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Keywords:

  • Chemoradiation;
  • advanced head and neck carcinoma;
  • quality of life;
  • survival

Abstract

  1. Top of page
  2. Abstract
  3. Definition
  4. QOL Questionnaires
  5. Normal Physiology of Speech and Swallowing
  6. Objective Evaluation of Speech and Swallowing in Patients with Head and Neck Cancer Carcinoma
  7. Major Issues Affecting Quality of Life
  8. CONCLUSIONS
  9. Acknowledgements
  10. REFERENCES

BACKGROUND

The standard of care for locally advanced head and neck carcinoma usually has been surgery followed by radiation therapy. Patient survival using this approach has been reported to be poor. The disfiguration resulting from surgery and the long-term morbidity of postoperative radiation often results in considerable distress. Concurrent chemotherapy and radiation was introduced to improve outcome. Excellent local control and survival results often have been reported in Phase II and Phase III studies. The acute toxicity of combined chemotherapy and radiation is significant. However, organ preservation may improve quality of life. This review article summarizes the findings from published series of surgery, postoperative radiation, radiation therapy alone, and chemoradiation with regard to quality of life issues for patients with locally advanced head and neck carcinoma.

METHODS

A literature search was used to identify quality-of-life studies of postoperative radiation, radiation therapy alone, and chemoradiation in patients with locally advanced head and neck carcinoma. Factors affecting long-term quality-of-life issues in each treatment modality were identified, compared, and evaluated.

RESULTS

Speech disorder, dysphagia, pain, and depression were found to be the common side effects affecting quality of life regardless of the treatment modality. Xerostomia is the major complication affecting patients undergoing radiation or chemoradiation.

CONCLUSIONS

Acute side effects of combined chemotherapy and radiation therapy usually were found to resolve after treatment. Long-term morbidity is substantial because of xerostomia and severe dysphagia. However, preliminary studies suggest that because of organ preservation, patients may achieve a better quality of life after chemoradiation compared with the conventional use of surgery and postoperative radiation. Cancer 2002;94:1131–41. © 2002 American Cancer Society.

DOI 10.1002/cncr.10257

Locally advanced head and neck carcinoma carries a poor prognosis.1 The 5-year survival usually is <40% with a combination of surgery followed by postoperative radiation.2 Because of the extent of the disease, surgical resection may require removal of a large volume of tissue. A surgical flap may be needed to fill the tissue defect and restore organ function.3 After extensive surgery, patients usually develop speech and swallowing dysfunction.4, 5 The severity of the speech and swallowing disorders depends on the site of the primary tumor, the stage of the disease, the type of surgical resection used, and the quality of the graft.6 Patients also may develop residual pain and body image alteration secondary to nerve damage and disfiguration, respectively.7, 8 If postoperative radiation is required because of the advanced stage of the disease, further alteration of the patient's quality of life (QOL) may occur because of the xerostomia and fibrosis induced by radiation.9

The concept of concurrent chemotherapy and radiation was introduced in an attempt to improve the local control and possibly influence the survival because of the high rate of local and distant failures observed with the combination of surgery and postoperative radiation.10 Many Phase II studies reported a high local control rate and improved survival with chemoradiation in patients with inoperable head and neck disease.11–13 Long-term survival ranging from 52–76% at 4–5 years was reported in these trials. Randomized Phase III studies comparing concurrent chemotherapy and radiation with radiation therapy alone also reported a statistically significantly improved survival rate for the combined modalities. The survival rates ranged from 42–74% and 9–52% for chemoradiation and radiation, respectively.14–17 Acute toxicity of the combined treatment can be severe and may result in patient death.11

However, patients who undergo chemoradiation may not require surgery if a complete response is obtained after treatment. Organ-sparing surgery also may be possible for a residual neck or tumor mass after its shrinkage. Therefore, QOL may be improved after chemotherapy and radiation.

Conversely, long-term sequelae may be due to the enhanced radiosensitization effects of chemotherapy. Late complications were observed in 7.5–20% of patients undergoing chemoradiation for locally advanced head and neck carcinoma.18 Excessive fibrosis and xerostomia may have a negative impact on speech and swallowing. These factors may counterbalance the benefit of organ preservation.

The goal of the current article was to review data concerning the effect of chemoradiation on QOL compared with the traditional approach of surgery and postoperative radiation for patients with locally advanced head and neck carcinoma.

Definition

  1. Top of page
  2. Abstract
  3. Definition
  4. QOL Questionnaires
  5. Normal Physiology of Speech and Swallowing
  6. Objective Evaluation of Speech and Swallowing in Patients with Head and Neck Cancer Carcinoma
  7. Major Issues Affecting Quality of Life
  8. CONCLUSIONS
  9. Acknowledgements
  10. REFERENCES

QOL is defined broadly as a person's sense of well-being stemming from satisfaction or dissatisfaction with areas of life that are important.19 Individuals differ in level of expectations. Frustrations may arise when the results do not match expectations.20 Given the definition's complexity and lack of specificity, it is not surprising that QOL is not an easily measured quantity. Assessment of QOL usually is assessed through questionnaires.21 The questions investigate specific items called domains that range from functional to economic status affected by the disease or treatment.

QOL Questionnaires

  1. Top of page
  2. Abstract
  3. Definition
  4. QOL Questionnaires
  5. Normal Physiology of Speech and Swallowing
  6. Objective Evaluation of Speech and Swallowing in Patients with Head and Neck Cancer Carcinoma
  7. Major Issues Affecting Quality of Life
  8. CONCLUSIONS
  9. Acknowledgements
  10. REFERENCES

All tests measuring QOL examine four basic domains: psychologic (e.g., depression, anxiety), social (e.g., sexual interests, leisure activities), occupational (e.g., employment, household activities), and physical (e.g., sleep, pain).22 The questions are aimed toward determining a possible causal relation (such as a correlation between severity of vomiting and QOL) or underlying indicators of a patient's personality, such as anxiety, which may influence their perception of symptoms (for example a depressed patient is more likely to perceive an episode of vomiting as severely affecting QOL). Each item is assigned a score (simple or weighted) and summation of the scores provide the global QOL. High scores for a functional scale (e.g., social functioning) represent a healthy level. However, high scores for a symptom item such as pain indicate a higher degree of impairment.

There are four types of questionnaires that address specific issues in cancer management: global, general, head and neck, and performance. The global questionnaires can be applied for any disease (malignant or not) because the questions are directed toward physical, social, and psychologic issues. The general questionnaires examine cancer symptoms such as fatigue, pain, and the side effects of treatment. Head and neck questionnaires focus on specific issues related to head and carcinoma treatment side effects and complications. Performance questionnaires may address specific functions such as speech or swallowing.

The questionnaires vary in their complexity and may or not include psychologic issues. Commonly used questionnaires in head and neck patients are: the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC-C30), Head and Neck Core 35 (EORTC-HN35), University of Washington Head and Neck Disease-Specific Measure (UW-QOL), and Head and Neck Radiotherapy Questionnaire (HNRQ).23–25 UW-QOL is a quick way to assess disease-specific functional items such as pain, disfigurement, and swallowing.23 However, psychologic issues are omitted in the UW-QOL questionnaires, making it best suited for a busy clinical practice because it is easy and simple to use.

EORTC-C30 questionnaires are more complex and include multiple functions ranging from emotional to social function.24 As a result, it may take more time for patients to answer the questions; EORTC-C30 questionnaires usually are employed for research purposes and are validated for a wide range of malignancies.

The EORTC-HN35 is used specifically for head and neck carcinoma. It contains seven symptom scales (pain, swallowing, taste, social eating, social contact, and sexuality) and six symptom items (teeth problems, trismus, dry mouth, sticky saliva, cough, speech, and feeling ill). Specific issues concerning radiation treatment, such as xerostomia, are measured by the McMaster University Head and Neck Radiotherapy Questionnaire (HNRT).25 The questionnaires may be used separately or in combination because they are complementary.26 Other types of head and neck questionnaires include the Head and Neck Survey, Functional Status in Head Neck Cancer, Head and Neck Cancer Specific Quality of Life, and Quality of Life Questionnaire.27–30

A questionnaire such as the Performance Status Scale for Head and Neck Cancer examines specific oral functions such as speech intelligibility and the patient's ability to eat.31

Although not specific to head and neck carcinoma, the Karnofsky Performance Index and Hospital Anxiety and Depression Scale are two global questionnaires most commonly used to assess physical activity and depression, respectively, in patients with tumors of the upper aerodigestive tract.32, 33

Normal Physiology of Speech and Swallowing

  1. Top of page
  2. Abstract
  3. Definition
  4. QOL Questionnaires
  5. Normal Physiology of Speech and Swallowing
  6. Objective Evaluation of Speech and Swallowing in Patients with Head and Neck Cancer Carcinoma
  7. Major Issues Affecting Quality of Life
  8. CONCLUSIONS
  9. Acknowledgements
  10. REFERENCES

To understand how head and neck malignancies and their treatment have an effect on the patient's QOL, a brief review of the normal physiology of speech and swallowing is necessary.34

Speech sounds are produced when the airflow passes through vibrating (vocal cords) and resonating (pharynx and the oral and nasal cavities) systems, and finally through a partially or totally occluded oral cavity. Two types of speech sounds are produced: vowels and consonants. Vowels are produced by the modification of size and shape of the resonant cavities. Consonants are produced when the airflow speed is modified by various articulators (tongue, lips). The tongue acts as a major modulator in the production of vowels or consonants because of its ability to modify the size and shape of the oral cavity as well as the degree of obstruction of the vocal tract. However, any disruption of the structures involved in speech production by the tumor or its treatment will affect the voice's intelligibility, and thus compromise a patient's QOL.

Swallowing movement occurs through three stages: oral, pharyngeal, and esophageal. The tongue pushes the food bolus against the hard palate during the oral stage. In the next (pharyngeal) stage, elevation of the tongue and depression of the soft palate force the bolus into the oropharynx. Closure of the airway and palatopharynx by the epiglottis and soft palate, respectively, prevents the food from being aspirated and regurgitated through the nasopharynx. In the last phase, the esophageal phase, the bolus enters the esophagus.

Objective Evaluation of Speech and Swallowing in Patients with Head and Neck Cancer Carcinoma

  1. Top of page
  2. Abstract
  3. Definition
  4. QOL Questionnaires
  5. Normal Physiology of Speech and Swallowing
  6. Objective Evaluation of Speech and Swallowing in Patients with Head and Neck Cancer Carcinoma
  7. Major Issues Affecting Quality of Life
  8. CONCLUSIONS
  9. Acknowledgements
  10. REFERENCES

There are two major methods of assessing speech function: articulatory and speech intelligibility testing. Articulatory testing evaluates the functions of major articulators such as the lips and tongue. Intelligibility testing examines the quality of the phonation. The two tests usually are performed before and after head and neck surgery to assess the impact of surgical treatment on voice quality. Before surgery, dysfunction of the voice was observed in patients with locally advanced head and neck tumors.35 Additional speech deterioration may occur after surgery.

Quality of the voice after surgery is dependent on multiple factors: extent of surgical resection, tumor stage, tumor site, type and quality of the graft, and severity of impairment of the tongue mobility.6, 35, 36 Extensive ablation of the tongue muscles is associated with severe reduction of speech intelligibility.37 As a result, surgery for advanced tumors (TNM stage T3 and T4) produce a higher degree of speech dysfunction because of the amount of tissue resected to achieve a negative margin.35, 38 Large surgical defects usually are reconstructed after surgery to restore normal functions. The method of surgical reconstruction also has an impact on speech quality. Myocutaneous and fasciocutaneous flaps result in decreased tongue mobility compared with jejunal grafts.5 Jejunal flaps produce better postoperative articulation because the jejunum is more pliable and may stretch extensively because of the surface folds. Local grafts may produce superior speech quality compared with other types of grafts.35 However, even with reconstructive surgery, a significant decrease in tongue mobility was observed after oral surgery for carcinoma of the floor of the mouth and tongue.6, 37, 39 The effect on the intelligibility of speech was more pronounced when the mobility of the tongue base and dorsum was reduced.36 As a result, surgery of the base of the tongue is associated with significant speech dysfunction compared with other tumor sites.38 The percentage of the soft palate that is resected also is reported to affect speech function negatively because of the decreased intraoral pressure required for the production of phonemes. Postoperative radiation does not appear to impair speech quality despite the xerostomia produced.6, 9

Swallowing motility disorders are investigated with videofluoroscopy or videofluorography. Dysphagia is a common symptom of tumors of the upper aerodigestive tract. Up to 59% of patients report a swallowing problem prior to treatment.40 All three phases of swallowing may be affected by the tumor. Compared with healthy volunteers, a significantly longer oral and pharyngeal time was observed in patients with head and neck carcinoma. In addition, symptomatic or asymptomatic aspiration may be present.41 The degree of impairment depends on the anatomic location of the tumor. Laryngeal and hypopharyngeal carcinomas are severely affected compared with other sites.41 A significantly high percentage of aspiration also is observed with laryngeal and hypopharyngeal tumors. Locally advanced tumors are associated with more swallowing dysfunction compared with early stage tumors. Given the baseline dysfunction, it is not surprising that the severity of dysphagia may be exacerbated after treatment. All three treatment modalities (surgery, radiation therapy, and chemotherapy) may adversely affect the swallowing mechanism.

After glossectomy and reconstruction, stasis has been observed in all areas of the oropharyngeal tract.42 Residue is more pronounced in the vallecula, flap, and tongue stump. Other types of surgery and reconstruction also have been reported to lead to an increase of the bolus transit time, especially the pharyngeal transit time.4 Dysphagia is increased markedly if postoperative irradiation is required.9 Postoperative radiation patients have been reported to experience a longer oral transit phase, increased pharyngeal residue, and reduced cricopharyngeal opening duration.

Radiation decreases the salivary flow and increases postoperative edema and fibrosis of the pharyngeal muscles. All these effects compound surgical complications Patients frequently develop swallowing dysfunction 18–22 weeks after postoperative radiation.43

Patients with carcinoma of the head and neck who are undergoing radiation therapy alone also experience abnormal swallowing studies after treatment. Increased fibrosis of the pharyngeal musculature may induce dysmotility of the pharyngeal wall leading to pharyngeal residue.44 A reduction of the following functions has been observed after head and neck radiation: laryngeal elevation, tongue base contact to the posterior pharyngeal wall, and true vocal cord closure during swallowing.9

Abnormal pharyngeal contraction was observed in 93% of patients undergoing radiation therapy for nasopharyngeal tumors. In addition, a high incidence of silent aspiration (22%) was recorded.45 High dosages as well as large radiation fields to cover the base of skull may explain the severity of swallowing abnormalities noted after radiation therapy to the nasopharynx.

Chemotherapy acts as a radiosensitizer and may enhance apoptosis induced by radiation.46 As a result, the fibrotic reaction may be more intense after chemoradiation. Reduction of movement of posterior tongue base and laryngeal elevation were observed in head and neck carcinoma patients who were undergoing chemotherapy and radiation for organ preservation.47 Impairment of laryngeal motion, pharyngeal stasis, pyriform and vallecular residue, and aspiration are functional abnormalities that are observed with the combined modalities. The severity of the fibrosis may lead to prolonged tube feeding; for example, 6 of 9 patients who received hydroxyurea concurrently with radiation therapy for oral cavity and pharyngeal tumors continued to require gastrotomy feeding 1 year after treatment.48

Major Issues Affecting Quality of Life

  1. Top of page
  2. Abstract
  3. Definition
  4. QOL Questionnaires
  5. Normal Physiology of Speech and Swallowing
  6. Objective Evaluation of Speech and Swallowing in Patients with Head and Neck Cancer Carcinoma
  7. Major Issues Affecting Quality of Life
  8. CONCLUSIONS
  9. Acknowledgements
  10. REFERENCES

After Surgery

It is difficult to assess the QOL after surgery because of the heterogeneity of tumor sites and the extent of resection. However, a few general conclusions may be made.

Pain

Pain remains a significant problem, particularly after neck dissection.7, 49 Arm and shoulder pain was reported to be persistent in up to 26% of patients at 2 years after neck surgery.7 Pain appears to have an adverse effect on the general well-being of cancer survivors and may cause serious psychologic distress. Many factors influence the development of pain: the type of neck dissection, the stage of the tumor, and the amount of tissue resected.

The choice of neck dissection depends on the level of lymph nodes affected by the tumor. Selective neck dissection (SND) involves resection of Level I–III or II–IV lymph node stations with sparing of the sternocleidomastoid (SCM) muscle, internal jugular vein (IJV), and spinal accessory nerve (XI). SND usually is indicated for patients with clinically negative cervical lymph nodes. The lymph nodes resected by SND are those most likely involved from the tumor based on its location. Radical neck dissection (RND) entails the removal of all Level I–V lymph nodes along with the SCM, IJV, and the XI nerve. Modified radical neck dissection (MRND) allows sparing of nerve XI even though Level I–V lymph nodes are resected. RND is associated with a higher incidence of pain and shoulder dysfunction compared with SND and MRND.50 The decrease in pain is due to the sparing of cranial nerve XI and accompanying sensory nerves during surgery. The patient's physical condition and activity also improve with preservation of the XI nerve.49

Neck and shoulder pain is less if Level V lymph nodes also are not resected, implying a better functional result after SND.49 Dissection of nerve XI (to preserve it) may cause additional pain. A similar result (better pain and improved physical activity) also is observed with the use of supraomohyoid neck dissection compared with RND and MRND.51

Resection of large tumors requires extensive surgery, which may lead to substantial postoperative pain. The severity of pain after surgery increases with tumor stage; patients who presented with T3 and T4 lesions were found to experience more pain compared with those patients with early-stage disease.52

Speech Disorders and Dysphagia

The ability to communicate and to swallow after surgery is a function of the tumor stage, the anatomic site of the tumor, and the compounding effect of radiation. Advanced tumor stage at diagnosis is known to have a deleterious effect on QOL scores. Speech, swallowing, and the ability to eat in public are affected adversely for patients with resected T3 and T4 lesions.3, 38 Despite reconstructive oral/throat surgery, substantial loss of soft tissue results in dysphagia, reflux of liquid, and insomnia.

To illustrate this point further, organ-preserving surgery, whenever feasible, is associated with a better quality of life. For example, patients undergoing supracricoid partial laryngectomy (SPL) were reported to have achieved better physical function, social function, and psychologic well-being compared with those patients who underwent total laryngectomy.53 Patients who undergo SPL appear to experience less pain and less emotional distress, which may be due to the absence of the tracheostoma. The presence of a stoma after total laryngectomy has a negative impact on cosmesis and social acceptability.54, 55 In addition, airway irritation associated with the stoma can result in excessive coughing, sleep difficulty, and fatigue.56

Among various head and neck anatomic sites, surgery at the base of the tongue has a negative impact on speech and deglutition even in patients with an early-stage tumor.38 This is not surprising given the reduced mobility of the stump, even with flap reconstruction.

Radiation therapy also impairs the QOL after surgery.9, 30 Patients often develop significant speech impediments, swallowing dysfunction, and psychologic discomfort. The QOL deterioration is more severe for these patients compared with patients treated with radiation therapy alone.30

Patients treated with postoperative radiation also were reported to have worse physical symptoms compared with the patients who were treated with surgery alone.57

Xerostomia and fibrosis are common after radiation and exacerbate the surgical complications. Because the majority of patients with advanced head and neck carcinoma require postoperative radiation, their QOL can be affected significantly by the treatment modality combinations.

Depression

The head and neck region is the most prominent and visible part of the body that is not covered by clothing. This anatomic area plays an important role in the perception of body image.

Head and neck surgery can be associated with facial disfigurement. Speech and swallowing impairment after surgery also impede a patient's abilities to communicate and endure public appearance. Dropkin described a cohort of 117 patients who were about to undergo disfigurative surgery for head and neck carcinoma. Anticipation of mutilation secondary to facial surgery was associated with a high level of distress. In another population of 75 patients who actually underwent surgery for head and neck carcinoma, alteration of body image was more likely to occur in patients who had mild to moderate disfiguration after surgery.8

The ability to cope after surgery depends on the preoperative coping behavior of the individual. Psychologic therapy can help patients with adjustment difficulties after surgery. Pilot studies suggest long-term improvement in QOL for patients receiving psychologic group therapy for head and neck carcinoma.

Psychiatric morbidity, emotional function, and global QOL was reported to improve in the group of patients receiving psychologic counseling compared with a control group.58 This psychologic support is important because some of the spouses of the patients also were found to suffer from depression resulting from the patient's illness and therefore were unable to provide the help needed after surgery. Both patients and their spouses developed difficulties with work and social activity after the patient underwent total or partial laryngectomy for laryngeal carcinoma.59 Table 1 summarizes those studies assessing issues affecting QOL after surgery.

Table 1. Factors Affecting Quality of Life Issues for Patients with Locally Advanced Head and Neck Carcinoma Who Undergo Surgery
AuthorsNo. of patientsSiteType of questionnaireType of surgeryType of issues
  1. FLI: Functional Living Index; STAI: State Trait Anxiety Inventory; HNQOL: Head and Neck Quality of Life; SF-36: Medical Outcome Short Form 36; SF-12: Medical Outcome Short Form 12; UWQOL: University of Washington Quality of Life; RND: radical neck dissection; MRND: modified radical neck dissection; SND: selective neck dissection; PSS-HN: Performance Status for Head and Neck Cancer; VRQOL: Voice-Related Quality of Life; EORTC-C30: European Organization for Research and Treatment of Cancer Core Questionnaire; EORTC-HN35: European Organization for Research and Treatment of Cancer Head and Neck Cancer Module; CES: Center for Epidemiologic Studies Depression Scale; PAIS-SR: Psychosocial Adjustment to Illness Scale Self Report; MCPLQ: Mayo Clinic Postlaryngectomy Questionnaire.

Schliephake et al.385Floor of mouthFLIPrimary surgery and reconstructionDysphagia, reflux of liquid, sleep disorders
Dropkin875Not specifiedSTAINot specifiedDepression
Terrel et al.49175Larynx, oral cavity, oropharynxHNQOL SF-36, SF-12Neck dissection with or without nerve sparingPain
Kuntz and Weymuller50149Oral cavity, oropharynx, larynx, hypopharynxUW-QOLRND, MRND, SNDPain
Rogers et al.5248Oral cavity, oropharynxUW-QOLPrimary surgery and reconstructionPain
Zelefsky et al.3829Oral cavity, oropharynxPSS-HNNot specifiedSpeech normalcy of diet
Weinstein et al.5356LarynxSF-36 HNQOL, VRQOLPartial laryngectomy total laryngectomySpeech
De Graeff et al.5775Oral cavity, oropharynxEORTC-C30 EORTC-HN35 CES-DPrimary surgery neck dissectionPhysical functioning depression
Herranz and Gavilan59111LarynxPAIS-SR MCPLQTotal laryngectomy supraglottic laryngectomy cordectomyDepression

After Radiation

The morbidity from radiation therapy increases with the volume and dose of radiation. The irradiated target volume varies depending on the primary tumor site and the tissue volume at risk for occult metastases. Therefore, treatment of the nasopharynx carries substantial toxicity because of the large radiation field covering the base of skull and the lymph node drainage. Xerostomia, trismus, and swallowing disorders frequently are reported complications in patients with nasopharyngeal carcinoma.45 Xerostomia is the most common side effect in patients undergoing radiation therapy secondary to damage of the salivary glands.60–62 Severe xerostomia significantly alters QOL scores for emotional, social, physical, and overall function.

Patients with early stage vocal cord carcinoma have the radiation field restricted to the glottis. As a result, the QOL scores are reported to be highest for patients with T1 vocal cord carcinoma compared with patients with advanced stage laryngeal carcinoma and tumors of other sites.60 Significantly lower scores for speech intelligibility also are reported for patients with advanced laryngeal carcinoma.61 Pain and nutrition also are major complications resulting in psychologic distress.62 Baseline and long-term depression also are observed in these patients.57 These long-term effects were observed with conventional fractionation, hyperfractionation, and hypofractionation radiation therapy.63–65

However, overall, patients undergoing radiation therapy appear to cope and adjust well. Harrison et al.66 reported excellent functional and employment status for patients who received radiation treatment for base of the tongue tumors. Moore et al.,67 also observed long-term functional results for patients who were treated with radiation for tumors of the base of the tongue that appeared superior to those of patients who were treated with surgery. Speech intelligibility and return to a normal diet were noted after 5 years. However, for patients with advanced tumors (T3 and T4), the ability to tolerate a normal diet was decreased compared with patients whose tumors were in the early stages. Organ preservation with radiation therapy for tumors of the base of the tongue most likely accounted for the good results reported.

The QOL for patients receiving radiation therapy may be improved further by the addition of amifostine. Amifostine is a thiol compound that protects normal tissues against radiation through the binding of the sulfhydryl group with hydroxyl radicals. The high concentration of amifostine in the salivary glands after its administration often decreases the severity of xerostomia after head and neck radiation.68 In a randomized study, Wasserman et al. reported an improvement in speech, eating, sleep, and overall well-being in patients receiving amifostine.69 Both arms of the study received curative doses of radiation for advanced head and neck carcinoma. The QOL benefits observed for the patients receiving amifostine were due to the improvement of xerostomia. Table 2 summarizes the QOL results after radiation therapy.

Table 2. Factors Affecting Quality of Life Issues for Patients with Locally Advanced Head and Neck Carcinoma who Undergo Radiation Therapy
AuthorsNo. of patientsSiteType of questionnaireRadiation dose (Gy)Type of issues
  1. Gy: grays; ESH: Eating and Swallowing History; EORTC-C30: European Organization for Research and Treatment of Cancer Core Questionnaire; EORTC-HN35: European Organization for Research and Treatment Head and Neck Cancer Module; PSSHN: Performance Status Scale for Head and Neck Cancer; HADS: Hospital Anxiety and Depression Scale; GHQ-20: General Health Questionnaire, 20-item version; RSCL: Rotterdam Symptom Checklist; BDI: Beck's Depression Inventory; FLIC: Functional Living Index-Cancer; MSAS: Memorial Symptom Assessment Scale; FACT: Functional Assessment of Cancer Therapy; PSS: Performance Status Scale for Head and Neck Cancer; SEQ: Sociodemographic and Economic Questionnaire; PBQ: Patient Benefit Questionnaire.

Hughes et al.4550NasopharynxESHNot specifiedXerostomia, dysphagia
Huguenin et al.6079Oral cavity, larynx, oropharynx, nasopharynx hypopharynxEORTC-C30 EORTC-HN3568–76.8Xerostomia, eating, trismus
Allal et al.6131Larynx, hypopharynxPSSHN EORTC-C3069.9Xerostomia, speech
Hammerlid et al.62105Oral cavity, oropharynx, hypopharynxEORTC-C30 EORTC-HN37 HADSNot specifiedXerostomia, pain, nutrition, depression
Bjordal et al.63245Oral cavity, larynx, pharynxEORTC-C30 EORTC-HN GHQ-2063–66Xerostomia, fatigue, emotion
Griffiths et al.64615Not specifiedRSCL HADSNot specifiedAnxiety, depression
Chawla et al.6550Oral cavity, oropharynx, nasopharynx, larynxBDI FLIC70Depression
Harrison et al.6636Base of tongueMSAS FACT PSS SEQ45–54 and implant up to 30Xerostomia dysphagiapaininsomnia
Moore et al.6749Base of tonguePSS73.8–79.2Normalcy of diet
Wasserman et al.69303Oral cavity, oropharynx, larynxPBQUp to 70Xerostomia

After Chemotherapy and Radiation Therapy

Many patients undergoing concurrent chemotherapy and radiation experience RTOG Grade 3–4 mucositis that usually requires a break in the radiation treatment. Other serious toxicities include hematologic and infectious complications that may lead to death.18 The acute side effects usually subside after treatment. General and physical functioning was reported to have returned to the pretreatment baseline after 12 months.70

Xerostomia and dysphagia were the most common side effects reported with long-term follow-up (77% and 50%, respectively).71–73 Dry mouth and sticky saliva were the most troublesome long-term effects reported in all studies. As a result of the xerostomia and dysphagia, only 50% of the patients were able to resume a normal diet after treatment.71 Residual pain occurred in 15% of patients and was reported to significantly alter their QOL.71 Depression was observed in 23% of patients and may have exacerbated the severity of the residual effects.

Other reported long-term side effects affecting the QOL were hoarseness, tasting impairment, and trismus. Despite the severity of these treatment sequelae, which influenced the QOL negatively, long-term survey results of the Veterans Affairs Laryngeal Cancer Study suggested that chemoradiation may result in a better QOL outcome compared with the conventional treatment of surgery and postoperative radiation for patients with advanced laryngeal carcinomas.74

Patients with TNM Stage III and IV laryngeal carcinoma in that trial were randomized into two groups; induction chemotherapy was performed in both groups followed by either radiation therapy or surgery and postoperative radiation. Survival was comparable, but among long-term survivors, those who had achieved successful organ preservation in the chemoradiation group were found to have a significantly better QOL compared with those patients who were treated with surgery and radiation therapy. Patients with preservation of the larynx reported less pain, better emotional well-being, and less depression.

The study suggested that chemotherapy and radiation may result in a better QOL compared with the conventional treatment of surgery and radiation because of organ preservation. McDonough et al.,75 also reported significantly higher QOL scores in the group of patients with head and neck carcinoma who received chemotherapy and radiation compared with those who were treated with induction chemotherapy followed by surgery and postoperative radiation. Social distress and avoidance were lower in the nonsurgical group of patients because they had superior communication abilities and less disfiguration. In another study, despite the poor prognosis associated with locally advanced head and neck hypopharynx tumors, Schrader et al. observed a locoregional control rate of 71% with hyperfractionated radiation therapy and concurrent chemotherapy.73 Late sequelae of treatment were tolerable and did not appear to have an impact on the survivors' QOL. With the exception of two patients, swallowing function was preserved. Xerostomia and trismus were the most common long-term effects. Good functional outcome also was confirmed by Huguenin et al. for long-term survivors of advanced head and neck malignancies who received chemoradiation.72 However, in that study, xerostomia was the main factor responsible for the deterioration of nutrition and poor social interaction.

The addition of amifostine could be beneficial in this setting. Two randomized trials have shown a significant reduction of high-grade xerostomia in patients undergoing chemoradiation or radiation for advanced head and neck carcinoma who also were receiving amifostine.76, 77 The addition of amifostine did not appear to have an impact on survival or local control. Severe hematologic toxicity and high-grade mucositis also were reported to be reduced with high doses of amifostine (500 mg intravenously during chemotherapy). However, QOL issues were not addressed in chemoradiation trials and should be integrated in future studies. Table 3 summarizes the QOL results in published studies of patients treated with chemoradiotherapy.

Table 3. Factors Affecting Quality of Life Issues for Patients with Locally Advanced Head and Neck Carcinoma Who Undergo Chemotherapy and Radiation Treatment
AuthorsNo. of patientsSiteType of questionnaireChemotherapyRadiation dose (Gy)Issues
  1. Gy: grays; PSS-HN: Performance Status Scale for Head and Neck Cancer Patients; 5-FU: 5-fluorouracil; HU: hydroxyurea; MUHNRQ: McMaster University Head and Neck Radiotherapy Questionnaire; bid: twice daily; CDDP: cisplatin; FATC-HN: Functional Assessment of Cancer Therapy-Head and Neck; EORTC-C30: European Organization for Research and Treatment of Cancer Core Questionnaire; EORTC-HN35: European Organization for Research and Treatment of Cancer Head and Neck Cancer Module; MTC: mitomycin C; HNQOL: Head and Neck Quality of Life; SF-36: Medical Outcome Short Form 36; BDI: Beck Depression Inventory; UWQOL: University of Washington Quality of Life; P: paclitaxel; CP: carboplatin; SADS: Social Avoidance and Distress Scale.

List et al.7064Oral cavity larynx pharynxPSS-HN MUHNRQ FACT-HN5-FU, HU CDDP75 bidXerostomia, taste, diet, dysphagia, pain
Huguenin et al.7264Oral cavity larynx oropharynx hypopharynxEORTC-C30 EORTC-HN35CDDP74.4 bidXerostomia, dysphagia, nutrition, social interaction
Schrader et al.7341HypopharynxEORTC-HN355-FU, MTC72 bidXerostomia, dysphagia, trismus
Terrell et al.7446LarynxHNQOL SF-36 BDI5-FU, CDDP70–76Pain, depression
McDonough et al.7524Not specifiedUWQOLSADSP, CPNot specifiedSocial distress, social avoidance

CONCLUSIONS

  1. Top of page
  2. Abstract
  3. Definition
  4. QOL Questionnaires
  5. Normal Physiology of Speech and Swallowing
  6. Objective Evaluation of Speech and Swallowing in Patients with Head and Neck Cancer Carcinoma
  7. Major Issues Affecting Quality of Life
  8. CONCLUSIONS
  9. Acknowledgements
  10. REFERENCES

Patients with advanced head and neck malignancies often have baseline dysfunction resulting from the destruction of normal tissues by the tumors. Regardless of the modalities of treatment (surgery, radiation, or chemoradiation), significant sequelae occur (e.g., pain, depression, dysphagia, xerostomia, and body image alteration).

Clinicians need to be aware of the long-term complications associated with treatment. Psychotherapy and emotional support are required for all patients with head and neck malignancies. Preliminary studies suggest that head and neck carcinoma patients with better self-confidence achieved a higher survival.78 Therefore, psychotherapy may have an impact not only on QOL but also on survival.

Chemotherapy and radiation together were found to produce significant acute toxicity that resolved after treatment. Current chemoradiotherapy studies suggest that QOL may improve with this combination compared with the conventional treatment of surgery and postoperative radiation because of organ preservation. However, additional studies and long-term follow-up are needed to confirm these findings.

Xerostomia remains a major side effect in patients undergoing radiation therapy. New treatment modalities may have an impact on this complication and QOL; the addition of amifostine reportedly decreases the incidence of severe xerostomia. Intensity-modulated radiation, which decreases the radiation dose to normal tissues, may reduce the incidence of xerostomia and other side effects.79 Future clinical trials should address these issues.

REFERENCES

  1. Top of page
  2. Abstract
  3. Definition
  4. QOL Questionnaires
  5. Normal Physiology of Speech and Swallowing
  6. Objective Evaluation of Speech and Swallowing in Patients with Head and Neck Cancer Carcinoma
  7. Major Issues Affecting Quality of Life
  8. CONCLUSIONS
  9. Acknowledgements
  10. REFERENCES