|Year : 2021 | Volume
| Issue : 2 | Page : 124-128
Evaluation of pain management and quality of life among oral cancer patients - A cross sectional study
John W Baliah1, Vaishali Keluskar2, David W Livingstone3, Arun Panwar2
1 Department of Oral Medicine and Radiology, Indira Gandhi Institute of Dental Sciences, Sri Balaji Vidyapeeth, Puducherry, India
2 Department of Oral Medicine and Radiology, KAHER's KLE Vishwanath Katti Institute of Dental Sciences, Belgaum, Karnataka, India
3 Department of Prosthodontics, Indira Gandhi Institute of Dental Sciences, Sri Balaji Vidyapeeth, Puducherry, India
|Date of Submission||14-Aug-2020|
|Date of Decision||05-Feb-2021|
|Date of Acceptance||09-Mar-2021|
|Date of Web Publication||23-Jun-2021|
Dr. Vaishali Keluskar
Department of Oral Medicine and Radiology, KAHER's KLE Vishwanath Katti Institute of Dental Sciences, Belgaum, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Oral cancer is a health concern in India, accounting for 90% of all head and neck cancers. Recent advances in treatment have improved survival rates, but unbearable pain creates a poor quality of life. Intense pain at the primary site significantly impairs speech, mastication, and swallowing. The use of extensive pain evaluation questionnaire may yield false responses from patients due to severe pain. Aim: The study aims to assess pain management and quality of life using an 8-point questionnaire among patients with squamous cell carcinoma of oral cavity, pharynx, and esophagus undergoing treatment procedures. Materials and Methods: A total of 64 oral cancer patients from two cancer hospitals were interviewed using the self-designed questionnaire to assess their pain level and quality of life. Statistical Analysis: Descriptive analysis was used to describe the frequencies and percentages. Chi-square test was used to determine statistical significance. Results and Conclusion: In 33% of the oral cancer patients, pain medication did not have an analgesic effect; 32.8% of the patients needed stronger pain medication; 36% had severe mood swings; 31.3% had severe sleep disturbance; and 39.1% had severe interference in eating food. On using numeric pain intensity scale, 42.2% had severe pain and 51.5% had moderate pain due to oral, pharyngeal, and esophageal squamous cell carcinoma and its treatment. This simplified questionnaire can be used as a preliminary tool to evaluate oral cancer pain and quality of life.
Keywords: Oral cancer pain, oral cancer, pain questionnaire, quality of life
|How to cite this article:|
Baliah JW, Keluskar V, Livingstone DW, Panwar A. Evaluation of pain management and quality of life among oral cancer patients - A cross sectional study. J Indian Acad Oral Med Radiol 2021;33:124-8
|How to cite this URL:|
Baliah JW, Keluskar V, Livingstone DW, Panwar A. Evaluation of pain management and quality of life among oral cancer patients - A cross sectional study. J Indian Acad Oral Med Radiol [serial online] 2021 [cited 2022 Jan 27];33:124-8. Available from: https://www.jiaomr.in/text.asp?2021/33/2/124/319061
| Introduction|| |
Advances in head and neck reconstructive techniques have improved aesthetic and functional results among cancer patients, leading to better quality of life. In oral cancer patients, pain is reported in 85% of cases., It is estimated that 45% to 80% of oral cancer patients have inadequate pain management.,, Pain management in orofacial region is challenging due to the rich nerve innervation. Oral mucosa is susceptible to the effects of chemotherapy and radiotherapy resulting in painful mucositis. Literature reveals limited data on evaluation of the pain level management and quality of life among patients undergoing chemotherapy and radiotherapy treatment. The existing questionnaires used are extensive and time consuming. This study aims to assess the pain management and quality of life among patients with cancer of oral cavity, pharynx, and esophagus using an 8-point self-designed oral cancer pain management and quality of life evaluation questionnaire.
| Materials and Methods|| |
This study was approved by the Research and Ethics Committee, KLEVKIDS (reference number-157/2018) in accordance with the Declaration of Helsinki and duration of the study spanned from September 2018 to December 2018. Sample size (n) was calculated to be 64 by the formula n = Z2pq/d2 with 〈 = 5%, ® = 20%, power = 80%, CI = 95% where prevalence was 4% (determined from the pilot study), q = 96, d = 5%, and Z2 = 3.96 ~ 4.
Patients diagnosed with squamous cell carcinoma of head and neck, and who were willing to participate voluntarily were included and patients unwilling to participate, denied to sign the informed consent and with metastasis, were excluded from the study. Other head and neck malignancy such as brain tumours, salivary gland tumours, and thyroid carcinomas were also excluded from the study. After written informed consent of the patients, the survey was carried out.
For illiterate patients and those who could not read or respond for any reason, the researcher read the questions and answers and recorded the responses.
Patients were interviewed by a single observer using a self-designed oral cancer pain management and quality of life evaluation questionnaire [Table 1]. Numeric Pain Intensity Scale was used to evaluate pain level. The 8-item questionnaire was validated by subjecting it to 35 subject experts and conducting a pilot test to ensure that the items can be understood and correctly interpreted by the intended respondents. The validation stage ensured that the questionnaire is psychometrically sound. As cancer patients go through pain and mental agony, it is not justified to use extensive questionnaires in the context of collecting in depth information about the disease from the patients. Furthermore, it is possible that in such a state, patient may provide a modified response. This 8-item questionnaire was developed to minimize the interaction time with oral cancer patients and simultaneously collect the required information with respect to pain management and quality of life. Eating, sleeping, and mood swings reflect their basic quality of life and hence were considered in assessing quality of life.
|Table 1: Simplified oral cancer pain and quality of life evaluation questionnaire|
Click here to view
The study was conducted at Belgaum Cancer Hospital, Belgaum, and Karnataka Cancer Therapy and Research Institute, Hubli, Karnataka, after requisite permissions. A total of 64 patients with histological diagnosis of squamous cell carcinoma of oral cavity, pharynx, and oesophagus undergoing treatments like surgery, or radiotherapy, concurrent chemoradiotherapy, and palliative therapy were included in the study through convenience sampling.
Data gathered from completed questionnaires were entered in a Microsoft Excel spreadsheet and statistical analysis was done by using Statistical Package of Social Science (SPSS 21). Chi-square test was used to determine statistically significant differences for the responses given by oral cancer patients. P ≤ 0.05 was considered statistically significant.
| Results|| |
An analysis of the data from the questionnaire revealed the mean age of the study population was 53.11 ± 7.3 years. The study recruited 64 patients out of which 44 patients were males (68.8%) and 20 patients were females (31.2%). 67.2% of the patients reported that their pain was due to their oral cancer, 15.6% of the patients reported pain was due to treatment, and 17.2% of the patients reported pain is due to oral cancer and its treatment. Most common site for oral squamous cell carcinoma was the buccal mucosa with 48.5% and the least common site was the tongue with 3.1%. The site distribution of oral squamous cell carcinoma is given in pie chart [Graph 1]. 51.6% of the patients experienced aching type of pain and 30.4% of the patients experienced burning type of pain during oral cancer treatment.
93.8% of the patients take pain medication on a regular basis whereas 6.3% of the patients take medication only when necessary. In 33% of the patients, pain medication does not have any analgesic effect. In 25% of the patient, pain medication works for 1–2 hours after administration of the medications [Graph 2].
32.8% of the patients reported that they need stronger medication [Graph 3]. 12.5% of the patients were uncertain about the need for stronger medication. 36% of the oral cancer patients had severe mood swings. 45.3% of the patients had moderate mood swings. 31.3% of the patients had severe sleep disturbance. 23.5% of the oral cancer patients had moderate sleep disturbance [Graph 4]. 39.1% of the patients had severe interference in eating. 25% of the patients had moderate interference in eating [Graph 5]. On using numeric pain intensity scale, 42.2% had severe oral cancer pain, 51.5% had moderate pain, and 6.3% had no pain.
| Discussion|| |
According to National Cancer Registry Programme (NCRP), around 80–90% of oral cancer is directly attributable to tobacco use. The mean age of oral cancer patients is 50 years. Treatment includes surgery, different types of radiotherapy, concomitant chemo radiotherapy, and palliative care. Pain and soreness in the mouth are the most common symptoms in patients undergoing oral cancer treatment. Patients were administered topical anaesthetics, non-steroidal anti-inflammatory drugs and morphine on a regular basis for pain management as per WHO ladder.
The mean age of the oral cancer patients in the present study is 53.11 ± 7.30 years which was consistent with the results of study done by Shenoi et al. The present study showed 67.2% of the patients had pain at the time of diagnosis which was higher to the results of the study conducted by Jean Potter et al. This suggested that there is delay in seeking oral cancer treatment. The most common acute oral side effect of chemotherapy and radiotherapy is oral mucositis. Combined chemotherapy and radiation therapy resulted in increased frequency, severity, and duration of mucositis. In the present study, 30.4% of the patients had burning type of pain which was lower compared to the study done by McGuire DB et al. This reduction in burning pain may be due to the advances in treatment like intensity-modulated radiotherapy and use of amifostiene. However, in the present study, 51.6% patients experienced aching type of pain.
According to Oliveira KG et al., 66.6% of patients used analgesics for pain control. In the present study, 93.7% of the patients used analgesics on regular basis for pain control which is higher compared to the study done by Olivieira KG, et al. Further, 33% patients had no pain relief despite taking pain medications which is consistent with the results of Hinther A, et al. 32.8% of the patients reported that they need stronger pain medication for their oral cancer pain. This further warrants the need for novel approaches in pain management.
Along with pain, the quality of life is also affected due to oral cancer. In the present study, 36% of the patients had severe mood swings due to oral cancer pain. Hence, according to Janosky JE, a psychologist should be a part of multidisciplinary approach to oral cancer management along with rational administration of antidepressants and anxiolytics for management of mood swings.
54.8% of oral cancer patients had moderate to severe sleep disturbance which is comparable to that of study done by Oliveira KG, et al. where moderate to severe pain indicated greater impairment on insomnia.
In the present study, 64.1% had moderate to severe interference in eating food. This is inconsistent with the study done by Nie M, et al. where drinking fluid, eating semi solid food, and choked when eating were also considered. Further, eating fluid and semifluid items leads to food leakage from the defects in surgically resected maxilla or mandible. Lango MN, et al. also suggested that dysphagia measure identifies patients predisposed to oral recurrence and death. According to Goswami et al., patients undergoing oral cancer treatments experience emotional distress, concerns for appearance, changes in daily activities, feeling blamed, denial, avoidance, discomfort, stigmatization, financial insecurity and public support, and eating and chewing difficulty. In the present study, on using numeric pain intensity scale, 42.2% had severe oral cancer pain and 51.5% had moderate pain. This result is not consistent with Saxena A, et al. where 70% had severe oral cancer pain and 14% had moderate pain. However, this result of the present study is significant because in two decades we have achieved reduction in pain intensity from severe to moderate in oral cancer patients.
Extensive discussion on assessment of pain through various questionnaires is given by H Brevik et al. The advantages of this simplified oral cancer pain management and quality of life evaluation questionnaire used in the present study are user friendliness, better patient cooperation, easily comprehensible by all patients, large population can be evaluated in short period of time, and can be translated in regional language.
Limitations and future prospects
Although this study focused on oral cancer, it did not differentiate among the stages of cancer and was done with a limited sample size. Therefore, the pain and quality of life could not be correlated among the various stages of oral cancer. In future, similar studies with larger sample size could be done with prime focus on correlating the findings of different stages of oral cancer in regard to pain and quality of life.
| Conclusion|| |
In 33% of the oral cancer patients, pain medication did not have analgesic effect. 93.7% of the oral, pharyngeal, and oesophageal squamous cell carcinoma patients undergoing treatment have moderate to severe pain. Focus in treating oral cancer patients should be on pain management, as pain causes moderate to severe eating difficulty, sleeping difficulty, and mood swings. This simplified questionnaire on quality of life can be used as preliminary tool to evaluate oral cancer pain and quality of life. Effective methods in pain management are required to improve the quality of life in oral cancer patients.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Davudov MM, Harirchi I, Arabkheradmand A, Garajei A, Mahmudzadeh H, Shirkhoda M, et al
. Evaluation of quality of life in patients with oral cancer after mandibular resection comparing no reconstruction, reconstruction with plate, and reconstruction with flap. Medicine (Baltimore) 2019;98:e17431.
Foley KM. The treatment of cancer pain. N Engl J Med 1985;313:84-95.
Foley KM, Inturrisi CE. Analgesic drug therapy in cancer pain: Principles and practice. Med Clin North Am 1987;71:207-32.
Cleeland CS, Gonin R, Hatfield AK, Edmonson JH, Blum RH, Stewart JA, et al
. Pain and its treatment in outpatients with metastatic cancer. N Engl J Med 1994;330:592-6.
de Wit R, van Dam F, Loonstra S, Zandbelt L, van Buuren A, van der Heijden K, et al
. The Amsterdam pain management index compared to eight frequently used outcome measures to evaluate the adequacy of pain treatment in cancer patients with chronic pain. Pain 2001;91:339-49.
Meuser T, Pietruck C, Radbruch L, Stute P, Lehmann KA, Grond S. Symptoms during cancer pain treatment following WHO-guidelines: A longitudinal follow-up study of symptom prevalence, severity and etiology. 2001;93:247-57.
Rose-Ped AM, Bellm LA, Epstein JB, Trotti A, Gwede C, Fuchs HJ. Complications of radiation therapy for head and neck cancers. Cancer Nurs 2002;25:461-7.
Shenoi R, Devrukhkar VC, Sharma BK, Sapre SB, Chikhale. Demographic and clinical profile of oral squamous cell carcinoma patients: A retrospective study. Indian J Cancer 2012;49:21-6.
] [Full text]
Jean P, Irene JH, John WS, Columba Q. Identifying neuropathic pain in patients with head and neck cancer: Use of the leeds assessment of neuropathic symptoms and signs scale. J R Soc Med 2003;96:379-83.
Sonis ST. The pathobiology of mucositis. Nat Rev Cancer 2004;4:277-84.
Cooper JS, Pajak TF, Forastiere AA, Jacobs J. Postoperative concurrent radiotherapy and chemotherapy for high-risk squamous-cell carcinoma of the head and neck. N Engl J Med 2004;350:1937-44.
McGuire DB, Altomonte V, Peterson DE, Wingard JR, Jones RJ, Grochow LB. Patterns of mucositis and pain in patients receiving preparative chemotherapy and bone marrow transplantation. Oncol Nurs Forum 1993;20:1493-502.
Oliveira KG, Zeidler SV, Podesta JR, Sena A, Souza ED, Lenzi J, et al
. Influence of pain severity on the quality of life in patients with head and neck cancer before antineoplastic therapy. BMC Cancer 2014;14:39.
Hinther A, Nakoneshny SC, Chandarana SP, Matthews TW, Dort JC. Efficacy of postoperative pain management in head and neck cancer patients. J Otolaryngol Head Neck Surg 2018;47:29.
Janosky JE, South-Paul JE, Lin CJ. Pain and depression in a cohort of underserved, community-dwelling primary care patients. J Am Board Fam Med 2012;25:300-7.
Nie M, Liu C, Pan YC, Jiang CX, Li BR, Yu XJ, et al
. Development and evaluation of oral cancer quality of life questionnaire. BMC Cancer 2018;18:523.
Lango MN, Egleston B, Fang C, Burtness B, Galloway T, Liu J, et al
. Baseline health perceptions, dysphagia, and survival in patients with head and neck cancer. Cancer 2014;120:840-7.
Goswami S, Gupta SS. How patients of oral cancer cope up with impact of the disease? A qualitative study in Central India. Indian J Palliat Care 2019;25:103-9.
] [Full text]
Saxena A, Mendoza T, Cleeland CS. The assessment of cancer pain in North India: The validation of the Hindi brief pain inventory – BPI-H. J Pain Symptom Manage 1999;17:27-41.
Breivik H, Borchgrevink PC, Allen SM, Rosseland LA, Romundstad L, Breivik Hals EK, et al
. Assessment of pain. Br J Anaesth 2008;101:17-24.