Determining the impact of COVID-19 pandemic on adjuvant therapy for oral cancer - A matched-pair analysis

Background

The ongoing coronavirus disease 2019 (COVID-19) pandemic has hard-pressed the health care systems beyond their capabilities, causing a lack of appropriate cancer treatment delivery. The aim of this study was to assess the impact of pandemic-related restrictions on adjuvant therapy delivery for oral cancer patients during these demanding times.

Materials and Methods

Oral cancer patients who were operated on between February and July 2020 and scheduled to receive prescribed adjuvant therapy during the COVID-19-related restrictions (Group I) were included in the study. The data were matched for the length of hospital stay and type of prescribed adjuvant therapy, with a set of patients who were similarly managed 6 months preceding the restrictions (Group II). Demographic and treatment-specific details, including inconveniences faced in procuring prescribed treatment, were obtained. Factors associated with delay in receiving adjuvant therapy were compared using regression models.

Results

A total of 116 oral cancer patients were considered for analysis, comprising 69% (n = 80) adjuvant radiotherapy alone and 31% (n = 36) concurrent chemoradiotherapy. The mean hospital stay was 13 days. In Group I, 29.3% (n = 17) of patients were not able to receive any form of their prescribed adjuvant therapy at all, which was 2.43 times higher than Group II (P = 0.038). None of the disease-related factors significantly predicted delay in receiving adjuvant therapy. Of the delay, 76.47% (n = 13) was present during the initial part of the restrictions, with the most common reason being unavailability of appointments (47.1%, n = 8), followed by inability to reach treatment centers (23.5%, n = 4) and redeem reimbursements (23.5%, n = 4). The number of patients who were delayed the start of radiotherapy beyond 8 weeks after surgery was double in Group I (n = 29) than in Group II (n = 15; P = 0.012).

Conclusions

This study highlights a small part of the rippling effect the COVID-19 restrictions have on oral cancer management and pragmatic actions may be needed by policymakers to deal with such challenges.

National Cancer Grid Virtual Tumor Boards of Head and Neck Cancers: An Innovative Approach to Multidisciplinary Care

PURPOSE

Virtual tumor board (VTB) via videoconference facility involving multiple specialists in the decision making for various tumors is well accepted, especially in high-income countries. Information on virtual tumor boards for head and neck cancers especially from low- and middle-income countries is sparse. In this study, we have audited the findings of the National Cancer Grid VTBs performed for head and neck cancers.

METHODS

All patients discussed in the head and neck VTBs at our center between December 2016 and February 2022 were included in the study. Details such as the type of institute sending patients for discussion, its location, subsites within the head and neck region, histopathology, treatment setting or question for the VTB, and availability of guidelines for such patient scenarios were assessed. Also, a survey was sent to assess the usefulness of the VTBs.

RESULTS

A total of 208 patients were discussed in 54 VTB sessions. The most common head and neck sites discussed in the VTBs were the oral cavity (n = 64, 30.7%) followed by skull base/nose and paranasal sinuses/eyelid-orbit tumors (n = 49, 23.5%). Nonsquamous cell carcinoma was the most common histopathology discussed; recurrent cancers/residual diseases were the most common treatment settings (n = 134, 64.4%) for which there were no existing guidelines. Survey results showed that most VTB decisions were implementable, and respondents felt that VTBs were a useful educational tool as well.

CONCLUSION

Our study affirms the feasibility of VTBs in low- and middle-income countries' health care systems for managing uncommon malignancies and clinical situations, which act as an important educational platform.

Population-level Outcomes of Early Thyroid Cancers: A Need to Revisit Current Practice

BACKGROUND

Early thyroid cancers have excellent long-term outcomes, yet the word "cancer" draws unnecessary apprehension. This study aimed to define when the recommendations for observation and surveillance may be extended to early thyroid cancers at the population level.

METHODS

Non-metastasized thyroid cancers ≤40 mm diameter were identified from the 1975-2016 Surveillance, Epidemiology and End Results (SEER) database. Causes of death were compared across demographic data. Disease-specific outcomes were compared to the age-adjusted healthy United States (US) population. Survival estimates were computed using Kaplan-Meier and compared using the Cox proportional hazard model. Dynamic benchmarks impacting disease-specific overall survival were determined by decision tree modeling and tested by the Cox model.

RESULTS

Of the 28,728 thyroid cancers included in this study, 98.4% underwent some form of thyroid-specific treatment and were followed for a maximum of 10.9 years. This group had a 4.3% mortality rate at the end of follow-up (10.9 years maximum), with 13 times more deaths attributed to competing risks rather than thyroid cancer (stage T1a versus stage T1b, P=1.000; T1 versus T2, P<0.001). Among the untreated T1a or T1b tumors, the risk of disease-specific death was 21 times lower than death due to other causes. There was no significant difference between T1a and T1b tumors nor across sex. The age-adjusted risk of death for the healthy US population was higher than for the population with thyroid cancer. Dynamic categorization demonstrated worsening outcomes up to 73 years, uninfluenced by sex or tumor size. For patients over 73 years of age, only tumors >26 mm impacted outcomes.

CONCLUSION

Based on the current data, T1a and T1b nodules have similar survival outcomes and are not significantly impacted even when left untreated. Multi-institutional prospective studies are needed to confirm these findings so that current observation and surveillance recommendations can be extended to certain T1 thyroid nodules.

Critical Review of the Current Evidence on Sentinel Node Biopsy in Oral Cancer

PURPOSE OF REVIEW

With contemporary surgery of the cN0 neck in early oral cancer becoming more selective, sentinel node biopsy (SNB) is gaining popularity as a possible alternate option to elective neck dissection (END). This review attempts to critically appraise the current evidence and highlight pertinent arguments for the use of SNB in early oral cancers.

RECENT FINDINGS

Based on the recent randomized trials, it is imperative to perform an END at the time of primary resection in cN0 oral cancers. The much criticized false negative rate of SNB can be argued to be equal to the regional failure rate after END for pN0 necks, possibly making a case for SNB due to the reduction in number of neck dissections. There still lies ambiguity on the technique, protocols, and benefit of SNB over END. The role of extended histopathological techniques and the implications of micrometastasis and isolated tumor cells for treatment intensification remain questionable. Currently, SNB is an intermediary between routine imaging and END that needs to evolve before it can become a practice changing alternative to END itself. More efforts are needed in standardizing the protocols for SNB.

Surgical Management of Parapharyngeal Tumors: Our Experience

Context Tumors of parapharyngeal space (PPS) are rare and histologically diverse. The management of these tumors requires diligent assessment and planning with due consideration of various anatomical and pathological aspects of the lesion.

Aims This retrospective study aims to present our experiences in the clinical and pathological aspects of PPS tumors with a critical evaluation of management.

Settings and Design Retrospective analytical study.

Methods and Material The electronic medical records of 60 cases of PPS tumors, managed surgically from 2007 to 2017, were reviewed and analyzed using SPSS 22 software. The mean follow-up duration was 44 months.

Results The mean age was 45 years with a male-to-female ratio of 1.7 (38:22). The majority of the tumors were benign (71.7%) and the most common presentation being upper neck mass or oropharyngeal mass. Histologically, neurogenic tumors were most common (43.3%) PPS tumors, followed by tumors of salivary gland origin. Magnetic resonance imaging was used as a diagnostic modality in 70% of cases, and computed tomography scan and positron emission tomography/CT were used in 26.7 and 3.3% of cases, respectively. In our study, the diagnostic accuracy of fine-needle aspiration cytology was 71% for benign and 47% for malignant lesions. The most common approach for surgery used was transcervical (72%).

Conclusion The study reveals that cranial nerve palsy is the most common complication associated with PPS tumors. Completely resected, malignant tumors originating within PPS have a good prognosis, as compared with tumors extending or metastasized to PPS.

Comparative study of functional outcomes following surgical treatment of early tongue cancer

BACKGROUND

Speech and swallowing are important outcomes following resection in early tongue cancers.

AIM

This prospective study was performed to compare speech, swallowing, and tongue mobility between secondary intention healing (SH) and primary closure (PC) in glossectomy for early tongue cancers.

METHODS

Forty T1/T2 tongue cancers underwent wide excision followed by either PC or SH. Operative time, tube feeding, complications, speech, and swallowing were assessed in both groups at 1, 6, 12, and 24 weeks after surgery.

RESULTS

SH showed better tongue mobility, less errors in continuous speech, and articulation as compared to PC at all-time points. Operative time, bleeding, duration of tube feeding, and pain scores were comparable in both groups. There were no major complications except minor secondary hemorrhage in one patient with SH.

CONCLUSION

Following early tongue cancer resection, secondary intention healing can result in better speech and tongue mobility with minimum morbidity.

Head and neck cancers in India

Head and neck cancers constitute a third of the cancer burden in India. These cancers have unique patient characteristics, presentation, and etiological differences from those in the West. Socioeconomic constraints, large patient population, scarcity of trained health workers, and inadequate infrastructure are major challenges faced in the management of these cancers. Despite these constraints, patients are treated with evidence based guidelines that are tailored to the local scenario.

The Indian scenario of head and neck oncology - Challenging the dogmas

Head and neck cancers (HNCs) are the most common malignancies worldwide. Asian populations bear major burden of this disease, with certain unique characteristics. Although significant research in HNCs is ongoing globally, many clinical issues still remain unanswered. We performed a literature search to find noteworthy Indian studies that changed practice of HNC as well as to look for areas for further research in this field. Many randomized controlled trials as well as large patient series are reported in the field of radiotherapy, chemotherapy, and surgical management of HNC. Still, many areas such as palliative therapy, targeted agents, and newer chemotherapeutic agents remain unexplored. Planned collaborative research is need of the hour to provide more evidenced based.