Long-term effect of a nurse-led psychosocial intervention on health-related quality of life in patients with head and neck cancer: a randomised controlled trial.

BACKGROUND: Head and neck cancer (HNC) patients are prone to have a poor health-related quality of life after cancer treatment. This study investigated the effect of the nurse counselling and after intervention (NUCAI) on the health-related quality of life and depressive symptoms of HNC patients between 12 and 24 months after cancer treatment. METHODS: Two hundred and five HNC patients were randomly allocated to NUCAI (N=103) or usual care (N=102). The 12-month nurse-led NUCAI is problem-focused and patient-driven and aims to help HNC patients manage with the physical, psychological and social consequences of their disease and its treatment. Health-related quality of life was evaluated with the EORTC QLQ-C30 and QLQ H&N35. Depressive symptoms were evaluated with the CES-D. RESULTS: At 12 months the intervention group showed a significant (P<0.05) improvement in emotional and physical functioning, pain, swallowing, social contact, mouth opening and depressive symptoms. At 18 months, global quality of life, role and emotional functioning, pain, swallowing, mouth opening and depressive symptoms were significantly better in the intervention group than in the control group, and at 24 months emotional functioning and fatigue were significantly better in the intervention group. CONCLUSION: The NUCAI effectively improved several domains of health-related quality of life and depressive symptoms in HNC patients and would seem a promising intervention for implementation in daily clinical practice.

Improved depiction of pterygopalatine fossa anatomy using ultrahigh-resolution magnetic resonance imaging at 7 tesla.

PURPOSE: To study the anatomy of the pterygopalatine fossa (PPF) using ultrahigh-resolution magnetic resonance imaging. METHODS: A human cadaveric tissue block containing the pterygopalatine fossa was examined on a clinical 7-Tesla magnetic resonance imaging system. Subsequently, cryosections of the tissue block were created in a coronal plane. The cryosections were photographed and collected on adhesive tape. The on-tape sections were stained for Mallory-Cason, in order to detail the anatomic structures within the fossa. Magnetic resonance images were compared with surface photos of the tissue block and on-tape sections. RESULTS: High-resolution magnetic resonance images demonstrated the common macroscopic structures in the PPF. Smaller structures, best viewed at the level of the operation microscope, which have previously been obscured on magnetic resonance imaging, could be depicted. Some of the orbital pterygopalatine ganglion branches and the pharyngeal nerve were clearly viewed. CONCLUSIONS: In our experience with one human cadaver specimen, magnetic resonance imaging at 7 Tesla seems effective in depicting pterygopalatine fossa anatomy and provides previously unseen details through its demonstration of the pharyngeal nerve and the orbital pterygopalatine ganglion branches. The true viability of depicting the pterygopalatine fossa with ultrahigh-resolution MR will depend on confirmation of our results in larger studies.

A gene expression profile for non-smoking and non-drinking patients with head and neck cancer.

OBJECTIVE: A small subset of patients with head and neck squamous cell carcinoma are non-smoking and non-drinking and have distinct clinical characteristics. We aimed to identify a possible different genetic profile for these patients when compared with their smoking and drinking counterparts. MATERIALS AND METHODS: The gene expression data previously detected from primary tumors located in the oral cavity and oropharynx, using DNA microarray was analyzed for their differential expression between non-smoking and non-drinking patients (n = 15) and smoking and drinking patients (n = 89). Student's T-test (P < 0.05) and 10-fold cross-validation procedure (100 times repeated) were performed to determine differentially expressed genes. RESULTS: Non-smoking and non-drinking patients were older, mostly female and had oral cavity-localized tumors, whereas smoking and drinking patients were younger male patients with 81% oral cavity and 19% oropharynx tumors. A set of 49 differentially expressed genes were detected. Among others, seven genes related to interferon-γ were upregulated and two genes linked to NFKB pathway were downregulated. CONCLUSIONS: Differentially expressed genes in non-smoking and non-drinking patients possibly indicate the presence of a different cellular response to carcinogenic events in these patients. Further studies are warranted to validate this gene set and explore possible therapeutic implications to improve prognosis for these patients.

Human Papillomavirus and Oropharyngeal Squamous Cell Carcinoma: A Case-Control Study regarding Tobacco and Alcohol Consumption.

We aimed to determine the role of HPV in the pathogenesis and outcome of oropharyngeal squamous cell carcinoma (OSCC) in lifelong nonsmoking and nondrinking patients. A case-case analysis was performed to compare the presence of HPV-DNA in tumor cells of 16 nonsmoking and nondrinking with 16 matched smoking and drinking patients (matching criteria: age at incidence, gender, tumor sublocation, tumor stage). HPV was detected using 2 PCR tests, FISH analysis, and p16(INK4A) immunostaining. Nonsmoking and nondrinking patients had more HPV-positive tumors than smoking and drinking patients (n = 12; 75% versus n = 2; 13%; P < 0.001). All HPV-positive tumors showed p16(INK4A) overexpression, and 1 HPV-negative tumor had p16(INK4A) overexpression, (P < 0.001). Overall survival and disease-specific survival were higher for HPV-positive compared to HPV-negative cases (P = 0.027, P = 0.039, resp.). In conclusion, HPV is strongly associated with OSCC of nonsmoking and nondrinking patients. Specific diagnostic and therapeutic actions should be considered for these patients to achieve a better prognosis.

Observing stage-shifts in head and neck squamous cell carcinoma from initial clinical outpatient staging to definite clinical tumour board staging using radiological and endoscopical investigations: will less do?

OBJECTIVES: Staging head and neck squamous cell carcinoma usually is initiated in the outpatient department (OPD) using patient history and physical examination. To reach consensus on stage and therapy, imaging and panendoscopy are more or less routinely applied as additional staging tests. Staging results from the outpatient department were evaluated for tumour and neck stage. We investigated in which situations additional staging tests are needed. DESIGN: Prospective cohort study. SETTING: Head and Neck Oncology Group, University Medical Centre. PARTICIPANTS: Of 341 patients, initial staging results from the outpatient department were compared with the ultimate staging results from the tumour board review, which provides the basis for decisions on therapy. MAIN OUTCOME MEASURES: Tumour stage and neck stage migrations during this staging tract. RESULTS: In staging head and neck tumours are squamous cell carcinomas, additional staging tests like imaging and/or panendoscopy remain necessary to evaluate the primary tumour stage. Average accuracies of T-staging in oral cavity, pharynx and larynx only amount to 71%, 47% and 61%, respectively. For T1N0 and T2N0 oral cavity tumours, neck assessment in the outpatient department was accurate in 100% (95% CI: 91-100%) and 93% (95% CI: 80-98%), respectively. In the larynx group, this was 100% (95% CI: 91-100%) and 97% (95% CI: 86-100%), respectively. CONCLUSIONS: For oral cavity and laryngeal tumours staged as T1-2N0 in the outpatient department, we concluded that the outpatient department staging is highly predictive of the final pre-treatment staging. In these cases, computer tomography and/or MRI remain a necessity but additional ultrasound with or without fine needle aspiration cytology can be omitted. In our institution, this would have resulted in a 46% reduction in ultrasound procedures. If T-stage is upgraded during imaging or panendoscopy, additional staging tests for N-stage should still be considered.

Sluder's neuralgia: a trigeminal autonomic cephalalgia?

The objective was to formulate distinctive criteria to substantiate our opinion that Sluder's neuralgia and cluster headache are two different clinical entities. A systematic review was carried out of all available, original literature on Sluder's neuralgia. Pain characteristics, periodicity and associated signs and symptoms were studied and listed according to frequency of appearance. Eleven articles on Sluder's neuralgia were evaluated. Several differences between Sluder's neuralgia and cluster headache became evident. Based on described symptoms, new criteria for Sluder's neuralgia could be formulated. Sluder's neuralgia and cluster headache could possibly be regarded as two different headache syndromes, and Sluder's neuralgia could be a trigeminal autonomic cephalalgia.

Head and neck squamous cell carcinoma in non-smoking and non-drinking patients with multiple tumors: etiologic significance of p53 and Ki-67 in non-tumorous epithelium.

BACKGROUND: Non-smoking and non-drinking patients with head and neck squamous cell carcinoma have different clinical characteristics than their smoking and drinking counterparts. They are predominantly older female patients with oral cavity tumors, however, both groups show the same percentage of second primary tumors. Expression of tumor suppressor gene p53 and proliferation marker Ki-67 in mucosal epithelial cells was analyzed to study whether biomarker expression is associated with a history of smoking and drinking and with single and multiple tumors. METHODS: Non-smoking and non-drinking patients with multiple (n = 18) and single tumors (n = 15), smoking and drinking patients with multiple (n = 15) and single tumors (n = 14) were selected. For all groups, p53 and Ki-67 expression patterns in non-tumorous (tumor-adjacent) mucosa including positivity of dispersed single cells and clusters for p53 and for suprabasal expression of Ki-67 were immunohistochemically analyzed and compared. RESULTS: p53 expression was significantly higher in users of tobacco and alcohol than in non-users. Ki-67 expression was not affected by tobacco and alcohol usage. Both Ki-67 and p53 were similarly expressed in the groups with single and multiple tumors and hence not significantly related to the number of tumors. CONCLUSIONS: Non-smoking and non-drinking patients with squamous cell carcinoma have the same risk for developing multiple tumors as their smoking and drinking counterparts. As this occurs without an increased expression of p53 or Ki-67, the significance of these proteins as biomarkers indicating pre-malignant mucosal alterations is doubtful. Further research is needed to clarify this predisposition for developing multiple head and neck cancer.

Non-smoking and non-drinking patients with head and neck squamous cell carcinoma: a distinct population.

OBJECTIVE: To recognize specific clinicopathological characteristics of non-smoking and non-drinking (NSND) head and neck squamous cell carcinoma (HNSCC) patients. This can increase our knowledge regarding a potentially different carcinogenesis in these patients. STUDY DESIGN/METHODS: Retrospective analysis of data for 195 NSND patients with HNSCC and comparison with data for patients with HNSCC obtained from the Netherlands Cancer Registry. RESULTS: Compared with all HNSCC patients in the Netherlands, our NSND patients with HNSCC were typically female (n = 142; 73%vs 26%), old at disease presentation (mean 73 years vs 64 years), and had tumors mainly of the oral cavity (n = 130; 66%vs 25%). Most tumors were stage I (n = 67; 34%) and stage IVA (n = 59; 30%). The incidence of second primary tumors (SPTs) was high (n = 32; 16%), mainly occurring in the oral cavity (n = 26; 13%). DISCUSSION/CONCLUSION: Our study confirms that NSND HNSCC patients have different clinicopathological characteristics from those of the overall HNSCC population; however, the frequency of SPTs is as high in NSND patients as in patients who smoke and drink alcohol. More research, and particularly molecular data are needed to obtain a better understanding of head and neck cancer in NSND patients.

Professional delay in head and neck cancer patients: analysis of the diagnostic pathway.

The aim of this study was to identify which factors are related to specialist delay and to determine the length of the diagnostic pathway in head and neck cancer patients. Three hundred and six patients with a carcinoma of the larynx, pharynx or oral cavity were included in the study. Logistic regression analysis was used to identify risk factors for specialist delay. Large (T3-T4) tumors showed significantly less specialist delay than small (T1-T2) tumors (p=0.045, odds ratio [OR]=0.6). Pharyngeal (p=0.00, OR=0.2) and oral carcinomas (p=0.00, OR=0.2) had less specialist delay than glottic carcinomas. Hoarseness was associated with prolonged specialist delay (p=0.00, OR=5.9). Heavy drinking in combination with smoking (p=0.005, OR=0.3), a sore throat (p=0.02, OR=0.4) or having a lesion (p=0.03, OR=0.2) showed a shorter diagnostic period. The duration of the diagnostic process in a general hospital ranged from 0 to 570 days, with a median of 14 days. Only a small group of patients met the ideal management standards in our head and neck clinic. Although prolonged delay was associated with small (glottic) tumors, the diagnostic process takes a fairly long time. The results indicate that continued educational programs for professionals are warranted.

Guidelines in head and neck oncology compliance and consequences of deviations from the standard protocol for tongue and floor of mouth squamous carcinoma.

OBJECTIVES: To investigate the extent of violation of a regional guideline for the treatment of patients with carcinoma of the tongue/floor of mouth (ICD0 C02, C04). Different aspects of protocol violation (i.e. undertreatment or overtreatment) and consequences for treatment outcome were evaluated. DESIGN: Retrospective analysis of data from medical records. SETTING: The Department of Maxillofacial and Oral Surgery and the Department of Otorhinolaryngology and Head and Neck Surgery of the University Medical Centre Utrecht. PARTICIPANTS: A total of 217 patients treated between 1991 and 2001 for a stage II and stage III carcinoma of the tongue/floor of mouth. MAIN OUTCOME MEASURES: Protocol violation, tumour recurrence. RESULTS: The overall adherence to the guideline was 55%. In the non-adherence group of patients, 21% were overtreated, 71% were undertreated, and 8% were both overtreated and undertreated. There was no statistically significant difference in tumour recurrence between the two groups for stage II (P=0.68) or stage III (P=0.97) disease, or between undertreatment and overtreatment of patients with stage II (P=0.47) or stage III (P=0.90) disease. CONCLUSIONS: Although protocol violation occurs in as many as 45% of patients, this does not result in a worse tumour recurrence. Neither overtreatment nor undertreatment appears to affect the overall tumour recurrence.

Warthin's tumour and smoking.

OBJECTIVE: In an evaluation of our patients with parotid gland neoplasms, we noticed that patients with a Warthin's tumour were heavy smokers. The aim of this study was to confirm earlier findings in the literature concerning a possible association between smoking and the development of a Warthin's tumour. METHODS: A case control study was performed using the clinical records and discharge letters of all consecutive patients with a Warthin's tumour in the pathology database of our hospital covering the last 15 years. Patients with a pleomorphic adenoma and a group of patients visiting our audiology department were used as controls. RESULTS: A smoking history was found in 97.5% of the patients with a Warthin's tumour. Of the patients with a pleomorphic adenoma, 59% had a smoking history; 56.5% of the audiology group had a smoking history. Mean age at the time of the operation was 60.1 years of age in the Warthin's tumour group and 48.6 for the pleomorphic adenoma group. CONCLUSION: The mean age for the development of a Warthin's tumour is ten years older than for a pleomorphic adenoma. Furthermore, the development seems to be closely related to smoking habits.

[Arguments favouring the pharmacotherapy of Bells' palsy]. / Vóór medicamenteuze behandeling van Bell-paralyse.

Some clinicians claim a spontaneous complete recovery of facial nerve function after Bell's palsy in more than 80% of patients. However, for elderly patients and patients with a severe paresis/paralysis this is not the case. The main cause of Bell's palsy is probably reactivation of latent herpes viruses. Recent literature supports treatment with corticosteroids and antiviral medication, inhibiting viral replication and reducing oedema in the bony canal of the facial nerve. Using this medication in the first days of the disease provides a further 15% of patients with a good outcome in addition to the ones that improve spontaneously. Therefore, prednisone and valacyclovir are recommended for all patients with Bell's palsy and severe dysfunction, i.e. House-Brackmann facial grading scale IV, V and VI.

Medical care-seeking and health-risk behavior in patients with head and neck cancer: the role of health value, control beliefs and psychological distress.

Health behavior plays an important role in the development, detection and course of cancer of the head and neck. Relevant health behavior includes prompt medical care seeking, and smoking and drinking cessation after diagnosis. This study examines the relationship between these health behaviors and health value and control beliefs, as well as psychological distress. Two hundred and sixty-four recently diagnosed head and neck cancer patients were interviewed about their health behavior, and they filled in a questionnaire on health beliefs and psychological distress. The results showed that one-quarter (25%) of the patients had waited more than 3 months before seeking medical care, 50% had continued to smoke and 80% had continued to drink after the diagnosis. The patients, particularly those who smoked and drank before diagnosis, reported lower levels of health value and perceived health competence than a general population sample with which they were compared. Patients who engaged in patient delay reported a lack of perceived health competence. Psychological distress and lack of perceived health competence were found to be more common among patients who continued to smoke. The implications of these findings are discussed with regard to interventions aimed at promoting these specific health behaviors.

Differences in coping style and locus of control between older and younger patients with head and neck cancer.

OBJECTIVES: This prospective study analyses whether older and younger patients with cancer of the head and neck make use of different coping styles and locus of control mechanisms, and how these mechanisms are related to quality of life (QOL) and depressive symptoms. DESIGN: Before treatment, 78 older (>or=70 years) and 105 younger patients (45-60 years) with carcinoma of the oral cavity, pharynx (stage II-IV), or larynx (stage III-IV) completed questionnaires on QOL (EORTC-QLQ-C30), depression (CES-D), coping (Utrecht Coping List), and locus of control (Cancer Locus of Control Scale). Fifty-one older and 70 younger patients completed the follow-up questionnaires at 6 and 12 months. RESULTS: Before treatment and at 12 months, the number of depressive symptoms and QOL scores, apart from physical functioning, did not differ between the two groups. Before treatment and at 6 months, younger patients used active coping strategies significantly more often and they perceived more internal control over the cause of their disease. Older patients used religious coping and religious control more frequently at all assessments. In both groups, avoidance coping was associated with more depressive symptoms and a worse QOL. CONCLUSIONS: Although older and younger patients use different coping and locus of control strategies, this does not give rise to differences in QOL and depressive symptoms after treatment.

Reasons for non-standard treatment in elderly patients with advanced head and neck cancer.

Elderly patients with head and neck cancer are less likely to receive standard treatment. This study assessed the influence that age, tumour characteristics, comorbidity, social support, depressive symptoms and quality of life have on treatment choice. One hundred and five patients between 45 and 60 years of age and 78 patients of > or =70 years of age with carcinoma of the oral cavity (stage > or =II), oro- and hypopharynx (stage > or =II) or larynx (stage > or =III) completed a questionnaire on quality of life (EORTC QLQ-C30 and H&N35), depressive symptoms (CES-D) and social support (RSS12-I). In the 45-60 age group, 89% received standard treatment, compared with 62% of the > or =70 age group. A multivariate logistic regression analysis showed that the following factors predicted non-standard treatment: marital status (widowed), advanced tumour stage, comorbidity, less pain, considering the length of life less important than its quality and old age. This study showed that age itself independently influences treatment choice. However, it should be emphasised that the choice of a treatment should be based on a medical assessment and the patient's preferences, not on chronological age.

Simultaneous radio- and chemotherapy for squamous cell carcinoma of the head and neck in daily clinical practice: 5 years experience in a University Hospital.

Several randomized studies and meta-analyses have shown that simultaneous radio- and chemotherapy prolongs survival in patients with unresectable squamous cell carcinoma of the head and neck as compared with conventional radiotherapy. We assessed the feasibility and effectiveness of simultaneous radiotherapy (35 x 2 Gy) and chemotherapy [cisplatinum 100 mg/m(2) or carboplatin (AUC 6) on days 1, 22 and 43] in daily clinical practice in a cohort of 87 patients treated at our institute between 1998 and 2002. Eighty patients completed radiotherapy according to schedule. Eighty patients received two courses of chemotherapy and 50 patients three courses. Nephrotoxity, bone marrow suppression and ototoxicity were the most frequent side-effects. Median weight loss was 8.5%. Median survival was 15 months and 44% of the patients were alive at 2 years. Patients receiving three courses of chemotherapy had a better survival than patients receiving two or less courses. Treatment with simultaneous radio- and chemotherapy for advanced head and neck cancer is a demanding, but feasible treatment in daily clinical practice. Survival seems to be comparable with the results achieved in patients selected for clinical trials.

Psychological factors and patient delay in patients with head and neck cancer.

There is a rising incidence of patients presenting with advanced cancer in the head and neck region. Late presentation may be due to a delay in seeking medical attention, which is sometimes surprisingly long. The aim of the present prospective study was to investigate the association between patient delay and the psychological factors of optimism, health hardiness, overall defensive functioning, coping styles and psychological distress in 277 patients with cancer of the head and neck. Significant correlations were found between patient delay and the psychological factors. Twenty-six percent of the patients waited more than three months before seeking medical attention and they reported less optimism (P = 0.0001), less health hardiness (P = 0.008), less active coping (P = 0.019) and less seeking support as a coping style (P = 0.017) than patients presenting within three months. Excessive drinkers (5+ alcoholic drinks/day) tended to show more delay than patients who did not drink or were moderate drinkers (0-2 drinks/day) or moderate-heavy drinkers (3-4 drinks/day). Together, the psychological factors could explain 25% of the variance of patient delay in excessive drinkers compared with 21% and 6% in moderate-heavy drinkers and non-drinkers to moderate drinkers, respectively. These results suggest that psychological factors affect health-care seeking behaviour. Health education aimed at the risk group of excessive drinkers should take psychological factors into account that influence their health behaviour.

Elderly patients with head and neck cancer: short-term effects of surgical treatment on quality of life.

Elderly patients with head and neck cancer are less likely to be treated surgically. However, little is known about surgical outcome and quality of life (QOL) in elderly patients after a major surgery. This prospective study compared the QOL and the surgical outcome of 54 elderly (> or =70 years) and 75 younger patients (45-60 years) with carcinoma of the oral cavity (stage > or = II), pharynx (stage > or = II) or larynx (stage > or = III). Before and 3 months after surgery, the patients completed questionnaires about QOL (EORTC QLQ-C30 and QLQ-H&N35) and depression (CES-D). Before treatment, elderly and younger patients did not differ in QOL. Three months after the treatment, both groups scored worse on most QOL aspects, but there were no significant differences between the elderly and the younger patients. Surgical and systemic complication rates were similar for both the groups. In conclusion, we found no significant differences in the complication rate and QOL aspects between surgically treated elderly and younger patients.

[Tumor growth during the waiting period for radiotherapy in patients with oropharyngeal carcinoma]. / Tumorgroei in de wachttijd voor radiotherapie bij patiënten met een orofarynxcarcinoom.

OBJECTIVE: To quantify the potential increase in tumour volume during the waiting time for radiotherapy in patients with oropharyngeal squamous cell carcinoma. DESIGN: Retrospective study. METHOD: The tumour volumes as assessed on the diagnostic CT scan and the planning CT scan were compared. Thirteen patients with oropharyngeal carcinoma were included in this study. Both their diagnostic CT scan (CT-1) and their planning CT scan (CT-2) were performed in the Utrecht university medical centre. Tumour volume was calculated by delineating the tumour on CT slices and multiplying the surface area by the inter-slice distance. Tumour volumes were delineated by three independent observers. Tumour growth during the waiting time was defined as the difference in tumour volume on CT-2 and CT-1, calculated as the average of three observations. RESULTS: The mean time between CT-1 and CT-2 was 33 days. The mean waiting period between the histopathological diagnosis and the start of radiotherapy was 56 days. Three groups could be distinguished: in one group the growth was less than 25% (n = 4), in one group the growth varied between 25 and 100% (n = 5), and in a third group there was growth of more than 100% (n = 4). Apart from this, in three cases the TNM stage had to be adjusted as a result of tumour progression. CONCLUSION: This study showed that the tumour volume increased by more than 50% during the waiting time for radiotherapy in 8 out of 13 patients with squamous cell carcinoma of the oropharynx.