IMPORTANCE: Multimodality management and increasing incidence of HPV-associated oropharyngeal cancer have increased disease-specific survival in head and neck cancer (HNC). Increased incidence of treatment-related toxicities has accompanied this trend. By identifying risk factors associated with symptom burden, we can implement interventional strategies to enhance functional and quality of life. outcomes in survivors. While neck morbidity has been described following neck dissection or surgical resection with and without radiation therapy, limited studies have investigated the association between non-surgical treatment and neck dysfunction.
OBJECTIVE: To 1) determine the prevalence and predictors of neck disability following HNC treatment and 2) explore the association between neck disability and quality of life.
DESIGN, SETTING, AND PARTICIPANTS: Prospective study of 173 patients who were treated for primary, non-metastatic head and neck squamous cell carcinoma and evaluated in a multidisciplinary HNC survivorship clinic between March 2017 and October 2017. Treatment groups were categorized as 1) non-operative [radiation therapy (RT) or chemoradiation (CRT)], 2) surgery alone, or 3) surgery and adjuvant therapy (RT or CRT).
MAIN OUTCOMES AND MEASURES: Symptom burden was measured using the previously validated Neck Disability Index (NDI), which is a self-reported questionnaire measuring pain, activity, and sleep related neck impairment. NDI scores were tabulated by degree of disability (none, mild, moderate, severe, complete) and categorized into two groups: absence or presence of disability. Health-related quality of life (HRQoL) was measured using The University of Washington Quality of Life Questionnaire Version 4 (UW-QOL), a 12-item self-administered survey of physical, mental, emotional, and social function. Physical and social subscale scores were calculated.
RESULTS: Over half of survivors (n=96, 55.5%) reported neck disability. Over one-third of these patients (n=33) describing moderate to complete impairment. Survivors were predominately male (n=132, 75.9%) with a mean age of 63.2 years (SD=11.1). The majority of survivors were diagnosed with advanced stage cancer (n=126, 72.8%) and were on average 4.0 years (SD=5.4) post-treatment. Primary tumor sites were oropharynx (n=77, 44.5%), oral cavity (n=45, 26.0%), and larynx (n=32, 18.5%). Seventy-three patients (42.2%) underwent non-operative treatment, 32 (18.5%) underwent surgery only, and 68 (39.3%) underwent surgery and adjuvant therapy. Patients who received surgery and adjuvant therapy were more likely to report neck disability than those with surgery only (p=0.047). More than half of patients (n=38, 52.1%) who underwent non-operative treatment reported neck disability, though this did not reach statistically significance. Survivors with neck disability had significantly lower UW-QOL physical (t170.2= 7.67, p<0.001) and social subscores (t145.4= 11.9, p<0.001) compared to those with no disability.
CONCLUSIONS AND RELEVANCE: Neck disability is an established sequela of surgical resection for HNC, particularly following neck dissection. This study demonstrates a high prevalence of neck disability and pain not only in the late post-operative setting, but also after non-surgical treatment with RT or CRT only. We found disability significantly impacts HRQoL beyond physical impairment alone. Neck disability represents a substantial treatment-related burden, even in the absence of surgery. In the longitudinal care of HNC survivors, more comprehensive screening is warranted particularly among those treated with cytotoxic and radiation modalities.