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Objective To assess the effect that implementation of a multimodal analgesic plan has on opioid requirements and pain control in head and neck (H&N) surgery patients. Study Design Prospective cohort. Setting Tertiary academic hospital. Subjects and Methods An institutional review board (IRB)–approved quality improvement initiative was undertaken to implement a multimodal analgesic protocol for all admitted H&N surgery patients starting November 2017. Postprotocol data from January to May 2018 were compared to preprotocol data from May to October 2017. Data were obtained from the electronic health records as well as through preoperative and postoperative surveys. Average pain scores and opioid use in morphine milligram equivalents (MMEs) before and after protocol implementation were compared. Results In total, 139 postprotocol patients were compared to 89 preprotocol patients. The adjusted MMEs in the first 24 hours after surgery decreased significantly from 93.7 mg to 58.6 mg ( P = .026) with protocol implementation. When averaged over the length of stay (MME/hospital day), the change was no longer statistically significant (57.9 vs 46.8 mg, P = .211). The average pain score immediately after surgery and on day of discharge did not change with protocol implementation. Conclusion Implementation of a multimodal analgesia plan reduced opioid use immediately after surgery but not over the course of hospitalization without any change in reported pain scores. This study shows that multimodal opioid-sparing analgesia after H&N surgery is feasible. Future studies are needed further refine the optimal analgesic strategy for H&N patients and assess the long-term efficacy, safety, and cost of such regimens.

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Background: DNA sequencing panels can simultaneously quantify human and viral tumor markers in blood. We explored changes in levels of plasma tumor markers following surgical resection of head and neck carcinoma. Methods: In preresection and postresection plasmas, targeted DNA sequencing quantified variants in 28 human cancer genes and levels of oncogenic pathogens (human papillomavirus [HPV], Epstein-Barr virus [EBV], Helicobacter pylori) from 21 patients with head and neck squamous cell carcinoma. Results: Preresection, 11 of 21 patients (52%) had detectable tumor markers in plasma, most commonly TP53 mutation or HPV genome. Several days postresection, levels fell to undetectable in 8 of 10 evaluable patients, while two high-stage patients retained circulating tumor markers. Conclusions: Modern sequencing technology can simultaneously quantify human gene variants and oncogenic viral genomes in plasma. Falling levels of cancer-specific markers upon resection can help identify viral and human markers to track at subsequent timepoints as a means to evaluate efficacy of interventions.

The increase in human papillomavirus (HPV)e related oropharyngeal squamous cell carcinoma (OPSCC) has resulted in drastically improved oncologic outcomes. To better prognosticate this cancer, the 8 th edition American Joint Committee on Cancer (AJCC) recently created a staging system specifically for HPV-related OPSCC. This system has not yet been validated in a population-based cohort. We sought to compare the prognostic ability of the new 8 th edition AJCC staging system to the 7 th edition system in a population-based cohort. Our hypothesis is that the 8 th edition AJCC staging system will provide better prognostication of HPV-related OPSCC. Materials/Methods: This retrospective cohort study used patients selected from the Carolina Head and Neck Cancer Study (CHANCE) database. The database contains head and neck cancer patients diagnosed between January 1, 2002 and February 28, 2006 who reside in a 46-county region in central North Carolina and were followed for over 5 years. Patients with OPSCC tumors positive for p16 expression by immunohistochemistry were selected for this study. One hundred and sixty-one HPV-associated OPSCC patients met inclusion criteria out of 1381 study patients. The outcome was 5-year overall survival. Results: The HPV-related OPSCC cohort was predominantly male (81.9%), white (92.9%), and between 51-65 years of age at time of diagnosis (53.5%). Approximately one-third of cases reported no previous tobacco use. Nearly the entire study population underwent radiation, while 66% underwent chemotherapy and 56% underwent surgery. AJCC 7 th edition stage I through stage IVA all had similar 5-year overall survival rates (85.71%-87.50%) and stage IVB had the worst survival (64.52%). AJCC 8 th edition stage I (85.0%) patients had a favorable 5-year overall survival compared with stage II (69.2%) and stage III (54.3%), respectively. Hazard ratios were calculated accounting for age, sex, insurance status, tobacco use, and treatment type. (Table) Only the 8 th edition stage III showed any statistical significance in risk stratification. Prognostic value was compared by C-index, which was 0.73 (95% CI: 0.63, 0.84) for the AJCC 7 th edition and 0.76 (95% CI: 0.65, 0.87) for the AJCC 8 th edition. Conclusion: When compared to the AJCC 7 th edition staging system, the 8 th edition system improved tumor distribution and risk stratification but did not significantly improve prognostication. While the limitations of the 7 th edition still exist, caution may be warranted as we transition to this new approach in staging.

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