Richard G. Wight

Comorbidity in head and neck cancer: A critical appraisal and recommendations for practice

Comorbidity, the presence of additional illnesses unrelated to the tumor, has a significant impact on the prognosis of patients with head and neck cancer. In these patients, tobacco and alcohol abuse contributes greatly to comorbidity. Several instruments have been used to quantify comorbidity including Adult Comorbidity Evaluation 27 (ACE 27), Charlson Index (CI) and Cumulative Illness Rating Scale. The ACE 27 and CI are the most frequently used indices. Information on comorbidity at the time of diagnosis can be abstracted from patient records. Self-reporting is less reliable than record review. Functional status is not a reliable substitute for comorbidity evaluation as a prognostic measure. Severity as well as the presence of a condition is required for a good predictive instrument. Comorbidity increases mortality in patients with head and neck cancer, and this effect is greater in the early years following treatment. In addition to reducing overall survival, many studies have shown that comorbidity influences disease-specific survival negatively, most likely because patients with high comorbidity tend to have delay in diagnosis, often presenting with advanced stage tumors, and the comorbidity may also prompt less aggressive treatment. The impact of comorbidity on survival is greater in younger than in older patients, although it affects both. For specific tumor sites, comorbidity has been shown to negatively influence prognosis in oral, oropharyngeal, laryngeal and salivary gland tumors. Several studies have reported higher incidence and increased severity of treatment complications in patients with high comorbidity burden. Studies have demonstrated a negative impact of comorbidity on quality of life, and increased cost of treatment with higher degree of comorbidity. Our review of the literature suggests that routine collection of comorbidity data will be important in the analysis of survival, quality of life and functional outcomes after treatment as comorbidity has an impact on all of the above. These data should be integrated with tumor-specific staging systems in order to develop better instruments for prognostication, as well as comparing results of different treatment regimens and institutions.

Applicability of the adult comorbidity evaluation – 27 and the Charlson indexes to assess comorbidity by notes extraction in a cohort of United Kingdom patients with head and neck cancer: a retrospective study

The term comorbidity stands for disease processes that co-exist and are not related to the index disease being studied. Comorbidity in cancer has been shown to be a major determinant in treatment selection and survival. Patients with head and neck cancer can have significant comorbidity owing to the high incidence of tobacco and alcohol abuse. No studies to date have addressed this problem in head and neck cancer patients in the United Kingdom. The applicability of the adult comorbidity evaluation - 27 index (ACE-27) and the Charlson index (CI) to assess the comorbidity burden by retrospective notes review is studied here. Retrospective data collection and completion of a comorbidity index in a United Kingdom setting is feasible. We conclude that the pre-assessment visit is a useful time to record comorbidity and as a significant amount of information required for grading relates to historical items, this is best done using a self-administered patient questionnaire.

Impact of comorbidity on the outcome of laryngeal squamous cancer

Comorbidity has been shown to be a determinant in treatment selection and survival in various cancers. We have previously shown that the Adult Comorbidity Evaluation—27 index is applicable in a United Kingdom setting, and the process of comorbidity grading by retrospective notes evaluation is an accurate and reliable process.

Consensus statement on management in the UK: Transoral laser assisted microsurgical resection of early glottic cancer

Background:  Transoral laser assisted microsurgical resection of early glottic laryngeal cancer is a relatively new treatment modality that is practised in many centres across the UK. In the absence of the results from randomised clinical trials, clinicians may be guided by an expert panel consensus statement on transoral laser assisted microsurgical resection of early squamous cell cancer of the larynx.

A cross-comparison of retrospective notes extraction and combined notes extraction and patient interview in the completion of a comorbidity index (ACE-27) in a cohort of United Kingdom patients with head and neck cancer

Co-existent comorbidity is a major determinant of treatment outcome in head and neck cancer. Most of the work pertaining to this topic has been done in the United States, where the standard practice is for trained cancer registrars to grade comorbidity using validated indexes by retrospective notes review. The adult comorbidity evaluation-27 index (ACE-27) is a validated instrument that has been widely used in head and neck cancer. Although the required clinical data may be available in the notes, a significant amount of historical information is required to grade comorbidity. The aim of this study was to assess the accuracy and inter-rater reliability of the retrospective notes review process, in a typical setting in the United Kingdom (UK), by comparing the information obtained on notes review alone by a physician to that available after a structured patient interview. The study concludes that the retrospective notes review is an accurate and reliable technique for grading comorbidity whose completeness can be improved by the use of patient questionnaire as part of a structured interview.

Descriptive study of the type and severity of decompensation caused by comorbidity in a population of patients with laryngeal squamous cancer.

The aim of this study was to systematically identify the type and severity of all comorbid conditions in a cohort of 180 patients with laryngeal squamous cancer. The authors retrospectively surveyed the notes using the Adult Comorbidity Evaluation -- 27 index (ACE-27) and applying a systematic process of data abstraction that had previously been shown to be accurate and reliable. The results provided insight into the distribution, site and extent of decompensation caused by comorbidity. It was found that 116 (64.4 per cent) of 180 patients in the study population had some form of comorbid illness, with the cardiovascular and respiratory systems being the top two body systems affected in 43.9 per cent and 24.1 per cent respectively. One-quarter (25.8 per cent) of these 116 patients had comorbid illnesses in more than one body system. Concurrent neurological disease is associated with high mortality. The ACE-27 is a comprehensive instrument that codes all forms of comorbid diseases in the head and neck cancer setting excepting malnutrition. This study suggests that routine collection of comorbidity will be important in future outcomes analysis and in comparing treatment results between centres. Apparent improvements in treatment outcome following newer therapeutic modalities will have to take into account any changes in the comorbidity type and burden over time.

TNM classification of malignant tumours 7th edition: what's new for head and neck?

The TNM System for the classification of malignant tumours was developed by Pierre Denoix, France, between 1943 and 1952. After international consultation, the system was adopted for clinical use by the UICC (International Union Against Cancer) Committee on Tumour Nomenclature and Statistics in 1953. In 1958, larynx and breast were the first anatomic sites to have site-specific clinical stages. Since then, seven editions of the classification have been published. The TNM system has delivered considerable benefits by standardising the description and reporting of cancers worldwide. It is primarily an anatomic ⁄ morphologic system that helps prognosticate by documenting the disease burden at the primary site, the neck and distant metastases. The system however has been challenged for not encompassing other factors that have been found to have a significant bearing on tumour behaviour, such as concurrent co-morbidity and unique tumour characteristics. In the latter situation for example, over 15 different malignant salivary gland pathologies share a single generic system designed to stage all salivary gland malignancies. It has been 7 years since the last edition of TNM. However, most head and neck clinicians will be pleased to hear that there are only minor changes in the classification system for head and neck cancers, compared to the more extensive overhaul that took place with the 6th edition. The main thrust behind the current edition (TNM 7) has been the recent advances in personalisation of prognostication in some cancer sites. The trend towards improving the prognostic efficacy of TNM by including of markers of poor prognosis, other than stage, is likely to continue. The current edition incorporates grade of histological differentiation for oesophageal cancer, and PSA (prostate specific antigen) and the Gleason score for prostate cancer. As knowledge expands on the role of human papillomavirus status in head and neck cancer, it would be hoped that this could to be incorporated into the prognostic system of head neck cancers, especially in oropharyngeal cancer. Comorbidity has been shown to have a significant impact on prognosis and is another candidate for inclusion.

Management of laryngeal dysplasia in the United Kingdom: a web-based questionnaire survey of current practice.

• Trans-nasal endoscopy (TNE) is a safe, well-tolerated and reliable tool for investigating benign upper gastro-intestinal symptoms. • TNE is a well established technique in the US but has yet to achieve the same prominence in the UK. • TNE offers substantial savings over established techniques for investigating upper aerodigestive tract disease. • If a third of patients currently investigated with barium swallow or oesophago-duedenoscopy underwent TNE instead, cost savings would be over £100 000 in 2 years. • The greater the proportion of patients undergoing TNE, the larger the saving with cost neutrality reached earlier.

Verrucous carcinoma of the paranasal sinuses: case report and clinical update.

Verrucous carcinoma is a low‐grade malignancy that has been reported to occur in all anatomic sites of the head and neck. Fourteen cases of verrucous carcinoma of paranasal sinus origin have been reported to date in the English literature.

Expression Of Mucin Gene Products in Laryngeal Squamous Cancer

OBJECTIVE: Mucins are high-molecular-weight glycoproteins present at the outer surface of mammalian cells. The objective of this study was to examine the expression of mucin (MUC) genes 3, 4, 5AC, 5B, 6, and 7 in early and late laryngeal squamous cancer using the in situ hybridization technique. STUDY DESIGN: Retrospective analysis of pathological archive specimens. RESULTS: While MUC 3 and 7 are expressed in a small proportion of early cancers, MUC 5AC, 5B, and 6 are not expressed in laryngeal squamous cancer. MUC 4 was expressed in 13 of the 30 patients. Ten patients and 3 patients with stage 1 and stage 4 disease respectively expressed MUC 4 gene (Fishers exact, P = 0.02). MUC 4-positive patients had a definite trend towards better survival (log rank test, P = 0.05). In the presence of tumor stage and comorbidity grade, Coxs proportional hazards model failed to statistically confirm the survival advantage provided by MUC 4 gene expression. CONCLUSION: There is a survival advantage for patients with advanced-stage nonmetastatic cancer when the MUC 4 gene is expressed.AIMS: To study the expression of mucin (MUC) genes 3, 4, 5AC, 5B, 6, and 7 in early and advanced squamous cell cancer of the larynx; to attempt to correlate changes in gene expression with tumor stage by studying stage I and stage IV (AJCC, 1988) tumors.