Individualized risk assessment of distant metastases in oral cavity carcinoma: a validated predictive-score model.

BACKGROUND: We aimed to develop and validate a risk-scoring system for distant metastases (DMs) in oral cavity carcinoma (OCC). METHODS: Patients with OCC who were treated at 4 tertiary cancer institutions with curative surgery with or without postoperative radiation/chemoradiation therapy were randomly assigned to discovery or validation cohorts (3:2 ratio). Cases were staged on the basis of tumor, node, and metastasis staging according to the eighth edition of the American Joint Committee on Cancer/Union for International Cancer Control guidelines. Predictors of DMs on multivariable analysis in the discovery cohort were used to develop a risk-score model and classify patients into risk groups. The utility of the risk classification was evaluated in the validation cohort. RESULTS: Overall, 2749 patients were analyzed. Predictors (risk score coefficient) of DMs in the discovery cohort were the following: pathological stage (p)T3-4 (0.4), pN+ (N1: 0.8; N2: 1.0; N3: 1.5), histologic grade (G) 3 (G3, 0.7), and lymphovascular invasion (0.4). The DM risk groups were defined by the sum of the following risk score coefficients: high (>1.7), intermediate (0.7-1.7), and standard risk (<0.7). The 5-year DM rates (high/intermediate/standard risk groups) were 30%/15%/4% in the discovery cohort (C-index = 0.79) and 35%/16%/5% in the validation cohort, respectively (C-index = 0.77; both P < .001). In the whole cohort, this predictive model showed excellent discriminative ability in predicting DMs without locoregional failure (29%/11%/1%), later (>2 year) DMs (11%/4%/2%), and DMs in patients treated with surgery (20%/12%/5%), postoperative radiation therapy (34%/17%/4%), and postoperative chemoradiation therapy (39%/18%/7%) (all P < .001). The 5-year overall survival rates in the overall cohort were 25%/51%/67% (P < .001). CONCLUSIONS: Patients at higher risk for DMs were identified by use of a predictive-score model for DMs that included pT3-4, pN1/2/3, G3, and lymphovascular invasion. Identified patients may be evaluated for individualized risk-adaptive treatment escalation and/or surveillance strategies.

Recommendations for head and neck surgical oncology practice in a setting of acute severe resource constraint during the COVID-19 pandemic: an international consensus.

The speed and scale of the global COVID-19 pandemic has resulted in unprecedented pressures on health services worldwide, requiring new methods of service delivery during the health crisis. In the setting of severe resource constraint and high risk of infection to patients and clinicians, there is an urgent need to identify consensus statements on head and neck surgical oncology practice. We completed a modified Delphi consensus process of three rounds with 40 international experts in head and neck cancer surgical, radiation, and medical oncology, representing 35 international professional societies and national clinical trial groups. Endorsed by 39 societies and professional bodies, these consensus practice recommendations aim to decrease inconsistency of practice, reduce uncertainty in care, and provide reassurance for clinicians worldwide for head and neck surgical oncology in the context of the COVID-19 pandemic and in the setting of acute severe resource constraint and high risk of infection to patients and staff.

Treatment Options for Hypopharyngeal Cancer in Developing Countries in Africa/South America/Asia.

Most cancers occur in developing countries, and therefore, a discussion about cancer care would be incomplete without providing a developing world perspective. This chapter focuses on challenges and practices relating to hypopharyngeal cancer in limited-resource public healthcare systems in developing countries and specifically in Sub-Saharan Africa, India and South America and by extension, most patients in the developing world. Management of hypopharyngeal cancer must be adapted to the availability of specialised diagnostic and therapeutic services, radiotherapy and surgical expertise, and tailored to patient factors such as reliability of follow-up and social support. A particular challenge for physicians is to decide who can be denied the opportunity to be cured when the burden of cancer cases exceeds available resources. Public education campaigns about reducing risk factors for hypopharyngeal cancer are an important aspect of reducing the burden of cancer.

Priority setting in head and neck oncology in low-resource environments.

PURPOSE OF REVIEW: Most information about priority setting comes from developed countries. In low-resource settings, many factors should be considered to select the best candidate for the treatments that are available. The physician is always under pressure to obtain better results in spite of the lower quantity of resources. This exposes physicians to daily ethical dilemmas and increases their anxiety and burnout. RECENT FINDINGS: Most low-resource settings have restrictions in major treatments, and the number of specialized centers that have all the services is low. The surgeon has to navigate through the system as a patient advocate, taking the responsibilities of other health system actors, has to 'negotiate' to design a treatment based on outdated results or to wait for new results and has to decide whether to start or to wait for other treatments to be ready to comply with protocol recommendations. SUMMARY: The surgeons face the dilemma of offering the best treatment with scarce resources but with a higher possibility of completion. Finally, we must do the best we can with what we have.

Total thyroidectomy with ultrasonic scalpel: a multicenter, randomized controlled trial.

BACKGROUND: The ultrasonic scalpel is a recently introduced device in head and neck surgery. Total thyroidectomy is the most common endocrine procedure performed by surgeons. METHODS: This was an open, phase IV, multicenter, randomized controlled trial (RCT) that compared the use of an ultrasonic scalpel with a conventional technique in patients who underwent total thyroidectomy. The outcomes were surgical complication rate, operative time, drainage volume, postoperative pain, and costs. RESULTS: In all, 261 patients were included in 11 centers. There was a mean difference of 17% of operative time in favor of the ultrasonic scalpel group. There were no differences in postoperative complications. There was a difference in costs of 14% in favor of the ultrasonic scalpel group, but it was not statistically significant. CONCLUSIONS: The use of an ultrasonic scalpel was as safe as that of the conventional technique and had the advantage of a shorter operative time and lower postoperative drainage. Costs were not different between groups.

Assessment of control selection bias in a hospital-based case-control study of upper aero-digestive tract cancers.

BACKGROUND: Most of the evidence identifying determinants of UADT cancer risk comes from hospital-based case-control studies. However, such studies are thought to be influenced by selection bias given the extent of association of tobacco smoking and alcohol drinking with other diseases in the general population. We assessed the extent of selection bias due to inclusion of controls with tobacco or alcohol related diseases in a hospital-based case-control study of upper aero-digestive tract (UADT) cancers in Brazil. METHODS: Risk factor information was obtained from 784 cases and 1568 non-cancer controls. Causes of hospitalization for controls were scored according to their likelihood of association with tobacco and alcohol. Odds ratios (OR) were calculated by conditional logistic regression with and without exclusion of controls with tobacco or alcohol related diseases. RESULTS: The OR for smoking slightly increased after exclusion of controls with tobacco-related diseases, from 15.3 (95% confidence interval [CI]: 9.7, 24.2) among heaviest smokers (pack-years > 91) to 18.6 (95%CI: 11.4, 30.2). The OR for alcohol consumption remained unchanged after exclusion of controls with alcohol related diseases. Associations of low magnitude for some dietary variables (citric fruits, carotene-rich foods, spicy foods, maté tea) and wood stove use were not appreciably affected by the exclusion of controls. CONCLUSION: The bias introduced by controls with tobacco and alcohol related diseases is small, when these exposures are investigated as determinants, and almost negligible when considered as confounders of the association between other factors and UADT cancers.