A review of quality of life assessment in oral cancer

Quality of Life after Mandibular Reconstruction Using Free Fibula Flap and Customized Plates: A Case Series and Comparison with the Literature

A single-center retrospective study was conducted to assess health-related quality of life (HRQoL) in 23 consecutive patients undergoing mandibular reconstruction using the computer-aided design (CAD) and computer-aided manufacturing (CAM) technology, free fibula flap, and titanium patient-specific implants (PSIs). HRQoL was evaluated after at least 12 months of surgery using the University of Washington Quality of Life (UW-QOL) questionnaire for head and neck cancer patients. In the 12 single question domains, the highest mean scores were found for "taste" (92.9), "shoulder" (90.9), "anxiety" (87.5), and "pain" (86.4), whereas the lowest scores were observed for "chewing" (57.1), "appearance" (67.9), and "saliva" (78.1). In the three global questions of the UW-QOL questionnaire, 80% of patients considered that their HRQoL was as good as or even better than it was compared to their HRQoL before cancer, and only 20% reported that their HRQoL had worsened after the presence of the disease. Overall QoL during the past 7 days was rated as good, very good or outstanding by 81% of patients, respectively. No patient reported poor or very poor QoL. In the present study, restoring mandibular continuity with free fibula flap and patient-specific titanium implants designed with the CAD-CAM technology improved HRQoL.

Validation of European Organization for Research and Treatment of Cancer Head and Neck Cancer Quality of Life Questionnaire (EORTC QLQ-H&N35) Across Languages: A Systematic Review

The purpose of this review was to identify cross-cultural and psychometric characteristics of the European Organization for Research and Treatment of Cancer Head and neck cancer questionnaire (EORTC QLQ-H&N35) in various languages. A literature search was performed for original papers in PubMed, EMBASE, and Google scholar electronic databases on validation, psychometric properties of the EORTC-H&N35 questionnaire for patients with head and neck cancer. A total of 17 papers had been reviewed systematically. The studies were conducted in 28 countries and EORTC QLQ-H&N35 questionnaire was validated in 21 different languages. The majority of papers reported high reliability having Cronbach's coefficient above 0.70. Low reliability was reported for senses and speech problems, pain, and less sexuality. Moderate to good convergent validity was found as the correlation coefficient was above 0.40 except for speech problems and social contact trouble. Discriminant validity (weak correlations < 0.70) was confirmed in 14 papers. This review provides comprehensive information on cross-cultural and psychometric properties of EORTC QLQ-H&N35 and can be recommended to implement in oncological practice.

Validation of Gujarati Version of European Organization for Research and Treatment of Cancer Quality of Life Modules in Head and Neck Cancer Patients of Western India

Head and neck cancer and its treatment had a significant impact on the quality of life. EORTC QLQ-C30 and EORTC QLQ-H&N35 are the two most widely used modules to assess the quality of life among head and neck cancer patients. The aim of the study is to test the reliability and validity of Gujarati version of EORTC QLQ-C30 and QLQ-H&N35module in a clinical setting. Gujarati version of EORTC QLQ-C30 and QLQ-H&N35 was administered to 400 histo-pathologically proven cases of head and neck cancer. For testing the internal consistency (reliability) Cronbach's alpha coefficient was used. The convergent and discriminant validity were explored by using Spearman's correlation coefficient test. Factor analysis was performed to obtain information about loading of the items for each scale. All most all scales of EORTC QLQ-C30 and QLQ-H&N35 showed high internal consistency having Cronbach's alpha coefficient > 0.70. Spearman's correlation coefficient ranges from -0.45 to 0.95 for EORTC QLQ-C30 and 0.42-0.94 for EORTC QLQ-H&N35 showing moderate to good convergent validity. The magnitude of the correlation of each item with its own scale exceeded the correlation with another scale confirming item discriminant validity. The factor analysis resulted in 7 and 11 different components for measuring quality of life for EORTC QLQ-C30 and QLQ-H&N35 respectively. Based on the results obtained it can be concluded that the Gujarati version of both the modules is a reliable and valid tool for measuring quality of life in head and neck cancer patients in clinical settings.

Combined quality of life and posttraumatic growth evaluation during follow-up care of patients suffering from oral squamous cell carcinoma

Oral cancer therapy is associated with a loss in health-related quality of life (HRQOL) and can also lead to post-traumatic growth (PTG). The current study analyzed the relationship between HRQOL, PTG and influencing clinical factors after treatment. The coherent clinical data of 15 patients were retrospectively analyzed over a 1-year study period. HRQOL and PTG were studied using the University of Washington Quality of Life Version 4 (UW-QOL v4) and Posttraumatic Growth Inventory (PTGI) questionnaires. The results revealed that HRQOL was significantly decreased in a pre- to postoperative manner (P=0.011). Sex demonstrated a nearly significant effect on HRQOL (P=0.058). PTG was experienced the most after surgery, and continuously decreased over the 1-year study period. Patient age had a significant effect on PTG (P=0.040). A significant correlation was also established between HRQOL and PTG (P<0.05). HRQOL and PTG are important influencing factors during postoperative tumor follow-up care and should be simultaneously recorded to address individual patient needs and improve quality of treatment.

Drawing: A novel approach to understanding appearance change in people following treatment for head and neck cancer

Objectives:

Appearance is a factor within head and neck cancer health-related quality of life measures; however, the issue of self-perceived appearance has received scant attention. Self-portraiture may provide insight into the patient’s perspective, allowing people to provide viewpoints that are not easily accessible. This research investigates the methodology of drawing and responses from patient-completed questionnaires in a head and neck cancer population.

Methods:

A sample of 30 people at least 3 months post-treatment for head and neck cancer were recruited. Participants completed the Derriford Appearance Scale, University of Washington Quality of Life scale, and two drawings: (1) how they recall themselves pre-treatment and (2) how they see themselves post-treatment. They were asked to discuss the methodology and their experience of it.

Results:

Correlations with Derriford Appearance Scale, University of Washington Quality of Life scale, and size drawings failed to find relationships between these variables. Post-treatment drawings were significantly smaller than pre-treatment. Qualitative analysis of the drawings found differences between the images. Participants related how drawing gave an opportunity to voice concerns that questionnaires and clinic appointments did not.

Conclusion:

Drawing can elicit distinctly different information about a person following treatment for head and neck cancer than that provided by health-related quality of life measures. Further research would clarify if clinical opinion matches patients’ drawing.

Pre-treatment quality of life as a predictor of distant metastasis-free survival and overall survival in patients with head and neck cancer who underwent free flap reconstruction

PURPOSE

This study examined the prognostic associations of pre-treatment quality of life (QoL) with overall survival (OS) and distant metastasis-free survival (DFMS) among patients with head and neck cancer (HNC) who underwent free flap reconstruction.

METHODS

A cohort of 127 HNC patients who received free flap reconstruction between November 2010 and June 2014 at a hospital were recruited. Pre-treatment QoL was measured by the University of Washington Quality of Life Questionnaire, which contains six physical domains, including speech, swallowing, appearance, saliva, taste and chewing, as well as the six social-emotional domains of pain, activity, recreation, shoulder, mood, and anxiety. Cox regression analyses were performed.

RESULTS

Results showed that pre-treatment QoL was predictive of OS and DMFS. Of the domains, swallowing, chewing, speech, taste, saliva, pain and shoulder were demonstrated to be significant predictors of OS. Additionally, swallowing, chewing, speech, pain and activity were demonstrated making significant contributions to DMFS.

CONCLUSION

Our data supported that physical domains of pre-treatment QoL were predictors for OS and DFMS in HNC patients with free-flap reconstruction. Longitudinal studies are warranted to clarify the prognostic abilities of social-emotional domains. Information on pre-treatment QoL should be taken into account to individualize care plan for these patients, and hence prolong their survival.

Patient-reported quality of life outcomes following treatment for oral cancer

Patient-reported quality of life (QoL) outcomes have the potential to assist clinicians in providing individually tailored treatment decisions. QoL assessments were collected prospectively for 168 consecutive patients treated for oral cancer between 1 January 2010 and 31 December 2014 using the University of Washington Quality of Life Questionnaire. Patients were followed up for 18 months post-treatment. Sub-group analyses were performed using paired t-tests and analysis of variance (ANOVA) to compare the effects of adjunctive chemoradiotherapy, type of bone resection, and methods of soft and hard tissue flap reconstruction. The greatest statistically significant reduction in QoL for all oral cavity sub-sites was found following the treatment of floor of mouth tumours (-18.9%, P=0.018). Laser excision for matched patient cohorts resulted in improved resultant QoL compared to other excision techniques (P=0.0002). No significant difference in QoL was found when radial forearm and anterolateral thigh flaps were matched, or when fibula and scapula flaps were matched. These findings support the use of laser excision and the avoidance of postoperative radiotherapy if curative intent and survival outcomes are maintained.

The impact of treatment for head and neck cancer on positive psychological change within a year of completing treatment

Head and neck cancer carries a high level of morbidity and mortality. So why could anyone find having such a disease a positive event? The adversity hypothesis of "what doesn't kill you makes you stronger" suggests that people can use adversity to develop as human beings. This positive psychological change has received little attention in relation to head and neck cancer. Responses to the Silver Lining Questionnaire, University of Washington Quality of Life Questionnaire, and Short-Form 12 were collected from a postal survey, 3 to 12 months after the completion of treatment for head and neck cancer. Fifty-two (63%) people returned the survey and were included in the analysis. Time since completion of therapy did not show any relationship with positive psychological change. Tumour stage and treatment regimen both had a relationship with positive change. Participants with lower stage tumours had higher levels of positive change than those with tumours of higher stages. Participants who had surgery alone reported more positive change than those who had surgery with radiotherapy. A social factor related to greater change was being married or living with a partner when compared to living alone. Further research would aid the identification of bio-psychosocial factors that influence the development of positive psychological change and inform the development of rehabilitation interventions.

Qualitative analysis of the impact of Oral Potentially Malignant Disorders on daily life activities

Objective

To evaluate the impact of Oral Potentially Malignant Disorders (OPMD) on daily life activities.

Materials and methods

Patients diagnosed with Oral Leukoplakia, Oral submucous fibrosis and Oral Lichen Planus attending the Oral Medicine clinic of Panineeya Institute of Dental Sciences & Research Centre, Hyderabad, India were invited to participate. Eighteen interviews and three focus groups were conducted in a non-clinical setting. Voice recordings were transcribed and translated from Telugu to English. Data coding was performed using the NVivo software.

Results

Sample size for this qualitative study comprised 32 patients. Four main themes emerged: (1) difficulties with diagnosis and knowledge about the condition, (2) physical impairment and functional limitations, (3) psychological and social wellbeing and (4) effects of treatment on daily life. In a majority of the patients, most of the interview time was spent discussing physical impairment and functional limitations. Patients also reported their mouth condition having a debilitating effect on their psychological well-being and social interactions.

Conclusions

‘Physical impairment and functional limitations’ was the most important theme for many of the patients. However, the impacts of OPMD also extended beyond physical impairment and functional limitations to aspects of daily living, notably psychological and social wellbeing.

Health-related quality of life after maxillectomy: obturator rehabilitation compared with flap reconstruction

Health-related quality of life (QoL) reported by patients has the potential to improve care after ablative surgery of the midface, as existing treatment algorithms still generally revolve around outcomes assessed traditionally only by clinicians. Decisions in particular relate to reconstruction with a flap compared with rehabilitation with an obturator, the need for adjuvant treatment, and morbidity related to the size of the defect. We prospectively collected health-related QoL assessments for 39 consecutive patients treated by maxillectomy between 01 January 2010 and 31 December 2014 using the University of Washington Quality of Life Questionnaire, and who had a mean (SD) duration of follow-up of 14 (4). We made sub-group analyses using paired t tests and analysis of variance (ANOVA) to compare reconstruction with a flap with rehabilitation with obturators, size of the vertical defect, and whether adjuvant treatment with radiotherapy or chemoradiotherapy adversely affected it. Overall there was a significant decrease in health-related QoL after treatment compared with before (p<0.001), but there was no significant difference in the effects of any of the paired reconstructive and rehabilitation treatments on it. Obturators remain an important option for rehabilitation in selected patients in addition to reconstruction with a flap. We found that neither increasing the size of the vertical defect (in an attempt to ensure clear margins) nor the use of postoperative radiotherapy seemed to have any adverse effect on QoL. More patients are required before we can conclude that the potential survival benefits of such measures may outweigh any adverse effects.

Comparing the Performance Status Scale and MD Anderson Dysphagia Inventory as swallowing outcome measures in head and neck cancer: a prospective cohort study

OBJECTIVES

To examine the relationship between the two disease-specific measures currently in use to assess swallowing outcomes following treatment in patients with head and neck cancer: the Performance Status Scale (PSS) and MD Anderson Dysphagia Inventory (MDADI).

DESIGN

A prospective cohort study.

SETTING

Four head and neck cancer multidisciplinary clinics in the North of England Cancer Network.

PARTICIPANTS

114 patients with cancers of the upper aerodigestive tract.

MAIN OUTCOME MEASURE

Measures of swallowing function administered prospectively across 4 timepoints

RESULTS

Spearman's correlation coefficients were used to measure the relationship between the two scales. There was statistically significant correlation between the two tools at pre-treatment (rs = 0.428, P < 0.000), 3 months post-treatment (rs = 0.454, P < 0.002), 6 months post-treatment (rs = 0.551, P < 0.000) and 12 months post-treatment (rs = 0.680, P < 0.000).

CONCLUSION

This is the first prospective study comparing the MDADI and PSS questionnaires at multiple time points. Our study shows that these different instruments have a good relationship in measuring swallowing function in patients with head and neck cancer in short and medium term after treatment.

Cross-cultural and Moroccan Validation of the University of Washington Quality of Life Questionnaire for Patients With Head and Neck Cancer

OBJECTIVES

To translate the original English version of the University of Washington Quality of Life (UW-QOL) questionnaire into Moroccan Arabic version and investigate its psychometric validity and reliability for Moroccan-speaking patients with head and neck cancer.

METHODS

The UW-QOL was conducted in 104 patients treated for head and neck cancer in the department of head and neck surgery, Ibn Rochd university hospital, Casablanca. A control group of 57 healthy volunteers was also evaluated. The questionnaire was translated into Moroccan language.

RESULTS

Cronbach's alpha coefficient was 0.829, suggesting good internal consistency, and test-retest reliability was excellent (intraclass correlation coefficient [ICC] = 0.987). A good correlation was observed between UW-QOL composite scores and European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30) global health status/QOL scores (P < .001). There was also low concordance between the UW-QOL scores and the Physical Component Summary and Mental Component Summary scores of the 36-Item Short-Form questionnaire (SF-36) (P = .017 and P = .014, respectively).

CONCLUSIONS

The Moroccan UW-QOL questionnaire appears to be culturally appropriate and psychometrically valid.

Understandability of Speech Predicts Quality of Life Among Maxillectomy Patients Restored With Obturator Prosthesis

PURPOSE

Maxillary malignant tumor resection by maxillectomy might lead to defects that can be repaired by prosthetic obturation. The aim of this study was to associate quality of life (QoL) and the Obturator Functioning Scale (OFS) with functional performance and salivary flow rate in Brazilian patients rehabilitated with an obturator prosthesis.

PATIENTS AND METHODS

This retrospective cross-sectional study included patients who underwent surgical resection with or without radiotherapy or without chemotherapy and the rehabilitation with an obturator prosthesis at the Fundação Oncocentro de São Paulo (São Paulo, Brazil). The predictor variables were Performance Status Scale for Head and Neck Cancer Patients (PSS-HN) domains and clinical evaluation of salivary flow rate. The outcome variables were overall scores obtained by the University of Washington QoL Scale (UWQOL) and the OFS. Sociodemographics (gender and age) and clinical characteristics (postoperative radiotherapy, tumor stage, classification of maxillary defect, tooth in maxilla, and type of obturator) also were evaluated. Univariate and multivariate analyses were performed to determinate whether PSS-HN domains and salivary flow were predictors of overall QoL and overall OFS.

RESULTS

The sample was composed of 73 patients with a mean age of 62 years and 51% were men. According to the PSS-HN domains, some patients (5%) always ate alone, 87% reported that speech is usually or always understandable, and 56% had no dietary restrictions. Sixty-one patients (65%) reported some degree of hyposalivation. The mean overall QoL score was 76.5 (standard deviation, 5.3). Patients with compromised PSS-HN domains had significantly worse overall UWQOL scores (P = .001, P < .001, and P = .006, respectively). In multiple regression analyses, understandability of speech was the only predictor of overall QoL scores.

CONCLUSION

The results of this study showed that understandability of speech was the only predictor of overall QoL scores.

Quality of life associated factors in head and neck cancer patients in a developing country using the FACT-H&N

Health-related quality of life (HRQoL) associated factors are vital considerations prior to treatment decision-making for head and neck cancer patients. The study aimed to identify potential socio-demographic and clinical prognostic value of HRQoL in head and neck cancer patients in a developing country. The Functional Assessment of Cancer Therapy-Head and Neck (FACT-H&N)-V4 in Urdu language was administered among 361 head and neck cancer patients. Data were statistically tested through multivariate analysis of variance (MANOVA) and regression modeling to identify the potentially associated factors. Treatment status, tumor stage and tumor site had the strongest negative impact on patients HRQoL, with a statistically significant decrement in FACT summary scales (effect size >0.15). Moderate associated factors of HRQoL included treatment type, marital status, employment status and age (effect size range 0.06-0.15). Weak associated factors of HRQoL with a small effect size (>0.01-0.06) included tumor size and type, gender, education level and ethnicity. This study reports 12 socio-demographic and clinical variables that have a significant impact on HRQoL of head, and neck cancer patients, and that should be considered during treatment decision-making by multidisciplinary teams and also in future HRQoL studies conducted in other developing countries.

Health-related quality of life of patients treated with primary chemoradiotherapy for oral cavity squamous cell carcinoma: a comparison with surgery

Our aim was to document the health-related quality of life (QoL) of patients with squamous cell carcinoma (SCC) of the oral cavity who were treated with chemoradiotherapy, and to compare it with that of patients treated with conventional surgery with or without adjuvant treatment. All patients who presented with SCC of the oral cavity treated with chemoradiotherapy alone at the Royal Brisbane & Women's Hospital between 2000 and 2011 and who were alive without disease were included. Health-related QoL was assessed by the University of Washington QoL questionnaire version 4, and the European Organisation for the Research and Treatment of Cancer (EORTC) QoL questionnaires C30 and HN35. The questionnaires were sent to all survivors. Those who responded to chemoradiotherapy were matched with patients who were treated by conventional surgery with or without adjuvant treatment by age, sex, subsite of tumour, and TNM stage. Sixteen patients completed the questionnaires (8 in each group). There was no significant difference between the 2 groups in any of the domains of any of the questionnaires. The overall outcome scores for both treatments in all 3 groups were reasonably high, which suggests that both treatments provided acceptable health-related QoL. The surgical group recorded higher scores than the chemoradiotherapy alone group in all domains of the UW-QoL except shoulder and anxiety. They recorded lower scores in all scales and items of EORTC HN35. There was no significant difference in health-related QoL between the 2 groups. Conventional surgery with or without adjuvant treatment recorded higher scores in most QoL domains including chewing, swallowing, saliva, and speech, issues most important to patients with SCC of the oral cavity.

Validade discriminante do questionário de qualidade de vida da Universidade de Washington no contexto brasileiro

OBJETIVO: Avaliar a validade discriminante do questionário de qualidade de vida da Universidade de Washington para pacientes com câncer de cabeça e pescoço e identificar possíveis fatores sociodemográficos que modifiquem seus resultados. MÉTODOS: Foram entrevistados 47 pacientes com câncer de boca e orofaringe em estágio pré-cirúrgico em um hospital no sul do município de São Paulo em 2007, e 141 pacientes sem câncer, pareados por sexo e idade em uma proporção de três para um, que foram atendidos em ambulatórios do mesmo hospital em 2008. Os resultados obtidos para os dois grupos foram comparados pelo teste t de Student. Para os pacientes sem câncer utilizou-se análise de regressão de Poisson para avaliar possíveis fatores de modificação da qualidade de vida. RESULTADOS: O escore geral de qualidade de vida foi significantemente mais elevado (p < 0,001) para os pacientes sem câncer (91,1) do que para os pacientes com câncer (80,6). Observações análogas foram efetuadas para oito dos doze domínios de qualidade de vida compreendidos no questionário (dor, aparência, deglutição, mastigação, fala, ombros, paladar e ansiedade). Como possíveis fatores de modificação dos escores de qualidade de vida foram identificados renda familiar (com impacto nos domínios de recreação, p = 0,017, e função dos ombros, p = 0,049), escolaridade (em ansiedade, p = 0,003), sexo (em função dos ombros, p = 0,038) e dor de dente (em mastigação, p = 0,015). CONCLUSÕES: O questionário tem validade discriminante, pois seus escores são especificamente mais afetados para pacientes com câncer. Reforça-se a indicação do questionário para monitorar o tratamento e recomenda-se avaliar os fatores que podem causar impacto nesses indicadores.

Long-term quality of life in young adults treated for oral cavity squamous cell cancer

OBJECTIVES

We assessed the long-term quality of life (QOL) in patients who survived oral cavity squamous cell cancer when they were young and looked for any clinical factors that might adversely affect function and QOL.

METHODS

We performed a retrospective case series and questionnaire survey in a tertiary care center. The subjects were consecutive patients treated for oral cancers during a 25-year period, when they were 40 years of age or less. The patients completed the University of Washington Quality of Life questionnaire and the M. D. Anderson Dysphagia Inventory (MDADI). We made an overall descriptive report of swallowing and QOL measures in the study population and looked for any clinical factors associated with functional outcomes.

RESULTS

Among the 62 patients treated over the course of 25 years, 46 were alive and disease-free. Twenty-six participated. The median follow-up duration was 14.7 years (range, 3 to 27 years). Age at diagnosis and duration of follow-up did not correlate with overall QOL or health-related QOL. Seventy-seven percent rated their overall QOL as outstanding, very good, or good. The key domains affected by cancer were appearance, mood, saliva, and shoulder function. Radiotherapy significantly adversely affected the QOL. The median MDADI scores on all 4 subscales were at least 85%. Higher T-stage and radiotherapy were significantly associated with lower scores on all subscales.

CONCLUSIONS

The long-term health-related QOL in this cohort was quite good. Radiotherapy and tumor stage correlated with swallowing outcomes, and only radiotherapy seemed to adversely affect the overall QOL.

The prosthodontic pathway of the oral cancer patient

Oral cancer patients undergo life-altering curative treatment that consists of surgery or a combination of surgery and radiotherapy. This can severely alter the functional anatomy of the oral cavity and create a challenging environment for successful oral rehabilitation. A multidisciplinary team approach is required to rehabilitate these patients successfully. It is essential to have assessment by an oral rehabilitation specialist before treatment, especially where primary rehabilitation interventions are being considered. Following cancer treatment, patients may suffer from a range of difficulties, from dento-facial appearance, to chewing, speech and swallowing. This dysfunction often leads to psychosocial problems, such as reduced self esteem, social contact and quality of life. Conventional prosthodontics has a role to play in the management of these patients but osseointegrated implants (OII), can be required to overcome the anatomical and physiological barriers. OII can be used in an environment where there is poor soft tissue function or little bone support, and where there is a dry mouth.

CLINICAL RELEVANCE

This paper introduces readers to the prosthodontic pathway taken by some oral cancer patients. It provides an overview of current oral rehabilitation techniques that supplement the supportive dental care provided by general dental practitioners and their team after cancer treatment.

Oral cancer teaching of medical students in the UK: time for a new approach?

Many patients with oral lesions present to general medical practitioners (GMPs). GMPs are also more likely to see patients with higher oral cancer risk. Therefore, GMPs play an important role in the early detection and prevention of oral cancer but is this reflected in undergraduate medical teaching. A questionnaire regarding oral cancer teaching was delivered to the curriculum directors of all UK medical schools. A response rate of 66% was achieved. There was wide variation in teaching time, teaching methods employed, and specialties involved. Sixty percent of schools provided clinical examination of patients with oral lesions. Up to 55% of medical schools included oral cancer in student assessment. There is wide variation in oral cancer teaching in UK medical schools. There is a need to develop a curriculum that addresses the important aspects of oral cancer from an evidence-based consensus approach.

A structured review of journal articles reporting outcomes using the University of Washington Quality of Life Scale

The University of Washington Quality of Life Scale (UW-QoL) is one of the most frequently reported health-related quality of life (HR-QoL) questionnaires in head and neck cancer, and since its first publication in 1993 has been used in many different cohorts. There is a considerable amount of information to assimilate and, to date, we know of no attempt that has been made to summarise publications specific to its use in a peer review journal. The aim of this review was to systematically search published papers that report its use, identify common themes, and present a tabulated summary. Several search engines were used (PubMed, Medline, Medical-Journals.com, eMedicine), and 222 abstracts were found and hand searched. A total of 66 papers were eligible for inclusion, 21 on functional outcome, 25 on predictors of HR-QoL, 19 on development or validation of the questionnaire, and one clinical trial. The review includes a diversity of studies and a range of HR-QoL outcomes following head and neck cancer. It provides clinicians and their colleagues in multidisciplinary teams with a source of quick reference to relevant papers reporting the UW-QoL, and gives a short summary of the pertinent conclusions drawn from each paper.

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.

Oral cancer awareness amongst hospital nursing staff: a pilot study

Background

Oral cancer is as prevalent as cervical and testicular cancer in the United Kingdom. Nursing staff provide the oral health care for the patient population in hospital. Admission to hospital provides a 'window of opportunity' for oral cancer 'screening' via an oral health check during nursing clerking. This study aimed to investigate whether nursing staff are aware of risk factors for oral cancer, its clinical signs, and could therefore provide a 'screening' service for oral cancer.

Method

Through the use of a questionnaire we assessed 121 nursing staff on oral health check behaviour and attitudes; their knowledge of risk factors for oral cancer; their understanding of common clinical signs of oral cancer; and their undergraduate and postgraduate training in oral health and oral cancer.

Results

Over 80% thought oral health checks were important although only 49% performed this task regularly; approximately 70% identified smoking as a risk factor but less than 30% identified alcohol. Awareness of the clinical signs of oral cancer was low with 21% identifying white patches, 15% identifying ulceration and only 2% identifying red patches despite their malignant potential. Nurses within 3 years of qualification were significantly better at recognising risk factors for oral cancer than their colleagues, identifying a need for continuing postgraduate education on oral health and oral cancer. Sixty-one percent of nursing staff received oral healthcare as an undergraduate with 34 percent receiving postgraduate training.

Conclusion

An oral health check upon admission to hospital provides an opportunity for nurses to 'screen' for oral diseases including oral cancer and allows nurses a greater role in total patient care. Nurses' awareness of oral cancer risk factors and clinical signs was, however, poor. This study highlights a need for improved education of nurses on oral cancer to make the oral health check on admission viable for oral cancer screening.

Can we predict which head and neck cancer survivors develop fears of recurrence?

OBJECTIVES

The objectives of this study were to investigate longitudinal predictors of fear of recurrence in survivors of head and neck cancer (HNC) using Leventhal's Common Sense Model (CSM) as a framework. The research questions were as follows: (a) to what extent do HNC patients report fear of cancer recurrence? (b) To what extent are fears of recurrence manifestations of illness-related anxiety? (c) Are fears of recurrence closely related to current symptoms, disease, and treatment-related factors, or psychological/socio-demographic factors? (d) What factors are predictive of long-term fears of recurrence?

METHODS

A prospective repeat measures design was employed whereby a sample of 82 newly diagnosed HNC patients (54 males, 28 females, mean age 60 years) completed measures of fears of recurrence, illness perceptions, coping, and anxiety and depression, prior to treatment and 6-8 months after treatment (fears of recurrence only).

RESULTS

A third of HNC patients at diagnosis reported relatively high levels of fears of recurrence, with 12% still reporting similar levels of fear 6-8 months after treatment. Fears of recurrence were not related to any socio-demographic factor (age, gender, ethnicity, marital status, and educational attainment) or disease, treatment, or symptom-related factors. Path analyses demonstrated that fears of cancer recurrence after treatment were directly predicted by pre-treatment fears and optimism.

CONCLUSION

Although components of the CSM (cognitive and emotional representations, coping strategies) were associated with fears of recurrence, optimism was found to be the strongest predictor of fear, independent of anxiety and level of fear reported prior to treatment.

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.

[The impact of radiotherapy on quality of life -- a survey of 1411 patients with oral cancer]

PURPOSE

The therapy of patients with oral cancer often requires a combination of surgery and radiotherapy. This leads to trauma of healthy tissue. The impact of this side effect on quality of life was investigated. Additionally the impairment of 19 factors was determined (comprehension of speech for unknown others, comprehension of speech for familiar others, eating/swallowing, mobility of the tongue, opening range of the mouth, mobility of lower jaw, mobility of neck, mobility of arms and shoulders, sense of taste, sense of smell, appearance, strength, appetite, respiration, pain, swelling, xerostomia, halitosis).

METHODS

This retrospective multicenter study was conducted under the auspices of DOESAK (a German, Austrian and Swiss cooperative group on tumors of the maxillofacial region). The Bochum Questionnaire on Rehabilitation was used to determine 147 items. 3894 questionnaires where sent to 43 clinics in Germany, Austria and Switzerland. 1761 questionnaires where returned, while 1411 of them included all of the answers necessary for this study.

RESULTS

686 of 1411 patients where irradiated. Before the beginning of therapy the impairment of the 19 factors was not significantly higher in the group that later received radiotherapy. After therapy there is a significantly higher impairment of the irradiated patients. The factors that are especially worse are xerostomia, swallowing and understanding of speech. The quality of life was not significantly lower.

CONCLUSIONS

Although radiotherapy leads to trauma of healthy tissue this method is indicated as it has no significant impact on quality of life. During the rehabilitation physiotherapists should relieve the impairment of speech, eating and swallowing.

Reconstructing Wide Palatomaxillary Defects Using Free Flaps Combining Bare Serratus Anterior Muscle Fascia and Scapular Bone

PURPOSE

Wide palatomaxillary defects, mostly after tumor resections, can cause severe functional and esthetic problems. Although prosthetic obturator devices or local flaps are mostly adequate for uncomplicated small-size defects, free flaps are preferred for a 3-dimensional multitissue reconstruction of more complicated defects. Regarding the anatomical structure of the palatomaxillary region, the flap must be thin enough to separate the oral and nasal cavities while not compromising palatal function, yet rigid enough for adequate dental restoration. This goal is usually accomplished with a combined or complex free flap. Numerous free flaps containing both soft tissues and bone have been described in the literature. In this study, we present a novel use of the free scapular bone flap combined with serratus anterior fascia and its functional and esthetic results.

PATIENTS AND METHODS

Nine cases are presented whose wide composite palatomaxillary defects were repaired with free angular scapular bone flap combined with serratus anterior fascia based on the subscapular vascular system, between 1999 and 2003. Scapular bone wrapped with the naked serratus anterior fascia, like a sandwich, was used to repair the palate.

RESULTS

The naked fascia was epithelialized with the help of the surrounding mucosa in 4 to 6 weeks. Results were satisfying with regard to breathing, eating, speech, and facial contour after follow-ups for 2 months to 6 years.

CONCLUSION

For the reconstruction of wide palatomaxillary defects, a combined flap of angular scapular bone wrapped with naked serratus anterior fascia was conceived useful for obtaining satisfactory functional and esthetic results.

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.

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.