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

BACKGROUND: The cost utility of image-guided surveillance using computed tomography (CT) and positron emission tomography (PET)-CT to planned postradiation neck dissection (PRND) was compared for the management of advanced nodal human papillomavirus-positive oropharyngeal cancer following chemoradiation. METHODS: A universal payer perspective was adopted. A Markov model was designed to simulate four treatment approaches with 3-month cycles over a lifetime horizon: 1) CT surveillance, 2) standard PET-CT surveillance, 3) a novel PET-CT approach with repeat PET at 6 months postchemoradiation for equivocal responders, and 4) PRND. Parameters including probabilities of CT nodal progression/resolution, PET avidity, recurrence, and survival were obtained from the literature. Costs were reported in 2019 Canadian dollars and utilities were expressed in quality-adjusted life years (QALYs). Deterministic and probabilistic sensitivity analyses were performed to evaluate model uncertainty. RESULTS: PET-CT surveillance dominated CT surveillance and PRND in the base case scenario, and the novel PET-CT approach was the most cost-effective strategy across a wide range of variables tested in one-way sensitivity analysis. On probabilistic sensitivity analysis, novel PET-CT surveillance was the most cost-effective strategy in 78.1% of model iterations at a willingness-to-pay of $50,000/QALYs. Novel PET-CT surveillance resulted in a 49% lower rate of neck dissection compared with traditional PET-CT, and yielded an incremental benefit of 0.14 QALYs with average cost savings of $1309. CONCLUSIONS: Image-guided surveillance including PET-CT and CT are more cost effective than PRND. The novel PET-CT approach with repeat PET for equivocal responders was the dominant strategy and yielded both higher benefit and lower costs compared with standard PET-CT surveillance.

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

BACKGROUND: The De-ESCALaTE HPV trial confirmed the dominance of cisplatin over cetuximab for tumour control in patients with human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC). Here, we present the analysis of health-related quality of life (HRQoL), resource use, and health care costs in the trial, as well as complete 2-year survival and recurrence. MATERIALS AND METHODS: Resource use and HRQoL data were collected at intervals from the baseline to 24 months post treatment (PT). Health care costs were estimated using UK-based unit costs. Missing data were imputed. Differences in mean EQ-5D-5L utility index and adjusted cumulative quality-adjusted life years (QALYs) were compared using the Wilcoxon signed-rank test and linear regression, respectively. Mean resource usage and costs were compared through two-sample t-tests. RESULTS: 334 patients were randomised to cisplatin (n = 166) or cetuximab (n = 168). Two-year overall survival (97·5% vs 90·0%, HR: 3.268 [95% CI 1·451 to 7·359], p = 0·0251) and recurrence rates (6·4% vs 16·0%, HR: 2·67 [1·38 to 5·15]; p = 0·0024) favoured cisplatin. No significant differences in EQ-5D-5L utility scores were detected at any time point. At 24 months PT, mean difference was 0·107 QALYs in favour of cisplatin (95% CI: 0·186 to 0·029, p = 0·007) driven by the mortality difference. Health care costs were similar across all categories except the procurement cost and delivery of the systemic agent, with cetuximab significantly more expensive than cisplatin (£7779 [P < 0.001]). Consequently, total costs at 24 months PT averaged £13517 (SE: £345) per patient for cisplatin and £21064 (SE: £400) for cetuximab (mean difference £7547 [95% CI: £6512 to £8582]). CONCLUSIONS: Cisplatin chemoradiotherapy provided more QALYs and was less costly than cetuximab bioradiotherapy, remaining standard of care for nonsurgical treatment of HPV-positive OPSCC.

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

PURPOSE OF REVIEW: To examine the ways in which quality of life assessment has been and can be used in the future to benefit patient care. RECENT FINDINGS: Quality of life has to date been used as an outcome measure, mainly in a research setting when comparing two interventions. This has led to a better understanding of quality of life changes during the patient journey, enabling better information provision to patients. In future, quality of life assessment will be incorporated into routine clinical practice in a quality of life-driven head and neck cancer clinic. Routine quality of life assessment, possibly in automated electronic (touch-screen) format, may be used to screen patients for quality of life problems. Such assessments could be used in a timely fashion by the clinician to instigate interventions such as psychological counselling and pain control, thereby resulting in improvements in patients' overall quality of life. SUMMARY: Quality of life assessment has contributed to patient benefit. However, its full and greater potential remains untapped, although it is beginning to be addressed by current research.

Does quality of life predict long-term survival in patients with head and neck cancer?

OBJECTIVE: To assess whether pretreatment and posttreatment quality of life (QOL) is associated with long-term survival in patients with head and neck cancer. DESIGN: Ten-year follow-up of an inception cohort. SETTING: Regional tertiary referral center. PATIENTS: The study included 200 consecutive patients with primary epithelial head and neck cancer. INTERVENTIONS: Quality of life and several recognized risk factors for death were assessed prospectively using the Auckland QOL questionnaire before treatment and 12 months after treatment; survival was determined at 10 years. MAIN OUTCOME MEASURES: Survival and odds of death (hazards ratio) were measured. RESULTS: At 10 years, 136 patients (68%) were deceased, 48 patients (24%) were alive, and the status of 16 patients (8%) was unknown. Median survival was 6 years (interquartile range, 4.4-7.7). Before treatment, patients with low QOL had no significantly increased odds of death (hazard ratio, 1.4; 95% confidence interval, 0.8-2.4). In contrast, after treatment, patients with low QOL at 1 year had significantly increased odds of death (2.5; 95% confidence interval, 1.4-4.3; P = .001) even after adjustment for covariates. CONCLUSIONS: Findings suggest potential survival benefits from improvements in QOL. However, the observed associations between survival benefit and QOL at 1 year may be confounded by comorbidity, which was not measured and deserves further investigation.

Fungal laryngitis in immunocompetent patients.

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

Postoperative hypocalcemia--the difference a definition makes.

BACKGROUND: Review of the literature reveals considerable variability in the definitions and criteria used for reporting postoperative hypocalcemia. The lack of standardization prevents a meaningful comparison of results and performance locally with the national standard. It also prevents the pooling of data when performing meta-analysis, and may affect the comparison of research results. METHODS: A literature review was performed to identify the different definitions used to define hypocalcemia in post-thyroidectomy patients. We analyzed the incidence of hypocalcemia in the same cohort of 202 post thyroidectomy patients using these definitions. RESULTS: The reported hypocalcemia rates varied from 0% to 46% for the same cohort depending on the definition of hypocalcemia used. Only one-third of biochemically hypocalcemic patients requested calcium supplementation. CONCLUSION: This study demonstrates the need for more uniformity and standardization in the definitions used for reporting hypocalcemia rates.

Treatment and follow-up of oral dysplasia - a systematic review and meta-analysis.

BACKGROUND: The aim of this study was to inform an evidence-based management policy for oral dysplastic lesions. METHODS: Systematic review was performed with meta-analysis. Studies reporting follow-up of patients with histologically confirmed oral dysplasia were included. Outcome measures included malignant transformation rate (MTR) and time to malignant transformation (TMT). Subgroup analysis was performed by histologic grade, clinical risk factors, and treatment modality. Heterogeneity was assessed. RESULTS: Fourteen nonrandomized studies, reporting on 992 patients, were included. There was considerable heterogeneity between studies: mean overall MTR = 12.1% (confidence interval: 8.1%, 17.9%) and mean TMT = 4.3 years. Histologic grade significantly affected mean MTR (p < .008). Lesions that were not excised demonstrated considerably higher MTR than those that were excised (p = .003). CONCLUSIONS: Oral dysplasia showed a significant rate of transformation to cancer, which was related to grade and was decreased significantly but not eliminated by excision. This suggested the need for excision and continued surveillance.

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

INTRODUCTION: With an increasing number of publications on health-related quality of life (HRQOL) following head and neck cancer, the recognition of a number of well-validated questionnaires and a growing awareness of the potential role of HRQOL in practice, it was our aim to repeat the survey of 2002 reported in the Annals to see how practice changed. MATERIALS AND METHODS: A postal survey of members of the British Association of Head and Neck Oncologists was undertaken in January 2006 with reminders sent in February, March and April. RESULTS: The response was 50% (106 of 210) of which 53% were using or had used HRQOL questionnaires. The main reasons for not using HRQOL questionnaires were that they were too time-consuming or intrusive in a clinic setting and that there was a lack of resources. CONCLUSIONS: Clinicians still see the use of questionnaires as a research-tool only, rather than an adjunct to giving patient information, promoting choice, and identifying patients with problems. The burden on HRQOL evaluation in routine clinical practice remains a substantial barrier. Advances with IT support in clinic should make it easier to collect and use these data in the future. As surgeons, we still need to be persuaded of the benefits of HRQOL outcomes in our practice.