Reliability and validity of an observer-rated disfigurement scale for head and neck cancer patients

Hand disease in scleroderma: a clinical correlate for chronic hand transplant rejection

Abstract

Chronic rejection remains a potential long-term consequence of hand composite tissue allotransplantation (CTA). Scleroderma has already been proposed as a model for chronic facial allograft rejection based on potential parallels of observed progression of disease and pathophysiology course. This study proposes a similar model for how chronic rejection may manifest itself in the context of hand CTA through the functional and psychological assessment of patients with scleroderma, should it occur.

Methods

100 consecutive patients with a clinical diagnosis of scleroderma were recruited into the study. Subjective assessment of static hand disfigurement was carried out through the use of standardised digital photographs. Hand function was assessed through the measurement of active range of motion (AROM) and using the activities of daily living (ADL) and Disabilities of the Arm, Shoulder & Hand (DASH) questionnaire. Psychological and quality of life evaluation comprised the Hospital Anxiety Depression Scale (HADS) and the SF36 health survey.

Results

Examination of standardised digital photographs of subjects revealed a variety of hand changes characteristic of scleroderma, ranging from mild to moderate through to severe. Objective assessment of hand disfigurement did not correlate with duration of disease, nor psychological distress. However, individuals with worsening disfigurement demonstrated poorer AROM. Longitudinally no deterioration in terms of function was seen over time in terms of the DASH and ADL results. Nevertheless deterioration of function did have a significant impact on quality of life. Overall HADS showed 22% of individuals as suffering from clinical levels of anxiety and 10% from clinical depression.

Conclusion

Chronic rejection has not yet occurred in any of the hand transplants performed to date. Scleroderma results in a spectrum of chronic functional and psychological disability that provides a model for the potential outcome of chronic hand allograft rejection. Findings from this study provide insight into the impact of this progressive disease for patients and contribute to the information and consent process for patients considering hand composite tissue transplantation.

Measuring health-related quality of life outcomes in head and neck reconstruction

A qualitative study was undertaken to understand the impact of omitted health concepts in existing patient-reported outcome (PRO) instruments for health-related quality of life (HR-QOL) evaluation following head and neck (H&N) cancer reconstruction. Twenty-six patients were interviewed. Patients described a broad range of symptoms. Oral competence, rhinorrhea, facial sensation, smile, vision and eye discharge are missing from existing PRO instruments. Altered appearance was a major stressor; both function and appearance changes had a negative psychosocial impact leading to social isolation and embarrassment. This framework is the foundation for development of a more complete PRO instrument, the FACE-Q Oncology.

Psychological factors associated with head and neck cancer treatment and survivorship: evidence and opportunities for behavioral medicine

Individuals diagnosed with head and neck cancer (HNC) not only face a potentially life-threatening diagnosis but must endure treatment that often results in significant, highly visible disfigurement and disruptions of essential functioning, such as deficits or complications in eating, swallowing, breathing, and speech. Each year, approximately 650,000 new cases are diagnosed, making HNC the 6th most common type of cancer in the world. Despite this, however, HNC remains understudied in behavioral medicine. In this article, the authors review available evidence regarding several important psychosocial and behavioral factors associated with HNC diagnosis, treatment, and recovery, as well as various psychosocial interventions conducted in this patient population, before concluding with opportunities for behavioral medicine research and practice.

The role of disgust emotions in the observer response to facial disfigurement

Social intrusions by observers are commonly reported by those with disfiguring conditions. This study examined the role of disgust emotions in the observer response. A group of students (N=48) completed quantitative questionnaires measuring extent of disfigurement, whilst viewing images of faces with varying disfigurements. Another group of students (N=84) completed quantitative questionnaires measuring level of disgust elicited by the same images. Disgust sensitivity was measured using the Disgust Scale Revised. Observers reported greater levels of disgust (p<.01) with increasing severity of facial disfigurement. Individuals with a higher disgust sensitivity reported increased levels of disgust in response to faces of mild (p=.03), moderate (p=.02) and severe (p<.01) disfigurement compared to those with a lower disgust sensitivity. This provides an explanatory framework for the avoidance reactions of observers and may be important in understanding variability in adjustment following disfigurement.

The psychological impact of facial changes in scleroderma

The physical disabilities associated with scleroderma are well known but the psychological impact of the condition has received less attention. Few studies have examined appearance related issues, most notably of the face. The aim of this study is to evaluate the psychological impact of facial, aesthetic and functional changes in scleroderma. One hundred seventy-one patients with a clinical diagnosis of scleroderma were recruited into the study. Digital photographs were objectively graded into groups based on severity of disfigurement as judged by an observer. Facial movement was recorded using a modified House-Brackmann Grading Scale. Psychological evaluation comprised the Derriford Appearance Scale short-form (DAS), the Noticeability and Worry score and the Hospital Anxiety and Depression Scale (HADS). Severity of disfigurement predicted decreased mouth opening, the extent to which participants judged their appearance as noticeable to others, and the level of appearance-related concern as measured by the DAS24. There was an inverse relationship with age. Facial changes were ranked as the most worrying aspect of the condition. This study shows facial disfigurement impacts on patient with scleroderma independent of functional changes related to systemic disease. The major difficulty is with the perceived noticeably of the condition to other people and the resulting self-consciousness in social encounters.

Early self-care rehabilitation of head and neck cancer patients

Conclusions: No positive effects of early preventive rehabilitation could be identified. The results do not contradict the proposition that rehabilitation based on self-care can be effective but it is important to establish evidence-based training programs and identify proper instruments for selection of patients and evaluation of intervention. Objectives: Patients with head and neck cancer suffer from functional impairments due to intense treatment. In this study, we investigated the effectiveness of an experimental early preventive rehabilitation using hard, objective end points in a nonselective, longitudinal, prospective cohort study. Methods: In all, 190 patients were included in the program and received instructions for training before the start of treatment with the aim of reducing swallowing problems and reducing mouth opening and stiffness in the neck. A control group of 184 patients was recruited. Results: There was no difference in weight loss and 2-year survival between the two groups. No positive effects concerning functional impairments were found in patient-reported outcome measures.

Adipofascial perforator flaps for "aesthetic" head and neck reconstruction

BACKGROUND

Most head and neck reconstructions are performed for wound closure or functional rehabilitation with aesthetic restoration being an important but secondary consideration.

METHODS

Contour deformities in 40 patients undergoing head and neck resections were reconstructed immediately with adipofascial perforator flaps, including 37 anterolateral thigh and 3 deep inferior epigastric perforator flaps.

RESULTS

Reconstructions could be grouped into 1 of 3 defect areas: temporal fossa (n = 3), malar cheek (n = 13), and parotid-mastoid (n = 24). The mean time needed for reconstruction in excess of the oncologic resection was 3.1 hours. There were no flap losses. In no case did a complication delay adjuvant therapy and no patient experienced a decrease in level of activity related to donor site morbidity.

CONCLUSION

Immediate restoration of facial contour with adipofascial perforator flaps is warranted in head and neck oncologic patients to help improve self-image and maintain quality of life.

Systemic sclerosis as a model of chronic rejection in facial composite tissue transplantation

INTRODUCTION

Chronic rejection remains a potential significant long-term problem of facial allograft transplantation. Scleroderma parallels chronic rejection in terms of its immunological pathophysiology and its histopathological processes. Through the analysis of facial changes in scleroderma we demonstrate how chronic facial allograft rejection may present and progress.

METHODS

129 consecutive patients with a clinical diagnosis of scleroderma were recruited into the study. Static facial disease assessment was carried out through the analysis of digital photographs. Facial motion dysfunction was assessed using a modified House-Brackmann Grading Scale and an established maximal static response assay. Psychological evaluation comprised the Derriford Appearance Scale short-form (DAS), the Noticeability and Worry score and the Hospital Anxiety and Depression Scale (HADS).

RESULTS

Static disease severity as measured using an observer-rated disfigurement scale revealed all grades of disease in the scleroderma cohort - from mild through to severe. Significant positive correlations were seen between observer rated disfigurement and DAS24, Noticeability and Worry scores. No significant relationship could be seen between the indices of facial motion impairment and psychological scores.

CONCLUSIONS

Progressive facial deterioration seen over time in scleroderma provides a comprehensive spectrum of static and dynamic facial changes which may be encountered in chronic facial graft rejection. This study provides valuable insight into the potentially significant long-term sequelae of allogenic reconstructive transplantation.

Measuring attentional bias to peripheral facial deformities

OBJECTIVES

Introduce a novel method for objectively evaluating attentional bias to peripheral facial deformities using an established metric of attention.

METHODS

The SMI eye-tracker system (SensoMotoric Inc., Boston, MA) was used to record the eye movement patterns, called scanpaths, of eight naïve observers gazing at pictures of faces with or without peripheral surgical deformities. The scanpaths of observers gazing on those novel faces were compared, and the fixation durations for different facial regions were compared between faces.

RESULTS

There were statistically significant differences in the mean fixation times between the faces considered normal and those considered abnormal (those with an obvious defect). When multivariate analysis of variance was performed with dependent variables total fixation time, fixation time in central triangle, and fixation time in the defect region and the independent variable face, all four tests were highly statistically significant. When univariate analysis of variance was performed to test the hypothesis that defect fixation times varied by face, the results were highly statistically significant (F = 8.79, P = .0003).

CONCLUSIONS

Observers gazing on faces typically focus their attention on discriminating features, such as eyes, nose, and mouth. The well-established method of eye movement recordings was applied in a novel way to provide quantitative data showing changes in observer gaze patterns to focus on deformities. These gaze patterns are a direct reflection of observer attention. This is the first objective method to quantify the amount of distraction caused by peripheral facial deformities and may provide insight into the perception of facial deformity.

Outcome measures in facial plastic surgery: patient-reported and clinical efficacy measures

OBJECTIVE

To survey the existing literature to identify, summarize, and evaluate procedure- and condition-specific outcome measures for use in facial plastic and reconstructive surgery.

METHODS

A review of the English-language literature was performed to identify outcomes instruments specific for targeted facial plastic surgery interventions and conditions. A search was performed using MEDLINE (1950 to September 2007), CINAHL (Cumulative Index to Nursing & Allied Health) (1982 to September 2007), and PsychINFO (1806 to September 2007). Outcomes instruments were categorized as patient-reported or clinical efficacy measures (observer-reported or objective measures). Instruments were then categorized to include relevant details on the intervention, degree of validation, and subsequent use.

RESULTS

Sixty-eight distinct instruments were identified (23 patient-reported, 35 observer-reported, and 10 objective measures), with some overlap among categories. Most patient-reported measures (76%) and half observer-reported instruments (51%) were developed in the past 10 years. The rigor of validation varied widely among measures, with formal validation being most common among the patient-reported outcome measures.

CONCLUSIONS

Validated outcomes measures are present for many common facial plastic surgery conditions and have become more prevalent during the past decade, especially for patient-reported outcomes. Challenges remain in harmonizing patient-reported, observer-based, and other objective measures to produce standardized clinically meaningful outcome measures.

Does severity predict distress? The relationship between subjective and objective measures of appearance and psychological adjustment, during treatment for facial lipoatrophy

The intuitive or lay belief that the severity of a disfiguring condition predicts psychological distress is not demonstrated in clinical practice, nor in research studies. This within group study used standardised measures repeated at six month intervals, to investigate the relationship between subjective and objective measures of appearance and psychological adjustment in 51 patients undergoing treatment for facial lipoatrophy using a synthetic filler, Newfill. Results demonstrate a dissociation between objective and subjective measures with only subjective assessment predicting psychological outcomes. It is recommended that Moss's (2005) hypothesis of discrete group membership (normal/not normal) should be adapted to include an internal standard for comparison, and that all evaluations of treatment modifying disfigurement should include a standardised subjective measure of appearance.

Facial appearance after operations for oral and oropharyngeal cancer: A comparison of casenotes and patient-completed questionnaire

Disfigurement after operations for oral and oropharyngeal cancer is an important issue. Our aim was to review the casenotes of patients who reported distress in the appearance domain of the University of Washington Quality of Life Scale (UWQOL) and to find out what help they were given. Of 278 patients with previously untreated oral and oropharyngeal squamous cell carcinoma treated between 1995 and 1999, 114 (41%) were concerned about their appearance. Factors that correlated with these concerns included tumours more than 2cm in size, T2 or worse stage, free tissue reconstruction, segmental mandibular resection, and neck dissection. In only 7 of the 114 was there any mention of the patient's appearance in the clinic notes, of whom 4 were given help (2 scar revisions and 2 oral rehabilitations). This study suggests that patients' concerns about disfigurement are poorly recognised in routine clinical practice and supports the principle of using the UWQOL scale to discuss problems of appearance with patients.

Psychosocial outcomes derived from an acid burned population in Bangladesh, and comparison with Western norms

Assault by acid burns typically results in severe disfigurement, yet the psychosocial impact of this injury is so far unreported. This study provides the first empirical data using standardised assessment scales, from 44 acid burns survivors in Bangladesh. Compared with published norms, individuals show high levels of psychological distress including social anxiety and avoidance, anxiety and depression. Consistent with the published literature, there is no relationship between severity of injury and level of psychological distress. One interesting feature of this population is the relative preservation of perceived self-concept, and this is discussed with relation to the supportive and therapeutic environment of the clinic where this group were studied. We also note an interesting sub-group who were attacked by members of their own family and for whom psychological morbidity seems particularly pronounced.

Physical and psychosocial correlates of head and neck cancer: an update of the literature and challenges for the future (1996-2003)

An update of the literature on physical and psychosocial aspects of head and neck cancer, with special emphasis on effects of treatment, patient-related factors and psychosocial intervention on quality of life (QoL). QoL deteriorates during and directly after treatment and returns only slowly to pre-treatment values. Organ preservation, gender and coping-strategies are factors related to QoL after treatment. As prognosis and survival were found to be comparable under different treatment regimes, we noticed a gradual shift in therapy towards organ preservation. Systematic care, using specific instruments is important for improving the QoL. We feel that more attention should be given to improving support, in order to optimize the QoL of patients during the palliative stage.

Psychosocial adjustment in head and neck cancer: the impact of disfigurement, gender and social support

BACKGROUND

The purpose of this study was to examine the psychosocial impact of disfigurement, gender, and social support after surgical treatment of head and neck cancer.

METHOD

Eighty-two ambulatory head and neck cancer patients, 6 months or more after treatment and free of active disease were assessed. Ratings of disfigurement were obtained using a valid and reliable 9-point scale developed for the study. Standardized measures of social support, depressive symptoms, well-being, and life happiness were used.

RESULTS

The sample as a whole displayed high levels of life happiness, low levels of depression, and positive feelings of well-being. Women demonstrated higher levels of depression and lower life happiness; subjects with greater disfigurement were more depressed. Social support seemed to buffer the impact of greater levels of disfigurement on well-being for women but not for men.

CONCLUSION

These results suggest that women with head and neck cancer who experience low social support and face disfiguring treatment are at greatest risk for psychosocial dysfunction.

Facial disfigurement: is it in the eye of the beholder? A study in patients with Graves' ophthalmopathy

OBJECTIVES

The importance of facial disfigurement in many diseases necessitates a reliable and valid measure of disfigurement severity for clinical studies. The hypothesis is that a universal concept of disfigurement exists and can be measured in a reliable way. The objectives of this study were to investigate if persons, in particular patients and physicians, can agree on facial disfigurement severity; and to determine the relative contribution of predefined clinical characteristics of patients with Graves' ophthalmopathy (GO) to the overall rating of facial disfigurement severity.

DESIGN

A panel study was carried out in four different panels, each consisting of four members.

PATIENTS

We randomly selected 100 slide pairs of GO patients from four available study populations, involving mild, moderate and severe GO patients (mean age 49 years, 76% female) who were treated with either radiotherapy, sham-irradiation, prednisone or orbital decompression.

MEASUREMENTS

All panel members individually scored the disfigurement severity of 100 GO patients shown on standardized slides on a Visual Analog Scale. In total, 1600 ratings were collected. We calculated within- and between-panel agreement of disfigurement severity and identified determinants of disfigurement.

RESULTS

Agreement within a panel varied from 0.65 to 0.79 and was highest within the panel of ophthalmologists. Between-panel agreement was 0.67 and was highest between ophthalmologists and laypersons. Compared with the global average, patients overrated and endocrinologists underrated disfigurement severity. Female panellists rated the patients, on average, more disfigured than male panellists. Important determinants of disfigurement were eyelid retraction, severe eyelid swelling and proptosis. Their relative importance was consistent across panels and in contrast to current measures of GO severity.

CONCLUSION

Facial disfigurement severity can be measured in a reliable way using panels of panellists. Except for some systematic differences between panellists, facial disfigurement does not seem to be in the eye of the beholder.

Homeobox genes: a molecular link between development and cancer

Homeobox genes are regulatory genes encoding nuclear proteins that act as transcription factors, regulating aspects of morphogenesis and cell differentiation during normal embryonic development of several animals. Vertebrate homeobox genes can be divided in two subfamilies: clustered, or HOX genes, and nonclustered, or divergent, homeobox genes. During the last decades, several homeobox genes, clustered and nonclustered ones, were identified in normal tissue, in malignant cells, and in different diseases and metabolic alterations. Homeobox genes are involved in the normal teeth development and in familial teeth agenesis. Normal development and cancer have a great deal in common, as both processes involve shifts between cell proliferation and differentiation. The literature is accumulating evidences that homeobox genes play an important role in oncogenesis. Many cancers exhibit expression of or alteration in homeobox genes. Those include leukemias, colon, skin, prostate, breast and ovarian cancers, among others. This review is aimed at introducing readers to some of the homeobox family functions in normal tissues and especially in cancer.

Ethical considerations in the treatment of head and neck cancer

BACKGROUND

The second half of the 20th century saw not only important developments in medical science and technology, but also a rapid growth in the application of biomedical ethics in medical decision making. Withdrawal of treatment, allowing to die, informed consent, and patient autonomy are concerns that now comprise a part of the overall medical treatment, particularly in patients with head and neck cancers.

METHODS

The author discusses ethical issues relating to disfigurement/dysfunction in head and neck cancer patients and examines the aspects of "principlism": autonomy, nonmaleficence, beneficence, and justice. Two case reports are presented to illustrate the ethical challenges that may confront physicians who treat head and neck cancer patients.

RESULTS

Head and neck oncology generates unique problems relating to disfigurement and dysfunction. An algorithm that considers the patient's medical good and greater good, as well as the goods of others, can assist in arriving at appropriate ethical decisions.

CONCLUSIONS

Bioethical decision making requires the integration of virtues with principles, followed by the application of these standards to each patient.

Quality of life after parotid and temporal bone surgery for cancer

OBJECTIVES

The purposes of this study were to examine the quality of life (QL) of patients who received treatment for cancer of the parotid or temporal region, and to identify factors contributing to it. The relationships between clinician-based measures of treatment outcome and the patient-based counterparts were also evaluated.

METHODS

A retrospective, cross-sectional study was conducted on 23 patients who had received either a temporal bone resection or a combination of parotidectomy and radiotherapy. The QL survey involved both global QL and measures of the appearance, communication, hearing, physical, psychological, and social domains. Patients were assessed clinically for their performance status, facial nerve function, disfigurement, and hearing and the results were compared with patient-rated QL. Correlation between the QL variables and global QL was identified using Spearman correlation tests.

RESULTS

Ongoing physical symptoms, communication difficulties, and social disturbances were associated with poorer global QL (P <.05). No correlation was detected between global QL and objective disfigurement, facial function, and measures of hearing loss. With the exception of hearing testing, clinical assessments generally did not correlate well with patient ratings.

CONCLUSION

QL measures provide insight into patients' perceptions of the treatment outcome but do not necessarily correlate with the clinicians' views. The use of a global QL measure overcomes the difficulty of extrapolating the impact of symptom scores or observational measures on patients' overall quality of survival.

Only sociodemographic variables predict quality of life after radiography in patients with head-and-neck cancer

PURPOSE

Psychosocial factors influence patient compliance and have an effect on survival. Identifying patients at risk of decreased quality of life (QOL) with no extra expenditure in terms of hospital staff time or resources is mandatory to plan psychosocial support.

METHODS AND MATERIALS

Between 1997 and 2000, 242 patients with head-and-neck cancer (30% pharyngeal, 29% oropharyngeal, and 13% laryngeal cancer) were screened. Of these, 28.5% refused to participate and 19.0% were excluded (Karnofsky performance score <50, language and cognitive deficits, death, or noncompliance). A total of 124 patients were assessed with the Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire at ti1 (beginning of radiotherapy [RT]). Eighty-three patients from this group were examined, with complete data from ti1 to ti3 (6 weeks after RT).

RESULTS

The QOL did not change during RT. In logistic regression analysis, medical information, in contrast to sociodemographic variables, turned out to have no influence on the ability to predict low QOL (sensitivity 80% vs. 32%). Four sociodemographic variables were entered in the regression model (children, currently employment, ethanol abuse, level of secondary education) and accounted for 26% of variance in QOL at ti3.

CONCLUSION

By routinely obtaining clinical information from the patient's history, patients at risk of low QOL after RT can be identified and could benefit from early psychosocial support.

A patient- and observer-rated analysis of the impact of lateral rhinotomy on facial aesthetics

OBJECTIVE

To determine, using patient- and observer-rated facial disfigurement measures, whether a lateral rhinotomy imparts significant aesthetic morbidity.

DESIGN

Retrospective and subject-controlled study in a large, tertiary-referral, academic otolaryngology department. Twenty-one consecutive patients who had undergone lateral rhinotomy for the treatment of inverted papilloma were studied in the long-term.

MAIN OUTCOME MEASURES

Scores on the following: (1) the novel Patient-Rated Facial Disfigurement Analogue Scale questionnaire and (2) the reliable and validated Observer-Rated Facial Disfigurement 9-Point Likert Scale.

RESULTS

Patients rated their facial appearance as minimally altered and significantly less apparent to others. The observers in this study, a surgeon (J.C.I.) and a psychiatrist (M.R.K.), rated the patients' facial disfigurement as minimally visible. Patients seem to rate how apparent their appearance is to others in a similar fashion to observers. The observer-rated facial disfigurement scale used is valid and reliable.

CONCLUSION

Patient- and observer-rated facial disfigurement measures suggest that a lateral rhinotomy does not impart significant aesthetic morbidity.