Health-Related Quality of Life in Patients With Laryngeal Cancer: A Post-Treatment Comparison of Different Modes of Communication

Effect of Augmentative Technology on Communication and Quality of Life After Tracheostomy or Total Laryngectomy

OBJECTIVE

Surgical procedures that render patients acutely aphonic can cause them to experience significant anxiety and distress. We queried patient perceptions after tracheostomy or laryngectomy and investigated whether introducing augmentative technology was associated with improvement in patient-reported outcomes.

METHODS

Participants included hospitalized patients who acutely lost the ability to speak due to tracheostomy or total laryngectomy from April 2018 to December 2019. We distributed questions regarding the patient communication experience and relevant questions from the validated V-RQOL questionnaire (Voice-Related Quality of Life). Patients were offered a tablet with the electronic communication application Verbally. Pre- and postintervention groups were compared with chi-square analyses.

RESULTS

Surveys were completed by 35 patients (n = 18, preintervention; n = 17, postintervention). Prior to using augmentative technology, 89% of patients who were aphonic reported difficulty communicating, specifically noting breathing or suctioning (56%), treatment and discharge plans (78%), or immediate needs, such as pain and using the bathroom (39%). Communication difficulties caused anxiety (55%), depression (44%), or frustration (62%), and 92% of patients were interested in using an electronic communication device. Patients reported less trouble communicating after the intervention versus before (53% vs 89%, P = .03), including less difficulty communicating about treatment or discharge plans (35% vs 78%, P < .01). V-RQOL scores were unchanged.

DISCUSSION

Acute loss of phonation arising from surgery can be highly distressing for patients, and use of augmentative technology may alleviate some of these challenges by improving communication. Further studies are needed to identify what additional strategies may improve overall well-being.

IMPLICATIONS FOR PRACTICE

Electronic communication devices may benefit patients with acute aphonia.

Comprehensive Evaluation of Vocal Outcomes and Quality of Life after Total Laryngectomy and Voice Restoration with J-Flap and Tracheoesophageal Puncture

Simple Summary

Laryngopharyngectomy is still the treatment of choice in locally advanced pharyngolaryngeal tumors not eligible for organ preservation protocols. Loss of speech capacity has been reported as one of the factors that most affect the patient-reported quality of life. Thus, the reconstructive goals are restoring the pharynx and possibly the voice in such a scenario. For decades, tracheoesophageal puncture (TEP) has allowed proper voice rehabilitation; however, TEP has a non-neglectable financial expenditure and complication rate. Therefore, we recently reported a novel flap design and surgical technique that shares the same principles of TEP, without the need to change any device over time, named J-flap. This study aimed to analyze both techniques’ subjective and objective vocal outcomes and their impact on overall and voice-related quality of life.

Abstract

Background: Tracheoesophageal puncture with a voice prosthesis is the gold standard for speech rehabilitation in patients that receive a laryngopharyngectomy. However, a novel surgical technique, using a tubularized anterolateral tight flap, named “J-flap,” has been demonstrated to produce adequate voice restoration. We aimed to compare the outcomes and the quality of life of patients who underwent voice rehabilitation with both techniques. Methods: We enrolled patients that underwent laryngopharyngectomy and voice restoration surgery. The control group received a tracheoesophageal puncture with a voice prosthesis, while the study group received J-flap reconstruction. A total of 20 patients received voice prosthesis rehabilitation, while 18 received J-flap reconstruction. Speech and vocal outcomes and quality of life metrics were collected. Results: The objective phonatory performances and the acoustic voice analysis did not outline a significant difference. Speech pathologists judged the consonant pronunciation in the J-flap group as less accurate (p < 0.001). The voice handicap index revealed a moderate impairment for the J-flap group (p < 0.001). Quality of life scores were higher for the voice prosthesis group. Conclusion: Voice prostheses and J-flaps share similar objective phonatory outcomes. Quality of life was more impaired in the J-flap group. In our view, these two techniques possess complementary characteristics in clinical practice, taking into account health care system regulations and patients’ social background.

Speech restoration with tracheoesophageal prosthesis after total laryngectomy: An observational study of vocal results, complications and quality of life

OBJECTIVES

To study voice prosthesis survival, complications, efficacy and impact on quality of life.

METHODS

A single-center observational study was performed in patients treated for squamous cell carcinoma of the larynx or hypopharynx by total (pharyngo)-laryngectomy between 2010 and 2015. Study data comprised: maximum phonation time (sec), number of and reasons for prosthesis exchanges (leakage through or around the prosthesis, expulsion or inclusion of the prosthesis), plus 2 quality of life questionnaires (QLQ-C30, QLQ-H&N35) and the Voice Handicap Inventory (VHI 30).

RESULTS

Forty-nine patients were included. The most common causes of prosthesis exchange were leakage through (73.2%) or around the prosthesis (18.5%). The median time between exchanges was 4 months. Global quality of life status on the QLQ-C30 was 63.5. Mean maximum phonation time was 7.4sec. Mean VHI was 46/120; 10 patients had a mild voice handicap, 12 moderate and 10 severe. No relation emerged between the number of prosthesis exchanges per year and quality of life. Voice handicap significantly decreased quality of life, with QLQ-C30 72.3 for the 22 patients with mild to moderate voice handicap and 44.2 for the 10 patients with severe voice handicap (P=0.001).

CONCLUSION

Voice restoration by tracheoesophageal prosthesis after total (pharyngo)-laryngectomy is a reliable technique that decreases voice handicap and, despite potentially serious complications, has little negative impact on quality of life.

Voice Rehabilitation After Laryngectomy: A Regional Cancer Centre Experience and Review of Literature

Alaryngeal speech in laryngectomees has revolutionized the patient outlook toward the morbid procedure and the concept of permanent stoma unlike olden era when stigma of stoma with loss of voice was rampant. To analyse acceptance of voice rehabilitation options and their success and management of complications in a tertiary care centre. All patients who underwent laryngectomy from August 2014 to 2018 June at our institution were included in the study. The voice rehabilitation options like oesophageal speech, tracheao-oesophageal puncture and voice prosthesis insertion (TEP), and electrolarynx were explained to the patients. The options put forward to the patients, the importance of Taub test, Interval between treatment and secondary TEP insertion, life span of the prosthesis, Patients acceptance and success rates and the troubleshooting were noted. A total of 96 patients underwent total laryngectomy, 72 patients were willing for rehabilitation. 15% (11) patients had primary TEP, 22% (16) had secondary TEP insertion, esophageal speech in 36% (26) patients and 27% (19) patients opted for the electrolarynx. The rest 24 patients were not keen on any further interventions after laryngectomy. Speech rehabilitation is an integral part in surgical management of carcinoma of the larynx. Alaryngeal speech in laryngectomees have revolutionized the patient outlook towards the morbid procedure. Esophageal speech is the least successful method of rehabilitation but still the cheapest method and requires a lot of motivation. Primary and Secondary TEP insertions have similar success rates. Successful treatment for cancer of larynx ends with successful voice rehabilitation.

Complications associated with tracheoesophageal voice prostheses from 2010 to 2020: A MAUDE study

PURPOSE

Tracheoesophageal puncture with voice prosthesis placement remains the gold standard for voice restoration following total laryngectomy, but may cause various complications. This study aims to summarize patient-related and device-related adverse events associated with tracheoesophageal puncture and voice prosthesis placement.

MATERIALS AND METHODS

The U.S. Food and Drug Administration's Manufacturer and User Facility Device Experience database was queried for reports of adverse events related to tracheoesophageal puncture with voice prosthesis placement from January 1, 2010, to April 30, 2020. Data were extracted from reports pertaining to tracheoesophageal prostheses.

RESULTS

Seventy-seven reports involving tracheoesophageal voice prostheses were identified, from which 111 adverse events were extracted. Of these, 58 (52.3%) were patient-related, while 53 (47.7%) were device-related. The most frequently reported patient-related adverse events were aspirated prosthesis (24 [41.4%]), foreign body during placement (11 [19.0%]), aspiration pneumonia (9 [15.5%]), and aspirated brush tip (8 [13.8%]). The most common device-related adverse events were detached brush tip (15 [28.3%]), leak (14 [26.4%]), and torn esophageal flange (11 [20.8%]).

CONCLUSIONS

While tracheoesophageal puncture with voice prosthesis placement has revolutionized voice rehabilitation following total laryngectomy, the procedure may be associated with adverse events both at the time of placement and later. Interventions aimed at improving both physician and patient education may help reduce adverse events attributed to improper use. Further research is needed to clarify optimal approaches to education.

The electrolarynx: voice restoration after total laryngectomy

The ability to speak and communicate with one’s voice is a unique human characteristic and is fundamental to many activities of daily living, such as talking on the phone and speaking to loved ones. When the larynx is removed during a total laryngectomy (TL), loss of voice can lead to a devastating decrease in a patient’s quality of life, and precipitate significant frustration over their inability to communicate with others effectively. Over the past 50 years there have been many advances in techniques of voice restoration after TL. Currently, there are three main methods of voice restoration: the electrolarynx, esophageal speech, and tracheoesophageal speech through a tracheoesophageal puncture (TEP) with voice prosthesis. Although TEP voice is the current gold standard for vocal rehabilitation, a significant minority of patients cannot use or obtain TEP speech for various reasons. As such, the electrolarynx is a viable and useful alternative for these patients. This article will focus on voice restoration using an electrolarynx with the following objectives: 1) To provide an understanding of the importance of voice restoration after total laryngectomy. 2) To discuss how the electrolarynx may be used to restore voice following total laryngectomy. 3) To outline some of the current electrolarynx devices available, including their mechanism of action and limitations. 4) To compare pros and cons of electrolaryngeal speech to TEP and esophageal speech.

An update on larynx cancer

Answer questions and earn CME/CNE Laryngeal cancer remains one of the most common tumors of the respiratory tract. Fortunately, significant advancements have been made over the past decade in the treatment of laryngeal cancer. Although surgery has been the historical mainstay for localized disease and still is an integral part of treatment, nonsurgical options like radiation and systemic therapy have emerged as viable options. In addition, in the metastatic setting, novel agents are showing promise for this patient population. The care for patients with laryngeal cancer continues to evolve and truly requires a multidisciplinary team-based approach. Unique morbidities, such as loss of natural voice, respiration, and airway protection during swallowing, are observed with this disease and require special consideration. CA Cancer J Clin 2017;67:31-50. © 2016 American Cancer Society.

Comparison of quality of life outcomes in laryngeal cancer patients following chemoradiation vs. total laryngectomy

OBJECTIVE: To evaluate quality of life issues in patients with laryngeal cancer after treatment with either chemoradiation or total laryngectomy and radiation therapy.

METHODS: Forty-nine patients with a history of stage II-IV laryngeal squamous cell carcinoma treated primarily with either chemoradiation or by total laryngectomy with postoperative radiation completed the University of Washington Quality of Life instrument, version 4. Patients were identified on a volunteer basis in an academic university head and neck clinic setting. Each patient completed the above instrument, and statistical analysis was performed by Wilcoxon and X 2 , tests.

RESULTS: Instruments were completed by all 49 patients: 15 patients who underwent primary chemoradiation and 34 patients who underwent a total laryngectomy followed by radiation. Domains reported in both treatment groups without significant differences were appearance, activity, recreation, moods, taste, saliva, anxiety, and general questions. However, there were significant differences between the 2 groups in the domains of pain, swallowing, chewing, speech, and shoulder function. The laryngectomy patients reported greater impairment of speech ( P = 0.001), and shoulder function ( P = 0.018), whereas the chemoradiation patients suffered from greater pain, difficulty swallowing ( P = 0.061), and problems chewing ( P = 0.027).

CONCLUSIONS: Most patients with laryngeal cancer, whether treated primarily with chemoradiation or total laryngectomy, reported excellent functional outcomes and health-related quality of life. Pain, swallowing, chewing, saliva, and shoulder function were recorded as significant factors affecting their daily quality of life.

Comparison of Oncological and Functional Outcomes between Initial Surgical versus Non-Surgical Treatments for Hypopharyngeal Cancer

BACKGROUND

Whether to administer surgical or non-surgical treatments (radiation or chemoradiation therapies) for the initial management of hypopharyngeal cancer (HPC) remains a topic of debate. Herein, we explored the differences between the two approaches in terms of oncological and functional outcomes in 332 HPC patients.

METHODS

The primary endpoint was survival probability; secondary outcomes included post-treatment speech and swallowing functions and necessity of additional surgical procedures for salvage or complication management. Cox proportional hazard models using clinical variables were constructed to identify significant factors.

RESULTS

The 2- and 5-year overall survival (OS) rates in all patients were 64.9 and 40.9 %, respectively. In early-stage HPC patients (N = 52), initial surgery ± radiation therapy (RT) or RT alone yielded similar oncological (60 % 5-year OS rate) and functional outcomes. As for resectable advanced-stage cancers (N = 177), initial surgery ± RT/chemoradiation therapy (SRC) and initial concurrent chemoradiation therapy (iCRT) resulted in similar 45-50 % 5-year OS rates. After sacrificing the larynx, 60 % of SRC patients recovered their speaking ability through voice prosthesis, which was less than the rate for iCRT patients (76.6 %; p = 0.008). Additional surgical interventions were required in 28.0-28.6 % of patients in both groups; however, 60 % of patients undergoing additional surgery in the iCRT group received multiple (two or more) surgical interventions (p = 0.029).

CONCLUSIONS

Our data revealed similar oncological outcomes, but different functional outcomes, between initial surgical and non-surgical treatments for HPC. In resectable advanced-stage HPC, iCRT resulted in better verbal communication outcomes than SRC; however, more iCRT patients required multiple surgical interventions during clinical courses.

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.

Practice of laryngectomy rehabilitation interventions: a perspective from South America

PURPOSE OF REVIEW

Treatment of laryngeal cancer will depend on several factors, including tumor factors, patient factors, as well as the technical resource and expertise of the surgical team and treatment center. In developing countries, most patients have their diagnosis performed at advanced stages, with a significant proportion at very advanced locoregionally, which results in a limitation to the use of organ-preserving approaches. A total laryngectomy is still the most frequent treatment for larynx cancer patients. The rehabilitation in such scenarios can be more demanding and can cost more compared with developed countries.

RECENT FINDINGS

For early-stage tumors, function-preserving strategies are mandatory, and can include partial laryngectomies and radiation therapy. In such cases, functional rehabilitation usually is easily achieved, with lower negative impact on the patient's daily life. For advanced tumor stages, a treatment shift toward a more conservative management has been observed. However, the success rates of organ-preserving strategies, mainly with chemoradiation approaches, will rely on a rigorous patient selection process.

SUMMARY

The rehabilitation of laryngectomy patients in developing countries can be more demanding and can cost more compared with developed countries. In such scenarios, some strategies can be employed by the multidisciplinary team, mainly by the surgical and speech-pathology teams, aiming to decrease the costs involved in the rehabilitation of total laryngectomy patients in developing countries.

Survival outcome depending on different treatment strategies in advanced stages III and IV laryngeal cancers: an audit of data from two European centres

In light of continued uncertainty regarding efficacy of treatment of Stages III and IV laryngeal tumours, this study aims to evaluate organ-preservation strategies, comprising radiotherapy and chemoradiotherapy versus surgical treatment (laryngectomy ± adjuvant treatment) by encompassing the long-established practice at two internationally acclaimed tertiary centres not previously presented in published literature. Retrospective review was conducted of non-randomised prospectively maintained Stages III and IV disease patient databases at two tertiary centres: Sahlgrenska University Hospital (SU) in Gothenburg, Sweden, and Aberdeen Royal Infirmary (ARI) in Aberdeen, Scotland. Primary outcome measures included 3-year overall, disease-specific survival and local control depending on treatment. A total of 176 patients were identified. Sixty-five patients (37 %) presented with Stage III tumours, of which 51 patients received organ-preserving treatment and 14 underwent total laryngectomy. The corresponding figures for the 111 patients (63 %) presenting with Stage IV disease were 42 and 69. Three-year overall and disease-specific survival for Stage III was 58 and 73 %, respectively. The corresponding figures for Stage IV disease were 42 and 53 %. The choice of treatment did not appear to significantly influence survival for Stage III (p = 0.56) or IV (p = 0.93) disease. The choice of treatment, whether organ preservation or surgery, does not seem to significantly influence the overall or disease-specific survival. Therefore, other factors such as quality of life and voice and efficacy of salvage treatments are perhaps more likely to indicate the preferred treatment options, but larger randomised trials are needed.

Does Prosthesis Diameter Matter?

Objective. To assess the impact of tracheoesophageal voice prosthesis diameter and treatment status on prosthesis-related complications.

Study Design. Historical cohort study.

Setting. Single academic medical institution.

Subjects and Methods. Patients who underwent total laryngectomy (TL) between 1996 and 2008 were divided into 2 subgroups according to prosthesis diameter: 16F (n = 19) and 20/22F (n = 71). Each patient only used 1 diameter of prosthesis. Time to leakage through the prosthesis, number of episodes of leakage around the prosthesis, number of prosthesis dislodgements, and length changes after the first 6 months were chosen as outcomes of interest.

Results. Analysis included 90 patients. Analysis of selected complications by prosthesis diameter revealed no significant differences for time to leakage through the prosthesis, number of leaks around the prosthesis, or dislodgement. Larger diameter prosthesis use was associated with a greater number of length changes ( P = .008). Multivariable regression analysis did not find any significant association between prosthesis-specific complications and prosthesis diameter when controlling for other variables. Prior radiation was associated with an increased number of size changes (β = 2.0, P = .004) and a decrease in time to leakage through the prosthesis (β = −4.4, P = .048), after controlling for other variables.

Conclusions. Prosthesis diameter is not associated with an increased prevalence of certain voice prosthesis complications in laryngectomy patients, regardless of initial treatment modality, whereas prior radiation or chemoradiation is associated with complications. These data suggest that factors affecting tissue health, rather than prosthesis size, may be more responsible for prosthesis complications.

How we do it: Secondary tracheoesophageal puncture under local anaesthetic, using a trans-nasal flexible laryngo-oesophagoscope (TNFLO)

We describe our technique for the formation of a secondary tracheoesophageal puncture and insertion of a voice prosthesis under local anaesthetic in the out-patient department. We use a trans-nasal flexible laryngo-oesophagoscope (TNFLO) to provide direct visualization of the procedure allowing early detection and rectification of any problems that might arise.

Neck and face surface electromyography for prosthetic voice control after total laryngectomy

The electrolarynx (EL) is a common rehabilitative speech aid for individuals who have undergone total laryngectomy, but they typically lack pitch control and require the exclusive use of one hand. The viability of using neck and face surface electromyography (sEMG) to control the onset, offset, and pitch of an EMG-controlled EL (EMG-EL) was studied. Eight individuals who had undergone total laryngectomy produced serial and running speech using a typical handheld EL and the EMG-EL while attending to real-time visual sEMG biofeedback. Running speech tokens produced with the EMG-EL were examined for naturalness by 10 listeners relative to those produced with a typical EL using a visual analog scale. Serial speech performance was assessed as the percentage of words that were fully voiced and pauses that were successfully produced. Results of the visual analog scale assessment indicated that individuals were able to use the EMG-EL without training to produce running speech perceived as natural as that produced with a typical handheld EL. All participants were able to produce running and serial speech with the EMG-EL controlled by sEMG from multiple recording locations, with the superior ventral neck or submental surface locations providing at least one of the two best control locations.

The effectiveness of voice rehabilitation on vocalization in post-laryngectomy patients: a systematic review

BACKGROUND

Laryngeal cancer is one of the most common malignant neoplasia of the head and neck. Its incidence has been increasing steadily all over the world. Many patients will undergo total laryngectomy with or without radical neck dissection after being diagnosed. After this surgery, normal speech is lost, and a permanent stoma in the middle of the neck is left. Therefore, voice rehabilitation is one of the most difficult challenges that these patients must overcome. In order to support the patients, otolaryngologists, nursing specialists and speech pathologists have explored several different methods for voice rehabilitation. Variations exist on the approaches of rehabilitation and indicators selected to measure the effectiveness. There is a need to undertake a systematic review to ascertain the effectiveness regarding different voice rehabilitation programs for post-laryngectomy patients.

REVIEW OBJECTIVE

To critically analyse the literature and present the best available evidence related to the effectiveness of voice rehabilitation program on post-laryngectomy patients.

SEARCH STRATEGY

A three-step search strategy was utilised. An initial limited search of MEDLINE and CINAHL databases was undertaken followed by an analysis of the text words contained in the title and abstract to identify the optimal index terms. A second extensive search using all identified keywords and index terms was then undertaken. Thirdly, the reference list and bibliographies of all identified reports and articles were searched for additional studies. The measurement index included voice intelligibility, volume, clarity, quality of voice, patients' satisfaction, quality of life, etc. The search included reports in English and Chinese.

SELECTION CRITERIA

The review considered any randomised controlled trials (RCT) that addressed voice rehabilitation methods in post-laryngectomy patients. In the absence of RCTs, other quantitative research designs, such as non-randomized controlled trials, cohort studies, and case-controlled studies were considered for inclusion.

DATA COLLECTION AND ANALYSIS

Full copies of articles considered to meet the inclusion criteria were obtained for critical appraisal by two reviewers using the CASP (Critical Appraisal Skills Program) and McMaster scales. We utilised the 60% fulfilling of the evaluation scale items as the cut off point and articles with a quality score less than 60% were excluded. Details of eligible trials were extracted and summarised by two reviewers independently using standardised data extraction tools developed by the Joanna Briggs Institute.

RESULTS

Two hundred and four papers in English and 11 papers in Chinese were initially selected and reviewed for inclusion through the titles and abstracts. Sixty-nine full reports of these papers were then retrieved. Twenty-two articles were included for the critical appraisal. Different voice rehabilitation methods for laryngectomees were investigated in the included studies including esophageal voice, electrolaryngx voice and surgical voice restoration. One cohort study, 5 prospective studies, 5 retrospective studies and 11 descriptive studies were included. Due to the heterogeneity of included studies, meta-analysis was not possible. Therefore, the results were presented in narrative summary. The following main findings were identified:˙ At present, ES (esophageal speech), EL (electrolarynx), and TEP (tracheoesophageal) were the commonly used voice rehabilitation methods with TL (total laryngectomy) patients.˙ Among these three methods, the success rate of EL and TEP is much higher than ES.˙ The intelligibility and speech quality of EL was lower than TEP.˙ Patient satisfaction and self-assessed quality of life was better in TEP group.˙ The objective index was similar between excellent TEP and ES patients.

CONCLUSION

EL is the easiest vocal rehabilitation method for TL patients to use as it requires little training and does not limit the patients. But patients' satisfaction was lower, due to the mechanical voice and noise. ES is the hardest vocal rehabilitation method to learn. It needs a long period of time to practice and requires the patient to be in good physical condition and to be relative young. The success rate was relatively lower, however it is the most commonly used rehabilitation method in developing countries due to low cost. TEP is the most commonly used voice rehabilitation method in developed countries. It is a surgical method that could be performed as either a primary procedure or secondary procedure. Reported patient quality of life and satisfaction following TEP were the best, however there are complications and the frequent replacement of the prostheses is an important problem yet to be solved.

IMPLICATION FOR PRACTICE

The health care workers should understand the advantages, disadvantages and impact of each voice rehabilitation method in detail. So that they are able to help laryngectomees decide on the most appropriate method according to their age, sex, physical condition, job, economic status, and so on.

IMPLICATION FOR RESEARCH

Further high quality comparative studies of the effectiveness among ES, EL and TEP vocal rehabilitation methods are needed, especially when used concurrently with the subjective and objective outcome indexes. Decreasing the complications of TEP and how to improve the life-duration of TEP requires further investigation. More research should be conducted into patients living in developing countries where health care resources may be limited.

Voice outcomes after radiotherapy treatment for early glottic cancer: assessment using multidimensional tools

BACKGROUND

This is the first prospective study to use instrumental and both clinician- and client-rated auditory-perceptual measures to examine voice and voice-related quality of life changes in patients after curative radiotherapy for early glottic cancer.

METHOD

Thirty patients undergoing curative radiotherapy treatment for early glottic cancer completed the following: 3 voice tasks for acoustic, aerodynamic, and auditory-perceptual voice measures (therapist-rated); a patient self-report rating of voice quality; and a voice-related quality of life assessment before and 12 months after radiotherapy.

RESULTS

Patients' perceptions of their voice quality and their voice-related quality of life significantly improved posttreatment, as did acoustic, aerodynamic, and auditory-perceptual voice measures. Mean speaking fundamental frequency did not change significantly, although breathiness and strain in the voice recordings were demonstrably reduced.

CONCLUSION

In describing postradiotherapy voices in this study, pertinent measures of voice outcomes have been established, setting the benchmark for comparison in future cohort studies.

Quality of life scores predict survival among patients with head and neck cancer

PURPOSE

The purpose of this study was to examine whether quality of life (QOL) scores predict survival among patients with head and neck cancer, controlling for demographic, health behavior, and clinical variables.

PATIENTS AND METHODS

A self-administered questionnaire was given to 495 patients being treated for head and neck cancer while they were waiting to be seen for a clinic appointment. Data collected from the survey included demographics, health behaviors, and QOL as measured by Short Form-36 (SF-36) physical and mental component scores and the Head and Neck QOL scores. Clinical measures were collected by chart abstraction. Kaplan-Meier plots and univariate and multivariate Cox proportional hazards models were used to determine the association between QOL scores and survival time.

RESULTS

After controlling for age, time since diagnosis, marital status, education, tumor site and stage, comorbidities, and smoking, the SF-36 physical component score and three of the four Head and Neck QOL scales (pain, eating, and speech domains) were associated with survival. Controlling for the same variables, the SF-36 mental component score and the emotional domain of the Head and Neck QOL were not associated with survival.

CONCLUSION

QOL instruments may be valuable screening tools to identify patients who are at high risk for poor survival. Those with low QOL scores could be followed more closely, with the potential to identify recurrence earlier and perform salvage treatments, thereby possibly improving survival for this group of patients.

Voice restoration following total laryngectomy by tracheoesophageal prosthesis: effect on patients' quality of life and voice handicap in Jordan

Background

Little has been reported about the impact of tracheoesophageal (TE) speech on individuals in the Middle East where the procedure has been gaining in popularity. After total laryngectomy, individuals in Europe and North America have rated their quality of life as being lower than non-laryngectomized individuals. The purpose of this study was to evaluate changes in quality of life and degree of voice handicap reported by laryngectomized speakers from Jordan before and after establishment of TE speech.

Methods

Twelve male Jordanian laryngectomees completed the University of Michigan Head & Neck Quality of Life instrument and the Voice Handicap Index pre- and post-TE puncture.

Results

All subjects showed significant improvements in their quality of life following successful prosthetic voice restoration. In addition, voice handicap scores were significantly reduced from pre- to post-TE puncture.

Conclusion

Tracheoesophageal speech significantly improved the quality of life and limited the voice handicap imposed by total laryngectomy. This method of voice restoration has been used for a number of years in other countries and now appears to be a viable alternative within Jordan.

Long-term quality of life after total laryngectomy and postoperative radiotherapy versus concurrent chemoradiotherapy for laryngeal preservation

OBJECTIVE

To compare the quality of life (QoL) of patients who underwent total laryngectomy with voice prosthesis insertion and postoperative radiotherapy (PORT) with those receiving concurrent chemoradiation for laryngeal preservation.

STUDY DESIGN

Retrospective, cross-sectional study in a tertiary academic center.

METHODS

The European Organization for Research and Treatment of Cancer Quality of Life Questionnaires were used to assess long-term QoL in 67 patients treated for laryngeal cancer.

RESULTS

The scores of functional scales for physical (P < .000), social (P = .001), and role functioning (P = .043) were more favorable in the chemoradiation group. The global QoL score was higher in the nonsurgical group (P = .016). Surgical patients reported on sleep disturbance (P < .000), dyspnea (P = .001), and pain (P = .003), with a higher scores and greater difficulties with the senses (P < .000), social contact (P = .002) and speech (P = .010). The chemoradiation group reported greater problems with dry mouth (P < .000) and sticky saliva (P = .005).

CONCLUSION

We found better long-term QoL scores in patients undergoing concurrent chemoradiation. This appears to be mainly because of better physical functioning, social functioning, and social contact and smaller problems with pain, respiration, speech, the senses, and sleep disturbances.

Psychiatric morbidity among patients with cancer of the esophagus or the gastro-esophageal junction: a prospective, longitudinal evaluation

Cancer of the esophagus is often diagnosed at a late stage and is related to severe morbidity and a low 5-year survival rate. Previous studies have reported low health-related quality of life and high suicide rates for these patients. The occurrence of psychiatric morbidity and thus the potential need for psychological support may vary over time after diagnosis. This has not been adequately studied in patients with newly diagnosed cancer of the esophagus or gastro-esophageal junction. The present study therefore aimed to prospectively evaluate the prevalence of psychiatric morbidity in 94 consecutive patients (median age 66, range 45-88 years) with all stages of disease. Psychiatric morbidity was evaluated with the Hospital Anxiety and Depression Scale (HADS) questionnaire at inclusion and 1, 2, 3, 6 and 12 months later. At inclusion, 42% of the patients had HADS scores indicating possible or probable anxiety disorder and/or depression. At all follow-ups except at 3 months, proportions of patients with possible/probable anxiety disorder were significantly lower than at inclusion. Among patients with a duration of tumor-specific symptoms exceeding 6 months pre-diagnosis, larger proportions of patients with a possible/probable anxiety disorder were found at the 1- and 6-month follow ups. The prevalence of possible/probable depression was greater among patients treated with a palliative intent than among those with a curative intent at inclusion. Patients who died during the study period scored worse for depression compared to the survivors. Apart from this, the proportion of patients with possible/probable psychiatric morbidity (anxiety and/or depression) was relatively stable over time and was unrelated to patient characteristics or clinical background, including the treatment regime. In conclusion, psychiatric morbidity is common among esophageal cancer patients, both at inclusion and over time, regardless of the cancer therapy given. The findings stress the importance of monitoring the patients' mental health and of offering adequate psychological care when needed.

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.

Is there a difference in quality of life, comparing summer and winter, in patients who have undergone total laryngectomy?

Introduction:

Several studies have implied that patients' quality of life stabilises six months after undergoing total laryngectomy. However, these studies may well have overlooked persistent short term variations in patients' quality of life. The aim of this study was to assess the impact of seasonal change (i.e. summervswinter) on the quality of life of patients following total laryngectomy.

Methods:

A prospective, cross-sectional study of recurrence-free laryngectomy patients was performed, using the European Organization for Research and Treatment of Cancer (version three) QLQ-C30 questionnaires (EORTC QLQ-C30), during January 2004 (i.e. winter), August 2004 (summer) and January 2005 (winter).

Results:

Thirty-six patients were entered into the study. The response rate was 70.3 per cent. Patient's time elapsed since surgery varied from six months to 12 years. In all questionnaire domains, responses seemed remarkably consistent over time.

Conclusion:

No statistically significant differences were found between summer and winter scores in all the domains analysed by the EORTC QLQ-C30.

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.

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.

Physical and psychosocial correlates of head and neck cancer: an update of the literature and challenges for the future (1996-2003)

An update of the literature on physical and psychosocial aspects of head and neck cancer, with special emphasis on effects of treatment, patient-related factors and psychosocial intervention on quality of life (QoL). QoL deteriorates during and directly after treatment and returns only slowly to pre-treatment values. Organ preservation, gender and coping-strategies are factors related to QoL after treatment. As prognosis and survival were found to be comparable under different treatment regimes, we noticed a gradual shift in therapy towards organ preservation. Systematic care, using specific instruments is important for improving the QoL. We feel that more attention should be given to improving support, in order to optimize the QoL of patients during the palliative stage.

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.

[The analysis of the quality of life in laryngectomized patients]

Total laryngectomy, as extremely mutilating surgical intervention, results in drastic changes of the style and quality of life. The trauma of laryngectomy is huge, both to patients and their environment. The most pronounced changes of the quality of life of laryngectomized patients are seen at marital, familial, professional, business and communication aspects. Malignant disease and total laryngectomy significantly reduce working capacity, producing, besides professional, the economical difficulties. Psychological implications associated with total laryngectomy are the most severe, comprehensive ones and require multidisciplinary approach. The study analyzes the frequency and distribution of factors affecting the quality of life of laryngectomized patients (sex, age, psychic status, probable history of chronic diseases, impairment of hearing and social-family environment of patients). Significant improvement of the quality of life of laryngectomized patients is achieved by systemic, planned and multidisciplinary rehabilitation of patients as well as their immediate environment. The need for the association of laryngectomized patients is stressed.

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.

Current indications and complications of tracheoesophageal puncture for voice restoration after laryngectomy

Surgical voice restoration by valved tracheoesophageal fistula is undoubtedly the most successful method of voice restoration for laryngectomy patients, is one of the most important developments in head and neck surgery, and has resulted in a greatly enhanced quality of life for most patients who have undergone this debilitating procedure. In developed countries, it is now unacceptable to perform laryngectomy without giving patients the opportunity to undergo surgical voice restoration. Successful voice acquisition should be achievable in approximately 80% of patients. Success rates will be highest and problems most effectively dealt with under the auspices of a properly organized surgical voice restoration program within a specialist head and neck cancer unit with a well structured specialist multidisciplinary team. This article reviews recent publications addressing indications for surgical voice restoration by tracheoesophageal puncture, expected success rates, and reasons for failure and complications and ways to manage them in the context of the author's own experience.