|Year : 2017 | Volume
| Issue : 1 | Page : 11-15
Oral health-related quality of life in patients treated for oral malignancy at Kanchipuram district, India: A cross-sectional study
K Indrapriyadharshini1, PD Madankumar1, GR Karthikeyan2
1 Department of Public Health Dentistry, Ragas Dental College and Hospital, Chennai, India
2 Department of Oral and Maxillofacial Surgery, Karpaga Vinayaga Institute of Dental Sciences, Kanchipuram, Tamil Nadu, India
|Date of Web Publication||1-Dec-2017|
Dr. K Indrapriyadharshini
Department of Public Health Dentistry, Ragas Dental College and Hospital, Chennai
Source of Support: None, Conflict of Interest: None
BACKGROUND: The modern-day onco-surgical therapy is now concerned on the overall Quality of Life after treatment of the patient. There is need to evaluate final outcome following the different combination of treatment modalities available to make better therapeutic treatment decisions. AIM: The aim of this study was to assess Oral health related quality of life (OHRQoL) in patients with oral malignancies who had undergone various treatments. SETTINGS AND DESIGN: A Cross sectional study was conducted among 90 patients between October 2016 to January 2017 in private hospitals, kanchipuram, India. MATERIALS AND METHODS: Participants were grouped based on the treatment they had undergone into Group I - Surgery alone, Group II - Surgery and Radiotherapy, Group III- Surgery, chemotherapy and radiotherapy and assessed for OHRQoL using the shorter version of Oral health impact profile -14 (OHIP-14) questionnaire. STATISTICAL ANALYSIS: Descriptive analysis of socio demographic variables and OHIP 14 was performed using Chi-square test and one way ANOVA. RESULTS: Among the 90 participants, 43.3% belonged to upper lower class and 38.3% to lower class. Buccal mucosa (58.9%) was found to be the most frequent site. Among the clinical staging, Stage II (33.33%) oral cancer was more prevalent. No statistically significant differences in the OHIP mean score for Groups, I, II, III. Among the domains functional limitation was significantly different in the three groups. CONCLUSION: Patients with oral malignancies who had been treated surgically alone had better Quality of life when compared to the combined treatment modalities.
Keywords: Oral health impact profile-14, oral health-related quality of life, oral malignancy, posttreatment
|How to cite this article:|
Indrapriyadharshini K, Madankumar P D, Karthikeyan G R. Oral health-related quality of life in patients treated for oral malignancy at Kanchipuram district, India: A cross-sectional study. Indian J Cancer 2017;54:11-5
|How to cite this URL:|
Indrapriyadharshini K, Madankumar P D, Karthikeyan G R. Oral health-related quality of life in patients treated for oral malignancy at Kanchipuram district, India: A cross-sectional study. Indian J Cancer [serial online] 2017 [cited 2021 Jul 24];54:11-5. Available from: https://www.indianjcancer.com/text.asp?2017/54/1/11/219531
| » Introduction|| |
Oral cancer is the most common type of head and neck cancer worldwide with approximately 263,000 new cases every year. In India, oral cancer being the third most common type of cancer affects every 20 persons/100,000 population and accounts to about 30% of all the types of cancer. According to the National Cancer Control Programme in India, the total cancer burden for all sites will increase from 7 lakhs new cases per year to 14 lakhs by 2026. Head and neck cancer and the side-effects of the treatment have a negative impact on many different aspects of quality of life (QOL) over time. Oral cancer patients are considered different to patients suffering from other head and neck tumors because of the complex tri-dimensional anatomy of the mouth.
Patients with oral malignancies can be treated by surgery, radiotherapy, chemotherapy or a combination of the three depending on the definitive diagnosis, the stage, and location of cancer and patients overall health. These treatment methods impair the integrity and functioning of oral cavity because they destroy not only neoplastic cells but also normal cells at the same time. Treating oral cancer produces important changes in the oral cavity which impairs normal functions such as speech, swallowing, chewing, and salivation. The patient's QOL can also be significantly impaired by these functions.
The World Health Organization (WHO) suggests that health influences QOL in multifaceted and complex ways depending on the person's physical health, psychological state, level of independence and social relationships, and their relationships to salient features of their environment. QOL is a multidimensional concept which looks at the way which patients feel about themselves in the context of a medical condition. The WHO 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.” The subjective evaluation of oral health-related QOL (OHRQOL) “reflects people's comfort when eating, sleeping and engaging in social interaction; their self-esteem; and their satisfaction with respect to their oral health.” For the patient with oral cancer, the self-oriented QOL evaluation is a useful adjunct to the more traditional measures assessing the effectiveness of therapies. Despite recent advances in diagnosis and treatment, oral cancer remains associated with disfigurement and dysfunctions that affect essential domains of life. These considerations account for the importance of OHRQOL assessments for patients treated for oral cancer.
The prognosis and QOL in patients treated for oral cancer remains uncertain, despite refinements in conventional therapy and more recent protocols using alternative treatment modalities. Remarkable advances in surgery like microvascular reconstructive techniques have greatly improved esthetic and functional results. Substantial improvements in radiotherapy such as computed tomography imaging for target volume delineation and intensity modulation radiation therapy using various computer-based optimization have ushered in a new paradigm that has completely revolutionized contemporary radiotherapy practice.
Moreover, despite constantly advanced surgical techniques and improved nonsurgical treatment protocols, QOL of oral cancer patients has not remarkably increased during the recent two decades. The need for additional instruments for more detailed outcome research has brought up the issue of measuring the QOL of cancer patients by assessing their functional status as well as their physical, social, and emotional well-being through self-administered questionnaires. Hence, this study was aimed to assess the OHRQOL in oral cancer patients who received such treatment.
| » Materials and Methods|| |
A cross-sectional study was conducted to assess the OHRQOL in oral cancer patients who had undergone treatment. The study protocol was approved, and the ethical clearance was obtained from the Institutional Review Board, Ragas Dental College, and Hospital, Chennai. The written permission to conduct the study was obtained from the private institutions and hospitals at Kanchipuram district. The study was conducted among ninety patients between the period of October 2016 and January 2017 in the outpatient department in private institutions and hospitals at Kanchipuram district. Informed consent was obtained from the participants before the study.
For the present study, patients who had completed their assigned protocol of treatment for oral malignancies, 6 months before, the initiation of the present study were included. However, those patients who had recurrence of their malignancy, and those who were not ambulatory and required assisted feeding were excluded from this study.
The patients were given a brief explanation about the study and those who consented to participate were enrolled into the study. The patients were grouped, based on the treatment they had undergone: Group I - treated by surgery alone (n = 30), Group II - treated by surgery and radiotherapy (n = 30), Group III - treated by surgery, chemotherapy, and radiotherapy (n = 30). Data collection was done in two parts. First, the data pertaining to the sociodemographic details consisting of age, gender, marital status, education, and the socioeconomic status (SES) were recorded through modified Kuppusamy scale, 2016. Second, the OHRQOL was assessed using the shorter version of oral health impact profile (OHIP) which consists of 14 items that explored seven dimensions of impact: functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability, and handicap. The participants respond to each item according to the frequency of impact on a 5-point Likert scale ranging from 0 to 4; never, hardly ever, occasionally, fairly often, and very often. The QOL was considered to be poorer with higher scores. The OHIP questionnaire was translated into Tamil, the local vernacular language by language experts. The questionnaire was back-translated to English to check for any discrepancy. Data regarding tumor, node, metastasis (TNM) staging, primary site involved, and types of treatment were obtained from the patient records.
Data collected in the study were entered into Microsoft Excel spreadsheet, and a master table was prepared. The data were analyzed using IBM Statistical Package for the Social Sciences for windows version 20.0 software(IBM Corp., Armonk.NY). Analysis of sociodemographic variables and comparison of OHIP-14 scores among the three groups were performed using Chi-square test and one-way ANOVA with post hoc Tukey test, respectively. For all analysis, P < 0.05 was considered to be statistically significant.
| » Results|| |
The present study was done to assess the QOL of patients with oral malignancies who had undergone various treatment modalities at tertiary care centers in Kanchipuram district. All ninety patients who were approached had completed the study.
[Table 1] shows the distribution of demographic variables among the study participants. Among the 90 participants enrolled, 50% were male, and 50% were female. The majority of the participants belonged to the upper lower class (43.33%) and lower class (38.3%). The most frequent location for oral cancer was found to be buccal mucosa (58.9%) and among the clinical staging, Stage II (33.33%) oral cancer was more prevalent among the study population. Among the population, 53.33% of the patients were found to be smokeless tobacco chewers. There existed a statistically significant differences found among the groups with respect to the sociodemographic data of gender, income, SES, and TNM staging.
|Table 1: Distribution of demographic variables among the study participants|
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[Table 2] shows the comparison of overall OHIP score and various domains of OHIP-14 scale among the three groups. The mean score for Group I, II, III (n = 30 each) were 33.33, 36.07, and 40.40, respectively. No statistically significant differences were found in overall score of OHIP-14 among the three study groups. Among the three groups, the “Functional limitation” domain score was found to be statistically significant difference between Group I and Group III.
|Table 2: Distribution of the overall score and various domains of oral health impact profile-14 among the three study groups|
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| » Discussion|| |
QOL is a global construct that emerges from several, overlapping aspects, or “domains” of life. In the last three decades, this construct has been developed quite extensively in medical research to assess the individual's perception of overall well-being. Unfortunately, only a few studies comparing QOL after surgery, chemotherapy, and radiotherapy for oral cancer patients are available.
Acknowledging the relatively miscellaneous nature of oral cancer patients and treatments experienced, the findings of OHRQOL outcome for oral cancer patients to be somewhat discordant and also complicated in the literature. The treatment of oral cancer instigates the other problems by worsening the QOL of individuals interpreting which could help in clinical judgment and the definition of the treatment approaches in the future. There are a variety of questionnaires used to assess OHRQOL in oral cancer patients such as University of Washington QOL scale, functional assessment of cancer therapy-Head and Neck Scale, the European Organization for Research and Treatment of Cancer QOL core questionnaire 30, oral impact of daily performances, OHIP scale. Among the various questionnaires, OHIP-14 is commonly used as it can better demonstrate the changes in QOL in oral cancer patients who have undergone treatment. The OHIP-14 is shorter version of OHIP-49 original which was often not practical in a clinical setting because of its length and also because many questions were irrelevant to specific oral health states. The OHIP-14, in spite of being a short-questionnaire with 14-items, has been shown to be reliable, sensitive to changes, and to have adequate cross-cultural consistency and aimed to measure self-reported functional limitation, discomfort, and disability attributed to oral conditions.
Most of the subjects in our present study belonged to lower and upper lower socioeconomic scale. This was in accordance with the study by Khandekar et al., who reported that the low SES may be a risk factor for poor oral hygiene, thereby further increasing the risk of oral cancer in tobacco chewers. The risk of oral cancer is inversely proportional to increasing the level of education, income, and occupation. In developing countries, a high proportion of patients with oral cancer is from lower socioeconomic classes. This high proportion is clearly associated with difficulties in accessing the health-care system, with most cases eventually diagnosed at advanced clinical stages. Consequently, more aggressive, multimodal, time-consuming and costly staging workups and treatments are needed to treat these patients. Earlier studies reported that SES is one of the most important variables affecting health-related QOL and an important predictor of disease morbidity and mortality.
In the present study, the most commonly affected site was the buccal mucosa (58.9%). The study by Singhania et al. stated that there is a significant variation in the site of occurrence of cancer in the oral cavity which has been attributed to the habit of tobacco consumption in its various forms. In the review of Sankaranarayanan et al., an extensive study of oral and pharyngeal cancer in Southeast Asia, concluded that the chewing of tobacco and lime mixture plays an important role in the etiology of oral cancer by causing cancer at the place where the quid is habitually kept, and the probability of developing cancer is directly correlated with the duration and intensity of chewing. However, in developing countries like India, tobacco and betel quid chewing contribute to the major risk factor for carcinoma occurrence, hence, the reason for maximum presentation of carcinoma of buccal mucosa in our population.
Among 90 oral cancer patients in the present study, 53.33% were tobacco chewers. The high prevalence of oral cancer and potentially malignant lesions in India has long been linked with the habit of betel quid chewing incorporating tobacco. Smokeless tobacco and poly ingredient oral dipping products may have a stronger effect than smoking because of the direct contact of the ingredient carcinogens with the oral epithelium.
In the present study among the ninety participants, 33.33% presented with Stage II cancer followed by Stage III (31.1%). Khandekar et al. had reported that though oral cavity is a site which is accessible for clinical examination and amendable to diagnosis by current diagnostic tools, the crux of the problem for the diagnosis of oral cancer was due to delayed reporting to the health-care facility. This is also evident from the findings of the present study where the study participants had reported with Stage II and Stage III of oral cancer.
In the present study on comparing among the groups, the mean overall OHIP-14 scores of the Group I (surgery alone) were lower than that of Group II (surgery and radiotherapy) and Group III (surgery, radiotherapy, and chemotherapy). The “functional limitation” “Physical pain” and “physical disability” domains were found to be more affected and participants in the Group III were found to be affected more which correlates to the results stated by Bhalla et al. 2015. Barrios et al. stated in his study that patients who received only surgical treatment obtained better QOL than those that received surgery and chemotherapy or combined surgery, radiotherapy, and chemotherapy. This states that only surgical treatment had resulted in little damage to the oral structure and function. The results of various studies reported that combined treatment showed complications including pain, mucositis, mucosal sensitivity, dry mouth, altered or reduced taste, mucosal and bony necrosis, increased risk of dental caries, difficulty with denture function, altered esthetics, reduced mobility of tongue, lips, and jaw, and limitation of mastication and swallowing.
The results of the present study have to be interpreted with the following limitations. The design of the study being cross-sectional in nature, issues related to temporality shall be of concern. Further, the generalizability of this study results may be affected according the standard of care rendered by the specialists and based on the infrastructure facilities at the tertiary care centers.
| » Conclusion|| |
The results of this study showed that the patients with oral malignancies who had been treated surgically alone had better QOL when compared to the combined treatment modalities. The results of this study assume the significance as constellation of factors including treatment modalities may affect OHRQOL of these patients. Thus, QOL has to be considered as an important outcome parameter in the decision-making for the treatment of oral malignancy patients.
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Conflicts of interest
There are no conflicts of interest.
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