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Revista Brasileira de Terapias Cognitivas

 ISSN 1808-5687 ISSN 1982-3746

Rev. bras.ter. cogn. vol.18 no.2 Rio de Janeiro jul./dez. 2022   24--2024

https://doi.org/10.5935/1808-5687.20220015 

Relatos de Pesquisas

Associação entre qualidade de vida e fatores psicológicos em pacientes diagnosticados com cancer de cabeça e pescoço

Association between quality of life and psychological factors in patients diagnosed with head and neck cancer

Marla Smille Pedrosa Cruz1 

Tércio Guimarães Reis2 

José de Bessa-Júnior1 

Antoniel Campos Oliveira3 

Alice Nobre Dantas3 

Marluce Matos Macedo3 

Márcio Campos Oliveira1 

1Universidade Estadual de Feira de Santana, Saúde - Feira de Santana - Bahia - Brasil

2Unidade de Alta Complexidade em Oncologia, Hospital - Feira de Santana - Bahia - Brasil

3Núcleo de Pesquisa em Câncer de Cabeça e Pescoço - Feira de Santana - Bahia - Brasil


Resumo

Objetivo:

O objetivo deste estudo foi avaliar a associaçao entre qualidade de vida e fatores psicossociais em pacientes com diagnóstico de câncer de cabeça e pescoço.

Métodos:

Este estudo transversal foi realizado com 148 pacientes. Um formulário foi preenchido com dados sociodemográficos e condições clínicas dos prontuários dos pacientes. O Questionário de Qualidade de Vida da Universaidade de Washington (UW-QOL) (versão 4) foi utilizado para avaliar a qualidade de vida (QV) e a Escala Hospitalar de Ansiedade e Depressão foi usada para estudar os fatores psicológicos. Para analisar a associação entre QV em todos os domínios, incluindo as subescalas de Função Física e Função Sócioemocional do UW-QOL, com ansiedade e depressão, o Teste T-Student foi utilizado para comparações entre médias das variáveis independentes.

Resultados:

Na amostra, 45,2% dos pacientes tinham câncer de boca e 74,3% apresentavam câncer nos estadios III e IV. Quantos aos fatores psicológicos, 32,4% dos pacientes eram ansiosos e 31,1% tinham depressão. Foi observado que indivíduos com ansiedade e depressão tinham pior qualidade de vida na maioria dos domínios e nas subescalas de QV.

Conclusão:

Fatores psicológicos como ansiedade e depressão têm forte relação com baixa qualidade de vida em pacientes com câncer de cabeça e pescoço.

Palavras-chave: Ansiedade; Depressão; Neoplasias de Cabeça e Pescoço; Qualidade de Vida

Abstract

Objective:

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.

Methods:

This cross-sectional study was conducted with 148 patients. A form was filled out with data on patient sociodemographic and clinical conditions from medical records. The University of Washington Quality of Life Questionnaire (UW-QOL) (version 4) was used to assess quality of life (QOL), and the Hospital Anxiety and Depression Scale was used to evaluate psychological factors. To analyze the association of QOL in all domains, including the Physical Function and Socioemotional Function subscales of the UW-QOL, with anxiety and depression, the Students t-test for comparisons between independent sample means was performed.

Results:

In our sample, 45.2% of patients had oral cancer, and 74.3% presented with stage III and IV HNC. Regarding psychological factors, 32.4% of patients were anxious, and 31.1% of them had depression. We observed individuals with anxiety and depression had worse quality of life in almost all domains and in the quality of life subscales.

Conclusion:

Psychological factors, such as anxiety and depression, have a strong relationship with low quality of life in patients with head and neck cancer.

Keywords: Anxiety; Depression; Head and Neck Neoplasms; Quality of Life

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

Study design and population

This was a cross-sectional study including 148 individuals diagnosed with head and neck cancer from February 2017 to September 2019. The patients included were those over 18 years of age with a histopathological diagnosis of squamous cell carcinoma or adenocarcinomas whose primary site was the oral cavity, larynx, or pharynx, who did not have any underlying immunological disease, psychosis, anxiety disorders, cognitive impairments, drug addictions, and were not on corticosteroids, anxiolytics, or antidepressants.

Data collection

Before starting data collection, the researchers went through a calibration and orientation process. One of the instruments used in the research was a questionnaire to be filled out by the research subject; however, since most of them had low education levels, the researchers were then responsible for applying the questionnaire and were told to ask the questions up to three times, and, in case of noncomprehension, they should replace the word that was difficult to understand with an easier one.

Data collection occurred on the day of diagnosis, and the participants were interviewed individually. A form was filled out with data on patient sociodemographic and clinical conditions from medical records and included the following information: age, sex, race, marital status, current occupation, place of residence, education, income, habits, TNM staging (tumor size and extent, metastatic cervical lymph nodes, and presence of distant metastasis) based on the 2002 AJCC/UICC classification (American Joint Committee on Cancer/ International Union Against Cancer), primary site, treatment plan, presence or absence of flaps for reconstruction, concomitant neck dissection, and associated tracheostomy.

Participants were interviewed individually in a private room, where the application of the University of Washington Quality of Life Questionnaire (UW-QOL) (version 4) was carried out. This questionnaire consists of twelve questions related to specific functions for the head and neck region, as well as related to activity, recreation, pain, mood, and anxiety, with each question including three to five response categories with a score ranging from zero (worst) to 100 (best); a composite score is also calculated as the mean of the twelve domains. The UW-QOL can be categorized into two subscales: Physical Function and Socioemotional Function, and the score for each subscale is the mean of their six domains. The Physical Function subscale contains the following six domains: speech, chewing, appearance, saliva, taste, and swallowing. The Socioemotional Function subscale comprises the domains pain, activity, recreation, shoulder, mood, and anxiety.

On the same day, it was applied the Hospital Anxiety and Depression Scale, which has 14 items, seven of which are aimed at assessing anxiety (HADS-A) and seven for depression (HADS-D). Each of its items can be scored from zero to three, making up a maximum score of 21 points for each scale. For the assessment of the frequency of anxiety and depression, responses to the HADS items were obtained. The cutoff points proposed by Zigmond and Snaith (1983) were adopted for both subscales as follows: without anxiety from 0 to 7, with anxiety > 7 (HADS-anxiety); without depression from 0 to 7, with depression > 7 (HADS-depression).

Statistical analysis

Quantitative variables were described by their central tendency and respective dispersion measures, while the nominal variables were described by their absolute values or percentages.

To analyze the association of quality of life in all domains, including the Physical Function and Socioemotional Function subscales of the Washington Questionnaire, with anxiety and depression as measured by the Hospital Anxiety and Depression Scale, the Student’s t-test for comparisons between independent sample means was performed.

The area under the ROC curve (AURC), sensitivity, and specificity were described to evaluate the diagnostic accuracy of the single UW-QOL questions about anxiety and depression. A stepwise regression analysis was used to establish a regression model for the prediction of better QOL. To assess quality of life in this model, the UW-QOL Physical Function subscale was used so as to remove socioemotional issues. The included variables were anxiety, depression, clinical staging, sex, and anatomical site of the tumor (oral cancer and nonoral cancer). Ninety-five percent confidence intervals were used as a measure of the precision of results. P values less than 0.05 (p < 0.05) were considered significant. MedCalc Statistical Software version 19.2.3 (MedCalc Software Ltd, Ostend, Belgium) and GraphPad Prism version 8.0.0 for Windows (GraphPad Software, San Diego, California USA) were used for statistical analysis.

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).

Table 1. Sociodemographic characteristics. 

Variables n %
Sex
Male 113 76.4
Female 35 23.6
Ethnicity
Brown 71 48.0
Black 46 31.1
White 31 20.9
Marital status
Married or in a stable relationship 60 40.5
Single 56 37.8
Widower 18 12.2
Divorced 14 9.5
Education
Illiterate 50 33.8
Can read and write 46 31.1
Primary 36 24.3
Secondary 15 10.1
Higher 1 0.7
Income
Less than one minimum wage 48 32.4
One minimum wage 71 48.0
Two or more times the minimum wage 29 19.6
Smoking
Smoker or abstinent for less than three years 127 85.9
No 21 14.1
Drinking
Drinker or abstinent for less than one year 120 81.2
No 28 18.8

Table 2. Clinical characteristics. 

Variables n %
Topography
Mouth 67 45.2
Pharynx 34 23.0
Larynx 47 31.8
Tumor size
T1 14 9.5
T2 35 23.6
T3 55 37.2
T4 44 29.7
Regional lymph nodes
N0 65 43.9
N1 31 20.9
N2a, b, or c 47 31.8
N3 5 3.4
Clinical staging
Stages I and II 38 25.7
Stages III and IV 110 74.3

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.

Table 3. Mean scores for the domains and subscales of the University of Washington Quality of Life Questionnaire by the presence or absence of depression. 

Variables With depression M (SD) Without depression M (SD) p1
Pain 53.2 (29.6) 65.9 (29.1) 0.016*
Appearance 74.4 (27.6) 83.5 (22.3) 0.035*
Activity 57.6 (32.0) 80.6 (24.8) < 0.001*
Recreation 53.2 (29.1) 76.7 (28.6) < 0.001*
Deglutition 64.5 (32.5) 77.1 (28.9) 0.020*
Chewing 52.1 (42.1) 66.1 (38.6) 0.049*
Speech 63.8 (35.7) 78.5 (25.1) 0.005*
Shoulder 78.2 (37.3) 88.2 (28.0) 0.073
Taste 55.7 (42.8) 85.6 (28.3) 0.000*
Saliva 79.7 (28.5) 90.8 (20.0) 0.007*
Humor 42.9 (32.7) 75.0 (30.2) < 0.001*
Anxiety 44.2 (39.8) 67.0 (36.8) 0.001*
Physical Function 65.0 (22.2) 80.3 (17.3) < 0.001*
Socioemotional Function 54.9 (18.0) 75.5 (18.9) < 0.001*

1Student’s t-test result for comparison of independent sample means; *p < 0.05.

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.

Table 4. Mean scores for the domains and subscales of the University of Washington Quality of Life Questionnaire by the presence or absence of anxiety. 

Variables With anxiety M (SD) Without anxiety M (SD) p1
Pain 50.5 (30.2) 67.5 (28.0) 0.001*
Appearance 73.4 (25.9) 84.2 (22.9) 0.011*
Activity 56.7 (29.5) 81.5 (25.5) < 0.001*
Recreation 49.4 (30.7) 79.0 (25.8) < 0.001*
Deglutition 62.4 (33.5) 78.3 (27.8) 0.003*
Chewing 57.2 (41.2) 64.0 (39.6) 0.343
Speech 62.5 (35.5) 79.4 (24.5) < 0.001*
Shoulder 75.6 (38.1) 89.6 (26.6) 0.011*
Taste 63.8 (41.2) 82.3 (31.9) 0.003*
Saliva 84.7 (26.6) 88.6 (21.8) 0.340
Humor 45.8 (33.1) 74.2 (31.0) < 0.001*
Anxiety 41.0 (39.1) 69.0 (35.8) < 0.001*
Physical Function 67.3 (20.2) 79.5 (19.0) 0.001*
Socioemotional Function 53.2 (17.7) 76.8 (17.8) < 0.001*

1Student’s t-test result for comparison of independent sample means; *p < 0.05.

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.

Table 5. Adjusted odds ratio from logistic regression analysis of variables (female sex, anatomical tumor site, clinical staging, depression, and anxiety) associated with quality of life in individuals with head and neck cancer. 

Variables OR 95% CI p value
Anxious 0.25 0.07 – 0.81 0.021*
Depressive 0.34 0.09 – 1.24 0.104
Advanced-stage HNC 0.09 0.03 – 0.25 < 0.001*
Women 2.63 0.92 – 7.53 0.070
Non-oral anatomical site 5.17 1.80 – 14.80 0.002*

CI: confidence interval; OR: odds ratio; *p < 0.05.

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.

Table 6. Diagnostic properties of the single anxiety question in the Washington Questionnaire when compared to the Hospital Anxiety Scale. 

Anxiety score Sensitivity 95% CI Specificity 95% CI
100 100 92.6 – 100 0 0.0 – 3.6
67 56.2 36.0 – 56.3 76.0 66.4 – 84.0
33 39.5 25.8 – 54.7 85.0 76.5 – 91.4
0 0 0.0 – 7.4 100 96.4 – 100

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.

Table 7. Diagnostic properties of the single depression question in the Washington Questionnaire when compared to the Hospital Depression Scale. 

Depression score Sensitivity 95% CI Specificity 95% CI
100 100 92.3 – 100 0.0 0.0 – 3.6
75 71.7 56.6 – 84.0 68.6 58.7 – 77.5
50 63.0 47.5 – 76.8 85.2 76.9 – 91.5
25 10.8 3.6 – 23.6 96.8 90.3 – 98.9
0 0.0 0.0 – 7.7 100 96.4 – 100

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.

Study Limitations

One of the limitations of our study was the fact that because our population was mostly made up of patients with low education levels, some of them may not have had a perfect understanding of the questions. This issue was mitigated by our strategy of repeating the question up to three times and replacing difficult words with synonyms more accessible to the subject in question when necessary.

Clinical implications

The knowledge that patients with head and neck cancer with anxiety and depression have a low quality of life makes necessary psychological monitoring and/or treatment during cancer treatment. Thus, patients diagnosed with anxiety and depression were referred to the specialized psychology service.

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.

DATA AVAILABILITY STATEMENT

All data generated or analysed during this study are included in this article. Further enquiries can be directed to the corresponding author.

STATEMENT OF ETHICS

This study was independently reviewed and approved by the Research Ethics Committee of State University of Feira de Santana (1.621.470). All subjects agreed voluntarily to participate in this study and provided written informed consent in full accordance with ethical principles.

FUNDING SOURCES

This work was supported by Fundação de Amparo a Pesquisa do Estado da Bahia (FAPESB).

ACKNOWLEDGMENTS

The authors would like to thank the staff of Head and Neck Cancer Research Center who have helped us during the research. And we would like to thank the High Complexity Oncology Unit of Santa Casa de Misericórdia de Feira de Santana, Dom Pedro de Alcantara Hospital and MULTICLIN clinic who who gave us the location for our research.

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Recebido: 03 de Fevereiro de 2022; Aceito: 04 de Agosto de 2023

Correspondência: Marla Smille Pedrosa Cruz. E-mail: m.smille@hotmail.com

CONFLICT OF INTEREST STATEMENT

All authors declare no conflict of interests

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