Research

Original Investigation

Depression Among Long-term Survivors of Head and Neck

Cancer Treated With Radiation Therapy
Allen M. Chen, MD; Megan E. Daly, MD; Esther Vazquez, RN; Jean Courquin, RN; Quang Luu, MD;
Paul J. Donald, MD; D. Gregory Farwell, MD

IMPORTANCE The diagnosis and subsequent treatment of head and neck cancer can have a
potentially devastating impact on psychosocial functioning. Although the long-term physical
adverse effects of radiation therapy (RT) for head and neck cancer have been well described,
relatively few studies have evaluated psychosocial functioning after treatment.

OBJECTIVE To determine the prevalence of self-reported depression among survivors of head

and neck cancer returning for follow-up after being treated with RT.

DESIGN, SETTING, AND PARTICIPANTS Cross-sectional analysis among 211 comprehensive

cancer center patients with squamous cell carcinoma of the head and neck, who had been
previously treated with RT and were disease-free with at least 1 year of follow-up. Patients
with a history of mood disorder, use of mental health services in the past, or previous or
current use of antidepressants or anxiolytics, excluding sleep medications, were specifically
excluded.

INTERVENTIONS The University of Washington Quality of Life instrument (UW-QOL), a brief,

previously validated, self-administered questionnaire, was used to analyze rates of
depression.

MAIN OUTCOMES AND MEASURES The UW-QOL assigned scores of 0, 25, 50, 75, and 100
subjective responses of mood being “extremely depressed,” “somewhat depressed,” “neither
in a good mood or depressed,” “generally good,” and “excellent,” respectively.

RESULTS The mean mood score did not differ at 1, 3, and 5 years after treatment, with scores
of 52.0, 55.7, and 62.1, respectively. The proportion of patients who reported their mood as
“somewhat depressed” or “extremely depressed” was 17%, 15%, and 13% at 1, 3, and 5 years,
respectively. Variables that were significantly associated with post-RT depression included
the presence of tracheostomy tube or laryngeal stoma (P = .01), gastrostomy tube
dependence (P = .01), and continued smoking at the time of follow-up (P < .001). Among the
patients reporting their mood as either “somewhat depressed” or “extremely depressed” at 1,
3, and 5 years, the proportion using antidepressants at the time was 6%, 11%, and 0%,
respectively. The corresponding proportion of patients actively undergoing or seeking Author Affiliations: Department of
psychotherapy and/or counseling was 3%, 6%, and 0%, respectively. Radiation Oncology, University of
California, Davis, Comprehensive
Cancer Center, Sacramento (Chen,
CONCLUSIONS AND RELEVANCE Despite a relatively high rate of depression among patients
Daly, Vazquez, Courquin);
with head and neck cancer in the post-RT setting, mental health services are severely Department of Otolaryngology–Head
underutilized. and Neck Surgery, University of
California, Davis, Comprehensive
Cancer Center, Sacramento (Luu,
Donald, Farwell); now with the
Department of Radiation Oncology,
David Geffen School of Medicine,
University of California, Los Angeles.
(Chen).
Corresponding Author: Allen M.
Chen, MD, Department of Radiation
Oncology, David Geffen School of
Medicine, 200 UCLA Medical Plaza,
Ste B265, Los Angeles, CA
JAMA Otolaryngol Head Neck Surg. 2013;139(9):885-889. doi:10.1001/jamaoto.2013.4072 90095-6951 (amchen@mednet.ucla
Published online August 15, 2013. .edu).

885

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 Research Original Investigation Cancer Survivors and Depression After Radiotherapy

T
he diagnosis and subsequent treatment of head and neck
Table 1. Patient and Disease Characteristics
cancer can have a potentially devastating impact on psy-
chosocial functioning. An analysis of the Surveillance, Characteristic Patients, No. (%)
Epidemiology, and End Results (SEER) program observed that Primary site

the suicide rate was more than 4 times greater among pa- Oropharynx 87 (41)
tients with head and neck cancer compared with that of the Oral cavity 56 (27)
general population.1 Although causative factors were not spe- Larynx/hypopharynx 30 (14)
cifically analyzed, it has long been hypothesized that pa- Unknown primary 21 (10)
tients with head and neck cancer, many of whom have a his- Nasopharynx 17 (8)
tory of tobacco and alcohol abuse, experience disproportionate T classification
emotional distress due to the possibility of physical disfigure- T0 21 (10)
ment from disease progression and/or treatment, as well dis- T1 46 (22)
tress due to impairment of such basic human functions as eat- T2 45 (21)
ing, speaking, and breathing.2 T3 49 (23)
Although the long-term physical adverse effects of radia- T4 50 (24)
tion therapy (RT) for head and neck cancer have been well de- RT technique
scribed, relatively few studies have evaluated psychosocial Intensity-modulated RT 134 (64)
functioning, including depression, among patients treated in
3-Dimensional conformal RT 77 (36)
this setting.3 This is of particular relevance because depres-
Neck dissection
sion not only adversely affects quality of life but is also treat-
Yes 109 (52)
able. The purposes of this study were to perform a cross-
No 102 (48)
sectional analysis of depression among long-term survivors of
Tracheostomy or stoma dependent
head and neck cancer who were previously treated with RT and
Yes 22 (10)
to identify potential risk factors.
No 189 (90)
Gastrostomy tube dependent
Yes 26 (12)
Methods No 185 (88)

Patient and Treatment Characteristics Concurrent chemotherapy

This study was approved by all relevant institutional review Yes 89 (42)
boards. The University of Washington Quality of Life instru- No 122 (58)
ment (UW-QOL) is a brief, previously validated, self- Ethnicity
administered questionnaire that patients returning for fol- White, non-Hispanic 141 (67)
low-up after completion of RT for head and neck cancer have Black 21 (10)
routinely completed at our institution since 2007.4 The UW- Hispanic 21 (10)
QOL scores were retrospectively reviewed for 211 patients with Asian 20 (10)
squamous cell carcinoma of the head and neck who had at least Other 8 (4)
1 year of follow-up and were disease-free. Patients with a his- Smoking history
tory of mood or psychiatric disorder, use of mental health ser- Yes 148 (70)
vices in the past, or previous or current use of antidepres- No 63 (30)
sants or anxiolytics, excluding sleep medications, were Marital status
specifically excluded from this analysis.
Married 116 (55)
Patients had a Karnofsky Performance Status score of at
Divorced or widowed 59 (28)
least 70 at the time of initial treatment. Of the 211 patients, 122
Single 36 (17)
(58%) were male and 89 (42%) were female (median [range]
Living situation
age, 57 [21-93] years), and 116 (55%) were treated by definitive
Family 129 (61)
RT and 95 (45%) were treated postoperatively. Concurrent che-
Roommates 49 (23)
motherapy was administered with RT for 89 patients (42%).
Alone 33 (16)
Patient and disease characteristics are listed in Table 1.
Abbreviation: RT, radiation therapy.
Description of Screening Instruments
The UW-QOL (version 4) was administered at each follow-up regard to that domain, while a score of 100 indicates no disabil-
visit and was completed by the patient with the assistance of ity in that domain. With respect to mood, scores of 0, 25, 50, 75,
nursing and/or physician staff. The UW-QOL consists of 12 do- and 100 correspond to responses of mood being “extremely de-
mains pertaining to the degree of quality of life in the catego- pressed,” “somewhat depressed,” “neither in a good mood or
ries of pain, appearance, activity, recreation, swallowing, chew- depressed,” “generally good,” and “excellent,” respectively. The
ing, speech, shoulder function, taste, saliva, mood, and anxiety. psychometric properties of the UW-QOL are excellent accord-
A score of 0 indicates very poor or no functional capacity with ing to a recent review with good internal consistency.5

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 Cancer Survivors and Depression After Radiotherapy
Statistical Analysis
Descriptive statistics were calculated to provide information
about participants’ characteristics, prevalence of depression,
and association between variables. Patient characteristics were
summarized as frequencies and means. The trend of the scores
over time was evaluated though 3 time points: 1 year, 3 years,
and 5 years after RT. Analysis of variance (ANOVA) was per-
formed to quantify the statistical significance of these differ-
ences over time. To explore for associations between poten-
tial predictors of post-RT depression, the χ2 test and Spearman
correlation coefficient were used for nominal and measure-
ment variables, respectively. Mean levels of post-RT depres-
sion were compared according to demographic variables using
a paired t test. All tests were 2-sided, with an α level of .05 used
to determine statistical significance.
Results
The number of evaluable patients at the 1-, 3-, and 5-year fol-
low-up was 211, 120, and 54. The mean mood score 1, 3, and 5
years after RT was 52.0, 55.7, and 62.1, respectively. The pro-
portion of patients who reported their mood as “somewhat de-
pressed” and “extremely depressed” at 1 year after comple-
tion of RT was 12% and 5%, respectively. At 3 years, the
corresponding percentage of patients was 8% and 7%, respec-
tively. Of the 54 patients in whom data were available at 5 years,
the corresponding percentages were 9% and 4%, respec-
tively. No statistical differences were noted with respect to
mood score or the prevalence of depression over time (P = .42).
The Figure illustrates the mean mood scores of patients re-
turning for follow-up over time after completion of RT. The UW-
QOL also indicated that 30%, 24%, and 29% of all evaluable sub-
jects cited mood as 1 of the 3 most important factors
contributing to their quality of life within the previous 7 days
at the 1-, 3-, and 5-year follow-up, respectively. Among the pa-
tients reporting their mood as either “somewhat depressed”
or “extremely depressed” at the 1-, 3-, and 5-year follow-up,
the proportion using antidepressant medications at the time
was 6% (2 of 36), 11% (2 of 18), and 0% (0 of 7), respectively.
The corresponding proportion of patients actively undergo-
ing or seeking psychotherapy and/or formal outpatient coun-
seling was 3%, 6%, and 0%, respectively. When the analysis
was limited to patients reporting their mood as “extremely de-
pressed” at the 1-, 3-, and 5-year follow-up, the proportion using
antidepressant medications was 10% (1 of 10), 13% (1 of 8), and
0% (0 of 2), respectively, with none undergoing or seeking
counseling. No patient expressed suicidal ideation or re-
quired inpatient hospitalization because of their psychoso-
cial functioning. The proportion of patients reporting “excel-
lent” mood at the 1-, 3-, and 5-year follow-up was 14%, 9%, and
11%, respectively.
Table 2 outlines the incidence of depression (mood score
of ≤25) at 1 year according to various clinical, disease, treat-
ment, and demographic factors. Variables found to be signifi-
cantly associated with increased post-RT depression were the
presence of tracheostomy tube or laryngeal stoma (P = .01), gas-
trostomy tube dependence (P = .01), and continued tobacco use
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Original Investigation Research
Figure. University of Washington Quality of Life (UW-QOL) Mood Scores
100
80
UW-QOL Mood Score
60
40
20
0
0 1 2 3 4 5
Years
Mean mood scores as determined serially using the UW-QOL over time for
patients after completion of radiation therapy for head and neck cancer.
The depicted error bars represent 1 standard deviation.
at the time of follow-up (P < .001). The mean scores were 33.1
and 36.3 for patients actively smoking at 1 and 3 years after RT,
respectively, compared with mean scores of 57.6 and 60.0, re-
spectively, for nonsmoking patients (P < .001).
Discussion
The results of this cross-sectional analysis, representing one
of the few studies that have evaluated rates of depression
among long-term survivors of head and neck cancer, are note-
worthy in several ways. Foremost, they demonstrate that a rela-
tively high proportion of patients report depressive symp-
toms after completing RT despite having their cancer evidently
under control. Just as surprising, only a small minority of these
patients were using appropriate antidepressant medications
and/or actively undergoing or seeking psychiatric care. The fact
that none of these patients had a pre-existing diagnosis of men-
tal health problems suggests that the diagnosis of cancer and/or
sequelae of subsequent treatment were likely the primary
causes for their psychosocial symptoms. Indeed, we found that
the proportion of patients reporting mild or severe depres-
sion was 17%, 15%, and 13% at 1, 3, and 5 years, respectively,
after completion of RT. Others have similarly suggested rates
of depression ranging from 8% to 44% at various time points
after head and neck cancer treatment, with the wide range
likely due to the variability in screening instruments and pa-
tient characteristics across studies.6-8
The late toxic effects of RT to the head and neck have been
well described, with adverse effects potentially including dys-
phagia, xerostomia, taste loss, neck fibrosis, speech difficul-
ties, aspiration, and neuropathy. Although these have been
shown to occur at a relatively high rate after RT, the present
series is one of the first to suggest that these might contribute
to long-term emotional distress. Indeed, both tracheostomy
and gastrostomy tube dependence, which are physically vis-
ible and chronic reminders of the disruption of treatment on
887
 Research Original Investigation Cancer Survivors and Depression After Radiotherapy

This study is particularly important because the conse-

Table 2. Analysis of Potential Factors Predicting for Depression Among
Survivors of Head and Neck Cancer at 1 Year quences of untreated depression can be severe. Several re-
ports have demonstrated that the incidence of suicide in pa-
Extremely or Somewhat
Depressed, tients with cancer may be as much as 10 times higher than
Factor No./Total No. (%) P Value among the general population.12 From a therapeutic stand-
Age, y point, untreated depression has been demonstrated to affect
<57 15/102 (15) compliance to prescribed therapy, wound healing, appetite, and
.13
≥57 21/109 (19) contribute to prolonged hospital stays.13 The effects of depres-
Sex sion on such functions as sleep, energy, and motivation have
Male 19/122 (16) also been well described.14 By intensifying weight loss and fa-
.17
Female 17/89 (19) tigue, depression also has the potential to exacerbate treat-
T classification ment-related adverse effects leading to a vicious cycle that may
T0-2 18/112 (16) not only worsen depression and increase disability but also
.35
T3-4 18/99 (18) affect disease control. Compounding this predicament is the
RT technique fact that mental health services are severely underutilized
Intensity-modulated RT 23/134 (17) among patients with cancer. Consistent with our findings, Pa-
3-Dimensional conformal 13/77 (17) .47 sik et al15 reported that even though 36% of 1109 patients had
RT significant depression, less than 3% sought professional coun-
Chemotherapy seling.
Yes 14/89 (16) There are several limitations to this study. First, socioeco-
.51
No 22/122 (18) nomic differences including financial status and educational
RT modality level were not analyzed, which may be important because
Definitive 17/116 (15) Galea et al16 showed that the poverty and crime associated with
.10
Postoperative 19/95 (20) urban neighborhoods were associated with depression. Simi-
Neck dissection larly, it was impossible to precisely assess the strength of the
Yes 20/109 (18) patients’ social network, which may also contribute to psy-
.20
No 16/102 (16) chosocial functioning. We were also unable to account for medi-
Ethnicity cal comorbidities, as others have shown higher rates of de-
White 25/141 (18) pression in the patients with chronic illnesses such as heart
.34 failure, chronic obstructive pulmonary disease, and periph-
Nonwhite 11/70 (16)
Tracheostomy or stoma
eral vascular disease.17 In addition, the effect of head and neck
dependent surgery on a patient’s form and function can also be notable,
Yes 8/22 (36) despite the fact that we were unable to show a difference in
.01
No 29/189 (15) psychosocial functioning between patients treated by defini-
Gastrostomy tube dependent tive and postoperative RT. This is likely due to variability in
Yes 10/26 (38) the extent and nature of the surgical procedures performed.
.01
No 26/185 (14) For instance, total laryngectomy is associated with more psy-
Smoking history chosocial morbidity than tonsillectomy. In this sense, hetero-
Yes 24/148 (16) geneity with respect to disease sites, histologic subtype, and
.39 various other characteristics makes interpreting conclusions
No 12/63 (19)
Active smoking at follow-up difficult. Furthermore, it was uncertain what the contribu-
Yes 18/43 (42) tions of continued alcohol and/or illicit or prescription drug
<.001 use—behaviors that can certainly contribute to impaired psy-
No 18/168 (11)
chosocial functioning—were with respect to depression. Fi-
Marital status
nally, the lack of baseline depression assessment at diagnosis
Married 18/116 (16)
.55 makes it more difficult to draw definitive conclusions. While
Single, divorced, or 18/95 (19)
widowed others have shown that many patients with depression after
Living situation completion of RT were already symptomatic to varying de-
Family or roommates 29/178 (16) grees prior to beginning treatment, the fact that we excluded
.12
Alone 7/33 (21) patients without a previous diagnosis of depression makes it
more likely that it was the underlying diagnosis of cancer and
Abbreviation: RT, radiation therapy.
the subsequent treatment, which contributed most to psycho-
social distress.18
normal functioning, have been shown to affect self-esteem.9,10 It must be recognized that the UW-QOL was developed as
Gotay et al11 reported that fear of the unknown, ability to at- a screening tool and not for formal diagnosis. Notably, it suf-
tend family functions, the effect of illness on employment, the fers from the problems inherent in any self-reporting inven-
possibility of a terminal illness, and restrictions on activities tory in that scores can be exaggerated or minimized. While the
drive psychosocial functioning for patients with cancer. accuracy of these screening tools has been extensively vali-

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 Cancer Survivors and Depression After Radiotherapy Original Investigation Research

dated, they are largely meant to measure severity of symp-
toms rather than for making a diagnosis. We thus acknowl-
edge that the cutoffs used to determine “somewhat” and
“extreme” depression, for instance, may appear somewhat ar-
bitrary and that the limited number of patients in this study
did not allow us to perform a more detailed analysis of poten-
tial differences between these groups.
Although patients with scores consistent for moderate or
severe depression in the present study were generally re-
ferred for subsequent counseling and/or psychiatric care, the
compliance to such recommendations were extremely low, as
exemplified by the persistently low rates of antidepressant
medication use during the period patients were screened. The
reasons for this observation are multifactorial but include in-
surance or other financial barriers, absence of a primary care
physician, lack of patient interest, poor follow-through, and
the social stigma of mental illness. Thus, our results identify
a sorely unmet need for survivors of head and neck cancer in
that psychosocial services for this population are underuti-
lized and/or inaccessible despite a relatively significant rate of
depression. Clearly, additional studies with longer follow-up
are needed to recognize and assess the potential impact of de-
pression on patient quality of life, as well as to better define
the role of aggressive and timely intervention in the future.

ARTICLE INFORMATION
Submitted for Publication: March 28, 2013; final
revision received May 9, 2013; accepted June 24,
2013.
Published Online: August 15, 2013.
doi:10.1001/jamaoto.2013.4072.
Author Contributions: Dr Chen had full access to
all of the data in the study and takes responsibility
for the integrity of the data and the accuracy of the
data analysis.
Study concept and design: Chen, Luu.
Acquisition of data: Chen, Vazquez, Courquin,
Donald.
Analysis and interpretation of data: Chen, Daly,
Donald, Farwell.
Drafting of the manuscript: Chen, Vazquez,
Courquin.
Critical revision of the manuscript for important
intellectual content: Chen, Daly, Luu, Donald,
Farwell.
Statistical analysis: Chen.
Administrative, technical, or material support:
Vazquez, Luu.
Study supervision: Donald.
Conflict of Interest Disclosures: None reported.
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