The course of health-related quality of life from diagnosis to two years follow-up in patients with oropharyngeal cancer: does HPV status matter?

The course of health-related quality of life in the first 2 years after a diagnosis of head and neck cancer: the role of personal, clinical, psychological, physical, social, lifestyle, disease-related, and biological factors

PURPOSE

The aim of this prospective cohort study was to estimate the relationship between the course of HRQOL in the first 2 years after diagnosis and treatment of head and neck cancer (HNC) and personal, clinical, psychological, physical, social, lifestyle, HNC-related, and biological factors.

METHODS

Data were used from 638 HNC patients of the NETherlands QUality of life and BIomedical Cohort study (NET-QUBIC). Linear mixed models were used to investigate factors associated with the course of HRQOL (EORTC QLQ-C30 global quality of life (QL) and summary score (SumSc)) from baseline to 3, 6, 12, and 24 months after treatment.

RESULTS

Baseline depressive symptoms, social contacts, and oral pain were significantly associated with the course of QL from baseline to 24 months. Tumor subsite and baseline social eating, stress (hyperarousal), coughing, feeling ill, and IL-10 were associated with the course of SumSc. Post-treatment social contacts and stress (avoidance) were significantly associated with the course of QL from 6 to 24 months, and social contacts and weight loss with the course of SumSc. The course of SumSc from 6 to 24 months was also significantly associated with a change in financial problems, speech problems, weight loss, and shoulder problems between baseline and 6 months.

CONCLUSION

Baseline clinical, psychological, social, lifestyle, HNC-related, and biological factors are associated with the course of HRQOL from baseline to 24 months after treatment. Post-treatment social, lifestyle, and HNC-related factors are associated with the course of HRQOL from 6 to 24 months after treatment.

Pretreatment pain predicts perineural invasion in patients with head and neck squamous cell carcinoma

OBJECTIVES

Perineural invasion (PNI) in head and neck cancer (HNC) is a distinct pathological feature used to indicate aggressive tumor behavior and drive treatment strategies. Our study examined the prevalence and predictors of PNI in HNC patients stratified by tumor site.

STUDY DESIGN AND METHODS

A retrospective analysis of head and neck squamous cell carcinoma (HNSCC) patients who underwent surgical resection at the University of Pittsburgh Medical Center between 2015 and 2018 was performed. Pretreatment pain was assessed at least 1 week before surgery using the Functional Assessment of Cancer Therapy-Head and Neck (FACT-H&N). Demographics, clinical characteristics, and concomitant medications were obtained from medical records. Patients with cancers at the oropharynx and non-oropharynx (i.e., cancer at oral cavity, mandible, larynx) sites were separately analyzed. Tumor blocks were obtained from 10 patients for histological evaluation of intertumoral nerve presence.

RESULTS

A total of 292 patients (202 males, median age = 60.94 ± 11.06) were assessed. Pain and PNI were significantly associated with higher T stage (p < 0.001) and tumor site (p < 0.001); patients with non-oropharynx tumors reported more pain and had a higher incidence of PNI compared to oropharynx tumors. However, multivariable analysis identified pain as a significant variable uniquely associated with PNI for both tumor sites. Evaluation of nerve presence in tumor tissue showed 5-fold higher nerve density in T2 oral cavity tumors compared to oropharyngeal tumors.

CONCLUSIONS

Our study finds that PNI is associated with pretreatment pain and tumor stage. These data support the need for additional research into the impact of tumor location when investigating targeted therapies of tumor regression.

Oral health-related quality of life after radiation therapy for head and neck cancer: the OraRad study

PURPOSE

Head and neck cancer (HNC) treatment results in morbidity impacting quality of life (QOL) in survivorship. This analysis evaluated changes in oral health-related QOL (OH-QOL) up to 2 years after curative intent radiation therapy (RT) for HNC patients and factors associated with these changes.

METHODS

572 HNC patients participated in a multicenter, prospective observational study (OraRad). Data collected included sociodemographic, tumor, and treatment variables. Ten single-item questions and 2 composite scales of swallowing problems and senses problems (taste and smell) from a standard QOL instrument were assessed before RT and at 6-month intervals after RT.

RESULTS

The most persistently impacted OH-QOL variables at 24 months included: dry mouth; sticky saliva, and senses problems. These measures were most elevated at the 6-month visit. Aspects of swallowing were most impacted by oropharyngeal tumor site, chemotherapy, and non-Hispanic ethnicity. Problems with senses and dry mouth were worse with older age. Dry mouth and sticky saliva increased more among men and those with oropharyngeal cancer, nodal involvement, and use of chemotherapy. Problems with mouth opening were increased by chemotherapy and were more common among non-White and Hispanic individuals. A 1000 cGy increase in RT dose was associated with a clinically meaningful change in difficulty swallowing solid food, dry mouth, sticky saliva, sense of taste, and senses problems.

CONCLUSIONS

Demographic, tumor, and treatment variables impacted OH-QOL for HNC patients up to 2 years after RT. Dry mouth is the most intense and sustained toxicity of RT that negatively impacts OH-QOL of HNC survivors.

CLINICALTRIALS

GOV IDENTIFIER

NCT02057510; first posted February 7, 2014.

Patient-Reported Outcome Measures of Psychosocial Quality of Life in Oropharyngeal Cancer Patients: A Scoping Review

Background: Oropharyngeal squamous cell carcinoma (OPSCC) patients are burdened by the effect of the disease process and treatment toxicities on organs important in everyday activities, such as breathing, speaking, eating, and drinking. There is a rise in OPSCC due to human papilloma virus (HPV)-associated OPSCC, affecting younger and healthier patients and with a better overall prognosis. Emphasis must be shared between oncologic outcomes and the effects on quality of life. While there have been efforts to study global and physical quality of life, the impact on psychosocial quality of life has not yet been specifically reviewed. Methods: A scoping review methodology was employed to explore the emotional, social, and mental quality of life in OPSCC patients and determine the impact of HPV status or treatment modalities. Results: Eighty-seven full-text articles were evaluated for eligibility. Fifteen articles met final inclusion criteria. The majority of the studies were conducted in the United States (n = 10) and study methodology was divided between cross-sectional (n = 6), prospective (n = 5), and retrospective studies (n = 4). Four psychosocial quality of life themes were explored: the impact on mental health and emotional wellbeing, social wellbeing and function, stress, and relationship and sexual behavior. Eighteen different patient-reported outcome measures were used, including both general head and neck oncology questionnaires and symptom-specific surveys. Conclusion: There is a paucity of research regarding the effect of OPSCC on patients' psychosocial quality of life. Learning more about this component of quality of life can guide outreach programs and multidisciplinary involvement in improving patient care.

Surgical Treatment for Advanced Oropharyngeal Cancer: A Narrative Review

Background and Objectives: to describe current scientific knowledge regarding the treatment options in advanced oropharyngeal cancer. The standard care for advanced oropharyngeal cancer (OPSCC) has been chemoradiotherapy, although surgical approaches followed by adjuvant treatment have been proposed. The best therapy for each patient should be decided by an interdisciplinary tumour-board. Different strategies should be considered for the specific patient's treatment: surgery, chemotherapy and radiation therapy or combinations of them. The treatment choice is influenced by tumour variability and prognostic factors, but it also depends on cancer extension, extranodal extension, nervous invasion, human papilloma virus (HPV) presence, making the decisional algorithm not always clear. HPV-related OPSCC is strongly associated with a favourable overall survival (OS) and disease-free survival rate (DSS); by contrast, HPV-negative OPSCC often flags a worse prognosis. Consequently, the American Joint Committee on Cancer (AJCC) differentiates OPSCC treatment and prognosis based on HPV status. Methods: we carried out a review of current scientific literature to analyze the different indications and limitations of surgical treatment options in OPSCC stage III and IV. Conclusion: robotic surgery or open approaches with reconstructive flaps can be considered in advanced stages, resulting in the de-intensification of subsequent systemic therapy and fewer related side effects. Furthermore, in the event of the primary failure of systemic therapy or disease recurrence, the surgical approach constitutes an additional therapeutic option which lengthens patient survival functions.

Evaluation of Concomitant Systemic Treatment in Older Adults With Head and Neck Squamous Cell Carcinoma Undergoing Definitive Radiotherapy

IMPORTANCE

The number of older adults with head and neck squamous cell carcinoma (HNSCC) is increasing, and these patients are underrepresented in clinical trials. It is unclear whether the addition of chemotherapy or cetuximab to radiotherapy is associated with improved survival in older adults with HNSCC.

OBJECTIVE

To examine whether the addition of chemotherapy or cetuximab to definitive radiotherapy is associated with improved survival in patients with locoregionally advanced (LA) HNSCC.

DESIGN, SETTING, AND PARTICIPANTS

The Special Care Patterns for Elderly HNSCC Patients Undergoing Radiotherapy (SENIOR) study is an international, multicenter cohort study including older adults (≥65 years) with LA-HNSCCs of the oral cavity, oropharynx/hypopharynx, or larynx treated with definitive radiotherapy, either alone or with concomitant systemic treatment, between January 2005 and December 2019 at 12 academic centers in the US and Europe. Data analysis was conducted from June 4 to August 10, 2022.

INTERVENTIONS

All patients underwent definitive radiotherapy alone or with concomitant systemic treatment.

MAIN OUTCOMES AND MEASURES

The primary outcome was overall survival. Secondary outcomes included progression-free survival and locoregional failure rate.

RESULTS

Among the 1044 patients (734 men [70.3%]; median [IQR] age, 73 [69-78] years) included in this study, 234 patients (22.4%) were treated with radiotherapy alone and 810 patients (77.6%) received concomitant systemic treatment with chemotherapy (677 [64.8%]) or cetuximab (133 [12.7%]). Using inverse probability weighting to attribute for selection bias, chemoradiation was associated with longer overall survival than radiotherapy alone (hazard ratio [HR], 0.61; 95% CI, 0.48-0.77; P < .001), whereas cetuximab-based bioradiotherapy was not (HR, 0.94; 95% CI, 0.70-1.27; P = .70). Progression-free survival was also longer after the addition of chemotherapy (HR, 0.65; 95% CI, 0.52-0.81; P < .001), while the locoregional failure rate was not significantly different (subhazard ratio, 0.62; 95% CI, 0.30-1.26; P = .19). The survival benefit of the chemoradiation group was present in patients up to age 80 years (65-69 years: HR, 0.52; 95% CI, 0.33-0.82; 70-79 years: HR, 0.60; 95% CI, 0.43-0.85), but was absent in patients aged 80 years or older (HR, 0.89; 95% CI, 0.56-1.41).

CONCLUSIONS AND RELEVANCE

In this cohort study of older adults with LA- HNSCC, chemoradiation, but not cetuximab-based bioradiotherapy, was associated with longer survival compared with radiotherapy alone.

The changing face of head and neck cancer: are patients with human papillomavirus-positive disease at greater nutritional risk? A systematic review

PURPOSE

Human papillomavirus (HPV) is now the primary cause of oropharyngeal head and neck cancer (OPC) worldwide; yet limited research has examined the effect of HPV-positive status (OPC+) on nutrition outcomes. This study aims to determine the impact of HPV status on nutritional outcomes for adult patients with OPC undergoing any treatment modality.

METHODS

A systematic literature review was conducted up to and including July 2021 of PubMed, Embase, CENTRAL, CINAHL, and Web of Science to identify studies conducted in adults (>18 years) with known OPC reporting on any outcome(s) related to nutrition, according to HPV status (OPC+ versus OPC-). Bias was assessed using QUIPS tool, with certainty of evidence assessed using GRADE system.

RESULTS

Six studies (total n = 635) all at moderate-high risk of bias were included. Three studies reported on weight change (n = 255), three feeding tube dependency (n = 380), three feeding tube timing of placement (prophylactic or reactive) and/or utilisation (n = 255), two nutritional (energy and/or protein) intake (n = 230), and one nutritional status (n = 83). Patients with OPC+ may experience greater weight loss, may have higher utilisation of reactive feeding tubes (both GRADE low certainty, downgraded due to serious bias and imprecision), and may have lower feeding tube dependency rates (GRADE low certainty, downgraded due to serious bias and inconsistency) versus OPC- . It is uncertain whether nutritional intake and nutritional status differed between populations (GRADE very low certainty, downgraded due to serious bias and very serious imprecision).

CONCLUSION

Further, high-quality research is needed to understand optimal nutritional care practices for patients with OPC + to achieve positive health outcomes into survivorship.

Basaloid Squamous Cell Carcinoma, an Aggressive and Rare Cancer of the Oral Cavity: Can We Prevent It at the Primary Care Setting?

Oral cavity cancer represents about 2%-3% of all cancers worldwide, with more than 355,000 new cases per year, one-third of which are reported in developed countries. Oral cancer is also known to be extremely aggressive when detected late, thus presenting one of the lowest cancer survival rates. It is estimated that as much as 90% of oral cancers are attributable to tobacco and/or alcohol consumption and that high-risk human papillomaviruses (HPV) infections pose an independently increased risk for their development. Therefore, it can be a preventable disease when associated with changes in lifestyle and possible modifiable risk factors, combined with early and preventive intervention. Basaloid squamous cell carcinoma (BSCC) constitutes an aggressive and rare form of oral cancer, being one of the rarest and most aggressive variants of squamous cell carcinoma (SCC, the most common), and usually presents as a high-grade disease with a poor prognosis. It is typically associated with heavy smoking and alcohol abuse, occurring most commonly in older men. Here, we report a clinical case of a 60-year-old man with excessive consumption of both tobacco and alcohol, poor oral hygiene, and partial edentulousness who came to our primary health department with complaints of odynophagia twice in a four-year time-lapse. The first time, two whitish ulcerated lesions on the left tonsil were detected and biopsied but revealed a negative histological result. After four years, he came again to our primary health care department with similar complaints of odynophagia and also sore throat with radiation to the right ear, accompanied by globus sensation and anorexia. No suspicious lesions were detected, except a globally hyperemic oropharynx. Considering the history of abusive consumption, no improvement with symptomatic treatment, and persistent clinical signs, an extended diagnostic approach was carried out. After four months, a pharyngeal mass measuring 53 mm was detected on pharyngeal-neck computed tomography (CT), and the diagnosis of a BSCC located in the right tonsillar pillar and base of the tongue was finally determined. Unlike other cancers that have been detected earlier through screening programs, oral cancer is often detected at an advanced stage, compromising survival and quality of life. The opportunity to intervene early and preventively in consumption habits, promote healthy lifestyles, and try to prevent disease is unique at the primary care level. Moreover, opportunistic screening through a thorough examination of the oral cavity is extremely important for timely diagnosis and treatment.

Understanding the Pattern of Oropharyngeal Cancers from North-East Romanian Patients

Background: Human papilloma virus (HPV) is acknowledged as a risk factor for oropharyngeal squamous cellular cancers (OPSCC), of which the dominant types are tonsillar (TSCC) and base of tongue cancer (BOTSCC). Objective: To assess the role of HPV in selected OPSCC cases, from Romanian patients by sensitive and complementary molecular assays. Material and Methods: Fifty-four formalin fixed paraffin embedded (FFPE) OPSCC samples were analyzed for HPV DNA by a PCR-based bead-based multiplex-assay. Thirty-four samples were tested for HPV RNA and for overexpression of p16INK4a by immunohistochemistry. Twenty samples were evaluated by Competitive Allele-Specific Taqman PCR (CAST-PCR) for fibroblast growth factor receptor 3 protein (FGFR3) status. Results: A total of 33.3% (18/54) OPSCC samples were positive for HPV DNA. HPV16 was the most frequent type (30%, 16/54); followed by HPV18 (3.7%, 2/54); and 1 sample (1.8%) was positive for both HPV16 and 18. HPV18 E6*I was detected in a HPV18 DNA-positive oropharynx tumor. Four samples positive for HPV16 were also positive for p16INK4a. All the tested samples were negative for FGFR3. Conclusions: The increased HPV16 prevalence is in line with similar studies and is a new confirmation that HPV16 is the most prevalent type in our country; supporting the potential benefit of prophylactic vaccines. Overall, there is no concordance between DNA and any of the two other analytes that are considered being markers of HPV-driven cancers. There is a need to explore novel screening strategies that could be broadly used in the clinical routine to initiate preventive measures.

Association of Deficits Identified by Geriatric Assessment With Deterioration of Health-Related Quality of Life in Patients Treated for Head and Neck Cancer

Importance

Accumulation of geriatric deficits, leading to an increased frailty state, makes patients susceptible for decline in health-related quality of life (HRQOL) after treatment for head and neck cancer (HNC).

Objective

To assess the association of single and accumulated geriatric deficits with HRQOL decline in patients after treatment for HNC.

Design, Setting, and Participants

Between October 2014 and May 2016, patients at a tertiary referral center were included in the Oncological Life Study (OncoLifeS), a prospective data biobank, and followed up for 2 years. A consecutive series of 369 patients with HNC underwent geriatric assessment at baseline; a cohort of 283 patients remained eligible for analysis, and after 2 years, 189 patients remained in the study. Analysis was performed between March and November 2020.

Interventions or Exposures

Geriatric assessment included scoring of the Adult Comorbidity Evaluation 27, polypharmacy, Malnutrition Universal Screening Tool, Activities of Daily Living, Instrumental Activities of Daily Living (IADL), Timed Up & Go, Mini-Mental State Examination, 15-item Geriatric Depression Scale, marital status, and living situation.

Main Outcomes and Measures

The primary outcome measure was the Global Health Status/Quality of Life (GHS/QOL) scale of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30. Differences between patients were evaluated using linear mixed models at 3 months after treatment (main effects, β [95% CI]) and declining course per year during follow-up (interaction × time, β [95% CI]), adjusted for baseline GHS/QOL scores, and age, sex, stage, and treatment modality.

Results

Among the 283 patients eligible for analysis, the mean (SD) age was 68.3 (10.9) years, and 193 (68.2%) were male. Severe comorbidity (β = -7.00 [-12.43 to 1.56]), risk of malnutrition (β = -6.18 [-11.55 to -0.81]), and IADL restrictions (β = -10.48 [-16.39 to -4.57]) were associated with increased GHS/QOL decline at 3 months after treatment. Severe comorbidity (β = -4.90 [-9.70 to -0.10]), IADL restrictions (β = -5.36 [-10.50 to -0.22]), restricted mobility (β = -6.78 [-12.81 to -0.75]), signs of depression (β = -7.08 [-13.10 to -1.06]), and living with assistance or in a nursing home (β = -8.74 [-15.75 to -1.73]) were associated with further GHS/QOL decline during follow-up. Accumulation of domains with geriatric deficits was a major significant factor for GHS/QOL decline at 3 months after treatment (per deficient domain β = -3.17 [-5.04 to -1.30]) and deterioration during follow-up (per domain per year β = -2.74 [-4.28 to -1.20]).

Conclusions and Relevance

In this prospective cohort study, geriatric deficits were significantly associated with HRQOL decline after treatment for HNC. Therefore, geriatric assessment may aid decision-making, indicate interventions, and reduce loss of HRQOL.

Trial Registration

trialregister.nl Identifier: NL7839.