Geriatric oncology: comparing health related quality of life in head and neck cancer patients

The United Nations Organization (UNO) considers the period between 1975 and 2025 the ageing era, once society is ageing and life expectancy is rapidly growing. This progressive ageing of the worldwide population is increasing the number of people annually diagnosed with cancer once most types of tumours are age-dependent. In Europe, sixty percent of new cancer cases and over seventy percent of cancer deaths occur in patients aged 65 years and older [1, 2].

Head and neck cancer is one of the sixth most prevalent worldwide neoplasm, with an estimated 900,000 new cases diagnosed annually. Independently of tumour site (oral cavity, oropharynx, sinus and nose, salivary glands, larynx), surviving patients experience a deterioration of their basic functions affecting such important functions as: breathing, mastication, salivating, swallowing, speaking, senses (hearing, taste and smell). Moreover, aesthetics appearance is perceived as profoundly affecting their lives [3–7].

High-quality healthcare in geriatric oncology (GO) requires a multimodal approach. The stratified patient outcome based on factors other than chronological age supports development of more effective interventions in order to optimize oncology care.

Geriatric patients are often under-treated, largely under-represented in cancer trials and do not receive standard treatments because they are considered unfit for treatment as a consequence of inaccurate estimation of the operative risk [8–11].

Health Related Quality of Life (HRQoL) begun to be considered as one of the hard end-points for clinical and research in GO. Such assessment can promote better patients selection and support treatment decisions. It may provide new measures and interventions in order to optimize the individual treatment plan and reducing inappropriate age-related inequity found in healthcare assessment [10, 12, 13].

The HRQoL assessment involves biological, psychological and socio-cultural criteria in a multidimensional perspective looking for well-being ageing indicators: longevity, biological, social and mental health, social competence and status, satisfaction, cognitive control and efficiency, productivity, activity, income, family and occupational roles and informal relations continuity. Methodological problems elderly related - illiteracy, concomitant diseases, social disorders, unviable validated instruments or trouble in question understanding - make the assessment a true challenge [14, 15].

HRQoL directed programs for GO professionals - developed in a multidisciplinary approach and focused on advanced research and clinical practice - could optimize HRQoL of both patients and their relatives.

Indeed, essential factors are recognized as important to expedite the progress and healthcare systems refining: the need of dedicated investigators, continuous health education planning and linkage efforts among comparative and multidisciplinary groups [16–18].

This study aims to evaluate the HRQoL in head and neck cancer patients (HNCP) and compare the scores in geriatric and younger patients.

Head and neck cancer occurs mainly between the fifth and sixth age decade, being the number of elderly HNC rising as the result of demographic changes. Aged patients are predisposed to spontaneous mutations and hypomethylation of the DNA, important predisposition factors for tumour cell transformation and oncogen activation and thus favouring tumour development. Actually, it is observed an increase of head and neck cancer in geriatric population [9, 19].

The participants, all from North of Portugal, are mainly males (86%) and mostly young (64%). Such gender asymmetry seems to be associated with cumulative risk factors exposure (oral hygiene, dental status, oral mucosal lesions, alcohol and tobacco use, virus infection and lifestyle). Moreover, the spontaneous mutations aged-related may have different expression in males and females [20, 21].

Considering tumour location, our data are in agreement with literature identifying oral cavity, oropharynx, hypopharynx, and larynx as the most common sites for head and neck cancer [22]. Furthermore, the more prevalent stages found were III and IV in males and II and III in females. Age seems not interfere in this tendency.

The male participants are predominantly ex-smokers and smokers and female HNCP are mainly non smokers. This corroborates other findings showing that men are more likely than women to be current smokers [23–26].

Head and neck cancer is an extremely distressing disease disturbing anatomy and physiology of cervicofacial region and affecting important functions - vision, hearing, balance, olfaction, taste, mastication, swallowing, breathing, voice - endocrine balance and body image. Consequently, when considering HNCP, the impact of the diagnosis and treatment on the multidimensional patient outcomes need the most serious consideration. Accordingly, HRQoL assessment in head and neck cancer is essential to know the HNCP perceptions.

Derks (2004) evaluated seventy-eight older (> or = 70 years) and 105 younger HNCP (45-60 years) and referred that before and after treatment, the physical functioning of the older was worse than that of YP [27]. Fang (2010) described that pretreatment HRQoL variables from patients with nasopharyngeal carcinoma, provided available prognostic value for distant metastasis and survival, particularly physical functioning. Additionally, other studies support the correlation of patient reported HRQoL scales with survival in head and neck cancer [28, 29].

Infante-Cossio reported in 2009 that HRQoL seemed to be associated with age, indicating that HNCP under 65 years scored better [30]. Our results corroborate these findings demonstrating that geriatric HNCP globally scored worse. The YP revealed more problems related to Financial Difficulties, Appetite Loss, and Nausea and Vomiting.

Results from the QLQ-H&N35 revealed YP female scored considerably worse in the majority of the domains - these findings are similar with those described in literature identifying advanced tumour stage, female gender, and long-term follow-up as the factors that adversely affect HRQoL in HNCP [30, 31].

The Global Health Status/QoL remains generally comparable between groups and according to van der Schroeff (2007) who found no significant differences between older and younger HNCP when considering survival or overall HRQoL [32].

HRQoL scores revealed to be associated with tumour location and age: Larynx tumours reveal more problems in GP when considering Physical, Role functioning, Constipation and Fatigue. Oral Cavity analysis indicated that younger HNCP had poor scores in Social Functioning, Diarrhoea and Financial Difficulties. Unexpectedly, YP with Pharynx cancer (base of the tongue) revealed a negative HRQoL impact in several domains - the opposite of GP that scored better in almost all domains.

The EORTC QLQ-H&N 35 scores identified that GP with Larynx cancer have poor results in all HRQoL domains. In Oral and Pharynx cancers (base of the tongue) there are no significant differences between the considered groups, being the scores lightly better in GP.

Presently, significant uncertainty exists in GO. The GP often do not receive aggressive therapy regimens as a consequence of imprecise evaluation of the operative risk. A comprehensive geriatric assessment and team approach may contribute to the identification of many previously unmet problems, allowing then better strategies planning in order to improve health outcomes [33].

There is almost an international consensus that HNCP should be treated with curative intention and aggressive treatment option should not be excluded [34, 35]. Geriatric HNCP should be considered to receive standard treatment - in fact previous studies reveal that therapy associated complications do not occur significantly more often in these patients. Age alone should not be the basis for therapeutic planning and decision-making in geriatric HNCP [9, 36, 37].

HRQoL assessment has been introduced as one of the hard end-points in GO. Survival remains the most significant end point and a HRQOL evaluation should be thus a secondary end point. In fact, an EORTC questionnaire module for older people with cancer was recently developed, the EORTC QLQ-ELD15. Such questionnaire is prepared for large-scale studies in combination with EORTC QLQ-C30 [38, 39].

HRQoL assessment should be integrated in the comprehensive geriatric assessment procedure in order to meet the GO healthcare professional's improvement expectations [8, 18, 39].

Worldwide oncology programs have been developed for the individualized management of HNCP in a multidimensional and multidisciplinary way.

This study reveals that geriatric HNCP globally scored worse in HRQoL assessment. Additionally advanced tumour stage, female gender, and long-term follow-up are variables that adversely affect HRQoL in HNCP.

Therapeutic planning and decision-making in Head and Neck Cancer must be based not only on tumour characteristics and chronological age, but also on performance status evaluation, co-morbidity and patient reported outcomes assessment. These outcomes associated with comprehensive HNCP assessment aims to screen unmet problems, contributing as prognosis predictors, substantiating the decision process, and reducing age-related inequity. These assessments are signalizing age-independent indicators that do optimize oncologic geriatric care.