Health Behaviors Linked to Survival in Head and Neck Cancer

Roxanne Nelson

April 03, 2009

April 3, 2009 — Pretreatment lifestyle behaviors might be pivotal in improving prognosis among patients with head and neck cancer. According to study published online March 16 in the Journal of Clinical Oncology, smoking, excessive alcohol use, a low consumption of fruit, and inadequate physical activity were associated with lower rates of survival.

The study authors report that pretreatment smoking status was the strongest predictor of survival; problematic alcohol intake and low fruit consumption were associated with worse survival, although vegetable intake was not. Physical activity was also associated with survival in univariate analysis and approached significance in the multivariate model (hazard ratio [HR], 0.98; 95% confidence interval [CI], 0.95 to 1.00).

"The study seems to confirm what has been suspected," said lead author Sonia Duffy, PhD, RN, associate professor of nursing at the University of Michigan School of Nursing, and research scientist at the VA Healthcare System, in Ann Arbor. "Health behaviors can play a role in preventing cancer and they also appear to affect survival after diagnosis."

In an interview, Dr. Duffy emphasized that currently, healthcare systems in the United States are focused on treatment. "We tend to overlook the influence of health behaviors, and they are not well integrated into healthcare systems," she said. "As we found, several of these behaviors can impact patient survival."

Smoking Strongest Predictor of Survival

In this prospective study, Dr. Duffy and colleagues evaluated whether 5 pretreatment health factors — smoking, alcohol use, diet, exercise, and sleep — could predict survival among 504 newly diagnosed patients with head and neck squamous cell carcinoma. After the initial assessment, patients were surveyed every 3 months for 2 years, and annually thereafter. The median follow-up time was 999 days (range, 19 to 2010), and the 2-year death rate was 24.2%.

At the time of diagnosis, 26.4% of patients were current smokers and 55.2% were former smokers. More than one quarter (26.2%) of patients screened positive for an alcohol problem, approximately one third ate fewer than 4 servings of fruit per month, and more than two thirds ate less than 1 vegetable per day.

Mean daily calorie intake was 2351 and mean body-mass index was 26.7 kg/m2. Mean physical activity score, measured using the validated Physical Activity Scale for the Elderly, was 115 (mean score for people 65 to 100 years is 103). Sleep was measured using validated questions from the Medical Outcomes Study; the mean sleep score for adults visiting a medical clinic was 72 and for the cohort in this study was 67.

Smoking is a major causative factor for head and neck cancer; therefore, it is not surprising that such a large number of patients were still smoking at diagnosis or that it was the strongest predictor of survival in the population, the researchers note. They found that being a current smoker (HR, 2.4; 95% CI, 1.3 to 4.4) or a former smoker (HR, 2.0; 95% CI, 1.2 to 3.5) was significantly associated with poor survival. Sleep, however, was not associated with survival in either the univariate or multivariate analysis.

In both univariate and multivariate analyses, smoking status was the strongest predictor of survival, whereas in the univariate analysis only, problem alcohol consumption, low fruit intake, and a low level of physical activity negatively affected survival.

"The next step is to see if behavior changes made after diagnosis will affect survival," said Dr. Duffy.

Multicomponent Interventions Need Further Study

Data have suggested that poor lifestyle practices do not occur independently or in isolation; rather, they band together in a constellation, write Ellen R. Gritz, PhD, and Wendy Demark-Wahnefried, PhD, from the University of Texas MD Anderson Cancer Center, in Houston, in an accompanying editorial. The current study is 1 of many to show that smokers not only have greater alcohol intake but also less-than-optimal dietary habits and levels of physical activity.

Head and neck cancer survivors who are current or former smokers represent a population in great need, the editorialists note. The need is not only for smoking-cessation interventions, but for interventions that target multiple behaviors.

"To date, however, no trial has tested a multiple-component intervention that includes smoking cessation, diet, exercise, and possibly alcohol components among individuals diagnosed with cancer," they write, adding that a number of basic behavioral-science research questions remain unanswered.

"In the years ahead, the alliance between oncologists and behavioral scientists will be key in successfully developing, delivering, and assessing multiple interventions across the spectrum of cancer survivors," the editorialists write.

The study was funded by a grant from the National Institutes of Health. None of the study authors or editorialists have disclosed any relevant financial relationships.

J Clin Oncol. Published online before print March 16, 2009. Abstract, Abstract

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