Smoking has a negative impact upon health related quality of life after treatment for head and neck cancer
Introduction
Smoking is a prevalent addictive behaviour with major implications on mortality and morbidity in all countries. It is the second major cause of death worldwide and is responsible for the death of 1 in 10 adults worldwide [www.who.int]. Tobacco is an important risk factor in the development of squamous cell head and neck cancer. Additionally, smoking decreases the effect of radiotherapy1, 2 and increases the rate of second primaries.3
The influence of smoking on radiotherapy side effects has only been sparsely studied. Smoking has been reported to lead to excess duration of mucositis in radiotherapy using the CHART schedule4 and increased severity of mucositis and acute skin reaction also in a more heterogeneous population of head and neck cancer patients.5 However, in another study, including 115 head and neck cancer patients receiving radiotherapy with or without chemotherapy, no influence was found of smoking on acute radiotherapy side effects.1 Smoking has been associated with late radiation induced toxicity of the lung,6 small bowel, rectum and bladder.7
A significant number of patients continue to smoke after diagnosis and definitive therapy. Smokers associate their habit with pleasure and relaxation. A few studies have suggested, however, that smoking is associated with decreased quality of life (QoL) in a general population,8 in survivors of lung cancer9 and head and neck cancer patients with non-terminal disease.10 The aim of the present study was to estimate the influence of continued smoking and smoking cessation, respectively, on observer-assessed morbidity and self-reported overall and tumour site specific QoL in a population of recurrence free head and neck cancer patients.
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Patients and methods
Patients in follow-up after radical radiotherapy or surgery for larynx, pharynx and oral cavity cancer were candidates for the study. The study set-up has been described in detail previously.11 In brief, consecutive eligible patients were asked to fill out the EORTC quality of life questionnaires (QLQ) C30 and H&N35, which have recently been validated in Danish.11 Exclusion criteria’s, applied before asking the patient to participate, were previously determined recurrences (57 patients) and
Results
At the time of follow-up there were 62 non-smokers and 52 smokers. Smoking status was independent of all registered clinical parameters as: age (at study time), PS, gender, stage, site, treatment modality or time since treatment. Patients who were smokers at follow-up invariably had the lowest function scores and the highest symptoms scores in both DAHANCA and EORTC QLQ except for FIBROSIS and HN Weight gain. The difference between smokers and non-smokers were significant (p < 0.05) in 20 of the
Discussion
In the present study we compared morbidity and quality of life between smokers and non-smokers in a population of 114 recurrence free head and neck cancer patients. The analysis clearly demonstrated that patients who continued smoking after diagnosis and treatment had poorer quality of life compared to quitters and never smokers. Smoking negatively influenced much wider range of QOL endpoints than well-known clinical parameters like performance status, stage, treatment etc. The statistically
Conclusion
Continued smoking after treatment of head and neck cancer adversely influenced a wide range of quality of life endpoints, of which many were apparently unrelated to the direct effect of smoking on the upper aero-digestive tract and lungs. Quitters had better quality of life than patients who continued to smoke after treatment, suggesting that smoking cessation may improve quality of life in addition to reducing the risk of new cancer.
Acknowledgements
The authors would like to thank the Danish Cancer Society Grant DP 03 112, Radiumstationens Forskningsfond, Agnes Niebuhr Anderssons Fond and William Nielsens Mindefond for financial support.
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