Dutch Head Research Articles

Nationwide clinical practice variation for reconstructive surgery following oral cavity cancer from the Dutch Head and Neck Audit: Are we all doing the same?

IntroductionQuality registries provide real-world data that can drive quality improvement which often starts with reducing interhospital variation. We explored outcomes and the extent of nationwide interhospital variation for patients undergoing reconstructive surgery after oral cavity cancer (OCC) using the Dutch Head and Neck Audit (DHNA). Material and MethodsWithin the DHNA, we selected all OCC patients between 2018 and 2022 who underwent curative reconstructive surgery. Patient, tumour, and treatment characteristics were compared, including reconstruction strategies (skin grafting, local transposition, pedicled and free flaps). Of those treated with free flap reconstruction, postoperative complications were scored according to the Clavien-Dindo (CD) classification and labelled minor (CD 1-2) or major (CD ≥3). ResultsA total of 1,383 patients were included in the analysis. Especially for patients with stage I tumours (10%), a wide variation in reconstructive surgeries was observed between centres, with a preference for local transposition (42.6%). Free flaps were used most for patients with a more extensive tumour load (65.4% - 89.2%), with the radial forearm flap as the preferred technique (54.7%, range 33.7% - 80.8%). Thirty-four percent of patients treated with a free flap had postoperative complications, with 38 cases of total flap loss (overall 3.9% complications). ConclusionStrategies and percentages varied strongly across centres, showing high interhospital variation in applied techniques and outcomes, and the need for national data improvement.

MYB immunohistochemistry as a predictor of MYB::NFIB fusion in the diagnosis of adenoid cystic carcinoma of the head and neck

Diagnosing adenoid cystic carcinoma (AdCC) is challenging due to histopathological variability and similarities with other tumors. In AdCC pathogenesis, the cellular myeloblastosis gene (c-MYB) often exhibits a MYB::NFIB fusion from a reciprocal translocation. This study aimed to assess the predictive accuracy of MYB immunohistochemistry for detecting this translocation compared to fluorescence in situ hybridization (FISH). This study included 110 AdCC patients (1999-2017) from two Dutch head and neck centers using tissue microarrays and full slides. Median MYB expression levels by immunohistochemistry were compared based on translocation status by FISH, and differences within clinicopathological parameters were examined. An immunohistochemical cut-off was established to estimate the translocation. MYB immunohistochemistry was available in 90/110 patients, with a median expression of 27%. FISH was interpretable in 79/108 tumors, identifying MYB::NFIB fusion in 44 (56%). Among 62 patients with both MYB expression and translocation data, the fusion was present in 38 (61%). These tumors had higher MYB expression (30%) than nontranslocated tumors (6%); P = .02. A 60% MYB expression cut-off yielded 100% specificity for detecting the translocation but had no prognostic value. Although MYB protein expression alone lacks diagnostic precision, protein expression >60% predicted the MYB::NFIB fusion in all tumors.

Organization of head and neck cancer rehabilitation care: a national survey among healthcare professionals in Dutch head and neck cancer centers

PurposeHead and neck cancer (HNC) treatment often leads to physical and psychosocial impairments. Rehabilitation can overcome these limitations and improve quality of life. The aim of this study is to obtain an overview of rehabilitation care for HNC, and to investigate factors influencing rehabilitation provision, in Dutch HNC centers, and to some extent compare it to other countries.MethodsAn online survey, covering five themes: organizational structure; rehabilitation interventions; financing; barriers and facilitators; satisfaction and future improvements, among HNC healthcare- and financial professionals of Dutch HNC centers.ResultsMost centers (86%) applied some type of rehabilitation care, with variations in organizational structure. A speech language therapist, physiotherapist and dietitian were available in all centers, but other rehabilitation healthcare professionals in less than 60%. Facilitators for providing rehabilitation services included availability of a contact person, and positive attitude, motivation, and expertise of healthcare professionals. Barriers were lack of reimbursement, and patient related barriers including comorbidity, travel (time), low health literacy, limited financial capacity, and poor motivation.ConclusionAlthough all HNC centers included offer rehabilitation services, there is substantial practice variation, both nationally and internationally. Factors influencing rehabilitation are related to the motivation and expertise of the treatment team, but also to reimbursement aspects and patient related factors. More research is needed to investigate the extent to which practice variation impacts individual patient outcomes and how to integrate HNC rehabilitation into routine clinical pathways.

Treatment of buccal mucosal carcinomas: A survey amongst head and neck surgeons in the Netherlands.

Currently, there is no up-to-date guideline for the treatment of buccal mucosal squamous cell carcinoma (BMSCC) in the Netherlands. A questionnaire was used to investigate the opinions of Dutch head and neck surgeons on BMSCC of the cheek treatment. A questionnaire was sent to all 91 head and neck surgeons in the Netherlands. Their opinions on surgical tumor-free margins, through-and-through defects, and indications for local adjuvant therapy were questioned. The response rate was 51%. To prevent a through-and-through defect, 67% of the surgeons would accept a deep clinical (macroscopic) margin of ≤5 mm. The less adverse histological characteristics a tumor has, the less consensus there is amongst the surgeons for local adjuvant treatment in case of close margins. There is no consensus amongst Dutch head and neck surgeons about the optimal treatment for BMSCC of the cheek. There are different opinions on acceptable resection margins, indications for a through-and-through defect, and indications for adjuvant treatment. BMSCC of the cheek treatment should be more uniform and less surgeon dependent. N/A.

Patients’ and Healthcare Professionals’ Perspectives on Better Use of Patient-Reported Outcome Measures in Head and Neck Cancer

ObjectivesPatients with head and neck cancer (HNC) are often highly affected by disease and treatment, resulting in impaired physical functioning and quality of life. Therefore, evaluation of patients’ psychosocial and functional outcomes can be facilitated by patient-reported outcome measures (PROMs). By providing the patients’ own perspectives, PROMs are crucial to improving patient-centered care. This study aimed to improve understanding of the perceived value of PROMs in HNC care and how to optimize their clinical value based on patients’ and multidisciplinary healthcare professionals’ (HCPs) perspectives. MethodsPopulation-based surveys among patients with HNC through their patient association and among HCPs nationwide through the Dutch Head and Neck Audit. ResultsA total of 54 patients and 40 multidisciplinary HCPs from all 14 nationwide HNC centers (100%) responded. For patients, the most important element of patient-reported outcome collection systems was including a call to action for those with worse-than-average scores (28%), whereas clinicians found discussing scores during clinical visits the most important (39%). Although 16% of clinicians found short completion time the most important element, none of the patients selected completion time as most important. Additionally, 17% of patients stated completion time was not an issue, provided clinicians would use the outcomes for clinical purposes. ConclusionsAlthough patients and clinicians acknowledged the value of patient-reported outcomes, patients would like to be more involved in the clinical implications of their outcomes. Enhancing patients’ involvement by a call to action and providing feedback on their scores during outpatient clinic visits may improve the clinical value of PROMs.

Lead time improvement through the nationwide Dutch Head and Neck Audit

Lead time improvement through the nationwide Dutch Head and Neck Audit

Is paternal height related to fertility outcomes? Evidence from the Netherlands during the secular growth trend

Over the past two centuries, the Dutch experienced a tremendous secular trend in height, and ultimately became the tallest nation in the world. Improving environmental conditions likely played the largest role in explaining these developments. But it is not yet precisely clear what factor set the Dutch head and shoulders above other nations, who were also experiencing improving environmental conditions. Could fertility also have played a role? To understand this, we would first need to know whether height and fertility were related during the secular growth trend. In this study, we investigated whether this was the case. A sample of Dutch men, birth years 1850–1900 (n = 3396), was examined. We tested the extents to which height was associated with having a certain number of children, and with having a certain number of children survive infancy. Multinomial logistic regressions were used. In terms of findings, height’s relationship to fertility outcomes was curvilinear: being shorter-than-average (0.75–0.5 standard deviations below the mean height) was associated with a higher probability of being married and having five to seven children, while being moderately tall (0.5 standard deviations above the mean height) was associated with the lowest probability of being unmarried. There was no relationship between paternal height and children surviving infancy in the sample overall, but taller height was associated with a decreased risk of being in a high-mortality family among men born between 1880 and 1900. If paternal fertility played a role in the secular growth trend, we would expect to see very tall men have the most children, and clearly have the most children surviving infancy. Given this study’s findings, it is unlikely that this was the case.

Nationwide interhospital variation in reconstructive surgery after primary oral cavity cancer: A cohort study within the Dutch Head and Neck Audit

Background: To explore nationwide interhospital variation – a common starting point for targeted interventions for quality improvement – of the different types of reconstructive surgery after primary oral cavity cancer in the Netherlands.

Nutritional interventions in patients with head and neck cancer undergoing chemoradiotherapy: Current practice at the Dutch Head and Neck Oncology centres.

ObjectiveTo assess variations in nutritional interventions during chemoradiotherapy (CRT) among the Dutch Head and Neck Oncology centres (HNOCs).MethodsAn online questionnaire about nutritional interventions and dietetic practices was sent to 14 oncology dietitians of the HNOCs.ResultsThe response rate was 93%. The number of scheduled dietetic consultations varied from two to seven during CRT. Most centres (77%) reported using a gastrostomy for tube feeding in the majority of patients. Gastrostomies were placed prophylactically upon indication (39%) or in all patients (15%), reactive (15%), or both (31%). For calculating energy requirements, 54% of the dietitians used the Food and Agriculture Organization/World Health Organization and United Nations University (FAO/WHO/UNU) formula and 77% uses 1.2–1.5 g/kg body weight for calculating protein requirements. Almost half of the centres (46%) reported to remove the gastrostomy between 8 and 12 weeks after CR. Most centres (92%) reported to end dietary treatment within 6 months after CRT.ConclusionThis study shows substantial variation in dietetic practice, especially in the use of a gastrostomy for tube feeding, between the HNOCs. There is a need for concise dietetic guidelines.

Nutritional interventions in patients with head and neck cancer undergoing chemoradiotherapy: current practice at the dutch head and neck oncology centers

Rationale: Nutritional interventions are essential for maintaining nutritional status in head and neck cancer (HNC) patients during chemoradiotherapy (CRT). Current guidelines provide little information on the dietetic care process, the nutrition prescription and gastrostomy placement and removal policy. The aim of this study is to assess variations in nutritional interventions during CRT among the Dutch Head and Neck Oncology Centers (HNOCs).

Does hyperbaric oxygen therapy play a role in the management of osteoradionecrosis? A survey of Dutch oral and maxillofacial surgeons

For decades, hyperbaric oxygen (HBO) has often been part of the treatment of osteoradionecrosis (ORN), despite controversy in the literature about its efficacy. An online survey was conducted to investigate the use of HBO in the treatment of ORN by Dutch oral and maxillofacial surgeons and to assess their perception of its efficacy. Of the 53 Dutch oral and maxillofacial surgery units contacted, 49 (92%) replied. Thirty-five were not head and neck cancer (HNC) units or preferred partner (PP-HNC) units recognized by the Dutch Head and Neck Association. All HNC and PP-HNC units (group 1) treated ORN patients, compared to only 12 (34%) of the non-HNC units (group 2). The average number of ORN patients seen and treated was higher in group 1. The units in group 1 more often referred patients for HBO therapy (HBOT) than those in group 2 (93% vs 84%). The efficacy of HBOT in curing ORN, rated on a scale of 1 to 5 points, was 3.7 in group 1 and 3.2 in group 2. This survey shows a trend towards centralization of ORN care to more experienced units. These units tend to use HBOT in curing ORN.

Patient-reported outcomes used to personalize Dutch head and neck cancer rehabilitation

Patient-reported outcomes used to personalize Dutch head and neck cancer rehabilitation

High rate of unexpected lymphatic drainage patterns and a high accuracy of the sentinel lymph node biopsy in oral cancer after previous neck treatment

RationaleThis study evaluates the lymphatic drainage patterns and determines the accuracy of the sentinel lymph node biopsy (SLNB) in patients diagnosed with a cT1-2N0 OSCC and a history of neck surgery or radiotherapy in three Dutch head and neck centers. Materials and MethodsRetrospective analysis of 53 cT1-2N0 OSCC patients, who underwent SLNB between 2007 and 2016, after a history of neck surgery or radiotherapy. Ten patients had previous treatment of the neck only contralateral from the current tumour. These ten patients were not used for the analysis of lymphatic drainage patterns. The 43 patients with previous ipsilateral or bilateral treatment of the neck had a history of ipsilateral SLN extirpation (n = 9; 21%), neck dissection (n = 16; 37%), radiotherapy (n = 10; 23%), or combined neck dissection and radiotherapy (n = 8; 19%). ResultsSLNs were detected in 45 patients, resulting in an identification rate of 85% (45/53). Three patients (7%) had at least one positive SLN. One patient (1/45; 2%) was diagnosed with regional recurrence during the follow-up after a negative SLNB (sensitivity 75%, negative predictive value 98%). The first SLN was detected in level I-III in 58% of the patients, unexpected drainage patterns were observed in 30% (first SLN level IV 9% and level V 5% and contralateral neck in well-lateralized tumours 16%). In 12% no lymphatic drainage pattern was visible. ConclusionsSLNB seems to be a reliable procedure for neck staging of cT1-2N0 OSCC patients with a previously treated neck. SLNB determines the individual lymphatic drainage patterns, enabling visualization of unexpected drainage pattern variability in 30% of these patients.

OC-020 Sentinel lymph node biopsy for early stage oral cancer; experience of 3 Dutch Head and Neck centers

OC-020 Sentinel lymph node biopsy for early stage oral cancer; experience of 3 Dutch Head and Neck centers

Clinicopathological characteristics and outcome of 31 patients with ETV6-NTRK3 fusion gene confirmed (mammary analogue) secretory carcinoma of salivary glands

ObjectivesIn 2010, a new subtype of salivary gland cancer (SGC), (mammary analogue) secretory carcinoma (SC), was defined, characterized by the ETV6-NTRK3 fusion gene. As clinical behavior and outcome data of this histological subtype tumor are still sparse, we aimed to describe the clinicopathological course and outcome of a series of translocation positive SC patients. Patient and methodsWe re-evaluated the pathological diagnosis of a subset of SGCs, diagnosed in 4 of 8 Dutch head and neck centers. Subsequently, tumors with a morphological resemblance to SC were tested for the ETV6-NTRK3 fusion gene using RT-PCR. Furthermore, patients prospectively diagnosed with SC were included. The clinical characteristics and outcomes were retrieved from the patient files. ResultsThirty-one patients with ETV6-NTRK3 fusion gene positive SC were included. The median age was 49 years, 17 patients (55%) were male. Eighteen tumors (58%) arose in the parotid gland. One patient presented with lymph node metastasis. All patients underwent tumor resection and 4 patients had a neck dissection. Four patients had re-resection and 15 patients (48%) received postoperative radiotherapy. One patient developed a local recurrence, no regional recurrences or distant metastases were observed. After a median follow-up of 49 months the 5- and 10-year overall survival were 95%, the 5- and 10-year disease free survival were 89%. ConclusionThe clinical course of SC is favorable with a low rate of locoregional recurrence and excellent survival. Given the low incidence of nodal metastases, elective neck treatment, i.e. surgery and/or radiotherapy, does not seem to be indicated.

The Dutch Head and Neck Audit: The First Steps

The treatment of Head and Neck Cancer (HNC) is an example of low volume, highly complex, multidisciplinary integrated care. To monitor and effectively improve high quality integrated care, the Dutch Head and Neck Audit (DHNA) was set up in 2014 (with quality indicators as a basis) to monitor, benchmark and find areas for improvement. This paper gives an overview of the development, first results, and implications.

Predictive factors for pharyngocutaneous fistulization after total laryngectomy: a Dutch Head and Neck Society audit.

Incidences of pharyngocutaneous fistulization (PCF) after total laryngectomy (TL) reported in the literature vary widely, ranging from 2.6 to 65.5%. Comparison between different centers might identify risk factors, but also might enable improvements in quality of care. To enable this on a national level, an audit in the 8 principle Dutch Head and Neck Centers (DHNC) was initiated. A retrospective chart review of all 324 patients undergoing laryngectomy in a 2-year (2012 and 2013) period was performed. Overall PCF%, PCF% per center and factors predictive for PCF were identified. Furthermore, a prognostic model predicting the PCF% per center was developed. To provide additional data, a survey among the head and neck surgeons of the participating centers was carried out. Overall PCF% was 25.9. The multivariable prediction model revealed that previous treatment with (chemo)radiotherapy in combination with a long interval between primary treatment and TL, previous tracheotomy, near total pharyngectomy, neck dissection, and BMI < 18 were the best predictors for PCF. Early oral intake did not influence PCF rate. PCF% varied quite widely between centers, but for a large extend this could be explained with the prediction model. PCF performance rate (difference between the PCF% and the predicted PCF%) per DHNC, though, shows that not all differences are explained by factors established in the prediction model. However, these factors explain enough of the differences that, compensating for these factors, hospital is no longer independently predictive for PCF. This nationwide audit has provided valid comparative PCF data confirming the known risk factors from the literature which are important for counseling on PCF risks. Data show that variations in PCF% in the DHNCs (in part) are explainable by the variations in these predictive factors. Since elective neck dissection is a major risk factor for PCF, it only should be performed on well funded indication.

Feedback preferences of patients, professionals and health insurers in integrated head and neck cancer care.

BackgroundAudit and feedback on professional practice and health care outcomes are the most often used interventions to change behaviour of professionals and improve quality of health care. However, limited information is available regarding preferred feedback for patients, professionals and health insurers.ObjectiveInvestigate the (differences in) preferences of receiving feedback between stakeholders, using the Dutch Head and Neck Audit as an example.MethodsA total of 37 patients, medical specialists, allied health professionals and health insurers were interviewed using semi‐structured interviews. Questions focussed on: “Why,” “On what aspects” and “How” do you prefer to receive feedback on professional practice and health care outcomes?ResultsAll stakeholders mentioned that feedback can improve health care by creating awareness, enabling self‐reflection and reflection on peers or colleagues, and by benchmarking to others. Patients prefer feedback on the actual professional practice that matches the health care received, whereas medical specialists and health insurers are interested mainly in health care outcomes. All stakeholders largely prefer a bar graph. Patients prefer a pie chart for patient‐reported outcomes and experiences, while Kaplan‐Meier survival curves are preferred by medical specialists. Feedback should be simple with firstly an overview, and 1‐4 times a year sent by e‐mail. Finally, patients and health professionals are cautious with regard to transparency of audit data.ConclusionsThis exploratory study shows how feedback preferences differ between stakeholders. Therefore, tailored reports are recommended. Using this information, effects of audit and feedback can be improved by adapting the feedback format and contents to the preferences of stakeholders.

PROMs and PREMs in Dutch integrated head and neck cancer care: Measurements and evaluation.

209 Background: Providing patient-centred care is an essential component of high quality integrated care. Nowadays, patient reported outcomes and experiences are increasingly used to measure quality of care. As part of a quality registration, the Dutch Head and Neck Audit, patient reported outcomes (PROs) and experiences (PREs) of patients with head and neck cancer (HNC) are measured with questionnaires and evaluated to increase patient-centred care. Methods: Patientswere recruited from nine hospitals participating in the DHNA. Validated questionnaires were distributed at baseline, 3, 6 and 12 months follow-up. Included PROMs were EQ-5D-3L, EORTC QLQ-C30 and EORTC QLQ-H&amp;N35. Included PREMs were Consumer Quality index for Oncologic care (CQO) and Radiotherapeutic care (CQR). CQO and CQR have similar domains with different questions. With descriptive analysis, ANOVA and mixed model analysis, differences over time and between treatment groups were analyzed. Results: Questionnaires were filled in by 238 patients. Pain decreased significantly at 6 and 12 months follow-up and dry mouth increased significantly at 3, 6 and 12 months follow-up compared to baseline. Sticky Salvia, problems with social eating and sense problems increased at 3 and 6 months follow-up, but were similar to the baseline score at 12 months follow-up. Pain and sticky saliva differed between radiotherapy and chemoradiotherapy or surgery and radiotherapy respectively (p ≤ 0.05). Regarding the CQO domain scores, all treatment groups differ significantly from each other (p ≤ 0.05). This was not regarding the CQR domain scores. Except for the domain Organisation, no differences between the CQO and CQR domain scores were found. Recognizing the emotional side of HNC (care) and intensifying guidance after the treatment period needs improvement. Conclusions: This study gives clues to improve healthcare according the experiences of the patient and we can predict more carefully the outcomes of the patients with different treatment types. PROMs according to the ICHOM criteria and PREMs are promising for measuring and improving quality and personalization of HNC care. However, the usage of two PREMs had no added value to evaluate and address points of improvement.

OC-007: Sentinel node biopsy for early stage oral cancer; experience of 2 Dutch head and neck centers

OC-007: Sentinel node biopsy for early stage oral cancer; experience of 2 Dutch head and neck centers