Dynamic Quality-of-Life Trajectories After Head and Neck Reconstruction

Importance: Quality of life (QOL) is considered the second most important outcome after survival in cancer care. In head and neck reconstruction, QOL has long been assumed to stabilize at 1 year, an assumption that guides clinical follow-up and trial design. Objective: To evaluate QOL beyond 1 year after head and neck reconstruction. Design, Setting, and Participants: This prospective cohort study of 315 patients with head and neck disease was conducted from 2015 through 2023 at a high-volume tertiary center in Taiwan. Data were analyzed March to August 2025. Exposure: Free flap reconstruction. Main Outcomes and Measures: The primary outcome was the physical domain of the University of Wisconsin QOL questionnaire. The primary end point was QOL time to deterioration (TTD), which accounts for reversibility and patient response shift, and to identify modifiable risk factors for deterioration, defined in TTD as a decline of 5 or more points without subsequent recovery of 5 or more points. For Cox proportional hazards models, statistical analysis included hazard ratios (HRs) with 95% CIs. The secondary end point was a composite of TTD or death. Results: Among 315 patients (mean [SD] age, 53.7 [11.8] years; 283 [89.8%] male; median follow-up, 1155 [95% CI, 1056 to 1254] days), baseline Cox models identified Charlson Comorbidity Index as associated with QOL deterioration (HR, 1.46; 95% CI, 1.22 to 1.74). In 12-month landmark models (N = 272), Charlson Comorbidity Index (HR, 1.70; 95% CI, 1.43 to 2.06), chemotherapy (HR, 1.60; 95% CI, 1.03 to 2.48), and complications (HR 2.01; 1.21 to 3.34) were associated with QOL deterioration. The composite end point showed similar results. QOL remained dynamic beyond 1 year, with 115 of 192 patients (59.9%) having clinically meaningful score changes between years 1 and 2 (58 of 192 [30.2%] improved, 57 of 192 [29.7%] deteriorated) despite stable cohort mean scores. Findings were consistent in analyses restricted to patients with malignant disease (n = 246). Exploratory baseline and 12-month risk scores demonstrated the feasibility of predicting dynamic QOL changes beyond 1 year. Conclusions and Relevance: Results of this cohort study question the assumption that QOL stabilizes at 1 year after head and neck reconstruction. More than half of patients continued to experience clinically meaningful changes, with complications at 1 year representing the strongest modifiable risk factor for deterioration. Prognostic QOL risk scores provide an approach for targeting survivorship interventions to patients at highest risk for deterioration, shifting the focus from survival alone to preservation of QOL.