European Archives of Oto-Rhino-Laryngology

, Volume 269, Issue 2, pp 629–638 | Cite as

Functional outcome in patients with advanced head and neck cancer: surgery and reconstruction with free flaps versus primary radiochemotherapy

  • Uta TschiesnerEmail author
  • Lena Schuster
  • Sebastian Strieth
  • Ulrich Harréus
Head and Neck


The objective was to compare functional outcome in patients with advanced head and neck cancer (HNC) treated with (a) surgical resection and reconstruction with microvascular free flaps (MVFF) followed by radiochemotherapy versus (b) primary radiochemotherapy (RCT) on the basis of the International Classification of Functioning, Disability and Health (ICF) from WHO. This was a cross-sectional, multi-institutional study. The outcome measures included ICF Core Sets for HNC, the EORTC–QLQ, modules c30 + hn35 and the University of Washington-Quality of life Questionnaire (UW-QOL). Analyses included descriptive statistics, ranking exercises, and regression analyses in a cumulative logit model; 27 patients were treated with MVFF and 22 with RCT. Global Quality of life scores suggested a slightly better functional outcome for the surgical approach. The majority of ICF categories (81/93, 87%) did not show a difference in functional outcome between the two treatment approaches. In the remaining 12 ICF categories, n = 3 body structures were more affected in the MVFF group, while n = 3 body functions, and n = 6 activities/participations were more problematic in the RCT group. This included oral swallowing and weight maintenance functions as well as social relationships, acquiring a job, and economic self-sufficiency. In addition, nine contextual environmental factors were more relevant to the RCT group. Both treatment approaches seemed appropriate to advanced HNC from the perspective of functional outcome. The influence of treatment modalities on the social and economic lives of cancer survivors needs to be explored further. In order to guide rehabilitation according to patients’ needs, the ICF offers a multidimensional view comprising body structures, body functions, and activities and participation in life.


Head and neck cancer Outcome assessment Quality of life Free flap 



For calculation with the logit model we thank Cornelia Oberhauser from the ICF Research Branch, Ludwig-Maximilians-Universität in Munich, Germany. For the coordination of study centers within the validation study we thank Elisabeth Linseisen from the ICF Research Branch, Ludwig-Maximilians-Universität in Munich, Germany. The study was part of the validation process for ICF Core Sets for HNC. In this context some of the work, namely the coordination of study centres, was financed through “Deutsche Krebshilfe e.V.”, a German non-profit organization against cancer. For patient recruitment and patient interviews we thank (in alphabetical order): Sebastian Baumann, at Saarbrücken University, Germany, Dept. of Oral and Maxillofacial Surgery. Nuria Blanco-Piñero at University of Seville, Spain, Dept. of Psychiatry and Serafín Sánchez Gómez and Tomás Herrero at University of Seville, Spain, Virgen Macarena Universitary Hospital, Dept. of Otorhinolaryngology. Kirsten Becker-Bikowski, University of Heidelberg, Dept. of Oral and Maxillofacial Surgery. Magdalena Chlabicz and Marek Rogowski at University of Bialystok, Poland, Dept. of Otorhinolaryngology. Suzie Forgie and Shirley Pringle at Aintree University Hospital, UK, Dept of Oral and Maxillofacial Surgery. Elma Heitmann Mares Azevedo and Elisabete Carrara de Angelis, Hospital AC Camargo, São Paulo, Brasil, Department for Voice, Speech and Swallowing Rehabilitation. Megan Nutt, ACT Health, Capital Region Cancer Service, Head & Neck Oncology; Canberra, Australia. Yehon Hee Park and Keunchil Park, Samsung Medical Center, Seoul, Korea, Dept of Hematology-Oncology. Rohan R. Walvekar, MD, at the LSU Health Sciences Center, Department of Otolaryngology Head & Neck Surgery, New Orleans, LA, USA.


  1. 1.
    Smith RB et al (2007) Utilization of free tissue transfer in head and neck surgery. Otolaryngol Head Neck Surg 137(2):182–191PubMedCrossRefGoogle Scholar
  2. 2.
    Thorwarth M et al (2008) Free flap transfer in cranio-maxillofacial surgery: a review of the current data. Oral Maxillofac Surg 12(3):113–124PubMedCrossRefGoogle Scholar
  3. 3.
    Rich J et al (2009) Transoral laser microsurgery (TLM) ± adjuvant therapy for advanced stage oropharyngeal cancer: outcomes and prognostic factors. Laryngoscope 119(9):1709–1719PubMedCrossRefGoogle Scholar
  4. 4.
    Grant D et al (2009) Oropharyngeal cancer: a case for single modality treatment with transoral laser microsurgery. Arch Otolaryngol Head Neck Surg 135(12):1225–1230PubMedCrossRefGoogle Scholar
  5. 5.
    Bogdanov-Berezovsky A et al (2008) The role of frozen section histological analysis in the treatment of head and neck skin basal and squamous cell carcinomas. Isr Med Assoc J 10(5):344–345PubMedGoogle Scholar
  6. 6.
    Villaret AB et al (2008) Quality of life in patients treated for cancer of the oral cavity requiring reconstruction: a prospective study. Acta Otorhinolaryngol Ital 28(3):120–125PubMedGoogle Scholar
  7. 7.
    Pignon J et al (2009) Meta-analysis of chemotherapy in head and neck cancer (MACH-NC): an update on 93 randomised trials and 17, 346 patients. Radiother Oncol 92(1):4–14PubMedCrossRefGoogle Scholar
  8. 8.
    El-Deiry M et al (2005) Long-term quality of life for surgical and nonsurgical treatment of head and neck cancer. Arch Otolaryngol Head Neck Surg 131(10):879–885PubMedCrossRefGoogle Scholar
  9. 9.
    Trivedi NP et al (2008) Comparison of quality of life in advanced laryngeal cancer patients after concurrent chemoradiotherapy vs total laryngectomy. Otolaryngol Head Neck Surg 139(5):702–707PubMedCrossRefGoogle Scholar
  10. 10.
    Boscolo-Rizzo P et al (2009) Long-term quality of life after treatment for locally advanced oropharyngeal carcinoma: surgery and postoperative radiotherapy versus concurrent chemoradiation. Oral Oncol 45(11):953–957PubMedCrossRefGoogle Scholar
  11. 11.
    Bozec A et al (2008) Free-flap head and neck reconstruction and quality of life: a 2 year prospective study. Laryngoscope 118(5):874–880PubMedCrossRefGoogle Scholar
  12. 12.
    Rogers SN et al (2002) The addition of mood and anxiety domains to the University of Washington quality of life scale. Head Neck 24(6):521–529PubMedCrossRefGoogle Scholar
  13. 13.
    Bjordal K et al (2000) A 12 country field study of the EORTC QLQ-C30 (version 3.0) and the head and neck cancer specific module (EORTC QLQ-H & N35) in head and neck patients. EORTC Quality of Life Group. Eur J Cancer 36(14):1796–1807PubMedCrossRefGoogle Scholar
  14. 14.
    World Health Organization (2001) ICF-International Classification of Functioning, Disability and Health. Geneva.
  15. 15.
    Stucki G, Grimby G (2004) Applying the ICF in medicine. J Rehabil Med (44 Suppl):5–6Google Scholar
  16. 16.
    Fleissig A et al (2006) Multidisciplinary teams in cancer care: are they effective in the UK? Lancet Oncol. 7(11):935–943PubMedCrossRefGoogle Scholar
  17. 17.
    Tschiesner U et al (2009) Shortfalls in international, multidisciplinary outcome data collection following head and neck cancer: does the ICF Core Set for HNC provide a common solution? Oral Oncol 45(10):849–855PubMedCrossRefGoogle Scholar
  18. 18.
    Westin T, Stalfors J (2008) Tumour boards/multidisciplinary head and neck cancer meetings: are they of value to patients, treating staff or a political additional drain on healthcare resources? Curr Opin Otolaryngol Head Neck Surg 16(2):103–107PubMedCrossRefGoogle Scholar
  19. 19.
    Kwok J et al (2009) The impact of health-insurance status on survival of patients with head and neck cancer. Cancer 116(2):476–485CrossRefGoogle Scholar
  20. 20.
    Stucki G et al (2002) Application of the International Classification of Functioning, Disability and Health (ICF) in clinical practice. Disabil Rehabil 24:281–282PubMedCrossRefGoogle Scholar
  21. 21.
    Tschiesner U et al (2010) Development of ICF core sets for head and neck cancer. Head Neck 32(2):210–220PubMedGoogle Scholar
  22. 22.
    Tschiesner U et al (2008) Content comparison of quality of life questionnaires used in head and neck cancer based on the international classification of functioning, disability and health: a systematic review. Eur Arch Otorhinolaryngol 265(6):627–637PubMedCrossRefGoogle Scholar
  23. 23.
    Tschiesner U, Becker S, Cieza A (2010) Health professional perspective on disability in head and neck cancer. Arch Otolaryngol Head Neck Surg 136(6):576–583PubMedCrossRefGoogle Scholar
  24. 24.
    Tschiesner U et al (2009) Assessment of functioning in patients with head and neck cancer according to the International Classification of Functioning, Disability, and Health (ICF): a multicenter study. Laryngoscope 119(5):915–923PubMedCrossRefGoogle Scholar
  25. 25.
    Tschiesner U et al (2009) Evaluating sequelae after head and neck cancer from the patient perspective with the help of the International Classification of Functioning, Disability and Health. Eur Arch Otorhinolaryngol 266(3):425–436PubMedCrossRefGoogle Scholar
  26. 26.
    Tschiesner UM et al (2009) Comparison of outcome measures in head and neck cancer––literature review 2000–2006. Head Neck 31(2):251–259PubMedCrossRefGoogle Scholar
  27. 27.
    Becker S et al (2009) Content validation of the Comprehensive ICF Core Set for Head and Neck Cancer (HNC): the perspective of psychologists. Psychooncology 19(6):594–605CrossRefGoogle Scholar
  28. 28.
    Tschiesner U et al (2010) Content validation of the international classification of functioning, disability and health core sets for head and neck cancer: a multicentre study. J otolaryngol head neck surg 39(6):674–687PubMedGoogle Scholar
  29. 29.
    Tschiesner U, Oberhauser C, Cieza A (2011) Do the categories of the ICF-HNC discriminate among clinically relevant subgroups of patients? Int J Rehabil Res 34(2):121–130Google Scholar
  30. 30.
    Tschiesner U et al (2010) Content Validation of ICF Core Sets for head and neck cancer, a multi-center study. J Otolaryngol Head Neck Surg 39(6):674–678PubMedGoogle Scholar
  31. 31.
    Kostanjsek N et al (2010) Assessing the impact of health conditions using the ICF. Disabil Rehabil [Epub ahead of print]Google Scholar
  32. 32.
    Fahrmeir L, Tutz G (2001) Multivariate statistical modelling based on generalized linear models, 2nd edn. Springer, New YorkGoogle Scholar
  33. 33.
    Tutz G (2000) Die Analyse kategorialer Daten Anwendungsorientierte Einführung in Logit-Modellierung und kategoriale Regression. Oldenbourg, München, WienGoogle Scholar
  34. 34.
    Langendijk JA et al (2009) A predictive model for swallowing dysfunction after curative radiotherapy in head and neck cancer. Radiother Oncol 90(2):189–195PubMedCrossRefGoogle Scholar
  35. 35.
    Salas S et al (2009) Impact of the prophylactic gastrostomy for unresectable squamous cell head and neck carcinomas treated with radio-chemotherapy on quality of life: prospective randomized trial. Radiother Oncol 93(3):503–509PubMedCrossRefGoogle Scholar
  36. 36.
    de Arruda FF et al (2006) Intensity-modulated radiation therapy for the treatment of oropharyngeal carcinoma: the Memorial Sloan-Kettering Cancer Center experience. Int J Radiat Oncol Biol Phys 64(2):363–373PubMedCrossRefGoogle Scholar
  37. 37.
    Bitar R et al (2004) Does tumor status influence cancer patients’ satisfaction with the doctor–patient interaction? Support Care Cancer 12(1):34–40PubMedCrossRefGoogle Scholar
  38. 38.
    Ross S et al (2010) Psychosocial adjustment of family caregivers of head and neck cancer survivors. Support Care Cancer 18(2):171–178PubMedCrossRefGoogle Scholar
  39. 39.
    Chaukar DA et al (2009) Quality of life in head and neck cancer survivors: a cross-sectional survey. Am J Otolaryngol 30(3):176–180PubMedCrossRefGoogle Scholar
  40. 40.
    McKoy JM et al (2007) Cost considerations in the management of cancer in the older patient. Oncology (Williston Park) 21(7):851–857 (discussion 858, 860, 862 passim)Google Scholar
  41. 41.
    Poirier P (2006) The relationship of sick leave benefits, employment patterns, and individual characteristics to radiation therapy-related fatigue. Oncol Nurs Forum 33(3):593–601PubMedCrossRefGoogle Scholar
  42. 42.
    Taylor JC et al (2004) Disability in patients with head and neck cancer. Arch Otolaryngol Head Neck Surg 130(6):764–769PubMedCrossRefGoogle Scholar
  43. 43.
    Nordgren M (2008) Quality of life in oral carcinoma: a 5 year prospective study. Head Neck 30(4):461–470PubMedCrossRefGoogle Scholar
  44. 44.
    Rogers SN et al (2010) Development of the brief ICF core set for head and neck cancer as a patient self-completed questionnaire. Int J Oral Maxillofac Surg 39(10):975–982PubMedCrossRefGoogle Scholar
  45. 45.
    Deutsche Krebshilfe eV (2010) Development of clinical guidelines on the use of outcome measures in head and neck cancer follow-up and rehabilitation-based on the ICF Core sets for HNC, in Deutsche Krebshilfe. Bonn, Germany Google Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Uta Tschiesner
    • 1
    Email author
  • Lena Schuster
    • 2
  • Sebastian Strieth
    • 3
  • Ulrich Harréus
    • 1
  1. 1.Department of Otorhinolaryngology Head and Neck SurgeryLudwig-Maximilians-University MunichMunichGermany
  2. 2.School of dentistryLudwig-Maximilians-University MunichMunichGermany
  3. 3.Department of Otorhinolaryngology Head and Neck SurgeryUniversity of FrankfurtFrankfurtGermany

Personalised recommendations