Clinical and Psychosocial Factors associated with Quality of Life in Patients with Head and Neck Cancer: An Analytical Cross-Sectional Study from a Lower-Middle-Income Country

doi:10.21203/rs.3.rs-2458637/v1

Introduction

The disease course of head and neck (H&N) cancers can severely impair patients’ quality of life (QoL). In Pakistan, a South Asian lower-middle-income country (LMIC), psychosocial factors may be associated with QoL. Thus, we aimed to assess QoL and associated factors amongst patients with H&N cancers in Pakistan.

Methods

An analytical cross-sectional study was conducted amongst adult (≥ 18 years) patients with H&N cancer who were ≥ 4 weeks post-initiation of treatment. The survey assessed QoL (European Organization for Research and Treatment of Cancer Quality of Life Questionnaires), mental health outcomes (Hospital Anxiety and Depression Scale), and social support (Enriched Social Support Instrument). Multivariable linear regression was used for analysis.

Results

A total of 250 patients (mean age: 51.6 years) were included. The majority of patients were married (87%) and living with multigenerational/extended family households (53%). On multivariable linear regression, ongoing cancer treatment (beta coefficient: -13.93), having a tracheostomy (-10.02), and receiving adjuvant chemoradiotherapy (-8.17) were significantly associated with poorer global QoL. Additionally, poorer QoL was associated with depression (-24.37) and anxiety (-13.34). However, having more household family member was associated with better global QoL (0.34).

Conclusion

The QoL of patients with H&N cancer in Pakistan is affected by both the nature of cancer treatment as well as sociocultural factors such as household size. Given that poorer QoL is associated with poorer mental health outcomes, there is a need to develop and implement psychosocial interventions to improve QoL of patients with H&N cancer in Pakistan, particularly during active treatment.

: Quality of life

psychosocial factors

head and neck cancer

oncology

depression

anxiety

low and middle income country

Globally, over 900,000 new cases of head and neck (H&N) cancer are diagnosed every year (1), with males being disproportionately affected (2). Over 500,000 deaths attributable to H&N cancer annually (1), making it the seventh leading cause of global mortality (2). In Pakistan, a lower-middle-income country in South Asian, H&N cancers account for over 18% of newly diagnosed cancers, with most cases linked to consumption of tobacco, alcohol, and betel nut (3). H&N cancers are the second leading cause of cancer-related mortality in the country, after breast cancer (4). The clinical course of H&N cancer, including its management, causes great distress to patients. Both the disease and its treatment may lead to the loss of body parts, scarring, hair loss, disfigurement, and weight changes, which can affect a self-perceptions and body image (5). In addition, functional impairment can include problems in speech, swallowing, and social interactions (6, 7).

Quality of life (QoL) is a multidimensional construct involving the subjective perceptions of positive and negative aspects of cancer symptoms, physical, emotional, social, cognitive functions, the disease symptoms, and the side effects of treatment (8). In patients with H&N cancer, QoL especially important due to reduced physical and social functionality, as well as impairment of the senses of taste and smell (7). Reductions in QoL occur fairly early in the disease course of H&N cancer, and may be further lowered by treatment interventions such as surgery, chemotherapy, and radiotherapy (9, 10). Even survivors of H&N cancer suffer from lingering QoL impairments due to pain, physical disability, and fatigue (11). Thus, QoL is an important outcome measure in patients with cancer, as treatment rarely offers complete recovery and life expectancy may frequently be limited (9). While several tools exist for the measurement of QoL in H&N cancer, the European Organisation for Research and Treatment of Cancer (EORTC) QoL Questionnaire (QLQ30) and its H&N specific module (H&N35) are amongst the most widely used and extensively validated (12).

In Pakistan, the QoL of patients with H&N cancer has been a neglected field of study. Only a single study of 84 patients has been published, which used only the EORTC QLQ30 to report changes in QoL before and after treatment (13). Other factors associated with QoL amongst patients with H&N cancer remain to be explored. These include socioeconomic factors, which is particularly relevant in the context of a lower-middle-income country like Pakistan (14). In addition, mental health issues, particularly depression and anxiety, are also associated with poorer QoL (15). On the contrary, social support plays an important role in protecting QoL in patients with cancer (16). Pakistan’s social framework is different to West, where most of QoL-related literature originates, as it consists predominantly of joint family structures as opposed to the nuclear families seen in the West (17). Moreover, resilience, which is associated with better QoL, is also greater in patients with cancer in Pakistan, compared to their Western counterparts, due to unique social structures and perennial exposure to financial stressors (18-20). Differences in baseline economic and psychosocial characteristics of the population Pakistan invite research exploring novel associations of these factors with QoL outcomes. Thus, this study aimed to explore factors influence the QoL of patients with H&N cancer in Pakistan, with a particular focus on sociodemographic and psychosocial characteristics.

Study Design and Participants

An analytical cross-sectional survey-based study was conducted from November 2019 to May 2020 among adult (≥ 18 years) patients with head and neck (H&N) cancer at the Aga Khan University Hospital (AKUH), a premiere tertiary care hospital in Pakistan. Patients were included if they were currently ≥4 weeks post-initiation of treatment at AKUH, living in Pakistan since the past 3 months, and provided written informed consent for participation in the study.

We excluded patients with debilitating physical ailments, (stroke, renal failure) or psychiatric disorders, as these conditions would confound QoL outcomes. Patients with comorbids such as hypertension, cardiovascular diseases (CVD), diabetes mellitus or chronic obstructive pulmonary disease (COPD) were not excluded. The high prevalence of these comorbids in the Pakistani population (22) would lead to their use as exclusion criteria hindering sample size achievability. Therefore, these confounders were adjusted during analysis (23).

Survey Tool

The survey tool consisted of a structured questionnaire in Urdu, the national language of Pakistan. It included the following sections:

Patient Sociodemographic Characteristics: Patients’ age, gender, ethnicity, education, family status, comorbidities conditions (hypertension, diabetes, cardiovascular disease), history of addictions (including smoking, substance abuse), employment status of patient and family members and monthly household income. These are described in full in a prior study from the same patient cohort (34).
Patient Disease-related Characteristics: Data regarding clinical characteristics; type of tumor, surgery, chemotherapy and/or radiotherapy and site of tumor was also collected. These are described in full in a prior study from the same patient cohort (34).
Psychosocial Characteristics: Data regarding depression and anxiety was collected via the validated Urdu version of Hospital Anxiety and Depression Scale (HADS) which comprises of 14 items, equally subdivided into the anxiety and depression subscales with each item scored from 0 to 3 (30,31). An individual who scored between 8-10 was classified as mildly anxious and depressed, whereas one scoring ≥ 11 was classified as anxious and depressed. Data regarding social support (functional and emotional) was collected through the validated Urdu version of Enriched Social Support Instrument (ESSI) (32) with a CVI for relevance of 0.95, clarity of 0.97, and Cronbach’s alpha of 0.82 (33). It comprises of 7 items and an aggregate score of at most 18 was considered as low social support. Resilience was measured using the validated Urdu version of Wagnild and Young’s 14-item resilience scale (RS-14), where each item is rated on a 7-point Likert scale (strongly disagree to strongly agree) (21). The test–retest correlation coefficient of the Urdu version of the RS-14 is 0.49, its Cronbach’s alpha is 0.76, and its concurrent validity is 0.813 (22).
Quality of Life: QoL was measured using the Urdu versions of the EORTC QLQ-C30 and H&N35. The comprehensive validation of the Urdu versions of these tools has been described previously by the authors (23)(27). The EORTC QLQ-C30 is composed of 9 multi-item scales: 5 functioning scales (physical, role, cognitive, emotional and social), a global QOL scale, and 3 symptom scales (fatigue, pain and nausea/vomiting). In addition, several single item symptom measures are used (26). It has excellent validity, with a having a content validity index (CVI) 0.81 and 0.95 for clarity and relevance, respectively, and similarly high internal consistency (Cronbach’s alpha ranging from 0.74 to 0.86 for the various scales) (27).

The QLQ-H&N35 is a H&N cancer-specific module supplement which incorporates seven multiple-item scales that assess the symptoms of pain, swallowing ability, senses (taste/smell), speech, social eating, social contact, and sexuality. Also included are six single-item scales, which survey the presence of symptomatic problems associated with teeth, mouth-opening, dry mouth (xerostomia), sticky saliva, coughing, and feeling ill. A high score for a symptom scale represents the presence of a symptom or problem(s) (24).

Both the EORTC QLQ-C30 and QLQ-H&N35 scales employ a 4-point response format (‘‘not at all” to ‘‘very much”), with the exception of the global QoL scale, which has a 7-point response format. Scale scores are transformed to a scale from 0 to 100 according to the EORTC scoring algorithm (28). For the functioning and the global QoL scale, a higher score indicates better health. For the symptoms scales, a higher score indicates a higher level of symptom burden (26,29).

Prior to participant recruitment, the questionnaire was piloted on 5% of the sample size to identify any ambiguities. No major changes were deemed necessary after this pilot testing.

Sample Size and Sampling Strategy

The minimum sample size was calculated to be 250 based on mean QoL scores for head and neck cancer patients from previous studies (24,25). It was calculated using the one population mean formula, based on a standard deviation (SD) range of 16.5–40.8, 5% level of significance with precision of 2.5, and adding non-response of 10%.

Nonprobability purposive sampling technique was employed. Trained research assistants approached all patients with H&N cancer visiting the surgical/oncology clinics at AKUH as per their scheduled appointments. Potential participants were screened for eligibility. Eligible participants were briefed on the scope and nature of the study, as well as the extent of their participation. Patients who provided written informed consent for participation were enrolled in the study, and the study questionnaire was administered to them by the research assistants. The administration of the questionnaire took approximately 30-40 minutes.

Plan of analysis

The data was analyzed on STATA version 15. Continuous variables were reported as mean ± standard deviation (SD)/median (IQR), while categorical variables were reported as frequency and percentages. The dependent variable was the QoL. The independent variables were demographic variables (age, gender, monthly income, working status), schooling background, role in family, medical comorbidities (hypertension, diabetes mellitus, CVD), use of addictive substances (tobacco and alcohol), family history of cancer, tumor and treatment-related factors (type of tumor, type of surgical intervention, and adjuvant therapy), social support, depression and anxiety.

General Linear Model (GLM) multivariate analysis of variance (MANOVA) was used to determine the relationship between the independent variables and the dependent variables (QLQ-C30 and QLQ-H&N34 scales and subscales). Initially, a one-factor model was used to identify independent variable with a p < 0.20. These variables were then assessed on a multi-factor model.

Linear regression was also used to report unadjusted and adjusted beta coefficients with 95% confidence intervals (CI), to determine the factors associated independently with QoL. A p value < 0.20 on univariate regression was considered the cut-off for inclusion into the multivariable regression model. Throughout all analyses, p < 0.05 was considered significant.

Ethical considerations

The study was approved by the Ethical Review Committee of the Aga Khan University Hospital. Written informed consent was obtained from all the study participants. Patient information was kept confidential, and no personal identifier was disclosed. Participants identified as having mild-moderate depression or anxiety via the HADS were provided on-the-spot counseling by a trained psychologist. Patients identified as having severe depression or anxiety (or having suicidal thoughts) were referred for urgent psychiatric care.

Study Participants

The sample comprised of 250 patients with H&N cancer, with the commonest being oral cancer (82%). Their average age was 51.59 years, and most patients (79%) were male. The majority of patients had received a formal education (87%), with 11.25 years of education on average. Urdu was the mother tongue in half of the patients, though all were able to understand and speak Urdu fluently. The majority of patients (87.2%) were married. Just over half (53.6%) lived in extended families and 51.6% of the patients had 6 or more family members in their household. Additionally, 55% of patients were family heads or decision-makers within their households.

Almost two-thirds of patients were unemployed (64%) and 73% had spouses who were unemployed. The median monthly household income was PKR 45000 (range: PKR22650–100,000). Further details of patients’ socio-demographic characteristic, medical history, tumor and treatment related factors, social support and mental health are shown Tables 1, 2 and 3 of the previous publication by the authors based on analysis of the same sample (34).

Quality of Life in Patients with H&N Cancer

The mean global QoL score was 72.23. The mean scores of the QLQ-C30 functioning scales ranged from 88.53 (cognitive functioning) to 78.42 (physical functioning). In the QLQ-C30 symptom scales, pain had the highest score (61.53), followed by appetite loss (34.40), financial difficulty (33.73), and insomnia (30.80). The worst symptoms on the QLQ-H&N35 symptom scale were weight gain (73.20) and pain killers (70.00). These are detailed in Table 1.

Factors associated with QoL outcomes among head and neck cancer patients

A total of 16 variables included in the multifactor model GLM-MANOVA with EORTC QLQ-C30 scales as the dependent variables (Table 2). Variables significantly associated on the multifactor model were age, working status, household monthly income, use of smokeless tobacco, type of intervention, resilience, depression, anxiety and social support (all p < 0.05).

A total of 18 variables included in the multifactor model GLM-MANOVA with EORTC QLQ-H&N35 scales as the dependent variables (Table 2). Variables significantly associated on the multifactor model were age, working status, household monthly income, use of smokeless tobacco, type of intervention, resilience, depression, anxiety and social support (p < 0.05).

Linear Regression Analysis

On univariate linear regression with global QoL as the dependent variable, no formal schooling (beta Coefficient: -5.18), no household income (-10.32) or PKR 6000-25,000 (-11.77) or PKR 25000-40000 (-4.41) or PKR 40000-80000 (-5.74), hypertension (-4.41), ongoing cancer treatment (-13.32), use of feeding tube (-11.86), current use of a urine catheter (-22.85), low social support (-12.48), mild (-13.36) or symptomatic (-29.71) depression, and mild (-18.34) or symptomatic (-14.76) anxiety, were significantly associated with poorer global QoL. However, number of people in the household and resilience was associated with better QoL (Beta Coefficient 0.32 and 0.83 respectively) and were thus included in the multivariable model.

On multivariable linear regression (Table 3), ongoing cancer treatment (beta coefficient: -13.93), having a tracheostomy (-10.02), and adjuvant chemoradiotherapy (-8.17) were significantly associated with poorer global QoL. Additionally, symptomatic depression (-24.37) and mild anxiety (-13.34) were also associated with poorer QoL. However, having more household family member was associated with better global QoL (0.34).

The influence of sociodemographic and psychosocial characteristics on the QoL of patients with H&N cancer is poorly understood in the context of a lower-middle-income country like Pakistan. Our study, the first of its kind, used the EORTC QLQ-C30 and H&N35 to investigate factors associated with the QoL of patients with H&N cancer in Pakistan. Our results showed ongoing cancer treatment, presence of a tracheostomy, and receiving combination adjuvant therapy to be independently associated with poorer global QoL. Amongst psychosocial characteristics, depression and anxiety were associated with poorer QoL, whereas having more household family members were associated with better QoL.

The patients with H&N cancer in our study had better global QoL compared to cohorts in Spain (24), China (25), and India (26). The scores on the EORTC QLQ-C30 general symptom scales were also lower (more favorable) that those seen in the study from Spain (24), but comparable to studies from China (25), Korea (27), and Brazil (28). Although the multifaceted nature of QoL makes it hard to identify a single reason for the better global QoL seen in our study, it is possible that psychosocial differences in Pakistan may play a role. Firstly, given that our found that more household family members were associated with better QoL, the extended family structure common to Pakistan (17) may provide much needed day-to-day physical and emotional support to a patient navigating the demanding clinical course of H&N cancer (29). Interestingly, high social support as a whole did not demonstrate an independent protective effect for patients’ QoL in our study, suggesting that it is the closer-to-home, familial relationships that nurture QoL.

Though the lack of proper assessment of mental health conditions has been linked to poorer QoL in patients with H&N cancer (30), such assessment is far from being routine practice in Pakistan. However, while depression and anxiety were associated with poorer QoL in our study, the prevalence of these mental health conditions (< 15% of patients with any depression and < 6% of patients with any anxiety) was low. Previous studies employing the HADS in patients with H&N cancer have varying rates of anxiety (12-44%) and depression (10-58%) at varying timepoints during the clinical course of the disease and its treatment (31). Thus, our cohort demonstrated lower rates of anxiety and depression compared to most previously studied populations, with our results being most similar to a study from another South Asian lower-middle-income country, India (31). Once again, it is possible that these more favorable mental health conditions may be due to the unique extended family structures seen in South Asian countries such as Pakistan and India. Additionally, more than two-third of patients in our cohort were found to have moderate-high resilience, which is a known protective factor for both mental health, including anxiety and depression, amongst patients with cancer (32). Nevertheless, despite the relatively low rates of psychological comorbidity seen in our cohort, the routine assessment of mental health conditions should be prioritized in the management of patients with H&N cancer in Pakistan. Both anxiety and depression tend to worsen with time over the course of H&N cancer treatment (33), with consequent impairment of QoL (34).

The H&N cancer-specific symptoms, such as dry mouth, mouth opening, and loss of senses (taste, smell), were significantly worse in our study compared to those seen in studies from China (25), Brazil (28), and the US (35). This could possibly be explained by the fact that 80% of patients in our cohort had oral cancers, which cause more severe mouth-related symptomatology, compared to studies in Brazil (28) and the US (35) where cancers of the pharynx and larynx were relatively more common. Additionally, all patients in our study were already on treatment, unlike the study in the US (35) where the cohort included patients who were yet to begin treatment, which could help explain the greater losses of taste and smell in our study. This notion is supported by the findings of our study, which found ongoing cancer treatment, adjuvant chemoradiotherapy, and tracheostomy to be significantly and independently associated with lower QoL. Surgery with chemoradiotherapy is the most debilitating treatment for patients with H&N cancer (9), and is understandably associated with poorer QoL. In addition, tracheostomies, due especially to their impairment of speech and social communication, have previously also been shown to lower QoL (36, 37). The QoL in patients with H&N cancer decreases post-initiation of treatment, remains low during the course of therapy, and even for a short time after completion of treatment (38), emphasizing that this is a critical phase during which efforts should be made to protect QoL. It is only as late as three months post-completion of treatment that QoL begins to increase again (38). Thus, it seems that with regards to QoL of patients being treated for H&N cancer, things tend to get worse before they get better.

Our study has a few limitations that we would like to acknowledge. Firstly, due to the cross-sectional nature of the study, we were unable to investigate changes in QoL during the disease and management course of H&N cancer. In addition, we were not able to establish a temporal relationship between QoL and mental health outcomes. Additionally, our results are based off results from a single center in Pakistan. However, given that AKUH is the largest private tertiary care hospital in the megacity of Karachi and the patient mix consisted of diverse ethnicities and socioeconomic groups, our results may be reasonably generalizable to other centers in Pakistan.

This is the first study exploring clinical and psychosocial factors associated with QoL in patients with H&N cancer in Pakistan, a lower-middle-income country in South Asia. Having more household family members was protective of QoL, which is interesting given the unique extended family structures that is common to South Asian populations. However, QoL was significantly worse amongst patients currently undergoing treatment, particularly amongst those receiving adjuvant chemoradiotherapy and those needing a tracheostomy, and was associated with poorer mental health. These results emphasize the need for periodic QoL evaluations and the implementation of QoL-improving and psychological support interventions for patients during and after the clinical course of H&N cancer.

Funding: The study is funded by Aga Khan University Seed Money Fund (Grant Number PF98/0417).

Conflict of interest: No potential conflict of interest exists.

Availability of Data and Material: The data that support the findings of this study are available from the corresponding author upon reasonable request.

Authors Contribution: NZ conceived the study, analyzed data, and critically reviewed the manuscript. RSM and ZD drafted, revised, and critically reviewed the manuscript. IA contributed to data analysis. WZ, SSB, NA and KA overlooked the study and critically reviewed the manuscript. AH collected the data. AAJ, SA, MIS, MSA and MI were the subject experts. All authors have contributed intellectually to this manuscript, and have read and approved the final manuscript.

Acknowledgements: We would like to acknowledge the study participants, our research associates Barka Raj and secretarial support, Mr. Mirza Anas. We would also like to acknowledge the European Organization for Research and Treatment of Cancer for giving permission to use their (EORCT) QoL tool. We are also grateful to Wagnild for granting us permission to use the Wagnild and Young’s resilience scale.

Ethics Approval and Consent participate: The institutional review board of AKUH granted ethical approval for this study (Reference Number: 5154-Sur-ERC-17). All methods were carried out in accordance with relevant guidelines and regulations. Written informed consent was obtained from the study participants. However, participants who had non formal education or were illiterate informed consent was obtained from legal representative of the participants.

Consent for publication- Not applicable

Original Publication: This manuscript has not been submitted or is not under consideration for publication elsewhere. The protocol of the study is published in BMJ Open (doi:10.1136/bmjopen-2019-029084)

WHO. Global Cancer Observatory.
Perdomo S, Roa GM, Brennan P, Forman D, Sierra MSJCe. Head and neck cancer burden and preventive measures in Central and South America. 2016;44:S43-S52.
Azeem A, Ijaz H, Muhammad T, Muhammad S, Muhammad F, Muhammad A, et al. Prevalence and diagnostic of head and neck cancer in Pakistan. 2016.
Sarwar MR, Saqib A. Cancer prevalence, incidence and mortality rates in Pakistan in 2012. Cogent Medicine. 2017;4(1):1288773.
Henry M, Albert JG, Frenkiel S, Hier M, Zeitouni A, Kost K, et al. Body Image Concerns in Patients With Head and Neck Cancer: A Longitudinal Study. 2022;13.
de Araújo Gomes EPA, Aranha AMF, Borges AH, Volpato LERJJoD. Head and neck cancer patients’ quality of life: analysis of three instruments. 2020;21(1):31.
de Melo Filho MR, Rocha BA, de Oliveira Pires MB, Fonseca ES, de Freitas EM, Junior HM, et al. Quality of life of patients with head and neck cancer. 2013;79(1):82-8.
Zahid N, Khalid W, Ahmad K, Bhamani SS, Azam I, Asad N, et al. Resilience and quality of life (QoL) of head and neck cancer and brain tumour survivors in Pakistan: an analytical cross-sectional study protocol. 2019;9(9):e029084.
Sharma Y, Mishra G, Parikh V. Quality of Life in Head and Neck Cancer Patients. Indian journal of otolaryngology and head and neck surgery : official publication of the Association of Otolaryngologists of India. 2019;71(Suppl 1):927-32.
Żmijewska-Tomczak M, Milecki P, Olek-Hrab K, Hojan K, Golusiński W, Rucińska A, et al. Factors influencing quality of life in patients during radiotherapy for head and neck cancer. 2014;10(6):1153-9.
Ortiz-Comino L, Galiano-Castillo N, Postigo-Martín EP, González-Santos Á, López-Garzón M, Martín-Martín LM, et al., editors. Factors Influencing Quality of Life in Survivors of Head and Neck Cancer: A Preliminary Study. Seminars in Oncology Nursing; 2022: Elsevier.
Bjordal K, De Graeff A, Fayers P, Hammerlid E, van Pottelsberghe C, Curran D, 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. 2000;36(14):1796-807.
Majid A, Sayeed BZ, Khan M, Lakhani M, Saleem MM, Rajani H, et al. Assessment and improvement of quality of life in patients undergoing treatment for head and neck cancer. 2017;9(5).
Roick J, Danker H, Kersting A, Dietrich A, Dietz A, Papsdorf K, et al. The association of socioeconomic status with quality of life in cancer patients over a 6-month period using individual growth models. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer. 2019;27(9):3347-55.
Shiraz F, Rahtz E, Bhui K, Hutchison I, Korszun A. Quality of life, psychological wellbeing and treatment needs of trauma and head and neck cancer patients. The British journal of oral & maxillofacial surgery. 2014;52(6):513-7.
Helgeson VS. Social support and quality of life. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation. 2003;12 Suppl 1:25-31.
Lodhi FS, Rabbani U, Khan AA, Raza O, Holakouie-Naieni K, Yaseri M, et al. Factors associated with quality of life among joint and nuclear families: a population-based study. BMC public health. 2021;21(1):234.
Zahid N, Martins RS, Zahid W, Khalid W, Azam I, Bhamani SS, et al. Resilience and its associated factors in brain tumor patients in Karachi, Pakistan: An analytical cross-sectional study. Psycho-oncology. 2021;30(6):882-91.
Bhamani SS, Pasha O, Karmaliani R, Asad N, Azam IJJoNM. Validation of the Urdu version of Wagnild and Young’s long and short resilience scales among 20-to 40-year-old married women living in urban squatter settlements of Karachi, Pakistan. 2015;23(3):425-35.
Surzykiewicz J, Konaszewski K, Wagnild GJFip. Polish version of the resilience scale (RS-14): A validity and reliability study in three samples. 2019;9:2762.
Wagnild GM. The resilience scale user's guide: For the US English version of the Resilience Scale and the 14-item Resilience Scale (RS-14): Resilience center; 2011.
Bhamani SS, Pasha O, Karmaliani R, Asad N, Azam I. Validation of the Urdu Version of Wagnild and Young's Long and Short Resilience Scales Among 20- to 40-Year-Old Married Women Living in Urban Squatter Settlements of Karachi, Pakistan. Journal of nursing measurement. 2015;23(3):425-35.
Zahid N, Martins RS, Zahid W, Azam I, Ikram M, Hassan A, et al. Psychometric properties of the Urdu version of the EORTC QLQ-H&N35 (European organization for research and treatment of cancer head and neck module) quality of life tool. BMC psychology. 2022;10(1):194.
López-Jornet P, Camacho-Alonso F, López-Tortosa J, Tovar TP, Rodríguez-Gonzales MAJJoC-MS. Assessing quality of life in patients with head and neck cancer in Spain by means of EORTC QLQ-C30 and QLQ-H&N35. 2012;40(7):614-20.
Wan Leung S, Lee T-F, Chien C-Y, Chao P-J, Tsai W-L, Fang F-MJBc. Health-related quality of life in 640 head and neck cancer survivors after radiotherapy using EORTC QLQ-C30 and QLQ-H&N35 questionnaires. 2011;11(1):1-10.
Noronha V, Joshi A, Marfatia S, Patil V, Juvekar S, Arya S, et al. Health-related quality of life in patients with metastatic, relapsed, or inoperable squamous cell carcinoma of the head and neck in India. 2016;24(4):1595-602.
Yang CJ, Roh JL, Kim MJ, Lee SW, Kim SB, Choi SH, et al. Pretreatment quality of life as a prognostic factor for early survival and functional outcomes in patients with head and neck cancer. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation. 2016;25(1):165-74.
Melo Filho MR, Rocha BA, Pires MB, Fonseca ES, Freitas EM, Martelli Junior H, et al. Quality of life of patients with head and neck cancer. Brazilian journal of otorhinolaryngology. 2013;79(1):82-8.
Banovcinova L, Baskova M, editors. Role of the family, friends and significant others in providing social support and enhancing quality of life in cancer patients. SHS Web of Conferences; 2016: EDP Sciences.
Hammermüller C, Hinz A, Dietz A, Wichmann G, Pirlich M, Berger T, et al. Depression, anxiety, fatigue, and quality of life in a large sample of patients suffering from head and neck cancer in comparison with the general population. BMC cancer. 2021;21(1):94.
Joseph LA, Routledge JA, Burns MP, Swindell R, Sykes AJ, Slevin NJ, et al. Value of the Hospital Anxiety and Depression Scale in the follow up of head and neck cancer patients. The Journal of laryngology and otology. 2013;127(3):285-94.
Mungase M, Chaudhury S, Patil AA, Jagtap B, Jain V. Stress, anxiety, depression, and resilience in cancer patients on radiotherapy. Industrial psychiatry journal. 2021;30(2):346-52.
Nikoloudi M, Lymvaios I, Zygogianni A, Parpa E, Strikou DA, Tsilika E, et al. Quality of Life, Anxiety, and Depression in the Head-and-Neck Cancer Patients, Undergoing Intensity-Modulated Radiotherapy Treatment. Indian journal of palliative care. 2020;26(1):54-9.
Kroenke K, Theobald D, Wu J, Loza JK, Carpenter JS, Tu WJJop, et al. The association of depression and pain with health-related quality of life, disability, and health care use in cancer patients. 2010;40(3):327-41.
Sherman AC, 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). Archives of otolaryngology--head & neck surgery. 2000;126(4):459-67.
Terrell JE, Ronis DL, Fowler KE, Bradford CR, Chepeha DB, Prince ME, et al. Clinical predictors of quality of life in patients with head and neck cancer. Archives of otolaryngology--head & neck surgery. 2004;130(4):401-8.
Ting FIL, Hernandez ARB, Cereno REP, Orolfo-Real IB, Ngelangel CA. Filipino head and neck cancer patients and their quality of life. 2020. 2020;6(3):9 %J International Journal of Otorhinolaryngology and Head and Neck Surgery.
do Nascimento Santos Lima E, Ferreira IB, Lajolo PP, Paiva CE, de Paiva Maia YC, das Graças Pena G. Health-related quality of life became worse in short-term during treatment in head and neck cancer patients: a prospective study. Health and Quality of Life Outcomes. 2020;18(1):307.

Table 1 Quality of life (QoL) of patients with H&N cancer as measured by the EORCT QLQ-C30 and QLQ-H&N35
QLQ-C30 Component	Mean (SD)
Global QoL	72.23 (18.48)
Functional Scale
Physical Functioning	78.42 (20.83)
Role Functioning	81.00 (26.69)
Emotional Functioning	79.63 (20.60)
Cognitive Functioning	88.53 (17.94)
Social Functioning	80.20 (27.50)
Symptom Scales
Fatigue	13.93 (19.52)
Nausea	14.33 (16.80)
Pain	61.53 (27.31)
Dyspnea	10.40 (21.43)
Insomnia	30.80 (25.52)
Appetite Loss	34.40 (30.98)
Constipation	5.20 (17.82)
Diarrhea	17.60 (29.54)
Financial Difficulties	33.73 (39.07)
QLQ-H&N 35 Component	Mean (SD)
Symptom Scale
Pain	13.93 (19.53)
Swallowing	14.33 (16.80)
Senses	61.53 (27.31)
Speech	32.31 (33.71)
Trouble eating	30.76 (25.46)
Trouble contacting	14.88 (23.01)
Less sexuality	44.77 (37.07)
Teeth	20.80 (34.61)
Opening mouth	46.00 (38.68)
Dry Mouth	40.26 (34.31)
Sticky Saliva	20.53 (35.32)
Cough	24.80 (30.33)
Felt ill	25.86 (29.22)
Pain killers	70.00 (45.90)
Nutritional supplements	71.60 (45.18)
Feeding tube	49.60 (50.09)
Weight loss	55.60 (49.78)
Weight gain	73.20(44.38)

Table 2: Association of clinicodemographic variables with QLQ-C30 and QLQ-H&N35 using GLM-MANOVA GLM-MANOVA: General Linear Model Multivariate Analysis of Variance. * p value < 0.2 by one factor model of GLM-MANOVA ** p value < 0.05 by multifactor model of GLM-MANOVA
EORTC QLQ-C30
Variables	One factor Model Wilk λ (p value)	Multifactor Model Wilk λ (p value)
Age (in years)	0.768 *	0.835 (<0.001) **
Working status	0.805 *	0.796 (<0.001) **
Household Monthly Income (in PKR)	0.499 *	0.555 (<0.001) **
Hypertension	0.911 *	NS
Diabetes Mellitus	0.915 *	NS
Smokeless tobacco use	0.746 *	0.783 (0.004) **
Family history of cancer	0.916 *	NS
Types of tumor	0.798 *	NS
Treatment of cancer	0.786 *	NS
Types of Intervention	0.663 *	0.71 (0.002) **
Feeding tube	0.73 *	NS
Urine bag	0.841 *	NS
Resilience	0.627 *	0.824 (0.0001) **
Depression	0.459 *	0.65 (<0.001) **
Anxiety	0.649 *	0.721 (<0.001) **
Social support	0.854 *	0.892 (0.041) **
EORTC QLQ H&N 35
Variables	One factor Model Wilk λ (p value)	Multifactor Model Wilk λ (p value)
Age (years)	0.851 *	0.855 (0.0129) **
Gender	0.864 *	0.825(0.0018) **
Monthly household income (PKR)	0.555 *	0.599(0.003) **
Working status	0.831 *	0.732 (<0.001) **
Hypertension	0.886 *	NS
Diabetes Mellitus	0.885 *	NS
Smoking	0.772 *	NS
Smokeless tobacco use	0.759 *	NS
Family history of any other cancer	0.853 *	NS
Types of tumor	0.682 *	NS
Treatment of cancer	0.577 *	NS
Types of Intervention	0.577 *	NS
Adjuvant therapy	0.691 *	0.678 (0.006) **
Urine bag	0.891 *	NS
Resilience	0.562 *	0.739 (<0.001) **
Depression	0.739 *	0.578 (<0.001) **
Anxiety	0.482 *	NS
Social support	0.775 *	0.811(<0.001) **

Table 3

Univariate and multivariable linear regression with Global QoL as dependent variable

SE: standard error; CI: confidence interval; NS non-significant

* p < 0.20 on univariate analysis

** p < 0.05

Variables

Univariate Analysis

Multivariable Analysis

Beta Coefficient (SE) [95% CI]

Formal Schooling

Yes (Reference)

No

Reference

-5.18 (3.47) [-12.03, -1.65] *

NS

Number of people in the household

0.32 (0.15) [0.007, 0.632] *

0.34 (0.14) [0.06, 0.63] **

Monthly Family Income (PKR/USD)

No Income

6000-25000/ 38-151

25000-40000/151-242

40000-80000/242–484

80000-1500000/484-1028

- 10.32 (4.85) [-19.88, -0.76] *

-15.14 (3.06) [-21.17, -9.09] *

-4.41 (3.47) [-11.26, 2.44] *

-5.74 (3.03) [-11.72,0.24] *

Reference

NS

Hypertension

-4.41 (2.65) [-0.81, 9.64] *

NS

Status of Cancer Treatment

Complete (Reference)

Ongoing

Reference

-13.32 (2.19) [-17.65, -9.01] *

Reference

-13.93 (2.16) [-18.20, -9.66) **

Feeding Tube

No (reference)

Yes

Reference

-11.86 (2.24) [-16.27, -7.45] *

NS

Tracheostomy

No(reference)

Yes

Reference

-14.09 (4.30) [22.57, -5.61] *

-10.02(3.94) [2.24, 17.80] **

Using Urine Catheter

No (reference)

Yes

Reference

-22.85 (6.59) [-35.85, -9.87] *

NS

Adjuvant Therapy

No Adjuvant therapy

Chemotherapy

Radiotherapy

Combination

Reference

1.66(5.74) [-12.98, 9.64]

3.13(3.56) [-3.87, 10.14]

-5.39 (2.82) [ -10.96, 0.179]

Reference

-4.36(5.23) [-14.67, 5.94]

-2.54(3.30) [-9.05, 3.96]

-8.17(2.62) [-13.36, -2.99] **

Resilience

0.83 (0.10) [0.64, 1.03] *

NS

Social Support

≤ 18 (Low Social Support)

> 18 (High Social Support)

-12.48 (4.43) [-21.22, -3.74] *

Reference

NS

Depression

0-7 (Normal)

8-10 (Mild Depression)

11-21 (Symptomatic Depression)

Reference

-13.36 (4.43) [-21.22, -3.74] *

-29.71 (3.94) [-37.49, -21.97] *

Reference

-6.64 (4.22) [-14.96, 1.68]

-24.37 (2.48) [-32.42, -16.32] **

Anxiety

0-7 (Normal)

8-10 (Mild Anxiety)

11-21 (Symptomatic Anxiety)

Reference

-18.34 (6.93) [-31.98, -4.68] *

-14.76 (7.46) [-29.48, -0.05] *

Reference

-13.34 (5.88) [-24.92, -1.76] **

0.85 (6.93) [-12.80, 14.50]

No competing interests reported.

Clinical and Psychosocial Factors associated with Quality of Life in Patients with Head and Neck Cancer: An Analytical Cross-Sectional Study from a Lower-Middle-Income Country

Status:

Journal Publication

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Abstract

Introduction

Methods

Results

Discussion

Conclusion

Declarations

References

Tables

Additional Declarations

Status:

Journal Publication

Version 1