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ORIGINAL ARTICLE
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Quality of life of head and neck cancer patients before and after cancer-directed treatment – A longitudinal study


1 Department of Community Medicine, Government Medical College, Jammu, Jammu and Kashmir, India
2 Department of Radiotherapy and Oncology, Government Medical College, Jammu, Jammu and Kashmir, India

Correspondence Address:
Deepika Dewan,
Government Medical College, Jammu, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrt.JCRT_311_18

 > Abstract 


Context: Head-and-neck cancer (HNC) is a major health problem worldwide and even disproportionately bigger in India. Their diagnosis and treatment create severe impact on the quality of life (QOL). We chose to study such patients because we were already reporting these cancers to the Indian Council of Medical Research as part of project titled “Pattern of care and survival studies.”
Aims: The aim of the study is to assess and compare QOL of H and N cancer patients before and after the completion of cancer-directed treatment (CDT).
Settings and Design: The present study was a hospital-based study conducted in the tertiary care hospital of Jammu with longitudinal study design.
Subjects and Methods: All newly diagnosed HNC patients registered with the Department of Radiotherapy and ENT on inpatient or outpatient basis were included over a period of 6 months. Each patient was followed for 4–6 weeks after the completion of CDT. QOL was assessed by the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core 30 (QLQ C30) (general) and EORTC QLQ H and N-35 (specific) questionnaires.
Statistical Analysis: Paired t-test was calculated to compare pre- and postmean scores. Pre- and post-Cronbach alpha reliability coefficient was also calculated.
Results: The most frequent site was larynx followed by the oral cavity. Regarding both EORTC QLQ C-30 questionnaire and Global health status and EORTC H and N-35 specific questionnaires, the mean scores across all domains showed worsening of QoL from their baseline. The worsening was more severe in emotional function (functional scale), while physical, cognitive, and social functions were comparatively less affected. Pain, swallowing, speech, and mouth problems were most worsened.
Conclusions: QoL showed worsening after CDT in all domains due to acute and subacute adverse effects of chemotherapy and radiotherapy in treatment course.

Keywords: European Organization for Research and Treatment of Cancer-Quality of Life Core 30, European Organization for Research and Treatment of Cancer-Quality of Life H and N-35, head-and-neck cancer, quality of life



How to cite this URL:
Bashir A, Kumar D, Dewan D, Sharma R. Quality of life of head and neck cancer patients before and after cancer-directed treatment – A longitudinal study. J Can Res Ther [Epub ahead of print] [cited 2019 Oct 14]. Available from: http://www.cancerjournal.net/preprintarticle.asp?id=263528




 > Introduction Top


Worldwide, cancers figure among the leading causes of morbidity and mortality. The annual incidence of head-and-neck cancers (HNCs) worldwide is more than 550,000 cases with around 300,000 deaths each year.[1] HNC is a major health problem worldwide and even disproportionately bigger in India. Their diagnosis and treatment create severe impact on the quality of life (QOL). They are the most common cancers among males in India and 70%–80% present in advanced stage.[2] It shatters the patients physically and psychologically. Arguably, the burden of cancers and its impact on the patient justify that the QOL of such patients is evaluated properly and suitable steps initiated to mitigate their suffering.[3] We chose to study such patients because we were already reporting these cancers to the Indian Council of Medical Research as part of project titled “Pattern of care and survival studies.”

Alcohol and tobacco consumptions are known risk factors for HNC [4] Human papillomavirus might be an additional risk factor [5],[6] QOL issues have been steadily gaining more importance in health-care practice and research. The European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-Core 30 (QLQ-C30) is a cross-culturally accepted and widely used generic instrument for assessing the health-related QOL (HR QOL) of cancer patients. EORTC QLQ H and N-35 is specific instrument that focuses on problems associated with HNCs.[7],[8],[9]

Since Health Related QOL measure in medical research is common in the West, but there is a paucity of literature on longitudinal studies on QOL in India. Western countries are culturally different from India, and HNCs are relatively common in low-socioeconomic status here as compared to developed countries where they are seen in people with better standard of living, so it will be difficult to apply same QOL parameters in Indian settings.[10] Thus, the present study was conducted to assess and compare QOL in HNC before and after the completion of cancer-directed treatment (CDT) in tertiary care hospital of Jammu City.


 > Subjects and Methods Top


The present longitudinal study was conducted in the Department of Radiotherapy, Government Medical College Jammu (GMCJ) after seeking clearance from the Institutional Ethical Committee, GMCJ. The department is a part of the Regional Cancer Center and caters to nearly 2000 cancer patients yearly and serves as a referral center for entire Jammu Province while drawing many patients from neighboring states as well. It has facilities for external radiotherapy, brachytherapy, and other modalities for diagnosis and management of cancer patients. The department is collaborating with the Department of Community Medicine in implementing National Cancer Registry Project of Indian Council of Medical Research (HBCR-POCSS) project since 2014.

All patients of H and E carcinoma registered with the department and being treated on outpatient or inpatient basis were eligible to participate. The new patients were recruited from October 1, 2015–March 31, 2016. Each patient was interviewed before initiation of CDT and followed till completion of CDT (within 4–6 weeks) and then interviewed again using the same questionnaire.

Inclusion criteria

All newly diagnosed cases of HNC with all stages and all sites, irrespective of age and sex were included in the study.

Exclusion criteria

Gross psychopathology (functional status sufficiently impaired to prevent answering the questionnaire), terminally ill and ambulatory patients, pregnant women, patient unable to understand language, and patients not consented to participate were excluded from the study.

The investigator on daily basis visited newly registered cases in the department of radiotherapy and contacted them. All such patients were requested to participate in the present study. After seeking written consent from them, the patients were subjected to personal interviews using predesigned validated cancer-specific QOL questionnaires.

Attempt was made to capture all patients of carcinoma H and E, who reported to the ENT department as well. Sensitization meetings with the faculty of the department were convened before the initiation of the study.

On getting information from various departments in Government Medical College Jammu and its associated hospitals regarding admission of patient with the cancer, the investigator approached the patients and seeks his or her consent to participate. The patients thereafter were interviewed in a similar manner and using similar tools.

Information was obtained using cancer-specific QOL questionnaire (EORTC QLQ H and N-35).[8] These standard questionnaires are validated cancer-specific measures of HR QOL with reliability Cronbach's alpha coefficient reported for HNC (EORTC QLQ C-30 and EORTC QLQ H and N-35) as 0.93 for global QOL and domain-wise reliability coefficient ranging from 0.32 (for cognitive functioning) to 0.93 (for less sexuality).[10] Salient features of these questionnaires are given below.

European Organization for Research and Treatment of Cancer Life Questionnaire Core 30

It is a 30-item generic validated questionnaire formulated to assess QOL during the previous week for assessing three symptom scales, five functioning scales, a global health status/QOL scale, one assessing financial impact, and six single items.[7]

European Organization for Research and Treatment of Cancer Life Questionnaire Core 30 Head and Neck-35

It has 35 specific questions concerning problems attributed to HNCs and its treatment-related side effects. There are 7-scaled answers for pain, swallowing, sensibility, speech, eating in a social setting, social contact, and sexuality. In addition, 11 individual topics are evaluated taking into account the anatomic site, symptoms, and treatment (dental problems, mouth opening, dry mouth, poor salivation, coughing, sense of illness, analgesic use, nutrition difficulties, gastric tube, and weight loss or gain).[8]

All the patients thus recruited were followed up as per the management protocol followed by the department of radiotherapy. All the patients thus registered were interviewed after the completion of CDT (within 4–6 weeks) using similar questionnaire to the one used to collect data before the initiation of treatment. In case the patients got registered after getting treatment from other institution in or outside the state, such patients were only subjected to QOL interview after the completion of CDT. Loss to follow-up was minimized by making telephone calls if the patient misses scheduled visit.

The below classification was used to collect other relevant information:

Physical activity

It is based on the recommendations on the WHO [11] experts committee as follows:

  1. Sedentary: namely, office workers, most professionals (doctors, lawyers, teachers, architects, etc.), shopkeepers, and homemakers in houses with mechanical household appliances
  2. Moderate: namely, students, farm workers, building workers (excluding heavy laborers), homemakers without mechanical household appliances, and departmental store workers
  3. Heavy: namely, agriculture workers, unskilled laborers, forestry workers, army recruits, soldiers on active services, mineworkers, steelworkers, dancers, athletes, blacksmiths, construction workers, and rickshaw pullers.


Occupation

  1. Labor class


    1. Skilled: Carpenters/masson, etc.
    2. Unskilled: Laborers/farmers, etc.


  2. Service class


    1. Professional: Medical/engineering, etc.
    2. Nonprofessional: Clerks/teachers/constables, etc.


  3. Business class


    1. Big: Big traders/factory owners, etc.


Classification of patients according to their exposure to tobacco and alcohol was assessed using CDC criteria.[12],[13],[14]

Current smoker

Current smokers are those respondents who reported smoking at least 100 cigarettes in their lifetime and who, at the time of survey, smoked either every day or some days.

Former smoker

Former smokers are those respondents who reported smoking at least 100 cigarettes in their lifetime and who, at the time of survey, did not smoke at all.

Never smoker

Never smokers are those respondents who have never smoked a cigarette or who smoked fewer than 100 cigarettes in their entire lifetime.

Current smokeless tobacco user

Current smokeless tobacco users are those respondents currently using smokeless tobacco and who, at the time of survey, used smokeless tobacco either every day or some days.

Former smokeless tobacco user

Former smokeless tobacco users are those respondents who are ever daily smokeless tobacco users and currently do not use smokeless tobacco.

Never user

Never users are those respondents who have never consumed smokeless tobacco.

Current drinker

Current drinking was defined as consumption of alcohol in past year. Among current drinkers, low intake was defined as up to 7 drinks per week; moderate intake was defined as 7–14 drinks per week for women or 7–21 drinks per week for men; and high intake was defined as more than 14 drinks per week for women and more than 21 drinks per week for men.

Former drinker

Former drinking was defined as having ceased alcohol consumption for 1 year or more.

Never drinker

Never drinkers are those respondents who have never consumed alcohol.

Statistical analysis

The data were analyzed using computer software MS Excel and SPSS Statistics for windows version 17.0. (Chicago, SPSS Inc). Data were entered in MS Excel for windows and double checked for accuracy. The scores recorded on each item of respective QOL question was linearly transformed to provide a score ranging from 0 to 100; a scoring algorithm recommended by EORTC was used.[15] A problematic group was defined as one with a Global QOL or functional scale score of 33 or less and symptom scale score of 66 or more on the QLQ-C30 and QLQ-Breast Cancer 23.[16],[17] Qualitative data were reported as percentages, whereas mean ± standard deviation was reported for quantitative variables. Pre- and postmean scores were compared by the use of paired t-test. P < 0.05 was considered as significant. All P values reported were two-tailed. Pre- and post-Cronbach alpha reliability coefficient was used.


 > Results Top


A total of 105 HNC patients were enrolled [Figure 1]. Pre- and post-QoL was available for 72 of the patients. The predominant reason for noncompletion of pre- and post-QoL assessment in all patients was recurrent cancers (12), reception of any form of CDT before enrolment (10), and deaths (6) followed by discontinuation of treatment (5).
Figure 1: Flow chart depicting recruitment of patients

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The overall mean age was 56.9 years with range of 19–85 years. There was predominance of male patients (83.8%) as compared to female patients (16.2%). More than half (52.4%) of HNCs were in age group of 51–70 years [Table 1]. Nearly half of HNC patients belonged to Jammu district (48.6%) followed by Kathua district (9.5%) and least numbers of patients belonged to District Ramban (1.9%) [Figure 2].
Table 1: Age and gender-wise distribution of head-and-neck cancer patients (n=105)

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Figure 2: District-wise distribution of head and neck cancer patients (n = 105)

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Regarding sociodemographic characteristics [Table 2], majority 94 (89.5%) of HNC patients belonged to Hindu religion. More than half, i.e., 60 cases (57.1%) belonged to labor class and were heavy workers (58.1%). Regarding smoking status, nearly, two-thirds, 72 (68.6%) of the patients were former smokers, 29 (27.6%) cases were never smokers, and only 4 (3.8%) were current smokers. As far as smokeless tobacco consumption was concerned, 60 (57.1%) patients were never users, and 44 (41.9%) and 1 (1%) were former users and current users, respectively. Majority 59 (56.2%) of the patients were current alcohol drinkers and 38 (36.2%) and 8 (7.6%) were never drinkers and former drinkers, respectively. Regarding status of existing comorbidities, 23 patients presented with one or more than one comorbidities. Ten patients were hypertensive, three patients had tuberculosis, three cases were diabetic, two patients had depression, and one case each had chronic bronchitis, goiter, heart disease, and positive hepatitis C antigen and hepatitis B antigen status. Majority (75.2%) of the HNC patients were living with their partner, 26 (24.8%) patients were living either with children or relatives, and only 3 (2.8%) were living alone. Clinical characteristics of patients revealed that approximately half of the patients (49.5%) had cancer of larynx followed by cancer of oral cavity (42.9%). Slightly more than half of patients (57.1%) presented with Stage (IVA + IVB). Only 9.5% presented with metastasis stage [Table 3].
Table 2: Sociodemographic characteristics of head-and-neck cancer patients (n=105)

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Table 3: Clinical characteristics of patients with head-and-neck cancer (n=105)

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As seen in [Table 4], the mean scores across all domains showed worsening of QOL from their baseline. The worsening was more severe in emotional function (functional scale), while physical, cognitive, and social functions were comparatively less affected. Symptoms such as nausea and vomiting, dyspnea, constipation, and diarrhea which were seen among 2.7%–22.0% of patients before commencement of CDT and were of milder nature showed increased frequency and severity post-CDT (9.7%–52.7%). However, symptoms such as pain, fatigue, and appetite loss which were seen in 50%–100% of patients before CDT showed increased severity after CDT and were present in almost all patients. All patients had financial difficulties after CDT as compared to baseline. There was substantial worsening in Global health status after CDT. All pre- and postcomparisons showed statistically significant differences except dyspnea.
Table 4: European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C-30 mean scores of patients before and after cancer-directed treatment (n=72)

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As evident in [Table 5], mean scores across all symptom scales showed worsening of QoL from their baseline. The symptoms which were not seen before the commencement of CDT (such as dry mouth and sticky saliva) were seen in all patients after CDT. Nutritional supplements and feeding tube were not used by any of patients before CDT, while 93% of the patients were taking nutrition supplements and 9.7% of patients were on feeding tube after CDT. Painkiller use was observed in almost all patients following CDT. Symptoms which were seen frequently before commencement of CDT (such as speech problems, less sexuality, and felt ill) continued to show increased frequency and worsening of QoL after CDT. However, the worsening was most severe for sexuality. Symptoms (such as sense problems, opening mouth, teeth, and coughing) which were seen infrequently before CDT (1.4%–12.5%) were seen in all patients and showed pronounced worsening in QoL after CDT. Loss of weight was seen in all patients both before and after CDT. Pain and swallowing difficulty which were seen in majority of patients albeit of milder nature before CDT showed increased severity after CDT. Similarly, worsening in social symptoms was also observed post-CDT. Statistically significance was observed across all symptom domains except use of feeding tube.
Table 5: European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Head and Neck-35 Mean scores of patients with Head-and-Neck cancer assessed before and after cancer-directed treatment (n=72)

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The reliability coefficients of generic and specific HN EORTC questionnaire (global and domain wise) were used for better understanding of the readers [Table 6].
Table 6: Reliability coefficients of generic and specific HN EORTC questionnaire (global and domain wise)

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 > Discussion Top


We undertook QOL investigation among patients with cancers premised on general understanding that their QOL is influenced more severely and its effects manifest over broad range of domains compared to other diseases.

However, the QOL investigation is challenging both for the clinicians and researchers alike. Measurement of QOL poses several problems. While clinicians may not find sufficient time to record QOL routinely, the research communities face huge challenges in evolving tools that measure it validly and reliably. Few will disagree that the entity is difficult to measure given its multidimensional construct. Further, the tools for measurement of QOL were initially developed by Western researchers. Although psychometric evaluation of the tools has been undertaken in the Indian setting, the QoL assessment studies are infrequent.[10]

Therefore, we thought it is pertinent to report reliability coefficients to see how the tool performs in our setting. It is clearly evident that pre- and post-Cronbach alpha coefficients for generic and H and N-specific QOL is acceptable for most domains. As reported by Chaukar et al.[10] in the Indian settings, Cronbach alpha ranged from 0.32 to 0.93 and as per another Indian study conducted by Damodar et al.,[18] Cronbach alpha was >0.7 in HNCs. Similar pattern of findings was observed by other authors as well.[10],[19]

Incidentally, the sociodemographic profile of patients studied by us was similar to reported by other investigators. The common characteristics such as male preponderance, middle age, low educational status, and higher prevalence of risk factors such as tobacco and alcohol allowed for direct comparisons.[19],[20],[21],[22] Similarly, many authors have reported almost similar rates of comorbidity as we did in our study.[23],[24],[25],[26] Needless to say, the presence of comorbidity is an independent predictor of QOL.

We observed worsening in QOL after CDT across all domains with emotional functioning most severely affected. While some reported worsening of QOL across functional domain, others reported disproportionate worsening in emotional and social domain. Studies carried out by Taher,[21] Alvarez-Buylla Blanco et al.,[27] and Bjordal et al.[28] found worst scores on functional scales. Scharloo et al. studied 177 patients prospectively and reported worsening in social functioning without much impact on emotional domain.[29] Worst affected emotional domain in our study may be is a reflection of how patients in our setup receives diagnosis of a cancer or lack of awareness or lack of communication thereafter.

As far as symptom scales are concerned, almost all investigators have reported deterioration at the end of CDT or worsening from baseline levels.[21],[27],[30],[31]

Pronounced deterioration has been reported in pain, fatigue, and appetite and weight loss after CDT. Some symptoms have been reported only after start of CDT. The changes are usually attributable to radiotherapy-induced mucositis.[30]

Increase in pain arising from chemotherapy or radiotherapy calls for the use of more effective analgesic medication.[21] Fatigue significantly worsened QOL in our study. Wan Leung et al.[32] also analyzed 640 HNC patients and found similar results. Similarly, there was substantial appetite loss post-CDT in our patients.

We observed pronounced dry mouth, sticky saliva, and swallowing impairments after CDT partly because a substantial proportion of cancers in our study involved oral cavity and larynx. Swallowing impairment might have occurred due to surgical procedures (15%) or use of chemoradiotherapy (57%). Other authors also found higher scores for dry mouth, difficulty in weight gain, and use of analgesics.[21],[33],[34] Boscolo-Rizzo et al.[35] found disadvantages in terms of dental problems, problems of opening mouth, dry mouth, and sticky saliva.

Still, others have reported loss of sense of taste and olfaction affects 50%–75% of those who submit to radiotherapy, chemotherapy, or both as we did.[36],[37] These may also have contributed to weight loss. Proper nutrition, therefore, is key to improve QOL and need to be emphasized despite increase in use of nutrition supplements at the completion of CDT.[37],[38],[39] Aggravation in speech problems have also been reported frequently. Aplak et al.[40] and Campbell et al.[41] found worse scores for speech problems in late-stage and laryngeal cancers. We reported them as we had substantial proportion of laryngeal cancers in our sample. Furthermore, many patients underwent tracheostomy in our study. Social eating and opening mouth difficulties have also been reported by others (Aplak et al.).[40]

Hence, the study concludes that EORTC QLQC-30 (generic) assessment revealed worsening of QOL across all domains after CDT. QOL showed severe deterioration in emotional domain, while physical role and cognitive functioning were comparatively less affected. Pain, fatigue, insomnia, and appetite loss showed pronounced worsening after CDT. Global health status and EORTC QLQ H and N-35 (specific) revealed worsening of all symptom scales/items after CDT.

Multifaceted systematic changes need to be infused in patient care and management so that we not only add “years to life” but also succeed in adding “life to years.” Research shows that palliative care is beneficial to patient and promotes well-being. In recent years, some studies have shown that integrating palliative care into a patient's usual cancer care soon after a diagnosis of advanced cancer can improve their QOL and mood and may prolong survival.[42],[43] The American Society of Clinical Oncology recommends that all patients with advanced cancer receive palliative care.[43]

Trained counselors should be made available in the department so that requisite psychosocial support is available at all times. Adequate support and management of conditions affecting QoL be made available such as diet counseling, speech rehabilitation, swallowing rehabilitation, sexual counseling, and pain management. Further research is needed to develop shortened and easier yet valid version of QoL so as assessment of QoL in routine care is easily incorporated.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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