Publications by authors named "David P Goldstein"

196 Publications

To ban or not to ban tanning bed use for minors: A cost-effectiveness analysis from multiple US perspectives for invasive melanoma.

Cancer 2021 Apr 12. Epub 2021 Apr 12.

Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York.

Background: Tanning bed use is common among US adolescents, but is associated with increased melanoma risk. The decision to ban tanning bed use by adolescents should be made in consideration of the potential health benefits and costs.

Methods: The US population aged 14 to 17 years was modeled by microsimulation, which compared ban versus no ban strategies. Lifetime quality-adjusted life years (QALYs) and costs were estimated from a health care sector perspective and two societal perspectives: with and without the costs of policy enforcement and the economic losses of the indoor-tanning bed industry.

Results: Full adherence to the ban prevented 15,102 melanoma cases and 3299 recurrences among 17.1 million minors, saving $61in formal and informal health care costs per minor and providing an increase of 0.0002 QALYs. Despite the intervention costs of the ban and the economic losses to the indoor-tanning industry, banning was still the dominant strategy, with a savings of $12 per minor and $205.4 million among 17.1 million minors. Findings were robust against varying inspection costs and ban compliance, but were sensitive to lower excess risk of melanoma with early exposure to tanning beds.

Conclusions: A ban on tanning beds for minors potentially lowers costs and increases cost effectiveness. Even after accounting for the costs of implementing a ban, it may be considered cost effective. Even after accounting for the costs of implementing a ban and economic losses in the indoor-tanning industry, a tanning bed ban for US minors may be considered cost effective. A ban has the potential to reduce the number of melanoma cases while decreasing health care costs.

Lay Summary: Previous meta-analyses have linked tanning bed use with an increased risk of melanoma, particularly with initial use at a young age. Yet, it remains unclear whether a ban of adolescents would be cost effective. Overall, a ban has the potential to reduce the number of melanoma cases while promoting a decrease in health care costs. Even after accounting for the costs of implementing a ban and the economic losses incurred by the indoor-tanning industry, a ban would be cost effective.
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http://dx.doi.org/10.1002/cncr.33499DOI Listing
April 2021

Elective neck dissection versus positron emission tomography-computed tomography-guided management of the neck in clinically node-negative early oral cavity cancer: A cost-utility analysis.

Cancer 2021 Feb 26. Epub 2021 Feb 26.

Department of Otolaryngology-Head & Neck Surgery, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.

Background: In early oral cavity cancer, elective neck dissection (END) for the clinically node-negative (cN0) neck improves survival compared with observation. This paradigm has been challenged recently by the use of positron emission tomography-computed tomography (PET-CT) imaging in the cN0 neck. To inform this debate, we performed an economic evaluation comparing PET-CT-guided therapy with routine END in the cN0 neck.

Methods: Patients with T1-2N0 lateralized oral tongue cancer were analyzed. A Markov model over a 40-year time horizon simulated treatment, disease recurrence, and survival from a US health care payer perspective. Model parameters were derived from a review of the literature.

Results: The END strategy was dominant, with a cost savings of $1576.30 USD, an increase of 0.055 quality-adjusted life years (QALYs), a net monetary benefit of $4303 USD, and a 0.22 life-year advantage. END was sensitive to variation in cost and utilities in deterministic and probabilistic sensitivity analyses. PET-CT became the preferred strategy when decreasing occult nodal disease to 18% and increasing the negative predictive value (NPV) of PET-CT to 89% in 1-way sensitivity analyses. In probabilistic sensitivity analysis, assuming a cost effectiveness threshold of $50,000 USD/QALY, END was dominant in 64% of simulations and cost effective in 69.8%.

Conclusion: END is a cost-effective strategy compared with PET-CT in patients who have node-negative oral cancer. Although lower PET standardized uptake value thresholds would result in fewer false negatives and improved NPV, it is still uncertain that PET-CT would be cost effective, as this would likely result in more false positive tests.
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http://dx.doi.org/10.1002/cncr.33446DOI Listing
February 2021

Evaluation of the Braden scale in predicting surgical outcomes in older patients undergoing major head and neck surgery.

Laryngoscope Investig Otolaryngol 2021 Feb 9;6(1):103-108. Epub 2020 Dec 9.

Department of Otolaryngology Head and Neck Surgery/Surgical Oncology University Health Network, Princess Margaret Cancer Center, University of Toronto Toronto Ontario Canada.

Background: Being able to predict negative postoperative outcomes is important for helping select patients for treatment as well for informed decision-making by patients. Frailty measures are often time and resource intensive to use as screening measures, whereas the Braden scale, a commonly used measure to assess patients at risk of developing pressure ulcers after surgery, may be a potential tool to predict postoperative complication rates and longer length of stay (LOS) in patients undergoing major head and neck cancer surgery.

Methods: A retrospective analysis of Braden scale scores was performed on a prospectively collected cohort of patients undergoing major head and neck surgery recruited between December 2011 and April 2014. The association of Braden scale score with the primary outcomes of complications and LOS was analyzed using logistic regression and linear regression models on univariate analysis (UVA), respectively. Multivariate analysis (MVA) was performed based on a backward stepwise selection algorithm.

Results: There were 232 patients with a mean (SD) Braden scale score of 14.9 (2.8) with a range from 9 to 23. The Braden scale (β = -.07 per point; 95% CI -0.09, -0.04,  < .001) was an independent predictor of increased LOS on UVA, but not on MVA when adjusted for other variables. For overall complications, as well as type of complication, the Braden scale score was not a significant predictor of complications on either UVA or MVA.

Conclusion: In the sample population, the Braden scale did not demonstrate an ability to predict negative outcomes in head and neck surgery patients.

Level Of Evidence: Level 2b individual cohort study.
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http://dx.doi.org/10.1002/lio2.491DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7883615PMC
February 2021

Head and neck imaging surveillance strategy for HPV-positive oropharyngeal carcinoma following definitive (chemo)radiotherapy.

Radiother Oncol 2021 Feb 16;157:255-262. Epub 2021 Feb 16.

Department of Medical Imaging, University of Toronto, Canada; Department of Medical Imaging, Princess Margaret Cancer Centre, University of Toronto, Canada.

Purpose: To describe the utilization pattern of head and neck (HN) surveillance imaging and explore the optimal strategy for radiologic "residual" lymph node (LN) surveillance following definitive (chemo)radiotherapy (RT/CRT) in human papillomavirus (HPV)+ oropharyngeal carcinoma (OPC).

Methods: All HPV+ OPC patients who completed RT/CRT from 2012 to 2015 were included. Schedule and rationale for post-treatment HN-CT/MRI were recorded. Imaging findings and oncologic outcomes were evaluated.

Results: A total of 1036 scans in 412 patients were reviewed: 414 scans for first post-treatment response assessment and 622 scans for the following reasons: follow-up of radiologic "residual" LN(s) (293 scans/175 patients); local symptoms (227/146); other (17/16); unknown (85/66). Rate of scans with "unstated" reason varied significantly among clinicians (3-28%, p < 0.001) and none of them yielded any positive imaging findings. First post-treatment scans identified 192 (47%) patients with radiologic "residual" LNs. Neck dissection (ND) was performed in 28 patients: 16 immediately (6/16 positive), 10 after one follow-up scan (2/10 positive), and 2 after 2nd follow-up scan (1/2 positive). Thirty patients had >2 consecutive follow-up scans at 2-3-month intervals, and none showed subsequent imaging progression or regional failure.

Conclusions: Pattern of HN imaging utilization for surveillance varied significantly among clinicians. Imaging surveillance reduces the need for ND. However, routine HN-CT/MR surveillance without clinical symptoms/signs does not demonstrate proven value in identifying locoregional failure or toxicity. Radiologic "residual" LNs without adverse features are common. If two subsequent follow-up scans demonstrate stable/regressing radiologic "residual" LNs, clinical surveillance without further imaging appears to be safe in this population.
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http://dx.doi.org/10.1016/j.radonc.2021.02.005DOI Listing
February 2021

Comparing unilateral vs. bilateral neck management in lateralized oropharyngeal cancer between surgical and radiation oncologists: An international practice pattern survey.

Oral Oncol 2021 Mar 30;114:105165. Epub 2021 Jan 30.

Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Canada.

Background: Management of the neck in oropharyngeal carcinoma varies due to a lack of clarity of patterns of lymphatic drainage and concern of failure in the contralateral neck. With recent advances in transoral surgical techniques, surgical management has become increasingly prevalent as the primary treatment modality. We compare international practice patterns between surgical and radiation oncologists.

Methods: A survey of neck management practice patterns was developed and pilot tested by 6 experts. The survey comprised items eliciting the nature of clinical practice, as well as patterns of neck management depending on extent of nodal disease and location and extent of primary site disease. Proportions of surgical and radiation oncologists treating the neck bilaterally were compared using the chi-squared statistic.

Results: Two-hundred and twenty-two responses were received from 172 surgical oncologists, 44 radiation oncologists, 3 medical oncologists, and 3 non-oncologists from 32 different countries. For tongue base cancers within 1 cm of midline (67% vs. 100%, p < 0.001), and for tonsil cancers with extension to the medial 1/3 of the soft palate (65% vs. 100%, p < 0.001) or tongue base (77% vs. 100%, p < 0.001), surgical oncologists were less likely to treat the neck bilaterally. For isolated tonsil fossa cancers with no nodal disease, both surgical and radiation oncologists were similarly likely to treat unilaterally (99% vs. 97%, p = NS). However, with increasing nodal burden, radiation oncologists were more likely to treat bilaterally for scenarios with a single node < 3 cm (15% vs. 2%, p < 0.001), a single node with extranodal extension (41% vs. 18%, p < 0.001), multiple positive nodes (55% vs. 23% p < 0.001), and node(s) > 6 cm (86% vs. 33%, p < 0.001). For tumors with midline extension, even with a negative PET in the contralateral neck, the majority of surgical and radiation oncologists would still treat the neck bilaterally (53% and 84% respectively).

Conclusions: The present study demonstrates significant practice pattern variability for management of the neck in patients with lateralized oropharyngeal carcinoma. Surgical oncologists are less likely to treat the neck bilaterally, regardless of tumor location or nodal burden. Even in the absence of disease in the contralateral neck on imaging, them majority of practitioners are likely to treat bilaterally when the disease approaches midline.
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http://dx.doi.org/10.1016/j.oraloncology.2020.105165DOI Listing
March 2021

Decision-making in Surgery or Active Surveillance for Low Risk Papillary Thyroid Cancer During the COVID-19 Pandemic.

Cancers (Basel) 2021 Jan 20;13(3). Epub 2021 Jan 20.

Princess Margaret Cancer Centre, Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology, University Health Network and University of Toronto, Toronto, ON M5G 2C4, Canada.

We describe our experience conducting a prospective observational cohort study on the management of small, low risk papillary thyroid cancer during the COVID-19 pandemic. Our study participants are given the choice of active surveillance (AS) or surgery, and those in the AS arm are followed at the study center, whereas surgical patients undergo usual care. During the pandemic we have transitioned from in-person research patient visits to largely virtual care of patients under AS. As of 30 October 2020, we had enrolled 181 patients enrolled in our study (including 25 during the pandemic), of which 92.3% (167/181) consented to telephone communication and 79.0% (143/181) consented to secure videoconferencing communication. Prior to the pandemic, 74.5% (117/157) of our patients chose AS over surgery, whereas during the pandemic, 96.0% (24/25) chose AS. Of the 133 study patients who were under AS within the timeframe from 12 March 2020, to 30 October 2020, the percentage of patients who missed appointments was 8.3% (11/133, for neck ultrasound and physician visits, respectively) and delayed appointments was 23.3% (31/133). This preliminary data suggests that prospective observational research on AS of thyroid cancer can safely continue during the pandemic.
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http://dx.doi.org/10.3390/cancers13030371DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7864172PMC
January 2021

Longitudinal Assessment of Frailty and Quality of Life in Patients Undergoing Head and Neck Surgery.

Laryngoscope 2021 Jan 11. Epub 2021 Jan 11.

Department of Otolaryngology - Head and Neck Surgery, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.

Objective: To understand changes in frailty and quality of life (QOL) in frail versus non-frail patients undergoing surgery for head and neck cancer (HNC).

Methods: Prospective cohort study of patients (median age 67 (50, 88)) with HNC undergoing surgery from December 2011 to April 2014. Fried's Frailty Index, Vulnerable Elders Survey (VES-13), and comprehensive QOL assessments (EORTC QLQ-C30 and HN35) were completed at baseline and 3, 6, and 12-month post-operative visits. Change in frailty and QOL over time was compared between frailty groups (non-frail (score 0), pre-frail (score 1-2), and frail (score 3-5)) using a mixed effects model. Predictors of long-term elevated frailty (12 months > baseline) were analyzed using logistic regression.

Results: The study had 108 patients classified as non-frail (47%), 104 pre-frail (mean (SD) 1.3 (0.4), 45%), and 17 frail (3.4 (0.6); 7%). Frailty score decreased significantly for frail patients 3 months post-operatively (2.1 (1.0); P = .002) and remained significantly lower than baseline at 6 and 12 months (2.1 (1.4); P = .0008 and 2.2 (1.5); P = .005, respectively) while frailty score increased for non-frail patients at 3 months (1.1 (1.0); P < .001) and then decreased. Forty-eight patients (21%) had long-term elevated frailty, with baseline frailty and marital status identified as predictors on univariate analysis. The frail population had significantly worse QOL scores at baseline, which persisted 12 months post-operatively.

Conclusions: Frail patients demonstrate a decrease in frailty score following surgical treatment of HNC. Frail patients have significantly worse QOL scores on longitudinal assessment and would benefit from supportive services throughout their care.

Level Of Evidence: 3 Laryngoscope, 2021.
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http://dx.doi.org/10.1002/lary.29375DOI Listing
January 2021

Temporal Artery Posterior Auricular Skin Free Flap for Secondary Oral Cavity Reconstruction.

Laryngoscope 2020 Dec 15. Epub 2020 Dec 15.

Department of Otolaryngology - Head and Neck Surgery / Surgical Oncology, University of Toronto, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.

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http://dx.doi.org/10.1002/lary.29250DOI Listing
December 2020

Healthcare resource utilization following unilateral versus bilateral radiation therapy for oropharyngeal carcinoma.

Radiother Oncol 2021 Mar 29;156:95-101. Epub 2020 Nov 29.

Department of Otolaryngology-Head & Neck Surgery/Surgical Oncology, Princess Margaret Cancer Centre/University of Toronto, Canada.

Purpose: To describe differences in healthcare resource utilization between patients treated with bilateral vs. unilateral neck radiation therapy (RT) for lateralized oropharyngeal cancer.

Methods: A propensity score matching strategy was used to identify two otherwise clinically similar cohorts of tonsillar cancer patients treated with either bilateral or unilateral neck RT. Cohorts were matched based on similar propensity scores for age, sex, ECOG performance status, pack-year smoking history, cT-category, cN-category, HPV-status, and use of concurrent chemotherapy. Short term (from start of RT to 3 months following end of RT) resource utilization included: 1) outpatient supportive care visits, 2) hospital admission, and 3) interventions (feeding tube insertion and outpatient intravenous hydration). Long-term resource utilization included feeding tube dependency at 1-year.

Results: Among 559 patients with tonsillar cancer treated between 2004-2017, propensity score matching identified a unilateral neck RT cohort (n = 81) and bilateral neck RT cohort (n = 81) with similar clinical and treatment characteristics. Bilateral neck RT was associated with a higher likelihood of hospitalization (33% vs 12%, p < 0.01), outpatient IV hydration (33% vs 17%, p = 0.03), and feeding tube insertion (33% vs 10%, p < 0.001); a greater number of total days of hospitalization (110 vs 47 days, p < 0.01) and outpatient IV hydration (135 vs 72 days, p = 0.02); and higher total number of supportive clinic visits (1226 vs 1053 days, p = 0.04). In the long-term, bilateral RT was associated with higher rate of feeding tube dependency at 1-year (7% vs 0%, p < 0.001).

Conclusion: Bilateral RT for tonsillar cancer resulted in significant increase in health resource utilization.
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http://dx.doi.org/10.1016/j.radonc.2020.11.028DOI Listing
March 2021

Short-term and long-term unstimulated saliva flow following unilateral vs bilateral radiotherapy for oropharyngeal carcinoma.

Head Neck 2021 Feb 15;43(2):456-466. Epub 2020 Oct 15.

Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, Toronto, Ontario, Canada.

Background: We aimed to compare unstimulated saliva flow using 3-minute modified Schirmer test (MST) following bilateral vs unilateral radiotherapy (RT) in oropharyngeal carcinoma (OPC).

Methods: We reviewed OPC patients treated with definitive intensity-modulated radiation therapy (IMRT) between 2011 and 2017. MST was measured at baseline, 1-/6-/12-/24-month post-RT. MST values were compared between bilateral-RT vs unilateral-RT groups. Multivariable logistic regression analysis (MVA) identified predictors of hyposalivation (MST < 25 mm).

Results: Total 498 bilateral-RT and 36 unilateral-RT patients were eligible. The MST values at 1-/6-/12-/24-month post-RT were all significantly reduced from baseline for the entire cohort. Baseline unilateral-RT and bilateral-RT MST values (in mm) were similar (P = .2), but much higher for unilateral-RT 1-month (mean: 19.1 vs 13.0, P = .03), 6-month (20.5 vs 9.3, P < .001), 12-month (20.1 vs 11.9, P < .01), and 24-month post-RT (22.2 vs 13.9, P = .04). MVA confirmed that unilateral RT reduced the likelihood of hyposalivation vs bilateral RT (OR 2.36, P = .006).

Conclusion: Unilateral RT reduces unstimulated salivary flow in OPC patients.
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http://dx.doi.org/10.1002/hed.26496DOI Listing
February 2021

Pre- and Post-Radiotherapy Radiologic Nodal Features and Oropharyngeal Cancer Outcomes.

Laryngoscope 2021 04 1;131(4):E1162-E1171. Epub 2020 Oct 1.

Department of Radiation Oncology, The Princess Margaret Cancer Centre/University of Toronto, Toronto, Ontario, Canada.

Objectives: To assess the prognostic value of pre-/post-radiotherapy (pre-/post-RT) radiologic lymph node (LN) features in human papillomavirus (HPV)-positive and HPV-negative oropharyngeal carcinoma (OPC) patients treated with definitive (chemo-)RT.

Methods: Clinical node-positive OPCs treated from 2011 to 2015 were reviewed. Nodal features were reviewed by a radiologist on pre-/post-RT computed tomography (CTs). Univariable analysis calculated hazard ratio (HR) for regional failure (RF), distant metastasis (DM), and deaths. Multivariable analysis estimated adjusted HR (aHR) of significant nodal features identified in univariable analysis adjusting for confounders.

Results: Pre-RT CT was undertaken in 344 HPV-positive and 94 HPV-negative OPC patients, of whom 242 (70%) HPV-positive and 67 (71%) HPV-negative also had a post-RT CT. Median follow-up was 4.9 years. Pre-RT LN calcification (pre-RT_LN-cal) increased the risk of RF in HPV-negative (aHR: 5.3, P = .007) but not HPV-positive patients (P = .110). Pre-RT radiologic extranodal extension (pre-RT_rENE+) increased the risk of DM and death in both HPV-negative (DM: aHR 6.6, P < .001; death: aHR 2.1, both P = .019) and HPV-positive patients (DM: aHR 4.9; death: aHR 3.0, both P < .001). Increased risk of RF occured with < 20% post-RT LN size reduction in both HPV-negative (HR 6.0, P = .002) and HPV-positive cases (HR 3.0, P = .049). Post-RT_LN-cal did not affect RF, DM, or death regardless of tumor HPV status (all P > .05).

Conclusion: Pre-RT_LN-cal is associated with higher RF risk in HPV-negative but not in HPV-positive patients. Pre-RT_rENE increases risk of DM and death regardless of tumor HPV status. Minimal post-RT LN size reduction (< 20%) increases risk of RF in both diseases. Post-RT_LN-cal + has no apparent influence on outcomes in either disease.

Level Of Evidence: 4 (a single institution case-control series) Laryngoscope, 131:E1162-E1171, 2021.
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http://dx.doi.org/10.1002/lary.29045DOI Listing
April 2021

Shared Decision Making for Surgical Care in the Era of COVID-19.

Otolaryngol Head Neck Surg 2021 02 1;164(2):297-299. Epub 2020 Sep 1.

Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.

The global pandemic caused by severe acute respiratory syndrome coronavirus 2 has upended surgical practice. In an effort to preserve resources, mitigate risk, and maintain health system capacity, nonurgent surgeries have been deferred in many jurisdictions, with urgent procedures facing increasing wait times and unpredictability given potential future surges. Shared decision making, a process that integrates patient values and preferences with the scientific expertise of clinicians, may be of particular benefit during these unprecedented times. Aligning patient choices with their values, reducing unnecessary health care use, and promoting consistency between providers are now more critical than ever before. We review important aspects of shared decision making and provide guidance for its perioperative application during the coronavirus disease 2019 pandemic.
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http://dx.doi.org/10.1177/0194599820954138DOI Listing
February 2021

Non-operative management for oral cavity carcinoma: Definitive radiation therapy as a potential alternative treatment approach.

Radiother Oncol 2021 01 28;154:70-75. Epub 2020 Aug 28.

Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Canada. Electronic address:

Purpose: To determine the outcomes of oral cavity squamous cell cancer (OSCC) patients treated with non-surgical approach i.e. definitive intensity-modulated radiation therapy (IMRT).

Methods: All OSCC patients treated radically with IMRT (without primary surgery) between 2005-2014 were reviewed in a prospectively collected database. OSCC patients treated with definitive RT received concurrent chemotherapy except for early stage patients or those who declined or were unfit for chemotherapy. The 5-year local, and regional, distant control rates, disease-free, overall, and cancer-specific survival, and late toxicity were analyzed.

Results: Among 1316 OSCC patients treated with curative-intent; 108 patients (8%) received non-operative management due to: medical inoperability (n = 14, 13%), surgical unresectability (n = 8, 7%), patient declined surgery (n = 15, 14%), attempted preservation of oral structure/function in view of required extensive surgery (n = 53, 49%) or extensive oropharyngeal involvement (n = 18, 17%). Sixty-eight (63%) were cT3-4, 38 (35%) were cN2-3, and 38 (35%) received concurrent chemotherapy. With a median follow-up of 52 months, the 5-year local, regional, distant control rate, disease-free, overall, and cancer-specific survival were 78%, 92%, 90%, 42%, 50%, and 76% respectively. Patients with cN2-3 had higher rate of 5-year distant metastasis (24% vs 3%, p = 0.001), with detrimental impact on DFS (p = 0.03) and OS (p < 0.02) on multivariable analysis. Grade ≥ 3 late toxicity was reported in 9% of patients (most common: grade 3 osteoradionecrosis in 6%).

Conclusions: Non-operative management of OSCC resulted in a meaningful rate of locoregional control, and could be an alternative curative approach when primary surgery would be declined, unsuitable or unacceptably delayed.
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http://dx.doi.org/10.1016/j.radonc.2020.08.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7453211PMC
January 2021

Nicotine dependence as a risk factor for upper aerodigestive tract (UADT) cancers: A mediation analysis.

PLoS One 2020 28;15(8):e0237723. Epub 2020 Aug 28.

Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada.

Purpose: This study investigated nicotine dependence as an independent risk factor for upper aerodigestive tract (UADT) cancers, including lung and head and neck cancers (HNC). The study aimed to isolate the direct effect of nicotine dependence, independent of tobacco smoking.

Methods: A case-control study with a total of 4957 participants was conducted in Ontario, Canada, of which 2964 categorized as either current or former smokers were used in the analysis. Nicotine dependence of ever-smokers (2360 UADT cases and 604 controls) was measured using the Fagerström Test for Nicotine Dependence. Using mediation analyses and adjusted logistic regression models, we decomposed the direct effect of nicotine dependence and the mediated effect of smoking duration to quantify the risks of lung and HNC. The role of human papillomavirus (HPV) and cancer subtypes were assessed.

Results: Most individual nicotine dependence behaviours showed positive associations with lung cancer with approximately 1.8 to 3.5-fold risk increase, and to lesser extent with 1.4 to 2.3-fold risk for HNC. Nicotine dependence is partially accountable for increased risks of lung cancer (OR = 1.20, 95%CI = 1.13-1.28) and HNC (1.12, 95%CI = 1.04-1.19). Nicotine dependence had a greater effect on the risk of HPV-negative oropharyngeal cancer (OR = 3.06, 95%CI = 1.65-5.66) in comparison to HPV-positive oropharyngeal cancer (OR = 1.05, 95%CI = 0.67-1.65). The direct effects of nicotine dependence remained significant after accounting for cumulative tobacco exposures.

Conclusion: Nicotine dependence increases the risks of lung and HNC cancers after accounting for tobacco smoking, suggesting potential toxic effects of nicotine. These results are informative for the safety consideration of nicotine exposures.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0237723PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7454981PMC
October 2020

Psychometric testing of the Skull Base Inventory health-related quality of life questionnaire in a multi-institutional study of patients undergoing open and endoscopic surgery.

Qual Life Res 2021 Jan 26;30(1):293-301. Epub 2020 Aug 26.

Department of Otolaryngology - Head & Neck Surgery, University of Toronto, Toronto, ON, Canada.

Purpose: The skull base inventory (SBI) was developed to better assess health-related quality of life (HR-QOL) in patients with anterior and central skull base neoplasms treated by endoscopic and open approaches. The primary objective of this study was to prospectively assess the psychometric properties of the SBI.

Methods: This study is part of a multi-center study of patients undergoing endoscopic and open procedures completed between 2012 and 2018. Participants were eligible if they were over 18 years of age; had benign or malignant anterior, antero-lateral, or central skull base tumors; and required either an open or endoscopic skull base surgical approach. In order to assess the psychometric properties of the SBI, patients completed the instrument at six time points (preoperative, 2 weeks, 3 months, 6 months, 12 months postoperative). Patients also completed the Anterior Skull Base (ASB) questionnaire and the Sinonasal Outcome Test (SNOT-22) to allow comparison to the SBI.

Results: One hundred and eighty-seven patients were included across five centers, with 121 having an endoscopic procedure. Internal consistency (Cronbach's alpha = 0.95) and test-retest at 12 months and 12 months plus 2 weeks (intraclass correlation > 0.90) were excellent. Concurrent validity was demonstrated by very strong correlation between total SBI scores and ASB scores (r = 0.810 to 0.869, p < 0.001) and moderate correlation between nasal domain SBI scores and SNOT-22 scores (r = - 0.616 to - 0.738, p < 0.001). Convergent validity was demonstrated by moderate correlation between change in SBI scores and global QOL change (r = 0.4942, p < 0.001). The minimally important clinical difference (global HR-QOL change of "a little better" or "a little worse") was 6.0.

Conclusion: The SBI questionnaire is reliable and valid for patients treated by both endoscopic and open approaches and can be used for assessment of HR-QOL in these settings.
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http://dx.doi.org/10.1007/s11136-020-02609-zDOI Listing
January 2021

Development and validation of a Surgical Prioritization and Ranking Tool and Navigation Aid for Head and Neck Cancer (SPARTAN-HN) in a scarce resource setting: Response to the COVID-19 pandemic.

Cancer 2020 11 11;126(22):4895-4904. Epub 2020 Aug 11.

Division of Surgical Oncology, Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, Ontario, Canada.

Background: In the wake of the coronavirus disease 2019 (COVID-19) pandemic, access to surgical care for patients with head and neck cancer (HNC) is limited and unpredictable. Determining which patients should be prioritized is inherently subjective and difficult to assess. The authors have proposed an algorithm to fairly and consistently triage patients and mitigate the risk of adverse outcomes.

Methods: Two separate expert panels, a consensus panel (11 participants) and a validation panel (15 participants), were constructed among international HNC surgeons. Using a modified Delphi process and RAND Corporation/University of California at Los Angeles methodology with 4 consensus rounds and 2 meetings, groupings of high-priority, intermediate-priority, and low-priority indications for surgery were established and subdivided. A point-based scoring algorithm was developed, the Surgical Prioritization and Ranking Tool and Navigation Aid for Head and Neck Cancer (SPARTAN-HN). Agreement was measured during consensus and for algorithm scoring using the Krippendorff alpha. Rankings from the algorithm were compared with expert rankings of 12 case vignettes using the Spearman rank correlation coefficient.

Results: A total of 62 indications for surgical priority were rated. Weights for each indication ranged from -4 to +4 (scale range; -17 to 20). The response rate for the validation exercise was 100%. The SPARTAN-HN demonstrated excellent agreement and correlation with expert rankings (Krippendorff alpha, .91 [95% CI, 0.88-0.93]; and rho, 0.81 [95% CI, 0.45-0.95]).

Conclusions: The SPARTAN-HN surgical prioritization algorithm consistently stratifies patients requiring HNC surgical care in the COVID-19 era. Formal evaluation and implementation are required.

Lay Summary: Many countries have enacted strict rules regarding the use of hospital resources during the coronavirus disease 2019 (COVID-19) pandemic. Facing delays in surgery, patients may experience worse functional outcomes, stage migration, and eventual inoperability. Treatment prioritization tools have shown benefit in helping to triage patients equitably with minimal provider cognitive burden. The current study sought to develop what to the authors' knowledge is the first cancer-specific surgical prioritization tool for use in the COVID-19 era, the Surgical Prioritization and Ranking Tool and Navigation Aid for Head and Neck Cancer (SPARTAN-HN). This algorithm consistently stratifies patients requiring head and neck cancer surgery in the COVID-19 era and provides evidence for the initial uptake of the SPARTAN-HN.
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http://dx.doi.org/10.1002/cncr.33114DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7436362PMC
November 2020

Tracheoesophageal voice prosthesis management in laryngectomy patients during the COVID-19 pandemic.

J Otolaryngol Head Neck Surg 2020 Aug 10;49(1):59. Epub 2020 Aug 10.

Speech pathology, University Helth Network, University of Toronto, Toronto, ON, Canada.

With the COVID-19 pandemic, there has been significant changes and challenges in the management of oncology patients. One of the major strategies to reduce transmission of the virus between patients and healthcare workers is deferral of follow-up visits. However, deferral may not be possible in total laryngectomy patients. Urgent procedures may be necessary to prevent complications related to ill-fitting tracheoesophageal puncture (TEP) voice prostheses, such as aspiration or loss of voicing. In this paper, we describe the Princess Margaret Cancer Center's approach to managing this unique patient population.
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http://dx.doi.org/10.1186/s40463-020-00456-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7416812PMC
August 2020

Measuring financial toxicity incurred after treatment of head and neck cancer: Development and validation of the Financial Index of Toxicity questionnaire.

Cancer 2020 Sep 30;126(17):4042-4050. Epub 2020 Jun 30.

Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada.

Background: The treatment of head and neck cancer (HNC) may cause significant financial toxicity to patients. Herein, the authors have presented the development and validation of the Financial Index of Toxicity (FIT) instrument.

Methods: Items were generated using literature review and were based on expert opinion. In item reduction, items with factor loadings of a magnitude <0.3 in exploratory factor analysis and inverse correlations (r < 0) in test-retest analysis were eliminated. Retained items constituted the FIT. Reliability tests included internal consistency (Cronbach α) and test-retest reliability (intraclass correlation). Validity was tested using the Spearman rho by comparing FIT scores with baseline income, posttreatment lost income, and the Financial Concerns subscale of the Social Difficulties Inventory. Responsiveness analysis compared change in income and change in FIT between 12 and 24 months.

Results: A total of 14 items were generated and subsequently reduced to 9 items comprising 3 domains identified on exploratory factor analysis: financial stress, financial strain, and lost productivity. The FIT was administered to 430 patients with HNC at 12 to 24 months after treatment. Internal consistency was good (α = .77). Test-retest reliability was satisfactory (intraclass correlation, 0.70). Concurrent validation demonstrated mild to strong correlations between the FIT and Social Difficulties Inventory Money Matters subscale (Spearman rho, 0.26-0.61; P < .05). FIT scores were found to be inversely correlated with baseline household income (Spearman rho, -0.34; P < .001) and positively correlated with lost income (Spearman rho, 0.24; P < .001). Change in income was negatively correlated with change in FIT over time (Spearman rho, -0.25; P = .04).

Conclusions: The 9-item FIT demonstrated internal and test-retest reliability as well as concurrent and construct validity. Prospective testing in patients with HNC who were treated at other facilities is needed to further establish its responsiveness and generalizability.
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http://dx.doi.org/10.1002/cncr.33032DOI Listing
September 2020

Response to Miyauchi re: "A Prospective Mixed-Methods Study of Decision Making on Surgery or Active Surveillance for Low-Risk Papillary Thyroid Cancer".

Thyroid 2020 10 2;30(10):1542-1543. Epub 2020 Jul 2.

Department of Otolaryngology and Head and Neck Surgery, University Health Network and University of Toronto, Toronto General Hospital, Toronto, Ontario, Canada.

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http://dx.doi.org/10.1089/thy.2020.0495DOI Listing
October 2020

Mapping the EORTC QLQ-C30 and QLQ-H&N35, onto EQ-5D-5L and HUI-3 indices in patients with head and neck cancer.

Head Neck 2020 09 25;42(9):2277-2286. Epub 2020 Apr 25.

Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre-University Health Network, University of Toronto, Toronto, Ontario, Canada.

Background: We sought to develop mapping functions that use EORTC responses to approximate health utility (HU) scores for patients with head and neck cancer (HNC).

Methods: In total, 209 outpatients with HNC completed the EORTC QLQ-C30 & QLQ-H&N35 (EORTC), EQ-5D-5L and the HUI-3. Results of the EORTC were mapped onto both EQ-5D-5L and HUI-3 scores using ordinary least squares regression and two-part models.

Results: The OLS model mapping EORTC onto the EQ-5D-5L performed best (adjusted R = .75, 10-fold cross-validation RMSE = 0.064, MAE 0.050). The HUI-3 model mapping onto EORTC through OLS was more limited (adjusted R = .5746, 10-fold cross cross-validation RMSE = 0.168, MAE 0.080). The EQ-5D-5L model was able to discriminate between certain clinical indices of disease severity on subgroup analysis.

Conclusion: The EORTC to EQ-5D-5L mapping algorithm has good predictive validity and may enable researchers to translate EORTC scores into HU scores for head and neck patients with cancer.
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http://dx.doi.org/10.1002/hed.26181DOI Listing
September 2020

Landscape mapping of shared antigenic epitopes and their cognate TCRs of tumor-infiltrating T lymphocytes in melanoma.

Elife 2020 04 21;9. Epub 2020 Apr 21.

Tumor Immunotherapy Program, Campbell Family Institute for Breast Cancer Research, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.

HLA-restricted T cell responses can induce antitumor effects in cancer patients. Previous human T cell research has largely focused on the few HLA alleles prevalent in a subset of ethnic groups. Here, using a panel of newly developed peptide-exchangeable peptide/HLA multimers and artificial antigen-presenting cells for 25 different class I alleles and greater than 800 peptides, we systematically and comprehensively mapped shared antigenic epitopes recognized by tumor-infiltrating T lymphocytes (TILs) from eight melanoma patients for all their class I alleles. We were able to determine the specificity, on average, of 12.2% of the TILs recognizing a mean of 3.1 shared antigen-derived epitopes across HLA-A, B, and C. Furthermore, we isolated a number of cognate T cell receptor genes with tumor reactivity. Our novel strategy allows for a more complete examination of the immune response and development of novel cancer immunotherapy not limited by HLA allele prevalence or tumor mutation burden.
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http://dx.doi.org/10.7554/eLife.53244DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7234812PMC
April 2020

Association of Patient Age With Progression of Low-risk Papillary Thyroid Carcinoma Under Active Surveillance: A Systematic Review and Meta-analysis.

JAMA Otolaryngol Head Neck Surg 2020 06;146(6):552-560

Division of Endocrinology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada.

Importance: Active surveillance is sometimes considered as a disease management option for individuals with small, low-risk papillary thyroid carcinoma.

Objective: To assess whether patient age is associated with progression of low-risk papillary thyroid carcinoma (tumor growth or incident metastatic disease) in adults under active surveillance.

Evidence Review: Eight electronic databases (MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Emcare, PsycINFO, Web of Science, and ClincalTrials.gov) were searched from inception to March 2019, supplemented with a hand search. Two investigators independently screened citations, reviewed full-text articles, and abstracted data. Additional data were sought from authors. Random-effects meta-analyses were performed using incidence data (statistically adjusted for confounders and crude rates).

Findings: A total of 1658 unique citations were screened, and 62 full-text articles were reviewed, including 5 studies. Three studies included exclusively microcarcinomas and 2 included tumors up to 2 cm in maximal diameter. The mean age of participants was 51.0 to 55.2 years in 4 studies reporting this value. The mean or median follow-up was 5 years or more in 3 studies and approximately 2 years in 2 studies. The pooled risk ratio for tumor growth of 3 mm or more in maximal diameter in individuals aged 40 to 50 years compared with younger individuals was 0.51 when adjusted for confounders (95% CI, 0.29-0.89; 1619 patients, 2 studies), and the unadjusted risk ratio of this outcome for individuals 40 years or older was 0.55 (95% CI, 0.36-0.82; 2097 patients, 4 studies). In adults aged 40 to 45 years, the unadjusted risk ratio for any tumor volume increase compared with younger individuals was 0.65 (95% CI, 0.51-0.83; 1232 patients, 4 studies). The pooled risk ratio for incident nodal metastases in individuals 40 years or older was 0.22 (95% CI, 0.10-0.47; 1806 patients, 3 studies); however, in a secondary analysis, the risk difference was not significantly different. There was no statistically significant heterogeneity in any of the meta-analyses. There were no thyroid cancer-related deaths nor incident distant metastases.

Conclusions And Relevance: This study suggests that older age may be associated with a reduced risk of primary papillary thyroid carcinoma tumor growth under active surveillance. Incident metastatic disease is uncommon during active surveillance.
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http://dx.doi.org/10.1001/jamaoto.2020.0368DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7163784PMC
June 2020

A Prospective Mixed-Methods Study of Decision-Making on Surgery or Active Surveillance for Low-Risk Papillary Thyroid Cancer.

Thyroid 2020 07 8;30(7):999-1007. Epub 2020 Apr 8.

Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and University of Toronto, Toronto, Canada.

Active surveillance (AS) of small, low-risk papillary thyroid cancers (PTCs) is increasingly being considered. There is limited understanding of why individuals with low-risk PTC may choose AS over traditional surgical management. We present a mixed-methods analysis of a prospective observational real-life decision-making study regarding the choice of thyroidectomy or AS for management of localized, low-risk PTCs <2 cm in maximum diameter (NCT03271892). Patients were provided standardized medical information and were interviewed after making their decision (which dictated disease management). We evaluated patients' levels of decision-self efficacy (confidence in medical decision-making ability) at the time information was presented and their level of decision satisfaction after finalizing their decision (using standardized questionnaires). We asked patients to explain the reason for their choice and qualitatively analyzed the results. We enrolled 74 women and 26 men of mean age 52.4 years, with a mean PTC size of 11.0 mm (interquartile range 9.0, 14.0 mm). Seventy-one patients (71.0% [95% confidence interval 60.9-79.4%]) chose AS over surgery. Ninety-four percent (94/100) of participants independently made their own disease management choice; the rest shared the decision with their physician. Participants had a high baseline level of decision self-efficacy (mean 94.3, standard deviation 9.6 on a 100-point scale). Almost all (98%, 98/100) participants reported high decision satisfaction. Factors reported by patients as influencing their decision included the following: perceived risk of thyroidectomy or the cancer, family considerations, treatment timing in the context of life circumstances, and trust in health care providers. In this Canadian study, ∼7 out of 10 patients with small, low-risk PTC, who were offered the choice of AS or surgery, chose AS. Personal perceptions about cancer or thyroidectomy, contextual factors, family considerations, and trust in health care providers strongly influenced patients' disease management choices.
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http://dx.doi.org/10.1089/thy.2019.0592DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7374636PMC
July 2020

Treatment de-escalation for HPV-associated oropharyngeal squamous cell carcinoma with radiotherapy vs. trans-oral surgery (ORATOR2): study protocol for a randomized phase II trial.

BMC Cancer 2020 Feb 14;20(1):125. Epub 2020 Feb 14.

Department of Radiation Oncology, London Health Sciences Centre, Western University, 800 Commissioners Rd. E, London, Ontario, N6A 5W9, Canada.

Background: Patients with human papillomavirus-positive (HPV+) oropharyngeal squamous cell carcinoma (OPC) have substantially better treatment response and overall survival (OS) than patients with HPV-negative disease. Treatment options for HPV+ OPC can involve either a primary radiotherapy (RT) approach (± concomitant chemotherapy) or a primary surgical approach (± adjuvant radiation) with transoral surgery (TOS). These two treatment paradigms have different spectrums of toxicity. The goals of this study are to assess the OS of two de-escalation approaches (primary radiotherapy and primary TOS) compared to historical control, and to compare survival, toxicity and quality of life (QOL) profiles between the two approaches.

Methods: This is a multicenter phase II study randomizing one hundred and forty patients with T1-2 N0-2 HPV+ OPC in a 1:1 ratio between de-escalated primary radiotherapy (60 Gy) ± concomitant chemotherapy and TOS ± de-escalated adjuvant radiotherapy (50-60 Gy based on risk factors). Patients will be stratified based on smoking status (< 10 vs. ≥ 10 pack-years). The primary endpoint is OS of each arm compared to historical control; we hypothesize that a 2-year OS of 85% or greater will be achieved. Secondary endpoints include progression free survival, QOL and toxicity.

Discussion: This study will provide an assessment of two de-escalation approaches to the treatment of HPV+ OPC on oncologic outcomes, QOL and toxicity. Results will inform the design of future definitive phase III trials.

Trial Registration: Clinicaltrials.gov identifier: NCT03210103. Date of registration: July 6, 2017, Current version: 1.3 on March 15, 2019.
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http://dx.doi.org/10.1186/s12885-020-6607-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7023689PMC
February 2020

Finding/identifying primaries with neck disease (FIND) clinical trial protocol: a study integrating transoral robotic surgery, histopathological localisation and tailored deintensification of radiotherapy for unknown primary and small oropharyngeal head and neck squamous cell carcinoma.

BMJ Open 2019 12 30;9(12):e035431. Epub 2019 Dec 30.

Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.

Introduction: Carcinomas of unknown primary site (CUP) of the head and neck have historically been worked up and managed heterogeneously. Failure to identify a primary site may result in large radiotherapy mucosal volumes. Transoral approaches such as Transoral Robotic Surgery (TORS) may improve the yield of identifying hidden primaries. We aim to assess the oncological and functional outcomes of a combined treatment approach with TORS and tailored radiotherapy.

Methods And Analysis: Twenty-five patients with metastatic squamous cell carcinoma to the neck without clinical or radiographic evidence of a primary site will be enrolled in a phase II trial. Patients will undergo a diagnostic or therapeutic approach with TORS based on specific algorithms incorporating tailored radiotherapy according to the location and laterality of the primary tumour. The primary outcome is to evaluate the out-of-field failure rate over a 2-year period. Secondary outcomes include identification rates, survival outcomes, patient reported outcomes and functional swallowing outcomes.

Ethics And Dissemination: The University Health Network Research Ethics Board approved this study (ID 15-9767). The results will be published in an open access journal.

Trial Registration Number: NCT03281499.
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http://dx.doi.org/10.1136/bmjopen-2019-035431DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6955504PMC
December 2019

Lymphatic mapping with SPECT-CT for evaluation of contralateral drainage in lateralized oropharyngeal cancers using an awake injection technique.

Head Neck 2020 03 28;42(3):385-393. Epub 2019 Nov 28.

Department of Otolaryngology - Head and Neck Surgery, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.

Background: Risk of contralateral nodal metastases in oropharyngeal squamous cell carcinoma (OPSCC) is currently based on clinical risk factors. We propose lymphatic mapping with single photon emission computed tomography (SPECT-CT) for tumor-specific delineation of lymphatic drainage to guide treatment.

Methods: Retrospective review of lymphatic drainage patterns in cT1-2 OPSCC and contralateral cN0 neck with a nonoperative, awake injection of 99 m-Tc sulfur colloid and SPECT-CT.

Results: Ten patients were reviewed. Primary sites included tonsil (n = 8, 80%) and tongue base (n = 2, 20%). All patients tolerated awake injections with no complications. Nine patients (90%) demonstrated satisfactory migration of radiotracer to neck node(s) with seven (78%) to the ipsilateral lateral neck, one (11%) to the ipsilateral lateral neck and retropharynx, and one (11%) to bilateral lateral neck nodes.

Conclusions: Characterization of lymphatic drainage in OPSCC is feasible using a nonoperative injection technique and SPECT-CT. Drainage to the contralateral neck is rare, warranting further study to tailor treatment appropriately.
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http://dx.doi.org/10.1002/hed.26011DOI Listing
March 2020

Mapping the University of Washington Quality of life questionnaire onto EQ-5D and HUI-3 indices in patients with head and neck cancer.

Head Neck 2020 03 24;42(3):513-521. Epub 2019 Nov 24.

Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre-University Health Network, University of Toronto, Toronto, Ontario, Canada.

Background: There is no mechanism to predict health utility (HU) values from the University of Washington Quality of Life Questionnaire (UWQoL) scores. We sought to develop a mapping algorithm capable of using UWQoL data to approximate HU scores.

Methods: Outpatients with head and neck cancer completed the UWQoL, EQ-5D, and the Health Utilities Index-Mark 3 (HUI-3). Results of the UWQoL were mapped onto both EQ-5D and HUI-3 scores using ordinary least-squares regression models. Two-part models were explored. The predictive power of the model was assessed using 10-fold cross-validation.

Results: A total of 209 patients were recruited. The reduced model converting UWQoL data into EQ-5D scores performed best (adjusted R = 0.628, root mean square error = 0.076). Both models demonstrated construct validity by discriminating between clinical indices of disease severity.

Conclusions: The abovementioned algorithms enable researchers to perform health economic evaluations with existing UWQoL data in cases where prospectively collected HU values are not available.
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http://dx.doi.org/10.1002/hed.26031DOI Listing
March 2020

Is Frailty Associated With Worse Outcomes After Head and Neck Surgery? A Narrative Review.

Laryngoscope 2020 06 21;130(6):1436-1442. Epub 2019 Oct 21.

Objective: Frailty has emerged as an important determinant of many health outcomes across various surgical specialties. We examined the published literature reporting on frailty as a predictor of perioperative outcomes in head and neck cancer (HNC) surgery.

Study Design: Narrative review with limited electronic database search and cross-referencing of included studies.

Methods: PubMed was searched from inception until June 2019 to capture studies evaluating an association between frailty and perioperative outcomes among patients undergoing HNC surgery. Primary outcomes included mortality and morbidity, whereas secondary outcomes included in-hospital cost, length of stay, readmission, and discharge disposition.

Results: We identified nine series examining frailty as a predictor of outcomes in HNC. The majority of studies (77%) identified patients using a large population-based database such as the National Surgical Quality Improvement Project or National Inpatient Sample. Frailty measures applied in the HNC surgery literature include the modified frailty index, Groningen Frailty Indicator, and John Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. Most studies demonstrated a significant association between frailty and perioperative outcomes, including mortality, perioperative complications, and Clavien-Dindo grade IV complications. Furthermore, frailty was associated with greater length of hospital stay, readmission rate, and likelihood of discharge to short-term or skilled nursing facilities.

Conclusion: The current literature demonstrates the utility of frailty as a predictor of perioperative mortality and morbidity. Further research is needed to develop frailty screening measures in order to risk-stratify patients and optimize modifiable factors preoperatively. Laryngoscope, 130:1436-1442, 2020.
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http://dx.doi.org/10.1002/lary.28307DOI Listing
June 2020

Differences in long-term quality of life between hemithyroidectomy and total thyroidectomy in patients treated for low-risk differentiated thyroid carcinoma.

Surgery 2020 01 15;167(1):94-101. Epub 2019 Oct 15.

Department of Surgery, University Health Network, Toronto, ON, Canada. Electronic address:

Background: The long-term health-related quality-of-life implications of treating low-risk differentiated thyroid cancer with total thyroidectomy or hemithyroidectomy is important to patients but remains poorly understood.

Methods: Using a cross-sectional mailed survey, we compared long-term health-related quality-of-life in low-risk differentiated thyroid cancer survivors treated with hemithyroidectomy to those treated with total thyroidectomy between 2005 and 2016 at a university hospital. European Organisation for Research and Treatment of Cancer Quality of Life core Questionnaire version 3.0, the supplementary Thyroid Cancer specific questionnaire module version 2.0, and the Assessment of Survivor Concerns (ASC) questionnaires were used. Our primary outcome was the global scale of quality of life. Exploratory outcomes included differences among other health-related quality-of-life items corrected for potential confounders in multivariable regression analyses.

Results: The response rate was 51.0% (270 of 529), of which 59 patients (21.9%) were treated with hemithyroidectomy. Main outcome score global quality of life did not differ between groups (76.9 hemithyroidectomy vs 77.7 total thyroidectomy, P = .450). Exploratory analyses showed hemithyroidectomy to be associated with more worry about recurrence on the Assessment of Survivor Concerns questionnaire (2.4 hemithyroidectomy vs 2.1 total thyroidectomy, P = .021).

Conclusion: Long-term quality of life was not significantly different between low-risk differentiated thyroid cancer patients treated with total thyroidectomy compared with hemithyroidectomy. In secondary analyses, worry about recurrence appeared to be higher in individuals treated with hemithyroidectomy. These data highlight previously unreported impact of surgical regimen to the health-related quality-of-life for low-risk differentiated thyroid cancer patients.
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http://dx.doi.org/10.1016/j.surg.2019.04.060DOI Listing
January 2020