THE LONG-TERM QUALITY OF LIFE OF HEAD AND NECK CANCER PATIENTS

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THE LONG-TERM QUALITY OF LIFE OF HEAD AND NECK
CANCER PATIENTS
FINDING OUR WAY TO SURVIVORSHIP MANAGEMENT

• Gerry F. Funk, MD

Department of Otolaryngology- Head and Neck
Surgery University of Iowa College of
Medicine Iowa City, Iowa
October 11, 2013
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CAN WE SIGNIFICANTLY IMPROVE THE SURVIVAL OF HNC
PATIENTS THROUGH POST-TREATMENT SURVIVIRSHIP CARE?
Co-morbidities General health maintenance Health
behaviors Oropharyngeal functioning Pain HRQOL
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UNIVERSITY OF IOWA HNC OUTCOMES PROGRAM

• 1995 Outcomes Assessment Program started
• Head and Neck Cancer Specific Function and QOL
• Medical Outcomes Study SF-36
• Psychosocial evaluation
• Case-mix data demographics, stage, survival,
  co-morbidity, tobacco alcohol use, pain,
  employment,
• Patients
• Over 2500 enrolled
• Information gathered pre-Rx, 3mo, 6mo, 1yr,
  yearly.
• Funding
• ACS Seed Grants
• ACS Career Development Award, 95-33
• NIH, NCI, Office of Cancer Survivorship, R01
  CA106908
• NIH, NCI Office of Cancer Survivorship, ARRA
  Admin Supplement R01 CA106908-04S1
• Iowa Cancer Consortium

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THE HNC OUTCOMES PROGRAM
25 Studies published with data from the Outcomes
Program

• Comparative, Psychosocial, Functional
• Smoking behavior
• General health outcomes
• Depression, Social Support
• Alcohol use
• Post-treatment employment
• Surgery vs Chemoradiation
• Long-term outcomes of Chemoradiation, XRT, IMRT
• Long-term HRQOL
• Relationship of PET (SUV) and XRT dose with HRQOL
• Predictors of survival and long-term outcomes
• HRQOL profiles
• Self-reported general health
• Pain
• Gastrostomy tube use and dysphagia
• 2-yr conditional survival
• Health Service Utilization and Survivorship
• Health care utilization by HNC patients
• HNC Survivorship Clinic

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FIRST-YEAR HRQOL PROFILES ARE ASSOCIATED WITH
SURVIVAL
HRQOL stratified short and long-term survivors.
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SELF-REPORTED GENERAL HEALTH
Co-morbidity predicted overall
survival. Self-reported physical health predicted
both overall and disease-specific survival.
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THE ROLE OF PAIN
Post-treatment pain is an independent predictor
of recurrence and is significantly associated
with decreased disease-specific survival.
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DYSPHAGIA AND SURVIVAL
RISK FACTORS FOR DEATH ON MVA
Patients gt70 yrs Hypopharyngeal primary Treatment
included XRT SPS 7
SPS 7 group (severe dysphagia) had significantly
lower overall survival than the other groups.
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2-YEAR CONDITIONAL SURVIVAL
Variables present at 2 years that are predictive
of 5-year survival in 2-year survivors of HNC.
Obs Survival DS Survival Obs Survival DS Survival Obs Survival DS Survival Obs Survival DS Survival Obs Survival DS Survival
Factor P value HR P value HR
Age 0.01 1.07 0.03 1.07
Stage 0.03 2.49 0.008 4.84
Tobac use --- --- 0.003 4.22
Pain _at_ 2yr 0.03 2.09 --- ---
QOL _at_ 2yr 0.02 4.62
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HOW ARE WE DOING WITH SURVIVAL OF HNC PATIENTS?
SUCCESS AT THE FRONT END OF TREATMENT
Surg Tech Anesth Rad Tech Chemo Molec Targ Rx
The 5-yr disease-specific survival for head and
neck cancer is 65
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THE QUESTION
Can the survival of HNC patients be improved
through focused survivorship care?
Co-morbidities General health maintenance Health
behaviors Oropharyngeal functioning Pain HRQOL
SUCCESS AT THE BACK END OF TREATMENT
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SURVIVORSHIP
In 1971 there were 3 M cancer survivors in the
US. Currently there are 13.7 M, and in 2022
there will be an estimated 18 M

• Survivorship Initiatives
• Office of Cancer Survivorship Established in
  1996 is dedicated to enhancing the length and QOL
  of cancer survivors (NCI)
• IOM, NRC From Cancer Patient to Cancer Survivor
  Lost in Transition
• CDC/LAF National Action Plan for Cancer
  Survivorship Advancing Public Health Strategies
• NCCS, IOM, LAF, NCI Implementing Cancer
  Survivorship Care Planning Commission on Cancer
  Standards

Over half of our patients will become cancer
survivors, and we need to engage them as cancer
survivors.
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COMMISSION ON CANCER STANDARDS REGARDING
SURVIVORSHIP JANUARY 1, 2015
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HNC SURVIVORSHIP CLINIC GOALS

• Facilitate focused attention to identified
  long-term survivorship issues
• Co-morbidities
• General health maintenance
• Health behaviors
• Oropharyngeal functioning
• Pain
• HRQOL
• Provide guideline-concordant, high-quality, HNC
  surveillance.
• Institute the use of Survivorship Care Plans
• Evaluate the use of a Survivorship Clinic on
  patient outcomes (survival, HRQOL, general health
  benchmarks)
• Improve resource use of HNC clinicians

Arch Otolaryngol Head Neck Surg.
2012138(2)123-133
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JUSTIFICATION FOR INSTITUTING A HNC SURVIVORSHIP
CLINIC

• Over half of patients treated for HNC will become
  long-term survivors.
• Co-morbid illnesses are not being optimally
  managed.
• Unhealthy lifestyles persist after treatment.
• HNC patients have unmet health care needs.
• HNC patients seen for follow-up make up 72 of
  patients seen in HNC clinics. The HNC clinics are
  poorly resourced to meet the global survivorship
  needs of these patients.
• The model selected for the survivorship clinic is
  financially sound.

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UNIVERSITY OF IOWA HNC SURVIVORSHIP CLINIC

• Hybrid - transitional and shared model
• HNC Survivorship Clinic is co-located with the
  HNC clinic
• PA-C directed care
• HNC survivorship PA spent 1 year
• Working in HNC clinics with HNC surgeons,
  radiation oncologists, medical oncologists
  learning about HNC post-treatment care and cancer
  surveillance
• Developing HNC Survivorship Care Plans with the
  HNC team
• Organizing adjuvant care collaborators
• Speech and swallowing
• Pain and symptom management
• Tobacco cessation intervention
• Social Services
• EMR Template for Survivorship Care Plan
  Survivorship Clinic Visit

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Support Services available through the
Survivorship Clinic
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HNC SURVIVORSHIP CLINIC ELIGIBILITY

• Initial visit (SCP, Psychosoc screen) at
  completion of treatment.
• Formal HNCSC referral.
• HNC Patients gt/ 2 year out from last cancer
  directed therapy.
• Referral from the primary Head and Neck
  Surgeon/Oncologist.
• Clinical assessment consistent with low risk of
  recurrence.
• Immediate return to HNC clinic if any concern for
  recurrence is identified.

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HNC SURVIVORSHIP CARE PLAN
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HNC SURVIVORSHIP CLINIC
Characteristic Number Percent
Age    
lt55 19 29.2
55-64 30 46.2
65-74 13 20.0
75 3 4.6
Gender    
Male 40 61.5
Female 25 38.5
Site    
Oral cavity 26 40.0
Oropharynx 27 41.5
Hypopharynx 2 3.1
Larynx 5 7.7
Other 5 7.7
Stage    
Early (1-2) 19 29.2
Advanced (3-4) 44 67.8
Unstageable/unknown 2 3.0
Treatment    
Surgery only 20 30.8
RT only 5 7.7
Surgery RT 15 23.1
RT Chemo 20 30.8
All 3 1 1.5
Unknown 4 6.2
Table 1 Patient, disease, and treatment
characteristics of patients enrolled in the
Survivorship Clinic who have filled out the
patient satisfaction survey to date (N65)
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PATIENT SATISFACTION WITH THE HNC SURVIVORSHIP
CLINIC
Item Strongly agree Agree Disagree Strongly disagree
Overall satisfaction with medical care 87 13 -- --
Competent/complete HNC care 89 11 -- --
Communicate well with P.A. 89.2 10.8 -- --
Receive courtesy/respect 92.3 7.7 -- --
Would recommend Survivorship Clinic 91 9 -- --
All med issues addressed 87.5 12.5 -- --
Survey of the first 100 HNC Survivorship Clinic
patients to evaluate their perceptions about the
care in the Clinic.
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HNC SURVIVORSHIP PATIENT POPULATION AND OUTCOMES
EVALUATING UTILITY

• Tobacco and alcohol use
• Preventable hospitalizations
• General health maintenance - benchmarks
• Age and gender appropriate cancer screening
  benchmarks
• Resource utilization
• Health-related quality of life

• Recurrence
• Overall and DS survival

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HNC SURVIVORSHIP CLINIC
Aggressive Survivorship Management as a Focused
Intervention
There are no associated toxicities It is not
rocket science May improve resource
utilization Begins implementation of Surv Care
Plans May improve HRQOL May improve survival
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THANK YOU