INTRODUCTION

Head and neck cancer (HNC) is a generic term defined on an anatomical-topographical basis to describe malignant tumors of the upper aerodigestive tract. This anatomical region includes the oral cavity, the pharynx, and the larynx, as well as salivary and thyroid glands (^{Dobrossy, 2005}).

In Brazil, according to INCA (National Cancer Institute) estimates for 2018 and 2019, 634,880 new cases of cancer are expected each year. Globally, cancer of the oral cavity stands out among HNC, ranking 5th overall in the male population, while larynx cancer ranks 8th overall among men. In women, cancers of the oral cavity and the larynx are the 12th and 17th most frequently diagnosed cancers, respectively (^{INCA, 2017}).

Despite a relatively lower incidence than that of other primary sites, a diagnosis of HNC has a relevant impact due to the morbidity and mortality associated with this neoplasia (^{Chu et al., 2011}). Because of the topography of the primary site of this type of cancer, resulting symptoms directly compromise patient quality of life: local pain, dyspnea, chronic fatigue, bleeding, intermittent cough, dysphagia, and dysphonia (^{Markkanen- Leppänen et al., 2006}).

Quality of life (QOL) is defined as an individual’s perception of their position in life, in the context of their culture and value system in which they are inserted, and in relation to their goals, expectations, standards, and concerns. It is a comprehensive concept, influenced in a complex way by physical health, psychological state, level of independence, social relationships, and relationships with the individual’s environment (^{World Health Organization [WHO], 1993}).

Quality of life evaluation in patients with HNC has become an increasingly important topic in several studies( ^{Moreno and Lopes, 2002}; ^{Mehanna and Morton, 2006}; ^{Vilaseca et al., 2006}), because, in addition to contributing to treatment monitoring, it enables health professionals to understand how patients experience disease progression and the consequences of their treatment.

In a 2016 systematic review, which studied the psychological variables associated with quality of life after primary treatment for head and neck cancer, depression was associated with worse QOL results in cross-sectional studies. High levels of anxiety and anguish (anxiety combined with depression scores) were also observed to be associated with a decrease in QOL among HNC survivors (^{Dunne et al., 2017}).

The experience of psychological distress, particularly depression, is very common among cancer patients and can occur throughout the course of the disease, often persisting months after treatment completion. The basis for this distress is multifaceted, and it may occur because of the diagnosis itself, sequelae of the disease and its treatment, decreased QOL, or the possibility of progression, recurrence, or death (^{Massie, 2004}).

Depression in patients with HNC is estimated to be more prevalent than in other types of cancer (^{Massie, 2004}). Estimates vary according to the evaluation method (self- report questionnaires or diagnostic interviews), but approximately 15% to 50% of patients with HNC suffer some degree of depression at some point over the course of the disease (^{Haisfield-Wolfe et al., 2009}), which may affect the immune system, adherence to treatment, self-care behavior, resocialization, and QOL (^{Howren et al, 2013}).

The aim of this study was thus to assess the association between quality of life and psychological factors in patients diagnosed with head and neck cancer.

MATERIALS AND METHODS

RESULTS

We evaluated 148 patients with a median age of 62 [54-69] years. Sociodemographics and clinical characteristics are detailed in Tables 1 and 2. The median composite quality of life score as assessed by the Washington Questionnaire was 75 [58.5-87.3]; the median Physical Function subscale score was 79 [63.8-93.7]; and the median Socioemotional Function subscale score was 70 [52.8-87.5]. The prevalence of anxiety and depression according to HADS scores was respectively 32.4% (48) and 31.1% (46).

And it was found that 48% (13) of patients with anxiety were also depressed (p=0,003). Table 3 shows the comparison between depression and quality of life domains, including the Physical Function and Socioemotional Function subscales of the Washington Questionnaire. A statistically significant association was found for both subscales and almost all domains, except for the shoulder domain, suggesting individuals with depression have worse quality of life than those without depression.

The comparison between anxiety and quality of life domains, including the Physical Function and Socioemotional Function subscales of the Washington Questionnaire, is detailed in Table 4. We observed both subscales and almost all domains, except for the chewing and saliva domains, had a statistically significant association, indicating anxious individuals have worse quality of life than subjects without anxiety.

After adjusting for confounders (age, sociode-mographics, and clinical characteristics), subjects with advanced-stage disease, depression, and anxiety were found to be less likely to have high quality of life, while women and those with non-oral HNC had a greater chance to have better QOL. The magnitude of these associations is described in Table 5.

The single UW-QOL question about anxiety had excellent diagnostic accuracy in detecting anxiety, when compared to HADS-A. The AURC was 70% (95% CI: 0.61 to 0.76; p < 0.001). Its diagnostic properties are detailed in Table 6.

Furthermore, the single UW-QOL question about depression had even better diagnostic accuracy in detecting depression cases (a score > 7 in HADS-D). The AURC was 75.5% (95% CI: 0.67 to 0.82; p < 0.001). Its diagnostic properties are detailed in Table 7.

DISCUSSION

Regarding sociodemographic data, lifestyle, and clinical characteristics of the studied population, our findings corroborate those of several studies that evaluated these features in individuals with head and neck cancer ( ^{Qiu et al. 2014}; ^{Alvarez-Camacho et al., 2016}; ^{Gobbo et al., 2016}; ^{Rocha et al., 2017}).

However, with regard to tumor site, a study by ^{Kelly et al. (2007)} found a discordant picture, in that most patients had laryngeal cancer (41%), followed by pharyngeal (30.6%) and oral (19.65%). Another study with different results was that by Alvarez-

Camacho et al. (2016), which found most cases to be of pharyngeal cancer, followed by laryngeal and oral. In our study, however, most patients had oral cancer, followed by laryngeal and pharyngeal.

The word “anguish” was chosen by the National Comprehensive Cancer Network to describe the psychological, social, or spiritual aspects that interfere with the ability to deal with the treatment of cancer and its physical symptoms. This term was used because it carries no stigmatized connotations, and patients are comfortable with its use. Anguish extends from common feelings of vulnerability, sadness, and fear, to disabling problems such as depression, anxiety, and panic (^{Holland and Bultz, 2007}).

We evaluated psychological factors (anxiety and depression) and quality of life, and their relationship in patients with HNC at the time of diagnosis. Anxiety and depression are the most common psychological issues among cancer patients. In fact, anxiety and depression can influence patient immune status, affecting the course of the disease, having been linked to poor nutrition and poor survival (^{Britton et al., 2012}; ^{So et al., 2010}; ^{Lazure et al., 2009}). The prevalence rate of depression found through HADS in our study was 32.4%, a figure similar to those of previous studies with patients with HNC, ranging from 20 to 43% (^{Haisfield-Wolfe et al., 2009}; ^{Kelly et al., 2007}; ^{Britton et al., 2012}; ^{Hong et al., 2013}; ^{Chiou et al., 2013}; ^{Almstahl et al., 2016}; ^{Holtmaat et al., 2017}).

As regards HADS-anxiety, we found anxiety in 31.1% of patients, which is in line with results found in the literature, varying from 24 to 46% (^{Britton et al., 2012}; ^{Hong et al., 2013}; ^{Almstahl et al., 2016}; ^{Holtmaat et al., 2017}). These data show individuals with HNC have a high prevalence of psychological changes (anxiety and depression). We believe this is due to the fear of the diagnosis itself and the consequences of the disease and its treatment. These factors make patients even more susceptible to immune system disturbances and lead them to difficulties in adhering to treatment, thus hindering their response to cancer therapy.

In addition, patients with head and neck cancer have lower socioeconomic and educational levels when compared to other cancer patients, and this leads to a higher prevalence of psychological issues (^{Hassanein et al., 2005}). Our findings also support these observations. Knowledge of the social issues these individuals face is therefore important for better management of cases by health professionals.

In this study, a comparison was made between the UW-QOL domains, including the Physical Function and Socioemotional Function subscale scores, and the HADS anxiety and depression subscales. Anxious and depressive patients were found to have poor quality of life in almost all domains and both UW-QOL subscales. Similar results were found in other studies that included this type of analysis ( ^{Chiou et al., 2013}; ^{Hassanein et al., 2005}; ^{Neilson et al., 2010}). These data indicate psychological factors, such as anxiety and depression, influence patient quality of life. The importance of this association resides in the assessment of the need for monitoring or psychological/psychiatric treatment of these individuals in an attempt to improve their response to cancer treatment and their quality of life.

In a study of 102 patients with head and neck cancer, ^{Neilson et al. (2010)} analyzed quality of life in relation to anxiety and depression and found high frequencies of these psychological issues were strongly correlated with poor quality of life. The same was found in a study by ^{Hassanein et al. (2005)} with 173 patients with oral cancer.

In our sample, patients who were diagnosed with stage III and IV HNC were found to be less likely to have high quality of life according to the Physical Function subscale than those with early-stage cancer, as in the studies by ^{Beisland et al. (2013)} and ^{Bonzanini et al. (2020)}, in which individuals with late-stage tumors were found to have poor quality of life.

We found depression and anxiety to have a negative correlation with high quality of life as measured by the Physical Function subscale, while female sex and non-oral HNC were found to be positively correlated with high quality of life in our sample. These results are in line with the literature in relation to depression and anxiety (^{Chiou et al., 2013}; ^{Hassanein et al., 2005}; ^{Neilson et al., 2010}, ^{Kung et al., 2006}) and also female sex (^{Bonzanini et al., 2020}). This suggests a greater need for monitoring and assessing quality of life of male individuals with advanced-stage cancer who present with depression and anxiety through the application of validated questionnaires.

The questions about mood (depression) and anxiety in the UW-QOL and in the HADS subscales were found to have high diagnostic accuracy of 70% and 75%, respectively, indicating these UW-QOL questions are adequate as an assessment tool for these domains. This study thus also validates the UW-QOL anxiety and depression domains, with good agreement observed between the UW-QOL and the HADS, allowing the former to be used as an instrument to screen HNC patients for anxiety and depression.

CONCLUSION

We showed psychological factors (anxiety and depression) have a strong relationship with low quality of life in patients with head and neck cancer. A strong correlation between low quality of life and advanced-stage disease as well as a negative association of female sex and non-oral HNC with low quality of life were also observed, suggesting the need for a better HNC screening system. In addition, this study validates the UW- QOL anxiety and depression domains as accurate instruments aimed at detecting the most severe cases.

Our findings support the psychological monitoring of HNC patients is fundamental not only to help the patient’s emotional well-being, but to help with the prospects of healing, reducing symptoms of anxiety and depression.so as to improve their quality of life and potentially enhance survival rates.