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ImportanceThe association of primary tumor volume with outcomes in T3 glottic cancers treated with radiotherapy with concurrent chemotherapy remains unclear, with some evidence suggesting worse locoregional control in larger tumors.ObjectiveTo evaluate the association of primary tumor volume with oncologic outcomes in patients with T3 N0-N3 M0 glottic cancer treated with primary (chemo)radiotherapy in a large multi-institutional study.Design, Setting, and ParticipantsThis multi-institutional retrospective cohort study involved 7 Canadian cancer centers from 2002 to 2018. Tumor volume was measured by expert neuroradiologists on diagnostic imaging. Clinical and outcome data were extracted from electronic medical records. Overall survival (OS) and disease-free survival (DFS) outcomes were assessed with marginal Cox regression. Laryngectomy-free survival (LFS) was modeled as a secondary analysis. Patients diagnosed with cT3 N0-N3 M0 glottic cancers from 2002 to 2018 and treated with curative intent intensity-modulated radiotherapy (IMRT) with or without chemotherapy. Overall, 319 patients met study inclusion criteria.ExposuresTumor volume as measured on diagnostic imaging by expert neuroradiologists.Main Outcomes and MeasuresPrimary outcomes were OS and DFS; LFS was assessed as a secondary analysis, and late toxic effects as an exploratory analysis determined before start of the study.ResultsThe mean (SD) age of participants was 66 (12) years and 279 (88%) were men. Overall, 268 patients (84%) had N0 disease, and 150 (47%) received concurrent systemic therapy. The mean (SD) tumor volume was 4.04 (3.92) cm3. With a mean (SD) follow-up of 3.85 (3.04) years, there were 91 (29%) local, 35 (11%) regional, and 38 (12%) distant failures. Increasing tumor volume (per 1-cm3 increase) was associated with significantly worse adjusted OS (hazard ratio [HR], 1.07; 95% CI, 1.03-1.11) and DFS (HR, 1.04; 95% CI, 1.01-1.07). A total of 62 patients (19%) underwent laryngectomies with 54 (87%) of these within 800 days after treatment. Concurrent systemic therapy was associated with improved LFS (subdistribution HR, 0.63; 95% CI, 0.53-0.76).Conclusions and RelevanceIncreasing tumor volumes in cT3 glottic cancers was associated with worse OS and DFS, and systemic therapy was associated with improved LFS. In absence of randomized clinical trial evidence, patients with poor pretreatment laryngeal function or those ineligible for systemic therapy may be considered for primary surgical resection with postoperative radiotherapy.

Importance: There is epidemiologic evidence that the increasing incidence of thyroid cancer is associated with subclinical disease detection. Evidence for a true increase in thyroid cancer incidence has also been identified. However, a true increase in disease would likely be heralded by an increased incidence of thyroid-referable symptoms in patients presenting with disease.Objectives: To evaluate whether modes of detection (MODs) used to identify thyroid nodules for surgical removal have changed compared with historic data and to determine if MODs vary by geographic location.Design, Setting, and Participants: This was a retrospective analysis of pathology and medical records of 1328 patients who underwent thyroid-directed surgery in 16 centers in 4 countries: 4 centers in Canada, 1 in Denmark, 1 in South Africa, and 12 in the US. The participants were the first 100 patients (or the largest number available) at each center who had thyroid surgery in 2019. The MOD of the thyroid finding that required surgery was classified using an updated version of a previously validated tool as endocrine condition, symptomatic thyroid, surveillance, or without thyroid-referable symptoms (asymptomatic). If asymptomatic, the MOD was further classified as clinician screening examination, patient-requested screening, radiologic serendipity, or diagnostic cascade.Main Outcomes and Measures: The MOD of thyroid nodules that were surgically removed, by geographic variation; and the proportion and size of thyroid cancers discovered in patients without thyroid-referable symptoms compared with symptomatic detection. Data analyses were performed from April 2021 to February 2022.Results: Of the 1328 patients (mean [SD] age, 52 [15] years; 993 [75%] women; race/ethnicity data were not collected) who underwent thyroid surgery that met inclusion criteria, 34% (448) of the surgeries were for patients with thyroid-related symptoms, 41% (542) for thyroid findings discovered without thyroid-referable symptoms, 14% (184) for endocrine conditions, and 12% (154) for nodules with original MOD unknown (under surveillance). Cancer was detected in 613 (46%) patients; of these, 30% (183 patients) were symptomatic and 51% (310 patients) had no thyroid-referable symptoms. The mean (SD) size of the cancers identified in the symptomatic group was 3.2 (2.1) cm (median [range] cm, 2.6 [0.2-10.5]; 95% CI, 2.91-3.52) and in the asymptomatic group, 2.1 (1.4) cm (median [range] cm, 1.7 [0.05-8.8]; 95% CI, 1.92-2.23). The MOD patterns were significantly different among all participating countries.Conclusions and Relevance: This retrospective analysis found that most thyroid cancers were discovered in patients who had no thyroid-referable symptoms; on average, these cancers were smaller than symptomatic thyroid cancers. Still, some asymptomatic cancers were large, consistent with historic data. The substantial difference in MOD patterns among the 4 countries suggests extensive variations in practice.

IMPORTANCE: Patients with head and neck cancer manage a variety of symptoms at home on an outpatient basis. Clinician review alone often leaves patient symptoms undetected and untreated. Standardized symptom assessment using patient-reported outcomes (PROs) has been shown in randomized clinical trials to improve symptom detection and overall survival, although translation into real-world settings remains a challenge. OBJECTIVE: To better understand how patients with head and neck cancer cope with cancer-related symptoms and to examine their perspectives on standardized symptom assessment. DESIGN, PARTICIPANTS, AND SETTING: This was a qualitative analysis using semistructured interviews of patients with head and neck cancer and their caregivers from November 2, 2020, to April 16, 2021, at a regional tertiary center in Canada. Purposive sampling was used to recruit a varied group of participants (cancer subsite, treatment received, sociodemographic factors). Drawing on the Supportive Care Framework, a thematic approach was used to analyze the data. Data analysis was performed from November 2, 2020, to August 2, 2021. MAIN OUTCOMES AND MEASURES: Patient perception of ambulatory symptom management and standardized symptom assessment. RESULTS: Among 20 participants (median [range] age, 59.5 [33-74] years; 9 [45%] female; 13 [65%] White individuals), 4 themes were identified: (1) timely physical symptom management, (2) information as a tool for symptom management, (3) barriers to psychosocial support, and (4) external factors magnifying symptom burden. Participants’ perceptions of standardized symptom assessment varied. Some individuals described the symptom monitoring process as facilitating self-reflection and symptom detection. Others felt disempowered by the process, particularly when symptom scores were inconsistently reviewed or acted on. CONCLUSIONS AND RELEVANCE: This qualitative analysis provides a novel description of head and neck cancer symptom management from the patient perspective. The 4 identified themes and accompanying recommendations serve as guides for enhanced symptom monitoring.

Importance Pharyngocutaneous fistula (PCF) results in an inflammatory reaction, but its association with the rate of locoregional and distant control, disease-free survival, and overall survival in laryngeal cancer remains uncertain. Objective To determine if pharyngocutaneous fistula after salvage laryngectomy is associated with locoregional and distant control, disease-free survival, and/or overall survival. Design, Setting, and Participants A multicenter collaborative retrospective cohort study conducted at 5 centers in Canada and the US of 550 patients who underwent salvage laryngectomy for recurrent laryngeal cancer from January 1, 2000, to December 31, 2014. The median follow-up time was 5.7 years (range, 0-18 years). Main Outcomes and Measures Outcomes examined included locoregional and distant control, disease-free survival, and overall survival. Fine and Gray competing risk regression and Cox-proportional hazard regression models were used for outcomes. Competing risks and the Kaplan-Meier methods were used to estimate outcomes at 3 years and 5 years. Results In all, 550 patients (mean [SD] age, 64 [10.4] years; men, 465 [85%]) met inclusion criteria. Pharyngocutaneous fistula occurred in 127 patients (23%). The difference in locoregional control between the group of patients with PCF (75%) and the non–PCF (72%) group was 3% (95% CI, −6% to 12%). The difference in overall survival between the group with PCF (44%) and the non–PCF group (52%) was 8% (95% CI, −2% to 20%). The difference in disease-free survival between PCF and non–PCF groups was 6% (95% CI, −4% to 16%). In the multivariable model, patients with PCF were at a 2-fold higher rate of distant metastases (hazard ratio, 2.00; 95% CI, 1.22 to 3.27). Distant control was reduced in those with PCF, a 13% (95% CI, 3% to 21%) difference in 5-year distant control. Conclusions and Relevance This multicenter retrospective cohort study found that development of PCF after salvage laryngectomy is associated with an increased risk for the development of distant metastases.

This cohort study examines the association of the COVID-19 pandemic with total laryngectomy volumes among patients in Ontario, Canada.

Importance 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. Objective To determine the association of Chinese and South Asian ethnicity, independent of immigration status, with HNC incidence. Design, Setting, and Participants 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). Exposures Chinese ethnicity, South Asian ethnicity, and immigration status. Main Outcomes and Measures 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. Results 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. Conclusions and Relevance 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.

Importance Postoperative delirium (POD) is associated with an increased rate of adverse events, higher health care costs, and longer hospital stays. At present, limited data are available regarding the risk factors for developing POD in patients undergoing head and neck free flap reconstruction. Identification of patients at high risk of developing POD will allow implementation of risk-mitigation strategies. Objective To determine the frequency of and risk factors associated with POD in patients undergoing free flap reconstruction secondary to head and neck disease. Design, setting, and participants This retrospective cohort study included 515 patients undergoing free flap reconstruction from January 1, 2006, through December 31, 2012, at the James Cancer Hospital and Solove Research Institute, The Ohio State University Comprehensive Care Center, a tertiary care cancer hospital. Preoperative, intraoperative, and postoperative data were collected retrospectively. Data from January 1, 2006, through December 31, 2012, were analyzed, and the final date of data analysis was January 8, 2018. Interventions Head and neck free flap reconstruction. Main outcomes and measures The primary outcome was the development of POD as defined by the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition). Univariable and multivariable logistic regression were used to identify risk factors associated with POD. Results Five hundred fifteen patients underwent free flap reconstruction during the study period (66.2% male; mean [SD] age, 60.1 [12.8] years). Of these, 56 patients (10.9%) developed POD. On multivariable analysis, risk factors associated with POD included increased age (odds ratio [OR], 1.06; 95% CI, 1.02-1.11), male sex (OR, 5.02; 95% CI, 1.47-17.20), increased operative time (OR for each 1-minute increase, 1.004 [95% CI, 1.001-1.006]; OR for each 1-hour increase, 1.26 [95% CI, 1.08-1.46]), advanced nodal disease (OR, 3.00; 95% CI, 1.39-6.46), and tobacco use (OR, 7.23; 95% CI, 1.43-36.60). Preoperative abstinence from alcohol was identified as a protective factor (OR, 0.24; 95% CI, 0.12-0.51). Conclusions and relevance This study identified variables associated with a higher risk of developing POD. Although many of these risk factors are nonmodifiable, they provide a target population for quality improvement initiatives. Furthermore, preoperative alcohol abstinence may be useful in preventing POD.

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was started by an act of the United States Congress in an attempt to decrease excessive mortality among patients within the Veterans Health Administration system. Currently, more than 200 hospitals participate in the ACSNSQIP system. The focus of the program has beenmainly on general surgery and vascular surgery procedures. A key part of ACS-NSQIP has been the recognition of the need for adjustment for patient-specific illness severity. Approximately 10years ago, the leadership at theACS recognized several problemswith ACS-NSQIP that they believed potentially limited thevalue andutility of theprogram.Toaddress these problems, they set about to change the structure and format of ACS-NSQIP. In 2008, the Measurement and Evaluation Committee of ACS published their recommendations for a newand improvedACS-NSQIP.1 Among their 8 recommendations was that the NSQIP develop a new, specialtyspecific approach in its outcomes registries, recognizing that to achieve this goal would require participation by specialty societies and the leadership within these societies. In this issue of JAMA Otolaryngology–Head & Neck Surgery, Lewis et al2 present the development and feasibility of a head and neck oncology–specific NSQIP module. This is a timely and important topic, especially in the context of ongoing efforts to implement value-based payment fundingmodelsandgreaterattentiontomeasurementandreportingofquality performance inmany jurisdictions inNorthAmerica.With the goal in mind of improving the delivery of health care by head and neck surgical oncologists, Lewis et al make an admirable start toward the development of a specialty-specific NSQIP. In the process, they modify existing ACS-NSQIP definitions to better suit the head and neck oncology patient and specialty. We outline some of the strengths and weaknesses of this approachandthechallenges to implementationofa specialty-specific module developed within NSQIP. Lewis et al2 identify 3main strengths of their process. The first is inclusion of amultidisciplinary teamof head and neck surgeons, plastic surgeons, a speech pathologist, and the institutionalACS-NSQIP surgeon to identify preoperative, intraoperative,andpostoperativevariablesspecific toheadandneck cancer andablative surgery requiring reconstruction.The second important strength is the inclusion of functional outcomes in the data collection process. All head and neck cancer physicians and patients understand the importance of capturing information related to the functional limitations associatedwith treatment.Andyet this information is rarely captured incancer registries andadministrativedatabases.A third strength is the identification of the operating surgeons to allow for individualized surgeon performance assessment. The authors also acknowledge a few weaknesses of their approach.2 The first is that several of the new functional variables have not yet been validated in the literature. A second weakness is the inability to capture pretreatment functional status because patients identified for inclusion in NSQIP are identifiedpostoperatively throughCurrent Procedural Terminology codes. The lack of pretreatment functional status decreasesmeaningful conclusions regarding the effects of treatmentbasedonthestudyofposttreatment functionaloutcomes alone. The flexibility of the NSQIP platform and its ability to incorporate newvariables andmodules is critical to the success of the subspecialty-specific NSQIP modules. The developmentof surgeon-and institution-specific report cards is apowerful quality improvement instrument andmust be included in futureNSQIPmodules. For example, surgeonandpathologist-level report cards were implemented in 3 of the 14 regions in Ontario, Canada. These report cards provide surgeons and pathologistswith positivemargin and lymphnode retrieval rates in prostate and colorectal cancer. In addition, all surgeons inOntario receive provider-level performanceon access to care for their patients, and their performance is compared with hospital, regional, and provincial peers. The preliminary results are promising. In an earlier study by Lewis et al,3 this sameapproachwas analyzed, and favorable improvement results were reported. Unfortunately, there arehigh costs associatedwith the retrievalandreportingofqualitydata throughNSQIP.Thesecosts include the training and auditing of surgical clinical reviewers.Unfortunately, not all centers can afford such training and auditing, andtheverycenters thatcannotmaybe theoneswith the higher-than-expected complication rates and lower quality of care. The contrary argument to the significant resource investment is that higher quality of care is safer, more effective, and ultimately more cost-efficient. The study by Lewis et al2 was performed at a highvolume tertiary institution and, as the authors note, the applicability of this type of data collection to smaller centers is unknown.Furthermore, evenwith themost sophisticated risk adjustment techniques, there are inherent and unmeasured differences between patients and across centers that will not orcannotbe included in themodel.TheNSQIP iswell equipped to drive quality improvement locally, but regionally, statewide, and nationally, this approach becomes challenging due Related article page 321 Research Original Investigation The Head and Neck–Reconstructive Surgery NSQIP