Metastasis properties of cancer and side effects of therapy cause insufficiency in breathing, swallowing, speaking, masticating functions. There is a strong correlation between tumor’s stage, area, treatment type, age and level of problems. Complications as pain, mucositis, mouth dryness, loss of taste and smell have negative effects on quality of life of patients due to extended radiotherapy’s dose and volume [1-10].

Hanna and Shearman [9] found that quality of life is affected particularly with disorders in eating, breathing and speaking functions in patients with H&N; cancers.

Clinical studies in this group focus on local control of tumor, evaluating survival and effectiveness of therapy methods. Factors affecting quality of life are equally important. Importance of quality of cancer patients resulted in development of specific quality of life questionnaires. One of those is EORTC Head-Neck Quality Of Life Questionnaire. The questionnaire that was developed by EORTC Quality of Life Study Group was used evaluate the quality of life in H&N; cancer patients. Many studies evaluated the reliability and validity of the questionnaire in different languages [11-18].

Our aim was to evaluate the quality of life in treated H&N; cancer patients in advanced stages.

Study measures
The following sociodemographic and clinical data were collected: gender, age, mental status, education, employment, side of tumor, date of diagnosis, treatment type, and radiotherapy doses.

QoL instruments
Patients completed the EORTC QLQ-C30 (Version 3.0), the EORTC QLQ-H&N; 35 at regular follow-up visit, using face to face interviews.

Turkish variation was provided by EORTC QoL Study Group.

EORTC QLQ-C30 (version 3.0) is a widely used questionnaire incorporating extensive QoL issues relevant to a broad range of cancer patients [6,16-20]. It has been validated for many types of cancer including H&N; cancer. It contains five functional scales (physical, role, cognitive, emotional, and social), three symptom scales (fatigue, pain, and nausea/vomiting), a global QoL scale, and six single items (dyspnea, insomnia, appetite loss, constipation, diarrhea, and financial difficulties). Version 30 (+3) contains two additional items on role functioning and one additional item on overall health. The EORTC QLQ-C30 (+ 3) is meant to be used in conjunction with a tumorspecific module.

The EORTC QLQ-H&N; 35 is meant to be used in conjunction with the QLQ-C30 in H&N; cancer patients. It contains seven subscales (pain, swollen, taste/smell, speech, social eating, social contacts, and sexuality). There are 10 single items relating to problems with teeth, dry mouth, and cough, opening the mouth wide, sticky saliva, weight loss, weight gain, use of nutritional supplements, feeding tubes and pain killers [6,16].

Items 1 to 30 are scored on four-point likart-type categorical scales (“not at all”, “ a little”, “quite a bit”, “very much”). Items 31 to 35 have a “no/yes” response format.

All scales and items of the EORTC QLQ-C30 and QLQ-H&N; 35 range in score from 0 to 100. A high score for a functioning or global QoL scale represents a high level of functioning or global QoL, whereas a high score for a symptoms scale or item represents a high level of symptoms or problems [17,18].

Statistical analysis
The data were analyzed using the statistical package SPSS for Windows (SPSS 10.0). Kruskal-Wallis variance analysis was used to compare the means of QoL score in the location of tumor, cancer stage, therapy method, surgical method and radiotherapy dose groups and multiple regression models to determine the effects of sociodemographic factors on quality of life.

Table 1: Patient characteristics

A total of 52 patients (51%) have been treated only with radiotherapy (RT), 3 patients (2.9%) have been treated with RT and chemotherapy, 46 patients (45.1%) have been treated with RT+surgery. Only one patient (1%) has been treated with RT+chemotherapy+surgery.

Fifty patients (49%) did not have any surgery, 19 patients (18.6%) have been treated with primary surgery; 22 patients (21.6%) have been treated with RND + primary surgery; 7 patients (6.9%) had modified neck dissection plus primary surgery and 4 patients (3.9%) had pectoralis major flap.

Total radiotherapy doses were 50 Gy in 32 patients (31.4%), 60 Gy in 21 patients (20.6%), 66 Gy in 34 patients (33.3%) and 70 Gy in 15 patients (14.7%).

Sociodemographic data
At the time of the evaluation 71 (69.6%) of the patients were on leave of absence and 11 (10.8%) were unemployed and 20 patients (19.6%) were retired. 94 patients (92.1%) had compulsory school education, 8 (7.8%) had a university education. Most of them were married (86 of the patients, 84.3%), and 16 of the patients (15.7%) were single.

EORTC QLQ- C30 and H&N; 35
The scales and single items of both questionnaires were compared according to sites of tumor, stage of cancer, type of treatment method.

When the scores from EORTC QLQ-C30 were compared among cancer sites, only the patients with laryngeal cancer scored worse for dyspnea (p=0.001) (Table 2).

Table 2: Differences of scales and single items of the QLQ-C30 and the QLQ-H&N; 35 by site of tumor

For the QLQ-H&N; 35, there were statistically significant differences for pain, swallowing, social eating, social contact, speech, taste/smell, and trismus. Patients with oral cavity cancer had the worst values for pain, social eating, taste loss, opening mouth, and trismus (p=0.035 for pain; p=0.002 for social eating, opening mouth and trismus; p=0.012 for taste loss). Patients with pharyngeal cancer scored worst for swallowing (p=0.001), whereas patients with laryngeal cancer had worse score for speech (p=0.003) (Table 2).

Both the QLQ-C30 and the QLQ-H&N; 35 had significant differences between the stages of the disease (Table 3). Patients with small tumors (stage I+II) scored better than those with large tumors (stage III+IV). Patients with large tumors (stage III+IV) scored higher on fatigue, dyspnea, insomnia, loss of appetite, swallowing difficulties, social contact, loss of taste/smell (p<0.05). Patients with small tumors also scored better for physical functioning (p<0.001).

Table 3: Comparison of quality of life points according to stage of cancer

When the scores were compared between the types of treatment, the patients who were treated with only radiotherapy had better scores for physical functioning, role functioning, emotional functioning, and global quality of life (p=0.029 for physical functioning, p=0.004 for role functioning, p<0.001 for emotional functioning, and p=0.009 for global quality of life) (Table 4).

Table 4: Comparison of quality of life points according to treatment type

Multiple regression model showed that lower socioeconomic level and being single have negative effects on quality of life ( B: 0.398; p: 0.012 and B: 1.938; p: 0.048, respectively).

Studies showed that pain, dental problems, mouth dryness, sensorial problems in oral cavity cancer, swallowing difficulty, throat pain, sticky saliva in pharynx cancer and speech problem, dyspnea in larynx cancer have high symptom points [15,19-26]

In our study, quality of life was evaluated with EORTC head and neck quality of life questionnaire. According to questionnaire results, in oral cavity cancers pain, difficulty in opening the mouth, taste loss, dental problems, difficulty in eating in social environment subscales, in pharynx cancers swallowing and social communication difficulties subscales and in larynx cancer speech problems and dyspnea subscales had significantly high points. Our data paralleled the findings from the literature.

Studies showed that disease stage and quality of life had a high negative correlation [4,8]. Hammerlid et al. [8] found that dental problems, sticky saliva excretion, taste loss, swallowing difficulty, feeling sick scale points were significantly high in stage III and IV head and neck cancers when compared with stage I and II.

In Campbell et al.’s study [15] patients with advanced cancer, swallowing difficulty, speech problems, physical activity difficulty points were significantly high. Investigations supporting these studies showed that symptom scale points are high and quality of life is low in patients with advanced stages.

Serious and long-term side effects of therapy, physical and functional differences due to surgery and psychosocial status of the patient have negative effects in patients with advanced cancer. In some manuscripts it was stated that therapy methods comprising of many modalities cause more and serious complications [5,22-29].

In our study, according to QoL results only in radiotherapy group physical functions, functions of role, emotional functions, global health status and quality of life points were significantly high. Fatigue, pain, insomnia, weakness, speech and swallowing problems, dyspnea, social communication difficulty subscale points were significantly high in radiotherapy+surgery group.

Surgical methods are directed to remove the cancer totally and to prevent the breathing, swallowing and voice functions [27-31]. In some studies it was shown that surgery increase the survival but permanent functional and physical changes negatively affect the QoL and performance level [11,30].

In our study, according to surgical method, swallowing and speech problems, insomnia, dyspnea, sensorial problems, social communication problem subscale points were significantly high in radical surgery group. Ninetytwo percent of radical neck dissections was total laryngectomy in our study. Pulmonary complications and speech problems negatively affect the general health status and QoL.

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