Oral health-related quality of life and depression/anxiety in long-term recurrence-free patients after treatment for advanced oral squamous cell cancer

Abstract

This report focuses on the association between oral health-related quality of life (OHRQoL) and depression/anxiety of a homogeneous group of cancer patients who were recurrence-free for 8 years after treatment for advanced oral squamous cell.

Participants were 24 patients (mean age 55 years, 75% men) treated with neoadjuvant concurrent radiochemotherapy followed by surgery with a mean recurrence-free period of 95 months (from 39 to 164 months). The OHRQoL (OHIP) and the anxiety/depression (HADS) were assessed twice (1 year between t1 and t2).

OHRQoL was impaired in this group (mean OHIP score 65 units). In cross-lagged correlation analysis, the correlation between OHRQoL to t1 and depression to t2 was significant and greater than the non-significant correlation for depression to t1 and OHRQoL to t2 indicating that OHRQoL predicts depression better than vice versa. However, the difference in the correlation coefficients was not significant (ZPF-test). The same was true for OHRQoL and anxiety.

The OHRQoL measured with the OHIP was impaired in comparison to the normal population. In the limitations of the study design and bearing the small sample size in mind, the results give evidence that OHRQoL predicts psychological outcomes, namely depression and anxiety, better than vice versa.

Introduction

Oral squamous cell carcinoma (OSCC) is currently the 10th most common human malignancy and affects more than 500,000 individuals per year worldwide (Casiglia and Woo, 2001). Because of locally aggressive tumour phenotypes and the high prevalence of recurrent and second primary carcinomas, the 5-year overall survival rate of all tumour stages has not risen above 55% during the last decade (Funk et al., 2002). Locally advanced OSCC of UICC (International Union Against Cancer) stages III and IV, especially, continues to be a major therapeutic challenge in the clinical management of this disease, and requires implementation of multi-modal approaches to treatment, including surgery and radiochemotherapy. Besides being a direct threat to life, the disease itself and the side-effects of the treatment have negative effects on many different aspects of life of the individual patient. This is related to functional or performance aspects, for example impairment of speech, swallowing, or eating, and also to social and psychological aspects, for example limitation of social contact because of disfigurement and depression or anxiety (Rogers et al., 2006). Consequently, the quality of life (QoL) and health-related QoL (HRQoL) of OSCC patients (OSCC-P) is reduced (Chandu et al., 2006; Rogers et al., 2007). This deterioration of HRQoL reaches a maximum during, approximately, the third month after surgical treatment, although it tends to return to the pretreatment level after 1 year and in the long-term (Chandu et al., 2006). HRQoL is affected by various conditions, for example socio-demographic factors, emotional status, tumour size or stage, treatment procedures, and post-operative radiotherapy (Chandu et al., 2006). The importance of HRQoL increases for the patients after the initial, life-saving, surgical and/or radiotherapy (RT) steps and is, therefore, a major outcome for therapy planning. The QoL of OSCC-P can be described by use of more global or general cancer instruments (for example EORTC QLQ-C30; Aaronson et al., 1988), head and neck-specific instruments (for example the H&N35 module of EORTC QLQ-C30; Bjordal et al., 1994), or performance instruments (for example subjective chewing ability; Stellingsma et al., 2005). Specific oral health-related physical, psychological, and social aspects can be described within the concept of oral HRQoL (OHRQoL) (Rohr Inglehart and Bagramian, 2002). The OHRQoL can be measured with different instruments with acceptable internal consistency, reliability, validity, and responsiveness, for example the most widespread instrument, the oral health impact profile (OHIP) (Slade and Spencer, 1994). Although the OHRQoL measurement instruments were not developed for OSCC-P in particular—and may not reflect all their specific impairments—the concept of OHRQoL is a widely accepted approach for assessing patient-centred oral health and enables comparison of OHRQoL of OSCC-P with that of the normal population. As far as the authors are aware, few reports have specifically assessed OHRQoL in OSCC-P; examples include Schoen et al. for edentulous head and neck cancer patients in the Netherlands (Schoen et al., 2007) and Pace-Balzan et al. in the United Kingdom (Pace-Balzan et al., 2008). Numerous clinical and psychosocial factors are related to OHRQoL, for example, dental status [lower OHRQoL is associated with removable dentures (John et al., 2004) and insufficient denture retention (Hassel et al., 2006)], and with psychological aspects, with lower OHRQoL being associated with higher levels of somatization (Hassel et al., 2007) or negative affectivity personality (Kressin et al., 2001). In this context, Schoen et al. have reported that edentulous head and neck cancer patients not wearing their dentures regularly or with indication of implant therapy had lower OHRQoL; they concluded that implant-retained mandibular denture treatment would be expected to improve quality of life.

In this report we focus on the association of OHRQoL and the psychological outcomes depression and anxiety, in particular, of a homogeneous group of patients who were recurrence-free for at least 39 months after treatment of initial stage III or IV. The direction of this association is of particular interest. If an impaired OHRQoL would cause higher depression/anxiety levels this would emphasise the role of oral health and the need for improving oral health for example by implant-treatment in this collective.

The study hypothesis stated therefore that OHRQoL predicts psychological outcomes, namely depression and anxiety, better than vice versa.