Clinical Investigation
Fear of Cancer Recurrence in Survivors of Human Papillomavirus–Associated Oropharyngeal Carcinoma

https://doi.org/10.1016/j.ijrobp.2021.07.006Get rights and content

Purpose

To estimate the prevalence of and characteristics associated with fear of cancer recurrence (FCR) among human papillomavirus (HPV)-associated oropharyngeal cancer (OPC) survivors.

Methods and Materials

We conducted a cross-sectional study in HPV-OPC survivors ≥12 months from completion of definitive (chemo)radiation therapy (RT/CRT). Eligible patients completed the Fear of Cancer Recurrence Inventory short-form (FCRI-SF), the European Organisation for research and Treatment of Cancer QLQ-C30, MD Anderson Symptom Inventory-Head and Neck, and PROMIS Anxiety and Depression short forms. Associations between FCRI-SF scores and other variables were investigated using linear regression models.

Results

A total of 136 HPV-OPC survivors were enrolled; the median age was 61 years (range, 42-87 years), 84% were male, 72% were currently partnered, 83% were current nonsmokers, 67% were regular alcohol consumers, and the median time since treatment was 2.8 years (range, 1.0-5.5 years). Clinical levels of FCR (≥13) were observed in 72 of 135 patients (53%; 95% confidence interval [CI], 45%-62%). Characteristics significantly associated with increasing FCR scores were younger age (–0.9/5 years; 95% CI, –1.7 to –0.01; P = .031), lower global quality of life (–0.8/10 unit increase; 95% CI, –1.4 to –0.2; P = .012), higher symptom interference (0.8/unit increase; 95% CI, 0.1-1.5; P = .017), and a higher burden of anxiety (0.4/unit; 95% CI, 0.3-0.5; P <.001) and depression (0.3/unit; 95% CI, 0.1-0.4; P <.001). Other sociodemographic tumor- and treatment-related characteristics were not statistically significant. Compared with patients reporting nonclinical levels of FCR, significantly more patients reporting clinical levels of FCR than expected believed professional psychological assistance would have been beneficial (60% vs 33%; P = .002).

Conclusions

Clinical levels of FCR were observed in approximately half of the HPV-OPC survivors. Survivors reporting higher FCR were younger with worse self-reported global quality of life and higher symptom interference and emotional distress. No other patient, tumor, or treatment factors were associated with higher FCR.

Introduction

The prevalence of human papillomavirus (HPV)-associated oropharyngeal cancer (OPC) has increased over the past 2 decades. Patients with HPV-OPC are typically younger, healthier, have a higher socioeconomic status, and have minimal smoking history compared with traditional patients with head and neck cancer (HNC).1,2 Although these patients also enjoy a more favorable prognosis,3,4 they remain at significant risk from long-term physical, social, and emotional consequences from curative-intent treatment, including radiation therapy (RT), concomitant chemotherapy (CRT), and surgery.5 Research to better understand the unmet needs of this growing survivorship group is vital to ensure survivors are supported as they transition back to life as usual after cancer treatment.

Fear of cancer recurrence (FCR) is recognized as one of cancer survivors’ greatest concerns and most endorsed unmet need.6,7 Although FCR has been measured in mixed HNC cohorts, an understanding of the prevalence in HPV-OPC survivors is lacking.8,9 With an increasing awareness of FCR and its impact on survivors, targeted research in specific survivorship subpopulations is needed to identify those most at risk of FCR and those who can be referred for specific FCR support. There are reasons to suspect a higher FCR burden in this expanding HNC subgroup; patients are generally younger, a characteristic known to correlate with a higher FCR burden in HNC and other cancer subpopulations.6 FCR has also been shown, across many cancer groups, to correlate with both lower patient-reported quality of life (QoL) and higher levels of emotional distress, indicating a complex interplay between FCR, psychological health, and physical and functional impairments.6,10, 11, 12, 13, 14 Patients with preexisting anxiety may also be more vulnerable to developing clinically significant FCR.13

The majority of studies reporting FCR in patients with HNC have not targeted specific subpopulations. In patients with newly diagnosed HNC, Mirosevic et al reported high FCR in 52% of cases, with a higher burden in younger patients, former smokers, and those with comorbid anxiety.15 After treatment for HNC, factors including younger age, smoking history, lower QoL and socioeconomic status, tumor stage, and higher anxiety and depression have been associated with variations in FCR (Table E1).7,9,16, 17, 18, 19

The purpose of this study was to estimate the prevalence of clinical levels of FCR in HPV-OPC survivors treated with definitive RT or CRT and to examine associations between demographic, clinical, and psychosocial characteristics and FCR scores. The underlying purpose was, however, to inform on the FCR burden in this population and determine the need for an FCR clinical pathway at our institution.

Section snippets

Study population and procedures

Eligible HPV-OPC survivors were recruited to a cross-sectional unmet needs study from November 8, 2018 to May 8, 2019 at the Peter MacCallum Cancer Centre. Patients were identified from an electronic institutional database before their usual oncosurveillance appointment. This study has also reported sexual health outcomes and self-reported changes in patients’ intimate relationships. The study eligibility criteria reflect those used to define the appropriate cohort to collect these outcomes as

Characteristics of the study population

During the enrollment period, 136 of 151 (90%) eligible patients were recruited (Fig. 1) and completed the survey. Sociodemographic, disease, and treatment variables are presented in Table 1. The median age of participants was 61 years (range, 42-87 years), and a majority were male (114 of 136 [84%]) and highly educated (75 of 136 [54%] had post secondary qualifications). Few patients were current smokers (24 of 116 [16%]), but many were regular consumers of alcohol (total: 91 of 136 [67%]; <10

Discussion

Despite the improved prognosis experienced by HPV-OPC survivors, FCR remains an important issue for this survivorship group, with approximately half (72 of 135 [53%]) experiencing clinically significant FCR more than 1 year after completion of treatment.

To our knowledge, this is the largest study evaluating FCR in HPV-OPC survivors using a multi-item severity score. In contrast, other studies have included heterogenous HNC populations or used single-item proxies from patient concern

Conclusion

Clinically significant FCR was identified in approximately half of HPV-OPC survivors at least 1 year after treatment completion. FCR was most pronounced in younger patients, particularly those self-reporting worse global QoL, for whom persistent symptoms interfere with daily life and higher levels of emotional distress are present. The study serves to highlight the prevalence of FCR in HPV-OPC cohorts and to alert clinicians to remain vigilant about its presence in this subpopulation. Further

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    Disclosures: none.

    G. Casswell is currently at Bristol Haematology and Oncology Centre, Bristol, United Kingdom.

    Research data are stored in an institutional repository and will be shared upon request to the corresponding author.

    Acknowledgments—We would like to acknowledge the patients who participated in this study. Although this project did not have direct funding, we would like to acknowledge the Cancer Trials Management Scheme Competitive Grants Programme, administered by Cancer Council Victoria, which provided salary support for research coordination in our department that aided data collection but was not specific for this study.

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