Palliative care in metastatic head and neck cancer

The Utilization of Specialist Palliative Care and Other Health Care Services at the End of Life Among Patients with Head and Neck Cancer: A Nationwide Cohort Study

INTRODUCTION

The end of life of patients with head and neck cancer (HNC) is plagued by significant morbidity and high symptom burden, emphasizing the need for palliative care. Our aim was to evaluate the utilization of health care services, including specialist palliative care (SPC), among patients with HNC at the end of life. In addition, we wanted to explore the timing of SPC contact on the utilization of health care services at the end of life.

METHODS

The study population consisted of all 281 patients who died of HNC in 2019 in Finland. Data were collected from nationwide registries. Patients were divided into two groups according to the timing of their first contact with an SPC unit: early (> 30 days before death), and late/no (≤ 30 days before death or no contact).

RESULTS

Mean age at death was 72 years, and 66% were male. The hospital was the most common place of death (82%). Ninety-three (33%) patients had contact with an SPC unit, and the median time of the first SPC contact was 62 days before death. Comparing those with early and late/no SPC contact, the early group was significantly associated with lower secondary health care hospitalization (31% vs. 53%; p = 0.002) and emergency care utilization (33% vs. 52%; p = 0.006) during the last month of life. The early SPC group was also associated with higher utilization of home care (52% vs. 36%; p = 0.021), SPC outpatient clinic (24% vs. 5%; p < 0.001), SPC ward (22% vs. 4%; p < 0.001), and palliative hospital-at-home services (45% vs. 5%; p < 0.001) during the last month of life. Among patients with the early SPC contact, SPC ward was significantly more likely to be the place of death (18% vs. 4%, p < 0.001) compared with patients with late/no SPC contact.

CONCLUSION

Patients with HNC utilize health care services at high rates at the end of life. Early SPC contact is associated with increased SPC service use and decreased utilization of secondary health care and emergency care, highlighting the need for early and greater access to SPC services for patients with HNC.

Palliative care utilization among head and neck cancer patients: A population-based analysis

PURPOSE

Head and neck cancer (HNC) patients face substantial morbidity and mortality. Despite the potential benefits of palliative care (PC) in improving quality of life, many HNC patients do not receive these services. This study aimed to quantify the proportion of HNC patients receiving PC, the timing of PC referrals, and the mental health and clinical outcomes of this population.

METHODS

A retrospective cohort study was conducted using the TriNetX database with de-identified electronic medical records. HNC patients were categorized based on whether they had at least one PC encounter. We examined time to first PC encounter, mortality rates, mental health diagnoses, and access to ACP and supportive care.

RESULTS

Of 304,404 HNC patients, only 22,470 (7.4 %) had at least one PC encounter. The median time from cancer diagnosis to initial PC referral was 318 days. After propensity score matching, the cohorts consisted of 24,916 patients each. Those who received PC had a significantly higher risk of mortality (RR 3.05, 95 % CI 2.97-3.14), depression (RR 1.38, 95 % CI 1.33-1.45), anxiety (RR 1.47, 95 % CI 1.42-1.53), failure to thrive (RR 3.26, 95 % CI 3.03-3.51), and were more likely to engage in advance care planning (RR 4.97, 95 % CI 4.39-5.62) and access supportive care services compared to patients who did not receive PC.

CONCLUSIONS

PC utilization among HNC patients is low, with patients often waiting nearly a year before their first PC encounter. This delay highlights a significant unmet need for early integrated PC in this population.

Provider Perspectives and Access to Palliative Care: An American Head and Neck Society (AHNS) Survey

BACKGROUND

To explore provider perspectives about palliative care (PC) in head and neck cancer (HNC) care.

METHODS

A 25-question electronic survey was disseminated to the membership of the American Head and Neck Society (AHNS) from April 10, 2023, through June 13, 2023.

RESULTS

Respondents were most likely to refer to PC at symptomatic disease progression (52%) or terminal diagnosis (29%) rather than at initial diagnosis (17%). Participants less likely to refer to PC were less likely to refer to symptomatic progression (8% vs. 39%, p = 0.0006) or address advance directives (62% vs. 87%, p = 0.0406). Symptom burden questionnaires were used by only 29% of respondents. Discordance was identified between self-reported and actual access to local inpatient and outpatient PC services.

CONCLUSIONS

Barriers to PC identified include a lack of established optimal timing of PC referral, a perceived lack of local access to PC, and a lack of uniform standardized assessment of symptom burden.

Palliative care outcome measures used in head and neck cancer: A scoping review

BACKGROUND

The palliative care (PC) needs of patients with head and neck cancer (HNC) are complex, due to high and unique symptom burdens. Uniform outcome measures are critical to assessing the impact of PC interventions in HNC.

METHODS

A scoping review of outcome measures used in patients with HNC receiving PC was performed using PubMed, Embase, and Web of Science from 1980 to 2022.

RESULTS

Of 20 eligible studies, 19 unique instruments were identified which assessed 22 physical, 5 mental, 4 social, 7 related quality of life, and 9 advanced care planning outcomes. Instruments were underutilized, with a larger number of outcomes measurable for instruments used than were reported. The average instrument assessed three domains whereas the average study only reported outcomes from two domains.

CONCLUSIONS

Comparison across studies is limited due to heterogeneity in outcome measures. Future work is needed to develop core PC outcome measures for use in HNC care.

Predisposing, Enabling, and Need Factors Driving Palliative Care Use in Head and Neck Cancer

OBJECTIVE

Characterizing factors associated with palliative care (PC) use in patients with stage III and VI head and neck cancer using Anderson's behavioral model of health service use.

STUDY DESIGN

A retrospective study of the 2004 to 2020 National Cancer Database.gg METHODS: We used multivariate logistic regression to assess the association of predisposing, enabling, and need factors with PC use. We also investigated the association of these factors with interventional PC type (chemotherapy, radiotherapy, surgery) and refusal of curative treatment in the last 6 months of life.

RESULTS

Five percent of patients received PC. "Predisposing factors" associated with less PC use include Hispanic ethnicity (adjusted odds ratio [aOR], 086; 95% confidence interval [CI], 0.76-0.97) and white and black race (vs white: aOR, 1.14; 95% CI, 1.07-1.22). "Enabling factors" associated with lower PC include private insurance (vs uninsured: aOR, 064; 95% CI, 0.53-0.77) and high-income (aOR, 078; 95% CI, 0.71-0.85). "Need factors" associated with higher PC use include stage IV (vs stage III cancer: aOR, 2.25; 95% CI, 2.11-2.40) and higher comorbidity index (vs Index 1: aOR, 1.58; 95% CI, 1.42-1.75). High-income (aOR, 0.78; 95% CI, 0.71-0.85) and private insurance (aOR, 0.6; 95% CI, 0.53, 0.77) were associated with higher interventional PC use and lower curative treatment refusal (insurance: aOR, 0.82; 95% CI, 0.55, 0.67; income aOR, 0.48; 95% CI, 0.44, 0.52).

CONCLUSION

Low PC uptake is attributed to patients' race/culture, financial capabilities, and disease severity. Culturally informed counseling, clear guidelines on PC indication, and increasing financial accessibility of PC may increase timely and appropriate use of this service.

Surgical Resection Improves Overall Survival in cT4b Major Salivary Gland Cancer

OBJECTIVE

To compare surgical and nonsurgical definitive treatment in cT4b major salivary gland cancer (MSGC).

STUDY DESIGN

Retrospective cohort study.

SETTING

The 2004 to 2019 National Cancer Database.

METHODS

The NCDB was queried for patients with cT4b MSGC (N = 976). Patients undergoing definitive treatment with (1) surgical resection + adjuvant therapy, (2) radiotherapy (RT) alone, or (3) chemoradiotherapy (CRT) were included in Kaplan-Meier and Cox survival analyses.

RESULTS

Of 219 patients undergoing definitive treatment, 148 (67.6%) underwent surgical resection + adjuvant therapy and 71 (32.4%) underwent RT or CRT. There were no documented mortalities within 90 days of surgical resection. Tumor diameter and nodal metastasis were associated with decreased odds of undergoing definitive treatment (P < 0.025). Patients with positive surgical margins (PSM) had higher 5-year overall survival (OS) than those undergoing definitive RT or CRT (48.5% vs 30.1%, P = 0.018) and similar 5-year OS as those with negative margins (48.5% vs 54.0%, P = 0.205). Surgical resection + adjuvant therapy (adjusted hazard ratio: 0.55, 95% confidence interval [CI]: 0.37-0.84) was associated with higher OS than definitive RT or CRT (P < 0.025). A separate cohort of 961 patients with cT4a tumors undergoing surgical resection + adjuvant therapy was created; cT4a and cT4b (hazard ratio: 1.02, 95% CI: 0.80-1.29, P = 0.896) tumors had similar OS.

CONCLUSION

A minority of patients with cT4b MSGC undergo definitive treatment. Surgical resection + adjuvant therapy was safe and associated with higher OS than definitive RT or CRT, despite high rate of PSM. In the absence of clinical trial data, appropriately selected patients with cT4b MSGC may benefit from surgical resection.

Comparative effectiveness of verbal instruction versus video-based education (VIVid) among family caregivers for improving the quality of life in advanced head and neck cancer patients receiving palliative care in Eastern India: a randomized controlled trial

PURPOSE

To determine if video-based educational intervention compared to the standard verbal guidelines, provided to caregivers on home-based palliative care could enhance the quality of life (QoL) in advanced head and neck cancer (HNC) patients.

METHODS

The study employed a prospective, two-arm parallel-group, randomized controlled trial design. Investigators prepared a real-world demonstrational video of ten minutes duration regarding home-based care for family caregivers, with voice-over in Odia language (Eastern India). The contents of the video addressed the management of common problems in palliative care among HNC patients. This study included 180 participants, 90 patient & caregiver dyads randomized to interventional (video-based education) or control (verbal instruction) groups. Patients' QoL was measured at baseline and 3 weeks follow-up using EORTC QLQ C30. Data were analyzed descriptively, and the Chi-square, Mann-Whitney U, T-test, spearman correlation, and multiple hierarchical regression analyses were employed for statistical analysis, with a significance level of p < 0.05.

RESULTS

Seventy participant dyads completed the planned two assessments: baseline and at the end of 3rd week (Intervention = 37; Control = 33). The intervention group showed a significant improvement in the patient's health-related QoL, physical, emotional, and social functioning. Symptom burden reduction was observed for pain, nausea, and fatigue. A significant increase in the change in QoL with the video-based education group (VBE) compared to the verbal instruction (VI) group after adjusting for age, gender, physical functioning, and pain symptomology (adjusted R2 = 0.402) was noted.

CONCLUSION

VBE intervention using smart-phone may offer caregivers a viable means of enhancing self-management while improving patients' QoL within the socio-cultural challenges for home-based palliative care in India. Further research on training caregivers using digital interventions and home-based visits is recommended.

TRIAL REGISTRATION NUMBER

CTRI/2021/06/034473 [Registered on: 30/06/2021].

Concordant palliative care delivery in advanced head and neck cancer

OBJECTIVES

To describe the palliative care consultation practices in an academic head and neck surgery practice.

METHODS

This is a retrospective review of a palliative care database and the health record for all palliative care consultations of patients suffering from advanced stage head and neck cancer within a 21-month period.

RESULTS

Ten head and neck cancer patients received palliative care consults while on the otolaryngology service. One consultation occurred preoperatively; nine occurred postoperatively, on a median of hospital day 9. At the time of referral, seven patients were in the ICU and three were on a surgical floor. Code status de-escalation occurred in six patients and psycho-socio-spiritual suffering was supported in all consultations. Nine patients died within six months, with a median post-consultation survival of 35 days. Of these, two died in an ICU, five were discharged to hospice, one to a SNF, and one to a LTACH.

CONCLUSION

Palliative care consultation in this advanced head and neck cancer cohort was commonly late, however, significant suffering was mitigated following most consults. Palliative care specialists are experts at eliciting patient values, determining acceptable tradeoffs and suffering limitations by employing a shared decision-making process that ends with a patient-centered value-congruent treatment recommendation. Oftentimes, this embraces curative-intent or palliative surgery, along with contingency plans for unacceptable value-incongruent postoperative outcomes. Enhanced awareness of the benefits of embracing concordant palliative care in advanced head and neck cancer patients may help overcome the significant barriers to involving palliative care experts earlier.