2017 Section 7 Green Book

Reprinted by permission of Laryngoscope. 2016; 126(12):2718-2725.

The Laryngoscope V C 2016 The American Laryngological, Rhinological and Otological Society, Inc.

Factors That Impact Health-Related Quality of Life Over Time for Individuals With Head and Neck Cancer

Bryce B. Reeve, PhD; Jianwen Cai, PhD; Hongtao Zhang, PhD; Mark C. Weissler, MD; Kathy Wisniewski, BS; Heather Gross, MEd; Andrew F. Olshan, PhD

Objectives/Hypothesis: To identify sociodemographic, behavioral, and clinical factors associated with health-related quality of life (HRQOL) for head and neck cancer (HNC) patients over time. Study Design: A population-based longitudinal cohort study. Methods: Newly diagnosed HNC patients (N 5 587) were administered the Functional Assessment of Cancer Therapy– Head and Neck questionnaire at baseline (median 3 months postdiagnosis) and two follow-up assessments (median 22 and 42 months). Linear mixed-effect models were used with backward variable selection to identify factors associated with HRQOL over time ( P < .05). Adjusted means reported at 2 years postdiagnosis. Results: African Americans reported better Functional Well-Being than whites (mean of 20.01 vs. 18.53) and fewer HNC symptoms over time. Older patients (75 1 years) reported better HRQOL than younger patients ( < 50 years). Current tobacco use compared to no tobacco use had worse Physical (20.20 vs. 21.50), Emotional (17.55 vs. 19.06), Social (21.28 vs. 22.88), and Functional (17.32 vs. 19.29) Well-Being and more HNC symptoms (21.50 vs. 23.71). Radiation therapy was associated with worse Physical and Functional Well-Being and more head and neck symptoms over time, but HRQOL was similar to those who were not irradiated by 2 to 4 years postdiagnosis. Conclusion: This study identified key factors for individuals at risk for poorer HRQOL that may help clinicians and caregiv- ers find solutions to address these decrements. Smoking cessation programs can be encouraged for survivors who use tobacco. Psychological and social support and medications may help for dealing with emotional distress and dealing with the physical symptoms from treatment. Key Words: Health-related quality of life, symptoms, head and neck cancer, radiation therapy, longitudinal study. Level of Evidence: 4. Laryngoscope , 00:000–000, 2016

INTRODUCTION Overall, the incidence of head and neck cancer (HNC) (oral cavity, pharynx, larynx) began decreasing in about 1991 but has stabilized since about 2003. 1 In 2015, an estimated 59,340 individuals in the United States were diagnosed, and approximately 12,290 died from a HNC. 2 Incidence rates are twice as high in men as women. Incidence rates in African Americans have also declined over the past two decades and are cur- rently lower than in non-Hispanic whites. The standard for treating HNC has been surgery; however, since the From the Department of Health Policy and Management ( B . B . R .); the Department of Biostatistics ( J . C ., H . Z .); the Department of Epidemiology ( K . W ., A . F . O .), Gillings School of Global Public Health; the Lineberger Com- prehensive Cancer Center ( B . B . R ., A . F . O .); the Sheps Health Services Research Center ( B . B . R ., H . G .); and the Department of Otolaryngology– Head & Neck Surgery ( M . C . W ., A . F . O .), University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A. Editor’s Note: This Manuscript was accepted for publication April 6, 2016. This study was funded by a grant from the Lance Armstrong Foun- dation and in part by the National Cancer Institute (R01-CA90731). The authors have no other funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Bryce B. Reeve, PhD, University of North Carolina at Chapel Hill, 1101-D McGavran-Greenberg Building, 135 Dauer Drive, CB 7411, Chapel Hill, NC 27599-7411. E-mail: bbreeve@email.UNC.edu

early 1990s there has been an increase in the use of pri- mary radiation and chemotherapy. 3,4 This has been par- tially driven by the increase in the number of human papilloma virus (HPV)-associated oropharyngeal cancers. Both the cancer and its treatment can have pro- found effects on an individual’s health-related quality of life (HRQOL). Physically, they may experience facial dis- figurement and problems with eating, breathing, and speaking. 5 Mentally, they may experience negative body image, depression, anxiety, and fatigue. 5–8 Socially, they may experience impaired communication, disrupted social relationships, social isolation, stigmatism, and work impairment. 5,9 Although some symptoms improve over time after treatment, some HRQOL decrements persist, including functional limitations and psychosocial impact. 5,9 Several factors have been found to be associated with HRQOL in HNCs. Behavioral factors include use of tobacco 10–15 and alcohol. 16–20 Sociodemographic variables include age, 9,13,21,22 race, 23 education, 13,18 and employ- ment status. 9 Clinical factors include disease stage and the use of radiation therapy. 9,24–31 However, much of the literature is either more than 10 years old, based on small sample sizes, or shows no or conflicting relation- ships with HRQOL. This study builds on a previous published study of the HRQOL of individuals receiving care for HNC in

DOI: 10.1002/lary.26073

Reeve et al.: Factors Associated With Quality of Life

129