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shown to be a risk factor for HNC, especially cancer of the base of tongue, tonsils, and oropharynx. 44 We did not have HPV data on all cases included in this analysis, and because its potential association with HRQOL is mediated only through treatment, we did not consider HPVas a covariate. CONCLUSION Despite these limitations, this study contributes to the literature by identifying sociodemographic, behav- ioral, and clinical factors associated with poorer HRQOL for HNC survivors. Understanding these factors will help to identify those at risk for decrements in HRQOL. Some factors, such as tobacco use, can be modifiable by encouraging patients to participate in smoking cessation program. For other factors, awareness of these factors can help to identify those at risk and provide more long- term care and surveillance to reduce the deleterious effects of the cancer and its treatment. The acute ill effects of radiation therapy on HRQOL seem to decrease significantly over time and return to levels seen in non- irradiated patients by 2 to 4 years posttherapy. Enhanced psychological and social support may help with issues of depression and dealing with the physical effects of surgery and radiation. 45 BIBLIOGRAPHY 1. Brown LM, Gridley G, Devesa SS. Descriptive epidemiology: U.S. patterns. In: Olshan AF, ed. Epidemiology, Pathogenesis, and Prevention of Head and Neck Cancer. New York, NY: Springer; 2010:23–39. 2. American Cancer Society. Cancer Facts & Figures 2015. Atlanta, GA: American Cancer Society; 2015. 3. Beadle BM, Liao KP, Elting LS, et al. Improved survival using intensity- modulated radiation therapy in head and neck cancers: a SEER- Medicare analysis. Cancer 2014;120:702–710. 4. Chera BS, Eisbruch A, Murphy BA, et al. Recommended patient-reported core set of symptoms to measure in head and neck cancer treatment tri- als. J Natl Cancer Inst 2014;106. pii: dju127. doi: 10.1093/jnci/dju127. 5. List MA, Ritter-Sterr CA, Baker TM, et al. Longitudinal assessment of quality of life in laryngeal cancer patients. Head Neck 1996;18:1–10. 6. Mochizuki Y, Matsushima E, Omura K. Perioperative assessment of psy- chological state and quality of life of head and neck cancer patients undergoing surgery. Int J Oral Maxillofac Surg 2009;38:151–159. 7. Neilson KA, Pollard AC, Boonzaier AM, et al. Psychological distress (depression and anxiety) in people with head and neck cancers. Med J Aust 2010;193(5 suppl):S48–S51. 8. Sawada NO, de Paula JM, Sonobe HM, Zago MM, Guerrero GP, Nicolussi AC. Depression, fatigue, and health-related quality of life in head and neck cancer patients: a prospective pilot study. Support Care Cancer 2012;20:2705–2711. 9. Penedo FJ, Traeger L, Benedict C, et al. Perceived social support as a pre- dictor of disease-specific quality of life in head-and-neck cancer patients. J Support Oncol 2012;10:119–123. 10. Duffy SA, Terrell JE, Valenstein M, Ronis DL, Copeland LA, Connors M. Effect of smoking, alcohol, and depression on the quality of life of head and neck cancer patients. Gen Hosp Psychiatry 2002;24:140–147. 11. Bloom EL, Oliver JA, Sutton SK, Brandon TH, Jacobsen PB, Simmons VN. Post-operative smoking status in lung and head and neck cancer patients: association with depressive symptomatology, pain, and fatigue. Psychooncology 2015;24:1012–1019. 12. Duffy SA, Ronis DL, Valenstein M, et al. Depressive symptoms, smoking, drinking, and quality of life among head and neck cancer patients. Psy- chosomatics 2007;48:142–148. 13. Fang FM, Chiu HC, Kuo WR, et al. Health–related quality of life for naso- pharyngeal carcinoma patients with cancer–free survival after treat- ment. Int J Radiat Oncol Biol Phys 2002;53:959–968. 14. Morse DE, Psoter WJ, Baek LS, et al. Smoking and drinking in relation to depressive symptoms among persons with oral cancer or oral epithelial dysplasia. Head Neck 2010;32:578–587. 15. Ronis DL, Duffy SA, Fowler KE, Khan MJ, Terrell JE. Changes in quality of life over 1 year in patients with head and neck cancer. Arch Otolaryn- gol Head Neck Surg 2008;134:241–248. 16. Allison PJ. Alcohol consumption is associated with improved health- related quality of life in head and neck cancer patients. Oral Oncol 2002;38:81–86.

There were several notable clinical factors associated with HRQOL. Consistently, individuals with comorbid conditions, higher stages of cancer, and continued need for a feeding tube reported poorer HRQOL on all domains except social well-being. This result is consistent with a large study by Terrell et al., 26 who found that feeding tube status and comorbid conditions were strong predictors of HRQOL, and that stage of cancer was a moderate predic- tor of HRQOL. The acute effects of radiation therapy had a negative impact on physical and functional well-being and increased HNC-associated symptoms. The literature supports this finding: irradiation has been associated with several side effects, including dry mouth, difficulty swal- lowing, mouth and gum sores, fatigue, nausea, and lym- phedema. 9,28–31,43 Our study found that the detrimental effects of radiation therapy lessened over the years such that Functional HRQOL was similar to those who were not irradiated by 2 years, and physical well-being was sim- ilar between those who did and didn’t receive radiation therapy by four or five years postdiagnosis. Limitations There were several limitations of this study. All partici- pants were receiving care in North Carolina. Although the sample was heterogeneous with respect to race, socioeco- nomic status, and clinical factors, it may not be generalizable to the U.S. population. The measures of HRQOL were added to the study after the parent study had begun, thus resulting in lower sample sizes at the baseline 3-month (median) assessment point. We did not have a pretreatment measure of HRQOL to know to what extent HRQOL differences existed prior to treatment. Future studies are recommended to better understand the factors associated with HRQOL in HNC patients. Strengths include the population-based rela- tively large sample size and diverse population with multiple follow-up surveys. Human papillomavirus infection has been Fig. 2. FACT-G Head and Neck Cancer Symptoms scores over time for those who received radiation therapy and those who did not receive radiation therapy. The adjusted means were calculated with the covariates taking the values at the proportions presented in Table I. The outside lines are 95% confidence interval lines. FACT-G 5 Functional Assessment of Cancer Therapy-General.

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