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

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH
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


THESIS COMPLETED IN:
HANOI MEDICAL UNIVERSITY

Supervisor: Assoc Prof. Pham Tuan Canh, MD, PhD

Reviewer 1:
Reviewer 2:
Reviewer 3:

Thesis will be defended at University level Doctoral thesis
assessment committee at .........Hanoi Medical University.

Thesis can be found in:
National library of Vietnam
Hanoi Medical University library

1

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 multimodal 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


2

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
aims:
1.Evaluate pre-operative health-related quality of life of
laryngeal cancer.
2. Evaluate post-operative health-related quality of life of
laryngeal cancer.
3.Compare pre-operative and post-operative health-related
quality of life to improve patient consultation.
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: preoperation, 1 month, 3 months, 6 months and 12 months postoperation. 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


3

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


4

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-epiglottohyoidoplasty: 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.


5

*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,

disability or disorder. Characteristics of HRQOL include: selfreported, 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 decisionmaking 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.


6

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: postoperative 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,


7

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


8

treatment, cognitive impairment or lack of proficiency in
Vietnamese, or loss to follow-up at any time-point.
2.2.Methods of study.
This was a longitudinal prospective study with convinience
sampling. There was no control group in the study.

2.3.Tool of measurement.
In this study, two questionnaires were used to assess QOL of
laryngeal cancer patients: EORTC QLQ-C30 and EORTC QLQH&N35. C30 is the core questionnaire for all cancer patients; and
H&N35 is the specific module for head and neck cancer patients
(including laryngeal cancer) using in combination with C30. These
two questionnaires were well developed by European Organisation
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


9

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.


10

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

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.

21.
22.
23.
24.
25.
26.
27.
28.

scales and items
Physical functioning
Cognitive functioning
Emotional functioning
Role functioning
Social functioning
Pain
Dyspnea
Appetite loss
Nausea - vomiting
Constipation
Diarrhea
Insomnia
Fatigue
Feeling ill
Less sexuality
Financial difficulty
Pain in mouth
Teeth
Swallowing
Opening mouth

Dry mouth
Sticky saliva
Senses problems
Trouble with social eating
Speech problems
Coughing
Trouble with social contact
Global HRQOL

Group

General functional
scales

11 scales / symptoms
caused by cancer and /
or its treatment

11 specific scales /
symptoms for head
and neck cancer


11

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 postoperation:


12

Table 3.16: QOL scores (symptom scales) in group LASER preand post-operation
Post-operation

Item / scale

Preop

1 month
𝑋̅

3 month
𝑋̅

6 month
𝑋̅

12 month
𝑋̅

Appetite loss
8.8
16.7*
30.7**
20.2*
16.7*
Sticky saliva
4.4
17.5**
30.7**
22.8**
18.4**
Senses problems
6.1

9.7
22.4**
16.7**
11.8*
Opening mouth
0.9
7.0*
8.8**
5.3*
6.1
Social eating
3.9
11.8*
28.3**
11.6**
8.8
Fatigue
11.1
18.7*
28.9**
27.5*
17.2
Dry mouth
14.1
21.1
35.1**
24.4*
19.3
Swallowing
7.0

11.4
23.1**
12.9**
11.5
Speech problem
40.9
52.3*
65.5**
48.8
43.9
Financial difficulty
14.9
32.5**
26.3*
17.5
13.2
Pain
8.8
9.7
16.2*
7.9
6.1
Pain in mouth
5.3
11.4
22.6**
7.9
7.0
Teeth
24.6

17.5
28.9
30.7
33.3*
Coughing
22.8
29.8
48.3**
28.1
26.3
Dyspnea
13.2
13.2
29.8**
14.9
13.2
Social contact
13.5
18.3
24.2**
15.3
13.9
Insomnia
31.6
34.2
57.0**
41.2
35.9
Constipation
15.8

14.9
20.2
14.9
23.7*
Feeling ill
8.8
16.7
28.9**
14.9
10.5
Nausea-vomiting
3.9
6.1
6.1
2.2
1.3
Diarrhea
0
2.6
2.4
1.8
1.5
Less sexuality
35.9
33.5
47.4
41.7
39.0
(*): p < 0.05; (**): p < 0.01 (in comparison with pre-operation)
Values > 20 were in bold font (can have impact to QOL)

13

Table 3.17: QOL score (general QOL and 5 functional scales)
in group LASER pre- and post-operation
Post-operation
Item / scale

Preop

Global QOL
Physical functioning
Role functioning
Emotional functioning
Cognitive functioning
Social functioning

74.8
95.3
92.9
87.1
92.9
95.6

1 month
𝑋̅

3 month
𝑋̅

6 month
𝑋̅

12 month
𝑋̅

62.2*
90.2*
86.4*
78.5*
89.5
79.4**

60.1**
79.7**
62.3**
70.4**
75.9**
66.7**

70.0
84.0**
70.2**
88.2
85.5*
78.5**

74.3
85.9**

73.3**
89.9
87.7
79.4**

Table 3.18: QOL score (general QOL and 5 functional scales)
in group OPL pre- and post-operation
Post-operation
Item / scale

Preop

1 month
𝑋̅

3 month
𝑋̅

6 month
𝑋̅

12 m.nth
𝑋̅

Global QOL

77.8

55.2**

65.8**

70.3**

75.3

Physical functioning

94.7

77.9**

86.5**

91.5*

93.9

Role functioning

98.7

53.0**

65.7**

72.7**

77.0**

Emotional functioning

74.5

77.3

90.8**

95.0**

95.8**

Cognitive functioning

94.7

86.0**

94.3

94.0

94.7

Social functioning

92.7

58.0**

72.1**

75.3**

79.9**

(*): p < 0.05; (**): p < 0.01 (in comparison with pre-operation)
Values < 80 were in bold font (can have impact to QOL)


14

Table 3.19: QOL scores (symptom scales) in group OPL preand post-operation
Post-operation
Item / scale

Preop

1 month
𝑋̅

3 month 6 month
𝑋̅
𝑋̅

12 month
𝑋̅

Speech problem
31.8 68.9** 55.1** 48.9** 47.3**

Social contact
3.3 33.5** 13.2** 9.1**
8.3*
Coughing
7.3 58.1** 36.7** 28.7* 27.3**
Swallowing
4.7 29.7** 15.1** 13.7** 10.7**
Dry mouth
10.0 31.3** 18.1* 18.0*
23.4*
Senses problems
2.0 17.1** 9.1** 9.3**
7.7*
Social eating
1.0 35.5** 20.3** 15.3** 13.7**
Less sexuality
22.3 61.3** 40.1** 35.1** 31.7*
Fatigue
4.9
30.7** 14.9** 10.9*
8.0
Appetite loss
11.3 39.2** 24.7** 18.7*
10.7
Sticky saliva
8.0 32.1** 16.7*
14.1
14.0*
Pain
2.1

22.0** 8.7*
3.7
4.1
Pain in mouth
4.0 27.0** 11.2**
6.8
4.5
Dyspnea
14.1 39.3** 28.0*
18.7
15.3
Insomnia
30.1 54.7** 40.0*
35.3
28.0
Feeling ill
4.7 37.3** 15.3**
9.3
4.7
Opening mouth
3.3 15.3**
8.2
5.3
4.7
Nausea - vomiting
3.7
17.3**
5.0
2.1
1.3

Constipation
18.7
10.7*
12.0
19.3
24.1
Financial difficulty
8.7
23.3*
20.7
13.3
12.7
Teeth
18.7
20.7
18.1
24.7
23.3
Diarrhea
2.1
12.7
5.3
4.7
3.3
(*): p < 0.05; (**): p < 0.01 (in comparison with pre-operation)
Values > 20 were in bold font (can have impact to QOL)


15

Table 3.20: QOL scores (symptom scales) in group TL pre- and
post-operation
Post-operation
Item / scale

Preop

1 month
𝑋̅

3 month
𝑋̅

6 month
𝑋̅

12 month
𝑋̅

Speech problems
36.6 92.5** 87.4** 82.3** 79.9**
Social contact
1.9 53.2** 42.2** 34.9** 22.9**
Coughing
9.0 72.9** 45.9** 34.2** 44.1**
Opening mouth
0.9
9.9**
7.2*
7.3*

7.2*
Dry mouth
4.5 35.1** 35.2** 30.6** 31.5**
Sticky saliva
1.8 36.9** 37.8** 26.1** 28.8**
Senses problems
0.5 41.0** 47.3** 48.7** 45.9**
Social eating
2.3 52.5** 29.5** 22.1** 20.5**
Appetite loss
9.9
55.9** 34.2** 23.4** 22.5**
Fatigue
2.7
43.5** 24.0** 14.7** 11.1**
Less sexuality
13.9 82.4** 65.8** 54.9** 42.8**
Feeling ill
3.6 61.3** 36.9** 26.1** 15.3**
Financial difficulty
9.0
39.6** 38.7** 30.6** 22.5**
Dyspnea
13.5 43.2** 30.6** 22.5**
18.9
Insomnia
35.1 68.5** 46.9*
42.3
36.9
Constipation

11.7
3.6*
11.7
5.4
25.2**
Diarrhea
0
0
10.8** 16.2**
0.9
Pain
3.2
31.9** 12.6**
3.2
0.9
Pain in mouth
4.1 40.8** 17.8**
5.2
2.7
Swallowing
8.1 42.8** 19.6** 14.9
11.9
Nausea-vomiting
4.9
30.6**
8.1
2.3
1.8
Teeth
17.1

23.4
20.7
27.0*
24.3
(*): p < 0.05; (**): p < 0.01 (in comparison with pre-operation)
Values > 20 were in bold font (can have impact to QOL)


16

Table 3.21: QOL score (general QOL and 5 functional scales)
in group TL pre- and post-operation
Post-operation
Item / scale

Pre-op

1 month
𝑋̅

3 month
𝑋̅

6 month
𝑋̅

12 month
𝑋̅

68.0**

Global QOL

77.9

38.7** 50.7** 59.6**

Physical functioning

94.6

69.9** 85.2**

Role functioning

98.2

44.1** 54.1** 61.3**

Emotional functioning

73.9

68.5

Cognitive functioning

98.2

82.9**

90.1*

85.6** 90.8**
94.1*

93.2*

92.4
64.4**
94.6**
96.9

Social functioning
96.4 38.7** 48.2** 62.2** 65.3**
(*): p < 0.05; (**): p < 0.01 (in comparison with pre-operation)
Values < 80 were in bold font (can have impact to QOL)

Chapter 4
DISCUSSION
4.2.Pre-operative QOL of laryngeal cancer patients.
Pre-operative QOL of laryngeal cancer patients was affected in
"Global QOL", "emotional functioning" scale and three symptom
scales "speech problems", "insomnia", "less sexuality". Our result
was similar to the study of Johansson et al. In laryngeal cancer,
speech disorder always the major symptom which appears at early
onset and lasts for long time, therefore this symptom causes great
impact on patient's QOL. At pre-operation, patients often worried
about their disease and their treatment process (including the

17

operation). That bad mood expresses in "insomnia" symptom as
well as negative "emotional functioning". All these impaction was
reflected in the deterioration of "global QOL".
4.3. Pre-operative QOL of laryngeal cancer patients.
4.3.1.Group TLM.
There was a moderate, clinically significant worsening in
global health QOL status at 1 month post-surgery (p<0.05).
However, there was essentially a return to baseline at 12 months
post-op. Five functional scores (“physical”, “emotional”
“cognitive”, “role”, and “social functioning”) had maximal
deterioration at 3 months (p<0.01). At 1 month, “physical” and
“emotional functioning” scores demonstrated subtle, clinically
relevant decrease (p<0.05), but “social functioning” scores showed
moderate, clinically relevant drop from baseline scores (p<0.01).
At 12 months, there was a slight, clinically significant improvement
in “physical functioning” scores from baseline (p<0.01). While
changes in “emotional functioning” scores from baseline were
trivial, “social functioning” scores saw a moderate, clinically
significant decrease from pre-operative scores (p<0.01). Symptoms
of “nausea-vomiting”, “pain”, “diarrhea”, “less sexuality”, and
“teeth” demonstrated no significant change from baseline. All other
symptoms except for “constipation” showed maximally significant
difference at 3 months. Five symptom-related scores that
demonstrated the most significant changes were identified as
“speech”, “social eating”, “sticky saliva”, “cough”, and
“insomnia”. All symptom scores were significantly worse at 3
months post-op. At 6 and 12 months, all items except for “sticky

saliva” and “social eating” returned to levels not significantly
different from baseline. “Appetite”, “social eating”, “senses (smell
and taste)", “constipation” (all P < .05), and “sticky saliva” (P <


18

.01) showed significantly increased severity at 12 months compared
to baseline. Our finding was similar to those of Minovi and
Stoeckli.
4.3.2.Group OPL.
*Symptom domains.
Symptom-related scores that demonstrated the most significant
net changes were: “speech”, “social eating”, “sexuality”, “cough”
and “feeling ill”. “Speech” showed significant improvement at 1
month post-surgery (p<0.01). Although this improvement declined
over time, there continued to be a significant improvement
compared with pre-operative speech function at 12 months
(p<0.01). The other symptoms, except for “feeling ill”, which
remained significantly worse than pre-operative scores (p<0.01),
gradually lessened over 12 months’ time. All other symptom
domains, except for “teeth”, were significantly worse at 1 month
post-surgery (p<0.01). At 12 months, the following symptoms
remained significantly worse when compared to pre-operative
scores: “fatigue” (p<0.05), “financial difficulty”(p<0.05),
“dysphagia” (p<0 .01), “senses (smell and taste)” (p<0.01), “social
contact”(p<0.05), “dry mouth” (p<0.01), and “sticky saliva”
(p<0.01). Voice disorder after laryngofissure was due to glottic
deficiency: vocal folds could not close properly during phonation,
reduced maximal phonation time, changed pitch and limited voice

intensity range. Most of major phonation structures were resected
in supracricoid partial laryngectomy, therefore voice was severrly
affected: reduced frequency range, low fundamental frequency, and
increased breathiness, increased effort required to talk. Coughing is
a common symptom after OPL: loss of protective barriers can


19

cause aspiration of food and saliva into lower respiratory tract.
About "swallowing disorder": the meta-analysis of Lips et al
showed that "swallowing disorder" was common within the first 3
months post-operation. After 6 months, most of patients regained
normal diet per os. These results were similar to our finding:
"swallowing disorder" increased significantly in the first postoperative month then improved gradually. About "less sexuality":
according to Singer et al, 53% of patient admitted of a worse sex
life; 42% of patient had erection dysfunction after open partial
laryngectomy. The mean score of "less sexuality" in Singer's study
was 27.8 and implied an impaction on patients' QOL. Singer
explained the cause of "less sexuality" with following reasons:
deterioration of physical strength, noisy breathing and increasing of
mucus discharge.
*Global QOL and functional scales.
There was a moderate, clinically significant worsening in
global health QOL status at 1 month after surgery (p<0.01) but
there was essentially a return to baseline at 12 months (p<0.01). At
1 month post-surgery, “physical functioning” saw an obvious,
clinically significant drop while “social functioning” saw a
moderate, clinically relevant decrease in scores (both p<0.01).
Notably, there was trivial change in “emotional functioning”

scores at 1 month. At 12 months, “physical functioning” scores
essentially returned to baseline (p<0.01), while “emotional
functioning” saw a moderate, clinically relevant increase and
“social functioning” saw a moderate, clinically relevant decrease
(both p<0.01). Our results was in accordance with the data of Braz
and Batioglu-Karaaltin. Base on these finding, healthcare


20

professionals can design an appropriate rehabilitation plan for postoperative patients. In the first month post-operation, when patients
suffered from swallowing disorder, speech-therapists could give
swallowing exercises to prevent aspiration and reduce coughing;
Nutritionists could give patients a special diet with changing of
food texture to ensure scar healing and post-operative recovering.
Similar speech exercises should be indicate early to improve and
maintain voice quality, therefore related scales "role functioning"
and "social functioning" could also improved.
4.3.3.Group TL.
*Symptom domains.
Symptom-related scores that saw the most significant net
change were: “speech”, “social eating”, “social contact”,
“cough”, “sense (smell and taste)”, “sexuality”, “sticky saliva”,
and “dry mouth”. All had significant peak deterioration at 1 month
post-surgery (p<0.01). Improvement was observed in “social
eating”, “social contact”, “sexuality”, “cough”, and “feeling ill”;
however, they remained significantly worse compared to presurgical scores (p<0.01). In contrast, “speech”, “sense (smell and
taste)”, and “sticky saliva” showed little to no improvement over
time and remained significantly worse compared to baseline
(p<0.01). Other symptoms that were significantly worse at 12

months compared to baseline included: “fatigue” (p<0.01),
“appetite”(p<0.01), “constipation” (p<0.01), and “financial
difficulty” (p<0.01). However, “nausea-vomiting”, although
significantly worse at 1 month post-op, became significantly
improved at 12 months compared to baseline (p<0.05). Our finding


21

was similar to those in studies of Baczyk, Batioglu-Karaaltin,
Boscolo-Rizzo and Singer. Birdford interviewed post-total
laryngectomy patients and found that when patients had lost their
natural voice, they felt the loss of part of their character and
personality. Most of patients reduced communicating, using only
body language (nod and shake head), then gradually reduced social
activities and became self - isolation. According to Carr et al, posttotal laryngectomy patients tended to give up many social
activities: talking in a noisy environment, singing, telephone calls,
meeting, eating out, visiting friends. "Speech disorder" can cause
great impact to global QOL of post-total laryngectomy patients.
"Coughing" symptom increased significantly at 1 month postoperation then gradually improved. However, at 12 month postoperation, "coughing" could not return to pre-operation baseline.
Similarly, "dyspnea" symptom increased significantly at 1 month
post-operation then gradually improved. Increasing coughing and
mucus discharge could also cause negative impact on patients'
emotional scale: easily irritated, more anxiety and depression.
"Senses problems" score deteriorated at 1 month post-operation and
did not improve over time. This deficiency in smell and taste can
significantly affect QOL of patients after TL. Mumovic's study on
105 patients post - total laryngectomy showed that olfaction was
impaired in 51.4%, and was even not possible in 30.5%, of patients.
Decreased gustation abilities were reported in 26.7%, and

dysgeusia in 11.4%, of patients. Almost 21% of patients were
bothered by an impaired gustatory ability and 50.5% of patients
were affected by their loss of olfaction. Patients who reported a
deterioration of olfaction and gustation tended to experience


22

negative consequences such as the inability to smell smoke, leaking
gas, or agreeable odors. About "less sexuality": our result was
accordance with data from Ozturk, Yilmaz and Singer (with the
rate of patient admitted a worse sex life 47.4, 51 and 53%
consequently).
*Global QOL and functional scales.
There was a moderate, clinically significant worsening in
global health QOL status at 1 month after surgery (p<0.01).
Moderate reduction from pre-operative scores remained at 12
months (p<0.01). “Physical functioning” saw an obvious,
clinically significant reduction, “emotional functioning” saw a
slight, clinically significant reduction, "role functioning" and
“social functioning” saw a moderate, clinically relevant reduction
from baseline scores at 1 month (all p<0.01). At 12 months,
“physical functioning” scores essentially returned to baseline,
“emotional functioning” scores saw a moderate, clinically relevant
increase (p<0.01); "role functioning" and “social functioning”
scores demonstrated a moderate, clinically relevant decrease from
baseline (p<0.01). According to Bussian et al: Psychiatric disorders
were diagnosed among 22.2% of the patients with total
laryngectomy. Noonan et al evaluated patients after total
laryngectomy: psychological concerns included altered mood, more

depression, regrets, anxiety and irritated. Ozturk et al also found
that after total laryngectomy, patients faced many psycho-social
problems such as difficulty in self-expression, irritability, "belief in
not regaining health" and "isolation from society". The
deteriorization of "fatigue" and "emotional functioning" scores
were also observed in the study of Olthoff et al. There was a strong


23

correlation between "speech problems", "social contact" and
"social functioning", "role functioning". Our finding was similar
with the data of Jayasuriya and Ramirez. After total laryngectomy,
patients' quality of life was affected early and continued during the
first 12 months post-operation. This impact should be describe to
patients before their decision making among treatment options.
Moreover, healthcare professionals can design an appropriate
rehabilitation plan for post-operative patients base on these
findings. When the essential functions (speech, swallowing and
respiration) were well - rehabilitated, the impact on post-operative
functional scales (such as "social functioning" or "role
functioning") could be reduced.

CONCLUSION
Through a longitudinal prospective study, quality of life of
laryngeal cancer patients pre- and post- surgical treatment were
evaluated.
* Pre-operative QOL of laryngeal cancer patients.
Pre-operative quality of life of laryngeal cancer patients was
affected in several scales and symptoms: "emotional functioning",

"speech problems", "insomnia" and "less sexuality". "Global QOL"
was slightly affected.
* Post-operative QOL of laryngeal cancer patients.
a) Group TLM: Quality of life deteriorated at 1 month, became
worst at 3 month then recovered at 6 month post-operation. At 12
month post-operation: QOL was affected in two scales: "role
functioning" and "social functioning" (73.3 and 79.4 points).