Reply to "Morbidity of the neck after head and neck cancer therapy"

Pain Predicts Survival After Head and Neck Cancer Treatment
From Medscape Medical News, by Nick Mulcahy

August 18, 2009 — Patients with head and neck cancer who experience little or no posttreatment pain have a higher survival rate than those who experience an intermediate or high level of posttreatment pain, according to a study in the August issue of the Archives of Otolaryngology–Head & Neck Surgery.

Specifically, the 5-year survival rate was significantly higher for patients with no/low posttreatment pain, at 81.8% compared with 65.1% for those with intermediate/high pain (P = .04), reported investigators from the University of Iowa College of Medicine in Iowa City.

In addition, a higher pain level was associated with recurrence in the first year after treatment. The mean pain score for those who experienced recurrence in the first year was significantly greater than the mean score of those who did not have recurrence (2.9 vs 1.4; P = .006).

"The onset of pain or an increase in pain should therefore prompt an aggressive workup for recurrent disease," advise the authors, led by Joseph Scharf, MD, from the department of otolaryngology, head and neck surgery.

The onset of pain or an increase in pain should therefore prompt an aggressive workup for recurrent disease
The new study's findings are especially important, write the authors, because posttreatment pain has often been "underreported by patients with head and neck cancer and marginalized by health care providers."

The study has one limitation that is of particular note: the single item on a patient questionnaire that captured pain did not differentiate between head and neck pain and other bodily pain. However, the authors note that it is "unlikely" that results would have shown an association among pain, recurrence, and survival if pain unrelated to the head and neck cancer was a "substantial problem."

Study Details

The new study comes from the University of Iowa's Head and Neck Cancer Outcomes Assessment Project, which enrolled patients between 1998 and 2001. Self-reported pain was measured at diagnosis and 3, 6, 9, and 12 months later.

At each self-report, patients indicated their average level of pain during the previous 4 weeks, using a scale from 0 to 10. In the analyses, pain scores were presented as none (0), low (1 – 3), intermediate (4 – 6), or high (7 – 10).

Of 339 patients in the analysis, most had primary disease (84.4%) or advanced-stage disease (59.9%), and the most common malignancies were oral cavity (42.2%) or laryngeal (23.3%) tumors. Most of the patients received either surgical treatment alone (37.2%) or surgery combined with radiotherapy (37.7%). About 13% received radiation alone; very few patients received any form of chemotherapy.

The results revealed trends in pain levels during the first year of follow-up: the mean pain level decreased from 2.7 at 3 months to 1.6 at 12 months. The percentage of patients reporting no pain increased from 45.9% at pretreatment to 61.4% at 12 months. However, about 10% of patients reported high levels of pain throughout the 1-year period.

Let Staff Collect Pain Information

The study results also indicated that a higher level of pain was also associated with younger age at diagnosis, worse general physical and mental health, and higher levels of depressive symptoms, as well as 5-year survival rate and recurrence within the first year.

Monitoring pain should be part of routine oncologic surveillance, note the authors. "The Joint Commission's requirement that pain be assessed as a 'fifth vital sign' may provide the means for documenting pain and identifying changes in pain levels across time," the authors write.

The Joint Commission's requirement that pain be assessed as a 'fifth vital sign' may provide the means for documenting pain. Who should perform this assessment? The authors suggest that it should be staff other than the physician, so that "patients might more freely communicate this complaint."

The study was supported in part by a grant from the National Institutes of Health, Office of Cancer Survivorship. The authors have disclosed no relevant financial relationships.

Arch Otolaryngol Head Neck Surg. 2009;135[8]:789–794.

Nick Mulcahy is a senior journalist for Medscape Hematology-Oncology. Medscape Medical News © 2009