All-Cause 30-Day Mortality After Surgical Treatment for Head and Neck Squamous Cell Carcinoma in the United States

Abstract

Objectives: Thirty-day (30-day) mortality, a common posttreatment quality metric, is yet to be described following surgery for head and neck squamous cell carcinoma (HNSCC). This study aimed to measure 30-day postoperative mortality in HNSCC and describe clinical/nonclinical factors associated with 30-day mortality. Methods: In this retrospective cohort study, the National Cancer Database (2004 to 2013) was queried for eligible cases of HNSCC (n=91,858). Adult patients were included who were treated surgically with curative intent for the primary HNSCC, not missing first treatment, survival, and follow-up information. The outcome of interest was all-cause mortality within 30 days of definitive surgery. Clinical and nonclinical factors associated with all-cause 30-day postoperative mortality were estimated using a fully adjusted, multivariable logistic regression, which accounted for time-varying nature of adjuvant therapy. Results: A total of 775 patients died within 30 days of definitive surgery for HNSCC (30-day mortality rate of 0.84%). Thirty-day mortality rate was however up to 2.33% (95% confidence interval [CI], 1.91%-2.75%) depending on comorbidity. In the fully adjusted model, increasing severity of comorbidity was associated with greater odds of 30-day mortality (Charlson-Deyo comorbidity scores of 1: adjusted odds ratio [aOR], 1.43; 95% CI, 1.21-1.69, and of 2+ aOR, 2.55; 95% CI, 2.07-3.14). Odds of 30-day mortality were greater among Medicaid patients (aOR, 1.77; 95% CI, 1.30-2.41), and in patients in neighborhoods with little education (≥ 29% missing high school diploma: aOR, 1.35; 95% CI, 1.02-1.78). Conclusions: Patients with higher 30-day mortality were those with a greater burden of comorbidities, with little education, and covered by Medicaid.

Survival outcomes for head and neck patients with Medicaid: A health insurance paradox

“…In the HNC context, the prognostic importance of comorbidity is underscored by a study that demonstrated that severe comorbidity burden is as impactful on HNC survival as T4 stage tumor 43 . While our study could not assess comorbidity burden due to lack of data, this association between Medicaid and comorbidity burden previously established in other studies might be a plausible explanation for the poor outcomes seen in these patients insured under Medicaid 44 …”

“…Second, we do not have any information on patients' comorbid conditions or smoking and alcohol habits, which would have been critical in appraising the overall health of patients at the time of diagnosis. There is reason to believe that patients under Medicaid may have greater comorbidity burden than those uninsured, 44 which might explain why they have poorer survival outcomes even when able to afford some care due to them having Medicaid 44,51 . Third, in regard to insurance status, patients coded as “insured, no specifics” for the insurance variable in SEER include patients with “Medicare/Medicare, NOS” and “Insurance, NOS.” These patients were included with patients with private insurance, but if 18–64‐year‐old patients actually had Medicaid, the point estimates of Medicaid could be biased toward the null.…”

“…43 While our study could not assess comorbidity burden due to lack of data, this association between Medicaid and comorbidity burden previously established in other studies might be a plausible explanation for the poor outcomes seen in these patients insured under Medicaid. 44 It should be noted that there are numerous social factors that affect health other than health insurance. McGinnis et al found that medical care was responsible for only 10% of preventable mortality in the United States.…”

Association of comorbidity score with perioperative outcomes following transoral robotic surgery: National analysis

“…Age was the only other clinical variable associated with perioperative mortality. The perioperative mortality rate for all surgically treated patients with head and neck cancer was recently reported as 0.84% by Bukatko et al using the NCDB 18 . In their review, the clinical variables with the strongest relationship with perioperative mortality were CDCC and tumor stage 18 .…”

Sociodemographic correlates of head and neck cancer survival among patients with metastatic disease

“…While sociodemographic factors such as marital status, [7][8][9] health insurance status, [10][11][12][13][14] and race/ethnicity [15][16][17][18][19][20] have been explored in HNC, it is unknown if these factors impact patients of HNC with end-stage disease. It is also unknown if there are differences in the impact of these sociodemographic factors based on whether cases are oropharyngeal vs non-oropharyngeal.…”