Psychological aspects affect quality of life in patients with oral squamous cell carcinomas

Health-Related Quality of Life (HRQoL) Assessments in Research on Patients with Adult Rare Solid Cancers: A State-of-the-Art Review

BACKGROUND

Health-related quality of life (HRQoL) is an important patient-reported outcome for all cancer patients, including adult patients with rare solid cancers. However, current knowledge of HRQoL in this population is limited, which hinders the delivery of personalized care. This review aimed to explore the heterogeneity of HRQoL among adult patients with a solid rare cancer across the ten European Reference Network for Rare Adult Solid Cancers (EURACAN) domains and to summarize the HRQoL measures used in clinical research.

METHODS

A systematic literature search was conducted to identify all clinical studies assessing HRQoL in adult patients with a solid rare cancer. Four databases (MEDLINE, PubMed, PsycINFO, and Web of Science/Scopus) were searched (February 2023).

RESULTS

The search yielded 18,704 articles, of which 1416 articles were fully screened and 463 were eligible for analysis. Of these, 397 studies used generic tools to assess HRQoL, while 270 used tumor-specific instruments. Three EURACAN domains (sarcoma, endocrine tumors, and thoracic tumors) primarily assessed HRQoL using generic questionnaires. Additionally, the rare gynecological tumor, rare male genitourinary, and sarcoma EURACAN domains lacked specific HRQoL measures. Brain, head and neck, and uveal melanoma EURACAN domains used tumor- or domain-specific questionnaires in more than half of the studies.

CONCLUSIONS

This state-of-the-art literature review shows that HRQoL assessment is gradually becoming more prevalent in adult solid rare cancer research. A combination of generic, tumor-specific, and domain-specific questionnaires across various rare cancer domains has proven effective in capturing a broad range of HRQoL issues. However, many EURACAN domains still lack specific strategies for assessing HRQoL, which limits the ability to fully understand and address patients' experiences. Future research should prioritize developing comprehensive and robust HRQoL measurement strategies and tools to enable meaningful clinical research and to ensure that the patient voice is incorporated in their clinical care.

Gender-specific differences concerning psychosocial aspects and functional impairments that influence quality of life in oral cancer treatment

PURPOSE

Patients with oral cancer have gender-specific differences with respect to health-related quality of life (HRQoL) and psychosocial variables (PV). The aim of the present study was to evaluate HRQoL and PV outcomes in patients treated for oral squamous cell carcinoma.

METHODS

Data of 1234 patients were collected from a multicenter rehabilitation study of the German-Austrian-Swiss Cooperative Group on Tumours of the Maxillofacial Region (DÖSAK). Patient characteristics, oncological variables, post-treatment impairments, general quality of life (QoL), and PV (coping strategies, control beliefs, personal traits, perceived social support, depression, anxiety, and fear of tumor recurrence) were recorded.

RESULTS

After treatment, HRQoL was similar between genders concerning general QoL, but men experienced significantly more treatment-related functional impairments influencing HRQoL. PV revealed gender-specific coping strategies, with women reporting significantly more "depressive coping," "religiosity," "fatalistic externality," and higher "social burden." Owing to their religious coping strategies, fatalistic attitude, and perceived higher social integration, women demonstrated superior disease acceptance, despite higher depression, anxiety, and lower psychosocial resilience. Conversely, men reported more introverted personal traits and lower social integration.

CONCLUSION

Interventions during oral cancer treatment should address PV and have gender-specific elements to improve HRQoL after therapy.

Postoperative quality of life and therapy-related impairments of oral cancer in relation to time-distance since treatment

PURPOSE

Oral cancer resection can cause physical and psychological impairments that influence the quality of life (QoL). Depending on the postoperative time-distance, the occurrence and intensity of these impairments may change. We evaluated the sequelae and changes in therapy-related impairments during the postoperative course to detect associations between the time since surgery and the presence of disorders.

METHODS

Data from a questionnaire completed by 1359 patients who underwent surgical treatment of oral squamous cell carcinoma and were involved in a multicenter rehabilitation study of the German-Austrian-Swiss Cooperative Group on Tumors of the Maxillofacial Region (DÖSAK) that included 43 oral and maxillofacial clinics in Germany, Austria, and Switzerland were retrospectively analyzed.

RESULTS

Physical impairments, including those in appearance, mouth opening ability, ability to smell, gastric disorders, mandible mobility, breathing, and shoulder/arm mobility, were significantly associated with and increased with time-distance since surgery. Esthetic appearance most strongly correlated with the highest perception of worsening. Regarding psychological disorders, worry about tumor recurrence, depression, and worse prospects were significantly associated. Among the postoperative sequelae, fear of tumor recurrence decreased continuously; however, depression and worse prospects increased. The general QoL did not significantly differ overall during the postoperative course.

CONCLUSIONS

Therapy-related impairments change during the postoperative course based on the time-distance since surgery. The general QoL may not markedly vary; however, single impairments, to some extent, can increase or decrease.

IMPLICATIONS FOR CANCER SURVIVORS

Continuous adaptation of supportive cancer therapy is required during follow-up to sufficiently address individual treatment needs.

Fulfillment of patients' information needs during oral cancer treatment and its association with posttherapeutic quality of life

PURPOSE

Surgical therapy for oral cancer can lead to severe physical and psychological disorders that negatively impact patient quality of life (QoL). This study aimed to evaluate the relationship between fulfillment of patients' information needs during oral cancer treatment and patients' perception of posttherapeutic disorders influencing QoL.

METHODS

A retrospective analysis of 1359 patients who were surgically treated for oral cancer using questionnaires administered during the multicenter rehabilitation study by the German-Austrian-Swiss Cooperative Group on Tumors of the Maxillofacial Region (DÖSAK). Patients and medical practitioners completed questionnaires following cancer treatment.

RESULTS

Approximately 37% of patients felt inadequately informed about possible physical and psychological consequences of surgery. In contrast, only 16% of patients felt they were given inadequate information about the operative procedure and possible complications, and with regard to tumor diagnosis and cancer disease, only 15% of patients. Significant correlations were found between lacking information and increased perception of posttherapeutic disorders, whereas correlations with tumor-specific and operation-related parameters were markedly lower. The patients with superior QoL after treatment stated more frequently, nearly independent of individual patient characteristics, that the information that they were given prior to therapy was adequate. Information concerning possible physical and psychological consequences of an operation, however, was frequently stated to be inadequate, independent of QoL.

CONCLUSION

Patients whose information needs concerning the diagnosis and treatment of oral cancer are adequately fulfilled may benefit in terms of their therapeutic outcome, experiencing less perception of posttherapeutic physical and psychological disorders and a superior QoL.

Evaluation of patient specific care needs during treatment for head and neck cancer

BACKGROUND

Tumorous diseases of the head and neck region annually occur in more than 550.000 cases worldwide. Little is known about patient specific care needs and potential relationships between non-fulfillment of those following therapeutic and especially surgical treatment of head and neck cancer (HNC).

OBJECTIVES

This study aimed to evaluate potential correlations between patient specific care needs, regarding physiological rehabilitation, family/social support, economic needs, and their impact on health-related quality of life (HRQoL).

METHODS

A total of 1359 patients were included in this retrospective analysis. Data derived from the exploratory international multicenter rehabilitation study of the German-Austrian-Swiss Cooperative Group on Tumors of the Maxillofacial Region (DÖSAK), including 43 oral and maxillofacial departments in Germany, Austria, and Switzerland using the Bochum patient questionnaire on rehabilitation and a questionnaire on tumor and treatment related data.

RESULTS

Results showed a significant correlation of a patient's social bonds and depression, coping with depression, and anxiety. Patients' needs for speech therapy, physiotherapy or respiratory training were hardly ever met and patients had to compensate for financial losses during hospitalization for acute treatment.

CONCLUSION

In conclusion, this study describes social, physical, and socio-economic care needs. A multidisciplinary approach managing cancer and treatment related side effects is necessary, as well as enhanced awareness of care needs of practitioners during early recovery after surgery.

Impact of weight loss on cancer patients' quality of life at the beginning of the chemotherapy

PURPOSE

Among the prognostic factors relevant to the condition of oncological patients, nutritional status (NS) has the greatest single impact on quality of life (QL). The goals of our study were to evaluate the influence of NS, weight loss (WL), and the presence of cachexia, prior to the initiation of chemotherapy, on the patient's QL.

METHODS

Adult patients (aged ≥ 18 years) diagnosed with solid tumours for whom chemotherapy was started between April 2016 and June 2017 were eligible for inclusion in the study. They were asked to complete a QL questionnaire (Functional Assessment of Cancer Treatment (FACT-G)) at the beginning. The presence or absence of cachexia was evaluated at the outset, following the definition proposed by Fearon and nutritional assessment by the Patient-Generated Subjective Global Assessment (PG-SGA) scale.

RESULTS

A total of 177 patients completed the FACT-G, the 60% receiving curative therapy. At the start of the treatment, 58.2% of patients had experienced WL, with an average of 4.4 ± 7.4%, and 19% were at risk of malnutrition. Patient who presented cachexia at diagnosis, were treated with palliative intention, had a Nutriscore ≥ 5 points or presented malnutrition in accordance with PG-SGA had a poorer QL (p < 0.05). Greater WL was associated with a worsened QL (p = 0.001). Breast cancer patients presented an inverse correlation between the %WL and the initial score in the FACT-G (r = - 0.304, p = 0.023), whereas no such correlation was observed for the other types of tumour (r = - 0.012, p = 0.892).

CONCLUSIONS

These results underline the relation of NS before starting chemotherapy and QL. Greater WL was associated with a worsened QL, especially in women with breast cancer.

Physical and Psychological Impairments Associated with Mucositis after Oral Cancer Treatment and Their Impact on Quality of Life

BACKGROUND

Posttherapeutic mucositis is a common secondary effect of oral cancer treatment. Mucositis affects the oral mucosa, which leads to specific physical impairments in oral function and a negative impact on quality of life.

OBJECTIVE

To evaluate the impairments associated with oral mucositis and their impact on posttherapeutic quality of life.

METHODS

A retrospective analysis was conducted on 1,652 patients treated for oral cancer during the multicenter rehabilitation study of the German-Austrian-Swiss Cooperative Group on Tumors of the Maxillofacial Region (DÖSAK), which included 43 clinics from Germany, Austria, and Switzerland. The analysis was based on questionnaires filled out by patients following treatment.

RESULTS

Approximately 10% of 1,652 patients included in our study had physical or psychological impairments due to increased posttreatment oral mucositis; this was mainly due to adjuvant radiotherapy or radiochemotherapy administered. Oral mucositis was significantly associated with specific physical impairments, especially xerostomia and pain (p = 0.000), which required supportive care and analgesia (p = 0.000). Additionally, impaired ingestion and speech significantly led to psychological disorders such as public avoidance behavior and social isolation (p = 0.001). Depressive coping of disease (p = 0.001) and concomitant depressive tendencies (p = 0.004) were highly associated with mucositis, which was accompanied by diminished general condition (p = 0.001), bleak future prospects (p = 0.006), and a reduction in quality of life (p = 0.002).

CONCLUSION

Minimizing mucositis-related impairments should be a main effort in oral cancer treatment to optimize patient outcome and improve quality of life after therapy.

Determinants for further wishes for cosmetic and reconstructive interventions in 1652 patients with surgical treated carcinomas of the oral cavity

Background

The impairment of the appearance is a major problem for patients with carcinomas of the oral cavity. These patients want to recover their preoperative facial appearance. Some do not realize that this is not always possible and hence develop a desire for further cosmetic and reconstructive surgery (CRS) which often causes psychological problems.

Method

The desire of patients for CRS (N = 410; 26%) has been acquired in this DÖSAK rehab study including multiple reasons such as medical, functional, aesthetic and psychosocial aspects. They relate to the parameters of diagnosis, treatment and postoperative rehabilitation. Patients without the wish for CRS (N = 1155; 74%) served as control group. For the surgeons, knowledge of the patient’s views is relevant in the wish for CRS. Nevertheless, it has hardly been investigated for patients postoperatively to complete resection of oral cancer. In this retrospective cross-sectional study, questionnaires with 147 variables were completed during control appointments. Thirty-eight departments of Oral and Maxillofacial Surgery took part, and 1652 German patients at least 6 months after complete cancer resection answered the questions. Additionally, a physician’s questionnaire (N = 1489) was available. Statistical analysis was performed with SPSS vers. 22.

Results

The patient’s assessment of their appearance and scarring are the most important criteria resulting in wishes for CRS. Furthermore, functional limitations such as eating/swallowing, pain of the facial muscles, numb regions in the operating field, dealing with the social environment, return to work, tumour size and location, removal and reconstruction are closely related.

Conclusion

The wish for CRS depends on diverse functional psychosocial and psychological parameters. Hence, it has to be issued during conversation to improve rehabilitation. A decision on the medical treatment can be of greater satisfaction if the surgeon knows the patients’ needs and is able to compare them with the medical capabilities. The informed consent between doctor and patient in regard to these findings is necessary.

Prospective Evaluation of Quality of Life in Patients Undergoing Primary Surgery for Oral Cancer: Preoperative and Postoperative Analysis

Background:

The purpose of the present study was to compare the preoperative and postoperative health related quality of life (HRQoL) of a sample of patients undergoing primary surgery for oral cancer in 2012-13.

Materials and Methods:

A cross-sectional, prospective study of 54 patients in a Brazilian population was performed. HRQoL was measured preoperatively (after histopathological diagnosis) and postoperatively (2 months after surgery) using the University of Washington Quality of Life Questionnaire (UW-QOL). Clinicopathological, sociodemographic and lifestyle data were collected.

Results:

Surgery had a negative impact on most HRQoL domains, but pain, mood and anxiety scores were significantly improved. Most patients rated their health-related and overall postoperative HRQoL as good or very good.

Conclusions:

The UW-QOL was efficient at measuring HRQoL in our sample of patients with oral cancer. Surgery had a negative impact on HRQoL, especially due to sequelae affecting the stomatognathic system, yet patients classified their postoperative health-related and overall QoL as positive. Qualitative studies are necessary for confirmation of our results and further exploration.

Neck Dissection's Burden on the Patient: Functional and Psychosocial Aspects in 1,652 Patients With Oral Squamous Cell Carcinomas

PURPOSE

In this study of patients with oral squamous cell carcinoma, the authors sought to clarify the functional and psychosocial harms of neck dissection (ND), which lessens quality of life.

MATERIALS AND METHODS

The study included questionnaire responses from patients with oral squamous cell carcinoma (n = 1,652) and clinicians (n = 1,489), as collected in the DÖSAK Rehab Study. Psychosocial and functional factors were assessed. Functional and psychosocial outcomes in patients who did not receive ND were compared with those in patients who underwent selective supraomohyoid ND (SND), modified radical ND (MND), and radical ND (RND).

RESULTS

Patients with ND had lower quality of life than those without ND. Burdens after SND (n = 923) were generally lesser than those after MND (n = 301) or RDN (n = 678). There were meaningful differences between the SND, MND, and RND and without-ND groups in impairments in speech intelligibility for strangers and familiar persons, ingestion and swallowing, tongue mobility, opening of the mouth, lower jaw mobility, neck mobility, and shoulder and arm movement (P < .05). Many patients with ND faced a lower functional status and negative professional and financial consequences.

CONCLUSIONS

Because of the burdens associated with ND, the decision to perform this treatment for oral squamous cell carcinoma should incorporate information on health-related quality of life and survival rates.

The Role of Virtual Surgical Planning in the Era of Robotic Surgery

Among various surgical methods introduced to optimize esthetic results, robotic surgery has gradually expanded in scope. As incision, approach, and operation view in robotic surgery differ from existing surgical methods, we should consider reconstruction from a different perspective. We recently experienced two mandibular reconstruction cases after tumor ablative surgery with robotic neck dissection using the conventional reconstruction method and virtual surgical planning (VSP), respectively. We found that the conventional reconstruction method is inappropriate in modified facelift incision in robotic neck dissection because it provides limited surgical scope, restricts access to the defect area, and therefore, consumes considerable time before anastomosis. For these reasons, the authors consider VSP far more viable in the era of robotic surgery.

Oral cancer malnutrition impacts weight and quality of life

Diet is important for both quality of life (QoL) and survival of patients with oral cancer. Their intake of food is impeded by functional restrictions in chewing and swallowing. In the DÖSAK REHAB STUDY 1652 patients from 38 hospitals within the German-language area of Germany; Austria and Switzerland were examined with regard to functional and psychological variables having an impact on diet. Chewing and swallowing are correlated with mobility of the tongue and the mandible as well as opening of the mouth. Thirty five percent of the patients lost weight; 41% maintained their weight and 24% gained weight. The QoL of patients who were able to maintain their weight and of those who gained weight was significantly better than that of patients who lost weight. A normal diet was important for maintaining weight. Mashed food; liquid food and loss of appetite were closely associated with loss of weight; although it was possible for nutritional counseling and dietary support to be implemented particularly favorably in this respect. Due to problems with eating patients' strength deteriorated; thus restricting activity. Radiotherapy had a negative impact on diet and weight. It influenced sense of taste; dryness of the mouth; swelling and discomfort when ingesting food. Pain and scars in the region of the operation also cause patients to dislike hard; spicy and sour food. Support from a nutritional counselor in implementing a calorie-rich diet remedied this and such support needs to be integrated into patient management. The fact that a poor nutritional status is of such great importance is well-known; but what is often lacking is the systematic implementation of continued professional nutritional counseling over a long period of time; weight control and psycho-social support of the operated patients; particularly those who also have had radiotherapy.

Coping with oral cancer: the impact of health and disease-related personality traits

PURPOSE

Oral tumours lead to critical reductions in quality of life and well being. Coping with illness is a multidimensional construct that is affected by various factors, including social structure, social support, locus of control and religious considerations. However, the effect of personality on coping with illness has hardly been studied. In this context, just one personality model has been developed, but this defines personality in very wide dimensions. Therefore, this study considered the personality factors related to health and disease and aimed to identify potential clinical applications in patients with oral cancer.

METHODS

We enrolled 104 patients suffering from oral cancer. Participants were asked about their personality and illness coping styles using the Freiburg Personality Inventory and the Freiburg Questionnaire of Coping with Illness, respectively.

RESULTS

Regression analyses revealed that specific personality structures of the patients determine their way of coping. Patients primarily used active and problem-oriented coping styles; spirituality, depressive coping and minimization were used less frequently.

CONCLUSIONS

The results demonstrate that personality affects coping behaviour. When treating patients, both situational factors and personality traits affect how patients cope with their disease. We note that it is important to give particular attention to patients who use depressive coping styles, as these patients are often incapable of coping with their diseases without external support.

Support needs and quality of life in oral cancer: a systematic review

PURPOSE

This review aims to systematically review the literature describing quality of life (QoL) outcomes and support needs in patients with oral cancer along the cancer trajectory. This is needed to form an evidence base for the design of interventions that enhance outcomes for this group.

METHODS

Six electronic databases were searched. The results were screened for eligibility, and articles were included if they described patient-reported QoL outcomes that were translatable to support needs in patients with oral cancer. Data were extracted and synthesized according to the support needs identified and their relative impact on QoL. Methodological quality was assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool.

RESULTS

Thirty-one articles met the inclusion criteria. Support needs related to coping with the burden of radiotherapy in both psychosocial and physical aspects, swallowing dysfunction, dry mouth and oral functional deficits. Issues of depression, anxiety and malnutrition were identified as having a significant impact on QoL.

CONCLUSIONS

Oral cancer support needs are highly subjective and varied in severity across the cancer continuum. Support needs that may warrant further investigation include management of changes to oral health and functioning, swallowing and nutritional compromise and psychological effects of cancer and treatment.

Are we able to reduce the mortality and morbidity of oral cancer; some considerations

Oral cancer makes up 1%-2% of all cancers that may arise in the body. The majority of oral cancers consists of squamous cell carcinomas. Oral cancer carries a considerable mortality rate, being mainly dependent on the stage of the disease at admission. Worldwide some 50% of the patients with oral cancer present with advanced disease. There are several ways of trying to diagnose oral cancer in a lower tumor stage, being 1) mass screening or screening in selected patients, 2) reduction of patients’ delay, and 3) reduction of doctors’ delay. Oral cancer population-based screening (“mass screening”) programs do not meet the guidelines for a successful outcome. There may be some benefit when focusing on high-risk groups, such as heavy smokers and heavy drinkers. Reported reasons for patients’ delay range from fear of a diagnosis of cancer, limited accessibility of primary health care, to unawareness of the possibility of malignant oral diseases. Apparently, information campaigns in news programs and TV have little effect on patients’ delay. Mouth self-examination may have some value in reducing patients’ delay. Doctors’ delay includes dentists’ delay and diagnostic delay caused by other medical and dental health care professionals. Doctors’ delay may vary from almost zero days up to more than six months. Usually, morbidity of cancer treatment is measured by quality of life (QoL) questionnaires. In the past decades this topic has drawn a lot of attention worldwide. It is a challenge to decrease the morbidity that is associated with the various treatment modalities that are used in oral cancer without substantially compromising the survival rate. Smoking cessation contributes to reducing the risk of oral cancers, with a 50% reduction in risk within five years. Indeed, risk factor reduction seems to be the most effective tool in an attempt to decrease the morbidity and mortality of oral cancer.

Key words:Oral cancer, early diagnosis, quality of life.