Rehabilitation problems of head and neck cancer patients.

Head and neck cancer and its treatment result in varying degrees of disability affecting various organ systems. Ideal treatment of such patients requires a unit capable of managing problems in the areas of: Reconstructive surgery, maxillofacial prosthodontia, dentistry, deglutition disorders, and psychological, social, and vocational rehabilitation. Provision of such facilities in an integrated manner will give the patient the optimal chance for rehabilitation from the complex disabilities occurring in head and neck cancer.     

A literature review of head and neck cancer patients information needs, experiences and views regarding decision-making

This study reviews the body of existing research undertaken to explore head and neck cancer patients experiences of treatment for surgery, their information needs and their views regarding decision-making. Patients who suffer head and neck cancers and undergo surgery often report considerable psychological distress and impaired social functioning. To optimize survival, the decision about what treatment option to follow is often made quickly, with little support in terms of counsel or the provision of information. It is suggested that there is inadequate previous work exploring the content and delivery of information required by patients, their experiences and their views regarding decision-making to guide appropriate clinical interventions. By assimilating and critiquing existing work in this review an appropriate focus for further research is likely to be determined. An electronic search of relevant databases was undertaken including Cinahl, Medline, Psychinfo, Assia, the Cochrane Library and British Nursing Index. In addition, a grey literature search was also undertaken by hand. The search strategy was developed using recommendations from the Centre for Reviews and Dissemination 'Guidance for Those Carrying Out or Commissioning Reviews' (CRD Report Number 4, 2001). There is significant psychosocial and other functional disturbance amongst survivors of head and neck cancer surgery. Improved information giving may play a part in determining these outcomes.     

Long-term intraarterial chemotherapy infusion of ambulatory head and neck cancer patients

The complications of percutaneous intraarterial infusion chemotherapy of the head-and-neck-cancer patient has dampened enthusiasm for this approach. A totally implantable infusion pump system circumvents many of these complications and will in the long term enhance the opportunity to expand upon the advantages of infusion chemotherapy for the benefit of all cancer patients.     

Cell-mediated immune response in head and neck cancer patients

The immune reactivity of 100 head and neck cancer patients was studied by means of DNCB, candidine, blastic transformation with PHA, and lymphocyte counts. DNCB reactivity was strong in only 21% of the population and was found impaired in patients with advanced primitive tumors, with more than one primitive tumor, and in patients after radiation. Candidine reactivity was impaired in bigger primitive tumors, positive nodes, and advanced stages, as well as in postradiation patients. Blastic transformation was significantly worse in patients over 70 years and tended to be lower in patients with more than one primitive tumor. Good blastic transformation was also lowered in postradiation patients.     

Parenteral hyperalimentation in surgical patients with head and neck cancer: A randomized study

Sixty-nine patients were entered in a randomized study to determine the usefulness and practicality of parenteral hyperalimentation (TPN) in preparing and supporting patients with head and neck cancer undergoing radical resections. The patients were stratified by nutritional status and prognosis and randomization were done within each strata to TPN or control. Minimum full TPN was given at 35 calories/kgm/day for at least 14 days postoperatively. Eight patients received preoperative TPN also. Control patients received customary enteral alimentation by feeding tubes. Under the conditions of this particular study, the administration schedules, and type of solutions used, we were unable to demonstrate any superiority of TPN over conventional enteral nutrition in terms of immune parameters, wound healing, complications, and survival.     

Local control in advanced head and neck cancer by combined modalities of treatment

From July 1979 to January 1983, 20 patients with locally advanced head and neck cancer were treated with a combination of chemotherapy and irradiation with or without surgery. A majority of the patients were in the age range of 45 to 54 years. Eighty-five percent of the patients were male. Seventy-five percent of the patients had oral cavity lesions, the tongue being the most common site. Eighty percent of the patients had T₄ lesion and 35% had N₃ disease in the neck. A majority of the patients had combination chemotherapy, including bleomycin, methotrexate, and cis-platinum (BMP). All patients received irradiation with megavoltage equipment and 55% of patients received a dose of 5,000 to 6,000 rads in 5–6 weeks time. The tumor was converted to be resectable in ten patients. Nine patients (45%) had the neck and primary tumor completely controlled, while six patients (30%) had partial control. Six of the ten patients who had resection had the tumor controlled at the primary site and neck. The median duration of follow-up is 12 months (range, 4–32 months). The median survival of the whole group of patients is 12.5 months. A brief review of the current literature is also done in this paper.     

Risk of second primary cancer among patients with head and neck cancers: A pooled analysis of 13 cancer registries

The objective of the study was to assess the risk of second primary cancers (SPCs) following a primary head and neck cancer (oral cavity, pharynx and larynx) and the risk of head and neck cancer as a SPC. The present investigation is a multicenter study from 13 population-based cancer registries. The study population involved 99,257 patients with a first primary head and neck cancer and contributed 489,855 person-years of follow-up. To assess the excess risk of SPCs following head and neck cancers, we calculated standardized incidence ratios (SIRs) by dividing the observed numbers of SPCs by the expected number of cancers calculated from accumulated person-years and the age-, sex- and calendar period-specific first primary cancer incidence rates in each of the cancer registries. During the observation period, there were 10,826 cases of SPCs after head and neck cancer. For all cancer sites combined, the SIR of SPCs was 1.86 (95% CI = 1.83-1.90) and the 20-year cumulative risk was 36%. Lung cancer contributed to the highest proportion of the SPCs with a 20-year cumulative risk of 13%. Excess second head and neck cancer risk was observed 10 years after diagnosis with lymphohaematopoietic cancers. The most common SPC following a first primary head and neck cancer was lung cancer. However, the highest excess of SPCs was in the head and neck region. These patterns were consistent with the notion that the pattern of cancer in survivors of head and neck cancer is dominated by the effect of tobacco smoking and alcohol drinking.     

Impact of multidisciplinary team management in head and neck cancer patients

Background:

We analysed the outcomes of 726 cases of primary head and neck cancer patients managed between 1996 and 2008, including those managed in the multidisciplinary clinic or team setting (MDT) and those managed outside of an MDT by individual disciplines (non-MDT) in the same institution.

Methods:

Data were collected from the Hospital Based Cancer Registry and a database within the Head and Neck Cancer Clinic. Univariable comparisons and multivariable analyses were performed using a logistic regression model. Survival by staging was analysed. Comparisons of management and outcomes were made between MDT and non-MDT patients.

Results:

395 patients (54%) had been managed in the MDT vs 331 patients (46%) non-MDT. MDT patients were more likely to have advanced disease (likelihood ratio χ²=44.7, P<0.001). Stage IV MDT patients had significantly improved 5-year survival compared with non-MDT patients (hazard ratio=0.69, 95% CI=0.51–0.88, P=0.004) and more synchronous chemotherapy and radiotherapy (P=0.004), and the non-MDT group had more radiotherapy as a single modality (P=0.002).

Conclusions:

The improved survival of MDT-managed stage IV patients probably represents both the selection of multimodality treatment and chemotherapeutic advances that these patients received in a multidisciplinary team setting by head and neck cancer specialists as opposed to cancer generalists in a non-MDT setting.     

Surveillance imaging following treatment of head and neck cancer

Post-treatment surveillance is an important component in the treatment of head and neck cancers, especially as the proportion of human papilloma virus-positive cancers increases. Early detection of recurrences or second malignancies can increase success and minimize the toxicity of salvage treatment. Unfortunately, there are no consensus guidelines on the frequency and modality of post-treatment imaging. Computed tomography, ultrasound, magnetic resonance imaging and positron emission tomography-computed tomography (PET-CT) all have unique advantages and disadvantages when used as surveillance imaging. There is evidence that PET-CT may be the most sensitive of these modalities, but further research is needed to show an improvement in patient outcomes. Institutions will benefit most from a surveillance plan that is consistent and tailored to the individualized needs of their patients. This review focuses on the available evidence for different imaging modalities and general guidelines for developing an institution-specific practice pattern.     

Fear of recurrence and psychological distress in head and neck cancer patients and their carers

Background: Fear of recurrence (FOR) has been increasingly recognised as an issue of significant burden for most cancer patients, and has been associated with psychological morbidity and reduced quality of life. More recently, the impact of recurrence fears has been indicated in the families of cancer patients. However, there has been a lack of prospective research. Aim: To systematically examine distress and illness concerns among patient–carer dyads. Methods: A multi‐centre prospective study of head and neck cancer patients and their carers (patients, n=101; carers, n=101), surveyed at two time‐points following diagnosis. Results: Carers recorded higher recurrence concerns on average than the patient group (p<0.001). A predictive path model of patient and carer self‐reports of distress and FORs was explored, with an excellent overall fit of the final model (χ²=15.4, df=12, p=0.22, Comparative Fit Index (CFI)=0.994, Root Mean Square Estimate of Approximation (RMSEA)=0.053). Conclusions: The preliminary results establish that early fears and distress within individuals govern later reports on these same attributes, but that there is some weak evidence of influence from one attribute to another within and across individuals in the dyad. Future prospective dyadic research is warranted to ascertain the level of these fears over an extended time and their relationship to patient and carer adaptation. Intervention may be needed to reduce this disease concern to a manageable level at an early stage of the illness trajectory. Copyright © 2008 John Wiley & Sons, Ltd.     

Predictors of smoking relapse in patients with thoracic cancer or head and neck cancer

BACKGROUND:

Cancer patients who continue smoking are at increased risk for adverse outcomes including reduced treatment efficacy and poorer survival rates. Many patients spontaneously quit smoking after diagnosis; however, relapse is understudied. The goal of this study was to evaluate smoking‐related, affective, cognitive, and physical variables as predictors of smoking after surgical treatment among patients with lung cancer and head and neck cancer.

METHODS:

A longitudinal study was conducted with 154 patients (57% male) who recently quit smoking. Predictor variables were measured at baseline (ie, time of surgery); smoking behavior was assessed at 2, 4, 6, and 12 months after surgery. Analyses of 7‐day point prevalence were performed using a Generalized Estimating Equations approach.

RESULTS:

Relapse rates varied significantly depending on presurgery smoking status. At 12 months after surgery, 60% of patients who smoked during the week prior to surgery had resumed smoking versus only 13% who were abstinent prior to surgery. Smoking rates among both groups were relatively stable across the 4 follow‐ups. For patients smoking before surgery (N = 101), predictors of smoking relapse included lower quitting self‐efficacy, higher depression proneness, and greater fears about cancer recurrence. For patients abstinent before surgery (N = 53), higher perceived difficulty quitting and lower cancer‐related risk perceptions predicted smoking relapse.

CONCLUSIONS:

Efforts to encourage early cessation at diagnosis, and increased smoking relapse‐prevention efforts in the acute period following surgery, may promote long‐term abstinence. Several modifiable variables are identified to target in future smoking relapse‐prevention interventions for cancer patients. Cancer 2013. © 2012 American Cancer Society.     

Molecular biology in head and neck cancer

Major changes in the treatment of head and neck cancer are possible today because of the knowledge that we have on the molecular biology of these tumors. Different pathways are active in the development of this cancer and field cancerization is a major problem for the cure in early stage disease. Epidermal growth factor signal transduction pathway is now the principal target for this disease. New therapeutic strategies such as monoclonal antibodies and small molecules have appeared, however no more than 20% of the patients have objective responses with these therapies. Consequently, new alternatives of treatment in the basis of the understanding of molecular biology are necessary to increase the number of patients that can be cured in the future. Supported by an unrestricted educational grant by Bristol-Myers Squibb.     

Experiences with intra-arterial chemotherapy for head and neck cancer

During the 10-year period from 1966-1975, 250 patients with various head and neck cancers were treated by intra-arterial chemotherapy using single agents or various combinations. Only 15 patients showed response of I-C category according to Karnofsky's criteria, and 100 patients had I-B response. Another 100 patients showed I-A category of response and 35 patient had progressive disease out of which 5 patients exhibited excessive toxicity to drugs, eventually succumbing to it. A majority of patients in nonresponding (O-O) category and I-A category were earlier treated by radiotherapy, and intra-arterial chemotherapy was given for recurrent disease. The responses were relatively good whenever chemotherapy was given as a primary treatment before surgery and radiotherapy. Again response was additive when chemotherapy was given concurrently with radiotherapy.     

Progression of head and neck squamous cell cancer

Squamous cell cancer in the head and neck region (HNSC) is unique concerning its progression since it remains locoregional for long time and visceral metastases develop only in a later stage of the disease. Accordingly, molecular markers of the local invasion and the lymphatic dissemination both have critical importance. HNSC progression is associated with deregulated control of cell proliferation and apoptosis but it seems equally significant the disregulation of the proteolytic machineries. Here we outline the lymphatic metastatic cascade for HNSC to depict key molecular determinants as possible prognostic factors or therapeutic targets identifying immunological selection as a major feature. Unlike in local spreading, invasive potential of cancer cells seems to be less significant during lymphatic dissemination due to the anatomical properties of the lymphatic vessels and tissues. There is a general believe that HNSC is one disease however, data indicate that the anatomical localization of the tumor (the soil) such as oral, lingual, glottic or pharyngeal has a significant effect on the gene expression profile and corresponding biological behavior of HNSC. Furthermore, even the endocrine milieu of the host was proved to be influential in modulating the progression of HNSC. Gene expression profiling techniques combined with proteomics could help to define and select usefull genetic and biomarkers of progression of HNSC, some of them could well be potential novel therapeutic target.     

Variation in survival of patients with head and neck cancer in Europe by the site of origin of the tumours

The study describes the prognosis of head and neck cancer in Europe on the basis of information available to population-based cancer registries collaborating in the EUROCARE II project. Variation in survival in relation to country and the anatomical site/sub-site of origin of the tumours was examined. Survival analysis was carried out on 35 004 head and neck cancer cases (ICD 141, 143–148 and 161) diagnosed between 1985 and 1989 in 17 European countries. Prognosis varied considerably according to anatomical site: the best 5-year survival rates were seen for cancer of the larynx (63% in men) and the worst for cancer of the hypopharynx (22% in men). Five-year relative survival of male patients with cancer of the tongue, mouth and pharynx (ICD 141, 143–148) was 34% and ranged from over 45% in Iceland, Sweden, The Netherlands and Austria to less than 25% in Eastern European countries. Survival for larynx cancer ranged from over 70% in Iceland, Sweden, The Netherlands and Germany to less than 50% in Slovakia, Poland and Estonia. Apparently, France had the lowest survival (relative risk (RR) of dying versus Finland=1.29) in Western Europe; after adjustment for ICD 3-digit anatomical sites the difference disappeared (RR=1.04). Eastern European countries remained at the bottom of the survival range (RR>1.4). The analyses adjusting by sub-site (ICD fourth digit) were confined to registries for which the proportion of unspecified sub-sites was less than 20%. Geographical differences in survival between Western European countries were largely due to a difference in case mix of anatomical sub-sites. However, after correcting for different sub-site distribution, differences persisted between Eastern and Western European countries. This is likely to be due to late diagnosis and to late referral or poor access of patients to adequately equipped treatment centres.     

Synchronous cancers in patients with head and neck cancer

BACKGROUND:

Second primary malignancies (SPMs) are the leading cause of death in survivors of head and neck squamous cell carcinoma (HNSCC). Synchronous SPMs are of significant clinical interest because they potentially can be identified by screening procedures at the time of diagnosis of the index cancer. Recently, human papillomavirus (HPV) has emerged as a distinct risk factor for oropharyngeal head and neck squamous cell carcinoma (HNSCC), differing from classic tobacco/alcohol‐associated HNSCC, suggesting that there also may be distinct patterns of synchronous SPMs.

METHODS:

The authors performed a population‐based cohort study in 64,673 patients in the National Cancer Institute Surveillance, Epidemiology, and End Results registry (1979‐2008), defining risks of synchronous SPM in patients with HNSCC who were diagnosed before and after the emergence of prevalent HPV‐associated oropharyngeal HNSCC. Excess risk was calculated using standardized incidence ratios (SIR) and excess absolute risk per 100 patients.

RESULTS:

Among patients with HNSCC, the SIR of synchronous SPM was 5.0, corresponding to 2.62 excess cases per 100 patients. The site with the highest excess risk of a second cancer was the head and neck (SIR, 41.4), followed by the esophagus (SIR, 21.8), and lung (SIR, 7.4). The risk of synchronous SPM changed markedly over time for patients with oropharyngeal HNSCC. In the 1970s and 1980s, oropharyngeal cancers carried the highest risk of SPM. Risk began to dramatically decline in the 1990s; and currently, oropharyngeal cancers carry the lowest risk of synchronous SPM.

CONCLUSIONS:

The current data are consistent with the etiologic shift of oropharyngeal HNSCC, from a primarily tobacco‐associated malignancy associated with significant field cancerization of the upper aerodigestive mucosa, to a malignancy primarily caused by oncogenic human papillomavirus. Cancer 2013. © 2013 American Cancer Society.     

Oral mucositis in head and neck cancer

This module explores the risk factors, pathogenesis and development of oral mucositis. It considers the early diagnosis and accurate management of oral mucositis in head and cancer patients undergoing treatment.