Return to work in head and neck cancer survivors: its relationship with functional, psychological, and disease-treatment factors

PURPOSE

Return to work (RTW) is important for survivors of head and neck cancer (HNC). The purposes of the study were to investigate the RTW ratio among HNC survivors and identify factors significantly affecting RTW in this population.

METHODS

A cross-sectional study with consecutive sampling was conducted in a medical center in Taiwan, with 111 patients with HNC who had completed major treatments within 5 years and were employed before their cancer diagnosis enrolled as participants. Cervical range of motion (CROM) functionality, handgrip and hip flexor strength, maximal mouth opening (MMO), selected symptoms, depression, and disease/treatment-related factors were assessed. All of the factors were analyzed using t-test, chi-square test, and multiple logistic regression.

RESULTS

Less than half (44.1%, n = 49) of the participants had returned to work. The t-test/chi-square test results showed the RTW group to be younger in age and better educated; have better handgrip/hip flexor strength, MMO, and CROM; have less speech difficulty and pain; and have less-advanced cancer than the non-RTW group. Further analysis of the above significant variables by logistic regression revealed early cancer stage, dominant handgrip strength, and less speech difficulty were the robust factors related to RTW.

CONCLUSIONS

The RTW ratio is low in HNC survivors. RTW in HNC survivors is a multifactorial and complicated issue and needs to be further examined.

IMPLICATIONS FOR CANCER SURVIVORS

Assessing the factors related to RTW systematically and developing comprehensive interventions and rehabilitation programs to reduce related dysfunctions are necessary to enhance RTW ability in HNC survivors.

A prospective evaluation of neck and shoulder function following treatments of early-stage human papillomavirus-associated oropharynx cancer

OBJECTIVES

To compare post-treatment neck and shoulder function between human papillomavirus-associated oropharynx squamous cell carcinoma (HPV + OPSCC) treatments.

DESIGN

Prospective, repeated-measures study.

SETTING

Tertiary care center.

PARTICIPANTS

Treatment-naïve patients with American Joint Committee on Cancer eighth edition stage T0-3/N0-2 HPV+OPSCC.

MAIN OUTCOME MEASURES

Patients completed the Neck Dissection Impairment Index (NDII) pre-treatment and 3-months and 1-year post-treatment. The NDII assesses 10 neck and shoulder functions scored 0-5 (total score 0-100), with higher scores suggesting better function.

RESULTS

A total of 106 patients underwent: surgery alone (SA, n = 46, 43%), surgery with adjuvant radiation ± chemotherapy (S + a[C]XRT, n = 18, 17%), or definitive radiation ± chemotherapy (d[C]XRT, n = 42, 40%). cTN classification and pre-treatment NDII scores did not differ between groups. SA patients reported worsened 3-month post-treatment versus pre-treatment self-care (4.6 vs. 5.0), lifting light (4.6 vs. 5.0) and heavy (4.2 vs. 4.8) objects, overhead reach (4.5 vs. 4.9), activity (4.5 vs. 4.9), socialization (4.7 vs. 4.9), recreation (4.6 vs. 4.9), and overall score (86.8 vs. 95.3) (all p < 0.05). One-year post-treatment scores (n = 34) were no different than pre-treatment in all domains. S + a[C]XRT patients reported worsened 3-month versus pre-treatment stiffness (4.0 vs. 4.8), lifting heavy objects (3.8 vs. 4.9), overhead reach (4.2 vs. 4.9), socialization (4.6 vs. 5.0), recreation (4.4 vs. 4.9) and overall score (82.4 vs. 96.0) (all p < 0.05). One-year post-treatment scores (n = 13) were no different than pre-treatment in all domains. d[C]XRT patients reported worsened 3-month versus pre-treatment difficulty lifting heavy objects (4.3 vs. 4.7) and recreation (4.3 vs. 4.7). One-year posttreatment scores (n = 21) were no different than pre-treatment in all domains.

CONCLUSION

HPV + OPSCC patients may experience mild shoulder/neck dysfunction 3 months after treatment that usually resolves by 1 year, independent of treatment modality.

Does Age Affect the Rate of Spinal Nerve Injury after Selective Neck Dissection? Age as a Prognostic Factor of Spinal Nerve Injury after Selective Neck Dissection

OBJECTIVE

The objective of this study is to investigate whether age is a significant risk factor for spinal nerve injury following selective neck dissection (SND) in patients with head and neck cancer.

METHODS

A retrospective cohort study was conducted on patients who had undergone SND for head and neck cancer at a tertiary hospital between 2020 and 2022. The primary outcome was the incidence of spinal nerve injury after SND. The secondary outcomes included the types and severity of spinal nerve injury and the impact of age on these outcomes.

RESULTS

A total of 78 patients were included in the study and subdivided into two groups. Two shoulder-specific questionnaires (the Shoulder Pain and Disability Index (SPADI) and the Shoulder Disability Questionnaire (SDQ)) were administered to assess shoulder morbidity postoperatively. Twelve patients showed shoulder impairment following surgery. We divided the sample into two age-based groups; the older group showed a higher rate of SAN injury and the younger group showed a lower rate of improvement over time.

CONCLUSION

This study suggests that age is a significant risk factor for spinal nerve injury following SND in patients with head and neck cancer. Older patients are more likely to experience spinal nerve injury after SND than younger patients. The findings of this study may help in the development of strategies to prevent spinal nerve injury in older patients undergoing SND for head and neck cancer.

The effects of myofascial induction therapy in survivors of head and neck cancer: a randomized, controlled clinical trial

PURPOSE

We aim to evaluate the effects of myofascial induction therapy (MIT) on the sequelae suffered by the survivors of HNC (sHNC).

METHODS

We enrolled 46 sHNC in a randomized controlled trial (RCT), of whom 20 received a MIT protocol and 23 were placed on a waitlist while receiving the recommended treatment for 6 weeks. The MIT protocol included a total of 18 sessions, 3 days a week on alternate days for 6 weeks. Maximal mouth opening, the presence of temporomandibular dysfunction, cervical endurance, active range of motion (AROM), shoulder AROM, handgrip strength, and perceived physical fitness were assessed.

RESULTS

Maximal mouth opening, temporomandibular dysfunction, cervical endurance, and AROM, affected shoulder abduction and unaffected shoulder flexion and external rotation significantly improved (p < .05) after an MIT protocol, but only cervical AROM and affected shoulder abduction changes were clinically meaningful. No statistically significant changes were observed in the other shoulder AROM, handgrip strength, or physical fitness perception (p > .05).

CONCLUSION

A 6-week MIT protocol improves mouth opening, TMD, cervical function (endurance and AROM), affected shoulder abduction and unaffected shoulder flexion, and external rotation AROM in the sHNC. However, no changes were observed in most of the shoulder AROM, muscular strength, or perceived physical fitness. Future studies should perform longer follow-up designs, increase the sample size, and include multimodal treatments to address these sequelae in the sHNC.

Neck and Shoulder Morbidity in Patients with Oral Cancer and Clinically Negative Node Neck Status: A Comparison between the Elective Neck Dissection and Sentinel Lymph Node Biopsy Strategies

The choice for the most optimal strategy for patients with a cT_1-2N₀ carcinoma of the oral cavity, sentinel lymph node biopsy (SLNB) or elective neck dissection (END), is still open for debate in many head and neck cancer (HNC) treatment centers. One of the possible benefits of the less invasive SLNB could be reduced neck and shoulder morbidity. Recent studies have shown a benefit in favor of SLNB the first year after intervention, but the long-term consequences and differences in neck morbidity remain unclear. This cross-sectional study aimed to research differences in neck and shoulder morbidity and Health-Related Quality of Life (HR-QoL) in patients with a cT_1-2N₀ carcinoma of the oral cavity, treated with either END or SLNB. Neck and shoulder morbidity and HR-QOL were measured with patient-reported questionnaires (SDQ, SPADI, NDI, NDII, EORTC-QLQ-C30, EORTC-QLQ-HN35) and active range of motion (AROM) measurements. In total 18 patients with END and 20 patients with SLNB were included. We found no differences between END and SLNB for long-term neck morbidity, shoulder morbidity, and HR-QOL. The significant differences found in the rotation of the neck are small and not clinically relevant.

FUNCTIONAL EXERCISE EVALUATION ON ATHLETES’ CERVICALGIA MANAGEMENT

ABSTRACT Introduction Cervicalgia generally refers to the pain syndrome caused by the cervical spine, joints, muscles, ligaments, fascia, soft tissues around the shoulder joint, and visceral diseases. Evidence suggests that resistance exercises are beneficial in solving this dysfunction in various groups, but there is no consensus in athletes. Objective This paper examines functional exercises’ effect on athletes’ cervicalgia. Methods Using mathematical statistics, the article randomizes equally the intensity of cervicalgia in the control and experimental groups, involving 60 individuals aged 18 to 20 years (31 males). While the control group received conventional rehabilitation treatment, the experimental group had a functional exercise training protocol three times a week, of 10 weeks. The pain was assessed by visual analog scale and self-assessment of functional limitation. Results Differences in shoulder and neck pain were found between the two groups of volunteers before and after the training rehabilitation. A complete improvement was seen in 15 subjects in the experimental group versus 8 in the control group (P<0.05). Conclusion Functional exercise effectively treats cervicalgia in athletes. Evidence Level II; Therapeutic Studies - Investigating the result.

Decreased muscle strength and scapular muscle endurance associated with shoulder function after neck dissection

BACKGROUND

Shoulder disability is a common problem following neck dissection. Even if nerve structures are preserved, this may occur after the surgery.

OBJECTIVE

The primary aim was to research changes in rotator cuff and scapular muscles strength, and scapular muscle endurance after neck dissection in patients with head and neck cancer. The secondary aim was to investigate the relationship between these changes and postoperative shoulder function.

METHODS

This cross-sectional and prospective follow-up study included 14 patients who underwent neck dissection (9 unilateral and 5 bilateral). Evaluations were performed preoperatively and at 3 months postoperatively. Muscle strength measurements, including trapezius, serratus anterior, and rotator cuff muscles, were obtained using a handheld dynamometer. The scapular muscle endurance test was used for muscle endurance assessment. Postoperative shoulder function was evaluated using Constant-Murley shoulder score.

RESULTS

A decrease in muscle strength and the scapular muscle endurance test was found at 3 months postoperatively, except for the subscapularis muscle strength (p< 0.05). There were moderate to strong correlations between Constant-Murley shoulder score and percentage changes in muscle strength and the scapular muscle endurance test, except for the upper trapezius muscle strength (p< 0.05).

CONCLUSIONS

Muscle strength and scapular muscle endurance may reduce following neck dissection. These reductions are associated with postoperative shoulder function. Thus, muscle strength and endurance training may be beneficial for early postoperative rehabilitation in patients with head and neck cancer.

Myofascial Induction Therapy Improves the Sequelae of Medical Treatment in Head and Neck Cancer Survivors: A Single-Blind, Placebo-Controlled, Randomized Cross-Over Study

Head and neck cancer (HNC) is the sixth most common cancer worldwide. Yet, less than 60% of HNC survivors receive adequate therapy for treatment-related sequelae. The objective of this study was to determine the efficacy of myofascial induction therapy (MIT) in improving cervical and shoulder pain and range of motion, maximal mouth opening, and cervical muscle function in HNC survivors. This crossover, blinded, placebo-controlled study involved 22 HNC survivors (average age 56.55 ± 12.71) of which 13 were males (59.1%) who received, in a crossover fashion, both a single 30-min session of MIT in the form of manual unwinding and simulated pulsed shortwave therapy (placebo), with a 4-week washout interval between the two. Cervical and shoulder pain (visual analogue scale) and range of motion (cervical range of motion device and goniometer), maximum mouth opening (digital caliper), and cervical muscle function (deep cervical flexor endurance test) were measured before and after the treatment and placebo sessions. A single session of MIT improved cervical and affected side shoulder pain, cervical range of motion, maximum mouth opening, and cervical muscle function. The associated effect sizes ranged from moderate to large. The present study suggests that MIT, in the form of manual unwinding, improves cervical (−3.91 ± 2.77) and affected-side shoulder (−3.64 ± 3.1) pain, cervical range of motion (flexion: 8.41 ± 8.26 deg; extension: 12.23 ± 6.55; affected-side rotation: 14.27 ± 11.05; unaffected-side rotation: 11.73 ± 8.65; affected-side lateroflexion: 7.95 ± 5.1; unaffected-side lateroflexion: 9.55 ± 6.6), maximum mouth opening (3.36 ± 3.4 mm), and cervical muscle function (8.09 ± 6.96 s) in HNC survivors.

The Role of IONM in Reducing the Occurrence of Shoulder Syndrome Following Lateral Neck Dissection for Thyroid Cancer

Lateral neck dissection (LND) leads to a significant morbidity involving accessory nerve injury. Modified radical neck dissection (MRND) aims at preservation of the accessory nerve, but patients often present with negative functional outcomes after surgery. The role of neuromonitoring (IONM) in the prevention of shoulder syndrome has not yet been defined in comparison to nerve visualization only. We retrospectively analyzed 56 thyroid cancer patients who underwent MRND over a period of six years (2015–2020) in a high-volume institution. Demographic variables, type of surgical procedure, removed lymph nodes and the metastatic node ratio, pathology, adoption of IONM and shoulder functional outcome were investigated. The mean number of lymph nodes removed was 15.61, with a metastatic node ratio of 0.2745. IONM was used in 41.07% of patients, with a prevalence of 68% in the period 2017–2020. IONM adoption showed an effect on post-operative shoulder function. There were no effects in 89.29% of cases, and temporary and permanent effects in 8.93% and 1.79%, respectively. Confidence intervals and two-sample tests for equality of proportions were used when applicable. Expertise in high-volume centres and IONM during MRND seem to be correlated with a reduced prevalence of accessory nerve lesions and limited functional impairments. These results need to be confirmed by larger prospective randomized controlled trials.

Physical activity and fitness in survivors of head and neck cancer

PURPOSE

The purposes of the study were (1) to assess the physical activity (PA) status, muscle strength (MS), and flexibility of survivors of head and neck cancer (HNC) and compare these findings with normative data from national labor fitness measures; (2) to examine the differences among PA subgroups, as categorized using Godin's scores; and (3) to examine the association between stretching exercises and cervical range of motion (CROM).

METHODS

A cross-sectional study with consecutive sampling was used to recruit HNC survivors from a medical center in Northern Taiwan who had completed either radiation therapy (RT) or multimodality treatments including RT within the current 5 years. The level of PA, daily function, fatigue, quality of life (QOL), MS (handgrip and hip flexor), BMI, and flexibility (CROM and fingertip-to-floor tests) of the participants were assessed.

RESULTS

A total of 108 participants completed the assessments from 135 eligible patients (80% response rate). Although 60.2% reported engaging in PA, only 16.7% met WHO guidelines. Compared to subjects in the normative data, the survivors of HNC in this study had poorer handgrip strength, BMI, and CROM, but better forward flexion. The participants who were consistent with WHO PA guidelines reported less fatigue, better right hip flexor MS, and better QOL than those who did not engage in any PA.

CONCLUSION

Lack of sufficient PA and generally poorer fitness were found in study subjects. Longitudinal research to explore changes in fitness and barriers to PA compliance is strongly suggested to better enhance HNC patients' PA and fitness.

Identifying unmet needs and limitations in physical health in survivors of Head and Neck Cancer

Objective

To gain insight into the level of unmet needs and limitations in physical health experienced by survivors of head and neck cancer, and to evaluate whether unmet needs in physical health and limitations in physical performance are associated.

Materials and methods

In this cross‐sectional study, unmet needs were measured with Supportive Care Needs Surveys (SCNS‐SF34, SCNS‐HNC). Limitations in physical health were measured for maximal mouth opening, neck and shoulder function, hand grip strength and lower body strength, level of mobility and walking ability.

Results

The SCNSs showed that 48% had a cancer generic unmet need and 46% had at least one HNC‐specific unmet need. In total, 76% of sHNC had a cancer generic limitation in physical health and that 58% had an HNC‐specific limitation in the mobility of neck and shoulders or maximum mouth opening. The domain of physical and daily living needs showed a weak association with lateral flexion of the neck to the left (R = −0.319; p = 0.024).

Conclusion

Survivors of HNC might benefit from the use of both SCNSs and physical performance measurements during usual care follow‐up for early and optimal identification of unmet needs and limitations in physical health.

Subjective and Objective Measures in Assessing Neck Disability and Pain in Head and Neck Cancer

OBJECTIVE/HYPOTHESIS

The intensification of treatment for head and neck cancers (HNCs) has created a cohort of patients living with short- and long-term comorbidities and functional deficits. This study aimed to determine whether there is a relationship between patient-reported outcomes (PROs) and objective measures of neck function in survivors of HNCs.

STUDY DESIGN

Cross-sectional study.

METHODS

Thirty-one subjects (aged 64 ± 8.7 years; 28 males and three females) were recruited and completed the Neck Disability Index (NDI) and a numeric pain scale. At the same visit, subjects were fitted with two portable motion sensors to collect range of motion (ROM) and velocity data. Differences between ROM, velocity, and PRO subgroups were assessed using a one-tailed t test (*P < .05). The Pearson correlation coefficient (r) was calculated between the NDI values and the ROM and velocity values for each motion.

RESULTS

A moderate correlation (r = 0.507) was observed between NDI and neck pain. Patients with no disability according to the NDI had significantly higher ROM and velocity than patients with mild to moderate disability. Velocity in all degrees of freedom (axial rotation, flexion and extension, and lateral bending) was significantly lower for patients who perceived higher levels of neck pain and neck disability.

CONCLUSIONS

This study notes that patients who report neck disability and pain have more limited ROM and velocity following HNC treatment. These data may improve treatment planning and care delivery by facilitating an understanding of the experiences of HNC survivors and the pathophysiology that must be targeted to address their psychosocial and functional deficits.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:2015-2022, 2021.

Perineural invasion, lactate dehydrogenase, globulin, and serum sodium predicting occult metastasis in oral cancer

OBJECTIVE

This study aimed to develop a nomogram to predict the neck occult metastasis in early (T1-T2 cN0) oral squamous cell carcinoma (OSCC).

MATERIALS AND METHODS

The nomogram was developed in a training cohort of 336 early OSCC patients and was validated in a validation cohort including 88 patients. Independent predictors were calculated by univariate and multivariate logistic regression analyses.

RESULTS

In univariate logistical regression analysis, gender, perineural invasion (PNI), blood vessel invasion, mean corpuscular hemoglobin, aspartate aminotransferase, prealbumin, globulin (GLO), lactate dehydrogenase (LDH), serum sodium (NA), and serum chloride were significant associated with neck occult metastasis. Multivariate logistical regression analysis identified PNI (p < .001), LDH (p = .003), GLO (p = .019), and NA (p = .020) as independent predictors of neck occult metastasis. Cut-off values for LDH, GLO, and NA obtained from AUC were 142.5, 26.35, and 139.5, respectively. The nomogram based on PNI and categorical GLO, LDH, and NA exhibited a strong discrimination, with a C-indexes of 0.748 (95%CI = 0.688 to 0.810) in the training cohort and 0.751 (95%CI = 0.639 to 0.863) in the validation cohort.

CONCLUSIONS

A nomogram based on PNI, LDH, GLO, and NA for predicting the risk of neck lymph nodes occult metastasis in OSCC could help surgeons with therapy decision-making.

Predictive Value of Occult Metastasis and Survival Significance of Metabolic Tumor Volume Determined by PET-CT in cT1-2N0 Squamous Cell Carcinoma of the Tongue

Objectives

Our goal was to analyze the possibility of using metabolic tumor volume (MTV) to predict occult cervical metastasis and survival in cT1-2N0 squamous cell carcinoma (SCC) of the tongue.

Methods

Data on the primary tumor MTV and cervical node status as determined by the maximum standardized uptake value were retrieved. The sensitivity and specificity in predicting occult metastasis were calculated with a fourfold table. Associations between occult metastasis and clinicopathological variables were evaluated by univariate and multivariate analyses. The main study endpoints were locoregional control (LRC) and disease-specific survival (DSS).

Results

A total of 24 (20.3%) of 118 patients had occult metastasis. An MTV cutoff value of 4.3 cm³ showed a sensitivity of 50.0% and a specificity of 76.6% in predicting occult metastasis. The sensitivity and specificity of PET-CT in predicting occult metastasis in cT1 tumors were 66.6 and 89.8%, respectively, with values of 83.3 and 67.3%, respectively, when combined with the MTV. The sensitivity and specificity of PET-CT in predicting occult metastasis in cT2 tumors were 72.2 and 82.2%, respectively, with values of 88.9 and 57.8%, respectively, when combined with the MTV. Patients with MTV ≥4.3 cm³ had a higher occult metastasis rate than patients with MTV <4.3 cm³. The 5-year LRC and DSS rates were 86 and 94%, respectively, in patients with MTV <4.3 cm³ and 54 and 72%, respectively, in patients with MTV ≥4.3 cm³. Both differences were found to be significant in univariate and multivariate analyses.

Conclusions

MTV ≥4.3 cm³ was associated with an increased probability of occult metastasis and lower LRC and DSS rates in early-stage SCC of the tongue.

Long-term donor site morbidity after radial forearm flap elevation for tongue reconstruction: Prospective observational study

BACKGROUND

To assess long-term donor site morbidity after radial forearm free (RFF) flap harvesting.

METHODS

Enrolled patients were asked to complete the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire and undergo wrist motion and hand strength examinations at different time points. The data were prospectively collected and retrospectively analyzed.

RESULTS

The postoperative DASH score did not return to normal until 24 months after the operation. The mean postoperative wrist motion degree of flexion was significantly decreased compared to the preoperative level and returned to normal at 12 months after the operation. Similar trends were noted regarding extension, radial abduction, and ulnar abduction. The mean postoperative grip strength was significantly decreased compared to the preoperative level and remained dysfunctional at 24 months after the operation. A similar trend was also noted with regard to tip pinch and key pinch.

CONCLUSION

The long-term negative effect on hand strength is sustained.

Reproducibility of measurements on physical performance in head and neck cancer survivors; measurements on maximum mouth opening, shoulder and neck function, upper and lower body strength, level of physical mobility, and walking ability

Background

Survivors of Head and Neck Cancer experience specific problems in functional performance. The aim of this study was to obtain the test-retest reliability of measurements on Maximal Mouth Opening (MMO), shoulder and neck function, lower and upper body strength, level of mobility and walking ability.

Materials and methods

Test-retest study design. Measurements on MMO (intra- and extra orally), Active range of motion of shoulders and neck, 30 Seconds Chair Stand Test, Grip Strength, Timed Up and Go test, and Six Minute Walk test.

Results

In total 50 participants were included. The mean age was 68.6. ± 9.9 years and median time since end of treatment was 3.0 years (Q1–Q3: 1.0–5.25 years). We found good to excellent test-retest reliability on the core set of measurements (Intraclass Correlation Coefficient (ICC) 0.77 to 0.98). Measurement of MMO with cardboard card, forward flexion shoulder and Six Minute Walk test had a relatively small measurement error (Smallest Detectable Change (SDC) % 5.4% - 15.1%). Measurement of MMO with a caliper, shoulder abduction, shoulder external rotation, later flexion and rotation of the neck, grip strength, 30 Seconds Chair Stand Test, and Timed up and Go test had a relatively large measurement error (SDC% 19.8% - 44.7%).

Conclusion

This core set of measurements on physical performance is found reliable and therefore able to differentiate in physical performance. The reported measurement errors should be taken into consideration when interpreting the results of repeated measurements.

Implications for cancer survivors

A core set of physical measurements can be used to measure physical performance in survivors of Head and Neck Cancer.