Elsevier

European Journal of Cancer

Volume 37, Issue 3, February 2001, Pages 332-339
European Journal of Cancer

Sociodemographic factors and quality of life as prognostic indicators in head and neck cancer

https://doi.org/10.1016/S0959-8049(00)00385-3Get rights and content

Abstract

Pre-treatment quality of life (QOL) has been found to be an independent prognostic factor for survival in cancer patients, in particular in patients with advanced cancer. Sociodemographic factors such as marital and socioeconomic status have also been recognised as prognostic factors. We studied the influence of QOL and mood (measured with the European Organization for Research and Treatment of Cancer Core Questionnaire (EORTC QLQ-C30) and the Head and Neck Cancer Questionnaire (EORTC QLQ-H&N35), and with the Center for Epidemiologic Studies-Depression Scale (CES-D)) as measured before treatment, the use of cigarettes and alcohol and sociodemographic factors (age, gender, marital status, income and occupation) on recurrence and survival in 208 patients with head and neck cancer prior to treatment with surgery and/or radiotherapy, using Kaplan–Meier and Cox regression analyses. Cognitive functioning and, to a lesser degree, marital status were independent predictors of recurrence and survival, along with medical factors (stage and radicality). Patients with less than optimal cognitive functioning and unmarried patients had a relative risk (RR) of recurrence of 1.72 (95% confidence interval (95% CI) 1.01–2.93) and 1.85 (95% CI 1.06–3.33), respectively, and a RR of dying of 1.90 (95% CI 1.10–3.26) and 1.82 (95% CI 1.03–3.23), respectively. Performance status, physical functioning, mood and global QOL and smoking and drinking did not predict for recurrence and survival. The influence of cognitive functioning might be related to the use of alcohol. Marital status may influence prognosis through mechanisms of health behaviour and/or social support mechanisms.

Introduction

Quality of life (QOL) is increasingly acknowledged as an important endpoint in cancer clinical trials and clinical practice, along with the traditional endpoints like tumour response rate, disease-free survival and overall survival 1, 2. Studies that include a QOL endpoint have focused primarily on the longitudinal impact of disease or treatment on QOL. However, recent studies have established that pretreatment QOL may also have prognostic significance [3].

One of the first measures of QOL was the Karnofsky performance status (KPS) [4], which is a physician-rated instrument evaluating three dimensions of health status simultaneously (activity, work, and self-care) [5]. Although by today's standards this is considered to be an inadequate tool to measure QOL, it has been shown to correlate with survival in several studies in cancer patients 6, 7, 8. However, it seems that some multidimensional measures of QOL may be more accurate predictors of survival than the KPS. Pre-treatment QOL has been shown to correlate with survival in studies in lung cancer 9, 10, 11, 12, 13, 14, breast cancer 15, 16, colorectal cancer 17, 18, multiple myeloma [19], malignant melanoma [20], and mixed populations of cancer patients 21, 22, 23, 24, 25, 26, 27. The majority of these studies used patient-rated instruments; in some of the studies a physician-rated instrument (the Spitzer QOL Index) [28] was also or only used 15, 18, 20, 21. Almost all of these studies were performed in patients with advanced and often incurable disease, and QOL was usually assessed prior to chemotherapy, usually within a clinical trial.

Sociodemographic factors, in particular marital and socioeconomic status, have been shown to correlate with survival in cancer patients. In a population-based study in 27 779 cancer patients, unmarried persons had an increased risk of dying (relative risk (RR) 1.23, 95% confidence interval (95% CI) 1.19–1.28) [29]. In one of the studies assessing the prognostic influence of QOL on survival in lung cancer patients, marital status was also found to have an influence on survival [10]. In a Canadian study, in several types of cancer (including head and neck cancer), a strong and statistically significant association was found between socioeconomic status and survival [30]. Socioeconomic differences in cancer survival were also found in another study [31].

In cancer patients, disease- and treatment-related factors have a major influence on prognosis, and any study of prognostic factors should take these into account. In head and neck cancer, stage is probably the most important factor. Other factors, such as site, grade of differentiation, growth pattern, type of treatment and positive tumour margins may also have an influence, but their prognostic influence is less clear [32].

We performed a prospective study in patients with head and neck cancer receiving surgery and/or radiotherapy with curative intent, in which QOL was measured before treatment. One of the aims of the study was to assess the prognostic significance (with regard to both recurrence and survival) of pre-treatment QOL variables in this patient group. We also studied whether smoking, drinking and sociodemographic variables were an independent prognostic factor. In this paper, we analyse the results after a minimum follow-up of 3 years.

Section snippets

Patients

Patients were eligible for the study if they had squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx or larynx treated with surgery and/or radiotherapy with curative intent. Other inclusion criteria were: age less than 80 years; no previous or synchronous malignancies; no cognitive impairment (as judged by the physician); ability to understand and to read Dutch. During the inclusion period (May 1994–June 1996), 266 patients met the inclusion criteria. Fifty-eight patients

Results

The median follow-up of the living patients is 45 months (range 36–62). The occurrence of local recurrence and/or distant metastases, secondary tumours and death is shown in Table 3. 55 patients developed a local recurrence and/or distant metastases. At the time of the analysis, 16 of these patients had received curative treatment (laryngectomy or neck dissection) and were free of disease, two were alive with incurable disease, and 37 had died of local recurrence or distant metastases.

Discussion

In this prospective study in patients with head and neck cancer receiving primary treatment with surgery and/or radiotherapy, we found that cognitive functioning, as measured by the EORTC QLQ-C30(+3), was a strong predictor of recurrence and survival, independent of medical factors (stage and radicality). Marital status was only an independent prognostic factor with regard to TTE. When only QOL variables were studied, social functioning was also predictive of survival, but this effect

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