Saral Mehra

Industry ties in otolaryngology: initial insights from the physician payment sunshine act.

Objective To characterize nonresearch payments made by industry to otolaryngologists in order to explore how the potential for conflicts of interests varies among otolaryngologists and compares between otolaryngologists and other surgical specialists. Study Design Retrospective cross-sectional database analysis. Setting Open Payments program database recently released by Centers for Medicare and Medicaid Services. Subjects Surgeons nationwide who were identified as receiving nonresearch payment from industry in accordance with the Physician Payment Sunshine Act. Methods The proportion of otolaryngologists receiving payment, the mean payment per otolaryngologist, and the standard deviation thereof were determined using the Open Payments database and compared to other surgical specialties. Otolaryngologists were further compared by specialization, census region, sponsor, and payment amount. Results Less than half of otolaryngologists (48.1%) were reported as receiving payments over the study period, the second smallest proportion among surgical specialties. Otolaryngologists received the lowest mean payment per compensated individual (

Treatment Factors Associated With Survival in Early-Stage Oral Cavity Cancer: Analysis of 6830 Cases From the National Cancer Data Base

573) compared to other surgical specialties. Although otolaryngology had the smallest variance in payment among surgical specialties (SD,

ACTIVE SURVEILLANCE FOR PAPILLARY THYROID MICROCARCINOMA: NEW CHALLENGES AND OPPORTUNITIES FOR THE HEALTH CARE SYSTEM.

2806), the distribution was skewed by top earners; the top 10% of earners accounted for 87% (

Hospital readmission and 30‐day mortality after surgery for oral cavity cancer: Analysis of 21,681 cases

2,199,254) of all payment to otolaryngologists. Otolaryngologists in the West census region were less likely to receive payments (38.6%, P < .001). Conclusion Over the study period, otolaryngologists appeared to have more limited financial ties with industry compared to other surgeons, though variation exists within otolaryngology. Further refinement of the Open Payments database is needed to explore differences between otolaryngologists and leverage payment information as a tool for self-regulation.

A Comparison of Prognostic Ability of Staging Systems for Human Papillomavirus-Related Oropharyngeal Squamous Cell Carcinoma.

IMPORTANCE Most patients with oral cavity squamous cell cancer (OCSCC) are initially seen at an early stage (I and II). Although patient and tumor prognostic features have been analyzed extensively, population-level data examining how variations in treatment factors impact survival are lacking to date. OBJECTIVE To analyze associations between treatment variables and survival in stages I and II oral cavity squamous cell carcinoma. DESIGN, SETTING, AND PARTICIPANTS Retrospective study of cases in the National Cancer Data Base. Patients diagnosed as having stage I or II OCSCC between January 1, 2003, and December 31, 2006, and treated with surgery were identified. Univariate and multivariable analyses of overall survival based on patient, disease, and treatment characteristics were conducted. MAIN OUTCOMES AND MEASURES Overall survival and survival at 5 years. RESULTS In total, 6830 patients were included. Survival at 5 years was 69.7% (4760 patients). On univariate analysis, treatment factors associated with improved survival included treatment at academic or research institutions, no radiation therapy, no chemotherapy, and negative margins (P < .001 for all). Neck dissection was associated with improved survival (P = .001), reflecting pathologic restaging and elimination of patients with occult nodal disease. Patients treated at academic or research institutions were more likely to receive neck dissection and less likely to receive radiation therapy or have positive margins. On multivariable analysis, neck dissection (hazard ratio [HR], 0.85; 95% CI, 0.76-0.94; P = .003) and treatment at academic or research institutions (HR, 0.88; 95% CI, 1.01-1.26; P = .03) were associated with improved survival, whereas positive margins (HR, 1.27; 95% CI, 1.08-1.49; P = .005), insurance through Medicare (HR, 1.45; 95% CI, 1.25-1.69; P < .001) or Medicaid (HR, 1.96; 95% CI, 1.60-2.39; P < .001), and adjuvant radiation therapy (HR, 1.31; 95% CI, 1.16-1.49; P < .001) or adjuvant chemotherapy (HR, 1.34; 95% CI, 1.03-1.75; P = .03) were associated with compromised survival. CONCLUSIONS AND RELEVANCE Prognostic impacts of treatment factors in early OCSCC are presented. Overall survival for early OCSCC varies with demographic and tumor characteristics but also varies with treatment and system factors, which may represent targets for improving outcomes in this disease.

Subscapular system of flaps: An 8‐year experience with 105 patients

OBJECTIVE The dramatic increase in papillary thyroid carcinoma (PTC) is primarily a result of early diagnosis of small cancers. Active surveillance is a promising management strategy for papillary thyroid microcarcinomas (PTMCs). However, as this management strategy gains traction in the U.S., it is imperative that patients and clinicians be properly educated, patients be followed for life, and appropriate tools be identified to implement the strategy. METHODS We review previous active surveillance studies and the parameters used to identify patients who are good candidates for active surveillance. We also review some of the challenges to implementing active surveillance protocols in the U.S. and discuss how these might be addressed. RESULTS Trials of active surveillance support nonsurgical management as a viable and safe management strategy. However, numerous challenges exist, including the need for adherence to protocols, education of patients and physicians, and awareness of the impact of this strategy on patient psychology and quality of life. The Thyroid Cancer Care Collaborative (TCCC) is a portable record keeping system that can manage a mobile patient population undergoing active surveillance. CONCLUSION With proper patient selection, organization, and patient support, active surveillance has the potential to be a long-term management strategy for select patients with PTMC. In order to address the challenges and opportunities for this approach to be successfully implemented in the U.S., it will be necessary to consider psychological and quality of life, cultural differences, and the patients clinical status.

Database and registry research in thyroid cancer: Striving for a new and improved national thyroid cancer database

Oral cavity squamous cell cancer (SCC) is treated primarily with surgery. Rates of 30‐day hospital readmission and mortality after surgery for oral cavity SCC are unknown.

Proposing prognostic thresholds for lymph node yield in clinically lymph node-negative and lymph node-positive cancers of the oral cavity.

Importance The current American Joint Committee on Cancer/Union for International Cancer Control (AJCC/UICC) staging system, developed for human papillomavirus (HPV)-unrelated disease, discriminates poorly when applied to HPV-related oropharyngeal squamous cell cancer (OPSCC), leading to calls for a new staging system. Objective To compare the prognostic ability of the AJCC/UICC seventh edition staging system; a recently proposed system, the International Collaboration on Oropharyngeal Cancer Network for Staging (ICON-S); and a novel objectively derived system for HPV-related OPSCC using a national database of patients primarily treated with either radiation or surgery. Design, Setting, and Participants In this observational study, patients with HPV-related nonmetastatic OPSCC were identified in the National Cancer Database between 2010 and 2012. Recursive partitioning analysis (RPA) was used to derive the proposed-RPA staging system. The data were analyzed from March to May 2016. Main Outcomes and Measures Overall survival was calculated using the Kaplan-Meier method. The performance of the 3 systems was compared using published criteria, and internal validation using bootstrap methods was performed. Survival differences between stage groups were evaluated using the log-rank test. Results A total of 5626 patients (86.0% male; median [range] age, 58 [21-90] years) were identified. The median (range) follow-up was 28.5 (0.1-58.8) months. A novel staging system (proposed-RPA) consisting of stage IA, T1-2N0-2a; stage IB, T1-2N2b-3; stage II, T3N0-3; stage III, T4a-bN0-3 resulted in 3-year overall survival rates of 91%, 87%, 81%, and 70%, respectively. This system, as well as the ICON-S, significantly prognosticated for survival when either primary surgery or primary radiation subgroups were examined (log-rank P < .001 for all). The AJCC/UICC system, ICON-S, and proposed-RPA all significantly predicted survival outcomes when analyzed globally (log-rank P < .001 for all). The AJCC/UICC system could not differentiate between survival when stages I and IVA were compared, however (log-rank P = .17). On comparative performance evaluation for survival prediction, the proposed-RPA provided superior prognostication compared with the other systems. Conclusions and Relevance We validated the ICON-S staging as prognostic, overall, and in primary radiation therapy and surgery subgroups, but ultimately found that a staging system consisting of stage IA, T1-2N0-2a; stage IB, T1-2N2b-3; stage II, T3N0-3; and stage III, T4a-bN0-3 (with stage IV representing M1 disease) outperformed the others. The proposed-RPA is an alternative staging system that should be evaluated for potential adoption as part of the next AJCC/UICC staging system.

NOTCH1 and SOX10 are Essential for Proliferation and Radiation Resistance of Cancer Stem–Like Cells in Adenoid Cystic Carcinoma

Review patient and defect factors in which this donor site is an optimal choice for reconstruction and to discuss strategies to overcome the perceived drawbacks of this system of flaps.

Esophageal perforation caused by edible foreign bodies: A systematic review of the literature

BACKGROUND Health registries have become extremely powerful tools for cancer research. Unfortunately, certain details and the ability to adapt to new information are necessarily limited in current registries, and they cannot address many controversial issues in cancer management. This is of particular concern in differentiated thyroid cancer, which is rapidly increasing in incidence and has many unknowns related to optimal treatment and surveillance recommendations. SUMMARY In this study, we review different types of health registries used in cancer research in the United States, with a focus on their advantages and disadvantages as related to the study of thyroid cancer. This analysis includes population-based cancer registries, health systems-based cancer registries, and patient-based disease registries. It is important that clinicians understand the way data are collected in, as well as the composition of, these different registries in order to more critically interpret the clinical research that is conducted using that data. In an attempt to address shortcoming of current databases for thyroid cancer, we present the potential of an innovative web-based disease management tool for thyroid cancer called the Thyroid Cancer Care Collaborative (TCCC) to become a patient-based registry that can be used to evaluate and improve the quality of care delivered to patients with thyroid cancer as well as to answer questions that we have not been able to address with current databases and registries. CONCLUSION A cancer registry that follows a specific patient, is integrated into physician workflow, and collects data across different treatment sites and different payers does not exist in the current fragmented system of healthcare in the United States. The TCCC offers physicians who treat thyroid cancer numerous time-saving and quality improvement services, and could significantly improve patient care. With rapid adoption across the nation, the TCCC could become a new paradigm for database research in thyroid cancer to improve our understanding of thyroid cancer management.