Long-term patient reported outcomes following radiation therapy for oropharyngeal cancer: cross-sectional assessment of a prospective symptom survey in patients ≥65 years old

Effect of Oral Somatosensory Training on Oral Somatosensory Dysfunction in Head and Neck Cancer Survivors

OBJECTIVE

The objective of this study was to determine the effect of an oral somatosensory training (OST) program on oral somatosensory dysfunction (OSD) in neck and head cancer survivors.

MATERIALS AND METHODS

One hundred and eight people with altered tastes were enrolled in this research based on inclusion and exclusion criteria and were randomized into groups A and B. Group A received conventional exercises whereas group B received OST. Focal sensations, subjective total taste acuity (STTA), objective taste test, range of motion (ROM), manual muscle testing (MMT), and MD Anderson Symptom Inventory-Head and Neck module (MDASI-HN) questionnaire were employed as outcome measures. To validate the outcomes, pre- and post-assessments of the above measures were conducted. Statistical analysis was done using SPSS statistical software (version 26.0).

RESULTS

The results showed significant improvement in temperature (p= 0.0037, 0.0099, 0.0007, 0.0006), two-point discrimination (p<0.0001, 0.0010, 0.0112), light touch sensation (p<0.0001, 0.0006, 0.0055), STTA and ROM (p<0.0001), MMT scores depressors, elevators, retractors and lateral deviation and protrusion (p<0.0001) of patients undergoing OST as compared to conventional training. Also, the MDASI-HN questionnaire revealed the five most severe items in Group B being dry mouth, food taste problems, difficulty swallowing, mucus problems, and choking, and showed a significant decrease in the mean difference from 4.33±0.77, 8.4±0.40, 6.20±0.62, 5.92±0.69, 2.31±0.46 to 2.38±049, 3.09±0.44, 2.61±0.49, 2.48±0.50, and 0.27±0.45 as compared to Group A.

CONCLUSION

The study concluded that OST program had shown a significant effect in improving OSD among head and neck cancer survivors.

Dyadic Yoga for Head and Neck Cancer Patients Undergoing Chemoradiation and their Family Caregivers

OBJECTIVES

Concurrent chemoradiation to treat head and neck cancer (HNC) may result in debilitating toxicities. Targeted exercise such as yoga therapy may buffer against treatment-related sequelae; thus, this pilot RCT examined the feasibility and preliminary efficacy of a yoga intervention. Because family caregivers report low caregiving efficacy and elevated levels of distress, we included them in this trial as active study participants.

METHODS

HNC patients and their caregivers were randomized to a 15-session dyadic yoga program or a waitlist control (WLC) group. Prior to randomization, patients completed standard symptom (MDASI-HN) and patients and caregivers completed quality of life (SF-36) assessments. The 15-session program was delivered parallel to patients' treatment schedules. Participants were re-assessed at patients' last day of chemoradiation and again 30 days later. Patients' emergency department visits, unplanned hospital admissions and gastric feeding tube placements were recorded over the treatment course and up to 30 days later.

RESULTS

With a consent rate of 76%, 37 dyads were randomized. Participants in the yoga group completed a mean of 12.5 sessions and rated the program as "beneficial." Patients in the yoga group had clinically significantly less symptom interference and HNC symptom severity and better QOL than those in the WLC group. They were also less likely to have a hospital admission (OR = 3.00), emergency department visit (OR = 2.14), and/or a feeding tube placement (OR = 1.78).

CONCLUSION

Yoga therapy appears to be a feasible, acceptable, and possibly efficacious behavioral supportive care strategy for HNC patients undergoing chemoradiation. A larger efficacy trial is warranted.

Roses Have Thorns: Understanding the Downside of Oncological Care Delivery Through Visual Analytics and Sequential Rule Mining

Personalized head and neck cancer therapeutics have greatly improved survival rates for patients, but are often leading to understudied long-lasting symptoms which affect quality of life. Sequential rule mining (SRM) is a promising unsupervised machine learning method for predicting longitudinal patterns in temporal data which, however, can output many repetitive patterns that are difficult to interpret without the assistance of visual analytics. We present a data-driven, human-machine analysis visual system developed in collaboration with SRM model builders in cancer symptom research, which facilitates mechanistic knowledge discovery in large scale, multivariate cohort symptom data. Our system supports multivariate predictive modeling of post-treatment symptoms based on during-treatment symptoms. It supports this goal through an SRM, clustering, and aggregation back end, and a custom front end to help develop and tune the predictive models. The system also explains the resulting predictions in the context of therapeutic decisions typical in personalized care delivery. We evaluate the resulting models and system with an interdisciplinary group of modelers and head and neck oncology researchers. The results demonstrate that our system effectively supports clinical and symptom research.

Improving Prediction of Late Symptoms using LSTM and Patient-reported Outcomes for Head and Neck Cancer Patients

Patient-Reported Outcomes (PRO) are collected directly from the patients using symptom questionnaires. In the case of head and neck cancer patients, PRO surveys are recorded every week during treatment with each patient's visit to the clinic and at different follow-up times after the treatment has concluded. PRO surveys can be very informative regarding the patient's status and the effect of treatment on the patient's quality of life (QoL). Processing PRO data is challenging for several reasons. First, missing data is frequent as patients might skip a question or a questionnaire altogether. Second, PROs are patient-dependent, a rating of 5 for one patient might be a rating of 10 for another patient. Finally, most patients experience severe symptoms during treatment which usually subside over time. However, for some patients, late toxicities persist negatively affecting the patient's QoL. These long-term severe symptoms are hard to predict and are the focus of this study. In this work, we model PRO data collected from head and neck cancer patients treated at the MD Anderson Cancer Center using the MD Anderson Symptom Inventory (MDASI) questionnaire as time series. We impute missing values with a combination of K nearest neighbor (KNN) and Long Short-Term Memory (LSTM) neural networks, and finally, apply LSTM to predict late symptom severity 12 months after treatment. We compare performance against clinical and ARIMA models. We show that the LSTM model combined with KNN imputation is effective in predicting late-stage symptom ratings for occurrence and severity under the AUC and F1 score metrics.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The influence of radiation dose on taste impairment in a prospective observational study cohort of oropharyngeal cancer patients

BACKGROUND

To analyze the influence of radiation dose on late radiation-associated taste impairment in oropharyngeal cancer (OPC) patients treated with intensity-modulated radiotherapy (IMRT) using the taste bud bearing tongue mucosa as organ at risk.

MATERIAL AND METHODS

This study is part of an ongoing, prospective observational study. Cancer-free OPC survivors with at least 24 months from IMRT were included in this analysis. Scores for taste impairment and dry mouth were extracted from the MD Anderson Symptom Inventory Head and Neck module (MDASI-HN) with scores of ≥5 considered as moderate-to-severe symptoms. The mean dose, minimum and maximum dose to the taste bud bearing tongue mucosa, the ipsi- and contralateral parotid and submandibular glands were extracted and analyzed for correlation with moderate-to-severe taste impairment.

RESULTS

One hundred sixteen T1-4 OPC patients were included (81% males, median age: 55). The primary tumor was in the tonsil in 92 cases (79%) and in the base of tongue in 21 cases (18%). Patients were treated with 64.2-72.0 Gy; 37 patients (32%) received concurrent chemotherapy and 22 (19%) concurrent targeted therapy. After a median of 58 months from RT (IQR: 43-68) 38 patients (33%) suffered from moderate-to-severe long-term radiation-associated taste impairment. No dose volume parameter of the taste bud bearing tongue mucosa and the salivary glands was significantly associated with moderate-to-severe taste impairment for the whole patient cohort. For patients without concurrent chemotherapy, the minimum and mean dose to the ipsilateral parotid gland, and the maximum dose to the submandibular gland was significantly associated with late taste impairment (all p < 0.05). A significant correlation was found between taste impairment and dry mouth (p < 0.001).

CONCLUSION

The dose to the ipsilateral parotid gland seems to play an important role in the development of late taste impairment. The influence of dose to the taste bud bearing tongue mucosa remains unclear and needs further investigation.

THALIS: Human-Machine Analysis of Longitudinal Symptoms in Cancer Therapy

Although cancer patients survive years after oncologic therapy, they are plagued with long-lasting or permanent residual symptoms, whose severity, rate of development, and resolution after treatment vary largely between survivors. The analysis and interpretation of symptoms is complicated by their partial co-occurrence, variability across populations and across time, and, in the case of cancers that use radiotherapy, by further symptom dependency on the tumor location and prescribed treatment. We describe THALIS, an environment for visual analysis and knowledge discovery from cancer therapy symptom data, developed in close collaboration with oncology experts. Our approach leverages unsupervised machine learning methodology over cohorts of patients, and, in conjunction with custom visual encodings and interactions, provides context for new patients based on patients with similar diagnostic features and symptom evolution. We evaluate this approach on data collected from a cohort of head and neck cancer patients. Feedback from our clinician collaborators indicates that THALIS supports knowledge discovery beyond the limits of machines or humans alone, and that it serves as a valuable tool in both the clinic and symptom research.

Patient-Reported Outcomes-Guided Adaptive Radiation Therapy for Head and Neck Cancer

Purpose

To identify which patient-reported outcomes (PROs) may be most improved through adaptive radiation therapy (ART) with the goal of reducing toxicity incidence among head and neck cancer patients.

Methods

One hundred fifty-five head and neck cancer patients receiving radical VMAT (chemo)radiotherapy (66-70 Gy in 30-35 fractions) completed the MD Anderson Symptom Inventory, MD Anderson Dysphagia Inventory (MDADI), and Xerostomia Questionnaire while attending routine follow-up clinics between June-October 2019. Hierarchical clustering characterized symptom endorsement. Conventional statistical approaches indicated associations between dose and commonly reported symptoms. These associations, and the potential benefit of interfractional dose corrections, were further explored via logistic regression.

Results

Radiotherapy-related symptoms were commonly reported (dry mouth, difficulty swallowing/chewing). Clustering identified three patient subgroups reporting: none/mild symptoms for most items (60.6% of patients); moderate/severe symptoms affecting some aspects of general well-being (32.9%); and moderate/severe symptom reporting for most items (6.5%). Clusters of PRO items broadly consisted of acute toxicities, general well-being, and head and neck-specific symptoms (xerostomia, dysphagia). Dose-PRO relationships were strongest between delivered pharyngeal constrictor Dmean and patient-reported dysphagia, with MDADI composite scores (mean ± SD) of 25.7 ± 18.9 for patients with Dmean <50 Gy vs. 32.4 ± 17.1 with Dmean ≥50 Gy. Based on logistic regression models, during-treatment dose corrections back to planned values may confer ≥5% decrease in the absolute risk of self-reported physical dysphagia symptoms ≥1 year post-treatment in 1.2% of patients, with a ≥5% decrease in relative risk in 23.3% of patients.

Conclusions

Patient-reported dysphagia symptoms are strongly associated with delivered dose to the pharyngeal constrictor. Dysphagia-focused ART may provide the greatest toxicity benefit to head and neck cancer patients, and represent a potential new direction for ART, given that the existing ART literature has focused almost exclusively on xerostomia reduction.

Evaluating dysphagia and xerostomia outcomes following transoral robotic surgery for patients with oropharyngeal cancer

BACKGROUND

We assessed long-term patient-reported dysphagia and xerostomia outcomes following definitive surgical management with transoral robotic surgery (TORS) in patients with oropharyngeal cancer (OPC) via a cross-sectional survey study.

METHODS

Patients with OPC managed with primary oropharyngeal surgery as definitive treatment at least 1 year ago between 2015 and 2019 were identified. The M. D. Anderson Dysphagia Inventory (MDADI) and Xerostomia Inventory (XI) scores were compared across treatment types (i.e., no adjuvant therapy [TORS-A] vs. adjuvant radiotherapy [TORS+RT] vs. adjuvant chemoradiotherapy [TORS+CT/RT]).

RESULTS

The sample had 62 patients (10 TORS-A, 30 TORS+RT, 22 TORS+CT/RT). TORS-A had clinically and statistically significantly better MDADI scores than TORS+RT (p = 0.03) and TORS+CT/RT (p = 0.02), but TORS+RT and TORS+CT/RT were not significantly different. TORS-A had clinically and statistically significantly less XI than TORS+RT (p < 0.01) and TORS+CT/RT (p < 0.01).

CONCLUSIONS

Patients with OPC who have undergone TORS+RT or TORS+CT/RT following surgery face clinically worse dysphagia and xerostomia outcomes relative to patients who undergo TORS-A.

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

OBJECTIVE

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

DATA SOURCES

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

CONCLUSION

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

IMPLICATIONS FOR NURSING PRACTICE

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

Predicting late symptoms of head and neck cancer treatment using LSTM and patient reported outcomes

Patient-Reported Outcome (PRO) surveys are used to monitor patients' symptoms during and after cancer treatment. Acute symptoms refer to those experienced during treatment and late symptoms refer to those experienced after treatment. While most patients experience severe symptoms during treatment, these usually subside in the late stage. However, for some patients, late toxicities persist negatively affecting the patient's quality of life (QoL). In the case of head and neck cancer patients, PRO surveys are recorded every week during the patient's visit to the clinic and at different follow-up times after the treatment has concluded. In this paper, we model the PRO data as a time-series and apply Long-Short Term Memory (LSTM) neural networks for predicting symptom severity in the late stage. The PRO data used in this project corresponds to MD Anderson Symptom Inventory (MDASI) questionnaires collected from head and neck cancer patients treated at the MD Anderson Cancer Center. We show that the LSTM model is effective in predicting symptom ratings under the RMSE and NRMSE metrics. Our experiments show that the LSTM model also outperforms other machine learning models and time-series prediction models for these data.

Using Ultrasound to Document the Effects of Expiratory Muscle Strength Training (EMST) on the Geniohyoid Muscle

Expiratory muscle strength training (EMST) is an exercise program designed to strengthen the muscles of expiration by increasing expiratory load during breathing exercises using either resistive or pressure threshold devices. Previous research has shown that EMST may increase submental suprahyoid muscle activity as measured with surface electromyography. The impact of EMST on submental muscles is of interest to those who treat dysphagia. The purpose of this study was to determine whether the cross-sectional area of the geniohyoid muscle changes as observed with ultrasound during a 5-week EMST program performed at 75% of maximum expiratory strength using the EMST150 device in healthy adults. Ten healthy adults participated in the 5-week program. Maximum expiratory pressure (MEP) and cross-sectional area of the geniohyoid muscle were measured weekly. Geniohyoid cross-sectional area was measured from ultrasound images recorded in the coronal plane. Repeated Measures ANOVA was used to determine whether there were significant changes among the dependent variables over the study period. Both MEP and geniohyoid area increased significantly in response to a 5-week program of EMST. EMST in healthy adults is effective at strengthening the geniohyoid muscle as reflected by significantly increased cross-sectional area measured with B-mode ultrasound. This is the first study to document weekly change in muscle morphology as a result of EMST. Increasing geniohyoid muscle mass and consequent strength through a program of EMST may be beneficial for persons with pharyngeal stage dysphagia resulting from reduced hyolaryngeal elevation, reduced laryngeal closure, or reduced UES opening.

[Clear resection margins to avoid escalation of adjuvant therapy in oropharyngeal squamous cell carcinoma]

BACKGROUND

Resection margins in patients with oropharyngeal squamous cell carcinoma (OPSCC) are a predictive marker for overall survival (OS) and recurrence-free interval (RFI). Adjuvant therapy is influenced by TNM status, extracapsular extension (ECE), and resection margin status (R) of the primary tumor. The R status can be directly influenced by the head and neck surgeon. The aim of the current study was to evaluate the impact of R status on treatment decisions, RFI, and OS.

MATERIALS AND METHODS

All patients with OPSCC who underwent surgery (with/without adjuvant therapy) between 2001 and 2011 were enrolled. Clinical data, survival parameters, histologic data such as ECE, resection margin status, and tumor size were retrospectively collected and analyzed.

RESULTS

A total of 208 patients were enrolled. Survival parameters showed that patients with microscopically clear (R0) resection margins had an RFI/OS of 89/87 months. These values decreased in patients with R1 (65/65 months), R2 (38/33 months), and Rx (unclear) resections (59/45 months; p =  0.036/p = 0.001). In patients with ECE and R1 resection, but also in those with R0 resections achieved by follow-up resection and those with Rx resections, adjuvant therapy was escalated.

CONCLUSION

Unclear resection status reduces OS and RFI in patients with OPSCC. Therefore, in surgical therapy, clear resection status in the first pass should be strived for to avoid escalation of adjuvant therapy due to an unclear R status.

Symptom Clusters and Quality of Life in Cervical Cancer Patients Receiving Concurrent Chemoradiotherapy: The Mediating Role of Illness Perceptions

OBJECTIVES

Although studies shows that symptom clusters and illness perceptions are negatively associated with quality of life (QoL), it is unclear how these variables of cervical cancer patients who receive concurrent chemoradiotherapy (CCRT) relate to each other. This study aimed to identify the symptom clusters in cervical cancer patients who receive CCRT and evaluate the mediating effect of illness perceptions on the relationship between symptom clusters and QoL.

METHODS

A cross-sectional survey was conducted on 286 cervical cancer patients receiving CCRT from October 2019 to October 2020. M.D. Anderson Symptom Inventory, Brief Illness Perception Questionnaire, and Functional Assessment Cancer Therapy-Cervix were applied to investigate the symptom clusters, illness perceptions and QoL of the participants, respectively. Exploratory factor analysis was conducted to identify symptom clusters. The relationships among symptom clusters, illness perceptions, and QoL were analyzed with the structural equation modeling.

RESULTS

A total of four symptom clusters were identified, including psychological status symptom cluster, therapy side-effect symptom cluster, sickness symptom cluster, and gastrointestinal symptom cluster (χ² = 1,552.282, Df = 78, P < 0.001). Symptom clusters, illness perceptions, and QoL were significantly correlated. Symptom clusters had significant direct (β = -0.38, P < 0.001) and indirect effects (β = -0.21, P < 0.001) on QoL.

CONCLUSION

Illness perceptions played a significant mediating role between symptom clusters and QoL in cervical cancer patients receiving CCRT. Strategies like prompting effective symptom management for the purposes of alleviating illness perceptions may contribute to improving their QoL.

Prospective observational evaluation of radiation-induced late taste impairment kinetics in oropharyngeal cancer patients: Potential for improvement over time?

•

The majority of OPC patients are affected from late taste impairment after RT.

•

Taste markedly improved in the first years from end of RT, but plateaued after year 5.

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Treatment site, CTV1 dose and age might have an influence on taste impairment.

Background and purpose

Taste impairment is a common radiation-induced toxicity in head and neck cancer (HNC) patients acutely. However, data on the potential for recovery and the time dependent course of late taste impairment are limited.

Materials and methods

As part of an IRB-approved observational prospective study, HNC patients underwent serial surveys including the MD Anderson Symptom Inventory - Head and Neck module (MDASI-HN). For our analysis, we extracted MDASI-HN taste item results from oropharyngeal cancer patients treated with intensity-modulated radiotherapy or volumetric modulated arc therapy and at least two taste assessments after ≥1 year from end of radiotherapy (RT).

Results

1214 MDASI taste items from 326 patients between 1 and 13 years post-RT were included. Median prescribed dose to the high-dose clinical target volume (CTV1) was 66.0 Gy, with 180 patients (55%) receiving chemotherapy. Taste markedly improved in the first years from end of RT, but plateaued after year 5. In patients with taste assessment in subsequent years, a significant reduction in taste impairment was found from the second to the third year (p = 0.001) and tended towards significance from the third to the fourth year (p = 0.058). Multivariate analysis revealed treatment site as significant factor in the sixth year from RT and CTV1 dose and age in the seventh year.

Conclusion

Radiation-induced taste impairment may improve over an extended time interval, but becomes relatively stable from year 5 post-RT. Direct characterization of RT-induced taste impairment and the calculation of normal tissue complication probability should include consideration of the time-dependent course in taste recovery.

Assessing patient-reported symptom burden of long-term head and neck cancer survivors at annual surveillance in survivorship clinic

BACKGROUND

This study reports long-term head and neck cancer (HNC) patient-reported symptoms using the MD Anderson Symptom Inventory Head and Neck Cancer Module (MDASI-HN) in a large cohort of HNC survivors.

METHODS

MDASI-HN results were prospectively collected from an institutional survivorship database. Associations with clinicopathologic data were analyzed using χ² , Mann-Whitney, and univariate regression.

RESULTS

Nine hundred and twenty-eight patients were included. Forty-six percent had oropharyngeal primary tumors. Eighty-two percent had squamous cell carcinoma. Fifty-six percent of patients had ablative surgery and 81% had radiation therapy as a component of treatment. The most severe symptoms were xerostomia and dysphagia. Symptom scores were worst for hypopharynx and varied by subsite. Patients treated with chemoradiation or surgery followed by radiation ± chemotherapy reported the worst symptoms while patient treated with surgery plus radiation ± chemotherapy reported the worst interference.

CONCLUSION

HNC survivors describe their long-term symptom burden and inform efforts to improve care many years into survivorship.

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

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

Symptom Burden Associated With Late Lower Cranial Neuropathy in Long-term Oropharyngeal Cancer Survivors

Importance

Lower cranial neuropathy (LCNP) is a rare but potentially disabling result of radiotherapy and other head and neck cancer therapies. Survivors who develop late LCNP may experience profound functional impairment, with deficits in swallowing, speech, and voice.

Objective

To investigate the association of late LCNP with severity of cancer treatment-related symptoms and subsequent general functional impairment among oropharyngeal cancer (OPC) survivors.

Design, Setting, and Participants

This cross-sectional survey study analyzed 889 OPC survivors nested within a retrospective cohort of OPC survivors treated at MD Anderson Cancer Center from January 1, 2000, to December 31, 2013. Eligible survey participants were disease free and completed OPC treatment 1 year or more before the survey. Data analysis was performed from October 10, 2017, to March 15, 2018.

Exposures

Late LCNP defined by onset 3 months or more after cancer therapy.

Main Outcomes and Measures

The primary outcome variable was the mean of the top 5 most severely scored symptoms of all 22 core and head and neck cancer-specific symptoms from the MD Anderson Symptom Inventory Head and Neck Cancer Module (MDASI-HN). Secondary outcomes included mean MDASI-HN interference scores and single-item scores of the most severe symptoms. Multivariate models regressed MDASI-HN scores on late LCNP status, adjusting for clinical covariates.

Results

Overall, 36 of 889 OPC survivors (4.0%) (753 [84.7%] male; 821 [92.4%] white; median [range] age, 56 [32-84] years; median [range] survival time, 7 [1-16] years) developed late LCNP. Late LCNP was significantly associated with worse mean top 5 MDASI-HN symptom scores (coefficient, 1.54; 95% CI, 0.82-2.26), adjusting for age, survival time, sex, therapeutic modality, T stage, subsite, type of radiotherapy, smoking, and normal diet before treatment. Late LCNP was also significantly associated with single-item scores for difficulty swallowing or chewing (coefficient, 2.25; 95% CI, 1.33-3.18), mucus (coefficient, 1.97; 95% CI, 1.03-2.91), fatigue (coefficient, 1.35; 95% CI, 0.40-2.21), choking (coefficient, 1.53; 95% CI, 0.65-2.41), and voice or speech symptoms (coefficient, 2.30; 95% CI, 1.60-3.03) in multivariable models. Late LCNP was not significantly associated with mean interference scores after correction for multiple comparisons (mean interference coefficient, 0.72; 95% CI, 0.09-1.35).

Conclusions and Relevance

In this large survey study, OPC survivors with late LCNP reported worse cancer treatment-related symptoms, a finding suggesting an association between late LCNP and symptom burden. This research may inform the development and implementation of strategies for LCNP surveillance and management.

Swallowing Function in Survivors of Oropharyngeal Cancer Is Associated With Advanced T Classification

OBJECTIVES

The incidence of oropharyngeal squamous cell carcinoma (OPSCC) is rapidly increasing in the United States. The aim of this study was to characterize the functional status of OPSCC survivors to identify predictors of swallowing dysfunction in this patient population.

METHODS

OPSCC survivors (n = 81) treated at the Michael E. DeBakey Veterans Affairs Medical Center between 2005 and 2015 with at least 2 years of clinical follow-up were reviewed. Functional status was ascertained using (1) gastrostomy and tracheostomy placement and retention, (2) gastrostomy use at last follow-up, (3) patient-reported diet, and (4) modified barium swallow.

RESULTS

Median follow-up duration was 5.6 years; 67% of patients had ≥10-pack-year tobacco exposure; 96% of tumors for which p16 data were available were p16 positive. At last follow-up, 82% of patients reported a regular diet, and only 9 patients required gastrostomy use. Gastrostomy use at last follow-up was higher in patients with T3 and T4 tumors compared with those with T1 and T2 tumors (P = .01). The relationship between T classification and gastrostomy use persisted even when the analysis was limited to p16+ tumors and p16+ tumors with ≥10-pack-year history of tobacco exposure.

CONCLUSIONS

Advanced T classification at presentation is a critical predictor of gastrostomy use in long-term OPSCC survivors irrespective of p16 status or tobacco exposure history.

LEVEL OF EVIDENCE

2b.

Single-item discrimination of quality-of-life-altering dysphagia among 714 long-term oropharyngeal cancer survivors: Comparison of patient-reported outcome measures of swallowing

BACKGROUND

Two patient-reported outcomes (PROs) of swallowing and their correlation to quality of life (QOL) were compared in long-term survivors of oropharyngeal cancer (OPC).

METHODS

Scores on the single dysphagia item from the 28-item, multisymptom MD Anderson Symptom Inventory-Head and Neck (MDASI-HN-S) were compared with scores on the dysphagia-specific composite MD Anderson Dysphagia Inventory (MDADI) and the EuroQol visual analog scale (EQ-VAS) in 714 patients who had received definitive radiotherapy ≥12 months before the survey. An MDASI-HN-S score ≥6 and an MDADI composite score <60 were considered representative of moderate/severe swallowing dysfunction.

RESULTS

Moderate/severe dysphagia was reported by 17% and 16% of respondents on the MDASI-HN-S and the composite MDADI, respectively. Both swallow PROs were predictive of QOL, and the MDASI-HN-S model was slightly more parsimonious for the discrimination of EQ-VAS scores compared with MDADI scores (Bayesian information criteria, 6062 vs 6076, respectively). An MDASI-HN-S cutoff score of ≥6 correlated best with a declining EQ-VAS score (P < .0001) and was associated with increased radiotherapy dose to several normal swallowing structures.

CONCLUSIONS

In this cohort, the single-item MDASI-HN-S performed favorably for the discrimination of QOL compared with the multi-item MDADI. A time-efficient model for PRO measurement of swallowing is proposed in which the MDADI may be reserved for patients who score ≥6 on the MDASI-HN-S.

The Effects of Yoga in Helping Cancer Patients and Caregivers Manage the Stress of a Natural Disaster: A Brief Report on Hurricane Harvey

Background: This small qualitative study reports on the experiences of patients and family caregivers who participated in a dyadic yoga pilot trial while undergoing cancer treatment in the midst of Hurricane Harvey. Our primary purpose was to determine if participants implemented components of the program to cope with the stressors associated with Hurricane Harvey and if they perceived benefits from the yoga practices. Methods: We administered brief semistructured interviews to the dyads participating in a dyadic yoga pilot trial. Participants (n = 5 dyads) were asked to discuss their experience with Hurricane Harvey, including factors that helped them cope with the event while receiving treatment. Result: Patients had a mean age of 55.6 years, were mostly non-Hispanic White, male, and had advance stage head and neck cancer. Caregivers had a mean age of 58 years and were mainly non-Hispanic White and female. Analyses of the interviews revealed 2 overarching themes: (1) the storm's negative impact and (2) the use of yoga to cope with the hurricane-related stressors. Conclusions: Patient-caregiver dyads experienced psychological distress during the storm and/or its aftermath. Dyads used yoga techniques to cope with these psychological stressors. Yoga served as a means of social support as dyads either participated in these activities together or with other family members.

Nomogram for preoperative prediction of nodal extracapsular extension or positive surgical margins in oropharyngeal squamous cell carcinoma

INTRODUCTION

Extracapsular extension (ECE) in regional lymph nodes and positive surgical margins (PSM) are considered high-risk adverse pathologic features in patients with oropharyngeal squamous cell carcinoma (OPSCC) that each constitute an indication for postoperative adjuvant chemoradiation. We identify pre-operative clinical factors that can predict post-operative ECE and/or PSM and create a nomogram to help clinical decision making.

METHODS

Adult patients with non-metastatic OPSCC with initial surgical treatment and confirmed HPV status diagnosed between 2010 and 2014 were selected from the National Cancer Database. Clinical staging was modified to American Joint Committee on Cancer 8th edition parameters. Logistic regression was used for multivariate analysis to identify predictors of pathologic ECE and/or PSM.

RESULTS

5065 patients were included. 47.5% of the 3336 HPV-positive (HPV+) patients had ECE/PSM. 40.4% of the 1729 HPV-negative (HPV-) patients with had ECE/PSM. A model was built that included age, clinical ECE, tumor grade, and clinical T and N staging for HPV+ patients. Increasing N-classification was highly predictive of pathologic ECE and/or PSM (N1 OR = 3.6, N2 OR = 7.0, N3 OR = 11.2, p < 0.01). Clinical ECE (OR = 4.1, p < 0.01), tumor grade (ORs 2.2-4.4 with p < 0.05), and increasing clinical T-classification (ORs 1.2-1.8, p < 0.05) were also associated with ECE and/or PSM. A similar model was built for HPV- with similar predictive capability. Two internally validated nomograms were designed that demonstrated good discrimination (HPV+ AUC = 0.66, 95% CI: 0.64-0.68, and HPV- AUC = 0.70, 95% CI: 0.67-0.72) and good calibration (goodness-of-fit statistic of HPV+ 6.32, p = 0.61 and HPV- 11.66, p = 0.17).

CONCLUSIONS

These are the first nomograms designed to help predict ECE or PSM for both HPV+ and HPV- OPSCC. The nomograms can facilitate shared decision-making between clinicians and patients as they consider upfront treatment selection for OPSCC.