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Health-Related Quality of Life Before and After Head and Neck
Squamous Cell Carcinoma: Analysis of the Surveillance,
Epidemiology, and End Results–Medicare Health Outcomes
Survey Linkage
Eleni M. Rettig, MD
1
; Gypsyamber D’Souza, PhD
1,2
; Carol B. Thompson, MS, MBA
3
; Wayne M. Koch, MD
1
;
David W. Eisele, MD
1
; and Carole Fakhry, MD, MPH
1,2
BACKGROUND:
Understanding health-related quality of life (HRQOL) is crucial to providing high-quality survivorship care for patients
with head and neck squamous cell carcinoma (HNSCC). Trends in and prognostic significance of HRQOL before and after HNSCC
have not been well described.
METHODS:
HRQOL for older individuals with HNSCC was examined using the linked Surveillance, Epi-
demiology, and End Results–Medicare Health Outcomes Survey database. Surveys assessing HRQOL from 5 years prediagnosis to 10
years postdiagnosis were included. HRQOL over time was modeled using multilevel linear regression with restricted cubic splines and
was reported as either total HRQOL or change in HRQOL (denoted
D
). The association of prediagnosis HRQOL with survival was
examined.
RESULTS:
In total, 1653 individuals were included; of these, 61% completed 1 survey, and 39% completed multiple surveys.
Overall HRQOL decreased progressively until 13 months postdiagnosis, then recovered toward baseline between 2 and 5 years. How-
ever, after stratification by survival group, the postdiagnosis recovery was not observed. Individuals with shorter survival had lower
HRQOL prediagnosis (
<
2-year survivors, 87.3;
>
5-year survivors, 96.4;
P
5
.004) with a steeper decline in HRQOL during diagnosis
and treatment (
<
2-year survivors:
D
,
2
16.6; 95% confidence interval [CI],
2
23.8,
2
9.4;
>
5-year survivors:
D
,
2
0.9; 95% CI,
2
1.8, 0.08).
Radiotherapy and advanced stage were associated with greater declines in HRQOL during diagnosis and treatment (
P
<
.001). Higher
prediagnosis HRQOL was independently associated with improved overall survival (adjusted hazard ratio for 10-point increase, 0.91;
95% CI, 0.85-0.97).
CONCLUSIONS:
HRQOL declines before and after HNSCC, whereas any observed posttreatment recovery is likely
an artifact of shorter survival among individuals with the lowest HRQOL. The prognostic implication of prediagnosis HRQOL may
inform patient counseling.
Cancer
2016;122:1861-70.
V
C
2016 American Cancer Society
.
KEYWORDS:
head and neck cancer, oropharynx, quality of life, radiotherapy, survival.
INTRODUCTION
Cancer survivorship has emerged as a health care priority in the United States (US) since the Institute of Medicine consen-
sus report in 2005.
1
Historically, health-related quality of life (HRQOL) was not a component of either medical educa-
tion curricula or cancer treatment and surveillance guidelines. However, the aging population and improving cancer
treatment outcomes have highlighted the need to describe the spectrum and determinants of cancer survivors’ HRQOL
and to educate providers accordingly. In addition, the need to accurately measure HRQOL has been underscored.
1
The
growing appreciation that HRQOL is paramount to improved cancer survivorship care is manifested by a growing litera-
ture of rigorous HRQOL evaluation in prostate and breast cancer survivors.
2,3
HRQOL is particularly important in the current era of head and neck cancer, because the incidence of new diagnoses
among young individuals with relatively few comorbidities and favorable expected long-term survival has increased signifi-
cantly in recent years and is expected to continue increasing.
4-6
In the context of these incidence and survival trends and
the short-term and long-term morbidities of head and neck cancer therapy, which range from speech and swallowing
Corresponding author:
Carole Fakhry, MD, MPH, Johns Hopkins University School of Medicine, 601 N. Caroline Street, Sixth Floor, Baltimore, MD 21287; Fax:
(410) 955-6526;
cfakhry1@jhmi.edu1
Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland;
2
Department of Epidemiology, Johns
Hopkins Bloomberg School of Public Health, Baltimore, Maryland;
3
Biostatistics Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
The content of this article is solely the authors’ responsibility and does not necessarily represent the official view of the National Institutes of Health.
Additional supporting information may be found in the online version of this article
DOI:
10.1002/cncr.30005,
Received:
September 30, 2015;
Revised:
January 31, 2016;
Accepted:
March 4, 2016,
Published online
May 16, 2016 in Wiley Online
Library
(wileyonlinelibrary.com)Cancer
June 15, 2016
Original Article
Reprinted by permission of Cancer. 2016; 122(12):1861-1870.
137