LARYNGEAL CANCER IN EGYPT: QUALITY OF LIFE MEASUREMENT WITH DIFFERENT TREATMENT MODALITIES

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1 ORIGINAL ARTICLE LARYNGEAL CANCER IN EGYPT: QUALITY OF LIFE MEASUREMENT WITH DIFFERENT TREATMENT MODALITIES Ossama A. Hamid, MD, 1 Lobna M. El Fiky, MD, 1 Medani M. Medani, MD, 1 Ayman AbdelHady, MBBCh, 2 Hanan H. Ali, MBBCh 3 1 Department of Otolaryngology, Ain Shams University, Cairo, Egypt. elfikylobna@hotmail.com 2 Department of Otolaryngology, Military Medical Academy, Cairo, Egypt 3 Department of Pathology, Cairo University, Cairo, Egypt Accepted 27 July 2010 Published online 27 October 2010 in Wiley Online Library (wileyonlinelibrary.com). DOI: /hed Abstract: Background. Quality of life (QOL) reflects the need to assess the patient s overall sense of well-being. A nonrandomized, prospective longitudinal study was conducted to evaluate QOL in Egyptian patients treated for laryngeal cancer. Methods. In all, 60 newly diagnosed patients with laryngeal cancer were divided into 3 groups: surgical resection, radiotherapy, and combined therapy. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaires (EORTC-QLQ) were administered to the patients at 4 points: prior to treatment, during active treatment, and at 3 and 6 months after completion of treatment. Results. All pretreatment scales were worse in the combined therapy group. The functional scales reached their lowest levels in all groups during active treatment. Radiotherapy group scales showed persistent slow recovery. There was striking prevalence of the financial difficulties score in all groups. Conclusion. QOL measurement provides information to guide clinical decision making in patients treated for laryngeal carcinoma. VC 2010 Wiley Periodicals, Inc. Head Neck 33: , 2011 Keywords: quality of life; EORTC; laryngeal cancer; total laryngectomy; radiotherapy The main outcome measure in oncology is traditionally expressed in terms of survival, progression and other disease minded variables. Although these parameters remain essential, there is a general recognition of the need to assess the impact of cancer and its treatment on patient s quality of life (QOL). 1 3 Quality of life measures seek to obtain a comprehensive, multidimensional picture of the patient s total health related experience. To achieve this goal, QOL measures evaluate broad domains including emotional, physical, functional, social, financial, and spiritual well-being. 4 Vartanian et al 2 stated that a high proportion of patients with head and neck cancer in Brazil belong to low socioeconomic classes and have difficulties in Correspondence to: L. M. El Fiky VC 2010 Wiley Periodicals, Inc. accessing the health care system, with most cases eventually diagnosed at advanced clinical stages. Low educational level and limited income status were reported as important factors associated with a low level of QOL in these patients. 5 The same socioeconomic problems are also found in Egypt, with most of our patients presenting with advanced stages, mainly resulting from the lack of proper health care. Different QOL instruments are being widely used and validated across different countries worldwide. Cancer-specific QOL instruments are responsive to all patients with cancer and to the change in their health status over time. Site-specific cancer instruments are designed to be most sensitive to the functional deficits peculiar to the affected organ. 6 Head and neck cancer modules allow specific assessment of a patient s ability to eat, swallow, and communicate, as well as other sequelae that are unique to this disease and its treatment. 7 The same questionnaires may not be sensitive to cultural and ethnical difference across different countries and civilizations. The objective of the present study was to assess QOL in patients receiving different treatment modalities for laryngeal cancer at a tertiary care hospital in Egypt. We assessed diverse domains of functioning, and changes over time, in an attempt to direct supportive treatment for such patients. In our study we used the European Organization for Research and Treatment of Cancer Quality of Life Questionnaires (EORTC-QLQ). EORTC QLQ-C30 core instrument is a widely used, validated multidimensional measure for cancer patients. This was combined with the head and neck module (QLQ-H&N35), which has demonstrated good reliability, validity, and responsiveness in studies of patients with head and neck cancer in Europe, the United States, India, as well as other countries. 1,8 10 PATIENTS AND METHODS Patients. In this nonrandomized prospective longitudinal study, 60 patients with newly diagnosed 1162 Laryngeal Cancer in Egypt HEAD & NECK DOI /hed August 2011

2 Table 1. Age and sex distribution among studied groups. No. of patients (%) by sex Study group Stage Age, mean (SD), y Male Female Combined therapy group, 20 patients Advanced stage (III and IV) 58.2 (4.9) 19 (95) 1 (5) Surgical group, 20 patients Early stage (I and II) 51.3 (9.2) 19 (95) 1 (5) Radiotherapy group, 20 patients Early stage (I and II) 54.7 (9.1) 18 (90) 2 (10) Control group, 20 patients Nonlaryngeal, Noncancer 49.1 (7.0) 19 (95) 1 (5) Significance F ¼ 3.9 ( ), p ¼ NS Chi-square ¼ 0.66 (3), p ¼ NS Abbreviation: NS, not significant. laryngeal cancer who presented to the otolaryngology department of Ain Shams University were included. All patients after endoscopic and pathologic confirmation of carcinoma, without knowledge of their stage or treatment decision and who agreed to participate in the study, were enrolled. A control group of 20 non cancer patients was evaluated as well (Table 1). The remaining patients were stratified in accord with their stage into 3 different treatment groups. Combined Therapy Group. This group included patients with stage III (n ¼ 7) or stage IV (n ¼ 13) laryngeal cancer, treated by surgery with planned postoperative radiotherapy. Total laryngectomy was done in all patients together with different forms of neck dissection (lateral neck dissection [n ¼ 16]; modified neck dissection [n ¼ 4]). They all received postoperative radiotherapy in the form of fractionated irradiation, 50 Gray (Gy)/25 treatments/5 weeks, and a booster of 10 Gy/5 treatments/1 week, to stoma and base of tongue. Surgical Group. This group included patients with stage I(n ¼ 18) and stage II (n ¼ 2) laryngeal cancer, treated by surgery only. Different types of laser cordectomy were done for all patients. Radiotherapy Group. This group included patients with stage I (n ¼ 4) and stage II (n ¼ 16) laryngeal cancer. The used dose fractionation schedule was 66 Gy for T1 lesions and 70 Gy for T2 lesions, given in 2 Gy fractions over 6 to 7 weeks, respectively. Control Group. This group was formed of 20 consecutive patients, matched for age and sex, who presented in the outpatient clinic, with no laryngeal complaints, or suspicion of malignancy in the head and neck. The decision to treat early cases with either surgery or radiotherapy in our department depends mainly on the advice of the surgeon in accord with the primary site of tumor as well as the preference of the patient. Upon written communication with EORTC we were granted permission to use both EORTC-C30 version 3.0 and the QLQ-H&N 35 module. 7,8 An already existing Arabic translation of QLQ-C30 version 3.0 was sent to us to be used, and we translated the QLQ-H&N 35 module using the EORTC instructions for translation. The core questionnaire QLQ-C30 version 3.0 includes 30 items comprising 6 functional scales (global health status scale; physical, role, emotional, cognitive, and social functioning), 3 symptom scales (fatigue, emesis, and pain), and 6 individual items (dyspnea, sleep, appetite, constipation, diarrhea, and financial impact). The core instrument was used in conjunction with the head and neck module QLQ- H&N35, a 35-item measure intended to assess symptoms specific to head and neck cancer. It yields 7 multiple-item scales (pain, swallowing, senses problems, speech problems, trouble with social eating, trouble with social contact, and sexuality), and 10 single items relating to problems with teeth, opening mouth, dry mouth, sticky saliva, coughing, feeling ill, pain killers, nutritional supplements, feeding tube, weight loss, and weight gain. All EORTC scales were scored and linearly transformed to 0- to 100-point scales. The functional scales were reversed scored, so that the higher scores represent better functioning. Higher scores on the symptom and individual item scales indicate greater difficulties. Procedures. The questionnaires were administered to patients by interview in the following phases of treatment: (1) prior to treatment once the patient was diagnosed as having laryngeal cancer; (2) while the patient was still in the hospital, 5 days postoperatively or after 3 weeks from start of radiotherapy; (3) after 3 months of completing treatment; (4) more than 6 months after completing treatment. Only patients who completed the 4 questionnaires were included in the study. The rate of dropout was similar in all groups (4 patients in each group). The dropout rate in the early stage (groups B and C) included cases lost to follow-up, whereas the dropout rate in the advanced stage (group A) was attributed to recurrence. The study was approved by the ethics committee of Ain Shams University hospitals. Written consent was taken from patients who agreed to participate in the study. The format and type of the questions and responses were first explained to them. The patients were interviewed by directly reading the questions Laryngeal Cancer in Egypt HEAD & NECK DOI /hed August

3 without change in the wording of the Arabic translation, avoiding any personal interference or suggestions. Analysis of data was done using statistical program for social science (SPSS version 10.0, SPSS, Inc., Chicago, IL) for Windows. Continuous variables were expressed as mean SD and range. Categorical variables were expressed as number and percentage. The different tests were used as follows: chi-square test to compare categorical variables, paired t test to compare parametric variables within the same group from baseline to specific follow-up assessment, Wilcoxon sign test to compare nonparametric data in the same group instead of paired t test, 1-way ANOVA test to compare between the different groups of the study with regard to parametric data, and Kruskal Wallis test was used instead of ANOVA test in nonparametric data. To detect any pretreatment difference between groups, chi-square was used for comparison of age, sex, smoking, and preexisting morbidity (hypertension, diabetes mellitus, etc.). There was no significant difference between any of the treatment groups and the control group (p >.05). Results were considered significant at. scores remained significantly worse than baseline in RF2 () and SF (). In the surgery group, scores remained significantly worse than baseline in QL2 () and PF (), whereas in the radiotherapy group scores remained significantly worse than baseline in QL2 (), PF (), RF (), EF (), and SF (). On the other hand, SF was significantly better than baseline for the surgery group (). There were no significant differences in functional scores between the treatment groups at the 3-month assessment, although the mean values were generally lower for the combined group relative to the other 2 groups. At the 6-month assessment there was a general trend toward continued improvement in the EORTC functional scales. In each of the 3 treatment groups, their scores had returned to roughly baseline values or better. For both the combined treatment group (p <.05) and the surgery group (), EF was significantly better at 6 months than at baseline. Compared with the other 2 treatment groups, the combined treatment group had significantly poorer scores in QL2 () and SF () at this point of evaluation. RESULTS The pretreatment scales of the patients in the control group were used for comparison with other groups because this was the first time a QOL questionnaire was used in laryngeal cancer patients in Egypt. Both surgical and radiotherapy groups had similar scores in most scales in the pretreatment as well as during treatment periods. Longitudinal Changes in the Global Health Status and Functional Scales of QLQ-C30. All pretreatment functional scales were lowest (worse) in the combined therapy group. The global health status scale (QL2; ), physical functioning scale (PF2, p <.001), and emotional functioning scale (EF, ) were each significantly lower compared with the control group. On the other hand, pretreatment scores were more favorable in the surgical and radiotherapy groups, with scores in the former group very close to those of the control group. The most affected functional scale in the surgery and radiotherapy groups was the social functioning scale (SF), but these scores did not differ significantly from those of the control group. treatment, patients in the 3 treatment groups experienced a significant deterioration from baseline in each of the EORTC functioning scales (Table 2). At the 3-month assessment, there was a general improvement in functional scales in each of the 3 treatment groups. However, there were areas of continued difficulty. In the combined treatment group, Longitudinal Changes in the Symptom Scales and the Individual Items of QLQ-C30. At pretreatment, compared with each of the other treatment groups, patients in the combined treatment group reported significantly worse fatigue (), pain (), insomnia (), and appetite (). On the other hand, these symptoms were the least affected in the surgical group throughout the study period (Table 3). treatment, all symptoms scales/individual items were significantly elevated in all groups compared with the pretreatment levels. An exception was the diarrhea score, which did not change in the combined treatment group. By 3 months after completion of treatment, there was notable improvement in EORTC symptom/individual scores. However, compared with baseline, the combined therapy group reported significantly worse constipation () and financial difficulties (p <.05), whereas the surgery group reported greater fatigue (), and the radiotherapy group reported significantly worse fatigue (), nausea (), pain (), and dyspnea (). On the other hand, insomnia had improved significantly relative to baseline in the combined treatment group () and financial concerns had become less pronounced than baseline in the surgery group (). At 6 months after treatment, the radiotherapy group showed persistent slow recovery in the symptom/individual items. Fatigue () and pain (p <.01) remained worse than baseline; however, constipation () and financial concerns () were significantly better. Compared with baseline scores, 1164 Laryngeal Cancer in Egypt HEAD & NECK DOI /hed August 2011

4 Table 2. Longitudinal changes in the functional scales of EORTC QLQ-C30 questionnaire, within-group. Combined therapy group, mean (SD) Surgical group, mean (SD) Radiotherapy group, mean (SD) Scale Score Pretreatment treatment 3 mo 6 mo Pretreatment treatment 3 mo 6 mo Pretreatment treatment 3 mo 6 mo 1 QL2 Global health status 2 PF2 Physical 53.4 (16) 27.7 (11) 79.4 (12) 42.3 (10.9) 3 RF2 Role 82.5 (15.6) 31.5 (9) 4 EF 5 CF Emotional Cognitive 64.0 (15.9) 34.9 (16) 92.5 (18.4) 73.3 (12.4) 6 SF Social 67.6 (19.8) 29.8 (19.9) 57.0 (18.8) 72.2 (12.1) 62.1 (16.1) 70.4 (13) 93.3 (10.2) 50.0 (16.5) 70.9 (10.2) 81.7 (8.7) (15.2) 80.9 (12.9) 97.5 (8.3) 61.8 (14.5) 82.4 (10.2) 41.1 (12.3) 89.4 (7.3) 45.9 (13.5) 88.4 (14.3) 34.1 (21) 82.6 (11.8) 40.1 (17.3) 95.8 (7.9) 72.9 (24) 80.9 (19.8) 49.1 (28) 71.8 (12.7) 78.0 (12.98) (6.3) 90.8 (9.7) 90.8 (9.8) (11.3) (8.3) 97.0 (6.3) 82.4 (18.2) 76.2 (5.9) 32.8 (8.9) 84.6 (4.6) 42.3 (13.9) 84.9 (11.8) 36.1 (11.2) 82.5 (8.9) 33.6 (13.3) 90.3 (13.1) 59.6 (16.9) 74.5 (18.9) 42.4 (20.6) 54.5 (7.4) 68.7 (5.9) 63.4 (12.8) 68.8 (8) 82.4 (12.3) 60.8 (17.3) 78.7 (6.8) 86.6 (5.8) 84.8 (9.2) 87.6 (8.4) 95.5 (10.6) 77.7 (18.8) Abbreviation: EORTC-QLQ-C30, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, 30 items. Note: High score represents better functioning. p values mentioned are the significant ones and refer to comparisons with baseline values. Control pretreatment, mean (SD) 87.6 (15.9) 91.0 (14.8) 91.6 (15.9) 89.2 (16.5) 97.4 (11.2) 90.7 (12.7)

5 Table 3. Longitudinal changes in the symptom scales and the individual items of EORTC QLQ-C30 questionnaire, within-group. Combined therapy group, mean (SD) Surgical group, mean (SD) Radiotherapy group, mean (SD) Scale Score Pretreatment treatment 3 mo 6 mo Pretreatment treatment 3 mo 6 mo Pretreatment treatment 3 mo 6 mo 1 FA 2 NV 3 PA 4 DY 5 SL 6 AP Fatigue Nausea Pain Dyspnea Insomnia Appetite 7 CO Constipation 8 DI 9 FI Diarrhea Financial 44.2 (19.5) 85.1 (9) 5.6 (11.4) 18.2 (10.6) (21) 44.9 (27) 78.4 (29) 63.4 (16) 88.4 (27) 50.0 (25) 85.3 (22) p < (19) 48.4 (25) 44.6 (15.9) 4.3 (7.6) 34.0 (14.8) 36.4 (18.5) 41.5 (18.6) 76.8 (14.1) 23.2 (21.9) 3.8 (14.9) (18.3) 80.0 (16.6) 95.0 (12) 91.7 (14.8) 35.2 (16.9) 5.8 (12.3) 20.1 (13.7) 18.2 (25.2) 39.8 (20.7) 26.4 (20.7) 13.3 (22.5) 6.7 (17.5) 65.2 (13.2) 23.2 (28) 67.5 (23.2) 7.6 (8) 31.5 (23) 12.5 (17.8) 73.3 (22.5) 24.1 (26) 76.0 (23.8) 33.3 (28) 76.8 (24.5) 25.0 (28) 71.8 (24.9) 19.9 (22.6) 56.7 (23.9) 3.4 (14.9) 11.7 (27) 53.4 (34.9) 74.3 (36) 34.6 (24.8) 10.5 (13.5) 16.8 (9.3) 14.9 (15.9) 25.7 (20.6) 19.9 (22.6) 14.9 (22.9) 6.6 (13.5) 43.3 (8.4) 26.3 (30) 6.9 (12.2) (10) 16.5 (16.9) 9.9 (14.6) 14.7 (22) 1.7 (7.4) 38.3 (31) 27.0 (25.6) 62.0 (27) 5.8 (10) 53.6(21) 8.4 (11.8) 62.5 (20) (17.4) 24.9 (21) 73.8(23.1) 23.2 (18.9) 78.5(19.5) 16.6 (22.9) 41.6(24) 11.6 (24.8) 3.4(14.9) 56.0 (29) 86.3 (33) 43.3 (13.8) 18.6 (16) 28.0 (14.2) 35.6 (14.7) 33.2 (21) 31.0 (22.9) 26.6 (25.6) 8.36 (18.3) 63.9 (33.7) 35.1 (26) 8.1 (8.8) 16.7 (11.9) (15.5) 1.7 (7.3) 37.0 (23.5) Abbreviation: EORTC-QLQ-C30, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, 30 items. Note: High score indicates greater difficulty. p values mentioned are the significant ones and refer to comparisons with baseline values. Control pretreatment, mean (SD) 16.7 (33.9) 1.4 (4.4) 6.7 (22.5) 1.7 (7.3) 18.2 (25.2) 9.9 (15.5) 4.9 (12) (30.4)

6 FIGURE 1. Affected items of European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Head and Neck module (QLQ-H&N35) 35-item questionnaire during treatment in all study groups. A high score indicates greater difficulty. the combined treatment group reported significantly better dyspnea (), appetite (), and financial concerns () at 6 months, and the surgery group reported better insomnia (), appetite (), constipation (), and financial worries (). problems and dry mouth occurred in this group after treatment. On the other hand, social eating, social contact, as well as speech scales at 6 months were relatively better than the surgical group, although there were no statistically significant differences between groups. treatment, both groups B and C had similar scores in most of the scales (Figures 1 and 2). Longitudinal Changes in Single and Multiple Items of QLQ-H&N35 Questionnaire. At pretreatment, the patients in the combined treatment group experienced significantly more problems with weight loss (p <.05), use of pain killers (), and speech (p <.001), compared with each of the other groups. This group retained the worst score during all stages of the study in swallowing, senses, speech, social eating, social contact, sexuality, and dental problems. On the other hand, the surgical group had the best scores during all stages of the study notably regarding pain, feeling ill, dry mouth, and sticky saliva. Long-term scores of this group at 6 months were also the best in swallowing, senses, dental problems, dry mouth, cough, and feeling ill. None of these group differences was statistically significant. The radiotherapy group had the best scores during treatment regarding speech, social contact, and social eating, with no significant difference. However, dental FIGURE 2. Affected items of QLQ-H&N35 questionnaire at 3 months follow-up in all study groups. A high score indicates greater difficulty. Laryngeal Cancer in Egypt HEAD & NECK DOI /hed August

7 DISCUSSION Laryngeal cancer is considered the most common head and neck cancer in Egypt because cigarette smoking, an indisputable risk factor, is on the rise in the community. We used the EORTC questionnaires to assess the effect of laryngeal cancer and its treatment on our patients. The control group score was compared with the scores of different laryngeal cancer groups at pretreatment. These scores became significantly worse during active treatment in each of the groups, relative to baseline. The similarity of most of the scores in the surgical and radiotherapy groups can be attributed to the similar stage of the disease in both groups. The financial impact (FI) score seemed worse during active treatment for patients who received radiotherapy (ie, those in the radiation group and the combined treatment group), compared with the surgery group, although this difference was not statistically significant. This is explained by the socioeconomic status of our patients in an underdeveloped society, in contradiction to the European countries or the United States. Cancer and its treatment are among the most frequent diseases associated with work losses, with advanced head and neck cancer affecting the patient s ability to communicate. 12,13 Smoking, poor nutrition, poverty, and illiteracy combine to produce poor health outcomes and poor QOL. The FI score was worse from the baseline, during active treatment for patients who received radiotherapy. In this situation, the patient is usually not hospitalized and is living in a remote area. This adds to the financial burden of transportation or accommodation for him/herself as well as for accompanying family members during the whole period of radiotherapy sessions. This was stated as hidden costs by Smith et al 13 and was found to be much higher in patients with early laryngeal cancer treated by radiotherapy when compared with surgical excision. 14 These hidden costs were least in the surgical group because they were actively resuming their work shortly. All patients in our study were not covered by social security, and with the economic downturn globally, this might have an impact on the choice of the primary treatment for the patients because the direct and hidden costs of treatment might therefore be higher after a prolonged time of bad QOL. In a tertiary care center, we receive patients from remote areas lacking the specialized care facilities, so they present with advanced stages. Patients in the surgical group had very close scores to the control group in the pretreatment period, which might indicate that early symptoms do not severely affect QOL of the patients. Some patients might skip medical advice until the disease is quite advanced; hence, the need for patient awareness and education. Health education about the role of smoking in developing laryngeal carcinoma needs to be emphasized. Training primary care doctors should focus on maintaining a high suspicion index for the early symptoms of laryngeal carcinoma. Standardized questionnaires of QOL can offer an easier way of communication with the patient. In our community, most of the patients are too scared to report emotional, mental, and physical problems. The various treatment options and alternatives are seldom discussed with the physician. Exploration of different domains of such a questionnaire can be used as a means of opening dialogue, as well as an educational tool for the patient. The global health score as well as the functional scales reached their lowest levels in all groups during active treatment. This reflects the short-term effects of different types of treatment. Higher stage and combination treatment have a more negative influence on QOL This underlines the need for maximum supportive care during the early treatment periods and especially in advanced stages. Support group programs must be created to provide the patient and family with the help they need to cope with problems of adaptation. Although the questionnaire was originally constructed to be self-administered, it was actually verbally administered to our patients because of the high rate of illiteracy. The questionnaire was well accepted by the patients, and the compliance was high when patients were repeatedly asked to answer the questionnaires. The differences in the results of QOL research in patients with head and neck cancer in the literature are probably related to the difference in the study methodology, patient case mix, social support, and cultural and ethnic beliefs. 7 In this study, we have included only cases of laryngeal cancer, making the patient population more homogeneous. In the same time, because this is the first evaluation in Egypt of QOL in patients with laryngeal cancer, comparison between different stages of the disease and different treatment modalities, was warranted. On the other hand, we have deliberately excluded patients with recurrence from our study, which might have created some kind of positive selection bias. The results of our study are therefore applicable only to recurrence-free survivors. The small number of patients in each group represents another limitation of the study, in that the statistical power was limited. In conclusion, standardized questionnaires measuring patients QOL offer a means of revealing unexpected treatment impacts and nonmedical problems facing our patients. QOL questionnaires are a practical, efficient, and cost-effective method of obtaining patient-based outcome data. 18 QOL measurement can provide information to guide clinical decision making, assess rehabilitation needs, understand patient preferences and policy making, and in patient education. The socioeconomic effects of the disease and its treatment need to be understood better because they possibly are more substantial in some countries. This 1168 Laryngeal Cancer in Egypt HEAD & NECK DOI /hed August 2011

8 can help physicians detect problems with significant impact on QOL that develop during treatment. 4 Acknowledgments. The authors gratefully acknowledge the European Organization for Research and Treatment of Cancer, Quality of Life group, for giving permission to use the QLQ by the user s agreement reference number 2735 for REFERENCES 1. Chaukar DA, Das AK, Deshpande MS, et al. 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&N35 in Indian patients. Indian J Cancer 2005;42: Vartanian JG, Carvalho AL, Yueh B, et al. Long-term quality-oflife evaluation after head and neck cancer treatment in a developing country. Arch Otolaryngol Head Neck Surg 2004; 130: Osoba D. Lessons learned from measuring health-related quality of life in oncology. J Clin Oncol 1994;12: Murphy BA, Ridner S, Wells N, Dietrich M. Quality of life research in head and neck cancer: a review of the current state of the science. Crit Rev Oncol Hematol 2007;62: Vartanian JG, Carvalho AL, Toyota J, Kowalski IG, Kowalski LP. Socioeconomic effects of and risk factors for disability in longterm survivors of head and neck cancer. Arch Otolaryngol Head Neck Surg 2006;132: Hanna E, Sherman A, Cash D, et al. Quality of life for patients following total laryngectomy vs chemoradiation for laryngeal preservation. Arch Otolaryngol Head Neck Surg 2004;130: Morton R. Studies in the quality of life of head and neck cancer patients: results of a 2 year longitudinal study and a comparative cross-sectional cross-cultural survey. Laryngoscope 2003; 113: Bjordal K, Hammerlid E, Ahlner-Elmqvist M, et al. Quality of life in head and neck cancer patients: validation of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-H&N35. J Clin Oncol 1999;17: Bjordal K, de Graeff, Fayers PM, Hammerlid E, et al. A 12 country field study of the EORTC QLQ-C30 (version 3.0) and the head and neck cancer specific module (EORTC QLQ-H&N35) in head and neck patients. Eur J Cancer 2000;36: Sherman A, Simonton S, Adams DC, Vural E, Owens B, Hanna E. Assessing quality of life in patients with head and neck cancer: cross validation of the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life head and neck module (QLQ-H&N35). Arch Otolaryngol Head Neck Surg 2000;126: Taylor JC, Terrell JE, Ronis DL, et al. Disability in patients with head and neck cancer. Arch Otolaryngol Head Neck Surg 2004;130: Terrell JE, Nanavati K, Esclamado RM, Bradford CR, Wolf GT. Health impact of head and neck cancer. Otolaryngol Head Neck Surg 1999;120: Smith J, Johnson J, Cognetti D, et al. Quality of life, functional outcome, and costs of early glottic cancer. Laryngoscope 2003; 113: De Graeff A, de Leeuw, Ros W, Hordijk GJ, Blijham GH, Winnubst J. Long term quality of life of patients with head and neck cancer. Laryngoscope 2000;110: List MA, Pinar Bilir S. Functional outcomes in head and neck cancer. Semin Radiat Oncol 2004;14: Hammerlid E, Bjordal K, Ahlner-Elmqvist M, et al. Prospective, longitudinal quality-of-life study of patients with head and neck cancer: a feasibility study including the EORTC QLQ-C30. Otolaryngol Head Neck Surg 1997;116: D Antonio LL, Zimmerman GJ, Cella DF, Long SA. Quality of life and functional status measures in patients with head and neck cancer. Arch Otolaryngol Head Neck Surg 1996;122: Laryngeal Cancer in Egypt HEAD & NECK DOI /hed August