Association between Geriatric 8 (G8) Scores and Self-Care Decline in Elderly Patients with Head and Neck Squamous Cell Carcinoma Undergoing Radiotherapy

Association between Geriatric 8 (G8) Scores and Self-Care Decline in Elderly Patients with Head and Neck Squamous Cell Carcinoma Undergoing Radiotherapy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Association between Geriatric 8 (G8) Scores and Self-Care Decline in Elderly Patients with Head and Neck Squamous Cell Carcinoma Undergoing Radiotherapy Tsuyoshi Katsuta, Ikuno Nishibuchi, Miki Fujioka, Megumi Nomura, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6689251/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 16 Sep, 2025 Read the published version in Supportive Care in Cancer → Version 1 posted 10 You are reading this latest preprint version Abstract Purpose Self-care during radiotherapy (RT) is crucial for managing mucositis and dermatitis in patients with head and neck squamous cell carcinomas (HNSCC). However, elderly patients often struggle with self-care. This study examined the relationship between self-care decline and the Geriatric 8 (G8) score. Methods A retrospective analysis was conducted on 66 patients (≥ 65 years) treated between December 2018 and February 2023. Self-care activities—medication adherence, oral care, grooming, skin ointment application, and gauze dressing—were assessed during definitive RT on a 0–5 scale. Patients were first grouped by initial self-care independence, and their G8 scores were compared. Among initially independent patients, those with self-care score changes were further analyzed based on their G8 scores. A threshold value was also determined to differentiate between the groups. Results The initially independent group exhibited significantly higher G8 scores than non-independent group (median G8 score: 14 vs. 9.75, P = 0.0067). Among the initially independent patients, 15 (24.2%) experienced self-care decline, and lower baseline G8 scores significantly predicted this deterioration (median G8 score: 12 vs. 15; P = 0.011). Multivariate analysis identified G8 scores as a significant predictor of self-care decline (odds ratio = 6.53, P = 0.0074). Receiver operating characteristic (ROC) analysis determined a G8 cutoff of 12 (area under the curve = 0.72) with 85.1% specificity. Conclusion These findings highlight the importance of geriatric assessment in predicting self-care maintenance in elderly HNSCC patients undergoing RT. Geriatric assessment G8 screening tool Elderly patients Self-care Head and neck cancer Chemoradiotherapy Figures Figure 1 1. Introduction Radiotherapy (RT) and chemoradiotherapy (CRT) are well-established standard treatments for head and neck squamous cell carcinomas (HNSCC) [ 1 , 2 , 3 ]. These approaches preserve anatomical structures and organ function and are preferred when surgery is not feasible due to advanced age, comorbidities, or patient refusal. However, RT often causes toxic effects like dermatitis and mucositis [ 4 , 5 ], which can result in significant discomfort, pain, systemic infections, or treatment interruptions. Effective management of these side effects is essential to ensure treatment adherence and completion. Treatment-related toxicities depend on factors such as treatment intensity, irradiated area extent, nutritional status, and supportive self-care [ 6 , 7 , 8 ]. Among these factors, self-care activities during treatment have gained increasing attention in recent years. For acute dermatitis, proper skin cleansing and prophylactic moisturizers promote recovery, and surgical pads can accelerate healing [8, 9 ]. To prevent mucositis progression, the Multinational Association of Supportive Care in Cancer (MASCC) and the International Society of Oral Oncology (ISOO) guidelines recommend the implementation of basic oral care [ 10 ]. Elderly patients face challenges maintaining self-care due to cognitive and physical decline [ 11 ]. Even within the same age group, health and functional abilities vary greatly, a phenomenon referred to as the “heterogeneity of the elderly,” which underscores the need for individualized care [ 12 ]. The American Society of Clinical Oncology (ASCO) and International Society of Geriatric Oncology (SIOG) recommend geriatric assessment (GA) as a gold standard to evaluate elderly patients’ health, predicting function, institutionalization risk, and mortality [ 13 , 14 ]. However, since the implementation of GA requires significant human and time resources, several simplified GA screening tools have been developed [ 15 , 16 ]. Among these tools, the geriatric-8 (G8) screening tool has been reported to be simple yet useful in identifying vulnerable patients [ 17 ]. Despite growing interest in self-care during RT, few studies have examined the relationship between self-care activities and GA among elderly patients with HNSCC. This study aimed to investigate the relationship between changes in self-care activities during definitive RT or CRT and G8 screening tool scores. 2. Materials and Methods Study Design Ethics This retrospective study aimed to evaluate the relationship between changes in self-care activities during definitive RT or CRT and the G8 screening tool scores in patients aged 65 years or older with HNSCC treated at our institution between December 2018 and February 2023. The study was approved by the Certified Clinical Research Committee of Hiroshima University (Certification Number: E2019-1656-10) and conducted in accordance with the principles of the Declaration of Helsinki. Patients Selection Patients were considered eligible if they had histological evidence of HNSCC, and the tumor stage was classified according to the 8th edition of the American Joint Committee on Cancer Staging Manual and Handbook [ 18 ]. Inclusion criteria included: (1) definitive RT or CRT for HNSCC, (2) a prescribed dose of 60–70 Gy to the laryngopharyngeal region, and (3) age ≥65 years at consent. Exclusion criteria included: (1) tumors of the parotid gland, nasal cavity, or paranasal sinuses, (2) histological types other than squamous cell carcinoma, (3) prior RT in the head and neck region, (4) palliative RT, and (5) patients who were judged inappropriate by the principal investigator or the research coordinator. Radiotherapy Patients were immobilized using thermoplastic masks, and contrast-enhanced CT scans were obtained for treatment planning (Varian Medical Systems, Palo Alto, CA, USA). Treatment plans utilized volumetric modulated arc therapy (VMAT) with the simultaneous integrated boost technique. A total dose of 70 Gy in 35 fractions was administered to primary tumors and metastatic lymph nodes, 63 Gy to areas adjacent to the primary tumor, and 56 Gy to selective lymph nodes. For patients with widespread lymph node metastases, early-stage cancer, or advanced age, the simultaneous integrated boost method was replaced with a 2-step VMAT approach or reduced irradiated fields limited to the primary tumor and surrounding area. The treatment plan was delivered to the patient through TrueBeam linear accelerators (Varian Medical Systems). Chemotherapy For fit patients with advanced or locally aggressive HNSCC, neoadjuvant chemotherapy was administered to reduce tumor volume [ 19 ]. The TPF regimen included docetaxel (70 mg/m²) on day 1, cisplatin (CDDP) (70 mg/m²) on day 1, and 5-fluorouracil (750 mg/m²) as a continuous 5-day infusion. Two cycles were delivered at 3–4-week intervals. Concurrent chemotherapy involved three cycles of CDDP (100 mg/m²) every three weeks. For patients unable to tolerate CDDP, carboplatin or cetuximab [ 20 ] was substituted. RT alone was performed for patients unsuitable for chemotherapy. Geriatric Assessment and Grading of the Self-care Activities The G8 consists of eight items that assess various aspects of health and functional status: 1) food intake in the last 3 months, 2) recent weight loss (< 3 months), 3) mobility, 4) neuropsychological problems, 5) body mass index (BMI), 6) polypharmacy (take ≥3 medications per day), 7) self-perceived health status compared to the same age people, and 8) age. The total score ranges from 0 to 17 (Supplementary table S1), with lower scores indicating poorer general health status and frailty. During therapy, patients were evaluated by radiation oncologists and radiation oncology nurses every 10 Gy to assess the severity of acute oral/pharyngeal radiation mucositis and neck radiation dermatitis based on the National Cancer Institute Common Terminology Criteria for Adverse Events (version 5.0). Simultaneously, face-to-face educational interviews, lasting approximately 20–30 minutes, were conducted by nurses. These interviews aimed to assess self-care activities related to managing radiation-induced side effects and to provide supportive care to promote patient actions. The following five activities were evaluated: 1) medication adherence, 2) oral care, 3) grooming, 4) skin ointment application, and 5) gauze dressing. For each self-care activity, one point was deducted if nursing intervention was required, resulting in a total point ranging from 0 to 5 (maximum: 5 points, minimum: 0 points). Specific criteria for judging self-care activities, such as whether or not needing the intervention, were based on the report of Nakano et al [ 21 ]. Patients were initially classified into two groups based on their self-care independence at the beginning of treatment: those who were independent in self-care (initially independent group) and those who required nursing intervention (initially non-independent group). The difference in G8 scores between these two groups was analyzed to explore the relationship between baseline self-care abilities and frailty. Further categorization was performed within the initially independent group, where patients were divided into those whose self-care abilities remained stable throughout treatment and those who eventually required nursing assistance. Differences in G8 scores between these subgroups were also examined. Additionally, among the five self-care activities, the most challenging one to maintain during treatment was identified. Statistical Analysis To evaluate the association between G8 scores and self-care independence, statistical analyses were conducted using Excel statistical software ver. 4.08 (BellCurve for Excel; Social Survey Research Information Co., Ltd., Tokyo, Japan). Statistical significance was set at P < 0.05. Comparisons of G8 scores between the initially independent and non-independent group were performed using the Mann-Whitney U test. Similarly, comparisons of G8 scores between subgroups within the initially independent group—those who maintained independence versus those who required nursing assistance—were also conducted using the Mann-Whitney U test. Additionally, logistic regression analysis was performed to explore potential predictors of self-care decline among clinical characteristics, excluding age, as it was already accounted for in G8 score. Variables with P < 0.1 in the univariate analysis were included in the multivariable model. Fisher’s exact test was used to examine associations between categorical baseline characteristics and self-care decline. To further evaluate significant findings, receiver operating characteristic (ROC) curve analysis was conducted to determine cutoff values, the area under the curve (AUC), sensitivity, and specificity, providing further insight into self-care deterioration in elderly patients undergoing RT. 3. Results From December 2018 and February 2023, 66 patients were enrolled. Their clinical data are summarized in Table 1. The gender were 60 patients (90.9%) were male, and the mean age was 74.2 years (range: 67–94). Eastern Cooperative Oncology Group (ECOG) Performance Status (PS) was distributed as follows: 52 patients (78.8%) with PS 0, 12 patients (18.2%) with PS 1, and 2 patients (3.0%) with PS 2. The mean G8 score was 13.5 (range: 7–17), with a median score of 14. Details of G8 scores are provided in Supplementary table S2. Treatment settings included 63 patients (95.5%) treated as inpatients and 3 patients (4.5%) as outpatients. The primary tumor sites included the nasopharynx (5 patients, 7.6%), oropharynx (15 patients, 22.7%), hypopharynx (33 patients, 50.0%), oral cavity and mouth floor (8 patients, 12.1%), and larynx (5 patients, 7.6%). Among oropharyngeal cases, 9 patients were tested for p16 expression. Disease stages were distributed as follows: Stage 0–I in 5 patients (7.6%), Stage II in 15 (22.7%), Stage III in 15 (22.7%), and Stage IVA–IVB in 31 (47.0%). For radiotherapy, 63 patients (95.5%) received 70 Gy in 35 fractions, 2 patients (3.0%) received 66–68 Gy in 33–34 fractions, and 1 patient (1.5%) received 62 Gy in 31 fractions, with treatment discontinued due to chemotherapy complications. VMAT was used in 64 patients (97.0%), while 2 (3.0%) received three-dimensional conformal radiation therapy. Whole-neck irradiation, including prophylactic lymph node areas, was performed in 57 patients (86.4%), while 9 (13.6%) received a shrinking field technique. Neoadjuvant chemotherapy was given to 23 patients (34.8%) with TPF. Concurrent chemotherapy included CDDP in 45 patients (68.2%), CBCDA in 2 (3.0%), cetuximab in 9 (13.6%), while 10 patients (15.2%) received radiotherapy alone. During treatment, grade 3 mucositis and dermatitis were observed in 14 (21.2%) and 12 (18.1%) patients, respectively, with no grade 4 or higher adverse events. Comparison of G8 Scores Between Initially Independent and Non-Independent Groups At the start of treatment, 62 patients (93.9%) were independent in self-care (initially independent group), while 4 patients (6.1%) required nursing assistance (initially non-independent group). The initially independent group had a significantly higher baseline G8 score compared to the non-independent group (median G8 score: 14 vs. 9.75; P = 0.0067). This suggests that patients requiring nursing intervention at baseline were frailer and had poorer general health. Self-Care Maintenance During Treatment Within the initially independent group, 47 patients (75.8%) maintained their self-care independence throughout the treatment period, while 15 patients (24.2%) eventually required nursing intervention. The G8 score at baseline was significantly lower in the subgroup that experienced self-care decline compared to those who remained independent (median G8 score: 12 vs. 15; P = 0.011). Declines of 1, 2, 3, and 4 points were observed in 3, 8, 2, and 2 patients, respectively. Skin ointment application was the most challenging activity, requiring assistance in 11 patients. Details of other items are listed in Table 2. Predictors of Self-Care Decline Among clinical variables, G8 scores were significant predictors of self-care decline, while PS ( P = 0.081) was not statistically significant but showed a trend toward significance in the univariate analysis (Table 3). In multivariate analysis, both variables reached significance, but G8 scores (OR = 6.53, 95% CI: 1.79–23.81, P = 0.0074) showed stronger predictive power compared to PS (OR = 3.42, 95% CI: 0.87–13.49, P = 0.029) (Table 4). ROC analysis identified a G8 score cutoff of 12, with an AUC of 0.72, sensitivity of 53.3%, and specificity of 85.1% (Figure 1). 4. Discussion To our knowledge, this is the first study to quantitatively evaluate the association between G8 screening scores and self-care capacity in elderly patients undergoing definitive RT or CRT for HNSCC. The results demonstrate that lower G8 scores are significantly associated with a decline in self-care abilities during treatment. Patients who were initially independent in self-care but later required nursing assistance had significantly lower baseline G8 scores than those who maintained their independence. Additionally, a G8 score cutoff of 12 was identified as a predictor of self-care deterioration, with an odds ratio of 6.53. GA had been widely recognized as essential tools for evaluating the overall health status of elderly patients undergoing cancer treatment. The G8 screening tool has been previously associated with treatment tolerance, chemotherapy-related toxicities, and survival outcomes in elderly cancer patients [ 22 , 23 , 24, 25 , 26 ]. Our study adds to this growing body of evidence by demonstrating its predictive value in self-care maintenance during RT. The strong association between lower G8 scores and self-care decline suggests that frailty, as measured by G8, affects not only treatment outcomes but also the ability of elderly patients to manage side effects effectively. This study emphasizes the importance of early assessment and intervention to support self-care maintenance. The G8 screening tool demonstrated high specificity (85.1%), making it valuable for minimizing false positives among patients predicted to struggle with self-care. This specificity is particularly relevant in resource-limited settings, such as facilities with fewer nurses who need to care for a large number of patients undergoing treatment. By focusing care on at-risk patients identified through the G8, more efficient and effective supportive interventions can be implemented. There are limited studies examining GA in the context of RT. Regarding RT-related toxicity, Cuccia et al. reported that lower G8 scores were associated with an increased likelihood of late toxicity in patients undergoing stereotactic radiotherapy for lung cancer [ 27 ]. Additionally, studies on instrumental activities of daily living have shown that lower G8 scores correlate with decreased functional independence [ 28 ]. Our findings align with these reports, further emphasizing the importance of assessing frailty in elderly cancer patients. However, unlike previous studies, our research specifically identifies self-care maintenance as a crucial factor influenced by baseline G8 scores in patients with HNSCC undergoing RT. The ECOG PS, a commonly used functional measure in oncology, showed an association with self-care decline; while, the G8 tool demonstrated a stronger and more significant correlation. This highlights the limitations of traditional metrics in geriatric populations and underscores the G8 tool’s ability to capture broader health dimensions, including physical, cognitive, and nutritional status. These results align with previous findings suggesting the G8 is a more sensitive and comprehensive predictor of general condition in geriatric care [ 29 , 25]. In this study, a G8 score of 12 was identified as the threshold. In other reports on the G8 screening tool, a score of ≤14 out of 17 points is considered abnormal [ 30 , 26]. In HNSCC, the progression of the disease itself is closely linked to nutritional status, which may result in generally lower scores. Additionally, in this study, G8 scores were obtained at the time of referral to the radiation oncology department. Approximately 35% of the patients had already undergone neoadjuvant chemotherapy, and it cannot be ruled out that the deterioration of nutritional status caused by chemotherapy or the increased use of medications to manage chemotherapy-related side effects may have influenced their scores. Therefore, further investigation is needed to determine whether similar results would be observed in other types of cancer. We selected 5 commonly recommended self-care activities for managing radiation-induced dermatitis and mucositis with reference to previous research and clinical guidelines [7, 8, 9, 10] in this study. For the assessment criteria, we adopted the framework proposed by Nakano et al., which discusses standards for evaluating patients’ self-care levels in managing cancer-related symptoms. Currently, there is no standardized method for assessing self-care activities or their measurement specific to HNSCC field. Instrument such as the Exercise of Self-Care Agency Scale (ESCA) [ 31 ] is well-known but was developed for broader applications, including chronic illnesses, and not specific to cancer care. Furthermore, its large number of items makes them impractical for routine clinical use. The evaluation items and criteria employed in this study will require further refinement. However, given that they were designed to be specific to RT for HNSCC, simple, and as clearly defined as possible, we believe they are valid and broadly applicable in clinical practice. Among the self-care activities, skin ointment application emerged as the most challenging, requiring nursing assistance in 11 patients. Reasons for the difficulty in proper ointment application included the anatomically complex structure of the head and neck region, as well as areas like the nape of the neck being hard to reach. These factors made it challenging to apply the ointment thinly and flatly. Additionally, symptoms of radiation dermatitis typically appear gradually a few weeks after the start of RT [ 32 , 8, 9], highlighting the difficulty of encouraging patients to perform appropriate preventive measures from the early stages of treatment [ 33 ]. At our department, during interviews, patients are provided with instructions on the importance and methods of ointment application, using each patient’s dose distribution map of RT. This approach is intended to encourage patients to continue self-care independently as much as possible. Moving forward, enhanced supportive care should be developed for patients with G8 scores ≤12 to improve their understanding and ability to maintain self-care activities. Strategies could include visual aids, such as illustrated instructional materials [ 34 ], and increasing the frequency of supportive care sessions from once per week to twice per week to provide more comprehensive assistance. Integrating the G8 score into the treatment plan may help tailor treatment approaches based on patients’ tolerance levels; for those with extremely low G8 scores and significant frailty, a shift toward irradiation focused on symptom palliation may be necessary [ 35 , 22]. Additionally, shortening the duration of radiotherapy through hypofractionated RT could be considered to reduce the treatment burden [ 36 , 37 ]. There are some limitations of our study. First, it is a single-institution, retrospective study, which may limit the generalizability of the findings. Conducting multi-center prospective studies in the future will enable us to more clearly establish the causal relationship between G8 scores and self-care activities. Second, the sample size was small, particularly in the initially non-independent group, may have influenced statistical power. Since the study focused specifically on patients ≥ 65 years, the overall sample volume was restricted. Third, setting the use of gauze dressing as self-care evaluation item may have introduced bias. At our facility, gauze dressing is not routinely recommended for all cases; it is typically initiated only when dermatitis becomes severe. For some patients, dermatitis remained mild throughout the treatment period, which may have led to an underestimation in this analysis. Nonetheless, the conclusion that lower G8 scores are associated with a decline in self-care remains robust. In conclusion, the G8 screening tool serves as a practical and reliable predictor of self-care challenges during RT and CRT in patients with HNSCC. Its integration into routine clinical practice enables early identification of at-risk individuals, allowing for timely nursing interventions and tailored support strategies. By addressing the unique needs of this population, the G8 tool contributes to better treatment outcomes, fewer complications, and an improved quality of life for elderly cancer patients. Declarations Funding: Not applicable. Author Contribution Conception and design : T. Katsuta, I. Nishibuchi, M. Fujioka. Data collection : T. Katsuta, M. Fujioka, M. Nomura. Analysis and interpretation of data : T. Katsuta. 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Mayo ZS, Ilori EO, Matia B, et al (2022) Limited Toxicity of Hypofractionated Intensity Modulated Radiation Therapy for Head and Neck Cancer. Anticancer Res 42: 1845-1849. https://doi.org/10.21873/anticanres.15660. Tables Table 1. Patients’ and treatment characteristics of head and neck squamous cell carcinoma. Characteristic Number of patients ( N = 66) ( % ) Gender Male 60 90.9 Female 6 9.1 Age(years) Mean 74.2 Range 67–94 Performance status 0 52 78.8 1 12 18.2 2 2 3.0 G8 score Mean 13.5 Range 7-17 Treatment setting Inpatient 63 95.5 Outpatient 3 4.5 Primary tumor site Nasopharynx 5 7.6 Oropharynx 15 22.7 Hypopharynx 33 50.0 Oral cavity and mouth floor 8 12.1 Larynx 5 7.6 Clinical stage Stage 0- I 5 7.6 Stage II 15 22.7 Stage III 15 22.7 Stage IVA and IVB 31 47.0 Total Dose (Gy) /fr 70 Gy/35fr 63 95.5 66-68 Gy/33-34fr 2 3.0 62 Gy/31fr 1 1.5 Combination Chemotherapy Cisplatin 45 68.2 Carboplatin 2 3.0 Cetuximab 9 13.6 RT alone 10 15.2 Self-care independence Independent 62 93.9 Need assistance 4 6.1 Abbreviations, G8: geriatric 8, fr: fractions, RT: radiation therapy Table 2. Self-care activities requiring nursing assistance at the end of RT. Self-care activities Medication adherence Oral care Grooming Skin ointment application Gauze dressing Number of patients ( N = 15) 2 5 5 11 10 Abbreviations, RT: radiation therapy Table 3. Results of Univariate analysis. Variables Self-care decline N = 15 (%) Not self-care decline N = 47 (%) P -value Gender Male 14 (93.3) 44 (93.6) 0.68 Female 1 (6.7) 3 (6.4) Performance status 0 10 (66.7) 41 (87.2) 0.081 1 5 (33.3) 6 (12.8) G8 score Median 12 15 0.011 Range 8-17 7-17 Treatment setting Inpatient 15 (100) 44 (93.6) 0.43 Outpatient 0 (0) 3 (6.4) Clinical stage Stage 0- II 3 (20.0) 16 (34.0) 0.24 Stage III-Ⅳ 12 (80.0) 31 (66.0) Chemotherapy Yes 12 (80.0) 43 (91.5) 0.22 No 3 (20.0) 4 (8.5) Abbreviations, G8: geriatric 8. Bold type indicates that the P -value is equal to or less than the level of statistical significance (0.05). Table 4. Multivariate logistic regression model for self-care decline. Variables Odds ratio 95% CI P -value Performance status 3.42 0.87-13.49 0.029 G8 score 6.53 1.79-23.81 0.0074 Abbreviations, CI: confidence interval, G8: geriatric 8. Bold type indicates that the P -value is equal to or less than the level of statistical significance (0.05). Additional Declarations No competing interests reported. Supplementary Files SupplymentalMaterials.docx Cite Share Download PDF Status: Published Journal Publication published 16 Sep, 2025 Read the published version in Supportive Care in Cancer → Version 1 posted Editorial decision: Revision requested 21 Jul, 2025 Reviews received at journal 09 Jul, 2025 Reviews received at journal 01 Jul, 2025 Reviewers agreed at journal 30 Jun, 2025 Reviewers agreed at journal 27 Jun, 2025 Reviewers agreed at journal 27 Jun, 2025 Reviewers invited by journal 27 Jun, 2025 Editor assigned by journal 24 Jun, 2025 Submission checks completed at journal 22 May, 2025 First submitted to journal 17 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Hospital","correspondingAuthor":false,"prefix":"","firstName":"Miki","middleName":"","lastName":"Fujioka","suffix":""},{"id":478324437,"identity":"d7e12e5a-cf66-44f5-b6dd-dc43df7ff454","order_by":3,"name":"Megumi Nomura","email":"","orcid":"","institution":"Hiroshima University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Megumi","middleName":"","lastName":"Nomura","suffix":""},{"id":478324440,"identity":"c1e8a93d-7109-4334-a0f0-a6b45a841eb8","order_by":4,"name":"Miho Kondo","email":"","orcid":"","institution":"Hiroshima University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Miho","middleName":"","lastName":"Kondo","suffix":""},{"id":478324441,"identity":"393ea251-6014-4142-bd72-aff7c66becbf","order_by":5,"name":"Takao Hamamoto","email":"","orcid":"","institution":"Hiroshima 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University","correspondingAuthor":false,"prefix":"","firstName":"Hiroshi","middleName":"","lastName":"Sakauchi","suffix":""},{"id":478324445,"identity":"a291073a-32cc-4fc1-b57a-7c0886460f5b","order_by":9,"name":"Shigeyuki Tani","email":"","orcid":"","institution":"Hiroshima University","correspondingAuthor":false,"prefix":"","firstName":"Shigeyuki","middleName":"","lastName":"Tani","suffix":""},{"id":478324446,"identity":"4e91301e-8b3a-4056-9643-d37475454a2b","order_by":10,"name":"Nobuki Imano","email":"","orcid":"","institution":"Hiroshima University","correspondingAuthor":false,"prefix":"","firstName":"Nobuki","middleName":"","lastName":"Imano","suffix":""},{"id":478324447,"identity":"3be20104-e158-4fa8-9a69-5c212ceee7fe","order_by":11,"name":"Yuji Murakami","email":"","orcid":"","institution":"Hiroshima University","correspondingAuthor":false,"prefix":"","firstName":"Yuji","middleName":"","lastName":"Murakami","suffix":""}],"badges":[],"createdAt":"2025-05-18 01:08:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6689251/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6689251/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00520-025-09936-2","type":"published","date":"2025-09-16T15:57:09+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":85828288,"identity":"03c855fd-e938-4de0-80d8-56c6bf4a11dc","added_by":"auto","created_at":"2025-07-02 07:28:27","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":15350,"visible":true,"origin":"","legend":"\u003cp\u003eThe receiver operator characteristic curve for Geriatric8 scores in the prediction of self-care activity decline.\u003c/p\u003e\n\u003cp\u003eAbbreviation: AUC, area under the curve.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6689251/v1/d67595f9d8c52d008dd8287a.png"},{"id":91889851,"identity":"e992bbfe-464c-450f-b8a8-c990747cc6f1","added_by":"auto","created_at":"2025-09-22 16:02:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":725921,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6689251/v1/3dff0b23-1a10-4b34-a1c7-dae818825233.pdf"},{"id":85830984,"identity":"7aef0493-61d7-4e68-b237-363a260e20a3","added_by":"auto","created_at":"2025-07-02 07:44:27","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":35983,"visible":true,"origin":"","legend":"","description":"","filename":"SupplymentalMaterials.docx","url":"https://assets-eu.researchsquare.com/files/rs-6689251/v1/ad8e05eb5e2b9dbf7c105e29.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Association between Geriatric 8 (G8) Scores and Self-Care Decline in Elderly Patients with Head and Neck Squamous Cell Carcinoma Undergoing Radiotherapy","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eRadiotherapy (RT) and chemoradiotherapy (CRT) are well-established standard treatments for head and neck squamous cell carcinomas (HNSCC) [\u003csup\u003e1\u003c/sup\u003e,\u003csup\u003e2\u003c/sup\u003e,\u003csup\u003e3\u003c/sup\u003e]. These approaches preserve anatomical structures and organ function and are preferred when surgery is not feasible due to advanced age, comorbidities, or patient refusal. However, RT often causes toxic effects like dermatitis and mucositis [\u003csup\u003e4\u003c/sup\u003e,\u003csup\u003e5\u003c/sup\u003e], which can result in significant discomfort, pain, systemic infections, or treatment interruptions. Effective management of these side effects is essential to ensure treatment adherence and completion.\u003c/p\u003e\n\u003cp\u003eTreatment-related toxicities depend on factors such as treatment intensity, irradiated area extent, nutritional status, and supportive self-care [\u003csup\u003e6\u003c/sup\u003e, \u003csup\u003e7\u003c/sup\u003e, \u003csup\u003e8\u003c/sup\u003e]. Among these factors, self-care activities during treatment have gained increasing attention in recent years. For acute dermatitis, proper skin cleansing and prophylactic moisturizers promote recovery, and surgical pads can accelerate healing [8, \u003csup\u003e9\u003c/sup\u003e]. To prevent mucositis progression, the Multinational Association of Supportive Care in Cancer (MASCC) and the International Society of Oral Oncology (ISOO) guidelines recommend the implementation of basic oral care [\u003csup\u003e10\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003eElderly patients face challenges maintaining self-care due to cognitive and physical decline [\u003csup\u003e11\u003c/sup\u003e]. Even within the same age group, health and functional abilities vary greatly, a phenomenon referred to as the \u0026ldquo;heterogeneity of the elderly,\u0026rdquo; which underscores the need for individualized care [\u003csup\u003e12\u003c/sup\u003e]. The American Society of Clinical Oncology (ASCO) and International Society of Geriatric Oncology (SIOG) recommend geriatric assessment (GA) as a gold standard to evaluate elderly patients\u0026rsquo; health, predicting function, institutionalization risk, and mortality [\u003csup\u003e13\u003c/sup\u003e,\u003csup\u003e14\u003c/sup\u003e]. However, since the implementation of GA requires significant human and time resources, several simplified GA screening tools have been developed [\u003csup\u003e15\u003c/sup\u003e,\u003csup\u003e16\u003c/sup\u003e]. Among these tools, the geriatric-8 (G8) screening tool has been reported to be simple yet useful in identifying vulnerable patients [\u003csup\u003e17\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003eDespite growing interest in self-care during RT, few studies have examined the relationship between self-care activities and GA among elderly patients with HNSCC. This study aimed to investigate the relationship between changes in self-care activities during definitive RT or CRT and G8 screening tool scores.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design Ethics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective study aimed to evaluate the relationship between changes in self-care activities during definitive RT or CRT and the G8 screening tool scores in patients aged 65 years or older with HNSCC treated at our institution between December 2018 and February 2023. The study was approved by the Certified Clinical Research Committee of Hiroshima University (Certification Number: E2019-1656-10)\u0026nbsp;and conducted in accordance with the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatients Selection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients were considered eligible if they had histological evidence of HNSCC, and the tumor stage was classified according to the 8th edition of the American Joint Committee on Cancer Staging Manual and Handbook [\u003csup\u003e18\u003c/sup\u003e]. Inclusion criteria included: (1) definitive RT or CRT for HNSCC, (2) a prescribed dose of 60\u0026ndash;70 Gy to the laryngopharyngeal region, and (3) age \u0026ge;65 years at consent. Exclusion criteria included: (1) tumors of the parotid gland, nasal cavity, or paranasal sinuses, (2) histological types other than squamous cell carcinoma, (3) prior RT in the head and neck region, (4) palliative RT, and (5) patients who were judged inappropriate by the principal investigator or the research coordinator.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRadiotherapy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients were immobilized using thermoplastic masks, and contrast-enhanced CT scans were obtained for treatment planning (Varian Medical Systems, Palo Alto, CA, USA). Treatment plans utilized volumetric modulated arc therapy (VMAT) with the simultaneous integrated boost technique. A total dose of 70 Gy in 35 fractions was administered to primary tumors and metastatic lymph nodes, 63 Gy to areas adjacent to the primary tumor, and 56 Gy to selective lymph nodes. For patients with widespread lymph node metastases, early-stage cancer, or advanced age, the simultaneous integrated boost method was replaced with a 2-step VMAT approach or reduced irradiated fields limited to the primary tumor and surrounding area. The treatment plan was delivered to the patient through TrueBeam linear accelerators (Varian Medical Systems).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChemotherapy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor fit patients with advanced or locally aggressive HNSCC, neoadjuvant chemotherapy was administered to reduce tumor volume [\u003csup\u003e19\u003c/sup\u003e]. The TPF regimen included docetaxel (70 mg/m\u0026sup2;) on day 1, cisplatin (CDDP) (70 mg/m\u0026sup2;) on day 1, and 5-fluorouracil (750 mg/m\u0026sup2;) as a continuous 5-day infusion. Two cycles were delivered at 3\u0026ndash;4-week intervals. Concurrent chemotherapy involved three cycles of CDDP (100 mg/m\u0026sup2;) every three weeks. For patients unable to tolerate CDDP, carboplatin or cetuximab [\u003csup\u003e20\u003c/sup\u003e] was substituted. RT alone was performed for patients unsuitable for chemotherapy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGeriatric Assessment and Grading of the Self-care Activities\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe G8 consists of eight items that assess various aspects of health and functional status: 1) food intake in the last 3 months, 2) recent weight loss (\u0026lt; 3 months), 3) mobility, 4) neuropsychological problems, 5) body mass index (BMI), 6) polypharmacy (take\u0026nbsp;\u0026ge;3 medications per day), 7) self-perceived health status compared to the same age people, and 8) age. The total score ranges from 0 to 17 (Supplementary table S1), with lower scores indicating poorer general health status and frailty.\u003c/p\u003e\n\u003cp\u003eDuring therapy, patients were evaluated by radiation oncologists and radiation oncology nurses every 10 Gy to assess the severity of acute oral/pharyngeal radiation mucositis and neck radiation dermatitis based on the National Cancer Institute Common Terminology Criteria for Adverse Events (version 5.0). Simultaneously, face-to-face educational interviews, lasting approximately 20\u0026ndash;30 minutes, were conducted by nurses. These interviews aimed to assess self-care activities related to managing radiation-induced side effects and to provide supportive care to promote patient actions. The following five activities were evaluated: 1) medication adherence, 2) oral care, 3) grooming, 4) skin ointment application, and 5) gauze dressing. For each self-care activity, one point was deducted if nursing intervention was required, resulting in a total point ranging from 0 to 5 (maximum: 5 points, minimum: 0 points). Specific criteria for judging self-care activities, such as whether or not needing the intervention, were based on the report of Nakano et al [\u003csup\u003e21\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003ePatients were initially classified into two groups based on their self-care independence at the beginning of treatment: those who were independent in self-care (initially independent group) and those who required nursing intervention (initially non-independent group). The difference in G8 scores between these two groups was analyzed to explore the relationship between baseline self-care abilities and frailty.\u003c/p\u003e\n\u003cp\u003eFurther categorization was performed within the initially independent group, where patients were divided into those whose self-care abilities remained stable throughout treatment and those who eventually required nursing assistance. Differences in G8 scores between these subgroups were also examined. Additionally, among the five self-care activities, the most challenging one to maintain during treatment was identified.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo evaluate the association between G8 scores and self-care independence, statistical analyses were conducted using Excel statistical software ver. 4.08 (BellCurve for Excel; Social Survey Research Information Co., Ltd., Tokyo, Japan). Statistical significance was set at \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05.\u003c/p\u003e\n\u003cp\u003eComparisons of G8 scores between the initially independent and non-independent group were performed using the Mann-Whitney U test. Similarly, comparisons of G8 scores between subgroups within the initially independent group\u0026mdash;those who maintained independence versus those who required nursing assistance\u0026mdash;were also conducted using the Mann-Whitney U test.\u003c/p\u003e\n\u003cp\u003eAdditionally, logistic regression analysis was performed to explore potential predictors of self-care decline among clinical characteristics, excluding age, as it was already accounted for in G8 score. Variables with \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.1 in the univariate analysis were included in the multivariable model. Fisher\u0026rsquo;s exact test was used to examine associations between categorical baseline characteristics and self-care decline.\u003c/p\u003e\n\u003cp\u003eTo further evaluate significant findings, receiver operating characteristic (ROC) curve analysis was conducted to determine cutoff values, the area under the curve (AUC), sensitivity, and specificity, providing further insight into self-care deterioration in elderly patients undergoing RT.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eFrom December 2018 and February 2023, 66 patients were enrolled. Their clinical data are summarized in Table 1. The gender were 60 patients (90.9%) were male, and the mean age was 74.2 years (range: 67\u0026ndash;94). Eastern Cooperative Oncology Group (ECOG) Performance Status (PS) was distributed as follows: 52 patients (78.8%) with PS 0, 12 patients (18.2%) with PS 1, and 2 patients (3.0%) with PS 2. The mean G8 score was 13.5 (range: 7\u0026ndash;17), with a median score of 14. Details of G8 scores are provided in Supplementary table S2. Treatment settings included 63 patients (95.5%) treated as inpatients and 3 patients (4.5%) as outpatients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe primary tumor sites included the nasopharynx (5 patients, 7.6%), oropharynx (15 patients, 22.7%), hypopharynx (33 patients, 50.0%), oral cavity and mouth floor (8 patients, 12.1%), and larynx (5 patients, 7.6%). Among oropharyngeal cases, 9 patients were tested for p16 expression. Disease stages were distributed as follows: Stage 0\u0026ndash;I in 5 patients (7.6%), Stage II in 15 (22.7%), Stage III in 15 (22.7%), and Stage IVA\u0026ndash;IVB in 31 (47.0%).\u003c/p\u003e\n\u003cp\u003eFor radiotherapy, 63 patients (95.5%) received 70 Gy in 35 fractions, 2 patients (3.0%) received 66\u0026ndash;68 Gy in 33\u0026ndash;34 fractions, and 1 patient (1.5%) received 62 Gy in 31 fractions, with treatment discontinued due to chemotherapy complications. VMAT was used in 64 patients (97.0%), while 2 (3.0%) received three-dimensional conformal radiation therapy. Whole-neck irradiation, including prophylactic lymph node areas, was performed in 57 patients (86.4%), while 9 (13.6%) received a shrinking field technique. Neoadjuvant chemotherapy was given to 23 patients (34.8%) with TPF. Concurrent chemotherapy included CDDP in 45 patients (68.2%), CBCDA in 2 (3.0%), cetuximab in 9 (13.6%), while 10 patients (15.2%) received radiotherapy alone.\u003cbr\u003e\u0026nbsp; During treatment, grade 3 mucositis and dermatitis were observed in 14 (21.2%) and 12 (18.1%) patients, respectively, with no grade 4 or higher adverse events.\u003cbr\u003e\u003cstrong\u003eComparison of G8 Scores Between Initially Independent and Non-Independent Groups\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAt the start of treatment, 62 patients (93.9%) were independent in self-care (initially independent group), while 4 patients (6.1%) required nursing assistance (initially non-independent group). The initially independent group had a significantly higher baseline G8 score compared to the non-independent group (median G8 score: 14 vs. 9.75; \u003cem\u003eP\u003c/em\u003e = 0.0067). This suggests that patients requiring nursing intervention at baseline were frailer and had poorer general health.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSelf-Care Maintenance During Treatment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWithin the initially independent group, 47 patients (75.8%) maintained their self-care independence throughout the treatment period, while 15 patients (24.2%) eventually required nursing intervention. The G8 score at baseline was significantly lower in the subgroup that experienced self-care decline compared to those who remained independent (median G8 score: 12 vs. 15; \u003cem\u003eP\u003c/em\u003e = 0.011). Declines of 1, 2, 3, and 4 points were observed in 3, 8, 2, and 2 patients, respectively. Skin ointment application was the most challenging activity, requiring assistance in 11 patients. Details of other items are listed in Table 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePredictors of Self-Care Decline\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong clinical variables, G8 scores were significant predictors of self-care decline, while PS (\u003cem\u003eP\u003c/em\u003e = 0.081) was not statistically significant but showed a trend toward significance in the univariate analysis (Table 3). In multivariate analysis, both variables reached significance, but G8 scores (OR = 6.53, 95% CI: 1.79\u0026ndash;23.81, \u003cem\u003eP\u003c/em\u003e = 0.0074) showed stronger predictive power compared to PS (OR = 3.42, 95% CI: 0.87\u0026ndash;13.49, \u003cem\u003eP\u003c/em\u003e = 0.029) (Table 4). ROC analysis identified a G8 score cutoff of 12, with an AUC of 0.72, sensitivity of 53.3%, and specificity of 85.1% (Figure 1).\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eTo our knowledge, this is the first study to quantitatively evaluate the association between G8 screening scores and self-care capacity in elderly patients undergoing definitive RT or CRT for HNSCC. The results demonstrate that lower G8 scores are significantly associated with a decline in self-care abilities during treatment. Patients who were initially independent in self-care but later required nursing assistance had significantly lower baseline G8 scores than those who maintained their independence. Additionally, a G8 score cutoff of 12 was identified as a predictor of self-care deterioration, with an odds ratio of 6.53.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGA had been widely recognized as essential tools for evaluating the overall health status of elderly patients undergoing cancer treatment. The G8 screening tool has been previously associated with treatment tolerance, chemotherapy-related toxicities, and survival outcomes in elderly cancer patients\u0026nbsp;[\u003csup\u003e22\u003c/sup\u003e, \u003csup\u003e23\u003c/sup\u003e, \u003csup\u003e24,\u003c/sup\u003e \u003csup\u003e25\u003c/sup\u003e, \u003csup\u003e26\u003c/sup\u003e]. Our study adds to this growing body of evidence by demonstrating its predictive value in self-care maintenance during RT. The strong association between lower G8 scores and self-care decline suggests that frailty, as measured by G8, affects not only treatment outcomes but also the ability of elderly patients to manage side effects effectively. This study emphasizes the importance of early assessment and intervention to support self-care maintenance. The G8 screening tool demonstrated high specificity (85.1%), making it valuable for minimizing false positives among patients predicted to struggle with self-care. This specificity is particularly relevant in resource-limited settings, such as facilities with fewer nurses who need to care for a large number of patients undergoing treatment. By focusing care on at-risk patients identified through the G8, more efficient and effective supportive interventions can be implemented.\u003c/p\u003e\n\u003cp\u003eThere are limited studies examining GA in the context of RT. Regarding RT-related toxicity, Cuccia et al. reported that lower G8 scores were associated with an increased likelihood of late toxicity in patients undergoing stereotactic radiotherapy for lung cancer [\u003csup\u003e27\u003c/sup\u003e]. Additionally, studies on instrumental activities of daily living have shown that lower G8 scores correlate with decreased functional independence [\u003csup\u003e28\u003c/sup\u003e]. Our findings align with these reports, further emphasizing the importance of assessing frailty in elderly cancer patients. However, unlike previous studies, our research specifically identifies self-care maintenance as a crucial factor influenced by baseline G8 scores in patients with HNSCC undergoing RT.\u003c/p\u003e\n\u003cp\u003eThe ECOG PS, a commonly used functional measure in oncology, showed an association with self-care decline; while, the G8 tool demonstrated a stronger and more significant correlation. \u0026nbsp;This highlights the limitations of traditional metrics in geriatric populations and underscores the G8 tool\u0026rsquo;s ability to capture broader health dimensions, including physical, cognitive, and nutritional status. These results align with previous findings suggesting the G8 is a more sensitive and comprehensive predictor of general condition in geriatric care [\u003csup\u003e29\u003c/sup\u003e, 25].\u003c/p\u003e\n\u003cp\u003eIn this study, a G8 score of 12 was identified as the threshold. In other reports on the G8 screening tool, a score of \u0026le;14 out of 17 points is considered abnormal [\u003csup\u003e30\u003c/sup\u003e, 26]. In HNSCC, the progression of the disease itself is closely linked to nutritional status, which may result in generally lower scores. Additionally, in this study, G8 scores were obtained at the time of referral to the radiation oncology department. Approximately 35% of the patients had already undergone neoadjuvant chemotherapy, and it cannot be ruled out that the deterioration of nutritional status caused by chemotherapy or the increased use of medications to manage chemotherapy-related side effects may have influenced their scores. Therefore, further investigation is needed to determine whether similar results would be observed in other types of cancer.\u003c/p\u003e\n\u003cp\u003eWe selected 5 commonly recommended self-care activities for managing radiation-induced dermatitis and mucositis with reference to previous research and clinical guidelines [7, 8, 9, 10] in this study. For the assessment criteria, we adopted the framework proposed by Nakano et al., which discusses standards for evaluating patients\u0026rsquo; self-care levels in managing cancer-related symptoms. Currently, there is no standardized method for assessing self-care activities or their measurement specific to HNSCC field. Instrument such as the Exercise of Self-Care Agency Scale (ESCA) [\u003csup\u003e31\u003c/sup\u003e] is well-known but was developed for broader applications, including chronic illnesses, and not specific to cancer care. Furthermore, its large number of items makes them impractical for routine clinical use. The evaluation items and criteria employed in this study will require further refinement. However, given that they were designed to be specific to RT for HNSCC, simple, and as clearly defined as possible, we believe they are valid and broadly applicable in clinical practice.\u003c/p\u003e\n\u003cp\u003eAmong the self-care activities, skin ointment application emerged as the most challenging, requiring nursing assistance in 11 patients. Reasons for the difficulty in proper ointment application included the anatomically complex structure of the head and neck region, as well as areas like the nape of the neck being hard to reach. These factors made it challenging to apply the ointment thinly and flatly. Additionally, symptoms of radiation dermatitis typically appear gradually a few weeks after the start of RT [\u003csup\u003e32\u003c/sup\u003e, 8, 9], highlighting the difficulty of encouraging patients to perform appropriate preventive measures from the early stages of treatment [\u003csup\u003e33\u003c/sup\u003e]. At our department, during interviews, patients are provided with instructions on the importance and methods of ointment application, using each patient\u0026rsquo;s dose distribution map of RT. This approach is intended to encourage patients to continue self-care independently as much as possible.\u003c/p\u003e\n\u003cp\u003e Moving forward, enhanced supportive care should be developed for patients with G8 scores \u0026le;12 to improve their understanding and ability to maintain self-care activities. Strategies could include visual aids, such as illustrated instructional materials [\u003csup\u003e34\u003c/sup\u003e], and increasing the frequency of supportive care sessions from once per week to twice per week to provide more comprehensive assistance. Integrating the G8 score into the treatment plan may help tailor treatment approaches based on patients\u0026rsquo; tolerance levels; for those with extremely low G8 scores and significant frailty, a shift toward irradiation focused on symptom palliation may be necessary [\u003csup\u003e35\u003c/sup\u003e, 22]. Additionally, shortening the duration of radiotherapy through hypofractionated RT could be considered to reduce the treatment burden [\u003csup\u003e36\u003c/sup\u003e,\u003csup\u003e37\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;There are some limitations of our study. First, it is a single-institution, retrospective study, which may limit the generalizability of the findings. Conducting multi-center prospective studies in the future will enable us to more clearly establish the causal relationship between G8 scores and self-care activities. Second, the sample size was small, particularly in the initially non-independent group, may have influenced statistical power. Since the study focused specifically on patients\u0026nbsp;\u0026ge;\u0026nbsp;65 years, the overall sample volume was restricted. Third, setting the use of gauze dressing as self-care evaluation item may have introduced bias. At our facility, gauze dressing is not routinely recommended for all cases; it is typically initiated only when dermatitis becomes severe. For some patients, dermatitis remained mild throughout the treatment period, which may have led to an underestimation in this analysis. Nonetheless, the conclusion that lower G8 scores are associated with a decline in self-care remains robust.\u003c/p\u003e\n\u003cp\u003eIn conclusion, the G8 screening tool serves as a practical and reliable predictor of self-care challenges during RT and CRT in patients with HNSCC. Its integration into routine clinical practice enables early identification of at-risk individuals, allowing for timely nursing interventions and tailored support strategies. By addressing the unique needs of this population, the G8 tool contributes to better treatment outcomes, fewer complications, and an improved quality of life for elderly cancer patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eFunding: Not applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConception and design\u003c/em\u003e: T. Katsuta, I. Nishibuchi, M. Fujioka.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData collection\u003c/em\u003e: T. Katsuta, M. Fujioka, M. Nomura.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAnalysis and interpretation of data\u003c/em\u003e: T. Katsuta.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eManuscriptwriting\u003c/em\u003e: T. Katsuta, I. Nishibuchi, M. Fujioka, M. Nomura,\u0026nbsp;M. Kondo, T. Hamamoto, T. Ueda, H. Ochi, H. Sakauchi, S. Tani,\u0026nbsp;N. Imano, Y. Murakami.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eApproval of final article\u003c/em\u003e: T. Katsuta, I. Nishibuchi, M. Fujioka, M. Nomura,\u0026nbsp;M. Kondo, T. Hamamoto, T. Ueda, H. Ochi, H. Sakauchi, S. Tani,\u0026nbsp;N. Imano, Y. Murakami.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manus\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eDisclosure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have declared no conflict of interest relative to this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNational Comprehensive Cancer Network Inc NCCN Clinical Practice Guidelines in Oncology (2025) Head and Neck Cancers version 1. Available online: https://www.nccn.org/professionals/physician_gls/pdf/head-and-neck.pdf.\u003cbr\u003e Accessed 06 May 2025.\u003c/li\u003e\n\u003cli\u003eImano N, Murakami Y, Nakashima T, et al (2017) Clinical outcomes of concurrent chemoradiotherapy with volumetric modulated arc therapy in patients with locally advanced nasopharyngeal carcinoma. Jpn J Radiol 35: 673-680. https://doi.org/10.1007/s11604-017-0680-5.\u003c/li\u003e\n\u003cli\u003eKubo K, Murakami Y, Imano N, et al (2020) A Single Institution\u0026apos;s Experience of Definitive Radiotherapy Using Volumetric-modulated Arc Therapy for Hypopharyngeal Cancers. Anticancer Res 40: 4183-4190. https://doi.org/10.21873/anticanres.14418.\u003c/li\u003e\n\u003cli\u003eGlover D, Harmer V (2014) Radiotherapy-induced skin reactions: assessment and management. Br J Nurs 23: S28, S30-5. https://doi.org/10.12968/bjon.2014.23.Sup2.S28.\u003c/li\u003e\n\u003cli\u003eSonis ST (2009) Mucositis: The impact, biology and therapeutic opportunities of oral mucositis. Oral Oncol 45: 1015-20. https://doi.org/10.1016/j.oraloncology.2009.08.006.\u003c/li\u003e\n\u003cli\u003eTrotti A, Bellm LA, Epstein JB, et al (2003) Mucositis incidence, severity and associated outcomes in patients with head and neck cancer receiving radiotherapy with or without chemotherapy: a systematic literature review. 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Ann Oncol 23: 2166\u0026ndash;72. https://doi.org/10.1093/annonc/mdr587.\u003c/li\u003e\n\u003cli\u003ePottel L, Lycke M, Boterberg T, et al (2012) Determination of an adequate screening tool for identification of vulnerable elderly head and neck cancer patients treated with radio(chemo)therapy. J Geriatr Oncol 3: 24\u0026ndash;32. https://doi.org/10.1186/s12885-015-1800-1\u003c/li\u003e\n\u003cli\u003eAmin MB, Greene FL, Edge SB, et al (2017) The Eighth Edition AJCC Cancer Staging Manual: Continuing to build a bridge from a population-based to a more \u0026quot;personalized\u0026quot; approach to cancer staging. CA Cancer J Clin 67: 93-99. https://doi.org/10.3322/caac.21388.\u003c/li\u003e\n\u003cli\u003eGhi MG, Paccagnella A, Ferrari D, et al (2017) GSTTC (Gruppo di Studio Tumori della Testa e del Collo) Italian Study Group. Induction TPF followed by concomitant treatment versus concomitant treatment alone in locally advanced head and neck cancer. A phase II-III trial. Ann Oncol 28: 2206-2212. https://doi.org/10.1093/annonc/mdx299.\u003c/li\u003e\n\u003cli\u003eOta Y, Kodaira T, Fujii H, et al (2022) Real-world clinical outcomes in Japanese patients with locally advanced squamous cell carcinoma of the head and neck treated with radiotherapy plus cetuximab: a prospective observational study (JROSG12-2). Int J Clin Oncol 27: 1675-1683. https://doi.org/10.1007/s10147-022-02228-3.\u003c/li\u003e\n\u003cli\u003eHiroe N, Atsuko U (2017) A Study of the Criteria for Assessing the Level of Self-care in Cancer Symptom Management; University of Hyogo College of Nursing Art and Science \u0026amp; Research Institute of Nursing Care for People and Community Bulletin: Kobe, Japan 24: 139\u0026ndash;150. Available online: http://id.nii.ac.jp/1214/00002884/. Accessed 06 May 2025.\u003c/li\u003e\n\u003cli\u003eIshii R, Ogawa T, Ohkoshi A, et al (2021) Use of the Geriatric-8 screening tool to predict prognosis and complications in older adults with head and neck cancer: A prospective, observational study. J Geriatr Oncol 12: 1039-1043. https://doi.org/10.1016/j.jgo.2021.03.008.\u003c/li\u003e\n\u003cli\u003eAkkus Yildirim B, Gokhan Acikgoz S, Akboru MH, et al (2024) Evaluating the Impact of Age and G8 Assessment on Definitive Treatment Strategies in Elderly Patients with Local Advanced Esophageal Carcinoma. Oncol Res Treat 47: 590-601. https://doi.org/10.1159/000542017.\u003c/li\u003e\n\u003cli\u003eChan WL, Ma T, Cheung KL, et al (2021) The predictive value of G8 and the Cancer and aging research group chemotherapy toxicity tool in treatment-related toxicity in older Chinese patients with cancer. J Geriatr Oncol 12: 557-562. https://doi.org/10.1016/j.jgo.2020.10.013.\u003c/li\u003e\n\u003cli\u003eAgemi Y, Shimokawa T, Sasaki J, et al (2019) Prospective evaluation of the G8 screening tool for prognostication of survival in elderly patients with lung cancer: A single-institution study. PLoS One 14: e0210499. https://doi.org/10.1371/journal.pone.0210499.\u003c/li\u003e\n\u003cli\u003eVan Walree IC, Scheepers E, van Huis-Tanja L, et al (2019) A systematic review on the association of the G8 with geriatric assessment, prognosis and course of treatment in older patients with cancer. J Geriatr Oncol 10: 847-858. https://doi.org/10.1016/j.jgo.2019.04.016.\u003c/li\u003e\n\u003cli\u003eCuccia F, Mortellaro G, Mazzola R, et al (2020) Prognostic value of two geriatric screening tools in a cohort of older patients with early stage Non-Small Cell Lung Cancer treated with hypofractionated stereotactic radiotherapy. J Geriatr Oncol 11: 475-481. https://doi.org/10.1016/j.jgo.2019.05.002.\u003c/li\u003e\n\u003cli\u003eShimaoka H, Yoshida Y, Yamada T, et al (2025) Distribution of Geriatric 8 screening tool scores in elderly and non-elderly patients with cancer. Int J Clin Oncol 30: 457-468.\u003cbr\u003e https://doi.org/10.1007/s10147-024-02688-9.\u003c/li\u003e\n\u003cli\u003eTakahashi M, Takahashi M, Komine K, et al (2017) The G8 screening tool enhances prognostic value to ECOG performance status in elderly cancer patients: A retrospective, single institutional study. PLoS One 12: e0179694. https://doi.org/10.1371/journal.pone.0179694.\u003c/li\u003e\n\u003cli\u003eBruijnen CP, Heijmer A, van Harten-Krouwel DG, et al (2021) Validation of the G8 screening tool in older patients with cancer considered for surgical treatment. J Geriatr Oncol 12: 793-798. https://doi.org/10.1016/j.jgo.2020.10.017.\u003c/li\u003e\n\u003cli\u003eWeizhen Liang, Ting Li, Yin Pan, et al (2025) Effect of case management based extended care model on mental state and quality of life of breast cancer patients. European Journal of Gynaecological Oncology 46: 92-100.\u003c/li\u003e\n\u003cli\u003eSzumacher E, Wighton A, Franssen E, et al (2001) Phase II study assessing the effectiveness of Biafine cream as a prophylactic agent for radiation-induced acute skin toxicity to the breast in women undergoing radiotherapy with concomitant CMF chemotherapy. Int J Radiat Oncol Biol Phys 51: 81-6. https://doi.org/10.1016/s0360-3016(01)01576-0.\u003c/li\u003e\n\u003cli\u003eMcQuestion M, Cashell A (2020) A qualitative descriptive study of patients\u0026apos; experiences of a radiation skin reaction associated with treatment for a head and neck cancer. Can Oncol Nurs J 30: 287-292. https://doi.org/10.5737/23688076304287292.\u003c/li\u003e\n\u003cli\u003eOsmar K, Webb D (2015) From idea to implementation: creation of an educational picture book for radiation therapy patients. J Cancer Educ 30: 193-6. https://doi.org/10.1007/s13187-014-0728-5.\u003c/li\u003e\n\u003cli\u003eGamez ME, Agarwal M, Hu KS, et al (2017) Hypofractionated Palliative Radiotherapy with Concurrent Radiosensitizing Chemotherapy for Advanced Head and Neck Cancer Using the \u0026quot;QUAD-SHOT Regimen\u0026quot;. Anticancer Res 37: 685-691. https://doi.org/10.21873/anticanres.11364.\u003c/li\u003e\n\u003cli\u003ePiras A, Boldrini L, Menna S, et al (2021) Hypofractionated Radiotherapy in Head and Neck Cancer Elderly Patients: A Feasibility and Safety Systematic Review for the Clinician. Front Oncol 11: 761393. https://doi.org/10.3389/fonc.2021.761393.\u003c/li\u003e\n\u003cli\u003eMayo ZS, Ilori EO, Matia B, et al (2022) Limited Toxicity of Hypofractionated Intensity Modulated Radiation Therapy for Head and Neck Cancer. Anticancer Res 42: 1845-1849. https://doi.org/10.21873/anticanres.15660.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"539\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 539px;\"\u003e\n \u003cp\u003eTable 1. Patients\u0026rsquo; and treatment characteristics of head and neck squamous cell carcinoma.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 246px;\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003eNumber of patients (\u003cem\u003eN\u003c/em\u003e = 66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e( % )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 246px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 246px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e90.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 246px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e9.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 246px;\"\u003e\n \u003cp\u003eAge(years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 246px;\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e74.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 246px;\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e67\u0026ndash;94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 454px;\"\u003e\n \u003cp\u003ePerformance status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 246px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e78.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 246px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e18.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 246px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 454px;\"\u003e\n \u003cp\u003eG8 score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e13.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e7-17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 454px;\"\u003e\n \u003cp\u003eTreatment setting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eInpatient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e95.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eOutpatient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 454px;\"\u003e\n \u003cp\u003ePrimary tumor site\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 246px;\"\u003e\n \u003cp\u003eNasopharynx\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e7.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 246px;\"\u003e\n \u003cp\u003eOropharynx\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e22.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 246px;\"\u003e\n \u003cp\u003eHypopharynx\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e50.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 246px;\"\u003e\n \u003cp\u003eOral cavity and mouth floor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e12.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 246px;\"\u003e\n \u003cp\u003eLarynx\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e7.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 246px;\"\u003e\n \u003cp\u003eClinical stage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 246px;\"\u003e\n \u003cp\u003eStage 0- I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e7.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 246px;\"\u003e\n \u003cp\u003eStage II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e22.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 246px;\"\u003e\n \u003cp\u003eStage III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e22.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 246px;\"\u003e\n \u003cp\u003eStage IVA and IVB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e47.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 454px;\"\u003e\n \u003cp\u003eTotal Dose (Gy) /fr\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 246px;\"\u003e\n \u003cp\u003e70 Gy/35fr\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e95.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 246px;\"\u003e\n \u003cp\u003e66-68 Gy/33-34fr\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 246px;\"\u003e\n \u003cp\u003e62 Gy/31fr\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 454px;\"\u003e\n \u003cp\u003eCombination Chemotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 246px;\"\u003e\n \u003cp\u003eCisplatin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e68.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 246px;\"\u003e\n \u003cp\u003eCarboplatin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 246px;\"\u003e\n \u003cp\u003eCetuximab\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e13.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 246px;\"\u003e\n \u003cp\u003eRT alone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e15.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 454px;\"\u003e\n \u003cp\u003eSelf-care independence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 246px;\"\u003e\n \u003cp\u003eIndependent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e93.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 246px;\"\u003e\n \u003cp\u003eNeed assistance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e6.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 539px;\"\u003e\n \u003cp\u003e\u003cem\u003eAbbreviations,\u003c/em\u003e G8: geriatric 8, fr: fractions, RT: radiation therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"567\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 567px;\"\u003e\u003cp\u003eTable 2. Self-care activities requiring nursing assistance at the end of RT.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003eSelf-care\u0026nbsp;\u003cbr\u003e\u0026nbsp;activities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eMedication adherence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eOral care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eGrooming\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eSkin ointment application\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eGauze dressing\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003eNumber of patients (\u003cem\u003eN\u003c/em\u003e = 15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 567px;\"\u003e\n \u003cp\u003e\u003cem\u003eAbbreviations,\u003c/em\u003e RT: radiation therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"567\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 463px;\"\u003e\n \u003cp\u003eTable 3. Results of Univariate analysis.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003eSelf-care decline\u003cbr\u003e\u003cem\u003eN\u003c/em\u003e = 15 (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003eNot self-care decline\u003cbr\u003e\u003cem\u003eN\u003c/em\u003e = 47 (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 567px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e14 (93.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e44 (93.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e3 (6.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 567px;\"\u003e\n \u003cp\u003ePerformance status\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e10 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e41 (87.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.081\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e5 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e6 (12.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 567px;\"\u003e\n \u003cp\u003eG8 score\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eMedian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.011\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e8-17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e7-17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 567px;\"\u003e\n \u003cp\u003eTreatment setting\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eInpatient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e15 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e44 (93.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.43\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eOutpatient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e3 (6.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003eClinical stage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003eStage 0- II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e3 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e16 (34.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003eStage III-Ⅳ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e12 (80.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e31 (66.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003eChemotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e12 (80.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e43 (91.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e3 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e4 (8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 567px;\"\u003e\n \u003cp\u003e\u003cem\u003eAbbreviations,\u003c/em\u003e G8: geriatric 8.\u003cbr\u003eBold type indicates that the \u003cem\u003eP\u003c/em\u003e -value is equal to or less than the level of statistical significance (0.05).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\u0026nbsp;\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"567\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 567px;\"\u003e\n \u003cp\u003eTable 4. Multivariate logistic regression model for self-care decline.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003eOdds ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003ePerformance status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e3.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0.87-13.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.029\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003eG8 score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e6.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1.79-23.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.0074\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 567px;\"\u003e\n \u003cp\u003e\u003cem\u003eAbbreviations,\u003c/em\u003e CI: confidence interval, G8: geriatric 8.\u003cbr\u003eBold type indicates that the \u003cem\u003eP\u003c/em\u003e -value is equal to or less than the level of statistical significance (0.05).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Geriatric assessment, G8 screening tool, Elderly patients, Self-care, Head and neck cancer, Chemoradiotherapy","lastPublishedDoi":"10.21203/rs.3.rs-6689251/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6689251/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003ePurpose\u003c/b\u003e\u003c/p\u003e \u003cp\u003eSelf-care during radiotherapy (RT) is crucial for managing mucositis and dermatitis in patients with head and neck squamous cell carcinomas (HNSCC). However, elderly patients often struggle with self-care. This study examined the relationship between self-care decline and the Geriatric 8 (G8) score.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA retrospective analysis was conducted on 66 patients (\u0026ge;\u0026thinsp;65 years) treated between December 2018 and February 2023. Self-care activities\u0026mdash;medication adherence, oral care, grooming, skin ointment application, and gauze dressing\u0026mdash;were assessed during definitive RT on a 0\u0026ndash;5 scale. Patients were first grouped by initial self-care independence, and their G8 scores were compared. Among initially independent patients, those with self-care score changes were further analyzed based on their G8 scores. A threshold value was also determined to differentiate between the groups.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe initially independent group exhibited significantly higher G8 scores than non-independent group (median G8 score: 14 vs. 9.75, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0067). Among the initially independent patients, 15 (24.2%) experienced self-care decline, and lower baseline G8 scores significantly predicted this deterioration (median G8 score: 12 vs. 15; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.011). Multivariate analysis identified G8 scores as a significant predictor of self-care decline (odds ratio\u0026thinsp;=\u0026thinsp;6.53, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0074). Receiver operating characteristic (ROC) analysis determined a G8 cutoff of 12 (area under the curve\u0026thinsp;=\u0026thinsp;0.72) with 85.1% specificity.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThese findings highlight the importance of geriatric assessment in predicting self-care maintenance in elderly HNSCC patients undergoing RT.\u003c/p\u003e","manuscriptTitle":"Association between Geriatric 8 (G8) Scores and Self-Care Decline in Elderly Patients with Head and Neck Squamous Cell Carcinoma Undergoing Radiotherapy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-02 07:28:23","doi":"10.21203/rs.3.rs-6689251/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-21T21:34:18+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-10T01:48:53+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-01T11:45:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"192908745256208308481046489890359970816","date":"2025-06-30T09:27:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"273453122004881139188000652867793741145","date":"2025-06-27T20:48:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"183981379677209788353049714317970637336","date":"2025-06-27T16:52:33+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-27T16:22:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-24T23:40:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-23T01:57:03+00:00","index":"","fulltext":""},{"type":"submitted","content":"Supportive Care in Cancer","date":"2025-05-18T00:57:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"cd7da1bd-e6be-4d6e-a220-0157c6770d8a","owner":[],"postedDate":"July 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-09-22T16:00:25+00:00","versionOfRecord":{"articleIdentity":"rs-6689251","link":"https://doi.org/10.1007/s00520-025-09936-2","journal":{"identity":"supportive-care-in-cancer","isVorOnly":false,"title":"Supportive Care in Cancer"},"publishedOn":"2025-09-16 15:57:09","publishedOnDateReadable":"September 16th, 2025"},"versionCreatedAt":"2025-07-02 07:28:23","video":"","vorDoi":"10.1007/s00520-025-09936-2","vorDoiUrl":"https://doi.org/10.1007/s00520-025-09936-2","workflowStages":[]},"version":"v1","identity":"rs-6689251","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6689251","identity":"rs-6689251","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}