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Health-related quality of life in oral cancer survivors

Musa, Hania; Mosleh, Mohameda; Shawky, Mahad; Mustafa, Magdab; Shouman, Tarekc

Egyptian Journal of Oral & Maxillofacial Surgery: October 2015 - Volume 6 - Issue 3 - p 81–95
doi: 10.1097/01.OMX.0000469293.75530.0d
ORIGINAL ARTICLE
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Aim After surgery and radiation for the treatment of oral cancer, patients often develop oral complications such as speech, swallowing problems, and limited mouth opening. These problems may be caused by surgery and radiation. This study is a survey guided by a questionnaire for the post-treatment quality of life (QOL) in oral cancer patients in terms of the complications of cancer therapy.

Patients and methods This study was carried out as a survey using the University of Washington Quality-of-Life Questionnaire aiming to identify different patterns of health-related QOL of patients with oral cancer. A total of 192 patients treated with surgery and/or radiation for oral cancer were interviewed. Maximal interincisal mouth opening was measured in these patients.

Results Patients with tumors of posterior areas and patients with late stages showed a statistically significantly higher prevalence of limited mouth opening. Patients with limited mouth opening (trismus) showed a statistically significant lower mean score in the swallowing domain. The overall QOL questionnaire showed that the highest mean score was found with saliva (84.7), followed by taste (84.5). The lowest mean score was found with chewing (53.8), followed by swallowing (74.2). The overall mean QOL score was 75.9.

Conclusion About half of the patients who underwent primary treatment for oral cancer developed trismus and reported problems with eating and speech. Chewing was identified as the poorest rating domain and presented the highest proportion of complaints in the sample of this study.

aDepartment of Oral and Maxillofacial Surgery, Faculty of Oral and Dental Medicine

bDepartment of Clinical Oncology, Faculty of Medicine

cDepartment of Radiation Oncology, National Cancer Institute, Cairo University, Cairo, Egypt

dDepartment of Oral and Maxillofacial Surgery, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia

Correspondence to Maha Shawky, PhD, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, King Abdulaziz University, 80209 Jeddah 21589, Saudi Arabia Tel: +966 058 289 8242; fax: +966 695 2847; e-mail: mahkhaimar@hotmail.com

Received February 10, 2015

Accepted June 16, 2015

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Introduction

Cancer is Latinized from the Greek word ‘Karkinos’, meaning crab, denoting how carcinoma extends its claws like a crab into the adjacent tissues. The global burden of cancer has continued to increase over the centuries as childhood mortality and deaths from infectious diseases have decreased and individuals live longer 1.

In the postantibiotic era, oral cancer remains one of the few life-threatening oral diseases in the world; it is a major health problem worldwide, causing over 127 000 deaths each year 2. With an annual incidence exceeding 274 000 cases, oral cancer ranks as one of the top 10 most common malignancies. Over two-thirds of cases and three-quarters of deaths because of oral cancer occur in developing countries 3.

Surgical treatment for cancer of the oral cavity has major effects on the quality of life (QOL), which has been defined as the perceived discrepancy between the actual status and the ideal standards of the patient 4. Esthetic and functional sequelae because of surgical incision and cancer resection, often associated with radiotherapy, always modify the patient’s self-perception and the ability to interact with others in daily social life. In situations such as mastectomy or vascular shunt for dialysis, body scars and alterations can be managed easily in public and usually remain hidden during social activities; however, oral cancer patients cannot hide their post-treatment condition. Despite media exaggeration of breakthroughs in cancer treatment, it still falls into three basic categories: surgery, radiation, or chemotherapy. With the advent of better surgical and reconstruction techniques and more effective chemoradiotherapy protocols, oncological outcomes have improved, but increasing numbers of patients encounter long-term negative side effects of these indispensable therapeutic interventions. Head and neck oncologists often face the difficult challenge of balancing cancer cure and patient survival with preservation of function, esthetics, and QOL when deciding on the best treatment regimen for a patient. The lives of oral cancer survivors are limited not only by the fear of death from cancer but also by deformities caused by the tumor and the effect of the disease on their daily functions, which seems to affect their QOL adversely.

Oral cancer most commonly occurs in middle-aged and older individuals, although a disturbing number of these malignancies have also been documented in younger adults in recent years 5,6. From an epidemiological and clinic pathological perspective, ‘oral cancer’ can be divided into three categories: carcinomas of the oral cavity proper, carcinomas of the lip vermilion, and carcinomas arising in the oropharynx. Intraoral and oropharyngeal tumors are more common among men than women, with a male : female ratio of over 2 : 1.2 7,8. However, the disparity in the male : female ratio has become less pronounced over the past half century, probably because women have also equally been exposing themselves to known oral carcinogens such as tobacco and alcohol 5,9.

The most common site for intraoral carcinoma is the tongue, which accounts for around 40% of all cases in the oral cavity proper. These tumors most frequently occur on the posterior lateral border and ventral surfaces of the tongue. The floor of the mouth is the second most common intraoral location. Less common sites include the gingiva, buccal mucosa, soft palate, and hard palate 9,10. The lateral tongue and floor of the mouth (with extension back to the lateral soft palate and the tonsillar area) combine to form a horseshoe-shaped region of the oral mucosa, which is at greatest risk for cancer development 11. There are two major factors that may explain why this region is at high risk: first, any carcinogens will mix with saliva, pool in the bottom of the mouth, and constantly bathe these sites; second, these regions of the mouth are covered by a thinner, nonkeratinized mucosa, which provides less protection against carcinogens 11. Most of the many different types of oral cancer are termed squamous cell carcinoma (SCC), which comprise more than 95% of the carcinomas of the oral cavity 12.

According to a meta-analysis, on average, current smokers have a three-fold increased risk of oral cancer 13. The risk of oral cancer associated with smoking is both dose and duration dependent, whereas smoking cessation leads to a decrease in risk 14,15. However, a recent study showed that it takes 20 years or longer for the risk to reduce to that of never smokers 1. The use of Toombak, a species of Nicotiana rustica, plays a significant role in the etiology of oral SCC, with the tobacco-specific nitrosamines present in Toombak possibly acting as principal carcinogens 16. Similarly, Qat chewing has been associated with an increased rate of oral cancer 17. The increasing trends in oral cancer mortality have been related to increasing levels of alcohol consumption. It has been suggested that it is the total amount of ethanol ingested rather than the type of alcohol that is important 18. Other etiologic risk factors include diet and nutrition 19,20, sun exposure 21,22, human papilloma virus immunosuppression and autoimmune factors 12,23,24, chronic tissue trauma 22, complex genetic mechanisms (individually or collectively), and other viral agents, such as herpes simplex virus 25.

Several oral lesions and conditions precede oral carcinoma and the most common of these are leukoplakia and erythroplakia. It has recently been estimated that the annual transformation rate of oral leukoplakia into oral SCC may not exceed 1% 26. Erythroplakia is rare and mainly occurs in individuals older than 60 years of age 27.

The boundaries of the oral cavity extend from the vermilion–cutaneous junction of the lips to the junction of the hard and soft palate posterior–superiorly and to the line created by the circumvallate papilla posterior–inferiorly. Posterior–laterally, the boundaries are represented by the anterior faucial pillars. The American Joint Committee of Cancer (AJCC) has divided the oral cavity into seven distinct anatomic locations from which primary lesions may develop 28. The diagnosis of oral cancer depends on the clinical examination, which is the first line of defense in the detection of oral cancer. Prognosis is directly dependent on the tumor stage at diagnosis. Nearly one-half of all oral cancers are not detected until they are in advanced stages. A study by Holmes et al. 29 showed that the detection of oral and oropharyngeal SCC during nonsymptom-driven examinations was associated with a lower stage at diagnosis.

QOL issues are becoming increasingly important in treatment planning. For most stage I and stage II cancers of the oral cavity, surgical resection with frozen section analysis of the margins is advocated by most clinicians 30. The importance of obtaining clear histological margins has been a foundation for the surgical treatment of oral cavity cancer and has been supported by several studies that have reported decreased survival associated with positive margins, even if follow-up radiation is administered. Additional studies 30,31 have shown that margins that are clear histologically may still have cells at the margin that show premalignant changes, and this can be associated with recurrence. Most surgeons agree that achievement of clear margins should be aimed for, given this impact of positive margins on survival. Excision with 1 –1.5 cm of normal tissue beyond the obvious tumor edge is generally sufficient 31. Radiotherapy is administered by different techniques, with different fractionations and doses administered using either internal, external, and sometimes interstitial therapy using radioactive isotopes 32,33. Chemotherapeutic agents are most effective against cells undergoing replication; smaller and faster growing tumors are more susceptible 34.

Complications with eradication of disease include failure to cure the disease 35,36, altered masticatory function and nutrition 37, speech and swallowing disruption 38–40, disfigurement 36, osteoradionecrosis in patients who have received doses of radiation for head and neck malignancies in excess of 6000 cGy 41,42, xerostomia 43 as residual saliva tends to be thick and viscous and loses its ability to lubricate, cleanse, and protect, in addition to reconstruction and donor-site morbidity such as unesthetic scar, hardware failure, and tissue deficits 36.

Restricted mouth opening is a common complaint following oral cancer surgery. Fibrosis and scar contraction, in addition to contraction of the muscles of mastication, are the main reasons for the inability of the patient to open the mouth 44,45. Trismus has been associated with significant health implications, including reduced nutrition because of impaired mastication, difficulty in speaking, and compromised oral hygiene 44. Limitations in jaw opening have been reported in 6–86% of patients who received radiation to the temporomandibular joint and/or masseter/pterygoid muscles, with frequency and severity that are somewhat unpredictable 46.

Several cranial nerves are at risk during resection of primary tumors as well as neck dissection for removal of ‘at-risk’ or involved lymph nodes 36,47,48.

Health-related quality of life (HRQOL) in cancer patients is currently considered a powerful predictor of mortality and morbidity 49. The assessment of HRQOL enables health professionals to appraise the physical, mental, and social impact of therapeutics, and improve their ability to anticipate the patient’s prognosis. QOL questionnaires have the advantage of gathering the patients’ most common problems in a structured manner and furthermore, ranking its intensity. Different structures have been used, which preceded regulated questionnaires with a precise number of graded questions 50. The main qualities that they must fulfill are validity (degree to which the questionnaire measures what it actually aims to measure), reproducibility (necessary in successive repetitions), consistency, reliability, and sensibility to change 51. Nowadays, patients with oral cancer favor a multidisciplinary approach involving an integral treatment strategy 46. Future lines of work should be aimed not only at controlling oral cancer but also functional and esthetic improvements after treatment. Therefore, before deciding on an oral cancer treatment, one has to be aware of the long-term complications and side effects in terms of QOL because an extension of a patient’s survival does not necessarily translate into an improvement in QOL.

Clinical applications of QOL questionnaires can be directed toward the understanding of emotional and physical after-effects and, therefore, optimized advising, treatment, and rehabilitation. QOL assessment will help identify more efficient therapeutic procedures and have developed into an essential tool to evaluate treatment results, along with mortality, morbidity, survival, and recurrence rates, as they allow the detection of early recurrences in oral cancer. The University of Washington Quality-of-Life Questionnaire (UW-QOL) scale has an extended use in oral cancer patients, especially when surgery is involved 50. The questionnaire focuses on the symptoms specifically related to head and neck cancer treatment with questions referring to areas such as eating, breathing, swallowing, external aspects, and tobacco use and alcohol consumption. It has been developed on the basis of psychometric criteria and patients’ evaluations 52.

In QOL short-term longitudinal studies, an improvement in the symptoms occurred after approximately a year, which becomes maximum after 2 or 3 months, recovering the diagnosis level after approximately a year 53,54. In long-term studies 55,56, some authors have found that QOL does not re-establish to normal levels until 3–5 years 55 because of parameters that permanently remain diminished as an after-effect of the disease and its treatment. However, other authors have reported no differences between QOL after a year or in the following years 56.

A large number of factors influence QOL such as sociodemographic aspects, tumor characteristics, and modality of treatment 54–59. After surgery, older patients achieve a better score in QOL, which can be attributed to a social life with less demand of future ambitions 57. However, they show a higher score in symptoms such as sexual problems, sensitive alteration, and use of nutritious supplements 59. Bjordal et al. 58 reported that QOL pretreatment in women led to worse results than in men, although after a year, these differences disappeared, finding more mental alterations, and bad nutrition in men. Women show, furthermore, more affectation in mobility, recreation and functions related to food.

Rogers et al. 59 described worse QOL in the posterior oropharynx location, especially because of a worse deglutition. Furthermore, worse prognosis in posterior tumors is because of a delay in diagnosis and major tumor size, which therefore leads to a worse prognosis. However, De Boer et al. 60 observed major survival and minor recurrence in patients in better physical condition, nonsmokers, and those who are less demanding before surgery.

Jaw resection is the parameter that appears to be most relevant in terms of postsurgery deterioration in QOL 61. It has been reported that jaw reconstruction does not contribute toward a significant improvement in QOL and there is also no improvement in mastication because of the lack of several soft parts of the jaw that coordinate the complex process of mastication. Worse QOL has been found in patients who have undergone cervical dissection operation compared with those who have not undergone this operation 62 as these patients in a more advanced stage. The cervical dissection, along with the scars that develop as a result of surgical reconstruction with a myocutaneous pedicled flap, significantly influence a patient’s complaints of esthetics and pain in the reconstructed location 62. Possible complications that result from a radical cervical dissection include shoulder dysfunction, secondary to the spinal nerve, and an esthetic deformity because of the sacrifice of the sternocleidomastoidus muscle.

In QOL transversal and longitudinal studies, patients who have received adjuvant radiotherapy showed worse scores in function parameters and more symptoms 63, and experience deterioration in QOL as a consequence of secondary effects as well as psychological deterioration 64.

The aim of the present study is to assess, using a survey guided by a questionnaire, the post-treatment QOL of oral cancer patients in terms of the complications of cancer therapy.

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Patients and methods

This study was carried out as a survey using the UW-QOL 50 aiming to identify different patterns of HRQOL of patients with oral cancer. The study included 192 patients (113 males, 79 females). The mean±SD age of the patients was 56.5±14.5 years (range 12–83 years). All patients had cancer of the oral cavity and had undergone treatment for oral cancer between March 2008 and April 2011. The patients were recruited from two centers: those attending the head and neck cancer aftercare consultations clinic at the National Cancer Institute and the Kasr Elaini Hospital Center of Clinical Oncology and Nuclear Medicine, Cairo University.

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Patients

All patients had biopsy-proven oral cancer and had undergone surgery and/or radiotherapy before 1 or more years. The study gathered information on patients with SCC in the following sites: cheek mucosa, alveolar ridge, floor of the mouth, lips, palate, retromolar area, and the tongue. The sample cannot be considered representative of patients with oral cancer in any broader context. As these hospitals are referral healthcare units for head and neck oncology, many of the patients lived outside the city of Cairo.

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Methods

Hospital files were used to identify the demographic data, clinical data, and type of treatment. According to age, patients were classified into two groups: younger than 60 years of age and older than or equal to 60 years of age. In terms of tumor site, the tumors were classified as follows: located in the anterior part of the oral cavity, which include the lips, the alveolar ridge anterior to the first molar, cheek mucosa, hard palate, and anterior two-thirds of the tongue or located in the posterior part of the oral cavity, which include the base of the tongue, soft palate, the alveolar ridge posterior to the first molar, and the retromolar area.

Patients were divided into two groups according to TNM classifications: the first group of patients had T1 and T2 tumors and the second group of patients had T3 and T4 tumors. According to treatment, patients were classified into three groups: patients who underwent both surgery and radiotherapy, patients who underwent only surgery, and patients who received only radiotherapy. For assessment of patients’ for limited mouth opening (trismus), the maximal interincisal mouth opening (MIO) was measured using a digital caliper; a MIO less than 36 mm was considered to be limited. The mouth opening should be voluntary and nonpainful. The interincisal opening was measured between maxillary and mandibular central incisors along the midline.

QOL was evaluated using a modified version of the UW-QOL, which was specifically developed for the QOL assessment of patients with cancer of the head and neck 49. The form that was distributed to the participants was in simple Arabic language (which was translated specifically for this study). It included specific questions addressing relevant dimensions for the QOL assessment of patients with oral cancer who completed the UW-QOL in terms of pain, appearance, swallowing, chewing, speech, taste, and saliva.

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Scoring

The UW-QOL has domains based on discrete ordinal responses. Scoring is scaled so that a score of 0 represents the worst possible response and a score of 100 represents the best possible response. Scoring is scaled into equal stages from 0 to 100 to reflect the number of possible responses. Thus, the pain and appearance domains have five possible responses, which are scored as 0, 25, 50, 75, and 100, swallowing, speech, taste, and saliva as 0, 30, 70, and 100, and chewing as 0, 50, and 100.

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Statistical analysis

Quantitative data were presented as mean and SD values. Student’s t-test was used for comparisons between two groups. The one-way analysis of variance test was used for comparisons between more than two groups. Tukey’s test was used for pair-wise comparisons between groups when the analysis of variance test was significant. Qualitative data were presented as frequencies and percentages. The χ 2-test was used for comparisons and to study associations between different qualitative variables. The significance level was set at P-value 0.05 or less. Statistical analysis was carried out using IBM SPSS Statistics (version 20 for Windows; IBM Corporation, New York, USA).

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Results

This study was carried out as a survey using the UW-QOL aiming to identify different patterns of HRQOL of patients with oral cancer.

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Demographic data

A total of 192 patients treated by surgery and/or radiation for oral cancer at the Center of Clinical Oncology and Nuclear Medicine at Kasr Elaini Hospital and the National Cancer Institute, Cairo University, were interviewed. Data on age, sex, clinical data, and type of treatment were obtained from the patients’ files. All patients had received primary therapy for oral cancer. The sample was divided into two age groups: patients 60 years of age or older, 130 (67.7%) patients, and patients younger than 60 years of age, 62 (32.3%) patients. The mean±SD of age was 56.5±14.5 years (range 12–83 years) (Fig. 1). The sample included 113 (58.9%) males and 79 (41.1%) females. The male : female ratio was 1.4 : 1 (Fig. 2).

Fig. 1

Fig. 1

Fig. 2

Fig. 2

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Clinical data

In total, 118 (61.5%) tumors were located in the anterior part of the oral cavity and 74 tumors (38.5%) were located in the posterior part of the oral cavity. The distribution of tumors in the anterior part was as follows: 14 (11.9%) tumors affected the lip (Fig. 3), 46 (39%) tumors affected the cheek, 17 (14.4%) tumors affected the hard palate, nine (7.6%) tumors affected the floor of the mouth, and 32 (27.1%) tumors affected the anterior two-thirds of the tongue and gum. The distribution of tumors in the posterior part was as follows: 42 (56.8%) tumors affected the base of the tongue, eight (0.8%) tumors affected the soft palate, and 32 (32.4%) tumors affected the retromolar area. Seventy-eight (40.6%) tumors were T1 and T2 stages, whereas 114 (59.4%) tumors were T3 and T4 stages (Fig. 4).

Fig. 3

Fig. 3

Fig. 4

Fig. 4

In terms of treatment, 107 (55.7%) patients underwent both surgery and radiotherapy, 63 (32.8%) patients underwent only surgery, and 22 (11.5%) patients only received radiotherapy (Fig. 5).

Fig. 5

Fig. 5

Eighty-nine (46.4%) patients had MIO less than 36 mm after treatment and 103 (53.6%) patients had MIO equal to or more than 36 mm (Figs 6 and 7 and Table 1). Results showed that there was a statistically significant association between MIO and tumor site. Patients with tumors of the posterior areas showed a statistically significantly higher prevalence of limited mouth opening (MIO<36 mm) than patients with tumors of the anterior area. However, patients with late stages (T3 and T4) showed a statistically significantly higher prevalence of limited mouth opening (MIO<36 mm) than patients with early stages (Table 2 and Fig. 8).

Fig. 6

Fig. 6

Fig. 7

Fig. 7

Table 1

Table 1

Table 2

Table 2

Fig. 8

Fig. 8

The association between pain scores in the UW-QOL questionnaire and different variables showed no statistically significant difference between the pain scores among different variables (Table 3 and Fig. 9).

Table 3

Table 3

Fig. 9

Fig. 9

The association between appearance scores in the UW-QOL questionnaire and different variables showed that in terms of age, patients aged 60 years or more showed a statistically significantly higher mean score than patients aged younger than 60 years. In terms of sex, there was no statistically significant difference between males and females. For tumor site, anterior tumors showed a statistically significantly higher mean score than posterior tumors (Table 4 and Figs 10–13).

Table 4

Table 4

Fig. 10

Fig. 10

Fig. 11

Fig. 11

Fig. 12

Fig. 12

Fig. 13

Fig. 13

Considering TNM stages, early-stage tumors (T1 and T2) showed a statistically significantly higher mean score than late-stage tumors (T3 and T4). In terms of treatment modalities, patients who received surgery alone showed the statistically significantly highest mean score. There was no statistically significant difference between patients who received surgery and radiotherapy and those who received radiotherapy alone; both showed the statistically significantly lowest mean scores. In terms of MIO, there was no statistically significant difference between the mean scores in patients with MIO less than 36 mm and MIO 36 mm or more.

The association between swallowing, chewing, taste, and saliva scores in the UW-QOL and different variables indicated that males showed a statistically significantly lower mean score than females. Anterior tumors showed a statistically significantly higher mean score than posterior tumors, and early-stage tumors (T1 and T2) showed higher mean score than late-stage tumors (T3 and T4). Patients who received surgery alone showed the highest mean score. In terms of MIO, patients with limited mouth opening showed a lower mean score than patients with normal mouth opening (Tables 5–8 and Figs 14–20). However, there was no statistically significant difference between patients who received surgery and radiotherapy and those who received radiotherapy alone; both showed the statistically significantly lowest mean scores. In terms of taste, males showed a statistically significant lower mean score. Anterior tumors showed a statistically significant higher mean score. Early-stage tumors (T1 and T2) showed a statistically significant higher mean score. Patients who received surgery alone showed the statistically significant highest mean score. In terms of MIO, patients with limited mouth opening showed a statistically significantly lower mean score. Results assessing speech indicated no statistically significant difference between speech scores among different variables, except for tumor site, TNM stages, and treatment. Anterior tumors showed a statistically significant lower mean score. For TNM stages, early-stage tumors (T1 and T2) showed a statistically significant higher mean score. In terms of treatment, patients who received surgery alone showed the statistically significant highest mean score (Table 9 and Fig. 20).

Table 5

Table 5

Table 6

Table 6

Table 7

Table 7

Table 8

Table 8

Fig. 14

Fig. 14

Fig. 15

Fig. 15

Fig. 16

Fig. 16

Fig. 17

Fig. 17

Fig. 18

Fig. 18

Fig. 19

Fig. 19

Fig. 20

Fig. 20

Table 9

Table 9

The overall QOL questionnaire showed that the highest mean score was found for saliva (84.7), followed by taste (84.5). The lowest mean score was found for chewing (53.8), followed by swallowing (74.2). The overall score was 75.9 (Table 10 and Fig. 21).

Table 10

Table 10

Fig. 21

Fig. 21

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Discussion

This study showed that 46.4% of the 192 oral cancer patients who were evaluated presented with a limited mouth opening less than 36 mm; this is similar to the result of Louise Kent et al. 46, who studied 40 head and neck cancer patients and identified trismus in 45%. Their results showed that the trismus group had greater QOL deficits. Normal mouth opening should be 46±7 mm. For this study, we chose a MIO less than 36 mm as trismus in analogy with O’Leary 65. Other trials have reported a wide range (6–86%) in the incidence of trismus in oral cancer patients 66,67. These wide differences appear to be related to varying definitions and measurements of trismus in other trials as well as tumor localizations. There was a statistically significant association between MIO and tumor site. Patients with tumors of posterior areas showed a statistically significantly higher prevalence of limited mouth opening (MIO<36 mm) than patients with tumors of the anterior area. In this study, 40.4% of patients with anteriorly located tumors showed limited mouth opening compared with 59.6% of patients with posteriorly located tumors; these differences were significant (P<0.001). This in agreement with Dijkstra et al. 45, who concluded that the location of the tumor affects the mouth opening and can be explained by the impact of surgical procedures on posterior tumors, which result in trismus, including maxillary surgery involving the origin of the medial and lateral pterygoid muscles from the pterygoid plates, or mandibulectomy procedures involving any of the muscles of mastication, including temporal muscle insertion into the coronoid process, masseter muscle insertion into the mandibular angle and ramus, and pterygoid insertions into the medial ramus and condylar neck as well as the field of radiation. Moreover, Villaret et al. 68 found that in advanced cancers of the retromolar trigone extending to the tonsillar region, resection of the pterygoid muscles always leads to heavy trismus that, in many cases, is irreversible and extremely incapacitating. There was a statistically significant association between MIO and tumor stages. Patients with late stages (T3 and T4) showed a statistically significantly higher prevalence of limited mouth opening (MIO<36 mm) than patients with early stages. This is similar to the result of Borggreven et al. 54 using the QOL questionnaire of head and neck (QLQH&N35), who found that patients with T3 and T4 tumors scored significantly worse on mouth opening (P=0.009) and reported feeling more ill (P=0.035) compared with patients with T2 tumors. As sequelae of an aggressive surgical intervention, fibrosis and scar contraction, in addition to contraction of the muscles of mastication, are the main reasons for the inability of the patient to open the mouth. Of course, adjuvant radiotherapy may lead to fibrotic changes that may exacerbate the magnitude of surgically induced trismus; this is clear from our results on the type of treatment; 39% of patients had received radiotherapy and 49% of patients had undergone surgery and radiotherapy.

The assessment of QOL is a complex issue involving the overall and specific evaluation of different dimensions (speech, pain, chewing, etc.) and covariates of age, sex, and clinical conditions. As both the outcome and the underlying variables involve multiple factors, alternative study designs could include multivariate assessments of QOL domains. However, we chose a less complicated analytical scheme and only estimated associations between unadjusted variables for the remaining factors modifying the QOL profile of patients. The UW-QOL has already been validated by studies comparing the results of its application with those obtained from other well-established questionnaires in the same field of study 69. Besides comparing favorably in its ability to effectively assess QOL, the UW-QOL was considered reliable, well accepted (by respondents), and practical for assessment of the functional status of patients with oral cancer. The use of an Arabic version of the UW-QOL enabled the identification of different patterns of HRQOL associated with the clinical characteristics of patients 69.

The nonstatistical significant difference between pain scores among different variables can be attributed to duration of time after treatment, which was not less than one year, as orofacial pain improved following treatment. This is in agreement with Cohen et al. 70, who found that after 12 months, only five (19%) patients still required regular medication for the pain, and reported a significant improvement in pain 12 months after treatment. In contrast, Fang et al. 71 found that pain at 2 years following surgery and radiation therapy was increased in 33% and remained unchanged in 36% of patients.

Early-stage tumors (T1 and T2) showed a statistically significantly higher mean score than late-stage tumors (T3 and T4). This is in agreement with Borggreven et al. 54, who found that patients with oral cavity tumors (vs. oropharyngeal tumors) and patients with T3–T4 tumors (vs. T2 tumors) had worse speech and oral function scores, which is in contrast to the results of earlier studies 72,73. Ablative surgery that involves the most anterior portion of the tongue is associated with significantly altered speech, whereas resections that incorporate the posterior tongue affect swallowing 38. Adjunctive radiotherapy further impairs speech and swallowing; this is also in agreement with the results of this study, in which patients who received radiotherapy and surgery and radiotherapy showed the statistically significant lowest mean score.

This study showed that difficulty in chewing was the most prevalent complaint of patients, which is in agreement with a previous study in which it was found that, among physiological functions, difficulty in chewing was the most prevalent complaint of patients with mouth neoplasms 52.

Early-stage tumors (T1 and T2) showed a statistically significantly higher mean score than late-stage tumors (T3 and T4). This in agreement with Borggreven et al. 54, who found that in terms of tumor stage, patients with T3–T4 tumors scored significantly worse on articulation mastication, swallowing, and trismus, all contributing toward limitations in food intake and compromising the nutritional status of patients.

Radiation therapy to the head and neck commonly impacts saliva production and taste receptor function, typically after 10–14 days of treatment, consistent with the taste receptor turnover. Following radiotherapy, taste may recover within several months of resolution of mucosal damage. However, change in taste may remain because of hyposalivation and receptor. Damage or taste disorders may occur following surgical procedures for oral cancer if surgery or administration of local anesthesia causes injuries to the nerves associated with taste. These may include the lingual branch of the glossopharyngeal nerve or the chorda tympani 74. Taste disorders are present in the majority oral cancer patients undergoing radiation therapy and chemotherapy 75. In the former group, taste complaints have been reported in 75–100% 76. Radiotherapy can lead to direct damage to taste receptors, synaptic, uncoupling, and other possible neurologic damage 60. Post-treatment recovery of taste is variable, in some studies improving in 2–6 months following cancer therapy, but may continue indefinitely 74. This study showed a statistically significant lower mean score for radiotherapy. Similarly, in one study, patients with head and neck cancer who had completed radiotherapy more than 6 months earlier reported dry mouth (92%) and change in taste (75%) as the most common symptoms 77. Another study found that physical functioning, taste/smell, dry mouth, and sticky saliva significantly altered up to 3 years following radiotherapy and added that long-term follow-up of oral cancer patients has shown taste disturbances persisting up to 7 years in those treated with radiotherapy 78.

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Conclusion

About half of the patients who underwent primary treatment for oral cancer developed trismus and reported problems with eating and speech. Patients at high risk of trismus were those with advanced stage; radiotherapy was a significant factor. Chewing was identified as the poorest rating domain and presented the highest proportion of complaints in the sample of this study. Oral cancer can significantly affect taste sensation and saliva, more commonly, because of the effects of cancer therapies. Anterior tumors showed a statistically significant lower mean score in the speech domain; however, posterior tumors showed a statistically significant lower mean score in the swallowing domain. Use of a QOL assessment as a standard procedure in hospital settings can contribute to anticipate the problems, and help emphasizing the interventions aimed at reducing the impact of therapeutic applications and improve subsequent patient life.

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Acknowledgements

Conflicts of interest

There are no conflicts of interest.

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