ABSTRACT
OBJECTIVES: Examine the relationship between hospital volume and overall mortality in a surgical cohort of head and neck squamous cell carcinoma (HNSCC) patients. MATERIALS & METHODS: A retrospective review of the NCDB was completed for adults with previously untreated HNSCC diagnosed between 2004 and 2016. Mean annual hospital volume was calculated using the number of head and neck cancer cases treated at a given facility divided by the number of years the facility reported to the NCDB. Facilities were separated into three categories based on their volume percentile, informed by inflection points from a natural cubic spline: Hospital Group 1 (<50%); Hospital Group 2 (50-90%); Hospital Group 3 (90%+). Cox proportional hazard models were used to examine the association between volume percentiles (continuous or categorical) with patient overall survival, adjusting for important patient and facility variables known to impact survival. RESULTS: Risk of death decreased by 2.97% for every 10% increase in facility percentile after adjusting for other risk factors. Patients treated at facilities in Hospital Group 1 had a 23.1% increase in risk of mortality (HR 1.231 [95% CI 1.12-1.35]) relative those at facilities in Hospital Group 3. No significant difference in mortality risk was found between Hospital Group 2 versus Hospital Group 3 (HR 1.031 [95% CI 0.97-1.10]). CONCLUSIONS: Survival of HNSCC patients is significantly improved when treated at facilities >50th percentile in annual hospital volume. This may support the regionalization of care to high volume head and neck centers with comprehensive facilities and supportive services to maximize patient outcomes.
Subject(s)
Head and Neck Neoplasms , Hospitals , Adult , Humans , Squamous Cell Carcinoma of Head and Neck , Retrospective Studies , Proportional Hazards ModelsABSTRACT
OBJECTIVES/HYPOTHESIS: We investigate the clinicopathologic and treatment factors associated with the use of postoperative radiation therapy (PORT) and its effect on overall survival (OS) for patients with oral cavity verrucous carcinoma (VC). STUDY DESIGN: Retrospective cohort study. METHODS: A retrospective cohort study of the National Cancer Database (NCDB) from 2006 to 2015 was performed. Multivariable logistic regression was used to identify independent predictive factors associated with the use of PORT. Cox Regression survival and propensity score analyses were used to evaluate the effect of PORT on mortality. RESULTS: A total of 356 adult patients with primary oral cavity VC who underwent definitive surgical resection were identified. A total of 10.7% of patients underwent definitive surgical resection followed by PORT. Variables associated with PORT included distance to the hospital per 10 miles (adjusted odds ratio [aOR], 0.81 [95% confidence interval (CI), 0.70-0.95]) and stage III-IV disease (aOR, 12.13 and 23.92, respectively). Multivariable Cox regression survival analysis indicated no evidence of survival benefit in patients undergoing PORT compared to surgery alone (adjusted hazard ratio 1.50 [0.74-3.05], P = .23). Propensity score analysis also showed no OS benefit with the use of PORT (P = .41). CONCLUSIONS: Variables associated with the use of PORT on multivariable analysis included closer distance to hospital and stage III-IV disease. No clear survival benefit with PORT was identified on either multivariable survival analysis or propensity score analysis. These results suggest that surgery alone with negative margins may be the optimal treatment for patients with oral cavity VC. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:1953-1961, 2022.
Subject(s)
Carcinoma, Verrucous , Head and Neck Neoplasms , Mouth Neoplasms , Adult , Carcinoma, Verrucous/radiotherapy , Carcinoma, Verrucous/surgery , Head and Neck Neoplasms/pathology , Humans , Mouth Neoplasms/pathology , Mouth Neoplasms/radiotherapy , Mouth Neoplasms/surgery , Neoplasm Staging , Radiotherapy, Adjuvant , Retrospective Studies , Squamous Cell Carcinoma of Head and Neck/pathologyABSTRACT
BACKGROUND: The COVID-19 pandemic has required triage and delays in surgical care throughout the world. The impact of these surgical delays on survival for patients with head and neck squamous cell carcinoma (HNSCC) remains unknown. METHODS: A retrospective cohort study of 37 730 patients in the National Cancer Database with HNSCC who underwent primary surgical management from 2004 to 2016 was performed. Uni- and multivariate analyses were used to identify predictors of overall survival. Bootstrapping methods were used to identify optimal time-to-surgery (TTS) thresholds at which overall survival differences were greatest. Cox proportional hazard models with or without restricted cubic splines were used to determine the association between TTS and survival. RESULTS: The study identified TTS as an independent predictor of overall survival (OS). Bootstrapping the data to dichotomize the cohort identified the largest rise in hazard ratio (HR) at day 67, which was used as the optimal TTS cut-point in survival analysis. The patients who underwent surgical treatment longer than 67 days after diagnosis had a significantly increased risk of death (HR, 1.189; 95% confidence interval [CI], 1.122-1.261; P < 0.0001). For every 30-day delay in TTS, the hazard of death increased by 4.6%. Subsite analysis showed that the oropharynx subsite was most affected by surgical delays, followed by the oral cavity. CONCLUSIONS: Increasing TTS is an independent predictor of survival for patients with HNSCC and should be performed within 67 days after diagnosis to achieve optimal survival outcomes.
Subject(s)
Hypopharyngeal Neoplasms/surgery , Laryngeal Neoplasms/surgery , Mouth Neoplasms/surgery , Oropharyngeal Neoplasms/surgery , Otorhinolaryngologic Surgical Procedures/statistics & numerical data , Squamous Cell Carcinoma of Head and Neck/surgery , Time-to-Treatment/statistics & numerical data , Aged , COVID-19 , Cohort Studies , Delivery of Health Care , Female , Humans , Hypopharyngeal Neoplasms/mortality , Laryngeal Neoplasms/mortality , Male , Middle Aged , Mouth Neoplasms/mortality , Oropharyngeal Neoplasms/mortality , Proportional Hazards Models , Retrospective Studies , SARS-CoV-2 , Squamous Cell Carcinoma of Head and Neck/mortality , Surgical OncologyABSTRACT
AIM: We examined the use of a Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) catheter during cardiopulmonary resuscitation (CPR) after cardiac arrest (CA) to assess its effect on haemodynamics such as coronary perfusion pressure (CPP), common carotid artery blood flow (CCA-flow) and end-tidal CO2 (PetCO2) which are associated with increased return of spontaneous circulation (ROSC). METHODS: Six male swine were instrumented to measure CPP, CCA-Flow, and PetCO2. A 7Fr REBOA was advanced into zone-1 of the aorta through the femoral artery. Ventricular fibrillation was induced and untreated for 8â¯min. CPR (manual then mechanical) was initiated for 24â¯min. Continuous infusion of adrenaline (epinephrine) was started at minute-4 of CPR. The REBOA balloon was inflated at minute-16 for 3â¯min and then deflated/inflated every 3â¯min for 3 cycles. Animals were defibrillated up to 6 times after the final cycle. Animals achieving ROSC were monitored for 25â¯min. RESULTS: Data showed significant differences between balloon deflation and inflation periods for CPP, CCA-Flow, and PetCO2 (pâ¯<â¯0.0001) with an average difference (SD) of 13.7 (2.28)â¯mmHg, 15.5 (14.12)â¯mLâ¯min-1 and -4 (2.76)â¯mmHg respectively. Three animals achieved ROSC and had significantly higher mean CPP (54 vs. 18â¯mmHg), CCA-Flow (262 vs. 135â¯mLâ¯min-1) and PetCO2 (16 vs. 8â¯mmHg) (pâ¯<â¯0.0001) throughout inflation periods than No-ROSC animals. Aortic histology did not reveal any significant changes produced by balloon inflation. CONCLUSION: REBOA significantly increased CPP and CCA-Flow in this model of prolonged CA. These increases may contribute to the ability to achieve ROSC.