Travel-associated cost savings to patients and the health system through provision of specialist head and neck surgery outreach clinics in rural New South Wales, Australia.

INTRODUCTION: Centralisation of head and neck surgical services means that patients in regional and remote Australia need to travel long distances for treatment and follow-up, imparting a significant financial burden on patients and the health system. OBJECTIVE: To estimate costs of travel to local outreach clinics and determine potential cost savings to patients and the health system by avoiding patient travel to major cities for head and neck surgical care. DESIGN: Retrospective audit of three head and neck surgery outreach clinics in New South Wales, Australia over 4 years (2017-2020). Direct costs of travel from a patient's residence to their local outreach clinic were estimated. Costs of travel and accommodation to Sydney for an appointment were calculated for different travel modes. Estimated reimbursements for travel through government support schemes were calculated based on published rates. FINDINGS: Some 657 patients attended the three clinics, accounting for 1981 appointments. Depending on mode of travel, the estimated median cost of return travel (including accommodation) to Sydney was $379 to $739 per patient per trip and the median government reimbursement ranged from $182 to $279 per trip. In comparison, the cost of return travel by car to local outreach clinics ranged from $28 to $163 per appointment. Outreach clinics were estimated to save patients a median of $285 per trip and avoided government reimbursements of $215 per trip. DISCUSSION: Despite uptake in telehealth, outreach medical services remain an important asset for people living in regional areas to address inequities in access. However, the cost benefits are likely to be underestimated as our approach did not account for indirect costs associated with travel. CONCLUSION: Outreach head and neck surgical services located in regional areas can reduce the financial burden on both patients and the healthcare system. Greater investment in outreach clinics could ensure sustainability of services to promote equitable access to specialised surgical services.

Epidemiology, staging and management of mucosal melanoma of the head and neck: a narrative review.

BACKGROUND AND OBJECTIVE: Mucosal melanoma of the head and neck (MMHN) are rare, aggressive neoplasms of melanocyte origin that remain incompletely understood and have a poor prognosis, with high rates of locoregional recurrence and distant metastasis. Several recent studies having expanded understanding of MMHN, we undertook a review of the latest evidence pertaining to its epidemiology, staging, and management. METHODS: A literature search was conducted for peer-reviewed articles reporting and discussing the epidemiology, staging, and management of MMHN. PubMed, Medline, Embase and the Cochrane Library were searched to identify relevant publications. KEY CONTENT AND FINDINGS: MMHN remains an uncommon disease. The current TNM staging system for MMHN provides inadequate risk stratification, and consideration of an alternative staging model such as one based on a nomogram may be justifiable. Tumour resection with clear histological margins remains the cornerstone of optimal treatment. Adjuvant radiotherapy may improve locoregional control but does not appear to affect survival. Immune checkpoint inhibitors and c-KIT inhibitors demonstrate promising efficacy in patients with advanced or unresectable mucosal melanomas, and warrant further research exploring the utility of combination therapies. Their roles as adjuvant therapies have not been determined. The efficacy of neoadjuvant systemic therapy is also not yet clear, although early results suggest that it may improve outcomes. CONCLUSIONS: New insights into the epidemiology, staging and management of MMHN have transformed the standard of care for this rare malignancy. Nonetheless, the results of ongoing clinical trials and future prospective studies are required to better understand this aggressive disease and optimise its management.

Representativeness of the Index Lymph Node for Total Nodal Basin in Pathologic Response Assessment After Neoadjuvant Checkpoint Inhibitor Therapy in Patients With Stage III Melanoma.

IMPORTANCE: Neoadjuvant checkpoint inhibition in patients with high-risk stage III melanoma shows high pathologic response rates associated with a durable relapse-free survival. Whether a therapeutic lymph node dissection (TLND) can be safely omitted when a major pathologic response in the largest lymph node metastasis at baseline (index lymph node; ILN) is obtained is currently being investigated. A previous small pilot study (n = 12) showed that the response in the ILN may be representative of the pathologic response in the entire TLND specimen. OBJECTIVE: To assess the concordance of response between the ILN and the total lymph node bed in a larger clinical trial population. DESIGN, SETTING, AND PARTICIPANTS: Retrospective pathologic response analysis of a multicenter clinical trial population of patients from the randomized Study to Identify the Optimal Adjuvant Combination Scheme of Ipilimumab and Nivolumab in Melanoma Patients (OpACIN) and Optimal Neo-Adjuvant Combination Scheme of Ipilimumab and Nivolumab (OpACIN-neo) trials. Included patients were treated with 6 weeks neoadjuvant ipilimumab plus nivolumab. Patient inclusion into the trials was conducted from August 12, 2015, to October 24, 2016 (OpACIN), and November 24, 2016, and June 28, 2018 (OpACIN-neo). Data were analyzed from April 1, 2020, to August 31, 2021. MAIN OUTCOMES AND MEASURES: Concordance of the pathologic response between the ILN and the TLND tumor bed. The pathologic response of the ILN was retrospectively assessed according to the International Neoadjuvant Melanoma Consortium criteria and compared with the pathologic response of the entire TLND specimen. RESULTS: A total of 82 patients treated with neoadjuvant ipilimumab and nivolumab followed by TLND (48 [59%] were male; median age, 58.5 [range, 18-80] years) were included. The pathologic response in the ILN was concordant with the entire TLND specimen response in 81 of 82 patients (99%) and in 79 of 82 patients (96%) concordant when comparing the ILN response with the response in every individual lymph node. In the single patient with a discordant response, the ILN response (20% viable tumor, partial pathologic response) underestimated the entire TLND specimen response (5% viable, near-complete pathologic response). Two other patients each had 1 small nonindex node that contained 80% viable tumor (pathologic nonresponse) whereas all other lymph nodes (including the ILN) showed a partial pathologic response. In these 2 patients, the risk of regional relapse might potentially have been increased if TLND had been omitted. CONCLUSIONS AND RELEVANCE: The results of this study suggest that the pathologic response of the ILN may be considered a reliable indicator of the entire TLND specimen response and may support the ILN response-directed omission of TLND in a prospective trial.

Time and cost-analysis of virtual surgical planning for head and neck reconstruction: A matched pair analysis.

OBJECTIVES: Virtual surgical planning (VSP) uses patient-specific modelling of the facial skeleton to provide a tailored surgical plan which may increase accuracy and reduce operating time. The aim of this study was to perform a time and cost-analysis comparing patients treated with and without VSP-technology. MATERIAL AND METHODS: A retrospective analysis of 138 patients undergoing microvascular free flap mandible (76.8%) or maxillary (23.2%) reconstruction between 2010 and 2018 was performed. The cohort was divided into two groups according to reconstruction-approach: non-VSP and proprietary-VSP (P-VSP). Cost-analysis was performed comparing non-VSP and P-VSP by matching patients according to site, bone flap, indication, complexity and age. RESULTS: Fibula, scapula and iliac crest free flaps were used in 92 patients (66.7%), 33 patients (23.9%) and 13 patients (9.4%), respectively. Eight patients (5.8%) required revision of the microvascular anastomosis, of which four flaps were salvaged giving a 2.9% flap failure rate. P-VSP was associated with shorter median length of stay (LOS) (10.0 vs 13.0 days, p = 0.009), lower mean procedure time (507.38 vs 561.75 min, p = 0.042), and similar median total cost ($34939.00 vs $34653.00, p = 0.938), despite higher complexity (2.0 vs 1.0, p = 0.09). In the matched-series, P-VSP was associated with a similar median LOS (10.5 vs 11 days), lower mean procedure time (497 vs 555 min, p = 0.231), lower mean total cost ($35,493 v $37,345) but higher median total cost ($35504.50 vs $32391.50, p = 0.607), although not statistically different. CONCLUSION: VSP-technology represents a helpful surgical tool for complex reconstructions, without adversely impacting on the overall-cost of treatment.

Prospective quality of life assessment between treatment groups for oral cavity squamous cell carcinoma.

BACKGROUND: Postoperative radiation therapy (PORT) is frequently recommended to improve survival outcome. The effect of PORT-associated morbidity on patients' quality of life (QOL) is, however, not well established. This study assessed the effect of PORT on medium-term (ie, at 6 months) QOL in patients with oral cavity squamous cell carcinoma (SCC). METHODS: Patients completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) and Quality of Life Questionnaire Core Head and Neck 35 (QLQ-HN35) at initial presentation, and at 3-, 6-, and 12-month follow-up. Baseline QOL scores were adjusted for using analysis of covariance (ANCOVA). RESULTS: Global health status (mean difference = 13.3; p = .042) and xerostomia (mean difference = 35.4; p = .003) were significantly worse at 6 months in patients who received PORT compared to those treated with surgery alone. CONCLUSION: The survival advantage needs to be balanced against increased treatment toxicity. PORT is associated with reduced global health status, increased xerostomia, and marginally increased levels of fatigue at 6 months posttreatment for oral cavity cancer.

Assessment of second tier lymph nodes in melanoma and implications for extent of elective neck dissection in metastatic cutaneous malignancy of the parotid.

BACKGROUND: The parotid is the commonest site of cutaneous metastases in the head and neck. The role and extent of neck dissection in patients with parotid metastatic cutaneous malignancy remains controversial. METHODS: We reviewed the lymphoscintigraphy and single photon emission CT (SPECT) of patients with melanoma who had a sentinel node in the parotid to determine the second tier cervical lymph nodes. RESULTS: Levels II and III cervical nodes make up 82% of second tier lymph nodes for the parotid, and levels IV and V, 12% and 4%, respectively. Second tier lymph nodes isolated to levels I, IV, or V, bypassing levels II and III, occurred in only 2% of cases. CONCLUSION: The risk of harboring occult metastasis in levels I, IV, and V when levels II and III are negative is low. Levels II and III neck dissection is likely to be an effective staging procedure in patients with isolated parotid metastases.