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Original Investigation |

Individualized Risk Estimation for Postoperative Complications After Surgery for Oral Cavity Cancer

Mahmoud I. Awad, MD1; Frank L. Palmer, BA1; Lei Kou, MA2; Changhong Yu, MS2; Pablo H. Montero, MD1; Andrew G. Shuman, MD1; Ian Ganly, MD, PhD1; Jatin P. Shah, MD1; Michael W. Kattan, PhD2; Snehal G. Patel, MD1
[+] Author Affiliations
1Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
2Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
JAMA Otolaryngol Head Neck Surg. 2015;141(11):960-968. doi:10.1001/jamaoto.2015.2200.
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Importance  Postoperative complications after head and neck surgery carry the potential for significant morbidity. Estimating the risk of complications in an individual patient is challenging.

Objective  To develop a statistical tool capable of predicting an individual patient’s risk of developing a major complication after surgery for oral cavity squamous cell carcinoma.

Design, Setting, and Participants  Retrospective case series derived from an institutional clinical oncologic database, augmented by medical record abstraction, at an academic tertiary care cancer center. Participants were 506 previously untreated adult patients with biopsy-proven oral cavity squamous cell carcinoma who underwent surgery between January 1, 2007, and December 31, 2012.

Main Outcomes and Measures  The primary end point was a major postoperative complication requiring invasive intervention (Clavien-Dindo classification grades III-V). Patients treated between January 1, 2007, and December 31, 2008 (354 of 506 [70.0%]) comprised the modeling cohort and were used to develop a nomogram to predict the risk of developing the primary end point. Univariable analysis and correlation analysis were used to prescreen 36 potential predictors for incorporation in the subsequent multivariable logistic regression analysis. The variables with the highest predictive value were identified with the step-down model reduction method and included in the nomogram. Patients treated between January 1, 2007, and December 31, 2008 (152 of 506 [30.0%]) were used to validate the nomogram.

Results  Clinical characteristics were similar between the 2 cohorts for most comparisons. Thirty-six patients in the modeling cohort (10.2%) and 16 patients in the validation cohort (10.5%) developed a major postoperative complication. The 6 preoperative variables with the highest individual predictive value were incorporated within the nomogram, including body mass index, comorbidity status, preoperative white blood cell count, preoperative hematocrit, planned neck dissection, and planned tracheotomy. The nomogram predicted a major complication with a validated concordance index of 0.79. Inclusion of surgical operative variables in the nomogram maintained predictive accuracy (concordance index, 0.77).

Conclusions and Relevance  A statistical tool was developed that accurately estimates an individual patient’s risk of developing a major complication after surgery for oral cavity squamous cell carcinoma.

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Figure 1.
Preoperative Nomogram Predicting Major Complications

Shown is a nomogram predicting the probability of developing a complication requiring invasive intervention (grade ≥III) based on preoperative variables only. BMI indicates body mass index (calculated as weight in kilograms divided by height in meters squared); WUHNCI, Washington University Head and Neck Comorbidity Index. To convert white blood cell count to ×109/L, multiply by 0.001; to convert hematocrit to proportion of 1.0, multiply by 0.01.

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Place holder to copy figure label and caption
Figure 2.
Postoperative Nomogram Predicting Major Complications

Shown is a nomogram predicting the probability of developing a complication requiring invasive intervention (grade ≥III) after postoperative variables become available. WUHNCI indicates Washington University Head and Neck Comorbidity Index. To convert white blood cell count to ×109/L, multiply by 0.001; to convert hematocrit to proportion of 1.0, multiply by 0.01.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.
Preoperative Nomogram Predicting All Complications

Shown is a nomogram predicting the probability of developing a complication requiring any intervention (grade ≥II) based on preoperative variables only. BMI indicates body mass index (calculated as weight in kilograms divided by height in meters squared); WUHNCI, Washington University Head and Neck Comorbidity Index. To convert white blood cell count to ×109/L, multiply by 0.001; to convert sodium level to millimoles per liter, multiply by 1.0; and to convert alkaline phosphatase level to microkatals per liter, multiply by 0.0167.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.
Postoperative Nomogram Predicting All Complications

Shown is a nomogram predicting the probability of developing a complication requiring any intervention (grade ≥II) after postoperative variables become available. BMI indicates body mass index (calculated as weight in kilograms divided by height in meters squared); WUHNCI, Washington University Head and Neck Comorbidity Index. To convert white blood cell count to ×109/L, multiply by 0.001; to convert sodium level to millimoles per liter, multiply by 1.0.

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