Abstract
Objectives: An estimated 20-60% of head and neck cancer patients have
reported distress during the evaluation and management of their disease.
This study aims to assess for a relationship between distress scores and
several perioperative metrics.
Design: Retrospective cohort study
Setting: Single tertiary care center
Main Outcome Measures: 34 head and neck cancer patients during the
designated time period were evaluated for their distress screening
results. Primary outcomes evaluated are distress scores, stratified by
age and subsite, as well as, staging. Power analysis and logistic
regression were performed.
Results: Significantly lower distress scores were associated with a skin
primary site (OR = 0.06, 0.003-0.41 95% CI, p =0.01<0.05), and there was a trend toward lower distress score
with Medicare insurance (OR=0.11, 0.01-0.76 95% CI,p =0.06>0.05) indicating potential protective factors
against distress scores >3.
Conclusions: Identifying specific protective factors may objectively
help identify new head and neck cancer patients who are at higher risk
for greater levels of distress.
Key words: Distress screening, predictor, head and neck cancer,
perioperative outcomes, protective factors
Key Points:
- The Distress Thermometer is a validated tool for assessing distress in
patients with cancer.
- The Distress Thermometer can be used to predict perioperative outcomes
in patients with head and neck cancer.
- Cutaneous malignancies of the head and neck are protective against
increased distress when compared to other head and neck cancers.
- Medicare insurance is a protective factor against increased distress
in patients with head and neck cancers.
- Identify other protective vs predisposing factors for distress in head
and neck cancer patients may help to optimize outcomes.
1.1) Introduction
The critical role of psychosocial care in the treatment of cancer
patients while addressing their distress, has been widely recognized as
a part of the standard of care set forth by the National Comprehensive
Cancer Network (NCCN).1 The NCCN guidelines provide a
distress thermometer (DT) screening tool that is recommended at initial
visits with new cancer patients, and at additional intervals as
clinically indicated. Risk factors for distress are highly prevalent in
the head and neck population, including smoking and alcohol use
disorders and side effects or functional losses that affect swallow,
speech, or cause disfigurement. There is evidence in the literature that
head and neck cancer patients have significantly greater psychological
distress than patients with other malignancies.2,3
Objective: This study aims to evaluate the NCCN Distress Thermometer as
it relates to head and neck cancer patient outcomes.
The NCCN distress thermometer allows patients to self-assign an overall
distress score on a scale of 1-10, where a score of 1 indicates no
distress and a score of 10 indicates extreme distress. Distress is
objectively defined on each handout as an “unpleasant experience of a
mental, physical, social, or spiritual nature. It can affect the way you
think, feel, or act. Distress may make it harder to cope with having
cancer, its symptoms, or its treatment”.4 A score of
less than four is considered “mild.” Patients also indicate areas of
particular distress among domains of practical problems, family
problems, emotional problems, spiritual/religious concerns, and physical
problems.4 The thermometer has been validated as a
relatively specific and sensitive tool (72% and 81% in one
meta-analysis, respectively) with this cutoff score of 4.5
Evidence suggests that higher levels of distress correspond to longer
hospital stays. Known risk factors for higher distress levels in
patients include the following: treatments that have significant side
effects (e.g. functional losses, such as impairment of swallow or speech
postoperatively), pre-treatment mental status, lack of perceived social
support, or smoking and alcohol use disorders. 4 For
patients who have clinically significant distress levels, there is
evidence that proper identification and early intervention affects
long-term outcomes. 6 There is evidence that distress
is a risk factor for nonadherence to treatment for cancer patients, and
is associated with increased length of postoperative hospital stay.7,8 Schell et al. published the DT findings for a
single head and neck cancer subsite - oral cavity squamous cell
carcinoma patients.9
In this study, we investigate our use of the distress thermometer
screening tool for patients undergoing surgical management of head and
neck malignancies. We describe quantitative and qualitative results of
patient-reported stress. Patient factors leading to higher or lower
distress scores were evaluated, as well as, correlation between distress
scores and clinical outcomes of time-to-surgery, missed appointments,
and cancelled appointments.
1.2) Materials and methods
This is a retrospective, single-institution study that evaluated
distress thermometer (DT) scores in head and neck cancer patients of all
subsites (except thyroid) who underwent primary surgical treatment of
their disease. Institutional Review Board approval was obtained through
our tertiary care institution. The patients included in the study were
male and female adult patients between the ages of 34 – 90 who
presented to a tertiary care referral center between July 2018 and March
2020. Consecutive surgically-treated patients with completed
preoperative distress screening were evaluated. The head and neck cancer
subsites included were oral cavity, oropharynx, hypopharynx,
supraglottis, glottis, unknown primary, and skin. Despite NCCN
guidelines recommending distress screening only for head and neck
squamous cell carcinomas, the inclusion of aerodigestive malignancies
was purposeful in part due to the availability of additional patient
populations and the potential to apply benefits of distress screening to
more people. Patients with thyroid malignancies were not included. Only
patients who underwent definitive surgery as the primary treatment of
their cancer were included, which eliminated patients who completed
their DT screening tool but were medically managed.
DT scores were initially manually recorded following new patient visits
with a head and neck oncologic surgeon. Patients presented to their
visits with a known diagnosis and were then counseled on surgical
approaches to their disease. No patients in this study received a new
diagnosis at the visit prior to filling out their DT. The DT data was
then collected via retrospective electronic medical record review.
Patients with DT scores which were recorded or charted incorrectly were
omitted.
The primary outcomes evaluated are distress scores, stratified by age,
subsite, and staging. The time from initial clinic visit to definitive
surgical management was a primary outcome, as well. Additional
care-related metrics are number of missed appointments, including
no-shows and cancellations and the time from primary surgical treatment
to adjuvant chemoradiation start date (ideally within 6 weeks). We also
collected insurance information, smoking status, ethnicity, staging, and
histology.
Patients distress was stratified as low (less than 4) or high (4 or
greater). Logistic regression analysis was performed to identify risk
factors for distress as a binary variable of low or high. Patient
factors included in analysis included gender, insurance type, recurrent
disease, tumor subsite, and the need for free flap reconstruction.
Logistic regression analyses were also conducted for the following
outcomes: greater than 25 days to surgery’ cancelled outpatient
post-operative appointments; and “no-show” post-operative appointments
as binary outcomes. Statistical analyses were performed using R
statistics package (R Core Team, Vienna, Austria, version 4.0.2). Odds
ratios were considered to be statistically significant at
p<0.05.
A priori power analysis using the Gpower 3.1.9 online calculator was
conducted to determine the sample size needed to establish sufficient
power of 80% (α=0.05) in a univariant logistic
regression.10 A sample size of >21 was
required and produced a power of 82%.
1.3) Results
The characteristics of the patients included in the study are listed in
Table 1. There were 24 males and 10 females in the study, with 15
privately insured, 9 on Medicare coverage, 8 on Medicaid, and 2 with VA
coverage. The average age was 66 years, with a range from 34-90. As
shown in Table 2, the mean DT scores for the patient population,
stratified by subsite. Table 3 reveals average DT scores stratified by
pathologic diagnosis. Twenty-six patients had squamous cell carcinoma
(SCC), four patients had melanoma, one had esthesioneuroblastoma, one
had mucoepidermoid carcinoma, one had basal cell carcinoma (BCC), and
one had multiphenotypic carcinoma.
The Distress Thermometer was completed for 34 patients. The mean DT
distress score was 3.56 (range 0-10) for all new cancer patients (Table
2). Responses for the problem list portion of the NCCN distress
thermometer are displayed in Table 4. Time from initial clinic visit to
definitive operative management was 25.5 days on average. For the 34
patients closely examined in the electronic medical record, 42 total
visits were cancelled. There was a total of 5 “no-show” visits for all
comers.
Subsites included seven patients with oral cavity cancer, with a mean DT
of 5 (range 0-10), five oropharynx with a mean DT of 3.8 (2-9), three
hypopharynx with a mean DT of 4.6 (0-7), three sinonasal with a mean DT
of 2.6 (1-5), one nasopharynx with a DT of 5, three larynx with a mean
DT of 3.3 (0-6), and twelve skin primaries with a mean DT of 3.6 (0-8).
There were no unknown primary patients in this study during the time
period of data collection. One person declined to respond to DT scoring
questions altogether (skin SCC group). Patients reported distress about
these particular categories: practical, physical, and emotional.
On logistic regression, significantly lower distress scores were
associated with a skin primary site (OR=0.06, 0.003-0.41 95% CI,p = 0.01<0.05), and there was a trend toward lower
distress score with Medicare insurance (OR=0.11, 0.01-0.76 95% CI,p =0.06>0.05). No other factors were significantly
associated with distress score. The results of this analysis are
displayed in Table 5, with Medicare highlighted in Figure 1 and skin
primary site in Figure 2. No identifiable patient factors, including
higher overall distress score, were associated with prolonged time to
surgery, visit cancellation, or visit no-show.
1.4) Discussion
Our review of distress screening among surgically treated head and neck
patients revealed a wide range of subjective distress. Analysis revealed
an association between skin primary malignancies and subsequent lower
distress scores when compared to other sub-site primaries. The analysis
also identified Medicare insurance and skin primary sites as being
associated with lower distress scores. Female gender was associated with
higher distress score, with an odds ratio of 3, although this was not
statistically significant. Previous studies have found that female
gender is significantly associated with increased pain levels and
distress scores. 9 While not statistically
significant, a distress score of greater than 3 was also associated with
greater than 25 days to surgery (OR=2.25). These results suggest that DT
results may be finely examined to further stratify head and neck cancer
patients into higher risk groups based on distress level. Increased
sample size and power may allow for improved detection of statistically
significant predictors of greater distress.11 These
studies may establish a more robust evaluation of how multiple
predictors simultaneously affect distress in head and neck cancer
patients.
Schell et al. published on the distress screening results from 100
consecutive oral cavity squamous cell carcinoma patients undergoing
primary surgical management and found that DT score did not correlate
with age or tumor size. Patients in this study with scores greater than
or equal to 5 were recommended to seek psychological support through
psychosocial support networks and social services provided through our
tertiary care institution. 9 The average DT in this
study was 5.7. They did find that female patients were more likely to
report pain and express fears or problems with nutrition. The head and
neck cancer patient population has additionally been identified as
increased risk of depression and suicide.12 There may
be a benefit to adjunctive questionnaires used in the clinic setting,
such as the Patient Health Questionnaire-4 (PHQ-4).13
In this study, there were significant barriers to data collection,
including the inconsistency of reporting during early stages of DT tool
implementation in 2018; there was significant heterogeneity between
documentation across multiple staff team members. There are also
barriers to collection of pen and paper forms in the outpatient clinic
visit setting, particularly in the context of multiple sheets being
handed out to patients (including, for instance, a comprehensive “new
patient” form, or medication list). Patients who established care with
the service as outside hospital transfers or inpatient or emergency room
consults were also not captured. Another limitation of this study is the
limited sample size. As use of the screening tool becomes more
ubiquitous and the healthcare team documents it in a uniform fashion,
there will be a larger patient population to study with greater power.
For future directions, it would be valuable to collect DT information at
visits beyond the initial clinic visit. Literature suggests initiating
DT at “pivotal medical visits,” which suggests that if, for instance,
there is a change in treatment plan or completion of treatment regimen,
then it would be appropriate to repeat the screen.13This will also help provide a more complete picture of distress for the
head and neck cancer patient over time, as he or she journeys through
diagnosis and treatment. Knowledge of the trends in distress scores is
valuable as it relates to patient outcomes and specific barriers to care
in the head and neck cancer patient population.
1.5) Conclusions
The DT screening tool provides insight into the head and neck cancer
patient experience. In this study having a skin subsite was found to be
a protective factor against distress scores greater than 3. This is a
preliminary investigation into our practice of distress screening that
provides imperative evidence that patients experience distress on
different levels, and there may be disease-specific factors leading to
distress. Understanding these disease-specific factors may allow us to
treat our whole-patients in a personalized manner, particularly as other
clinicians adopt similarly holistic approaches to patient care.
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