Health-related quality of life of patients with squamous cell carcinoma : a comparison according to tumor location

The aim of this study was to evaluate the health-related quality of life (QOL) of patients with squamous cell carcinoma (SCC) according to tumor location. The sample consisted of 27 patients with primary SCC in the oral cavity (n = 15), pharynx (n = 7), and larynx (n = 5) who were undergoing cancer treatment at the Cancer Hospital of Londrina, regardless of age, sex, clinical stage, and type of antineoplastic treatment. Health-related QOL was evaluated using the 30-item CancerQuality of Life Questionnaire (QLQ-C30), the 35-item Head and Neck Cancer-Quality of Life Questionnaire (QLQ-HN35), and the University of Washington Quality of Life Questionnaire (UW-QOL). These questionnaires were administered individually to each patient before ambulatory care. Sociodemographic data (age and sex) and clinical data (T stage, tumor location, and type of antineoplastic treatment) were collected from the patients’ medical records. Scores were compared according to tumor location using the chi-squared test and one-way analysis of variance (p < 0.05). No score differed significantly according to tumor location. It can be concluded that the health-related QOL of patients with SCC was not influenced by tumor location.


Introduction
The World Health Organization defined quality of life (QOL) as being relative to an individual's perception of their position in life, the cultural context, and the individual's goals, expectations, parameters, and social relations. 1QOL is a multidimensional abstract construct that may be based on individual or collective assessment, and may be evaluated generically or specifically by various instruments and questionnaires. 2,3,4,5,6,7Generic questionnaires do not evaluate a specific disease; specific questionnaires are used to evaluate groups of patients with a certain type of disease in common. 3,8Head and neck cancer is among the diseases that can affect health-related QOL profoundly. 4,5,9,10,11,12ost tools available for evaluation of QOL in head and neck cancer patients were developed originally in English, 13 and must be translated and validated for use in populations that speak other languages. The QLQ-C30 and QLQ-HN35 are instruments composed of questions that assess the patient's QOL in the last week with total score ranges of 0-100L. 3,14The QLQ-C30, which is the EORTC's core QOL instrument, includes a single general health/QOL scale, five functional scales, eight physical symptom scales, and a single item related to financial difficulty (see Table 1 for scales).The QLQ-HN35 is the EORTC's head and neck cancer-specific module questionnaire (EORTC modules are each administered with the core QLQ-C30 assessment).It includes 7 multi-item scales and 11 single-item scales (see Table 2 for scales).The UW-QOL questionnaire is structured as a 12-item (see Table 3 for items). 5,8Each item is scored on a 0-100 scale. 3,14iven the small number of QOL studies in patients with head and neck cancer, an expansion of knowledge about QOL assessment in patients undergoing cancer treatment is needed. 15Therefore, the aim of this study was to evaluate the health-related QOL of patients with squamous cell carcinoma (SCC) according to tumor location.

Methodology
This study was quantitative, observational, and cross-sectional.The sample consisted of 27 patients with primary SCC in the oral cavity (n = 15), pharynx (n = 7), and larynx (n = 5) who were undergoing treatment at the Cancer Hospital of Londrina.Inclusion did not depend on patients' age, sex, clinical stage, or type of antineoplastic treatment.Patients with recurrent disease were not included.The Ethics Committee of the University of North Paraná approved this study (protocol no.846,397).All patients provided written information consent to participate in this study.
Patients' health-related QOL was evaluated individually using the QLQ-C30 (version 3.0), the QLQ-HN35 module, and the UW-QOL (version 4) prior to outpatient care.The UW-QOL domain-importance question, in which patients are asked to identify which 3 of the 12 domains have been the most important to their QOL in the last 7 days, was applied in addition to the 12 main domain items.After questionnaire application, sociodemographic (age and sex) and clinical (diagnostic, tumor location, clinical stage, type of antineoplastic treatment) data were collected from the patients' medical records.Questionnaire   scores were calculated according to the instructions provided in the instrument manuals.The chi-square test and one-way analyses of variance (ANOVAs) were used to compare QLQ-C30, QLQ-HN35, and UW-QoL scores across tumor location groups.The Statistica software (version 7.0 for Windows; StatSoft, Inc., Tulsa, OK) was used, and the significance level was established as p < 0.05.

Results
Patients' sociodemographic and clinical data are presented, and compared between the groups, in Table 4. Age, sex, T stage, and antineoplastic treatment type did not differ according to tumor location, namely oral, pharyngeal, or laryngeal.QLQ-C30, QLQ-HN35, and UW-QoL scores are presented according to tumor location in Tables 1-3.None of the mean scores obtained for the three questionnaires differed significantly among the three tumor location groups.
As reported in Table 1, QLQ-C30 scores did not differ among SCC location groups for any of the scales.Among patients with oral-cavity SCC, the highest average scale score was for social function and the lowest was for dyspnea.Among those with pharyngeal cancer, the highest average scale score was for physical function and the lowest was for diarrhea.Among patients with SCC in the larynx, the highest average scale score was for social function and the lowest was for nausea and vomiting.
As reported in Table 2, the QLQ-HN35 scale with the highest mean score in the oral-cavity cancer group was weight loss and the lowest scores were for coughing, feeding tube, and weight gain.Among patients with pharyngeal cancer, the highest average score was for the painkillers scale and the lowest was for the teeth scale.Among patients with laryngeal cancer, the highest average score was for the painkillers scale and the lowest was for the mouth opening scale.
Among the UW-QOL scales (Table 3), the shoulder function scale had the highest mean score in the all three tumor-location groups.The lowest mean scale scores among patients with oral-cavity cancer were obtained for pain and chewing.The lowest mean scale scores among patients with pharyngeal cancer was taste.Finally, the lowest mean scale scores among patients with laryngeal cancer were obtained for recreation and chewing.Regarding the UW-QOL issue importance question, patients with oral SCC prioritized taste, pain, and chewing; those with pharyngeal SCC prioritized pain, appearance, and taste; and patients with laryngeal SCC tended to rank pain, chewing, and speech as most important (Table 5).

Discussion
To our knowledge, this work is the first to assess health-related QoL in patients with SCC according to tumor location.In this study, health-related QOL was evaluated using the QLQ-C30, QLQ-HN35, and UW-QOL, as in previous studies. 2,3,5,6,8,14,16,17Our QLQ-C30 results are similar to those reported by Crombie et al. 3 and Ch'ng et al. 16 for oral SCC and to those reported by Tribius et al. 17 for head and neck SCC.The global health status scores obtained in this study are similar to those reported in a previous study of patients with head and neck cancer. 17lthough questionnaire scores did not differ significantly among the study groups for any of the scales, we observed some trends that could be clinically relevant.Notably, the mean QLQ-HN35 dyspnea score was 20 or more points worse in the oral-cavity SCC group than in the other two groups.The mean role and social function scores were more than 10 points worse in the pharyngeal SCC group than in the other groups, and the mean financial difficulties score was more than 10 points worse in the laryngeal cancer group than in the other two groups.
Our QLQ-HN35 results were similar to those reported by Tribius et al. 17 for head and neck SCC.Relative to the other two tumor-location groups' mean QLQ-HN35 scores, the mean QLQ-HN35 scale scores obtained for the oral-cavity cancer group were 20 points worse for painkillers and 10 points worse for coughing and feeling ill.Meanwhile, the pharyngeal cancer group's mean teeth score was more than 20 points worse than the scores of the other two groups; and the laryngeal cancer group's mean scores for mouth opening, nutritional supplements, and feeding tube were more than 20 points worse than those of the other two groups.
Our finding that the shoulder function scale score was the highest UW-QOL scale score for all three tumor-location groups (oral cavity, pharynx, and larynx) corroborates the results of Andrade et al. 2 and Crombie et al. 3 Notably, the UW-QOL appearance score was more than 20 points worse in the pharyngeal SCC group than in the other groups.The UW-QOL data show that pain was one of the most important problems experienced by these patients in the previous 7 days.This finding, similar to that reported by Andrade et al., 2 reflects the importance of patient monitoring in all phases of treatment and rehabilitation.
This study had several limitations.First, the sample was small, reflecting the number of patients with SCC undergoing treatment at the Cancer Hospital of Londrina.Second, previous studies have suggested that variables such as age, sex, T stage, and antineoplastic treatment type can influence health-related QOL analysis. 2,7,8However, the homogeneity of the present sample in terms of these variables and the treatment of all of the patients in the same hospital strengthen the validity of the comparisons made in this study.

Conclusion
Based on the results of this study, it can be concluded that the health-related QOL of patients with SCC was not influenced by tumor location.

Table 3 .
UW-QOL scores according to tumor location.

Table 4 .
Sociodemographic and clinical data.Some patients received more than one type of antineoplastic therapy.

Table 5 .
Ranking of patient priorities according to tumor location.