International Journal of Radiation Oncology*Biology*Physics
Clinical InvestigationFear of Cancer Recurrence in Survivors of Human Papillomavirus–Associated Oropharyngeal Carcinoma
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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Cited by (15)
Perceptions of life and experiences of health care support among individuals one year after head and neck cancer treatment – An interview study
2023, European Journal of Oncology NursingLong-Term Toxic Effects, Swallow Function, and Quality of Life on MC1273: A Phase 2 Study of Dose De-escalation for Adjuvant Chemoradiation in Human Papillomavirus-Positive Oropharyngeal Cancer
2022, International Journal of Radiation Oncology Biology PhysicsCitation Excerpt :Depression and suicide are higher among survivors of head and neck cancer compared with the general population,28,29 and depressive symptoms in patients with head and neck cancer have been shown to affect overall survival.30 The incidence of mental illness in survivors of HPV-OPC specifically is not well-described, but clinically significant fear of cancer recurrence has been shown in over half of patients with HPV-OPC31; further study and attention to the mental health of HPV-OPC survivors is warranted. One limitation of the present study is the lack of presurgical data on swallowing function and QOL.
Patient-Reported Outcomes After Chemoradiation in Patients With Anal Cancer: A Qualitative Analysis
2022, Advances in Radiation OncologyCitation Excerpt :CRT results in specific acute and late toxicities for many patients,16 resulting in significant stress and lifestyle changes. Moreover, fear of cancer recurrence is a well-described post-treatment phenomenon that occurs in up to 50% of patients with cancer.17,18 Interventions to improve support for these post-treatment fears and anxieties are warranted, such as shorter time to follow-up and early initiation of cognitive behavioral therapy.17
Symptom burden, quality of life, functioning and emotional distress in survivors of human papillomavirus associated oropharyngeal cancer: An Australian cohort
2021, Oral OncologyCitation Excerpt :This perhaps suggests that factors in the post treatment period, such as symptom burden and its impacts on day-to-day function (symptom interference) may be more important drivers of long-term emotional distress HPV-OPC survivors than pre-existing issues, but this speculation is limited by the small event rate, the absence of baseline assessments and we also cannot exclude that patients may have been unwilling to divulge their prior mental health history in this survey. Our previous work in this population has shown a high rate of fear of cancer recurrence, and although some studies have suggest these to be separate psychopathologies [50], the degree to which the general emotional distress of HPV-OPC overlaps with fear of cancer recurrence requires further research [17]. The findings from this study are limited by its cross-sectional nature and the absence of baseline data.
Head and Neck Cancer: United Kingdom National Multidisciplinary Guidelines, Sixth Edition
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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.