JAMA otolaryngology-- head & neck surgery最新文献

Importance: The care for a small subset of patients is responsible for a disproportionately large share of health care expenditures. Head and neck cancer is associated with significant health care costs due to complex treatment regimens and long-term sequelae. Given this high baseline cost, identifying patients with high care costs within a population with cancer might help inform interventions to optimize resource allocation.

Objective: To characterize patients with head and neck cancer with the highest health care costs during the first year after diagnosis.

Design, setting, and participants: A population-based, retrospective cohort study was conducted using administrative data from the Institute for Clinical and Evaluative Sciences in Ontario, Canada, and included adults diagnosed with head and neck cancer between January 2007 and October 2020 (identified from the provincial cancer registry) with a full 1.5-year follow-up from the date of diagnosis to the date of death or October 31, 2021. The total 1-year health care costs were estimated using a patient-level algorithm and were collected in 2020 Canadian dollar values. The main analyses were performed in April 2023 and a sensitivity analysis was performed in April 2025.

Main outcomes and measures: High health care costs (>75th percentile) during the first year after a head and neck cancer diagnosis. Predictors of high health care costs were identified using a multivariable logistic regression model.

Results: The cohort included 13 795 patients (mean age, 63.2 [SD, 11.7] years and 3452 [25.0%] were female), 3448 (25%) of whom had high health care costs. Cancer stage was the strongest predictor of high health care costs. Compared with patients with stage I cancer, those with stage II cancer had 2-fold greater odds for high health care costs (odds ratio [OR], 3.14 [95% CI, 2.56-3.84]), those with stage III cancer had 5-fold greater odds for high health care costs (OR, 6.08 [95% CI, 4.99-7.41]), and those with stage IV cancer had 8-fold greater odds for high health care costs (OR, 8.94 [95% CI, 7.43-10.80]). Receiving multiple treatment modalities also was associated with greater odds for high-cost care.

Conclusions and relevance: This cohort study found that more advanced disease stage and receiving multiple treatment modalities were the strongest predictors of high-cost care among patients diagnosed with head and neck cancer. Prioritizing research and implementation of screening programs, earlier cancer diagnoses, and effective treatment deescalation strategies might mitigate a significant portion of these high costs.

Importance: Initiation of postoperative radiation therapy (PORT) within 6 weeks of surgery is associated with improved outcomes among patients with head and neck squamous cell carcinoma. However, the relationship of barriers to care with timely PORT is unknown.

Objective: To categorize barriers to timely PORT, evaluate the association of barriers to care with initiation of timely PORT, and describe the primary reason for delay among patients without timely PORT.

Design, setting, and participants: This prospective cohort study at a US academic medical center included adults with head and neck squamous cell carcinoma undergoing curative-intent surgery with an indication for PORT. Patients were recruited for the study from May 19, 2020, to November 6, 2023.

Main outcomes and measures: The primary outcome was initiation of timely PORT, defined as starting radiation therapy within 6 weeks of surgery. Barriers to PORT were prospectively collected via patient self-report and the electronic health record. Among patients who did not start PORT within 6 weeks of surgery, the primary reason for delay was defined as the singular barrier category that most directly led to the delay.

Results: Among 78 patients (mean [SD] age, 61.5 [10.8] years; 54 males [69.2%]), 32 patients (41%) initiated PORT within 6 weeks of surgery, and 46 patients (59%) did not initiate PORT within 6 weeks of surgery. Each additional barrier was associated with a decreased odds of initiating timely PORT (adjusted odds ratio, 0.81 [95% CI, 0.63-1.01]); patients with 5 or more barriers had a 76% reduction in the odds of starting PORT within 6 weeks of surgery relative to those with 0 to 2 barriers (adjusted odds ratio, 0.24 [95 CI%, 0.06-0.84]) on multivariable analysis. When analyzed by barrier category, patients with a perioperative adverse effects-related barrier were less likely to initiate timely PORT than patients without a perioperative adverse effects barrier (adjusted odds ratio, 0.17 [95% CI, 0.04-0.66]) on multivariable analysis. Among patients without timely PORT, the most common primary reason for delay was a barrier related to poor care coordination (19/46 [41.3%]).

Conclusions and relevance: In this prospective cohort study, patients with a greater number of barriers and those with a barrier related to the perioperative adverse effects category were less likely to initiate timely PORT. Among patients without timely PORT, the most common primary reason for delay was a barrier related to poor care coordination. Efforts to improve timely PORT should focus on decreasing the number of barriers, improving surgical quality, and enhancing care coordination.

Importance: The palatine tonsil is the most common subsite of human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (SCC). There is debate on how to manage the contralateral clinically uninvolved tonsil in patients undergoing a primary surgical approach via transoral robotic surgery (TORS).

Objective: To assess postoperative complications, functional outcomes, contralateral tonsil second primary rates, and survival in patients undergoing unilateral vs bilateral TORS with pathology-guided adjuvant treatment.

Design, setting, and participants: A retrospective cohort study was carried out in a quaternary care academic medical center. All consecutive unilateral tonsillar patients with SCC undergoing TORS as primary treatment from June 2016 to July 2023 were included. Analysis was conducted between October 1, 2024, and January 1, 2025.

Exposure: Unilateral TORS (ipsilateral radical tonsillectomy) vs bilateral TORS (ipsilateral radical tonsillectomy and contralateral extracapsular tonsillectomy).

Main outcomes: The primary outcome measure was rate of postoperative oropharyngeal hemorrhage. Secondary outcome measures included postoperative emergency department (ED) visit/hospitalization rate, time to nasogastric tube (NGT) removal, rate of discharge with an NGT tube, G-tube dependence rates, second primary rates in the contralateral tonsil, length of stay, and 2-year and 5-year disease-free survival (DFS) and overall survival (OS).

Results: A total of 158 (106 unilateral, 52 bilateral TORS) patients with HPV-associated tonsillar SCC were evaluated, including 18 women and 139 men with a mean (SD) age of 60 (10) years. There were clinically meaningful differences in oropharyngeal hemorrhage rates (7% vs 15%; percent difference, -7.8; 95% CI, -18.8% to 3.2%), 30-day ED visit/hospitalization rates (9% vs 21%; percent difference, -11.7%; 95% CI, -24.1 to 0.7), and median length of stay (2 vs 3 days) for unilateral and bilateral TORS, respectively. Swallowing outcomes, DFS, and OS were not significantly different between the 2 groups. A total of 3 patients (1.9%) had a second primary tumor in the contralateral tonsil, including 2 metachronous primary tumors in the unilateral group (1.8%) and 1 synchronous primary tumor incidentally removed at the time of surgery in the bilateral group (1.9%).

Conclusions and relevance: This cohort study found that omission of contralateral elective extracapsular tonsillectomy in HPV-positive SCC was safe and associated with a trend toward lower posttonsillectomy hemorrhage, postoperative ED visits for pain control, and hospital length of stay without compromising survival. Prophylactically resecting the contralateral tonsil may add patient harm without any clear benefits.

Introduction: Head and neck cancer (HNC), one of the most emotionally distressing cancers, carries a significant burden of psychiatric comorbidities. While opioids are commonly prescribed in cancer care, the association between preexisting psychiatric risk factors and prescription opioid use in HNC remains unclear.

Objective: To test the hypothesis that preexisting psychiatric risk factors are associated with any opioid prescription and long-term opioid therapy in patients with HNC.

Design, setting, and participants: This retrospective longitudinal cohort study used deidentified data from the Optum electronic health record database, comprising a random sample of 5 million patients across the US between January 2010 and December 2018. Eligible patients were adults diagnosed with HNC. Using a 2-year look-back prior to the index date of HNC diagnosis, patients who used prescription opioids prior to HNC diagnosis were excluded. The data analysis was conducted between July 2022 and July 2023.

Main outcomes and measures: Outcomes of interest were receipt of any prescription opioid within 12 months of index HNC and long-term opioid therapy (LTOT), defined as 10 or more opioid prescriptions within 12 months of index HNC. Psychiatric risk factors included anxiety disorders, depression, smoking/nicotine dependence, substance use disorders, and benzodiazepine prescription. Multivariate logistic regression estimated the odds of opioid use based on preexisting psychiatric factors.

Results: Of 20 286 patients with an HNC diagnosis, 11 335 met all eligibility criteria. Patients in the analytic cohort had a mean (SD) age of 57.1 (15.5) years, and 55.4% were female. Within 12 months of HNC diagnosis, 23.4% received an opioid prescription, and 4.9% received LTOT. In fully adjusted models, depression (adjusted odds ratio [aOR], 1.21; 95% CI, 1.01-1.45), nicotine dependence (aOR, 1.56; 95% CI, 1.40-1.73), and benzodiazepine comedication (aOR, 1.44; 95% CI, 1.22-1.70) were associated with increased odds of receiving any opioid prescription. Furthermore, male patients had 49% greater odds of receiving opioid prescriptions (aOR, 1.49; 95% CI, 1.36-1.64). Only smoking/nicotine dependence was associated with increased odds of LTOT (aOR, 1.77; 95% CI, 1.21-2.61).

Conclusions and relevance: Preexisting psychiatric comorbidities, especially depression and smoking/nicotine dependence, were associated with increased odds of prescription opioid use and LTOT in patients with HNC in this longitudinal cohort study. Screening for these comorbidities during the management of patients with HNC can be impactful in informing clinical decisions that contribute to safer opioid prescribing.