HEALTH RELATED QUALITY OF LIFE OF HEAD AND NECK CANCER PATIENTS TREATED WITH CHEMORADIATION

1. HEALTH RELATED QUALITY OF
LIFE OF HEAD AND NECK
CANCER PATIENTS TREATED
WITH CHEMORADIATION
SUMITH GUNAWARDANE1*, MANJULA ATTYGALLA 1, PRIYANTHA MADAWALA 2, RUWAN JAYASINGHE 3 RANJITH PALLEGAMA 4
1 DEPARTMENT OF ORAL & MAXILLOFACIAL SURGERY, FACULTY OF DENTAL SCIENCES, UNIVERSITY OF PERADENIYA
2 TEACHING HOSPITAL, KANDY
3DEPARTMENT OF ORAL MEDICINE & PERIODONTOLOGY, FACULTY OF DENTAL SCIENCES, UNIVERSITY OF PERADENIYA
4 DEPARTMENT OF BASIC SCIENCES, FACULTY OF DENTAL SCIENCES, UNIVERSITY OF PERADENIYA

2. INTRODUCTION
• The effectiveness of addition of chemotherapy (CH) either as induction (neoadjuvant),
adjuvant, or concomitant treatment with radiotherapy (RT) has been explored for head and
neck cancers.
• The goal of these combined regimens is to improve disease control, survival, and health
related quality of life (HRQOL) through the preservation of function.
• Less data is available on the performance of the CH&RT combination on the resulting
improvement of HRQOL in patients with head and neck cancer (HNC).
• However, by minimizing surgery, these treatments generally known to reduce the occurrence
of severe cosmetic impairment and certain functional deficits such as impairment of speech.
• On the other hand, these advantages are not without other costs to the patient such as
increased risk of treatment toxicity.

3. OBJECTIVE
• To prospectively evaluate the changes of health related quality of life and
level of depression in patients with head and neck cancer undergoing chemo
radiation.

4. METHODOLOGY
• Ethical approval was obtained from the Ethics Review Committee, Faculty of
Dental Sciences, University of Peradeniya.
• A prospective analytical study was conducted at Oncology clinic, Teaching
Hospital, Kandy from August 2015 to June 2016.
• A convenience consecutive sample of patients having histopathologically
confirmed squamous cell carcinoma of head and neck region who were
prescribed chemoradiation was included in the study.
• Informed written consent were obtained prior to the study.
• Socio-demographic data (age, gender, ethnicity and educational level) and
clinical data (tumour stage and sub site) were recorded.

5. • The validated Sinhala and Sri Lankan Tamil versions of the European
Organization for Research and Treatment of Cancer Quality of Life
questionnaire (EORTC QLQ C30) and the validated Sinhala version and the
Malaysian Tamil version of the Head and Neck specific questionnaire of EORTC
(EORTC H&N 35) were administered on three occasions
• : before the commencement of chemoradiation,
• at the end of chemoradiation cycle (at six weeks from baseline)
• at three-months from the baseline.

6. • The EORTC QLQ C30 comprises
• 5 Functional scales (Physical, Role, Cognitive, Emotional and Social),
• 3 Symptom scales (Fatigue, Pain and Emesis),
• 6 single items assessing dyspnea, loss of appetite, insomnia, constipation, diarrhea and functional
impact
• one global health and QOL scale.
• The EORTC H&N 35 QLQ, which is used together with the EORTC C30 QLQ comprises
• 5 functional scales (Physical, role, emotional, cognitive and social functioning)
• 10 single items (fatigue, nausea, vomiting, pain, dyspnea, insomnia, loss of appetite, constipation,
diarrhea and financial difficulties).
• Demographic distinctiveness was summarized by descriptive statistics.
• HRQOL scores were calculated based on the scoring manual of EORTC
• Differences between three occasions were compared with repeated measures ANOVA using SPSS 20.

7. RESULTS
• During the study period, a total of 47 cancer patients (37 males and 10
females) were recruited (mean age, 58.68 ± 10.88 SD years).
• Among them, there were 72% Sinhala and 28% Tamil patients, and 81% of the
patients were married while 10% were unmarried.

8. Domain Pre Treatment
Mean± SD
After 6 weeks
Mean±SD
After 3 months
Mean±SD
ANOVA (F values)
Overall HRQOL 672.6±91.1 600.8±48.8 627.5±62 0.76*
Global health
status
64.7±23.9 68.4±18.8 69.3±15.8 0.07*
Functional Scale 410.9±91.1 422.2±65.8 375.3±57.2 0.55*
Symptom Scale 197.0±127.0 110.2±79.2 182.9±98.9 1.07*
Table1: Changes of quality of life domains with time (*, Not significant)

9. • Compared to the pretreatment level of the overall HRQOL (672.61±91.92), the
post-hoc tests revealed that the overall HRQOL significantly decreased at six
weeks (600.80±48.80, P=0.008) and three months (627.50±62.85, P=0.001) but
the score significantly increased at 3 months compared to six weeks (P=0.001).
• Although the Global health status showed an improvement it was not significant
(64.71±23.09, 68.43±18.78 and 69.32±15.83 P>0.05).
• The functional scale significantly increased at six weeks (422.19±9.48, P=0.043)
and decreased at 3 months (375.31±57.17, P>0.05) compared to the baseline
value (410.85±13.52).
• The symptom scale decreased both at 6 weeks (110.16±79.18) and 3 months
(182.86±98.97) compared to baseline (197.04±18.90).
• However, it increased significantly at 3 months compared to 6 weeks (P=0.001).

10. DISCUSSION
• In this study, a significant reduction in the overall HRQOL was observed after
six weeks followed by a significant improvement after 3 months.
• The initial drop could result from acute toxicity of the chemoradiation which
manifests as general body weakness, hair loss, gastrointestinal problems and
oral symptoms such as ulceration and dry mouth.
• These symptoms tend to recover with time and are obvious with data (Table
01).
• Further, the positive attitudes of patients towards cure may also have
contributed to improve the overall HRQOL.

11. • Functional values of the individuals improved immediately after
chemoradiation therapy (at 6 weeks) followed by a reduction
beyond the baseline value at the three months.
• The later reduction could also be explained by the impact of the
severe side effects that may negatively influence patient’s physical
and emotional functions.
• Though the overall HRQOL appear to improve, the functions may
still be affected by the side effects.

12. • The symptoms significantly improved at the end of the treatment
but worsened at 3 months.
• At first cancer related symptoms may have reduced giving rise to
an improvement on the symptom scale.
• However, symptom scale is still below the baseline value after
three months signifying a beneficial effect of the treatment despite
the presence of side effects.
• The presence study has a limitation of not being able to do a sub
site analysis as we could not achieve adequate sample size for
each category.

13. • In modern practice, an improvement in HRQOL is considered as an
endpoint for treatment particularly in advanced cancer stages.
• A wide range of HRQOL tools are available to determine HRQOL of
patients with different medical conditions.
• The most widely applicable instrument to measure the HRQOL in
cancer patients is the EORTC QLQ-C30 together with the disease
specific module such as EORTC HN35 for HNC.
• Using these tools, the current study assessed the changes of
HRQOL in cancer patients undergoing chemoradiation for head
and neck cancers.

14. CONCLUSION
• Improvements in the HRQOL status of the patients suggest that the use of
chemo radiation as a primary treatment for head and neck cancer patients is
beneficial.
• However, deterioration in the functional domains and symptom domains
suggest that further care should target the side effects of chemoradiation.
• Further studies are recommended to assess the long-term influence (at least
for 6 to 12 months) on the HRQOL in this group of patients.
• Further, it would also be useful to compare the changes of HRQOL between
HNC patients receiving chemoradiation and surgical management.

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