Quality of life in patients with squamous cell carcinoma of hypopharynx after radiotherapy in a tertiary care centre

EORTC is a well-accepted and peer reviewed tool of assessment. EORTC QLQ 30 measures the general clinical features of any cancer and specific EORTC. ObjectivesTo determine the quality of life in patients who have undergone Radiotherapy following various modalities of treatment for different subsites of Hypopharyngeal Squamous cell carcinoma. MethodsTwo Hundred and two patients seen in ENT, Head and Neck surgery department after postoperative Radiotherapy for Hypopharyngeal Squamous Cell cancers were served with both EORTC quality of life questionnaire 30 and specific Head and Neck 35. Patients above the age of 20 years, 6 weeks after Radiotherapy with Pyriform Fossa, Posterior Pharyngeal wall and Post cricoid region squamous cell carcinoma were assessed. The study aimed at determining the quality of life and associated comorbidities. AnalysisData was entered into Microsoft Excel (Windows 7; Version 2007) and analyses were done using the Statistical Package for Social Sciences (SPSS) for Windows software (version 22.0; SPSS Inc, Chicago). Descriptive statistics such as mean and standard deviation (SD)for continuous variables, frequencies and percentages were calculated for categorical Variables were determined. Association between Variables was analyzed by using Chi-Square test for categorical variables. ResultsDyspnoea and Odynophagia were the most important symptoms which crippled the patients irrespective of the subsite in which cancer presented (PFS 3.35, PPW 3.35, PCR 3.31 ;<0.001) Psychological ,Cognitive, Social functions though were affected there was not much difference amongst the individual subsites (PFS 3.66, PPW 3.18, PCR 3.01; 0.001). Almost all the patients had significant financial problems (PFS 3.36, PPW 2.91, PCR 3.59;0.001). ConclusionQuality of life questionnaires provide an insight into the life of patients who suffer from morbidity of the disease as well as its treatment. Thorough assessment of the condition of the patient in the post treatment status helps in timely rehabilitation.


Introduction
Squamous Cell Carcinomas of the Hypopharynx form one of the major tumours of the Head and Neck. They constitute nearly 35% of the total tumours of the region. Hypopharynx is oncologically is divided into three different subsites based on the anatomy of the region and spread of the malignancies. These three subsites are Pyriform Fossa (PFS), Posterior Pharyngeal Wall (PPW), Post Cricoid Region (PCR).
Pyriform fossa SCC is a commonly occurring malignancy of the Head and Neck which is second only to Laryngeal SCC. Management of these tumours involves extensive surgery like Laryngopharyngectomy which can be partial or total with primary or Flap based reconstruction of the tumour site. This will be followed by Selective or Modified Radical Neck dissection depending on the Neck Node status. All these patients undergo post-operative radiotherapy. Some pts where surgery is not possible, or RT and surgery carry same 3/5-year survival primary RT will be administered. While surgery addresses the bulk of the tumour radiotherapy takes care of the margins [1].
Radiotherapy causes significant morbidity to the patient even though it is a effective curative option in substantial cases with varied stages of the tumour. Radiation toxicity significantly brings down the quality of life with severe psychosocial impact also. Patients treated with RT take a long time to recover from its The study was a Prospective study with Descriptive analysis based on EORTC questionnaire.
The study was carried out for a period of 2 years from October 2015 to September 2017 Ethical consideration: The study was started after permission from the Institutional Ethical Committee.
The study does not involve any interventions or procedures. It is a purely questionnaire-based study.
Sampling: Purposive sampling technique was used sample size was 202 Inclusion criteria were, patients above the age of 20 years, 6 weeks after radiotherapy with pyriform fossa, Posterior pharyngeal wall and post cricoid region squamous cell carcinoma.
Patients who were unable to comprehend the questionnaire even after adequate support were excluded from the study.
A detailed history, socio demographic details were collected followed by clinical examination and all the data was recorded on a pre-prepared chart.
Patient consent was taken and comprehension to understand the questionnaire was assessed.
Patients with difficulty to understand the questionnaire and those who were not interested were duly excluded.
English and Kannada translation of general quality of life (EORTC QLQ-C30) was used followed by specific (EORTC QLQ H&N 35) head and neck questionnaire. Descriptive statistics such as mean and standard deviation (SD)for continuous variables, frequencies and percentages were calculated for categorical variables were determined. Chi-Square Test, P Value *Significant    Loss of appetite, insomnia, constipation and diarrhoea were also the major constituent symptoms. Head and Neck 35 EORTC questionnaire shows significant alterations in quality of life due to local complications and also sequele of residual disease. Swallowing and Social eating were affected badly because of severe mucositis and post-surgical scarring and complications involving flap healing (PFS 3.0, PPW 3.82, PCR 3.60;<0.001).

Results
When the same QLQ 30 and 35 questionnaires were applied to assess the quality of living in different stages of hypopharyngeal cancers individually, Role functioning was found to be very poor, probably due to morbidity of surgery and radiation toxicity (PFS 3.31, PPW 3.55, PCR 2.90;<0.001).

Discussion
Poor quality life secondary to Radiation toxicity lasts for years together and can be never ending since radiation induces irreversible changes at molecular level and stimulates accelerated fibrosis. Even though tissue or organ preservation is achieved with good control of micrometastasis at the margins, the damage is long lasting which cripples the life of the patient. The preserved anatomy of the organ is poor physiologically and rehabilitation has to be simultaneously carried out along with improvement of nutrition and general condition, taking care of the comorbidities.
In the present study with 202 patients who had undergone RT for Hypopharyngeal cancers on whom EORTC QLQ 30 and H&N 35 were applied, morbidity was observed due to RT itself other than the Primary disease as well as Surgery. Bjordal, Hammerlid.,in a study on QLQ in RT pts found compliance rate was high, and the questionnaires were well accepted by the patients The QLQ-H & N35, in conjunction with the QLQ-C30, provides a valuable tool for the assessment of health-related quality of life in clinical studies of H&N cancer patients before, during, and after treatment with radiotherapy, surgery, or chemotherapy [2].
Dyspnoea formed one of the important symptoms in cancers of all the three subsites of hypopharynx.de Graffe A., mentions that there was a significant but temporary deterioration of physical functioning, fatigue and most head and neck symptoms. Speech was the only symptom which improved. Patients with T2 tumors had significantly worse physical symptoms compared with patients with T1 tumors. There was a high level of depressive symptomatology at baseline, followed by an improvement after treatment. After radiotherapy for laryngeal cancer, a temporary deterioration of physical functioning and symptoms occurs, mostly caused by side effects of treatment. Despite physical deterioration, there is an improvement of emotional functioning and mood after treatment, probably as a result of psychological adaptation and coping processes [3].
Generalised symptoms of malignacies like Insomnia, Loss of appetite, Constipation and Diarrhoea were universally present. Bjordal K et al., Seventy-eight percent of the patients who were alive after 12 months filled in all questionnaires (218/280). The general trend was that HRQL deteriorated significantly during treatment, followed by a slow recovery until the 12month follow-up with few exceptions (senses, dry mouth, and sexuality). Pain is common in patients with HNC and is reported by approximately half of patients prior to cancer therapy, 81% during therapy, 70% at the end of therapy, and by 36% at 6 months after treatment. Pain is experienced beyond the 6-month period by approximately one third of patients and is typically more severe than pre-treatment cancer-induced pain [7].
More disturbing was the fact that all pts were poor financially and were unable to bear the cost of treatment as well as rehabilitation Martino and Ringash., state that ,common concerns of head and neck squamous cell cancer patients include concerns about illness and their future, general physical and emotional wellbeing, speech, body image, and financial issues.
Patients receiving radiotherapy report high levels of problems with swallowing, eating, and dry mouth. This article focuses on several of the most common and severe lasting issues for head and neck squamous cell cancer patients: impairments of overall quality of life, xerostomia, speech, and swallowing, focusing primarily on the tools and techniques for measuring such effects [8].
Gandhi AK et al., found that, female: male ratio was 17:83.42% of them were ≥60 years of age. Median value for SW, HO, WL, BL, PALMP, OM, and OS was 33.33 (100-0) while TA, CG, NV, DY, and HE had a median score of 0.00. Advanced HNCa has a significant burden of symptoms. These results would help in giving patients better symptom directed therapies and improve their QOL [9].
Cooper JS., in their book on Radiation toxicity states that, head and neck region is composed of numerous structures, each with an inherent response to radiation that is largely governed by the presence or absence of mucosa, salivary glands, or specialized organs within that site. Irradiated mucocutaneous tissues demonstrate increased vascular permeability that leads to fibrin deposition, subsequent collagen formation, and eventual fibrosis. Irradiated salivary tissue degenerates after relatively small doses, leading to markedly diminished salivary output. This, in turn, effects the teeth by promoting dental decay which, in turn, effects the integrity of the mandible. Details of these changes are presented, including their pathophysiology, clinical syndromes, and potential treatment [10].
Poor physical functioning, Decreased Cognitive skills and Emotions along with low social life were present in all the patients. Schrloo et al. reported better emotional functioning at both follow-ups (p < 0.001), worse social functioning at 12 months (p < 0.05), and better global health status at 24 months (p < 0.05). Patients' own implicit common-sense beliefs about their illness added small but significant amounts of variance to the prediction of QoL after 2 years.
Less belief in own behavior causing the illness predicted better functioning and better global health. Strong illness identity beliefs predicted worse functioning and worse global health. Negative perceptions about the duration of the illness (chronic timeline beliefs) and more negative perceived consequences also predicted worse QoL [11].

Conclusion
Quality of life questionnaires provide an insight into the life of patients who suffer from morbidity of the disease as well as its treatment.
What the study adds to the existing knowledge?
Thorough assessment of the condition of the patient in the post treatment status helps timely rehabilitation. Standardisation and updating of the questionnaire with advances in treatment and its implications in decreasing disease burden might be necessary.