Behavior modification and risk perception in patients with nonmelanoma skin cancer.

CONTEXT: Nonmelanoma skin cancer (NMSC) is the most common cancer among humans, yet risk perceptions and preventive health behaviors in those who survive this cancer are relatively unknown. OBJECTIVES: To assess the impact of the disease and its treatment on sun-protective behaviors, general preventive health behaviors, and risk perception in NMSC patients, and to determine factors associated with behavioral change. DESIGN AND SETTING: A prospective study was conducted of 211 consecutive NMSC patients presenting to a dermatologic surgery clinic at a tertiary care university medical center from February 2005 to March 2006. These patients were all adults, were fluent in English, and had NMSC of the head and neck. Of the 211 eligible patients, complete data was obtained for 183 (87%). The most common reasons for dropout were voluntary withdrawal and incompletely answered surveys. INTERVENTION AND OUTCOME MEASURES: Surveys that assessed disease-specific quality of life (QoL), preventive health behaviors, sun-protective behaviors, and risk perception were administered before and after surgical treatment of NMSC. RESULTS: Sun-protective behaviors improved postsurgery even after controlling for seasons (P<0.001). Predictor factors associated with increased sun-protective behavior included poor skin tanning ability, summer season, no employment, less comorbid conditions, and previous NMSC treatment. Baseline QoL was not predictive of behavioral change. As for risk perception, respondents thought they were more likely than someone similar to themselves to develop future NMSCs but thought they had similar risks of developing melanoma or other non-skin cancers (P<0.001). NMSC patients demonstrated disease-specific behavior modifications by selectively improving their sun habits but showed no significant improvement in other preventive health behaviors. This finding is consistent with patients' specific perception of increased risk for future NMSCs, but surprisingly, not for melanoma. Increased patient education of associated cancer risks with NMSC is warranted. CONCLUSIONS: NMSC patients demonstrated disease-specific behavior modifications by selectively improving their sun habits but showed no significant improvement in other preventive health behaviors. This finding is consistent with patients' specific perception of increased risk for future NMSCs, but surprisingly, not for melanoma. Increased patient education of associated cancer risks with NMSC is warranted.

The skin cancer index: clinical responsiveness and predictors of quality of life.

OBJECTIVE: To establish the clinical responsiveness of the Skin Cancer Index (SCI), a new disease-specific quality of life (QOL) instrument, and to assess demographic and clinical factors which impact QOL in patients with nonmelanoma skin cancer (NMSC). STUDY DESIGN: Prospective study of 183 patients with NMSC of the face and neck referred to a tertiary care Mohs surgery clinic. METHODS: The SCI is a 15 item, validated, disease-specific QOL instrument with 3 distinct subscales, Emotion, Social, and Appearance. Higher scores reflect better QOL. The SCI and the Dermatology Life Quality Index (DLQI), a general dermatology instrument, was administered at initial consultation and 4 months after surgical treatment. Multivariate analysis was conducted to assess demographic and clinical factors predictive of QOL for both instruments. RESULTS: The SCI total score and all three subscale scores increased with treatment, demonstrating strong evidence of responsiveness over time (P < .001) in contrast with the DLQI (P = .46). Predictors of poorer QOL for the SCI included female sex and cancers located on the lip. Patients who demonstrated greatest improvement in QOL with treatment included those who were younger (<50 yr) and had lower reported household income. Also, first time NMSC patients and those patients who underwent less extensive reconstructions demonstrated greater improvements in QOL. CONCLUSION: The SCI is a sensitive and responsive QOL instrument for patients with NMSC. Distinct demographic and clinical variables that impact QOL have been demonstrated using this multidimensional, disease-specific instrument.

Validation of a quality-of-life instrument for patients with nonmelanoma skin cancer.

OBJECTIVE: To validate a disease-specific quality-of-life instrument--the Skin Cancer Index--intended to measure quality-of-life issues relevant to patients with nonmelanoma skin cancer. METHODS: Internal reliability, convergent and divergent validity with existing scales, and factor analyses were performed in a cross-sectional study of 211 patients presenting with cervicofacial nonmelanoma skin cancer to a dermatologic surgery clinic. RESULTS: Factor analyses of the Skin Cancer Index confirmed a multidimensional scale with 3 distinct subscales-emotional, social, and appearance. Excellent internal validity of the 3 subscales was demonstrated. Substantial evidence was observed for convergent validity with the Dermatology Life Quality Index, Rosenberg Self-Esteem Scale, Lerman's Cancer Worry Scale, and Medical Outcomes Survey Short-Form 12 domains for vitality, emotion, social function, and mental health. CONCLUSIONS: These findings validate a new disease-specific quality-of-life instrument for patients with cervicofacial nonmelanoma skin cancer. Studies on the responsiveness of the Skin Cancer Index to clinical intervention are currently under way.

Nasal valve surgery improves disease-specific quality of life.

OBJECTIVES/HYPOTHESIS: Disease-specific quality-of-life (QOL) assessment of patients with nasal valve compromise and symptomatic nasal obstruction has not been studied previously. The objectives of the study were to determine whether surgical treatment of the nasal valve improves disease-specific QOL and to identify clinical or demographic variables predictive of patients' baseline QOL or change in QOL. STUDY DESIGN: Prospective, multi-institutional outcomes study of 20 patients with nasal obstruction and a surgically treatable diagnosis of nasal valve compromise. METHODS: Disease-specific QOL assessment was performed using the Nasal Obstruction Symptom Evaluation (NOSE) scale preoperatively (n = 20) and at 3 (n = 14) and 6 months (n = 20) after surgery. Clinical and demographic data were collected, along with physician-reported assessments of degree of nasal obstruction. RESULTS: Mean NOSE scores significantly improved from baseline to 3 months after surgery (68.9 vs. 20.7 [P < .0001]), from baseline to 6 months after surgery (68.9 vs. 15.8 [P < .0001]), and from 3 to 6 months after surgery (20.7 vs. 15.8 [P = .0077]). Physician assessment of degree of nasal obstruction using a visual analogue scale was significantly correlated with baseline NOSE scores (P = .013) and change in NOSE scores at 6 months (P = .0015). No other clinical or demographic factors were found to be predictive. CONCLUSION: In patients with symptomatic nasal obstruction and nasal valve compromise, surgical repair of the nasal valve improves disease-specific QOL. Physician rating of degree of nasal obstruction was found to be significantly correlated with patient-reported QOL.

Creation of a quality of life instrument for nonmelanoma skin cancer patients.

OBJECTIVE: Malignancies of the skin are the most common cancers among humans. The cervicofacial region is most affected by cutaneous malignancies, with approximately 80% of nonmelanoma skin cancers (NMSC) occurring in the head and neck. Treatment of cervicofacial skin cancers also is more likely to result in significant patient morbidity, because of the functional and cosmetic importance of this region. Unlike other malignancies, skin cancer has not been well investigated in terms of patient quality of life (QOL) assessment. Furthermore, no validated disease-specific QOL instrument currently exists for skin cancer. The aim of this study was to construct a new QOL instrument, The Facial Skin Cancer Index (FSCI), that captures the relevant QOL issues for NMSC patients. STUDY DESIGN: Cross-sectional study of patients presenting to a dermatologic surgery clinic with NMSC of the head and neck. METHODS: For stage I, item generation, a sample of 20 patients with cervicofacial NMSC and six health care providers specializing in the care of NMSC patients completed semistructured interviews. For stage II, item reduction, a second sample (n = 52) of NMSC patients rated the items in terms of their importance for QOL among skin cancer patients. Domains of the FSCI were evaluated in terms of data quality, item variability, internal consistency, and range and skewness of scale score on aggregation and floor and ceiling effects. RESULTS: A total of 71 distinct items were generated in stage I. After using the outlined item reduction techniques in stage II, the FSCI was reduced from 71 to 36 items, representing 6 domains. With the exception of Physical Functioning (alpha = 0.63) that suggested adequate reliability, all subscale scores showed excellent reliability coefficients, with Cronbach's alpha ranging from 0.78 (Lifestyle) to 0.87 (Social/Family). CONCLUSIONS: A new disease-specific QOL instrument for patients with NMSC of the head and neck has been created. Validation studies are currently underway. Future directions will include sensitivity analysis to determine whether the FSCI is sensitive to change over time among patients undergoing treatment for NMSC.

Quality of life assessment in nasal airway obstruction.

OBJECTIVES/HYPOTHESIS: Quality of life (QOL) assessment of patients with nasal obstruction has not been well studied. The objectives of the study were to determine the QOL of patients with nasal obstruction, to identify baseline variables predictive of patients' QOL, and to examine the relationship of QOL scores with patient assessment of nasal obstruction. STUDY DESIGN: Preliminary, cross-sectional study of a larger, prospective investigation. METHODS: Forty individuals met the criteria for inclusion. Participants were required to have a surgically treatable diagnosis of septal deviation, nasal valve collapse, and/or turbinate hypertrophy. Quality of life assessment was performed using the Rhinoconjunctivitis Quality of Life Questionnaire and the Rhinosinusitis Disability Index. Demographic data, along with patient assessment of nasal obstruction with a visual analogue scale, were recorded. RESULTS: Both instruments demonstrated good inter-item correlation as measured by Cronbach's alpha. Demographic variables, previous nasal surgeries, and comorbid conditions were not significantly correlated with QOL scores with either instrument. Correlations between visual analogue scale scores and the Rhinoconjunctivitis Quality of Life Questionnaire "sleep" (correlation coefficient [r] = 0.35, P =.02) and "nasal symptom" (r = 0.36, P =.02) domains demonstrated a trend toward significance. Patients with nasal valve collapse reported higher visual analogue scale scores for nasal obstruction compared with those with septal deviation alone (P <.01). CONCLUSIONS: Patients with nasal valve collapse demonstrated greater perception of nasal obstruction than those with septal deviation alone. The Rhinoconjunctivitis Quality of Life Questionnaire appears to be a more sensitive instrument than the Rhinosinusitis Disability Index for patients with nasal obstruction. However, existing measures may lack sensitivity in estimating the QOL of patients with nasal obstruction. A disease-specific instrument for nasal obstruction may be necessary to further evaluate this disease process.

Quality of life assessment in nonmelanoma cervicofacial skin cancer.

OBJECTIVES/HYPOTHESIS: Health-related quality of life (QOL) assessment of patients with nonmelanoma skin cancer is poorly understood. The objectives of the study were to determine the general QOL of patients with cervicofacial skin cancer and to identify patient, clinical, and preventive behavior variables associated with patients' QOL. STUDY DESIGN: Cross-sectional study of 121 consecutive patients (65 female and 56 male patients) presenting to a dermatological Mohs surgery clinic with nonmelanoma skin cancer of the head and neck. METHODS: Quality of life assessment was performed before counseling or treatment. Measures included the Medical Outcomes Study Short Form 36-item Health Survey (SF-36) and the Functional Assessment of Cancer Therapy-General (FACT-G). RESULTS: Both instruments demonstrated good internal consistency as measured by Cronbach's alpha (SF-36, alpha = 0.45-0.91; FACT-G, alpha = 0.61-0.90). The SF-36 scores were similar to historical norms. Bivariate analysis indicated significant correlation coefficients between QOL and patients' coexisting illnesses and medical risk factors. Sun-protective behaviors were associated with better QOL. The relationship appeared to be minimally influenced by patients' sociodemographic characteristics and disease-related variables (size, location, extent). CONCLUSIONS: Sun-protective behaviors were positively associated with certain QOL subscale scores in the population in the study. General QOL instruments demonstrated minimal impact of nonmelanoma skin cancer on patients at initial diagnosis. However, general measures may not be sensitive to the impact of nonmelanoma skin cancer. The development of a more disease-specific instrument may be necessary to evaluate this disease process.

Quality of life and sun-protective behavior in patients with skin cancer.

OBJECTIVES: To determine whether change occurred in the general quality of life (QOL) of nonmelanoma skin cancer (NMSC) patients following surgery, to identify variables associated with patients' change in QOL, and to assess the impact of the disease and treatment on sun-protective behaviors and cigarette smoking. DESIGN: Longitudinal prospective study of 121 consecutive patients referred to a dermatologic Mohs surgery clinic with NMSC of the head and neck. INTERVENTIONS: Quality-of-life, smoking habit, and sun-protective behavior assessments were performed before treatment (N=121) and after surgical treatment at 1 (n=105) and 4 (n=101) months. Quality-of-life measures included the Medical Outcomes Study 36-Item Short-Form Health Survey and the Functional Assessment of Cancer Therapy-General. RESULTS: Overall, general QOL measures demonstrated little change over time. Only the mental (Medical Outcomes Study 36-Item Short-Form Health Survey) and emotional (Functional Assessment of Cancer Therapy-General) domains of QOL showed statistically significant change over time. A 2-way interaction showing effects for age and time on emotional well-being was modified by a 3-way interaction that depended on employment status. Emotional well-being scores for younger employed NMSC patients increased over time compared with scores among younger unemployed patients. In addition, many patients adopted greater use of sun-protective behaviors at 4 months following surgery. No change in cigarette smoking status was evidenced. CONCLUSIONS: Use of sun-protective behaviors increases after treatment. General QOL instruments demonstrate little change following treatment of NMSC. Although the associations are modest, improvements in emotional and mental health well-being following treatment of NMSC were demonstrated, especially for those younger than 65 years and employed. A disease-specific instrument may be necessary to further study this disease process.

Development of the facial skin care index: a health-related outcomes index for skin cancer patients.

BACKGROUND: Existing health-related quality-of-life (HRQOL) tools do not appear to capture patients' specific skin cancer concerns. OBJECTIVE: To describe the conceptual foundation, item generation, reduction process, and reliability testing for the Facial Skin Cancer Index (FSCI), a HRQOL outcomes tool for skin cancer researchers and clinicians. METHODS: Participants in Phases I to III consisted of adult patients (N=134) diagnosed with biopsy-proven nonmelanoma cervicofacial skin cancer. Data were collected via self-report surveys and clinical records. RESULTS: Seventy-one distinct items were generated in Phase I and rated for their importance by an independent sample during Phase II; 36 items representing six theoretical HRQOL domains were retained. Test-retest I results indicated that four subscales showed adequate reliability coefficients (alpha=0.60 to 0.91). Twenty-six items remained for test-retest II. Results indicated excellent internal consistency for emotional, social, appearance, and modified financial/work subscales (range 0.79 to 0.95); test-retest correlation coefficients were consistent across time (range 0.81 to 0.97; lifestyle omitted). CONCLUSION: Pretesting afforded the opportunity to select items that optimally met our a priori conceptual and psychometric criteria for high data quality. Phase IV testing (validity and sensitivity before surgery and 4 months after Mohs micrographic surgery) for the 20-item FSCI is under way.

Skin cancer and quality of life: assessment with the Dermatology Life Quality Index.

BACKGROUND: Quality of life (QOL) has been identified as an important outcome in cancer research, yet the most common malignancy among humans, nonmelanoma skin cancer (NMSC), has been poorly studied in this regard. OBJECTIVE: To determine whether change occurred in the QOL of NMSC patients after surgery using a general, validated dermatology QOL instrument: the Dermatology Life Quality Index (DLQI). METHODS: A prospective study was conducted on 121 consecutive patients referred to a dermatologic Mohs surgery clinic with NMSC of the head and neck. QOL assessment was performed using the DLQI before (n=121) and after surgical treatment at 4 months (n=101). RESULTS: QOL scores demonstrated little handicap at initial diagnosis. The total DLQI scores showed little change over time, but an item analysis revealed that 2 of the 10 items demonstrated statistically significant change over time, with QOL improving after treatment-decreased painfulness/itchiness/soreness and less necessity to use concealing clothing. CONCLUSIONS: General dermatology QOL instruments demonstrated minimal handicap at initial diagnosis and little change after treatment of NMSC. Although the associations were modest, improvement in some aspects of well-being after treatment of NMSC was demonstrated. A more disease-specific instrument may be necessary to study this disease process further.

Objective testing and quality-of-life evaluation in surgical candidates with chronic rhinosinusitis.

BACKGROUND: Discordance has been reported between patient symptoms and objective measures of disease in chronic sinusitis, such as radiographic evaluation. The objective of this study was to evaluate the association between presurgical objective studies and presurgical quality of life (QOL). This work was designed as a cross-sectional study of 90 consecutive patients presenting to a tertiary rhinology practice for surgical management of sinonasal disease. METHODS: QOL assessment was performed using disease-specific instruments (Chronic Sinusitis Survey and Rhinosinusitis Disability Index). Computed tomography (CT) scans were scored according to the Lund-Mackay CT scoring system and endoscopy evaluation was scored by the system proposed by Lund and Kennedy. RESULTS: Ninety surgical candidates were enrolled and included in the analysis. Correlation between the QOL total scores and subscale scores was excellent (r = 0.39; p = 0.0001) as was the correlation between CT and endoscopy scores (r = 0.59; p = 0.0001). In contrast, correlation between QOL and objective measures was poor. These results were not significantly influenced by subgroup analysis by diagnosis, comorbidity, and other patient factors. CONCLUSION: Preoperative objective measures of CRS disease show little, if any, correlation with disease-specific QOL measures in surgical candidates. It is likely that CT and endoscopy are measuring a different aspect of CRS disease than the QOL measures. In addition, it is possible that preoperative QOL, either alone or in combination with CT and endoscopy, may prove important in selecting patients most likely to benefit from surgery.