Und Gesichtschirurgie (Direktor Universitätsprofessor Dr

Aus der Klinik für Mund-, Kiefer - und Gesichtschirurgie (Direktor Universitätsprofessor Dr. med. Dr. med. dent. Frank Hölzle)

Distress thermometer for preoperative screening of patients with oral squamous cell carcinoma

Von der Medizinischen Fakultät der Rheinisch-Westfälischen Technischen Hochschule Aachen zur Erlangung des akademischen Grades einer Doktorin der Zahnmedizin genehmigte Dissertation

vorgelegt von

Juliana-Theresa Schell

aus Herford

Berichter: Herr Universitätsprofessor Berichter: Dr. med. Dr. med. dent. Bernd Lethaus, MHBA

Berichter: Frau apl. Professorin Berichter: Dr. med. dent. Marcella Esteves Oliveira

Berichter:

Tag der mündlichen Prüfung: 07.06.2019

Diese Dissertation ist auf den Internetseiten der Universitätsbibliothek online verfügbar. Veröffentlicht in: Journal of Cranio-Maxillo-Facial Surgery [46 (2018) 1111-1116] Elsevier B.V. Amsterdam, Niederlande https://doi.org/10.1016/j.jcms.2018.04.022

D 82 (Diss. RWTH Aachen University, 2019)

Journal of Cranio-Maxillo-Facial Surgery 46 (2018) 1111e1116

Contents lists available at ScienceDirect

Journal of Cranio-Maxillo-Facial Surgery

journal homepage: www.jcmfs.com

Distress thermometer for preoperative screening of patients with oral squamous cell carcinoma

Juliana-Theresa Schell a, Andrea Petermann-Meyer b, Anita Kloss-Brandstatter€ a, Alexander K. Bartella a, Mohammad Kamal a, Frank Holzle€ a, Bernd Lethaus a, *, Jan Teichmann a a Department of Oral and Maxillofacial Surgery, (Head: Prof. Dr. Dr. F. W. Holzle),€ RWTH Aachen University, Pauwelstr 30, 52054, Aachen, Germany b Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Section Psychooncology, Euregionales Comprehensive Cancer Center, RWTH Aachen University, Pauwelstr 30, 52054, Aachen, Germany article info abstract

Article history: In this study, we evaluate the association between distress, various demographic and medical variables, Paper received 20 October 2017 and the prevalence of psychosocial distress in preoperative patients with oral squamous cell carcinoma. Accepted 23 April 2018 A total of 100 consecutive patients were recruited into the study and asked to complete the Distress Available online 9 May 2018 Thermometer (DT) form with the Problem List questionnaire prior to surgical intervention; the average distress score was 5.7 ± 2.7. The distress score was neither correlated with age (r 0.025; p 0.804) ¼À ¼ Keywords: nor with tumor size (r 0.028; p 0.785). General worries, anxiety, sadness, depression, pain, Distress thermometer ¼ ¼ exhaustion, sleeping disorders, or problems with nutrition resulted in signiﬁcantly higher distress scores OSCC compared to patients without these complaints. Individuals with a DT score of 5 or higher (p 0.006) Head and neck ¼ Psychooncology were advised to seek out psychological support. There is a strong correlation between a high DT score and emotional disorders, as well as physical problems. © 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

1. Introduction their esthetic self-perception and overall quality of life. It is not surprising to find a higher distress level in these patient groups The assessment and evaluation of psychological distress in when compared to the healthy population (Aarstad et al., 2014; oncological patients has become a routine procedure in care giving Beisland et al., 2013; Haman, 2008). It is additionally known that of patients with most common tumor entities. Most clinicians and head and neck oncology patients display significantly higher psy- researchers recognize the importance of screening for distress and chological distress, and are more likely to be diagnosed with other incorporate the relevant information in synthesizing a compre- mental health conditions when compared to patients with other hensive treatment plan for oncologic patients (Haman, 2008; malignancies (Fischer et al., 2010; Katz et al., 2004; Singer et al., Martinez et al., 2013). In Germany, the National Cancer Taskforce 2005, 2011; Zabora et al., 2001). These findings may explain the advocates for utilizing psycho-oncological assessment tools, and higher suicide rate among these patient groups (Anguiano et al., demands that psycho-oncological support be offered by the 2012; Misono et al., 2008; Zeller, 2006), and prompt the need for healthcare provider for every oncological patient. implementing a professional psychological support regimen as part Patients with tumors in the head and neck region pose a special of their overall treatment plan. challenge for psychooncology. This could be attributed to tumor Multiple screening tests have been reported in the literature as a location being near numerous vital structures, thus affecting the means to monitor distress parameters in patients with malignant expressive and communicative nature of the patient, as well as conditions (Martinez et al., 2013; Mitchell, 2010; Vodermaier et al., 2009). The Distress Thermometer (DT) (Roth et al., 1998), as a short test, has been internationally validated and proved to deliver reli- able results in multiple languages (Ma et al., 2014). Several studies * Corresponding author. RWTH Aachen University, Pauwelstr 30, 52054, Aachen, Germany. Fax: 49 241 80230. have been recommending the standardized implementation of the þ E-mail address: [email protected] (B. Lethaus). DT, due to its effectiveness and easy incorporation in the daily https://doi.org/10.1016/j.jcms.2018.04.022 1010-5182/© 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved. 1112 J.-T. Schell et al. / Journal of Cranio-Maxillo-Facial Surgery 46 (2018) 1111e1116 patient management routine to detect clinically significant distress 3. Results early and to introduce the patient to psychooncological support if necessary (Donovan et al., 2013; Holland et al., 2011; Vodermaier Of a total of 100 consecutive patients, 57 were male and 43 were et al., 2009). female with a mean age of 64.4 ± 14.7 years, and all presented with However, previous clinical reports have focused solely on pa- newly diagnosed oral squamous cell carcinoma. Sixty-three patients with head and neck cancer undergoing radiotherapy (Chen tients were married or described themselves as “in a relationship.” et al., 2009; Lewis et al., 2013). The objective of this study was to Eight patients were single, 12 patients were divorced, and 17 pa- determine the prevalence of psychosocial distress among patients tients were widowed. undergoing surgical management for oral squamous cell carci- The average distress score of the patients included in the anal- noma, and broaden current knowledge of the correlation between ysis was 5.7 ± 2.7. Seventy-two patients were at or above the cut-off distress and several demographic and medical variables. score of 5. The distress score was neither correlated with age (Spearman rank correlation: r 0.025; p 0.804), nor with tu- ¼À ¼ 2. Materials and methods mor size (Spearman rank correlation: r 0.028; p 0.785). ¼ ¼ Patients who had indicated on the problem list that they suf- This study was conducted in 100 consecutive patients with head fered from general worries, anxiety, sadness, depression, pain, and neck cancer at the Department of Oral and Maxillofacial Sur- exhaustion, sleeping disorders, or problems with nutrition showed gery at the Oncologic Comprehensive Care Center at Aachen Uni- significantly higher distress scores compared to patients without versity Hospital over a time period of 2 years between June 2013 these complaints (Table 1). and November 2015. Eligible patients who had been diagnosed Gender had a significant influence on the patients' specific with new squamous cell carcinoma were asked to complete the DT problems. Female patients were more likely to report pain (Chi- and the problem list questionnaire on the day of admission to the squared test; p 0.041) and to express fears (Chi-squared test; ¼ clinic before being cleared for head and neck cancer surgery. At p 0.043) or problems with nutrition (Chi-squared test; p 0.014) ¼ ¼ least 1 week prior to delivery of the survey, patients were thor- than male patients. On the other hand, more male patients stated oughly informed about their diagnosis and therapeutic strategy by problems with their housing situation (Chi-squared test; p 0.042) ¼ the attending physician. and a higher incidence of sweating than female patients (Chi- All participants were provided with a written consent and had squared test; p 0.042) (see Table 2). ¼ to meet the following criteria: age 18 years, undergoing surgical It was discovered that marital status exhibited a significant in- ! intervention for cancer treatment, no prior history of cancer fluence on the patients' complaints and ability to handle the cancer treatment, sufficient understanding and comprehension of the diagnosis. Patients who were “married” or “in a relationship” at the German language, and absence of self-reported psychological det- time of this study reported considerably fewer problems with their riments. Patients who did not meet the following criteria were not housing situation of statistical significance (Chi-squared test; included in this study. This study was approved by the local ethical p 0.012). ¼ committee. Psychological support was received by 43 individuals, who had a Under the supervision of a trained nurse, participants received higher distress score on their DT than patients who refused support the DT questionnaire and were asked to self-report their level of (Chi-squared test; p 0.006); the patients' age, however, displayed ¼ distress on a visual analog scale from 0 (no distress) to 10 (extreme no significant correlation in this matter (p 0.627). Out of the 43 ¼ distress) (Fig. 1). participants, 35 patients (81.2 %) had a cut-off score of 5 or higher. Attached to the actual DT was a problem list with 40 questions Only 8 patients scoring less than 5 sought out psychological sup- divided into practical problems, family problems, emotional prob- port out of self-motivation. We also found a uniform distribution lems, spiritual issues, and physical problems, which could be between men and women (Chi-squared test; p 0.206). The civil ¼ answered by checking “yes” or “no” (Fig. 1). The problem list status did not influence this choice (Chi-squared test; p 0.100). All ¼ specified the actual cause of the patients' distress. If the patient individuals who decided to accept psychooncological consultations selected a DT stress level of 5 or higher, they were advised to accept either due to our recommendation or out of self-motivation, stated professional psychological consultation according to the guidelines on the problem list that they were suffering from either worries of the German Society for Psychooncology (Mehnert et al., 2006). (Chi-squared test; p 0.041), fears (Chi-squared test; p 0.030), ¼ ¼ Typically, the customary problem list contains 39 items, but in this sadness (Chi-squared test; p 0.032), depression (Chi-squared ¼ study an additional item was incorporated so that regardless of test; p 0.006), tension (Chi-squared test; p < 0.001), pain (Chi- ¼ their score, an individual who indicated the wish for psychological squared test; p 0.005), exhaustion (Chi-squared test; p 0.016), ¼ ¼ help could receive such care. sleeping disorders (Chi-squared test; p 0.027), irritations in the ¼ Additionally, age, gender, marital status, tumor size, the pres- oral cavity (Chi-squared test; p 0.017), and/or problems with ¼ ence of lymph node metastasis, grading, and TNM classification of nutrition (Chi-squared test; p 0.014). ¼ the tumor were documented and considered factors in determining whether a patient needed professional psychological consultation 4. Discussion as part of their overall treatment. The Pearson chi-squared test was applied to sets of unpaired The purpose of this prospective study was to determine the categorical data to evaluate the likelihood that any observed dif- average distress score of patients suffering from oral squamous cell ference between the sets was due to chance. The Spearman rank carcinoma prior to undergoing surgical intervention. We aimed to correlation coefficient (“Spearman's rho”) was calculated as a expose the medical and demographic variables that influence the measure of the association between two ordinal or metric variables. distress score, and to assess the demand for professional psy- An independent sample t-test was used when two separate sets of chooncological support while understanding the rationale behind independent and identically distributed samples were obtained, this decision by the patients. and their population means were compared to each other. In our sample, the mean DT score was 5.7 ± 2.7, which is notably For descriptive statistics, mean values and standard deviations higher than the DT scores of patients diagnosed with different tu- were calculated. Statistical analyses were performed with IBM SPSS mor entities. Bulli et al. published an average score of 4.9 (n 290) ¼ version 23 (IBM Corp., Armonk, NY). when investigating patients with breast, colon, uterine or prostate J.-T. Schell et al. / Journal of Cranio-Maxillo-Facial Surgery 46 (2018) 1111e1116 1113

Fig. 1. English translation of the Distress Thermometer and attached Problem List questionnaire used in this study. 1114 J.-T. Schell et al. / Journal of Cranio-Maxillo-Facial Surgery 46 (2018) 1111e1116

Table 1 Comparison of distress score between answers to selected questionnaire items, between treatment options and the occurrence of a tumor relapse.

Variable Yes No p Value

Worries, general 6.6 ± 2.3 (n 47) 4.9 ± 2.8 (n 53) p 0.001 ¼ ¼ ¼ Anxiety 6.6 ± 2.4 (n 58) 4.6 ± 2.7 (n 42) p < 0.001 ¼ ¼ Sadness 7.2 ± 2.2 (n 33) 5.0 ± 2.7 (n 67) p < 0.001 ¼ ¼ Depression 7.8 ± 1.9 (n 18) 5.3 ± 2.7 (n 82) p < 0.001 ¼ ¼ Pain 6.8 ± 2.6 (n 47) 4.8 ± 2.5 (n 53) p < 0.001 ¼ ¼ Exhaustion 7.1 ± 2.2 (n 38) 4.9 ± 2.7 (n 62) p < 0.001 ¼ ¼ Sleeping disorder 6.8 ± 2.1 (n 37) 5.1 ± 2.9 (n 63) p 0.002 ¼ ¼ ¼ Mobility problems 7.0 ± 2.3 (n 25) 5.3 ± 2.7 (n 75) p 0.009 ¼ ¼ ¼ Problems with personal hygiene 7.3 ± 2.2 (n 14) 5.5 ± 2.7 (n 86) p 0.021 ¼ ¼ ¼ Problems with nutrition 7.0 ± 2.2 (n 49) 4.5 ± 2.6 (n 51) p < 0.001 ¼ ¼ Dizziness 7.7 ± 2.2 (n 15) 5.4 ± 2.7 (n 85) p 0.002 ¼ ¼ ¼ Patient made use of psychological treatment 6.6 ± 2.5 5.1 ± 2.8 p 0.006 ¼ Metastases in lymph nodes 6.6 ± 2.7 (n 36) 5.3 ± 2.7 (n 64) p 0.022 ¼ ¼ ¼

Table 2 van der et al., 1999). Half of our sample group indicated problems Contingency between different patient-related problems and the use of psycho- with nutrition. The mean DT score of this subgroup was 7.0 ± 2.2, logical help. which was significantly higher than the mean DT score of all pa- fi Variable Patient made use of tients. This signi cantly greater distress score was also a consistent psychological treatment finding by other researchers during all phases of treatment in patients with malnutrition (Britton et al., 2012). Worries 4 0.190; p 0.053 ¼ ¼ Anxiety 4 0.203; p 0.038 It has been previously shown that elevated levels of depression ¼ ¼ Sadness 4 0.202; p 0.039 and anxiety can be observed in head and neck cancer patients prior ¼ ¼ Depression 4 0.267; p 0.006 ¼ ¼ to undergoing radiation therapy (Kohda et al., 2005; Neilson et al., Pain 4 0.265; p 0.006 ¼ ¼ 2010). However, to the best of our knowledge, there are neither re- Exhaustion 4 0.229; p 0.019 ¼ ¼ Sleeping disorder 4 0.208; p 0.033 ports using the Distress Thermometer prior to the surgical inter- ¼ ¼ Mobility problems 4 0.150; p 0.130 vention nor direct comparisons of the impact of the therapeutic ¼ ¼ Problems with personal hygiene 4 0.171; p 0.083 strategy in this specific patient group. Another possible explanation ¼ ¼ Problems with nutrition 4 0.233; p 0.017 ¼ ¼ for the high DT scores in our analysis could have been that all pa- Dizziness 4 0.031; p 0.756 ¼ ¼ tients were well aware of the pending operation and were suffi- Metastases in lymph nodes 4 0.147; p 0.139 ¼ ¼ ciently informed about the expected outcomes, which included 4 contingency coefficient. ¼ limitations in speech, worsening of nutrition, and visible facial dis- figurements. Other studies have not shown significant correlations cancer (Bulli et al., 2009). Lazenby et al. reported a mean score of between visible facial disfigurement and quality of life in head and 3.9 in newly diagnosed patients (n 113) with advanced cancers of neck cancer patients (Morton et al., 1984; Vickery et al., 2003). ¼ a gastrointestinal, gynecological, and pulmonary nature (Lazenby Howren et al. (Howren et al., 2010) illustrated in their patient group et al., 2014). In addition to the high average DT score, we also that preexisting depressive symptoms prior to the initiation of the found a high number of patients (72%) with a DT score above the therapeutic intervention had detrimentally affected the quality of cut-off score of 5. In a recent multi-center study, Faller et al. pub- life. Another reason could be the fear of the unknown and the pro- lished a study on a large patient group (n 3519), with only 52% of gression of the disease. A randomized controlled trial by Carlson ¼ the patients above the cut-off (Faller et al., 2016). In this population, et al. (Carlson et al., 2012) provided an online screening tool for various cancer entities were included, and the patients with head patients with newly diagnosed cancer with various tumor entities, and neck cancer contributed to only 3% or less. and they concluded that the DT level consistently decreased over the Patients with cancer in the head and neck region are known to course of treatment. Multiple time point assessments and survival have high emotional distress levels, which exceeds the levels seen studies are needed to better evaluate DT scores as a function of time. in other oncological entities (Chen et al., 2009; Katz et al., 2004; The problem list is attached to the DT to categorize the etiology of Kugaya et al., 2000; Singer et al., 2011). The reasons for these reported problems into five vital domains. These include practical, findings are still subject to discussion and not yet fully understood. family/social, emotional, spiritual, and physical problems. We found Some authors have commented that head and neck malignancies a strong association between a high DT score and problems listed in are responsible for a certain stigma and may lead to depression due the emotional domain such as general worries, anxiety, sadness, and to an awareness of the high probability of facial disfigurement post- depression, in addition to problems listed in the physical problems surgery (Katz et al., 2003). Others have speculated that it is not the domain such as pain, exhaustion, sleeping disorders, and problems area of the tumor, but the weak social support of the patient that is with nutrition. Several studies have formerly described the corre- causative of this higher stress level. Head and neck cancer is lation between elevated pain level and distress score and thus associated with specific risk factors such as alcohol and tobacco use, support our findings (Kanatas et al., 2012; Maher et al., 2013; Zaza found more often in lower socioeconomic classes. This group of and Baine, 2002). Gunn et al. identified the same problems as in patients may also experience less social support than other patients our study, describing a connection between pain, sleeping disorders, in their peer groups (Singer et al., 2011). In contrast to other tumor fatigue, problems with nutrition, and a higher symptom burden entities, squamous cell carcinoma in the oral cavity can directly (Gunn et al., 2013). Lin et al. (Lin et al., 2013) showed this specific affect deglutition, which subsequently increases the likelihood of symptom cluster in lung cancer surgery patients as well. malnutrition (Santarpia et al., 2011). It is known, yet likely under- Moreover, our data suggest that female patients were more estimated, how malnutrition influences the distress level, and likely to report pain (Chi-squared test; p 0.041) than male pa- ¼ quality of life and ultimately leads to cachexia and a drastic dete- tients, which was also confirmed by Filingim et al. (Fillingim et al., rioration of the clinical prognosis (Ma et al., 2013; van Bokhorst-de 2009) in a large-scale review of clinical and experimental findings, J.-T. Schell et al. / Journal of Cranio-Maxillo-Facial Surgery 46 (2018) 1111e1116 1115 and by Gerdle et al. (Gerdle et al., 2008), independent of the loca- Anguiano L, Mayer DK, Piven ML, Rosenstein D: A literature review of suicide in tion of the malignancy. cancer patients. Cancer Nurs 35: E14eE26, 2012 Beisland E, Aarstad AKH, Osthus AA, Aarstad HJ: Stability of distress and health- Four of the six possible problem items consisted of emotional related quality of life as well as relation to neuroticism, coping and TNM disorders, while only four of the 23 possible items in the physical stage in head and neck cancer patients during follow-up. Acta Otolaryngol 133: domain were statistically significant for causing a high DT score. 209e217, 2013 Britton B, Clover K, Bateman L, Odelli C, Wenham K, Zeman A, et al: Baseline This could be explained by the typical symptoms of oral carcinoma, depression predicts malnutrition in head and neck cancer patients undergoing but it seems that emotional problems have a greater impact on the radiotherapy. Support Care Cancer 20: 335e342, 2012 patients' distress. This emphasizes the necessity of psychoonco- Bulli F, Miccinesi G, Maruelli A, Katz M, Paci E: The measure of psychological distress in cancer patients: the use of Distress Thermometer in the Oncological logical care immediately after establishing the diagnosis in patients Rehabilitation Center of Florence. Support Care Cancer 17: 771e779, 2009 with oral cell carcinoma (Gunn et al., 2013) and would be our Carlson LE, Waller A, Groff SL, Zhong L, Bultz BD: Online screening for distress, the recommendation as well. It has been shown that a high percentage 6th vital sign, in newly diagnosed oncology outpatients: randomised controlled trial of computerised vs personalised triage. Br J Cancer 107: 617e625, 2012 of patients with head and neck cancer suffer from severe psycho- Chen AM, Jennelle RL, Grady V, Tovar A, Bowen K, Simonin P, et al: Prospective social distress and their depression rates can be as high as 43% study of psychosocial distress among patients undergoing radiotherapy for before undergoing surgical intervention (Chen et al., 2009; head and neck cancer. Int J Radiat Oncol Biol Phys 73: 187e193, 2009 Haisfield-Wolfe et al., 2009). Donovan KA, Grassi L, McGinty HL, Jacobsen PB: Validation of the Distress Ther- mometer worldwide: state of the science. Psycho-Oncology 23: 241e250, 2013 Zeissig et al. found statistical differences among tumor entities Faller H, Koch U, Brahler€ E, Harter€ M, Keller M, Schulz H, et al: Satisfaction with and the utilization of professional support: 11% of the patients with information and unmet information needs in men and women with cancer. breast cancer, 9% of the patients with colon cancer, and 7% of pa- J Cancer Surviv 10: 62e70, 2016 Fillingim RB, King CD, Ribeiro-Dasilva MC, Rahim-Williams B, Riley JL: 3rd: sex, tients with prostate cancer sought out psychological help, whereas gender, and pain: a review of recent clinical and experimental findings. J Pain 43% of our patients obtained psychological support. 10: 447e485, 2009 This particular group of patients had a higher distress score than Fischer DJ, Villines D, Kim YO, Epstein JB, Wilkie DJ: Anxiety, depression, and pain: differences by primary cancer. Support Care Cancer 18: 801e810, 2010 patients who did not wish to receive this support (Chi-squared test; Gerdle B, Bjork J, Coster L, Henriksson K, Henriksson C, Bengtsson A: Prevalence of p 0.01); 33 of the 43 individuals (80%) had a cut-off score of 5 or widespread pain and associations with work status: a population study. BMC ¼ higher, which proved our hypothesis. Patients' age, gender, and civil Musculoskelet Disord 9: 102, 2008 fi Gunn GB, Mendoza TR, Fuller CD, Gning I, Frank SJ, Beadle BM, et al: High symptom status however, displayed no signi cant correlation in this matter burden prior to radiation therapy for head and neck cancer: a patient-reported (Chi-squared test; p 0.627). This is an interesting finding because outcomes study. Head Neck 35: 1490e1498, 2013 ¼ females were more likely to report pain (Chi-squared test; p 0.041) Haisfield-Wolfe ME, McGuire DB, Soeken K, Geiger-Brown J, De Forge BR: Preva- ¼ lence and correlates of depression among patients with head and neck cancer: a and to express fears (Chi-squared test; p 0.043) or problems with ¼ systematic review of implications for research. Oncol Nurs Forum 36: nutrition (Chi-squared test; p 0.014), and those items were also E107eE125, 2009 ¼ found in all patients who received psychological support. Haman KL: Psychologic distress and head and neck cancer: part 1ereview of the e The indication of pain and depression on the questionnaire was literature. J Support Oncol 6: 155 163, 2008 Holland J, Watson M, Dunn J: The IPOS new International Standard of Quality most significantly associated with the decision to consult a psy- Cancer Care: integrating the psychosocial domain into routine care. Psy- chologist. This is not surprising, but it emphasizes the necessity for chooncology 20: 677e680, 2011 early screenings and the detection of depression again to provide Howren MB, Christensen AJ, Karnell LH, Funk GF: Health-related quality of life in head and neck cancer survivors: impact of pretreatment depressive symptoms. optimal care for these individuals. Additionally, negative emotions Health Psychol 29: 65e71, 2010 such as anxiety, sadness, exhaustion, and physical problems such as Kanatas A, Ghazali N, Lowe D, Rogers SN: The identification of mood and anxiety sleeping disorders and problems with nutrition were also associ- concerns using the patients concerns inventory following head and neck cancer. Int J Oral Maxillofac Surg 41: 429e436, 2012 ated with the request for professional psychological advice. Katz MR, Irish JC, Devins GM, Rodin GM, Gullane PJ: Psychosocial adjustment in A patient's decision to seek professional help can be affected by head and neck cancer: the impact of disfigurement, gender and social support. many different variables. Personal, behavioral, psychological, and Head Neck 25: 103e112, 2003 Katz MR, Kopek N, Waldron J, Devins GM, Tomlinson G: Screening for depression in economic factors can play a role in this decision-making process head and neck cancer. Psychooncology 13: 269e280, 2004 (Faller et al., 2016). The high amount of distress measured in our Kohda R, Otsubo T, Kuwakado Y, Tanaka K, Kitahara T, Yoshimura K, et al: Pro- group of patients with head and neck cancer could be an additional spective studies on mental status and quality of life in patients with head and fl neck cancer treated by radiation. Psychooncology 14: 331e336, 2005 factor in uencing the patients' decision (Fischer et al., 2010; Katz Kugaya A, Akechi T, Okuyama T, Nakano T, Mikami I, Okamura H, et al: Prevalence, et al., 2004; Singer et al., 2005, 2011; Zabora et al., 2001). Predictive factors, and screening for psychologic distress in patients with newly diagnosed head and neck cancer. Cancer 88: 2817e2823, 2000 Lazenby M, Dixon J, Bai M, McCorkle R: Comparing the distress thermometer (DT) 5. Conclusion with the patient health questionnaire (PHQ)-2 for screening for possible cases of depression among patients newly diagnosed with advanced cancer. Palliat The findings in this study support the hypothesis that patients Support Care 12: 63e68, 2014 Lewis S, Salins N, Kadam A, Rao R: Distress screening using distress thermometer in with oral squamous cell carcinoma suffer from high distress levels. head and neck cancer patients undergoing radiotherapy and evaluation of Elevated distress levels prior to surgical treatment and the higher causal factors predicting occurrence of distress. Indian J Palliat Care 19: 88e92, demand for psychological support emphasize the necessity for 2013 Lin S, Chen Y, Yang L, Zhou J: Pain, fatigue, disturbed sleep and distress comprised a early screenings and therapy. There is a strong correlation between symptom cluster that related to quality of life and functional status of lung a high DT score and emotional disorders such as general worry, cancer surgery patients. J Clin Nurs 22: 1281e1290, 2013 sadness, and depression, in addition to physical problems such as Ma L, Poulin P, Feldstain A, Chasen MR: The association between malnutrition and psychological distress in patients with advanced head-and-neck cancer. Curr pain, exhaustion, sleeping disorders, and problems with nutrition. Oncol 20: 554e557, 2013 Ma X, Zhang J, Zhong W, Shu C, Wang F, Wen J, et al: The diagnostic role of a short screening toolethe Distress Thermometer: a meta-analysis. Support Care Funding Cancer 22: 1741e1755, 2014 No grants supported this study. Maher NG, Britton B, Hoffman GR: Early screening in patients with head and neck cancer identified high levels of pain and distress. J Oral Maxillofac Surg 71: 1458e1464, 2013 References Martinez P, Galdon MJ, Andreu Y, Ibanez E: The Distress Thermometer in Spanish cancer patients: convergent validity and diagnostic accuracy. 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Den nachstehenden Personen möchte ich besonderen Dank entgegenbringen, denn ohne deren Mithilfe wäre die Anfertigung dieser Promotionsschrift nicht zustande gekommen.

An erster Stelle danke ich meinem Doktorvater Priv.-Doz. Dr. Dr. Bernd Lethaus für dessen erstklassige Betreuung, fachliche Expertise und professionelle Unterstützung. Ich hätte mir keinen besseren Doktorvater wünschen können.

Explizit möchte ich auch dem Team der Mund-, Kiefer- und Gesichtschirurgie des Universitätsklinikums der RWTH Aachen unter der Leitung von Univ.-Prof. Dr. Dr. Frank Hölzle für die Betreuung und Unterstützung dieser Arbeit danken. Besonderer Dank gilt hier natürlich allen Co-Autoren des Artikels, ohne deren individueller Anteile die Publikation nicht auf dem Niveau veröffentlicht worden wäre.

An dieser Stelle möchte ich auch Frau Silvia Wilm vom Case Management erwähnen und für die wunderbare Unterstützung bei der Sammlung der Daten danken.

Es gibt viele Menschen, die mich bis heute auf meinem Lebensweg begleitet und unterstützt haben, allerdings haben mich wenige so inspiriert und unterstützt wie Dr. Pascal

Schumacher. Danke, dass ich Dich meinen Mentor und guten Freund nennen darf.

Weiterer Dank gilt auch Tamara Shamlian und Kristina Sakas, die mich bei meinem Auslandsaufenthalt in Los Angeles liebevoll begleitet haben und meine Englischkenntnisse auf ein neues Level gehoben haben.

Die letzten Worte gehören an dieser Stelle meinen lieben Eltern, Kerstin und Hartmut Schell, die mir meinen bisherigen Werdegang ermöglicht haben und denen ich diese Arbeit widme.

Erklärung § 5 Abs. 1 zur Datenaufbewahrung

Hiermit erkläre ich, dass die dieser Dissertation zu Grunde liegenden Originaldaten

- in der Klinik für Mund-, Kiefer- und Gesichtschirurgie des Universitätsklinikums Aachen

hinterlegt sind. Erklärung gemäß § 5 Abs. (1) und (2), und § 11 Abs. (3) 12. der Promotionsordnung

Hiermit erkläre ich, Juliana-Theresa Schell, an Eides statt, dass ich den wesentlichen Anteil an der Publikation: Schell J-T., Petermann-Meyer A., Kloss -Brandstätter A., Bartella AK., Kamal M., Hölzle F., Lethaus B.,Teichmann J.: Distress Thermometer for preoperative screening of patients with oral squamous cell carcinoma; Journal of Cranio-Maxillo-Facial Surgery 46 (2018) 1111-1116 geleistet habe. Die Anteile an der Arbeit waren wie folgt:

Schell Petermann- Kloss- Bartella Kamal Hölzle Lethaus Teichmann Summe

Meyer Brandstätter (%)

Studienüberwachung 20 10 70 100

Studiendesign/ 60 10 30 100

Konzeption

Untersuchung der 100 100

Probanden

Datenauswertung 100 100

Statistische Auswertung 70 30 100

Bereitstellung von 10 20 10 25 25 10 100 Materialien

Interpretation der 60 20 10 10 100

Datenauswertung

Verfassung des 100 100

Manuskripts

Korrektur des 10 10 5 20 5 40 10 100

Manuskripts

Aus diesem wesentlichen Anteil ergibt sich selbstverständlich die Stellung als Erstautor / in.

______Unterschrift der Doktorandin

Als Doktorvater und korrespondierender Autor bestätige ich die Angaben von Juliana-Theresa Schell und in Vertretung für die Kooperationspartner

______Unterschrift des Doktorvaters

Ich schließe mich der Erklärung von Priv.-Doz. Dr. Dr. Bernd Lethaus als Koautor an

Andrea Petermann-Meyer

Anita Kloss-Brandstätter

Alexander Karl Heinz Bartella

Mohammad Kamal

Frank Hölzle

Jan Teichmann