The addition of mood and anxiety domains to the University of Washington quality of life scale

Fear of recurrence following head and neck cancer in the outpatient clinic

Fear of recurrence (FOR) following head and neck cancer is one of the most frequent concerns of patients and is associated with psychological distress. The aims of this study were, first, to report the clinical characteristics of patients selected for FOR concerns on a patient concerns inventory (PCI) and, second, to compare the degree of FOR using a FOR questionnaire of those patients expressing FOR concerns on the PCI with those who did not. Two cohorts were used. The first comprised consecutive oncology patients attending clinics from August 2007 for 9 months (N = 123). These patients completed the PCI only. The second comprised patients attending the same clinic for over 4 months from October 2008 (N = 68), and this group completed both the PCI and the FOR questionnaire. FOR was the most frequently selected issue on the PCI (42%). There were no obvious differences in selecting FOR by patient characteristics. Those who scored 'a lot' or 'all the time' for questions 1-6 in the FOR questionnaire and responses (on a 10-point scale) of 7-10 for question 7 were deemed as having 'significant' FOR. In those raising the issue of FOR on the PCI, 79% (15/19) had significant problems compared to 24% (12/49) if they did not. FOR is a common concern and because it is not possible to identify patients based on clinical parameters, it is important to screen for FOR to direct patients to appropriate support and intervention.

Development of ICF core sets for head and neck cancer

BACKGROUND

Based on the International Classification of Functioning (ICF)-Disability and Health, participants from different professional and cultural backgrounds were invited to achieve consensus on a first version of ICF Core Set for head and neck cancer (HNC). It was designed to set standards for the assessment of functioning in HNC.

METHODS

The ICF was adopted by the World Health Organization (WHO) in 2001 and was used as the frame of reference. Preselection of potential ICF categories was based on 4 different preparatory studies: patient interviews, health professional surveys, literature review, and multicenter study applying ICF-nomenclature. After training on the ICF, the results of preparatory studies were presented to 21 invited participants to vote in a formal consensus process on both the Brief and Comprehensive ICF Core Set for HNC. Participants came from all 6 WHO world regions, covering 12 different countries. Professional backgrounds included otorhinolaryngologists, maxillofacial surgeons, medical/radiation oncologists, psychologists, physiotherapists, nurses, and social workers.

RESULTS

The Comprehensive ICF Core Set for HNC included 112 categories (8% of entire ICF) and the Brief ICF Core Set for HNC included 19 categories (1% of ICF).

CONCLUSION

A first version of ICF Core Sets for HNC was defined. Further validation is in process.

[Olfactory rehabilitation after total laryngectomy]

OBJECTIVES

To analyze the olfactory function in patients after total laryngectomy and evaluate the outcomes of the use of the induced nasal airflow manoeuvre.

MATERIAL AND METHODS

A prospective clinical intervention study was carried out with 41 patients who had undergone total laryngectomy, of which 39 were male and 2 female. After verifying that there were no anatomical disorders, the patients were given an olfaction test that classified them into two groups, those with olfactory perception and those without. All underwent rehabilitation using the induced nasal airflow technique and, subsequently, the olfaction test was repeated to enable a comparison with the first results obtained. A semi-structured interview was held to evaluate the senses of taste and smell of the participants, also taking into account their own opinion.

RESULTS

Out of the 41 patients included in the study, 9 had olfactory perception before rehabilitation, according to the first olfaction test. The use of the nasal airflow maneuver meant the recovery or improvement of the olfactory capacity in 90.24% of the patients.

CONCLUSIONS

The induced nasal airflow technique enables an important recovery of olfaction and improvement of taste after total laryngectomy. This technique is easy to learn and to repeat. It does not require expensive materials. The recovery of olfaction and taste implies an improvement in quality of life for the patient, so this technique should be included in all protocols of comprehensive rehabilitation after total laryngectomy.

Dysphagia following a total laryngectomy: the effect on quality of life, functioning, and psychological well-being

The aim of this study was to investigate the effect that dysphagia has on quality of life (QoL), functioning, and psychological well-being of people who have undergone a total laryngectomy. A questionnaire battery was sent to all members (N = 197) of the Laryngectomee Association of NSW, Australia. QoL and functioning were assessed using the World Health Organisation Quality of Life-Bref (WHOQoL-Bref) and the University of Washington QoL (UW-QoL) measures. Psychological well-being was measured using the Depression Anxiety and Stress Scale (DASS). One hundred ten questionnaires (56%) were completed and returned. There were no significant differences in QoL, as measured by the WHOQoL-Bref, between those laryngectomees with and without dysphagia. Laryngectomees with dysphagia, however, had significantly impaired functioning and markedly reduced social participation as measured by the UW-QoL. Significantly higher levels of depression and anxiety were also documented in those laryngectomees who had dysphagia. Dysphagia may not necessarily determine QoL following a total laryngectomy. However, it may have a negative impact on functioning and on psychological well-being.

Quality of life of oral cancer patients after low-dose-rate interstitial brachytherapy

PURPOSE

To assess the quality of life (QOL) of oral cancer patients treated with low-dose-rate interstitial brachytherapy (LDR-BT) alone.

METHODS AND MATERIALS

Between June 2005 and July 2006, a total of 56 patients with oral cancer were enrolled in this prospective study. QOL was assessed by means of the core questionnaire and head and neck questionnaire module of the European Organization for Research and Treatment of Cancer (EORTC Quality of Life Questionnaire-Core 30 [QLQ-C30] and QLQ Head and Neck 35 [H&N35]). The questionnaires were distributed to the patients before the start of treatment and 3 months, 6 months, and 12 months after the start of LDR-BT.

RESULTS

It was possible to analyze the results for 20 of the initial 56 patients because they did not experience metastasis or recurrence during this study. No functions or symptoms asked about in the QLQ-C30 deteriorated during the first year. The emotional function score steadily and significantly increased. No symptoms in the QLQ-H&N35 significantly deteriorated. The scores for pain, trouble with social eating, and weight loss on the QLQ-H&N35 steadily and significantly decreased. Age, gender, and LDR-BT source had no effect on the change in QOL during the first year, but T-stage significantly affected the change in global health status, tumor site affected the changes in swallowing, sensory problems, sticky saliva, and complications affected the changes in pain, swallowing, and mouth opening.

CONCLUSIONS

QOL of oral cancer patients treated with LDR-BT is high. However, tumor stage, tumor site, and complications affected the changes in a few functions and symptoms during the first year.

Current status and perspectives of brachytherapy for head and neck cancer

Brachytherapy delivers a high radiation dose to a limited volume while sparing surrounding normal tissues. In head and neck cancer, severe soft-tissue damage and bone damage to the mandible has decreased markedly since the introduction of computer dosimetry and the use of spacers during treatment. For the curative treatment of head and neck cancer, the selection of brachytherapy sources from among the several linear and small permanent implant sources available, not only according to the tumor site but also according to the patient's physical and mental condition is important. Following the successful treatment of early head and neck cancer by brachytherapy, two major problems and one minor problem may confront the physician. The major problems are neck node metastasis and a second primary cancer of the respiratory tract or upper digestive tract, and the minor problem is radiation-induced cancer.

The development of a Patients Concerns Inventory (PCI) to help reveal patients concerns in the head and neck clinic

The purpose of the Patients Concerns Inventory (PCI) is to identify the concerns that patients would like to discuss during their consultation. The PCI covers a range of issues including hearing, intimacy, fatigue, financial/benefits, PEG tube, relationships, regret, support for family, and wound healing. It also lists MDT members that patients would like to see or be referred on to. The PCI is completed using a touch-screen computer (TST) immediately before consultation. Responses are networked into the consultation room. A 28 weeks pilot for one consultant ran from August 2007 with 123 (of maximum 150) patients. The median time to complete the TST was 8min. Patients most frequently selected fear of recurrence (37%), dental health/teeth (27%), chewing (24%), pain in head/neck (20%), fatigue/tiredness (19%), saliva (18%) and swallowing (18%). The two MDT members they wished to see were dentist (19%) and speech/language therapist (10%). The vast majority felt the PCI made a difference (quite a bit/very much) to their consultation as it made it 'a bit more personal', 'reminds them of the points they want discussed', 'allows the consultation to get straight to the point'. Although the PCI can raise many issues it did not noticeably prolong the consultation (median 8min with PCI, 7min without PCI). The Patients Concerns Inventory (PCI) helps focus the consultation onto patient needs and promotes multidisciplinary care. Following this very successful pilot the PCI is being rolled out to other consultants in the H & N clinic.

Quality of life evaluation for patients receiving vascularized versus nonvascularized bone graft reconstruction of segmental mandibular defects

PURPOSE

Head and neck neoplasms requiring surgical resection of the mandible can have negative consequences on patient quality of life. For patients with segmental resections, the vascularized fibular free flap and nonvascularized iliac crest are frequently used. The fibula has surpassed the iliac crest in popularity due to the success associated with a vascularized graft; however, there still remain significant advantages with the nonvascularized graft. There has not been a study comparing the quality of life associated with these two methods of mandibular reconstruction. We carried out the following study to compare quality of life of both grafts in an attempt to help guide therapeutic decisions.

PATIENTS AND METHODS

Twenty-nine patients at the University of California, San Francisco undergoing mandibular resection with subsequent reconstruction with either a vascularized fibular free flap or nonvascularized iliac crest bone graft were identified. Patient quality of life was assessed with a modified version of the University of Washington Quality of Life Questionnaire, version 4.

RESULTS

Eighteen patients responded (10 reconstructed previously with a fibula, 8 with iliac crest reconstructions). Patients with an iliac crest bone graft had significantly better chewing and swallowing scores (P = .04, P = .049 respectively). There was also a trend for better taste (P = .067). When patients with a history of radiation therapy were excluded, differences in chewing and swallowing were not significant (P = .26 and P = .31 respectively), whereas taste was (P = .038).

CONCLUSIONS

These findings suggest that reconstruction with the iliac crest had benefits in improved function (chewing, swallowing, and taste) rather than esthetics, donor site morbidity, or psychologic discomfort as was anticipated. However, prior radiation, a relatively frequent therapy in this patient population, presents an important confounding factor. Radiation therapy is difficult to control for without limiting an already scarce patient pool, and bears with it significant morbidity that likely influenced these findings. Further study is warranted to confirm the results and further distinguish the 2 groups.

Impact of perioperative hyperbaric oxygen therapy on the quality of life of maxillofacial patients who undergo surgery in irradiated fields

From 2001 to 2005, 66 patients referred for perioperative hyperbaric oxygen therapy (HBO2) for debridement of necrotic tissue or prevention of radionecrosis were assessed with quality of life measures, before and after completion of HBO2 and surgery. The Medical Outcomes Short Form 36 (SF-36) and Hospital Anxiety and Depression Scale (HADS) showed no significant changes. The European Organisation for Research and Treatment of Cancer Core (EORTC-C30) questionnaire showed significant improvement in pain, global health, and dyspnoea (p=0.011; p=0.027; p=0.008, respectively). The Head and Neck sub-module (H&N35) identified significant improvements in teeth, dry mouth and social contact (p=0.002; p=0.038; p=0.029, respectively). The University of Washington Scale (UW), showed significant changes in relation to chewing and shoulders (p=0.031; p=0.047). When sub-group analysis using 'osteoradionecrosis' and 'dental extraction or implants' was performed on the EORTC and UW data, variations in the patterns of significance were found. Adjunctive HBO2 should be considered for the treatment and prevention of some of the long-term complications of radiotherapy.

Swing of the pendulum: optimizing functional outcomes in larynx cancer

For years, total laryngectomy was the only treatment option for patients with intermediate to advanced laryngeal cancer. Over the past two decades, great progress has been made in the management of this disease, with multimodality approaches aimed at laryngeal preservation reshaping the treatment landscape. In the era of chemoradiation, greater focus and attention are now directed toward functional laryngeal preservation--not simply "organ preservation." The continued development and integration of new treatment approaches, including organ preservation surgery (eg, transoral minimally invasive surgery of the head and neck, supracricoid partial laryngectomy), intensity-modulated radiotherapy, and targeted molecular therapies, offer the potential to improve clinical outcomes, function, and quality of life. Incorporation of these new approaches advances the concept of personalized medicine, with treatment strategies tailored to the circumstances and future of each patient.

A structured review and theme analysis of papers published on ‘quality of life’ in head and neck cancer: 2000–2005

Over the past 10 years, quality of life (QOL) has been increasingly recognised as an important outcome parameter in head and neck cancer. Validated questionnaires have emerged and there has been an increase in the number of papers published each year. The aim of this article is to review the literature over the past five years (2000-2005 inclusive), to identify papers reporting outcomes using patient self-competed questionnaires and group these into themes. The tabulated summary allows for the areas of health related quality of life research to be identified and to explore issues that are perhaps deficit in the literature. The three authors independently searched the literature published in the English language using the ISI search engine with cross-reference using Pub Med and Ovid. The search terms were; quality of life, questionnaire, and head and neck cancer. Studies were placed in to one of five themes. There were 165 studies identified. The numbers in each theme were predictors of QOL [Hassanein KA, Musgrove BT, Bradbury E. Functional status of patients with oral cancer and its relation to style of coping, social support and psychological status. Br J Oral Maxillofac Surg 2001;39:340-5.], functional outcome [Klug C, Neuburg J, Glaser C, Schwarz B, Kermer C, Millesi W. Quality of life 2-10 years after combined treatment for advanced oral and oropharyngeal cancer. Int J Oral Maxillofac Surg 2002;31:664-9.], questionnaire development [Hanna E, Sherman A, Cash D, Adams D, Vural E, Fan CY, et al. Quality of life for patients following total laryngectomy vs chemoradiation for laryngeal preservation. Arch Otolaryngol Head Neck Surg 2004;130:875-9.], randomised clinical trials [Kanatas AN, Rogers SN. A national survey of health-related quality of life questionnaires in head and neck oncology. Ann R Coll Surg Engl 2004;86:6-10.], and reviews [Kanatas AN, Rogers SN. A national survey of health-related quality of life questionnaires in head and neck oncology. Ann R Coll Surg Engl 2004;86:6-10.]. Although many facets of HRQOL following head and neck cancer have been explored over the last five years the paper identifies issues where research is still lacking.

Factors associated with restricted mouth opening and its relationship to health-related quality of life in patients attending a Maxillofacial Oncology clinic

Trismus can be a problematic consequence of treatment for oral and oropharyngeal cancer. The aim of this study was to investigate the relationship between trismus, subjective function and health-related quality of life, in order to postulate a clinically relevant cut-off that might be useful as an indicator of patients who might benefit from intervention. One hundred consecutive patients attending the Maxillofacial Oncology clinic at the University Hospital Aintree were assessed during a period of four months. Mouth opening was recorded in millimetres. Subjective outcomes were evaluated using UW-QOL questionnaire for chewing, saliva, mood, anxiety and overall quality of life. The median age of patients was 63 (IQR 56-69) years. The median time since treatment was 16 (IQR 6-34) months. The median mouth opening (32 mm; range 6-53, IQR 24-40) was associated strongly with clinical T stage (Tis/T1-2 35 mm, T3-4 24 mm), radiotherapy (no 38 mm, yes 27 mm) and type of primary surgery (primary closure 38 mm, soft-tissue flaps 30 mm, composite flaps 24 mm). The amount of mouth opening and of the single question (about how much less mouth opening since treatment) was significantly associated with patients perception of chewing deficit, less than full diet and less than good overall quality of life. This study supports a 35 mm cut-off for trismus. There is merit including the two elements together (opening in mm and the single item question on mouth opening since treatment) as outcome parameters.

Analysis of functional results and quality of life following free jejunal flaps for reconstruction after upper aerodigestive neoplastic resection: the St James's experience

Surgical treatment of hypopharyngeal cancers with extension to the postcricoid region generally requires a circumferential pharyngolaryngoesphagectomy followed by reconstruction of the upper aerodigestive tract. Many techniques have been described in order to achieve a safe and functional reconstruction. Interposition of the jejunal free flap (JFF) is a well-established technique and is the flap of choice in our unit. This is a retrospective review of all patients who required a JFF following pharyngolaryngoesphagectomy over an 9-year period. We studied medical charts, histological reports, and speech and language therapy assessments. Eight of the nine surviving patients completed a quality of life questionnaire. Analysis was carried out on patient demographics, flap survival, patient survival and quality of life including swallow function and speech restoration. A total of 23 patients had 24 jejunal free flaps. There were four perioperative deaths. Two flaps failed, and were salvaged with a second JFF in one case and a gastric pull-up in the second. Functioning swallow was established in 74% of patients with four patients complaining of dysphagia. Speech was restored using an electrolarynx or Blom Singer valve in 70% of patients. Most patients required radiotherapy as part of their adjuvant treatment. In our hands the JFF for reconstruction following pharyngolaryngoesophageal resection allows restoration of function following major ablative surgery.

Patients experience with long-term percutaneous endoscopic gastrostomy feeding following primary surgery for oral and oropharyngeal cancer

Percutaneous endoscopic gastrostomy feeding (PEG) has an important role in providing nutritional support in selected patients undergoing treatment for oral and oropharyngeal cancer. Although morbidity data have been published there is very little from the patient perspective. The aim of this project was to devise, pilot and survey a PEG specific questionnaire and relate outcomes to health-related quality of life. A cross-sectional survey was conducted in April 2005 of patients who were alive and disease free and treated by primary surgery for oral and oropharyngeal squamous cell carcinoma between 1992 and June 2004. The survey comprised the University of Washington Quality of Life questionnaire and a 24 item PEG questionnaire. Of 344 alive and disease free patients, 243 (71%) responded. Clinical characteristics of responders and non responders were similar. Mean age of responders was 65 (SD 12) and 59% were male. There were 193 (79%) patients who never had a PEG as part of their treatment, 30 (12%) who had their PEG removed (median 7 months), and 20 (8%) who still had a PEG (median 34 months). Patients with PEGs reported significant deficits in all UW-QOL domains compared to non-PEG or PEG-removed patients and also reported a much poorer quality of life. The major PEG related problems were not those of discomfort, leakage or blockage, but interference with family life, intimate relationships, social activities, and hobbies. More can be done to counsel and support patients with long-term PEG placement.

Longitudinal evaluation of the oral mucositis weekly questionnaire-head and neck cancer, a patient-reported outcomes questionnaire

BACKGROUND

Quality-of-life instruments that measure specific functional consequences of mucositis are needed to assess the efficacy of therapeutic interventions targeted against mucositis and to guide patient care. The authors undertook a prospective, multicenter, observational study to assess the validity, reliability, and feasibility of a new instrument, the Oral Mucositis Weekly Questionnaire-Head and Neck Cancer (OMWQ-HN). The OMWQ-HN is a patient-reported outcome questionnaire that measures the symptoms of mucositis, including mouth and throat soreness (MTS), and their impact on patient well-being and function.

METHODS

The OMWQ-HN, along with the Functional Assessment of Cancer Therapy-Head and Neck (FACT-HN), was administered 5 times over an approximately 6-week period to patients with head and neck cancer (HNC) who were receiving radiation therapy with or without chemotherapy. Information on supportive care measures also was collected.

RESULTS

Seventy-five patients were enrolled and completed 93% of scheduled assessments (100% at baseline). The OMWQ-HN demonstrated good test-retest reliability (correlation coefficient, 0.80-0.89). Cross-sectional analyses to assess validity showed that OMWQ-HN scores were different across levels of pain, with those in the worst pain category reporting the highest OMWQ-HN scores. Strong correlations were observed between OMWQ-HN and FACT-HN. Patients experienced increases in MTS, which corresponded with a steady decline in function. MTS scores were highest in the patients who were taking opioid analgesics, suggesting that mucositis pain continued despite standard pain therapy.

CONCLUSIONS

The current results indicated that the OMWQ-HN is a valid, reliable, and feasible instrument for assessing the impact of mucositis on patients who are receiving radiation therapy with or without chemotherapy for HNC.

An evaluation of the shoulder domain of the University of Washington quality of life scale

The aim of this study was to compare the shoulder domain in the University of Washington quality of life (UW-QoL) scale with two shoulder-specific questionnaires.

METHODS

We did a cross-sectional survey of 100 consecutive outpatients who had had operations on the head and neck for cancer using the UW-QoL, the neck dissection impairment index, and the shoulder disability questionnaire.

RESULTS

The types of neck dissection were none (n=12), unilateral selective (n=63), bilateral selective (n=17), and radical or modified radical (n=8). There were significant correlations among the three questionnaires. The worst scores were found in the group who had modified radical or radical neck dissection. Although responses were similar between those who had no neck dissection and those who had unilateral level 3 neck dissection, a few patients reported considerable dysfunction after selective neck dissection.

CONCLUSION

Although the UW-QoL shoulder domain is limited to one of four responses, our results support the conclusion that it is sufficiently sensitive to screen for dysfunction of the shoulder.

Communication strategies and interpersonal skills of instructors of esophageal speech: an observation study

OBJECTIVE

In this article, the way that the Instructor of Esophageal Speech (IES) works is considered from an interactive-analytic perspective.

METHODS

The observation project data were gathered during 6 months in 2004 at the training sessions of the Ginreikai-Asian Federation of Laryngectomees' Association using the Six Category Intervention Analysis framework (6CIA) by a trained communication specialist as an active-observer.

RESULTS

Mean scores of each of the six categories and a series of percentage distributions were extracted from the usage-frequency data and interpreted together with the results of Chi-square analysis of usage-frequency units. We found the IES used more frequently authoritative categories and used less facilitative categories. Our results of the data analysis show that the 30 IES used more authoritative interventions and used more frequently the prescription and information giving than the confrontation or cathartic interventions.

CONCLUSION

The results of the present study show that the 6CIA framework has its potential and value as an analytic tool to explore the IES' actual behavior in a specific therapy related context.

PRACTICE IMPLICATIONS

We argue for the utility of the 6CIA as an analytic framework to investigate the interpersonal behavior of the IES in the Japanese cultural setting.

Facial appearance after operations for oral and oropharyngeal cancer: A comparison of casenotes and patient-completed questionnaire

Disfigurement after operations for oral and oropharyngeal cancer is an important issue. Our aim was to review the casenotes of patients who reported distress in the appearance domain of the University of Washington Quality of Life Scale (UWQOL) and to find out what help they were given. Of 278 patients with previously untreated oral and oropharyngeal squamous cell carcinoma treated between 1995 and 1999, 114 (41%) were concerned about their appearance. Factors that correlated with these concerns included tumours more than 2cm in size, T2 or worse stage, free tissue reconstruction, segmental mandibular resection, and neck dissection. In only 7 of the 114 was there any mention of the patient's appearance in the clinic notes, of whom 4 were given help (2 scar revisions and 2 oral rehabilitations). This study suggests that patients' concerns about disfigurement are poorly recognised in routine clinical practice and supports the principle of using the UWQOL scale to discuss problems of appearance with patients.

Patients' perceived health status following primary surgery for oral and oropharyngeal cancer

How oral and oropharyngeal cancer patients view their 'quality of life' is of fundamental importance. Any differences seen in their health state compared with normative data and with other disease conditions allows a wider perspective on their outcome after surgery. A cross-sectional postal survey was undertaken of patients treated for oral/oropharyngeal squamous cell carcinoma by primary surgery using the University of Washington Quality of Life Questionnaire Version 4 (UW-QOL v4) and the EuroQol EQ-5D. Of 348 patients surveyed, 224 returned analysable forms, (response rate 64%). In the EQ-5D items, 40% of the group reported a problem in walking, 23% with self-care, 44% in performing usual activities, 50% with pain or discomfort and 33% with anxiety or depression. The mean overall health visual analogue scale (VAS) score was 74 (SE 1) minimum 30 and maximum 100. The mean utility (health index) score was 0.75 (SE 0.02) minimum -0.18 and maximum 1.0. Compared to national reference data, patients in our cohort of under 60 years of age fared significantly worse than expected for their age but this was not so for older patients. There were strong correlations between appropriate domains of the EQ-5D and UW-QOLv4 and between UW-QOL global measures and EQ-5D VAS.

Long-term quality of life after total laryngectomy

BACKGROUND

There is a perception that a total laryngectomy has a devastating effect on patients and their families, but only a few studies have addressed long-term quality of life (QOL) after laryngectomy.

METHODS

A cross-sectional study of 49 patients more than 2 years since laryngectomy was performed with a general health status instrument (Short Form-12, version 2 [SF-12 v2.]) and a disease-specific QOL instrument (University of Washington Quality of Life questionnaire, version 4 [UW-QOL v4.]) in a national meeting of laryngectomy survivors.

RESULTS

As measured by the UW-QOL, patients identified speech, appearance, and activity as the most important problems after total laryngectomy, but surprisingly, no correlation was seen between speech and overall QOL. Age was a predictor of appearance and anxiety, women were more likely to report difficulties swallowing, irradiated patients reported more difficulties with speech and anxiety, and patients who received chemotherapy were more likely to report difficulties with mood. The SF-12 captured no differences between normal subjects and laryngectomees in the physical summary domain (p = .21); however, laryngectomees scored better in the mental domain (p = .004). Laryngectomees had lower scores in physical function (p = .005) and role physical (p = .036).

CONCLUSIONS

Long-term QOL is not decreased after total laryngectomy when it is measured with general health instruments and compared with the normal population, but impairment in physical scales is found when disease-specific questionnaires or subscale scores are included. Age, sex, radiation therapy, and chemotherapy are independent predictors of UW-QOL subscales. Voice handicap is identified as a problem but is not predictive of overall QOL. A strong relationship exists between UW-QOL and SF-12.

A feasibility study of computer-assisted health-related quality of life data collection in patients with oral and oropharyngeal cancer

Touchscreen technology (TST) has been widely used in the field of medicine. The purpose of this study was to pilot a standard TST system to administer the University of Washington Quality of Life Questionnaire (UWQOL) in a routine head and neck oncology clinic. The UWQOLv4 was completed using TST and a semi-structured interview was used to evaluate patients' experience of the data collection process. Forty-one of 44 consecutive cancer patients agreed to participate in the study. Although over three-quarters of patients reported never having used a computer, all but one found the UWQOLv4 'easy' or 'very easy' to complete using the TST. They preferred the TST method to paper copy and the vast majority completed the TST in 10min or less. TST provides a very suitable mechanism for routine health-related quality of life data collection. The system is easy to programme and relatively inexpensive.

Health-Related Quality of Life in Oral Cancer: A Review

PURPOSE

Health-related quality of life (HRQOL) has now become an important outcome measure in the assessment of patients treated for oral cancer. We summarize the influence of various factors in the treatment of oral cancer on HRQOL after surgery.

METHODS

A review of the current literature was carried out.

RESULTS

Site-specific assessment of HRQOL should be encouraged, rather than assessment of head and neck cancer as a whole. In general the long-term HRQOL of oral cancer patients seems good with HRQOL at 1 year being equivalent to long-term HRQOL. A number of different patient and treatment factors were identified that affect HRQOL. These include age, gender, site, stage, emotional status, smoking and alcohol, marital status and income, performance status, method of reconstruction, access, mandibular resection, neck dissection, percutaneous endoscopic gastrostomy, and post-operative radiotherapy.

CONCLUSIONS

HRQOL should be considered as part of the overall process of care for oral cancer patients.

A comparison of tongue and soft palate squamous cell carcinoma treated by primary surgery in terms of survival and quality of life outcomes

In the surgical management of oral cancer the resection and reconstruction of the mobile tongue and soft palate are most important if function is to be maintained. The present trend towards primary laryngeal surgery for early disease has emphasized the importance of primary surgery if good functional outcomes can be achieved. This study compares the functional and health-related quality of life outcomes for primary surgery and reconstruction of the anterior tongue and soft palate. From a cohort of 566 patients treated from 1992 to 2002, 118 fitted the criteria for anterior tongue and 44 for soft palate resection. University of Washington Quality of Life scores were available in around three quarters of patients. In terms of speech and swallowing a 3/4 or total anterior glossectomy had a worse outcome than a 1/4 or 1/2. In patients having a 3/4 or total resection of the soft palate however, the results showed a similar outcome to those with 1/4 or 1/2 resection. The functional results of 3/4 and total soft palate reconstruction were superior to 3/4 and total anterior tongue resections and were similar to the whole cohort. This finding extends the role of functional surgery in the oropharynx for which primary radiotherapy is often preferred to preserve function.

Predictors of speech and swallowing function following primary surgery for oral and oropharyngeal cancer

OBJECTIVES

To examine the association between the speech and swallowing aspect of health-related quality of life (HRQOL) and selected clinical parameters, and particularly to determine those that are predictive of good outcomes at 1 year after surgery.

DESIGN

Prospective questionnaire and clinical study.

SETTING

Regional Maxillofacial Unit.

PARTICIPANTS

A total of 278 consecutive patients undergoing primary surgery for squamous cell carcinoma between 1995 and 1999. HRQOL was assessed using the University of Washington Quality of Life questionnaire (UW-QOL) pre-surgery, and post-surgery at 6 months, 1 year and later (median 39 months).

MAIN OUTCOME MEASURES

Presentation of results was mainly descriptive, involving percentages and mean scores. Association of clinico-demographic factors with tumour site, and with UW-QOL swallowing and speech after 12 months, was tested with Fisher's exact or chi-squared tests as appropriate and modelled using logistic regression methods.

RESULTS

Univariate relationships were seen between speech and swallowing scores and with tumour size, T staging, radiotherapy, type of surgery (primary closure or free tissue transfer), tumour site, extent of resection of posterior tongue and soft palate, and UW-QOL taste and saliva scores. Multiple logistic regression showed that no radiotherapy (P<0.001) and primary surgical closure/laser surgery (P=0.003) were the main predictors of good swallowing, and primary surgical closure/laser surgery was the main predictor of good speech (P<0.001) at 1 year.

CONCLUSIONS

A number of clinical parameters can influence the speech and swallowing aspect of quality of life in these patients and when feasible, primary closure results in a better outcome than free flap reconstruction.

Comparison of the domains of anxiety and mood of the University of Washington Head and Neck Cancer Questionnaire (UW-QOL V4) with the CES-D and HADS

BACKGROUND

Version 4 of the University of Washington Head and Neck Cancer Questionnaire (UW-QOLv4) includes items on mood and anxiety. The aim of this study was to compare the responses to these single items with the Centre for Epidemiology Studies Depression Scale (CES-D) and the Hospital Anxiety Depression Scale (HADS).

METHODS

A cross-sectional postal survey was undertaken in April 2003. The survey was composed of all patients treated for oral and oropharyngeal squamous cell carcinoma between 1992 and 2002 who were alive and disease free.

RESULTS

We distributed 306 questionnaires; there were 197 replies (65%) from 110 male and 87 female patients. Most patients reported relatively little depression, with 170 of 190 (89%) reporting a HADS depression score of less than 11. Similarly, most patients were not anxious, with 158 of 183 (86%) reporting a HADS anxiety score of less than 11. UW-QOL mood, UW-QOL anxiety, HADS anxiety, HADS depression, and CES-D scores were all moderately intercorrelated (Spearman correlations from 0.39-0.68 ignoring the signs, all p < .001). The UW-QOL mood correlated with the scores and "case-ness" categories of the HADS depression and CES-D scales, whereas the UW-QOL anxiety correlated with the scores and "case-ness" of the HADS anxiety.

CONCLUSIONS

Questions on mood and anxiety can help identify significant psychological morbidity, taking a score of less than 75 for UW-QOL mood and less than 70 for UW-QOL anxiety. This could be used to trigger formal psychological assessment and with a view to possible therapeutic intervention.

Brazilian–Portuguese validation of the University of Washington Quality of Life Questionnaire for patients with head and neck cancer

BACKGROUND

The University of Washington Quality of Life (UW-QOL) questionnaire is an English-language survey instrument used worldwide to assess the quality of life of patients with head and neck cancer. To be used in other cultures, such instruments require careful translation and psychometric validation in other languages.

METHODS

The translation and cultural adaptation of the questionnaire were performed following accepted international guidelines. The psychometric validation was performed on a consecutive series of patients with at least 1 year of disease-free survival after treatment for squamous cell carcinoma of the upper aerodigestive tract, recruited from October 2004 to January 2005 from a tertiary cancer center hospital. Eligible subjects were invited to complete the Portuguese version of the UW-QOL questionnaire during routine clinical consultation and complete it again within 15 days. They also completed a validated Portuguese version of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and a questionnaire to evaluate anxiety and depression symptoms (Hospital Anxiety and Depression Scale [HADS]).

RESULTS

A Portuguese version of the questionnaire was developed in iterative fashion. In the psychometric validation process, a total of 109 patients were analyzed. Reliability was excellent, including both internal consistency (Cronbach's alpha [alpha] of 0.744) and test retest reliability (intraclass correlation coefficient [ICC] of 0.882). Construct validity was supported by statistically significant relationships between the SF-36 and HAD questionnaires and the translated UW-QOL questionnaire.

CONCLUSIONS

The Brazilian-Portuguese version of the UW-QOL questionnaire appears to be culturally appropriate and psychometrically valid. This version is a valuable tool to evaluate accurately the quality of life of Brazilian patients with head and neck cancer.

Psychological responses and support needs of patients following head and neck cancer

The patient with head and neck (H&N) cancer is prone to psychological distress immediately following diagnosis and during the treatment phase. Lowered mood is typical and tends to extend beyond the treatment phase. There is little evidence for a specific treatment method predicting a characteristic psychological response. Rather, patients' reactions vary widely according to fears of recurrence, health beliefs, personality, coping and available support. Patient reports of quality of life show a return to pre-treatment status after a year but are determined to some degree by initial depression levels and dispositional factors such as optimism. Information provided to patients (e.g. leaflets, booklets of written guidance) by specialist treatment centres about the disease and its management require sustained effort in their design and distribution. Our understanding of patient responses to this disease has improved and has assisted in the development of psychological interventions. Controlled trials will provide important evidence of the components, effects and sustainability of these experimental programmes, and improve overall care plans for this often neglected patient group.

Health-related quality of life measured by the UW-QoL--reference values from a general dental practice

The objective of this study was to obtain age and sex-specific reference values for the University of Washington head and neck cancer questionnaire version 4 (UW-QoLv4) and to compare this with patients with oral and oropharyngeal cancer. Cross-sectional reference data was collected from 372 patients in six local general dental practices, 349 of whom presented for routine appointments. Quota sampling was used to collect data for similar numbers of patients by gender by four age bands (40-49, 50-59, 60-69, 70-79 yr). The longitudinal sample consisted of 450 consecutive patients undergoing primary surgery for previously untreated oral and oropharyngeal squamous cell carcinoma presenting to the Regional Maxillofacial Unit Liverpool, between the years 1995 and 2002. At baseline the key differences were anxiety, pain, swallowing, chewing, and mood. At 1yr there were big differences in all domains with deterioration in the oral cancer group. The difference was least notable in pain, shoulder, mood and anxiety. Reference data from a non-cancer population is very important when considering UW-QoL domains as an outcome parameter in clinical trials and also when discussing health-related quality of life outcomes with patients and their families.

The Assessment of Quality of Life in Patients Who Have Undergone Surgery for Oral Cancer: A Preliminary Report

PURPOSE

The outcome of management strategies for the treatment of oral cancer has always been in terms of disease-specific survival. Modern assessment of outcome now also includes assessment of quality of life (QOL). Little has been done previously in Australia to assess the QOL of patients treated primarily by surgery for oral cancer.

MATERIALS AND METHODS

Twenty-two patients who had undergone primary surgical management for oral cancer underwent assessment of QOL using the European Organization for Research and Treatment of Cancer QOL questionnaire version 3 (EORTC QLQ-C30) and the University of Washington Head and Neck QOL questionnaire version 4 (UWQOL). Similar emotional domains were compared and factors affecting QOL were determined.

RESULTS

Fifty-five percent of patients were male and 45% were female. The mean age was 61.8 years (range, 38 to 86 years) with a mean review time of 24.6 months (SD, 20.3 months) postoperatively. Good QOL scores were experienced by most patients. A new addition to the UWQOL version 4 was the mood and anxiety domains, and these correlated well with the emotional domains of the EORTC QLQ-C30 using Spearman rank correlations. Factors significantly affecting survival included age, overall stage, neck dissection, free flap, and postoperative radiotherapy using Mann-Whitney tests (P < .05). No significant difference in QOL was found in patients reviewed at either less than or greater than 1 year.

CONCLUSIONS

This study confirms previous reports in the literature. It has provided us with the foundation for further investigation of QOL in patients who have been and who will be treated for oral cancer. It also gives us a new measure of outcome to compare against survival rates.

Zygoma implant-supported midfacial prosthetic rehabilitation: a 4-year follow-up study including assessment of quality of life

OBJECTIVE

Successful prosthetic rehabilitation is crucial for quality of life in cases of large maxillary defects when surgical reconstruction is not advisable because of general health or patient refusal. For this purpose, the extended indications for Zygomaticus fixtures in different defect types were evaluated.

PATIENTS AND METHODS

Twelve patients received 28 zygoma implants and 23 dental implants (if a segment of alveolar process was available) and were followed-up 14-53 months. Zygoma implants were positioned classically in the maxillary molar region and to reduce leverage, a premolar and a canine position was developed. The quality of life was assessed by a validated questionnaire after complete rehabilitation.

RESULTS

Cumulative zygoma implant survival was 82%. Three losses occurred because of persistent infection and gradual loosening. Lost implants were immediately replaced in adjacent bone. Insufficient implant length within soft tissue reconstructions was prone to chronic infection by pocketing and recurrent overgrowth of granulating tissue. Longer implants were free of soft tissue inhibition, yet prone to overloading and high leverage in cases when no anterior alveolar process and dental implants were present. Zygoma implant success was therefore 71%, including the new premolar and canine Zygomaticus fixture-position. Periotest values increased from 0 to +7 to the fourth year, peri-implant bleeding and plaque index were decreasing from 56% to 0% and 33% to 0%, respectively, and good general quality of life with the priorities on chewing and activity was noted.

CONCLUSION

Zygoma implants can reliably anchor the midfacial maxillary prostheses and enable a quality of life comparable with autologous maxillary reconstruction. They can be replaced immediately if local infection or loosening should occur. A premolar and canine position reduce leverage when no anterior alveolar process is present. The patient can alternatively be provided with dental implants.

Mood, anxiety and sense of humor in head and neck cancer patients in relation to disease stage, prognosis and quality of life

CONCLUSION

At diagnosis, control patients had the lowest depression levels and anxiety scores, followed by those with limited HNSCC disease and these with extended HNSCC disease. Anxiety and depression levels at diagnosis predicted prognosis via an association with extent of disease. Sense of humor, but not anxiety or depression level, predicted lower QoL and depression levels at follow-up.

OBJECTIVE

To study the association between anxiety score, depression level at sense of humor at diagnosis in head and neck squamous cell carcinoma (HNSCC) patients versus TNM stage, prognosis and depression level/quality of life (QOL) 6 years following diagnosis. A control group of patients with benign HN disease was also included.

MATERIAL AND METHODS

Male patients with newly diagnosed HNSCC (n =78) or benign HN (n =61) disease completed the following questionnaires: the Beck Depression Inventory, the Spielberger Trait Anxiety Inventory (state) and the Svebak humor questionnaire. Patients with cachexia or those aged >80 years were excluded. In the HNSCC patients, TNM stage, prognosis and QOL/depression level (n =27) were determined following successful therapy.

RESULTS

HNSCC patients reported high anxiety scores and lower depression levels than control patients, although there was overlap between the groups. N stage was associated with high anxiety scores and depression levels, whereas T stage was only associated with depression levels. Both anxiety scores and depression levels at diagnosis predicted prognosis through an association with TNM stage. Sense of humor, but not depression levels or anxiety scores, at diagnosis predicted QoL and depression levels at follow-up.

The relation between health-related quality of life, past medical history, and American Society of Anesthesiologists’ ASA grade in patients having primary operations for oral and oropharyngeal cancer

Pre-existing medical problems have the potential to affect postoperative survival, complications, and health-related quality of life (QoL). Our aim was to explore the relation between past medical history, American Society of Anesthesiologists' (ASA) score, health-related QoL, and survival. We collected data from 278 consecutive patients with previously untreated oral and oropharyngeal squamous cell carcinoma operated on primarily from 1995 to 1999 inclusive. Past medical history was recorded from the case notes, ASA grade from the anaesthetic record, and QoL was measured using the University of Washington Quality of Life Questionnaire (UW-QoL). Responses to questionnaires were received from (71%) at baseline (63%) at 6 months (73%) at 1 year, and (65%) 18 months or longer. Past medical history was associated with lower ASA scores. At baseline both history and ASA scores were related to the UW-QoL. Longitudinally patients in ASA grade 1 or with no past history scored better in these UW-QoL domains. Past history did not predict survival (P = 0.83), nor did the UW-QoL composite score (P = 0.30), whilst ASA was associated with crude survival (P = 0.003) and disease-specific survival (P = 0.03). When analyses were stratified for adjuvant radiotherapy, type of operation, size of tumour, and age then the relation to ASA was maintained and trends in the past history and UW-QoL remained not significant. ASA, which is often recorded as part of preoperative assessment, reflects both survival and health-related QoL, and is more useful than past history alone for predicting outcome.

Survey of oral rehabilitation in a consecutive series of 130 patients treated by primary resection for oral and oropharyngeal squamous cell carcinoma

The purpose of this study was to investigate the use of oral rehabilitation in a group of patients who had primary resection of oral and oropharyngeal squamous cell carcinoma. Of 132 consecutive patients operated on for previously untreated disease between January 1995 and June 1997, 130 were recruited. The University of Washington Quality of Life questionnaire was completed on the day before operation at 6 and 12 months, and at last review. A larger similar dataset was used to predict survival. Twenty-eight patients (22%) were seen by the oral rehabilitation team. The median (IQR) time from operation to start of treatment was 12 months (6-21). The median (IQR) time from beginning to end of rehabilitation was 14 months (5-49). Patients with larger tumours (P=0.06) and patients who were edentulous with dentures in the maxilla (P=0.07) were most likely to be seen for oral rehabilitation.

Impact of dysphagia on quality-of-life in nasopharyngeal carcinoma

BACKGROUND

Little is known about dysphagia or quality of life (QOL) in patients treated for nasopharyngeal carcinoma (NPC). The aim of this study was to determine the impact of dysphagia on QOL in patients treated for NPC as measured by two standard tools, the University of Washington Quality-of-Life Questionnaire(1) (UW-QOL) and the Swallow Quality-of-Life Questionnaire(3) (SWAL-QOL).

METHODS

This is a cross-sectional survey of 59 consecutive disease-free survivors of NPC attending the head and neck cancer clinic at the National University Hospital, Singapore. The UW-QOL and SWAL-QOL underwent minor modification and were translated into Mandarin. A linear regression analysis was performed to identify significant predictors of health-related QOL.

RESULTS

Fifty-one patients (86%) responded; of these, 43 had self-reported swallowing difficulties. On the UW-QOL, respondents indicated the three most important issues to be swallowing (59%), hearing (45%), and saliva/dry mouth (41%). Respondents with swallowing difficulty reported a lower UW-QOL composite score (p = .002) and a lower health-related QOL score (HR-QOL) than those without swallowing difficulty (p = .004). Self-reported swallowing difficulty predicted a lower HR-QOL score (p = .004). A longer time since treatment predicted a better score in HR-QOL (p = .024). A lower score in fatigue predicted a lower HR-QOL score (p = .001).

CONCLUSIONS

Swallowing difficulties negatively impact QOL. It is recommended that future QOL studies aimed specifically at swallowing function in NPC use a swallowing specific questionnaire (eg, SWAL-QOL) in addition to a head and neck-specific measure. Further research is needed to look at the adaptation and usefulness of swallowing-specific QOL surveys for use with people treated for NPC.

Evaluation of pain in patients with oral squamous cell carcinoma

In this study we have developed and tested a novel pain questionnaire to measure the pain experienced by patients with oral squamous cell carcinoma. The questionnaire consisted of 8 questions rated by the patient on a visual analog scale. Patients completed the questionnaire at the time of initial presentation before surgical treatment. None of the patients were taking analgesics. The responses were then scored and compiled with patient data and pathology reports. Of the 15 completed questionnaires, 14 patients reported some level of functional restriction from pain (mean, 46.6 +/- 25.2, scale of 0 to 100 mm). On average, patients experienced significantly higher function-related, rather than spontaneous, pain intensity and sharpness. Men (n = 8) had a significantly higher level of function-related pain intensity and sharpness than women had (n = 7). There was a strong correlation between nodal disease and increased levels of spontaneous intensity, sharpness, throbbing, and overall functional restriction.

PERSPECTIVE

The results of this study indicate the heterogeneous nature and function dependence of oral cancer pain. The questionnaire we have developed in this study will allow for correlations between pain parameters and specific tumor biology in future studies.