The validity and reliability of the Turkish version of the University of Washington Quality of Life Questionnaire for patients with head and neck cancer.

PURPOSE: The University of Washington Quality of Life Questionnaire (UW-QOL) is an English-language survey used to assess the quality of life of patients with head and neck cancer. The present study aimed to translate this widely used questionnaire into Turkish according to international guidelines and to statistically determine its validity and reliability by administering it to native Turkish-speaking patients. MATERIALS AND METHODS: This prospective study was performed at Hacettepe University, Faculty of Medicine, Turkey. The study included patients newly diagnosed as having head and neck cancer. Translation and cultural adaptation of the questionnaire were performed first. Then, the translated version was tested on a consecutive series of patients seen in the department of otorhinolaryngology head and neck surgery and the department of radiation oncology between September 2006 and February 2008. The patients were asked to complete 3 sets of questionnaires. The first set was completed 1 day before the beginning of treatment, the second 3 months after the completion of treatment, and the third 10 days after the second questionnaire was completed. The first and second sets included the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire-Turkish version and UW-QOL-Turkish version. The third set included the Turkish UW-QOL only. Performance status was assessed and rated by a physician using the Karnofsky and ZEW (Zubrod/The Eastern Cooperative Oncology Group (ECOG)/World Health Organization) performance scales, synchronous with the first and second sets of questionnaires. RESULTS: The original English version of UW-QOL was carefully translated into Turkish, and a final Turkish version of UW-QOL was developed in an iterative fashion. To determine its validity and reliability, 67 patients were included in the study. Internal consistency (Cronbach α = .757) was adequate, and test-retest reliability (interclass correlation coefficient, 0.941) was excellent. The composite scores of the translated UW-QOL were compared statistically with the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire scores, Karnofsky and ZEW performance scales, T stage of the disease, and UW-QOL global questions scores to support the scale's construct validity, and statistically significant associations were observed. CONCLUSIONS: The Turkish UW-QOL appears to be a valid and reliable tool for use with Turkish patients with head and neck cancer; it can also be used in clinical investigations and routine clinical practice in Turkey.

Reevaluation of gastroesophageal reflux disease as a risk factor for laryngeal cancer.

OBJECTIVES/HYPOTHESIS: The relationship between gastroesophageal reflux disease (GERD) and laryngeal cancer has not been fully elucidated. This case-control study investigates whether GERD increases the odds of developing these malignancies. STUDY DESIGN: Case-control study. METHODS: Rates of GERD among cases of laryngeal cancer identified in the Veterans Health Administration outpatient care files (year 2000-2006) were compared with controls. Cases (N = 14,449) were frequency matched 1:1 with controls. Multivariate logistic regression was used to determine the association between GERD and cancer. RESULTS: After adjusting for tobacco and/or alcohol use, there was no association between GERD and laryngeal cancer (adjusted odds ratio, 1.01; 95% confidence interval, 0.92-1.12, P =.780). Although an association was found when time from GERD diagnosis to malignancy was less than 3 months, it disappeared when this period was extended further. CONCLUSIONS: In this population, there was no increased risk of laryngeal cancer among patients with GERD. However, in subsite analysis, a possible relationship between GERD and glottic cancer was observed. Reverse causality must be considered in future studies assessing the relationship between reflux and laryngeal cancer to limit misclassification bias.

Spanish validation of the University of Washington Quality of Life questionnaire for head and neck cancer patients.

OBJECTIVE: The University of Washington Quality of Life (UW-QOL) questionnaire is one of the most widely used instruments to evaluate the quality of life of head and neck cancer patients. The aim of this study was to perform a Spanish translation and validation of the UW-QOL questionnaire. STUDY DESIGN: A cross-sectional study. SETTING: Three tertiary-care hospitals and a laryngectomee rehabilitation center. SUBJECTS AND METHODS: The translation and cultural adaptation of the questionnaire were performed following accepted international guidelines. The psychometric validation was performed on a consecutive series of patients treated for squamous cell carcinoma of the upper aerodigestive tract with no signs of relapse, recruited from May 2007 to December 2008. Eligible subjects were invited to complete the Spanish version of the UW-QOL questionnaire during routine clinical consultation, and complete it again within 15 days. Subjects also completed a validated Spanish version of the Goldberg Mental Health Survey and were evaluated by the use of the Karnofsky Index. RESULTS: A Spanish version of the questionnaire was developed in iterative fashion. In the psychometric validation process, a total of 76 patients were analyzed. Reliability was excellent, including both internal consistency (Cronbach's alpha of 0.84) and test-retest reliability (intraclass correlation coefficient between 0.91 and 0.97 with a confidence interval of 95%). Construct validity was supported by statistically significant relationships between the Karnofsky Index, the Goldberg Mental Health Survey, and the translated UW-QOL questionnaire. CONCLUSION: The Spanish version of the UW-QOL questionnaire appears to be culturally appropriate and psychometrically valid.

Dysphagia, stricture, and pneumonia in head and neck cancer patients: does treatment modality matter?

OBJECTIVES: Dysphagia-related sequelae are common after head and neck cancer treatment. Our aims were 1) to document overall and site-specific dysphagia, stricture, and pneumonia rates in a Medicare population, 2) to calculate treatment-specific rates and adjusted odds of developing these complications, and 3) to track changes in rates between 1992 and 1999. METHODS: Head and neck cancer patients between 1992 and 1999 were identified in combined Surveillance Epidemiology and End Results (SEER) registry and Medicare databases. Multivariate analyses determined odds of dysphagia, stricture, and pneumonia based on modality. RESULTS: Of 8,002 patients, 40% of experienced dysphagia, 7% stricture, and 10% pneumonia within 3 years of treatment. In adjusted analyses, patients treated with chemoradiation had more than 2.5-times-greater odds of dysphagia than did those treated with surgery alone. Combined therapy was associated with increased odds of stricture (p<0.05). The odds of pneumonia were increased in patients treated with radiation with or without chemotherapy. Temporally, the dysphagia rates increased 10% during this period (p<0.05). CONCLUSIONS: Sequelae of head and neck cancer treatment are common and differ by treatment regimen. Those treated with chemoradiation had higher odds of experiencing dysphagia and pneumonia, whereas patients treated with any combined therapy more commonly experienced stricture. These sequelae represent major sources of morbidity and mortality in this population.

The physical function and social-emotional function subscales of the University of Washington Quality of Life Questionnaire.

OBJECTIVES: To perform a factor analysis using the University of Washington Quality of Life Questionnaire version 4 (UW-QOLv4) to establish subscales; to report their normative values and variations for patients by age, sex, extent of disease, and time from treatment; and to estimate clinical effect sizes and potential for use in comparative treatment studies. DESIGN: Retrospective cohort. SETTING: Regional Maxillofacial Unit, University Hospital Aintree, Liverpool, England. PATIENTS: Patients with primary oral and oropharyngeal cancer treated by surgery with or without adjuvant radiotherapy since 1992. A database accumulating since 1995 contains more than 2600 UW-QOLs completed by these patients. A data set of 372 patients without cancer attending 10 general dental practices provided normative data. MAIN OUTCOME MEASURES: UW-QOLv4. RESULTS: Factor analysis indicated a 2-factor solution: (1) physical function, involving chewing, swallowing, speech, taste, saliva, and appearance, and (2) social-emotional function, involving anxiety, mood, pain, activity, recreation, and shoulder function. The best scores were for those with less advanced oral cancer tumors not requiring free-flap surgery or adjuvant radiotherapy. Older patients reported better scores, but associations were weak, and no sex differences were found. Significant differences were seen for T category, site, free-flap surgery, and adjuvant radiotherapy (P < .001). Preoperative scores were close to normative values. Patients regain social-emotional deficits by 1 year after surgery but continue with significant deficits in physical function. Comparative studies using these UW-QOL subscales as outcome measures should recruit at least 80 patients per treatment arm to detect moderately sized treatment effects. CONCLUSION: With the UW-QOLv4, it is appropriate to analyze and report outcomes using the 2 subscales of physical and social-emotional function.

Impact of surveillance on survival after laryngeal cancer in the medicare population.

OBJECTIVES/HYPOTHESIS: Routine surveillance is advocated to detect recurrent disease after treatment for laryngeal cancer. This aim of this study was to determine the 1- and 5-year postrecurrence mortality for laryngeal cancers and evaluate whether more intensive surveillance improved survival. STUDY DESIGN: Retrospective cohort study. METHODS: Patients with recurrent cancers (1992-1999) were identified in a national cancer clinical database. Multivariate analysis was used to evaluate the effect of surveillance on postrecurrence survival. RESULTS: Of 2,121 recurrent cancers identified, 913 were laryngeal. Patients with laryngeal cancer recurrence had 27% (P = .001) and 22% (P = .007) better odds of 1- and 5-year survival than other sites. The 1- and 5-year postrecurrence survival rates for laryngeal cancer patients were 72.4% and 41.3%, respectively. Glottic cancer cases had the best postrecurrence life expectancy. Multivariate regression revealed that clinical surveillance intensity had no independent impact on their survival (P < .05). However, patients with recurrent glottic cancer seen in surveillance had 23% improved odds of survival (P = .037). CONCLUSIONS: More frequent surveillance visits was not associated with a survival advantage in the overall population. Patients with glottic cancer had a postrecurrence survival advantage if seen during the surveillance period. Laryngeal cancer patients had better postrecurrence survival than other head and neck sites.

Influences and predictors of long-term quality of life in head and neck cancer survivors.

OBJECTIVE: To examine the impact of clinical predictors (pretreatment variables) and other influences (treatment and posttreatment variables) on long-term quality of life (QOL) in patients treated for squamous cell carcinoma of the upper aerodigestive tract. We hypothesized that baseline QOL and comorbidity would be predictors of QOL 1 year after treatment. DESIGN: Retrospective cohort study. SETTING: Academic Medical Center in Seattle, Washington. PATIENTS: Patients (N = 173) with baseline (pretreatment) and 1-year posttreatment QOL data. MAIN OUTCOME MEASURE: Head and neck-specific QOL scores at 1 year after treatment (as measured by the University of Washington Quality of Life [UW-QOL] scale). RESULTS: We identified strong relationships between 1-year UW-QOL scores and baseline UW-QOL scores (correlation coefficient [Pearson r] = 0.58; P < .001) and pretreatment comorbidity (as measured by the Adult Comorbidity Evaluation scale) (Spearman rho = 0.23; P < .001). T stage and N stage were also predictive. Although not a predictive variable, the presence of a gastrostomy tube at 1 year also strongly influenced 1-year UW-QOL scores. Patients with gastrostomy tubes had UW-QOL scores 11.5 points worse than those without (P < .001), when a 7-point difference is considered clinically significant. In predictive multivariate regression models, pretreatment QOL scores, comorbidity, and T stage had the strongest prognostic impact on 1-year UW-QOL scores. CONCLUSIONS: In bivariate analyses, the presence of a gastrostomy tube worsens UW-QOL scores at 1 year and requires further investigation. When considering predictive variables only, baseline QOL and comorbidity appear to have strong influences on posttreatment QOL and have greater impact than treatment modality. Greater attention to these baseline predictors should be given when counseling patients about long-term function after treatment.

Comparison of approaches for oral cavity cancer resection: lip-split versus visor flap.

OBJECTIVE: To compare lip-split and visor flap approaches to the oral cavity in terms of morbidity, margins, and locoregional recurrence. DESIGN AND SETTING: Retrospective case series at the University of Washington, Seattle. METHODS: Seventy patients undergoing resection of advanced (T4) anterior oral cavity squamous cell carcinoma requiring fibula reconstruction were grouped according to surgical access procedure performed (lip-split [LS] or visor flap [VF]). Data on surgical morbidity, margin status, and outcomes were compared. RESULTS: Recurrence rates and positive margins were similar for both groups. Rates of postoperative fistulae were 6.8% (LS) vs 0% (VF) and for oral incompetence 14.6% (LS) vs 6.9% (VF). Most of the fistulas (37.5%) were in irradiated patients. Neither group had any malunions. CONCLUSIONS: There is no significant difference in pathological margins or rates of local recurrence when using either the lip-split or the visor approach. The lip-split approach has a higher rate of postoperative fistula formation than the visor flap approach; fistula formation may be associated with previous irradiation.

Tumor-specific genetic expression profile of metastatic oral squamous cell carcinoma.

BACKGROUND: Metastasis is the most important predictor of survival in patients with oral squamous cell carcinoma (OSCC). We tested the hypothesis that there is a genetic expression profile associated with OSCC metastasis. METHODS: We obtained samples from 6 OSCC node-positive primary tumors and their matched metastatic lymph nodes, and 5 OSCC node-negative primary tumors. Using laser capture microdissection, we isolated OSCC cells from metastatic lymph nodes and compared them with those from matched primary tumors and unmatched node-negative primary tumors using Affymetrix Human Genome Focus arrays. RESULTS: Comparison of tumor cells from the lymph nodes with those from the unmatched, node-negative primary tumors revealed differential expression of 160 genes. Hierarchical clustering and principal component analysis using this 160-gene set showed that the node-negative samples were distinguishable from both, node-positive primary tumors and tumors in the lymph nodes. Many of the expression changes found in the metastatic cells from the lymph nodes were also found in the node-positive primary tumors. Immunohistochemical analysis for transglutaminase-3 and keratin 16 confirmed the differential genetic expression for these genes. CONCLUSION: These preliminary results suggest that there may be a metastatic gene expression profile present in node-positive primary OSCC.

Brazilian-Portuguese validation of the University of Washington Quality of Life Questionnaire for patients with head and neck cancer.

BACKGROUND: The University of Washington Quality of Life (UW-QOL) questionnaire is an English-language survey instrument used worldwide to assess the quality of life of patients with head and neck cancer. To be used in other cultures, such instruments require careful translation and psychometric validation in other languages. METHODS: The translation and cultural adaptation of the questionnaire were performed following accepted international guidelines. The psychometric validation was performed on a consecutive series of patients with at least 1 year of disease-free survival after treatment for squamous cell carcinoma of the upper aerodigestive tract, recruited from October 2004 to January 2005 from a tertiary cancer center hospital. Eligible subjects were invited to complete the Portuguese version of the UW-QOL questionnaire during routine clinical consultation and complete it again within 15 days. They also completed a validated Portuguese version of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and a questionnaire to evaluate anxiety and depression symptoms (Hospital Anxiety and Depression Scale [HADS]). RESULTS: A Portuguese version of the questionnaire was developed in iterative fashion. In the psychometric validation process, a total of 109 patients were analyzed. Reliability was excellent, including both internal consistency (Cronbach's alpha [alpha] of 0.744) and test retest reliability (intraclass correlation coefficient [ICC] of 0.882). Construct validity was supported by statistically significant relationships between the SF-36 and HAD questionnaires and the translated UW-QOL questionnaire. CONCLUSIONS: The Brazilian-Portuguese version of the UW-QOL questionnaire appears to be culturally appropriate and psychometrically valid. This version is a valuable tool to evaluate accurately the quality of life of Brazilian patients with head and neck cancer.

Clinical utility of somatostatin receptor scintigraphic imaging (octreoscan) in esthesioneuroblastoma: a case study and survey of somatostatin receptor subtype expression.

BACKGROUND: For tumors that express somatostatin receptors (SSTR), radiolabeled somatostatin analogs, such as 111In-pentetreotide, can demonstrate the presence of tumor by radioligand uptake using somatostatin receptor scintigraphy (SRS). The use of 111In-pentetreotide for SRS depends on the specific high affinity of octreotide for SSTR subtypes 2, 3, and 5. Of these, SSTR2 has the greatest affinity for octreotide and the greatest relevance for tumor detection with Octreoscan imaging. Discriminating between postoperative changes and residual or recurrent tumor after extensive skull base surgery is often difficult, but in a case of recurrent esthesioneuroblastoma (ENB) we found the use of Octreoscan imaging clinically useful. To better define the general relevance of this imaging technique in this setting, we analyzed SSTR subtype expression in a panel of ENB tumors. METHODS: The case history and correlations between MRI and 111In-pentetreotide SRS of a patient with recurrent ENB were reviewed. The expression pattern of the SSTR subtypes in a panel of ENB tumors was then analyzed by reverse transcriptase-polymerase chain reaction (RT-PCR) to better define the potential of more general use of Octreoscan for imaging ENB. To correlate SSTR2 protein expression with 111In-pentetreotide uptake, immunohistochemistry to detect SSTR2 was performed on tumor samples from regions of increased uptake on Octreoscan. RESULTS: The SSTR2 message was expressed at high levels in all five ENB tumor samples, and either SSTR2 protein or histologic findings typical for ENB were found in all tumor tissue obtained from regions of increased 111In-pentetreotide uptake. Furthermore, Octreoscan imaging in this case proved useful in clinical decision making. CONCLUSION: The expression pattern of SSTR2 and the specificity of the Octreoscan for regions of active tumor growth support further investigation of the utility of Octreoscan imaging in the diagnosis and surveillance of ENB. Recent advances in novel therapies based on SSTR ligand binding also provide the rationale to consider such novel therapeutic approaches in patients with ENB.

Psychiatric distress amplifies symptoms after surgery for chronic rhinosinusitis.

BACKGROUND: Psychiatric disorders are associated with increased symptom burden when combined with chronic medical conditions. However, there are no reports of how psychiatric distress influences outcomes with surgical treatment for chronic rhinosinusitis (CRS). We hypothesized that subjects with psychiatric distress (somatization, anxiety, and depression) would report more severe long-term sinus symptoms and worse quality of life (QOL) than subjects without psychiatric distress. METHODS: This is a community-based, prospective, observational cohort study of patients diagnosed with CRS presenting for surgery. Patients were interviewed before surgery; CT scans were reviewed, and questionnaires were completed about sinusitis-related symptoms (SNOT-16), general health status and QOL (SF-36), and psychiatric distress (BSI and PHQ). Outcomes were also assessed 1, 3, 6, and 12 months postoperatively. RESULTS: Ninety-five patients had complete records for analysis. Psychiatric distress was prevalent, with 31% screening positive for somatization, 17% positive for anxiety, and 25% positive for depressive disorders. Subjects with somatization had significantly worse SNOT-16 scores at each time point compared with those without somatization ( P < 0.05). Subjects with depression reported more severe symptoms at 6 and 12 months after surgery than those without depression ( P < 0.05). The presence of somatization preoperatively was also independently associated with worse symptom severity 12-months after surgery, even after adjusting for prior sinus surgery, CT stage, Charlson Index, and deviated septum. In addition, subjects with psychiatric distress reported significantly worse SF-36 physical and mental component summary scores 12-months after surgery than subjects without psychiatric distress. CONCLUSIONS: Psychiatric distress is associated with worse reported sinus symptoms and lower QOL throughout surgical management of chronic rhinosinusitis. Despite this, subjects with psychiatric distress report a similar degree of improvement in sinus symptoms after surgery compared with those without distress. CLINICAL SIGNIFICANCE: Psychiatric distress should be considered in patients with persistent symptoms after surgery. Psychiatric distress should also be considered in efforts to design a chronic sinusitis staging system.

The impact of sinus computed tomography on treatment decisions for chronic sinusitis.

OBJECTIVES: To determine the impact of sinus computed tomography (CT) on treatment decisions by otolaryngologists and to explore the factors leading to choice of surgical treatment for patients suspected of having chronic sinusitis. DESIGN: Prospective cohort study. SETTING: A tertiary academic medical center. PATIENTS: Questionnaires were administered to 3 otolaryngologists in a tertiary academic institution regarding diagnosis and treatment decisions in 27 patients suspected of having chronic sinusitis, before and after they reviewed sinus CT scans. MAIN OUTCOME MEASURES: The dichotomous decisions regarding surgical or nonsurgical treatment and the agreement of treatment decisions among surgeons were evaluated. The factors strongly influencing surgeons' treatment decisions regarding patients selected for surgery were also determined. RESULTS: The dichotomous treatment decisions were changed in one third of patients (9 of 27) after the sinus CT scans were reviewed. The agreement of treatment decisions among the 3 surgeons was markedly improved after they reviewed sinus CT scans. The factors favorably influencing surgical treatment were obstruction of the ostiomeatal complex on CT and concordance of CT abnormality with a patient's symptoms. Lund-Mackay stage, symptoms, and corticosteroid or antibiotic use were not significant predictors. CONCLUSIONS: Despite the common belief that treatment decisions for chronic sinusitis should be solely based on clinical grounds, with sinus CT providing only anatomic detail before surgery, our study indicates that the decision to perform surgery was altered by CT in a substantial portion of the patients. In our preliminary study, CT increased the tendency to elect surgical treatment by all 3 surgeons.

Postradiotherapy surveillance practice for head and neck squamous cell carcinoma--too much for too little?

INTRODUCTION: Limited information is available regarding surveillance patterns after head and neck cancer radiotherapy. We cataloged follow-up for a specified patient cohort treated at three neighboring university, community, and Veterans Administration institutions. METHODS: One hundred fifteen patients were treated with curative intent between 1994-1998 with definitive or postoperative radiotherapy for newly diagnosed squamous cell carcinoma of the oral cavity, oropharynx, larynx, or hypopharynx. One hundred patients had continuous follow-up at their treating institution and were included for analysis. Median follow-up until disease recurrence or censorship was 28.5 months. RESULTS: Median follow-up frequency was 5.7 visits/year and was highly variable. Although visit frequency correlated with disease stage and the presence of high-risk disease features, this association was lost when patients with early recurrences were removed from analysis. Procedure and test utilization closely mirrored visit frequency, resulting in a wide range of estimated yearly charges (0-15,668 dollars/year; median, 1,772 dollars/year). Actuarial 3-year overall survival for the study group was 71%. Eighty-six percent (19 of 22) of potentially salvageable locoregional failures were discovered secondary to symptomatic complaint rather than by test results. Disease failure, whether detected by symptom or testing, predicted for poor survival (22% at 24 months after recurrence). CONCLUSIONS: Postradiotherapy surveillance for head and neck cancer is inconsistently pursued. A proven correlation between intensive follow-up and improved patient survival is lacking. Surveillance directed by patient symptoms should be investigated as an alternative approach.

Health care utilization and cost among adults with chronic rhinosinusitis enrolled in a health maintenance organization.

OBJECTIVE: Our goal was to measure the impact of chronic rhinosinusitis (CRS) on the use and cost of health care by adults in a health maintenance organization (HMO). SETTING AND SUBJECTS: In the setting of the Group Health Cooperative, an HMO in Washington State, we conducted a study of all 218,587 adults (>/=18 years) who used services during 1994. Using automated data, 20,175 adults were identified with one or more CRS diagnoses during 1994. OUTCOME MEASURES: We identified nonurgent outpatient visits, pharmacy fills, urgent visits, hospital days, and their associated costs (per adult per year). RESULTS: The marginal utilization associated with a diagnosis of CRS was 2.0 nonurgent outpatient visits, 5.1 pharmacy fills, 0.01 urgent visit, and -0.07 hospital day. The marginal total cost of CRS was $206. CONCLUSIONS: Adults with CRS had higher costs primarily because of increased nonurgent outpatient visit and pharmacy fill utilization. The overall direct cost of CRS in the United States in 1994 is estimated to have been $4.3 billion.