Comparison of psychosocial outcomes in head and neck cancer patients receiving a coping strategies intervention and control subjects receiving no intervention

This feasibility study aimed at comparing psychosocial outcomes in head and neck cancer patients receiving the Nucare program with a group of control subjects receiving no intervention. A prospective, nonrandomized study design was used. The Nucare program, a short-term psychoeducational coping strategies intervention, was the test intervention. Control subjects were matched to intervention subjects by cancer stage and time since cancer diagnosis. Outcomes were quality of life and depressive symptoms evaluated at baseline and 3 to 4 months later. One hundred thirty-eight subjects were recruited, and outcome data were available on 101 subjects. At outcome evaluation, compared with their baseline scores, the intervention group had improved physical and social functioning, global quality of life, fatigue, sleep disturbance, and depressive symptoms; the control group showed no changes in quality of life or depressive symptoms. The results suggest that the Nucare program may improve quality of life and reduce depressive symptoms in head and neck cancer patients.     

A prospective population-based study of cutaneous malignant melanoma of the head and neck

OBJECTIVES/HYPOTHESIS For cutaneous malignant melanoma (CMM) of the head and neck, neither prognostic factors in population-based groups, nor outcome with respect to surgical resection margins is clear. Therefore, we analyzed data in a regional registry to align treatment results for CMM of the head and neck with prognosis and survival times. STUDY DESIGN: Patient material collected prospectively for an 18-year period in a Swedish cancer registry underwent statistical analyses to establish the most reliable prognostic factors and the influence of surgical treatment on the survival of patients with CMM of the head and neck. METHODS: Data originated from the CMM database of the Stockholm-Gotland area of Sweden. Tumor thickness or invasiveness (Breslow or Clark's levels), extent of surgical margin, sex, histogenetic type, anatomic site, and ulceration were compared statistically for 469 patients. RESULTS: Male patients with head and neck CMM had a 68% 10-year survival rate; the 10-year survival rate for female patients was 87%. The corresponding figures for CMM at other sites were 83% and 90%, respectively. Tumor thickness (or Clark level of invasion) was the only statistically significant prognostic factor in a multivariate analysis (P < .001). The surgical resection margin seemed to be of no importance to outcome. CONCLUSIONS: Long-term survival after treatment for CMM of the head and neck is better than reported in most earlier publications, presumably because our evaluation used population-based materials, an important factor in accurate reporting of this kind. Tumor thickness is the main prognostic factor in estimating outcome.     

Quality of life in head and neck cancers patients: predictive factors,functional and psychosocial outcome

The principal endpoints in head and neck cancer are survival with improvement of quality of life (QoL) in cancer patients. Patients treated for head and neck cancer suffer from a number of symptom domains: physical symptoms linked to diet and feeding, communication disorders, pain and their general state of health; psychological symptoms including depression, irritability, loss of self-esteem (occasionally feelings of shame), and social symptoms including relationship difficulties with partner (sexual disorders) or with other family members, loss of work, reduction in salary, and sense of uselessness, resulting in a negative impact on their daily life. At present, most tools only partially evaluate patient QoL, concentrating on the global impact of disease and its treatment on patients’ physical and psychological condition. The “sociability” of individual patients is rarely evaluated, and the development of qualitative studies in this domain will enable improved understanding of the social factors involved in each patient’s adaptability to disease, its treatment and after-effects.     

Changes in quality of life over 1 year in patients with head and neck cancer

OBJECTIVES: To characterize and compare quality of life (QOL) in patients with head and neck cancer shortly before initial treatment and 1 year later and to study the predictors of changes in QOL over 1 year. DESIGN: Prospective cohort study. SETTING: Three otolaryngology clinics. PATIENTS: Three hundred sixteen patients having newly diagnosed squamous cell head and neck cancer. MAIN OUTCOME MEASURE: Health-related QOL was assessed using the 36-item Short-Form Health Survey and a head and neck cancer-specific QOL scale. RESULTS: Over 1 year, QOL decreased for physical functioning measures and eating but improved for mental health QOL. Depression and smoking were major predictors of poor QOL at baseline. Major predictors of change in QOL from baseline to 1 year were treatment factors, especially feeding tube placement (9 scales), chemotherapy (3 scales), and radiation therapy (3 scales). Baseline smoking and depressive symptoms also remained significant predictors of several QOL scales at 1 year. CONCLUSIONS: Health-related physical QOL tended to decline over 1 year and mental health QOL improved. The major predictors of change in QOL were treatment factors, smoking, and depressive symptoms. Physicians should alert patients to the relative effects on QOL one may experience with different treatments.     

Long-term quality of life of patients with head and neck cancer

Objectives: To describe prospectively the long‐term changes of quality of life and mood in patients with squamous cell carcinoma of the head and neck treated with surgery and/or radiotherapy. Patients and Methods: One hundred seven patients completed the European Organization for Research and Treatment of Cancer (EORTC) Core Questionnaire, the EORTC Head and Neck Cancer Module, and the Center for Epidemiological Studies Depression Scale before treatment, and 6, 12, 24, and 36 months later. Results: There was limited deterioration of physical and role functioning and of many head and neck symptoms at 6 months, with improvement thereafter. After 36 months only physical functioning, taste/smell, dry mouth, and sticky saliva were significantly worse, compared with baseline. Female sex, higher cancer stage, and combination treatment were associated with more symptoms and worse functioning. Despite physical deterioration, there was a gradual improvement of depressive symptomatology and global quality of life. Conclusion: Treatment for head and neck cancer results in short‐term morbidity, most of which resolves within 1 year. Despite an initially high level of depressive symptomatology, there is gradual improvement of psychological functioning and global quality of life over the course of 3 years. In this prospective study, the impact of the disease and its treatment in long‐term survivors seems to be less severe than it is often assumed to be.     

The effect of age on survival and quality of life in elderly head and neck cancer patients: a long-term prospective study

Little is known about long-term treatment outcome of elderly head and neck cancer patients and their quality of life (QOL). One hundred and eighteen older (≥70 years) and 148 younger (45–60 years) patients with head and neck cancer were followed up for 3–6 years. In the long-term follow-up 33 younger and 24 older patients completed the EORTC QLQ-C30 and H&N35 and a questionnaire about depression. The survival rate after 3–6 years for younger patients was 36%, as compared to 31% in the older patient group. Higher tumour stages, more co-morbidity and non-standard treatment showed to be independent prognostic factors for mortality. No independent prognostic value of age could be found. The global QOL score remains roughly comparable. Even up to 6 years after treatment, we found no significant differences in survival or overall QOL between older and younger head and neck cancer patients.     

Distress in spouses and patients after treatment for head and neck cancer

BACKGROUND: The objective of this study is to obtain insight into distress in spouses and patients treated for head and neck cancer. METHODS: Forty-one patient-spouse pairs completed the Hospital Anxiety and Depression Scale (HADS). Inclusion criteria included curative treatment for head and neck cancer. Exclusion criteria were visiting the clinic without a spouse, bad news at the routine follow-up examination, diseases causing cognitive dysfunction, and poor understanding of the Dutch language. Next to the HADS, the assessment protocol included age, gender, health status, coping strategy, time since cancer treatment, tumor stage and site, treatment modality, functional and social impairment, and caregiving burden. RESULTS: A clinical level of distress was noted in 20% of the spouses and in 27% of the patients. Distress in spouses was related to the presence of a feeding tube in patients, a passive coping style, less vitality, and a disrupted daily life schedule resulting from caregiving. Distress in patients was related to the presence of a feeding tube, speech and swallowing problems, less social contacts, a passive style of coping, and nonexpression of emotions. CONCLUSION: Distress is often present in spouses and patients treated for head and neck cancer. Routine screening for psychologic distress is recommended.     

Health‐Related Quality of Life Scores in long‐term head and neck cancer survivors predict subsequent survival: a prospective cohort study

Clin. Otolaryngol. 2011, 36 , 361–368 Objective: To examine the survival prediction of long‐term health‐related quality of life in patients with head and neck squamous cell carcinoma. Design: Patients with head and neck squamous cell carcinoma diagnosed in the period between July 1992 and October 2001, who had been disease free for a minimum of 1 year following therapy, responded to structured interviews including several validated questionnaires in the period from October 2002 to March 2004. The study ended in June 2009 with a mean observation time of 75 ± 4 months among the survivors. Twenty‐four deaths were observed. Setting: University hospital, referral centre of the Western Norway. Participants: One hundred and thirty‐nine cognitive functioning patients. Main outcome measurements: Overall survival as of June 2009. This was correlated with various clinical factors and the EORTC QLQ‐C30 questionnaire, the Eysenck Personality Inventory and the Coping inventory completed between October 2001 and March 2004. Results: A general symptom sum score was significantly predictive of survival directly and after sequential adjustment for self‐reported levels of neuroticism, avoidance focused coping, coping by suppression of competing activity, alcohol consumption, smoking status and heart/lung disease, as well as gender, age, time between diagnosis and inclusion, tumour node metastasis (TNM) stage and tumour site. Similar results were found for the health‐related quality of life indices ‘fatigue’, ‘dyspnoea’ and ‘sleep disturbance’. A dichotomised variable based on the general symptom sum score was calculated, and a high risk group, as to mortality, including less than a quintile of the total patient population was established. A hazard ratio of 5.15 was found for the dichotomised general symptom sum score. Conclusion: We have shown a unique and independent survival prediction from long‐term EORTC QLQ‐C30 scores in successfully treated and cognitive functioning head and neck squamous cell carcinoma patients.     

Knowledge and expectations about miRNAs as biomarkers in head and neck squamous cell cancers

Head and neck squamous cell cancer patients suffer from a high postoperative recurrence rate and poor prognosis. Thus, it is essential to better understand the underlying molecular mechanisms and identify the role of new biomarkers. Recent research has shown that the dysregulation of microRNAs is a potential biomarker as a screening or prognostic tool. Moreover, the literature reveals its promising usefulness to select the best treatment strategy and monitor tumour response.The purpose of this review is to identify and synthesize the available literature on microRNAs as biomarkers that could help manage patients with head and neck squamous cell cancer. A search in scientific databases was completed, including all relevant articles related to circulating microRNAs in head and neck squamous cell cancer published in English or Spanish. We focused on articles whose main findings were related to their usefulness in diagnosis and prognosis.Conclusion: Knowledge of microRNAs opens the possibilities that these molecules offer in terms of monitoring cancer disease in a less-invasive, simple manner, allowing for serial sampling to assess the response to treatment and minimal residual disease. It is yet to be determined whether liquid biopsy will replace the traditional biopsy in the future but it represents a change in the paradigm of management of head and neck squamous cell cancer.     

Pretherapeutic nutritional/inflammatory factors as predictors for survival of both early and advanced staged head and neck cancer patients

ObjectivesMalnutrition and inflammation are common in patients with head and neck cancer and are closely associated with prognosis. Although several parameters for evaluating nutritional/inflammatory status have been assessed in relation to the prognosis of patients with head and neck cancer, previous studies primarily included patients with advanced-stage disease. To date, there is no consensus regarding the most reliable parameter for predicting the prognosis of early and advanced-stage head and neck cancer. This study sought to evaluate nutritional/inflammatory prognostic factors before treatment in patients with early and advanced-stage head and neck cancer.MethodsWe retrospectively reviewed medical records of patients treated between 2008 and 2015 at our institution in order to evaluate the effects of nutritional/inflammatory parameters, including C-reactive protein/albumin ratio, modified Glasgow prognostic score, neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, and Geriatric Nutritional Risk Index, on overall survival. Effects of potential risk factors on overall survival were analyzed by computing Kaplan-Meier estimates; curves were compared using the log-rank test.ResultsA total of 164 patients were enrolled. C-reactive protein/albumin ratio, modified Glasgow prognostic score, platelet/lymphocyte ratio, and Geriatric Nutritional Risk Index were found to be statistically significantly correlated with overall survival. Only the Geriatric Nutritional Risk Index remained statistically significant in the multivariate analysis. The three-year survival rates according to the four-group Geriatric Nutritional Risk Index scores for normal, low, moderate, and high risk were 95.5%, 84.3%, 53.8%, and 23.4%, respectively.ConclusionThe Geriatric Nutritional Risk Index is therefore a useful prognostic factor for patients with early and advanced-stage head and neck cancer.     

Examining the need for neck dissection in the era of chemoradiation therapy for advanced head and neck cancer

OBJECTIVES: To (1) determine clinical factors that predict pathologic complete response (pCR) on neck dissection after sequential chemoradiotherapy (SCRT) for advanced head and neck cancer and (2) compare survival parameters between those who underwent neck dissection and those who did not among those patients with a clinical complete response (cCR) in the neck after SCRT, thus assessing the benefit of neck dissection in patients with a cCR in the neck. DESIGN: Retrospective review with a mean follow-up of 3.5 years. SETTING: Regional cancer center. PATIENTS: The study population comprised 55 patients undergoing SCRT for advanced head and neck cancer with N2 or N3 neck disease. Three patients developed progressive disease and were excluded, and 28 patients underwent neck dissection. INTERVENTIONS: Patients were assessed by physical examination and radiographically after SCRT. MAIN OUTCOME MEASURES: Physical examination and radiographic assessments of residual neck disease were compared with pathologic findings in those patients who underwent neck dissection. Survival comparisons were made between patients with a cCR in the neck who underwent neck dissection and those who did not. RESULTS: Of 28 patients who underwent neck dissection, 8 had persistent pathologically positive nodal disease: 5 (45%) of 11 had N3 and 3 (18%) of 17 had N2 disease. Individual clinical neck assessments after SCRT were fairly predictive of a negative pathologic finding at neck dissection. The negative predictive values were physical examination (75%), computed tomography or magnetic resonance imaging (71%), and positron emission tomography (75%). However, when physical examination, imaging studies, and positron emission tomography all indicated a complete response, this accurately predicted a pCR on neck dissection. There appeared to be no improvement in survival parameters when a neck dissection was performed on patients with a cCR in the neck. CONCLUSIONS: Patients with N3 disease are at high risk for residual neck metastasis after SCRT. Patients with N2 disease can be assessed with physical examination, imaging studies, and positron emission tomography. If these all indicate a cCR, then neck dissection is likely not needed. Neck dissection did not appear to further improve survival parameters for patients with a cCR in the neck.     

Pre‐treatment haemoglobin level predicts response and survival after TPF induction polychemotherapy in advanced head and neck cancer patients

Objective: To investigate the prognostic value of the pre‐treatment haemoglobin level in patients with advanced squamous cell head and neck cancer treated with induction polychemotherapy. Design: Seventy‐two patients with advanced squamous cell head and neck cancer received primary combination chemotherapy consisting of docetaxel 75 mg/m² on day 1, cisplatin 100 mg/m² on day 1, and 5‐fluorouracil (5‐FU) 1000 mg/m²/day on days 1–4 (total dose 4000 mg/m²), repeated on days 1, 22 and 43 followed by chemoradiation. The data collected included pre‐treatment haemoglobin, response to treatment, disease‐free and overall survival. Results: The pre‐treatment haemoglobin level was found to be a significant predictor of response to induction chemotherapy (P = 0.01) and an independent predictor of overall survival [hazard ratio (HR) 0.77, 95% confidence interval (CI) 0.58–1.03, P = 0.0001] and disease free survival (HR 2.09, 95% CI 1.41–3.09, P = 0.0001). Furthermore N‐stage was found to be a significant prognostic factor of overall survival (HR 9.24, 95% CI 6.90–21.34, P = 0.005). The Eastern Cooperative Oncology Group performance status scale was also found to be significant for disease free survival (HR 7.66, 95% CI 2.61–22.46, P = 0.003). Conclusion: In patients with advanced squamous cell head and neck cancer, the haemoglobin level prior to induction chemotherapy is significantly related to outcome including response and survival.     

Physical and psychosocial correlates of head and neck cancer: an update of the literature and challenges for the future (1996–2003)

? An update of the literature on physical and psychosocial aspects of head and neck cancer, with special emphasis on effects of treatment, patient‐related factors and psychosocial intervention on quality of life (QoL). ? QoL deteriorates during and directly after treatment and returns only slowly to pre‐treatment values. ? Organ preservation, gender and coping‐strategies are factors related to QoL after treatment. ? As prognosis and survival were found to be comparable under different treatment regimes, we noticed a gradual shift in therapy towards organ preservation. ? Systematic care, using specific instruments is important for improving the QoL. ? We feel that more attention should be given to improving support, in order to optimize the QoL of patients during the palliative stage.     

The prognostic value of cyclin D1 expression in head and neck squamous cell carcinoma

The correlation between cyclin D1 overexpression and the clinical outcome of head and neck cancer is not defined. The aim of this meta-analysis was to evaluate the prognostic value of cyclin D1 in patients with head and neck cancer. A search thorough Ovid MEDLINE was performed to enroll all eligible articles. Twenty-two studies comprising a total of 1,929 patients with different head and neck cancers were included. Cyclin D1 overexpression was significantly associated with lymph node metastasis [OR 2.25; 95 % confidence interval (CI) 1.76–2.87] and worse disease-free survival (OR 3.06; 95 % CI 2.42–3.87]. Subgroup analysis revealed that cyclin D1 overexpression correlated significantly with nodal metastasis for laryngeal cancer (OR 2.26; 95 % CI 1.61–3.16) and was a significant poor predictor for nasopharyngeal cancer (OR 4.44; 95 % CI 1.89–10.42). Our meta-analysis suggests that cyclin D1 overexpression could represent an important prognostic indicator for patients with head and neck cancer.     

Comorbidity in nasopharyngeal carcinoma: a preliminary communication on the prevalence,descriptive distribution and impact on outcome

Objectives: Comorbidity has been shown to be a determinant in treatment selection and survival in squamous cell cancer of the head and neck at various subsites. The objective of this study is to analyse the effect of comorbidity burden on outcome of nasopharyngeal cancer using the Adult Comorbidity Evaluation‐27 (ACE‐27) instrument. Design: Retrospective analysis. Setting: Tertiary care centres. Participants: This study included 59 patients diagnosed with nasopharyngeal carcinoma between 1989–2003 in the North‐East of England. Exclusion criteria included non‐squamous neoplasms of the nasopharynx. Comorbidity was assessed retrospectively from the notes using standard validated techniques described earlier. Tumour, treatment and survival data were obtained from prospective databases. Data was analysed using SPSS for Windows. Main outcome measures: Comorbidity and outcome of treatment. Results: Comorbid burden was evident in 44% of patients, with moderate or severe comorbidity in 19%. The cardiovascular system was the most commonly affected system (27%). Cox's proportional hazard model showed age and stage of tumour to have an impact on disease specific survival. Comorbidity was not seen to predict the outcome independent of other factors. The sample size of this study is powered to detect only medium to large effects. We estimate that 614 subjects will be needed to detect a correlation coefficient of 0.1 with 80% power, assuming a type 1 error rate of 5%. Conclusion: This study shows for the first time that the comorbidity burden seen in nasopharyngeal cancer does not affect prognosis independent of the TNM staging.     

Observations of benefit finding in head and neck cancer patients

The management of head and neck cancer (HNC) can lead to potentially severe physical, functional and psychological disturbances. As a result, many HNC patients develop symptoms of depression following diagnosis and treatment. Finding benefit in a disease and its treatment can reduce the symptoms of depression and enhance quality of life (QOL). 92 patients from the Head and Neck Cancer Clinic at Auckland Hospital completed measures of unmet needs and quality of life at diagnosis, and completed measures of benefit finding, coping, fear of recurrence and depression 12–18 months later. Patients reported at least moderate benefit finding in the majority of areas. More benefit finding was predicted by the presence of more advanced disease, Maori/Pacific Island ethnicity, lower baseline QOL, and the use of active coping strategies. These findings support the view that screening for QOL at diagnosis and facilitating the development of coping skills may lead to improved benefit finding and psychological adjustment in people with head and neck cancer. Identification of the factors that facilitate benefit finding may assist management of patients after treatment for HNC.     

Sentinel node biopsy: the technique and the feasibility in head and neck cancer

Management of the clinically N(0) neck in head and neck squamous cell carcinoma is still under debate. Tumour spread to the neck is the most important prognostic factor in head and neck cancer patients. The sentinel node technique comprises the identification of the sentinel node by means of dye or isotope or a combination, and surgical removal followed by histological examination. We have reviewed the preliminary reports indicating that sentinel node identification is technically feasible in head and neck cancer surgery, i.e. in solitary and unilaterally oral and pharyngeal cancer stages T1 and T2 with clinical N(0). However, the existing reports enrole observational studies, thus randomised trials should be considered to gain maximum valid data to prove that sentinel node biopsy has an effect on parameters such as loco-regional control and survival.     

Impact of delay in diagnosis on survival to head and neck carcinomas: a systematic review with meta-analysis

Clin. Otolaryngol. 2012, 37 , 99–106 Objective:  To address the contradictory information on the role of delay in diagnosis on head and neck cancer survival. Study design:  Systematic review and meta‐analysis. Search strategy:  Search on MEDLINE (1966 to March 2011), EMBASE (1980 to March 2011) and ISI proceedings (from inception to March 2011). The terms used were (‘Head and neck cancers’) AND (‘delay’OR‘prognostic’OR‘survival’) both in MeSH terms and free‐text words. The reference lists of the retrieved articles were also revised manually to identify other potentially relevant papers. All searches were independently undertaken by two clinicians and one epidemiologist, and the results merged. Setting:  Primary and specialised care levels. Participants:  Meta‐analysis of data from papers on the subject published from 1966 to 2011. Main outcome measures:  Survival. Methods:  After search in Medline and other databases, we computed pooled relative risks (RR) and 95% confidence interval (95%CI) from the 10 studies retrieved. Results:  The estimate of the relative risk of mortality related to any diagnostic delay (either patient or professional delay) was 1.34 (95%CI 1.12–1.61). Referral delay was associated with a three‐fold increase in mortality. Total delay was marginally related to mortality (RR: 1.04, 95%CI: 1.01–1.07). By anatomic location, pharynx cancer shows the highest association (RR: 1.68, 95%CI: 1.22–2.31). Conclusions:  Diagnostic delay is a moderate risk factor of mortality from head and neck cancer. However, part of the effect observed may be due to residual confounding (confounding from unknown variables that are not eliminated by adjustment).     

Quality-of-life outcomes in the evaluation of head and neck cancer treatments

OBJECTIVES: To review the published literature to evaluate the design, use of terminology, and interpretation of results in studies using quality-of-life (QOL) instruments to measure differences between head and neck cancer treatments at a point in time or to report changes over time in one or more treatment groups. DATA SOURCE: MEDLINE search for subject headings "head and neck neoplasms" (as a main topic) and "quality of life" or "health status" restricted to English-language sources and a 10-year period from 1989 to 1999. STUDY SELECTION: Four hundred forty-five abstracts were reviewed to find articles using an instrument to compare head and neck cancer therapy groups with a QOL outcome (13.7% included). DATA EXTRACTION: Two readers reviewed each article to determine how terminology was used, if a scientific study design was used, and if differences or changes in scores were clinically interpreted. RESULTS: Sixty-one articles were reviewed. Forty different instruments were used. Terminology was used inconsistently in 21 (34.4%) of the 61 articles. A scientific study design was used in only 11 (18.0%) of the 61 articles (P<.001). A clinical interpretation of results was given in 16 (26.2%) of the 61 articles (P<.001). CONCLUSIONS: While QOL outcomes show promise for assisting with treatment decisions in head and neck cancer therapy, few studies using instruments to measure QOL outcomes are hypothesis driven and clinical interpretations of results are not commonly provided. We recommend that future studies identify the construct to be measured, specify comparator groups and hypotheses a priori, and provide clinical interpretations of results.     

Prognostic significance of presentation-to-diagnosis interval in patients with oropharyngeal carcinoma

OBJECTIVE: To evaluate the prognostic impact of presentation-to-diagnosis interval (PDI) and its association with other clinical factors in patients with oropharyngeal squamous cell carcinoma (OpSCC). DESIGN: Retrospective cohort study. SETTING: Otolaryngology clinic of an academic medical center. PATIENTS: Eighty-seven patients with OpSCC referred to the otolaryngology service at the Johns Hopkins Medical Institutions from March 1994 to August 2001 were included in the study. Selection criteria included confirmed pathological diagnosis of OpSCC, availability of referral record for PDI determination, and no past history of oropharyngeal cancer. MAIN OUTCOME MEASURES: The PDI is defined as the time between the patient's first presentation to a medical professional for tumor-related symptoms and the time when the diagnosis of OpSCC was made. The prognostic impact of PDI and its association with other clinical factors were assessed using univariate and multivariate analyses. RESULTS: Forty percent of patients (35/87) had a PDI of 3 months or longer. Referred otalgia, active smoking status at the time of diagnosis, stage IV disease, and advanced T stage were associated with a poor prognosis. Prolonged PDI itself was not associated with a significant decrease in survival in univariate analysis (hazard ratio, 1.27; P =.52). Furthermore, no significant correlation was found between PDI and N stage, T stage, young age at presentation (<45 years), or tobacco use. CONCLUSIONS: Difficulty in making the diagnosis of OpSCC is evident by the high proportion of patients with PDI of 3 months or longer. The PDI does not appear to have an impact on survival. Referred otalgia, widely recognized as a strong indicator of invasive head and neck cancer, portends a poor prognosis.