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Original Investigation |

Association Between Multimodality Neck Treatment and Work and Leisure Impairment A Disease-Specific Measure to Assess Both Impairment and Rehabilitation After Neck Dissection

K. Kelly Gallagher, MD1; Assuntina G. Sacco, MD2; Julia Shin-Jung Lee, MS, MPH3; Rodney Taylor, MD, MSPH4; Eric J. P. Chanowski, MD3; Carol R. Bradford, MD, MS3; Mark E. Prince, MD3; Jeffrey S. Moyer, MD3; Gregory T. Wolf, MD3; Francis P. Worden, MD2; Avraham Eisbruch, MD5; Douglas B. Chepeha, MD, MSPH, FRCSC3,6
[+] Author Affiliations
1Department of Otolaryngology–Head and Neck Surgery, Baylor College of Medicine, Houston, Texas
2Department of Hematology and Oncology, University of Michigan, Ann Arbor
3Department of Otolaryngology–Head and Neck Surgery, University of Michigan Health System, Ann Arbor
4Department of Otolaryngology–Head and Neck Surgery, University of Maryland, Baltimore
5Department of Radiation Oncology, University of Michigan Health System, Ann Arbor
6Department of Otolaryngology–Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
JAMA Otolaryngol Head Neck Surg. 2015;141(10):888-893. doi:10.1001/jamaoto.2015.2049.
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Importance  This study describes the effect of adjuvant treatment on shoulder-related quality of life, leisure activities, and employment for patients undergoing neck dissection for head and neck cancer.

Objective  To explore the association between treatment outcome and shoulder-related on critical daily life functions such as employment and recreation.

Design, Setting, and Participants  Cross-sectional study of patients with head and neck cancer at a tertiary care hospital.

Exposures  Level V–sparing selective neck dissection or modified radical neck dissection sparing the accessory nerve, with or without radiation therapy and/or chemotherapy.

Main Outcomes and Measures  Patients completed the Neck Dissection Impairment Index (NDII), with scores ranging from 0 to 100 and higher scores indicating better shoulder functioning and shoulder-related quality of life, and underwent objective testing with the Constant-Murley Shoulder Function Test (Constant test) at least 12 months after the completion of all adjuvant treatment. Additional outcome measures related to physical therapy, pain medication use, leisure activity, and employment status.

Results  We evaluated 167 patients who underwent 121 selective neck dissections and 46 modified radical neck dissections. The median (range) NDII score was 90 (10-100). Patients with modified radical neck dissection reported lower scores than those with selective neck dissection (85 [10-100] vs 92 [30-100]; P = .01). Multivariable analysis showed that advanced-stage disease (mean, 77 [range, 25-100] vs 87 [18-100]; P = .006), radiation therapy (80 [10-100] vs 88 [50-100]; P = .03), and chemotherapy (77 [30-100] vs 83 [18-100]; P = .002) were associated with greater shoulder impairment. The NDII and Constant test were well correlated (0.64; P < .001). Change in leisure activity was correlated with greater impairment (median [range] NDII score, 90 [18-100] for patients with no change vs 53 [10-100] for patients with change, P = .005; Constant score, 85 [12-100] vs 68 [10-88], P = .004). Patients who remained employed or resumed working had higher median (range) NDII scores (94 [10-100] and 88 [75-100], respectively) than those who limited or stopped working (70 [10-100]), which also correlates with greater shoulder impairment (P < .001).

Conclusions and Relevance  More aggressive treatment, either in the form of increased surgical dissection, radiation therapy, or chemotherapy, was associated with worse shoulder function and quality of life. The degree of impairment perceived by the patient and measured in objective testing was correlated with leisure activity and employment status. These findings may stimulate further investigation related to optimizing quality of life following neck dissection.

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Figure 1.
Neck Dissection Impairment Index
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Figure 2.
Neck Dissection Impairment Index (NDII) Severe Score by Neck Dissection Type

For patients who underwent bilateral neck dissection with completion of separate shoulder assessments, only the side of the neck with the most extensive neck dissection was included (severe score). Patients who underwent modified radical neck dissection (MRND) had NDII scores that were broadly distributed, whereas patients who underwent selective neck dissection (SND) were skewed to higher NDII scores. Approximately 30% of patients who underwent MRND scored greater than 90 whereas 60% of patients who underwent SND scored greater than 90 on the NDII (higher scores indicate better function). The mean (range) NDII score for no radiation was 88 (50-100); postoperative radiation, 82 (10-100); preoperative radiation, 74 (18-100); no chemotherapy, 83 (18-100); and chemotherapy, 77 (30-100).

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Figure 3.
Neck Dissection Type, Leisure Activity, and Change of Work Status by Neck Dissection Impairment Index (NDII) Severe Score

For patients who underwent bilateral neck dissection with completion of separate shoulder assessments, only the side of the neck with the most extensive neck dissection was included (severe score). Patients who underwent modified radical neck dissection (MRND) had significantly worse NDII scores than patients who underwent spinal accessory nerve–sparing selective neck dissection (Wilcoxon P = .005). Patients with a negative change in leisure activity had significantly worse NDII scores compared with patients who maintained the same amount of leisure activity (Wilcoxon P = .006). Patients who remained employed had significantly better NDII scores than patients who stopped working (Kruskal-Wallis P < .001). A positive change was one in which a patient went from not working to working. A negative change was one in which a patient was working and either stopped working or retired. The horizontal line in the middle of each box indicates the median, while the top and bottom borders of the box mark the 75th and 25th percentiles, respectively. The whiskers above and below the box mark the 90th and 10th percentiles. The points beyond the whiskers are outliers beyond the 90th or 10th percentiles.

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Figure 4.
Radiation Therapy and Chemotherapy by Neck Dissection Impairment Index (NDII) Severe Score

For patients who underwent bilateral neck dissection with completion of separate shoulder assessments, only the side of the neck with the most extensive neck dissection was included (severe score). Patients who received other treatment modalities in addition to neck dissection (radiation therapy [Kruskal-Wallis P = .003] or chemotherapy [Wilcoxon rank-sum P = .03]) had worse subjective shoulder function as evidenced by lower mean NDII scores.

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