Unmet needs, quality of life and psychological distress: insights regarding head and neck cancer patients in a rural setting.

OBJECTIVE: This study aimed to evaluate the perceived quality of life, unmet needs and psychological distress in patients with head and neck cancer in a rural setting in New Zealand. METHOD: Patients presenting with head and neck cancer in Northland, New Zealand, were asked to complete questionnaires on quality of life, unmet needs, and anxiety or depression together with a free-text option. RESULTS: About one quarter of respondents (27 per cent) scored high in the anxiety and depression scale, with corresponding diminished quality of life scores and increased needs. Over half of respondents (54 per cent) found it challenging to travel for treatment. Financial difficulties were encountered more frequently with indigenous patients. Rurality alone does not lead to significant differences in quality of life or needs. CONCLUSION: After treatment for head and neck cancer, it is important to monitor and manage patients' psychological distress and ease of access to health services to improve quality of life.

Quality of life and functional outcomes in the management of early glottic carcinoma: a systematic review of studies comparing radiotherapy and transoral laser microsurgery.

BACKGROUND: Early glottic carcinoma can be managed by radiotherapy and transoral laser microsurgery with similar control and survival rates. The functional and quality of life outcomes of these interventions are therefore important to guide management. OBJECTIVE OF REVIEW: To compare the different treatment modalities for early glottic carcinoma with respect to quality of life, post-treatment voice character and swallowing outcomes. TYPE OF REVIEW: A systematic review of the literature with defined search strategy. SEARCH STRATEGY: Searches of EBM databases, and literature databases using key words: glotti*, laryn*, neoplasm, radiotherapy and laser surgery from 1970 to November 2009. Articles were screened for relevance using pre-determined inclusion and exclusion criteria. EVALUATION METHOD: Articles reviewed by authors and data compiled in tables for analysis. RESULTS: No randomised controlled trials were identified. There were 15 studies reporting vocal outcomes, and perception of voice disability was measured in eight studies; numbers were low in all the papers. Cumulatively, results for 880 patients were included, 448 had trans-oral laser microsurgery and 442 had radiotherapy. For vocal outcomes, 12 studies found no significant difference between radiotherapy and laser surgery, three reported superior outcomes for radiotherapy, whereas for the perception of voice disability, five reported no difference between treatment groups, while the remaining three reported conflicting results. Nine studies reported quality of life outcomes; seven of these reported no difference between the treatment groups in overall scores although some report differences in subsets of questions. CONCLUSIONS: The evidence base to date demonstrates comparable vocal and quality of life outcomes for radiotherapy and transoral laser surgery for early glottic carcinoma. There is a need for consensus on which measures of vocal quality and life satisfaction to be used in research trials to allow comparison between studies.

The association of psycho-social factors and survival in head and neck cancer.

OBJECTIVE: Update a previous review examining associations between psycho-social factors and survival in head and neck cancer patients. DATA SOURCES: Searched Cochrane, Psych info and Embase for the period from 1 January 1995 to 1 June 2007, as well as personal and article reference lists and article archives. STUDY SELECTION: Identified articles assessed by consensus for eligibility using following criteria: survival as outcome measure; psycho-social factors as prognostic indicators; results specifically for head and neck cancer patients, not including oesophageal or thyroid cancer. Seven of 64 articles fulfilled criteria. DATA EXTRACTION: Data abstracted independently by two reviewers using pre-determined proformas. Quality also rated using Scottish Intercollegiate Guidelines Network 50 tool. DATA SYNTHESIS: At baseline, expression of intense psycho-social complaints, higher self-perceived physical ability and self-reported high physical functioning were significantly associated with increased survival. Uncertainty about the diagnosis and treatment was found to be a negative prognostic indicator, as was being single, poor cognitive function, baseline fatigue and alcoholism. Overall quality of life and head and neck pain 12 months after date of diagnosis were found to be significantly associated with survival in one study. However, overall quality of life and depression at the time of diagnosis were not. CONCLUSIONS: There appears to be some association between selected psycho-social factors and long-term survival from head and neck cancer. However this relationship is currently neither strong nor proven, requiring examination by multi centred trials with standardisation of research definitions and methodologies, and examination of post-treatment psycho-social factors.

Utility of transcervical management of Zenker's diverticulum.

OBJECTIVE: To evaluate our results in treating Zenker's diverticulum via the transcervical approach, and to compare our experiences with a recent systematic review of both open and endoscopic approaches to the pharyngeal pouch. METHOD: An audit yielded 41 consecutive cases of Zenker's diverticulum treated between 2003 and 2013. RESULTS: All 41 patients underwent transcervical cricopharyngeal myotomy; 29 sacs also required 'inversion'. The median and mean length of hospital stay was 1 night and 2.5 nights respectively. The recurrence rate was 2.4 per cent and the complication rate was 9.8 per cent. CONCLUSION: When compared to reported endoscopic techniques, transcervical cricopharyngeal myotomy (with or without inversion) in our unit resulted in: shorter hospital stay, a comparable complication rate and fewer recurrences.

In vitro validation of endovascular Doppler-derived flow rates in models of the cerebral circulation.

This study presents validation of endovascular Doppler velocimetry-based volumetric flow rate measurements conducted in a pulsatile flow loop simulating conditions in both the internal carotid and basilar artery. In vitro models of cerebral vessels, each containing an aneurysm, were fabricated from patient anatomies extracted from 3D rotational angiography. Flow velocity measurements were collected with three different experimental techniques: an endovascular Doppler wire, Particle Image Velocimetry, and a time-resolved ultrasonic flow meter. Womersley's theory of pulsatile flow in a cylindrical vessel was used to compute time-resolved volumetric flow rates from the endovascular Doppler velocity. The volumetric flow rates computed from the Doppler measurements were compared to those from the Particle Image Velocimetry profile measurements, and the direct measurements from the ultrasonic flow meter. The study establishes confidence intervals for any systematic or random errors associated with the wire-derived flow rates as benchmarked to the other two modalities. There is an approximately 10% random error in the Doppler-derived peak and time-averaged flow rates. There is a measurable uniform bias, about 15% too low, in the time-averaged Doppler-derived flow rates. There is also a small proportional bias in the peak systolic Doppler-derived flow rates. Potential sources of error are also discussed.

Comparison of the metabolic effects of continuous postoperative enteral feeding and feeding at night only.

The effects of two different feeding patterns on oxygen consumption, nitrogen balance, blood biochemistry, and urinary catecholamine excretion were investigated over 5 d in patients after major head and neck surgery. Both groups of nine patients each were fed a regimen that provided 4.7 MJ on day 1 and 10 MJ on days 2-5 via a nasogastric tube by continuous infusion with an enteral feeding pump. One group was fed continuously for 24 h, the other was fed only at night, ie, from 1700 to 0900 the next morning. Oxygen consumption was significantly higher (P less than 0.01), nitrogen balance better (P less than 0.05), and urinary catecholamine excretion higher (P less than 0.05) in the 24-h-fed patients than in the night-fed patients. Postoperatively, feeding at night only is more energy efficient than is feeding continuously for 24 h, but is associated with poorer nitrogen balance. These differences may be mediated by sympathoadrenal mechanisms.

A comparison of the effects of intermittent and continuous nasogastric feeding on the oxygen consumption and nitrogen balance of patients after major head and neck surgery.

Ten patients were fed by nasogastric tube for 5 days after major surgery of the head and neck. Five were fed by continuous infusion 24 h/day using an enteral nutrition pump and five were fed comparable quantities by 2-h bolus administration between 0600 and 2200 h. Those fed by bolus had lower resting oxygen consumption on the 4th and 5th postoperative days and better cumulative nitrogen balance over the 5 days than the continuously fed group. It appears that metabolically it may be better to use an intermittent feeding regimen than a continuous one when feeding patients postoperatively via a nasogastric tube.

A 12 country field study of the EORTC QLQ-C30 (version 3.0) and the head and neck cancer specific module (EORTC QLQ-H&N35) in head and neck patients. EORTC Quality of Life Group.

This study tests the reliability and validity of the European Organization for Research and Treatment of Cancer (EORTC) head and neck cancer module (QLQ-H&N35) and version 3.0 of the EORTC Core Questionnaire (QLQ-C30) in 622 head and neck cancer patients from 12 countries. The patients completed the QLQ-C30, the QLQ-H&N35 and a debriefing questionnaire before antineoplastic treatment or at a follow-up. 232 patients receiving treatment completed a second questionnaire after treatment. Compliance was high and the questionnaire was well accepted by the patients. Multitrait scaling analysis confirmed the proposed scale structure of the QLQ-H&N35. The QLQ-H&N35 was responsive to differences between disease status, site and patients with different Karnofsky performance status, and to changes over time. The new physical functioning scale (with a four-point response format) of version 3.0 of the QLQ-C30 was shown to be more reliable than previous versions. Thus, the QLQ-H&N35, in conjunction with the QLQ-C30, appears to be reliable, valid and applicable to broad multicultural samples of head and neck cancer patients.

Cisplatinum and bleomycin for advanced or recurrent squamous cell carcinoma of the head and neck: a randomised factorial phase III controlled trial.

A phase III 2 X 2 factorial trial of cisplatinum and bleomycin in 116 patients with recurrent or advanced squamous cell carcinoma of the head and neck is reported. Thirty percent of patients proved to be unfit for chemotherapy, and of those treated progression of tumour was the commonest "response". However, 25% of patients achieved a partial or complete response, with no significant difference in response rates between the treated arms. The median number of courses received was 1 (range 0-6) and the commonest causes for discontinuation of treatment were renal toxicity and death. Bleomycin reduced survival, but not significantly so, whereas cisplatinum prolonged median survival significantly by 10 weeks. Significant predictors of survival, in addition to treatment by cisplatinum, were age, performance status, N status, number of courses and response of the tumor.

Tumor thickness in early tongue cancer.

OBJECTIVE: To review the relationship between tumor thickness and the subsequent development of cervical nodal metastases in 26 patients with stage I and II carcinomas of the oral tongue. METHODS: The histologic features of 26 consecutive patients treated for squamous carcinoma of the oral tongue were reviewed "blindly" by a pathologist, and the variables were correlated with clinical outcome. RESULTS: No association between tumor thickness and nodal metastases was found. Perineural infiltration was the only factor to approach statistical significance. There was also no statistically significant correlation between tumor thickness and patient survival. CONCLUSIONS: The histologic factors considered herein probably should be controlled for when comparing results of treatment of cancer of the oral tongue.

Staging of maxillary cancer. Which classification?

Of the many proposed classifications for staging maxillary sinus cancer, none has been adopted universally and none is known to be superior to the others. This study identified the best of six currently used classifications using data from 53 previously untreated patients with squamous cell carcinoma of the maxillary sinus. Analysis of each classification's ability to stage the majority of patients, produce a balanced distribution of T stages, and correlate T stage with treatment and prognosis revealed Harrison's classification to be the best. Harrison's classification should be adopted worldwide as the classification of choice for staging squamous cell carcinoma of the maxillary sinus.

Late ear sequelae in cleft palate patients.

This retrospective study looks at the incidence and nature of ear disease in 50 adolescent patients who had cleft palates repaired in infancy. Half of these patients had a history of grommet insertion. We found that most patients had normal hearing (81%) and middle-ear pressures (86%), although about half had tympanic membrane abnormalities. Grommet insertion did not result in better long-term hearing in this study but was strongly associated with tympanosclerosis. Cleft type did not influence the degree of ear disease although more patients with complete clefts had a history of repeated grommet insertion. Otitis media with effusion is almost universal in cleft palate infants and may influence later language, speech and educational development. At the time of palatal repair grommets should be inserted to improve hearing in these infants.

A randomized phase III trial of cisplatinum, methotrexate, cisplatinum + methotrexate, and cisplatinum + 5-fluoro-uracil in end-stage head and neck cancer.

In a previous phase III trial of chemotherapy for patients with end-stage squamous cell carcinoma of the head and neck we have shown that Bleomycin shortened the survival period, compared with untreated controls. The survival of patients treated with Cisplatinum and Bleomycin did not differ significantly from untreated patients, but Cisplatinum significantly prolonged survival. A further similar trial is reported here, the four treatment arms were Methotrexate alone, Cisplatinum alone, Cisplatinum + Methotrexate, and Cisplatinum + 5-Fluoro-uracil. The response rates were: Methotrexate alone 19%, Cisplatinum alone 40%, Cisplatinum + Methotrexate 31%, and Cisplatinum + 5-Fluoro-uracil 33%. The median survival time for the Cisplatinum alone group, 260 days, was significantly longer than the 80 days for the Methotrexate alone group. The median survival times for Cisplatinum + Methotrexate (160 days) and for Cisplatinum + 5-Fluoro-uracil (200 days) did not differ significantly from that for Cisplatinum alone.

Evolution of quality of life assessment in head and neck cancer.

Quality of life assessment as part of clinical practice in head and neck oncology began over 40 years ago. Early studies were narrative and cross-sectional; these were followed, at first, by simple quantitative measures of various parameters and later by longitudinal studies of greater complexity. More recently quality of life has been employed in a randomized clinical trial of head and neck cancer. Quality of life has evolved to become a standard means of assessing clinical outcomes, and an accepted end point measurement in clinical trials, to be considered alongside survivorship and side effects/complications.

Current use of chemotherapy for head and neck cancer.

A postal survey of 100 members of the Association of Head and Neck Oncologists of Great Britain was conducted in the first 6 months of 1983. The sample consisted principally of Otolaryngologists (50 per cent), Radiotherapists (14 per cent), Medical Oncologists (10 per cent), Oral Surgeons (10 per cent) and Plastic Surgeons (10 per cent). More than 80 per cent of those who completed the questionnaire used chemotherapy for Head and Neck cancer (72 per cent used it for palliation, and 64 per cent as part of combined modality therapy). There was great variation in the chemotherapeutic regimens used by the various responders. Furthermore, most responders used more than one regimen. Methotrexate was the agent most frequently used. No specific regimen, either single-agent or multiple-agent, enjoyed universal acceptance, although the combination of Vincristine, Bleomycin and Methotrexate was popular. Chemotherapy was thought by most responders to have a useful but as yet undefined place in the management of Head and Neck cancer. This survey underlines the need for prospective, controlled, clinical trials into the efficacy of cytotoxic chemotherapy for Head and Neck cancer.

Presumed laryngo-pharyngeal reflux: investigate or treat?

A review of a combined gastroenterology and laryngology clinic was conducted to determine the effectiveness of treatment and the predictive value of clinical findings and investigations. Data were collected prospectively. Investigations were performed according to clinical criteria. Patients with symptoms suspected to be due to laryngopharyngeal reflux (based on a positive oesophageal pH test and/or changes on videolaryngoscopy consistent with posterior laryngitis) were treated with omeprazole for at least two to three months. There were 87 patients; the most common symptoms were cough (38 per cent) and hoarseness (36 per cent); 77 per cent had some symptoms suggestive of gastro-oesophageal reflux. Sixty-seven patients were given omeprazole. A good response to laryngo-pharyngeal symptoms was seen in 37 patients (55 per cent). The presence of reflux symptoms was not a predictor of a good response. Increasing severity of oesophageal acid exposure over the 24 hours of pH testing was associated with a better symptom response (Spearman rank correlation, p = 0.01). Posterior laryngitis was not associated with the response to treatment, although there was a trend towards an association between improvement in laryngitis (after treatment) and improvement in symptoms (p = 0.08). The response to proton pump inhibitors was lower than other published results. Oesophageal pH monitoring may have a role in predicting which patients will respond to proton pump inhibitors. This study does not support the decision to treat with anti-secretory therapy, based only on the presence of posterior laryngitis.

Surgery of snoring.

Habitual, loud snoring is common in the adult population, and may be the only symptom of the more serious Obstructive Sleep Apnoea syndrome. We report here our results of uvulo-palato-pharyngo-plasty (UPPP), with or without nasal surgery, for snoring. Quantitative grading of the severity of the snoring shows that all patients were cured of symptomatic snoring, but that snoring was not altogether abolished in all patients.

A profile of laryngeal cancer in Auckland 1965-1979.

Laryngeal cancer presents early with hoarseness, but other symptoms such as cough, throat pain, dysphagia or dyspnoea should not be ignored. Middle-aged men with a history of high tobacco and alcohol consumption are particularly at risk. The age, sex incidence and anatomical site of the tumour in Auckland, New Zealand, is similar to that reported in Australia.

When does middle ear effusion signify nasopharyngeal cancer?

AIM: To analyse the presenting symptoms of patients with nasopharyngeal carcinoma seen in Auckland, New Zealand, with emphasis on the significance of otological symptoms. METHOD: The records of 85 patients with nasopharyngeal carcinoma seen in the department between 1980-93 were reviewed. RESULTS: Twenty eight of patients were Pacific Island Polynesian, 21 caucasian, and 18 Chinese. The youngest patient was 11 years old. The most prominent symptoms were neck mass (53), deafness/otalgia (45), nasal obstruction (35) and epistaxis (30). The ear symptoms, representing middle ear effusion were evident for more than 9 months, on average, before a diagnosis was made. Most patients presented with multiple symptoms: 95% of patients had one or more of the above four cardinal symptoms. Only two patients presented with middle ear effusion alone: 95 of the patients with middle ear effusion had another, accompanying, cardinal symptom. Nineteen patients had cranial nerve involvement. CONCLUSIONS: Neck mass, deafness/otalgia, progressive nasal obstruction and epistaxis are the cardinal symptoms of nasopharyngeal carcinoma. A persisting middle ear effusion in people over 10 years of age must be examined for nasopharyngeal carcinoma, if an accompanying cardinal symptom is also present, or develops.