Change in symptom clusters in head and neck cancer patients undergoing postoperative radiotherapy: A longitudinal study

Symptom Patterning Across the Cancer Care Trajectory for Patients Receiving Chemoradiation for Head and Neck Cancer: A Retrospective Longitudinal Study Using Latent Transition Analysis

BACKGROUND

Patients with head and neck cancer (HNC) experience a multitude of symptoms because of the tumor and its treatment.

OBJECTIVE

To identify the symptom patterns present in cancer treatment and survivorship periods for patients with HNC using latent class analysis.

METHODS

A retrospective longitudinal chart review was conducted to examine symptoms reported by patients who received concurrent chemoradiation for HNC in a regional Northeastern United States cancer institute. Latent class analysis was performed to identify the latent classes present across multiple timepoints during treatment and survivorship for the most commonly reported symptoms.

RESULTS

In 275 patients with HNC, the latent transition analysis revealed 3 latent classes for both treatment and survivorship periods: (1) mild, (2) moderate, and (3) severe symptoms. Patients were more likely to report a greater number of symptoms in a more severe latent class. During treatment, moderate and severe classes had representation of all most common symptoms: pain, mucositis, taste alterations, xerostomia, dysphagia, and fatigue. Different symptom patterns emerged for survivorship, with prominence of taste alterations and xerostomia across all classes, and all symptoms present in the severe class. The probability of symptom expression varied more in the survivorship period compared with the treatment period.

CONCLUSIONS

Patients reported numerous symptoms during active treatment persisting into survivorship. Patients tended to transition to more severe symptomatology as treatment progressed and to more moderate symptomatology as survivorship evolved.

IMPLICATIONS FOR PRACTICE

Examining the trend of persistent moderate symptomatology into survivorship is useful to optimize symptom management.

Associations of inflammation with neuropsychological symptom cluster in patients with Head and neck cancer: A longitudinal study

Purpose

Head and neck cancer (HNC) patients may experience multiple co-occurring neuropsychological symptoms (NPS) cluster, including fatigue, depression, pain, sleep disturbance, and cognitive impairment. While inflammation has been attributed as a key mechanism for some of these symptoms, its association with the NPS as a cluster of symptoms is unknown. Thus, the aim of this study was to examine the association between peripheral inflammation and NPS cluster among HNC patients over cancer treatment (radiotherapy with or without chemotherapy).

Methods

HNC patients were recruited and followed at pre-treatment, end of treatment, three months and one-year post-treatment. Plasma inflammatory markers, including C-reactive protein (CRP), tumor necrosis factor-alpha (TNFA), soluble tumor necrosis factor receptor-2 (sTNFR2), interleukin-1 beta (IL1-β), interleukin-6 (IL-6), interleukin-10 (IL-10), monocyte chemotactic protein-1 (MCP-1), and interleukin-1 receptor antagonist (IL-1RA) and patient-reported NPS cluster were collected at the 4 time points. Associations between inflammatory markers and the NPS cluster were analyzed using linear mixed-effects models and generalized estimating equations (GEE) models controlling covariates.

Results

147 HNC patients were eligible for analysis. 56% of the patients received chemoradiotherapy as treatment. The highest NPS cluster score was reported at the end of treatment, which gradually decreased over time. An increase in inflammatory markers including CRP, sTNFR2, IL-6 and IL-1RA was associated with higher continuous NPS cluster scores (p<0.001, p = 0.003, p<0.001, p<0.001; respectively). GEE further confirmed that patients with at least two moderate symptoms had elevated sTNFR2, IL-6, and IL-1RA (p = 0.017, p = 0.038, p = 0.008; respectively). Notably, this positive association between NPS cluster and inflammatory markers was still significant at one-year post-treatment for CRP (p = 0.001), sTNFR2 (p = 0.006), and IL-1RA (p = 0.043).

Conclusions

Most HNC patients experienced NPS clusters over time, especially immediately after the end of treatment. Elevated inflammation, as represented by inflammatory markers, was strongly associated with worse NPS cluster over time; this trend was also notable at one-year post-treatment. Our findings suggest that peripheral inflammation plays a pivotal role in the NPS cluster over cancer treatment, including long-term follow-ups. Interventions on reducing peripheral inflammation may contribute to alleviating the NPS cluster in cancer patients.

Symptom Cluster Experiences of Patients Operated for Oral Cancer: A Mixed Methods Study

OBJECTIVE

This convergent mixed methods study aimed to obtain a comprehensive understanding of symptom cluster experiences in patients with oral cancer. Survey and phenomenological interviews were conducted in parallel to identify distinct patient subgroups based on symptom cluster experiences along with their predictors and explore experiences of living with symptom clusters, respectively.

DATA SOURCES

A convenience sample of 300 patients with oral cancer who had completed surgery provided the quantitative data, and a maximum variation purposive subsample of 20 participants, drawn from the survey sample, provided the qualitative data. Agglomerative hierarchical cluster analysis was used to identify subgroups, multivariate analyses were done to identify predictors, and thematic analysis was used for patient narratives.

CONCLUSION

Almost 94% of the survey participants had two or more co-occurring symptoms. The four most severe and prevalent symptoms were dysphagia, problems with teeth or gums, speech difficulty, and dry mouth. A distinct subgroup consisting of 61% of patients reported severe dysphagia and teeth problems, which was associated with age, oral cancer stage and site. Interviews revealed the causes and the context influencing the perception and response to these symptoms. Thus, the quantitative data provided information on severity and patient subgroups based on symptom cluster experiences, while the qualitative data validated these conclusions and additionally provided in-depth details and meaningful insight on perceived causes and contextual influences of their experiences. This comprehensive picture of symptom cluster experiences can aid in the development of patient-centered interventions for people with oral cancer.

IMPLICATIONS FOR NURSING PRACTICE

An interdisciplinary approach to targeting concurrent symptoms incorporating psychological and physical interventions is necessary. Older patients treated for Stage IV cancers and for buccal mucosa tumors are at high-risk of having severe dysphagia postoperatively, and these patients should be targeted for dysphagia interventions. The contextual factors play an important role in developing patient-centered interventions.

World Workshop on Oral Medicine VIII: Development of a Core Outcome Set for Dry Mouth: A Systematic Review of Outcome Domains for Xerostomia

OBJECTIVE

The purpose of this study was to identify all outcome domains used in clinical studies of xerostomia, that is, subjective sensation of dry mouth. This study is part of the extended project "World Workshop on Oral Medicine Outcomes Initiative for the Direction of Research" to develop a core outcome set for dry mouth.

STUDY DESIGN

A systematic review was performed on MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials databases. All clinical and observational studies that assessed xerostomia in human participants from 2001 to 2021 were included. Information on outcome domains was extracted and mapped to the Core Outcome Measures in Effectiveness Trials taxonomy. Corresponding outcome measures were summarized.

RESULTS

From a total of 34,922 records retrieved, 688 articles involving 122,151 persons with xerostomia were included. There were 16 unique outcome domains and 166 outcome measures extracted. None of these domains or measures were consistently used across all the studies. The severity of xerostomia and physical functioning were the 2 most frequently assessed domains.

CONCLUSION

There is considerable heterogeneity in outcome domains and measures reported in clinical studies of xerostomia. This highlights the need for harmonization of dry mouth assessment to enhance comparability across studies and facilitate the synthesis of robust evidence for managing patients with xerostomia.

Predictive effect of pretreatment nutritional risk and GLIM-defined malnutrition on the nutrition impact symptom clusters in patients with head and neck cancer undergoing radiotherapy

BACKGROUND

Evidence supporting predictive effects of pretreatment nutritional risk and nutritional status on nutrition impact symptom (NIS) clusters during radiotherapy in patients with head and neck cancer (HNC) is insufficient.

METHODS

At baseline (T₁ ), we collected severity and interference of NIS (Head and Neck Patient Symptom Checklist), nutritional risk, and nutritional status. During (T₂ ) and at the end of radiotherapy (T₃ ), we re-evaluated NIS. Symptom clusters were identified by exploratory factor analysis using mean scores of NIS severity at T₂ and T₃ . Predictive effects were explored by generalized estimating equations.

RESULTS

Five hundred thirty-seven patients were recruited and 334 of them completed. Four clusters were identified; the oropharyngeal symptom cluster was the most severe and had the greatest interference with diet. Patients with pretreatment nutritional risk or malnutrition experienced more severe oropharyngeal symptom cluster.

CONCLUSIONS

Pretreatment nutritional risk or malnutrition could predict the oropharyngeal symptom cluster in patients with HNC undergoing radiotherapy.

A network analysis of self-reported psychoneurological symptoms in patients with head and neck cancer undergoing intensity-modulated radiotherapy

BACKGROUND

Patients with head and neck cancer experience psychoneurological symptoms (PNS) (i.e., depression, fatigue, sleep disturbance, pain, and cognitive dysfunction) during intensity-modulated radiotherapy (IMRT) that decrease their functional status, quality of life, and survival rates. The purpose of this study was to examine and visualize the relationships among PNS within networks over time and evaluate for demographic and clinical characteristics associated with symptom networks.

METHODS

A total of 172 patients (mean age, 59.8 ± 9.9 years; 73.8%, male; 79.4%, White) completed symptom questionnaires four times, namely, before IMRT (T1), 1 month (T2), 3 months (T3), and 12 months (T4) post IMRT. Network analysis was used to examine the symptom-symptom relationships among PNS. Centrality indices, including strength, closeness, and betweenness, were used to describe the degrees of symptom network interconnections. Network comparison test was used to assess the differences between two symptom networks.

RESULTS

Depression was associated with the other four symptoms, and fatigue was associated with the other three symptoms across the four assessments. Based on the centrality indices, depression (rstrength  = 1.3-1.4, rcloseness  = 0.06-0.08, rbetweeness  = 4-10) was the core symptom in all symptom networks, followed by fatigue. Female gender, higher levels of stress, and no alcohol use were associated with stronger symptom networks in network global strength before IMRT.

CONCLUSION

Network analysis provides a novel approach to gain insights into the relationships among self-reported PNS and identify the core symptoms and associated characteristics. Clinicians may use this information to develop symptom management interventions that target core symptoms and interconnections within a network.

LAY SUMMARY

This study describes the symptom-symptom relationships for five common symptoms in patients with head and neck cancer receiving radiotherapy. Depression and fatigue appeared to be two core symptoms that were connected with sleep disturbance, pain, and cognitive dysfunction within a network. Several characteristics (i.e., female, higher stress, no alcohol use) were associated with stronger symptom networks.

Association of post-treatment longitudinal symptom severity clusters with subsequent survival in oropharyngeal cancer

BACKGROUND

Patients with cancer often experience multiple symptoms concurrently. We identified patient clusters based on longitudinal symptom severity trajectories in oropharyngeal cancer (OPC) and evaluated the potential clinical utility of this approach.

METHODS

A retrospective OPC patient cluster analysis using 6 months of symptom severity data from radiotherapy initiation. The clinico-demographic characteristics and overall survival of patients were compared between clusters.

RESULTS

We identified four clusters of patients differing in longitudinal symptom severity. Cluster A (n = 168) included patients with the mildest longitudinal symptoms, cluster B (n = 59) and cluster C (n = 63) were intermediate, and cluster D (n = 30) included patients with the worst symptoms. The clusters differed in their HPV status, ECOG performance status, smoking history, drinking history, treatment modality, and 5-year survival. These clusters separated symptom severity trajectories more distinctly than individual clinico-demographic characteristics.

CONCLUSIONS

Early symptom severity trajectory clustering revealed distinct patient clusters that were prognostic of overall survival.

The effect of navigation programme on the management of symptoms related to head and neck radiotherapy

BACKGROUND

This study aims to determine the effect of navigation programme in the management of symptoms related to head and neck cancer (HNC) radiotherapy.

METHODS

This randomized, controlled and experimental study was conducted between November 2018 and March 2020 with the participation of 88 patients with HNC receiving radiotherapy. Referring to the pre-prepared randomization checklist, 41 people were randomized to the experimental group and 47 to the control group. While the standard treatment approaches of the hospital were applied to all patients, the patients in the experimental group were applied an additional nursing navigation program. At the beginning of the navigation program, the patients were given a 30-minute visual training on the first day of radiotherapy and a handbook related to the expected adverse effects. Throughout subsequent seven weeks, the patient continued to be followed up via phone reminders, providing daily counseling and a weekly follow-up. Patient identification form, CTCAE v5.0 toxicity criteria and EORTC QLQ-30, H&N35 assessment questionnaires were used in the study. The first result was the difference observed in quality of life scores at the beginning, middle and end of radiotherapy.

RESULTS

Data obtained from the study revealed that the quality of life scores (p < 0.05) improved while the navigation program reduced the severity of symptoms such as mucositis, dysphagia, oral pain and weight loss (p < 0.05).

CONCLUSION

It was concluded that navigation programme is an effective approach for patients receiving head and neck radiotherapy.

TRIAL REGISTRATION

NCT04857749.

Symptom Clusters in Head and Neck Cancer: A Systematic Review and Conceptual Model

OBJECTIVE

The two approaches to symptom-cluster research include grouping symptoms and grouping patients. The objective of this systematic review was to examine the conceptual approaches and methodologies used in symptom-cluster research in patients with head and neck cancer.

DATA SOURCES

Articles were retrieved from electronic databases (CINAHL, MEDLINE via Ovid, APA PsycINFO, Scopus, Embase, and Cochrane Central Register of Controlled Trials-CENTRAL), five grey literature portals, and Google Scholar. Seventeen studies met the eligibility criteria. Eight studies grouped symptoms to identify symptom clusters, of which two used qualitative methods. The number of symptom clusters ranged from two to five, and the number of symptoms in a cluster ranged from 2 to 11. Nine studies grouped patients based on their experiences with multiple symptoms. Cluster analysis and factor analysis were most commonly used. Despite variable names and composition of symptom clusters, synthesis revealed three prominent symptom clusters: general, head and neck cancer-specific, and gastrointestinal. Being female and quality of life were significantly associated with high symptom group or cluster severity. Biological mechanisms were sparsely examined.

CONCLUSION

Symptom cluster research in head and neck cancer is emerging. Consensus on nomenclature of a symptom cluster will facilitate deduction of core clinically relevant symptom clusters in head and neck cancer. Further research is required on understanding patients' subjective experiences, identifying predictors and outcomes, and underlying mechanisms for symptom clusters.

IMPLICATIONS FOR NURSING PRACTICE

Identification of clinically relevant symptom clusters would enable targeted symptom assessment and management strategies, thus improving treatment efficiencies and patient outcomes.

Nutrition Impact Symptom Clusters in Patients With Head and Neck Cancer Receiving Concurrent Chemoradiotherapy

OBJECTIVES

The objective of this study was to identify the nutrition impact symptom (NIS) clusters in patients with head and neck cancer (HNC) receiving concurrent chemoradiotherapy (CCRT) and explore their relationships with the weight loss rate (WLR).

METHODS

This longitudinal study included 169 patients. At baseline (T₁), the demographics, clinical information, and weight before radiotherapy (RT) were recorded. At the third week (T₂) and the end of RT (T₃), we assessed the weight, prevalence, severity, and interference of the NIS with the Head and Neck Patient Symptom Checklist. The mean scores of the severity of NIS at T₂ and T₃ were used as a whole to perform the exploratory factor analysis and identify the symptom clusters. Cronbach's α coefficient was used to evaluate the internal consistency of the symptom clusters. Generalized estimating equations were used to analyze the relationships between clusters and the WLR.

RESULTS

We extracted three clusters from 14 NISs: the RT-specific symptom cluster including pain, difficulty swallowing, oral mucositis, thick saliva, difficulty chewing, and dry mouth (Cronbach's α = 0.820); the gastrointestinal symptom cluster including nausea, loss of appetite, feeling full, vomiting, and taste change (Cronbach's α = 0.592); the psychological status cluster including depressed, anxious, and lack of energy (Cronbach's α = 0.710). The multivariable model showed that participants with more serious RT-specific symptom cluster (β = 1.020, 95% CI: 0.570-1.471, P < 0.001) had higher WLR.

CONCLUSIONS

The NIS had close internal connections with each other, so the strategies applied by healthcare professionals should focus on multiple related symptoms, especially to manage the RT-specific symptom cluster.

Postoperative oral dysfunction following oral cancer resection and reconstruction: A preliminary cross-sectional study

OBJECTIVES

Oral cancer treatment reportedly causes decreased oral function, but few studies have examined the effects of oral cancer treatment on oral function in depth. This study aimed to comprehensively evaluate the oral function after treatment and classify the conditions related to oral dysfunction in patients with oral cancer.

MATERIALS AND METHODS

We recruited participants, collected their background data, and evaluated their oral function from September 2019 to March 2021. Principal component analysis was used to identify the components of oral function measurement and oral health perception. Receiver operating characteristic analysis was performed to investigate the accuracy of oral function measurements in predicting oral intake and nutritional status.

RESULTS

Fifty patients treated for oral cancer, including 33 (66.0%) males and 17 (34.0%) females, were included. Their median age was 71.0 years (interquartile range: 63.0-76.0). There were significant differences in oral dryness between males and females, occlusal force among different age groups, tongue pressure based on the tumor stage and performance of reconstructive procedures, and masticatory function and Eating Assessment Tool scores based on whether radiotherapy was performed (P < 0.05). The principal component analysis proposed that oral function measurements and subjective oral health perception could be divided into three main components (transport, oral hygiene, and occlusion type), which explain 61.5% of the variance of the phenomenon.

CONCLUSION

A significant decrease in oral function after oral cancer treatment should be diagnosed as postoperative oral dysfunction. Postoperative oral dysfunction can be classified into three types, each of which may present with different pathologies.

Symptom clusters in head and neck cancer patients with endotracheal tube: Which symptom clusters are independently associated with health-related quality of life?

PURPOSE

The point of view of symptom clusters (SCs) may develop an efficient symptom management strategy to enhance health-related quality of life (HRQoL) in head and neck (HNC) patients with endotracheal tube (ETT). The study aims to investigate the possible SCs in HNC patients with ETT and determine whether there was an independent relationship between one or more SCs and HRQoL.

METHODS

A cross-sectional study design was adopted, and 203 HNC patients with ETT were recruited. They took measurements of General Information Questionnaire, MD Anderson Symptom Inventory-Head & Neck, and Twelve-Item Short-Form Health Survey (SF-12). Spearman correlations, partial correlations, and hierarchical cluster analysis were performed to determine latent number of SCs, and covariance analyses were used to determine independent associations between SCs and SF-12. This study followed STROBE Statement.

RESULTS

Pain SCs (pain, distressed, short of breath, and sadness), fatigue SCs (fatigue/weakness, restless, and sleepy), digestive SCs (appetite loss, constipation, and nausea), HNC-specific SCs (dry mouth and mucus), and tracheostomy-related SCs (difficulty swallowing and difficulty with voice and speech) were found. After adjusting covariant variables, this study found independent relationships of pain SCs and fatigue SCs with physical component summary of SF-12, and between fatigue SCs and mental component summary of SF-12.

CONCLUSIONS

Multiple SCs were found in those HNC patients. Pain SCs and fatigue SCs were independently associated with HRQoL. In process of caring HNC patients with ETT, it is vital to focus on SCs, especially on pain SCs and fatigue SCs, which might effectively improve patients' HRQoL.

Gut Microbiome Associated with the Psychoneurological Symptom Cluster in Patients with Head and Neck Cancers

Cancer patients experience a cluster of co-occurring psychoneurological symptoms (PNS) related to cancer treatments. The gut microbiome may affect severity of the PNS via neural, immune, and endocrine signaling pathways. However, the link between the gut microbiome and PNS has not been well investigated in cancer patients, including those with head and neck cancers (HNCs). This pilot study enrolled 13 patients with HNCs, who reported PNS using the Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (CTCAEs). Stool specimens were collected to analyze patients' gut microbiome. All data were collected pre- and post-radiation therapy (RT). Associations between the bacterial abundances and the PNS clusters were analyzed using the linear discriminant analysis effect size; functional pathway analyses of 16S rRNA V3-V4 bacterial communities were conducted using Tax4fun. The high PNS cluster had a greater decrease in microbial evenness than the low PNS cluster from pre- to post-RT. The high and low PNS clusters showed significant differences using weighted UniFrac distance. Those individuals with the high PNS cluster were more likely to have higher abundances in phylum Bacteroidetes, order Bacteroidales, class Bacteroidia, and four genera (Ruminiclostridium9, Tyzzerella, Eubacterium_fissicatena, and DTU089), while the low PNS cluster had higher abundances in family Acidaminococcaceae and three genera (Lactococcus, Phascolarctobacterium, and Desulfovibrio). Both glycan metabolism (Lipopolysaccharide biosynthesis) and vitamin metabolism (folate biosynthesis and lipoic acid metabolism) were significantly different between the high and low PNS clusters pre- and post-RT. Our preliminary data suggest that the diversity and abundance of the gut microbiome play a potential role in developing PNS among cancer patients.

Changes in Gut Microbiome Associated With Co-Occurring Symptoms Development During Chemo-Radiation for Rectal Cancer: A Proof of Concept Study

PURPOSE

To examine a) whether there are significant differences in the severity of symptoms of fatigue, sleep disturbance, or depression between patients with rectal cancer who develop co-occurring symptoms and those with no symptoms before and at the end of chemotherapy and radiation therapy (CRT); b) differences in gut microbial diversity between those with co-occurring symptoms and those with no symptoms; and c) whether before-treatment diversity measurements and taxa abundances can predict co-occurrence of symptoms.

METHODS

Stool samples and symptom ratings were collected from 31 patients with rectal cancer prior to and at the end of (24-28 treatments) CRT. Descriptive statistics were computed and the Mann-Whitney U test was performed for symptoms. Gut microbiome data were analyzed using R's vegan package software.

RESULTS

Participants with co-occurring symptoms reported greater severity of fatigue at the end of CRT than those with no symptoms. Bacteroides and Blautia2 abundances differed between participants with co-occurring symptoms and those with no symptoms. Our random forest classification (unsupervised learning algorithm) predicted participants who developed co-occurring symptoms with 74% accuracy, using specific phylum, family, and genera abundances as predictors.

CONCLUSION

Our preliminary results point to an association between the gut microbiota and co-occurring symptoms in rectal cancer patients and serves as a first step in potential identification of a microbiota-based classifier.

Impact of Clustering Oral Symptoms in the Pathogenesis of Radiation Caries: A Systematic Review

Radiation-related caries (RRC) is a disease with a high potential for destruction of the dentition, which impairs quality of life in head-and-neck (HN) cancer (HNC) patients who undergo radiotherapy. In light of the recently described “clustering of oral symptoms theory,” the present systematic review (PROSPERO CRD42019132709) aims to assess HN and gastrointestinal (GI) symptom clusters among HNC patients and discusses how these indirect effects of cancer therapy play a pivotal role in the pathophysiology of RRC. The search was performed at PubMed, Scopus, and Embase and resulted in 11 studies that met the inclusion criteria. Data extraction was performed with respect to the presence of HN/GI symptom clusters among HNC patients. The methodological data of the studies included were assessed using the MAStARI and GRADE instruments. The most prevalent reported HN symptoms were dysphagia, xerostomia, and pain. Taste alterations and fatigue were also commonly reported by the patients. Loss of appetite and weight loss were regularly reported in the studies, as well as nausea and vomiting. The results of the present study suggest that HNC treatment generates clusters of oral symptoms, leading to dietary changes, impaired oral hygiene, enamel fragility, and a highly cariogenic oral environment, which may impact the risk for RRC. A better understanding of oral symptom clustering could be of considerable clinical significance for the oral health and quality of life of HNC patients. Therefore, contemporary protocols of RRC prevention must take this broader treatment scenario of symptom clusters such as oral side effects into account.