Suicide: A Major Threat to Head and Neck Cancer Survivorship

Authors: Nosayaba Osazuwa-Peters, Eric Adjei Boakye, and Ronald J. Walker
, Mark A. Varvares

TO THE EDITOR: The article by Ringash that was recently published in Journal of Clinical Oncology provided a compelling narrative of both the improvements made in head and neck cancer survivorship, as well as the challenges created by longer-term treatment and associated toxicities. There are currently at least 280,000 head and neck cancer survivors in the United States. As the article by Ringash stated, the upturn in head and neck cancer survivorship in the last three decades has coincided with the emergence of human papilloma virus-positive oropharyngeal cancer, as well as a decrease in tobacco use in the general population. These make it a challenge to isolate survival gains as a function of improved therapy from the natural prognostic value of a diagnosis of human papilloma virus-positive oropharyngeal cancer. Whatever the case, the fact that more than one-quarter million Americans are currently alive after a diagnosis of head and neck cancer means there needs to be a more deliberate effort in longer-term management of treatment-related toxicities, some of which are lifelong.

We agree with Ringash’s conclusion that new models of care need to be developed in response to the significant quality-of-life issues faced by patients with head and neck cancer. The Institute of Medicine publication From Cancer Patient to Cancer Survivor: Lost in Transition, also cited by Ringash, called for a clear individualized survivorship plan for cancer patients. There is a serious need for this model to be implemented universally in head and neck cancer management. Although we agree with Ringash that patients with head and neck cancer face competing mortality risks from second primary cancers and other noncancers, what we found lacking was recognition of an important competing cause of mortality in head and neck cancer survivors: suicide.

Suicide associated with head and neck cancer is not just a competing cause of death; it is also a quality-of-life issue. Many authors agree that head and neck cancer is among the top cancer sites associated with suicide. One national study of 1.3 million cancer patients even found that head and neck cancer carried the highest risk of suicide among cancer survivors. As a quality-of-life issue as well as a competing cause of death, the elevated risk of head and neck cancer-related suicide, although it peaks during the first few years after diagnosis, remains virtually throughout the course of the cancer survivor’s life. Additionally, some other well-known quality-of-life issues associated with head and neck cancer (eg, pain, disability, esthetic compromise and body image issues, psychosocial function, anxiety, emotional distress, and depression) are all associated with suicide. Therefore, it is difficult to have a discussion of quality-of-life interventions in head and neck cancer without addressing the issue of suicide.

Thus, we believe that suicide in patients with head and neck cancer should be addressed as a major threat to cancer survivorship. Cardiovascular disease, for example, is a known competing cause of death among patients with head and neck cancer, and is listed in Figure 4 of Ringash’s article. Cardiovascular disease may be managed for a long time; however, when a cancer patient decides that he/she is “better off dead,” a finality, or terminality, is invoked. This is quite unique to suicide compared with other competing causes of death.

Thus, in the urgent call for “new strategies and models of care to better address quality-of-life issues and meet the needs of survivors of head and neck cancer,” we believe it is pertinent that suicide is recognized as an important threat to head and neck cancer survivorship.

DOI: 10.1200/JCO.2015.65.4673; published online ahead of print at on January 19, 2016

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*This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.
March, 2016|Oral Cancer News|

Cancer patients who smoke report worse pain, symptoms

Author: Kate Johnson

Cancer patients who smoke experience more severe symptoms than nonsmoking cancer patients and are also at greater risk of misusing opioids, a new study shows.

“Our findings show a profile of higher levels of physical symptoms (pain, fatigue, poor appetite, and insomnia) and psychological symptoms (depression and anxiety) among smokers than non-smokers,” report Diane Novy, PhD, from the Pain Management Center at the University of Texas MD Anderson Cancer Center in Houston, Texas, and colleagues.

The findings underscore the importance of smoking cessation for this patient population, she told Medscape Medical News, even though it’s unclear if there is a causal effect.

“We don’t know the cause. They may smoke more because of the pain,” she said in an interview. However, studies also show that smoking has been known to increase certain types of pain such as back pain, and nerve pain, she added. “If we can motivate them to stop smoking, I think they’re better off.”

The findings were presented here at the American Academy of Pain Medicine (AAPM) 28th Annual Meeting.

Pain, Fatigue, Insomnia
The study included 486 cancer patients (52% female), with a mean age of 55 years, who were referred to the Pain Management Center for uncontrolled pain. Ninety-four patients were smokers, and the rest (n = 356), classified as nonsmokers, were former smokers or never-smokers. The patients were diagnosed with a wide range of cancers, the most common being gastrointestinal (18.5%), followed by hematologic (15%) and head and neck cancer (14.6%).

The most common cancer among the smokers was head and neck cancer (22.3% vs 12.8% in nonsmokers), and the most common cancer in nonsmokers was gastrointestinal (19.9% vs 12.8% in smokers). Lung cancer was slightly less common among smokers than nonsmokers (10.6% vs 11.5%).

As part of their intake, patients completed the Edmonton Symptom Assessment Scale (ESAS) and the Screener and Opioid Assessment for Patients with Pain (SOAPP).

The ESAS showed that pain, fatigue, insomnia, appetite, depression, and anxiety were all statistically significantly worse in smokers than nonsmokers.

Specifically, on a scale of 0 (no symptoms) to 10, smokers reported the following:

a median pain level of 6.5 compared with 5 in nonsmokers (P < .001);
a median fatigue level of 8 compared with 7 in nonsmokers (P < .001);
a median depression level of 5 compared with 3 in nonsmokers (P < .001);
a median anxiety level of 6 compared with 3 in nonsmokers (P < .001);
a median level of 5 for poor appetite compared with 3 in nonsmokers (P = .023); and
a median insomnia level of 6 compared with 4 in nonsmokers (P = .026).
In addition, the SOAPP suggested that smokers were at greater risk for opioid misuse than were nonsmokers. Smokers reported more frequent mood swings than nonsmokers (26.6% vs 12.5%; P = .002) and were more likely to admit to occasional use of medication in a manner other than how it was prescribed (39.4% vs 19.6%; P < .001), occasional use of illegal drugs in the past 5 years (13.8% vs 2.6%; P < .001), and past legal problems or arrest (25.5% vs 8.2%; P < .001).

Further, among the smokers, 51% reported that they smoke within an hour of waking — an indication of higher risk for opioid misuse compared with smokers who delay their first cigarette.

Taken together, the findings point to the importance of extra caution when managing pain in cancer patients, said Dr. Novy.

“With cancer patients, opioids will always be the mainstay of treatment,” she said. With smokers, “we might change the route of delivery, so it might be a fentanyl patch that the patient can’t misuse, or it might be an opioid that does not have as much addiction potential like methadone, or maybe nerve blocks or other procedures.”

Smoking cessation should also be emphasized, she added. “When we work with patients and we’re able to say smokers seem to experience more pain and more of a symptom burden… for some patients it is an amazing wake-up call.”

On the basis of her results she suggests a clinical interview that explores a patient’s pain coping mechanisms and smoking triggers could help to inform treatment.

“For example, if expectation of analgesic benefit appeared to be an important smoking motivator, challenging these expectations and increasing coping self-efficacy would be reasonable treatment goals,” she reported.

If future studies confirm that smoking is associated with depression symptoms, treatment of depression would be appropriate.

Bi-Directional Interaction
The study by Dr. Novy and colleagues “makes an important contribution to a small, but rapidly growing scientific literature regarding complex and potentially bi-directional interactions between pain and smoking,” commented Joseph W. Ditre, PhD, a clinical psychologist at Texas A & M University in College Station.

“There is growing empirical and clinical interest in purported associations between tobacco smoking and the aggravation of cancer symptoms and treatment side effects, such as pain,” said Dr. Ditre, who recently published findings very similar to those of the current study.

“The current findings are highly consistent with the results of our 2011 study, which showed that continued smoking despite a cancer diagnosis was associated with greater pain severity and interference from pain,” he told Medscape Medical News.

“Some researchers have suggested that other factors (eg, depression) may be responsible for observed relations between smoking and increased pain,” he noted. “Thus, it would be interesting to know whether the current findings remain significant after accounting for sociodemographic, disease-specific, and psychiatric factors. Also, to get a better sense of whether continued smoking may increase pain and functional impairment in a causal fashion, future research should investigate longitudinal relations between continued smoking, smoking abstinence, and pain-related outcomes among persons with cancer.”

He said he agreed with Dr. Novy that smoking cessation should be emphasized in this population.

“Interestingly, our 2011 study showed a negative correlation between pain ratings and number of years since quitting smoking, suggesting that quitting smoking may confer benefit with respect to pain reporting,” he told Medscape Medical News. “Conversely, there is some question as to whether abstaining from smoking may increase pain in the short term (perhaps via removal of a preferred coping strategy, or via direct neurobiological processes).

“That said, smoking cessation is clearly indicated for persons with cancer, not just because smoking may increase pain, but because persistent smoking has been associated with impaired healing, reduced treatment efficacy, and increased risk for developing a second primary cancer,” Dr. Ditre added. “Thus, the advantages of quitting smoking likely greatly outweigh potential disadvantages, especially with respect to cancer-related outcomes.”

Note: The study was supported by funding from the American Cancer Society and the National Institute on Drug Abuse. Dr. Novy has disclosed no relevant financial relationships. Dr. Ditre and his coauthors have disclosed no relevant financial relationships.

Source: American Academy of Pain Medicine 28th Annual Meeting: Abstract #180. Presented February 23, 2012.

February, 2012|Oral Cancer News|

Many Head and Neck Cancer Survivors Face Eating Problems

Source: HealthDay News

Persistent pain, eating problems and depression are the most common problems experienced by long-term survivors of head and neck cancer, a new study finds.

In the study, published in the Jan. 16 online issue of the journal Archives of Otolaryngology — Head &amp; Neck Surgery, researchers looked at 337 people who were diagnosed with head and neck cancer from 1995 to 2004 and survived at least five years.

More than 50 percent of the survivors had problems eating because of poor throat functioning, 28.5 percent had symptoms of depression and more than 17 percent had substantial pain, the researchers found.

However, when the long-term survivors were compared to age-matched people in the general population, their average general health was similar, Dr. Gerry Funk, of the University of Iowa Hospitals and Clinics in Iowa City, and colleagues explained in a journal news release.

The investigators also found that pain and diet in the first year after cancer treatment were the strongest independent predictors of five-year, health-related quality-of-life outcomes.

Problems with mouth and throat function in head and neck cancer survivors can be due to factors such as neuromuscular changes, anatomic deficits after surgery, pain and dental problems, the researchers noted.

“Early interventions addressing eating issues, swallowing problems and pain management will be a crucial component in improving this patient population’s long-term quality of life, especially in those who are functioning poorly one year after diagnosis,” the study authors concluded.

This story was also covered in a narrative form here:

This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.

January, 2012|Oral Cancer News|

Trying to improve oral cancer treatment

Author: staff

It’s a journey that can begin in the mirror or at the dentist’s office.

A small lesion in the mouth or throat can turn out to be oral cancer. Notoriously known to be unpredictable, these cancers are hard to treat, but some young doctors at the New York University’s School of Dentistry are working to change that.

Oral cancers take one American life every hour and it’s because the unpredictability is a challenge. One person’s cancer might be slow growing and another’s wildly aggressive. It is impossible to tell which it is.

The NYU researchers are trying to decipher their instruction codes, their genomics. If doctors know which way the cancer is going, it can be stopped.

Halima Mohammed always carries water she constantly needs to drink. She is also a big consumer of fruits and vegetables. The reason: for nine years she has been fighting an oral cancer.

“I can’t have solid food so I get my nutrition from juices and most of these foods, especially the cabbage and the broccoli, are cancer fighting foods,” she said. The cancer has had a huge impact on her life. She’s already lost part of her tongue.

“It is from my research one of the most painful type of cancers that you can have and I’m not diminishing cancer and the types of cancer, there is a constant pain, constant pain,” said Mohammed. “It makes masticating difficult, swallowing difficult. You cannot have your favorite food anymore.”

But, Mohammed carries on, and now at the NYU College of Dentistry she’s helping the doctors find out more about cancers like hers.

It’s a challenge Dr. Brian Schmdit has taken on. He wears many hats at the school, among them he’s clinical director of the Bluestone Center for Clinical Research and he’s trying to understand more about oral cancers.

“Oral cancers are very tricky because they have highly variable clinical patterns where one patient can do very well after treatment and another patient does not do well,” he said. ”

That different behavior lies in the cancer’s genes and their genomics are the subject of his research, identifying and tracking the genes of the different cancer will eventually benefit patients.

“We’re hoping that it can be personalized, that we can use certain genetic markers in the cancer to tailor our treatment, to know which persons need aggressive treatment and which patients don’t need that aggressive treatment,” said Dr. Schmdit

With information about the cancer’s genes, doctors might be better able to predict who needs radiation, which needs no de dissection and prevent much of the overtreatment that now is necessary.

Oral cancer is found by dentists and patients, so if there is a pain or a ulcer or a suspicious area, get checked out for it.

September, 2011|Oral Cancer News|

Trans-oral robotic surgery has all the right stuff to remove head & neck cancers

Author: T Goodman

Historically, surgical removal or oral and throat cancers have not allowed patients to go back to living their normal daily lives. Oral cancer removals caused severe pain, particularly ugly scarring, and an inability to eat, speak, or swallow normally. Even breathing problems might result. But now along comes TORS, the robot with the right stuff.
Just over a dozen hospitals in the U.S. currently have the TORS, which stands for Trans-Oral Robotic Surgery. The system uses the da Vinci Surgical System, which has developed since the mid 90’s to arguably be the most successful robotic surgery system in the world. It employs tiny robotic surgical instruments, operated from a command station by the appropriately trained human surgeon who maneuvers the robot’s ‘arms’ and instruments.

The Trans-Oral Robotic Surgery (TORS) setup: image via


TORS, like other da Vinci robotic surgeons, needs a human surgeon at the command center

A TORS patient: image via

As with other da Vinci procedures, TORS has the benefits of being less invasive, with fewer complications and shorter hospital stays. There is less blood loss, little scarring, and fewer temporary and permanent side effects, such as loss of speech or swallowing ability. Generally, there is no need to begin cancer therapy with radiation, which would increase the discomfort and recovery time.

Tamer A. Ghanem, M.D., Ph.D., director of Head and Neck Oncology and Reconstructive Surgery Division in the Department of OtolaryngologyHead & Neck Surgery at Henry Ford Hospital in Detroit, says that with TORS, “Surgeons operate with greater precision and control using the TORS approach, minimizing the pain, and reducing the risk of possible nerve and tissue damage linked to large incisions.”

Hospitals that currently have the Trans Oral Robotic Surgery include the Mayo Clinic, Jefferson University Hospitals (Delaware), University of Pennsylvania (training center), Sharp Hospital (San Diego), Washington Hospital Center (DC), Summerlin Hospital (Nevada) and Sparrow Hospital (Lansing, MI).

Source: Michigan State University News via MedicalXpress,

September, 2011|Oral Cancer News|

Smoking may worsen pain for cancer patients

Author: Fran Lowry

Patients with cancer who continue to smoke despite their diagnosis experience greater pain severity than their counterparts who quit or who have never smoked, according to new research published in the January 2011 issue of Pain.

Not only is their pain more severe, but it interferes more with their activities of daily living, lead author Joseph W. Ditre, PhD, a clinical psychologist at Texas A & M University in College Station, told Medscape Medical News.

“Many smokers, when they get cancer, feel that smoking is one of the only pleasures they have left to them and refuse to quit,” he said in an interview. “But our research suggests that quitting has definite benefits. It’s one more thing that doctors can tell their patients to help them stop smoking.”

Continued smoking has been associated with an increased risk of developing a second primary tumor, reduces the effectiveness of treatment, and is associated with poorer survival rates, Dr. Ditre said. “The subtext for this is that smoking can also worsen cancer-related symptoms and treatment side effects, such as pain and fatigue.”

“About 75% of people with advanced-stage cancer report moderate to very severe pain, so it is a very big factor in terms of the disease course, and yet there is surprisingly little research on this topic,” he added.

Dr. Ditre, who led this work while he was earning his doctorate at the University of South Florida and Moffitt Cancer Center in Tampa, told Medscape Medical News that the aim of his research was to examine the association with pain across diverse cancer types with regard to potential benefits of quitting smoking.

“Smoking is known to decrease oxygen, and there is also a possibility that tobacco smoke over time has some type of direct influence on the neurological processing of sensory information, and so may actually change the way pain receptors operate,” he said. “There are many potential mechanisms, and this is something that is under study.”

More Smoking, More Pain
In the current study, Dr. Ditre and colleagues looked at the association between multiple levels of smoking status and several pain-related outcomes in a sample of 224 patients who were about to begin chemotherapy for a variety of cancers, including breast, lung, bladder, ovarian, colon, head and neck, testicular, endometrial, prostate, and rectal/anal cancers; mesothelioma; and sarcoma.

The patients were part of a larger study investigating the efficacy of 2 interventions — stress management and exercise training — for improving quality of life during chemotherapy. Ten percent of patients had stage I disease, 26% had stage II, 30% had stage III, and 34% had stage IV.

The patients self-reported their smoking status and cigarette consumption at study entry. Patients who reported smoking more than 100 cigarettes in their lifetime were defined as smokers, and never-smokers were defined as smoking fewer than 100 cigarettes.

Smokers were further defined as former smokers (those who had quit smoking and had not smoked any cigarettes in the past month) and current smokers (those who reported having smoked in the past month). Current smokers were also asked how many cigarettes they currently smoked per day.

The patients used the Medical Outcomes Survey 36-item Short Form Body Pain subscale, rating their perceived severity of bodily pain on a scale of 1 to 6, where 1 indicated “none” and 6 indicated “very severe,” and the degree to which pain interfered with their daily routine on a scale of 1 to 5, where 1 indicated “not at all” and 5 indicated “extremely.”

They also rated their distress on the Memorial Symptom Assessment Scale-Short Form, where 0 indicated no distress at all and 4 indicated the most stress.

Current smokers reported experiencing significantly more severe pain than never-smokers and greater interference from pain than former smokers or never-smokers.

In addition, there was also an inverse relation between pain severity and the number of years since quitting: The longer it had been since a patient had quit smoking, the less pain that patient reported.

Dr. Ditre stressed that the findings are correlational and do not point to a direct cause between smoking and cancer pain. In fact, the direction of causality is unclear. “You cannot infer exactly what is causing what, only that they are connected in some way,” he said.

“Smoking may be increasing the pain that these cancer patients are experiencing, or another possibility is that their pain may have caused them to continue smoking. It could be one way or the other,” he noted. “In fact, we’ve done work with noncancer populations in which we have demonstrated that pain is a significant motivator of smoking behavior. People who experience pain have a greater desire to smoke and will be more motivated to smoke, and will smoke more.”

Whether or not there is a causal relationship, it is important for patients with cancer to realize that smoking appears to be worsening their pain, he said.

“Doctors can tell their patients that they now have information that suggests that if you stop smoking you may experience less pain than you would otherwise, although we are not 100% sure yet why that is,” Dr. Ditre said.

Research Needed to Understand Mechanisms
In an accompanying editorial, Lori Bastian, MD, from Duke University and Durham Veterans Affairs Medical Center in North Carolina, writes that the findings by Dr. Ditre and his team are consistent with those of other studies and that they have public health significance.

“Clinicians must do more to assist cancer patients to quit smoking after their diagnosis,” Dr. Bastian writes. “If pain increases the urge to smoke, a formal smoking cessation program for cancer patients should also include efforts to control pain severity.”

She concludes that more research is needed to understand the mechanisms that relate nicotine to pain and that prospective longitudinal studies should be performed to clarify “the issue of directionality, demonstrate no harm, and determine the impact of smoking cessation on pain severity among cancer patients.”

Pain. 2011;152:10-11, 60-65. Abstract

1. This study was supported by funding from the American Cancer Society and the National Institute on Drug Abuse. The study authors have disclosed no relevant financial relationships. Dr. Bastian is supported by grants from the Department of Veterans Affairs, Health Services Research and Development, and the National Institutes of Health/National Cancer Institute.

January, 2011|Oral Cancer News|

Neuropathic and nociceptive pain in head and neck cancer patients receiving radiation therapy

Author: staff

Pain is common in head and neck cancer (HNC) patients and may be attributed to the malignancy and/or cancer treatment. Pain mechanisms and patient report of pain in HNC are expected to include both nociceptive and neuropathic components.

The purpose of this study was to assess the trajectory of orofacial and other pain during and following treatment, using patient reports of neuropathic pain and nociceptive pain and pain impact.

124 consecutive HNC patients receiving radiation therapy (RT) (95 men, 29 women; mean age: 54.7 +/- 12.3 years) participated in a patient-reported outcome (PRO) assessment. Patients completed the McGill Pain Questionnaire three times during therapy and 3 months following study entry.

The majority of patients related their pain to the tumor and/or cancer treatment.

Whereas 59% reported their pain to be less severe than they expected, 29% were not satisfied with their level of pain despite pain management during cancer therapy. Worst pain was 3.0 +/- 1.3 on a 0- to 5-point verbal descriptor scale.

Pain intensity was present at entry, highest at 2-week follow-up, declining towards the end of treatment and persisting at 3-month follow-up. The most common neuropathic pain descriptors chosen were aching (20%) and burning (27%); nociceptive words chosen were dull (22%), sore (32%), tender (35%), and throbbing (23%), and affective/evaluative descriptors were tiring (25%) and annoying (41%).

57% of patients reported continuous pain, and combined continuous and intermittent pain was reported by 79% of patients.

This study provides evidence that patients with HNC experience nociceptive and neuropathic pain during RT despite ongoing pain management. The affective and evaluative descriptors chosen for head and neck pain indicate considerable impact on quality of life even with low to moderate levels of pain intensity.

These findings suggest that clinicians should consider contemporary management for both nociceptive and neuropathic pain in head and neck cancer patients.

1. Author: Joel EpsteinDiana WilkieDena FischerYoung-Ok KimDana Villines
2. Source: Head &Neck Oncology 2009, 1:26