Quality of Life after Total Laryngectomy Cyprus experience Dr Giannis Thrasyvoulou, MD, PG Cert MEd A. Aspris, G. Vassiliou, Y. Kyamides Nicosia General Hospital , Cyprus

Background Cyprus has a population of around 1 million Very high percentage of smokers 39% males 14% females Nicosia General Hospital is the island’s tertiary referral center for advanced laryngeal tumours (approximately 10-12 laryngectomy cases per year)

Methods Questionnaire packs requested from laryngectomy patients at their follow- up visits at Nicosia General Hospital. MD Anderson Dysphagia Inventory (MDDADI) University of Washington Quality of Life Questionnaire (UW-QOL) The method of pharyngeal closure was also documented as there was a change of practice in recent years (vertical versus horizontal closure)

MD Anderson Dysphagia Inventory (MDDADI) Rigorously validated in head and neck cancer patients 20 statements related to dysphagia in 4 subscales: Global :impact of swallowing on daily routine Emotional :patient’s affective response to dysphagia Functional :impact on daily activities Physical : reflects how patients perceive their swallowing ability 5 possible responses , total score : 20 to 100

University of Washington Quality of Life Questionnaire (UW-QOL) First part: 12 domains pain, appearance, activity, recreation, swallowing, chewing, speech, shoulder function, taste, saliva, mood and anxiety Second part: Asks to choose which 3 of the 12 domains have been the most important in the last 7 days Third part: Asks to compare current quality of life with perceived quality of life one month before diagnosis and document overall quality of life in the last 7 days

Aims Is quality of life or dysphagia after total laryngectomy affected by: Treatment modality Age (above or below 65) Type of pharyngeal closure (horizontal or vertical closure)

Results 26 laryngectomy patients returned completed questionnaires (70 % response rate) 24 men and 2 women (M:F ratio 12:1) Median age: 63 (range 52-89)

Results 6 patients treated by primary laryngectomy alone 6 patients received postoperative radiotherapy 14 patients treated by salvage laryngectomy after failure of organ preservation Only one patient (2%) underwent flap reconstruction 14 patients (52%) underwent vertical closure and 12 patients (48%) horizontal closure

Most problematic domains in the last 7 days

Less important domains in the last 7 days

Quality of Life Outcomes-Treatment Modality We have obtained a mean quality of life for each patient and categorised them into the three groups. Then we assign ranks to each value with the lowest value receiving the rank 1 and the highest value rank 26. Hence we obtain the following : Modality Number of patients Score Total Laryngectomy alone 6 92 Total Laryngectomy followed by RT 69 Salvage Total Laryngectomy 14 190

Quality of Life Outcomes The mean of quality of life of patients in ”Laryngectomy alone" group is slighly higher than that of patients in ”Salvage Laryngectomy” and “Total Laryngectomy followed by radiotherapy” group. (Kruskal –Wallis test) There is no significant evidence to suggest that either group is better. A larger dataset is required 

Swallowing Outcomes-Treatment Modality Number of patients Score Total Laryngectomy alone 6 83.5 Total Laryngectomy followed by RT 99 Salvage Laryngectomy 14 166.5 We conclude that there is no significant evidence to suggest that there is a difference in dysphagia inventory based on the three different modalities.

Quality of Life and dysphagia outcomes Are they age dependent? We compared QOL indicators as well as MD Anderson Dysphagia Index for patients having laryngectomy before and after the age of 65. (two tailed t- test) We concluded that there is no significant evidence to suggest that patients under 65 have a different quality of life indicator or worse dysphagia than those over 65.

Horizontal pharyngeal closure versus Vertical pharyngeal closure

Horizontal versus Vertical closure two sample t-test using 5% significance level Comparing MD Anderson Dysphagia Index for each type of closure Horizontal closure 100 90 97 98 65 78 99 96 Vertical Closure 72 74 73 58 61 25 50 80 49 54

Advantage of horizontal closure versus vertical We conclude that there is strong significant evidence to suggest that Horizontal leads to a higher MD Anderson Dysphagia Inventory value (P<0.01) Horizontal closure provides better swallowing outcomes and we perform this type of closure whenever it’s possible.

Conclusion Measuring the functional outcome and quality of life of patients with cancer is a very important process. This will guide especially patients with T3 laryngeal cancer on the likelihood of success of organ preservation and the functional outcome that may be expected from nonorgan preserving modalities. A prospective and multicenter clinical audit should be organized as clearly a larger number of patients is needed to reach statistically significant conclusions.

Special Thanks Assistant Professor ENT Christos Themelis (Aristotle University of Thessaloniki) Mr Nick Violaris, FRCS (Consultant Head & Neck Surgeon, Eastbourne and Brighton Hospitals Trust) For supporting our ENT Department in Head & Neck cases in the previous years