Đánh giá chất lượng cuộc sống của bệnh nhân ung thư thanh quản trước và sau phẫu thuật tr tiếng anh

HANOI MEDICAL UNIVERSITY BÙI THẾ ANH HEALTH-RELATED QUALITY OF LIFE OF LARYNGEAL CANCER PATIENTS PRE- AND POST- SURGICAL TREATMENT Major: Otorhinolaryngology Code: 62.72.01.55 SUMMARY

HANOI MEDICAL UNIVERSITY

BÙI THẾ ANH

HEALTH-RELATED QUALITY OF LIFE OF LARYNGEAL CANCER PATIENTS PRE- AND POST- SURGICAL TREATMENT

Major: Otorhinolaryngology

Code: 62.72.01.55

SUMMARY OF THESIS FOR DOCTOR OF MEDICINE

HANOI - 2019

HANOI MEDICAL UNIVERSITY

Thesis can be found in:

National library of Vietnam

Hanoi Medical University library

INTRODUCTION

Topic "quality of life" was obviuosly mentioned in philossophy, literature and sociology Recently, this topic has been widely mentioned in other different fields In medicine, this topic appears as "health-related quality of life" (HRQOL) After World

Health Organisation, HRQOL is an assessment of how the individual's well-being may be affected over time by a disease, disability or disorder Healthiness is not only evaluated in medical view but also in psychological, social and economic views

Nowadays, the "outcome" is used to measure treatment result so

QOL is considered as an outcome of treatment, especially in oncology because every modality of cancer treatment can eliminate the tumor but also affect patient's quality of life QOL researches provide complete and thorough information about the disease process as well as post-treatment health status, therefore it help patients (Pt) both in selecting appropriate treatment method and improving their post-treatment adaptation

Laryngeal cancer is a malignancy disease originating from epithelial cells in larynx Laryngeal cancer can be cured by multi-modal treatment (surgery, radiotherapy or chemo-radiotherapy), with 5-year overall survival rate about 60% The disease itself and its surgical treatment can change the laryngeal structure and therefore affect laryngeal functions Laryngeal cancer surgery may also change patients' appearance and cause cosmetic effect Those anatomical and functional changes can impact patient's quality of life in physical, emotional and social scales (voice disorder, reduction of speech communication, swallowing disorder, eating habitude, reduction of olfactory and gustatory ability, dyspnea, cough, limited social integration, loss of work, increasing risk of stress and depression) Based on these essential quality of life informations, healthcare professionals can provide good

recommendation for patients pre-treatment; plan post-treatment psychological consult and adaptive rehabilitation for every single patient Up to now, there are few published researches in Vietnam mentioned health-related quality of life of laryngeal cancer pre- and

post- surgical treatment The study "Quality of life of laryngeal

cancer pre- and post- surgical treatment" was carried out with 3

NEW CONTRIBUTIONS OF THESIS

 For the fisrt time, health-related quality of life assessment using modern tool (EORTC-C30 and EORTC-H&N35 questionnaires) was successfully applied on Vietnamese laryngeal cancer patients pre-operation and post-operation

 Provide a thorough database about health-related quality of life of Vietnamese laryngeal cancer patient treated with different surgical techniques (Transoral Laser Microsurgery, Open Partial Laryngectomy and Total Laryngectomy) in 5 occasions: pre-operation, 1 month, 3 months, 6 months and 12 months post-operation Post-operative QOL in three patient groups were worse both in functional scales and symptom scales, the most significant declineation was seen within total laryngectomy group This declineation in QOL existed for longtime post-operatively

STRUCTURE OF THESIS

This thesis contains 116 pages in which Introduction (2 pages), Chapter 1 (Overview - 31 pages), Chapter 2 (Materials and

Methods: 12 pages), Chapter 3 (Results: 36 pages), Chapter 4 (Disscussion: 31 pages), Conclusion (2 pages), Recommendation (1 page), New contributions of thesis (1 page) There are 28 tables, 9 charts, 3 figures and 155 references (11 references in Vietnamese,

143 references in English, 1 reference in French)

Chapter 1 OVERVIEW 1.3.Physiology of larynx

There are 4 main functions of human larynx:

 Protection: larynx works as a sphincter, preventing the ingress

of anything other than air into lower respiratory tract (trachea, bronchi and lungs)

 Speech: Sound is produced by the larynx when expiratory airflow from lung and bronchi) goes through glottis and induces vibration of free edges of the vocal folds

 Regulation of airflow: Larynx helps control the volume of inspiratory and expiratory airflow; it also stops the respiratory process temporarily during swalowing phase

 Closure of glottis: Forced expiration against a tightly closed glottis is known as the Valsalva maneuver It is important in defecation and also serves to stabilize the thorax during heavy lifting by the arms

1.5.Treatment of laryngeal cancer

Treament of laryngeal cancer includes surgery, radiotherapy or chemotherapy (single- or multi-modal treatment) Surgery is still the most common method of treatment in Vietnam Early stage disease (S1 - S2) is treated by conservative surgery (transoral laser microsurgery; laryngofissure or open partial laryngectomy) When the disease is on locally advanced stage but resectable: indication

of total laryngectomy plus neck dissection and adjuvant

radiotherapy With advanced stage and unresectable disease: indication of concurrent chemoradiotherapy or palliative treatment

1.5.1.Surgery

Common surgical techniques for laryngeal cancer in Vietnam are: transoral laser microsurgery, laryngofissure, partial laryngectomy with crico-epiglotto-hyoidoplasty or total laryngectomy

* Transoral laser microsurgery (TLM): tumor mass is resected

together with partial or total cordectomy (other structures may also

be included in the resection: impaired vocal process, anterior commissure, ventricular fold, subglottic mucosa) Anatomy of glottis and vocal cords is modified after TLM, therefore glottis can not close properly in phonation and voice is disturbed (hoarseness, breathy voice, increased effort required to talk) Sometimes glottic scar (possible sequelae of TLM) can cause glottic stenosis and laryngeal dyspnea

*Laryngofissure: thyroid cartilage is cut vertically in the midline

to approach endolarynx, the tumor mass and ipsilateral vocal cord are resected completely Anatomy of glottis and vocal cords is modified after laryngofissure, therefore glottis can not close properly in phonation and voice is disturbed (hoarseness, breathy voice, increased effort required to talk) Sometimes glottic scar (possible sequelae of laryngofissure) can cause glottic stenosis and laryngeal dyspnea

*Supracricoid partial laryngectomy with

crico-epiglotto-hyoidoplasty: The tumor mass is resected together with a portion

of thyroid cartilage, two vocal cords, two ventricular folds, petiole Preservative structures include most of epiglottis, hyoid bone, cricoid cartilage and at least one arytenoid cartilage Many functions of larynx (Protection, speech and swallowing) are affected after the surgery, causing voice disorders, swallowing disorder, cough, aspiration and inhalation pneumonia

*Total laryngectomy (TL): tumor mass is resected together with

the whole larynx structure, hyoid bone, one or two tracheal rings and infrahyoid muscles Removal of the entire larynx and separation of the upper and lower airways results in a significant alteration in the ability to verbally communicate After total laryngectomy, the vibrating body is removed and there is alteration

of the air source and resonant tract Other functions (protection of lower respiratory tract and respiratory regulation) are also severely impacted

1.6.Introduction of "health-related quality of life"

“Health-related quality of life” is an assessment of how the individual's well-being may be affected over time by a disease,

self-reported, subjective, multi-dimensional and changes over time HRQOL may be measured globally or componently with different domains: physical activity, psychological state, social interaction

and somatic sensation / symptoms HRQOL research plays more

and more important role in general medicine In oncology, HRQOL

is considered an index in assessing treatment outcomes (similar to other classic indexes such as overall survival, 5-year specific survival…) HRQOL research provides multi-dimensional information about patient's health status as well as adverse effects during or after treatment Based on these data, healthcare professionals can plan to treat those adverse effects and apply better rehabilitation for patients In clinical practice, HRQOL data give patients more concrete information about the disease process and prognosis This information contributes in patient's decision-making before treatment HRQOL research also helps to compare different treatment modalities and to assess novel therapeutic

treatment

1.7.Tools to measure HRQOL of laryngeal cancer patients

It is common to use subjective methods to measure HRQOL: those methods are patient-reported questionnaires Two questionnaires were selected (EORTC-C30 and EORTC-H&N35, developed by European Organization of Research and Treatment of Cancer) to use as measuring tool to assess HRQOL of laryngeal cancer in this study

1.8.Post-operative QOL of laryngeal cancer patients

Treatment of head and neck cancer (including laryngeal cancer) can cause many sequelae: voice disorder, swallowing disorder, dyspnea, cough, mouth dryness, olfactory and gustatory deficiency, teeth damage, pain in mouth, lomited moth opening, change in appearance These sequelae can affect patient's QOL in many different way There have been many published studies about QOL of laryngeal cancer patients after surgical treatment (TLM; open partial laryngectomy - OPL; or TL) However, most of those studies were cross-sectional or retrospective studies: all laryngeal patients treated with surgery were recruited into the study sample, then they were classified into different groups (depend on type of surgery) and QOL were measured The different interval between surgery and OQL assessment timepoint could cause bias in QOL measurement because QOL might change over time Some authors reduced this bias by using longitudinal prospective study method: laryngeal cancer patients were recruited into study sample before surgery, then QOL was measured at the same timepoint after surgery According to these longitudinal prospective studies: post-operative QOL of laryngeal cancer patients changed significantly within the first year post-operation and became stable since then Based on this result, we decided to assess post-operative QOL of laryngeal cancer patients at specific timepoints: 1 month, 3 months,

6 months and 12 months post-operatively There was some limit in published longitudinal studies: QOL of laryngeal cancer patients was assessed with only one technique of surgery (TLM, OPL or TL) then QOL of patients underwent different techniques could not

be compared

Chapter 2 MATERIALS AND METHODS 1.Study subjects

Sample patients were selected among laryngeal cancer patients underwent curative surgery in Department of Oncology - Head and Neck Surgery (National ENT Hospital of Vietnam - 78 Giai Phong Road, Dong Da - Hanoi)

Sample selection criteria

Patient with definitive diagnosis of primary laryngeal cancer (confirmed by histological result of squamous cell carcinoma) without any previous treatment; All medical records were available; curative surgery indicated; Agreed to participate into this study; Had at least 12 months of follow-up; completely all questionnaires at all 5 timepoints: pre-operation; 1 month, 3 months, 6 months and 12 months post-operation Sample patients Patients were categorized into three groups based on surgical treatment of the primary tumor These groups were: Group 1-TLM, Group 2-Open Partial Laryngectomy (OPL), and Group 3-Total Laryngectomy (TL)

Exclusion criteria

Exclusion criteria included: previous treatment of cancer, distant metastases or second primary tumor (confirmed before treatment or during first-year follow-up period), palliative surgical

treatment, cognitive impairment or lack of proficiency in Vietnamese, or loss to follow-up at any time-point

of Research and Treatment of Cancer The EORTC QLQ-C30, which assesses physical, psychological and social functions of cancer patients, includes 30 questions, 24 of which form nine scales representing various dimensions for health-related QOL, including

a global scale, five functional scales (physical, role, emotional, cognitive, and social), and three symptom scales (fatigue, pain, and nausea) The remaining six items measure cancer-oriented symptoms (dyspnea, insomnia, appetite, constipation, diarrhea, and financial difficulty) The EORTC QLQ-H&N35, which assesses QOL, includes 35 questions, which constitute seven symptom scales (pain, dysphagia, gustatory and olfactory senses, speech, social eating, social contact, and sexuality), and six single items for symptoms specific to head and neck cancers Responses were converted into a linear scoring scale, with values ranging from 0 to

100 per EORTC Scoring Manual

2.5.QOL scales and items used in this study

QOL of laryngeal cancer patients was measured and evaluated

by a set of items and scales (listed in Table 2.3) A higher score for a functional scale (numbered from 1 to 5 in table 2.3) represents a healthier level of functioning A higher score for the global health status (numbered 28 in table 2.3) indicates a lower QOL A higher score for a symptom scale item (numbered from 6 to 27 in table 2.3) also represents a greater severity of symptoms or problems

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

1 Physical functioning

General functional scales

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 post-operation:

Table 3.16: QOL scores (symptom scales) in group LASER pre-

3 month 𝑋̅

6 month 𝑋̅

12 month 𝑋̅

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

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