2017 Section 7 Green Book

HRQOL Before and After HNSCC/Rettig et al

TABLE 4. Characteristics Associated With Health-Related Quality of Life (HRQOL) Among Individuals Diag- nosed With Head and Neck Cancer in Which the Association With HRQOL Varies Significantly by Time From Diagnosis

Difference in HRQOL: D (95% CI)

Univariate Analysis a

Multivariate Analysis a,b

2 Years Prediagnosis

13 Months Postdiagnosis

5 Years Postdiagnosis

2 Years Prediagnosis

13 Months Postdiagnosis

5 Years Postdiagnosis

Characteristic

P

P

Stage

< .001

< .001

Early Late

REF

REF

REF

REF

REF

REF

0.3 ( 2 3.2, 3.7)

2 10.1 ( 2 13.5, 2 6.7)

2 0.5 ( 2 4.1, 3.0)

0.2 ( 2 2.8, 3.1)

2 6.8 ( 2 9.8, 2 3.8)

1.5 ( 2 1.5, 4.4)

Radiotherapy

.001

.01

No

REF

REF

REF

REF

REF

REF

2.2 ( 2 1.2, 5.6)

2 7.3 ( 2 10.6, 2 4.0)

2 0.8 ( 2 3.9, 2.2)

1.9 ( 2 1.1, 4.9)

2 5.1 ( 2 8.1, 2 2.2)

2 1.2 ( 2 3.9, 1.5)

Yes

Abbreviations: D , absolute difference in HRQOL compared with reference category; CI, confidence interval; REF, reference category. a Models include cubic spline terms for time relative to head and neck squamous cell carcinoma diagnosis. b Model includes all characteristics for which multivariate analysis results are reported in Tables 3 and 4, survey by proxy, and calendar year of diagnosis.

score was associated with a 9% reduction in the risk of death (adjusted HR, 0.91; 95% CI, 0.85-0.97). OPSCC Most OPSCCs in the United States are human papillo- mavirus (HPV)-related, and HPV-related OPSCC (HPV-OPSCC) is considered a distinct disease from HPV-negative HNSCC. 6 Therefore, we examined trends in HRQOL and the prognostic significance of HRQOL among individuals who had OPSCC compared with those who had non-OPSCC. Two years before HNSCC diagnosis, the HRQOL of individuals with OPSCC (N 5 295) and non-OPSCC (N 5 1358) was similar (Supporting Fig. 2, Supporting Table 3; see online sup- porting information). However, 13 months after diagno- sis, HRQOL for individuals with OPSCC was significantly lower than for those with non-OPSCC (dif- ference: 2 5.4; 95% CI, 2 9.0, 2 1.2). At 5 and 10 years after diagnosis, HRQOL was again similar between the 2 groups. Overall, HRQOL was not significantly different for individuals with OPSCC and those with non-OPSCC ( P 5 .13). Higher prediagnosis HRQOL quartile was nonsignificantly associated with improved survival after OPSCC among 131 individuals who had prediagnosis surveys available (HR, 0.95; P 5 .32). DISCUSSION To our knowledge, this study is the first to examine both prediagnosis and postdiagnosis HRQOL among individ- uals with HNSCC. A significant and progressive decline in HRQOL is observed before and after HNSCC diagno- sis, and the magnitude of decline in HRQOL differs by survival group. HRQOL in the years leading up to

Figure 2. Overall survival is illustrated according to health- related quality-of-life quartiles assessed within 5 years before head and neck cancer diagnosis.

To account for the observed decline in HRQOL before diagnosis, survival was evaluated according to the timing of surveys before HNSCC diagnosis. Prediagnosis HRQOL quartile was significantly associated with OS af- ter HNSCC diagnosis after limiting analysis to surveys from 1 to 5 years (N 5 428; P < .001), 2 to 5 years (N 5 239; P < .001), and 3 to 5 years (N 5 155; P 5 .006) before diagnosis. The prognostic significance of clinically relevant 10- point changes in HRQOL was also evaluated. A 10-point increase in prediagnosis HRQOL was associated with a 14% reduced risk of death (HR, 0.86; 95% CI, 0.82-0.91) (Table 5). Even after adjustment for other factors associated with survival (age, smoking status, marital status, comorbid- ities, household income, tumor site, stage, and radiother- apy), each 10-point increase in the prediagnosis HRQOL

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