Quality of life and performance in advanced head and neck cancer patients on concomitant chemoradiotherapy: a prospective examination.

PURPOSE: To prospectively evaluate performance and quality of life (QOL) in advanced-stage head and neck cancer (HNC) patients on a curative-intent, concomitant-chemoradiotherapy (CT/XRT) (twice-daily radiation, fluorouracil, hydroxyurea, and cisplatin) regimen aimed at improving locoregional control, survival, and QOL. PATIENTS AND METHODS: Sixty-four patients were assessed before, during, and at 3-month intervals after treatment. Standardized measures of QOL (Functional Assessment of Cancer Therapy-Head and Neck), performance (Performance Status Scale for Head and Neck Cancer Patients and Karnofsky Performance Status Rating Scale), and patient-reported symptoms (McMaster University Head and Neck Radiotherapy Questionnaire) were administered. RESULTS: Acute treatment toxicities were severe, with declines in virtually all QOL and functional domains. Marked improvement was seen by 12 months; general functional and physical measures returned to baseline levels of good to excellent. Although up to a third of the patients continued to report problems with swallowing, hoarseness, and mouth pain, these difficulties were present in similar magnitudes before treatment. The following symptoms were more frequent at 12 months: dry mouth (58% v 17%), difficulties tasting (32% v 8%), and soft food diet (82% v 42%). Twelve-month diet was not related to pretreatment functioning, disease, treatment, or patient characteristics. Twelve-month QOL was best predicted by pretreatment QOL, with very little relationship to residual side effects or functional impairments. Small numbers of patients in four of the five disease sites precluded examination of outcome by site. CONCLUSION: These data support the feasibility of intense CT/XRT as primary treatment for advanced HNC. Results confirm acute toxicity but indicate that many of the treatment-related performance and QOL declines resolve by 12 months. The persistent inability to eat a full range of foods warrants further attention and monitoring.

How Do head and neck cancer patients prioritize treatment outcomes before initiating treatment?

PURPOSE: To determine, pretreatment, how head and neck cancer (HNC) patients prioritize potential treatment effects in relationship to each other and to survival and to ascertain whether patients' preferences are related to demographic or disease characteristics, performance status, or quality of life (QOL). PATIENTS AND METHODS: One hundred thirty-one patients were assessed pretreatment using standardized measures of QOL (Functional Assessment of Cancer Therapy-Head and Neck) and performance (Performance Status Scale for Head and Neck Cancer). Patients were also asked to rank a series of 12 potential HNC treatment effects. RESULTS: Being cured was ranked top priority by 75% of patients; another 18% ranked it second or third. Living as long as possible and having no pain were placed in the top three by 56% and 35% of patients, respectively. Items that were ranked in the top three by 10% to 24% of patients included those related to energy, swallowing, voice, and appearance. Items related to chewing, being understood, tasting, and dry mouth were placed in the top three by less than 10% of patients. Excluding the top three rankings, there was considerable variability in ratings. Rankings were generally unrelated to patient or disease characteristics, with the exception that cure and living were of slightly lower priority and pain of higher priority to older patients compared with younger patients. CONCLUSION: The data suggest that, at least pretreatment, survival is of primary importance to patients, supporting the development of aggressive treatment strategies. In addition, results highlight individual variability and warn against making assumptions about patients' attitudes vis-à-vis potential outcomes. Whether patients' priorities will change as they experience late effects is currently under investigation.

Absence of major depressive disorder in female cancer patients.

This investigation evaluated the prevalence of depression in female patients who had cancer in any of five predesignated sites. Five hundred five women aged 17 to 80 (190 with breast cancer, 143 with gynecologic malignancies, 111 with melanoma, 37 with bowel cancer, and 24 with lymphoma) were randomly screened. Assessment included the Hamilton rating scale for depression, the Zung self-rating depression scale, the Karnofsky performance scale, and a 10-cm visual pain analogue line. The results revealed a mean Hamilton of 10.2 (range, 0 to 41; SD, 7.5), a mean Zung score of 35.3 (range, 11 to 68; SD, 9.6), a Karnofsky median score of 80, and a median pain score of 0. Scores on the Zung scale were highly correlated with those of the Hamilton scale (r = .75). Based on cutoff scores accepted as indicating depression (Hamilton greater than or equal to 20 and Zung greater than or equal to 50), patients were depressed. The depressed subgroup was in significantly more pain, experienced greater physical disability, and was more likely to have had prior episodes of depression as compared to the non-depressed women. The two best predictors of current depression were performance status (Karnofsky) and history of depression. No relationship was found between depression and other demographic variables or disease parameters (diagnosis, time since diagnosis, stage or phase of illness, and current treatment). Our findings indicate that the prevalence of major depression in cancer patients is lower than many previous studies have indicated and falls within the range seen in the general population.

Psychosocial adjustment of patients and caregivers prior to allogeneic bone marrow transplantation.

There are many studies that examine the psychosocial adjustment of survivors of bone marrow transplantation (BMT). On the other hand, there are relatively few studies that examine the psychosocial adjustment of patients prior to BMT, and even fewer that focus on the psychosocial adjustment of the patient's caregiver. The purpose of the present study was to assess performance status and psychosocial adjustment to illness, mood and stress response of patients and caregivers prior to admission for allogeneic BMT. Forty patients and their 39 caregivers were assessed using standardized measures. One-fourth of the patients reported clinical levels of psychosocial maladjustment on the Psychosocial Adjustment to Illness Scale and had greater adjustment problems than BMT survivors. Approximately one-third (35%) and one-quarter (23%) of the patients reported significant symptoms of intrusive and avoidance stress responses, respectively on the Impact of Events Scale. Caregivers reported more impairments in family relationships than patients, but overall reported similar distress to that of patients. Information about the pre-BMT process appears to be critical to understanding the psychosocial impact that BMT can have on patients and their caregivers.

Evaluation of quality of life in patients definitively treated for squamous carcinoma of the head and neck.

This paper reviews quality-of-life (QOL) assessment in head and neck cancer with a focus on research and methodologic developments of the past year. Issues of QOL measurement, as well as the challenges to data synthesis in light of the heterogeneity of head and neck cancer and its treatment, are discussed briefly. Methodologic advances include increased use of validated measures, longitudinal study design, and attention to patients' attitudes. Although the majority of studies assessed multiple QOL domains, including both physical/functional and emotional/social, more focused areas of investigation included pain, organ preservation, and depression. Examinations of the relation among domains suggested that impaired function does not necessarily lead to poor QOL and that the best predictor of 12-month global QOL is pretreatment global QOL. Future challenges include the need for large multi-institutional studies, consensus about instrument selection, addressing the problem of missing data, and how to apply group OOL to individual patient decisions.

Cancer during adolescence.

Specific developmental issues and long-term psychosocial implications are associated with a diagnosis of cancer during the period of adolescence. Effects on the adolescent's developing independence, sexual identity, and social and psychological maturity must be considered. Repercussions of these disruptions emphasize the need for creative treatment approaches which incorporate both immediate and long-term preventive and rehabilitative strategies.

Psychosocial consequences of cure.

Survivors of childhood cancer, having overcome the biggest hurdle to a normal life span, must continue to be vigilant toward health care issues as well as toward certain psychological and social problems for which they are at a greater than normal risk. The long-term survivor's knowledge about his/her illness, its treatment, and the consequent need for health surveillance and maintenance practices must be continually updated. Equally important is the survivor's preparation for coping with any long-term consequences of disruption in family, academic, and social activities engendered by cancer treatment. Existing research has frequently focused on patients diagnosed in early childhood. Recent studies, however, suggest that the developmental disruptions may have special significance for the adolescent, who is already struggling with unique issues of separation, changes in peer relationships, emergent sexuality, and future academic and occupational goals. Previous investigations addressing the medical and psychiatric problems encountered by the long-term survivor of adolescent cancer are presented with a focus on current psychological adjustment and degree of emancipation achieved. A recent pilot study, from three major medical centers, collected extensive interview data on a group of long-term survivors and sibling controls. Preliminary analyses of these data are described, and areas for future research are suggested.

Improving knowledge about prostate cancer: the development of an educational program for African-Americans.

This study aimed to develop and test a prostate cancer educational program, as well as an electronic keypad survey procedure, among African-Americans. A 1 h seminar and 12-item knowledge questionnaire were reviewed by both professional and lay consultants and then tested among African-American men and women recruited from the city of Chicago. Eight free presentations were delivered to a total of 63 attendees. Mean percent correct rose from 20% pre-program to 57% post-program (P<0.001) and there was an increase on all individual questions. This feasibility study demonstrated: (a) there is a general lack of information about prostate cancer among African-Americans; (b) know-ledge can be significantly increased by means of an hour-long seminar; and (c) electronic keypads provide an easy, acceptable means of collecting data. Finally, the study underscored the need for the development of active and creative recruitment strategies to increase attendance. Such efforts are currently underway.

A performance status scale for head and neck cancer patients.

Effective assessment of treatment outcome and the development of successful rehabilitation for head and neck cancer patients demand an evaluation of the relevant parameters of functional status. This paper reports the development and testing of a new Performance Status Scale for Head and Neck Cancer Patients designed to assess the unique areas of dysfunction experienced by this population. The instrument is a simple, practical, clinician-rated assessment tool consisting of three subscales: (1) Understandability of Speech, (2) Normalcy of Diet, and (3) Eating in Public. The scale was administered to a group of 181 head and neck patients and a comparison group of 30 breast cancer patients. Results indicate that the scale is reliable across raters and sensitive to functional differences across a broad spectrum of head and neck cancer.

You're never too old: a cancer education and risk reduction program for the elderly.

BACKGROUND: Although age is the most significant risk factor for cancer, older adults are less likely to be informed about and to follow through with screening procedures. METHODS: The University of Chicago Cancer Research Center, working in collaboration with health educators and city elderly organizations, developed a carefully scripted, hour-long presentation on cancer awareness and screening, designed specifically for older adults. The program was designed to be delivered in the community by trained graduate students. Pre-post-program surveys were used to evaluate the program's effectiveness in increasing cancer awareness. RESULTS: The presentation was delivered 40 times at Chicago nutrition sites, regional senior centers, retirement homes, and community clinics, reaching close to 1,000 individuals. Responses to revised surveys showed improvements of an average of 22 (ranging from one to 41) percentage points per question. CONCLUSIONS: This program gives older adults the basic knowledge and tools they need to take more active roles in their health care, follow healthier lifestyles, and reduce cancer risk.

The measurement of performance in childhood cancer patients.

The performance status of the child with cancer is an important outcome consideration in pediatric oncology research and practice. However, no single measure for children has been available. This is a report of the development and standardization of such a scale. The play-performance scale for children is a parent-rated instrument which records usual play activity as the index of performance. Performance status ratings were obtained on three groups of children: patients (n = 98), patients' siblings (n = 29), and an independent sample of hospital employees' children (n = 40). Children with all types and stages of childhood malignant neoplasms were represented. Test results established the parent as a competent, reliable rater and demonstrated the validity of the scale. Interrater reliability was examined using correlational statistics and percentage agreement. Agreement between parents was good, and there were no systematic rater biases. In addition, parents' ratings significantly discriminated differences in levels of functioning (mean score, patients 75.4 versus siblings 97.4). Correlational and analysis of variance (ANOVA) procedures demonstrated that the play-performance scale was significantly related to the global performance measures of experienced clinicians and was sensitive to change. Inpatients received a mean score of 42.3, outpatients 90.7, and normals 98.2. These findings indicate that the scale is both feasible and effective. It is concise, can be administered repeatedly even to extremely ill patients, and uses parents as observer reporters. The play-performance scale for children provides quantifiable, reproducible, and meaningful data, which is necessary for effective monitoring and management of the child with cancer.

Performance and quality of life outcome in patients completing concomitant chemoradiotherapy protocols for head and neck cancer.

This study evaluated post-treatment performance and quality of life (QOL) outcome in head and neck cancer (HNC) patients treated with organ preservation, intensive chemoradiotherapy (FHX). Participants were 47 Stage II-IV HNC patients with no evidence of disease at least one year post-completion of organ preservation, concomitant FHX treatment. Patients were assessed via a semi-structured in-person interview, standardized measures of QOL (FACT-H&N, CES-D), performance (PSS-HN) and patients' perception of residual side effects. Disease, treatment and toxicity data were retrieved from medical charts and protocol records. The most salient performance impairment was inability to eat a normal solid food diet, with 50% of patients able to eat soft foods or take liquids only. This specific functional deficit was not related to global QOL, nor to specific quality of life dimensions. Dry mouth, the most frequent and severe residual effect, was not associated with outcome diet, depression or QOL. Residual pain, seen in only 15% of patients, appeared to influence both functional and QOL parameters as well as being a marker for other troublesome symptoms. Twenty-three per cent of patients were depressed; depression was associated with past problems related to alcohol abuse. Decreased QOL and increased depressive symptomatology were related to total number and severity of residual effects. The data highlight the importance of systematic study of QOL dimensions and caution against making assumptions about patients' experience of particular disease and treatment sequelae.

The Performance Status Scale for Head and Neck Cancer Patients and the Functional Assessment of Cancer Therapy-Head and Neck Scale. A study of utility and validity.

BACKGROUND: The goal of this investigation was to examine the relationship between, and application of, two disease specific quality of life (QL) measures currently being employed for head and neck cancer patients: the Functional Assessment of Cancer Therapy-Head and Neck Scale (FACT-H&N) and the Performance Status Scale for Head and Neck Cancer Patients (PSS-HN). METHODS: The FACT-H&N and PSS-HN were administered to 151 head and neck cancer patients with a range of disease sites, treatment status (on vs. off treatment), and treatment modalities (surgery, radiation, and chemotherapy). RESULTS: FACT-H&N subscale and total scores and PSS-HN subscale scores proved sensitive to patients groups (showed significant and clinically meaningful differences) on the basis of treatment status (on vs. off treatment) and global performance status (Karnofsky scores). The pattern of correlations between FACT-H&N and PSS-HN subscales supported the scales' construct (convergent vs. divergent) validity. The strongest and most significant associations were observed between PSS-HN Normalcy of Diet and Eating in Public, and the head and neck subscale (HNS) of FACT-H&N, both of which were designed to measure the unique problems of head and neck cancer patients. More modest associations were observed between subscales measuring physical and functional areas of performance, social functioning, and emotional well-being. CONCLUSIONS: The FACT-HNS was found to be reliable and valid when applied to head and neck cancer patients. It clearly adds information to that collected by the parent (core) instrument. The PSS-HN also provides unique information, independent of that provided by the Karnofsky or the FACT-H&N. This study supported the multidimensional nature of QL for head and neck cancer patients, and thus the importance of assessing disease specific concerns in addition to general health status when assessing functional and QL outcome.

Tissue/dose compensation to reduce toxicity from combined radiation and chemotherapy for advanced head and neck cancers.

This study was undertaken to quantify the reduction in normal tissue complications resulting from the aggressive management of advanced head and neck cancers (AHNCs) utilizing tissue/dose compensation (TDC). Thirty-nine patients with AHNC were treated on an intensive chemotherapy + radiation regimen. Eighteen of 39 patients were treated using TDC; the remaining 21 patients were radiated without TDC (NTDC). Acute and chronic toxicities, swallowing, speech function, and quality of life were assessed. The TDC group had a smaller radiation dose gradient across the entire treatment volume. Unscheduled treatment breaks were required in 11% of TDC patients as compared with 43% of the NTDC group (P = 0.04). The TDC group had fewer Grade 3 or 4 acute and chronic toxicities and lower SOMA scores. At 3 months posttreatment, patients in the TDC group had better oral intake, lower pharyngeal residue, and better oropharyngeal swallowing efficiency and were able to swallow more bolus types. Patients in the TDC group also had better articulation. Use of TDC resulted in reduced treatment-related interruptions, decreased acute and chronic toxicities, and better speech and swallowing functions. Techniques to improve radiation dose conformality around the target tissues while decreasing the radiation dose to the normal tissues should be an integral part of aggressive combined modality therapy.

Toward the development of a play performance scale for children (PPSC).

Performance scales (i.e., Karnofsky), as they measure quality of life, have been used effectively as an integral part of repeated assessment of adult cancer patients for the last several years. An equally concise measure of performance has not been developed for children. The task of developing a scale to assess performance in infants, toddlers, school-age children, and adolescents is formidable, as the activity measured should be of equal merit at each age level. Although all childhood cancer patients could benefit from a simple-to-administer, rapid assessment, children with brain tumors have the greatest need for a repeated measure of performance. The goal, then, is to develop a simplified set of criteria that can be used for assessment of children with brain tumors during hospitalization, at the time of clinic visits, and/or at the time of diagnostic procedures when the patient is in a reasonable state of health. The assessment should be able to performed by nonprofessional persons.

Longitudinal assessment of quality of life in laryngeal cancer patients.

BACKGROUND: Although quality of life (QL) and performance status are important outcomes in head and neck (HN) cancer, there is little systematic inclusion of these parameters in treatment trials. METHODS: Rate and recovery of function were evaluated over a 6-month period in 21 laryngeal cancer patients, 7 in each of 3 treatment groups: total laryngectomy (group 1), hemilaryngectomy (group 2), and radiotherapy only (group 3). Assessment included Performance Status Scale for Head and Neck Cancer Patients (PSS-HN: Diet, Speech, and Eating in Public subscales) and the FACT-HN, a multidimensional QL measure. RESULTS: Groups differed in patterns of performance recovery over time in expected directions. Group 1 recovered most slowly, without achieving normal functioning by 6 months; most of group 2 returned to normal functioning by 3 months; group 3 showed little overall dysfunction. There was no difference in overall QL between groups or over time. Performance status was significantly correlated with the FACT head and neck subscale and somewhat with the Physical subscale. In contrast, ability to eat and/or speak was not associated with overall QL nor with any other specific QL dimension (eg, emotional or social well-being). CONCLUSIONS: Results support the sensitivity and applicability of two site-specific performance/QL measures: PSS-HN and FACT-HN. Findings also emphasize the need to employ multidimensional tools to adequately evaluate the nonmedical outcomes in head and neck patients.

Induction chemotherapy followed by concomitant chemoradiotherapy in the treatment of locoregionally advanced oropharyngeal cancer.

PURPOSE: Locoregionally advanced oropharyngeal cancer has been conventionally treated with either surgery and adjuvant radiotherapy or radiotherapy alone, and clinical and functional outcomes have been poor. Chemoradiotherapy has been demonstrated to improve functional outcome and disease control over conventional treatment in recent randomized head and neck trials. Herein, we report overall survival, progression-free survival, and patterns of failure in locoregionally advanced oropharyngeal cancer treated with induction chemotherapy with or without conservative surgery followed by concomitant chemoradiation. MATERIALS AND METHODS: Three cycles of induction chemotherapy consisting of cisplatin, 5-fluorouracil, leucovorin, and interferon alpha-2b (PFL-IFN) were followed by conservative, organ-sparing surgery for residual disease. All patients then proceeded to concomitant chemoradiation consisting of seven or eight cycles of 5-fluorouracil, hydroxyurea, and a total radiotherapy dose of roughly 7,000 cGy. RESULTS: Sixty-one patients with predominantly stage IV disease were treated. Clinical complete response was observed in 65% of patients after induction therapy. The median follow-up was 68.0 months for survivors and 39.0 months for all patients. At 5 years, overall survival is 51%, progression-free survival is 64%, locoregional control is 70%, and distant control is 89%. Locoregional recurrence accounted for 80% of all initial failures. Only five radical surgeries (none were total glossectomy) were performed for initial disease control. Treatment-related toxicity accounted for four deaths. CONCLUSION: PFL-IFN given with 5-fluorouracil, hydroxyurea, and radiotherapy produces a high rate of cures with organ preservation in a disease group that has traditionally fared poorly. Local and distant disease control and survival rates exceed those observed with more standard treatment approaches involving surgery and radiotherapy. Further investigation into chemoradiotherapy as a curative modality for this disease is warranted.

Sequential induction chemotherapy and concomitant chemoradiotherapy in the management of locoregionally advanced laryngeal cancer.

PURPOSE: To determine overall survival, progression-free survival, rate of voice preservation, and patterns of failure in locoregionally advanced laryngeal cancer treated with induction chemotherapy with or without surgery followed by concomitant chemoradiation. BACKGROUND: Locoregionally advanced laryngeal cancer has been conventionally treated with either surgery and adjuvant radiotherapy or radiotherapy alone, and clinical and functional outcomes have been poor. Chemoradiotherapy has been demonstrated to improve functional outcome and disease control over conventional treatment in recent randomized head and neck trials. PATIENTS AND METHODS: Advanced head and neck cancer patients were enrolled onto two consecutive phase II studies. Induction treatment consisted of three cycles of cisplatin, 5-fluorouracil (5-FU), leucovorin, and interferon-alpha 2b (PFL-IFN) followed by surgery for residual disease. Surgical intent was to spare the larynx when possible. All patients then proceeded to concomitant chemoradiation consisting of seven or eight cycles of 5-FU, hydroxyurea, and a planned total radiotherapy dose of 7000 cGy (FHX). RESULTS: A subset of thirty-two laryngeal cancer patients with predominantly stage IV disease comprises the study group for this report. Clinical CR was observed in 59% of patients following induction therapy. The median follow-up was 63.0 months for surviving patients and 44.5 months for all patients. At five years, overall survival is 47%, progression-free survival is 78%, and locoregional control is 78%. No distant failures were observed. Voice preservation with disease control was 75% at five years. Only two total laryngectomies were performed during the course of treatment and follow-up. Treatment-related toxicity accounted for two deaths. CONCLUSIONS: The addition of concomitant chemoradiotherapy to induction chemotherapy for locoregionally advanced laryngeal cancer appears to increase locoregional control and survival rates. PFL-IFN-FHX resulted in high rates of disease cure and voice preservation in a group of patients that has traditionally fared poorly in both clinical and functional outcome.