Distress Management in Patients With Head and Neck Cancer Before Start of Palliative Chemotherapy: A Practical Approach

Palliative care utilization among head and neck cancer patients: A population-based analysis

PURPOSE

Head and neck cancer (HNC) patients face substantial morbidity and mortality. Despite the potential benefits of palliative care (PC) in improving quality of life, many HNC patients do not receive these services. This study aimed to quantify the proportion of HNC patients receiving PC, the timing of PC referrals, and the mental health and clinical outcomes of this population.

METHODS

A retrospective cohort study was conducted using the TriNetX database with de-identified electronic medical records. HNC patients were categorized based on whether they had at least one PC encounter. We examined time to first PC encounter, mortality rates, mental health diagnoses, and access to ACP and supportive care.

RESULTS

Of 304,404 HNC patients, only 22,470 (7.4 %) had at least one PC encounter. The median time from cancer diagnosis to initial PC referral was 318 days. After propensity score matching, the cohorts consisted of 24,916 patients each. Those who received PC had a significantly higher risk of mortality (RR 3.05, 95 % CI 2.97-3.14), depression (RR 1.38, 95 % CI 1.33-1.45), anxiety (RR 1.47, 95 % CI 1.42-1.53), failure to thrive (RR 3.26, 95 % CI 3.03-3.51), and were more likely to engage in advance care planning (RR 4.97, 95 % CI 4.39-5.62) and access supportive care services compared to patients who did not receive PC.

CONCLUSIONS

PC utilization among HNC patients is low, with patients often waiting nearly a year before their first PC encounter. This delay highlights a significant unmet need for early integrated PC in this population.

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.

Screening for Distress and Health Outcomes in Head and Neck Cancer

Head and neck cancers (HNC) have higher rates of emotional distress than other cancer types and the general population. This paper compares the prevalence of emotional distress in HNC across various distress screening measures and examines whether significant distress or distress screening are associated with cancer-related survival. A retrospective observational cohort design was employed, with data collected from the Distress Assessment and Response Tool (DART) and linkages to administrative databases from 2010 to 2016. Descriptive and prevalence data were reported using multiple concurrently administered distress tools, including the Patient Health Questionaire-9 (PHQ-9), Generalized Anxiety Disorders-7 (GAD-7), Edmonton Symptom Assessment Scale-revised (ESAS-r), and MD Anderson Symptom Index-Head and Neck module (MDASI-HN). Across measures, 7.8 to 28.1% of the sample reported clinically significant emotional distress, with PHQ-9 and GAD-7 identifying lowest prevalence of moderate/severe distress, and the ultrashort distress screens within ESAS-r and MDASI-HN performing equivalently. Cox hazards models were used in univariate and multivariate survival analyses. ESAS depression (≥4), but not anxiety, was associated with increased risk of cancer-related mortality and patient completion of DART was associated with greater cancer-related survival. The findings underscore the importance of implementing routine distress screening for HNC populations and the utility of ultra-brief screening measures.

Distress and Spiritual Well-Being in Brazilian Patients Initiating Chemotherapy during the COVID-19 Pandemic-A Cross-Sectional Study

Social distancing and the priority given to COVID-19 patients in health services, which caused postponement of appointments and cancer treatment, may have triggered unprecedented levels of distress in cancer patients. The aim of this study was to analyze the prevalence of distress and the levels of spiritual well-being of people initiating chemotherapy during the COVID-19 pandemic, identifying the factors associated with distress, and determining if there is a relationship between distress and spiritual well-being. A cross-sectional study was conducted with 91 Brazilians. Data were collected by applying the Spiritual Well-Being Scale (SWBS) and the Distress Thermometer and Problem List for Patients. The prevalence of distress was 59.5%, and the average score of spiritual well-being was 106.54 (±9.06). Emotional issues were the most reported by patients with distress. The Poisson regression showed that male sex (PR = 0.588; 95% CI 0.392-0.881), age (PR = 0.985; 95% CI 0.973-0.996), and spiritual well-being score were predictors of distress (PR = 0.971; 95% CI 0.946-0.996). These findings indicate that distress relief involves implementation of public health programs capable of integrating spiritual interventions into cancer care.

'Patients with Cancer are Distressed!' Indian Healthcare Provider Perspectives on Distress Screening and Referrals to Psycho-oncology Services - A Mixed Methods Study

Objectives:

Routine screening for distress is a guideline prescribed by the National Comprehensive Cancer Network (NCCN) to adequately assess distress in a cancer setting. Our centre conducted routine screening but failed to utilize psycho-oncology services. Our aim was to assess the extent of self-reported distress, referrals to psycho-oncology services and healthcare provider perspectives about the existing distress management system and psycho-oncology services.

Materials and Methods:

We conducted a record review of adult patients (n=372) who reported to the Out-patient department of the tertiary cancer centre. Semi-structured interviews were conducted with fourteen healthcare providers. We used a concurrent mixed methods study design. Adult patients were screened for distress using NCCN-Distress Thermometer and problem checklist. Healthcare providers from different oncology specialties were interviewed and the data was analysed using descriptive thematic analysis.

Results:

Patients screened for distress were found to report moderate to extreme levels of distress (53.5%). The total referrals to psycho-oncology support services were low (8.6%). Interviews with healthcare providers revealed three major themes: Enablers, barriers and solutions for utilization of distress management system and psycho-oncology services.

Conclusions:

Moderate to extreme distress was found among patients routinely screened for distress, although there was poor utilization of distress management system and psycho-oncology support services due to time constraints, patient’s negative attitudes towards mental health referrals, generic screening tools and use of own clinical judgement to make referrals by healthcare providers. Future research warrants implementation of strategies to integrate psycho-oncology services into routine cancer care by focusing on improving visibility of services.

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.

Making the Best of Limited Resources: Improving Outcomes in Head and Neck Cancer

The overwhelming majority of head and neck cancers and related deaths occur in low- and middle-income countries, which have challenges related to burden of disease versus access to care. Yet the additional health care burden of the COVID-19 pandemic has also impacted access to care for patients with head and neck cancer in the United States. This article focuses on challenges and innovation in prioritizing head and neck cancer care in Sub-Saharan Africa, the Indian experience of value-added head and neck cancer care in busy and densely populated regions, and strategies to optimize the management of head and neck cancer in the United States during the COVID-19 pandemic.

The palliative care needs and experiences of people with advanced head and neck cancer: A scoping review

BACKGROUND

The palliative care needs of people with advanced head and neck cancer pose unique complexities due to the impact the illness has on eating, speaking, appearance and breathing. Examining these needs would help provide guidance about developing relevant models of care and identify gaps in research knowledge.

AIM

To identify and map out the palliative care needs and experiences for people with advanced head and neck cancer.

DESIGN

A scoping literature review following the methods described by the Joanna Briggs Institute.

DATA SOURCES

An electronic search of the literature was undertaken in MEDLINE (Ovid), EMBASE and CINAHL covering the years January 1996 to January 2019.

RESULTS

People with advanced head and neck cancer often had palliative care needs but there was variability in the timing and access to relevant services. A high prevalence of interventions, for example hospital admissions were needed even during the last month of life. This was not necessarily negated with early engagement of palliative care. Dissonance between patients and family carers about information needs and decision-making was an additional complexity. Studies tended to be descriptive in nature, and often involved a single centre.

CONCLUSION

This scoping review demonstrates the complexity of care for people with advanced head and neck cancer and the issues related to the current healthcare systems. Focus on appropriate referral criteria, increased integration and coordination of care and robust evaluation of specific care components seems key. Linkage between research and service design delivery across teams, disciplines and care settings seems pertinent.

Quality Assessment in Supportive Care in Head and Neck Cancer

Quality assessment is a key issue in every clinical intervention, to be periodically performed so to measure the adherence to standard and to possibly implement strategies to improve its performance. This topic is rarely discussed for what concerns supportive care; however, it is necessary to verify the quality of the supportive measures; “supportive care makes excellent cancer care possible,” as stated by the Multinational Association of Supportive Care in Cancer (MASCC). In this regard, the quality of supportive care in head and neck cancer patients is a crucial topic, both to allow administration of treatments according to planned dose intensity or surgical indications and to maintain or improve patients' quality of life. This paper aims to provide insight on state of the art supportive care and its future developments for locally advanced and recurrent/metastatic head and neck cancer, with a focus on quality assessment in relation to surgery, radiotherapy, and systemic therapy.

A cross-sectional audit of distress in patients undergoing adjuvant therapy or follow-up in central nervous system malignancies

Background

Unaddressed high distress leads to noncompliance with treatment, negatively affects quality of life, and may also have a negative impact on the prognosis of cancer patients. Patients with brain tumors have higher levels of distress than the general population and hence we hypothesize that even routine visits during adjuvant treatment or follow-up are likely to be stressful. This analysis was performed to identify the incidence of distress and factors affecting it.

Methods

This was an audit of 84 consecutive patients seen in an adult neuro-medical oncology outpatient department who were either receiving adjuvant chemotherapy or were on follow-up. Distress screening with the National Comprehensive Cancer Network (NCCN) distress thermometer was performed. Patients in whom distress was scored as 4 or above were considered as having high distress. Descriptive statistics and logistic regression analysis were performed to identify factors affecting distress.

Results

The median age of the cohort was 40 years (interquartile range, 28.3 to 50 years). Actionable distress defined as a distress score of 4 or more was seen in 52 patients (61.9%, 95% CI 51.2% to 71.5%). Presence of physical deficit (odds ratio [OR] = 3.412, P = .020) and treatment under the private category (OR = 5.273, P = .003) had higher odds of having high distress.

Conclusion

A high proportion of brain tumor patients either on adjuvant chemotherapy or on follow-up have high distress levels that need to be addressed even during follow-up.