Ed’s Choice reviews a paper aiming to create a reliable index to predict postoperative outcomes in head and neck cancer patients. This interesting study identifies variables that may assist in risk assessing prospective surgical candidates. There have been a few conferences in recent years dedicated to the management of head and neck cancer in the elderly. Much work is being done in identifying pre-frailty and frailty in this group prior to starting treatment. National studies in prehabilitation are underway to assess the benefits of exercise programmes and global geriatric assessments to evaluate: physical fitness; nutrition; comorbidity; polypharmacy; cognition; and social and mental health. There is emerging evidence that these assessments lead to benefits in morbidity, mortality, length of stay and cost. An excellent review was published in Laryngoscope (Noor A, Gibb C, Boase S, et al. Frailty in Geriatric Head and Neck Cancer: A Contemporary Review. Laryngoscope 2018;128:E416-24) for those who are interested.
Charles Giddings FRCS(ORL-HNS), FRACS
Consultant ENT, head and neck surgeon, Monash Health, Melbourne, Australia.
Patients with head and neck cancer (HNC) often have coexistent medical conditions and nutritional deficiencies, which may contribute to increased postoperative adverse events. Up to 40% of patients experience postoperative adverse events, most within the first 30 days from surgery. The increase in comorbid conditions and functional deficits in the elderly has prompted the development of strategies to stratify care in the preoperative setting. The ability to accurately predict postoperative risk in the preoperative setting can guide patient counselling. This cohort study of 31,399 operations registered in the American College of Surgeons database demonstrated that multiple patient characteristics were independently associated with major adverse events or death on multiple regression analysis. The Head and Neck Surgery Risk Index (HNSRI), using all of these characteristics, demonstrated a sensitivity of 80% (95%CI, 79.4-80.8) and specificity of 72% (95%CI, 70-74) regarding occurrence. Older age (above 50 years), male sex, smoking, anticoagulation, recent weight loss, functional dependence, free-tissue transfer, tracheotomy, duration of surgery (more than four hours), wound classification (clean contaminated or contaminated), anaemia, leukocytosis, and hypoalbuminemia were independently associated with major adverse events or death on multiple regression analysis. This Head and Neck Surgery Risk Index can be used by head and neck surgeons, anaesthesiologists and oncologists to better counsel patients and their families preoperatively. By stratifying patients into groups based on risk score, clinicians can identify vulnerable patients who may require additional care postoperatively.