Psychosomatics 48:142-148, March-April 2007
doi: 10.1176/appi.psy.48.2.142
© 2007 Academy of Psychosomatic Medicine
Depressive Symptoms, Smoking, Drinking, and Quality of Life Among Head and Neck Cancer Patients
Sonia A. Duffy, Ph.D., R.N.,
David L. Ronis, Ph.D.,
Marcia Valenstein, M.D.,
Karen E. Fowler, M.P.H.,
Michael T. Lambert, M.D.,
Carol Bishop, M.S.N., ARNP-BC, CCRN,
Jeffrey E. Terrell, M.D., and
the University of Michigan Head and Neck Cancer Team
Received October 3, 2005; revised March 1, 2006; accepted March 8, 2006. From the VA HSR&D Center for Practice Management and Outcomes Research; VA Ann Arbor Healthcare System, Ann Arbor, MI; Dept. of Otolaryngology, Dept. of Psychiatry, School of Nursing, Univ. of Michigan, Ann Arbor, MI; VA North Texas Health Care System, Dallas VA Medical Center, Dallas, TX; Dept. of Psychiatry, Univ. of Texas Southwestern Medical School, Dallas, TX; and the Dept. of Otolaryngology, Malcom Randall VA Medical Center, Gainesville, FL. Send correspondence and reprint requests to Sonia A. Duffy, Ph.D., R.N., VA HSR&D Center for Practice Management and Outcomes Research, VA Ann Arbor Healthcare System (11H), P.O. Box 130170, Ann Arbor, MI 48113-0170. e-mail: Sonia.Duffy{at}med.va.gov
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ABSTRACT
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The authors examined the relationship between depressive symptoms, smoking, problem drinking, and quality of life among 973 head and neck cancer patients who were surveyed and had their charts audited. Forty-six percent screened positive for depressive symptoms, 30% smoked, and 16% screened positive for problem drinking. Controlling for clinical and demographic variables, linear-regression analyses showed that depressive symptoms had a strong negative association with all 12 quality-of-life scales; smoking had a negative association on all but one of the quality-of-life scales; and problem drinking was not associated with any of the quality-of-life scales. Interventions targeting depression, smoking, and problem drinking need to be integrated into oncology clinics.
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INTRODUCTION
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More than 40% of head and neck cancer patients have been shown to exhibit depressive symptoms during the course of their treatment.1 For head and neck cancer patients, emotional status and mental health may affect their global quality-of-life scores and disability status.2,3 Depression is also a risk factor for overall mortality.4 It has been shown that adequate treatment of depression can increase social functioning, patient productivity, and quality of life.5 Also, depression has been found to be associated with both smoking and problem drinking.6,7
Smoking and alcohol act synergistically to increase the likelihood of developing head and neck cancer.8 Yet, 35% to 46% of head and neck cancer patients continue to smoke after a diagnosis of cancer,9,10 and 41% to 54% are estimated to drink alcohol.1,11,12 Unfortunately, continued smoking and alcohol intake after the first diagnosis of head and neck cancer significantly increase medical complications (especially those related to surgery and radiation)13 and increase the likelihood of developing a second malignancy that adversely affects survival.14 One study showed that patients with oral cancer are often unaware that smoking and alcohol can cause oral cancer.15
In a previous pilot study, we found that depressive symptoms and smoking were associated with decreased quality-of-life scores among 81 head and neck cancer patients, whereas problem drinking was not associated with the quality-of-life scores.1 However, this former study was limited by a small sample size and the inability to control for a large number of important clinical measures (such as cancer site and stage, laryngectomy, radiation, chemotherapy, feeding tube, tracheotomy, comorbidities, and time since diagnosis), which might also affect quality of life. Hence, the purpose of this larger, cross-sectional, observational study was to determine the association of depressive symptoms, smoking, and drinking with quality of life, adjusting for important clinical and demographic measures.
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METHOD
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A convenience sample of head and neck cancer patients were surveyed from the year 2000 to 2002 while they were waiting to be seen for scheduled otolaryngology clinic appointments at four hospital facilities (Veterans Affairs [VA] Ann Arbor Healthcare System, Ann Arbor, MI; Malcom Randall VA Medical Center, Gainesville, FL; VA North Texas Healthcare System, Dallas, TX, VA Medical Center, Dallas, TX; and the University of Michigan Medical Center, Ann Arbor, MI). Medical records were also audited. Human subjects approval was received from all four sites.
Sample
Patients were included in the study if they had smoking-related cancers of the upper aerodigestive tract and excluded if they were 1) less than 18 years old; 2) pregnant; 3) non–English-speaking; 4) psychiatrically or mentally unstable (e.g., had suicidal ideation, acute psychosis, or dementia); 5) found to have a non–smoking-related cancer (such as thyroid, parotid, or skin cancer); or 6) known to be terminally ill/palliative. Of the 1,561 patients approached to participate in the study, 465 (29.8%) refused or never returned a completed survey, and 123 (7.9%) were ineligible because they were given a diagnosis that was not included in this study, yielding a final sample of 973.
Measures
Depressive symptoms, smoking, and alcohol-independent variables Depressive symptoms were measured with the validated Geriatric Depression Scale–Short Form (GDS–SF). (The GDS’s efficacy as a screener is not affected by age in the range of 50 to 96 years.16,17) Those who had smoked within the last month were considered current smokers. The validated, 10-item Alcohol Use Disorders Identification Test (AUDIT)18 was used to assess the level of alcohol intake and any related problems, including hazardous drinking, alcohol abuse, and symptoms of dependence.
Clinical and demographic control variables Clinical measures abstracted from the medical records included tumor site (oropharynx/hypopharynx, oral cavity/other versus larynx) and stage (in-situ, I, and II versus Stage III and IV), whether the patient had undergone (Yes/No) surgery (laryngectomy, neck dissection, other primary-site surgery), radiation, and chemotherapy, and had a feeding tube or tracheotomy at the time of the survey. Self-reported medical comorbidities were collected by survey (other cancer, lung disease, heart disease, stroke, psychiatric problems, diabetes, and arthritis). These conditions were then totaled and classified into three groups, including 0, 1, or >1 comorbid condition. Since time-since-diagnosis is associated with quality of life,19 time-since-diagnosis was included as a control variable: 0–1 month and >1 year were compared with 1 month–1 year (those most likely to be receiving treatment).
Demographic measures consisted of age, gender, race, marital status, and education. Since there were few African American and other-race participants, versus Whites, race was dichotomized into White and non-White. Education was classified into high school-or-less, some college, or a 4-year college degree-or-more. Marital status was classified into Married versus Widowed versus Divorced/Separated/Never Married.
Quality-of-life dependent variables Quality-of-life scores have been shown to be a marker for survival.20–22 Hence, quality of life was assessed, using the Short Form 36-item scale (SF–36),23 a well-validated general health status measure commonly used to assess physical, social, role, and emotional functioning. The validated Head and Neck Quality-of-Life instrument (HNQoL)24 was also used to measure disease-specific quality of life. The HNQoL includes 20 items, scored on a 5-point rating scale covering four domains: 1) eating and swallowing; 2) communication; 3) head and neck pain; and 4) emotional well-being.
Data Analysis
We compiled descriptive statistics (means and frequencies) on depressive symptoms, smoking, drinking, clinical and demographic measures, and quality-of-life scores. Chi-square and Student t-tests were computed to determine associations between the independent and control variables. Controlling for clinical and demographic measures, we conducted 12 multivariate, linear-regression tests to determine the association of depressive symptoms, smoking, and problem drinking with the eight quality-of-life scales on the SF–36 and the four scales on the HNQoL instrument. Variables that were included in the model were chosen on the basis of clinical relevance. The data were analyzed with SAS (SAS Institute, Inc.; Cary, NC). Values for p<0.05 are reported.
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RESULTS
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Description of the Sample
Almost half the participants screened positive for depressive symptoms. Even though smoking is a significant risk factor for head and neck cancer, almost one-third of participants had smoked in the last month, and although alcohol is also a significant risk factor for head and neck cancer, 16% of the subjects had AUDIT scores >7, putting them at risk for problem drinking. (See Table 1 for detailed information about depression, smoking, and alcohol, as well as clinical and demographic control variables.)
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TABLE 1. Characteristics of the Study Sample: Depressive Symptoms, Smoking, Drinking, Clinical, and Demographic Variables (N=973)
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Bivariate Analyses
The three independent variables—depressive symptoms, smoking, and drinking—were all significantly associated with each another (p<0.05). Also, both depressed persons and smokers were more likely to be younger, not married, have a high school degree or less, and to be within 1 year of their diagnosis (p<0.05). Smokers were also more likely to be from a VA hospital (p<0.02). Problem drinkers were more likely to be younger, not married, from a VA hospital, and within 1 year of their diagnosis (p<0.01). Unlike depressed persons and smokers, problem drinkers were more likely to be male and to have attended some college but not have a college degree (p<0.05).
Multivariate Analyses
We conducted 12 multivariate, linear-regression analyses, using the eight SF–36 and four HNQoL scales as the dependent variables, with depressive symptoms, smoking, and problem drinking as independent variables, and controlling for important clinical and demographic variables (e.g., age, tumor site and stage, time-since-diagnosis, comorbid conditions, etc.). All 12 models were significant (p<0.001). Depressive symptoms were found to have a strong negative association on all eight scales of the SF–36 and all four scales of the HNQoL instrument. Also, smoking was found to have a negative association on all eight scales of the SF–36 and three of the four scales on the HNQoL instrument. Surprisingly, problem drinking was not associated with any of the quality-of-life scales (see Table 2).
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TABLE 2. ß Parameter Estimates (p  0.05) for Linear Regressions of Depressive Symptoms, Smoking, and Alcohol Problems on Quality-of-Life Scales (SF–36 and HNQoL)
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Clinical control variables were also found to be associated with quality of life. Having two or more comorbidities was negatively associated with all 12 of the quality-of-life scales; having a feeding tube was negatively associated with 10 of the 12 quality-of-life scales; greater time since diagnosis was positively associated with 9 of the 12 quality-of-life scales; having a tracheotomy was negatively associated with 4 of the 12 quality-of-life scales. Cancer site (oral cavity/other and oropharynx/hypopharynx versus larynx) and having a neck dissection, chemotherapy, and radiation were all negatively associated with three of the quality-of-life scales; cancer stage and having a laryngectomy were each negatively associated with two of the quality-of-life scales, whereas having surgery at the primary cancer site was not associated with any of the quality-of-life scales.
Demographic control variables were also found to be associated with the quality-of-life scales. VA hospital site was negatively associated with 10 of the 12 quality-of-life scales. Age and educational level were each associated with 5 of the 12 quality-of-life scales; race (non-White) was negatively associated with only one of the quality-of-life scales, and marital status was not associated with any of the quality-of-life scales.
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DISCUSSION
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Depressive Symptoms Almost half of the respondents screened positive for depressive symptoms, and depressive symptoms were associated with all of the quality-of-life scales. Depression has been shown to be associated with greater pain and fatigue among cancer patients.25 Depression has also been shown to complicate therapy, increase the length of hospital stays, decrease patients’ ability to care for themselves and make treatment decisions, and decrease survival.26,27 However, depression, a treatable disease, is often undetected in cancer patients,28 perhaps because it is difficult to detect among head and neck cancer patients because of problems with speech, appetite, sleeping, pain, fatigue, discomfort, nicotine withdrawal, alcohol-related mood disorders, cognitive impairments, and treatment-related symptoms or weight loss.29 Hence, careful screening and subsequent treatment for depression are needed services for this population. Referrals for psychiatric services may be effective for some patients, whereas "on-the-spot" treatment may be necessary for those too depressed or physically ill to attend additional appointments.
Smoking We found, similar to findings of other studies,9,10 that about one-third of head and neck cancer patients continued to smoke and that smoking was negatively associated with quality of life. Smoking may be a form of self-medication, and nicotine withdrawal may mimic and/or exacerbate depression.30,31 Many head and neck cancer patients are interested in quitting,1 and the more severe the disease or invasive the treatment, the higher the cessation rate among cancer patients.9,32 Nicotine-replacement therapies may reduce the discomfort associated with nicotine withdrawal.33 For patients who smoke and are depressed, antidepressants (such as bupropion) that also reduce smoking may be effective strategies to treat these comorbid conditions/behaviors. Brief interventions, referrals to smoking cessation clinics, telephone "quit" lines, Internet smoking cessation programs, and print materials are all strategies that providers can recommend to patients.34,35 Head and neck cancer patients who have relapsed to smoking have been found to be more likely to quit by gradual reduction versus abrupt cessation, or "going cold turkey."36
Problem Drinking Sixteen percent of head and neck cancer patients screened positive for problem drinking, as compared with 8.5% in the general population,37 yet problem drinking was not associated with any of the quality-of-life scales in this study or in our previous (pilot) study.1 In fact, a study by Allison12 found that head and neck cancer patients who drank at least once in the last month had better quality of life than those who had not. However, drinking has been shown to increase mortality among head and neck cancer patients either from the disease, exacerbation of comorbidities, or health habits related to cigarette-smoking, diet, and emotional problems.11 Alcohol may cause immunosuppression that can impair the patient’s ability to destroy cancer cells and/or impair nutrient absorption, causing malnutrition and further immunosuppression.11 Similar to smoking, alcohol use may serve as a form of coping and/or self-medication for head and neck cancer patients. Head and neck cancer patients have been reported to actually increase their drinking after diagnosis.19 Alcohol screening and treatment may be beneficial to many head and neck cancer patients. For those who are highly alcohol-dependent, inpatient detoxification programs may be needed. For others, referrals to outpatient and community-based programs such as Alcoholics Anonymous are effective strategies.38
Clinical and Demographic Variables Several clinical variables, particularly comorbidities and having a feeding tube, were also negatively associated with most of the scales. Important associations between clinical variables and quality of life have been described in a previous article,39 as have clinical predictors of feeding tube placement in head and neck cancer patients.40 Differences found between hospital sites have also been explored further.41 The head and neck cancer patients treated at the VA Medical Centers were more likely to be smokers and problem drinkers, and were particularly at risk for poor quality of life when compared with those seen in the university setting.
A limitation of the study is that depressive symptoms, although measured by a validated screener, were not confirmed by a medical evaluation; this may have resulted in an overestimation of the number of patients with depressive symptoms. Despite our efforts to recruit from VA hospitals with a large number of minority-group patients, the sample was still predominantly white. Approximately 30% of the patients approached refused to participate, which may reflect higher refusal rates among minorities, patients who are depressed, or problem drinkers, thus possibly biasing the results. This was a cross-sectional study and therefore cannot determine changes in quality of life over time. Although we controlled for time-since-diagnosis, patients were evaluated at different points in their treatment. Nonetheless, the large number of variables that were found to be associated with quality of life point to the need for large studies that can control for multiple factors.
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CONCLUSION
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Despite major technological advances (surgical reconstructive techniques, sophisticated radiotherapy, and organ-preservation treatment), little progress has been made in 5-year survival rates for head and neck cancer, which have stabilized at around 60%.42,43 Many head and neck cancer patients screen positive for the modifiable conditions of depressive symptoms, smoking, and/or alcohol misuse, which adversely affect their quality of life and survival. Treating depression, smoking, and drinking behavior more aggressively is likely to improve quality of life and may perhaps lead to improvement in survival.
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ACKNOWLEDGMENTS
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The members of the University of Michigan Head and Neck Cancer Team, all of whom are authors of this article, are Carol R. Bradford, M.D., Douglas B. Chepeha, M.D., Mark E. Prince, M.D., Theodoros N. Teknos, M.D., and Gregory T. Wolf, M.D.
The authors express their appreciation to Larry Myers, M.D.; Lynn Gregory, nurse-practitioner; Sharon Stephens, nurse; and research assistant Cynthia Wampler, B.S., for their participation in data collection and management. The authors also thank the clinic personnel at the Univ. of Michigan Medical Center, and the Ann Arbor, Gainesville, and Dallas VA Medical Centers’ Otolaryngology clinics for their cooperation in this study. Most importantly, the authors thank the head and neck cancer patients who participated in this study for their time and cooperation.
This study was supported in part by the Dept. of Veterans Affairs (Grant IIR-98500); GlaxoSmithKline, Research Triangle Park, NC; the Academic Medicine and Managed Care Forum, Hartford, CT; the Oncology Nursing Society, Sigma Theta Tau (both the International and Rho Chapters), and the National Institutes of Health, through the Univ. of Michigan’s Head and Neck SPORE (Grant #1 P50 CA97248).
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ABSTRACT
INTRODUCTION
