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Table 2.3: QOL scales and items in EORTC-C30 and H&N35

Table 2.3: QOL scales and items in EORTC-C30 and H&N35

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11



Chapter 3

RESULTS

3.1.Socio-demographic characteristics of sample patients.

125 patients were divided into 3 groups: Group 1-TLM had

38 patients; Group 2-OPL had 60 patients; and Group 3-TL had

37 patients. Mean age was 57.0 [SD 7.8], ranging from 38 to 77.

There were 135 males (96.4%) and 5 females (3.6%). The majority

of patients achieved high school level education (79.3%).

Occupational distribution was: manual labor (46.4%), intellectual

labor (23.6%) and retired (30%). T-stage distribution: 100%

patients in group 1 were in T1 (34 T1a and 4 T1b); 54% of patients

in group 2 were in T2 (46% patients were in T1: there was

contraindication for TLM in these patients); 83.8% of patients in

group 3 were in T3-4. N-stage distribution: 100% patients in group

1 and group 2 were in N0; 83.8% patients in group 3 were in N0.

Nhóm laser và nhóm TQBP có 100% BN ở giai đoạn hạch N0,

nhóm TQTP đa số BN cũng ở giai đoạn N0 (83,8%). M-stage

distribution: 100% patients in sample study were in M0. Distribution

of surgery type: 100% patients in group 1 had endoscopic resection

of tumor without neck dissection. Group 2: 42% of patients had

unilateral and 4% had bilateral neck dissection. Group 3: 100%

patients had neck dissection (most of them were bilateral).

Distribution of adjuvant radiotherapy: no patient in group 1 and

group 2 was indicated adjuvant radiotherapy; In contrast: 100% BN

in group 3 had adjuvant radiotherapy.

3.2.QOL of laryngeal cancer patients pre- and post-operation.

Tables 3.16 to 3.21 showed mean scores of each scale / item

in each group of patient (TLM, OPL and TL) at different timepoint:

pre-operation; 1 month, 3 month, 6 month and 12 month postoperation:



12



Table 3.16: QOL scores (symptom scales) in group LASER preand post-operation

Post-operation

Item / scale



Preop



1 month

𝑋̅



3 month

𝑋̅



6 month

𝑋̅



12 month

𝑋̅



Appetite loss

8.8

16.7*

30.7**

20.2*

16.7*

Sticky saliva

4.4

17.5**

30.7**

22.8**

18.4**

Senses problems

6.1

9.7

22.4**

16.7**

11.8*

Opening mouth

0.9

7.0*

8.8**

5.3*

6.1

Social eating

3.9

11.8*

28.3**

11.6**

8.8

Fatigue

11.1

18.7*

28.9**

27.5*

17.2

Dry mouth

14.1

21.1

35.1**

24.4*

19.3

Swallowing

7.0

11.4

23.1**

12.9**

11.5

Speech problem

40.9

52.3*

65.5**

48.8

43.9

Financial difficulty

14.9

32.5**

26.3*

17.5

13.2

Pain

8.8

9.7

16.2*

7.9

6.1

Pain in mouth

5.3

11.4

22.6**

7.9

7.0

Teeth

24.6

17.5

28.9

30.7

33.3*

Coughing

22.8

29.8

48.3**

28.1

26.3

Dyspnea

13.2

13.2

29.8**

14.9

13.2

Social contact

13.5

18.3

24.2**

15.3

13.9

Insomnia

31.6

34.2

57.0**

41.2

35.9

Constipation

15.8

14.9

20.2

14.9

23.7*

Feeling ill

8.8

16.7

28.9**

14.9

10.5

Nausea-vomiting

3.9

6.1

6.1

2.2

1.3

Diarrhea

0

2.6

2.4

1.8

1.5

Less sexuality

35.9

33.5

47.4

41.7

39.0

(*): p < 0.05; (**): p < 0.01 (in comparison with pre-operation)

Values > 20 were in bold font (can have impact to QOL)



13



Table 3.17: QOL score (general QOL and 5 functional scales)

in group LASER pre- and post-operation

Post-operation

Item / scale



Preop



Global QOL

Physical functioning

Role functioning

Emotional functioning

Cognitive functioning

Social functioning



74.8

95.3

92.9

87.1

92.9

95.6



1 month

𝑋̅



3 month

𝑋̅



6 month

𝑋̅



12 month

𝑋̅



62.2*

90.2*

86.4*

78.5*

89.5

79.4**



60.1**

79.7**

62.3**

70.4**

75.9**

66.7**



70.0

84.0**

70.2**

88.2

85.5*

78.5**



74.3

85.9**

73.3**

89.9

87.7

79.4**



Table 3.18: QOL score (general QOL and 5 functional scales)

in group OPL pre- and post-operation

Post-operation

Item / scale



Preop



1 month

𝑋̅



3 month

𝑋̅



6 month

𝑋̅



12 m.nth

𝑋̅



Global QOL



77.8



55.2**



65.8**



70.3**



75.3



Physical functioning



94.7



77.9**



86.5**



91.5*



93.9



Role functioning



98.7



53.0**



65.7**



72.7**



77.0**



Emotional functioning



74.5



77.3



90.8**



95.0**



95.8**



Cognitive functioning



94.7



86.0**



94.3



94.0



94.7



Social functioning



92.7



58.0**



72.1**



75.3**



79.9**



(*): p < 0.05; (**): p < 0.01 (in comparison with pre-operation)

Values < 80 were in bold font (can have impact to QOL)



14



Table 3.19: QOL scores (symptom scales) in group OPL preand post-operation

Post-operation

Item / scale



Preop



1 month

𝑋̅



3 month 6 month

𝑋̅

𝑋̅



12 month

𝑋̅



Speech problem

31.8 68.9** 55.1** 48.9** 47.3**

Social contact

3.3 33.5** 13.2** 9.1**

8.3*

Coughing

7.3 58.1** 36.7** 28.7* 27.3**

Swallowing

4.7 29.7** 15.1** 13.7** 10.7**

Dry mouth

10.0 31.3** 18.1* 18.0*

23.4*

Senses problems

2.0 17.1** 9.1** 9.3**

7.7*

Social eating

1.0 35.5** 20.3** 15.3** 13.7**

Less sexuality

22.3 61.3** 40.1** 35.1** 31.7*

Fatigue

4.9

30.7** 14.9** 10.9*

8.0

Appetite loss

11.3 39.2** 24.7** 18.7*

10.7

Sticky saliva

8.0 32.1** 16.7*

14.1

14.0*

Pain

2.1

22.0** 8.7*

3.7

4.1

Pain in mouth

4.0 27.0** 11.2**

6.8

4.5

Dyspnea

14.1 39.3** 28.0*

18.7

15.3

Insomnia

30.1 54.7** 40.0*

35.3

28.0

Feeling ill

4.7 37.3** 15.3**

9.3

4.7

Opening mouth

3.3 15.3**

8.2

5.3

4.7

Nausea - vomiting

3.7

17.3**

5.0

2.1

1.3

Constipation

18.7

10.7*

12.0

19.3

24.1

Financial difficulty

8.7

23.3*

20.7

13.3

12.7

Teeth

18.7

20.7

18.1

24.7

23.3

Diarrhea

2.1

12.7

5.3

4.7

3.3

(*): p < 0.05; (**): p < 0.01 (in comparison with pre-operation)

Values > 20 were in bold font (can have impact to QOL)



15



Table 3.20: QOL scores (symptom scales) in group TL pre- and

post-operation

Post-operation

Item / scale



Preop



1 month

𝑋̅



3 month

𝑋̅



6 month

𝑋̅



12 month

𝑋̅



Speech problems

36.6 92.5** 87.4** 82.3** 79.9**

Social contact

1.9 53.2** 42.2** 34.9** 22.9**

Coughing

9.0 72.9** 45.9** 34.2** 44.1**

Opening mouth

0.9

9.9**

7.2*

7.3*

7.2*

Dry mouth

4.5 35.1** 35.2** 30.6** 31.5**

Sticky saliva

1.8 36.9** 37.8** 26.1** 28.8**

Senses problems

0.5 41.0** 47.3** 48.7** 45.9**

Social eating

2.3 52.5** 29.5** 22.1** 20.5**

Appetite loss

9.9

55.9** 34.2** 23.4** 22.5**

Fatigue

2.7

43.5** 24.0** 14.7** 11.1**

Less sexuality

13.9 82.4** 65.8** 54.9** 42.8**

Feeling ill

3.6 61.3** 36.9** 26.1** 15.3**

Financial difficulty

9.0

39.6** 38.7** 30.6** 22.5**

Dyspnea

13.5 43.2** 30.6** 22.5**

18.9

Insomnia

35.1 68.5** 46.9*

42.3

36.9

Constipation

11.7

3.6*

11.7

5.4

25.2**

Diarrhea

0

0

10.8** 16.2**

0.9

Pain

3.2

31.9** 12.6**

3.2

0.9

Pain in mouth

4.1 40.8** 17.8**

5.2

2.7

Swallowing

8.1 42.8** 19.6** 14.9

11.9

Nausea-vomiting

4.9

30.6**

8.1

2.3

1.8

Teeth

17.1

23.4

20.7

27.0*

24.3

(*): p < 0.05; (**): p < 0.01 (in comparison with pre-operation)

Values > 20 were in bold font (can have impact to QOL)



16



Table 3.21: QOL score (general QOL and 5 functional scales)

in group TL pre- and post-operation

Post-operation

Item / scale



Pre-op



1 month

𝑋̅



3 month

𝑋̅



6 month

𝑋̅



12 month

𝑋̅



68.0**



Global QOL



77.9



38.7** 50.7** 59.6**



Physical functioning



94.6



69.9** 85.2**



Role functioning



98.2



44.1** 54.1** 61.3**



Emotional functioning



73.9



68.5



Cognitive functioning



98.2



82.9**



90.1*



85.6** 90.8**

94.1*



93.2*



92.4

64.4**

94.6**

96.9



Social functioning

96.4 38.7** 48.2** 62.2** 65.3**

(*): p < 0.05; (**): p < 0.01 (in comparison with pre-operation)

Values < 80 were in bold font (can have impact to QOL)



Chapter 4

DISCUSSION

4.2.Pre-operative QOL of laryngeal cancer patients.

Pre-operative QOL of laryngeal cancer patients was affected in

"Global QOL", "emotional functioning" scale and three symptom

scales "speech problems", "insomnia", "less sexuality". Our result

was similar to the study of Johansson et al. In laryngeal cancer,

speech disorder always the major symptom which appears at early

onset and lasts for long time, therefore this symptom causes great

impact on patient's QOL. At pre-operation, patients often worried

about their disease and their treatment process (including the



17



operation). That bad mood expresses in "insomnia" symptom as

well as negative "emotional functioning". All these impaction was

reflected in the deterioration of "global QOL".

4.3. Pre-operative QOL of laryngeal cancer patients.

4.3.1.Group TLM.

There was a moderate, clinically significant worsening in

global health QOL status at 1 month post-surgery (p<0.05).

However, there was essentially a return to baseline at 12 months

post-op. Five functional scores (“physical”, “emotional”

“cognitive”, “role”, and “social functioning”) had maximal

deterioration at 3 months (p<0.01). At 1 month, “physical” and

“emotional functioning” scores demonstrated subtle, clinically

relevant decrease (p<0.05), but “social functioning” scores showed

moderate, clinically relevant drop from baseline scores (p<0.01).

At 12 months, there was a slight, clinically significant improvement

in “physical functioning” scores from baseline (p<0.01). While

changes in “emotional functioning” scores from baseline were

trivial, “social functioning” scores saw a moderate, clinically

significant decrease from pre-operative scores (p<0.01). Symptoms

of “nausea-vomiting”, “pain”, “diarrhea”, “less sexuality”, and

“teeth” demonstrated no significant change from baseline. All other

symptoms except for “constipation” showed maximally significant

difference at 3 months. Five symptom-related scores that

demonstrated the most significant changes were identified as

“speech”, “social eating”, “sticky saliva”, “cough”, and

“insomnia”. All symptom scores were significantly worse at 3

months post-op. At 6 and 12 months, all items except for “sticky

saliva” and “social eating” returned to levels not significantly

different from baseline. “Appetite”, “social eating”, “senses (smell

and taste)", “constipation” (all P < .05), and “sticky saliva” (P <



18



.01) showed significantly increased severity at 12 months compared

to baseline. Our finding was similar to those of Minovi and

Stoeckli.

4.3.2.Group OPL.

*Symptom domains.

Symptom-related scores that demonstrated the most significant

net changes were: “speech”, “social eating”, “sexuality”, “cough”

and “feeling ill”. “Speech” showed significant improvement at 1

month post-surgery (p<0.01). Although this improvement declined

over time, there continued to be a significant improvement

compared with pre-operative speech function at 12 months

(p<0.01). The other symptoms, except for “feeling ill”, which

remained significantly worse than pre-operative scores (p<0.01),

gradually lessened over 12 months’ time. All other symptom

domains, except for “teeth”, were significantly worse at 1 month

post-surgery (p<0.01). At 12 months, the following symptoms

remained significantly worse when compared to pre-operative

scores: “fatigue” (p<0.05), “financial difficulty”(p<0.05),

“dysphagia” (p<0 .01), “senses (smell and taste)” (p<0.01), “social

contact”(p<0.05), “dry mouth” (p<0.01), and “sticky saliva”

(p<0.01). Voice disorder after laryngofissure was due to glottic

deficiency: vocal folds could not close properly during phonation,

reduced maximal phonation time, changed pitch and limited voice

intensity range. Most of major phonation structures were resected

in supracricoid partial laryngectomy, therefore voice was severrly

affected: reduced frequency range, low fundamental frequency, and

increased breathiness, increased effort required to talk. Coughing is

a common symptom after OPL: loss of protective barriers can



19



cause aspiration of food and saliva into lower respiratory tract.

About "swallowing disorder": the meta-analysis of Lips et al

showed that "swallowing disorder" was common within the first 3

months post-operation. After 6 months, most of patients regained

normal diet per os. These results were similar to our finding:

"swallowing disorder" increased significantly in the first postoperative month then improved gradually. About "less sexuality":

according to Singer et al, 53% of patient admitted of a worse sex

life; 42% of patient had erection dysfunction after open partial

laryngectomy. The mean score of "less sexuality" in Singer's study

was 27.8 and implied an impaction on patients' QOL. Singer

explained the cause of "less sexuality" with following reasons:

deterioration of physical strength, noisy breathing and increasing of

mucus discharge.

*Global QOL and functional scales.

There was a moderate, clinically significant worsening in

global health QOL status at 1 month after surgery (p<0.01) but

there was essentially a return to baseline at 12 months (p<0.01). At

1 month post-surgery, “physical functioning” saw an obvious,

clinically significant drop while “social functioning” saw a

moderate, clinically relevant decrease in scores (both p<0.01).

Notably, there was trivial change in “emotional functioning”

scores at 1 month. At 12 months, “physical functioning” scores

essentially returned to baseline (p<0.01), while “emotional

functioning” saw a moderate, clinically relevant increase and

“social functioning” saw a moderate, clinically relevant decrease

(both p<0.01). Our results was in accordance with the data of Braz

and Batioglu-Karaaltin. Base on these finding, healthcare



20



professionals can design an appropriate rehabilitation plan for postoperative patients. In the first month post-operation, when patients

suffered from swallowing disorder, speech-therapists could give

swallowing exercises to prevent aspiration and reduce coughing;

Nutritionists could give patients a special diet with changing of

food texture to ensure scar healing and post-operative recovering.

Similar speech exercises should be indicate early to improve and

maintain voice quality, therefore related scales "role functioning"

and "social functioning" could also improved.

4.3.3.Group TL.

*Symptom domains.

Symptom-related scores that saw the most significant net

change were: “speech”, “social eating”, “social contact”,

“cough”, “sense (smell and taste)”, “sexuality”, “sticky saliva”,

and “dry mouth”. All had significant peak deterioration at 1 month

post-surgery (p<0.01). Improvement was observed in “social

eating”, “social contact”, “sexuality”, “cough”, and “feeling ill”;

however, they remained significantly worse compared to presurgical scores (p<0.01). In contrast, “speech”, “sense (smell and

taste)”, and “sticky saliva” showed little to no improvement over

time and remained significantly worse compared to baseline

(p<0.01). Other symptoms that were significantly worse at 12

months compared to baseline included: “fatigue” (p<0.01),

“appetite”(p<0.01), “constipation” (p<0.01), and “financial

difficulty” (p<0.01). However, “nausea-vomiting”, although

significantly worse at 1 month post-op, became significantly

improved at 12 months compared to baseline (p<0.05). Our finding



21



was similar to those in studies of Baczyk, Batioglu-Karaaltin,

Boscolo-Rizzo and Singer. Birdford interviewed post-total

laryngectomy patients and found that when patients had lost their

natural voice, they felt the loss of part of their character and

personality. Most of patients reduced communicating, using only

body language (nod and shake head), then gradually reduced social

activities and became self - isolation. According to Carr et al, posttotal laryngectomy patients tended to give up many social

activities: talking in a noisy environment, singing, telephone calls,

meeting, eating out, visiting friends. "Speech disorder" can cause

great impact to global QOL of post-total laryngectomy patients.

"Coughing" symptom increased significantly at 1 month postoperation then gradually improved. However, at 12 month postoperation, "coughing" could not return to pre-operation baseline.

Similarly, "dyspnea" symptom increased significantly at 1 month

post-operation then gradually improved. Increasing coughing and

mucus discharge could also cause negative impact on patients'

emotional scale: easily irritated, more anxiety and depression.

"Senses problems" score deteriorated at 1 month post-operation and

did not improve over time. This deficiency in smell and taste can

significantly affect QOL of patients after TL. Mumovic's study on

105 patients post - total laryngectomy showed that olfaction was

impaired in 51.4%, and was even not possible in 30.5%, of patients.

Decreased gustation abilities were reported in 26.7%, and

dysgeusia in 11.4%, of patients. Almost 21% of patients were

bothered by an impaired gustatory ability and 50.5% of patients

were affected by their loss of olfaction. Patients who reported a

deterioration of olfaction and gustation tended to experience



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Table 2.3: QOL scales and items in EORTC-C30 and H&N35

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