Concomitant twice-a-day radiotherapy and chemotherapy in unresectable head and neck cancer patients: A long-term quality of life analysis

Survival and long-term quality-of-life of concurrent chemoradiotherapy versus surgery followed by radiotherapy with or without concurrent chemotherapy for the treatment of resectable stage III/IV hypopharyngeal carcinoma

OBJECTIVE

We evaluated the utility of concurrent chemoradiotherapy (CCRT) compared to surgery followed by adjuvant radiotherapy (with or without concurrent chemotherapy) (SRT) in terms of improving the life expectancy and quality-of-life (QOL) of patients with stage III/IV hypopharyngeal squamous cell carcinomas (HPSCCs).

METHODS

From January 2010 to July 2018, a total of 299 patients with stage III/IV HPSCC who received surgery followed by adjuvant radiotherapy (with or without concurrent chemotherapy) (SRT, n = 111), or concurrent chemoradiotherapy (CCRT, n = 188) in our hospital were included. We measured overall survival (OS) and disease-free survival (DFS). We used the EORTC QLQ-C30, QLQ-H&N35, and Voice handicap index-30 (VHI-30) instruments to assess the long-term QOL.

RESULTS

The OS and DFS afforded by SRT were significantly better than those associated with CCRT (p = 0.039; p = 0.048 respectively), especially for stage N2-N3 patients. CCRT patients experienced better speech outcomes.

CONCLUSION

For resectable stage III/IV HPSCC patients, appropriate treatment plans should be selected comprehensively considering survival rate, QOL, patient preference and multidisciplinary treatment.

Serious Long-Term Effects of Head and Neck Cancer from the Survivors' Point of View

The long-term problems of head and neck cancer survivors (HNCS) are not well known. In a cross-sectional international study aimed at exploring the long-term quality of life in this population, 1114 HNCS were asked to state their two most serious long-term effects. A clinician recorded the responses during face-to-face appointments. A list of 15 example problems was provided, but a free text field was also available. A total of 1033 survivors responded to the question. The most frequent problems were 'dry mouth' (DM) (n = 476; 46%), 'difficulty swallowing/eating' (DSE) (n = 408; 40%), 'hoarseness/difficulty speaking' (HDS) (n = 169; 16%), and 'pain in the head and neck' (PHN) (n = 142; 14%). A total of 5% reported no problems. Logistic regression adjusted for age, gender, treatment, and tumor stage and site showed increased odds of reporting DM and DSE for chemo-radiotherapy (CRT) alone compared to surgery alone (odds ratio (OR): 4.7, 95% confidence interval (CI): 2.5-9.0; OR: 2.1, CI: 1.1-3.9), but decreased odds for HDS and PHN (OR: 0.3, CI: 0.1-0.6; OR: 0.2, CI: 0.1-0.5). Survivors with UICC stage IV at diagnosis compared to stage I had increased odds of reporting HDS (OR: 1.9, CI: 1.2-3.0). Laryngeal cancer survivors had reduced odds compared to oropharynx cancer survivors of reporting DM (OR: 0.4, CI: 0.3-0.6) but increased odds of HDS (OR: 7.2, CI: 4.3-12.3). This study provides evidence of the serious long-term problems among HNCS.

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.

Determinants for further wishes for cosmetic and reconstructive interventions in 1652 patients with surgical treated carcinomas of the oral cavity

Background

The impairment of the appearance is a major problem for patients with carcinomas of the oral cavity. These patients want to recover their preoperative facial appearance. Some do not realize that this is not always possible and hence develop a desire for further cosmetic and reconstructive surgery (CRS) which often causes psychological problems.

Method

The desire of patients for CRS (N = 410; 26%) has been acquired in this DÖSAK rehab study including multiple reasons such as medical, functional, aesthetic and psychosocial aspects. They relate to the parameters of diagnosis, treatment and postoperative rehabilitation. Patients without the wish for CRS (N = 1155; 74%) served as control group. For the surgeons, knowledge of the patient’s views is relevant in the wish for CRS. Nevertheless, it has hardly been investigated for patients postoperatively to complete resection of oral cancer. In this retrospective cross-sectional study, questionnaires with 147 variables were completed during control appointments. Thirty-eight departments of Oral and Maxillofacial Surgery took part, and 1652 German patients at least 6 months after complete cancer resection answered the questions. Additionally, a physician’s questionnaire (N = 1489) was available. Statistical analysis was performed with SPSS vers. 22.

Results

The patient’s assessment of their appearance and scarring are the most important criteria resulting in wishes for CRS. Furthermore, functional limitations such as eating/swallowing, pain of the facial muscles, numb regions in the operating field, dealing with the social environment, return to work, tumour size and location, removal and reconstruction are closely related.

Conclusion

The wish for CRS depends on diverse functional psychosocial and psychological parameters. Hence, it has to be issued during conversation to improve rehabilitation. A decision on the medical treatment can be of greater satisfaction if the surgeon knows the patients’ needs and is able to compare them with the medical capabilities. The informed consent between doctor and patient in regard to these findings is necessary.

Systematic Review of Tobacco Use after Lung or Head/Neck Cancer Diagnosis: Results and Recommendations for Future Research

Tobacco use after cancer diagnosis is associated with adverse cancer outcomes, yet reliable prevalence estimates for this behavior are lacking. We conducted a systematic literature review of the prevalence of current tobacco use among individuals with a history of lung or head/neck cancer (CRD #42012002625). An extensive search of electronic databases (MEDLINE, EMBASE, Cochrane Library, CINAHL, PsycINFO, and Web of Science) identified 7,777 potentially relevant articles published between 1980 and 2014 and 131 of these yielded pertinent information. Aggregating results across heterogeneous study designs and diverse patient samples, the overall mean prevalence rate of current tobacco use (mostly cigarette smoking) was 33.0% (median, 31.0%). Among current tobacco users at cancer diagnosis, the mean prevalence rate of current tobacco use (mostly cigarette smoking) was 53.8% (median, 50.3%). In many cases, an operational definition of "current" tobacco use was absent, and biochemical verification of self-reported smoking status was infrequent. These and other observed methodologic limitations in the assessment and reporting of cancer patients' tobacco use underscore the necessity of uniform tobacco use assessment in future clinical research and cancer care.

Long-term quality of life after intensified multi-modality treatment of oral cancer including intra-arterial induction chemotherapy and adjuvant chemoradiation

Background:

Quality of life (QoL) studies are well established when accompanying trials in head and neck cancer, but studies on long-term survivors are rare.

Aims:

The aim was to evaluate long-term follow-up patients treated with an intensified multi-modality therapy.

Setting and Design:

Cross-sectional study, tertiary care center.

Patients and Methods:

A total of 135 oral/oropharyngeal cancer survivors having been treated with an effective four modality treatment (intra-arterial induction chemotherapy, radical surgery, adjuvant radiation, concurrent systemic chemotherapy) filled European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 and HN35 questionnaires. Mean distance to treatment was 6.1 (1.3–16.6) years. Results were compared with a reference patient population (EORTC reference manual). In-study group comparison was also carried out.

Statistical Analysis:

One-sample t-test, Mann–Whitney-test, Kruskal–Wallis analysis.

Results:

QoL scores of both populations were well comparable. Global health status, cognitive and social functioning, fatigue, social eating, status of teeth, mouth opening and dryness, and sticky saliva were significantly worse in the study population; pain and need for pain killers, cough, need for nutritional support, problems with weight loss and gain were judged to be significantly less. Patients 1-year posttreatment had generally worse scores as compared to patients with two or more years distance to treatment. Complex reconstructive measures and adjuvant (chemo) radiation were main reasons for significant impairment of QoL.

Conclusion

Subjective disease status of patients following a maximized multi-modality treatment showed an expectable high degree of limitations, but was generally comparable to a reference group treated less intensively, suggesting that the administration of an intensified multi-modality treatment is feasible in terms of QoL/effectivity ratio.

Oral cancer malnutrition impacts weight and quality of life

Diet is important for both quality of life (QoL) and survival of patients with oral cancer. Their intake of food is impeded by functional restrictions in chewing and swallowing. In the DÖSAK REHAB STUDY 1652 patients from 38 hospitals within the German-language area of Germany; Austria and Switzerland were examined with regard to functional and psychological variables having an impact on diet. Chewing and swallowing are correlated with mobility of the tongue and the mandible as well as opening of the mouth. Thirty five percent of the patients lost weight; 41% maintained their weight and 24% gained weight. The QoL of patients who were able to maintain their weight and of those who gained weight was significantly better than that of patients who lost weight. A normal diet was important for maintaining weight. Mashed food; liquid food and loss of appetite were closely associated with loss of weight; although it was possible for nutritional counseling and dietary support to be implemented particularly favorably in this respect. Due to problems with eating patients' strength deteriorated; thus restricting activity. Radiotherapy had a negative impact on diet and weight. It influenced sense of taste; dryness of the mouth; swelling and discomfort when ingesting food. Pain and scars in the region of the operation also cause patients to dislike hard; spicy and sour food. Support from a nutritional counselor in implementing a calorie-rich diet remedied this and such support needs to be integrated into patient management. The fact that a poor nutritional status is of such great importance is well-known; but what is often lacking is the systematic implementation of continued professional nutritional counseling over a long period of time; weight control and psycho-social support of the operated patients; particularly those who also have had radiotherapy.

The role of surgery in the palliation of head and neck cancer

PURPOSE OF REVIEW

The public demands that 'all modes of treatment' should be offered to patients who present with head and neck cancer. Up to 40% of patients present with advanced stage disease, of whom some 10% have metastatic disease and are currently deemed incurable. This review summarizes the current role and philosophy of surgical interventions in the palliation of head and neck cancer.

RECENT FINDINGS

Patients who present with advanced or recurrent head and neck cancers over the past decade have been offered nonsurgical palliative treatments of radiotherapy with or without chemotherapy, with variable responses. The aims are to achieve tumour shrinkage and gain effective relief of symptoms, such as pain, breathing and swallowing. The use of surgery in the palliation of disease and its symptoms has declined significantly since the 1980s. Within the concept of multidisciplinary clinical working as the 'gold standard' for the provision of optimum care for the head and neck patient, the place for surgery should be discussed within the many options available currently.

SUMMARY

Patients who present with advanced, incurable or recurrent head and neck cancer should be made aware of their prognosis and the potential need and benefits of palliative care. The active involvement of patients and their carers, their desires and wishes should be the prime consideration for any interventions. Careful selection of suitable patients can achieve prolonged symptom relief safely and result in an improvement in their quality of living. The ultimate goal should incorporate not only quality of life but quality of dying.

Head and neck cancer pain: systematic review of prevalence and associated factors

OBJECTIVES

Pain is a major symptom in patients with cancer; however information on head and neck cancer related pain is limited. The aim of this review was to investigate the prevalence of pain and associated factors among patients with HNC.

MATERIAL AND METHODS

The systematic review used search of MEDLINE, EMBASE and CINAHL databases to December 2011. Cancers of the oral mucosa, oropharynx, hypopharynx and larynx were included in this review with pain as main outcome. The review was restricted to full research reports of observational studies published in English. A checklist was used to assess the quality of selected studies.

RESULTS

There were 82 studies included in the review and most of them (84%) were conducted in the past ten years. Studies were relatively small, with a median of 80 patients (IQR 44, 154). The quality of reporting was variable. Most studies (77%) used self-administered quality of life questionnaires, where pain was a component of the overall scale. Only 33 studies reported pain prevalence in HNC patients (combined estimate from meta-analysis before (57%, 95% CI 43% - 70%) and after (42%, 95% CI 33% - 50%) treatment. Only 49 studies (60%) considered associated factors, mostly tumour- or treatment-related.

CONCLUSIONS

The study has shown high levels of pain prevalence and some factors associated with higher levels of pain. There is a need for higher quality studies in a priority area for the care of patients with head and neck cancer.

A systematic review of orofacial pain in patients receiving cancer therapy

PURPOSE

We present the findings of a structured systematic review of the literature assessing orofacial pain induced by malignant disease and/or its therapy (excluding mucositis). This evaluation of the literature published after the 1989 NIH Development Consensus conference on the oral complications of cancer therapies is an effort to assess the prevalence of pain, quality of life and economic impact, and management strategies for cancer therapy-induced orofacial pain.

METHODS

A systematic medical literature search was conducted with assistance from a research librarian in MEDLINE/PubMed and EMBASE databases for articles published between January 1, 1990 and December 31, 2008. Each study was independently assessed by two reviewers with expertise in the field of oral oncology.

RESULTS

Thirty-nine studies assessed pain in the head and neck region. The measure was commonly embedded in quality of life studies. Most of these studies described pain in head and neck cancer (HNC) patients, which therefore became the focus of the report. Pain is common in patients with HNC and is reported by approximately half of patients prior to cancer therapy, 81% during therapy, 70% at the end of therapy, and by 36% at 6 months after treatment. Pain is experienced beyond the 6-month period by approximately one third of patients and is typically more severe than pre-treatment cancer-induced pain.

CONCLUSIONS

This systematic review identified the presence of pain before cancer therapy, likely attributable to the cancer; an increase in pain during therapy and the common persistence of pain following cancer treatment. Continuing research should use validated tools to prospectively assess orofacial pain, its causes and pathophysiology, and its effect on quality of life and economic impact. Clinical trials of pain management in this setting are also warranted.

A systematic review of salivary gland hypofunction and xerostomia induced by cancer therapies: prevalence, severity and impact on quality of life

PURPOSE

This systematic review aimed to assess the literature for prevalence, severity, and impact on quality of life of salivary gland hypofunction and xerostomia induced by cancer therapies.

METHODS

The electronic databases of MEDLINE/PubMed and EMBASE were searched for articles published in English since the 1989 NIH Development Consensus Conference on the Oral Complications of Cancer Therapies until 2008 inclusive. Two independent reviewers extracted information regarding study design, study population, interventions, outcome measures, results and conclusions for each article.

RESULTS

The inclusion criteria were met by 184 articles covering salivary gland hypofunction and xerostomia induced by conventional, 3D conformal radiotherapy or intensity-modulated radiotherapy in head and neck cancer patients, cancer chemotherapy, total body irradiation/hematopoietic stem cell transplantation, radioactive iodine treatment, and immunotherapy.

CONCLUSIONS

Salivary gland hypofunction and xerostomia are induced by radiotherapy in the head and neck region depending on the cumulative radiation dose to the gland tissue. Treatment focus should be on optimized/new approaches to further reduce the dose to the parotids, and particularly submandibular and minor salivary glands, as these glands are major contributors to moistening of oral tissues. Other cancer treatments also induce salivary gland hypofunction, although to a lesser severity, and in the case of chemotherapy and immunotherapy, the adverse effect is temporary. Fields of sparse literature included pediatric cancer populations, cancer chemotherapy, radioactive iodine treatment, total body irradiation/hematopoietic stem cell transplantation, and immunotherapy.

Targeting the Vascular Endothelial Growth Factor Pathway in the Treatment of Human Malignancy

Over 30 years ago, it was proposed that blocking new blood vessel formation would significantly inhibit solid tumor growth and hence, limit cancer progression. Efforts guided by this philosophy have resulted in a better understanding of the molecular basis of tumor angiogenesis. The first successful therapeutic to emerge from this work, an antibody (bevacizumab) targeting the vascular endothelial growth factor (VEGF), was recently approved for the treatment of colorectal cancer. Additional positive clinical data with bevacizumab in the treatment of breast and lung carcinoma have also been reported. These clinical achievements have validated the approach of anti-angiogenesis therapy for cancer and provided further confirmation for antibodies as a therapeutic class in this disease. Nevertheless, important unanswered questions with regard to preclinical and clinical results of VEGF pathway inhibitors remain. For example, preclinical models with a number of VEGF pathway inhibitors suggest that these agents would have significant clinical activity on their own; yet, clinical activity in patients with bevacizumab or other VEGF pathway inhibitors as monotherapy have been disappointing. Moreover, while bevacizumab is approved for the treatment of colorectal cancer in combination with cytotoxics, the mechanism for the benefits of this combination are still poorly understood, with a number of viable mechanisms under active experimental evaluation. The 3-8-month survival benefit in colorectal cancer patients treated with bevacizumab is a positive step forward. However, improving our understanding of the mechanism for these effects, as well as the mechanism underlying the inability as yet to achieve greater effects, is needed in order to follow up on the positive clinical results with improved strategies. This review discusses the experimental results surrounding the current status of our understanding of the mechanism of action of VEGF signaling inhibitors, and the potential for utilizing these agents in the future so that clinical benefits will be measured in years rather than months.

Long-term outcomes and toxicity of concurrent paclitaxel and radiotherapy for locally advanced head-and-neck cancer

PURPOSE

To report the long-term outcomes and toxicity of a regimen of infusion paclitaxel delivered concurrently with radiotherapy in patients with locally advanced squamous cell carcinoma of the head and neck.

PATIENTS AND METHODS

Between 1995 and 1999, 35 patients with nonmetastatic, Stage III or IV squamous cell carcinoma of the head and neck were treated with three cycles of paclitaxel as a 120-h continuous infusion beginning on Days 1, 21, and 42, concurrent with radiotherapy. The initial 16 patients received 105 mg/m(2)/cycle, and the subsequent 19 patients received 120 mg/m(2)/cycle. External beam radiotherapy was delivered to a dose of 70.2-72 Gy at five fractions weekly. Patients were followed to evaluate the disease outcomes and late toxicity of this regimen.

RESULTS

The median follow-up for all patients was 56.5 months. The median survival was 56.5 months, and the median time to local recurrence was not reached. Of the 35 patients, 15 (43%) developed hypothyroidism. Of the 33 patients who underwent percutaneous endoscopic gastrostomy tube placement, 11 were percutaneous endoscopic gastrostomy tube dependent until death or their last follow-up visit. Also, 5 patients (14%) required a tracheostomy until death, and 3 (9%) developed a severe esophageal stricture. All evaluated long-term survivors exhibited salivary hypofunction. Fibrosis in the radiation field occurred in 24 patients (69%).

CONCLUSION

The results of our study have shown that concurrent chemoradiotherapy with a 120-h infusion of paclitaxel provides long-term local control and survival in patients with squamous cell carcinoma of the head and neck. Xerostomia, hypothyroidism, esophageal and pharyngeal complications, and subcutaneous fibrosis were common long-term toxicities; however, the vast majority of toxicities were grade 1 or 2.

Gastrointestinal dysmotility in 5-fluorouracil-induced intestinal mucositis outlasts inflammatory process resolution

AIM

To evaluate gastrointestinal motility during 5-fluorouracil (5-FU)-induced intestinal mucositis.

MATERIALS AND METHODS

Wistar rats received 5-FU (150 mg kg(-1), i.p.) or saline. After the 1st, 3rd, 5th, 15th and 30th day, sections of duodenum, jejunum and ileum were removed for assessment of epithelial damage, apoptotic and mitotic indexes, MPO activity and GSH concentration. In order to study gastrointestinal motility, on the 3rd or 15th day after 5-FU treatment, gastric emptying in vivo was measured by scintilographic method, and stomach or duodenal smooth muscle contractions induced by CCh were evaluated in vitro.

RESULTS

On the third day of treatment, 5-FU induced a significant villi shortening, an increase in crypt depth and intestinal MPO activity and a decrease in villus/crypt ratio and GSH concentration. On the first day after 5-FU there was an increase in the apoptosis index and a decrease in the mitosis index in all intestinal segments. After the 15th day of 5-FU treatment, a complete reversion of all these parameters was observed. There was a delay in gastric emptying in vivo and a significant increase in gastric fundus and duodenum smooth muscle contraction, after both the 3rd and 15th day.

CONCLUSION

5-FU-induced gastrointestinal dysmotility outlasts intestinal mucositis.

Quality of life in head and neck cancers patients: predictive factors, functional and psychosocial outcome

The principal endpoints in head and neck cancer are survival with improvement of quality of life (QoL) in cancer patients. Patients treated for head and neck cancer suffer from a number of symptom domains: physical symptoms linked to diet and feeding, communication disorders, pain and their general state of health; psychological symptoms including depression, irritability, loss of self-esteem (occasionally feelings of shame), and social symptoms including relationship difficulties with partner (sexual disorders) or with other family members, loss of work, reduction in salary, and sense of uselessness, resulting in a negative impact on their daily life. At present, most tools only partially evaluate patient QoL, concentrating on the global impact of disease and its treatment on patients' physical and psychological condition. The "sociability" of individual patients is rarely evaluated, and the development of qualitative studies in this domain will enable improved understanding of the social factors involved in each patient's adaptability to disease, its treatment and after-effects.

A structured review and theme analysis of papers published on ‘quality of life’ in head and neck cancer: 2000–2005

Over the past 10 years, quality of life (QOL) has been increasingly recognised as an important outcome parameter in head and neck cancer. Validated questionnaires have emerged and there has been an increase in the number of papers published each year. The aim of this article is to review the literature over the past five years (2000-2005 inclusive), to identify papers reporting outcomes using patient self-competed questionnaires and group these into themes. The tabulated summary allows for the areas of health related quality of life research to be identified and to explore issues that are perhaps deficit in the literature. The three authors independently searched the literature published in the English language using the ISI search engine with cross-reference using Pub Med and Ovid. The search terms were; quality of life, questionnaire, and head and neck cancer. Studies were placed in to one of five themes. There were 165 studies identified. The numbers in each theme were predictors of QOL [Hassanein KA, Musgrove BT, Bradbury E. Functional status of patients with oral cancer and its relation to style of coping, social support and psychological status. Br J Oral Maxillofac Surg 2001;39:340-5.], functional outcome [Klug C, Neuburg J, Glaser C, Schwarz B, Kermer C, Millesi W. Quality of life 2-10 years after combined treatment for advanced oral and oropharyngeal cancer. Int J Oral Maxillofac Surg 2002;31:664-9.], questionnaire development [Hanna E, Sherman A, Cash D, Adams D, Vural E, Fan CY, et al. Quality of life for patients following total laryngectomy vs chemoradiation for laryngeal preservation. Arch Otolaryngol Head Neck Surg 2004;130:875-9.], randomised clinical trials [Kanatas AN, Rogers SN. A national survey of health-related quality of life questionnaires in head and neck oncology. Ann R Coll Surg Engl 2004;86:6-10.], and reviews [Kanatas AN, Rogers SN. A national survey of health-related quality of life questionnaires in head and neck oncology. Ann R Coll Surg Engl 2004;86:6-10.]. Although many facets of HRQOL following head and neck cancer have been explored over the last five years the paper identifies issues where research is still lacking.

Health-related quality of life profiles based on survivorship status for head and neck cancer patients

BACKGROUND

As the methodologies for evaluating health-related quality of life (HRQOL) in head and neck cancer patients have matured over the past 10 years, there has been an increasing focus on reporting longitudinal data. These studies have primarily focused on long-term survivors. This study addresses the HRQOL of both long-term and short-term survivors.

METHODS

This is a prospective, longitudinal study of 479 head and neck cancer patients followed for at least 3 years after diagnosis. Analysis of longitudinally collected HRQOL scores was based on survivorship status.

RESULTS

The HRQOL for 3 survivorship groups: short-term (died <1 year), intermediate-term (died 1-3 years), and long-term survivors (alive >3 years) were different at all time points (pretreatment, 3, 6, and 12 months). Differences were greatest between the short-term and long-term survivors. Long-term survivors demonstrated the best HRQOL and an improving HRQOL trajectory at 12 months. The HRQOL of short-term survivors declined precipitously throughout all available follow-up. Intermediate-term survivors did show some improvement following treatment but had a declining HRQOL trajectory at 12 months.

CONCLUSION

The HRQOL profiles of head and neck cancer patients differed significantly depending on survivorship status. Long-term HRQOL results should be analyzed within the context of the results for all of the patients eligible to have been included in the initial study cohort.

Functional outcomes after organ preservation treatment in head and neck cancer: a critical review of the literature

The use of radiation therapy and/or chemotherapy in advanced head and neck cancer is increasing in popularity, driven by the notion that sparing the organs of speech and swallowing from surgical resection will also spare function. This critical review of the literature considered functional outcomes after organ preservation to assess the impact of such treatment on speech, swallowing and quality of life in patients with head and neck cancer. Literature searches were conducted on several library databases. A total of 50 relevant articles were identified and found to meet the inclusion criteria specified a priori. The majority of reports suggested that organ preservation techniques have the potential to result in swallowing disorders, often related to dysmotility of the oropharyngeal and laryngeal structures, and resulting in frequent episodes of aspiration. This may lead to the need for enteral feeding in the short term for some patients while, in others, this need is life long. Speech does not appear to be affected to the same degree as swallowing. These results suggest that organ preservation does not translate into function preservation for all patients with head and neck cancer.

Deterioration in quality-of-life of late (10-year) survivors of head and neck cancer

OBJECTIVES

To determine 10-year quality-of-life (QOL) in head and neck cancer patients and to examine the potential predictors of late QOL.

DESIGN

Prospective 10-year (QOL) assessment in a cohort of head and neck cancer patients.

SETTING

Tertiary referral head and neck cancer centre in Auckland, New Zealand.

PARTICIPANTS

Two hundred patients diagnosed and were treated for head and neck cancer. Exclusion criteria were blindness, learning difficulties or inability to understand or read English.

MAIN OUTCOME MEASURES

Quality-of-life at 10 years measured by Auckland QOL questionnaire, and analysed for associations with the following co-variates: age, gender; co-morbidities (alcohol intake and smoking), type and stage of disease; treatment modality; and QOL measures.

RESULTS

At 10 years following diagnosis, overall QOL (life satisfaction), decreased significantly by an average of 11% (95% CI: -5, -17) compared with before treatment, and by 15% when compared with years 1 and 2. Pre-treatment QOL significantly predicted late QOL, whilst QOL 1 year after treatment did not. None of the socio-demographic, disease- or treatment-related factors predicted long-term QOL on univariate analysis, but this may be due to the small sample size.

CONCLUSIONS

This observed, late drop in the QOL of head and neck cancer patients requires further corroboration and investigation. Due to small sample sizes associated with long-term studies in head and neck cancer cohorts, studies of predictors of long-term QOL will only be likely to succeed if done as multi-centre studies. As there is some evidence to suggest that psychosocial interventions improve the QOL of head and neck cancer patients, it may be appropriate to consider screening for risk of a late deterioration in QOL in order to plan appropriate psycho-social intervention.

Recent new approaches to the treatment of head and neck cancer

Head and neck squamous cell carcinoma (HNSCC) is the sixth most common cancer in the world and affects 50,000 Americans annually. During the past 20 years, treatments for HNSCC have changed dramatically due largely to the advent of novel approaches such as combined modality therapy, as well as improvements in surgical and radiotherapeutic techniques. Ongoing advances in the multidisciplinary management of this complex and multivariate disease process are resulting in improved function, quality of life and survival. Here, we review state-of-the-art therapy and presents selected advances in the treatment of head and neck cancer.

French multicenter phase III randomized study testing concurrent twice-a-day radiotherapy and cisplatin/5-fluorouracil chemotherapy (BiRCF) in unresectable pharyngeal carcinoma: Results at 2 years (FNCLCC-GORTEC)

BACKGROUND

Unresectable carcinomas of the oropharynx and hypopharynx still have a poor long-term prognosis. Following a previous phase II study, this phase III multicenter trial was conducted between November 1997 and March 2002.

METHODS

Nontreated, strictly unresectable cases were eligible. Twice-daily radiation: two fractions of 1.2 Gy/day, 5 days per week, with no split (D1-->D46). Total tumor doses: 80.4 Gy/46 day (oropharynx), 75.6 Gy/44 day (hypopharynx). Chemotherapy (arm B): Cisplatin 100 mg/m2 (D1, D22, D43); 5FU, continuous infusion (D1-->D5), 750 mg/m2/day cycle 1; 430 mg/m2/day cycles 2 and 3.

RESULTS

A total of 163 evaluable patients. Grade 3-4 acute mucositis 82.6% arm B/69.5% arm A (NS); Grade 3-4 neutropenia 33.3% arm B/2.4% arm A (p < 0.05). Enteral nutrition through gastrostomy tube was more frequent in arm B before treatment and at 6 months (p < 0.01). At 24 months, overall survival (OS), disease-free survival (DFS), and specific survival (SS) were significantly better in arm B. OS: 37.8% arm B vs. 20.1% arm A (p = 0.038); DFS: 48.2% vs. 25.2% (p = 0.002); SS: 44.5% vs. 30.2% (p = 0.021). No significant difference between the two arms in the amount of side effects at 1 and 2 years.

CONCLUSION

For these unresectable cases, chemoradiation provides better outcome than radiation alone, even with an "aggressive" dose-intensity radiotherapy schedule.

Health-related quality of life in patients with pharyngeal carcinoma: A five-year follow-up

PURPOSE

The purpose was to evaluate the health-related quality of life (HRQL) of patients with pharyngeal carcinoma at diagnosis and after 1 and 5 years in relation to tumor location and treatment modality in a prospective multicenter study.

METHODS

Eighty-nine patients with pharyngeal carcinoma (mean age, 60.0 years; 76% men) were evaluated using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30) and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Head and Neck Cancer Module (EORTC QLQ-H&N35).

RESULTS

Problems with dry mouth and teeth became worse between diagnosis and the 5-year follow-up. Problems with thick secretions and teeth increased between 1 and 5 years. The HRQL at diagnosis was associated with survival. Patients with oropharyngeal carcinoma reported better HRQL than patients with hypopharyngeal carcinoma.

CONCLUSIONS

For patients with pharyngeal carcinoma, the HRQL at diagnosis seems to be an important factor for the prognosis of both HRQL over time and survival. Treatment of pharyngeal carcinoma often results in long-term side effects such as dry mouth, problems with teeth, and thick secretions.

A randomized pilot study of cognitive-behavioral therapy versus basic health education for smoking cessation among cancer patients

BACKGROUND

Previously, we have linked theoretically based cognitive and emotional variables to the ability of cancer patients to quit smoking.

PURPOSE

In this study, we evaluated the impact of cognitive-behavioral therapy (CBT), which addressed these theoretically derived cognitive and emotional variables linked to tobacco use in this population, for promoting smoking cessation in a sample of cancer patients and assessed longitudinal predictors of smoking cessation.

METHODS

Cancer patients (N=109) were randomized to either the theoretically based CBT intervention or to a general health education (GHE) condition, and all patients received nicotine replacement therapy.

RESULTS

Contrary to our expectation, no significant difference in 30-day point-prevalence abstinence between the CBT and GHE conditions was detected at either a 1-month (44.9 vs. 47.3%, respectively) or 3-month (43.2% vs. 39.2%, respectively) follow-up evaluation. Higher quit motivation and lower cons of quitting were related to smoking cessation.

CONCLUSIONS

Implications for the implementation of smoking cessation behavioral treatments in the oncologic context are discussed, as are directions for future research in this area.

[Oncology and quality of life. Study in head and neck cancer]

The principal endpoints in oncology are survival with improvement of quality of life in cancer patients.

OBJECTIVES

To give an accurate account of current literature on quality of life and head and neck cancers.

METHODS

Two keys words are used: "quality of life" and "cancer" enabling to trace articles in Medical and Human Science journals. Analysis and synthesis of these documents.

RESULTS

Quality of life is difficult to evaluate as it is a multidimensional concept with three main symptom domains: physical, psychological and social. Several quality of life evaluation scales have been developed enabling authors to estimate the effects of disease on patients as well as treatment-related symptoms. Reports on quality of life in ENT patients have offered improved knowledge on patient experience and aftereffects, and therapies have been adapted and improved in view of such studies.

CONCLUSION

Quality of life evaluation tools need to be improved. At present, most tools only partially evaluate patient quality of life, concentrating on the global impact of disease and its treatment on patients' physical and psychological condition. The "sociability" of individual patients is rarely evaluated, and the development of qualitative studies in this domain will enable improved understanding of the social factors involved in each patient's adaptability to disease, its treatment and after-effects.

Evaluations of quality of life and organ function

For advanced head and neck cancer (HNC) patients, aggressive radiation and chemoradiation treatments offer new therapy options. The aims of these regimens are increased survival and organ preservation, with the goals of preserving organ function, minimizing late effects, and improving quality of life (QOL). At the same time, the toxicities of these regimens are acknowledged as is the potential for long-term dysfunction. Thus, particularly now, with the increasing use of aggressive chemoradiation therapy (CRT) regimens, documentation of the QOL and functional outcomes of these treatments is critical. The implications for speech and swallowing are widely recognized and the broader effects of these impairments on overall QOL have received some attention. This article presents data on the performance, functional, and QOL results of radiation therapy (RT) and various CRT regimens in HNC.

Prospective studies on mental status and quality of life in patients with head and neck cancer treated by radiation

Factors affecting the quality of life (QOL) in patients undergoing radiation therapy for head and neck cancer were determined in a prospective study. Full psychiatric interviews and self-report questionnaires concerning patients' QOL, pain, anxiety, mood, coping style and personality were administered to 35 patients with Stage I or II head and neck cancer before radiation therapy (week 0), and approximately one month (week 4) and two months (week 8) after starting of radiation. Anxiety, depression and pain were more severe at week 4 than at baseline. Anxiety was less at week 8, but depressive symptoms remained remarkable. Stepwise regression analyses revealed that changes in depressed mood and pain partially accounted for changes in disease-specific QOL. General health QOL related to a premorbid personality of openness and an emotional aspect of a coping style. Therapeutic interventions including psychiatric management of depression and physical management of pain appear to be crucial for preserving QOL during radiation treatment of patients with head and neck cancer.

[Assessment of quality of life in patients treated by supracricoid partial laryngectomy with cricohyoidoepiglottopexy (CHEP)]

OBJECTIVES

To assess quality of life in patients diagnosed with epidermoid carcinoma of the larynx, after supracricoid partial laryngectomy (SCPL) with cricohyoidoepiglottopexy (CHEP). To examine how quality-of-life may be associated to the treatment received: neck dissection, decannulation and radiotherapy.

PATIENTS AND METHOD

A descriptive, observational, cross-sectional study was conducted involving 26 patients out of a group of 51. They were all males with an average age of 61.7 years at the time of the interview. We used the disease-specific quality of life questionnaire devised by the University of Michigan: the Head and Neck Cancer-specific Quality of life instrument (HNQOL).

RESULTS

During an average follow-up period of 83.65 months, 2 patients (3.92%) suffered a recurrence. Estimated survival after 3, 5 and 10 years was 95.83%. Communication and overall disturbances caused by treatment were found to be the two quality-of-life domains mainly affected. Generally speaking, patients who had received radiotherapy, those who had not had their tracheal cannula removed or those that had undergone neck dissection were the most affected.

CONCLUSIONS

SCPL with CHEP as a surgical technique allows good control of the condition and has a low impact on the patient's quality of life.

Rationale and clinical validation of epidermal growth factor receptor as a target in the treatment of head and neck cancer

Recurrent/metastatic head and neck cancer is an area of high, unmet treatment need. There is a strong rationale for targeting the epidermal growth factor receptor (EGFR) in head and neck cancer as most of these tumors express high levels of EGFR relative to normal tissue, with high expression correlating with poor patient outcome. This rationale has been validated in extensive preclinical studies. Two small molecules with EGFR inhibitory activity, gefitinib ('Iressa', ZD1839) and erlotinib ('Tarceva', OSI-774), and a humanized monoclonal antibody against the EGFR extracellular domain, cetuximab ('Erbitux', C225), are in clinical trials for advanced head and neck cancer. The initial results of these trials are promising. Gefitinib and erlotinib show activity as monotherapy in patients with recurrent or metastatic head and neck cancer, and have an acceptable safety profile compared with conventional chemotherapy. Gefitinib, which can be given at doses below the maximum tolerated dose, is associated with slightly lower rates of adverse events than erlotinib, which is dosed at the maximum tolerated dose. Combinations of cetuximab with radiotherapy or platinum-based chemotherapy have also shown activity in phase I/II studies. Both gefitinib and cetuximab have entered phase III studies. The results of these trials, which will mature over the next few years, will help determine the optimal use of EGFR agents in head and neck cancers.

[Hypopharyngeal cancer: analysis of the evolution and surgical results]

OBJECTIVE

Hypopharyngeal carcinoma is an aggressive malignancy that usually presents at a late stage, thereby resulting in an overall poor prognosis for these patients. The aim of this study is to determine the evolution and postoperative results of patients treated in our department for hypopharyngeal cancer.

METHODS

We retrospectively reviewed 60 patients who had undergone surgery followed by radiation therapy between 1980-1999. Most of them were advanced stage (III-IV) and 75% patients showed regional metastases at presentation.

RESULTS

The 5-year survival rate was 38.4%. The overall incidence of distant metastases and second neoplasms was 12.5% and 10.4%.

CONCLUSIONS

Hypopharyngeal cancer remains one of the most lethal ones in head and neck cancer. The poor survival rate is related primary to advanced stage disease and particularly to lymph node metastases.

Impact of cancer occurrence on health-related quality of life: a longitudinal pre-post assessment

Background

Investigations focusing and implementing on the impact of cancer on health-related quality of life (HRQoL) by the way of a mean comparison between cancer patients and subjects from the general population, are scarce and usually cross-sectional. Longitudinal application of HRQoL instruments to a general, initially healthy population allows for change to be assessed as an event occurs, rather than afterwards. The objective of the present study was to investigate the impact of new cancer on HRQoL.

Methods

The 36-item Short Form (SF-36) and 12-item General Health Questionnaire (GHQ-12) were applied to the French SU.VI.MAX cohort in 1996 and 1998. A controlled longitudinal study was used to determine the impact on HRQoL of newly diagnosed cancer: 84 patients with cancer that occurred between the 2 HRQoL measures were compared with 420 age- and sex-matched cancer-free controls.

Results

Initial HRQoL level was similar in the two groups. A new cancer had a particularly marked effect on the SF-36 Physical functioning, Role-physical and General health dimensions (more than 6.6-point difference in change in HRQoL evolution on a 0–100 scale). The Bodily pain and Vitality dimensions were less severely affected (difference in change varying from 4.4 to 6.3 points), and there was no effect on either the GHQ-12 score or the SF-36 Mental health, Role-emotional and Social functioning dimensions.

Conclusions

The negative impact of cancer on the lives of patients was assessed in terms of HRQoL. The aspects most likely to be affected were those with a physical component, and general health perceptions. These results can thus help quantify the impact of a new cancer on HRQoL evolution and potentially facilitate early intervention by identifying the most affected HRQoL domains.

Depressive symptoms during and after radiotherapy for head and neck cancer

BACKGROUND

Patients with head and neck cancer are extraordinarily susceptible to depressive traits. Thus, a general screening of these patients at their first admission to the ital is desirable.

METHODS

From 1997-2001, 133 patients with head and neck tumors filled in the Self-Rating-Depression-Scale (SDS) at the beginning and end of radiotherapy (ti1/ti2), 6 weeks, and 6 months after radiotherapy (ti3/ti4). RESULTS.: The SDS index increased significantly from 46.44 (ti1) to 48.91(ti2) (p =.025) and then remained stable. The subdomain "somatic-eating-related symptoms" at ti1 was significantly lower than ti2 (p <.001). In contrast to inpatients, outpatients and those with conventional instead of hyperfractionated-accelerated radiotherapy were less impaired by eating-related symptoms. Patients with higher education showed a lower SDS index and cognitive scale. Marital status, tumor stage, histologic grading, and substance abuse had no influence.

CONCLUSIONS

Patients with a higher risk of depression should receive long-term monitoring during and after the end of radiotherapy, and prompt intervention strategies should be applied.

An exploration of the pretreatment coping strategies of patients with carcinoma of the head and neck

BACKGROUND

Patients with head and neck carcinoma (HNC) often face exhaustive and debilitating treatment as well as physical and functional residual effects, such as disfigurement, compromised speech, dry mouth, and difficulties swallowing. Understanding how patients cope with these challenges is important in comprehensive care of patients with HNC.

METHODS

Seventy-nine patients with HNC were assessed for quality of life (QOL) and coping strategy. Measures included the Functional Assessment of Cancer Therapy-Head and Neck, the Performance Status Scale for Head and Neck Cancer Patients, and the Ways of Coping-Cancer Version. Coping strategies were summarized and related to patient demographics and QOL.

RESULTS

The results suggested that patients with HNC used a wide range of coping strategies, with social support seeking behaviors representing the greatest proportion of total coping effort (25%). The use of avoidant coping strategies (both cognitive and behavioral escape) was associated with poorer overall QOL.

CONCLUSIONS

Although further examination of these issues in larger groups of patients with HNC is warranted, the current findings suggest the adaptability of this group of patients and the potential benefit of social support-based assistance or intervention.