Addressing body-image distress in head and neck cancer patients

Previous research has suggested nearly a third of patients with head and neck cancer experience body image distress, a term for the negative psychological effects caused by changes in physical appearance and associated function resulting from a patient’s treatment.

Another study found that a majority of patients feel at least some body image concerns.

A recent small randomized clinical trial found that BRIGHT, a novel cognitive behavioral treatment approach, had potential to improve body image distress among head and neck cancer survivors.

Short for “Building a Renewed ImaGe After Head & Neck Cancer Treatment (BRIGHT) Multi-Site RCT,” the ongoing multi-institutional trial is seeking to confirm these promising results and help establish BRIGHT as the first evidence-based intervention to improve body image distress among head and neck cancer survivors and new standard of care.

The work is led by Evan Michael Graboyes, M.D., M.P.H., professor of otolaryngology - head & neck surgery at the Medical University of South Carolina.

David Forner, M.D., M.Sc. FRCSC, an assistant professor of otolaryngology at the University of Michigan Medical School, discusses why Michigan Medicine has joined the trial, and the various ways in which body image distress impacts patients and providers.

What are the details of the BRIGHT clinical trial?

David Forner: Body image distress interventions have been developed for other cancers, such as breast cancer, for which they’ve been shown to be efficacious.

Prior to this trial, however, there haven’t been beneficial interventions developed for head and neck cancer.

There have even been interventions that have been shown to be effective in other cancers but not effective for patients with head and neck cancer.

This showcases the unique problems our patients deal with.

Body image distress is incredibly important to recognize and provide treatment for.

Patients with body image distress have a higher rate of social isolation and depression and report a lower quality of life.

Researchers at MUSC, led by Dr. Graboyes, developed BRIGHT, a disease-specific cognitive behavioral therapy based on a coping model for head and neck cancer related body image distress.

They have previously completed a single-institution phase I trial, as well as a pilot randomized trial.

Michigan Medicine is now participating in the phase III trial, comparing BRIGHT to a control arm of routine survivorship discussion.

To what extent is potential future body image distress a hurdle to getting patients to agree to treatment?

Forner: If a patient has a cancer that clearly will have an external effect on them, it's much more likely that they’ll take this into consideration when they're deciding whether to undergo treatment.

When I talk to patients about postoperative or post-treatment expectations, we talk about reconstructive considerations and what their appearance would look like afterwards.

This is especially true for surgeries that will significantly alter their external appearance, such as on the face or of the jaws.

It’s not just surgery that can affect the patient’s appearance either.

The treatment of head and neck cancer often also includes radiation after surgery, and this can also affect a patient’s appearance, such as through the development of lymphedema or swelling.

Are considerations like speech ability factored into body image distress?

Forner: We do take that into account when we are assessing body image concerns and body image distress.

Patients report issues related to speaking, eating, and drinking as they relate to their treatment, including social situations.

Body image concerns are incredibly varied.

Of course, you can consider things like aesthetics and external appearance.

But there is a big intersection with patients’ general ability to be social and go out in the world, and these factors play a major role in body image.

How do technological advances in treating head and neck cancer affect body image distress?

Forner: When a patient had a cancer at the back of their tongue or their tonsil, we previously needed to perform highly morbid surgeries to access these areas for treatment.

It was not uncommon to perform what is called a mandibulotomy – a procedure where the lip and jawbone is cut in half to provide access to the back of the throat.

There were potential issues with aesthetics and body image because of the resulting facial scar and the effect on speech and swallowing.

Now, transoral robotic surgery can access those areas without having to cut the lip and jawbone.

This results in a less major procedure for the patient and no external scars.

There’s also virtual surgical planning, where we can use computer imaging and radiologic images to model what a surgery will look like and to plan both our cancer surgery and our reconstructive surgery very precisely.

It lets us do a better job at reconstructing, for example, the contour of the jaw after it's been removed.

How is body image distress dealt with in surgical training?

Forner: For things like shared decision-making, discussion about depression and mental health, and discussions around body image distress, there's no formal training within most surgical programs.

It's an area for improvement.

That is another reason why it's exciting that we're able to participate in this clinical trial and draw attention to a very prevalent but underdiscussed issue.

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