Longitudinal Assessment of Frailty and Quality of Life in Patients Undergoing Head and Neck Surgery

Impact of pretreatment quality of life on tolerance and survival outcome in head and neck cancer patients undergoing definitive CCRT

BACKGROUND

Health-related quality of life (HRQoL) is a predictor of treatment outcomes in cancer patients. This study aimed to evaluate the effect of pretreatment HRQoL on treatment tolerance and survival outcomes in patients with HNC planned for concurrent chemoradiotherapy (CCRT) in Taiwan.

METHODS

This study included 461 patients with HNC planned for definitive CCRT at three medical centers in Taiwan between August 2017 and December 2018. HRQoL was assessed using the QLQ-HN35 one week before the initiation of CCRT. Patients were grouped based on the sum scores of QLQ-HN35 (

RESULTS

The median QLQ-HN35 sum score among 461 patients was 39 (range, 30 to 96), varying with tumor site: 34 for nasopharynx, 44 for oropharynx, 45 for oral cavity, and 38 for hypopharynx. Patients with sum scores ≥ median were associated with higher risk for incomplete CCRT (13.4 % vs 6.5 %, odds ratio [OR] = 2.22, 95 % confidence interval [CI] = 1.17-4.24, p = 0.015), emergency room visits (36.4 % vs 27.0 %, OR = 1.55, 95 % CI = 1.04-2.30, p = 0.030), unexpected hospitalization (33.8 % vs 19.6 %, OR = 2.10, 95 % CI = 1.37-3.21, p = 0.001), ≥ grade 3 hematological toxicities (34.2 % vs 21.3 %, OR = 1.92, 95 % CI = 1.27-2.91, p = 0.002), ≥ grade 3 non-hematological toxicities (78.8 % vs 68.7 %, OR = 1.69, 95 % CI = 1.11-2.58, p = 0.014), and low survival outcomes (hazard radio = 2.76, 95 % CI = 1.67-4.54, p < 0.001). Patients with lower sum scores in nasopharyngeal/oropharyngeal tumors exhibited better OS than those with higher scores, while no significant difference in OS based on HRQoL was observed in oral cavity/hypopharyngeal cancer patients. Higher sum scores remained a negative indicator even after adjusting for other confounding factors.

CONCLUSION

In patients with HNC planned for definitive CCRT, pre-treatment HRQoL was significantly associated with treatment-related complications, tolerance, and survival outcomes. Furthermore, our results validated the clinical value of QLQ-HN35 as an indicator for predicting treatment tolerance and outcomes.

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Key Words

• Concurrent chemoradiotherapy
• Head and neck cancer
• Prognosis
• Quality of life

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Affiliation(s)

Chia-Yen Hung Department of Hematology and Oncology, Chang Gung University, Taoyuan, Taiwan; Division of Hema-oncology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
Mei-Hui Hsu Department of Nursing, Chang Gung University, Taoyuan, Taiwan
Shu-Hui Lee Department of Nursing, Chang Gung University, Taoyuan, Taiwan
Shun-Wen Hsueh Department of Hematology and Oncology, Chang Gung Memorial Hospital at Chiayi, Chiayi, Taiwan
Chang-Hsien Lu Department of Hematology and Oncology, Chang Gung Memorial Hospital at Chiayi, Chiayi, Taiwan
Kun-Yun Yeh Department of Hematology and Oncology, Chang Gung Memorial Hospital at Keelung, Keelung, Taiwan
Hung-Ming Wang Department of Hematology and Oncology, Chang Gung University, Taoyuan, Taiwan
Joseph Tung-Chieh Chang Department of Radiation Oncology Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
Yu-Shin Hung Department of Hematology and Oncology, Chang Gung University, Taoyuan, Taiwan
Wen-Chi Chou Department of Hematology and Oncology, Chang Gung University, Taoyuan, Taiwan.

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Frailty is an independent factor for health-related quality of life in patients with head and neck cancer receiving definitive concurrent chemoradiotherapy

PURPOSE

Health-related quality of life (HRQoL) is associated with treatment-related complications and poor survival in patients with head and neck cancer (HNC). We investigated the effects of frailty on HRQoL in patients with HNC receiving definitive concurrent chemoradiotherapy (CCRT).

METHODS

A total of 461 consecutive patients with locally advanced HNC who received CCRT between 2017 and 2018 at three medical centers in Taiwan were included. Frailty and HRQoL were assessed using the Comprehensive Geriatric Assessment and QLQ-H&N35 before CCRT. The sum score was calculated based on the first 30 questions of QLQ-H&N35. Multivariate analysis was performed to evaluate the impact of frailty on HRQoL.

RESULTS

The overall sum score was 39 (34-49). The sum scores of patients with impairments in 0, 1, 2, 3, and ≥ 4 frailty domains were 34 (32-38), 40 (34-47), 46 (36-55), 48 (41-64), and 56 (50-60), respectively. Patients with impairments in more frailty domains had a higher symptom burden (p for trend < 0.001). Frail patients tended to experience symptoms across all QLQ-H&N35 subscales. Sex, body mass index, tumor type, tumor stage, Eastern Cooperative Oncology Group performance status, and frailty were determinants of HRQoL in the univariate analysis. Frailty was an independent determinant of HRQoL in the multivariate analysis.

CONCLUSION

Routine frailty assessment may serve as a surrogate for the selection of patients with HNC with poor HRQoL before CCRT. Further studies are needed to determine whether appropriate interventions in frail patients would improve their HRQoL during CCRT.

Frail but Resilient: Frailty in Autologous Breast Reconstruction is Associated with Worse Surgical Outcomes but Equivalent Long-Term Patient-Reported Outcomes

BACKGROUND

Frailty is associated with higher risk of complications following breast reconstruction, but its impact on long-term surgical and patient-reported outcomes has not been investigated. We examined the association of the five-item modified frailty index (MFI) score with long-term surgical and patient-reported outcomes in autologous breast reconstruction.

PATIENTS AND METHODS

We conducted a retrospective cohort study of consecutive patients who underwent mastectomy and autologous breast reconstruction between January 2016 and April 2022. Primary outcome was any flap-related complication. Secondary outcomes were patient-reported outcomes and predictors of complications in the frail cohort.

RESULTS

We identified 1640 reconstructions (mean follow-up 24.2 ± 19.2 months). In patients with MFI ≥ 2, the odds of surgical [odds ratio (OR) 2.13, p = 0.023] and medical (OR 17.02, p < 0.001) complications were higher than in nonfrail patients. We found no significant difference in satisfaction with the breast (p = 0.287), psychosocial well-being (p = 0.119), or sexual well-being (p = 0.314) according to MFI score. Chronic obstructive pulmonary disease was an independent predictor of infection (OR 3.70, p = 0.002). Tobacco use (OR 7.13, p = 0.002) and contralateral prophylactic mastectomy (OR 2.36, p = 0.014) were independent predictors of wound dehiscence. Dependent functional status (OR 2.36, p = 0.007) and immediate reconstruction (compared with delayed reconstruction; OR 3.16, p = 0.026) were independent predictors of skin flap necrosis. Dependent functional status was also independently associated with higher odds of reoperation (OR 2.64, p = 0.011).

CONCLUSION

Frailty is associated with higher risk of complications in breast reconstruction, but there is no significant difference in long-term patient-reported outcomes. MFI should be considered in breast reconstruction to improve outcomes in high-risk frail patients.

Salivary gland cancers in elderly patients: challenges and therapeutic strategies

Salivary gland carcinomas (SGCs) are the most heterogeneous subgroup of head and neck malignant tumors, accounting for more than 20 subtypes. The median age of SGC diagnosis is expected to rise in the following decades, leading to crucial clinical challenges in geriatric oncology. Elderly patients, in comparison with patients aged below 65 years, are generally considered less amenable to receiving state-of-the-art curative treatments for localized disease, such as surgery and radiation/particle therapy. In the advanced setting, chemotherapy regimens are often dampened by the consideration of cardiovascular and renal comorbidities. Nevertheless, the elderly population encompasses a broad spectrum of functionalities. In the last decades, some screening tools (e.g. the G8 questionnaire) have been developed to identify those subjects who should receive a multidimensional geriatric assessment, to answer the question about the feasibility of complex treatments. In the present article, we discuss the most frequent SGC histologies diagnosed in the elderly population and the relative 5-years survival outcomes based on the most recent data from the Surveillance, Epidemiology, and End Results (SEER) Program. Moreover, we review the therapeutic strategies currently available for locoregionally advanced and metastatic disease, taking into account the recent advances in precision oncology. The synergy between the Multidisciplinary Tumor Board and the Geriatrician aims to shape the most appropriate treatment pathway for each elderly patient, focusing on global functionality instead of the sole chronological age.

Association of Deficits Identified by Geriatric Assessment With Deterioration of Health-Related Quality of Life in Patients Treated for Head and Neck Cancer

Importance

Accumulation of geriatric deficits, leading to an increased frailty state, makes patients susceptible for decline in health-related quality of life (HRQOL) after treatment for head and neck cancer (HNC).

Objective

To assess the association of single and accumulated geriatric deficits with HRQOL decline in patients after treatment for HNC.

Design, Setting, and Participants

Between October 2014 and May 2016, patients at a tertiary referral center were included in the Oncological Life Study (OncoLifeS), a prospective data biobank, and followed up for 2 years. A consecutive series of 369 patients with HNC underwent geriatric assessment at baseline; a cohort of 283 patients remained eligible for analysis, and after 2 years, 189 patients remained in the study. Analysis was performed between March and November 2020.

Interventions or Exposures

Geriatric assessment included scoring of the Adult Comorbidity Evaluation 27, polypharmacy, Malnutrition Universal Screening Tool, Activities of Daily Living, Instrumental Activities of Daily Living (IADL), Timed Up & Go, Mini-Mental State Examination, 15-item Geriatric Depression Scale, marital status, and living situation.

Main Outcomes and Measures

The primary outcome measure was the Global Health Status/Quality of Life (GHS/QOL) scale of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30. Differences between patients were evaluated using linear mixed models at 3 months after treatment (main effects, β [95% CI]) and declining course per year during follow-up (interaction × time, β [95% CI]), adjusted for baseline GHS/QOL scores, and age, sex, stage, and treatment modality.

Results

Among the 283 patients eligible for analysis, the mean (SD) age was 68.3 (10.9) years, and 193 (68.2%) were male. Severe comorbidity (β = -7.00 [-12.43 to 1.56]), risk of malnutrition (β = -6.18 [-11.55 to -0.81]), and IADL restrictions (β = -10.48 [-16.39 to -4.57]) were associated with increased GHS/QOL decline at 3 months after treatment. Severe comorbidity (β = -4.90 [-9.70 to -0.10]), IADL restrictions (β = -5.36 [-10.50 to -0.22]), restricted mobility (β = -6.78 [-12.81 to -0.75]), signs of depression (β = -7.08 [-13.10 to -1.06]), and living with assistance or in a nursing home (β = -8.74 [-15.75 to -1.73]) were associated with further GHS/QOL decline during follow-up. Accumulation of domains with geriatric deficits was a major significant factor for GHS/QOL decline at 3 months after treatment (per deficient domain β = -3.17 [-5.04 to -1.30]) and deterioration during follow-up (per domain per year β = -2.74 [-4.28 to -1.20]).

Conclusions and Relevance

In this prospective cohort study, geriatric deficits were significantly associated with HRQOL decline after treatment for HNC. Therefore, geriatric assessment may aid decision-making, indicate interventions, and reduce loss of HRQOL.

Trial Registration

trialregister.nl Identifier: NL7839.