Abstract
Introduction:
Patients with head and neck skin cancer experience adverse functional, psychosocial, and financial impacts as a result of the disease and/or its treatment. This study aimed at evaluating the pattern of presentation, clinical outcomes, and quality of life of patients with head and neck skin cancer.
Materials and Methods:
A retrospective cross-sectional study of patients with head and neck skin cancer presenting to the Department of Plastic, Reconstructive & Aesthetic Surgery of the University College Hospital, Ibadan, from January 2017 to December 2021. Data obtained from the clinical records included sociodemographic characteristics, clinical and surgical details, as well as clinical outcomes. Quality of life was assessed using EORTC QLQ-C30 questionnaires. Data were summarized using descriptive statistics.
Results:
Nineteen patients were reviewed with a median age of 38 years (ranging from 18 to 85 years) and a male-to-female ratio of 1:1.4. Eight (42.1%) of the patients were albinos. Squamous cell carcinoma was the predominant histologic type (63.2%), while the scalp was the commonest location (42.1%). Only one patient (5.3%) presented with metastatic disease. A greater percentage of treated patients, eight (61.5%), had surgery as the only treatment modality. After a mean follow-up period of 33 months, a recurrence rate of 10.5% (two patients) and a mortality rate of 15.8% (three patients) were recorded. Quality of life assessment revealed an adverse financial impact of the disease on our patients.
Conclusion:
Although albinism is a recognized risk factor for skin cancers, head and neck skin cancers can occur in the dark-skinned.
Keywords: Head and neck, quality of life, skin cancer
Introduction
Skin cancer constitutes the most common malignancy worldwide.[1,2,3] Its incidence has been on the increase, and this has been attributed to increased ultraviolet (UV) radiation exposure, ozone depletion, increased life span, genetics, and immune suppression.[2,3] Epidemiological studies have demonstrated a higher incidence of skin cancers in whites compared to blacks.[1,3] The photo-protective effect of melanin in dark-skinned individuals has been implicated as a key factor responsible for this racial disparity.[4] Nevertheless, blacks are more likely to die from skin cancers compared to whites due to late presentation and delayed diagnosis.[1] Albinism is an important risk factor for skin cancer in sub-Saharan Africa, and black albinos residing in the region have a 1000-fold increased risk of squamous cell carcinoma compared to the general population.[5,6] Skin cancers can be broadly classified into melanoma and non-melanoma skin cancers (NMSC). Histologic types of NMSC include basal cell carcinoma, squamous cell carcinoma, basosquamous cell carcinoma, Merkel cell carcinoma, Kaposi sarcoma, and adnexal skin cancer.[7] Over 80% of NMSCs occur in sun-exposed areas of the body, such as the head, neck, and dorsum of the hands.[3]
Skin cancers of the head and neck can lead to life-changing cosmetic and functional deficits with resultant psychological, physical, and nutritional detriments.[8] Therefore, preventive measures are pertinent and include the use of sunscreens, protective clothing, avoidance of sun exposure during peak sunshine hours, and regular self-skin examination.[9] Management is multidisciplinary. Treatment modalities include surgery, radiotherapy, chemotherapy, photodynamic therapy, immunotherapy, and targeted therapy.[1] Lifelong follow-up is needed to detect recurrence and measure outcomes. Patient-reported outcome measures (PROM) are important for determining the effect of disease and treatment on the quality of life of patients.[10] The European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Core Questionnaire (QLQ-C30) is one of the most widely used cancer-specific PROM.[11] EORTC QLQ-C30 has published general population normative data[11] as well as reference values for various cancer populations.[12] This study aimed at evaluating the pattern of presentation, clinical outcomes, and quality of life of patients with head and neck skin cancers presenting to a plastic surgery service.
Materials and Methods
Study design/setting/participants
The study was a retrospective cross-sectional study of patients with head and neck skin cancer that presented to the Department of Plastic, Reconstructive & Aesthetic Surgery of the University College Hospital, Ibadan, between January 2017 and December 2021. The clinical records of the patients were reviewed.
Study instrument and data collection
Data were obtained from the out- and in-patient records. These included sociodemographic characteristics, clinical and surgical details, as well as clinical outcomes (postoperative complications, recurrence, and mortality). Additional clinical outcome data was obtained through phone calls to the patients or next of kin (in case of the demise of a patient). EORTC QLQ-C30 questionnaires were administered to 10 out of the 19 patients with head and neck skin cancers managed during the period of review; three were dead, while six patients were lost to follow-up. This was done by an interviewer through phone calls and during follow-up clinic visits. Informed consent was obtained from the patients before administering the questionnaires. EORTC QLQ-C30 is a 30-item scale with responses to each item graded from 0 to 100.[13] The 30 items are grouped under two broad scales: functioning and symptom scales. Higher scores for items under the functioning scale represent a higher level of functioning, while higher scores for items under the symptom scale represent a greater degree of symptoms. The functioning scale has six subscales: physical, role, cognitive, emotional, social, and global quality of life. The symptom scale comprises nine subscales/items: fatigue, nausea and vomiting, pain, dyspnea, sleep disturbance, appetite loss, constipation, diarrhea, and financial impact.[13]
Data analysis
The data were analyzed using the IBM SPSS Statistics for Windows, version 23 (IBM Corp., Armonk, New York). Descriptive statistics was used to summarize the sociodemographic characteristics, clinical and surgical details, as well as clinical outcomes of the patients. The mean scores of the EORTC QLQ-C30 subscales were obtained from the average of the sum of the scores of the items under the subscales. These mean scores were compared with EORTC QLQ-C30 normative values and reference values for head and neck cancer patients.
Results
Between January 2017 and December 2021, 19 patients presented to the department with head and neck skin cancers. However, 13 of these had their case-notes retrieved (68.4% case-note retrieval rate). The age of the patients at presentation ranged from 18 to 85 years, with a median of 38 years. A male-to-female ratio of 1:1.4 was recorded. Most of the patients were married, 12 (63.2%) and had secondary education as their highest educational qualification, eight (42.1%). The sociodemographic characteristics of the patients are shown in Table 1.
Table 1.
Sociodemographic characteristics of patients
| Variable | Frequency | Percentage |
|---|---|---|
| (n = 19) | ||
| Age (years) | ||
| <45 | 11 | 57.9 |
| 45–64 | 5 | 26.3 |
| ≥65 | 3 | 15.8 |
| Sex | ||
| Male | 8 | 42.1 |
| Female | 11 | 57.9 |
| Marital status | ||
| Married | 12 | 63.2 |
| Single | 3 | 15.8 |
| Widowed | 2 | 10.5 |
| Not specified | 2 | 10.5 |
| Highest educational level | ||
| No formal education | 1 | 5.3 |
| Primary | 4 | 21 |
| Secondary | 8 | 42.1 |
| Tertiary | 3 | 15.8 |
| Not specified | 3 | 15.8 |
Clinical and surgical details
Eight (42.1%) of the patients were albinos [Table 2]. The histologic types of skin malignancy were squamous cell carcinoma (63.2%, n = 12), basal cell carcinoma (26.3%, n = 5), melanoma (5.3%, n = 1), and basosquamous carcinoma (5.3%, n = 1) [Figure 1]. The scalp was the commonest location of head and neck skin cancers (42.1%, n = 8) [Figure 2]. Only four patients (21.1%) had a comorbid condition (hypertension). Most of the patients had localized (47.4%, n = 9) and locally advanced disease (47.4%, n = 9) at presentation. Only one patient (5.3%) presented with metastatic disease. Out of 13 patients who received treatment, eight (61.5%) had surgery as the only treatment modality, with only two patients (15.4%) having more than one surgery. Fifteen surgeries were done during the period of review, with pedicled flap (53.3%; n = 8) being the commonest reconstructive procedure and free flap (6.7%; n = 1), the least common reconstructive procedure, following wide local excision of the skin malignancy. None of the patients had Mohs micrographic surgery (MMS). The clinical and surgical details of the patients are shown in Table 2.
Table 2.
Clinical and surgical details
| Variable | Frequency | Percentage |
|---|---|---|
| (n = 19) | ||
| Albinism | ||
| Yes | 8 | 42.1 |
| No | 11 | 57.9 |
| Comorbidities | ||
| Hypertension | 4 | 21.1 |
| None | 15 | 78.9 |
| Stage of disease at presentation | ||
| Localized | 9 | 47.4 |
| Locally advanced | 9 | 47.4 |
| Metastatic | 1 | 5.3 |
| Treatment modality (n = 13) | ||
| Surgery only | 8 | 61.5 |
| Multimodal therapy | 5 | 38.5 |
| Number of surgeries (n = 13) | ||
| One | 11 | 84.6 |
| ≥2 | 2 | 15.4 |
| Surgery done (n = 15) | ||
| WLE * and direct closure | 2 | 13.3 |
| WLE and skin grafting | 4 | 26.7 |
| WLE and pedicled flap | 8 | 53.3 |
| WLE and free flap | 1 | 6.7 |
*WLE—wide local excision
Figure 1.
Histologic types of head and neck skin cancers
Figure 2.
Site distribution of head and neck skin cancers
Clinical outcomes
The mean duration of hospital stay was 9.68 (±11.70) days. Postoperative complications were recorded in five (26.3%) patients [Table 3]. After a mean follow-up period of 33 months (ranging from 15.8 to 57.5 months), a mortality rate of 15.8% (three patients) was recorded, while six (31.6%) patients were lost to follow-up [Table 3]. Two (10.5%) patients had recurrence during the follow-up period.
Table 3.
Clinical outcomes
| Variable | Frequency | Percentage |
|---|---|---|
| Postoperative complications (n = 5) | ||
| Donor site morbidity | 3 | 60.0 |
| Flap necrosis | 1 | 20.0 |
| Flap venous congestion | 1 | 20.0 |
| Outcome (n = 19) | ||
| Lost to follow-up | 6 | 31.6 |
| Alive | 10 | 52.6 |
| Dead | 3 | 15.8 |
Quality of life outcome
EORTC QLQ-C30 questionnaires were administered to ten patients by an interviewer. Our study patients had the highest level of functioning in the emotional subscale (96.25 ± 5.27) and the least level of functioning in the global quality of life subscale (83.56 ± 14.71). On the other hand, the patients were most adversely impacted financially (57.50 ± 31.29) and had the least degree of symptoms in constipation (32.50 ± 23.72) and sleep disturbance (32.50 ± 23.72) subscales. The mean values for the functioning and symptom subscales of the EORTC QLQ-C30 of the patients are shown in Table 4.
Table 4.
Quality of life outcome (EORTC QLQ-C30)
| Scale | Mean ± SD |
|---|---|
| Functioning scales | |
| Physical | 90.48 ± 12.36 |
| Role | 88.75 ± 14.96 |
| Cognitive | 90.00 ± 11.49 |
| Emotional | 96.25 ± 5.27 |
| Social | 95.00 ± 6.45 |
| Global quality of life | 83.56 ± 14.71 |
| Symptom scales | |
| Fatigue | 40.83 ± 20.58 |
| Nausea and vomiting | 35.00 ± 24.15 |
| Pain | 41.25 ± 25.03 |
| Dyspnea | 45.00 ± 28.38 |
| Sleep disturbance | 32.50 ± 23.72 |
| Appetite loss | 52.50 ± 34.25 |
| Constipation | 32.50 ± 23.72 |
| Diarrhea | 42.50 ± 28.99 |
| Financial impact | 57.50 ± 31.29 |
Comparison of the mean values of our study patients with normative values[11] and mean values of head and neck cancer patients from prior studies[12] showed better functionality but greater degree of symptoms by our study patients [Figures 3 and 4].
Figure 3.
Comparison of EORTC QLQ-C30 functioning subscales mean values of study patients, normative values,[11] and reference values[12] for head and neck cancer patients
Figure 4.
Comparison of EORTC QLQ-C30 symptom subscales mean values of study patients, normative values,[11] and reference values[12] for head and neck cancer patients
Discussion
A female preponderance of head and neck skin cancers was found in our study. Most prior studies recorded a male preponderance of head and neck skin cancers.[14,15,16] However, Adeyemi et al.[17] in their review of melanoma of the head and neck found a female-to-male ratio of 3:1 in patients younger than 40 years. Multicenter epidemiological studies will elucidate the role of gender as a risk factor for head and neck skin cancers.
About one-fifth of our study population had a comorbid condition, which is much lower than the 75% recorded in a study in the Netherlands.[16] This can be attributed to the much younger population in our study.
Squamous cell carcinoma was the most common head and neck skin cancer in our study. This is similar to the findings from previous studies in Nigeria[14,18,19] and in African-Americans.[20] However, in Caucasians, basal cell carcinoma ranks highest amongst the other histologic skin cancer types in terms of frequency of occurrence.[15,16] The reason for this racial disparity is unclear but may be due to genetic factors.[21] Unlike prior studies in Nigeria,[14,18] Kaposi sarcoma was not recorded in our study. This may be explained by the lower incidence of HIV, an important risk factor for Kaposi sarcoma,[21,22] in Oyo state compared to the other study locations.[23] The scalp was the commonest site of head and neck skin cancers in our study. A similar site distribution pattern was recorded by Yakubu et al.[14] in their study in Zaria, Nigeria. This site predilection is postulated to be linked to the prevalence of chronic scalp infections, such as fungal infections and viral warts in the population.[14]
Albinism is a recognized risk factor for skin cancers in Black African populations[5,6] and was seen in eight (42.1%) of our study patients. This incidence is much higher than the findings from Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, Nigeria,[14] but lower than the values from the University of Calabar Teaching Hospital (UCTH), Calabar, Nigeria.[18] However, a greater percentage (57.9%) of our study patients were dark-skinned and one had melanoma. In vitro studies have demonstrated that melanin releases toxic intermediates on exposure to UV radiation, which can induce single-strand DNA breaks in skin cells, leading to melanoma formation.[4] This has been implicated as the explanation for the rarity of melanoma in albinos and underscores the fact that no skin type has absolute protection from the deleterious effect of UV radiation. Therefore, even dark-skinned individuals should be educated on photo-protective measures.
MMS is a surgical technique that utilizes layer-by-layer excision and microscopic margin assessments to obtain complete and precise excision of tumors.[24] MMS has the advantage of maximum preservation of normal tissues, which is important in the excision of head and neck skin cancers as the maintenance of form, cosmesis, and function is critical in the head and neck region.[25] In addition, studies have shown lower local recurrence rates for head and neck skin cancers after treatment with MMS compared to wide local excision.[24,26] However, none of our patients had MMS due to the unavailability of the facilities in our institution.
When compared to EORTC QLQ-C30 normative values[11] and reference values for head and neck cancer patients,[12] our study patients had better functionality and global quality of life. This can be attributed to the response shift phenomenon. The response shift phenomenon is a type of bias in Health-related Quality of life (QOL) studies in which there is a change or recalibration in a patient’s QOL perception as the patient progresses through a healthy state, different stages of the disease, as well as following treatment.[27] Having experienced the difficulty of the pretreatment phase of the disease, the patient tends to assign more significance to any improvement in the QOL following treatment compared to the premorbid healthy state.[27] The response shift phenomenon has been reported by previous QOL studies in head and neck skin cancer patients and patients with melanoma.[16,28] However, the normative values and reference values for head and neck cancer patients were obtained from a different study population (13 European countries, Canada, and the United States). In addition, the financial impact of the disease was higher in our patients compared to normative values and reference values for head and neck cancer patients. This could be due to health-related productivity loss as a result of the disease and/or the adverse impact of out-of-pocket payment for cancer treatment on our patients with head and neck skin cancer. This study, however, did not determine the proportion of the study patients who paid out of pocket for their cancer treatment. The National Health Insurance Scheme is yet to have universal coverage in Nigeria. In addition, the available scheme does not cover most cancer treatments.[29] Though a Cancer Health Fund (CHF) has been provided by the Federal government to support indigent cancer patients, this intervention did not include patients with skin cancers.[30] In addition, the CHF is only available in six Federal Teaching Hospitals in the country.[30]
Furthermore, our study patients had worse cancer-related symptoms compared to head and neck skin cancer patients in developed countries. This may be the result of better cancer treatment modalities and follow-up in these countries.[31]
Strength of the study
The study assessed the quality of life of our study patients, which is a patient-reported outcome measure.
Limitations of the study
The small sample size of the study limits the scientific inference that can be made from the study. In addition, the EORTC QLQ-C30 normative values and reference values for head and neck cancer patients used to compare with EORTC QLQ-C30 mean values of our study patients were obtained from a different socioeconomic and cultural setting.
Conclusion
Although albinism is a recognized risk factor for skin cancers, head and neck skin cancers can occur in the dark-skinned. There is, therefore, a need for photo-protective measures for individuals with significant sun exposure, irrespective of skin type. Furthermore, multicenter studies are needed to further elucidate the effect of disease and treatment on the quality of life of patients with head and neck skin cancer.
Presentation at a meeting
This article was presented at the Grand Round meeting of the Department of Surgery, University College Hospital, Ibadan, on April 19, 2022, at the Department of Surgery’s seminar room, Prof Akinkugbe’s building, University College Hospital, Ibadan.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgement
None.
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