• 3/18/2008
  • Little Falls, NJ
  • Judith Groch
  • MedPageToday (www.medpagetoday.com)

Although head and neck cancer patients had improved mental health scores a year after diagnosis and treatment, their quality of life, particularly the ability to eat, had declined markedly, a study here found.

Treatment, especially a feeding-tube still in place at one year, and the effects of chemotherapy and radiation therapy, were major factors in diminished quality of life at follow-up, David L. Ronis, Ph.D., of the University of Michigan here, and colleagues reported in the March issue of Archives of Otolaryngology–Head & Neck Surgery.

But there was a modest improvement in mental health after a year.

Treatments tend to produce pain, disfigurement, and eating and communication problems, the researchers noted. Many patients become disabled, and about one-third continue to smoke, while half are depressed.

It is likely, the researchers said, that the improvement in mental health the researchers found is a consequence of low baseline levels because anxiety and depressive reactions to a cancer diagnosis are common. Thus, there may be some “floor effect” for mental well-being that occurs near the time of diagnosis, and patients are likely to improve in most cases.

In the survey of more than 300 patients, about 43% of patients with newly diagnosed head and neck cancer had smoked in the month prior to treatment (baseline). Smoking at baseline was highly correlated with decreased quality-of-life scores at baseline and at one year of follow-up, the researchers said.

Even after controlling for baseline quality of life, those who smoked at baseline had poorer physical functioning, general health perception, social functioning, mental health, and pain scores at one year.

The study prospectively followed 316 patients (79% men) for one year of an original group of 441 eligible patients with newly diagnosed squamous-cell head and neck cancer.

The patients came from three otolaryngology clinics in Michigan. Of those not included in the one-year follow-up, 68 had died and the rest either did not return the survey, possibly due to moderate or severe comorbidities, or had missing data.

Health-related quality of life was assessed using the 36-item Short-Form Health Survey (SF-36) and a head and neck cancer-specific quality-of-life scale.

At one year, most patients had had chemotherapy (64.9%), radiation therapy (86.4%), or surgery (50.6%). Of the patients, 76.9% had undergone more than one of these treatments.

At baseline, mean quality-of-life scores on the subscales of the 36-item health survey ranged from 51.8 (vitality) to 72.7 (physical functioning), each about 10 points lower than the mean in U.S. general population. Mean scores on the subscales of the head-and-neck scale ranged from 65.8 for bodily pain to 80.9 for eating.

Baseline depressive symptoms and smoking, as well as moderate to severe comorbidities, each remained significant predictors of negative change.

Smoking prior to treatment was a significant predictor in all but the depression category of the 36-item quality-of-life scale, while depression was a significant predictor on all the scales.

Most of the prediction beyond the baseline scores came from four indicators of treatment, namely presence of a feeding tube, chemotherapy, radiation therapy, and surgery.

The presence of a feeding tube at one year was negatively associated with changes in nine of the 12 quality-of-life scores. Chemotherapy and radiation therapy were each negatively associated with changes in three of the scores. Surgery was associated with an increase in pain scores.

For example, at one year, eating was down 16.5 on a scale of 0 to 100, whereas emotional distress had improved with a 9.2 point difference from baseline. Physical functioning was down 9.9 points, whereas the mental health index rose 5.3 points (P for all, 0.01).

Despite worse general physical health scores and eating scores, this group of patients exhibited mild improvement in mental health.

The most interesting finding, the researchers said, is that the significant predictors of quality of life at baseline before any treatment and the change in these scores at one year were different.

At baseline, psychosocial factors (smoking and depression) were the most consistent predictors. However, at one year after controlling for baseline scores, clinical factors also became predictive. Baseline smoking and depressive symptoms remained predictive, although less so than having a feeding tube and less so than at baseline.

In particular, having a feeding tube at one year was associated with reductions in speech, eating, vitality, physical and social functioning, pain, emotion, and perception of general health. This corroborates previous findings that a feeding tube has the most negative effect on these patients, the investigators said.

Radiation treatment was negatively associated with changes in speech, eating, and pain, while chemotherapy was negatively associated with changes in speech, eating, and physical function.

In contrast, surgical treatment was associated with a negative change in physical pain but not in any of the cancer-specific quality-of-life domains. This suggests that surgery has a general effect on quality of life, whereas radiation and chemotherapy have more localized effects, the researchers said.

Each method is associated with somewhat different adverse effects. If one or more methods of treatment could be avoided without affecting disease-free survival, a better quality of life might be expected, the researchers said.

Another possibility, they said, is that advances in imaging, biological markers, genomics, and sentinel-node testing might reduce the quality-of-life toxic effects, especially those improving speech and swallowing.

Study limitations included the lack of randomization and that only 12% of the patients were members of a minority group, limiting generalizability. The limited one-year follow-up will be improved when two-year data become available, the researchers said.

At one year follow-up, the most consistent predictor of quality of life was the baseline score. The only exception was the emotional domain, which approached significance (P=0.10). Thus special consideration for rehabilitation should be considered for patients with poor baseline scores, the researchers said.

It is possible that clinicians are not getting the message across that smoking affects quality of life. Perhaps a new diagnosis of head and neck cancer might provide an opportunity to encourage patients to quit smoking, they said. Previous studies have shown that smoking cessation interventions are effective for these patients.

In addition, depression needs to be assessed and actively treated. It may also help, they said, to explain the different effects patients might expect with different treatments, the investigators said.

Note:
This study was supported by a grant made available by the National Institutes of Health through the University of Michigan Head and Neck Specialized Program of Research Excellence. No financial conflicts were reported.

Primary source:
Archives of Otolaryngology — Head & neck Surgery
Source reference: Ronis DL, et al “Changes in quality of life over 1 year in patients with head and neck cancer” Arch Otolaryngol Head Neck Surg 2008; 134: 241-248.