IMPORTANCE A patient's decision to undergo surgery may be fraught with uncertainty and decisional conflict. The unpredictable nature of the COVID-19 pandemic warrants further study into factors associated with patient decision-making.OBJECTIVE To assess decisional conflict and patient-specific concerns for people undergoing otolaryngologic surgery during the pandemic. DESIGN, SETTING, PARTICIPANTSThis prospective cross-sectional survey study was conducted via telephone from April 22 to August 31, 2020. English-speaking adults scheduled for surgery from a single academic surgical center were invited to participate. Individuals who were non-English speaking, lacked autonomous medical decision-making capacity, scheduled for emergent surgery, or had a communication disability were excluded. For race and ethnicity reporting, participants were classified dichotomously as White according to the Behavioral Risk Factor Surveillance System from the Centers for Disease Control and Prevention or non-White as a collective term including Black or African American, American Indian or Alaska Native, Asian, or Pacific Islander race and ethnicity.EXPOSURES The SURE Questionnaire (sure of myself, understand information, risks/benefits ratio, and encouragement) was used to screen for decisional conflict, with a total score greater than or equal to 3 indicating clinically significant decisional conflict. Participants were asked to share their specific concerns about having surgery. MAIN OUTCOME AND MEASURESDecisional conflict and patient demographic data were assessed via bivariate analyses, multivariable logistic regression and conjunctive consolidation. Patient-specific concerns were qualitatively analyzed for summative themes. RESULTSOf 444 patients screened for eligibility, 182 (40.9%) respondents participated. The median age was 60.5 years (interquartile range, 48-70 years). The racial and ethnic identity of the participants was classified as binary White (84% [153 of 182]) and non-White (16% [29 of 182]). The overall prevalence of decisional conflict was 19% (34 of 182). Decisional conflict was more prevalent among non-White than White participants (proportion difference 18.8%, 95% CI, 0.6%-37.0% and adjusted odds ratio 3.0; 95% CI, 1.2-7.4). Combining information from multiple variables through conjunctive consolidation, the group with the highest rate of decisional conflict was non-White patients with no college education receiving urgent surgery (odds ratio, 10.8; 95% CI, 2.6-45.0). Intraoperative and postoperative concerns were the most common themes expressed by participants. There was a clinically significant difference in the proportion of participants who screened positive for decisional conflict (30%) and expressed postoperative concerns than those who screened negative for decisional conflict (17%) (proportion difference, 13%; 95% CI, 1%-25%). Among patients reporting concerns about COVID-19, most screened positive for decisional conflict.CONCLUSIONS AND RELEVANCE Results of this cross-sectional survey study suggest t...

Background: Oropharyngeal squamous cell carcinoma (OPSCC) epidemiology has not been examined previously in the nationwide Veterans Affairs (VA) population. Methods: Joinpoint regression analysis was applied to OPSCC cases identified from VA administrative data from 2000 to 2012. Results: We identified 12 125 OPSCC cases (incidence: 12.2 of 100 000 persons). OPSCC incidence declined between 2000 and 2006 (annual percent change [APC] = −4.27, P < .05), then increased between 2006 and 2012 (APC = 7.02, P < .05). Significant incidence increases occurred among white (APC = 7.19, P < .05) and African American (APC = 4.87, P < .05) Veterans and across all age cohorts. The percentage of never-smokers increased from 8% in 2000 to 15.7% in 2012 (P < .001), and 2-year overall survival improved from 31.2% (95% confidence interval (CI) [30-33.4]) to 55.7% (95% CI [54.4-57.1]). Conclusions: OPSCC incidence is increasing across all racial and age cohorts in the VA population. Smoking rates remain high among Veterans with OPSCC and gains in survival lag those reported in the general population.

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6063 Background: HPV genomic DNA in plasma and saliva has been widely studied, however more recently, circulating tumor human papillomavirus DNA (ctHPVDNA) has emerged as a reliable biomarker for surveillance in HPV+ oropharyngeal squamous cell carcinoma (OPSCC). A commercial assay for this biomarker distinguishes tumor-derived viral DNA (tumor-tissue modified viral DNA or TTMV) from other non-cancer associated sources of HPV DNA. The use of this technology has been previously described in plasma, but its utility in saliva is currently unknown. Methods: A prospectively collected and banked biospecimen repository was used to identify 46 patients with HPV+ OPSCC with paired pre treatment plasma and saliva samples. All samples were assessed for DNA integrity and TTMV using a clinically validated ddPCR-based assay (NavDx™; Naveris Inc, Natick, MA) to measure TTMV for HPV-16, -18, -31, -33 and -35 from frozen plasma and saliva samples. Retrospective chart review was performed to collect clinical and pathological data. Graphpad was used for statistical analysis. Spearman’s r was used to correlate TTMV copies in saliva and plasma. Wilcoxon test was used to compare between sample types. Mann-Whitney test was used for categorical variables. Results: TTMV DNA was detectable in 43 of 46 plasma samples and in 44 of 46 saliva samples. One plasma sample failed quality control measures, one of each sample type had undetectable TTMV, and one of each type was indeterminate. Of 41 evaluable patients with paired samples, there were 38 (93%) males, 36 (88%) were stage I-II, 5 (12%) were stage III-IV (AJCC 8th, clinical staging), and 25 (61%) had a history of smoking with a median of 37.5 pack years. TTMV was significantly enriched in saliva compared to plasma (p<0.0001), with median copy number 14,139 copies/ml (IQR=193,339.5) and 774.7 copies/ml (IQR=4,826.1), respectively. There was a significant positive correlation between plasma and saliva TTMV levels (r=0.344, p=0.028). There was no difference in overall stage for either specimen type. There was a trend in both sample types toward higher TTMV in patients with a history of smoking. Pack-year history was available for 38 (93%) patients in the final cohort. When grouping by pack-years, plasma TTMV approached significance (p=0.058) while high saliva TTMV was significantly associated with >10 pack-year history (p=0.011). Conclusions: This is the first study to demonstrate successful quantification of tumor-tissue modified HPV DNA in saliva. Compared to plasma, pre treatment saliva samples demonstrated significantly higher levels of TTMV. TTMV distinguishes ctHPVDNA from other sources of HPV. These data highlight the potential use of TTMV detection in saliva for early detection of HPV+ OPSCC as well as its potential role in local surveillance after treatment. More research is needed to elucidate the effects of smoking on TTMV levels.

Given the high prevalence of otolaryngology infections such as tonsillitis, otitis, and pharyngitis in low and middle income countries, the field of global otolaryngology continues to grow to accommodate patients around the world. This commentary focuses on best practices in transcultural communications between US doctors and foreign patients with an emphasis on cultural competency. We use alternative medicine as an exemplar for how to collaborate with patients to develop treatment plans that respect their cultural beliefs and lifestyles. Rather than assigning value to the patient’s alternative medicine practices, we believe that instructing and counseling a patient on how to incorporate follow-up visits and rehabilitation after allopathic medical procedures such as surgical tonsillectomy should be done in a way that respects the patient’s preexisting health regimen. By doing so, these new aspects of their health care will take a discrete place in their wellness practices and engender more trust and better health outcomes.