The Impact of Medicaid Expansion on Head and Neck Malignancies Presentation and Survival

OBJECTIVE

Under the Affordable Care Act (ACA), Medicaid expansion became effective in states that have adopted it. We aim to examine its impact on head and neck cancers.

METHODS

A retrospective study that utilizes the Surveillance, Epidemiology, and End Results database, 2010-2016. Study population included patients with head and neck squamous cell carcinoma (HNSCC), differentiated thyroid carcinoma, and head and neck cutaneous melanoma. The objective is to examine disease-specific survival before and after Medicaid expansion.

RESULTS

In states that adopted Medicaid expansion, the ratio of Medicaid: uninsured patients increased from 3:1 to 9:1 (p < 0.001). In states that did not adopt Medicaid expansion, the ratio increased from 1:1 to 2:1 (p < 0.001), making the increase in Medicaid coverage in states that adopted the expansion significantly higher (p < 0.001). Patients diagnosed with HNSCC before the expansion had worse survival (hazard ratio [HR]: 1.24, 95% confidence interval: 1.11, 1.39, p < 0.001) in states that adopted Medicaid expansion.

CONCLUSIONS

Early data indicate that implementation of ACA improved disease-specific survival of patients with HNSCC.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:1409-1414, 2023.

Factors Associated With the Choice of Radiation Therapy Treatment Facility in Head and Neck Cancer

OBJECTIVE

To analyze the clinicodemographic characteristics and treatment outcomes of patients receiving postoperative radiation therapy (PORT) at a different treatment facility rather than the initial surgical facility for head and neck cancer.

STUDY DESIGN

Retrospective cohort analysis.

METHODS

Utilizing the National Cancer Data Base, 2004 to 2015, patients with a diagnosis of oral cavity/oropharyngeal, hypopharyngeal, and laryngeal squamous cell carcinoma were studied. Multivariate analysis was completed with multivariate regression and Cox proportional hazard model, and survival outcomes were examined using Kaplan-Meier analysis.

RESULTS

A total of 15,181 patients who had surgery for a head and neck cancer at an academic/research center were included in the study population. Of the study population, 4,890 (32.2%) patients completed PORT at a different treatment facility. Treatment at a different facility was more common among patients who were ≥65 years old, white, Medicare recipients, those with a greater distance between residence and surgical treatment facility, and with lower income within area of residence (each P < .05). Overall survival was worse in patients completing PORT at a different treatment facility versus at the institution where surgery was completed (61.9% vs. 66.4%; P = .002).

CONCLUSIONS

PORT at a different facility was more common in older individuals, Medicare recipients, those with greater distance to travel, and lower-income individuals. Completing PORT outside the hospital where surgery was performed was associated with inferior survival outcomes among head and neck cancer patients.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:1019-1025, 2021.

Prevalence and Risk of Metastatic Thyroid Cancers and Management Outcomes: A National Perspective

OBJECTIVES

Examine the prevalence and risk of metastasis in thyroid cancers and management outcomes.

STUDY DESIGN

Retrospective analysis of the National Cancer Database, 2004-2014.

METHODS

The study population included adult (≥ 18 years) patients with thyroid cancer. Analysis included multivariate logistic regression and Cox hazard ratio modeling.

RESULTS

A total of 152,979 patients were included. Distant metastasis was reported in 1,867 (1.22%) patients. The distribution of metastatic cases based on pathology and tumor size were as follows in descending order: papillary thyroid carcinoma (PTC) 1 to 4 cm (30.53%), PTC > 4 cm (19.34%), undifferentiated (UTC) > 4 cm (14.14%), PTC < 1 cm (8.46%), follicular thyroid carcinoma (FTC) > 4 cm (7.28%), FTC 1 to 4 cm (5.52%), medullary thyroid cancer (MTC) ≤ 4 cm (3.96%), MTC > 4 cm (3.91%), UTC ≤ 4 cm (3.32%), Hürthle (HCC ) > 4 cm (2.09%), and HCC 1 to 4 cm (1.45%). Significant predictors of distant metastasis, while controlling for tumor pathology and size, included older age, male gender, non-White minorities, presence of multiple comorbidities, minimal, gross extrathyroidal extension (ETE), lymphovascular invasion (LVI), and concomitant central and lateral lymph node metastasis (LNM) (P < .05 each). The risk of distant metastasis in the absence of nodal metastasis, ETE, and LVI was highest for FTC > 4 cm.

CONCLUSION

Although the risk of metastasis in well-differentiated thyroid carcinoma (WDTC) is low, the prevalence of metastatic thyroid cancer is highest in WDTC population because it is the most common type of thyroid cancer. Certain pathological features, including minimal ETE and central LNM, are associated with a higher prevalence of metastatic disease.

LEVEL OF EVIDENCE

NA Laryngoscope, 131:237-244, 2021.

Analysis of patients who decline treatment for squamous cell carcinoma of the head and neck: National perspective

BACKGROUND

To analyze demographic and socioeconomic factors that influence patients' decisions to decline treatment for head and neck squamous cell carcinoma (SCC).

METHODS

Retrospective cohort analysis utilizing the National Cancer Data Base of patients with oral cavity/oropharyngeal, hypopharyngeal, and laryngeal SCC.

RESULTS

A total of 166 204 patients were included, of which 689 patients declined all treatment. Among early-stage (I-II) patients, Charlson/Deyo score ≥ 3, hypopharyngeal cancer, and no insurance or Medicare were more likely to decline all recommended treatment (P < .05). Among advanced stage (III-IV) patients, females (odds ratio 1.27, 95% confidence interval 1.05-1.53; P = .013), Charlson Deyo score ≥ 1, non-oral cavity cancers, and closer distance between patient's area of residence from treating facility were more likely to decline all treatment (P < .05).

CONCLUSIONS

Female patients and patients with no insurance, Medicare, or Medicaid are more likely to decline recommended treatment for SCC of the head and neck. Educational status is not predictive of declining treatment.

Clonal analysis of meningococci during a 26 year period prior to the introduction of meningococcal serogroup C vaccines

Meningococcal disease remains a public health burden in the UK and elsewhere. Invasive Neisseria meningitidis, isolated in Scotland between 1972 and 1998, were characterised retrospectively to examine the serogroup and clonal structure of the circulating population. 2607 isolates causing invasive disease were available for serogroup and MLST analysis whilst 2517 were available for multilocus sequence typing (MLST) analysis only. Serogroup distribution changed from year to year but serogroups B and C were dominant throughout. Serogroup B was dominant throughout the 1970s and early 1980s until serogroup C became dominant during the mid-1980s. The increase in serogroup C was not associated with one particular sequence type (ST) but was associated with a number of STs, including ST-8, ST-11, ST-206 and ST-334. This is in contrast to the increase in serogroup C disease seen in the 1990s that was due to expansion of the ST-11 clonal complex. While there was considerable diversity among the isolates (309 different STs among the 2607 isolates), a large proportion of isolates (59.9%) were associated with only 10 STs. These data highlight meningococcal diversity over time and the need for ongoing surveillance during the introduction of new meningococcal vaccines.

Abstract 3235: Identification of the potential inhibitors of DNA polymerase kappa

Background and Purpose:

The therapeutic effect of many anticancer agents is due to induction of replication-blocking DNA lesions. Human DNA polymerase kappa (pol κ) is a trans-lesion synthesis polymerase that can catalyze direct replication past minor groove lesions, such as the one induced by mitomycin C. Pol κ has been found to be upregulated in ∼70% of gliomas and its upregulation associated with poorer prognosis in glioma patients. Therefore, small molecule inhibitors of pol κ in combination with chemotherapy may be useful in the treatment of cancer with upregulated pol κ expression.

Methodology:

Lead hits were initially identified from a screen of a library of ∼400,000 compounds at 5 different concentrations, using a strand-displacement DNA synthesis approach. From several thousand potential hits, these were systematically triaged, with 335 potential inhibitors of pol κ identified for further analyses.

A direct, gel-based primer extension assay was used to test for inhibitory effects of these 335 bioactive compounds. In this assay, pol κ was preincubated with individual compounds, and added to 32P-labeled DNA substrate to initiate primer extensions. The reactions were incubated for 30 minutes at room temperature and terminated by the addition of a DNA-denaturing solution. The products were then separated through a 15% acrylamide gel and visualized with a PhosphorImager screen. Compounds that significantly inhibited the polymerization activity of pol κ were further tested for the ability to intercalate into DNA by incubation with double-stranded DNA for 15 minutes at room temperature, followed by separation through a 1% agarose gel. DNA was stained with ethidium bromide and visualized by Alpha Innotech ChemiImager.

Results:

Through a series of rigorous triaging procedures, this investigation identified a total of 42 small molecule inhibitors of pol κ with the estimated potencies being the low micromolar range or less. All 42 compounds were confirmed not to exhibit their inhibitory effects through DNA intercalation. These compounds need to be further tested with other members of the Y family polymerase to ensure their specificity to pol κ and determine if they are amenable to medicinal chemistry.

Conclusion:

Further investigation and characterization of these compounds will allow for a more efficient therapeutic approach in patients who have upregulated pol κ receiving chemotherapy.

Citation Format: Christopher B. Sullivan, Irina G. Minko, Kinrin Yamanaka, Amanda K. McCullough, Stephen Lloyd. Identification of the potential inhibitors of DNA polymerase kappa. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 3235. doi:10.1158/1538-7445.AM2014-3235

Multilocus sequence typing: Data analysis in clinical microbiology and public health

Numerous computer-based statistical packages have been developed in recent years and it has become easier to analyze nucleotide sequence data and gather subsequent information that would not normally be available. Multilocus sequence typing (MLST) is used for characterizing isolates of bacterial and fungal species and uses nucleotide sequences of internal fragments of housekeeping genes. This method is finding a place in clinical microbiology and public health by providing data for epidemiological surveillance and development of vaccine policy. It adds greatly to our knowledge of the genetic variation that can occur within a species and has therefore been used for studies of population biology. Analysis requires the detailed interpretation of nucleotide sequence data obtained from housekeeping and nonhousekeeping genes. This is due to the amount of data generated from nucleotide sequencing and the information generated from an array of analytical tools improves our understanding of bacterial pathogens. This can benefit public health interventions and the development of enhanced therapies and vaccines. This review concentrates on the analytical tools used in MLST and their use in the clinical microbiology and public health fields.

Automation of MLST Using Third-Generation Liquid-Handling Technology

The molecular characterization of bacterial pathogens of clinical significance is increasingly important. Methods, such as multilocus sequence typing (MLST), allow bacterial strains to be characterized during case clusters, for antibiotic-resistant strains to be monitored, and for the impact of new vaccines to be assessed. Our laboratory performs MLST on Neisseria meningitidis, Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus. We have developed high-throughput automated methods to allow MLST to be performed in a time scale useful in a clinical setting. Here we describe the automation of MLST on a third-generation liquid-handling robot.

Prenatal gender preference of mothers of feminine and masculine boys: relation to sibling sex composition and birth order

A mother's (prenatal) wish for a girl has, at times, been implicated as an etiological factor for boyhood femininity or its DSM-III-R diagnostic equivalent, the Gender Identity Disorder of Childhood. In one sample of 52 feminine and 52 nonclinical control boys from Los Angeles, the proportion of mothers who recalled a wish for a girl during the pregnancy did not differ significantly between groups (26.9% vs. 19.2%, respectively); however, in both groups, the maternal wish for a girl was significantly more common in sibships in which all of the proband's older siblings were male. In a second sample of 103 feminine boys from Toronto, the maternal wish for a girl was significantly higher than that found in the Los Angeles sample (43.7% vs. 26.9%), but a control group was not available; as in the Los Angeles sample, the maternal wish for a girl was significantly more common in sibships in which all of the proband's older siblings were male. Implications of these findings for further study of maternal influences on boyhood femininity are discussed.

A gender identity interview for children

A 12-item gender identity interview schedule was administered to 85 children referred for concerns regarding their gender identity development and 98 clinical and normal control children. Factor analysis identified two factors, which were labeled Affective Gender Confusion and Cognitive Gender Confusion. The gender-referred group gave significantly more deviant responses than did the controls on both factors. Results were discussed with regard to several diagnostic and assessment issues pertaining to children with gender identity disorder.

Employer-sponsored health insurance in 1991

Since 1987 the Health Insurance Association of America (HIAA) has documented features of employer-sponsored group health insurance through detailed surveys of over 3,000 U.S. firms. The 1991 employer survey reveals several noteworthy developments. The percentage of small firms (100 employees and under) that offer health insurance to their employees has declined since 1989. With a significant increase in health maintenance organization (HMO) market share, more than half (54 percent) of employees in employer-sponsored plans are now covered by managed care plans. Premiums increased 14 percent in 1991, showing identical increases for conventional, HMO, and preferred provider organization (PPO) plans. The percentage of employees in self-insured health plans decreased from 45 percent in 1990 to 40 percent in 1991.

Multiple sclerosis and age at exposure to childhood diseases and animals: Cases and their friends

Eighty-eight multiple sclerosis case-friend pairs were interviewed by telephone to elicit information about early-life exposures. Available mothers were also interviewed. Risk factors included childhood diseases, exposures to animals, and residence. We found a positive association between MS and having measles at a later than usual age. Analysis of the data in the literature showed that this was the third statistically significant association between MS and later age for measles. This is consistent with the hypothesis that the pathogenesis of MS includes an age-dependent host response to measles.

Measles antibody titers in multiple sclerosis patients and HLA-matched and unmatched siblings

Antibody titers to measles, cytomegalovirus, and herpesviruses 1 and 2 were compared for siblings of multiple sclerosis (MS) patients sharing two, one, and no histocompatibility antigen haplotypes with the case. Significant differences were observed only for measles. Titers were significantly lower in siblings sharing no haplotypes with the case. Within case-sibling pairs, the presence of HLA-A-A3 and/or B7 affected measles antibody titers more than the presence of MS. These findings suggest that the immune response to measles in these sibships is influenced by the presence of HLA-A-A3 and/or B7 as well as another familial factor.