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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 8  |  Issue : 2  |  Page : 129-133

Prognosticators for quality of life in surgically treated head-and-neck cancer patients


Neeti Clinics, Nagpur, Maharashtra, India

Date of Submission10-Nov-2020
Date of Decision10-Nov-2020
Date of Acceptance10-Nov-2020
Date of Web Publication8-Dec-2020

Correspondence Address:
Neeti Kapre Gupta
Neeti Clinics, Nagpur, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jhnps.jhnps_57_20

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  Abstract 


Introduction: Physiological, functional, and psychological implications of head-and-neck cancer treatment are significant. Improving outcomes in cancer care must include due diligence to quality of life (QOL) along with disease control. This study assesses QOL of head-and-neck cancer patients before and after treatment and explores predictive factors. Materials and Methods: Prospective observational study of consecutive head-and-neck cancer patients. QOL assessments were made at baseline, and different stages of their treatment and prognostic factors such as age, gender, socioeconomic strata, comorbidities, tumor stage, requirement of reconstruction, adjuvant treatment, were examined. EORTC QOL questionnaire-H and N0 35 were employed, and prognostic factor correlation was studied by logistic regression analysis. Results: Ninety-eight patients at least 12 months post-treatment scored worst for dryness of the mouth (33.4), followed by sticky saliva (23.4). Although results steadily improved over time, this did not reach statistical significance (P = 0.235). Stage of the primary tumor, requirement of reconstruction, and adjuvant treatment were statistically significant prognostic factors (P < 0.05). Conclusion: Understanding of QOL parameters would improve treatment planning, counseling of head-and-neck cancer patients and care-givers and enable physical, functional, and social rehabilitation.

Keywords: Head-and-neck cancer, quality of life, surgery


How to cite this article:
Gupta NK, Jani S, Dubey P, Fidvi Z, Kapre M. Prognosticators for quality of life in surgically treated head-and-neck cancer patients. J Head Neck Physicians Surg 2020;8:129-33

How to cite this URL:
Gupta NK, Jani S, Dubey P, Fidvi Z, Kapre M. Prognosticators for quality of life in surgically treated head-and-neck cancer patients. J Head Neck Physicians Surg [serial online] 2020 [cited 2021 Jan 17];8:129-33. Available from: https://www.jhnps.org/text.asp?2020/8/2/129/302639




  Introduction Top


Anatomical structures in the head and neck serve extremely important basic functions such as respiration, communication, nutrition (chewing/swallowing), and appearance. Therefore, any affliction of this area is bound to be accompanied by measurable amounts of morbidity and functional compromise. Cancer treatment, be it surgery, radiation, or multimodality treatment, is not without additional side effects of its own. Hence, in addition to maintaining superior survival and disease control outcomes, it has been a conscientious strive on the part of head-and-neck physicians to improve “Quality of Life” (QOL) in head-and-neck cancer patients.

The World Health Organization defines QOL as an “individual’s perception of their position in life in the context of the culture and value systems, in which they live and in relation to their goals, expectations, standards, and concerns.”[1] Health-related QOL evaluation indicates how the patient perceives the impact of their cancer and its treatment. There are specific instruments to measure the QOL of head and neck cancer patients, for example, questionnaires-the University of Washington QOL Questionnaire (QLQ), the QLQ of EORTC for head-and-neck cancer patients (EORTC H and N 35), the MD Anderson symptom inventory head-and-neck questionnaire, neck dissection impairment index and shoulder pain and disability index.[2]

Head-and-neck cancers form a major health-care problem in India, with majority patients presenting with advanced cancers requiring more aggressive treatment.[3] Majority of the burden of management of these head-and-neck cancers falls on peripheral institutions in view of the inability to access tertiary health care by most of the population. Therefore, to evaluate and address QOL issues in this population is more pertinent. The following study aims to study QOL before and after treatment and explores predictive factors in surgically treated head-and-neck cancer patients from a three-tier city in India.


  Materials and Methods Top


This is a prospective observational study of consecutive head-and-neck squamous cell cancer patients receiving definitive surgical treatment between May 2018 and January 2019. All head-and-neck subsites underwent thorough work-up and were advised treatment based on current clinical practice guidelines.[4] QOL assessments were made before and after definitive surgery at the intervals of 3, 6, and 12 months and prognostic factors such as age, gender, socio-economic strata, comorbidities, tumor stage, reconstruction, type of treatment (single modality vs. multi-modality) were examined. Patients treated primarily by nonsurgical techniques were excluded. All data were entered and analyzed using SPSS version 23 (IBM Corp.,Armonk, New York).

We used the EORTC H and N 35 QLQ as a reference since it has previously been validated in the Indian population.[5] It comprises 35 tumor-specific questions assessing symptoms and side-effects of treatment. Most items are scored on a four-point response scale: 1 (not at all) to 4 (very much). Twenty-five questions are organized into seven multi-item subscales: Pain (HNPA: Items 1–4 regarding pain in the mouth, pain in the jaw, soreness in the mouth, and painful throat), swallowing (HNSW: Items 5–8 and 17 items that assess different degrees of swallowing problems: Problems in swallowing liquid, pureed food or solid food, and choking when swallowing), senses (HNSE: Items 13–14 regarding smell and taste), speech (HNSP: Items 16 and 23–24 assess hoarseness and problems with talking to other people or on the phone), social eating (HNSO: Items 19–22 regarding trouble in eating, individually or in front of family or others), social contact (HNSC: Items 18 and 25–28 regarding trouble with body image and having physical and social contact with family and others) and sexuality (HNSX: Items 29–30 assess interest in sex and sexual enjoyment). The remaining 10 single items address problems with teeth, dry mouth, sticky saliva, cough, mouth opening, weight loss, weight gain, use of nutritional supplements, feeding tubes, and pain medication.[6]

Frequencies of demographic variables were calculated by descriptive statistics. The paired t-test was used to compare the situations before and after treatment. A P ≤ 0.05 was considered significant. Prognostic factors correlation was studied by logistic regression multi-variate analysis.


  Results Top


Ninety-eight patients with a mean average postoperative follow-up period of 15.4 months were included in the study. The recorded information included the age at treatment, the gender, socioeconomic strata, comorbidities, the tumor localization and stage, the treatment method (single modality vs. multi-modality), and the type of reconstruction. The demographic data are listed in [Table 1]. Eighty-eight percent of the patients were men and 12% women (M: F ratio 7:1). The average age was 47.78 years (ranging from 24 to 77 years), with most of the patients (35%) aged between 40 and 50 years. Comorbidities were present in 14.3% of patients. The oral cavity was the predominant tumor site, with 49% gingiva-buccal complex and 32.7% tongue cancers. In view of the advanced tumor stage at presentation (75.5%), majority received combined modality treatment, i.e., surgery and adjuvant radiotherapy (46.9%) and surgery with adjuvant concurrent chemo-radiation (35.7%). Seventeen percent underwent surgery alone. [Figure 1] depicts the type of reconstructive surgery performed.
Table 1: Demographic variables of the patient population

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Figure 1: Type of reconstructive surgery

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The mean EORTC QOL H and N 35 scores at 3, 6, and 12 months after surgery are presented in [Table 2]. Because there is no standard reference score, we labeled all symptom scores above 20 as poor scores. The worst problem was for dryness of the mouth (33.4) followed by sticky saliva (23.4). The scores had a significant decline at 3 months, especially for those who received adjuvant treatment and the 6 months and 12 months scores improved steadily; however, the increase did not reach a statistical significance (P = 0.235). [Table 3] shows the multivariate analysis for predictive factors. Stage of the primary tumor, requirement of reconstruction, and adjuvant treatment were statistically significant prognostic factors (P = 0.02, 0.04, and 0.01, respectively) for predicting a worse cumulative QOL score.
Table 2: Mean values of EORTC quality of life H and N 35 scores at 3, 6, and 12 months after surgery

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Table 3: Multivariate analysis for predictive factors

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  Discussion Top


Head-and-neck cancers constitute approximately 25% of the total cancer burden in India. Advanced oral cancers requiring aggressive multi-modality treatment form the vast majority among these. Therefore, a study on QOL scores and predictive factors is most relevant. These QOL self-assessments have manifold advantages. It encourages the patients to realize their own perception of disease and treatment-related effects and sometimes also to communicate their symptoms to the physician more effectively.[7] For the surgeon, this knowledge enables improved shared decision making, better patient counseling, to develop and provide survivorship resources and as an audit for their practice. In a survey conducted by reaching out to 500 otolaryngologists treating head-and-neck cancers, they inferred that all clinicians agreed about the paramount importance of QOL measurements, how it impacted decision making and that it enabled better patient participation in treatment.[8]

Gingivo-buccal complex cancers comprised the vast majority of our data set. This is not surprising owing to chewed tobacco being the commonest addiction in the Indian population. Patients also present late, often in advanced stages of the disease and therefore, require multi-modality treatment.[9] Our institute caters to the lower middle socioeconomic strata of the country. Hence, owing to the financial implications, even after detailed counseling, more patients opt for pedicled flap reconstruction. The most common reasons quoted by the patients are expenses and unwillingness to take the risk of re-exploration. Although it is agreed that patients with surgical defects requiring reconstruction will fare worse than those without; literature is not unanimous about the advocacy of microvascular reconstruction over pedicled flaps as a tool for improving QOL in a direct manner.[10] Thus, we do not consider the larger proportion of pedicled reconstructions to be a true weakness of the study.

On looking at the temporal progression of QOL assessments, our scores of mouth opening do not show a significant decline in the postoperative period. This is because we follow the principal of addressing submucus fibrosis-induced trismus of the opposite side at the same sitting as the definitive cancer surgery. This is done only for Grade 3 and 4a trismus and after primary tumor excision and due sterilization of the field. For all other parameters, there was a steady improvement of QOL scores over time, with 12 months assessments being significantly better. This finding has been supported by other authors as well.[11],[12] This may be attributed to the alleviation of immediate adjuvant treatment toxicity and better adjustment to their “new way of life” on part of the patients. Certain symptoms such as sticky saliva, dryness of mouth, pain, and fatigue show persistently poor scores. This is often a result of certain nonpreventable treatment factors and only thorough preoperative counseling can help prepare the patients for this outcome. Detailed preoperative counseling while filling out the questionnaire is carried out as a routine at our center, along with the provision of arranging personal independent meetings with fellow cancer survivors in the absence of a health care professional. We have found these interactions helpful in morale-building for patients and care-givers.

A study of predictive factors reveals the tumor stage, requirement of reconstruction, adjuvant treatment to be significant predictors of QOL. A systematic review published in 2015 validates similar observations.[13] This review also similar to our study included primarily surgical candidates suffering from head-and-neck cancers. They reported that advanced tumors, extensive surgical resection, need for flap reconstruction, neck dissection, and postoperative radiation are associated with worse QoL outcomes. They also demonstrated that anterior oral cancer subsites such as anterior alveolus, the anterior floor of mouth did worse than posterior subsites such as palate, retro-molar trigone. Smaller tumor volume warranting lesser resection and not requiring adjuvant treatment can account for better performance on the QOL assessments. In an Italian study looking at diagnostic and therapeutic features associated with modification of QOLs outcomes between 1 and 6 months after major surgery for head and neck cancer, they found that patients affected by bigger tumors and submitted to more invasive interventions, especially with complicated reconstructions, usually experience severe QoL alterations immediately after major surgery, but are likely to improve quickly within the first 6 months.[14] Comorbidities and age did not have a significant bearing. Published literature supports this view.[15],[16] There is some data to suggest that the older population, in fact, adjust better with parameters such as pain and appearance. Thus, barring medical contra-indications, treatment regimens can be adhered to in elderly patients or those with co-morbidities and alterations based only on QOL scores are not validated. The addition of adjuvant chemoradiation has a definite cumulative effect on xerostomia, trismus, shoulder function, mucositis, etc., All long-term evaluations of head and neck cancer QOL scores resonate that single modality treatment performs better than multi-modality treatment.[17],[18],[19] In a cross-sectional survey of 212 head-and-neck cancer patients conducted at Tata Memorial hospital,[9] dry mouth, dental problems, sticky saliva, cough, and problems with mouth opening were the most common QOL problems faced. Patients with early-stage tumors and those treated with surgery alone had significantly better QOL scores when compared with advanced-stage tumors and patients receiving either radiation alone or multimodality treatment, respectively. Over and above the proven clinicopathological factors, QOL assessment, both before and after treatment, provides significant prognostic information as well on locoregional recurrence rates and overall survival.[20] Thus, in view of the manifold benefits of QOL assessments, they should be routine practice, not just at tertiary care institutions but almost uniformly across physicians.


  Conclusion Top


Study of QOL affords a better understanding of the patients’ perception of their physical, functional, and psychosocial predicaments. Analysis of possible predictive factors helps physicians towards individualized decision making, treatment implementation, patient counseling and developing survivorship resources. This is a study of QOL outcomes in head-and-neck cancer patients. Gingivobuccal cancers constituted the majority of patients. The worst problem was dryness of mouth, followed by sticky saliva. Multivariate analysis for predictive factors showed that the stage of the primary tumor, the requirement of reconstruction, and adjuvant treatment were statistically significant prognostic factors for the poor QOL.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Disclosure

This material has never been published and is not currently under evaluation in any other peer reviewed publication.

Ethical approval

The permission was taken from Institutional Ethics Committee prior to starting the project. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.



 
  References Top

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Bansal M, Mohanti BK, Shah N, Chaudhry R, Bahadur S, Shukla NK. Radiation related morbidities and their impact on quality of life in head and neck cancer patients receiving radical radiotherapy. Qual Life Res 2004;13:481-8.  Back to cited text no. 3
    
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Pfister DG, Spencer S, Adelstein D, Adkins D, Anzai Y, Brizel DM, et al. Head and Neck Cancers, Version 2.2020, NCCN. Clin Practice Guidelines Oncol 2020;18:873-98.  Back to cited text no. 4
    
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Mehanna HM, Morton RP. Patients’ views on the utility of quality of life questionnaires in head and neck cancer: A randomised trial. Clin Otolaryngol 2006;31:310-6.  Back to cited text no. 7
    
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