TREATED HEAD AND NECK CANCER

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GHQ SCORES PREDICT UNIQUELY

SUBSEQUENT SURVIVAL IN SUCCESSFULLY TREATED HEAD AND NECK CANCER

PATIENTS: A PROSPECTIVE COHORT STUDY

Anne K.H. Aarstad

^2,3

, Arild A Osthus

¹

, Jan Olofsson

^1,2

, Hans J. Aarstad

^1,2

1Department of Surgical Sciences, Faculty of Medicine, University of Bergen, N-5021 Bergen, Norway.

2Department of Otolaryngology/Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway.

3Faculty of Health and Social Sciences, Bergen University College, Bergen.

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This varied incidence throughout the world implies external causes of the disease

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Tobacco smoking is an important

risk factor of head and neck carcinoma

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Alcohol consumption is an important risk factor of head and neck

carcinoma

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• A combination of smoking and alcohol consumption is what matters.

• There is a social gradient as to smoking.

• Head and neck cancer is to some extent a poor man’s disease.

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Survival following diagnosis of oral cavity/pharynx carcinoma

Data from the Norwegian cancer registry

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Sequels following radiation therapy

Vissinck, 2003

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Distress

• Distress is defined as “an unpleasant emotional experience of a psychological, social, or spiritual nature.

• Distress extends along a continuum, ranging from common normal feelings of vulnerability, sadness, and fear to problems that can become disabling, such as depression, anxiety, panic, social isolation, and spiritual crisis”

• (US National Comprehensive Cancer Network) [White, Macleod, 2002].

• Distress may be measured by the “General Health Questionnaire”. Level of distress may be used as an indicator of mental disease [Vodermaier, 2009].

• Bjordal and Kaasa [1995] have e.g. studied distress by the GHQ-20 in long term survivors of HNC. About 30% of patients fulfilled the criteria of being

“cases”.

• We have shown similar levels of GHQ scores in HNSCC patients [Aarstad et al., 2011].

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Neuroticism

Coping

Disease-related factors

GHQ 25% Gen QoL

Personality

Beisland E., Aarstad A.H.K, Østhus A.A., Aarstad H.J. (2012) Stability of distress and health-related quality of life

as well as relation to neuroticism, coping and TNM stage in head and neck cancer patients during follow up. Acta Otolaryngol. In press.

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HRQoL scores predict survival among former HNSCC patients [Østhus et al., 2011].

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AIM

Does the GHQ scores predict survival as well?

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Patients included

• By October 1st 2002 all patients (n=162) diagnosed with head and and neck

squamous cell carcinoma ( HNSCC) in Western Norway in the period from July 1st 1992 to October 1st 2001, below 80 years of age and who had been disease free for at least one year following therapy by October 1st 2002 were identified.

• All patients, except for 18 patients who were found not to be eligible for the study, due to cognitive impairment or other serious disease, were approached to participate in this study. Three patients refused to participate and two patients have been lost to follow-up.

• 139 patients, yielding a 97% total response rate, were enrolled for structured interviews.

• These were completed in the period between October 21^st 2002 and March 29^th 2004.

The observation was ended as of June 30^th 2009, yielding a mean observation period of 75±4 (range 63-80) months among the survivors. Twenty-four deaths were

observed.

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Questionnaires employed

•

General Health Questionnaire

• The general health questionnaire (GHQ)-30 was employed

• [Goldberg & Williams,1998].

• The patients scored according to a standard 4 point response matrix. The GHQ was analyzed with the responses calculated as Likert scores.

•

Quality of life inventory

• Employed the EORTC QLQ (C30 & H&N35) inventory

• [Aaronson et al., 1993. Bjordal et al., 1994. Bjordal et al., 2000].

• Answers in a 4-point Likert format, and the scales were transformed so that 0% indicated least and 100% most symptoms.

• In addition, HRQoL sum scores based on the EORTC QLQ indices were calculated.

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Tumour stage

is 6 4,3

1 66 47,5

2 39 28,1

3 15 10,8

4 13 9,4

Nodal stage

0 98 70,5

1 13 9,4

2 26 18,7

3 2 1,4

Treatment

Tumour surgery 86 61,9

Neck dissection 52 37,4

Free flap reconstruction 16 11,5

Tumour RT 95 68,3

Neck RT 67 48,2

Chemotherapy 6 4,3

Gender

Male 104 74,8

Female 35 25,2

Co-morbidities

Angina pectoris 9 6,5

Myocardial infarction 10 7,2

Heart medication 28 20,1

Asthma and/or chronic bronchitis 13 9,4

Lung medication 6 4,3

Tumour site

Larynx 52 37,4

Oral cavity 44 31,7

Oropharynx 31 22,3

Others 12 8,6

N % N %

Patient characteristics

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Post treatment GHQ scores and multiple Cox proportional hazards regression analyses of survival

Predictors HR 95% CI P

GHQ sum score adjusted by gender and age

GHQ sum score 1.1 1.02-1.11 0,004

Dichotomized GHQ sum score 3.8 1.7-8,6 0,001

GHQ sum score adjusted for neuroticism and avoidance focused coping*

GHQ sum score 1.06 1.00-1.12 0,056

Dichotomized GHQ sum score 3.4 1.3-9.0 0,015

GHQ sum score adjusted for T-stage and site (oropharynx vs others)*

GHQ sum score 1.06 1.02-1.1 0,007

GHQ sum score adjusted for alcohol consumption and cigarettes smoked per week*

H&N HRQoL sum score 1.07 1.02-1.12 0,003

GHQ sum score adjusted for a sum score of heart disease*

GHQ sum score 1.06 1.02-1.11 0,009

GHQ sum score adjusted for gender, age, neuroticism, avoidance focused coping, T-stage, site (oropharynx versus others), alcohol consumption, cigarettes smoked per week, and a heart disease

GHQ sum score 1.06 0.99-1.13 0,080

*The analyses were in addition to the presented variables adjusted for gender and age

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Survival dependent on GHQ score

p<0.01

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Survival dependent on H&N HRQoL score

p<0.01

p=0.06

Østhus A.A., Aarstad A.K.H., Olofsson J., Aarstad H.J. (2011). Head and neck specific Health Related Quality of Life scores predict subsequent survival in successfully treated head and neck cancer patients; a prospective cohort study. Oral Oncol. 47: 974-9.

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Discussion

•General Health Questionnaire (GHQ) scores predict survival in former HNSCC patients.

•What are the mechanisms of the GHQ prediction?

•Is a distressed person more «stressed» (by e.g. from low income or due to death of spouse), with consequently less defense against disease?

•The close association between Health Related Quality of Life scores indicate that present co-morbidity; perhaps in addition to smoking and alcohol use, is responsible for the GHQ prediction

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Tobacco/alcohol

metakron = secondary primary

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Survival dependent on reported hearth disease

p<0.05

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Annual Reviews

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Trends in head and neck cancer incidence in Denmark, 1978–2007: Focus on human papillomavirus associated sites

International Journal of Cancer

Volume 129, Issue 3, pages 733-741, 26 OCT 2010 DOI: 10.1002/ijc.25699 http://onlinelibrary.wiley.com/doi/10.1002/ijc.25699/full#fig1

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Conclusions

• Our findings indicate a “unique” survival prediction from distress scores in successfully treated HNSCC patients.

• The mechanisms are not known

• In any case, dichotomized GHQ-scores (highest quartile) may be a screening tool for identifying successfully treated HNSCC patients with high mortality risk.

• The HPV epidemic may change the picture of head and neck cancer from being the poor man’s disease to also being the sexual active man’s disease.

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Social gradient in life expectancy and expected lifetime in self rated good health in different smoking categories.

Brønnum-Hansen H , Juel K J Epidemiol Community Health 2004;58:604-610