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The Laryngoscope
VC 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 (751 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
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
tobacco10–15 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
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:
DOI: 10.1002/lary.26073
Reeve et al.: Factors Associated With Quality of Life
Reprinted by permission of Laryngoscope. 2016; 126(12):2718-2725.
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