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ORIGINAL ARTICLE
Evaluation of the correlation between side effects to oral mucosa,
salivary glands, and general health status with quality of life
during intensity-modulated radiotherapy for head and neck cancer
Marina Kimie Oba
1
&Lara Maria Alencar Ramos Innocentini
1
&Gustavo Viani
2
&Hilton Marcos Alves Ricz
1
&
Thiago de Carvalho Reis
1
&Tatiane Cristina Ferrari
1
&Leandro Dorigan de Macedo
1,3
Received: 4 December 2019 / Accepted: 1 April 2020
#Springer-Verlag GmbH Germany, part of Springer Nature 2020
Abstract
Purpose The aim of this study was to evaluate the distribution of acute clinical complications that involve the oral cavity (oral
mucositis and salivary flow), general health status (Karnofsky performance status scale (KPS) and weight), and quality of life
using the worst performance throughout radiotherapy treatment by intensity-modulated radiation therapy (IMRT) in the head and
neck region and to evaluate the correlation between these variables.
Methods This prospective, longitudinal study evaluated 32 patients who were undergoing IMRT for head and neck tumors. The
measures were collected weekly through standardized protocols and a quality of life questionnaire (UW-QOL version 4).
Results The worst performance for all variables was concentrated in treatment weeks 2 and 5. Regarding quality of life, the
emotional dimensions were the most affected (pain 62.86; activity 55; recreation 43.57; mood 49.97; shoulder 57.06; anxiety
42.91). There were a higher number of moderate mucositis correlations with quality of life (mucositis × KPS 0.002; mucositis ×
weight loss 0.03; mucositis × pain 0.001; mucositis × activity 0.002; mucositis × recreation 0.001; mucositis × swallowing 0.002;
mucositis × saliva 0.006; mucositis × mood 0.007; mucositis × anxiety 0.002).
Conclusions IMRT treatment severely deteriorated the patients’quality of life. There were important correlations between the
clinical variables and quality of life, especially mucositis.
Keywords Radiotherapy .Head and neck neoplasms .Radiation effects .Quality of life .Hyposalivation .Oral mucositis
Introduction
Head and neck cancers (HNC) localized in oral cavity, larynx,
oropharynx, and hypopharynx added up anestimated 705,781
new cases with 358,144 deaths in 2018 [1,2]. Most of these
tumors are squamous cell carcinoma, and more usual thera-
peutic options involve surgery and/or chemoradiation [3]. In
the last decades, intensity-modulated radiation therapy
(IMRT) has contributed to the increase in overall survival of
these patients [4]. However, despite the technological evolu-
tion obtained with IMRT, the wide variety of structures locat-
ed in this region makes adverse effects one of the greatest
challenges in the therapeutic process [5]. These effects are
divided into acute and chronic. Lesions that occur up to the
first 3 months postradiotherapy are called acute [5–9].
Chronic effects represent late alterations in the tissues that
result from the evolution or consolidation of acute lesions
[9]. The most frequent acute adverse effects are mucositis,
xerostomia, trismus, secondary infections, and dysgeusia,
while main late side effects are radiation caries and
osteoradionecrosis [9,10].
The most frequent and limiting acute effect is oral mucosi-
tis (OM), with a prevalence of 85–100% in patients who
*Leandro Dorigan de Macedo
dorigan@fmrp.usp.br
1
Dentistry and Stomatology Division, Ophthalmology,
Otolaryngology and Head and Neck Surgery Department, Clinical
Hospital ofRibeirão Preto School of Medicine, São Paulo University,
Ribeirão Preto, SP, Brazil
2
Internal Medicine, Ribeirão Preto School of Medicine, University of
São Paulo, Ribeirão Preto, São Paulo, Brazil
3
Fundação Hemocentro de Ribeirão Preto, Rua Tenente Catão Roxo,
2501, Ribeirão Preto, SP CEP: 14051-140, Brazil
Supportive Care in Cancer
https://doi.org/10.1007/s00520-020-05454-5
received radiation in the head and neck region [6,9,11]. Its
severity and extension are associated with pain, dysgeusia,
dysphagia, and use of nasogastric tube, all of which compro-
mise the patient’s general health status [5,7,9]. The salivary
glands show changes from 20 to 25 Gy radiation doses;
changes are irreparable at doses greater than 60 Gy [5].
Salivary changes are both qualitative and quantitative and
have implications for the development of secondary infections
(e.g., candidiasis), rampant caries, mucositis, dysgeusia, and
dysphagia [12].
Weight loss and physical limitations are recurrent findings
in patients with HNC at different stages of treatment. The loss
of appetite appears to be due to several factors: xerostomia,
difficulty in swallowing, depression, loss of taste, nausea, and
mucositis [7]. Langendijk et al. reported that 41% of patients
have loss of appetite as a side effect [13]. Additionally, psy-
chological factor apparently play an important role in the pa-
tient’s general health.
The combination of all factors described above impairs the
general health of the patient, which in clinical practice is com-
monly evaluated by Karnofsky performance status scale
(KPS). KPS less than 70 is a predictor of unscheduled radio-
therapy pause, a phenomenon that results in poor local control
of head and neck tumors and decreased overall survival
[14–16]. Pauses longer than 5 days are associated with a
68% increase in the risk of death in patients with laryngeal
cancer [17].
Studies have shown that quality of life is significantly im-
pacted in these patients; radiotherapy appears to have an im-
portant relationship with the findings. However, assessing the
impact of adverse effects is a challenge because the patient’s
subjective perception may differ from clinical perception [18].
Understanding the incidence and distribution of the acute
complications during radiotherapy treatment, as well as their
correlation with the impact on the patient’s quality of life, is
essential for the development and optimization of care proto-
cols for each stage of the radiotherapy treatment. In this con-
text, the objective of this study was to evaluate the distribution
of the acute clinical complications that involve the oral cavity
(oral mucositis and salivary flow), general health status (KPS
and weight), and quality of life using the worst performance
throughout the weeks of IMRT in the head and neck region
and to evaluate the correlations among these variables.
Methods
This prospective, longitudinal, and observational study en-
rolled between April and November 2018 was approved by
the ethical committee of the Clinical Hospital of the School of
Medicine of Ribeirão Preto-USP (a Brazilian tertiary care in-
stitution), where the study was conducted (CAAE number
86496418.5.0000.5440). Informed consent was obtained from
all individual participants included in the study.
The inclusion criteria were patients with laryngeal,
hypopharyngeal, oropharyngeal, and mouth squamous cell
carcinoma with an indication for radiotherapy treatment by
IMRT. All patients were recruited and selected for conve-
nience. The exclusion criteria were as follows: patients previ-
ously treated with radiotherapy in the head and neck region (or
with positive history for any other oncological treatment),
under 18 years of age, patients who did not adhere to multi-
disciplinary care protocols, and those with psychosocial and
psychomotor alterations that impaired self-care, comprehen-
sion, and verbal expression.
The radiotherapy treatment was performed using the IMRT
technique with a Unique system (Varian Medical Systems,
Palo, Alto, CA, USA) and a thermoplastic mask, with one
fraction a day, 2.0 Gy/fraction, 5 days/week, during 6 or
7 weeks and a total dose varying from 60 to70 Gy. All patients
enrolled in the study underwent a dental protocol based on [9,
19], and the follow-up was at the institution where the study
was performed. All patients that received chemotherapy were
submitted to the same protocol (cisplatin, 100 mg/m
2
in D1,
D22, and D43). After pre-radiotherapy dental preparation, pa-
tients were evaluated during radiotherapy with preventive
dental follow-up 3 times a week. All patients were treated
by a Laser Duo (MMOptics, São Carlos, Brazil) PBM device.
Parameters for photobiomodulation (PBM) therapy used in
this study were wavelength 660 nm for preventive and
808 nm for therapeuthic PBM, power 100 mW, beam area
0.03 cm
2
, irradiance 1 W/cm
2
, time per point 10 s, energy
1.0 J, and energy density 33 J/cm
2
. PBM therapy was not
delivered over active tumor area. These sites included lips
mucosae (3 points for each lip), buccal mucosa (3 points for
each side), and lateral borders of the tongue (3 points for each
side), ventral tongue (2 points), and anterior floor of the
mouth. During each appointment, we included oral hygiene
orientation, prevention, and treatment of any oral infection.
The tumor site was grouped into three areas according to
the irradiated region: (1) mouth—tongue, retromolar trigone,
floor of the mouth, and buccal mucosa; (2) oropharynx—
tongue base, soft palate, and amygdala; (3) larynx and hypo-
pharynx—larynx, hypopharynx, and lower cervical.
The study protocol included weekly assessments from D0
(immediately before radiotherapy onset) to the last week of
treatment. In all evaluations, the following variables were col-
lected: (1) oral complications—salivary flow rates and muco-
sitis (based on the World Health Organization scale) [20]; (2)
general conditions—KPS index and weight (kg); (3) quality of
life—University of Washington Quality of Life (UW-QOL,
version 4) in Portuguese [21–23]. Unstimulated saliva collec-
tionwasperformed1haftermealsduring15minandweighed
for salivary flow rate estimation [24]. Information such as
KPS was obtained from patient’s charts, with KPS index
Support Care Cancer
performed by an oncologist and weight was performed by the
dentist researcher before each weekly evaluation. All evalua-
tions were performed by the same dentist and oncologist. For
the quality of life questionnaire, the worst performance event
was defined as the domain with the worst value reported dur-
ing treatment. It also had to be among the three conditions
cited as the most limiting in the previous week.
Our endpoint was the week of IMRT treatment when each
variable (salivary flow rate, mucositis, KPS, weight, and each
domain of the quality of life questionnaire) showed the worst
performance. If the patient showed the worst performance in a
variable during more than 1 week, the first week during which
the event occurred was defined as the endpoint. Thus, al-
though the patients were evaluated weekly, only a single mea-
surement (worst performance) per patient was used for each
variable in the data analysis. The trend for concentration of the
“worst case”event over the treatment weeks was assessed
using the chi-square test for independent samples (because a
single measurement was used per patient).
To evaluate the severity of the complications, the meanand
median values for the salivary flow, KPS, and each domain of
the qualityof life questionnaire were calculated. Formucositis
and general quality of life, which are initially categorized, the
frequency of each category was calculated. For all variables,
the worst performance for each patient during IMRT treatment
was used. Weight was not evaluated in a descriptive manner
due to the wide variation in values among the patients and the
limited number of individuals in this study.
To evaluate the correlation between each clinical variable (oral
clinical complications and general conditions) and quality of life, the
exact chi-square test for trends and the Spearman correlation coeffi-
cient were applied. A positive correlation between two variables was
considered when both tests showed statistically significant results
(p≤0.05). Statistical analyses were performed with IBM SPSS
Statistics for Windows (version 22.0; IBM Corp., Armonk, NY).
Results
The sample comprised 32 patients with a median age of
61.5 years (range 29–81) and male prevalence (71.87%).
The diagnosis was performed with advanced staging,
68.75% in stage IV, and the most prevalent primary site was
the larynx and hypopharynx (43.75%). The most commonly
performed treatment was the combination of surgery, radio-
therapy, and chemotherapy (40.6%). Furthermore, 67% of the
patients underwent an operation, 60% received chemotherapy,
and only 12.5% received radiotherapy alone. The median ra-
diation dose was 6.6 Gy, and median treatment duration was
8 weeks. Two patients (6.25%) required an unplanned treat-
ment interruption due to KPS status; one of them had a grade
III OM associated with the KPS status (Table 1).
Figure 1presents the percentage of patients that showed the
worst status for clinical outcomes for each treatment week.
There was a general pattern of poorer clinical status at weeks
2 and 5 of IMRT treatment. The chi-square test confirmed a
significant concentration of the worst events during this period
for most variables. Table 2presents the worst-case distribution
assessments for clinical complications and the different do-
mains of quality of life (Table 2).
Table 3presents the mean and median for descriptive clin-
ical complication variables and domains of quality of life.
Although it was not our objective, we tested the correlation
between salivary flow and treatment (chi-square test, not
shown in the table). Surgery showed positive correlation (p
0.03) while no correlation was found to chemotherapy (p0.2).
Table 4presents the frequency of events for each type of
mucositis and response to global quality of life. In all evalua-
tions, the worst values obtained for each patient during the
treatment were considered.
The greatest complaints regarding the domains of quality
of life were related to recreation, anxiety, shoulder, taste, pain,
activity, chewing, and humor. Most patients had a KPS of
approximately 80, which indicates a good capacity for self-
care and independence for daily functions, as well as perfor-
mance for oncological treatment. None of the patients had
grade IV mucositis, only 22.85% had grade III, and most of
the patients had grade 0 (34.28%). The most prevalent general
quality of life scores were “Good”(48.57%) and “Average”
(34.28%).
Table 5presents the results of the correlation analyses be-
tween the worst outcomes for the studied variables. KPS was
positively correlated with weight loss, mucositis, and the do-
mains activity, recreation, swallowing, chewing, speech,
shoulder, taste, and mood and overall quality of life. For
weight loss, the positive correlations were KPS, mucositis,
and the domains appearance, activity, recreation, speech, sali-
va, mood, and anxiety. Mucositis correlatedwith KPS, weight
loss, and the domains pain, activity, recreation, swallowing,
saliva, mood, and anxiety. Salivary flow correlated positively
with the domains, appearance, swallowing, chewing, saliva,
and anxiety and overall quality of life.
Discussion
Currently, the importance of the quality of life in cancer pa-
tients as a determining factor for therapeutic decisions has
been widely discussed. In this context, patients with HNC
deserve special attention because the studies have shown that
both disease and treatment are a determinant for quality of life
[25–30]. The UW-QOL was developed specifically for use in
patients with cancer in the head and neck region, and it is the
most commonly used measure for this purpose worldwide. It
is currently in the fourth version and was validated for the
Support Care Cancer
Portuguese-Brazilian language in 2012 [21,22]. The
questionnaire comprises 12 domains, divided between
socioemotional and physical dimensions. Each question
presents a number of points, and smaller values indicate
greater commitment in the domain. Additionally, three
questions provide categorical options for assessing qual-
ity of life associated with health, overall quality of life
before and after the tumor, and in the last 7 days;
another question addresses which domain was most lim-
iting in the last 7 days [22,23]. Most of the studies
found in our review evaluated quality of life at the time
of diagnosis or during posttreatment [26–30]. To our
knowledge, previous studies evaluated the association
between oral side effects and quality of life [31,32];
however, this association with general health conditions
was not previously described.
Table 1 Demographic characteristics of the studied population
Feature Val u e ( n=32)
Age (years) (mean ± SD) 60.84 ± 10.48
Sex (% male:% female) 71.87:28.13
Tumor staging (%) I 3.12
II 3.12
III 25.00
IV 68.76
Tumor location (%) Mouth 25
Oropharynx 31.25
Larynx and hypopharynx 43.75
Treatment (%) Surgery+Rtx+Chx* 40.6
Surgery+Rtx 28.1
Rtx+Chx* 18.8
Rtx 12.5
Information regarding radiation therapy
Total radiation dose (Gy) (median) 6.6 (5.4–7.0)
Treatment duration (weeks) (median) 8(7–9)
Number of patients with an unplanned interruption 2 (6.25%)
Number of patients and reason(s) for unplanned disruptions per treatment week 1st week 0
2nd week 0
3rd week 1; KPS status
4th week 1; KPS status and OM
5th week 0
6th week 0
7th week 0
8th week 0
Rtx radiotherapy, Chx chemotherapy, SD standard deviation, KPS Karnofsky performance scale, OM oral mucositis
*Cisplatin, 100 mg/m
2
Fig. 1 Percentage of patients who
showed their worst status for
clinical complications for each
treatment week
Support Care Cancer
Our demographic findings are consistent with the literature,
both with respect to age and male prevalence [2]. Like most
studies, our patients presented different tumor sites in the head
and neck region. However, we chose to specifically evaluate
adult patients with squamous cell carcinoma who underwent
IMRT. The vast majority (70%) of our patients underwent
surgery; division by anatomical sites showed a balanced dis-
tribution between low (44%: larynx and hypopharynx) and
high (56%: mouth and oropharynx) tumors. This regularity
allowed us to infer that our results, despite the sample size,
allow a general evaluation in the context of patients treated
with radiotherapy for head and neck tumors.
The glandular or nerve damage due to surgery may have
been responsible for the lower salivary flow found in our
study when compared to the literature for preradiotherapy
(0.2 ml/min) and during treatment (0.1 ml/min). Lal et al.
reported a significant reduction in nonstimulated salivary flow
in months 3 (0.366 ml/min) and 6 posttreatment, with partial
recovery after month 12 in patients who underwent IMRT
[33]. Our sample size may be insufficient to identify the effect
of chemotherapy suggested in other studies. Future prospec-
tive studies with larger numbers of patients and evaluations at
different treatment times are necessary to better understand
this subject.
Our patients presented a general incidence and severity of
mucositis (0% grade IV mucositis and only 22% grade III)
that was lower than described for IMRT in the literature (be-
tween 45 and 63% of mucositis III and IV) [33,34]. Most of
the grade III mucositis in our study were found in oral cavity
tumors. The low incidence of severe OM was probably due to
our application protocol of photobiomodulation three times a
week throughout the treatment and to the low dose of radiation
in oral cavity for radiotherapy protocols in sites such as larynx
and hypopharynx.
There was a concentration of the worst events, both clinical
(mucositis, salivary flow, KPS, and weight) and quality of life,
in the second and fifth weeks of treatment. Franco et al. de-
scribed the occurrence of more severe degrees of mucositis
during the sixth week of treatment [35]. We found two peaks
for the worst mucositis events, namely weeks 2 and 5. The
early peak was defined by the large incidence of mucositis
grades 0, I and II (77.13%) and the second peak by grade
Table 2 Chi-square test to evaluate specific weeks with regard to the
concentration of the worst results for each variable
Event Chi-
square
pWeek(s) of worst event
Weight loss 16.230 0.049 2and5
KPS 15.657 0.048 3
Salivary flow 9.486 0.303 2
Mucositis 15.783 0.05 2and5
Qv-Pain 20.800 0.002 2
Qv-Activity 9.572 0.214 2
Qv-Appearence 11.200 0.82 2
Qv-Recreation 13.686 0.05 2
Qv-Swallowing 29.200 0.000 3
Qv-Chewing 11.294 0.80 1
Qv-Speech 13.600 0.34 1, 2, and 4
Qv-Shoulder 5.971 0.309 3
Qv-Taste 8.250 0.220 2 and 3
Qv-Saliva 17.800 0.13 2 and 4
Qv-Mood 20.543 0.005 3
Qv-Anxiety 15.514 0.030 4
Quality of life 15.971 0.025 2
Italic numbers shows statistically significant values
Table 3 Mean and median for descriptive clinical complication
variables
Variables Mean (standard deviation) Median (min–max)
KPS 78.86 (12.78) 80 (50–100)
Salivary flow 1.77 (1.6) 1.4 (0–7.2)
Qv-Pain 62.86 (27.37) 50 (25–100)
Qv-Appearance 73.57 (24.21) 75 (25–100)
Qv-Activity 55 (35.25) 50 (0–100)
Qv-Recreation 43.57 (33.95) 25 (0–100)
Qv-Swallowing 47.77 (31.74) 67 (0–100)
Qv-Chewing 67.65 (29.85) 50 (0–100)
Qv-Speech 59.14 (28.23) 67 (0–100)
Qv-Shoulder 57.06 (37.64) 33 (0–100)
Qv-Taste 25.94 (31.38) 33 (0–100)
Qv-Saliva 51.10 (30.59) 67 (0–100)
Qv-Mood 49.97 (26.46) 50 (0–100)
Qv-Anxiety 42.91 (40.14) 33 (0–100)
Table 4 Frequency of worst events for oral mucositis and quality of life
Variables Type Frequency (%)
Mucositis (classification) 0 34.28
I14.28
II 28.57
III 22.85
IV 0
Overall quality of life (classification) Excelent 2.85
Very Good 5.71
Good 48.57
Average 34.28
Bad 5.71
Very Bad 2.85
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III. Thus, our findings are consistent with those reported by
other authors who presented a concentration of grade III mu-
cositis in the fifth week of treatment [36,37].
The domains evaluated by the quality of life questionnaire
are divided into physical-functional (appearance, chewing,
swallowing, speech, taste, and saliva) and socioemotional
(pain, activity, recreation, mood, shoulder, and anxiety) di-
mensions. Although there are variations among the affected
domains, studies have presented greater deterioration of the
emotional dimensions after the diagnosis and physical one’s
posttreatment. Rogers et al. [25] and Michaelsen et al. [27]
evaluated more than 400 patients in the first year after treat-
ment and found an important impact in the physical domains.
Viana et al. [28] and de Oliveira et al. [30] compared the time
of diagnosis with early posttreatment and reported an im-
provement in the pain, mood, and anxiety domains, with sig-
nificant worsening in the physical domains. On the other
hand, Dzebo et al. evaluated posttreatment oral cavities at
different times and found an impact in the physical domains
as well as mood and anxiety [29]. Radiotherapy and staging
were identified as risk factors for worse performance in qual-
ity of life [26,28,30].
Our patients showed worse values for many of the quality
of life domains compared to other studies. Indeed, 8 of 12
domains were less than 50; 6 of these were in the
socioemotional dimension. These data are consistent with
the literature that the emotional dimensions are most affected
during the initial phase of the disease. Most of the studies
presented results above 60 for the worst performance. The
impact of recreation (25), anxiety and shoulder (33), mood,
activity, and pain (50) allows us to infer that deterioration at
diagnosis is aggravated during treatment, probably one of the
most critical periods in the course of a primary disease. As
most of our patients (70%) underwent an operation, poor taste
performance (33) and mastication (50) may be associated with
the surgical effect, as previously reported [28,30]. The fact
that we used the worst performance for each patient to com-
pose the median, that 87.5% of the cases were advanced tu-
mors (staging III + IV), and that all of them having undergone
radiotherapy may have influenced this result.
There were 35 significant positive correlations among the
studied variables. In other words, the worst performance for
one variable coincided with the other. KPS presented the
highest number of correlations (11), followed by weight loss
and mucositis (9), and salivary flow (5). Despite the number
of correlations, only 12 were moderate (greater than 0.50).
Weight loss did not present any moderate correlation, salivary
flow presented 2 (chewing and saliva), KPS presented 4 (gen-
eral quality of life, mood, mucositis and recreation), and mu-
cositis presented 6 (KPS, recreation, pain, activity, anxiety,
Table 5 Correlation between the worst outcomes for the evaluated variables
Variables Clinical complications
KPS Weight loss Mucositis Salivary flow
χ
2
(p) Spearman p
(correlation)
χ
2
(p) Spearman p
(correlation)
χ
2
(p) Spearman p
(correlation)
χ
2
(p) Spearman p
(correlation)
KPS –– 0.009 0.01 (0.43) 0.01 0.002 (0.50) 0.18 0.28 (0.19)
Wei g ht 0.009 0.01 (0.43) –– 0.04 0.03 (0.36) 0.18 0.33 (0.17)
Mucositis 0.01 0.002 (0.50) 0.04 0.03 (0.36) –– 0.21 0.13 (0.26)
Salivary flow 0.18 0.28 (0.19) 0.18 0.33 (0.17) 0.21 0.13 (0.26) ––
Qv-Pain 0.08 0.03 (0.37) 0.10 0.06 (0.32) 0.001 0.001 (0.57) 0.24 0.16 (0.24)
Qv-Appearance 0.45 0.16 (0.24) 0.02 0.02 (0.38) 0.13 0.05 (0.34) 0.002 0.003 (0.49)
Qv-Activity 0.02 0.006 (0.46) 0.001 0.001 (0.32) 0.004 0.002 (0.50) 0.09 0.04 (0.35)
Qv-Recreation 0.02 0.001 (0.52) 0.04 0.03 (0.37) 0.003 0.001 (0.57) 0.61 0.31 (0.18)
Qv-Swallowing 0.04 0.01 (0.43) 0.49 0.35 (0.16) 0.002 0.002 (0.50) 0.04 0.01 (0.41)
Qv-Chewing 0.09 0.03 (0.38) 0.08 0.15 (0.25) 0.19 0.16 (0.25) 0.001 0.001 (0.57)
Qv-Speech 0.04 0.01 (0.42) 0.04 0.05 (0.34) 0.11 0.10 (0.28) 0.25 0.18 (0.29)
Qv-Shoulder 0.03 0.02 (0.40) 0.91 0.98 (0.00) 0.06 0.11 (0.18) 0.09 0.03 (0.37)
Qv-Taste 0.04 0.006 (0.47) 0.22 0.14 (0.27) 0.16 0.04 (0.38) 0.06 0.08 (0.31)
Qv-Saliva 0.31 0.17 (0.24) 0.06 0.05 (0.33) 0.02 0.006 (0.46) 0.003 0.001 (0.53)
Qv-Mood 0.01 0.001 (0.54) 0.04 0.03 (0.37) 0.02 0.007 (0.46) 0.87 0.62 (0.09)
Qv-Anxiety 0.43 0.25 (0.20) 0.008 0.009 (0.44) 0.03 0.002 (0.50) 0.01 0.005 (0.46)
Qv-Event 0.02 0.001 (0.56) 0.42 0.32 (0.17) 0.30 0.08 (0.30) 0.05 0.02 (0.40)
Italic numbers shows statistically significant values
Support Care Cancer
and swallowing). The strongest correlations were found be-
tween mucositis × pain and mucositis × recreation. In addition
to the obvious correlations, mucositis was significant for the
socioemotional domains and swallowing. This finding con-
firms that controlling this outcome is crucial for the success
of the treatment as well as the patient’s quality of life and
comfort. The KPS correlation with 11 of the 16 items evalu-
ated and the reported causes for interruption (Table 1)reiter-
ates the idea that it is a predictor of unscheduled pauses in
radiotherapy [15].
An important limitation of this study is heterogeneity of
tumors sites which might influence in lower incidence of se-
vere cases of oral mucositis. Indeed, in the presented study
sample, the lower radiation doses on oral mucosa are related to
the protocol for tumors in sites such as larynx and hypophar-
ynx. For future studies, a homogenous sample should be
considered.
Conclusion
In conclusion, IMRT period severely deteriorated patients’
quality of life, especially in the socioemotional domains.
Therapeutic strategies that reduce the impact to salivary flow
and oral mucositis may be effective in maintaining quality of
life during radiotherapy treatment in HNC patients. Future
studies to assess such impacts are needed.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
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