Reply to Symptom Burden and Quality of Life in Long-Term Survivors With Head and Neck Cancer

Dear Editor,

We commend Gostian et al for their valuable research, which provides critical insights into the symptom burden and quality of life (QoL) of 212 long-term head and neck cancer survivors (HNC). ¹ In this retrospective study, the authors analyzed data using the MIDOS and the University of Washington Quality of Life Questionnaire (UW-QoL). ² For analysis, the patients were classified based on their disease stages: early (I-II) versus advanced (III-IV). Gostian et al identified the 3 most prevalent symptoms as tiredness, anxiety, and drowsiness. ¹ In addition, they observed that patients diagnosed with stages III-IV experienced a significantly higher frequency and severity of loss of appetite. Given the predominantly mild nature of most symptoms experienced, the authors concluded that the overall symptom burden for long-term survivors of HNC is notably low. The authors’ findings are crucial in revealing the symptom burden and their impact on QoL measures in long-term HNC survivors. However, it is essential to acknowledge frequently overlooked specific late-onset toxicities that may contribute to an increased symptom burden and a diminished QoL in affected patients. Such an emphasis may further enhance our understanding of the challenges faced by this population and guide future research designs.

While the present study concedes common symptoms such as tiredness, anxiety, and loss of appetite, it overlooks oral health-related issues such as xerostomia, tooth loss, periodontitis, trismus, and osteoradionecrosis. ¹ However, these late-onset toxicities may have a higher incidence and more significantly impact the patient’s functionality, QoL, and even prognosis than the issues mentioned by the authors. For example, xerostomia may lead to sore throat, taste alteration, tooth decay, tooth loss, osteoradionecrosis, changes in voice quality, and impaired chewing and swallowing functions. Similarly, trismus resulting from disease, surgical interventions, or radiation therapy can substantially negatively impact oral health and vital daily functions, including the ability to speak, drink, and eat. This condition may also hinder effective oral hygiene practices, lead to weight loss, compromise the immune system, and pose life-threatening challenges to airway management during emergencies.^2-4 Moreover, these factors can ultimately decrease food consumption and result in weight loss, significantly affecting overall health and patient prognosis. ⁵

Within 3 months following radiotherapy, signs of deterioration in the hard dental tissues manifest. Subsequently, deeper carious lesions and tooth loss may occur. ⁶ The loss of multiple teeth can result in nutritional deficiencies, significant weight reduction, interruptions in oncological treatment, and may adversely affect the long-term survival of patients.^5-7 Both pre- and post-radiotherapy tooth extractions are significantly associated with an increased risk of osteoradionecrosis, which poses a considerable health and economic burden for up to 9.2% of irradiated HNC patients. ⁸

In conclusion, while the symptoms mentioned above are notably prevalent, the study did not address them due to their exclusion from surveys such as the UW-QoL, which rely on general symptom questionnaires. Hence, executing tools like the Oral Health Impact Profile may capture some of these overlooked symptoms and provide a broader view of the symptom burden and their impact on patient functionality and QoL in long-term HNC survivors.