Symptoms as an index of biologic behavior in head and neck cancer

The TNM staging system for head and neck cancer is based on the morphologic description of the tumor and disregards the clinical condition of the pati ent. Cancer symptoms were evaluated as a biologic index of disease to impro ve survival estimates. The medical records of 1010 patients receiving initi al cancer treatment between 1980 and 1991 were retrospectively reviewed. Th e mean survival duration was 62 months for the entire population. By use of SAS statistical software (SAS Institute, Cary, NC), 48 symptom variables w ere screened by univariate analysis, and 23 of these variables were selecte d for entry into a Cox proportional hazards model on the basis of survival duration. Dysphagia, otalgia, neck lump, and weight loss were identified as independent predictors of survival duration (P < 0.01). A composite sympto m-severity staging system was created on the basis of the 4 symptoms. Mean survival duration (95% CI) by symptom-severity stage was as follows: none, 74 months (70 to 79 months); mild, 56 months (51 to 61 months); moderate, 4 0 months (33 to 47 months); and severe, 31 months (22 to 41 months) (chi(2) = 30.8, P = 0.0001). Survival duration by TNM stage was as follows: I, 89 months (82 to 95 months); II, 71 months (65 to 78 months); III, 53 months ( 47 to 59 months); and IV, 42 months (37 to 47 months) (chi(2) = 56.2, P = 0 .0001). When symptom-severity stage was entered in a proportional-hazards m odel along with TNM stage, comorbidity, age, and alcohol use, all 5 variabl es were independently predictive of survival duration (risk ratio: symptom severity 1.28, TNM 1.33, comorbidity 1.80, age 1.47, alcohol use 1.09). App ropriately defined symptom variables contain important prognostic informati on, which is independent of the TNM system. Therefore symptoms provide an i ndex of biologic behavior in head and neck cancer.