1. DiGiulio, Sarah

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Use and abuse of tobacco and alcohol, as well as mental health issues, are known to be common in patients with head and neck cancer. But previous data has not adequately identified the prevalence and interdependence of these issues using population-level data, according to Andrew Day, MD, MPH, Assistant Professor of Otolaryngology - Head and Neck Surgery and Associate Member of the Simmons Comprehensive Cancer Center Population Science and Cancer Control Program at the University of Texas Southwestern Medical Center. "It is important because continued tobacco use, heavy alcohol use, and depression all predict for increased perioperative complications, increased risk of recurrence, and increased risk of mortality," he told Oncology Times.

Andrew Day, MD, MPH.... - Click to enlarge in new windowAndrew Day, MD, MPH. Andrew Day, MD, MPH

Day is the corresponding author of a recent study that analyzed National Health Interview Survey data from 1997 to 2016 to better capture the burden of these issues in survivors of head and neck cancer (Cancer 2022; The data included 918 survivors of head and neck cancer and 3,672 matched survivors of other cancers. Compared with other cancer survivors, more survivors of head and neck cancer were current smokers and/or heavy drinkers (24.6% vs. 18%) and exhibited a high mental health burden (18.6% vs. 13.0%). In multivariable analyses, a high mental health burden predicted for smoking and/or heavy drinking; current cigarette smoking predicted for a high mental health burden; and non-partnered marital status and uninsured/Medicaid insurance status were significantly associated with cigarette smoking and/or heavy alcohol use and a high mental health burden.


An editorial accompanying the research noted: "It is important, however, that we also focus research efforts on the person in whom the cancer develops, is detected, is treated, and is cured or clinically managed for the rest of his or her life" (Cancer 2022; Here's more from Day about the new data and why they are important.


1 What did the findings show that wasn't previously known?

"Head and neck cancer survivors commonly smoke, drink heavily, or are depressed. Each of these patient-level factors adversely influence patient outcomes, including likelihood of recurrence and survival. We need to precisely measure the prevalence of these issues at a population-level and understand their interdependence so we can best manage them.


"This topic has been extensively researched in the past, but most studies haven't used population-based data and haven't compared the prevalence of these issues to survivors of other cancers. According to primarily institutional and limited population-based data, we have known that these are common issues. We didn't know how common these problems were in head and neck cancer survivors relative to other cancer survivors. We also knew that these issues were interrelated, but to our knowledge this interdependence hadn't been characterized using population-based data.


"[This new data shows that], among survivors of head and neck cancer with known substance use behaviors, 21.4 percent are current smokers and 5.2 percent are heavy alcohol users. Among survivors of head and neck cancer with known mental health symptoms, 14.3 percent had frequent depressive symptoms, 12.2 percent had frequent anxiety symptoms, and 7.1 percent had severe psychological distress. Each of these issues is significantly more common in survivors of head and neck cancer compared to survivors of other cancers. Across virtually every social determinant of health, survivors of head and neck cancer exhibit greater disparities compared to survivors of other cancers. This includes poverty, underinsurance (Medicaid or uninsured), and education (high school education or less).


"Also, current smoking correlated with high mental health burden in adjusted (multivariable) analyses and high mental health burden associated with current smoking and/or heavy alcohol use. This highlights that these issues are interdependent and need to be addressed together-and not in isolation of each other."


2 Why do you suspect these survivors specifically are at higher risk?

"Seventy percent of head and neck cancers are caused by smoking and/or heavy alcohol use. Many of these patients are unable to quit smoking or reduce their alcohol dependence after their cancer diagnosis, despite the fact that continued substance use predicts for poor oncologic outcomes. The fact that they persist in substance use is reflected in the fact that among survivors 24.6 percent still smoke or use alcohol heavily. And this study is unable to account for survivorship bias. Since it only measures survivors, this data does not capture patients who died because they continued to smoke or drink heavily. Substance use is often comorbid with social determinants of health and all of these factors are often comorbid with depression and mental health burden."


3 What's the next step in terms of future research?

"We need to systematically screen patients for these issues, ideally at the time of diagnosis. We then need to connect them with supportive care in a timely fashion, ideally prior to initiation of oncologic treatment. This will only happen through team-based, coordinated, multidisciplinary cancer care.


"Ultimately, we need to develop and test new interventions to 1) deliver survivors of head and neck cancer treatment for tobacco, alcohol abuse, and mental health issues, and 2) deliver coordinated, multimodal treatment to patients with more than one substance abuse and/or mental health issue.


"Smoking, heavy alcohol use, depressive symptoms, anxiety symptoms, and severe psychological distress are disproportionately common among survivors of head and neck cancer. These issues have significant downstream influences on patient outcomes. [Clnicians should make] sure they are screening for all of these problems and coordinate treatment for them, either directly or through referral, as soon as possible in their cancer survivorship journey."