Screening Psychosocial Distress in Head and Neck Cancer

The announcement of cancer marks a major turning point in the lives of those affected, profoundly impacting the physical, psychological, and social dimensions of their daily lives1. Head and neck cancer (HNC) perfectly illustrates this reality, as it is frequently associated in the literature with pain, disfigurement, dysfunction, and psychosocial distress2. Referred to in the literature as "Head and Neck Cancer," it encompasses a group of malignant tumors affecting a complex anatomical region situated at the crossroads of the respiratory, phonatory, and digestive systems. The impairment of two vital functions, respiration and swallowing, as well as phonation, highlights the vulnerable and traumatic nature of this cancer3. In 2022, global cancer statistics recorded nearly 947,000 new cases of head and neck cancer, placing it 7th among the most frequent cancers worldwide4. Predominantly male, its incidence is nevertheless increasing in women, partly due to increased exposure to certain risk factors (tobacco and alcohol consumption), as well as an increase in tumors associated with human papillomavirus (HPV)5. In France, the National Cancer Institute6 estimates that approximately 15,000 new cases of HNC are diagnosed each year, causing nearly 3,600 deaths.

Survivors of HNC report significant repercussions on their daily functioning, particularly regarding eating, speech, pain, and physical appearance7. HNC treatments are heavy and frequently rely on various approaches combining surgical resection, radiotherapy, and chemotherapy2,8. While these strategies improve tumor control, they also expose patients to often persistent adverse effects. Long-term psychosocial disorders (anxiety, mood disorders, fatigue, depression) also alter the patient's overall quality of life. The fear of no longer being able to speak or be heard, the fear of suffocating or no longer being able to eat normally are major anxiety-inducing factors9. More tragically, psychological disorders may be responsible for higher suicide rates in HNC patients. A 2025 systematic review with meta-analysis demonstrates a suicide risk incidence three times higher than that of the general population, particularly among men10.

The psychological, social, and behavioral dimensions associated with cancer are therefore essential components of the disease, influencing both the patient's experience, their adaptation to the diagnosis, and their engagement in care11. Over the past two decades, psychosocial (or emotional) distress has progressively been recognized as a central issue in psycho-oncology, to the point of being qualified as the "sixth vital sign," after temperature, respiration, heart rate, blood pressure, and pain12. This recognition reflects a major evolution in care models, now integrating psychological and social dimensions into the global assessment of cancers patients. According to the National Comprehensive Cancer Network, distress is defined as " a multifactorial unpleasant experience of a psychological (i.e., cognitive, behavioral, and emotional), social, spiritual, and/or physical nature that may interfere with a person's ability to cope effectively with cancer, its physical symptoms, and its treatment. Distress spans a continuum, ranging from common and normal feelings of vulnerability, sadness, and fears, to problems that can become disabling, such as depression, anxiety, panic, social isolation, as well as existential and spiritual crisis. ".3 Among HNC patients, this issue appears particularly prominent. HNC ranks high among those generating very high levels of distress, behind lung cancer, breast cancer, pancreatic cancer, and Hodgkin's lymphoma13. Emotional distress also represents a major clinical challenge. Zabora et al. (2001) emphasize that when left unrecognised and unmanaged, it can compromise therapeutic outcomes, impair quality of life, and increase healthcare costs14. Despite its high prevalence demonstrated in HNC patients, psychosocial distress is still poorly screened and insufficiently managed in routine care3. It is therefore frequently under-identified and undertreated in clinical practice15. However, National Comprehensive Cancer Network (NCCN) recommendations emphasize the implementation of regular screening at various key moments of the care pathway, particularly at diagnostic disclosure, during treatments, and during post-therapeutic follow-up, to allow early identification of struggling patients3.

To identify the level and nature of distress, the Distress Thermometer was designed and recommended by the NCCN in 199716. On a scale from 0 to 10, with 0 representing no distress and 10 maximum distress, the person graphically indicates their feelings over the past week. The Distress Thermometer is a reliable and validated instrument, widely tested internationally, and translated into 21 languages, including French17. A threshold of 4 is frequently used to identify clinically significant distress, although this may vary across populations and cultural contexts. The Distress Thermometer is completed by the Canadian Problem List, allowing the collection of the patient's physical, emotional, social, practical, and spiritual concerns18.

The assessment of the needs of HNC patients is part of the foundations of speech-language pathology (SLP) evaluation19. The SLP care of patients, often undergoing major surgeries, is particularly complex and addresses individuals largely confronted with major disruptions in their social reference points9. Assessments of voice, speech, and swallowing must be performed by the SLP, who will propose appropriate interventions to maintain these functions upstream of treatment. Speech therapy also extends to the management of post-treatment complications, such as trismus or radiation-induced fibrosis. According to Zuydam et al. (2023), establishing a solid therapeutic relationship makes it possible to identify patient concerns19. Indeed, unmet needs have been identified in 60% to 70% of patients diagnosed with HNC20. Taking these different dimensions into account is therefore part of a perspective of improving care outcomes, preserving patients' quality of life, and increasing their satisfaction with care21. This cross-functional competency of psychosocial support, offered by professionals involved in regular cancer care, appears essential here and must not be underestimated22 . Although psychosocial distress screening is recommended throughout the cancer care pathway, ils integration into routine clinical practice remains poorly documented, particulary in the field of speech-language pathology. Speech-language pathologists play a specific role in care pathway of patients with HNC because their involvement is early and regular and focuses on the functional consequences of cancer and its treatments. This close and repeated contact with patients may place them in a relevant position to identify psychosocial difficulties encountered during care.

To date, no study has specifically investigated the relevance of integrating systematic psychosocial distress screening by speech-language pathologists at the beginning of care in patients treated for HNC. The DEP-VADS-ORTHO study may therefore contribute to assessing the relevance of incorporating the Distress Thermometer into routine speech-language pathology practice and to better defining the role of speech-language pathologists within the multidisciplinary care pathway of these patients.