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Effect of Cognition on Quality of Life After Head and Neck Cancer Treatment.

Head and neck cancers (HNCs) currently comprise about 6% of all malignant neoplasms in the United States,1 with an estimated incidence of 61 760 cases in 2016.2 These numbers are expected to continue to increase because of the recent surge in human papillomavirus– related oropharyngeal cancer. Advances in surveillance, diagnosis, and delivery of treatment modalities have improved survival rates and functional outcomes for some HNCs, particularly human papillomavirus–related cancers, which tend to present at younger ages and have superior prognosis.3 These advances in treatment have translated into a larger number of HNC survivors, creating a situation in which more patients are surviving with the resultant functional impairments and disabilities of their cancer and treatment, without adequate recognition of the specific survivorship challenges they face. The integration of the principles of survivorship care in HNC has significantly lagged behind the integration of survivorship care in other common cancers, especially breast cancer. This failure to lead in survivorship care planning is disappointing because HNCs and their treatment are associated with higher degrees of physical, functional, and emotional disability than other cancers due to the alterations in speech, swallowing, and aesthetic qualities that define human characteristics. The National Cancer Institute established the Office of Cancer Survivorship in 1996 to promote investigations concerned with addressing challenges encountered by cancer survivors and improving their quality of life. Survivorship research includes investigations into the physical, psychosocial, and economic sequelae of cancer.4 The posttreatment cognitive status of patients with cancer and its role in the survivor’s quality of life has received little attention in HNC. Multiple studies in other cancer cohorts, especially breast cancer, have delineated the detrimental effect of cancer treatment on cognition and the resulting impediments to societal reintegration. Studies in breast cancer survivors have identified cognitive deficits in attention, learning, working memory, motor speed, executive function (planning and problem solving), and information processing after chemotherapy.5,6 Anderson-Hanley et al5 also found that cancer survivors who received chemotherapy had cognitive deficits that were associated with decreased productivity and information processing in day-to-day functioning. Some survivors also avoided social activities where their cognitive deficits might have been noticed by others. Recently, a metaanalysis by Hodgson et al6 found chemotherapy to significantly affect cognitive domains of executive function and memory in 4 cancer sites, including breast cancer, testicular cancer, lymphoma, and leukemia. In comparison, to our knowledge, only 11 studies to date have been performed to evaluate cognitive changes associated with HNC treatment. Of these studies, 9 occurred in the pre-Intensity Modulated Radiation Therapy era in patients with nasopharyngeal cancer, where collateral temporal lobe necrosis resulted in expected cognitive deficits. In the post-Intensity Modulated Radiation Therapy era with minimal collateral brain irradiation even for nasopharyngeal and skull base cancers, only 2 studies7,8 have investigated the neurocognitive effect of treatment of nonnasopharyngeal HNC on survivorship. Hsiao et al7 and Gan et al8 identified treatment-related cognitive dysfunctions mainly in the domains of memory and language in patients with HNC. Because HNC is associated with smoking, alcohol consumption, and poor diet, which have been associated with cognitive dysfunction,6 it is imperative that more resources be dedicated to this area of research to better investigate the differential role of surgery, radiotherapy, chemotherapy, and the various combinations of these treatments in the development of cognitive dysfunction in HNC survivors. It is the lack of studies in this area of cognitive impairments after HNC treatment that highlights the importance of the study by Bolt et al.9 In this cross-sectional study, Bolt et al9 investigated the variables associated with everyday communication, also termed communicative participation, in 197 adult patients who were 6 months postcompletion of treatment of HNC. These patients were recruited to complete questionnaires providing information on a variety of variables, including demographics, medical and cancer history, speech severity, use of speech, emotional health, cognition, and swallowing. Bolt et al9 hypothesized that variables not overtly associated with communication symptoms may be important in communicative participation and proposed to evaluate a large number of variables. In their backward stepwise regression analyses, they established that self-rated speech severity, self-rated cognitive function, laryngectomy status, and time since HNC diagnosis were significantly associated with communicative participation. More remarkable was that self-rated cognition, a variable that had not been hypothesized a priori to be important for communicative participation, was the second strongest predictor of communicative participation. To our knowledge, this article is the first study to demonstrate the effect of cognition on communicative survivorship in patients with HNC. Despite the limitations of the study design, including the absence of pretreatment baseline data, absence of longitudinal posttreatment data, and the use of subjective rather than objective methods of assessment, the article has highlighted the importance of cognition and provided new insight into its potential role in the quality of life of patients with HNC. With these results, there is now a need to expand research in HNC survivorship as it associates with cognition. Related article Effect of Cognition on Quality of Life After HNC Treatment Invited Commentary