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10 Quality ofLife inHead & Neck Surgical Oncology andThyroid Surgery
149
Table 10.1
Quality of Life (QoL) instruments and patient reported outcome measures (PROMs) in head and neck
surgical oncology and thyroid surgery
Measurement
tool
Site-specic quality of life (QoL) instruments and patient reported outcome measures (PROMs)
AQLQ [6] NR Likert (2–4,
COH-QoL
Thyroid [7]
EORTC
QLQ-H&N 35
[8]
EORTC
QLQ-THY [9]
FACT-HN [10] 11–27 Likert (5pt) Physical, functional areas of
FACT-NP [11] 16–27 Likert (5pt) Physical, social/family,
FSCI [12] 15 Likert (5pt) 3 subscales– Emotional,
FSH&N-SR
[13]
H&NS [14] 13 Likert (5pt)
HNCI [15] 30 Likert (5pt) Overall QoL item and four
HNQOL [16] 20 Likert (5pt) Eating, communication,
MDASI-HN
[17]
Parotidectomy
QOL Survey
[18]
Number of
items Scale Domains Scoring Time frame
7pt)
41 Ordinal
35 Likert
34 Likert (4pt) Burden, symptoms
15 and
free hand
item
9 Likert
8 Ordinal
(10pt)
(4pt), yes/
no
Likert (5pt) Overall QoL item and
(11pt)
(7pt),
multiple
answer
choices and
1 freelance
item
Physical functioning,
symptoms, social
functioning, psychological
functioning, well-being,
overall life satisfaction
Physical, psychological,
social and spiritual
well-being
Pain, swallowing, senses,
speech, social eating, social
contact, sexuality
including tiredness, pain,
voice change, dysphagia,
dry mouth, palpitations,
joint pain, tingling, muscle
cramps
performance, social
functioning, relationship
with physician, emotional
well-being
emotional and functional
well-being, nasopharyngeal
carcinoma subscale
social, appearance
symptom categories– Upper
body mobility, chewing,
swallowing, drooling, taste,
dry mouth, eating, speech,
breathing, appearance, pain,
fatigue
Eating/swallowing, speech/
communication, appearance,
head and neck pain
domains– Speech, earing,
aesthetics, social disruption
pain, emotion
Swallowing/chewing,
mucous, taste, voice/speech,
mouth/throat sores, teeth/
gum issues, choking/cough,
constipation, diarrhoea, hair
loss, skin issues
Frequency, duration, degree
of bother, size of affected
area, daily activity interface,
frequency and worry caused
by abnormal sensation
around ear or neck
No global score NR Y
Domain, reverse
anchoring
Global Past
NR Past
Global, module Past
Domain Past
Subscale, total
skin cancer index
Domain Past
Global, domain Past
Domain Past
Domain Past
In conjunction
with 13 MDASI
NR Past
Past
7days
7days
7days
7days
7days
Current N
7days
4weeks
4weeks
4weeks
Past 24h Y
4weeks
following
surgery
Translations
(yes/no)
N
Y
N
Y
N
N
N
Y
Y
N
(continued)
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Table 10.1
Measurement
tool
QLQ-Rathmell
[19]
QOL-NPC [20] 30 Liner
QOL-Thyroid
[21]
THYCA-QOL
[22]
ThyCAT [23] <59 NR Physical, psychological,
University of
Frankfurt QLQ
[24]
University of
Liverpool QLQ
[25]
UWQOL [26] 15 Likert
VHNSS [27] 28 Likert
Treatment-specic quality of life (QoL) instruments and patient reported outcome measures (PROMs)
HNRT-Q [28] 23 Likert
NDI [29] 10 Likert (6pt) Pain intensity, personal care,
NDQ [30] 12 5pt. rating Neck and shoulder
(continued)
Number of
items Scale Domains Scoring Time frame
13 4–5 answer
categories
(11pt)
30 Ordinal
(11pt)
24 Seven
conceptual
scales
17–31 Likert (6pt) Patient belief’s, hopes and
10 Likert (5,
10pt), yes/
no
(3-6pt)
(11pt)
(3-7pt)
Pain frequency/severity,
eating ability, mouth
dryness, taste, appetite,
weight loss, speech, energy
level, work, social contact,
state of mind, physical
appearance,
Four domains– Physical,
psychological, social, side
effect
Subscales- physical,
psychological, social,
spiritual
Dry mouth, dysphagia,
voice change, scar,
temperature intolerance,
weight gain, neuromuscular
symptoms, fatigue, anxiety
social and spiritual
well-being
expectations, care
satisfaction, symptoms
(physical and
psychological), relationships
Communication, diet, social
activity physical
functioning, appearance,
emotional function,
relationships, treatment
regret
Pain, appearance, activity
level, recreation,
swallowing, chewing,
speech, shoulder function,
taste, saliva, depression,
anxiety
Subscales– Nutrition, pain,
voice, swallow, mucous/dry
mouth
Domains- oral cavity/
mouth, throat, skin,
digestive function, energy,
psychosocial
lifting, reading, headaches,
concentration, work,
driving, sleeping, recreation
symptoms, limitations in
activities of daily living,
occupational and leisure
activities
NR Past week N
Domain NR Y
Mean, subscale,
reverse anchor
Domain NR N
NR NR N
NR Past
Global Past
Composite
scores for
physical and
social function,
domain
Global, subscale Past
Mean (global and
domain)
Global (none,
mild, moderate,
severe, complete)
Domain Since
During
illness and
treatment
2–3weeks
4weeks
Past
7days
7days
Past
7days
Everyday
life
treatment
Translations
(yes/no)
N
N
N
Y
N
N
N
N
(continued)
10 Quality ofLife inHead & Neck Surgical Oncology andThyroid Surgery
151
Table 10.1
Measurement
tool
POS-HN [31] 6
QOL-ACD
[32]
QOL-EF [33] 20 Likert (5pt) Physical, psychological,
QOL-RTI [34] 14 Likert
SDQ [35] 16 Yes/no/not
SPADI [36] 13 VA S Pain, disability Mean of both
Symptom-specic quality of life (QoL) instruments and patient reported outcome measures (PROMs)
DAS24 [37] 24 Likert type Disgurement- general
EAT-10 [38] 10 Likert (5pt) Dysphagia
EDQ [39] 28 Yes/no/
FaCE [40] 15 Likert (5pt) Facial nerve paralysis-
LORQ [41] 40 Likert
MDADI [42] 20 Likert (5pt) Emotional, functional and
NAFEQ [43] 14 Likert (5pt) Nasal reconstruction- nasal
OHIP-14 [44] 14 Likert (5pt) Functional limitation,
(continued)
Number of
items Scale Domains Scoring Time frame
(presurgery)
9
(postsurgery)
22 Likert (5pt) Domains- daily activities,
Likert
(3-5pt)
(11pt)
applicable
don’t know,
multiple
answer
(4pt), free
text
Psychological functioning,
cosmetic appearance,
satisfaction
physical condition, social
activities, mental/
psychological status
nancial, occupational,
relationship issues
Pain, appearance, speech,
chewing and swallowing,
mucous and saliva, taste,
cough
NR Summary Past 24h Y
self-consciousness of
appearance, sexual and body
Dysphagia- eating habits,
personal feelings, seeking
help
social function, facial
comfort, facial movement,
oral function, eye comfort,
lacrimal control
Oral function, oro-facial
appearance, social
interaction, prosthesis,
denture, prosthetic
satisfaction
physical perceptions of
swallowing ability
function (airow, snoring,
smell, dry mucosa,
epistaxis, phonation), nasal
appearance satisfaction
physical pain, psychological
discomfort, physical,
psychological, and social
disabilities, handicap
Pre-surgery:
Global
Post-surgery:
Domain
Global, domain Past few
Global NR N
Mean Past
domains
Global NR N
Score≥3 is
abnormal
NR Current Y
Global, domain Past
NR Past
Global, subscale Past
Domain NR N
NR Past
Past
4weeks
days
7days
NR N
Since onset
of
swallowing
disorder
7days
7days
7days
4weeks
Translations
(yes/no)
N
Y
Y
N
N
N
Y
Y
(continued)
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Table 10.1
Measurement
tool
OMAS [45] 3 VAS,
OMDQ [46] 12 Likert
OMQOL [47] 31 Likert (4pt) Symptoms, diet, social
OMWQ [48] 12 Likert
OPDI [49] 17 VA S Symptom severity
SECEL [50] 35 Likert (4pt) Voice related subscales–
SHI [51] 31 Likert (4pt) Speech, psychological Global Current Y
SSQ [52] 17 VAS, 0–5
SWAL-QOL
[53]
VASS [54] 5 Likert
VHI and
VHI-10 [55]
VOS [56] 5 Likert
VPQ [57] 45 Differential
V-RQOL [58] 10 Likert (5pt) Voice related- physical
XeQoLS [59] 15 Likert (5pt) Physical functioning, pain/
XI [60] 11 Likert (5pt) Mouth, eye, lip dryness,
(continued)
Number of
items Scale Domains Scoring Time frame
4-response
(5pt), linear
scale
(11pt),
multiple
choice
(5,7,11pt)
scale
44 Likert
(5pt), yes/
no,
5-response
answer
(10pt)
10.30 Likert (5pt) Voice related– Functional,
(3.5pt)
response
(10pt),
open-ended
questions
Pain, swallowing Patient and
Overall health, mouth throat
soreness, medication use
function, swallowing
Global health, QoL, mouth
and throat soreness, mouth
and throat pain
(oropharyngeal dysphagia)
General, environmental,
attitudinal
Dysphagia, time taken to eat Sum, global Current N
Dysphagia related burden,
eating duration, eating
desire, symptom frequency,
food selection,
communication, fear, mental
health, social, generic
fatigue, sleep
Voice impairment <6 on at least 1
physical emotional
Voice issues Global NR Y
Speech-related, removalreplacement related,
maintenance, QoL,
humidication, hands-free
issues
functioning, social,
emotional
discomfort, personal/
psychological, social
functioning
dysphagia
doctor rated
mean mucositis
score, extent of
mucositis and
worst site score
Mean mucositis Past 24h N
Global, subscale NR N
Global Past
Global Current N
Global Past
Domain Past
question shows
overall voice
impairment
Global, domain NR Y
Differential scale
use to audit
laryngectomies
Global, domain Past
Global, domain Past
Global Past
Current N
7days
4weeks
4weeks
NR N
NR N
2weeks
7days
2weeks
Translations
(yes/no)
N
Y
Y
N
N
N
(continued)
10 Quality ofLife inHead & Neck Surgical Oncology andThyroid Surgery
153
Table 10.1
Measurement
tool
XQ (2001) [61] 8 Likert
XQ (2002) [62] 17 4/5 grades,
XQ2 [63] 20 Likert
NR, not reported; VAS, visual analogue scale; Pt, point; AQLQ, Auckland quality of life questionnaire; EORTC QLQ-H&N35,
European organization for Research and treatment of Cancer questionnaire head and neck module; EORTC QLQ-THY,
European organization for Research and treatment of Cancer questionnaire thyroid; FACT-HN, Functional assessment of cancer therapy– head and neck module; FACT-NP, Functional assessment of cancer therapy– nasopharyngeal module; FSCI,
Facial skin cancer index; FSH&N-SR, Functional status in head and neck cancer– self report measure; H&NS, Head & Neck
Survey; HNC, head and neck cancer; HNCI, Head and Neck Cancer Inventory; HNQOL, University of Michigan head and
neck QOL questionnaire; MDASI-HN, MD Anderson Symptom Inventory– Head and Neck; QOL, quality of life; QLQ, quality of life questionnaire; QOL-NPC, Quality of life for nasopharyngeal carcinoma; UWQOL, University of Washington quality
of life questionnaire; VHNSS, Vanderbilt head and neck symptom survey; HNRT-Q, Head and neck radiotherapy questionnaire;
NDI, Neck disability index; NDQ, Neck dissection quality of life questionnaire; POS-HN, Patient Outcomes of Surgery–
Head/Neck; QOL, quality of life; QOL-ACD, QOL instrument for patients treated with anticancer drugs; QOL-EF, QOL
instrument for patients with enteral feeding tubes; QOL-RTI, QOL radiation therapy index; SDQ, Shoulder disability questionnaire; SPADI, Shoulder pain and disability index; DAS24, Derriford Appearance Scale– short form; FaCE, Facial clinimetric
evaluation scale; NAFEQ, Nasal appearance and functional evaluation questionnaire; EAT-10, Eating assessment tool-10 item
version; EDQ, European dysphagia questionnaire; HNC, head and neck cancer; LORQ, Liverpool oral rehabilitation questionnaire; MDADI, MD Anderson Dysphagia Inventory; OHIP-14, Oral health impact prole- 14 item version; OMAS, Oral
mucositis assessment scale; OMDQ and OMWQ, Oral mucositis daily and weekly questionnaires; OMQOL, Oral mucositis
quality of life measure; OPDI, Oral pharyngeal dysphagia inventory; SSQ, Sydney swallow questionnaire; SWAL-QOL,
Outcome measure of quality of life and quality of care in dysphagia patients; THYCA-QOL, thyroid cancer quality of life;
ThyCAT, computerized adaptive test thyroid; XeQoLS, Xerostomia-related quality of life scale; XI, Xerostomia inventory; XQ,
Xerostomia questionnaire; SECEL, Self evaluation of communication experiences after laryngeal cancer; SHI, Speech handicap index; VASS, Vocal abilities and social situations questionnaire; VHI, Voice handicap index; VOS, Voice outcome survey;
VPQ, Voice prosthesis questionnaire; V-RQOL, Voice-related quality of life questionnaire.
(continued)
Number of
items Scale Domains Scoring Time frame
ordinal
(11pt)
yes/no, VAS
(4-5pt),
VA S
Dryness while eating/
chewing, dryness while not
eating/chewing
Degree of dry mouth,
xerostomia related problems
Xerostomia symptoms,
QoL, xerostomia experience
Global NR N
NR NR N
Sum NR N
Translations
(yes/no)
allow for valid comparisons to be made. In
addition, other properties such as accessibility
(web or app enabled tools) and time taken to
completion and responsiveness, are key features in enabling the widespread use of such
instruments to allow for adequately powered
studies and direct comparisons. Such research
can enable development of a gold-standard
instrument that can be standardised according
to a valid guideline based on the most important
outcomes (to patients). In turn, this will enable
reliable comparisons to be drawn between different patient groups to allow for more accurate
information regarding predicted QoL outcomes
to be portrayed to patients when counselling
them regarding their treatment options.
Figure10.2 summarises the key points around
QoL for the clinician practicing in the elds of
head and neck surgical oncology and thyroid
surgery.
154
Within
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G. Garas et al.
Fig. 10.1 Predictors of poor Quality of Life (QoL) in head and neck surgical oncology and thyroid surgery
Head and neck
cancer involves a
highly
heterogenous
group of
malignancies in
terms of their
anatomy and
histopathology
Treatment options
such as radical
surgery and/or
chemoradiotherapy
can contribute to
significant physical,
functional and
psychosocial
burdens
Patients tend to
suffer with speech,
taste and
swallowing,
breathing and social
isolation issues that
can negatively
impact their QoL
There are a variety
of QoL tools that
often overlap to
allow clinicians to
assess patients QoL
outcomes
In patients with
laryngeal cancer,
there needs to be a
balance between
organ-preserving
versus organ non-
preserving
treatment options
in terms of
oncological benefit
and QoL
oropharyngeal
cancer patients
there is significant
subgroup
heterogeneity
leading to various
treatment options
that each carry
benefits and
drawbacks in terms
of QoL outcomes
Thyroid-specific
QoL tools can be
beneficial in
comparing
outcomes between
different treatment
modalities
Future research
should focus on
robust comparisons
between QoL
measurement tools,
heterogenous
patient subgroups
and treatment
modalities
Fig. 10.2 Key points on Quality of Life (QoL) for the clinician practicing in the elds of head and neck surgical oncology and thyroid surgery
harm caused by excessive drinking and smoking
Organ-specic Quality ofLife (QoL)
Considerations inHead & Neck
Surgical Oncology
[69, 70]. The incidence of laryngeal cancer has
also been shown to strongly correlate with socioeconomic deprivation; within the UK, its incidence is highest in the North of England and
Quality ofLife (QoL) inLaryngeal
Cancer
Scotland, which are among the most socioeconomically deprived parts of the British Isles [71].
Cancers of the larynx are typically classied
Laryngeal cancer is the second most common
head and neck cancer in the UK [67]. Like most
head and neck cancers, it is strongly associated
with the synergistic effect of alcohol consumption and tobacco smoking [68], however, within
Northern Europe and America the incidence of
laryngeal cancer has gradually declined, mostly
due to the public health messaging around the
on the basis of their anatomical origin; the vocal
cords (glottis), and the laryngeal structures above
(supraglottis) and below (subglottis) the vocal
cords. This sub-classication is more useful for
smaller tumours as larger tumours often occupy
more than one subsite and it can thus be difcult
to accurately identify their origin. The relevance
of identifying the primary site of tumours comes
10 Quality ofLife inHead & Neck Surgical Oncology andThyroid Surgery
155
to the fore in considering the incidence of occult
metastases in the neck. In a recent systematic
review, the incidence of occult neck metastases in
early supraglottic cancer has been reported at just
under 20% [72], although some centres have
reported rates as high as 48% [73]. In contrast,
early glottic cancer has an occult cervical metastasis rate of about 8% [72]. Thus, patients presenting with early supraglottic cancer are likely
to need simultaneous treatment of their neck,
whereas for early glottic cancer most centres will
adopt an expectant approach with the neck. Aside
from the benets in 5-year survival, this of course
will have implications when considering posttreatment QoL.
Early-stage laryngeal cancer is generally a
treatable condition via single modality therapy,
with T1 glottic tumours having a 5-year survival
at almost 90% irrespective of the treatment
modality used [74]. A few studies have suggested
however that surgery may confer a marginally
better 5-year survival over radiotherapy [75, 76].
The reality of course is that expertise will vary
within different head and neck cancer units and
alongside this, various patient factors and tumour
characteristics will dictate the optimum treatment
paradigm a patient receives.
The key post-treatment side effect of concern
for T1 laryngeal cancer is voice disruption, which
is particularly relevant for those patients where
vocal function is a quintessential aspect of their
occupation. Given that 5-year survival is similar
between treatment with radiotherapy or surgery,
the question therefore arises as to the long-term
impact these treatments have on vocal function.
The Vocal Handicap Index (VHI) is the fundamental QoL assessment tool used in studies to
compare voice outcomes following radiotherapy
or Transoral Laser Microsurgery (TLM). As a
tool, it has a broad function and is not specic to
patients with cancer. It consists of 30 questions
relating to the domains of functional, physical,
and emotional aspects of vocal function. Scores
range from 0–120, with lower scores indicating
less severe vocal function [77]. An abbreviated
version of the tool is also in use consisting of 10
questions which has been validated [55].
A meta-analysis including 362 patients has
demonstrated that there was no signicant difference in VHI scores in patients with T1 laryngeal
cancer treated with either radiotherapy or surgery, however there was a trend towards slightly
better VHI scores in the radiotherapy group [78].
A number of systematic reviews have also drawn
similar conclusions [75, 79]. Unfortunately,
robust Randomised Controlled Trials (RCTs) on
the subject are lacking, which would help to
counter the treatment allocation bias that is likely
to be present in some of the studies included in
these reviews [80]. The EASTER trial (EArly
STage glottis cancer: Endoscopic resection or
Radiotherapy trial) attempted to address this
issue but failed to recruit enough participants. Of
the factors identied for the failure of this trial,
the key feature seemed to be the logistical benets that TLM offers when compared to radiotherapy; TLM offers patients a daycase solution to
their treatment versus a 6-week course of daily
hospital visits (Monday– Friday) for radiotherapy and the short- and long-term morbidity associated with this [81]. Thus, patients with
squamous cell carcinoma (SCC) localised to the
mid-third of the vocal cords constitute optimal
candidates for TLM. As for lesions located in the
anterior third of the vocal cords, concerns around
impact on voice become more apparent due to the
potential for scarring and subsequent anterior
glottic web formation, which can result in longlasting effects on voice [82]. In these instances,
patients need to be carefully counselled about the
pros and cons of surgery versus radiotherapy; and
for the occupational voice user, radiotherapy may
be a more favourable treatment option.
When considering T2 glottic SCC, although
this also comes under the early stage disease category, 5-year survival in this patient cohort is signicantly poorer than those with T1 glottic
tumours, with a meta-analysis on the subject
demonstrating 5-year survival ranging between
65–75% [83]. These patients have a higher propensity for locoregional recurrence. The goal of
single modality therapy remains oncologically
treating the disease whilst preserving the larynx;
not only anatomically but also in terms of its
156
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G. Garas et al.
function. For patients receiving radiotherapy as
their primary treatment modality, the risk of
recurrence is about one in three [84, 85]. When
this is the case, the main salvage option for the
majority of radiorecurrent laryngeal cancer cases
remains open surgery, usually in the form of total
laryngectomy, which carries a signicant level of
morbidity including in terms of voice and swallowing function. Conversely, with TLM a systematic review has estimated recurrence rate with
transoral laser surgery to be slightly lower at just
under 25% [86]. However, in this circumstance,
further options for organ preservation exist,
including second look TLM with further resection and radiotherapy, thus potentially avoiding
the morbidity of a total laryngectomy and the
long-term impact this has on QoL [87]. Indeed,
the laryngeal preservation rate has been shown to
be signicantly higher for patients undergoing
TLM at 88% versus radiotherapy at 79% as primary treatment for T2 glottic SCC in a recent
systematic review [86]. The same review also
attempted to compare functional outcomes
between TLM and radiotherapy, specically with
regards to voice and swallowing, however, due to
the large heterogeneity, this could not be conducted in a statistical fashion.
Alongside using the VHI (a patient-centred
tool), other tools have also been used in a variety
of studies in this patient population. These
include the GRBAS scale, clinician- orientated
perceptual analysis questionnaire to help assess a
patient’s voice quality for Grade of hoarseness,
Roughness, Breathiness, Asthenia and Strain
[88]. Voice outcomes can also be objectively
measured with acoustic analysis and aerodynamic analysis. Generally, poorer vocal function
is associated with more extensive resections [89],
and tumours of the anterior commissure are also
associated with deleterious functional outcomes
[82]. However, whilst these are important considerations when devising a treatment strategy and
counselling a patient with T2 disease, the importance of laryngeal preservation supersedes these
factors.
The treatment of advanced laryngeal cancer
traditionally has been with total laryngectomy,
commonly followed by adjuvant (chemo)radio-
therapy. Whilst total laryngectomy offers satisfactory locoregional control, the procedure is not
without morbidity and a signicant adverse
impact on QoL. In the short-term, patients can
experience wound breakdown, ap necrosis and
pharyngocutaneous stula, which can all result in
prolonged hospital admission and delay adjuvant
treatment [90]. In the medium- to long-term,
issues with dysphagia, voice, and communication, as well as anosmia can all negatively impact
QoL.A systematic review looking at QoL tools
in total laryngectomy highlights some of these
issues; a common theme that emerges is the negative impact total laryngectomy has on social
interaction and emotional wellbeing, reected
particularly in the EORTC QLQ-C30 and H&N35
tools [91].
Research focussing on QoL predictors has
also shown that several domains deteriorate during treatment periods and slowly improve once
treatment has been completed [92, 93]. Domains
most signicantly affected include xerostomia,
pain, voice disturbance and overall reduced physical functioning. These factors seem to be negatively inuenced by both treatment modalities
(surgery and radiotherapy) [94–96]. Patients who
have a lower socio-economic status also appear
to have lower QoL scores [97].
The notion of organ preservation has also made
its way into the discourse around management of
advanced laryngeal cancer. The landmark Veretan
Affairs study compared patients undergoing
organ-preserving chemoradiotherapy (induction
chemotherapy plus radiation) with those undergoing total laryngectomy plus radiation and demonstrated similar survival between both groups at
2years [98]. Although the prospect of laryngeal
preservation seems appealing in preserving QoL
in this patient cohort, non- surgical treatment for
advanced laryngeal cancer carries substantial
morbidity. Importantly, this can include the development of a non-functioning larynx, thus defeating the purpose of organ preservation and
ultimately necessitate a functional laryngectomy
(even if the patient has been ‘cured’ from an
oncologic perspective). A recent systematic
review attempted to compare total laryngectomy
with organ- preservation treatment for advanced
10 Quality ofLife inHead & Neck Surgical Oncology andThyroid Surgery
157
laryngeal cancer, however, there were insufcient
studies of necessary quality to draw any meaningful conclusions [99]. Until such studies become
available, the current modus operandi will remain,
that patients who have laryngeal dysfunction at
the time of presentation are likely to have worse
QoL with organ preservation strategies, and thus
be more amenable for total laryngectomy.
Quality ofLife (QoL)
inOropharyngeal Cancer
The treatment of oropharyngeal cancer is currently an area of considerable interest due to its
sharp rise in incidence across the Western world
over recent decades [100]. Whereas traditionally
oropharyngeal cancers have been closely related
to heavy smoking and excessive alcohol consumption, much of the current disease burden
comes from an increasing cohort of patients
infected with the Human Papilloma Virus (HPV)
[101].
Patients with HPV-mediated oropharyngeal
cancer tend to be younger with a more favourable
performance status than the traditional HPV negative patient cohort. Within this context, the
impact of curative treatment on the patient’s QoL
becomes even more pertinent as these patients
are expected to live for decades with the side
effects of their treatment. Thus, minimising these
is equally important as is considering 5-year survival outcomes when evaluating the efcacy of a
treatment paradigm [102].
The treatment of early stage oropharyngeal
cancer traditionally involved single modality
treatment in the form of radiotherapy, with concurrent chemoradiation reserved for patients with
advanced stage disease. Surgery typically tended
to be reserved as a salvage option, due to the
extensive morbidity associated with open
approaches to the oropharynx. With increasing
concerns around subjecting the generally
younger, tter HPV positive oropharyngeal cancer patients to the toxicity of (chemo)radiation
and its late effects, research has focused on the
prospect of treatment de-escalation amongst this
cohort [103]. Furthermore, the advent and evolu-
tion of minimally invasive head and neck surgical
techniques such as TLM and TransOral Robotic
Surgery (TORS), which circumvent much of the
morbidity associated with open surgery, has substantially changed the approach to treating HPV
positive oropharyngeal cancer and presents a
paradigm shift in modern head and neck oncological practice [104, 105].
Regardless of the treatment strategy employed,
it is clear that patients who undergo treatment for
oropharyngeal cancer will suffer both short- and
long-term consequences to their swallowing
function [106, 107] with up to 80% of patients
treated for oropharyngeal cancer reporting problems with their swallowing on a daily basis with
a demonstrable detrimental impact on QoL [108,
109]. Swallowing function in this patient popula-
tion can be assessed by using either objective
methods such as modied Barium swallow or
functional endoscopic assessment of swallow
(FEES), as well as subjective measures in the
form of patient questionnaires or validated QoL
assessment tools. Commonly used QoL instruments amongst this patient population include
the University of Washington Quality of Life
Questionnaire (UW-QOL) [26], the MD
Anderson Dysphagia Index (MDADI) [42] and
the European Organisation for the Research and
Treatment of Cancer (EORTC) Quality of Life
Questionnaire Head and Neck 35 (QLQ-H&N35)
[110], all of which are specic for head and neck
cancer patients. Tools not specic for head and
neck cancer are also frequently used. These
include the Radiation Therapy Oncology Group
Grade (RTOG) [111], and the EORTC QLQ
core- 30 [110]. Challenges exist when interpreting results from both subjective and objective
forms of swallowing assessment; objective measures often do not accurately reect patient
reported outcomes, whilst scores from subjective
measures can vary depending upon the assessment tool used making comparisons between
studies challenging [112–114].
A systematic review examining the various
tools available to assess swallowing outcomes in
patients treated for oropharyngeal cancer has
demonstrated that just over three quarters of studies reported subjective outcomes of swallowing
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G. Garas et al.
function, with only around one in three reporting
objective measures [115]. This is not surprising,
given that data from patient reported outcomes
are easier to collate than from objective investigations. The most common assessment tool used
was the RTOG, whilst the MDADI and the
UW-QOL were the most common head and neck
cancer-specic tools.
The existing heterogeneity within the oropharyngeal cancer population, coupled with the
numerous methods and tools available for assessing post-treatment QoL can pose challenges in
analysing the published data on the subject.
Nevertheless, attempts have been made to try and
undertake meta-analysis of studies in this area. In
a recent systematic review, data was pooled from
41 studies that met the inclusion criteria, yielding
a total of 1366 patients [116]. The authors were
particularly interested in examining long-term
QoL outcomes, therefore only studies that collated data after 12months were included in their
analysis. It was shown that deteriorations in average QoL scores became most apparent in the
UW-QOL domains of swallow, chewing, saliva,
taste, in the MDADI physical, global, and emotional domains and in the QLQ-H&N35 domains
for sticky saliva and dry mouth. Of note, a common theme of difculty in swallowing and xerostomia existed with all three QoL instruments
featuring in this meta-analysis. Unfortunately,
most of the included studies predated routine
HPV testing, and furthermore, the effects of confounding variables such as tumour staging and
underlying co-morbidities meant that it was difcult for the authors to compare various treatment paradigms with one another.
Studies comparing QoL outcomes between
HPV positive and negative patients are lacking.
Another recent meta-analysis attempted to examine the effects of differing treatment paradigms
on QoL in HPV positive patients [117].
Specically, chemoradiotherapy with cisplatin
was compared to surgery with adjuvant therapy.
The results showed that surgery with adjuvant
therapy was more likely to result in patients
remaining dependent on gastrostomy in the longterm compared to chemoradiotherapy with cisplatin, although these differences did not reach
statistical signicance. This also correlated with
the fact that surgery and adjuvant therapy resulted
in signicantly worse swallowing outcomes as
per the MDADI, UW-QOL, and the EORTC
QLQ-HN35 tools. The ndings from this metaanalysis appear to agree with those from the
ORATOR RCT, which seems to favour radiotherapy over surgery, although their conclusions also
did not reach statistical signicance [118].
Whilst it may appear that (chemo)radiotherapy performs better on QoL outcomes versus surgery plus adjuvant therapy, it is worth considering
that when surgery alone is employed to treat oropharyngeal cancer (single modality surgery),
morbidity is naturally reduced; for example, gastrostomy dependence rates and incidence and
severity of xerostomia. Thus, within the HPV
positive oropharyngeal cancer patient population, it is vital to better dene the role of deescalation strategies regarding adjuvant therapy,
which the long-awaited PATHOS trial is currently evaluating [103].
Quality ofLife (QoL) inThyroid
Cancer
Thyroid cancer is the most common endocrine
malignancy [119], more frequently affecting
women than men [120]. Despite an increase in its
global incidence [121], earlier diagnosis and
improved treatment options have resulted in an
overall reduced mortality, also most certainly a
result of the increasing overdiagnosis of indolent
low-risk thyroid cancers driving a thyroid cancer
‘epidemic’ [122]. This ‘paradox’ of concurrently
increasing incidence and reducing mortality for
thyroid cancer, though clearly benecial from an
oncological standpoint, can pose substantial
challenges in clinical decision making, especially
when it comes to QoL considerations in patients
with incidental, low-risk thyroid cancers of
doubtful clinical signicance. Thyroid cancer
survivors are often managed with lifelong surveillance that can further contribute to anxiety
surrounding recurrence as well as regular healthcare appointments that can disrupt social and
professional life [123–125].
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