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Saraswathula A, Austin JM, Fakhry C, Vosler PS, Mandal R, Koch WM, Tan M, Eisele DW, Frick KD, Gourin CG. Surgeon Volume and Laryngectomy Outcomes. Laryngoscope 2023; 133:834-840. [PMID: 35634691 PMCID: PMC9708934 DOI: 10.1002/lary.30229] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/11/2022] [Accepted: 05/12/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To examine the relationship between surgeon volume and operative morbidity and mortality for laryngectomy. DATA SOURCES The Nationwide Inpatient Sample was used to identify 45,156 patients who underwent laryngectomy procedures for laryngeal or hypopharyngeal cancer between 2001 and 2011. Hospital and surgeon laryngectomy volume were modeled as categorical variables. METHODS Relationships between hospital and surgeon volume and mortality, surgical complications, and acute medical complications were examined using multivariable regression. RESULTS Higher-volume surgeons were more likely to operate at large, teaching, nonprofit hospitals and were more likely to treat patients who were white, had private insurance, hypopharyngeal cancer, low comorbidity, admitted electively, and to perform partial laryngectomy, concurrent neck dissection, and flap reconstruction. Surgeons treating more than 5 cases per year were associated with lower odds of medical and surgical complications, with a greater reduction in the odds of complications with increasing surgical volume. Surgeons in the top volume quintile (>9 cases/year) were associated with a decreased odds of in-hospital mortality (OR = 0.09 [0.01-0.74]), postoperative surgical complications (OR = 0.58 [0.45-0.74]), and acute medical complications (OR = 0.49 [0.37-0.64]). Surgeon volume accounted for 95% of the effect of hospital volume on mortality and 16%-47% of the effect of hospital volume on postoperative morbidity. CONCLUSION There is a strong volume-outcome relationship for laryngectomy, with reduced mortality and morbidity associated with higher surgeon and higher hospital volumes. Observed associations between hospital volume and operative morbidity and mortality are mediated by surgeon volume, suggesting that surgeon volume is an important component of the favorable outcomes of high-volume hospital care. Laryngoscope, 133:834-840, 2023.
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Affiliation(s)
- Anirudh Saraswathula
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - J. Matthew Austin
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Carole Fakhry
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Peter S. Vosler
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rajarsi Mandal
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Wayne M. Koch
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Marietta Tan
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - David W. Eisele
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kevin D. Frick
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Johns Hopkins Carey Business School, Baltimore, MD
| | - Christine G. Gourin
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD
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Chidambaram S, Hong SA, Simpson MC, Osazuwa-Peters N, Ward GM, Massa ST. Temporal trends in oropharyngeal cancer incidence, survival, and cancer-directed surgery among elderly Americans. Oral Oncol 2022; 134:106132. [PMID: 36191478 DOI: 10.1016/j.oraloncology.2022.106132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/26/2022] [Accepted: 09/16/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVE This study assesses longitudinal epidemiologic trends in the oldest head and neck cancer (HNC) patients, comparing the oropharynx to other mucosal HNC sites. MATERIALS AND METHODS Using data from the Surveillance, Epidemiology, and End Results database, trends in incidence, two-year cancer specific mortality, and percent of cases recommended for and which received surgery from 2000 to 2018 in patients ages ≥85 years were assessed using Joinpoint analysis by HNC site. Trends were quantified as annual percentage change (APC) with 95% confidence intervals (CI). RESULTS Among older adults, oropharyngeal cancer (OPC) incidence increased (APC = 1.80% [95% CI: 0.94-2.67]), while mortality decreased (APC = -2.01% [95% CI: -3.26--0.74]) from 2000 to 2018. At other mucosal HNC sites, incidence and mortality remained stable. Percentage of patients who received surgery significantly changed for oropharyngeal (APC = -15.34% from 2000 to 2005 [95% CI: -24.37 to -4.79]) and laryngeal (APC = -4.61% from 2000 to 2008 [95% CI -8.28 to -0.80]) cancers. Trends in recommendation for surgery varied by site with significant decreases at the larynx, oral cavity, and oropharynx. CONCLUSION OPC incidence is increasing among the oldest HNC patients. An increasing proportion of HPV-associated tumors could account for associated mortality improvement. There has been a shift towards non-surgical therapy possibly due to known favorable response of HPV-associated OPC to radiation therapy and/or poor surgical candidacy in this age group. The evolving treatment approach has not been detrimental to population-level survival outcomes, but optimal treatment has yet to be established. Future studies with pathologically confirmed HPV status are needed to better understand older adult OPC burden.
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Affiliation(s)
- Smrithi Chidambaram
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, St. Louis, MO 63104, United States.
| | - Scott A Hong
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, St. Louis, MO 63104, United States.
| | - Matthew C Simpson
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, St. Louis, MO 63104, United States.
| | - Nosayaba Osazuwa-Peters
- Department of Otolaryngology-Head and Neck Surgery, Duke University School of Medicine, Durham, NC 27710, United States.
| | - Gregory M Ward
- Northside Hospital Cancer Institute (NHCI) Head & Neck Program, Atlanta, GA 30342, United States.
| | - Sean T Massa
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, St. Louis, MO 63104, United States.
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Paderno A, Lancini D, Bosio P, Del Bon F, Fior M, Berretti G, Alparone M, Deganello A, Peretti G, Piazza C. Transoral Laser Microsurgery for Glottic Cancer in Patients Over 75 Years Old. Laryngoscope 2021; 132:135-141. [PMID: 34233029 PMCID: PMC9291037 DOI: 10.1002/lary.29738] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 06/16/2021] [Accepted: 06/28/2021] [Indexed: 12/22/2022]
Abstract
Objectives/Hypothesis Laryngeal squamous cell carcinoma (LSCC) has a non‐negligible incidence in elderly patients. However, there is still no clear indication on the ideal treatment for early‐intermediate glottic LSCC in this specific age group. Both surgical and nonsurgical approaches may be burdened by complications and sequelae that negatively impact patient's health. In this setting, carbon dioxide transoral laser microsurgery (CO2 TOLMS) is a promising minimally invasive treatment option. Study Design Retrospective case series in a single tertiary academic institution. Methods Patients who underwent CO2 TOLMS for Tis‐T3 glottic LSCC from 1997 to 2017 were reviewed. Demographic, clinical, and tumor characteristics, as well as postoperative complications were recorded. Overall (OS), disease‐specific (DSS), recurrence‐free (RFS), laryngo‐esophageal dysfunction free survivals (LEDFS), and organ preservation (OP) were calculated. Results A total of 134 patients (mean age, 80 ± 4 years; median, 79; range, 75–93) were included in the study. Seven lesions were classified as pTis, 65 as pT1a, 22 as pT1b, 35 as pT2, and 5 as pT3. No treatment‐related death was observed. Twenty‐eight (20.9%) patients reported 10 surgical and 19 medical complications. Five‐year OS, DSS, RFS, LEDFS, and OP were 68.9%, 95.4%, 79.5%, 66%, and 92.5%, respectively. Age and comorbidities were associated with OS and LEDFS. Advanced T categories were negatively correlated with OS, DSS, RFS, LEDFS, and OP. Age and comorbidities were not significant risk factors for complications. Conclusions CO2 TOLMS can be considered a valuable therapeutic approach for selected Tis‐T3 glottic LSCC even in the elderly given its favorable oncologic outcomes and minimal aggressiveness. Level of Evidence 4 Laryngoscope, 132:135–141, 2022
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Affiliation(s)
- Alberto Paderno
- Unit of Otorhinolaryngology-Head and Neck Surgery, ASST Spedali Civili, Brescia, Italy.,Department of Surgical and Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Davide Lancini
- Unit of Otorhinolaryngology-Head and Neck Surgery, ASST Spedali Civili, Brescia, Italy
| | - Paolo Bosio
- Unit of Otorhinolaryngology-Head and Neck Surgery, ASST Spedali Civili, Brescia, Italy.,Department of Surgical and Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Francesca Del Bon
- Unit of Otorhinolaryngology-Head and Neck Surgery, ASST Spedali Civili, Brescia, Italy
| | - Milena Fior
- Unit of Otorhinolaryngology-Head and Neck Surgery, ASST Spedali Civili, Brescia, Italy.,Department of Surgical and Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Giulia Berretti
- Unit of Otorhinolaryngology-Head and Neck Surgery, ASST Spedali Civili, Brescia, Italy.,Department of Surgical and Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marco Alparone
- Unit of Otorhinolaryngology-Head and Neck Surgery, ASST Spedali Civili, Brescia, Italy.,Department of Surgical and Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Alberto Deganello
- Unit of Otorhinolaryngology-Head and Neck Surgery, ASST Spedali Civili, Brescia, Italy.,Department of Surgical and Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Giorgio Peretti
- Unit of Otorhinolaryngology-Head and Neck Surgery, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Cesare Piazza
- Unit of Otorhinolaryngology-Head and Neck Surgery, ASST Spedali Civili, Brescia, Italy.,Department of Surgical and Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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Pei R, Shi Y, Lv S, Dai T, Zhang F, Liu S, Wu B. Nivolumab vs Pembrolizumab for Treatment of US Patients With Platinum-Refractory Recurrent or Metastatic Head and Neck Squamous Cell Carcinoma: A Network Meta-analysis and Cost-effectiveness Analysis. JAMA Netw Open 2021; 4:e218065. [PMID: 33956130 PMCID: PMC8103222 DOI: 10.1001/jamanetworkopen.2021.8065] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 03/09/2021] [Indexed: 12/12/2022] Open
Abstract
Importance Nivolumab and pembrolizumab are approved for treating platinum-refractory recurrent or metastatic head and neck squamous cell carcinoma (R/M HNSCC). Physicians and patients are uncertain which drug is preferable, rendering a cost-effectiveness comparison between them necessary. Objective To evaluate the cost-effectiveness of nivolumab vs pembrolizumab in treating platinum-refractory R/M HNSCC. Design, Setting, and Participants Both the network meta-analysis and cost-effectiveness analysis included patients from the CheckMate 141 and the KEYNOTE 040 phase 3 randomized clinical trials. The Checkmate 141 trial started on May 1, 2014, with the present analysis based on a September 2017 data cutoff. The KEYNOTE 040 trial started on November 17, 2014, with the present analysis based on a May 15, 2017, data cutoff. A bayesian network meta-analysis that included 856 patients was carried out, and a cost-effectiveness analysis that included 487 patients was conducted by developing a partitioned survival model, both between February and November 2020. The robustness of the model was assessed via 1-way, 2-way, and probabilistic sensitivity analyses; subgroup analyses were included; and scenario analyses were conducted to investigate the associations of dosage adjustment of nivolumab with cost-effectiveness. Main Outcomes and Measures Life-years, quality-adjusted life-years (QALYs), overall costs, and incremental cost-effectiveness ratios (ICERs) were measured. Results In the cost-effectiveness analysis that included 487 patients, for US health care payers, when nivolumab was administered based on patient weight (3 mg/kg biweekly), at a willingness-to-pay (WTP) threshold of $100 000 per QALY, the probability of nivolumab being cost-effective compared with pembrolizumab was 56%; at a WTP threshold of $150 000 per QALY, the probability was 62%. When nivolumab was administered at a fixed dose of 240 mg biweekly or 480 mg monthly, at a WTP threshold of $100 000 per QALY, the probability of nivolumab being cost-effective was 42% to 45%; at a WTP threshold of $150 000 per QALY, the probability was 52% to 55%. Conclusions and Relevance Findings from this network meta-analysis and cost-effectiveness analysis suggest considering both WTP threshold and patient body weight when choosing between nivolumab and pembrolizumab for the treatment of patients with platinum-refractory R/M HNSCC. When the WTP threshold was $100 000 per QALY, for patients weighing less than 72 kg, nivolumab (3 mg/kg, biweekly) was considered cost-effective; otherwise, pembrolizumab was preferable. When the WTP threshold was $150 000 per QALY, nivolumab (3 mg/kg biweekly) was considered cost-effective for patients weighing less than 75 kg; otherwise, fixed-dose nivolumab (240 mg biweekly or 480 mg monthly) provided more cost savings.
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Affiliation(s)
- Rui Pei
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, Hunan, China
- The Hunan Institute of Pharmacy Practice and Clinical Research, Changsha, Hunan, China
- Institute for Rational and Safe Medication Practices, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yin Shi
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, Hunan, China
- The Hunan Institute of Pharmacy Practice and Clinical Research, Changsha, Hunan, China
- Institute for Rational and Safe Medication Practices, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Shuhe Lv
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, Hunan, China
- The Hunan Institute of Pharmacy Practice and Clinical Research, Changsha, Hunan, China
- Institute for Rational and Safe Medication Practices, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Tingting Dai
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, Hunan, China
- The Hunan Institute of Pharmacy Practice and Clinical Research, Changsha, Hunan, China
- Institute for Rational and Safe Medication Practices, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Fengyu Zhang
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, Hunan, China
- The Hunan Institute of Pharmacy Practice and Clinical Research, Changsha, Hunan, China
- Institute for Rational and Safe Medication Practices, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Shao Liu
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, Hunan, China
- The Hunan Institute of Pharmacy Practice and Clinical Research, Changsha, Hunan, China
- Institute for Rational and Safe Medication Practices, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Bin Wu
- Medical Decision and Economic Group, Department of Pharmacy, South Campus, Ren Ji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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5
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Gourin CG, Stewart CM, Frick KD, Fakhry C, Pitman KT, Eisele DW, Austin JM. Association of Hospital Volume With Laryngectomy Outcomes in Patients With Larynx Cancer. JAMA Otolaryngol Head Neck Surg 2019; 145:62-70. [PMID: 30476965 DOI: 10.1001/jamaoto.2018.2986] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Importance A volume-outcome association exists for larynx cancer surgery, but to date it has not been investigated for specific surgical procedures. Objectives To characterize the volume-outcome association specifically for laryngectomy surgery and to identify a minimum hospital volume threshold associated with improved outcomes. Design, Setting, and Participants In this cross-sectional study, the Nationwide Inpatient Sample was used to identify 45 156 patients who underwent laryngectomy procedures for a malignant laryngeal or hypopharyngeal neoplasm between January 2001 and December 2011. The analysis was performed in 2018. Hospital laryngectomy volume was modeled as a categorical variable. Main Outcomes and Measures Associations between hospital volume and in-hospital mortality, complications, length of hospitalization, and costs were examined using multivariate logistic regression analysis. Results Among 45 156 patients (mean age, 62.6 years; age range, 20-96 years; 80.2% male) at 5516 hospitals, higher-volume hospitals were more likely to be teaching hospitals in urban locations; were more likely to treat patients who had hypopharyngeal cancer, were of white race/ethnicity, were admitted electively, had no comorbidity, and had private insurance; and were more likely to perform flap reconstruction or concurrent neck dissection. After controlling for all other variables, hospitals treating more than 6 cases per year were associated with lower odds of surgical and medical complications, with a greater reduction in the odds of complications with increasing hospital volume. High-volume hospitals in the top-volume quintile (>28 cases per year) were associated with decreased odds of in-hospital mortality (odds ratio, 0.45; 95% CI, 0.23-0.88), postoperative surgical complications (odds ratio, 0.63; 95% CI, 0.50-0.79), and acute medical complications (odds ratio, 0.63; 95% CI, 0.48-0.81). A statistically meaningful negative association was observed between very high-volume hospital care and the mean incremental length of hospitalization (-3.7 days; 95% CI, -4.9 to -2.4 days) and hospital-related costs (-$4777; 95% CI, -$9463 to -$900). Conclusions and Relevance Laryngectomy outcomes appear to be associated with hospital volume, with reduced morbidity associated with a minimum hospital volume threshold and with reduced mortality, morbidity, length of hospitalization, and costs associated with higher hospital volume. These data support the concept of centralization of complex care at centers able to meet minimum volume thresholds to improve patient outcomes.
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Affiliation(s)
- Christine G Gourin
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland.,Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - C Matthew Stewart
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland.,Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Kevin D Frick
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Johns Hopkins Carey Business School, Baltimore, Maryland
| | - Carole Fakhry
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Karen T Pitman
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - David W Eisele
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - J Matthew Austin
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medical Institutions, Baltimore, Maryland.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
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6
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Gourin CG, Herbert RJ, Quon H, Fakhry C, Kiess AP, Eisele DW, Frick KD. Quality of care and short and long‐term outcomes of oropharyngeal cancer care in the elderly. Head Neck 2019; 41:3542-3550. [DOI: 10.1002/hed.25869] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 06/04/2019] [Accepted: 06/26/2019] [Indexed: 11/09/2022] Open
Affiliation(s)
- Christine G. Gourin
- Department of Otolaryngology ‐ Head and Neck SurgeryJohns Hopkins University Baltimore Maryland
| | - Robert J. Herbert
- Department of Health Policy and ManagementJohns Hopkins Bloomberg School of Public Health Baltimore Maryland
| | - Harry Quon
- Department of Radiation Oncology and Molecular Radiation SciencesJohns Hopkins University Baltimore Maryland
| | - Carole Fakhry
- Department of Otolaryngology ‐ Head and Neck SurgeryJohns Hopkins University Baltimore Maryland
| | - Ana P. Kiess
- Department of Radiation Oncology and Molecular Radiation SciencesJohns Hopkins University Baltimore Maryland
| | - David W. Eisele
- Department of Otolaryngology ‐ Head and Neck SurgeryJohns Hopkins University Baltimore Maryland
| | - Kevin D. Frick
- Department of Health Policy and ManagementJohns Hopkins Bloomberg School of Public Health Baltimore Maryland
- Johns Hopkins Carey Business School Baltimore Maryland
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7
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Swegal WC, Herbert RJ, Eisele DW, Chang J, Bristow RE, Gourin CG. Observed-to-expected ratio for adherence to treatment guidelines as a quality of care indicator for laryngeal cancer. Laryngoscope 2019; 130:672-678. [PMID: 31169916 DOI: 10.1002/lary.28104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 02/25/2019] [Accepted: 05/20/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVES/HYPOTHESIS To examine associations between survival and adherence to National Comprehensive Cancer Network (NCCN) treatment guidelines using an observed-to-expected (O/E) ratio for greater adherence as a risk-adjusted hospital measure of quality care in elderly patients treated for larynx cancer. STUDY DESIGN Retrospective analysis of Surveillance, Epidemiology, and End Results (SEER)-Medicare data. METHODS Patients diagnosed with larynx cancer from 2004 to 2007 were evaluated using multivariate regression and survival analysis. A fit logistic regression model was used to calculate an O/E ratio for guideline adherence for each hospital using quality indicators derived from NCCN guidelines for recommended treatment and stratified by hospital volume. RESULTS Of 1,721 patients treated at 395 hospitals, 43.0% of patients received NCCN guideline-adherent care. Low-volume hospitals (N = 295) treating six or fewer cases treated 765 patients (44.5%), with a mean O/E of 0.96 ± 0.45. Hospitals treating more then six cases with an O/E <1 (N = 32) treated 284 patients (16.5%), with a mean O/E of 0.77 ± 0.18. Hospitals treating more than six cases with an O/E ≥1 (N = 68) treated 672 patients (39.1%), with a mean O/E of 1.17 ± 0.11. Treatment at hospitals with an O/E ≥1 was associated with improved survival (hazard ratio [HR] = 0.83 [95% confidence interval [CI]: 0.70 to 0.98]) and lower mean incremental treatment-related costs (-$3,009 [-$5,226 to -$791]) compared with hospitals with an O/E <1 (HR = 1.00 [0.80 to 1.24]) and the reference group of low-volume hospitals. CONCLUSIONS A hospital-specific O/E for NCCN treatment guideline adherence, combined with a minimum case volume criterion, is associated with survival and treatment-related costs in elderly patients with larynx cancer, and may be a feasible measure of larynx cancer quality of care. LEVEL OF EVIDENCE NA Laryngoscope, 130:672-678, 2020.
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Affiliation(s)
- Warren C Swegal
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Robert J Herbert
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - David W Eisele
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Jenny Chang
- Department of Epidemiology, University of California Irvine, Irvine, California
| | - Robert E Bristow
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, Irvine Medical Center, Orange, California, U.S.A
| | - Christine G Gourin
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland
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8
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Ambrosio A, Jeffery DD, Hopkins L, Burke HB. Cost and Healthcare Utilization Among Non-Elderly Head and Neck Cancer Patients in the Military Health System, a Single-Payer Universal Health Care Model. Mil Med 2019; 184:e400-e407. [PMID: 30295883 DOI: 10.1093/milmed/usy192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 07/17/2018] [Accepted: 07/19/2018] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Examining costs and utilization in a single-payer universal health care system provides information on fiscal and resource burdens associated with head and neck cancer (HNC). Here, we examine trends in the Department of Defense (DoD) HNC population with respect to: (1) reimbursed annual costs and (2) patterns and predictors of health care utilization in military only, civilian only, and both systems of care (mixed model). MATERIALS AND METHODS A retrospective, cross-sectional study was conducted using TRICARE claims data from fiscal years 2007 through 2014 for reimbursement of ambulatory, inpatient, and pharmacy charges. The study was approved by the Defense Health Agency Office of Privacy and Civil Liberties as exempt from institutional review board full review. The population was all beneficiaries, age 18-64, with a primary ICD-9 diagnosis of HNC, on average, 2,944 HNC cases per year. The outcomes of regression models were total reimbursed health care cost, and counts of ambulatory visits, hospitalizations, and bed days. The predictors were fiscal year, demographic variables, hospice use, type and geographic region of TRICARE enrollment, use of military or civilian care or mixed use, cancer treatment modalities, the number of physical and mental health comorbid conditions, and tobacco use. A priori, null hypotheses were assumed. RESULTS Per annual average, 61% of the HNC population was age 55-64, and 69% were males. About 6% accessed military facilities only for all health care, 60% accessed civilian only, and 34% accessed both military and civilian facilities. Patients who only accessed military care had earlier stage disease as indicated by rates of single modality treatment and hospice use; military care only and mixed use had similar rates of combination treatment and hospice use. The average cost per patient per year was $14,050 for civilian care only, $13,036 for military care only, and $29,338 for mixed use of both systems. The strongest predictors of higher cost were chemotherapy, radiation therapy, head and neck surgery, hospice care, and mixed-use care. The strongest predictors of health care utilization were chemotherapy, use of hospice, the number of physical and mental health comorbidities, radiation therapy, head and neck surgery, and system of care. CONCLUSIONS To a single payer, the use of a single system of care exclusively among HNC patients is more cost-effective than use of a mixed-use system. The results suggest an over-utilization of ambulatory care services when both military and civilian care are accessed. Further investigation is needed to assess coordination between systems of care and improved efficiencies with respect to the cost and apparent over-utilization of health care services.
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Affiliation(s)
- Art Ambrosio
- LCDR, Department of Defense, U.S. Navy Medical Corps, Naval Medical Center San Diego, Naval Hospital Camp Pendleton, CA
| | - Diana D Jeffery
- Department of Defense, Defense Health Agency, Clinical Support Division, 7700 Arlington Boulevard, DHHQ, MS 5140, Falls Church, VA
| | - Laura Hopkins
- Kennell and Associates, Inc., 3130 Fairview Park Drive, Suite 450, Falls Church, VA
| | - Harry B Burke
- Department of Defense, Uniformed Services University of the Health Sciences, Biomedical Informatics Department, Rm. G058D, 4301 Jones Bridge Road, Bethesda, MD
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9
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Jeffery DD, Art Ambrosio L, Hopkins L, Burke HB. Mental health comorbidities and cost/utilization outcomes in head and neck cancer patients. J Psychosoc Oncol 2019; 37:301-318. [DOI: 10.1080/07347332.2018.1519626] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Diana D. Jeffery
- Department of Defense, Defense Health Agency, Falls Church, Virginia, USA
| | - Lcdr Art Ambrosio
- Department of Defense, U.S. Navy Medical Corps, Naval Medical Center San Diego, Naval Hospital Camp Pendleton, California, USA
| | - Laura Hopkins
- Kennell and Associates, Inc., Falls Church, Virginia, USA
| | - Harry B. Burke
- Department of Defense, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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10
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Zhang M, Deng W, Gong H, Li C, Wang Y, Liu X, Tao L, Zhou L. Clinical effect of postoperative chemoradiotherapy in resected advanced laryngeal squamous cell carcinoma. Oncol Lett 2019; 17:4717-4725. [PMID: 30988826 DOI: 10.3892/ol.2019.10104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Accepted: 01/25/2019] [Indexed: 11/06/2022] Open
Abstract
Laryngeal squamous cell carcinoma (LSCC) is one of the most prevalent types of head and neck malignancies. Advanced LSCC has failed to demonstrate a satisfactory prognosis, despite the progresses in the diagnosis and treatment, and the optimal treatment modality continues to be debated. To evaluate the clinical utility and survival outcomes of adjuvant chemoradiotherapy (CRT) for patients with resected advanced LSCC, a retrospective analysis of 232 patients with LSCC who had undergone total laryngectomy and neck dissection between 2005 and 2010 was conducted. Of the 232 eligible patients, 167 patients (72%) received surgery alone, whereas 65 patients (28%) received surgery + adjuvant CRT. In the overall cohort, the 5- and 10-year overall survival (OS) rates were 55.2 and 48.3%, respectively. Multivariate analysis revealed that the clinical stage was significantly associated with OS. However, the N classification was an independent indicator in disease-free survival and laryngeal cancer-specific survival. In those patients with stage IV disease, patients receiving adjuvant CRT exhibited a markedly improved survival benefit compared with patients receiving surgical treatment only, following propensity score matching of the data (P<0.05). The application of adjuvant CRT confers additional survival benefits in comparison with surgery-only treatment regimens for advanced LSCC. However, additional prospective studies are required.
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Affiliation(s)
- Ming Zhang
- Department of Otorhinolaryngology-Head and Neck Surgery, Eye, Ear, Nose and Throat Hospital of Fudan University, Shanghai 200031, P.R. China
| | - Weiye Deng
- Departments of Radiation Oncology, The University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Hongli Gong
- Department of Otorhinolaryngology-Head and Neck Surgery, Eye, Ear, Nose and Throat Hospital of Fudan University, Shanghai 200031, P.R. China
| | - Cai Li
- Department of Otorhinolaryngology-Head and Neck Surgery, Eye, Ear, Nose and Throat Hospital of Fudan University, Shanghai 200031, P.R. China
| | - Yifan Wang
- Departments of Radiation Oncology, The University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Xiangyu Liu
- Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Lei Tao
- Department of Otorhinolaryngology-Head and Neck Surgery, Eye, Ear, Nose and Throat Hospital of Fudan University, Shanghai 200031, P.R. China
| | - Liang Zhou
- Department of Otorhinolaryngology-Head and Neck Surgery, Eye, Ear, Nose and Throat Hospital of Fudan University, Shanghai 200031, P.R. China
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11
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Fisher MD, Fernandes AW, Olufade TO, Miller PJ, Walker MS, Fenton M. Patient Characteristics and Costs in Recurrent or Refractory Head and Neck Cancer: Retrospective Analysis of a Community Oncology Database. Clin Ther 2018. [PMID: 29530457 DOI: 10.1016/j.clinthera.2018.02.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE The goal of this study was to describe patient characteristics, health resource utilization (HRU), and costs associated with treating recurrent or refractory head and neck cancer (HNC) among patients with disease progression in the community oncology setting. METHODS This retrospective observational study was conducted by using data from the Vector Oncology Data Warehouse. Patients had been diagnosed with locally advanced or metastatic (stage III-IVc) HNC between January 1, 2007, and October 1, 2015. Patients also had evidence of at least 1 systemic anticancer therapy regimen following the diagnosis of advanced HNC, with at least 1 disease progression. Costs, treatment patterns, and HRU were evaluated beginning with diagnosis of advanced HNC through 3 lines of therapy. Costs of surgery or radiation were not available for inclusion in the analysis. Total cost for the study period and cost per month were analyzed by using a generalized linear regression model. FINDINGS The study included 462 patients (median age, 61 years; range, 26-99 years); of these, 81% were male, 77% were white, and 21% were black. At initial diagnosis, the most frequent tumor locations were the hypopharynx/larynx (31%) and the oropharynx (31%). Human papilloma virus testing was most frequent among the oropharynx group (22% tested, 52% positive). Overall, 42% were current tobacco users and 22% were current or past alcohol abusers/excessive users. Platinum-based combination therapies were the most frequently administered chemotherapy in both first (42%) and second (40%) lines of treatment. Through the overall study period (mean, 20.5 months), 74% of patients were hospitalized, 19% had an emergency department visit, and 100% had an office visit. The overall mean (SD) duration of hospital stay was 12.6 days, and the median number of office visits per patient was 35. The mean monthly health care cost for the overall study period was $14,391 (95% CI, 12,739-16,044). Hospitalization costs represented ~57% of the total expenditures. Statistically significant predictors of higher overall cost included primary tumor location in the oral cavity, history of alcohol abuse/excess use, use of cetuximab, and higher comorbidity index. Older age and being stage IV versus other stages of disease at diagnosis were associated with lower overall cost. IMPLICATIONS These data suggest that costs of care in patients with recurrent or refractory HNC are related to patient characteristics and treatment patterns. Identification of factors contributing to the costs of care in HNC may provide a useful foundation for developing strategies to control rising costs.
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12
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Dziegielewski PT, Reschly WJ, Morris CG, DeJesus RD, Silver N, Boyce BJ, Santiago I, Amdur RJ, Mendenhall WM. Tumor volume as a predictor of survival in T3 glottic carcinoma: A novel approach to patient selection. Oral Oncol 2018; 79:47-54. [PMID: 29598950 DOI: 10.1016/j.oraloncology.2018.02.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 02/14/2018] [Accepted: 02/16/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND The optimal treatment for T3 glottic cancers continues to be debated. Organ preservation has become the standard of care, but not all tumors respond equally. The purpose of this was to investigate the long-term survival outcomes of organ preservation protocols based on tumor volume. METHODS A retrospective review of prospectively collected data from 1966 to 2016 was performed. Patients with T3 vocal cord cancer treated with radiation therapy (RT) at the University of Florida were included. Local control rates as well as survival rates were determined with a Kaplan Meier and Cox regression analysis. Survival was analyzed as a function of tumor volume and an optimal cut point was determined. RESULTS 107/234 patients were included. 79% received RT and 21% chemo-RT. 5-year local control was 61.5% and 5-year disease specific survival was 79.3%. Tumor volume was a significant predictor of survival (p = 0.007). An optimal cut point for tumor volume was 2.5 cc. Patients with tumor volumes ≥2.5 cc had significantly worse (p < 0.05) tumor control rates (100% vs. 70.4%). CONCLUSION Tumor volume is a significant predictor of survival outcomes in T3 vocal cord cancers, but will need external validation. Tumors <2.5 cc have favorable outcomes. Those with higher volume tumors should be counselled appropriately and be considered for primary surgical management.
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Affiliation(s)
- Peter T Dziegielewski
- Department of Otolaryngology, University of Florida, Gainesville, FL, USA; University of Florida Health Cancer Center, Gainesville, FL, USA.
| | - William J Reschly
- Department of Otolaryngology, University of Florida, Gainesville, FL, USA
| | - Chris G Morris
- Department of Radiation Oncology, University of Florida, Gainesville, FL, USA
| | | | - Natalie Silver
- Department of Otolaryngology, University of Florida, Gainesville, FL, USA
| | - Brian J Boyce
- Department of Otolaryngology, University of Florida, Gainesville, FL, USA
| | - Inocente Santiago
- Department of Otolaryngology, University of Florida, Gainesville, FL, USA
| | - Robert J Amdur
- University of Florida Health Cancer Center, Gainesville, FL, USA; Department of Radiation Oncology, University of Florida, Gainesville, FL, USA
| | - William M Mendenhall
- University of Florida Health Cancer Center, Gainesville, FL, USA; Department of Radiation Oncology, University of Florida, Gainesville, FL, USA
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13
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Jansen F, Coupé VMH, Eerenstein SEJ, Leemans CR, Verdonck-de Leeuw IM. Costs from a healthcare and societal perspective among cancer patients after total laryngectomy: are they related to patient activation? Support Care Cancer 2017; 26:1221-1231. [PMID: 29098402 PMCID: PMC5847025 DOI: 10.1007/s00520-017-3945-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 10/23/2017] [Indexed: 11/30/2022]
Abstract
Purpose The aim of this study is to investigate the associations between patient activation and total costs in cancer patients treated with total laryngectomy (TL). Methods All members of the Dutch Patients’ Association for Laryngectomees were asked to participate in this cross-sectional study. TL patients who wanted to participate were asked to complete a survey. Costs were measured using the medical consumption and productivity cost questionnaire and patient activation using the Patient Activation Measure (PAM). Sociodemographic and clinical characteristics were self-reported, and health status measured using the EQ-5D. The difference in total costs from a healthcare and societal perspective among four groups with different PAM levels were compared using (multiple) regression analyses (5000 bootstrap replications). Results In total, 248 TL patients participated. Patients with a higher (better) PAM (levels 2, 3, and 4) had a probability of 70, 80, and 93% that total costs from a healthcare perspective were lower than in patients with the lowest PAM level (difference €−375 to €−936). From a societal perspective, this was 73, 87, and 82% (difference €−468 to €−719). After adjustment for time since TL, education, and sex, the probability that total costs were lower in patients with a higher PAM level compared to patients with the lowest PAM level changed to 62–91% (healthcare) and 63–92% (societal). After additional adjustment for health status, the probability to be less costly changed to 35–71% (healthcare) and 31–48% (societal). Conclusions A better patient activation is likely to be associated with lower total costs from a healthcare and societal perspective.
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Affiliation(s)
- Femke Jansen
- Department of Otolaryngology-Head and Neck Surgery, Cancer Center Amsterdam (CCA), VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Veerle M H Coupé
- Department of Epidemiology and Biostatistics, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Simone E J Eerenstein
- Department of Otolaryngology-Head and Neck Surgery, Cancer Center Amsterdam (CCA), VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - C René Leemans
- Department of Otolaryngology-Head and Neck Surgery, Cancer Center Amsterdam (CCA), VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Irma M Verdonck-de Leeuw
- Department of Otolaryngology-Head and Neck Surgery, Cancer Center Amsterdam (CCA), VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands.
- Department of Clinical Psychology, Faculty Behavioural and Movement Sciences, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Van der Boechorststraat 1, 1081 BT, Amsterdam, The Netherlands.
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14
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Webster KT, Tippett D, Simpson M, Abrams R, Pietsch K, Herbert RJ, Eisele DW, Gourin CG. Speech‐language pathology care and short‐ and long‐term outcomes of oropharyngeal cancer treatment in the elderly. Laryngoscope 2017; 128:1403-1411. [DOI: 10.1002/lary.26950] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 08/29/2017] [Accepted: 09/07/2017] [Indexed: 11/09/2022]
Affiliation(s)
- Kimberly T. Webster
- Department of Otolaryngology–Head and Neck SurgeryJohns Hopkins UniversityBaltimoreMarylandU.S.A
| | - Donna Tippett
- Department of Otolaryngology–Head and Neck SurgeryJohns Hopkins UniversityBaltimoreMarylandU.S.A
| | - Marissa Simpson
- Department of Otolaryngology–Head and Neck SurgeryJohns Hopkins UniversityBaltimoreMarylandU.S.A
| | - Rina Abrams
- Department of Otolaryngology–Head and Neck SurgeryJohns Hopkins UniversityBaltimoreMarylandU.S.A
| | - Kristine Pietsch
- Department of Otolaryngology–Head and Neck SurgeryJohns Hopkins UniversityBaltimoreMarylandU.S.A
| | - Robert J. Herbert
- Department of Health Policy and Managementthe Johns Hopkins Bloomberg School of Public HealthBaltimoreMarylandU.S.A
| | - David W. Eisele
- Department of Otolaryngology–Head and Neck SurgeryJohns Hopkins UniversityBaltimoreMarylandU.S.A
| | - Christine G. Gourin
- Department of Otolaryngology–Head and Neck SurgeryJohns Hopkins UniversityBaltimoreMarylandU.S.A
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15
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Gourin CG, Fakhry C, Quon H, Kang H, Kiess AP, Herbert RJ, Eisele DW, Frick KD. Treatment, survival, and costs of oropharyngeal cancer care in the elderly. Laryngoscope 2017; 128:1103-1112. [PMID: 28988469 DOI: 10.1002/lary.26887] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2017] [Indexed: 02/05/2023]
Abstract
OBJECTIVES/HYPOTHESIS To examine associations between treatment, survival, and costs in elderly patients with oropharyngeal squamous cell cancer (OPSCC). STUDY DESIGN Retrospective cross-sectional analysis of Surveillance, Epidemiology, and End Results-Medicare data. METHODS We evaluated 666 patients diagnosed with OPSCC from 2004 to 2007 using cross-tabulations, multivariate logistic and generalized linear regression modeling, and survival analysis. RESULTS The majority of patients were nonsmokers (79%), had advanced-stage disease (59%), and received chemoradiation (38%) or radiation (28%). Surgery with postoperative radiation (hazard ratio [HR]: 0.33 [95% CI: 0.20-0.53]) and chemoradiation (HR: 0.45 [95% CI: 0.29-0.71]) were associated with improved survival, whereas stage IV disease was associated with poorer survival (HR: 1.95 [95% CI: 1.13-3.38]). Additional cancer-directed treatment after primary treatment was more likely following chemoradiation (odds ratio [OR]: 3.44 [95% CI: 1.78-6.63]). Salvage surgery was performed in 25% of patients undergoing subsequent additional cancer-directed treatment, and was associated with high-volume hospitals (OR: 2.81 [95% CI: 1.07-7.74]). Additional radiation (HR: 0.47 [95% CI: 0.31-0.72]) and salvage surgery (HR: 0.61 [95% CI: 0.38-0.99]) were associated with improved overall survival when performed >6 months following initial treatment, whereas salvage neck dissection alone was not significantly associated with survival after controlling for time to salvage (HR: 0.38 [95% CI: 0.05-2.78]). Treatment and 5-year overall costs were highest for chemoradiation, surgery with postoperative radiation, and additional cancer-directed treatment. CONCLUSIONS Multimodality treatment in elderly OPSCC patients was associated with improved survival and increased costs. Chemoradiation was associated with an increased likelihood of additional cancer-directed treatment. Salvage surgery was centralized at high-volume hospitals, and was associated with improved survival when performed >6 months after last initial treatment date, but was performed in <20% of patients undergoing additional treatment. LEVEL OF EVIDENCE 2c. Laryngoscope, 128:1103-1112, 2018.
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Affiliation(s)
- Christine G Gourin
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, U.S.A
| | - Carole Fakhry
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, U.S.A
| | - Harry Quon
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, U.S.A
| | - Hyunseok Kang
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland, U.S.A
| | - Ana P Kiess
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, U.S.A
| | - Robert J Herbert
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, U.S.A
| | - David W Eisele
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, U.S.A
| | - Kevin D Frick
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, U.S.A.,Johns Hopkins Carey Business School, Baltimore, Maryland, U.S.A
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16
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Motz K, Chang HY, Quon H, Richmon J, Eisele DW, Gourin CG. Association of Transoral Robotic Surgery With Short-term and Long-term Outcomes and Costs of Care in Oropharyngeal Cancer Surgery. JAMA Otolaryngol Head Neck Surg 2017; 143:580-588. [PMID: 28358930 DOI: 10.1001/jamaoto.2016.4634] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Importance The treatment of oropharyngeal cancer has undergone a paradigm shift in the past 2 decades, with an increase in the use of nonoperative treatment owing to poor functional outcomes associated with traditional surgical approaches. Transoral robotic surgery (TORS) allows surgical resection of oropharyngeal cancer (OPC) with less morbidity through a minimally invasive approach. Objective To investigate the relationship among TORS and short- and long-term outcomes and costs in surgically treated patients with OPC. Design, Setting, and Participants Retrospective cross-sectional analysis of 3573 patients who underwent an ablative procedure for OPC in 2010 to 2012 using the MarketScan Commercial Claim and Encounters database. Main Outcomes and Measures The association between TORS and short- and long-term outcomes, length of hospitalization, and treatment-related costs was analyzed using descriptive statistics and multivariate regression modeling. Results Transoral robotic surgery was performed in 304 surgical cases (8.5%); 94.7% of patients were 40 to 64 years old, and 70.7% were male. The use of TORS increased from 4.1% of surgical cases in 2010 to 13.2% of surgical cases in 2012. Patients who underwent TORS had a lower rate of tracheotomy during treatment (3.9% vs 11.4%), and posttreatment gastrostomy tube use (21.9% vs 34.2%), compared with patients undergoing non-TORS procedures. On multivariate analysis, TORS was not associated with significant differences in postoperative complications or length of hospitalization. There was no significant difference in the odds of receiving postoperative radiation therapy between patients who underwent TORS and those who did not; however, among patients receiving radiation therapy, chemoradiation was significantly less likely following TORS (odds ratio [OR], 0.52; 95% CI, 0.29-0.90). TORS was associated with significantly decreased odds of posttreatment gastrostomy (OR, 0.54; 95% CI. 0.30-0.95) and tracheostomy during treatment (OR, 0.17; 95% CI, 0.06-0.55) at 1 year, and was associated with significantly decreased overall treatment-related costs of care (mean incremental cost, -$22 724). Conclusions and Relevance The use of TORS for surgical resection of OPC is increasing in the United States and is associated with significantly lower use of adjuvant chemoradiation, late gastrostomy and tracheostomy dependence, and lower overall treatment-related costs of care. These data have implications for discussions of value in OPC care at a time of health care reform.
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Affiliation(s)
- Kevin Motz
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Hsien-Yen Chang
- Department of Health Policy and Management, the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Harry Quon
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Jeremy Richmon
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland
| | - David W Eisele
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Christine G Gourin
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland
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17
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Britt CJ, Gourin CG. Contemporary management of advanced laryngeal cancer. Laryngoscope Investig Otolaryngol 2017; 2:307-309. [PMID: 29085911 PMCID: PMC5655558 DOI: 10.1002/lio2.85] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2017] [Indexed: 01/05/2023] Open
Abstract
The treatment of advanced laryngeal cancer has undergone a paradigm shift in recent years, with an increase in chemoradiation for organ preservation and a decrease in primary surgery. This review will summarize the contemporary management of advanced laryngeal cancer and discuss treatment‐related toxicity and strategies to improve outcomes. Level of Evidence NA.
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Affiliation(s)
| | - Christine G Gourin
- Department of Otolaryngology-Head and Neck Surgery Baltimore Maryland U.S.A
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18
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Day AT, Chang HY, Quon H, Kang H, Kiess AP, Eisele DW, Frick KD, Gourin CG. Treatment, short-term outcomes, and costs associated with larynx cancer care in commercially insured patients. Laryngoscope 2017; 128:91-101. [PMID: 28685830 DOI: 10.1002/lary.26717] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 03/22/2017] [Accepted: 05/05/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS To examine associations between treatment, complications, and costs in patients with laryngeal cancer. STUDY DESIGN Retrospective cross-sectional analysis of MarketScan Commercial Claim and Encounters data. METHODS We evaluated 10,969 patients diagnosed with laryngeal cancer from 2010 to 2012 using cross-tabulations and multivariate regression. RESULTS Chemoradiation was significantly associated with supraglottic tumors (relative risk ratio [RRR] = 5.9 [4.4-7.8]), pretreatment gastrostomy (RRR = 4.0 [2.7-6.1]), and alcohol abuse (RRR = 0.5 [0.3-0.9]). Treatment-related complications occurred in 23% of patients, with medical complications in 22% and surgical complications in 7%. Chemoradiation (odds ratio [OR] = 3.7 [2.6-5.2]), major surgical procedures (OR = 4.9 [3.5-6.8]), reconstruction (OR = 7.7 (4.1-14.7)], and advanced comorbidity (OR = 9.7 [5.7-16.5] were associated with acute complications. Recurrent/persistent disease occurred in 23% of patients and was associated with high-volume care (OR = 1.4 [1.1-1.8]). Salvage surgery was performed in 46% of patients with recurrent/persistent disease and was less likely for supraglottic disease (OR = 0.5 [0.4-0.8]) and after chemoradiation (OR = 0.4 [0.2-0.6]). Initial treatment and 1-year overall costs for chemoradiation were higher than all other treatment categories, after controlling for all other variables including complications and salvage. High-volume care was associated with significantly lower costs of care for surgical patients but was not associated with differences in costs of care for nonoperative treatment. CONCLUSIONS In commercially insured patients <65 years old with laryngeal cancer, chemoradiation was associated with increased costs, an increased likelihood of treatment-related medical complications, and a reduced likelihood of surgical salvage. Higher-volume surgical care was associated with lower initial treatment and 1-year costs of care. These data have implications for discussions of value and quality in an era of healthcare reform. LEVEL OF EVIDENCE 2c. Laryngoscope, 128:91-101, 2018.
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Affiliation(s)
- Andrew T Day
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, U.S.A
| | - Hsien-Yen Chang
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, U.S.A
| | - Harry Quon
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins Medical Institutions, Baltimore, Maryland, U.S.A
| | - Hyunseok Kang
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Medical Institutions, Baltimore, Maryland, U.S.A
| | - Ana P Kiess
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins Medical Institutions, Baltimore, Maryland, U.S.A
| | - David W Eisele
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, U.S.A
| | - Kevin D Frick
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, U.S.A.,Johns Hopkins Carey Business School, Baltimore, Maryland, U.S.A
| | - Christine G Gourin
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, U.S.A
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19
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Eskander A, Mifsud M, Irish J, Gullane P, Gilbert R, Brown D, de Almeida JR, Urbach DR, Goldstein DP. Overview of surgery for laryngeal and hypopharyngeal cancer in Ontario, 2003-2010. Head Neck 2017; 39:1559-1567. [PMID: 28593742 DOI: 10.1002/hed.24787] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Revised: 01/24/2017] [Accepted: 02/14/2017] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND The primary purpose of this study was to describe variations in incidence rates, resections rates, and types of surgical resection for patients diagnosed with laryngeal and hypopharyngeal cancers in Ontario. METHODS All laryngeal and hypopharyngeal cancer cases in Ontario (2003-2010) were identified from the Ontario Cancer Registry (n = 3034). Variations in incidence rates, resection rates, and type of surgical resection were compared by sex, age group, neighborhood income, community population, health region, and physician specialty. RESULTS Incidence rates per 100 000 vary significantly by sex, age, neighborhood income, and community size. Women, the elderly (75+ years), those in the higher income quintiles, and those living in larger communities were significantly less likely to receive a laryngectomy procedure. CONCLUSIONS Laryngeal and hypopharyngeal cancer incidence rates vary by sex, age, neighborhood income, community size, and health region. Resection rates vary by age, sex, and health region. These disparities warrant further evaluation to improve the quality of delivered care in Ontario.
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Affiliation(s)
- Antoine Eskander
- Department of Otolaryngology - Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Matthew Mifsud
- Department of Otolaryngology - Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan Irish
- Department of Otolaryngology - Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology - Head and Neck Surgery, Department of Surgical Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Patrick Gullane
- Department of Otolaryngology - Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology - Head and Neck Surgery, Department of Surgical Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Ralph Gilbert
- Department of Otolaryngology - Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology - Head and Neck Surgery, Department of Surgical Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Dale Brown
- Department of Otolaryngology - Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology - Head and Neck Surgery, Department of Surgical Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - John R de Almeida
- Department of Otolaryngology - Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology - Head and Neck Surgery, Department of Surgical Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - David R Urbach
- Division of General Surgery, Department of General Surgery and Surgical Oncology, University of Toronto, Toronto, Ontario, Canada
| | - David P Goldstein
- Department of Otolaryngology - Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology - Head and Neck Surgery, Department of Surgical Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
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20
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Wang J, Wu Y, Gao W, Li F, Bo Y, Zhu M, Fu R, Liu Q, Wen S, Wang B. Identification and characterization of CD133 +CD44 + cancer stem cells from human laryngeal squamous cell carcinoma cell lines. J Cancer 2017; 8:497-506. [PMID: 28261352 PMCID: PMC5332902 DOI: 10.7150/jca.17444] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 11/10/2016] [Indexed: 01/23/2023] Open
Abstract
Background: Laryngeal squamous cell carcinoma ranks second among head and neck squamous-cell carcinomas. Cancer stem cells can support cancer growth and malignant behavior. Therefore, cancer stem cells isolated from laryngeal squamous cell carcinoma tissue could be used to investigate the initiation, progression, and treatment strategies of this cancer. Methods: We isolated CD133-CD44-, CD133-CD44+, CD133+CD44- and CD133+CD44+ cell populations from laryngeal squamous-cell carcinoma cell lines Hep2 and TU-177 by magnetic-activated cell sorting. Sphere formation, cell proliferation, migration, invasion, colony formation, resistance to radio- and chemotherapy, and in vivo tumorigenicity of these populations were evaluated. Moreover, we investigated the expression of the stem-cell markers (sex determining region Y)-box 2 (SOX2) and octamer-binding transcription factor 4 (OCT4) in CD133-CD44-, CD133-CD44+, CD133+CD44-, CD133+CD44+ cell populations and parental Hep2 and TU-177 cells. Results: As compared with CD133-CD44-, CD133-CD44+, CD133+CD44- populations and parental cells, CD133+CD44+ cells showed higher cell viability, migration and invasive capability and colony formation ability as well as stronger resistance to cisplatin and irradiation. Moreover, levels of SOX2 and OCT4 and tumorigenicity in nude mice were greater in CD133+CD44+ Hep2 and TU-177 cells than other cell populations and parental cells. Conclusion: The CD133+CD44+ population of laryngeal squamous-cell carcinoma Hep2 and TU-177 cells have stem cell properties and showed more malignant features than CD133+CD44- and CD133-CD44+ cell populations. CD133+CD44+ cancer stem cells may be a promising target for developing anticancer drugs and treatment strategies for laryngeal squamous cell carcinoma.
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Affiliation(s)
- Jue Wang
- Department of Otolaryngology, Head & Neck Surgery, The First Hospital Affiliated with Shanxi Medical University, Taiyuan, Shanxi, China;; Shanxi Key Laboratory of Otolaryngology Head & Neck Cancer, Taiyuan, Shanxi, China
| | - Yongyan Wu
- Department of Otolaryngology, Head & Neck Surgery, The First Hospital Affiliated with Shanxi Medical University, Taiyuan, Shanxi, China;; Shanxi Key Laboratory of Otolaryngology Head & Neck Cancer, Taiyuan, Shanxi, China
| | - Wei Gao
- Department of Otolaryngology, Head & Neck Surgery, The First Hospital Affiliated with Shanxi Medical University, Taiyuan, Shanxi, China;; Shanxi Key Laboratory of Otolaryngology Head & Neck Cancer, Taiyuan, Shanxi, China
| | - Fei Li
- Department of Otolaryngology, Head & Neck Surgery, The First Hospital Affiliated with Shanxi Medical University, Taiyuan, Shanxi, China;; Shanxi Key Laboratory of Otolaryngology Head & Neck Cancer, Taiyuan, Shanxi, China
| | - Yunfeng Bo
- Department of Pathology, Shanxi Cancer Hospital, Taiyuan, Shanxi, China
| | - Meixia Zhu
- Department of Otolaryngology, Head & Neck Surgery, The First Hospital Affiliated with Shanxi Medical University, Taiyuan, Shanxi, China;; Shanxi Key Laboratory of Otolaryngology Head & Neck Cancer, Taiyuan, Shanxi, China
| | - Rong Fu
- Department of Otolaryngology, Head & Neck Surgery, The First Hospital Affiliated with Shanxi Medical University, Taiyuan, Shanxi, China;; Shanxi Key Laboratory of Otolaryngology Head & Neck Cancer, Taiyuan, Shanxi, China
| | - Qingqing Liu
- Department of Otolaryngology, Head & Neck Surgery, The First Hospital Affiliated with Shanxi Medical University, Taiyuan, Shanxi, China;; Shanxi Key Laboratory of Otolaryngology Head & Neck Cancer, Taiyuan, Shanxi, China
| | - Shuxin Wen
- Department of Otolaryngology, Head & Neck Surgery, The First Hospital Affiliated with Shanxi Medical University, Taiyuan, Shanxi, China;; Shanxi Key Laboratory of Otolaryngology Head & Neck Cancer, Taiyuan, Shanxi, China
| | - Binquan Wang
- Department of Otolaryngology, Head & Neck Surgery, The First Hospital Affiliated with Shanxi Medical University, Taiyuan, Shanxi, China;; Shanxi Key Laboratory of Otolaryngology Head & Neck Cancer, Taiyuan, Shanxi, China
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Predictive and prognostic factors for patients with locoregionally advanced laryngeal carcinoma treated with surgical multimodality protocol. Eur Arch Otorhinolaryngol 2016; 274:1701-1711. [DOI: 10.1007/s00405-016-4411-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 11/26/2016] [Indexed: 01/11/2023]
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22
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Geographic variation in Medicare treatment costs and outcomes for advanced head and neck cancer. Oral Oncol 2016; 61:83-8. [DOI: 10.1016/j.oraloncology.2016.08.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 08/26/2016] [Accepted: 08/30/2016] [Indexed: 11/30/2022]
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Chaudhary H, Stewart CM, Webster K, Herbert RJ, Frick KD, Eisele DW, Gourin CG. Readmission following primary surgery for larynx and oropharynx cancer in the elderly. Laryngoscope 2016; 127:631-641. [DOI: 10.1002/lary.26311] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 08/08/2016] [Accepted: 08/10/2016] [Indexed: 11/08/2022]
Affiliation(s)
- Hamad Chaudhary
- Department of Otolaryngology-Head and Neck Surgery; Johns Hopkins Medical Institutions; Baltimore Maryland U.S.A
| | - C. Matthew Stewart
- Department of Otolaryngology-Head and Neck Surgery; Johns Hopkins Medical Institutions; Baltimore Maryland U.S.A
| | - Kimberly Webster
- Department of Otolaryngology-Head and Neck Surgery; Johns Hopkins Medical Institutions; Baltimore Maryland U.S.A
| | - Robert J. Herbert
- Department of Health Policy and Management; the Johns Hopkins Bloomberg School of Public Health; Baltimore Maryland U.S.A
| | - Kevin D. Frick
- Department of Health Policy and Management; the Johns Hopkins Bloomberg School of Public Health; Baltimore Maryland U.S.A
- Johns Hopkins Carey Business School; Baltimore Maryland U.S.A
| | - David W. Eisele
- Department of Otolaryngology-Head and Neck Surgery; Johns Hopkins Medical Institutions; Baltimore Maryland U.S.A
| | - Christine G. Gourin
- Department of Otolaryngology-Head and Neck Surgery; Johns Hopkins Medical Institutions; Baltimore Maryland U.S.A
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Sagiv D, Migirov L, Lipschitz N, Dagan E, Glikson E, Wolf M, Alon EE. The admission patterns of octogenerians nonagenerians and centenarians to the Department of Otoloaryngology. Eur Arch Otorhinolaryngol 2016; 273:4615-4621. [PMID: 27356556 DOI: 10.1007/s00405-016-4165-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 06/22/2016] [Indexed: 11/30/2022]
Abstract
Life expectancy in Israel has risen by almost 6 years during the last 25 years, and the proportion of people 65 years of age or older is expected to reach 12 % of the total population by 2020. A substantial increase in the workload for Otolaryngologists and Head and Neck surgeons is anticipated. Our goal was to characterize the admissions of patients 80 years of age and older to the Department of Otolaryngology, Head and Neck Surgery in a tertiary medical center. The study group included all patients 80 years of age and older who were admitted to the Department of OTOHNS in our institute between 2009 and 2013. There were two control groups for comparison divided by age; one group 40-59 years old and the other group 60-79 years old. There were 385 admissions of 317 patients aged 80-103 years (4.2 % of overall admissions). Over the study period, admissions of patients over 80 years increased on average by 3 % per annum (p = 0.4), and those patients over 90 years old by 52 % per annum (p < 0.001). The most common indication was HN malignancy (28.8 %) followed by otologic disorders (22.0 %). Of the overall 158 operations conducted, 131 patients (82.9 %) underwent elective procedures (mainly oncology) and 27 patients (17.1 %) underwent emergent procedures. The distribution of the reasons for admission of the patients older than 80 years is surprisingly different from that of the "younger" patients. With life expectancy rising, our study predicts a workload increase mainly in the HN oncologic and otologic services.
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Affiliation(s)
- Doron Sagiv
- Department of Otolaryngology and Head & Neck Surgery, Sheba Medical Center, Tel Hashomer, 52621, Ramat Gan, Israel.
| | - Lela Migirov
- Department of Otolaryngology and Head & Neck Surgery, Sheba Medical Center, Tel Hashomer, 52621, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noga Lipschitz
- Department of Otolaryngology and Head & Neck Surgery, Sheba Medical Center, Tel Hashomer, 52621, Ramat Gan, Israel
| | - Elad Dagan
- Department of Otolaryngology and Head & Neck Surgery, Sheba Medical Center, Tel Hashomer, 52621, Ramat Gan, Israel
| | - Eran Glikson
- Department of Otolaryngology and Head & Neck Surgery, Sheba Medical Center, Tel Hashomer, 52621, Ramat Gan, Israel
| | - Michael Wolf
- Department of Otolaryngology and Head & Neck Surgery, Sheba Medical Center, Tel Hashomer, 52621, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eran E Alon
- Department of Otolaryngology and Head & Neck Surgery, Sheba Medical Center, Tel Hashomer, 52621, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Li F, Wang J, Chen M. Single nucleotide polymorphisms in DNA repair genes and the risk of laryngeal cancer: A meta-analysis. Biomed Pharmacother 2016; 78:92-100. [DOI: 10.1016/j.biopha.2015.12.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 12/14/2015] [Indexed: 12/19/2022] Open
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Concurrent chemoradiotherapy in older adults with squamous cell head & neck cancer: Evidence and management. J Geriatr Oncol 2016; 7:145-53. [PMID: 26924572 DOI: 10.1016/j.jgo.2016.01.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 12/06/2015] [Accepted: 01/29/2016] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Treatment for head and neck cancers incurs substantial associated morbidities, which can be of potentially greater significance in older patients. Though the geriatric population forms a substantial portion of patients with head and neck cancers, this group remains underrepresented in large clinical trials. Hence, management for this unique subpopulation remains empiric and mostly based on data from younger patients. MATERIALS AND METHODS Review of key publications on geriatric patients treated for head and neck cancers. CONCLUSIONS We discuss data regarding chemoradiation for head and neck cancers, as well as management of associated side effects in this population. We encourage oncologists to treat older patients not as a homogeneous subpopulation, but rather assess several factors associated with potential tolerance to chemoradiotherapy. Aggressive supportive treatments for chemoradiotherapy toxicities are highly encouraged in this population, and with new technical/technological developments, there is potential to continually reduce toxicity in this cohort in the future.
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Cramer JD, Patel UA, Samant S, Smith SS. Postoperative Complications in Elderly Patients Undergoing Head and Neck Surgery. Otolaryngol Head Neck Surg 2015; 154:518-26. [DOI: 10.1177/0194599815618204] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Accepted: 10/29/2015] [Indexed: 11/17/2022]
Abstract
Objective To assess the frequency and nature of postoperative complications that occur in elderly patients, as compared with younger patients, following head and neck surgery. Study Design Cohort study of national database. Setting American College of Surgeons National Surgical Quality Improvement Program from 2005 to 2013. Subjects and Methods We identified 29,891 patients who had head and neck surgery during the study period and classified them as having upper aerodigestive tract surgery (n = 8383) or endocrine/salivary gland (n = 21,508) surgery. We analyzed patients stratified by age categories: young (<65 years), intermediate age (65-75 years), and elderly (≥75 years). Risk-adjusted 30-day morbidity and mortality outcomes were compared across age categories with multivariable logistic regression models to adjust for patient characteristics, comorbidities, and surgical procedure. Results Elderly patients had increased odds for morbidity (adjusted odds ratio [OR] = 1.47, 95% CI: 1.22-1.78; OR = 1.89, 95% CI: 1.46-2.44) for upper aerodigestive tract and endocrine/salivary gland groups, respectively, versus young patients and for mortality (OR = 2.52, 95% CI: 1.26-5.06; OR = 3.73, 95% CI: 1.32-10.52). Elderly patients were more likely to develop pulmonary, urologic, and blood clotting–related complications. Elderly patients undergoing endocrine/salivary gland surgery were significantly more likely to have cardiac complications; however, this was not the case for aerodigestive tract operations. Conclusions Head and neck surgery in the elderly carries an increased risk of certain types of postoperative complications as compared with younger patients treated similarly. Quality improvement efforts should focus on minimizing the risk of cardiac, pulmonary, and urologic complications in elderly patients.
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Affiliation(s)
- John D. Cramer
- Department of Otolaryngology–Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Urjeet A. Patel
- Department of Otolaryngology–Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sandeep Samant
- Department of Otolaryngology–Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Stephanie Shintani Smith
- Department of Otolaryngology–Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Kaplan DJ, Kim JH, Wang E, Snyderman C. Prognostic Indicators for Salvage Surgery of Recurrent Sinonasal Malignancy. Otolaryngol Head Neck Surg 2015; 154:104-12. [PMID: 26424747 DOI: 10.1177/0194599815606699] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 08/27/2015] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Identify prognostic factors after salvage surgery for recurrent sinonasal malignancy (SNM). STUDY DESIGN Case series with chart review. SETTING University of Pittsburgh Medical Center. SUBJECTS Forty-two patients who underwent curative surgery for locally recurrent SNM ± adjuvant therapy from June 5, 2000, to December 19, 2012. Patients without follow-up were excluded. METHODS Chart review with established prognostic indicators for primary malignancies. Statistical analysis included Kaplan-Meier log-rank test, Fisher's exact test, Student's t test, and Cox regression. RESULTS Forty-two patients met inclusion criteria: 38.5% developed a second recurrence, and 21.4% had metastases following treatment. The average disease-free interval (DFI) was 26.9 months (range, 2-90 months). DFI was significantly affected by ethmoid versus nonethmoid site (P = .049), histology (P = .012), carotid artery involvement (P = .008), perineural extension (P = .006), and clival invasion (P = .015). The overall survival rates at 6 months, 12 months, and 5 years following surgery were 83.3%, 69%, and 47.6%, respectively. Survival was affected by histology (P = .014), stratified grade (P = .042), tumor extension into the orbit (P = .019), carotid artery (P = .001), perineural space (P = .028), and clivus (P = .022). Complications occurred in 28.6% of patients and were associated with histology (P = .04). Length of hospital stay related to treatment was affected by histology (P = .009), grade (P = .013), and postoperative complication (P < .001). The median percentage of time hospitalized was 8%, and 43% of patients who died within 12 months spent >10% of their remaining days in the hospital. CONCLUSION High-risk histologic subtype (melanoma, sinonasal undifferentiated carcinoma, adenocarcinoma, neuroendocrine cancer, sarcoma, and squamous cell carcinoma), grade, and orbital and skull base involvement negatively affect survival and/or DFI for patients with local recurrence of SNM. Improved stratification of patients can be used to guide decision making for patients with recurrent SNM and to avoid inappropriate surgery.
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Affiliation(s)
| | - Jee Hong Kim
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Eric Wang
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Carl Snyderman
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Starmer HM, Quon H, Simpson M, Webster K, Tippett D, Herbert RJ, Eisele DW, Gourin CG. Speech-language pathology care and short- and long-term outcomes of laryngeal cancer treatment in the elderly. Laryngoscope 2015; 125:2756-63. [DOI: 10.1002/lary.25454] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 05/19/2015] [Accepted: 06/03/2015] [Indexed: 11/10/2022]
Affiliation(s)
| | - Harry Quon
- Department of Radiation Oncology and Molecular Radiation Sciences; Johns Hopkins University
| | | | | | | | - Robert J. Herbert
- Department of Health Policy and Management; the Johns Hopkins Bloomberg School of Public Health; Baltimore Maryland U.S.A
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Gourin CG, Starmer HM, Herbert RJ, Frick KD, Forastiere AA, Quon H, Eisele DW, Dy SM. Quality of care and short‐ and long‐term outcomes of laryngeal cancer care in the elderly. Laryngoscope 2015; 125:2323-9. [DOI: 10.1002/lary.25378] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2015] [Indexed: 11/07/2022]
Affiliation(s)
| | | | - Robert J. Herbert
- Department of Health Policy and Managementthe Johns Hopkins Bloomberg School of Public Health
| | - Kevin D. Frick
- Department of Health Policy and Managementthe Johns Hopkins Bloomberg School of Public Health
- Johns Hopkins Carey Business School
| | - Arlene A. Forastiere
- Department of OncologySidney Kimmel Comprehensive Cancer CenterBaltimore Maryland U.S.A
| | - Harry Quon
- Department of Radiation Oncology and Molecular Radiation SciencesJohns Hopkins University
| | | | - Sydney M. Dy
- Department of Health Policy and Managementthe Johns Hopkins Bloomberg School of Public Health
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31
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Mulvey CL, Pronovost PJ, Gourin CG. Hospital volume and failure to rescue after head and neck cancer surgery. Otolaryngol Head Neck Surg 2015; 152:783-9. [PMID: 25681489 DOI: 10.1177/0194599815570026] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Accepted: 01/08/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To investigate the relationship between hospital volume and mortality, complications, and failure-to-rescue rates among patients undergoing head and neck cancer (HNCA) surgery. STUDY DESIGN Cross-sectional analysis. SETTING Nationwide Inpatient Sample. SUBJECTS AND METHODS Discharge data for 159,301 patients who underwent an ablative procedure for a malignant oral cavity, laryngeal, hypopharyngeal, or oropharyngeal neoplasm from 2001 to 2010 were analyzed using cross-tabulations and multivariate regression modeling. Failure to rescue was defined as death after a major complication, including acute myocardial infarction, acute renal failure, venous thromboembolism, pneumonia, gastrointestinal bleed, pulmonary failure, hemorrhage, or surgical site infection. We compared the incidence of mortality, major complications, and failure-to-rescue rates across hospital volume tertiles. RESULTS The majority of hospitals performing HNCA surgery were low-volume hospitals, which performed a mean of 6 HNCA cases per year (n = 7635). Intermediate-volume hospitals performed a mean of 37 cases per year (n = 729), and high-volume hospitals performed a mean of 131 cases (n = 207). High-volume hospital care was associated with significantly decreased odds of death (odds ratio, 0.56; 95% confidence interval, 0.46-0.86) and failure to rescue (odds ratio, 0.56; 95% confidence interval, 0.33-0.97) compared to low-volume hospital care. However, there was no significant difference in major complication rates between patients undergoing HNCA surgery at high-volume hospitals and those at low-volume hospitals. CONCLUSION Patients with HNCA who receive care at high-volume hospitals compared with low-volume hospitals have a 44% lower odds of mortality, which appears to be associated with differences in the response to and management of complications rather than differences in complication rates.
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Affiliation(s)
- Carolyn L Mulvey
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Peter J Pronovost
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medical Institutions, Baltimore, Maryland Department of Health Policy and Management, Bloomberg School of Public Health, Baltimore, Maryland
| | - Christine G Gourin
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medical Institutions, Baltimore, Maryland
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32
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Gourin CG, Starmer HM, Herbert RJ, Frick KD, Forastiere AA, Eisele DW, Quon H. Short- and long-term outcomes of laryngeal cancer care in the elderly. Laryngoscope 2014; 125:924-33. [PMID: 25367258 DOI: 10.1002/lary.25012] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 09/03/2014] [Indexed: 12/14/2022]
Abstract
OBJECTIVES/HYPOTHESIS To examine associations between pretreatment variables, short-term and long-term swallowing and airway impairment, and survival in elderly patients treated for laryngeal squamous cell cancer (SCCA). STUDY DESIGN Retrospective analysis of Surveillance, Epidemiology, and End Results-Medicare data. METHODS Longitudinal data from 2,370 patients diagnosed with laryngeal SCCA from 2004 to 2007 were evaluated using cross-tabulations, multivariate logistic regression, and survival analysis. RESULTS Dysphagia (odds ratio [OR] = 1.5 [1.2-1.7]), weight loss (OR = 1.3 [1.1-1.6]), esophageal stricture (OR = 3.8 [2.5-5.9]), airway obstruction (OR = 1.9, [1.6-2.3]), tracheostomy (OR = 1.5 [1.2-1.9]), and pneumonia (OR = 1.8 [1.4-2.2]) increased 1 year after treatment. The odds of airway obstruction, esophageal stricture, and pneumonia increased over subsequent years, with significantly increased risk at 5 years for airway obstruction (OR = 3.3 [1.8-5.8]) and pneumonia (OR = 5.2 [2.5-10.7]). Pretreatment dysphagia, chemoradiation, and salvage surgery were significant predictors of long-term dysphagia, weight loss, tracheostomy, and gastrostomy, with pretreatment dysphagia and salvage surgery also associated with pneumonia. Surgery and postoperative radiation was associated with long-term dysphagia (OR = 1.4 [1.0-1.9]) but reduced odds of long-term pneumonia (OR = 0.7 [0.5-0.9]). Long-term dysphagia, gastrostomy or tracheostomy dependence, weight loss, airway obstruction, and pneumonia were associated with poorer survival, with pneumonia associated with the greatest risk of death at 5 years (hazard ratio = 2.6 [2.4-2.9]). CONCLUSIONS Airway and swallowing impairment is common after laryngeal SCCA treatment in elderly patients, increases over time, and is associated with poorer survival-with pneumonia associated with the highest risk of long-term mortality. Patients with pretreatment dysphagia, initial treatment with chemoradiation, and salvage surgery represent a high-risk group with an increased risk of disability and death.
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Affiliation(s)
- Christine G Gourin
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, U.S.A
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