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© 1999 American Society for Clinical Oncology First Year After Head and Neck Cancer: Quality of LifeFrom the University of Texas M.D. Anderson Cancer Center, Houston, TX; and University of California Los Angeles School of Public Health and Department of Surgery, Head and Neck Division, University of California Los Angeles School of Medicine, Jonsson Comprehensive Cancer Center, Los Angeles, CA. Address reprint requests to Ellen R. Gritz, PhD, Department of Behavioral Science, Box 243, University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030-4095; Email egritz{at}notes.mdacc.tmc.edu
PURPOSE: Treatment regimens for head and neck cancer patients profoundly affect several quality-of-life domains. Rehabilitative needs have been identified through cross-sectional analyses; however, few studies have prospectively assessed quality of life, included assessment of psychosocial variables, and identified predictors of long-term follow-up. PARTICIPANTS AND METHODS: The present study addresses these limitations through a prospective assessment of 105 patients with a newly diagnosed first primary squamous cell carcinoma of the oral cavity, pharynx, or larynx. Participants were enrolled onto a larger randomized controlled trial comparing a provider-delivered smoking cessation intervention with a usual-care-advice control condition. Participants completed a battery of self-report measures after diagnosis and before treatment and additional quality-of-life instruments at 1 and 12 months after initial smoking cessation advice. RESULTS: Participants displayed improvements at 12 months in functional status (P = .006) and in the areas of eating, diet, and speech; however, the latter three represent areas of continued dysfunction, and the changes were not statistically significant. Despite these improvements, patients reported a decline in certain quality-of-life domains, including marital (P = .002) and sexual functioning (P = .017), as well as an increase in alcohol use (P < .001). Predictors of quality of life at 12 months included treatment type, the Vigor subscale of the Profile of Mood States instrument, and quality-of-life scores obtained 1 month after initial smoking cessation advice. CONCLUSION: Results reinforce the need for rehabilitation management through the integration of psychologic and behavioral interventions in medical follow-up.
AN ESTIMATED 41,400 NEW cancer cases of the oral cavity, pharynx, and larynx and 12,300 deaths from these cancers will occur in the United States in 1998.1 Although upper aerodigestive tract cancers account for a small percentage of incident cancers and cancer deaths in the United States, overall, they have a substantially high risk of treatment failure and death.2 Additionally, upper aerodigestive tract cancers are "an important contributor to the burden of cancer."3 Those who survive and become disease free frequently have altered appearances and/or disabilities associated with their treatment that can have significant medical and psychosocial consequences.2 Given the potential for morbidity associated with treatment, assessment of quality of life is particularly important with head and neck cancer patients. Quality of life is a multidimensional construct that includes, at a minimum, physical, functional, psychologic, and social well-being.4 Other dimensions might include spirituality, sexuality/intimacy, occupational functioning, treatment satisfaction, and global ratings of quality of life.5 Cancer and its associated treatment regimens can result in the disruption of one or more dimensions of quality of life. Careful and objective assessment of these areas can provide information regarding long-term outcomes of cancer treatments and their associated side effects with the goal of identifying rehabilitation needs and guiding appropriate tertiary interventions. Treatment of many malignancies of the head and neck may result in an adverse effect on patients' physical, functional, psychologic, and social functioning, dimensions that cannot be "equated with statistics on treatment response, disease progression, and survival."6,1 For example, the loss of the ability to swallow or chew normally may follow treatment. In a cross-sectional study assessing 181 head and neck cancer patients (mean, 48.6 months postdiagnosis), List and colleagues7 found that only 33% of patients obtained a perfect score on the Normalcy of Diet subscale and 60% on the Eating in Public subscale of the Performance Status Scale for Head and Neck Cancer Patients. Furthermore, quality-of-life issues may be even more pronounced when verbalization and speech are involved.6 List and colleagues7 found that only 55% of head and neck cancer patients obtained a perfect score on the Understandability of Speech subscale. Collectively, a patient's ability to communicate and eat may be compromised,8 thus affecting the ability to function in socially meaningful ways.6 In addition to functional disability, treatment can result in permanent disfigurement. Gamba and colleagues9 conducted a study examining the impact of disfigurement on adjustment in patients whose tumors had been surgically resected and who were disease free 6 months to 8 years after surgery. Those with more extensive disfigurement reported greater changes in self-image, worsened relationship with their partner, reduced sexuality, and increased social isolation than those with minor disfigurement. In addition to marked functional and physical impairments, head and neck cancer patients frequently experience significant psychologic distress. A recent cross-sectional study examined psychologic distress in long-term survivors of head and neck cancer 7 to 11 years posttreatment.10 Results indicated that 30% of patients were experiencing psychologic distress, as measured by the General Health Questionnaire. Similarly, a study examining depression in male cancer patients, approximately 22% of whom had head/neck cancer, indicated that 40% of participants reported symptoms of moderate depression and almost 20% reported symptoms of clinical depression.11 It has been suggested that patients with head and neck cancer are at an even greater risk for depression than other cancer patients, owing to surgeries that may alter their appearances. Since head and neck cancers also are frequently associated with chronic alcohol and tobacco use, depression may be related to withdrawal from these toxins or to preexisting psychopathology.12 Furthermore, depression may be related to pain or discomfort.6 Patients at highest risk for depression include those with a history of mood disorder, advanced stage, uncontrolled pain, or a treatment regimen that produces depressive symptoms,13 all of which may be seen in head and neck cancer patients. Despite the numerous rehabilitative needs and quality-of-life concerns of head and neck cancer patients, few studies have prospectively assessed quality of life with standardized instruments.8,14 List and colleagues14 also noted that studies typically focus on function and fail to include psychosocial measures. Additionally, few studies assess correlates or predictors of quality of life.8 Collectively, such information can assist in delineating long-term rehabilitative needs of head and neck cancer patients. Since side effects may surface months after treatment, only prospective analyses can provide documentation of changes in such needs. Furthermore, identifying predictors of quality of life in head and neck cancer patients can assist in determining the need for early intervention immediately posttreatment with the ultimate goal of reducing or preventing long-term problems. The present study examines the following questions: (1) Does the quality of life of head and neck cancer patients change over time? (2) Does quality of life vary systematically with differing treatment regimens? (3) How does the quality of life of head and neck cancer patients compare with that of other cancer patients? (4) Are there predictable demographic, medical, and/or psychologic factors that account for head and neck cancer patients' quality of life 1 year postdiagnosis?
Participants The sample for this study included 186 patients with newly diagnosed first primary squamous cell carcinoma of the oral cavity, pharynx, or larynx. Participants were treated with either primary radiation (60 to 75 Gy using standard radiation ports), or appropriate surgeries followed by planned postoperative irradiation. Individual surgeries depended on the site and stage of disease. For laryngeal cancers, treatment consisted of total laryngectomy for stage III or higher disease. For other sites (buccal cavity, hypopharynx, and so on), surgery consisted of wide local excision with or without modified neck dissection. Reconstruction was performed with either local or pedicled flaps. Postoperative radiation also used standard ports and 60 to 75 Gy. Further breakdown of surgeries into those reconstructed with local flaps or pedicled flaps was not performed. The purpose of our study was to examine general quality of life rather than to compare quality of life by surgical regimen. Moreover, since different surgeons were involved and different reconstructions were used, such an analysis would not be valid. Complete data after 1 year or more of follow-up were collected on 105 of these participants. Individuals over the age of 18 years were recruited from 10 participating hospitals in southern California. Enrollment criteria included (1) life expectancy of more than 1 year, (2) tobacco use within the past year, (3) absence of gross psychopathology, (4) medical follow-up by local providers, (5) ability to speak and read English, and (6) agreement to undergo medical treatment. Additional details regarding eligibility and accrual are published elsewhere.15 Participants in this study were originally recruited for a larger randomized controlled trial comparing a provider-delivered smoking cessation intervention with a usual-care-advice control condition.16
Measures
Karnofsky Performance Scale.
CAncer Rehabilitation Evaluation System-Short Form. Like the CARES, the CARES-SF yields a Global Score and five summary scales, including Physical, Psychosocial, Marital, Sexual, and Medical Interaction. The Physical scale assesses disease-related physical changes and disruption in daily activities. The Psychosocial scale includes psychologic symptoms, communication, and relationship problems other than those with partners, whereas the Marital scale addresses problems specifically with marital-type relationships. The Sexual scale includes problems with interest in and performance of sexual activity. Finally, the Medical Interaction scale assesses problems with communications and interactions with medical providers.18 The CARES has been demonstrated to possess good psychometric properties, including high internal consistency and test-retest reliability as well as validation with other standardized measures.20 Research on the CARES-SF indicated that it has similar psychometric properties to that of the CARES. Correlations between the CARES and the CARES-SF on the Global and five summary scales range from 0.90 to 0.98.18
Performance Status Scale for Head and Neck Cancer Patients.
Profile of Mood States.
Demographic and medical data.
Procedures
Statistical Analyses Multiple linear regression was used to construct prediction models of the 12-month CARES-SF scores. Models were constructed both for the overall CARES-SF scores as well as for the five summary scores. Predictor variables included demographic variables, disease stage, treatment type, baseline alcohol consumption and smoking, baseline POMS subscale scores, 1-month KPS score, 1-month PSS subscale scores, and 1-month overall and subscale CARES-SF scores. Square root transformations were used on the CARES-SF and POMS scores to correct the skewness of the distributions. Univariate associations between the predictor variables and the overall and subscale CARES-SF scores were first evaluated using simple linear regression. Predictor variables with P less than .25 were then selected for subsequent model building. Multiple linear regression with backwards elimination was then used with alpha = .05 as the significance criterion to select the final models. Standard residuals-based diagnosed procedures were used to assess model assumptions and adequacy of the model fit.
The 105 participants who provided complete data were included in the analyses. These 105 patients on whom we had 12-month follow-up data were compared with the 81 persons who did not complete the follow-up assessment, with respect to treatment type, primary tumor site, and stage at diagnosis. Participants on whom we did not have 12-month follow-up data tended to have a later stage of disease at diagnosis than those on whom we did have follow-up data (34.2% stage IV v 17.3% stage IV; P < .05). There were no significant differences by primary tumor site or treatment type. The participants' mean age was 58.4 years (SD, 9.2 years), and 69.5% were male (n = 73). With respect to ethnicity, 74.3% were white, and 18.1% were African-American. Approximately two thirds (64.8%) had at least a high school education, and more than half (56.2%) were currently married. Approximately half of the participants had cancer of the buccal cavity (50.5%; n = 53), and the remainder had cancer of the larynx (41.9%; n = 44) or cancer of the pharynx (5.7%; n = 6). Stage III disease was the most common stage at diagnosis (46.2%; n = 48), followed by stage I and II disease (36.5%; n = 38) and stage IV disease (17.3%; n = 18). Approximately half of the participants had been treated with either primary radiation (22.9%; n = 24) or a total laryngectomy (26.7%; n = 28), and the remainder had been treated with other surgeries and/or radiation (50.5%; n = 53). Table 1 contains baseline, 1-month, and 12-month scores on smoking and alcohol status; the baseline, 1-month, and 12-month scores on the POMS scales; and the 1-month and 12-month scores on the KPS and PSS scales. Results indicate a statistically significant reduction in smoking status at 1 year after smoking cessation advice.16 There also was a significant decline in alcohol use from baseline to 1 month, with a significant increase in alcohol use between 1 month and 1 year. The POMS Total Mood Disturbance score showed substantial and statistically significant improvements from the baseline scores. Similar significant improvements were observed for each of the subscales, with the exception of the Fatigue-Inertia scale. In four of the subscales, Depression-Dejection, Tension-Anxiety, Anger-Hostility, and Confusion-Bewilderment, the improvements occurred primarily between the baseline and 1-month time periods. Smaller improvements occurred between the 1-month and 12-month time periods. There was a significant improvement in scores on the Karnofsky Performance Status scale. No significant changes were noted on any of the PSS subscales. The largest improvement was observed for Normalcy of Diet (P = .06), followed by Eating in Public (P = .09) and Speech (P < .18).
In Table 2, the changes from 1-month to 12-month CARES-SF scores are listed. The overall CARES-SF score showed no significant change; however, the means were in the direction of decline in quality of life. Significant changes were observed for two of five summary scales. There was a decline in both the Marital and Sexual functioning summary scale scores. The Psychosocial summary scale showed no significant change, although the means were in the direction of increased number of problems (P = .11).
Comparison of the 12-month CARES-SF scores to those of short-term (< 2 years) lung and colon cancer survivors22 showed that head and neck cancer patients reported substantially worse quality of life (Table 3). The overall CARES-SF score for lung cancer was 0.54, for colon cancer 0.45, for stage I and II head and neck cancer 0.87, and for all stages of head and neck cancer 0.91. These differences were consistent across all of the summary scales and were independent of whether stage I and II patients or all stages were considered.
Comparison of the 12-month quality-of-life scores between smokers and quitters indicated that, in general, smokers reported lower quality of life, although only two of the differences approached statistical significance. The mean of the overall CARES-SF score among smokers was 1.1 (SD, 0.70) and among quitters 0.84 (SD, 0.59) (P = .07). A similar difference was observed on the Physical Functioning summary scale, with the mean of the Physical Functioning score among smokers 1.37 (SD, 0.97) and among quitters 1.05 (SD, 0.86) (P = .07). Smokers also displayed higher scores on the Psychosocial, Sexual, and Marital Functioning summary score scales, although none of these differences were statistically significant. The quality-of-life scores of smokers and quitters were equivalent at 1 month. In Table 4, results of the linear regression analyses are listed. The number of variables in the final models varied from a minimum of one for the Medical Interactions summary scale to a maximum of four for the Psychosocial Functioning summary scale. The proportion of variability in the CARES scores explained by the predictor variables ranged from a high of 35% for the overall CARES-SF to a low of 11% for the Medical Interactions and Sexual summary scales. The 1-month overall or summary scale score corresponding to the 12-month score was a significant predictor in each of the six models. Treatment type was a significant predictor in three of the models: overall CARES-SF, Physical Functioning, and Psychosocial Functioning. The coefficients for the treatment variable indicated that subjects who received primary radiation treatment had worse quality of life at month 12 than those who did not receive this treatment. In addition, patients with total laryngectomy had slightly better quality of life at month 12 than those who had other treatments. The POMS Vigor subscale score at month 1 was also an important predictor in all but the Medical Interaction model. Here, the coefficients indicated that patients with a higher level of Vigor at month 1 had better quality of life at month 12. Finally, the Karnofsky score at baseline was a significant predictor of Psychosocial quality of life at month 12. The sign of the coefficient indicates that participants with higher performance at baseline had better quality of life at month 12. Interestingly, disease stage did not significantly contribute to any of the six models.
The present study is the first to prospectively assess the quality of life of head and neck cancer patients over a 1-year period after diagnosis and treatment and to determine predictors of quality of life at 12 months posttreatment. Other prospective studies have used standardized instruments but have covered a shorter time frame,23 included a smaller sample size,24 or failed to examine correlates of quality of life.23,24 Our findings indicate that the quality of life of head and neck cancer patients changes over time. Patients displayed significant changes in several domains of functioning, with improvements in some areas and declines in others. These results were consistent across measures and reinforce the need for ongoing assessment of rehabilitation needs, as the changes that we observed occurred over a relatively short time period. Considering head and neck patients overall, irrespective of treatment type, stage of disease, or disease status at 12 months, a functional status rating reflecting normal activity was reached within 1 year. Scores on the KPS were within the range indicating that there may be some signs or symptoms of disease, but they reflect the ability to function independently. Scores on the Vigor-Activity and Fatigue-Inertia subscales significantly improved from 1 month to 12 months and may be a result of these functional improvements. Although a trend toward improvement was observed on the PSS subscales, scores indicated continued dysfunction in speech and eating. This finding was consistent with that obtained on the Physical summary scale of the CARES-SF, indicating no significant changes. Both of these findings may reflect continued problems in areas specific to head and neck cancer patients. Problems may be even more pronounced in those with recurrent or progressive disease than in those who are disease free at 12 months. Despite some improvements in physical changes and the ability to engage in normal daily activities, patients reported a decline in certain quality-of-life domains. This finding is important, as the majority of quality-of-life studies with head and neck cancer patients assess physical health status but fail to provide a comprehensive assessment of quality-of-life dimensions.8 Results of such studies could be misleading in terms of providing an accurate reflection of quality-of-life problems. Specifically, patients in the present study reported declines in the areas of marital and sexual functioning, domains of functioning which may not be evaluated in standard quality-of-life assessments. Although there were no statistically significant changes in the area of psychosocial functioning as measured by the CARES-SF, the 12-month score did show a modest decline relative to the 1-month score. The Psychosocial summary scale measures a variety of areas, including psychologic distress, interaction with family, work-related concerns, and body image. It is possible that when the details of this scale are scrutinized, we may find improvements in some areas and declines in others. Given the improvements in mood as indicated by the POMS scores, the slight decrease in psychosocial function may be a reflection of problems in other domains assessed by the Psychosocial subscale, including communication and relationship problems with others. Both of these areas previously have been shown to decline in head and neck cancer patients.25 Overall, our findings are consistent with those obtained by Schag and colleagues, who concluded that cancer survivors "do not return to a normal state of health."22,27 Even more compelling is the fact that head and neck cancer patients in this study displayed more impaired quality of life than the lung and colon cancer survivors in their study. Whereas this finding may be related to the additional year or so from treatment completion or the "survivor" status of the latter groups, our data also indicate that head and neck patients have a more impaired quality of life than other populations who are not disease free, including normative samples of male cancer patients, male non–prostate cancer patients, and female breast cancer patients.26 Given that the subset of 105 participants on whom the data were analyzed are a group of patients with earlier-stage disease at diagnosis than those who did not provide complete data, quality of life may be even more compromised in head and neck cancer patients than our data indicate. Results of this study also indicate that there are unique predictors of quality of life that are specific to head and neck cancer. In contrast to findings by Schag and colleagues,22 the KPS did not predict overall quality of life in the multivariate analyses. In their samples of prostate, lung, and colon cancer survivors, the KPS was the best predictor of overall quality of life in each of these cancer populations. For these populations, functional status may be an important quality-of-life dimension owing to the impact that each of these cancers can have on mobility and the ability to perform activities of daily living. However, in the present study, KPS was an important predictor of psychosocial functioning at the 1-year follow-up, indicating that impaired functional status may result in subsequent psychologic distress and/or future problems in interacting with others. These findings underscore the importance of delineating unique predictors of quality of life in specific cancer patient populations, instead of assuming that all cancer patients experience comparable quality-of-life concerns. Interestingly, none of the scales on the Performance Status Scale for Head and Neck Cancer Patients predicted overall quality of life or any of the five dimensions. Obviously, the role of eating, diet, and speech in quality of life needs to be further investigated because of the results indicating continued dysfunction in these areas and their clinical centrality for these tumor sites.27 Although quality of life and rehabilitation needs change over time, the best predictors of overall quality of life and each of its domains at 12 months were scores obtained at 1 month after initial smoking cessation advice, a time when patients were in the acute phase of their treatments and recovery. These results emphasize the necessity of targeting intervention needs early in an effort to minimize or prevent long-term sequelae. A recent review of long-term cancer survivors, including head and neck cancer patients, indicated that even 5 years postdiagnosis, some patients continue to experience impairments in daily functioning as a result of their cancer and its associated treatment regimen.28 Interestingly, the POMS Vigor subscale, which may reflect having a positive affect, was an important predictor of overall quality of life and four of its five domains as measured by the CARES-SF. This component of mood may actually reflect an adaptive coping style and could potentially be a target for tertiary intervention. Having received primary radiation therapy also was an important predictor of overall quality of life as well as physical and psychosocial functioning at month 12, as measured by the CARES. Patients receiving primary radiation treatment had better quality of life at month 1. However, these patients demonstrated an overall decline in quality of life over time, whereas the other two groups demonstrated improvements in these areas over the 1-year time frame of the study. The findings of our prospective study contrast with several prior reports indicating improved quality of life over time in primary radiation patients,29,30 as well as in comparison to surgically treated patients.14,30 The differences in quality of life among the various treatment regimens need to be further explored. Few studies actually assessed quality-of-life differences as a function of treatment; several studies used cross-sectional designs29,30; and many studies were limited by small sample sizes.14 Clinically, primary radiation patients often report worse side effects than individuals treated with surgery. Radiation therapy may include ports that encompass the salivary glands, thus resulting in dry mouth (xerostomia) and loss of taste function for up to a year after the end of therapy. Moreover, radiation therapy entails daily visits for up to 6 weeks, as opposed to the single hospital admission for surgery. As a result, primary radiation therapy patients may be at increased risk for long-term treatment effects and may require frequent and thorough monitoring. Disease stage did not significantly contribute to any of the prediction models. It is worth noting that the staging system used in the present study is limited by the heterogeneity of the patient population within stage with respect to tumor size and nodal status. As one of the reviewers noted, quality of life is likely to be affected by treatment related to tumor size. The results of some of our analyses might therefore have changed had more detailed information related to staging been available. Results of this study argue for a comprehensive assessment of quality-of-life concerns by incorporating evaluations of psychosocial issues as well as physical function domains. Other variables that may provide information regarding long-term quality of life may include self-perceived disfigurement, self-image, and premorbid coping style. These areas were not assessed in the present study but may provide insight into the high variability of mood scores obtained in this study. The present findings support the role of mood, specifically positive affect, in relation to quality of life. The head and neck cancer patient's psychologic functioning, including negative affect, should be closely monitored, because previous data suggest the potential for psychologic distress years after treatment,10 and our data demonstrate an increase in alcohol use and a decline in marital and sexual functioning. Interestingly, results of this study also show some indication that cigarette smoking may affect certain quality-of-life domains, suggesting that the role of smoking in the quality of life in head and neck cancer patients should be further explored. Collectively, these results indicate the necessity for integrating psychologic and behavioral change interventions into medical follow-up. Previous research indicates that tobacco use is highly modifiable owing to the impact of disease, treatment, and recovery.16 These results are encouraging and may suggest that head and neck cancer patients are good candidates for other psychosocial interventions. Several limitations of this study warrant discussion. The first is that only current and recent former smokers were eligible; therefore, head and neck cancer patients who were not in these categories (ie, nonsmokers and long-term ex-smokers) were excluded. Because smoking prevalence in this population has been estimated to be above 75%,15,31,32 our sample should be fairly representative of head and neck cancer patients in general. Additionally, some of the quality-of-life measures in this study were not assessed at baseline (CARES, PSS, and KPS); however, the CARES assesses rehabilitation needs and is designed to be administered after treatment. Unfortunately, this precludes deducing the overall degree of change from premorbid functioning in quality-of-life domains. A final shortcoming of this study reflects the present state of quality-of-life research in general. Measures such as the CARES identify domains that reflect rehabilitation needs but do not assess individual factors, such as patients' motivation, interpretation, expectation, and personality.4 The quality-of-life literature also has been criticized for its failure to examine quality-of-life domains within the context of conceptual models4,33 that integrate these domains with specific factors that could be targets for intervention. Theoretical variables such as self-efficacy for coping with cancer,34 social support,35 and coping style36 could serve as mediating variables that account for differences in quality-of-life concerns. The empirical studies to date have successfully identified dimensions that constitute the construct "quality of life." Studies including the present one also have demonstrated that quality of life varies as a function of treatment. This study provided unique information regarding the changes in quality of life and rehabilitation needs of head and neck cancer patients. Overall, it demonstrated that this patient population exhibits continuing disability and dysfunction, justifying tailored interventions and a greater focus on rehabilitation management. Additionally, it identified factors that predicted quality of life at 1 year follow-up, an area that is understudied in the quality-of-life literature in general4 and in head and neck cancer patients in particular.8
Supported in part by National Cancer Institute grants no. CA43461 and CA16042.
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Vokes EE, Weichselbaum RR, Lippman SM, et al: Medical progress: Head and neck cancer. N Engl J Med 328:184-194, 1993 3. Spitz MR: Epidemiology and risk factors for head and neck cancer. Semin Oncol 21:281-288, 1994[Medline] 4. Gotay CC: Trial-related quality of life: Using quality-of-life assessment to distinguish among cancer therapies. J Natl Cancer Inst Monogr 20:1-16, 1996 5. Cella DF, Tulsky DS: Measuring quality of life today: Methodological aspects. Oncology 4:29-38, 1990[Medline] 6. Gritz ER, Hoffman A: Behavioral and psychosocial issues in head and neck cancer, in Beumer J, Curtis T, Marunick M (eds): Maxillofacial Rehabilitation: Prosthodontic and Surgical Considerations. St. Louis, MO, and Tokyo, Japan, Ishiyaku Euromica, 1996, pp 1-14 7. List MA, Ritter-Sterr C, Lansky SB: A performance status scale for head and neck cancer patients. Cancer 66:564-569, 1990[Medline] 8. Gotay CC, Moore TD: Assessing quality of life in head and neck cancer. Qual Life Res 1:5-17, 1992[Medline] 9. Gamba A, Romano M, Grosso IM, et al: Psychosocial adjustment of patients surgically treated for head and neck cancer. Head Neck 14:218-223, 1992[Medline] 10. Bjordal K, Kaasa S: Psychological distress in head and neck cancer patients 7-11 years after curative treatment. Br J Cancer 71:592-597, 1995[Medline] 11. Godding PR, McAnulty RD, Wittrock DA, et al: Predictors of depression among male cancer patients. J Nerv Ment Dis 183:95-98, 1995[Medline] 12. Breitbart W, Holland J: Psychosocial aspects of head and neck cancer. Semin Oncol 15:61-69, 1988[Medline] 13. Massie MJ, Holland JC: Depression and the cancer patient. J Clin Psychiatry 51:12-17, 1990 14. List MA, Ritter-Sterr CA, Baker TM, et al: Longitudinal assessment of quality of life in laryngeal cancer patients. Head Neck 18:1-10, 1996[Medline] 15. Gritz ER, Carr CR, Rapkin DA, et al: A smoking cessation intervention for head and neck cancer patients: Trial design, patient accrual, and characteristics. Cancer Epidemiol Biomarkers Prev 1:67-73, 1991[Abstract] 16. Gritz ER, Carr CR, Rapkin D, et al: Predictors of long-term smoking cessation in head and neck cancer patients. Cancer Epidemiol Biomarkers Prev 2:261-270, 1993[Abstract] 17. Karnofsky DA, Burchenal JH: The clinical evaluation of chemotherapeutic agents in cancer, in MacLeod CM (ed): Evaluation of Chemotherapeutic Agents. New York, NY, Columbia Press, 1949 18. Schag CA, Ganz PA, Heinrich RL: Cancer Rehabilitation Evaluation System—short form (CARES-SF): A cancer specific rehabilitation and quality of life instrument. Cancer 68:1406-1413, 1991[Medline] 19. McNair DM, Lorr M, Droppleman LF: EDITS Manual for the Profile of Mood States. San Diego, CA, Educational and Industrial Testing Service, 1971, pp 3-29 20. Schag CA, Heinrich RL, Aadland RL, et al: Assessing problems of cancer patients: Psychometric properties of the cancer inventory of problem situations. Health Psychol 9:83-102, 1990[Medline] 21. Cella DF, Tross S, Orav EJ, et al: Mood states of patients after the diagnosis of cancer. J Psychosoc Oncol 7:45-54, 1989 22. Schag CA, Ganz PA, Wing DS, et al: Quality of life in adult survivors of lung, colon and prostate cancer. Qual Life Res 3:127-141, 1994[Medline] 23. Hassan SJ, Weymuller EA Jr: Assessment of quality of life in head and neck cancer patients. Head Neck 15:485-496, 1993[Medline] 24. Hammerlid E, Bjordal K, Ahlner-Elmqvist M, et al: Prospective, longitudinal quality-of-life study of patients with head and neck cancer: A feasibility study including the EORTC QLQ-C30. Otolaryngol Head Neck Surg 116:666-673, 1997[Medline] 25. Pruyn JFA, De Jong PC, Bosman LJ, et al: Psychosocial aspects of head and neck cancer: A review of the literature. Clin Otolaryngol 11:469-474, 1986[Medline] 26. Schag CAC, Heinrich R: Cancer Rehabilitation Evaluation System CARES Manual. Los Angeles, CA, CARES Consultants, 1988 27. List MA, D'Antonio LL, Cella DF, et al: The performance status scale for head and neck cancer patients and the Functional Assessment of Cancer Therapy-Head and Neck scale. Cancer 77:2294-2301, 1996[Medline]
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Gotay C, Muraoka M: Quality of life in long-term survivors of adult-onset cancers. J Natl Cancer Inst 90:656-667, 1998 29. Moore GJ, Parsons JT, Mendenhall WM: Quality of life outcomes after primary radiotherapy for squamous cell carcinoma of the base of the tongue. Int J Radiat Oncol Biol Phys 36:351-354, 1996[Medline] 30. de Boer M, Pruyn J, van den Borne B, et al: Rehabilitation outcomes of long-term survivors treated for head and neck cancer. Head Neck 17:503-515, 1995[Medline]
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Stevens MH, Gardner JW, Parkin JL: Head and neck cancer survival and lifestyle change. Arch Otolaryngol 109:746-749, 1983 32. Spitz MR, Fueger JJ, Goepfert H, et al: Squamous cell carcinoma of the upper aerodigestive tract: A case comparison analysis. Cancer 61:203-208, 1988[Medline]
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Wilson IB, Cleary PD: Linking clinical variables with health-related quality of life: A conceptual model of patient outcomes. JAMA 273:59-65, 1995 34. Merluzzi TV, Martinez Sanchez MA: Assessment of self-efficacy and coping with cancer: Development and validation of the Cancer Behavior Inventory. Health Psychol 16:163-170, 1997[Medline] 35. Rowland JH: Interpersonal resources: Social support, in Holland JC, Rowland JH (eds): Handbook of Psychooncology: Psychological Care of the Patient with Cancer. New York, NY, Oxford University Press, 1990, pp 58-71 36. Rowland JH: Intrapersonal resources: Coping, in Holland JC, Rowland JH (eds): Handbook of Psychooncology: Psychological Care of the Patient with Cancer. New York, NY, Oxford University Press, 1990, pp 44-57 Submitted December 4, 1997; accepted September 4, 1998.
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Copyright © 1999 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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ABSTRACT
INTRODUCTION
