Identifying characteristics of disciplined surgeons is important for public safety. A database of all physicians disciplined by a Canadian provincial medical regulatory authority (College of ...Physicians and Surgeons) between 2000 and 2017 was constructed, and comparisons between surgeons and other physicians were undertaken. Of 1100 disciplined physicians, 174 (15.8 %) were surgeons. Obstetrics and gynecology was the specialty with the most disciplined surgeons (57 of 174 32.8%), followed by general surgery (48 of 174 27.6%). The overall disciplinary rate for surgeons was higher than for other physicians (12.59, 95 % confidence interval CI 10.69-14.83 v. 9.85, 95 % CI 8.88-10.94 cases per 10 000 physician-years, p = 0.013). Even after adjusting for surgeon age, sex, international medical graduation and years in practice, surgeons remained more likely than other physicians to be disciplined for standard of care issues (55.6%, 95% CI 46.6-64.2 v. 38.7%, 95% CI 32.6-45.2, p < 0.001).
Introduction
The extirpation of skull base malignancies may be associated with significant morbidity and can profoundly impact health related quality of life (HRQOL). In this review, we sought to ...provide an overview of HRQOL and the factors that influence it for patients with skull base malignancies.
Materials and Methods
Narrative review.
Results
HRQOL tends to improve in the months to years following treatment and is profoundly impacted by both tumor location and treatment approach. Wherever possible, HRQOL should always be elicited from the patient directly. Several HRQOL instruments have been used in this population including generic, site-specific and disease specific measures.
Conclusion
Given that HRQOL is a multidimensional concept with several important facets, validated disease-specific instruments are generally preferred.
While several studies have documented a link between socioeconomic status and survival in head and neck cancer, nearly all have used ecologic, community-based measures. Studies using more granular ...patient-level data are lacking.
To determine the association of baseline annual household income with financial toxicity, health utility, and survival.
This was a prospective cohort of adult patients with head and neck cancer treated at a tertiary cancer center in Toronto, Ontario, between September 17, 2015, and December 19, 2019. Data analysis was performed from April to December 2021.
Annual household income at time of diagnosis.
The primary outcome of interest was disease-free survival. Secondary outcomes included subjective financial toxicity, measured using the Financial Index of Toxicity (FIT) tool, and health utility, measured using the Health Utilities Index Mark 3. Cox proportional hazards models were used to estimate the association between household income and survival. Income was regressed onto log-transformed FIT scores using linear models. The association between income and health utility was explored using generalized linear models. Generalized estimating equations were used to account for patient-level clustering.
There were 555 patients (mean SD age, 62.7 10.7 years; 109 20% women and 446 80% men) included in this cohort. Two-year disease-free survival was worse for patients in the bottom income quartile (<$30 000: 67%; 95% CI, 58%-78%) compared with the top quartile (≥$90 000: 88%; 95% CI, 83%-93%). In risk-adjusted models, patients in the bottom income quartile had inferior disease-free survival (adjusted hazard ratio, 2.13; 95% CI, 1.22-3.71) and overall survival (adjusted hazard ratio, 2.01; 95% CI, 0.94-4.29), when compared with patients in the highest quartile. The average FIT score was 22.6 in the lowest income quartile vs 11.7 in the highest quartile. In adjusted analysis, low-income patients had 12-month FIT scores that were, on average, 134% higher (worse) (95% CI, 16%-253%) than high-income patients. Similarly, health utility scores were, on average, 0.104 points lower (95% CI, 0.026-0.182) for low-income patients in adjusted analysis.
In this cohort study, patients with head and neck cancer with a household income less than CAD$30 000 experienced worse financial toxicity, health status, and disease-free survival. Significant disparities exist for Ontario's patients with head and neck cancer.
Shared decision-making is a partnership between physicians and patients whereby patient values and preferences are incorporated with the best medical evidence. Shared decision-making may reduce ...decisional conflict, improve value-choice congruence, and increase patient involvement. Despite potential benefit in many key areas of otolaryngology-head and neck surgery, both clinical and research focuses on shared decision-making are scarce. Head and neck surgical oncology is of particular interest owing to the frequency by which preference-sensitive decisions must be made. Information used in this review was obtained between January 1 and February 1, 2020.
Various conceptual models have been developed in an attempt to define the concept of shared decision-making. More than 40 instruments have endeavored to measure the construct of shared decision-making. However, in head and neck surgery, few studies to date have explicitly done so. Situations of clinical equipoise, such as in the management of indeterminate thyroid nodules and in the treatment of laryngeal cancer, are frequent. In contrast, value-option incongruence may occur when patient values do not align with the most oncologically sound treatment choice, such as when the resection and reconstruction of oral cancer may leave patients with significant sequelae. Several patient decision aids have been developed to improve shared decision-making in specific clinical scenarios, for example, in considering total laryngectomy or primary chemoradiotherapy.
Despite its potential benefit, there is a dearth of research and clinical applications of shared decision-making in head and neck surgery. Shared decision-making represents an area of substantial need in this regard, and additional efforts should be put forth.
Head and neck cancer (HNC) incidence varies worldwide, although it remains one of the most common cancers among those of East Asian and South Asian ethnicity.
To determine the association of Chinese ...and South Asian ethnicity, independent of immigration status, with HNC incidence.
This was a retrospective population-based matched cohort study that examined data collected between 1994 and 2017 in Ontario, Canada. Data were analyzed between July 2019 and March 2020. Individuals who immigrated to Canada between 1985 and 2017 were classified as immigrants, whereas Canadian-born individuals and those who immigrated prior to 1985 were classified as long-standing residents. Two separate, matched cohorts were created: an immigration cohort, consisting of immigrants and long-standing residents hard matched on age and sex, and an ethnicity cohort, where participants were further matched on ethnicity (Chinese, South Asian, or non-Chinese/non-South Asian).
Chinese ethnicity, South Asian ethnicity, and immigration status.
Patients newly diagnosed with primary HNC were captured in both the immigration and the ethnicity cohorts. Cause-specific hazard models were used to estimate the association of immigration status and ethnicity with HNC incidence.
In the immigration cohort, 3 328 434 matched individuals (mean SD age, 36.73 13.46 years; 52.8% female) were followed, across which 3173 unique HNC diagnoses were made. The hazard ratio (HR) for a new diagnosis of oropharynx cancer was lower in immigrants compared with long-standing residents (HR, 0.26 95% CI, 0.22-0.31). In the ethnicity cohort, after adjusting for age, sex, rurality, and deprivation, the rate of HNC diagnosis was higher for Chinese individuals (HR, 1.49 95% CI, 1.36-1.64) and South Asian individuals (HR, 1.29 95% CI, 1.14-1.45), although it was lower for immigrants (HR, 0.48 95% CI, 0.44-0.52) when compared with non-Chinese and non-South Asian individuals. There was no difference in the incidence of nasopharynx cancer when comparing immigrants and long-standing residents of Chinese ethnicity.
Immigration status appears to offer a protective effect against a diagnosis of HNC. Chinese and South Asian ethnic groups may experience higher HNC incidence when compared with the general Ontario population.
•Consistent risk factors for unplanned hospitalization and emergency department use and were identified.•Risk factors can be categorized as: ‘patient-related’, ‘cancer severity’ or ‘process’ ...factors.•This work is a critical step towards the development of patient-level risk prediction tools.
To identify predictors of unplanned hospitalization and emergency department (ED) use among head and neck oncology patients.
Peer reviewed publications were identified through a systematic search of MEDLINE, Embase and Cochrane CENTRAL. Studies describing a cohort of HNC patients that detailed predictors of unplanned hospitalization or ED use in risk-adjusted models were eligible for inclusion. The methodologic quality of included studies was assessed using the Quality In Prognostic Studies (QUIPS) tool and an adapted version of the GRADE framework.
Of the 932 articles identified, 39 studies met our inclusion criteria with 31/39 describing predictors of surgical readmission and 10/39 describing predictors of ED use or unplanned hospitalization during radiation/chemoradiation treatment. Risk factors were classified into either ‘patient-related’, ‘cancer severity’ or ‘process’ factors. In the subset of studies looking at readmission following surgery wound complications (10/14 studies), presence of comorbidity (16/28 studies), low socioeconomic status (8/17 studies), cancer stage (9/14 studies), and prolonged hospital stay (7/18 studies) were the variables most frequently associated with readmission on multivariable analysis. Presence of comorbidity (6/10) and chemotherapy use (4/10) were more frequently associated with ED use and unplanned hospitalization.
Several consistent predictors have been identified across a variety of studies. This work is a critical first step towards the development of readmission and ED prediction models. It also enables meaningful comparison of hospital readmission rates with risk adjustment in HNC patients.
Patient-reported symptom burden was recently found to be associated with emergency department use and unplanned hospitalization (ED/Hosp) in patients with head and neck cancer. It was hypothesized ...that symptom scores could be combined with administrative health data to accurately risk stratify patients.
To develop and validate a machine learning approach to predict future ED/Hosp in patients with head and neck cancer.
This was a population-based predictive modeling study of patients in Ontario, Canada, diagnosed with head and neck cancer from January 2007 through March 2018. All outpatient clinical encounters were identified. Edmonton Symptom Assessment System (ESAS) scores and clinical and demographic factors were abstracted. Training and test cohorts were randomly generated in a 4:1 ratio. Various machine learning algorithms were explored, including (1) logistic regression using a least absolute shrinkage and selection operator, (2) random forest, (3) gradient boosting machine, (4) k-nearest neighbors, and (5) an artificial neural network. Data analysis was performed from September 2021 to January 2022.
The main outcome was any 14-day ED/Hosp event following symptom assessment. The performance of each model was assessed on the test cohort using the area under the receiver operator characteristic (AUROC) curve and calibration plots. Shapley values were used to identify the variables with greatest contribution to the model.
The training cohort consisted of 9409 patients (mean SD age, 63.3 10.9 years) undergoing 59 089 symptom assessments (80%). The remaining 2352 patients (mean SD age, 63.3 11 years) and 14 193 symptom assessments were set aside as the test cohort (20%). Several models had high predictive accuracy, particularly the gradient boosting machine (validation AUROC, 0.80 95% CI, 0.78-0.81). A Youden-based cutoff corresponded to a validation sensitivity of 0.77 and specificity of 0.66. Patient-reported symptom scores were consistently identified as being the most predictive features within models. A second model built only with symptom severity data had an AUROC of 0.72 (95% CI, 0.70-0.74).
In this study, machine learning approaches predicted with a high degree of accuracy ED/Hosp in patients with head and neck cancer. These tools could be used to accurately risk stratify patients and may help direct targeted intervention.
Objectives
To assess the association between surgeons thyroidectomy case volume and disease‐free survival (DFS) for patients with well‐differentiated thyroid cancer (WDTC). A secondary objective was ...to assess a surgeon volume cutoff to optimize outcomes in those with WDTC. We hypothesized that surgeon volume will be an important predictor of DFS in patients with WDTC after adjusting for hospital volume and sociodemographic and clinical factors.
Methods
In this retrospective population‐based cohort study, we identified WDTC patients in Ontario, Canada, who underwent thyroidectomy confirmed by both hospital‐level and surgeon‐level administrative data between 1993 and 2017 (N = 37,233). Surgeon and hospital volumes were calculated based on number of cases performed in the year prior by the physician and at an institution performing each case, respectively and divided into quartiles. A multilevel hierarchical Cox regression model was used to estimate the effect of volume on DFS.
Results
A crude model without patient or treatment characteristics demonstrated that both higher surgeon volume quartiles (p < 0.001) and higher hospital volume quartiles (p < 0.001) were associated with DFS. After controlling for clustering and patient/treatment covariates and hospital volume, moderately low (18–39/year) and low (0–17/year) volume surgeons (hazard ratios HR: 1.23, 95% confidence interval CI: 1.09–1.39 and HR: 1.34, 95% CI: 1.17–1.53 respectively) remained an independent statistically significant negative predictor of DFS.
Conclusion
Both high‐volume surgeons and hospitals are predictors of better DFS in patients with WDTC. DFS is higher among surgeons performing more than 40 thyroidectomies a year.
Level of Evidence
3 Laryngoscope, 133:S1–S15, 2023
In this population‐based cohort study involving 37,233 thyroidectomies performed in Ontario, Canada between 1993 and 2017, we found both high‐volume surgeons and hospitals to be predictors of better disease‐free survival (DFS) in patients with well‐differentiated thyroid cancer. DFS is higher among surgeons performing more than 40 thyroidectomies a year.
Objective
We recently described the development of the Neck Fibrosis Scale (NFS). In this submission, we confirm domain structure and validate a scoring system for the NFS.
Study Design
Prospective ...cross‐sectional study.
Methods
Between January 2020 and December 2021, 127 head and neck cancer patients with varying degrees of cutaneous neck fibrosis completed the original 15 item NFS. Exploratory factor analysis was used to identify optimal groupings with similar underlying factors. The association between the domains of the NFS and various measures of neck morbidity (i.e., construct validity) were assessed using gamma regression.
Results
Exploratory factor analysis confirmed 13 of the 15 items from the NFS mapped onto two factors, which were labelled ‘physical’ and ‘emotional’ domains. Of the remaining two items, ‘energy’ did not load uniquely onto one factor and was removed. ‘Neck‐swelling’ did not load on either factor (loadings <0.3) but was retained within the physical domain based on clinical importance. This resulted in a revised 14‐item questionnaire. Internal consistency for these two domains was high (>0.8, p < 0.01). Both the physical and emotional domains of the revised NFS show strong correlation with the neck dissection impairment index and neck range of motion. The physical domain strongly correlated with neck elasticity (0.902 95%CI 0.839–0.972, p < 0.01). Patients receiving multimodal therapy had physical domain scores that were 31.6% 95% 13.9–51.8 higher (worse) than unimodal therapy patients.
Conclusions
A domain structure and scoring strategy have been developed for the NFS. Future efforts should be directed toward an evaluation of responsiveness.
Level of Evidence
NA Laryngoscope, 133:2198–2202, 2023
In this submission, we confirm domain structure and validate a scoring system for the Neck Fibrosis Scale. We present a revised 14 item questionnaire. Exploratory factor analysis confirms a two‐factor solution and establishes a physical and emotional domain.
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