BACKGROUND:Malnutrition screening is not widely practiced in outpatient cancer centers. This review aims to determine the validity of malnutrition screening tools and provide recommendations for clinical use. METHODS:Studies identified by a systematic review assessed the general validity of screening tools in adult oncology outpatients from five databases through 2022. The American Society for Parenteral and Enteral Nutrition (ASPEN) convened a working group of members from the Academy of Nutrition and Dietetics, Academy of Oncology Nurse and Patient Navigators, American Cancer Society, American Society for Clinical Oncology, American Society for Nutrition, American Society for Radiation Oncology, Association of Cancer Care Centers, and Oncology Nursing Society to answer the following questions: (1) should clinicians screen for malnutrition, (2) which malnutrition screening tools are recommended, and (3) what are the clinical applications for malnutrition risk screening in adult oncology outpatients? RESULTS:Twenty of 738 studies met the criteria and were reviewed. Six screening tools with specific cut-points demonstrated validity and are recommended, including the Mini Nutritional Assessment (≤23.5), Malnutrition Screening Tool (MST; MST ≥ 2 and patient-led MST ≥ 2), Malnutrition Universal Screening Tool (MUST; MUST ≥ 1 and MUST ≥ 2), Nutrition Risk Screening-2002 (NRS-2002; NRS-2002 ≥ 2 and NRS-2002 ≥ 3), NUTRISCORE ≥ 5, and Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF; PG-SGA SF ≥ 7 and PG-SGA SF ≥ 8). CONCLUSION:Six screening tools are valid for malnutrition risk identification in oncology ambulatory settings and recommended before treatment initiation and regularly thereafter, depending on treatment course. Research is needed to understand to what extent early diagnosis and management of malnutrition improves the clinical care of oncology patients.

Study of polymorphisms in genes related to the generation and removal of oxidative stress and repair of oxidative DNA damage will lead to new insights into the genetic basis of prostate cancer. In the Prostate Cancer Prevention Trial (PCPT), a double-blind, randomized controlled trial testing finasteride versus placebo for prostate cancer prevention, we intend to investigate the role of oxidative stress/DNA repair mechanisms in prostate cancer etiology and whether these polymorphisms modify prostate cancer risk by interacting with antioxidant status in both placebo and finasteride arms. We evaluated associations of selected candidate polymorphisms in genes in these pathways, and interactions with pre-diagnostic serum antioxidants, and the risk of prostate cancer among 1,598 cases and 1,706 frequency-matched controls enrolled in the PCPT. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using multivariable-adjusted logistic regression models. While there were no statistically significant associations observed in the placebo arm, several SNPs were associated with prostate cancer in the finasteride arm. Specifically, APEX1-rs1760944 was associated with increased risk of total prostate cancer (per minor allele: p-trend=0.04). OGG1-rs1052133 was positively (CG/GG vs. CC: OR=1.32, 95% CI: 1.01-1.73) and NOS3-rs1799983 was inversely (per minor allele: p-trend=0.04) associated with risk of low-grade prostate cancer. LIG3-rs1052536 and XRCC1-rs25489 were suggestively associated with reduced risk of high-grade prostate cancer (per minor allele: both p-trend=0.04). In the placebo arm, significant associations were observed among men with higher serum lycopene for APEX1-rs1760944 and NQO1-rs1800566, or higher serum β-cryptoxanthin for ERCC4-rs1800067. In the finasteride arm, stronger associations were observed among men with lower serum lycopene for NOS3-rs1799983, higher serum α-carotene, β-carotene, and β-cryptoxanthin for LIG3-rs1052536, or lower serum retinol for SOD2-rs1799725. These results suggest that germline variations in oxidative stress and DNA repair pathways may contribute to prostate carcinogenesis and that these associations may differ by intraprostatic sex steroid hormone status and be further modified by antioxidant status. Findings provide insights into the complex role of gene, gene-antioxidant and -finasteride interactions in prostate cancer etiology, and thus may lead to the development of preventative strategies.

Purpose/Objective(s) Recent systematic reviews suggested that hemoglobin (Hgb) level may play a role as biomarker for survival outcome among patients with head and neck cancer. However, the optimal threshold for anemia and its role in a current human papillomavirus (HPV) era remain unclear. To address this knowledge gap, we performed an observational cohort study to investigate pre-treatment Hgb and its association with survival outcomes in patients with head and neck cancer treated with radiation therapy. Materials/Methods A single-institution, retrospective database was queried for patients with non-metastatic head and neck cancer who underwent radiation therapy from January 2005 to April 2021. Pre-radiation Hgb was evaluated as a continuous variable using restricted cubic splines (RCS), and the model-derived threshold was used to stratify patients into low and high Hgb. Cox multivariable analysis (MVA) and Kaplan-Meier method were used to analyze overall survival (OS) and disease-specific survival (DSS). Logistic MVA was performed to identify variables associated with low Hgb level. Propensity score matching was used to construct matched pairs. A subgroup analysis was also performed among patients with available HPV data. Results Among a total of 753 patients, median follow up was 29.7 months (interquartile range 17.8-57.8). Cox MVA based on RCS showed a threshold of Hgb at 12.96, with worsening survival in a continuous fashion without plateau as Hgb decreases. Low Hgb was associated with worse OS (aHR 1.55, 95% CI 1.17-2.05, p=0.002) and DSS (aHR 1.79, 95% CI 1.28-2.51, p<0.001). Similar findings were observed in 178 matched pairs (OS: HR 1.47, 95% CI 1.05-2.06, p=0.03; DSS: HR 1.82, 95% CI 1.19-2.78, p=0.006). On logistic MVA, patients were more likely to have low Hgb if they were female, had a higher T staging, underwent induction chemotherapy or surgery prior to radiation therapy, and had feeding tubes placed. They were less likely to have low Hgb if they had a good performance status and HPV-associated head and neck cancer. Among 466 patients with available HPV data, low Hgb was associated with DSS (aHR 1.84, 95% CI 1.30-2.61, p<0.001), but not OS (aHR 1.32, 95% CI 0.89-1.95, p=0.16). Conclusion In this study, low Hgb was associated with worse survival outcomes even among those with available HPV data. Patients with significant primary disease burden, feeding tube placement, and poor performance status who underwent either induction chemotherapy or surgery were more likely to have low Hgb. Further studies would be warranted to investigate the role of Hgb to identify patients early with poor prognosis and tailor treatments based on their risk factors. Recent systematic reviews suggested that hemoglobin (Hgb) level may play a role as biomarker for survival outcome among patients with head and neck cancer. However, the optimal threshold for anemia and its role in a current human papillomavirus (HPV) era remain unclear. To address this knowledge gap, we performed an observational cohort study to investigate pre-treatment Hgb and its association with survival outcomes in patients with head and neck cancer treated with radiation therapy. A single-institution, retrospective database was queried for patients with non-metastatic head and neck cancer who underwent radiation therapy from January 2005 to April 2021. Pre-radiation Hgb was evaluated as a continuous variable using restricted cubic splines (RCS), and the model-derived threshold was used to stratify patients into low and high Hgb. Cox multivariable analysis (MVA) and Kaplan-Meier method were used to analyze overall survival (OS) and disease-specific survival (DSS). Logistic MVA was performed to identify variables associated with low Hgb level. Propensity score matching was used to construct matched pairs. A subgroup analysis was also performed among patients with available HPV data. Among a total of 753 patients, median follow up was 29.7 months (interquartile range 17.8-57.8). Cox MVA based on RCS showed a threshold of Hgb at 12.96, with worsening survival in a continuous fashion without plateau as Hgb decreases. Low Hgb was associated with worse OS (aHR 1.55, 95% CI 1.17-2.05, p=0.002) and DSS (aHR 1.79, 95% CI 1.28-2.51, p<0.001). Similar findings were observed in 178 matched pairs (OS: HR 1.47, 95% CI 1.05-2.06, p=0.03; DSS: HR 1.82, 95% CI 1.19-2.78, p=0.006). On logistic MVA, patients were more likely to have low Hgb if they were female, had a higher T staging, underwent induction chemotherapy or surgery prior to radiation therapy, and had feeding tubes placed. They were less likely to have low Hgb if they had a good performance status and HPV-associated head and neck cancer. Among 466 patients with available HPV data, low Hgb was associated with DSS (aHR 1.84, 95% CI 1.30-2.61, p<0.001), but not OS (aHR 1.32, 95% CI 0.89-1.95, p=0.16). In this study, low Hgb was associated with worse survival outcomes even among those with available HPV data. Patients with significant primary disease burden, feeding tube placement, and poor performance status who underwent either induction chemotherapy or surgery were more likely to have low Hgb. Further studies would be warranted to investigate the role of Hgb to identify patients early with poor prognosis and tailor treatments based on their risk factors.

ImportanceAfter 10 pack-years of smoking was initially established as a threshold for risk stratification, subsequent clinical trials incorporated it to identify candidates for treatment deintensification. However, several recent studies were unable to validate this threshold externally, and the threshold for smoking exposure remains unclear.ObjectiveTo estimate the threshold of pack-years of smoking associated with survival and tumor recurrence among patients with head and neck cancer.Design, Setting, and ParticipantsThis single-institution, cohort study included patients with nonmetastatic head and neck cancer receiving chemoradiation from January 2005 to April 2021. Data were analyzed from January to April 2022.ExposuresHeavy vs light smoking using 22 pack-years as a threshold based on maximizing log-rank test statistic.Main Outcomes and MeasuresOverall survival (OS), progression-free survival (PFS), locoregional failure (LRF), and distant failure (DF).ResultsA total of 518 patients (427 male [82.4%]; median [IQR] age, 61 [55-66] years) were included. Median (IQR) follow-up was 44.1 (22.3-72.8) months. A nonlinear Cox regression model using restricted cubic splines showed continuous worsening of OS and PFS outcomes as pack-years of smoking increased. The threshold of pack-years to estimate OS and PFS was 22. Cox multivariable analysis (MVA) showed that more than 22 pack-years was associated with worse OS (adjusted hazard ratio [aHR] 1.57; 95% CI, 1.11-2.22; P = .01) and PFS (aHR, 1.38; 95% CI, 1.00-1.89; P = .048). On Fine-Gray MVA, heavy smokers were associated with DF (aHR, 1.71; 95% CI, 1.02-2.88; P = .04), but not LRF (aHR, 1.07; 95% CI, 0.61-1.87; P = .82). When 10 pack-years of smoking were used as a threshold, there was no association for OS (aHR, 1.23; 95% CI, 0.83-1.81; P = .30), PFS (aHR, 1.11; 95% CI, 0.78-1.57; P = .56), LRF (aHR, 1.19; 95% CI, 0.64-2.21; P = .58), and DF (aHR, 1.45; 95% CI, 0.82-2.56; P = .20). Current smoking was associated with worse OS and PFS only among human papillomavirus (HPV)-positive tumors (OS: aHR, 2.81; 95% CI, 1.26-6.29; P = .01; PFS: aHR, 2.51; 95% CI, 1.22-5.14; P = .01).Conclusions and RelevanceIn this cohort study of patients treated with definitive chemoradiation, 22 pack-years of smoking was associated with survival and distant metastasis outcomes. Current smoking status was associated with adverse outcomes only among patients with HPV-associated head and neck cancer.

Objectives: We sought to define the optimal threshold for anemia in North American head and neck cancer patients and evaluate its role as a prognostic biomarker. Materials and Methods: A single-institution database was queried for patients with head and neck cancer who underwent chemoradiation from January 2005 to April 2021. An optimal threshold of hemoglobin (Hgb) level was defined based on maximum log-rank test statistic. Cox multivariable analysis (MVA), Kaplan-Meier, and propensity score matching were performed to evaluate treatment outcomes. Results: A total of 496 patients were identified. Threshold for Hgb was determined to be 11.4 for both overall survival (OS) and progression-free survival (PFS). Low Hgb was associated with worse OS (adjusted hazards ratio [aHR] 2.41, 95 % confidence interval [CI] 1.53-3.80, p < 0.001) and PFS (aHR 2.01, 95 % CI 1.30-3.11, p = 0.002). Similar findings were observed among 39 matched pairs for OS (5 year OS 22.3 % vs 49.0 %; HR 2.22, 95 % CI 1.23-4.03, p = 0.008) and PFS (5-year PFS 24.3 % vs 39.1 %; HR 1.78, 95 % CI 1.02-3.12, p = 0.04). Among those with HPV-negative tumors, low Hgb was associated with worse OS (aHR 13.90, 95 % CI 4.66-41.44, p < 0.001) and PFS (aHR 5.24, 95 % CI 2.09-13.18, p < 0.001). However, among those with HPV-positive tumors, low Hgb was not associated with both OS (aHR 1.75, 95 % CI 0.60-5.09, p = 0.31) and PFS (aHR 1.13, 95 % CI 0.41-3.14, p = 0.82). Conclusion and relevance: Low Hgb below 11.4 was an independent adverse prognostic factor for worse survival. It was also prognostic among patients with HPV-negative tumors, but not for HPV-positive tumors.

The overall 5-year relative survival rate for all cancers combined is now 68%, and there are over 16.9 million survivors in the United States. Evidence from laboratory and observational studies suggests that factors such as diet, physical activity, and obesity may affect risk for recurrence and overall survival after a cancer diagnosis. The purpose of this American Cancer Society guideline is to provide evidence-based, cancer-specific recommendations for anthropometric parameters, physical activity, diet, and alcohol intake for reducing recurrence and cancer-specific and overall mortality. The audiences for this guideline are health care providers caring for cancer survivors as well as cancer survivors and their families. The guideline is intended to serve as a resource for informing American Cancer Society programs, health policy, and the media. Sources of evidence that form the basis of this guideline are systematic literature reviews, meta-analyses, pooled analyses of cohort studies, and large randomized clinical trials published since 2012. Recommendations for nutrition and physical activity during cancer treatment, informed by current practice, large cancer care organizations, and reviews of other expert bodies, are also presented. To provide additional context for the guidelines, the authors also include information on the relationship between health-related behaviors and comorbidities, long-term sequelae and patient-reported outcomes, and health disparities, with attention to enabling survivors' ability to adhere to recommendations. Approaches to meet survivors' needs are addressed as well as clinical care coordination and resources for nutrition and physical activity counseling after a cancer diagnosis.

IMPORTANCE Given the role of inflammation in cancer progression, neutrophil-lymphocyte ratio (NLR) from peripheral blood has been suggested as a readout of systemic inflammation and a prognostic marker in several solid malignant neoplasms. However, optimal threshold for NLR in US patients with head and neck cancer remains unclear. OBJECTIVE To evaluate the optimal NLR threshold as a potential prognostic biomarker for survival outcomes. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study was conducted at a single institution. Participants included 496 patients with nonmetastatic head and neck cancer who underwent chemoradiation from April 2007 to March 2021. Statistical analysis was performed from September to December 2021. EXPOSURES High vs low NLR. MAIN OUTCOMES AND MEASURES Overall survival (OS) and cancer-specific survival (CSS). RESULTS A total of 496 patients (411 male patients [82.9%]; 432 White patients [87.1%]; 64 patients with other race or ethnicity [12.9%]; median [IQR] age, 61 [55-67] years) were identified. Median (IQR) follow-up was 44.4 (22.8-74.0) months. Thresholds of NLR for both OS and CSS were 5.71. High NLR above 5.71 was associated with worse OS (adjusted hazard ratio [aHR], 1.97; 95% CI, 1.26-3.09; P = .003) and CSS (aHR, 2.33; 95% CI, 1.38-3.95; P = .002). On logistic multivariable analysis, patients were more likely to have high NLR if they had higher T and N staging (T3-4: aOR, 4.07; 95% CI, 1.92-9.16; P < .001; N2: aOR, 2.97; 95% CI, 1.04-9.17; P = .049; N3: aOR, 11.21; 95% CI, 224-46.97; P < .001), but less likely if they had a good performance status (Karnofsky Performance Status 90-100: aOR, 0.29; 95% CI, 0.14-0.59; P < .001). Among 331 patients (66.7%) with available human pa pilloma virus (HPV) data, high NLR was not associated with OS (HPV-negative: aHR, 2.46; 95% CI. 0.96-6.31; P = .06; HPV-positive: aHR, 1.17; 95% CI, 0.38-3.56; P = .78) and CSS (HPV-negative: aHR, 2.55; 95% CI, 0.81-7.99; P = .11; HPV-positive: aHR, 1.45; 95% CI, 0.44-4.76; P = .54). CONCLUSIONS AND RELEVANCE High NLR was associated with worse survival. Patients with substantial disease burden and poor performance status were more likely to have high NLR. These findings suggest that further studies would be warranted to investigate the role of such prognostic marker to identify patients at risk to tailor interventions.

Purpose/Objective(s) Combined modality therapy with surgery, chemotherapy, and/or radiation often results in significant morbidity among patients with head and neck cancer, including dysphagia and weight loss. Given extensive side effect profiles, body mass index (BMI) has been shown to play a role in the clinical outcome of such patients. To validate this finding, we performed an observational cohort study to investigate BMI and its association with survival outcomes in patients with head and neck cancer treated with multimodal therapies. Materials/Methods A single-institution, retrospective database was queried for patients with non-metastatic head and neck cancer who underwent either definitive-intent chemoradiation or postoperative radiation therapy from 1/2005 to 4/2021. BMI was stratified by underweight, normal, overweight, and obese by <18.5, 18.5-24.9, 25.0-29.9, and 30.0 or above, respectively. Cox multivariable analysis (MVA) and Kaplan-Meier method were used to analyze overall survival (OS) and cancer-specific survival (CSS) outcomes. Logistic MVA was performed to identify variables associated with post-treatment responses. Propensity score matching was used to construct matched pairs based on nearest neighbor method in a 1:1 ratio with no replacement. Results A total of 738 patients (n=206 with normal BMI, n=27 with underweight, n=274 with overweight, and n=231 with obese BMI) were included for analysis. Median follow up was 31.0 months (interquartile range 18.5-58.0). On Cox MVA, being overweight was associated with improved OS (aHR 0.70, 95% CI 0.51-0.97, p=0.03), but not CSS (aHR 0.82, 95% CI 0.55-1.22, p=0.34). Similar findings were noted in 163 matched pairs of patients with normal BMI and overweight (OS: HR 0.69, 95% CI 0.48-0.99, p=0.04; CSS: HR 0.80, 95% CI 0.51-1.24, p=0.32). Among 683 patients with available treatment response, being overweight was associated with complete response after treatments (aOR 0.52, 95% CI 0.30-0.90, p=0.02). Being underweight (OS: aHR 0.84, 95% CI 0.49-1.44, p=0.53; CSS: aHR 1.83, 95% CI 0.98-3.41, p=0.06) or obese (OS: aHR 0.77, 95% CI 0.53-1.11, p=0.16; CSS: aHR 0.92, 95% CI 0.58-1.46, p=0.73) was not associated with survival outcomes. Conclusion In this study, being overweight was associated with improved OS and increased likelihood of complete response after treatments, while it had no association with CSS. However, having normal BMI or obesity were not associated with improved survival outcomes. Further studies would be warranted to investigate the role of BMI as a prognostic marker among patients who underwent multimodal therapies. Combined modality therapy with surgery, chemotherapy, and/or radiation often results in significant morbidity among patients with head and neck cancer, including dysphagia and weight loss. Given extensive side effect profiles, body mass index (BMI) has been shown to play a role in the clinical outcome of such patients. To validate this finding, we performed an observational cohort study to investigate BMI and its association with survival outcomes in patients with head and neck cancer treated with multimodal therapies. A single-institution, retrospective database was queried for patients with non-metastatic head and neck cancer who underwent either definitive-intent chemoradiation or postoperative radiation therapy from 1/2005 to 4/2021. BMI was stratified by underweight, normal, overweight, and obese by <18.5, 18.5-24.9, 25.0-29.9, and 30.0 or above, respectively. Cox multivariable analysis (MVA) and Kaplan-Meier method were used to analyze overall survival (OS) and cancer-specific survival (CSS) outcomes. Logistic MVA was performed to identify variables associated with post-treatment responses. Propensity score matching was used to construct matched pairs based on nearest neighbor method in a 1:1 ratio with no replacement. A total of 738 patients (n=206 with normal BMI, n=27 with underweight, n=274 with overweight, and n=231 with obese BMI) were included for analysis. Median follow up was 31.0 months (interquartile range 18.5-58.0). On Cox MVA, being overweight was associated with improved OS (aHR 0.70, 95% CI 0.51-0.97, p=0.03), but not CSS (aHR 0.82, 95% CI 0.55-1.22, p=0.34). Similar findings were noted in 163 matched pairs of patients with normal BMI and overweight (OS: HR 0.69, 95% CI 0.48-0.99, p=0.04; CSS: HR 0.80, 95% CI 0.51-1.24, p=0.32). Among 683 patients with available treatment response, being overweight was associated with complete response after treatments (aOR 0.52, 95% CI 0.30-0.90, p=0.02). Being underweight (OS: aHR 0.84, 95% CI 0.49-1.44, p=0.53; CSS: aHR 1.83, 95% CI 0.98-3.41, p=0.06) or obese (OS: aHR 0.77, 95% CI 0.53-1.11, p=0.16; CSS: aHR 0.92, 95% CI 0.58-1.46, p=0.73) was not associated with survival outcomes. In this study, being overweight was associated with improved OS and increased likelihood of complete response after treatments, while it had no association with CSS. However, having normal BMI or obesity were not associated with improved survival outcomes. Further studies would be warranted to investigate the role of BMI as a prognostic marker among patients who underwent multimodal therapies.

e18597 Background: Head and neck cancer (HNC) is a debilitating disease that affects tens of thousands each year and both the disease and its treatment can cause long-term morbidity. HNC patients with greater physical function at baseline may better withstand both disease and treatment, therefore we hypothesized that baseline physical function is associated with baseline skeletal muscle density (SMD). Methods: A cross-sectional study of existing medical records was conducted. SMD was classified using pre-treatment PET-CT scans and interpreted using Sliceomatic software, and pre-treatment physical function assessed in three ways: hand grip strength, timed up and go, and short physical performance battery. Linear regression models were utilized to assess the association between SMD and each measure of physical function, with adjustment for muscle mass, sex and cancer stage in the hand grip strength model and adjustment for muscle mass and age in both the timed up and go, and short physical performance battery models. Results: The sample of 90 HNC patients, was mostly white, male, former smokers with an average BMI of 28 kg/m2. In adjusted models that included men only, we observed that for every Hounsfield unit increase in SMD there was a 0.08 increase in SPPB score (p=0.005), a 0.31 kg increase in hand grip strength (p=0.04), and a 0.13 second decrease in timed up and go (p=0.0007). In adjusted models that included women only, we observed that for every Hounsfield unit increase in SMD there was a 0.03 decrease in SPPB score (p=0.75), a 0.12 kg increase in hand grip strength (p=0.65), and a 0.01 second increase in timed up and go (p=0.84). Conclusions: Baseline physical function is associated with higher baseline physical SMD. Larger studies involving a more women are needed to replicate these findings and to further examine the potential role of effect modification by both sex and muscle mass.

Background While often life-saving, treatment for head and neck cancer (HNC) can be debilitating resulting in unplanned hospitalization. Hospitalizations in cancer patients may disrupt treatment and result in poor outcomes. Pre-treatment muscle quality and quantity ascertained through diagnostic imaging may help identify patients at high risk of poor outcomes early. The primary objective of this study was to determine if pre-treatment musculature was associated with all-cause mortality. Methods Patient demographic and clinical characteristics were abstracted from the cancer center electronic database ( n = 403). Musculature was ascertained from pre-treatment CT scans. Propensity score matching was utilized to adjust for confounding bias when comparing patients with and without myosteatosis and with and without low muscle mass (LMM). Overall survival (OS) was evaluated using the Kaplan–Meier method and Cox multivariable analysis. Results A majority of patients were male (81.6%), white (89.6%), with stage IV (41.2%) oropharyngeal cancer (51.1%) treated with definitive radiation and chemotherapy (93.3%). Patients with myosteatosis and those with LMM were more likely to die compared to those with normal musculature (5-yr OS HR 1.55; 95% CI 1.03–2.34; HR 1.58; 95% CI 1.04–2.38). Conclusions Musculature at the time of diagnosis was associated with overall mortality. Diagnostic imaging could be utilized to aid in assessing candidates for interventions targeted at maintaining and increasing muscle reserves.

Head and neck cancer (HNC) treatment-related morbidity can be detrimental to quality of life (QOL). Myosteatosis is associated with poor QOL in multiple cancers. If predictive of poor QOL trajectories, myosteatosis would be a tool for clinicians to determine which patients may require additional support during treatment. The purpose of this study was to determine if pretreatment myosteatosis is associated with a poor QOL trajectory following treatment completion. Methods: In a retrospective cohort design, myosteatosis was determined from pretreatment CT scans. Both physical and global QOL score was assessed through patient interview on follow-up appointment. Demographic, cancer-specific, and social covariates were collected, reported, and considered as potential confounders. Results: The population of 163 patients was mostly male (82.2%) and white (91.4%) with oropharyngeal cancer (55.8%). Males with myosteatosis had a physical QOL score 46.84 points lower at one-year following treatment completion (p = 0.01) than those with normal muscle density (p = 0.01). Males with myosteatosis averaged 57.57 points lower at one-year post-treatment (p = 0.01) in global QOL scores. Conclusions: Over one year following completion of treatment, patients with myosteatosis reported worse physical and global QOL scores than patients with normal muscle density.

Patient-reported quality of life (QoL) metrics, frailty status, and physical functioning are emerging concepts in head and neck cancer (HNC) with implications on both treatment decision-making and prognosis. The impact of treatment-related functional decline on QoL and frailty has not been well-characterized in HNC and was the focus of this investigation. Methods: Patients who underwent radiation therapy for HNC from 2018 to 2020 were evaluated as a prospective observational cohort. Functional decline, QoL, and the frailty phenotype were measured via the Short Physical Performance Battery (SPPB), European Organization for Research and Treatment of Cancer (EORTC) qlq-C30, and Fried Frailty index, respectively. Results: A total of 106 HNC patients were included, 75 of which received concurrent chemoradiation therapy (CCRT) and 31 received radiation alone, both with and without surgery. There was a decrease in SPPB overall (p < 0.001) from the beginning to the end of treatment in the CCRT group but not the radiation group (p = 0.43). Change in overall SPPB points following treatment correlated with the decline in physical QoL for both groups (p < 0.05) as well as transition frail status in the CCRT group (p < 0.001) with a trend in the radiation group (p = 0.08). Conclusions: Change in SPPB correlates with QoL and transition to frailty status in patients undergoing definitive CCRT for HNC with similar trends in those receiving radiation alone. Decline in SPPB could potentially be useful in identification of those who may benefit from rehabilitation in future studies.

Background: To compare head and neck cancer (HNC) patients treated with three-weekly versus weekly cisplatin-based or other chemotherapy-based concurrent chemoradiation (CRT) and CRT with versus without induction chemotherapy (ICT) to investigate differences in overall survival (OS) and cancer-specific survival (CSS). Methods: HNC patients treated with definitive or adjuvant CRT at Roswell Park Comprehensive Cancer Center between 2003 and 2017 were retrospectively reviewed. Propensity score matching was performed to obtain three sets of balanced matched pairs: three-weekly and weekly cisplatin CRT, three weekly and non-cisplatin CRT, CRT with and without ICT. Multivariate Cox regression and Kaplan-Meier analyses were used to estimate and compare survival outcomes. Results: A total of 623 patients received either definitive (81%) or post-operative (19%) RT. Of these, 283 patients concurrently received three-weekly cisplatin (45%); 189 patients (30%) received weekly cisplatin; 151 patients (24%) received non-cisplatin regimen. Median follow-up was 55.4 months (interquartile range, 38.0-88.7). Patients who received CRT alone and those who received ICT and CRT had no difference in 5-year OS (51.5% and 41.0% respectively, P=0.53) and CSS (64.9% and 49.7% respectively, P=0.21). Compared to patients who received three-weekly cisplatin, patients who received weekly cisplatin had no difference in 5-year OS (59.3% vs. 54.1%, P=0.35) and CSS (70.3% vs. 62.4%, P=0.09); patients who received non-cisplatin CRT also had no difference in 5-year OS (54.5% vs. 58.3%, P=0.51) and CSS (67.5% vs. 64.7%, P=0.45). Conclusions: No significant difference in OS and CSS was observed in any of the three pairs of CRT regimens. ICT prior to CRT did not improve survival of CRT alone. Non-cisplatin and weekly cisplatin regimens did not prove to be inferior to the standard three-weekly cisplatin.

Prognostication for cancer patients is integral for patient counseling and treatment planning, yet providing accurate prediction can be challenging using existing patient-specific clinical indicators and host factors. In this work, we evaluated common machine learning models in predicting head and neck squamous cell carcinoma (HNSCC) patients’ overall survival based on demographic, clinical features and host factors. We found random survival forest had best performance among the models evaluated, which achieved a C-index of 0.729 and AUROC of 0.792 in predicting two-year overall survival. In addition, we verified that host factors are independently predictive of HNSCC overall survival, which improved the C-index by a margin of 0.026 and the AUROC by 0.034. Due to the strong correlation among host factors, we showed that proper dimension reduction is an important step before their incorporation into the machine learning models, which provides a host factor score reflecting the patients’ nutrition and inflammation status. The score by itself showed excellent discriminating capacity with the high-risk group having a hazard ratio of 3.76 (1.93–7.32, p < 0.0001) over the low-risk group. The hazard ratios were further improved to 7.41 (3.66–14.98, p < 0.0001) by the random survival forest model after including demographic and clinical features.

OBJECTIVE:To assess the association between financial toxicity and survival in patients with head and neck cancer (HNC). MATERIALS AND METHODS:Using a single-institution database, we retrospectively reviewed HNC patients treated at Roswell Park Comprehensive Cancer Center treated with definitive or postoperative radiation therapy between 2013 and 2017. Kaplan-Meier method and log-rank tests were used to analyze survival outcomes. Propensity score matching on all clinically relevant baseline characteristics was performed to address selection bias. All statistical tests were two-sided and those less than 0.05 were considered statistically significant. RESULTS:Of a total of 284 HNC patients (age: median 61 years, IQR 55-67; 220 [77.5%] men), 204 patients (71.8%) received definitive radiation and 80 patients (28.2%) received adjuvant radiation. There were 41 patients (14.4%) who reported high baseline financial toxicity. Chemotherapy was used in 237 patients (83.5%). On multivariable analysis, those with high financial toxicity exhibited worse overall survival (hazards ratio [HR] 1.75, 95% confidence interval [CI] 1.05-2.94, p = 0.03) and cancer specific survival (HR 2.28, 95% CI 1.31-3.96, p = 0.003). On matched pair analysis of 66 patients, high financial toxicity remained associated with worse OS (HR 2.72, 95% CI 1.04-7.09, p = 0.04) and CSS (HR 3.75, 95% CI 1.22-11.5, p = 0.02). CONCLUSION:HNC patient reported baseline financial toxicity was significantly correlated with both decreased overall and cancer specific survival. These significant correlations held after match pairing. Further research is warranted to investigate the impact of financial toxicity in HNC and mitigate its risk.

Introduction Contralateral prophylactic mastectomy has the potential to decrease the occurrence of cancer and reduce psychological burden. However, it is known that complications after bilateral mastectomy are higher compared with unilateral mastectomy. Our goal was to evaluate outcomes of immediate breast reconstruction in patients undergoing bilateral mastectomy and to compare complication rates between therapeutic and prophylactic sides. Patients and Methods Electronic medical records of patients with unilateral breast cancer who underwent bilateral mastectomy and immediate reconstruction with expanders were reviewed. Postoperative complications were compared between therapeutic and prophylactic mastectomy sides. Results Sixty-two patients were analyzed. The overall complication rate after both stages was 23.9% on the therapeutic side and 16.5% on the prophylactic side. Infection was the most common complication on both sides. All infections on the prophylactic mastectomy side were successfully treated with intravenous (IV) antibiotics (salvage rate of 100%), whereas 35.7% of infected tissue expander/implants on the therapeutic mastectomy side were explanted despite treatment. Conclusion Careful counselling of patients undergoing elective contralateral prophylactic mastectomy is essential as complications can develop in either breast after reconstruction.

Background: Financial toxicity (FT) can be devastating to cancer patients, and solutions are urgently needed. We investigated the impact of financial counseling (FC) on FT in head and neck cancer (HNC) patients. Methods: Via a single-institution database, we reviewed the charts of HNC patients who underwent definitive or post-operative radiotherapy, from October 2013 to December 2020. Of these patients, 387 had provided baseline and post-treatment information regarding financial difficulty. In July 2018, a dedicated financial counselor was provided for radiation therapy patients and we subsequently examined the impact of FC on financial difficulty scores. Results: Following the hiring of a dedicated financial counselor, there was a significant increase in the proportion of patients receiving FC (5.3% vs. 62.7%, p < 0.0001). Compared with baseline scores, patients who did not undergo FC had a significant increase in reported financial difficulty at the end of treatment (p = 0.002). On the other hand, there was no difference in pre- and post-treatment scores in patients who had received FC (p = 0.588). After adjusting for gender and nodal status with a multiple linear regression model, FC was significantly associated with change in financial difficulty (β = −0.204 ± 0.096, p = 0.035). On average, patients who received FC had a 0.2 units lower change in financial difficulty score as compared with those with the same gender and nodal stage but without FC. Conclusions: Providing a dedicated financial counselor significantly increased the proportion of HNC receiving FC, resulting in the stabilization of financial difficulty scores post-treatment. Based on a multiple linear regression model, FC was independently associated with reduced financial difficulty. The employment of a financial counselor may be a viable, hospital-based approach to begin to address FT in HNC.

Background: One frequent consequence of radiation therapy (RT) for head and neck cancer (HNC) is weight loss (WL). HNC patients reportedly lose about 9% of their weight during treatment, regardless of pre-treatment WL and nutritional support. We investigated whether high WL during RT has an association with overall (OS) and cancer-specific survival (CSS). Methods: We retrospectively reviewed weight during RT in HNC patients treated at Roswell Park Comprehensive Cancer Center between 2003 and 2017. High WL was defined as greater than or equal to the median WL. Logistic regression analysis was performed to identify predictors for WL during RT. Multivariate Cox regression and Kaplan-Meier analyses were used to estimate survival outcomes. Propensity score matching was performed to obtain balanced matched-pairs and compare survival outcomes. Results: A total of 843 patients received either definitive (71%) or post-operative (29%) RT. Median follow-up was 53.6 months [interquartile range (IQR) 35.7-88.9]. Median WL was 5.8% (IQR 0.24-10.6) from baseline weight. Patients with high WL had better OS [hazard ratio (HR) 0.75, 95% confidence interval (CI), 0.61-0.93, P=0.01] and CSS (HR 0.71, 95% CI, 0.55-0.93, P=0.01). 258 matched-pairs were analyzed. Median follow-up was 54.8 months (IQR 35.8-90.4). Median OS was 39.2 months (IQR 21.4-75.7) for high WL versus 36.7 months (IQR 14.6-61.7) for low WL cohorts (P=0.047). Conclusions: Different from previous reports, this study shows that patients with less WL have worse OS. WL during RT may not be a reliable marker for worse prognosis. A better way to evaluate malnutrition in patients undergoing RT is warranted.

Background: Health-related quality of life (HRQOL) metrics can be associated with survival in head and neck cancer (HNC); however, the impact of HRQOL recovery and the relevant HRQOL domains regarding outcome are unclear. Methods: Using a single-institution database, we retrospectively reviewed HNC patients treated with definitive or postoperative radiation therapy between 2013 and 2018. The recovery of individual HRQOL domains were determined by the ratio of the post-treatment to baseline scores. Univariate and Multivariate Cox regression were used to analyze survival outcomes. Principal component analysis was used to adjust for multicollinearity of HRQOL domains. Results: In 218 HNC patients who received radiation therapy, median follow-up was 24.8 months (interquartile range (IQR) 14.5–32.0). Principal component analysis evaluating the recovery of HRQOL domains revealed two independent principal components (PC), PC1 and PC2. PC1, which received contributions from the functional domains; physical (PF), role (RF), emotional (EF), cognitive (CF), and global health status (GQOL) was significantly associated with disease-free (HR = 0.77, 95% CI 0.61–0.98, p = 0.034) and overall survival (HR = 0.76, 95% CI 0.65–0.91, p = 0.004) on multivariate analysis and PC2, had no correlation with outcome and was mainly represented by social functioning. Unplanned hospitalization was significantly associated with lower PC1 scores (β = −0.997, Std. Error = 0.244, p < 0.001). Conclusion: Our study provides evidence that post-treatment recovery of HRQOL domains were associated with overall survival (OS) in HNC. PC1 is an attractive clinical tool to assess the recovery across multiple different HRQOL and the relationship with survival. Future prospective studies may identify patients who could benefit from additional rehabilitation based on PC1 score.

Background: Limited treatment options are available for oral mucositis, a common, debilitating complication of cancer therapy. We examined the association between daily delivery time of radiotherapy and the severity of oral mucositis in patients with head and neck cancer. Methods: We used electronic medical records of 190 patients with head and neck squamous cell carcinoma who completed radiotherapy, with or without concurrent chemotherapy, at Roswell Park Comprehensive Cancer Center (Buffalo, NY) between 2015 and 2017. Throughout a 7-week treatment course, patient mouth and throat soreness (MTS) was self-reported weekly using a validated oral mucositis questionnaire, with responses 0 (no) to 4 (extreme). Average treatment times from day 1 until the day before each mucositis survey were categorized into seven groups. Multivariable-adjusted marginal average scores (LSmeans) were estimated for the repeated- and maximum-MTS, using a linear-mixed model and generalized-linear model, respectively. Results: Radiation treatment time was significantly associated with oral mucositis severity using both repeated-MTS (n = 1,156; P = 0.02) and maximum-MTS (n = 190; P = 0.04), with consistent patterns. The severity was lowest for patients treated during 8:30 to <9:30 am (LSmeans for maximum-MTS = 2.24; SE = 0.15), increased at later treatment times and peaked at early afternoon (11:30 am to <3:00 pm, LSmeans = 2.66-2.71; SEs = 0.16/0.17), and then decreased substantially after 3 pm. Conclusions: We report a significant association between radiation treatment time and oral mucositis severity in patients with head and neck cancer. Impact: Although additional studies are needed, these data suggest a potential simple treatment time solution to limit severity of oral mucositis during radiotherapy without increasing cost.