Background: Patients with head and neck cancers have comorbidities, functional limitations, and constitutional symptoms that are associated with adverse outcomes. The impact of comorbidity in these patients is well-studied, but the independent relationship between functional performance and outcomes is unclear. Our objective was to assess the independent associations between functional performance and three important postoperative outcomes: 30-day unplanned hospital readmission, 90-day medical complications, and overall survival.
Methods: This was a single-center, retrospective, cohort study utilizing data from two prospectively maintained institutional registries, supplemented with chart review. Patients had squamous cell cancer situated at the lip, oral cavity, pharynx, or larynx, and underwent surgery with curative intent from January 2012 to December 2016. Functional performance was estimated as a maximum Metabolic equivalent (MET) capability score of <4 (poor functional performance) and ≥4 (good functional performance). Other variables included overall comorbidity severity, measured by the ACE-27 scale; preoperative weight loss; and TNM tumor staging by AJCC 7th edition guidelines. All variables were recorded prospectively. Primary outcomes were 30-day unplanned readmission and 90-day complications; the secondary outcome was overall survival rate. Unadjusted logistic regression analysis identified variables associated with outcomes. Conjunctive consolidation was used to create a practical severity staging system.
Results: A total of 654 patients were studied. The average age was 62 years (SD = 11.3), 73% were male, and 88% were white. Of the 654 patients, 75 (11%) had a 30-day unplanned readmission, 204 (31%) developed a 90-day complication, and 127 (19%) patients died during the observation period. Most patients had good functional performance (516/657; 79%), none to mild comorbidity (398/651; 61%), no preoperative weight loss (527/644; 82%), and high TNM Stage (3 or 4) disease (438/657; 67%). Poor functional performance (<4 METs), high comorbidity burden, preoperative weight loss, and advanced TNM stage were all independently associated with each of the 3 outcomes, with increased risk for each outcome ranging from 1.5 to 3 times the reference range. Using these 4 variables, a 3-step, four-category clinical severity staging system was developed to predict 30-day unplanned readmissions, 90-day complications, and overall survival.
Conclusion: Poor preoperative functional performance, comorbidity burden, preoperative weight loss, and tumor stage are all independent predictors of patient outcomes. The model developed in this study provides patient-centered risk assessment, identifies opportunities for intervention, and facilitates shared decision-making.