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Original Investigation
June 13, 2019

Prognostic Case Volume Thresholds in Patients With Head and Neck Squamous Cell Carcinoma

Author Affiliations
  • 1Section of Otolaryngology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
  • 2Department of Otolaryngology, Harvard University School of Medicine, Boston, Massachusetts
  • 3Department of Internal Medicine, Yale University School of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven
  • 4Yale Cancer Center, New Haven, Connecticut
JAMA Otolaryngol Head Neck Surg. 2019;145(8):708-715. doi:10.1001/jamaoto.2019.1187
Key Points

Question  Are prognostic thresholds identifiable for facility case volume in the treatment of patients with head and neck squamous cell carcinoma?

Findings  In this US nationally based cohort study of 250 229 patients at 1229 facilities with head and neck squamous cell carcinoma, improvements in patient survival were reported at moderate-volume facilities (>54 to ≤165 cases per year). Additional improvements in survival were reported at high-volume facilities (>165 cases per year).

Meaning  Facility case volume thresholds that may support the use of quality benchmarks for treatment of patients with head and neck squamous cell carcinoma.


Importance  Though described as an important prognostic indicator, facility case volume thresholds for patients with head and neck squamous cell carcinoma (HNSCC) have not been previously developed to date.

Objective  To identify prognostic case volume thresholds of facilities that manage HNSCC.

Design, Setting, and Participants  Retrospective analysis of 351 052 HNSCC cases reported from January 1, 2004, through December 31, 2014, by Commission of Cancer–accredited cancer centers from the US National Cancer Database. Data were analyzed from August 1, 2018, to April 5, 2019.

Exposures  Treatment of HNSCC at facilities with varying case volumes.

Main Outcomes and Measures  Using all-cause mortality outcomes among adult patients with HNSCC, 10 groups with increasing facility case volume were created and thresholds were identified where group survival differed compared with each of the 2 preceding groups (univariate log-rank analysis). Groups were collapsed at these thresholds and the prognostic value was confirmed using multivariable Cox regression. Prognostic meaning of these thresholds was assessed in subgroups by category (localized [I/II] and advanced [III/IV]), without metastasis (M0), with metastasis (M1), and anatomic subsites (nonoropharyngeal HNSCC and oropharyngeal HNSCC with known human papillomavirus status).

Results  Of 250 229 eligible patients treated at 1229 facilities in the United States, there were 185 316 (74.1%) men and 64 913 (25.9%) women and the mean (SD) age was 62.8 (12.1) years. Three case volume thresholds were identified (low: ≤54 cases per year; moderate: >54 to ≤165 cases per year; and high: >165 cases per year). Compared with the moderate-volume group, multivariate analysis found that treatment at low-volume facilities (LVFs) was associated with a higher risk of mortality (hazard ratio [HR], 1.09; 99% CI, 1.07-1.11), whereas treatment at high-volume facilities (HVFs) was associated with a lower risk of mortality (HR, 0.92; 99% CI, 0.89-0.94). Subgroup analysis with Bonferroni correction revealed that only the moderate- vs low- threshold had meaningful differences in outcomes in localized stage (I/II) cancers, (LVFs vs moderate-volume facilities [MVFs]: HR, 1.09 [99% CI, 1.05-1.13]; HVF vs MVF: HR, 0.95 [99% CI, 0.90-1.00]), whereas both thresholds were meaningful in advanced stage (III/IV) cancers (LVF vs MVF: HR, 1.09 [99% CI, 1.06-1.12]; HVF vs MVF: HR, 0.91 [99% CI, 0.88-0.94]). Survival differed by prognostic thresholds for both M0 (LVF vs MVF: HR, 1.09 [99% CI, 1.07-1.12]; HVF vs MVF: HR, 0.91 [99% CI, 0.89-0.94]) and nonoropharyngeal HNSCC (LVF vs MVF: HR, 1.10 [99% CI, 1.07-1.13]; HVF vs MVF: HR, 0.93 [99% CI, 0.90-0.97]) site cases, but not for M1 (LVF vs MVF: HR, 1.00 [99% CI, 0.92-1.09]; HVF vs MVF: HR, 0.94 [99% CI, 0.83-1.07]) or oropharyngeal HNSCC cases (when controlling for human papillomavirus status) (LVF vs MVF: HR, 1.10 [99% CI, 0.99-1.23]; HVF vs MVF: HR, 1.07 [99% CI, 0.94-1.22]).

Conclusions and Relevance  Higher volume facility threshold results appear to be associated with increases in survival rates for patients treated for HNSCC at MVFs or HVFs compared with LVFs, which suggests that these thresholds may be used as quality markers.