Relationship between psychological status and compliance in a sample of patients treated for cancer of the head and neck

Supporting Patient Autonomy in Shared Decision Making for Individuals With Head and Neck Cancer

PURPOSE

Management of head and neck cancer (HNC) can result in substantial long-term, multifaceted disability, leading to significant deficits in one's functioning and quality of life (QoL). Consequently, treatment selection is a challenging component of care for patients with HNC. Clinical care guided by shared decision making (SDM) can help address these decisional challenges and allow for a more individualized approach to treatment. However, due in part to the dominance of biomedically oriented philosophies in clinical care, engaging in SDM that reflects the individual patient's needs may be difficult.

CONCLUSIONS

In this clinical focus article, we propose that health care decisions made in the context of biopsychosocial-framed care-one that contrasts to decision making directed solely by the biomedical model-will promote patient autonomy and permit the subjective personal values, beliefs, and preferences of individuals to be considered and incorporated into treatment-related decisions. Consequently, clinical efforts that are directed toward biopsychosocial-framed SDM hold the potential to positively affect QoL and well-being for individuals with HNC.

Preexisting stress-related diagnoses and mortality: A Danish cancer cohort study

BACKGROUND

This study evaluated the association between preexisting stress-related diagnoses and mortality in a Danish population-based cancer cohort.

METHODS

This study included Danish patients with cancer diagnosed in 1995-2011 who had a stress-related diagnosis before their cancer diagnosis. Cancer patients without a prior stress-related diagnosis were matched 5:1 to the stress disorder cohort by cancer site, age group, calendar period, and sex. The 5-year cumulative incidence of cancer-specific and all-cause mortality was computed by stress-related diagnosis category. Hazard ratios and 95% confidence intervals (CIs) associating stress-related diagnoses with mortality were computed by follow-up time, stress-related diagnosis category, stage, comorbidity status, and cancer type.

RESULTS

This study identified 4437 cancer patients with a preexisting stress-related diagnosis and 22,060 matched cancer cohort members. The 5-year cumulative risk of cancer-specific mortality was 33% (95% CI, 32%-35%) for those with a preexisting stress-related diagnosis and 29% (95% CI, 28%-29%) for those without a prior stress-related diagnosis. Cancer patients with a preexisting stress-related diagnosis had a 1.3 times higher cancer-specific mortality rate than the comparison cohort members (95% CI, 1.2-1.5). This increase persisted across categories of stress-related diagnosis. The association varied by stage and cancer type, with more pronounced associations found among those with a late stage at diagnosis and hematological malignancies.

CONCLUSIONS

Cancer patients with preexisting stress-related diagnoses had increased rates of cancer-specific and all-cause mortality. The results suggest that psychiatric comorbidities may be an important consideration for cancer prognosis, and cancer treatment informed by a patient's history may improve outcomes.

Predictors of psychiatric comorbidity in cancer patients at the time of their discharge from the hospital

PURPOSE

A cancer diagnosis can have a substantial impact on one's mental health. The present study investigated the prevalence and predictors of psychiatric comorbidities in cancer patients at the time of their discharge from the hospital.

METHODS

Psychiatric comorbidities were assessed shortly before hospital discharge and half a year after hospitalization using a structured clinical interview (SCID), based on the diagnostic and statistical manual of mental disorders (DSM-IV). Frequencies at both time points were estimated using percentages and corresponding 95% confidence intervals. Predictors of mental disorders were identified using binary logistic regression models.

RESULTS

At time of hospital discharge, 39 out of 334 patients (12%) were diagnosed with a psychiatric comorbidity, and 15 (7%) were diagnosed half a year later. Among the diagnoses, adjustment disorders (3%) were most frequent at the time of hospital release, while major depression (3%) was the most frequent 6 months later. Having a mental disorder was associated with unemployment (odds ratio (OR) 3.4, confidence interval (CI) 1.1-10.9, p = 0.04). There was no evidence that school education (OR 2.0, CI 0.4-9.0, p = 0.38), higher education (OR 0.7, CI 0.2-2.4, p = 0.60), income (OR 1.0, CI 1.0-1.0, p = 0.06), tumor stage (OR 1.1, CI 0.4-3.2, p = 0.85), type of disease (OR 0.6, CI 0.2-2.1, p = 0.47), pain (OR 1.0, CI 1.0-1.0, p = 0.15), fatigue (OR 1.0, CI 1.0-1.0, p = 0.77), or physical functioning (OR 1.0, CI 1.0-1.0, p = 0.54) were related to the presence of a psychiatric comorbidity.

CONCLUSIONS

Unemployment was associated with at least a threefold increased risk of mental disorder, which highlights the need for special attention to be given to this subgroup of cancer patients.

Resilience: an essential element in head and neck cancer survivorship and quality of life

PURPOSE

Individuals with head and neck cancer (HNCa) face myriad biopsychosocial challenges. Even after treatment completion, these challenges may cause continued disablement and diminished quality of life (QoL). Resilience may serve to minimize the disabling impact of HNCa and, in turn, maximize QoL. The purpose of this study was to formally assess resilience in HNCa survivors and explore its relationship with QoL.

METHODS

A cross-sectional descriptive study was conducted. Forty HNCa survivors completed three validated, self-report questionnaires pertaining to the collection of resilience and QoL data. Descriptive and correlational analyses were performed.

RESULTS

Resilience was identified in HNCa survivors and a positive correlation was found between resilience and QoL.

CONCLUSIONS

Data suggest that resilience may buffer the influence of HNCa on QoL. Thus, screening for reduced levels of resilience may proactively facilitate identification of those who are most vulnerable to the psychosocial impact of HNCa. Interventions that foster resilience may ameliorate the challenges of HNCa and maximize QoL.

Adherence to intensive nutrition care in head and neck cancer patients undergoing radiotherapy

PURPOSE

The aim of this study was to determine the prevalence and effect of adherence to intensive nutritional care on nutritional outcomes and survival in head and neck cancer patients undergoing radiotherapy.

METHODS

Three-hundred and seventeen head and neck cancer patients referred to intensive nutrition support during radiotherapy were retrospectively analyzed. Patients who missed less than 25% of their appointments with the dietitian were considered adherent. Primary outcome was percentage weight loss during treatment. Secondary outcomes were overall survival and patients' capacity to accomplish their caloric and protein recommendations. Logistic regression was used to examine predictors of weight loss and Kaplan-Meier to estimate survival.

RESULTS

Less than half of the patients (n = 145, 45.7%) were adherent. Statistically significant less weight loss in the adherent group (42.8% vs 55.8%; p = 0.02) was found, despite no difference in energy or protein intake. Logistic regression models after adjusting for other variables demonstrated that adherence resulted in 43% protection from significant weight loss (odds ratio 0.57, 95% CI 0.34-0.97). Overall survival was not different between groups.

CONCLUSION

Findings demonstrated that patients who were adherent to weekly contacts with the dietitian had less weight loss, but not better survival or nutritional intake. Additional investigation of factors that may act as barriers or enablers for adherence could help improve the outcomes in this population.

Distress Management in Patients With Head and Neck Cancer Before Start of Palliative Chemotherapy: A Practical Approach

Purpose

This study reports the incidence of distress, the factors associated with distress, and a practical strategy to resolve distress in patients with head and neck cancer who are starting palliative chemotherapy.

Methods

Adult patients with head and neck cancer planned for palliative chemotherapy underwent distress screening before the start of treatment as part of this single-arm prospective study. Patients who had a distress score > 3 on the National Comprehensive Cancer Network (NCCN) distress thermometer were counseled initially by the clinician. Those who continued to have high distress after the clinician-led counseling were referred to a clinical psychologist and were started on palliative chemotherapy. After counseling, distress was measured again. The relation between baseline distress and compliance was tested using Fisher's exact test.

Results

Two hundred patients were enrolled, and the number of patients with high distress was 89 (44.5% [95% CI, 37.8% to 51.4%]). The number of patients who had a decrease in distress after clinician-led counseling (n = 88) was 52 (59.1% [95% CI, 48.6% to 68.8%]) and after psychologist-led counseling (n = 32) was 24 (75.0% [95% CI, 57.6% to 72.2%]; P = .136). Compliance rates did not differ between the patients with or without a high level of distress at baseline (74.2% v 77.4%, P = .620).

Conclusion

The incidence of baseline distress is high in patients awaiting the start of palliative chemotherapy. It can be resolved in a substantial number of patients using the strategy of clinician-led counseling, with additional referral to a clinical psychologist as required. Patients with a greater number of emotional problems usually require psychologist-led counseling.

Head and neck cancer survivors' preferences for and evaluations of a post-treatment dietary intervention

BACKGROUND

Dietary preferences vary depending on cancer type. The purpose of this study was to report dietary intervention preferences and a study program evaluation from post-treatment head and neck cancer survivors participating in a dietary intervention.

METHODS

Between January 2015 and August 2016, 24 head and neck cancer survivors participated in a 12-week randomized clinical dietary intervention trial that promoted weekly consumption of 2.5 cups of cruciferous vegetables and 3.5 cups of green leafy vegetables. At study completion, survivors completed a preferences survey and a study program evaluation to probe interests and improvement aspects for planning future dietary intervention trials. Descriptive statistics (means and frequencies) were generated for multiple choice question responses. Responses to open-ended questions were recorded and grouped based on themes, and verified by quality assurance checks by a second study team member.

RESULTS

Twenty-three survivors completed the preferences and evaluation surveys (response rate 96%). Overall, most participants reported a preference for one-on-one telephone counseling from a registered dietitian nutritionist before beginning treatment. Ninety-six percent of participants ranked the overall study program as "very good" to "excellent," and all agreed the objectives of the study were clear, the study staff was helpful and easy to contact, and the registered dietitian nutritionist was knowledgeable.

CONCLUSIONS

Future research and dietary intervention planning for head and neck cancer survivors should focus on strategies to promote one-on-one telephone or other distance-based counseling combined with face-to-face visits, according to survivor preference.

Emotional disclosure and cognitive processing in couples coping with head and neck cancer

Head and neck cancer (HNC) patients and their spouses experience communication problems and high rates of emotional distress. Couple-based interventions that encourage emotional disclosure hold promise for improving cognitive processing and distress in this population, but more research needs to examine when and for whom emotional disclosure is an effective coping strategy. In this observational study, 125 HNC patients (83% male) and their spouses were videotaped discussing a cancer-related concern in the laboratory. Discussions were coded with the specific affect coding system. Actor-partner interdependence models showed that patient expression of negative emotions (i.e., disdain, contentiousness, distress) was not related to his/her own or the spouse's cognitive processing (assessed as reaction times to cancer and noncancer words on a computerized cognitive task administered immediately following the discussion). When spouses expressed support (e.g., interest, validation), they had better cancer- (effect size r = - 0.21) and noncancer-related cognitive processing (r = - 0.17), but patients did not. However, when spouses expressed disdain (e.g., contempt) and contentiousness (e.g., criticism, domineering), patients had poorer cancer- (r = 0.20-0.22) and noncancer-related cognitive processing (r = 0.19-0.26). Findings suggest consideration of the valence of affective expression and which partner is disclosing/listening before unilaterally encouraging HNC couples to openly express emotions as a means of alleviating distress.

Feasibility Outcomes of a Pilot Randomized Clinical Trial to Increase Cruciferous and Green Leafy Vegetable Intake in Posttreatment Head and Neck Cancer Survivors

BACKGROUND

Higher intakes of cruciferous vegetables (CVs) and green leafy vegetables (GLVs) in observational studies are associated with improvements in survival and cancer-related biomarkers in patients diagnosed with head and neck cancer (HNC). These results have yet to be corroborated in a randomized clinical trial (RCT).

OBJECTIVE

Determine the feasibility of implementing a 12-week RCT to increase CV and GLV intake in posttreatment HNC survivors.

DESIGN AND PARTICIPANTS

This was a two-arm RCT conducted among 24 posttreatment HNC survivors. Survivors were recruited from a southeastern, National Cancer Institute-designated Comprehensive Cancer Center between January 2015 and September 2016.

INTERVENTION

There were two groups: (1) an experimental group (n=12) receiving weekly 15- to 30-minute telephone dietary counseling from a registered dietitian nutritionist stressing 2.5 cups per week CVs and 3.5 cups per week GLVs, and (2) an attention control group (n=12) receiving weekly 15- to 30-minute telephone dietary counseling from a registered dietitian nutritionist focusing on general healthy eating for cancer survivors. Participants completed a baseline survey, three 24-hour dietary recalls, phlebotomy, and anthropometric measures prior to randomization and at the end of the 12-week study period. The experimental group also completed weekly vegetable record recalls.

MAIN OUTCOME MEASURES

Primary outcomes included feasibility, recruitment, retention, adherence, and safety. Secondary outcomes included inflammatory markers and carotenoids.

STATISTICAL ANALYSES PERFORMED

Descriptive statistics were generated for demographic, epidemiological, and clinical variables as well as the primary feasibility outcomes. Between- and within-group comparisons of mean serum cytokine and carotenoid levels were performed using appropriate statistical tests depending on their respective distributions for the purpose of generating preliminary effect sizes.

RESULTS

Overall, 350 incident HNC cases were screened for eligibility, and 98 were eligible for study participation. Reasons for ineligibility and exclusion included deceased (n=93); wrong or inactive telephone numbers, or unable to be reached, or lost to follow-up (n=93); not meeting inclusion criteria (n=39); and too ill to participate (n=27). Of the 98 eligible HNC cases, 24 agreed to participate, for an enrollment rate of 25%. The most common reason for nonparticipation was distance (n=48), as participants were asked to report for two on-site assignments. The retention rate was 96%. Mean intervention adherence rates for weekly goals were 67% CV, 74% GLV, and 71% overall. Completion rate of weekly counseling calls was 90%. The experimental group reported an overall mean increase of 5.5 cups GLV and 3.5 cups CV per week from baseline intake, respectively. No significant between- or within-arm differences were observed for inflammatory markers or carotenoids.

CONCLUSION

A posttreatment intervention aimed at increasing CV and GLV intake in HNC survivors is feasible. A larger RCT is needed to assess the efficacy of this intervention on disease outcomes.

Effectiveness of clinical practice change strategies in improving dietitian care for head and neck cancer patients according to evidence-based clinical guidelines: a stepped-wedge, randomized controlled trial

Best practice guidelines make a number of recommendations regarding dietitian management of head and neck cancer (HNC) patients. Randomized trials assessing the effectiveness of clinical practice change strategies for improving the nutritional management of HNC patients have not previously been conducted. The purpose of this study was to evaluate the effect of practice change strategies on improving the implementation of best practice guideline recommendations for the nutritional management of HNC patients. Four Australian radiotherapy departments participated in a stepped-wedge, randomized controlled trial. Baseline data were collected across all sites simultaneously, and the intervention was then introduced to each site sequentially, in a randomly determined order. During the intervention phase, sites received a range of supportive clinical practice change strategies to facilitate dietitian adherence to clinical practice guidelines. To assess the associated practice change by dietetic staff, we evaluated the change in implementation of six guideline recommendations for dietitians from preintervention to postintervention periods. Adherence to the clinical practice guidelines during the preintervention period was generally very low. The clinical practice change strategies significantly improved the odds of provision of four of the six guideline recommendations. The study found the intervention significantly enhanced dietitian provision of recommended care for HNC patients during the postintervention period. This finding holds clinical importance for clinician and health service effective implementation of guideline recommendations as well as HNC patient treatment outcomes. Trial registration number ACTRN12613000320752, https://www.anzctr.org.au.

Is patient empowerment the key to promote adherence? A systematic review of the relationship between self-efficacy, health locus of control and medication adherence

Background

Current health policies emphasize the need for an equitable doctor-patient relationship, and this requires a certain level of patient empowerment. However, a systematic review of the empirical evidence on how empowerment affects medication adherence—the extent to which patients follow the physician’s prescription of medication intake—is still missing. The goal of this systematic review is to sum up current state-of-the-art knowledge concerning the relationship between patient empowerment and medication adherence across medical conditions. As our conceptualization defines health locus of control and self-efficacy as being crucial components of empowerment, we explored the relationship between these two constructs and medication adherence.

Methods

Relevant studies were retrieved through a comprehensive search of Medline and PsychINFO databases (1967 to 2017). In total, 4903 publications were identified. After applying inclusion and exclusion criteria and quality assessment, 154 articles were deemed relevant. Peer-reviewed articles, written in English, addressing the relationship between empowerment (predictor) and medication adherence (outcome) were included.

Findings

High levels of self-efficacy and Internal Health Locus of Control are consistently found to promote medication adherence. External control dimensions were found to have mainly negative (Chance and God attributed control beliefs) or ambiguous (Powerful others attributed control beliefs) links to adherence, except for Doctor Health Locus of Control which had a positive association with medication adherence. To fully capture how health locus of control dimensions influence medication adherence, the interaction between the sub-dimensions and the attitudinal symmetry between the doctor and patient, regarding the patient’s control over the disease management, can provide promising new alternatives.

Discussion

The beneficial effect of patients’ high internal and concurrent physician-attributed control beliefs suggests that a so-called “joint empowerment” approach can be suitable in order to foster medication adherence, enabling us to address the question of control as a versatile component in the doctor-patient relationship.

Online support groups for head and neck cancer and health-related quality of life

Purpose

To investigate the association between using online support groups (OSGs) and health-related quality of life (HRQoL), and the psychosocial factors that may influence this association among individuals with head and neck (H&N) cancer.

Method

A sample of 199 persons with H&N cancer using four OSGs completed an online questionnaire using six pre-validated measures for social network, self-efficacy, anxiety and depression, adjustment, empowerment and quality of life. In addition, socio-demographic as well as illness-related and OSGs-related information was collected.

Results

Participants who had better HRQoL had been using OSGs for a longer time than those who had worse HRQoL (B = 0.07, p < 0.05). Depression and adjustment were the only direct mediators in this association, whereas self-efficacy, anxiety and empowerment appeared as indirect mediators.

Conclusion

Participation in OSGs was found to be associated to better HRQoL either directly or indirectly through decreasing depression, anxiety and the negative adjustment behaviours and increasing self-efficacy and empowerment of the users. The study presented a potential model of pathways linking OSG use and HRQoL for those with H&N cancer. However, the model needs to be tested in future longitudinal studies and the associations proposed need to be explored in greater detail.

Purposefulness as a critical factor in functioning, disability and health

Guided by theoretical frameworks of health and illness such as the International Classification of Functioning, Disability, and Health (ICF), we seek to describe the importance of purposefulness in the context of rehabilitation. We argue that ascribing meaning to life events, particularly changes in health, and acting in a manner that is driven by purpose is a universal characteristic of human beings. The ability to contextualize purposefulness within the broader biopsychosocial model of illness may provide a greater understanding of the relationship of purpose in the process of rehabilitation.

We support the notion that purposefulness is an ever-present component throughout our lives and it exists as a convergence of personal factors, past experiences, and our personal narrative. Having a sense of purposefulness and being able to understand the meaning of different aspects of our lives is what allows us to find purpose while experiencing a health condition. More importantly, and in the context of rehabilitation efforts, we believe that if purposefulness can be identified or collectively defined by the individual, then rehabilitation outcomes may be enhanced.

In a variety of contexts ranging from disease, aging, severe trauma, and even war, purposefulness and its component elements consistently distinguish themselves as being essential for regaining a sense of direction and facilitating one’s response to any health condition.

The Management of Patients after Surgical Treatment of Maxillofacial Tumors

Morphological and functional disturbances induced by postsurgical defects and loss of tissues in the stomatognathic system due to the treatment of tumors in the maxillofacial region determine the therapeutic needs of patients. The study aimed at clinical and epidemiological evaluation of patients under prosthetic treatment in order to establish the algorithm for rehabilitation. The study group was composed of the patients after midface surgery (45.74%); surgery in a lower part of the face (47.38%); mixed postoperative losses (3.44%); loss of face tissues and surgery in other locations in the head and neck region (3.44%). The supplementary treatment was applied in 69.63% of patients. Clinical and additional examinations were performed to obtain the picture of postoperative loss, its magnitude, and location to plan the strategy of prosthetic rehabilitation. The management algorithm for prosthetic rehabilitation in patients after surgical treatment of maxillofacial neoplasms was based on its division in stages. The location and magnitude of postoperative losses, as well as the implementation of supplementary treatment of the patients after treatment of maxillofacial tumors, influence the planning of prosthetic rehabilitation that plays a key role and facilitates the patients' return to their prior living situation, occupational and family lives.

Psychological distress in patients and caregivers over the course of radiotherapy for head and neck cancer

OBJECTIVES

Head and neck cancer patients and their caregivers report high rates of psychological distress. High rates of physical symptom burden and the increased need for family members to provide caregiving during treatment may contribute to this distress.

METHODS

This study examined trajectories of patient and caregiver distress over the course of radiotherapy for head and neck cancer as well as how patients and caregivers influence each other's distress. Forty-nine head and neck cancer patient-caregiver dyads completed 6 weekly assessments of physical symptoms (MDASI-HN) and distress (e.g., NCCN distress thermometer) over the course of radiotherapy.

RESULTS

Patient and caregiver distress increased steadily over the course of treatment, peaking at week 5; patients (82% male; 69% Stage 4) and caregivers (90% female) reported significant distress in 77% of cases. Linear mixed models with the patient-caregiver dyad as the unit of analysis showed that increases in patient-rated head and neck specific physical symptoms had a significant (p<.05) time-varying effect on both patient and caregiver distress. Increases in one dyad member's distress levels were also significantly associated with decreases in the other's distress levels over time.

CONCLUSION

Findings highlight the adverse impact of patient physical symptoms during radiotherapy on both patient and caregiver distress. They also support a dyadic coping model whereby patients and caregivers manage their distress together as a unit. Overall, dyadic supportive care interventions that focus on controlling patient physical symptoms and that address both patient and caregiver distress are sorely needed in head and neck cancer.

Influence of the BDNF Val66Met polymorphism on coping response to stress in patients with advanced gastric cancer

OBJECTIVE

Coping with cancer is an important determinant of psychological morbidity, quality of life, and treatment adherence in cancer patients. The aim of this study was to elucidate the association between the brain-derived neurotrophic factor (BDNF) Val66Met polymorphism and coping response to stress in patients diagnosed with advanced gastric cancer.

METHODS

Ninety-one subjects (60 males, 31 females) recently diagnosed with advanced gastric cancer were recruited. Coping style and distress level were examined using the Mini-Mental Adjustment to Cancer (Mini-MAC) scale and Hospital Anxiety and Depression Scale, and genotyping was evaluated. To examine the temporal stability of the Mini-MAC scores, a 6-week follow-up evaluation was conducted in 72 patients, after completion of two chemotherapy cycles.

RESULTS

Coping style to cancer significantly differed between the Met carriers of BDNF Val66Met and the Val/Val homozygotes. The Met carriers were significantly more anxious than the Val/Val homozygotes.

CONCLUSION

The present findings suggest that the BDNF Val66Met polymorphism may be involved in individual coping responses to cancer. The Met allele of BDNF Val66Met may be predictive of an anxious coping style in patients with advanced cancer.

A correlational study of suicidal ideation with psychological distress, depression, and demoralization in patients with cancer

PURPOSE

This study aims to study the effects of depression and demoralization on suicidal ideation and to determine the feasibility of the Distress Thermometer as a screening tool for patients with cancer who experience depression and demoralization, and thus to establish a model screening process for suicide prevention.

METHODS

Purposive sampling was used to invite inpatients and outpatients with lung cancer, leukemia, and lymphoma. Two hundred participants completed the questionnaire, which included the Distress Thermometer (DT), Patient Health Questionnaire-9 (PHQ-9), Demoralization Scale-Mandarin Version (DS-MV), and Beck Scale for Suicide Ideation. All data obtained were analyzed using SPSS 18.0 and SAS 9.3.

RESULTS

Tobit regression analysis showed that demoralization influenced suicidal ideation more than depression did (t = 2.84, p < 0.01). When PHQ-9 ≥ 10 and DS-MV ≥42 were used as criteria for the DT, receiver operating characteristic analysis revealed that the AUC values were 0.77-0.79, with optimal cutoff points for both of DT ≥5; sensitivity 76.9 and 80.6 %, respectively; and specificity of 73.9 and 72.2 %, respectively.

CONCLUSIONS

Demoralization had more influence on suicidal ideation than depression did. Therefore, attention should be paid to highly demoralized patients with cancer or high demoralization comorbid with depression for the purposes of suicide evaluation and prevention. The DT scale (with a cutoff of ≥5 points) has discriminative ability as a screening tool for demoralization or depression and can also be used in clinical settings for the preliminary screening of patients with cancer and high suicide risk.

The identification of mood and anxiety concerns using the patients concerns inventory following head and neck cancer

The aim of this study was to investigate the concurrent use of the Patient Concerns Inventory (PCI) and the University of Washington Quality of life instruments (UW-QOL), as a means of identifying mood and anxiety concerns in patients following head and neck cancer treatment. From August 2007 to July 2009, 204 patients (454 clinic appointments) attending one consultant's oncology review clinic completed the UW-QOLv4 and PCI prior to their consultation. Before entering consultations, 17% (79/454) of patients reported problems with mood and 20% (89/454) reported problems with anxiety on the UW-QOL. Regarding the items raised by patients using the PCI prior to consultation, 'mood' was raised in 10% (46/454), 'anxiety' in 13% (58/454) and 'depression' in 10% (44/454) of cases. In 32% (145/454) of consultations, 44% (89/204) patients had reported significant anxiety or mood problems on the UW-QOL, or highlighted issues of anxiety, mood and/or depression on the PCI for discussion. Patients completing the PCI were more often referred to the clinical psychologist and to the emotional support worker. The results showed that the combination of the UW-QOL questionnaire and the PCI provide a practical means of screening for psychological distress in clinics.

Perceived social support as a predictor of disease-specific quality of life in head-and-neck cancer patients

BACKGROUND

Treatment for head-and-neck cancer (HNC) can lead to severe decrements in disease-specific quality of life (DSQOL) due to disfigurement and disability in speech, eating, and/or breathing. Psychosocial factors such as social support may explain individual variance in DSQOL outcomes.

OBJECTIVE

The researchers sought to evaluate changes in perceived availability of social support from pretreatment to posttreatment and to determine whether decreases in perceived social support predicted poorer posttreatment DSQOL among HNC patients, controlling for disease- and treatment-related factors.

METHODS

Participants (n = 32) were newly diagnosed with HNC and were awaiting surgery and/or radiation treatment. Measures included the ENRICHD Social Support instrument (ESSI) to assess perceived social support and the Functional Assessment of Cancer Therapy-Head & Neck (FACT-H&N) to assess DSQOL. Paired-samples t-tests and hierarchical regression analyses were conducted to determine relationships between pretreatment and posttreatment perceived social support and DSQOL.

RESULTS

Perceived social support decreased significantly from pre- to posttreatment (F[31] = -2.71, P < .01). After adjusting for relevant covariates and pretreatment DSQOL, change in perceived social support remained a significant predictor of posttreatment DSQOL (β = .47, P < .01).

LIMITATIONS

This study included a relatively small sample of HNC patients, which limited power to evaluate mechanisms of observed relationships.

CONCLUSIONS

Increased social isolation may be a risk factor for poorer physical recovery from, or adjustment to, treatment-related side effects. Social support may be an important target for psychosocial interventions for patients who face challenging treatment side effects.

RCT of a psychological intervention for patients with cancer: I. mechanisms of change

Little is known about the therapeutic processes contributing to efficacy of psychological interventions for patients with cancer. Data from a randomized clinical trial yielding robust biobehavioral and health effects (B. L. Andersen et al., 2004, 2007) were used to examine associations between process variables, treatment utilization, and outcomes. Novel findings emerged. Patients were highly satisfied with the treatment, but their higher levels of felt support (group cohesion) covaried with lower distress and fewer symptoms. Also, specific treatment strategies were associated with specific outcomes, including lower distress, improved dietary habits, reduced symptomatology, and higher chemotherapy dose intensity. These data provide a comprehensive test of multiple therapeutic processes and mechanisms for biobehavioral change with an intervention including both intensive and maintenance phases.

Comparison of the domains of anxiety and mood of the University of Washington Head and Neck Cancer Questionnaire (UW-QOL V4) with the CES-D and HADS

BACKGROUND

Version 4 of the University of Washington Head and Neck Cancer Questionnaire (UW-QOLv4) includes items on mood and anxiety. The aim of this study was to compare the responses to these single items with the Centre for Epidemiology Studies Depression Scale (CES-D) and the Hospital Anxiety Depression Scale (HADS).

METHODS

A cross-sectional postal survey was undertaken in April 2003. The survey was composed of all patients treated for oral and oropharyngeal squamous cell carcinoma between 1992 and 2002 who were alive and disease free.

RESULTS

We distributed 306 questionnaires; there were 197 replies (65%) from 110 male and 87 female patients. Most patients reported relatively little depression, with 170 of 190 (89%) reporting a HADS depression score of less than 11. Similarly, most patients were not anxious, with 158 of 183 (86%) reporting a HADS anxiety score of less than 11. UW-QOL mood, UW-QOL anxiety, HADS anxiety, HADS depression, and CES-D scores were all moderately intercorrelated (Spearman correlations from 0.39-0.68 ignoring the signs, all p < .001). The UW-QOL mood correlated with the scores and "case-ness" categories of the HADS depression and CES-D scales, whereas the UW-QOL anxiety correlated with the scores and "case-ness" of the HADS anxiety.

CONCLUSIONS

Questions on mood and anxiety can help identify significant psychological morbidity, taking a score of less than 75 for UW-QOL mood and less than 70 for UW-QOL anxiety. This could be used to trigger formal psychological assessment and with a view to possible therapeutic intervention.

Physical and psychosocial correlates of head and neck cancer: an update of the literature and challenges for the future (1996-2003)

An update of the literature on physical and psychosocial aspects of head and neck cancer, with special emphasis on effects of treatment, patient-related factors and psychosocial intervention on quality of life (QoL). QoL deteriorates during and directly after treatment and returns only slowly to pre-treatment values. Organ preservation, gender and coping-strategies are factors related to QoL after treatment. As prognosis and survival were found to be comparable under different treatment regimes, we noticed a gradual shift in therapy towards organ preservation. Systematic care, using specific instruments is important for improving the QoL. We feel that more attention should be given to improving support, in order to optimize the QoL of patients during the palliative stage.

[Quality of life of patients with squamous cell carcinoma of the oral cavity]

OBJECTIVE

The aim of this study was to assess the changes in quality of life during and after treatment in patients with cancer of the oral cavity.

PATIENTS AND METHODS

In the period between October 1999 and September 2000, 57 patients of the Department of Craniomaxillofacial Surgery, University of Cologne, underwent surgery, radiation therapy or the combination of both for the treatment of cancer of the oral cavity. Before, during and after the therapy their quality of life was measured with two psychometric scales.

RESULTS

The average loss of quality of life in the female group was less than in the male group. Younger patients suffered more than older ones did. All patients had a loss of quality of life 3 months after the beginning of the therapy. The biggest decrease was in the group of patients treated with combined therapy, and the lowest loss in the radiated group. During the assessment period of 9 months, there were significant differences between all three groups. The size of the tumor did not show any influence on the reduction of quality of life. Patients with cancer of the tongue or maxilla showed more loss of quality of life than patients with tumors located in other regions of the oral cavity.

CONCLUSION

Location of the tumor, age, gender of the patient, and type of therapy influenced the quality of life, while the size of the tumor did not.

Sociodemographic risk indicators for depressive symptoms among persons with oral cancer or oral epithelial dysplasia

PURPOSE

We report findings from a study that measured associations between sociodemographic risk indicators and depressive symptoms among individuals diagnosed with either oral cancer or a premalignant lesion.

MATERIALS AND METHODS

Incident cases of oral cancer and oral epithelial dysplasia (OED) were identified by reviewing pathology reports generated by 3 oral pathology laboratories serving primarily community-based oral and maxillofacial surgeons. Subjects were interviewed by telephone to collect information on sociodemographic characteristics, depressive symptoms using the Center for Epidemiologic Studies-Depression (CES-D) Scale, and social support using the Berkman Social Network Inventory.

RESULTS

The analysis included 167 oral cancer and 234 OED cases. Nineteen percent of the subjects had a CES-D score indicative of clinical depression (CES-D > or =16). Forward and backward stepwise logistic regression identified diagnosis (cancer/OED), age, social support, employment status, and gender as sociodemographic indicators of CES-D scores of 16+. In the final model, which also controlled for smoking and drinking, the odds of having elevated CES-D scores (16+) were 79% higher among oral cancer relative to OED cases. The odds of high CES-D scores were significantly reduced in persons over the age of 50 compared with those aged 50 years and younger as well as in persons with higher, relative to low, levels of social support and in persons employed outside the home compared with those who were not. Although not statistically significant, men were more likely to have CES-D scores indicative of clinical depression.

CONCLUSIONS

Knowledge of sociodemographic characteristics may assist the clinician in identifying those individuals with an elevated risk of concomitant depressive symptoms.

Can Collaborative Care Address the Needs of Low-Income Latinas With Comorbid Depression and Cancer? Results From a Randomized Pilot Study

In a pilot study, 55 low-income Latina patients with breast or cervical cancer and comorbid depression were randomly assigned to receive collaborative care as part of the Multifaceted Oncology Depression Program or usual care. Relative to patients in the usual care condition, patients receiving collaborative care were more likely to show>or=50% improvement in depressive symptoms as measured by the Personal Health Questionnaire (OR=4.51, 95% CI=1.07-18.93). Patients in the collaborative care program were also more likely to show improvement in emotional well-being (increase of 2.15) as measured by the Functional Assessment of Cancer Therapy Scale than were those receiving usual care (decrease of 0.50) (group difference=2.65, 95% CI: 0.18-5.12). Despite health system, provider, and patient barriers to care, these initial results suggest that patients in public sector oncology clinics can benefit from onsite depression treatment.

Prospective studies on mental status and quality of life in patients with head and neck cancer treated by radiation

Factors affecting the quality of life (QOL) in patients undergoing radiation therapy for head and neck cancer were determined in a prospective study. Full psychiatric interviews and self-report questionnaires concerning patients' QOL, pain, anxiety, mood, coping style and personality were administered to 35 patients with Stage I or II head and neck cancer before radiation therapy (week 0), and approximately one month (week 4) and two months (week 8) after starting of radiation. Anxiety, depression and pain were more severe at week 4 than at baseline. Anxiety was less at week 8, but depressive symptoms remained remarkable. Stepwise regression analyses revealed that changes in depressed mood and pain partially accounted for changes in disease-specific QOL. General health QOL related to a premorbid personality of openness and an emotional aspect of a coping style. Therapeutic interventions including psychiatric management of depression and physical management of pain appear to be crucial for preserving QOL during radiation treatment of patients with head and neck cancer.

Psychosocial Interventions for Patients With Head and Neck Cancer

A diagnosis of head and neck cancer, like any cancer diagnosis, is often accompanied by much fear and uncertainty. In addition, patients with head and neck cancer face difficulties in eating, chewing, drinking, breathing, speaking, as well as changes in appearance. Simultaneously, the burden of head and neck cancer is often manifested in psychosocial dysfunction, which can have a negative impact on quality of life. Although a phenomenon well recognized, little is known about many factors that influence or impact psychosocial dysfunction in individuals with head and neck cancer. Even less is known about the effective management of psychosocial dysfunction. To date, there is evidence to suggest that psychosocial interventions generally provide an overall positive effect. Moreover, some intervention studies, such as education alone, have failed to achieve the desired results. In addition, some studies suggest an advantage of cognitive- behavioral therapy over other forms of psychological treatment. With the growing impetus to investigate factors associated with psychosocial dysfunction, and considerable advancement in the development and validation of many global and disease-specific measures, there is an opportunity for further research to develop an appropriate clinical intervention program for such patients.

Periodontal Changes in Patients Undergoing Radiotherapy

BACKGROUND

The purpose of this study was to evaluate changes in the periodontium in patients who received head and neck radiation therapy.

METHODS

Periodontal clinical parameters (probing depth, clinical attachment level, gingival recession, plaque index, and bleeding on probing) were assessed on 27 patients before and 6 to 8 months following radiation therapy in the head and neck area.

RESULTS

The greatest changes occurred in clinical attachment level: overall, 70.3% of the patients showed a loss, with 92% evincing loss in the mandible. Attachment loss was directly related to the field of radiation and was greater when the jaws were actually included in the irradiated area.

CONCLUSION

Periodontal status should be evaluated prior to and following radiation therapy in the oral-maxillary-facial region to help ensure that periodontal health is maintained in oncology patients.

Depression in Epilepsy: Ignoring Clinical Expression of Neuronal Network Dysfunction?

Epilepsy is a chronic disorder that adversely affects social, vocational, and psychological functioning. Despite the variety and complexity of the negative clinical associations with epilepsy, depression is remarkable in prevalence and related adverse effects on health status. An estimated 30-50% of persons with refractory epilepsy have major depression, and depression has a stronger correlation than seizure rate with quality of life. Suicide is one of the leading causes of death in epilepsy. Available data indicate that depression may result from underlying brain dysfunction rather than social and vocational disability. Most patients with depression are not screened systematically for the diagnosis, and are subsequently not treated. Although the density of serotonin receptors is greatest in limbic brain regions commonly involved in human epilepsy, such as the mesial temporal and prefrontal areas, no prior randomized controlled trials have evaluated the efficacy of serotonin reuptake inhibitors for depression in epilepsy.

Studies in the quality of life of head and neck cancer patients: results of a two-year longitudinal study and a comparative cross-sectional cross-cultural survey

OBJECTIVES

To examine quality-of-life (QL) changes that occur over time among patients treated for head and neck cancer and to compare QL outcomes in two geographically separate and culturally distinct populations.

STUDY DESIGN

A prospective, observational longitudinal study was made of QL changes over time in head and neck cancer patients, and a matched-pairs cross-sectional study was conducted for comparison of QL outcomes between groups of head and neck cancer patients from two different sociocultural environments.

METHODS

Patients attending a tertiary head and neck cancer center in Auckland, New Zealand, were interviewed using a validated questionnaire before treatment and at 3, 12, and 24 months after treatment. Changes over time were assessed according to gender, site and stage of primary tumor, and type of treatment received. A second group of patients from Toronto, Ontario, Canada, were matched to the first group for age, gender, site and stage of tumor, and time since treatment and interviewed using the same questionnaire. The group comparison was followed by a matched-pairs analysis for the 12-month follow-up interval.

RESULTS

In the longitudinal study, combined modality treatment resulted in greater physical and somatic dysfunction than single modality treatment. Patients learned to cope well with dysfunction and disability and with adjusting their lifestyle so that overall QL was not related to treatment received. Even so, pain scores and measures of psychological distress were related to overall QL. Otherwise there was no consistent correlation between specific symptoms and QL. An illustration of patients' adaptation to dysfunction was evident in scores for perceived difficulty swallowing, which decrease despite the ongoing need for a soft or liquid diet. In the comparative study, significantly different global QL scores were evident in the two clinical groups studied, despite similar social, somatic, and physical functioning. There was also a significant but inconstant difference in emotional functioning. Although the clinical groups received significantly different treatment regimens, the observed differences in global QL were independent of treatment received.

CONCLUSIONS

Patients with head and neck cancer generally managed well despite disability and dysfunction after treatment. Patients' expectations, emotional responses, and desired outcomes seemed to be determined by sociocultural factors, causing different patient groups to view their overall QL outcome somewhat differently.

Biobehavioral outcomes following psychological interventions for cancer patients

Psychological interventions for adult cancer patients have primarily focused on reducing stress and enhancing quality of life. However, there has been expanded focus on biobehavioral outcomes--health behaviors, compliance, biologic responses, and disease outcomes--consistent with the Biobehavioral Model of cancer stress and disease course. The author reviewed this expanded focus in quasiexperimental and experimental studies of psychological interventions, provided methodologic detail, summarized findings, and highlighted novel contributions. A final section discussed methodologic issues, research directions, and challenges for the coming decade.

Biobehavioral outcomes following psychological interventions for cancer patients

Psychological interventions for adult cancer patients have primarily focused on reducing stress and enhancing quality of life. However, there has been expanded focus on biobehavioral outcomes--health behaviors, compliance, biologic responses, and disease outcomes--consistent with the Biobehavioral Model of cancer stress and disease course. The author reviewed this expanded focus in quasiexperimental and experimental studies of psychological interventions, provided methodologic detail, summarized findings, and highlighted novel contributions. A final section discussed methodologic issues, research directions, and challenges for the coming decade.

Prediction of depression 6 months to 3 years after treatment of head and neck cancer

BACKGROUND

Head and neck cancer and its treatment can have important psychosocial implications. Many patients become depressed. The aim of this prospective study is to examine whether pretreatment variables can be used to predict depression up to 3 years after treatment.

METHODS

Head and neck cancer patients (n = 197) treated with surgery and/or radiotherapy completed both before and after treatment a questionnaire including items on social support, coping, depressive symptoms, physical functioning, and physical symptoms.

RESULTS

Eight pretreatment variables (tumor stage, sex, depressive symptoms, openness to discuss cancer in the family, available appraisal support, received emotional support, tumor-related symptoms, and size of the informal social network) were used to calculate a risk score to determine which patients were depressed at 6 months to 3 years after treatment (positive predicted value, 58%; negative predicted value, 83%).

CONCLUSIONS

Eight pretreatment variables can be used to predict accurately those head and neck cancer patients who are likely to become depressed up to 3 years after treatment.

Anxiety, coping strategies, and coping behaviors in patients undergoing head and neck cancer surgery

BACKGROUND

Little is reported in the scientific literature about the modulating effect of anxiety on the coping process before and after surgical treatment for head and neck cancer.

OBJECTIVES

The major purpose of this article is to describe the relationships among preoperative anxiety and use of coping strategies, and postoperative self-care and resocialization behaviors in patients who sustain facial disfigurement/dysfunction with head and neck cancer surgery.

METHODS

Using a prospective descriptive design, 75 (N = 75) adults who were about to sustain facial disfigurement and dysfunction associated with head and neck cancer surgery were entered into the study. The State Trait Anxiety Inventory and the Ways of Coping Questionnaire were administered to the respondents. The Disfigurement/Dysfunction Scale and Coping Behaviors Score values were calculated by the investigator.

RESULTS

Self-care and anxiety were significantly correlated on postoperative day 4 (r = 2.30; p < .05) and on postoperative day 5 (r = 2.35; p < .05). For the 3 days under study, the relationship between total self-care and anxiety became stronger on postoperative day 5 (r = 2.39; p < .01), indicating that self-care on postoperative day 4 is related to reduced anxiety on postoperative day 5. In other words, self-care appears to precede reduction in anxiety in this sample. Secondly, there was a negative relationship between self-care and anxiety that increased over the early postoperative period.

CONCLUSIONS

This study prospectively documents anxiety in surgical head and neck cancer patients. The findings suggest that at a specific point in time (postoperative day 5), self-care precedes reduction in anxiety, and that this negative relationship increases over time. Additional investigation is now critical in order to describe long-term recovery after surgical treatment for head and neck cancer and to develop appropriate interventions to meet the unique needs of this population.

A Prospective Study of Quality of Life in Head and Neck Cancer Patients. Part I: At Diagnosis

PURPOSE

A Swedish and Norwegian study was designed to examine health-related quality of life (HQL) in patients with head and neck cancer (head and neck) at diagnosis and during treatment and rehabilitation. The overall aim was to examine the impact on HQL at diagnosis depending on tumor location, stage, sex, and age (part I) and to describe HQL longitudinally and determine for which patients and during which period HQL deteriorated most (part II). This article presents the results at diagnosis.

METHOD

Patients with head and neck cancer at five hospitals in Sweden and Norway were consecutively requested to participate. They were asked to answer the EORTC QLQ-C30 and QLQ-H&N35 (the European Organization for Research and Treatment of Cancer, Core 30 questionnaire and head and neck cancer module) repeatedly during 1 year. A total of 357 patients (mean age, 63 y; 72% males) were included.

RESULTS

Patients with different tumor locations all had their special problems at diagnosis, for example, those with tumors in the larynx with communication, those with oral tumors with pain, and those with pharyngeal tumors with nutrition and pain. The patients with hypopharyngeal cancer reported the worst HQL. Stage appeared to have the strongest impact on HQL. Patients with a more advanced tumor stage reported significantly worse HQL scores for 24 of 32 variables reflecting functioning or problems. The females scored worse than the males for some areas, in particular, emotional functioning. The older patients scored significantly better for emotional and social functioning than patients <65 years but worse for physical functioning and various symptoms. The traditional way of grouping the tumor locations into oral, pharyngeal, laryngeal, and "other" tumors (salivary gland, sinus and nose, and unknown primary) was tested from a HQL point of view and found to be consistent.

CONCLUSIONS

The chosen questionnaires differentiated between different sites of head and neck cancer at diagnosis. Tumor stage had the most powerful impact on HQL score.

Health-related quality of life three years after diagnosis of head and neck cancer--a longitudinal study

PURPOSE

To examine health-related quality of life (HRQL) of all head and neck cancer patients from diagnosis until 3 years later and to analyze its dependence on tumor site and other patient characteristics.

SUBJECTS AND METHODS

Two hundred thirty-two patients (mean age 61 years; 70% men) were included and followed with clinical measures and mailed standardized HRQL questionnaires (The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 (EORTC QLQ-C30), the EORTC QLQ-Head and Neck Cancer module (QLQ-H&N35), and the Hospital Anxiety and Depression Scale (HADS).

RESULTS

After 3 years 66% of the patients were alive and 88% of these completed the study. The HRQL was worse during treatment and returned slowly thereafter to pretreatment values with few exceptions. After 3 years the best improvement was found for mental distress, followed by a significant global quality of life improvement and reduced pain compared with diagnosis. A significant deterioration was found for problems with dry mouth, senses, and teeth, as well as for opening the mouth wide (ie, they seemed to be related to the treatment given). There were few significant improvements between the 1- and 3-year follow-ups. Depression and physical functioning at diagnosis were independent predictors for global quality of life at 3 years. Patients who died during the study had a worse HRQL at diagnosis compared with patients completing the study. Patients with advanced disease (stage III + IV) scored worse than patients with small tumors for most of the HRQL domains. These differences increased over time. Few differences were found relating to gender and age. The pharyngeal cancer group scored worse compared with the other tumor sites, and these patients would probably benefit from a rehabilitation program right from diagnosis, including treatment for malnutrition and pain.

CONCLUSIONS

The largest HRQL changes for head and neck cancer patients are seen within the first year after diagnosis, with a significant deterioration just after finishing treatment. Thereafter, most of the variables return to pretreatment values. The significant problems with dry mouth, senses, and teeth after treatment are constant over time.

Psychological distress in patients with head and neck cancer: review

Cancer of the head and neck is common. Both the disease and its treatment are associated with considerable psychological distress. Here, I review factors that affect psychological adjustment, describe screening instruments that are used to measure anxiety and depression in cancer, and make recommendations for the early detection, management, and reduction of the distress associated with cancer of the head and neck.

Coping with head and neck cancer during different phases of treatment

BACKGROUND

Little is known about how patients cope with head and neck cancer despite its devastating impact on basic functioning. This study examined coping patterns among patients at different phases of illness.

METHODS

Participants were 120 patients with advanced disease, who were grouped according to the following phases of illness: (1) pretreatment, (2) on treatment, (3) <6 months after treatment, and (4) >6 months after treatment. Coping was assessed with the COPE questionnaire, and outcome measures assessed general distress (Profile of Mood States) and illness-specific distress (Impact of Events Scale).

RESULTS

Use of specific coping responses differed among the groups. Denial (p <.05), behavioral disengagement (ie, giving up or withdrawing, p <.05), suppression of competing activities (ie, focusing exclusively on the illness, p <.01), and emotional ventilation (p <.10) were most characteristic of patients who were receiving or had recently completed treatment. There were no differences in flexibility of coping or overall effort expended, but patients who were on treatment or who had recently completed treatment used the greatest number of strategies. Generally, denial, behavioral disengagement, and emotional ventilation were associated with greater distress.

CONCLUSIONS

Results suggest that phase of illness may be important in shaping patients' responses to life-threatening illness.

Prediction of depressive symptomatology after treatment of head and neck cancer: the influence of pre-treatment physical and depressive symptoms, coping, and social support

BACKGROUND

Head and neck cancer and its treatment can have important psychosocial implications, and many patients become depressed. The aim of this prospective study is to examine whether pretreatment variables can be used to predict depression 6 and 12 months later.

METHODS

Head and neck cancer patients (155) treated with surgery and/or radiotherapy completed a questionnaire including items on social support, coping, depressive symptoms, physical functioning, and physical symptoms before and after treatment.

RESULTS

By using 5 variables (physical symptoms, depressive symptoms, emotional support, extent of the social network, and avoidance coping), it was possible to predict those patients who would have symptoms at 6 (81%) and 12 months (67%) after treatment. Inclusion of actual physical symptoms reported at follow-up increased these percentages to 89% and 82%.

CONCLUSIONS

It is concluded that screening for psychosocial variables and physical symptoms before treatment can be used to determine which patients are at risk of developing depressive symptoms after treatment.

Pretreatment factors predicting quality of life after treatment for head and neck cancer

BACKGROUND

Quality of life (QOL) has become an important issue in head and neck cancer. Explanation of factors predicting QOL after treatment has important implications for patient management.

METHODS

In this prospective study we analyzed which pretreatment factors predicted QOL after surgery and/or radiotherapy with curative intent in a cohort of 153 patients with cancer of the oral cavity, oropharynx, hypopharynx, or larynx. The patients completed the EORTC Core Questionnaire, the EORTC Head and Neck Cancer module, and the Center for Epidemiologic Studies Depression scale before treatment and 6 and 12 months later. The influence of gender, age, performance status, and depressive symptoms at baseline, site, stage, and treatment on QOL (and its dimensions) and depressive symptoms after 6 and 12 months was studied, using linear regression analysis.

RESULTS

A high level of depressive symptoms and a low performance status at baseline and combination treatment were significant predictors of increased severity of symptoms and poor functioning after treatment. Treatment was a predictor of head and neck symptoms, whereas performance status and depressive symptoms were predictors of general symptoms and functioning. Gender and age had little predictive value.

CONCLUSIONS

Patients with depressive symptoms or a low performance status who receive combination treatment for cancer of the head and neck are at risk for physical and psychologic morbidity after treatment. Special attention should be given to these patients in rehabilitation programs.

Prevalence, predictive factors, and screening for psychologic distress in patients with newly diagnosed head and neck cancer

BACKGROUND

High levels of distress are a concern regarding patients with head and neck cancer. Early detection of and intervention for such distress are needed to predict patients' adaptation to treatment or rehabilitation, but few studies have investigated the detection of their distress in a patient population of significant size.

METHODS

The authors examined 107 consecutive patients with head and neck cancer to assess their psychologic distress (adjustment disorders or major depression) or other psychiatric problems by structured psychiatric interview before the initial cancer treatment. They also evaluated predictive factors for psychologic distress and assessed the ability of a self-rating questionnaire (Hospital Anxiety and Depression Scale, HADS) to screen for distress.

RESULTS

Of 107 subjects, 18 (16.8%) had an adjustment disorder or major depression. Thirty-six (33.6%), 7 (6. 5%), and 35 (32.7%) met criteria for alcohol dependence, alcohol abuse, and nicotine dependence, respectively. Logistic regression analysis revealed that having advanced stage cancer (odds ratio, 5. 77; 95% confidence interval [CI], 1.41-39.7; P = 0.03) and living alone (odds ratio, 4.83; 95% CI, 1.04-22.2; P = 0.04) were significantly associated with having psychologic distress. The optimal cutoff point for the HADS screening for psychologic distress was 15. This cutoff point gave 72.2% sensitivity and 81.4% specificity.

CONCLUSIONS

Head and neck cancer patients who have advanced disease or live alone should be assessed so that psychologic distress can be detected and intervention made. HADS is a useful clinical instrument to screen for their distress.

Body image and quality of life after head and neck cancer surgery

OBJECTIVES

The purpose of this paper is to describe the process of body image reintegration as it relates to quality of life in the surgical head and neck cancer patient.

MATERIALS AND METHODS

To illustrate the course of body image reintegration after head and neck cancer surgery, the results of two major studies are presented. In the first study, a cohort sample of 75 adults about to undergo disfigurative surgery for head and neck cancer was examined to determine levels of anxiety before and after the procedure. The State Trait Anxiety Inventory was administered before and after surgery on postoperative days 4 through 6. In the large study, from which the cohort sample was derived, 117 adults about to undergo disfigurative surgery were investigated to determine the relationship between coping with surgical disfigurement/dysfunction and length of hospital stay. The Ways of Coping Checklist was administered before surgery. Disfigurement/dysfunction, as measured by the Disfigurement/Dysfunction Scale, and postoperative coping behaviors, as measured by the Coping Behaviors Score, were accounted for in both samples. Self-care and resocialization behaviors were observed and measured on postoperative days 4 through 6.

RESULTS

In the cohort study, anticipation of disfigurative facial surgery was associated with extremely high levels of anxiety. In the large sample, coping effectiveness was diminished. The degree of surgical deficit ranged from mild to severe disfigurement and dysfunction. Preoperative coping effectiveness predicted postoperative coping behavior. It was concluded that body image reintegration was characterized by self-care, resocialization, and reduced anxiety. Further, that these components, when taken together, constitute assimilation of the surgical defect into self.

CONCLUSIONS

Body image reintegration is critical to subsequent quality of life after head and neck cancer surgery. When disfigurement/dysfunction is associated with treatment, quality of life may be profoundly and adversely affected. Findings from the studies presented indicate a significant correlation between postoperative self-care and reduction in level of anxiety. The implications of this findings are important to care during the early period after surgery and to long-term follow-up after hospital discharge.