HYPORT: Phase 1 Study of 3-Week Hypofractionated Postoperative Radiation Therapy for Head and Neck Squamous Cell Carcinoma

PURPOSE

Shortening the overall radiation therapy (RT) treatment time has advantages in cost and treatment burden, but data on hypofractionated RT in head and neck squamous cell carcinoma are limited. This study assessed the safety of moderately hypofractionated RT in the postoperative setting.

METHODS AND MATERIALS

Patients with completely resected stage I-IVB squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx, or larynx with intermediate risk factor(s) including T3/4 disease, positive lymph node(s), close margin(s), perineural invasion, and/or lymphovascular invasion were enrolled on a rolling 6-design phase 1 study. Levels 0 and 1 consisted of 46.5 Gy in 15 fractions delivered 5 days a week and 44.4 Gy in 12 fractions delivered 4 days a week, respectively. The primary endpoint was maximum tolerated dose/fractionation of moderately hypofractionated postoperative RT.

RESULTS

Twelve patients were enrolled with 6 each on levels 0 and 1. No patient experienced a dose-limiting toxicity or grade 4 to 5 toxicity. Acute grade 3 toxicity occurred in 2 patients on level 0 (weight loss, neck abscess) and 3 patients on level 1 (all oral mucositis). One patient on level 0 experienced late grade 3 toxicity (persistent neck abscess). With a median follow-up of 18.6 months, 2 patients on level 1 had a recurrence: a regional recurrence in the undissected, unirradiated contralateral neck from a well-lateralized tonsil primary and an in-field local recurrence of oral tongue primary. The maximum tolerated dose/fractionation was determined to be 44.4 Gy in 12 fractions, but owing to more favorable tolerability in the setting of equivalent biologically effective dose, 46.5 Gy in 15 fractions was deemed the recommended phase 2 dose/fractionation.

CONCLUSIONS

Moderately hypofractionated RT delivered over 3 weeks is well tolerated in the short term in this phase 1 cohort of patients with head and neck squamous cell carcinoma following surgical resection. The follow-up phase 2 randomized trial will deliver 46.5 Gy in 15 fractions as the experimental arm.

Supportive Care Needs Among Head and Neck Cancer Patients Prior to Oncologic Treatment: A Prospective, Nested Cross-Sectional Qualitative Analysis

OBJECTIVES

To qualitatively characterize pretreatment head and neck cancer (HNC) patients' supportive care (SC) needs, attitudes toward SC, and barriers to SC utilization.

MATERIALS AND METHODS

A prospective, nested, bi-institutional, cross-sectional pilot study design was employed. Participants were sub-selected from a representative sample of 50 patients newly diagnosed with mucosal or salivary gland HNC or sarcoma of the head and neck. Eligibility criteria included reporting ≥2 unmet needs (according to the Supportive Care Needs Survey-Short Form 34) or clinically-significant distress (National Comprehensive Cancer Network Distress Thermometer score ≥4). Semi-structured interviews were performed prior to initiation of oncologic treatment. Audio-recorded interviews were transcribed and thematically analyzed using NVivo 12.0 (QSR Australia). Thematic findings and representative quotes were interpreted by the entire research team.

RESULTS

Twenty-seven patients were interviewed. One-third were treated at the county safety-net hospital and the remainder were treated at the university health system. An equal proportion of patients presented with oral cavity, oropharyngeal, and laryngeal or other tumors. Two significant findings were identified on semi-structured interviews. First, patients did not perceive the relevance of SC prior to treatment. Second, anxiety surrounding the HNC diagnosis and impending treatment dominated in the pretreatment phase.

CONCLUSION

Improved HNC patient education about the relevance and importance of SC in the pretreatment setting is needed. Integration of social work or psychological services in HNC clinics is warranted to address patients' cancer-related worry-a discrete, dominant pretreatment SC need.

Unmet Needs and Receipt of Supportive Care Services in Head and Neck Cancer Patients Prior to Oncologic Treatment: A Prospective, Cross-Sectional Pilot Study

OBJECTIVE

To characterize the supportive care (SC) needs and receipt of SC services among head and neck cancer (HNC) patients prior to oncologic treatment and to explore the influence of social determinants of health on these outcomes.

MATERIALS AND METHODS

Newly diagnosed HNC patients were surveyed via telephone prior to oncologic treatment between 10/2019 and 1/2021 using a prospective, cross-sectional, bi-institutional, pilot study design. The primary study outcome was unmet SC needs (Supportive Care Needs Survey-Short Form34 [SCNS-SF34]). Hospital type (university- vs county safety-net) was explored as an exposure. Descriptive statistics were performed using STATA16 (College Station, TX).

RESULTS

Among 158 potentially eligible patients, 129 were successfully contacted, 78 met the study criteria, and 50 completed the survey. The mean age was 61, 58% exhibited clinical stage III-IV disease, and 68% and 32% were treated at the university and county safety-net hospital, respectively. Patients were surveyed a median of 20 days after their first oncology visit and 17 days prior to initiation of oncology treatment. They had a median of 24 total needs (11 were met and 13 were unmet) and preferred to see a median of 4 SC services but received care from none. County safety-net patients had comparatively more unmet needs than university patients (14.5 vs 11.5, P = .04).

CONCLUSION

Pretreatment HNC patients at a bi-institutional academic medical center report a high number of unmet SC needs with corollary poor receipt of available SC services. Novel interventions to address this significant gap in care are needed.

Data envelopment analysis to evaluate the efficiency of tobacco treatment programs in the NCI Moonshot Cancer Center Cessation Initiative

BACKGROUND

The Cancer Center Cessation Initiative (C3I) is a National Cancer Institute (NCI) Cancer Moonshot Program that supports NCI-designated cancer centers developing tobacco treatment programs for oncology patients who smoke. C3I-funded centers implement evidence-based programs that offer various smoking cessation treatment components (e.g., counseling, Quitline referrals, access to medications). While evaluation of implementation outcomes in C3I is guided by evaluation of reach and effectiveness (via RE-AIM), little is known about technical efficiency-i.e., how inputs (e.g., program costs, staff time) influence implementation outcomes (e.g., reach, effectiveness). This study demonstrates the application of data envelopment analysis (DEA) as an implementation science tool to evaluate technical efficiency of C3I programs and advance prioritization of implementation resources.

METHODS

DEA is a linear programming technique widely used in economics and engineering for assessing relative performance of production units. Using data from 16 C3I-funded centers reported in 2020, we applied input-oriented DEA to model technical efficiency (i.e., proportion of observed outcomes to benchmarked outcomes for given input levels). The primary models used the constant returns-to-scale specification and featured cost-per-participant, total full-time equivalent (FTE) effort, and tobacco treatment specialist effort as model inputs and reach and effectiveness (quit rates) as outcomes.

RESULTS

In the DEA model featuring cost-per-participant (input) and reach/effectiveness (outcomes), average constant returns-to-scale technical efficiency was 25.66 (SD = 24.56). When stratified by program characteristics, technical efficiency was higher among programs in cohort 1 (M = 29.15, SD = 28.65, n = 11) vs. cohort 2 (M = 17.99, SD = 10.16, n = 5), with point-of-care (M = 33.90, SD = 28.63, n = 9) vs. no point-of-care services (M = 15.59, SD = 14.31, n = 7), larger (M = 33.63, SD = 30.38, n = 8) vs. smaller center size (M = 17.70, SD = 15.00, n = 8), and higher (M = 29.65, SD = 30.99, n = 8) vs. lower smoking prevalence (M = 21.67, SD = 17.21, n = 8).

CONCLUSION

Most C3I programs assessed were technically inefficient relative to the most efficient center benchmark and may be improved by optimizing the use of inputs (e.g., cost-per-participant) relative to program outcomes (e.g., reach, effectiveness). This study demonstrates the appropriateness and feasibility of using DEA to evaluate the relative performance of evidence-based programs.

Stepped Behavioral and Biological Screening for Oral Oncogenic HPV DNA in Middle-aged and Elderly Adults: A Feasibility Study

Novel preventive interventions are needed to address the rising incidence of human papillomavirus (HPV)-mediated oropharyngeal cancer (HPV+ OPC). This pilot study evaluated the feasibility of a stepped, behavioral and biological screening program for oral oncogenic HPV infection, an intermediate HPV+ OPC outcome.

This was a cross-sectional, feasibility study. Eligible 45-74 years old adults identified from three clinical research registries were administered a behavioral risk survey (step 1). Participant tobacco use and sexual behavior history were translated into a quantifiable risk of oral oncogenic HPV DNA, according to prior National Health and Nutrition Examination Survey analyses. Females with >2% risk and males with >7% risk were offered biological screening for oral oncogenic HPV DNA (step 2) via an oral rinse and gargle specimen.

A total of 292 individuals were contacted, but only 144 (49%) were reached. Among these, 56 individuals (19%) were uninterested and 18 (13%) were ineligible. Seventy individuals began the survey and 66 completed it (step 1), among whom 46 were classified as low-risk. Among the remaining 20 participants classified as high-risk for an oral oncogenic HPV infection, 5% were current smokers and the median participant had performed oral sex on 10 unique partners. During step 2 (biological screening), 45% (9/20) completed testing, all of whom tested negative for oral oncogenic HPV DNA.

In this pilot of a stepped, oral oncogenic HPV screening program, enrollment and study completion were suboptimal. These barriers to screening should be characterized and addressed before reevaluating the feasibility of this program.

PREVENTION RELEVANCE

Novel preventive interventions are needed to address the rising incidence of HPV+ OPC. In this feasibility study, we characterized barriers to a two-step, behavioral and biological screening program for oral oncogenic HPV infection, an intermediate outcome for HPV+ OPC.

Therapeutic Vaccination for HPV-Mediated Cancers

Purpose of Review

The goal of this narrative review is to educate clinicians regarding the foundational concepts, efficacy, and future directions of therapeutic vaccines for human papillomavirus (HPV)-mediated cancers.

Recent Findings

Therapeutic HPV vaccines deliver tumor antigens to stimulate an immune response to eliminate tumor cells. Vaccine antigen delivery platforms are diverse and include DNA, RNA, peptides, proteins, viral vectors, microbial vectors, and antigen-presenting cells. Randomized, controlled trials have demonstrated that therapeutic HPV vaccines are efficacious in patients with cervical intraepithelial neoplasia. In patients with HPV-mediated malignancies, evidence of efficacy is limited. However, numerous ongoing studies evaluating updated therapeutic HPV vaccines in combination with immune checkpoint inhibition and other therapies exhibit significant promise.

Summary

Therapeutic vaccines for HPV-mediated malignancies retain a strong biological rationale, despite their limited efficacy to date. Investigators anticipate they will be most effectively used in combination with other regimens, such as immune checkpoint inhibition.

Clinical and Biologic Characteristics and Outcomes in Young and Middle-Aged Patients With Laryngeal Cancer: A Retrospective Cohort Analysis

OBJECTIVE

To describe the clinical and biologic characteristics and outcomes of young and middle-aged (YMA; <65 years) patients according to the presence or absence of traditional risk factors for laryngeal cancer.

STUDY DESIGN

Retrospective cohort analysis.

SETTING

Single-institution academic medical center.

METHODS

Patients without a history of clinically significant tobacco use or heavy alcohol use were defined as "nontraditional": ≤5 pack-years, ≤5 years smoked, ≤14 alcoholic drinks per week, and ≥15-year interval from last tobacco abuse use to diagnosis. Remaining patients were categorized as "traditional." Select tumor samples were evaluated for bacterial and viral DNA by multiplex polymerase chain reaction.

RESULTS

Seventy-eight YMA patients with primary laryngeal squamous cell carcinoma were identified, 23% (n = 18) of whom were nontraditional. Nontraditional patients were younger than traditional patients (median age, 51 vs 59 years; P < .001). Twenty-eight tumors were prospectively tested for human papillomavirus (HPV), and nontraditional patients were more likely to exhibit high-risk HPV (57% vs 5%, P < .01). Among 17 select tumors (nontraditional, n = 8; traditional, n = 9), 35% exhibited HPV16 (nontraditional, 63%; traditional, 11%; P = .05). Other viruses were identified but did not differ according to risk status: herpesviruses (40%) and Merkel cell polyomavirus (7%). Chlamydia, β-HPV, and γ-HPV DNA was not detected in any samples. Median length of follow-up was 42 months. On adjusted analyses, nontraditional patients exhibited nonsignificantly improved overall survival (hazard ratio, 0.24 [95% CI, 0.03-1.82]; P = .17) and disease-free survival (hazard ratio, 0.34 [95% CI, 0.10-1.23]; P = .08) as compared with traditional patients.

CONCLUSION

Almost one-quarter of YMA patients lacked characteristic risk factors for laryngeal squamous cell carcinoma, and their tumors exhibited a higher prevalence of high-risk HPV. The significance of HPV16 and other tumor viruses with outcomes in nontraditional patients should be evaluated further.

Adherence to the American Cancer Society Head and Neck Cancer Survivorship Care Guideline According to Chart Review: A Nested Retrospective Cohort Pilot Study

OBJECTIVES

The purpose of this study was to explore adherence to the American Cancer Society (ACS) Head and Neck Cancer (HNC) Survivorship Care Guideline and their outlined 33 recommendations among posttreatment HNC survivors.

METHODS

A bi-institutional, retrospective, nested cohort study of mucosal or salivary gland HNC survivors diagnosed in 2018 was designed. Guideline adherence was assessed via retrospective chart review between 0 and 13 months after completion of oncologic treatment according to 4 categories: (1) problem assessed, (2) problem diagnosed, (3) management offered; (4) problem treated. Adherence was defined as meeting a recommendation subcategory at least once over the 13-month period.

RESULTS

Among 60 randomly selected HNC survivors, a total of 38 were included in the final cohort after exclusion of individuals with ineligible cancers and those who died or were lost to follow-up over the study period. Approximately 95% of HNC survivors were assessed for HNC recurrence and screened for lung cancer. Certain common problems such as xerostomia, dysphagia, and hypothyroidism were screened for and managed in ≥70% of eligible survivors. Conversely, screening for other second primary cancers and assessment of a majority of other physical and psychosocial harms occurred in <70% of survivors, and in many cases none to a slim minority of survivors (eg, sleep apnea and sleep disturbance, body and self-image concerns). Only 5% of survivors received a survivorship care plan.

CONCLUSION

Overall adherence to the ACS HNC Survivorship Care Guideline in early posttreatment survivors was suboptimal. Interventions are needed to better implement and operationalize these guideline recommendations.

Is 2045 the best we can do? Mitigating the HPV-related oropharyngeal cancer epidemic

INTRODUCTION

Oropharyngeal cancer (OPC) will be among the most common cancers in men by 2045 due to a rapid rise in human papillomavirus (HPV)-related OPC. Those who survive their cancer often suffer life-long treatment effects and early death. HPV vaccination could prevent virtually all HPV-related cancers but is not an effective preventive strategy for those already exposed. Without a dramatic increase in vaccine uptake in the U.S., HPV vaccination will have a negligible effect on OPC incidence through 2045 and no substantial impact until 2060. Additionally, targeted screening for earlier diagnosis may soon be feasible for those inadequately protected by vaccination.

AREAS COVERED

PubMed search for English-language articles related to incidence, screening, and prevention of HPV-related malignancies, focused on OPC in the U.S.

EXPERT OPINION

HPV-related OPC incidence will continue to increase for the foreseeable future with prophylactic vaccination offering no substantial public health impact for decades. Consequently, we must rapidly increase vaccination rates and develop screening methods to identify high-risk individuals. Such individuals would be eligible for potential preventive treatments and screening to diagnose early-stage HPV-related OPC allowing less morbid treatments. These methods will bridge the population into an era of decreasing incidence after vaccination takes effect.

Survival and disease progression following solitary locoregional recurrence after head and neck radiotherapy

PURPOSE

The management of solitary locoregional recurrence (sLRR) of head and neck squamous cell carcinoma (HNSCC) previously treated with radiotherapy (RT) is challenging. We aimed to identify characteristics associated with improved outcome.

METHODS

We identified patients treated with non-sinus, mucosal HNSCC who initially received IMRT. We characterized overall survival (OS) and locoregional control (LRC). Multivariable analysis (MVA) on survival and patterns-of-failure were performed using Cox and Fine-Gray competing risks analysis.

RESULTS

We identified 90 patients with available follow-up. In total, 67 (74%) patients received curative-intent salvage, while 23 (26%) received palliative care. On MVA, significantly improved OS and LRC were associated with lower initial N-classification and use of salvage total laryngectomy (TL) or neck dissection (ND).

CONCLUSION

A nontrivial number of patients with sLRR cannot undergo salvage. Among patients treated with curative intent, TL or ND were clearly associated with improved OS and LRC.

Pilot Study of a Wearable Activity Monitor During Head and Neck Radiotherapy to Predict Clinical Outcomes

PURPOSE

Given the established associations between performance status and survival in a variety of cancers, there is significant interest in using a biometric wearable device (WD) to predict outcomes in the oncology population. In this pilot study, we investigated the ability of a WD to predict meaningful clinical end points in patients undergoing head and neck radiotherapy.

METHODS

Patients receiving head and neck definitive chemoradiotherapy or postoperative radiotherapy/chemoradiotherapy were enrolled in this pilot study, designed to show 90% compliance with using the device. Individuals were asked to wear the WD for 23 hours a day, and hospital admissions, pain medication usage, and FACT-G quality-of-life (QoL) score were prospectively recorded.

RESULTS

Fifty-one patients were enrolled and started using the WD, but eight patients stopped wearing it, resulting in a compliance probability of only 84%. There were 15 hospital admissions, 13 of which were planned for feeding tube placement. There was no step count threshold that predicted the need for admission or more pain medications. However, among the 25 patients with a significant reduction in FACT-G score, the average reductions in daily steps during the week and weekend before the decline were 988 (P = .005) and 1,311 (P = .018), respectively, and the odds of a QoL reduction were more than 4-fold higher among patients experiencing a week-to-week reduction of at least 1,000 daily steps. There was no association between heart rate and any end point.

CONCLUSION

Although not meeting the compliance goal, the majority of patients did use the WD. The WD signal could not identify patients requiring hospitalization or significantly more pain medication, but the finding of reduced step counts before a significant reduction in QoL is provocative.

Prognostic impact of matted lymphadenopathy in patients with oropharyngeal squamous cell carcinoma treated with definitive chemoradiotherapy

OBJECTIVE

To determine whether cervical matted lymphadenopathy (ML) is associated with outcomes in patients with oropharyngeal squamous cell carcinoma (OPSCC) treated with definitive chemoradiotherapy (CRT).

MATERIALS AND METHODS

OPSCC patients treated at our institution with CRT were included (n = 417). ML was defined by three adjacent nodes without an intervening fat plane. Patients were stratified into favorable OPSCC (p16 + with ≤ 10 pack-years smoking history) or unfavorable OPSCC (p16- and/or > 10 pack years). Primary outcomes were overall survival (OS) and progression-free survival (PFS) and the cumulative incidences of regional recurrence (RR) and distant metastasis (DM).

RESULTS

The median follow-up time for the surviving cohort was 49.9 months. In favorable OPSCC (n = 220), there were no significant associations between ML and any outcome. In unfavorable OPSCC (n = 197), ML had a significant negative impact on OS and PFS, with 3-year OS for patients without and with matted nodes at 74% and 56% (HR, 1.61, 95% CI 1.01-2.58). On multivariable Cox regression, patients with ML experienced significantly worsened OS (HR 1.65, 95% CI 1.03-2.65) and PFS (HR 1.94, 95% CI 1.28-2.93). The cumulative incidence of DM was also higher with ML (31% vs. 9%, adjusted HR 3.3, 95% CI 1.71-6.48).

CONCLUSION

ML carries no prognostic importance in patients with favorable OPSCC. However, ML portends significantly worse outcomes in individuals with HPV-negative disease or a significant smoking history. Thus, ML may help risk-stratify this latter population for treatment intensification, but does not seem to be a contraindication for treatment de-escalation in the former.

Substance use and mental health burden in head and neck and other cancer survivors: A National Health Interview Survey analysis

BACKGROUND

Tobacco dependence, alcohol abuse, depression, distress, and other adverse patient-level influences are common in head and neck cancer (HNC) survivors. Their interrelatedness and precise burden in comparison with survivors of other cancers are poorly understood.

METHODS

National Health Interview Survey data from 1997 to 2016 were pooled. The prevalence of adverse patient-level influences among HNC survivors and matched survivors of other cancers were compared using descriptive statistics. Multivariable logistic regressions evaluating covariate associations with the primary study outcomes were performed. These included 1) current cigarette smoking and/or heavy alcohol use (>14 drinks per week) and 2) high mental health burden (severe psychological distress [Kessler Index ≥ 13] and/or frequent depressive/anxiety symptoms).

RESULTS

In all, 918 HNC survivors and 3672 matched survivors of other cancers were identified. Compared with other cancer survivors, more HNC survivors were current smokers and/or heavy drinkers (24.6% [95% CI, 21.5%-27.7%] vs 18.0% [95% CI, 16.6%-19.4%]) and exhibited a high mental health burden (18.6% [95% CI, 15.7%-21.5%] vs 13.0% [95% CI, 11.7%-14.3%]). In multivariable analyses, 1) a high mental health burden predicted for smoking and/or heavy drinking (odds ratio [OR], 1.4; 95% CI, 1.0-1.9), and 2) current cigarette smoking predicted for a high mental health burden (OR, 1.7; 95% CI, 1.2-2.3). Furthermore, nonpartnered marital status and uninsured/Medicaid insurance status were significantly associated with both cigarette smoking and/or heavy alcohol use (ORs, 1.9 [95% CI, 1.4-2.5] and 1.5 [95% CI, 1.0-2.1], respectively) and a high mental health burden (ORs, 1.4 [95% CI, 1.1 -1.8] and 3.0 [95% CI, 2.2-4.2], respectively).

CONCLUSIONS

Stakeholders should allocate greater supportive care resources to HNC survivors. The interdependence of substance abuse, adverse mental health symptoms, and other adverse patient-level influences requires development of novel, multimodal survivorship care interventions.

Extracapsular extension, pathologic node status, and adjuvant treatment in primary surgery patients with human papillomavirus-mediated oropharyngeal cancer: A national hospital-based retrospective cohort analysis

BACKGROUND

The significance of extracapsular extension (ECE) and adjuvant treatment paradigm in patients with surgically managed human papillomavirus-positive (HPV+) oropharyngeal cancer (OPC) is debated.

METHODS

National, hospital-based, retrospective cohort study of 2663 patients pN+ HPV+ OPC who underwent primary surgery.

RESULTS

Patients with ECE had a 1.74-times risk of death (95% confidence interval [CI]: 1.26-2.40, p = 0.001) compared to patients without ECE. Among patients with pN1, ECE-positive disease, risk of overall mortality was similar across treatment paradigms (surgery alone: ref; adjuvant radiation therapy [RT]: aHR: 0.81; 95% CI: 0.36-1.85; p = 0.62; adjuvant CRT: aHR: 0.66; 95% CI: 0.34-1.32; p = 0.24). Patients with pN2 ECE-positive disease treated with adjuvant RT alone exhibited similar risk of all-cause mortality (hazard ratio: 1.04, 95% CI: 0.24-4.47, p = 0.96) compared to adjuvant chemoradiation (CRT). In patients with advanced, ECE-positive disease (e.g., pT3-T4pN2), adjuvant CRT did not reduce the risk of overall mortality relative to adjuvant RT.

CONCLUSION

Although pathologic ECE negatively predicts for survival in patients with HPV+ OPC, our analyses support expansion of postoperative de-intensification clinical trial eligibility criteria in patients with ECE-positive disease.

High-Risk Cutaneous Squamous Cell Carcinoma of the Head and Neck: A Clinical Review

BACKGROUND

Given the rapidly evolving nature of the field, the current state of "high-risk" head and neck cutaneous squamous cell carcinoma (HNcSCC) is poorly characterized.

METHODS

Narrative review of the epidemiology, diagnosis, workup, risk stratification, staging and treatment of high-risk HNcSCC.

RESULTS

Clinical and pathologic risk factors for adverse HNcSCC outcomes are nuanced (e.g., immunosuppression and perineural invasion). Frequent changes in adverse prognosticators have outpaced population-based registries and the variables they track, restricting our understanding of the epidemiology of HNcSCC and inhibiting control of the disease. Current heterogeneous staging and risk stratification systems are largely derived from institutional data, compromising their external validity. In the absence of staging system consensus, tumor designations such as "high risk" and "advanced" are variably used and insufficiently precise to guide management. Evidence guiding treatment of high-risk HNcSCC with curative intent is also suboptimal. For patients with incurable disease, an array of trials are evaluating the impact of immunotherapy, targeted biologic therapy, and other novel agents.

CONCLUSION

Population-based registries that broadly track updated, nuanced, adverse clinicopathologic risk factors, and outcomes are needed to guide development of improved staging systems. Design and development of randomized controlled trials (RCTs) in advanced-stage HNcSCC populations are needed to evaluate (1) observation, sentinel lymph node biopsy, or elective neck dissection for management of the cN0 neck, (2) indications for surgery plus adjuvant radiation versus adjuvant chemoradiation, and (3) the role of immunotherapy in treatment with curative intent. Considering these knowledge gaps, the authors explore a potential high-risk HNcSCC treatment framework.

Screening for HPV-related oropharyngeal, anal, and penile cancers in middle-aged men: Initial report from the HOUSTON clinical trial

BACKGROUND

The Human papillomavirus (HPV)-related Oropharyngeal and Uncommon Cancers Screening Trial of Men (HOUSTON) was designed to determine the prevalence of IgG antibodies to HPV type 16 E proteins (HPV16EAbs), to screen for persistence of HPV and/or detect HPV-related premalignancies and cancers, and to assess acceptance of screening among middle-aged men.

METHODS

HOUSTON consists of a cross-sectional study and a longitudinal cohort study of men aged 50-64 years. Serologic HPV16EAb status and oral rinse HPV16 status were determined. All HPV16EAb-positive (HPV16EAb+) men and a matched cohort of HPV16EAb-negative (HPV16EAb-) men as well as all oral rinse HPV16-positive (HPV16+) men were included in the longitudinal study (blinded to their results) and underwent oropharyngeal screening every 6 months as well as one-time anal and penile screening.

RESULTS

Of 553 men enrolled in the cross-sectional study, six (1.1%) were HPV16EAb+ (two were also oral rinse HPV16+), and 41 (7.4%) were HPV16EAb- but oral rinse HPV16+. These 47 men, along with five matched controls, were invited to participate in the longitudinal study, and 42 (81%) agreed and completed baseline in-person screening, with 93% and 90% completeing 6-month and 12-month follow-up visits. One HPV16EAb+ (also oral rinse HPV16+) man, who declined participation in the longitudinal study, presented 4 months after enrollment with an early-stage HPV16-related pharyngeal cancer. Additionally, one HPV16EAb+ (oral rinse HPV16-) man and two oral rinse HPV16+ (HPV16EAb-) men were diagnosed with oncogenic HPV-associated anal dysplasia.

CONCLUSIONS

This biomarker panel deserves further prospective study to explore potential utility for HPV-related cancer screening among men.

Oncologic outcomes in primary squamous cell carcinoma of the auricle: a retrospective cohort analysis

PURPOSE

The prognostic significance of auricular location in cutaneous squamous cell carcinoma (cSCC) is controversial. We aimed to characterize risk factors for, and evaluate the cumulative incidence of, locoregional recurrence in a cohort of patients with primary auricular cSCC.

METHODS

The study design was a single-institution retrospective cohort review from 1/2007 to 12/2016.

RESULTS

Among 851 potentially eligible individuals, 178 patients with primary auricular cSCC met strict criteria for inclusion. Median follow-up was 32 months, 93% were AJCC 8th edition (AJCC8) stage I and 6% were AJCC8 stage II. Most underwent Mohs micrographic surgery (MMS; 97%) and the remainder underwent wide local excision ± parotidectomy ± neck dissection ± adjuvant therapy (3%). Recurrences occurred in seven patients (4%): six were local and one was regional. The 3-year cumulative incidence of local and regional recurrence for AJCC8 stage I-II tumors were 1% (95% CI 0-5%) and 0%, respectively. Among ten patients upstaged to pT3 disease who underwent MMS alone, none recurred locoregionally. Compared to their respective counterparts, advanced stage, PNI, and LVI associated with a significantly increased risk of locoregional recurrence.

CONCLUSIONS

Our findings suggest that auricular location may not be a significant risk factor for cSCC staging systems. In the absence of other risk factors, unimodal therapy appears adequate for patients with primary, stage I-II auricular cSCC. The prognostic significance of pT3 auricular cSCC stage due to depth of invasion alone should be evaluated further.

Mixed-methods economic evaluation of the implementation of tobacco treatment programs in National Cancer Institute-designated cancer centers

Background

The Cancer Center Cessation Initiative (C3I) was launched in 2017 as a part of the NCI Cancer Moonshot program to assist NCI-designated cancer centers in developing tobacco treatment programs for oncology patients. Participating centers have implemented varied evidence-based programs that fit their institutional resources and needs, offering a wide range of services including in-person and telephone-based counseling, point of care, interactive voice response systems, referral to the quitline, text- and web-based services, and medications.

Methods

We used a mixed methods comparative case study design to evaluate system-level implementation costs across 15 C3I-funded cancer centers that reported for at least one 6-month period between July 2018 and June 2020. We analyzed operating costs by resource category (e.g., personnel, medications) concurrently with transcripts from semi-structured key-informant interviews conducted during site visits. Personnel salary costs were estimated using Bureau of Labor Statistics wage data adjusted for area and occupation, and non-wage benefits. Qualitative findings provided additional information on intangible resources and contextual factors related to implementation costs.

Results

Median total monthly operating costs across funded centers were $11,045 (range: $5129–$20,751). The largest median operating cost category was personnel ($10,307; range: $4122–$19,794), with the highest personnel costs attributable to the provision of in-person program services. Monthly (non-zero) cost ranges for other categories were medications ($17–$573), materials ($6–$435), training ($96–$516), technology ($171–$2759), and equipment ($10–$620). Median cost-per-participant was $466 (range: $70–$2093) and cost-per-quit was $2688 (range: $330–$9628), with sites offering different combinations of program components, ranging from individually-delivered in-person counseling only to one program that offered all components. Site interviews provided context for understanding variations in program components and their cost implications.

Conclusions

Among most centers that have progressed in tobacco treatment program implementation, cost-per-quit was modest relative to other prevention interventions. Although select centers have achieved similar average costs by offering program components of various levels of intensity, they have varied widely in program reach and effectiveness. Evaluating implementation costs of such programs alongside reach and effectiveness is necessary to provide decision makers in oncology settings with the important additional information needed to optimize resource allocation when establishing tobacco treatment programs.

Blood-based biomarkers of human papillomavirus-associated cancers: A systematic review and meta-analysis

BACKGROUND

Despite the significant societal burden of human papillomavirus (HPV)-associated cancers, clinical screening interventions for HPV-associated noncervical cancers are not available. Blood-based biomarkers may help close this gap in care.

METHODS

Five databases were searched, 5687 articles were identified, and 3631 unique candidate titles and abstracts were independently reviewed by 2 authors; 702 articles underwent a full-text review. Eligibility criteria included the assessment of a blood-based biomarker within a cohort or case-control study.

RESULTS

One hundred thirty-seven studies were included. Among all biomarkers assessed, HPV-16 E seropositivity and circulating HPV DNA were most significantly correlated with HPV-associated cancers in comparison with cancer-free controls. In most scenarios, HPV-16 E6 seropositivity varied nonsignificantly according to tumor type, specimen collection timing, and anatomic site (crude odds ratio [cOR] for p16+ or HPV+ oropharyngeal cancer [OPC], 133.10; 95% confidence interval [CI], 59.40-298.21; cOR for HPV-unspecified OPC, 25.41; 95% CI, 8.71-74.06; cOR for prediagnostic HPV-unspecified OPC, 59.00; 95% CI, 15.39-226.25; cOR for HPV-unspecified cervical cancer, 12.05; 95% CI, 3.23-44.97; cOR for HPV-unspecified anal cancer, 73.60; 95% CI, 19.68-275.33; cOR for HPV-unspecified penile cancer, 16.25; 95% CI, 2.83-93.48). Circulating HPV-16 DNA was a valid biomarker for cervical cancer (cOR, 15.72; 95% CI, 3.41-72.57). In 3 cervical cancer case-control studies, cases exhibited unique microRNA expression profiles in comparison with controls. Other assessed biomarker candidates were not valid.

CONCLUSIONS

HPV-16 E6 antibodies and circulating HPV-16 DNA are the most robustly analyzed and most promising blood-based biomarkers for HPV-associated cancers to date. Comparative validity analyses are warranted. Variations in tumor type-specific, high-risk HPV DNA prevalence according to anatomic site and world region highlight the need for biomarkers targeting more high-risk HPV types. Further investigation of blood-based microRNA expression profiling appears indicated.

Impact of a tobacco treatment program on abstinence and survival rates among current smokers with head and neck squamous cell carcinoma

BACKGROUND

Approximately one quarter of head and neck cancer (HNC) patients smoke cigarettes at the time of diagnosis. Despite HNC guideline recommendations to treat tobacco dependence, the effectiveness of treatment in this population is poorly described.

METHODS

This retrospective cohort review evaluated 117 current smokers with p16-negative mucosal head and neck squamous cell carcinoma prospectively enrolled in a tobacco treatment program. Seven-day point prevalence tobacco abstinence rates at 9 months and survival outcomes were compared among abstinent and nonabstinent groups.

RESULTS

Median follow-up among survivors was 62.4 months. Forty percent of patients were abstinent at 9 months according to intention-to-treat analysis. After adjustment for age, comorbidity and site, abstinent stage I to II patients had a decreased risk of death compared to smoking stage I to II patients (HR 0.15, 95% CI 0.03-0.82).

CONCLUSIONS

High cohort abstinence rates and favorable survival among abstinent patients with early-stage HNC confirm the importance of tobacco dependence treatment in this population.

Considerations in Human Papillomavirus-Associated Oropharyngeal Cancer Screening: A Review

Importance

The incidence of human papillomavirus (HPV)-positive oropharyngeal cancer (OPC) is anticipated to rise over the next few decades until the effects of prophylactic vaccination are realized, which highlights the potential importance of secondary prevention. The objective of this review is to evaluate the evidence associated with screening for HPV-positive OPC.

Observations

Evaluation of a potential clinical preventive screening service requires characterization of the disease burden, the at-risk target screening population, screening tests, treatment, and screening benefits and harms. The lifetime risk of OPC is 0.7% for men and 0.2% for women and is expected to increase. The disease burden of HPV-positive OPC is substantial; most patients undergo morbid multimodality treatment and incur high costs in the process. Middle-aged and older adult men with elevated number of lifetime vaginal or oral sex partners are at highest risk. Patients may benefit from early detection of the disease-the 4-year overall survival of patients with stage I HPV-positive OPC is 87%, a considerable portion of whom are eligible for less morbid single-modality therapy. However, available screening tests are insufficiently sensitive and specific considering the current HPV-positive OPC incidence rates in the most at-risk patients. Further, the benefits and harms of screening for HPV-positive OPC are unknown.

Conclusions and Relevance

The current and projected future population-level burden of HPV-positive OPC supports further exploration of secondary preventive interventions. However, screening for HPV-positive OPC is not currently justified. Advances in biomarker discovery and improved characterization of (1) a highly at-risk, target screening population and (2) the benefits and harms of screening will be necessary. Large-scale clinical trials and rigorous evaluation of how to best implement this service into clinical practice will also be needed.

Head and neck oncology during the COVID-19 pandemic: Reconsidering traditional treatment paradigms in light of new surgical and other multilevel risks

The COVID-19 pandemic demands reassessment of head and neck oncology treatment paradigms. Head and neck cancer (HNC) patients are generally at high-risk for COVID-19 infection and severe adverse outcomes. Further, there are new, multilevel COVID-19-specific risks to patients, surgeons, health care workers (HCWs), institutions and society. Urgent guidance in the delivery of safe, quality head and neck oncologic care is needed. Novel barriers to safe HNC surgery include: (1) imperfect presurgical screening for COVID-19; (2) prolonged SARS-CoV-2 aerosolization; (3) occurrence of multiple, potentially lengthy, aerosol generating procedures (AGPs) within a single surgery; (4) potential incompatibility of enhanced personal protective equipment (PPE) with routine operative equipment; (5) existential or anticipated PPE shortages. Additionally, novel, COVID-19-specific multilevel risks to HNC patients, HCWs and institutions, and society include: use of immunosuppressive therapy, nosocomial COVID-19 transmission, institutional COVID-19 outbreaks, and, at some locations, societal resource deficiencies requiring health care rationing. Traditional head and neck oncology doctrines require reassessment given the extraordinary COVID-19-specific risks of surgery. Emergent, comprehensive management of these novel, multilevel surgical risks are needed. Until these risks are managed, we temporarily favor nonsurgical therapy over surgery for most mucosal squamous cell carcinomas, wherein surgery and nonsurgical therapy are both first-line options. Where surgery is traditionally preferred, we recommend multidisciplinary evaluation of multilevel surgical-risks, discussion of possible alternative nonsurgical therapies and shared-decision-making with the patient. Where surgery remains indicated, we recommend judicious preoperative planning and development of COVID-19-specific perioperative protocols to maximize the safety and quality of surgical and oncologic care.

Palatine Tonsilloliths and Actinomyces: A Multi-institutional Study of Adult Patients Undergoing Tonsillectomy

OBJECTIVE

To better characterize associations between Actinomyces and tonsillolith versus nontonsillolith tonsillectomy specimens.

STUDY DESIGN

Bi-institutional retrospective case-case study.

SETTING

University and county hospital.

SUBJECTS AND METHODS

Adult patients with a clinical history of tonsilloliths who underwent tonsillectomy from January 2006 to December 2018 were included. Patients undergoing tonsillectomy for tonsillar hypertrophy and chronic tonsillitis were identified as comparative cases. Similarly, patients with ipsilateral oropharyngeal cancer (OPC) who underwent contralateral tonsillectomy of a normal-appearing tonsil for prophylaxis against a second primary cancer were also included as comparative cases.

RESULTS

The study population comprised 134 patients who underwent tonsillectomy: 62 tonsillolith and 72 nontonsillolith (tonsillar hypertrophy, n = 30; chronic tonsillitis, n = 30; normal-appearing contralateral tonsil in patients with ipsilateral OPC, n = 12). Actinomyces was reported in 11% of the patients with tonsilloliths on initial pathology reports but in 95% after re-evaluation (n = 54 of 57). Actinomyces prevalence was significantly higher in patients with tonsilloliths as compared with patients with recurrent tonsillitis (73%, n = 22 of 30, P < .001) and normal-appearing contralateral tonsils in patients with ipsilateral OPC (58%, n = 7 of 12, P < .001). Actinomyces prevalence was not significantly different between patients with tonsilloliths and tonsillar hypertrophy (83%, n = 25 of 30, P = .11).

CONCLUSION

The prevalence of Actinomyces in tonsillolith tonsil specimens is high; however, Actinomyces routinely colonizes nontonsillolith tonsil specimens. Therefore, Actinomyces is unlikely to be the primary driver of tonsillolith pathogenesis, and Actinomyces-targeted treatment of tonsilloliths may not be effective. Treatment strategies addressing tonsilloliths should be further investigated.

A Review of and Algorithmic Approach to Soft Palate Reconstruction

Importance

The soft palate contributes to deglutition, articulation, and respiration. Current reconstructive techniques focus on restoration of both form and function. The unique challenges of soft palate reconstruction include maintenance of complex upper aerodigestive tract function, with minimal local or donor site morbidity.

Objective

To review the literature on soft palate reconstruction and present an algorithm on how to approach soft palate defects based on this review.

Evidence Review

A review of the literature for articles reporting studies on and that described concepts related to soft palate reconstruction was conducted in March 2017. In all, 1804 candidate titles and abstracts were independently reviewed. English-language articles that discussed acquired soft palate defect reconstruction were included. Non-English language studies without available translations, studies on primary soft palate defect reconstruction (ie, cleft palate repair) and primary cleft palate repair, studies in which the soft palate was not the focus of the article, and studies involving animals were excluded.

Findings

The following observations were made from the review of 92 included articles. Soft palate anatomy is a complex interplay of multiple structures working in a 3-dimensional area. Three of the authors created an initial algorithmic framework based on the selected studies. After this, a round table discussion among 3 authors considered experts was used to refine the algorithm based on their expert opinion. The 4 most important factors were determined to be defect size, defect extension to other subsites, defect thickness, and history of radiotherapy or planned radiotherapy. This algorithm includes both surgical and nonsurgical options. Defects in the soft palate not only affect the size and shape of the organ but, more critically, the function. The reconstructive ladder is used to help maximize the remaining soft palate functional tissue and minimize the effect of nonfunctional implanted tissue. Partial-thickness defects or defects less than one-fourth of the soft palate may not require locoregional tissue transfer. Patients with a history of radiotherapy or defects of up to 75% of the soft palate may require locoregional tissue transfer. Defects greater than 75% of the soft palate, defects that include exposure of the neck vasculature, or defects that include significant portions of the hard palate or adjacent oropharyngeal subsites may require free tissue transfer. Obturation should be considered a second-line option in most cases.

Conclusions and Relevance

Ideal reconstruction of the soft palate relies on a comprehensive understanding of soft palate anatomy, a full consideration of the armamentarium of surgical techniques, consideration for adjacent subsite deficits, and a detailed knowledge of various intrinsic and extrinsic patient factors to optimize speech, swallowing, and airway outcomes. The included algorithm may serve as a useful starting point for the surgeon when considering reconstruction.

Submental flap practice patterns and perceived outcomes: A survey of 212 AHNS surgeons

OBJECTIVES

To describe American Head and Neck Society (AHNS) surgeon submental flap (SMF) practice patterns and to evaluate variables associated with SMF complications.

METHODS

The design is a cross-sectional study. An online survey was distributed to 782 AHNS surgeons between 11/11/16 and 12/31/16. Surgeon demographics, training, practice patterns and techniques were characterized and evaluated for associations with frequency of SMF complications.

RESULTS

Among 212 AHNS surgeons, 108 (50.9%) reported performing SMFs, of whom 86 provided complete responses. Most surgeons who performed the SMF routinely reconstructed oral cavity defects with the flap (86.1%, n = 74). Thirty-seven surgeons (43.0%) experienced "very few" complications with the SMF. Surgeons who practiced in the United States versus internationally (p = 0.003), performed more total career SMFs (p = 0.02), and routinely reconstructed parotid and oropharyngeal defects (p = 0.04 and p < 0.001) with SMFs were more frequently perceived to have "very few" complications. SMF surgeons reported more perceived complications with the SMF compared to pectoralis major (p = 0.001) and radial forearm free flaps (p = 0.01). However, similar perceived complications were reported between all three flaps when surgeons performed >30 SMF. Among 94 surgeons not performing SMFs, 71.3% had interest in a SMF training course.

CONCLUSIONS

Practice patterns of surgeons performing SMFs are diverse, although most use the flap for oral cavity reconstruction. While 43% of surgeons performing the SMF reported "very few" complications, overall complication rates with the SMF were higher compared to other flaps, potentially due to limited experience with the SMF. Increased training opportunities in SMF harvest and inset are indicated.

Commercial Claims-Based Comparison of Survival and Toxic Effects of Definitive Radiotherapy vs Primary Surgery in Patients With Oropharyngeal Squamous Cell Carcinoma

Importance

Definitive radiotherapy (RT) and primary surgery (PS) are considered to be equally viable local therapy modalities for oropharyngeal squamous cell carcinoma (OPSCC). The comparative effectiveness of these therapies is often debated, and treatment decisions are based on a paucity of comparative data.

Objective

To examine the differences in overall survival and key toxic effects in patients with OPSCC treated with RT and PS.

Design, Setting, and Participants

This retrospective cohort analysis used the HealthCore Integrated Research Database to identify 884 patients diagnosed with OPSCC from January 1, 2007, to December 31, 2014. Patients were categorized as receiving definitive RT (with or without chemotherapy) or PS (with or without adjuvant RT or chemoradiotherapy). Administrative claims data were linked with state cancer registries from California, Connecticut, Georgia, Kentucky, New York, and Ohio. Data analysis was performed from February 29, 2016, to February 6, 2018.

Exposures

Definitive RT or PS.

Main Outcomes and Measures

Overall survival was analyzed using Cox proportional hazards regression. Risks of gastrostomy dependence, esophageal stricture, and osteoradionecrosis were determined through claims and analyzed using logistic regression.

Results

A total of 884 patients (608 [68.8%] in the RT group and 276 [31.2%] in the PS group; mean [SD] age, 61.5 [10.7] years; 727 [82.2%] male; 842 [95.3%] white) were included in this study. The 3-year overall survival was 76% among patients treated with RT and 81% among patients treated with PS (hazard ratio, 0.76; 95% CI, 0.54-1.01). On multivariable analysis, increasing age, female sex, and low income were associated with inferior survival; treatment type was not. Patients treated with RT were more likely to have gastrostomy dependence within the first year (391 [64.3%] vs 127 [46.0%]; adjusted OR, 0.57; 95% CI, 0.42-0.77). After treating chemotherapy as an effect modifier, there was no difference between modalities. Treatment type was not associated with esophageal stricture or osteoradionecrosis risk. Mean costs were approximately $100 000 for payers and $5000 for patients, with no adjusted differences between RT and PS.

Conclusions and Relevance

This study suggests that RT and PS are equally viable treatment options for OPSCC; therefore, local therapy decisions may be individualized to each patient. However, the frequent addition of chemotherapy was associated with increased gastrostomy dependence among patients undergoing RT, which may be relevant in clinical decision making.

Perioperative outcomes after tracheoplasty: A NSQIP analysis 2014-2016

OBJECTIVES

Tracheoplasty or tracheal resection and are essential components of the care of patients with severe tracheal stenosis. We aimed to study the perioperative outcomes of patients after tracheoplasty or resection using a national surgical registry.

METHODS

We analyzed the 2014 to 2016 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) participant use file for patients who underwent tracheal resection or tracheoplasty (CPT codes 31750, 31760, 31780, and 31781). We analyzed the perioperative outcomes including length of stay (LOS), dehiscence, unplanned reintubations, unplanned surgeries, and 30-day readmission rates. A random 4:1 sample of non-tracheoplasty patients served as the control group.

RESULTS

From 2014 to 2016, 126 patients underwent tracheoplasty. The median age was 56 years (IQR = 45-63). There were 93 (74%) females, 88 (70%) white, and 3.2% (4/126) Hispanic. The median LOS was 7 days (IQR = 5-10 days). Of these, 4.8% (6/126) developed wound infections and 3/126 (2.4%) developed wound dehiscence. Five out of 126 required unplanned reintubation (4.0%) and 16/126 (13%) had an unplanned reoperation. The 30-day unplanned readmission rate was 16% (20/126). The wound infection, unplanned intubations, and readmission rates were significantly higher (P < .005) than the control group.

CONCLUSIONS

The 30-day perioperative outcomes of adult patients undergoing tracheoplasty showed that adverse events are common, but severe adverse events such as death are rare. Continued research into risk mitigation among these patients is warranted.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:1514-1519, 2020.

Evaluating sociodemographic, behavioral and psychologic disparities in 918 head and neck cancer survivors

e17541

Background: Minority race, low-income status, tobacco dependence, alcohol abuse, and depression negatively impact overall survival among head and neck cancer (HNC) survivors. Understanding the prevalence and associations of these factors will inform the development of targeted HNC survivorship interventions. Methods: We pooled cross-sectional samples of HNC patients participating in the National Health Interview Survey from 1997-2016. Descriptive statistics were used to compare: 1) HNC survivors to age- and sex-matched adults without cancer (1:4) and 2) behavioral and psychologic conditions in HNC survivors by income status. Results: Mean age of the 918 HNC survivors was 64.8 years and 65.2% were male. Most HNC survivors were non-Hispanic white (85.3%); 7.6% were non-Hispanic black, 4.9% were Hispanic, and 2.2% were of other race and ethnicity. A substantial portion reported income below the poverty threshold (13.9%) and 5.0% consumed > 14 alcoholic drinks per week. Compared to adults without cancer (n = 3,612), a higher proportion (p < 0.05) of HNC survivors (n = 903) exhibited: current tobacco use (21.3% vs 17.4%); serious psychological distress (Kessler-6 score of ≥13; 6.9% vs 3.9%); depressive symptoms most or all of the time (14.1% vs 8.9%). There were particularly striking differences in the prevalence of these factors among HNC survivors by income. Specifically, a higher proportion of HNC survivors with income below the poverty threshold (n = 133) were non-Hispanic black (15.5% vs 5.8%) and exhibited current tobacco use (42.9% vs 18.6%), serious psychological distress (17.4% vs 5.7%) and depressive symptoms most or all of the time (25.3% vs 12.7%) compared to those at or above the poverty threshold (n = 646; all p < 0.05). Conclusions: HNC survivors experience a disproportionate burden of behavioral and psychologic health conditions compared to age- and sex-matched adults without cancer. Low-income status exacerbates these disparities. HNC survivors, especially those in low-income settings, require comprehensive survivorship care targeting these needs.

Risk of Unplanned Hospital Encounters in Patients Treated With Radiotherapy for Head and Neck Squamous Cell Carcinoma

CONTEXT

Radiotherapy is highly effective for treating squamous cell carcinoma of the head and neck but is often associated with significant toxicities and severe morbidity. Unplanned emergency department (ED) visits and hospitalizations are common during treatment and come with a substantial financial and health burden as well as the potential for impaired long-term outcomes due to treatment disruption.

OBJECTIVES

The objective of this study was to identify patient, disease, and treatment characteristics that were associated with ED encounters and admissions.

METHODS

A cohort of 462 patients with cancer of the head and neck treated with radiotherapy at UT Southwestern between 2010 and 2015 was retrospectively analyzed. The risks of ED visits, admissions, multiple admissions, and extended admissions were determined. Risk factors for an unplanned hospital encounter were analyzed using univariate and multivariate logistic regression.

RESULTS

Overall, 36% of patients had an unplanned hospital encounter during the treatment window. Patients with advanced disease, those with high comorbidity score, and those treated with concurrent chemotherapy were more likely to have unplanned admissions/ED visits. Social factors such as marital status, smoking status, and registration in the public hospital system were also strongly associated with admissions and multiple encounters.

CONCLUSION

The high rate of admissions and ED visits emphasizes the importance of anticipating and managing toxicities during treatment. Social factors have a strong association with unplanned encounters and may present opportunities for targeted interventions to reduce admissions for patients at highest risk.

Supraclavicular flap practice patterns and outcomes: A survey of 221 AHNS surgeons

OBJECTIVES

To describe American Head and Neck Society (AHNS) surgeon supraclavicular flap (SCF) practice patterns and to identify variables associated with SCF complications.

METHODS

The design is a cross-sectional study. An online survey was distributed to 782 AHNS surgeons between November 11, 2016, and December 31, 2016. The primary outcome was frequency of SCF complications. Independent variables included demographics, training, practice patterns, and SCF techniques.

RESULTS

Adequate survey responses were obtained from 221 AHNS surgeons. Among these, 54.3% (n = 120) performed supraclavicular flaps (SCFs). Most surgeons used the SCF for cutaneous (n = 85; 78.7%) or parotid-temporal bone (n = 59; 54.6%) defects. Nearly one-third (n = 31; 29.8%) of surgeons experienced more than a "few" SCF complications. Surgeons experienced fewer pectoralis major flap (P < 0.001) and radial forearm free flap (P < 0.001) complications compared to SCF complications. Univariate analysis demonstrated no association between surgeons with "few" SCF complications and Doppler use in SCF design (P = 0.90), harvest location (P = 0.51), and pedicle skeletonization (P = 0.25). Multivariable logistic regression revealed that surgeons performing more than 30 SCFs compared to less than or equal to 30 SCFs had a greater odds of having "few" SCF complications (odds ratio 7.1, 95% confidence interval [1.1-43.9], P = 0.04).

CONCLUSION

A majority of surgeons performing SCFs use the flap to reconstruct cutaneous and parotid-temporal bone defects. The significance of relatively higher SCF complications compared to other routine flaps should be explored further. Surgeon experience with the SCF appears to be significantly associated with SCF success, whereas training characteristics, practice patterns, and technical variations may not be associated with SCF outcomes.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:2012-2019, 2019.

Surgical Fires in Otolaryngology: A Systematic and Narrative Review

Objective

To bring attention to the epidemiology, prevention, management, and consequences of surgical fires in otolaryngology by reviewing the literature.

Data Sources

PubMed, EMBASE, Web of Science, and Scopus.

Review Methods

Comprehensive search terms were developed, and searches were performed from data source inception through August 2016. A total of 4506 articles were identified; 2351 duplicates were removed; and 2155 titles and abstracts were independently reviewed. Reference review was also performed. Eligible manuscripts described surgical fires involving patients undergoing otolaryngologic procedures.

Results

Seventy-two articles describing 87 otolaryngologic surgical fire cases were identified. These occurred during oral cavity or oropharyngeal procedures (11%), endoscopic laryngotracheal procedures (25%), tracheostomies (36%), “other” general anesthesia procedures (3%), and monitored anesthesia care or local procedures (24%). Oxidizing agents consisted of oxygen alone (n = 63 of 81, 78%), oxygen and nitric oxide (n = 17 of 81, 21%), and room air (n = 1 of 81, 1%). The fractional inspired oxygen delivered was >30% in 97% of surgical fires in non–nitrous oxide general anesthesia cases (n = 35 of 36). Laser-safe tubes were used in only 12% of endoscopic laryngotracheal cases with endotracheal tube descriptions (n = 2 of 17). Eighty-six percent of patients experienced acute complications (n = 76 of 87), including 1 intraoperative death, and 22% of patients (n = 17 of 77) experienced long-term complications.

Conclusion

Surgical fires in otolaryngology persist despite aggressive multi-institutional efforts to curb their incidence. Guideline recommendations to minimize the concentration of delivered oxygen and use laser-safe tubes when indicated were not observed in many cases. Improved institutional fire safety practices are needed nationally and internationally.

Treatment, short-term outcomes, and costs associated with larynx cancer care in commercially insured patients

OBJECTIVES/HYPOTHESIS

To examine associations between treatment, complications, and costs in patients with laryngeal cancer.

STUDY DESIGN

Retrospective cross-sectional analysis of MarketScan Commercial Claim and Encounters data.

METHODS

We evaluated 10,969 patients diagnosed with laryngeal cancer from 2010 to 2012 using cross-tabulations and multivariate regression.

RESULTS

Chemoradiation was significantly associated with supraglottic tumors (relative risk ratio [RRR] = 5.9 [4.4-7.8]), pretreatment gastrostomy (RRR = 4.0 [2.7-6.1]), and alcohol abuse (RRR = 0.5 [0.3-0.9]). Treatment-related complications occurred in 23% of patients, with medical complications in 22% and surgical complications in 7%. Chemoradiation (odds ratio [OR] = 3.7 [2.6-5.2]), major surgical procedures (OR = 4.9 [3.5-6.8]), reconstruction (OR = 7.7 (4.1-14.7)], and advanced comorbidity (OR = 9.7 [5.7-16.5] were associated with acute complications. Recurrent/persistent disease occurred in 23% of patients and was associated with high-volume care (OR = 1.4 [1.1-1.8]). Salvage surgery was performed in 46% of patients with recurrent/persistent disease and was less likely for supraglottic disease (OR = 0.5 [0.4-0.8]) and after chemoradiation (OR = 0.4 [0.2-0.6]). Initial treatment and 1-year overall costs for chemoradiation were higher than all other treatment categories, after controlling for all other variables including complications and salvage. High-volume care was associated with significantly lower costs of care for surgical patients but was not associated with differences in costs of care for nonoperative treatment.

CONCLUSIONS

In commercially insured patients <65 years old with laryngeal cancer, chemoradiation was associated with increased costs, an increased likelihood of treatment-related medical complications, and a reduced likelihood of surgical salvage. Higher-volume surgical care was associated with lower initial treatment and 1-year costs of care. These data have implications for discussions of value and quality in an era of healthcare reform.

LEVEL OF EVIDENCE

2c. Laryngoscope, 128:91-101, 2018.

The robotic ENT microsurgery system: A novel robotic platform for microvascular surgery

OBJECTIVE

Assess the feasibility of a novel robotic platform for use in microvascular surgery.

STUDY DESIGN

Prospective feasibility study.

SETTING

Robotics laboratory.

METHODS

The Robotic ENT (Ear, Nose, and Throat) Microsurgery System (REMS) (Galen Robotics, Inc., Sunnyvale, CA) is a robotic arm that stabilizes a surgeon's instrument, allowing precise, tremor-free movement. Six microvascular naïve medical students and one microvascular expert performed microvascular anastomosis of a chicken ischiatic artery, with and without the REMS. Trials were blindly graded by seven microvascular surgeons using a microvascular tremor scale (MTS) based on instrument tip movement as a function of vessel width. Time to completion (TTC) was measured, and an exit survey assessed participants' experience. The interrater reliability of the MTS was calculated.

RESULTS

For microvascular-naïve participants, the mean MTS score for REMS-assisted trials was 0.72 (95% confidence interval [CI] 0.64-1.07) and 2.40 (95% CI 2.12-2.69) for freehand (P < 0.001). The mean TTC was 1,265 seconds for REMS-assisted trials and 1,320 seconds for freehand (P > 0.05). For the microvascular expert, the mean REMS-assisted MTS score was 0.71 (95% CI 0.15-1.27) and 0.86 (95% CI 0.35-1.37) for freehand (P > 0.05). TTC was 353 seconds for the REMS-assisted trial and 299 seconds for freehand. All participants thought the REMS was more accurate and improved instrument handling and stability. The intraclass correlation coefficient for MTS ratings was 0.914 (95% CI 0.823-0.968) for consistency and 0.901 (95% CI 0.795-0.963) for absolute value.

CONCLUSION

The REMS is a feasible adjunct for microvascular surgery and a potential teaching tool capable of reducing tremor in novice users. Furthermore, the MTS is a feasible grading system for assessing microvascular tremor.

LEVEL OF EVIDENCE

NA. Laryngoscope, 127:2495-2500, 2017.

Transoral robotic thyroidectomy: a preclinical feasibility study using the da Vinci Xi platform

Transoral thyroid surgery allows the surgeon to conceal incisions within the oral cavity without significantly increasing the amount of required dissection. TORT provides an ideal scarless, midline access to the thyroid gland and bilateral central neck compartments. This approach, however, presents multiple technical challenges. Herein, we present our experience using the latest generation robotic surgical system to accomplish transoral robotic thyroidectomy (TORT). In two human cadavers, the da Vinci Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA) was used to complete TORT. Total thyroidectomy and bilateral central neck dissection was successfully completed in both cadavers. The da Vinci Xi platform offered several technologic advantages over previous robotic generations including overhead docking, narrower arms, and improved range of motion allowing for improved execution of previously described TORT techniques.

Salvage arterial anastomosis using a microvascular coupler in head and neck free flap reconstruction

Microvascular free tissue transfer is essential in complex head and neck reconstruction. The mainstay of microvascular anastomosis has classically been the suture technique, but the coupling device has emerged as a valuable alternative. Couplers are commonly used for venous anastomoses, but most head and neck reconstructive surgeons do not routinely couple arteries. However, coupling may afford reconstructive surgeons a unique tool for addressing difficult arterial anastomoses. In this case report, we describe the successful use of a microvascular coupler for salvage arterial anastomosis after recurrent thrombosis following multiple attempts at suture anastomosis in head and neck free flap reconstruction.

Management of primary T1-T4 glottic squamous cell carcinoma by transoral laser microsurgery

OBJECTIVES/HYPOTHESIS

Evaluate the oncologic outcomes of patients with early and select advanced primary glottic squamous cell carcinoma (SCCa) managed by transoral laser microsurgery (TLM).

STUDY DESIGN

Retrospective cohort study.

METHODS

Ninety cases of TLM-managed primary glottic SCCa were identified retrospectively using a prospectively collected database.

RESULTS

Outcomes of patients with pTis-pT2a disease (n = 65) and pT2b-pT4a disease (n = 25) were, respectively: 5-year local control, 86.2% and 67.5%; 5-year disease-free survival, 64.9% and 44.9%; 5-year disease-specific survival, 96.4% and 59.0%; laryngeal preservation, 96.9% and 80%. Five of nine patients (56%) with supraglottic-glottic-subglottic tumors were local recurrence-free compared to the 70 of 81 (86%) patients with glottic, supraglottic-glottic, and glottic-subglottic tumors. Seven of 13 patients (54%) with positive or indeterminate margins were local recurrence-free compared to 68 of 77 (88%) patients with negative margins.

CONCLUSIONS

Given sample size considerations, this study highlights the satisfactory oncologic outcomes of TLM-treated glottic cancer and the potential importance of margin management and disease extension within the larynx.

LEVEL OF EVIDENCE

4 Laryngoscope, 127:597-604, 2017.

Severe nasal frostbite injury from nasal cannula supplemental oxygen malfunction

We describe the presentation and management of a patient who presented to our institution with severe nasal frostbite from nasal cannula supplemental oxygen malfunction. This rare complication has not previously been reported in the English Literature. We describe the physical properties of compressed oxygen release that may contribute to these malfunctions and the role of the otolaryngologist in the management of the resulting injuries.

Safety and efficacy of glycerol and amino acids in combination with lipid emulsion for peripheral parenteral nutrition support

The safety and efficacy of administering lipid emulsion with ProcalAmine, a glycerol-based parenteral nutrition solution, for peripheral nutrition has not been previously studied. Thirty-four patients recovering from major trauma or surgery were studied while receiving a peripheral parenteral nutrition regimen of either ProcalAmine with 10% lipid emulsion (group 1) or ProcalAmine with 20% lipid emulsion (group 2) for up to 5 days postinjury. Daily dose was 45 mL/kg ProcalAmine, providing 1.35 g of amino acids/kg and 1.35 g of glycero/kg, and 500 mL/day lipid emulsion. The mean daily nitrogen balance was -0.3 g/day in group 1 and -4.1 g/day in group 2. There was no progressive accumulation of circulating glycerol, and urinary glycerol excretion was minimal (less than 0.2 g/day), indicating effective utilization of glycerol as an energy substrate. Our finding that nitrogen balance was better with 10% fat emulsion suggests a limitation in fat utilization in this setting. Both regimens were well tolerated; there were no adverse clinical reactions and no occurrences of phlebitis in either group.

Nitrogen balance in adult hospitalized patients with the use of a pediatric amino acid model

Normalization of plasma amino acid patterns and that relationship to improved nitrogen balance was studied using a pediatric-specific amino acid solution in 21 adults requiring total parenteral nutrition therapy. There was a significantly positive correlation between improved nitrogen balance and the amino acids cystine, tyrosine, total cysteine/cystine, and ornithine. When additional cysteine was added to the solution of 11 subjects, taurine also correlated with nitrogen balance. Despite higher amounts of histidine in solution, plasma amino acid levels were not normalized. These amino acids, heretofore considered nonessential, may be required in specific molar ratios in stress. The use of a 30% branched-chain pediatric-balanced amino acid solution resulted in near normalization of plasma amino acid levels and group mean positive nitrogen balance.

Recommendations of nutrition support team promote cost containment

Traditionally, Nutrition Support Teams (NST) have been employed in an advisory capacity to recommend the most beneficial type of total nutritional support. Frequently, this form of therapy is also the most economical, particularly when enteral nutrition can replace parenteral nutrition. In a retrospective study, we reviewed the files of 31 patients who had received total nutritional support and compared the nutritional therapy initiated by their attending physicians to the therapy recommended by the NST. Based on guidelines established by the NST, we evaluated patient records for appropriateness of therapy and potential monetary savings had the NST's recommendations been followed. In the majority of cases in which compliance with the NST's recommendations was not accepted, the NST had encouraged the use of enteral nutritional support rather than parenteral nutrition. In the 14 noncompliant cases (representing 280 days of nutritional support) the potential savings to these patients was estimated at $70,200 (more than $5,000 per patient).

Use of the Broviac central venous catheter for intravenous antibiotic therapy in the orthopaedic patient

Broviac central venous catheters were placed in twenty patients who required long-term intravenous antibiotics for the treatment of osteomyelitis, septic arthritis, or an infected total joint arthroplasty. As a group, the twenty patients completed a total of 1,131 days with the catheter in place. There was only one catheter-related complication: extrusion of the Dacron cuff after removal of the catheter. Six antibiotic-related complications occurred, all of which resolved when the antibiotic was changed. No patient had sepsis related to use of the catheter, breakage of the catheter, or thrombosis. Twelve patients had part of their antibiotic treatment on an outpatient basis.