-to-surgery (TTS) and overall survival (OS), disease specific survival (DSS) and quality of life (QoL) in patients with oral squamous cell carcinoma (OSCC). MATERIALS AND METHODS 116 patients with OSCC candidate to surgery were examined. TTS intervals starting from diagnosis (TTS-clinical-based) and from histological reports (TTS-biopsy-based) were calculated. The effects of TTS intervals and prognostic factors on 5-year OS and DSS were explored. RESULTS In our cohort advanced T-categories OSCCs with TTS < 30 days showed a trend to have higher DSS rate (p = 0.049). Patients with TTS-clinical-based < 30 days showed better postoperative QoL. Positive surgical margins, nodal involvement (pN+), DOI >10 mm, invasive surgery and extra-capsular extension in pN+ were found to be significantly associated with a poor OS and DSS. CONCLUSIONS TTS ≥ 30 days can adversely affect DSS, especially in the advanced T categories. Short TTS intervals resulted associated with a better postoperative QoL.
Collapse
Affiliation(s)
- Giancarlo Tirelli
- Department of Medical, Surgical and Health Sciences, Section of Otolaryngology, University of Trieste, Trieste, Italy
| | - Paolo Boscolo-Rizzo
- Department of Medical, Surgical and Health Sciences, Section of Otolaryngology, University of Trieste, Trieste, Italy
| | - Ludovica Pelloso
- Department of Medical, Surgical and Health Sciences, Section of Otolaryngology, University of Trieste, Trieste, Italy
| | - Nicoletta Gardenal
- Department of Medical, Surgical and Health Sciences, Section of Otolaryngology, University of Trieste, Trieste, Italy
| | - Fabiola Giudici
- Department of Medicine, Surgery and Health Sciences, Biostatistics Unit, University of Trieste, Trieste, Italy
| | - Alberto Vito Marcuzzo
- Department of Medical, Surgical and Health Sciences, Section of Otolaryngology, University of Trieste, Trieste, Italy
| | - Margherita Tofanelli
- Department of Medical, Surgical and Health Sciences, Section of Otolaryngology, University of Trieste, Trieste, Italy.
| |
Collapse
|
17
|
Renslo B, Sawaf T, Virgen CG, Farrokhian N, Yu KM, Somani SN, Penn J, Ziegler A, Gan GN, Kakarala K, Shnayder Y, Bur AM, Sykes KJ. Assessing the Risk of Adjuvant Radiotherapy Initiation Delays With Social Support Surveys. Otolaryngol Head Neck Surg 2023; 169:928-937. [PMID: 36939526 PMCID: PMC10688033 DOI: 10.1002/ohn.270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/23/2022] [Accepted: 12/29/2022] [Indexed: 01/30/2023]
Abstract
OBJECTIVE In patients with head and neck squamous cell carcinoma (HNSCC), initiating postoperative radiotherapy (PORT) greater than 42 days after surgery is associated with a higher risk of poor survival outcomes. Social support has been shown to modulate behaviors related to care-seeking and treatment adherence. In this study, we sought to determine the relationship between social support metrics and PORT delays. STUDY DESIGN Prospective cohort study. SETTING Single tertiary medical center. METHODS Patients with HNSCC who underwent primary surgical excision requiring PORT were prospectively enrolled. Patient-perceived social support metrics were assessed using the Medical Outcomes Study Social Support Survey (MOS-SSS) at initial presurgical evaluation. Associations with PORT delays were evaluated via univariable and multivariable logistic regression analysis. RESULTS A total of 111 patients met the inclusion criteria for the study. An additional 28 patients were recommended to receive PORT but did not initiate treatment and were included for secondary analysis. All four subscales of the MOS-SSS (positive social interaction, affectionate support, tangible support, and emotional/informational support) were significantly associated with PORT initiation delays on univariable analysis. On multivariable analysis, the overall MOS-SSS score (odds ratio [OR] 2.08, 1.15-4.35, p = .028) was significantly associated with PORT initiation delays. On secondary analysis, lower tangible support was associated with a lack of PORT initiation (OR 1.63, 1.05-2.54, p = .028). CONCLUSION Social support metrics were significantly associated with PORT delays, which may help promote tighter scheduling and closer monitoring of high-risk patients.
Collapse
Affiliation(s)
- Bryan Renslo
- Department of Otolaryngology–Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Tuleen Sawaf
- Department of Otolaryngology–Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Celina G. Virgen
- Department of Otolaryngology–Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Nathan Farrokhian
- Department of Otolaryngology–Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Katherine M. Yu
- Department of Otolaryngology–Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Shaan N. Somani
- Department of Otolaryngology–Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Joseph Penn
- Department of Otolaryngology–Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Andrea Ziegler
- Department of Otolaryngology–Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Gregory N. Gan
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Kiran Kakarala
- Department of Otolaryngology–Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Yelizaveta Shnayder
- Department of Otolaryngology–Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Andrés M. Bur
- Department of Otolaryngology–Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Kevin J. Sykes
- Department of Otolaryngology–Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| |
Collapse
|
18
|
Lee DY, Sudhandiran G, Sharma SD. Editorial: Reviews in radiation oncology. Front Oncol 2023; 13:1283431. [PMID: 37746255 PMCID: PMC10512018 DOI: 10.3389/fonc.2023.1283431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 08/28/2023] [Indexed: 09/26/2023] Open
Affiliation(s)
- David Y. Lee
- Department of Internal Medicine, Division of Hematology/Oncology, Section of Radiation Oncology, University of New Mexico School of Medicine and Comprehensive Cancer Center, Albuquerque, NM, United States
| | | | - Sunil D. Sharma
- Radiological Physics and Advisory Division, Bhabha Atomic Research Centre, Mumbai, India
| |
Collapse
|
19
|
Kim MS, Sheridan M, Rajaraman M, Hollenhorst H, Caissie A, Mahmoud-Ahmed A, Lamond N, Snow S, Corsten M, Mark Taylor S, Trites JR, Rigby MH, Bullock M, Wilke D. The impact of national holidays on postoperative radiotherapy of squamous cell carcinoma of the head and neck. Clin Transl Radiat Oncol 2023; 42:100668. [PMID: 37608964 PMCID: PMC10440354 DOI: 10.1016/j.ctro.2023.100668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 07/25/2023] [Accepted: 08/04/2023] [Indexed: 08/24/2023] Open
Abstract
Background Delays in starting postoperative radiotherapy (PORT) have been established as negative predictors for clinical outcomes in head and neck squamous cell carcinomas (HNSCC). Our study aimed to examine the effect of delays during PORT, and the impact of national holidays in Canada, a publicly funded system, on oncologic outcomes such as Overall Survival (OS) and Local Recurrence (LR). Methods The provincial cancer registry was queried to obtain demographic, pathologic, and outcomes data from cancer patients treated for all squamous cell carcinomas of the head and neck region treated between January 1, 2007 and November 30, 2019. All extracted information was cross-referenced and supplemented by chart review of patient electronic medical records. Extracted data were analyzed for OS and LR, in the context of Canadian national holidays causing delays during PORT. Results 1433 patients treated for HNSCCs were identified, of whom 338 were treated curatively with surgery followed by PORT. 68.6% of patients experienced at least one day of interruption during treatments due to holidays. LR was 15.4% and OS was 59.6% at 5 years. Treatment interruptions by holidays were predictive of local recurrence (HR, 2.38; 95% CI 1.17-4.83; p = 0.017). Patients that developed early recurrence prior to PORT had very poor oncologic outcomes. Conclusion Our findings were consistent with previously published studies in limiting the interval between surgery and PORT. We identified the novel finding of paired holidays as a significant predictor in determining LR, suggesting the importance of modifying RT delivery schedules and timing.
Collapse
Affiliation(s)
- Michael S. Kim
- Department of Radiation Oncology, Nova Scotia Cancer Centre, Dalhousie University, Halifax, Canada
| | - Margaret Sheridan
- Division of Medical Oncology – Department of Medicine, Dalhousie University, Halifax, Canada
| | - Murali Rajaraman
- Department of Radiation Oncology, Nova Scotia Cancer Centre, Dalhousie University, Halifax, Canada
| | - Helmut Hollenhorst
- Department of Radiation Oncology, Nova Scotia Cancer Centre, Dalhousie University, Halifax, Canada
| | - Amanda Caissie
- Department of Radiation Oncology, Nova Scotia Cancer Centre, Dalhousie University, Halifax, Canada
| | - Ashraf Mahmoud-Ahmed
- Department of Radiation Oncology, Cape Breton Cancer Centre, Dalhousie University, Halifax, Canada
| | - Nathan Lamond
- Division of Medical Oncology – Department of Medicine, Dalhousie University, Halifax, Canada
| | - Stephanie Snow
- Division of Medical Oncology – Department of Medicine, Dalhousie University, Halifax, Canada
| | - Martin Corsten
- Division of Otolaryngology – Head and Neck Surgery, Dalhousie University, Halifax, Canada
| | - S. Mark Taylor
- Department of Pathology, Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Jonathan R.B. Trites
- Department of Pathology, Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Matthew H. Rigby
- Department of Pathology, Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Martin Bullock
- Department of Pathology, Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Derek Wilke
- Department of Radiation Oncology, Nova Scotia Cancer Centre, Dalhousie University, Halifax, Canada
| |
Collapse
|
20
|
Sun K, Tan JY, Thomson PJ, Choi SW. Influence of time between surgery and adjuvant radiotherapy on prognosis for patients with head and neck squamous cell carcinoma: A systematic review. Head Neck 2023; 45:2108-2119. [PMID: 37194205 DOI: 10.1002/hed.27401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 02/06/2023] [Accepted: 04/30/2023] [Indexed: 05/18/2023] Open
Abstract
The timing of postoperative radiotherapy following surgical intervention in patients with head and neck cancer remains a controversial issue. This review aims to summarize findings from available studies to investigate the influence of time delays between surgery and postoperative radiotherapy on clinical outcomes. Articles between 1 January 1995 and 1 February 2022 were sourced from PubMed, Web of Science, and ScienceDirect. Twenty-three articles met the study criteria and were included; ten studies showed that delaying postoperative radiotherapy might negatively impact patients and lead to a poorer prognosis. Delaying the start time of radiotherapy, 4 weeks after surgery did not result in poorer prognoses for patients with head and neck cancer, although delays beyond 6 weeks might worsen patients' overall survival, recurrence-free survival, and locoregional control. Prioritization of treatment plans to optimize the timing of postoperative radiotherapy regimes is recommended.
Collapse
Affiliation(s)
- Kaiyuan Sun
- Division of Oral and Maxillofacial Surgery, Faculty of Dentistry, The University of Hong Kong, Hong Kong, China
| | - Jia Yan Tan
- Division of Oral and Maxillofacial Surgery, Faculty of Dentistry, The University of Hong Kong, Hong Kong, China
| | - Peter James Thomson
- College of Medicine and Dentistry, James Cook University, Queensland, Australia
| | - Siu-Wai Choi
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, Pokfulam, Hong Kong, China
| |
Collapse
|
21
|
Lorenz FJ, Mahase SS, Miccio J, King TS, Pradhan S, Goyal N. Update on adherence to guidelines for time to initiation of postoperative radiation for head and neck squamous cell carcinoma. Head Neck 2023; 45:1676-1691. [PMID: 37102787 PMCID: PMC10797635 DOI: 10.1002/hed.27380] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 03/28/2023] [Accepted: 04/16/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND A prior study reported that over half of patients with HNSCC initiated PORT after 6 weeks from surgery during 2006-2014. In 2022, the CoC released a quality metric for patients to initiate PORT within 6 weeks. This study provides an update on time to PORT in recent years. METHODS The NCDB and TriNetX Research Network were queried to identify patients with HNSCC who received PORT during 2015-2019 and 2015-2021, respectively. Treatment delay was defined as initiating PORT beyond 6 weeks after surgery. RESULTS In NCDB, PORT was delayed for 62% of patients. Predictors of delay included age >50, female sex, black race, nonprivate insurance/uninsured status, lower education, oral cavity site, negative surgical margins, increased postoperative length of stay, unplanned hospital readmissions, IMRT radiation modality, treatment at an academic hospital or in the Northeast, and surgery and radiation at different facilities. In TriNetX, 64% experienced treatment delay. Additional associations with prolonged time to treatment included never married/divorced/widowed marital status, major surgery (neck dissection/free flaps/laryngectomy), and gastrostomy/tracheostomy dependence. CONCLUSIONS There continue to be challenges to timely initiation of PORT.
Collapse
Affiliation(s)
- F. Jeffrey Lorenz
- College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Sean S. Mahase
- College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA
- Department of Radiation Oncology, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Joseph Miccio
- College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA
- Department of Radiation Oncology, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Tonya S. King
- Department of Public Health Sciences, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Sandeep Pradhan
- Department of Public Health Sciences, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Neerav Goyal
- College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA
- Department of Public Health Sciences, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
- Department of Otolaryngology – Head and Neck Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| |
Collapse
|
22
|
Sawaf T, Virgen CG, Renslo B, Farrokhian N, Yu KM, Somani SN, Bur AM, Kakarala K, Shnayder Y, Gan GN, Graboyes EM, Sykes KJ. Association of Social-Ecological Factors With Delay in Time to Initiation of Postoperative Radiation Therapy: A Prospective Cohort Study. JAMA Otolaryngol Head Neck Surg 2023; 149:477-484. [PMID: 37079327 PMCID: PMC10119772 DOI: 10.1001/jamaoto.2023.0308] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 02/14/2023] [Indexed: 04/21/2023]
Abstract
Importance Timely initiation of postoperative radiation therapy (PORT) is associated with reduced recurrence rates and improved overall survival in patients with head and neck squamous cell carcinoma (HNSCC). Measurement of the association of social-ecological variables with PORT delays is lacking. Objective To assess individual and community-level factors associated with PORT delay among patients with HNSCC. Design, Setting, and Participants This prospective cohort study carried out between September 2018 and June 2022 included adults with untreated HNSCC who were enrolled in a prospective registry at a single academic tertiary medical center. Demographic information and validated self-reported measures of health literacy were obtained at baseline visits. Clinical data were recorded, and participant addresses were used to calculate the area deprivation index (ADI), a measure of community-level social vulnerability. Participants receiving primary surgery and PORT were analyzed. Univariable and multivariable regression analysis was performed to identify risk factors for PORT delays. Exposures Surgical treatment and PORT. Main Outcomes and Measures The primary outcome was PORT initiation delay (>42 days from surgery). Risk of PORT initiation delay was evaluated using individual-level (demographic, health literacy, and clinical data) and community-level information (ADI and rural-urban continuum codes). Results Of 171 patients, 104 patients (60.8%) had PORT delays. Mean (SD) age of participants was 61.0 (11.2) years, 161 were White (94.2%), and 105 were men (61.4%). Insurance was employer-based or public among 65 (38.5%) and 75 (44.4%) participants, respectively. Mean (SD) ADI (national percentile) was 60.2 (24.4), and 71 (41.8%) resided in rural communities. Tumor sites were most commonly oral cavity (123 [71.9%]), with 108 (63.5%) classified as stage 4 at presentation. On multivariable analysis, a model incorporating individual-level factors with health literacy in addition to community-level factors was most predictive of PORT delay (AOC= 0.78; R2, 0.18). Conclusions and Relevance This cohort study provides a more comprehensive assessment of predictors of PORT delays that include health literacy and community-level measures. Predictive models that incorporate multilevel measures outperform models with individual-level factors alone and may guide precise interventions to decrease PORT delay for at-risk patients with HNSCC.
Collapse
Affiliation(s)
- Tuleen Sawaf
- Department of Otolaryngology–Head and Neck Surgery, University of Kansas Medical Center, Kansas City
| | - Celina G. Virgen
- Department of Otolaryngology–Head and Neck Surgery, University of Kansas Medical Center, Kansas City
| | - Bryan Renslo
- Department of Otolaryngology–Head and Neck Surgery, University of Kansas Medical Center, Kansas City
| | - Nathan Farrokhian
- Department of Otolaryngology–Head and Neck Surgery, University of Kansas Medical Center, Kansas City
| | - Katherine M. Yu
- Department of Otolaryngology–Head and Neck Surgery, University of Kansas Medical Center, Kansas City
| | - Shaan N. Somani
- Department of Otolaryngology–Head and Neck Surgery, University of Kansas Medical Center, Kansas City
| | - Andrés M. Bur
- Department of Otolaryngology–Head and Neck Surgery, University of Kansas Medical Center, Kansas City
| | - Kiran Kakarala
- Department of Otolaryngology–Head and Neck Surgery, University of Kansas Medical Center, Kansas City
| | - Yelizaveta Shnayder
- Department of Otolaryngology–Head and Neck Surgery, University of Kansas Medical Center, Kansas City
| | - Gregory N. Gan
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City
| | - Evan M. Graboyes
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston
| | - Kevin J. Sykes
- Department of Otolaryngology–Head and Neck Surgery, University of Kansas Medical Center, Kansas City
| |
Collapse
|
23
|
Zhao F, Yang D, Li X. Effect of radiotherapy interruption on nasopharyngeal cancer. Front Oncol 2023; 13:1114652. [PMID: 37091186 PMCID: PMC10116059 DOI: 10.3389/fonc.2023.1114652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 03/27/2023] [Indexed: 04/25/2023] Open
Abstract
Nasopharyngeal carcinoma (NPC) is a malignant tumor originating from the epithelial cells of the nasopharynx with a unique geographic distribution, and is particularly prevalent in East and Southeast Asia. Due to its anatomical location, the surgery is difficult to access and the high sensitivity of nasopharyngeal cancer to radiotherapy (RT) makes it the main treatment modality. Radical radiotherapy is the first-line treatment for early-stage nasopharyngeal carcinoma and the cornerstone of multidisciplinary treatment for patients with locally advanced nasopharyngeal carcinoma. Nevertheless, radiotherapy interruption is inevitable as a consequence of unavoidable factors such as public holidays, machine malfunction, patient compliance, and adverse response to treatment, which in turn leads to a reduction in bioactivity and causes sublethal loss of tumor cells to repair. Unirradiated tumor cells are more likely to repopulate at or near their original fastest growth rate during this interval. If no measures are taken after the radiotherapy interruption, such as increasing the dose of radiotherapy and systemic therapy, the tumor is most likely to go uncontrolled and then progress. This review describes the effects of radiotherapy interruption on nasopharyngeal carcinoma, the mechanism of the effect, and explores the measures that can be taken in response to such interruption.
Collapse
Affiliation(s)
- Fangrui Zhao
- Department of Oncology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Dashuai Yang
- Department of Hepatobiliary Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xiangpan Li
- Department of Oncology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| |
Collapse
|
24
|
Bhandari S, Wadhwa Soni B, Gupta A, Ghoshal S. Time required for prophylactic oral care in head and neck cancer patients scheduled for radiotherapy: A single center, prospective cohort study. Head Neck 2023; 45:913-920. [PMID: 36794635 DOI: 10.1002/hed.27317] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 01/21/2023] [Accepted: 02/05/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Prophylactic oral care (POC) before radiotherapy (RT) is an adjunct but an integral process toward preparing patients for RT, however, time to be invested in POC remains unexplored. METHODS Prospective treatment records were maintained in head and neck cancer patients, who received POC following a standardized protocol with definite timelines. Data collected for oral treatment time (OTT), interruption in RT due to oro-dental issues, future extraction(s), and incidence of osteoradionecrosis (ORN) up to 18 months after treatment were analyzed. RESULTS Three hundred thirty-three patients, 275 males and 58 females, mean age 52.45 ± 11.2 years were included. Mean OTT was 21.0 ± 6.2 days and was influenced significantly with the number of extractions (p < 0.00). There was no interruption in RT schedule due to oro-dental issues. Five patients were diagnosed with ORN. CONCLUSION Performing POC as demonstrated aid in timely removal of nidus of infection(s), perform RT as scheduled, and maintain satisfactory oral health through the survivorship of patients.
Collapse
Affiliation(s)
- Sudhir Bhandari
- Unit of Prosthodontics, Oral Health Sciences Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Bhavita Wadhwa Soni
- Unit of Prosthodontics, Oral Health Sciences Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ankita Gupta
- Department of Radiation Oncology, Advanced Centre for Treatment, Research, and Education in Cancer, Tata Memorial Centre, HBNI, Navi Mumbai, India
| | - Sushmita Ghoshal
- Department of Radiotherapy, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
25
|
Tsutsumi K, Ahmed KH, Goshtasbi K, Torabi SJ, Mohyeldin A, Hsu FPK, Kuan EC. Impact of esthesioneuroblastoma treatment delays on overall patient survival. Laryngoscope 2023; 133:764-772. [PMID: 35460271 DOI: 10.1002/lary.30136] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 03/13/2022] [Accepted: 04/01/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To characterize clinical factors associated with esthesioneuroblastoma treatment delays and determine the impact of these delays on overall survival. STUDY DESIGN Retrospective database analysis. METHODS The 2004-2016 National Cancer Database was queried for patients with esthesioneuroblastoma managed by primary surgery and adjuvant radiation. Durations of diagnosis-to-treatment initiation (DTI), diagnosis-to-treatment end (DTE), surgery-to-RT initiation (SRT), radiotherapy treatment (RTD), and total treatment package (TTP) were analyzed. The cohort was split into two groups for each delay interval using the median time as the threshold. RESULTS A total of 814 patients (39.6% female, 88.5% white) with mean ± SD age of 52.6 ± 15.1 years who underwent both esthesioneuroblastoma surgery and adjuvant radiotherapy were queried. Median DTI, DTE, SRT, RTD, and TTP were 34, 140, 55, 45, and 101 days, respectively. A significant association was identified between increased regional radiation dose above 66 Gy and decreased DTI (OR = 0.54, 95% CI 0.35-0.83, p = 0.01) and increased RTD (OR = 3.94, 95% CI 2.36-6.58, p < 0.001) durations. Chemotherapy administration was linked with decreased SRT (OR = 0.64, 95% CI 0.47-0.89, p = 0.01) and TTP (OR = 0.59, 95% CI 0.43-0.82, p = 0.001) durations. Cox proportional-hazards analysis revealed that increased RTD was associated with decreased survival (HR = 1.80, 95% CI 1.26-2.57, p < 0.005), independent of age, sex, race, regional radiation dose, facility volume, facility type, insurance status, modified Kadish stage, chemotherapy status, Charlson-Deyo comorbidity index, and surgical margins. CONCLUSIONS Delays during, and prolongation of radiotherapy for esthesioneuroblastoma appears to be associated with decreased survival. LEVEL OF EVIDENCE 4 Laryngoscope, 133:764-772, 2023.
Collapse
Affiliation(s)
- Kotaro Tsutsumi
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, USA
| | - Khwaja H Ahmed
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, USA
| | - Khodayar Goshtasbi
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, USA
| | - Sina J Torabi
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, USA
| | - Ahmed Mohyeldin
- Department of Neurological Surgery, University of California, Irvine, California, USA
| | - Frank P K Hsu
- Department of Neurological Surgery, University of California, Irvine, California, USA
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, USA.,Department of Neurological Surgery, University of California, Irvine, California, USA
| |
Collapse
|
26
|
Llanos AAM, Ashrafi A, Ghosh N, Tsui J, Lin Y, Fong AJ, Ganesan S, Heckman CJ. Evaluation of Inequities in Cancer Treatment Delay or Discontinuation Following SARS-CoV-2 Infection. JAMA Netw Open 2023; 6:e2251165. [PMID: 36637818 PMCID: PMC9856904 DOI: 10.1001/jamanetworkopen.2022.51165] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
IMPORTANCE There is a disproportionately greater burden of COVID-19 among Hispanic and non-Hispanic Black individuals, who also experience poorer cancer outcomes. Understanding individual-level and area-level factors contributing to inequities at the intersection of COVID-19 and cancer is critical. OBJECTIVE To evaluate associations of individual-level and area-level social determinants of health (SDOH) with delayed or discontinued cancer treatment following SARS-CoV-2 infection. DESIGN, SETTING, AND PARTICIPANTS This retrospective, registry-based cohort study used data from 4768 patients receiving cancer care who had positive test results for SARS-CoV-2 and were enrolled in the American Society for Clinical Oncology COVID-19 Registry. Data were collected from April 1, 2020, to September 26, 2022. EXPOSURES Race and ethnicity, sex, age, and area-level SDOH based on zip codes of residence at the time of cancer diagnosis. MAIN OUTCOMES AND MEASURES Delayed (≥14 days) or discontinued cancer treatment (any cancer treatment, surgery, pharmacotherapy, or radiotherapy) and time (in days) to restart pharmacotherapy. RESULTS A total of 4768 patients (2756 women [57.8%]; 1558 [32.7%] aged ≥70 years at diagnosis) were included in the analysis. There were 630 Hispanic (13.2%), 196 non-Hispanic Asian American or Pacific Islander (4.1%), 568 non-Hispanic Black (11.9%), and 3173 non-Hispanic White individuals (66.5%). Compared with non-Hispanic White individuals, Hispanic and non-Hispanic Black individuals were more likely to experience a delay of at least 14 days or discontinuation of any treatment and drug-based treatment; only estimates for non-Hispanic Black individuals were statistically significant, with correction for multiple comparisons (risk ratios [RRs], 1.35 [95% CI, 1.22-1.49] and 1.37 [95% CI, 1.23-1.52], respectively). Area-level SDOH (eg, geography, proportion of residents without health insurance or with only a high school education, lower median household income) were associated with delayed or discontinued treatment. In multivariable Cox proportinal hazards regression models, estimates suggested that Hispanic (hazard ratio [HR], 0.87 [95% CI, 0.71-1.05]), non-Hispanic Asian American or Pacific Islander (HR, 0.79 [95% CI, 0.46-1.35]), and non-Hispanic Black individuals (HR, 0.81 [95% CI, 0.67-0.97]) experienced longer delays to restarting pharmacotherapy compared with non-Hispanic White individuals. CONCLUSIONS AND RELEVANCE The findings of this cohort study suggest that race and ethnicity and area-level SDOH were associated with delayed or discontinued cancer treatment and longer delays to the restart of drug-based therapies following SARS-CoV-2 infection. Such treatment delays could exacerbate persistent cancer survival inequities in the United States.
Collapse
Affiliation(s)
- Adana A. M. Llanos
- Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, New York
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York
| | - Adiba Ashrafi
- Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, New York
| | - Nabarun Ghosh
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey
| | - Jennifer Tsui
- Keck School of Medicine, University of Southern California, Los Angeles
| | - Yong Lin
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey
- Rutgers Cancer Institute of New Jersey, New Brunswick
| | - Angela J. Fong
- Rutgers Cancer Institute of New Jersey, New Brunswick
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Shridar Ganesan
- Rutgers Cancer Institute of New Jersey, New Brunswick
- Department of Medicine and Pharmacology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Carolyn J. Heckman
- Rutgers Cancer Institute of New Jersey, New Brunswick
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| |
Collapse
|
27
|
Hutten RJ, Weil CR, Gaffney DK, Kokeny K, Lloyd S, Rogers CR, Suneja G. Racial and Ethnic Health Disparities in Delay to Initiation of Intensity-Modulated Radiotherapy. JCO Oncol Pract 2022; 18:e1694-e1703. [PMID: 35930751 PMCID: PMC9663141 DOI: 10.1200/op.22.00104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 06/01/2022] [Accepted: 06/22/2022] [Indexed: 01/14/2023] Open
Abstract
PURPOSE Delays in initiation of radiotherapy may contribute to inferior oncologic outcomes that are more commonly observed in minoritized populations in the United States. We aimed to examine inequities associated with delayed initiation of intensity-modulated radiotherapy (IMRT). MATERIALS AND METHODS The National Cancer Database was queried to identify the 10 cancer sites most commonly treated with IMRT. Interval to initiation of treatment (IIT) was broken into quartiles for each disease site, with the 4th quartile classified as delayed. Multivariable logistic regression for delayed IIT was performed for each disease site using clinical and demographic covariates. Differences in magnitude of delay between subsets of patients stratified by race and insurance status were evaluated using two-sample t-tests. RESULTS Among patients (n = 350,425) treated with IMRT between 2004 and 2017, non-Hispanic Black (NHB), Hispanic, and Asian patients were significantly more likely to have delayed IIT with IMRT for nearly all disease sites compared with non-Hispanic White (NHW) patients. NHB, Hispanic, and Asian patients had significantly longer median IIT than NHW patients (NHB 87 days, P < .01; Hispanic 76 days, P < .01; Asian 74 days, P < .01; and NHW 67 days). NHW, Hispanic, and Asian patients with private insurance had shorter median IIT than those with Medicare (P < .01); however, NHB patients with private insurance had longer IIT than those with Medicare (P < .01). CONCLUSION Delays in initiation of IMRT in NHB, Hispanic, and Asian patients may contribute to the known differences in cancer outcomes and warrant further investigation, particularly to further clarify the role of different insurance policies in delays in advanced modality radiotherapy.
Collapse
Affiliation(s)
- Ryan J. Hutten
- Department of Radiation Oncology, Huntsman Cancer Hospital, University of Utah, Salt Lake City, UT
| | - Christopher R. Weil
- Department of Radiation Oncology, Huntsman Cancer Hospital, University of Utah, Salt Lake City, UT
| | - David K. Gaffney
- Department of Radiation Oncology, Huntsman Cancer Hospital, University of Utah, Salt Lake City, UT
| | - Kristine Kokeny
- Department of Radiation Oncology, Huntsman Cancer Hospital, University of Utah, Salt Lake City, UT
| | - Shane Lloyd
- Department of Radiation Oncology, Huntsman Cancer Hospital, University of Utah, Salt Lake City, UT
| | - Charles R. Rogers
- Department of Family & Preventive Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Gita Suneja
- Department of Radiation Oncology, Huntsman Cancer Hospital, University of Utah, Salt Lake City, UT
| |
Collapse
|
28
|
Shah HP, Cohen O, Sukys J, Dibble J, Mehra S. The impact of frailty on adjuvant treatment in patients with head and neck free flap reconstruction-A retrospective study using two independent frailty scores. Oral Oncol 2022; 132:106006. [PMID: 35835056 DOI: 10.1016/j.oraloncology.2022.106006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 05/17/2022] [Accepted: 06/27/2022] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Reconstructive surgery may result in prolonged postoperative recovery, especially in frail patients, which in turn may impact delivery of adjuvant therapy. To date, no studies have investigated potential associations between frailty and adjuvant treatment delivery after reconstructive surgery. We examine the impact of frailty on time to initiation, duration, and completion of adjuvant treatment after reconstructive surgery for head and neck cancers (HNCs). METHODS A retrospective review of patients who underwent free flap reconstruction for HNC at a single institution from 2015 to 2021 and received adjuvant radiation was performed. Frailty was assessed using two independent scales: the 11-item modified frailty index (mFI) score and binary Johns Hopkins Adjusted Clinical Groups (ACG) frailty indicator. Timely adjuvant initiation (within six weeks of surgery), duration of adjuvant treatment, and completion were compared between frail and non-frail patients. RESULTS Of the 163 patients included for analysis, 52 (31.9%) were identified as frail by the ACG indicator and 24 (14.7%) were identified as frail with an mFI score ≥ 3. Frail patients (mFI score ≥ 3) were significantly less likely than non-frail patients to initiate adjuvant treatment within six weeks (OR:0.21, CI:0.04-0.85, p = 0.046). Frailty designated by either frailty scale was not significantly associated with adjuvant treatment duration. Likelihood of adjuvant treatment completion was significantly lower for frail compared to non-frail patients by both scales: ACG indicator (OR 0.02, CI:9.05 × 10-4-0.25, p = 0.007) and mFI score ≥ 3 (OR:0.01, CI:6.85 × 10-4-0.13, p = 0.007). CONCLUSIONS Frailty is associated with decreased likelihood of timely adjuvant treatment initiation and completion in patients with HNCs after free flap reconstruction.
Collapse
Affiliation(s)
- Hemali P Shah
- Yale University School of Medicine, Department of Surgery, Division of Otolaryngology, Section of Head and Neck Surgery, New Haven, CT, USA
| | - Oded Cohen
- Yale University School of Medicine, Department of Surgery, Division of Otolaryngology, Section of Head and Neck Surgery, New Haven, CT, USA
| | - Jordan Sukys
- Yale University School of Medicine, Department of Surgery, Division of Otolaryngology, Section of Head and Neck Surgery, New Haven, CT, USA
| | - Jacqueline Dibble
- Yale University School of Medicine, Department of Surgery, Division of Otolaryngology, Section of Head and Neck Surgery, New Haven, CT, USA
| | - Saral Mehra
- Yale University School of Medicine, Department of Surgery, Division of Otolaryngology, Section of Head and Neck Surgery, New Haven, CT, USA; Yale Cancer Center, New Haven, CT, USA.
| |
Collapse
|
29
|
Marwah R, Goonetilleke D, Smith J, Chilkuri M. Evaluating delays in patients treated with post-operative radiation therapy for head and neck squamous cell carcinoma. J Med Imaging Radiat Oncol 2022; 66:840-846. [PMID: 35726770 PMCID: PMC9544161 DOI: 10.1111/1754-9485.13449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 05/07/2022] [Indexed: 11/30/2022]
Abstract
Introduction Delays in commencing post‐operative radiation therapy (PORT) and prolongation of overall treatment times (OTT) are associated with reduced overall survival and higher recurrence rates in patients with head and neck squamous cell carcinoma (HNSCC). The objective of this study was to evaluate treatment delays, factors contributing to those delays and to explore strategies to mitigate them. Methods This retrospective study included patients with mucosal HNSCC at Townsville University Hospital treated with curative intent surgery and PORT between June 2011 and June 2019. The proportion of patients who experienced delays in commencing PORT (>6 weeks) and OTT were evaluated and reasons for these delays were explored. Results The study included 94 patients of which 70% experienced PORT delay. Surgery at an external facility (81% vs 56%, P = 0.006) and longer post‐operative length of stay (P = 0.011) were significantly associated with a higher incidence of PORT delay. Aboriginal and Torres Strait Islander patients had a higher rate of PORT delay (89% vs 68.2%, P = 0.198). Significant delays were noted from time of surgery to radiation oncology (RO) consult and from RO consult to commencement of radiation treatment. Conclusion This study demonstrates that the prevalence of PORT delay for patients with HNSCC remains high with room for improvement. Potential strategies to improve delays include developing effective care coordination, addressing specific needs of Indigenous patients, implementing reliable automated tracking and communication systems between teams and harnessing existing electronic referral systems.
Collapse
Affiliation(s)
- Ravi Marwah
- Townsville University Hospital, Townsville, Queensland, Australia
| | | | - Justin Smith
- Townsville University Hospital, Townsville, Queensland, Australia.,James Cook University, Townsville, Queensland, Australia
| | - Madhavi Chilkuri
- Townsville University Hospital, Townsville, Queensland, Australia.,James Cook University, Townsville, Queensland, Australia
| |
Collapse
|
30
|
Johnsson A, Norman D, Angenete E, Cavalli-Björkman N, Lagerbäck C, Leon O, Lindh B, Lydrup ML, Nilsson MP, Perman M, Radu C, Zackrisson B. Anal cancer in Sweden 2015-2019. Implementation of guidelines, structural changes, national registry and early results. Acta Oncol 2022; 61:575-582. [PMID: 35274596 DOI: 10.1080/0284186x.2022.2048069] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Squamous cell cancer of the anus is an uncommon malignancy, usually caused by human papilloma virus (HPV). Chemoradiotherapy (CRT) is the recommended treatment in localized disease with cure rates of 60-80%. Local failures should be considered for salvage surgery. With the purpose of improving and equalizing the anal cancer care in Sweden, a number of actions were taken between 2015 and 2017. The aim of this study was to describe the implementation of guidelines and organizational changes and to present early results from the first 5 years of the Swedish anal cancer registry (SACR). METHODS The following were implemented: (1) the first national care program with treatment guidelines, (2) standardized care process, (3) centralization of CRT to four centers and salvage surgery to two centers, (4) weekly national multidisciplinary team meetings where all new cases are discussed, (5) the Swedish anal cancer registry (SACR) was started in 2015. RESULTS The SACR included 912 patients with a diagnosis of anal cancer from 2015 to 2019, reaching a national coverage of 95%. We could show that guidelines issued in 2017 regarding staging procedures and radiotherapy dose modifications were rapidly implemented. At baseline 52% of patients had lymph node metastases and 9% had distant metastases. Out of all patients in the SACR 89% were treated with curative intent, most of them with CRT, after which 92% achieved a local complete remission and the estimated overall 3-year survival was 85%. CONCLUSIONS This is the first report from the SACR, demonstrating rapid nation-wide implementation of guidelines and apparently good treatment outcome in patients with anal cancer in Sweden. The SACR will hopefully be a valuable source for future research.
Collapse
Affiliation(s)
- Anders Johnsson
- Department of Oncology, Skåne University Hospital, Lund, Sweden
| | | | - Eva Angenete
- Department of Surgery, Sahlgrenska University Hospital and Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | | | - Otilia Leon
- Department of Oncology, Skåne University Hospital, Lund, Sweden
| | - Birgitta Lindh
- Department of Oncology, University Hospital of Northern Sweden, Umeå, Sweden
| | | | | | - Mats Perman
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Calin Radu
- Department of Oncology, Akademiska Sjukhuset, Uppsala, Sweden
| | - Björn Zackrisson
- Department of Oncology, University Hospital of Northern Sweden, Umeå, Sweden
| |
Collapse
|
31
|
Survival benefit associated with postoperative PET–CT before adjuvant radiotherapy or chemoradiotherapy in patients with oral squamous cell carcinoma. Int J Oral Maxillofac Surg 2022; 51:1382-1388. [DOI: 10.1016/j.ijom.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 01/21/2022] [Accepted: 03/01/2022] [Indexed: 11/21/2022]
|
32
|
Lee CW, Dupré S, Marlborough F, Iqbal MS, Kelly C, Bashir MA, Ahmed OA, Ragbir M, Saleh DB. Postoperative radiotherapy delay in head and neck cancer patients undergoing major resection and free flap reconstruction. J Plast Reconstr Aesthet Surg 2022; 75:2084-2089. [PMID: 35351393 DOI: 10.1016/j.bjps.2022.02.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 01/16/2022] [Accepted: 02/15/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Delays to postoperative radiotherapy (PORT) are frequent and associated with poorer oncologic outcomes in head and neck cancer (HNC) patients. Free flap patients have been suggested as the most at-risk group. Thus, PORT delivery experienced by HNC patients who required a free flap reconstruction was analysed, identifying reasons for the delays if any. METHODS A retrospective analysis of a single tertiary unit's PORT delivery to HNC patients undergoing major resection followed by free flap reconstruction between 2017 and 2020. RESULTS Eighty-seven patients were identified. Thirty-two patients received PORT within 6 weeks of their surgery date. Reasons for the delays could be categorised into surgery-derived, system-derived and patient-derived reasons. Five patients (5.74%) received PORT >6 weeks after their surgery due to surgical complications. No patients experienced surgical complications during their PORT. CONCLUSION In our experience, surgical aspects of free flap reconstructions do not appear to overtly delay or interrupt PORT.
Collapse
Affiliation(s)
- Chang Woo Lee
- Department of Plastic and Reconstructive Surgery, The Newcastle upon Tyne Hospitals NHS Foundation Trust, United Kingdom.
| | - Sophie Dupré
- Department of Plastic and Reconstructive Surgery, The Newcastle upon Tyne Hospitals NHS Foundation Trust, United Kingdom
| | - Fergal Marlborough
- Department of Plastic and Reconstructive Surgery, The Newcastle upon Tyne Hospitals NHS Foundation Trust, United Kingdom
| | - Muhammad Shahid Iqbal
- Department of Clinical Oncology, Northern Centre for Cancer Care, The Newcastle upon Tyne Hospitals NHS Foundation Trust, United Kingdom
| | - Charles Kelly
- Department of Clinical Oncology, Northern Centre for Cancer Care, The Newcastle upon Tyne Hospitals NHS Foundation Trust, United Kingdom
| | - Muhammad Asim Bashir
- Department of Plastic and Reconstructive Surgery, The Newcastle upon Tyne Hospitals NHS Foundation Trust, United Kingdom
| | - Omar A Ahmed
- Department of Plastic and Reconstructive Surgery, The Newcastle upon Tyne Hospitals NHS Foundation Trust, United Kingdom
| | - Maniram Ragbir
- Department of Plastic and Reconstructive Surgery, The Newcastle upon Tyne Hospitals NHS Foundation Trust, United Kingdom
| | - Daniel B Saleh
- Department of Plastic and Reconstructive Surgery, The Newcastle upon Tyne Hospitals NHS Foundation Trust, United Kingdom
| |
Collapse
|
33
|
Mascarella MA, Patel T, Vendra V, Gardiner L, Kergoat MJ, Kubik MW, Solari MG, Snyderman CH, Traylor KS, Ferris RL, Kim S, Duvvuri U, Sridharan SS. Poor treatment tolerance in head and neck cancer patients with low muscle mass. Head Neck 2022; 44:844-850. [PMID: 35020252 DOI: 10.1002/hed.26978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 12/05/2021] [Accepted: 01/03/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND We ascertain the role of a low cervical paraspinal skeletal muscle index (CPSMI) as a biomarker for poor treatment tolerance in patients with operable mucosal head and neck squamous cell carcinoma (HNSCC). METHODS A prospective cohort of patients with operable HNSCC requiring microvascular reconstruction was evaluated. Low CPSMI was calculated using preoperative CT neck imaging. Poor treatment tolerance, a composite measure of incomplete therapy or severe morbidity/mortality during treatment, was the primary outcome. RESULTS One hundred and twenty-seven patients underwent extirpative surgery with a mean age was 60.5. Poor treatment tolerance occurred in 71 (56%) patients with 21 not completing recommended adjuvant therapy and 66 having severe treatment-related morbidity. A low CPSMI was independently associated with poor treatment tolerance (OR 2.49, 95%CI 1.10-5.93) and delay to adjuvant therapy (OR 4.48, 95%CI 1.07-27.6) after adjusting for multiple confounders. CONCLUSION Low CPSMI was independently associated with poor treatment tolerance in patients with operable HNSCC.
Collapse
Affiliation(s)
- Marco A Mascarella
- Department of Otolaryngology - Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Biomedical Sciences, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
- Lady Davis Institute of the Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Terral Patel
- Department of Otolaryngology - Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Varun Vendra
- Department of Otolaryngology - Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Lauren Gardiner
- Department of Otolaryngology - Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Marie-Jeanne Kergoat
- Department of Biomedical Sciences, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
- Division of Geriatrics, Department of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Mark W Kubik
- Department of Otolaryngology - Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Plastic and Reconstructive Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Mario G Solari
- Department of Otolaryngology - Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Plastic and Reconstructive Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Carl H Snyderman
- Department of Otolaryngology - Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Katie S Traylor
- Department of Diagnostic Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Robert L Ferris
- Department of Otolaryngology - Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Seungwon Kim
- Department of Otolaryngology - Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Umamaheswar Duvvuri
- Department of Otolaryngology - Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Shaum S Sridharan
- Department of Otolaryngology - Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Plastic and Reconstructive Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
34
|
Noyes EA, Burks CA, Larson AR, Deschler DG. An equity-based narrative review of barriers to timely postoperative radiation therapy for patients with head and neck squamous cell carcinoma. Laryngoscope Investig Otolaryngol 2021; 6:1358-1366. [PMID: 34938875 PMCID: PMC8665479 DOI: 10.1002/lio2.692] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 10/15/2021] [Accepted: 10/25/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES The majority of patients with head and neck squamous cell carcinoma (HNSCC) do not commence postoperative radiation treatment (PORT) within the recommended 6 weeks. We explore how delayed PORT affects survival outcomes, what factors are associated with delayed PORT initiation, and what interventions exist to reduce delays in PORT initiation. METHODS We conducted a PubMed search to identify articles discussing timely PORT for HNSCC. We performed a narrative review to assess survival outcomes of delayed PORT as well as social determinants of health (SDOH) and clinical factors associated with delayed PORT, using the PROGRESS-Plus health equity framework to guide our analysis. We reviewed interventions designed to reduce delays in PORT. RESULTS Delayed PORT is associated with reduced overall survival. Delays in PORT disproportionately burden patients of racial/ethnic minority backgrounds, Medicaid or no insurance, low socioeconomic status, limited access to care, more comorbidities, presentation at advanced stages, and those who experience postoperative complications. Delays in PORT initiation tend to occur during transitions in head and neck cancer care. Delays in PORT may be reduced by interventions that identify patients who are most likely to experience delayed PORT, support patients according to their specific needs and barriers to care, and streamline care and referral processes. CONCLUSIONS Both SDOH and clinical factors are associated with delays in timely PORT. Structural change is needed to reduce health disparities and promote equitable access to care for all. When planning care, providers must consider not only biological factors but also SDOH to maximize care outcomes.
Collapse
Affiliation(s)
| | - Ciersten A. Burks
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and EarHarvard Medical SchoolBostonMassachusettsUSA
| | - Andrew R. Larson
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and EarHarvard Medical SchoolBostonMassachusettsUSA
| | - Daniel G. Deschler
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and EarHarvard Medical SchoolBostonMassachusettsUSA
| |
Collapse
|
35
|
Chilkuri M, Vangaveti V, Smith J. Head and neck cancers: Monitoring quality and reporting outcomes. J Med Imaging Radiat Oncol 2021; 66:455-465. [PMID: 34851013 PMCID: PMC9299932 DOI: 10.1111/1754-9485.13359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 11/13/2021] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Head and neck cancers (HNC) require high level multidisciplinary care to achieve optimal outcomes. Reporting of quality indicators (QIs) has been instigated by some health services in an effort to improve quality of care. The aim of this study was to determine the quality of care provided to patients with HNC at a single institution by analysing compliance with QIs and to explore the feasibility and utility of collecting this data. METHODS This was a single institution retrospective chart review of all patients with squamous cell HNC at Townsville Hospital who were treated with curative intent between June 2011 and June 2019. Data was entered into a RedCap database and then exported to Stata V16 for analysis. RESULTS A total of 537 patients were included in the overall study, with six patients who had a synchronous non-HNC and two patients who received previous radiotherapy (RT) to the head and neck region excluded from the outcome analysis. Overall, compliance with pre-treatment, treatment and post-treatment QIs was high, with the exception of smoking cessation support (66%), post-treatment dental review and time to post-operative RT (33% of patients within 6 weeks). The 5-year overall survival was 69.4% (CI; 64-73.2%). The cumulative incidence of locoregional relapse for the overall study cohort was 18% (CI; 14.8-21.4%). CONCLUSION Collecting and evaluating quality metrics is feasible and helps identify areas for improvement. Centres treating HNC patients should strive towards monitoring quality against benchmarks and demonstrate transparency in outcome data.
Collapse
Affiliation(s)
- Madhavi Chilkuri
- Department of Radiation Oncology, Townsville University Hospital, Townsville, Queensland, Australia.,James Cook University, Townsville, Queensland, Australia
| | | | - Justin Smith
- Department of Radiation Oncology, Townsville University Hospital, Townsville, Queensland, Australia
| |
Collapse
|
36
|
Balk M, Rupp R, Mantsopoulos K, Allner M, Grundtner P, Mueller SK, Traxdorf M, Eckstein M, Speer S, Semrau S, Fietkau R, Iro H, Hecht M, Gostian AO. Relevance of the time interval between surgery and adjuvant radio (chemo) therapy in HPV-negative and advanced head and neck carcinoma of unknown primary (CUP). BMC Cancer 2021; 21:1236. [PMID: 34794411 PMCID: PMC8600706 DOI: 10.1186/s12885-021-08885-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 10/12/2021] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION In contrast to head and neck squamous cell carcinoma (HNSCC), the effect of treatment duration in HNSCC-CUP has not been thoroughly investigated. Thus, this study aimed to assess the impact of the time interval between surgery and adjuvant therapy on the oncologic outcome, in particular the 5-year overall survival rate (OS), in advanced stage, HPV-negative CUPs at a tertiary referral hospital. 5-year disease specific survival rate (DSS) and progression free survival rate (PFS) are defined as secondary objectives. MATERIAL AND METHODS Between January 1st, 2007, and March 31st, 2020 a total of 131 patients with CUP were treated. Out of these, 59 patients with a confirmed negative p16 analysis were referred to a so-called CUP-panendoscopy with simultaneous unilateral neck dissection followed by adjuvant therapy. The cut-off between tumor removal and delivery of adjuvant therapy was set at the median, i.e. patients receiving adjuvant therapy below or above the median time interval. RESULTS Depending on the median time interval of 55 days (d) (95% CI 51.42-84.52), 30 patients received adjuvant therapy within 55 d (mean 41.69 d, SD = 9.03) after surgery in contrast to 29 patients at least after 55 d (mean 73.21 d, SD = 19.16). All patients involved in the study were diagnosed in advanced tumor stages UICC III (n = 4; 6.8%), IVA (n = 27; 45.8%) and IVB (n = 28; 47.5%). Every patient was treated with curative neck dissection. Adjuvant chemo (immune) radiation was performed in 55 patients (93.2%), 4 patients (6.8%) underwent adjuvant radiation only. The mean follow-up time was 43.6 months (SD = 36.7 months). The 5-year OS rate for all patients involved was 71% (95% CI 0.55-0.86). For those patients receiving adjuvant therapy within 55 d (77, 95% CI 0.48-1.06) the OS rate was higher, yet not significantly different from those with delayed treatment (64, 95% CI 0.42-0.80; X2(1) = 1.16, p = 0.281). Regarding all patients, the 5-year DSS rate was 86% (95% CI 0.75-0.96). Patients submitted to adjuvant treatment in less than 55 d the DSS rate was 95% (95% CI 0.89-1.01) compared to patients submitted to adjuvant treatment equal or later than 55 d (76% (95% CI 0.57-0.95; X2(1) = 2.32, p = 0.128). The 5-year PFS rate of the entire cohort was 72% (95% CI 0.59-0.85). In the group < 55 d the PFS rate was 78% (95% CI 0.63-0.94) and thus not significantly different from 65% (95% CI 0.45-0.85) of the group ≥55 d; (X2(1) = 0.29, p = 0.589). CONCLUSIONS The results presented suggest that the oncologic outcome of patients with advanced, HPV-negative CUP of the head and neck was not significantly affected by a prolonged period between surgery and adjuvant therapy. Nevertheless, oncologic outcome tends to be superior for early adjuvant therapy.
Collapse
Affiliation(s)
- Matthias Balk
- Department of Otolaryngology, Head & Neck Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, 91054, Erlangen, Germany.
| | - Robin Rupp
- Department of Otolaryngology, Head & Neck Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, 91054, Erlangen, Germany
| | - Konstantin Mantsopoulos
- Department of Otolaryngology, Head & Neck Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, 91054, Erlangen, Germany
| | - Moritz Allner
- Department of Otolaryngology, Head & Neck Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, 91054, Erlangen, Germany
| | - Philipp Grundtner
- Department of Otolaryngology, Head & Neck Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, 91054, Erlangen, Germany
| | - S K Mueller
- Department of Otolaryngology, Head & Neck Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, 91054, Erlangen, Germany
| | - Maximilian Traxdorf
- Department of Otolaryngology, Head & Neck Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, 91054, Erlangen, Germany
| | - Markus Eckstein
- Department of Pathology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Stefan Speer
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Sabine Semrau
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Heinrich Iro
- Department of Otolaryngology, Head & Neck Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, 91054, Erlangen, Germany
| | - Markus Hecht
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Antoniu-Oreste Gostian
- Department of Otolaryngology, Head & Neck Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, 91054, Erlangen, Germany
| |
Collapse
|
37
|
Graboyes EM, Sterba KR, Li H, Warren GW, Alberg AJ, Calhoun EA, Nussenbaum B, McCay J, Marsh CH, Osazuwa-Peters N, Neskey DM, Kaczmar JM, Sharma AK, Harper J, Day TA, Hughes-Halbert C. Development and Evaluation of a Navigation-Based, Multilevel Intervention to Improve the Delivery of Timely, Guideline-Adherent Adjuvant Therapy for Patients With Head and Neck Cancer. JCO Oncol Pract 2021; 17:e1512-e1523. [PMID: 33689399 PMCID: PMC8791819 DOI: 10.1200/op.20.00943] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
PURPOSE More than half of patients with head and neck squamous cell carcinoma (HNSCC) experience a delay initiating guideline-adherent postoperative radiation therapy (PORT), contributing to excess mortality and racial disparities in survival. However, interventions to improve the delivery of timely, equitable PORT among patients with HNSCC are lacking. This study (1) describes the development of NDURE (Navigation for Disparities and Untimely Radiation thErapy), a navigation-based multilevel intervention (MLI) to improve guideline-adherent PORT and (2) evaluates its feasibility, acceptability, and preliminary efficacy. METHODS NDURE was developed using the six steps of intervention mapping (IM). Subsequently, NDURE was evaluated by enrolling consecutive patients with locally advanced HNSCC undergoing surgery and PORT (n = 15) into a single-arm clinical trial with a mixed-methods approach to process evaluation. RESULTS NDURE is a navigation-based MLI targeting barriers to timely, guideline-adherent PORT at the patient, healthcare team, and organizational levels. NDURE is delivered via three in-person navigation sessions anchored to case identification and surgical care transitions. Intervention components include the following: (1) patient education, (2) travel support, (3) a standardized process for initiating the discussion of expectations for PORT, (4) PORT care plans, (5) referral tracking and follow-up, and (6) organizational restructuring. NDURE was feasible, as judged by accrual (88% of eligible patients [100% Blacks] enrolled) and dropout (n = 0). One hundred percent of patients reported moderate or strong agreement that NDURE helped solve challenges starting PORT; 86% were highly likely to recommend NDURE. The rate of timely, guideline-adherent PORT was 86% overall and 100% for Black patients. CONCLUSION NDURE is a navigation-based MLI that is feasible, is acceptable, and has the potential to improve the timely, equitable, guideline-adherent PORT.
Collapse
Affiliation(s)
- Evan M. Graboyes
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC,Hollings Cancer Center, Medical University of South Carolina, Charleston, SC,Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC,Evan M. Graboyes, MD, MPH, Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Ave, MSC 550, Charleston, SC 29425; e-mail:
| | - Katherine R. Sterba
- Hollings Cancer Center, Medical University of South Carolina, Charleston, SC,Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Hong Li
- Hollings Cancer Center, Medical University of South Carolina, Charleston, SC,Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Graham W. Warren
- Hollings Cancer Center, Medical University of South Carolina, Charleston, SC,Department of Radiation Oncology, Medical University of South Carolina, Charleston, SC,Department of Cell and Molecular Pharmacology, Medical University of South Carolina, Charleston, SC
| | - Anthony J. Alberg
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC
| | | | - Brian Nussenbaum
- American Board of Otolaryngology - Head and Neck Surgery, Houston, TX
| | - Jessica McCay
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Courtney H. Marsh
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Nosayaba Osazuwa-Peters
- Department of Head and Neck Surgery and Communication Sciences, Duke University, Durham, NC,Department of Population Health Sciences, Duke University, Durham, NC
| | - David M. Neskey
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC,Hollings Cancer Center, Medical University of South Carolina, Charleston, SC
| | - John M. Kaczmar
- Department of Medicine, Division of Medical Oncology, Medical University of South Carolina, Charleston, SC
| | - Anand K. Sharma
- Department of Radiation Oncology, Medical University of South Carolina, Charleston, SC
| | - Jennifer Harper
- Department of Radiation Oncology, Medical University of South Carolina, Charleston, SC
| | - Terry A. Day
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Chanita Hughes-Halbert
- Hollings Cancer Center, Medical University of South Carolina, Charleston, SC,Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC
| |
Collapse
|
38
|
Yan F, Li H, de Almeida JR, Kaczmar JM, Pipkorn P, Zenga J, Richardson MS, Neskey DM, Sharma AK, Day TA, Graboyes EM. Microscopic Extranodal Extension in HPV-Negative Head and Neck Cancer and the Role of Adjuvant Chemoradiation. Otolaryngol Head Neck Surg 2021; 165:536-549. [PMID: 33618570 PMCID: PMC8380754 DOI: 10.1177/0194599821989637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 01/04/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Pathologic extranodal extension (ENE) is an important adverse feature for human papillomavirus (HPV)-negative head and neck squamous cell carcinoma (HNSCC), but the prognostic significance of microscopic ENE (ENEmi) and role of adjuvant concurrent chemoradiation (CRT) for ENEmi remain unclear. This study evaluates (1) the prognostic significance of ENEmi in HPV-negative HNSCC and (2) whether adjuvant CRT is associated with improved overall survival (OS) for these patients. STUDY DESIGN Retrospective cohort study. SETTING Commission on Cancer (CoC)-accredited facilities. METHODS This retrospective cohort study included patients in the National Cancer Database from 2009 to 2015 with pathologic node-positive (pN+) HPV-negative HNSCC with either pathologic ENEmi or no ENE who had undergone margin-negative surgery. The association of ENEmi with OS was evaluated using Cox proportional hazard analyses. Analyses were repeated in patients with ENEmi receiving adjuvant therapy to evaluate the association of adjuvant CRT with OS. RESULTS We included 5483 patients with pN+ HPV-negative HNSCC, of whom 24% had ENEmi. On multivariable analysis, ENEmi was associated with decreased OS relative to no ENE (adjusted hazard ratio [aHR], 1.43; 95% CI, 1.28-1.59). Among patients with ENEmi who received ≥60 Gy of adjuvant radiation therapy (RT) (n = 617), adjuvant CRT was not associated with improved OS relative to RT (aHR, 0.91; 95% CI, 0.66-1.27). CONCLUSION For patients with HPV-negative HNSCC, pN+ with ENEmi is associated with worse OS than pN+ without ENE. However, for patients with ENEmi, concurrent CRT is not associated with improved OS relative to RT. The optimal adjuvant paradigm for ENEmi requires additional investigation.
Collapse
Affiliation(s)
- Flora Yan
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Hong Li
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - John R. de Almeida
- Department of Otolaryngology–Head and Neck Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - John M. Kaczmar
- Division of Medical Oncology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Patrik Pipkorn
- Department of Otolaryngology–Head and Neck Surgery, Washington University, St Louis, Missouri, USA
| | - Joseph Zenga
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Mary S. Richardson
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - David M. Neskey
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Anand K. Sharma
- Department of Radiation Oncology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Terry A. Day
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Evan M. Graboyes
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| |
Collapse
|
39
|
Voora RS, Stramiello JA, Sumner WA, Finegersh A, Mohammadzadeh A, Fouania J, Ramsey C, Blumenfeld L, Sacco AG, Mell LK, Califano JA, Orosco RK. Quality improvement intervention to reduce time to postoperative radiation in head and neck free flap patients. Head Neck 2021; 43:3530-3539. [PMID: 34492135 DOI: 10.1002/hed.26852] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 07/07/2021] [Accepted: 08/18/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Best-practice guidelines for head and neck cancer patients advise postoperative radiation therapy (PORT) initiation within 6 weeks of surgery. We report our institutional experience improving timeliness of adjuvant radiation in free-flap patients. METHODS Thirty-nine patients met inclusion criteria in the 2017-2019 study period. We divided into "Early" (n = 19) and "Late" (n = 20) time-period groups to compare performance over time. The primary endpoint was time to PORT initiation, with success defined as <6 weeks. RESULTS The number of patients achieving timely PORT improved from 10.5% in the Early group to 50.0% in the Late group (p = 0.014). Patients undergoing concurrent adjuvant chemoradiation were more likely to meet the PORT target in the Late group (p = 0.012). CONCLUSIONS We ascribe this quality improvement in free-flap patients to increased communication among multidisciplinary care teams, proactive consultation referrals, and a targeted patient-navigator intervention. Though work is needed to further improve performance, insight gained from our experience may benefit other teams.
Collapse
Affiliation(s)
- Rohith S Voora
- University of California, San Diego School of Medicine, La Jolla, California, USA.,Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of California San Diego School of Medicine, La Jolla, California, USA
| | - Joshua A Stramiello
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of California San Diego School of Medicine, La Jolla, California, USA.,Moores Cancer Center, La Jolla, California, USA
| | - Whitney A Sumner
- Moores Cancer Center, La Jolla, California, USA.,Department of Radiation Medicine and Applied Sciences, University of California San Diego School of Medicine, La Jolla, California, USA
| | - Andrey Finegersh
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of California San Diego School of Medicine, La Jolla, California, USA.,Moores Cancer Center, La Jolla, California, USA
| | - Amir Mohammadzadeh
- University of California, San Diego School of Medicine, La Jolla, California, USA.,Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of California San Diego School of Medicine, La Jolla, California, USA
| | | | | | | | - Assuntina G Sacco
- Moores Cancer Center, La Jolla, California, USA.,Division of Hematology-Oncology University, Department of Medicine, University of California San Diego School of Medicine, La Jolla, California, USA
| | - Loren K Mell
- Moores Cancer Center, La Jolla, California, USA.,Department of Radiation Medicine and Applied Sciences, University of California San Diego School of Medicine, La Jolla, California, USA
| | - Joseph A Califano
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of California San Diego School of Medicine, La Jolla, California, USA.,Moores Cancer Center, La Jolla, California, USA
| | - Ryan K Orosco
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of California San Diego School of Medicine, La Jolla, California, USA.,Moores Cancer Center, La Jolla, California, USA
| |
Collapse
|
40
|
Young Adult Populations Face Yet Another Barrier to Care With Insurers: Limited Access to Proton Therapy. Int J Radiat Oncol Biol Phys 2021; 110:1496-1504. [PMID: 33677051 DOI: 10.1016/j.ijrobp.2021.02.049] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 02/11/2021] [Accepted: 02/23/2021] [Indexed: 11/20/2022]
Abstract
PURPOSE Young patients, including pediatric, adolescent, and young adult (YA) patients, are most likely to benefit from the reduced integral dose of proton beam radiation therapy (PBT) resulting in fewer late toxicities and secondary malignancies. This study sought to examine insurance approval and appeal outcomes for PBT among YA patients compared with pediatric patients at a large-volume proton therapy center. METHODS AND MATERIALS We performed a cross-sectional cohort study of 284 consecutive patients aged 0 to 39 years for whom PBT was recommended in 2018 through 2019. Pediatric patients were defined as aged 0 to 18 years and YA patients 19 to 39 years. Rates of approval, denials, and decision timelines were calculated. Tumor type and location were also evaluated as factors that may influence insurance decisions. RESULTS A total of 207 patients (73%) were approved for PBT at initial request. YA patients (n = 68/143, 48%) were significantly less likely to receive initial approval compared with pediatric patients (n = 139/141; 99%) (P < .001). Even after 47% (n = 35 of 75) of the PBT denials for YA patients were overturned, YAs had a significantly lower final PBT approval (72% vs pediatric 99%; P < .001). The median wait time was also significantly longer for YA patients (median, 8 days; interquartile range [IQR] 3-17 vs median, 2 days; IQR, 0-6; P < .001). In those patients requiring an appeal, the median wait time was 16 days (IQR, 9-25). CONCLUSION Given the decades of survivorship of YA patients, PBT is an important tool to reduce late toxicities and secondary malignancies. Compared with pediatric patients, YA patients are significantly less likely to receive insurance approval for PBT. Insurance denials and subsequent appeal requests result in significant delays for YA patients. Insurers need to re-examine their policies to include expedited decisions and appeals and removal of arbitrary age cutoffs so that YA patients can gain easier access to PBT. Furthermore, consensus guidelines encouraging greater PBT access for YA may be warranted from both medical societies and/or AYA experts.
Collapse
|
41
|
Beeram M, Kennedy A, Hales N. Barriers to Comprehensive Multidisciplinary Head and Neck Care in a Community Oncology Practice. Am Soc Clin Oncol Educ Book 2021; 41:1-10. [PMID: 34010055 DOI: 10.1200/edbk_320967] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Complex, coordinated, and collaborative care of patients with head and neck cancer can be challenging yet amazingly rewarding and successful. The high symptom burden across multiple functional domains in patients with head and neck cancer, even in early stages of disease, mandates a multidisciplinary team approach that harnesses the combined contributions of physicians and ancillary providers to drive greater patient-centered care, addressing factors that heavily influence morbidity, mortality, and quality of life. Well-organized community-based multidisciplinary teams fulfill this unmet need and benefit patients with conveniently located comprehensive services that are typically found in large academic centers. Equivalent, if not superior, outcomes can be achieved in a unified community-based multidisciplinary team with shared patient-centered and outcomes-based goals. However, implementing true multidisciplinary team care in today's complex health care environment is fraught with challenges and pitfalls. So how have some community-based practices managed to create safe and efficient programs with successful outcomes? The purpose of this review is to discuss barriers to reaching this success and emphasize practical solutions to such challenges.
Collapse
|
42
|
Hansen CC, Egleston B, Leachman BK, Churilla TM, DeMora L, Ebersole B, Bauman JR, Liu JC, Ridge JA, Galloway TJ. Patterns of Multidisciplinary Care of Head and Neck Squamous Cell Carcinoma in Medicare Patients. JAMA Otolaryngol Head Neck Surg 2020; 146:1136-1146. [PMID: 33090191 PMCID: PMC7582229 DOI: 10.1001/jamaoto.2020.3496] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Importance Multidisciplinary care (MDC) yields proven benefits for patients with cancer, although it may be underused in the complex management of head and neck squamous cell carcinoma (HNSCC). Objective To characterize the patterns of MDC in the treatment of HNSCC among elderly patients in the US. Design, Setting, and Participants This nationwide, population-based, retrospective cohort study used Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data from January 1, 1991, to December 31, 2011, to identify patients 66 years or older diagnosed with head and neck cancer and determine the dates of diagnosis, oncology consultations, treatment initiation, and speech therapy evaluation in addition to MDC completion. Multidisciplinary care was defined in a stage-dependent manner: localized disease necessitated consultations with radiation and surgical oncologists, and advanced-stage disease also included a medical oncology consultation, all before definitive treatment. Data were analyzed between December 2016 and September 2020. Main Outcomes and Measures Rates of MDC across all subsites of head and neck cancer as measured by the presence of an evaluation for each oncologist on the MDC team and its effect on treatment initiation. Results This cohort study assessed 28 293 patients with HNSCC (mean [SD] age, 75.1 [6.6] years; 67% male; 87% White) from the SEER-Medicare linked database. The HNSCC subsites included larynx (40%), oral cavity (30%), oropharynx (21%), hypopharynx (7%), and nasopharynx (2%). Overall, the practice of MDC significantly increased over time, from 24% in 1991 to 52% in 2011 (P < .001). For patients with localized (stage 0-II) tumors, 60% received care in the multidisciplinary setting, whereas 28% of those with advanced-stage disease did. A total of 18 181 patients (64%) were treated with initial definitive nonsurgical therapy across all stages. Regardless of stage and subsite, few patients (2%) underwent evaluation by a speech-language pathologist before definitive therapy. Multidisciplinary care prolonged the time to initiation of definitive treatment by 11 days for localized disease and 10 days for advanced disease. Conclusions and Relevance This cohort study found that most elderly patients with localized HNSCC received MDC, whereas few patients with advanced-stage disease received such care, although a significant proportion received adjuvant therapy. Multidisciplinary care may prolong time to initiation of definitive treatment with an uncertain impact. Consultation with a speech-language pathologist before definitive therapy was rare.
Collapse
Affiliation(s)
- Chase C. Hansen
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Brian Egleston
- Department of Biostatistics, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Brooke K. Leachman
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Thomas M. Churilla
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Lyudmila DeMora
- Department of Biostatistics, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Barbara Ebersole
- Department of Otolaryngology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Jessica R. Bauman
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Jeffrey C. Liu
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - John A. Ridge
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Thomas J. Galloway
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| |
Collapse
|
43
|
Jin MC, Shi S, Wu A, Sandhu N, Xiang M, Soltys SG, Hiniker S, Li G, Pollom EL. Impact of proton radiotherapy on treatment timing in pediatric and adult patients with CNS tumors. Neurooncol Pract 2020; 7:626-635. [PMID: 33312677 PMCID: PMC7716142 DOI: 10.1093/nop/npaa034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Despite putative benefits associated with proton radiotherapy in the setting of CNS tumors, numerous barriers limit treatment accessibility. Given these challenges, we explored the association of proton use with variations in treatment timing. METHODS Pediatric and adult patients with histologically confirmed CNS tumors were identified from the National Cancer Database (2004-2015). Univariable and multivariable regression models were constructed to assess factors impacting radiation timing. Multivariable Cox regression was used to evaluate the effect of treatment delay on survival. RESULTS A total of 76 157 patients received photon or proton radiotherapy. Compared to photons, time to proton administration was longer in multiple pediatric (embryonal, ependymal, nonependymal glial, and other) and adult (ependymal, nonependymal glial, meningeal, other) tumor histologies. On adjusted analysis, proton radiotherapy was associated with longer delays in radiotherapy administration in pediatric embryonal tumors (+3.00 weeks, P = .024) and in all adult tumors (embryonal [+1.36 weeks, P = .018], ependymal [+3.15 weeks, P < .001], germ cell [+2.65 weeks, P = .024], glial [+2.15 weeks, P < .001], meningeal [+5.05 weeks, P < .001], and other [+3.06 weeks, P < .001]). In patients with high-risk tumors receiving protons, delays in adjuvant radiotherapy were independently associated with poorer survival (continuous [weeks], adjusted hazard ratio = 1.09, 95% CI = 1.02-1.16). CONCLUSIONS Proton radiotherapy is associated with later radiation initiation in pediatric and adult patients with CNS tumors. In patients with high-risk CNS malignancies receiving protons, delayed adjuvant radiotherapy is associated with poorer survival. Further studies are needed to understand this discrepancy to maximize the potential of proton radiotherapy for CNS malignancies.
Collapse
Affiliation(s)
- Michael C Jin
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Siyu Shi
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Adela Wu
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Navjot Sandhu
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Michael Xiang
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Susan Hiniker
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Gordon Li
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Erqi L Pollom
- Palo Alto Veterans Affairs Health Care System, Palo Alto, California
| |
Collapse
|
44
|
Rygalski CJ, Zhao S, Eskander A, Zhan KY, Mroz EA, Brock G, Silverman DA, Blakaj D, Bonomi MR, Carrau RL, Old MO, Rocco JW, Seim NB, Puram SV, Kang SY. Time to Surgery and Survival in Head and Neck Cancer. Ann Surg Oncol 2020; 28:877-885. [PMID: 33188461 PMCID: PMC7664584 DOI: 10.1245/s10434-020-09326-4] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 09/16/2020] [Indexed: 02/06/2023]
Abstract
Background The COVID-19 pandemic has required triage and delays in surgical care throughout the world. The impact of these surgical delays on survival for patients with head and neck squamous cell carcinoma (HNSCC) remains unknown. Methods A retrospective cohort study of 37 730 patients in the National Cancer Database with HNSCC who underwent primary surgical management from 2004 to 2016 was performed. Uni- and multivariate analyses were used to identify predictors of overall survival. Bootstrapping methods were used to identify optimal time-to-surgery (TTS) thresholds at which overall survival differences were greatest. Cox proportional hazard models with or without restricted cubic splines were used to determine the association between TTS and survival. Results The study identified TTS as an independent predictor of overall survival (OS). Bootstrapping the data to dichotomize the cohort identified the largest rise in hazard ratio (HR) at day 67, which was used as the optimal TTS cut-point in survival analysis. The patients who underwent surgical treatment longer than 67 days after diagnosis had a significantly increased risk of death (HR, 1.189; 95% confidence interval [CI], 1.122–1.261; P < 0.0001). For every 30-day delay in TTS, the hazard of death increased by 4.6%. Subsite analysis showed that the oropharynx subsite was most affected by surgical delays, followed by the oral cavity. Conclusions Increasing TTS is an independent predictor of survival for patients with HNSCC and should be performed within 67 days after diagnosis to achieve optimal survival outcomes. Electronic supplementary material The online version of this article (10.1245/s10434-020-09326-4) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Chandler J Rygalski
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Songzhu Zhao
- Department of Biomedical Informatics and Center for Biostatistics, The Ohio State University, Columbus, OH, USA
| | - Antoine Eskander
- Department of Otolaryngology-Head and Neck Surgery, Sunnybrook Health Sciences Center, ON, Toronto, Canada
| | - Kevin Y Zhan
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Edmund A Mroz
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Guy Brock
- Department of Biomedical Informatics and Center for Biostatistics, The Ohio State University, Columbus, OH, USA
| | - Dustin A Silverman
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Dukagjin Blakaj
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Marcelo R Bonomi
- Department of Internal Medicine, Division of Medical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Ricardo L Carrau
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Matthew O Old
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - James W Rocco
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Nolan B Seim
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sidharth V Puram
- Department of Otolaryngology-Head & Neck Surgery, Washington University School of Medicine, Ear, Nose & Throat Center, St. Louis, MO, USA
| | - Stephen Y Kang
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
| |
Collapse
|
45
|
Jurica JM, Rubio F, Hernandez DJ, Sandulache VC. Institutional financial toxicity of failure to adhere to treatment guidelines for head and neck squamous cell carcinoma. Head Neck 2020; 43:816-824. [PMID: 33166016 DOI: 10.1002/hed.26539] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 09/04/2020] [Accepted: 10/29/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Delays in treatment of head and neck squamous cell carcinoma (HNSCC) are known to increase disease recurrence, generating the need for additional salvage treatment, often with immunotherapy. METHODS Three treatment metrics were identified: time from diagnosis to treatment initiation (TTI), time from surgery to postoperative radiotherapy (surg → PORT), and total treatment package time (TPT). Financial toxicity was calculated using hazard ratios, pembrolizumab cost, and dosing data for a Veterans Health Administration (VHA) institutional cohort (n = 338) and a standardized cohort (n = 100). RESULTS Estimated financial toxicity for the VHA cohort was $2 047 407, $316 545, and $1 114 101 for TTI, surg → PORT, and TPT, respectively. Estimated financial toxicity for the standardized patient cohort was $454 028, $544 576, and $1 879 628 for TTI, surg → PORT, and TPT, respectively. CONCLUSIONS Failure to meet established HNSCC treatment metrics generates significant, yet avoidable, institutional financial toxicity which is particularly relevant to integrated single-payer systems such as the VHA in the modern immunotherapy era.
Collapse
Affiliation(s)
- James M Jurica
- School of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Felixnando Rubio
- School of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - David J Hernandez
- ENT Section, Operative Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.,Bobby R. Alford Department of Otolaryngology - Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Vlad C Sandulache
- ENT Section, Operative Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.,Bobby R. Alford Department of Otolaryngology - Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA.,Center for Translational Research on Inflammatory Diseases (CTRID), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| |
Collapse
|
46
|
Hanna TP, King WD, Thibodeau S, Jalink M, Paulin GA, Harvey-Jones E, O'Sullivan DE, Booth CM, Sullivan R, Aggarwal A. Mortality due to cancer treatment delay: systematic review and meta-analysis. BMJ 2020; 371:m4087. [PMID: 33148535 PMCID: PMC7610021 DOI: 10.1136/bmj.m4087] [Citation(s) in RCA: 571] [Impact Index Per Article: 142.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To quantify the association of cancer treatment delay and mortality for each four week increase in delay to inform cancer treatment pathways. DESIGN Systematic review and meta-analysis. DATA SOURCES Published studies in Medline from 1 January 2000 to 10 April 2020. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Curative, neoadjuvant, and adjuvant indications for surgery, systemic treatment, or radiotherapy for cancers of the bladder, breast, colon, rectum, lung, cervix, and head and neck were included. The main outcome measure was the hazard ratio for overall survival for each four week delay for each indication. Delay was measured from diagnosis to first treatment, or from the completion of one treatment to the start of the next. The primary analysis only included high validity studies controlling for major prognostic factors. Hazard ratios were assumed to be log linear in relation to overall survival and were converted to an effect for each four week delay. Pooled effects were estimated using DerSimonian and Laird random effect models. RESULTS The review included 34 studies for 17 indications (n=1 272 681 patients). No high validity data were found for five of the radiotherapy indications or for cervical cancer surgery. The association between delay and increased mortality was significant (P<0.05) for 13 of 17 indications. Surgery findings were consistent, with a mortality risk for each four week delay of 1.06-1.08 (eg, colectomy 1.06, 95% confidence interval 1.01 to 1.12; breast surgery 1.08, 1.03 to 1.13). Estimates for systemic treatment varied (hazard ratio range 1.01-1.28). Radiotherapy estimates were for radical radiotherapy for head and neck cancer (hazard ratio 1.09, 95% confidence interval 1.05 to 1.14), adjuvant radiotherapy after breast conserving surgery (0.98, 0.88 to 1.09), and cervix cancer adjuvant radiotherapy (1.23, 1.00 to 1.50). A sensitivity analysis of studies that had been excluded because of lack of information on comorbidities or functional status did not change the findings. CONCLUSIONS Cancer treatment delay is a problem in health systems worldwide. The impact of delay on mortality can now be quantified for prioritisation and modelling. Even a four week delay of cancer treatment is associated with increased mortality across surgical, systemic treatment, and radiotherapy indications for seven cancers. Policies focused on minimising system level delays to cancer treatment initiation could improve population level survival outcomes.
Collapse
Affiliation(s)
- Timothy P Hanna
- Division of Cancer Care and Epidemiology, Cancer Research Institute at Queen's University, 10 Stuart Street, 2nd Level, Kingston, ON K7L3N6, Canada
- Department of Oncology, Queen's University, Kingston, ON, Canada
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - Will D King
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | | | - Matthew Jalink
- Division of Cancer Care and Epidemiology, Cancer Research Institute at Queen's University, 10 Stuart Street, 2nd Level, Kingston, ON K7L3N6, Canada
- Department of Oncology, Queen's University, Kingston, ON, Canada
| | - Gregory A Paulin
- Department of Oncology, Queen's University, Kingston, ON, Canada
| | | | - Dylan E O'Sullivan
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - Christopher M Booth
- Division of Cancer Care and Epidemiology, Cancer Research Institute at Queen's University, 10 Stuart Street, 2nd Level, Kingston, ON K7L3N6, Canada
- Department of Oncology, Queen's University, Kingston, ON, Canada
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | | | - Ajay Aggarwal
- Department of Clinical Oncology, Guy's & St Thomas' NHS Trust, London, UK
- Institute of Cancer Policy, King's College London, London, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
47
|
Brooker RC, Hobkirk A, Cashman H, Sato T, Broderick D, Wong H, Kyzas P, Haridass A, Sacco JJ, Schache AG. Adjuvant management of locally advanced oral squamous cell carcinoma - real-world challenges and opportunities. Br J Oral Maxillofac Surg 2020; 59:952-958. [PMID: 33131802 DOI: 10.1016/j.bjoms.2020.08.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 08/11/2020] [Indexed: 11/17/2022]
Abstract
Patients with locally advanced oral squamous cell cancer (LAOSCC) are treated with adjuvant radiotherapy (RT) or chemoradiotherapy (CRT) following surgical ablation. This depends on the pathological risk factors and aims to reduce the risk of local recurrence and improve survival. Delivery of these aggressive treatments is, however, challenging particularly following major surgery. To inform the adaptations necessary to deliver gold-standard therapy, we aimed to describe real-world delivery of multimodality treatment in LAOSCC, in a UK population with high levels of disease incidence and low socioeconomic status. Patients with LAOSCC (T1-4 N1-3/T3-4 N0) who were treated between October 2014 and October 2016 and had a minimum follow up of 24 months were included. They were identified using the Somerset Cancer Register and data were collected through retrospective case note review. Approval was obtained from the audit departments at the relevant NHS institutions, and data were analysed using IBM SPSS Statistics for Windows version 24 (IBM Corp). The analysis included 129 patients with 82% having an initial performance status (PS) of 0-1. The most frequent change in PS was a one point drop (46%). Twenty of the 93 eligible patients (22%) underwent adjuvant CRT. A total of 37 (40%) began adjuvant CRT/RT within 42 days, and 79 (85%) within 56 days. A delay in initiating adjuvant therapy was associated with higher rates of complications and a longer postoperative hospital stay. Concordance between imaging and pathological nodal staging was poor (cK 0.223). PS frequently declines after complex surgical procedures and long postoperative recovery periods, leading to difficulties providing adjuvant treatments within the national guidance of 42 days. Frequent deviation from planned adjuvant therapies highlights the need for improved treatment strategies.
Collapse
Affiliation(s)
- R C Brooker
- The Clatterbridge Cancer Centre NHS Foundation Trust, Clatterbridge Road, Bebington, Wirral, CH63 4JY, United Kingdom; Liverpool Head & Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool Cancer Research Centre, University of Liverpool, Liverpool, L69 3BX, United Kingdom.
| | - A Hobkirk
- Head and Neck Unit, Aintree University Hospital NHS Foundation Trust, Longmoor Lane, Fazakerly, Liverpool, L9 7AL, United Kingdom
| | - H Cashman
- Head and Neck Unit, Aintree University Hospital NHS Foundation Trust, Longmoor Lane, Fazakerly, Liverpool, L9 7AL, United Kingdom
| | - T Sato
- Head and Neck Unit, Aintree University Hospital NHS Foundation Trust, Longmoor Lane, Fazakerly, Liverpool, L9 7AL, United Kingdom
| | - D Broderick
- Head and Neck Unit, Aintree University Hospital NHS Foundation Trust, Longmoor Lane, Fazakerly, Liverpool, L9 7AL, United Kingdom
| | - H Wong
- The Clatterbridge Cancer Centre NHS Foundation Trust, Clatterbridge Road, Bebington, Wirral, CH63 4JY, United Kingdom
| | - P Kyzas
- North Manchester General Hospital, Delaunays Road, Crumpsall, Manchester, M8 5RB, United Kingdom
| | - A Haridass
- The Clatterbridge Cancer Centre NHS Foundation Trust, Clatterbridge Road, Bebington, Wirral, CH63 4JY, United Kingdom
| | - J J Sacco
- The Clatterbridge Cancer Centre NHS Foundation Trust, Clatterbridge Road, Bebington, Wirral, CH63 4JY, United Kingdom; Liverpool Head & Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool Cancer Research Centre, University of Liverpool, Liverpool, L69 3BX, United Kingdom
| | - A G Schache
- Head and Neck Unit, Aintree University Hospital NHS Foundation Trust, Longmoor Lane, Fazakerly, Liverpool, L9 7AL, United Kingdom; Liverpool Head & Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool Cancer Research Centre, University of Liverpool, Liverpool, L69 3BX, United Kingdom
| |
Collapse
|
48
|
Bone Healing Evaluation Following Different Osteotomic Techniques in Animal Models: A Suitable Method for Clinical Insights. APPLIED SCIENCES-BASEL 2020. [DOI: 10.3390/app10207165] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Osteotomy is a common step in oncological, reconstructive, and trauma surgery. Drilling and elevated temperature during osteotomy produce thermal osteonecrosis. Heat and associated mechanical damage during osteotomy can impair bone healing, with consequent failure of fracture fixation or dental implants. Several ex vivo studies on animal bone were recently focused on heating production during osteotomy with conventional drill and piezoelectric devices, particularly in endosseous dental implant sites. The current literature on bone drilling and osteotomic surface analysis is here reviewed and the dynamics of bone healing after osteotomy with traditional and piezoelectric devices are discussed. Moreover, the methodologies involved in the experimental osteotomy and clinical studies are compared, focusing on ex vivo and in vivo findings.
Collapse
|
49
|
Cancerona: Challenges of Cancer Management in Times of COVID-19 Pandemic. ACTA ACUST UNITED AC 2020; 2:2005-2014. [PMID: 33015555 PMCID: PMC7524598 DOI: 10.1007/s42399-020-00549-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2020] [Indexed: 02/06/2023]
Abstract
Coronavirus disease 2019 (COVID-19) has infected millions of people worldwide and emerged to be the biggest global health threat claiming hundreds of thousands of lives at exponential rates. The severity of the disease increases with old age and presence of underlying health conditions, such as cancer. Managing cancer patients under these circumstances is rather challenging, given their compromised immunity and the overwhelmed health care services by COVID-19 community transmission. Thus, it is prudent to establish common guidelines for the monitoring and treatment of cancer patients. In this review, we comprehensively investigate the various aspects of cancer care during the COVID-19 pandemic, discuss challenges faced while treating cancer patients, and propose potential approaches to manage COVID-19 among this vulnerable population. We also discuss molecular aberrations and genetic changes associated with cancer and their role in affecting the virus' infectivity and severity. Lastly, we shed light on therapeutic approaches that can encompass both diseases without compromising one over the other.
Collapse
|
50
|
Lee DY, Abraham J, Ross E, Ridge JA, Lango MN, Liu JC, Bauman JR, Avkshtol V, Galloway TJ. Rapid recurrence in head and neck cancer: Underappreciated problem with poor outcome. Head Neck 2020; 43:212-222. [PMID: 32989878 DOI: 10.1002/hed.26479] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 07/21/2020] [Accepted: 09/09/2020] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Rapid recurrence, defined as gross tumor recurrence after primary operation but prior to initiating postoperative radiation therapy (PORT), is underappreciated in head and neck cancer (HNC). METHODS CT simulation images in patients with HNC managed surgically with adjuvant therapy at a single center between 2010 and 2017 were retrospectively reviewed. RESULTS A total of 194 patients with HNC were included. Rapid recurrence occurred in 39 patients (20%) with a median time from operation to CT simulation of 37 days. On multivariable analysis (MVA), extranodal extension (ENE) was the only predictor of rapid recurrence (P = .03). While rapid recurrence, ENE, and perineural invasion were all associated with poor overall survival (OS) on MVA, rapid recurrence was the strongest predictor (hazard ratio [HR] 5.47). CONCLUSION Rapid recurrence occurs at an underappreciated rate and is associated with poor survival outcomes. Patients with ENE are at highest risk and may benefit from diagnostic imaging evaluations immediately prior to PORT.
Collapse
Affiliation(s)
- Douglas Y Lee
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Jesty Abraham
- Department of Diagnostic Radiology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Eric Ross
- Department of Biostatistics, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - John A Ridge
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Miriam N Lango
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Jeffrey C Liu
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Jessica R Bauman
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Vladimir Avkshtol
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Thomas J Galloway
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| |
Collapse
|