Patterns of symptom burden during radiotherapy or concurrent chemoradiotherapy for head and neck cancer: a prospective analysis using the University of Texas MD Anderson Cancer Center Symptom Inventory-Head and Neck Module

Abstract

Background: A prospective longitudinal study to profile patient-reported symptoms during radiotherapy (RT) or concurrent chemoradiotherapy (CCRT) for head and neck cancer was performed. The goals were to understand the onset and trajectory of specific symptoms and their severity, identify clusters, and facilitate symptom interventions and clinical trial design.

Methods: Participants in this questionnaire-based study received RT or CCRT. They completed the University of Texas MD Anderson Cancer Center Symptom Inventory-Head and Neck Module before and weekly during treatment. Symptom scores were compared between treatment groups, and hierarchical cluster analysis was used to depict clustering of symptoms at treatment end. Variables believed to predict symptom severity were assessed using a multivariate mixed model.

Results: Among the 149 patients studied, the majority (47%) had oropharyngeal tumors, and nearly one-half received CCRT. Overall symptom severity (P < .001) and symptom interference (P < .0001) became progressively more severe and were more severe for those receiving CCRT. On multivariate analysis, baseline Eastern Cooperative Oncology Group performance status (P < .001) and receipt of CCRT (P < .04) correlated with higher symptom severity. Fatigue, drowsiness, lack of appetite, problem with mouth/throat mucus, and problem tasting food were more severe for those receiving CCRT. Both local and systemic symptom clusters were identified.

Conclusions: The findings from this prospective longitudinal study identified a pattern of local and systemic symptoms, symptom clusters, and symptom interference that was temporally distinct and marked by increased magnitude and a shift in individual symptom rank order during the treatment course. These inform clinicians about symptom intervention needs, and are a benchmark for future symptom intervention clinical trials.

Keywords: chemoradiotherapy; head and neck cancer; patient-reported outcomes; radiotherapy; symptoms.

Figure 1

Mean severity of the MD Anderson Symptom Inventory—Head and Neck Module individual symptoms items and overall symptom interference across the treatment period, according to treatment group. Mean individual symptom severity differences for the treatment groups (chemoradiation vs. radiation) for the total sample period were compared by independent t tests; P-values shown (group differences were considered significant if P<0.002 for the 22 symptom items).

Figure 2

Proportions of patients experiencing moderate to severe levels (ratings of ≥5) (top panel) or severe levels (ratings of ≥7) (bottom panel) of the 13 most commonly experienced symptoms of the MD Anderson Symptom Inventory—Head and Neck Module, according to treatment period.

Figure 3

Dendrogram illustrating the clustering of various symptoms at the end of treatment. Those items that join with others earlier along the relative distance scale of 0–25 (i.e., further to the left in this figure) were rated by patients more similarly. For example, the items pain, fatigue, and drowsiness joined together quickly, indicating that patients perceived and rated these items similarly.

Figure 4

Mean overall symptom severity of the MD Anderson Symptom Inventory—Head and Neck Module symptom items across the treatment period, according to treatment group.