1012

Quality of Life of Nasopharyngeal Carcinoma Patients

Yoav P. Talmi, M.D.1
Zeev Horowitz, M.D.1
Lev Bedrin, M.D.1
Michael Wolf, M.D.1
Gavriel Chaushu, D.M.D.2
Jona Kronenberg, M.D.1
M. Raphael Pfeffer, M.D.2,3
1

Department of Otolaryngology-Head and Neck

Surgery, the Chaim Sheba Medical Center, Tel
Hashomer and the Tel Aviv University Sackler
School of Medicine, Tel Aviv, Israel.

Department of Oral and Maxillofacial Surgery, the

Chaim Sheba Medical Center, Tel Hashomer and
the Tel Aviv University Sackler School of Medicine,
Tel Aviv, Israel.

Department of Oncology, the Chaim Sheba Medical Center, Tel Hashomer and the Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel.

BACKGROUND. Quality of life (QOL) issues in patients with head and neck carcinoma are of importance beyond the incidence of these tumors because of the
impact of the disease and its treatment on external appearance and function of the
upper aerodigestive tract. Nasopharyngeal carcinoma (NPC) patients comprise a
unique subgroup in whom, to our knowledge, QOL has not been studied directly.
METHODS. Adult patients with NPC treated during the past 15 years at the Chaim
Sheba Medical Center with a minimum follow-up of 6 months were included in the
current study. Patients were mailed the revised University of Washington quality of
life (UW-QOL) questionnaire and data pertaining to their disease were recorded.
Patients with recurrent disease or another malignancy or those whose present
status could not be ascertained were excluded from the study. QOL scores were
analyzed based on treatment, disease stage, and patient age.
RESULTS. Twenty-eight patients of 35 disease-free patients (80%) responded to the
questionnaire sent to patients meeting the study criteria. The mean score for
general health was 3.1 (range, 15). Pain was not a significant factor. Other
domains without noteworthy problems were speech and shoulder disability. The
majority of patients described their appearance as normal or with minor changes,
and questions concerning activity, recreation/entertainment, employment, and
swallowing all scored 70 (range, 0 100). Dry mouth, chewing, and ear problems
were of major concern with the majority of patients and affected the QOL indices.
Nevertheless, the overall mean QOL score of these patients was rated as good (4.2
on a scale of 1 6).
CONCLUSIONS. In the current study, patients with NPC reported ear problems,
difficulties in chewing, and dry mouth but their overall QOL appeared to be good.
Ear problems such as secretory otitis media should be recognized at the time of
presentation and treated. Conformal radiotherapy techniques sparing the salivary
glands and temporal bone most likely will be useful in reducing the morbidity
associated with treatment. Cancer 2002;94:10127.
2002 American Cancer Society.
DOI 10.1002/cncr.10342

KEYWORDS: nasopharynx, carcinoma, quality of life (QOL), xerostomia, ear.

I
Address for correspondence: Yoav P. Talmi, M.D.,
Head and Neck Service, Chaim Sheba Medical
Center, Tel Hashomer 52621, Israel; Fax: (011)
972-3-5368020; E-mail: talmi@attglobal.net
Received June 26, 2001; revision received October
9, 2001; accepted October 15, 2001.
2002 American Cancer Society

n recent years there has been an increasing awareness of quality of

life (QOL) issues in clinical care. A MEDLINE search revealed only 6
articles with QOL as a key word in 1970, 234 articles in 1980, and 1384
articles in 1990, whereas 4532 articles were found in the year 2000.
Beginning with scattered publications in the late 1970s and early
1980s, reports regarding QOL issues in otolaryngology-head and neck
surgery have increased nearly threefold in the past decade. Although
carcinoma of the nasopharynx constitutes 0.3 4.0% of all malignant
tumors in the Western world, it ranks among the most common
tumors in Southeast Asia. A total of 7557 new cases of NPC were found
in the U.S. National Cancer Data Base report in the years 19851994,1
comprising 2.6% of all reported head and neck malignancies. An

Quality of Life of Nasopharyngeal Carcinoma Patients/Talmi et al.

annual incidence rate of 0.6 per 100,000 was reported

in the U.S. and NPC was reported in another publication to account for 4% of head and neck tumors or
0.25% of all cancers.2 A nationwide study of NPC in
Israel during a 9-year period (1960 1968) demonstrated a mean annual incidence rate of 1.0 per
100,000 in males and 0.4 per 100,000 in females.3
Numerous studies of QOL in patients with carcinoma of the head and neck have been reported but to
our knowledge none of these, including two large recent studies,4,5 focused on NPC. NPC has unique features among head and neck malignancies that increase the significance of QOL issues. NPC affects a
younger group of patients compared with other carcinomas of the head and neck and it usually is not
associated with smoking or alcohol abuse. Consequently, NPC patients have a lower incidence of associated comorbidity and many are gainfully employed
at the time of presentation of their disease. NPC usually is not treated with surgery and the majority of
patients are treated with radiotherapy or chemoradiation.1 QOL assessment is a critical tool in the development and evaluation of novel techniques of chemotherapy and radiotherapy such as intensity-modulated
radiation therapy (IMRT) that may significantly reduce the morbidity associated with treatment.6
We have undertaken a retrospective, cross-sectional study of NPC survivors to determine their disease-related QOL.

MATERIALS AND METHODS

Adult patients (age 17 years) with NPC who were
treated at the Chaim Sheba Medical Center between
1986 2000 were included in the current study. Clinical
data obtained from patient charts included age at
diagnosis, gender, follow-up period, treatment modalities, radiotherapy fields and dose scheduling, and
tumor restaging according to the 1997 American Joint
Committee on Cancer staging manual. Patients with
recurrent disease or a diagnosis of other malignancies
were excluded. Inclusion in the current study required
a minimum follow-up period of 6 months after the
conclusion of treatment. A Hebrew version of the revised validated University of Washington (UW)-QOL
questionnaire7 was mailed to the patients. The questionnaire included an exact verified version using a
double-back translation method between independent translators. Two extra questions pertaining to
NPC were added but were not validated. These incorporated information regarding dryness of the mouth
and ear problems. Although the patients did not undergo surgery, the question regarding shoulder function was not deleted to ensure maximal uniformity of
the questionnaire. Scoring varied from a scale of 15

1013

TABLE 1
Patient Data (n 28)

Age range (yrs)

Mean age (yrs)
M:F ratio
Chemotherapy
T1
T2
T3
T4
N0
N1
N2
N3
M

Age < 45 yrs

Age > 45 yrs

2143
32.8
8:2
9 (90%)
1
4
3
3
2
2
2
4
0

4574
55.8
12:6
9 (50%)
5
3
5
4
13
0
2
3
0

M: male; F: female.

or 1 6 in some questions and from 0 100 on others.7

The questionnaire was sent to patients who underwent recent follow-up in any of our medical center
clinics. If patient status could not be verified, no questionnaire was sent.
Data analysis included global QOL scores according to the standard questionnaire. A breakdown of
results comparing patients receiving chemoradiation
and radiotherapy only, patients age 45 years with
those age 45 years, and patients with T1-2 tumors
with those whose tumors were classified as T3-4 was
performed as well. Statistical analysis was performed
using the Student t test.

RESULTS
A computerized database search found 99 adult NPC
patients who were diagnosed and/or treated over the
past 15 years in the Departments of OtolaryngologyHead and Neck Surgery and Oncology at the Chaim
Sheba Medical Center. Of this group, 21 patients were
known to be dead either of disease or other causes and
6 patients were known to be alive with disease. An
additional 37 patients were not being followed in the
hospital-based clinic. Twenty-eight of 35 disease free
patients (80%) responded to the questionnaire.
Twenty patients were males and 8 were females. The
mean age was 47 years (range, 2174 years). The mean
follow-up was 5.4 years (range, 7 months14 years,
median, 5 years). Tumor staging is presented in Table
1. The radiotherapy dose ranged from 6800 to 7240
centigrays. Ten patients were treated with radiotherapy only and 18 patients were treated with chemotherapy and radiotherapy comprised of 23 cycles of cisplatin and continuous infusion 5-fluorouracil prior to
radiotherapy and weekly cisplatin during radiother-

1014

CANCER February 15, 2002 / Volume 94 / Number 4

TABLE 2
Results of the Revised University of Washington (UW) QOL Questionnaire
Questions

Results, mean (range) [significance]

1. In general your health is: (Range: poorexcellent; 15)

2. Compared to 1 year prior to diagnosis your health is now (range: much worsemuch better, 15)
Importance of each following item to overall QOL:
1 Not important
2 A little bit important
3 Somewhat important
4 Quite a bit important
5 Extremely important
3. Pain (range: no painsevere, not controlled pain; 1000)
4. Appearance (range: no changecannot be with people; 1000)
5. Activity (range: as active as everusually in bed or chair, does not leave home; 1000)
6. Recreation/entertainment (range: no limitationsI cant do anything enjoyable; 1000)
7. Employment (range: work full timeunemployed due to cancer treatment; 1000)
8. Chewing (range: as well as evercannot chew even soft solids; 1000)
9. Swallowing (range: as well as evercannot swallow; 1000)
10. Speech (range: same as alwayscannot be understood; 1000)
11. Shoulder disability (range: no problemcannot work due to shoulder problems; 1000)
12. Dry mouth
No dryness
Mouth dry but does not constitute a problem
Mouth very dry and needs constant drinking
Severe dryness not alleviated by any measures
13. Ear problems
No ear problems
Ear/s fullness
Ear/s fullness with need for ventilation tubes
Chronic ear infection
Rate your overall QOL in the past week (range: very poorexcellent; 16)

3.1 (24)
3.3 (15)

89 (50100) [4.13]
78 (25100) [4.26]
74 (0100) [4.56]
77 (0100) [4.52]
73 (20100) [4.43]
61 (0100) [4.52]
73 (30100) [4.60]
92 (70100) [4.95]
90 (0100) [4.69]
41 (0100) [4.61]
100
70
30
0
65 (0100) [4.65]
100
70
30
0
4.2 (26)

QOL: quality of life.

Questions 12 and 13, which were specifically added to the standard questionnaire, are portrayed fully.

apy. None of the patients included in the current study

underwent neck dissection or other surgical procedures other than endoscopy and biopsy.
The results are summarized in Tables 2 and 3.
The mean score of general health was 3.1 (range,
15) corresponding with good on the scale. Pain was
not a significant factor although the majority of patients ranked its presence as quite a bit important.
Other domains without significant problems were
speech (mean score of 92 of 100) and, as expected,
shoulder disability (mean score of 90). The majority of
patients described their appearance as either normal
or with minor changes. Activity, recreation/entertainment, employment, and swallowing all scored 70.
Low scores were obtained for chewing (61) and ear
problems (65). Dry mouth was a major concern with
the majority of patients (mean score of 41).
Overall, the mean QOL score over the previous
week was 4.2, corresponding to good on the questionnaire.
Patients age 45 years demonstrated a statistically significant reduction in swallowing compared

with those age 45 years. Patients age 45 years

tended to assign less importance to the activity and
employment scores. Patients treated with chemoradiation had statistically significantly reduced swallowing scores and assigned less importance to xerostomia. Significantly increased scores were found for the
importance of appearance and activity in patients
treated with chemoradiation (Table 3). Patients with
advanced tumors (T3 4) tended to report better
scores for xerostomia and to assign lower importance
to speech impairment, although these results were not
found to be statistically significant.

DISCUSSION
There are difficulties in using a single questionnaire
to evaluate QOL adequately;8,9 nevertheless, the
UW-QOL questionnaire is a suitable routine measure
of outcome in patients with head and neck carcinoma,
being quick and simple for patients to complete and
easy to process. The European Organization for Research and Treatment of Cancer (EORTC) QLQ-H&N35
module is more comprehensive and has been used

Quality of Life of Nasopharyngeal Carcinoma Patients/Talmi et al.

1015

TABLE 3
Results of the Revised University of Washington (UW)-QOL Questionnaire Comparing Patient Groups
Patient age (yrs)
< 45
Question
no.
1
2
3
Significance
4
Significance
5
Significance
6
Significance
7
Significance
8
Significance
9
Significance
10
Significance
11
Significance
12
Significance
13
Significance
14

> 45
Scores

3.33
3.33
94.44
4
80.55
4.66
72.22
4.88
77.77
4.11
80
4.87
55.55
4.44
64.44
4.55
85.55
4.88
96.66
4.11
35.55
4.44
55.55
4.55
4.22

Treatment

2.94
3.17
85.29
4.29
76.47
4
73.52
4.35
73.52
4.47
70.58
4.05
64.70
4.29
78.82
4.35
94.70
4.70
87.05
4.70
44.11
4.70
70
4.70
4.17

Cx

XRT
Statistics
NS
NS
NS
NS
NS
NS
NS
P 0.055
NS
NS
NS
P 0.060
NS
NS
P 0.05
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS

Scores
3.2
3.5
90
4.5
85
3.7
80
4.2
80
4.3
72
4.1
65
4.1
82
4.4
94
4.6
91
4.6
46
4.9
68
4.9
4.12

Staging
T1-2
Statistics

3
3.06
87.5
4
73.43
4.56
68.75
4.75
71.87
4.37
74.66
4.46
59.37
4.5
68.75
4.43
90
4.87
90
4.43
38.12
4.43
63.12
4.5
4.18

NS
NS
NS
NS
NS
P 0.05
NS
P 0.05
NS
NS
NS
NS
NS
NS
P 0.05
NS
NS
NS
NS
NS
NS
P 0.05
NS
P 0.05
NS

T3-4
Scores

3.14
2.92
91.07
4.07
82.14
4.28
75
4.42
80.35
4.5
77.14
4.57
64.28
4.57
73.57
4.64
90.71
5
95.71
4.57
34.28
4.57
62.85
4.57
4.21

Statistics
3
3.58
85.41
4.33
72.91
4.16
70.83
4.66
68.75
4.16
69.09
4
58.33
4.08
74.16
4.16
92.5
4.5
84.16
4.41
49.16
4.66
67.5
4.75
4.16

NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
P 0.060
NS
NS
P 0.060
NS
NS
NS
NS

QOL: quality of life; XRT: radiation treatment; Cx: chemotherapy; NS: not significant.

widely,10 and is a valuable tool in conjunction with the

QLQ-C30, but has undergone limited reliability and
validity testing.9
Asking patients to define their current health
compared with 1 year prior to diagnosis is problematic, especially in those patients followed for long time
periods. Nevertheless, routine use of the UW-QOL
questionnaire in clinical practice has not led to a modification of this question (Question 2). Its value is in
the current recollection of the patient of his or her
status prior to diagnosis rather than the actual past
condition.
In a prospective study of QOL at the time of diagnosis in head and neck carcinoma patients, Hammerlid et al.11 separately described results for 11 NPC
patients of their total group of 357 head and neck
cancer patients. These patients scored the second
worst global QOL (after patients with hypopharyngeal
carcinoma) and NPC patients also had the worst social
and role functioning and were the group with the
highest pain score and highest use of painkillers. The
three major concerns in NPC patients were trouble

enjoying meals, feeling ill, and dry mouth. Rather surprisingly, dry mouth was a significant concern in these
patients at the time of presentation and scored the
highest of all tumors reported. Despite the relatively
small number of NPC patients in this report, this finding is intriguing. Dry mouth is an expected and major
concern after treatment and scored the lowest of the
domains addressed in the current study; however, we
did not specifically inquire regarding the situation
prior to treatment. Although pain was a foremost
complaint in the patients in the study by Hammerlid
et al.11 prior to treatment, our posttreatment results
imply that it is not a major concern with the current
study patients. Presumably, the use of chemoradiation
in the patients in the current study served well to
control the tumor and reduce pain associated with its
presence. Treatment-related pain that is associated
with surgical tumor ablation was not encountered in
this group of patients, who were treated with a combination of chemotherapy and radiotherapy or radiotherapy only.
Huguenin et al.12 examined the importance of the

1016

CANCER February 15, 2002 / Volume 94 / Number 4

radiotherapy target volume on the QOL of patients

cured of head and neck carcinoma. The EORTC QLQC30 core questionnaire with the head and neck carcinoma module was used and administered by mail.
The response rate for the NPC group was 71% compared with the response rate of 80% in the current
study. Follow-up ranged from 5.15.9 years compared
with a mean of 5.4 years in the current study. The
series in the report by Huguenin et al. included 87
patients, 12 of whom were treated for NPC. These 12
patients were treated with hyperfractionated radiotherapy, 8 of whom also received chemotherapy. Radiation fields included the temporomandibular joints
and salivary glands. Increased problems reported in
the NPC group were dry mouth, sticky saliva, trismus,
problems with teeth, and eating difficulty. Although
role function was reduced significantly in patients
with NPC compared with those with carcinoma of the
larynx (T1/T2), no impact was noted on their global
QOL scores.
These results are compatible with the findings of
the current study both in the domains addressed and
global QOL scores. Dry mouth and sticky saliva are
recognized problems in patients with carcinoma of
the head and neck, and for the most part are induced
by treatment. Candidiasis frequently accompanies xerostomia, especially in terminally ill patients, leading
to severely hampered QOL.13
The global score of NPC patients in the current
study was surprisingly good and this finding may imply that other domains not addressed in the UW-QOL
questionnaire have a positive, moderating effect on
the global score. The addition of a question addressing
ear function is important in these patients. Only six
patients did not report having any ear problems
whereas scores of 70 denoting chronic ear fullness
were noted by 13 patients (46%). Six patients required
tympanocentesis and the introduction of ventilation
tubes and one patient reported a chronic state of
infection with a score of 0 for this domain.
Statistically significantly worse swallowing scores
for patients age 45 years compared with those age
45 years could well be attributed to the fact that all
but 1 of the patients in this group received chemotherapy (90%) compared with only 50% of the patients
age 45 years. In addition, patient expectations may
differ rather than actual difficulties. However, because
no difference appeared to be associated with the importance of swallowing with regard to QOL between
the two groups, further studies are warranted to determine whether if an objective discrepancy exists.
Hughes et al. noted the occurrence of dysphagia in
treated NPC patients by both subjective reports and
objective measures such as videofluoroscopy.14 A total

of 76% reported dysphagia and 97% had xerostomia.

The mean follow-up time was 56 months, which is
quite similar to the follow-up in the current study.
Hughes et al. attributed long-term dysphagia to radiation-induced changes such as xerostomia or decreased pharyngeal mobility due to fibrosis or damage
to pharyngeal innervation.14
As anticipated, patients age 45 years tended to
assign less importance to the activity and employment
scores. Patients treated with chemoradiation had statistically significantly reduced swallowing scores. Although xerostomia was not found to be more severe in
the patients treated with chemoradiation, it was assigned reduced importance. Significantly increased
scores were found with regard to the importance of
appearance and activity in patients treated with chemoradiation. Scores for appearance and activity were
reduced in the chemoradiation group but no apparent
statistical significance was attained (Table 3).
Patients with advanced tumors (T3 4) tended to
have better scores for xerostomia and assigned lower
importance to speech impairment although these results were not statistically significant.
The majority of statistically significant differences
between the groups compared were with regard to the
importance associated with the domains addressed.
This in itself is indicative of the importance of the
incorporation of such questions into a QOL instrument. Scores for different domains may vary but if the
importance of such variability to the patient is minimal the actual significance of this variation is questionable.
The toxicity of radiotherapy for NPC is influenced
by the tumor volume irradiated. In particular, major
salivary gland irradiation largely is responsible for dryness of the mouth, the major reported toxicity of irradiation. With the advent of computed tomographybased conformal irradiation, it has become possible to
adequately cover the tumor in the nasopharynx and
high risk lymph node groups, yet reduce the dose of
radiation to the parotid glands to below the threshold
dose for parotid dysfunction.15 More recently, IMRT,6
which allows the delivery of different doses of radiation to various tumor volumes within the treatment
field, has been introduced into clinical use.16 This
greatly simplifies the planning and delivery of parotidsparing radiotherapy techniques without compromising target coverage.17
It is oversimplification to link QOL with a single
cause such as salivary function. Nevertheless, minimizing radiation damage to the salivary glands could
well alleviate many of the problems reported by NPC
patients. Unfortunately, although the mean parotid
gland radiation dose can be reduced with IMRT, to our

Quality of Life of Nasopharyngeal Carcinoma Patients/Talmi et al.

knowledge it is not at present low enough to preserve

salivary function completely16 in all patients.
Defining QOL in any given patient group is important for portraying the expected course of disease
and treatment to the patient. In the majority of cases
this serves to reduce anxiety and allows the patient
and family to plan ahead. This has particular importance in the NPC patient population (mean age 47
years), and patients may be expected to resume their
normal productive activities, including work, after
treatment with good survival rates. To assess current
and future treatment regimens, appropriate quantification of QOL using validated instruments should be
performed in NPC patients. Longitudinal studies indicating QOL variability during the course of diagnosis
and treatment in these patients are essential.
Patients treated with curative intent for NPC
should receive more focused care for reported longterm problems defined as severe such as ear problems, xerostomia, and chewing difficulties.

7.

8.

9.

10.

11.

12.

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