Head & Neck/Thyroid Cancers

ORLANDO – Sentinel node biopsies may be a useful staging tool for patients with cutaneous squamous cell carcinomas of the head and neck.

These patients – especially those with compromised immune systems – appear to be at sufficiently high risk of metastasis to justify the procedure, Dr. Jonathan Lopez said at the annual meeting of the American College of Mohs Surgery.

“We found that sentinel lymph node biopsy in our clinic had a 91% negative predictive value for local recurrence, nodal recurrence, and disease-specific death. It provides valuable prognostic information for patients at increased risk of nodal metastasis,” said Dr. Lopez, a dermatology resident at the Mayo Clinic, Rochester, Minn.

He and his associates conducted a chart review of 24 patients treated at the Mayo Clinic from 2000 to 2014 for a cutaneous squamous cell carcinoma (SCC) of the head or neck. Of these, 11 patients were immunosuppressed. Five had undergone a kidney transplant and three a lung transplant. One patient had Hodgkin’s lymphoma, one had cutaneous lymphocytic leukemia, and one, metastatic urothelial carcinoma.

Before sentinel node biopsy, eight patients had a wide local excision; 12 were treated with Mohs micrographic surgery only; and four had a Mohs procedure followed by resection for better margins.

The biopsies identified two patients with nodal disease, but failed to identify a third who had it, Dr. Lopez said.

Patient No. 1 had a primary SCC on the nasal tip that was stage 2, according to the American Joint Committee on Cancer (AJCC) staging system, and 2b according to the Brigham and Women’s Hospital (BWH) system. He had undergone a prior double lung transplant and his lymph node dissection showed no nodal metastasis. He declined radiotherapy and died within 2 months of the biopsy, of unclear causes that were not related to his skin cancer.

Patient No. 2 had a primary lesion on the right cheek, and a history of kidney transplant. His cancer was stage 2 by the AJCC system and 2b by the BWH system. His lymph node dissection of the right parotid and neck was negative. At last follow-up of 3.5 years, he was cancer free. However, Dr. Lopez noted, the patient died at 4 years’ follow-up of unknown causes.

The final patient had a primary lesion on the right conchal bowl. It was a stage 2 cancer by the AJCC system and 2a by the BWH system. His sentinel node biopsy was negative. However, the otolaryngologist who performed the biopsy also took seven superficial parotid nodes and one of those was positive. This patient had no recurrence at the last visit, 1.5 years after the biopsy.

The sentinel node biopsies were negative in the 21 other patients. Of these, 14 had no evidence of recurrence at a mean of 3 years’ follow-up after the sentinel lymph node biopsy. Two developed local recurrence and two others, both of whom had a history of multiple squamous cell carcinomas, developed nodal spread and died of metastatic disease. Three have died of causes unrelated to their cancer.

Dr. Lopez had no financial disclosures.

[email protected]

ORLANDO – Sentinel node biopsies may be a useful staging tool for patients with cutaneous squamous cell carcinomas of the head and neck.

These patients – especially those with compromised immune systems – appear to be at sufficiently high risk of metastasis to justify the procedure, Dr. Jonathan Lopez said at the annual meeting of the American College of Mohs Surgery.

“We found that sentinel lymph node biopsy in our clinic had a 91% negative predictive value for local recurrence, nodal recurrence, and disease-specific death. It provides valuable prognostic information for patients at increased risk of nodal metastasis,” said Dr. Lopez, a dermatology resident at the Mayo Clinic, Rochester, Minn.

He and his associates conducted a chart review of 24 patients treated at the Mayo Clinic from 2000 to 2014 for a cutaneous squamous cell carcinoma (SCC) of the head or neck. Of these, 11 patients were immunosuppressed. Five had undergone a kidney transplant and three a lung transplant. One patient had Hodgkin’s lymphoma, one had cutaneous lymphocytic leukemia, and one, metastatic urothelial carcinoma.

Before sentinel node biopsy, eight patients had a wide local excision; 12 were treated with Mohs micrographic surgery only; and four had a Mohs procedure followed by resection for better margins.

The biopsies identified two patients with nodal disease, but failed to identify a third who had it, Dr. Lopez said.

Patient No. 1 had a primary SCC on the nasal tip that was stage 2, according to the American Joint Committee on Cancer (AJCC) staging system, and 2b according to the Brigham and Women’s Hospital (BWH) system. He had undergone a prior double lung transplant and his lymph node dissection showed no nodal metastasis. He declined radiotherapy and died within 2 months of the biopsy, of unclear causes that were not related to his skin cancer.

Patient No. 2 had a primary lesion on the right cheek, and a history of kidney transplant. His cancer was stage 2 by the AJCC system and 2b by the BWH system. His lymph node dissection of the right parotid and neck was negative. At last follow-up of 3.5 years, he was cancer free. However, Dr. Lopez noted, the patient died at 4 years’ follow-up of unknown causes.

The final patient had a primary lesion on the right conchal bowl. It was a stage 2 cancer by the AJCC system and 2a by the BWH system. His sentinel node biopsy was negative. However, the otolaryngologist who performed the biopsy also took seven superficial parotid nodes and one of those was positive. This patient had no recurrence at the last visit, 1.5 years after the biopsy.

The sentinel node biopsies were negative in the 21 other patients. Of these, 14 had no evidence of recurrence at a mean of 3 years’ follow-up after the sentinel lymph node biopsy. Two developed local recurrence and two others, both of whom had a history of multiple squamous cell carcinomas, developed nodal spread and died of metastatic disease. Three have died of causes unrelated to their cancer.

Dr. Lopez had no financial disclosures.

[email protected]

ORLANDO – Sentinel node biopsies may be a useful staging tool for patients with cutaneous squamous cell carcinomas of the head and neck.

These patients – especially those with compromised immune systems – appear to be at sufficiently high risk of metastasis to justify the procedure, Dr. Jonathan Lopez said at the annual meeting of the American College of Mohs Surgery.

“We found that sentinel lymph node biopsy in our clinic had a 91% negative predictive value for local recurrence, nodal recurrence, and disease-specific death. It provides valuable prognostic information for patients at increased risk of nodal metastasis,” said Dr. Lopez, a dermatology resident at the Mayo Clinic, Rochester, Minn.

He and his associates conducted a chart review of 24 patients treated at the Mayo Clinic from 2000 to 2014 for a cutaneous squamous cell carcinoma (SCC) of the head or neck. Of these, 11 patients were immunosuppressed. Five had undergone a kidney transplant and three a lung transplant. One patient had Hodgkin’s lymphoma, one had cutaneous lymphocytic leukemia, and one, metastatic urothelial carcinoma.

Before sentinel node biopsy, eight patients had a wide local excision; 12 were treated with Mohs micrographic surgery only; and four had a Mohs procedure followed by resection for better margins.

The biopsies identified two patients with nodal disease, but failed to identify a third who had it, Dr. Lopez said.

Patient No. 1 had a primary SCC on the nasal tip that was stage 2, according to the American Joint Committee on Cancer (AJCC) staging system, and 2b according to the Brigham and Women’s Hospital (BWH) system. He had undergone a prior double lung transplant and his lymph node dissection showed no nodal metastasis. He declined radiotherapy and died within 2 months of the biopsy, of unclear causes that were not related to his skin cancer.

Patient No. 2 had a primary lesion on the right cheek, and a history of kidney transplant. His cancer was stage 2 by the AJCC system and 2b by the BWH system. His lymph node dissection of the right parotid and neck was negative. At last follow-up of 3.5 years, he was cancer free. However, Dr. Lopez noted, the patient died at 4 years’ follow-up of unknown causes.

The final patient had a primary lesion on the right conchal bowl. It was a stage 2 cancer by the AJCC system and 2a by the BWH system. His sentinel node biopsy was negative. However, the otolaryngologist who performed the biopsy also took seven superficial parotid nodes and one of those was positive. This patient had no recurrence at the last visit, 1.5 years after the biopsy.

The sentinel node biopsies were negative in the 21 other patients. Of these, 14 had no evidence of recurrence at a mean of 3 years’ follow-up after the sentinel lymph node biopsy. Two developed local recurrence and two others, both of whom had a history of multiple squamous cell carcinomas, developed nodal spread and died of metastatic disease. Three have died of causes unrelated to their cancer.

Dr. Lopez had no financial disclosures.

[email protected]

Background Concurrent chemotherapy radiation therapy may result in significant nausea and vomiting. There have been few studies reporting effective interventions for preventing treatment-related nausea and vomiting.

Objective To compare olanzapine with fosaprepitant for the prevention of nausea and vomiting in patients receiving concurrent highly emetogenic chemotherapy (HEC) and radiotherapy for locally advanced head and neck or esophageal cancer.

Methods 120 chemotherapy and radiotherapy naïve patients with head and neck cancer who were receiving concurrent local radiation and cisplatin were randomized to receive either olanzapine or fosaprepitant in combination with palonosetron and dexamethasone for the prevention of chemotherapy- and radiation-induced nausea and vomiting. The olanzapine, palonosetron, dexamethasone (OPD) regimen was 10 mg oral olanzapine , 0.25 mg IV palonosetron, and 20 mg IV dexamethasone before chemotherapy on day 1, and 10 mg/day of oral olanzapine before chemotherapy on days 2-4. The fosaprepitant, palonosetron, dexamethasone (FPD) regimen was 150 mg IV fosaprepitant, 0.25 mg IV palonosetron, and 12 mg IV dexamethasone before chemotherapy on day 1, and 4 mg dexamethasone PO BID, before chemotherapy days 2 and 3.

Results 101 of the 120 patients were evaluable. In 51 patients who received the OPD regimen, the complete response (CR; no emesis, no rescue medication) rate was 88% for the acute period (24 h after chemotherapy), 76% for the delayed period (days 2-5), and 76% for the overall period (0-120 h). In 50 patients who received the FPD regimen, the CR was 84% acute, 74% delayed, and 74% overall (P > .01 for all periods). Patients with no nausea (0, on a scale 0-10, visual analogue scale) were: OPD: 86% acute, 71% delayed, 71% overall; FPD: 78% acute, 40% delayed, 40% overall (P > .01 for acute; P < .01 for delayed and overall) There were no grade 3 or 4 toxicities.

Conclusions CR was similar for OPD and FPD; nausea in the delayed and overall periods was signifcantly improved with OPD compared with FPD (P < .01).

Funding Reich Endowment for the Care of the Whole Patient
 

Click on the PDF icon at the top of this introduction to read the full article.
 

Background Concurrent chemotherapy radiation therapy may result in significant nausea and vomiting. There have been few studies reporting effective interventions for preventing treatment-related nausea and vomiting.

Objective To compare olanzapine with fosaprepitant for the prevention of nausea and vomiting in patients receiving concurrent highly emetogenic chemotherapy (HEC) and radiotherapy for locally advanced head and neck or esophageal cancer.

Methods 120 chemotherapy and radiotherapy naïve patients with head and neck cancer who were receiving concurrent local radiation and cisplatin were randomized to receive either olanzapine or fosaprepitant in combination with palonosetron and dexamethasone for the prevention of chemotherapy- and radiation-induced nausea and vomiting. The olanzapine, palonosetron, dexamethasone (OPD) regimen was 10 mg oral olanzapine , 0.25 mg IV palonosetron, and 20 mg IV dexamethasone before chemotherapy on day 1, and 10 mg/day of oral olanzapine before chemotherapy on days 2-4. The fosaprepitant, palonosetron, dexamethasone (FPD) regimen was 150 mg IV fosaprepitant, 0.25 mg IV palonosetron, and 12 mg IV dexamethasone before chemotherapy on day 1, and 4 mg dexamethasone PO BID, before chemotherapy days 2 and 3.

Results 101 of the 120 patients were evaluable. In 51 patients who received the OPD regimen, the complete response (CR; no emesis, no rescue medication) rate was 88% for the acute period (24 h after chemotherapy), 76% for the delayed period (days 2-5), and 76% for the overall period (0-120 h). In 50 patients who received the FPD regimen, the CR was 84% acute, 74% delayed, and 74% overall (P > .01 for all periods). Patients with no nausea (0, on a scale 0-10, visual analogue scale) were: OPD: 86% acute, 71% delayed, 71% overall; FPD: 78% acute, 40% delayed, 40% overall (P > .01 for acute; P < .01 for delayed and overall) There were no grade 3 or 4 toxicities.

Conclusions CR was similar for OPD and FPD; nausea in the delayed and overall periods was signifcantly improved with OPD compared with FPD (P < .01).

Funding Reich Endowment for the Care of the Whole Patient
 

Click on the PDF icon at the top of this introduction to read the full article.
 

Background Concurrent chemotherapy radiation therapy may result in significant nausea and vomiting. There have been few studies reporting effective interventions for preventing treatment-related nausea and vomiting.

Objective To compare olanzapine with fosaprepitant for the prevention of nausea and vomiting in patients receiving concurrent highly emetogenic chemotherapy (HEC) and radiotherapy for locally advanced head and neck or esophageal cancer.

Methods 120 chemotherapy and radiotherapy naïve patients with head and neck cancer who were receiving concurrent local radiation and cisplatin were randomized to receive either olanzapine or fosaprepitant in combination with palonosetron and dexamethasone for the prevention of chemotherapy- and radiation-induced nausea and vomiting. The olanzapine, palonosetron, dexamethasone (OPD) regimen was 10 mg oral olanzapine , 0.25 mg IV palonosetron, and 20 mg IV dexamethasone before chemotherapy on day 1, and 10 mg/day of oral olanzapine before chemotherapy on days 2-4. The fosaprepitant, palonosetron, dexamethasone (FPD) regimen was 150 mg IV fosaprepitant, 0.25 mg IV palonosetron, and 12 mg IV dexamethasone before chemotherapy on day 1, and 4 mg dexamethasone PO BID, before chemotherapy days 2 and 3.

Results 101 of the 120 patients were evaluable. In 51 patients who received the OPD regimen, the complete response (CR; no emesis, no rescue medication) rate was 88% for the acute period (24 h after chemotherapy), 76% for the delayed period (days 2-5), and 76% for the overall period (0-120 h). In 50 patients who received the FPD regimen, the CR was 84% acute, 74% delayed, and 74% overall (P > .01 for all periods). Patients with no nausea (0, on a scale 0-10, visual analogue scale) were: OPD: 86% acute, 71% delayed, 71% overall; FPD: 78% acute, 40% delayed, 40% overall (P > .01 for acute; P < .01 for delayed and overall) There were no grade 3 or 4 toxicities.

Conclusions CR was similar for OPD and FPD; nausea in the delayed and overall periods was signifcantly improved with OPD compared with FPD (P < .01).

Funding Reich Endowment for the Care of the Whole Patient
 

Click on the PDF icon at the top of this introduction to read the full article.
 

BALTIMORE – Hemithyroidectomy for low-risk micropapillary thyroid cancer can have advantages over active surveillance, according to findings from a study that examined outcomes by cost and quality of life data.

Endocrinologists and surgeons need to have in-depth conversations with their patients to determine their level of anxiety about cancer, surgery, and about their quality of life, to determine the best course of treatment, researchers at the University of California, San Francisco (UCSF) reported at the annual meeting of the American Association of Endocrine Surgeons.

“Our study found that hemithyroidectomy is cost effective in the majority of scenarios,” presenter Shriya Venkatesh said. “However, patient perception of micropapillary thyroid cancer as well as [the patient’s] life expectancy can play a major role in deciding which therapeutic option to choose.”

The study involved a cost-effectiveness analysis of the surgery vs. active surveillance, “which is especially relevant in our current times,” Ms. Venkatesh said in an interview. “What we wanted to do is give physicians information for when they approach their patients, not only in assessing the tumor from the medical aspect but also when looking at it from quality-of-life and cost-benefit perspectives.”

Both courses of management were modeled over a 20-year period with Medicare data and literature review to calculate costs and health utilities. The UCSF researchers used Markov statistical models for both approaches in which the reference case was a 40-year-old, otherwise healthy patient with a recent diagnosis of micropapillary thyroid cancer without high-risk factors. Either hemithyroidectomy or surveillance would be reasonable treatment options.

“We found that hemithyroidectomy was about $8,000 more costly than active surveillance, but it also afforded an increase in about 1.09 quality-adjusted life years,” Ms. Venkatesh said. Hemithyroidectomy is most cost effective for patients with a life expectancy of 3 years or more and who perceive that living with low-grade thyroid cancer would have even a modest detriment on their quality of life, she said.

“Unfortunately there is no current published quality-of-life assessment of active surveillance for thyroid cancer,” Ms. Venkatesh said. “We believe that estimating active surveillance to the equivalent of surgery underestimates the anxiety some patients may feel upon receiving their diagnosis.”

The paucity of literature on active surveillance for thyroid cancer prompted the UCSF researchers to turn to the prostate cancer literature, which has more data on active surveillance, to try to determine the disutility of active surveillance for micropapillary thyroid cancer. “Our extrapolation from the literature yields a mean disutility of 0.11,” she said.

However, the utility estimates the researchers came up with were variable, Ms. Venkatesh said. “This really pushes physicians to have that conversation with their patients, not only about the physical aspects of how they’re doing but also the mental aspects,” she said.

But quality of life is difficult to quantify, senior author Dr. Insoo Suh said in an interview. “What we found is that no matter how one measures quality of life, the qualitative degree of quality of life decrease that people associate with ‘living with cancer’ need not be that significant in order for surgery to be a potentially cost-effective treatment for them,” said Dr. Suh, an endocrine surgeon at UCSF and an ACS Fellow.

During the discussion, Dr. Peter Angelos of the University of Chicago and an ACS Fellow, said, “I’m curious how this information should impact the individual decision-making and informed consent for a specific patient, because I’m not sure that an individual patient would care if active surveillance is more cost effective or not.”

“When speaking to your patients, obviously discussing the rates of progression of the disease is important and then [so is] talking to them about different therapeutic options,” Ms. Venkatesh said. “The physician should also make an assessment about the patient’s quality of life to see if there are likely to be any changes due to the diagnosis.”

The limitations of the study include the extrapolation of data from the prostate cancer literature to define a utility scale and also the reference case used in the Markov model. Other utility measures showed variability as well.

Ms. Venkatesh, Dr. Suh and their coauthors had no financial relationships to disclose.

BALTIMORE – Hemithyroidectomy for low-risk micropapillary thyroid cancer can have advantages over active surveillance, according to findings from a study that examined outcomes by cost and quality of life data.

Endocrinologists and surgeons need to have in-depth conversations with their patients to determine their level of anxiety about cancer, surgery, and about their quality of life, to determine the best course of treatment, researchers at the University of California, San Francisco (UCSF) reported at the annual meeting of the American Association of Endocrine Surgeons.

“Our study found that hemithyroidectomy is cost effective in the majority of scenarios,” presenter Shriya Venkatesh said. “However, patient perception of micropapillary thyroid cancer as well as [the patient’s] life expectancy can play a major role in deciding which therapeutic option to choose.”

The study involved a cost-effectiveness analysis of the surgery vs. active surveillance, “which is especially relevant in our current times,” Ms. Venkatesh said in an interview. “What we wanted to do is give physicians information for when they approach their patients, not only in assessing the tumor from the medical aspect but also when looking at it from quality-of-life and cost-benefit perspectives.”

Both courses of management were modeled over a 20-year period with Medicare data and literature review to calculate costs and health utilities. The UCSF researchers used Markov statistical models for both approaches in which the reference case was a 40-year-old, otherwise healthy patient with a recent diagnosis of micropapillary thyroid cancer without high-risk factors. Either hemithyroidectomy or surveillance would be reasonable treatment options.

“We found that hemithyroidectomy was about $8,000 more costly than active surveillance, but it also afforded an increase in about 1.09 quality-adjusted life years,” Ms. Venkatesh said. Hemithyroidectomy is most cost effective for patients with a life expectancy of 3 years or more and who perceive that living with low-grade thyroid cancer would have even a modest detriment on their quality of life, she said.

“Unfortunately there is no current published quality-of-life assessment of active surveillance for thyroid cancer,” Ms. Venkatesh said. “We believe that estimating active surveillance to the equivalent of surgery underestimates the anxiety some patients may feel upon receiving their diagnosis.”

The paucity of literature on active surveillance for thyroid cancer prompted the UCSF researchers to turn to the prostate cancer literature, which has more data on active surveillance, to try to determine the disutility of active surveillance for micropapillary thyroid cancer. “Our extrapolation from the literature yields a mean disutility of 0.11,” she said.

However, the utility estimates the researchers came up with were variable, Ms. Venkatesh said. “This really pushes physicians to have that conversation with their patients, not only about the physical aspects of how they’re doing but also the mental aspects,” she said.

But quality of life is difficult to quantify, senior author Dr. Insoo Suh said in an interview. “What we found is that no matter how one measures quality of life, the qualitative degree of quality of life decrease that people associate with ‘living with cancer’ need not be that significant in order for surgery to be a potentially cost-effective treatment for them,” said Dr. Suh, an endocrine surgeon at UCSF and an ACS Fellow.

During the discussion, Dr. Peter Angelos of the University of Chicago and an ACS Fellow, said, “I’m curious how this information should impact the individual decision-making and informed consent for a specific patient, because I’m not sure that an individual patient would care if active surveillance is more cost effective or not.”

“When speaking to your patients, obviously discussing the rates of progression of the disease is important and then [so is] talking to them about different therapeutic options,” Ms. Venkatesh said. “The physician should also make an assessment about the patient’s quality of life to see if there are likely to be any changes due to the diagnosis.”

The limitations of the study include the extrapolation of data from the prostate cancer literature to define a utility scale and also the reference case used in the Markov model. Other utility measures showed variability as well.

Ms. Venkatesh, Dr. Suh and their coauthors had no financial relationships to disclose.

BALTIMORE – Hemithyroidectomy for low-risk micropapillary thyroid cancer can have advantages over active surveillance, according to findings from a study that examined outcomes by cost and quality of life data.

Endocrinologists and surgeons need to have in-depth conversations with their patients to determine their level of anxiety about cancer, surgery, and about their quality of life, to determine the best course of treatment, researchers at the University of California, San Francisco (UCSF) reported at the annual meeting of the American Association of Endocrine Surgeons.

“Our study found that hemithyroidectomy is cost effective in the majority of scenarios,” presenter Shriya Venkatesh said. “However, patient perception of micropapillary thyroid cancer as well as [the patient’s] life expectancy can play a major role in deciding which therapeutic option to choose.”

The study involved a cost-effectiveness analysis of the surgery vs. active surveillance, “which is especially relevant in our current times,” Ms. Venkatesh said in an interview. “What we wanted to do is give physicians information for when they approach their patients, not only in assessing the tumor from the medical aspect but also when looking at it from quality-of-life and cost-benefit perspectives.”

Both courses of management were modeled over a 20-year period with Medicare data and literature review to calculate costs and health utilities. The UCSF researchers used Markov statistical models for both approaches in which the reference case was a 40-year-old, otherwise healthy patient with a recent diagnosis of micropapillary thyroid cancer without high-risk factors. Either hemithyroidectomy or surveillance would be reasonable treatment options.

“We found that hemithyroidectomy was about $8,000 more costly than active surveillance, but it also afforded an increase in about 1.09 quality-adjusted life years,” Ms. Venkatesh said. Hemithyroidectomy is most cost effective for patients with a life expectancy of 3 years or more and who perceive that living with low-grade thyroid cancer would have even a modest detriment on their quality of life, she said.

“Unfortunately there is no current published quality-of-life assessment of active surveillance for thyroid cancer,” Ms. Venkatesh said. “We believe that estimating active surveillance to the equivalent of surgery underestimates the anxiety some patients may feel upon receiving their diagnosis.”

The paucity of literature on active surveillance for thyroid cancer prompted the UCSF researchers to turn to the prostate cancer literature, which has more data on active surveillance, to try to determine the disutility of active surveillance for micropapillary thyroid cancer. “Our extrapolation from the literature yields a mean disutility of 0.11,” she said.

However, the utility estimates the researchers came up with were variable, Ms. Venkatesh said. “This really pushes physicians to have that conversation with their patients, not only about the physical aspects of how they’re doing but also the mental aspects,” she said.

But quality of life is difficult to quantify, senior author Dr. Insoo Suh said in an interview. “What we found is that no matter how one measures quality of life, the qualitative degree of quality of life decrease that people associate with ‘living with cancer’ need not be that significant in order for surgery to be a potentially cost-effective treatment for them,” said Dr. Suh, an endocrine surgeon at UCSF and an ACS Fellow.

During the discussion, Dr. Peter Angelos of the University of Chicago and an ACS Fellow, said, “I’m curious how this information should impact the individual decision-making and informed consent for a specific patient, because I’m not sure that an individual patient would care if active surveillance is more cost effective or not.”

“When speaking to your patients, obviously discussing the rates of progression of the disease is important and then [so is] talking to them about different therapeutic options,” Ms. Venkatesh said. “The physician should also make an assessment about the patient’s quality of life to see if there are likely to be any changes due to the diagnosis.”

The limitations of the study include the extrapolation of data from the prostate cancer literature to define a utility scale and also the reference case used in the Markov model. Other utility measures showed variability as well.

Ms. Venkatesh, Dr. Suh and their coauthors had no financial relationships to disclose.

For patients with squamous cell carcinoma (SCC) of the tongue, recurrence is common and closely associated with survival, say researchers from Capital Medical University, Beijing. The researchers conducted a retrospective study of 204 patients with SCC of the tongue that aimed to identify the factors that predict relapse and prognosis.

Related: IBD and the Risk of Oral Cancer

In an earlier study, the researchers assessed the best indications for neck dissection and the prognostic factors of oral SCC. Their results showed that middle-late oral SCC is an indication for simultaneous neck dissection, even in patients whose nodes are clear. But few studies have focused on the outcomes of treatment after different surgical approaches, such as en bloc resection and discontinuous resection. En bloc dissection requires continuity between the tumor and the level I neck nodes, and the technique involves removal of the sublingual gland and the mylohyoid muscle, as well as the associated sublingual nodes.

Related: A Team Approach to Nonmelanotic Skin Cancer Procedures

Within the median follow-up of 82 months, 59 patients died (29%), 4 from non-cancer causes. Two patients in the en bloc group and 12 in the control group (discontinuous resection) had relapses. Ten of the 14 in this group had recurrences within a year of the first operation. Nine patients had salvage operations; however, only 2 experienced a successful outcome.

Surgical technique and pathological nodal (pN) status independently predicted both 5-year recurrence and disease-specific survival.

Related: Nivolumab Approved for Expanded Indication

The analysis showed a “dramatic” decrease in the 5-year disease-specific survival if the cancer recurred after the primary operation (no recurrence, 77% vs recurrence, 14%). Patients in the en bloc group “could expect an obviously lower” 5-year recurrence rate (2%, compared with 11% in the control group). They also had a better 5-year disease-specific survival (80%, versus 66%). An aggressive pN status was closely correlated with recurrence.

Source:
Feng Z, Xu QS, Qin LZ, et al. Br J Oral Maxillofac Surg. 2016;54(1):88-93.
doi: 10.1016/j.bjoms.2015.09.024

For patients with squamous cell carcinoma (SCC) of the tongue, recurrence is common and closely associated with survival, say researchers from Capital Medical University, Beijing. The researchers conducted a retrospective study of 204 patients with SCC of the tongue that aimed to identify the factors that predict relapse and prognosis.

Related: IBD and the Risk of Oral Cancer

In an earlier study, the researchers assessed the best indications for neck dissection and the prognostic factors of oral SCC. Their results showed that middle-late oral SCC is an indication for simultaneous neck dissection, even in patients whose nodes are clear. But few studies have focused on the outcomes of treatment after different surgical approaches, such as en bloc resection and discontinuous resection. En bloc dissection requires continuity between the tumor and the level I neck nodes, and the technique involves removal of the sublingual gland and the mylohyoid muscle, as well as the associated sublingual nodes.

Related: A Team Approach to Nonmelanotic Skin Cancer Procedures

Within the median follow-up of 82 months, 59 patients died (29%), 4 from non-cancer causes. Two patients in the en bloc group and 12 in the control group (discontinuous resection) had relapses. Ten of the 14 in this group had recurrences within a year of the first operation. Nine patients had salvage operations; however, only 2 experienced a successful outcome.

Surgical technique and pathological nodal (pN) status independently predicted both 5-year recurrence and disease-specific survival.

Related: Nivolumab Approved for Expanded Indication

The analysis showed a “dramatic” decrease in the 5-year disease-specific survival if the cancer recurred after the primary operation (no recurrence, 77% vs recurrence, 14%). Patients in the en bloc group “could expect an obviously lower” 5-year recurrence rate (2%, compared with 11% in the control group). They also had a better 5-year disease-specific survival (80%, versus 66%). An aggressive pN status was closely correlated with recurrence.

Source:
Feng Z, Xu QS, Qin LZ, et al. Br J Oral Maxillofac Surg. 2016;54(1):88-93.
doi: 10.1016/j.bjoms.2015.09.024

For patients with squamous cell carcinoma (SCC) of the tongue, recurrence is common and closely associated with survival, say researchers from Capital Medical University, Beijing. The researchers conducted a retrospective study of 204 patients with SCC of the tongue that aimed to identify the factors that predict relapse and prognosis.

Related: IBD and the Risk of Oral Cancer

In an earlier study, the researchers assessed the best indications for neck dissection and the prognostic factors of oral SCC. Their results showed that middle-late oral SCC is an indication for simultaneous neck dissection, even in patients whose nodes are clear. But few studies have focused on the outcomes of treatment after different surgical approaches, such as en bloc resection and discontinuous resection. En bloc dissection requires continuity between the tumor and the level I neck nodes, and the technique involves removal of the sublingual gland and the mylohyoid muscle, as well as the associated sublingual nodes.

Related: A Team Approach to Nonmelanotic Skin Cancer Procedures

Within the median follow-up of 82 months, 59 patients died (29%), 4 from non-cancer causes. Two patients in the en bloc group and 12 in the control group (discontinuous resection) had relapses. Ten of the 14 in this group had recurrences within a year of the first operation. Nine patients had salvage operations; however, only 2 experienced a successful outcome.

Surgical technique and pathological nodal (pN) status independently predicted both 5-year recurrence and disease-specific survival.

Related: Nivolumab Approved for Expanded Indication

The analysis showed a “dramatic” decrease in the 5-year disease-specific survival if the cancer recurred after the primary operation (no recurrence, 77% vs recurrence, 14%). Patients in the en bloc group “could expect an obviously lower” 5-year recurrence rate (2%, compared with 11% in the control group). They also had a better 5-year disease-specific survival (80%, versus 66%). An aggressive pN status was closely correlated with recurrence.

Source:
Feng Z, Xu QS, Qin LZ, et al. Br J Oral Maxillofac Surg. 2016;54(1):88-93.
doi: 10.1016/j.bjoms.2015.09.024

Patients with inflammatory bowel disease (IBD) may have a higher risk of oral cancer, according to a study at Mount Sinai Medical Center. Researchers collected data on 7,294 patients from 2000 through 2011. The results were published in the March issue of Clinical Gastroenterology and Hepatology.

Related: Exercise and Inflammatory Bowel Disease

In the study, the expected incidence of oral cancer was calculated for the patients who were stratified by gender and age using the Surveillance, Epidemiology and End Results (SEER) 18 registry data. Seven men and 4 women had biopsy-proven oral cancer. Six had cancer of the tongue, 2 had cancer of the hard palate, and 3 had tonsillar, buccal, or mandibular sarcoma. Seven patients had been treated for IBD before the cancer diagnosis.

Women had a higher risk of oral cancer. Adjusted for age and sex, the incidence ratio for oral cancer in patients with IBD was 9.77:12.07 for women12.07 and 9.77:8.49 for men. The age-adjusted incidence ratio for tongue cancer was 18.91: 17.06 for men, 22.10 for women.

Related: More Illnesses Linked to Camp Lejeune Water

The authors concluded that, “we found patients with IBD to be at increased risk for oral cancers, especially tongue cancer. Women are at higher risk than men.”

Source:
Katsanos KH, Roda G, McBride RB, Cohen B, Colombel JF. Clin Gastroenterol Hepatol. 2016;14(3):413-420
doi: 10.1016/j.cgh.2015.09.041. 

Patients with inflammatory bowel disease (IBD) may have a higher risk of oral cancer, according to a study at Mount Sinai Medical Center. Researchers collected data on 7,294 patients from 2000 through 2011. The results were published in the March issue of Clinical Gastroenterology and Hepatology.

Related: Exercise and Inflammatory Bowel Disease

In the study, the expected incidence of oral cancer was calculated for the patients who were stratified by gender and age using the Surveillance, Epidemiology and End Results (SEER) 18 registry data. Seven men and 4 women had biopsy-proven oral cancer. Six had cancer of the tongue, 2 had cancer of the hard palate, and 3 had tonsillar, buccal, or mandibular sarcoma. Seven patients had been treated for IBD before the cancer diagnosis.

Women had a higher risk of oral cancer. Adjusted for age and sex, the incidence ratio for oral cancer in patients with IBD was 9.77:12.07 for women12.07 and 9.77:8.49 for men. The age-adjusted incidence ratio for tongue cancer was 18.91: 17.06 for men, 22.10 for women.

Related: More Illnesses Linked to Camp Lejeune Water

The authors concluded that, “we found patients with IBD to be at increased risk for oral cancers, especially tongue cancer. Women are at higher risk than men.”

Source:
Katsanos KH, Roda G, McBride RB, Cohen B, Colombel JF. Clin Gastroenterol Hepatol. 2016;14(3):413-420
doi: 10.1016/j.cgh.2015.09.041. 

Patients with inflammatory bowel disease (IBD) may have a higher risk of oral cancer, according to a study at Mount Sinai Medical Center. Researchers collected data on 7,294 patients from 2000 through 2011. The results were published in the March issue of Clinical Gastroenterology and Hepatology.

Related: Exercise and Inflammatory Bowel Disease

In the study, the expected incidence of oral cancer was calculated for the patients who were stratified by gender and age using the Surveillance, Epidemiology and End Results (SEER) 18 registry data. Seven men and 4 women had biopsy-proven oral cancer. Six had cancer of the tongue, 2 had cancer of the hard palate, and 3 had tonsillar, buccal, or mandibular sarcoma. Seven patients had been treated for IBD before the cancer diagnosis.

Women had a higher risk of oral cancer. Adjusted for age and sex, the incidence ratio for oral cancer in patients with IBD was 9.77:12.07 for women12.07 and 9.77:8.49 for men. The age-adjusted incidence ratio for tongue cancer was 18.91: 17.06 for men, 22.10 for women.

Related: More Illnesses Linked to Camp Lejeune Water

The authors concluded that, “we found patients with IBD to be at increased risk for oral cancers, especially tongue cancer. Women are at higher risk than men.”

Source:
Katsanos KH, Roda G, McBride RB, Cohen B, Colombel JF. Clin Gastroenterol Hepatol. 2016;14(3):413-420
doi: 10.1016/j.cgh.2015.09.041. 

BOSTON – An analysis of data from medullary thyroid cancer patients that partitioned the patients into groups with similar overall survival has spurred a rethink of the current American Joint Committee on Cancer (AJCC) staging system.

The results from researchers at Duke University, Durham, N.C., presented at the annual meeting of the Endocrine Society by Dr. Mohamed Abdelgadir Adam, are timely, as the AJCC has embarked on a reconsideration of the staging of cancers, including medullary thyroid cancer (MTC), as part revisions for the eighth edition of the staging system.

“The existing AJCC staging system for MTC appears to be less than optimal in discriminating the risk of mortality among disease stage groups,” said Dr. Adam, who discussed the findings in a video interview.

MTC, a neuroendocrine tumor that affects C cells of the thyroid, comprises 3%-5% of all cases of thyroid cancer and it can be a more aggressive disease than differentiated thyroid cancer. Yet the current AJCC MTC staging system has been extrapolated from differentiated thyroid cancer data.

“We sought to evaluate how well the current AJCC seventh edition stage groupings predict survival for patients with MTC, to suggest a possible staging revision to sharpen estimates of prognosis,” said Dr. Adam.

The researchers utilized the National Cancer Data Base, representing over 70% of incident cancer cases in the United States.

MTC patients who underwent thyroid surgery from 1998 to 2012 were identified. Patients with missing values for pathologic T, N, or M were excluded. The primary outcome in the 3,315 patients was survival.

The researchers used a form of decision-tree analysis called recursive partitioning. In general, recursive partitioning is able to classify a population by splitting subjects into subgroups, each of which is homogeneous based on the particular outcome. In this study, the subgroup allocations were based on T, N, and M stages, with the outcome being overall survival. Kaplan-Meier and adjusted survival analyses enabled survival differences among the four subgroups (groups I, II, III and IV) to be explored.

The four groups were distinct in terms of survival time and allowed more accurate risk stratification. In particular, groups I and II were markedly better distinguished from one another than is the case with the current staging system. Survival differences across the stages were more distinct with the newly created T, N, and M groupings, compared with the current AJCC staging system.

After adjustment, survival differences across TNM groups were more distinct with the newly created TNM groupings (compared to subgroup I, hazard ratio of 3.06 for subgroup II; HR, 6.79 for III; and HR, 17.03 for IV), compared with the current AJCC staging (compared to stage I, HR, 1.45 for stage II; HR, 2.17 for III; and HR, 5.33 for IV).

“The AJCC is reevaluating all staging schemas, including MTC. The current AJCC staging system could be improved with the newly identified TNM groupings suggested here for more accurate patient risk stratification and possibly treatment selection,” said Dr. Adam.

Dr. Adam had no disclosures.

BOSTON – An analysis of data from medullary thyroid cancer patients that partitioned the patients into groups with similar overall survival has spurred a rethink of the current American Joint Committee on Cancer (AJCC) staging system.

The results from researchers at Duke University, Durham, N.C., presented at the annual meeting of the Endocrine Society by Dr. Mohamed Abdelgadir Adam, are timely, as the AJCC has embarked on a reconsideration of the staging of cancers, including medullary thyroid cancer (MTC), as part revisions for the eighth edition of the staging system.

“The existing AJCC staging system for MTC appears to be less than optimal in discriminating the risk of mortality among disease stage groups,” said Dr. Adam, who discussed the findings in a video interview.

MTC, a neuroendocrine tumor that affects C cells of the thyroid, comprises 3%-5% of all cases of thyroid cancer and it can be a more aggressive disease than differentiated thyroid cancer. Yet the current AJCC MTC staging system has been extrapolated from differentiated thyroid cancer data.

“We sought to evaluate how well the current AJCC seventh edition stage groupings predict survival for patients with MTC, to suggest a possible staging revision to sharpen estimates of prognosis,” said Dr. Adam.

The researchers utilized the National Cancer Data Base, representing over 70% of incident cancer cases in the United States.

MTC patients who underwent thyroid surgery from 1998 to 2012 were identified. Patients with missing values for pathologic T, N, or M were excluded. The primary outcome in the 3,315 patients was survival.

The researchers used a form of decision-tree analysis called recursive partitioning. In general, recursive partitioning is able to classify a population by splitting subjects into subgroups, each of which is homogeneous based on the particular outcome. In this study, the subgroup allocations were based on T, N, and M stages, with the outcome being overall survival. Kaplan-Meier and adjusted survival analyses enabled survival differences among the four subgroups (groups I, II, III and IV) to be explored.

The four groups were distinct in terms of survival time and allowed more accurate risk stratification. In particular, groups I and II were markedly better distinguished from one another than is the case with the current staging system. Survival differences across the stages were more distinct with the newly created T, N, and M groupings, compared with the current AJCC staging system.

After adjustment, survival differences across TNM groups were more distinct with the newly created TNM groupings (compared to subgroup I, hazard ratio of 3.06 for subgroup II; HR, 6.79 for III; and HR, 17.03 for IV), compared with the current AJCC staging (compared to stage I, HR, 1.45 for stage II; HR, 2.17 for III; and HR, 5.33 for IV).

“The AJCC is reevaluating all staging schemas, including MTC. The current AJCC staging system could be improved with the newly identified TNM groupings suggested here for more accurate patient risk stratification and possibly treatment selection,” said Dr. Adam.

Dr. Adam had no disclosures.

BOSTON – An analysis of data from medullary thyroid cancer patients that partitioned the patients into groups with similar overall survival has spurred a rethink of the current American Joint Committee on Cancer (AJCC) staging system.

The results from researchers at Duke University, Durham, N.C., presented at the annual meeting of the Endocrine Society by Dr. Mohamed Abdelgadir Adam, are timely, as the AJCC has embarked on a reconsideration of the staging of cancers, including medullary thyroid cancer (MTC), as part revisions for the eighth edition of the staging system.

“The existing AJCC staging system for MTC appears to be less than optimal in discriminating the risk of mortality among disease stage groups,” said Dr. Adam, who discussed the findings in a video interview.

MTC, a neuroendocrine tumor that affects C cells of the thyroid, comprises 3%-5% of all cases of thyroid cancer and it can be a more aggressive disease than differentiated thyroid cancer. Yet the current AJCC MTC staging system has been extrapolated from differentiated thyroid cancer data.

“We sought to evaluate how well the current AJCC seventh edition stage groupings predict survival for patients with MTC, to suggest a possible staging revision to sharpen estimates of prognosis,” said Dr. Adam.

The researchers utilized the National Cancer Data Base, representing over 70% of incident cancer cases in the United States.

MTC patients who underwent thyroid surgery from 1998 to 2012 were identified. Patients with missing values for pathologic T, N, or M were excluded. The primary outcome in the 3,315 patients was survival.

The researchers used a form of decision-tree analysis called recursive partitioning. In general, recursive partitioning is able to classify a population by splitting subjects into subgroups, each of which is homogeneous based on the particular outcome. In this study, the subgroup allocations were based on T, N, and M stages, with the outcome being overall survival. Kaplan-Meier and adjusted survival analyses enabled survival differences among the four subgroups (groups I, II, III and IV) to be explored.

The four groups were distinct in terms of survival time and allowed more accurate risk stratification. In particular, groups I and II were markedly better distinguished from one another than is the case with the current staging system. Survival differences across the stages were more distinct with the newly created T, N, and M groupings, compared with the current AJCC staging system.

After adjustment, survival differences across TNM groups were more distinct with the newly created TNM groupings (compared to subgroup I, hazard ratio of 3.06 for subgroup II; HR, 6.79 for III; and HR, 17.03 for IV), compared with the current AJCC staging (compared to stage I, HR, 1.45 for stage II; HR, 2.17 for III; and HR, 5.33 for IV).

“The AJCC is reevaluating all staging schemas, including MTC. The current AJCC staging system could be improved with the newly identified TNM groupings suggested here for more accurate patient risk stratification and possibly treatment selection,” said Dr. Adam.

Dr. Adam had no disclosures.

BOSTON – A study of over 60 years of patient data from the Mayo Clinic suggests a reconsideration of the routine use of unilateral thyroid lobectomy (UL) as the initial treatment for papillary thyroid microcarcinoma.

“Papillary thyroid microcarcinoma [PTM] patients have a normal life expectancy and typically are cured by adequate tumor resection. More than 99% of PTM patients are not at risk of either distant spread or mortality from cancer,” said Dr. Ian D. Hay of the Mayo Clinic, Rochester, Minn. Unilateral thyroid lobectomy is one treatment option for papillary thyroid microcarcinoma along with conventional bilateral nodal resection approaches of near-total thyroidectomy (NT) or total thyroidectomy (TT), or selective radioactive iodine remnant ablation (RRA).

Awareness of PTM is not new; examination of thyroid glands at autopsy going back decades has revealed their presence in 6%-36% of samples. A more recent development is the use of high-resolution ultrasound-guided biopsies of papillary thyroid carcinoma (PTC) lesions as small as 3 cm. For example, at the Mayo Clinic the diagnosis of PTM was about one annually from 1935 to 1944, while from 2005 to 2014 the average was close to one per day. “At Mayo, 34% of PTCs seen since 1995 are PTMs,” Dr. Hay said at the annual meeting of the Endocrine Society.

The best initial management of PTMs is disputed, with observation favored by some, TT and RRA favored by others, and ethanol ablation having been found to be effective by institutions including the Mayo Clinic. UL has been deemphasized, despite the 2015 American Thyroid Association Guidelines recommendation of UL as the usual surgical procedure for adults with PTM.

Dr. Hay and his colleagues sought to provide some clarity to the issue by taking advantage of the institute’s database of adult (18+ years) PTM patients who were consecutively treated from 1935 to 2014. The decades of data allowed a long-term look at patient outcomes. They examined data from 1,345 patients, 954 women and 391 men with a median age at surgery of 48 years. The mean follow-up was 15.4 years, representing almost 21,000 patient years. Data on tumor recurrence and cause-specific mortality were derived from a data base of over 4,300 PTC patients representing over 66,000 patient-years of observation.

Median tumor size was 7 mm (range, 0.08-1.0 cm). Extrathyroid invasion was evident in 18 (1.3%) cases and 298 tumors (26%) were multifocal. There were 399 (30%) node-positive tumors at diagnosis and 4 (0.3%) cases featuring initial distant metastases.

The mean MACIS (metastasis, age at presentation, completeness of surgical resection, invasion [extrathyroidal], size) score was 4.25 with little variation in score over time. Almost all (96%) patients had a MACIS score of under 6. Bilateral lobar resection was done in 1,132 (95%) patients, with NT or TT comprising 80% of the cases. UL was done in only 202 (15%) cases. The use of TT skyrocketed from 3% of the cases done in the first 2 decades to 40% in the last 2 decades. Regional nodes were removed at surgery in 743 (55%) cases, either by “node picking” (23%) or compartmental dissection (32%).

Overall survival following surgery in PTM patients was similar to age- and gender-matched controls (397 deaths observed, 431 deaths expected; P = .16). Only four (0.3%) patients died of PTM. The rates of locoregional recurrence were similar for the unilateral and bilateral approaches (P = .90). In 1,148 patients with potentially curable PTM, defined as the absence of metastasis at diagnosis and no gross residual disease, the rates of tumor recurrence 10, 20, and 40 years after surgery were 6%, 7%, and 10%, respectively. In these 1,148 patients, the 30-year locoregional recurrence rates after UL alone were similar to those seen after NT or TT followed by RRA (P = .99).

UL did not result in permanent unilateral vocal cord paresis or permanent hypoparathyroidism. These adversities were more likely to develop following bilateral lobectomy.

“Since [UL] produces comparable recurrence results when compared to bilateral surgery and is not associated with either cord paresis or hypoparathyroidism, then perhaps it is overdue for institutions like Mayo to individualize our treatment policies and more often employ UL when surgery, and not observation or ultrasound-guided percutaneous ethanol ablation, is chosen to treat PTM,” said Dr. Hay.

Dr. Hay was adamant on the overuse of ultrasound in the detection of small-diameter carcinomas in the decision for bilateral surgery. “It’s embarrassing how much we are wasting resources and doing too much ultrasound too often,” he said in an interview.

Dr. Hay had no disclosures.

BOSTON – A study of over 60 years of patient data from the Mayo Clinic suggests a reconsideration of the routine use of unilateral thyroid lobectomy (UL) as the initial treatment for papillary thyroid microcarcinoma.

“Papillary thyroid microcarcinoma [PTM] patients have a normal life expectancy and typically are cured by adequate tumor resection. More than 99% of PTM patients are not at risk of either distant spread or mortality from cancer,” said Dr. Ian D. Hay of the Mayo Clinic, Rochester, Minn. Unilateral thyroid lobectomy is one treatment option for papillary thyroid microcarcinoma along with conventional bilateral nodal resection approaches of near-total thyroidectomy (NT) or total thyroidectomy (TT), or selective radioactive iodine remnant ablation (RRA).

Awareness of PTM is not new; examination of thyroid glands at autopsy going back decades has revealed their presence in 6%-36% of samples. A more recent development is the use of high-resolution ultrasound-guided biopsies of papillary thyroid carcinoma (PTC) lesions as small as 3 cm. For example, at the Mayo Clinic the diagnosis of PTM was about one annually from 1935 to 1944, while from 2005 to 2014 the average was close to one per day. “At Mayo, 34% of PTCs seen since 1995 are PTMs,” Dr. Hay said at the annual meeting of the Endocrine Society.

The best initial management of PTMs is disputed, with observation favored by some, TT and RRA favored by others, and ethanol ablation having been found to be effective by institutions including the Mayo Clinic. UL has been deemphasized, despite the 2015 American Thyroid Association Guidelines recommendation of UL as the usual surgical procedure for adults with PTM.

Dr. Hay and his colleagues sought to provide some clarity to the issue by taking advantage of the institute’s database of adult (18+ years) PTM patients who were consecutively treated from 1935 to 2014. The decades of data allowed a long-term look at patient outcomes. They examined data from 1,345 patients, 954 women and 391 men with a median age at surgery of 48 years. The mean follow-up was 15.4 years, representing almost 21,000 patient years. Data on tumor recurrence and cause-specific mortality were derived from a data base of over 4,300 PTC patients representing over 66,000 patient-years of observation.

Median tumor size was 7 mm (range, 0.08-1.0 cm). Extrathyroid invasion was evident in 18 (1.3%) cases and 298 tumors (26%) were multifocal. There were 399 (30%) node-positive tumors at diagnosis and 4 (0.3%) cases featuring initial distant metastases.

The mean MACIS (metastasis, age at presentation, completeness of surgical resection, invasion [extrathyroidal], size) score was 4.25 with little variation in score over time. Almost all (96%) patients had a MACIS score of under 6. Bilateral lobar resection was done in 1,132 (95%) patients, with NT or TT comprising 80% of the cases. UL was done in only 202 (15%) cases. The use of TT skyrocketed from 3% of the cases done in the first 2 decades to 40% in the last 2 decades. Regional nodes were removed at surgery in 743 (55%) cases, either by “node picking” (23%) or compartmental dissection (32%).

Overall survival following surgery in PTM patients was similar to age- and gender-matched controls (397 deaths observed, 431 deaths expected; P = .16). Only four (0.3%) patients died of PTM. The rates of locoregional recurrence were similar for the unilateral and bilateral approaches (P = .90). In 1,148 patients with potentially curable PTM, defined as the absence of metastasis at diagnosis and no gross residual disease, the rates of tumor recurrence 10, 20, and 40 years after surgery were 6%, 7%, and 10%, respectively. In these 1,148 patients, the 30-year locoregional recurrence rates after UL alone were similar to those seen after NT or TT followed by RRA (P = .99).

UL did not result in permanent unilateral vocal cord paresis or permanent hypoparathyroidism. These adversities were more likely to develop following bilateral lobectomy.

“Since [UL] produces comparable recurrence results when compared to bilateral surgery and is not associated with either cord paresis or hypoparathyroidism, then perhaps it is overdue for institutions like Mayo to individualize our treatment policies and more often employ UL when surgery, and not observation or ultrasound-guided percutaneous ethanol ablation, is chosen to treat PTM,” said Dr. Hay.

Dr. Hay was adamant on the overuse of ultrasound in the detection of small-diameter carcinomas in the decision for bilateral surgery. “It’s embarrassing how much we are wasting resources and doing too much ultrasound too often,” he said in an interview.

Dr. Hay had no disclosures.

BOSTON – A study of over 60 years of patient data from the Mayo Clinic suggests a reconsideration of the routine use of unilateral thyroid lobectomy (UL) as the initial treatment for papillary thyroid microcarcinoma.

“Papillary thyroid microcarcinoma [PTM] patients have a normal life expectancy and typically are cured by adequate tumor resection. More than 99% of PTM patients are not at risk of either distant spread or mortality from cancer,” said Dr. Ian D. Hay of the Mayo Clinic, Rochester, Minn. Unilateral thyroid lobectomy is one treatment option for papillary thyroid microcarcinoma along with conventional bilateral nodal resection approaches of near-total thyroidectomy (NT) or total thyroidectomy (TT), or selective radioactive iodine remnant ablation (RRA).

Awareness of PTM is not new; examination of thyroid glands at autopsy going back decades has revealed their presence in 6%-36% of samples. A more recent development is the use of high-resolution ultrasound-guided biopsies of papillary thyroid carcinoma (PTC) lesions as small as 3 cm. For example, at the Mayo Clinic the diagnosis of PTM was about one annually from 1935 to 1944, while from 2005 to 2014 the average was close to one per day. “At Mayo, 34% of PTCs seen since 1995 are PTMs,” Dr. Hay said at the annual meeting of the Endocrine Society.

The best initial management of PTMs is disputed, with observation favored by some, TT and RRA favored by others, and ethanol ablation having been found to be effective by institutions including the Mayo Clinic. UL has been deemphasized, despite the 2015 American Thyroid Association Guidelines recommendation of UL as the usual surgical procedure for adults with PTM.

Dr. Hay and his colleagues sought to provide some clarity to the issue by taking advantage of the institute’s database of adult (18+ years) PTM patients who were consecutively treated from 1935 to 2014. The decades of data allowed a long-term look at patient outcomes. They examined data from 1,345 patients, 954 women and 391 men with a median age at surgery of 48 years. The mean follow-up was 15.4 years, representing almost 21,000 patient years. Data on tumor recurrence and cause-specific mortality were derived from a data base of over 4,300 PTC patients representing over 66,000 patient-years of observation.

Median tumor size was 7 mm (range, 0.08-1.0 cm). Extrathyroid invasion was evident in 18 (1.3%) cases and 298 tumors (26%) were multifocal. There were 399 (30%) node-positive tumors at diagnosis and 4 (0.3%) cases featuring initial distant metastases.

The mean MACIS (metastasis, age at presentation, completeness of surgical resection, invasion [extrathyroidal], size) score was 4.25 with little variation in score over time. Almost all (96%) patients had a MACIS score of under 6. Bilateral lobar resection was done in 1,132 (95%) patients, with NT or TT comprising 80% of the cases. UL was done in only 202 (15%) cases. The use of TT skyrocketed from 3% of the cases done in the first 2 decades to 40% in the last 2 decades. Regional nodes were removed at surgery in 743 (55%) cases, either by “node picking” (23%) or compartmental dissection (32%).

Overall survival following surgery in PTM patients was similar to age- and gender-matched controls (397 deaths observed, 431 deaths expected; P = .16). Only four (0.3%) patients died of PTM. The rates of locoregional recurrence were similar for the unilateral and bilateral approaches (P = .90). In 1,148 patients with potentially curable PTM, defined as the absence of metastasis at diagnosis and no gross residual disease, the rates of tumor recurrence 10, 20, and 40 years after surgery were 6%, 7%, and 10%, respectively. In these 1,148 patients, the 30-year locoregional recurrence rates after UL alone were similar to those seen after NT or TT followed by RRA (P = .99).

UL did not result in permanent unilateral vocal cord paresis or permanent hypoparathyroidism. These adversities were more likely to develop following bilateral lobectomy.

“Since [UL] produces comparable recurrence results when compared to bilateral surgery and is not associated with either cord paresis or hypoparathyroidism, then perhaps it is overdue for institutions like Mayo to individualize our treatment policies and more often employ UL when surgery, and not observation or ultrasound-guided percutaneous ethanol ablation, is chosen to treat PTM,” said Dr. Hay.

Dr. Hay was adamant on the overuse of ultrasound in the detection of small-diameter carcinomas in the decision for bilateral surgery. “It’s embarrassing how much we are wasting resources and doing too much ultrasound too often,” he said in an interview.

Dr. Hay had no disclosures.

BOSTON – Access to and acceptance of thyroid cancer surgery varies by race, with black patients in particular appearing to be disadvantaged, compared with whites, investigators reported.

A review of data on nearly 138,000 patients diagnosed with thyroid cancer showed that blacks were significantly less likely than were whites to be offered surgery – despite its generally excellent outcomes and low rates of morbidity and mortality, reported Dr. Herbert Castillo Valladares and his colleagues from the department of surgery at the Yale University in New Haven, Conn.

SciePro/Science Source

American Indians/Alaskan natives and Asian/Pacific Islanders were significantly more likely to refuse surgery than were whites, the investigators also reported in a poster session at the Society of Surgical Oncology annual cancer symposium.

“In this project, we wanted to focus on the provider-level factors that might be perpetuating these racial disparities, and it appears that we need to educate some providers about the recommendation of surgery or how to educate patients who refuse thyroid cancer surgery,” Dr. Valladares said in an interview.

The investigators noted that although incidence and prevalence rates of thyroid cancer are similar among various racial groups, survival differs by race, and they wanted to find out why. To do so, they polled the Surveillance, Epidemiology, and End Results (SEER) registry to identify 137,483 patients diagnosed with thyroid cancer during 1988-2012. Results were stratified by thyroid cancer type, either papillary, medullary, follicular, or anaplastic.

In all, 82% of the sample were white, 75% were female, 87% had a diagnosis of papillary thyroid cancer, and 95% underwent thyroid cancer surgery.

In logistic regression analysis that controlled for race, the investigators found that blacks, Asian/Pacific Islanders, and persons of unknown race were significantly less likely than whites were to have thyroid cancer surgery (odds ratios, 0.7, 0.82, and 0.34, respectively; P for each less than .0001).

Similarly, surgery was more frequently not recommended for blacks (OR, 1.34; P less than .0001), Asian/Pacific Islanders (OR, 1.2; P = .004) and those of unknown race (OR, 3.06; P less than .0001).

American Indians/Alaskan natives and Asian/Pacific Islanders were also significantly more likely than were whites to refuse surgery (OR, 4.45; P = .0001; OR, 2.96; P less than .0001, respectively).

Compared with whites, blacks – but not other races – had significantly worse 5-year survival (hazard ratio, 1.14; P = .0002).

In an analysis by cancer type, the investigators saw that race was not a predictor for surgery recommendation or refusal of surgery by patients with medullary or anaplastic cancer. However, among patients with papillary thyroid cancer, the most common type, surgery was recommended less often for blacks (OR, 1.2), Asian/Pacific Islanders (OR, 1.3), and patients of unknown race (OR, 3.1; all comparisons significant by 95% confidence interval).

Among patients with follicular histology, patients of unknown race were significantly less likely than were whites to have the surgery recommended (OR, 2.7; significant by 95% CI).

Dr. Valladares explained that the SEER data set does not include information about provider type, such as those in community based versus academic settings, so the next step will be to find a method for analyzing factors at both the patient level and the provider level that might influence recommendations for surgery or patient refusals to accept surgery.

The study was supported by the Paul H. Lavietes, M.D., Summer Research Fellowship of Yale University. The investigators reported no relevant conflicts of interest.

BOSTON – Access to and acceptance of thyroid cancer surgery varies by race, with black patients in particular appearing to be disadvantaged, compared with whites, investigators reported.

A review of data on nearly 138,000 patients diagnosed with thyroid cancer showed that blacks were significantly less likely than were whites to be offered surgery – despite its generally excellent outcomes and low rates of morbidity and mortality, reported Dr. Herbert Castillo Valladares and his colleagues from the department of surgery at the Yale University in New Haven, Conn.

SciePro/Science Source

American Indians/Alaskan natives and Asian/Pacific Islanders were significantly more likely to refuse surgery than were whites, the investigators also reported in a poster session at the Society of Surgical Oncology annual cancer symposium.

“In this project, we wanted to focus on the provider-level factors that might be perpetuating these racial disparities, and it appears that we need to educate some providers about the recommendation of surgery or how to educate patients who refuse thyroid cancer surgery,” Dr. Valladares said in an interview.

The investigators noted that although incidence and prevalence rates of thyroid cancer are similar among various racial groups, survival differs by race, and they wanted to find out why. To do so, they polled the Surveillance, Epidemiology, and End Results (SEER) registry to identify 137,483 patients diagnosed with thyroid cancer during 1988-2012. Results were stratified by thyroid cancer type, either papillary, medullary, follicular, or anaplastic.

In all, 82% of the sample were white, 75% were female, 87% had a diagnosis of papillary thyroid cancer, and 95% underwent thyroid cancer surgery.

In logistic regression analysis that controlled for race, the investigators found that blacks, Asian/Pacific Islanders, and persons of unknown race were significantly less likely than whites were to have thyroid cancer surgery (odds ratios, 0.7, 0.82, and 0.34, respectively; P for each less than .0001).

Similarly, surgery was more frequently not recommended for blacks (OR, 1.34; P less than .0001), Asian/Pacific Islanders (OR, 1.2; P = .004) and those of unknown race (OR, 3.06; P less than .0001).

American Indians/Alaskan natives and Asian/Pacific Islanders were also significantly more likely than were whites to refuse surgery (OR, 4.45; P = .0001; OR, 2.96; P less than .0001, respectively).

Compared with whites, blacks – but not other races – had significantly worse 5-year survival (hazard ratio, 1.14; P = .0002).

In an analysis by cancer type, the investigators saw that race was not a predictor for surgery recommendation or refusal of surgery by patients with medullary or anaplastic cancer. However, among patients with papillary thyroid cancer, the most common type, surgery was recommended less often for blacks (OR, 1.2), Asian/Pacific Islanders (OR, 1.3), and patients of unknown race (OR, 3.1; all comparisons significant by 95% confidence interval).

Among patients with follicular histology, patients of unknown race were significantly less likely than were whites to have the surgery recommended (OR, 2.7; significant by 95% CI).

Dr. Valladares explained that the SEER data set does not include information about provider type, such as those in community based versus academic settings, so the next step will be to find a method for analyzing factors at both the patient level and the provider level that might influence recommendations for surgery or patient refusals to accept surgery.

The study was supported by the Paul H. Lavietes, M.D., Summer Research Fellowship of Yale University. The investigators reported no relevant conflicts of interest.

BOSTON – Access to and acceptance of thyroid cancer surgery varies by race, with black patients in particular appearing to be disadvantaged, compared with whites, investigators reported.

A review of data on nearly 138,000 patients diagnosed with thyroid cancer showed that blacks were significantly less likely than were whites to be offered surgery – despite its generally excellent outcomes and low rates of morbidity and mortality, reported Dr. Herbert Castillo Valladares and his colleagues from the department of surgery at the Yale University in New Haven, Conn.

SciePro/Science Source

American Indians/Alaskan natives and Asian/Pacific Islanders were significantly more likely to refuse surgery than were whites, the investigators also reported in a poster session at the Society of Surgical Oncology annual cancer symposium.

“In this project, we wanted to focus on the provider-level factors that might be perpetuating these racial disparities, and it appears that we need to educate some providers about the recommendation of surgery or how to educate patients who refuse thyroid cancer surgery,” Dr. Valladares said in an interview.

The investigators noted that although incidence and prevalence rates of thyroid cancer are similar among various racial groups, survival differs by race, and they wanted to find out why. To do so, they polled the Surveillance, Epidemiology, and End Results (SEER) registry to identify 137,483 patients diagnosed with thyroid cancer during 1988-2012. Results were stratified by thyroid cancer type, either papillary, medullary, follicular, or anaplastic.

In all, 82% of the sample were white, 75% were female, 87% had a diagnosis of papillary thyroid cancer, and 95% underwent thyroid cancer surgery.

In logistic regression analysis that controlled for race, the investigators found that blacks, Asian/Pacific Islanders, and persons of unknown race were significantly less likely than whites were to have thyroid cancer surgery (odds ratios, 0.7, 0.82, and 0.34, respectively; P for each less than .0001).

Similarly, surgery was more frequently not recommended for blacks (OR, 1.34; P less than .0001), Asian/Pacific Islanders (OR, 1.2; P = .004) and those of unknown race (OR, 3.06; P less than .0001).

American Indians/Alaskan natives and Asian/Pacific Islanders were also significantly more likely than were whites to refuse surgery (OR, 4.45; P = .0001; OR, 2.96; P less than .0001, respectively).

Compared with whites, blacks – but not other races – had significantly worse 5-year survival (hazard ratio, 1.14; P = .0002).

In an analysis by cancer type, the investigators saw that race was not a predictor for surgery recommendation or refusal of surgery by patients with medullary or anaplastic cancer. However, among patients with papillary thyroid cancer, the most common type, surgery was recommended less often for blacks (OR, 1.2), Asian/Pacific Islanders (OR, 1.3), and patients of unknown race (OR, 3.1; all comparisons significant by 95% confidence interval).

Among patients with follicular histology, patients of unknown race were significantly less likely than were whites to have the surgery recommended (OR, 2.7; significant by 95% CI).

Dr. Valladares explained that the SEER data set does not include information about provider type, such as those in community based versus academic settings, so the next step will be to find a method for analyzing factors at both the patient level and the provider level that might influence recommendations for surgery or patient refusals to accept surgery.

The study was supported by the Paul H. Lavietes, M.D., Summer Research Fellowship of Yale University. The investigators reported no relevant conflicts of interest.

SCOTTSDALE, ARIZ. – Patients with head and neck cancer have substantial disparities in presentation, treatment, and outcomes according to their health insurance status, suggest results of a cohort study reported at the Multidisciplinary Head and Neck Cancer Symposium.

The analysis of more than 50,000 patients from the Surveillance, Epidemiology, and End Results (SEER) registry found that relative to counterparts with insurance, those with Medicaid or no insurance had more advanced disease at presentation.

Additionally, the Medicaid and uninsured patients were 23% and 32% less likely, respectively, to receive radiation therapy, and the uninsured were 23% less to receive surgery, according to data reported in a session and related press briefing.

Both overall and cancer-specific survival were worse for these two groups as well. And when compared with each other, the Medicaid patients actually had poorer overall survival than the uninsured, and similar cause-specific survival.

“We noted important disparities among Medicaid and uninsured cancer patients with head and neck malignancies in the United States,” said lead author Dr. Thomas M. Churilla of the Fox Chase Cancer Center in Philadelphia. “We hypothesize that lack of access to primary care and dental providers may be one of the reasons why patients are presenting with more locally advanced disease.”

The Patient Protection and Affordable Care Act aims to address lack of insurance in part by expanding Medicaid, he noted. However, “given the excess in cancer mortality seen in the Medicaid group and striking similarity with the uninsured group, expansions in Medicaid may have limited effect on outcomes among head and neck cancer patients without further study into figuring out which patient, provider, and health care system factors may be underlying these differences.”

Press briefing moderator Dr. Randall J. Kimple of the University of Wisconsin–Madison, asked, “In your data set, do you have any information on the length of insurance coverage? We see a fair number of patients who come in with no insurance but ultimately get enrolled in Medicaid. Would they have been included in the Medicaid group or the insured group in this study?”

The SEER database does not provide that information, Dr. Churilla said. “The inability to tell the length of insurance coverage is an important limitation of our study, and it may limit our inferences to tell the difference between these two groups,” he acknowledged, adding that the database also lacks information about other important potential confounders, including systemic therapies; risk factors such as smoking, alcohol intake, and human papillomavirus status; and the size, type, and experience of the treating center.

A session attendee said, “You showed that uninsured patients did better than Medicaid patients. Is this possibly due to the uninsured getting free care rather than [clinicians] needing to follow Medicaid-approved treatment?”

“We are scratching our heads a little bit with this one as well, but I think some of the difference may be due in part to the age differences,” Dr. Churilla replied. “The Medicaid patients on average were older than uninsured patients, so perhaps more competing causes of death leading to a difference in overall survival yet similar cancer-specific survival.”

For the study, the investigators analyzed outcomes among 53,848 patients who had primary squamous cell carcinoma of the oral cavity, pharynx, or larynx diagnosed during 2007-2012. Overall, 80% were insured (through private insurance or Medicare), 15% had Medicaid, and 5% were uninsured.

Results showed that patients with Medicaid or no insurance had more advanced cancer at presentation than insured peers. For example, 56% and 59% of patients with Medicaid and no insurance, respectively, had stage 4 disease, compared with 43% of insured patients.

In multivariate analyses adjusted for socioeconomic characteristics, clinical factors (including stage), and treatments, the likelihood of receiving external-beam radiation therapy was lower for the Medicaid group (hazard ratio, 0.77; P less than .001) and the uninsured group (HR, 0.68; P less than .001). Additionally, the uninsured were less likely to receive cancer-directed surgery, defined as at least a wide local excision (HR, 0.77; P less than .001).

In addition, both Medicaid and uninsured patients had poorer overall survival (HRs, 1.54 and 1.49) and cancer-specific survival (HRs, 1.59 and 1.66) relative to insured counterparts.

Findings were generally the same after propensity score weighting and in a sensitivity analysis that excluded all patients aged 65 or older because of their Medicare eligibility.

Addressing the observed disparities for the uninsured patients will require action on both the clinician and policy levels, Dr. Churilla said.

“One of the first steps is awareness among both dental and medical communities and trying to provide social services and financial counseling to help these patients enroll in certain programs such as Medicaid that they may be eligible for,” he elaborated. “And then I think the rest of it really lies with national policy – how do we expand coverage to help get these people the health care that they need and the appropriate services that they require.”

SCOTTSDALE, ARIZ. – Patients with head and neck cancer have substantial disparities in presentation, treatment, and outcomes according to their health insurance status, suggest results of a cohort study reported at the Multidisciplinary Head and Neck Cancer Symposium.

The analysis of more than 50,000 patients from the Surveillance, Epidemiology, and End Results (SEER) registry found that relative to counterparts with insurance, those with Medicaid or no insurance had more advanced disease at presentation.

Additionally, the Medicaid and uninsured patients were 23% and 32% less likely, respectively, to receive radiation therapy, and the uninsured were 23% less to receive surgery, according to data reported in a session and related press briefing.

Both overall and cancer-specific survival were worse for these two groups as well. And when compared with each other, the Medicaid patients actually had poorer overall survival than the uninsured, and similar cause-specific survival.

“We noted important disparities among Medicaid and uninsured cancer patients with head and neck malignancies in the United States,” said lead author Dr. Thomas M. Churilla of the Fox Chase Cancer Center in Philadelphia. “We hypothesize that lack of access to primary care and dental providers may be one of the reasons why patients are presenting with more locally advanced disease.”

The Patient Protection and Affordable Care Act aims to address lack of insurance in part by expanding Medicaid, he noted. However, “given the excess in cancer mortality seen in the Medicaid group and striking similarity with the uninsured group, expansions in Medicaid may have limited effect on outcomes among head and neck cancer patients without further study into figuring out which patient, provider, and health care system factors may be underlying these differences.”

Press briefing moderator Dr. Randall J. Kimple of the University of Wisconsin–Madison, asked, “In your data set, do you have any information on the length of insurance coverage? We see a fair number of patients who come in with no insurance but ultimately get enrolled in Medicaid. Would they have been included in the Medicaid group or the insured group in this study?”

The SEER database does not provide that information, Dr. Churilla said. “The inability to tell the length of insurance coverage is an important limitation of our study, and it may limit our inferences to tell the difference between these two groups,” he acknowledged, adding that the database also lacks information about other important potential confounders, including systemic therapies; risk factors such as smoking, alcohol intake, and human papillomavirus status; and the size, type, and experience of the treating center.

A session attendee said, “You showed that uninsured patients did better than Medicaid patients. Is this possibly due to the uninsured getting free care rather than [clinicians] needing to follow Medicaid-approved treatment?”

“We are scratching our heads a little bit with this one as well, but I think some of the difference may be due in part to the age differences,” Dr. Churilla replied. “The Medicaid patients on average were older than uninsured patients, so perhaps more competing causes of death leading to a difference in overall survival yet similar cancer-specific survival.”

For the study, the investigators analyzed outcomes among 53,848 patients who had primary squamous cell carcinoma of the oral cavity, pharynx, or larynx diagnosed during 2007-2012. Overall, 80% were insured (through private insurance or Medicare), 15% had Medicaid, and 5% were uninsured.

Results showed that patients with Medicaid or no insurance had more advanced cancer at presentation than insured peers. For example, 56% and 59% of patients with Medicaid and no insurance, respectively, had stage 4 disease, compared with 43% of insured patients.

In multivariate analyses adjusted for socioeconomic characteristics, clinical factors (including stage), and treatments, the likelihood of receiving external-beam radiation therapy was lower for the Medicaid group (hazard ratio, 0.77; P less than .001) and the uninsured group (HR, 0.68; P less than .001). Additionally, the uninsured were less likely to receive cancer-directed surgery, defined as at least a wide local excision (HR, 0.77; P less than .001).

In addition, both Medicaid and uninsured patients had poorer overall survival (HRs, 1.54 and 1.49) and cancer-specific survival (HRs, 1.59 and 1.66) relative to insured counterparts.

Findings were generally the same after propensity score weighting and in a sensitivity analysis that excluded all patients aged 65 or older because of their Medicare eligibility.

Addressing the observed disparities for the uninsured patients will require action on both the clinician and policy levels, Dr. Churilla said.

“One of the first steps is awareness among both dental and medical communities and trying to provide social services and financial counseling to help these patients enroll in certain programs such as Medicaid that they may be eligible for,” he elaborated. “And then I think the rest of it really lies with national policy – how do we expand coverage to help get these people the health care that they need and the appropriate services that they require.”

SCOTTSDALE, ARIZ. – Patients with head and neck cancer have substantial disparities in presentation, treatment, and outcomes according to their health insurance status, suggest results of a cohort study reported at the Multidisciplinary Head and Neck Cancer Symposium.

The analysis of more than 50,000 patients from the Surveillance, Epidemiology, and End Results (SEER) registry found that relative to counterparts with insurance, those with Medicaid or no insurance had more advanced disease at presentation.

Additionally, the Medicaid and uninsured patients were 23% and 32% less likely, respectively, to receive radiation therapy, and the uninsured were 23% less to receive surgery, according to data reported in a session and related press briefing.

Both overall and cancer-specific survival were worse for these two groups as well. And when compared with each other, the Medicaid patients actually had poorer overall survival than the uninsured, and similar cause-specific survival.

“We noted important disparities among Medicaid and uninsured cancer patients with head and neck malignancies in the United States,” said lead author Dr. Thomas M. Churilla of the Fox Chase Cancer Center in Philadelphia. “We hypothesize that lack of access to primary care and dental providers may be one of the reasons why patients are presenting with more locally advanced disease.”

The Patient Protection and Affordable Care Act aims to address lack of insurance in part by expanding Medicaid, he noted. However, “given the excess in cancer mortality seen in the Medicaid group and striking similarity with the uninsured group, expansions in Medicaid may have limited effect on outcomes among head and neck cancer patients without further study into figuring out which patient, provider, and health care system factors may be underlying these differences.”

Press briefing moderator Dr. Randall J. Kimple of the University of Wisconsin–Madison, asked, “In your data set, do you have any information on the length of insurance coverage? We see a fair number of patients who come in with no insurance but ultimately get enrolled in Medicaid. Would they have been included in the Medicaid group or the insured group in this study?”

The SEER database does not provide that information, Dr. Churilla said. “The inability to tell the length of insurance coverage is an important limitation of our study, and it may limit our inferences to tell the difference between these two groups,” he acknowledged, adding that the database also lacks information about other important potential confounders, including systemic therapies; risk factors such as smoking, alcohol intake, and human papillomavirus status; and the size, type, and experience of the treating center.

A session attendee said, “You showed that uninsured patients did better than Medicaid patients. Is this possibly due to the uninsured getting free care rather than [clinicians] needing to follow Medicaid-approved treatment?”

“We are scratching our heads a little bit with this one as well, but I think some of the difference may be due in part to the age differences,” Dr. Churilla replied. “The Medicaid patients on average were older than uninsured patients, so perhaps more competing causes of death leading to a difference in overall survival yet similar cancer-specific survival.”

For the study, the investigators analyzed outcomes among 53,848 patients who had primary squamous cell carcinoma of the oral cavity, pharynx, or larynx diagnosed during 2007-2012. Overall, 80% were insured (through private insurance or Medicare), 15% had Medicaid, and 5% were uninsured.

Results showed that patients with Medicaid or no insurance had more advanced cancer at presentation than insured peers. For example, 56% and 59% of patients with Medicaid and no insurance, respectively, had stage 4 disease, compared with 43% of insured patients.

In multivariate analyses adjusted for socioeconomic characteristics, clinical factors (including stage), and treatments, the likelihood of receiving external-beam radiation therapy was lower for the Medicaid group (hazard ratio, 0.77; P less than .001) and the uninsured group (HR, 0.68; P less than .001). Additionally, the uninsured were less likely to receive cancer-directed surgery, defined as at least a wide local excision (HR, 0.77; P less than .001).

In addition, both Medicaid and uninsured patients had poorer overall survival (HRs, 1.54 and 1.49) and cancer-specific survival (HRs, 1.59 and 1.66) relative to insured counterparts.

Findings were generally the same after propensity score weighting and in a sensitivity analysis that excluded all patients aged 65 or older because of their Medicare eligibility.

Addressing the observed disparities for the uninsured patients will require action on both the clinician and policy levels, Dr. Churilla said.

“One of the first steps is awareness among both dental and medical communities and trying to provide social services and financial counseling to help these patients enroll in certain programs such as Medicaid that they may be eligible for,” he elaborated. “And then I think the rest of it really lies with national policy – how do we expand coverage to help get these people the health care that they need and the appropriate services that they require.”