Reconsidering Individuals With Normal Hearing

Dementia, called the “greatest global challenge for health and social care in the 21st century,”1(p2673) occurs in 47 million persons globally. This number is projected to triple by 2050. With no cure and no treatments to alter its natural history, public health prevention efforts are paramount. Hearing loss (HL) is a novel yet treatable risk factor for dementia.1 In the article by Golub and colleagues2 in this issue of JAMA Otolaryngology–Head & Neck Surgery, the importance of understanding the association between hearing and cognitive performance for older adults is highlighted. Novel to this study is the focus on adults with hearing in the normal range.

Original Article

Association of Subclinical Hearing Loss With Cognitive Performance

Key Points

Question  Is the association between hearing and cognition present among individuals who have classically defined normal hearing levels?

Findings  In this cross-sectional study of 6451 individuals, there was an inverse association between decreasing hearing and decreasing cognition among those classically defined as having normal hearing, after adjusting for confounders.

Meaning  The findings suggest that the association between hearing loss and impaired cognition may be present at earlier levels of hearing loss than previously recognized; the current 25-dB threshold for defining adult hearing loss may be too high.

Importance  Age-related hearing loss (HL) is a common and treatable condition that has been associated with cognitive impairment. The level of hearing at which this association begins has not been studied to date.

Objective  To investigate whether the association between hearing and cognition is present among individuals traditionally classified as having normal hearing.

Design, Setting, and Participants  Cross-sectional study of 2 US epidemiologic studies (Hispanic Community Health Study [HCHS], 2008-2011, and National Health and Nutrition Examination Study [NHANES], 1999-2000, 2001-2002, and 2011-2012 cycles). The dates of analysis were November 2018 to August 2019. Multivariable generalized additive model (GAM) regression and linear regression were used to assess the association between HL (exposure) and cognition (outcome). Participants included 6451 individuals aged 50 years or older from the general Hispanic population (HCHS [n = 5190]) and the general civilian, noninstitutionalized US population (NHANES [n = 1261]).

Exposures  Audiometric HL (4-frequency pure-tone average).

Main Outcomes and Measures  Neurocognitive performance measured by the Digit Symbol Substitution Test (DSST) (score range, 0-113), Word Frequency Test (range, 0-49), Spanish-English Verbal Learning Test (SEVLT) 3 trials (range, 5-40), SEVLT recall (range, 0-15), and Six-Item Screener (range, 0-6); higher scores indicated better cognitive performance.

Results  Among 6451 individuals, the mean (SD) age was 59.4 (6.1) years, and 3841 (59.5%) were women. The GAM regression showed a significant inverse association between hearing and cognition across the entire spectrum of hearing after adjusting for demographics and cardiovascular disease. In separate multivariable linear regressions stratified by the classic binary definition of HL, decreased hearing was independently associated with decreased cognition in adults with normal hearing (pure-tone average ≤25 dB) across all cognitive tests in the HCHS. For example in this group, a 10-dB decrease in hearing was associated with a clinically meaningful 1.97-point (95% CI, 1.18-2.75) decrease in score on the DSST. When using a stricter HL cut point (15 dB), an association was also present in NHANES. The associations between hearing and cognition were stronger or equivalent in individuals with normal hearing than among those with HL. For example, there was a 2.28-point (95% CI, 1.56-3.00) combined cohort DSST score decrease per 10-dB decrease among individuals with normal hearing vs a 0.97-point (95% CI, 0.20-1.75) decrease among those with HL, with a significant interaction term between continuous and binary hearing.

Conclusions and Relevance  An independent association was observed between cognition and subclinical HL. The association between hearing and cognition may be present earlier in HL than previously understood. Studies investigating whether treating HL can prevent impaired cognition and dementia should consider a lower threshold for defining HL than the current 25-dB threshold.

Original Article

Prolonging Life, but at What Price?

“Doc, how long have I got to live anyway if I do nothing?” This is a question from an elderly patient that is familiar to any oncologist. As the proportion of elderly patients continues to increase steadily worldwide, clinicians can expect that this will become an increasingly present scenario in medical offices. In particular, there will be a dramatic increase between 2015 and 2050 in patients currently regarded as the so-called oldest old (those 80 years and older) to more than 440 million worldwide, tripling the current population in this category.1 Whether to subject patients who have already exceeded normal life expectancy to the stressors of major surgery for an aggressive malignant condition is as much an ethical issue as it is a medical one, and clinicians are badly in need of tools to assist patients in shared decision-making. The lay press has caught wind of this issue as well; witness the title to a New York Times article published in June 2019: “The Elderly are Getting Complex Surgeries. Often It Doesn’t End Well.”2

Original Article

Treatment of Head and Neck Cancer—Sometimes, Less Is More

In this issue of JAMA Otolaryngology-Head & Neck Surgery, Saraswathula and colleagues1 used the Surveillance, Epidemiology, and End Results Program (SEER)–Medicare outcomes and claims database to compare the value of 3 different radiotherapy (RT) regimens (ie, RT alone, RT plus cisplatin, or RT plus cetuximab) administered to patients older than 65 years with locally advanced head and neck cancer (HNC) of the oral cavity, oropharynx, larynx, and hypopharynx. In this setting, RT plus cetuximab was not associated with improved survival compared with RT alone, but it was associated with an increased number of emergency department visits and increased costs. The authors concluded that cetuximab concurrently administered with RT seems to be of low value in terms of improved survival and higher costs for older patients with HNC.

Original Article

Care Value for Older Patients Receiving Radiotherapy With or Without Cisplatin or Cetuximab for Head/Neck Cancer

Key Points

Question  What is the value of cetuximab chemoradiotherapy compared with radiotherapy alone for older patients with locoregionally advanced head and neck cancer?

Findings  In this cohort study of 1091 older patients with stages III to IVB head and neck cancer, radiotherapy with cetuximab treatment was not associated with improved survival compared with radiotherapy alone, but radiotherapy with cisplatin was associated with improved survival. Cetuximab use was associated with higher Medicare spending but not with higher rates of inpatient admission compared with radiotherapy alone, unlike radiotherapy with cisplatin.

Meaning  Despite performing better on some Medicare quality metrics, cetuximab appears to be of low value for older patients with advanced disease; composite metrics should be used in the future to assess care quality within the context of outcomes and treatment cost.

Importance  Clinicians frequently use radiotherapy with cetuximab over radiotherapy only or radiotherapy with cisplatin because of a perceived survival and tolerability advantage, but scant data are available to support this perception.

Objective  To measure the 3 aspects of value (quality, outcomes, and cost) in older patients receiving radiotherapy only, radiotherapy with cisplatin, or radiotherapy with cetuximab for locoregionally advanced head and neck cancer.

Design, Setting, and Participants  For this cohort study, patient records were obtained from the Surveillance, Epidemiology, and End Results Program (SEER)–Medicare outcomes and claims database from January 1, 2004, to December 31, 2014. Participants were 65 years or older; received a diagnosis between 2006 and 2013 of stages III to IVB head and neck cancer; had only 1 cancer on record; and did not undergo surgical intervention. Data analysis was conducted from February 5, 2018, to March 27, 2019.

Exposures  Patients were divided into exposure arms on the basis of their first-line therapy or identified chemoradiotherapy and radiotherapy regimen.

Main Outcomes and Measures  Overall survival was analyzed by propensity score matching Cox proportional hazards regression models, quality by measuring 90-day emergency department (ED) visit and inpatient admission rates, and costs by assessing 90-day total Medicare spending.

Results  The overall cohort included 1091 patients, of whom 815 (74.7%) were male; the mean (SD) age was 73.9 (6.6) years. Patients receiving radiotherapy with cisplatin had higher overall survival compared with those receiving radiotherapy only (adjusted hazard ratio [HR], 0.64; 95% CI, 0.47-0.87). This finding was not seen in patients receiving radiotherapy with cetuximab (adjusted HR, 0.95; 95% CI, 0.75-1.20), compared with the radiotherapy only group, and it persisted after stratifying patients by age. The ED visit (adjusted incidence rate ratio [IRR], 1.72; 95% CI, 1.30-2.30) and inpatient admission (adjusted IRR, 1.48; 95% CI, 1.12-1.98) rates in the 90 days after treatment start were higher in patients receiving radiotherapy with cisplatin compared with those treated with radiotherapy only. Patients receiving radiotherapy with cetuximab had a higher rate of ED visits (adjusted IRR, 1.38; 95% CI, 1.05-1.82) compared with those in the radiotherapy only group. The 90-day after-treatment spending for patients receiving radiotherapy with cetuximab was $48 620 (95% CI, $46 466-$50 775) compared with $33 009 (95% CI, $31 499-$34 519) for radiotherapy with cisplatin and $27 622 (95% CI, $25 118-$30 126) for radiotherapy only.

Conclusions and Relevance  In this cohort study, no survival difference, a higher rate of ED visits but not of inpatient admissions, and higher spending were observed in patients receiving radiotherapy with cetuximab compared with patients receiving radiotherapy only. The findings suggest that radiotherapy alone should be maintained as a treatment arm in evaluation of novel therapeutics for locoregionally advanced head and neck cancer in older and sicker patients.

Original Article

Variation in Insurance Coverage Among Patients With Head and Neck Cancer After the ACA

Key Points

Question  How does the association between implementation of the Patient Protection and Affordable Care Act (ACA) and change in insurance status vary across sociodemographic subpopulations of patients with head and neck cancer (HNC)?

Findings  In this cohort study of 131 779 patients from the National Cancer Database, patients with HNC experienced a significant reduction in uninsured rates after implementation of the ACA. Young adults and patients from low-income zip codes experienced greater increases in coverage than those from older age groups and higher-income zip codes.

Meaning  Implementation of the ACA was associated with greater insurance coverage among populations of patients with HNC with historically limited access to care.

Importance  Health insurance status has a significant association with early diagnosis and stage at presentation, which are the most important predictors of survival among patients with head and neck cancer (HNC). Literature on the association of the Patient Protection and Affordable Care Act (ACA) with changes in insurance status among patients with HNC remains limited. To our knowledge, no studies have evaluated changes in insurance rates across sociodemographic subgroups of patients with HNC.

Objective  To assess the association of the implementation of the ACA with insurance status across socioeconomic and demographic subpopulations of patients with HNC.

Design, Setting, and Participants  A retrospective cohort study using data from the National Cancer Database (NCDB), a hospital-based cancer registry (2011-2015) for adults diagnosed with a malignant primary HNC was carried out. The analyses were conducted from November 2018 through December 2018.

Main Outcomes and Measures  Changes in the percentage of patients with insurance.

Results  A total of 131 779 patients with HNC were identified in the pre-ACA (77 071) and post-ACA (54 708) periods. Overall, 98 207 (74.5%) participants were men and 33 572 (25.5) were women, with 73 124 (55.5%) being aged between 50 to 64 years. There was a 2.68 percentage point decrease (PPD) (95% CI, 2.93-2.42) in the percentage of patients with HNC without insurance from the pre-ACA to the post-ACA period. Changes in the percentage of uninsured patients varied significantly by age, with the largest reduction in uninsured status among patients with HNC aged 18 to 34 years (5.12 PPD; 95% CI, 3.18-7.06) and the smallest reduction in uninsured among those aged 65 to 74 years (0.24 PPD; 95% CI, 0.03-0.45). There was a significantly greater reduction in uninsured status in low-income zip codes (3.45 PPD; 95% CI, 2.76-4.14) than in high-income zip codes (1.99 PPD; 95% CI, 1.63-2.36).

Conclusions and Relevance  There was a significant association between ACA implementation and percentage decrease in uninsured patients. Young adults and those residing in low-income zip codes experienced a significantly higher rate of insurance uptake compared with older adults and residents of high-income areas. This suggests that coverage expansions enacted through the ACA are not only associated with increased access to care among the broader HNC population, but that they may also yield a greater benefit among subpopulations with historically limited insurance coverage.

Original Article

Variation in Insurance Coverage Among Patients With Head and Neck Cancer After the ACA

Key Points

Question  How does the association between implementation of the Patient Protection and Affordable Care Act (ACA) and change in insurance status vary across sociodemographic subpopulations of patients with head and neck cancer (HNC)?

Findings  In this cohort study of 131 779 patients from the National Cancer Database, patients with HNC experienced a significant reduction in uninsured rates after implementation of the ACA. Young adults and patients from low-income zip codes experienced greater increases in coverage than those from older age groups and higher-income zip codes.

Meaning  Implementation of the ACA was associated with greater insurance coverage among populations of patients with HNC with historically limited access to care.

Importance  Health insurance status has a significant association with early diagnosis and stage at presentation, which are the most important predictors of survival among patients with head and neck cancer (HNC). Literature on the association of the Patient Protection and Affordable Care Act (ACA) with changes in insurance status among patients with HNC remains limited. To our knowledge, no studies have evaluated changes in insurance rates across sociodemographic subgroups of patients with HNC.

Objective  To assess the association of the implementation of the ACA with insurance status across socioeconomic and demographic subpopulations of patients with HNC.

Design, Setting, and Participants  A retrospective cohort study using data from the National Cancer Database (NCDB), a hospital-based cancer registry (2011-2015) for adults diagnosed with a malignant primary HNC was carried out. The analyses were conducted from November 2018 through December 2018.

Main Outcomes and Measures  Changes in the percentage of patients with insurance.

Results  A total of 131 779 patients with HNC were identified in the pre-ACA (77 071) and post-ACA (54 708) periods. Overall, 98 207 (74.5%) participants were men and 33 572 (25.5) were women, with 73 124 (55.5%) being aged between 50 to 64 years. There was a 2.68 percentage point decrease (PPD) (95% CI, 2.93-2.42) in the percentage of patients with HNC without insurance from the pre-ACA to the post-ACA period. Changes in the percentage of uninsured patients varied significantly by age, with the largest reduction in uninsured status among patients with HNC aged 18 to 34 years (5.12 PPD; 95% CI, 3.18-7.06) and the smallest reduction in uninsured among those aged 65 to 74 years (0.24 PPD; 95% CI, 0.03-0.45). There was a significantly greater reduction in uninsured status in low-income zip codes (3.45 PPD; 95% CI, 2.76-4.14) than in high-income zip codes (1.99 PPD; 95% CI, 1.63-2.36).

Conclusions and Relevance  There was a significant association between ACA implementation and percentage decrease in uninsured patients. Young adults and those residing in low-income zip codes experienced a significantly higher rate of insurance uptake compared with older adults and residents of high-income areas. This suggests that coverage expansions enacted through the ACA are not only associated with increased access to care among the broader HNC population, but that they may also yield a greater benefit among subpopulations with historically limited insurance coverage.

Original Article

December Issue Highlights

In this cohort study, Cramer et al assess the performance of the traditional pathologic risk stratification system for surgically resected human papillomavirus (HPV)–associated oropharyngeal squamous cell carcinoma (OPSCC) and propose a novel composite risk stratification system. Using the National Cancer Database, the authors identified 15 324 patients diagnosed with nonmetastatic head and neck squamous cell carcinoma (HNSCC) who were treated with upfront surgery and neck dissection. They compared traditional pathologic risk stratification for HPV+ OPSCC and HPV-unassociated HNSCC and derived a novel pathologic risk stratification system.

Original Article