Abstract
Dear Editor,
We congratulate Balk et al on their research investigating the relationships between cancer localizations and symptom burden and long-term quality of life (QoL) measures using the University of Washington Quality of Life Questionnaire (UW-QoL) Version 4 in 138 head and neck cancer (HNC) patients. 1 This retrospective analysis included patients previously treated for oral cavity, oropharyngeal, hypopharyngeal, laryngeal, and cancer of unknown primary (CUP) cancers. Despite the symptom differences not significantly affecting the health-related and overall QoL metrics, patients with oral cavity and laryngeal carcinomas exhibited markedly higher swallowing and salivation scores than those with oropharyngeal carcinoma and CUP. In contrast, speech-related scores were lower for patients with oral cavity and laryngeal carcinomas. While this is a retrospective study, this real-world data offers valuable insights into specific symptom burdens, including swallowing, speech, and salivation, exhibiting notable variability between different HNC sites. Such variations highlight the intricate connections between cancer localization and posttreatment QoL in these patients. However, two pertinent concerns require attention to enhance the interpretation of the results, which could offer valuable guidance for future research on this critical subject.
First, the need for higher statistical power in comparing five distinct tumor types with different treatment approaches, irradiation portal sizes, and total doses may have obscured the individual impact of some factors on specific QoL metrics. For example, the physical activity score in patients treated for a CUP was 50, half of the 100 observed in oral cavity cancer patients, although it did not reach statistical significance (P = .118). Nevertheless, this disparity holds undeniable clinical significance. Moreover, the outcomes observed in patients with CUP, as opposed to those with oral cavity cancer, are consistent with the prevailing literature, which implies the presence of persistent functional deficits in at least one functional domain in 40% of HNC patients. 2 The observed disparity in Balk and colleagues’ study may be attributed to the lower frequency of an “only surgery” approach in 0% of CUP patients compared to oral cavity cancer patients (41.7%), sparing 41.7% of CUP patients from the adverse effects of radiochemotherapy. 1 Nevertheless, the absence of treatment-based comparisons precludes us from making definitive conclusions, underscoring the necessity for additional subgroup analyses.
And second, UW-QoL is a specific QoL tool that does not account for certain radiation- or radiochemotherapy-induced late toxicities and their impact on related measures, such as periodontitis, tooth caries, tooth loss, trismus, and osteoradionecrosis of the jaws. However, these late toxicities cumulatively occur frequently and can significantly impair various domains of UW-QoL in HNC patients undergoing these treatments.3,4 These toxicities might even trigger or exacerbate other late toxicities, such as difficulties with swallowing and speech in patients with HNC undergoing radiotherapy or radiochemotherapy.3,4 Hence, it is crucial to take into consideration these toxicities, as well as mental and sexual well-being and the potential for suicide, to accurately evaluate the QoL of impacted patients at various intervals rather than just once.3-5 Indeed, this goal can only be achieved by implementing more comprehensive QoL tools and well-constructed multidisciplinary approaches.
