Cost-Effectiveness of Surgery Versus Organ Preservation in Advanced Laryngeal Cancer.

OBJECTIVE: Treatment decision-making for patients with laryngeal cancer consists of a complex trade-off between survival and quality of life. For decision makers on coverage and guidelines, costs come in addition to this equation. Our aim was to perform a cost-effectiveness analysis of surgery (laryngectomy with or without radiotherapy) versus organ preservation (OP: radiotherapy, chemo- and/or bioradiation) in advanced laryngeal cancer patients from a healthcare perspective. METHODS: A cost-effectiveness analysis was conducted using a Markov model. For each modality, data on survival and quality-adjusted life years (QALYs) were sourced from relevant articles in agreement with experts, and national benchmark cost prices were included regarding treatment, follow-up, adverse events, and rehabilitation. RESULTS: Total QALYs of the surgical approach (6.59) were substantially higher compared to the OP approach (5.44). Total lifetime costs were higher for the surgical approach compared to the OP approach, namely €95,881 versus €47,233. The surgical approach was therefore more effective and more costly compared to OP, resulting in an incremental cost-effectiveness ratio of €42,383/QALY. CONCLUSION: Based on current literature, surgical treatment was cost-effective compared to OP in advanced laryngeal cancer within most willingness-to-pay thresholds. The study provides information on the survival adjusted for quality of life in combination with costs of two different approaches for advanced laryngeal cancer, relevant for patients, physicians, and policy makers. As financial toxicity is a relevant aspect in this population, collection of real-world data on country-specific costs and utilities is strongly recommended to enable further generalization. LEVEL OF EVIDENCE: N/A. Laryngoscope, 131:E509-E517, 2021.

Cost-effectiveness analysis of voice rehabilitation for patients with laryngeal cancer: a randomized controlled study.

INTRODUCTION: Voice problems are common following radiotherapy for laryngeal cancer. Few studies exist covering the effect of voice rehabilitation, and no previous studies exist regarding the cost of said rehabilitation. This randomized controlled study aimed to analyze the cost-effectiveness of voice rehabilitation after radiotherapy for patients with laryngeal cancer. MATERIAL AND METHODS: A total of 66 patients with laryngeal cancer with follow-up data 12 months post-radiotherapy were included. Patients were randomized into receiving either voice rehabilitation (n = 32) or no voice rehabilitation (n = 34). The patient outcome was measured as quality-adjusted life years (QALYs). The index range between 0 and 1, where 0 equals death and 1 represents perfect health. The QALYs were assessed with the European Organization for Research and Treatment of Cancer questionnaire QLQ-C30 mapped to EuroQoL 5 Dimension values. The cost of rehabilitation and other healthcare visits was derived from hospital systems. The patients reported the total amount of sick leave days during the first 12 months following radiotherapy. The cost-effectiveness of the voice rehabilitation was compared with no rehabilitation intervention based on the incremental cost-effectiveness ratio. RESULTS: The cost per gained QALY with voice rehabilitation compared to no rehabilitation from a societal perspective was - 27,594 € (SEK - 250,852) which indicates that the voice rehabilitation is a cost-saving alternative compared to no rehabilitation due to lower costs and a slightly better health outcome. From a healthcare perspective, the voice rehabilitation indicates a cost 60,800 € (SEK 552,725) per gained QALY. CONCLUSION: From a societal perspective, i.e., including the costs of production loss, voice rehabilitation compared to no voice rehabilitation following radiotherapy for laryngeal cancer seems to be cost-saving. When analyzing only the healthcare costs in relation to health outcomes, voice rehabilitation indicates an incremental cost of 60,800 € per gained QALY, which is just above the threshold of the maximum willingness to pay level.

Observed-to-expected ratio for adherence to treatment guidelines as a quality of care indicator for laryngeal cancer.

OBJECTIVES/HYPOTHESIS: To examine associations between survival and adherence to National Comprehensive Cancer Network (NCCN) treatment guidelines using an observed-to-expected (O/E) ratio for greater adherence as a risk-adjusted hospital measure of quality care in elderly patients treated for larynx cancer. STUDY DESIGN: Retrospective analysis of Surveillance, Epidemiology, and End Results (SEER)-Medicare data. METHODS: Patients diagnosed with larynx cancer from 2004 to 2007 were evaluated using multivariate regression and survival analysis. A fit logistic regression model was used to calculate an O/E ratio for guideline adherence for each hospital using quality indicators derived from NCCN guidelines for recommended treatment and stratified by hospital volume. RESULTS: Of 1,721 patients treated at 395 hospitals, 43.0% of patients received NCCN guideline-adherent care. Low-volume hospitals (N = 295) treating six or fewer cases treated 765 patients (44.5%), with a mean O/E of 0.96 ± 0.45. Hospitals treating more then six cases with an O/E <1 (N = 32) treated 284 patients (16.5%), with a mean O/E of 0.77 ± 0.18. Hospitals treating more than six cases with an O/E ≥1 (N = 68) treated 672 patients (39.1%), with a mean O/E of 1.17 ± 0.11. Treatment at hospitals with an O/E ≥1 was associated with improved survival (hazard ratio [HR] = 0.83 [95% confidence interval [CI]: 0.70 to 0.98]) and lower mean incremental treatment-related costs (-$3,009 [-$5,226 to -$791]) compared with hospitals with an O/E <1 (HR = 1.00 [0.80 to 1.24]) and the reference group of low-volume hospitals. CONCLUSIONS: A hospital-specific O/E for NCCN treatment guideline adherence, combined with a minimum case volume criterion, is associated with survival and treatment-related costs in elderly patients with larynx cancer, and may be a feasible measure of larynx cancer quality of care. LEVEL OF EVIDENCE: NA Laryngoscope, 130:672-678, 2020.

Association of Hospital Volume With Laryngectomy Outcomes in Patients With Larynx Cancer.

Importance: A volume-outcome association exists for larynx cancer surgery, but to date it has not been investigated for specific surgical procedures. Objectives: To characterize the volume-outcome association specifically for laryngectomy surgery and to identify a minimum hospital volume threshold associated with improved outcomes. Design, Setting, and Participants: In this cross-sectional study, the Nationwide Inpatient Sample was used to identify 45 156 patients who underwent laryngectomy procedures for a malignant laryngeal or hypopharyngeal neoplasm between January 2001 and December 2011. The analysis was performed in 2018. Hospital laryngectomy volume was modeled as a categorical variable. Main Outcomes and Measures: Associations between hospital volume and in-hospital mortality, complications, length of hospitalization, and costs were examined using multivariate logistic regression analysis. Results: Among 45 156 patients (mean age, 62.6 years; age range, 20-96 years; 80.2% male) at 5516 hospitals, higher-volume hospitals were more likely to be teaching hospitals in urban locations; were more likely to treat patients who had hypopharyngeal cancer, were of white race/ethnicity, were admitted electively, had no comorbidity, and had private insurance; and were more likely to perform flap reconstruction or concurrent neck dissection. After controlling for all other variables, hospitals treating more than 6 cases per year were associated with lower odds of surgical and medical complications, with a greater reduction in the odds of complications with increasing hospital volume. High-volume hospitals in the top-volume quintile (>28 cases per year) were associated with decreased odds of in-hospital mortality (odds ratio, 0.45; 95% CI, 0.23-0.88), postoperative surgical complications (odds ratio, 0.63; 95% CI, 0.50-0.79), and acute medical complications (odds ratio, 0.63; 95% CI, 0.48-0.81). A statistically meaningful negative association was observed between very high-volume hospital care and the mean incremental length of hospitalization (-3.7 days; 95% CI, -4.9 to -2.4 days) and hospital-related costs (-$4777; 95% CI, -$9463 to -$900). Conclusions and Relevance: Laryngectomy outcomes appear to be associated with hospital volume, with reduced morbidity associated with a minimum hospital volume threshold and with reduced mortality, morbidity, length of hospitalization, and costs associated with higher hospital volume. These data support the concept of centralization of complex care at centers able to meet minimum volume thresholds to improve patient outcomes.

Laryngeal cancer: Global socioeconomic trends in disease burden and smoking habits.

OBJECTIVES/HYPOTHESIS: To characterize health burden and determine the associated level of equality of laryngeal carcinoma (LC) burden at a global level. METHODS: One hundred eighty-four countries were organized by socioeconomic status using Human Development Index (HDI) categorizations provided by the United Nations Development Program. Disability-adjusted life years (DALYs), obtained from The Global Health Data Exchange, were calculated and compared between each HDI category for the period from 1990 to 2015. Equality of LC burden was then evaluated with concentration indices. RESULTS: Global LC burden, as measured by age-standardized DALYs, has improved significantly over the 25-year period studied. This burden has declined for very high, high, and medium HDI countries, whereas it has remained unchanged for low HDI countries. The majority of LC global burden was found in high socioeconomic countries before 2010 and has shifted toward low socioeconomic countries, as indicated by concentration indices. Over the last 25 years, Central and Eastern Europe continue to have the largest disease burden in the world. CONCLUSION: This is the first analysis that we are aware of investigating health disparities of LC at a global level. The global burden of the disease has declined, which is a trend corresponding with significantly reduced smoking behaviors in developed countries. Although the global inequality gap decreased between 2010 and 2015, there remain reasons for concern. Smoking continues to trend upward in low socioeconomic countries, which could increase LC burden in low socioeconomic countries in the near future. A new global initiative directed toward low socioeconomic countries may yield dividends in preventing subsequent disparities in the LC burden. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:2039-2053, 2018.

Treatment, short-term outcomes, and costs associated with larynx cancer care in commercially insured patients.

OBJECTIVES/HYPOTHESIS: To examine associations between treatment, complications, and costs in patients with laryngeal cancer. STUDY DESIGN: Retrospective cross-sectional analysis of MarketScan Commercial Claim and Encounters data. METHODS: We evaluated 10,969 patients diagnosed with laryngeal cancer from 2010 to 2012 using cross-tabulations and multivariate regression. RESULTS: Chemoradiation was significantly associated with supraglottic tumors (relative risk ratio [RRR] = 5.9 [4.4-7.8]), pretreatment gastrostomy (RRR = 4.0 [2.7-6.1]), and alcohol abuse (RRR = 0.5 [0.3-0.9]). Treatment-related complications occurred in 23% of patients, with medical complications in 22% and surgical complications in 7%. Chemoradiation (odds ratio [OR] = 3.7 [2.6-5.2]), major surgical procedures (OR = 4.9 [3.5-6.8]), reconstruction (OR = 7.7 (4.1-14.7)], and advanced comorbidity (OR = 9.7 [5.7-16.5] were associated with acute complications. Recurrent/persistent disease occurred in 23% of patients and was associated with high-volume care (OR = 1.4 [1.1-1.8]). Salvage surgery was performed in 46% of patients with recurrent/persistent disease and was less likely for supraglottic disease (OR = 0.5 [0.4-0.8]) and after chemoradiation (OR = 0.4 [0.2-0.6]). Initial treatment and 1-year overall costs for chemoradiation were higher than all other treatment categories, after controlling for all other variables including complications and salvage. High-volume care was associated with significantly lower costs of care for surgical patients but was not associated with differences in costs of care for nonoperative treatment. CONCLUSIONS: In commercially insured patients <65 years old with laryngeal cancer, chemoradiation was associated with increased costs, an increased likelihood of treatment-related medical complications, and a reduced likelihood of surgical salvage. Higher-volume surgical care was associated with lower initial treatment and 1-year costs of care. These data have implications for discussions of value and quality in an era of healthcare reform. LEVEL OF EVIDENCE: 2c. Laryngoscope, 128:91-101, 2018.

Costs from a healthcare and societal perspective among cancer patients after total laryngectomy: are they related to patient activation?

PURPOSE: The aim of this study is to investigate the associations between patient activation and total costs in cancer patients treated with total laryngectomy (TL). METHODS: All members of the Dutch Patients' Association for Laryngectomees were asked to participate in this cross-sectional study. TL patients who wanted to participate were asked to complete a survey. Costs were measured using the medical consumption and productivity cost questionnaire and patient activation using the Patient Activation Measure (PAM). Sociodemographic and clinical characteristics were self-reported, and health status measured using the EQ-5D. The difference in total costs from a healthcare and societal perspective among four groups with different PAM levels were compared using (multiple) regression analyses (5000 bootstrap replications). RESULTS: In total, 248 TL patients participated. Patients with a higher (better) PAM (levels 2, 3, and 4) had a probability of 70, 80, and 93% that total costs from a healthcare perspective were lower than in patients with the lowest PAM level (difference €-375 to €-936). From a societal perspective, this was 73, 87, and 82% (difference €-468 to €-719). After adjustment for time since TL, education, and sex, the probability that total costs were lower in patients with a higher PAM level compared to patients with the lowest PAM level changed to 62-91% (healthcare) and 63-92% (societal). After additional adjustment for health status, the probability to be less costly changed to 35-71% (healthcare) and 31-48% (societal). CONCLUSIONS: A better patient activation is likely to be associated with lower total costs from a healthcare and societal perspective.

Quality indicators of laryngeal cancer care in commercially insured patients.

OBJECTIVE: To examine associations between quality, complications, and costs in commercially insured patients treated for laryngeal cancer. STUDY DESIGN: Retrospective cross-sectional analysis of MarketScan Commercial Claim and Encounters data (Truven Health Analytics, Ann Arbor, Michigan, U.S.A.). METHODS: We evaluated 10,969 patients diagnosed with laryngeal cancer from 2010 to 2012 using cross-tabulations and multivariate regression. Using quality indicators derived from guidelines for recommended care, summary measures of quality were calculated for diagnosis, initial treatment, surveillance, treatment for recurrence, performance, and an overall summary measure of quality. RESULTS: Higher-quality care in the initial treatment period was associated with lower odds of 30-day mortality (odds ratio [OR] = 0.21, 95% confidence interval [CI] [0.04-0.98]), surgical complications (OR = 0.39 [0.17-0.88]), and medical complications (OR = 0.68 [0.49-0.96]). Mean incremental 1-year costs were higher for higher-quality diagnosis ($20,126 [$14,785-$25,466]), initial treatment ($17,918 [$10,481-$25,355]), and surveillance ($25,424 [$20,014-$30,834]) quality indicators, whereas costs were lower for higher-quality performance measures (-$45,723 [-$56,246--$35,199]) after controlling for all other variables. Higher-quality care was associated with significant differences in mean incremental costs for initial treatment in surgical patients ($-37,303 [-$68,832--$5,775]), and for the overall summary measure of quality in patients treated nonoperatively ($10,473 [$1,121-$19,825]). After controlling for the overall summary measure of quality, costs were significantly lower for patients receiving high-volume surgical care (mean -$18,953 [-$28,381--$9,426]). CONCLUSION: Higher-quality larynx cancer care in commercially insured patients was associated with lower 30-day mortality and morbidity. High-volume surgical care was associated with lower 1-year costs, even after controlling for quality. These data have implications for discussions of value and quality in an era of healthcare reform. LEVEL OF EVIDENCE: 2c. Laryngoscope, 127:2805-2812, 2017.

Prevalence and Occupation of Patients Presenting With Dysphonia in the United States.

OBJECTIVE: Voice disorders are common conditions that may have a significant impact on patient quality of life, yet their prevalence and epidemiology are poorly documented. In this study, we estimated the prevalence, demographics, and occupation of patients with dysphonia. METHODS: Using the Commercial and Medicare MarketScan databases of 146.7 million lives (2008-2012), the prevalence of dysphonia was estimated. Patient demographics and industry occupation were evaluated. Prevalence estimates overall and by industry were made using Medical Expenditure Panel Survey. Industry estimates were compared with US government employment statistics to assess differences between dysphonia and the general population. RESULTS: A gradual increase in the diagnosis of dysphonia was noted from 1.3% to 1.7% of the population from 2008 to 2012, with an associated increase in the diagnosis of acute laryngitis, the largest diagnostic category. A strong correlation was present between diagnosis and age, with acute laryngitis more common in the younger populations and malignancies in older ages. Benign neoplasms were more prevalent in the service industry, with 2.6 times increased likelihood compared with the general population, and malignancies were more prevalent in the manufacturing industry, with 1.4 times increased likelihood. Almost 3 million laryngoscopies and stroboscopies were performed with $900 million in costs. CONCLUSION: Prevalence rates of the diagnosis of dysphonia are increasing and are associated with large healthcare costs. Prevalence rates also differ somewhat between industries, and there appears to be a higher percentage of malignant neoplasms in the manufacturing industry and benign neoplasms in the service industry.

Impact of chronic obstructive pulmonary disease on patients undergoing laryngectomy for laryngeal cancer.

OBJECTIVES/HYPOTHESIS: Although chronic obstructive pulmonary disease (COPD) is a common comorbidity in patients undergoing laryngeal cancer surgery, the impact of this comorbidity in this setting is not well established. In this analysis, we used the Nationwide Inpatient Sample (NIS) to elucidate the impact of COPD on outcomes after laryngectomy for laryngeal cancer. METHODS: The NIS was queried for patients admitted from 1998 to 2010 with laryngeal cancer who underwent total or partial laryngectomy. Patient demographics, type of admission, length of stay, hospital charges, and concomitant diagnoses were analyzed. RESULTS: Our inclusion criteria yielded a cohort of 40,441 patients: 3,051 with COPD and 37,390 without. On average, COPD was associated with an additional $12,500 (P < 0.001) in hospital charges and an additional 1.4 days (P < 0.001) of hospital stay. There was no significant difference in incidence of in-hospital mortality between the COPD and non-COPD groups after total laryngectomy (1.1% in COPD vs. 1.0% in non-COPD; P = 0.776); however, there was an increased incidence of in-hospital mortality in the COPD group compared to the non-COPD group after partial laryngectomy (3.4% in COPD vs. 0.4% in non-COPD; P < 0.001). Multivariate adjusted logistic regression revealed that COPD was associated with greater odds of pulmonary complications after both partial laryngectomy (odds ratio [OR] = 3.198; P < 0.001) and total laryngectomy (OR = 1.575; P < 0.001). CONCLUSION: Chronic obstructive pulmonary disease appears to be associated with greater hospital charges, length of stay, and postoperative pulmonary complications in patients undergoing laryngectomy for laryngeal cancer. Chronic obstructive pulmonary disease after partial, but not total, laryngectomy appears to be associated with increased risk of in-hospital mortality. LEVEL OF EVIDENCE: 2C. Laryngoscope, 2016 127:417-423, 2017.

Effect of Payer Status on Relative Survival of Patients with Laryngeal Cancer.

BACKGROUND: Relative survival (RS) for patients with laryngeal cancer in the US population has yet to be described. Additionally, survival of patients with laryngeal cancer has demonstrated socioeconomic and racial disparities which have not been previously examined through the lens of RS. MATERIALS AND METHODS: Data on 58,814 patients with laryngeal cancer were obtained from the National Cancer Database. Patients were diagnosed between 1998 and 2006, and had at least 5 years of follow-up. Birth-, year-, age-, sex- and race-specific matched life expectancies were used to estimate expected survival. Stage-stratified RS rates were calculated with multiple factors assessed for significance. Excess mortality ratios were estimated in multivariate analysis utilizing Poisson regression. RESULTS: Younger age, African-American race, uninsured or Medicaid insurance, and treatment at an academic center were all significantly associated with stage IV disease. Uninsured and Medicaid patients demonstrated decreased RS when compared to privately insured individuals. Excess mortality was markedly pronounced in the first year for patients over 50 years old with stage II-IV disease, especially for the over 75-year-old cohort. CONCLUSION: Survival disparities for uninsured and Medicaid populations were found, with these patients exhibiting increased excess mortality. Additionally, RS calculations highlight the negative effects of increasing age on survival of patients with laryngeal cancer.

Quality of care and short- and long-term outcomes of laryngeal cancer care in the elderly.

OBJECTIVES/HYPOTHESIS: To examine associations between quality of care, short- and long-term treatment-related outcomes, and costs in elderly patients treated for laryngeal squamous cell cancer (SCCA). STUDY DESIGN: Retrospective analysis of Surveillance, Epidemiology, and End Results-Medicare data. METHODS: We evaluated longitudinal data from 2,370 patients diagnosed with laryngeal SCCA from 2004 to 2007 using cross-tabulations, multivariate regression, and survival analysis. Using quality indicators derived from guidelines for recommended care and performance measures, an overall summary measure of quality was calculated incorporating summary quality measures for diagnosis, initial treatment, performance, surveillance, treatment for recurrence, and end-of-life care. RESULTS: Higher-quality care was associated with a lower likelihood of long-term weight loss (odds ratio [OR] = 0.6 [0.5-0.8]), stricture (OR = 0.5 [0.3-0.8]), gastrostomy dependence (OR = 0.5 [0.4-0.7]), airway obstruction (OR = 0.7 [0.6-0.9]), tracheostomy (OR = 0.5 [0.3-0.7]), and pneumonia (OR = 0.7 [0.5-0.9]), but had no impact on the likelihood of dysphagia. Higher-quality care was associated with lower risk of death in patients with dysphagia (hazard ratio [HR] = 0.7 [0.6-0.8]), weight loss (HR = 0.8 [0.6-0.9]), airway obstruction (HR = 0.7 [0.6-0.8]), tracheostomy (HR = 0.7 [0.5-0.9]), and pneumonia (HR = 0.8 [0.6-0.9]), but was not associated with survival differences in patients with gastrostomy dependence or stricture. Costs associated with dysphagia, weight loss, stricture, airway obstruction, and pneumonia were lower for patients receiving higher-quality care. CONCLUSIONS: Higher-quality larynx cancer care was associated with a reduced incidence of late airway and swallowing impairment after laryngeal SCCA treatment in elderly patients, with improved survival and reduced costs. These data suggest that greater attention to evidence-based practices associated with quality indicators may lead to improved functional outcomes in the elderly. LEVEL OF EVIDENCE: 2c.

The impact of life tables adjusted for smoking on the socio-economic difference in net survival for laryngeal and lung cancer.

BACKGROUND: Net survival is a key measure in cancer control, but estimates for cancers that are strongly associated with smoking may be biased. General population life tables represent background mortality in net survival, but may not adequately reflect the higher mortality experienced by smokers. METHODS: Life tables adjusted for smoking were developed, and their impact on net survival and inequalities in net survival for laryngeal and lung cancers was examined. RESULTS: The 5-year net survival estimated with smoking-adjusted life tables was consistently higher than the survival estimated with unadjusted life tables: 7% higher for laryngeal cancer and 1.5% higher for lung cancer. The impact of using smoking-adjusted life tables was more pronounced in affluent patients; the deprivation gap in 5-year net survival for laryngeal cancer widened by 3%, from 11% to 14%. CONCLUSIONS: Using smoking-adjusted life tables to estimate net survival has only a small impact on the deprivation gap in survival, even when inequalities are substantial. Adjusting for the higher, smoking-related background mortality did increase the estimates of net survival for all deprivation groups, and may be more important when measuring the public health impact of differences or changes in survival, such as avoidable deaths or crude probabilities of death.

Treatment, survival, and costs of laryngeal cancer care in the elderly.

OBJECTIVES/HYPOTHESIS: To examine associations between treatment and volume with survival and costs in elderly patients with laryngeal squamous cell cancer (SCCA). STUDY DESIGN: Retrospective cross-sectional analysis of Surveillance, Epidemiology, and End Results-Medicare data. METHODS: We evaluated 2,370 patients diagnosed with laryngeal SCCA from 2004 to 2007 using cross-tabulations, multivariate logistic and generalized linear regression modeling, and survival analysis. RESULTS: Chemoradiation was significantly associated with supraglottic tumors (relative risk ratio: 2.6, 95% confidence interval [CI]: 1.7-4.0), additional cancer-directed treatment (odds ratio [OR]: 1.8, 95% CI: 1.2-2.7), and a reduced likelihood of surgical salvage (OR: 0.3, 95% CI: 0.2-0.6). Surgery with postoperative radiation was associated with significantly improved survival (hazard ratio [HR]: 0.7, 95% CI: 0.6-0.9), after controlling for patient and tumor variables including salvage. High-volume care was not associated with survival for nonoperative treatment but was associated with improved survival (HR: 0.7, 95% CI: 0.5-0.8) among surgical patients. Initial treatment and 5-year overall costs for chemoradiation were higher than for all other treatment categories. High-volume care was associated with significantly lower costs of care for surgical patients but was not associated with differences in costs of care for nonoperative treatment. CONCLUSIONS: Chemoradiation in elderly patients with laryngeal cancer was associated with increased costs, additional cancer-directed treatment, and a reduced likelihood of surgical salvage. Surgery with postoperative radiation was associated with improved survival in this cohort, and high-volume hospital surgical care was associated with improved survival and lower costs. These findings have implications for improving the quality of laryngeal cancer treatment at a time of both rapid growth in the elderly population and diminishing healthcare resources.

Inventory of economic evaluation of head and neck oncology from the German perspective.

New treatment strategies for head and neck neoplasms include induction chemotherapy and biomarker treatment. Moreover, different therapeutic modalities, especially robotic surgery, induction chemotherapy, biotherapy and altered fractionation schedules of chemo-(radio)therapy are newly combined to optimize treatment benefit and minimize treatment-associated morbidity. Often, overall survival does not change significantly between the competing treatment schedules. Therefore, the evaluation of the patient's treatment-related quality of life (QoL) and organ function becomes more and more important. Finally, the sponsor's financial resources are restricted, which makes it necessary to evaluate therapies for pricing and effectiveness. In head and neck cancer in Europe, analyses of the current situation are lacking. Selective literature research for publications on economic cost-effectiveness analyses was performed. An overview of the current situation with a special focus on Europe is provided. Cost-effectiveness values and QoL assessments should be respected in former prospective study construction to gain systematic information on this topic.

Exploring SEER-Medicare for changes in the treatment of laryngeal cancer among elderly medicare beneficiaries.

OBJECTIVE: To explore the change in frequency of treatment, and its association with 5-year survival, among elderly Medicare enrollees with squamous cell carcinoma of the larynx (SCCL). STUDY DESIGN: Retrospective analysis of a national cancer database. SUBJECTS AND METHODS: This was an analysis of the Surveillance, Epidemiology, and End Results (SEER)-Medicare data set of elderly patients diagnosed with SCCL between 1992 and 2007. Surgical and nonsurgical treatments were identified, and changes in frequency by year of cancer diagnosis were explored. A propensity-matched multivariate Cox proportional hazards model was used to compare the impact of treatment. RESULTS: There were 3324 cases of primary SCCL diagnosed between 1992 and 2007 studied. Most were male (n = 2605; 78%), white (n = 2845; 87%), and between 66 and 74 years of age (n = 1874; 56%). Between 1992 and 2005, there was a significant trend for increasing 5-year overall survival (43% in 1992 to 54% in 2005-2007; P < .01). There was a significant trend for decreasing frequency of surgical therapy (47% in 1992-1995 to 41% in 2005-2007; P = .03). Surgical therapy was associated with a decreased risk of overall mortality (hazard ratio, 0.76; 95% confidence interval, 0.68-0.86) in comparison to nonsurgical treatments. CONCLUSION: The analysis demonstrates an increase in survival among elderly Medicare enrollees diagnosed with SCCL between 1992 and 2007. Despite a significant trend for its decreasing use, there was a significantly decreased risk of overall mortality associated with surgical therapy.

Quality indicators of laryngeal cancer care in the elderly.

OBJECTIVES/HYPOTHESIS: To examine associations between quality of care, survival, and costs in elderly patients treated for laryngeal squamous cell cancer (SCCA). STUDY DESIGN: Retrospective analysis of Surveillance, Epidemiology, and End Results Medicare data. METHODS: We evaluated 2,370 patients diagnosed with laryngeal SCCA from 2004 to 2007 using multivariate regression and survival analysis. Using quality indicators derived from guidelines for recommended care, summary measures of quality were calculated for diagnosis, initial treatment, surveillance, treatment of recurrence, end-of-life care, performance, and an overall summary measure of quality. RESULTS: High-quality care was associated with significant differences in survival for diagnosis [HR = 0.80, 95% CI (0.66-0.97)], initial treatment [HR = 0.75 (0.63-0.88)], surveillance [HR = 0.54 (0.44-0.66)], treatment of recurrence [HR = 1.54 (1.26-1.89)], end-of-life care [HR = 0.69 (0.52-0.92)], performance [HR = 0.41 (0.33-0.52)], and an overall summary measure of quality [HR = 0.66 (0.54-0.80)], which was significantly associated with lower mean incremental costs [-$24,958 (-$35,873 - -$14,042)]. There was a significant survival advantage for initial treatment with surgery and postoperative radiation [HR = 0.66 (0.53-0.82)] and high-volume surgical care [HR = 0.64 (0.43-0.96)] after controlling for all other variables, including quality of care. CONCLUSIONS: High-quality larynx cancer care in elderly patients was associated with improved survival and reduced costs; however, high-quality care for treatment of recurrence was associated with poorer survival. These data suggest that survival outcomes in elderly patients with laryngeal cancer are not entirely explained by differences in the receipt of quality care using existing treatment and performance quality indicators and also suggest a need to develop sensitive and valid quality indicators of larynx cancer care in this population.

Estimating the social cost of respiratory cancer cases attributable to occupational exposures in France.

PURPOSE: The objective of this article was to estimate the social cost of respiratory cancer cases attributable to occupational risk factors in France in 2010. METHODS: According to the attributable fraction method and based on available epidemiological data from the literature, we estimated the number of respiratory cancer cases due to each identified risk factor. We used the cost-of-illness method with a prevalence-based approach. We took into account the direct and indirect costs. We estimated the cost of production losses due to morbidity (absenteeism and presenteeism) and mortality costs (years of production losses) in the market and nonmarket spheres. RESULTS: The social cost of lung, larynx, sinonasal and mesothelioma cancer caused by exposure to asbestos, chromium, diesel engine exhaust, paint, crystalline silica, wood and leather dust in France in 2010 were estimated at between 917 and 2,181 million euros. Between 795 and 2,011 million euros (87-92%) of total costs were due to lung cancer alone. Asbestos was by far the risk factor representing the greatest cost to French society in 2010 at between 531 and 1,538 million euros (58-71%), ahead of diesel engine exhaust, representing an estimated social cost of between 233 and 336 million euros, and crystalline silica (119-229 million euros). Indirect costs represented about 66% of total costs. CONCLUSION: Our assessment shows the magnitude of the economic impact of occupational respiratory cancers. It allows comparisons between countries and provides valuable information for policy-makers responsible for defining public health priorities.

Cost-minimisation and cost-effectiveness analysis comparing transoral CO2 laser cordectomy, laryngofissure cordectomy and radiotherapy for the treatment of T1-2, N0, M0 glottic carcinoma.

The financial costs of laryngeal cancer treatment are a notable burden on healthcare budgets. In this study, we assess whether CO2 laser surgery is cheaper than radiotherapy or laryngofissure and cordectomy in the treatment of T1-2, N0, M0 glottic squamous cell carcinoma. 56 patients with a mean age of 65.88 years (SD = 10.04), 53 men and 3 women, with T1-2, N0, M0 glottic squamous cell carcinoma were retrospectively analysed. We conducted a comparative analysis of costs associated with three treatments: carbon dioxide laser cordectomy (n = 21), radiotherapy (n = 20), and laryngofissure cordectomy (n = 15). Complications of the radiotherapy and surgical treatments, need for tracheotomy and its permanence, length of hospital stay, occupation and ability to work and economic costs of treatments were recorded. Cost-minimisation and cost-effectiveness analysis were obtained. The cost of transoral laser cordectomy (2,289.79 euro) is statistically significantly lower than that of radiotherapy (4,804.72 euro) or laryngofissure cordectomy (13,229.75 euro) (p < 0.001). Transoral carbon dioxide laser surgery is the best option in terms of cost-effectiveness for the treatment of T1-2, N0, M0 glottic cancer.

Comparison of efficacy, safety, and cost-effectiveness of in-office cup forcep biopsies versus operating room biopsies for laryngopharyngeal tumors.

OBJECTIVE: To compare the diagnostic yield, safety, and cost of biopsies of laryngopharyngeal tumor performed in an office setting with those performed in the operating room (OR) under general anesthesia. STUDY DESIGN: This was a retrospective review of patients' records at Boston Medical Center from 2006 to 2008. METHODS: In-office biopsies were performed using flexible digital videolaryngoscopy with cup forcep biopsies taken via the working channel in patients in whom cancer was strongly suspected. Patients whose in-office biopsies were nondiagnostic or suspected to be falsely negative were taken to the OR for biopsy under general anesthesia and served as the control group. RESULTS: Twelve patients fit the selection criteria and had in-office biopsies attempted. One patient could not tolerate the in-office biopsy. Seven of the 11 in-office biopsies performed were diagnostic for squamous cell carcinoma. The average cost (facility and professional otolaryngology charges) for an in-office biopsy was $2053.91. Five of these patients required further biopsy in the OR at an average cost (charges for surgeon, OR, anesthesia, and recovery room) of $9024.47. There were no significant complications reported for any of the procedures. CONCLUSIONS: In patients with strongly suspected laryngopharyngeal cancer, in-office cup forcep biopsies were 64% diagnostic. When compared with the OR, in-office cup biopsies of laryngopharyngeal tumor are safe and considerably more cost-effective. Although 36% of patients required operative biopsies, the cost would have been considerably higher in this cohort if all patients had gone to the OR for biopsies.