A Learning Health System Approach to Increasing Human Papillomavirus Immunizations Among Young Adults.

INTRODUCTION Immunization rates against the human papillomavirus (HPV) remain suboptimal in the young adult population. Little is known about the most effective means for encouraging vaccination in this population. METHODS The authors conducted a clinical trial of 3 methods to encourage HPV vaccination in a large Northern California integrated Health Plan. Young adults aged 18-26 with evidence of insufficient HPV vaccination were sent a bulk secure message from the Health Plan (standard outreach); those who did not respond were randomized to no further outreach, a second, personalized secure message from a specific practitioner, or a letter mailed to their home. The primary outcome was receipt of at least 1 HPV vaccine within 3 months following the initial bulk secure message. RESULTS In total, 7718 young adults were randomized. After 3 months, 86 patients (3.5%) who received no additional outreach obtained an immunization, compared with 114 (4.6%) who received the second secure message (p = 0.05) and 126 (5.1%) who received the mailed letter (p = 0.006). DISCUSSION Supplemental mailed or personalized electronic messages increased vaccination beyond no additional intervention, although gains were not clinically meaningful. These findings highlight the need for more successful alternatives to encourage uptake of such preventive health interventions among young adults. The successful conduct of this rapid-cycle, randomized trial showed that such evaluations are feasible, providing actionable data to inform implementation strategies. CONCLUSIONS Further study is needed to identify effective strategies for improving preventive health uptake in this important and underserved population. Rapid-cycle randomized evaluation strategies can provide critical information to focus efforts for achieving this goal.

Ten-year Thyroid Cancer Incidence in an Integrated Healthcare Delivery System.

INTRODUCTION: The incidence of papillary thyroid cancer (PTC) has increased in recent decades, but data from community-based settings are limited. This study characterizes PTC trends in a large, integrated healthcare system over 10 years. METHODS: The annual incidence of PTC (2006-2015) was examined among Kaiser Permanente Northern California adults aged 21 to 84 years using Cancer Registry data, including tumor size and stage. Incidence estimates were age-adjusted using the 2010 US Census. RESULTS: Of 2990 individuals newly diagnosed with PTC (76.8% female, 52.7% non-Hispanic White), 38.5% and 61.5% were aged < 45 and < 55 years, respectively. At diagnosis, 60.9% had PTC tumors ≤ 2 cm, 9.2% had tumors > 4 cm, and 66.1% had Stage I disease. The annual age-adjusted incidence of PTC increased from 9.4 (95% confidence interval [CI] = 8.1-10.7) to 14.5 (95% CI = 13.1-16.0) per 100,000 person-years and was higher for female patients than for male patients. Incidence tended to be higher in Asian/Pacific Islanders and lower in Black individuals. Increasing incidence was notable for Stage I disease (especially 2006-2012) and evident across a range of tumor sizes (3.0-4.6 for ≤ 1 cm, 2.5-3.5 for 1-2 cm, and 2.4-4.7 for 2-4 cm) but was modest for large tumors (0.9-1.5 for > 4 cm) per 100,000 person-years. DISCUSSION: Increasing PTC incidence over 10 years was most evident for tumors ≤ 4 cm and Stage I disease. Although these findings may be attributable to greater PTC detection, the increase across a range of tumor sizes suggests that PTC burden might also have increased.

The Adult Neck Mass: Predictors of Malignancy.

OBJECTIVE: Distinguishing benign from malignant adult neck masses can be challenging because data to guide risk assessment are lacking. We examined patients with neck masses from an integrated health system to identify patient and mass factors associated with malignancy. STUDY DESIGN: Retrospective cohort. SETTING: Kaiser Permanente Northern California. METHODS: The medical records of adults referred to otolaryngology in 2017 for a neck mass were evaluated. Bivariate and multivariable logistic regression analyses were performed. RESULTS: Malignancy was found in 205 (5.0%) of the cohort's 4103 patients. Patient factors associated with malignancy included sex, age, and race/ethnicity. Males had more than twice the odds of malignancy compared with females (adjusted odds ratio [aOR] = 2.38). Malignancy rates increased with age, ranging from 2.1% for patients younger than 40 years to 8.4% for patients 70 years or older. White non-Hispanic patients had 1.75 times the risk of malignancy compared with patients of other race/ethnicities. The percentage of patients with malignancy increased with increasing minimum mass dimension, from 3.0% in patients with mass size <1 cm to over 31% in patients with mass sizes 2 cm or larger (P < .0001). Imaging-based mass factors most highly predictive of malignancy included larger minimum mass dimension (≥1.5 cm vs <1.5 cm: aOR = 3.87), multiple masses (2 or more vs 1: aOR = 5.07), and heterogeneous/ill-defined quality (aOR = 2.57). CONCLUSION: Most neck masses referred to otolaryngology were not malignant. Increasing age, male sex, white non-Hispanic ethnicity, increasing minimum mass dimension, multiple neck masses, or heterogeneous architecture/ill-defined borders were associated with malignancy.

Association of NCCN-Recommended Posttreatment Surveillance With Outcomes in Patients With HPV-Associated Oropharyngeal Squamous Cell Carcinoma.

IMPORTANCE: National Comprehensive Cancer Network (NCCN) guidelines recommend routine clinical follow-up as posttreatment surveillance for patients with head and neck cancer (HNC). Human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPV-associated OPSCC) is a unique subset of HNC, associated with fewer recurrences and improved survival. The utility of this guideline in this patient population is unknown. OBJECTIVE: To determine adherence to the NCCN clinical follow-up guideline, frequency of recurrence detection method, classified as symptom-directed, physician-detected, or imaging-detected, and survival benefit associated with adherence to the NCCN guideline. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of patients with HPV-associated OPSCC diagnosed between January 1, 2011, and April 30, 2014, at a large integrated health care system. Multivariable analyses were conducted using the Cox proportional hazards regression model, with patient adherence to NCCN visit guidelines constructed as a time-dependent variable. All data analyses were complete on September 1, 2018. EXPOSURES: Posttreatment clinical and imaging surveillance. MAIN OUTCOMES AND MEASURES: Recurrence and overall survival. Secondary outcome was salvage therapy. RESULTS: Of the 233 study patients with HPV-associated OPSCC, the mean (SD) age at diagnosis was 60.5 (8.7) years; 201 (86.3%) were male, 189 (81.1%) were white, and 109 (46.8%) had a positive smoking history. Median follow-up time through recurrence or all-cause mortality was 4.5 years (interquartile range, 3.8-5.6). Patients demonstrated 83.0% (180 of 217) adherence to NCCN surveillance guidelines in year 1, 52.7% (106 of 201) in year 2, 73.4% (141 of 192) in year 3, 62.3% (96 of 154) in year 4, and 52.9% (45 of 85) in year 5. A total of 3358 clinical surveillance examinations were performed with 22 patients having recurrences. There were 10 symptom-directed, 1 physician-detected, and 11 imaging-detected recurrences. Of the symptom-directed recurrences, salvage therapy was attempted in 5; at the study end date, 1 was alive. Salvage neck dissection was attempted in the physician-detected recurrence; this patient subsequently died. All locoregional recurrences occurred within the first 2 years, and all salvageable recurrences within the first year. Adherence to NCCN guidelines was not protective against all-cause mortality in the multivariable Cox proportional hazards regression model (hazard ratio, 0.76; 95% CI, 0.28-2.05). CONCLUSIONS AND RELEVANCE: Among patients with HPV-associated OPSCC, clinical surveillance is of limited utility. Nearly all clinically detected recurrences were elicited by patient symptoms that prompted earlier presentation to the clinician. Adherence to the current schedule does not appear to confer survival advantage, and locoregional recurrences are almost never detected beyond 2 years. These findings support reduction of posttreatment clinical surveillance in this population.

Diagnostic Pathway of Oral Cavity Cancer in an Integrated Health Care System.

CONTEXT: Survival for patients with oral cavity squamous cell carcinoma (OCSCC) has remained relatively stagnant despite advances in treatment. Few studies have examined why advanced-stage disease is diagnosed in 40% of patients with OCSCC nationally. OBJECTIVE: To characterize the diagnostic pathway of OCSCC in an integrated health care system. DESIGN: Retrospective study of patients with OCSCC (2007-2010). MAIN OUTCOME MEASURES: Referral patterns and demographic, clinical, and tumor characteristics associated with time to diagnosis (diagnostic interval). RESULTS: Of 247 patients, 167 (68%) had early-stage (I/II) disease, 86 (35%) were referred by dentists, and 70 (28%) had a history of premalignancy. The median time (interquartile range) from symptom onset to care sought from a primary care physician (patient interval), from primary care physician to otolaryngologist, and from otolaryngologist to diagnosis was 8.6 (4.0-25.8), 1.0 (0.6-3.1), 0.0 (0.0-3.0) weeks, respectively. These intervals did not differ by demographic characteristics, clinical factors, or tumor stage. Prolonged diagnostic intervals were observed among patients with premalignant lesions. CONCLUSION: The patient interval was the largest component of the total diagnostic interval. The subsequent professional workup proceeded relatively efficiently. Prolonged diagnostic interval in patients with premalignant lesions may reflect the natural history of malignant transformation rather than a delay in diagnosis. However, nearly one-fourth of these cases were diagnosed at an advanced stage; closer surveillance may represent an opportunity for diagnosis at an earlier stage. Surveillance for premalignant lesions and facilitating referrals from dentists may expedite the diagnosis and treatment of OCSCC. Further investigation is warranted.

The diagnostic pathway of oropharyngeal squamous cell carcinoma in a large U.S. healthcare system.

OBJECTIVE: To examine the current diagnostic pathway of oropharyngeal squamous cell carcinoma (OPSCC) and identify factors associated with time to diagnosis. METHODS: Retrospective cohort study of patients with OPSCC in an integrated healthcare system from January 1, 2013, to December 31, 2013. Patient demographics, tobacco and alcohol use, chief complaint, tumor stage, human papilloma virus (HPV) status, physician factors (diagnosis, antibiotic prescription, performance of endoscopic exam, biopsy), and time intervals were examined. Time variations by patient characteristics and physician practice were assessed. RESULTS: We identified 152 patients with OPSCC. Of those, 90% had stage III to IV disease. The cohort was largely male (85%), white (79%), with HPV-positive tumors (84%). Most common chief complaints were neck mass (52%) and sore throat (20%). Among those with neck a mass, 94% had HPV-positive tumors. Prescription of antibiotics was associated with longer time to first otolaryngology evaluation. Median time from symptom onset to first primary care physician (PCP) contact was 3.0 weeks; from PCP to otolaryngologist was 1.1 weeks, and from otolaryngologist to tissue diagnosis was 0.4 weeks. At the first otolaryngology visit, 82% underwent in-office flexible endoscopy and 58% had same-day biopsy, resulting in rapid time to tissue diagnosis. Diagnostic time intervals did not differ by HPV status. CONCLUSION: The overall diagnostic process was efficient, although initial antibiotic treatment resulted in longer time to first otolaryngology visit. Tumor HPV status was associated with presenting findings but not time to diagnosis. The variation in diagnostic delay time and impact on survival outcomes is unknown and merits further investigation. LEVEL OF EVIDENCE: 4. Laryngoscope, 1867-1873, 2018.

Nasopharyngeal Carcinoma Diagnostic Challenge in a Nonendemic Setting: Our Experience with 101 Patients.

INTRODUCTION: We studied the presenting symptoms, time intervals, and workup involved in the diagnosis of nasopharyngeal carcinoma in an integrated health care system. METHODS: A retrospective chart review of all patients with a nasopharyngeal carcinoma diagnosis between 2007 and 2010 at Kaiser Permanente Northern California. Main outcome measures included diagnostic time intervals, presenting symptoms, diagnostic accuracy of nasal endoscopy, imaging, and diagnosis at first otolaryngologist (Oto-HNS) visit. RESULTS: This study included 101 patients: 70 (70%) were of Chinese or of Southeast Asian descent. The median time intervals along the diagnostic pathway were symptom onset to primary care physician visit, 6.0 weeks; primary care physician to Oto-HNS, 2.4 weeks; Oto-HNS to pathologic diagnosis, 1.1 weeks; and diagnosis to treatment onset, 5.5 weeks. The most common presenting symptoms were otologic issues (41, 41%), neck mass (39, 39%), nasal issues (32, 32%), and headache/cranial neuropathy (16, 16%). A nasopharyngeal lesion was detected in 54 (53%) patients after the first Oto-HNS visit. Among the initial nasal endoscopy reports, 32 (32%) did not reveal a nasopharyngeal lesion; 32 (32%) initial imaging studies also did not reveal a nasopharyngeal lesion. There was no correlation between diagnostic delay and disease stage. CONCLUSION: Nasopharyngeal carcinoma presenting symptoms are extremely variable, and initial misdiagnosis is common. Median time from symptom onset to treatment was almost six months among patients studied. Nearly one-third of nasopharyngeal cancers were missed with nasal endoscopy and imaging. An understanding of the risk factors, presenting symptoms, and limitations associated with these diagnostic tests is necessary to support earlier detection of this insidious cancer.