108 Journal of the College of Physicians and Surgeons Pakistan 2009, Vol. 19 (2): 108-112

INTRODUCTION

Head and neck cancers make-up 4% of all themalignancies worldwide but in South Asia (Pakistan andIndia), they make 35% of these, mainly due to the betelleaf and nut chewing and tobacco smoking.1,2 The oralcavity is the most common site for head and neckmalignancies, constituting 30% of the total.3Oropharyngeal cancer is the sixth most common cancerin the world.4

Most of the patients of head and neck malignancy in ourcountry present late due to poor literacy rate, ill defined

referral protocols and poverty.5 Despite the sensitivityand routine care of the oral cavity, the average delay inseeking medical treatment is about 5 months. Nearlyhalf of the patients present with advanced disease andabout one-third with neck metastasis. Local diseasecontrol is the cornerstone in the management of thesetumours. Achieving tumour-free resection marginsfollowed by primary reconstruction of the resultantdefect considerably reduces the morbidity, allows therapid healing and improves the quality of life (QOL).6 Avariety of reconstructive options are available forreconstructing head and neck defects, ranging fromlocal flaps, pedicled flaps and microvascular free flaps.During past two decades, the advances in head andneck reconstruction by revascularised tissue transferhave allowed for more extensive tumour ablation inpatients with locally advanced cancer of this areas.7

In the current economic climate of rising healthcarecosts and emphasis on resource allocation, complextreatment of advanced head and neck cancers is oftenquestioned. A compounding factor is the postoperativeradiotherapy, which is almost always given to thesepatients.8 During the past two decades, there has beenan increased trend towards resection along with

ABSTRACTObjective: To assess the improvement in Quality Of Life (QOL) after ablative surgery in locally advanced head and neckmalignancies by microvascular free flaps reconstruction.Study Design: Quasi-experimental. Place and Duration of Study: Department of Plastic Surgery, Combined Military Hospital, Rawalpindi, from September2005 to February 2007. Methodology: A total of 44 patients with locally advanced stage III and IV malignancy of head and neck were included inthe study. All patients were treated with ablative surgery and reconstruction with microvascular free flaps. QOL wasassessed by using a scoring questionnaire (including 5 parameters for extra oral cancers including physical and rolefunction, body image, weight loss score and pain donor site morbidity; and an additional 5 parameters for intraoral tumoursthat included swallowing, speech, drooling of saliva and mouth opening). A high score indicated a poor QOL. Patients wereassessed pre-operatively and then at 2, 4 and 6 months postoperatively.Results: Mean accumulative score and mean individual parameter scores for both extra- and intraoral tumours weresignificantly improved (p <0.05). Conclusion: Microvascular free flap reconstruction after ablative surgery in locally advanced head and neck malignancyhad a profound impact on the improvement of QOL. There was an initial deterioration of physical scores postoperativelyand postradiotherapy, followed by gradual improvement. By the end of 6 months, it surpassed the pre-operative QOLscores.

Key words: Quality of life. Head and neck malignancy. Microvascular free flaps. Reconstruction.

1 Department of Plastic Surgery, Combined Military Hospital,Rawalpindi.

2 Department of ENT, Combined Military Hospital, Rawalpindi.3 Department of Plastic Surgery, Combined Military Hospital,

Multan.4 Department of Plastic Surgery, NESCOM Hospital, Islamabad.5 Department of Plastic Surgery, Combined Military Hospital,

Pano Aqil.

Correspondence: Dr. Mamoon Rashid, 185, The Heaven,Street 7, Gulraiz II, Rawalpindi.E-mail: ltcolmamoon@yahoo.com

Received February 23, 2008; accepted November 29, 2008.

Quality of Life Assessment in Patients with Locally AdvancedHead and Neck Malignancy after Ablative Surgery and

Reconstruction with Microvascular Free Flaps Taokeer Ahmed Rizvi1, Mamoon Rashid1, Bashir Ahmed2, Ehtesham-ul-Haq3, Saad-ur-Rahman Sarwar4,

Muhammad Zia-ul-Islam5 and Muhammad Sarmad Tamimy1

ORIGINAL ARTICLE

immediate microvascular reconstruction for thesetumours so that the patients can be rehabilitated earlierand are reintegrated more rapidly into their social lifeand professional environment.5

Postoperatively, patient’s satisfaction, both functionaland cosmetic, is the key factor for success of such aprocedure. Assessing the QOL of the patients withvarious diseases is not a new concept but it has startedgaining importance in the local literature only.9,10 Nostudy on aspects of patient satisfaction after head andneck reconstructions are available in the local setting.

The aim of this study was to assess the QOL in patientswith locally advanced head and neck malignancy afterablative surgery and reconstruction with microvascularfree flaps.

METHODOLOGY

The study was carried out at the Department of PlasticSurgery, Combined Military Hospital, Rawalpindi, fromSeptember 2005 to February 2007. All the head andneck tumour patients with stage III and IV of head andneck malignancy (T3&4, N1&2 and M0) with goodperformance status were included in the study. Thepatients with distant metastasis and/or inoperabledisease were excluded from the study.

All the patients were assessed and discussed in aMultidisciplinary Joint Head and Neck Oncology Clinicfor treatment planning, selection of reconstructiveprocedure and patients counseling. The clinic involvesENT surgeons, Radiation oncologists, Pathologist,Maxillofacial surgeons and Plastic surgeons. Thepatients underwent resection with tumour-free-marginsand reconstruction with microvascular free flaps.Tumour resection +/- lymph node dissection wasperformed by the ENT colleagues. Plastic surgeonsperformed reconstruction with microvascular free flap.Methods of reconstruction included radial forearmmicrovascular free flap, microvascular free fibula, rectusabdominis free flap and anterolateral thigh free flapaccording to the defect in anatomy. Postoperativeradiotherapy was given to the patients as and whenrequired.

QOL was assessed by using a modified proformaconceived from European Organization for Researchand Treatment of Cancer (EORTC QLQ-C30) and Headand neck quality of life core questionnaire (QLQ H andN35).11-13 Some parameters had to be modified and / oromitted as per local suitability, and based upon theearlier patients’ inability to answer or understand manyof the edited questions.

The assessment was made on a 5-point scale for allhead and neck tumours, whereas an additional 5 pointsscale was used for intraoral tumours (Table I). An

accumulative score was calculated by adding up all theparameter scores for each patient. The maximum scorefor intraoral tumours was 33 and for extra-oral tumours,it was 18; a high score indicated a high level ofsymptomatology and problems, and therefore, signify apoor QOL. Patients were assessed pre-operatively andthen every two monthly till six months according to theproforma. Only those patients who completed all of 4assessments were finally included for resultscompilation. A longitudinal analysis was carried out.Sociodemographic variables as age, gender, personalhabits and any known risk factors were noted. Thepatients presenting complaints, findings on examinationand important investigations were endorsed. Statisticalsoftware (SPSS version 10.0) was used for analysis ofdata. The pre-operative and postoperative scores wereanalyzed using ‘t-test’ and p-value of < 0.05 wasconsidered significant.

Journal of the College of Physicians and Surgeons Pakistan 2009, Vol. 19 (2): 108-112 109

Quality of life assessment in patients with locally advanced head and neck malignancy

Table I: Assessment of QOL for both intra and extra oral tumours.Intra and extra oral tumours Score1. Physical and role function

Continues same routine activities as pre-morbid 1Mildly affected routine activities 2Moderately affected routine activities 3Severely affected /restricted routine activities 4Confined to home 5

2. Body imageNo change 1Mild deformity 2Moderate disfigurement or deformity 3Severe disfigurement or deformity 4

3. Donor site morbidityMinimal 1Moderate 2Severe 3

4. Weight lossMild 1Moderate (5-10 kg) 2Severe (>10 kg) 3

5. PainNo pain 1Mild to moderate pain, relieved by analgesics 2Severe pain, may or may not respond to analgesics 3

Intra oral tumours only Score6. Swallowing

Normal diet 1Soft diet 2Tube feeding 3

7. SpeechNo effect, normal 1Intelligible 2Borderline 3Un-intelligible 4

8. Drooling of salivaAbsent 1Present 2

9. Mouth openingAdequate 1Moderate 2Severely restricted 3

10. Oral hygieneClean 1Compromised 2Poor 3

RESULTS

A total of 37 patients could complete the study. Male tofemale ratio was almost equal (18:19).They were agedbetween 22-70 years, with a mean age of 51.76 + 9.55years. Histologically, squamous cell carcinoma was thepredominant malignancy affecting 29 (78.38%) patients.Other tumours included 2 cases each of basal cellcarcinoma (5.41%), malignant peripheral nerve sheathtumour (5.41%) and one (2.71%) each of osteogenicsarcoma, malignant melanoma, ameloblastic sarcomaand adenoid cystic carcinoma. Thirty (81.1%) patientswere affected with intra-oral malignancy, while 7 (18.9%)had extra-oral tumours. Commonest method forreconstruction was radial forearm microvascular freeflap used in 59.46% (22 patients), followed bymicrovascular free fibula in 24.32% (9 patients), rectusabdominis free flap in 10.81% (4 patients) andanterolateral thigh free flap in 5.41% (2 patients).

Mean individual parameter scores are depicted inTable II. For physical and role function, it was 3.95 pre-operatively, 2.73 at 2 months, 1.78 at 4 months and 1.14at 6 months. Body image score improved gradually as3.22, 2.27, 1.7 and 1.49 respectively. Weight loss scoreimproved as 2.12, 1.65, 1.03 and 1.04 respectively. Painameliorated progressively as 2.14, 1.35, 1 and 1respectively. For intra-oral tumors, swallowing improvedwith scores of 2.20, 1.53, 1 and 1; speech improved withscores 2.43, 1.70, 1.13 and 1; drooling of salivaimproved with scores of 1.97, 1.30, 1 and 1; mouthopening showed improvement with scores of 2.07, 1.43,1.03 and 1.03 and oral hygiene improved as 2.67, 1.20,1 and 1 respectively for pre-operatively and at 2, 4 and6 months. Donor site morbidity reduced in postoperativeperiod gradually from 1.58, 1 to 1 at 2, 4 and 6 monthsrespectively. All the changes between the pre-operativeand follow-up scores at 06 months were statisticallysignificant except for donor site morbidity. Thisparameter was even otherwise not applicable in thiscase as there were no pre-operative scores (Figures 1and 2).

DISCUSSIONMeasurements of functional status and QOL outcomesare becoming increasingly important in modernmedicine.12 QOL is a global concept that is bothsubjective and multidimensional and includes emotionalstatus, mental health and physical status. Manyresearchers add disease-specific functional status whendescribing the functional deficits caused by a particulardisease process.14 Improvement in QOL is a gapbetween the patient’s expectation and achievements, orthe functional effect of an illness and its treatment on apatient as perceived by that individual.15 Several studieshave evaluated QOL with a variety of outcomemeasurement instruments following radiotherapy forhead and neck cancers,16,17 whereas other reports havecontrasted surgical treatment outcomes with organ-preserving treatment modalities (chemotherapy andradiation therapy).18,19

110 Journal of the College of Physicians and Surgeons Pakistan 2009, Vol. 19 (2): 108-112

Taokeer Ahmed Rizvi, Mamoon Rashid, Bashir Ahmed, Ehtesham-ul-Haq, Saad-ur-Rahman Sarwar, Muhammad Zia-ul-Islam and Muhammad Sarmad Tamimy

Table II: Results: pre-operative and follow-up scores.Parameter score (mean + SD) P-value

Pre-operative 2 months 4 months 6 months (comparisonpre-operative to

6 months follow-up)Physical and role function 3.95 (+ 0.705) 2.73 (+ 0.450) 1.78 (+ 0.584) 1.14 (+ 0.347) < 0.05Body image 3.22 (+ 0.75) 2.27 (+ 0.508) 1.70 (+ 0.571) 1.49 (+ 0.507) < 0.05Donor site morbidity - 1.58 (+ 1.751) 1.00 (+ 0.00) 1.00 (+ 0.00) 0.068Weight loss 2.12 (+ 0.431) 1.65 (+ 0.588) 1.03 (+ 0.167) 1.04 (+ 0.196) < 0.05Pain 2.14 (+ 0.419) 1.35 (+ 0.484) 1.00 (+ 0.00) 1.00 (+ 0.00) < 0.05Swallowing 2.20 (+ 0.407) 1.53 (+ 0.507) 1.00 (+ 0.00) 1.00 (+ 0.00) < 0.05Speech 2.43 (+ 0.728) 1.70 (+ 0.596) 1.13 (+ 0.346) 1.00 (+ 0.00) < 0.05Drooling of saliva 1.97 (+ 0.183) 1.30 (+ 0.466) 1.00 (+ 0.00) 1.00 (+ 0.00) < 0.05Mouth opening 2.07 (+ 0.479) 1.43 (+ 0.504) 1.03 (+ 0.183) 1.03 (+ 0.183) < 0.05Oral hygiene 2.67 (+ 0.479) 1.20 (+ 0.407) 1.00 (+ 0.00) 1.00 (+ 0.00) < 0.05Accumulative score 20.68 15.32 10.57 8.51 < 0.05

Figure 1: Changing scores for extra and intra-oral tumour parameters.

Figure 2: Changing scores for parameters specific to intra-oral tumour only.

Journal of the College of Physicians and Surgeons Pakistan 2009, Vol. 19 (2): 108-112 111

Quality of life assessment in patients with locally advanced head and neck malignancy

Despite modern advances in the treatment of head andneck cancer, the survival rate fails to improve.12

Considering the different treatment modalities involved,QOL has been thought of as an additional end pointcriterion for use in clinical trials.13

Scores were calculated for each parameter, whichshowed a progressive improvement over the follow-upperiod. There was slight improvement at 2 months pointbecause patients were recovering from major surgeryand radiotherapy (when indicated). After 2 months,there was marked progressive improvement in patients.Although Netscher et al. have used a different QOL /functional status instrument, their patients also had animprovement of QOL and functional scores aftermicrovascular reconstructive surgery.6 Incontrast to theirfindings, our patients improved significantly in terms ofQOL, quite earlier (within 6 months). This difference canbe attributable to a late presentation in these cases, thusa poorer pre-operative QOL score.

To summarize this study of head and neck cancerpatients, many global and disease specific QOLsubclasses initially remained same or improved slightlyin response to extensive surgery and radiotherapy(when indicated), but most returned to baseline by 4months posttreatment and had surpassed pre-treatment values by 6 months. Untreated, these patientswould be expected to experience declining QOLmeasurements as their local head and neck diseaseprogressed. This can be attributed to the tumourcachexia itself as well as poor nutritional status of thepatient related to poor oral intake, secondary to themass effect of the tumour, involvement of various oraland oro-pharyngeal structures and decreased mouthopening.2

Large resections and reconstructions in head and neckcancer patients are justified despite the predictableinitial significant worsening of the measured criteria anddespite the fact that some of these patients will die ofsystemic cancer or concurrent illness within the year;extensive resections controls the local disease, andmicrovascular reconstruction restores QOL andfunctional status.

CONCLUSION

Microvascular free flap reconstruction after ablativesurgery in locally advanced head and neck malignancyhas a profound impact on the improvement of QOL.There is an initial deterioration of physical scores in theimmediate postoperative period and duringradiotherapy, followed by gradual improvement over thesucceeding 2-4 months period. By the end of 6 months,the QOL of these patients surpasses the pre-operativelevel of QOL.

Acknowledgement: The authors thank Dr. NasserRashid Dar, Dr. Jawad Jalil and Dr. Rashad Siddiqui fortheir assistance in the preparation of this article.

REFERENCES1. Rashid M, Ahmad T, Sarwar SR, Ansari TN, Ahmed B, Ahmed

S, et al. Management of oromandibular cancers. J Coll PhysiciansSurg Pak 2004; 14: 29-34.

2. Carlson GW. Oncology and reconstructive principles. In:Achauer BM, Eriksson E, Guyuron B, Coleman JJ, Russell RC,Kolk C, (edi). Plastic surgery; indications, operations andoutcomes. Missouri: Mosby; 2000: p.1067-79.

3. de Lacure MD, Kuriakose MA. The oral cavity. In: Achauer BM,Eriksson E, Guyuron B, Coleman JJ, Russell RC, Kolk CA, (edi).Plastic surgery; indications, operations and outcomes. Missouri:Mosby; 2000: p.1211-1228.

4. Warnakulasuriya S. Global trends in the epidemiology of oralcancer. Oral Oncol 2008; [Epub ahead of print].

5. Cheema SA, Cheema RA. Head and neck tumours-reconstructive options for soft tissue defects. Ann KE Med Coll2001; 7:11-3.

6. Netscher DT, Meade RA, Goodman CM, Alford EL, Stewart MG.Quality of life and disease-specific functional status followingmicrovascular reconstruction for advanced (T3 and T4)oropharyngeal cancers. Plast Reconstr Surg 2000; 105:1628-34.

7. Schliephake H, Jamil MU. Impact of intraoral soft-tissuereconstruction on the development of quality of life after ablativesurgery in patients with oral cancer. Plast Reconstr Surg 2002;109:421-30, Discussion 431-2.

8. de Graeff A, de Leeuw JR, Ros WJ, Hordijk GJ, Blijham GH,Winnubst JA. A prospective study on quality of life of patientswith cancer of oral cavity or oropharynx treated with surgery withor without radiotherapy. Oral Oncol 1999; 35: 27- 32.

9. Qayyum A, Zaidi SHM. Comparison of patients’ quality of lifetreated with two different regimens for advanced gallbladdercancer. Pak J Med Sci 2007; 23:703-7.

10. Zuberi BF, Memon AR, Afsar S, Qadeer R, Kumar R. Correlationof quality of life in patients of cirrhosis of liver with etiology anddisease severity using disease-specific quality of lifequestionnaire. J Ayub Med Coll (Abottabad) 2007; 19:7-11.

11. Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A,Duez NJ, et al. The European Organization for Research andTreatment of Cancer QLQ-C30. A quality-of-life instrument foruse in international clinical trials in oncology. J Natl Cancer Inst1993; 85:365-76.

12. Rogers SN, Ahad SA, Murphy AP. A structured review andtheme analysis of papers published on 'quality of life' in headand neck cancer: 2000-2005. Oral Oncol 2007; 43:843-68.

13. Mehanna HM, Morton RP. Patients' views on the utility of qualityof life questionnaires in head and neck cancer: a randomizedtrial. Clin Otolaryngol 2006; 31: 310-6.

14. Chaukar DA, Das AK, Deshpande MS, Pai PS, Pathak KA,Chaturvedi P, et al. Quality of life of head and neck cancerpatient: validation of the European Organization for Researchand Treatment of Cancer QLQ-C30 and European organizationfor research and treatment of cancer QLQ-H&N 35 in Indianpatients. Indian J Cancer 2005; 42:178-84.

112 Journal of the College of Physicians and Surgeons Pakistan 2009, Vol. 19 (2): 108-112

Taokeer Ahmed Rizvi, Mamoon Rashid, Bashir Ahmed, Ehtesham-ul-Haq, Saad-ur-Rahman Sarwar, Muhammad Zia-ul-Islam and Muhammad Sarmad Tamimy

15. Shah JP. Quality of life and functional rehabilitation. In: Shah JP,(edi). Head and neck surgery and oncology. 3rd ed. Missouri:Mosby; 2003:p.673-7.

16. Harrison LB, Zelefsky MJ, Pfister DG, Carper E, Raben A, KrausDH, et al. Detailed quality of life assessment in patients treatedwith primary radiotherapy for squamous cell cancer of the baseof tongue. Head Neck 1997; 19:169-75.

17. Brownman GP, Levine MN, Hodson DI, Sathya I, Russell R,Skingley P, et al. The head and neck radiotherapy questionnaire:

a morbidity quality-of-life instrument for clinical trials of radiationtherapy in locally advanced head and neck cancer. J Clin Oncol1993; 11:863-72.

18. Rashid M, Ahmed B, Ahmed T, Haq EU, Sarwar SUR, IslamZUI. Functional results of microsurgical reconstruction of thetongue after major reconstructions. Oral Oncol 2005; 1(Suppl):27.

19. Terrell JE, Fisher SG, Wolf GT. Long-term quality of life aftertreatment of laryngeal cancer. The veterans affairs laryngealcancer study group. Arch Otolaryngol Head Neck Surg 1998; 124:964-71.

l l l l lOl l l l l