Impact of comorbidity on outcome of young patients with head and neck squamous cell carcinoma.
Singh B. Bhaya M. Zimbler M. Stern J. Roland JT. Rosenfeld RM. Har-El G. Lucente FE.
Department of Otolaryngology, State University of New York Health Science Center at Brooklyn, The Long Island College Hospital, 11201, USA.
BACKGROUND: Comorbid conditions have a significant impact on the actuarial survival of patients with head and neck cancer. However, no studies have evaluated the impact of comorbidity on tumor- and treatment-specific outcomes. This study was performed to evaluate the impact of comorbidity, graded by the Kaplan-Feinstein comorbidity index (KFI) on the incidence and severity of complications, disease-free interval, and tumor-specific survival in patients undergoing curative treatment for head and neck cancer. METHODS: A multi-institutional, retrospective cohort of 70 patients 45 years of age and under with head and neck squamous cell carcinoma (SCC) presenting over an 11-year period was studied. RESULTS: Advanced comorbidity (KFI grade 2 or 3) was present in 21 patients (30%). Patients with advanced comorbidity did not differ from patients with low-level comorbidity (KFI grades 0 or 1) in sex distribution, race, presence of human immunodeficiency virus (HIV) infection, tobacco use, location of primary lesion, stage at presentation, pathologic differentiation of the tumor, or type of initial treatment. The overall incidence of treatment-associated complications was similar between the groups (57% versus 49%; p > 0.05), but a higher proportion of patients with advanced comorbidity developed high-grade complications (24% versus 6%; p = .04). The median disease-free interval (11.1 months versus 21.6 months; p = .045) and tumor-specific survival (13.7 months versus 57.6 months; p = .03) was poorer for patients with advanced comorbidity. The effects of comorbidity on survival remained significant even after adjusting for the confounding effects of HIV status and tumor stage (p = .05). CONCLUSIONS: The presence of comorbid conditions has a significant impact on tumor- and treatment-specific outcomes. Although the presence of advanced comorbid conditions is not associated with an increase in the rate of treatment-associated complications, complications tend to be more severe in this population. More importantly, advanced comorbidity has a detrimental effect on the disease-free interval and tumor-specific survival in patients with head and neck cancer, independent of other factors. This suggests that comorbidity may impact on tumor behavior, presumably by altering the host's response to cancer. Accordingly, to be more predictive and reliable, the current staging system for head and neck cancer should include a description of the patient's comorbidity.
Acute and chronic changes in swallowing and quality of life following intraarterial chemoradiation for organ preservation in patients with advanced head and neck cancer.
Murry T. Madasu R. Martin A. Robbins KT.
Department of Otolaryngology The Eye & Ear Institute, University of Pittsburgh School of Medicine, Pennsylvania 15213, USA.
BACKGROUND: Health-related quality of life (QOL) provides a measure of the patient's perception of his life after treatment. This study was undertaken to assess changes in QOL and swallowing in patients undergoing concurrent chemoradiotherapy (CR) for head and neck cancer. The assessment tools consisted of the Head and Neck Radiotherapy Questionnaire (HNRQ) and a swallowing questionnaire (SQ). METHODS: The HNRQ and SQ were administered to a group of CR patients prior to treatment (n = 58), after the last week of treatment (n = 37), and 6 months after treatment (n = 27). Weight change was monitored in treatment subjects. RESULTS: The results indicate that QOL and swallowing function decrease acutely during CR (p < .05) but improvement begins shortly after the treatment-related decline. At 6 months after CR, mean QOL exceeds pretreatment level. The oropharynx patients have the poorest outcome when compared with laryngeal and hypopharyngeal patients. A stronger correlation exists between swallowing and QOL at 6 months post-CR than during treatment (R = .52 versus R = .30). CONCLUSIONS: Quality of life and swallowing are compromised in advanced head and neck cancer patients prior to treatment. There was a further decrease in QOL and swallow function during CR. Organ-preservation programs in head and neck cancer result in improved QOL and swallowing 6 months after treatment. The degree of improvement is site-specific.
Light digital occlusion of the tracheostomy tube: a pilot study of effects on aspiration and biomechanics of the swallow.
Logemann JA. Pauloski BR. Colangelo L.
Department of Communication Sciences and Disorders, Northwestern University, Evanston, Illinois 60208, USA.
BACKGROUND: This study examined the effects of digital occlusion of the tracheostomy tube versus no occlusion on oropharyngeal swallowing in head and neck cancer patients. METHODS: Eight treated head and neck cancer patients were studied, six of whom had undergone surgical treatment for oral or laryngeal cancer and two who had undergone high-dose chemotherapy and radiotherapy for laryngeal cancer. Videofluorographic studies of oropharyngeal swallowing were accomplished on 3-mL boluses of liquid in seven patients and 3-mL boluses of paste in three patients, first with the tracheostomy not occluded and then with it lightly digitally occluded by the patient. Videofluorographic studies of swallow were examined for observations of aspiration and residue. Biomechanical analysis of each liquid swallow was also completed. RESULTS: Four of the seven patients aspirated on thin liquids with the tube unoccluded. Aspiration was eliminated with the tracheostomy digitally occluded in two of these four patients. One of the patients also aspirated on paste with the tube unoccluded, and the aspiration was eliminated with the tube occluded. A third patient who aspirated on thin liquid had no change when the tube was occluded, and one patient's swallow worsened with the tube occluded on liquid. There were significant changes in five measures of swallow biomechanics on liquids with the tube occluded: (1) duration of base of tongue contact to the posterior pharyngeal wall was reduced, (2) maximal laryngeal elevation increased, (3) and (4) laryngeal and hyoid elevation at the time of initial cricopharyngeal opening increased, and (5) onset of anterior movement of the posterior pharyngeal wall relative to the onset of cricopharyngeal opening began later. CONCLUSION: Light digital occlusion of the tracheostomy tube appears to be a safe procedure, because most biomechanics of swallow are positively affected, perhaps because of the increased resistance provided by the closed trachea. However, not all patients received benefit from tube occlusion, indicating that each patient must be evaluated individually to determine whether or not tube occlusion improves their swallow.
Current status of pharyngolaryngo-esophagectomy and pharyngogastric anastomosis.
Wei WI. Lam LK. Yuen PW. Wong J.
Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong.
BACKGROUND: Pharyngolaryngo-esophagectomy and pharyngogastric anastomosis (PLO & PGA) is one of the surgical options in the management of tumors arising from the hypopharynx and cervical esophagus. Indications of the operation and the outcome are changing over the years. To examine these, the experience of this operation in one Institute (the Head and Neck Division of the Department of Surgery, The University of Hong Kong at Queen Mary Hospital, Hong Kong) over the last 30 years was reviewed. METHODS: From 1966 to 1995, a total of 317 patients underwent PLO & PGA. The clinical results of 69 patients operated on between 1986 and 1995 were analyzed and compared with those of the two groups of patients reported previously from the same Institute to establish the current status of PLO & PGA. RESULTS: The demographic data of three groups of patients were similar. In previous years, 53% of the primary tumors were advanced laryngeal carcinomas extending to the hypopharynx, whereas the other 47% originated from hypopharyngeal and cervical esophageal regions. In recent years, all patients belonged to the latter group. CONCLUSIONS: The hospital mortality has decreased from 31% to 9%, and the incidence of morbidity such as anastomotic leakage and bleeding has also been reduced, from 20% to 10%. This may be related to the introduction of transthoracic endoscopic mobilization of the esophagus and patient selection. The overall minor morbidity has, however, remained at about 49%, and the 5-year actuarial survival rate has improved, from 18% in the 1970s to 24.5% at present.