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      Association of Risk Factors With Patient-Reported Voice and Speech Symptoms Among Long-term Survivors of Oropharyngeal Cancer

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          Key Points

          Question

          What factors are associated with moderate to severe voice and speech symptoms among long-term survivors of oropharyngeal cancer (OPC)?

          Findings

          In this retrospective cohort study with cross-sectional survivorship survey administration, of 881 survivors of OPC who were included in analysis, 113 (12.8%) reported moderate to severe voice and speech symptoms. Increasing survival time and total radiation dose, Black race, Hispanic ethnicity, current cigarette smoking at the time of the survey, multimodality treatment with induction and concurrent chemotherapy, and late and baseline lower cranial neuropathy were identified as risk factors for moderate to severe voice and speech symptoms, and an intensity-modulated split-field radiotherapy regimen was associated with better voice and speech symptoms.

          Meaning

          These findings may have clinical implications for OPC treatment and survivorship, and the preservation of function and quality of life should be considered without compromising oncological outcomes.

          Abstract

          Importance

          Voice and speech production are critical physiological functions that affect quality of life and may deteriorate substantially after oropharyngeal cancer (OPC) treatment. There is limited knowledge about risk factors associated with voice and speech outcomes among survivors of OPC.

          Objective

          To identify the risk factors of voice and speech symptoms among long-term survivors of OPC.

          Design, Setting, and Participants

          This retrospective cohort study with cross-sectional survivorship survey administration includes cancer-free survivors of OPC who were treated curatively between January 2000 and December 2013 at MD Anderson Cancer Center (Houston, Texas) who participated in a survey from September 2015 to July 2016. Of 906 survivors of OPC with a median survival duration at time of survey of 6 years (range, 1-16 years), patient-rated voice and speech outcomes for 881 were available and analyzed. The data were analyzed from June 30, 2020, to February 28, 2021.

          Main Outcomes and Measures

          The primary outcome variable was patient-reported voice and speech scores that were measured using the MD Anderson Symptom Inventory–Head and Neck Cancer Module. Voice and speech scores of 0 to 4 were categorized as none to mild symptoms, and scores of 5 to 10 were categorized as moderate to severe symptoms. Risk factors for moderate to severe voice and speech symptoms were identified by multivariable logistic regression.

          Results

          Among 881 survivors of OPC (median [range] age, 56 [32-84] years; 140 women [15.5%]; 837 White [92.4%], 17 Black [1.9%], and 35 Hispanic individuals [3.8%]), 113 (12.8%) reported moderate to severe voice and speech scores. Increasing survival time (odds ratio [OR], 1.17; 95% CI, 1.06-1.30) and increasing total radiation dose (OR, 1.16; 95% CI, 1.00-1.34), Black race (OR, 3.90; 95% CI, 1.02-14.89), Hispanic ethnicity (OR, 3.74; 95% CI, 1.50-9.35), current cigarette smoking at the time of survey (OR, 3.98; 95% CI, 1.56-10.18), treatment with induction and concurrent chemotherapy (OR, 1.94; 95% CI, 1.06-3.57), and late (OR, 7.11; 95% CI, 3.08-16.41) and baseline lower cranial neuropathy (OR, 8.70; 95% CI, 3.01-25.13) were risk factors associated with moderate to severe voice and speech symptoms. Intensity-modulated radiotherapy split-field regimen (OR, 0.31; 95% CI, 0.12-0.80; P = .01) was associated with lower likelihood of moderate to severe voice and speech symptoms.

          Conclusions and Relevance

          This large OPC survivorship cohort study identified many treatment-related factors, including increasing total radiotherapy dose, multimodality induction and concurrent chemotherapy regimens, and continued smoking, as well as clinical and demographic factors, as risk factors that were associated with moderate to severe voice and speech symptoms. The key findings in this study were the protective associations of split-field radiation and that longer-term survivors, and those who continued to smoke, had worse voice and speech symptoms. These findings may inform research and effective targeted clinical voice and speech preservation interventions and smoking cessation interventions to maximize voice and speech function and address quality of life among patients with OPC.

          Abstract

          This cross-sectional study examines risk factors of voice and speech symptoms among survivors of long-term oropharyngeal cancer.

          Related collections

          Most cited references 24

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          Prevalence and characteristics of moderate to severe fatigue: a multicenter study in cancer patients and survivors.

          The effective management of fatigue in patients with cancer requires a clear delineation of what constitutes nontrivial fatigue. The authors defined numeric cutpoints for fatigue severity based on functional interference and described the prevalence and characteristics of fatigue in patients with cancer and survivors.
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            Parotid gland function after radiotherapy: the combined michigan and utrecht experience.

            To analyze the combined and updated results from the University of Michigan and University Medical Center Utrecht on normal tissue complication probability (NTCP) of the parotid gland 1 year after radiotherapy (RT) for head-and-neck (HN) cancer. A total of 222 prospectively analyzed patients with various HN malignancies were treated with conventional and intensity-modulated RT. Stimulated individual parotid gland flow rates were measured before RT and 1 year after RT using Lashley cups at both centers. A flow ratio <25% of pretreatment was defined as a complication. The data were fitted to the Lyman-Kutcher-Burman model. A total of 384 parotid glands (Michigan: 157; Utrecht: 227 glands) was available for analysis 1 year after RT. Combined NTCP analysis based on mean dose resulted in a TD(50) (uniform dose leading to 50% complication probability) of 39.9 Gy and m (steepness of the curve) of 0.40. The resulting NTCP curve had good qualitative agreement with the combined clinical data. Mean doses of 25-30 Gy were associated with 17-26% NTCP. A definite NTCP curve for parotid gland function 1 year after RT is presented, based on mean dose. No threshold dose was observed, and TD(50) was equal to 40 Gy. 2010 Elsevier Inc. All rights reserved.
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              Measuring head and neck cancer symptom burden: the development and validation of the M. D. Anderson symptom inventory, head and neck module.

              The aim of this study was to develop and validate a symptom inventory for patients with head and neck cancer and to assess the occurrence and severity of symptoms, the overall symptom burden, and the interference the symptoms cause in daily life. Items were generated from a comprehensive literature review, our prior work, and focus groups with head and neck cancer patients, symptom researchers, and a multidisciplinary group of head and neck cancer health care workers. We selected 11 provisional head and neck cancer-specific items for addition to the core M. D. Anderson Symptom Inventory (MDASI), and conducted a cross-sectional validation study among patients with head and neck cancer. Construct validity was established using principal axis factoring with direct oblimin rotation, and tests of concurrent and known-groups validity were conducted. Two items were dropped because of low severity scores and low frequency of complaint, leaving 9 final head and neck cancer-specific items. The coefficient alpha reliabilities were 0.88, 0.83, and 0.92 for the 13 core MDASI items, the 9 head and neck cancer-specific items, and the 6 interference items, respectively. The most prevalent severe symptoms were problems with mucus, mouth/throat sores, tasting food, difficulty with chewing or swallowing, dry mouth, pain, and fatigue. The M. D. Anderson Symptom Inventory-Head and Neck (MDASI-HN) is a reliable and valid instrument to measure head and neck cancer symptom burden, and the interference symptoms cause in the major aspects of a patient's daily life. A subset of specifically distressing symptoms was identified, many of which are not included in commonly used head and neck cancer quality of life instruments.
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                Author and article information

                Journal
                JAMA Otolaryngol Head Neck Surg
                JAMA Otolaryngol Head Neck Surg
                JAMA Otolaryngol Head Neck Surg
                JAMA Otolaryngology-- Head & Neck Surgery
                American Medical Association
                2168-6181
                2168-619X
                6 May 2021
                July 2021
                6 May 2021
                : 147
                : 7
                : 1-9
                Affiliations
                [1 ]Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston
                [2 ]Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston
                [3 ]Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
                [4 ]Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
                [5 ]Department of Otolaryngology–Head and Neck Surgery, Baylor College of Medicine, Houston, Texas
                [6 ]Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston
                [7 ]Division of Cancer Prevention and Population Sciences, The University of Texas MD Anderson Cancer Center, Houston
                Author notes
                Article Information
                Accepted for Publication:
                Published Online:10.1001/jamaoto.2021.0698
                Open Access: CC-BY License JAMA Otolaryngology–Head & Neck Surgery
                Corresponding Author: Sanjay Shete, PhD, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1411, Houston, TX 77030-4009 ( sshete@ 123456mdanderson.org ).
                Author Contributions:
                Concept and design:
                Acquisition, analysis, or interpretation of data:
                Drafting of the manuscript:
                Critical revision of the manuscript for important intellectual content:
                Statistical analysis: .
                Obtained funding:
                Administrative, technical, or material support:
                Supervision:
                Conflict of Interest Disclosures:
                Funding/Support:
                Role of the Funder/Sponsor:
                Additional Contributions:
                Article
                ooi210016
                10.1001/jamaoto.2021.0698
                8103354
                33956062
                Copyright 2021 Aggarwal P et al. JAMA Otolaryngology–Head & Neck Surgery.

                This is an open access article distributed under the terms of the CC-BY License.

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                Research
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