Assessment of oral health-related quality of life among head-and-neck cancer patients attending cancer care center at Kanchipuram, Tamil Nadu – A cross-sectional study

INTRODUCTION

The head-and-neck cancers (HNCs) are a heterogeneous collection of malignancies that arise from the lips, oral cavity, tongue, nose, tonsil, larynx, nasopharynx, oropharynx, hypopharynx, paranasal sinus, parotids, and thyroid.^[1] Worldwide, the HNC accounts for more than 650,000 cases and 330,000 deaths annually. Overall, 57.5% of global HNC occur in Asia, especially in India. HNC in India accounted for 30% of all cancers.^[2,3]

Patients with HNC have multiple, unique, and challenging symptoms due to their disease and treatment such as xerostomia, taste disturbances, dietary restrictions, dysphagia, pain, fatigue, distortions of physical appearance, infirmity, weight loss, and permanent disfigurement,. which has a severe impact on the patients quality of life (QoL).^[4] Treatment usually consists of surgery, radiotherapy, chemotherapy, or combination. Treatment strategies are, therefore, not only directed at increasing the chances of cure but also at diminishing the impact of treatment on QoL.^[5]

Quality of Life is a multidimensional concept which looks at how patients feel about themselves in the context of a medical condition.^[6] The subjective evaluation of oral health-related QoL “reflects people’s comfort when eating, sleeping, and engaging in social interaction; their self-esteem; and their satisfaction concerning their oral health.”^[7] An individual’s health-related QoL will be affected if the oral health is worsened. No study has been conducted on HNC patients regarding their oral health related QoL (OHRQoL) in South India. Quantifying subjective experience of OHRQoL has been a challenging issue. Hence, a questionnaire-based study was conducted to assess OHRQoL in HNC patients attending cancer care center in Kanchipuram, Tamil Nadu.

MATERIALS AND METHODS

The present study is a cross-sectional study conducted at Government Arignar Anna Memorial Cancer Hospital and Research Institute in Kanchipuram District of Tamil Nadu. The study was conducted from August to October 2019. The study protocol was discussed and permission was obtained from the Directorate of Medical Education, Government of Tamil Nadu. Ethical clearance was then obtained from the Government Arignar Anna Memorial Cancer Hospital and Research Institute’s ethical committee. Written consent was also obtained from the patients.

RESULTS

[Table 1] shows the demographic variables, habits, and disease-related details of the patients. About 72.4% were male; 50.9% were aged between 41 and 60 years; 36.2% were illiterates; 45% were elementary workers; the majority of them had tobacco habit; buccal mucosa and tongue are the most common site of HNC. The majority of them stopped their tobacco habit after diagnosis (88.5%). We divided the site of cancer into six categories for ease of analysis.

Buccal mucosa, tongue, lips, the floor of the mouth, palate, alveolus, maxilla, and mandible were clubbed into a single category, that is, oral cavity. The remaining categories were oropharynx, nasopharynx, hypopharynx, larynx, and others. The “others” category includes malignancies of the thyroid and salivary glands.

[Graph 1] shows the percentage of all the domains and single items of the OHRQoL H&N-35 questionnaire. Based on the scores calculated, the major factors affecting OHRQoL were taking painkillers, loss of sexuality, teeth problems, feeling ill, weight loss, and social contact. The domains and single items of the QoL questionnaire were compared according to sites of the tumor, stage of cancer, and type of treatment method.

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Graph 1:

Percentage distribution of factors affecting OHRQoL.

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[Table 2] shows a comparison of OHRQoL items with the stage of cancer. Stage IV HNC with high scores illustrates that OHRQoL is impaired severely in comparison with other stages of the disease. After carrying out ANOVA, statistically significant differences were found for pain, swallowing, sense, speech, social eating, social contact, dry mouth, sticky saliva, falling ill, and nutritional supplement.

[Table 3] shows a comparison of OHRQoL domains/items with the site of cancer. Nasopharynx and oropharynx cancer patients have crumbled OHRQoL than other HNC. Statistically significant differences were found for swallowing, sense, social eating, sexuality, teeth, reduced mouth opening, sticky saliva, cough, and falling ill.

[Table 4] shows the comparison of OHRQoL factors with various treatment modalities given for HNC. Patients who were treated surgically had better OHRQoL than other combined treatment modalities. Factors such as pain, sense, speech, social eating, social contact, teeth, dry mouth, sticky saliva, cough, felt ill, nutritional supplement, and weight loss were found to be statistically significant.

DISCUSSION

QoL is the way with which the individual faces the different aspects of his/her life as a whole. It is associated with the individual’s degree of satisfaction found in family life, love life, social and environmental life, and the very existential sense. To assess the QoL of the patients affected by HNC, it is important to better understand the impact of the disease and its treatment on the patient’s daily routine, and improve the care protocol with more encompassing clinical, social and rehabilitation support measures.^[8] de Graeff et al. and Alicikus et al. found that the male:female ratio was 4:1, in the present study, it was 3:1.^[9,10]

Meyer et al. found 64% of tobacco users among their studied patients’ groups whereas in our study it was 97.3%.^[11,12] Most of the subjects belonged to upper lower and lower socioeconomic status and this complied with the results of Khandekar et al. who reported that the low SES may be a risk factor for poor oral hygiene, and in this way, it further increases the risk for cancer.

In the present study, the common location for the tumor was buccal mucosa and it correlates with the results of Shavi et al.^[13]

Factors such as painkillers intake, loss of sexual interest, teeth problems, weight loss, the feeling of being ill, and difficulties in maintaining social contact greatly pull down the OHRQoL in our study and it was found to be analogous with the results of Campbell et al.^[14] Social contact helps to cope with stress, whereas here poor social contact hints that they may be embarrassed by their disabilities or health problems such that they tend to isolate themselves to avoid social interaction out of fear that they would be judged or stigmatized. Sometimes, rather than embarrassment, the disability itself and a person’s lack of a support network can be the cause of social isolation.

Fang et al.^[15] found that patients presented with the tumor in Stage IV had lower QoL than patients in Stages I, II, and III, and this is consistent with the results of the present study.^[15] This proclaims that approaching the physician without neglecting the initial stage of the disease will prevent the spread of the disease to other places, make treatment easier and also the QoL will not be greatly affected.

Dry mouth and sticky saliva are found to be significantly high in patients treated with radiotherapy and chemotherapy. This is due to the damage caused by these treatment modalities on salivary glands. Due to the quantitative and qualitative salivary changes, patients become more prone to dental diseases with important impairment in QoL.^[16-18]

Based on the scores, patients treated surgically alone had better OHRQoL than others and it is similar to the findings of Barrios et al.^[19] The results of various studies reported that combined treatment showed complications including pain, mucositis, mucosal sensitivity, dry mouth, altered or reduced taste, mucosal and bony necrosis, increased risk of dental caries, difficulty with denture function, altered esthetics, reduced mobility of the tongue, lips, and jaw, and limitation of mastication and swallowing.^[20-25]

CONCLUSION

The results showed that the patients treated by surgery alone had slightly better OHRQoL compared with others. In recent years, the management of HNC has been more complex with combined-modality programs, as well as the integration of new diagnostic and therapeutic technologies. The head and neck is the most complex organ, so the treatment decision should best support the patient. The assessment of OHRQoL not only provides information about the impact of cancer and its treatment outcome but the information can also be applied to direct patient care, education, and counseling to optimize physical and psychological well-being.

We recommend further research and awareness among health professionals, patient groups, and policy-makers on whether and how the QoL assessment measures and tools can help patients with cancer.