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10 Quality ofLife inHead & Neck Surgical Oncology andThyroid Surgery
159
Emotional, functional, and social effects on a patient’s life can be measured with a variety of QoL instruments and PROMs questionnaires. In view of the high survivorship rate in thyroid can­cer, there is an increasing onus on accurately measuring patients’ QoL to further improve patient outcomes by inuencing treatment path­ways [126]. The most commonly used thyroid­specic QoL instruments are COH-QoL Thyroid and QOL-Thyroid [127]. These generally assess similar domains such as the general effect on physical, psychological, social, and spiritual wellbeing during illness and/or treatment. The EORTC QLQ-THY [9] and THYCA-QOL [22] are other common tools that evaluate the effect of symptoms including tiredness, pain, voice change, dysphagia, palpitations, tingling, and muscle cramps, amongst others.
Current treatment options for thyroid cancer patients depend on the specic (sub-)type. Management strategies include surgery (thyroid lobectomy or total thyroidectomy), RadioActive Iodine (RAI) ablation, Thyroid Stimulating Hormone (TSH) suppression, active surveillance, or targeted systemic therapy in cases of relapsing and metastatic disease, among others [128]. Increased survivorship in thyroid cancer patients means longer periods of disease-free life, but also an increased chance of living with the adverse effects associated with treatment(s). It is there­fore imperative to understand the impact of treat­ment choices on thyroid cancer patients’ QoL.
Interestingly, despite thyroid cancer having a relatively good prognosis, thyroid cancer patients appear to suffer a disproportionately lower QoL than would have been expected, especially when considering the QoL impact on patients with dif­ferent cancer sites known to carry a much worse prognosis [7, 129–131]. Specically, thyroid cancer survivors have a lower reported overall QoL compared to breast cancer survivors, and similar results compared to gynaecological, gli­oma, and colorectal cancer survivors [132].
There is a multitude of factors contributing to this [133–135]. Due to its relatively good progno­sis, many thyroid cancer patients report their diagnosis can be trivialised as they are frequently told about having a ‘good cancer type’. [129]
However, they still experience anxiety related to their initial diagnosis, and fear of a second can­cer, but can feel that they do not have as much support from their families and physicians as a result of the good prognosis [132, 136]. As previ­ously mentioned, lifelong surveillance can con­tribute to this anxiety and disrupt patients’ social and professional lives. The impact of such post­treatment surveillance is only magnied in younger patients who have more disease-free years as is often the case in thyroid cancer survi­vors [129]. Patients can also enter a hypothyroid state which can contribute to a wide range of unpleasant symptoms including fatigue, increased appetite, and sleep changes that can all negatively impact on QoL [21].
Surgical complications have also been shown to contribute to negative QoL scores with postop­erative dysphonia and dysphagia representing key predictors of worse QoL post-thyroid surgery [137]. In addition, negative scar perception, espe­cially in females, can contribute to lower QoL scores [138]. Complications of RAI such as appetite changes, sialadenitis, xerostomia, and xerophthalmia, as well as its impact on fertility, have also been associated with inferior QoL scores [137]. In addition, further issues can arise with RAI, where some patients report being mis­informed regarding its possible side effects resulting in them being unclear on the benets and risks of the therapy [139]. There is also data to suggest that RAI can shorten the reproductive life of a female, which can substantially impact on QoL from a psychosocial standpoint. [140] Overall, RAI has been shown to be associated with poorer QoL scores [141].
Patients with hypoparathyroidism as a com­plication of thyroid surgery also report lower QoL compared to those without in domains such as global health, physical, emotional, and social functioning as well as tiredness, pain, and insom­nia [142]. This is important to recognise as up to 14% of thyroid cancer patients can have low cal­cium levels even up to 1 year after diagnosis [143]. Furthermore, permanent hypoparathyroid­ism following total thyroidectomy has been shown to be associated with an increased risk of death [144]. This can further add to health-related
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anxiety in thyroid cancer survivors. Generally, utilisation of QoL instruments has found that lowest overall scores were attributed to the dis­tress following initial diagnosis, RAI ablation, surgery, withdrawal of levothyroxine, and fear of a second cancer [129]. These QoL scores were lower when evaluated less than one year com­pared to more than 5years post-treatment.
Comparison ofQuality ofLife Between Dierent Treatments forThyroid Cancer
Given the above concerns, recent studies have aimed to compare QoL between treatment options for thyroid cancer patients. Of course, the main factor governing treatment choice is typi­cally curative potential. However, patients’ QoL should not be underestimated when making per­sonalised treatment recommendations. These should always be made in a multidisciplinary fashion with active patient involvement.
Robotic Versus Open Thyroidectomy
The use of robotic thyroidectomy emerged in 2009 [145–147]. In comparison to traditional open approaches, robotic thyroidectomy can achieve superior cosmesis - with its associated benecial effect on QoL- but this is at the expense of time and cost [148]. In terms of post-operative complications, robotic thyroidectomy carries a reduced incidence of (permanent) Recurrent Laryngeal Nerve (RLN) paralysis and temporary hypoparathyroidism, with no signicant differ­ence in (temporary) RLN neurapraxia, permanent hypoparathyroidism, haematoma and chyle leak rates compared to open thyroidectomy [149, 150]. In addition, there is no difference in disease recur­rence between the surgical approaches.
With respect to QoL measures, while there is no demonstrable difference in pain at 1 month post-operatively, there is less neck paraesthesia, less voice change and better voice reported with robotic thyroidectomy compared to open. There is also a signicant increase in patient reported sat­isfaction with ‘invisible’ axillary/chest scars com­pared to traditional neck incisions [150–153]. Despite this, it is important to note that the use of
robotic thyroidectomy remains limited outside South Korea, where the majority of this data orig­inates from, with a questionable value in health­care settings across the Western World [154]. The translatability of the outcomes discussed above in other countries is therefore likely to be limited.
Radioactive Iodine Ablation Versus Surgery
RAI can be administered to patients as an adju­vant therapy following total thyroidectomy for high-risk differentiated thyroid cancer. When examining the effect of RAI on QoL, there are known factors that can lead to worse scores, already discussed above. There is limited data comparing QoL outcomes in patients undergoing RAI ablation and surgery versus surgery alone. PROMs studies suggest no difference between the 2 groups when it comes to domains such as anxiety, fatigue, pain, insomnia, and physical functioning. There is also no difference in overall self-reported health-related QoL between the 2 groups [155].
Radiofrequency Ablation Versus Surgery
In cases of papillary thyroid microcarcinoma, RadioFrequency Ablation (RFA) can be adminis­tered as an independent treatment modality to surgery. Use of QoL instruments such as SF-36 and the thyroid specic THYCA-QoL, demon­strate better physical and mental outcomes with RFA compared to surgery. Understandably, there are also better reported outcomes with respect to scar perception in RFA alone compared to total thyroidectomy. There is no reported difference in fear of progression/recurrence between these groups [156].
Hemithyroidectomy Versus Total Thyroidectomy
Hemithyroidectomy alone can be a viable treat­ment option in patients with low-risk differenti­ated thyroid cancer [157]. This has stemmed from research demonstrating no additional ben­et with total thyroidectomy compared to hemithyroidectomy in overall survival in
10 Quality ofLife inHead & Neck Surgical Oncology andThyroid Surgery
161
Papillary Thyroid Cancer (PTC) even for tumours exceeding 1cm (i.e. beyond microcar­cinomas) [158]. Hemithyroidectomy has been shown to have less adverse patient-reported health-related QoL outcomes and adverse treat­ment effects compared to total thyroidectomy [159]. In addition, those undergoing hemithy­roidectomy report less concerns regarding their scar compared to total thyroidectomy as evalu­ated by THYCA-QOL [156]. However, overall long-term QoL outcomes have shown no differ­ence between hemi- and total thyroidectomy patients [160, 161]. In addition, evaluation of thyroid-specic domains such as voice con­cerns, neck discomfort, swallowing and tem­perature intolerance with EORTC QLQ-C30, THYCA-QOL, and EORTC QLQ-THY34 QoL instruments has not shown any difference between the 2 treatment groups [160, 162]. In fact, when considering patient worry surround­ing recurrence, patients undergoing hemithy­roidectomy scored worse than those who had total thyroidectomy [160]. However, this needs to be balanced against the lower complication prole of hemithyroidectomy compared to total thyroidectomy [163]. As previously discussed, post- thyroidectomy complications can have an independent effect on QoL outcomes and should thus be taken into consideration and clearly explained to patients.
Active Surveillance Versus Surgery
For papillary thyroid microcarcinomas, active surveillance with serial imaging by an appropri­ate multidisciplinary thyroid team lifelong has been shown to constitute a safe alternative to immediate surgery [164]. When comparing QoL measures between the 2 groups, utilisation of THYCA-QOL has demonstrated that patients undergoing surgery tend to report inferior QoL outcomes. This is particularly relevant for domains relating to voice, scar, neuromuscular, and psychological outcomes [165, 166]. When assessing outcomes with more generic QoL instruments such as fear of progression (FoP­Q- SF), there is no difference in outcomes between these 2 groups [165].
Conclusion
Patient reported outcomes constitute a vital com­ponent in optimising overall treatment outcomes in all aspects of modern head and neck oncology. This is especially true in thyroid cancer patients who experience disproportionately worse QoL compared to patients with other primary cancers carrying a much worse prognosis. This is in part related to the younger demographic of thyroid cancer patients who naturally have a longer period of disease-free life to worry about factors such as recurrence. Utilisation of thyroid-specic QoL tools can be benecial in comparing QoL outcomes between treatment modalities. This can help guide multidisciplinary consultations with patients by presenting to them all options and dis­cussing the benets and risks of each including the possible impact of each treatment strategy to their QoL, a key consideration for all patients. It is the hope that this can further improve overall outcomes related to thyroid cancer management by allowing patients to make more informed decisions regarding their care.
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Quality ofLife andPatient
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Reported Outcomes inBreast Cancer
KimBorsky andFionaTsang-Wright
11
Introduction
Breast cancer is the most common cancer world­wide and, in absolute numbers, one of the most common causes of cancer deaths [1]. There has been a lot of development over the past few decades in regard to treatment leading to a variety of treatment options in breast cancer patients, including surgery, endocrine therapy, chemother­apy, targeted therapy, and radiotherapy. These, combined with improvements in early detection and prevention, have led to vastly improved sur­vival rates with an estimated average 5-year sur­vival of over 90% [1, 2]. These new therapies, of course, come at a trade-off. Besides the obvious benets in survival, the variety of different surgi­cal options as well as the drugs in use and the exposure to radiation all have a specic set of adverse effects that have to be taken into consid­eration. Therefore, it is of interest to investigate the health-related quality of life (HRQOL) of breast cancer survivors. The literature body on this topic is extensive. This chapter aims to com­prehensively summarize the evidence in the available literature on HRQOL in breast cancer patients to identify key factors that inuence the
HRQOL and identify areas for improvement that should be considered in future clinical practice.
Material andMethods
Search Strategy
Due to the extensive literature related to this topic, only systematic reviews related to HRQOL in breast cancer patients were considered. This guarantees a certain degree of quality of the respective articles. Regarding the 10-year time frame, this comes shortly after the advent of all commonly used adjuvant therapies, which, of course, can potentially inuence HRQOL and therefore make results more comparable. A PubMed search using the following criteria was performed: ((((Quality[Title]) AND (Breast[Title])) AND ((“2011/01/01”[Date ­Publication]: “3000”[Date- Publication]))) AND (Systematic Review[Filter])) AND (quality of
these search terms were then hand searched for any other relevant systematic reviews.
Inclusion andExclusion Criteria
K. Borsky · F. Tsang-Wright (*) Bucks Breast Unit, Buckinghamshire Healthcare NHS Trust, High Wycombe, UK e-mail: kim.borsky@nhs.net;
ona.tsangwright@nhs.net
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 T. Athanasiou et al. (eds.), Patient Reported Outcomes and Quality of Life in Surgery,
https://doi.org/10.1007/978-3-031-27597-5_11
Systematic reviews from January 2011 onwards in English reporting on the HRQOL in breast cancer patients were included. Only papers unre-
169
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