Irma M. Verdonck-de Leeuw

Impact of Late Treatment-Related Toxicity on Quality of Life Among Patients With Head and Neck Cancer Treated With Radiotherapy

PURPOSE To investigate the impact of treatment-related toxicity on health-related quality of life (HRQoL) among patients with head and neck squamous cell carcinoma treated with radiotherapy either alone or in combination with chemotherapy or surgery. PATIENTS AND METHODS The study sample was composed of 425 disease-free patients. Toxicity was scored according to the European Organisation for Research and Treatment of Cancer (EORTC)/Radiation Therapy Oncology Group (RTOG) late radiation-induced morbidity scoring system. HRQoL was assessed using the EORTC Quality of Life Questionnaire C30. These assessments took place at 6, 12, 18, and 24 months after completion of radiotherapy. The analysis was performed using a multivariate analysis of variance. RESULTS Of the six RTOG scales investigated, two significantly affected self-reported HRQoL, salivary gland (RTOG(xerostomia)) and esophagus/pharynx (RTOG(swallowing)). Although RTOG(xerostomia) was reported most frequently, HRQoL was most affected by RTOG(swallowing), particularly in the first 18 months after completion of radiotherapy. CONCLUSION Late radiation-induced toxicity, particularly RTOG(swallowing) and RTOG(xerostomia), has a significant impact on the more general dimensions of HRQoL. These findings suggest that the development of new radiation-induced delivery techniques should not only focus on reduction of the dose to the salivary glands, but also on anatomic structures that are involved in swallowing.

A predictive model for swallowing dysfunction after curative radiotherapy in head and neck cancer

INTRODUCTION Recently, we found that swallowing dysfunction after curative (chemo) radiation (CH) RT has a strong negative impact on health-related quality of life (HRQoL), even more than xerostomia. The purpose of this study was to design a predictive model for swallowing dysfunction after curative radiotherapy or chemoradiation. MATERIALS AND METHODS A prospective study was performed including 529 patients with head and neck squamous cell carcinoma (HNSCC) treated with curative (CH) RT. In all patients, acute and late radiation-induced morbidity (RTOG Acute and Late Morbidity Scoring System) was scored prospectively. To design the model univariate and multivariate logistic regression analyses were carried out with grade 2 or higher RTOG swallowing dysfunction at 6 months as the primary (SWALL(6months)) endpoint. The model was validated by comparing the predicted and observed complication rates and by testing if the model also predicted acute dysphagia and late dysphagia at later time points (12, 18 and 24 months). RESULTS After univariate and multivariate logistic regression analyses, the following factors turned out to be independent prognostic factors for SWALL(6months): T3-T4, bilateral neck irradiation, weight loss prior to radiation, oropharyngeal and nasopharyngeal tumours, accelerated radiotherapy and concomitant chemoradiation. By summation of the regression coefficients derived from the multivariate model, the Total Dysphagia Risk Score (TDRS) could be calculated. In the logistic regression model, the TDRS was significantly associated with SWALL(6months) ((p<0.001). Subsequently, we defined three risk groups based on the TDRS. The rate of SWALL(6months) was 5%, 24% and 46% in case of low-, intermediate- and high-risk patients, respectively. These observed percentages were within the 95% confidence intervals of the predicted values. The TDRS risk group classification was also significantly associated with acute dysphagia (P<0.001 at all time points) and with late swallowing dysfunction at 12, 18 and 24 months (p<0.001 at all time points). CONCLUSION The TDRS is a simple and validated measure to predict swallowing dysfunction after curative (CH) RT for HNC. This classification system enables identification of patients who may benefit from strategies aiming at prevention of swallowing dysfunction after curative (CH) RT such as preventive swallowing exercises during treatment and/or emerging IMRT techniques aiming at sparing anatomical structures that are involved in swallowing.

Predictive modelling for swallowing dysfunction after primary (chemo)radiation: Results of a prospective observational study

BACKGROUND AND PURPOSE The purpose of this large multicentre prospective cohort study was to identify which dose volume histogram parameters and pre-treatment factors are most important to predict physician-rated and patient-rated radiation-induced swallowing dysfunction (RISD) in order to develop predictive models for RISD after curative (chemo) radiotherapy ((CH) RT). MATERIAL AND METHODS The study population consisted of 354 consecutive head and neck cancer patients treated with (CH) RT. The primary endpoint was grade 2 or more swallowing dysfunction according to the RTOG/EORTC late radiation morbidity scoring criteria at 6 months after (CH) RT. The secondary endpoints were patient-rated swallowing complaints as assessed with the EORTC QLQ-H&N35 questionnaire. To select the most predictive variables a multivariate logistic regression analysis with bootstrapping was used. RESULTS At 6 months after (CH) RT the bootstrapping procedure revealed that a model based on the mean dose to the superior pharyngeal constrictor muscle (PCM) and mean dose to the supraglottic larynx was most predictive. For the secondary endpoints different predictive models were found: for problems with swallowing liquids the most predictive factors were the mean dose to the supraglottic larynx and radiation technique (3D-CRT versus IMRT). For problems with swallowing soft food the mean dose to the middle PCM, age (18-65 versus >65 years), tumour site (naso/oropharynx versus other sites) and radiation technique (3D-CRT versus IMRT) were the most predictive factors. For problems with swallowing solid food the most predictive factors were the mean dose to the superior PCM, the mean dose to the supraglottic larynx and age (18-65 versus >65 years). And for choking when swallowing the V60 of the oesophageal inlet muscle and the mean dose to the supraglottic larynx were the most predictive factors. CONCLUSIONS Physician-rated and patient-rated RISD in head and neck cancer patients treated with (CH) RT cannot be predicted with univariate relationships between the dose distribution in a single organ at risk and an endpoint. Separate predictive models are needed for different endpoints and factors other than dose volume histogram parameters are important as well.

Distress in Spouses and Patients After Treatment for Head and Neck Cancer

Background: The objective of this study is to obtain insight into distress in spouses and patients treated for head and neck cancer.

Health status and voice outcome after treatment for T1a glottic carcinoma

Radiotherapy as well as endoscopic laser surgery as the most widely used treatment modalities for T1a glottic carcinoma cause minor morbidity and negligible mortality and result in more or less comparable, excellent cure and larynx preservation rates. Therefore, other outcome measures such as voice-related problems and health status are important factors in the choice of treatment for T1a glottic cancer. The present study focuses on voice-related problems in the daily life of patients treated by radiotherapy or endoscopic laser surgery for T1a glottic cancer. Self ratings on health status assessed by means of COOP/WONCA health status charts and voice problems evaluated with a validated voice-specific questionnaire (the Voice Handicap Index) and overall judgment on voice quality were obtained. A total of 102 patients (56 treated by endoscopic laser surgery and 46 treated by radiotherapy) with at least 1-year follow-up were included. Response scores were high: 52 (93%) patients after endoscopic laser surgery versus 40 (87%) patients after radiation therapy completed and returned the questionnaires. A high percentage of patients reported voice problems in daily life: 58% of the patients following radiotherapy and 40% of the patients following endoscopic treatment had abnormal VHI scores. The difference between both treatment modalities proved to be significant. No significant differences were found concerning health status or overall judgment of voice quality. Moderate correlations were found between total VHI score and voice quality judgment and the COOP/WONCA social activities chart. This study reveals that treatment for T1a glottic cancer often does result in voice problems in daily life, negatively influencing patients social activities. Patients selected for endoscopic laser surgery on average report fewer voice-related problems than those who underwent radiotherapy.

Cordectomy by CO2 laser or radiotherapy for small T1a glottic carcinomas: Costs, local control, survival, quality of life, and voice quality

The clinical results of radiotherapy and endoscopic cordectomy for T1a glottic carcinoma are reported to be similar, but costs of both treatments may differ. Therefore, we retrospectively evaluated the costs, voice quality, quality of life, and clinical results of both treatments.

Employment and return to work in head and neck cancer survivors

To investigate employment in working-age head and neck cancer (HNC) survivors before and after treatment in relation to sociodemographic and clinical factors, health related quality of life, and emotional distress. Patients younger than 65 years at time of diagnosis and at least 2 years after curative treatment for HNC were included. Exclusion criteria were cognitive dysfunction and no understanding of Dutch language. Primary outcome measures were employment status and return to work assessed by a study specific questionnaire. Secondary outcome measures were health related quality of life (EORTC QLQ-C30 and QLQ-H&N35) and emotional distress (Hospital Anxiety and Depression Scale (HADS)). Sociodemographic and disease and treatment related parameters, health related quality of life, and distress were compared to employment status. Eighty-five out of 113 included patients completed the questionnaires (response rate 75%). At time of diagnosis 32 patients were not working (38%), significantly associated with (higher) age and (lower) education level. Of the 53 patients who were employed at time of diagnosis, 44 patients returned to work (83%): 28 to the same work, 7 to adapted work and 9 to other work. Median time was 6 months to return to work (range 0-24 months) and 71% of the patient returned to work within 6 months after treatment. Anxiety and oral dysfunction as xerostomia, trismus, sticky saliva, problems with teeth, and loss of appetite, problems with social eating and social contacts were significantly associated with employment after treatment. The majority of employed HNC survivors return to work within 6 months after treatment. Oral dysfunction, loss of appetite, deteriorated social functioning, and high levels of anxiety are barriers for HNC survivors to return to work after treatment.

The efficacy of voice therapy in patients after treatment for early glottic carcinoma.

After treatment for early glottic carcinoma, a considerable number of patients end up with voice problems that interfere with daily life activities. The objective of this randomized and controlled study was to assess the efficacy of voice therapy in these patients.

Computerized prospective screening for high levels of emotional distress in head and neck cancer patients and referral rate to psychosocial care

To investigate prospectively the prevalence of high levels of emotional distress and referral rate to psychosocial care in head and neck cancer (HNSCC) patients. Fifty-five consecutive newly diagnosed HNSCC patients were asked to complete the hospital anxiety and depression scale (HADS) and the EORTC QLQ-C30 and H&N35 quality of life questionnaires on a touch screen computer-assisted data collection system on their first visit and during follow-up visit. Sociodemographic, clinical, and quality of life parameters were compared to a high level of distress (HADS score >15). Number of patients with a high level of distress were compared to referral rates to psychosocial care as retrieved from patient hospital files. At time of diagnosis, 18% (10/55) of the patients had a high level of distress (related to tumor stage and site, and global quality of life and social eating) versus 25% (14/55) at follow-up (related to a variety of quality of life parameters). Low levels of distress at baseline or follow-up was noted in 64%; 18% had normal scores at baseline and developed distress at follow-up; 11% had high levels at baseline and returned to normal scores at follow-up, and 7% had persistent distress from baseline to follow-up. No patients were referred to psychosocial care at time of diagnosis. At follow-up visit 21% (3/14) were referred, all patients who developed a high level of distress after initial diagnosis. High level of emotional distress is common and few patients are referred to psychosocial care. Development of a stepped care model (including careful monitoring by using a touch screen computer system) may meet the potentially unmet needs of HNC patients and contribute improving cancer care.

Beyond treatment - Psychosocial and behavioural issues in cancer survivorship research and practice.

The population of cancer survivors has grown steadily over the past several decades. Surviving cancer, however, is not synonymous with a life free of problems related to the disease and its treatment. In this paper we provide a brief overview of selected physical and psychosocial health problems prevalent among cancer survivors, namely pain, fatigue, psychological distress and work participation. We also address issues surrounding self-management and e-Health interventions for cancer survivors, and programmes to encourage survivors to adopt healthier lifestyles. Finally, we discuss approaches to assessing health-related quality of life in cancer survivors, and the use of cancer registries in conducting psychosocial survivorship research. We highlight research and practice priorities in each of these areas. While the priorities vary per topic, common themes that emerged included: (1) Symptoms should not be viewed in isolation, but rather as part of a cluster of interrelated symptoms. This has implications for both understanding the aetiology of symptoms and for their treatment; (2) Psychosocial interventions need to be evidence-based, and where possible should be tailored to the needs of the individual cancer survivor. Relatively low cost interventions with self-management and e-Health elements may be appropriate for the majority of survivors, with resource intensive interventions being reserved for those most in need; (3) More effort should be devoted to disseminating and implementing interventions in practice, and to evaluating their cost-effectiveness; and (4) Greater attention should be paid to the needs of vulnerable and high-risk populations of survivors, including the socioeconomically disadvantaged and the elderly.