Optimizing Screening for Body Image Distress in Head and Neck Cancer Survivors

Introduction: Body image distress (BID) is a common and clinically significant concern among head and neck cancer (HNC) survivors and is best assessed using patient-reported outcome measures (PROMs). The IMAGE-HN is a validated, 21-item PROM of HNC-related BID that has been widely used in clinical trials, but its length may limit feasibility in routine clinical care. More efficient approaches are needed to screen HNC survivors for BID in busy clinical settings and facilitate referral to evidence-based treatment.

Methods: The study included adult HNC survivors from 7 academic centers who completed the IMAGE-HN between 2019 and 2022. Responses to the 21 items comprising the IMAGE-HN global score were analyzed using item response theory to assess item discrimination and model fit, with the highest-performing items selected to construct the IMAGE-HN short form (SF).

Results: Among 612 head and neck cancer survivors, the three items with the highest discrimination parameters (IMAGE-HN item 21, “I worry about how others react to my appearance,” 22, “I dislike the way I look”, and 23 "I avoid going out in public") were selected to form the IMAGE-HN SF (discrimination range: 4.95–7.35). The resulting three-item IMAGE-HN SF demonstrated a strong correlation with the 21-item global IMAGE-HN score (r = 0.94) and high internal consistency (Cronbach’s α = 0.89). Receiver operating characteristic (ROC) analyses for a 3-item IMAGE-HN SF score > 3 showed excellent discriminative ability (AUC = 0.97), with sensitivity of 0.91 and specificity of 0.90 for identifying clinically significant BID as determined relative to the entire 21-item IMAGE-HN.

Conclusions: The three-item IMAGE-HN SF strongly correlates with the 21-item IMAGE-HN global scale and demonstrates high reliability in identifying clinically significant BID among HNC survivors. Future studies should evaluate the feasibility, acceptability, usability and implementation of IMAGE-HN SF as a strategy to screen HNC survivors for BID.