Long-term cognitive, psychosocial, and neurovascular complications of unilateral head and neck irradiation in young to middle-aged adults.

BACKGROUND: With a growing, younger population of head and neck cancer survivors, attention to long-term side-effects of prior, often radiotherapeutic, treatment is warranted. Therefore, we studied the long-term cognitive effects in young adult patients irradiated for head and neck neoplasms (HNN). METHODS: Young to middle-aged adults with HNN (aged 18-40 years) and treated with unilateral neck irradiation ≥ 5 years before inclusion underwent cardiovascular risk and neuropsychological assessments and answered validated questionnaires regarding subjective cognitive complaints, fatigue, depression, quality of life, and cancer-specific distress. Additionally, magnetic resonance imaging (MRI) of the brain was performed to assess white matter hyperintensities (WMH), infarctions, and atrophy. RESULTS: Twenty-nine patients (aged 24-61, 13 men) median 9.2 [7.3-12.9] years post-treatment were included. HNN patients performed worse in episodic memory (Z-score = -1.16 [-1.58-0.34], p < 0.001) and reported more fatigue symptoms (Z-score = 1.75 [1.21-2.00], p < 0.001) compared to normative data. Furthermore, patients had a high level of fear of tumor recurrence (13 patients [44.8%]) and a heightened speech handicap index (13 patients [44.8%]). Only a small number of neurovascular lesions were found (3 infarctions in 2 patients and 0.11 [0.00-0.40] mL WMH), unrelated to the irradiated side. Cognitive impairment was not associated with WMH, brain atrophy, fatigue, or subjective speech problems. CONCLUSIONS: HNN patients showed impairments in episodic memory and an increased level of fatigue ≥ 5 years after radiotherapy compared to normative data. Cognitive impairments could not be explained by WMH or brain atrophy on brain MRI or psychological factors. TRIAL REGISTRATION: Clinicaltrials.gov ( https://clinicaltrials.gov/ct2/show/NCT04257968 ).

Sentido de la enfermedad y afrontamiento en pacientes con cáncer de cabeza y cuello / Sense of the disease and coping in patients with head and neck cancer

El cáncer entraña la necesidad de llevar a cabo una movilización de los recursos físicos, instrumentales y psicológicos para lograr una adaptación óptima de la persona enferma a su nueva situación. Asimismo, el sufrimiento derivado de la enfermedad lleva a los pacientes a plantearse el sentido de la misma y genera cambios en distintas áreas de la vida. Objetivo: explorar el sentido que la enfermedad posee para los pacientes con cáncer de cabeza y cuello (en adelante CCC) y los cambios derivados de ésta, en relación con las relaciones interpersonales y prioridades vitales de éstos. En segundo lugar, explorar la relación del afrontamiento del cáncer en función del sentido dado a la enfermedad. Método: la muestra está constituida por 114 pacientes diagnosticados de CCC. Se utilizaron los siguientes instrumentos de evaluación: cuestionario de datos sociodemográficos elaborado ad hoc y Mini-Mental Adjustment to Cancer Scale (Mini-MAC). Resultados: los pacientes que han dado un sentido negativo a la enfermedad se caracterizan por una mayor evitación cognitiva. Aquellos que han experimentado cambios positivos en sus relaciones personales se caracterizan por afrontar la enfermedad con mayor espíritu de lucha, y los que han vivenciado cambios en sentido negativo afrontan su enfermedad con mayor desamparo/desesperanza. Los pacientes que se dan prioridad a sí mismos obtienen una puntuación más elevada en fatalismo (U = 124,0), con respecto a los que tienen como prioridad su familia y los demás. Conclusión: se ha hallado una relación entre el sentido positivo y los cambios positivos en las relaciones personales con un afrontamiento más adaptativo de la enfermedad (AU)

Cancer implies the need to carry out a mobilization of physical, instrumental and psychological resources to achieve an optimal adaptation of the sick person to their new situation. Likewise, the suffering derived from the disease leads patients to consider the meaning of it and generates changes in different areas of life. Objective: to explore the meaning that the disease has for patients with head and neck cancer (hereinafter CCC) and the changes derived from it, in relation to their interpersonal relationships and vital priorities. Second, to explore the relationship between coping with cancer in terms of the meaning given to the disease. Method: the sample is made up of 114 patients diagnosed with CCC. The following assessment instruments were used: ad hoc sociodemographic data questionnaire and Mini-Mental Adjustment to Cancer Scale (Mini-MAC). Results: patients who have given a negative sense to the disease are characterized by greater cognitive avoidance. Those who have experienced positive changes in their personal relationships are characterized by facing the disease with a greater fighting spirit, and those who have experienced negative changes face their disease with greater helplessness/hopelessness. Patients who prioritize themselves obtain a higher score in fatalism (U = 124.0), compared to those who prioritize their family and others. Conclusion: a relationship has been found between the positive sense and positive changes in personal relationships with a more adaptive coping with the disease. And less adaptive coping for those who target their own people, rather than family or others (AU)

Clinician Attitudes and Beliefs About Deintensifying Head and Neck Cancer Surveillance.

Importance: Surveillance imaging and visits are costly and have not been shown to improve oncologic outcomes for patients with head and neck cancer (HNC). However, the benefit of surveillance visits may extend beyond recurrence detection. To better understand surveillance and potentially develop protocols to tailor current surveillance paradigms, it is important to elicit the perspectives of the clinicians who care for patients with HNC. Objective: To characterize current surveillance practices and explore clinician attitudes and beliefs on deintensifying surveillance for patients with HNC. Design, Setting, and Participants: This qualitative study was performed from January to March 2021. Guided by an interpretive description approach, interviews were analyzed to produce a thematic description. Data analysis was performed from March to April 2021. Otolaryngologists and radiation oncologists were recruited using purposive and snowball sampling strategies. Main Outcomes and Measures: The main outcomes were current practice, attitudes, and beliefs about deintensifying surveillance and survivorship as well as patients' values and perspectives collected from interviews of participating physicians. Results: Twenty-one physicians (17 [81%] men) were interviewed, including 13 otolaryngologists and 8 radiation oncologists with a median of 8 years (IQR, 5-20 years) in practice. Twelve participants (57%) stated their practice comprised more than 75% of patients with HNC. Participants expressed that there was substantial variation in the interpretation of the surveillance guidelines. Participants were open to the potential for deintensification of surveillance or incorporating symptom-based surveillance protocols but had concerns that deintensification may increase patient anxiety and shift some of the burden of recurrence monitoring to patients. Patient and physician peace of mind, the importance of maintaining the patient-physician relationship, and the need for adequate survivorship and management of treatment-associated toxic effects were reported to be important barriers to deintensifying surveillance. Conclusions and Relevance: In this qualitative study, clinicians revealed a willingness to consider altering cancer surveillance but expressed a need to maintain patient and clinician peace of mind, maintain the patient-clinician relationship, and ensure adequate monitoring of treatment-associated toxic effects and other survivorship concerns. These findings may be useful in future research on the management of posttreatment surveillance.

Risk of Suicidal Self-directed Violence Among US Veteran Survivors of Head and Neck Cancer.

Importance: Head and neck cancer (HNC) survivors are about twice as likely to die by suicide compared with other cancer survivors. Objective: To examine the associations between precancer mental health and pain and postcancer receipt of mental health, substance use disorder (SUD), or palliative care services with risk of suicidal self-directed violence (SSDV). Design, Setting, and Participants: This retrospective cohort study used the Veterans Health Administration data of 7803 veterans with a diagnosis of HNC (stage I-IVB) who received cancer treatment between January 1, 2012, and January 1, 2018. Data were analyzed between May 2020 and July 2021. Exposures: Presence of precancer chronic pain and SUD diagnoses, and postcancer SUD, mental health, or palliative care treatment. Exposures were defined using International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes in Veterans Health Administration administrative data. Main Outcomes and Measures: Documented SSDV event, including suicide attempt or death by suicide, after HNC diagnosis. Results: Among the cohort of 7803 veterans (7685 [98.4%] male; mean [SD] age, 65 [10.7] years), 72 (0.9%) had at least 1 documented SSDV event following their cancer diagnosis, and 51 (0.7%) died by suicide. Four adjusted modified Poisson regression analyses identified that precancer chronic pain (incidence rate ratio [IRR], 2.58; 95% CI 1.54-4.32) or mood disorder diagnoses (IRR, 1.95; 95% CI, 1.17-3.24) were associated with higher risk of postcancer SSDV. Those who had at least 1 documented mental health (IRR, 2.73; 95% CI, 1.24-6.03) or SUD (IRR, 3.92; 95% CI, 2.46-6.24) treatment encounter in the 90 days following HNC diagnosis were at higher risk for SSDV. A palliative care encounter within 90 days of postcancer diagnosis was associated with decreased risk of SSVD (IRR, 0.49; 95% CI, 0.31-0.78). Conclusions and Relevance: In this cohort study, a high proportion of HNC survivors with an SSVD event died from their injuries. Identification of risk factors for SSDV among HNC survivors may help direct additional resources to those who are at high risk. Referral to palliative care appears to be an important component of supportive oncologic care to reduce the risk of SSDV.

Risk Factors for Sleep Disturbances in Patients Scheduled for Radiotherapy of Head-and-Neck Cancer.

BACKGROUND/AIM: Many patients with head-and-neck cancer are scheduled for irradiation. This study was performed to determine the frequency of and risk factors for pre-radiotherapy sleep disturbances in these patients. PATIENTS AND METHODS: A total of 103 patients with head-and-neck cancer scheduled for radiotherapy were included in this retrospective study. Eighteen characteristics were evaluated including timing of start of radiotherapy relative to COVID-19 pandemic; age; gender; Karnofsky performance score; Charlson comorbidity index; history of another malignancy; family history of malignancy; distress score; number of emotional, physical or practical problems; request for psychological support; tumor site and stage; upfront surgery; planned chemotherapy; and brachytherapy boost. RESULTS: The frequency of pre-radiotherapy sleep disturbances was 42.7%. This was significantly associated with age ≤63 years (p=0.049), Karnofsky performance score ≤80 (p=0.002), Charlson comorbidity index ≥3 (p=0.005), history of another malignancy (p=0.012), emotional (p=0.001) or physical (p<0.001) problems, and request for psychological support (p=0.002). CONCLUSION: Sleep disturbances were frequent in patients assigned to radiotherapy of head-and-neck cancer. Recognizing risk factors for sleep disturbance helps identify patients requiring psychological support.

Disparity of perception of quality of life between head and neck cancer patients and caregivers.

BACKGROUND: Caregivers are invaluable sources of support for individuals recovering from head and neck cancer (HNC). Accordingly, minimizing caregiver distress is essential to promote the well-being of both caregivers and their patients. This study assessed if psychosocial distress (i.e., anxiety and depression) among HNC caregivers is associated with a difference in how caregivers and their patients perceive patients' quality of life (QOL) after treatment completion. METHODS: Caregivers' and patients' perceptions of patient QOL were assessed using the University of Washington QOL Questionaire (UWQOL), a validated HNC-specific health-related QOL questionnaire. The survey is interpreted in terms of its two composite scores: a physical QOL score and a social-emotional QOL score with higher scores indicating better QOL. Caregiver anxiety was assessed using the Generalized Anxiety Questionaire-7 (GAD-7) and caregiver depression was assessed using the Patient Health Questionaire 8 (PHQ-8). Patients completed the UWQOL as part of clinic intake while caregivers were asked to complete the UWQOL for their patients in addition to the PHQ-8 and GAD-7 in private. Linear regression was used to analyze the association between differences in caregivers' and patients' QOL scores (both social-emotional and physical QOL subscale scores) and GAD-7 and PHQ-8 scores. RESULTS: Of 47 caregivers recruited, 42.6% (n = 20) viewed patients' social-emotional QOL more negatively than patients themselves, while 31.9% viewed patients' physical QOL more negatively. After controlling for covariates, differences in perception of social-emotional QOL (p = .01) and differences in perception of physical QOL (p = .007) were significantly associated with caregiver depression, but not anxiety. Caregivers who disagreed with patients regarding patients' social-emotional QOL scored 6.80 points higher on the PHQ8 than agreeing caregivers. Caregivers who disagreed regarding patients' physical QOL scored 6.09 points higher. CONCLUSION: Caregivers commonly view patients' QOL more negatively than patients themselves. These caregivers tend to have greater psychosocial distress than caregivers who agree with their patients. Interventions designed to identify and aid at-risk caregivers are critically needed. We propose screening for differences in perception of patient QOL as a way of identifying distressed caregivers as well as provider-facilitated communication between patients and caregivers as possible interventions that should be examined in future research.

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, ß [95% CI]) and declining course per year during follow-up (interaction × time, ß [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 (ß = -7.00 [-12.43 to 1.56]), risk of malnutrition (ß = -6.18 [-11.55 to -0.81]), and IADL restrictions (ß = -10.48 [-16.39 to -4.57]) were associated with increased GHS/QOL decline at 3 months after treatment. Severe comorbidity (ß = -4.90 [-9.70 to -0.10]), IADL restrictions (ß = -5.36 [-10.50 to -0.22]), restricted mobility (ß = -6.78 [-12.81 to -0.75]), signs of depression (ß = -7.08 [-13.10 to -1.06]), and living with assistance or in a nursing home (ß = -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 ß = -3.17 [-5.04 to -1.30]) and deterioration during follow-up (per domain per year ß = -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.

Multiple Sequential Free Flap Reconstructions of the Head and Neck: A Single-Center Experience.

BACKGROUND: Free flap reconstruction is the standard of care in extensive defects of the head and neck area, and although most patients may be treated sufficiently with one flap, recurrence of a malignant tumor or failure of a previous reconstruction may make the use of a second (or more) flap necessary. The aim of this study was to evaluate the indications and success rates of multiple consecutive reconstructive procedures in a large cohort of patients. METHODS: Nine hundred ninety-six free flap reconstructions were retrospectively analyzed and cases of sequential reconstructions in the same patient were identified. Indications, success rates, perioperative procedures, and frequently used flaps were evaluated. RESULTS: Two hundred twenty cases of sequential microvascular reconstructions were identified, ranging from two to six flaps per patient. The overall flap success rate was 89.1 percent. A history of diabetes was identified as a risk factor for flap failure (p = 0.029). There was no association of flap loss with the number of reconstructive procedures per patient. CONCLUSIONS: The use of several free flaps in the same patient is a feasible option for patients suffering from recurrent tumors or to improve quality of life by a secondary reconstruction. A salvage free flap transfer to replace a lost transplant exhibits good success rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Assessment of the perceived stress and burden of family caregivers of the head-and-neck cancer patients at a tertiary care cancer center: A cross-sectional study.

INTRODUCTION: Cancer is a major life-threatening disease and has an impact on both patients and their family members. Caring for cancer patients may lead to several levels of stress which may affect their own health as well as their quality of life. AIM: To assess the perceived stress and burden of family caregivers of head and neck cancer patients (HNC) attending cancer care centre at a tertiary care centre, Tamil Nadu. OBJECTIVES: To assess the perceived stress and the burden among caregivers of patients with head and neck cancer using the Perceived Stress Scale (PSS) and Caregiver Strain Index (CSI) respectively. MATERIALS AND METHOD: A Cross-sectional study was carried out for a period of three months among the caregivers of head and neck cancer patients at a cancer care centre, Madurai. A total of 200 caregivers were selected by Convenience sampling method. Data was collected using a pretested, self-structured, closed-ended questionnaire by face to face interview method. RESULTS: The study population consisted of Caregivers aged 21-60 years, mostly females (80%), spouses (54%), employed (57%) and uneducated (66%). Most of the caregivers were from lower socioeconomic status (66%) and those who are providing care for 1 to 6 months were more in number. In this study, 82% of caregivers reported high caregiver burden (CSI ≥7) and 67% of caregivers reported high stress (PSS ≥ 26 - 40). CONCLUSION: Caregivers are experiencing significant burden, particularly with respect to their physical and psychological well-being, economic circumstances, social and personal relationships.

Patient perspectives on surveillance after head and neck cancer treatment: A systematic review.

OBJECTIVES: Current guidelines advise post-treatment surveillance of head and neck cancer (HNC) patients should involve scheduled appointments with a variety of practitioners. Increasing numbers of HNC survivors raise the burden to provide efficient and effective care. With resource limitation, there is growing importance to identify how surveillance can be justified and optimised for survivors. This systematic review presents current evidence on patient perspectives of post-treatment HNC surveillance, aiming to inform future work putting patient priorities at the forefront of surveillance planning. DESIGN: MEDLINE, Embase, the Cochrane Library, NIHR Dissemination Centre, The Kings Fund Library, Clinical Evidence, NHS Evidence and NICE Clinical Evidence were searched to identify publications regarding patient perspectives of HNC post-treatment surveillance. Studies not reporting on both surveillance and patient perspectives were excluded. RESULTS: Three thousand five hundred fifty-eight citations were screened and 49 full-text articles reviewed. Sixteen studies were included in the final review. Three authors reviewed all articles prior to final analysis to ensure all met inclusion criteria. Most evidence was low quality. Study models returned included cross-sectional surveys, structured interviews and one systematic review. Overall, positive perceptions of HNC surveillance were mostly related to increased reassurance. Negative perceptions predominantly focused on anxiety and fear of recurrence, but a lack of psychological support and inadequate access to certain aspects of care were also reported. CONCLUSIONS: This systematic review demonstrates that patients' perceptions of surveillance after HNC are mostly positive, feeling it provides reassurance. However, several studies report unmet needs, particularly regarding managing anxiety.

Patient-Reported Aesthetic and Psychosocial Outcomes After Microvascular Reconstruction for Head and Neck Cancer.

Importance: Aesthetic outcomes are key determinants of psychosocial functioning among surgically treated patients with head and neck cancer (HNC); however, long-term aesthetic outcomes after microvascular free tissue transfer (MFTT) are not well described. Objective: To examine risk factors for impaired long-term aesthetic satisfaction and appearance-related psychosocial functioning after HNC ablation with MFTT. Design, Setting, and Participants: A cross-sectional, web-based survey was conducted at an academic tertiary care center. A total of 228 individuals who underwent MFTT between January 1, 2015, and December 31, 2019, for treatment of HNC were included. The study was conducted from November 1, 2020, through January 15, 2021. Exposures: Head and neck cancer ablation with MFTT. Main Outcomes and Measures: Patient-reported outcomes were assessed via Aesthetic FACE-Q scales. The primary objective was aesthetic satisfaction determined by the Satisfaction With Facial Appearance scale. Secondarily, the Appearance-Related Psychosocial Distress, Psychological Function, and Social Function scales were used to assess appearance-related psychosocial functioning. Patients were stratified by demographic, disease, surgical, and postoperative characteristics. Survey scores on a 100-point scale were compared and subjected to univariable and multivariable linear regression. Results: A total of 124 of 228 patients (54.4%) completed surveys a median of 34.4 months after MFTT (interquartile range, 22.6-48.8). Most responders (79 [63.7%]) were men with advanced cancer of the oral cavity or skin, reconstructed with anterolateral thigh or osteocutaneous fibula free flaps. Nonresponders had no significant differences in baseline characteristics. The Satisfaction With Facial Appearance score was independently lower among patients who received osteocutaneous flaps (regression coefficient, -10.6 points, 95% CI, -20.4 to -0.8 points) and/or adjuvant (chemo)radiotherapy (regression coefficient, -6.9 points; 95% CI, -13.8 to -0.1 points). Impaired appearance-related psychosocial functioning was independently associated with female sex, a history of anxiety or depression, osteocutaneous flaps, prolonged tube feeding requirements, and any recurrent or persistent disease. After adjustment for covariates, each 1-point increase in the Satisfaction With Facial Appearance score independently estimated improved appearance-related psychosocial functioning as determined by the Appearance-Related Psychosocial Distress scale (regression coefficient, -0.5 points; 95% CI, -0.7 to -0.4 points), Psychological Function scale (regression coefficient, 0.4 points; 95% CI, 0.3 to 0.5 points), and Social Function scale (regression coefficient, 0.4 points; 95% CI, 0.3 to 0.6 points). Conclusions and Relevance: The findings of this cross-sectional, web-based survey study suggest that osteocutaneous reconstruction and adjuvant therapy independently increase the risk of poor patient-reported long-term aesthetic satisfaction, which correlated with impaired appearance-related psychosocial functioning. Aesthetic outcomes appear to be a priority to address in patients with HNC undergoing MFTT.

Prevalence, trends, and demographic characteristics associated with self-reported financial stress among head and neck cancer patients in the United States of America.

BACKGROUND: Understanding the economic burden imposed by head and neck cancer diagnoses essential to contextualize healthcare decision-making for these patients. METHODS: A retrospective, cross-sectional analysis of the US National Health Interview Survey was performed between 2013 and 2018. Demographic and socioeconomic characteristics of adult head and neck cancer patients were analyzed in relation to survey responses related to financial stress factors. RESULTS: Among 710 head and neck cancer patients, 21.39% (95% Cl, 17.69%-25.09%) reported difficulty paying medical bills within the previous 12 months. Multivariable logistic regression revealed insurance status [aOR 2.17 (95% CI, 1.15-4.07), p < 0.001] and poverty status [aOR 2.55 (95% CI, 1.48-4.37), p = 0.017] to be significantly associated with difficulty paying medical bills. CONCLUSION: A large proportion of HNC patients may experience financial stress related not only to out-of-pocket health care costs, but also exogenous financial challenges. These findings suggest that a significant proportion of HNC patients may experience financial stress related not only to out-of-pocket health care costs, but also exogenous financial challenges. Such barriers may impede patients' ability to access and adhere to treatment or force detrimental tradeoffs between health care and other essential needs.

Factors Associated With Risk of Body Image-Related Distress in Patients With Head and Neck Cancer.

Importance: Body image-related distress (BID) is common among head and neck cancer (HNC) survivors and associated with significant morbidity. Risk factors for HNC-related BID remain poorly characterized because prior research has used outcome measures that fail to fully capture BID as experienced by HNC survivors. Objective: To assess the association of demographic and oncologic characteristics with HNC-related BID using the Inventory to Measure and Assess imaGe disturbancE-Head & Neck (IMAGE-HN), a validated, multidomain, patient-reported outcome measure of HNC-related BID. Design, Setting, and Participants: This cross-sectional study assessed 301 adult survivors of surgically managed HNC at 4 academic medical centers. Main Outcomes and Measures: The primary outcome measure was IMAGE-HN scores, for which higher scores reflect more severe HNC-related BID. Multivariable linear regression analyses were performed to evaluate the association of patient characteristics with IMAGE-HN global and 4 subdomain (other-oriented appearance concerns, personal dissatisfaction with appearance, distress with functional impairments, and social avoidance) scores. Results: Of the 301 participants (212 [70.4%] male; mean [SD] age, 65.3 [11.7] years), 181 (60.1%) underwent free flap reconstruction. Graduation from college (ß = -9.6; 95% CI, -17.5 to -1.7) or graduate school (ß = -12.6; 95% CI, -21.2 to -3.8) was associated with lower IMAGE-HN social avoidance scores compared with less than a high school education. Compared with paid work, unemployment was associated with higher IMAGE-HN other-oriented appearance (ß = 10.7; 95% CI, 2.0-19.3), personal dissatisfaction with appearance (ß = 12.5; 95% CI, 1.2-23.7), and global (ß = 8.0; 95% CI, 0.6-15.4) scores. Compared with no reconstruction, free flap reconstruction was associated with higher IMAGE-HN global scores (ß = 11.5; 95% CI, 7.9-15.0) and all subdomain scores (other-oriented appearance: ß = 13.1; 95% CI, 8.6-17.6; personal dissatisfaction with appearance: ß = 15.4; 95% CI, 10.0-20.7; distress with functional impairment: ß = 12.8; 95% CI, 8.1-17.4; and social avoidance and isolation: ß = 10.2; 95% CI, 5.8-14.6). Higher IMAGE-HN distress with functional impairment scores were found in those who received surgery and adjuvant radiation (ß = 7.8; 95% CI, 2.9-12.7) or chemoradiotherapy (ß = 6.5; 95% CI, 1.8-11.3) compared with surgery alone. The multivariable regression model accounted for a modest proportion of variance in IMAGE-HN global (R2 = 0.18) and subdomain scores (R2 = 0.20 for other-oriented appearance, 0.14 for personal dissatisfaction with appearance, 0.21 for distress with functional impairment, and 0.13 for social avoidance and isolation). Conclusions and Relevance: In this cross-sectional study, factors associated with risk of HNC-related BID included free flap reconstruction, lower educational attainment, unemployment, and multiple treatment modalities. These characteristics explain a modest proportion of variance in IMAGE-HN scores, suggesting that other characteristics may be the major risk factors for HNC-related BID and should be explored in future studies.

Incidence and Risk of Suicide Among Patients With Head and Neck Cancer in Rural, Urban, and Metropolitan Areas.

Importance: Patients with head and neck cancer (HNC) are known to be at increased risk of suicide compared with the general population, but there has been insufficient research on whether this risk differs based on patients' rural, urban, or metropolitan residence status. Objective: To evaluate whether the risk of suicide among patients with HNC differs by rural vs urban or metropolitan residence status. Design, Setting, and Participants: This cross-sectional study uses data from the Surveillance, Epidemiology, and End Results database on patients aged 18 to 74 years who received a diagnosis of HNC from January 1, 2000, to December 31, 2016. Statistical analysis was conducted from November 27, 2020, to June 3, 2021. Exposures: Residence status, assessed using 2013 Rural Urban Continuum Codes. Main Outcomes and Measures: Death due to suicide was assessed by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes (U03, X60-X84, and Y87.0) and the cause of death recode (50220). Standardized mortality ratios (SMRs) of suicide, assessing the suicide risk among patients with HNC compared with the general population, were calculated. Suicide risk by residence status was compared using Fine-Gray proportional hazards regression models. Results: Data from 134 510 patients with HNC (101 142 men [75.2%]; mean [SE] age, 57.7 [10.3] years) were analyzed, and 405 suicides were identified. Metropolitan residents composed 86.6% of the sample, urban residents composed 11.7%, and rural residents composed 1.7%. The mortality rate of suicide was 59.2 per 100 000 person-years in metropolitan counties, 64.0 per 100 000 person-years in urban counties, and 126.7 per 100 000 person-years in rural counties. Compared with the general population, the risk of suicide was markedly higher among patients with HNC in metropolitan (SMR, 2.78; 95% CI, 2.49-3.09), urban (SMR, 2.84; 95% CI, 2.13-3.71), and rural (SMR, 5.47; 95% CI, 3.06-9.02) areas. In Fine-Gray competing-risk analyses that adjusted for other covariates, there was no meaningful difference in suicide risk among urban vs metropolitan residents. However, compared with rural residents, residents of urban (subdistribution hazard ratio, 0.52; 95% CI, 0.29-0.94) and metropolitan counties (subdistribution hazard ratio, 0.55; 95% CI, 0.32-0.94) had greatly lower risk of suicide. Conclusions and Relevance: The findings of this cross-sectional study suggest that suicide risk is elevated in general among patients with HNC but is significantly higher for patients residing in rural areas. Effective suicide prevention strategies in the population of patients with HNC need to account for rural health owing to the high risk of suicide among residents with HNC in rural areas.

Patient-Reported Toxicity and Quality-of-Life Profiles in Patients With Head and Neck Cancer Treated With Definitive Radiation Therapy or Chemoradiation.

PURPOSE: Radiation therapy is an effective but burdensome treatment for head and neck cancer (HNC). We aimed to characterize the severity and time pattern of patient-reported symptoms and quality of life in a large cohort of patients with HNC treated with definitive radiation therapy, with or without systemic treatment. METHODS AND MATERIALS: A total of 859 patients with HNC treated between 2007 and 2017 prospectively completed the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-Head and Neck Cancer module (QLQ-HN35) and Core Quality of Life Questionnaire (QLQ-C30) at regular intervals during and after treatment for up to 5 years. Patients were classified into 3 subgroups: early larynx cancer, infrahyoideal cancer, and suprahyoideal cancer. Outcome scales of both questionnaires were quantified per subgroup and time point by means of average scores and the frequency distribution of categorized severity (none, mild, moderate, and severe). Time patterns and symptom severity were characterized. Toxicity profiles were compared using linear mixed model analysis. Additional toxicity profiles based on age, human papillomavirus status, treatment modality, smoking status, tumor site, and treatment period were characterized as well. RESULTS: The study population consisted of 157 patients with early larynx cancer, 304 with infrahyoideal cancer, and 398 with suprahyoideal cancer. The overall questionnaire response rate was 83%. Generally, the EORTC QLQ-HN35 symptoms reported showed a clear time pattern, with increasing scores during treatment followed by a gradual recovery in the first 2 years. Distinct toxicity profiles were seen across subgroups (P < .001), with generally less severe symptom scores in the early larynx subgroup. The EORTC QLQ-C30 functioning, quality-of-life, and general symptoms reported showed a less evident time pattern and less pronounced differences in mean scores between subgroups, although differences were still significant (P < .001). Differences in mean scores were most pronounced for role functioning, appetite loss, fatigue, and pain. CONCLUSIONS: We established patient-reported toxicity and quality-of-life profiles that showed different patterns for 3 subgroups of patients with HNC. These profiles provide detailed information on the severity and persistence of various symptoms as experienced by patients during and after definitive radiation therapy. These profiles can be used to inform treatment of future patients and may serve as a benchmark for future studies.

Appearance-Related Distress and Social Functioning after Head and Neck Microvascular Reconstruction.

OBJECTIVES/HYPOTHESIS: To better understand aesthetic patient-reported outcomes and psychosocial quality of life (QOL) after head and neck microvascular reconstruction for benign or malignant tumors. STUDY DESIGN: Single-center prospectively obtained in-office validated questionnaire-based study. METHODS: Analysis of prospectively collected surveys at a tertiary care academic center from June 2018 to February 2021. Patients completed two FACE-Q scales: Appearance-Related Psychosocial Distress (ARPD) and Social Function (SF). Survey scores, demographics, operative course, and adjuvant therapy data underwent univariate and multivariable analyses. RESULTS: One hundred and three patients completed surveys at a median of 13.5 months postoperatively (interquartile range: 5.2-30.8). Mean ARPD from 0 (no distress) to 100 (maximum distress) was 32.4 (standard error of the mean [SEM]: 2.7). Mean SF from 0 (worst functioning) to 100 (best functioning) was 55.5 (SEM: 2.7). Postoperative adjuvant radiation was associated with 13.9% higher ARPD (95% CI: 3.4-24.4, P = .019) and 10.4% lower SF (95% CI: -20.7 to -0.1, P = .047). Each appearance-related question on the ARPD scale independently predicted impaired SF (P < .001 for all questions). Upon multivariable logistic regression, osteocutaneous reconstruction, compared to soft tissue alone (P = .043), and postoperative adjuvant radiation (P = .014) were associated with higher levels of ARPD. Age, sex, relationship status, anxiety or depression history, defect location, and hospital stay were not significantly associated with ARPD or SF scores. CONCLUSIONS: Aesthetic outcomes are important determinants of psychosocial QOL following head and neck microvascular reconstruction: an effect that is worsened by adjuvant radiation. Reconstructive surgeons should prioritize aesthetic outcomes, in addition to functional restoration, to optimize social functioning in patients with head and neck tumors. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:E2204-E2211, 2021.

Association of Epigenetic Age Acceleration With Risk Factors, Survival, and Quality of Life in Patients With Head and Neck Cancer.

PURPOSE: Epigenetic age acceleration (EAA) is robustly linked with mortality and morbidity. This study examined risk factors of EAA and its association with overall survival (OS), progression-free survival (PFS), and quality of life (QOL) in patients with head and neck cancer (HNC) receiving radiation therapy. METHODS AND MATERIALS: Patients without distant metastasis were enrolled and followed before and at the end of radiation therapy and at 6 and 12 months after radiation therapy. EAA was calculated with DNAmPhenoAge at all 4 time points. Risk factors included demographic characteristics, lifestyle, clinical characteristics, treatment-related symptoms, and blood biomarkers. Survival data were collected until August 2020, and QOL was measured using Functional Assessment of Cancer Therapy-HNC. RESULTS: Increased comorbidity, symptoms unrelated to human papilloma virus, and more severe treatment-related symptoms were associated with higher EAA (P = .03 to P < .001). A nonlinear association (quadratic) between body mass index (BMI) and EAA was observed: decreased BMI (<35 kg/m2; P = .04) and increased BMI (≥35 kg/m2; P = .01) were linked to higher EAA. Increased EAA (per year) was associated with worse OS (hazard ratio [HR], 1.11 [95% confidence interval {CI}, 1.03-1.18; P = .004]; HR, 1.10 [95% CI, 1.01-1.19; P = .02] for EAA at 6 and 12 months after treatment, respectively) and PFS (HR, 1.10 [95% CI, 1.02-1.19; P = .02]; HR, 1.14 [95% CI, 1.06-1.23; P < .001]; and HR, 1.08 [95% CI, 1.02-1.14; P = .01]) for EAA before, immediately after, and 6 months after radiation therapy, respectively) and QOL over time (ß = -0.61; P = .001). An average of 3.25 to 3.33 years of age acceleration across time, which was responsible for 33% to 44% higher HRs of OS and PFS, was observed in those who died or developed recurrence compared with those who did not (all P < .001). CONCLUSIONS: Compared with demographic and lifestyle factors, clinical characteristics were more likely to contribute to faster biological aging in patients with HNC. Acceleration in epigenetic age resulted in more aggressive adverse events, including OS and PFS. EAA could be considered as a marker for cancer outcomes, and decelerating aging could improve survival and QOL.

Screening for distress, related problems and perceived need for psycho-oncological support in head and neck squamous cell carcinoma (HNSCC) patients: a retrospective cohort study.

BACKGROUND: In different cancer entities, several studies have shown the adverse effects of cancer on mental health, psychological well-being and the increased risk of high emotional distress in cancer patients. This study aims to analyze psychosocial distress levels and their relationship between sociodemographic parameters and selected items on the Distress Thermometer (DT) Problem List in head and neck squamous cell carcinoma (HNSCC) patients. PATIENTS AND METHODS: We assessed a total of 120 HNSCC patients using the Distress Thermometer (DT) Problem List. Distress scores (DTS) of 90 patients were available. A DTS of ≥ 5 on the visual analogue scale represents clinically relevant distress. Data analysis consisted of descriptive statistics, comparison of mean values for different DTS subcategories and correlation between DTS scores and parameters of tumor classification, sociodemographic variables and selected problems. RESULTS: Distress was present in 57.7% of the sample, with a total of 52 patients with a DTS  ≥ 5. The mean DTS was 4.7 (SD 2.4). Patients with newly diagnosed HNSCC had significantly higher DTS. Distress levels were significantly associated with sadness, general worries, anxiety, nervousness, sleeping disorders, mouth sores and fever. Out of the total sample, 6 patients and out of these 6 individuals, 5 patients with a DTS ≥ 5 requested referrals to psycho-oncological service. CONCLUSION: High distress levels were common in HNSCC patients but only few patients desired psycho-oncological care. Addressing patients' supportive care needs in routine clinical practice is essential to meet unmet needs of HNSCC patients and thus improve cancer care.

The effect of comprehensive oral care program on oral health and quality of life in patients undergoing radiotherapy for head and neck cancer: A quasi-experimental case-control study.

OBJECTIVES: The purpose of this study is to investigate the effect of the comprehensive oral care program on oral health status and symptoms in head and neck cancer (HNC) patients undergoing radiotherapy. METHODS: This was a quasi-experimental study using a non-equivalent control group in non-synchronized design. All participants including control and experimental group were asked for the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire H&N35 (EORTC QLQ-H&N35) and given an oral health education 4 times at baseline, immediate postradiotherapy, 3 months after radiotherapy, and 6 months after radiotherapy. In each visit except for final, the experimental group was given fluoride varnish application and fluoride mouth rinsing solution for daily use. Oral health examination for dental caries, plaque score (PS), bleeding on probing (BOP), and salivary flow rate was performed in baseline and 6 months after radiotherapy. Statistical analyses were done by paired t-tests and mixed ANCOVA repeated-measures analysis. RESULTS: From November 1, 2013 to October 31, 2015, a total 61 patients undergoing radiotherapy for HNC cancer were enrolled (30 in control and 31 in experimental groups). Decrease in salivary flow rate was comparable between 2 groups. Dental caries increased in control group (P = .006); PS and BOP were decreased in experimental group (P < .001 and .004, respectively). Experimental group showed lower swallowing, speech problems, and less sexuality scores in EORTC QLQ-H&N35 than control group. CONCLUSION: We found improvement in oral health and the quality of life in HNC patients with comprehensive oral care intervention by dental professionals. Communicating and cooperating between the healthcare and dental professionals is needed to raise the quality of health care services for HNC patients receiving radiotherapy.

Post-treatment head and neck cancer survivors' approaches to self-management: A qualitative study.

PURPOSE: Post-treatment head and neck cancer (HNC) survivors contend with distinct, long-term challenges related to cancer treatments that impact their day-to-day lives. Alongside follow-up cancer care, they also must be responsible for the daily management of often intrusive physical and psychological symptoms, as well as maintaining their health and a lifestyle to promote their well-being. The purpose of this study was to identify HNC survivors' approaches toward engagement in self-management activities. METHODS: Post-treatment HNC survivors (N=22) participated in the study through purposeful sampling. Participants were eligible if they 1) had a history of upper aerodigestive tract cancer; 2) completed their most recent primary treatment (i.e. chemotherapy, radiation, and surgery) more than eighteen months prior and had no evidence of HNC, and 3) could speak in English. A semi-structured interview was used. Data was analyzed using content analysis. RESULTS: We identified three approaches that survivors took towards self-management activities: taking charge, living with it, and engaging as needed. Our results showed that taking charge is when survivors take an active role in evaluating their health and taking action subsequently; as needed represents engaging in self-management as necessary; and living with it reflects adapting to the symptoms and side effects without managing them. CONCLUSIONS: We propose self-management approaches as a novel mechanism to understand the relationship between survivors' characteristics and health preferences and their self-management. It is important for clinicians to highlight the variation in individuals 'self-management approaches as they work to identify tailored patient-centered strategies that compliment specific patient needs.