American Cancer Society Head and Neck Cancer Survivorship Care Guideline

Suicide risk among cancer survivors: Head and neck versus other cancers

BACKGROUND

Cancer survivors face psychosocial issues that increase their risk of suicide. This study examined the risk of suicide across cancer sites, with a focus on survivors of head and neck cancer (HNC).

METHODS

The Surveillance, Epidemiology, and End Results 18-registry database (from 2000 to 2014) was queried for the top 20 cancer sites in the database, including HNC. The outcome of interest was suicide as a cause of death. The mortality rate from suicide was estimated for HNC sites and was compared with rates for 19 other cancer sites that were included in the study. Poisson regression was used to estimate adjusted rate ratios (aRRs) and 95% confidence intervals (CIs) for 1) HNC versus non-HNC sites (the other 19 cancer sites combined), and 2) HNC versus each individual cancer site. Models were stratified by sex, controlling for race, marital status, age, year, and stage at diagnosis.

RESULTS

There were 404 suicides among 151,167 HNC survivors from 2000 to 2014, yielding a suicide rate of 63.4 suicides per 100,000 person-years. In this timeframe, there were 4493 suicides observed among 4219,097 cancer survivors in the study sample, yielding an incidence rate of 23.6 suicides per 100,000 person-years. Compared with survivors of other cancers, survivors of HNC were almost 2 times more likely to die from suicide (aRR, 1.97; 95% CI, 1.77-2.19). There was a 27% increase in the risk of suicide among HNC survivors during the period from 2010 to 2014 (aRR, 1.27; 95% CI, 1.16-1.38) compared with the period from 2000 to 2004.

CONCLUSIONS

Although survival rates in cancer have improved because of improved treatments, the risk of death by suicide remains a problem for cancer survivors, particularly those with HNC.

The complicated 'Yes': Decision-making processes and receptivity to lung cancer screening among head and neck cancer survivors

OBJECTIVE

Shared decision making (SDM) is recommended when offering lung cancer screening (LCS)-which presents challenges with tobacco-related cancer survivors because they were excluded from clinical trials. Our objective was to characterize head and neck cancer (HNC) survivors' knowledge, attitudes, and beliefs toward LCS and SDM.

METHODS

Between November 2017 and June 2018, we conducted semi-structured qualitative interviews with 19 HNC survivors, focusing on patients' cancer and smoking history, receptivity to and perceptions of LCS, and decision-making preferences RESULTS: Participants were receptive to LCS, referencing their successful HNC outcomes. They perceived that LCS might reduce uncertainty and emphasized the potential benefits of early diagnosis. Some expressed concern over costs or overdiagnosis, but most minimized potential harms, including false positives and radiation exposure. Participants preferred in-person LCS discussions, often ideally with their cancer specialist.

CONCLUSION AND PRACTICE IMPLICATIONS

HNC survivors may have overly optimistic expectations for LCS, and clinicians need to account for this in SDM discussions. Supporting these patients in making informed decisions will be challenging because we lack clinical data on the potential benefits and harms of LCS for cancer survivors. While some patients prefer discussing LCS with their cancer specialists, the ability of specialists to support high-quality decision making is uncertain.

Patient experience of head and neck lymphedema therapy: a qualitative study

PURPOSE

Lymphedema is a common late effect from head and neck cancer and/or its treatment. Guidelines recommend that patients with lymphedema should be referred for therapy in a timely manner to maximize control of lymphedema-related symptoms. However, there is paucity of information regarding treatment outcomes in the head and neck cancer population. To address this gap, we conducted a qualitative study to gain understanding of head and neck cancer patients' experience pertaining to lymphedema therapy, barriers to treatment, perceptions concerning physical and psychological benefits, opinions about therapists, and suggestions to enhance outcomes.

METHODS

Twenty head and neck cancer patients who underwent lymphedema therapy completed semi-structured face-to-face interviews. Interviews were audio-recorded, and verbatim transcriptions were completed. Thematic analysis was employed to analyze the interview data.

RESULTS

A majority of the participants (n = 15, 75%) completed a full course of lymphedema treatment. Most participants expressed physical (n = 18, 90%) and psychological (n = 14, 70%) benefits about the lymphedema therapy, e.g., decreased swelling, increased swallowing function, and multi-faceted healing. More than one third of the participants described barriers hampering their lymphedema therapy, e.g., insurance coverage, return to work, and availability of lymphedema therapy. Many participants proposed suggestions for improvement of lymphedema therapy, e.g., personalized education, longer treatment time, and caregiver education.

CONCLUSIONS

The study has underscored the potential benefit of lymphedema therapy in the head and neck cancer population. Substantial barriers to therapy were reported and need to be addressed. Opportunities to improve lymphedema therapy outcomes were suggested. Personalized strategies should be considered for ensuring optimal patient outcomes.

Case-control study of oral disease indexes in individuals with head and neck cancer after antineoplastic therapy

ABSTRACT Objective To evaluate the oral health of patients with head and neck cancer after antineoplastic treatment, and to compare them with patients with no history of cancer. Methods A total of 75 patients, divided into Study Group, composed of individuals after antineoplastic treatment (n=30), and Control Group, with individuals with no history of cancer (n=45), aged 37 to 79 years. The oral health status was evaluated through the index of decayed, missing or filled permanent teeth (DMFT), community periodontal index and evaluation of the use and need of prosthesis. All of these items were evaluated according to the criteria recommended by the World Health Organization. The statistical analysis was descriptive and used the Pearson’s χ2 test. Results The community periodontal index was higher in the Study Group when compared to the Control Group (p<0.0001). The need for an upper (p<0.001) and lower (p<0.0001) prostheses was higher in the Study Group. Also, the use of upper prosthesis was higher in the Study Group (p<0.002). The missing or filled permanent teeth index between the two groups (p>0.0506) and the use of lower prosthesis (p>0.214) did not present a relevant statistical difference. Conclusion Periodontal disease and edentulism are the most significant changes in individuals who received antineoplastic therapy for head and neck cancer as well as greater need for oral rehabilitation.

High-fluence low-power laser irradiation promotes odontogenesis and inflammation resolution in periodontitis by enhancing stem cell proliferation and differentiation

Periodontitis can exert a severe impact on the life of patients, and the use of stem cell therapy for this disease is promising. The inflammatory response consequent to periodontitis can promote stem cell proliferation. Activated inflammation triggers inhibitory cytokine secretion, thus reducing inflammation subsequent to stem cell activation. High-fluence low-power laser irradiation (HF-LPLI) has the ability to regulate stem cell function through its effect on inflammation. Thus, the aim of the present study was to examine whether HF-LPLI is able to activate stem cells to promote regeneration in periodontitis by promoting inflammation resolution, as well as to evaluate the underlying mechanism of action if an effect is observed. Stem cells were treated with HF-LPLI following inflammation activation. Reverse transcription-quantitative polymerase chain reaction and EdU assay were used to evaluate cell proliferation and differentiation. Flow cytometry and immunofluorescence were also used to detect the ability of HF-LPLI to regulate the surrounding inflammatory environment. Animal models of periodontal disease were treated with stem cells and HF-LPLI, and regeneration was detected by hematoxylin and eosin staining and in vivo imaging. It was observed that HF-LPLI promoted inflammation resolution by reducing the excessive inflammatory response, and finally stimulated stem cell proliferation and differentiation. Furthermore, in vivo results revealed that stem cells treated with HF-LPLI induced bone regeneration. HF-LPLI stimulated stem cell proliferation and differentiation by promoting inflammation resolution subsequent to stem cell activation, providing a new strategy for the clinical treatment of periodontitis.

Content analysis of rehabilitation goals for patients following non-surgical head and neck cancer treatment

PURPOSE

Following head and neck cancer (HNC) treatment, individuals experience an array of side effects which can impact on physical, emotional, and practical aspects of their lives. Responsive, supportive rehabilitation services are therefore essential to address ongoing survivorship needs. This study examined the nature of patient-reported goals from acute to long-term post-treatment, to inform design/delivery of future rehabilitation services.

METHODS

Using a cross-sectional cohort design, 91 patients between 2 weeks and 5 years of post non-surgical HNC treatment (acute n = 29; sub-acute n = 28; long-term n = 34), provided their top four rehabilitation goals considering any aspect of their lives. Content analysis was used to categorise responses at each time point.

RESULTS

Three core categories of patient goals were identified relating to: (1) treatment side effects (TSE), (2) overall health (OH), and (3) living life (LL). TSE goals were a priority during the acute and sub-acute phases, with less focus long-term. LL goals were prevalent across all time points, though increased in the long-term. Approximately a third of all goals at each time point related to OH.

CONCLUSIONS

A variety of rehabilitation goals were identified, and the focus shifted over time. These data highlight the importance of changing the focus of rehabilitation as patients' priorities vary over time. Early multidisciplinary care from allied health services is crucial to provide support with managing side effects and returning to daily activities. In the long-term, greater input from services to address health, nutrition, leisure, and fitness goals may be more beneficial.

Characterization of Alternative Splicing Events in HPV-Negative Head and Neck Squamous Cell Carcinoma Identifies an Oncogenic DOCK5 Variant

Purpose: Head and neck squamous cell carcinoma (HNSCC) is one of the most common cancers worldwide, and alternative splicing is considered to play important roles in tumor progression. Our study is designed to identify alternative splicing events (ASEs) in human papillomavirus (HPV)-negative HNSCC.Experimental Design: RNA sequencing data of 407 HPV-negative HNSCC and 38 normal samples were obtained from The Cancer Genome Atlas (TCGA), and splice junctions were discovered using MapSplice. Outlier analysis was used to identify significant splicing junctions between HPV-negative HNSCC and normal samples. To explore the functional role of the identified DOCK5 variant, we checked its expression with qRT-PCR in a separate primary tumor validation set and performed proliferation, migration, and invasion assays.Results: A total of 580 significant splicing events were identified in HPV-negative HNSCC, and the most common type of splicing events was an alternative start site (33.3%). The prevalence of a given individual ASE among the tumor cohort ranged from 9.8% and 64.4%. Within the 407 HPV-negative HNSCC samples in TCGA, the number of significant ASEs differentially expressed in each tumor ranged from 17 to 290. We identified a novel candidate oncogenic DOCK5 variant confirmed using qRT-PCR in a separate primary tumor validation set. Loss- and gain-of-function experiments indicated that DOCK5 variant promoted proliferation, migration, and invasion of HPV-negative HNSCC cells, and patients with higher expression of DOCK5 variant showed decreased overall survival.Conclusions: Analysis of ASEs in HPV-negative HNSCC identifies multiple alterations likely related to carcinogenesis, including an oncogenic DOCK5 variant. Clin Cancer Res; 24(20); 5123-32. ©2018 AACR.

Establishing a Multidisciplinary Head and Neck Clinical Pathway: An Implementation Evaluation and Audit of Dysphagia-Related Services and Outcomes

Head and neck cancer (HNC) guidelines recommend regular multidisciplinary team (MDT) monitoring and early intervention to optimize dysphagia outcomes; however, many factors affect the ability to achieve these goals. The aims of this study were to explore the barriers/facilitators to establishing and sustaining a MDT HNC care pathway and to examine the dysphagia-related speech-language pathology (SLP) and dietetic components of the pathway. Using the Consolidated Framework for Implementation Research (CFIR), a mixed methods study design was used to evaluate an established MDT HNC pathway. Ten MDT members provided perceptions of facilitators/barriers to implementing and sustaining the pathway. Patients attending the SLP and dietetic components of the pathway who commenced treatment between 2013 and 2014 (n = 63) were audited for attendance, outcome data collected per visit, and swallowing outcomes to 24-month post-treatment. Dysphagia outcomes were compared to a published cohort who had received intensive prophylactic dysphagia management. Multiple CFIR constructs were identified as critical to implementing and sustaining the pathway. Complexity was a barrier. Patient attendance was excellent during treatment, with low rates of non-compliance (< 15%) to 24 months. Collection of clinician/patient outcome tools was good during treatment, but lower post-treatment. Dysphagia outcomes were good and comparable to prior published data. The pathway provided patients with access to regular supportive care and provided staff opportunities to provide early and ongoing dysphagia monitoring and management. However, implementing and sustaining a HNC pathway is complex, requiring significant staff resources, financial investment, and perseverance. Regular audits are necessary to monitor the quality of the pathway.

Prevalence and Risk Factors of Suicidal Ideation among Patients with Head and Neck Cancer: Longitudinal Study

OBJECTIVES

(1) Determine 1-year period prevalence of suicidal ideation, suicide attempt, and completed suicide among patients newly diagnosed with a first occurrence of head and neck cancer (HNC). (2) Characterize stability and trajectory of suicidal ideation over the year following cancer diagnosis. (3) Identify patients at risk of suicidal ideation.

STUDY DESIGN

Prospective longitudinal study with 1-year follow-up.

SETTING

Three university-affiliated outpatient departments of otolaryngology-head and neck surgery.

SUBJECTS AND METHODS

The study comprised a representative sample of 223 consecutive patients who were newly diagnosed (<2 weeks) with a first occurrence of primary HNC, were ≥18 years old and able to consent, and had a Karnofsky Performance Scale score ≥60. Patients completed the Beck Scale for Suicidal Ideation and Structured Clinical Interview for DSM-IV-TR Axis I Disorders.

RESULTS

Sixteen percent (15.7%) of patients with HNC were suicidal <1 year from diagnosis, with point prevalences of 8.1% <2 weeks, 14.8% at 3 months, 9.4% at 6 months, and 10.4% at 12 months; 0.4% committed suicide within 3 months, and 0.9% attempted suicide. An a priori comprehensive conceptual model revealed 2 predictors of 1-year period prevalence of suicidal ideation in HNC: psychiatric history ( P = .017, β = 2.1, 95% CI = 0.4-3.8) and coping with the diagnosis by using substances (alcohol/drugs; P = .008, β = 0.61, 95% CI = 0.16-1.06). All other predictors, including medical predictors, were nonsignificant. A clinical suicide risk assessment revealed low risk among 71.4% and medium to high risk among 28.6%.

CONCLUSION

Suicide prevention strategies are clearly needed as part of routine clinical care in head and neck oncology, as well as their integration into clinical practice guidelines for HNC.

Clinical Evaluation and Management of Radiation Fibrosis Syndrome

Radiation fibrosis syndrome describes the multiple neuromuscular, musculoskeletal, visceral, and other late effects that result from radiation-induced fibrosis. Radiation can damage the spinal cord, nerve roots, plexus, local peripheral nerves, and muscles within the radiation field. This constellation is known as a "myelo-radiculo-plexo-neuro-myopathy" and can result in pain, sensory loss, weakness, and other signs and symptoms. Although there is no curative treatment for radiation damage, supportive management of symptoms can be helpful in restoring and maintaining function and quality of life.

PDCD1 (PD-1) promoter methylation predicts outcome in head and neck squamous cell carcinoma patients

Background

Biomarkers that facilitate the prediction of disease recurrence in head and neck squamous cell carcinoma (HNSCC) may enable physicians to personalize treatment. In the current study, DNA promoter methylation of programmed cell death 1 (PDCD1, PD-1) was evaluated as a prognostic biomarker in HNSCC patients.

Results

High PDCD1 methylation (mPDCD1) was associated with a significantly shorter overall survival after surgical resection in both the discovery (HR = 2.24 [95%CI: 1.08–4.64], p = 0.029) and the validation cohort (HR = 1.54 [95%CI: 1.08–2.21], p = 0.017). In multivariate Cox proportional hazards analysis, PDCD1 methylation remained a significant prognostic factor for HNSCC (HR = 2.14 [95%CI: 1.19–3.84], p = 0.011). Further, mPDCD1 was strongly associated with the human papilloma virus (HPV) status.

Materials and Methods

mPDCD1 was assessed retrospectively in a discovery cohort of 120 HNSCC patients treated at the University Hospital of Bonn and a validation cohort of 527 HNSCC cases analyzed by The Cancer Genome Atlas Research Network.

Conclusions

Variation in routine follow-up care after curative treatment for head-and-neck cancer: a population-based study in Ontario

Background

The actual practices of routine follow-up after curative treatment for head-and-neck cancer are unknown, and existing guidelines are not evidence-based.

Methods

This retrospective population-based study used administrative data to describe 5 years of routine follow-up care in 3975 head-and-neck cancer patients diagnosed between 2007 and 2012 in Ontario.

Results

The mean number of visits per year declined during the follow-up period (from 7.8 to 1.9, p < 0.001). The proportion of patients receiving visits in concordance with guidelines ranged from 80% to 45% depending on the follow-up year. In at least 50% of patients, 1 head, neck, or chest imaging test was performed in the first follow-up year; that proportion subsequently declined (p < 0.001). Factors associated with follow-up practices included comorbidity, tumour site, treatment, geographic region, and physician specialty (p < 0.05).

Conclusions

Given current practice variation and the absence of an evidence-based standard, the challenge in identifying a single optimal follow-up strategy might be better addressed with a harmonized approach to providing individualized follow-up care.

Social network, autonomy, and adherence correlates of future time perspective in patients with head and neck cancer

OBJECTIVE

Socioemotional selectivity theory proposes that, with more limited future time perspective (FTP), the meaning of individual life goals shifts from instrumental and long-term goals, such as autonomy, to emotionally meaningful and short-term life goals, especially concerning meaningful social relationships. Adverse side effects of cancer therapy may conflict with the realization of emotionally meaningful goals leading to nonadherence. In line with the theoretical assumptions, this study aimed to investigate (a) associations among disease symptoms, physical and cognitive limitations, and FTP and (b) among FTP, family network size, striving for autonomy, and treatment adherence.

METHOD

One hundred fifty-seven patients (43-90 years; 75% male) with head and/or neck cancer of a German University Medical Centre completed a questionnaire measuring FTP, age, disease symptoms, physical and cognitive functioning, family network size, and treatment adherence. Autonomy was assessed with a card sort task.

RESULTS

A structural equation model yielded an acceptable fit χ² (28) = 44.41, P = .025, χ² /df = 1.59, root mean square error of approximation = 0.06 (90% CI = 0.02, 0.09), Tucker-Lewis Index = 0.92, and Comparative Fit Index = 0.96. An increased level of disease symptoms and physical and cognitive limitations was related to a shorter subjective FTP. Furthermore, individuals with a limited FTP reported a smaller family network, a lowered quest for autonomy, and lower treatment adherence.

CONCLUSIONS

Hypotheses derived from socioemotional selectivity theory were supported by the data. Longitudinal investigations should follow to corroborate findings and to focus on underlying mechanisms as improving patients FTP may play a crucial role in future disease management programs.

Synthesis, Characterization, and in Vitro Biological Evaluation of Copper-Containing Magnetic Bioactive Glasses for Hyperthermia in Bone Defect Treatment

Hyperthermia treatment induced by magnetic mesoporous glasses has been applied as a potential therapeutic approach for bone defects due to malignant tumors. The objective of this study was to synthesize and characterize the structural and biological properties of magnetic bioactive glasses (BGs) for producing multifunctional materials. The effect of the addition of copper (Cu) to the bioactive glass composition was also evaluated. Fe BG and FeCu BG as magnetic mesoporous BGs, and Cu BG as mesoporous BG were synthesized and dried by template sol-gel method. Then the synthesized bioglasses were characterized and analyzed using Fourier transform infrared spectroscopy (FTIR), X-ray diffraction (XRD), scanning electron microscopy (SEM), transmission electron microscopy (TEM), energy-dispersive electron disperse spectroscopy (EDS), Brunauer-Emmett-Teller (BET), and vibrating sample magnetometer (VSM). In addition, the antibacterial behavior, cytotoxicity assay (MTT test), proliferation assay of HUVEC cell assay, and bioactivity (ALP activity test) of the synthesized BGs were evaluated. The characterization results exhibited that the synthesized powders formed mesoporous glasses with nanoparticle morphology, good surface area, and magnetic properties. The synthesized BGs also demonstrated suitable biological behavior. The magnetic saturation of bioactive glasses was increased by the addition of copper oxide. A two-phase structure was observed for the magnetic glasses compared to the copper-containing glasses, thus making them suitable for drug delivery systems. The antibacterial behavior was found to be better for the Cu BG and Fe BG compared to the FeCu BG. However, the least amount of cytotoxicity was observed for the Fe BG and FeCu BG, compared to the Cu BG. In addition, the Fe-containing BGs compared with the control group showed a lack of HUVEC cell proliferation and angiogenesis motivation. From the ALP assay, higher bioactivity for the magnetic bioglasses in the presence of mesenchymal cells was found. From the results of this in vitro study, the Cu-containing magnetic bioglass (FeCu BG) could be considered as a new generation of magnetic glasses for inducing hyperthermia in treatment of bone defects due to malignant tumors. However, further in vitro and in vivo studies are required to confirm their applications in healing of bone defects and tissue engineering.

Non-invasive prediction of the tumor growth rate using advanced diffusion models in head and neck squamous cell carcinoma patients

We assessed parameters of advanced diffusion weighted imaging (DWI) models for the prediction of the tumor growth rate in 55 head and neck squamous cell carcinoma (HNSCC) patients. The DWI acquisition used single-shot spin-echo echo-planar imaging with 12 b-values (0−2000). We calculated 14 DWI parameters using mono-exponential, bi-exponential, tri-exponential, stretched exponential and diffusion kurtosis imaging models. We directly measured the tumor growth rate from two sets of different-date imaging data. We divided the patients into a discovery group (n = 40) and validation group (n = 15) based on their MR acquisition dates. In the discovery group, we performed univariate and multivariate regression analyses to establish the multiple regression equation for the prediction of the tumor growth rate using diffusion parameters. The equation obtained with the discovery group was applied to the validation group for the confirmation of the equation's accuracy. After the univariate and multivariate regression analyses in the discovery-group patients, the estimated tumor growth rate equation was established by using the significant parameters of intermediate diffusion coefficient D₂ and slow diffusion coefficient D₃ obtained by the tri-exponential model. The discovery group's correlation coefficient between the estimated and directly measured tumor growth rates was 0.74. In the validation group, the correlation coefficient (r = 0.66) and intra-class correlation coefficient (0.65) between the estimated and directly measured tumor growth rates were respectively good. In conclusion, advanced DWI model parameters can be a predictor for determining HNSCC patients’ tumor growth rate.

New developments in the management of head and neck cancer - impact of pembrolizumab

Head and neck squamous cell carcinoma (HNSCC), a heterogeneous group of upper aerodigestive tract malignancies, is the seventh most common cancer worldwide. Tobacco use and alcohol consumption were the most identified risk factors of HNSCC. However, human papilloma virus, a sexually transmitted infection, has been determined as another primary cause of HNSCC. Early-stage disease is treated with surgery or radiotherapy. Recurrent or metastatic HNSCC is associated with poor prognosis with a median overall survival of 10 months. The EXTREME protocol is commonly used in first-line setting. Recently, pembrolizumab, an anti-programmed death-1 agent, has been approved by the US Food and Drug Administration for the treatment of patients with recurrent or metastatic squamous cell carcinoma of the head and neck with disease progression on or after a platinum-based therapy. It demonstrated a durable objective response rate with a good safety profile and quality of life. Many ongoing trials are evaluating the use of pembrolizumab for the treatment of HNSCC in various indications such as adjuvant and neoadjuvant setting, maintenance and recurrent disease, alone or in combination with chemotherapy, radiation and targeted therapy. Finding those biomarkers predictive of response to immune checkpoints inhibitors has been a major concern. However, markers have been identified, such as PD-L1 expression, human papilloma virus infection, interferon-γ signature score, microsatellite instability and neoantigen production.

Chemotherapy and immunotherapy for recurrent and metastatic head and neck cancer: a systematic review

Head and neck cancer (HNC) is a fatal malignancy with an overall long-term survival of about 50% for all stages. The diagnosis is not rarely delayed, and the majority of patients present with loco-regionally advanced disease. The rate of second primary tumors after a diagnosis of HNC is about 3-7% per year, the highest rate among solid tumors. Currently, a single-modality or a combination of surgery, radiotherapy and chemotherapy (CHT), is the standard treatment for stage III-IV HNC. For the recurrent/metastatic setting, in the last 40 years great efforts have been made in order to develop a more effective CHT regimen, from the use of methotrexate alone, to the combination of cisplatin (CDDP) and 5-fluorouracile (5FU) or paclitaxel. Recently, the introduction of cetuximab, an anti-EGFR monoclonal antibody, to the CDDP-5FU doublet (EXTREME regimen) has improved the overall response rate, the progression-free survival and the overall survival (OS) compared to CHT alone. Nowadays, the EXTREME regimen is the standard of care for the first-line treatment of recurrent/metastatic head and neck carcinoma (RMHNC). In the last years, new promising therapies for RMHNC such as immune checkpoint inhibitors (ICIs), which have demonstrated favorable results in second-line clinical trials, gained special interest. Nivolumab and pembrolizumab are the first two ICIs able to prolong OS in the second-, later-line and platinum-refractory setting, with tolerable toxicities. This review summarizes the current state of the art in RMHNC treatment options.

KDM5B overexpression predicts a poor prognosis in patients with squamous cell carcinoma of the head and neck

Purpose: Lysine demethylase (KDM) 5B, as a member of the histone lysine demethylase family, is overexpressed and functions abnormally in various human cancers. However, its expression in the squamous cell carcinoma of the head and neck (SCCHN) remains unclear.

Methods: KDM5B expression was analyzed by immunohistochemistry and correlated with clinicopathological parameters in 103 archival SCCHN tissue samples and 24 adjacent noncancerous epithelial tissues.

Results: We found that KDM5B expression was higher in SCCHN than that in adjacent noncancerous tissues. This was closely associated with lymph node metastasis and tumor recurrence. In addition, Kaplan-Meier analysis revealed that patients with high KDM5B expression had shorter disease-free and overall survival times than those with low KDM5B expression. Importantly, both univariate and multivariate analysis demonstrated that KDM5B level was an independent prognostic factor in SCCHN patients.

Conclusions: These results indicate that KDM5B is a valuable biomarker that can be used to predict SCCHN patient outcome.

Survivorship Care Planning and Quality of Life

Roughly 436,000 survivors are living with a history of head and neck cancer (HNC), accounting for approximately 3% of all cancer survivors in the United States [1, 2]. With advances in treatment, long-term survival is increasingly common in HNC populations. Despite increasing awareness of survivorship issues, many challenges remain. These include lack of knowledge on late and long-term effects of treatment, and poor integration of survivorship care guidelines into oncology practice. Survivorship care plans (SCPs) are increasingly important for HNC survivors to improve quality of long-term survival. Quality survivorship care should focus on management of late and long-term effects of treatment, surveillance for cancer recurrence and second primaries, promotion of healthy lifestyle, and care coordination between providers. This chapter will describe common quality of life (QOL) issues in HNC survivorship, and review the current survivorship care guidelines in HNC.

Supportive Care for the Head and Neck Cancer Patient

Patients with head and neck cancers (HNC) face multiple psychosocial and physical challenges that require multidisciplinary attention and care throughout their disease process. The psychoemotional symptoms may be triggered by cosmetic disfigurement and/or functional deficits related to the cancer itself or cancer-directed treatments. These physical and emotional symptoms can be demoralizing and require acute and long-term professional assistance throughout a patient's lifespan. HNC remains one of the most challenging cancers to treat due to disfigurement, emotional suffering, social isolation, and loss of self-esteem. The emotional and physical symptoms a supportive care team can address are discussed in this chapter.

Feasibility of assessing patient health benefits and incurred costs resulting from early dysphagia intervention during and immediately after chemoradiotherapy for head-and-neck cancer

Background

Resource limitations affect the intensity of speech-language pathology (slp) dysphagia interventions for patients with head-and-neck cancer (hnc). The objective of the present study was to assess the feasibility of a prospective clinical trial that would evaluate the effects on health and patient costs of early slp dysphagia intervention for hnc patients planned for curative concurrent chemoradiotherapy (ccrt).

Methods

Patients with hnc planned for curative ccrt were consecutively recruited and received dysphagia-specific intervention before, during, and for 3 months after treatment. Swallowing function, body mass index, health-related quality of life (qol), and out-of-pocket costs were measured before ccrt, at weeks 2 and 5 during ccrt, and at 1 and 3 months after ccrt. Actuarial percutaneous endoscopic gastrostomy (peg) removal rates and body mass index in the study patients and in a time-, age-, and disease-matched cohort were compared.

Results

The study enrolled 21 patients (mean age: 54 years; 19 men). The study was feasible, having a 95% accrual rate, 10% attrition, and near completion of all outcomes. Compared with the control cohort, patients receiving dysphagia intervention trended toward a higher rate of peg removal at 3 months after ccrt [61% (32%-78%) vs. 53% (23%-71%), p = 0.23]. During ccrt, monthly pharmaceutical costs ranged between $239 and $348, with work loss in the range of 18-30 days for patients and 8-12 days for caregivers.

Conclusions

We demonstrated the feasibility of comparing health and economic outcomes in patients receiving and not receiving early slp dysphagia intervention. These preliminary findings suggest that early slp dysphagia intervention for hnc patients might reduce peg dependency despite worsening health. Findings also highlight effects on financial security for these patients and their caregivers.

Cancer Survivorship Care in Advanced Primary Care Practices: A Qualitative Study of Challenges and Opportunities

IMPORTANCE

Despite a decade of effort by national stakeholders to bring cancer survivorship to the forefront of primary care, there is little evidence to suggest that primary care has begun to integrate comprehensive services to manage the care of long-term cancer survivors.

OBJECTIVE

To explain why primary care has not begun to integrate comprehensive cancer survivorship services.

DESIGN, SETTING, AND PARTICIPANTS

Comparative case study of 12 advanced primary care practices in the United States recruited from March 2015 to February 2017. Practices were selected from a national registry of 151 workforce innovators compiled for the Robert Wood Johnson Foundation. Practices were recruited to include diversity in policy context and organizational structure. Researchers conducted 10 to 12 days of ethnographic data collection in each practice, including interviews with practice personnel and patient pathways with cancer survivors. Fieldnotes, transcripts, and practice documents were analyzed within and across cases to identify salient themes.

MAIN OUTCOMES AND MEASURES

Description of cancer survivorship care delivery in advanced patient-centered medical homes, including identification of barriers and promotional factors related to that care.

RESULTS

The 12 practices came from multiple states and policy contexts and had a mix of clinicians trained in family or internal medicine. All but 3 were recognized as National Committee on Quality Assurance level 3 patient-centered medical homes. None of the practices provided any type of comprehensive cancer survivorship services. Three interdependent explanatory factors emerged: the absence of a recognized, distinct clinical category of survivorship in primary care; a lack of actionable information to treat this patient population; and current information systems unable to support survivorship care.

CONCLUSIONS AND RELEVANCE

To increase the potential for primary care transformation efforts to integrate survivorship services into routine care, survivorship must become a recognized clinical category with actionable care plans supported by a functional information system infrastructure.

Association Between Head and Neck Squamous Cell Carcinoma Survival, Smoking at Diagnosis, and Marital Status

Importance

While the adverse association between smoking and head and neck squamous cell carcinoma (HNSCC) survival has been well described, there are also inconclusive studies and those that report no significant changes in HNSCC survival and overall mortality due to smoking. There is also a lack of studies investigating the association of marital status on smoking status at diagnosis for patients with HNSCC.

Objective

To examine the association between patient smoking status at HNSCC diagnosis and survival and the association between marital status and smoking in these patients.

Design, Setting, and Participants

This retrospective cohort study was conducted by querying the Saint Louis University Hospital Tumor Registry for adults with a diagnosis of HNSCC and treated at the university academic medical center between 1997 and 2012; 463 confirmed cases were analyzed.

Main Outcomes and Measures

Cox proportional hazards regression analysis was used to evaluate association of survival with smoking status at diagnosis and covariates. A multivariate logistic regression model was used to assess whether marital status was associated with smoking at diagnosis adjusting for covariates.

Results

Of the 463 total patients (338 men, 125 women), 92 (19.9%) were aged 18 to 49 years; 233 (50.3%) were aged 50 to 65 years; and 138 (29.8%) were older than 65 years. Overall, 56.2% of patients were smokers at diagnosis (n = 260); 49.6% were married (n = 228); and the mortality rate was 54.9% (254 died). A majority of patients were white (81.0%; n = 375). Smokers at diagnosis were more likely to be younger (ie, <65 years), unmarried, and to drink alcohol. We found a statistically significant difference in median survival time between smokers (89 months; 95% CI, 65-123 months) and nonsmokers at diagnosis (208 months; 95% CI, 129-235 months). In the adjusted Cox proportional hazards model, patients who were smokers at diagnosis were almost twice as likely to die during the study period as nonsmokers (hazard ratio, 1.98; 95% CI, 1.42-2.77). In the multivariate logistic regression analysis, unmarried patients were 76% more likely to use tobacco than married patients (adjusted odds ratio, 1.76; 95% CI, 1.08-2.84).

Conclusions and Relevance

Smokers were almost twice as likely as nonsmokers to die during the study period. We also found that those who were married were less likely to be smokers at diagnosis. Our study suggests that individualized cancer care should incorporate social support and management of cancer risk behaviors.

Exergame Grading Scheme: Concept Development and Preliminary Psychometric Evaluations in Cancer Survivors

The challenge of using exergames to promote physical activity among cancer survivors lies in the selection of the exergames that match their fitness level. There is a need for a standardized grading scheme by which to judge an exergame's capacity to address specific physical fitness attributes with different levels of physical engagement. The study aimed to develop an Exergame Grading Scheme and preliminarily evaluate its psychometric properties. Fourteen (14) items were created from the human movement and exergame literature. The content validity index (CVI) was rated by content experts with two consecutive rounds (N = 5 and N = 3 independently). The interrater reliability (IRR) was determined by two raters who used the Exergame Grading Scheme to determine the grading score of the five exergames performed by two cancer survivors (N = 10). Each item had a score of 1 for item-level CVI and 1 for k. For IRR, 9 items had rho values of 1, 1 item had 0.93, and 4 items had between 0.80 and 0.89. This valid and reliable Exergame Grading Scheme makes it possible to develop a personalized physical activity program using any type of exergame or fitness mobile application in rehabilitation practice to meet the needs of cancer survivors.

Long-Term and Latent Side Effects of Specific Cancer Types

Although many cancer survivors diagnosed with early-stage disease will outlive their cancer, they may continue to experience long-term and/or latent side effects due to cancer treatment. Many of these side effects are common and contribute to worse quality of life, morbidity, and mortality for cancer survivors. This article summarizes the treatment side effects for several of the most prevalent cancers in the United States.

Agenda for Translating Physical Activity, Nutrition, and Weight Management Interventions for Cancer Survivors into Clinical and Community Practice

Evidence supporting physical activity, diet, and weight management for cancer survivors has grown, leading to the development of guidelines and interventions. The next step is to identify necessary practice and policy changes and to develop a research agenda to inform how interventions can be delivered to survivors most effectively and efficiently in health care settings and by community-based organizations. Here, an agenda is proposed for research, practice, and policy that incorporates recommendations for a range of programming options, a patient-centered, tailored screening and referral approach, and training needs for survivorship care providers and providers of exercise, nutrition, and weight management services. Research needs to focus on sustainability, dissemination, and implementation. Needed policy changes are presented, as well as opportunities to leverage current health care policies.

Predictors of survival after total laryngectomy for recurrent/persistent laryngeal squamous cell carcinoma

BACKGROUND

Total laryngectomy remains the treatment of choice for recurrent/persistent laryngeal squamous cell carcinoma (SCC) after radiotherapy (RT) or chemoradiotherapy (CRT). However, despite attempts at aggressive surgical salvage, survival in this cohort remains suboptimal.

METHODS

A prospectively maintained single-institution database was queried for patients undergoing total laryngectomy for recurrent/persistent laryngeal SCC after initial RT/CRT between 1998 and 2015(n = 244). Demographic, clinical, and survival data were abstracted. The Kaplan-Meier survival curves and hazard ratios (HRs) were calculated.

RESULTS

Five-year overall survival (OS) was 49%. Five-year disease-free survival (DFS) was 58%. Independent predictors of OS included severe comorbidity (Adult Comorbidity Evaluation-27 [ACE-27] scale; HR 3.76; 95% confidence interval [CI] 1.56-9.06), and positive recurrent clinical nodes (HR 2.91; 95% CI 1.74-4.88).

CONCLUSION

Severe comorbidity status is the strongest predictor of OS, suggesting that increased attention to mitigating competing risks to health is critical. These data may inform a risk prediction model to allow for focused shared decision making, preoperative health optimization, and patient selection for adjuvant therapies.

Psychiatric Care of the Radiation Oncology Patient

BACKGROUND

In recent decades, psychiatrists have become increasingly involved in the care of patients with cancer. Psychiatrists are often less familiar with the field of radiation oncology than with other medical specialties.

OBJECTIVE

Therefore, it is beneficial for consulting psychiatrists to be familiar with the basic principles of radiation therapy (RT) and its potential neuropsychiatric sequelae.

METHODS

We performed a PubMed search to identify articles describing neuropsychiatric symptoms resulting from RT, including anxiety, claustrophobia, posttraumatic stress disorder, and neurocognitive impairment. We also searched for other sequelae of RT that may produce psychiatric symptoms, such as radiation necrosis and endocrinopathies. We provide a basic introduction to the delivery of RT.

RESULTS

Psychiatrists may be involved in the treatment of patients before, during, or after RT, and each phase of treatment produces unique considerations. Anxiety about the treatment, especially the need for immobilization with a mask, can be treatment-limiting. Adverse effects from treatment, including cognitive impairment and endocrinopathies, can result in psychiatric symptoms.

CONCLUSIONS

Consulting psychiatrists should be familiar with the basic principles of RT and the neuropsychiatric sequelae that may result from the treatment. Further research is needed to identify strategies to help patients tolerate RT and to identify additional preventive and therapeutic options for RT-induced cognitive impairment.

Psychosocial Issues in Patients with Head and Neck Cancer: an Updated Review with a Focus on Clinical Interventions

PURPOSE OF REVIEW

There are frequent and diverse psychosocial issues that afflict patients with head and neck cancer (HNC) across the illness trajectory, prompting a focus on clinical interventions to prevent and mitigate psychosocial distress. We sought to characterize current understanding on the cause, effects, and interplay of various psychosocial factors in HNC and summarize updated, evidence-based interventions.

RECENT FINDINGS

The psychosocial experience of patients with HNC is characterized by a disproportionately high incidence of depression, suicide, continued substance dependence/abuse, and distress related to relationship conflict, social isolation, disfigurement, and damage to self-image. As we move towards a more thorough understanding and greater appreciation of the relationship between HNC and patient quality of life (QoL), future research focuses on implementation of effective, accessible clinical interventions to alleviate psychosocial distress in this population.

Impact of Type 2 Diabetes Mellitus on Survival in Head and Neck Squamous Cell Carcinoma

Objective To identify any association between type 2 diabetes mellitus (T2DM) and survival outcomes for mucosal squamous cell carcinoma of the head and neck. An association has been demonstrated between T2DM and cancer outcomes at numerous sites, but data for the head and neck are limited. Improving our understanding of the impact that diabetes has on head and neck cancer survival is relevant for making treatment decisions and counseling patients regarding prognosis. Study Design Retrospective cohort study. Setting Academic tertiary referral head and neck cancer center. Subjects and Methods By accessing data retrospectively from prospectively collected databases at the Princess Margaret Cancer Centre, patients were studied who were treated for mucosal head and neck squamous cell cancer between January 2005 and December 2011. Collection of clinical, pathologic, and survival data was completed with an emphasis on T2DM. Results Of 2498 patients identified in the study period, 319 (12.8%) had T2DM. Five-year overall survival was not different between the diabetic (64%, 95% CI = 58%-71%) and nondiabetic (67%, 95% CI = 65%-69%; P = .078) groups. Furthermore, cause-specific survival did not demonstrate a statistically significant difference between groups (diabetic: 84%, 95% CI = 79%-88%, vs nondiabetic: 84%, 95% CI = 82%-86%; P = .67). Conclusion Despite contradictory evidence at other cancer sites, the presence of T2DM alone does not appear to adversely affect cancer survival outcomes in head and neck squamous cell cancer. This is encouraging for the diabetic patients with head and neck squamous cell cancer, and it provides guidance for the multidisciplinary team that treats them.

Survivorship: Morbidity, Mortality, Malignancy

Survivorship encompasses the entire therapeutic, psychosocial, functional, and financial experience of living with and through a cancer diagnosis. The period of survivorship starts on the day of the cancer diagnosis and lasts until the end of the survivor's life, regardless of the cause of death. The National Cancer Institute's Office of Cancer Survivorship expands the term "survivor" to include, importantly, caregivers, family, and friends close to the survivor who also live through this period.

Survivorship of patients with head and neck cancer receiving care in a tertiary health facility in Nigeria

Background

Head and neck cancer (HNC) is a major clinical and public health concern worldwide which impairs the vital functions of life. The treatment of metastatic HNCs is mainly palliative. This study examined the survival patterns and treatment outcomes in patients with HNCs in a tertiary hospital in Nigeria.

Materials and methods

A review of the case files and treatment cards of patients with histological diagnosis of HNCs seen between January 2002 and December 2011 at the Radiotherapy Department, University College Hospital, Ibadan, was conducted. A total of 494 cases were identified, of which 481 had valid records. Analyses were done using Kaplan–Meier survival function and Cox proportional hazard regression techniques at 5% significance level.

Results

The median age of patients was 42 years with a male-to-female ratio of 2:1. Most patients presented at stages 3 (50.7%) and 4 (36.8%). Nasopharyngeal carcinoma was the most common (42.6%) HNC, followed by paranasal sinus (17.7%) and laryngeal cancer (11.6%). The lung was the most common site of metastasis (25.5%). Patients who presented at stages 1 and 4 disease had a median survival of 7.8 years and 1.9 years, respectively. Patients treated with a combination of chemotherapy and radiotherapy had a median survival of 8.0 years compared with those who had a single modality of treatment (~6.3 years).

Conclusion

Patient survival was inversely proportional to the stage of the disease. To encourage the early presentation of HNC cases, health education of the population on routine medical check-ups and on the symptoms suggestive of HNC is recommended. Health care providers should be trained to refer suspected cases promptly to tertiary health facilities for management.