Background The cost of head and neck cancer treatment is of interest to clinicians and providers. The aim of this work was to estimate the costs of treating and rehabilitating patients following different head and neck cancer diagnoses. Design A single-centre retrospective cohort study using purposive sampling of patient records. Patient-level costing was performed using the hospital’s Patient Level Information and Costing System (PLICS), capturing costs across surgical, radiotherapeutic, and oral rehabilitation pathways. Results Ten patients were included. Treatment costs ranged from £15,560 to £69,536. Advanced-stage cancers were costly, requiring multi-modality treatment and complex oral rehabilitation. Primary dental implant placement was more cost-effective than delayed placement. Conclusion There is substantial variability in the cost of curative treatment and oral rehabilitation for head and neck cancer. Stage at diagnosis and modality of rehabilitation significantly influence total cost. These findings support the economic rationale for early detection and standardised rehabilitation protocols.

Head and neck cancers and their respective treatments have a profound impact on quality of life. Many oropharyngeal and oral cancers are likely to have implications for oral health-related quality of life (OHRQoL), but research investigating tools to measure this are lacking. We conducted a scoping review to ascertain the available tools for measuring OHRQoL in head and neck cancer patients. The primary objective was to compile a summary of the existing tools and determine their completeness, validity, and reliability. The literature search yielded 1239 articles. Thirty-one studies were included in the review and multiple tools were identified. None of the tools assessed all potential OHRQoL impacts, and none had undergone comprehensive testing using a range of assessments. Most of the tools did not adhere to published guidance, with only the European Organisation for Research and Treatment of Cancer (EORTC) citing methodological guidance in their survey tool development protocols. All tools achieved recommended readability scores in English. Due to methodological flaws in the evidence base, it was not possible to definitively establish the completeness of any available tool. There was discordance between tools regarding the relevant OHRQoL impacts. Several tools failed to assess accepted domains of OHRQoL, calling into question their concordance with the construct of OHRQoL. In addition, there was a lack of adherence to published standards regarding both the construction and testing methods for quality-of-life instruments. Studies reporting on OHRQoL in head and neck cancer may, therefore, not comprehensively assess the actual impacts of the disease and its treatment.

Mandibular osteoradionecrosis (ORN) is a severe late radiation toxicity affecting 5–10

BACKGROUND:Cancer patients are at risk of developing a wide range of treatment-related toxicities that may affect the head and neck region. Iatrogenic necrosis of bone and soft tissue in this area represents a distinct clinical entity characterized by significant complexities and challenges, arising as a consequence of radiotherapy (osteoradionecrosis) or the administration of bone-modifying and/or antiangiogenic therapies (medication-related osteonecrosis of the jaw). OBJECTIVE:This review provides a comprehensive understanding of this potentially highly impactful complication of cancer therapy and antiresorptive therapy by examining its pathophysiology, risk factors, clinical presentation, and management strategies. RESULTS:Risk factors associated with these conditions include radiotherapy-related variables, medication-related factors, and local predisposing conditions. CONCLUSION:This review highlights the importance of preventive strategies, including comprehensive dental evaluations and the development of personalized treatment plans before, during, and after cancer therapy, as well as when patients are undergoing or are expected to undergo treatment with bone-modifying medications. By addressing these critical aspects, clinicians can better manage and mitigate the impact of this challenging complication on the quality of life and morbidity outcomes.

Cancer cachexia (CC) syndrome, a feature of cancer-associated muscle wasting, is particularly pronounced in older patients, and is characterised by decreased energy intake and upregulated skeletal muscle catabolic pathways. To address CC, appetite stimulants, anabolic drugs, cytokine mediators, essential amino acid supplementation, nutritional counselling, cognitive behavioural therapy, and enteral nutrition have been utilised. However, pharmacological treatments that have also shown promising results, such as megestrol acetate, anamorelin, thalidomide, and delta-9-tetrahydrocannabinol, have been associated with gastrointestinal and cardiovascular complications. Emerging evidence on the efficacy of probiotics in modulating gut microbiota also presents a promising adjunct to traditional therapies, potentially enhancing nutritional absorption and systemic inflammation control. Additionally, low-dose olanzapine has demonstrated improved appetite and weight management in older patients undergoing chemotherapy, offering a potential refinement to current therapeutic approaches. This review aims to elucidate the molecular mechanisms underpinning CC, with a particular focus on the role of anorexia in exacerbating muscle wasting, and to propose pharmacological and non-pharmacological strategies to mitigate this syndrome, particularly emphasising the needs of an older demographic. Future research targeting CC should focus on refining appetite-stimulating drugs with fewer side-effects, specifically catering to the needs of older patients, and investigating nutritional factors that can either enhance appetite or minimise suppression of appetite in individuals with CC, especially within this vulnerable group.

Health -related quality of life and patient-reported outcome measurement in Head and Neck Oncology Improvements in head and neck cancer (HNC) care strive to enhance a range of patient outcomes including survival, reduced treatment burden, better shared decision making, more individualised and tailored treatments and health related quality of life (HRQOL).HRQOL is now an established component and represents the patients' physical, psychological, and social response to the disease and therapy (WHOQOL, 1998) (1).There is a range and complexity of the literature on HNC reporting HRQOL outcomes (quantitative and qualitative) and this is reflected in the "Handle on QOL' resource (2).A broader scope of outcomes is addressed through the terms patient-reported outcomes (PROs) or patient-reported outcome measurements (PROMs).These encompass any measures obtained directly from the patient, which include areas of HRQOL, as well as wider concepts such as patient satisfaction with care (3).Over the last three decades, HRQOL has become a significant outcome measure for cancer patients in clinical trials (4).In this setting, patient-reported HRQOL data is commonly required alongside progression-free survival, and overall survival to assess the efficacy of a given therapeutic intervention.In addition, in some units, HRQOL is routinely collected during follow-up and this serves to establish large longitudinal datasets and also provides the opportunity for using the HRQOL data to inform individual patient care (5).As part of NHS England improving cancer outcomes programme (QOL Metric) all cancer patients are being invited to complete the ED-5d (6) and EORTC-C30 (7) instruments, at 18 months of being told of the diagnosis (8).This data is available on a dashboard as well as for individual patients.Such national initiatives will serve to provide a very useful material to help drive changes in practice and care which will result in improved HRQOL outcomes.The clinical care of individual patients in oncology clinics is augmented by regular measurement of PRO such as symptoms, functioning, and HRQOL, both before and during treatment (9).This plays an important role in informing clinicians of the degree of dysfunction in specific domains.In addition to HRQOL, it is feasible to monitor symptoms and ask about patient concerns and this helps to disclose potential unmet needs and provide a mechanism through which additional multidisciplinary support can be initiated.A better understanding by the patient, carers and clinicians as to the PRO can aid communication and allow more active treatment decision making.Published evidence indicate that measuring the HRQOL early after the completion of treatment may provide an indication of the likely HRQOL at 12 months post-treatment (10).There are a number of questionnaires currently being used by various health and social care professionals (3) but these are limited in their scope of enquiry by the nature of the number of items included, the format of the measure, such as Likert scale, the wording and formatting.HRQOL can be measured reliably and validly (11) so as to help clinicians gain insights into a patient's perspective of their disease and treatment.One of the key challenges to the use of PRO in clinical care is poor communication and lack of co-ordination between primary and secondary healthcare, social care and third sector providers (voluntary agencies).This results in patients having repeated assessments on their care pathway, repeatedly providing the same information, inefficiencies in terms of untargeted support, resources used in those with low needs and requirement and repetition of already stretched services.The use of disease specific prompt lists allows for a much better opportunity for holistic assessment by virtue of the range of issues covered.One such example is the HNC specific Patient Concerns Inventory (PCI-HN) that has been tested in a randomised control trial (12).Papers reporting on specific aspects of HRQOL have been published in a variety of journals (2).Clinical teams need time and effort to identify what may be relevant to their practice.The purpose of a special series on HRQOL is to provide an update by bringing together all the important, and often interrelated issues in HNC care.These include holistic needs assessments, identification of unmet needs and their effect on patients and families, functional outcomes as well as the psychological impact of a cancer diagnosis on relationships and sexual wellbeing.

Introduction: Oral cancer surgery is complicated by the diverse nature of clinical and histopathological presentations that occur. Current National guidance recognises the significant role that surgical margin status plays in the overall survival of patients. Many other histopathological factors influence patient survival, the importance of which varies between the literature.Materials and methods: In this prospective longitudinal study, all patients diagnosed with squamous cell carcinoma who had primary surgical treatment under general anaesthesia were included. Surgery was performed by one surgical team within this tertiary referral centre. Patients were followed up for a maximum of 7 years following their surgery.Results: A total of 250 patients were included from 2015 to 2022. Patients were 61.44 years old (SD 13.23) at diagnosis, and 56.4% were male (n = 141). Pathology was mainly pT1 (39.1%) and the most common sites were the border of tongue (31.2%) and floor of mouth (18.8%). 43.4% of patients had clear surgical margins, with overall survival being significantly associated with margin status (p = 0.0079). Extra -capsular spread was significantly associated with higher risk of death from metastatic head and neck cancer (p = 0.014), whereas presence of high-grade dysplasia at surgical margins and depth of invasion of tumour were not.Conclusion: This study has reinforced the importance of surgical margin clearance and as such the development of intra-operative techniques to ensure this is imperative. The significance of extra-capsular spread in survival has also been demonstrated. Discussion regarding the current deficiency in accurate pre-operative diagnostic methods for extra capsular spread is covered.(c) 2022 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

INTRODUCTION:The aim of this paper is to report the pattern of follow-up that occurred for a cohort of head and neck cancer (HNC) patients across two large centres in the UK (Aintree and Leeds), as a consequence of the COVID-19 pandemic. METHODS:Patients had been treated for HNC with curative intent between April 2017 and October 2019 by 14 oral and maxillofacial (OMFS) and ear nose and throat (ENT) oncology surgeons in the Patient Concerns Inventory intervention trial. In October 2020, hospital records were reviewed, and information collected on the timing and mode (face-to-face/telephone/video) of follow-up consultations. In addition, recurrence, second primary tumours and deaths were recorded. RESULTS:At the start of 'lockdown', 212 members of the cohort were known to be alive. During the post-lockdown period (follow-up appointment data comprised 5 months in Aintree and 7 months in Leeds) 7 died and 13 were identified as palliative/recurrence/new primary/metastases ('new event'). In Aintree, the first ENT/OMFS consultations after lockdown were 51 (67%) telephone and 25 (33%) face-to-face appointments. In Leeds, 46 (78%) consultations were by telephone and 13 (22%) were face-to-face. The second ENT/OMFS consultations post lockdown included 11 (44%) telephone and 14 (56%) face-to-face in Aintree, and 21 (75%) telephone and 7 (25%) face-to-face in Leeds. CONCLUSIONS:These data suggest that clinicians favoured remote consultations. Variations in practice were observed but reached a point of a 'hybrid follow-up approach' that included both face-to-face and remote consultations. With the emergence of telemedicine, clinicians may consider a follow-up model tailored to risk stratification. The development of the mode of such a consultation model needs further evaluation.

Venous-only perfusion flaps have not been used widely because of the associated high failure rate. Tissue conditioning offers a broad scope of techniques that can be applied pre-, peri-, or postoperatively to promote the adaptation of the affected tissue to any subsequent stress. This study aimed to assess the survival rates associated with a pure venous perfusion flap and investigate whether the timing of the vascular conditioning can affect free flap survival. Forty-four rats were included in the experiment. Group I underwent veno-arterial anastomoses with epigastric graft with pure venous perfusion without tissue conditioning. Groups II and III were pretreated for 7 or 14 days with ischemic conditioning. These groups were compared with a control group (group IV) of conventionally perfused flaps. After the initial surgery, all flaps were assessed clinically, photometrically, and by indocyanine green videoangiography. The flap success rates were 0% in group I, 49.97% ± 24.34% in group II, and 64.95% ± 20.36% in group III. The control group showed an overall survival of 89.3% ± 6.51%. With suitable conditioning, pure venous blood supply can provide adequate perfusion in the rat epigastric flap model. The timing of vascular conditioning appears to be critical for flap survival.

Head and neck cancer has a significant impact on a patient’s health related quality of life (HRQOL). The head and neck specific Patient Concerns Inventory (PCI-HN) has been utilised to enhance doctor-patient dialogue in routine consultations. To date there has been no formal training for oral and maxillofacial surgery (OMFS) surgical trainees in the use of the PCI-HN in consultations. The aim of the study was to evaluate training for OMFS surgical trainees in the use of the PCI-HN, using simulated follow-up HNC consultations, in order to improve doctor-patient communication skills. Material and methods: Ten oral and maxillofacial surgical trainees completed actor simulated HNC consultations before and after training. A study-specific mark scheme was developed based on the ComOn-Coaching rating scales and used to score the doctor-patient interaction. A group debrief afterwards explored the trainee’s experiences of the training and consultations. Results: All trainees showed an improvement in doctor-patient communication scores following their training. Overall, the six participants who were Specialty registrars, year 3 (ST3) or above, scored higher, than the four Specialty registrars, year 1–2 (ST1-2). The scores were higher if fewer PCI-HN items were discussed (3–4). The most frequently avoided PCI-HN items were intimacy and relationships. The trainees considered that their training was useful for organising their consultations and for providing holistic care. Conclusion: Although training improved surgeon-patient communication, further evaluation is required with a larger number of trainees and actual consultations in clinic.

People treated for head and neck cancer (HNC) face various barriers in communicating concerns with consultants. Our aim was to investigate the number of concerns raised between patients using the Patient Concerns Inventory (PCI) and those who did not. The PCI is a 57-item prompt list used in routine HNC follow-up clinics. Additionally, we aimed to examine whether who initiated the concerns differed between groups and the factors that may predict this initiation. Secondary data analysis included 67 participants across 15 HNC consultants from specialist cancer centres in Liverpool and Leeds. Seven consultants utilised the PCI and eight did not, assigned by preferential and random assignment. Patients in the PCI group raised on average 2.5 more concerns than patients in the non-PCI group (p < .001). There was no significant relationship between group and who initiated the first concern (p = .28). A mixed-effects logistic regression was found to significantly predict who initiated the first concern in consultations (p < .05). The number of concerns raised by patients increased when the PCI was introduced pre-HNC consultation. A number of factors were shown to predict the number of concerns raised in consultations by both patient and consultant. As concerns may not be raised further following the concern mentioned, we propose that the discussion of concerns needs to be maintained by the clinician throughout the consultation and not solely at the start. The PCI promoted the sharing of concerns in follow-up consultations between patient and consultant.

PURPOSE:Osteoradionecrosis (ORN) of the mandible is a serious complication of head and neck radiotherapy. This study aims to investigate the effect of hyperbaric oxygen (HBO) treatment on ORN in two randomized, controlled multicentre trials.METHODS AND MATERIALS:Patients with ORN with indication for surgical treatment were randomised to either group 1: surgical removal of necrotic mandibular bone supplemented by 30 pre- and 10 postoperative HBO exposures at 243 kPa for 90 min each, or group 2: surgical removal of necrotic bone only. Primary outcome was healing of ORN one year after surgery evaluated by a clinically adjusted version of the Common Toxicity Criteria of Adverse Events (CTCAE) v 3.0. Secondary outcomes included xerostomia, unstimulated and stimulated whole salivation rates, trismus, dysphagia, pain, Activities of Daily Living (ADL) and quality of life according to EORTC. Data were combined from two separate trials. Ninety-seven were enrolled and 65 were eligible for the intent-to-treat analysis. The 33% drop-out was equally distributed between groups.RESULTS:In group 1, 70% (21/30) healed compared to 51% (18/35) in group 2. HBO was associated with an increased chance of healing independent of baseline ORN grade or smoking status as well as improved xerostomia, unstimulated whole salivary flow rate, and dysphagia. Due to insufficient recruitment, none of the endpoints reached a statistically significant difference between groups. ADL data could only be obtained from 50 patients.CONCLUSION:Hyperbaric oxygen did not significantly improve the healing outcome of osteoradionecrosis after surgical removal of necrotic bone as compared to standard care (70% vs. 51%). This effect is not statistically significant due to the fact that the study was underpowered and is therefore prone to type II error.

INTRODUCTION:The Patient Concerns Inventory (PCI) is a condition specific prompt list that was initially developed for head and neck cancer (HNC) and is referred to as the PCI-HN. There have been numerous publications regarding the PCI-HN, since it was first published in 2009. To date, there has not been a review of its development, validation and clinical implications. A collation of relevant papers into key sections allows multidisciplinary teams and researchers to have an overview of the PCI-HN's background, evaluation and utility. This is essential if colleagues are to have confidence in the tool and be able to reflect on how to optimise its use in clinical practice.METHODS:Five search engines were used: EMBASE, Medline, PubMed, CINAHL and Handle-on-QOL for the specific term 'Patient Concerns Inventory' up to and including 1st February 2022. In addition, an accumulation of PCI-HN data of 507 HNC patients was drawn from previous studies in Liverpool and Leeds between 2007 and 2020 and was analysed specifically for this paper.RESULTS:54 papers relating to the PCI-HN were identified. The review is structured into eight sections: (1) What is the PCI-HN and how does it work; (2) Feasibility and acceptability; (3) Psychometrics; (4) Items selected and frequency (5) Associations with Health-Related Quality of Life (HRQOL) and casemix; (6) Other observational studies; (7) Randomised trial evaluation; (8) General discussion and further research.CONCLUSIONS:As the term PCI is quite ubiquitous and produces many hits when searching the literature, this review provides a very concise and convenient historical context for the PCI-HN and collates the current literature.

The aim of this work was to evaluate the usability of a single-page, patient-completed, condition-specific prompt list, the Patient Concerns Inventory (PCI-HN), to risk-stratify for poor health-related quality of life (HRQOL). Data were collected between 2008 and 2017. The main dataset comprised 310 patients first completing the PCI-HN and University of Washington Quality of Life questionnaire (UW-QOLv4) between 2012 and 2017. Another 201 patients first completing the PCI-HN between 2008 and 2011 provided a second dataset for independent validation. Subsequent completions of the PCI-HN in both groups and the distress thermometer (DT) were also used as further validation datasets. Associations between PCI-HN items selected by patients and a range of UW-QOLv4 outcomes were explored using conventional logistic regression and Chi-squared automated interaction detection (CHAID) analyses. One quarter of patients reported less than good HRQOL, range 26-29% across the four datasets. Several individual items from within the PCI-HN were predictive of adverse outcomes. The total number of items selected was also predictive. The single-sheet prompt list enables clinicians to identify patients at high risk of poor HRQOL. This simple approach has the potential to be integrated into routine clinical practice.

The head and neck cancer (HNC) Patient Concerns Inventory (PCI) is a condition-specific prompt list that allows patients to raise concerns to cancer consultants that otherwise might be overlooked. This is the first economic evaluation of the PCI in patients with HNC investigating the costs and effects to the health service of not prioritising certain treatment pathways in addition to the primary cancer pathway. Additional costs can be accrued due to delayed referral to other appropriate services, e.g. hospital dentist. Economic evidence could influence future policy direction in this area globally. Alongside a 3-year clustered randomised controlled trial, an economic evaluation was undertaken with Client Service Receipt Inventory data collected at three different time points (baseline and 6 and 12 months post-baseline). Patients were identified by a multidisciplinary team at the trial clinics. This economic analysis compared the PCI intervention versus the non-PCI treatment pathway. A deterministic and probabilistic sensitivity analysis was conducted to investigate the cost per quality-adjusted life-year (QALY) gain of the PCI versus non-PCI intervention treatment pathways. Qualitative data were also collected from seven consultants to triangulate findings from the economic evaluation. The analysis used data from 191 patients (66% of the full trial sample). The PCI inventory was low cost, at just over £13 per participant. The PCI intervention was cost effective and also cost saving, with an incremental cost difference of £295.91 over the 12-month follow-up period. The QALY values were higher in the PCI intervention strategy, with a value of 0.79, whereas the non-PCI group had a value of 0.76, thus the PCI intervention was dominant. The sensitivity analysis showed that, at a willingness-to-pay threshold of £20,000 per QALY gained, the probability of being cost effective was 0.85 (95% confidence interval [CI] 0.80–0.83). Qualitative results showed that consultants using the PCI reported an enhanced awareness of patients’ overall post-treatment needs. The PCI provided an effective means to conduct clinical consultations by avoiding unnecessary healthcare costs and focussing on aspects of care most important to patients. The cost per QALY gain was within the National Institute for Health and Care Excellence guideline threshold. The economic evaluation showed that the PCI intervention strategy was dominant and therefore cost saving to the national health service (NHS) and was more effective in terms of treatment. The PCI appears to be a low-cost intervention that generates a cost-effective benefit to patients from a NHS perspective if rolled out as part of routine care. Qualitative evidence has shown that the use of the PCI is supported by consultants in routine practice. Clinical Trials Identifier: NCT03086629.

Abstract Introduction During clinical follow‐up it can be difficult to identify those head and neck cancer (HNC) patients who are coping poorly and could benefit from additional support. Health‐related quality of life (HRQOL) questionnaires and prompt lists provide a means by which patients can express their perceived outcomes and raise concerns. The first aim of this secondary analysis following a randomized trial was to explore which patient characteristics, at around 3 months following treatment completion (baseline), best predict HRQOL 12 months later. The second aim was to attempt to ascertain which patients were most likely to benefit from using prompt list. Methods Cluster‐controlled pragmatic trial data were analyzed. HRQOL was measured by the University of Washington Quality of life questionnaire (UW‐QOLv4). The prompt list was the Patient Concerns Inventory (PCI‐HN). Results The trial involved 15 eligible consultants and a median (inter‐quartile range) of 16 (13–26) primary HNC patients per consultant, with 140 PCI patients and 148 controls. Baseline HRQOL was the dominant predictor of 12‐month HRQOL with other predictors related to social, financial, and lifestyle characteristics as well as clinical stage and treatment. Although formal statistical tests for interaction were non‐significant the trend in analyses over a range of outcomes suggested that patients with worse baseline HRQOL could benefit more from the PCI‐HN. Discussion HRQOL early post‐treatment is a key predictor of longer‐term outcome. Measuring and using HRQOL and the PCI‐HN are not only surrogates for predicting HRQOL at 15 months post‐treatment, but also tools to help guide interventions.

Necrotising fasciitis (NF) is a rapidly spreading bacterial infection of the fascial planes and can be fatal if is not treated urgently. Here, we present the case of a 65-year-old female, with oral squamous cell carcinoma, treated surgically with curative intent. On the second post-operative day from a mandibulectomy, selective neck dissection and reconstruction with a fibula free flap, she developed rapidly progressing NF, at the surgical site.