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Sfreddo HJ, Koh ES, Zhao K, Swartzwelder CE, Untch BR, Marti JL, Roman BR, Dublin J, Wang RS, Xia R, Cohen JM, Xu B, Ghossein R, Givi B, Boyle JO, Tuttle RM, Fagin JA, Wong RJ, Morris LGT. RAS-Mutated Cytologically Indeterminate Thyroid Nodules: Prevalence of Malignancy and Behavior Under Active Surveillance. Thyroid 2024; 34:450-459. [PMID: 38407967 DOI: 10.1089/thy.2023.0544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Background: Genomic profiling is now available for risk stratification of cytologically indeterminate thyroid nodules (ITNs). Mutations in RAS genes (HRAS, NRAS, KRAS) are found in both benign and malignant thyroid nodules, although isolated RAS mutations are rarely associated with aggressive tumors. Because the long-term behavior of RAS-mutant ITNs is not well understood, most undergo immediate surgery. In this multicenter retrospective cohort study, we characterize tumor growth kinetics of RAS-mutant ITNs followed with active surveillance (AS) using serial ultrasound (US) scans and examine the histopathologic diagnoses of those surgically resected. Methods: US and histopathologic data were analyzed retrospectively from two cohorts: (1) RAS-mutant ITNs managed with AS at three institutions (2010-2023) and (2) RAS-mutant ITNs managed with immediate surgery at two institutions (2016-2020). AS cohort subjects had ≥3 months of follow-up and two or more US scans. Cumulative incidence of nodule growth was determined by the Kaplan-Meier method and growth by ≥72% change in tumor volume. Pathological diagnoses for the immediate surgery cohort were analyzed separately. Results: Sixty-two patients with 63 RAS-mutated ITNs under AS had a median diameter of 1.7 cm (interquartile range [IQR] 1.2-2.6) at time of diagnosis. During a median AS period of 23 months (IQR 9.5-53.5 months), growth was observed in 12 of 63 nodules (19.0%), with a cumulative incidence of 1.9% (1 year), 23.0% (3 years), and 28.0% (5 years). Most nodules (81.0%) demonstrated stability. Surgery was ultimately performed in 6 nodules, of which 1 (16.7%) was malignant. In the cohort of 209 RAS-mutant ITNs triaged to immediate surgery, 33% were malignant (23.9% American Thyroid Association [ATA] low-risk cancers, 7.2% ATA intermediate-risk, and 1.9% ATA high-risk. During a median follow-up of 6.9 (IQR 4.4-7.1) years, there were no disease-specific deaths in these patients. Conclusions: We describe the behavior of RAS-mutant ITNs under AS and find that most demonstrate stability over time. Of the resected RAS-mutant nodules, most were benign; of the cancers, most were ATA low-risk. Immediate surgical resection of all RAS-mutant ITNs appears to be a low-value practice. Further research is needed to help define cases most appropriate for AS or immediate surgery.
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Affiliation(s)
- Hannah J Sfreddo
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Elizabeth S Koh
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Karena Zhao
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Christina E Swartzwelder
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Brian R Untch
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jennifer L Marti
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Benjamin R Roman
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jared Dublin
- Department of Otolaryngology, NYU School of Medicine, New York, New York, USA
| | - Ronald S Wang
- Department of Otolaryngology, NYU School of Medicine, New York, New York, USA
| | - Rong Xia
- Department of Pathology, NYU School of Medicine, New York, New York, USA
| | - Jean-Marc Cohen
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Bin Xu
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ronald Ghossein
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Babak Givi
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jay O Boyle
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - R Michael Tuttle
- Endocrinology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - James A Fagin
- Endocrinology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Richard J Wong
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Luc G T Morris
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Lipitz-Snyderman A, Chimonas S, Mailankody S, Kim M, Silva N, Kriplani A, Saltz LB, Sihag S, Tan CR, Widmar M, Zauderer M, Weingart S, Perchick W, Roman BR. Clinical value of second opinions in oncology: A retrospective review of changes in diagnosis and treatment recommendations. Cancer Med 2023; 12:8063-8072. [PMID: 36737878 PMCID: PMC10134380 DOI: 10.1002/cam4.5598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 12/08/2022] [Accepted: 12/17/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Data on the clinical value of second opinions in oncology are limited. We examined diagnostic and treatment changes resulting from second opinions and the expected impact on morbidity and prognosis. METHODS This retrospective cohort study included patients presenting in 2018 to a high-volume cancer center for second opinions about newly diagnosed colorectal, head and neck, lung, and myeloma cancers or abnormal results. Two sub-specialty physicians from each cancer type reviewed 30 medical records (120 total) using a process and detailed data collection guide meant to mitigate institutional bias. The primary outcome measure was the rate of treatment changes that were "clinically meaningful", i.e., expected to impact morbidity and/or prognosis. Among those with treatment changes, another outcome measure was the rate of clinically meaningful diagnostic changes that led to treatment change. RESULTS Of 120 cases, forty-two had clinically meaningful changes in treatment with positive expected outcomes (7 colorectal, 17 head and neck, 11 lung, 7 myeloma; 23-57%). Two patients had negative expected outcomes from having sought a second opinion, with worse short-term morbidity and unchanged long-term morbidity and prognosis. All those with positive expected outcomes had improved expected morbidity (short- and/or long-term); 11 (0-23%) also had improved expected prognosis. Nine involved a shift from treatment to observation; 21 involved eliminating or reducing the extent of surgery, compared to 6 adding surgery or increasing its extent. Of the 42 with treatment changes, 13 were due to clinically meaningful diagnostic changes (1 colorectal, 5 head and neck, 3 lung, 4 myeloma; 3%-17%) . CONCLUSIONS Second-opinion consultations sometimes add clinical value by improving expected prognoses; more often, they offer treatment de-escalations, with corresponding reductions in expected short- and/or long-term morbidity. Future research could identify subgroups of patients most likely to benefit from second opinions.
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Affiliation(s)
- Allison Lipitz-Snyderman
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Susan Chimonas
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Sham Mailankody
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Michelle Kim
- Strategy and Innovation, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Nicholas Silva
- Strategy and Innovation, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Anuja Kriplani
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Leonard B Saltz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Smita Sihag
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Carlyn Rose Tan
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Maria Widmar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Marjorie Zauderer
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Saul Weingart
- Rhode Island Hospital and Hasbro Children's Hospital, Providence, Rhode Island, USA
| | - Wendy Perchick
- Strategy and Innovation, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Benjamin R Roman
- Strategy and Innovation, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Underwood HJ, Mott NM, Saucke MC, Roman BR, Voils CI, Pitt SC. What do patients want to know about surgery for low-risk thyroid cancer? A qualitative study. Surgery 2023; 173:226-231. [PMID: 36336505 PMCID: PMC10353734 DOI: 10.1016/j.surg.2022.05.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/20/2022] [Accepted: 05/12/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Shared decision-making about treatment for low-risk thyroid cancer requires patients and surgeons to work together to select treatment that best balances risks and expected outcomes with patient preferences and values. To participate, patients must be activated and ask questions. We aimed to characterize what topics patients prioritize during treatment decision-making. METHODS We identified substantive questions by patients with low-risk (cT1-2, N0) thyroid cancer during audio-recorded consultations with 9 surgeons at 2 unique health care systems. Logistics questions were excluded. Qualitative content analysis was used to identify major themes among patients' questions and surgeon responses. RESULTS Overall, 28 of 30 patients asked 253 substantive questions, with 2 patients not asking any substantive questions (median 8, range 0-25). Patients were 20 to 71 years old, mostly White (86.7%) and female (80.0%). The questions addressed extent of surgery, hormone supplementation, risk of cancer progression, radioactive iodine, and etiology of thyroid cancer. When patients probed for a recommendation regarding extent of surgery, surgeons often responded indirectly. When patients asked how surgery could impact quality of life, surgeons focused on oncologic benefits and surgical risk. Patients commonly asked about hormone supplementation and radioactive iodine. CONCLUSION Patient questions focused on the decision regarding extent of surgery, quality of life, and nonsurgical aspects of thyroid cancer care. Surgeon responses do not consistently directly answer patients' questions but focus on the risks, benefits, and conduct of surgery itself. These findings suggest an opportunity to help surgeons with resources to improve shared decision-making by providing information that patients prioritize.
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Affiliation(s)
- Hunter J Underwood
- Department of Surgery, School of Medicine, University of Michigan, Ann Arbor, MI. https://twitter.com/@HJUnderwoodMD
| | - Nicole M Mott
- Department of Surgery, School of Medicine, University of Michigan, Ann Arbor, MI. https://twitter.com/@nmmott
| | - Megan C Saucke
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI. https://twitter.com/@megan_saucke
| | - Benjamin R Roman
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Corrine I Voils
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI. https://twitter.com/@VoilsCorrine
| | - Susan C Pitt
- Department of Surgery, School of Medicine, University of Michigan, Ann Arbor, MI.
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Abstract
Background: Little is known about the role of emotions in treatment decisions for thyroid cancer. We aimed to characterize the emotional content of patient-surgeon communication during decision-making about low-risk thyroid cancer treatment. Methods: We audio-recorded conversations about treatment for clinically low-risk thyroid cancer or biopsy suspicious for thyroid cancer between patients (n = 30) and surgeons (n = 9) in two diverse, academic hospitals in the United States. Inductive and deductive content analyses were used to characterize the emotional content in verbatim transcripts. Results: Patients' expression of emotion focused on primarily on their diagnosis and treatment outcomes. Patients commonly expressed negative emotions like fear and anxiety about "the C-word" and worried about the cancer growing or spreading. In response, most surgeons used education, as opposed to empathy or validation, to reassure patients, often highlighting low probabilities of adverse events. Surgeons emphasized the "slow-growing" nature and excellent prognosis of thyroid cancer compared with other malignancies. When discussing treatment options, surgeons often described alternatives in terms of their emotional outcomes. Some described total thyroidectomy as providing "peace of mind" or a "sense of completeness," warning that cancer or thyroid tissue remaining in the body with active surveillance or lobectomy might "worry" or "bother" patients. Surgeons supported deliberation by reassuring patients that there are "two right answers" and "no rush" to decide. Conclusions: Patients express negative emotions during treatment decision-making. In response, surgeons often miss opportunities to provide empathy in addition to education. Surgeons and patients both acknowledge patient fear and anxiety as a reason to choose thyroidectomy instead of active surveillance. Peace of mind gained by patients and surgeons as a result of thyroidectomy may lead to overtreatment of patients with low-risk thyroid cancer.
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Affiliation(s)
- Susan C. Pitt
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Address correspondence to: Susan C. Pitt, MD, MPHS, Department of Surgery, University of Michigan, 1500 E. Medical Center Dr., Tubman 2920F, Ann Arbor, MI 48109, USA
| | - Megan C. Saucke
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Benjamin R. Roman
- Division of Head and Neck, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | - Corrine I. Voils
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Research Service, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA
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5
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Roman BR, Aragones A. Epidemiology and incidence of HPV-related cancers of the head and neck. J Surg Oncol 2021; 124:920-922. [PMID: 34558067 DOI: 10.1002/jso.26687] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 09/13/2021] [Indexed: 11/12/2022]
Abstract
Globally, 4.5% of cancers are due to the human papillomavirus (HPV). In the United States, 80 million people are infected with HPV, and the incidence of HPV oropharyngeal cancer has surpassed HPV cervical cancer. The highest burden of oropharyngeal cancer is seen in middle-aged and increasingly older White men. HPV vaccination promises to change the epidemiology of this disease, but HPV vaccination rates remain too low today to reduce disease transmission.
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Affiliation(s)
- Benjamin R Roman
- Departments of Surgery and Strategy & Innovation, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Abraham Aragones
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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6
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Morse E, Lohia S, Dooley LM, Gupta P, Roman BR. Travel distance is associated with stage at presentation and laryngectomy rates among patients with laryngeal cancer. J Surg Oncol 2021; 124:1272-1283. [PMID: 34390494 DOI: 10.1002/jso.26643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 07/18/2021] [Accepted: 08/03/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND The impact of travel distance on stage at presentation and management strategies of laryngeal squamous cell carcinoma (SCC) is unknown. We investigated this relationship. METHODS Retrospective review of patients with laryngeal SCC in the National Cancer Data Base from 2004 to 2016. Multivariate analysis determined relationships between travel distance, sociodemographic, geographic, and hospital factors. Logistic regression determined the influence of travel distance on T-stage and overall stage at presentation, and receipt of total laryngectomy. RESULTS Sixty thousand four hundred and thirty-nine patients were divided into groups based on distance to treatment: short (<12.5 miles); intermediate (12.5-49.9 miles); and long (>50 miles). Increased travel was associated with T4-stage (intermediate vs. short OR 1.11, CI 1.04-1.18, p = 0.001; long vs. short OR 1.5, CI 1.36-1.65, p < 0.001), and total laryngectomy (intermediate vs. short OR 1.40, CI 1.3-1.5, p ≤ 0.001; long vs. short OR 2.52, CI 2.28-2.79, p ≤ 0.001). In T4 disease, total laryngectomy was associated with improved survival compared to nonsurgical treatment (HR 0.75, CI 0.70-0.80, p < 0.001) regardless of travel distance. CONCLUSION Longer travel distance to care is associated with increased stage at presentation, rate of laryngectomy, and improved survival in advanced laryngeal SCC. Health policy efforts should be directed towards improving early access to diagnosis and care.
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Affiliation(s)
- Elliot Morse
- Department of Otolaryngology, Head and Neck Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Shivangi Lohia
- Department of Surgery, Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Department of Otolaryngology, Henry Ford Health System, Detroit, Michigan, USA
| | - Laura M Dooley
- Department of Surgery, Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Department of Otolaryngology, Henry Ford Health System, Detroit, Michigan, USA
| | - Piyush Gupta
- Department of Otolaryngology, University of Missouri, Columbia, Missouri, USA
| | - Benjamin R Roman
- Department of Surgery, Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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7
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Lohia S, Morris LGT, Roman BR. Association Between Implementation of the 2009 American Thyroid Association Guidelines and De-escalation of Treatment for Low-risk Papillary Thyroid Carcinoma. JAMA Otolaryngol Head Neck Surg 2021; 146:1081-1082. [PMID: 33022058 DOI: 10.1001/jamaoto.2020.3024] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Shivangi Lohia
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Luc G T Morris
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Benjamin R Roman
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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8
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Husain S, Lohia S, Petkov V, Blackwell T, Swisher-McClure S, Mizrachi A, Morris LG, Cohen MA, Wong RJ, Roman BR. Disparities and guideline adherence for HPV testing among patients with oropharyngeal squamous cell carcinoma, NCDB, and SEER. Head Neck 2021; 43:2110-2123. [PMID: 33851469 DOI: 10.1002/hed.26679] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 02/28/2021] [Accepted: 03/09/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Human papilloma virus testing for oropharyngeal squamous-cell carcinoma has been recommended by the National Comprehensive Cancer Network since 2012. We examine disparities, reported rates of human papillomavirus (HPV) testing, and the impact on these findings of limitations with the variable in database registries. METHODS The HPV variable was queried for patients with oropharyngeal squamous carcinoma (OPSCC) from 2013 to 2016 in National Cancer Data Base (NCDB) and Surveillance, Epidemiology, and End Results (SEER). Multivariable regression was used to identify disparities based on sociodemographic variables. Sensitivity analyses were used to investigate limitations of the variable. RESULTS Despite limitations in the HPV variable in the databases, there was less than 100% adherence to recommended testing, and there were significant disparities in multiple sociodemographic variables. For example, in NCDB 70% of white versus 60.4% of black patients were tested (odds ratio [OR] 0.75, confidence interval [CI] 0.66-0.85, p ≤ 0.0001); in SEER 59.8% of white and 47.6% of black patients were tested (OR 0.73, CI 0.67-0.81; p ≤ 0.0001). CONCLUSIONS Disparities exist among patients undergoing testing for HPV-associated OPSCC and adherence to guideline recommended HPV testing has been suboptimal. In addition, the HPV variable definition, especially as it relates to p16 positivity, and use in these two registries should be improved.
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Affiliation(s)
- Solomon Husain
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Penn Medicine Abramson Cancer Center, Philadelphia, Pennsylvania, USA
| | - Shivangi Lohia
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Department of Otolaryngology, Henry Ford Health Systems, Detroit, Michigan, USA
| | - Valentina Petkov
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland, USA
| | - Timothy Blackwell
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | - Aviram Mizrachi
- Otorhinolaryngology Head and Neck Surgery, Rabin Medical Center, Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Luc G Morris
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Marc A Cohen
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Richard J Wong
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Benjamin R Roman
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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9
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Pitt SC, Yang N, Saucke MC, Marka N, Hanlon B, Long KL, McDow AD, Brito JP, Roman BR. Adoption of Active Surveillance for Very Low-Risk Differentiated Thyroid Cancer in the United States: A National Survey. J Clin Endocrinol Metab 2021; 106:e1728-e1737. [PMID: 33373458 PMCID: PMC7993571 DOI: 10.1210/clinem/dgaa942] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT Active surveillance (AS) of thyroid cancer with serial ultrasounds is a newer management option in the United States. OBJECTIVE This work aimed to understand factors associated with the adoption of AS. METHODS We surveyed endocrinologists and surgeons in the American Medical Association Masterfile. To estimate adoption, respondents recommended treatment for 2 hypothetical cases appropriate for AS. Established models of guideline implementation guided questionnaire development. Outcome measures included adoption of AS (nonadopters vs adopters, who respectively did not recommend or recommended AS at least once; and partial vs full adopters, who respectively recommended AS for one or both cases). RESULTS The 464 respondents (33.3% response) demographically represented specialties that treat thyroid cancer. Nonadopters (45.7%) were significantly (P < .001) less likely than adopters to practice in academic settings, see more than 25 thyroid cancer patients/year, be aware of AS, use applicable guidelines (P = .04), know how to determine whether a patient is appropriate for AS, have resources to perform AS, or be motivated to use AS. Nonadopters were also significantly more likely to be anxious or have reservations about AS, be concerned about poor outcomes, or believe AS places a psychological burden on patients. Among adopters, partial and full adopters were similar except partial adopters were less likely to discuss AS with patients (P = .03) and more likely to be anxious (P = .04), have reservations (P = .03), and have concerns about the psychological burden (P = .009) of AS. Few respondents (3.2%) believed patients were aware of AS. CONCLUSION Widespread adoption of AS will require increased patient and physician awareness, interest, and evaluation of outcomes.
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Affiliation(s)
- Susan C Pitt
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Correspondence: Susan C. Pitt, MD, MPHS, Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, CSC H4/721, Madison, WI 53792, USA.
| | - Nan Yang
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Megan C Saucke
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Nicholas Marka
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Bret Hanlon
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Kristin L Long
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Alexandria D McDow
- Division of Surgery Oncology, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - J P Brito
- Division of Diabetes, Endocrinology, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Benjamin R Roman
- Division of Head and Neck, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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10
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Roman BR, Gupta P, Tuttle RM, Morris LGT, Lohia S. Assessing the Number of Candidates There Are for Active Surveillance of Low-risk Papillary Thyroid Cancers in the US. JAMA Otolaryngol Head Neck Surg 2021; 146:585-586. [PMID: 32379291 DOI: 10.1001/jamaoto.2020.0523] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Benjamin R Roman
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Piyush Gupta
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - R Michael Tuttle
- Endocrinology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Luc G T Morris
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Shivangi Lohia
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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Roman BR, Brito JP, Saucke MC, Lohia S, Jensen CB, Zaborek N, Jennings JL, Tuttle RM, Davies L, Pitt SC. NATIONAL SURVEY OF ENDOCRINOLOGISTS AND SURGEONS REGARDING ACTIVE SURVEILLANCE FOR LOW-RISK PAPILLARY THYROID CANCER. Endocr Pract 2021; 27:1-7. [PMID: 33471727 PMCID: PMC8185804 DOI: 10.1016/j.eprac.2020.11.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Active surveillance for low-risk papillary thyroid cancer (PTC) was endorsed by the American Thyroid Association guidelines in 2015. The attitudes and beliefs of physicians treating thyroid cancer regarding the active surveillance approach are not known. METHODS A national survey of endocrinologists and surgeons treating thyroid cancer was conducted from August to September 2017 via professional society emails. This mixed-methods analysis reported attitudes toward potential factors impacting decision-making regarding active surveillance, beliefs about barriers and facilitators of its use, and reasons why physicians would pick a given management strategy for themselves if they were diagnosed with a low-risk PTC. Survey items about attitudes and beliefs were derived from the Cabana model of barriers to guideline adherence and theoretical domains framework of behavior change. RESULTS Among 345 respondents, 324 (94%) agreed that active surveillance was appropriate for at least some patients, 81% agreed that active surveillance was at least somewhat underused, and 76% said that they would choose surgery for themselves if diagnosed with a PTC of ≤1 cm. Majority of the respondents believed that the guidelines supporting active surveillance were too vague and that the current supporting evidence was too weak. Malpractice and financial concerns were identified as additional barriers to offering active surveillance. The respondents endorsed improved information resources and evidence as possible facilitators to offering active surveillance. CONCLUSION Although there is general support among physicians who treat low-risk PTC for the active surveillance approach, there is reluctance to offer it because of the lack of robust evidence, guidelines, and protocols.
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Affiliation(s)
- Benjamin R Roman
- Head and Neck Division, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Juan P Brito
- Division of Diabetes, Endocrinology, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Megan C Saucke
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Shivangi Lohia
- Head and Neck Division, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Catherine B Jensen
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Nick Zaborek
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | | | - Robert M Tuttle
- Head and Neck Division, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Louise Davies
- Department of Veterans Affairs Medical Center, White River Junction, Vermont, and Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Susan C Pitt
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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12
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Lohia S, Gupta P, Curry M, Morris LGT, Roman BR. Life Expectancy and Treatment Patterns in Elderly Patients With Low-Risk Papillary Thyroid Cancer: A Population-Based Analysis. Endocr Pract 2020; 27:228-235. [PMID: 33779556 DOI: 10.1016/j.eprac.2020.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/07/2020] [Accepted: 12/03/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Guidelines endorse active surveillance for low-risk papillary thyroid carcinoma (PTC), but this is not commonly utilized. Those with limited life expectancy due to age and comorbidity may be best suited for active surveillance given their higher likelihood of other-cause mortality compared to disease-specific mortality. METHODS Surveillance, epidemiology, and end results-Medicare was queried for patients >65 years with T1, N0, M0 PTC who received surgery. We evaluated the overall survival, disease-specific survival (DSS), and survival based on tumor size and extent of surgery (hemi- vs total thyroidectomy). We created a competing risk model to identify the cumulative incidence of other-cause mortality to define patient groups with life expectancies of less than 10 and 15 years. RESULTS A total of 3280 patients were included. The 20-year overall survival and DSS were 38.2% and 98.5%, respectively. DSS was comparable between patients based on tumor size and surgery. The cancer cohort had better survival compared to matched controls (P < .001). Life expectancy was less than 15 years for any patient aged >80 years regardless of Charlson comorbidity score (CCS ≥ 0) and any patient aged >70 years with CCS ≥ 1. Life expectancy was less than 10 years for any patient a >80 years with CCS ≥ 1 and aged >70 years with CCS ≥ 3. CONCLUSION Older patients with comorbidities have limited life expectancies but excellent DSS from low-risk PTC. Incorporating life expectancy into management decisions and guidelines would likely promote selection of less aggressive management for populations that are most suited for this approach.
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Affiliation(s)
- Shivangi Lohia
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, New York
| | - Piyush Gupta
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, New York
| | - Michael Curry
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, New York
| | - Luc G T Morris
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, New York
| | - Benjamin R Roman
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, New York.
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13
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McDow AD, Roman BR, Saucke MC, Jensen CB, Zaborek N, Jennings JL, Davies L, Brito JP, Pitt SC. Factors associated with physicians' recommendations for managing low-risk papillary thyroid cancer. Am J Surg 2020; 222:111-118. [PMID: 33248684 DOI: 10.1016/j.amjsurg.2020.11.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 10/27/2020] [Accepted: 11/07/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND The 2015 American Thyroid Association endorsed less aggressive management for low-risk papillary thyroid cancer (LR-PTC). We aimed to identify factors influencing physicians' recommendations for LR-PTC. METHODS We surveyed members of three professional societies and assessed respondents' recommendations for managing LR-PTC using patient scenarios. Multivariable logistic regression models identified clinical and non-clinical factors associated with recommending total thyroidectomy (TT) and active surveillance (AS). RESULTS The 345 respondents included 246 surgeons and 99 endocrinologists. Physicians' preference for their own management if diagnosed with LR-PTC had the strongest association with their recommendation for TT and AS (TT: OR 12.3; AS: OR 7.5, p < 0.001). Physician specialty and stated patient preference were also significantly associated with their recommendations for both management options. Respondents who received information about AS had increased odds of recommending AS. CONCLUSIONS Physicians' recommendations for LR-PTC are strongly influenced by non-clinical factors, such as personal treatment preference and specialty.
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Affiliation(s)
- Alexandria D McDow
- Division of Surgery Oncology, Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive EH 537, Indianapolis, IN, 46202, USA.
| | - Benjamin R Roman
- Division of Head and Neck, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA.
| | - Megan C Saucke
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave., Madison, WI, 53792, USA.
| | - Catherine B Jensen
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave., Madison, WI, 53792, USA.
| | - Nick Zaborek
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave., Madison, WI, 53792, USA.
| | - Jamia Linn Jennings
- Wisconsin Department of Health Services, 1 West Wilson Street, Madison, WI, 53703, USA.
| | - Louise Davies
- The VA Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, VT, USA and The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH, 1 Medical Center Drive, Lebanon, NH, 03756, USA.
| | - Juan P Brito
- Division of Diabetes, Endocrinology, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Susan C Pitt
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave., Madison, WI, 53792, USA.
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14
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Flukes S, Lohia S, Barker CA, Cracchiolo JR, Ganly I, Patel SG, Roman BR, Shah JP, Shoushtari AN, Tabar V, Cohen MA. Are our patients doing better? A single institution experience of an evolving management paradigm for sinonasal mucosal melanoma. Oral Oncol 2020; 112:105006. [PMID: 32958401 DOI: 10.1016/j.oraloncology.2020.105006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 09/06/2020] [Accepted: 09/07/2020] [Indexed: 02/03/2023]
Affiliation(s)
- Stephanie Flukes
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Shivangi Lohia
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Christopher A Barker
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Jennifer R Cracchiolo
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Ian Ganly
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Snehal G Patel
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Benjamin R Roman
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Jatin P Shah
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Alexander N Shoushtari
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Viviane Tabar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Marc A Cohen
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States.
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15
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Flukes S, Lohia S, Barker CA, Cracchiolo JR, Ganly I, Patel SG, Roman BR, Shah JP, Shoushtari AN, Tabar V, Shah A, Cohen MA. Primary tumor volume as a predictor of distant metastases and survival in patients with sinonasal mucosal melanoma. Head Neck 2020; 42:3316-3325. [PMID: 32737953 DOI: 10.1002/hed.26380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 06/04/2020] [Accepted: 06/26/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Sinonasal mucosal melanoma (SNMM) is an aggressive cancer with high mortality. Identifying patients at risk of distant metastasis assists with management and prognostication. We aimed to define the relationship between volume, survival, and risk of distant metastases. METHODS A retrospective review of all patients with SNMM treated at a single institution over a 21-year period was conducted. Tumor volume was calculated using cross-sectional imaging and survival analysis was performed. RESULTS Sixty-one patients were included. Tumor volume was predictive of local progression-free survival (P = .03), distant metastases-free survival (DMFS) (P = .002), and overall survival (OS) (P = .02). It was a better predictor than AJCC stage and T-classification. Tumor volume equal to or greater than 5 cm3 was associated with a significantly worse DMFS and OS (P = .02 and .009, respectively). CONCLUSION Calculation of tumor volume assists in quantifying the risk of distant metastases and death in SNMM.
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Affiliation(s)
- Stephanie Flukes
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Shivangi Lohia
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Christopher A Barker
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jennifer R Cracchiolo
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ian Ganly
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Snehal G Patel
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Benjamin R Roman
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jatin P Shah
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | - Viviane Tabar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Multidisciplinary Skull Base and Pituitary Center, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Akash Shah
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Marc A Cohen
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Multidisciplinary Skull Base and Pituitary Center, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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16
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Kang JJ, Wong RJ, Sherman EJ, Rybkin A, McBride SM, Riaz N, Tsai CJ, Yu Y, Chen L, Zakeri K, Gelblum DY, Gillespie EF, Cohen MA, Cracchiolo JR, Ganly I, Patel S, Singh B, Boyle JO, Roman BR, Morris LG, Shaha AR, Dunn LA, Ho AL, Fetten JV, Shah JP, Pfister DG, Lee NY. The 3 Bs of cancer care amid the COVID-19 pandemic crisis: "Be safe, be smart, be kind"-A multidisciplinary approach increasing the use of radiation and embracing telemedicine for head and neck cancer. Cancer 2020; 126:4092-4104. [PMID: 32639615 PMCID: PMC7361524 DOI: 10.1002/cncr.33031] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/09/2020] [Indexed: 12/22/2022]
Abstract
Because of the national emergency triggered by the coronavirus disease 2019 (COVID-19) pandemic, government-mandated public health directives have drastically changed not only social norms but also the practice of oncologic medicine. Timely head and neck cancer (HNC) treatment must be prioritized, even during emergencies. Because severe acute respiratory syndrome coronavirus 2 predominantly resides in the sinonasal/oral/oropharyngeal tracts, nonessential mucosal procedures are restricted, and HNCs are being triaged toward nonsurgical treatments when cures are comparable. Consequently, radiation utilization will likely increase during this pandemic. Even in radiation oncology, standard in-person and endoscopic evaluations are being restrained to limit exposure risks and preserve personal protective equipment for other frontline workers. The authors have implemented telemedicine and multidisciplinary conferences to continue to offer standard-of-care HNC treatments during this uniquely challenging time. Because of the lack of feasibility data on telemedicine for HNC, they report their early experience at a high-volume cancer center at the domestic epicenter of the COVID-19 crisis.
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Affiliation(s)
- Jung Julie Kang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Richard J Wong
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Eric J Sherman
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alisa Rybkin
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sean M McBride
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nadeem Riaz
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - C Jillian Tsai
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yao Yu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Linda Chen
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kaveh Zakeri
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daphna Y Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Erin F Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marc A Cohen
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Ian Ganly
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Snehal Patel
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Bhuvanesh Singh
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jay O Boyle
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Benjamin R Roman
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Luc G Morris
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ashok R Shaha
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lara A Dunn
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alan L Ho
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - James V Fetten
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jatin P Shah
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David G Pfister
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nancy Y Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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17
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Fan D, Kang JJ, Fan M, Wang H, Lee A, Yu Y, Chen L, Jillian Tsai C, McBride SM, Riaz N, Gelblum DY, Neal BP, Fetten J, Dunn LA, Michel LS, Boyle JO, Cohen MA, Roman BR, Ganly I, Singh B, Wong RJ, Sherman EJ, Lee NY. Last-line local treatment with the Quad Shot regimen for previously irradiated head and neck cancers. Oral Oncol 2020; 104:104641. [PMID: 32182548 DOI: 10.1016/j.oraloncology.2020.104641] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/05/2020] [Accepted: 03/08/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Patients with prior irradiated head and neck cancer (HNC) who are ineligible for definitive retreatment have limited local palliative options. We report the largest series of the use of the Quad Shot (QS) regimen as a last-line local palliative therapy. MATERIALS AND METHODS We identified 166 patients with prior HN radiation therapy (RT) treated with QS regimen (3.7 Gy twice daily over 2 consecutive days at 4 weeks intervals per cycle, up to 4 cycles). Palliative response defined by symptom(s) relief or radiographic tumor reduction, locoregional progression free survival (LPFS), overall survival (OS) and radiation-related toxicity were assessed. RESULTS Median age was 66 years. Median follow-up for all patients was 6.0 months and 9.7 months for living patients. Overall palliative response rate was 66% and symptoms improved in 60% of all patients. Predictors of palliative response were > 2 year interval from prior RT and 3-4 QS cycles. Median LPFS was 5.1 months with 1-year LPFS 17.7%, and median OS was 6.4 months with 1-year OS 25.3%. On multivariate analysis, proton RT, KPS > 70, presence of palliative response and 3-4 QS cycles were associated with improved LPFS and improved OS. The overall Grade 3 toxicity rate was 10.8% (n = 18). No Grade 4-5 toxicities were observed. CONCLUSION Palliative QS is an effective last-line local therapy with minimal toxicity in patients with previously irradiated HNC. The administration of 3-4 QS cycles predicts palliative response, improved PFS, and improved OS. KPS > 70 and proton therapy are associated with survival improvements.
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Affiliation(s)
- Dan Fan
- Department of Radiation Oncology, Xiangya Hospital, Central South University, Changsha, Hunan, China; Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jung J Kang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ming Fan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Radiation Oncology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Huili Wang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Radiation Oncology, Cancer Hospital, Chinese Academy of Medical Science, Peking Union Medical College, Beijing, China
| | - Anna Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yao Yu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Linda Chen
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - C Jillian Tsai
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sean M McBride
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nadeem Riaz
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daphna Y Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Brian P Neal
- ProCure Proton Therapy Center, Somerset, NJ, USA
| | - James Fetten
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lara A Dunn
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Loren S Michel
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jay O Boyle
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marc A Cohen
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Benjamin R Roman
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ian Ganly
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Bhuvanesh Singh
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Richard J Wong
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Nancy Y Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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18
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Abstract
Importance The burden of concern for patients with thyroid cancer who undergo surgical intervention with or without radioactive iodine is known to be substantial. For patients under active surveillance, this aspect of the patient experience has not been described to date and could be a potential barrier to broader acceptance of surveillance as a cancer management strategy. Objective To describe the experiences of patients in the longest-standing and largest thyroid cancer active surveillance program. Design, Setting, and Participants This study used a mixed method of survey, semistructured interviews, and field observation and was conducted at Kuma Hospital in Kobe, Japan. The survey was administered from September 4, 2017, through October 18, 2017, and the field observation was conducted from August 28, 2017, to October 20, 2017. Survey participants were a consecutive sample of 249 patients under active surveillance who were attending the hospital for a surveillance visit, and the semistructured interviewees were a subset of 21 patients. The English-language survey instrument was translated by native Japanese speakers, back-translated into English, and then further refined by a panel of Japanese speakers with expertise in health research. Main Outcomes and Measures Survey and interview responses and field observations. Results In total, 249 surveys were distributed to patients with thyroid cancer on active surveillance. Two hundred forty-three patients (97.6%) completed the survey. Among the respondents, 195 (80.2%) were female and 20 (8.2%) were male (28 [11.5%] responses were missing). Among the subset of 21 patients who participated in the semistructured interview, 3 were male (14.3%), and the mean (range) age was 64 (32-85) years. Thirty-seven percent rated the frequency of cancer worry as occurring sometimes or more. Thirty-two percent said their worry affected their mood somewhat or a lot. Fourteen percent reported that their worry affected their ability to carry out daily activities somewhat or a lot. Cancer spread, later need for surgical intervention, and difficulty with interpreting bodily experiences in the general location of the cancer were among the main sources of worry. Most respondents (60.0%) said their worry was less than it was when they first found out about their cancer. By 3 years after diagnosis, the proportion of participants who reported they were not at all worried increased from 14% (95% CI, 12%-16%) to 25% (95% CI, 23%-26%). Eighty percent (95% CI, 79%-81%) of respondents agreed or strongly agreed that their decision to do active surveillance matched their personal values, and 83% (95% CI, 82%-84%) agreed or strongly agreed that choosing active surveillance was the best decision for them personally. Most patients (77%) had not heard of active surveillance before they were offered the option. Conclusions and Relevance Cancer concern was common among patients with thyroid cancer under active surveillance, which is comparable to the worry among actively treated patients. Levels of cancer worry reported by patients under active surveillance decreased over time, and patients expressed satisfaction with their disease management decision. These findings suggest that the possibility of cancer worry should not be viewed as prohibitive to successful active surveillance in thyroid cancer.
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Affiliation(s)
- Louise Davies
- The VA Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, Vermont.,Section of Otolaryngology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.,The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Benjamin R Roman
- Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Yasuhiro Ito
- Department of Surgery, Kuma Hospital, Kobe, Japan
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19
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Roman BR, Lohia S, Mitra N, Wang MB, Pou AM, Holsinger FC, Myssiorek D, Goldenberg D, Asch DA, Shea JA. Perceived value drives use of routine asymptomatic surveillance PET/CT by physicians who treat head and neck cancer. Head Neck 2020; 42:974-987. [PMID: 31919944 DOI: 10.1002/hed.26071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 12/19/2019] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Why physicians use surveillance imaging for asymptomatic cancer survivors despite recommendations against this is not known. METHODS Physicians surveilling head and neck cancer survivors were surveyed to determine relationships among attitudes, beliefs, guideline familiarity, and self-reported surveillance positron-emission-tomography/computed-tomography use. RESULTS Among 459 responses, 79% reported using PET/CT on some asymptomatic patients; 39% reported using PET/CT on more than half of patients. Among attitudes/beliefs, perceived value of surveillance imaging (O.R. 3.57, C.I. 2.42-5.27, P = <.0001) was the strongest predictor of high imaging, including beliefs about outcome (improved survival) and psychological benefits (reassurance, better communication). Twenty-four percent of physicians were unfamiliar with guideline recommendations against routine surveillance imaging. Among physicians with high perceived-value scores, those less familiar with guidelines imaged more (O.R. 3.55, C.I. 1.08-11.67, P = .037). CONCLUSIONS Interventions to decrease routine surveillance PET/CT use for asymptomatic patients must overcome physicians' misperceptions of its value. Education about guidelines may modify the effect of perceived value.
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Affiliation(s)
- Benjamin R Roman
- Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York
| | - Shivangi Lohia
- Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York
| | - Nandita Mitra
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marilene B Wang
- Department of Head and Neck Surgery, University of California, Los Angeles, California
| | - Anna M Pou
- Department of Otolaryngology, Ochsner Health System, Covington, Louisiana
| | | | - David Myssiorek
- Department of Surgery, Division of Otolaryngology Head and Neck Surgery, The Albert College of Medicine, Bronx, New York
| | - David Goldenberg
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, The Pennsylvania State University-Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - David A Asch
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Judy A Shea
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Mori S, Navarrete-Dechent C, Petukhova TA, Lee EH, Rossi AM, Postow MA, Dunn LA, Roman BR, Yin VT, Coit DG, Hollmann TJ, Busam KJ, Nehal KS, Barker CA. Tumor Board Conferences for Multidisciplinary Skin Cancer Management: A Survey of US Cancer Centers. J Natl Compr Canc Netw 2019; 16:1209-1215. [PMID: 30323091 DOI: 10.6004/jnccn.2018.7044] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 05/07/2018] [Indexed: 02/06/2023]
Abstract
Background: Tumor board conferences (TBCs) are used by oncologic specialists to review patient cases, exchange knowledge, and discuss options for cancer management. These multidisciplinary meetings are often a cornerstone of treatment at leading cancer centers and are required for accreditation by certain groups, such as the American College of Surgeons' Commission on Cancer. Little is known regarding skin cancer TBCs. The objective of this study was to characterize the structure, function, and impact of existing skin cancer TBCs in the United States. Methods: A cross-sectional online survey was administered to physician leaders of skin cancer TBCs at NCI-designated Comprehensive and Clinical Cancer Centers. Results: Of the 59 centers successfully contacted, 14 (24%) reported not having a conference where skin cancer cases were discussed, and 45 (76%) identified 53 physician leaders. A total of 38 physicians (72%) completed the survey. Half of the meeting leaders were medical and/or surgical oncologists, and dermatologists led one-third of meetings. TBCs had a moderate to significant impact on patient care according to 97% of respondents. All respondents indicated that the meetings enhanced communication among physicians and provided an opportunity for involved specialists and professionals to discuss cases. The most frequently cited barrier to organizing TBCs was determining a common available date and time for attendees (62%). The most common suggestion for improvement was to increase attendance, specialists, and/or motivation. Conclusions: Results showed overall consistency in meeting structure but variability in function, which may be a reflection of institutional resources and investment in the conference. Future directions include defining metrics to evaluate changes in diagnosis or management plan after tumor board discussion, attendance, clinical trial enrollment, and cost analysis. Results of this survey may aid other institutions striving to develop and refine skin cancer TBCs.
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21
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Obayemi A, Cracchiolo JR, Migliacci JC, Husain Q, Rahmati R, Roman BR, Cohen MA. Elective neck dissection (END) and cN0 hard palate and upper gingival cancers: A National Cancer Database analysis of factors predictive of END and impact on survival. J Surg Oncol 2019; 120:1259-1265. [PMID: 31549410 DOI: 10.1002/jso.25706] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 09/08/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVES The reported risk of nodal metastasis in hard palate and upper gingival squamous cell carcinoma (SCC) has been inconsistent with inadequate consensus regarding the utility of neck dissection in the clinically negative (cN0) neck. MATERIALS AND METHODS Using the National Cancer Database, cN0 patients diagnosed with SCC of the head and neck with the subsites of the hard palate and upper gingiva were identified from 2004 to 2014. RESULTS A total of 1830 patients were identified, and END was performed on 422 patients with cN0 tumors. Pathologically positive nodes occurred in 14% (59/422) of patients in this cohort. Higher tumor stage, academic hospital type, and large hospital volume (>28 cancer-specific cases/year) were associated with a higher likelihood of END both in univariate and multivariate analyses (P < .05). Patients >80 years of age were less likely to receive END on multivariate analysis (OR 0.52, 0.32-0.84). No variables, including advanced T stage, predicted occult metastases. Cox proportional hazards regression analysis showed that patients who underwent END demonstrated improved OS over an 11-year period (hazard ratio 0.75, P = .002). On subgroup analysis, this improvement was significant in patients with both stage T1 and T4 tumors. CONCLUSIONS Tumor stage, hospital type, and hospital volume were associated with higher rates of END for patients with cN0 hard palate SCC and after controlling for clinical factors, END was associated with improved overall survival.
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Affiliation(s)
- Adetokunbo Obayemi
- Department of Otolaryngology Head and Neck Surgery, Columbia University Medical Center, New York, New York
| | - Jennifer R Cracchiolo
- Department of Surgery, Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jocelyn C Migliacci
- Department of Surgery, Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Qasim Husain
- Coastal Ear, Nose, and Throat, Hackensack Meridian School of Medicine at Seton Hall University, Nutley, New Jersey
| | - Rahmatullah Rahmati
- Department of Otolaryngology Head and Neck Surgery, Columbia University Medical Center, New York, New York
| | - Benjamin R Roman
- Department of Surgery, Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marc A Cohen
- Department of Surgery, Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, New York
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22
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Xiao R, Joshi RR, Husain Q, Cracchiolo JR, Lee N, Tsai J, Yu Y, Chen L, Kang JJ, McBride S, Riaz N, Roman BR, Ganly I, Tabar V, Gray ST, Cohen MA. Timing of surgery and adjuvant radiation therapy for sinonasal malignancies: Effect of surgical approach. Head Neck 2019; 41:3551-3563. [PMID: 31294897 DOI: 10.1002/hed.25873] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 06/03/2019] [Accepted: 06/26/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Timely postoperative radiation therapy (RT) within 50 days of surgery for head and neck cancers provides a survival advantage. METHODS Using the National Cancer Database, we performed a propensity score-matched analysis comparing patients undergoing open or endoscopic surgery for squamous cell carcinoma (SCC) of the nasal cavity and paranasal sinuses from 2010 to 2015. RESULTS Among 168 pairs, patients undergoing endoscopic surgery had shorter time to surgery (24.2 vs 36.7 days, P < .001) and shorter postoperative time to RT (PTTR, 51.2 vs 58.4 days, P = .02). On multivariable linear regression, endoscopic surgery predicted shorter PTTR (β = -7.6, P = .01). Using the Kaplan-Meier method, patients in the longest PTTR quartile had decreased overall survival (OS; Q1 vs Q4, 3-year OS 76.5% vs 53.3%, P = .007), a durable finding when adjusted for covariates (Q1 vs Q4, HR 0.50, P = .008). CONCLUSIONS Patients undergoing endoscopic surgery for sinonasal SCC experience shorter PTTR. Shorter PTTR is associated with extended OS.
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Affiliation(s)
- Roy Xiao
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard University, Boston, Massachusetts
| | - Rohan R Joshi
- Department of Otolaryngology - Head and Neck Surgery, Case Western Reserve University, Cleveland, Ohio
| | - Qasim Husain
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard University, Boston, Massachusetts
| | - Jennifer R Cracchiolo
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nancy Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jillian Tsai
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yao Yu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Linda Chen
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jung J Kang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sean McBride
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nadeem Riaz
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Benjamin R Roman
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ian Ganly
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Viviane Tabar
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Stacey T Gray
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard University, Boston, Massachusetts
| | - Marc A Cohen
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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Abstract
This article focuses on conventional surgical management of thyroid cancer, reviewing long-standing and well-accepted main principles and practices. It also covers newer controversies and techniques to conventional thyroidectomy, including changes in the indications for thyroidectomy, the intraoperative management of the recurrent and superior laryngeal nerves and parathyroid glands, the extent of thyroidectomy, and the importance of outcomes measurement and quality improvement.
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Affiliation(s)
- Benjamin R Roman
- Department of Surgery, Division of Head and Neck, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Room C-1075, New York, NY 10065, USA
| | - Gregory W Randolph
- Department of Otolaryngology, Division of Thyroid and Parathyroid Endocrine Surgery, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, USA.
| | - Dipti Kamani
- Department of Otolaryngology, Division of Thyroid and Parathyroid Endocrine Surgery, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, USA
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24
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Sayed Z, Migliacci JC, Cracchiolo JR, Barker CA, Lee NY, McBride SM, Tabar VS, Ganly I, Patel SG, Morris LT, Roman BR, Shoushtari AN, Cohen MA. Association of Surgical Approach and Margin Status With Oncologic Outcomes Following Gross Total Resection for Sinonasal Melanoma. JAMA Otolaryngol Head Neck Surg 2019; 143:1220-1227. [PMID: 29049462 DOI: 10.1001/jamaoto.2017.2011] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Zafar Sayed
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jocelyn C Migliacci
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jennifer R Cracchiolo
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Christopher A Barker
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nancy Y Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sean M McBride
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Viviane S Tabar
- Neurosurgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ian Ganly
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Snehal G Patel
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Luc T Morris
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Benjamin R Roman
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alexander N Shoushtari
- Neurosurgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marc A Cohen
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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25
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Korenstein D, Husain S, Gennarelli RL, White C, Masciale JN, Roman BR. Impact of Clinical Specialty on Attitudes Regarding Overuse of Inpatient Laboratory Testing. J Hosp Med 2018; 13:844-847. [PMID: 29964278 PMCID: PMC6265055 DOI: 10.12788/jhm.2978] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Routine laboratory testing is common among hospitalized patients, with associated harm. Attitudes toward testing and drivers across clinical specialties have not been described. We performed a cross-sectional study and anonymously surveyed inpatient clinicians (nurses, advanced practice providers, and physicians) at a tertiary cancer center regarding attitudes toward unnecessary laboratory testing and its drivers across clinical specialties. A total of 837 providers completed surveys (response rate 53%). Most respondents agreed with daily testing of hospitalized patients and that daily labs generally enhance safety, and those from pediatric and surgical specialties generally valued testing less than others. Participants most commonly indentified habit and institutional culture as important drivers of unnecessary testing. There were differences in other drivers across specialties, with pediatric clinicians identifying family pressure more commonly and fear of litigation less commonly compared to others. Future interventions to reduce unnecessary inpatient laboratory testing should acknowledge different attitudes based on specialty and tailor interventions accordingly.
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Affiliation(s)
- Deborah Korenstein
- Memorial Sloan Kettering Cancer Center, Department of Medicine, New York, New York, USA.
- Memorial Sloan Kettering Cancer Center, Center for Health Policy and Outcomes, New York, New York, USA
| | - Solomon Husain
- Memorial Sloan Kettering Cancer Center, Department of Surgery, Head & Neck Division, New York, New York, USA
| | - Renee L Gennarelli
- Memorial Sloan Kettering Cancer Center, Center for Health Policy and Outcomes, New York, New York, USA
| | - Cilian White
- Morristown Medical Center, Department of Medicine, Morristown, New Jersey, USA
| | - James N Masciale
- Memorial Sloan Kettering Cancer Center, Department of Quality and Safety, New York, New York, USA
| | - Benjamin R Roman
- Memorial Sloan Kettering Cancer Center, Center for Health Policy and Outcomes, New York, New York, USA
- Memorial Sloan Kettering Cancer Center, Department of Surgery, Head & Neck Division, New York, New York, USA
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26
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Joshi RR, Husain Q, Roman BR, Cracchiolo J, Yu Y, Tsai J, Kang J, McBride S, Lee NY, Morris L, Ganly I, Tabar V, Cohen MA. Comparing Kadish, TNM, and the modified Dulguerov staging systems for esthesioneuroblastoma. J Surg Oncol 2018; 119:130-142. [PMID: 30466166 DOI: 10.1002/jso.25293] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 10/22/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Esthesioneuroblastoma (ENB) is a rare neuroendocrine tumor. The purpose of this study was to compare the Kadish, tumor-node-metastasis (TNM), and Dulguerov's modified TNM staging in order to determine the impact of the stage on primary surgical treatment selection, margin status, and survival. METHODS The National Cancer Database (NCDB) was used to identify patients diagnosed with ENB between 2004 to 2015. Patients were excluded based on the ability to properly stage their disease as well as the availability of treatment data. RESULTS Eight-hundred eighty-three patients had sufficient data for analysis. On multivariate analysis, age and government insurance were associated with primary surgical treatment, whereas tumor stage, gender, race, hospital type and volume, and comorbidity score were not. Age, charlson-deyo comorbidity (CDCC) score, hospital volume, and nodal status were found to be predictors of survival. Multivariate-analysis controlling for stage failed to demonstrate clear survival differences between staging in both TNM and Kadish systems. T-stage and the presence of regional nodal metastasis were associated with an increased risk of positive margins on multivariate analysis. CONCLUSION Although primary surgical management and positive margins can be predicted by certain patient and tumor factors, clinical staging systems for ENB poorly predict prognosis over a 10-year horizon.
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Affiliation(s)
- Rohan R Joshi
- Department of Otolaryngology-Head & Neck Surgery, Columbia University Medical Center, New York, New York.,Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College, New York, New York
| | - Qasim Husain
- Department of Otolaryngology-Head & Neck Surgery, Columbia University Medical Center, New York, New York.,Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College, New York, New York
| | | | - Jennifer Cracchiolo
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yao Yu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jillian Tsai
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Julie Kang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sean McBride
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nancy Y Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Luc Morris
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ian Ganly
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Viviane Tabar
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marc A Cohen
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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27
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Husain Q, Joshi RR, Cracchiolo JR, Roman BR, Ganly I, Tabar V, Cohen MA. Surgical Management Patterns of Sinonasal Malignancy: A Population-Based Study. J Neurol Surg B Skull Base 2018; 80:371-379. [PMID: 31316883 DOI: 10.1055/s-0038-1675233] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 08/29/2018] [Indexed: 02/03/2023] Open
Abstract
Objectives Determining surgical trends and outcomes for sinonasal tumors is challenging given their low incidence and heterogeneous pathology. This study utilized the National Cancer Database (NCDB) to identify trends and outcomes associated with surgical management of sinonasal tumors. Design Retrospective database analysis. Setting National Cancer Database. Participants Patients with sinonasal malignancies identified from the NCDB between 2010 and 2015. Main Outcome Measures The primary outcome was the choice of surgical therapy used for sinonasal tumor resection: endoscopic versus open approach. Each was cohort analyzed with respect to various demographic and clinicopathologic factors. A treatment effect model was used to identify potential differences between surgical approaches. Survival was evaluated using Kaplan-Meier analysis. Results A total of 10,193 patients with sinonasal malignancies were identified in the NCDB database; of these, 2,292 had a documented subsite, histology, and definitive surgical treatment with documented surgical approach and were included in the analysis. About 71.9% of patients had an open approach and 28.1% a purely endoscopic procedures. Tumor histology, treatment facility type, margin status, and length of stay were all variables that were associated with significant differences between the open and endoscopic cohort. Five-year survival rates for the open and endoscopic cohorts were not significantly different (59.6 and 60.8%, respectively). Conclusions Assessment of the NCDB revealed that 28% patients with sinonasal malignancy were selected for endoscopic surgery. These patients had comparable oncologic outcomes to open resection.
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Affiliation(s)
- Qasim Husain
- Department of Otolaryngology - Head and Neck Surgery, Columbia University Medical Center, New York, New York, United States.,Department of Otolaryngology - Head and Neck Surgery, Weill Cornell Medical College, New York, New York, United States
| | - Rohan R Joshi
- Department of Otolaryngology - Head and Neck Surgery, Columbia University Medical Center, New York, New York, United States.,Department of Otolaryngology - Head and Neck Surgery, Weill Cornell Medical College, New York, New York, United States
| | - Jennifer R Cracchiolo
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Benjamin R Roman
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Ian Ganly
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Viviane Tabar
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Marc A Cohen
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, United States
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28
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Xu B, Farhat N, Barletta JA, Hung YP, Biase DD, Casadei GP, Onenerk AM, Tuttle RM, Roman BR, Katabi N, Nosé V, Sadow P, Tallini G, Faquin WC, Ghossein R. Should subcentimeter non-invasive encapsulated, follicular variant of papillary thyroid carcinoma be included in the noninvasive follicular thyroid neoplasm with papillary-like nuclear features category? Endocrine 2018; 59:143-150. [PMID: 29204912 PMCID: PMC5766404 DOI: 10.1007/s12020-017-1484-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 11/23/2017] [Indexed: 02/05/2023]
Abstract
OBJECTIVE In 2016, non-invasive, well-circumscribed and encapsulated, follicular variant of papillary thyroid carcinoma (NI-EFV PTC) was reclassified as noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) in order to reduce overtreatment of this indolent tumor. However, the study cohort did not include subcentimeter tumors, i.e., papillary thyroid microcarcinoma (mPTC) with NI-EFV morphology, and such lesions are still regarded and staged by most pathologists as microcarcinomas. It is therefore crucial to evaluate the clinical outcome of subcentimeter NI-EFVs. METHODS A total of 52 patients with unifocal mPTC, NI-EFV from five tertiary hospitals who had at least one year clinical follow-up (FU) without post-operative RAI administration were included in the study. A control group of 57 invasive mPTC follicular variant was also included. RESULTS The median tumor size was 0.44 cm (range 0.1-0.9 cm). There were no distant or lymph node metastases at diagnosis in all patients. Twenty-three patients (44%) underwent lobectomy alone, while the remaining received total thyroidectomy. No recurrence was observed in the entire cohort (n = 52) including all 38 patients with at least 2 years of FU (median FU: 6.3 years). Among 25 patients with ≥5 years of FU, none recurred with a median FU of 9.6 years (range 5.2-18.1 years). In contrast, in the control group with invasive mPTC follicular variant, there were 5 (9%) patients with nodal metastasis at presentation and 1 (2%) who displayed nodal recurrence. CONCLUSION Papillary thyroid microcarcinoma, NI-EFV, when stringently selected for, lacks metastasis at presentation and follows an extremely indolent clinical course, even when treated conservatively without RAI therapy. Provided stringent inclusion criteria are met, classification of subcentimeter mPTC, NI-EFV as NIFTP should be considered in order to avoid overtreatment of these biologically indolent lesions.
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Affiliation(s)
- Bin Xu
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Nada Farhat
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Justine A Barletta
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
- Department of Pathology, Harvard Medical School, Boston, MA, USA
| | - Yin P Hung
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - Dario de Biase
- Department of Pharmacy and Biotechnology (Dipartimento di Farmacia e Biotecnologie), University of Bologna, Bologna, Italy
| | | | - Ayse Mine Onenerk
- Departments of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - R Michael Tuttle
- Departments of Medicine, and Memorial Sloan Kettering Cancer center, New York, NY, USA
| | - Benjamin R Roman
- Department of Surgery, Memorial Sloan Kettering Cancer center, New York, NY, USA
| | - Nora Katabi
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Vania Nosé
- Department of Pathology, Harvard Medical School, Boston, MA, USA
- Departments of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Peter Sadow
- Department of Pathology, Harvard Medical School, Boston, MA, USA
- Departments of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Giovanni Tallini
- Department of Medicine (Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale), University of Bologna School of Medicine, Bologna, Italy
| | - William C Faquin
- Department of Pathology, Harvard Medical School, Boston, MA, USA
- Departments of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Ronald Ghossein
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
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29
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Leeman JE, Li JG, Pei X, Venigalla P, Zumsteg ZS, Katsoulakis E, Lupovitch E, McBride SM, Tsai CJ, Boyle JO, Roman BR, Morris LGT, Dunn LA, Sherman EJ, Lee NY, Riaz N. Patterns of Treatment Failure and Postrecurrence Outcomes Among Patients With Locally Advanced Head and Neck Squamous Cell Carcinoma After Chemoradiotherapy Using Modern Radiation Techniques. JAMA Oncol 2017; 3:1487-1494. [PMID: 28542679 DOI: 10.1001/jamaoncol.2017.0973] [Citation(s) in RCA: 131] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance Even though 15% to 50% of patients with head and neck squamous cell carcinoma (HNSCC) experience recurrence, relatively little is known regarding patterns of treatment failure and postrecurrence outcomes after chemoradiotherapy using modern radiation techniques (intensity-modulated radiotherapy [IMRT]). Recurrence patterns are significantly affected by variations in the quality of radiotherapy, which may confound findings from multicenter trials. Objective To assess patterns of treatment failure and postrecurrence outcomes for patients with HNSCC treated with contemporary radiotherapy techniques. Design, Setting, and Participants This large single-institution cohort study reviewed the outcomes of 1000 consecutive patients with stage III to IVB oropharyngeal carcinoma (n = 703), laryngeal carcinoma (n = 126), or hypopharyngeal carcinoma (n = 46) treated with definitive IMRT with or without concurrent chemotherapy, as well as patients with oral cavity carcinoma (n = 125) treated with postoperative IMRT with or without concurrent systemic therapy, from December 1, 2001, to December 31, 2013, with a median follow-up of 65.1 months among surviving patients. Data analysis was performed from January 31, 2016, to February 17, 2017. Main Outcomes and Measures Patterns of treatment failure and overall survival following locoregional failure or distant metastasis. Results Among the 1000 patients (186 women and 814 men; mean [SD] age, 59.3 [10.8] years), there were no marginal or isolated out-of-radiation-field failures. Among subsites, the cumulative incidence of local failure was highest among patients with oral cavity carcinoma vs those with oropharyngeal carcinoma (hazard ratio, 5.2; 95% CI, 3.1-8.6; P < .001). Furthermore, patients with oral cavity carcinoma experienced significantly shorter survival following distant metastasis (hazard ratio, 3.66; 95% CI, 1.98-6.80; P < .001). Patients with oropharyngeal carcinoma positive for human papillomavirus or p16 lived longer after locoregional failure compared with patents with oropharyngeal carcinoma negative for human papillomavirus or p16 (median survival, 36.5 vs 13.6 months; P = .007) but not after distant metastasis. Salvage surgery was associated with improved overall survival following locoregional failure (hazard ratio, 0.51; 95% CI, 0.34-0.77; P = .001); oligometastatic disease (1 vs ≥2 lesions: hazard ratio, 0.32; 95% CI, 0.16-0.63; P = .001) was associated with improved overall survival following distant metastasis. Conclusions and Relevance Overall survival after recurrence of HNSCC is influenced by the HNSCC subsite and human papillomavirus or p16 status, as well surgical and systemic interventions. An oligometastatic phenotype characterizes patients with solitary metastasis after chemoradiotherapy. These findings have important implications for clinical trial designs for HNSCC in the recurrent and oligometastatic setting.
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Affiliation(s)
- Jonathan E Leeman
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jin-Gao Li
- Department of Radiation Oncology, Jiangxi Cancer Hospital, Nanchang, China
| | - Xin Pei
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Praveen Venigalla
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Zachary S Zumsteg
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Evangelia Katsoulakis
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Eitan Lupovitch
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sean M McBride
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Chiaojung J Tsai
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jay O Boyle
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Benjamin R Roman
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Luc G T Morris
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lara A Dunn
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Eric J Sherman
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nancy Y Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nadeem Riaz
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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Cracchiolo JR, Patel K, Migliacci JC, Morris LT, Ganly I, Roman BR, McBride SM, Tabar VS, Cohen MA. Factors associated with a primary surgical approach for sinonasal squamous cell carcinoma. J Surg Oncol 2017; 117:756-764. [PMID: 29193098 DOI: 10.1002/jso.24923] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 10/26/2017] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND OBJECTIVES Primary surgery is the preferred treatment of T1-T4a sinonasal squamous cell carcinoma (SNSCC). METHODS Patients with SNSCC in the National Cancer Data Base (NCDB) were analyzed. Factors that contributed to selecting primary surgical treatment were examined. Overall survival (OS) in surgical patients was analyzed. RESULTS Four-thousand seven hundred and seventy patients with SNSCC were included. In T1-T4a tumors, lymph node metastases, maxillary sinus location, and treatment at high-volume centers were associated with selecting primary surgery. When primary surgery was utilized, tumor factors and positive margin guided worse OS. Adjuvant therapy improved OS in positive margin resection and advanced T stage cases. CONCLUSIONS Tumor and non-tumor factors are associated with selecting surgery for the treatment of SNSCC. When surgery is selected, tumor factors drive OS. Negative margin resection should be the goal of a primary surgical approach. When a positive margin resection ensues, adjuvant therapy may improve OS.
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Affiliation(s)
- Jennifer R Cracchiolo
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Krupa Patel
- Weill Cornell Medical College, New York, New York
| | - Jocelyn C Migliacci
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Luc T Morris
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ian Ganly
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Benjamin R Roman
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sean M McBride
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Viviane S Tabar
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marc A Cohen
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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Abstract
PURPOSE OF REVIEW Thyroid cancer incidence and mortality trends have been identified as being consistent with overdiagnosis, and several recent efforts have been made to mitigate this problem. RECENT FINDINGS Major guidelines for thyroid nodule management recommend against general biopsy of nodules less than 1 cm in size. Data supporting the safety of active surveillance of low-risk thyroid cancers is now recognized. Tumors previously labeled as encapsulated follicular variant papillary thyroid cancers are now recommended to be called noninvasive follicular thyroid neoplasm with papillary-like nuclear features. SUMMARY Workup, diagnostic, and management of papillary thyroid cancer are changing rapidly to accommodate the recognition that many thyroid cancers are low risk and do not require aggressive, immediate intervention.
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Affiliation(s)
- Benjamin R. Roman
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Luc G. Morris
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Louise Davies
- VA Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, Vermont; Section of Otolaryngology, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire; The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
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Affiliation(s)
- Benjamin R Roman
- Head and Neck Division, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.,Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Annie Yang
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, New York
| | - James Masciale
- Department of Quality and Safety, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Deborah Korenstein
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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Roman BR, Baxi SS, Cracchiolo JR, Blackwell TJ, Pfister DG, McBride S, Ganly I, Shah JP, Patel SG, Morris LG, Cohen MA. Variation in use of postoperative chemoradiation following surgery for T1 and T2 oropharyngeal squamous cell carcinoma; National Cancer Database. J Surg Oncol 2017; 116:351-358. [PMID: 28570758 DOI: 10.1002/jso.24674] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 04/08/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND OBJECTIVES Primary surgical treatment of patients with early T-classification (T1-T2) oropharyngeal squamous cell carcinoma (OPSCC) has increased. We sought to determine how often these patients receive postoperative chemoradiation (CRT). METHODS Patients with T1-T2 OPSCC in the National Cancer Database who underwent primary surgery were evaluated for receipt of postoperative CRT. Postoperative CRT use was examined among patients with high risk factors (positive margins and/or extracapsular spread [ECS]), intermediate risk factors (negative margins, no ECS, and either pT3-4 and/or N2-N3), and no apparent risk factors. RESULTS Of 4833 patients with T1-T2 OPSCC who underwent primary surgery, 43% had high risk pathologic factors, of whom only 63% received postoperative CRT. Another 31% had no apparent risk factors, of whom 16% nonetheless received postoperative CRT. On multivariable analysis, in addition to tumor and demographic factors, patients treated at community hospitals were more likely to receive postoperative CRT (O.R. 1.41 C.I. 1.18-1.87, P = 0.001). CONCLUSIONS Variation in postoperative CRT use indicates a lack of consensus and/or knowledge about its benefits and indications. Usage of postoperative CRT regardless of pathologic risk factors suggests an area where future efforts at implementation of best practices may be targeted.
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Affiliation(s)
| | - Shrujal S Baxi
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | | | - Sean McBride
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ian Ganly
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jatin P Shah
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Snehal G Patel
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Luc G Morris
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marc A Cohen
- Memorial Sloan Kettering Cancer Center, New York, New York
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Abstract
BACKGROUND In 2016, encapsulated follicular variant of papillary thyroid carcinoma without invasion was renamed "noninvasive follicular thyroid neoplasm with papillary-like nuclear features" (NIFTP) in order to reduce overtreatment of this indolent tumor. However, many endocrinologists remain uneasy about managing large (≥4 cm) NIFTP conservatively without radioactive iodine (RAI) therapy. The objectives of this study are to characterize the clinicopathologic characteristics and outcome of large NIFTP in order to assist therapeutic decision making. METHODS The pathology databases of four tertiary hospitals were searched for large (≥4 cm) NIFTP. Cases with separate foci of carcinoma were excluded. Seventy-nine cases fulfilled the inclusion criteria. Among them, 56 (71%) had at least two years of clinical follow-up (FU), and 49 (62%) had four or more years of FU. The clinicopathologic characteristics were reviewed and documented by four endocrine pathologists. RESULTS The median size of the NIFTP was 4.5 cm (range 4.0-8.0 cm). The entire capsule was sampled in 50 (63%) tumors, while in the remaining 29 (37%) cases, it was submitted representatively, with a median of 2.1 blocks per centimeter of tumor examined. Large NIFTP had a female preponderance with a male:female ratio of 1:1.8, and presented at a median age of 49 years. There were no lymph node metastases at diagnosis in any of the patients, and none of the patients (n = 25) in whom nodal tissue was available for microscopic examination had positive findings. Twenty-six (33%) underwent thyroid lobectomy alone, and 37 (47%) did not receive RAI ablation. No recurrence was observed in the entire cohort, including all 32 patients with two or more years of FU who did not receive RAI therapy (median FU: 6.7 years). Among patients with four or more years of FU, all 25 individuals without RAI therapy did not recur, with a median FU of 11.2 years. Patients with a larger tumor size tended to receive postoperative RAI ablation (p = 0.001). CONCLUSIONS Similar to their small counterparts, large NIFTP appear to have an extremely low risk of recurrence (zero in this cohort), even when treated conservatively without RAI therapy. Surgical treatment alone, including lobectomy, appears to be adequate for large NIFTP.
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Affiliation(s)
- Bin Xu
- 1 Department of Pathology, Sunnybrook Health Sciences Centre , Toronto, Canada
| | - Giovanni Tallini
- 2 Department of Pathology, Bologna University School of Medicine , Bologna, Italy
| | | | - Benjamin R Roman
- 4 Department of Surgery, Memorial Sloan Kettering Cancer Center , New York, New York
| | - R Michael Tuttle
- 5 Department of Medicine, Memorial Sloan Kettering Cancer Center , New York, New York
| | - Ronald A Ghossein
- 6 Department of Pathology, Memorial Sloan Kettering Cancer Center , New York, New York
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Morris LGT, Chandramohan R, West L, Zehir A, Chakravarty D, Pfister DG, Wong RJ, Lee NY, Sherman EJ, Baxi SS, Ganly I, Singh B, Shah JP, Shaha AR, Boyle JO, Patel SG, Roman BR, Barker CA, McBride SM, Chan TA, Dogan S, Hyman DM, Berger MF, Solit DB, Riaz N, Ho AL. The Molecular Landscape of Recurrent and Metastatic Head and Neck Cancers: Insights From a Precision Oncology Sequencing Platform. JAMA Oncol 2017; 3:244-255. [PMID: 27442865 DOI: 10.1001/jamaoncol.2016.1790] [Citation(s) in RCA: 167] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Importance Recurrent and/or metastatic head and neck cancer is usually incurable. Implementation of precision oncology for these patients has been limited by incomplete understanding of the molecular alterations underlying advanced disease. At the same time, the molecular profiles of many rare head and neck cancer types are unknown. These significant gaps in knowledge need to be addressed to rationally devise new therapies. Objective To illuminate the distinct biology of recurrent and metastatic head and neck cancers and review implementation of precision oncology for patients with advanced disease. Design, Setting, and Participants After exclusions, 151 patients with advanced, treatment-resistant head and neck tumors, including squamous cell carcinoma (HNSCC), adenoid cystic carcinoma (ACC), and other salivary and cutaneous cancers, whose tumors were sequenced between January 2014 and July 2015 at Memorial Sloan Kettering were recruited. Next-generation sequencing of tumors as part of clinical care included high-depth (median 600×) exonic coverage of 410 cancer genes and whole-genome copy number analysis. Interventions Next-generation sequencing of tumors and matched normal DNA. Main Outcomes and Measures Feasibility, the frequency of actionable molecular alterations, the effect on decision making, and identification of alterations associated with recurrent and metastatic disease. Results Overall, 151 patients (95 men and 56 women; mean [range] age, 61.8 [17-100] years) were included in the study. Next-generation sequencing ultimately guided therapy in 21 of 151 patients (14%) (13 of 53 [25%] of patients with HNSCC) by refining diagnoses and matching patients to specific therapies, in some cases with dramatic responses on basket studies. Molecular alterations were potentially actionable in 28 of 135 patients (21%). The genetic profiles of recurrent and metastatic tumors were often distinct from primary tumors. Compared to primary human papillomavirus (HPV)-positive tumors, many recurrent and metastatic HPV-positive tumors exhibited a molecular profile more similar to HPV-negative tumors, including enriched frequencies of TP53 mutation (3 of 20 tumors [15%]), whole genome duplication (5 of 20 tumors [25%]), and 3p deletion (11 of 20 tumors [55%]). There were high rates of TERT promoter mutation in recurrent and metastatic HPV-negative HNSCC (13 of 30 tumors [43%]), cutaneous SCC (11 of 21 tumors [52%]), basal cell carcinoma (3 of 4 tumors [75%]), and ACC (5 of 36 tumors [14%]). Activating NOTCH1 mutations were enriched in metastatic ACCs (8 of 36 tumors [22%]). Conclusions and Relevance These findings reveal the molecular landscape of advanced disease and rare cancer subtypes, both predominant challenges in head and neck oncology. To understand the repertoire of targetable alterations in advanced cancers, it is necessary to sequence recurrent and metastatic tumors. These data are important first steps toward implementation of precision head and neck oncology.
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Affiliation(s)
- Luc G T Morris
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York2Head and Neck Surgical Oncology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Raghu Chandramohan
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lyndsay West
- Head and Neck Surgical Oncology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ahmet Zehir
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, New York4Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Debyani Chakravarty
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David G Pfister
- Head and Neck Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Richard J Wong
- Head and Neck Surgical Oncology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nancy Y Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Eric J Sherman
- Head and Neck Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Shrujal S Baxi
- Head and Neck Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ian Ganly
- Head and Neck Surgical Oncology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Bhuvanesh Singh
- Head and Neck Surgical Oncology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jatin P Shah
- Head and Neck Surgical Oncology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ashok R Shaha
- Head and Neck Surgical Oncology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jay O Boyle
- Head and Neck Surgical Oncology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Snehal G Patel
- Head and Neck Surgical Oncology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Benjamin R Roman
- Head and Neck Surgical Oncology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Christopher A Barker
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sean M McBride
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Timothy A Chan
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York6Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Snjezana Dogan
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David M Hyman
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael F Berger
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, New York4Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David B Solit
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nadeem Riaz
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alan L Ho
- Head and Neck Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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Cracchiolo JR, Roman BR, Kutler DI, Kuhel WI, Cohen MA. Adoption of transoral robotic surgery compared with other surgical modalities for treatment of oropharyngeal squamous cell carcinoma. J Surg Oncol 2016; 114:405-11. [PMID: 27392812 DOI: 10.1002/jso.24353] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 06/18/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Transoral robotic surgery (TORS) has increased for treatment of oropharyngeal squamous cell carcinoma (OPSCC). To define the adoption of TORS, we analyzed patterns of surgical treatment for OPSCC in the US. METHODS Cases of T1-T3 OPSCC treated with surgery between 2010 and 2013 from the National Cancer Database were queried. RESULTS Of 3,071 patients who underwent primary surgical management for T1-T3 OPSCC, 846 (28%) underwent TORS. On multivariable analysis, low tumor stage (T2 vs. T1: OR 0.75, CI 0.37-0.51, P < 0.0001; T3 vs. T1: O.R. 0.33, CI 0.28-0.38, P < 0.0001), treatment at an academic cancer center (O.R. 2.23, C.I. 1.29-3.88, P = 0.004) and treatment at a high volume hospital (34-155 cases vs. 1-4 cases: O.R. 9.07, C.I. 3.19-25.79, P < 0.0001) were associated with increased TORS approach. Significant geographic variation was observed, with high adoption in the Middle Atlantic. Positive margin rates were lower when TORS was performed at a high volume versus low volume hospital (8.2% vs. 16.7% respectively, P = 0.001). CONCLUSIONS Tumor and non-tumor factors are associated with TORS adoption. This analysis suggests uneven diffusion of this technology in the treatment of OPSCC. J. Surg. Oncol. 2016;114:405-411. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
| | | | | | | | - Marc A Cohen
- Memorial Sloan Kettering Cancer Center, New York, New York
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Leeman JE, Li JG, Venigalla P, Zumsteg ZS, McBride SM, Boyle J, Roman BR, Sherman EJ, Lee NY, Riaz N. Natural history following recurrence after definitive locoregional treatment in 1000+ cases of locally advanced head and neck squamous cell carcinoma. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.6062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Jonathan Eric Leeman
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jin-Gao Li
- Department of Radiation Oncology, Jiangxi Cancer Hospital, Nanchang, China
| | - Praveen Venigalla
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Jay Boyle
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Nancy Y. Lee
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nadeem Riaz
- Memorial Sloan Kettering Cancer Center, New York, NY
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Leeman JE, Li JG, Venigalla P, Zumsteg ZS, McBride SM, Boyle J, Roman BR, Sherman EJ, Lee NY, Riaz N. Comparison of outcomes following recurrence or metastasis in HPV+ and HPV- oropharyngeal carcinoma treated with definitive chemoradiation using IMRT. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.6063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Jonathan Eric Leeman
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jin-Gao Li
- Department of Radiation Oncology, Jiangxi Cancer Hospital, Nanchang, China
| | - Praveen Venigalla
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Jay Boyle
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Nancy Y. Lee
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nadeem Riaz
- Memorial Sloan Kettering Cancer Center, New York, NY
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Affiliation(s)
| | | | | | - Annie Yang
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY
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Sharma S, Bekelman J, Lin A, Lukens JN, Roman BR, Mitra N, Swisher-McClure S. Clinical impact of prolonged diagnosis to treatment interval (DTI) among patients with oropharyngeal squamous cell carcinoma. Oral Oncol 2016; 56:17-24. [PMID: 27086482 PMCID: PMC4968047 DOI: 10.1016/j.oraloncology.2016.02.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 02/03/2016] [Accepted: 02/18/2016] [Indexed: 11/23/2022]
Abstract
PURPOSE/OBJECTIVE(S) We examined practice patterns using the National Cancer Data Base (NCDB) to determine risk factors for prolonged diagnosis to treatment interval (DTI) and survival outcomes in patients receiving chemoradiation for oropharyngeal squamous cell carcinoma (OPSCC). METHODS AND MATERIALS We identified 6606 NCDB patients with Stage III-IV OPSCC receiving chemoradiation from 2003 to 2006. We determined risk factors for prolonged DTI (>30days) using univariate and multivariable logistic regression models. We examined overall survival (OS) using Kaplan Meier and multivariable Cox proportional hazards models. RESULTS 3586 (54.3%) patients had prolonged DTI. Race, IMRT, insurance status, and high volume facilities were significant risk factors for prolonged DTI. Patients with prolonged DTI had inferior OS compared to DTI⩽30days (Hazard Ratio (HR)=1.12, 95% CI 1.04-1.20, p=0.005). For every week increase in DTI there was a 2.2% (95% CI 1.1-3.3%, p<0.001) increase in risk of death. Patients receiving IMRT, treatment at academic, or high-volume facilities were more likely to experience prolonged DTI (High vs. Low volume: 61.5% vs. 51.8%, adjusted OR 1.38, 95% CI 1.21-1.58; Academic vs. Community: 59.5% vs. 50.6%, adjusted OR 1.26, 95% CI 1.13-1.42; non-IMRT vs. IMRT: 53.4% vs. 56.5%; adjusted OR 1.17, 95% CI 1.04-1.31). CONCLUSIONS Our results suggest that prolonged DTI has a significant impact on survival outcomes. We observed disparities in DTI by socioeconomic factors. However, facility level factors such as academic affiliation, high volume, and IMRT also increased risk of DTI. These findings should be considered in developing efficient pathways to mitigate adverse effects of prolonged DTI.
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Affiliation(s)
- Sonam Sharma
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, United States.
| | - Justin Bekelman
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, United States
| | - Alexander Lin
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, United States
| | - J Nicholas Lukens
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, United States
| | - Benjamin R Roman
- Memorial Sloan Kettering Cancer Center Department of Surgery, Head & Neck Service, United States
| | - Nandita Mitra
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, United States
| | - Samuel Swisher-McClure
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, United States
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Cracchiolo JR, Baxi SS, Morris LG, Ganly I, Patel SG, Cohen MA, Roman BR. Increase in primary surgical treatment of T1 and T2 oropharyngeal squamous cell carcinoma and rates of adverse pathologic features: National Cancer Data Base. Cancer 2016; 122:1523-32. [PMID: 26970050 DOI: 10.1002/cncr.29938] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 01/21/2016] [Accepted: 01/26/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND There has been increasing interest in the primary surgical treatment of patients with early T classification (T1-T2) oropharyngeal squamous cell carcinoma (OPSCC), with the stated goal of de-escalating or avoiding adjuvant treatment. Herein, the authors sought to determine the degree to which this interest has translated into changes in practice patterns, and the rates of adverse postoperative pathologic features. METHODS Patients with T1 to T2 OPSCC in the National Cancer Data Base who were treated from 2004 through 2013 were categorized as receiving primary surgical or primary radiation-based treatment. Trends in treatment selection and factors related to the selection of primary surgery were examined. The rates of adverse pathologic features including positive surgical margins, extracapsular spread (ECS), and advanced T and N classifications after surgery were analyzed. RESULTS Of 8768 patients with T1 to T2 OPSCC, 68% underwent primary surgical treatment, increasing from 56% in 2004 to 82% in 2013 (P<.0001). The highest versus lowest volume hospitals treated 78% versus 59% of patients with primary surgery (odds ratio, 2.23; 95% confidence interval, 1.55-3.22 [P<.0001]). Higher lymph node classification was found to be predictive of lower rates of primary surgery, but the majority of patients with clinical N2/N3 disease underwent primary surgery. Among patients treated with surgery, positive surgical margins were present in 24% and ECS in 25% of patients. The rate of positive surgical margins decreased over time (P<.0001) and was observed less often at high-volume centers (P<.0001). Among candidates for single-modality therapy (those with clinical T1-T2/N0-N1 disease), 33% had positive surgical margins and/or ECS and 47% had at least 1 adverse feature (T3-T4 disease, N2-N3 disease, positive surgical margins, and/or ECS). CONCLUSIONS Primary surgical treatment among patients with early T classification OPSCC has become more widespread. Cancer 2016;122:1523-32. © 2016 American Cancer Society.
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Affiliation(s)
- Jennifer R Cracchiolo
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Shrujal S Baxi
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Luc G Morris
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ian Ganly
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Snehal G Patel
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marc A Cohen
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Otolaryngology-Head and Neck Surgery, Joan and Sanford I. Weill Medical College of Cornell University, New York, New York
| | - Benjamin R Roman
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Wang LY, Roman BR, Palmer FL, Tuttle RM, Shaha AR, Shah JP, Patel SG, Ganly I. Effectiveness of routine ultrasonographic surveillance of patients with low-risk papillary carcinoma of the thyroid. Surgery 2015; 159:1390-5. [PMID: 26747227 DOI: 10.1016/j.surg.2015.11.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 11/11/2015] [Accepted: 11/11/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Over the last 15 years, there has been a change in clinical practice for the detection of recurrence in all patients with papillary thyroid cancer (PTC). In the past, recurrence was detected by clinical examination supplemented with fine-needle aspiration cytology; however, routine neck ultrasonography (US) and measurements of serum thyroglobulin were introduced for follow-up in 2000 and are now used widely for recurrence surveillance. The aim of this study was to describe the effectiveness of this changing trend in the use of routine surveillance ultrasonography for the detection of recurrence in low-risk PTC at a single institution. METHODS Patients undergoing total thyroidectomy for PTC between January 2000 and December 2010 were identified from an institutional database. Of these, 752 (43.1%) were categorized as low risk by the risk stratification of the American Thyroid Association and included for analysis. The number of US examinations per patient per year of follow-up was then determined. The number of recurrences and deaths from disease was recorded similarly. RESULTS The median age was 48 years (range, 16-83) and the median follow-up was 34 months (range, 1-148). Between 2003 and 2012, the number of US examinations per patient-year of follow-up increased by 5.3-fold. Over the same time period, 3 structural recurrences (clinically evident neck masses or nodes) were detected with no disease-related deaths. CONCLUSION At our institution, the annual rate of neck US examination increased by 5.3-fold per low-risk PTC patients between 2003 and 2012. Despite this increase, only 3 structural recurrences were detected. The routine use of neck US for surveillance of low-risk PTC patients requires review.
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Affiliation(s)
- Laura Y Wang
- Department of Surgery, Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Benjamin R Roman
- Department of Surgery, Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Frank L Palmer
- Department of Surgery, Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - R Michael Tuttle
- Department of Medicine, Endocrine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ashok R Shaha
- Department of Surgery, Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jatin P Shah
- Department of Surgery, Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Snehal G Patel
- Department of Surgery, Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ian Ganly
- Department of Surgery, Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, NY.
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Shkedy Y, Alkan U, Roman BR, Hilly O, Feinmesser R, Bachar G, Mizrachi A. Role of perioperative antibiotic treatment in parotid gland surgery. Head Neck 2015; 38 Suppl 1:E1876-80. [PMID: 26702565 DOI: 10.1002/hed.24339] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Revised: 06/21/2015] [Accepted: 10/04/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The value of routine prophylactic antibiotic treatment in parotid gland surgery remains undetermined. METHODS A retrospective analysis was conducted of all patients who underwent parotidectomy at a university-affiliated tertiary care center between 1992 and 2009. Patients with insufficient data, specifically regarding postoperative complications and antibiotic administration were excluded from the study cohort. RESULTS A total of 593 patients underwent parotidectomy during the study period. After exclusion, 464 patients were eligible for the study. Perioperative antibiotic treatment was given to 206 patients (45%). There was no difference in wound infection rates between patients who received perioperative antibiotic therapy and those who did not (p = .168). Multivariate analysis showed that female sex, neck dissection, and drain output >50 cc/24 hours were predictive of postoperative wound infection. CONCLUSION Routine prophylactic antibiotic treatment has no role in parotid gland surgery. Perioperative antibiotic treatment is recommended for patients undergoing extensive parotid gland surgery with neck dissection. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1876-E1880, 2016.
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Affiliation(s)
- Yotam Shkedy
- Department of Otolaryngology Head and Neck Surgery, Rabin Medical Center, Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Alkan
- Department of Otolaryngology Head and Neck Surgery, Rabin Medical Center, Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Benjamin R Roman
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ohad Hilly
- Department of Otolaryngology Head and Neck Surgery, Rabin Medical Center, Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Raphael Feinmesser
- Department of Otolaryngology Head and Neck Surgery, Rabin Medical Center, Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gideon Bachar
- Department of Otolaryngology Head and Neck Surgery, Rabin Medical Center, Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aviram Mizrachi
- Department of Otolaryngology Head and Neck Surgery, Rabin Medical Center, Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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Wang LY, Roman BR, Migliacci JC, Palmer FL, Tuttle RM, Shaha AR, Shah JP, Patel SG, Ganly I. Cost-effectiveness analysis of papillary thyroid cancer surveillance. Cancer 2015; 121:4132-40. [PMID: 26280253 DOI: 10.1002/cncr.29633] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 06/28/2015] [Accepted: 06/29/2015] [Indexed: 11/12/2022]
Abstract
BACKGROUND The recent overdiagnosis of subclinical, low-risk papillary thyroid cancer (PTC) coincides with a growing national interest in cost-effective health care practices. The aim of this study was to measure the relative cost-effectiveness of disease surveillance of low-risk PTC patients versus intermediate- and high-risk patients in accordance with American Thyroid Association risk categories. METHODS Two thousand nine hundred thirty-two patients who underwent thyroidectomy for differentiated thyroid cancer between 2000 and 2010 were identified from the institutional database; 1845 patients were excluded because they had non-PTC cancer, underwent less than total thyroidectomy, had a secondary cancer, or had <36 months of follow-up. In total, 1087 were included for analysis. The numbers of postoperative blood tests, imaging scans and biopsies, clinician office visits, and recurrence events were recorded for the first 36 months of follow-up. Costs of surveillance were determined with the Physician Fee Schedule and Clinical Lab Fee Schedule of the Centers for Medicare and Medicaid Services. RESULTS The median age was 44 years (range, 7-83 years). In the first 36 months after thyroidectomy, there were 3, 44, and 22 recurrences (0.8%, 7.8%, and 13.4%) in the low-, intermediate-, and high-risk categories, respectively. The cost of surveillance for each recurrence detected was US $147,819, US $22,434, and US $20,680, respectively. CONCLUSIONS The cost to detect a recurrence in a low-risk patient is more than 6 and 7 times greater than the cost for intermediate- and high-risk PTC patients. It is difficult to justify this allocation of resources to the surveillance of low-risk patients. Surveillance strategies for the low-risk group should, therefore, be restructured.
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Affiliation(s)
- Laura Y Wang
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Benjamin R Roman
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jocelyn C Migliacci
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Frank L Palmer
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - R Michael Tuttle
- Endocrine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ashok R Shaha
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jatin P Shah
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Snehal G Patel
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ian Ganly
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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Marti JL, Davies L, Haymart MR, Roman BR, Tuttle RM, Morris LG. Inappropriate Use of Radioactive Iodine for Low-Risk Papillary Thyroid Cancer Is Most Common in Regions with Poor Access to Healthcare. Thyroid 2015; 25:865-6. [PMID: 25963001 PMCID: PMC4948217 DOI: 10.1089/thy.2015.0112] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Jennifer L. Marti
- Division of Endocrine Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Louise Davies
- VA Outcomes Group, Veterans Affairs Medical Center, White River Junction, Vermont
| | - Megan R. Haymart
- Division of Endocrinology, Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Benjamin R. Roman
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - R. Michael Tuttle
- Endocrinology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Luc G.T. Morris
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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Abstract
In the USA, increasing attention is being paid to adopting a value-based framework for measuring and ultimately improving health care delivery. Value is defined as the benefit achieved relative to costs. The numerator of the value equation includes quality of care and outcomes achieved. The denominator includes costs, both financial costs and harms of treatment. Herein, we describe these elements of value as they pertain to head and neck cancer. A particular focus is to identify areas of the value equation where physicians have some control. We examine quality in each of three dimensions: structure, process, and outcomes. We also adopt Porter's three-tiered hierarchy of outcomes model, with specific outcomes relevant to patients with head and neck and thyroid cancer. Finally, we review issues related to costs and harms. We believe these findings can serve as a framework for further efforts to drive value-based delivery of head and neck cancer care.
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Affiliation(s)
- Benjamin R Roman
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA,
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Affiliation(s)
- Benjamin R Roman
- From the Robert Wood Johnson Foundation Clinical Scholars Program, University of Pennsylvania, Philadelphia; and the Department of Surgery, Memorial Sloan Kettering Cancer Center, New York
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Roman BR, Patel SG, Wang MB, Pou AM, Holsinger FC, Myssiorek D, Goldenberg D, Swisher-McClure S, Lin A, Shah JP, Shea JA. Guideline Familiarity Predicts Variation in Self-Reported Use of Routine Surveillance PET/CT by Physicians Who Treat Head and Neck Cancer. J Natl Compr Canc Netw 2015; 13:69-77. [DOI: 10.6004/jnccn.2015.0010] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Roman BR, Asch DA. The challenge of deadopting low-value care. Ann Intern Med 2014; 161:843. [PMID: 25437422 DOI: 10.7326/l14-5031-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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