Psychological factors associated with head and neck cancer treatment and survivorship: evidence and opportunities for behavioral medicine

Prevalence of pain in a sample of long-term survivors of head and neck cancer

PURPOSE

The experience of long-term pain in head and neck cancer (HNC) survivors is important but has received less attention in the HNC literature. The present study sought to examine the prevalence of pain from 2 to 5 years postdiagnosis and its association with HNC-specific health-related quality of life.

MATERIALS & METHODS

Prospective observational study at a single-institution tertiary care center. Pain was measured using a single item ranging from 0 to 10 with 0 representing no pain and 10 representing worst pain possible at 2 through 5 years postdiagnosis. HNC-specific HRQOL was measured using the Head and Neck Cancer Inventory (HNCI).

RESULTS

Pain reports were consistent across time. At 2 years postdiagnosis (N = 581), 27.6 % experienced at least some pain with 14.3 % reporting moderate or severe pain. At 3 years postdiagnosis (N = 417), 21.4 % experienced at least some pain with 14.2 % indicating moderate or severe pain. At 4 years postdiagnosis (N = 334), 26.7 % experienced at least some pain with 15.9 % reporting moderate or severe pain. At 5 years postdiagnosis (N = 399), 30.5 % experienced at least some pain with 17.5 % indicating moderate or severe pain. In general, across all four HNCI domains, those in the moderate and severe pain categories largely failed to reach 70 which is indicative of high functioning on the HNCI.

CONCLUSIONS

Pain is a considerable issue in long-term HNC survivors up to 5 years postdiagnosis. More research is needed to understand correlates of pain after treatment, including opportunities for screening and intervention, to improve outcomes and optimize recovery in HNC.

Anxiety symptoms predict head and neck cancer survival: Exploring mediation by systemic inflammation and tumor response to treatment

BACKGROUND

Head and neck cancers (HNC) are associated with high rates of anxiety. Anxiety has been linked to biological pathways implicated in cancer progression, though little is known about its effects on overall survival. We hypothesized that higher pretreatment anxiety levels in patients with HNC would predict poorer 2-year overall survival and expected this relationship to be mediated by both systemic inflammation and tumor response to treatment.

METHODS

Patients (N = 394) reported anxiety symptomatology via the GAD-7 at treatment planning. Pre-treatment hematology workup provided an index of systemic inflammation (SII; N = 292). Clinical data review yielded tumor response and overall survival. Logistic and multiple regressions and Cox proportional hazard models tested hypothesized relationships.

RESULTS

Higher pretreatment anxiety levels were significantly associated with poorer 2-year survival (hazard ratio [HR], 1.039; 95% confidence interval [CI], 1.014-1.066, p = 0.002). The association between anxiety and SII was not significant, though anxiety was associated with poorer tumor response (odds ratio [OR], 1.033; 95% CI, 1.001-1.066, p = 0.043). Tumor response fully mediated the relationship between anxiety symptoms and 2-year survival (HR, 9.290, 95% CI, 6.152-14.031, p < 0.001).

CONCLUSIONS

Anxiety was associated with overall survival. Tumor response, but not systemic inflammation, emerged as a potential biological pathway mediating this effect. Screening for anxiety may be beneficial to help prospectively address these concerns and ameliorate potentially detrimental impact on clinically meaningful cancer outcomes.

Prevalence and persistence of depressive symptoms during the first year postdiagnosis in a large sample of patients with head and neck cancer

PURPOSE

The experience of persistent depressive symptomatology during the first year postdiagnosis has implications for recovery and adjustment by one year postdiagnosis. The present descriptive study sought to examine the prevalence and persistence of mild to moderate-severe depressive symptomology and associated disease-specific health-related quality of life (HRQOL) in patients with HNC.

MATERIALS & METHODS

This study was a prospective observational study at a single-institution tertiary cancer center. Depressive symptomatology was measured using the Beck Depression Inventory (BDI), captured at diagnosis and 3-, 6-, 9-, and 12-months postdiagnosis. HNC-specific HRQOL was measured using the Head and Neck Cancer Inventory (HNCI). Four subgroups were defined by BDI scores over time: persistent-moderate/severe subgroup, persistent-mild subgroup, transient subgroup, and resilient subgroup.

RESULTS

The distribution of patients (N = 946) was 65 (6.9 %) in the persistent-moderate/severe subgroup, 190 (20.1 %) in the persistent-mild subgroup, 186 (19.7 %) in the transient subgroup, and 505 (53.3 %) in the resilient subgroup. Across all four HNCI domains, patients in the persistent-moderate/severe subgroup failed to reach a score of 70 by 12-months postdiagnosis which is indicative of high functioning on the HNCI (aesthetics: M = 42.32, SD = 28.7; eating: M = 32.08, SD = 25.7; speech: M = 47.67, SD = 25.3; social disruption: M = 52.39, SD = 24.3). Patients in the persistent-mild subgroup failed to reach 70 in three of four domains. Patients in the resilient subgroup reached, on average, >70 on all HNCI domains.

CONCLUSIONS

Depression is a considerable issue during the first year postdiagnosis. Avenues for screening and intervention should be incorporated into HNC patient care per clinical practice guidelines to optimize recovery and HRQOL.

Understanding Barriers and Distress Experienced Among Cancer Patients: Analysis from an Urban Academic Emergency Department

The purpose of this study was to examine barriers and facilitators to compliance for cancer care in patients utilizing an emergency department (ED)-based assessment. Adult ED patients who either had active cancer or a history of cancer were enrolled between August 2020 and Jan 2022 for this prospective cohort study. We piloted the National Comprehensive Cancer Network (NCCN) Distress Thermometer. Multivariable regression analyses were used to assess the predictors of high distress. Of the 152 patients enrolled, 73% were Black patients, 11% were non-Hispanic White, and 16% included patients from other racial and ethnic groups (including 10.5% Hispanic patients); 73% of the sample had active cancer. The current ED visit was cancer related for 44%. The mean score on the Distress Thermometer was 4 (SD = 2; range 0-8) with 30% having a high distress level of ≥ 6. Having an active cancer and race/ethnicity were significant predictors of high distress. Patients who had active cancer had three times (aOR = 3.01; 95% CI 1.12-8.10) higher odds of experiencing high distress in the past week compared to those who did not have active cancer, after adjusting for race/ethnicity and reason for visit. Practical problems and physical problems were the most common, with 43% (n = 66) and 40% (n = 61) of the patients reporting these problems, respectively. Despite significant progress in cancer care, cancer patients/survivors face difficulty in transitioning between care environments and end up seeking episodic care in the ED and experience a high level of distress.

Rethinking treatment paradigms: Neoadjuvant therapy and de-escalation strategies in HPV-positive head and neck cancer

Head and neck cancer (HNC) is the 6th most common cancer across the world, with a particular increase in HNC associated with human papilloma virus (HPV) among younger populations. Historically, the standard treatment for this disease consisted of combined surgery and radiotherapy or curative platinum-based concurrent chemoradiotherapy, with associated long term and late toxicities. However, HPV-positive HNC is recognized as a unique cancer subtype, typically with improved clinical outcomes. As such, treatment de-escalation strategies have been widely researched to mitigate the adverse effects associated with the current standard of care without compromising efficacy. These strategies include treatment de-escalation, such as novel surgical techniques, alternative radiation technologies, radiation dose and volume reduction, as well as neoadjuvant chemotherapies, immunotherapies, and combined therapies. Although these therapies show great promise, many of them are still under investigation due to hesitation surrounding their widespread implementation. The objective of this review is to summarize the most recent progress in de-escalation strategies and neoadjuvant therapies designed for HPV-positive HNC. While specific treatments may require additional research before being widely adopted, encouraging results from recent studies have highlighted the advantages of neoadjuvant chemotherapy and immunotherapy, as well as radiation and surgical de-escalation approaches in managing HPV-positive HNC.

Examining the relationship between nutritional status and wound healing in head and neck cancer treatment: A focus on malnutrition and nutrient deficiencies

The research was conducted to examine the correlation between nutritional status and wound healing in individuals who were receiving treatment for head and neck cancer. Specifically, this study sought to identify crucial nutritional factors that influenced both the recovery process and efficacy of the treatment. From February 2022 to September 2023, this cross-sectional study was undertaken involving 300 patients diagnosed with head and neck cancer who were treated at Tianjin Medical University Cancer Institute and Hospital, Tianjin, China. In order to evaluate nutritional status, body mass index (BMI), serum protein levels and dietary intake records were utilized. The assessment of wound healing was conducted using established oncological wound healing scales, photographic documentation and clinical examinations. After treatment, we observed a noteworthy reduction in both BMI (p < 0.05) and serum albumin levels (p < 0.05). There was slightly increased prevalence of head and neck cancer among males (61.0%, p < 0.05). Over the course of 6 months, significant enhancement in wound healing scores was noted, exhibiting overall improvement of 86% in the healing process. An inverse correlation was identified between nutritional status and wound healing efficacy through multivariate analysis. A logistic regression analysis revealed a significant positive correlation (p < 0.05) between elevated levels of serum protein and total lymphocytes and enhanced wound healing. Conversely, negative correlation (p < 0.05) was observed between larger wound size at baseline and healing. The research findings indicated noteworthy association between malnutrition and impaired wound repair among individuals diagnosed with head and neck cancer. The results underscored the significance of integrating nutritional interventions into therapeutic protocol in order to enhance clinical results. This research study provided significant contributions to the knowledge of intricate nature of head and neck cancer management by advocating for multidisciplinary approach that incorporates nutrition as the critical element of patient care and highlighted the importance of ongoing surveillance and customized dietary approaches in order to optimize wound healing and treatment efficacy.

Survival-weighted quality of life profiles in patients treated for laryngeal and hypopharyngeal cancers

Objectives: This study assessed functional outcomes and quality of life (QoL) in the long term in individuals treated for laryngohypopharyngeal cancer (LHC) by estimating their life expectancy (LE), survival-weighted psychometric scores (SWPSs), and quality-adjusted LE (QALE). Materials and methods: To estimate survival outcomes, we retrospectively reviewed the data of 1576 patients treated for primary LHC between January 2010 and December 2018 and followed them until death or December 2020. We also prospectively collected QoL and functional data between October 2013 and November 2022 from 232 patients by administering the Taiwanese Chinese versions of the QoL Questionnaire Core 30, Head and Neck 35, and EQ-5D-3L. To estimate LE, we employed linear extrapolation of a logit-transformed curve. We calculated QALE and SWPSs by combining the QoL data with the LE results. Results: We estimated the LE of the patients with LHC to be 7.8 years and their loss of LE to be 15.7 years. The estimated QALE was 7.0 QALYs, with a loss of QALE of 16.5 QALYs. Lifetime impairment durations were estimated for cognitive (4.9 years), physical (4.2 years), emotional (3.4 years), social (3.4 years), and role functions (2.7 years). We estimated the durations of problems related to swallowing, speech, and teeth to be 6.2, 5.6, and 4.8 years, respectively. The patients were expected to be dependent on feeding tubes for 1.2 years. Conclusions: Patients with LHC experience significant reductions in both LE and QALE. SWPSs may constitute a valuable tool for obtaining subjective information regarding how LHC affects multifaceted QoL outcomes.

Management of nasal vestibule carcinomas: recommendations by the Oncological Committee of the Italian Society of Otorhinolaryngology - Head and Neck Surgery

Objective

Squamous cell carcinoma of the nasal vestibule (NV SCC) is a head and neck malignancy for which there is no established consensus on most aspects of clinical management. The purpose of this document is to give updated recommendations that incorporate recent evidence on its clinical characteristics and the high efficacy of brachytherapy as primary treatment modality.

Methods

A working group consisting of the members of the Scientific Committee for Oncology and Reconstructive Surgery of the Italian Society of Otorhinolaryngology Head and Neck Surgery and radiation oncologists expert in brachytherapy was formed to achieve a consensus.

Results

Consensus was reached on a set of recommendations, proposing a refined anatomical definition of the nasal vestibule, a novel T staging system of the NV SCC, and brachytherapy as standard of care, with a new method for catheter implantation.

Conclusions

The Committee emphasises the critical role of an accurate classification in clinical practice and encourages further research to validate the novel staging system and further improve treatment strategies. Where appropriate, it is recommended that patients be referred to centres with specific experience in brachytherapy for NV SCC.

Interventions to Reduce Psychosocial Burden in Head and Neck Cancer Patients: A Narrative Review

BACKGROUND

The diagnosis and treatment of head and neck cancer (HNC) is associated with several life-altering morbidities including change in appearance, speech, and swallowing, all of which can significantly affect quality of life and cause psychosocial stress.

COMMENTARY

The aim of this narrative review is to provide an overview of the evidence on psychosocial interventions for patients with HNC. Evidence regarding screening tools, psychological interventions, smoking and alcohol cessation, and antidepressant therapy in the HNC population is reviewed.

CONCLUSION

There is a large body of evidence describing various psychosocial interventions and several of these interventions have shown promise in the literature to improve psychosocial and health outcomes in the HNC population. Psychosocial interventions should be integrated into HNC care pathways and formal recommendations should be developed.

Examination of Predictors of Pain at 12 Months Postdiagnosis in Head and Neck Cancer Survivors

OBJECTIVE

Pain following the completion of treatment is important but has received less attention in the head and neck cancer (HNC) literature. The present study sought to examine the prevalence and predictors of pain measured 12 months postdiagnosis and its impact on HNC-specific health-related quality of life (HRQOL) in 1038 HNC survivors.

STUDY DESIGN

Prospective observational study.

SETTING

Single-institution tertiary care center.

METHODS

Pain was measured using a single item ranging from 0 to 10 with 0 representing no pain and 10 representing the worst pain possible. Self-reported depressive symptomatology was measured using the Beck Depression Inventory and self-reported problem alcohol use was measured by the Short Michigan Alcoholism Screening Test. HNC-specific HRQOL was measured using the Head and Neck Cancer Inventory (HNCI).

RESULTS

Hierarchical multivariable linear regression analyses indicated that in addition to pain at 3 months postdiagnosis (β = .145, t = 3.18, sr2  = .019, p = .002), both depressive symptomatology (β = .110, t = 2.49, sr2  = .011, p = .015) and problem alcohol use (β = .092, t = 2.07, sr2  = .008, p = .039) were significant predictors of pain at 12 months postdiagnosis. Subgroup analyses suggest that across all 4 HNCI domains, those in the moderate and severe pain groups at 12 months postdiagnosis failed to reach 70 which is indicative of high functioning.

CONCLUSION

Pain in patients with HNC is a considerable issue at 12 months postdiagnosis, deserving further attention. Behavioral factors such as depression and problem alcohol use may be associated with pain and require systematic screening over time to identify and treat issues that impact optimal long-term recovery from HNC, including disease-specific HRQOL.

Supportive Care Needs Among Head and Neck Cancer Patients Prior to Oncologic Treatment: A Prospective, Nested Cross-Sectional Qualitative Analysis

OBJECTIVES

To qualitatively characterize pretreatment head and neck cancer (HNC) patients' supportive care (SC) needs, attitudes toward SC, and barriers to SC utilization.

MATERIALS AND METHODS

A prospective, nested, bi-institutional, cross-sectional pilot study design was employed. Participants were sub-selected from a representative sample of 50 patients newly diagnosed with mucosal or salivary gland HNC or sarcoma of the head and neck. Eligibility criteria included reporting ≥2 unmet needs (according to the Supportive Care Needs Survey-Short Form 34) or clinically-significant distress (National Comprehensive Cancer Network Distress Thermometer score ≥4). Semi-structured interviews were performed prior to initiation of oncologic treatment. Audio-recorded interviews were transcribed and thematically analyzed using NVivo 12.0 (QSR Australia). Thematic findings and representative quotes were interpreted by the entire research team.

RESULTS

Twenty-seven patients were interviewed. One-third were treated at the county safety-net hospital and the remainder were treated at the university health system. An equal proportion of patients presented with oral cavity, oropharyngeal, and laryngeal or other tumors. Two significant findings were identified on semi-structured interviews. First, patients did not perceive the relevance of SC prior to treatment. Second, anxiety surrounding the HNC diagnosis and impending treatment dominated in the pretreatment phase.

CONCLUSION

Improved HNC patient education about the relevance and importance of SC in the pretreatment setting is needed. Integration of social work or psychological services in HNC clinics is warranted to address patients' cancer-related worry-a discrete, dominant pretreatment SC need.

Underserved head-and-neck and lung cancer patient characteristics are associated with caregiver participation in a clinical trial

Background

Patient-caregiver relationships affect cancer outcomes, yet factors related to joint enrollment in cancer research trials are unclear. This work examined associations between cancer patients' sociodemographic and health factors and their caregivers' trial participation.

Methods

Baseline data were drawn from a parent trial testing psychosocial interventions delivered to medically underserved head-and-neck cancer (HNC) and lung cancer (LC) patients (N = 274) and caregivers (N = 210). Logistic regression evaluated whether patient characteristics were associated with participating alone versus with a caregiver(s) and type of caregiver.

Results

Many patients (65.0%) had a caregiver in the study, which was more common for married (OR = 2.05, p < .01) and retired patients (OR = 1.95, p < .05). Patients who indicated Hispanic (OR = 2.31, p < .05), Medicaid insurance (OR = 4.12, p < .001), monthly income <$4000 (OR = 3.04, p < .01), and smoked (OR = 2.87, p < .01) were more likely to enroll with a non-spouse/partner caregiver versus a spouse/partner. Participation was unrelated to distress.

Conclusions

Patient characteristics highlight caregiver relationships, informing trial design and recruitment for medically underserved cancer populations. Psychosocial interventions targeting underserved patients and their informal caregivers, those most in need of intervention support, should consider the inclusion of non-spousal cancer caregivers. Understanding how patient factors may be associated with caregiver involvement informs recruitment strategies and increases the utility of psychosocial interventions.

The "Medicare effect" on head and neck cancer diagnosis and survival

BACKGROUND

Uninsured individuals age 55-64 experience disproportionately poor outcomes compared to their insured counterparts. Adequate coverage may prevent these delays. This study investigates a "Medicare-effect" on head and neck squamous cell carcinoma (HNSCC) diagnosis and treatment.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was queried for persons ages 60-70 years in the United States from 2000 to 2016 with HNSCC. A "Medicare effect" was defined as an increase in incidence, reduction in advanced stage presentation, and/or decrease in cancer-specific mortality (CSM).

RESULTS

Compared to their Medicaid or uninsured counterparts, patients age 65 have an increased incidence of HNSCC diagnosis, reduction in advanced stage presentation, decrease in cancer-specific mortality, and higher likelihood of receiving cancer-specific surgery.

CONCLUSIONS

Patients age 65 with Medicare have decreased incidence of HNSCC, less hazard of late-stage diagnosis, and lower cancer-specific mortality than their Medicaid or uninsured counterparts, supporting the idea of a "Medicare effect" in HNSCC.

Primary prevention of depression in head and neck cancer patients: a scoping review

OBJECTIVES

To conduct a scoping review of the literature on psychological interventions directed to identify primary prevention strategies for depression among adult head and neck cancer (HNC) patients.

METHODS

Systematic searches were conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Review including relevant studies within the PubMed, PsycINFO, and EMBASE databases. Two authors independently screened the searches and reviewed the included articles according to the predetermined eligibility criteria based on the PICOS format. Studies included subjects with previous or current diagnosis of depression were excluded. The risk of bias assessment of these trials was conducted following the Cochrane tool for assessing the risk of bias in randomized trials. The search was repeated prior to submission to ensure all current articles meeting criteria were included.

RESULTS

The search yielded 875 studies. The title and abstract screen, followed by the review of full texts identified five articles that met inclusion criteria. Four were randomized controlled trials (RCT) and the fifth was a non-randomized but controlled study. Different psychosocial interventions were used, including psycho-educational interventions, psychosocial counseling, and pharmacotherapy. All studies established the diagnosis of depression or screened for the diagnosis using standardized psychiatric assessment tools, either Diagnostic and Statistical Manual of Mental Disorders criteria or validated patient reported outcome measures. The average follow-up periods after intervention was 9.8 months. There was a significant decrease in the incidence of depression or depressive symptoms favoring the intervention group in three out of the five studies that were included.

CONCLUSION

Psychological interventions identified thus far studying primary prevention of depression in HNC patients show promising results. However, the paucity of data and heterogeneity of the interventions challenges the ability to compare the prevention modalities and outcomes. Future well-designed RCTs with large sample sizes are recommended to better conclude a result of effectiveness.

Empowering Cancer Survivors in Managing Their Own Health: A Paradoxical Dynamic Process of Taking and Letting Go of Control

In cancer care, gaps in support to help patients manage and live with the side-effects from cancer treatments have increased the emphasis on empowering patients to be more active and involved in managing their own health. However, empowerment in relation to promoting self-management behaviors is not well understood. Using the social constructivist grounded theory approach, our goal was to develop a theoretical understanding of this phenomenon in relation to the self-management behaviors of post-treatment cancer patients. Twenty-two post-treatment cancer patients participated in a semi-structured focused interview to co-construct with us how empowerment is defined, described, and experienced in relation to their capacity to self-manage. Through this co-construction, we defined empowerment as a process of personal growth, a display of fortitude and strength when participants confronted the impact of their illness that emerged in two dynamic and paradoxical ways: 1) establishing control over the impact of the illness as a means to maintain normalcy and to circumvent change over an eroding and changing sense of self and 2) relinquishing control over aspects of the illness deemed irrepressible and acknowledging and accepting change. When successful at establishing and/or relinquishing control, participants no longer viewed cancer as a threat, but re-interpreted their illness as also having a beneficial "empowering" experience and more capable of managing. Findings will guide the development of self-management interventions that use empowerment as a core construct.

Long-term Survivorship and Non-cancer Competing Mortality in Head and Neck Cancer: A Nationwide Population-Based Study in South Korea

PURPOSE

As the survival of head and neck cancer (HNC) improves, survivors increasingly confront non-cancer-related deaths. This nationwide population-based study aimed to investigate non-cancer-related deaths in HNC survivors.

MATERIALS AND METHODS

Data from the Korean Central Cancer Registry were obtained to characterize causes of death, mortality patterns, and survival in patients with HNC between 2006 and 2016 (n=40,890). Non-cancer-related mortality relative to the general population was evaluated using standardized mortality ratios (SMRs). The 5- and 10-year cause-specific competing risks probabilities of death (cumulative incidence function, CIF) and subdistribution hazards ratios (sHR) from the Fine-Gray models were estimated.

RESULTS

Comorbidity-related mortality was frequent in older patients, whereas suicide was predominant in younger patients. The risk of suicide was greater in patients with HNC than in the general population (SMR, 3.1; 95% confidence interval [CI], 2.7 to 3.5). The probability of HNC deaths reached a plateau at 5 years (5-year CIF, 33.9%; 10-year CIF, 39.5%), whereas the probability of non-HNC deaths showed a long-term linear increase (5-year, CIF 5.6%; 10-year CIF, 11.9%). Patients who were male (sHR, 1.56; 95% CI, 1.41 to 1.72), diagnosed with early-stage HNC (localized vs. distant: sHR, 1.86; 95% CI, 1.58 to 2.21) and older age (65-74 vs. 0-44: sHR, 6.20; 95% CI, 4.92 to 7.82; ≥ 75 vs. 0-44: sHR, 9.81; 95% CI, 7.76 to 12.39) had an increased risk of non-cancer mortality.

CONCLUSION

Non-HNC-related deaths continue increasing. HNC survivors are at increased risk of suicide in the younger and comorbidity-related death in the older. Better population-specific surveillance awareness and survivorship plans for HNC survivors are warranted.

The psychosocial experiences of human papillomavirus (HPV) positive oropharyngeal cancer patients following (chemo)radiotherapy: A systematic review and meta-ethnography

OBJECTIVE

The UK incidence of oropharyngeal cancer has risen sharply over the last 30 years with an increase in human papillomavirus (HPV) associated diagnoses, most prevalent in younger, working age populations. This meta-ethnography explores the psychosocial needs of HPV+ve oropharyngeal cancer patients during early recovery following (chemo)radiotherapy.

METHODS

Meta-ethnography methods were used, based on the approach of Noblit and Hare. Systematic searches for relevant qualitative studies were conducted in five electronic databases (MEDLINE, PubMed, CINAHL, PsycINFO and Cochrane database) between 2010 and 2021, followed by citation searching.

RESULTS

Twenty-three papers exploring the psychosocial needs of HPV+ve oropharyngeal cancer patients after treatment were included. Findings were synthesised to develop five constructs: 'gaps in continuity of support from healthcare professionals' reflecting unmet needs; 'changes to self-identity' revealing the comprehensive disruption of this disease and treatment; 'unrealistic expectations of recovery' highlighting the difficulty of preparing for the impact of treatment; 'finding ways to cope' describing the distinct complexity of this experience; and 'adjusting to life after the end of treatment' exploring how coping strategies helped patients to regain control of their lives.

CONCLUSIONS

Completing (chemo)radiotherapy signalled a transition from hospital-based care to home-based support, challenging patients to address the constructs identified. An unexpectedly difficult and complex recovery meant that despite a favourable prognosis, poor psychosocial well-being may threaten a successful outcome. The provision of tailored support is essential to facilitate positive adjustment.

An Overview on the Evidence of Physical Activity Interventions in the Health of Individuals with Head and Neck Cancer: Literature Systematic Review

Introduction: Head and neck cancer is considered a global public health problem, which arises in aesthetically and functionally critical areas. The practice of physical exercise has been considered one of the significant and effective non-pharmacological strategies to minimize the physical and psychological consequences. Objective: To analyze the evidence of physical activity interventions in the physical and psychological health of individuals with head and neck cancer. Method: A systematic review was conducted blindly and independently, from March to May 2021, according to the PRISMA guidelines. The search was performed in the following databases: PubMed Central®; Cochrane Library; Web of Science, Scopus, ScienceDirect. Results: Of the 515 selected studies, 15 were included in this systematic review with a total of 670 participants aged between 18 and 76 years old. The studies included aerobic exercises, endurance, mobility, stretching, strengthening, and yoga. Conclusion: Evidence proves that physical activity interventions performed with individuals with head and neck cancer may be beneficial in the treatment and physical/psychological health of this population. This study may help new researches considering the detailed information described previously regarding the interventions applied, in addition to discussing the most used instruments with this public and indicating the modalities that are being safely performed. It is suggested that more randomized trials be conducted to obtain more concise results.

Guided imagery for treatment (GIFT): protocol of a pilot trial of guided imagery versus treatment as usual to address radiotherapy-related distress in head and neck cancer

BACKGROUND

Cancers of the head and neck region are associated with high symptom burden and elevated levels of psychological distress. Radiotherapy (RT) is a common treatment for patients with head and neck cancer (HNC) that is associated with psychological distress related to the immobilizing nature of the treatment, frequency of treatment delivery, and side effects. Guided imagery is a relaxation technique that is beneficial in reducing psychological distress in patients with other cancer diagnoses but has not been studied in this patient population. The purpose of this study is to evaluate the feasibility and acceptability of a brief guided imagery intervention (guided imagery for treatment, GIFT) to reduce RT-related anxiety and depression in patients with HNC relative to treatment as usual (TAU).

METHODS

Patients with HNC planning to receive RT will be recruited to participate in a randomized controlled trial evaluating a brief, two-session guided imagery intervention (GIFT) relative to TAU alone. Primary aims include acceptability and feasibility evaluated through quantitative and qualitative methods. Measures of anxiety and depression, symptom burden, health-related quality of life, and anxiolytic medication use will be collected at baseline, during treatment, and at 1-month follow-up.

DISCUSSION

There are no published interventions of guided imagery for anxiety and depression in patients with HNC despite its efficacy in other populations of patients with cancer. This proposed project evaluates the feasibility and acceptability of an intervention that has the potential to reduce psychological distress in a vulnerable population. Additionally, we will preliminarily examine the impact of behavioral intervention on psychological distress and the use of anxiolytic medication, a novel area of study.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03662698 ; registered on 9/6/2018.

Considerations for developing supportive care interventions for survivors of head and neck cancer: A qualitative study

OBJECTIVE

This study aimed to describe considerations for developing supportive care interventions targeted to head and neck cancer (HNC) survivors.

METHODS

One-time semi-structured interviews (N = 33) were conducted with HNC survivors who had recently finished treatment (n = 20) and HNC providers (e.g., physicians, nurses; n = 13). Interviews were transcribed verbatim and coded using inductive applied thematic analysis techniques to identify themes.

RESULTS

HNC survivors (75% male; M = 61 years old) and providers (54% physicians; 62% female) were unanimously supportive of developing HNC-specific supportive care interventions. Participants described potential benefits of offering interventions at various points throughout the HNC treatment and survivorship trajectory rather than at a single critical time. Many participants preferred group-based interventions because of the high value of peer-support. Others described how group interventions may not be appropriate for all HNC survivors due to risks for negative social comparisons and exacerbated anxiety. Participants suggested topics that should be addressed in HNC-specific interventions including education about acute and long-term side effects, symptom management, nutritional support, relationship/social role changes, grief/loss, and fear of recurrence.

CONCLUSIONS

HNC-specific supportive care interventions are critically needed, as survivors experience persistent symptoms and distinct psychosocial concerns that impact quality of life. Findings from this study can inform the development of supportive care interventions targeted to the unique psychosocial concerns of HNC survivors.

A Qualitative Study of Patient and Healthcare Provider Perspectives on Building Multiphasic Exercise Prehabilitation into the Surgical Care Pathway for Head and Neck Cancer

Head and neck cancer (HNC) surgical patients experience a high symptom burden. Multiphasic exercise prehabilitation has the potential to improve patient outcomes, and to implement it into the care pathway, the perspectives of patients and healthcare providers (HCPs) must be considered. The purpose of this study was thus to gather feedback from HNC surgical patients and HCPs on building exercise into the standard HNC surgical care pathway. Methods: Semi-structured interviews were conducted with patients and HCPs as part of a feasibility study assessing patient-reported outcomes, physical function, and in-hospital mobilization. Interview questions included satisfaction with study recruitment, assessment completion, impact on clinical workflow (HCPs), and perceptions of a future multiphasic exercise prehabilitation program. This study followed an interpretive description methodology. Results: Ten patients and ten HCPs participated in this study. Four themes were identified: (1) acceptability and necessity of assessments, (2) the value of exercise, (3) the components of an ideal exercise program, and (4) factors to support implementation. Conclusion: These findings highlight the value of exercise across the HNC surgical timeline from both the patient and the HCP perspective. Results have informed the implementation of a multiphasic exercise prehabilitation trial in HNC surgical patients.

Implementing a Tailored Psychosocial Distress Screening Protocol in a Head and Neck Cancer Program

OBJECTIVES/HYPOTHESIS

Psychosocial distress is common among patients with head and neck cancer (HNC) and is associated with poorer quality of life and clinical outcomes. Despite these risks, distress screening is not widely implemented in HNC care. In this study, we investigated the prevalence of psychosocial distress and its related factors in routine care of patients with HNC.

METHODS

Data from medical records between September 2017 and March 2020 were analyzed. Psychosocial distress was measured by the National Comprehensive Cancer Network's Distress Thermometer (DT), and a modified HNC-specific problem list; depression and anxiety were assessed using the Patient Health Questionnaire-4. Descriptive statistics and logistic regression were conducted to report prevalence of distress, depression and anxiety, and factors associated with clinical distress. Implementation outcomes, including rates of referrals and follow-up for distressed patients, are also reported.

RESULTS

Two hundred and eighty seven HNC patients completed the questionnaire (age 64.3 ± 14.9 years), with a mean distress score of 4.51 ± 3.35. Of those, 57% (n = 163) reported clinical distress (DT ≥ 4). Pain (odds ratio [OR] = 3.31, 95% CI = 1.75-6.26), fatigue (OR = 2.43, 95% CI = 1.1.7-5.05), anxiety (OR = 1.63, 95% CI = 1.30-2.05), and depression (OR = 1.51, 95% CI = 1.04-2.18) were significantly associated with clinical distress (P < .05). Of patients identified as distressed, 79% received same-day psychosocial evaluation.

CONCLUSIONS

Clinical distress was identified in 57% of patients who completed the questionnaire, suggesting that an ultra-brief psychosocial screening protocol can be implemented in routine ambulatory oncology care, and identifies patients whose distress might otherwise go unrecognized.

LEVEL OF EVIDENCE

4 Laryngoscope, 132:1600-1608, 2022.

A biochemical research focused on the association of the levels of oxidative stress and nitric oxide with premalignant disorders and oral squamous cell carcinoma

CONTEXT

The reactive oxygen species such as superoxide radicals (O2 •), hydroxyl radicals (OH•), and hydrogen peroxide play a vital role in the pathogenesis of human cancer development and have become one of the areas of key interest in the field of biochemical analysis.

AIMS

The present study was designed to determine the significance of oxidative stress and levels of nitric oxide (NO) in patients with premalignant disorders and oral squamous cell carcinoma (OSCC), by evaluating the levels of lipid peroxidation products, antioxidants, and NO products.

SETTINGS AND DESIGN

The present study was conducted on 280 patients for 2 years. These patients were divided into 4 groups, Group I (n = 70, control), Group II (n = 70, oral submucous fibrosis), Group III (n = 70, OSCC), and Group IV (n = 70, OL).

SUBJECTS AND METHODS

The levels of lipid peroxidation products, antioxidants, and NO products were determined by colorimetric methods.

STATISTICAL ANALYSIS USED

Paired t-test was used to compare the mean.

RESULTS

Lipid peroxidation products such as lipid hydroperoxide and malondialdehyde and NO products such as nitrite (NO2-), nitrate (NO3-), and total nitrite (TNO2-) were significantly elevated, whereas enzymatic and nonenzymatic antioxidants were significantly lowered in OSCC, oral submucous fibrosis, and oral leukoplakia when compared to normal healthy participants. The P values were calculated and came as statistically significant (<0.05).

CONCLUSIONS

Antioxidant enzyme impairment and NO status may be considered as one of the factors responsible for oral cancer pathogenesis and may serve as a promising biomarker and therapeutic target for minimizing malignant transformation in oral premalignant disorders.

Supporting Patient Autonomy in Shared Decision Making for Individuals With Head and Neck Cancer

PURPOSE

Management of head and neck cancer (HNC) can result in substantial long-term, multifaceted disability, leading to significant deficits in one's functioning and quality of life (QoL). Consequently, treatment selection is a challenging component of care for patients with HNC. Clinical care guided by shared decision making (SDM) can help address these decisional challenges and allow for a more individualized approach to treatment. However, due in part to the dominance of biomedically oriented philosophies in clinical care, engaging in SDM that reflects the individual patient's needs may be difficult.

CONCLUSIONS

In this clinical focus article, we propose that health care decisions made in the context of biopsychosocial-framed care-one that contrasts to decision making directed solely by the biomedical model-will promote patient autonomy and permit the subjective personal values, beliefs, and preferences of individuals to be considered and incorporated into treatment-related decisions. Consequently, clinical efforts that are directed toward biopsychosocial-framed SDM hold the potential to positively affect QoL and well-being for individuals with HNC.

Palliation of head and neck cancer: a review of the unique difficulties

Each year, there are 11 900 new diagnoses of head and neck cancers in the UK, with around 4000 deaths. Survival rates are higher for those diagnosed earlier, however, patients are often diagnosed later, with 20% palliative at the time of diagnosis. There is a scarcity of head and neck cancer palliative care literature available. This review article aims to discuss the unique challenges of head and neck cancer palliation. It specifically focusses on the challenges of pain management, airway obstruction, dysphagia, haemorrhage and the psychology of palliative head and neck cancer management. This article explores the advantages and disadvantages of many of the different treatment options available. It is hoped that this article will highlight the unique difficulties encountered by patients with head and neck cancer towards the end of their life and offer insights and suggestions to improve patients' quality of life in their final weeks and months.

Problem alcohol and tobacco use in head and neck cancer patients at diagnosis: associations with health-related quality of life

Purpose

Problem alcohol and tobacco use in patients with head and neck cancer (HNC) frequently co-occur and each are associated with poor outcomes including health-related quality of life (HRQOL). The purpose of this descriptive exploratory study was to identify the prevalence of these co-occurring behaviors and associations with HNC-specific HRQOL within the first year of diagnosis in a large sample of patients with HNC.

Methods

Cross-sectional study examined prevalence of co-occurring problem alcohol and tobacco use at diagnosis in a large sample of patients with HNC (N = 1327). Problem alcohol use was assessed using the Short Michigan Alcoholism Screening Test (SMAST); patients were classified as current/previous/never smokers based on self-reported tobacco use. HNC-specific HRQOL was assessed using the Head and Neck Cancer Inventory (HNCI), measured at diagnosis and 3 and 12 months postdiagnosis.

Results

Three hundred twenty-five of 1327 (24.5%) scored 3 + on the SMAST at diagnosis, suggesting problem alcohol use and nearly 30% (28.4%) were current smokers. Of those with problem alcohol use, 173 (53.2%) were also current smokers. In total, 173 of 1327 (13.0%) exhibited both behaviors at diagnosis. Covariate-adjusted mean HNCI scores suggest that patients classified as both problem drinkers and current smokers have lower HRQOL scores during the first year postdiagnosis in multiple HNC-specific domains.

Conclusion

HNC patients should be screened for alcohol and tobacco use at diagnosis. Multimodal behavioral health interventions may provide one avenue for improved access and outcomes, particularly for patients at distance, and deserve further study in HNC.

Examination of risk factors for discontinuation of follow-up care in patients with head and neck cancer

BACKGROUND

Little research has examined discontinuation of follow-up care in patients with head and neck cancer. This exploratory study sought to examine key demographic, disease, and behavioral factors as possible correlates of discontinuation (N = 512).

METHODS

Cross-sectional study examined correlates of discontinuation of follow-up care within 1 year. The primary outcome was defined as a disease-free survivor not returning to cancer clinic for two consecutive follow-up appointments within the first year of care and not reentering oncologic care at any point thereafter. Demographic, disease, and behavioral factors were examined using multivariable logistic regression.

RESULTS

One hundred twenty-six (24.6%) patients discontinued by 12-month follow-up. Being unmarried (OR = 1.28, 95% CI = 1.01-1.63, p = 0.041) and having elevated depressive symptomatology (OR = 1.04, 95% CI = 1.01-1.07, p = 0.034) were significantly associated with discontinuation. Receipt of a single (vs. multimodal) treatment approached significance (OR = 1.71, 95% CI = 0.96-3.07, p = 0.071).

CONCLUSION

Approximately one quarter of patients disengaged from important follow-up care within 1 year. Lack of social support, depressive symptomatology, and single treatment modality may be important correlates of discontinuation of care in patients with head and neck cancer. Additional studies of this outcome are needed. Improved understanding of correlates associated with discontinuation could facilitate the identification of at-risk patients and further development of interventions to keep patients engaged at a crucial time in the survivorship care trajectory.

Trajectory of anxiety related to radiation therapy mask immobilization and treatment delivery in head and neck cancer and radiation therapists’ ability to detect this anxiety. “Anxiety during radiation therapy with mask”

Purpose

Receiving radiation therapy treatment with an immobilization mask is a source of anxiety in people with head and neck cancer (HNC). This study aimed to document the trajectory of situational anxiety during HNC treatment delivery and explore radiation therapists’ (RTs’) ability to identify it.

Methods and Materials

Participants with HNC commencing radiation therapy completed the state-trait anxiety inventory at their mask-making session, and once each week immediately before and after their radiation treatment. Treating RTs independently rated their perception of participant's anxiety at the same time points. Participant- and RT-rated anxiety scores were calculated at each time point together with the proportion of participants reporting clinically significant anxiety (state-trait anxiety inventory ≥ 40). Intraclass correlations were calculated to assess concordance between participant- and RT-ratings.

Results

Sixty-five participants and 16 RTs took part in this study. Participants were classified into 1 of 5 trajectory groups: stable high (16%), increasing (19%), decreasing (27%), fluctuating (19%), and no anxiety (19%). Nearly half (43%) of participants reported clinically significant anxiety before their mask-making session, and between 30% and 43% across trajectories reported significant anxiety immediately before treatments. Intraclass correlation values indicated poor agreement between participant- and RT-ratings.

Conclusions

Situational anxiety is prevalent in people receiving HNC radiation therapy with mask immobilization. RTs did not reliably capture patients’ situational anxiety. There is no single best time point to provide intervention, suggesting people should be screened for anxiety regularly throughout their treatment. Resources and education should also be available to improve RT skills in providing psychosocial support.

Psychological variables associated with quality of life in patients with head and neck cancer: the role of body image distress

OBJECTIVE

The aim of this cross-sectional study was to explore the relationship between quality of life (QoL) and body image distress in patients with head and neck cancer (HNC), considering relevant psychological variables (i.e., coping strategies, social anxiety symptoms, self-esteem, intolerance of uncertainty, pain, and distress). We also aimed to explore gender differences in patients with HNC in terms of relevant psychological variables in HNC.

METHODS

Fifty-one HNC patients (37 males and 14 females) completed self-report questionnaires to assess body image distress, physical and mental QoL, and relevant psychological variables in HNC (coping strategies, social anxiety symptoms, self-esteem, intolerance of uncertainty, pain, and distress) before undergoing treatment. Pearson's correlations and four-step hierarchical regressions were performed to assess the relationship between body image distress, QoL, and the abovementioned psychological variables, while one-way analyses of variance and one-way analysis of covariance were employed to assess gender differences.

RESULTS

Physical QoL was associated with body image distress above and beyond disease duration, distress, coping strategies, pain, mental QoL, and self-esteem, while mental QoL was associated with pain above and beyond distress, coping strategies, physical QoL, self-esteem, and body image distress. Concerning gender differences, females scored higher than males on most of the explored psychological variables, except for physical QoL and intolerance of uncertainty, and showed lower mental QoL and self-esteem than males.

CONCLUSION

Body image distress and pain emerged as negatively associated with QoL, and almost all the explored psychological variables differed among genders. Psychological interventions targeting body image distress and pain should be promoted in patients with HNC to increase their QoL, while keeping gender differences in mind.

Health-related quality of life in head and neck cancer survivors: Evaluating the rural disadvantage

PURPOSE

Head and neck cancer (HNC) survivors often experience distress and health-related quality of life (HRQOL) impairment. Research suggests that rural cancer patients may have poorer outcomes than urban patients. This study examined whether HNC patient emotional and HRQOL outcomes differ in those living in a rural versus urban location at 6 and 12 months postdiagnosis.

METHODS

A total of 261 HNC patients were included from a longitudinal study of HNC outcomes. The majority were diagnosed with advanced stage cancer (51.3%); the most common cancer site was oral cavity (41.0%). Rurality was measured using the US Department of Agriculture Rural Urban Commuting Area codes. Depression was measured using the Beck Depression Inventory (BDI), general HRQOL using the Short Form-36 (SF-36), and HNC-specific HRQOL using the Head and Neck Cancer Inventory (HNCI). Analyses were 2 (group) × 3 (assessment) repeated measures ANCOVAs, controlling for demographic and clinical characteristics.

FINDINGS

Approximately 45% of the sample lived in a rural location. Follow-up comparisons of significant overall models indicated that rural patients reported significantly more nonsomatic depression symptoms at 6-month follow-up. Rural patients were also more likely to report significantly poorer general mental HRQOL at 12-month follow-up, significantly poorer HNC-specific HRQOL related to eating at 6- and 12-month follow-up, and marginally worse aesthetics at 12-month follow-up.

CONCLUSIONS

These findings are consistent with suggestions that rural HNC patients may be at heightened risk for depression symptoms and decrements in HRQOL. Patients should be screened and regularly monitored for issues with depression and HNC-specific HRQOL throughout the survivorship period.

Short-Term Relocation Stress-Induced Hematological and Immunological Changes in Saimiri boliviensis boliviensis

Nonhuman primates are frequently transported to a new location or temporarily relocated within their colony. Both transportation and relocation expose animals to new environments, causing them to undergo a stress response (before adapting). In our NHP colony, the mentioned situations are not infrequent for many reasons, including maintenance. The objective of this study was to determine whether abrupt changes consisting of relocation, housing, separation, and grouping could influence hematological and immunological parameters and thereby functional activity. The current study used squirrel monkeys as a model to investigate the stress-inducing effects of relocation within a facility, while animals acclimated to new situations (physical, housing). A detailed blood analysis revealed significant changes in lymphocytes, triglycerides, total protein, creatinine, and ALT. Flow cytometric analysis of peripheral blood showed reduction in CD3+, CD4+, and CD8+ T cells and monocytes, while B cells and natural killer (NK) cells changed with relocation. Simultaneously, changes in functional activity of immune cells altered proliferative responses and as shown by ELISpot (IFN γ). Though the parameters studied are not affected as severely as those in animals transported by road or air, stress responses induced by intrafacility relocation are significant and worth consideration. Our findings indicate that squirrel monkeys mimic the features seen in humans exposed to social stressors and may serve an important model for understanding the mechanisms of stress-induced immune dysfunction in humans.

Survival-Weighted Health Profiles in Patients Treated for Advanced Oral Cavity Squamous Cell Carcinoma

Objectives

For patients with oral cavity squamous cell carcinoma (OSCC), particularly for those with advanced disease, quality of life (QoL) is a key outcome measure. Therefore, we estimated survival-weighted psychometric scores (SWPS), life expectancy (LE), and quality-adjusted LE (QALE) in patients with advanced OSCC.

Methods and Materials

For estimation of survival function, we enrolled 2313 patients with advanced OSCC diagnosed between January 1, 2007, and December 31, 2013. The patients were followed until death or December 31, 2014. To acquire the QoL data, data from 194 patients were collected by employing the Taiwan Chinese versions of the Quality of Life Questionnaire Core 30 and Quality of Life Questionnaire Head and Neck 35 developed by the European Organisation for Research and Treatment of Cancer and the EQ-5D-3L between October 1, 2013, and December 31, 2017. The LE of the patients with OSCC were estimated through linear extrapolation of a logit-transformed curve. SWPS and QALE were determined by integrating the LE and corresponding QoL outcomes.

Results

For the patients with advanced OSCC, the estimated LE and QALE were 8.7 years and 7.7 quality-adjusted life years (QALYs), respectively. The loss of LE and QALE was 19.0 years and 20.0 QALYs, respectively. The estimated lifetime impairments of swallowing, speech, cognitive functioning, physical functioning, social functioning, and emotional functioning were 8.3, 6.5, 6.5, 6.1, 5.7, and 5.4 years, respectively. The estimated lifetime problems regarding mouth opening, teeth, social eating, and social contact were 6.6, 6.1, 7.5, and 6.1 years, respectively. The duration of feeding tube dependency was estimated to be 1.6 years.

Conclusions

Patients with advanced OSCC had an estimated LE of 8.7 years and QALE of 7.7 QALYs. SWPS provided useful information regarding how advanced OSCC affects the subjective assessment of QoL. Our study results may serve as a reference for the allocation of cancer treatment resources.

Rehabilitation Needs of Head and Neck Cancer Patients and Stakeholders: Case Study

Background

The incidents of Head and Neck Cancer (HNC) are rising worldwide, suggesting that this type of cancer is becoming more common. The foreseen growth of incidents signifies that future rehabilitation services will have to meet the needs of a wider population.

Objective

The aim of this paper is to explore the needs of patients, caregivers and healthcare professionals during HNC rehabilitation.

Methods

This paper reports the empirical findings from a case study that was conducted in a cancer rehabilitation center in Copenhagen to elicit the needs of HNC cancer patients, informal caregivers and healthcare professionals.

Results

Four areas of needs during the rehabilitation process were identified: service delivery, emotional, social and physical needs. Service delivery needs and emotional needs have been identified as the most prevalent.

Conclusions

Stakeholders' needs during the rehabilitation process were found to be interrelated. All stakeholders faced service delivery challenges in the form of provision and distribution of information, including responsibilities allocation between municipalities, hospitals and rehabilitation services. Emotional and social needs have been reported by HNC patients and informal caregivers, underlining the importance of inclusion of all actors in the design of future healthcare interventions. Connected Health (CH) solutions could be valuable in provision and distribution of information.

Association Between Objective Ratings of Swallowing and Dysphagia-Specific Quality of Life in Patients Receiving (Chemo)radiotherapy for Oropharyngeal Cancer

The pervasive nature of dysphagia in the head/neck cancer (HNC) population necessitates a comprehensive evaluation approach, including both objective assessment of dysphagia, and subjective patient-reported functional measures. However, the congruence between clinician-rated and patient-perceived function is still not well understood. The current study investigated the association between objective clinician-rated swallow physiology (using the MBSImP) and patient-reported measures of swallowing-related quality of life (using the MDADI) in a secondary analysis of patients with oropharyngeal HNC treated with (chemo)radiotherapy. Seventy-nine patients with oropharyngeal HNC receiving (chemo)radiotherapy completed a standardised videofluoroscopic swallow study (VFSS) rated using the MBSImP, and the MDADI, at pre-treatment (baseline), 6 weeks and 3 months post-treatment as per a previous prospective RCT. Data on n = 67 participants were analysed as part of the secondary analysis. Association between MBSImP oral and pharyngeal composite scores versus MDADI Global and subscale scores was examined using ordinary least squares regression and mixed-effects general linear modelling (GLM). Univariable analyses demonstrated significant associations between MBSImP oral composite scores and each of the MDADI subscales, as well as the MBSImP pharyngeal composite scores and all MDADI subscales. GLM analysis revealed significant associations were maintained between MBSImP pharyngeal scores and the MDADI global and emotional subscale scores at the multivariable level, with the physical subscale trending towards significance. No significant association was observed between the MBSImP oral composite scores and any of the MDADI subscales at the multivariable level. This study found significant associations between objective measures of pharyngeal swallow physiology and patient-perceived swallowing-related quality of life. These findings suggest a higher degree of concordance between clinician-rated and patient-reported measures up to 3 months post-(C)RT than previously reported.

Identifying Patient-Reported Outcome Measures (PROMs) for Routine Surveillance of Physical and Emotional Symptoms in Head and Neck Cancer Populations: A Systematic Review

The aims of this review were to identify symptoms experienced by head and neck cancer (HNC) patients and their prevalence, as well as to compare symptom coverage identified in HNC specific patient-reported outcome measures (PROMs). Searches of Ovid Medline, Embase, PsychInfo, and CINAHL were conducted to identify studies. The search revealed 4569 unique articles and identified 115 eligible studies. The prevalence of reported symptoms was highly variable among included studies. Variability in sample size, timing of the assessments, and the use of different measures was noted across studies. Content mapping of commonly used PROMs showed variability and poor capture of prevalent symptoms, even though validation studies confirmed satisfactory reliability and validity. This suggests limitations of some of the tools in providing an accurate and comprehensive picture of the patient's symptoms and problems.

Association of depressive symptomatology with problem alcohol use in rural head and neck cancer patients at diagnosis

PURPOSE

Problem alcohol use is a risk factor for the development of head and neck cancer (HNC) and continued use is associated with poor outcomes; depressive symptoms may be associated with this behavior.

DESIGN

Exploratory cross-sectional study examined depressive symptoms as a correlate of self-reported problem alcohol use at diagnosis.

SAMPLE/METHODS

Multivariable linear regression examined depressive symptoms as a correlate of problem alcohol use in a sample of rural HNC patients (N = 249).

FINDINGS

Over half (55.2%) of rural patients with potentially problem alcohol use exhibited mild to moderate depressive symptomatology. Regression models controlling for age, cancer site, stage, sex, tobacco use, and treatment modality indicated that depressive symptoms at diagnosis were associated with self-reported problem alcohol use scores at diagnosis (ß = .186, sr² = .031, p < .01). Follow-up subgroup analyses demonstrated that depressive symptoms at diagnosis were significantly associated with self-reported problem alcohol use in male patients, those with advanced stage disease, and of older age.

CONCLUSIONS/IMPLICATIONS

HNC patients should be screened for alcohol use and depression at diagnosis. Access to behavioral health treatment and/or referral options may be lacking in rural areas thus additional ways of connecting rural patients to specialty care should be explored. These may include telehealth and multimodal interventions to address complex behavioral health cases. Additional research in important patient subgroups such as older patients and those presenting with advanced disease is also warranted.

Resilience: an essential element in head and neck cancer survivorship and quality of life

PURPOSE

Individuals with head and neck cancer (HNCa) face myriad biopsychosocial challenges. Even after treatment completion, these challenges may cause continued disablement and diminished quality of life (QoL). Resilience may serve to minimize the disabling impact of HNCa and, in turn, maximize QoL. The purpose of this study was to formally assess resilience in HNCa survivors and explore its relationship with QoL.

METHODS

A cross-sectional descriptive study was conducted. Forty HNCa survivors completed three validated, self-report questionnaires pertaining to the collection of resilience and QoL data. Descriptive and correlational analyses were performed.

RESULTS

Resilience was identified in HNCa survivors and a positive correlation was found between resilience and QoL.

CONCLUSIONS

Data suggest that resilience may buffer the influence of HNCa on QoL. Thus, screening for reduced levels of resilience may proactively facilitate identification of those who are most vulnerable to the psychosocial impact of HNCa. Interventions that foster resilience may ameliorate the challenges of HNCa and maximize QoL.

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.

Barriers to Comprehensive Multidisciplinary Head and Neck Care in a Community Oncology Practice

Complex, coordinated, and collaborative care of patients with head and neck cancer can be challenging yet amazingly rewarding and successful. The high symptom burden across multiple functional domains in patients with head and neck cancer, even in early stages of disease, mandates a multidisciplinary team approach that harnesses the combined contributions of physicians and ancillary providers to drive greater patient-centered care, addressing factors that heavily influence morbidity, mortality, and quality of life. Well-organized community-based multidisciplinary teams fulfill this unmet need and benefit patients with conveniently located comprehensive services that are typically found in large academic centers. Equivalent, if not superior, outcomes can be achieved in a unified community-based multidisciplinary team with shared patient-centered and outcomes-based goals. However, implementing true multidisciplinary team care in today's complex health care environment is fraught with challenges and pitfalls. So how have some community-based practices managed to create safe and efficient programs with successful outcomes? The purpose of this review is to discuss barriers to reaching this success and emphasize practical solutions to such challenges.

Problem alcohol use among rural head and neck cancer patients at diagnosis: Associations with health-related quality of life

OBJECTIVE

Problem alcohol use in persons with head and neck cancer (HNC) is associated with poor outcomes, including survival. Some evidence suggests that individuals living in rural areas may be at greater risk of problem alcohol use. The present exploratory cross-sectional study sought to examine problem alcohol use at diagnosis in a sample of HNC patients by rural versus urban status.

METHODS

Self-reported problem alcohol use as measured by the Short Michigan Alcoholism Screening Test (SMAST) was examined in rural and urban HNC patients at diagnosis (N = 454). Multivariable linear regression analysis was conducted to examine correlates of problem alcohol use. Subgroup analyses examined HNC-specific health-related quality of life (HRQOL) by problem drinking status at diagnosis and 3- and 12-month postdiagnosis in rural patients.

RESULTS

Multivariable linear regression analysis controlling for age, cancer site, cancer stage, depressive symptoms at diagnosis, and tobacco use at diagnosis indicated that rural residence was significantly associated with SMAST scores at diagnosis such that rural patients were more likely to report higher scores (ß = 0.095, sr2  = 0.010, p = 0.04). Covariate-adjusted subgroup analyses suggest that rural patients with self-reported problem alcohol use may exhibit deficits in HNC-specific HRQOL at diagnosis and 3- and 12-month postdiagnosis.

CONCLUSIONS

HNC patients should be screened for problem alcohol use at diagnosis and counseled regarding the deleterious effects of continued drinking during treatment and beyond. Because access to treatment and referral options may be lacking in rural areas, additional ways of connecting rural patients to specialty care should be explored.

Neoadjuvant and adjuvant end-points in health technology assessment in oncology

Health technology assessment (HTA) of clinical and economic value of a new intervention is an integral step in providing the access of patients to innovative cancer care and treatment. Overall survival (OS) is the preferred criterion for demonstrating the therapeutic efficacy in HTA given its direct clinical and patient relevance. However, with often long life expectancy of patients with early cancer, analysis of OS becomes less practical. Partially due to this reason, pathological complete response (pCR) and time-to-event end-points like disease-free survival are frequently incorporated into the pivotal clinical trials in the neoadjuvant and adjuvant settings. However, there exists a discrepancy between different national HTA bodies regarding the acknowledgement of patient relevance of these end-points. In this article, we analysed the perspectives of patients on different aspects of end-points used in clinical trials in early cancer. Gathered evidence strongly suggests that complete tumour eradication and reduced risk of recurrence provide important psychological benefits thus signifying that pCR and time-to-event end-points are directly relevant to patients. Additionally, we reviewed opinions on patient relevance of neoadjuvant and adjuvant therapy end-points adopted by HTA bodies during the recent evaluations. We found that improvements in end-points used in the adjuvant setting were commonly considered as valuable to patients. In contrast, opinions on patient relevance of neoadjuvant therapy end-points varied between the national HTA bodies. Universal acknowledgement of patient relevance of therapeutic end-points for early cancer by HTA bodies is necessary to balance the inequality in uptake of innovative therapies into national healthcare systems.

European white paper: oropharyngeal dysphagia in head and neck cancer

PURPOSE

To develop a European White Paper document on oropharyngeal dysphagia (OD) in head and neck cancer (HNC). There are wide variations in the management of OD associated with HNC across Europe.

METHODS

Experts in the management of specific aspects of OD in HNC across Europe were delegated by their professional medical and multidisciplinary societies to contribute to this document. Evidence is based on systematic reviews, consensus-based position statements, and expert opinion.

RESULTS

Twenty-four sections on HNC-specific OD topics.

CONCLUSION

This European White Paper summarizes current best practice on management of OD in HNC, providing recommendations to support patients and health professionals. The body of literature and its level of evidence on diagnostics and treatment for OD in HNC remain poor. This is in the context of an expected increase in the prevalence of OD due to HNC in the near future. Contributing factors to increased prevalence include aging of our European population (including HNC patients) and an increase in human papillomavirus (HPV) related cancer, despite the introduction of HPV vaccination in various countries. We recommend timely implementation of OD screening in HNC patients while emphasizing the need for robust scientific research on the treatment of OD in HNC. Meanwhile, its management remains a challenge for European professional associations and policymakers.

Head and Neck Cancer Treatments from Chemotherapy to Magnetic Systems: Perspectives and Challenges

BACKGROUND

Cancer is one of the diseases causing society's fears as a stigma of death and pain. Head and Neck Squamous Cell Carcinoma (HNSCC) is a group of malignant neoplasms of different locations in this region of the human body. It is one of the leading causes of morbidity and mortality in Brazil, because these malignant neoplasias, in most cases, are diagnosed in late phases. Surgical excision, chemotherapy and radiotherapy encompass the forefront of antineoplastic therapy; however, the numerous side effects associated with these therapeutic modalities are well known. Some treatments present enough potential to help or replace conventional treatments, such as Magnetic Hyperthermia and Photodynamic Therapy. Such approaches require the development of new materials at the nanoscale, able to carry out the loading of their active components while presenting characteristics of biocompatibility mandatory for biomedical applications.

OBJECTIVE

This work aims to make a bibliographical review of HNSCC treatments. Recent techniques proven effective in other types of cancer were highlighted and raised discussion and reflections on current methods and possibilities of enhancing the treatment of HNSCC.

METHOD

The study was based on a bibliometric research between the years 2008 and 2019 using the following keywords: Cancer, Head and Neck Cancer, Chemotherapy, Radiotherapy, Photodynamic Therapy, and Hyperthermia.

RESULTS

A total of 5.151.725 articles were found, 3.712.670 about cancer, 175.470 on Head and Neck Cancer, 398.736 on Radiotherapy, 760.497 on Chemotherapy, 53.830 on Hyperthermia, and 50.522 on Photodynamic Therapy.

CONCLUSION

The analysis shows that there is still much room for expanding research, especially for alternative therapies since most of the studies still focus on conventional treatments and on the quest to overcome their side effects. The scientific community needs to keep looking for more effective therapies generating fewer side effects for the patient. Currently, the so-called alternative therapies are being used in combination with the conventional ones, but the association of these new therapies shows great potential, in other types of cancer, to improve the treatment efficacy.

Cancer and Stress: Does It Make a Difference to the Patient When These Two Challenges Collide?

Simple Summary

Head and neck cancers are the sixth most common cancer in the world. The burden of the disease has remained challenging over recent years despite the advances in treatments of other malignancies. The very use of the word malignancy brings about a stress response in almost all adult patients. Being told you have a tumour is not a word anyone wants to hear. We have embarked on a study which will investigate the effect of stress pathways on head and neck cancer patients and which signalling pathways may be involved. In the future, this will allow clinicians to better manage patients with head and neck cancer and reduce the patients’ stress so that this does not add to their tumour burden.

Abstract

A single head and neck Cancer (HNC) is a globally growing challenge associated with significant morbidity and mortality. The diagnosis itself can affect the patients profoundly let alone the complex and disfiguring treatment. The highly important functions of structures of the head and neck such as mastication, speech, aesthetics, identity and social interactions make a cancer diagnosis in this region even more psychologically traumatic. The emotional distress engendered as a result of functional and social disruption is certain to negatively affect health-related quality of life (HRQoL). The key biological responses to stressful events are moderated through the combined action of two systems, the hypothalamus–pituitary–adrenal axis (HPA) which releases glucocorticoids and the sympathetic nervous system (SNS) which releases catecholamines. In acute stress, these hormones help the body to regain homeostasis; however, in chronic stress their increased levels and activation of their receptors may aid in the progression of cancer. Despite ample evidence on the existence of stress in patients diagnosed with HNC, studies looking at the effect of stress on the progression of disease are scarce, compared to other cancers. This review summarises the challenges associated with HNC that make it stressful and describes how stress signalling aids in the progression of cancer. Growing evidence on the relationship between stress and HNC makes it paramount to focus future research towards a better understanding of stress and its effect on head and neck cancer.

Coping With Oral Tongue Cancer and COVID-19 Infection

To date, April 19, 2021, the coronavirus disease 2019 (COVID-19) caused about 140,886,773 confirmed cases and more than 3,000,000 deaths worldwide since the beginning of the pandemic. Oncology patients are usually frail due to the fear of prognosis, recurrence, and outcomes of treatments. Thus, coping with cancer is a complicated process that is necessary to overcome oncological challenge, even more in case of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) disease. This is a brief case report on a middle-aged man affected by advanced oral tongue cancer and COVID-19, describing his experience of cancer diagnosis, surgical treatment, and rehabilitation during the hospital quarantine for COVID-19. Besides the traumatic experience due to the functional alteration in breathing, eating, and speaking caused by major surgery and the concurrent facial disfigurement, our patient had to face a COVID-19 diagnosis, which implied hospital and social isolation. The aim of this perspective work is to focus on the role of the psychological support in the management of hospital distress related to COVID-19 psychophysical loneliness or alienation. In our experience, such support should anticipate patients' oncological surgery or treatment and should be implemented through telemedicine in case of isolation or after hospital discharge.

Perspectives of Esophageal Cancer Survivors on Diagnosis, Treatment, and Recovery

Simple Summary

An esophageal cancer diagnosis signals the start of a difficult period of health-related physical, psychological, and social challenges. To date, relatively few studies have explored the diagnosis, treatment, and recovery experiences of esophageal cancer survivors. Esophageal cancer diagnosis and treatment pose challenges to all aspects of wellbeing, and necessitate an extended period of recovery. As such, supportive education and rehabilitative interventions must encompass a range of strategies to help survivors maintain an adequate quality of life during treatment and recovery. This study aimed to examine patient experiences of esophageal cancer diagnosis, treatment, and recovery, to enable researchers and health professionals to better understand the education and rehabilitative needs of esophageal cancer survivors.

Abstract

Esophageal cancer poses challenges to all domains of wellbeing. This qualitative study aimed to explore the experiences of esophageal cancer diagnosis, treatment, and recovery, with a view to informing the health education needs of this group. Eighteen persons who had undergone an esophagectomy participated in one of four audio-taped focus groups in a specialist hospital for cancer care. Transcriptions were analyzed thematically. Fear and uncertainty underpinned all stages of diagnosis, treatment, and recovery. Participants emphasized: (a) a lack of understanding over what to expect throughout treatment and recovery; (b) the demanding and traumatic period of adjustment required as a result of changes to their physical, psychological, and social functioning; and, (c) that support provided by family, friends, and acquaintances was variable and uninformed, often to the point of being counterproductive to physical and psychosocial recovery. Tailored education is needed to enable patients to prepare for each stage of their cancer journey. Equally, families and wider social networks should receive education that enables them to provide esophageal cancer survivors with appropriate support. Education should be provided at intervals that enable patients, survivors, and support networks to prepare for the physical, emotional, and social challenges experienced during diagnosis, treatment, and recovery.