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Objective: To investigate whether patients treated with laryngectomy had less comorbidity than those treated with chemoradiation, which could help explain the improved survival for the laryngectomy cohorts in recent studies. Design: Observational cross-sectional study. Patients: Patients receiving diagnoses of primary invasive advanced squamous cell carcinoma of the larynx between 2003 and 2008 were selected from the National Cancer Database, which collects information from more than 1400 facilities accredited by the American College of Surgeons' Commission on Cancer. Patient-level independent variables included age at diagnosis, sex, diagnosis year, race/ethnicity, primary payer status, and zip code-level education. Main Outcome Measures: Primary treatment information. The association between treatment and patient clinical, sociodemographic, and facility-level and zip code- level socioeconomic status variables were analyzed using univariate statistics and multivariate models. Charlson Deyo Comorbidity and The Washington University Head and Neck Comorbidity Index scores were calculated from the hospital face sheet. Results: The study demonstrated that receipt of treatment (chemoradiation vs total laryngectomy) was significantly associated with comorbidity. Treatment was not significantly associated with insurance status, race/ethnicity, or age. Patients with comorbidity were less likely to receive chemoradiation than subtotal or total laryngectomy, with a risk ratio (RR) of 0.84 (95% CI, 0.81-0.87) for patients with 1 or more comorbidities compared with those without any comorbidity, after controlling for factors such as tumor stage, age, race/ethnicity, insurance, and socioeconomic status. Patients were also less likely to receive chemoradiation than total laryngectomy if they had stage IV disease (RR, 0.81; 95% CI, 0.79-0.83) and if they had been diagnosed at a teaching or research institution (RR, 0.80; 95% CI, 0.77-0.84). Patients were more likely to receive chemoradiation if they were diagnosed after 2003 (RR, 1.37; 95% CI, 1.30-1.45) or if they lived in a zip code with a high percentage of high school graduates (RR, 1.1; 95% CI, 1.05-1.15). Conclusions: This is the first study, to our knowledge, that demonstrates that patients with advanced laryngeal cancer with 1 or more comorbidities are more likely to receive surgery than chemoradiation compared with patients without any comorbidity, independent of numerous clinical and nonclinical variables among a large national cohort. A limitation of this study is the use of comorbidity data from the National Cancer Database, which gathers its information from hospital discharge face sheets. We recognize that the National Cancer Database may be an imperfect system for the collection of comorbidity data and encourage discussion on different methods to improve the system, including incorporating comorbidity data from the Surveillance, Epidemiology, and End Results Medicare Database and medical chart- based comorbidity data collection by cancer registrars. [ABSTRACT FROM AUTHOR]

Objective: To describe trends in mortality rates for patients with oral cavity and pharynx cancer by educational attainment, race/ethnicity, sex, and association with human papillomavirus infection. Design: Study of age-standardized mortality rates for patients with oral cavity and pharynx cancer by level of education using National Center for Health Statistics data. Setting: Twenty-six states. Patients: White and black men and women aged 25 to 64 years. Main Outcome Measure: Age-standardized mortality rates for 2005 to 2007 and trends for 1993 to 2007. Results: From 1993 to 2007, overall mortality rates for patients with oral cavity and pharynx cancer decreased among black and white men and women; however, rates among white men have stabilized since 1999. The largest decreases in mortality rates were among black men and women with 12 years of education (-4.95% and -3.72%, respectively). Mortality rates for patients with oral cavity and pharynx cancers decreased significantly among men and women with more than 12 years of education, regardless of race/ethnicity (except for black women), whereas rates increased among white men with less than 12 years of education. Mortality trends vary substantially for human papillomavirus-related and human papillomavirus-unrelated sites. Conclusions: We observed decreasing mortality rates for patients with oral cavity and pharyngeal cancer among whites and blacks; however, decreases were greatest among those with at least 12 years of education. This difference in mortality trends may reflect the changing prevalence of smoking and sexual behaviors among populations of different educational attainment. [ABSTRACT FROM AUTHOR]

Objective: To describe trends and 4-year survival rate of surgical and nonsurgical treatment for laryngeal cancer. Design: Observational cross-sectional study. Patients: A total of 131 694 cases of laryngeal cancer diagnosed from 1985 to 2007 identified from the National Cancer Database. Main Outcome Measures: Primary treatment information, including radiation therapy (RT), chemoradiation (CRT), and curative intent surgery, were identified. The association between treatment and the patient's clinical and nonclinical variables was analyzed using univariate and multivariate statistics. The 4-year survival rate was generated through Kaplan-Meier estimates, and multivariate Cox proportional hazard models were used to generate hazard ratios. Results: Among patients with early-stage cancer, the proportion receiving primary surgery increased (from 20% in 1985 to 33% in 2007), whereas the use of RT decreased from 64% to 52%. Patients with early-stage cancer who resided in areas with higher socioeconomic status (SES) zip codes, had private insurance, who were not African American, and who were treated at academic facilities were more likely to receive surgery. The 4-year survival rate for patients with early-stage laryngeal cancer treated with surgery was higher than the rate for those treated with RT (79% vs 71%). Among patients with advanced- stage cancer, the use of CRT increased from less than 7% to 45%, whereas the use of total laryngectomy decreased from 42% to 32%. The use of CRT was more common among patients who resided in areas with higher SES zip codes, had private insurance, and who were younger. The 4-year survival rates for patients with advanced laryngeal cancer treated with total laryngectomy, CRT, and RT were 51%, 48%, and 38%, respectively. Factors associated with an increased risk of death from advanced laryngeal cancer included receiving CRT and race/ethnicity. Conclusions: Among patients with early-stage laryngeal cancer, we observed an increasing proportion of primary surgical therapy during this study period. Among patients with advanced-stage cancer, we observed an increasing proportion of CRT. Not only were clinical factors associated with type of treatment, but select sociodemographic elements were also associated with treatment. Further investigation as to the decision-making process of patients with different sociodemographic backgrounds will assist in mitigating the differences in survival for this group of patients. [ABSTRACT FROM AUTHOR]

Objective: To assess relationships between voice satisfaction and global quality of life in patients who have been treated for laryngeal cancer. Design: Cross-sectional survey study. Setting: Veterans Affairs Medical Center. Patients: Eighty patients who had completed treatment for laryngeal cancer with either total laryngectomy (n=17), radiotherapy (n=24), or both (n=39). Main Outcome Measures: Subscale scores on a general health status instrument (the Medical Outcomes Study 36-item short-form health survey), and a validated voice-specific functional status instrument (the Voice Handicap Index). Results: Self-rated global health did not correlate significantly with emotional, functional, or physical voice handicap, although some subscales on the 36-item short-form health survey correlated with voice handicap scores. Global health status scores did not differ between patients who had undergone laryngectomy with a tracheoesophageal puncture and patients treated with radiotherapy only. Physical voice handicap scores did not differ significantly between those who underwent tracheoesophageal puncture and those who had radiotherapy, but emotional (P=.07) and functional (P=.01) handicap scores were lower in patients treated with radiotherapy. However, there was considerable overlap in voice handicap scores, with many patients who had had tracheoesophageal puncture showing less voice handicap than patients treated with radiotherapy. Conclusions: These data demonstrate that health status is affected by other factors than voice handicap in patients with laryngeal cancer. In addition, there is a large amount of individual variation in voice handicap after treatment. These findings illustrate the need for prospective studies assessing voice handicap and quality of life after treatment for laryngeal cancer. [ABSTRACT FROM AUTHOR]

Importance: The factors that contribute to gender discrepancies among attending head and neck surgeons have yet to be fully characterized., Objective: To evaluate the association of gender difference with the perceived quality of life of head and neck oncological surgeons., Design, Setting, and Participants: Following approval from the American Head and Neck Society (AHNS) review board, a web-based survey study of 37 questions, mainly assessing daily lifestyle and quality of life, was sent to the entire membership., Main Outcomes and Measures: The main outcome assessed was perceived quality of life among female and male surgeons., Results: A total of 261 members (13.0%) responded, 71 women (27.2%) and 190 men (72.8%). In all, 66 female (92.5%) and 152 male (80%) surgeons worked at an academic institution. A greater percentage of women were at the associate professor level than men (20/64 [31%] vs 37/152 [24%]; difference, 6.9%; 95% CI, -5.6% to 20.5%) and a greater percentage of men were at the professor level than women (72/152 [47%] vs 18/64 [28%]; difference, 19%; 95% CI, 4.9% to 31.6%). This discrepancy was evident in administrative roles as well, with 4 female (6.2%) vs 23 male (17.6%) department chairs (difference, 11.3%; 95% CI, 0.9%-19.6%). Of the 71 women, 18 (25%) were not in a long-term relationship or were divorced, as opposed to 6 (3.2%) men (difference, 22%; 95% CI, 12.8%-33.5%). Women had a mean (median) 1.18 (1) children, whereas men had 2.29 (2) children. Mean age that participating women had their first child was 35.1 years, whereas the man age for men was 31.9 years. Overall, 117 men (61.9%) and 45 women (67.2%) found their family time limited compared with other otolaryngological subspecialties. Despite these results, 101 men (53.4%) vs 37 women (55.2%) stated that they had a good work-life balance. Six women vs 8 men indicated they would choose a different subspecialty if they could., Conclusions and Relevance: Despite improvements in work hours and gender balance in residency programs, discrepancy in the number of female surgeons with senior academic rankings continues. However, female and male head and neck surgeons appear equally content with their subspecialty choice.

Importance: Medullary thyroid cancer (MTC) is a relatively rare neoplasm of the thyroid but accounts for 14% of thyroid cancer-related deaths. Female sex, young age, and stage at presentation have been found to predict survival and treatment. However, patterns of survival and treatment by socioeconomic status and race/ethnicity have not been fully described., Objective: To determine whether socioeconomic status and race/ethnicity are associated with survival and treatment in patients with MTC., Design, Setting, and Participants: Data for 1647 patients with MTC from January 1, 1998, to December 31, 2011, in the Surveillance, Epidemiology, and End Results (SEER) Program registry were examined. Data analysis was conducted from June 1, 2013, to July 31, 2014., Main Outcomes and Measures: Differences in receipt of thyroidectomy and lymph node examination by race/ethnicity were examined using logistic regression models. Overall and disease-specific survival were examined by race/ethnicity using Kaplan-Meier survival curves and adjusted Cox proportional hazards regression models., Results: Of the 1647 patients with MTC were 1192 white (72.4%), 139 black (8.4%), 222 Hispanic (13.5%), and 94 other races/ethnicities (5.7%). Of these, 1539 (93.4%) underwent surgical treatment. There were no differences in receipt of thyroidectomy by race/ethnicity; however, black patients (adjusted odds ratio, 0.61; 95% CI, 0.39-0.93) and female patients (adjusted odds ratio, 0.76; 95% CI, 0.59-0.99) were less likely to undergo lymph node examination compared with non-Hispanic white and male patients. Black patients had lower overall (adjusted hazard ratio, 2.40; 95% CI, 1.45-3.98) and disease-specific survival (adjusted hazard ratio, 2.9; 95% CI, 1.64-5.14) compared with non-Hispanic white patients., Conclusions and Revelance: In this population-based study of patients with MTC, black patients were less likely to have lymph node examination following surgery. Furthermore, Hispanic and black patients had poorer overall and disease-specific survival compared with non-Hispanic white patients after accounting for clinical factors. Racial/ethnic disparities exist in the type of treatment as well as outcomes in patients with MTC.

Importance: Previous studies of prognostic factors of carcinoma of the minor salivary gland (MSG) have been limited to single-institution studies and small case series. Thus, limited data are available to guide the head and neck oncologist in counseling patients on the prognosis and management of these malignant neoplasms., Objective: To examine 5- and 10-year cause-specific survival (CSS) rates of MSG carcinomas across all histologic subtypes and head and neck tumor subsites., Design, Setting, and Patients: Retrospective, population-based study using National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) data from January 1, 1988, through December 31, 2009. The study included 5334 patients diagnosed as having MSG carcinoma and registered in the SEER database. Patients without follow-up, diagnostic confirmation, and/or race designation were excluded from the analysis (131 [2.4%]). Final follow-up was completed on December 31, 2009, and data were analyzed from August 5, 2013, to July 1, 2014., Main Outcomes and Measures: Five- and 10-year CSS rates for US patients with MSG carcinoma. Cox proportional hazard models were used to estimate adjusted hazard ratios (HRs) and 95% CIs., Results: Among the 5334 patients with MSG carcinoma included, the most common histologic subtypes included mucoepidermoid carcinoma (1568 [29.4%]), adenoid cystic carcinoma (1228 [23.0%]), and adenocarcinoma (1313 [24.6%]). The most frequent sites of primary tumor were the oral cavity (3132 [58.7%]) and pharynx (1130 [21.2%]). Five-year CSS rate was significantly worse for MSG malignant neoplasms located in the larynx (HR, 2.42; 95% CI, 1.67-3.50) and nasal cavity and/or paranasal sinus (HR, 1.73; 95% CI, 1.29-2.32). Being older than 75 years was associated with a significantly worse 5-year CSS rate (HR, 2.88; 95% CI, 2.05-4.06). Compared with no surgery, local tumor destruction (HR, 0.44; 95% CI, 0.30-0.64), partial surgery (HR, 0.33; 95% CI, 0.23-0.47), and total surgery (HR, 0.55; 95% CI, 0.41-0.74) were each found to be a significant positive prognostic factor. No differences were observed in the 5-year hazard of death for race/ethnicity, sex, diagnosis year, or socioeconomic status, and 10-year adjusted HRs were similar to the 5-year patterns., Conclusions and Relevance: This study, to date, represents the largest US survival analysis of carcinoma of the MSG. Prognosis is associated with histologic subtype, tumor subsite, age at diagnosis, grade, and surgical therapy.

Importance: Cost containment is at the forefront of responsible health care delivery. One way to decrease costs is to decrease hospital length of stay (LOS). Data are lacking on factors contributing to LOS in patients with head and neck cancer (HNC) undergoing fibular free-tissue reconstruction (FFTR) of head and neck defects., Objective: To identify factors contributing to increased LOS following FFTR of head and neck defects in patients with HNC using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) methodology., Design: Retrospective medical record review, with reference to the ACS NSQIP form, of 30 consecutive patients with HNC undergoing FFTR of head and neck defects in a single tertiary academic institution from July 2013 through June 2014. Data were collected on demographic and tumor characteristics, preoperative risk factors, operative variables, and postoperative adverse events., Main Outcomes and Measures: Factors associated with increased hospital LOS., Results: Median LOS was 10 days (range, 8-31 days), and patients were divided into 2 groups (LOS, ≤ 10 days [n = 16]; and LOS, >10 days [n = 14]). There were no significant differences in demographics, tumor characteristics, or preoperative medical comorbidities between the 2 groups. Univariate analysis demonstrated that operative time, ventilator dependence, wound event, and altered mental status were associated with longer LOS. Multivariate analysis revealed significant association with LOS greater than 10 days for operative time of longer than 11 hours (odds ratio [OR], 7.26; 95% CI, 1.12-47.29; P = .04) and ventilator dependence for more than 48 hours postoperatively (OR, 12.05; 95% CI, 1.06-137.43; P = .045)., Conclusions and Relevance: Evaluated by the ACS NSQIP criteria, FFTR of head and neck defects in patients with HNC was associated with LOS longer than 10 days for procedures lasting longer than 11 hours and for patients who are ventilator dependent for more than 48 hours.

Objective: To investigate whether patients treated with laryngectomy had less comorbidity than those treated with chemoradiation, which could help explain the improved survival for the laryngectomy cohorts in recent studies., Design: Observational cross-sectional study., Patients: Patients receiving diagnoses of primary invasive advanced squamous cell carcinoma of the larynx between 2003 and 2008 were selected from the National Cancer Database, which collects information from more than 1400 facilities accredited by the American College of Surgeons' Commission on Cancer. Patient-level independent variables included age at diagnosis, sex, diagnosis year, race/ethnicity, primary payer status, and zip code-level education., Main Outcome Measures: Primary treatment information. The association between treatment and patient clinical, sociodemographic, and facility-level and zip code-level socioeconomic status variables were analyzed using univariate statistics and multivariate models. Charlson Deyo Comorbidity and The Washington University Head and Neck Comorbidity Index scores were calculated from the hospital face sheet., Results: The study demonstrated that receipt of treatment (chemoradiation vs total laryngectomy) was significantly associated with comorbidity. Treatment was not significantly associated with insurance status, race/ethnicity, or age. Patients with comorbidity were less likely to receive chemoradiation than subtotal or total laryngectomy, with a risk ratio (RR) of 0.84 (95% CI, 0.81-0.87) for patients with 1 or more comorbidities compared with those without any comorbidity, after controlling for factors such as tumor stage, age, race/ethnicity, insurance, and socioeconomic status. Patients were also less likely to receive chemoradiation than total laryngectomy if they had stage IV disease (RR, 0.81; 95% CI, 0.79-0.83) and if they had been diagnosed at a teaching or research institution (RR, 0.80; 95% CI, 0.77-0.84). Patients were more likely to receive chemoradiation if they were diagnosed after 2003 (RR, 1.37; 95% CI, 1.30-1.45) or if they lived in a zip code with a high percentage of high school graduates (RR, 1.1; 95% CI, 1.05-1.15)., Conclusions: This is the first study, to our knowledge, that demonstrates that patients with advanced laryngeal cancer with 1 or more comorbidities are more likely to receive surgery than chemoradiation compared with patients without any comorbidity, independent of numerous clinical and nonclinical variables among a large national cohort. A limitation of this study is the use of comorbidity data from the National Cancer Database, which gathers its information from hospital discharge face sheets. We recognize that the National Cancer Database may be an imperfect system for the collection of comorbidity data and encourage discussion on different methods to improve the system, including incorporating comorbidity data from the Surveillance, Epidemiology, and End Results Medicare Database and medical chart-based comorbidity data collection by cancer registrars.

Objective: To describe trends in mortality rates for patients with oral cavity and pharynx cancer by educational attainment, race/ethnicity, sex, and association with human papillomavirus infection., Design: Study of age-standardized mortality rates for patients with oral cavity and pharynx cancer by level of education using National Center for Health Statistics data., Setting: Twenty-six states., Patients: White and black men and women aged 25 to 64 years., Main Outcome Measure: Age-standardized mortality rates for 2005 to 2007 and trends for 1993 to 2007., Results: From 1993 to 2007, overall mortality rates for patients with oral cavity and pharynx cancer decreased among black and white men and women; however, rates among white men have stabilized since 1999. The largest decreases in mortality rates were among black men and women with 12 years of education (-4.95% and -3.72%, respectively). Mortality rates for patients with oral cavity and pharynx cancers decreased significantly among men and women with more than 12 years of education, regardless of race/ethnicity (except for black women), whereas rates increased among white men with less than 12 years of education. Mortality trends vary substantially for human papillomavirus-related and human papillomavirus-unrelated sites., Conclusions: We observed decreasing mortality rates for patients with oral cavity and pharyngeal cancer among whites and blacks; however, decreases were greatest among those with at least 12 years of education. This difference in mortality trends may reflect the changing prevalence of smoking and sexual behaviors among populations of different educational attainment.

Objective: To describe trends and 4-year survival rate of surgical and nonsurgical treatment for laryngeal cancer., Design: Observational cross-sectional study., Patients: A total of 131 694 cases of laryngeal cancer diagnosed from 1985 to 2007 identified from the National Cancer Database., Main Outcome Measures: Primary treatment information, including radiation therapy (RT), chemoradiation (CRT), and curative intent surgery, were identified. The association between treatment and the patient's clinical and nonclinical variables was analyzed using univariate and multivariate statistics. The 4-year survival rate was generated through Kaplan-Meier estimates, and multivariate Cox proportional hazard models were used to generate hazard ratios., Results: Among patients with early-stage cancer, the proportion receiving primary surgery increased (from 20% in 1985 to 33% in 2007), whereas the use of RT decreased from 64% to 52%. Patients with early-stage cancer who resided in areas with higher socioeconomic status (SES) zip codes, had private insurance, who were not African American, and who were treated at academic facilities were more likely to receive surgery. The 4-year survival rate for patients with early-stage laryngeal cancer treated with surgery was higher than the rate for those treated with RT (79% vs 71%). Among patients with advanced-stage cancer, the use of CRT increased from less than 7% to 45%, whereas the use of total laryngectomy decreased from 42% to 32%. The use of CRT was more common among patients who resided in areas with higher SES zip codes, had private insurance, and who were younger. The 4-year survival rates for patients with advanced laryngeal cancer treated with total laryngectomy, CRT, and RT were 51%, 48%, and 38%, respectively. Factors associated with an increased risk of death from advanced laryngeal cancer included receiving CRT and race/ethnicity., Conclusions: Among patients with early-stage laryngeal cancer, we observed an increasing proportion of primary surgical therapy during this study period. Among patients with advanced-stage cancer, we observed an increasing proportion of CRT. Not only were clinical factors associated with type of treatment, but select sociodemographic elements were also associated with treatment. Further investigation as to the decision-making process of patients with different sociodemographic backgrounds will assist in mitigating the differences in survival for this group of patients.