The most prevalent subsite within the laryngeal cancer site the glottis, the vocal apparatus of the larynx, resulting in hoarseness is an early symptom of even small tumors. A cancer or carcinoma located above the glottis, is not as prevalent, and these patients often have a combination of symptoms such as swallowing problems, pain, and hoarseness. Previous health related quality of life (HRQL) studies of laryngeal carcinoma patients have focused on speech and voice quality but recent studies have considered patients’ well-being and HRQL in a broader sense.

Between 1993 and 1995, a prospective longitudinal multicenter study of HRQL was performed in Sweden and Norway, including 357 newly diagnosed head-and-neck cancer patients. Patients were included consecutively, and therefore the patient group could be regarded as a convenience sample. The patients’ HRQL was assessed repeatedly during one year using three standardized questionnaires: the European Organization for Research and Treatment of Cancer (EORTC), Quality of Life Questionnaire-Core30 (QLQ-C30) (18), the EORTC Head and Neck Cancer Module (EORTC QLQ-H&N35), and the Hospital Anxiety and Depression Scale (HADS).

This research focused on the 86 patients with laryngeal carcinoma who were included in the initial study group of 357 patients and performed a five-year follow-up, both of clinical data and their HRQL, using the same questionnaires. The aims of the study were to: (1) assess changes in HRQL between diagnosis and the five-year follow-up, as well as between the one-year follow-up and the five-year follow-up; (2) analyze HRQL results in relation to anatomic location within the larynx, i.e., supraglottic and glottic carcinoma; (3) analyze HRQL results in relation to the treatment given, i.e., conventional radiotherapy, hyperfractionated accelerated radiotherapy, combined treatment, and laryngectomy; (4) explore whether HRQL at diagnosis may predict the HRQL and the survival rate five years after diagnosis.

The authors of “Health-Related Quality of Life Five Years after Diagnosis of Laryngeal Carcinoma,” are Mats Nordgren MD, Magnus Jannert MD PhD, and Marianne Ahlner-Elmqvist RN, from the Department of Otorhinolaryngology, Malmo¨ University Hospital, Lund University, Malmo¨, Sweden; Helmut Abendstein MD, at the Department of Otolaryngology and Head and Neck Surgery, St. Olav’s Hospital, Trondheim, University, Trondheim, Norway; Morten Boysen MD PhD, at the Department of Otolaryngology and Head and Neck Surgery, Rikshospitalet, Oslo University, Oslo, Norway; Ewa Silander RD, and Eva Hammerlid MD PhD, both from the Department of Otolaryngology and Head and Neck Surgery, Sahlgrenska University Hospital, Goteborg University, Goteborg, Sweden; and Kristin Bjordal MD PhD, at the Department of Radiation Oncology, The Norwegian Radium Hospital, Oslo, Norway. Their findings were presented September 24, 2003, at the American Academy of Otolaryngology-Head and Neck Surgery Foundation http://www.entnet.org Annual Meeting and OTO EXPO, being held September 21-24, 2003, at the Orange County Convention Center, Orlando, FL. (note: This study has been accepted for publication in the International Journal of Radiation Oncology, Biology, Physics)

Methodology: The original cohort of 357 patients were asked to answer HRQL questionnaires on six occasions during one year: at diagnosis, and one, two, three, six, and 12 months after the start of treatment. The 86 patients taking part in the study and who were still alive were asked, five years after diagnosis, to fill in the same HRQL questionnaires again. Laryngeal cancer patients who dropped out during the first study year but were alive at the five-year follow-up were also asked to answer the questionnaires. Clinical data related to the treatment given, relapse, and survival rate were collected at the one and five year follow-ups. Comorbidity including other cancers, other serious illnesses as well as heart and pulmonary diseases were recorded at the same time-points.

The HRQL questionnaires used were the EORTC QLQ-C30, a 30-item questionnaire widely used cancer-specific, patient-based measure designed for self-administration. The questionnaire comprises five functional scales—physical, emotional, role, cognitive, and social functioning; three symptom scales—fatigue, nausea-vomiting, and pain; six single items concerning dyspnea, sleep disturbance, loss of appetite, constipation, diarrhea, and financial difficulties; and a global quality of life scale; EORTC QLQ-H&N35. This 35-item head-and-neck cancer specific module consists of questions related to problems due to the tumor location and treatment; and HADS., the Hospital Anxiety and Depression Scale.

Eighty-six patients were included, of whom 84 percent were male. The patients were divided into subgroups according to stage, tumor location, and treatment. Forty-nine of 62 patients (79 percent) were diagnosed with Stage I /II glottic carcinoma and 6/24 patients (25 percent) with Stage I /II supraglottic carcinoma. Twelve patients underwent laryngectomy during the first year and one patient after 2 1⁄2 years. Eight of the 13 laryngectomized patients had glottic carcinoma, and five had supraglottic carcinoma. Chemotherapy was given to eight patients with Stage III/IV tumors; seven were given the combination of cis-platinum and 5-fluorouracil and one carbo platinum and 5-fluorouracil.

Results: Seventy-four of the 86 patients (85 percent) were alive after one year, and 53 patients (62 percent) were alive after 5 years. The disease-specific survival rate was 73 percent. At the five-year follow-up, 33 patients were dead, 20 due to the laryngeal carcinoma and one due to another form of malignancy. Eleven patients died from other diseases and one from unknown causes. Patients treated with hyperfractionated radiotherapy had a five-year survival rate of 90 percent, whereas patients treated with laryngectomy had a 31 percent survival rate at five years. Key findings included:

Change in HRQL scores for all patients between diagnosis and the five -year follow-ups. A clinically and statistically significant improvement between the score at diagnosis and the five-year follow-up was found in the speech scale. Five scales and single items showed both clinical and statistical deterioration (physical functioning scale, role functioning scale, problems with dyspnea, dry mouth, and sticky saliva).

Change in HRQL scores for all patients between the one-year and the five-year follow-up. None of the variables showed both clinically and statistically significant improvement in HRQL, but one scale showed statistical improvement (diarrhea). A few scales showed deterioration both clinically and statistically (physical functioning scale, role functioning scale, and problems with social eating).

Comparison of HRQL at diagnosis between survivors and patients who died during follow-up. Patients who survived five years had better HRQL at diagnosis than those who died during the first year after treatment. The largest differences were seen in the speech scale, social eating scale, physical functioning scale, role functioning scale, coughing, appetite loss sticky saliva, fatigue scale, feeling ill, and pain scale

Conclusions: Comparing cancer subsites showed that patients with glottic carcinoma had better HRQL values at diagnosis and after one year. After five years the supraglottic carcinoma group had better quality of life, but the number of patients was small and the five-year results are therefore inconclusive. Patients with supraglottic carcinoma not surviving five years had worse HRQL already at diagnosis compared with supraglottic survivors. The patients with supraglottic carcinoma had lower survival rates compared with patients with glottic carcinoma (25 vs. 75 percent), and they were often diagnosed at a later stage due to the differences in symptomatology.

The laryngectomized patients showed an unexpected improvement in speech at the five-year follow-up, with scores comparable to those of patients grouped as “all other treatments.” Previous studies have shown that laryngectomized patients experienced severe problems with speech or at least no improvement compared with diagnosis.

Patients with laryngeal carcinoma had better speech after five years compared with the time of diagnosis. However, physical function and role function deteriorated during the same period, and treatment-related side effects, such as dyspnea, dry mouth, and sticky saliva, became worse. From the first year to five years after diagnosis, a few scales deteriorated, such as physical function and role function, and problems with social eating increased.