Variations in pain prevalence, severity, and analgesic use by duration of survivorship: a cross-sectional study of 505 post-treatment head and neck cancer survivors

BACKGROUND

Studies suggest a high prevalence of pain in head and neck cancer (HNC) patients at diagnosis, during and after treatment; however, these studies had small sample sizes and did not comprehensively assess factors known to influence pain. We surveyed a large cohort of HNC survivors to determine variations in the prevalence of pain, its treatment and management by duration of survivorship, and assessed a comprehensive list of risk factors.

METHODS

A cross sectional survey of post-treatment survivors of HNC during routine follow-up clinic visits.

RESULTS

A total of 505 HNC survivors with a median follow up of 3 years from cancer diagnosis were included in the study. Overall, 45% (n = 224) reported pain and 14.5, 22 and 7% reported use of prescribed pain medication, over-the-counter pain medication and alternative pain therapies, respectively. Prevalence of severe pain was 7.3% and did not vary significantly by years of survivorship (< 1 year = 5.7%; 1 to < 3 years = 7.1%; 3 to < 8 years = 7.6%; 8 years or more =9.7%; P = 0.392). However, use of prescribed pain medication significantly varied by years of survivorship (< 1 year = 45.7%; 1 to < 3 years = 24.6%; 3 to < 8 years = 18.9; 8 years or more = 18.3%; p < 0.001). Of note, a significant proportion of survivors reported moderate to severe pain (moderate to severe = 55.7% versus none to mild = 44.3%) despite step 3 analgesic use (p < 0.001). Multivariable regression shows that recurrent disease (OR 6.77, 95% CI [1.44, 31.80]), history of chemotherapy (OR 6.00, 95% CI [2.10, 17.14]), and depression (Mild-moderate OR 5.30, 95% CI [2.20, 12.78]; Major OR 8.00, 95% CI [2.67, 23.96]) were significant risk factors for severe pain.

CONCLUSIONS

We identified a high prevalence of pain among HNC survivors and determined that analgesic use varied by the duration of survivorship. Therefore, routine surveillance for pain must be consistent throughout the course of survivorship.

Cost-effectiveness of physical activity interventions in cancer survivors of developed countries: a systematic review

PURPOSE

Physical activity has been shown to improve survival and quality of life of cancer patients. Due to differences in patient populations, healthcare settings, and types of intervention, cost-effectiveness analyses of physical activity interventions in cancer survivors are difficult to compare. Available evidence from breast cancer survivor research has shown inconsistent results, and transfer of results to other types of cancer is not straightforward. This paper systematically reviewed current evidence on the cost-effectiveness of physical activity interventions in cancer survivors independent of cancer type compared to usual care or another experimental intervention.

METHODS

The literature search was conducted in seven databases and enhanced by a search for gray literature. Eligible studies were restricted to developed countries and assessed using the CHEERS, CHEC, and PHILIPS checklists. The study protocol was pre-published in PROSPERO.

RESULTS

Seven studies, five cost-utility, and two combined cost-utility/cost-effectiveness analyses fully met the inclusion criteria. They covered eight different types of cancer and various interventions. The cost-effectiveness analyses were of moderate to high methodological quality. A high probability of cost-effectiveness was reported in two analyses. One intervention appeared to be not cost-effective, and one to be cost-effective only from an organizational perspective. Three other analyses reported a cost-effectiveness better than US$ 101,195 (€ 80,000) per QALY gained.

CONCLUSIONS

Physical activity interventions in cancer survivors of developed countries were cost-effective in some but not all clinical trials reviewed.

IMPLICATIONS FOR CANCER SURVIVORS

Cost-effectiveness of physical activity interventions appear to depend upon the intensity of the activity.

Chronic pain, functionality and quality of life in cancer survivors

The increasing number of cancer survivors associated to a longer average life-span after diagnosis of an oncological disease facilitates the observation of deleterious long-term effects of both oncological disease and its treatment. Among these effects, chronic pain emerges as one of the most prevalent and, with its onset, there is a decrease in these patients' functionality and quality of life. The main focus in oncological disease treatment has been tumour eradication and average life expectancy extension after diagnosis, neglecting these deleterious long-term effects. This study aims at assessing the prevalence and characteristics of chronic pain in cancer survivors as well as pain interference in their quality of life and functionality. The study selected cancer survivors (n = 85) after dismissal from oncology service to assess the presence and characteristics of chronic pain, their health-related quality of life (HRQoL) and pain-related disability through a combination of different questionnaires. Chronic pain prevalence was 23.5%. In total, 85% of patients reported neuropathic pain descriptors and 45% presented diagnostic criteria for neuropathic pain. Of these patients, 45% were followed-up for pain surveillance and 35% underwent analgesic medication. There was a median pain disability index of 20.50 (14.50-35.00) and an average HRQoL of 0.5338 in chronic pain patients and 0.8872 in patients without pain. We found that chronic pain was the main negative predictor of HRQoL and was associated with decreased functionality. This study also concluded that these patients often were not offered the appropriate long-term medical follow-up. These findings highlight a need to raise awareness among health professionals to the importance of timely diagnosis and treatment of pain and its impact on HRQoL and functionality of long-term cancer survivors as well as the need to change clinical practice in order to improve healthcare provided to these patients.

Risk of Suicidal Self-directed Violence Among US Veteran Survivors of Head and Neck Cancer

Importance

Head and neck cancer (HNC) survivors are about twice as likely to die by suicide compared with other cancer survivors.

Objective

To examine the associations between precancer mental health and pain and postcancer receipt of mental health, substance use disorder (SUD), or palliative care services with risk of suicidal self-directed violence (SSDV).

Design, Setting, and Participants

This retrospective cohort study used the Veterans Health Administration data of 7803 veterans with a diagnosis of HNC (stage I-IVB) who received cancer treatment between January 1, 2012, and January 1, 2018. Data were analyzed between May 2020 and July 2021.

Exposures

Presence of precancer chronic pain and SUD diagnoses, and postcancer SUD, mental health, or palliative care treatment. Exposures were defined using International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes in Veterans Health Administration administrative data.

Main Outcomes and Measures

Documented SSDV event, including suicide attempt or death by suicide, after HNC diagnosis.

Results

Among the cohort of 7803 veterans (7685 [98.4%] male; mean [SD] age, 65 [10.7] years), 72 (0.9%) had at least 1 documented SSDV event following their cancer diagnosis, and 51 (0.7%) died by suicide. Four adjusted modified Poisson regression analyses identified that precancer chronic pain (incidence rate ratio [IRR], 2.58; 95% CI 1.54-4.32) or mood disorder diagnoses (IRR, 1.95; 95% CI, 1.17-3.24) were associated with higher risk of postcancer SSDV. Those who had at least 1 documented mental health (IRR, 2.73; 95% CI, 1.24-6.03) or SUD (IRR, 3.92; 95% CI, 2.46-6.24) treatment encounter in the 90 days following HNC diagnosis were at higher risk for SSDV. A palliative care encounter within 90 days of postcancer diagnosis was associated with decreased risk of SSVD (IRR, 0.49; 95% CI, 0.31-0.78).

Conclusions and Relevance

In this cohort study, a high proportion of HNC survivors with an SSVD event died from their injuries. Identification of risk factors for SSDV among HNC survivors may help direct additional resources to those who are at high risk. Referral to palliative care appears to be an important component of supportive oncologic care to reduce the risk of SSDV.

Data analytics for predicting quality of life changes in head and neck cancer survivors: a scoping review

Head and neck cancer is the seventh most common cancer worldwide. The incidence of this cancer is increasing, but at the same time, the cancer-related mortality rate has decreased over time, leaving more head and neck cancer survivors. More emphasis is needed on quality-of-life research in the head and neck cancer field to improve their daily lives and reduce the disease and treatment response burden. To achieve this, we conducted a scoping review to find and learn which predictors and data analysis techniques have been used in previous studies. This work is undertaken in the context of the BD4QoL EU Research project.

Myofascial Induction Therapy Improves the Sequelae of Medical Treatment in Head and Neck Cancer Survivors: A Single-Blind, Placebo-Controlled, Randomized Cross-Over Study

Head and neck cancer (HNC) is the sixth most common cancer worldwide. Yet, less than 60% of HNC survivors receive adequate therapy for treatment-related sequelae. The objective of this study was to determine the efficacy of myofascial induction therapy (MIT) in improving cervical and shoulder pain and range of motion, maximal mouth opening, and cervical muscle function in HNC survivors. This crossover, blinded, placebo-controlled study involved 22 HNC survivors (average age 56.55 ± 12.71) of which 13 were males (59.1%) who received, in a crossover fashion, both a single 30-min session of MIT in the form of manual unwinding and simulated pulsed shortwave therapy (placebo), with a 4-week washout interval between the two. Cervical and shoulder pain (visual analogue scale) and range of motion (cervical range of motion device and goniometer), maximum mouth opening (digital caliper), and cervical muscle function (deep cervical flexor endurance test) were measured before and after the treatment and placebo sessions. A single session of MIT improved cervical and affected side shoulder pain, cervical range of motion, maximum mouth opening, and cervical muscle function. The associated effect sizes ranged from moderate to large. The present study suggests that MIT, in the form of manual unwinding, improves cervical (−3.91 ± 2.77) and affected-side shoulder (−3.64 ± 3.1) pain, cervical range of motion (flexion: 8.41 ± 8.26 deg; extension: 12.23 ± 6.55; affected-side rotation: 14.27 ± 11.05; unaffected-side rotation: 11.73 ± 8.65; affected-side lateroflexion: 7.95 ± 5.1; unaffected-side lateroflexion: 9.55 ± 6.6), maximum mouth opening (3.36 ± 3.4 mm), and cervical muscle function (8.09 ± 6.96 s) in HNC survivors.

Surgical factors associated with patient-reported quality of life outcomes after free flap reconstruction of the oral cavity

OBJECTIVES

To determine which surgical factors are associated with quality-of-life (QOL) outcomes in oral cavity cancer survivors after free flap reconstruction of the oral cavity.

PATIENTS AND METHODS

A cross-sectional study was conducted from a multidisciplinary head and neck cancer (HNC) survivorship clinic. Oral cavity cancer survivors with at least 6-months of postoperative follow-up from ablation and free flap reconstruction were included. Primary outcome measures were validated patient-reported outcome measures (PROMs) including the Eating Assessment Tool-10 (EAT-10) measure of swallowing-specific QOL, University of Washington Quality of Life (UW-QOL) physical and social-emotional subscale scores and feeding tube dependence.

RESULTS

Extent of tongue resection was associated with EAT-10 and the UW-QOL Physical subscale scores. Patients with oral tongue defects reported worse scores than with composite defects in the EAT-10 and UW-QOL physical domain (p = 0.0004, 0.0025, respectively). This association no longer applies when controlling for differences in extent of tongue resection. Patients with anterior composite resections reported worse EAT-10 scores than lateral resections (p = 0.024). This association no longer applies when controlling for extent of tongue resection (p = 0.46). Gastric tube dependence demonstrates similar trends to PROMs.

CONCLUSION

Extent of tongue resection was strongly associated with poor QOL outcomes after free tissue reconstruction of the oral cavity and mediates the associations between other defect characteristics and QOL. These findings demonstrate the need for emphasis on expected oral tongue defects when counseling patients and highlight the need to address QOL in a multidisciplinary fashion post-operatively.

Prevalence and Severity of Pain in Cancer Patients in Germany

Pain is a common symptom in cancer patients, restricts daily life activities and reduces survival time. Identification of sociodemographic, medical and psychological correlates of pain among cancer patients in Germany could help identify subgroups most in need of pain management. In this multicenter, epidemiologic cross-sectional study, we assessed pain prevalence and severity, quality of life (QoL) and psychological distress in a sample of 3,745 cancer patients across all tumor entities. In total, 37.9% patients suffered from cancer-related pain and 56.1% suffered from non-specific pain. Younger, female, less educated and unemployed patients reported pain more frequently and more severe pain (p < 0.001). Pain was associated with distress, depression, anxiety, QoL, tumor stage (p < 0.001), and time since diagnosis (p = 0.012). Pain assessment and pain management should be a routine part of cancer treatment and cancer survivorship care plans.

Evaluation of Sarcopenia, Frailty, and Inflammation on Adverse Events and Survival Outcomes in Patients with Oral Cavity Squamous Cell Carcinoma under Adjuvant Chemoradiotherapy

In this study, we aimed to evaluate the prognostic impact of sarcopenia, five-item modified frailty index (mFI-5), neutrophil/lymphocyte ratio (NLR), and platelet/lymphocyte ratio (PLR) in patients with oral cavity squamous cell carcinoma (OSCC) treated with adjuvant chemoradiotherapy (CRT) and their survival outcomes. We retrospectively enrolled 175 patients with OSCC undergoing adjuvant CRT between 2011 and 2018, who were divided into groups with (n = 112) and without (n = 63) sarcopenia. Logistic regression analysis and Cox proportional hazards models were used to determine prognostic factors for CRT-related toxicity, three-year overall survival (OS), and disease-free survival (DFS). Sarcopenia and high PLR were independently associated with CRT-induced anemia (CIA); advanced tumor stage was related to poor three-year OS. CRT and survival did not differ by mFI-5 and NLR. Our results indicate that sarcopenia and high PLR are significant predictors of adjuvant CRT, increasing toxicity outcomes and indicating worse short-term OS. Accurately identifying sarcopenia and high PLR in patients with OSCC is critical to help better select candidates for adjuvant CRT to improve their outcomes.

Identifying Patient-Reported Outcome Measures (PROMs) for Routine Surveillance of Physical and Emotional Symptoms in Head and Neck Cancer Populations: A Systematic Review

The aims of this review were to identify symptoms experienced by head and neck cancer (HNC) patients and their prevalence, as well as to compare symptom coverage identified in HNC specific patient-reported outcome measures (PROMs). Searches of Ovid Medline, Embase, PsychInfo, and CINAHL were conducted to identify studies. The search revealed 4569 unique articles and identified 115 eligible studies. The prevalence of reported symptoms was highly variable among included studies. Variability in sample size, timing of the assessments, and the use of different measures was noted across studies. Content mapping of commonly used PROMs showed variability and poor capture of prevalent symptoms, even though validation studies confirmed satisfactory reliability and validity. This suggests limitations of some of the tools in providing an accurate and comprehensive picture of the patient's symptoms and problems.

Oral Complications of Head and Neck Cancer Therapy

Current therapies for Head and Neck cancer treatment are extremely advanced. Though, they cause oral complications which have deleterious effects on basic life functions, affect oral and overall health, may lead to significant morbidity and treatment discontinuation and have an impact on survivorship and quality of life. As new therapies are introduced, a new spectrum of oral complications is rising, compromising the mucosal integrity and the salivary function, that may not be recognized, reported and treated properly. Oral complications, often permanent and extremely painful, may include mucositis, xerostomia, dysgeusia, infections, trismus and fibrosis, risk of dental disease and necrosis of the jaw, neurosensory disorders and when targeted therapies and immunotherapy are involved, aphthoid and lichenoid lesions can also be reported. Increased awareness is required for the prevention and management of these complications, which can be best provided by a multidisciplinary team.

Patterns of alcohol use among early head and neck cancer survivors: A cross-sectional survey study using the alcohol use disorders identification test (AUDIT)

OBJECTIVE

Alcohol use among survivors of head and neck cancer (HNC) negatively impacts patient outcomes and is an important risk factor for recurrent and second primary tumors. Despite recommendations from several cancer societies, alcohol consumption remains a common problem in this population.

METHODS

A cross-sectional study was performed with the Alcohol Use Disorders Identification Test (AUDIT) Self-Report questionnaire. Patients with HNC completed surveys at pre-treatment and follow-up appointments every 3-6 months for at least 2-years after treatment.

RESULTS

796 surveys were available for analysis. Most participants were male (75.7%) and had either oropharyngeal (34.5%) or laryngeal (16.7%) cancer. The percentage of alcohol drinkers decreased from 56.1% at pre-treatment to 40.4% at 0-3 months post-treatment, but then increased and surpassed baseline levels by 24 + months post-treatment (64.4%, p = 0.0079). Concurrently, moderate drinkers (AUDIT = 1 - 3) decreased from 34.2% at pre-treatment to 25.2% at 0-3 months post-treatment, but then increased and surpassed baseline levels at 24 + months post-treatment (39.7%, p = 0.0129). Trends among heavy (AUDIT > 3), and heaviest (AUDIT > 6) drinkers were similar, but not statistically significant. At 24 + months post-therapy, we observed a statistically significant increase in female users (39.1% to 63.2%, p = 0.0213) and moderate drinkers < 55 years old (43.4% to 61.9%, p = 0.0184).

CONCLUSION

Alcohol consumption in survivors of HNC transiently decreases in the immediate months after treatment, but then increases and remains largely stable by 24 months. This pattern is particularly concerning and highlights the need for timely interventions.

Examination of a distress screening intervention for rural cancer survivors reveals low uptake of psychosocial referrals

Purpose

To determine the impact of a telemedicine-delivered intervention aimed at identifying unmet needs and cancer-related distress (CRD) following the end of active treatment on supportive care referral patterns.

Methods

We used a quasi-experimental design to compare supportive care referral patterns between a group of rural cancer survivors receiving the intervention and a control group (N = 60). We evaluated the impact of the intervention on the number and type of referrals offered and whether or not the participant accepted the referral. CRD was measured using a modified version of the National Comprehensive Cancer Network Distress Thermometer and Problem List.

Results

Overall, 30% of participants received a referral for further post-treatment supportive care. Supporting the benefits of the intervention, the odds of being offered a referral were 13 times higher for those who received the intervention than those in the control group. However, even among the intervention group, only 28.6% of participants who were offered a referral for further psychosocial care accepted.

Conclusions

A nursing telemedicine visit was successful in identifying areas of high distress and increasing referrals. However, referral uptake was low, particularly for psychosocial support. Distance to care and stigma associated with seeking psychosocial care may be factors. Further study to improve referral uptake is warranted.

Implications for Cancer Survivors

Screening for CRD may be inadequate for cancer survivors unless patients can be successfully referred to further supportive care. Strategies to improve uptake of psychosocial referrals is of high importance for rural survivors, who are at higher risk of CRD.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11764-021-01052-4.

A Mobile Patient-Facing App for Tracking Patient-Reported Outcomes in Head and Neck Cancer Survivors: Single-Arm Feasibility Study

BACKGROUND

Patients with head and neck cancer (HNC) frequently experience disease-related symptoms and treatment adverse effects that impact their overall quality of life. Cancer-specific mobile health apps for patient-related outcomes allow patients to communicate with their clinicians and proactively track their symptoms, which have been shown to improve clinical management and disease outcomes.

OBJECTIVE

The purpose of this study was to evaluate the feasibility of LogPAL, a novel iPhone-based mobile health app designed to help HNC survivors track and manage their posttreatment symptoms.

METHODS

Patients who completed curative treatment for HNC in the preceding 24 months were recruited from 2 clinical sites within a single institution. Upon enrollment, participants completed a brief sociodemographic survey, downloaded the app onto their iPhone devices, and were asked to complete a series of biweekly questionnaires (based on the Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events) via the app for an 8-week study period. The primary feasibility endpoints included retention (retaining >80% of the enrolled participants for the duration of the study period), adherence (>50% of the participants completing 100% of the questionnaires over the study period), and usability (a mean system usability scale [SUS] score >68). Additional postintervention questions were collected to assess perceived usefulness, acceptance, and overall satisfaction.

RESULTS

Between January and October 2019, 38 participants were enrolled in the study. Three participants dropped out, and 3 were classified as nonusers. The remaining 32 (87%) were eligible for analysis. Their mean age was 57.8 (SD 12.3) years (range 24-77 years, 81% [26/32] male). Overall, 375 of 512 (73.2%) questionnaires were completed, with 17 (53%) of the 32 participants adherent. Participant-reported usability was acceptable; the mean SUS score was 71.9 (95% CI 64.3-79.5) with high satisfaction of LogPAL usefulness and likelihood to recommend to other cancer survivors.

CONCLUSIONS

This single-arm prospective pilot study showed that LogPAL is a feasible, regularly used, accepted app for HNC survivors, justifying a full-scale pilot. Based on the findings from this study, future iterations will aim to improve usability and test intervention efficacy.

Subjective and Objective Measures in Assessing Neck Disability and Pain in Head and Neck Cancer

OBJECTIVE/HYPOTHESIS

The intensification of treatment for head and neck cancers (HNCs) has created a cohort of patients living with short- and long-term comorbidities and functional deficits. This study aimed to determine whether there is a relationship between patient-reported outcomes (PROs) and objective measures of neck function in survivors of HNCs.

STUDY DESIGN

Cross-sectional study.

METHODS

Thirty-one subjects (aged 64 ± 8.7 years; 28 males and three females) were recruited and completed the Neck Disability Index (NDI) and a numeric pain scale. At the same visit, subjects were fitted with two portable motion sensors to collect range of motion (ROM) and velocity data. Differences between ROM, velocity, and PRO subgroups were assessed using a one-tailed t test (*P < .05). The Pearson correlation coefficient (r) was calculated between the NDI values and the ROM and velocity values for each motion.

RESULTS

A moderate correlation (r = 0.507) was observed between NDI and neck pain. Patients with no disability according to the NDI had significantly higher ROM and velocity than patients with mild to moderate disability. Velocity in all degrees of freedom (axial rotation, flexion and extension, and lateral bending) was significantly lower for patients who perceived higher levels of neck pain and neck disability.

CONCLUSIONS

This study notes that patients who report neck disability and pain have more limited ROM and velocity following HNC treatment. These data may improve treatment planning and care delivery by facilitating an understanding of the experiences of HNC survivors and the pathophysiology that must be targeted to address their psychosocial and functional deficits.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:2015-2022, 2021.

Head and neck cancer survivors' pain in France: the VICAN study

PURPOSE

Pain is an increasing concern in the growing number of head and neck cancer survivors. This study aimed to analyze the 5-year prevalence of pain in French survivors of head and neck cancer and to identify associated factors.

METHODS

Analyses were performed among 296 5-year cancer survivors diagnosed in 2010. Using multivariable logistic regressions, we studied the associations between pain and factors collected in the French representative national "vie après le cancer" (VICAN) survey. Eligible participants were aged from 18 to 82 years; patients' living conditions, socioeconomic characteristics, and medical data were collected.

RESULTS

Pain was reported by 72.6% of the participants. In the multivariable analyses, decreasing level of physical activity was the only determinant of increased overall pain (OR= 2.77, CI= 1.48-5.17). The chronic pain prevalence was 62.3%. The main risk factors found were tumor localization in the oropharynx (OR= 2.49, CI= 1.27-4.88), education (at least a high school's degree) (OR= 0.33, CI= 0.13-0.9), and decreased physical activity (OR= 2.20, CI= 1.24-3.9).

CONCLUSIONS

Five years after diagnosis, pain is a very frequent sequelae that has a significant impact on quality of life in head and neck cancer survivors. Reduced physical activity, a low level of education, and tumor localization in the oropharynx are factors associated with pain.

IMPLICATIONS FOR CANCER SURVIVORS

Pain frequency and its impact on patients' lives imply that an adaptation must be made in terms of both pain diagnosis and management and the training of healthcare professionals.

CLINICAL TRIAL REGISTRATION

This is not a clinical trial. ISP number: INSERM C11-63.

Exploring Factors Associated With Long-Term Opioid Therapy in Cancer Survivors: An Integrative Review

CONTEXT

The prevalence of chronic pain in cancer survivors is double that of the general U.S.

POPULATION

Opioids have been the foundation of cancer pain management for decades; however, there is a paucity of literature on long-term opioid therapy (LTOT) in cancer survivors. An understanding of factors related to LTOT use in cancer survivors is needed to address chronic pain and balance opioid harms in the expanding population of cancer survivors.

OBJECTIVES

To analyze the research of LTOT utilization and factors associated with persistent opioid use in cancer survivors.

METHODS

A five-stage integrative review process was adapted from Whittemore and Knafl. Data sources searched included Web of Science, PubMed, Embase, Cochrane, and Google Scholar. Quantitative research studies from 2010 to present related to cancer survivors managed on LTOT were included. Editorials, reviews, or abstracts were excluded.

RESULTS

After reviewing 315 articles, 21 articles were included. We found that there were several definitions of LTOT in the reviewed studies, but the duration of opioid use (i.e., more than three months after completion of curative treatment) was the most common. The reviewed literature describes a relationship between LTOT and important biopsychosocial factors (cancer type, socioeconomic factors, and comorbidities).

CONCLUSION

The studies in this review shed light on the factors associated with LTOT in cancer survivors. LTOT was common in certain populations of cancer survivors and those with a collection of patient-specific characteristics. This review suggests that there is a critical need for specialized research on chronic cancer pain and opioid safety in cancer survivors.

Pain medication adherence in patients with cancer: a pragmatic review

OBJECTIVE

Adherence to pain medication in patients with cancer is crucial for successful pain therapy. This review aimed to investigate: the rate of adherence, which factors influence adherence, whether adherence differs in diverse patient populations, whether there are methods to improve adherence, and the relationship between adherence and pain relief.

METHODS

This review was performed following the PRISMA guidelines. MEDLINE/Pubmed, Embase, Web Of Science, Cochrane and ClinicalTrials.gov were searched. All types of studies investigating adherence of patients with cancer, factors influencing adherence, and methods to improve adherence to pain medication were included. They were first screened on title and abstract and thereafter on full text. Selected articles were subjected to a quality assessment according to the PRISMA checklist. From included articles, study characteristics and outcomes were extracted.

RESULTS

Out of 795 articles, 18 were included. Different methods were used to measure adherence, which led to adherence rates ranging from 8.9% to 82.0%. White Americans and men were found to be more adherent than African Americans and women. Due to various barriers, adherence is often suboptimal. Fear of addiction, physiological and harmful effects, tolerance, and disease progression are common concerns. Interventions, such as pain education booklets, pain consults, and specialised nurses, may be beneficial to increase the adherence. Lower adherence rates were associated with lower pain relief.

CONCLUSION

Adherence of cancer patients to pain medication is suboptimal. Health care workers should focus on barriers to increase the adherence in order to obtain a better pain relief.

Dysphagia, voice problems, and pain in head and neck cancer patients

PURPOSE

Head and neck cancer (HNC) and its treatment can leave devastating side effects with a relevant impact on physical and emotional quality of life (QoL) of HNC patients. The objectives were to examine the amount of dysphagia, voice problems, and pain in HNC patients, the impact of sociodemographic, behavioral, and clinical factors on these symptoms, the psychometric properties of the EAT-10, and the relationship between these symptoms and QoL variables.

METHODS

HNC patients attending for regular follow-up from 07/2013 to 09/2019 completed questionnaires (Eating Assessment Tool-10 (EAT-10); questions from the EORTC QLQ-C30 and EORTC H&N35) on dysphagia, voice problems, pain, fatigue, and QoL collected with the software OncoFunction. Associations between prognostic factors and symptoms were tested with analyses of variance (ANOVAs). Associations between the symptom scales and QoL variables were expressed with Pearson correlations.

RESULTS

Of 689 patients, 54.9% suffered from dysphagia, the EAT-10 proved to be a reliable measure. The mean voice score was 37.6 (± 33.9) [range 0-100], the mean pain score 1.98 (± 2.24) [range 0-10]. Trimodality treatment was associated with the highest dysphagia scores. Dysphagia, voice problems, and pain significantly correlated with each other, the highest association was found for dysphagia and pain (r = 0.51). QoL was strongly correlated with dysphagia and pain (r = - 0.39 and r = - 0.40, respectively), while the association with voice problems was weaker (r = - 0.28).

CONCLUSION

Dysphagia is an important symptom in HNC patients greatly affecting patients' QoL and significantly correlating with voice problems and pain.

Chronic opioid use after laryngeal cancer treatment

BACKGROUND

Survivors of head and neck cancer may be at increased risk for chronic opioid use and questions remain about risk factors.

METHODS

Retrospective study of patients with laryngeal cancer prescribed opioids utilizing the Truven Health Marketscan database. Patients had laryngeal cancer, underwent treatment, filled an opioid prescription, and were enrolled in this private insurance plan 1 year prior to and after treatment.

RESULTS

In this study, 7484 patients were included; 17.2% developed chronic opioid use, defined as consecutive opioid fills at least 90 days after treatment cessation. Early opioid use (OR = 3.607, 95% CI [3.125-4.163]), tobacco use (OR = 1.28, 95% CI [1.117-1.467]), median morphine milligram equivalent (MME; OR = 1.001, 95% CI [1.000-1.0001]), and radiation alone (OR = 1.435, 95% CI [1.199-1.717]) were predictive of chronic opioid use.

CONCLUSIONS

Nearly one in five patients prescribed opioids during treatment developed chronic use. Providers should discuss the risk of chronic opioid use, set expectations for opioid weaning, and consider adjunct pain regimens to develop effective pain management strategies.

Attitudes and appropriateness of pain management in cancer patients using pain management index

Objectives

Inadequate management of cancer pain (CP) remains a global medical problem. In this study, the aim was to assess attitudes of cancer patients towards their CP treatment and to evaluate effectiveness of pain management.

Methods

A sample of 300 adult cancer patients admitted to a single hospital were face-to-face interviewed in a cross-sectional study design using a structured questionnaire. The short form of the Brief Pain Inventory was used to collect data on pain, and Pain Management Index (PMI) was calculated to assess adequacy of pain management.

Key findings

Median age of patients was 53 years (interquartile range, 43–63). Half of patients (50.5%) believed their pain therapy needs improvement. Almost half patients had severe pain at interview (49.8%). Pain interfered most with patient enjoyment of life with a mean interference score 6.13 ± 2.37. Majority of cancer patients (84.3%) received a non-opioid analgesic while a minority (15.7%) received opioid analgesic in which morphine was the most common drug. The use of non-opioid adjuvants was minimal. Mean PMI for patients was −1.15 ± 0.75 (range −2 to +1), and most patients (80.3%) had inadequate pain treatment. Gender and smoking status of patients were significantly associated with adequacy of pain management (P = 0.009 and P = 0.004, respectively). There were no associations between patient age, educational level or tumour characteristics and adequacy of pain management.

Conclusions

Cancer patients in this study present with severe pain and the rates of undertreatment are high. There is an urgent need to improve management plans to assure appropriate use of therapeutic modalities for treatment of cancer-related pain.

Implications of Treatment Modality on Chronic Opioid Use Following Treatment for Head and Neck Cancer

Objective

To investigate the relationship between treatment modality and chronic opioid use in a large cohort of patients with head and neck cancer.

Study Design

Retrospective cohort study.

Setting

Single academic center.

Methods

There were 388 patients with head and neck cancer treated between January 2011 and December 2017 who met inclusion criteria. Clinical risk factors for opioid use at 3 and 6 months were determined with univariate and multivariate analyses.

Results

The prevalence of opioid use was 43.0% at 3 months and 33.2% at 6 months. On multivariate analysis, primary chemoradiation (odds ratio [OR], 4.04; 95% CI, 1.91-8.55) and surgery with adjuvant chemoradiation (OR, 2.39; 95% CI, 1.09-5.26) were associated with opioid use at 3 months. Additional risk factors at that time point included pretreatment opioid use (OR, 7.63; 95% CI, 4.09-14.21) and decreasing age (OR, 1.03; 95% CI, 1.01-1.06). At 6 months, primary chemoradiation (OR, 2.40; 95% CI, 1.34-4.28), pretreatment opioid use (OR, 5.86; 95% CI, 3.30-10.38), current tobacco use (OR, 2.00; 95% CI, 1.18-3.40), and psychiatric disorder (OR, 1.79; 95% CI, 1.02-3.14) were associated with opioid use.

Conclusion

Of the patients who receive different treatment modalities, those receiving primary chemoradiation are independently at highest risk for chronic opioid use. Other risk factors include pretreatment opioid use, tobacco use, and a psychiatric disorder. In an effort to reduce their risk of chronic opioid use, preventative strategies should be especially directed to these patients.

Preventive use of gabapentin to decrease pain and systemic symptoms in patients with head and neck cancer undergoing chemoradiation

BACKGROUND

Radiation for patients with head and neck cancer (HNC) is associated with painful mucositis that impacts the delivery of treatment and contributes to high symptom burden.

METHODS

This was a prospective, randomized pilot trial. Eligible patients received primary or adjuvant chemoradiation. Patients were randomized to usual care vs usual care plus gabapentin titrated to drug tolerance during radiation. Patients completed a symptom survey at baseline and weekly during therapy.

RESULTS

Seventy-nine patients were enrolled in the study (38 control, 41 treatment). At interim analysis, gabapentin use resulted in a decrease in pain (P = .004), with the biggest decreases being in the latter weeks of therapy. By week 7, the median pain score in the treatment group was below the 0.25 quantile of the control group.

CONCLUSION

Prophylactic use of gabapentin during chemoradiation for HNC patients resulted in a decrease in pain, neurosensory symptoms, and general systemic symptoms.

Longitudinal perioperative pain, neuromusculoskeletal complications and quality-of-life assessment in partial parotidectomy

AIM

The aim of this study was to evaluate the pain, neuromusculoskeletal complications, and quality of life (QoL) in patients who had undergone partial parotidectomy (PP) for benign parotid tumors.

PATIENTS AND METHODS

All patients were evaluated before (T0) and at 1 week (T1) and 1 month (T2) after surgery. The patients were assessed for cervical range of motion (ROM), neck pain (NRS), neuropathic pain (DN4), neck disability (NDI), facial disability (FDI), and the presence of facial neuropathy, and QoL.

RESULTS

Twenty patients were included. A slight decrease was noted in cervical ROM, mild neck pain and disability were seen in T1. The DN4 score markedly increased at T1 (4.25) compared to T0 (0.1). Then it declined to 1.95 at T2. While there was no neuropathy in any of the patients at T0, it was present in 3 patients at T1. However, all improved at T2. QoL was negatively affected at T1 but showed improvement at T2. There was a significant correlation between NRS and NDI, FDI.

CONCLUSION

Neuromusculoskeletal problems and impaired QoL may develop in patients who have undergone PP. It would be beneficial to evaluate these patients using a multidisciplinary approach and inform them before surgery.

Acute Pain Management Following Head and Neck Surgery

Acute pain management following major head and neck (HN) surgery is complex. Multimodal analgesia (MMA) regimens including acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids, and locoregional anesthetics are safe and effective in this population (including patients undergoing HN free flap surgery). Special considerations for patients undergoing HN free flap surgery include judicious use of steroids and attention to donor site pain. Evidence for specific analgesic regimens following transoral robotic surgery is limited but should include MMA and perioperative dexamethasone. Further study is required to optimize combinations, dosages, and duration of perioperative analgesia medications, opioid and nonopioid, for patients undergoing major HN surgery.

Prevision of multidisciplinary head and neck cancer survivorship care during the 2019 novel coronavirus pandemic

The 2019 Coronavirus Pandemic challenges the delivery of care for patients with head and neck cancer. An important aspect of this care has been the evolution of enhanced survivorship services, which include surveillance for recurring cancer and prevention of second primaries. The application of evidence‐based approaches to the identification and management of treatment and tumor‐related toxicities has embraced the use of validated patient‐reported outcomes instruments, health promotion, and care coordination. In this manuscript, we describe how our multidisciplinary team of survivorship providers has accommodated to the need to provide patients with social distancing while acknowledging the importance of continued care during treatment and through the spectrum of survivorship.

Persistent and Chronic Postoperative Opioid Use in a Cohort of Patients with Oral Tongue Squamous Cell Carcinoma

BACKGROUND

Recently, the concept of persistent postsurgical opioid use has been described for patients undergoing cancer surgery. Our hypothesis was based on the premise that patients with oral tongue cancer require high dosages of opioids before, during, and after surgery, and thus a large percentage of patients might develop persistent postsurgical opioid use.

METHODS

After institutional review board approval, we conducted a retrospective study that included a cohort of patients with oral tongue cancers who underwent curative-intent surgery in our institution. Multivariable logistic regression models were fit to study the association of the characteristics of several patients with persistent (six months after surgery) and chronic (12 months after surgery) postoperative opioid use.

RESULTS

A total of 362 patients with oral tongue malignancies were included in the study. The rate of persistent use of opioids after surgery was 31%. Multivariate analysis showed that patients taking opioids before surgery and those receiving adjuvant therapy were 2.9 and 1.78 times more likely to use opioids six months after surgery. Fifteen percent of the patients were taking opioids 12 months after surgery. After adjusting for clinically relevant covariates, patients complaining of moderate tongue pain before surgery and those taking opioids preoperatively had at least three times higher risk of still using these analgesics one year after surgery.

CONCLUSIONS

Patients with oral tongue cancers have a high risk of developing persistent and chronic postsurgical opioid use.

Temporomandibular disorders in head and neck cancers: Overview of specific mechanisms and management

Diagnosis classification system of Temporomandibular disorders (TMD) is based on the biopsychosocial model of pain. The pathogenesis is poorly understood, leading to difficulties in treating these multifactorial conditions. The predisposing factors are pathophysiological, psychological or structural processes that alter the masticatory system and lead to an increase in the risk of development of TMD. The purpose of this integrative review was then to point out the specific mechanisms of TMD in the oral oncologic context to optimize the TMJ functional results in the management of patients with oral oncologic conditions. We explored in this paper the role of Axis II assessment of the biopsychosocial model of pain, the involvement of mechanical concepts such as dental occlusion, mandibular condyle positioning and related-structures reconstruction, and the stomatognathic changes induced by radiation.

Chronic Opioid Use after Laryngeal Cancer Treatment: A VA Study

OBJECTIVE

To investigate opioid utilization in veterans undergoing laryngeal cancer treatment and describe the risk of chronic use after treatment cessation.

STUDY DESIGN

A retrospective cohort study.

SETTING

A single Veterans Health Administration site.

SUBJECTS AND METHODS

Veterans with newly diagnosed and treated laryngeal cancer with attributable opioid use from 2005 to 2015. Milligram morphine equivalents (MMEs) were calculated from 90 days prior to diagnosis for up to 1 year. Adjuvant pain medications filled 30 days prior to and up to a year from the date of diagnosis were assessed.

RESULTS

Of 74 veterans with biopsy-proven laryngeal carcinoma, 73 (98.6%) were male and 71 (96%) were white. Forty-three (58%) patients were stage 0/I/II; 31 (42%) were III/IV. Eleven (14.9%) were treated with surgery alone, 35 (47.3%) with radiation alone, and 28 (38%) with multimodal therapy. Twenty-four (32.4%) patients had preexisting opioid use prior to cancer diagnosis. Patients who used opioids more than 30 days prior to date of diagnosis were found to be 10 times more likely to have persistent opioid use at 90 days (P = .0024) and 8 times more likely to have chronic use at 360 days (P = .0041). Maximum MMEs within 1 year of diagnosis were significantly associated with chronic use at 90 days (P = .00045) and chronic use at 360 days (P = .0006).

CONCLUSION

Preexisting opioid use and maximum MMEs are strongly associated with chronic opioid use among veterans treated for laryngeal carcinoma independent of stage and treatment type.

Chronic Systemic Symptoms in Head and Neck Cancer Patients

The systemic effects and manifestations of disease and treatment have been of interest for millennium. Until recently, basic and clinical research is just now reaching a watershed. Systemic symptoms usually do not occur in isolation but rather in clusters; however, much of the cutting-edge research pertaining to the etiology, mechanism, manifestations, and moderators of systemic symptoms in humans has been directed at individual symptoms, thus creating silos of knowledge. Breaching these silos and bridging the knowledge from disparate arenas of investigation to build a comprehensive depiction of acute and chronic systemic symptoms has been a challenge. In addition, much of the recent work in systemic symptoms has been conducted in the setting of nonmalignant disease. The degree to which the findings from other chronic disease processes can be translated into the oncologic realm is unknown. This article will explore inflammation as a major contributing factor to systemic symptoms and sickness behavior, discuss the most common manifestations in cancer survivors, and, where available, discuss specific data pertaining to head and neck cancer survivors.

Very late xerostomia, dysphagia, and neck fibrosis after head and neck radiotherapy

BACKGROUND

Acute and late toxicity after intensity-modulated radiotherapy (IMRT) for head and neck cancer (HNC) impacts on patient quality of life; yet, very late toxicity data remain scarce. This study assessed dysphagia, xerostomia, and neck fibrosis 3-8 years after IMRT.

METHODS

A retrospective analysis using generalized estimated equations was performed on 60 patients with HNC treated with fractionated IMRT between 2000 and 2015 who had a follow-up ≥8 years. Toxicity was scored using LENT-SOMA scales.

RESULTS

A trend towards a nonlinear global time effect (P = .05) was noted for dysphagia with a decrease during the 5 years post-treatment and an increase thereafter. A significant decrease in xerostomia (P = .001) and an increase in neck fibrosis (P = .04) was observed until 8 years.

CONCLUSIONS

Dysphagia, xerostomia, and neck fibrosis do not appear stable over time and remain highly prevalent in the very late follow-up. Our findings support the need for prospective trials investigating very late toxicity in patients with HNC.

The point of pain in head and neck cancer

Head and neck cancer (HNC) can have a devastating impact on patient's lives as both disease and treatment may affect the ability to speak, swallow and breathe. These conditions limit the oral intake of food and drugs, reduce social functioning and impact on patient's quality of life. Up to 80% of patients suffering from HNC have pain due to the spread of the primary tumor, because of consequences of surgery, or by developing oral mucositis, dysphagia or neuropathy as toxic side effects of radiotherapy, chemotherapy or both. All healthcare professionals caring for HNC patients should assess palliative and supportive care needs in initial treatment planning and throughout the disease, with awareness when specialist palliative care expertise is needed. This paper focuses on assessment, characterizations and clinical management of pain in advanced HNC patients undergoing surgery, chemotherapy and radiotherapy, also underlining the importance of symptom assessment in HNC survivors and the need of clinical research in this field.