Postlaryngectomy quality-of-life dimensions identified by patients and health care professionals

Voice-Related Quality of Life Outcomes from Pneumatic Artificial Laryngeal and Esophageal Speakers

The self-reporting voice-related quality of life (V-RQOL) instrument has been viewed as a modular index of quality of life for speakers using tracheoesophageal, esophageal (ES), or electrolaryngeal speech. However, V-RQOL has never been studied with pneumatic artificial laryngeal (PA) individuals. This study attempted to quantify the self-assessed voice-related performance of PA and ES speakers in Taiwan via the V-RQOL questionnaire, and further to compare the results for PA and ES speakers.

METHODS

V-RQOL was assessed in 79 PA and 25 ES speakers undergoing total laryngectomy without using tracheoesophageal puncture. Data were collected from members of Taiwan's Association of Laryngectomees.

RESULTS

There was no significant difference between PA and ES participants in social-emotional, physical functioning and total scores, suggesting both may consider their quality of life comparable with each other. In ES participants, there was a significant effect of time after total laryngectomy in physical functioning and total scores.

CONCLUSIONS

PA speakers did not exhibit more dissatisfaction or disability than ES speakers on 10 statements in the V-RQOL, but after total laryngectomy the ES have been shown to improve over time. Information on the experience of PA and ES speakers could be used by clinicians to inform patients of potential outcomes, and help them select suitable rehabilitation techniques.

Improving heat and moisture exchanger therapy with a hydrogel base adhesive in laryngectomised patients: an open, randomised, crossover trial

OBJECTIVE

This study aimed to assess individual preference, symptoms and compliance between habitual use of Provox XtraFlow and the combination of Provox XtraFlow during the day and Provox Luna during the night for heat and moisture exchanger therapy in laryngectomised patients.

METHOD

This was an open, randomised, crossover trial for 25 days. After this first study period and a 5-day wash-out period, treatments were switched for another 25 days.

RESULTS

A total of 28 patients were enrolled. Differences were found (p = 0.009) in the incidence of dermatological problems with XtraFlow (46.4 per cent) versus Provox Luna (14.3 per cent), as well as in the need to abandon the use of adhesives (46.4 per cent vs 10.7 per cent; p = 0.003). A total of 60.7 per cent of the patients preferred the Provox Luna system as their preference for heat and moisture exchanger therapy.

CONCLUSION

The Provox Luna system is a viable additive to heat and moisture exchanger therapy, especially in the setting of compliance concerns and in patients who desire dermatological relief overnight.

Enrichment of Oesophageal Speech: Voice Conversion with Duration–Matched Synthetic Speech as Target

Pathological speech such as Oesophageal Speech (OS) is difficult to understand due to the presence of undesired artefacts and lack of normal healthy speech characteristics. Modern speech technologies and machine learning enable us to transform pathological speech to improve intelligibility and quality. We have used a neural network based voice conversion method with the aim of improving the intelligibility and reducing the listening effort (LE) of four OS speakers of varying speaking proficiency. The novelty of this method is the use of synthetic speech matched in duration with the source OS as the target, instead of parallel aligned healthy speech. We evaluated the converted samples from this system using a collection of Automatic Speech Recognition systems (ASR), an objective intelligibility metric (STOI) and a subjective test. ASR evaluation shows that the proposed system had significantly better word recognition accuracy compared to unprocessed OS, and baseline systems which used aligned healthy speech as the target. There was an improvement of at least 15% on STOI scores indicating a higher intelligibility for the proposed system compared to unprocessed OS, and a higher target similarity in the proposed system compared to baseline systems. The subjective test reveals a significant preference for the proposed system compared to unprocessed OS for all OS speakers, except one who was the least proficient OS speaker in the data set.

Rehabilitation following total laryngectomy: Oncologic, functional, socio-occupational and psychological aspects

GOAL

To review rehabilitation following total laryngectomy by an analysis of epidemiological, oncologic and functional data.

MATERIALS AND METHODS

This retrospective observational study focused on patients having undergone total laryngectomy or pharyngolaryngectomy between January 1, 2005 and December 31, 2016. Oncologic data notably comprised survival and relapse and predictive factors. The impact of the procedure on quality of life and the voice was analyzed by self-administered questionnaires (EORTC QLQ-C30 and H&N35, VHI 30). A satisfaction questionnaire was also sent to patients.

RESULTS

One hundred and thirty three patients were included. Overall specific 5-year survival was 65%. The relapse rate was 32%. Factors influencing survival were WHO performance status ≥2 (P<0.05), tumor location (P=0.07), metastatic lymphadenopathy (P=0.017) and positive resection margins (P=0.01). Quality of life was moderately degraded (global EORTC QLQ-C30 status: 61.4±23.9). Type of rehabilitation (P=0.03), tube feeding (P=0.03) and relapse (P<0.01) influenced quality of life. There were no differences in voice quality according to rehabilitation method, and no predictive factors for failure of voice rehabilitation. More than 90% of patients were satisfied with their hospital stay; 43%, however, were not satisfied with community caregiver training for laryngectomy patients.

CONCLUSION

Rehabilitation of laryngectomized patients is a current therapeutic challenge. A therapeutic education tool was designed to better meet patient expectations.

Intelligibility and Listening Effort of Spanish Oesophageal Speech

Communication is a huge challenge for oesophageal speakers, be it for interactions with fellow humans or with digital voice assistants. We aim to quantify these communication challenges (both human–human and human–machine interactions) by measuring intelligibility and Listening Effort (LE) of Oesophageal Speech (OS) in comparison to Healthy Laryngeal Speech (HS). We conducted two listening tests (one web-based, the other in laboratory settings) to collect these measurements. Participants performed a sentence recognition and LE rating task in each test. Intelligibility, calculated as Word Error Rate, showed significant correlation with self-reported LE ratings. Speaker type (healthy or oesophageal) had a major effect on intelligibility and effort. More LE was reported for OS compared to HS even when OS intelligibility was close to HS. Listeners familiar with OS reported less effort when listening to OS compared to nonfamiliar listeners. However, such advantage of familiarity was not observed for intelligibility. Automatic speech recognition scores were higher for OS compared to HS.

Patient perspectives and treatment regret after de-escalated chemoradiation for human papillomavirus-positive oropharyngeal cancer: Findings from a phase II trial

BACKGROUND

We evaluated priorities, expectations, and regret among patients treated on a phase II trial of de-escalated chemoradiation for human papillomavirus (HPV)-positive oropharyngeal cancer.

METHODS

Eligibility included stage III/IV squamous cell carcinoma of the oropharynx, p16-positivity, age ≥18 years, and Zubrod score 0-1. Participants were surveyed with validated measures evaluating their treatment experience.

RESULTS

Twenty-four of 27 (89%) patients participated with a median follow-up of 24 months. Twenty-three subjects (96%) selected "being cured" or "living as long as possible" as top priority. No patient reported any regret about the decision to enroll on a de-escalation protocol. Sixteen participants (67%) found retrospectively reported long-term swallowing function to be either better than or as originally expected.

CONCLUSIONS

These data offer a baseline landscape of perspectives and priorities for patients treated with de-escalation for HPV-positive oropharyngeal carcinoma and provide support to the fundamental premise underlying ongoing efforts to establish a new standard of care.

Horizontal (vs. vertical) closure of the neo-pharynx is associated with superior postoperative swallowing after total laryngectomy

We conducted a cross-sectional study to compare the horizontal and vertical methods used in the surgical closure of the neo-pharynx after total laryngectomy in terms of their effect on swallowing function, swallowing-related quality of life (QOL), and overall QOL. We also assessed the potential influence of age (≤64 vs. ≥65 yr) and the type of treatment modality (primary, salvage, or total laryngectomy with radiotherapy) on outcomes. Our final study population was made up of 34 patients-31 men and 3 women, aged 49 to 89 years (mean: 66.8)-who had undergone a total laryngectomy. One year after surgery, all patients were asked to complete the M.D. Anderson dysphagia inventory (MDADI), which quantifies swallowing function and swallowing-related QOL, and the University of Washington quality-of-life questionnaire (UW-QOL), which quantifies overall QOL. Of the 34 patients, 16 had undergone a horizontal surgical closure of their neo-pharynx and 18 a vertical closure. According to the MDADI, patients in the horizontal group experienced significantly better swallowing function/QOL; the mean composite MDADI scores were 91.5 in the horizontal group and 68.3 in the vertical group (p = 0.005). We found no significant difference in terms of overall QOL, as the respective mean UW-QOL scores were 81.0 and 80.8 (p = 0.93). The population correlation coefficient was positive in both groups, but more so in the horizontal group (ρ_horizontal = 0.876 and ρ_vertical = 0.676). Neither age nor the type of treatment modality employed influenced swallowing function/QOL (p_age = 0.10, p_{treatment modality} = 0.78) or overall QOL (p_age = 0.08, p_{treatment modality} = 0.59). We conclude that horizontal closure of the neo-pharynx is superior to vertical closure in terms postoperative swallowing function/QOL but not overall QOL.

Head and Neck Cancer in the Elderly: Frailty, Shared Decisions, and Avoidance of Low Value Care

Head and neck cancer (HNC) is a disease of older adults. Recurrent and metastatic head and neck squamous cell carcinoma portends a poor prognosis, with median overall survival of less than 12 months. Within this vulnerable population, significant treatment-related toxicities and physical and psychosocial sequelae can be devastating to quality of life at the end of life. Shared decision making and early comprehensive palliative and support services are at the crux of the approach to older adults with HNC. In doing so, low-value care that fails to meet the goals of patients and their caregivers at the end-of-life may be avoided.

Cetuximab and Radiotherapy in Laryngeal Preservation for Cancers of the Larynx and Hypopharynx: A Secondary Analysis of a Randomized Clinical Trial

IMPORTANCE

The appropriate use of surgery or radiotherapy-based approaches for organ preservation has been the subject of much debate. Unfortunately, there has been a lack of improvement in overall survival for patients with laryngeal carcinoma in the last 30 years.

OBJECTIVE

To assess the rates of laryngeal preservation and laryngectomy-free survival in patients receiving cetuximab and radiotherapy (CRT) and patients receiving radiotherapy alone.

DESIGN, SETTING, AND PARTICIPANTS

Patients were enrolled in a multicenter, open-label, stratified, randomized, phase 3 study from April 1, 1999, through March 31, 2002, from 73 centers in the United States and 14 other countries. A secondary subgroup analysis of patients with hypopharyngeal and laryngeal carcinoma was undertaken. Rates of laryngeal preservation and laryngectomy-free survival were estimated by the Kaplan-Meier method. The hazard ratios (HRs) were calculated using a Cox proportional hazards regression model. Quality of life was evaluated using the European Organization for Research and Treatment of Cancer core questionnaire and head and neck module.

MAIN OUTCOMES AND MEASURES

Laryngeal preservation and laryngectomy-free survival.

RESULTS

Of the 424 patients included in the trial, 168 treated patients with cancer of the larynx or hypopharynx were included in this analysis (90 in the CRT group and 78 in the radiotherapy alone group). The median (range) age of the patients was 59 (40-80) years in the CRT group and 61 (35-81) years in the radiotherapy alone group. In the CRT group, 72 patients (80.0%) were male and 18 (20.0%) were female. In the radiotherapy alone group, 62 (79.5%) were male and 16 (20.5%) were female. The rates of laryngeal preservation at 2 years were 87.9% for CRT vs 85.7% for radiotherapy alone, with an HR of 0.57 (95% CI, 0.23-1.42; P = .22). Similarly, the HR for laryngectomy-free survival comparing CRT vs radiotherapy alone was 0.78 (95% CI, 0.54-1.11; P = .17). This study was not powered to assess organ preservation. Median overall survival was 27 (95% CI, 20-45) vs 21 (95% CI, 17-35) months for the CRT and radiotherapy alone groups, respectively, with an HR of 0.87 (95% CI, 0.60-1.27). No differences between treatments were reported regarding overall quality of life, need for a feeding tube, or speech.

CONCLUSIONS AND RELEVANCE

The results of a possible cetuximab-related laryngeal preservation benefit for patients with hypopharyngeal or laryngeal cancer are intriguing; these results need to be interpreted in the context of a retrospective subset analysis with limited sample size.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00004227.

Potential for low-value palliative care of patients with recurrent head and neck cancer

Curative treatment for patients with advanced head and neck cancer can be associated with many side-effects, and many patients suffer from persistent treatment-related side-effects. Patients with recurrent cancer bear the burden of these effects along with additional symptoms attributed to the recurrent tumour. To better understand the benefits and burden of palliative treatments for patients with recurrent head and neck cancer, we reviewed the evidence on commonly used palliative treatments and their effect on quality of life. When used for palliative care purposes, chemotherapy and radiotherapy have limited effectiveness in improving quality of life. Moreover, if these treatments are not congruent with a patient's end-of-life goals, they could constitute low-value care. We recommend that patients with advanced and recurrent cancer should be offered early, comprehensive palliative and supportive services to maximise benefit. The principles of beneficence and respect for patients in the context of shared decision making must prevail if the trust of this vulnerable patient population is to be honoured.

Informational and Support Needs of Patients with Head and Neck Cancer: Current Status and Emerging Issues

The objective of this article is to review and summarize the extant literature on head and neck cancer (HNC) patients’ informational needs and to characterize emerging issues in this patient population in order to define priorities for future research. HNC patients may undergo challenging treatment regimens and experience treatment-related alterations in primary daily functions such as speech and eating. These changes often persist following treatment and may lead to significant deficits in quality of life and interpersonal relations. Despite empirical evidence demonstrating that receipt of adequate information and support is predictive of improved outcomes post-treatment, relatively limited attention has been paid to the informational and support needs of HNC patients. This review focuses primarily on three topic domains: (1) managing treatment-related side effects; (2) addressing alcohol and tobacco dependence; and (3) informational needs in the areas of human papillomavirus (HPV) and clinical trials. While there is increasing awareness of the rehabilitation and survivorship needs in this patient population, patients note that the impact of treatment on social activities and interactions is under-discussed and of key concern. In addition, there is a significant gap in addressing communication and informational needs of caregivers and family members who are integral for promoting healthy behaviors and self-care post-treatment. Greater integration of programs that address tobacco or alcohol dependency within a comprehensive treatment and support plan may increase patient motivation to seek help and enhance patient success in maintaining long-term abstinence. Finally, emerging patient-provider communication needs, particularly in the context of decision making about clinical trials or surrounding an HPV-related diagnosis, have been noted among both patients and healthcare providers. Future research on the development of novel programs that offer feasible and acceptable methods for addressing unmet informational and support needs is warranted and may yield benefit for improving patient-reported outcomes.

Multidisciplinary team decision-making in cancer and the absent patient: a qualitative study

OBJECTIVE

To critically examine the process of multidisciplinary team (MDT) decision-making with a particular focus on patient involvement.

DESIGN

Ethnographic study using direct non-participant observation of 35 MDT meetings and 37 MDT clinics, informal interviews and formal, semistructured interviews with 20 patients and 9 MDT staff members.

SETTING

Three head and neck cancer centres in the north of England.

PARTICIPANTS

Patients with a diagnosis of new or recurrent head and neck cancer and staff members who attend the head and neck cancer MDT.

RESULTS

Individual members of the MDT often have a clear view of which treatment they consider to be 'best' in any clinical situation. When disagreement occurs, the MDT has to manage how it presents this difference of opinion to the patient. First, this is because the MDT members recognise that the clinician selected to present the treatment choice to the patient may 'frame' their description of the treatment options to fit their own view of best. Second, many MDT members feel that any disagreement and difference of opinion in the MDT meeting should be concealed from the patient. This leads to much of the work of decision-making occurring in the MDT meeting, thus excluding the patient. MDT members seek to counteract this by introducing increasing amounts of information about the patient into the MDT meeting, thus creating an 'evidential patient'. Often, only highly selected or very limited information of this type can be available or known and it can easily be selectively reported in order to steer the discussion in a particular direction.

CONCLUSIONS

The process of MDT decision-making presents significant barriers to effective patient involvement. If patients are to be effectively involved in cancer decision-making, the process of MDT decision-making needs substantial review.

Pulmonary Rehabilitation After Total Laryngectomy: A Multicenter Time-Series Clinical Trial Evaluating the Provox XtraHME in HME-Naïve Patients

BACKGROUND

Both the immediate beneficial physiological changes in a laboratory setting and the long-term clinical outcomes of heat and moisture exchanger (HME) use are well described. So far, there has not been any research published that provides detailed insight in the pattern of changes in both respiratory function and patients' experiences with HMEs in the first weeks of use.

METHODS

A multicenter time-series study design with a 2-week double baseline period. All patients used the XtraHME for 12 weeks afterward. Data were collected 2 weeks, 6 weeks, and 12 weeks after the start of HME use.

RESULTS

Data of 30 patients were analyzed. Pulmonary symptoms decreased significantly during the 12 weeks of HME use. After 2 weeks, a significant decrease in daily coughs and daily forced expectorations was seen. The general quality of life showed a significant increase throughout the study. More general physical complaints also significantly decreased with HME use. Patient satisfaction with the HME was high.

CONCLUSIONS

This study shows that there is a significant influence of the XtraHME on pulmonary status that can already be observed after 2 weeks of using the XtraHME and continues to improve further after 6 weeks of XtraHME use.

Larynx cancer: quality of life and voice after treatment

Introduction

Treatments for patients with laryngeal cancer often have an impact on physical, social, and psychological functions.

Objective

To evaluate quality of life and voice in patients treated for advanced laryngeal cancer through surgery or exclusive chemoradiation.

Methods

Retrospective cohort study with 30 patients free from disease: ten total laryngectomy patients without production of esophageal speech (ES); ten total laryngectomy patients with tracheoesophageal speech (TES), and ten with laryngeal speech. Quality of life was measured by SF-36, Voice-Related Quality of Life (V-RQOL), and Voice Handicap Index (VHI) protocols, applied on the same day.

Results

The SF-36 showed that patients who received exclusive chemoradiotherapy had better quality of life than the TES and ES groups. The V-RQOL showed that the voice-related quality of life was lower in the ES group. In the VHI, the ES group showed higher scores for overall, emotional, functional, and organic VHI.

Discussion

Quality of life and voice in patients treated with chemoradiotherapy was better than in patients treated surgically.

Conclusion

The type of medical treatment used in patients with laryngeal cancer can bring changes in quality of life and voice.

Long-Term Use of Heat and Moisture Exchangers among Laryngectomees: Medical, Social, and Psychological Patterns

Objectives:

After laryngectomy, pulmonary protection is mostly acquired by means of a heat and moisture exchanger (HME) that is placed on an airtight seal around the stoma. The effects of HMEs on the tracheal climate have been well described, and the filtration effect of an HME with an electrostatic filter has been described in vitro. The effects of HME use in patients have been documented in several trials in different countries. The follow-up time of the patients in these trials, however, is limited. Less is known about long-term use of HMEs, and studies describing long-term compliance with HME use are scarce. This study investigated the long-term use of HMEs in laryngectomees.

Methods:

Questionnaires were sent to 195 laryngectomees, and 75 questionnaires were returned.

Results:

More than 85% of the respondents used an HME, of whom 77% were compliant users (ie, use for more than 20 hours per day). The incidence of pulmonary illnesses (either before or after surgery) was about 25%. More than 90% of the respondents were heavy smokers before laryngectomy. One third of the respondents are regularly exposed to dusty environments. Compliant HME users tend to make less use of external humidifiers and vaporizers, and have better pulmonary status and lower health-care costs. Regarding quality of life, patients who use a FreeHands device tended to have more frequent social contacts (r = 0.251; p = 0.030). The prevalence of depression is high, pointing to an urgent need to recognize and treat psychiatric problems such as depression and suicidal ideation in this patient group.

Conclusions:

These findings have implications for any postlaryngectomy research that uses pulmonary parameters.

Decision making in the management of recurrent head and neck cancer

Despite substantial improvements in head and neck squamous cell carcinoma (HNSCC) treatment, the major obstacle to long-term survival remains disease recurrence. Salvage options are often limited due to prior therapy and the escalated morbidity of retreatment. The costs of treatment must be measured against the anticipated quality and quantity of life recovered, even with resectable disease. This review surveys the recurrent HNSCC literature to better guide decision making. Across multiple studies, negative prognostic factors include impaired performance status, advanced recurrent stage, brief disease-free interval, previous chemotherapy, and nonlaryngeal sites of recurrence. When possible, surgical salvage remains the principal option for durable disease control, quality of life preservation, and cure. Nonsurgical therapies have also demonstrated measurable improvements in locoregional control. Interpretation of salvage literature must be tempered by recognition of significant selection bias. The decision for salvage therapy must be individualized, with management that involves well-informed patients resulting in the best outcomes.

Patient satisfaction with the colonoscopy procedure: endoscopists overestimate the importance of adverse physical symptoms

BACKGROUND

Colonoscopy is a frequently performed procedure associated with a substantial burden for the patient. Most of what is known about patient satisfaction stems from surveys that target issues doctors believe to be important. It has been noticed that patients often focus on different aspects.

AIM

To have patients and endoscopists rate the extent to which each of a list of patient-generated issues-of-concern contributes to patient satisfaction with the colonoscopy procedure.

SUBJECTS

A sample of consecutive patients undergoing colonoscopy in a Dutch tertiary teaching hospital and a convenience sample of endoscopists.

METHODS

Colonoscopy patients and endoscopists were asked to rate on a five-point Likert scale the importance of 55 items concerning the colonoscopy procedure for patient satisfaction. Items were derived from focus group sessions with colonoscopy patients. Endoscopists were invited to rate the importance of the same set of items from a patient perspective. An analysis was carried out of whether patients and endoscopists rated the importance of items differently.

RESULTS

69 patients and 34 endoscopists completed the questionnaire. The ratings of the endoscopists were significantly different from those of patients (p<0.0001). Endoscopists underestimated the importance of involving patients in decisions, discussing risks and complications, providing the opportunity for substantive questions and offering a comfortable temperature in the examination room. Endoscopists overestimated the importance of adverse physical symptoms, such as pain and abdominal cramps, and the role of the treating doctor.

CONCLUSIONS

Endoscopists do not have a good perception of the items that contribute most to patient satisfaction with the colonoscopy procedure. Overcoming this gap may be an essential step towards improving patient satisfaction by targeting those concerns most relevant to patients.

[Multimodal laryngeal preservation: current data-based opinion]

This article presents the current data and discussion on multimodal laryngeal preservation strategies in advanced laryngeal/hypopharyngeal carcinoma. Principally a distinction is made between simultaneous and induction chemoradiation protocols. In terms of late toxicity and related functional limitations, induction protocols are far superior to simultaneous platinum-based chemoradiation. Currently, the individual response to the first cycle of (short) induction chemotherapy appears to be the most reliable clinical marker for making treatment decisions, and this is under clinical investigation. No standard multimodal therapeutic alternative to laryngectomy exists; therefore, at this time multimodal strategies should only be carried out within the framework of clinical trials.

Voice-related Quality of Life in Laryngectomees: Assessment Using the VHI and V-RQOL Symptom Scales

The primary purpose of this study was to investigate the effect of the voice impairment across the physical, emotional, and functional domains in patients using valved speech following total laryngectomy with the help of two symptom specific scales. The study design used was a cross-sectional cohort. The setting was the Head and Neck Oncology Unit of a tertiary referral centre. Subjects were 54 patients who had undergone total laryngectomy. Two voice-specific questionnaires, the Voice-Related Quality of Life (V-RQOL-short form) Measure, and the Voice Handicap Index (VHI-long form) were used. The main outcome measure was patient perception of the voice following total laryngectomy in response to specific questions correlated with sociodemographic/treatment factors. Responses were received from 40 males and 14 females (response rate of 85.7%) with a median age of 63.4 years (range: 37-84). The V-RQOL overall analysis showed that 3 patients (5.6%) scored "excellent," 29 patients (53.7%) "fair to good," 14 patients (25.9%) "poor to fair," and 8 patients (14.8%) "poor." Analysis of the VHI revealed that 20 patients (37.0%) had a minimal handicap, 20 patients (37.0%) a moderate handicap, and 14 patients (25.9%) had a serious voice handicap. The individual domain or subscale scores for the VHI revealed a mean (SD) functional score of 15.8 (7.7), a physical score of 13.6 (7.2), and finally an emotional score of 11.6 (8.9). Functional aspects of the voice were significantly affected by age, radiotherapy, and chemotherapy (Spearman rho, P=0.01; Mann-Whitney, P=0.04 and P=0.01). The physical aspects of the voice were significantly affected by age and chemotherapy (Spearman rho, P=0.004; Mann-Whitney, P=0.04). Only age significantly affected the emotional aspects of the voice (Spearman rho, P=0.002). We found a strong correlation (Spearman rho, P<0.001) between the V-RQOL and VHI questionnaires. Our study revealed that the V-RQOL and VHI scores in our series of patients following voice restoration in laryngectomees were consistent with that reported in the literature. Only age, radiation, and chemotherapy were seen to influence the voice handicap scores. In addition, both symptom scales had good correlation between them and either one could be used with reliability in laryngectomees with a few modifications.

Developing core sets for patients with head and neck cancer based on the International Classification of Functioning, Disability and Health (ICF)

Problems in functioning are frequently seen in survivors of head and neck cancer (HNC) and proof to have increasing impact on their quality of life. With the approval of the International Classification of Functioning, Disability and Health (ICF) by the World Health Assembly in May 2001, we can now rely on a globally accepted framework and classification system based on a bio-psycho-social mode to assess and compare functional outcome. To make the ICF-classification with more than 1.400 categories applicable to every-day clinical practice, ICF core sets are established. The objective of this paper is to outline the proposed development process for the ICF core set for HNC and to invite international experts to participate in this process. The ICF core set will be defined at a Consensus conference, which will integrate evidence from preparatory studies, namely: (a) a systematic literature review regarding the outcome measures of clinical trails and observational studies, (b) semi-structured patient interviews, (c) international experts participating in a internet-based survey and (d) cross-sectional, multi-center studies for clinical applicability. To validate the ICF core set field-testing will follow. The ICF provides useful standards of clinical rehabilitation practice, research and teaching. Its application stimulates comparability of outcome parameters, eventually improving understanding of functioning and disability. The ICF can function as a new language, simplifying communication and cooperation between various professional backgrounds and between health professionals and their patients eventually leading to a more effective and economic rehabilitation. The ICF core set for HNC is designed to translate the benefits of the ICF into clinical routine. The development of ICF core sets is an inclusive and open process. Anyone who wishes to actively participate is invited to contact the project coordinator (Uta.Tschiesner@med.uni-muenchen.de). Individuals, institutions and associations can be formally associated as partners of the project.

Generic health-related quality of life amongst patients employing different voice restoration methods following total laryngectomy

Three methods of voice restoration--tracheosophageal speech (TEP), oesophageal speech, electrolarynx--are available following total laryngectomy. TEP produces better voice quality compared with other methods and is assumed to result in better quality of life. Little evidence exists to support the relationship between voice quality and quality of life, however. Advertising this study through several leading laryngectomy charities resulted in the completion of 226 questionnaires (TEP = 147; oesophageal speech = 42; electrolarynx = 37) comprising the Short Form 36 (SF-36) quality of life measure and questions examining perceived voice intelligibility. Additionally, 89 questionnaires comprising only the SF-36 were completed by participants who reported having no serious medical problems, to form a healthy control group. Results indicate that improved voice quality does not result in widespread benefits to quality of life. On only a few dimensions were there differences between voice restoration method: electrolarynx and TEP better than oesophageal speech with respect to pain, TEP better than oesophageal speech with respect to role limitation: physical problems. Additionally whilst widespread differences between voice restoration methods did not occur, all three groups had a worse quality of life compared with the healthy control group. Implications of the results for the selection of voice restoration method to maximize quality of life are discussed.

Quality of Life following Total Laryngectomy: Assessment Using the UW-QOL Scale

OBJECTIVES

To determine the quality of life (QOL) in patients using valved speech following total laryngectomy with a validated patient self-report scale.

STUDY DESIGN

Cross-sectional cohort study.

PATIENTS

63 patients following total laryngectomy using valved speech.

INTERVENTION

University of Washington Quality of Life (UW-QOL) questionnaire.

MAIN OUTCOME MEASURES

Patient perception of the QOL over the last 7 days following total laryngectomy in response to specific questions and correlated with sociodemographic and treatment factors.

RESULTS

Responses were received from 44 males and 11 females (response rate: 87.3%) with a median age of 66 years (range: 40-84). The mean (SD) composite score of the QOL in our series of patients with total laryngectomy was 81.3 (10.9). As regards the overall QOL, 80% of our patients cited it as very good (45.5%) to good (34.5%). Patients identified speech, appearance, and activity as the most important issues following total laryngectomy. Only age and pharyngo-oesophageal segment closure were significant predictors of QOL scores (Student t test, p < 0.05) and not other demographic and treatment variables.

CONCLUSIONS

The composite score and overall QOL were high in our series of total laryngectomy patients and this possibly reflects adequate multidisciplinary management. We strongly urge the use of prospective longitudinal studies that will adequately identify any QOL changes over time. Although the UW-QOL questionnaire is a simple and brief scale, it has limitations that can curtail its effective use in laryngectomy patients and we advise supplementing it with the use of domain-specific questionnaires.

Long-term quality of life after total laryngectomy

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Oncology and quality of life. Study in head and neck cancer]

The principal endpoints in oncology are survival with improvement of quality of life in cancer patients.

OBJECTIVES

To give an accurate account of current literature on quality of life and head and neck cancers.

METHODS

Two keys words are used: "quality of life" and "cancer" enabling to trace articles in Medical and Human Science journals. Analysis and synthesis of these documents.

RESULTS

Quality of life is difficult to evaluate as it is a multidimensional concept with three main symptom domains: physical, psychological and social. Several quality of life evaluation scales have been developed enabling authors to estimate the effects of disease on patients as well as treatment-related symptoms. Reports on quality of life in ENT patients have offered improved knowledge on patient experience and aftereffects, and therapies have been adapted and improved in view of such studies.

CONCLUSION

Quality of life evaluation tools need to be improved. At present, most tools only partially evaluate patient quality of life, concentrating on the global impact of disease and its treatment on patients' physical and psychological condition. The "sociability" of individual patients is rarely evaluated, and the development of qualitative studies in this domain will enable improved understanding of the social factors involved in each patient's adaptability to disease, its treatment and after-effects.

Assessing the quality of life—reality or impossible dream?

Many now claim that maintaining or improving the quality of life is the essence of healthcare (i.e. care and/or treatment that improves the patients' quality of life). Interest in QL, however, stems from increasing recognition that individuals are an integrated whole rather than a series of disconnected parts or disease states. Though this represents a significant change from the past--when the emphasis lay solely on physical or medical condition--it is not, in itself, meaningful unless reliable and valid ways of evaluating the human aspects of the experience can be identified (i.e. quality of life). As quality of life (QL) is seen as a positive state, a desirable outcome of healthcare interventions, it has gained credence as an appropriate outcome measure and has intuitive appeal. Indeed, it is suggested that, because of its close relationship to mortality, self-perceived QL may be the most important outcome of both acute and, particularly, chronic disease. Lack of consensus about its meaning has, however, resulted in ambiguity and, therefore, difficulties in its measurement reflecting, in turn, the difficulty in identifying the components of this multifaceted concept. This paper explores these issues and questions whether we are, in fact, attempting to measure something that cannot truly be measured.

Speech intelligibility and quality of life in head and neck cancer survivors

OBJECTIVE

Poor speech intelligibility adversely affects quality of life self-assessment in long term survivors of head and neck cancer treatment.

STUDY DESIGN

Observational case series including both objective clinical speech testing and subjective quality of life questionnaire administration.

METHODS

Five-year head and neck cancer survivors were recruited to study the association between speech intelligibility and quality of life. Survivors were analyzed as an entire group, and also subdivided into laryngectomees and non-laryngectomees. Objective testing included sentence and word intelligibility. Subjective testing included quality of life questionnaires (UWQOL, FACT, FACT-head and neck, and PSS-HN) and a locally prepared "cancer concern" question. Associations were sought between intelligibility, quality of life and demographics.

RESULTS

Sixty-two survivors underwent testing. Lower sentence intelligibility and word intelligibility scores were associated with diminished self-perceived UWQOL Speech (P = .0001 and P = .0001, respectively) and PSS-HN Understandability of Speech (P = .009 and P = .005). Decreased word intelligibility was additionally associated with decreased UWQOL Chewing (P = .003), UWQOL Swallowing (P = .02), UWQOL Recreation (P = .05), PSS-HN Willingness to Eat in Public (P = .03), and PSS-HN Normalcy of Diet (P = .0001). The associations continued even after patients who had undergone laryngectomy were excluded.

CONCLUSIONS

Long-term survivors of head and neck cancer continue to have both objective and subjective deficits in speech parameters five years after treatment. Objective deficits are associated with subjective concerns about speech, eating, and recreation. Understanding how communication deficits affect quality of life in long-term head and neck cancer survivors may allow more effective therapies to modulate these concerns in the recovery period.

Evaluations of quality of life and organ function

For advanced head and neck cancer (HNC) patients, aggressive radiation and chemoradiation treatments offer new therapy options. The aims of these regimens are increased survival and organ preservation, with the goals of preserving organ function, minimizing late effects, and improving quality of life (QOL). At the same time, the toxicities of these regimens are acknowledged as is the potential for long-term dysfunction. Thus, particularly now, with the increasing use of aggressive chemoradiation therapy (CRT) regimens, documentation of the QOL and functional outcomes of these treatments is critical. The implications for speech and swallowing are widely recognized and the broader effects of these impairments on overall QOL have received some attention. This article presents data on the performance, functional, and QOL results of radiation therapy (RT) and various CRT regimens in HNC.

[Quality of life in patients treated for early laryngeal cancer, in healthy people and in those with other associated pathologies]

Nowadays there are different non aggressive treatment options for early laryngeal cancer. However, they are not free of undesirable effects. We have studied this patients' quality of life, by comparing it with that obtained from healthy population and other illness groups (post-AMI patients, Chronic Kidney patients). We have studied 62 T1-T2NoMo laryngeal carcinoma diagnosed at the "Virgen de la Victoria" clinical hospital from Malaga, Spain, between 1990 and 1998. We used the Quality of Life in Málaga (QLM), general QL questionnaire which was developed and validated at the Department of Preventive Medicine of the University of Málaga, Spain. The results were compared with those obtained from ramdom samples in healthy population from Málaga and from various pathology groups. The global QOL of our patients treated for an early glottic cancer (Index Quality of life 29.4%) was better than almost all the other ones.

Prioritizing treatment outcomes: head and neck cancer patients versus nonpatients

BACKGROUND

Treatment decisions in head and neck cancer (HNC) might involve consideration of uncertain tradeoffs of one late effect against another or increasing toxicity or residual impairment for increased chance of survival. Understanding how patients prioritize potential outcomes, as well as whether these preferences are similar to those of nonpatients, is important to informed decision making and treatment planning.

METHODS

Two hundred forty-seven newly diagnosed HNC patients from nine institutions and 131 nonpatients rank ordered a set of 12 potential treatment outcomes (eg, cure; being able to swallow; normal voice) from highest (1) to lowest (12).

RESULTS

Patients and nonpatients were similar with respect to the three items most frequently ranked in the top three, that is, "being cured of cancer," "living as long as possible," and "having no pain" in that order. In contrast, patients more frequently ranked "cure" (90% vs 80%) and less frequently ranked "no pain" (34% vs 52%) in the top three.

CONCLUSIONS

Survival seems to be of paramount importance to both patient and nonpatient groups, overshadowing associated toxicities and potential dysfunction. At the same time, patients might be more willing than nonpatients to undergo aggressive treatments and endure acute distress in the interest of potential long-term gains (ie, cure or longer survival).

Auditory-perceptual scaling and quality of life in tracheoesophageal speakers

OBJECTIVES/HYPOTHESIS

The purposes of the study were to determine listeners' auditory-perceptual ratings of tracheoesophageal speakers, to determine quality of life in tracheoesophageal speakers, and to determine the potential relationship between listeners' ratings of speech and tracheoesophageal speakers' self-rated quality of life.

STUDY DESIGN

Twenty-eight laryngectomized individuals who used tracheoesophageal speech as their primary mode of communication were studied. Fifteen naïve listeners provided auditory-perceptual ratings.

METHODS

Twenty-eight tracheoesophageal speakers (22 men and 6 women) completed a general information form, in addition to the University of Michigan Head and Neck Quality of Life (HNQOL) instrument; speakers also provided connected speech samples of a standard passage. Fifteen naïve listeners evaluated the tracheoesophageal speech samples for overall speech severity, naturalness, acceptability, and pleasantness using direct magnitude estimation procedures.

RESULTS

Listeners were able to discriminate among tracheoesophageal speech samples relative to the auditory-perceptual dimensions. Male tracheoesophageal speakers were judged as having significantly better, more acceptable, and more pleasant voices than women. Scores on the HNQOL instrument were determined to be higher among the group of tracheoesophageal speakers in the present study than those reported in previous studies. No significant differences were found among men and women for quality of life scores. Quality of life domains and auditory-perceptual judgments of tracheoesophageal speech were moderately correlated.

CONCLUSION

Women who use tracheoesophageal speech may be differentially penalized for dimensions related to voice quality. Limitations in voice did not necessarily translate into worse overall quality of life, indicating that auditory-perceptual evaluation and quality of life questionnaires are evaluating different aspects of function after laryngectomy.

Communication Needs, Methods, and Perceived Voice Quality Following Head and Neck Surgery

Patients with head and neck cancer experience complex and frustrating communication problems after surgery, yet patient communication during the in-hospital postoperative period has received relatively little attention in clinical and research literature. A computerized and hand search of the medical (MEDLINE, Cancerlit), psychological (health and psychosocial instruments), and nursing (CINAHL) literature (1968 to April 2002) produced 10 published studies and 1 clinical case report specifically addressing the communication needs, methods, or perceived voice quality of patients with head and neck cancer during the postoperative period (< or = 12 months after surgery). This review presents a summary and critique of research and related literature on in-hospital postoperative communication with adult patients who have head and neck cancer. Three major themes are addressed: (1) information needs, (2) communication methods and perceived voice quality and (3) quality-of-life perceptions related to communication, disfigurement, and socialization. This review shows that the communication needs, communication methods, and perception of voice quality among patients with head and neck cancer have been ignored during the in-hospital period. Clinical issues and technological advancements in augmentative and alternative communication applicable to the in-hospital period are discussed, and research implications are presented.

Communication Needs, Methods, and Perceived Voice Quality Following Head and Neck Surgery

Patients with head and neck cancer experience complex and frustrating communication problems after surgery, yet patient communication during the in-hospital postoperative period has received relatively little attention in clinical and research literature. A computerized and hand search of the medical (MEDLINE, Cancerlit), psychological (health and psychosocial instruments), and nursing (CINAHL) literature (1968 to August, 2001) produced 10 published studies and 1 clinical case report specifically addressing the communication needs, methods, or perceived voice quality of patients with head and neck cancer during the postoperative period (3 days to 19 months). This review presents a summary and critique of research and related literature on in-hospital postoperative communication with adult patients who have head and neck cancer. Four major themes are addressed: 1) information needs, 2) communication methods and perceived voice quality, 3) adjustment and adaptation to communication impairment, and 4) quality-of-life perceptions related to communication and socialization. This review shows that the communication needs, communication methods, and perception of voice quality among patients with head and neck cancer have been ignored during the in-hospital period. Clinical issues and technological advancements in augmentative and alternative communication applicable to the in-hospital period are discussed, and research implications are presented.