The Laryngoscope

C 2013 The American Laryngological,

V
Rhinological and Otological Society, Inc.

The Effect of Cancer Stage and Treatment Modality on Quality

of Life in Oropharyngeal Cancer

Justine Oates, RN, BSc; Sarah Davies, RN, BSc; Jessica K. Roydhouse, BA, MPH(Hons);
Judith Fethney, BA(Hons), BTeach; Kate White, RN, PhD

Objectives/Hypothesis: To examine changes in health-related quality of life among oropharyngeal cancer patients by
stages and across treatment types among advanced cancer patients.
Study Design: Individual prospective cohort study.
Methods: All newly diagnosed patients with oropharyngeal cancer treated with curative intent were routinely assessed.
The European Organization for Research and Treatment of Cancer (EORTC) both the Main Module quality-of-life questionnaire
(QLQ-C30) and the Head and Neck Cancer (HNC) Module (QLQ-H&N35) were administered at diagnosis and 3, 6, and 12
months thereafter. Complete case analysis was used following assessment of missing data. The proportion of patients with
clinically significant deterioration (changes of 10 points) from baseline were calculated for each follow-up time point and
compared by stage (I/II vs. III/IV) and then treatment type (chemotherapy and radiotherapy [CRT] vs. surgery and postopera-
tive radiotherapy [S&PORT]).
Results: Deterioration in most domains was most frequent for stage III/IV patients at 3 months (both modules),
whereas stage I/II patients experienced this at 6 months (QLQ-C30) and 12 months (H&N35). Among stage III/IV patients,
this happened at all time points for S&PORT patients (QLQ-C30) versus 12 months for CRT patients (H&N35). The number of
patients reporting deterioration was lower for most domains at 12 months compared to earlier periods, although dry mouth
remained a problem for most patients (60%–85% across treatment/stage groups).
Conclusions: Our preliminary findings suggest that general and disease-specific deterioration is of most concern for
stage I/II patients at 6 and 12 months and at 3 months for advanced cancer patients. For stage III/IV patients receiving
S&PORT, general deterioration remains a problem after diagnosis, whereas for CRT patients, disease-specific deterioration is
of most concern at 12 months.
Key Words: Head and neck cancer, oropharyngeal cancer, quality of life, surgery and postoperative radiotherapy,
chemoradiation.
Level of Evidence: 4.
Laryngoscope, 124:151–158, 2014

INTRODUCTION patients experience a worsening in quality of life (QOL)

Head and neck cancer (HNC) and its treatment
affects both the physical and psychosocial aspects of
health-related quality of life (HRQOL).1 Most HNC
From the Sydney Head and Neck Cancer Institute (J.O., S.D.),
Royal Prince Alfred Hospital, Camperdown, Australia; Sydney Cancer
Centre (J.O., S.D., J.K.R., K.W.), Royal Prince Alfred Hospital, Missenden
Road, Camperdown, Australia; Cancer Nursing Research Unit (J.K.R.,
J.F., K.W.), Sydney Nursing School (K.W., J.K.R., J.F.), University of Sydney,
Sydney, Australia; School of Nursing, Edith Cowan University, Joon-
dalup, Australia.
Editor’s Note: This Manuscript was accepted for publication
March 11, 2013.
This work was performed at the Sydney Head and Neck Cancer
Institute, Royal Prince Alfred Hospital, Camperdown, Australia.
Presented at the Cancer Nurses Society of Australia 14th Winter
Congress, Sydney, New South Wales, Australia, July 21–23, 2011; the
Multinational Association of Supportive Care in Cancer International
Symposium on Supportive Care, New York, New York, U.S.A., June 28–
30, 2012; and the 17th International Conference on Cancer Nursing
(Biennial Meeting of the International Society of Nurses in Cancer
Care), Prague, Czech Republic, September 9–13, 2012.
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
Send correspondence to Justine Oates, RN, Sydney Head and Neck
Cancer Institute, Royal Prince Alfred Hospital, Missenden Road, Camper-
down NSW 2050 Australia. Email: justine.oates@sswahs.nsw.gov.au
DOI: 10.1002/lary.24136
during treatment, but then return to pretreatment
(baseline) levels by 12 months after treatment,2–5
although some disease-specific items such as dry mouth,
senses, or saliva remain below baseline levels.2,4
Stage of disease, cancer site, and treatment type
are predictors of post-treatment HRQOL, particularly
disease-specific symptoms.5 Findings of statistically sig-
nificant differences in HRQOL scores favoring patients
receiving a single therapy compared to combination
therapies5–7 are not consistent across studies.3 Compari-
sons of the effect of chemotherapy and radiotherapy
(CRT) to surgery and postoperative radiotherapy(S&-
PORT) on HRQOL have likewise been inconclusive
regarding which therapy is associated with more dis-
ease-specific symptoms.8,9 Further research is required
to ascertain the impact of treatment modality on
HRQOL, particularly for patients with oropharyngeal
cancers.7
Since 2001, prospective longitudinal assessment of
HRQOL pre- and post-treatment has been incorporated
into standard clinical practice in a tertiary head and
neck oncology service at a major metropolitan cancer
center in Sydney, Australia.10 The aim of this article

Laryngoscope 124: January 2014 Oates et al.: Quality of Life in Oropharyngeal Cancer
151
was to examine clinically significant HRQOL changes
over time by cancer stage and by treatment modality in
oropharyngeal cancer patients.
MATERIALS AND METHODS
Study Design and Sample
The study design is a prospective cohort study. The patient
population was drawn from patients being treated at the Syd-
ney Cancer Centre Head and Neck Unit, Royal Prince Alfred
Hospital for HNC. Eligibility criteria were treatment with cura-
tive intent, no recurrence, English-language ability, no cognitive
impairment, and a first diagnosis of HNC. This study presents
data collected from 2002 to 2010; data collection, as part of rou-
tine multidisciplinary care at the Sydney Cancer Centre Head
and Neck Unit, is ongoing. To date, there have been no refusals
to participate.
Data Collection Measures
HRQOL was assessed using the European Organization
for Research and Treatment of Cancer (EORTC) quality-of-life
questionnaire (QLQ), both the Main Module (QLQ-C30) and the
Head and Neck Cancer (HNC) Module (QLQ-H&N35). These
questionnaires are valid and reliable11–13 and have been tested
widely.14 The QLQ-C30 includes general function and symptom
items and the QLQ-H&N35 assesses HNC-specific symptoms.
As per EORTC scoring guidelines, scores were linearly trans-
formed to a 0- to 100-point scale.15 For function scales (QLQ-
C30), 100 represents maximum function and 0 represents mini-
mum function, therefore higher scores indicate better function.
For symptom scales (QLQ-C30, H&N35) 100 represents maxi-
mum symptoms and 0 represents minimum symptoms, there-
fore higher scores indicate worse symptoms. This article reports
scale measures only.
Information on patient survival status was obtained from
the death registry of New South Wales and the database at the
Sydney Cancer Centre Head and Neck Unit, which contains
patient information including notifications of patient death. In-
formation about patient diagnosis, stage of disease (staged as
per American Joint Committee on Cancer recommendations),16
and treatment type and dose was obtained from hospital
records.
Statistical Analysis
Handling of missing data. It was apparent there were
missing data due to death and individuals lost to follow-up, and
therefore a number of checks were required to determine the
best approach for analyzing the data (i.e., complete case or im-
putation of missing data). Logistic regression analysis could not
identify any significant association between clinical characteris-
tics (cancer stage, treatment type, global health status from the
previous period) and missing data (P > 0.10 in all analyses).
Nonparametric tests were used to explore whether there
were differences in change over time between the different
datasets created to explore missing values: 1) complete case; 2)
complete case and deceased patients, with worst possible scores
(0 for function scores, 100 for symptom scores)17,18 assumed for
deceased patients; 3) imputation of all missing data; and 4)
worst possible scores assumed for deceased patients, other miss-
ing data imputed. Imputation was by single imputation using
the expectation maximization algorithm (n 5 100 iterations) for
all HRQOL items with clinical characteristics included as auxil-
iary variables. Little’s missing completely at random (MCAR)
test was employed for datasets 2 and 4, and in both cases the
Laryngoscope 124: January 2014
152
null hypothesis of MCAR was not rejected. The median HRQOL
scores and pattern of changes in the scores over time were com-
pared for all datasets and were similar if not identical across
datasets, supporting a complete case analysis approach.
Analytical approach. All analyses were conducted using
IBM SPSS version 19 (IBM, Armonk, NY). Clinical significance
is of relevance when employing HRQOL assessments as part of
clinical practice,19 therefore clinically significant changes in
HRQOL outcomes, defined to be a change of 10 points or
more,20,21 were assessed. Clinically significant change has been
described as a difference in score that is large enough to have
an implication for the patient’s treatment or care.22 Changes in
each domain for each time point for individuals were computed
by taking the difference for each HRQOL domain from the base-
line (e.g., 3 months–baseline). As per recommendation,19 the
proportion of patients with clinically significant deterioration
compared to baseline (decrease of 10 points for function scales,
increase of 10 points for symptom scales), clinically significant
improvement (increase of 10 points for function scales,
decrease of 10 points for symptom scales), or clinically stable
HRQOL was estimated. Recently, there have been suggestions
to consider other approaches to clinical significance, and
changes in scores that vary across the domains of the main
module have been suggested. The differences in scores com-
pared to baseline were also assessed using the recent guidelines
of Cocks et al.,23 which are available for the main (QLQ-C30)
module, specifically the proportion of patients with trivial,
small, medium, and large deterioration by the Cocks et al.
guidelines.
Clinically significant changes in HRQOL scores are
reported in preference to P values, as statistically significant
changes in HRQOL measures do not necessarily imply clinical
relevance.22 For readability only, results relating to clinically
significant deterioration are presented.
The proportion of patients with clinically significant dete-
rioration could not be compared across treatment groups
directly, because the treatments were not evenly balanced
across stages. CRT was used predominantly in stage III/IV
patients (95%), as was S&PORT (72%), whereas radiotherapy
alone was predominantly used in stage I/II patients (57%). Pro-
portions were therefore compared by cancer stage (early: stage
I/II, advanced: stage III/IV) and then treatment type within the
advanced cancer group, as most patients were in that group.
Due to the low number of patients with stage III/IV cancer
receiving radiotherapy alone (n 5 3), comparisons within this
group were restricted to patients receiving combination therapy.
Ethical Approval
The study was approved by the Human Research Ethics
Committee of the Sydney Southwest Area Health Service (Royal
Prince Alfred Hospital Zone). Because the study is ongoing, the
application is resubmitted for review and approval on an an-
nual basis. Informed consent was obtained from all patients
prior to data collection.
RESULTS
Demographic and Clinical Characteristics
Ninety-six participants have participated since
2002, and 60 patients completed questionnaires at all
time points. Table I presents the demographic and clini-
cal characteristics of the full sample. When survival sta-
tus was assessed in April 2011, just over half of the
patients (59%) were still alive. The most common cancer
Oates et al.: Quality of Life in Oropharyngeal Cancer
 TABLE I.
Demographic and Clinical Characteristics of Participating Patients
(N 5 96).
Characteristic
Gender
Male
Female
Survival status as of April 2011
Alive
Dead
Diagnosis
Tonsil
Soft palate
Tongue base
Stage* N0 N1 N2
T1 0 2 11
T2 15 12 24
T3 5 2
T4 3 4
Treatment
Surgery only
Radiotherapy only
Surgery and postoperative radiotherapy
Chemotherapy and radiotherapy
*Valid percent used as data missing for one patient.
site was the tonsil (56%), and most patients were stage
IV at diagnosis (62%).
Fifty-six patients received CRT. Among these
patients, 27 (48%) received cisplatin third weekly,
whereas seven (13%) received cetuximab weekly, nine
(16%) received cisplatin weekly, and two (4%) received
carboplatin weekly. A further six (11%) were enrolled in
a trial of tirapazamine, and regimen information was
unknown for the five (9%) treated at another hospital.
Among CRT patients, 44 had percutaneous endo-
scopic gastrostomy (PEG) tubes inserted pretreatment.
Of these, six (11%) had PEG tubes until 2 months follow-
ing treatment, 15 (27%) at 3 months, and 11 (20%) at 6
months. Although 11 (20%) were PEG dependent, three
(5%) refused PEG and four (7%) had a comorbidity that
excluded PEG use. Information on PEG tubes was not
available for the five (9%) treated at another hospital.
For those 88 patients who received radiotherapy, 43
(49%) had a dose of <70 Gy, and 21 (24%) had a dose of
70 Gy. Intensity-modulated radiotherapy (IMRT) was
given to 11 (13%) patients; as the hospital introduced
IMRT in 2008, all patients receiving IMRT have been
treated since that time. Information on radiotherapy
dose is not available for the 13 patients (15%) who were
treated at another hospital.
Table II compares the proportion of patients with
clinically significant worsening for the main HRQOL
module. The highest proportion of stage III/IV patients
with worsened scores compared to baseline occurred at
Laryngoscope 124: January 2014
3 months, whereas for stage I//II patients, the highest
proportion occurred at 6 months. Between the two
stages, at each time point a higher proportion of patients
No. (%) with stage III/IV cancer experienced clinically significant
deterioration across more domains compared to patients
with stage I/II cancer. The disparity between the two
71 (74) groups was greatest at 3 months, where stage III/IV
25 (26) patients reported a higher proportion of clinically worse
scores (13 of the 15 domains) compared to stage I/II (one
of the 15 domains). By 6 and 12 months, the differences
57 (59)
between the groups were less pronounced, and the num-
39 (41)
ber of patients experiencing deterioration was lower.
However, one-third or more of patients still experienced
54 (56) clinically significant deterioration at 12 months: global
5 (5) health status (31% of stage III/IV), role function (33% of
37 (39) stage III/IV), fatigue (38% of stage III/IV), and insomnia
(36% of stage I/II and 33% of stage III/IV).
N3 For the comparison across treatment types, the
0 greatest deterioration in the main module was reported
1 at 3 months, as these were all stage III/IV patients.
9 0 Between the two treatment types, a higher proportion of
7 0 patients receiving S&PORT experienced clinically signifi-
cant deterioration in more domains compared to patients
No. (%) receiving CRT, although differences between the two
8 (8) groups were smaller by 12 months. S&PORT was consis-
11 (11) tently worse than CRT across all time periods for cogni-
21 (22) tive function, fatigue, and pain, whereas CRT was
consistently worse for physical function.
56 (58)
Clinically significant deterioration in fatigue was
reported by just over half to two-thirds of both treatment
groups at 3 months. Although a smaller proportion of
the CRT group reported worsening at 12 months, over
50% of the S&PORT group were still reporting clinically
significant deterioration at 12 months. Nearly one-third
of S&PORT patients continued to report deterioration in
the domains of global health status, role function, and
insomnia at 12 months.
By the Cocks et al. guidelines,23 for the symptom
scales, when clinically significant deterioration was
present, such deterioration was entirely medium and/or
large. For the function scales, at least 50% of patients
had medium and/or large clinically significant deteriora-
tion when such deterioration was present. The highest
proportion of patients with small and/or trivial deterio-
ration for the function scales at any time point was
33.4% (physical function at 6 months compared to
baseline).
Table III compares the proportion of patients with
clinically significant worsening for the disease-specific
HRQOL module. For the comparison across disease
stages, results were similar for the head and neck mod-
ule. Within each of the two stages, the highest propor-
tion with clinically significant worsening occurred at 3
months for stage III/IV and at 12 months for stage I/II.
Between the two stages a higher proportion of stage
III/IV patients reported worsening than stage I/II at
3 months (11 of 13 domains compared to two of 13) and
6 months (eight of 13 compared to two of 13).
By 12 months, both groups reported a similar num-
ber of deteriorated symptoms. Despite the overall trend
toward improvement, over one-third of patients from
Oates et al.: Quality of Life in Oropharyngeal Cancer
153
 TABLE II. TABLE II.
Clinically Significant Worsening Compared to Baseline for the (Continued)
EORTC QLQ-C30.*
When Highest
When Highest Proportion
Proportion 3 6 12 Within Each
3 6 12 Within Each Months Months Months Group Occurs
Months Months Months Group Occurs
Dyspnea
Global health status Overall 15% 10% 10%
Overall 51% 36% 27% Stage I/II 0% 18% 18% 6 and 12 months
Stage I/II 18% 36% 9% 6 months Stage III/IV 19% 8% 8% 3 months
Stage III/IV 58% 35% 31% 3 months CRT 16% 3% 9% 3 months
CRT 59% 34% 28% 3 months S&PORT 23% 15% 0% 3 months
S&PORT 54% 31% 31% 3 months Insomnia
Physical function† Overall 42% 37% 33%
Overall 30% 25% 22% Stage I/II 27% 36% 36% 6 and 12 months
Stage I/II 18% 27% 27% 6 and 12 months Stage III/IV 46% 38% 33% 3 months
Stage III/IV 33% 25% 21% 3 months CRT 50% 38% 31% 3 months
CRT 38% 28% 22% 3 months S&PORT 39% 39% 31% 3 and 6 months
S&PORT 31% 23% 15% 3 months Appetite loss‡
‡
Role function Overall 35% 30% 18%
Overall 42% 37% 28% Stage I/II 9% 18% 18% 3 and 6 months
Stage I/II 9% 27% 9% 6 months Stage III/IV 42% 33% 19% 3 months
Stage III/IV 50% 40% 33% 3 months CRT 34% 31% 19% 3 months
CRT 50% 44% 31% 3 months S&PORT 62% 39% 15% 3 months
S&PORT 54% 39% 39% 3 months Constipation
Emotional function‡ Overall 8% 13% 8%
Overall 25% 23% 22% Stage I/II 0% 18% 0% 6 months
Stage I/II 9% 9% 9% Same Stage III/IV 10% 13% 10% 6 months
Stage III/IV 29% 27% 25% 3 months CRT 16% 9% 6% 3 months
CRT 28% 28% 25% 6 months S&PORT 0% 15% 15% 6 and 12 months
S&PORT 31% 15% 23% 3 months Diarrhea
Cognitive function§ Overall 5% 0% 0%
Overall 22% 23% 13% Stage I/II 0% 0% 0% N/A
Stage I/II 9% 27% 9% 6 months Stage III/IV 6% 0% 0% 3 months
Stage III/IV 25% 23% 15% 3 months CRT 3% 0% 0% 3 months
CRT 19% 16% 9% 3 months S&PORT 15% 0% 0% 3 months
S&PORT 39% 31% 23% 3 months Financial difficulties‡
Social functionk Overall 22% 23% 12%
Overall 30% 30% 22% Stage I/II 9% 18% 0% 6 months
Stage I/II 36% 36% 27% 3 and 6 months Stage III/IV 25% 25% 15% 3 and 6 months
Stage III/IV 29% 29% 21% 3 and 6 months CRT 25% 31% 19% 6 months
CRT 31% 28% 19% 3 months S&PORT 31% 8% 8% 3 months
S&PORT 31% 39% 23% 6 months Across domains
FatigueठStage I/II worse 1/15 4/15 4/15
Overall 52% 48% 33% Stage III/IV worse 13/15 6/15 8/15
Stage I/II 27% 46% 18% 6 months Similar 1/15 5/15 3/15
Stage III/IV 58% 50% 38% 3 months CRT worse 4/15 5/15 4/15
CRT 56% 44% 28% 3 months S&PORT worse 10/15 8/15 7/15
S&PORT 69% 69% 54% 3 and 6 months Similar{ 1/15 2/15 4/15
Nausea and vomiting
*Proportions of patients over time by stage (overall, n 5 60; stage I/II,
Overall 10% 2% 0%
n 5 11; stage III/IV, n 5 48; cancer stage information not available for all
Stage I/II 9% 0% 0% 3 months patients) and across advanced cancer patients receiving combination
Stage III/IV 10% 2% 0% 3 months therapies (overall, n 5 45; CRT, n 5 32; S&PORT, n 5 13; only n 5 3
advanced cancer patients received radiotherapy alone, therefore combina-
CRT 9% 0% 0% 3 months tion therapies were compared). Percents were rounded and therefore may
S&PORT 15% 8% 0% 3 months not add up to 100.
†
PainठCRT consistently worse than S&PORT across all time periods.
‡
Stage III/IV consistently worse than stage I/II across all time
Overall 42% 25% 15% periods.
§
Stage I/II 18% 18% 9% 3 and 6 months S&PORT consistently worse than stage CRT across all time periods.
k
Stage I/II consistently worse than stage III/IV across all time periods.
Stage III/IV 48% 27% 17% 3 months {
Within 6 two points.
CRT 41% 19% 13% 3 months CRT 5chemotherapy and radiotherapy; EORTC QLQ-C30 5 European
S&PORT 69% 46% 23% 3 months Organization for Research and Treatment of Cancer Quality-of-Life Question-
naires, Main Module; S&PORT 5surgery and postoperative radiotherapy.

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154
 TABLE III. TABLE III.
Clinically Significant Worsening Compared to Baseline for the (Continued)
EORTC QLQ-H&N35. * When
Highest
When
Proportion
Highest
3 6 12 Within Each
Proportion
Months Months Months Group Occurs
3 6 12 Within Each
Months Months Months Group Occurs
Opening mouth
Pain† Overall 30% 32% 20%
Overall 25% 17% 13% Stage I/II 36% 27% 0% 3 months
Stage I/II 9% 18% 0% 6 months Stage III/IV 29% 33% 25% 6 months
Stage III/IV 29% 17% 17% 3 months CRT 22% 34% 28% 6 months
CRT 19% 9% 9% 3 months S&PORT 54% 39% 8% 3 months
S&PORT 54% 31% 31% 3 months Dry mouth§
Swallowing‡ Overall 73% 67% 62%
Overall 35% 22% 17% Stage I/II 82% 73% 73% 3 months
Stage I/II 9% 0% 9% 3 and 12 months Stage III/IV 73% 67% 60% 3 months
Stage III/IV 42% 27% 19% 3 months CRT 66% 63% 63% 3 months
CRT 47% 28% 22% 3 months S&PORT 85% 69% 54% 3 months
S&PORT 39% 31% 8% 3 months Sticky saliva†
Senses Overall 35% 28% 23%
Overall 42% 28% 23% Stage I/II 18% 27% 27% 6 and 12 months
Stage I/II 18% 18% 27% 12 months Stage III/IV 40% 29% 23% 3 months
Stage III/IV 48% 31% 23% 3 months CRT 34% 25% 19% 3 months
CRT 44% 31% 19% 3 months S&PORT 54% 46% 31% 3 months
S&PORT 62% 31% 39% 3 months Coughing
Speech‡ Overall 17% 10% 8%
Overall 20% 17% 10% Stage I/II 0% 9% 18% 12 months
Stage I/II 9% 9% 9% Same Stage III/IV 21% 10% 6% 3 months
Stage III/IV 23% 19% 10% 3 months CRT 16% 9% 9% 3 months
CRT 19% 19% 13% 3 and 6 months S&PORT 39% 8% 0% 3 months
S&PORT 39% 23% 8% 3 months Feeling ill‡
Social eating Overall 25% 17% 7%
Overall 53% 37% 17% Stage I/II 9% 9% 0% 3 and 6 months
Stage I/II 36% 18% 18% 3 months Stage III/IV 29% 19% 8% 3 months
Stage III/IV 58% 42% 17% 3 months CRT 28% 19% 13% 3 months
CRT 56% 47% 16% 3 months S&PORT 39% 23% 0% 3 months
S&PORT 69% 39% 15% 3 months Across domains
Social contact Stage I/II worse 2/13 2/13 5/13
Overall 22% 5% 5% Stage III/IV worse 11/13 8/13 5/13
Stage I/II 18% 9% 9% 3 months Similark — 3/13 3/13
Stage III/IV 23% 4% 4% 3 months CRT worse 1/13 3/13 9/13
CRT 25% 6% 6% 3 months S&PORT worse 10/13 8/13 3/13
S&PORT 23% 0% 0% 3 months Similark 2/13 2/13 1/13
Sexuality‡
*Proportions of patients over time by stage (overall, n 5 60; stage I/II,
Overall 40% 48% 38% n 5 11; stage III/IV, n 5 48; cancer stage information not available for all
Stage I/II 27% 36% 36% 6 and 12 months patients) and across advanced cancer patients receiving combination
therapies (overall, n 5 45; CRT, n 5 32; S&PORT n 5 13; only n 5 3
Stage III/IV 44% 52% 40% 6 months advanced cancer patients received radiotherapy alone, and therefore com-
CRT 44% 53% 44% 6 months bination therapies were compared. Percents were rounded and therefore
may not add up to 100.
S&PORT 46% 46% 23% 3 and 6 months †
S&PORT consistently worse than stage CRT across all time
Teeth periods.
‡
Stage III/IV consistently worse than stage I/II across all time
Overall 22% 28% 25% periods.
§
Stage I/II 9% 18% 27% 12 months Stage I/II consistently worse than stage III/IV across all time
periods.
Stage III/IV 25% 31% 25% 6 months k
Within 6 two points.
CRT 25% 31% 25% 6 months CRT 5chemotherapy and radiotherapy; EORTC QLQ-
H&N35 5 European Organization for Research and Treatment of Cancer
S&PORT 31% 39% 15% 6 months Quality-of-Life Questionnaires, Head and Neck Module; S&PORT 5surgery
and postoperative radiotherapy.

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155
both groups continued to report deterioration at 12
months in the sexuality domain (stage I/II: 36%, stage
III/IV: 40%), and a majority of patients from both groups
reported deterioration for dry mouth (stage I/II: 73%,
stage III/IV: 60%). Furthermore, there was greater dete-
rioration over time for five domains for stage I/II: senses
(18% to 18% and 27%), sexuality (27% to 36% and 36%),
teeth (9% to 18% to 27%), sticky saliva (18% to 27% to
27%), and coughing (0% to 9% to 18%).
For comparison across treatments, the greatest
deterioration in the head and neck module was reported
at 3 months. Between the two treatment types, a higher
proportion of patients receiving S&PORT experienced
clinically significant deterioration in more domains com-
pared to CRT patients at 3 months, although by 12
months this had reversed, when higher proportions of
CRT patients reported clinically significant deteriora-
tion. Deterioration in dry mouth symptoms was reported
by a majority of both treatment groups at 3 months
(66% for CRT, 85% for S&PORT) and was still reported
by more than 50% of both groups at 12 months. For
S&PORT patients, worsening of pain and sticky saliva
remained relatively high at 12 months (both 31%),
whereas 44% of CRT patients reported worsening sex-
uality at 12 months.
DISCUSSION
The prevalence of clinically significant deterioration
among patients with oropharyngeal cancer varied by
cancer stage and by treatment type among patients with
advanced cancer. Furthermore, differences were appa-
rent across the HRQOL modules, with proportionally
more advanced cancer and S&PORT patients experienc-
ing deterioration in domains of the main module but
proportionally more stage I/II and CRT patients experi-
encing deterioration in domains of the head and neck-
specific module.
These findings, although preliminary due to the
small number of patients in the study, are broadly con-
sistent with other findings of deterioration during treat-
ment and then subsequent improvement within the next
12 months.2,24 Differences in terms of length of follow-
up25 and type of treatment2 may help explain why our
findings for dry mouth and sexuality show much greater
deterioration than reported in a number of other
studies.2,26,27 Furthermore, other studies examining
HRQOL in oropharyngeal cancer have used different
instruments28,29or have not been prospective,7–9,30 which
may also explain the divergence in findings. Few studies
have also reported clinical significance as part of their
analysis,24,31 presenting an additional challenge. In this
study, a difference of at least 10 points was considered
clinically significant, and an assessment of the differen-
ces in scores against newly released guidelines23 relating
to interpretation of differences in the main module indi-
cated that most clinically significant deterioration seen
in this study was medium to large.
In contrast to Tschudi et al., we found differences
among the treatment types in both the main and head
and neck specific modules.7 In our study, S&PORT
Laryngoscope 124: January 2014
156
patients experienced deterioration in higher proportions
in more domains of the main module, whereas the
reverse was true for the head and neck-specific module.
Tschudi et al. found differences to be most pronounced
in the head and neck module only. The domains in which
we found greater deterioration for S&PORT patients
also differed from those reported in Tschudi et al.
However, like Boscolo-Rizzo and colleagues, we
found that patients receiving CRT performed compara-
bly better in the domains of the main module but worse
in the domains of teeth, opening mouth, and dry mouth
in the head and neck module.9 For S&PORT patients,
we found less deterioration in the domains Boscolo-Rizzo
et al. found to be more problematic for this patient
group. We also found that differences remained after
treatment, in contrast to the findings of Mowry et al.8 A
possible explanation for these divergences is length of
follow-up and study design; we used a prospective design
and followed patients for 1 year after treatment,
whereas all three studies looked at patients at least 2
years post-treatment.
Comparing our findings with regard to stage and
HRQOL is difficult, as most studies looking across stage
in HNC do not focus specifically on oropharyngeal can-
cer patients. Previous work has identified that unsur-
prisingly, patients with advanced-stage cancer have
worse symptom and function scores and greater deterio-
ration over time than patients with early-stage cancer.4
Our results supported this in that patients with
advanced cancer had greater deterioration at all time
periods compared to early-stage patients, and was par-
ticularly marked at 3 months, although the differences
between the two groups were much less pronounced by
12 months. Only social function appeared to be a consis-
tently worse problem for early-stage cancer patients.
In this study, xerostomia remained a significant
complaint at 12 months; these results may improve since
IMRT was performed at this institution 7 years after the
introduction of prospective QOL assessment. IMRT has
been shown to have fewer oral-related symptoms and
better global QOL outcomes compared to two-dimen-
sional radiotherapy and three-dimensional conformal
radiotherapy.32
A strength of this study is the thorough assessment
of missing data, which lends support for the ultimate de-
cision to use complete case analysis. Furthermore,
although attrition did occur in this study, primarily due
to death, missing data due to not completing aspects of
the questionnaire were minimal. In particular, the prob-
lem of patients not completing the sexuality item6,14,33
did not occur in this study. The integration of prospec-
tive HRQOL assessment into routine clinical practice
and the high participation rate may make these findings
particularly relevant for clinicians treating patients with
oropharyngeal cancer with curative intent.
This study also had several limitations. Although
missingness was rigorously assessed, definitive conclu-
sions regarding the missingness mechanism are not pos-
sible,34 therefore we cannot rule out bias. Due to the
small numbers of patients in the early-stage cancer
group, the findings for this group cannot be considered
Oates et al.: Quality of Life in Oropharyngeal Cancer
definitive. Similarly, the small numbers in each treat-
ment group among the advanced cancer patients mean
that this study is an exploratory assessment, and the
findings are useful in indicating further areas for
research and assessment rather than providing clear
guidelines for clinical practice. This was a prospective
study conducted over a long time period, and during this
time chemoradiation treatment changed; as noted above,
IMRT was introduced several years after the prospective
assessment commenced. A subset analysis to examine
HRQOL variations across differing treatment groups
was not possible due to the small number of patients.
This study is also one of few to carry out prospec-
tive assessment of HRQOL in oropharyngeal cancer. It is
also one of very few to examine the impact of combina-
tion therapies on HRQOL in patients with oropharyn-
geal carcinomas,8,9 rather than assessing a combination
therapy versus a primary therapy or some mixture of
combination and/or primary therapies.27,35
CONCLUSION
Among patients with oropharyngeal cancer, HRQOL
varied across cancer stage and then across treatment
modality for patients with advanced cancer. Although
improvement was seen in most domains by 12 months
after treatment, our findings indicate that closer atten-
tion may need to be paid to early-stage patients at 6 and
12 months after diagnosis, and to advanced-stage
patients at 3 months after diagnosis. In addition, atten-
tion should be paid to general symptoms and function af-
ter diagnosis for advanced cancer patients receiving
S&PORT, as well as a focus on head and neck-specific
symptoms 3 months after diagnosis for this group.
Advanced cancer patients receiving CRT may need addi-
tional attention at 12 months postdiagnosis for head and
neck specific symptoms. Further research is required to
confirm these findings.
ACKNOWLEDGMENTS
The authors gratefully acknowledge their participants,
without whom the study would not have been possible. The
assistance of Claire Chang, Louise Acret, and Eleanor
Whitford with data entry and literature searching is also
acknowledged. The authors also thank the audiences at
the Cancer Nurses Society of Australia Winter Congress
(2011), Multinational Association for Supportive Care
International Symposium (2012), and International Con-
ference on Cancer Nursing (2012) for helpful feedback.
Attendance at the Winter Congress was supported by the
Cancer Council NSW.
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