ORIGINAL ARTICLE

Quality of life in patients with larygeal/hypopharyngeal cancer

following total/partial laryngectomy
Marijana Filipovska-Mušanović1, \enad Hodžić2, Nermin Hrnčić2, Haris Hatibović2

1
Health Care Centre with Outpatient Clinic, Kakanj, 2Department of Otorhinolaryngology and Maxillofacial Surgery, Cantonal Hospital
Zenica, Zenica; Bosnia and Herzegovina

ABSTRACT

Aim To estimate the quality of life (QOL) of patients

with carcinoma of larynx/hypopharynx using the EORTC
QLQ-C30 and QLQ-H&N35 questionnaires in relation to
the reference values (RV), total (TL) / partial (PL) laryn-
gectomy/pharyngectomy, combined treatment (surgery, radiot-
herapy, chemotherapy) (CT) and the time elapsed since surgery.
Methods The questionnaires were answered by 45 patients in the first
6 months of 2011. Sixteen (35.6%) patients had PL and 29 (64.4%)
TL. Postoperatively, CT was performed in 34 (75.6%) patients
(group A), and 11 (24.4%) patients (group B) only had surgery. The
time elapsed from surgery of ≤12 months was found in 11 (24.4%)
patients in the group A1, and 34 (75.6%) of >12 months in the gro-
Corresponding author: up B1. Comparison was made between all scales of the questionna-
Marijana Filipovska-Mušanović ires, global (GS), functional (FS) and general symptomatic (GSS)
QLQ-C30 and specific symptomatic scale (SSS) QLQ-H&N35.
Health Care Centre with Outpatient Clinic,
Results Comparing our results from all scales of both questionnai-
Kakanj
res with RV there was no statistically significant differences, except
ZPO 50, 72240 Kakanj for SSS relating to speech problems (p=0.052574). Comparing PL
Bosnia and Herzegovina and TL there was a decrease in FS (p=0.025517) and increased pro-
Phone/Fax: +387 32 553 111; blems with speech, swallowing, sensation, coughing and social con-
E-mail: maryam.fil@gmail.com tact in SSS (p=0.017595) in TL. Comparing A and B groups, there
was a decrease in FS (p=0.00531) increase of all symptoms in GSS
(p=0.043388) and SSS (p=0.0505385) in the A group. Comparing
A1 and B1 groups better FS (p=0.042271) was registered in A1.
Conclusion Quality of life of our patients is not significantly diffe-
rent from the QOL of similar patients in the world. Comparing all
groups, QLQ-C30 and QLQ-H&N35 showed us clear differences
in QOL and their clinical use is justified.
Original submission:
15 March 2012; Key words: EORTC QLQ-C30, EORTC QLQ-H & N35, quality
Revised submission: of life, head and neck cancer, Bosnia and Herzegovina
28 May 2012;
Accepted:
03 June 2012.

Med Glas Ljek komore Zenicko-doboj kantona 2012; 9(2):287-292

287
 Medicinski Glasnik, Volumen 9, Number 2, August 2012
INTRODUCTION
By significant prolongation of human life fo-
llowing better cancer treatment, estimation of
quality of life (QOL) in cancer patients became
an ethical progress in clinical evaluation.
Over the last decade, clinicians have accepted
that while survival and disease-free survival are
critical factors for cancer patients, overall QOL is
fundamental (1).
While QOL is not easy to define, the literature yi-
elds a number of attempts to define this subjective
term. Some of those attempts define QOL as the
state of well being that is a composite of two com-
ponents: the ability to perform everyday activities
that reflect physical, psychological, and social we-
ll-being; and patient’s satisfaction with levels of
functioning and control of the disease (1). QOL
is measurable by using different types of questi-
onnaires. There are more than 40 questionnaires
that are frequently used in oncology (2,3).
One group of them used in cancer patients with
different modules for different cancer locations is
developed by the European Organization for the
Research and Treatment of Cancer (EORTC) and
by some authors, which are the most used in can-
cer patients (2). The EORTC quality of life core
questionnaire (QLQ-C30), general questionnaire,
version 3.0, is currently the standard version of the
QLQ-C30, and should be used for all new studies
(4, 5). EORTC QLQ-C30 version 3.0 incorporates
nine multi-item scales. Five of them are functional
scales: physical (PF), role (RF), cognitive (CF),
emotional (EF) and social functioning (SF). Three
of them are symptom scales including fatigue
(FA), pain (PA) and nausea/vomiting (NV), and
another one is the Global Health Status/QOL scale
(QL). Six single item scales are also included, dys-
pnoea (DY), insomnia (SL), appetite loss (AP),
constipation (CO), diarrhoea (DI) and financial di-
fficulties (FI). All of the scales range in score from
0 to 100. A high score for a functional scale repre-
sents a high/healthy level of functioning whereas a
high score for a symptom scale or item represents
a high level of symptomatology or problems. Can-
cer site or treatment specific modules are intended
to supplement the QLQ-C30 and should not nor-
mally be used without concurrently administering
the QLQ-C30 (6). QLQ H&N35 module consists
of 35 symptom questions related to head and neck
cancer location and are scored as symptom scale
of EORTC QLQ-C30 (7).
288
Aim of this study was to estimate, for the first
time in the Cantonal Hospital of Zenica, QOL in
patients with larygeal/hypopharyngeal cancer fo-
llowing total/partial laryngectomy/ pharyngecto-
my, chemotherapy and/ or irradiation comparing
with reference values and in relation to type of
treatment and time passed from the treatment.
PATIENTS AND METHODS
The questionnaires were filled by 45 patients on
regular controls in the first 6 months of 2011. Pa-
tients participated voluntarily and were very sa-
tisfied to answer when they saw questionnaires,
especially because it was the first time that some-
one was interested in their complete health and
life status. Because of the problems of communi-
cation, some members of family or nurses helped
them fill in the questionnaires. Institutional revi-
ew board approval was obtained from the Ethics
Committee in the Cantonal Hospital Zenica prior
to the initiation of the study, and all the partici-
pants read and signed informed consent about the
purpose of the study (participation was voluntary
and anonymous) as well.
The average age of patients was 61.39 (40-77). All
patients were males. Partial laryngectomy/ (PL)
had 16 (35.6%) patients and total laryngectomy
(TL) was performed in 29 (64.4%) patients. 11
(24.4%) patients had only surgery. After surgery,
34 (75.6%) patients were treated by irradiation
and three (6.7%) patients combined with cytosta-
tic therapy. According to the time that passed from
surgery patients were divided into 2 groups: first
group included 11 (24.4%) patients with 12 mon-
ths passed after the surgery, and the second group
included 34 (75.6%) patients in whom more than
12 months passed after the surgery.
The results were compared with reference values
from EORTC QLQ-C30 Reference Values manu-
al (7) between the groups with different treatment
as well as between the groups with different time
passed from the surgery.
For statistical evaluation Student t-test was used.
RESULTS
By comparing the results with reference values
(4) no statistically significant difference in fun-
ctional scale of EORTC QLQ-C30 questionnaire
(p=0.097359) was found, even the PF, RF, CF, EF
and SF values were slightly decreased, especially
in SF. Concerning symptom scales of EORTC
 Filipovska-Mušanović et al Quality of life in laryngeal cancer patients

QLQ-C30 (FA, PA, NV, DY, SL, AP, CO, DI Table 2. Comparison of results of QLQ H&N35 between patients
and FI) there was no statistically significant dif- after total (TL) and partial (PL) laryngectomy / pharyngectomy
QLQ H&N35 PL TL
ference (p=0.40086) except in higher level of FI
Pain HNPA 11.97813 12.06897
(46.54315 vs. 18.3). Statistical significance was Swallowing HNSW 8.68625 26.0531
at border value (p=0.052574) for the whole scale Senses problems HNSE 7.291875 31.48259
Speech problems HNSP 30.384 54.36464
of EORTC QLQ H&N35 questionnaire (Table 1).
Trouble with social eating HNSO 7.222 25.69464
An increasing values were noted in speech pro- Trouble with social contact HNSC 12.88933 25.89321
blems of HNSP, but less problems with feeding Less sexuality HNSX 13.33267 19.75259
tube HNFE, pains HNPA, using of pain killers Teeth HNTE 25 25.28724
Opening mouth HNOM 10.41625 13.79241
HNPK and less sexuality HNSX. Dry mouth HNDR 37.49875 27.58448
By comparing results between the groups with dif- Sticky saliva HNSS 22.915 38.09429
Coughing HNCO 18.74875 48.27517
ferent type of surgery (TL vs. PL) there were stati- Feeling ill HNFI 14.5825 22.98759
stically significant differences in QLQ-C30 functi- Pain killers HNPK 26.66667 28.57143
onal scale (p= 0.025517) with significant decrease Nutritional supplements HNNU 6.666667 17.85714
Feeding tube HNFE 0 3.571429
of the values in whole functional scale in patients
Weight loss HNWL 26.66667 21.42857
after TL, especially relating to RF (p= 0.001363). Weight gain HNWG 26.66667 32.14286
Concerning QLQ-C30 symptom scale there was
ents). There were statistically significant differen-
no significant difference, but an increase relating to
ces between these groups in all estimated scales
problems with financial status and fatigue in TL pa-
of both questionnaires. Concerning general health
tients was noted. Statistically significant difference
status, it was significantly better in patients with
(p=0.017595) was noted in EORTC QLQ H&N35
surgery only (the first group) (p=0.01621). Con-
scale (Table 2), with increased level of mostly
cerning functional scale of QLQ-C30, there was a
symptomatology in TL patients, especially pro-
statistically significant better score in all estimated
blems with swallowing, senses problems, speech
functions in the first group (p=0.00531), especially
problems, trouble with social eating and coughing.
in cognitive functions. Observing QLQ-C30 symp-
For the comparison of the values between the gro- tomatic scale, all symptoms were significantly in-
ups with different types of the treatment, including creased in the second group (p=0.043388), in pati-
irradiation and cytostatic therapy after surgery, all ents with combined therapy, especially in financial
patients were divided into two groups: the first difficulties, insomnia, appetite loss, constipation
group included the patients with only surgery as and fatigue. Concerning QLQ H&N35 symptoma-
definitive treatment (11 patients) and second gro- tic scale, there was (mostly) significant increased
up included the patients with combined treatment of these symptoms in the patients with combined
with irradiation and/or chemotherapy (34 pati- therapy (p= 0.0505385), except in weight gain and

Table 1. Comparison of the results of EORTC quality of life Table 3. Comparison of results of QLQ H&N35 questionnaire
questionnaire, head and neck module (QLQ H&N35) with between patients with surgery only and patients with combined
EORTC QLQ-C30 Reference Values Manual treatment with surgery, irradiation and/or chemotherapy
QLQ H&N35 RV Results from this study Combined Only
QLQ H&N35
Pain HNPA 27 12.02355 therapy surgery
Swallowing HNSW 24.4 17.36968 Pain HNPA 14.46059 4.544545
Senses problems HNSE 20.1 19.38723 Swallowing HNSW 21.97971 13.38273
Speech problems HNSP 29.3 42.37432 Senses problems HNSE 26.26333 20.002
Trouble with social eating HNSO 21.1 16.45832 Speech problems HNSP 48.96469 37.37273
Trouble with social contact HNSC 13.5 19.39127 Trouble with social eating HNSO 20.13875 16.66727
Less sexuality HNSX 31.9 16.54263 Trouble with social contact HNSC 23.75031 14.39455
Teeth HNTE 25.8 25.14362 Less sexuality HNSX 20.9671 7.575455
Opening mouth HNOM 19.9 12.10433 Teeth HNTE 28.43147 15.15091
Dry mouth HNDR 30.6 32.54162 Opening mouth HNOM 15.68559 3.03
Sticky saliva HNSS 32.3 30.50464 Dry mouth HNDR 35.29265 18.18
Coughing HNCO 35.6 33.51196 Sticky saliva HNSS 35.29265 23.333
Feeling ill HNFI 22.3 18.78504 Coughing HNCO 37.25441 39.39182
Pain killers HNPK 48.7 27.61905 Feeling ill HNFI 23.52853 9.09
Nutritional supplements HNNU 27.2 12.2619 Pain killers HNPK 25 36.36364
Feeding tube HNFE 21.8 1.785714 Nutritional supplements HNNU 15.625 9.090909
Weight loss HNWL 39.9 24.04762 Feeding tube HNFE 3.125 0
Weight gain HNWG 28.9 29.40476 Weight loss HNWL 28.125 9.090909
RV, reference values; Weight gain HNWG 28.125 36.36364

289
 Medicinski Glasnik, Volumen 9, Number 2, August 2012
Figure 1. QLQ-C30 functional scale in the groups concerning
the time that passed from surgery SF, social functioning; CF,
cognitive functioning; EF, emotional functioning; RF, role func-
tioning; PF; physical functioning
using of pain killers (Table 3). Dominant symp-
toms in the group with combined therapy (the se-
cond group) were weight loss, feeling ill, sticky
saliva, dry mouth, opening mouth, teeth, less sexu-
ality and speech problems.
Concerning the time that passed after surgery, pa-
tients were divided into two groups: the first group
included 11 patients with the surgery performed
12 before, and the second group including 34 pati-
ents who had the surgery performed more than 12
months before. The comparison of questionnaire
results between these two groups has shown no
statistically significant differences in the three sca-
les, global health status scale, QLQ-C30 sympto-
matic scale and QLQ H&N35 symptomatic scale.
Statistically significant difference was found only
in QLQ-C30 functional scale (p=0.042271) with
better functioning in the first group (≤ 12 months)
especially concerning a role and cognitive functions
(Figure 1). It was noted, even without statistically
significant difference, that all QLQ-C30 symptoms
were accentuated in the second group (> 12 mon-
ths) especially financial difficulties, constipation,
dyspnoea and insomnia. Concerning QLQ H&N35
symptoms, also without statistically significant di-
fference between these two groups, it should noted
that some symptoms, like weight gain and use of
pain killers, were dominant in the first group (≤ 12
months), and symptoms like trouble with social ea-
ting, teeth, coughing and feeling ill were dominant
in the second group (> 12 months).
DISCUSSION
EORTC QLQ-C30 Reference Values Manual
is a result of Cross-Cultural Meta-Analysis of
23553 patients from 49 counties from all over the
world (7). Even though Bosnia and Herzegovina
(B&H) was not included in this Meta-Analysis,
290
countries surrounding B&H, like Croatia, Serbia
and Montenegro were included and because of
socioeconomic, cultural and demographic simi-
larity we took these reference values as valid for
the population of B&H. According to our results,
there was no statistically significant difference in
QOL estimated by these two questionnaires as
compared to world population (7).
Regarding the type of the treatment (TL vs. PL),
the QLQ-H&N35 was better than the QLQ-C30
for discrimination between various patient gro-
ups (8), which was also proved in this study. Inte-
restingly, speech problems (QLQ-H&N35) were
not found in previous studies (8), but they were
expected because the quality of the postoperative
voice is considerably better when the larynx can
be preserved, which was specific and dominant
symptom in our patients after TL. Symptomatic
scale of the QLQ-C30 showed no significant dif-
ference in our patients, but in the previous study
(8) significantly worse results were noted in TL
patients concerning fatigue, nausea and vomi-
ting, dyspnoea and appetite loss.
The type of treatment of laryngeal/hypopharyngeal
cancer was the most important variable interfering
with QOL, and combined treatment including che-
motherapy and/or irradiation was associated with
the worst scores (9). Those patients with combined
treatment had worse scores than those who un-
derwent single-modality treatment in the domains
of appearance, recreation, chewing, swallowing
and speech (9), which is particularly found in our
study too. Some authors (10) have not found sta-
tistically significant difference in the overall QOL
score between the groups with combined treatment
relative to single-modality treatment, which is op-
posite to our results. But in some studies (10), fun-
ctional subscale analysis revealed a trend for pati-
ents in the combined treatment group to experience
greater difficulties with social functioning and in
our study cognitive functioning was compromised
the most. Others, like Sherman (11) found on the
EORTC core questionnaire that patients who had
received radiation treatment reported worse role
functioning. On QLQ-C30 symptomatic scale
some authors (8,11) reported greater difficulties
with pain and constipation in groups with combi-
ned treatment, so the other problems like financial
difficulties, insomnia, appetite loss and fatigue fo-
und in our study are characteristic of our patients
with combined therapy. Reportedly, the patients
with combined therapy (QLQ-H&N35) had signi-
 Filipovska-Mušanović et al Quality of life in laryngeal cancer patients
ficantly greater difficulties with sensory disturban-
ces (smell and taste), use of painkillers, coughing
(10), swallowing, dry mouth and weight loss (11),
which is particularly found in our research. Inspec-
tion of the means suggested greater distress for the
radiation treatment patients on all EORTC scales,
with the exception of the appetite, social contact,
opening mouth, and felt ill scales that show no dif-
ference between these groups (11). Feeling ill, stic-
ky saliva, less sexuality, teeth problems, opening
mouth and less use of pain killers are more specific
for our patients with combined therapy.
There are data about the improving QOL relati-
ve to time that passed from treatment (11). Those
patients who had completed treatment more than
6 months ago or those who were recovering had
less QLQ-H&N35 symptoms than patients in the
active treatment group (11). No significant diffe-
rence found in QLQ-H&N35 symptoms relative to
the time that passed from surgery in our patients
could be due to small sample. Also, concerning
the mental health in head and neck cancer patients
the prevalence of depression was reported to be
17–29% one year after the diagnosis (12). After an
initial period of deterioration during and just after
the treatment, patients tended to report improved
mental health at 6 months and full return to pre-
treatment levels at 12 months. According to these
authors (12,13) such results are optimistic indica-
ting the continued long-term mental health impro-
vement, reaching levels corresponding to norms
for the general population. Opposite to a previous
study, in our patients cognitive functioning was
worse one year after the treatment, which could
be due to non-relevance of the recovery process.
The QOL scores decreased in patients after one
year for -physical functioning (13) and the role-
physical domain and changes were also significant
in decreased eating quality and increased emoti-
onal distress, what is also particularly found in
our study. Financial difficulties, constipation, dys-
pnoea and insomnia (QLQ-C30) and less use of
pain killers, teeth problems and coughing (QLQ-
H&N35) found in our patients one year after the
treatment are not reported in previous studies.
Studies that have dealt with the validity of both
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ACKNOWLEDGEMENT
We wish to thank medical nurses/technicians
from Department of Otorhinolaryngology and
Maxillofacial Surgery, especially Dina Seferović-
Halilović, Branka Vinš and Dejan Trifunović for
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head nurse of Department of Otorhinolaryngology
and Maxillofacial Surgery, Azemina Dautbegović
for coordinating the entire process of collecting
data, her achievements and support during the
process, and Jasmin Mušanović, MA, Faculty of
Medicine, University of Sarajevo, for technical
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This study was partly presented by Đenad Hodžić,
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Kvalitet života pacijenata s karcinomom larinksa/hipofarinksa

nakon totalne/parcijalne laringektomije
Marijana Filipovska-Mušanović1, \enad Hodžić2, Nermin Hrnčić2, Haris Hatibović2
1
Dom zdravlja sa poliklinikom, Kakanj, 2Služba za bolesti uha, grla, nosa i maksilofacijalnu hirurgiju, Kantonalna bolnica Zenica; Bosna i
Hercegovina

SAŽETAK
Cilj Procijeniti kvalitet života (KŽ) pacijenata s karcinomom larinksa/hipofarinksa upotrebom EORTC
QLQ-C30 i QLQ-H&N35 upitnika u odnosu na referentne vrijednosti (RV), totalnu (TL)/parcijalnu
(PL) laringektomiju/faringektomiju, kombinovani tretman (hirurgija, radioterapija, hemoterapija) i vri-
jeme proteklo od hirurškog tretmana.
Metod Upitnik je popunilo 45 pacijenata u prvih šest mjeseci 2011. godine. PL je imalo 16 (35,6%) pac-
ijenata, a TL 29 (64,4%). Postoperativno, zračenjem i hemoterapijom tretirana su 34 (75,6%) pacijenta
(grupa A), a samo hirurškim tretmanom 11 (24,4%) pacijenata (grupa B). Prema vremenu proteklom
od operacije, u grupi A1 (≤12 mjeseci) bilo je 11 (24,4%) pacijenata, a u grupi B1 (>12 mjeseci), 34
(75,6%). Poređene su sve skale upitnika (globalna (GS), funkcionalna (FS) i opšta simptomatska (OSS)
QLQ-C30 i specifična simptomatska skala (SSS) QLQ-H&N35).
Rezultati Poređenjem rezultata s RV-a nije zabilježena statistički značajna (SZ) razlika, osim značajno
zastupljenih govornih problema u SSS-u (p=0,052574). Poređenjem PL-a i TL-a, zabilježen je SZ pad
u FS (p=0,025517) u TL i SZ porast u SSS (p=0,017595), s izraženim problemima s govorom, guta-
njem, osjetima, kašljem i socijalnim kontaktom u TL. Poređenjem grupa A i B, uočen je SZ pad u FS
(p=0,00531), izraženiji simptomi u OSS-u (p=0,043388) i u SSS-u (p=0,0505385) u grupi A. Poređe-
njem grupa A1 i B1 registrovana je SZ bolja FS (p= 0,042271) u grupi A1.
Zaključak Kvalitet života naših pacijenata ne razlikuje se značajno od kvaliteta života istih pacijenata
u svijetu. Poređenjem posmatranih grupa, QLQ-C30 i QLQ-H&N35 pokazali su značajne razlike u
kvaliteti života, te je njihova klinička upotreba opravdana.
Ključne riječi: EORTC QLQ-C30, EORTC QLQ-H&N35, kvalitet života, karcinom regije glave i vra-
ta, Bosna i Hercegovina

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