HEALTHRELATED QUALITY OF LIFE IN HEAD AND NECK CANCER SURVIVORS

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HEALTH-RELATED QUALITY OF LIFE IN HEAD AND NECK
CANCER SURVIVORS

• Gerry F. Funk, MD

Department of Otolaryngology-Head and Neck
Surgery University of Iowa College of
Medicine Iowa City, Iowa
Iowa Cancer Summit Maximizing Collaboration Minim
izing Disparities October 17, 2008
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LONG-TERM HRQOL FOR HEADAND NECK CANCER PATIENTS
Collaborators Lucy H. Karnell, PhD Alan J.
Christensen, PhD Mark Vander Weg, PhD Amy
Trullinger, BA Head Neck Faculty Henry
Hoffman, MD Kristi Chang, MD Nitin Pagedar,
MD Rad Oncology Faculty John Buatti, MD
Anjali Gupta, MD William McGuiness, MD Medical
Oncology Gerry Clamon, MD Head Neck Nurses
Margaret Colwill BSN Helen Stegall BSN Nancy
Scroggs

• Iowa HNC Outcomes Assessment Program
• Iowa HNC Research Consortium

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Cancer Survivorship and HNC Patients

• Over 50 of patients treated for cancer,
  including HNC, in the U.S. will become long-term
  survivors.
• Long-term cancer survivors face physical and
  psychological treatment effects, recurrence, risk
  of 2nd primary, co-morbid illnesses,
  financial-employment-family issues.
• HNC survivors are confronted with all the general
  issues of other cancer survivors including
  dysfunction of the upper aerodigestive tract.
• There are significant knowledge deficits
  regarding the challenges faced by HNC survivors
  and an increasing focus on cancer survivorship
  issues.
• NCI Office of Cancer Survivorship, Lance
  Armstrong Foundation, Center for Disease Control,
  Institute of Medicine, National Research Council,
  American Society of Clinical Oncologists.

Carvalho et al. Int J Cancer 114806-816,2005. Tra
sk et al. Am J Prev Med 28351-356,
2005.References Hewitt M, Greenfield S, Stovall
E, Eds. From cancer patient to cancer survivor
lost in transition. National Academies Presses,
2006. CDC. A national action plan for cancer
survivorship advancing public health strategies.
Dept of Health and Human Services, 2004. Aziz,
Acta Oncologica 46417-432, 2007. Buckwalter et
al. Arch Otolaryngol Head Neck Surg
133464-470,2007. Karnell et al, Head Neck
28453-461,2006.
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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
• Anchor health-state data demographics, stage,
  survival, co-morbidity, tobacco alcohol use,
  employment,
• Patients
• 1462 Enrolled
• Analysis based on intent to enroll
• Information gathered pre-Rx, 3mo, 6mo, 1yr,
  yearly
• Funding
• ACS Seed Grants
• ACS Career Development Award, 95-33
• NIH, Office of Cancer Survivorship, RO1,CA 04-003

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LONG-TERM OUTCOMES OF HEAD AND NECK CANCER
PATIENTS
KEY AIMS

• Determine the proportion of 5-year survivors with
  poor health-related quality of life (HRQOL)
  outcomes.
• Determine differences between short-term (1-year)
  and long-term (5-year) HRQOL outcomes.
• Identify case-mix variables that have predictive
  value for long-term HRQOL outcomes.

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LONG-TERM OUTCOMES OF HEAD AND NECK CANCER
PATIENTS
STUDY DESIGN

• 5-year survivors from an ongoing HNC outcomes
  study diagnosed between 1/1995-12/2002
• 1201 eligible 268 refused, 198 not enrolled
• 735 enrolled in the outcomes study
• 376 dead, 11 refused long-term study, 103 lost to
  F/U
• 245 (20) provided data for the long-term study
• Data collection at pretx, 3, 6, and 9 mo. 1, 5,
  and 5 yr.
• Case-mix variables include age, gender, site,
  stage, treatment type, social support (Social
  Provisions Scale), co-morbidity (ACE-27), alcohol
  tobacco use, and pain

No information
Funk et al, Head Neck 25561-575,2003. Ware et
al, Med Care 199230473-483. Beck et al, Arch
Gen Psychiatry 4561-571,1961. Cutrona et al, JAI
Press,1987. Piccirillo JF, Laryngoscope
110593-602,2000.
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The Need For Multi-institutional Data Collection
Major Findings
STUDY N, Original
Cohort Nordgren et al, Int J Rad Onc Biol
Phys, 2003 (46, 53) Nordgren et al, Head
Neck, 2006 (36, 40) Abendstein et al,
Laryngoscope, 2005 (141, 39) Bjordal et al,
Int J Rad Onc Biol Phys, 1994 (204, 24) Bjordal
et al, Oral Oncol Eur J Cancer,1995 (204,
25) Bjordal Kassa, Br J Cancer, 1995 (204,
24) Mehanna et al, Arch OHNS, 2006 (48,
24) Mehanna Morton, Clin Otolaryngol,
2006 (43, 21) Holloway et al, Head Neck,
2005 (105, CS) Duke et al, Laryngoscope,
2005 (86, CS) Meyer et al, Laryngoscope,
2004 (64, CS) Campbell et al, Arch OHNS,
2004 (62, CS) Zelefsky et al, Am J Surg,
1996 (29, 27) Terrell et al, Arch OHNS, 1998
(46, 14) Rogers et al, J Cranio-maxillofac
Surg,1999 (38, 17) Laccourreye et al, OHNS,
2000 (90, ?) Evensen et al, Int J Rad Onc Biol
Phy,2002 (67, 15) Wijers et al, Head Neck,
2002 (39, ?) Funk et al, AHNS, 2008 (245, 20)
Physical function poor. No substantial clin
signif deterioration except dry mouth (1-5yr). No
signif change in global QOL for group.
Low life satisfaction general health compared
with Age-matched norms. 35 smoking. Pain,
cognitive fxn, social fxn, and stage predict
psychological problems.
Overall life satisfaction decreased over 10
years. Global QOL at 1 year predicted long-term
survival.
Long-term survivors demonstrated significant
aspiration. Personality traits predicted QOL.
Poor dental status disrupted global measures of
QOL.
Global QOL tied much closer to pain
depression than functional status. There is a
disconnect between toxicity and QOL. Long-term
effects may be related to and predate late
effects. No significant change 1 to 5 years. 50
long-term pain. Problems related to dry mouth.
All studies consisted of survivors gt5 years
after diagnosis. CSconvenience sample,
?unable to determine.
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LONG-TERM OUTCOMES OF HEAD AND NECK CANCER
PATIENTS
245 patient enrolled in long-term study
Substantial co-morbidity
Cohort is not dominated by early-stage disease
High percentage continuing to use tobacco and
alcohol
Substantial number of participants with
persistent depressive symptoms and pain
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LONG-TERM OUTCOMES OF HEAD AND NECK CANCER
PATIENTS
Objective 1 Proportion with poor HRQOL
5-year HRQOL outcomes
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LONG-TERM OUTCOMES OF HEAD AND NECK CANCER
PATIENTS
Objective 2 Change in HRQOL from short-term (1
yr) to long-term (5 yr)
1- vs 5-year HRQOL outcomes
a Repeated-measures general linear model tests of
within-subject effects B Funk et al, Arch
Otolaryngol Head Neck Surg 130825-829,2004.
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LONG-TERM OUTCOMES OF HEAD AND NECK CANCER
PATIENTS
Objective 3 Predictors of 5-year HRQOL outcomes
Linear regression multivariate analysis
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LONG-TERM OUTCOMES OF HEAD AND NECK CANCER
PATIENTS
Significant association of pain with long-term
HRQOL
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LONG-TERM OUTCOMES OF HEAD AND NECK CANCER
PATIENTS

• We have the largest longitudinal cohort of
  long-term HNC survivors with HRQOL data. It is
  dynamic and increasing in size.
• Treatment and site-specific analysis
• Overall HRQOL measured at 1 year does not show
  any clinically significant change at 5 years
  (better or worse)
• By 1 year, the acute effects are largely resolved
• The long-term effects of HNC treatment are stable
• Less than 50 of HNC survivors have a normal
  eating pattern
• A high percentage of HNC survivors have
  identifiable depressive symptoms
• A high percentage of HNC survivors have
  substantial co-morbid illness
• In comparison to age-matched norms, HNC survivors
  have worse physical and mental health
• Pain is long-term and predictive of poor HRQOL.
• Long-term survivorship is not an issue confined
  to early-stage patients.

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HNC PATIENTS AS CANCER SURVIVORS

• Well over 50 of HNC patients will survive their
  cancer.
• The average age at HNC diagnosis is 64 years
  and is increasing.
• Co-morbid illness will account for 30 of
  deaths within 5 years of HNC diagnosis.
• In the US, the percentage of HNC patients of
  ethnic minority is increasing.
• Patients from lower economic strata are
  overrepresented among the HNC population.
• Rates of second primary cancer and recurrence are
  high in HNC population.
• Unhealthy lifestyles persist after treatment (20
  tobacco and gt40 alcohol, higher levels of poor
  nutrition).

The percentage of HNC patients who fall into
groups at risk for underutilization of necessary
health care services is increasing.
Hoffman et al, Arch OHNS, 1998 Argiris et al,
Clin Can Res, 2004 Sikora et al, Laryngoscope,
2004 Funk et al, Head Neck, 2002 Allison et al,
Oral Onc, 2001
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HNC PATIENTS AS CANCER SURVIVORS
Underutilization of necessary health care
services has been identified in colorectal,
breast, childhood, and other cancer survivors.
There are few published series and conflicting
results.

• General preventive care
• Recommended cancer screening

Provider dependent?
Earle et al, J Clin Oncol, 2003 Earle et al,
Cancer, 2004 Hewitt et al, J Clin Oncol,
2002 Oeffinger et al, Pediatr Blood Cancer, 2004
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HNC Patients as Cancer Survivors and Survivorship
Practice Guidelines
T4N2c SCCA Oropharynx

• comprehensive evidence-based guidelines for the
  care of adult cancer survivors are not currently
  feasible.
• Comprehensive, evidence based, age- and gender-
  specific guidelines addressing general health
  maintenance and cancer screening among HNC
  survivors are lacking.
• NCCN, AHNS Limited recommendations
• General health screening, cancer screening,
  swallowing evaluation, orodental rehabilitation

Earle CC, J Clin Oncol, 2007
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HNC PATIENTS AS CANCER SURVIVORS
Cancer and Aging Program Proposal Investigators
Gerry F. Funk, MD Lucy H. Karnell, PhD
Alan J. Christensen, PhD Title
Evaluation of Health Care Utilization by Head and
Neck Cancer Survivors. Specific Aims
1) Determine the rate of health maintenance
interventions, cancer screening interventions,
and preventable hospitalizations for ambulatory
care-sensitive conditions for head and neck
cancer survivors compared to age, race, gender,
and geographic location matched controls. 2)
Evaluate the influence of age, race, gender,
provider specialty, and residence within a
poverty ZIP code on health care utilization by
HNC survivors.
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TALKING POINTS

• HRQOL can be improved in HNC survivors through
  directed interventions.
• The overall survival of HNC patients can be
  improved by improving the global health
  management of survivors.
• Comprehensive, evidence based guidelines for the
  healthcare of HNC survivors would be helpful.
• Specialized services within the University
  setting AND community resources will be required
  to accomplish these goals.