1. QUALITY of LIFE Head & Neck Cancer and Chemotherapy Lisa Licitra Head and Neck Medical Oncology Unit Istituto Nazionale Tumori Milano

2. Why assessing QoL in cancer research ? Efficacy endpoint Compare treatment modalities Focus rehabilitation interventions Predictive/prognostic factor Help patients in their decision-making

3. Assumptions Functional impairments translate into poor QoL Emotional well being is related to physical deterioration

4. Disease specific QoL instruments EORTC H&N FACT H&N HNRQ QL-H&N QL-RTI/H&N H&N QoL UW QoL QLQ Self administration Items, subscales Summary score Purpose Phase of disease Responsiveness Cross cultural Content validity Face validity Internal reliability

5. Semin Oncol 2004; 31: 827

7. H&N cancer Patients Pain Sexuality Cough Voice Eating Diet Aspiration Astenia

8. H&N cancer Patients Finances Employment Family Social activities

9. Pretreatment Health Related H&N QoL  Past medical history and ASA score (Br J Oral Maxillofacial Surg 2005)  Weight loss can be predicted by QoL (Head & Neck, 2005)  Depression, PS, gender  Psychosocial > physiologic factors  Interaction of pts characteristics with global QoL  Pretreatment score predicts the postreatment value

10. QoL in laryngeal cancer pts  Cross sectional studies  High variability in the purpose of the study (laryngectomy vs RT, total vs subtotal surgery…)  In most studies global post-treatment QoL was similar (differences in subscales)

11. Long-term quality of life after treatment of laryngeal cancer. The Veterans Affaires Laryngeal Study Group Terrel JE, Fisher SG, Wolf GT Arch Otolaryngol 1998; 124: 964-971

12. QoL: surgery vs C/RT  Hanna F et al: Arch Otolaryngol Head Neck Surg 2004; 130: 875-9  LoTempio M et al: Otolaryngol Head neck Surg 2005; 132: 948-53  El Deiry et al: Arch Otolaryngol Head Neck Surg 2005; 131: 879-85

13. Results  Most pts report excellent global health related QoL and these are independent of TX  C/RT pts: pain, difficulty in swallowing, chewing, dry mouth  Laryngectomy: impairement in speech, shoulder function, social functioning, sensory disturbances, painkillers, cough

14. Oropharyngeal/oral cavity cancer  Disability, distress, dysfunction > laryngectomy  Depression, anxiety was similar  Subscales differences Surg vs (C)RT  Type of reconstruction is not affecting QoL rather speech, cosmetic, swallowing  Loss of confidence, uncertainty reagarding the future

15. Post TX Health Related H&N QoL  Treatment (type of surgery, target RT volume)   Intrarterial CT similar to iv CT  similar to adjuvant CT  Neoadjuvant similar to adjuvant CT  Coping strategies affect QOL  (Clin Otolaryngol 2005)  Speech, swallowing (no postoperative RT, primary surgical closure) (Clin Otolaryngol 2005)  FT, trach, neck dissection (Arch Otolarygol 2004)  Confilcting results on xerostomia (Int J Radiat Oncol Biol Physics 2003-2005)

16. Semin Oncol 2004; 31: 827

17. Results of QoL research in H&N  QoL deteriorates during treatment and slowly returns to pre-treatment values independently of tx  Counterintuitive results  QoL prognostic factor  Dependant on several pretreatment factors

18. Nevertheless…  QoL poorly utilised for rehab interventions  QoL not utilsed as prognostic tool  QoL for clinical decision making poorly explored

19. Why?   “poor” quality instruments ?   particular patient setting ?   what are we measuring: adaptability ?

20. How do Head & Neck Cancer patients prioritize treatment outcomes before initiating treatment? List M, Stracks J, Colangelo L et al J Clin Oncol 2000; 18: 877-884

21. Priority items

22. Priority items Pretreatment priority : Survival High individual variability Postreatment priority: ?

23. From QoL to clinical decision randomised studies utility clinical decision QoL measurement state of art QoL informations

24. Shared decision making