Purpose: Pain is a common complaint of cancer patients which is found to significantly affect the quality of life of Head and Neck cancer patients. For patients suffering from cancer, control of symptoms and pain play a significant role in improving the overall quality of life of head and neck cancer patients. A literature search revealed that studies on the intensity of pain and quality of life before receiving anticancer therapy are lacking. Thus, this study was an attempt to assess the influence of intensity of pain on quality of life of cancer patients before receiving anticancer treatments
Methods: A total of 100 histopathologically confirmed cases of head and neck cancer were interviewed. Intensity of pain was evaluated using the Brief Pain Inventory and the quality of life of patients was evaluated using EORTC QLQ-C30 module..
Results: The results showed that majority of patients suffering from oral cancer belonged to 5th and 6th decade of life. Kruskal Wallis test showed statistically significant in the quality of life and tumour stages. Chi square test also gave significant association between the quality of life and pain.
Conclusions:. Assessment of Quality of life in cancer patients will direct the attention of clinician to the most important symptom; pain. Thus appropriate interventions can be instituted at right time along with palliative care to improve the Quality of Life of cancer patients.
Keywords: Pain, Quality of Life, Cancer, Palliative care
Head and neck cancer encompasses a group of tumours involving the lip, oral cavity, nasal cavity, larynx, pharynx and paranasal sinuses. By incidence, it is the sixth leading cancer worldwide and eighth by fatality. Every year 0.5 million new cases are reported. It usually develops in 6th-7th decade of life and five year survival rate in a patient suffering from HNSCC is 40-50%. Approximately 40% of these tumours occur in the oral cavity, 15% occur in the pharynx, and 25% occur in the larynx; in 90% of the cases, the most common histologic type is squamous cell carcinoma. (1)
Pain is the most burdensome symptom and is one of the most common complaints in a patients suffering from Head and Neck cancer. A systematic review evaluating the prevalence of pain in cancer patients over past 40 years reported high figures in the range of 52-77%. (2) The review also stated that as the stage of cancer advanced the prevalence of pain also increased. They reported a prevalence of 62%–86% in patients with advanced cancer. (2) These figures are in contrast to rapidly increasing research work in the field of pain relief.
Pain is one of the most significant symptoms of cancer patients that affects multiple domains of life ranging from its impact on physical functioning to emotional functioning. It is a usual symptom of cancer patients, accounting for 30% to 40% of their chief complaints, and is of multifactorial aetiology. Approximately 58% of cancer patients suffer from unbearable pain, and this prevalence increases to 85% in patients with cancer in advanced stages. (3. A metanalysis which was carried out in the year of 52 studies for evaluating the prevalence of pain in cancer patients, reported that head and neck cancer patients had the highest prevalence of pain exceeding gastrointestinal gynaecological, breast and lung tumours. (2) In Head and Neck cancer patients, pain distresses the oral functions and is chief complaint in approximately 58% of the patients awaiting treatment and in 30% of the treated patients (4,5).
The term “Quality of Life” has been used in literature in various ways both as a concept and an instrument of measurement. Very rarely has it been defined clearly. It may be considered as a subjective term which conveys the perception of a patient about his life which may either be positive or negative. It includes an assessment of general health, satisfaction, fulfilment, ability to cope, happiness, being in control and degree of independence. (6)
Not only does pain affect the life of quality of patients before seeking antineoplastic treatment, also it has devastating effect in patients undergoing treatment. Thus there has been a growing interest in the inclusion of measures for improving life quality of patients before, during and after undergoing quality of life treatments.
Literature search revealed that studies on the intensity of pain and quality of life before receiving anticancer therapy are lacking. Thus, this study was undertaken to assess the severity of pain and its impact on the quality of life (QoL) in untreated patients with head and neck carcinoma using questionnaire. Also the association of pain severity with clinical stage of the tumour and lymph node involvement was assessed.
Materials and Methods:
The study was carried out in the patients reporting to the outpatient department of K.L.E.V.K.I.D.S and Belgaum Cancer Institute. Ethical clearance was obtained from the institution. A total of 100 confirmed head and neck cancer patients were interviewed. Untreated histopathologically confirmed head and neck cancer patients were included in the study while patients who were receiving, or had completed their course of treatment for cancer, with recurring malignant disease and with compromised physical and mental state which prevented them from answering questions were excluded from the study.
Patients were divided into four groups depending on their stage of tumour as follows:-
Group I = Stage I=23 patients
Group II = Stage II=25 patients
Group III = Stage III=25 patients
Group IV = stage IV=27 patients
Pain was evaluated using “Brief Pain Inventory (BPI)” (7) which was validated in the North Indian Population.(8) The BPI is a 11 point scale which is presented horizontally from numbers ranging from 0-10. The Questions were translated in the local language of the patient. Patients were asked to rate their pain in the last 24 hours at its Worst, Least and on Average. Patients were also asked to encircle the number indicating the amount of pain they were having at present. The pain was then categorized into four groups: No pain (0), Mild pain (1-4), Moderate pain (5-6) and Severe pain (7-8)
The Quality of Life of patients was assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 (EORTC QLQ-C30) version 3.0 (9) which was validated in Indian Population (10).EORCTC QLQ-C30 is a 30 item questionnaire which consists of five functional scale, three symptom scale, six single items and Global Quality of life question.(8) The functional scale comprises a set of questions to evaluate the functioning of a cancer patient which includes Physical, Role, Cognitive, Social and Emotional Functioning. Symptom Scale includes three items to evaluate the fatigue, pain and nausea in patients. A number of single items such as Dyspnoea, Insomnia, Insomnia, Constipation, appetite loss, Diarrhoea and Financial difficulties were also included. The Symptom scale evaluated Fatigue, Pain and Nausea.
Patients were asked to answer each question on a 4 point scale ranging from 1-4; corresponding to pain as Not at all (1), A little bit (2), Quite a Bit (3, Very Much (4). Patients were asked to rate the last two items (Global Quality of Life ) on a horizontal scale ranging from 1-7. All the scores thus obtained were linearly transformed to be expressed on a scale from 0-100.
All the data was tabulated and non-parametric tests were applied. The data was subjected to Descriptive statistics, Mann-Whitney and Kruskal – Wallis test.
100 histopathologically confirmed cases were enrolled in the study. The results showed that head and neck cancer was common in patients in 5th and 6th decade of life (35% and 32% respectively) with a mean age of 54.8 years (age range-24-86 years). Strong predominance of male population (79%) was seen. Out of a total 100 patients, 67% patients had the site of primary tumour in Oral cavity followed by Oropharynx (22 %), Larynx (6%)and Hypopharynx (5%). Lymph node involvement was present in 66% patients.
The Mean scores for all the items on the scale was obtained using the EORTC QLQ-C30 Scoring Manual. Patients in the early stages of tumour scored significantly higher on function scale indicating higher functionality and ease in their daily activities. On contrary patients with advanced cancer scored higher on symptom scale indicating hampered quality of life and greater difficulty in doing their day to day work.
Kruskal wallis test showed significant difference in the quality of life and the tumour stages, which was statistically significant .(p value<0.05). i.e. as the tumour stage progressed the quality of life of patients deteriorated.
On applying Mann Whitney test significant differences in the quality of life of patients with lymph node involvement and without lymph node involvement. (p value <0.05) were obtained. Patients with lymph node involvement had greater tendancy of nausea, vomiting, diarrhoea and experienced more interference in their daily activities.
Chi square test also gave significant association between the quality of life and pain. (p value<.05). The group of cancer patients without pain had much better scores on all the five function scales (physical, role, cognitive, emotional and social functioning) as compared to the group with pain which had significantly higher scores on symptom scale. Patients with pain felt more tensed, irritable and depressed as in contrast to without pain patients.
This study was carried out to assess the influence of pain severity on quality of life of head and neck cancer patients before receiving any antineoplastic treatment. With approximately one million of new cancer cases being added every year in India and 80% of them presenting in advanced stages ( stage III and stage IV)(11)the need for pain relief and palliative therapy is imperative.
Cancer pain still being one of the most dreaded and burdensome aspects of cancer patients draws attention to the management of pain in head and neck cancer patients. Inspite of introduction of WHO’s step ladder pattern for the management of pain control in cancer patients (12) it has been reported that less than 3% patients in India have an adequate access to pain relief. (13) . The present study also showed signification association between the cancer pain and stage of tumour. Patients with advanced stage of tumour experienced more difficulty in talking, swallowing etc. and poorer quality of life thus indicating a greater need for the institution of pain relief measures. The findings were consistent with the study done by Oliveira KG et al (14) who concluded that patients in advanced stages showed higher impairment in their functional status. Similar findings were noted by Connely et al (4) who reported that patients with squamous cell carcinoma experienced significantly increased function-related intensity of pain rather than spontaneous.
The reasons for under treatment and inadequate pain relief could be attributed to poor resources, inaccessibility to morphine, misconception about the drugs for pain relief e.g. addiction, opiophobia of patients and communication problems. (15) Also the nature of Cancer pain is not fixed. It has multiple complex aetiologies and is recurring in nature. One of the very important reasons for the inadequate pain relief in cancer patients is that currently no such medication exists for chronic cancer pain that will provide more than 30% relief to the cancer patients.(16) This makes the institution of palliative and support care even more essential.
The World Health Organization has defined Palliative care as “An approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.” (17) WHO emphasizes on meeting the psychological, social and mental needs of the patients so as to improve their quality of life. However, it has been reported that approximately 85% of patients who are admitted to palliative care centres have inadequate relief of pain. (18).
Despite the fact that HNC has the highest pain prevalence of all the cancers and is one of the initial symptoms that motivate the patients to seek medical opinion, health care professionals concentrate solely on the surgical aspects, radiotherapy and chemotherapy. The management of chief complain of the patient i.e. pain is neglected which leads to poor quality of life. Therefore an evaluation of cancer patients before initiating any antineoplastic treatment is critical to because most of the studies concentrate on the assessment of pain during or after treatment.
The average time from the admission of patients to palliative care unit and their death is usually less than a month thus indicating that palliative care is usually initiated only in the terminally ill patients, An assessment of quality of life of cancer patients before treatment will draw the attention of the clinician to the most symptomatic and feared aspect of cancer i.e. pain.
Thus appropriate measures for pain relief along with supportive and palliative care can be instituted right from the beginning of the treatment which will greatly enhance the quality of life of cancer patients.
Parkin DM, Bray F, Ferlay J, Pisani P:Global cancer statistics, 2002. CA Cancer J Clin2005,55:74-108.
Van den Beuken-van Everdingen MH1, de Rijke JM, Kessels AG, Schouten HC, van Kleef M, Patijn J. Prevalence of pain in patients with cancer: a systematic review of the past 40 years. Ann Oncol. 2007 Sep;18(9):1437-49.
Cuffari L, de Tesseroli SJT, Nemr K, Rapaport A:Pain complaint as the first symptom of oral cancer: a descriptive study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod2006,102:56-61.
Connelly ST, Schmidt BL: Evaluation of pain in patients with oral squamous cell carcinoma. J Pain 2004, 5:505-510
Epstein JB, Emerton S, Kolbinson DA, Le ND, Phillips N, Stevenson-Moore P, Osoba D: Quality of life and oral function following radiotherapy for head and neck cancer. Head Neck 1999, 21:1-11.
Bjordal K1, Kaasa S. Psychometric validation of the EORTC Core Quality of Life Questionnaire, 30-item version and a diagnosis-specific module for head and neck cancer patients. Acta Oncol. 1992;31(3):311-21.
Cleeland CS, Ryan K: Pain assessment: global use of the Brief Pain Inventory. Ann Acad Med Singapore 1994, 23:129-138.
Saxena A , Mendoza T,. Cleeland C. The assessment of cancer pain in north India: the validation of the Hindi Brief Pain Inventory–BPI-H. J Pain Symptom Manage. 1999 Jan;17(1):27-41
Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ, Filiberti A, Flechtner H, Fleishman SB, de Haes JCJM, Kaasa S, Klee MC, Osoba D, Razavi D, Rofe PB, Schraub S, Sneeuw KCA, Sullivan M, Takeda F.The European Organisation for Research and Treatment of Cancer QLQ-C30: A quality-of-life instrument for use in international clinical trials in oncology. Journal of the National Cancer Institute 1993; 85: 365-376.
Chaukar DA, Das AK, Deshpande MS, Pai PS, Pathak KA, Chaturvedi P, Kakade AC, Hawaldar RW, D’Cruz AK. Quality of life of head and neck cancer patient: validation of the European organization for research and treatment of cancer QLQ-C30 and European organization for research and treatment of cancer QLQ-H&N 35 in Indian patients. Indian J Cancer. 2005 Oct-Dec; 42(4):178-84.
Seamark D, Ajithakumari K, Burn G, Saraswalthi Devi P, Koshy R, Seamark C. Palliative care in India. J R Soc Med. 2000;93:292–5.
Vardy J, Agar M. Nonopioid drugs in the treatment of cancer pain. J Clin Oncol. 2014 Jun 1;32(16):1677-90.
Khosla D, Patel F, and Sharma S. Palliative Care in India: Current Progress and Future Needs. Indian J Palliat Care. 2012 Sep-Dec; 18(3): 149–154.
Oliveira KG, von Zeidler SV, Podesta JR, Sena A, Souza ED, Lenzi J, Bissoli NS, Gouvea SA. Influence of pain severity on the quality of life in patients with head and neck cancer before antineoplastic therapy. BMC Cancer. 2014 Jan 24;14:39.
Thapa D, Rastogi V, Ahuja V. Cancer pain management-current status. J Anaesthesiol Clin Pharmacol. 2011 Apr-Jun; 27(2): 162–168.
Bloodworth D. Opioids in the treatment of chronic pain: Legal framework and therapeutic indications and limitations. Phys Med Rehabil Clin N Am. 2006;17:355–79.
Geneva: World Health Organization; [Last accessed on 2012 Mar 02]. “WHO Definition Of Palliative Care “Available from: http://www.who.int/cancer/palliative/definition/en .
Lin YL, Lin IC, Liou JC: Symptom patterns of patients with head and neck cancer in a palliative care unit. J Palliat Med 2011, 14:556-559.