This Article Abstract Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Karvonen-Gutierrez, C. A. Articles by Duffy, S. A. Search for Related Content PubMed PubMed Citation Articles by Karvonen-Gutierrez, C. A. Articles by Duffy, S. A. Social Bookmarking                            What's this?

Quality of Life Scores Predict Survival Among Patients With Head and Neck Cancer

Carrie A. Karvonen-Gutierrez, David L. Ronis, Karen E. Fowler, Jeffrey E. Terrell, Stephen B. Gruber, Sonia A. Duffy

From the Veterans’ Affairs (VA) Health Services Research and Development Center for Practice Management and Outcomes Research, VA Ann Arbor Healthcare System; Departments of Otolaryngology, Psychiatry, Internal Medicine, Epidemiology, and Human Genetics; and the School of Nursing, University of Michigan, Ann Arbor, MI

Corresponding author: Sonia A. Duffy, PhD, RN, Veterans’ Affairs (VA) Health Services Research and Development Center for Practice Management & Outcomes Research, VA Ann Arbor Healthcare System (11H), PO Box 130170, Ann Arbor, MI 48113-0170; e-mail: bump{at}med.umich.edu

	ABSTRACT

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION AUTHORS' DISCLOSURES OF... AUTHOR CONTRIBUTIONS REFERENCES

 
Purpose The purpose of this study was to examine whether quality of life (QOL) scores predict survival among patients with head and neck cancer, controlling for demographic, health behavior, and clinical variables.

Patients and Methods A self-administered questionnaire was given to 495 patients being treated for head and neck cancer while they were waiting to be seen for a clinic appointment. Data collected from the survey included demographics, health behaviors, and QOL as measured by Short Form-36 (SF-36) physical and mental component scores and the Head and Neck QOL scores. Clinical measures were collected by chart abstraction. Kaplan-Meier plots and univariate and multivariate Cox proportional hazards models were used to determine the association between QOL scores and survival time.

Results After controlling for age, time since diagnosis, marital status, education, tumor site and stage, comorbidities, and smoking, the SF-36 physical component score and three of the four Head and Neck QOL scales (pain, eating, and speech domains) were associated with survival. Controlling for the same variables, the SF-36 mental component score and the emotional domain of the Head and Neck QOL were not associated with survival.

Conclusion QOL instruments may be valuable screening tools to identify patients who are at high risk for poor survival. Those with low QOL scores could be followed more closely, with the potential to identify recurrence earlier and perform salvage treatments, thereby possibly improving survival for this group of patients.

	INTRODUCTION

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION AUTHORS' DISCLOSURES OF... AUTHOR CONTRIBUTIONS REFERENCES

 
Patients with head and neck cancer experience significant changes in their quality of life (QOL) associated with disease and treatment adverse effects. Common problems include difficulty with speech, respiration, and eating, as well as the psychological impact of loss of function and physical disfigurement. With the advent of more aggressive treatment modalities, QOL assessment has become an essential part of clinical care and research studies.

There is conflicting evidence regarding the association between QOL and survival in patients with cancer. While some research of patients with breast cancer,¹ myeloma,² and head and neck cancers,³ suggest that there is no relationship between QOL and survival, other studies have shown that QOL scores were significantly higher among cancer survivors, suggesting that they may have prognostic value.^4-6 This association has also been reported in studies of patients with terminal or advanced cancer.^7,8

Among patients with head and neck cancer, there are also conflicting results. In a small sample (N = 48), Hammerlid et al⁵ demonstrated that global QOL persisted as an independent predictor of survival after controlling for covariates. In contrast, de Graeff et al³ found that only cognitive functioning independently predicted survival after controlling for covariates (N = 208), while Allison et al⁹ found that cognitive functioning did not predict 1-year survival (N = 101). Unlike Hammerlid et al, neither de Graeff et al nor Allison et al observed any relationship between the global QOL score and survival. Recently, a large study of 479 patients with head and neck cancer, by Goldstein et al,¹⁰ found QOL scores to be associated with short-term, moderate, and long-term survival.

Given the conflicting evidence in the literature as to whether or not QOL can predict survival, further study is needed. If QOL is predictive of survival among patients with head and neck cancer, QOL instruments may be a practical and noninvasive means of identifying those patients at most risk, who then might be followed more closely. Hence, the purpose of this study was to examine the relationship of QOL and survival among patients with head and neck cancer controlling for demographic, health behavior, and clinical variables.

	PATIENTS AND METHODS

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION AUTHORS' DISCLOSURES OF... AUTHOR CONTRIBUTIONS REFERENCES

 
This study was conducted using data from a larger multisite study assessing health behaviors and QOL of a general population of patients with head and neck cancer. For the larger study, conducted between 2000 and 2002, participants completed a self-administered questionnaire on QOL, health behaviors, and demographics while waiting to be seen in the otolaryngology clinic. Clinical measures were collected by chart abstraction. Institutional review board approval was obtained at each site before the study.

Sample
Subjects were recruited from the University of Michigan hospital and three Veterans’ Affairs Hospitals (Ann Arbor, MI, Dallas, TX, and Gainesville, FL). Of 1,561 patients initially approached for the larger study, 62% (n = 973) agreed to participate and completed questionnaires.¹¹ Inclusion criteria for this analysis was having a head and neck cancer diagnosis within 2 years of the date of the survey. Excluded from this analysis were patients who, from the time of diagnosis and any time thereafter, were pregnant; younger than 18 years; non-English speaking; found to only have a cancer not arising from the upper aerodigestive tract (such as thyroid, parotid, or skin cancer); or found to have a prior history of head and neck cancer. Because QOL varies after a cancer diagnosis, the total sample population was restricted to include only those individuals who were diagnosed within the past 2 years from the date of survey, leaving a sample size of 495.

All patients were within 2 years of the date of their initial diagnosis for head and neck cancer; 80% of patients were within 1 year of the date of their initial diagnosis and 62% were within 6 months. Because patients could be surveyed at any point within the 2 years since their diagnosis, patients could either have not yet received treatment, be in active treatment protocols, or be post-treatment. Treatment status is strongly associated with the amount of time since diagnosis.

Measures
The independent variables were the physical and mental component scores from the Short Form-36 (SF-36)¹² and the pain, eating, speech, and emotion domains from the Head and Neck QOL (HNQOL) scale.¹³ The SF-36 is a general health QOL measure that is well-validated and commonly used. The eight subscales of the SF-36 are compounded to calculate two component scores, physical and mental. Low scores indicate a poorer QOL. The population mean for the SF-36 component scores are 50, with a standard deviation of 10.¹² The HNQOL is a disease-specific QOL instrument for patients with head and neck cancer. It includes 20 items scored on a 5-point rating scale covering four domains: head and neck pain, eating and swallowing, speech/communication, and emotional well-being. HNQOL domain scores were calculated using algorithms, with 0 being the worst and 100 being the best possible QOL score.¹³ Information on the HNQOL scoring algorithm can be obtained from the authors. Our previous work has identified that the HNQOL domain mean scores among a general population of head and neck cancer patients are 59.2 (pain), 60.9 (eating), 57.1 (speech), and 70.8 (emotion).¹⁴

The dependent variable was days of survival (up to August 1, 2007) from date of survey. Survival was determined using the Beneficiary Identification and Records Locator Subsystem Death File for Veterans’ Affairs patients or from the Social Security Death Master File for university patients. Date of death was compared with date of survey to determine the survival time for each patient. If a date of death was not listed in the database for an individual, they were assumed to be alive and were censored as of August 1, 2007.

Demographic variables included age, sex, race (non-Hispanic white v other), marital status (married v not married), education (high school or less v some college or more), and hospital site (VA hospital v university hospital). Clinical variables extracted from the patient medical records included tumor site, tumor stage, time since diagnosis, and treatment/procedural modalities including radiation, chemotherapy, head and neck surgery, total laryngectomy, current feeding tube, and current tracheotomy. Tumor sites were dichotomized into two groups (larynx v all others) based on other QOL studies indicating that laryngeal patients do best.¹⁵ Tumor stage 4 was found to be an independent predictor of survival compared with stage 0/1, whereas stage 2 and 3 were statistically indistinguishable from stage 0/1. Thus, for analysis purposes, tumor stage was dichotomized as (stage 4 v 0 to 3). Because patients were surveyed at different points within 2 years of their diagnosis, months since diagnosis was calculated based on the elapsed time between diagnosis date and survey date and treated as a continuous variable. Self-reported comorbidity status was collected from the patient survey and was categorized as having no comorbid conditions versus having any comorbid conditions.¹⁶ The Geriatric Depression Scale-Short Form (GDS-SF)¹⁷ was used to measure depressive symptoms; a score of 4 or higher indicated probable depression. The Alcohol Use Disorder Identification Test (AUDIT)¹⁸ was used to measure alcohol use; a score of 8 or higher indicated problem drinking. Because relapse rates are high in smokers, patients who smoked in the last 1 month were considered to be smokers.

Data Analysis
The data were analyzed using SAS software version 9.1 (SAS Institute Inc, Cary, NC). All P values reported represent two-sided tests. Because all of the respondents did not answer all of the questions, the sample size may vary for individual results.

Descriptive statistics were computed for all demographic, health behavior, clinical, and QOL characteristics. Associations of the possible predictor variables with the dependent variable, survival, were determined using the Kaplan-Meier estimator, and univariate Cox proportional hazards regression models. Multivariate Cox proportional hazards regression models were conducted to explore the relationship between QOL and survival. Variables shown to have a significant association with survival from the univariate models were considered for inclusion in the multivariate Cox proportional hazards regression models, as were variables shown in the literature to be associated with survival. Each QOL variable was considered separately in the Cox proportional hazards regression models because of the high collinearity among these variables (highest correlation = 0.65).

	RESULTS

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION AUTHORS' DISCLOSURES OF... AUTHOR CONTRIBUTIONS REFERENCES

 
Univariate Analyses
Patient demographic, health behavior, and clinical characteristics are summarized in Table 1. The mean age was 58 years. Most patients were non-Hispanic white, married, males recruited from the University of Michigan hospital. Approximately one third smoked, one in five scored positive for problem drinking, and almost one half scored positive for depressive symptoms. More than one half self-reported one or more comorbid conditions, almost one third had cancer of the larynx, and one half had stage 4 cancers. The median time since diagnosis was 4 months (range, 0 to 24 months). As of August 1, 2007, 39% of the patients (n = 193) were deceased; the other 302 patients in this population were censored as of this date. The median follow-up time was 5.1 years (range, 13 days to 7.2 years).

View larger version (23K): [in this window] [in a new window] [PowerPoint Slide for Teaching]   Fig 1. Overall survival curves for quality of life (QOL) scales comparing low scores to high scores. (A) Short Form-36 (SF-36) physical component score (n = 477: 185 events and 292 censored); (B) SF-36 mental component score (n = 477: 185 events and 292 censored); (C) Head and Neck QOL (HNQOL) pain score (n = 491: 192 events and 299 censored); (D) HNQOL eating score (n = 481: 186 events and 295 censored); (E) HNQOL speech score (n = 493: 192 events and 301 censored); (F) HNQOL emotion score (n = 490: 190 events and 300 censored). Each QOL score was split at the median into low and high categories.

Although tumor site was not associated with survival in the univariate models, it has been found to be predictive of survival in other studies of patients with head and neck cancer¹⁵ and was included in the final models. While treatment is known to be strongly related to QOL,^19-21 treatments were not included as covariates in the final models because all patients were treated with a standard protocol based on their cancer site and stage and treatments were inextricably associated with tumor site/stage. In addition, some subjects were surveyed at the time of their diagnosis, before the start of their treatment, and therefore treatment covaried with the time since diagnosis variable. While sex, race, and alcohol have been predictors of survival in other head and neck cancer studies,^22-25 they were not associated with survival in the univariate models and have not been predictive of QOL or survival in our prior work¹¹ and were thus not included in the multivariate analyses.

Four of six proportional hazards regression models showed a significant relationship between QOL and survival. Table 4 summarizes the hazard ratios and 95% CIs for the variables in each model.

The HNQOL pain score was significantly associated with survival, with a hazard ratio of 0.92 (95% CI, 0.87 to 0.98) in the multivariate model. Thus, for every 10-unit increase in the HNQOL pain scale (better QOL) the risk of death was 0.08 times lower. The HNQOL eating score (HR, 0.94; 95% CI, 0.89 to 0.99), and the HNQOL speech score (HR, 0.92; 95% CI, 0.87 to 0.96) were also significantly associated with survival in the adjusted analyses. Before and after adjustment for covariates, the HNQOL emotion score was not a predictor of survival.

In all models, age, time since diagnosis, marital status, tumor stage, and smoking were independently and significantly associated with survival. Comorbidities were marginally associated with survival in model 2, but were nonsignificant in all other models. Tumor site and education and were not significantly associated with survival in any of the analyses.

	DISCUSSION

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION AUTHORS' DISCLOSURES OF... AUTHOR CONTRIBUTIONS REFERENCES

 
This study shows that the general physical health QOL measure (the SF-36 physical component score) as well as the pain, eating, and speech domains of the HNQOL were highly associated with survival after a diagnosis of head and neck cancer. These findings support the results of two other large studies of patients with head and neck cancer which found that QOL is associated with survival.^10,26 A study by Goldstein et al¹⁰ found that patients with head and neck cancer who were long-term survivors (ie, survived for > 3 years) had the best QOL (including domains of eating and speech) at all measurements and had an improved QOL score trajectory after 1 year.¹⁰ A study by Gringnon et al²⁶ also found a predictive association of the SF-36 physical component score and 5-year survival and the magnitude of the association was almost identical to the magnitude of the association found in this study. Similar to other studies^3,5,26,27 there was no association between emotional QOL (as measured by the SF-36 mental component score or the HNQOL emotion domain) and survival.

It is possible that low QOL scores, particularly those on the HNQOL questionnaire (pain, eating, and speech) are reflective of persistent or recurrent disease. Persistent, recurrent, or metastatic head and neck cancer will cause worse pain, dysphagia, weight loss, fatigue, and other symptoms. Bodily pain has been shown to be associated with both disease risk, particularly cancer risk, and survival in other population studies.^28,29 While there is no obvious explanation for this association, the investigators of these studies state that it is likely due to a biologic mechanism; possibilities include abnormalities of the hypothalamic-pituitary-adrenal axis or the influence of insulinlike growth factor-1.²⁹ Measures to reduce pain among patients with head and neck cancer include systemic opioid analgesics, nonsteroidal anti-inflammatory drugs, tricyclic antidepressants, topical and coating agents, nerve blocks, or neurolytic procedures to palliate the pain.^30,31 Efforts to reduce oral pain, either by limiting the toxicities of interventions (ie, parotid sparing radiation therapy techniques),³² or by rehabilitating patients after therapy may have implications for overall well being that are far beyond simply relieving oral symptoms.

Eating problems may result from the location of head and neck cancer and treatment-induced adverse effects (eg, pain in the mouth, problems with dentition, decreased saliva, and problems swallowing). Hence, weight loss is reported to affect 35% to 50% of patients with head and neck cancer and is known to increase morbidity and mortality.³³ Speech problems may result in social isolation and depression^34,35 which may impact self care activities.^36,37

Identifying QOL issues gives clinicians the opportunity to initiate interventions to improve QOL simply to help patients feel better. For instance, interventions to control pain, improve swallowing, and improve speech rehabilitation can be planned. Identifying patients with poor QOL might also allow for early identification of patients with particularly aggressive tumors. Thus, identifying patients with low QOL may have screening value. If patients with low QOL were followed more closely for recurrence, there might be potential to identify recurrence earlier and perform salvage treatments, thereby possibly improving survival for this group of patients. Hence, if a patient's physical QOL appears poor, as clinicians, we ought to intervene to improve QOL, but we should also look a bit deeper for potential clinical disease that may explain their poor health-related QOL.

There were several control variables that were also associated with survival. As one might expect, age, time since diagnosis, and cancer stage were all associated with survival. As shown in other studies, marriage was associated with survival and is thought to be a marker for social support.^3,38 As has been shown by our group³⁹ as well as by others⁴⁰ smoking (a causative factor for head and neck cancer) was found to be one of the strongest predictors of survival. Quitting smoking may be the single most modifiable behavior to prolong survival, yet, similar to other studies^11,14,41 about one third of patients with head and neck cancer continued to smoke which compares with approximately 21% of the general population.⁴² While smoking is highly addictive, many patients with head and neck cancer are interested in quitting.¹⁴ Both pharmaceutical and behavioral interventions have been effective in assisting patients with head and neck cancer to quit smoking.^43,44

A limitation of this study was that the patients were surveyed at different points within 2 years of diagnosis, however, time since diagnosis was included as a control variable. Surveying patients at different times made it impossible to include treatment modality in the analysis. Time since diagnosis was used as a proxy for treatment, assuming that all patients receive treatment within the same general timeframe. Based on our research and clinical experience, we recommend routine QOL assessment at baseline (pretreatment), 6 months (post-treatment), 1 year (stabilization point) and 2 years (disease free or recurrent/persistent disease status). While extensive efforts were made to verify vital status, it is possible that we were unable to obtain dates of death for some individuals who were in fact deceased, thus resulting in possible misclassification of some patients. However, this type of nondifferential misclassification would have only biased our associations toward the null. Thus, we remain confident that the relationships are at least as strong as observed in this analysis.

In this large cohort study of patients with head and neck cancer, four of six QOL scales predicted survival. It is possible that these QOL scales are detecting subclinical recurrences of cancer. Hence, QOL surveys may offer clinicians the opportunity to improve QOL and possibly diagnose early recurrence and improve survival.

	AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION AUTHORS' DISCLOSURES OF... AUTHOR CONTRIBUTIONS REFERENCES

 
The author(s) indicated no potential conflicts of interest.

	AUTHOR CONTRIBUTIONS

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION AUTHORS' DISCLOSURES OF... AUTHOR CONTRIBUTIONS REFERENCES

 
Conception and design: Carrie A. Karvonen-Gutierrez, Karen E. Fowler, Jeffrey E. Terrell, Sonia A. Duffy

Financial support: Jeffrey E. Terrell, Sonia A. Duffy

Administrative support: Karen E. Fowler, Sonia A. Duffy

Provision of study materials or patients: Jeffrey E. Terrell

Collection and assembly of data: Karen E. Fowler, Sonia A. Duffy

Data analysis and interpretation: Carrie A. Karvonen-Gutierrez, David L. Ronis, Karen E. Fowler, Jeffrey E. Terrell, Stephen B. Gruber, Sonia A. Duffy

Manuscript writing: Carrie A. Karvonen-Gutierrez, David L. Ronis, Karen E. Fowler, Jeffrey E. Terrell, Sonia A. Duffy

Final approval of manuscript: Carrie A. Karvonen-Gutierrez, David L. Ronis, Karen E. Fowler, Jeffrey E. Terrell, Stephen B. Gruber, Sonia A. Duffy

	NOTES

 
Supported by the Department of Veterans Affairs IIR 98-500, GlaxoSmithKline through the Managed Care Forum, and by the National Institutes of Health grant No. P50 CA97248 through the University of Michigan's Head and Neck Specialized Program of Research Excellence.

Authors’ disclosures of potential conflicts of interest and author contributions are found at the end of this article.

	REFERENCES

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION AUTHORS' DISCLOSURES OF... AUTHOR CONTRIBUTIONS REFERENCES

 
1. Goodwin PJ, Ennis M, Bordeleau LJ, et al: Health-related quality of life and psychosocial status in breast cancer prognosis: Analysis of multiple variables. J Clin Oncol 22:4184-4192, 2004[Abstract/Free Full Text]

2. Silberfarb PM, Anderson KM, Rundle AC, et al: Mood and clinical status in patients with multiple myeloma. J Clin Oncol 9:2219-2224, 1991[Abstract]

3. de Graeff A, de Leeuw JR, Hordijk GJ, et al: Sociodemographic factors and quality of life as prognostic indicators in head and neck cancer. Eur J Cancer 37:332-339, 2001[CrossRef][Medline]

4. Chang VT, Thaler HT, Polyak TA, et al: Quality of life and survival: The role of multidimensional symptom assessment. Cancer 83:173-179, 1998[CrossRef][Medline]

5. Hammerlid E, Wirblad B, Sandin C, et al: Malnutrition and food intake in relation to quality of life in head and neck cancer patients. Head Neck 20:540-548, 1998[CrossRef][Medline]

6. Dancey J, Zee B, Osoba D, et al: Quality of life scores: An independent prognostic variable in a general population of cancer patients receiving chemotherapy: The National Cancer Institute of Canada Clinical Trials Group. Qual Life Res 6:151-158, 1997[Medline]

7. Coates A, Porzsolt F, Osoba D: Quality of life in oncology practice: Prognostic value of EORTC QLQ-C30 scores in patients with advanced malignancy. Eur J Cancer 33:1025-1030, 1997[CrossRef][Medline]

8. Vigano A, Donaldson N, Higginson IJ, et al: Quality of life and survival prediction in terminal cancer patients: A multicenter study. Cancer 101:1090-1098, 2004[CrossRef][Medline]

9. Allison PJ, Guichard C, Fung K, et al: Dispositional optimism predicts survival status 1 year after diagnosis in head and neck cancer patients. J Clin Oncol 21:543-548, 2003[Abstract/Free Full Text]

10. Goldstein DP, Hynds Karnell L, Christensen AJ, et al: Health-related quality of life profiles based on survivorship status for head and neck cancer patients. Head Neck 29:221-229, 2007[CrossRef][Medline]

11. Duffy SA, Ronis DL, Valenstein M, et al: Depressive symptoms, smoking, drinking, and quality of life among head and neck cancer patients. Psychosomatics 48:142-148, 2007[Abstract/Free Full Text]

12. Ware JE, Kosinski M, Keller SD: SF-36 Physical and Mental Summary Scales: A Users Manual. Boston, MA, The Health Institute, 1994

13. Terrell JE, Nanavati KA, Esclamado RM, et al: Head and neck cancer-specific quality of life: Instrument validation. Arch Otolaryngol Head Neck Surg 123:1125-1132, 1997[Abstract/Free Full Text]

14. Duffy SA, Terrell JE, Valenstein M, et al: Effect of smoking, alcohol, and depression on the quality of life of head and neck cancer patients. Gen Hosp Psychiatry 24:140-147, 2002[CrossRef][Medline]

15. Weymuller EA, Yueh B, Deleyiannis FW, et al: Quality of life in patients with head and neck cancer: Lessons learned from 549 prospectively evaluated patients. Arch Otolaryngol Head Neck Surg 126:329-335, 2000[Abstract/Free Full Text]

16. Mukerji SS, Duffy SA, Fowler KE, et al: Comorbidities in head and neck cancer: Agreement between self-report and chart review. Otolaryngol Head Neck Surg 136:536-542, 2007[CrossRef][Medline]

17. Lewinsohn PM, Seeley JR, Roberts RE, et al: Center for Epidemiologic Studies Depression Scale (CES-D) as a screening instrument for depression among community-residing older adults. Psychol Aging 12:277-287, 1997[CrossRef][Medline]

18. Saunders JB, Aasland OG, Babor TF, et al: Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption–II. Addiction 88:791-804, 1993[CrossRef][Medline]

19. Bjordal K, Kaasa S, Mastekaasa A: Quality of life in patients treated for head and neck cancer: A follow-up study 7 to 11 years after radiotherapy. Int J Radiat Oncol Biol Phys 28:847-856, 1994[Medline]

20. Nguyen NP, Sallah S, Karlsson U, et al: Combined chemotherapy and radiation therapy for head and neck malignancies: Quality of life issues. Cancer 94:1131-1141, 2002[CrossRef][Medline]

21. Terrell JE, Ronis DL, Fowler KE, et al: Clinical predictors of quality of life in patients with head and neck cancer. Arch Otolaryngol Head Neck Surg 130:401-408, 2004[Abstract/Free Full Text]

22. Bhattacharyya N: Cancer of the nasal cavity: Survival and factors influencing prognosis. Arch Otolaryngol Head Neck Surg 128:1079-1083, 2002[Abstract/Free Full Text]

23. Gourin CG, Podolsky RH: Racial disparities in patients with head and neck squamous cell carcinoma. Laryngoscope 116:1093-1106, 2006[CrossRef][Medline]

24. Park SM, Lim MK, Shin SA, et al: Impact of prediagnosis smoking, alcohol, obesity, and insulin resistance on survival in male cancer patients: National Health Insurance Corporation Study. J Clin Oncol 24:5017-5024, 2006[Abstract/Free Full Text]

25. Piccirillo JF, Spitznagel EL Jr, Vermani N, et al: Comparison of comorbidity indices for patients with head and neck cancer. Med Care 42:482-486, 2004[CrossRef][Medline]

26. Grignon LM, Jameson MJ, Karnell LH, et al: General health measures and long-term survival in patients with head and neck cancer. Arch Otolaryngol Head Neck Surg 133:471-476, 2007[Abstract/Free Full Text]

27. Mehanna HM, Morton RP: Does quality of life predict long-term survival in patients with head and neck cancer? Arch Otolaryngol Head Neck Surg 132:27-31, 2006[Abstract/Free Full Text]

28. Macfarlane GJ, McBeth J, Silman AJ: Widespread body pain and mortality: Prospective population based study. BMJ 323:662-665, 2001[Abstract/Free Full Text]

29. McBeth J, Silman AJ, Macfarlane GJ: Association of widespread body pain with an increased risk of cancer and reduced cancer survival: A prospective, population-based study. Arthritis Rheum 48:1686-1692, 2003[CrossRef][Medline]

30. Epstein JB, Raber-Durlacher JE: Topical agents for the management of oral complications in cancer patients. Business Briefing: US Oncology Review 2004. http://www.touchbriefings.com/cdps/cditem.cfm?nid=1033&cid=5

31. Epstein JB, Epstein JD, Epstein MS, et al: Oral doxepin rinse: The analgesic effect and duration of pain reduction in patients with oral mucositis due to cancer therapy. Anesth Analg 103:465-470, 2006[Abstract/Free Full Text]

32. Eisbruch A, Ship JA, Dawson LA, et al: Salivary gland sparing and improved target irradiation by conformal and intensity modulated irradiation of head and neck cancer. World J Surg 27:832-837, 2003[CrossRef][Medline]

33. van Bokhorst-de, van der Schuer, van Leeuwen PA, Kuik DJ, et al: The impact of nutritional status on the prognoses of patients with advanced head and neck cancer. Cancer 86:519-527, 1999[CrossRef][Medline]

34. Finizia C, Bergman B: Health-related quality of life in patients with laryngeal cancer: A post-treatment comparison of different modes of communication. Laryngoscope 111:918-923, 2001[CrossRef][Medline]

35. Hassanein KA, Musgrove BT, Bradbury E: Functional status of patients with oral cancer and its relation to style of coping, social support and psychological status. Br J Oral Maxillofac Surg 39:340-345, 2001[CrossRef][Medline]

36. Evans DL, Charney DS, Lewis L, et al: Mood disorders in the medically ill: Scientific review and recommendations. Biol Psychiatry 58:175-189, 2005[CrossRef][Medline]

37. Fisch M: Treatment of depression in cancer. J Natl Cancer Inst Monogr 32:105-111, 2004[Abstract/Free Full Text]

38. Kugaya A, Akechi T, Okuyama T, et al: Prevalence, predictive factors, and screening for psychologic distress in patients with newly diagnosed head and neck cancer. Cancer 88:2817-2823, 2000[CrossRef][Medline]

39. Duffy SA, Taylor JGM, Terrell JE, et al: IL-6 predicts recurrence among head and neck cancer patients. Cancer (in press)

40. Allen C, Duffy S, Teknos T, et al: Nuclear factor-kappaB-related serum factors as longitudinal biomarkers of response and survival in advanced oropharyngeal carcinoma. Clin Cancer Res 13:3182-3190, 2007[Abstract/Free Full Text]

41. Terrell JE, Fisher SG, Wolf GT: Long-term quality of life after treatment of laryngeal cancer: The Veterans Affairs Laryngeal Cancer Study Group. Arch Otolaryngol Head Neck Surg 124:964-971, 1998[Abstract/Free Full Text]

42. Centers for Disease Control and Prevention: Cigarette smoking among adults–United States, 2004. MMWR Morb Mortal Wkly Rep 54:1121-1124, 2005[Medline]

43. Duffy SA, Ronis DL, Valenstein M, et al: A tailored smoking, alcohol, and depression intervention for head and neck cancer patients. Cancer Epidemiol Biomarkers Prev 15:2203-2208, 2006[Abstract/Free Full Text]

44. Duffy SA, Khan MJ, Ronis DL, et al: Health behaviors of head and neck cancer patients the first year after diagnosis. Head Neck 30:93-102, 2008[CrossRef][Medline]

Submitted June 12, 2007; accepted February 29, 2008.

CiteULike    Complore    Connotea    Del.icio.us    Digg    Facebook    Reddit    Technorati    Twitter    What's this?

This article has been cited by other articles:

				T. Tanvetyanon, T. Padhya, J. McCaffrey, W. Zhu, D. Boulware, R. DeConti, and A. Trotti Prognostic Factors for Survival After Salvage Reirradiation of Head and Neck Cancer J. Clin. Oncol., April 20, 2009; 27(12): 1983 - 1991. [Abstract] [Full Text] [PDF]

				M. W. El-Deiry, N. D. Futran, J. A. McDowell, E. A. Weymuller Jr, and B. Yueh Influences and Predictors of Long-term Quality of Life in Head and Neck Cancer Survivors Arch Otolaryngol Head Neck Surg, April 1, 2009; 135(4): 380 - 384. [Abstract] [Full Text] [PDF]

				O. Guntinas-Lichius, T. Tanvetyanon, J. B. Vermorken, and the EXTREME Investigators Cetuximab in Head and Neck Cancer N. Engl. J. Med., December 18, 2008; 359(25): 2725 - 2726. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Karvonen-Gutierrez, C. A. Articles by Duffy, S. A. Search for Related Content PubMed PubMed Citation Articles by Karvonen-Gutierrez, C. A. Articles by Duffy, S. A. Social Bookmarking                            What's this?