A study of quality of life of head and neck cancer patients attending ear, nose, throat out-patient department of tertiary care centre in upper Assam region

INTRODUCTION

Head and neck cancers are malignant tumours of the upper aero-digestive tract including oral cavity, nasopharynx, oropharynx, hypopharynx and larynx.¹ They account for about 4% of all cancers in developed countries like the United States.² However, in developing nations like India, approximately 30-40% of all cancer cases are head and neck cancers.³ In India, one-fourth cases of head and neck cancers are seen in males and one-tenth in females.

This is mainly attributed to tobacco, areca nut, alcohol.⁴

Etiology

Tobacco

It contains over 30 known carcinogens such as polycyclic aromatic hydrocarbons and nitrosamines and its synergism is seen with alcohol.^5,6

Dental factors

Poor oral hygiene is one of the etiological factors.

Viral infections

Human papilloma virus (HPV), herpes simplex virus (HSV), Epstein-Barr virus (EBV) are the etiological factors.

Inflammatory

The inflammatory factors were gastroesophageal reflux disease, pre-cancerous lesions like erythroplakia, leukoplakia

Occupational exposure

Exposure to wood dust, organic chemicals and coal dust were some of the occupational exposures.⁷

Nutritional factors

Intake of red meat and salted meat increases the risk, whereas high fruit and vegetable intake is associated with a decreased risk of head and neck cancer probably due to increased amounts of antioxidants or free radical scavenging vitamins A, C and E.⁸

Genetic and immunologic predisposition

Few genetic conditions are associated with increased cancer risk, for instance, Li-Fraumeni syndrome, Fanconi’s anemia, Bloom syndrome, ataxia-telangiectasia. There is a genetic susceptibility in the capacity to metabolize carcinogens and repair consequent DNA damage. This involves polymorphisms in GST genes, CYP genes and the cytochrome P450 system.^9-12

According to the cancer atlas project by the Indian council for medical research (ICMR) reports, among incidences of different cancers across India, the incidence in Assam, Manipur, Mizoram, Tripura and Nagaland has been reported to be higher (54%).

The world's highest incidence of cancers in men, which was of the lower pharynx (11.50/100,000 people) and the tongue (7.60/100,000 people), was reported from Mizoram. Pondicherry had also reported the incidence of oral cancer in males (7.80-8.90/100,000). However, the highest incidence of nasopharyngeal cancer had been reported from Nagaland.^13-17

Although the treatment for head and neck cancer had resulted in a significant improvement in survival rates, yet the correct assessment and aiding the patient’s quality of life still remained a pivotal challenge.

QoL

It is defined as an individual’s perceptions of their position in life taken in the context of the culture and value systems in which they live and in relation to their goals, standards and concerns (according to WHO).¹⁸

It is defined as the measure between age expectations or present experience and the perceived and actual goals (according to Calman-gap theory).¹⁹

It was observed that the patients usually do not have a good standard of living, owing to their morbidity. QoL information can change clinical practice both in terms of treatment protocols and strategies and also in terms of individualized patient care.²⁰

The patient’s perspective of outcome is a critical component of healthcare evaluation.²¹ Hence, it was decided to study the quality of life of all diagnosed cases of head and neck cancer.

Aim

The aim of the study was to assess the QoL amongst all diagnosed cases of head and neck cancer.

METHODS

This was a hospital-based, descriptive, cross-sectional study in which the quality of life of 54 patients diagnosed with head and neck cancer attending the out-patient department of ENT, Assam medical college were studied. The study was conducted from July 2020 to June 2021. Patients presenting to outpatient department and fulfilling the following criteria were included in the study.

Inclusion criteria

Patients of head and neck cancers attending the OPD of ENT, AMCH; patients above 18 years of age; patients who were able to understand the questions of the questionnaire UW-QoL; patients who gave consent were included in the study.

Exclusion criteria

Patients whose diagnosis had not been confirmed; terminal cases who were not able to understand and/or answer the questionnaire, by any means whatsoever were excluded.

Data collection

Patients satisfying the inclusion criteria were subjected to a questionnaire on QoL using UW-QOL, which included the dietary and sexual aspects of their lifestyle.

The data collected were tabulated in Microsoft excel worksheet and computer-based analysis was performed using Microsoft excel 2013. The categorical variables were summarised as proportions and percentages.

The study was a hospital-based observational study, so no statistical analysis between the parameters were evaluated.

The study was approved by the institutional ethics committee.

RESULTS

The number of cases were significantly higher in males with 43 cases (79.62%) as compared to females who comprised only 11 cases (20.38%).

The highest number of cases was observed in the sixth decade of life (29.63%), followed by seventh decade (22.22%).When asked to state the aspect of lifestyle was most distressing/inconvenient for the patient in past one week (up to three choices per patient), the highest fraction of patients responded pain (54.50%), followed by appearance and chewing (37.03% each) and subsequently, swallowing and speech (31.48% each).

Majority of patients (38.88%) stated that they experienced moderate pain needing regular non-narcotic medication. Majority (44.44%) of the patients stated that they can chew soft solids, but cannot chew some foods.

29.62% patients responded that they can swallow certain soft solids, but cannot swallow certain foods. 7 of the patients were tube fed and one patient had undergone feeding jejunostomy.

Around half of the patients complained of dry mouth, due to reduced salivation.

25 of such patients, who had reduced salivation, had undergone/were undergoing radiotherapy as either curative or palliative purpose.

On being asked about the sexual aspect of their lifestyle, around 25.92% patients responded that they were a little dissatisfied, 16.66% patients were moderately dissatisfied and 3.70% patients were very dissatisfied with their sex lives. On being asked about their mood, around 37.03% patients stated that they were neither in a good mood nor depressed, while around 33.33% revealed that they were depressed about their cancer.

Around 33.33% patients experienced shoulder stiffness with or without pain. 15 of these patients were post-operative cases and 13 had undergone radical/modified radical/selective neck dissection, inducing the risk for injury to the spinal accessory nerve.

DISCUSSION

All patients of head and neck cancer attending department of otorhinolaryngology during the study period who fulfil the inclusion criteria were included in the study. There was a total of 54 patients of head and neck cancers during this study period.

The number of cases were significantly higher in males with 43 cases (79.62%) in comparison to females which was only 11 cases (20.38%). The male to female ratio was 3.9:1. A study, head and neck cancer patients’ QoL: analysis of three instruments, consisted of 33 individuals where 69.70% were males, which was somewhat similar to our study.²²

The highest incidence of cases was observed in the sixth decade of life (29.63%), followed by seventh decade (22.22%). In the study, head and neck cancer patients’ quality of life: analysis of three instruments with 33 individuals, the mean age was (63.42±11.25) years, which was almost similar to our study.²²

When asked to state the aspect of lifestyle which was most important for the patient in past one week (up to three choices per patient), the highest fraction of patients answered pain (54.50%), followed by appearance and chewing (37.03% each), followed by swallowing and speech (31.48% each). In the study, importance-rating using the UW-QoL questionnaire in patients treated by primary surgery for oral and oro-pharyngeal cancer, patients tended to rate speech, chewing and swallowing as more important than the other UW-QOL domains, which was majorly consistent with our study.²³

According to the severity of pain experienced, majority of patients (38.88%) experienced moderate pain needing regular non-narcotic medication. In the study, Influence of pain severity on the quality of life in patients with head and neck cancer before antineoplastic therapy, 66.9% of all patients reported that they used analgesics for pain control, despite which the number of patients with pain (59%) remained high.²⁴

On the basis of effect of appearance, 25.92% patients stated that they felt significantly disfigured and their activities were limited due to their appearance.

Majority (44.44%) of the patients stated that they can chew soft solids, but cannot chew some foods, but 29.62% patients stated that they can swallow certain soft solids, but cannot swallow certain foods. 7 patients were tube fed and one patient had undergone feeding jejunostomy. A maximum of 33.33% patients stated that they had some difficulty in speech, however they could be understood over phone.

Around half of the patients complained of reduced salivation. It was noteworthy that 25 of these 27 patients had undergone/were undergoing radiotherapy as either curative or palliative purpose. This was almost similar to the study QoL and salivary output in patients with head-and-neck cancer five years after radiotherapy, where around 40 percent of the patients complained of reduced salivation.²⁵

Around 25.92% patients were a little dissatisfied, 16.66% patients were moderately dissatisfied and 3.70% patients were very dissatisfied with their sex lives. In the study, issues of intimacy and sexual dysfunction following major head and neck cancer treatment, one-third of those answering the intimacy and sexuality questions reported substantial problems with sexual interest and enjoyment.²⁶ Around 37.03% patients were neither in a good mood nor depressed, while around 33.33% were depressed about their cancer. In the study, the identification of mood and anxiety concerns using the patients concerns inventory following head and neck cancer, 44% patients had reported significant anxiety or mood problems on the UW-QOL or highlighted issues of anxiety, mood and/or depression.²⁷

Around 33.33% patients experienced shoulder stiffness and/or pain. Of these 18 patients, 15 were post-operative cases and 13 had undergone radical/modified radical/selective neck dissection. It was noteworthy to mention that by shoulder activity, we referred to risk of injury to the spinal accessory nerve.

Limitations

The main limitation of this study was that it included patients who were yet to start any form of treatment for their cancer as well as those who were currently undergoing treatment and also those who had completed their regime of treatment, which led to a loss of uniformity in the overall condition of the selected patients. Furthermore, there was a considerable loss in follow-up of patients.

CONCLUSION

Head and neck cancers greatly impact the healthcare system in a developing nation like India. It affects people of all age groups, and merely seeking curative intent for the disease is not sufficient. Assessment of quality of life of those afflicted by the disease plays a significant role in the overall well-being of the patients. Pain, appearance, chewing, swallowing and speech are the important aspects which encompass the quality of life of the patients. Early detection of the disease, and spreading awareness about head and neck cancers is of utmost importance and is the need of the hour.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Vigneswaran N, Williams MD. Epidemiologic trends in head and neck cancer and aids in diagnosis. Oral Maxillofac Surg Clin North Am. 2014;26(2):123-41.
2. 2. Cancer.net. Fact sheet: Head and neck cancer: statistics, 2022. Available at: https://www.cancer.net/cancer-types/head-and-neck-cancer/statistics. Accessed on 5 March 2022
3. 3. Prabhash K, Babu G, Chaturvedi P, Kuriakose M, Birur P, Anand AK, et al. Indian clinical practice consensus guidelines for the management of squamous cell carcinoma of head and neck. Indian J Cancer. 2020;57:1-5.
4. 4. Francis D. Trends in incidence of head and neck cancers in India. Eur J Cancer. 2018;92(1):23.
5. 5. International Agency for Research on Cancer. Tobacco smoking. IARC monographs on the evaluation of the carcinogenic risk of chemicals to humans. Washington DC: IARC; 1986.
6. 6. Blot WJ, McLaughlin JK, Winn DM, Austin DF, Greenberg RS, Preston-Martin S, et al. Smoking and drinking in relation to oral and pharyngeal cancer. Cancer Res. 1988;48(11):3282-7.
7. 7. Schildt EB, Eriksson M, Hardell L, Magnuson A. Occupational exposures as risk factors for oral cancer evaluated in a Swedish case-control study. Oncol Rep. 1999;6(2):317-20.
8. 8. LaVecchia C, Tavani A. Fruit and vegetables and human cancer. Eur J Cancer Prevent. 1998;7(1):3-8.
9. 9. Li FP, Correa P, Fraumeni JF. Testing for germ line p53 mutations in cancer families. Cancer Epidemiol Biomarkers Prev. 1991;1(1):91-4.
10. 10. Kutler DI, Auerbach AD, Satagopan J, Giampietro PF, Batish SD, Huvos AG, et al. High incidence of head and neck squamous cell carcinoma in patients with Fanconi anemia. Arch Otolaryngol Head Neck Surg. 2003;129(1):106-12.
11. 11. Berkower AS, Biller HF. Head and neck cancer associated with Bloom syndrome. Laryngoscope. 1988;98(7):746-8.
12. 12. Hecht F, Hecht BK. Cancer in ataxia-telangiectasia patients. Cancer Genet Cytogenet. 1990;46(1):9-19.
13. 13. Nandakumar A. National cancer registry programme. Consolidated report of the population based cancer registries. incidence and distribution of cancer: 1990-96. Bangalore, India: National Cancer Registry Programme (ICMR); 2001.
14. 14. Bhattacharjee A, Bahar I, Saikia A. Nutritional assessment of patients with head and neck cancer in north-East India and dietary intervention. Indian J Palliat Care. 2015;21(3):289-95.
15. 15. Mudur G. India has some of the highest cancer rates of the world. BMJ. 2005;330:215.
16. 16. Joshi P, Dutta S, Chaturvedi P, Nair S. Head and neck cancers in developing countries. Rambam Maimonides Med J. 2014;5(2):0009.
17. 17. Nandakumar A, Gupta PC, Gangadharan P, Visweswara RN, Parkin DM. Geographic pathology revisited: Development of an atlas of cancer in India. Int J Cancer. 2005;116(5):740-54.
18. 18. World Health Organization. What quality of life? The WHOQOL Group. World Health Forum. 1996;17(4):354-6.
19. 19. Calman KC. Definitions and dimensions of quality of life In: Aaronson NK, Beckmann J, eds. The quality of life of cancer patients. New York: Raven Press; 1987: 1-9.
20. 20. Rogers SN. Quality of life of head and neck cancer patients. Has treatment planning altered? Oral Oncol. 2009;45(4-5):435-9.
21. 21. Rogers SN, Ahad SA, Murphy AP. A structured review and theme analysis of papers published on ’quality of life’ in head and neck cancer: 2000 to 2005. Oral Oncol. 2007;43(9):843-68.
22. 22. Gomes EPAA, Aranha AMF, Borges AH, Volpato LER. Head and neck cancer patients' quality of life: analysis of three instruments. J Dent (Shiraz). 2020;21(1):31-41.
23. 23. Rogers SN, Laher SH, Overend L, Lowe D. Importance-rating using the University of Washington quality of life questionnaire in patients treated by primary surgery for oral and oro-pharyngeal cancer. J Cranio-Maxillofac Surg. 2002;30(2):125-32.
24. 24. Oliveira KG, vonZeidler SV, Podestá JR, Sena A, Souza ED, Lenzi J, et al. Influence of pain severity on the quality of life in patients with head and neck cancer before antineoplastic therapy. BMC Cancer. 2014;14(1):1-8.
25. 25. Braam PM, Roesink JM, Raaijmakers CP, Busschers WB, Terhaard CH. Quality of life and salivary output in patients with head-and-neck cancer five years after radiotherapy. Radiation Oncol. 2007;2(1):1-8.
26. 26. Low C, Fullarton M, Parkinson E, O’Brien K, Jackson SR, Lowe D, et al. Issues of intimacy and sexual dysfunction following major head and neck cancer treatment. Oral Oncol. 2009;45(10):898-903.
27. 27. Kanatas A, Ghazali N, Lowe D, Rogers SN. The identification of mood and anxiety concerns using the patients concerns inventory following head and neck cancer. Int J Oral Maxillofac Surg. 2012;41(4):429-36.