Psychological Distress and Quality of Life among Head and Neck Cancer Patients after 3- and 6-Months Post-Treatment—A Hospital-Based Study

ABSTRACT

Introduction:

Cancers affecting the parts of the head and neck significantly impact patients. Among head and neck cancer (HNC) patients, the visible signs and symptoms of the disease or the side effects of treatment modalities can cause various degrees of functional impairment such as mastication, swallowing, communication, and disfigurement.

Objective:

To assess psychological distress and quality of life in head and neck cancer patients after 3 and 6 months’ post-treatment.

Materials and Methods:

A hospital-based follow-up study was conducted among head and neck cancer patients who came for routine follow-up after treatment in five cancer hospitals in Hyderabad City. Patients were categorized based on the treatment into surgery, chemotherapy, radiotherapy, and combination of all and the same subjects were followed; after 3 months, psychological distress and quality of life were assessed by distress thermometer and functional assessment of cancer therapy head and neck (FACT H and N).

Results:

A total of 235 participants were included in the study. Mean age was 58.2 ± 8.7 years. The mean scores of psychological distress at baseline were 4.6 ± 1.2, and after follow-up, it was 3.4 ± 1.2 and the mean scores of quality of life at baseline were 76.4 ± 15.6, and after follow-up, it was 75.5 ± 12.5.

Conclusion:

The mean scores of psychological distress had reduced from baseline to follow-up with negligible improvement in the quality of life.

INTRODUCTION

Cancer, a group of diseases characterized by abnormal cell growth, is the second leading cause of mortality worldwide in 2017, accounting for 8.8 million deaths. Seventy percent of cancer-related fatalities occur in low- and middle-income countries. The economic repercussions of cancer are significant and growing.[1,2]

Head and neck malignancies are the sixth most prevalent type of cancer worldwide but are most prevalent in Indian men and third in women. In India, over two hundred thousand head and neck cancer cases are diagnosed annually, while nearly eighty thousand cases of oral cancer are identified. Males aged 55 and older have the highest incidence of mouth cancer, except in Mumbai, where the 45–49 age bracket is more prevalent. Numerous cancer patients develop psychological comorbidity due to the disease’s propensity to cause intense psychological reactions and long-lasting effects.[3,4]

H and N cancers significantly impact HRQOL, which correlates with prognosis. Evaluating HRQOL is crucial for optimal patient care, treatment alternatives evaluation, and informed rehabilitation and patient education services. HNC can significantly impact patient quality of life for years after treatment.[5]

Cancer patients often struggle with distress, making it difficult to manage their physical symptoms and treatment. Even with recent breakthroughs, psychological distress is still a major problem in supportive cancer care. This discomfort lowers quality of life, makes it more difficult to comply with medical treatment plans, and increases rates of co-morbidities and mortality. Every cancer patient feels some degree of distress due to their diagnosis and course of therapy.[5,6]

This study seeks to evaluate psychological distress and quality of life in patients with head and neck cancer three and six months after treatment, as untreated psychological needs can lead to reduced quality of life, increased risk of suicide, more extended hospital stays, more treatment complications, and non-compliance with treatment. While extensive research has been conducted on quality of life in head and neck cancer patients, there is limited research on post-treatment distress.

MATERIALS AND METHODS

This study aimed of this study was to evaluate the psychological distress and quality of life of head and neck cancer patients in Hyderabad three and six months after treatment. Patients returning to cancer hospitals for routine follow-ups after treatment constituted the target population. The institutional review board of Sri Sai College of Dental Surgery, Vikarabad, the Ethical Committee, and authorities of all cancer hospitals granted ethical approval. Using a sample of 30 individuals from two cancer institutions, a pilot study was conducted to determine the feasibility of the study, document any difficulties encountered during data collection, and test the questionnaire’s readability and clarity. The quality of life and psychological distress were assessed using a standardized questionnaire. Functional Assessment of Cancer Therapy Head and Neck (FACT-H and N)[7] version 4 administered by Cella, David. F, Marcy A, D Antonia, Linda L. in 1996 was used to measure quality of life, while a distress thermometer from Roth[8] was used to measure psychological distress. The questionnaire measured head and neck cancer symptoms across five domains: physical well-being, social/family well-being, emotional well-being, functional well-being, and additional concerns. Face validity was established by giving the questionnaire to five professionals about this study’s topic and letting them assess if the questions accurately conveyed the topic under investigation. Internal consistency was determined to be satisfactory (Cronbach’s alpha = 0.80) based on the pilot study’s determination of content validity. After the pilot trial, 90 patients per treatment group (surgery, chemotherapy, radiotherapy, and combination therapy) were selected. From five cancer hospitals, a total of 235 patients were selected. Inclusion criteria for individuals included those with head and neck cancer in stages I and II as well as those who presented for routine follow-up at least three months after treatment. Patients with malignancy in stages III and IV were excluded. Before examination, informed consent was obtained from all patients participating in the study after thoroughly explaining the study’s purpose.

The study used a baseline data collection method to gather information from patients who visited the outpatient department for follow-up visits. Patients met the inclusion criteria and were informed about the purpose of the study. To ensure they completed three months’ post-treatment, hospital records were checked. Demographic data, cancer stage, treatment types, and FACT H and N Questionnaire were recorded. Psychological distress was measured using a distress thermometer. Data was collected through questionnaires for patients who could read and write, and interviews for illiterates. Patients were contacted via telephone during the follow-up period and scheduled for follow-up visits. Patients who attended the follow-up visit were included in the study, and those who failed to attend were reminded. 199 patients were recruited during the period of follow-up. The SPSS 21.0 version of the Statistical Package for the Social Sciences was utilized for the statistical analysis. The results were coded and imported into Microsoft Excel after a descriptive analysis was performed. ANOVA was used to compare quality of life and distress with treatment type, age, occupation, cancer stage, and level of education. Post hoc analyses were utilized to identify significant group differences. Two population means were compared using unpaired t-tests, whereas quality of life and distress at baseline and after follow-up were compared using paired t-tests. Using multiple linear regression, the impact of independent variables on the dependent variable was predicted.

RESULTS

In the present study, a total of 235 patients were recruited at baseline, and the same subjects were followed up after three months. Out of 235 patients, 90 belonged to the surgery group, 34 belonged to the chemotherapy group, 21 belonged to the radiotherapy group, and 90 to the combination therapy group. Among 235 patients, a total of 199 participants turned up during the follow-up period follow-up. Of 235 patients, 133 (56.6%) were men and 102 (43.4%) were women. The mean age of those involved was 58 ± 8 years; 97 (41.3%) belonged to stage 1 cancer, and 138 (58.7%) belonged to stage 2 cancer. 90 (38.3%) had surgery, 34 (14.5%) received chemotherapy. 21 (8.9%) received radiotherapy, and 90 (38.3%) received a combination of all the above three types of treatment.

49.7% of participants at baseline and 50.2% at the time of follow-up had a good quality of life, 50.2% had a poor baseline quality of life, and 49.7% had a poor quality of life throughout the follow-up period [Table 1].

Table 1.

Distribution of participants based on the categories of quality-of-life scores

Categories	Total QoL B	Total QoL F
Good quality of life	≥75 (n=117, 49.7%)	≥76 (n=100, 50.2%)
Poor quality of life	≤74 (n=118, 50.2%)	≤75 (n=99, 49.7%)

The mean score of psychological distress at baseline was 4.6 ± 1.2, and after follow-up, it was reduced to 3.4 ± 1.2, indicating a decrease in the patient’s distress from baseline to follow-up. From baseline to follow-up, a significant difference was found in the psychological distress levels from baseline to follow-up [Table 2].

Table 2.

Mean scores of quality of life at baseline and follow-up

Domain	n	Baseline Mean	n	Follow-up mean
Physical well-being	235	20.8±4.1	199	15.3±3.9
Social well-being	235	12.6±5.1	199	13.1±3.6
Emotional well-being	235	16.3±4.5	199	12.6±3.6
Functional well-being	235	8.4±5.5	199	11.8±3.5
H and N concerns	235	18.4±6.4	199	22.4±5.5
Total QoL	235	76.6±14.9	199	75.5±12.5
Distress	235	4.6±1.2	199	3.4±1.2

Among all the quality-of-life domains, there was a significant difference in the physical domain when comparing the quality of life and distress at baseline and follow-up (0.001), emotional well-being (P = 0.001), functional well-being (P = 0.001), H and N concerns (P = 0.001). There was no significant difference in the social well-being domain and overall QoL. At baseline to follow-up, there was a significant difference found in the psychological distress levels from baseline to follow-up [Table 3].

Table 3.

Pair-wise comparison of quality of life and distress at baseline and follow-up

Domain	n	Baseline mean	n	Follow-up mean	P
Physical well-being	235	20.6±4.1	199	15.3±3.9	0.001
Social well-being	235	12.5±5.3	199	13.1±3.6	0.15
Emotional well-being	235	16.1±4.6	199	12.6±3.6	0.001
Functional well-being	235	8.4±5.6	199	11.8±3.8	0.001
H and N concerns	235	18.6±6.6	199	22.4±5.5	0.001
Total quality of life	235	76.4±15.6	199	75.5±12.5	0.51
Distress	235	4.5±1.1	199	3.4±1.2	0.001

Multiple regression analysis showed that there was no significant association found with independent variables (age, gender, occupation, education, stage of cancer, and type of RX) on the dependent variable (QoL) at baseline and also during the follow-up period. Still, there was a significant difference between the type of treatment on the dependent variable (distress) at baseline and the stage of cancer on the dependent variable (distress) during follow-up [Tables 4 and 5].

Table 4.

Linear regression analysis with demographic details on distress at baseline

Model	Unstandardized coefficients		Standardized coefficients Beta	t	P
	B	Std. Error
Age	0.013	0.010	0.090	1.370	0.172
Gender	-0.019	0.170	-0.007	-0.109	0.913
Occupation	0.034	0.043	0.054	0.802	0.424
Education	-0.017	0.056	-0.020	-0.307	0.759
Stage of cancer	0.033	0.176	0.013	0.189	0.851
Type of RX	0.204	0.066	0.215	3.080	0.002

Table 5.

Linear regression analysis with demographic details on distress during follow-up

Model	Unstandardized coefficients		Standardized coefficients Beta	t	P
	B	Std. Error
Age	-0.010	0.011	-0.066	-0.0906	0.366
Gender	0.090	0.188	0.035	0.482	0.630
Occupation	0.113	0.049	0.168	2.291	0.023
Education	0.068	0.060	0.082	1.134	0.258
Stage of cancer	-0.478	0.195	-0.185	-2.454	0.015
Type of RX	0.107	0.073	0.113	1.471	0.143

DISCUSSION

In contemporary society, cancer is still seen as a very serious illness due to its potential to negatively impair the quality of life following treatment, particularly in poor nations like India. Individuals with head and neck cancer must deal with functional impairment and deformity brought on by their disease and/or their treatment.[9,10,11]

In this investigation, which is a follow-up study conducted in a hospital, patients with head and neck cancer were asked to rate their psychological distress and quality of life three and six months after starting treatment. Men comprised the majority of this research’s study participants (57%). The participants’ average age was 58 ± 8 years old. Males and older persons are more likely to get head and neck malignancies.

In this study, the mean quality-of-life score at baseline was 76.6 ± 14.9, and at the time of follow-up, it was 75.5 ± 12.5. This implies a negligible improvement in the patient’s quality of life from baseline to follow-up. The results are similar to the study conducted by Melo Filho et al.[12] where the mean score of quality of life in patients after treatment was 71.7 ± 20. This might be because this study included patients who had completed just three months after their treatment, and as cancer is a life-threatening disease the ability of the patients to cope and lead a better life may not have improved within the short span of time.

Before and after treatment, patients with head and neck cancer typically had depression and other psychosocial morbidities like anxiety. These responses are typical since cancer and cancer therapy have historically been connected to misery and death. Patients with head and neck cancer who have depressive symptoms prior to therapy are more likely to experience physical and psychological morbidity and a lower quality of life following treatment, as shown by Mücke et al.’s 2000 study.[13,14,15,16]

The mean score of psychological distress at baseline was 4.6 ± 1.2, and at the time of follow-up, it was 3.4 ± 1.2. The distress levels of the patients decreased in the follow-up period. This finding is in contrast with a study conducted by Ninu et al.[5] 2006 in which patients showed severe psychological distress in patients after treatment. This might be because patients in this study were assessed for distress after completion of their treatment, and the symptoms may subside after undergoing treatment patients might have less pain and suffer from the disease, and their ability to do work increases. Hence, distress levels may decrease.[17,18]

A significant association was found between the type of treatment and the distress levels at baseline. The reason might be because of the pain and suffering they had experienced while undergoing treatment which led to distress. This study showed a significant association between cancer stage and distress after follow-up. This might be because stage 1 cancer generally has a single treatment modality, and stage 2 cancer requires a combination type of treatment. It might require a longer duration for the patients’ recovery, and thus their distress levels might differ.

The present study showed negligible improvement in the quality of life from baseline to follow-up. Still, there was a significant decrease in the distress levels from baseline to follow-up. As the follow-up period was short and patients’ quality of life may not be improved within a short follow-up period, further studies should be done longitudinally to know how the quality of life may change after treatment. Many factors can influence quality of life. Among those factors, tumor site and size may also have some influence. The type of treatment modality depends on the size of the tumor. The treatment dosage varies according to the tumor, and the site of the tumor influences the eating, speech, and breathing of the patients, especially in head and neck cancers. Tumor site and size were not addressed in this study, which may influence the patient’s quality of life and distress levels. So, further research should be planned by considering the above parameters.

CONCLUSION

Three and six months after treatment, the study evaluated the psychological distress and quality of life of patients with head and neck cancer. The mean scores at baseline were 76.6 ± 14.9 and 75.5 ± 12.5, respectively. Post-treatment, distress levels reduced to 3.4 ± 1.2. There was no significant improvement in quality of life or psychological distress compared to age, occupation, education, treatment type, or cancer stage. However, there was a significant difference in cancer stage and treatment type.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.