Influence of deprivation on health-related quality of life of patients with cancer of the head and neck in Merseyside and Cheshire

Survival Outcomes of Total Laryngectomy: Evaluating the Intersection of Race and Social Determinants

OBJECTIVE

Analyze joint effects of race and social determinants on survival outcomes for patients undergoing total laryngectomy for advanced or recurrent laryngeal cancer at a tertiary care institute.

METHODS

Retrospective chart review of adult patients undergoing total laryngectomy for laryngeal cancer at a tertiary care center from 2013 to 2020. Extracted data included demographics, pathological staging and features, treatment modalities, and outcomes such as recurrence, fistula formation, and 2- and 5-year disease-free survival (DFS) and overall survival (OS). Area Deprivation Index (ADI) was calculated for each patient.

RESULTS

Among 185 patients identified, 113 were Black (61.1%) and 69 were White (37.3%). No significant differences were observed between racial groups regarding age, gender, ADI, or cancer stage. There was no significant difference in 2-year DFS/OS between groups. ADI was comparable between racial groups, with the majority in the highest deprivation quintile (63.8% of Whites vs. 62.5% of Blacks). No significant differences were observed in gender, race, cancer stage, positive margins, extracapsular extension, or smoking status among ADI quintiles. We observed a significant difference in 2-year DFS stratified by ADI (p = 0.025). Stratifying by ADI and race revealed improved survival of White patients in lower quintiles but higher survival of Black patients in the highest disparity quintile (p = 0.013).

CONCLUSION

Overall, survival outcomes by race were comparable among laryngectomy patients, but there was a significant difference in 2-year DFS when stratified by ADI. Further research into survival outcomes related to social determinants is needed to better delineate their effects on head and neck cancer outcomes.

LEVEL OF EVIDENCE

3 Laryngoscope, 2024.

Health-Related Quality of Life, Psychosocial Distress and Unmet Needs in Older Patients With Head and Neck Cancer

Head and neck squamous cell carcinoma (HNSCC) is the most common cancer involving the mucosal surfaces of the head and neck and is associated with a number of etiological factors, including cigarette smoking, alcohol and betel nut consumption and exposure to high-risk human papillomavirus. The risk of HNSCC increases with age, peaking in the seventh and eighth decade, but this varies by anatomical and histological subtype. While several advancements have been made in the treatment of head and neck cancer (HNC) in recent decades, undertaking curative treatment still subjects the majority of HNSCC patients to substantial treatment-related toxicity requiring patients to tolerate a gamut of physical, psychological, and emotional demands on their reserves. In conjunction with other patient-related factors, clinicians involved in treating patients with HNSCC may incorporate advancing chronological age into their decision-making process when determining treatment recommendations. While advancing chronological age may be associated with increased concerns regarding physical treatment tolerability, clinicians may also be concerned about heightened vulnerability in various health and wellbeing outcomes. The available literature, however, does not provide evidence of this vulnerability in patients with advancing age, and, in many instances, older patients self-report greater resilience compared to their younger counterparts. While this data is reassuring it is limited by selection bias and heterogeneity in trial and study design and the absence of a consistent definition of the elderly patient with HNSCC. This narrative review article also includes a review of the measures used to assess HRQL, psychosocial outcomes and unmet needs in elderly or older patients with HNSCC.

Associations between markers of social functioning and depression and quality of life in survivors of head and neck cancer: Findings from the Head and Neck Cancer 5000 study

OBJECTIVE

To investigate associations between markers of social functioning (trouble with social eating and social contact), depression and health-related quality of life (QOL) among head and neck cancer survivors.

METHODS

This cross-sectional analysis included individuals with oral cavity, oropharynx, larynx, salivary gland and thyroid cancers from Head and Neck 5000 alive at 12 months. Trouble with social eating and social contact were measured using items from EORTC QLQ-H&N35 and QOL using EORTC QLQ-C30; responses were converted into a score of 0-100, with a higher score equalling more trouble or better QOL. A HADS subscale score of ≥8 was considered significant depression. Associations between tertiles of trouble with social eating and social contact and depression and QoL were assessed using multivariable logistic and linear regression (with robust errors), respectively.

RESULTS

Of 2561 survivors, 23% reported significant depression. The median QOL score was 75.0 (interquartile range 58.3-83.3). For trouble with social eating, after confounder adjustment, those in the intermediate and highest tertiles had higher odds of depression (intermediate: OR = 4.5, 95% CI 3.19-6.45; high: OR = 21.8, 15.17-31.18) and lower QOL (intermediate:β = -8.7, 95% CI -10.35 to -7.14; high: β = -24.8, -26.91 to -22.77). Results were similar for trouble with social contact.

CONCLUSION

We found strong clinically important associations between markers of social functioning and depression and QOL. More effective interventions addressing social eating and contact are required. These may help survivors regain their independence, reduce levels of isolation and loneliness, and depression, and improve QOL outcomes generally.

Which Head and Neck Cancer Patients Are Most at Risk of High Levels of Fear of Cancer Recurrence

Background: Fear of cancer recurrence (FCR) is recognized as a common concern for patients with head and neck cancer (HNC). The aim of this study is to describe in greater detail the demographic and clinical characteristics of HCN patients who indicate a high level of FCR in their review consultation.

Methods: A pragmatic cluster-controlled trial was conducted between January 2017 and December 2018 at two UK HNC centers (Leeds and Liverpool) to test the efficacy of a prompt tool called the Patient Concerns Inventory (PCI). Patients completed the PCI and the UW-QOLv4 which included a single 5 category rating of FCR. Secondary statistical analyses focused on variables associated with high FCR.

Results: Two hundred and eighty-eight trial patients were recruited in this trial. At a median of 194 days after diagnosis and 103 days after the end of treatment 8% stated (n = 24) “I get a lot of fears of recurrence and these can really preoccupy my thoughts” and 3% (n = 8) “I am fearful all the time that my cancer might return, and I struggle with this.” Thus, 11% (n = 32) responded in the worst two categories, 95% Confidence interval 7.7–15.3% for high FCR. Stepwise logistic regression resulted in female gender (p < 0.001), age (p = 0.007), and receiving financial benefits (p = 0.01) as independent predictors.

Conclusions: Around one in ten HNC patients attending routine outpatient follow-up consultations report high FCR, however for female patients under the age of 55 the rate was one in three. This group requires specialist attention and could be the focus of a multicenter intervention trial.

Fear of Cancer Recurrence in Survivors of Human Papillomavirus-Associated Oropharyngeal Carcinoma

PURPOSE

To estimate the prevalence of and characteristics associated with fear of cancer recurrence (FCR) among human papillomavirus (HPV)-associated oropharyngeal cancer (OPC) survivors.

METHODS AND MATERIALS

We conducted a cross-sectional study in HPV-OPC survivors ≥12 months from completion of definitive (chemo)radiation therapy (RT/CRT). Eligible patients completed the Fear of Cancer Recurrence Inventory short-form (FCRI-SF), the European Organisation for research and Treatment of Cancer QLQ-C30, MD Anderson Symptom Inventory-Head and Neck, and PROMIS Anxiety and Depression short forms. Associations between FCRI-SF scores and other variables were investigated using linear regression models.

RESULTS

A total of 136 HPV-OPC survivors were enrolled; the median age was 61 years (range, 42-87 years), 84% were male, 72% were currently partnered, 83% were current nonsmokers, 67% were regular alcohol consumers, and the median time since treatment was 2.8 years (range, 1.0-5.5 years). Clinical levels of FCR (≥13) were observed in 72 of 135 patients (53%; 95% confidence interval [CI], 45%-62%). Characteristics significantly associated with increasing FCR scores were younger age (-0.9/5 years; 95% CI, -1.7 to -0.01; P = .031), lower global quality of life (-0.8/10 unit increase; 95% CI, -1.4 to -0.2; P = .012), higher symptom interference (0.8/unit increase; 95% CI, 0.1-1.5; P = .017), and a higher burden of anxiety (0.4/unit; 95% CI, 0.3-0.5; P <.001) and depression (0.3/unit; 95% CI, 0.1-0.4; P <.001). Other sociodemographic tumor- and treatment-related characteristics were not statistically significant. Compared with patients reporting nonclinical levels of FCR, significantly more patients reporting clinical levels of FCR than expected believed professional psychological assistance would have been beneficial (60% vs 33%; P = .002).

CONCLUSIONS

Clinical levels of FCR were observed in approximately half of the HPV-OPC survivors. Survivors reporting higher FCR were younger with worse self-reported global quality of life and higher symptom interference and emotional distress. No other patient, tumor, or treatment factors were associated with higher FCR.

Trends in, and predictors of, swallowing and social eating outcomes in head and neck cancer survivors: A longitudinal analysis of head and neck 5000

OBJECTIVE

To investigate the recovery trajectory and predictors of outcome for swallowing difficulties following head and neck cancer treatment in a large prospective cohort.

MATERIALS AND METHODS

Data from 5404 participants of the Head and Neck 5000 study were collected from 2011 to 2014. Patient-reported swallowing was measured using the EORTC HN35, recorded at baseline (pre-treatment) and 4 and 12 months post-baseline. Mixed-effects linear multivariable regression was used to investigate time trends, compare cancer sites, and identify associations between clinical, socio-demographic and lifestyle variables.

RESULTS

2458 participants with non-recurrent oral (29%) oropharyngeal (46%) and laryngeal (25%) cancer were included in the analysis. There was a clinically significant deterioration in scores between baseline and four months for swallowing (11.7 points; 95% CI 10.7-12.8) and trouble with social eating (17.9 points; 95% CI 16.7-19.2), but minimal difference between baseline and 12 months. Predictors of better swallowing and social eating were participants with larynx cancer, early-stage disease, treatment type, age, gender, co-morbidity, socio-economic status, smoking behaviour and cohabitation.

CONCLUSION

Swallowing problems persist up to a year after head and neck cancer treatment. These findings identify disease and demographic characteristics for particularly vulnerable groups, supporting the need for holistic interventions to help improve swallowing outcomes. People diagnosed with head and neck cancer at risk of severe eating and drinking problems following treatment can be identified earlier in the pathway, receive more accurate information about early and late post-treatment side-effects, which can inform shared decision-making discussions.

What are the underlying reasons behind socioeconomic differences in doctor-patient communication in head and neck oncology review clinics?

OBJECTIVE

To explore socioeconomic status (SES) differences in patterns of doctor-patient communication within head and neck cancer clinics and why such differences exist.

METHODS

Thirty-six head and neck cancer review appointments with five Physicians were observed and audio-taped, along with follow-up interviews involving 32 patients. Data were analysed using Thematic Analysis, and compared by patient SES (education, occupation and Indices of Multiple Deprivation).

RESULTS

Three main themes were identified: (a) Physicians used more humour and small talk in their consultations with high SES patients; (b) Low SES patients were more passive in their participation, engaged in less agenda setting and information-seeking, and framed their clinical experience differently; (c) Low SES patients had different preferences for involvement, defining involvement differently to high SES patients and were seen to take a more stoical approach.

CONCLUSION

Low SES patients take a more passive role in medical consultations, engage in less relational talk and are less likely to raise concerns, but were satisfied with this. Physicians may adapt their communication behaviour in response to low SES patients' expectations and preferences.

PRACTICE IMPLICATIONS

A question prompt list may help low SES patients to raise concerns during their consultations. This may reduce inequalities in communication and health.

Health literacy impacts self-management, quality of life and fear of recurrence in head and neck cancer survivors

PURPOSE

Little is known about whether health literacy is associated with affects certain key outcomes in head and neck cancer (HNC) survivors. We investigated (i) the socio-demographic and clinical profile of health literacy and (ii) associations among between health literacy and self-management behaviours, health-related quality of life (HRQL) and fear of recurrence (FoR) in HNC survivors.

METHODS

A population-based survey was conducted in Ireland. Health literacy was assessed using a validated single-item question. Socio-demographic, clinical and psychosocial outcome variables (FoR, self-management behaviours, HRQL) were collected. Multivariable linear regression was performed to estimate associations between health literacy and each psychosocial outcome.

RESULTS

Three hundred ninety-five (50%) individuals responded to the survey. Inadequate health literacy was evident among 47% of the sample. In adjusted models, HNC survivors with inadequate health literacy had significantly lower levels of self-management behaviours in the domains of health-directed behaviour, positive and active engagement in life, self-monitoring and insight, constructive attitudes and approaches and skills and technique acquisition. Inadequate health literacy was independently associated with lower functional well-being and HNC disease-specific HRQL. FoR was also significantly higher among those with inadequate health literacy.

CONCLUSIONS

HNC survivors with inadequate health literacy have lower levels of self-management behaviours, lower functional HRQL and increased FoR compared to those with adequate health literacy.

IMPLICATIONS FOR CANCER SURVIVORS

Clinicians, healthcare providers and those developing interventions should consider how inadequate health literacy among HNC survivors might affect post-treatment outcomes when developing services and providing support for this group.

Health anxiety and illness-related fears across diverse chronic illnesses: A systematic review on conceptualization, measurement, prevalence, course, and correlates

BACKGROUND

Patients with chronic diseases commonly report fears of illness or symptoms recurring or worsening. These fears have been addressed from an illness-specific perspective (e.g., fear of cancer recurrence), a generic illness perspective (e.g., fear of progression), and a psychiatric perspective (DSM-5 illness anxiety disorder and somatic symptom disorder). The broader concept of health anxiety (HA) can also be applied to patients with a chronic disease. This review was conducted to investigate the conceptual, theoretical, measurement-overlap, and differences between these distinct perspectives. We also aimed to summarize prevalence, course, and correlates of these fears in different chronic illnesses.

METHODS

We used PsycINFO, PubMED, CINAHL, Web of Science, SCOPUS, and PSYNDEX to conduct a systematic review of studies pertaining to these fears in chronic illness published from January 1996 to October 2017. A total of 401 articles were retained.

RESULTS

There were commonalities across different conceptualizations and diseases: a high prevalence of clinical levels of fears (>20%), a stable course over time, and a deleterious impact on quality of life. Reviewed studies used definitions, models, and measures that were illness-specific, with only a minority employing a psychiatric perspective, limiting cross-disease generalizability. There appears to be some applicability of DSM-5 disorders to the experience of fear of illness/symptoms in patients with a chronic illness. While conceptualizing HA on a continuum ranging from mild and transient to severe may be appropriate, there is a lack of agreement about when the level of fear becomes 'excessive.' The definitions, models, and measures of HA across chronic illnesses involve affective, cognitive, behavioral, and perceptual features.

CONCLUSIONS

The concept of HA may offer a unifying conceptual perspective on the fears of illness/symptoms worsening or returning commonly experienced by those with chronic disease.

Depressive symptoms in relation to overall survival in people with head and neck cancer: A longitudinal cohort study

OBJECTIVE

The objective of the study is to investigate the relation between pretreatment depressive symptoms (DS) and the course of DS during the first year after cancer diagnosis, and overall survival among people with head and neck cancer (HNC).

METHODS

Data from the Head and Neck 5000 prospective clinical cohort study were used. Depressive symptoms were measured using the Hospital Anxiety and Depression Scale (HADS) pretreatment, at 4 and 12-month follow-up. Also, socio-demographic, clinical, lifestyle, and mortality data were collected. The association between before start of treatment DS (HADS-depression > 7) and course (never DS, recovered from DS, or persistent/recurrent/late DS at 12-month follow-up) and survival was investigated using Cox regression. Unadjusted and adjusted analyses were performed.

RESULTS

In total, 384 of the 2144 persons (18%) reported pretreatment DS. Regarding DS course, 63% never had DS, 16% recovered, and 20% had persistent/recurrent/late DS. People with pretreatment DS had a higher risk of earlier death than people without DS (hazard ratio (HR) = 1.65; 95% confidence interval (CI) 1.33-2.05), but this decreased after correcting for socio-demographic, clinical, and lifestyle-related factors (HR = 1.21; 95% CI 0.97-1.52). Regarding the course of DS, people with persistent/recurrent/late DS had a higher risk of earlier death (HR = 2.04; 95% CI 1.36-3.05), while people who recovered had a comparable risk (HR = 1.12; 95% CI 0.66-1.90) as the reference group who never experienced DS. After correcting for socio-demographic and clinical factors, people with persistent/recurrent/late DS still had a higher risk of earlier death (HR = 1.66; 95% CI 1.09-2.53).

CONCLUSIONS

Pretreatment DS and persistent/recurrent/late DS were associated with worse survival among people with HNC.

Relationship between Tobacco Craving and Quality of Life among French Students: Results of a Cross-Sectional Study

BACKGROUND

Understanding the factors leading to smoking cessation is of primary importance in reducing the death burden. Recently introduced in the DSM-5, craving is a potentially promising mechanism involved in relapse, but its articulation with quality of life and deprivation on tobacco student's consumers has never been investigated.

OBJECTIVES

Our study explores the relationship between tobacco craving and sub-dimensions of quality of life when controlling effect of deprivation on a youth population with tobacco consumption.

METHOD

Comparison between deprived and non-deprived students were conducted with online questionnaires on demographic data, level of dependency, perceived quality of life, deprivation and craving. Multivariate linear regression with backward procedure was conducted to assess the predictive validity of these variables on craving. Finally, Bayesian analysis was conducted to evaluate the model proposed by the regression.

RESULTS

One hundred and seventy-four participants were included. Craving was significantly correlated with all the other variables and increases when the level of deprivation rises, while it decreases when physical health improves. These results are confirmed by Bayesian linear regression. Conclusions/Importance: Environmental and social factors are usually overlooked when it comes to understanding individuals, deeply rooted biological mechanisms such as craving. Working on physical health is of interest to diminished craving and improves the quality of life during smoking cessation and thereby to support success on the student population. Consequences for the triadic neurocognitive model of addiction are discussed.

Is social inequality related to different patient concerns in routine oral cancer follow-up clinics?

Oral cancer has a higher incidence in the lower social strata, and these patients are less likely to engage in supportive interventions and report a poorer quality of life (QoL). The aim of this paper is to compare the Patient Concerns Inventory (PCI) responses across social groups attending routine oral cancer follow-up clinics with particular focus on the deprivation lower quartile. The PCI package is completed by patients as part of their routine review consultation with SNR. Patients were those diagnosed between 2008 and 2012. Deprivation was stratified using the IMD 2010 from postcode. Of the 106 eligible patients, 85 % used the PCI. Just over half (54 %) were living in the most deprived quartile, with two-thirds (68 %) of males in the most deprived quartile, compared with 35 % of females (p = 0.004). In regard to number and type of PCI items selected by patients at their first PCI clinic, there were no notable differences in respect of IMD classification. The two commonest concerns were fear of recurrence (43 %) and sore mouth (43 %). The most deprived quartile reported significant problems in regard to mood (p = 0.004) and recreation (p = 0.02), and a non-significant trend (36 vs 18 %, p = 0.09) in stating their overall QoL as being less than good. It is possible to identify the concerns of patients from lower socioeconomic strata as part of routine follow-up clinics. This allows for targeted multi-professional intervention and supports to improve the outcome in this hard to reach group.