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Original Investigation |

Positron Emission Tomography and Stage Migration in Head and Neck Cancer

Noam A. VanderWalde, MD1,2; Ramzi G. Salloum, PhD3; Tsai-Ling Liu, MSPH4; Mark C. Hornbrook, PhD5; Maureen C. O’Keeffe Rosetti, MS5; Debra P. Ritzwoller, PhD6; Paul A. Fishman, PhD7; Jennifer Elston Lafata, PhD8,9; Amir H. Khandani, MD2,10; Bhishamjit S. Chera, MD1,2
[+] Author Affiliations
1Department of Radiation Oncology, University of North Carolina at Chapel Hill
2Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill
3Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia
4Department of Health Policy and Management, Gillings School of Public Health, University of North Carolina at Chapel Hill
5The Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
6Institute for Health Research, Kaiser Permanente Colorado, Denver
7Group Health Research Institute, Group Health Cooperative, Seattle, Washington
8Social and Behavioral Health and Massey Cancer Center, School of Medicine Virginia Commonwealth University, Richmond
9Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan
10Division of Nuclear Medicine, Department of Radiology, University of North Carolina at Chapel Hill
JAMA Otolaryngol Head Neck Surg. 2014;140(7):654-661. doi:10.1001/jamaoto.2014.812.
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Importance  Since 2001, there has been a rapid adoption of positron emission tomography (PET) for diagnosis and American Joint Committee on Cancer (AJCC) staging of head and neck cancer (HNC) without data describing improved clinical outcomes.

Objective  To determine the association between increased use of PET and stage and/or survival for patients with HNC in the managed care environment.

Design, Setting, and Participants  Adult patients diagnosed as having HNC (n = 958) from 2000 to 2008 at 4 integrated health systems were identified via tumor registries linked to administrative data. The AJCC stage distribution, patient and treatment characteristics, and survival between pre-PET era (2000-2004) vs PET era (2005-2008) and use of PET vs no use of PET during the PET era were compared. The AJCC stages were categorized to represent localized (stage I or II), locally advanced (stage III, IVA, or IVB), and metastatic (stage IVC) disease.

Interventions  Treatments were determined by billing codes for surgery, radiation treatment, and chemotherapy.

Main Outcomes and Measures  The primary outcome for this study was the use of PET. Secondary outcomes included treatment received and 2-year survival. A logit model estimated the effects of PET on diagnosis of locally advanced disease. Kaplan-Meier estimates described overall survival differences between PET and non-PET. Cox regression evaluated the association of PET on survival in patients with locally advanced disease.

Results  An association between PET and locally advanced disease was found (odds ratio, 2.86 [95% CI, 1.90-4.29) (P < .001). Two-year overall survival for patients with locally advanced disease with and without PET was 52% and 32%, respectively (P = .004), but there was no difference for all stages (P = .69). On Cox proportional hazard regression, PET had no association with survival in patients with locally advanced disease (hazard ratio, 1.208 [95% CI, 0.778-1.877]) (P = .40).

Conclusions and Relevance  The increasing use of PET among patients with HNC is associated with a greater number of patients with higher-stage disease and a dilution of the population with higher-stage disease with patients who have a better prognosis. Thus, the improved survival in patients with locally advanced disease likely reflects selection bias and stage migration. Further research on PET use among patients with HNC is necessary to determine if it results in improved treatment for individual patients.

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Figure 1.
Diagnosis Stage in All Patients Across Eras and PET vs No PET in the PET Era

Localized disease was defined as American Joint Committee on Cancer stage I or II; locally advanced, stage III, IVA, or IVB; and metastatic, stage IVC disease. PET indicates positron emission tomography.

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Figure 2.
Kaplan-Meier Survival Curves Within the PET Era

Localized disease was defined as American Joint Committee on Cancer stage I or II; locally advanced, stage III, IVA, or IVB. PET indicates positron emission tomography.

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