Functional outcomes in head and neck cancer

For advanced head and neck cancer (HNC) patients, the effects of disease and the side effects of aggressive treatments have the potential to severely affect function and quality of life. More recent treatment strategies offer patients many options and have increased rates of locoregional control. However, they have not eliminated either acute treatment side effects or the spectrum of negative late sequelae, such as eating and speech dysfunction, residual pain, and troublesome dryness of the mouth. Understanding this broad spectrum of side effects and how patients experience them as well as the functional and quality of life implications is important to treatment evaluation and patient decision making. The heterogeneity of HNC patients (in terms of tumor site), the diversity of surgical techniques and chemoradiotherapy regimens, together with individual patient differences in response to these variables, make it particularly difficult to describe precise outcomes attached to various treatment options. However, in the context of this caveat, there are increasing data documenting the impact of various treatment modalities on physical, functional, and QOL outcomes. This article presents some of these data with a focus on the performance and functional results of radiation therapy, surgery, or concomitant chemoradiation therapy.     

Evaluation of comorbidity in 9388 head and neck cancer patients: A national cohort study from the DAHANCA database

Background

Comorbidity is common in head and neck squamous cell carcinoma (HNSCC) patients due to the etiology of the disease being primarily smoking. The aim of this study was to investigate the impact of comorbidity on survival in a national population-based cohort study on 9388 HNSCC-patients treated with radiotherapy (RT), to re-evaluate the prognostic impact of individual diseases within the Charlson Comorbidity Index (CCI), and to develop a revised head and neck comorbidity index (HN-CCI).

Material and methods

A national cohort of 9388 HNSCC-patients treated with curative intended RT diagnosed from 1992 to 2008 was identified from the DAHANCA-database. Data on comorbidity prior to HNSCC-diagnosis was obtained from the National Patient Registry and adapted to the CCI.

Results

By dividing the patients into two groups, we tested and validated which type of comorbidities within the CCI affected overall survival (OS) and cancer specific death (CSD). In total, 36% of patients had comorbidity. Six comorbid conditions within the CCI significantly reduced five-year OS probability: congestive heart failure, cerebrovascular disease, chronic pulmonary disease, peptic ulcer disease, liver disease, and diabetes, and based on these conditions the new head and neck specific comorbidity index was developed, the HN-CCI. Comorbidity according to HN-CCI had a highly significant impact on OS, whereas it was not associated with CSD. Chronological age was not associated with increased risk of CSD after controlling for comorbidity.

Conclusions

Comorbidity is frequent in HNSCC patients and negatively impacts OS. Therefore assessment of comorbidity will be of great importance, both in order to treat/optimize patient’s health before radiotherapy, but also in order to be able to stratify/control for comorbidity in randomized trials to avoid bias. Re-evaluation of the CCI revealed that only six conditions had an impact on survival, and a new modified index to assess comorbidity for HNSCC-patients was developed. The performance of HN-CCI to stratify patients on survival was good and HN-CCI is highly recommended for future assessment of comorbidity and prognostic staging of radiotherapy-treated HNSCC-patients.     

Increase in stroke risk in patients with head and neck cancer: a retrospective cohort study

Background:

This study investigated the stroke risk in patients with head and neck cancers (HNCs) using population-based data.

Methods:

From claims collected in the Taiwan National Health Insurance database, we identified 13 390 HNC patients with diagnosis made in 2000–2002. A reference cohort of 53 517 non-cancer individuals matched for age, gender, and stroke risk factors was used for assessing stroke risk in follow-up to 2008.

Results:

The overall stroke incidence was 1.44-fold higher in the HNC than in the reference cohort (11.4 vs 7.9 per 1000 person-years). Adjusted hazard ratios (HRs) were 1.54 (95% confidence interval (CI): 1.40–1.68) for ischaemic stroke and 1.36 (95% CI: 1.09–1.69) for haemorrhagic stroke. The cancer-to-reference stroke incidence rate ratio was age dependent and the highest in the age group younger than 40 years (5.45, 95% CI: 3.78–7.87) and decreased with aging. Comparing different therapeutic modalities, HNC patients receiving both radiotherapy (RT) and chemotherapy (CT) had the highest stroke risk (HR: 1.46, 95% CI: 1.22–1.74), followed in sequence by those who had CT alone, RT alone, and without therapy.

Conclusion:

Patients with HNC are at increased risk of developing stroke, especially in the young age group and in those who received both RT and CT.     

Improved immobilization using an individual head support in head and neck cancer patients

The benefits of a patient-specific head support, developed to improve immobilization during radiotherapy, were determined in head and neck cancer patients. Cone-beam CTs were registered to the planning CT in five regions. Compared to the standard head support, the individual head support decreased the systematic and random errors of the inter- and intrafraction displacements and reduced deformations.     

Mental health comorbidities and cost/utilization outcomes in head and neck cancer patients

Purpose: Examine the relationship between mental health comorbidities and health services outcomes in non-elderly adults with head and neck cancer (HNC).

Design: Retrospective, cross-sectional.

Sample: Non-elderly adults with a primary diagnosis of HNC in U.S. Department of Defense (TRICARE) administrative claims data for fiscal years (FY) 2007–2014.

Methods: Linear regression and generalized linear models were used to examine predictors of reimbursed cost and healthcare utilization, respectively.

Findings: On average, there were 2944 HNC patients each year, the majority age 55–64, male, military retirees or family members of retirees, cared for in civilian facilities, and residing in the U.S. southern region. Between FY2007 and FY2014, there were slight increases in prevalence rates for diagnosed depression (12.4%–13.1%), anxiety (8.2%–11.9%), adjustment disorders (3.7%–5.8%), and drug use disorders (10.3%–19.4%), and a slight decrease in alcohol use disorders (12.3%–11.4%). In the cost regression model, depression and anxiety were the seventh and eighth strongest predictors (p?<?.001), behind hospice use, treatment modalities, chronic physical conditions, and tobacco use. In the utilization regression models, depression, adjustment disorder, and anxiety ranked seventh, ninth, and eleventh as the strongest predictors for the number of ambulatory visits; anxiety, depression and substance use disorder ranked fifth, sixth, and eighth in the model examining predictors of the number of annual hospitalizations; and anxiety and depression ranked fifth and sixth in the model examining predictors of the annual number of bed days.

Conclusions: We found strong evidence that mental health comorbidities impact cost and utilization among HNC patients, independent of other factors.

Implications for Psychosocial Providers or Policy: Addressing mental health comorbidities among HNC patients may reduce cost and improve resource efficiency.     

Improved outcomes in patients with osteogenic sarcoma of the head and neck

BACKGROUND: The current study reviews the authors' recent institutional experience in the treatment of osteosarcoma of the head and neck (OSHN). METHODS: The clinical records of 44 patients who were treated between 1981 and 1998 for OSHN were reviewed retrospectively. Archived histologic material was reviewed and data were analyzed to identify factors predictive of disease control and survival. Outcomes were compared with a previously reported historic cohort treated at the study institution. RESULTS: Patients ranged in age from 6 to 64 years (median, 31 years). The mandible was the primary site in 18 patients (41%), the maxilla in 20 patients (45%), and the skull in 6 patients (14%). Surgery was employed in all 44 patients, neoadjuvant chemotherapy was administered in 30 patients (68%), and postoperative radiation therapy was given to 7 patients (16%). The surgical excision margins were positive in 13 patients (30%). High-grade lesions were reported in 50% patients and low-grade lesions were noted in 18% of patients (grade was not assessable in 32%). Histologic response was "unfavorable" in 22 of 30 patients (73%) who were treated with neoadjuvant chemotherapy. The 3-year overall, disease-specific, and recurrence-free survival rates were approximately 81%, 81%, and 73%, respectively (median follow-up of 41 months). Positive surgical margins were found to be the only significant predictor of worse disease-specific survival. Compared with the historical cohort, the current experience demonstrated an obvious improvement in the 5-year local control (35% vs. 78%), distant metastases (37% vs. 13%), and overall survival (23% vs. 70%). CONCLUSIONS: Negative surgical margins were found to be the only significant predictor of overall and disease-specific survival. The results of the current study represent a considerable improvement over the authors' previously published experience and compare favorably with the results reported in the literature.     

Treatment-related dysgeusia in head and neck cancer patients

Head and neck cancer patients treated with radiotherapy and/or chemotherapy agents may develop altered taste acuity. This, together with radiation induced xerostomia and dysphagia, is a major contributory factor to the anorexia and concomitant morbidity often seen in this group of patients. This paper examines the existing literature in order to assess the prevalence of clinician and patient-reported dysgeusia in HNC patients undergoing oncological treatment. We also describe the temporal manifestations of the same and its reported impact on QOL.     

Chromosome instability in head and neck cancer patients

Genetic changes play a crucial role in the process of neoplastic transformation. Mutations may occur spontaneously, but most of them (60-90%) are induced by mutagens. The epidemiological data indicate that only a part of the population exposed to mutagens/carcinogens develops cancer. Studies of the mechanisms leading to individual sensitivity to mutagens as well as tests allowing to recognize individuals susceptible to cancer have been performed. The bleomycin test is widely used for this purpose. In this classical test introduced by Hsu et al, the mean number of breaks per cell is analysed. In our study we present first results of the bleomycin test in patients suffering from head and neck cancer. In these patients, an increased number of breaks/cell (1.22 +/- 0.5 vs 0.79 +/- 0.3 in the control group) and an increased number of damaged cells (47% vs 36%) were observed. The results were also analysed in regard to the clinical stage of the disease. The data suggest that the chromosome instability does not correlate with the progression of the disease.     

How Do head and neck cancer patients prioritize treatment outcomes before initiating treatment?

PURPOSE: To determine, pretreatment, how head and neck cancer (HNC) patients prioritize potential treatment effects in relationship to each other and to survival and to ascertain whether patients' preferences are related to demographic or disease characteristics, performance status, or quality of life (QOL). PATIENTS AND METHODS: One hundred thirty-one patients were assessed pretreatment using standardized measures of QOL (Functional Assessment of Cancer Therapy-Head and Neck) and performance (Performance Status Scale for Head and Neck Cancer). Patients were also asked to rank a series of 12 potential HNC treatment effects. RESULTS: Being cured was ranked top priority by 75% of patients; another 18% ranked it second or third. Living as long as possible and having no pain were placed in the top three by 56% and 35% of patients, respectively. Items that were ranked in the top three by 10% to 24% of patients included those related to energy, swallowing, voice, and appearance. Items related to chewing, being understood, tasting, and dry mouth were placed in the top three by less than 10% of patients. Excluding the top three rankings, there was considerable variability in ratings. Rankings were generally unrelated to patient or disease characteristics, with the exception that cure and living were of slightly lower priority and pain of higher priority to older patients compared with younger patients. CONCLUSION: The data suggest that, at least pretreatment, survival is of primary importance to patients, supporting the development of aggressive treatment strategies. In addition, results highlight individual variability and warn against making assumptions about patients' attitudes vis-à-vis potential outcomes. Whether patients' priorities will change as they experience late effects is currently under investigation.