Socioeconomic Status, Length of Stay, and Postoperative Complications in Oral Cavity Squamous Cell Carcinoma.

Background: Despite universal healthcare in Canada, low socioeconomic status (SES) has been associated with worse survival in oral cavity squamous cell carcinoma (OCSCC) patients. However, the relationship between SES and outcomes during the acute postoperative period is poorly defined. Hamilton, Ontario, presents a unique population with widely varying SES within the same geography. The objective of this study was to examine the relationship between SES, length of hospital stay (LOHS), and postoperative complications in OCSCC. Methods: Newly diagnosed OCSCC patients receiving primary surgical treatment from 2010 to 2014 were identified within a prospectively collected database. Inclusion criteria included age >18 years old, pathological diagnosis of oral cavity cancer, and primary surgical treatment with curative intent. Patients were excluded if they were undergoing palliative treatment or had previous head and neck surgery/radiotherapy. Postal codes were used to identify neighborhood-level socioeconomic variables via 2011 Canada Census data. Income quartiles were defined from groups of neighboring municipalities based on Canada Census definitions. Demographic, social, pathological, staging, and treatment data were collected through chart review. Results: One hundred and seventy-four patients were included in the final analysis. OCSCC patients with lower SES were more likely to be younger (P = .041), male (P = .040), have significant tobacco and alcohol use (P = .001), higher Charlson Comorbidity Index (CCI; P = .014), lower levels of education (P = .001), and have lower employment levels (P = .001). Lower SES patients had higher clinical tumor (P = .006) and clinical nodal (P = .004) staging and were more likely to receive adjuvant therapy (P = .001) and G-tubes (P = .001). Multivariable regression analysis showed that low SES was a statistically significant predictor of postoperative complications [ß 2.50 (95% confidence interval (CI) 0.200, 3.17); P = .014] and LOHS [ß 2.03 (95% CI 1.06, 2.99); P = .0001]. Tobacco and alcohol use, clinical tumor, and nodal stage, CCI, and planned adjuvant therapy were also statistically significant predictors of postoperative complications and LOHS (P < .05). Conclusion: Patients with lower SES have more advanced OCSCC disease with increased comorbidities that owes itself to more acute postoperative complications and LOHS within this study population. Patients with low SES should be identified as patients that require more support during their cancer treatment.

The Usefulness of the Thyroid Imaging Reporting and Data System in Determining Thyroid Malignancy.

OBJECTIVES/HYPOTHESIS: To determine the effect of a modified Thyroid Imaging and Reporting Data System (TIRADS) in predicting malignancy in surgically treated nodules. STUDY DESIGN: Retrospective review. METHODS: This study was carried out at a tertiary care center from July 2016 to July 2017. Patients were included if they had a thyroid nodule that had an ultrasound assessment with subsequent fine-needle aspiration biopsy (FNAB) as well as surgical resection. Patients were excluded if they had previous head and neck surgery. Patients were stratified into those who had a formal modified TIRADS report by the radiologist versus those who had an ultrasound report without TIRADS reporting. FNAB results were reported as per Bethesda Thyroid Cytology Criteria, and the final pathology report was nominalized as malignant or benign. RESULTS: One hundred twenty-four consecutive patients who met the inclusion criteria listed above were included within the study. Thirty one patients (25%) had a modified TIRADS report from the radiologist, whereas 93 patients (75%) did not. There was no statistical significance between the two groups in terms of: gender (P = .24), age (P = .77), FNAB results (P = .95), final surgical pathology (P = .90), or incidental findings of malignancy (P = .09). Comparative analysis showed no statistically significant difference between the two groups in terms of the concordance of FNAB and a final pathological diagnosis of malignancy (P = .91). CONCLUSIONS: Despite the known diagnostic utility of the TIRADS in relation to FNAB results and its widespread use, this study shows that the overall detection of malignancy is not statistically different in those who received a modified TIRADS report. LEVEL OF EVIDENCE: 3 Laryngoscope, 130: 2087-2091, 2020.

Rate of Second Primary Head and Neck Cancer With Cannabis Use.

Objective To determine whether there is an association between cannabis use and developing a second primary cancer in head and neck cancer patients, as well as determining the prevalence of cannabis use amongst head and neck cancer patients. Study design This retrospective cohort study investigated patients from the Hamilton Region Head and Neck Cancer Database who were enrolled prospectively between 2011 and 2015, with follow-up data up to November 2018. Patients were contacted to confirm current cannabis and tobacco smoking status. Setting All patients were enrolled from a single tertiary cancer center in Hamilton, Ontario. Subjects and methods Consecutive patients with a newly diagnosed head and neck cancer were prospectively enrolled between 2011 to 2015. Cannabis users and controls were compared using standard modes of comparison. The odds ratio from a multivariable logistic regression model was then determined. Results A total of 513 patients were included in this study: 59 in the cannabis group and 454 in the control group. In terms of baseline characteristics, there was no significant difference between cannabis users and controls except that cannabis users were more likely to develop primary oropharyngeal cancer (p=0.0046). Two of 59 (3.4%) cannabis users developed a second primary cancer, in comparison to 23 of 454 (5.1%) non-cannabis users. The odds ratio for cannabis use on the second primary cancer was 0.19 (95% CI [0.01-3.20], p=0.25). Conclusion This study suggests that cannabis use behaves differently than tobacco smoking, as the former may not be associated with field cancerization.

Survival outcomes of marijuana users in p16 positive oropharynx cancer patients.

BACKGROUND: Oropharynx squamous cell carcinoma (OPSCC) has become the predominant subsite for head and neck mucosal cancers (HNC) due to the rise of human papillomavirus (HPV) related disease. Previous studies have suggested an association between marijuana use and HPV-related OPSCC. Despite this, no study has examined the potential relationship between marijuana use and survival in this subset of patients. OBJECTIVE: To examine the survival outcomes of HPV-related OPSCC patients in marijuana users. METHODS: Patients who were marijuana users were identified from a prospectively collected database of HNC patients from January 2011 to 2015. A physical review of clinic records was undertaken to extract relevant patient, tumor, treatment, follow-up, as well as survival data. Patients greater than 17 years of age with pathologically proven p16 positive OPSCC were included. They were then case-matched in a 1-to-1 basis to patients who were non-marijuana users based on age, gender, and cTNM staging. RESULTS: Forty-Seven patients met inclusion criteria within each group. Univariate logistic regression analysis showed that age, gender, and cT-Stage were predictive of disease recurrence within both groups (p < 0.05). However, cN-stage, treatment modality, tumor subsite, tobacco use, and tobacco dose were not (p > 0.05). There was no statistically significant difference between marijuana and non-marijuana user groups in 5-year (p = 0.400) overall survival, disease-specific (p = 0.993), disease-free (p = 0.404), and metastasis-free survival (p = 0.384). CONCLUSIONS: No survival difference is found between HPV-related OPSCC marijuana users and non-users. This finding has implications for both de-escalation regimes and the use of cannabis as a therapeutic agent.

Association of Marijuana Use With Psychosocial and Quality of Life Outcomes Among Patients With Head and Neck Cancer.

Importance: Cannabis sativa, the most widely used illicit substance in Canada, has a unique ability to facilitate relaxation and relieve anxiety while reducing pain. However, no study to date has examined quality of life (QOL) and psychosocial issues in relation to the use of this drug among patients with newly diagnosed head and neck cancer (HNC). Objective: To examine the differences in QOL and psychosocial outcomes between marijuana users and nonusers with newly diagnosed HNC. Design, Setting, and Participants: This prospective cohort study was conducted at a tertiary care cancer center. Patients were enrolled consecutively and prospectively at the time of HNC diagnosis from January 1, 2011, to January 1, 2015. Seventy-four patients who were current marijuana users were case matched to 74 nonusers in a 1:1 scheme based on age, sex, and tumor subsite. All patient demographic and QOL data were collected prospectively, and data analysis was conducted from November 1 to December 1, 2017. Main Outcomes and Measure: The QOL outcome was assessed using the EuroQol-5D (EQ5D) and the Edmonton Symptom Assessment System (ESAS) questionnaires. Results: A total of 148 patients were included in this study: 74 in the marijuana user group (mean [SD] age, 62.3 [10.3] years; male sex, 61 patients [82%]) and 74 in the marijuana nonuser group (mean age, 62.2 years; male sex, 63 patients [85%]). There was no statistically significant difference in age, sex, tumor subsite, clinical TNM staging, treatment modality, or mean Karnofsky score between the 2 groups. On univariate analysis, there was no statistically significant difference in the mobility, self-care, and usual activities domains of the EQ5D. Marijuana users had significantly lower scores in the anxiety/depression (difference, 0.74; 95% CI, 0.557-0.930) and pain/discomfort (difference, 0.29; 95% CI, 0.037-1.541) domains. Wilcoxon rank sum test confirmed the results of the EQ5D with improvements in the pain/discomfort (z score, -2.60) and anxiety/depression (z score, -6.71) domains. Marijuana users had less pain, were less tired, were less depressed, were less anxious, had more appetite, were less drowsy, and had better general well-being according to the ESAS. A Wilcoxon rank sum test confirmed a statistically significant improvement in ESAS scores within the domains of anxiety (z score, -10.04), pain (z score, -2.36), tiredness (z score, -5.02), depression (z score, -5.96), drowsiness (z score, -5.51), appetite (z score, -4.17), and general well-being (z score, -4.43). Conclusions and Relevance: This prospective case-matched study suggests that there may be significant QOL benefits, including decreased anxiety, pain, and depression and increased appetite and generalized feelings of well-being, associated with marijuana use among patients with newly diagnosed HNC.

Marijuana and head and neck cancer: an epidemiological review.

BACKGROUND: Marijuana is the most widely used illicit substance in Canada. To date, no conclusive study has looked at the epidemiologic basis of marijuana use and head and neck cancer (HNC). Due to the imminent recreational legalization of marijuana in Canada, the epidemiologic relationship between marijuana use and HNC is becoming increasingly important. OBJECTIVE: To examine the epidemiologic characteristics of HNC patients who are recreational marijuana users. METHODS: This study was conducted at a single tertiary care centre from 2011 to 2014. Patients were enrolled consecutively at time of diagnosis of malignancy. Data was prospectively collected and included socioeconomic factors, alcohol/tobacco history, tumor characteristics, and treatment modality. Marijuana use was defined as current usage on an at least weekly basis. RESULTS: Eight hundred seventy-nine patients met inclusion and exclusion criteria. Seventy-four (8.4%) patients were classified as marijuana users. Compared to non-users, marijuana users were less likely to be married (p = 0.048) and had less significant tobacco smoking history (p = 0.004). There were no significant differences between other socioeconomic factors or local and regional disease (p > 0.05). Marijuana users differed in the proportion of cancers stratified by primary site (p < 0.0001), with higher rates of p16+ oropharyngeal cancers, and treatment modality (p < 0.0001), with more use of chemoradiation. CONCLUSIONS: HNC patients who were marijuana users were less likely to be married and smoke tobacco. They have a distinct cancer site prevalence and are more likely to be treated by chemoradiation. Understanding the epidemiological breakdown of marijuana users amongst HNC patients will be a useful adjunct for future studies.

Local molecular analysis of indeterminate thyroid nodules.

BACKGROUND: Thyroid nodules are common but only a minority are malignant. Molecular testing can assist in helping determine whether indeterminate nodules are suspicious for malignancy or benign. The objective of the study was to determine if the analysis of mutations (BRAF, NRAS, KRAS and HRAS) using readily available molecular techniques can help better classify indeterminate thyroid nodules. METHODS: A retrospective cohort of consecutive patients undergoing diagnostic thyroid surgery were analyzed for the presence or absence of specific mutations known to be associated with thyroid malignancy in FNA samples. Markers chosen were BRAF, NRAS, KRAS and HRAS. All were locally available and currently in use at our centre for other clinical indications. Results from the molecular analysis were then compared to the histopathology from thyroidectomy specimens to determine the sensitivity and specificity of these molecular techniques to classify indeterminate thyroid nodules. RESULTS: Sixty consecutive patients with indeterminate FNAs were recruited. Twenty-three patients had malignant tumors while 37 specimens were benign. Multiple different mutations were identified in the FNA samples. Overall 18 cases had a positive mutation (10 malignant and 8 benign). The sensitivity of BRAF, HRAS, KRAS, and NRAS was 8.7, 8.7, 8.7, and 17.4 respectively while the specificity was100, 83.7, 100 and 94.6. CONCLUSION: While molecular analysis remains promising, it requires further refinement. Several markers showed promise as good "rule-in" tests.

Brain metastases from papillary adenocarcinoma of the thyroid.

BACKGROUND: Papillary thyroid adenocarcinoma (PTA) is the most common type of thyroid malignancy. Distant metastatic spread is relatively rare, most commonly affecting the lungs and bone. Brain metastases are very uncommon. We present a series of four patients with this development and review their diagnosis and treatment. METHODS: A retrospective chart review analysis of patients diagnosed with PTA between 1983 and 2003 at St. Joseph's Healthcare Centre in Hamilton, Ontario, was conducted. RESULTS: Four patients with brain metastasis from their PTA were identified. Three were female and one was male. Their ages at the initial presentation ranged from 20 to 67 years (mean 48 years). The time between the initial treatment and presentation of distant metastasis ranged from 15 to 167 months (mean 89 months). Thyroglobulin data were followed on all four patients. Thyroglobulin results rose with the development of brain and other distant metastasis for two patients but never increased in the other two patients despite distant metastases at multiple sites. Treatment of brain metastasis was with a combination of surgery, external beam radiation, and radioactive iodine. All patients eventually died of their disease, and the overall survival after the diagnosis of brain metastases was 15.3 months in the four patients. CONCLUSION: This study shows that brain metastasis may or may not be the first site of distant metastasis in patients with PTA. The distant metastasis cannot always be predicted from thyroglobulin data. Once brain metastases are diagnosed, palliation with preservation of quality of life becomes the goal of therapy.