|Year : 2021 | Volume
| Issue : 2 | Page : 88-93
Correlation between international classification of functioning and quality of life in head and neck cancer survivors in Indian population: A cross-sectional study
Renu B Pattanshetty, Sailee K Bambolkar, Karrishma Karampure, Mansi Karnik
Departments of Oncology Physiotherapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka, India
|Date of Submission||08-Jul-2020|
|Date of Decision||28-Sep-2020|
|Date of Acceptance||22-Oct-2020|
|Date of Web Publication||12-Jan-2022|
Dr. Renu B Pattanshetty
Department of Oncology Physiotherapy, KAHER Institute of Physiotherapy, Nehrunagar, Belagavi - 590 010, Karnataka
Source of Support: None, Conflict of Interest: None
Context: Cancer is counted as the second most leading cause of death worldwide. Cancer adversely affects one's physical, functional, social, and emotional well-being.
Aim: The objective of the present study was to determine a correlation between components of the International Classification of Functioning (ICF) and quality of life (QOL) in head and neck cancer survivors in the Indian population.
Settings and Design: This was an observational study undertaken in a tertiary health care and cancer hospital for a period of 6 months.
Subjects and Methods: Fifty-two head and neck cancer patients were evaluated for their QOL using the Functional Activity of Cancer Therapy-Head and Neck Cancer (FACT-HNC) and impairments and disabilities given by ICF.
Statistical Analysis Used: Test like Karl Pearson's coefficient for correlation between ICF and FACT-H and N was used.
Results: There was a negative correlation between the physical and emotional well-being of FACT-H and N and ICF component of body function (r = −4.25, P ≤ 0.002, r = 27.8, P ≤ 0.046). Activities and participation of ICF also demonstrated similar results (r = −49.5, P ≤ 0.001and r = −40.0, P ≤ 0.003). No correlation was found between environmental factors of ICF and FACT-H and N scores.
Conclusions: The study concluded that there was a strong negative correlation in terms of emotional well between ICF and FACT-H and N.
Keywords: Head and neck cancer, International classification of functioning, Quality of life
|How to cite this article:|
Pattanshetty RB, Bambolkar SK, Karampure K, Karnik M. Correlation between international classification of functioning and quality of life in head and neck cancer survivors in Indian population: A cross-sectional study. Indian J Phys Ther Res 2021;3:88-93
|How to cite this URL:|
Pattanshetty RB, Bambolkar SK, Karampure K, Karnik M. Correlation between international classification of functioning and quality of life in head and neck cancer survivors in Indian population: A cross-sectional study. Indian J Phys Ther Res [serial online] 2021 [cited 2022 Jan 25];3:88-93. Available from: https://www.ijptr.org/text.asp?2021/3/2/88/335664
| Introduction|| |
Cancer is one of the leading causes of death worldwide. Head and neck cancer (HNC), an umbrella term for malignancies of the larynx and hypopharynx, nasal cavity, paranasal sinuses, nasopharynx, oropharynx, oral cavity, and salivary gland, accounts for about half a million cases annually, ranking it as the sixth most common cancer globally. Head and neck cancer in India accounts for 30% of all cancers. About 90% of head and neck cancer are squamous cell carcinoma arising from the epithelium in the region of head and neck after exposure to carcinogens such as tobacco, alcohol, and smoking. Chewing of pan (betel quid) has been strongly associated with an increased risk of oral cancer. Multiple types of viral infections have been associated with an increased risk of head and neck cancer, including Epstein–Barr virus, human papillomavirus, hepatitis C virus, and human immunodeficiency virus.
The primary cancer treatments are radiation therapy, surgery, or both combined. Chemotherapy is often used as an additional or adjuvant treatment. The optimal combination of the three treatment modalities for a patient with a particular head and neck cancer depends on the site of the cancer and the stage (extent) of the disease.
HNC patients undergoing concomitant chemoradiotherapy frequently experience loss of muscle mass and reduced functional performance. Overall, the most troublesome and debilitating adverse effect of radiation therapy is lethargy and weakness, dry mouth, pain, and sore throat which negatively affect the patient's ability to eat and drink which may result in poor nutritional status and weight loss. Usually, temporomandibular joint hypomobility is regarded as a late effect of high radiation dose. The damage to the structures in head and neck by tumor or therapy can also result in significant structural, cosmetic, and functional deficits that negatively impact the patient's temperament and personality.
Impaired body image is related to greater anxiety, unhealthy relationship with a partner, impaired sexual function, and increased social isolation among HNC survivors. Shoulder pain and limited abduction range of motion are also suggested to add to the distress of the patient. Such patients with more severe shoulder pain, distress, impaired eating and speaking functions, and impaired body image could be at risk for reduced levels of Health-Related Quality Of Life (HRQOL). HRQOL is known to be an integral part of treatment planning, refining treatment protocols, and more personalized follow-up support. There is a dearth in the literature demonstrating the correlation between the International Classification of Function (ICF) and FACT-H and N in the Indian population that may help physical therapists to focus on treatment options for various impairments and disabilities in these patients. Thus, the present study aimed to establish a correlation between ICF and FACT-H and N.
| Subjects and Methods|| |
The present cross-sectional study was conducted at a tertiary health care hospital and cancer hospital in Belagavi, India. An ethical clearance was obtained from the Institutional Review Committee before the commencement of the study. A total of 52 patients were recruited in the study that was calculated with the previous incidence rate at the hospital and the attrition rate of 5%. A written informed consent was obtained from all patients before their inclusion. All patients were explained in detail about the study in their vernacular language including the risks and benefits associated with it. The patients were recruited in the study if they had head and neck cancer as primary cancer and were willing to participate in the study with normal cognitive levels above score of 24 as per the Mini Mental Scale Examination (scale) so as to answer the FACT-H and N questionnaire. The patients were excluded from the study if they had secondary metastasis.
FACT-H and N is a multidimensional, self-reporting quality of life (QoL) instrument specially designed for use with head and neck cancer patients. It consists of 27 core items which assess patient function in four domains: physical, social/family, emotional, and functional well-being, which is further supplemented by 12 site-specific items to assess for head and neck-related symptoms. Each item is rated on a 0–4 Likert type scale and then combined to produce subscale scores for each domain for overall scoring. Higher QoL scores represent better QoL.
The ICF comprehensive core set for head and neck cancer is a framework and classification which is a valid tool for measuring or assessing individual functioning. The broad framework puts assessment in context and provides the focus for selecting relevant aspects of functions and disability for assessment in head and neck cancer.
ICF evaluation and scoring were performed by the interns who underwent a training in assessing and scoring of the ICF for head and neck cancer patients. Each patient included in the study was made to sit in a comfortable position. The impairment level was evaluated by the therapist using the ICF (comprehensive core set for head and neck cancer) functioning profile that was documented in the ICF form. After the ICF assessment, a translated version of the FACT-H and N questionnaire in the patients' vernacular language was administered to all the patients. Total scores of ICF and FACT-H and N were calculated and entered in the MS Excel sheet.
| Results|| |
Raw data obtained in the present study were analyzed using the Statistical Package of the Social Sciences version 23.0 (IBM Corp. Released 2015 IBM, SPSS Statistics for Windows, Version 23.0 Armonk, NY: IBM Corp). Nominal data such as mean and standard deviation were used to analyze the demographic profile of all patients in the study. Karl Pearson's correlation coefficient was used if the values were between -1.0 (negative correlation) and +1.0 (positive correlation) with a p value of less than or equal to 0.05 were considered significant if a correlation existed between ICF and FACT H & N. Furthermore, the data were analyzed to evaluate if there was a correlation between the demographic variables and ICF and also between demographic variables and FACT-H and N.
A total of 52 head and neck cancer patients were included in the study. The demographic data suggested that the number of males was 76.9% (n = 40) and females 23.1% (n = 12). The age group of all the patients in the study >40 years was (n = 40) 76.9% compared to patients <40 years (n = 12) 23.17%.The number of both male and female patients with <25 body mass index (BMI) was 43 and >25 BMI was 9. The common type of cancer affected in all the patients in the study was Ca tongue (n = 19), followed by Ca thyroid (n = 6), Ca buccal mucosa (n = 5), and Ca pharynx (n = 5). All the patients in the study either underwent surgery (n = 34), radiotherapy (n = 15), and chemotherapy (n = 3) [Table 1].
Patients with buccal mucosa cancer (n = 5) demonstrated a positive correlation with the total scores of FACT-H and N suggesting these patients had lower QOL compared to other types of cancers (r = 89.0, P ≤ 0.043). QOL had a positive correlation (r = 54.9, P ≤ 0.001) suggesting lower QOL as compared to females. Patients above the 40 years of age had lower QOL demonstrating a positive correlation (r = 54.0, P ≤ 0.001) [Table 2].
|Table 2: Correlation between Functional Activity of Cancer Therapy-Head and Neck scores and demographic variables of all patients in the study|
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There was no correlation between ICF and demographic variables except for a negative correlation between the environmental factors' component of ICF and types of cancer treatment in the head and neck cancer survivors who participated in the study (r = −29, P ≤ 0.03) [Table 3].
|Table 3: Correlation between the international classification of functioning and demographic variables of all patients in the study|
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A negative correlation was seen between the body function component of ICF with physical (P = 0.002) and emotional well-being (P = 0.046) of FACT-H and N highlighting that more the body functions were affected, less is the scores of the physical and emotional well-being of the individual. Activities and participation component of ICF are also strongly correlated with physical (P = 0.001) and emotional well-being (P = 0.003) of FACT-H and N [Table 4].
|Table 4: Correlation between the international classification of functioning and functional activity of cancer therapy-head and neck of all patients in the study|
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| Discussion|| |
The major results of the study answered the research question stating whether there was a correlation with the ICF and functional assessment of cancer therapy (FACT-H and N). The study demonstrated a negative correlation between the body function component of ICF and FACT-H and N, i.e., physical well-being and emotional well-being with statistical significance. Patients in the age group of >40 years in the present study demonstrated a strong positive correlation with total FACT–H and N scores. However, age had a negative correlation with the activities and participation among components of ICF, suggesting activities and participation decrease with an increase in age. This may be due to the fact that older head and neck cancer patients are at risk for adverse health outcomes as compared to younger patients of the same disease. However, it is observed that functioning and cognitive impairments, depression, and social isolation are highly prevalent in head and neck cancer patients who may be associated with high risky outcomes. This may also suggest that the older head and neck cancer patients (in the present study >40 years of age) may be benefited from multidisciplinary approach rather than only physical therapists or an oncologist. Although heterogeneity in terms of gender was noted in the study, the authors could not categorize the age group since the sample size was small and also the affection of head and neck cancer was observed more in males than in females.
Gama et al. suggested that BMI seems to be associated with head and neck cancer outcomes and improvement in survival rates is better in individuals with head and neck cancer having normal weight as compared to the underweight patients. Although the present study did not aim to study BMI as a prognostic factor for head and neck cancer, the study suggested that there is no correlation between the BMI of the patients and the components of the ICF. Other components like environmental factors may have a role to play along with the types of cancer treatment that the patient undergoes as observed in this study. The World Health Organization has widely studied musculoskeletal impairments in head and neck cancer which has focused primarily on trismus and shoulder dysfunction since there are two major impairments noted in head and neck cancer patients.
The correlation between body function and physical well-being had a negative correlation which demonstrated statistical significance in the present study. QOL studies in such cancer population undergoing cancer therapy have shown to reduce both physical and psychosocial stress for better rehabilitation of patients.,
The assessment of QOL enables health professionals to understand how patients experience consequences of the disease on their life, the state of metastasis, and the effectiveness of cancer treatment offered. A positive correlation was noted between the questionnaires of FACT-H and N, University of Washington Quality of Life questionnaire and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Head and Neck Module 30 and 35 (EORTC QLQ-C30/EORTC QOL-H and N 35) suggesting the major domains offered to design and choosing the components of the FACT H and N in head and neck cancer patients are dominantly pain, eating activities such as deglutition, chewing, taste, saliva, mood, and anxiety.
The present study correlated between emotional components of FACT-H and N and activity and participation of ICF suggesting that patients who were emotionally affected showed less participation. Body function and physical well-being were correlated suggesting decrease in body functioning (ICF) affected the physical well-being of the patients in general. Head and neck cancer patients experienced significant changes following cancer treatment that included physical and emotional aspects of FACT-H and N. Cancer treatment had negative impact on the eating ability suggesting decrease in body function with the affection of body structure. This has truly been significant as per the results of the present study as well that suggested that the physical well-being of FACT-H and N is affected more because of the decrease in the body function as well as body structure which negatively affects the emotional component of FACT-H and N.
Head and neck cancer patients experience the highest weight of major depression disorder of all oncology patients., Although the present study did not aim to study depression in the present population, it demonstrated that the emotional component of FACT-H and N is definitely affected and is strongly correlated with the body structure and body function of the ICF component. It is suggested that future studies should focus on coping strategies of the psychological component along with the physical therapy exercise rehabilitation which may prove better in terms of overall emotional outcome in head and neck cancer patients.
| Conclusions|| |
It may be stated that though the size of the target population under the study was small due to time constraint of the study, the outcomes of the present study seemed to be significant in terms of a strong association between body function and body structure component of ICF and physical well-being, emotional well-being of FACT-H and N of all the patients irrespective of gender difference, age difference, BMI, type of head and neck cancer, and the undergoing cancer treatment.
The study also focuses that physical therapists need to concentrate more on the emotional well-being (component of FACT-H and N) that is less addressed along with the focus on the physical well-being of the patients which is commonly addressed. The study also throws light that there is a serious need to address the coping strategies to combat stress, anxiety, and depression which is neglected from the therapist's point of view.
The authors are thankful to the medical director of tertiary care hospital for permitting to conduct the study. Our heartfelt gratitude to all the patients who agreed to participate in this study and to the statistician Mr. Prasad Daddikar, for his help with statistical analysis of the data.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer 2010;127:2893-917.
Kulkarni MR. Head and neck cancer burden in India. Int J Head Neck Surg 2013;4:29-35.
Vanneman M, Dranoff G. Combining immunotherapy and targeted therapies in cancer treatment. Nat Rev Cancer 2012;12:237-51.
Jain A, Banerjee PK, Manjunath D. Effects of chemoradiation on hearing in patients with head and neck malignancies: Experience at a tertiary referral care hospital. Indian J Otolaryngol Head Neck Surg 2016;68:456-61.
Wang HL, Keck JF, Weaver MT, Mikesky A, Bunnell K, Buelow JM, et al
. Shoulder pain, functional status, and health-related quality of life after head and neck cancer surgery. Rehabil Res Pract 2013;2013:1-10.
Gama RR, Song Y, Zhang Q, Brown MC, Wang J, Habbous S, et al
. Body mass index and prognosis in patients with head and neck cancer. Head Neck 2017;39:1226-33.
Ghiam MK, Mannion K, Dietrich MS, Stevens KL, Gilbert J, Murphy BA. Assessment of musculoskeletal impairment in head and neck cancer patients. Support Care Cancer 2017;25:2085-92.
Agarwal SK, Munjal M, Koul R, Agarwal R. Prospective evaluation of the quality of life of oral tongue cancer patients before and after the treatment. Ann Palliat Med 2014;3:238-43.
Devi S, Singh N. Dental care during and after radiotherapy in head and neck cancer. Natl J Maxillofac Surg 2014;5:117-25.
] [Full text]
Gomes EP, Aranha AM, Borges AH, Volpato LE. Head and neck cancer patients' quality of life: Analysis of three instruments. J Dent (Shiraz) 2020;21:31-41.
Ganzer H, Touger-Decker R, Byham-Gray L, Murphy BA, Epstein JB. The eating experience after treatment for head and neck cancer: A review of the literature. Oral Oncol 2015;51:634-42.
Hammerlid E, Mercke C, Sullivan M, Westin T. A prospective quality of life study of patients with oral or pharyngeal carcinoma treated with external beam irradiation with or without brachytherapy. Oral Oncol 1997;33:189-96.
Lydiatt WM, Denman D, McNeilly DP, Puumula SE, Burke WJ. A randomized, placebo-controlled trial of citalopram for the prevention of major depression during treatment for head and neck cancer. Arch Otolaryngol Head Neck Surg 2008;134:528-35.
[Table 1], [Table 2], [Table 3], [Table 4]