Patient reported outcomes in head and neck cancer: selecting instruments for quality of life integration in clinical protocols
- Augusta P Silveira†1, 2, 3Email author,
- Joaquim Gonçalves†4Email author,
- Teresa Sequeira†1, 5,
- Cláudia Ribeiro†6, 7,
- Carlos Lopes†8,
- Eurico Monteiro†9, 10 and
- Francisco L Pimentel†11
© Silveira et al; licensee BioMed Central Ltd. 2010
Received: 11 October 2010
Accepted: 31 October 2010
Published: 31 October 2010
Health Related Quality of Life has been used in medical research for more than twenty years, being progressively accepted during the last decade as an important patient reported outcome. Considering the multidimensional approach involved in Health Related Quality of Life assessment, instrument applicability and cultural adaptation must be tested for each population. In order to select the most appropriate instrument for Head and Neck cancer patients, two major Health Related Quality of Life specific questionnaires for Head and Neck cancer patients were compared. Conceptual differences, psychometric characteristics, scores, reliability, construct validity and sensitivity to symptomatology, tumour location, tumour size were analyzed.
102 consecutive Head and Neck cancer patients completed two different Health Related Quality of Life questionnaires: EORTC QLQ-C30 and its specific head and neck module QLQ-H&N35 and the Functional Assessment of Cancer Therapy Scales (FACT-H&N). Patients completed the questionnaires, immediately before consultation as a part of the routine evaluation.
A greater variability was always found in the EORTC QLC-C30 questionnaire's scores for all comparable domains. Both instruments revealed a good internal consistency and demonstrated to be good tools to distinguish symptomatic patients. The EORTC questionnaires still demonstrated sensitivity to distinguish T3 and T4 staging. Conceptual differences and the psychometric characteristics are discussed. Our results suggest that these two instruments assess different aspects of Health Related Quality of Life - the questionnaires should be used separately and chosen according to the study objectives and methodology.
This study emphases the importance in selecting the appropriate tool as a critical success factor in implementing routine Health Related Quality of Life assessment in clinical practice. This decision assumes particularly importance when utilization of results in real time and integration into clinical protocols are considered.
Health related Quality of Life Quality of life (HRQoL) is by definition a multi-dimensional global construct, introduced as keyword in the United States National Library of Medicine in 1977 [1, 2]. HRQoL, has been used in medical research for more than twenty years, and has been introduced in clinical practice as an important outcome parameter in present medicine practice according to the contemporary holistic approach to the patient [3, 4].
Over the past 10 years, HRQoL has been progressively more accepted as an important patient outcome result in oncology along with the other conventional outcomes used before such as treatment success, mean survival, disease free survival or cancer controlled survival [5, 6].
Importance of Health Related-Quality of Life assessment in head and neck cancer patients
Head and neck cancer is undoubtedly related to a decrease in HRQoL. After diagnosis, the treatment most frequently determines a deterioration of basic functions such as breathing, mastication, salivating, swallowing and speaking. Sense's impairment such as hearing, taste and smell along with possible esthetics changes will promote a negative impact in both patients and their relatives HRQoL [1, 4, 7].
HRQoL assessment allows head and neck cancer patients careful monitoring, may recognize risk patient groups being predictive for time to progression suggesting this evaluation as a new prognostic marker for survival [8–10]. HRQoL questionnaires enable patient's clustering according to their most frequent health concerns, ranking its intensity [1, 11]. Also, HRQoL assessment can be considered a stimulating approach for effectiveness and the cost-effectiveness promotion (survival and quality-adjusted survival) contributing thus to the construction of an economical decision model [12–14].
Instruments for HRQoL assessment in head and neck cancer patients
HRQoL instruments must exhibit comproved psychometric characteristics, such as: consistency, reliability, reproducibility, validity and sensibility to change.
Considering the multidimensional approach involved in the HRQoL assessment, instrument applicability and cultural adaptation must be tested for each population.
The instruments that fulfill the minimal requisites for Oncology HRQoL assessment include: Breast Cancer Chemotherapy Questionnaire (BCQ), Cancer Rehabilitation Evaluation Systems (CARES), European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ), Functional Assessment of Cancer Therapy Scales (FACT), Functional Living Index Scale (FLIC), Linear Analogue Self-Assessment, Medical Outcome Study Short Form (MOS SF-36), Multidimensional Quality of Life Scale, Quality of Life Index (QL- Index) (Spitzer Index), Rotterdam Symptom Check List (RSCL) [5, 15, 16]. The questionnaires EORTC-QLQ C30, FACT-G, MOS SF-36 and FLIC stand out as the main general in oncology.
There are specific instruments for head and neck cancer patients HRQoL evaluation such as: the EORTC QLQ-H&N35, the FACT H&N, the FLIC, the University of Washington Quality of Life Questionnaire (UW-QOL), the University of Michigan Head and Neck Quality of Life Questionnaire (HNQOL), the Head and Neck Radiotherapy Questionnaire (HNRQ), the Performance Status Scale-Head and Neck-(PSS-H&N), the Obturator Functioning Scale (OFS), the Late Side Effects on Daily Life Scale and the Oral and Pharyngeal Nursing Care Questionnaire (OPNCQ) [17–23].
Clinical trials and clinical practice
HRQoL has been used as a health outcome measure mainly associated to clinical trials. The implementation of routine HRQoL assessment in clinical practice can be used for scientific documentation as well for clinical settings [24–26]. This advance is fundamental to obtain clinical meaningful data that can be a helpful outcome considering patients undergoing cancer treatments and, particularly, when additional supportive services and symptom management are concerned. Moreover, the careful HRQoL monitoring of cancer patients may identify potentially unmet needs and generate the basis of a stepped care model [26–28]. HRQoL information can thus support clinical decisions and promote health gains. However, results obtained either from clinical practice or research must be interpreted, not only in statistical terms, but also considering the clinical importance - it is required then an wide comprehension of the relationship between the patients outcome results and the patients perception of the change [29, 30].
The present study aims to compare the two major HRQoL questionnaires specific for head and neck cancer patients: the EORTC QLQ-C30 and its specific head and neck module QLQ-H&N35 and the Functional Assessment of Cancer Therapy Scales (FACT H&N) in the Portuguese Institute for Oncology, Porto (IPO-Porto). Conceptual differences, psychometric characteristics and scores are analyzed and discussed. A major attention is made on significant differences that can be related to clinical important data.
From September 2008 to January 2010, 102 outpatients admitted to the Otorhinolaringology service (ORL service) IPO-Porto, Portugal, completed two different HRQoL questionnaires, immediately before consultation as a part of the routine evaluation. The completion order was randomized. Inclusion criteria were a Karnofsky index above 30, age below 90 years, ability to understand written and spoken Portuguese and provision of written consent.
The questionnaires under comparison were from the European Organisation for Research and Treatment of Cancer (EORTC) and the Functional Assessment of Cancer Therapy (FACT), both targeted to cancer patients. HRQoL was assessed by general questionnaires, EORTC QLQ-C30 and Functional Assessment of Cancer Therapy - General (FACT-G), and its disease-specific modules for head and neck (FACT H&N) cancer patients was also considered, the QLQ-H&N35 and the FACT H&N, respectively. Scores and conceptual characteristics were compared: between the two core questionnaires - EORTC-QLQC30/FACT-G - and between their disease-specific modules/extensions for H&N patients - QLQ-H&N35/FACT H&N (FACT-G + 12 H&N-specific questions), respectively.
EORTC QLQ-C30 and the disease-specific module QLQ-H&N35
The EORTC QLQ-C30 (version 3.0) is a questionnaire developed to assess the HRQoL of cancer patients. It consists of 30 questions: twenty four form nine multi-item scales presenting various aspects of HRQoL: five functional scales (PF, Physical functioning; SF, Social functioning; EF, Emotional functioning; RF, Role functioning; CF, Cognitive functioning), three symptom scales (fatigue, pain, nausea and vomiting) and a global condition (health and quality of life). The remaining six are single-item scales describing different cancer relevant symptoms. During the scoring procedure, raw EORTC QLQ-C30 scores are linearly transformed into 0 e100 scales. For global health status and the five functioning scales, a score of 100 corresponds to a high HRQoL. For financial difficulties and the eight symptoms, a score of 100 implies maximum difficulty or symptom burden. The additional module - QLQ-H&N35 (version 3.0) - is disease-specific for head and neck patients. It consists of 35 questions organized in seven symptoms multi-item scales (twenty four questions are presented) and eleven are single-item scales describing different specific concerns of these head and neck cancer patients.
FACT-G and the disease-specific FACT H&N
The FACT H&N (version 4) is a multidimensional, self-report HRQoL instrument specifically designed for use with head and neck cancer patients. It consists of 27 core items - FACT-G - assessing patient function in four domains: Physical, Social/Family, Emotional, and Functional well-being (Pwb, Swb, Ewb, and Fwb, respectively). It is further supplemented by 12 site specific items for head and neck related symptoms assessment - FACT - (H&N-G). Each item is rated on a 0 to 4 Likert type scale, and then combined to produce subscale scores for each domain, as well as a global HRQoL score. Higher scores represent better QoL.
The autonomy expressed for questionnaire completion as well the time patient needed to complete both questionnaires - EORTC QLQ-C30 (version 3)/QLQ H&N35 and FACT H&N - was evaluated.
Sociodemographic and clinical data
Clinical data - such as tumour location, performance status (Karnofsky index), tobacco habits and present symptomatology - as well socio-demographic data - age, gender and schooling years - were collected from the patient's clinical process and complemented, when needed, in semi structured interviews.
All patients gave their informed consent. The data were collected for research purposes as part of the routine evaluation. The Committee for Ethics in Medical Research approved the use of these data for research.
Analysis Strategies and Statistics
Completed questionnaires were scored according to the developers' instructions.
For tool comparison, 4 similar domains were always considered in EORTC QLQ-C30 and FACT-G, respectively: PF/Pwb, EF/Ewb, SF/Swb and RF/Fwb.
Descriptive data are presented with means, SDs, medians, ranges, and proportions as appropriate.
Instrument's scores characteristics
In probability theory and statistics, skewness is a measure of the asymmetry of the probability distribution of a real-valued random variable. Qualitatively, a negative skew indicates that the tail on the left side of probability density function is longer than the right side and the bulk of the values (including the median) lie to the right of the mean. A positive skew indicates that the tail on the right side is longer than the left side and the bulk of the values lie to the left of the mean. Kurtosis is a measure of the "peakedness" of the probability distribution of a real-valued random variable. Higher kurtosis means more of the variance is the result of infrequent extreme deviations, as opposed to frequent modestly sized deviations.
Reliability expressed as internal consistency is a measure of how well the items in a multi-item scale interrelate. This is usually assessed by computing Cronbach's coefficient (Cronbach's alpha). The score reflects both the number of items and the degree of correlation between items.
Sensitivity measures how well the instrument identifies differences between groups. An instrument with a high sensitivity is able to detect a relatively small difference with a modest sample size. Sensitivity is measured by comparing the scores of different groups of patients. In this study the patient population was divided: i) in two groups according to the expressed symptomatology (symptomatic and asymptomatic) ii) into five broad groups according tumour location (vocal cord neoformation, laryngeal neoformation, pharynx neoformation, pharynxlaryngeal neoformation, and tongue neoplasia), iii) into four broad groups according tumour size (T1, T2 T3 and T4) and iv) into four broad groups according age (less than 45 year old, 46-55 years old, 56-65 years old and older than 65). The scores were compared using the Mann-Whitney or Kruskal-Wallis tests. Based on clinical experience, significant differences between these patient groups were expected.
Construct validation evaluates how well an instrument measures the construct it is intended to measure. Convergence between instruments (external convergent validity) is an assessment of the correlation between EORTC and FACT measures of the same concept. This is included in the multi-trait multi-method (MTMM) analysis where Pearson's correlations are used to compute the degree of correlation. A correlation above 0.70 between scales measuring the same concept is considered to be an indication of the same underlying concept. Discriminant validity was analysed to verify if the HRQoL operationalization does not correlate with other operationalizations that theoretically should not be correlated with.
Sociodemographic and clinical characteristics of the participants (n = 102)
Displasic premalignant lesions
Patients presented 59.4 ± 12.1 years and revealed a low educational level presenting 5 ± 3 schooling years and long tobacco habits being the majority (60.6%) exposed for more than 31 years.
The Karnofsky performance status scale revealed that all patients performed above 50% and 57% of head and neck cancer patients were mainly ascribed to high Karnofsky Index (90-100%).
The time response varied between 3 and 20 minutes (9,3 ± 3,1) for EORTC QLQ-C30 (version 3)/QLQ H&N35 and 3 to 23 minutes (7,3 ± 2,7) for FACT-H&N. Most head and neck cancer patients (79,4%) required some kind of help to answer the questionnaires.
Questionnaire's conceptual characteristics
Relevant instrument's characteristics.
No. of items
Instrument's scores characteristics
EORTC QLQ-C30 and FACT -G characteristics: mean scores, standard deviation, skweness and kurtosis measurements and Cronbach's Alpha
Global Health Status
Concerning SF and Swb, the most evident difference was the extent of the flattening where FACT-G showed a leptokurtic distribution (-0.67) and EORTC QLQ- C30 a platikurtic one (-0.84). The EF and Ewb domain presented similar measurement's distribution and may be considered as normal; RF and Fwb revealed a similar distribution in shape. The Cognitive domain exhibited a distribution very skewed to the right (-1.78).
EORTC H&N35 and FACT - (H&N-G) characteristics: mean scores, standard deviation, skweness and kurtosis measurement, and Cronbach's Alpha.
Trouble with social eating
Trouble with social contact
When internal consistency was compared by measuring how well the items interrelate, EORTC demonstrated a higher total consistency, both in the core questionnaire EORTC QLQ-C30 (α = 0.87 versus 0.76 for FACT-G) as well in the disease specific module H&N35 (α = 0.90 versus 0.79 for FACT - (H&N-G)). Most values observed (Table 3, 4) were above 0.7 although the EF scale was found below in both questionnaires, EORTC QLQ-C30 and FACT-G (α = 0.46 and 0.69, respectively). Cognitive functioning scale revealed a low reliability (0.27).
The disease-specific module H&N35 revealed an internal consistency in all scales (α = 0.72 to 0.99) except in Speech problems (α = 0.46).
Patient symptoms Sensitivity
Scores of the four corresponding HRQoL scales of EORTC QLQ-C30 and FACT-G for the two group of patients: symptomatic and asymptomatic
EORTC and FACTG scores
62% (n = 53)
38% (n = 32)
Disease specific module EORTC QLQ-H&N35 was also able to discriminate in all scales except Senses problems nor three simple item questions considering Dry mouth, Weight loss and Weight loss. FACT - (H&N-G) was found to be sensitive when total score was considered and statistical significant differences were found in 5 single items (questions 1, 5, 7, 10 and 11).
Tumour location sensitivity
EORTC QLQ-C30 revealed no sensitivity to tumour location being Fatigue in the discrimination boundary for Vocal cord neoformation (p = 0.05). The Pwb in FACT-G is sensitive to Vocal cord neoformation location (p = 0.008) presenting higer HRQoL score.
Scores of the corresponding HRQoL scales of EORTC QLQ-C30 and FACT-G for the five group of patients according to their tumour location
EORTC and FACTG scores
Kruskal-Wallis (p value)
(n = 18)
(n = 17)
(n = 13)
(n = 6)
(n = 5)
Tumour size sensitivity
Patients with different tumour size are not depicted by the FACT-G assessment and EORTC QLC-C30 is only able to discriminate T3 and T4 when SF or the 2 simple items Diarrhea and Financial difficulties are considered.
Scores of the corresponding HRQoL scales of EORTC QLQ-C30 and FACT-G for the four group of patients according to their tumour size
EORTC and FACTG scores
(n = 11)
(n = 13)
(n = 18)
(n = 32)
Internal convergent validity
The EORTC QLQ C-30's revealed two correlations, between scales PF - RF (0.79) and RF - SF (0.72), whereas only one was found in FACT-G - between Fwb and Pwb scales (0.70).
External convergent validity
MTMM Correlation Matrix
A convergence between instruments was found for PF and Pwb scales (0.80), PF and Fwb scales (0.71), SF and Pwb scales (0.70), PF and Fwb scales (0.71).
Both Physical and Role functions depicted in EORTC assessment revealed to correlate with either FACT-G Physical and Functional well-being (0.80 for Pwb, 0.71 for Fwb and 0.75 for Pwb, 0.70 for Fwb, respectively). Thus, for these two functional dimensions the two questionnaires seem to assess in a similar way. In opposition the Social and Emotional scales were found to evaluate the same issues but in a different way - Social function revealed a correlation with the Physical well-being (0.70) and no correlation were found for the Emotion function.
Head and neck cancer affects mainly men (ratio male : female ranges between 2 - 5:1, depending on tumour location), contributing to 4% of deaths among males in Portugal and represents the fifth cause of death with cancer in men [31, 32]. In the present study it was found that 86.3% of cancer patients were men, long time smokers with low literacy. The most frequent tumour locations identified is in agreement with literature identifying the larynx as the most common site for head and neck cancer, being squamous cell carcinoma the preferential histopathology diagnostic[33–35].
Most cancer patients (54%) were in a symptomatic phase although a high Karnofsky Index (90-100%) was reported. These data emphases that the viewer's perception is different from the patient self-perception obtained by HRQoL assessment [36, 37].
The instrument's characteristics analysis revealed that syntax is different between questionnaires: EORTC proposes a mixed order of questions and FACT-G chooses preferably statements organized into modules. The content of the EORTC questionnaires focuses on the everyday situations observing mainly physical and symptoms, and the FACT-G explores the existential problems and personal satisfaction. The EORTC version used head not a total score as FACT-G but presented a richer specific questionnaire for head and neck cancer patients.
Although the EORTC questionnaires- QLQ C30 and H&N 35- were administered separately and FACT H&N just once (it includes the core questionnaire plus the H&N specific module), more unanswered items (missing data) were obtained with FACT-H&N being the sexuality items the lesser answered. The fact that FACT-H&N considers these items answer optional, may encourage patients to not answer such questions and justify these results, which are consistent with other studies reporting a large proportion of missing data when considering the Sexuality item [38, 39]. Asymmetry and flatness measures do not differentiate the questionnaires although EORTC QLQ-C30 flattening measure revealed to be closer to a normal distribution.
The higher variability found in EORTC QLQ- C30 functional scales and the leptokurtic distribution of Swb dimension in FACT-G suggest that when answering FACT-G questionnaire, patients tend to respond in the core values, reducing thus the effect of the measure.
Although both instruments showed good internal consistency it was found to be higher in the EORTC questionnaires. Low reliability in Cognitive Function scale from EORTC QLQ- C30 and FACT-(H&N-G) may be explained by the conceptual characteristics of these instruments. Both are good tools to distinguish symptomatic patients, however, both questionnaires show similar inefficiency differentiates tumour location. The EORTC questionnaires also revealed sensitivity to distinguish the two staging T3 and T4.
Just like other authors, it was found that administration of both questionnaires proved to be feasible, with acceptable response times. The easy, acceptable and understandable questionnaires format may facilitate its potential inclusion in routine clinical protocols [38–40].
The data demonstrate that the EORTC QLQ-C30 (version 3) and EORTC QLQ-H& N35 and FACT H&N (Version 4) are good tools for HRQoL assessment in head and neck cancer patients, although the psychometric characteristics - fidelity, validity and sensitivity - are different.
Thus, our results suggest that these two instruments assess different aspects of QoL. The EORTC QLQ-C30 questionnaire provides a vision focused on physical and symptoms aspects, while the FACT H&N gives a multidimensional view of the concept, a broader perspective and comprehensive description of different areas. These results agree in general with other HRQoL instruments comparative studies and demonstrate that a tool does not replace the other and direct result comparison was not possible. The questionnaires should be used separately and chosen according to the study objectives and methodology.
This study emphases the importance in selecting the appropriate tool as a critical success factor in implementing routine Health Related Quality of Life assessment in clinical practice. This decision assumes particularly importance when utilization of results in real time and integration into clinical protocols is considered.
We acknowledge to all patients who have voluntarily collaborated in the study and health professionals from the Oncology Portuguese Institute (IPO-Porto), ORL Service for their generous support. We also acknowledge the The Centre of Health Studies and Research of the University of Coimbra.
- Torres-Carranza E, Infante-Cossío P, Hernández-Guisado JM, Hens-Aumente E, Gutierrez-Pérez JL: Assessment of quality of life in oral cancer. Med Oral Patol Oral Cir Bucal. 2008, 13 (11): E735-41.PubMedGoogle Scholar
- Kruse AL, Bredell M, Luebbers HT, Gratz KW: Head and Neck Cancer in the Elderly: A Retrospective Study over 10 Years (1999 - 2008). Head & Neck Oncology. 2010, 2: 2-View ArticleGoogle Scholar
- Koller M, Lorenz W: Quality of life: a deconstruction for clinicians. J R Soc Med. 2002, 95: 481-488. 10.1258/jrsm.95.10.481.PubMed CentralView ArticlePubMedGoogle Scholar
- Wierzbicka M, Kuśnierkiewicz M, Wójtowicz JG, Maune S, Szyfter W: The quality of life in head and neck cancer patients: description of randomized examination formula based on standardized questionnaires EORTC QLQ C-30, EORTC QTQ-H-N35 and Kiel Questionnaire. Otolaryngol Pol. 2001, 55: 287-92.PubMedGoogle Scholar
- Rogers SN, Ahad SA, Murphy AP: A structured review and theme analysis of papers published on 'quality of life' in head and neck cancer: 2000-2005. Oral Oncol. 2007, 43: 843-68. 10.1016/j.oraloncology.2007.02.006.View ArticlePubMedGoogle Scholar
- Fayers PM, Aaronson NK, Bjordal K, Groenvold M, Curran DA, Bottomley A: On behalf of the EORTC Quality o Life Group. EORTC QLQ-C30 Scoring Manual. Guidelines for assessing Quality of Life in EORTC Clinical Trials. 2001, Brussels, EORTC, 3Google Scholar
- Terrell JE, Ronis DL, Fowler KE, Bradford CR, Chepeha DB, Prince ME, Teknos TN, Wolf GT, Duffy SA: Clinical predictors of quality of life in patients with head and neck cancer. Arch Otolaryngol Head Neck Surgery. 2004, 130: 401-408. 10.1001/archotol.130.4.401.View ArticleGoogle Scholar
- Karvonen-Gutierrez CA, Ronis DL, Fowler KE, Terrell JE, Gruber SB, Duffy SA: Quality of life scores predict survival among patients with head and neck cancer. J Clin Oncol. 2008, 26: 2754-60. 10.1200/JCO.2007.12.9510.View ArticlePubMedGoogle Scholar
- Yeo W, Mo FK, Koh J, Chan AT, Leung T, Hui P, Chan L, Tang A, Lee JJ, Mok TS, Lai PB, Johnson PJ, Zee B: Quality of life is predictive of survival in patients with unresectable hepatocellular carcinoma. Ann Oncol. 2006, 1083-1089. 10.1093/annonc/mdl065.Google Scholar
- Luoma ML, Hakamies-Blomqvist L, Sjöström J, Pluzanska A, Ottoson S, Mouridsen H, Bengtsson NO, Bergh J, Malmström P, Valvere V, Tennvall L, Blomqvist C: Prognostic value of quality of life scores for time to progression (TTP) and overall survival time (OS) in advanced breast cancer. Eur J Cancer. 2003, 39: 1370-1376. 10.1016/S0959-8049(02)00775-X.View ArticlePubMedGoogle Scholar
- Mehanna HM, Morton RP: Patients' views on the utility of quality of life questionnaires in head and neck cancer: a randomised trial. Clin Otolaryngol. 2006, 31: 310-316. 10.1111/j.1749-4486.2006.01256.x.View ArticlePubMedGoogle Scholar
- Meeuwsen EJ, German P, Melis RJ, Adang EM, Golüke-Willemse GA, Krabbe PF, de Leest BJ, van Raak FH, Schölzel-Dorenbos CJ, Visser MC, Wolfs CA, Vliek S, Rikkert MG: Cost-effectiveness of post-diagnosis treatment in dementia coordinated by Multidisciplinary Memory Clinics in comparison to treatment coordinated by general practitioners: an example of a pragmatic trial. J Nutr Health Aging. 2009, 13: 242-248. 10.1007/s12603-009-0066-1.View ArticlePubMedGoogle Scholar
- Kim MM, Califano JA: Molecular pathology of head-and-neck cancer. Int J Cancer. 2004, 112: 545-553. 10.1002/ijc.20379.View ArticlePubMedGoogle Scholar
- Hilarius DL, Gundy CM, Aaronson NK: Use of health-related quality-of-life assessments in daily clinical oncology nursing practice: a community hospital-based intervention study. Cancer. 2008, 113: 628-37. 10.1002/cncr.23623.View ArticlePubMedGoogle Scholar
- Chang JT, Juang YY, Hsiao JC, Lin CY, Huang SF, Huang YC, Kuan KH, Liao CT, Wang HM, Chen IH: Internal consistency of the traditional Chinese character version of the Functional Assessment of Cancer Therapy-Head and Neck (FACT-H&N). Chang Gung Med J. 2008, 31: 384-394.PubMedGoogle Scholar
- Pimentel FL: Qualidade de Vida - revisão bibliográfica. Qualidade de Vida do Doente Oncológico, Edição: De autor. 2003Google Scholar
- Infante-Cossio P, Torres-Carranza E, Cayuela A, Hens-Aumente E, Pastor-Gaitan P, Gutierrez-Perez JL: Impact of treatment on quality of life for oral and oropharyngeal carcinoma. Int J Oral Maxillofac Surg. 2009, 38: 1052-8. 10.1016/j.ijom.2009.06.008.View ArticlePubMedGoogle Scholar
- Ringash J, O'Sullivan B, Bezjak A, Redelmeier DA: Interpreting clinically significant changes in patient-reported outcomes. Cancer. 2007, 110: 196-202. 10.1002/cncr.22799.View ArticlePubMedGoogle Scholar
- Cheung YB, Goh C, Thumboo J, Khoo K, Wee J: Quality of life scores differed according to mode of administration in a review of three major oncology questionnaires. Journal of Clinical Epidemiology. 2006, 59: 185-191. 10.1016/j.jclinepi.2005.06.011.View ArticlePubMedGoogle Scholar
- Holzner B, Bode RK, Hahn EA, Cella D, Kopp M, Sperner-Unterweger B, Kemmler G: Equating EORTC QLQ-C30 and FACT-G scores and its use in oncological research. Eur J Cancer. 2006, 42: 3169-77. 10.1016/j.ejca.2006.08.016.View ArticlePubMedGoogle Scholar
- Rogers SN, Ahad SA, Murphy AP: A structured review and theme analysis of papers published on 'quality of life' in head and neck cancer:2000-2005. Oral Oncology. 2007, 43: 843-868. 10.1016/j.oraloncology.2007.02.006.View ArticlePubMedGoogle Scholar
- Kemmler G, Holzner B, Kopp M, Dunser M, Margreiter R, Greil R, Sperner-Unterweger B: Comparison of two quality-of-life instruments for cancer patients: The Functional Assessment of Cancer Therapy. General and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30. 1999, 17: 2932-2940.Google Scholar
- Rogers SN, Lowe D, Brown JS, Vaughan ED: A comparision between the University of Washington head and neck disease-specific measure and the Medical Short form 36, EORTC QLQ-C33 and EORTC-H&N35. Oral Oncology. 1998, 34: 361-372. 10.1016/S1368-8375(98)00031-1.View ArticlePubMedGoogle Scholar
- de Bree R, Verdonck-de Leeuw IM, Keizer AL, Houffelaar A, Leemans CR: Touch screen computer-assisted health-related quality of life and distress data collection in head and neck cancer patients. Clinical Otolaryngology. 2008, 33: 138-10.1111/j.1749-4486.2008.01676.x.View ArticlePubMedGoogle Scholar
- Sayed SI, Elmiyeh B, Rhys-Evans P, Syrigos KN, Nutting CM, Harrington KJ, Kazi R: Quality of life and outcomes research in head and neck cancer: A review of the state of the discipline and likely future directions. Cancer Treatment Reviews. 2009, 35: 397-402. 10.1016/j.ctrv.2009.03.001.View ArticlePubMedGoogle Scholar
- Trask PC, Hsu MA, McQuellon R: Other paradigms: health-related quality of life as a measure in cancer treatment: its importance and relevance. Cancer. 2009, 15: 435-40. 10.1097/PPO.0b013e3181b9c5b9.View ArticleGoogle Scholar
- Coyne JC, Pajak TF, Harris J, Konski A, Movsas B, Ang K, Watkins Bruner D: Emotional well-being does not predict survival in head and neck cancer patients: a Radiation Therapy Oncology Group. Cancer. 2008, 112: 2326-7. 10.1002/cncr.23436.View ArticleGoogle Scholar
- Barnes ML, Williamson PA, Lipworth BJ: The minimal clinically important difference in allergic rhinitis. Clin Exp Allergy. 2010, 40: 242-50. 10.1111/j.1365-2222.2009.03381.x.View ArticlePubMedGoogle Scholar
- Vaidyanathan S, Barnes M, Lipworth B: R159: Minimal Clinically Important Differences in Rhinology. Otolaryngolog -Head and Neck Surgery. 2007, 137: 206-10.1016/j.otohns.2007.06.496.View ArticleGoogle Scholar
- Johnson S, Corsten MJ, McDonald JT, Chun J: Socio-economic factors and stage at presentation of head and neck cancer patients in Ottawa, Canada: A logistic regression analysis. Oral Oncology. 2010, 46: 366-368. 10.1016/j.oraloncology.2010.02.010.View ArticlePubMedGoogle Scholar
- Pinheiro PS, Tyczynski JE, Bray F, Amado J, Matos E, Miranda AC, Limbert E: Cancer in Portugal/Cancro em Portugal. IARC Technical Publication. 2002, 38-Google Scholar
- Cripps C, Winquist E, Devries MC, Stys-Norman D, Gilbert R: Epidermal growth factor receptor targeted therapy in stages III and IV head and neck cancer. Curr Oncol. 2010, 17: 37-48.PubMed CentralView ArticlePubMedGoogle Scholar
- Scarpa R: Surgical Management of Head and Neck Carcinoma. Seminars in Oncology Nursing. 2009, 25: 172-182. 10.1016/j.soncn.2009.05.007.View ArticlePubMedGoogle Scholar
- Jemal A, Murray T, Ward E, Samuels A, Tiwari RC, Ghafoor A: Cancer statistics, 2005, CA. Cancer J Clin. 2005, 55: 10-30. 10.3322/canjclin.55.1.10.View ArticleGoogle Scholar
- Varricchio CG, Ferran CE: Quality of Life Assessments in Clinical Practice. Seminars in Oncology Nursing. 2010, 26: 12-17. 10.1016/j.soncn.2009.11.003.View ArticlePubMedGoogle Scholar
- Janse AJ, Gemke BJ, Uiterwaal PM, van der Tweel I, Kimpen LL, Sinnema G: Quality of life: patients and doctors don't always agree: a meta-analysis. Journal of Clinical Epidemiology. 2004, 57: 653-661. 10.1016/j.jclinepi.2003.11.013.View ArticlePubMedGoogle Scholar
- Conroy T, Mercier M, Bonneterre J, Luporsi E, Lefevre JL, Lapeyre M, Puyraveau M, Schraub S: French version of FACT-G: Validation and comparison with other cancer-specific instruments. European Journal of Cancer. 2004, 40: 2243-2252. 10.1016/j.ejca.2004.06.010.View ArticlePubMedGoogle Scholar
- Bjordal K, de Graeff A, Fayers PM, Hammerlid van Posttelsberhge C, Curran D, Ahlner-Elmqvist M, Maher EJ, Meyza JW, Bredart A, Soderholm AL, Arraras JJ, Feine JS, Abendstein H, Morton RP, Pignon T, Huguenin P, Bottomly A, Kaasa S: 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. EORTC Quality of Life Group. Eur J Cancer. 2000, 36: 1796-1807. 10.1016/S0959-8049(00)00186-6.View ArticlePubMedGoogle Scholar
- Smith DJ, Huntington J, Sloan JA: Choosing the "Correct" Assessment Tool. Current Problems in Cancer. 2006, 30: 272-282. 10.1016/j.currproblcancer.2006.08.005.View ArticlePubMedGoogle Scholar
- Holzner B, Kemmler G, Sperner-Unterweger B, Kopp M, Dunser M, Margreiter R, Marschitz I, Nachbaur D, Fleischhacker WW, Greil R: Quality of life measurement in concology-a matter of the assessment instrument?. European Journal of Cancer. 2001, 37: 2349-2356. 10.1016/S0959-8049(01)00307-0.View ArticlePubMedGoogle Scholar
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