Transcript Document

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
Minimizing Disparities”
October 17, 2008
LONG-TERM HRQOL FOR HEAD
AND 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
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 114:806-816,2005.
Trask et al. Am J Prev Med 28:351-356, 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 46:417-432, 2007.
Buckwalter et al. Arch Otolaryngol Head Neck Surg 133:464-470,2007.
Karnell et al, Head Neck 28:453-461,2006.
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
LONG-TERM OUTCOMES OF HEAD AND NECK
CANCER PATIENTS
KEY AIMS
1.
2.
3.
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.
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
No information
– 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
Funk et al, Head Neck 25:561-575,2003.
Ware et al, Med Care 1992;30:473-483.
Beck et al, Arch Gen Psychiatry 4:561-571,1961.
Cutrona et al, JAI Press,1987.
Piccirillo JF, Laryngoscope 110:593-602,2000.
The Need For Multi-institutional
Data Collection
STUDY*
N, % Original Cohort**
Major Findings
Nordgren et al, Int J Rad Onc Biol Phys, 2003
Nordgren et al, Head & Neck, 2006
Abendstein et al, Laryngoscope, 2005
(46, 53%)
(36, 40%)
(141, 39%)
Physical function poor. No substantial clin signif
deterioration except dry mouth (1-5yr). No signif
change in global QOL for group.
Bjordal et al, Int J Rad Onc Biol Phys, 1994
Bjordal et al, Oral Oncol Eur J Cancer,1995
Bjordal & Kassa, Br J Cancer, 1995
(204, 24%)
(204, 25%)
(204, 24%)
Low life satisfaction & general health compared with
Age-matched norms. 35% smoking. Pain, cognitive fxn,
social fxn, and stage predict psychological problems.
Mehanna et al, Arch OHNS, 2006
Mehanna & Morton, Clin Otolaryngol, 2006
(48, 24%)
(43, 21%)
Overall life satisfaction decreased over 10 years.
Global QOL at 1 year predicted long-term survival.
Holloway et al, Head & Neck, 2005
Duke et al, Laryngoscope, 2005
Meyer et al, Laryngoscope, 2004
Campbell et al, Arch OHNS, 2004
(105, CS)
(86, CS)
(64, CS)
(62, CS)
Long-term survivors demonstrated significant
aspiration. Personality traits predicted QOL. Poor
dental status disrupted global measures of QOL.
Zelefsky et al, Am J Surg, 1996
Terrell et al, Arch OHNS, 1998
Rogers et al, J Cranio-maxillofac Surg,1999
Laccourreye et al, OHNS, 2000
Evensen et al, Int J Rad Onc Biol Phy,2002
Wijers et al, Head & Neck, 2002
(29, 27%)
(46, 14%)
(38, 17%)
(90, ?)
(67, 15%)
(39, ?)
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.
Funk et al, AHNS, 2008
(245, 20%)
* All studies consisted of survivors >5 years after diagnosis.
** CS=convenience sample, ?=unable to determine.
LONG-TERM OUTCOMES OF HEAD AND
NECK CANCER PATIENTS
245 patient enrolled in long-term study
Characteristic
Age (median = 57)
<57
57 or older
Comorbidity at dx
None
Mild
Moderate
Severe
Unknown
Site
Oral cavity
Oropharynx
Hypopharynx
Larynx
Other site a
Stage
Early (0-2)
Advanced (3-4)
Unstageable
Unknown
Treatment type
Single modality
Multimodality
No treatment
Recurrence status
Recurred
Did not recur
Never disease free
Unknown
Number
%
119
126
48.6
51.4
78
97
49
12
9
31.8
39.6
20.0
4.9
3.7
97
49
6
58
35
39.6
20.0
2.4
23.7
14.3
102
130
7
6
41.6
53.1
2.9
2.4
127
117
1
51.8
47.8
0.4
31
204
3
7
12.7
83.2
1.2
2.9
Characteristic
Tobacco use
Current
Previous
Never
Unknown
Alcohol use
Current
Previous
Never
Unknown
Depression
Normal (0-9)
Mild (10-20)
Moderate (21-30)
Severe (31+)
Unknown
Pain
None (0)
Mild (1-3)
Moderate (4-6)
Severe (7-10)
Unknown
Number
%
36
137
58
14
14.7
55.9
23.7
5.7
98
87
42
18
40.0
35.6
17.1
7.3
169
54
10
4
8
69.0
22.0
4.1
1.6
3.3
150
46
23
11
15
61.2
18.8
9.4
4.5
6.1
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
LONG-TERM OUTCOMES OF HEAD AND
NECK CANCER PATIENTS
Objective 1
Proportion with poor HRQOL
5-year HRQOL outcomes
Outcome
Percent in functional levels
Mean
Count
High
Intermediate
Low
score
Eating
48.0
38.8
13.2
63.6
227
Speech
65.6
29.7
4.7
74.0
232
Aesthetics
74.1
14.6
11.3
78.2
239
Soc. Disruption
80.2
17.2
2.6
84.8
232
Physical health
30.7
37.2
32.1
47.2
218
Mental health
22.9
41.8
35.3
50.2
218
Dep. Symptoms
71.3
22.8
5.9
7.7
237
Objective 2
Change in HRQOL from short-term (1 yr)
to long-term (5 yr)
LONG-TERM OUTCOMES OF HEAD AND
NECK CANCER PATIENTS
1- vs 5-year HRQOL outcomes
Outcome
Mean score
Count
p-valuea
Small
CIDb
1-year 5-year
HNC-specific
Eating
62.0
64.3
179
0.075
5.1
Speech
74.2
75.9
183
0.187
5.1
Aesthetics
78.5
80.0
191
0.380
4.8
Social disruption
86.2
86.5
180
0.847
3.4
Physical
48.4
47.5
195
0.173
2.2
Mental
50.7
50.5
195
0.826
2.7
Depressive symps
6.5
6.3
97
0.730
1.3
General health
a Repeated-measures
B Funk
general linear model tests of within-subject effects
et al, Arch Otolaryngol Head Neck Surg 130:825-829,2004.
LONG-TERM OUTCOMES OF HEAD AND
NECK CANCER PATIENTS
Independent variable
(used in multivariate
analysis)
Age
(Continuous variable)
Comorbidity at dx
(0-3)
“Combined” stage
(0-4)
Site a
Oral cavity (Y/N)
Oropharynx (Y/N)
Hypopharynx/Larynx
(Y/N)
Treatment
(Single v. multimod)
Recurrence status
(Recurred v. Didn’t
recur)
Tobacco use at FU b
(Current v prev/never)
Alcohol use at FU b
(Current v prev/never)
Social support at FU
(Continuous variable)
Pain at FU
(Continuous variable)
Eating
Objective 3
Predictors of 5-year HRQOL outcomes
P-values of variables predicting 5-year scores
Speech Aesth Social Phys
Mental
Dep
etics Disrpt Health health
symps
0.008
--
--
<0.001
0.021
0.004
0.008
NS
0.045
NS
0.003
0.005
--
--
<0.001
--
Overall
QOL
--
0.029
0.030
0.010
--
--
--
--
----
--
--
0.033
--
--
--
--
--
--
--
-0.021
<0.001
--
<0.001
--
<0.001 <0.001
--
-<0.001
<0.001
<0.001
Linear regression multivariate analysis
LONG-TERM OUTCOMES OF HEAD AND
NECK CANCER PATIENTS
Association of Pain with Long-term Outcomes
100
90
80
None (0)
60
50
Mild (1-3)
40
Moderate/Severe
(4-10)
30
20
10
di
sr
up
ti o
Ph
n
ys
ic
al
he
al
th
M
en
D
ta
ep
lh
re
ea
ss
lth
iv
e
sy
m
pt
om
s*
So
ci
al
Sp
ee
ch
0
Ea
t in
g
Mean score
70
Significant association of pain with
long-term HRQOL
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.
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 >40% 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
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
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.”
Earle CC, J Clin Oncol, 2007
•
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…
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.
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.