Health-related quality of life: a retrospective study on local vs. microvascular reconstruction in patients with oral cancer

Disease-free overall survival seems to have been the most important measure of success of oncological treatment for decades. Over the past few years, however, functional and psychosocial rehabilitation has progressively become an essential secondary outcome [1‐5]. In this regard, the model of Health-Related Quality of Life (HRQOL) was developed to assess patient function and well-being after oncological therapy and to gain structured insight into disease- and therapy-derived problems [2, 6, 7] HRQOL needs certainly to be seen as a complex multidimensional construct with a very individual character [1, 7, 8]. Different aspects and measurement instruments have been suggested to obtain comprehensive and comparable data on cancer patients [4‐6]. For patients with head and neck cancer, targeted questionnaires on disease and site specificity have been developed [8]. Cancer originating from complex anatomical regions such as the oral cavity or the pharynx frequently requires extensive treatment with adverse effects on pivotal functions. Loss of swallowing, chewing, and speaking or having to deal with disfigured facial traits has an enormous physical and social impact on patients’ lives [8‐11]. To avoid impairment and to restore functionality, microvascular and local flap reconstruction techniques have been developed that are implemented according to the surgeon’s expertise and the tumor characteristics [12‐14]. In larger T-graded tumors, microvascular reconstruction, for instance with radial or fibula flaps, provides reliable functional and esthetic outcomes [9, 15]. Nevertheless, the therapeutic regimen is being constantly further developed, and data on oral cancer are still somewhat limited [8]. Further aspects of HRQOL have to be identified in the future to be able to use quality of life as a standardized outcome parameter after flap reconstruction and to enhance oncological outcome while minimizing postoperative handicaps [8, 10, 13].

The aim of this study was to measure HRQOL in patients with oral squamous cell carcinoma after oncological and reconstructive surgery. Predictors for HRQOL were identified by means of the targeted University of Washington Quality of Life Questionnaire (UW-QOL) followed by the evaluation of retrospective data.

Ablative surgery for oral cancer, for instance resection of parts of the tongue, the floor of mouth, or the jaw bones, has a major influence on the quality of life of patients. Reconstruction of the surgical defect is mandatory to restore function and appearance [10, 21]. Small defects can be reconstructed with local techniques such as primary closure, local flaps such as tongue flaps or nasolabial flaps, or in some patients with free skin transplants. Larger defects often require more elaborate techniques. For many years, pedicled flaps such as pectoralis major flaps were preferred. Over the past 20 years, reconstruction with free micro vascularized transplants has become standard, improving oncological and functional outcomes [11, 14]. Quality of Life has become a constant marker of success in any oncological treatment. Microvascular and local flap techniques have been widely used to restore functionality in patients with head and neck cancer. In this study, we investigated what parameters influence HRQOL and how quality of life differs between patients with complex and local reconstructions. We used the University of Washington Quality of Life questionnaire because it is well established, short, and easy to understand.

In our study, HRQOL was significantly influenced by the type of reconstruction. Patients treated with a microvascular flap scored significantly worse in various oral domains with an overall difference of 10 points. There seems to be a variety of reasons for the better health-related outcome of local reconstructive techniques in comparison to microvascular free flap reconstructions in our cohort. First of all, microvascular reconstruction may result in higher donor side morbidity and requires more complex postoperative management. In this study, radial forearm flaps and fibula flaps were the mostly used types of microvascular flaps. De Witt et al. could show in their study on donor side morbidity in radial forearm flaps that basically one out of three patients had substantial functional limb complaints 6 months after surgery [22]. Literature reports have described donor and recipient site complications in up to 45% of patients [23]. Furthermore, free fibula harvest is associated with multiple postoperative complications such as ischemia of the ipsilateral foot, wound dehiscence, and chronic pain [24‐26] with a possible negative impact on global QOL scores. With regard to delicate intraoral function, the patients with microvascular reconstruction in our study had significantly impaired HRQOL in chewing (p = 0.00), swallowing (p = 0.001), speech (p = 0.011), and taste (p = 0.014). The consecutive destruction of nerve, bone, and muscle structures negatively influences chewing and speaking; additionally, intraoral flaps can often be relatively voluminous and inflexible, thus interfering with usual mastication and deglutition [27]. The T-status was also a predictor for HRQOL scores. Whereas 62% of MVRs were conducted in the case of T2-T4-sized tumors, 69% of local reconstructions were carried out in the case of T1 tumors. This trend may be due to the advanced T-status that naturally requires more extensive surgery to achieve R0 resection [28]. Nevertheless, we found that the predictive character of the T-status was decreasing under multivariate observation. Additionally, reconstructions of the floor of the mouth showed worse scores than those for buccal mucosa (Table 6). Particularly the floor of the mouth guarantees mobility of the tongue; thus, defects in this region significantly impair swallowing, mastication, and speaking. In contrast, reconstructed defects in the buccal mucosa are more associated with salivary retention and pain [21, 29]. The tongue is also essential for propulsion processes. Dwivedi et al. found low scores for swallowing in patients with cancer of the tongue [28, 30]. Furthermore, microvascular transplant techniques are time-consuming and require extended operating times, which could also affect outcomes, particularly in elderly patients [31, 32]. In addition, adjuvant therapies such as chemotherapy and neck dissection are more frequently used in the case of increasing UICC staging. In our study, the number of adjuvant therapies was higher in the MVR group, and chemotherapy had an impact on HRQOL. Among others, chemotherapy and radiotherapy lead to xerostomia and mucositis which could explain the increasingly impairment in swallowing, chewing, speech, and taste as well as the increased level of pain [33, 34]. In contrast, in adequate defects, local reconstructive approaches allow the use of local tissue anatomy, which is not only usually followed by uncomplicated healing but also avoids nutritional graft problems because no vessel anastomosis is required. The procedures are quick to carry out and may even be achieved under local anesthesia in selected patients, facilitating favorable outcomes [35].

Two key elements of studies observing HRQOL are evaluating postoperative time and the point of interrogation [36]. Assuming that oncological treatment itself is an extraordinary experience for patients in generally reduced health, we started HRQOL evaluation at least 3 months after surgery. Since data were only collected postoperatively, we had no baseline of physical and social functioning. Previous studies have shown that HRQOL experiences sometimes change over the first 12 months after surgery. However, such aggravations seem to stabilize within 1 year after surgery and can be used as a long-term indicator [5, 7, 10]. Comparing domains with regard to the point in time the survey was carried out, we found differences in the category pain that had improved within the first year and two years after surgery. The category speech had also improved 1 year after surgery. No interaction effects were found between postoperative time and HRQOL under reconstructive therapy. The literature lacks information on postoperative oral functioning. Naturally, postoperative healing processes and functional restitution take their time, so that the already mentioned period of 1 year seems to be realistic for the healing process.

Finally, our patients with microvascular reconstruction nevertheless showed global scores of 73.3, which is still considered good quality of life. Markkanen-Leppänen et al. found scores comparable to our findings [37]. In consideration of these findings, there are reasons to opt for a microvascular graft in the oral cavity. MVR allows greater flexibility in both planning and implementation. Septocutaneous ALT flaps are used because of their enormous flexibility and comparably low donor site morbidity, especially in comparison to pedicled pectoralis major flaps that are associated with greater aesthetic donor site issues, particularly in female patients with breast deformation [38‐41]. Furthermore, ALT flaps enable wider tumor resections with R0 margins as well as sufficient defect closures [9, 10]. To improve outcome for oncological patients, it seems necessary to implement HRQOL assessment in preoperative planning and patient management.

This study has several limitations. First of all, because of the unavailability of pre-treatment data, UW-QOL scores could not be compared with preoperative functioning scores to evaluate if our results reflect long-term HRQOL. Since we only used one targeted head and neck questionnaire but oncological patients are treated interdisciplinary, our results could have been influenced by other medical conditions. Furthermore, HRQOL should be assessed in a larger cohort to reach better uniform distribution. In the future, it seems reasonable to include general cancer questionnaires in the assessment setup. This in mind, we accept that our results only allow limited conclusions.

Patients’ reconstruction with microvascular flaps after oral squamous cell carcinoma has good postoperative HRQOL. The T-status is a predictor for HRQOL. Swallowing, chewing, speaking, taste, and pain were the most important issues in our cohort.