Symptom clusters in patients with head and neck cancer receiving concurrent chemoradiotherapy

Exploring the Acceptability of Behavioral Swallowing Interventions for Head and Neck Cancer Patients During Radiotherapy: A Qualitative Study of Patients' Experience

The PRO-ACTIVE randomized clinical trial offers 3 swallowing therapies to Head and Neck Cancer (HNC) patients during radiotherapy namely: reactive, proactive low- ("EAT-RT" only), and high-intensity ("EAT-RT + exercises"). Understanding the perceived acceptability of these interventions is important to inform eventual implementation into clinical practice. This study explored patients' perspectives using qualitative methodology. At 2 Canadian PRO-ACTIVE trial sites, 24 trial participants were recruited for individual semi-structured interviews, representing each of the 3 trial arms. Data collection and thematic analysis were guided by the Theoretical Framework of Acceptability (TFA). Member checking was conducted through follow-up focus groups. Seven themes were derived reflecting the TFA constructs. Overall, regardless of trial arm, patients reported a positive experience with therapy. Patients identified benefits of EAT-RT therapy, reporting that it provided meaningful feedback on diet progress and supported goal setting for oral intake. Patients who received proactive therapies valued the opportunity to set expectations early, build mealtime routine iteratively over time, and have an extended engagement with the SLP. Regardless of trial arm, patients agreed proactive therapy aligned with what they think is best and that therapy intensity should accommodate individual needs. This study identified the value to HNC patients of receiving swallowing interventions during RT and setting realistic expectations around swallowing. Compared to reactive care, proactive therapies were perceived helpful in consolidating habits early, establishing realistic expectations around swallowing and building an extended rapport with the SLP. These findings will inform the implementation of proactive versus reactive swallowing therapies in clinical practice.

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.

Qualitative Classification of Late Systemic Symptoms in Head and Neck Cancer Survivors

Improved rates of cancer control have increased the head and neck cancer survivor population. Cancer survivorship clinics are not widely available in the USA, and longitudinal supportive care for patients undergoing multimodal therapy has not advanced at a pace commensurate with improvements in cancer control. Consequently, a large head and neck cancer survivor population whose quality of life may be chronically and/or permanently diminished presently exists. This lack of awareness perpetuates under-recognition and under-investigation, leaving survivors' (mostly detrimental) experiences largely uncharted. We conducted a qualitative exploration of survivors' experiences, aiming to unpack the profound impact of late systemic symptoms on daily life, encompassing work, relationships, and self-identity in the head and neck cancer survivor community. The study included 15 remitted head and neck survivors, ≥12 months from their final treatment, who participated in semi-structured interviews conducted by a medical oncologist. Data analysis comprised qualitative thematic analysis, specifically inductive hierarchical linear modeling, enriched by a deductive approach of anecdotal clinical reporting. Results highlighted that 43.36% of all quotation material discussed in the interviews pertained to chronic emotion disturbance with significant implications for other domains of life. A central symptom cluster comprised impairments in mood/emotions, daily activity, and significant fatigue. Dysfunction in sleep, other medical conditions, and cognitive deficits comprised a secondary cluster. Physical dysfunctionality, encompassing pain, appetite, and eating, and alterations in experienced body temperature, constituted a tertiary cluster, and perhaps were surprisingly the least discussed symptom burden among head and neck cancer survivors. Symptoms causing heightened long-term survivor burden may be considered epiphenomenal to central physical dysfunctionality, albeit being presently the least represented in cancer survivor care programs. Moving forward, the development of targeted and multi-dimensional treatment programs that encompass physical, psychosocial, and spiritual domains are needed to increase clinical specificity and effective holistic long-term solutions that will foster a more compassionate and informed future of care for the cancer survivorship community.

Rehabilitation Interventions in Head and Neck Cancer: A Scoping Review

OBJECTIVE

The aim of the study is to identify and appraise current evidence for rehabilitation interventions in head and neck cancer.

DESIGN

A previously published scoping review spanning 1990 through April 2017 was updated through January 11, 2023 and narrowed to include only interventional studies (Arch Phys Med Rehabil. 2019;100(12):2381-2388). Included studies had a majority head and neck cancer population and rehabilitation-specific interventions. Pairs of authors extracted data and evaluated study quality using the PEDro tool. Results were organized by intervention type.

RESULTS

Of 1338 unique citations, 83 studies with 87 citations met inclusion criteria. The median study sample size was 49 (range = 9-399). The most common interventions focused on swallow (16 studies), jaw (11), or both (6), followed by whole-body exercise (14) and voice (10). Most interventions took place in the outpatient setting (77) and were restorative in intent (65 articles). The overall study quality was fair (median PEDro score 5, range 0-8); none were of excellent quality (PEDro >9).

CONCLUSIONS

Most head and neck cancer rehabilitation interventions have focused on restorative swallow and jaw exercises and whole-body exercise to address dysphagia, trismus, and deconditioning. More high-quality evidence for head and neck cancer rehabilitation interventions that address a wider range of impairments and activity and social participation limitations during various cancer care phases is urgently needed to reduce head and neck cancer-associated morbidity.

A Preliminary Validation of an Optimal Cutpoint in Total Number of Patient-Reported Symptoms in Head and Neck Cancer for Effective Alignment of Clinical Resources with Patients' Symptom Burden

Background

Patients with head and neck cancer (HNC) often experience high symptom burden leading to lower quality of life (QoL).

Objective

This study aims to conceptually model optimal cutpoint by examining where total number of patient-reported symptoms exceeds patients' coping capacity, leading to a decline in QoL in patients with HNC.

Methods

Secondary data analysis of 105 individuals with HNC enrolled in a clinical usefulness study of the NYU Electronic Patient Visit Assessment (ePVA)©, a digital patient-reported symptom measure. Patients completed ePVA and European Organization for Research and Treatment of Cancer (EORTC©) QLQ-C30 v3.0. The total number of patient-reported symptoms was the sum of symptoms as identified by the ePVA questionnaire. Analysis of variance (ANOVA) was used to define optimal cutpoint.

Results

Study participants had a mean age of 61.5, were primarily male (67.6%), and had Stage IV HNC (53.3%). The cutpoint of 10 symptoms was associated with significant decline of QoL (F= 44.8, P<.0001), dividing the population into categories of low symptom burden (< 10 symptoms) and high symptom burden (≥ 10 symptoms). Analyses of EORTC© function subscales supported the validity of 10 symptoms as the optimal cutpoint (Physical: F=28.3, P<.0001; Role: F=21.6, P<.0001; Emotional: F=9.5, P=.003; Social: F=33.1, P<.0001).

Conclusions

In HNC, defining optimal cutpoints in the total number of patient-reported symptoms is feasible.

Implications for Practice

Cutpoints in the total number of patient-reported symptoms may identify patients experiencing a high symptom burden from HNC.

Foundational

Using optimal cutpoints of the total number of patient-reported symptoms may help effectively align clinical resources with patients' symptom burden.

Associations of differentially expressed genes with psychoneurological symptoms in patients with head and neck cancer: A longitudinal study

OBJECTIVE

Patients with head and neck cancer (HNC) experience psychoneurological symptoms (PNS, i.e., depression, fatigue, sleep disturbance, pain, and cognitive dysfunction) during intensity-modulated radiotherapy (IMRT) that negatively impact their functional status, quality of life, and overall survival. The underlying mechanisms for PNS are still not fully understood. This study aimed to examine differentially expressed genes and pathways related to PNS for patients undergoing IMRT (i.e., before, end of, 6 months, and 12 months after IMRT).

METHODS

Participants included 142 patients with HNC (mean age 58.9 ± 10.3 years, 72.5% male, 83.1% White). Total RNA extracted from blood leukocytes were used for genome-wide gene expression assays. Linear mixed effects model was used to examine the association between PNS and gene expression across time. Gene Ontology (GO) enrichment analysis was employed to identify pathways related to PNS.

RESULTS

A total of 1352 genes (162 upregulated, 1190 downregulated) were significantly associated with PNS across time (false discovery rate (FDR) < 0.05). Among these genes, 112 GO terms were identified (FDR < 0.05). The top 20 GO terms among the significant upregulated genes were related to immune and inflammatory responses, while the top 20 GO terms among the significant downregulated genes were associated with telomere maintenance.

CONCLUSION

This study is the first to identify genes and pathways linked to immune and inflammatory responses and telomere maintenance that are associated with PNS in patients with HNC receiving IMRT. Inflammation and aging markers may be candidate biomarkers for PNS. Understanding biological markers may produce targets for novel interventions.

Symptom clusters among breast cancer patients in relation to chemotherapy cycles: a longitudinal study

PURPOSE

The aim of this study was to identify symptom clusters in breast cancer patients undergoing adjuvant chemotherapy.

METHODS

A prospective longitudinal study was conducted. And a sample of 620 breast cancer patients receiving adjuvant chemotherapy was recruited using convenience sampling from May 20, 2020, to March 31, 2021. Data were collected eight times: the first chemotherapy cycle (T1) to the eighth cycle of chemotherapy (T8). Exploratory factor analysis was used to explore the composition of symptom clusters.

RESULTS

Symptoms with an incidence of less than 20% were deleted and the remaining symptoms were included in the factor analysis. Three common factors were extracted in T1, including gastrointestinal symptom cluster, emotional and psychological symptom cluster, and menopausal symptom cluster. Five common factors were extracted from T2 to T7, including gastrointestinal symptom cluster, emotional and psychological symptom cluster, neurological symptom cluster, menopausal symptom cluster, and self-image disorder symptom cluster. Four common factors were extracted at T8, including gastrointestinal symptom cluster, emotional and psychological symptom cluster, neurological symptom cluster, and menopausal symptom cluster.

CONCLUSION

Breast cancer patients undergoing adjuvant chemotherapy experience multiple symptoms and different symptom clusters in different chemotherapy cycles. It is a benefit for health care providers to better understand and care for breast cancer patients. It will also help such women to manage concurrent symptoms ahead to promote their quality of life.

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.

Distinct Dysphagia Profiles in Patients With Oral Cancer After Surgery

OBJECTIVES

To determine distinct profiles based on symptom severity in patients undergoing surgery for oral cancer and examine whether these profiles differ by participant characteristics.

SAMPLE & SETTING

300 patients who underwent surgery for oral cancer at two outpatient clinics between June and December 2021.

METHODS & VARIABLES

Symptoms were assessed using the MD Anderson Symptom Inventory-Head and Neck Cancer Module. Sociodemographic and clinical characteristics were collected. Latent profile analysis was performed.

RESULTS

Five distinct dysphagia profiles were identified, which qualitatively differed regarding co-occurrence patterns of dysphagia, mucus-related symptoms, speech disturbances, and psychoneurologic symptoms. Significant differences were reported in interference to function, number of co-occurring symptoms, time since diagnosis and treatment completion, use of symptom management medications, oral cancer stage and site, and treatment completed.

IMPLICATIONS FOR NURSING

Identifying distinct dysphagia profiles can improve patient outcomes and help in planning specific nursing interventions to influence nutritional and functional status in oral cancer survivors. Dysphagia and dry mouth can persist beyond one year post-treatment, so follow-up dysphagia assessments are needed.

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.

Symptom clusters and impact on quality of life in esophageal cancer patients

BACKGROUND

Esophageal cancer patients can experience co-occurring, related symptoms labeled symptom clusters. This study aimed to identify symptom clusters and explore which SCs independently affect the quality of life (QoL) among esophageal cancer patients.

METHODS

This cross-sectional study was performed in Shenyang, China, from February 2021 to February 2022. Finally, 118 esophageal cancer patients effectively completed the survey. Questionnaires' information included the Functional Assessment of Cancer Therapy-General (FACT-G), the MD Anderson Symptom Inventory Gastrointestinal Cancer Module (MDASI-GI), the Multidimensions Scale of Perceived Social Support, and demographic and clinical characteristics. Exploratory factor analysis with principal axis factoring was used to identify symptom clusters, and multiple regression analysis was employed to analyze the influencing factors of QoL.

RESULTS

The mean score of FACT-G was 69.88 (SD = 17.85) among 118 esophageal cancer patients. Four symptom clusters were identified: psychological-somatic, dysphagia, fatigue-pain, and gastrointestinal symptom clusters. Results of regression analysis indicated a significant impact on QoL for chemotherapy (β = 0.140, P < 0.045), psychological-somatic symptom cluster (β = - 0.329, P = 0.013), and social support (β = 0.409, P < 0.001) after adjusting demographic and clinical characteristics. The linear combination explained 47.8% of the variance in QoL.

CONCLUSIONS

There is a critical need to emphasize the importance of psychological-somatic symptoms clusters management programs and increasing social support to improve QoL in esophageal cancer patients.

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.

Effect of Race and Ethnicity on Risk of Radiotherapy Toxicity and Implications for Radiogenomics

AIMS

Patient factors affect the risk of radiotherapy toxicity, but many are poorly defined. Studies have shown that race affects cancer incidence, survival, drug response, molecular pathways and epigenetics. Effects on radiosensitivity and radiotherapy toxicity are not well studied. The aim of the present study was to identify the effects of race and ethnicity on the risk of radiotherapy toxicity.

MATERIALS AND METHODS

A systematic review was carried out of PubMed, Ovid Medline and Ovid Embase with no year limit. PRISMA 2020 guidelines were followed. Two independent assessors reviewed papers.

RESULTS

Of 607 papers screened, 46 fulfilled the inclusion criteria. Papers were published between 1996 and 2021 and involved 30-28,354 individuals (median 433). Most involved patients with prostate (33%), breast (26%) and lung (9%) cancer. Both early and late toxicities were studied. Some studies reported a higher risk of toxicity in White men with prostate cancer compared with other races and ethnicities. For breast cancer patients, some reported an increased risk of toxicity in White women compared with other race and ethnic groups. In general, it was difficult to draw conclusions due to insufficient reporting and analysis of race and ethnicity in published literature.

CONCLUSIONS

Reporting of race and ethnicity in radiotherapy studies must be harmonised and improved and frameworks are needed to improve the quality of reporting. Further research is needed to understand how ancestral heritage might affect radiosensitivity and risk of radiotherapy toxicity.

Symptom clusters change over time among patients with gynecological cancer receiving chemotherapy

PURPOSE

This study aimed to explore symptom clusters at different time points among patients with gynecological cancer undergoing chemotherapy.

METHODS

A longitudinal design was used to explore the patterns of symptom clusters four times: during prechemotherapy (T0), first (T1), second (T2), and third (T3) cycles of chemotherapy. The Memorial Symptom Assessment Scale was used to assess the dimension of symptoms. The study was conducted in Indonesia. Exploratory factor analysis was used to analyze the structures of symptom clusters across time.

RESULTS

A total of 120 subjects provided baseline data, and 82 were retained at T3. Before chemotherapy, the most prevalent symptoms were pain and difficulty in sleeping. However, after starting chemotherapy, the patients suffered from chemotherapy-related side effects, including nausea, change in taste, lack of appetite, hair loss, fatigue, and feeling of "I don't look like myself." Six symptom clusters were identified in patients with gynecological cancer across four time points during chemotherapy: pain-related, nutritional, emotional, hormonal-related, fatigue-related, and body-image symptom clusters. Nutrition and emotion symptom clusters occurred consistently from T0 to T3, fatigue-related clusters appeared after chemotherapy at T1 and T2, and body-image symptom clusters emerged at late T2 and T3.

CONCLUSION

The structures of symptom clusters in this study were dynamic and various. The nutrition and emotional-related symptoms constituted a cluster during chemotherapy. Oncology nurses should provide physical and psychosocial interventions to relieve these symptoms in patients with gynecological cancer undergoing chemotherapy.

A mHealth-based nursing model for assessing the health outcomes of the discharged patients with nasopharyngeal carcinoma: a pilot RCT

Background

Nasopharyngeal carcinoma (NPC) is one of the most common head and neck malignancies, having a high incidence in Guangxi, China. Although chemoradiotherapy offers more effective cancer treatment, it also causes a variety of acute and chronic side effects, seriously affecting the quality of life. NPC has evolved into a chronic disease with most patients opting for home-based rehabilitation. Therefore, efforts on improving the home-based extended care services to improve the quality of life of patients are booming. The Chinese government encourages the use of internet technology for expanding the prospect of nursing. This study aimed to evaluate the impact of a mHealth-based care model on the health outcomes of discharged patients with nasopharyngeal carcinoma.

Methods

An experimental design was applied for this study. The study enrolled 116 discharged patients who were re-examined in the Radiotherapy Department of the First Affiliated Hospital of Guangxi Medical University from November 2019 to February 2020. These patients were randomized into control and intervention groups (n = 58 per group), but during the implementation of the project, there was one dropout in the control group due to the loss of follow-up, and one dropout in the intervention group due to distant metastasis. In the end, 57 patients in the control and intervention groups completed the trial. The control group was subjected to routine discharge guidance and follow-up, while the experimental group was implemented with a mobile health (mHealth)-based continuous nursing intervention model. The scores of the side effects, cancer fatigue, and quality of life were compared between the two groups of patients for 3, 6, and 12 months, respectively after discharge from the hospital.

Results

This study included 114 patients and there were no significant differences in the baseline data between the two groups. After 6 and 12 months of intervention, the severity of radiation toxicity and side effects, the scores of cancer-related fatigue, and quality of life (symptom field) of the patients in the interventional group were significantly lowered statistically compared to those in the control group.

Conclusion

This study is based on the mHealth continuous nursing intervention model, which can reduce the side effects of radiotherapy and cancer fatigue, and improve the quality of life.

Trial registration

This study was retrospectively registered as a randomized controlled trial in the Chinese Clinical Trial Center. Registration Date: January 12, 2021, Registration Number: ChiCTR2100042027.

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.

Salivary Gland Dysfunction Secondary to Cancer Treatment

The number of cancer survivors are increasing and so are the oral toxicities from cancer therapy. Most patients receiving treatment for cancer develop some form of oral adverse events including, but not limited to, mucositis, opportunistic infections, dry mouth, and/or osteonecrosis of the jaw. One of the most common complications from head and neck cancer radiation therapy is salivary gland dysfunction (SGD). SGD is an umbrella term that includes the subjective sensation of dry mouth (xerostomia) and hyposalivation (objective reduction of the salivary flow rate). Dry mouth in cancer patients may lead to functional defects (e.g., eating, speaking, and swallowing), increase the risk of dental caries and oral candidiasis, and can have a negative effect on the nutritional and psychological status of the patients. The aim of this mini review was to summarize the current criteria for diagnosis and management of SGD associated with cancer treatment.

Effectiveness of glass ionomer cements in the restorative treatment of radiation-related caries - a systematic review

PURPOSE

The aim of this systematic review was to investigate the clinical effectiveness of glass ionomer cements (GICs) compared to other restorative materials in the treatment of radiation-related caries.

METHODS

Two independent researchers searched literature databases (PubMed, Scopus, Web of Science, Cochrane Library, Lilacs/BBO) and the grey literature to identify clinical trials that compared GICs with other restorative materials for the treatment of radiation-related caries. The clinical criteria considered for the performance of the restorations were based on the parameters of marginal adaptation/anatomical form, secondary caries, retention, and cumulative failures of the restorations. The methodological quality and risk of bias were evaluated using the Cochrane Collaboration tool.

RESULTS

From a total of 511, only four articles fulfilled the inclusion criteria. Conventional GIC restorations presented higher marginal adaptation failures than the resin-modified glass ionomer cements (RM-GICs) and composite restorations in all of the follow-up periods. Secondary caries was not observed in conventional GIC restorations throughout the follow-up periods, in three out of four of the included studies. RM-GICs and composite restorations showed significantly lower cumulative failure rates than conventional GICs at 6-, 12-, and 18-month follow-ups.

CONCLUSION

Due to insufficient scientific evidence, it was not possible to conclude that GICs are more effective than other restorative materials for the treatment of radiation-related caries.

Indices for the assessment of radiation-related caries

Radiation therapy, either used alone or in combination with surgery and or chemotherapy, is the most commonly utilized modality for treating head and neck cancers. Patients undergoing radiation therapy usually experience significant early and late-onset toxicities/adverse effects. Radiation-related caries (RRC) is a common complication that detrimentally affects patients' quality of life (QoL). A clearer understanding and more uniform approach to scoring systems help provide a more accurate diagnosis, form treatment protocols, plan, and evaluate outcomes of preventive initiatives and create scientific databases. Many indices have been used to assess and quantify the dental caries experience after radiotherapy. Considering the need for uniform standards for measuring radiation caries, indices specific to radiation caries have been proposed in the literature to capture postradiation damage to the dentition accurately. This narrative review aims to consolidate the evolution of different indices used for scoring RRC to improve the understanding of radiation caries assessment.

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.

Symptom clusters in 1330 survivors of 7 cancer types from the PROFILES registry: A network analysis

Background

Research into the clustering of symptoms may improve the understanding of the underlying mechanisms that affect survivors' symptom burden. This study applied network analyses in a balanced sample of cancer survivors to 1) explore the clustering of symptoms and 2) assess differences in symptom clustering between cancer types, treatment regimens, and short‐term and long‐term survivors.

Methods

This study used cross‐sectional survey data, collected between 2008 and 2018, from the population‐based Patient Reported Outcomes Following Initial Treatment and Long Term Evaluation of Survivorship registry, which included survivors of 7 cancer types (colorectal cancer, breast cancer, ovarian cancer, thyroid cancer, chronic lymphocytic leukemia, Hodgkin lymphoma, and non‐Hodgkin lymphoma). Regularized partial correlation network analysis was used to explore and visualize the associations between self‐reported symptoms (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire) and the centrality of these symptoms in the network (ie, how strongly a symptom was connected to other symptoms) for the total sample and for subgroups separately.

Results

In the total sample (n = 1330), fatigue was the most central symptom in the network with moderate direct relationships with emotional symptoms, cognitive symptoms, appetite loss, dyspnea, and pain. These relationships persisted after adjustments for sociodemographic and clinical characteristics. Connections between fatigue and emotional symptoms, appetite loss, dyspnea, and pain were consistently found across all cancer types (190 for each), treatment regimens, and short‐term and long‐term survivors.

Conclusions

In a heterogenous sample of cancer survivors, fatigue was consistently the most central symptom in all networks. Although longitudinal data are needed to build a case for the causal nature of these symptoms, cancer survivorship rehabilitation programs could focus on fatigue to reduce the overall symptom burden.

In a sample of 1330 survivors, fatigue is found to be the most central symptom (ie, the symptom most strongly connected to other symptoms) in the network with moderate direct relationships with emotional symptoms, cognitive symptoms, appetite loss, dyspnea, and pain. Connections between fatigue and emotional symptoms, appetite loss, dyspnea, and pain were consistently found across all cancer types (colorectal cancer, breast cancer, ovarian cancer, thyroid cancer, chronic lymphocytic leukemia, Hodgkin lymphoma, and non‐Hodgkin lymphoma, n = 190 for each group), treatment regimens, and short‐term and long‐term survivors.

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.

Self-reported late effect symptom clusters among young pediatric cancer survivors

PURPOSE

Most survivors of childhood cancer experience subsequent chronic conditions but little is known about concurrent symptoms. This study seeks to identify late effect symptom clusters among young pediatric cancer survivors.

METHODS

Survivors ≥ 18 or parents of survivors < 18 years enrolled in an institutional cohort study indicated (yes/no) if they experienced certain symptoms after treatment. The sample was randomly divided in half for exploratory factor analyses to identify symptom clusters followed by confirmatory factor analyses. Symptoms with ≥ 10% prevalence were included. Cluster structure generalizability across subgroups was examined using congruence coefficients.

RESULTS

The sample included 579 survivors (74% non-Hispanic white, 45% leukemia, 12.8 ± 4.5 years at survey, 5.9 ± 3.5 years since therapy). Respondents averaged three symptoms. Three clusters were identified: (1) gastrointestinal: abdominal pain, diarrhea, constipation, nausea, vomiting (Cronbach's α = 0.74); (2) psychological: depression, anxiety, memory problems, anger management problems, sleep problems (α = 0.71); and (3) neurologic: problems walking, numbness/tingling, fatigue, back pain, chronic pain, weakness/inability to move legs (α = 0.71). Confirmatory factor analysis confirmed the three-cluster structure (standardized root mean square residual: 0.09; parsimonious goodness of fit: 0.96; Bentler-Bonett normed fit index: 0.95). The gastrointestinal and psychological clusters were generalizable across most subgroups while the neurologic cluster varied across age and race/ethnicity subgroups.

CONCLUSION

Three distinct late effect symptom clusters were identified in young childhood cancer survivors with gastrointestinal and psychological clusters remaining relatively stable across subgroups. Future studies should focus on the characteristics of patients who experience these symptoms, especially those with high symptom burden, and the synergistic impact on quality of life.

Correlation between Symptom Burden and Perceived Distress in Advanced Head and Neck Cancer: A Prospective Observational Study

OBJECTIVES

Head and neck cancer (HNC) account for major cancer burden in the Indian population. Patients often present with a diversity of distressing physical and psychological symptoms, significantly affecting their quality of life. This study aims to determine the correlation between symptom cluster and perceived distress in such patients.

MATERIALS AND METHODS

This single center prospective observational study was done on 175 adults advanced HNC patients referred to palliative medicine outpatient clinic. Patients fulfilling eligibility criteria were regularly assessed for their symptoms and distress at baseline and followed up at days 7, 14, and 28.

RESULTS

Most patients belong to the age group of 40-50 years and having a diagnosis carcinoma of the tongue. The most common symptoms presented were pain, tiredness, loss of appetite, and feeling of well-being. We observed statistically significant correlation between total ESAS score and distress levels in patients at days 0, 7, and 14, respectively, (P = 0.003 vs. 0.0004 vs. 0.002). However, at day 28, no such statistically significant correlation was found (P = 0.085) suggesting attention to other factors during assessment.

CONCLUSION

Outpatient palliative care consultations have shown significant improvement in symptom and distress score. Perceived distress in a person can not only be related to physical symptoms. Acute control of symptom may uncover underlying psychosocial and spiritual issues which need to be addressed promptly for better quality of life.

Epigenetic age acceleration, fatigue, and inflammation in patients undergoing radiation therapy for head and neck cancer: A longitudinal study

BACKGROUND

The authors measured epigenetic age acceleration (EAA) during and after cancer treatment and its association with inflammation and fatigue, which is a debilitating symptom in patients with cancer.

METHODS

Patients who had head and neck cancer without distant metastases were assessed before, immediately after, and at 6 months and 12 months postradiotherapy. Blood DNA methylation was assessed using a proprietary bead chip (the Illumina MethylationEPIC BeadChip). EAA was calculated using the Levine epigenetic clock (DNAmPhenoAge), adjusted for chronological age. Fatigue was assessed using the Multidimensional Fatigue Inventory-20. Inflammatory markers were measured using standard techniques.

RESULTS

Most patients (N = 133) were men, White, had advanced disease, and received concurrent chemoradiation. EAA changes over time were significant, with the largest increase (4.9 years) observed immediately after radiotherapy (P < .001). Increased EAA was associated with elevated fatigue (P = .003) over time, and patients who had severe fatigue experienced 3.1 years higher EAA than those who had low fatigue (P < .001), which was more prominent (5.6 years; P = .018) for patients who had human papillomavirus-unrelated disease at 12 months posttreatment. EAA was also positively associated with inflammatory markers, including C-reactive protein (CRP) and interleukin-6 (IL-6), over time (P < .001), and patients who had high CRP and IL-6 levels exhibited increases of 4.6 and 5.9 years, respectively, in EAA compared with those who had low CRP and IL-6 levels (P < .001). CRP and IL-6 mediated the association between EAA and fatigue (CRP: 95% CI, 0.060-0.279; IL-6: 95% CI, 0.024-0.220).

CONCLUSIONS

Patients with head and neck cancer experienced increased EAA, especially immediately after treatment completion. EAA was associated with greater fatigue and inflammation, including 1 year after treatment. Inflammation may be a target to reduce the impact of age acceleration on poor functional outcomes.

Association of Epigenetic Age Acceleration With Risk Factors, Survival, and Quality of Life in Patients With Head and Neck Cancer

PURPOSE

Epigenetic age acceleration (EAA) is robustly linked with mortality and morbidity. This study examined risk factors of EAA and its association with overall survival (OS), progression-free survival (PFS), and quality of life (QOL) in patients with head and neck cancer (HNC) receiving radiation therapy.

METHODS AND MATERIALS

Patients without distant metastasis were enrolled and followed before and at the end of radiation therapy and at 6 and 12 months after radiation therapy. EAA was calculated with DNAmPhenoAge at all 4 time points. Risk factors included demographic characteristics, lifestyle, clinical characteristics, treatment-related symptoms, and blood biomarkers. Survival data were collected until August 2020, and QOL was measured using Functional Assessment of Cancer Therapy-HNC.

RESULTS

Increased comorbidity, symptoms unrelated to human papilloma virus, and more severe treatment-related symptoms were associated with higher EAA (P = .03 to P < .001). A nonlinear association (quadratic) between body mass index (BMI) and EAA was observed: decreased BMI (<35 kg/m²; P = .04) and increased BMI (≥35 kg/m²; P = .01) were linked to higher EAA. Increased EAA (per year) was associated with worse OS (hazard ratio [HR], 1.11 [95% confidence interval {CI}, 1.03-1.18; P = .004]; HR, 1.10 [95% CI, 1.01-1.19; P = .02] for EAA at 6 and 12 months after treatment, respectively) and PFS (HR, 1.10 [95% CI, 1.02-1.19; P = .02]; HR, 1.14 [95% CI, 1.06-1.23; P < .001]; and HR, 1.08 [95% CI, 1.02-1.14; P = .01]) for EAA before, immediately after, and 6 months after radiation therapy, respectively) and QOL over time (β = -0.61; P = .001). An average of 3.25 to 3.33 years of age acceleration across time, which was responsible for 33% to 44% higher HRs of OS and PFS, was observed in those who died or developed recurrence compared with those who did not (all P < .001).

CONCLUSIONS

Compared with demographic and lifestyle factors, clinical characteristics were more likely to contribute to faster biological aging in patients with HNC. Acceleration in epigenetic age resulted in more aggressive adverse events, including OS and PFS. EAA could be considered as a marker for cancer outcomes, and decelerating aging could improve survival and QOL.

Impact of non-compliance with oral care on radiation caries in head and neck cancer survivors

PURPOSE

A cross-sectional study was performed to quantify radiation caries (RC); explore the possible influence of various covariates like elapsed time since radiotherapy, cancer site and stage, treatment modality(ies), grades of xerostomia (GOX), and inter-incisal mouth opening on RC; and also to estimate the unmet treatment needs in head and neck cancer (HNC) survivors, where personal and professional oral care was neglected before and after completion of the treatment.

METHODOLOGY

Clinical status of the dentition was recorded using decayed missing filled surface/decayed missing filled teeth (DMFS/DMFT) index. Patients were grouped according to the respective covariates, and relevant statistical analysis was performed considering p value ≤ 0.05 as statistically significant.

RESULTS

Eighty nine patients, 72 males and 17 females, with a mean age of 52.37±11.19 (range 18-70) years were included in this study. Overall, 85% (76/89) and 78% (29/37), 87.5% (35/40), and 100% (12/12) of patients reporting within 1, 1-3, and 3-5 years after RT, respectively, were affected with RC. The mean DMFS/DMFT score, range, and standard deviation in the included patients up to 5 years post-RT were 61.12/15.99, 0-128/0-28, and 36.608/8.66, respectively. Unmet treatment needs concerning dental decay were 97%. A statistically significant difference was found between the mean DMFS with elapsed time since radiotherapy and different GOX, respectively.

CONCLUSION

Oral health will be worse, treatment needs will be high, and limitations to performing desirable treatment will be numerous in HNC patients, where the oral care component of their treatment is ignored. Future studies are required to identify the true relationship between various risk factors and the development and progression of RC.

Symptoms and factors associated with symptom clusters among older adults with oral and oropharyngeal cancers at diagnosis

OBJECTIVE: Describe differences in pretreatment symptoms and the composition of symptom clusters in older patients with oral and oropharyngeal cancer. METHODS: In this cross-sectional study, quality of life (QoL) assessments for cancer patients (EORCT QLQ-C30 and QLQ-H & N35) were applied to 161 cases of oral and oropharyngeal cancer at the time of enrollment in an outpatient clinic. They were used to evaluate QoL-related symptoms reported by patients, according to their occurrence. To identify symptom clusters, an exploratory factor analysis (EFA) was performed, and the relationships between these clusters and independent variables were assessed with linear regression models. RESULTS: The most prevalent symptoms were pain (52%), worry (48%), and weight loss (44%). Five factors were extracted from the EFA, of which 3 were noteworthy. The dysphagia cluster was common to both cancer sites, although more frequent in oropharyngeal cancer patients, and included symptoms such as difficulty swallowing, pain, and weight loss. The psychological cluster included symptoms related to feeling worried, nervous, and depressed. The asthenia cluster, in addition to being age-related, may represent the advanced stage or progression of the disease. CONCLUSION: The dysphagia cluster loaded the most symptoms and was common to both cancers. In addition to pain (one of the main symptoms of the dysphagia cluster), psychological symptoms were also important in both groups of patients. Adequate and early control of these symptom clusters at diagnosis could favor better management of symptoms during treatment.

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.

Pilot study of combined aerobic and resistance exercise on fatigue for patients with head and neck cancer: Inflammatory and epigenetic changes

This pilot study examined whether a combined aerobic resistance exercise program reduced fatigue and the potential inflammatory and epigenetic mechanisms in patients with head and neck cancer (HNC) receiving intensity-modulated radiotherapy. The exercise group (N = 12) received a 3-month supervised aerobic resistance exercise intervention that was initiated before a 6-week radiotherapy regimen; the control group (N = 14) received standard care. Fatigue was measured using Multidimensional Fatigue Inventory-20; physical function measures included a 6-minute walk distance (6MWD), chair stands, bicep curls, and hand grip strength. Inflammatory markers and DNA methylation data were acquired using standardized protocol. Patients were mostly white (93%) and male (81%) with a mean age of 57 years. At the end of the intervention, the exercise group had a marginal decrease in fatigue compared with the control (-5.0 vs. 4.9; P = 0.10). The exercise group had a significantly greater improvement in 6MWD (29.8 vs. -55.5 m; P = 0.04), and a marginally smaller decline in hand grip (-0.3 vs. -5.8 lbs; P = 0.05) at the end of the intervention than the control. No significant difference in inflammatory markers was observed between groups. Lower plasma interleukin (IL) 6, IL1 receptor antagonist, tumor necrosis factor α (TNFα), soluble TNF receptor II and C-reactive protein were significantly associated with increased 6MWD, chair stand, and bicep curl at the end of the intervention (p < 0.05). Among the 1152 differentially methylated sites (DMS) after intervention (p < 0.001), 163 DMS were located in gene promoter regions. Enrichment analysis suggested that the top 10 upstream regulators were associated with tumor (HNF4A, RPP38, HOXA9, SAHM1, CDK7, NDN, RPS15) and inflammation (IRF7, CRKL, ONECUT1). The top 5 diseases or functions annotations of the 62 hypermethylated DMS indicated anti-tumor and anti-inflammatory effects that might be linked to exercise. These findings suggest that exercise may improve physical performance and reduce fatigue, which could be further linked to decreased inflammation, during active radiotherapy for HNC patients. Larger studies are warranted.

Symptom patterns, physical function and quality of life among head and neck cancer patients prior to and after surgical treatment: A prospective study

PURPOSE

This study aimed to evaluate patterns of symptoms, physical function and quality of life (QoL) among patients with head and neck cancer (HNC) prior to, 3-9 days post-surgery, and one month post-surgery.

METHODS

A prospective, repeated-measures design with consecutively-identified sampling was used to recruit HNC patients undergoing surgical treatment. Data collected included demographic and clinical characteristics, symptoms by M.D. Anderson Symptom Inventory-Head and Neck Module-Chinese version (MDASI-H&N-C), physical function and QoL by Function Subscales of European Cancer Research Treatment Organization Quality of Life Core Scale (EORTC QLQ C30).

RESULTS

105 HNC patients suffered multiple symptoms prior to and after surgery. Pain, difficulty with voice/speech, disturbed sleep and problems with mucus (30.48%~91.43%) were the most prevalent symptoms prior to and post-surgery. Numbers of symptoms as well as specific symptoms, such as fatigue, dry mouth, problems with mucus, pain and disturbed sleep, were significantly associated with poor physical function (p < 0.05). Tracheostomy, feeding tube and age were also linked with poor physical function and poor QoL (p < 0.05).

CONCLUSIONS

Findings of our study underscore the importance of managing symptoms in HNC patients to ensure patients' physical function and QoL prior to and after surgical treatment. Further research should focus on developing targeted interventions for symptoms that are linked to HNC patients' poor physical function and QoL.

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.

Is pain part of a systemic syndrome in head and neck cancer?

Head and neck cancers (HNC) represent 5% of all malignancies worldwide with about 180,000 cancer deaths per year. Patients with HNC are characterized by a systemic inflammatory state, generally associated with worse outcomes. Treatment-related toxicity is common among HNC patients and causes systemic consequences such as fatigue or cognitive dysfunction. The therapeutic treatments of HNC involve the release in circulation of inflammatory systemic mediators, whose effects trigger a vicious circle that may lead to functional and behavioral alterations. The areas of the head and neck are highly sensitive to pain. Literature data confirm that in HNC patients, pain is one of the most distressing symptoms across all the phases of treatment. Pain is associated with worse general conditions, depression, fatigue, impaired cognitive functions, and lower survival rate. The treatment of advanced HNC cases is multimodal and requires a multidisciplinary psycho-socio-pharmacological approach mediated by a team of experts. The pharmacological approach in management of HNC patients with pain is fundamental and involves the use of opioids, NSAIDs, steroids, or other drugs. Opioids in pain management therapy in patients with HNC could allow the pain level to be adequately monitored, thus improving quality of life. The integration of opioid and non-opioid therapy as well as non-pharmacological interventions is essential for the rehabilitation of physical, social, and psychological functions and to achieve pain control in patients with HNC. Opioid treatment is the mainstay for pain control, being used both for background and breakthrough cancer pain (BTcP) episodes. Fentanyl, easily absorbed and generally well tolerated, appears to be a possible choice due to its versatility. Non-pharmacological interventions, such as tailored yoga, physical exercise, and acupuncture, may have a role in pain management in patients with HNC.

Chronic Systemic Symptoms in Head and Neck Cancer Patients

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

Avaliação clínica dos sintomas de pacientes com câncer de cabeça e pescoço

Objetivo: avaliar os sintomas mais frequentes apresentados pelos pacientes com câncer de cabeça e pescoço e fatores associados.Metodologia: trata-se de um estudo transversal realizado com 77 pacientes do serviço de cirurgia de cabeça e pescoço do Instituto Nacional de Câncer (Brasil). Foi utilizado o Memorial Symptom Assessment Scale (MSAS), adaptado ao Brasil. Foi avaliada a prevalência dos sintomas, bem como sua associação com variáveis demográficas e clínicas por meio dos testes de qui- quadrado e de ANOVA.Resultados: os sintomas mais prevalentes foram boca seca (62,5 %), tristeza (60 %), preocupações (53,75 %), nervosismo (48,75 %) e tosse (46,25 %). Quanto à faixa etária, identificou-se diferença nos sintomas físicos de baixa frequência (PHYS-L), com maior queixa entre os jovens (p < 0,01). Na escala global (TMSAS) houve queixa maior dos pacientes ambulatoriais comparados aos internados (p = 0,05). Houve, ainda, queixa maior de sintomas de baixa frequência entre pacientes sem metástase (p = 0,05).Conclusão: considerando-se a ocorrência de múltiplos sintomas no paciente oncológico, é necessário ter métodos que sejam capazes de avaliar, de forma mais ampla, os sintomas. Dessa forma, o enfermeiro terá melhor compreensão da complexidade dos grupos de sintomas, permitindo aperfeiçoar as intervenções clínicas no processo de enfermagem.

Modeling symptom drivers of oral intake in long-term head and neck cancer survivors

PURPOSE

This study examined the relationship between self-reported symptom severity and oral intake in long-term head and neck cancer (HNC) survivors.

METHODS

An observational survey study with retrospective chart abstraction was conducted. HNC patients who had completed an MD Anderson Symptom Inventory-Head and Neck (MDASI-HN) questionnaire and also had clinician graded oral intake ratings (Functional Oral Intake Scale [FOIS]) were included. Correlation coefficients were computed. FOIS scores were regressed on MDASI-HN symptom items using stepwise backwards elimination for multivariate models.

RESULTS

One hundred and fifty-two survey pairings were included in the analysis (median 44 months follow-up, range 7-198). Per FOIS, 28% of survivors maintained a total oral diet with no restrictions, 67% reported a restricted oral diet (without tube), 3% were partially tube-dependent with some oral intake, and 2% were NPO. Of the 22 symptom items, the most severe items in decreasing order were dry mouth, difficulty swallowing\chewing, problems with mucus, tasting food, and choking/coughing. Significant bivariate correlations, after Bonferroni correction for multiple comparisons, were present for 8 of 22 symptoms with FOIS. On multivariate analysis, symptom severity for difficulty swallowing and problems with teeth/gums remained significantly associated with FOIS.

CONCLUSIONS

Oral intake in HNC survivorship is a multidimensional issue and functional outcome that is impacted not only by dysphagia but also by dental status. Symptom drivers of oral intake likely differ in acute survivorship. Nonetheless, these findings highlight the lack of specificity in this end point and also the need for multidisciplinary supportive care to optimize oral intake in survivors.

Estimating the Frequency, Severity, and Clustering of SPADE Symptoms in Chronic Painful Chemotherapy-Induced Peripheral Neuropathy

BACKGROUND

Patients undergoing treatment for cancer commonly experience symptoms such as sleep disturbance, pain, anxiety, depression, and low energy/fatigue (SPADE), subsequently altering physical function and complicating effective symptom management. However, little is known about the frequency, severity, and clustering of SPADE symptoms in individuals with chronic painful chemotherapy-induced peripheral neuropathy (CIPN). Aims/Design: The purpose of this cross-sectional, secondary analysis was to describe the frequency, severity, and clustering of SPADE symptoms and their association with physical function in individuals with chronic painful CIPN. Participants/Subjects: Sixty individuals with chronic painful CIPN were recruited from five academic and community oncology outpatient center to participate in a randomized controlled pilot trial designed to test the efficacy of a cognitive behavioral therapy-based pain management program.

METHODS

Participants completed the 0-10 Average CIPN Pain Numerical Rating Scale and Patient-Reported Outcome Measurement Information System measures for sleep-related impairment, anxiety, depression, fatigue, and pain interference via tablet before being randomly assigned to a study arm. The frequency, severity, and clustering of SPADE symptoms were calculated via descriptive statistics and Partitioning Around Medoids cluster analysis. Spearman rank correlation was performed to determine the association between number of SPADE symptoms and pain interference severity.

RESULTS AND CONCLUSIONS

Participants (n = 59) experienced numerous SPADE symptoms. 66.1% of participants experienced at least two SPADE symptoms concurrently. The cluster analysis revealed high (n = 36) and low (n = 23) severity subgroups. There was a moderate correlation (r = 0.48) between the number of SPADE symptoms and pain interference severity. Determining the clustering of SPADE symptoms in individuals with chronic painful CIPN may lead to targeted multifaceted interventions to improve physical function.

Impact of Electronic Self-Assessment and Self-Care Technology on Adherence to Clinician Recommendations and Self-Management Activity for Cancer Treatment-Related Symptoms: Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

Patients undergoing cancer treatment experience symptoms that negatively affect their quality of life and adherence to treatment. The early identification and management of treatment-related symptoms are critical to prevent symptom distress due to unmanaged symptoms. However, the early identification and management of treatment-related symptoms are complex as most cancer treatments are delivered on an outpatient basis where patients are granted less face-to-face time with clinicians. The Electronic Symptom Assessment and Self-Care (ESRA-C) promotes participant self-management of treatment-related symptoms by providing participants with communication coaching and symptom self-report, education, and tracking features. While the ESRA-C intervention has been demonstrated to improve symptom distress significantly, little is known as to how the ESRA-C influenced participants' self-management practices and adherence to clinician recommendations for symptom/quality of life issues (SQIs).

OBJECTIVE

To compare participant adherence to clinician recommendations and additional self-management strategy use for SQIs between ESRA-C intervention and control (electronic symptom assessment and participant symptom reports alone) group participants. Secondarily, we explored the impact of participant adherence to clinician recommendations and additional self-management strategy use for SQIs on symptom control, symptom management satisfaction, and symptom distress. Lastly, we examined baseline predictors of participant adherence to clinician recommendations and additional self-management strategy use for SQIs.

METHODS

This study presents an analysis of a randomized controlled trial. Participants beginning a new chemotherapy or radiotherapy regimen were recruited from oncology outpatient centers and were randomized to receive the ESRA-C intervention or control during treatment. Patients were included in this analysis if they remained on study through the duration of treatment and self-reported at least one bothersome SQI three-to-six weeks after beginning treatment. The Symptom Distress Scale-15 and Self-Management of SQIs Questionnaire were completed two weeks later. Based on Self-Management of SQIs Questionnaire ratings, participants were placed into adherence to clinician recommendations (adhered/did not adhere/did not receive recommendations) and additional self-management strategy use (yes/no) categories.

RESULTS

Most participants were adherent to clinician recommendations (273/370, 73.8%), while fewer used additional self-management strategies for SQIs (182/370, 49.2%). There were no differences in the frequency of participant adherence to clinician recommendations (chi-square test, P=.99) or self-management strategy use (chi-square test, P=.80) between intervention (n=182) and control treatment groups (n=188). Participants who received clinician recommendations reported the highest treatment satisfaction (n=355, P<.001 by analysis of variance; ANOVA), although lowest distress was reported by participants who did not follow clinician recommendations (n=322, P=.04 by ANOVA) for top 2 SQIs. Women (n=188) reported greater additional self-management strategy use than men (n=182, P=0.03 by chi-square test).

CONCLUSIONS

ESRA-C intervention use did not improve participants' adherence to clinician recommendations or additional self-management strategy use for SQIs in comparison to the control. Future research is needed to determine which factors are important in improving patients' self-management practices and symptom distress following ESRA-C use.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00852852; https://clinicaltrials.gov/ct2/show/NCT00852852 (Archived by WebCite at http://www.webcitation.org/73rEhNWkU).

Differential regulation of NF-kB and IRF target genes as they relate to fatigue in patients with head and neck cancer

Previous studies have linked plasma inflammatory markers to elevated fatigue in patients with head and neck cancer (HNC). To identify the molecular mechanisms underlying this association, we conducted promoter-based bioinformatics analyses to determine the relationship between fatigue and specific gene expression profiles associated with inflammation in human papillomavirus (HPV)-related and -unrelated HNC patients undergoing treatment. Patients with newly diagnosed HNC without distant metastasis were assessed at baseline (pre-radiotherapy) and one-month post-radiotherapy. Fatigue was measured by the Multidimensional Fatigue Inventory. Genome-wide gene expression profiles were collected from peripheral blood mononuclear cells (PBMC). Promoter-based bioinformatics analyses were employed to identify transcription control pathways underlying transcriptomic correlates of fatigue in the sample as a whole and in HPV-related and HPV-unrelated HNC patients separately. In transcriptome profiling analyses of PBMC from 44 patients, TELiS bioinformatics analyses linked fatigue to increased nuclear factor-kappa B (NF-kB) transcriptional activity and decreased interferon regulatory factor family (IRF) transcription factor activity. Patients with HPV-related HNC showed lower levels of fatigue-related gene expression profile compared to HPV-unrelated HNC. Fatigue in HNC patients undergoing treatment is associated with gene expression profiles consistent with the conserved transcriptional response to adversity (CTRA) characterized by increased proinflammatory and decreased anti-antiviral transcriptional activity. Interestingly, this CTRA response was mitigated in patients with HPV-related HNC and may explain the lower level of fatigue they experience relative to HPV-unrelated HNC.

Associations among human papillomavirus, inflammation, and fatigue in patients with head and neck cancer

BACKGROUND

Human papillomavirus (HPV) infection has contributed to an increased incidence of squamous cell carcinoma of the head and neck (SCCHN). Fatigue is a major side effect of SCCHN and its treatment. However, to the authors' knowledge, the association between HPV and fatigue has not been examined to date, nor is it known whether HPV influences biological mechanisms of fatigue, including inflammation.

METHODS

Patients with SCCHN who were without distant metastasis were assessed at baseline (pre-radiotherapy) and 1 month and 3 months postradiotherapy. Fatigue was measured using the Multidimensional Fatigue Inventory. Peripheral inflammation was assessed by plasma C-reactive protein (CRP), interleukin 1 receptor antagonist (IL-1ra), soluble tumor necrosis factor receptor 2 (sTNFR2), and IL-6. Mixed effect models were used to examine associations.

RESULTS

A total of 94 patients who were newly diagnosed were enrolled; 53% had HPV-related tumors. Patients with HPV-unrelated tumors had higher fatigue and higher plasma CRP, sTNFR2, and IL-6 over time, especially at baseline and 3 months after intensity-modulated radiotherapy compared with those with HPV-related tumors (all P < .05). However, fatigue and plasma sTNFR2 increased more significantly from baseline to 1 month after radiotherapy in the HPV-related group compared with the HPV-unrelated group (both P < .01). Controlling for significant covariates, HPV status and inflammation were found to be independent predictors of fatigue over time.

CONCLUSIONS

HPV status is an important marker of vulnerability to the behavioral and immune consequences of SCCHN and its treatment, providing support for different symptom management strategies. Special emphasis should be placed on addressing marked persistent fatigue in patients with HPV-unrelated tumors, whereas attention should be paid to the large increases in fatigue during treatment among patients with HPV-related tumors. Cancer 2018. © 2018 American Cancer Society.

Symptom Clusters in Patients With Pancreatic Cancer Undergoing Surgical Resection: Part II

OBJECTIVES

To explore the relationship between 16 symptom clusters (SCs), clinical and demographic influencing factors, and clinical outcomes over time in patients with pancreatic cancer (PC) undergoing surgical resection.

SAMPLE & SETTING

143 patients with stage II PC undergoing surgical resection were recruited to participate in this longitudinal, exploratory study conducted at Thomas Jefferson University Hospital, a National Cancer Institute-designated cancer center.

METHODS & VARIABLES

Quality of life was measured preoperatively and at three, six, and nine months postoperatively. Statistical methods included simple linear and Cox proportional hazard regression.

RESULTS

Preoperative pain was significantly associated with the pain-gastrointestinal SC, and preoperative worry was significantly associated with the mood SC. The strongest negative association with emotional well-being across all study time points was found with the preoperative mood SC. The insomnia-digestive problems SC and the nutritional problems SC demonstrated a trend toward poor survival.

IMPLICATIONS FOR NURSING

Findings provide evidence that preoperative worry and pain are associated with SC severity and that SCs may have a detrimental effect on quality of life and survival in patients with PC undergoing surgical resection.

Symptom Clusters in Patients With Pancreatic Cancer Undergoing Surgical Resection: Part I

OBJECTIVES

To describe patient-reported symptoms and symptom clusters in patients with pancreatic cancer (PC) undergoing surgical resection.

SAMPLE & SETTING

143 patients with stage II PC undergoing surgical resection alone or with subsequent adjuvant chemoradiation or chemotherapy were recruited to participate in a nested, longitudinal, exploratory study through convenience sampling techniques from Thomas Jefferson University Hospital, a National Cancer Institute-designated cancer center.

METHODS & VARIABLES

The Functional Assessment in Cancer Therapy-Hepatobiliary questionnaire was used to assess 17 PC symptoms preoperatively and at three, six, and nine months postoperatively. Exploratory and confirmatory factor analyses were used to identify symptom clusters.

RESULTS

Fatigue, trouble sleeping, poor appetite, trouble digesting food, and weight loss were consistently reported as the most prevalent and severe symptoms. Sixteen distinct symptom clusters were identified within nine months of surgery. Four core symptom clusters persisted over time.

IMPLICATIONS FOR NURSING

Findings may be used to provide anticipatory patient and family guidance and to inform clinical assessments of symptoms and symptom clusters in this population.