Changes in health-related quality of life of oral cancer patients treated with curative intent: experience of a developing country

Oral health related quality of life of oral cancer patients treated with radiotherapy alone or with chemotherapy in a tertiary referral centre in Sri Lanka

BACKGROUND

Oral cancer is the number one cancer among males in Sri Lanka. Radiotherapy is a common treatment modality for oral cancer, but this can affect oral health related quality of life (OHRQOL). This study assessed the OHRQOL and its changes from baseline to the last week of radiotherapy and three months post radiotherapy among oral cancer patients who received this treatment alone or with chemotherapy.

METHODS

A prospective longitudinal study was conducted among 90 oral cancer patients awaiting for radiotherapy alone or with chemotherapy. The modified Sinhala version of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Oral Health Module (EORTC QLQ-OH15) was used to gather data related to OHRQOL before radiotherapy. Socio-demographic and clinical data were also recorded. The same cohort of patients were followed up and assessed their OHRQOL during the last week of radiotherapy and three months post radiotherapy. The Modified EORTC QLQ-OH15 assesses the OHRQOL under three domains namely 'Eating problem', 'Gum and speech problem' and 'Soreness', and one item named as 'Teeth'.

RESULTS

The majority of the sample (88%) was males. The anterior two-thirds of the tongue (40%) and buccal mucosa (22%) were the most common sites. The median scores of 'Eating problem' domain at baseline, last week of radiotherapy and three months post radiotherapy were 20 (IQR = 6.7-33.3), 100 (IQR = 86.9-100.0) and 66.7 (IQR = 46.7-93.3) respectively. 'Gum and speech problem' was higher during last week of radiotherapy (median, 50.0, IQR, 25.0-58.3) than three months post radiotherapy (median, 8.3, IQR, 0.0-33.3). The changes of OHRQOL between the time frames were statistically significant (p < 0.05). Baseline OHRQOL in relation to 'Gum and speech problem' domain and 'Teeth' item was identified as an influential factor for OHRQOL during last week of radiotherapy.

CONCLUSION

The OHRQOL of oral cancer patients who received radiotherapy alone or with chemotherapy had deteriorated from the baseline level to the last week of radiotherapy but then improved at three months post radiotherapy. The OHRQOL however did not return to the baseline level three months post radiotherapy. OHRQOL during the last week of radiotherapy was influenced by the OHRQOL at baseline, civil status and sites of metastasis.

Psychosocial Adjustment Changes and Related Factors in Postoperative Oral Cancer Patients: A Longitudinal Study

Disease and treatment-related symptoms and dysfunctions can interfere with the psychosocial adjustment of patients with oral cancer. Identifying factors influencing psychosocial maladjustment is important because at-risk individuals can be targeted for early intervention. This prospective longitudinal study investigated psychosocial adjustment changes and associated factors in postoperative oral cancer patients. Data on psychosocial adjustment, facial disfigurement, symptoms, and social support were collected before surgery (T1) at one month (T2), three months (T3), and five months after discharge (T4). Fifty subjects completed the study, and their data were included in the analysis. Psychosocial maladjustment was reported in 50%, 59.2%, 66%, and 62% of subjects at T1, T2, T3, and T4, respectively. The subjects' psychosocial adjustment deteriorated after surgery. Results from generalized estimating equations indicated that financial status, cancer stage, pain, speech problems, social eating problems, and less sexuality were significant predictors of changes in psychosocial adjustment. Patients with insufficient income, stage III/IV cancer, severe pain, speech problems, social eating problems, and less sexuality were at higher risk for postoperative psychosocial maladjustment. Continued psychosocial assessment and appropriate supportive measures are needed to strengthen the psychosocial adjustment of these high-risk groups.

Health-related quality of life at 3 months following head and neck cancer treatment is a key predictor of longer-term outcome and of benefit from using the patient concerns inventory

INTRODUCTION

During clinical follow-up it can be difficult to identify those head and neck cancer (HNC) patients who are coping poorly and could benefit from additional support. Health-related quality of life (HRQOL) questionnaires and prompt lists provide a means by which patients can express their perceived outcomes and raise concerns. The first aim of this secondary analysis following a randomized trial was to explore which patient characteristics, at around 3 months following treatment completion (baseline), best predict HRQOL 12 months later. The second aim was to attempt to ascertain which patients were most likely to benefit from using prompt list.

METHODS

Cluster-controlled pragmatic trial data were analyzed. HRQOL was measured by the University of Washington Quality of life questionnaire (UW-QOLv4). The prompt list was the Patient Concerns Inventory (PCI-HN).

RESULTS

The trial involved 15 eligible consultants and a median (inter-quartile range) of 16 (13-26) primary HNC patients per consultant, with 140 PCI patients and 148 controls. Baseline HRQOL was the dominant predictor of 12-month HRQOL with other predictors related to social, financial, and lifestyle characteristics as well as clinical stage and treatment. Although formal statistical tests for interaction were non-significant the trend in analyses over a range of outcomes suggested that patients with worse baseline HRQOL could benefit more from the PCI-HN.

DISCUSSION

HRQOL early post-treatment is a key predictor of longer-term outcome. Measuring and using HRQOL and the PCI-HN are not only surrogates for predicting HRQOL at 15 months post-treatment, but also tools to help guide interventions.

Lateral Approach With a Mouth Corner Incision for the Molar Part of Mandibulectomy

OBJECTIVES

The aim of the present study was to evaluate the functional and esthetic results of marginal mandibulectomy for mandibular cancer using a lateral approach with a simple, straightforward mouth corner incision.

STUDY DESIGN

Six mandibular cancer patients (2 men, 4 women; age range: 65-80 years; mean age, 73.1 years; all stage I) were treated using this approach. With this approach, the surgical field was widely exposed, and mandibulectomy was performed with sufficient surgical margins. Intraoperative frozen specimens of remaining tissues showed no malignancy in all cases. In all 6 patients, follow-up imaging assessments were obtained, with no local recurrence after 12 to 78 months.

RESULTS AND CONCLUSIONS

An overall functional, physical, and esthetic assessment of oral behavior and oral appearance was made of all patients by the FACT-H&N questionnaire, which showed that functional lip behavior and esthetic lip appearance were not much affected by the present surgical approach, and good quality of life was maintained. Thus, the lateral approach with the mouth corner incision is an effective and useful alternative for the molar part of mandibulectomy.

Cancer and Stress: Does It Make a Difference to the Patient When These Two Challenges Collide?

Simple Summary

Head and neck cancers are the sixth most common cancer in the world. The burden of the disease has remained challenging over recent years despite the advances in treatments of other malignancies. The very use of the word malignancy brings about a stress response in almost all adult patients. Being told you have a tumour is not a word anyone wants to hear. We have embarked on a study which will investigate the effect of stress pathways on head and neck cancer patients and which signalling pathways may be involved. In the future, this will allow clinicians to better manage patients with head and neck cancer and reduce the patients’ stress so that this does not add to their tumour burden.

Abstract

A single head and neck Cancer (HNC) is a globally growing challenge associated with significant morbidity and mortality. The diagnosis itself can affect the patients profoundly let alone the complex and disfiguring treatment. The highly important functions of structures of the head and neck such as mastication, speech, aesthetics, identity and social interactions make a cancer diagnosis in this region even more psychologically traumatic. The emotional distress engendered as a result of functional and social disruption is certain to negatively affect health-related quality of life (HRQoL). The key biological responses to stressful events are moderated through the combined action of two systems, the hypothalamus–pituitary–adrenal axis (HPA) which releases glucocorticoids and the sympathetic nervous system (SNS) which releases catecholamines. In acute stress, these hormones help the body to regain homeostasis; however, in chronic stress their increased levels and activation of their receptors may aid in the progression of cancer. Despite ample evidence on the existence of stress in patients diagnosed with HNC, studies looking at the effect of stress on the progression of disease are scarce, compared to other cancers. This review summarises the challenges associated with HNC that make it stressful and describes how stress signalling aids in the progression of cancer. Growing evidence on the relationship between stress and HNC makes it paramount to focus future research towards a better understanding of stress and its effect on head and neck cancer.

Can post-treatment oral cancer patients' concerns reflect their cancer characteristics, HRQoL, psychological distress level and satisfaction with consultation?

Background

Oral cancer and its treatment impact patients' post-treatment outcomes, challenging clinicians to manage them optimally. Addressing patients' concerns is central to holistic patient-centred care.

Objectives

This study aimed to determine post-treatment oral cancer patients' concerns and its relationship with patients' clinical characteristics, health-related quality of life (HRQoL), psychological distress and patient satisfaction with the follow-up consultation.

Methods

A total of 85 oral cancer patients were recruited from a three-armed pragmatic RCT study on the patient concerns inventory for head and neck cancer (PCI-H&N), which was conducted at six hospital-based oral maxillofacial specialist clinics throughout Malaysia. Malaysians aged 18 years and above and on follow-ups from 1 month to 5 years or more were eligible. Patients completed the PCI-H&N, functional assessment of cancer therapy -H&N v4.0 and Distress Thermometer at pre-consultation and satisfaction questionnaire at post-consultation. The data were analysed descriptively; multiple linear regression and multivariate logistic regression analyses were used to determine possible predictors of patients' HRQoL and psychological distress.

Results

'Recurrence or fear of cancer coming back' (31.8%) was most frequently selected. 43.5% of patients selected ≥4 concerns. A significantly high number of concerns were associated with patients of '1-month to 1-year post-treatment' (n = 84%; p = 0.001). A significant association existed between 'time after treatment completed' and patients' concerns of 'chewing/eating', 'mouth opening', 'swelling', 'weight', 'ability to perform', 'cancer treatment' and 'supplement/diet-related'. 'Chewing/eating' was predicted for low HRQoL (p < 0.0001) followed by 'appearance' and 'ability to perform recreation activities' (personal functions domain). Patients with high psychological distress levels were 14 times more likely to select 'ability to perform recreation activities' and seven times more likely to select 'feeling depressed'. No significant association was identified between patients' concerns and patients' satisfaction with the consultation.

Conclusion

Routine follow-up consultations should incorporate the PCI-H&N prompt list to enhance patient-centred care approach as the type and number of patients' concerns are shown to reflect their HRQoL and psychological distress.TRIAL REGISTRATION: NMRR-18-3624-45010 (IIR).

Symptom Burden Associated With Late Lower Cranial Neuropathy in Long-term Oropharyngeal Cancer Survivors

Importance

Lower cranial neuropathy (LCNP) is a rare but potentially disabling result of radiotherapy and other head and neck cancer therapies. Survivors who develop late LCNP may experience profound functional impairment, with deficits in swallowing, speech, and voice.

Objective

To investigate the association of late LCNP with severity of cancer treatment-related symptoms and subsequent general functional impairment among oropharyngeal cancer (OPC) survivors.

Design, Setting, and Participants

This cross-sectional survey study analyzed 889 OPC survivors nested within a retrospective cohort of OPC survivors treated at MD Anderson Cancer Center from January 1, 2000, to December 31, 2013. Eligible survey participants were disease free and completed OPC treatment 1 year or more before the survey. Data analysis was performed from October 10, 2017, to March 15, 2018.

Exposures

Late LCNP defined by onset 3 months or more after cancer therapy.

Main Outcomes and Measures

The primary outcome variable was the mean of the top 5 most severely scored symptoms of all 22 core and head and neck cancer-specific symptoms from the MD Anderson Symptom Inventory Head and Neck Cancer Module (MDASI-HN). Secondary outcomes included mean MDASI-HN interference scores and single-item scores of the most severe symptoms. Multivariate models regressed MDASI-HN scores on late LCNP status, adjusting for clinical covariates.

Results

Overall, 36 of 889 OPC survivors (4.0%) (753 [84.7%] male; 821 [92.4%] white; median [range] age, 56 [32-84] years; median [range] survival time, 7 [1-16] years) developed late LCNP. Late LCNP was significantly associated with worse mean top 5 MDASI-HN symptom scores (coefficient, 1.54; 95% CI, 0.82-2.26), adjusting for age, survival time, sex, therapeutic modality, T stage, subsite, type of radiotherapy, smoking, and normal diet before treatment. Late LCNP was also significantly associated with single-item scores for difficulty swallowing or chewing (coefficient, 2.25; 95% CI, 1.33-3.18), mucus (coefficient, 1.97; 95% CI, 1.03-2.91), fatigue (coefficient, 1.35; 95% CI, 0.40-2.21), choking (coefficient, 1.53; 95% CI, 0.65-2.41), and voice or speech symptoms (coefficient, 2.30; 95% CI, 1.60-3.03) in multivariable models. Late LCNP was not significantly associated with mean interference scores after correction for multiple comparisons (mean interference coefficient, 0.72; 95% CI, 0.09-1.35).

Conclusions and Relevance

In this large survey study, OPC survivors with late LCNP reported worse cancer treatment-related symptoms, a finding suggesting an association between late LCNP and symptom burden. This research may inform the development and implementation of strategies for LCNP surveillance and management.

m-Health for Early Detection of Oral Cancer in Low- and Middle-Income Countries

Background: Up to 86% of oral cancer (OC) patients present at the late stage where survival is dismal. Limited access to specialist diagnosis is a significant factor for late presentation. The increasing use of smartphones presents an opportunity to use digital technology to facilitate early detection of OC. Aim: To evaluate the feasibility of using Mobile Mouth Screening Anywhere (MeMoSA^®) to facilitate early detection of OC. Methods: A mobile phone app named MeMoSA was developed and the feasibility of integrating this for documentation of oral lesions, and communication between dentists and specialists for management decisions were evaluated. The experience of dentists and specialists in using MeMoSA was determined using qualitative questionnaires. Results: Communication between specialist and dentists using MeMoSA stratified cases and streamlined referral of patients. Twelve of 48 patients were found to have oral lesions or signs suspicious of cancer and 3 required referrals. The patient's compliance for referral was tracked with MeMoSA. All dentists agreed that MeMoSA could facilitate early detection of OC and believed that MeMoSA could assist in the identification of oral mucosal lesions through direct communication with specialists and continuous learning in the recognition of high-risk lesions. Conclusions: MeMoSA has the potential to be used to promote equitable health care and streamline patient management that could result in early detection of OC.

Oral health related quality of life and determinant factors in patients with head and neck cancer

Background

The present study aimed to measure the impact of oral health on the quality of life of patients with head and neck cancer.

Material and Methods

A cross-sectional study was conducted with 130 patients diagnosed with head and neck cancer at two medical centers. Participants answered a sociodemographic questionnaire and the Oral Health Impact Profile - 14 (OHIP-14). Clinical aspects, cancer staging, and treatment approach were also investigated. Mann-Whitney and Kruskal-Wallis non-parametric tests were used for statistical analysis, followed by Poisson regression analysis (with robust error variance), to associate the OHIP-14 scores with independent variables.

Results

The OHIP-14 presented good internal consistency (Cronbach’s Alpha = 0.861). The mean score obtained was 19.52 (±11.79). Physical pain (3.70±2.44), physical disability (3.26±2.62) and functional limitation (3.24±2.45) were ranked as the main factors affecting the quality of life. Patients non-Caucasians (PR = 1.30; IC 95% = 1.07-1.58; p = 0.009), widowers (PR = 1.36; IC 95% = 1.13-1.64; p = 0.001), diagnosed with squamous cell carcinoma (PR = 1.28; IC 95% = 1.05-1.58; p = 0.017) and with temporomandibular pain (PR = 1.31; IC 95% = 1.08-1.60; p = 0.007) were more likely to exhibit lower rates of quality of life.

Conclusions

The results showed a high impact of the oral health in the quality of life of patients with head and neck cancer was observed. Sociodemographic and clinical characteristics can exert influence on the quality of life of patients with head and neck cancer.

Key words:Quality of life, malignant neoplasms, head and neck neoplasms, oral health, epidemiology.

Burden of treatment: Reported outcomes in a head and neck cancer survivorship clinic

OBJECTIVE

With the intensification and utilization of multimodal treatment, acute toxicities have increased; however, the frequency of treatment sequelae in long-term head and neck cancer (HNC) survivors are poorly described. The purpose of this analysis was to determine the prevalence and predictors of patient-reported late and long-term treatment-related sequelae in HNC survivors.

METHODS

We performed a cross-sectional analysis of patient-reported outcomes from 228 survivors attending a multidisciplinary HNC survivorship clinic. The primary outcomes comprised quality of life (QOL), symptoms of anxiety and depression, and swallowing dysfunction.

RESULTS

Male gender, tumor sites in the oropharynx and larynx, longer time since treatment, and treatment with surgery alone were associated with higher physical QOL (P < .05). Male gender, longer time since treatment, and treatment with surgery alone were associated with higher social-emotional QOL (P < .05). A reduction in anxiety symptoms and a higher QOL were related to longer time since treatment; however, a reduction in swallowing dysfunction symptoms was only related to longer time since treatment until approximately 6 years. After 6 years, survivors reported worse swallowing dysfunction (P < .05). One hundred thirty-two survivors (56%) reported at least three treatment-related effects that impacted their daily life. Finally, advanced stage disease at diagnosis (stage III-IV) was also associated with severe swallowing dysfunction (P = .004).

CONCLUSION

These data indicate the remarkable prevalence of treatment-related effects in HNC survivors. These results highlight the need for de-intensification of therapies, where appropriate, and for a better understanding of pathophysiology and new approaches to mitigating treatment effects.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:E437-E444, 2019.

Influences of facial disfigurement and social support for psychosocial adjustment among patients with oral cancer in Taiwan: a cross-sectional study

OBJECTIVE

To explore the influences of facial disfigurement and social support for psychosocial adjustment in patients with oral cancer.

DESIGN

A cross-sectional design was used for the study.

PARTICIPANTS AND SETTING

A convenience sample of 77 patients with oral cancer was recruited from the otolaryngology and oral and maxillofacial surgery outpatient clinics of three general hospitals in Taiwan.

MEASURES

Data were collected using the study questionnaires, including the Facial Disfigurement Scale, the Social Support Scale and the Psychosocial Adjustment to Illness Scale.

RESULTS

The mean score on the Psychosocial Adjustment to Illness Scale was 413.01 (SD=32.32); 71.4% of the participants were maladjusted. Results of multiple regression analysis showed statistically significant main effects of tumour site (beta=0.37), facial disfigurement (beta=0.35) and social support (beta=-1.01), and the interaction effect of facial disfigurement and social support (beta=0.79) (all p<0.05) on psychosocial adjustment after controlling for other sociodemographic and clinical variables. All variables together explained 62% of the variance in psychosocial adjustment (F(16, 55)=14.98, p<0.001).

CONCLUSIONS

The level of psychosocial adjustment in patients with oral cancer was suboptimal. Poorer psychosocial adjustment was reported by patients with more severe facial disfigurement and less social support. Patients with cancers in other areas of the oral cavity also reported poorer psychosocial adjustment than patients with cancers in the buccal mucosa. Medical professionals may use these variables to identify higher risk groups for early intensive intervention.

[Systematic retrospective study of oral cancer-related quality of life scale]

OBJECTIVE

The quality of life (QOL) related to oral cancer has recently become a focus of clinical studies. This study aims to systematically review the current research situation of QOL of local and foreign oral cancer patients and explore the existing related problems and future research directions to provide references and solutions.

METHODS

Through relevant key words, PubMed, Wiley InterScience, Science Direct, CNKI, and Wanfang databases were first searched. The related target literature from 2000 to 2017 were screened. Finally, the frequency of oral cancer related to QOL scale used in literature was calculated, and the related scales were briefly introduced.

RESULTS

From the target literature, 218 English target literature, 55 Chinese target literature, 24 English scales, and 12 Chinese scales were selected. The most widely used scales for assessing the QOL of patients with oral cancer were as follows: University of Washington Quality of Life Questionnaire (UW-QOL), European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire Core 30/Head and Neck 35 (EORTC QLQ-C30/H&N35), 36-Item Short-Form Health Survey (SF-36), Functional Assessment of Cancer Therapy-Head and Neck (FACT-H&N), and Oral Health Impact Profile (OHIP).

CONCLUSIONS

The QOL related to oral cancer was well underway, and the study of geographical distribution was widespread. However, the work on self-developed scale remains inadequate. UW-QOL, EORTC QLQ-C30/H&N35, and FACT-H&N can be utilized as the preferred scales for evaluating the QOL of oral cancer patients. A specific disease-related function scale can also be selected according to specific research objectives.

Assessment of cellular and serum proteome from tongue squamous cell carcinoma patient lacking addictive proclivities for tobacco, betel nut, and alcohol: Case study

The intriguing molecular pathways involved in oral carcinogenesis are still ambiguous. The oral squamous cell carcinoma (OSCC) ranks as the most common type constituting more than 90% of the globally diagnosed oral cancers cases. The elevation in the OSCC incidence rate during past 10 years has an alarming impression on human healthcare. The major challenges associated with OSCC include delayed diagnosis, high metastatic rates, and low 5-year survival rates. The present work foundations on reverse genetic strategy and involves the identification of genes showing expressional variability in an OSCC case lacking addictive proclivities for tobacco, betel nut, and/or alcohol, major etiologies. The expression modulations in the identified genes were analyzed in 16 patients comprising oral pre-cancer and cancer histo-pathologies. The genes SCCA1 and KRT1 were found to down regulate while DNAJC13, GIPC2, MRPL17, IG-Vreg, SSFA2, and UPF0415 upregulated in the oral pre-cancer and cancer pathologies, implicating the genes as crucial players in oral carcinogenesis.