Reliability and validity of an observer-rated disfigurement scale for head and neck cancer patients

BACKGROUND: Facial disfigurement is considered to be one of the most distressing aspects of head and neck cancer and its treatment, but it has been the focus of little systematic study. Existing studies have yielded conflicting results about the psychosocial impact of disfigurement. No studies to date have examined disfigurement using a valid and reliable observer-rated measure. The purpose of the current study was to examine the validity (convergent and discriminant) and the inter-rater reliability of a novel nine-point observer-rated disfigurement scale. METHODS: The sample consisted of 74 ambulatory head and neck cancer patients more than 6 months post treatment. Ratings of disfigurement were assigned independently by surgical and nonsurgical raters. Validity was assessed by comparing the association between disfigurement ratings and sociodemographic and illness treatment variables. Reliability was assessed by examining the concordance between the surgical and nonsurgical ratings. RESULTS: Disfigurement ratings were not associated with several sociodemographic variables, supporting the discriminant validity of the scale. Disfigurement was significantly related to a diagnosis of oral cancer, a history of adjunctive radiation, the type of surgical procedure performed, the degree of physical dysfunction, and the presence of postoperative complications. Observer ratings of disfigurement were significantly related to patient ratings of disfigurement. These findings support the convergent validity of the disfigurement scale. Inter-rater reliability of the scale was high (intraclass correlation coefficient =.91). CONCLUSION: The study provides preliminary evidence for the validity and inter-rater reliability of a novel nine point observer-rated disfigurement scale that may be useful in evaluating the impact of disfigurement on quality of life in head and neck cancer.     

The impact of head and neck cancer and facial disfigurement on the quality of life of patients and their partners

BACKGROUND: Psychological and physical stresses from head and neck cancer can be substantial for patients and partners. There is minimal research exploring treatment impact, particularly facial disfigurement after surgery. MATERIALS AND METHODS: Twenty-eight surgery and radiotherapy/brachytherapy/chemoradiation patients and 25 of their partners were compared with 23 radiotherapy/brachytherapy patients and 19 partners. Participants completed the Hospital Anxiety and Depression Scale, Psychosocial Adaptation to Illness Scale, Dyadic Adjustment Scale, and European Organisation for Research and Treatment of Cancer Quality Of Life Scale, including the Head and Neck Cancer module. The Dropkin Disfigurement and Dysfunction scale classified surgical impairment. RESULTS: Partners reported greater distress than patients on some scales. Patients did not have a lower quality of life compared with normal populations and other cancer patients. However, on the EORTC they did and were comparable to a normed sample of head and neck cancer patients. Treatment modality was not predictive of psychological vulnerability. DISCUSSION: Head and neck cancer patients do not necessarily experience poor quality of life. The disease can have a significant impact on partners.     

Psychosocial adjustment in head and neck cancer: the impact of disfigurement,gender and social support

BACKGROUND: The purpose of this study was to examine the psychosocial impact of disfigurement, gender, and social support after surgical treatment of head and neck cancer. METHOD: Eighty-two ambulatory head and neck cancer patients, 6 months or more after treatment and free of active disease were assessed. Ratings of disfigurement were obtained using a valid and reliable 9-point scale developed for the study. Standardized measures of social support, depressive symptoms, well-being, and life happiness were used. RESULTS: The sample as a whole displayed high levels of life happiness, low levels of depression, and positive feelings of well-being. Women demonstrated higher levels of depression and lower life happiness; subjects with greater disfigurement were more depressed. Social support seemed to buffer the impact of greater levels of disfigurement on well-being for women but not for men. CONCLUSION: These results suggest that women with head and neck cancer who experience low social support and face disfiguring treatment are at greatest risk for psychosocial dysfunction.     

Modified radical neck dissection and postoperative radiotherapy in squamous cell head and neck cancer

Between 1978 and 1982, 41 patients with clinically staged N1, N2, or N3b disease underwent unilateral or bilateral modified radical neck dissection. Five patients died free from their original disease with less than 24 months follow-up. Twenty-four patients with histologically positive nodes received postoperative radiotherapy with 2 (8 percent) neck recurrences. Another four patients with histologically positive nodes refused postoperative radiotherapy and had two (50 percent) neck recurrences. Three patients did not respond to radiotherapy at the time of their surgery and had no neck recurrences. The final five patients had histologically negative nodes, did not receive radiotherapy, and had no neck recurrences. These results suggest that modified radical neck dissection can be used in lieu of the classical radical dissection in many patients with clinically positive nodes who have squamous cell head and neck cancer without compromising survival.     

Serial estimations of blood lactate predict postoperative outcome in cancer patients undergoing head and neck surgeries

To determine predictability of serial estimations of blood lactate levels for postoperative outcome of head and neck cancer patients and determine validity of single versus serial estimations for accurate prediction of outcome.The study included 322 cancer patients assigned for major head and neck surgeries and admitted to ICU. Data collection included age, sex, and associated comorbidities, and clinical status was determined using APACHE II score. Arterial lactate was measured at time of admission (T0), and 8-hourly (T8, T16, T24), and percentage of change of blood lactate level was calculated versus T0 level. Patients were categorized as survivor and non-survivors, and among each group, patients were categorized according to estimated level of blood lactate into four categories.The mean of APACHE score at ICU admission was 16.6 ± 3.1, and mean duration of ICU and hospital stay was 3.2 ± 1.2 and 19.3 ± 5.5 days, respectively. Fifty-two patients died for postoperative mortality rate 16.1%. Non-survivors were significantly older and had significantly higher APACHE score and significantly longer ICU and hospital stay. At admission blood lactate level was significantly higher in non-survivors compared to survivors. All patients showed progressive increase of blood lactate level, but non-survivors showed significantly higher frequency of elevated blood lactate strata compared to survivors with significantly higher difference between both groups at T8, T16, and T24. There was positive significant correlation between high at admission blood lactate level and APACHE score. Regression analysis defined % of change of blood lactate at T16, high APACHE score, high at admission blood lactate and old age as specific predictors for postoperative mortality in descending order of specificity. Serial estimations of blood lactate are conclusive test for follow-up of patients undergoing major surgical procedures requiring ICU admission. Combined high APACHE score and percentage of change of blood lactate could discriminate survivors from non-survivors especially 16-h after ICU admission.     

Genomic instability in head and neck cancer patients

BACKGROUND: In the normal host, there are a variety of cellular systems that ensure the accurate replication and repair of DNA. Recent evidence suggests that there are individual variations in the ability to preserve the genome. Certain individuals have defects in these checkpoints and have an inherent genomic instability. They are susceptible to the accumulation of DNA damage and are prone to carcinogenesis. This article examines the role of genomic instability in the development of head and neck cancer. RESULTS: Patients with either the chromosomal instability syndromes or the Li-Fraumeni syndrome have marked defects in either DNA repair or apoptosis. These patients are prone to have head and neck neoplasms develop. Head and neck cancer patients also have a diminished ability to repair DNA damage compared with the "normal" population. Abnormalities have been identified in mutagen sensitivity, the expression of DNA mismatch repair enzymes, the expression of p53, and telomerase activity when head and neck cancer patients are compared with controls. CONCLUSION: Subpopulations exist who have increased genomic instability. These individuals are at an increased risk for the accumulation of DNA mutations and the development of head and neck cancer. More research is needed to identify specific mechanisms of genomic instability and to further define the importance of this phenomenon.     

Benefit of postoperative chemoradiotherapy for patients with unknown primary squamous cell carcinoma of the head and neck

BACKGROUND: Postopertative adjuvant chemoradiotherapy recently became an established modality for patients with selected high-risk locally advanced head and neck cancers. The optimal treatment of unknown primary squamous cell cancer of the head and neck (SCCHN) continues to be controversial, since major randomized studies excluded those patients. METHODS: We conducted a retrospective review of patients treated during 1995 to 2002 for unknown primary SCCHN. All patients were treated with a neck dissection followed by concurrent high-dose cisplatin (100 mg/m(2)) and bilateral neck radiotherapy. RESULTS: Thirty-seven patients were identified with nodal disease distribution of N1 (5%), N2a (22%), N2b (41%), N2c (8%), N3 (22%), and Nx (3%). Modified neck dissection was done on the majority (30/37 = 81%) of patients. With a median follow-up of 42 months among the survivors, very few patients had regional recurrence (5%) or distant failure (11%), and 89% of patients were alive. The actuarial 5-year overall survival rate could not be estimated because there were no deaths beyond 20 months after surgery. Substantial yet acceptable acute and late morbidities were demonstrated in this cohort of patients. CONCLUSIONS: Postoperative chemoradiotherapy is of potential benefit to patients with unknown primary SCCHN by improving survival and reducing failures. This treatment warrants further prospective evaluation.     

Problems of terminal head and neck cancer patients

In recent years, there has been increased interest in defining what constitutes good quality of care for the terminal cancer patient. Progress in this area depends upon adequate knowledge of the problems in the terminal period for patients with cancer in specific sites. The present study is a survey of the final period of life in 60 head and neck cancer patients. The average survival time from diagnosis to death was 17.2 months. The mean time of hospitalization was 4 months. Pain was a problem in 85% of the patients, with feeding problems in 62% and respiratory difficulties in 43%. Eighty-six percent of the patients died in a hospital setting, with the average duration of the final hospitalization being 68 days. Our analysis documents the complex problems in the terminal phase of a head and neck cancer patient's life. These problems challenge medical facilities caring for such patients to develop programs that will provide the best possible levels of care for head and neck cancer patients and to develop approaches that will reduce the suffering experienced by the patient's family.     

Efficacy of neck treatment in patients with head and neck squamous cell carcinoma

BACKGROUND: Treatment of head and neck squamous cell carcinoma (HNSCC) addresses the primary tumor and the lymphatic drainage. Modalities for the neck are neck dissection and/or radiation therapy. In most cases, the neck is treated by the modality that seems more appropriate for the primary. The aim of this study was to analyze the results of the neck treatments either by neck dissection alone, by radiation therapy alone or by neck dissection followed by radiation therapy. METHODS: This was a retrospective chart analysis of 699 patients treated for a previously untreated HNSCC. The primary endpoint was recurrence at the treated neck. RESULTS: Two hundred eighty-one (40%) patients underwent primary neck irradiation, 219 (31%) neck dissection alone, and 199 (29%) neck dissection followed by adjuvant irradiation. The 5-year regional control rates after neck dissection alone were 83% for pN0, 75% for pN1, 60% for pN2a, 59% for pN2b, and 50% for pN2c; after radiation alone, 89% for cN0, 87% for cN1, 40% for cN2a, 60% for cN2b, and 48% for cN2c; and after neck dissection with adjuvant radiation, 86% for pN0, 96% for pN1, 100% for pN2a, 88% for pN2b, and 88% for pN2c. CONCLUSIONS: Radiation or neck dissection alone are efficient to control early neck disease. For advanced N2/3 neck disease, neck dissection followed by adjuvant radiation is highly efficient, whereas primary radiation results in a high number of regional failures. The literature suggests planned neck dissection to improve regional control for these patients.     

Interleukin-2 production in head and neck cancer patients

Interleukin-2, a lymphocyte-produced hormone or lymphokine, is required to support proliferation of antigen-triggered T lymphocytes and cytotoxic T cells that are considered essential elements for host tumor control. We have addressed the question of whether interleukin-2 production is altered in head and neck cancer patients, a group that is frequently immunosuppressed. Interleukin-2 production was measured by the tritium-labeled thymidine CT6 assay on the supernatants of peripheral blood lymphocytes of head and neck cancer patients and controls after 24 hour stimulation with phytohemagglutinin. The mean levels of interleukin-2 produced were 127 units (range 3 to 336 units) in the head and neck cancer patients versus 125 units (range 26 to 307 units) in the control group (not statistically significant). There were no significant differences in mean interleukin-2 values between cancer patients with stages I and II or III and IV disease compared with the control subjects. Twenty-seven percent of the cancer patients had interleukin-2 levels below the 10th percentile cutoff point (p = 0.015). The lymphocyte proliferative response to phytohemagglutinin was significantly depressed in the head and neck cancer patients compared with the control subjects. This did not correlate with interleukin-2 production abnormalities, except in patients with advanced disease, in whom there was a borderline correlation between phytohemagglutinin response and interleukin-2 production (correlation coefficient 0.23, p = 0.05). We conclude that the commonly observed depressed T-cell proliferative response to phytohemagglutinin in head and neck cancer patients is not explained by impaired interleukin-2 production.