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Kowalski LP. Eugene Nicholas Myers' Lecture on Head and Neck Cancer, 2020: The Surgeon as a Prognostic Factor in Head and Neck Cancer Patients Undergoing Surgery. Int Arch Otorhinolaryngol 2023; 27:e536-e546. [PMID: 37564472 PMCID: PMC10411134 DOI: 10.1055/s-0043-1761170] [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: 08/23/2022] [Accepted: 09/26/2022] [Indexed: 08/12/2023] Open
Abstract
This paper is a transcript of the 29 th Eugene N. Myers, MD International Lecture on Head and Neck Cancer presented at the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) in 2020. By the end of the 19 th century, the survival rate in treated patients was 10%. With the improvements in surgical techniques, currently, about two thirds of patients survive for > 5 years. Teamwork and progress in surgical reconstruction have led to advancements in ablative surgery; the associated adjuvant treatments have further improved the prognosis in the last 30 years. However, prospective trials are lacking; most of the accumulated knowledge is based on retrospective series and some real-world data analyses. Current knowledge on prognostic factors plays a central role in an efficient treatment decision-making process. Although the influence of most tumor- and patient-related prognostic factors in head and neck cancer cannot be changed by medical interventions, some environmental factors-including treatment, decision-making, and quality-can be modified. Ideally, treatment strategy decisions should be taken in dedicated multidisciplinary team meetings. However, evidence suggests that surgeons and hospital volume and specialization play major roles in patient survival after initial or salvage head and neck cancer treatment. The metrics of surgical quality assurance (surgical margins and nodal yield) in neck dissection have a significant impact on survival in head and neck cancer patients and can be influenced by the surgeon's expertise. Strategies proposed to improve surgical quality include continuous performance measurement, feedback, and dissemination of best practice measures.
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Affiliation(s)
- Luiz P. Kowalski
- Head and Neck Surgery Department, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
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Temporal Trends and Regionalization of Acute Mastoiditis Management in the United States. Otol Neurotol 2021; 42:733-739. [PMID: 33481546 DOI: 10.1097/mao.0000000000003050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe demographics and to analyze temporal trends in the inpatient management of acute mastoiditis admissions. STUDY DESIGN Cross-sectional analysis. SETTING National Inpatient Sample, 2002-2014. PATIENTS 26,072 nonelective inpatient admissions with primary diagnosis of acute mastoiditis. INTERVENTION Myringotomy, mastoidectomy, or no procedure. MAIN OUTCOME MEASURES We described the patient- and hospital-level demographics of acute mastoiditis admissions and the frequency of complications. We evaluated the percentage of patients requiring surgical management. Binary logistic regression was performed to determine whether there was a significant increase in the percentage of patients treated at academic institutions. RESULTS The majority of patients were ≤40 years old (64.9%) and Elixhauser comorbidity index ≥4 (57.4%); 23.3% (SE 0.8%) presented with complications associated with acute mastoiditis, the most common of which was a subperiosteal abscess (11.5%, SE 0.7%). Among all admissions, 30.9% (SE 1.1%) underwent myringotomy, 13.8% (SE 0.8%) required both myringotomy and mastoidectomy. On multivariate analysis, there was a statistically significant increase in the percentage of mastoiditis admissions to teaching hospitals for all admissions (OR 1.55 [CI 1.22-1.97], p < 0.001) and even more evident for cases with associated complications (OR 1.85 [CI 1.21-2.83], p = 0.004). CONCLUSIONS AND RELEVANCE A sizeable percentage of patients with acute mastoiditis present with complications which may require surgical intervention. From 2002 to 2014, inpatient care of acute mastoiditis became increasingly regionalized to teaching hospitals, suggestive of increased specialization within certain facilities. This trend may have significant impacts on the cost and subsequent quality of care provided to these patients.
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Schoppy DW, Rhoads KF, Ma Y, Chen MM, Nussenbaum B, Orosco RK, Rosenthal EL, Divi V. Measuring Institutional Quality in Head and Neck Surgery Using Hospital-Level Data: Negative Margin Rates and Neck Dissection Yield. JAMA Otolaryngol Head Neck Surg 2017; 143:1111-1116. [PMID: 28983555 DOI: 10.1001/jamaoto.2017.1694] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Importance Negative margins and lymph node yields (LNY) of 18 or more from neck dissections in patients with head and neck squamous cell carcinomas (HNSCC) have been associated with improved patient survival. It is unclear whether these metrics can be used to identify hospitals with improved outcomes. Objective To determine whether 2 patient-level metrics would predict outcomes at the hospital level. Design, Setting, and Participants A retrospective review of records from the National Cancer Database (NCDB) was used to identify patients who underwent primary surgery and concurrent neck dissection for HNSCC between 2004 and 2013. The percentage of patients at each hospital with negative margins on primary resection and an LNY 18 or more from a neck dissection was quantified. Cox proportional hazard models were used to define the association between hospital performance on these metrics and overall survival. Main Outcomes and Measures Margin status and lymph node yield at hospital level. Overall survival (OS). Results We identified 1008 hospitals in the NCDB where 64 738 patients met inclusion criteria. Of the 64 738 participants, 45 170 (69.8%) were men and 19 568 (30.2%) were women. The mean SD age of included patients was 60.5 (12.0) years. Patients treated at hospitals attaining the combined metric of a 90% or higher negative margin rate and 80% or more of cases with LNYs of 18 or more experienced a significant reduction in mortality (hazard ratio [HR] 0.93; 95% CI, 0.89-0.98). This benefit in survival was independent of the patient-level improvement associated with negative margins (HR, 0.73; 95% CI, 0.71-0.76) and LNY of 18 or more (HR, 0.85; 95% CI, 0.83-0.88). Including these metrics in the model neutralized the association of traditional measures of hospital quality (volume and teaching status). Conclusions and Relevance Treatment at hospitals that attain a high rate of negative margins and LNY of 18 or more is associated with improved survival in patients undergoing surgery for HNSCC. These surgical outcome measures predicted outcomes independent of traditional, but generally nonmodifiable characteristics. Tracking of these metrics may help identify high-quality centers and provide guidance for institution-level quality improvement.
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Affiliation(s)
- David W Schoppy
- Division of Head and Neck Surgery, Department of Otolaryngology, Stanford University School of Medicine, Stanford, Palo Alto, California
| | | | - Yifei Ma
- Division of Head and Neck Surgery, Department of Otolaryngology, Stanford University School of Medicine, Stanford, Palo Alto, California
| | - Michelle M Chen
- Division of Head and Neck Surgery, Department of Otolaryngology, Stanford University School of Medicine, Stanford, Palo Alto, California
| | - Brian Nussenbaum
- Division of Head and Neck Surgery, Department of Otolaryngology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Ryan K Orosco
- Division of Head and Neck Surgery, Department of Otolaryngology, Stanford University School of Medicine, Stanford, Palo Alto, California
| | - Eben L Rosenthal
- Division of Head and Neck Surgery, Department of Otolaryngology, Stanford University School of Medicine, Stanford, Palo Alto, California
| | - Vasu Divi
- Division of Head and Neck Surgery, Department of Otolaryngology, Stanford University School of Medicine, Stanford, Palo Alto, California
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Hoban CW, Beesley LJ, Bellile EL, Sun Y, Spector ME, Wolf GT, Taylor JMG, Shuman AG. Individualized outcome prognostication for patients with laryngeal cancer. Cancer 2017; 124:706-716. [PMID: 29112231 DOI: 10.1002/cncr.31087] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 09/13/2017] [Accepted: 09/27/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Accurate prognostication is essential to the optimal management of laryngeal cancer. Predictive models have been developed to calculate the risk of oncologic outcomes, but extensive external validation of accuracy and reliability is necessary before implementing them into clinical practice. METHOD Four published prognostic calculators that predict 5-year overall survival for patients with laryngeal cancer were evaluated using patient information from a prospective epidemiology study cohort (n = 246; median follow-up, 60 months) with previously untreated, stage I through IVb laryngeal squamous cell carcinoma. RESULTS Different calculators yielded substantially different predictions for individual patients. The observed 5-year overall survival was significantly higher than the averaged predicted 5-year overall survival of the 4 calculators (71.9%; 95% confidence interval [CI], 65%-78%] vs 47.7%). Statistical analyses demonstrated the calculators' limited capacity to discriminate outcomes for risk-stratified patients. The area under the receiver operating characteristic curve ranged from 0.68 to 0.72. C-index values were similar for each of the 4 models (range, 0.66-0.68). There was a lower than expected hazard of death for patients who received induction (bioselective) chemotherapy (hazard ratio, 0.46; 95% CI, 0.24-0.88; P = .024) or primary surgical intervention (hazard ratio, 0.43; 95 % CI, 0.21-0.90; P = .024) compared with those who received concurrent chemoradiation. CONCLUSIONS Suboptimal reliability and accuracy limit the integration of existing individualized prediction tools into routine clinical decision making. The calculators predicted significantly worse than observed survival among patients who received induction chemotherapy and primary surgery, suggesting a need for updated consideration of modern treatment modalities. Further development of individualized prognostic calculators may improve risk prediction, treatment planning, and counseling for patients with laryngeal cancer. Cancer 2018;124:706-16. © 2017 American Cancer Society.
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Affiliation(s)
- Connor W Hoban
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Lauren J Beesley
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Emily L Bellile
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Yilun Sun
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Matthew E Spector
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Gregory T Wolf
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Jeremy M G Taylor
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Andrew G Shuman
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan
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Health Services Research and Regionalization of Care—From Policy to Practice: the Ontario Experience in Head and Neck Cancer. Curr Oncol Rep 2016; 18:19. [DOI: 10.1007/s11912-016-0500-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Eskander A, Monteiro E, Irish J, Gullane P, Gilbert R, de Almeida J, Brown D, Freeman J, Urbach DR, Goldstein DP. Adherence to guideline-recommended process measures for squamous cell carcinoma of the head and neck in Ontario: Impact of surgeon and hospital volume. Head Neck 2016; 38 Suppl 1:E1987-92. [DOI: 10.1002/hed.24364] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2015] [Indexed: 11/05/2022] Open
Affiliation(s)
- Antoine Eskander
- Department of Otolaryngology - Head and Neck Surgery; University Health Network, University of Toronto; Toronto Ontario Canada
| | - Eric Monteiro
- Department of Otolaryngology - Head and Neck Surgery, Mt Sinai Hospital; University of Toronto; Toronto Ontario Canada
| | - Jonathan Irish
- Department of Otolaryngology - Head and Neck Surgery; University Health Network, University of Toronto; Toronto Ontario Canada
| | - Patrick Gullane
- Department of Otolaryngology - Head and Neck Surgery; University Health Network, University of Toronto; Toronto Ontario Canada
| | - Ralph Gilbert
- Department of Otolaryngology - Head and Neck Surgery; University Health Network, University of Toronto; Toronto Ontario Canada
| | - John de Almeida
- Department of Otolaryngology - Head and Neck Surgery; University Health Network, University of Toronto; Toronto Ontario Canada
| | - Dale Brown
- Department of Otolaryngology - Head and Neck Surgery; University Health Network, University of Toronto; Toronto Ontario Canada
| | - Jeremy Freeman
- Department of Otolaryngology - Head and Neck Surgery, Mt Sinai Hospital; University of Toronto; Toronto Ontario Canada
| | - David R. Urbach
- Division of General Surgery, Department of Surgery; University Health Network, University of Toronto; Toronto Ontario Canada
| | - David P. Goldstein
- Department of Otolaryngology - Head and Neck Surgery; University Health Network, University of Toronto; Toronto Ontario Canada
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Roman BR, Goldenberg D, Givi B. AHNS Series-Do you know your guidelines? Guideline recommended follow-up and surveillance of head and neck cancer survivors. Head Neck 2016; 38:168-74. [DOI: 10.1002/hed.24100] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 04/16/2015] [Indexed: 12/17/2022] Open
Affiliation(s)
- Benjamin R. Roman
- The Education Committee of American Head and Neck Society (AHNS) and Head and Neck Service; Memorial Sloan Kettering Cancer Center; New York New York
| | - David Goldenberg
- The Education Committee of American Head and Neck Society (AHNS) and Division of Otolaryngology-Head and Neck Surgery, The Pennsylvania State University; College of Medicine; Hershey Pennsylvania
| | - Babak Givi
- The Education Committee of American Head and Neck Society (AHNS) and Department of Otolaryngology; New York University Langone Medical Center; New York New York
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Lewis CM, Nurgalieva Z, Sturgis EM, Lai SY, Weber RS. Improving patient outcomes through multidisciplinary treatment planning conference. Head Neck 2015; 38 Suppl 1:E1820-5. [PMID: 26690552 DOI: 10.1002/hed.24325] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 09/20/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this study was for us to determine National Comprehensive Cancer Network (NCCN) guideline-compliance of multidisciplinary conference (MDC) recommendations and actual treatment received, and to determine this impact on patient outcomes. METHODS We conducted a retrospective review of patients presented at MDC between January 1, 2006, and December 31, 2006, with previously untreated incident cancers. RESULTS We identified 232 patients, for whom MDC recommendations were NCCN guideline-compliant in 201 (86.6%). Actual treatment was NCCN guideline-compliant in 170 of 197 patients (86.3%). Adherence of MDC recommendations to NCCN guidelines was associated with superior overall survival (hazard ratio [HR] = 0.69; 95% confidence interval [CI] = 0.33-1.39; p = .3), as was guideline-compliance of actual treatment (HR = 0.6; 95% CI = 0.64-1.07; p = .07); congruence between MDC recommendations and actual treatment conferred a statistically significant overall survival benefit (HR = 0.49; 95% CI = 0.27-0.89; p = .02). CONCLUSION Our findings argue for patient-centered application of NCCN guidelines. Prospective evaluation will enable more timely identification of systematic NCCN guideline deviations that quality improvement interventions may address. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1820-E1825, 2016.
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Affiliation(s)
- Carol M Lewis
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Zhannat Nurgalieva
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Erich M Sturgis
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Stephen Y Lai
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Randal S Weber
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
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Lira RB, de Carvalho AY, de Carvalho GB, Lewis CM, Weber RS, Kowalski LP. Quality assessment in head and neck oncologic surgery in a Brazilian cancer center compared with MD Anderson Cancer Center benchmarks. Head Neck 2015; 38:1002-7. [DOI: 10.1002/hed.24304] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 08/17/2015] [Accepted: 09/19/2015] [Indexed: 11/08/2022] Open
Affiliation(s)
- Renan Bezerra Lira
- Head and Neck Surgery and Otorhinolaryngology Department; A.C. Camargo Cancer Center; São Paulo Brazil
| | - André Ywata de Carvalho
- Head and Neck Surgery and Otorhinolaryngology Department; A.C. Camargo Cancer Center; São Paulo Brazil
| | | | - Carol M. Lewis
- Department of Head and Neck Surgery; University of Texas, MD Anderson Cancer Center; Houston Texas
| | - Randal S. Weber
- Department of Head and Neck Surgery; University of Texas, MD Anderson Cancer Center; Houston Texas
| | - Luiz Paulo Kowalski
- Head and Neck Surgery and Otorhinolaryngology Department; A.C. Camargo Cancer Center; São Paulo Brazil
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Lewis CM, Hutcheson KA, Kupferman ME. Comparative effectiveness in head and neck malignancies. Cancer Treat Res 2015; 164:89-99. [PMID: 25677020 DOI: 10.1007/978-3-319-12553-4_6] [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: 02/16/2023]
Abstract
To date, there is limited comparative effectiveness research (CER) in head and neck surgical oncology. Several barriers exist, the most common of which include low patient accrual, selection bias inherent to observational studies, and the difficulty of integrating both clinical and functional outcomes. Areas in need of meaningful CER range from initial evaluation to post-treatment surveillance, as well as the identification and evaluation of significant quality metrics and patient-reported outcomes. Despite existing hurdles, careful study design and statistical analyses can address current gaps in head and neck cancer care.
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Affiliation(s)
- Carol M Lewis
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, US,
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Eskander A, Merdad M, Irish JC, Hall SF, Groome PA, Freeman JL, Urbach DR, Goldstein DP. Volume-outcome associations in head and neck cancer treatment: a systematic review and meta-analysis. Head Neck 2014; 36:1820-34. [PMID: 24123512 DOI: 10.1002/hed.23498] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2013] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Because of the relative rarity of head and neck malignancies and their complex treatment, some groups have advocated for regionalized care. Studies comparing high- and low-volume centers have demonstrated mixed results. METHODS We conducted a systematic review using MEDLINE and EMBASE including all studies examining a volume-outcome relationship in the treatment of patients with head and neck cancer with meta-analysis for long-term survival results. RESULTS Seventeen studies were identified. Meta-analysis was performed for studies that assessed long-term survival. High-volume hospitals (5 studies; hazard ratio [HR], 0.886; 95% confidence interval [CI], 0.820-0.956) and high-volume surgeons (2 studies; HR, 0.767; 95% CI, 0.641-0.919) have better overall survival than low-volume hospitals and surgeons, respectively. CONCLUSION Volume-outcome associations exist for head and neck oncologic procedures, although this has not been fully investigated for salivary gland malignancies. Future quality of care studies in head and neck oncology should focus on processes of care, which may explain this relationship.
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Affiliation(s)
- Antoine Eskander
- Department of Otolaryngology - Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
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