ABSTRACT
Background
We compared treatment delays, costs, and management impact between oropharyngeal squamous cell carcinoma (OPSCC) patients undergoing in‐office versus general anesthesia panendoscopy‐guided biopsies in two large tertiary centers in a public healthcare system.
Methods
All OPSCC patients included were treated between 2010 and 2024 with either curative radiation alone or chemoradiation.
Results
Demographic and tumor characteristics were comparable, except for smaller tumors in the panendoscopy group (n = 36) compared to the in‐office group (n = 37) (mean size; 29.4 mm vs. 36.6 mm, respectively; difference −7.2 mm [95% CI, −11.3 to −3.1]). The panendoscopy group experienced substantially longer treatment initiation delays (mean days; 70.1 days vs. 44.5 days; difference 25.7 days [95% CI 13.0 to 38.2]). No additional synchronous tumors were detected through panendoscopy. Panendoscopy incurred a mean additional cost of 2025CAD $3886.
Conclusions
Panendoscopy for OPSCC prolongs treatment initiation, incurs additional expenses, and provides no incremental synchronous tumor detection. When clinically feasible, in‐office biopsies should be preferred.
Keywords: biopsy, delay to treatment, oropharyngeal cancer, panendoscopy, synchronous primary cancer
Abbreviations
- AJCC
American Joint Committee on Cancer
- CCI
Charlson Comorbidity Index
- CITADEL
Centre for the Integration and Analysis of Medical Data
- CT
computed tomography
- MRI
magnetic resonance imaging
- OPSCC
oropharyngeal squamous cell carcinoma
- PET
positron emission tomography
- TORS
transoral robotic surgery
1. Introduction
The incidence of oropharyngeal squamous cell cancer (OPSCC) has been increasing in recent years [1]. Improving treatment timelines for head and neck cancers, including OPSCC, has been associated with better survival outcomes [2, 3, 4]. In this context, optimizing the timelines of our management pathways becomes critical for enhancing patient survival.
Historically, panendoscopy under general anesthesia has been extensively used to biopsy suspicious oropharyngeal lesions, evaluate its extent, and detect synchronous aerodigestive cancers. However, with advancements in imaging techniques and biopsy methods, the role of panendoscopy has come into question. Modern imaging modalities now allow for better evaluation of primary tumor extent and detection of synchronous cancers [5]. Additionally, biopsies can be performed under local anesthesia, including direct transoral and transnasal flexible endoscopic biopsies, offering less invasive alternatives. Furthermore, panendoscopy implies additional resource utilization and potentially introduces delays in the treatment pathway.
Given these considerations, our study aimed to assess the impact of panendoscopy on the management of OPSCC. Our primary objective was to compare treatment initiation delays between patients undergoing biopsy under general anesthesia (panendoscopy group) and those receiving in‐office biopsies. Secondary analyses focused on three key outcomes: (1) the incidence of synchronous primary aerodigestive cancers, (2) the relationship between management strategies and time to treatment initiation, and (3) a comprehensive assessment of direct panendoscopy‐related costs.
2. Materials and Methods
2.1. Study Design
Following ethical committee approval (#MP‐02‐2023‐110 640), we conducted a retrospective bicentric study in two academic tertiary care institutions within a public healthcare system. We compared the time between the first otolaryngology visit and treatment initiation for OPSCC patients who underwent panendoscopy versus those who did not. Additionally, we analyzed the panendoscopy group to determine the incidence of synchronous aerodigestive cancers detected during the procedure.
2.2. Patient Selection
This study included patients diagnosed with OPSCC between January 2010 and December 2024 who received curative radiation therapy, with or without chemotherapy. We excluded patients with unknown primary head and neck cancers due to their distinct diagnostic trajectory. Hence, all included patients had a clinical or radiological suspicion of oropharyngeal cancer. Additionally, patients who underwent primary surgical treatment were also excluded. This was due to the small number of such patients and the fact that panendoscopy is almost always performed on the same day as surgery, making it impossible to isolate the costs of panendoscopy from those of the surgery itself. Patients were further excluded if they were under 18 years old or non‐adherent to the diagnostic and/or treatment plan.
We formed two distinct groups for comparative analysis. The panendoscopy group consisted of patients who underwent oropharyngeal biopsy, direct laryngoscopy, and rigid esophagoscopy under general anesthesia in the operating room. The in‐office group was composed of patients who did not undergo panendoscopy and who had biopsies done under local anesthesia.
For evident oropharyngeal cancer cases, an oropharyngeal biopsy or a fine needle aspiration (FNA) of a suspicious lymph node was considered sufficient to initiate treatment. For more ambiguous cases where an oropharyngeal cancer source was still clinically or radiologically suspected but less evident, our team preferred to rely on an oropharyngeal biopsy to initiate treatment.
2.3. Data Collection
Demographic data was collected including sex, age, tobacco consumption (quantified in pack‐years), alcohol consumption, and the Charlson Comorbidity Index (CCI). To calculate each patient's CCI, we gathered additional information on specific comorbidities such as myocardial infarction history, peripheral vascular disease, liver disease, diabetes mellitus, and other relevant conditions. We also recorded tumor‐specific data, encompassing oropharyngeal subsite, p16 status, tumor size, and clinical TNM stage based on the 8th edition of the American Joint Committee on Cancer (AJCC) staging system.
In the panendoscopy group, we aimed to determine the incidence of synchronous primary tumors and identify the diagnostic modality that detected them. To do so, we documented the imaging techniques employed for each patient, including computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) scans. We noted the presence of synchronous primary tumors and, when present, determined whether they were first identified by imaging or panendoscopy.
Financial data was collected through CITADEL (Centre for the Integration and Analysis of Medical Data), an internal organizational unit responsible for comprehensive financial tracking of patient care at the University of Montreal Health Centre. In our public health system's unique structure, where physician compensation is independent from hospital billing, we assessed the professional fees for otolaryngologists and anesthesiologists. We cross‐verified these data with specialists in the same disciplines to ensure valid financial accuracy. Comprehensive hospital fee collection included all components: preoperative assessment, operating room costs, surgical equipment, nursing care, administrative work, and hospitalization where required. All costs were converted to 2025 Canadian dollars (2025CAD) using the Bank of Canada's historical inflation rates, enabling valid year‐over‐year comparisons.
2.4. Statistical Analysis
Descriptive statistics were presented as frequencies and percentages for categorical variables and means with standard deviations for continuous variables. Comparisons between groups were performed using appropriate effect size metrics (mean and proportion differences), and the precision of estimates was evaluated with 95% confidence intervals. All statistical tests were two tailed with a significance level set at p < 0.05. Data analyses were conducted using Microsoft Excel version 2311.
3. Results
3.1. Demographic and Tumor Data
The demographic data is summarized in Table 1. Among the 73 patients included in our study, 36 underwent a panendoscopy. There were no statistically significant differences in the demographic characteristics between both groups. Only one patient in the panendoscopy group had to undergo awake fiberoptic intubation due to an obstructive oropharyngeal lesion (2.8%, n = 1/36).
TABLE 1.
Demographic data.
| With panendoscopy, n (%) (N = 36) | Without panendoscopy, n (%) (N = 37) | Effect size (95% CI) | p | |
|---|---|---|---|---|
| Sex | ||||
| Men | 27 (75.0) | 24 (64.9) | 10.1 (−11.1 to 30.6) b | 0.491 |
| Women | 9 (25.0) | 13 (35.1) | −10.1 (−30.6 to 11.1) b | 0.491 |
| Mean age, years (SD) | 62.8 (7.3) | 61.4 (14.4) | 1.4 (−4.0 to 6.8) a | 0.620 |
| Tobacco history | ||||
| None | 13 (36.1) | 9 (24.3) | 11.8 (−9.5 to 32.2) b | 0.400 |
| < 20 PY | 5 (13.9) | 8 (21.6) | −7.7 (−25.8 to 10.5) b | 0.577 |
| ≥ 20 PY | 18 (50.0) | 20 (54.1) | −4.1 (−26.3 to 18.6) b | 0.911 |
| Alcoholism history | ||||
| None | 5 (13.9) | 8 (21.7) | −7.7 (−10.4 to 34.1) b | 0.577 |
| < 20/week | 22 (61.1) | 18 (48.6) | 12.5 (−10.4 to 34.1) b | 0.404 |
| ≥ 20/week | 7 (19.4) | 10 (27.0) | −7.6 (−27.0 to 12.2) b | 0.625 |
| Not specified | 2 (5.6) | 1 (2.7) | 2.9 (−9.1 to 15.6) b | 0.981 |
| Charlson comorbidity index, mean (SD) | 2.4 (1.3) | 2.7 (1.8) | −0.3 (−0.1 to 1.3) a | 0.603 |
Abbreviations: PY, pack years; SD, standard deviation.
Mean difference.
Proportion difference.
Indications for panendoscopy were the following:
Negative in‐office oropharyngeal biopsy despite a high clinical suspicion of oropharyngeal cancer, when the clinician judged that nodal FNA would be insufficient to reliably establish the squamous cell carcinoma primary site (14%, n = 5/36).
Cases in which in‐office biopsy was not feasible and nodal FNA of a suspicious lymph node was considered insufficient to definitively confirm the oropharyngeal origin of the squamous cell carcinoma (53%, n = 19/36).
Confirmation of an oropharyngeal primary in the setting of nodal FNA positive for squamous cell carcinoma with a suspicious oropharyngeal lesion not amenable to in‐office biopsy (33%, n = 12/36).
Table 2 presents the baseline tumor characteristics of the primary OPSCC. The “Not‐specified” oropharyngeal location represents an identifiable tumor in the oropharynx for which the specific subsite was not well described. The two groups were similar, except that patients who underwent panendoscopy had smaller average tumor sizes (29.4 [12.5] mm vs. 36.6 [0.3] mm; difference −7.2 mm [95% CI, −11.3 to −3.1]).
TABLE 2.
Tumor characteristics.
| With panendoscopy, n (%) (N = 36) | Without panendoscopy, n (%) (N = 37) | Effect size (95% CI) | p | |
|---|---|---|---|---|
| Location | ||||
| Tonsil | 16 (44.4) | 20 (54.1) | −9.6 (−31.5 to 13.2) b | 0.486 |
| Soft palate | 1 (2.8) | 2 (5.4) | −2.6 (−15.5 to 9.5) b | 1.000 |
| Posterior wall | 2 (5.6) | 1 (2.7) | 2.9 (−9.1 to 16.0) b | 0.615 |
| Tongue base | 14 (38.9) | 11 (29.7) | 9.2 (−12.7 to 30.3) b | 0.465 |
| Not‐specified | 3 (8.3) | 3 (8.1) | 0.2 (−0.1 to 15.1) b | 1.000 |
| p16 status | ||||
| p16+ | 30 (80.0) | 25 (67.6) | 15.8 (−4.3 to 35.0) b | 0.175 |
| p16− | 6 (20.0) | 8 (21.6) | −5.0 (−23.5 to 13.8) b | 0.768 |
| Unknown | 0 (0.0) | 4 (10.8) | −10.8 (−25.8 to −0.5) b | 0.115 |
| Tumor size, mm (mean ± SD) | 29.4 (12.5) | 36.6 (0.3) | −7.2 (−11.3 to −3.1) a | 0.047 |
| T‐stage | ||||
| T1 | 10 (27.8) | 4 (10.8) | 17.0 (−17.6 to 17.9) b | 0.158 |
| T2 | 16 (44.4) | 12 (32.4) | 12.0 (−10.3 to 33.3) b | 0.341 |
| T3 | 5 (13.9) | 8 (21.6) | −7.7 (−25.8 to 10.5) b | 0.543 |
| T4 | 5 (13.9) | 13 (35.1) | −21.2 (−40.0 to −1.4) b | 0.056 |
| Tis | 0 (0.0) | 0 (0.0) | 0 (0 to 0) b | |
| N‐stage | ||||
| N0 | 5 (13.9) | 6 (16.2) | −2.3 (−19.7 to 15.2) b | 1.000 |
| N+ | 31 (86.1) | 31 (83.8) | 2.3 (−15.2 to 19.7) b | 1.000 |
| M‐stage | ||||
| cM0 | 36 (100) | 37 (100) | 0 (0 to 0) b | 1.000 |
Abbreviation: SD, standard deviation.
Mean difference.
Proportion difference.
3.2. Synchronous Primary Tumor
Regarding synchronous cancer detection among patients who received a panendoscopy, Table 3 presents the various tests used and identifies whether a synchronous aerodigestive tumor was found. All patients underwent a CT‐scan of the neck and, if needed, an MRI was added. They also all had chest imaging either by chest CT‐scan or PET‐scan. The only synchronous cancer detected was an adenocarcinoma of the right upper lobe, which was not within the reach of a bronchoscopy. It was identified on the patient's chest CT‐scan, and the diagnosis was confirmed with a transthoracic biopsy. The primary tumor was a T2N1 right tonsil p16‐positive OPSCC.
TABLE 3.
Imaging and panendoscopy for synchronous cancer detection.
| n (%) | Synchronous tumor | |
|---|---|---|
| Number of patients | 36 (100.0) | 1 |
| P16 status | ||
| Positive | 30 (83.3) | 1 |
| Negative | 6 (16.7) | 0 |
| Investigation | ||
| Neck CT | 36 (100.0) | 0 |
| Neck MRI | 18 (50.0) | 0 |
| Chest CT | 25 (69.4) | 1 |
| PET‐CT | 26 (72.2) | 0 |
| Panendoscopy | 36 (100.0) | 0 |
Abbreviations: CT, computed tomography; MRI, magnetic resonance imaging; PET, positron emission tomography.
3.3. Delay to Treatment Initiation
The data on delay to treatment initiation are presented in Table 4. In the panendoscopy group, there was a significantly longer delay measured from initial otolaryngology consultation to treatment initiation (70.1 [34.8] days vs. 44.5 [16.1] days; difference: 25.7 [95% CI 13.0 to 38.2]). This difference remained similar regardless of whether the treatment was radiation alone or chemoradiation. Although not shown in Table 4, there was no significant difference in the delay to treatment initiation between radiotherapy alone and chemoradiotherapy within each group (with panendoscopy; radiation 73.2 [18.5] days vs. chemoradiation 69.0 [40.7] days; difference 4.2 [95% CI −14.5 to 25.1]) (without panendoscopy; radiation 42.2 [10.4] days vs. chemoradiation 45.3 [17.9] days; difference −3.1 [95% CI −12.9 to 6.7]). Four patients (11%) in the panendoscopy group had an attempted in‐office biopsy under local anesthesia (all transorally), which had demonstrated absence of malignancy. These patients still had a persistent clinical suspicion of malignancy and underwent a panendoscopy for a second biopsy, which confirmed the diagnosis of OPSCC in all cases. All four patients had tonsillar OPSCC.
TABLE 4.
Delay to treatment.
| With panendoscopy, n (%) (N = 36) | Without panendoscopy, n (%) (N = 37) | Effect size (95% CI) | p | |
|---|---|---|---|---|
| Delays | ||||
| ENT consultation to treatment, mean days (SD) | 70.1 (34.8) | 44.5 (16.1) | 25.7 (13.0 to 38.2) a | < 0.001 |
| ENT consultation to panendoscopy, mean days (SD) | 21.5 (17.2) | NA | NA | NA |
| Panendoscopy to treatment, mean days (SD) | 47.8 (32.9) | NA | NA | NA |
| Treatment type | ||||
| Radiation, n (%) | 9 (25.0) | 10 (27.0) | −2.0 (−22.2 to 18.4) b | 1.000 |
| Chemoradiation, n (%) | 27 (75.0) | 27 (73.0) | 2.0 (−18.4 to 22.2) b | 1.000 |
| Delays according to treatment type | ||||
| Radiation, mean days (SD) | 73.2 (18.5) | 42.2 (10.4) | 31.0 (21.9 to 40.1) a | 0.001 |
| Chemoradiation, mean days (SD) | 69.0 (40.7) | 45.3 (17.9) | 23.7 (9.1 to 38.3) a | 0.018 |
Abbreviations: ENT, otolaryngology; NA, not applicable; SD, standard deviation.
Mean difference.
Proportion difference.
3.4. Panendoscopy Costs
The cost analysis presented in Table 5 provides a comprehensive breakdown of panendoscopy‐related expenses in 2025 Canadian dollars (2025CAD). Hospital costs encompassed a full spectrum of services, including nursing care, operating room resources, administrative processes, pharmaceuticals, day surgery charges, and laboratory investigations. One patient required an overnight admission due to sleep apnea, resulting in an additional cost of 2025CAD $799.82. Patients mandating pre‐operative medical evaluations from internal medicine or anesthesiology departments incurred a mean supplementary expense of 2025CAD $430.43. The total cost of 2025CAD $3886.22 in Table 5 does not include the overnight admission fee.
TABLE 5.
Panendoscopy costs.
| Cost category | Mean cost (2025CAD) a | (±SD) |
|---|---|---|
| Surgeon | $270.46 | $215.24 |
| Anesthesiologist | $377.39 | $64.04 |
| Preoperative assessment | $430.43 | $67.46 |
| Hospital fee | $2807.95 | $855.54 |
| Total | $3886.22 | $1239.83 |
Abbreviation: SD, standard deviation.
2025CAD: 2025 Canadian dollars.
4. Discussion
In the context of OPSCC, panendoscopy offers several utilities such as evaluating surgical exposure for future robotic surgery of the oropharynx (TORS), biopsy of suspicious lesions, and assessing the presence of synchronous aerodigestive cancers. However, panendoscopy also presents considerable disadvantages, such as increasing delays to treatment and risks associated with general anesthesia. It is also important to use resources judiciously, especially in a resource‐limited public health care system. The present discussion aims to address the pros and cons of general anesthesia biopsies with panendoscopy performed in the context of OPSCC and its associated financial costs.
4.1. Clinical Utility of Panendoscopy
In the context of an identifiable OPSCC, panendoscopy is recognized as the gold standard for evaluating exposure for TORS. To date, no other method has been proven as effective. Historically, panendoscopy played a well‐established role in the staging workup of head and neck mucosal cancers. It simultaneously evaluated the primary cancer and searched for synchronous cancer along the aerodigestive mucosa. The search for synchronous aerodigestive cancers is based on the principle of mucosal field cancerization secondary to chronic exposure to carcinogens such as alcohol and tobacco. The development of modern and precise imaging modalities such as CT scans, MRI, and PET scans has made it possible to easily identify synchronous cancers. The role of panendoscopy in identifying synchronous cancers has thus been questioned. A systematic review published in 2025 revealed minimal clinical impact of panendoscopy in patients with pre‐existing neck and chest imaging. Among patients who had undergone CT scans, panendoscopy altered management in only 1.1% of cases (n = 268). Similarly, for patients with PET scans, no management changes were observed (n = 544) [5]. Accordingly, our study demonstrated only one synchronous pulmonary tumor, which was identified by CT scan and was beyond the reach of panendoscopy. We conclude that patients who have undergone a PET or CT scan of the neck and chest would not systematically need panendoscopy to detect synchronous cancers. If suspicious aerodigestive findings on imaging are accessible by panendoscopy, then it should be considered.
Furthermore, safety related to oropharyngeal mass biopsies is another factor to consider. Most OPSCCs are biopsied via transoral or endonasal endoscopic access through a working port. In our study, OPSCCs were larger in the in‐office biopsy group. We hypothesize that the larger the tumor size, the more easily accessible it is for an in‐office biopsy. Factors that may influence the surgeon to perform a biopsy under general anesthesia may include tumor location, presence of significant trismus, limited patient cooperation, and presence of comorbidities such as coagulopathy. Overall, pharyngolaryngeal in‐office biopsies are recognized as safe [6].
4.2. Delay to Treatment
Minimizing treatment delays is a proven method to improve survival in cancer patients [7]. Accordingly, we aimed to compare therapeutic delays between biopsies performed under general anesthesia via panendoscopy and those done in clinic for patients with OPSCC. We sought to help clinicians quantify the additional delays caused by procedures under general anesthesia within a resource‐limited public healthcare system.
Our study demonstrated a significant extension of approximately 25 days between the initial ENT consultation and the first day of treatment in the panendoscopy biopsy group compared to those biopsied in clinic. More invasive diagnostic procedures have already been identified in the literature as a factor extending treatment delays [8]. We acknowledge that this value may vary depending on operating room accessibility specific to each center. Nevertheless, this is the first study in the literature quantifying treatment delays generated by panendoscopy for OPSCC biopsy in a public healthcare system. A similar study to ours in OPSCC patients (n = 98) but in an American private center demonstrated comparable results. The treatment delay was 8.84 days shorter when biopsies were done in‐office (n = 46) compared to those under general anesthesia (n = 52) (mean = 33.7 vs. 42.4 days, p < 0.05). Patients biopsied in clinic had their biopsy on average 14.15 days earlier (mean = 17.5 vs. 3.4 days, p < 0.05) [9]. While these data do not directly demonstrate improved survival, they allow for improved treatment delays, a factor strongly recognized for improving cancer survival. We thus conclude that biopsy under general anesthesia causes additional treatment delays, particularly in a resource‐limited public healthcare system. If possible, in‐office biopsies should be preferred.
When an oropharyngeal lesion is difficult to access by transoral biopsy, we encourage clinicians to perform a biopsy via flexible transnasal endoscopy before considering panendoscopy under general anesthesia. A study in a public center in the Netherlands evaluating this type of biopsy (n = 53) for laryngopharyngeal lesions suspicious for malignancy reported a diagnostic rate of 92.5% and no complications. On average, patients had three biopsies per lesion. All non‐diagnostic biopsies were supraglottic lesions. Treatment delays were also improved by 27 days (p < 0.05) compared to the group under general anesthesia [10]. A 2022 systematic review including 16 studies evaluating in‐office biopsies for pharyngolaryngeal lesions demonstrated a diagnostic rate of 81.6% (n = 1283), of which 87.5% had sufficient tissue for pathological analysis. There was no difference in diagnostic validity between transoral biopsies and those via endonasal endoscopic approach, although comparison remains difficult according to the authors. Only 0.41% of patients (n = 7) experienced complications, including epistaxis (n = 3), aspiration (n = 2), choking (n = 1), and dizziness (n = 1). However, studies in the review inconsistently reported specific biopsy sites, and the authors judged that the majority were laryngeal lesions [11]. A 2018 study evaluating flexible transnasal endoscopic biopsies of laryngopharyngeal lesions (n = 90), including 19 oropharyngeal lesions, revealed no difference in diagnostic efficacy according to tumor site (Pearson χ 6.30, p = 0.614) [12]. Ultimately, biopsy under local anesthesia via endonasal endoscopic approach is a low‐risk technique that appears to be associated with an adequate diagnostic rate. However, we believe that any oropharyngeal lesion remaining suspicious despite a negative in‐office biopsy should undergo biopsy under general anesthesia.
In our study, there was no significant difference in treatment delays between patients treated with radiotherapy alone or chemoradiotherapy (intra‐ and inter‐group comparison). Thus, the addition of chemotherapy did not negatively impact therapeutic delays, reflecting good interdisciplinary cooperation, a recognized method for improving therapeutic delays [8].
4.3. Panendoscopy Cost‐Analysis
In a budget‐constrained healthcare system, resource optimization is critical for system efficiency. A 2025 systematic review on panendoscopy costs revealed exclusively American private healthcare studies, underscoring the necessity of cost analyses in public healthcare settings—a gap our research addresses [5]. The review highlighted two 2022 publications reporting markedly disparate panendoscopy costs: one study documented a base expense of US$ 3802 (2025CAD $5343), excluding anesthesia and medication [13], while another estimated a fee of US$ 17 296 (2025CAD $24 308) [14].
Our study presents a significantly lower procedural cost of $3886. This substantial cost reduction likely stems from our public healthcare system's non‐profit structure. Moreover, the previously referenced studies incorporated bronchoscopy in their panendoscopy protocol—a component we intentionally omitted. This decision is justified by the rare occurrence of synchronous tracheobronchial cancer in oropharyngeal squamous cell carcinoma (OPSCC), with an incidence of approximately 1%, and the reliability of pre‐identification through imaging [5].
For OPSCC patients amenable to non‐surgical treatment with accessible in‐office biopsy, panendoscopy offers minimal additional clinical value. Such procedures potentially introduce treatment delays, operative risks, and substantial resource allocation that can overwhelm surgical waiting lists. Consequently, we advocate for a strategic approach to panendoscopy, recommending the procedure only in the following specific clinical scenarios: (1) when in‐office biopsy is unsafe or technically unfeasible, (2) investigating an unknown primary head and neck cancer, (3) negative in‐office biopsy results for a clinical lesion that remains suspicious, (4) confirming suspicious imaging findings requiring direct visualization, and (5) preoperative assessment for surgical management planning.
Regarding the latter indication, our institution's protocol considers surgical management of OPSCC only when adjuvant radiation can be completely avoided. Therefore, preoperative panendoscopy is offered exclusively to patients who meet all TORS eligibility criteria and for whom adjuvant radiation is deemed avoidable. This excludes patients with large tumors, medialized carotid on imaging, extensive soft palate invasion on physical examination, multiple suspicious cervical lymph nodes, nodes exceeding 3 cm, or extranodal extension on imaging.
4.4. Limitations
We are aware that our study has several inherent limitations. As the first comprehensive assessment of panendoscopy‐induced costs and therapeutic delays within a public healthcare setting, our research necessarily lacks direct comparative benchmarks. The limited sample size restricts the generalizability of our findings, acknowledging that costs and treatment delays can vary substantially across different healthcare centers. These methodological constraints underscore the need for additional research to validate our observations. While we meticulously documented direct hospital expenses associated with panendoscopy, our analysis did not encompass indirect costs. Patient‐related expenditures, including lost work hours, transportation expenses, and other accommodation fees, remain unaccounted for and represent important considerations for future comprehensive economic evaluations. Consequently, we recommend subsequent multicenter studies within public healthcare systems to develop a more holistic understanding of procedural economic implications and establish more robust cost–benefit analyses for panendoscopy. Additionally, retrospectively determining why patients required general anesthesia biopsy with panendoscopy and identifying the primary limitations that prevented in‐office biopsy (e.g., surgeon preference, safety concerns, need for endoscopic screening) is challenging. Consequently, it is difficult to properly estimate what proportion of general anesthesia biopsies that could have been avoided.
5. Conclusion
Our study reveals that OPSCC patients undergoing biopsy under general anesthesia experience significantly prolonged therapeutic delays compared to those receiving in‐office biopsies. Furthermore, panendoscopy failed to identify additional synchronous aerodigestive tumors while incurring substantial additional healthcare costs. As the first comprehensive assessment of panendoscopy implications in a public healthcare setting, our findings underscore the critical importance of strategic diagnostic approaches. When clinically feasible, we recommend that clinicians prioritize in‐office biopsy techniques to mitigate treatment delays and optimize healthcare resource utilization.
Author Contributions
Samuel Bellavance: conceptualization, data curation, formal analysis, methodology, project administration, writing – original draft, writing – review and editing. Michel Khoury: conceptualization, methodology, formal analysis, writing – review and editing. Justine Colivas: data curation, formal analysis, writing – original draft. Jonathan Primiani: data curation, formal analysis, writing – original draft. Gabriel Dayan: conceptualization, methodology, writing – review and editing. Eric Bissada: formal analysis, writing – review and editing. Tareck Ayad: formal analysis, writing – review and editing. Apostolos Christopoulos: formal analysis, writing – review and editing. Jean‐Claude Tabet: formal analysis, writing – review and editing. Louis Guertin: formal analysis, writing – review and editing. Paul Tabet: conceptualization, data curation, formal analysis, methodology, project administration, writing – review and editing.
Funding
This research was supported by the Université de Montréal. Funding was used to cover costs associated with financial data extraction from the Centre for the Integration and Analysis of Medical Data (CITADEL) at the Centre Hospitalier de l'Université de Montréal (CHUM). The authors maintained complete independence in manuscript preparation and interpretation of results.
Ethics Statement
This study was approved by the Research Ethics Board of both participating institutions (#MP‐02‐2023‐110 640).
Conflicts of Interest
This manuscript has never been published and is not currently under evaluation in any other peer‐reviewed publication. The authors have no conflicts of interest.
Acknowledgments
The authors specifically thank Alexandra Constant and acknowledge that the financial data used in this study were provided by the Centre for the Integration and Analysis of Medical Data (CITADEL) of the Centre Hospitalier de l'Université de Montréal (CHUM; https://www.chumontreal.qc.ca/en/crchum/core‐facilities‐and‐services/citadel).
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.