Exploring transitions in care among patients with head and neck CANCER: a multimethod study

BACKGROUND

Patients with head and neck cancers (HNC) experience many transitions in care (TiC), occurring when patients are transferred between healthcare providers and/or settings. TiC can compromise patient safety, decrease patient satisfaction, and increase healthcare costs. The evidence around TiC among patients with HNC is sparse. The objective of this study was to improve our understanding of TiC among patients with HNC to identify ways to improve care.

METHODS

This multimethod study consisted of two phases: Phase I (retrospective population-based cohort study) characterized the number and type of TiC that patients with HNC experienced using deterministically linked, population-based administrative health data in Alberta, Canada (January 1, 2012, to September 1, 2020), and Phase II (qualitative descriptive study) used semi-structured interviews to explore the lived experiences of patients with HNC and their healthcare providers during TiC.

RESULTS

There were 3,752 patients with HNC; most were male (70.8%) with a mean age at diagnosis of 63.3 years (SD 13.1). Patients underwent an average of 1.6 (SD 0.7) treatments, commonly transitioning from surgery to radiotherapy (21.2%). Many patients with HNC were admitted to the hospital during the study period, averaging 3.3 (SD 3.0) hospital admissions and 7.8 (SD 12.6) emergency department visits per patient over the study period. Visits to healthcare providers were also frequent, with the highest number of physician visits being to general practitioners (average = 70.51 per patient). Analysis of sixteen semi-structured interviews (ten patients with HNC and six healthcare providers) revealed three themes: (1) Navigating the healthcare system including challenges with the complexity of HNC care amongst healthcare system pressures, (2) Relational head and neck cancer care which encompasses patient expectations and relationships, and (3) System and individual impact of transitions in care.

CONCLUSIONS

This study identified challenges faced by both patients with HNC and their healthcare providers amidst the frequent TiC within cancer care, which was perceived to have an impact on quality of care. These findings provide crucial insights that can inform and guide future research or the development of health interventions aiming to improve the quality of TiC within this patient population.

Effectiveness of mHealth intervention for trismus exercise in patients with head and neck cancer undergoing proton and heavy ion therapy: a randomized control trial

PURPOSE

This study aimed to compare the effects of a mobile health intervention based on social cognitive theory with standard care on maximal mouth opening, exercise compliance, and self-efficacy in patients receiving proton and heavy ion therapy for head and neck cancer.

METHODS

This open-label, parallel-group, randomized, superiority trial involved a self-developed "Health Enjoy System" intervention. We assessed maximal mouth opening, exercise compliance, and self-efficacy at baseline (T0), post-treatment (T1), and at 1 month (T2) and 3 months (T3) after radiotherapy. Generalized estimating equations were used to analyze differences between the groups over time, with results reported as P values and 95% confidence intervals (CIs).

RESULTS

The study included 44 participants. At T3, the intervention group showed a 6 mm greater increase in maximal interincisal opening than the control group (mean difference = 6.0, 95% CI = 2.4 to 9.5, P = 0.001). There was also a significant difference in exercise compliance between the groups (mean difference = 31.7, 95% CI = 4.6 to 58.8, P = 0.022). However, no significant difference in self-efficacy was found between the groups.

CONCLUSION

This study demonstrated that an mHealth intervention incorporating behavior change theory could effectively enhance or maintain maximal mouth opening in patients undergoing proton and heavy ion therapy for head and neck cancer in China. This approach provides valuable support during and after treatment.

TRIAL REGISTRATION

ChiCTR: ChiCTR2300067550. Registered 11 Jan 2023.

Interventions for head and neck cancer survivors: Systematic review

BACKGROUND

Interventions for head/neck cancer (HNC) survivors may not address their cancer-related and general health needs.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guided this systematic review of studies from 2000 to 2021 of interventions targeting cancer survivors treated with curative-intent, using MEDLINE, Embase, Emcare, and PsycINFO. Interventions were categorized into domains of the Quality of Cancer Survivorship Care Framework to characterize the scope and quality of interventions.

RESULTS

We identified 28 studies for inclusion: 13 randomized and 15 non-randomized. Most targeted surveillance/management of physical effects (n = 24) including 13 that also targeted psychosocial effects. Four studies addressed prevention/surveillance for recurrence/new cancers, one addressed health promotion/disease prevention, and one addressed chronic medical conditions. Most studies (n = 27) had medium-high risk of bias.

CONCLUSIONS

There are few high-quality studies addressing HNC survivorship. Future rigorously designed studies should address broader areas of care, including chronic disease management and health promotion/disease prevention.

Factors associated with loss to follow-up after radiation therapy for head and neck cancer

OBJECTIVES

Head and neck cancer (HNC) patients are at high risk for late occurring radiation-related morbidity and recurrence, necessitating close long-term medical surveillance. This study identified factors associated with becoming lost to follow-up (LTFU) at a comprehensive cancer center.

MATERIALS AND METHODS

Patients were drawn from survivors who received radiation for HNC at a single institution between 2001 and 2018. LTFU was defined as living patients without a clinical encounter within 2 years of the data query.

RESULTS

In total, 537 patients met the inclusion criteria and 57 (10.6%) were identified as LTFU. Individual comparisons identified time since completing radiation, non-White race and being unmarried as associated with LTFU. Multiple regression identified time since treatment and being unmarried as factors associated with LTFU. A decision tree correctly sorted 89.4% using time, distance, and marital status.

CONCLUSION

Time since radiation, distance to clinic, and being unmarried were factors associated with becoming LTFU.

Effects of Exercise in Patients Undergoing Chemotherapy for Head and Neck Cancer: A Pilot Randomized Controlled Trial

Background: Cisplatin administration may induce muscle atrophy, thereby reducing the fitness level of patients with head and neck cancer (HNC). To date, only animal studies have been conducted to test the effectiveness of exercise interventions in diminishing side effects of cisplatin. Aim: To determine whether exercise training improves physical fitness and health-related quality of life (HRQoL) in patients receiving chemotherapy for Head & Neck (H&N). Material and methods: This pilot-randomized controlled trial was conducted on 57 participants receiving chemotherapy for HNC. The participants were randomized into an exercise group and a control group. The exercise group received moderate-intensity combined aerobic, resistance and flexibility exercises three times a week for eight weeks during chemotherapy. The control group received no specific information regarding exercise. The outcome measures including body composition, muscle strength, balance, flexibility, cardiovascular fitness and health-related quality of life (HRQoL) were assessed at baseline and eight weeks following baseline. Results: The body composition (body fat percentage, p = 0.002; skeletal muscle percentage, p = 0.008), dynamic balance (p = 0.01), muscle strength (upper extremity, p = 0.037; lower extremity, p = 0.025) and HRQoL (p = 0.001) showed a significant difference between the exercise group and the control group eight weeks following baseline. Significant deteriorations were noted in flexibility, muscle strength, cardiovascular fitness and several domains of HRQoL scale in the control group at eight weeks following baseline. Conclusions: This study found that a combined aerobic, resistance and flexibility exercise program during chemotherapy may improve physical fitness (i.e., muscle strength, balance, flexibility and body composition) and HRQoL and alleviate the deterioration of cardiovascular fitness in patients with HNC. Further research studies with large sample sizes are warranted to investigate the long-term effects of exercise in this population.

Impact of provider type and number of providers on surveillance testing among survivors of head and neck cancers

BACKGROUND

Guidelines for follow-up after head and neck cancer (HNC) treatment recommend frequent clinical examinations and surveillance testing. Here, the authors describe real-world follow-up care for HNC survivors and variations in surveillance testing.

METHODS

Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, this study examined a population-based cohort of HNC survivors between 2001 and 2011 Usage of cross-sectional head and neck imaging (CHNI), chest imaging (CI), positron emission tomography (PET), fiberoptic nasopharyngolaryngoscopy (FNPL), and, in irradiated patients, thyroid function testing (TFT) was captured over 2 consecutive surveillance years. Multivariate modeling with logistic regression analyses was used to assess variations by clinical factors, nonclinical factors, number and types of providers seen and their evolution over time.

RESULTS

Among 13,836 HNC survivors, the majority saw a medical, radiation, or surgical oncologist and a primary care provider (PCP; 81.7%) in their first year of surveillance. However, only 58.1% underwent either PET or CHNI, 47.8% underwent CHNI, 64.1% underwent CI, 32.5% underwent PET scans, 55.0% underwent FNPL, and 55.9% underwent TFT. In multivariate analyses, patients who followed up with more providers and those who followed up with both a PCP and an oncologist were more likely to undergo surveillance testing (P < .007). However, adjusting for providers seen did not explain the variations in surveillance testing rates based on age, race, education, income level, and place of residence. Over time, there was a gradual increase in the use of PET scans and TFT during surveillance years.

CONCLUSIONS

In this large SEER-Medicare data study, only half of HNC survivors received the recommended testing, and greater compliance was seen in those who followed up with both an oncologist and a PCP. More attention is needed to minimize variations in surveillance testing across sociodemographic groups.

Perceptions of care coordination among older adult cancer survivors: A SEER-CAHPS study

OBJECTIVE

Care coordination reflects deliberate efforts to harmonize patient care. This study examined variables associated with patient-reported care coordination scores among Medicare beneficiaries with a history of cancer.

METHODS

We utilized Surveillance, Epidemiology, and End Results-Consumer Assessment of Healthcare Providers and Systems (SEER-CAHPS) linked data, which includes cancer registry data, patient experience surveys, and Medicare claims. We identified Medicare beneficiaries with a CAHPS survey ≤10 years after cancer diagnosis who reported seeing a personal doctor within six months. Multivariable regression models examined associations between cancer survivor characteristics and patient-reported care coordination, with higher scores indicating better coordination.

RESULTS

Cancer site distribution of the 14,646 survey respondents was 33.7% prostate, 22.1% breast, 11.1% colorectal, 7.2% lung, and 25.9% other. Rural residence at diagnosis (versus urban, 1.1-point difference; p = 0.04) and reporting >4 visits with a personal doctor (versus 1-2 visits, 3.0-point difference; p < 0.001) were significantly associated with higher care coordination. Older age (p < 0.001) and seeing more specialists (p = 0.006) were associated with significantly lower care coordination. Patients with melanoma (women: 5.2-point difference, p < 0.001; men: 2.7 points, p = 0.01) or breast cancer (women: 2.4 points; p < 0.001) reported significantly lower care coordination scores than did men with prostate cancer (reference group). Time from diagnosis to survey, cancer stage, number of cancers, and comorbidities were not significantly associated with care coordination scores.

DISCUSSION

Cancer site, rural residence, and number of physician interactions are associated with patient-reported care coordination scores. Future research should address multilevel influences that lead to worse care coordination for older adult cancer survivors.

Predictive quantitative ultrasound radiomic markers associated with treatment response in head and neck cancer

Aim:

We aimed to identify quantitative ultrasound (QUS)-radiomic markers to predict radiotherapy response in metastatic lymph nodes of head and neck cancer.

Materials & methods:

Node-positive head and neck cancer patients underwent pretreatment QUS imaging of their metastatic lymph nodes. Imaging features were extracted using the QUS spectral form, and second-order texture parameters. Machine-learning classifiers were used for predictive modeling, which included a logistic regression, naive Bayes, and k-nearest neighbor classifiers.

Results:

There was a statistically significant difference in the pretreatment QUS-radiomic parameters between radiological complete responders versus partial responders (p < 0.05). The univariable model that demonstrated the greatest classification accuracy included: spectral intercept (SI)-contrast (area under the curve = 0.741). Multivariable models were also computed and showed that the SI-contrast + SI-homogeneity demonstrated an area under the curve = 0.870. The three-feature model demonstrated that the spectral slope-correlation + SI-contrast + SI-homogeneity-predicted response with accuracy of 87.5%.

Conclusion:

Multivariable QUS-radiomic features of metastatic lymph nodes can predict treatment response a priori.

In this study, quantitative ultrasound (QUS) and machine-learning classification was used to predict treatment outcomes in head and neck cancer patients. Metastatic lymph nodes in the neck were scanned using conventional frequency ultrasound (US). Quantitative data were collected from the US-radiofrequency signal a priori. Machine-learning classification models were computed using QUS features; these included the linear fit parameters of the power spectrum, and second-order texture parameters of the QUS parametric images. Treatment outcomes were measured based on radiological response. Patients were classified into binary groups: radiologic complete response (CR) or radiological partial response (PR), which was assessed 3 months following treatment. Initial results demonstrate high accuracy (%Acc = 87.5%) for predicting radiological response. The results of this study suggest that QUS can be used to predict head and neck cancer response to radiotherapy a priori.

Financial Vulnerability: A Case Study Involving a Patient With Head and Neck Cancer

BACKGROUND

Patients with head and neck cancer (HNC) face unique financial challenges. Even with stable income and health insurance, many patients become overwhelmed with direct and indirect treatment-associated costs.

OBJECTIVES

This article discusses how prolonged financial burden in patients with cancer can result in compromised patient outcomes.

METHODS

A case study is presented that highlights financial burden associated with reduced income, treatment-related commuting, and challenges in resuming a job while dealing with functional impairments and long-term treatment effects from HNC. It also describes the financial impact on a spousal caregiver.

FINDINGS

Nurses must initiate discussions with their patients about potential and actual financial concerns and barriers to care. In addition, nurses should include repeated assessment of financial health throughout the cancer care trajectory and provide appropriate resources and referrals when issues are identified.

What Are We Really Measuring? A Content Comparison of Swallowing Outcome Measures for Head and Neck Cancer Based on the International Classification of Functioning, Disability and Health (ICF)

A combination of outcome measures are required to provide important information on the physiological profile and associated impact of dysphagia in head and neck cancer (HNC). Choosing the most appropriate tool can be a difficult and time-consuming process. The aim of this study was to identify and then compare the content of tools commonly used to assess swallowing post HNC care using the International Classification of Functioning Disability and Health (ICF) as a reference. A literature audit of 11 databases was conducted for relevant articles published between January 2004 and June 2017 and total of 502 papers met the inclusionary criteria. These papers were audited and 27 tools were identified which met the study criteria. The meaningful concepts contained in each tool were mapped to the ICF. Within the 27 tools, 898 meaningful concepts were identified and matched to 60 ICF categories. The most frequently matched ICF categories related to body functions, while comparatively few concepts matched to activity and participation and environmental factors. This study has identified that a large number of tools are currently being used in HNC research to measure swallowing outcomes. The sheer number of tools available to explore dysphagia post HNC highlights the lack of a uniform approach to outcome measurement which limits the potential to compare and combine research studies in order to strengthen treatment evidence. There is a need to develop an international consensus for a core outcome set of swallowing related measures, that capture the holistic impact of dysphagia, for HNC.

Survivorship care planning and implementation in neuro-oncology

Survivorship has become a significant topic within oncologic care. The tools and means by which the provision of survivorship care can be implemented and delivered are in development and are the focus of significant research oncology-wide. These tools and methods include innovations of survivorship care delivery, survivorship care plans, and improving communication among all stakeholders in an individual patient's care as the means to elevate health-related quality of life. The merits of these survivorship care provisions in the field of neuro-oncology and its patients' exigent need for more patient-centric care focused on living with their illness are discussed. Since 2014 there has been a mandate within the United States for adult cancer patients treated with curative intent to receive survivorship care plans, comprising a treatment summary and a follow-up plan, intended to facilitate patients' care after initial diagnosis and upfront treatment. Several cancer-specific survivorship care plans have been developed and endorsed by health care professional organizations and patient advocacy groups. A survivorship care plan specific for neuro-oncology has been collaboratively developed by a multidisciplinary and interprofessional committee; it is endorsed by the Society for Neuro-Oncology Guidelines Committee. It is available as open access for download from the Society for Neuro-Oncology website under "Resources": https://www.soc-neuro-onc.org/SNO/Resources/Survivorship_Care_Plan.aspx. Survivorship care offers an opportunity to begin directly addressing the range of issues patients navigate throughout their illness trajectory, an oncology initiative to which neuro-oncology patients both need and deserve equitable access.