Amy M. Williams

Socioeconomic disparities and comorbidities, not race, affect salivary gland malignancy survival outcomes

This study sought to determine whether comorbidities, race, and socioeconomic factors affect 5‐ and 10‐year survival outcomes for patients with salivary gland malignancies treated at a single large academic institution with a large African American population.

Clinical Assessment of Cognitive Function in Patients with Head and Neck Cancer: Prevalence and Correlates

Objective Identify the prevalence and clinical correlates of cognitive impairment in patients presenting for treatment of head and neck cancer (HNC) using brief screening within a multidisciplinary care team. Study Design A case series with planned data collection of cognitive function, quality of life (QoL), and psychosocial variables. Setting Urban Midwest academic medical center. Subjects and Methods In total, 209 consecutive patients with a diagnosis of HNC between August 2015 and September 2016 who had a pretreatment assessment with a clinical health psychologist. At pretreatment assessment, the Montreal Cognitive Assessment (MoCA), a brief screening tool for cognitive function, was administered along with a semistructured interview to gather information on psychiatric symptoms, social support, and substance use. Patient information, including demographics, clinical variables, and psychosocial variables, was extracted via chart review. A subset of patients with HNC completed the Functional Assessment of Cancer Therapy–Head and Neck Cancer at pretreatment assessment and was included in the QoL analyses. Results Cognitive impairment was associated with current alcohol use, past tobacco use and number of pack years, time in radiotherapy, and adherence to treatment recommendations. Social, emotional, and functional QoL scales were associated with cognitive impairment, including executive function, language, and memory. Conclusion Cognitive impairment is common in patients with HNC, and there are important associations between cognitive impairment and psychosocial, QoL, and treatment adherence variables. The results argue for the incorporation of cognitive screening as part of pretreatment assessment for patients, as well as further research into more direct, causal relationships via longitudinal, prospective studies.

Considerations for antibiotic prophylaxis in head and neck cancer surgery

Peri/post-operative antibiotic prophylaxis (POABP) has become standard practice for preventing surgical site infections (SSI) in head and neck cancer patients undergoing microvascular reconstruction, but few data exist on optimal POABP regimens. Current surgical prophylaxis guideline recommendations fail to account for the complexity of microvascular reconstruction relative to other head and neck procedures, specifically regarding wound classification and antibiotic duration. Selection of POABP spectrum is also controversial, and must balance the choice between too narrow, risking subsequent infection, or too broad, and possible unwanted effects (e.g. antibiotic resistance, Clostridium difficile-associated diarrhea). POABP regimens should retain activity against bacteria expected to colonize the upper respiratory/salivary tracts, which include Gram-positive organisms and facultative anaerobes. However, Gram-negative bacilli also contribute to SSI in this setting. POABP doses should be optimized in order to achieve therapeutic tissue concentrations at the surgical site. Antibiotics targeted towards methicillin-resistant Staphylococcus aureus or Pseudomonas aeruginosa are not warranted for all patients. Prolonged POABP durations have shown no differences in SSI when compared to short POABP durations, but prolonged durations provide unnecessarily antibiotic exposure and risk for adverse effects. Given the lack of standardization behind antibiotic POABP in this setting and the potential for poor patient outcomes, this practice necessitates an additional focus of surgeons and antimicrobial stewardship programs. The purpose of this review is to provide an overview of POABP evidence and discuss pertinent clinical implications of appropriate use.

Association Between Cognitive Function and Quality of Life in Patients With Head and Neck Cancer

Importance There is a dearth of research examining the associations between cognitive function and quality of life (QoL) in patients with head and neck cancer (HNC), despite much research examining QoL and some research examining cognitive function in this population. Objective To identify the associations between cognitive functioning and QoL in patients prior to treatment for HNC within a multidisciplinary care team. Design, Setting, and Participants Case series with planned data collection of cognitive function, QoL, and psychosocial variables at an urban Midwest academic medical center including 83 patients with a diagnosis of HNC between August 2015 and December 2016 who underwent a pretreatment assessment with a clinical health psychologist and a speech and language pathologist. Main Outcomes and Measures At pretreatment assessment, the Montreal Cognitive Assessment and Functional Assessment of Cancer Therapy–Head & Neck, version 4, were administered along with a semistructured interview to gather data on psychiatric symptoms, social support, and substance use. Patient demographic, clinical, and psychosocial variables were extracted via medical record review. Results Of 83 patients (64 [77%] male; mean age, 59.54 [95% CI, 57.23-61.73] years), cognitive impairment was identified in 55% (n = 46) at pretreatment. Number of depressive symptoms (mean, 2.43 [95% CI, 2.06-2.89] symptoms) was associated with impairments in delayed recall (r = −0.28; 95% CI, −0.47 to −0.07) and all domains of QoL. Cognitive impairment in delayed recall was associated with lower QoL in both overall QoL and the domains of emotional and functional well-being. Current benzodiazepine use, history of heavy alcohol use, and current and past tobacco use were also associated with lower QoL in specific domains. Conclusions and Relevance Cognitive impairment is common in patients with HNC and is associated with QoL and psychosocial variables. Together with previous research indicating that cognitive function and QoL can influence treatment adherence and outcomes, the results argue for the incorporation of cognitive screening and QoL assessment as part of pretreatment assessment for patients.

Multicenter Assessment of Antibiotic Prophylaxis Spectrum on Surgical Infections in Head and Neck Cancer Microvascular Reconstruction

Objective To characterize and identify risk factors for 30-day surgical site infections (SSIs) in patients with head and neck cancer who underwent microvascular reconstruction. Study Design Cross-sectional study with nested case-control design. Setting Nine American tertiary care centers. Subjects and Methods Hospitalized patients were included if they underwent head and neck cancer microvascular reconstruction from January 2003 to March 2016. Cases were defined as patients who developed 30-day SSI; controls were patients without SSI at 30 days. Postoperative antibiotic prophylaxis (POABP) regimens were categorized by Gram-negative (GN) spectrum: no GN coverage, enteric GN coverage, and enteric with antipseudomonal GN coverage. All POABP regimens retained activity against anaerobes and Gram-positive bacteria. Thirty-day prevalence of and risk factors for SSI were evaluated. Results A total of 1307 patients were included. Thirty-day SSI occurred in 189 (15%) patients; median time to SSI was 11.5 days (interquartile range, 7-17). Organisms were isolated in 59% of SSI; methicillin-resistant Staphylococcus aureus (6%) and Pseudomonas aeruginosa (9%) were uncommon. A total of 1003 (77%) patients had POABP data: no GN (17%), enteric GN (52%), and antipseudomonal GN (31%). Variables independently associated with 30-day SSI were as follows: female sex (adjusted odds ratio [aOR], 1.6; 95% CI, 1.1-2.2), no GN POABP (aOR, 2.2; 95% CI, 1.5-3.3), and surgical duration ≥11.8 hours (aOR, 1.9; 95% CI, 1.3-2.7). Longer POABP durations (≥6 days) or antipseudomonal POABP had no association with SSI. Conclusions POABP without GN coverage was significantly associated with SSI and should be avoided. Antipseudomonal POABP or longer prophylaxis durations (≥6 days) were not protective against SSI. Antimicrobial stewardship interventions should be made to limit unnecessary antibiotic exposures, prevent the emergence of resistant organisms, and improve patient outcomes.

In response to Socioeconomic disparities and comorbidities, not race, affect salivary gland malignancy survival outcomes : Letter to the Editor

Thank you for the opportunity to respond to Mr. Aponte-Ortiz, Dr. Greenberg-Worisek, and Dr. Janus’s letter in reference to our article “Socioeconomic Disparities and Comorbidities, Not Race, Affect Salivary Gland Malignancy Survival Outcomes.” We appreciate the interest that this important topic in salivary gland malignancies has attracted. In designing our study, we hoped to stimulate discourse and further investigations in the complex roles that race and socioeconomic status—related though not identical issues—play in cancer survival. Certainly, with existing literature that argues for and against the role of race specifically in salivary malignancy survival, we acknowledge the controversial nature of the topic. Aponte-Ortiz and colleagues have observed that the cancer stage or the time to treatment was not addressed with regard to race, and may have confounded our conclusion that race was not associated with survival. Although our study did not directly offer this, it did show that advanced overall stage, clinical T, or clinical N staging resulted in shorter median survival. In the same analysis, race did not. If staging confounded the conclusions about race, then the black patients would demonstrate a statistically significant different median survival compared to that of white patients. The role of ethnicity and the lack of a separate Hispanic group as an entity in our study are also relevant points. However, according to the United States Census Bureau, only 5.0% of the Michigan population identified themselves as Hispanic, and 7.6% within Detroit, Michigan identified themselves as Hispanic. In addition, within Detroit, 0.4% identified as American Indian or an Alaska Native, and 0.01% were Native Hawaiian or Other Pacific Islanders. The low proportion of these minority groups make statistical analysis difficult, and conclusions drawn about those groups would likely not be meaningful within the current study. That is not to say, however, that further investigation in this area is not warranted, as Aponte-Ortiz and colleagues suggest. Salivary malignancies have not been well studied. Although they are a distinct entity in histology and behavior, they are often times grouped into conclusions drawn about the more common aerodigestive squamous cell carcinomas of the head and neck. We are hopeful that more studies will elucidate the nature of race and socioeconomic status in relatively rare cancers, so that we as a society may take steps in addressing treatable disparities.

Introduction to the Special Issue: Invited Papers from the 2017 APAHC Conference

The 8th biennial national conference of the Association of Psychologists in Academic Health Centers (APAHC) was held in Detroit, MI, March 9–11, 2017. All speakers were invited to contribute manuscripts based on their conference presentations to this special issue of the Journal of Clinical Psychology in Medical Settings, and five presenters did so. All manuscripts were peer reviewed by experts in the field. The Conference Co-Chairs, Drs. Amy M. Williams and John A. Yozwiak, serve as Guest Editors for the special issue with Associate Editorial support from Dr. Elizabeth D. Cash. This article provides a brief overview of the rationale for the choice of the conference theme and the speakers, and a brief introduction to the articles in this special issue.

Comparison of incidental versus palpable thyroid nodules presenting for fine‐needle aspiration biopsy

BACKGROUND Many attribute the rise in incidence of thyroid cancer to a deluge of radiologically identified incidental thyroid nodules. The clinical implications are unclear. METHODS A review was performed of all patients who underwent fine-needle aspirations of thyroid nodules by our academic medical centers Endocrinology Division between 2006 and 2010. Medical records were reviewed to identify whether the thyroid nodule was discovered incidentally or by palpation. RESULTS Of 1153 patients, 37.4% underwent a biopsy because of an incidental thyroid nodule. These patients were significantly more likely to be >45 years old, men, white race, and with a body mass index >30 kg/m2 . Of the 17.2% of incidentalomas that led to surgery, 8.5% were found to be thyroid cancer. CONCLUSION Thyroid nodules discovered incidentally are increasing the diagnosis of subclinical thyroid cancers. Not investigated previously, our study found that the mode of detection was not related to malignancy or surgery.

INCIDENTAL THYROID NODULES: RACE / ETHNICITY DISPARITIES AND OUTCOMES

OBJECTIVE Black patients have a significantly lower incidence of well-differentiated thyroid cancer (WDTC) compared to all other race/ethnic groups, while white patients appear to be at greater risk. This study examines incidental thyroid nodules (ITNs) to assess whether racial disparities in WDTC arise from a differential discovery of ITNs-perhaps due to socioeconomic disparities-or reflect true differences in thyroid cancer rates. METHODS A retrospective review was performed of all patients who underwent fine-needle aspiration (FNA) of thyroid nodules by our academic medical centers endocrinology division between January 2006 and December 2010. Medical records were reviewed to identify whether the biopsied thyroid nodule was discovered incidentally through nonthyroid-related imaging or identified by palpation. RESULTS FNAs were performed on 1,369 total thyroid nodules in 1,141 study patients; 547 (48%) were classified as white, and 593 (52%) were classified as nonwhite. Among this cohort, 36.6% of patients underwent biopsy for an ITN. White patients were 1.6 times more likely to have undergone a biopsy for a nodule that was incidentally identified compared to nonwhites ( P<.0001). Indicators of socioeconomic status (SES) did not have a significant association with ITNs. Within the ITN cohort, 4.9% of nonwhite patients were found to have a thyroid malignancy compared to 12.9% of white patients ( P<.01). CONCLUSION The higher incidence of thyroid cancer in white patients appears to be not only due to diagnostic bias, but also to a true difference in cancer prevalence. ABBREVIATIONS FNA = fine-needle aspiration; ITN = incidental thyroid nodule; SEER = Surveillance Epidemiology and End Results; SES = socioeconomic status; WDTC = well-differentiated thyroid cancer.