A cost-utility analysis comparing CT surveillance, PET-CT surveillance, and planned postradiation neck dissection for advanced nodal HPV-positive oropharyngeal cancer

BACKGROUND

The cost utility of image-guided surveillance using computed tomography (CT) and positron emission tomography (PET)-CT to planned postradiation neck dissection (PRND) was compared for the management of advanced nodal human papillomavirus-positive oropharyngeal cancer following chemoradiation.

METHODS

A universal payer perspective was adopted. A Markov model was designed to simulate four treatment approaches with 3-month cycles over a lifetime horizon: 1) CT surveillance, 2) standard PET-CT surveillance, 3) a novel PET-CT approach with repeat PET at 6 months postchemoradiation for equivocal responders, and 4) PRND. Parameters including probabilities of CT nodal progression/resolution, PET avidity, recurrence, and survival were obtained from the literature. Costs were reported in 2019 Canadian dollars and utilities were expressed in quality-adjusted life years (QALYs). Deterministic and probabilistic sensitivity analyses were performed to evaluate model uncertainty.

RESULTS

PET-CT surveillance dominated CT surveillance and PRND in the base case scenario, and the novel PET-CT approach was the most cost-effective strategy across a wide range of variables tested in one-way sensitivity analysis. On probabilistic sensitivity analysis, novel PET-CT surveillance was the most cost-effective strategy in 78.1% of model iterations at a willingness-to-pay of $50,000/QALYs. Novel PET-CT surveillance resulted in a 49% lower rate of neck dissection compared with traditional PET-CT, and yielded an incremental benefit of 0.14 QALYs with average cost savings of $1309.

CONCLUSIONS

Image-guided surveillance including PET-CT and CT are more cost effective than PRND. The novel PET-CT approach with repeat PET for equivocal responders was the dominant strategy and yielded both higher benefit and lower costs compared with standard PET-CT surveillance.

Concurrent cisplatin or cetuximab with radiotherapy for HPV-positive oropharyngeal cancer: Medical resource use, costs, and quality-adjusted survival from the De-ESCALaTE HPV trial

BACKGROUND

The De-ESCALaTE HPV trial confirmed the dominance of cisplatin over cetuximab for tumour control in patients with human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC). Here, we present the analysis of health-related quality of life (HRQoL), resource use, and health care costs in the trial, as well as complete 2-year survival and recurrence.

MATERIALS AND METHODS

Resource use and HRQoL data were collected at intervals from the baseline to 24 months post treatment (PT). Health care costs were estimated using UK-based unit costs. Missing data were imputed. Differences in mean EQ-5D-5L utility index and adjusted cumulative quality-adjusted life years (QALYs) were compared using the Wilcoxon signed-rank test and linear regression, respectively. Mean resource usage and costs were compared through two-sample t-tests.

RESULTS

334 patients were randomised to cisplatin (n = 166) or cetuximab (n = 168). Two-year overall survival (97·5% vs 90·0%, HR: 3.268 [95% CI 1·451 to 7·359], p = 0·0251) and recurrence rates (6·4% vs 16·0%, HR: 2·67 [1·38 to 5·15]; p = 0·0024) favoured cisplatin. No significant differences in EQ-5D-5L utility scores were detected at any time point. At 24 months PT, mean difference was 0·107 QALYs in favour of cisplatin (95% CI: 0·186 to 0·029, p = 0·007) driven by the mortality difference. Health care costs were similar across all categories except the procurement cost and delivery of the systemic agent, with cetuximab significantly more expensive than cisplatin (£7779 [P < 0.001]). Consequently, total costs at 24 months PT averaged £13517 (SE: £345) per patient for cisplatin and £21064 (SE: £400) for cetuximab (mean difference £7547 [95% CI: £6512 to £8582]).

CONCLUSIONS

Cisplatin chemoradiotherapy provided more QALYs and was less costly than cetuximab bioradiotherapy, remaining standard of care for nonsurgical treatment of HPV-positive OPSCC.

The risk and interval to malignancy of patients with laryngeal dysplasia; a systematic review of case series and meta-analysis

BACKGROUND

Laryngeal dysplasia is a pre-malignant condition with wide variability in rates of malignant transformation reported in the literature. The management and follow-up strategies of these lesions vary widely.

OBJECTIVES

To assess the risk of and interval to malignant transformation in patients with laryngeal dysplasia, the effect of different treatment modalities on malignant transformation and the effects that risk factors such as smoking, excessive alcohol intake and histological grade may have on this.

TYPE OF REVIEW

Systematic of observational studies with attempted meta-analysis.

SEARCH STRATEGY

A structured search of Medline (1966 to January 2010), EMBASE (1980 to January 2010), CINAHL (1981 to January 2010) and Cochrane databases (CENTRAL, Cochrane Library, 1995 to January 2010).

RESULTS

Nine hundred and forty cases from nine studies were included in the analysis. Overall malignant transformation rate was 14% (confidence interval 8, 22) and mean time to malignant transformation was 5.8 years. The malignant transformation rate is higher with increased severity of dysplasia grade - severe/CIS 30.4%versus mild/moderate 10.6% (P < 0.0002). Treatment modality did not show significant effects.

CONCLUSIONS

Laryngeal dysplasia carries a significant risk of malignant transformation. This risk triples with increasing severity of dysplasia. Transformation often occurs late and is not related to the grade of dysplasia. There is little evidence, therefore, to support the early discharge of patients with mild/moderate dysplasia, which is practised by some clinicians.

Postoperative hypocalcemia--the difference a definition makes

BACKGROUND

Review of the literature reveals considerable variability in the definitions and criteria used for reporting postoperative hypocalcemia. The lack of standardization prevents a meaningful comparison of results and performance locally with the national standard. It also prevents the pooling of data when performing meta-analysis, and may affect the comparison of research results.

METHODS

A literature review was performed to identify the different definitions used to define hypocalcemia in post-thyroidectomy patients. We analyzed the incidence of hypocalcemia in the same cohort of 202 post thyroidectomy patients using these definitions.

RESULTS

The reported hypocalcemia rates varied from 0% to 46% for the same cohort depending on the definition of hypocalcemia used. Only one-third of biochemically hypocalcemic patients requested calcium supplementation.

CONCLUSION

This study demonstrates the need for more uniformity and standardization in the definitions used for reporting hypocalcemia rates.

A second national survey of health-related quality of life questionnaires in head and neck oncology

INTRODUCTION

With an increasing number of publications on health-related quality of life (HRQOL) following head and neck cancer, the recognition of a number of well-validated questionnaires and a growing awareness of the potential role of HRQOL in practice, it was our aim to repeat the survey of 2002 reported in the Annals to see how practice changed.

MATERIALS AND METHODS

A postal survey of members of the British Association of Head and Neck Oncologists was undertaken in January 2006 with reminders sent in February, March and April.

RESULTS

The response was 50% (106 of 210) of which 53% were using or had used HRQOL questionnaires. The main reasons for not using HRQOL questionnaires were that they were too time-consuming or intrusive in a clinic setting and that there was a lack of resources.

CONCLUSIONS

Clinicians still see the use of questionnaires as a research-tool only, rather than an adjunct to giving patient information, promoting choice, and identifying patients with problems. The burden on HRQOL evaluation in routine clinical practice remains a substantial barrier. Advances with IT support in clinic should make it easier to collect and use these data in the future. As surgeons, we still need to be persuaded of the benefits of HRQOL outcomes in our practice.

The association of psycho-social factors and survival in head and neck cancer

OBJECTIVE

Update a previous review examining associations between psycho-social factors and survival in head and neck cancer patients.

DATA SOURCES

Searched Cochrane, Psych info and Embase for the period from 1 January 1995 to 1 June 2007, as well as personal and article reference lists and article archives.

STUDY SELECTION

Identified articles assessed by consensus for eligibility using following criteria: survival as outcome measure; psycho-social factors as prognostic indicators; results specifically for head and neck cancer patients, not including oesophageal or thyroid cancer. Seven of 64 articles fulfilled criteria.

DATA EXTRACTION

Data abstracted independently by two reviewers using pre-determined proformas. Quality also rated using Scottish Intercollegiate Guidelines Network 50 tool.

DATA SYNTHESIS

At baseline, expression of intense psycho-social complaints, higher self-perceived physical ability and self-reported high physical functioning were significantly associated with increased survival. Uncertainty about the diagnosis and treatment was found to be a negative prognostic indicator, as was being single, poor cognitive function, baseline fatigue and alcoholism. Overall quality of life and head and neck pain 12 months after date of diagnosis were found to be significantly associated with survival in one study. However, overall quality of life and depression at the time of diagnosis were not.

CONCLUSIONS

There appears to be some association between selected psycho-social factors and long-term survival from head and neck cancer. However this relationship is currently neither strong nor proven, requiring examination by multi centred trials with standardisation of research definitions and methodologies, and examination of post-treatment psycho-social factors.

Will measuring quality of life in head and neck cancer alter individuals' treatment?

PURPOSE OF REVIEW

To examine the ways in which quality of life assessment has been and can be used in the future to benefit patient care.

RECENT FINDINGS

Quality of life has to date been used as an outcome measure, mainly in a research setting when comparing two interventions. This has led to a better understanding of quality of life changes during the patient journey, enabling better information provision to patients. In future, quality of life assessment will be incorporated into routine clinical practice in a quality of life-driven head and neck cancer clinic. Routine quality of life assessment, possibly in automated electronic (touch-screen) format, may be used to screen patients for quality of life problems. Such assessments could be used in a timely fashion by the clinician to instigate interventions such as psychological counselling and pain control, thereby resulting in improvements in patients' overall quality of life.

SUMMARY

Quality of life assessment has contributed to patient benefit. However, its full and greater potential remains untapped, although it is beginning to be addressed by current research.

Patients' views on the utility of quality of life questionnaires in head and neck cancer: a randomised trial

OBJECTIVES

(i) To evaluate head and neck cancer patient perspectives regarding the usefulness of quality of life questionnaires in communicating their health problems to clinicians and (ii) to identify the quality of life questionnaire that head and neck cancer patients find most useful.

DESIGN

Randomised questionnaire study. Patients completed all four validated head and neck cancer quality of life questionnaires - European Organisation for Research and Treatment of Cancer (EORTC), Functional Assessment of Cancer Therapy Scale (FACT) HN35, Washington quality of life questionnaire, Auckland quality of life questionnaire. Order of questionnaire presentation was randomised to counterbalance order effects.

SETTING

Tertiary referral head and neck cancer centre.

PARTICIPANTS

Eighty patients diagnosed and treated for head and neck cancer.

EXCLUSION CRITERIA

blindness, learning difficulties or inability to understand or read English.

MAIN OUTCOME MEASURES

Patient ratings of perceived usefulness and preferences of studied questionnaires.

RESULTS

Patients reported high relevance to their problems and high ease of understanding of all questionnaires, with FACT scoring highest (79% and 89%, respectively); 58% of participants (67% respondents) would like to complete a questionnaire in clinic, as it would help them describe their health problems to their doctors; 28% of participants did not. Almost half preferred a particular quality of life questionnaire, FACT being most preferred. Length of questionnaire did not affect reported usefulness, but most would prefer a short questionnaire (<20 items).

CONCLUSIONS

Patients report that head and neck cancer quality of life questionnaires effectively describe their health concerns. Most are in favour of completing quality of life questionnaires in clinic, as an aid for describing health problems to clinicians. There appears to be a difference between clinicians and patients regarding the perceived usefulness of quality of life questionnaires in the clinic setting, which needs to be highlighted to clinicians.

Deterioration in quality-of-life of late (10-year) survivors of head and neck cancer

OBJECTIVES

To determine 10-year quality-of-life (QOL) in head and neck cancer patients and to examine the potential predictors of late QOL.

DESIGN

Prospective 10-year (QOL) assessment in a cohort of head and neck cancer patients.

SETTING

Tertiary referral head and neck cancer centre in Auckland, New Zealand.

PARTICIPANTS

Two hundred patients diagnosed and were treated for head and neck cancer. Exclusion criteria were blindness, learning difficulties or inability to understand or read English.

MAIN OUTCOME MEASURES

Quality-of-life at 10 years measured by Auckland QOL questionnaire, and analysed for associations with the following co-variates: age, gender; co-morbidities (alcohol intake and smoking), type and stage of disease; treatment modality; and QOL measures.

RESULTS

At 10 years following diagnosis, overall QOL (life satisfaction), decreased significantly by an average of 11% (95% CI: -5, -17) compared with before treatment, and by 15% when compared with years 1 and 2. Pre-treatment QOL significantly predicted late QOL, whilst QOL 1 year after treatment did not. None of the socio-demographic, disease- or treatment-related factors predicted long-term QOL on univariate analysis, but this may be due to the small sample size.

CONCLUSIONS

This observed, late drop in the QOL of head and neck cancer patients requires further corroboration and investigation. Due to small sample sizes associated with long-term studies in head and neck cancer cohorts, studies of predictors of long-term QOL will only be likely to succeed if done as multi-centre studies. As there is some evidence to suggest that psychosocial interventions improve the QOL of head and neck cancer patients, it may be appropriate to consider screening for risk of a late deterioration in QOL in order to plan appropriate psycho-social intervention.

Why are head and neck cancer clinicians not measuring quality of life?

AIM

To quantify and qualify the use of quality of life (QOL) measures by head and neck cancer clinicians and to identify any impediments to the use of these measures.

METHODS

Questionnaire survey of members of the Australia and New Zealand Head and Neck Society.

RESULTS

One hundred and twenty-eight of 187 (68.5 per cent) responded. Only 43 (34 per cent) had ever used a QOL questionnaire (QLQ), and only 17 (13 per cent) were currently using one. Impediments to QLQ use included clinicians' perceptions that QLQs were too time-consuming and conferred no proven benefit for clinical management. Nevertheless, 113 (88 per cent) respondents indicated willingness to use a minimum core QLQ--for routine clinical use and for research--but indicated a preference for a short (10-15 questions), quick (less than 10 minutes) questionnaire.

CONCLUSIONS

Most head and neck cancer clinicians did not use a QOL measure routinely, with impediments to routine use being mainly clinician-based. Most respondents would use a minimum core QOL measure, especially if it were a short, quick consensus questionnaire.

Fungal laryngitis in immunocompetent patients

The diagnosis of fungal laryngitis is often overlooked in systemically immunocompetent patients because it is commonly considered a disease of the immunocompromised, and because it often mimics, clinically and histologically, more common and more serious conditions e.g. leukoplakia. A high index of suspicion is required to make the diagnosis, and should be considered in any immunocompetent patient with persistent or refractory laryngitis and factors predisposing to local mucosal barrier impairment e.g. gastropharyngeal reflux, smoking or inhaled steroid use. In such cases, demonstration of hyperkeratosis, particularly if associated with intraepithelial neutrophils, on biopsy should trigger a search for fungal elements using specialized stains. Prolonged treatment by systemic antimycotics is required. Treatment should also include the elimination of any predisposing factors, as failure to do so may result in difficulty with disease eradication or recurrence of the condition.

Does Quality of Life Predict Long-term Survival in Patients With Head and Neck Cancer?

OBJECTIVE

To assess whether pretreatment and posttreatment quality of life (QOL) is associated with long-term survival in patients with head and neck cancer.

DESIGN

Ten-year follow-up of an inception cohort.

SETTING

Regional tertiary referral center.

PATIENTS

The study included 200 consecutive patients with primary epithelial head and neck cancer.

INTERVENTIONS

Quality of life and several recognized risk factors for death were assessed prospectively using the Auckland QOL questionnaire before treatment and 12 months after treatment; survival was determined at 10 years.

MAIN OUTCOME MEASURES

Survival and odds of death (hazards ratio) were measured.

RESULTS

At 10 years, 136 patients (68%) were deceased, 48 patients (24%) were alive, and the status of 16 patients (8%) was unknown. Median survival was 6 years (interquartile range, 4.4-7.7). Before treatment, patients with low QOL had no significantly increased odds of death (hazard ratio, 1.4; 95% confidence interval, 0.8-2.4). In contrast, after treatment, patients with low QOL at 1 year had significantly increased odds of death (2.5; 95% confidence interval, 1.4-4.3; P = .001) even after adjustment for covariates.

CONCLUSIONS

Findings suggest potential survival benefits from improvements in QOL. However, the observed associations between survival benefit and QOL at 1 year may be confounded by comorbidity, which was not measured and deserves further investigation.

National audit of the management of peritonsillar abscess

An anonymous postal survey of 200 consultants was used to audit the current prevalent practices in the management of quinsy in the UK; 101 responded. The findings reveal that on average an otolaryngology department treats 29 cases per year, the vast majority (94%) on an inpatient basis. The main initial treatment was needle aspiration combined with intravenous antibiotics. Interestingly, those departments treating more than 20 cases a year are more likely to use needle aspiration, while departments in England and Wales use significantly more incision and drainage than those in Scotland. Incision and drainage (52%) was the most common form of treatment of non-resolving patients. The median hospital stay was two days.

The case of the missing carotid artery--a well aimed knife!

A 20-year-old male presented with a small stab wound to the neck and with haemodynamic signs of significant haemorrhage, but no signs of local bleeding. On exploration, an intact vagus nerve and internal jugular vein were found, but the common carotid artery was not immediately apparent. Careful dissection confirmed a completely transected common carotid artery with the two ends contracted and retracted. A primary repair was performed and post-operatively the patient recovered completely and had no neurological deficit.