Competing causes of death and medical comorbidities among patients with human papillomavirus-positive vs human papillomavirus-negative oropharyngeal carcinoma and impact on adherence to radiotherapy.

IMPORTANCE: Survival of patients with head and neck cancer can be affected by competing causes of mortality, as well as comorbidities that result in radiation treatment interruptions. OBJECTIVE: To discern how differences in preexisting medical and psychosocial comorbidities potentially influence adherence to radiation therapy according to human papillomavirus (HPV) status. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis at a comprehensive cancer center of 162 consecutive patients with locally advanced squamous cell carcinoma of the oropharynx treated with primary chemoradiation (n = 95) or primary surgery followed by adjuvant radiation (n = 67). Immunostaining for p16 was used to determine HPV status. MAIN OUTCOMES AND MEASURES: Difference in alcohol, tobacco, and marijuana use was compared between patients with HPV-positive and HPV-negative tumors, as well as the prevalence of the following comorbidities: diabetes mellitus, chronic obstructive pulmonary disease (COPD), anxiety disorder, and major depression. The number of total missed treatment days was analyzed as both a continuous and categorical variable. RESULTS: Rates of self-reported heavy alcohol use (47% vs 16%; P = .02) and any marijuana use (47% vs 23%; P = .003) were significantly higher among HPV-negative patients. Fifty-four percent of HPV-positive patients self-identified as never smokers, compared with only 12% of HPV-negative patients (P < .001). HPV-negative patients had more missed treatment days (mean, 2.8 vs 1.7 days; P = .02), as well as an increased rate of at least 5 missed days (24% vs 10%; P = .04), and higher prevalences of COPD (12% vs 7%; P = .37) and anxiety disorder (12% vs 6%; P = .35). CONCLUSIONS AND RELEVANCE: Pronounced differences exist in lifestyle habits between patients with HPV-negative and HPV-positive oropharyngeal cancer at diagnosis. These differences, as well as those of medical and psychosocial burden, may contribute to observed discrepancies in treatment adherence and need to be considered in outcomes reporting and clinical trial design.

Quality of life among long-term survivors of head and neck cancer treated by intensity-modulated radiotherapy.

IMPORTANCE: Radiation therapy to the head and neck has traditionally been associated with adverse effects that can affect oral health and physical functioning. Although intensity-modulated radiotherapy (IMRT) has been widely adopted as a means of decreasing toxic effects, limited clinical data exist on its potential effect on long-term quality of life. OBJECTIVE: To analyze quality of life among long-term survivors of head and neck cancer treated with IMRT. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional analysis studied 50 consecutive long-term survivors of head and neck cancer from a comprehensive cancer center who had previously undergone IMRT that required bilateral neck irradiation for locally advanced disease. All patients were clinically without evidence of recurrent disease and had at least 5 years of follow-up. MAIN OUTCOMES AND MEASURES: The University of Washington Quality of Life (UW-QOL) scores were reviewed for all study participants. The UW-QOL questionnaire consists of 12 domains that pertain to the degree of quality of life in the categories of pain, appearance, activity, recreation, swallowing, chewing, speech, shoulder function, taste, saliva, mood, and anxiety. RESULTS: Five years after completion of IMRT, 42 patients (84%) reported that their health-related quality of life was "much better" or "somewhat better" than at the time of cancer diagnosis. With respect to recent health-related quality of life during the preceding 7 days at the time of completing the UW-QOL questionnaire, 40 patients (80%) treated with IMRT reported "outstanding" or "very good" levels of functioning. Five years after completion of treatment, 41 (82%) rated their overall quality of life as "outstanding" or "very good." The lowest domain score on the UW-QOL questionnaire at 5 years pertained to salivary dysfunction. However, 42 patients (84%) reported saliva "of normal consistency" or "less saliva than normal but enough" compared with 8 (16%) reporting "too little saliva." No patient reported having "no saliva." CONCLUSIONS AND RELEVANCE: Our findings add to the body of literature that supports the acceptance of IMRT as standard treatment for head and neck cancer. The fact that most 5-year survivors were satisfied with their quality of lives points to the ability of IMRT to preserve long-term functioning.

Depression among long-term survivors of head and neck cancer treated with radiation therapy.

IMPORTANCE: The diagnosis and subsequent treatment of head and neck cancer can have a potentially devastating impact on psychosocial functioning. Although the long-term physical adverse effects of radiation therapy (RT) for head and neck cancer have been well described, relatively few studies have evaluated psychosocial functioning after treatment. OBJECTIVE: To determine the prevalence of self-reported depression among survivors of head and neck cancer returning for follow-up after being treated with RT. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional analysis among 211 comprehensive cancer center patients with squamous cell carcinoma of the head and neck, who had been previously treated with RT and were disease-free with at least 1 year of follow-up. Patients with a history of mood disorder, use of mental health services in the past, or previous or current use of antidepressants or anxiolytics, excluding sleep medications, were specifically excluded. INTERVENTIONS: The University of Washington Quality of Life instrument (UW-QOL), a brief, previously validated, self-administered questionnaire, was used to analyze rates of depression. MAIN OUTCOMES AND MEASURES: The UW-QOL assigned scores of 0, 25, 50, 75, and 100 subjective responses of mood being "extremely depressed," "somewhat depressed," "neither in a good mood or depressed," "generally good," and "excellent," respectively. RESULTS: The mean mood score did not differ at 1, 3, and 5 years after treatment, with scores of 52.0, 55.7, and 62.1, respectively. The proportion of patients who reported their mood as "somewhat depressed" or "extremely depressed" was 17%, 15%, and 13% at 1, 3, and 5 years, respectively. Variables that were significantly associated with post-RT depression included the presence of tracheostomy tube or laryngeal stoma (P = .01), gastrostomy tube dependence (P = .01), and continued smoking at the time of follow-up (P < .001). Among the patients reporting their mood as either "somewhat depressed" or "extremely depressed" at 1, 3, and 5 years, the proportion using antidepressants at the time was 6%, 11%, and 0%, respectively. The corresponding proportion of patients actively undergoing or seeking psychotherapy and/or counseling was 3%, 6%, and 0%, respectively. CONCLUSIONS AND RELEVANCE: Despite a relatively high rate of depression among patients with head and neck cancer in the post-RT setting, mental health services are severely underutilized.

Skin dose effects of postmastectomy chest wall radiation therapy using brass mesh as an alternative to tissue equivalent bolus.

PURPOSE: The use of brass mesh as a bolus is relatively uncommon in postmastectomy chest wall radiation therapy (PMRT). This study aimed to characterize the skin dose effects of using 2-mm fine brass mesh as an alternative to the traditional tissue-equivalent bolus during chest wall PMRT. METHODS AND MATERIALS: Data were collected from patients who received PMRT using brass mesh at the University of California Davis Department of Radiation Oncology between January 2008 and June 2011. Several patient characteristics including age, body habitus, and ethnicity were analyzed along with several disease and treatment characteristics to determine whether or not they had an impact on the skin reaction observed during radiation treatment. Additionally, in vivo surface dose measurements were obtained for 16 of the 48 patients (33%). RESULTS: Forty-eight female patients aged 28-83 received PMRT using brass mesh. As expected, the severity of skin toxicity increased with subsequent doses of radiation with all patients beginning treatment with no skin reaction (National Cancer Institute scores [NCIS] = 0) and the majority of patients completing treatment with either faint to moderate erythema (n = 19, 40%, NCIS = 1) or moderate to brisk erythema (n = 23, 48%, NCIS = 2). In vivo dosimetry analysis revealed surface doses between 81% and 122% of the prescribed dose, with an average of 99% of the prescribed radiation dose and standard deviation of 10% being delivered. CONCLUSIONS: For postmastectomy chest wall radiation therapy, brass mesh is an effective alternative to tissue-equivalent bolus. The brass mesh achieved moderate erythema in the majority of patients at the end of treatment and the surface dose was validated using in vivo dosimetry.