Health Psychology © 2010 American Psychological Association

2010, Vol. 29, No. 1, 65–71 0278-6133/10/$12.00 DOI: 10.1037/a0017788

Health-Related Quality of Life in Head and Neck Cancer Survivors:

Impact of Pretreatment Depressive Symptoms

M. Bryant Howren and Alan J. Christensen Lucy Hynds Karnell and Gerry F. Funk
The University of Iowa and VA Iowa City Healthcare System University of Iowa Hospitals & Clinics

Objective: Symptoms of depression are common in those with cancer. The authors investigated whether
depressive symptoms assessed before the initiation of cancer treatment predicted diminished health-
related quality of life (HRQOL) at follow-up. Design: As part of a large, prospective study of oncologic
outcomes, 306 patients with head and neck cancer (HNC) were assessed on several clinical and
psychosocial characteristics during a pretreatment clinic visit and then at 3- and 12-month follow-up
appointments. Main Outcome Measures: Depressive symptomatology was assessed with the Beck
Depression Inventory and HNC-specific HRQOL (main outcome measure) was assessed with the Head
and Neck Cancer Inventory. Results: Controlling for age, gender, marital status, cancer site, stage of
disease, alcohol and tobacco use, comorbidity status, and pretreatment HRQOL, simultaneous multiple
regression analyses revealed that depressive symptoms present at study enrollment, before the initiation
of cancer treatment, significantly predicted lower HRQOL at 3- and 12-month follow-up assessments
across the 4 HNC-specific domains of speech, eating, aesthetics, and social disruption (all ps ⱕ .01).
Conclusion: Results suggest that depressive symptomatology present near the time of diagnosis can have
a significant, deleterious impact on HRQOL over time in HNC survivors. Thus, it may be useful to assess
depression at diagnosis to identify individuals at greater risk for poor HRQOL outcomes.

Keywords: head and neck cancer, depressive symptoms, health-related quality of life

Depressive symptoms are prevalent among cancer patients and
occur throughout the course of illness, often persisting months
beyond the conclusion of treatment in cancer survivors (e.g.,
Karnell, Funk, Christensen, Rosenthal, & Magnuson, 2006; Pirl,
2004). Depression occurs at a significantly higher rate in those
with cancer, compared with its occurrence in the general popula-
tion (Spiegel & Giese-Davis, 2003). Median point prevalence rates
have been reported to range from 22% to 29%, dependent upon the
type of cancer and whether depression is defined categorically or
symptomatically (Hotopf, Chidgey, Addington-Hall, & Ly, 2002;
McDaniel, Musselman, Porter, Reed, & Nemeroff, 1995). In ad-
M. Bryant Howren and Alan J. Christensen, Department of Psychology,
The University of Iowa, and the Center for Research in the Implementation
of Innovative Strategies in Practice, Iowa City Veterans Affairs (VA)
Medical Center; Lucy Hynds Karnell and Gerry F. Funk, Department of
Otolaryngology—Head and Neck Surgery, University of Iowa Hospitals
and Clinics.
This project was supported in part by National Institutes of Health Grant
R01 CA106908 through the Office of Cancer Survivorship. This project
was also supported in part by an Agency for Healthcare Research and
Quality Centers for Education and Research on Therapeutics cooperative
agreement (5U18HSO16094). The views expressed in this article are those
of the authors and do not necessarily represent the views of the Department
of Veterans Affairs.
A portion of the information contained in this article was presented at
the 30th Annual Meeting and Scientific Sessions of the Society of Behav-
ioral Medicine in Montreal, Quebec, Canada.
Correspondence concerning this article should be addressed to M.
Bryant Howren, Department of Psychology, The University of Iowa, 11
Seashore Hall East, Iowa City, IA 52242. E-mail: matthew-howren@
uiowa.edu
dition, depression is underrecognized and undertreated by practi-
tioners, in part because depressed mood is viewed as a natural
reaction not only to the diagnosis but also to the pain and fatigue
associated with the course of disease and its treatment (Massie,
2004; Passik, Dugan, McDonald, Rosenfeld, Theobald, & Edger-
ton, 1998). Further complicating matters, patients are often reluc-
tant to report symptoms of emotional distress unless first asked,
fearing embarrassment and stigmatization (Passik et al., 1998).
Although depression in some form is relatively common in
those with cancer, many cancer patients do not develop major
depression (McDaniel et al., 1995; Raison & Miller, 2003). It has
been reported that as many as one third of cancer patients report
mild or moderate symptoms of depression (McDaniel et al., 1995),
yet the detrimental effects of such symptoms remain debated
(Coyne, Benazon, Gaba, Calzone, & Weber, 2000).
Depression and Health-Related Quality of Life
(HRQOL)
Historically, the success of cancer treatment has largely been
measured in terms of survival, whereas the impact of treatment on
the individual’s quality of life has been less emphasized (Hassan &
Weymuller, 1993; Otto, Dobie, Lawrence, & Sakai, 1997). Con-
sequently, previous research has focused heavily on cancer mor-
tality in the context of depression (cf. Irwin, 2007). However, there
is much evidence suggesting that depression in patients with
cancer is related to adherence problems, increased hospital stays,
deficits in self-care, lack of social support, poor health habits (e.g.,
excessive use of alcohol and/or tobacco), and (thus) poor overall
quality of life (DiMatteo, Lepper, & Croghan, 2000; Duffy, Ter-
rell, Valenstein, Ronis, Copeland, & Connors, 2002; Koenig,

65
66 HOWREN, CHRISTENSEN, KARNELL, AND FUNK
Cohen, Blazer, Meador, & Westlund, 1992; Koenig, Shelp, Goli,
Cohen, & Blazer, 1989; Neuling & Winefield, 1988; Pelletier,
Verhoef, Khatri, & Hagen, 2002; Pirl & Roth, 1999; Stoudemire &
Thompson, 1983).
Oncology research has increasingly focused on patients’
HRQOL, which has been defined as the degree to which physical
dysfunction, pain, and related distress limit or disrupt one’s daily
behaviors, social activities, and psychological well-being (Lawton,
2001). This is primarily due to growing recognition that patient
survival is a wholly insufficient indicator of patient outcome
(Babin, Sigston, Hitier, Dehesdin, Marie, & Choussy, 2008; Ham-
merlid et al., 1997; Morton, 1995; Stewart, Chen, & Stach, 1998;
Weymuller, Yueh, Deleviannis, Kuntz, Alsarraf, & Coltrera,
2000). Both patient-related (e.g., age, gender, functional and psy-
chological status) and disease-related (e.g., site, stage, and treat-
ment) factors have been studied as predictors or correlates of
HRQOL. Less is known, however, about the ways in which de-
pressive symptomatology may affect HRQOL in cancer survivors
over time.
Head and Neck Cancer (HNC), Depression,
and HRQOL
Depression is highly associated with HNC. The percentage of
patients experiencing mild to severe levels of depressive symp-
toms ranges from 16% to 44% (Karnell et al., 2006). Additionally,
HNC and its treatment have an enormous, deleterious impact on
HRQOL. Disruptions of essential daily functions are widespread in
survivors of this disease, such as deficits in eating and speech that
often undermine patient functioning as well as contribute to dis-
ruptions of family and other social activities (Breitbart & Holland,
1988; List, Ritter-Sterr, & Lansky, 1990).
Studies assessing the trajectory of HRQOL in survivors of HNC
suggest that, overall, HRQOL is lowest during treatment, and a
short time after (because of treatment-related sequelae), before
gradually improving and eventually returning to (near) baseline
levels approximately 12 months after diagnosis (Hammerlid,
Silander, Hörnestam, & Sullivan, 2001). However, there are clear
individual differences in this trajectory, as some survivors improve
rapidly after treatment, whereas others remain substantially im-
paired in various HRQOL domains (e.g., de Graeff, de Leeuw,
Ros, Hordijk, Blijham, & Winnubst, 2000a, 2000b; Gritz et al.,
1999; Ronis, Duffy, Fowler, Khan, & Terrell, 2008).
The goal of the present study was to investigate the extent to
which symptoms of depression assessed near the time of diagnosis,
before treatment, explain individual differences in HRQOL at
specific time points over this trajectory in survivors of HNC.
Previous work has suggested that even mild depressive symptoms
may negatively affect global and HNC-specific HRQOL out-
comes, including general health perceptions, physical and social
functioning, pain, and eating (e.g., de Graeff et al., 2000a, 2000b;
Hammerlid et al., 2001; Karnell et al., 2006; Ronis et al., 2008).
However, little prospective research has specifically examined the
potential impact of pretreatment depressive symptoms on HNC-
specific HRQOL in this population over a moderately long
follow-up period (Llewellyn, McGurk, & Weinman, 2005).
With a prospective longitudinal design, we describe the effect of
pretreatment depressive symptomatology (measured near the time
of diagnosis before the initiation of oncologic treatment) on HNC-
specific HRQOL outcomes at two specific follow-up time points
(i.e., 3 and 12 months) in a large cohort of HNC survivors. These
two follow-up assessment periods were selected a priori, given the
expectation that most HNC patients report their lowest HRQOL
around 3 months postdiagnosis (because of short-term treatment-
related sequelae), whereas by 12 months their HRQOL has stabi-
lized at a level approximating their pretreatment values (Hammer-
lid et al., 2001).
It was hypothesized that higher levels of pretreatment depres-
sive symptoms would serve as a risk factor for diminished
HRQOL at both follow-up points. That is, the “recovery of func-
tion” typically seen in HNC survivors 1 year after diagnosis was
expected to be significantly and negatively affected by the level of
pretreatment depressive symptoms. Specifically, we expected that
elevated levels of pretreatment depressive symptoms would be
associated with decrements in pretreatment-adjusted HRQOL up
to 12 months later, relative to survivors with lower baseline de-
pressive symptoms, after controlling for relevant clinical and de-
mographic factors.
Method
Participants and Procedure
Participants were 18 years old and older with upper aerodiges-
tive tract carcinomas from the Department of Otolaryngology’s
head and neck oncology clinic at the University of Iowa Hospitals
and Clinics (UIHC). These patients are enrolled in the Outcomes
Assessment Project (OAP), an ongoing longitudinal study of on-
cologic treatment outcomes in HNC. The OAP parent study suc-
cessfully accrued 72.9% of all eligible patients with HNC seen at
the UIHC from November 1998 through November 2006, the
period including the sample of patients described later (N ⫽ 355).
Information regarding patients’ site and stage of cancer, comor-
bidities, treatment, survival outcome, demographics, and other
clinical and psychosocial characteristics are collected as part of the
OAP. All study procedures were approved by the institutional
review board.
Patients were approached during an initial clinic visit and asked
if they would be interested in participating in a longitudinal study
of cancer-related outcomes. Upon consent, patients were assessed
on several clinical and psychosocial characteristics near the time of
diagnosis (before the initiation of oncologic treatment) and then at
3-, 6-, 9-, and 12-month follow-up appointments. Information
regarding cancer site and stage was abstracted from medical charts.
As noted, 3- and 12-month follow-up assessments were chosen a
priori because previous research has demonstrated that HRQOL is
lowest during or shortly after treatment (near the 3-month
follow-up period) before gradually improving and, in many pa-
tients, approaching baseline by 12 months postdiagnosis (Ham-
merlid et al., 2001).
Forty-nine of 355 patients (13.8%) completed only baseline—
but not follow-up—assessments and thus were excluded. The final
sample comprised the remaining 306 patients, of whom 259
(84.6%) completed at least three assessments. Comparisons re-
vealed no differences between those patients with and those with-
out follow-up data in terms of age, site or stage of disease,
treatment, alcohol/tobacco use, comorbidity status, baseline de-
pressive symptomatology, or baseline HRQOL scores ( ps ⬎ .25).
 IMPACT OF DEPRESSIVE SYMPTOMS ON HRQOL IN CANCER
Measures
Beck Depression Inventory (BDI; Beck, Rush, Shaw, &
Emery, 1979). Depressive symptomatology was assessed with
the BDI. The BDI is an extensively validated, widely used self-
report measure of depression consisting of 21 items, each assessing
a unique category of depressive symptoms (Beck, Steer, & Garbin,
1988). The BDI has been used in both nonclinical and clinical
samples, including those with HNC (e.g., Katz, Kopek, Waldron,
Devins, & Tomlinson, 2004).
Additionally, two separate scores may be calculated: one rep-
resenting the cognitive–affective symptoms of depression (Items
1–14) and another representing the somatic symptoms often asso-
ciated with depression (e.g., fatigue, appetite loss, and insomnia;
Items 15–21; Beck et al., 1988). Because the latter may reflect
extant physical disease instead of depression in chronic illness
populations, we repeated our analyses using BDI scores comprised
of only the nonsomatic (cognitive–affective) subset of items.
Head and Neck Cancer Inventory (HNCI; Funk, Karnell,
Christensen, Moran, & Ricks, 2003). The HNCI is a 30-item,
self-report survey assessing HNC-specific HRQOL outcomes in-
cluding speech, eating, aesthetics, and social disruption. It captures
both functional (i.e., how well the patient is functioning) and
attitudinal (i.e., the patient’s satisfaction with level of function)
aspects with a 5-point scale. In addition, the HNCI contains one
item addressing overall quality of life. Scores transformed into a
scale ranging from 0 to 100 may be classified into low (0 –30),
intermediate (31– 69), and high (70 –100) functioning (Funk, Kar-
nell, Smith, & Christensen, 2004). Patients with scores in the high
category have relatively normal functioning, and those in the
intermediate and low ranges have abnormal or severely compro-
mised functioning, respectively. Good reliability and validity have
also been demonstrated (Funk et al., 2003).
Data analysis and assessment of key variables. We used
simultaneous, or forced entry, multiple regression to evaluate the
effect of pretreatment depressive symptomatology on each of the
HNC-specific HRQOL domains at 3- and 12-month follow-up
assessments while adjusting for covariates and pretreatment
HRQOL values. Depressive symptomatology was treated as a
continuous variable in regression analyses. Covariates were as
follows: age, gender, marital status, cancer site, stage of disease,
alcohol and tobacco use, and physical comorbidities.
Cancer site was classified as one of the following: oral cavity,
pharynx, or larynx. Stage of disease was coded to reflect one of
four possible stages (i.e., Stages I–IV), with higher numbers indi-
cating more extensive disease.1 Alcohol and tobacco use were
categorized as current, previous, or never. Physical comorbidities
were measured with the Adult Comorbidity Evaluation-27 (Bang,
Piccirillo, Littenberg, & Johnston, 2000), an index developed and
validated specifically for adult cancer patients. Medical record
information is used to code comorbidity on a scale ranging from 0
(no comorbidities) to 3 (severe comorbidities), with 1 and 2
representing mild and moderate comorbidities, respectively.
SPSS’s linear trend at point method, a regression imputation
procedure, was used to impute HRQOL values for those patients
who did not complete the 12-month follow-up assessment.2 This
procedure replaces missing values using the entire set of reported
values which, in this case, includes data collected before treatment
67
and then at 3-, 6-, and 9-month follow-up appointments. Missing
values are replaced with their predicted values.
Results
Description of the Sample
Demographic and clinical characteristics are presented in Table 1.
Similar to national epidemiological data published on individuals
with HNC (see Cooper et al., 2009), the majority of patients in the
present sample (N ⫽ 306) were male (62.7%), with a mean age of
60.0 years (SD ⫽ 12.5, range ⫽ 25–93). The distribution of cancer
site is also similar to that reported elsewhere (see American Cancer
Society, 2009) and, consistent with behavioral patterns typically
observed in HNC patients (Schnoll & Lerman, 2003), most had
either previously used or currently were using alcohol and/or
tobacco products (76.4% and 74.5%, respectively). However, the
present sample was more ethnically homogenous (95.6% Cauca-
sian) and presented with a somewhat more advanced stage of
disease (i.e., 58.2% at Stage III or IV) than is generally reported
for this population.
At baseline, the average BDI score was 8.14 (SD ⫽ 6.60;
range ⫽ 0 – 46). Of note, this value is comparable with levels
reported in other samples of HNC patients (e.g., D’Antonio et al.,
1998; Katz et al., 2004). Additionally, the number of patients
falling within the range indicative of mild depressive symptoms
(i.e., 10 –18; Beck, Steer, & Garbin) was 81 (26.5%). At the
3-month follow-up, the average BDI score increased slightly to
9.51 (SD ⫽ 7.13; range ⫽ 0 – 40), and at the 12-month follow-up,
the average BDI score was 7.96 (SD ⫽ 7.51; range ⫽ 0 – 42). The
total percentage of patients falling within the ranges indicative of
moderate (19 –29) and severe (30 – 63) depressive symptoms was
less than 10% across all three time points.
Mean HRQOL levels for each domain across the three time
points are presented in Table 2. Overall, these values follow the
same general pattern previously described (Hammerlid et al.,
2001), with levels being lowest in the weeks nearest the conclusion
of treatment followed by a gradual improvement evident by 12
months postenrollment.
Primary Analyses
Three-month follow-up. Simultaneous multiple regression
analyses demonstrated that, at the 3-month follow-up, both disease
stage (␤ ⫽ ⫺0.164, p ⬍ .01, sr2 ⫽ .025) and, as predicted,
symptoms of depression (␤ ⫽ ⫺0.163, p ⬍ .01, sr2 ⫽ .022) were
significantly associated with poorer pretreatment-adjusted speech
domain scores. Similar results were obtained for the eating domain
as well (see Table 3). Disease stage (␤ ⫽ ⫺0.108, p ⬍ .05, sr2 ⫽
.011), depressive symptoms (␤ ⫽ ⫺0.193, p ⬍ .001, sr2 ⫽ .033),
and physical comorbidities (␤ ⫽ ⫺0.133, p ⬍ .05, sr2 ⫽ .016) all
predicted lower aesthetics domain scores at 3 months. Finally,
disease stage (␤ ⫽ ⫺0.153, p ⬍ .01, sr2 ⫽ .022), depressive
symptoms (␤ ⫽ ⫺0.227, p ⬍ .001, sr2 ⫽ .034), and age (␤ ⫽
1
For illustrative purposes, “combined” stages are reported in Table 1.
2
SPSS for Windows (Version 15.0) was used to analyze the data (SPSS,
2006).
68 HOWREN, CHRISTENSEN, KARNELL, AND FUNK

⫺0.107, p ⬍ .05, sr2 ⫽ .010) predicted lower scores on the social Table 2
disruption domain at the 3-month follow-up. Mean HNCI Domain Scores Across Time
Twelve-month follow-up. For all four HNC-specific HRQOL
domains at the 12-month follow-up, both stage of disease and HNCI domain/time point M SD
depressive symptoms also significantly predicted lower Speech
pretreatment-adjusted HRQOL scores.3 Specifically, disease stage Pretreatment 75.33a 23.31
(␤ ⫽ ⫺0.207, p ⬍ .001, sr2 ⫽ .040) and depressive symptoms 3 Months 62.28b 21.72
(␤ ⫽ ⫺0.177, p ⬍ .001, sr2 ⫽ .026) uniquely predicted speech 12 Months 70.28c 20.19
Eating
domain scores; similar results were obtained for the aesthetics
Pretreatment 70.89a 24.19
domain (disease stage: ␤ ⫽ ⫺0.153, p ⬍ .01, sr2 ⫽ .022; depres- 3 Months 46.99b 22.60
sive symptoms: ␤ ⫽ ⫺0.165, p ⬍ .01, sr2 ⫽ .024) and the social 12 Months 56.41c 23.19
disruption domain (disease stage: ␤ ⫽ ⫺0.166, p ⬍ .01, sr2 ⫽ Aesthetics
.026; depressive symptoms: ␤ ⫽ ⫺0.309, p ⬍ .001, sr2 ⫽ .063). Pretreatment 88.10a 21.49
3 Months 72.13b 24.20
Finally, disease stage (␤ ⫽ ⫺0.227, p ⬍ .001, sr2 ⫽ .046), 12 Months 76.44c 24.00
depressive symptoms (␤ ⫽ ⫺0.281, p ⬍ .001, sr2 ⫽ .068), and site Social disruption
(oral cavity; ␤ ⫽ 0.117, p ⬍ .05, sr2 ⫽ .013) predicted lower Pretreatment 82.10a 18.82
eating domain scores. 3 Months 69.78b 20.86
12 Months 80.45a 18.35
Global HRQOL. As described, the HNCI also contains one
item assessing overall quality of life. Such items have demon- Note. HNCI ⫽ Head and Neck Cancer Inventory. Higher scores reflect
strated substantial utility in predicting morbidity and mortality greater functioning on each domain. Means not sharing a subscript within
(e.g., Idler & Benyamini, 1997). Regression analyses, adjusting for each domain are significantly different from one another at p ⬍ .01.

the covariates described above, demonstrated that pretreatment

Table 1 depressive symptoms significantly predicted pretreatment-adjusted
Patient Characteristics (N ⫽ 306) global HRQOL at both 3-month (␤ ⫽ ⫺0.210, p ⬍ .001, sr2 ⫽
.033) and 12-month (␤ ⫽ ⫺0.329, p ⬍ .001, sr2 ⫽ .081) follow-up
Characteristic n % M SD
assessments.
Gender Pretreatment-adjusted mean HRQOL. The pretreatment-
Male 192 62.7 adjusted mean HRQOL values at 3- and 12-month follow-up
Female 114 37.3 assessments as a function of BDI score (divided into tertiles) are
Marital status
Married 193 63.1 presented in Table 4. These results demonstrate that HNC-specific
Never married 21 6.9 HRQOL scores were lowest (worst) for patients whose BDI scores
Disrupted marriagea 75 16.5 were in the highest tertile, corresponding to a score of 10 or above
Unknown/not reported 17 5.6 on the BDI (indicating, at least, possible mild depression; Kendall,
Site
Oral cavity 118 38.6
Hollon, Beck, Hammen, & Ingram, 1987).
Pharynx 88 28.8
Larynx 60 19.6 Discussion
Other/unknown 40 13.0
Stage of disease The present findings suggest that the presence of depressive
Early (I–II) 105 34.3 symptoms before the initiation of oncologic treatment is related to
Advanced (III–IV) 178 58.2
Not “stageable”/unknown 23 7.5
a range of HRQOL outcomes in HNC survivors. Specifically,
Treatment pretreatment depression scores predicted poorer pretreatment-
Surgery only 115 37.6 adjusted HRQOL at 3- and 12-month follow-up assessments in the
Radiotherapy only 35 11.4 HNC-specific domains of speech, eating, aesthetics, and social
Combination 146 47.7 disruption after controlling for several covariates, including stage
Other/unknown 10 3.3
Alcohol use of disease. Given the strong negative association between disease
Current 128 41.8 stage and HRQOL in HNC patients (e.g., de Graeff et al., 2000a,
Previous 106 34.6 2000b; Hammerlid, Mercke, Sullivan, & Westin, 1998; Hammer-
Never 72 23.5 lid et al., 2001), the fact that self-reported depressive symptom-
Tobacco use
Current 91 29.7
atology is a unique, independent predictor of these outcomes is
Previous 137 44.8 notable.
Never 78 25.4 Previous research has debated the need to screen for symptoms
Age 60.0 12.5 of depression in medical populations (e.g., Coyne et al., 2000;
BDI total score Coyne, Thompson, Palmer, Kagee, & Maunsell, 2000). The
Pretreatment 8.14 6.60
3 Months 9.51 7.13
12 Months 7.96 7.51 3
The primary analyses for both time points were repeated with only the
Note. BDI ⫽ Beck Depression Inventory. nonsomatic items of the BDI. Without exception, these results mirrored
a
Separated, divorced, or widowed. those with the total BDI score.
 IMPACT OF DEPRESSIVE SYMPTOMS ON HRQOL IN CANCER 69

Table 3 living and tend to improve markedly over the first year after
Summary of Simultaneous Multiple Regression Analyses treatment in long-term survivors (e.g., Goldstein, Karnell, Chris-
tensen, & Funk, 2007; Hammerlid et al., 2001). The present
HNCI domain/predictora R2 ␤b sr2 results, however, demonstrate that this trajectory may be nega-
Speech (3 months) .211ⴱⴱⴱ tively affected by the presence of relatively mild pretreatment
BDI ⫺.163ⴱⴱ .022 depressive symptoms in some individuals.
Stage of disease ⫺.164ⴱⴱ .025 Overall, HRQOL in this sample improved over time in a similar
Speech (12 months) .273ⴱⴱⴱ fashion to that reported by others (e.g., Hammerlid et al., 2001).
BDI ⫺.177ⴱⴱⴱ .026
Stage of disease ⫺.207ⴱⴱⴱ .040 However, pretreatment-adjusted HRQOL values for patients expe-
Eating (3 months) .224ⴱⴱⴱ riencing mild to moderate symptoms of depression were lower
BDI ⫺.290ⴱⴱⴱ .072 (worse) than the scores for patients with fewer depressive symp-
Stage of disease ⫺.222ⴱⴱⴱ .044 toms. Specifically, by the 12-month follow-up, patients scoring 10
ⴱⴱⴱ
Eating (12 months) .323
BDI ⫺.281ⴱⴱⴱ .068 or above on the BDI (pretreatment) failed to reach a level of high
Stage of disease ⫺.227ⴱⴱⴱ .046 functioning (i.e., relatively normal) as defined by a score of 70 or
Site (oral cavity) .117ⴱ .013 higher on the HNCI across all four HRQOL domains. These results
Aesthetics (3 months) .147ⴱⴱⴱ are noteworthy, given that a score of at least 10 on the BDI
BDI ⫺.193ⴱⴱⴱ .033
Stage of disease ⫺.108ⴱ .011 indicates possible mild depression (Kendall et al., 1987). In com-
Physical comorbidities ⫺.133ⴱ .016 parison, those patients falling below this threshold on the BDI
Aesthetics (12 months) .125ⴱⴱⴱ failed to reach a level of high functioning in only one of four
BDI ⫺.165ⴱⴱ .024 HRQOL domains (i.e., eating; see Table 4). Thus, even mild
Stage of disease ⫺.153ⴱⴱ .022
Social disruption (3 months) .211ⴱⴱⴱ symptoms of depression near the time of diagnosis appear to have
BDI ⫺.227ⴱⴱⴱ .034 a meaningful impact on these outcomes beyond the conclusion of
Stage of disease ⫺.153ⴱⴱ .022 treatment.
Age ⫺.107ⴱ .010 Strengths of the present research include a large sample, pro-
Social disruption (12 months) .259ⴱⴱⴱ
BDI ⫺.309ⴱⴱⴱ .063 spective design, a well-validated assessment of HNC-specific
Stage of disease ⫺.166ⴱⴱ .026 HRQOL domains, and a high accrual rate of eligible patients seen
at the UIHC since 1998 (i.e., 72.9%). Several important limitations
Note. HNCI ⫽ Head and Neck Cancer Inventory. BDI ⫽ Beck Depres- are also present. First, the data presented here are strictly correla-
sion Inventory.
a
Only significant predictors shown. b Standardized regression coefficient.
tional, preventing us from discerning a clear causal association
ⴱ
p ⱕ .05. ⴱⴱ p ⱕ .01. ⴱⴱⴱ p ⱕ .001. between symptoms of depression and diminished HRQOL. Addi-
tionally, the ethnic homogeneity of the sample (greater than 95%
Caucasian) limits our ability to generalize to ethnic minorities.
present results suggest that, in this patient population, even rela- Evidence indicates that, compared with Caucasian patients, Afri-
tively mild depressive symptoms present near diagnosis may war- can American patients generally present with a more advanced
rant attention because of the adverse effects that they appear to stage of disease and have lower survival rates (Nichols & Bhatta-
have on HNC-specific HRQOL outcomes in survivors. As noted, charyya, 2007). Thus, it is possible that other clinical and psycho-
functions such as eating and speech are essential to (healthy) daily social variables, in addition to depressive symptomatology, may

Table 4
Pretreatment-Adjusted Mean HRQOL Values at 3- and 12-Month Follow-Up Assessments as a
Function of Pretreatment BDI Total Score

Mean pretreatment BDI score (and SE)

HNCI domain/time point 0–4 (n ⫽ 100) 5–9 (n ⫽ 106) 10⫹ (n ⫽ 100)

Speech
3 Months 70.74 (1.91) 60.31 (1.86) 55.91 (2.02)
12 Months 77.05 (1.74) 71.10 (1.68) 62.64 (1.95)
Eating
3 Months 55.64 (2.21) 47.98 (2.11) 37.28 (1.90)
12 Months 65.40 (2.02) 60.48 (2.07) 43.12 (1.83)
Aesthetics
3 Months 78.38 (2.14) 74.71 (1.97) 63.14 (2.61)
12 Months 81.54 (2.43) 80.66 (1.82) 66.81 (2.52)
Social disruption
3 Months 77.72 (1.81) 70.49 (1.91) 61.10 (1.96)
12 Months 88.97 (1.32) 83.77 (1.43) 68.41 (1.89)

Note. All values were adjusted for the respective pretreatment health-related quality of life (HRQOL) value.
BDI ⫽ Beck Depression Inventory; HNCI ⫽ Head and Neck Cancer Inventory.
70 HOWREN, CHRISTENSEN, KARNELL, AND FUNK
differentially affect HRQOL in these individuals. Finally, we did
not have access to information indicating whether patients were
receiving or had received mental health services, formal psycho-
logical intervention, or structured psychosocial support. Thus, we
are unable to determine whether the pattern of results observed are,
in part, due to differences in receipt of mental health or support
services.
In conclusion, these results are consistent with a growing body
of literature suggesting that depressive symptoms, present around
the time of diagnosis, negatively affect HRQOL over time in HNC
survivors after adjustment for pretreatment HRQOL levels, disease
severity, and other relevant clinical and demographic characteris-
tics. These findings support the value of screening for depression
in patients with HNC. Given that several self-report measures
(e.g., the BDI) are inexpensive, are quick and easy to administer,
do not require a trained interviewer, and may be completed while
the patient is waiting to see the physician, such screening tools
may have significant clinical utility. A range of psychosocial
interventions have proven successful in reducing depression—
including subclinical depression—and related distress (Meyer &
Mark, 1995; Osborn, Demoncada, & Feuerstein, 2006; Ross,
Boesen, Dalton, & Johansen, 2002; Spiegel & Giese-Davis, 2003).
Therefore, screening for depressive symptom levels might be
readily (and usefully) incorporated into the risk stratification of
HNC survivors, including the identification of patients who may
benefit from ongoing psychosocial support, to substantively im-
prove HRQOL.
References
American Cancer Society. (2009). Cancer facts and figures 2009. Atlanta,
GA: Author.
Babin, W., Sigston, E., Hitier, M., Dehesdin, D., Marie, J. P., & Choussy,
O. (2008). Quality of life in head and neck cancer patients: Predictive
factors, function and psychosocial outcome. European Archives of Oto-
rhinolaryngology, 265, 265–270.
Bang, D., Piccirillo, J. F., Littenberg, B., & Johnston, A. (2000, May 20).
The Adult Comorbidity Evaluation-27 (ACE-27) test: A new comorbidity
index for patients with cancer. Presented at the annual meeting of the
American Society of Clinical Oncology, New Orleans, LA.
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive
therapy of depression. New York: Guilford Press.
Beck, A. T., Steer, R., & Garbin, M. (1988). Psychometric properties of the
Beck Depression Inventory: Twenty-five years of evaluation. Clinical
Psychology Review, 8, 77–100.
Breitbart, W., & Holland, J. (1988). Psychosocial aspects of head and neck
cancer. Seminars in Oncology, 15, 61– 69.
Cooper, J. S., Porter, K., Mallin, K., Hoffman, H. T., Weber, R. S., Ang,
K. K., Gay, E. G., et al. (2009). National Cancer Database report on
cancer of the head and neck: 10-year update. Head & Neck, 31, 748 –
758.
Coyne, J. C., Benazon, N. R., Gaba, C. G., Calzone, K., & Weber, B. L.
(2000). Distress and psychiatric morbidity among women from high-risk
breast and ovarian cancer families. Journal of Consulting and Clinical
Psychology, 68, 864 – 874.
Coyne, J. C., Thompson, R., Palmer, S. C., Kagee, A., & Maunsell, E.
(2000). Should we screen for depression? Caveats and potential pitfalls.
Applied & Preventive Psychology, 9, 101–121.
de Graeff, A., de Leeuw, J. R. J., Ros, W. J. G., Hordijk, G. J., Blijham,
G. H., & Winnubst, J. A. M. (2000a). Long-term quality of life of
patients with head and neck cancer. The Laryngoscope, 110, 98 –106.
de Graeff, A., de Leeuw, J. R. J., Ros, W. J. G., Hordijk, G. J., Blijham,
G. H., & Winnubst, J. A. M. (2000b). Pretreatment factors predicting
quality of life after treatment for head and neck cancer. Head & Neck,
22, 398 – 407.
DiMatteo, M. R., Lepper, H. S., & Croghan, T. W. (2000). Depression is
a risk factor for noncompliance with medical treatment: Meta-analysis of
the effects of anxiety and depression on patient adherence. Archives of
Internal Medicine, 160, 2101–2107.
D’Antonio, L. L., Long, S. A., Zimmerman, G. J., Peterman, A. H., Petti,
G. H., & Chonkich, G. D. (1998). Relationship between quality of life
and depression in patients with head and neck cancer. Laryngoscope,
108, 806 – 811.
Duffy, S. A., Terrell, J. E., Valenstein, M., Ronis, D. L., Copeland, L. A.,
& Connors, M. (2002). Effect of smoking, alcohol, and depression on the
quality of life of head and neck cancer patients. General Hospital
Psychiatry, 24, 140 –147.
Funk, G. F., Karnell, L. H., Christensen, A. J., Moran, P. J., & Ricks, J.
(2003). Comprehensive head and neck oncology health status assess-
ment. Head & Neck, 25, 561–575.
Funk, G. F., Karnell, L. H., Smith, R. B., & Christensen, A. J. (2004).
Clinical significance of health status assessment measures in head and
neck cancer. What do quality-of-life scores mean? Archives of Otolar-
yngology—Head & Neck Surgery, 130, 825– 829.
Goldstein, D. P., Karnell, L. H., Christensen, A. J., & Funk, G. F. (2007).
Health-related quality of life profiles based on survivorship status for
head and neck cancer patients. Head & Neck, 29, 221–229.
Gritz, E. R., Carmack, C. L., de Moor, C., Coscarelli, A., Schacherer,
C. W., Meyers, E. G., & Abemayor, E. (1999). First year after head and
neck cancer: Quality of life. Journal of Clinical Oncology, 17, 352–360.
Hammerlid, E., Bjordal, K., Ahlner-Elmqvist, M., Jannert, M., Kaasa, S.,
Sullivan, M., & Westin, T. (1997). Prospective, longitudinal quality-of-
life study of patients with head and neck cancer: A feasibility study
including the EORTC QLQ-C30. Otolaryngology & Head & Neck
Surgery, 116, 666 – 673.
Hammerlid, E., Mercke, C., Sullivan, M., & Westin, T. (1998). A prospec-
tive quality of life study of patients with laryngeal carcinoma by tumor
stage and different radiation therapy schedules. The Laryngoscope, 108,
747–759.
Hammerlid, E., Silander, E., Hörnestam, L., & Sullivan, M. (2001). Health-
related quality of life three years after diagnosis of head and neck
cancer—A longitudinal study. Head & Neck, 23, 113–125.
Hassan, S. J., & Weymuller, E. A. (1993). Assessment of quality of life in
head and neck cancer patients. Head & Neck, 15, 485– 496.
Hotopf, M., Chidgey, J., Addington-Hall, J., & Ly, K. L. (2002). Depres-
sion in advanced disease: A systematic review, Part 1. Prevalence and
case finding. Palliative Medicine, 16, 81–97.
Idler, E. L., & Benyamini, Y. (1997). Self-rated health and mortality: A
review of twenty- seven community studies. Journal of Health and
Social Behavior, 38, 21–37.
Irwin, M. R. (2007). Depression and risk of cancer progression: An elusive
link. Journal of Clinical Oncology, 25, 2343–2344.
Karnell, L. H., Funk, G. F., Christensen, A. J., Rosenthal, E. L., &
Magnson, S. M. (2006). Persistent posttreatment depressive symptoms
in patients with head and neck cancer. Head & Neck, 28, 453– 461.
Katz, M. R., Kopek, N., Waldron, J., Devins, G. M., & Tomlinson, G.
(2004). Screening for depression in head and neck cancer. Psycho-
oncology, 13, 269 –280.
Kendall, P. C., Hollon, S. D., Beck, A. T., Hammen, C. L., & Ingram, R. E.
(1987). Issues and recommendations regarding the use of the Beck
Depression Inventory. Cognitive Therapy and Research, 11, 289 –299.
Koenig, H. G., Cohen, H. J., Blazer, D. G., Meador, K. G., & Westlund, R.
(1992). A brief depression scale for use in the medically ill. Interna-
tional Journal of Psychiatry in Medicine, 22, 183–195.
Koenig, H. G., Shelp, F., Goli, V., Cohen, H. J., & Blazer, D. G. (1989).
 IMPACT OF DEPRESSIVE SYMPTOMS ON HRQOL IN CANCER
Survival and health care utilization in elderly medical inpatients with major
depression. Journal of the American Geriatrics Society, 37, 599 – 606.
Lawton, M. P. (2001). Quality of life and end of life. In J. E. Birren &
K. W. Schaie (Eds.), Handbook of the psychology of aging (5th ed., pp.
593– 616). San Diego, CA: Academic Press.
List, M. A., Ritter-Sterr, C., & Lansky, S. B. (1990). A performance status
scale for head and neck cancer patients. Cancer, 66, 564 –569.
Llewellyn, C. D., McGurk, M., & Weinman, J. (2005). Are psycho-social
and behavioural factors related to health related-quality of life in patients
with head and neck cancer? A systematic review. Oral Oncology, 41,
440 – 454.
Massie, M. J. (2004). Prevalence of depression in patients with cancer.
Journal of the National Cancer Institute Monographs, 32, 57–71.
McDaniel, J. S., Musselman, D. L., Porter, M. R., Reed, D. A., & Nem-
eroff, C. B. (1995). Depression in patients with cancer. Diagnosis,
biology, and treatment. Archives of General Psychiatry, 52, 89 –99.
Meyer, T. J., & Mark, M. M. (1995). Effects of psychosocial interventions
with adult cancer patients: A meta-analysis of randomized experiments.
Health Psychology, 14, 101–108.
Morton, R. P. (1995). Evolution of quality of life assessment in head and
neck cancer. Journal of Laryngology and Otology, 109, 1029 –1035.
Neuling, S. J., & Winefield, H. R. (1988). Social support and recovery after
surgery for breast cancer: Frequency and correlates of supportive be-
haviours by family, friends and surgeon. Social Science & Medicine, 27,
385–392.
Nichols, A. C., & Bhattacharyya, N. (2007). Racial differences in stage and
survival in head and neck squamous cell carcinoma. Laryngoscope, 177,
770 –775.
Osborn, R. L., Demoncada, A. C., & Feuerstein, M. (2006). Psychosocial
interventions for depression, anxiety, and quality of life in cancer sur-
vivors: Meta-analyses. International Journal of Psychiatry in Medicine,
36, 13–34.
Otto, R. A., Dobie, R. A., Lawrence, V., & Sakai, C. (1997). Impact of a
laryngectomy on quality of life: Perspective of the patient versus that of
the health care provider. Annals of Otology, Rhinology, & Laryngology,
106, 693– 699.
Passik, S. D., Dugan, W., McDonald, M. V., Rosenfeld, B., Theobald,
71
D. E., & Edgerton, S. (1998). Oncologists’ recognition of depression in
their patients with cancer. Journal of Clinical Oncology, 16, 1594 –1600.
Pelletier, G., Verhoef, M. J., Khatri, N., & Hagen, N. (2002). Quality of life
in brain tumor patients: The relative contributions of depression, fatigue,
emotional distress, and existential issues. Journal of Neuro-Oncology,
57, 41– 49.
Pirl, W. F. (2004). Evidence report on the occurrence, assessment, and
treatment of depression in cancer patients. Journal of the National
Cancer Institute Monographs, 32, 32–39.
Pirl, W. F., & Roth, A. J. (1999). Diagnosis and treatment of depression in
cancer patients. Oncology, 13, 1293–1302.
Raison, C. L., & Miller, A. H. (2003). Depression in cancer: New devel-
opments regarding diagnosis and treatment. Biological Psychiatry, 54,
283–294.
Ronis, D. L., Duffy, S. A., Fowler, K. E., Khan, M. J., & Terrell, J. E.
(2008). Changes in quality of life over 1 year in patients with head and
neck cancer. Archives of Otolaryngology—Head & Neck Surgery, 134,
241–248.
Ross, L., Boesen, E. H., Dalton, S. O., & Johansen, C. (2002). Mind and
cancer: Does psychological intervention improve survival and psycho-
logical well-being? European Journal of Cancer, 38, 1447–1457.
Schnoll, R. A., & Lerman, C. (2003). Smoking behavior and smoking
cessation among head and neck cancer patients. In J. F. Ensley, J. S.
Gutkind, J. R. Jacobs, & S. M. Lippman (Eds.), Head and neck cancer:
Emerging perspectives (pp. 185–200). San Diego: Academic Press.
Spiegel, D., & Giese-Davis, J. (2003). Depression and cancer: Mechanisms
and disease progression. Biological Psychiatry, 54, 269 –282.
SPSS. (2006). SPSS for Windows (Version 15.0). Chicago: Author.
Stewart, M. G., Chen, A. Y., & Stach, C. B. (1998). Outcomes analysis of
voice and quality of life in patients with laryngeal cancer. Archives of
Otolaryngology—Head & Neck Surgery, 124, 143–148.
Stoudemire, A., & Thompson, T. L. (1983). Medication noncompliance:
Systematic approaches to evaluation and intervention. General Hospital
Psychiatry, 5, 233–239.
Weymuller, E. A., Jr., Yueh, B., Deleviannis, F. W., Kuntz, A. L., Alsarraf,
R., & Coltrera, M. D. (2000). Quality of life in head and neck cancer.
Laryngoscope, 110, 4 –7.