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Original Investigation |

Selection of Ideal Candidates for Surgical Salvage of Head and Neck Squamous Cell Carcinoma Effect of the Charlson–Age Comorbidity Index and Oncologic Characteristics on 1-Year Survival and Hospital Course

JeeHong Kim, BS1; Seungwon Kim, MD2; William G. Albergotti, MD2; Phillip A. Choi, BS1; Daniel James Kaplan, BA1; Shira Abberbock, MS3; Jonas T. Johnson, MD2; Neil Gildener-Leapman, MD4
[+] Author Affiliations
1University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
2Department of Otolaryngology–Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
3Biostatistics Facility, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
4Department of Surgery, Division of Otolaryngology–Head and Neck Surgery, Albany Medical College, Albany, New York
JAMA Otolaryngol Head Neck Surg. 2015;141(12):1059-1065. doi:10.1001/jamaoto.2015.2158.
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Importance  Salvage surgery for recurrent head and neck squamous cell carcinoma (HNSCC) carries substantial risks of morbidity and mortality. Risk factors for death within 1 year should be better defined.

Objectives  To report preoperative oncologic prognostic factors predictive of short-term (<1 year) survival after salvage surgery in patients with HNSCC, to assess whether preoperative age and comorbidity predicts 1-year mortality, and to report hospital courses after salvage surgery within 1 year.

Design, Setting, and Participants  A retrospective medical record review of 191 patients with recurrent HNSCC treated with salvage surgery from January 1, 2003, through December 31, 2013, at a tertiary academic center.

Interventions  Surgical salvage of HNSCC (larynx, oral cavity, oropharynx, or hypopharynx) with curative intent.

Main Outcomes and Measures  Primary outcome was survival 1 year after salvage surgery. Secondary outcomes were length of inpatient hospital stay, days of admissions, and skilled nursing facility disposition within 1 year stratified by survival status. Presalvage Charlson–Age Comorbidity Index (CACI) was calculated. Associations among CACI, oncologic risk factors, and risk of death within 1 year after salvage surgery are investigated using multivariable analysis.

Results  Of 191 patients studied, 53 (27.7%) died within 1 year after salvage surgery. Patients who died within 1 year had more total inpatient admissions (P < .001), longer total length of stay (P < .001), and higher risk of discharge to a skilled nursing facility (P < .001) and spent 17.3% (interquartile range, 5.2-36.3) of their remaining days in the hospital. Independent risk factors for death within 1 year are CACI (relative risk [RR], 1.43; 95% CI, 1.16-1.76), primary T3 or T4 stage (RR, 2.34; 95% CI, 1.27-4.31), and disease-free interval of less than 6 months (RR, 5.61; 95% CI, 1.78-16.7).

Conclusions and Relevance  Medical comorbidity and age as measured by the CACI, primary T3 or T4 stage, and short disease-free interval must be considered in selecting patients ideal for surgical salvage surgery for recurrent HNSCC. Patients with these risk factors should be more strongly considered for palliative measures.

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Figure.
Kaplan-Meier Plot for Overall Survival of Patients After Salvage Surgery, Stratified by Comorbidity Score

Patients with Charlson–Age Comorbidity Index (CACI) scores less than 6 had a survival advantage. Estimated median survival was 19 months (95% CI, 10-25 months) for the group with CACI scores of 6 or higher and 81 months (95% CI, 41 months to not reached) for the group with CACI scores less than 6. Number at risk was 104 for CACI score less than 6 and 87 for CACI score of 6 or higher.

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