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Impact of comorbidities on perioperative outcomes for carcinoma of oral cavity
Abstract
Introduction:
Surgical management of oral cavity carcinoma involves composite resection with reconstruction. Comorbidities increase the risk of perioperative complications. Objective stratification is important for uneventful recovery. The Charlson Comorbidity Index and the Washington University Head and Neck Comorbidity Index were used to assess perioperative morbidity and mortality.
Materials and methods:
This was a prospective study of 531 patients with head and neck squamous cell carcinoma who were treated between January 2014 and December 2017. Patients' comorbidity scores on the Charlson Comorbidity Index and Washington University Head and Neck Comorbidity Index were recorded.
Results:
The median age of the cohort was 49 years. Median Charlson Comorbidity Index score was 3 and Washington University Head and Neck Comorbidity Index was 0. There were five mortalities with a Charlson Comorbidity Index score of 4 or more. Fifteen patients had either infection, leak or postoperative bleeding. A Charlson Comorbidity Index of 4 or more was associated with higher event rate and poor overall survival (p=0.001).
Conclusion:
Higher Charlson Comorbidity Index score is associated with increased incidence of peri-operative morbidity and mortality, while the Washington University Head and Neck Comorbidity Index is a poor predictor of the same.
... In contrast, other authors found poorer survival in older individuals. This fact has been associated with comorbidities, which usually limit treatment choices and enhance the likelihood of complications (16,17). Evidence also highlights the increasing association between HPV infection and oropharyngeal lesions in younger patients, with HPVpositive cancers presenting a better treatment response and survival than HPV-unrelated tumors (18). ...
... However, the presence of comorbidities has been reported as an important factor in assessing the survival of patients with oral cancer, as the time required to investigate and monitor these other diseases can lead to delay in antineoplastic treatment (30). In addition, depending on the type and severity of the comorbidity, therapeutic modalities such as surgical resection may be contraindicated, negatively impacting patient prognosis (17). The frequency of comorbidities was considered low in the sample studied. ...
Background:
This study aimed to evaluate sociodemographic and clinical factors influencing overall survival (OS) in patients with oral squamous cell carcinoma (OSCC).
Material and methods:
Medical charts of 547 patients with OSCC from a public hospital in northeastern Brazil seen between 1999 and 2013 were evaluated. Survival analysis was performed using the Kaplan-Meier method. The influence of age, sex, ethnicity, clinical stage, anatomical location, type of treatment, and comorbidities on the patients' prognosis was evaluated. Cox proportional hazards regression model was used to identify independent prognostic factors.
Results:
The 5-year OS was 39%. Multivariate analysis showed that age < 40 years (HR = 2.20; 95%CI: 1.02-4.72) and a single treatment modality (HR = 1.91; 95%CI: 1.37-2.67) were associated with a poor prognosis, while early clinical stage resulted in better outcomes (HR = 0.38; 95%CI: 0.25-0.58).
Conclusions:
OSCC patients in advanced clinical stages, diagnosed at a younger age, and submitted to a single therapeutic modality have a poorer prognosis.
... Oral squamous cell carcinoma (OSCC) is common malignant neoplasia with significant morbidity and mortality rates [1][2][3]. ...
... The survival rate of patients within 5 years after the diagnosis of OSCC is around 50% to 60% [4,5]. Therefore, the prevention and early diagnosis of this disease are the best alternatives so far [1,3,4,6,7]. ...
*FULL TEXT: https://rdcu.be/b57EZ*
OBJECTIVE: To perform an epidemiological survey comparing the cell proliferative activity of 107 cases of oral leukoplakia with their clinical and histopathological characteristics. MATERIALS AND METHODS: A cross-sectional, observational, and histological-histochemical study. The cases came from the Histopathological Diagnostic Service of UPF/RS and the School of Dentistry of Araçatuba FOA/UNESP/SP (1986–2016). The histopathological sections were stained using the silver staining (AgNOR) technique and the nuclei of 100 epithelial cells selected randomly were recorded to count the number of nucleolar organizer regions (NORs). The mean NORs per lesion were correlated to clinical and histological characteristics using ANOVA, at 5% significance. RESULTS: Most of the cases included men (62.62%), white (64.49%), and with an average age of 53.94 years. The most probable etiological factors were smoking (44.7%) and alcohol consumption (9.85%). The evolution time of most lesions was fast (33.65%), manifesting mainly in the form of plaques (70.37%) and without symptoms (58.88%). They were located mainly in the cheek mucosa (26.62%) and presented white color (66.35%), well-defined edges (59.81%), firm consistency (47.5%), and keratinized surface (49.53%). Etiological factor (p = 0.003), evolution time (p = 0.006), symptoms (p = 0.029), location (p = 0.020), consistency (p = 0.047), histopathological characteristics (p = 0.004), and superficial keratinization (p = 0.001) were statistically significant regarding the mean NORs of the leukoplakias studied. CLINICAL RELEVANCE: Oral leukoplakias caused by alcohol consumption and/or tobacco use, considering an evolution time of fewer than 12 months, asymptomatic, located in the lower lip or tongue, and with a firm consistency and increased superficial keratinization should be treated more aggressively by the clinician to avoid cancerization.
... Some studies showed that adding more years of comorbidity data improved mortality prediction [47,127], while another study suggested that including 6 years of prior comorbidity data produced optimal validity and reliability [128]. In practice, many studies have used shorter look-back intervals, such Oral cavity cancer [53] Laryngeal cancer [54] Gastric cancer [14] Colorectal cancer [12,13,[55][56][57] Pancreatic cancer [15,58] Ovarian cancer [16,17] Endometrial cancer [18] Kidney cancer [18,59] Prostate cancer [20, [60][61][62] Bladder cancer [63][64][65][66] Urological cancer [31] Acute myeloid leukemia [67,68] Hodgkin's lymphoma [69] Nephrology/Urology Dialysis [23, 70] Diabetic nephropathy [71] Hyponatremia [72] Acute kidney injury [73] Benign prostate hyperplasia [74,75] Renal stone [76] Infectious disease Human immunodeficiency virus (HIV) infection [77] Community-acquired pneumonia [78,79] Coronavirus disease (COVID) [80,81] Orthopedic/Trauma Hip fracture [22,82-85] ...
The number of large-scale epidemiological studies using administrative databases has rapidly increased in recent years. However, in observational studies, the outcomes of interest are heavily influenced by concurrent or pre-existing comorbidities, which act as confounders, and appropriate adjustment of comorbidities is essential to minimize bias. Although several comorbidity indices are available for this purpose, Charlson comorbidity index (CCI) is the most widely used one. The original version of the CCI was developed for use in longitudinal studies, to classify comorbidities that might alter the risk of mortality. It included 19 comorbidities, with each comorbidity having an assigned weight from 1 to 6; the total CCI score is a simple sum of the weights. Although the original CCI was based on a review of medical records, many modified versions have been proposed in subsequent studies using claims data. The CCI and its modified versions are used in virtually all clinical settings, including oncology, cardiology, respiratory care, emergency care, surgery, intensive care, and geriatrics. Appropriate use of a comorbidity index, such as the CCI, is necessary to minimize bias in observational studies in the era of increasing use of administrative data for healthcare research.
... This may lead to poorer outcomes despite the potential for longer survival. Older patients with OSCC often face additional challenges due to comorbid conditions, which can complicate treatment and lead to poorer outcomes(46). Moreover, the concept of "time to cure" underscores the potentially longer and more complex treatment journey for older adults(32). ...
Introduction
Oral cavity cancer (OCC), primarily oral squamous cell carcinoma (OSCC), is a growing concern in Europe, particularly among younger populations. Preventable lifestyle factors and social determinants of health contribute significantly to the disease burden. Limited access to healthcare and delayed diagnoses further complicate treatment and reduce survival rates.
Methods
This systematic literature review adhered to PRISMA guidelines to explore trends in OSCC epidemiology, etiology, diagnosis, treatment, and survival across Europe. A comprehensive search strategy using PubMed, GLOBOCAN data, and the EUROCARE-5 study identified relevant articles focusing on human populations in Europe with a primary interest in OSCC epidemiology. Only peer-reviewed publications in English with full-text access were included.
Results
This study investigated the burden of OSCC across Europe, revealing variations in incidence, mortality, and prognosis. Eastern and Central Europe displayed the highest burden. Males exhibited a significantly higher risk compared to females. Age-related disparities existed in life expectancy and time to achieve favorable outcomes. HPV emerged as a growing risk factor for oropharyngeal cancer. Public health strategies should target modifiable risk factors and improve early detection.
Conclusion
This review reveals concerning disparities in European OSCC. Region, sex, and age all influence burden and prognosis. Future research should focus on controlling risk factors and personalized medicine to optimize treatment. This will lead to a Europe with reduced OSCC incidence and demonstrably better patient outcomes.
... Additionally, patients who had undergone elective tracheostomy scored higher in their Charleson score as our multivariate models suggests ( Table 3). As Katna et al. display, patients with cardiovascular predisposition and poor vessel status who scored high in CCI presented a higher perioperative event rate, moderating microvascular flap success [39]. ...
Elective tracheotomy (ET) secures the airway and prevents adverse airway-related events as unplanned secondary tracheotomy (UT), prolonged ventilation (PPV) or nosocomial infection. The primary objective of this study was to identify factors predisposing for airway complications after reconstructive lower ja surgery. We reviewed records of patients undergoing mandibulectomy and microvascular bone reconstruction (n = 123). Epidemiological factors, modus of tracheotomy regarding ET and UT, postoperative ventilation time and occurrence of hospital-acquired pneumonia HAP were recorded. Predictors for PPV and HAP, ET and UT were identified. A total of 82 (66.7%) patients underwent tracheotomy of which 12 (14.6%) were performed as UT. A total of 52 (42.3%) patients presented PPV, while 19 (15.4%) developed HAP. Increased operation time (OR 1.004, p = 0.005) and a difficult airway (OR 2.869, p = 0.02) were predictors, while ET reduced incidence of PPV (OR 0.054, p = 0.006). A difficult airway (OR 4.711, p = 0.03) and postoperative delirium (OR 6.761, p = 0.01) increased UT performance. HAP increased with anesthesia induction time (OR 1.268, p = 0.001) and length in ICU (OR 1.039, p = 0.009) while decreasing in ET group (HR 0.32, p = 0.02). OR for ET increased with mounting CCI (OR 1.462, p = 0.002) and preoperative radiotherapy (OR 2.8, p = 0.018). ET should be strongly considered in patients with increased CCI, preoperative radiotherapy and prolonged operation time. ET shortened postoperative ventilation time and reduced HAP.
... The CCI predicted inhospital mortality in 279 patients after surgery for colorectal carcinoma [21]. In 531 postoperative patients with oral cavity cancer, the CCI predicted in-hospital mortality [222]. In 8,080 dementia patients after hip fracture surgery, the CCI predicted in-hospital mortality especially in the oldest [223]. ...
The present critical review was conducted to evaluate the clinimetric properties of the Charlson Comorbidity Index (CCI), an assessment tool designed specifically to predict long-term mortality, with regard to its reliability, concurrent validity, sensitivity, incremental and predictive validity. The original version of the CCI has been adapted for use with different sources of data, ICD-9 and ICD-10 codes. The inter-rater reliability of the CCI was found to be excellent, with extremely high agreement between self-report and medical charts. The CCI has also been shown either to have concurrent validity with a number of other prognostic scales or to result in concordant predictions. Importantly, the clinimetric sensitivity of the CCI has been demonstrated in a variety of medical conditions, with stepwise increases in the CCI associated with stepwise increases in mortality. The CCI is also characterized by the clinimetric property of incremental validity, whereby adding the CCI to other measures increases the overall predictive accuracy. It has been shown to predict long-term mortality in different clinical populations, including medical, surgical, intensive care unit (ICU), trauma, and cancer patients. It may also predict in-hospital mortality, although in some instances, such as ICU or trauma patients, the CCI did not perform as well as other instruments designed specifically for that purpose. The CCI thus appears to be clinically useful not only to provide a valid assessment of the patient’s unique clinical situation, but also to demarcate major diagnostic and prognostic differences among subgroups of patients sharing the same medical diagnosis.
... Serletti et al. [13], in their series of 104 free flap procedures in patients aged ≥ 65 years, observed that free flaps in elderly patients had similar success rate to those of the general population and concluded that age alone should not be considered a risk factor. Other authors have also concluded that pre-existing co-morbidities and general condition of the patient, not chronological age, are more significant for free flap complications [14][15][16][17], (our comorbidity paper). Yet some authors have described age to be an individual risk factor [18,19]. ...
Head and neck cancers are one of the leading causes of morbidity and mortality in Indian population. Reconstruction and restoration of function are also of paramount importance in these patients. The aim of this study was to report outcomes for free flaps and pedicle flaps in patients with oral cavity cancers. A retrospective analysis of 628 patients with oral cavity cancers who underwent reconstruction with either free flaps or pedicle flaps during 2014–2020 was done. The median age of the cohort was 49 years. The free flap reconstruction was performed in 481 (76%) and pedicle flap in 147 (24%) patients. Among free and pedicle flaps, 27 (5.6%) and 3 (2.1%) respectively had major flap complications and 25 (5.1%) and 14 (9.9%) respectively had minor complications. CCI score > 4 was associated with higher events (p = 0.02) in free flap group. The outcomes of free flaps are similar in comparison to pedicle flaps in patients with oral cavity cancers. The higher CCI score is significantly associated with increased flap-related complications for the free flap group.
... CCI score is one of the commonly used scoring system to assess comorbidity in patients preoperatively and has been validated by the authors as a predictor of perioperative outcomes in head and neck cancer patients. 7 The comorbidity variables pertaining to the CCI score were obtained for all patients from their record file. All patients were evaluated preoperatively and stratified according to ASA score, which is routinely used by anesthesiologists to grade patients at risk in operating rooms. ...
Introduction
Microvascular reconstruction is the gold standard for reconstruction in oral cavity cancers. Age and comorbidities determine the type of reconstruction. We aimed to analyse the impact of high-risk comorbidities on perioperative morbidity.
Methods
This is a retrospective study of 317 patients undergoing microvascular reconstruction from January 2014 to December 2017. High risk patients were based on age, American Society of Anaesthesiologists (ASA) grade (III/IV) and Charlson comorbidity index (CCI) score >4; overall, 73 out of 317 patients were evaluated.
Results
Median age was 59 years. Five patients (6.8%) had complete flap failures and seven (9.5%) had minor complications (wound breakdown, bleeding, wound dehiscence, partial flap loss). ASA score of IV was significantly associated with morbidity while age >65 years and CCI >4 was not associated. The overall flap success rate was 93.2%.
Conclusions
A high-risk population has nearly similar outcomes for microvascular reconstruction as a younger age group. High ASA score adversely affects surgery-related outcomes.
... sixth most common (1), accounting for over 90% of all oral cancers (2). In India, owing to the socioeconomic standards, around 77,000 cases are diagnosed every year in advanced stages (3). OSCC prognosis turns abysmal because of its late detection at a stage where local and distant metastasis has already occurred. ...
The 5‐year survival rates in OSCC depends on the stage at diagnosis. Patients have better survival and favorable outcomes if detected early, as compared to those diagnosed in advanced stages. Apart from biopsy and mucosal scraping examinations, exosomes from saliva and blood are emerging as an accessible source for diagnosis and providing additional information about the tumor’s characteristics. Hence, the study of tumors‐derived exosomal (TEX) biomarkers obtained from a liquid biopsy is emerging as a promising diagnostic tool.In this systematic review our effort is to assess the role of TEX as a biomarker.
Objective
The objective of the study was to develop a nomogram for the prediction of length of hospital stay (LOS) in patients undergoing oral cavity cancer surgery.
Background
LOS is an important indicator of patient recovery and healthcare resource utilization in OSCS. Several factors influence LOS, including patient-related, disease-related, and healthcare system-related factors.
Methods
We retrospectively analyzed data from 874 OSCS patients treated at our institution between 2016 and 2020. Multivariate logistic regression was used to identify factors associated with LOS of more than 7 days. A nomogram was developed based on the significant factors.
Results
The following factors were significantly associated with longer LOS: advanced tumor stage (odds ratio [OR] = 3.21, P < 0.001), type of reconstruction (free flap: OR = 2.43, P < 0.001; regional flap: OR = 1.82, P = 0.002), ASA grade ≥3 (OR = 1.67, P = 0.002), and extensive primary surgery (OR = 1.53, P = 0.012). The nomogram showed good discrimination, with an area under the receiver operating characteristic curve of 0.699.
Conclusion
The nomogram developed in this study can be used to predict LOS in OSCS patients, which may help to optimize resource allocation and improve patient care.
Introduction
The present study aimed to calculate the burden of oral cavity cancer (OCC) including incidence, mortality rate, survival rate, and influence of predictive factors such as clinicopathological, demographic findings, and treatment modalities.
Materials and Methods
Data in this retrospective study were collected from India’s population-based cancer registry (PBCR) from 2010 to 2016. A total of 1051 cases of OCC were noted. Incidence and mortality rates were calculated. The cumulative survival outcome was calculated using Kaplan–Meier (KM) method. Prognostic factors were estimated using the Cox proportional hazard regression model.
Results
The age-standardized incidence rates (ASR), and mortality rate (ASMR), of overall OCC cases were 10.1 and 8.4 per 100 thousand population, respectively. Five-year overall survival (OS) was 32.3%. Survival outcome was significantly associated with the given treatment (Chi-square value = 58.17, P = 0.0001) and anatomical site (Chi-square value = 26.70, P = 0.0001). 17.6% of cases in males were <39-year age group. The hazard ratio (HR) in the age group of >50 years was 2.065 (95% CI 1.34-3.18, P = 0.001). Combination therapy had an HR of 2.630 (95% CI 1.91-3.63, P value 0.000). Tonsillar carcinoma (C09) (95% CI 1.04-3.12) had 1.8 times more chances of death than lip carcinoma (C00).
Conclusion
OCC cases are increasing in the younger population, and overall, cases show higher mortality rates with reduced survival outcomes. Prognostic factors such as age >50 years, single modality treatment, and alveolar and tonsillar malignancy are associated with poor survival. OCC robust screening by a trained health professional can improve early detection and increases awareness and lower mortality of the disease.
Background: A decision tree is a popular predictive modeling technique used to classify observations based on their properties and can also be used for numeric or categorical predictions. A logistic regression model estimates the relationship between a dependent categorical variable and one or more independent variables.
Objective: To compare the performances of logistic regression and decision tree models for predicting mortality in patients with oral cavity cancer.
Materials and Methods: This was a retrospective study on de-identified records of patients with oral cavity cancer who received treatment at Jawaharlal Institute of Post Graduate Medical Education and Research, a tertiary healthcare hospital in Puducherry, South India, from 2011 to 2017. The models were built by incorporating potential predictive variables such as stage of the cancer, tumor and node categories, and margin status. The performances of the classification models were compared using sensitivity, specificity, predictive accuracy, and by plotting the area under the receiver operating characteristic (ROC) curves.
Results: Among the 427 patients who received treatment for oral cavity cancer between 2011 and 2017, we included 275 who had undergone surgery and whose histopathology details were available. There were 180 (65.5%) male patients. The median age was 55 years (range, 26-87). The tumor stage and margin status of the cancer were found to be significant predictors of mortality in a multiple logistic regression model. The predictive accuracies and the areas under the ROC curves of logistic regression and decision tree models were found to be similar.
Conclusion: A decision tree method along with other machine learning algorithms could be an innovative alternative to statistical models for the prediction of outcomes when the assumptions of these models fail. The application of these machine learning algorithms can help risk stratify patients with oral cavity cancer and thus aid in their treatment planning.
Introduction:
Reconstruction of a surgical defect is an important part of the management of oral cancers. Microvascular free flap construction provides better functional and cosmetic outcomes.
Methods:
Between 2014 and 2020, some 524 patients underwent microvascular reconstruction. Comorbidity variables were scored using the Charlson Comorbidity Index (CCI). Complications were recorded using Clavien-Dindo criteria.
Results:
Eighty-three (15.84%), 339 (64.69%) and 102 (19.47%) patients underwent free radial forearm flap, free anterolateral thigh flap and free fibula osteocutaneous flap (FFOCF), respectively. Clavien-Dindo complications of grade III and above were seen in 39 (7.44%) patients. Total flap loss was seen in 18 patients and of these, 16 were salvaged using alternative free flaps or pedicled flaps. On univariate analysis, overall and major complication rates were higher in FFOCF (p=0.171). Major complications significantly more common in patients with a CCI score >4 (p=0.001). Patients aged >65 years had higher rates of complications (p=0.03).
Conclusion:
Microvascular free tissue transfer is a reliable, safe and gold standard modality in surgical reconstruction and can be replicated in non-institutional settings.
Background: Free flap reconstruction in the head and neck region is a complex
field in which patient comorbidities, radiation therapy, tumor recurrence, and
variability of clinical scenarios make some cases particularly challenging and prone
to devastating complications. Despite low free flap failure rates, the impact of flap
failure has enormous consequences for the patients.
Methods: Acknowledging and predicting high risk intra- and postoperative situations
and having planned strategies on how to deal with them can decrease their
rate and improve the patient’s reconstructive journey.
Results: Herein, the authors present 4 examples of significant complications in
complex microvascular head and neck cancer reconstruction, encountered for the
last 10 years: compression and kinking of the vascular pedicle, lack of planning of
external skin coverage in osteoradionecrosis, management of the vessel-depleted
neck, and vascular donor site morbidity after fibula harvest.
Conclusion: The authors reflect on the causes and propose preventative strategies
in each peri-operative stage.
Background
The presence of comorbidities may play an important role in the way treatment plans are developed for management of cancer. The aim of this study was to investigate the prevalence and impact of comorbidities in a retrospective nationwide population-based study of patients with oral cavity cancers.
Material and methods
A total of 16,676 oral cavity cancer patients diagnosed in the period 2007–2010 were identified through the Taiwan Cancer Registry database. By linking this data set to the National Health Insurance Research Database and the death registry, information on comorbidity and cause of death was obtained and adapted to the Charlson’s comorbidity index. The influence of comorbidity on overall survival and cancer-related death was evaluated by Kaplan–Meier estimates and Cox regressions.
Results
In total, 21.3% of patients had some comorbidity during the year before cancer diagnosis. Diabetes mellitus was found to be the most common comorbidity (10%). Methods of management were significantly different in patients with stages 2, 3 and 4 of the disease. Those with severe comorbidity conditions received less surgical interventions (5–13%) compared with the patients without any comorbidity. Differences in the survival rates were only significant in all-cause death, but not in cancer-related death in the early stages (stages 1 and 2). Two-year survival rates for patients with severe comorbidity conditions were lower by 10–22% given the same stage of disease and treatment modality.
Conclusion
The survival rates of oral cancer patients in early stages are lower in patients with comorbidity conditions and this may be due to the less aggressive cancer treatment offered to this group of patients. Comorbidities affect the decision on cancer treatment modality and thereby outcomes.
Head and neck cancers (HNCs) are the most common malignancies worldwide. Asian populations bear major burden of this disease, with certain unique characteristics. Although significant research in HNCs is ongoing globally, many clinical issues still remain unanswered. We performed a literature search to find noteworthy Indian studies that changed practice of HNC as well as to look for areas for further research in this field. Many randomized controlled trials as well as large patient series are reported in the field of radiotherapy, chemotherapy, and surgical management of HNC. Still, many areas such as palliative therapy, targeted agents, and newer chemotherapeutic agents remain unexplored. Planned collaborative research is need of the hour to provide more evidenced based.
Tobacco use is a well-established risk factor for cancers of the lung, head and neck, nasopharynx, esophagus, stomach, pancreas, liver, kidney, bladder, leukemia, and cervix. Alcohol consumption is a well-established risk factor for cancers of the head and neck, esophagus, liver, colorectum, and breast for women only. The majority of studies on tobacco and alcohol were conducted in high-income countries (HICs).
The aim of this review was to assess the extent of tobacco and alcohol usage and to compare the cancer burden between low- and high-income regions.
Overall, tobacco smoking is estimated to account for 21% of cancer deaths worldwide (29% in HICs and 18% in low- and middle-income countries [LMICs]). Alcohol consumption is estimated to account for 5% of all cancer deaths worldwide, with similar proportions in LMICs. Cancers of the breast, lung, stomach, liver, head and neck, esophagus, cervix, and nasopharynx, and leukemia are already diagnosed in greater numbers each year in less-developed countries compared with more developed countries. The future burden of tobacco- and alcohol-related cancers on less-developed regions is expected to increase greatly based on demographic effects, with a 69.9% increase in tobacco-related cancer cases and a 68% increase in cancers related to alcohol. Although HICs have experienced a decrease in tobacco prevalence in recent decades, LMICs are still in the early stages of the tobacco epidemic.
Tobacco use and alcohol consumption will clearly remain important risk factors that must be targeted with public health efforts particularly in LMICs.
Copyright © 2014 Icahn School of Medicine at Mount Sinai. Published by Elsevier Inc. All rights reserved.
A number of studies have shown poorer survival among cancer patients with comorbidity. Several mechanisms may underlie this finding. In this review we summarize the current literature on the association between patient comorbidity and cancer prognosis. Prognostic factors examined include tumor biology, diagnosis, treatment, clinical quality, and adherence.
All English-language articles published during 2002-2012 on the association between comorbidity and survival among patients with colon cancer, breast cancer, and lung cancer were identified from PubMed, MEDLINE and Embase. Titles and abstracts were reviewed to identify eligible studies and their main results were then extracted.
Our search yielded more than 2,500 articles related to comorbidity and cancer, but few investigated the prognostic impact of comorbidity as a primary aim. Most studies found that cancer patients with comorbidity had poorer survival than those without comorbidity, with 5-year mortality hazard ratios ranging from 1.1 to 5.8. Few studies examined the influence of specific chronic conditions. In general, comorbidity does not appear to be associated with more aggressive types of cancer or other differences in tumor biology. Presence of specific severe comorbidities or psychiatric disorders were found to be associated with delayed cancer diagnosis in some studies, while chronic diseases requiring regular medical visits were associated with earlier cancer detection in others. Another finding was that patients with comorbidity do not receive standard cancer treatments such as surgery, chemotherapy, and radiation therapy as often as patients without comorbidity, and their chance of completing a course of cancer treatment is lower. Postoperative complications and mortality are higher in patients with comorbidity. It is unclear from the literature whether the apparent undertreatment reflects appropriate consideration of greater toxicity risk, poorer clinical quality, patient preferences, or poor adherence among patients with comorbidity.
Despite increasing recognition of the importance of comorbid illnesses among cancer patients, major challenges remain. Both treatment effectiveness and compliance appear compromised among cancer patients with comorbidity. Data on clinical quality is limited.
To validate the prognostic ability of the Washington University Head and Neck Comorbidity Index (WUHNCI) relative to 5-year survival in a cohort of older patients with head and neck cancer and to compare it with that of the Adult Comorbidity Evaluation 27 (ACE-27).
Validation study.
Academic research.
Three hundred twenty-one patients older than 70 years with head and neck cancer in a tertiary cancer center. Comorbidity was measured using the ACE-27, WUHNCI, and National Cancer Institute (NCI) comorbidity index.
Five-year overall survival.
Five-year overall and cancer-specific survival, respectively, were as follows: Using the WUHNCI, 52.2% and 62.9% for a score of 0; 25.1% and 41.7% for a score of 1; 39.3% and 64.9% for a score of 2; and 19.5% and 45.0% for a score of 3 or higher. Using the ACE-27, 54.4% and 61.7% for a score of 0 (no comorbidity); 46.8% and 61.7% for a score of 1 (mild comorbidity); 31.7% and 51.6% for a score of 2 (moderate comorbidity); and 13.8% and 43.7% for a score of 3 (severe comorbidity). The C statistics were 0.641 for the NCI comorbidity index, 0.656 for the ACE-27, and 0.686 for the WUHNCI.
The WUHNCI did not demonstrate good discriminative power compared with the ACE-27 in a cohort of older patients. To be widely used, instruments developed to measure comorbidities must be reliable in any population. We believe that the ACE-27 is still the best index to assess comorbidities and that it should be used in studies evaluating the prognostic effect of comorbidities.
Objectives:
The aim was to evaluate the importance of clinical factors in the prediction of postoperative complications in patients with microvascular reconstruction for head and neck squamous cell cancer (HNSCC).
Design:
A retrospective review of case notes was performed.
Setting:
Patients treated at a single institute.
Participants:
The present study included 259 patients with HNSCC treated with radical surgery and microvascular reconstruction between 1993 and 2014.
Main outcome measures:
We allocated the patients to three groups using a preoperative comorbidity score based on risk factors: group A (≥ 3 risk factors, n=16), group B (2 risk factors, n=49), and group C (0 or 1 risk factor, n=194).
Results:
Surgical mortality in this cohort was 1.9% (5 of 259 patients). The preoperative comorbidity score was associated with surgical mortality (p<0.001). Pharyngocutaneous fistula (p=0.001) and flap compromise (p=0.023) were more frequent as preoperative comorbidity score increased. Preoperative comorbidity score (p<0.001), advanced age (p=0.007), advanced pathologic T stage (p=0.028), advanced pathologic N stage (p=0.005), preoperative (chemo)radiotherapy (p<0.001), history of cardiovascular disease (p=0.015) and pulmonary disease (p=0.007), and diabetes (p<0.001) had significant adverse effects on 5-year disease-specific survival (DSS) in a univariate analysis. The 5-DSS rates of groups A, B, and C were 30%, 37%, and 70%, respectively. Multivariate analysis showed that preoperative comorbidity score was significantly correlated with 5-year DSS (hazard ratio [HR], 3.56; 95% confidence interval [CI], 1.81-6.99; p<0.001 for group A and HR, 1.91; 95% CI, 1.15-3.18; p=0.013 for group B compared with group C).
Conclusion:
Patients with a high preoperative comorbidity score have an increased risk of surgical mortality and morbidity after microvascular reconstruction for HNSCC. This article is protected by copyright. All rights reserved.
The objective of this study was to develop a prospectively applicable method for classifying comorbid conditions which might alter the risk of mortality for use in longitudinal studies. A weighted index that takes into account the number and the seriousness of comorbid disease was developed in a cohort of 559 medical patients. The 1-yr mortality rates for the different scores were: "0", 12% (181); "1-2", 26% (225); "3-4", 52% (71); and "greater than or equal to 5", 85% (82). The index was tested for its ability to predict risk of death from comorbid disease in the second cohort of 685 patients during a 10-yr follow-up. The percent of patients who died of comorbid disease for the different scores were: "0", 8% (588); "1", 25% (54); "2", 48% (25); "greater than or equal to 3", 59% (18). With each increased level of the comorbidity index, there were stepwise increases in the cumulative mortality attributable to comorbid disease (log rank chi 2 = 165; p less than 0.0001). In this longer follow-up, age was also a predictor of mortality (p less than 0.001). The new index performed similarly to a previous system devised by Kaplan and Feinstein. The method of classifying comorbidity provides a simple, readily applicable and valid method of estimating risk of death from comorbid disease for use in longitudinal studies. Further work in larger populations is still required to refine the approach because the number of patients with any given condition in this study was relatively small.
Comorbid conditions are medical illnesses that accompany cancer. The impact of these conditions on the outcome of patients with head and neck cancer is well established. However, all of the comorbidity studies in patients with head and neck cancer reported in the literature have been performed using the Kaplan-Feinstein index (KFI), which may be too complicated for routine use. This study was performed to introduce and validate the use of the Charlson comorbidity index (CI) in patients with head and neck cancer and to compare it with the Kaplan-Feinstein comorbidity index for accuracy and ease of use. Study design was a retrospective cohort study. The study population was drawn for three academic tertiary care centers and included 88 patients 45 years of age and under who underwent curative treatment for head and neck cancer. All patients were staged by the KFI and the CI for comorbidity and divided into two groups based on the comorbidity severity staging. Group 1 included patients with advanced comorbidity (stages 2 or 3), and group 2 included those with low-level comorbidity (stages 0 or 1). Outcomes were compared based on these divisions. The KFI was successfully applied to 80% of this study population, and the CI was successfully applied in all cases (P< 0.0001). In addition, the KFI was found to be more difficult to use than the CI (P< 0.0001). However, both indices independently predicted the tumor-specific survival (P= 0.007), even after adjusting for the confounding effects of TNM stage by multivariate analysis. Overall, the CI was found to be a valid prognostic indicator in patients with head and neck cancer. In addition, because comorbidity staging by the CI independently predicted survival, was easier to use, and more readily applied, it may be better suited for use for retrospective comorbidity studies.
To evaluate the reliability of free-flap head and neck reconstruction in the elderly.
All patients who underwent free-flap head and neck reconstruction in our institution between 2000 and 2010 were included in this retrospective study. In all, 418 patients (301 men and 117 women) were enrolled, including 95 patients aged 70 years or older (mean age=60.2±11.6 years). The impact of age on free-flap failure and local and general complication rates was assessed on univariate and multivariate analysis.
Advanced age had no impact on free-flap failure and local complications rate but was correlated with a higher risk of general complications (multivariate analysis: P=0.007). A high level of comorbidity also had a significant impact on the general complications rate (multivariate analysis: P=0.001). Patients who underwent circular total pharyngolaryngectomy showed elevated risk of free-flap failure (P=0.005) and local complications (P=0.001) on multivariate analysis.
Free-flap reconstruction of the head and neck is safe and reliable in the elderly. Nevertheless, meticulous patient selection, mainly based on the level of comorbidity, is necessary.
The objective of this study was to develop a prospectively applicable method for classifying comorbid conditions which might alter the risk of mortality for use in longitudinal studies. A weighted index that takes into account the number and the seriousness of comorbid disease was developed in a cohort of 559 medical patients. The 1-yr mortality rates for the different scores were: "0", 12% (181); "1-2", 26% (225); "3-4", 52% (71); and "greater than or equal to 5", 85% (82). The index was tested for its ability to predict risk of death from comorbid disease in the second cohort of 685 patients during a 10-yr follow-up. The percent of patients who died of comorbid disease for the different scores were: "0", 8% (588); "1", 25% (54); "2", 48% (25); "greater than or equal to 3", 59% (18). With each increased level of the comorbidity index, there were stepwise increases in the cumulative mortality attributable to comorbid disease (log rank chi 2 = 165; p less than 0.0001). In this longer follow-up, age was also a predictor of mortality (p less than 0.001). The new index performed similarly to a previous system devised by Kaplan and Feinstein. The method of classifying comorbidity provides a simple, readily applicable and valid method of estimating risk of death from comorbid disease for use in longitudinal studies. Further work in larger populations is still required to refine the approach because the number of patients with any given condition in this study was relatively small.
The associated co-morbid diseases present at the time of discovery of adult maturity-onset diabetes mellitus have not hitherto been quantitatively related to the subsequent course of the patients.From existing medical records and other solicited data, complete 5-yr follow-up was obtained for an ‘inception cohort’ of 188 patients who were treated during the years 1959–1962 at the West Haven VA Hospital and whose diabetes was first diagnosed within 6 months before ‘zero time’, which was the date of discharge for the ailment that had provoked hospitalization. A special classification was developed for categorizing the zero-time co-morbidity of the patients as prognostically cogent or non-cogent, and for dividing cogent co-morbidity into vascular and nonvascular types, with functional severity graded as none, moderate, and severe.The fatality rate at 5 yr after zero time was 40 per cent (76/188) for all patients, but distinctive gradients of fatality were noted for age, for type of co-morbidity, and particularly for severity of co-morbidity. The 5-yr fatality rate after zero time was 7 per cent in forty-one patients with no cogent co-morbidity, 33 per cent in seventynine patients with moderate co-morbidity and 69 per cent in sixty-eight patients with severe co-morbidity.Of the sixty-eight patients with severe initial co-morbidity, 53 per cent later died of the same or a related ailment; in the seventy-nine patients with moderate co-morbidity, the analogous death rate was 13 per cent. Death was due to ‘vascular causes’ in 52 per cent of seventy-seven patients who initially had vascular co-morbidity, in 7 per cent of seventy patients with nonvascular co-morbidity, and in 2 per cent of forty-one patients with no cogent co-morbidity. Among 5-yr survivors, the occurrence rate of new vascular events (or ‘diabetic complications’) was directly related to the same features of age and co-morbidity that seemed to affect fatality.These data indicate that the outcome of patients with maturity-onset diabetes mellitus depends on the type and functional severity of the co-morbid diseases present when the diabetes is detected. An appropriate analysis of co-morbidity, although omitted from existing statistical studies of diabetes, is pre-requisite to evaluating the results of different modes of therapy.
Objectives/Hypothesis Patients with head and neck cancer are staged according to the morphology of the tumor with little or no attention given to the importance of the other diseases, illnesses, or conditions. These other conditions are generally referred to as comorbidities. Although not a feature of the cancer itself, comorbidity is an important attribute of the patient with cancer. Comorbidity has direct impact on the care of patients, selection of initial treatment, and evaluation of treatment effectiveness. The objective of this thesis is to demonstrate the importance of comorbidity in head and neck cancer. Specifically, the aims are 1) to demonstrate the burden of comorbidity among head and neck cancer patients by comparing the incidence of none , mild , moderate , and severe comorbidity among patients with head and neck cancer to patients with cancers of the colorectum, lung, breast, gynecological sites, or prostate, 2) to demonstrate the independent impact of comorbidity on overall survival, and 3) to demonstrate the importance of comorbidity in the assessment of initial treatment effectiveness.
Study Design This was a prospective cohort study of the impact of comorbidity on head and neck cancer patients presenting for treatment between January 1995 and December 1996.
Methods In 1994, the author trained cancer registrars at an academic teaching hospital to code comorbidity from the medical record of new patients using a standard comorbidity index. Standard statistical techniques, including multivariable analysis, were used to compare and contrast the burden of comorbidity for patients with different cancers. Life survival techniques and multivariable logistic regression analysis were used to assess the independent prognostic impact of comorbidity. Further, the technique of conjunctive consolidation was used to augment the TNM system with comorbidity information, to more completely assess the impact of different initial treatments for patients with head and neck cancers.
Results The cohort consisted of 3,378 patients with cancers of the head and neck (341), colorectum (307), lung (655), breast (483), gynecological sites (482), and prostate (1,110). The percentage of head and neck cancer patients with moderate to severe comorbidity was 21%; this degree of comorbidity burden was second only to patients with lung (40%) and colorectal (25%) cancer. There was a significant relationship between severity of comorbidity and overall survival (log‐rank test, ξ ² = 15.75; P < .0013). For cancers of the head and neck, lung, breast, and prostate the prognostic significance of comorbidity remained even after controlling for other factors, such as age and TNM stage.
Conclusions The results of this study show that comorbidity is an important feature of patients with head and neck cancer. Valid instruments exist to measure and classify the overall severity of comorbidity. The scientific evaluation of treatment and the care of patients are impeded by a rigid adherence to a staging system based solely on morphological descriptions of the cancer while ignoring suitable descriptions of the patient. The author believes that the addition of comorbidity information will improve the value of cancer statistics and the care of cancer patients.
Important comorbidities recorded on outpatient claims in administrative datasets may be missed in analyses when only inpatient care is considered. Using the comorbid conditions identified by Charlson and colleagues, we developed a comorbidity index that incorporates the diagnostic and procedure data contained in Medicare physician (Part B) claims. In the national cohorts of elderly prostate (n = 28,868) and breast cancer (n = 14,943) patients assessed in this study, less than 10% of patients had comorbid conditions identified when only Medicare hospital (Part A) claims were examined. By incorporating physician claims, the proportion of patients with comorbid conditions increased to 25%. The new physician claims comorbidity index significantly contributes to models of 2-year noncancer mortality and treatment received in both patient cohorts. We demonstrate the utility of a disease-specific index using an alternative method of construction employing study-specific weights. The physician claims index can be used in conjunction with a comorbidity index derived from inpatient hospital claims, or employed as a stand-alone measure.
Most patients with head and neck squamous cell carcinoma are older and may have coexistent or comorbid diseases.
To determine the prognostic impact of individual comorbid conditions in patients with head and neck cancer, to combine the individual comorbid conditions to form a new a head and neck-specific comorbidity instrument, and to compare it with the Modified Kaplan-Feinstein Index to determine if the new disease-specific instrument offers any improvement in survival prediction over a general comorbidity index.
Retrospective review of medical records.
The study population comprised 1153 patients with biopsy-proven, newly diagnosed squamous cell carcinoma of the oral cavity, oropharynx, or larynx.
Seven comorbid conditions (congestive heart disease, cardiac arrhythmia, peripheral vascular disease, pulmonary disease, renal disease, cancer controlled, and cancer uncontrolled) were significantly related to survival. These comorbid conditions were assigned integer weights to reflect their relative prognostic importance and combined to create the new Washington University Head and Neck Comorbidity Index (WUHNCI). Survival was significantly related to levels of comorbidity severity as defined by the WUHNCI. The WUHNCI predicted survival better than the Modified Kaplan-Feinstein Index despite containing far fewer ailments.
Comorbidity is an important feature of the patient with head and neck cancer. The WUHNCI can be used for retrospective review or prospective outcomes research.
To describe the impact of comorbidity on complications of surgery and mortality in patients with head and neck squamous cell carcinoma (HNSCC).
A total of 120 consecutive patients with HNSCC, treated surgically between January 1999 and December 2001, were included. The Adult Comorbidity Evaluation 27 index (ACE-27) and the American Society of Anesthesiologists (ASA) risk classification system were used to describe comorbidity. Major complications were defined and scored by review of the medical records. Univariate and multivariate analyses were performed to determine the impact of 17 clinical variables, including the ACE-27 grade and the ASA class.
Twenty-five patients (21.4%) had 1 or more major complications. In the univariate analysis, ACE-27 grade, ASA class, T stage, surgical procedure used for the primary tumor, type of neck dissection, and duration of anesthesia had a significant relation with major complications. In the multivariate analysis, duration of anesthesia and comorbidity reflected by the ACE-27 grade or the ASA class remained significant. The odds ratios (95% confidence intervals) associated with ACE-27 grades of 1 and 2 were 1.9 (0.6-6.8) and 4.6 (1.4-15.2), respectively; with ASA classes 2 and 3, 2.0 (0.5-8.2) and 10.0 (2.2-45.1), respectively. Duration of anesthesia longer than 360 minutes was characterized by an odds ratio of 7.8 (1.8-12.9).
Duration of anesthesia and comorbidity reflected by the ACE-27 grade and the ASA class are important predictors of major complications in head and neck surgery. Optimizing the general condition of patients with HNSCC might reduce morbidity and treatment-related costs.