Gastrostomy tubes in patients with advanced head and neck cancer

OBJECTIVES: To measure the percentage of patients requiring gastrostomy tubes (G-tubes) and the timing of their placement, in addition to studying whether pretreatment variables (T stage, tumor site, N stage) and intratreatment variables (weight loss during treatment) are valid predictors for the need for G-tube placement. STUDY DESIGN: Retrospective case control study. METHODS: Retrospective review of a prospectively collected database with chart reviews was carried out on 477 patients treated on a regimen of intraarterial cisplatin and concurrent radiation. The likelihood of requiring a G-tube was calculated by studying several independent variables using chi-square analysis and the unpaired t test. RESULTS: Two hundred twenty (46%) patients had G-tubes placed, with mean time of placement being on day 20 after the initiation of treatment. Patients with T4 disease were statistically more likely to require a G-tube (50% vs. 37%, P < .05). Patients were less likely to require a G-tube when the primary site of tumor involved the larynx or paranasal sinuses (P < .05). There were no statistically significant differences between the two groups with regards to patient age, sex, N stage, and weight changes over the course of treatment. The odds of requiring a G-tube were highest for tumors involving the hypopharynx (80%), oral cavity (52%), and oropharynx (49%). CONCLUSIONS: Although clinical judgment appears to be sufficient for deciding when G-tube placement is warranted in our population, the threshold for placing a tube should be lower in those patients who had a higher likelihood of requiring a G-tube during the course of treatment, including those with advanced disease of the oral cavity, oropharynx, and hypopharynx.     

Predictors of prolonged length of stay after major elective head and neck surgery

OBJECTIVE/HYPOTHESIS: Longer length of stay (LOS) after elective surgery is associated with an increased use of health care resources and higher costs. The objectives of this study were to determine the perioperative factors that predict a prolonged LOS after elective major head and neck operations and to test the hypothesis that factors related to process of care (intra- and postoperative) independently predict prolonged LOS after adjustment for preoperative patient characteristics. STUDY DESIGN: Prospective hospital-based cohort study. METHODS: The National VA Surgical Quality Improvement Program data were accessed for seven head and neck operations: radical neck dissection (RND) (n = 398), modified RND (n = 891), total laryngectomy (n = 431), total laryngectomy with RND (n = 747), hemiglossectomy with unilateral RND (n = 201), composite resection (n = 105), and composite resection with RND (n = 312). Prolonged LOS was defined as exceeding the 75th percentile for the LOS distribution of each operation. Multivariable logistic regression analysis was performed to identify factors that predicted prolonged LOS. RESULTS: Sixty-eight variables were analyzed among 3,050 patients who qualified for inclusion. Preoperative patient characteristics that predicted prolonged LOS were older age, poorer functional status, consumption of more than two drinks of alcohol per day, history of chronic obstructive pulmonary disease, and diabetes mellitus. Intraoperative processes that predicted prolonged LOS were a longer operative time and transfusion of erythrocytes. The postoperative variables that predicted a prolonged LOS were a return to the operating room within 30 days of the index operation and the occurrence of two or more operative complications. CONCLUSION: Several intraoperative processes and postoperative adverse events contributed additional predictive information for prolonged LOS, after consideration of preoperative patient characteristics.     

Life-satisfaction in patients with head and neck cancer

Life-satisfaction is a measure of a patient's perception of the difference between his reality and his needs, or wants. This study reports the results of a longitudinal survey of patients’self-reported life-satisfaction following treatment for head and neck cancer. Life-satisfaction scores improved with time, and were related to pain, speech difficulty, and dysphagia. Lack of adequate family support was also important, although an uncommon problem. Treatment modality did not emerge as a significant determinant of life-satisfaction; speech difficulties were more likely to be due to articulation problems than voicing difficulty.     

Measuring comorbidity in patients with head and neck cancer

BACKGROUND: Comorbidities are diseases or conditions that coexist with a disease of interest. The importance of comorbidities is that they can alter treatment decisions, change resource utilization, and confound the results of survival analysis. OBJECTIVE: The objective of this study was to determine the best comorbidity index to use in survival analysis of patients with squamous cell carcinoma of the head and neck. METHOD: Four validated indexes, with very different methodologies (i.e., the Charlson Index, the Cumulative Illness Rating Scale, the Kaplan-Feinstein Classification, the Index of Co-existent Disease), were tested using data from 379 unselected consecutive patients with complete 3-year follow-up from the Kingston Regional Cancer Center. Kaplan-Meier analysis and Cox Proportional Hazards Regression were used to stratify patients into three levels of increasing severity of comorbidity for each index. The Proportion of Variance Explained and Receiver Operating Characteristics curves were used to compare the performance of the indexes. CONCLUSION: The Kaplan-Feinstein Classification was the most successful in stratifying patients in this population.     

Quality of life of patients with head and neck cancer

Patients with head and neck cancer have to deal with the impact of treatment on its functional and aesthetic aspects, and its self-report enables improvements in clinical and social support.ObjectiveTo evaluate the quality of life of patients dealing with squamous cell carcinoma of the head and neck.MethodA prospective analytical study. Twenty nine patients with mean age of 57 years answered at three stages: onset, middle and end of treatment, the questionnaires: Quality of Life Core Questionnaire - Cancer 30 and the Quality of Life Questionnaire - Head and Neck, the European Organization for Research and Treatment of Cancer. We used the Friedman test at: 0.05.ResultsThere were high mean values concerning physical, cognitive, social functions; improvements in general health and social function decline during treatment; and a significant difference in taste and smell (p = 0.020), swallowing (p = 0.040), cough (p = 0.013) and weight loss (p = 0.011).ConclusionThere was a significant reduction in the quality of life for some common symptoms resulting from cancer treatment, which was not seen in the evaluation of the aspects related to physical, cognitive and social functions, and general health.     

Microsatellite alterations in african americans with head and neck cancer

OBJECTIVE: To determine the genetic differences between African Americans (AA) and Non-African Americans (NAA) with head and neck squamous cell carcinoma (HNSCC). METHODS: DNA was obtained from tumor tissues and peripheral blood from 18 AA and 19 NAA patients with HNSCC. Microsatellite analysis using a fluorescent technique was performed on chromosomal arms 1p, 3p, 4q, 9p, 13q, and 17p. Statistical analyses were performed on the molecular and clinical outcome data. RESULTS: Based on the Surveillance, Epidemiologic, and End Result (SEER) data from southeast Michigan, the incidence rate of HNSCC in AA has been higher than for NAA, and the overall 5-year relative survival rate is lower for AA than NAA (36.2% vs. 47.6%). In this study, we found that the rate of loss of heterozygosity of chromosomal arms 1p, 3p, 4q, 9p, 13q, and 17p ranged from 68.8% to 83.3% for HNSCC in AA and from 66.7% to 90.0% in NAA. The difference in the rates of microsatellite alterations in chromosomal arms 3p, 4q, and 9p between AA and NAA were between 12.5% and 20% and were not statistically significant. CONCLUSION: The incidence and clinical outcomes for AA with HNSCC are different from that of NAA in southeast Michigan. In our group of patients with HNSCC, differences in rates of microsatellite alterations and survival were found between AA and NAA; however, these differences were not statistically significant. We conclude that genetic difference, as determined by the rates of microsatellite alterations, is not predictive of outcome difference between AA and NAA HNSCC patients.     

Elderly patients with head and neck cancer: physical,social and psychological aspects after 1 year

Objective Elderly patients with head and neck cancer often receive non-standard treatment for reasons other than comorbidity. In this prospective study we investigated how elderly patients fare 1 year after treatment in comparison with their younger counterparts.

Material and Methods Seventy patients aged 45–60 years and 51 patients aged ≥70 years with cancer of the oral cavity, pharynx (stage II–IV) or larynx (stage III–IV) participated in the study before treatment and 1 year later. Each patient was interviewed and given a questionnaire concerning physical functioning, social contacts, depressive symptoms, satisfaction with treatment and future expectations.

Results At 12 months, patients in both age groups reported significantly more depressive symptoms and less social support than before treatment, and their Karnofsky Performance Score was lower. However, there were no differences between elderly and younger patients. Approximately 90% of those in both age groups said that they would choose the same treatment again, and there was no age difference regarding the impact of treatment or expectations for the future.

Conclusion This study shows that the impact of treatment on quality of life did not differ between elderly and younger patients with head and neck cancer. Therefore, standard treatment should be considered in elderly patients if no severe contraindications exist.     

Nonopioid perioperative analgesia in head and neck cancer surgery: A systematic review

ObjectiveManagement of postoperative pain after head and neck cancer surgery is a complex issue, requiring a careful balance of analgesic properties and side effects. The objective of this review is to discuss the efficacy and safety of multimodal analgesia (MMA) for these patients.MethodsPubmed, Cochrane, Embase, Scopus, and clinicaltrials.gov were systematically searched for all comparative studies of patients receiving MMA (nonsteroidal anti‐inflammatory drugs (NSAIDs), acetaminophen, anticonvulsants, local anesthetics, and corticosteroids) for head and neck cancer surgeries. The primary outcome was additional postoperative opioid usage, and secondary outcomes included subjective pain scores, complications, adverse effects, and 30‐day outcomes.ResultsA total of five studies representing 592 patients (MMA, n = 275; non‐MMA, n = 317) met inclusion criteria. The most commonly used agents were gabapentin, NSAIDs, and acetaminophen (n = 221), NSAIDs (n = 221), followed by corticosteroids (n = 35), dextromethorphan (n = 40), and local nerve block (n = 19). Four studies described a significant decrease in overall postoperative narcotic usage with two studies reporting a significant decrease in hospital time. Subjective pain scores widely varied with two studies reporting reduced pain at postoperative day 3. There were no differences in surgical outcomes, medical complications, adverse effects, or 30‐day mortality and readmission rates.ConclusionMMA is an increasingly popular strategy that may reduce dependence on opioids for the treatment of postoperative pain. A variety of regimens and protocols are available for providers to utilize in the appropriate head and neck cancer patient.     

Palliative care in patients with cancer of the head and neck

Palliative care is the active total care of patients whose disease is not responsive to curative treatment. Patients with end-stage head and neck cancer have particular problems because of the impact of the tumour on the airway, the upper gastrointestinal tract and the major senses. Patients referred for palliative care were identified from the hospice database and the nature, incidence and management of their problems, and the role of the hospice in their care, was reviewed from in-patient and home care notes and patient-generated problem lists. Thirty-two male and six female patients with a median age of 64 years were identified. Locoregional recurrence was present in 79% of patients. Pain, weight loss, feeding difficulties, dysphagia, respiratory symptoms, xerostomia, oral thrush and communication difficulties were the major problems. The management of each, and of the terminal events encountered in the group, is discussed.     

Demands on caring relatives of head and neck cancer patients

BACKGROUND: Relatives of cancer patients experience high levels of stress that influence the quality of life of these individuals. To investigate whether there is a necessity for simultaneous supportive care of patient relatives, we performed for the first time a study asking the closest relatives of head and neck cancer patients about their needs during and after the treatment to consider how to optimize the situation for such patient groups. MATERIAL AND METHODS: Patients' relatives were assessed using an anonymous self-report questionnaire that was established in our department by expanding on a questionnaire for cancer patients' relatives from the psycho-oncologic society in Switzerland. The evaluation was multidimensional, cancer specific, and relative based. RESULTS: Relatives feel confronted themselves with cancer, although indirectly. The majority of the respondents were of the opinion that simultaneous psychological care of the patients and for the caring relatives would be helpful to cope with the situation. CONCLUSION: This study shows the significant impact of cancer on caring relatives of head and neck cancer patients. In our opinion, health services should become more aware of this potential to ensure that the needs of the involved patient relatives are met as well as those of the patients.