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MINI SYMPOSIUM: HEAD NECK CANCER
Year : 2013  |  Volume : 50  |  Issue : 1  |  Page : 14-20
 

Prognosticators and the relationship of depression and quality of life in head and neck cancer


1 Department of Radiation Oncology, Buddhist Dalin Tzu Chi General Hospital, Chiayi; School of Medicine, Tzu Chi University, Hualien, Taiwan
2 School of Medicine, Tzu Chi University, Hualien; Department of Otolaryngology, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan
3 School of Medicine, Tzu Chi University, Hualien; Department of Hematological Oncology, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan

Date of Web Publication20-May-2013

Correspondence Address:
C C Lee
School of Medicine, Tzu Chi University, Hualien; Department of Otolaryngology, Buddhist Dalin Tzu Chi General Hospital, Chiayi
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.112279

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 » Abstract 

Background and Purpose: To evaluate the relationship of emotional status and health-related quality of life (HRQOL) in disease-free head and neck cancer (HNC) patients post treatment and to explore their predictive factors. Materials and Methods: Seventy-three HNC patients, post treatment at least 1 year, were recruited to complete three questionnaires, EORTC QLQ-C30, EORTC-H&N35 cancer module, and the Beck Depression Inventory-II (BDI-II). Results: Patients with depression demonstrated significantly poor global health status/QoL (score 41.7 vs. 71.9, P<0.001) and almost all functioning, except for role functioning. Besides, depressive patients presented statistically significant worse symptoms in all QLQ-C30 items, except constipation and financial problems, and in all QLQ-H&N35 symptoms except for teeth and coughing problems. Depression was significantly negative correlated with all functional scales and global health status/QoL (r = -0.341 to -0.750, all P<0.05), and was significantly positive correlated with symptom scales (r = 0.348 to 0.793, all P<0.05), except for constipation. Stepwise multiple linear regression analyses showed that physical functioning and physical distressful symptoms play an important role in the perception of HRQOL (total 46% explained). Global health status and impaired social functioning could explain depression in addition to emotional functioning (total 64% explained). Conclusions: HNC patients with depression were noted to have poorer HRQOL in almost every functioning symptom. HNC patients may get benefit from early interventions to improve HRQOL, emotional status, or both by a more rapid and friendly questionnaire to earlier identify patients with poor HRQOL or depressive status.


Keywords: Depression, head and neck cancer, predictor, quality of life


How to cite this article:
Chiou W Y, Lee M S, Ho H C, Hung S K, Lin H Y, Su Y C, Lee C C. Prognosticators and the relationship of depression and quality of life in head and neck cancer. Indian J Cancer 2013;50:14-20

How to cite this URL:
Chiou W Y, Lee M S, Ho H C, Hung S K, Lin H Y, Su Y C, Lee C C. Prognosticators and the relationship of depression and quality of life in head and neck cancer. Indian J Cancer [serial online] 2013 [cited 2020 Jun 5];50:14-20. Available from: http://www.indianjcancer.com/text.asp?2013/50/1/14/112279



 » Introduction Top


Head and neck cancer (HNC) is one of the 10 most frequently occurring cancers worldwide, with estimates of over 500,000 new cases annually, and one of the 10 leading causes of cancer mortality. [1] The incidence of HNC is relatively low in developed countries and highest in South East Asia. [2] The incidence rate and mortality rate in Taiwan both have doubled several times in past decades, with age at diagnosis dropping steadily over time. HNC is now one of the 10 leading causes of cancer deaths in Taiwan. The main risk factors are smoking and heavy alcohol consumption. Treatment strategies usually include surgery, radiotherapy, and chemotherapy, depending on the tumor site and cancer stage. All these treatments may cause significant temporary or permanent damage to the head and neck region; head and neck functions (such as speech, swallowing, taste, and smell) may be significantly impaired, and changes in body appearance and body image are almost universal. Both functional and cosmetic problems significantly impair health-related quality of life (HRQOL), and HRQOL, especially physical functioning, is ever reported to be an important predictor of survival and distant metastases. [3],[4] Fang showed that a 10-point increase in the physical functioning score was associated with a 23% reduction in the likelihood of death and a 22% reduction in the likelihood of distant metastasis. Another important issue in HNC is depression: major depressive disorder (MDD) has been reported in up to 40% of patients with HNC, typically within the first 3 months of diagnosis. [5] Depression is reported to be a risk factor for malnutrition and has been associated with lower survival. [6],[7] Patients' concerns about the possible severe physical and functional effects of treatment may also contribute to poorer psychological outcomes. Prophylactic antidepressant treatment has been reported to decrease the incidence of depression during HNC therapy. [8] Lydiatt showed prophylactic treatment with the antidepressant, citalopram hydrobromide, compared with placebo, could prevent MDD in patients undergoing therapy for HNC.

This study aimed to assess the emotional status, HRQOL, and their relationship among disease-free HNC patients.


 » Materials and Methods Top


This cross-sectional study was designed to evaluate HRQOL and depression in HNC patients. Patients were evaluated by questionnaires one time at 1 year after treatment finished. Eligible participants were recurrence-free oral cancer or nasopharyngeal cancer (NPC) patients. Patients who were unable to complete questionnaires as a result of senile dementia, mental disturbance, or severe intercurrent disease were excluded. A total of 73 patients were recruited in this study. This study was conducted from 2008 to 2010 in Taiwan. Written informed consent and approval from the Institutional Review Board were obtained before data collection began.

Patients were seen individually at the outpatient clinic and were asked to complete three self-reported questionnaires: The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, version 3.0 (EORTC QLQ-C30 v.3), the EORTC Head and Neck Cancer Module (EORTC QLQ-H&N35), and the Beck Depression Inventory-II (BDI-II). Data pertaining to the HRQOL of HNC patients were collected using the Taiwan Chinese versions of the EORTC QLQ-C30 and EORTC QLQ-H&N35. Depression was evaluated by the Beck Depression Inventory-II questionnaire (BDI-II).

The EORTC QLQ-C30 core questionnaire is a validated and broadly used cancer-specific questionnaire designed for self-assessment of different dimensions of HRQOL and symptom scores relevant to cancer patients. [9] It has previously been used in studies of HNC. [10],[11] It is a 30-item questionnaire scored on a four-point scale (1 = not at all, 4 = very much). All scales (five function scales, three symptom scales, and one global health status /QOL), and six single-item symptom measures ranged in a transformed score of 0 to 100 [Table 1]. Five function scales are physical, role, emotional, cognitive, and social function scales. A high score on a function and global health status scale indicates a high level of functioning and QOL, whereas a high score on a symptom scale or single item indicates more severe symptoms or problems. The EORTC QLQ C-30 was translated into Chinese and validated in Taiwan. The Taiwan Chinese version of the EORTC QLQ-C30 has been shown to have moderate to high test-retest reliability and high internal consistency. [10],[12]
Table 1: Mean scores and standard deviations for different scales of the EORTC QLQ-C30 and EORTC QLQ-H&N35 in cancer patients (n = 73)

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The EORTC QLQ-H&N35 is a site-specific module for HNC as a supplement to the EORTC QLQ C-30. It is used to measure symptoms and problems related to tumor location and treatment in HNC patients. [13],[14],[15] Seven multi-items scales have been constructed that assess pain, swallowing, senses (taste and smell), speech, social eating, social contact, and sexuality [Table 1]. There are also 11 single items. For all items and scales, high scores indicate more problems. It was translated into Chinese and validated in Taiwan. The Taiwan Chinese version of the QLQ-H&N35 has been validated for the assessment of HRQOL in HNC patients. [10],[16]

Emotional status was measured using the Chinese version of The Beck Depression Inventory II (BDI-II) questionnaire. BDI-II is a 21-item, four-point Likert scored scale (0 = not at all, 3 = always) that assess the presence and severity of affective, cognitive, motivational, vegetative, and psychomotor components of depression in the last 2 weeks. Items in BDI-II include questions on changes in sleep patterns, changes in appetite, tiredness or fatigue, degrees of sadness, feelings of guilt and pessimism, and others. The total BDI-II score is the sum of the ratings for each of the 21 items. Higher scores indicate more severe depression. The BDI-II has produced reliable and valid results. [17],[18]

The Cronbach's α coefficients of these three questionnaires were between 0.82 to 0.85 in this study.

The mean scores of the five dimensions of functional scales, symptom scales, and global health/QoL in the QLQ-C30 and symptom scales in QLQ-H&N35 were calculated according to the EORTC Scoring Manual. Depression was defined as a BDI-II score >13. The independent-sample t-test was used to compare mean scores of QOL between different groups. Correlation between depression and QOL items was evaluated by Pearson's correlation test. Stepwise multiple linear regression was used to explore predictors of global QOL, depression, and their relationship. All tests were two-tailed, and a significance level of 5% was selected. The SAS (version 9.2; SAS Institute, Inc., Cary, NC, USA), and SPSS (version 17, SPSS Inc., Chicago, IL, USA) statistical packages were used for data analysis.


 » Results Top


Basic background information of the patients is shown in [Table 2]. The mean age was 50 ± 9 years. There were 26 patients with NPC and 47 with oral cancer. Of the 73 patients, 45 (62%) were classified in advanced stage (stage III/IV) disease. Seventy-one patients (97%) received more than one kind of treatment modality. Sixty-one patients were married (84%). Fifty-two (71%) patients received over 6 years of education.
Table 2: Demographic and clinical characteristics of the subjects (n = 73)

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Social, emotional, and cognitive functions (76.0 ± 31.4, 81.7 ± 22.2 and 81.7 ± 23.6, respectively) were affected significantly, and financial problems (34.2 ± 38.5), insomnia (27.4 ± 35.7), and fatigue (25.4 ± 23.7) were the main complaints. The mean score of global QoL was low (63.6 ± 22.3). The most distressful symptoms specific to HNC patients were dry mouth (56.2 ± 37.2), trouble with opening mouth (49.8 ± 41.2), and sticky saliva (40.6 ± 36.1).

In total, 20 (27.4%) patients had depression. A comparison of all functioning, symptoms, and global health status/QoL scores between patients with and without depression revealed statistically significant differences. The detailed mean scores for each EORTC QLQ-C30 scale of these two groups are shown in [Table 3]. Patients with depression demonstrated significantly poor global health status/QoL and almost all functioning, except for role functioning. Besides, depressive patients presented statistically significant worse symptoms of fatigue, nausea/vomiting, pain, dyspnea, insomnia, appetite loss, and diarrhea than those not, except constipation and financial problems.
Table 3: Comparison of scores of quality of life dimension between patients with and without depression (n = 73)

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Patients with depression were also noted to have statistically significantly worse QLQ-H&N35 symptoms of pain, swallowing, senses and speech problems, trouble with social eating and social contact, sexuality and teeth problem, opening mouth difficulty, dry mouth, sticky saliva, and ill-feeling than those without depression, except for teeth and coughing problems [Table 4].
Table 4: Comparison of EORTC QLQ-H&N35 scores between patients with and without depression

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Depression was significantly negative correlated with all functional scales and global health status/QoL (Pearson's correlation coefficient r = -0.341 to -0.750, all P<0.05), and were significantly positive correlated with symptom scales (r = 0.348 to 0.793, all P<0.05), except for constipation.

Variables used for evaluating their contribution to HRQOL were the five functioning dimensions, symptom scales, H&N35 symptom scales, and BDI-II. A series of stepwise linear regression analyses was performed, which demonstrated that physical function and physical distress symptoms of QLQ-C30 were the significant predictors of HRQOL [Table 5]. Physical functioning accounted for 38.1% of the variance in the final model, and physical distress symptoms explained an additional 8.1% (P = 0.001).
Table 5: Stepwise multiple linear regression analysis of the relationship of functioning and symptoms to global health status/quality of life

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To predict depression, the five functioning dimensions and global health status/QoL variables were entered into the regression analysis. We found that the model explained 63.9% of the variance (P<0.001). Emotional functioning (P<0.001), global health status/QoL (P = 0.004), and social functioning (P = 0.004) were the significant predictors. H&N35 symptom scales were also entered into the regression analysis and this model explained 70.4% of the variance (P<0.001). Felt ill, swallowing problem, and dry mouth were the significant predictors of depression [Table 6].
Table 6: Stepwise multiple linear regression analysis of the relationship of the QLQ-C30 module and QLQ-H&N35 modules to depression status (BDI- II)

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 » Discussion Top


This study examined emotional status, HRQOL and their relationship in HNC (oral cancer and NPC) patients post treatment. Depression is a severe problem in HNC patients. The depression prevalence rate in our study (23%) was similar to other previous studies in HNC patients (15-22%). [18],[19],[20] However, in our study we found that patients with depression had statistically significant poorer HRQOL in almost all functioning, symptoms, and global health status/QoL than those without depression. We also found that depression was statistically significant correlated with all functioning, all symptoms, and global health status/QoL, except for constipation. We thought that according to our result medication or treatment to improve symptoms and functioning may be helpful to improve or resolve depressive status. On the other hand, prophylactic medication for depression may decrease bad feelings to distressful symptoms, although this needs further investigation. Lydiatt have shown that prophylactic treatment with the antidepressant, citalopram hydrobromide, could prevent depression in HNC patients undergoing therapy. Other prophylactic therapy or early intervention, such as counseling with psychiatrists and social workers, psychological group therapy and short-term psychoeducational programs, has been demonstrated to be able to decrease the incidence of depression. [8],[21]

In this study, the most adversely affected functioning was social function. Oral cancer patients usually have more obvious body appearance change compared to NPC. That the worst functioning was social functioning is compatible with previous HRQOL of HNC patients studies but not NPC alone study. [22],[23] The relatively unaffected social functioning in NPC patients may be due to unaffected body appearance. Early intervention strategies, like speech therapy, swallowing training or group psychotherapy, etc., to improve social functioning in HNC patients could potentially be useful. In a study focus on specific group of NPC patients complicated with endocrinopathies due to side effect of radiotherapy, emotional functioning was the most affected functioning that may be due to endocrinopathies. [24] In our study patients group, emotional functioning was affected but not the worst functioning. The worst symptoms of our patients in QLQ-C30 questionnaire were financial problems, insomnia, and fatigue. Insomnia and fatigue were usual complaints of cancer patients. [25],[26] In this study, we found that financial difficulty was a serious problem in our patients.

The worst symptoms in H&N35 in our patients were, in sequence by severity, dry mouth, difficulty with opening the mouth, and sticky saliva. Oral dryness and thick saliva are attributable to damage caused by radiotherapy. The problem of opening the mouth may be caused by surgery, radiotherapy injury to the temporomandibular joint, or buccal mucosa fibrosis associated with areca nut chewing. These symptoms of dry mouth, opening the mouth and sticky saliva were severe at 1-year follow-up and persisted even after 5-year follow-up. [27] Compared to other studies, pain and less sexuality were the worst symptoms in oral cancer patients in Swedish and Norwegian patients.

As to the relationship between HRQOL and emotional status, regression analysis revealed that global health status and impaired social functioning could explain depression in addition to the contribution of emotional functioning measured by QLQ-C30.

In our HNC study, we found that physical functioning and physical distressful symptoms play a much more important role in the perception of HRQOL. Both symptoms included in the QLQ-C30 and QLQ-H&N35. This issue was not yet explored in HNC patients but already in NPC patients. One NPC study with only 12 NPC patients showed that neither functions nor symptoms had high impact on global QOL, but another NPC study with 43 patients complicated with endocrinopathies showed results similar to ours except for the fact that in that study increased symptoms explained most of the effect on global QOL. [23],[24]

Our study had several limitations. One limitation was that depression was assessed with the self-administered BDI-II questionnaire but not diagnosed by psychiatrists. However, the BDI-II is a widely used instrument to assess depression severity, the validity of which has been proven by several papers. [28],[29],[30] Another limitation was relative small sample size of the study and the fact that it was a convenience sample, rather than a random one. Further larger scale randomized study is needed. Continuing this study at different follow-up time point will be done in the future.


 » Conclusion Top


Depression is a severe problem in HNC patients. HNC Patients with depression were noted to have poorer HRQOL in almost every functioning symptom. Besides, physical functioning and physical distressful symptoms play a much more important role in the perception of HRQOL. Global health status and impaired social functioning could explain depression in addition to the contribution of emotional functioning. A more rapid and friendly questionnaire to detect poor HRQOL patients or depressive patients early is worth developing. For this group of patients, they may benefit from early interventions.


 » Acknowledgment Top


Chiou WY and Lee MS contributed to this paper equally.

 
 » References Top

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]

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