Publications by authors named "Nitin A Pagedar"

70 Publications

Association of depressive symptomatology with problem alcohol use in rural head and neck cancer patients at diagnosis.

J Psychosoc Oncol 2021 Sep 6:1-13. Epub 2021 Sep 6.

Department of Otolaryngology-Head and Neck Surgery, Carver College of Medicine, The University of Iowa, Iowa City, IA, USA.

Purpose: Problem alcohol use is a risk factor for the development of head and neck cancer (HNC) and continued use is associated with poor outcomes; depressive symptoms may be associated with this behavior.

Design: Exploratory cross-sectional study examined depressive symptoms as a correlate of self-reported problem alcohol use at diagnosis.

Sample/methods: Multivariable linear regression examined depressive symptoms as a correlate of problem alcohol use in a sample of rural HNC patients ( = 249).

Findings: Over half (55.2%) of rural patients with potentially problem alcohol use exhibited mild to moderate depressive symptomatology. Regression models controlling for age, cancer site, stage, sex, tobacco use, and treatment modality indicated that depressive symptoms at diagnosis were associated with self-reported problem alcohol use scores at diagnosis (ß = .186, sr = .031, < .01). Follow-up subgroup analyses demonstrated that depressive symptoms at diagnosis were significantly associated with self-reported problem alcohol use in male patients, those with advanced stage disease, and of older age.

Conclusions/implications: HNC patients should be screened for alcohol use and depression at diagnosis. Access to behavioral health treatment and/or referral options may be lacking in rural areas thus additional ways of connecting rural patients to specialty care should be explored. These may include telehealth and multimodal interventions to address complex behavioral health cases. Additional research in important patient subgroups such as older patients and those presenting with advanced disease is also warranted.
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http://dx.doi.org/10.1080/07347332.2021.1971816DOI Listing
September 2021

Characterizing head and neck cancer survivors' discontinuation of survivorship care.

Cancer 2021 Aug 30. Epub 2021 Aug 30.

Department of Otolaryngology-Head and Neck Surgery, University of Iowa, Iowa City, Iowa.

Background: Little is known about cancer survivors who discontinue survivorship care. The objective of this study was to characterize patients with head and neck cancer who discontinue survivorship care with their treating institution and identify factors associated with discontinuation.

Methods: This was a retrospective cohort study of patients diagnosed with head and neck cancer between January 1, 2014, and December 31, 2016, who received cancer-directed therapy at the University of Iowa Hospitals and Clinics (UIHC). Eligible patients achieved a cancer-free status after curative-intent treatment and made at least 1 visit 90+ days after treatment completion. The primary outcome was discontinuation of survivorship care, which was defined as a still living survivor who had not returned to a UIHC cancer clinic for twice the expected interval. Demographic and oncologic factors were examined to identify associations with discontinuation.

Results: Ninety-seven of the 426 eligible patients (22.8%) discontinued survivorship care at UIHC during the study period. The mean time in follow-up for those who discontinued treatment was 15.4 months. Factors associated with discontinuation of care included an unmarried status (P = .036), a longer driving distance to the facility (P = .0031), and a single-modality cancer treatment (P < .0001). Rurality was not associated with discontinuation (24.3% vs 21.6% for urban residence; P = .52), nor was age, gender, or payor status.

Conclusions: The study results indicate that a sizeable percentage of head and neck cancer survivors discontinue care with their treating institution. Both demographic and oncologic factors were associated with discontinuation at the treating institution, and this points to potential clinical and care delivery interventions.
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http://dx.doi.org/10.1002/cncr.33888DOI Listing
August 2021

Airway Management in Substernal Goiter Surgery.

Ann Otol Rhinol Laryngol 2021 May 25:34894211014794. Epub 2021 May 25.

Department of Otolaryngology-Head & Neck Surgery, University of Iowa Hospitals & Clinics, Iowa City, IA, USA.

Objective(s): To review the experience of 3 hospitals with airway management during surgery for substernal goiter and identify preoperative factors that predict the need for advanced airway management techniques.

Methods: A retrospective chart review between 2009 and 2017 of patients with substernal goiter treated surgically at 1 of 3 hospitals was performed.

Results: Of the 179 patients included in the study, 114 (63.7%) were female, the mean age was 55.1 years (range 20-87). Direct laryngoscopy or videolaryngoscopy was successful in 162 patients (90.5%), with fiberoptic intubation used for the remaining 17 patients. Thirty-one patients (17.4%) required >1 intubation attempt; these patients had larger thyroids (201.3 g, 95% CI 155.3-247.2 g) than those intubated with 1 attempt (144.7 g, 95% CI 127.4-161.9 g,  = .009). Those who required >1 attempt had higher BMI (38.3, 95% CI 34.0-42.6 vs. 32.9, 95% CI 31.5-34.3,  = .02). Mallampati score was found to be a predictor of >1 attempt, though tracheal compression and tracheal shift were not found to be predictors of >1 attempt, nor was the lowest thyroid extent. BMI was the only independent factor on multivariable logistic regression of needing >1 attempt (odds ratio 1.056, 95% CI 1.011-1.103,   .015).

Conclusions: The majority of patients undergoing surgery for substernal goiter can be intubated routinely without the need for fiberoptic intubation. Thyroid-specific factors such as lowest thyroid extent and mass effect of the gland on the trachea do not appear to be associated with difficult intubation, whereas classic patient factors associated with difficulty intubation are.

Level Of Evidence: VI.
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http://dx.doi.org/10.1177/00034894211014794DOI Listing
May 2021

Post-treatment head and neck cancer survivors' approaches to self-management: A qualitative study.

Eur J Oncol Nurs 2021 Jun 21;52:101944. Epub 2021 Mar 21.

Institute for Clinical and Translational Research, Iowa City, IA, USA; Department of Internal Medicine, College of Medicine, University of Iowa, Iowa City, IA, USA.

Purpose: Post-treatment head and neck cancer (HNC) survivors contend with distinct, long-term challenges related to cancer treatments that impact their day-to-day lives. Alongside follow-up cancer care, they also must be responsible for the daily management of often intrusive physical and psychological symptoms, as well as maintaining their health and a lifestyle to promote their well-being. The purpose of this study was to identify HNC survivors' approaches toward engagement in self-management activities.

Methods: Post-treatment HNC survivors (N=22) participated in the study through purposeful sampling. Participants were eligible if they 1) had a history of upper aerodigestive tract cancer; 2) completed their most recent primary treatment (i.e. chemotherapy, radiation, and surgery) more than eighteen months prior and had no evidence of HNC, and 3) could speak in English. A semi-structured interview was used. Data was analyzed using content analysis.

Results: We identified three approaches that survivors took towards self-management activities: taking charge, living with it, and engaging as needed. Our results showed that taking charge is when survivors take an active role in evaluating their health and taking action subsequently; as needed represents engaging in self-management as necessary; and living with it reflects adapting to the symptoms and side effects without managing them.

Conclusions: We propose self-management approaches as a novel mechanism to understand the relationship between survivors' characteristics and health preferences and their self-management. It is important for clinicians to highlight the variation in individuals 'self-management approaches as they work to identify tailored patient-centered strategies that compliment specific patient needs.
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http://dx.doi.org/10.1016/j.ejon.2021.101944DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8217137PMC
June 2021

Health-related quality of life in head and neck cancer survivors: Evaluating the rural disadvantage.

J Rural Health 2021 Mar 15. Epub 2021 Mar 15.

Department of Otolaryngology, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA.

Purpose: Head and neck cancer (HNC) survivors often experience distress and health-related quality of life (HRQOL) impairment. Research suggests that rural cancer patients may have poorer outcomes than urban patients. This study examined whether HNC patient emotional and HRQOL outcomes differ in those living in a rural versus urban location at 6 and 12 months postdiagnosis.

Methods: A total of 261 HNC patients were included from a longitudinal study of HNC outcomes. The majority were diagnosed with advanced stage cancer (51.3%); the most common cancer site was oral cavity (41.0%). Rurality was measured using the US Department of Agriculture Rural Urban Commuting Area codes. Depression was measured using the Beck Depression Inventory (BDI), general HRQOL using the Short Form-36 (SF-36), and HNC-specific HRQOL using the Head and Neck Cancer Inventory (HNCI). Analyses were 2 (group) × 3 (assessment) repeated measures ANCOVAs, controlling for demographic and clinical characteristics.

Findings: Approximately 45% of the sample lived in a rural location. Follow-up comparisons of significant overall models indicated that rural patients reported significantly more nonsomatic depression symptoms at 6-month follow-up. Rural patients were also more likely to report significantly poorer general mental HRQOL at 12-month follow-up, significantly poorer HNC-specific HRQOL related to eating at 6- and 12-month follow-up, and marginally worse aesthetics at 12-month follow-up.

Conclusions: These findings are consistent with suggestions that rural HNC patients may be at heightened risk for depression symptoms and decrements in HRQOL. Patients should be screened and regularly monitored for issues with depression and HNC-specific HRQOL throughout the survivorship period.
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http://dx.doi.org/10.1111/jrh.12571DOI Listing
March 2021

Problem alcohol use among rural head and neck cancer patients at diagnosis: Associations with health-related quality of life.

Psychooncology 2021 May 2;30(5):708-715. Epub 2021 Jan 2.

Department of Otolaryngology-Head and Neck Surgery, Carver College of Medicine, the University of Iowa, Iowa City, Iowa, USA.

Objective: Problem alcohol use in persons with head and neck cancer (HNC) is associated with poor outcomes, including survival. Some evidence suggests that individuals living in rural areas may be at greater risk of problem alcohol use. The present exploratory cross-sectional study sought to examine problem alcohol use at diagnosis in a sample of HNC patients by rural versus urban status.

Methods: Self-reported problem alcohol use as measured by the Short Michigan Alcoholism Screening Test (SMAST) was examined in rural and urban HNC patients at diagnosis (N = 454). Multivariable linear regression analysis was conducted to examine correlates of problem alcohol use. Subgroup analyses examined HNC-specific health-related quality of life (HRQOL) by problem drinking status at diagnosis and 3- and 12-month postdiagnosis in rural patients.

Results: Multivariable linear regression analysis controlling for age, cancer site, cancer stage, depressive symptoms at diagnosis, and tobacco use at diagnosis indicated that rural residence was significantly associated with SMAST scores at diagnosis such that rural patients were more likely to report higher scores (ß = 0.095, sr  = 0.010, p = 0.04). Covariate-adjusted subgroup analyses suggest that rural patients with self-reported problem alcohol use may exhibit deficits in HNC-specific HRQOL at diagnosis and 3- and 12-month postdiagnosis.

Conclusions: HNC patients should be screened for problem alcohol use at diagnosis and counseled regarding the deleterious effects of continued drinking during treatment and beyond. Because access to treatment and referral options may be lacking in rural areas, additional ways of connecting rural patients to specialty care should be explored.
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http://dx.doi.org/10.1002/pon.5616DOI Listing
May 2021

Analysis of palliative care treatment among head and neck patients with cancer: National perspective.

Head Neck 2021 03 5;43(3):805-815. Epub 2020 Nov 5.

Department of Otolaryngology-Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.

Background: To analyze the characteristics and survival patterns of patients with head and neck squamous cell carcinoma (SCC) who received palliative treatment during their first course of treatment.

Methods: Cohort analysis utilizing the National Cancer Data Base (NCDB) of patients with a diagnosis of oral cavity/oropharyngeal, hypopharyngeal, and laryngeal SCC. Statistical analysis included multivariate logistic regression and Cox Hazard ratio modeling, and Kaplan-Meier survival analysis.

Results: 165 081 patients were included, of which 2747 patients received palliative treatment. Patients who received palliative treatment tended to be ≥65 years old, black, Charlson/Deyo score ≥3, hypopharyngeal cancer, stage (III-IV), with Medicaid insurance (P < .05). Patients were more likely to be treated with palliative intent if they underwent chemotherapy/radiotherapy and declined surgery (P < .001) compared to patients who underwent surgery and declined chemotherapy/radiotherapy (P = .006).

Conclusions: Palliative care use in head and neck oncology is associated with older patients, non-whites, Medicaid patients, and nonsurgically treated patients.
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http://dx.doi.org/10.1002/hed.26532DOI Listing
March 2021

Rebuilding survivorship care during Covid-19.

Ann Otol Rhinol Laryngol 2021 Jun 21;130(6):545-546. Epub 2020 Oct 21.

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http://dx.doi.org/10.1177/0003489420966588DOI Listing
June 2021

Better Visualization of Oral Cancer Margins-A Struggle of Cancer and Technology.

Authors:
Nitin A Pagedar

JAMA Otolaryngol Head Neck Surg 2020 12;146(12):1156-1157

Department of Otolaryngology-Head and Neck Surgery, University of Iowa, Iowa City.

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http://dx.doi.org/10.1001/jamaoto.2020.3262DOI Listing
December 2020

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

Laryngoscope 2021 05 26;131(5):1019-1025. Epub 2020 Aug 26.

Department of Otolaryngology-Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A.

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

Study Design: Retrospective cohort analysis.

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

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

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

Level Of Evidence: 3 Laryngoscope, 131:1019-1025, 2021.
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http://dx.doi.org/10.1002/lary.29033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7907264PMC
May 2021

Head and neck cancer survivorship from the patient perspective.

Head Neck 2020 09 23;42(9):2431-2439. Epub 2020 May 23.

Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA.

Background: Survivorship is a critical part of head and neck cancer (HNC) care. In order to design better processes, we assessed care provided to long-term HNC survivors and their priorities for ongoing care.

Methods: A survey was provided to HNC survivors at clinic appointments, including our HNC survivorship clinic. Questions focused on priorities for care in the otolaryngology clinic, types of care provided, and opioid use.

Results: Of 168 respondents, the most common priority for survivors was surveillance for recurrence (first priority in 75%), with general health the next most common (8%). Few respondents reported active primary care involvement in survivorship. About 10% of patients reported current opioid use.

Conclusion: Survivors face a large burden of symptoms and deficits, but our data show that most survivors focus on recurrence. Few survivors reported recall of survivorship care plan delivery or discussing cancer care needs with primary care providers.
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http://dx.doi.org/10.1002/hed.26265DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7524584PMC
September 2020

Melanoma Characteristics in Patients with a History of UV Tanning Bed Usage.

Ann Otol Rhinol Laryngol 2020 Jul 6;129(7):684-688. Epub 2020 Feb 6.

Department of Otolaryngology-Head and Neck Surgery, University of Iowa, Iowa City, IA, USA.

Objective: The purpose of this study was to evaluate the effect of tanning bed use on the behavior of subsequent melanomas.

Methods: Cases of invasive cutaneous melanoma who completed a baseline questionnaire within 1 year of biopsy were ascertained using an institutional registry. Patients were categorized into one of two groups: (1) no history of UV tanning bed usage or (2) any history of tanning bed usage. Data analysis looked for group differences on the following variables: TNM staging, mitotic rate, family history of melanoma, and basic demographic variables.

Results: Among 141 cases, a higher percentage of women (48.28%) reported tanning bed usage compared to men (26.51%,  < .01). Additionally, the average age at biopsy for people who reported tanning bed usage was significantly lower compared to those who had not reported using a tanning bed. There was no significant difference in stage at presentation ( = .56). Those with tanning bed usage presented significantly less often with melanoma of unknown primary (MUP). After controlling for the effects of gender and nodal status, tanning bed usage was not a significant independent predictor of 5 year overall survival.

Conclusions: If we remove the subject with MUP on the basis that more of these are mucosal in origin, lower TNM stage at presentation are found in patients with no tanning bed melanoma compared to those with history of tanning bed usage. In addition, tanning bed patients are younger and more likely female but with an equivalent mortality rate.

Level Of Evidence: Case Series.
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http://dx.doi.org/10.1177/0003489420904744DOI Listing
July 2020

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

Head Neck 2020 04 2;42(4):698-707. Epub 2020 Jan 2.

Department of Otolaryngology-Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa.

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

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

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

Conclusions: Female patients and patients with no insurance, Medicare, or Medicaid are more likely to decline recommended treatment for SCC of the head and neck. Educational status is not predictive of declining treatment.
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http://dx.doi.org/10.1002/hed.26040DOI Listing
April 2020

Primary Laryngectomy Versus Salvage Laryngectomy: A Comparison of Outcomes in the Chemoradiation Era.

Laryngoscope 2020 09 25;130(9):2179-2185. Epub 2019 Oct 25.

Department of Otolaryngology-Head and Neck Surgery, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, U.S.A.

Objective: To compare primary total laryngectomy (TL) versus salvage TL and analyze the functional outcomes, complications, recurrence rates, and survival.

Study Design: Case series with chart review.

Setting: Tertiary care center.

Subjects And Methods: Fifteen-year retrospective analysis of 208 patients with laryngeal squamous cell carcinoma treated by TL was completed. Outcome measures included survival, swallowing rehabilitation, speech rehabilitation, complications, and assessment of comorbidity. Survival estimates were analyzed with Kaplan-Meier method, and regression analysis utilized the Cox proportional hazards model.

Results: Alaryngeal speech was not significantly different between primary TL and salvage TL, 68% versus 82% (P = 0.14). Comparing primary and salvage TL, the perioperative complication rate was 33% versus 48% (P = 0.036). Thirty-six percent of primary TL patients had recurrence compared to 26% of salvage patients. Five-year overall survival rates between primary TL and salvage TL were not significantly different (P = 0.68). Comorbidity was an independent predictor of survival.

Conclusions: Development of a functional voice was not significantly different between salvage and primary TL patients, with a majority achieving alaryngeal speech. Perioperative complications were more prevalent in the salvage TL group. Recurrence and survival are significantly associated with comorbidity status.

Level Of Evidence: 4 Laryngoscope, 130:2179-2185, 2020.
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http://dx.doi.org/10.1002/lary.28343DOI Listing
September 2020

Novel Use of Porcine Urinary Bladder Matrix in the Exenterated Socket.

Ophthalmic Plast Reconstr Surg 2019 Sep/Oct;35(5):e122-e124

Department of Ophthalmology and Visual Sciences.

The aim of exenteration reconstruction is to stabilize the postsurgical wound bed to promote expeditious healing particularly in patients who are undergoing adjuvant radiation and/or chemotherapy. Porcine urinary bladder matrix has previously been used successfully as a wound-healing scaffold in treatment of burns and in acute, chronic, and surgical wounds, but the use of these products has not previously been reported in the exenterated orbit. The authors present a case of the novel use of porcine urinary bladder matrix in a pediatric patient who underwent exenteration for recurrent embryonal rhabdomyosarcoma, subsequent split-thickness skin grafting, and adjuvant radiation.
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http://dx.doi.org/10.1097/IOP.0000000000001453DOI Listing
January 2020

Attitudes of Clinicians about Screening Head and Neck Cancer Survivors for Lung Cancer Using Low-Dose Computed Tomography.

Ann Otol Rhinol Laryngol 2020 Jan 13;129(1):23-31. Epub 2019 Aug 13.

Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, USA.

Objective: National guidelines recommend lung cancer screening (LCS) using low-dose computed tomography (LDCT) for high-risk patients, including survivors of other tobacco-related cancers like head and neck cancer (HNC). This qualitative study investigated clinicians' practices and attitudes toward LCS with LDCT with patients who have survived HNC, in the context of mandated requirements for shared decision making (SDM) using decision aids.

Methods: Thematic analysis of transcribed semi-structured clinician interviews and focus group.

Results: Clinicians recognized LCS' utility for some HNC survivors with smoking histories. However, they identified many challenges to SDM in diverse clinic settings, including time, workflow, uncertainty about guidelines and reimbursement, decision aids, competing patient priorities, unclear evidence, potentially heightened patient receptivity and stress, and the complexity of discussions. They also identified challenges to LCS implementation.

Conclusions: While clinicians feel that LDCT LCS may benefit some HNC survivors, there are barriers both to implementing LCS SDM for these patients in primary care as currently recommended and to integrating it into cancer clinics. Challenges for SDM across settings include a lack of decision aids tailored to patients with cancer histories. Given recommendations to broaden LCS eligibility criteria, more research may be required before refinement of current guidelines.
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http://dx.doi.org/10.1177/0003489419868245DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6945809PMC
January 2020

Unilateral Nasal Mass in a Woman in Her 20s.

JAMA Otolaryngol Head Neck Surg 2019 Sep;145(9):862-863

Department of Otolaryngology-Head & Neck Surgery, University of Iowa Hospitals & Clinics, Iowa City.

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http://dx.doi.org/10.1001/jamaoto.2019.1671DOI Listing
September 2019

Treatment trends in head and neck cancer: Surveillance, Epidemiology, and End Results (SEER) Patterns of Care analysis.

Cancer Causes Control 2019 Jul 22;30(7):721-732. Epub 2019 May 22.

Department of Epidemiology, University of Iowa College of Public Health, 145 N. Riverside, Dr, Iowa City, IA, 52242, USA.

Purpose: Recent advances in head and neck cancer (HNC) treatment, such as increased use of organ-preserving advanced radiation treatments, the approval of cetuximab for HNC treatment, and the increase in human papillomavirus (HPV)-related HNC, have changed clinical approaches to HNC management. We sought to identify treatment trends in a population-based cohort of HNC patients.

Methods: The Surveillance, Epidemiology, and End Results Patterns of Care program collected additional treatment and HPV testing information on stratified random samples of HNC patients diagnosed in 1997 (n = 473), 2004 (n = 1,317), and 2009 (n = 1,128). Rao-Scott Chi-square tests were used to examine unadjusted associations between year of diagnosis and patient sociodemographic, tumor, and treatment characteristics. Cochran-Armitage tests for trend were used to examine the hypothesis that certain treatments were used increasingly (or decreasingly) over the time period, while logistic regression was used to examine factors associated with particular treatments.

Results: Use of radiation and chemotherapy without surgery significantly increased for all HNC sites between 1997 and 2009. Cetuximab and taxane use also showed a significantly increasing trend. Lack of insurance was associated with not receiving treatment in multivariate models. The majority (64%) of cases undergoing radiation in 2009 received an advanced treatment, with 55% receiving intensity modulated. The majority of oropharyngeal cases with known HPV status received chemotherapy and radiation only (62%) and nearly all were insured and had one or fewer comorbidities.

Conclusions: Treatment patterns have changed for HNC, leading to increased incorporation of systemic therapy and newer radiation techniques. HPV testing should be targeted for more widespread use, especially in traditionally underserved groups.
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http://dx.doi.org/10.1007/s10552-019-01185-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6668728PMC
July 2019

Survival Outcomes for Advanced Cutaneous Squamous Cell Carcinoma of the Head and Neck.

Ann Otol Rhinol Laryngol 2019 Oct 15;128(10):949-955. Epub 2019 May 15.

1 University of Iowa, Iowa City, IA, USA.

Objectives: Survival outcomes for advanced non-melanoma skin cancers of the head and neck treated with surgical resection are not well described in the literature. We aimed to describe outcomes for T3 and T4 cutaneoous squamous cell carcinoma of the head or neck treated with surgical resection at 1 tertiary academic medical center.

Methods: We analyzed a retrospective cohort of patients diagnosed with T3 or T4 cutaneous squamous cell carcinoma (SCC) of the head or neck from 2005 to 2016 treated with definitive surgical resection. Survival outcomes were examined using Kaplan-Meier analysis, and multivariate analysis was completed with Cox proportional hazard model.

Results: Forty-three patients met inclusion criteria. The mean age at diagnosis was 74.7 years (SD = 10.2), and 34 (79.1%) patients were male. Twelve (27.9%) patients were immunosuppressed. Radical resection, defined as temporal bone resection, orbital exenteration, calvarial resection, mandibulectomy, or maxillectomy, was performed in 25 (58.1%) cases. Final surgical margins were positive in 19 (44.2%) cases. Patients with tumors of the scalp/neck had a 1-year survival probability of 85.7%, and the probability of survival 1 year after a neck dissection was greater than 93%.

Conclusion: Anatomical subsites, specifically scalp/neck tumors, tended to have worse overall survival. Positive final margins tended to indicate a worse prognosis, and overall survival and recurrence were not significantly different among patients who underwent radical surgical resection compared to soft tissue resection.
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http://dx.doi.org/10.1177/0003489419848786DOI Listing
October 2019

Incidence trends for upper aerodigestive tract cancers in rural United States counties.

Head Neck 2019 08 7;41(8):2619-2624. Epub 2019 Mar 7.

Department of Epidemiology, University of Iowa, Iowa City, Iowa.

Background: Recent declines in cancer incidence and mortality have not been distributed equally across the United States. Factors such as tobacco cessation and human papillomavirus presence might differentially affect urban and rural portions of the country.

Methods: We used the Surveillance, Epidemiology, and End Results database to assess cancer incidence rates and trends from 1973 to 2015. We compared incidence rates for oral cavity, oropharynx, and larynx cancer in urban and rural counties and identified trends using Joinpoint software.

Results: Incidence of larynx and oral cavity cancer are decreasing faster in urban areas than in rural areas, while incidence of oropharynx cancer is increasing faster in rural areas than urban areas.

Conclusions: Relative trends in incidence of larynx, oral cavity, and oropharynx cancer over the past 40 years are unfavorable for rural United States counties compared with urban areas. Cancer control programs should take this into account.
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http://dx.doi.org/10.1002/hed.25736DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7133543PMC
August 2019

Population analysis of socioeconomic status and otolaryngologist distribution on head and neck cancer outcomes.

Head Neck 2019 04 14;41(4):1046-1052. Epub 2018 Dec 14.

Department of Epidemiology, University of Iowa, Iowa City, Iowa.

Background: The relationship between clinical outcomes and geographic determinants is not well known for head and neck cancer. Socioeconomic status (SES) factors and the distribution of health care resources might impact outcomes.

Methods: Head and neck cancer cases in the Surveillance, Epidemiology, and End Results (SEER) database were studied. Patient-level prognostic factors were identified from the SEER, and county-level factors were identified from the Area Health Resource File. Stage at presentation and observed survival were the outcomes of interest, with predictive factors identified by multivariate logistic and Cox proportional hazards regression.

Results: On multivariate analysis, tumor site, sex, race, marital status, rural residence, and county poverty level predicted stage at presentation. Sex, race, marital status, county-level poverty, and number of otolaryngologists predicted observed survival.

Conclusion: Adverse county-level SES predicted advanced cancer stage at presentation and diminished observed survival. SES was a stronger predictor of patient outcomes than rurality or number of otolaryngologists.
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http://dx.doi.org/10.1002/hed.25521DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6420379PMC
April 2019

Surgical Volumes and Outcomes-Does Practice Make Perfect?

Authors:
Nitin A Pagedar

JAMA Otolaryngol Head Neck Surg 2019 01;145(1):70-71

Department of Otolaryngology-Head and Neck Surgery, University of Iowa, Iowa City.

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http://dx.doi.org/10.1001/jamaoto.2018.3171DOI Listing
January 2019

Operative technique: Lateral neck dissection.

Head Neck 2018 12 26;40(12):2701-2703. Epub 2018 Nov 26.

Department of Otolaryngology - Head and Neck Surgery, University of Iowa.

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http://dx.doi.org/10.1002/hed.25348DOI Listing
December 2018

Worsening solid facial edema: An unusual case of angiosarcoma.

JAAD Case Rep 2018 Sep 14;4(8):794-796. Epub 2018 Sep 14.

University of Iowa Hospitals and Clinics, Iowa City, Iowa.

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http://dx.doi.org/10.1016/j.jdcr.2018.05.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6141638PMC
September 2018

Impact of PET/CT on Staging and Treatment of Advanced Head and Neck Squamous Cell Carcinoma.

Otolaryngol Head Neck Surg 2019 02 21;160(2):261-266. Epub 2018 Aug 21.

5 Department of Otolaryngology-Head and Neck Surgery, University of Iowa, Iowa City, Iowa, USA.

Objective: To understand the effects of positron emission tomography/computed tomography (PET/CT) evaluation on patients with previously untreated head and neck squamous cell carcinoma (HNSCC) with clinical evidence of regional lymph node involvement.

Study Design: Prospective blinded study.

Setting: Tertiary care cancer center.

Subjects And Methods: Informed consent was obtained and data collected from 52 consecutive previously untreated patients with HNSCC and clinical evidence of cervical metastasis. All patients underwent conventional evaluation for HNSCC and whole body PET/CT. Data were evaluated by 5 independent reviewers, who performed TNM staging per the American Joint Committee on Cancer (seventh edition) manual and proposed a treatment plan prior to viewing, and after reviewing, PET/CT. Cases where at least 3 of 5 reviewers agreed were considered significant.

Results: There were 0 patients for whom review of the PET/CT altered the T-class assessment (95% CI, 0-6.8), 12 (23.1%) for whom PET/CT altered N classification (95% CI, 12.5-34.5), and 2 (3.8%) for whom PET/CT altered the M classification (95% CI, 0.5-13.2). For 5 patients (9.6%), overall stage was altered per PET/CT review (95% CI, 3.2-21). For 3 patients (5.8%), PET/CT findings prompted reviewers to alter treatment recommendations (95% CI, 1.2-15.9).

Conclusion: When added to more conventional patient evaluation, PET/CT results in changes to the TNM categories, but overall staging and treatment were less frequently affected. Whether PET/CT should be used routinely for patients with stage III and IV HNSCC is still subjective and merits further study.
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http://dx.doi.org/10.1177/0194599818794479DOI Listing
February 2019

Ultrasound-Guided Salivary Gland Techniques and Interpretations.

Atlas Oral Maxillofac Surg Clin North Am 2018 Sep;26(2):119-132

Department of Otolaryngology, University of Iowa, University of Iowa Hospital, 200 Hawkins Drive, Iowa City, IA 52242, USA.

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http://dx.doi.org/10.1016/j.cxom.2018.04.001DOI Listing
September 2018

Health-Related Internet Use Among Otolaryngology Patients.

Ann Otol Rhinol Laryngol 2018 Aug 2;127(8):551-557. Epub 2018 Jul 2.

1 Department of Otolaryngology-Head and Neck Surgery, University of Iowa, Iowa City, Iowa, USA.

Objective: The association between online health resources use in specific otolaryngology patients is poorly understood. To better understand health-related Internet use by otolaryngology patients, we surveyed first-visit patients at academic and private practice clinics in Iowa.

Methods: Data on socioeconomic status, access, and utilization of online resources were collected. Age distributions were compared by t test, and categorical variables were compared by chi-square analysis. Multivariate logistic regression was used to estimate odds ratios for association between independent variables (age, sex, educational attainment, otolaryngology subspecialty, etc).

Results: Data showed that 8.7% lacked Internet access; an additional 5.4% reported access only in a public place or at work. Younger, more educated, and more urban patients reported higher rates of Internet access. Among university patients, patients seeing head and neck oncologists were most likely to report no Internet access (10.9%). Just over one-third of patients used the Internet to research their health condition prior to their appointment.

Conclusions: Internet access was far from universal among this large cohort of otolaryngology outpatients. Head and neck cancer (HNC) patients report the least online access among all otolaryngology subspecialties. Providers should consider nonelectronic patient resources for older, more rural, less educated, and HNC patient populations as online/electronic methods of communication may not be accessible to these groups.
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http://dx.doi.org/10.1177/0003489418779414DOI Listing
August 2018

Accuracy of the HPV status site-specific factor 10 (SSF-10) variable for patients with oropharyngeal cancers in the Iowa Cancer Registry, 2010-2014.

Head Neck 2018 10 22;40(10):2199-2209. Epub 2018 Jun 22.

University of Iowa College of Public Health & the Iowa Cancer Registry, Iowa City, Iowa.

Background: Surveillance, Epidemiology, and End Results Cancer Registries (SEER) began collecting human papillomavirus (HPV) status for upper aerodigestive tract cancers in 2010. However, classification of p16-testing was not included in the Collaborative Stage coding guidelines, potentially leading to inconsistent coding.

Methods: The HPV values for Iowa patients with oropharyngeal cancers (n = 824) were recoded based on modified guidelines that included p16 test results, and compared with the original guidelines.

Results: Forty percent of patients were recoded to a different value, and the HPV testing rate increased from 45% to 55%; 56% received p16-testing only. Of those originally coded as HPV-type 16 (n = 187), 89% were recoded to HPV-not otherwise specified (NOS). When comparing high-level positive/negative/not done categories, original coding captured 81% of patients with HPV-positive cancers.

Conclusion: p16 was the most common HPV test but was inconsistently coded as HPV-testing. p16-positivity was also erroneously equated with HPV-type 16. Adding a separate p16 variable would improve consistency and accuracy of HPV coding.
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http://dx.doi.org/10.1002/hed.25314DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6197903PMC
October 2018

Independent Predictors of Prognosis Based on Oral Cavity Squamous Cell Carcinoma Surgical Margins.

Otolaryngol Head Neck Surg 2018 10 8;159(4):675-682. Epub 2018 May 8.

1 Department of Otolaryngology-Head and Neck Surgery, University of Iowa, Iowa City, Iowa, USA.

Objective To conduct a multivariate analysis of a large cohort of oral cavity squamous cell carcinoma (OCSCC) cases for independent predictors of local recurrence (LR) and overall survival (OS), with emphasis on the relationship between (1) prognosis and (2) main specimen permanent margins and intraoperative tumor bed frozen margins. Study Design Retrospective cohort study. Setting Tertiary academic head and neck cancer program. Subjects and Methods This study included 426 patients treated with OCSCC resection between 2005 and 2014 at University of Iowa Hospitals and Clinics. Patients underwent excision of OCSCC with intraoperative tumor bed frozen margin sampling and main specimen permanent margin assessment. Multivariate analysis of the data set to predict LR and OS was performed. Results Independent predictors of LR included nodal involvement, histologic grade, and main specimen permanent margin status. Specifically, the presence of a positive margin (odds ratio, 6.21; 95% CI, 3.3-11.9) or <1-mm/carcinoma in situ margin (odds ratio, 2.41; 95% CI, 1.19-4.87) on the main specimen was an independent predictor of LR, whereas intraoperative tumor bed margins were not predictive of LR on multivariate analysis. Similarly, independent predictors of OS on multivariate analysis included nodal involvement, extracapsular extension, and a positive main specimen margin. Tumor bed margins did not independently predict OS. Conclusion The main specimen margin is a strong independent predictor of LR and OS on multivariate analysis. Intraoperative tumor bed frozen margins do not independently predict prognosis. We conclude that emphasis should be placed on evaluating the main specimen margins when estimating prognosis after OCSCC resection.
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http://dx.doi.org/10.1177/0194599818773070DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6341475PMC
October 2018

The complicated 'Yes': Decision-making processes and receptivity to lung cancer screening among head and neck cancer survivors.

Patient Educ Couns 2018 10 22;101(10):1741-1747. Epub 2018 Apr 22.

Department of Otolaryngology-Head and Neck Surgery, University of Iowa Carver College of Medicine, Iowa City, USA.

Objective: Shared decision making (SDM) is recommended when offering lung cancer screening (LCS)-which presents challenges with tobacco-related cancer survivors because they were excluded from clinical trials. Our objective was to characterize head and neck cancer (HNC) survivors' knowledge, attitudes, and beliefs toward LCS and SDM.

Methods: Between November 2017 and June 2018, we conducted semi-structured qualitative interviews with 19 HNC survivors, focusing on patients' cancer and smoking history, receptivity to and perceptions of LCS, and decision-making preferences RESULTS: Participants were receptive to LCS, referencing their successful HNC outcomes. They perceived that LCS might reduce uncertainty and emphasized the potential benefits of early diagnosis. Some expressed concern over costs or overdiagnosis, but most minimized potential harms, including false positives and radiation exposure. Participants preferred in-person LCS discussions, often ideally with their cancer specialist.

Conclusion And Practice Implications: HNC survivors may have overly optimistic expectations for LCS, and clinicians need to account for this in SDM discussions. Supporting these patients in making informed decisions will be challenging because we lack clinical data on the potential benefits and harms of LCS for cancer survivors. While some patients prefer discussing LCS with their cancer specialists, the ability of specialists to support high-quality decision making is uncertain.
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http://dx.doi.org/10.1016/j.pec.2018.04.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6119119PMC
October 2018
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