|Year : 2017 | Volume
| Issue : 2 | Page : 447-452
Quality of life outcome measures using University of Washington questionnaire version 4 in early T1/T2 anterior tongue cancers with and without radiotherapy: A cross-sectional study
P Sakthivel, DV K Irugu, CA Singh, H Verma, R Yogal, B Jat, A Chadran, K Sikka, A Thakar, SC Sharma
Department of Otorhinolaryngology and Head and Neck Surgery, All Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||21-Feb-2018|
Dr. D V K Irugu
Department of Otorhinolaryngology and Head and Neck Surgery, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
CONTEXT: To evaluate the quality of life (QOL) outcome measures in disease-free survivors of pathological T1/T2 tongue cancers and to compare QOL in patients treated with only surgery and with adjuvant treatment. SETTINGS AND DESIGN: Cross-sectional survey. PATIENTS AND METHODS: All pathological T1/T2 anterior tongue cancer cases with follow-up from January 2011 till December 2015, who had locoregionally controlled disease with a minimum disease-free survival period of 1 year, were included in the study. RESULTS: A total of 36 patients, 28 are males and 8 are females with an age range of 24–66 years (median age of 43) were enrolled in the study. The patients were divided into two groups with (n = 26) and without adjuvant postoperative radiotherapy (RT) (n = 10) and the University of Washington-QOL questionnaire version 4 for physical and social domains, global questions and three important domains were analyzed. On the physical and social domain scores, the surgery-alone group outscored the combined modality group on all scales and the differences were statistically significant for specific physical domains such as saliva (0.0001), taste (P = 0.0001), chewing (P = 0.0004), swallowing (P = 0.0026), and social domains such as mood (0.0001), pain (P = 0.0001), and shoulder function (P = 0.0061). The overall global QOL scores were also better for the surgical group compared with group which received adjuvant RT but was not statistically significant. All patients chose saliva as their top priority domain in the group which received radiation, and 60% chose “swallowing ability” as the preferred top priority domain in the only surgical group. CONCLUSIONS: Although locoregional control and disease-free survival are the major treatment-related endpoints for cancer management, QOL outcome measures have to assess to determine the impact of a treatment modality on patients well-being and for better rehabilitation of cancer-free patients.
Keywords: Adjuvant radiotherapy, early tongue cancer, health-related quality of life, quality of life, University of Washington-quality of life
|How to cite this article:|
Sakthivel P, K Irugu D V, Singh C A, Verma H, Yogal R, Jat B, Chadran A, Sikka K, Thakar A, Sharma S C. Quality of life outcome measures using University of Washington questionnaire version 4 in early T1/T2 anterior tongue cancers with and without radiotherapy: A cross-sectional study. Indian J Cancer 2017;54:447-52
|How to cite this URL:|
Sakthivel P, K Irugu D V, Singh C A, Verma H, Yogal R, Jat B, Chadran A, Sikka K, Thakar A, Sharma S C. Quality of life outcome measures using University of Washington questionnaire version 4 in early T1/T2 anterior tongue cancers with and without radiotherapy: A cross-sectional study. Indian J Cancer [serial online] 2017 [cited 2021 Jul 30];54:447-52. Available from: https://www.indianjcancer.com/text.asp?2017/54/2/447/225796
| » Introduction|| |
The head and neck malignancies are the most debilitating in terms of pre- and post-surgical outcomes in the aspect of affecting not only the physiological but also the social and physical domains. Resection of tongue impairs important functions such as chewing, swallowing, and speech, significantly affecting quality of life (QOL) in patients with tongue malignancies. In our setting, to evaluate the aforementioned QOL domains, a retrospective study was done using the widely acclaimed University of Washington-QOL [UW-QOL] questionnaire. UW-QOL questionnaire, currently in its fourth version, has become a simple tool to measure the functional, social and emotional domains after being introduced by Hassan and Weymuller in 1993. In 2003, Roger et al. added mood and anxiety domains in the questionnaire raising the credibility and effectiveness of the original questionnaire.
Various surgical modalities offered to the patients include locoregional flaps and free flaps augmented by postoperative chemotherapy or radiotherapy (RT) which substantiates the favorable outcome of the primary surgery of tongue carcinomas. Currently, the consensus among the operating surgeons is to correct the small defects using locoregional flaps in T1/T2 disease. Although free flaps have emerged as a popular new method of reconstruction providing tissue unaffected by the disease, their role is mainly limited to T3/T4 lesions. Adjuvant RT is given to patients with close margins and nodal metastasis, and chemotherapy in patients with positive margins. In our study, we retrospectively analyzed the patient's post-treatment QOL in early pT1/T2 anterior tongue cancers who were disease free till the last follow-up.
| » Patients and Methods|| |
All pT1/T2 anterior tongue cancer cases from January 2011 till December 2015 were retrieved from the hospital database. Among these, only cases with follow-up were included in the study. All the patients had locoregionally controlled disease with a minimum disease-free survival period of 1 year.
The patients were enrolled into the study after a brief explanation about the study and were given the UW-QOL version 4 questionnaires. Data regarding the patient demographics, primary site involved, tumor, node and metastasis staging, type of surgery, reconstruction carried out and adjuvant treatment like RT and chemotherapy were collected.
UW-QOL version 4 questionnaire consists of brief, multifactorial questions specific to head and neck functions and the patient's perception of his/her QOL in the last 7 days. It has physical domains such as chewing, speech, swallowing, taste, saliva, appearance, and social domains such as anxiety, mood, pain, activity, recreation, and shoulder function. Each functional domain is scored from 0 to 100 by the patient. The other scores, which may or may not be available for each domain, are 25, 30, 40, 50, 70, 75, 80 indicating the level of the response between the worst and the best. These physical and social domains were compared with two groups which received surgery with adjuvant RT and those with only surgery.
The global questions required enquiring (a) about how patients feel relative to before they developed their cancer, (b) about their health-related QOL, and (c) about their overall QOL in the past 1 week. In addition, “three important domains” allows the patient to select three of the physical or social domains affecting them the most in their day-to-day life.
Wilcoxon rank sum test and independent t-test were used to calculate the median, standard error and P value for physical and social domain analysis between two groups. P< 0.05 is taken as statistically significant for all observed correlations.
| » Results|| |
There were a total of 86 patients of pT1/T2 anterior tongue cancer registered during the study, out of which only 36 patients were in regular follow-up and were enrolled in the study. Of the total 36 patients, 28 are males and 8 are females with an age range of 24–66 years (median age of 43). All of them (n = 36) had squamous cell carcinoma histologically. Fourteen were of pathological stage T1, and 22 were T2, and 19 cases had regional nodal metastasis [Table 1]. Six patients underwent only wide local excision including two cases of laser excision. Ten patients underwent unilateral extended supraomohyoid neck dissection (SOND), 12 patients underwent bilateral extended SOND, and 8 patients underwent type 3 modified neck dissection. Restoration of the surgical defects was done by primary closure (n = 22), tongue rotation flap (n = 6), local tissue advancement (n = 4), secondary healing (n = 2), and skin grafting (n = 2). Twenty-six patients were given postoperative RT (PORT) as per the tumor board decision. The median radiation doses for those treated postoperatively and definitively were 32 Gy (range, 28–35 Gy). The mean duration of follow-up was 45 months of all the patients. The follow-up duration ranged from 14 to 65 months with a median follow-up of 34 months.
| » UW-QOL version 4 questionnaire data|| |
The patients were divided into two groups with and without adjuvant PORT and the UW QOL questionnaire version 4 for physical and social domains, global questions, and three important domains were analyzed [Table 2], [Table 3], [Table 4].
UW-QOL outcomes in the patients who were treated with surgery alone were compared with patients treated with surgery with adjuvant RT [Table 5]. Patients treated with surgery alone fared better on than patients receiving combined modality treatment on the global domains. However, the difference was not statistically significant. On the physical and social domain scores, the surgery-alone group outscored the combined modality group on all scales and the differences were statistically significant for specific physical domains such as saliva (0.0001), taste (P = 0.0001), chewing (P = 0.0004), swallowing (P = 0.0026), and social domains such as mood (0.0001), pain (P = 0.0001), and shoulder function (P = 0.0061).
The box plots for percentage best scores for physical and social domains for both groups indicates those group which received adjuvant treatment with RT had poorer scores compared with the other group and are shown in [Figure 1].
| » Discussion|| |
Only very few units in India are currently collecting health-related QOL information due to increased burden to provide care to a larger number of patients per day, time constraints mandating the examination to be focused on ensuring disease control rather collecting data on QOL and the problem in selecting the most appropriate questionnaire.
The UW questionnaire has the advantages of being (1) brief and self-administered, (2) multi-factorial, allowing sufficient detail to identify subtle change, (3) provides questions specific to head and neck cancer (HNC), and (4) allows no input from the health provider, thus reflecting the QOL as indicated by the patient. UWQOL version 4 has emerged as a simple and clinically relevant measure suitable for routine clinical practice and hence was used in our study.
Although answers to the global questions were satisfactory in both groups, when probed into the individual domains there was a very significant reduction in the QOL outcome measures affecting both physical and social domains in the group which received adjuvant RT.
Pain scores were extremely significant in the group which received adjuvant treatment along with surgery (P < 0.0001). Approximately, 25% of cancer patients who undergo surgery or radiation develop postsurgical or post-radiation pain causing increased morbidity, reduced performance status, increased anxiety and depression, and diminished QOL in HNC patients who were free of disease. A study by Portenoy revealed that decrease in oral intake, swallowing, speech and other motor functions of the head and neck, and altered microbial flora were constant pain triggers in disease-free patients. Surgery, RT, and chemotherapy all can damage somatic tissues and nerves permanently leading to persistent pain. In another longitudinal study, long-term pain strongly correlated with surgical treatment of the neck, although no difference was seen with the type of neck dissection. Various treatment options for pain relief include lidocaine patches, opioids, and topical treatments such as trolamine, Calendula officinalis, and hyaluronic acid application. In a recent study by Mittal et al., local treatment with onabotulinumtoxin A significantly reduced pain and improved QOL in cancer patients suffering from pain in the area of surgery and radiation without any side effects.
The shoulder syndrome, which is characterized by shoulder pain, limitation of abduction, and scapular wing, is seen at varying degrees in patients who have undergone ND.,, Numerous studies have proved that spinal accessory nerve is always functionally impaired even if we preserve it macroscopically during ND and surgical manipulation of the nerve may be associated with severe impairment of nerve conduction when level IIB is involved in the dissection.,,, In a study by Shone and Yardley, the incidence of shoulder disability following radical neck dissection was around 77%. While Schuller et al. reported that postoperative radiation therapy could be detrimental to shoulder function, others have shown that adjuvant RT does not have a negative effect on shoulder function after ND.,, Shoulder function scores were significant in the group which received adjuvant treatment along with surgery (P < 0.0061) clearly indicating that neck dissection in any form impairs shoulder function to some extent. Various physiotherapy interventions such as auto-assisted exercises, free active exercises, gravity-assisted pendular exercises, home exercise programs, inferential therapy, infrared radiation, passive accessory mobilization, proprioceptive neuromuscular facilitation, progressive resisted exercise training are available for the treatment of shoulder dysfunction after HNC treatment. Despite these available options, Lauchlan et al. found that it is not routine post-operative practice to refer patients to outpatient physiotherapy until the patient reports pain and loss of shoulder function, which may reduce the effectiveness of the intervention.
Various studies have reported the side effects of RT in patients with HNC and its detrimental effects on oral health affecting the QOL significantly. Only one of the 26 patients who underwent PORT achieved best scores for domains like saliva, taste, and mood indicating that these QOL domains are interlinked and significantly affect long-term QOL. Xerostomia is considered the most inevitable consequence of RT.,, The degree of xerostomia depends on the total radiation dose and there is almost no recovery of salivary flow when the major salivary glands are situated in the treatment portals receiving a cumulative radiation dose in excess of 40 Gy. Studies have shown that problems with salivation, swallowing difficulties, and taste abnormalities persist even at 3 years posttreatment indicating that these treatment-related side effects are unpreventable and needs to be informed and counseled preoperatively to cope better with these long-term sequelae of treatment. A study by Vainshtein et al. in 40 patients who received swallowing and salivary organ-sparing chemo-intensity modulated RT (IMRT) reported stable or improved HRQOL in nearly all domains compared to both pre-treatment and 2-year follow-up. Chen et al. in their study on 42 patients who received IMRT found that only 16% reported “too little saliva” and no patient reported having “no saliva” indicating the ability of IMRT to preserve long-term functioning and acceptance of IMRT as standard treatment for HNC in the future for better QOL.
Although there is no optimal substitute for saliva, sialagogues such as pilocarpine, cevimeline, anetholetrithione, bethanechol and saliva replacements such as UniMist (Westons Health), Mouth Kote (Parnell Pharmaceuticals), and Oral Balance Gel can be used which can provide temporary relief for xerostomia. Frequent usage of sugar-free popsicles, milk sips, plain ice cubes or ice water may be used to keep the mouth cool and moist. Dental team experienced in caring for patients undergoing treatment for HNC should be available to minimize the oral morbidity of these patients before, during, and after cancer treatment and throughout the patient's lifetime.,,,
Surgical resection of cancers in the oral cavity especially tongue results in loss of two important functions, i.e., speech and swallowing. As time progresses, scaring at the site of surgery along with fibrosis and xerostomia from adjunctive RT further impairs speech and swallowing to a greater extent.,,, In addition, chewing difficulties arise because of loss of soft tissue bulk and sensations leading to difficulties in manipulating the food bolus to the occlusal table, retrieving the bolus, and then consolidating it before deglutition. Since it is difficult to restore the complexity of function of oral cavity, adequate rehabilitation with swallowing and speech therapy consultants are imperative in assisting the patient to regain their pretreatment status and to avoid these to persist in the long term.
Constitutional symptoms such as fatigue may be related to a depressive mood, malnutrition, or a poor cardiovascular status and are often under investigated by physicians and probably underreported by patients because it seems to be a logical consequence of cancer and its treatment. Fatigue has a significant impact on the overall QOL in HNC survivors., In across-sectional study of HNC survivor, psychological distress was prevalent in 31% of patients, 7–11 years after treatment. Hammerlid et al. showed depression to be an independent prognostic indicator of global QOL at 3 years. Chen et al. found that despite a relatively high rate of depression among patients with HNC in the post-RT setting, mental health services are severely underutilized. Psychosocial intervention is useful in improving QOL and can be offered to those who demonstrate adjustment problems.
In a longitudinal study by Morton et al., even though combined modality treatment resulted in greater physical and somatic dysfunction than single modality treatment, patients learned to cope well with dysfunction and disability adjusting their lifestyle so that overall QOL was not related to treatment received as in our study.
| » Conclusion|| |
Our study is unique as it peers into QOL outcome measures and effects on the lifestyle of the patients who underwent primary surgery of carcinoma tongue with and without adjuvant PORT with disease-free status at least for more than a year. Even with early stage disease, neck dissections, and adjuvant RT significantly affect individual physical and social domains which are unpreventable. Patients need to be counseled preoperatively to cope better with these long-term sequelae of treatment. Although ensuring disease-free status is the main aim of follow-up visits of patients with HNCs, detailed QOL measures not only with overall QOL, individual physical and social domains has to be taken into account for better rehabilitation and thereby better QOL in these patients.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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