The Clinical Utility and Cost of Routine Staging Exam under Anesthesia for Oral Cavity Squamous Cell Carcinoma.

INTRODUCTION: The standard complete evaluation of patients with head and neck squamous cell carcinoma (HNSCC) has included a staging exam under anesthesia (EUA) since the 1970s. The EUA for all sites of HNSCC has historically consisted of panendoscopy for the purpose of diagnostic biopsy, accurate staging of primary disease, and identification of second primary tumors. However, due to the accessibility of the oral cavity, the sole purpose of EUA for tumors of this site is to identify second primary tumors. Since the EUA became the gold standard for evaluation of HNSCC, there have been significant advancements in less invasive technologies such as CT, PET-CT, MRI, and fiberoptic examination. In this study, we sought to determine the value to patient care and cost-effectiveness of EUA in patients with oral cavity squamous cell carcinoma (OCSCC). METHODS: A retrospective chart review identified 77 patients who underwent EUA for OCSCC. RESULTS: The most common subsites were the oral tongue and floor of mouth (59.7% and 24.7% respectively). All underwent direct laryngoscopy, 94.8% underwent esophagoscopy, and 20.8% underwent flexible transnasal examination in clinic prior to EUA. For 90.9% of patients, the EUA did not change initial T-staging based on clinical examination and imaging. The remaining 9.1% of patients were upstaged after EUA, however this change did not impact the treatment plan. Second primary tumors were identified in 3.9% of patients, all were found in either the oral cavity or oropharynx, and were also identified with clinical examination or imaging. Analysis of patient charges determined an average cost of $8,022.93 per patient under the current paradigm involving EUA, however with a new algorithm eliminating mandatory EUA average cost decreases to $1,448.44. CONCLUSION: Formal EUA has historically been the gold standard for all HNSCC tumors. However, when performed for cases of oral cavity carcinoma, it is safe and cost effective to limit its use to select clinical scenarios.

Feasibility of ecological momentary assessment to study depressive symptoms among cancer caregivers.

OBJECTIVE: Ecological momentary assessment (EMA) may help with the development of more targeted interventions for caregivers' depression, yet the use of this method has been limited among cancer caregivers. This study aimed to demonstrate the feasibility of EMA among cancer caregivers and the use of EMA data to understand affective correlates of caregiver depressive symptoms. METHODS: Caregivers (N = 25) completed a depressive symptom assessment (Patient Health Questionnaire-8) and then received eight EMA survey prompts per day for 7 days. EMA surveys assessed affect on the orthogonal dimensions of valence and arousal. Participants completed feedback surveys regarding the EMA protocol at the conclusion of the week-long study. RESULTS: Of 32 caregivers approached, 25 enrolled and participated (78%), which exceeded the a priori feasibility cutoff of 55%. The prompt completion rate (59%, or 762 of 1,286 issued) did not exceed the a priori cutoff of 65%, although completion was not related to caregivers' age, employment status, physical health quality of life, caregiving stress, or depressive symptoms or the patients' care needs (ps > 0.22). Caregivers' feedback about their study experience was generally positive. Mixed-effects location scale modeling showed caregivers' higher depressive symptoms were related to overall higher reported negative affect and lower positive affect, but not to affective variability. CONCLUSIONS: Findings from this feasibility study refute potential concerns that an EMA design is too burdensome for distressed caregivers. Clinically, findings suggest the potential importance of not only strategies to reduce overall levels of negative affect, but also to increase opportunities for positive affect.

First-year trends in self-reported general health predict survival in patients with head and neck cancer.

OBJECTIVE: To demonstrate that first-year trends in a self-reported subjective general health assessment tool can provide prognostic information and help predict long-term survival in patients with head and neck cancer. DESIGN: Prospective observational cohort study. SETTING: Tertiary care center. PATIENTS: Four hundred three patients with head and neck cancer who were enrolled in a longitudinal outcomes project between January 1, 1995, and December 31, 2005. INTERVENTION: Self-reported general physical health assessments were collected using the Medical Outcomes Study 36-Item Short-Form Health Survey at diagnosis (pretreatment) and at 3, 6, 9, and 12 months after diagnosis. MAIN OUTCOME MEASURES: Actuarial 5-year observed (all deaths) and disease-specific (death with cancer present) survival. RESULTS: Mean physical component summary (PCS) scores decreased at 3 months in all patient groups. While patients who died within the second or third year exhibited virtually no recovery, those who died within the fourth or fifth year exhibited some recovery, and those who survived 5 years or longer approached baseline PCS scores by 12 months. Shorter survival correlated with a greater net decrease in PCS score at 12 months. Groups based on pretreatment and 12-month PCS scores had significantly different survival curves. The net change in PCS score at 12 months (DeltaPCS) was a predictor of both observed and disease-specific survival at univariate analysis and an independent predictor of disease-specific survival in multivariate analysis. CONCLUSION: First-year trends in the 36-Item Short-Form Health Survey PCS score, a self-reported subjective measure of general physical health, are predictive of long-term survival.