Importance: Cognitive dysfunction (CD) is recognized by American Cancer society as a late effect of treatment but the extent of this problem in head and neck cancer (HNC) is not well-understood. Due to the increasing HNC survivorship, particularly for oropharyngeal cancer (OPC), a greater number of survivors are at risk of experiencing CD as a late treatment effect. Knowledge of baseline performance is imperative to meaningfully determine the nature of post-treatment CD, and inform survivorship care practices. However, cognition assessment in clinical practice is made challenging by the lack of targeted instruments and standardized metrics.
Objective: To assess the baseline cognitive performance of OPC patients using standardized National Institutes of Health (NIH)-sponsored instruments of Patient-Reported Outcomes Measurement System (PROMIS) and NIH Toolbox Cognitive Battery (NIHTB-CB) administered via short-forms or computerized adaptive testing.
Design: Prospective cohort study
Settings: Tertiary center
Participants: Of 83 consecutive, newly-diagnosed OPC patients from 9/2016 to 5/2017, 16 were ineligible, 8 refused, and 3 were lost after screening.
Main outcomes: Self-perceived and objective cognition with PROMIS and NIHTB-CB, respectively, were main outcomes. Secondary outcomes were fatigue, pain, anxiety and depression from PROMIS. Fully-adjusted T-scores below 0.5 standard deviation (SD) were considered abnormal (i.e., threshold for clinically meaningful difference).
Results: Of the 56 study subjects (52 males, 4 females), 29% (n=16) were ≥ 65 years-old. Approximately, 34% (n=19) had a college degree, and 36% (n=20) had a professional/technical occupation. About 53% (n=30) were never-smokers, 46% (n=26) were never-drinkers, 52% (n=29) were obese, 23% (n=13) had moderate-severe comorbidity, 5% (n=3) used antidepressants, and 70% (n=39) had some degree of hearing loss. AJCC 8th edition Stage II-III disease was present in 41% (n=23); 89% (n=50) had p16-positive OPC. Upfront surgery was planned in 53% (n=30) and chemoradiation in 47% (n=26). Abnormal self-perceived/PROMIS cognition scores were observed in 11% (n=6), and abnormal objective/NIHTB-CB composite scores in 21% (n=12). For objective cognition, abnormal scores were most common in the domain of processing speed (n=25) followed by attention (n=19), episodic memory (n=17), working memory (n=12) and executive function (n=9). Abnormal PROMIS scores for secondary outcomes were noted in 36% (n=20) for the domain of anxiety, 30% (n=17) for pain interference, 23% (n=13) for depression, and 20% (n=11) for fatigue. Among all demographic, patient and tumor-related variables, abnormal objective cognition scores were more frequent in the cohort aged ≥65 years (56% vs 8%), ever-smokers (27% vs 15%), hearing loss (26% vs 12%), and Stage II-III disease (53% vs 19%).
Conclusions: Abnormal objective cognitive performance was more common at baseline than self-perceived, and was more frequent in ≥ 65 years-old subjects, ever-smokers, and those with hearing loss and advanced OPC. NIHTB-CB allowed immediate scoring of fully-adjusted cognitive performance in our study cohort. In clinical practice, these scores can be used to screen and identify patients with abnormal cognition at baseline who may be more susceptible to developing further impairment after treatment. Identification of susceptible patients and the affected domains will help to institute early cognitive interventions for an improved post-treatment quality of life.