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Int. J. Radiation Oncology Biol. Phys., Vol. 63, No. 5, pp. 1347–1353, 2005Copyright © 2005 Elsevier Inc.

Printed in the USA. All rights reserved0360-3016/05/$–see front matter

doi:10.1016/j.ijrobp.2005.05.057

LINICAL INVESTIGATION Head and Neck

ASSESSMENT OF QUALITY OF LIFE OF NASOPHARYNGEAL CARCINOMAPATIENTS WITH EORTC QLQ-C30 AND H&N-35 MODULES

MUSTAFA CENGIZ, M.D.,* ENIS ÖZYAR, M.D.,* MUSTAFA ESASSOLAK, M.D.,* MUSA ALTUN, M.D.,*MÜGE AKMANSU, M.D.,* MEHMET SEN, M.D.,* ÖMER UZEL, M.D.,* AYDıN YAVUZ, M.D.,*

GAMZE DALMAZ, M.D.,* CEM UZAL, M.D.,* AYSE HIÇSÖNMEZ, M.D.,* SÜREYYA SARIHAN, M.D.,*BÜNYAMIN KAPLAN, M.D.,* BESTE MELEK ATASOY, M.D.,* CÜNEYT ULUTIN, M.D.,*UFUK ABACIOGLU, M.D.,* AYSE NUR DEMIRAL, M.D.,* AND MUTLU HAYRAN, M.D.†

*Turkish Oncology Group (TOG)–Head and Neck Cancer Working Party, and †Department of Preventive Oncology, HacettepeUniversity, Ankara, Turkey

Purpose: The current study reports on long-term quality of life (QoL) status after conventional radiotherapy in187 nasopharyngeal carcinoma patients from 14 centers in Turkey.Patients and Methods: Patients with the diagnosis of nasopharyngeal carcinoma, who were treated in 14 centersin Turkey with minimum 6 months of follow-up and were in complete remission, were asked to complete Turkishversions of EORTC QLQ-C30 questionnaire and the HN-35 module. Each center participated with the requiredclinical data that included age at diagnosis, gender, symptoms on admission, follow-up period, treatmentmodalities, radiotherapy dose, and AJCC 1997 tumor stage. Each patient’s 33 QoL scores, which includedfunction, global health status, and symptoms, were calculated as instructed in EORTC QLQ-C30 scoring manual.All of the scales and single-item measures range from 0 to 100. A high score represents a higher response level.Kruskal-Wallis and Mann-Whitney U nonparametric tests were used for comparisons.Results: One hundred eighty-seven patients with median age of 46 years (range, 16–79 years) participated andcompleted the questionnaires. Median follow-up time was 3.4 years (range, 6 months–24 years). All patients havereceived external-beam radiotherapy. Beside external-beam radiotherapy, 59 patients underwent brachytherapyboost, 70 patients received concomitant chemotherapy, and 95 patients received adjuvant/neoadjuvant chemo-therapy. Most of the patients in the analysis (75%) were in advanced stage (Stage III, n � 85 [45.4%]; Stage IV,n � 55 [29%]). Mean global health status was calculated as 73. Parameters that increased global health statuswere male gender, early-stage disease, and less than 4-year follow-up (p < 0.05). Functional parameters werebetter in males and in early-stage disease. Factors that yielded better symptom scores were short interval aftertreatment (10 scores), male gender (7 scores), and lower radiation dose (6 scores). Neoadjuvant or adjuvantchemotherapy did not have any effect on QoL, whereas concomitant chemotherapy adversely affected 5 symptomscores.Conclusion: Quality of life is adversely affected in our nasopharyngeal carcinoma patients treated with combinedtherapies. The factors that adversely affect quality of life are advanced tumor stage, female gender, andlong-term follow-up. Further controlled studies to evaluate both preradiotherapy and postradiotherapy statusare necessary to clarify the contribution of each treatment modality to QoL. © 2005 Elsevier Inc.

Nasopharyngeal cancer, Radiotherapy, Quality of life, EORTC questionnaire, Chemotherapy.

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INTRODUCTION

hereas the incidence of nasopharyngeal carcinoma (NPC)s greater than 20 of 100,000 in Southern China, it is lesshan 1 of 100,000 in most of the United States and Westernurope. However, an intermediate incidence rate is ob-erved among the peoples of the Mediterranean regionhere Turkey is located (1). NPC has several unique fea-

ures compared with other head-and-neck carcinomas. Un-

Reprint requests to: Mustafa Cengiz, M.D., Department of Ra-iation Oncology, Hacettepe University, Sihhiye, Ankara 06100,urkey. Tel: (�90) 312-305-2903; Fax: (�90) 312-309-2914;-mail: mcengiz@hacettepe.edu.tr

Presented at the 46th Annual Meeting of the American Society

1347

ike other head-and-neck carcinomas, it is seen in a youngge group and is not associated with smoking or alcoholbuse. The primary treatment of NPC is radiotherapy aloner chemoradiotherapy, depending on stage of the disease,nd surgery is generally not an initial option. The tumor isocated in close proximity to base of the skull and importantital structures, such as optic nerves, optic chiasma, brain,ars, and major salivary glands. Most of these structures are

or Therapeutic Radiology and Oncology (ASTRO), October 3–7,004, Atlanta, GA.Received April 22, 2005 and in revised form May 31, 2005.

ccepted for publication May 31, 2005.

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1348 I. J. Radiation Oncology ● Biology ● Physics Volume 63, Number 5, 2005

ncluded within or in close proximity to the radiotherapyeld. After radiotherapy, late effects such as xerostomia,

rismus, swallowing difficulties, neck stiffness, hearingroblems, and neuroendocrine dysfunction may lead to de-erioration of patients overall well-being (2).

In addition to such conventional outcome parameters asurvival and disease-free survival, subjective well-being ofatients cured of their disease is equally important and isncreasingly emphasized in the literature (3). Disturbancesf the patient, singly or in combination, profoundly affectuality of life (QoL). QoL is most appropriately consideredo be a construct that reflects the individual’s perception ofverall well-being. The QoL concerns are a fundamentalspect of care for patients with head-and-neck cancer, andhis concern is reflected by a growing interest in the inves-igation of QoL issues (4).

In previous studies, self-assessment by patients of theomplaints caused by disease and treatment side effects wasound to yield worse results compared with assessment byhysicians (5, 6). Self-assessment by the patients should,herefore, become an integrated component of the analysisf treatment results. This critical tool should be included inhe assessment of the risks and benefits associated with differ-nt treatment options such as intensity-modulated radiotherapyIMRT) and novel chemoradiotherapy schedules (7).

Although several QoL studies in patients with head-and-eck cancer have been reported in the literature, data con-erning QoL in patients with NPC are only rarely reported8–12). These few reported series used Fact-G, ChineseF-36, or University of Washington questionnaires for thevaluation of QoL issues. To the best of our knowledge, theurrent QoL study of NPC patients is the first publishedtudy that made use of the European Organization for Re-earch and Treatment of Cancer (EORTC) quality of lifeuestionnaire (QLQ) C30 and the head-and-neck (H&N) 35odule.

PATIENTS AND METHODS

Patients with the diagnosis of nonmetastatic NPC from 14 TOGTurkish Oncology Group) member radiation oncology centersith a minimum of 6 months follow-up were included in the

urrent study. All centers were academic university hospitals,oordinated by the Department of Radiation Oncology at Hacet-epe University. Patients were asked to complete Turkish versionsf the EORTC QLQ-C30 and the H&N-35 module during theiratest follow-up visit to the hospital. Inclusion criteria were historyf NPC treated by radiotherapy or chemoradiotherapy without anyvidence of second primary or recurrent tumor at their latestvaluation and freedom from major psychiatric disorder that mightonfound QoL evaluation.

Each center provided clinical data that included age at diagnosis,ender, tumor stage according to the AJCC 1997, treatment mo-alities, and radiotherapy parameters. No limitations were imposedith regard to age or performance status.

uestionnairesA core QoL questionnaire—EORTC QLQ-C30 version 3.0

13)—is used together with diagnosis-specific modules to increase u

he coverage, sensitivity, and specificity of the assessments inarious patient and treatment groups. It is a cancer-specific, self-eport questionnaire validated in several studies and includes 30uestions. The cross-cultural validity and psychometric propertiesre considered satisfactory (14–16). The questionnaire comprises

functioning scales (physical, role, emotional, cognitive, andocial functioning), 9 symptom scales (fatigue, nausea and vom-ting, pain, dyspnea, insomnia, appetite loss, constipation, diarrhea,nd financial difficulties), and a global health status/QL scale.

The EORTC QLQ H&N-35 module is designed to be usedogether with the core QLQ-C30 to measure symptoms and prob-ems related to tumor location and treatment. Seven subscales haveeen constructed that measure pain, swallowing, sense, speech,ocial eating, social contact, and sexuality. Eleven items relate toeeth, mouth opening, dry mouth, sticky saliva, coughing, ill feel-ng, weight loss, weight gain, use of pain killer, nutritional sup-lements, and feeding tube. The time frame of the module isduring the past week,” and the format is similar to the coreuestionnaire. Thirty-five questions regarding the functions andymptoms of the patients were included in this questionnaire.

Each patient’s 33 QoL scores, including function, global healthtatus, and symptoms, were calculated as instructed in EORTCLQ-C30 scoring manual. All of the scales and single-item mea-

ures range from 0 to 100. A high score represents a higheresponse level. Thus, a high score for a functional scale represents

high/healthy level of functioning, a high score for the globalealth status/QoL represents a high QoL, but a high score for aymptom scale/item represents a high level of symptomatology/roblems.Statistical analyses made use of the Kruskal-Wallis test for

ariables with more than 2 categories and the Mann-Whitney-test for pairwise comparisons that accounted for the nonpara-etric distribution of the QoL scores. A p value of 0.05 was used

o flag significant determinants.

RESULTS

One hundred eighty-seven patients with median age of 46ears (range, 16–79 years) participated in this study byompleting the questionnaires. The patient characteristicsre summarized in Table 1. Median follow-up time is 3.4ears (range, 6 months–24 years). Most of the patients in thenalysis (75%) were in advanced stage. Eighty-five patients45.4%) and 55 patients (29%) had Stage III and Stage IVisease, respectively.All patients received external-beam radiotherapy by

-MV linear accelerator or 60Co teletherapy machine. Me-ian external-beam radiotherapy dose was 67.8 Gy (range,0–74 Gy) by use of conventional fractionation. External-eam radiotherapy was delivered in 2 lateral opposing por-als. In addition to external-beam radiotherapy, 59 patients32%) received adjuvant brachytherapy boost after external-eam radiotherapy by HDR 192Ir source. Brachytherapy waselivered by use of a single-channel nasal applicator mod-fied from a pediatric endotracheal tube. The brachytherapyose was prescribed to a point 1 cm from the source axis,nd a total dose of 12 Gy in 3 fractions was administeredmmediately after external-beam radiotherapy on 3 consec-

tive days. Median external-beam radiotherapy dose to na-

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1349Quality of life of nasopharyngeal carcinoma patients ● M. CENGIZ et al.

opharynx in the brachytherapy group was 66 Gy (range,0–72 Gy) and for the external-beam radiotherapy onlyroup, median dose was 70 Gy (range, 50–74 Gy). Exter-al-beam radiotherapy dose was significantly higher in thexternal-beam radiotherapy only group (p � 0.001).

Overall, 138 patients (74%) were treated with chemother-py beside external-beam radiotherapy. Whereas 70 patientseceived concomitant chemotherapy, 95 patients receiveddjuvant/neoadjuvant chemotherapy. Concomitant chemo-herapy was solely cisplatinum and adjuvant/neoadjuvanthemotherapy was also cisplatin-based protocols. Only 3

Table 1. Patient characteristics

Characteristics Number %

exMale 121 64.7Female 66 35.3

tageI 9 4.8IIa 13 7IIb 24 12.8III 86 46IVA 37 19.8IVB 18 9.6

hemotherapyNone 49 26.2Neoadjuvant 70 37.4Concomitant 70 37.4Adjuvant 25 13.4

adiotherapy dose�70 Gy 79 57.8�70 Gy 108 42.2

rachytherapy 59 31.6ollow-up�4 years 111 59.4�4 years 76 40.6

Table 2. Calculated sco

Scale name Mean score

Global health status/QOLGlobal health status 73.0

Functional ScalesPhysical functioning 84.8Role functioning 91.3Emotional functioning 76.7Cognitive functioning 81.2Social functioning 83.0

Symptom scales/itemsFatigue 25.2Nausea and vomiting 5.4Pain 13.8Dyspnoea 4.5Insomnia 13.8Appetite loss 10.5Constipation 19.1Diarrhea 4.2Financial difficulties 27.5

Abbreviations: IQR � interquartile range;

questionnaire.

atients underwent surgery in the form of neck dissectionfter radiotherapy.

Our observation showed that completion of question-aires took 15 to 30 minutes among the patients. Calculatedcores for the QLQ-C30 and the H&N-35 module are shownn Tables 2 and 3, respectively. Mean global health statusas calculated as 73. In our patient population, the highest

ymptom scores of EORTC QLQ-C30 were financial diffi-ulties and fatigue. Among functional scales, emotionalunctioning was the worst and role functioning ranked theighest scores. In the H&N-35 module, dry mouth andticky saliva ranked the highest scores, followed by weightain, teeth problems, pain killers, and mouth opening.Global health status was better in patients with male

ender, early-stage disease, and less than 4-year follow-upp � 0.05) (Figs. 1 and 2). Functional parameters wereetter in males and in early-stage disease (p � 0.05). Fac-ors that yielded better symptom scores were short intervalfter treatment (10 scores: dyspnea, pain, financial difficul-ies, swallowing, speech problems, trouble with social eat-ng, coughing, feeling ill, pain killer, and weight gain), maleender (7 scores: fatigue, appetite loss, nausea-vomiting,ense problems, opening mouth, and feeling ill), and lowerxternal-beam radiation dose (6 scores: financial difficul-ies, swallowing, sense problems, trouble with social eating,eeth problems, and dry mouth) (p � 0.05). Patients whoeceived neoadjuvant or adjuvant chemotherapy did as wells patients who did not receive chemotherapy as far as QoLcores were concerned, whereas concomitant chemotherapyeem to adversely effect 5 symptom scores (insomnia, trou-le with social eating, ill feeling, weight gain, and the needf nutritional supplement) when compared with radiothera-y-only patients. Because of a possible bias in which stagef the disease might determine the treatment, we ran the

QLQ-C30 Version 3.0

ian score IQR Range

66.7 (50.0–83.3) (8.3–100.0)

86.7 (73.3–93.3) (13.3–100.0)00.0 (83.3–100.0) (0.0–100.0)83.3 (66.7–91.7) (0.0–100.0)83.3 (66.7–100.0) (0.0–100.0)00.0 (66.7–100.0) (16.7–100.0)

33.3 (11.1–33.3) (0.0–88.9)0.0 (0.0–0.0) (0.0–100.0)

16.7 (0.0–33.3) (0.0–100.0)0.0 (0.0–0.0) (0.0–100.0)0.0 (0.0–33.3) (0.0–100.0)0.0 (0.0–33.3) (0.0–100.0)0.0 (0.0–33.3) (0.0–100.0)0.0 (0.0–0.0) (0.0–100.0)

33.3 (0.0–33.3) (0.0–100.0)

� quality of life; QLQ � quality of life

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1350 I. J. Radiation Oncology ● Biology ● Physics Volume 63, Number 5, 2005

tatistics for correlation among selected treatment and stagef disease. The analysis showed the stages were similaretween the groups who received and did not receive con-omitant chemotherapy (p � 0.958). Patients who receiveddjuvant brachytherapy boost after external-beam radiother-py did as well as patients who did not undergo suchrocedure in regard to QoL. We also analyzed the effect ofenters on QoL both descriptively and analytically andoncluded that the effect of centers was negligible. Noifferences occurred in treatment among centers in regard toeld size, technique, and chemotherapy usage.

Table 3. Calculated

Scale name Mean score

Symptom scales/itemsPain 14.8Swallowing 24.2Sense problems 17.4Speech problems 11.9Trouble with social eating 13.2Trouble with social eating 9.5Less sexuality 19.3Teeth 44.9Opening mouth 36.0Dry mouth 66.4Sticky saliva 57.3Coughing 17.5Feeling ill 16.9Pain killers 42.7Nutritional supplements 15.3Feeding tube 0.0Weight loss 16.2Weight gain 45.0

Abbreviations: IQR � interquartile range;questionnaire.

Fig. 1. Median global health status and f

We also performed statistical analysis to see if any coin-idence occurred between weight gain and mouth and teethroblems. However, our data showed that all the correlationoefficients between the weight gain and other symptomcales mentioned are statistically insignificant (all r � 0.1,ll p � 0.2).

DISCUSSION

Radiotherapy treatment fields for NPC are usually largend include several critical structures that may adversely

for QLQ H&N-35

edian score IQR Range

8.3 (0.0–25.0) (0.0–91.7)25.0 (16.7–41.7) (0.0–100.0)

8.3 (0.0–33.3) (0.0–100.0)11.1 (0.0–22.2) (0.0–100.0)

8.3 (0.0–25.0) (0.0–100.0)0.0 (0.0–13.3) (0.0–86.7)0.0 (0.0–33.3) (0.0–100.0)

33.3 (0.0–100.0) (0.0–100.0)33.3 (0.0–66.7) (0.0–100.0)66.7 (33.3–100.0) (0.0–100.0)66.7 (33.3–100.0) (0.0–100.0)33.3 (0.0–33.3) (0.0–100.0)16.7 (0.0–33.3) (0.0–100.0)0.0 (0.0–100.0) (0.0–100.0)0.0 (0.0–0.0) (0.0–100.0)0.0 (0.0–0.0) (0.0–100.0)0.0 (0.0–0.0) (0.0–100.0)0.0 (0.0–100.0) (0.0–100.0)

� head and neck; QLQ � quality of life

scores

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1351Quality of life of nasopharyngeal carcinoma patients ● M. CENGIZ et al.

ffect QoL, such as the parotid glands, neural structures, andemporomandibular joints (2). A previous QoL study inead-and-neck cancer patients performed by Huguenin etl. (17) showed that the patients with nasopharyngeal car-inoma had the highest morbidity, most probably because ofarge radiotherapy fields used during treatment.

In our study, we used the EORTC C30 version 3.0ogether with the H&N-35 module. These questionnairesre comprehensive, and their validity, internal consistency,nd reliability in patients from different nations were testedn large patient groups (14–16). The Turkish version of theuestionnaires were previously tested, confirmed, and vali-ated by EORTC. However, completion of the question-aires takes approximately 15 to 30 minutes, and calcula-ion of the scores requires statistical expertise. Differencesf high and low means in global QoL score, symptomcales, and functional scales make the process complicated.urthermore, EORTC C30 version 3.0, together with the&N-35 module, is a general head-and-neck QoL scoring

ystem and may have some limitations for evaluation ofasopharyngeal carcinoma patients, because it does not dealith deafness, otitis media, symptoms from temporal lobe

njury, and hypopituitarism well enough.Our results showed that patients with early-stage disease,ale gender, and shorter follow-up time had better QoL.lthough higher radiation dose and concomitant chemother-

py did not have any effect on global health status, theyaused significantly higher scores in some symptoms. Theore questionnaire revealed that financial difficulties andatigue ranked the highest symptom scores and emotionalunctioning was the worst of the functional scores among

Fig. 2. Median global health statu

ur patient population. Moreover, the H&N-35 question- v

aire showed that the NPC survivors suffered mostlyouth, teeth, and swallowing problems and weight gain.ur analysis did not show any coincidence with weight gain

nd mouth problems. Despite absence of coincidence,eight gain in such a group of patients is still a confusingroblem. We speculate that the patients dealing with such aisease eat more to feel better.We observed that our patients mostly experienced symp-

oms directly related to xerostomia, beside limitation ofouth opening. These side effects mainly result from irra-

iation of the parotid gland, temporomandibular joint, andasticatory mucles. The new treatment modalities, such as

MRT and use of stereotactic boost, may help to loweradiation dose to these structures and to improve QoL in thePC patient group (7). Although IMRT and stereotactic

echniques are present in only a few centers, the number ofew facilities is increasing in Turkey. However, the contra-ictory issue is that the use of these expensive sophisticatedechniques in radiotherapy will increase the expenses forancer treatment and eventually increase the financial dif-culties of individuals in developing countries such as Tur-ey and, consequently, might adversely affect QoL. Thempact of financial or socioeconomical status on health-elated QoL is also discussed by other authors. Yu et al. (9)nd Fang et al. (12) reported the importance of financialroblems on QoL by use of Fact-G and Chinese SF-36uestionnaires. Nevertheless, further controlled studieshould be performed to test impact of new treatment mo-alities on QoL.Intensification of the treatment by increase of the radia-

ion dose and use of concomitant chemotherapy have ad-

functional scale scores by stage.

erse effects on symptom scores but no effect on global

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1352 I. J. Radiation Oncology ● Biology ● Physics Volume 63, Number 5, 2005

ealth status and functional scores. Previous studies on NPCid not analyze the effect of treatment factors on QoL8–12). Although no change in global health status oc-urred, we believe that change in symptom scores is alsomportant and should have some impact on the choice ofreatment plan. Our findings point out the importance ofeduction of radiation dose, especially when chemothera-eutic agents are used. To increase radiation dose to naso-harynx, brachytherapy boost might be a rational strategy inelected patients because it did not lead to any worsening inoL scales when patient groups were compared.The strongest determinant of global health score, major-

ty of functional scores, and symptom scales was gender inur study. We cannot explain why males did significantlyetter than females. Gender of the patients has not beenhown to be an important determinant in previous studies byuthors who used Fact-G, Chinese SF-36, and University of

ashington questionnaires (9–12). The reason might be theubjectivity of questionnaires and use of different question-aires in previous studies or cultural differences amongatient populations.Early-stage disease was another important factor that

ielded better QoL in our analysis. This finding is consistentith the other findings that relatively less-intensive treat-ents used in early-stage disease led to decreased worsen-

ng of the QoL. However, this observation is not the case inur patient group. Therefore, in our patient population,election of treatments is not associated with stage of theisease, and tumor burden probably is the leading factor fororsening of QoL. Yu et al. (9) also showed that early-stageisease had less effect on QoL with respect to advancedtage.

In our study, the reported severity of the symptoms wasigher in the patients with more than 4 years of follow-upfter radiotherapy, and global health score was significantlyower in this group when compared with patients at earlier

eriods, which is consistent with the previous report by t

REFEREN

J Cancer Ed 1992;7:421.

1

1

1

uguenin et al. (17). The patients in his study reported mostevere symptoms 5 years after radiotherapy. Therefore,lose attention and care should be given to patients not onlyuring the period of radiotherapy but also during follow-up.e believe that this finding also might result from subjec-

ivity of the questionnaires. Cure of the tumor may leadatients to stop worrying about tumor and put treatment-elated morbidity up front and, consequently, experienceorsening of the health-related QoL as time passes by. On

he other hand, these findings do not necessarily mean thathe symptoms are getting worse with time. However, theseroblems warrant clinical attention because they were stillery important issues for patients who survived longnough. The design of our study is cross-sectional, and QoLs measured only once for each of the patients. The patternf changes in QoL with time can best be evaluated byongitudinal studies, in which QoL is measured before,uring, and at specified timepoints after treatment for everyatient.The scores of most of the function and symptom scales on

he QLQ-C30 in our patients are comparable to previousesults from studies that used different instruments in NPCatients. In all studies, regardless of the questionnaires used9–12), the main QoL concerns are pain, mouth, teeth, andating problems, as is the case in our study.

In conclusion, radiation therapy adversely affected QoLn NPC patients. Through the use of new radiotherapyechniques, such as IMRT, and biologic agents, such asadioprotectors, the critical structures within the radiother-py field, especially temporomandibular joints and salivarylands, can be protected while radiotherapy is escalated toigher doses. Thus, patients might benefit in terms of tumorontrol without severe side effects and might have a higheroL in the long run. Further controlled longitudinal studies

re necessary to clarify the contribution of patient-related,

umor-related, and treatment-related factors to QoL.

CES

1. Hoffman HT, Karnell LH, Funk GF, et al. The national cancerdatabase report on cancer of the head and neck. Arch Otolar-yngol Head Neck Surg 1998;124:951–962.

2. Chao KSC, Perez CA. Nasopharynx. In: Perez CA, BradyLW, Halperin EC, Schmidt-Ullrich RK, editors. Principles andpractice of oncology. 4th ed. Philadelphia: Lippincott Wil-liams & Wilkins: 2004. p. 918–961.

3. Morton RP, Izzard ME. Quality of life outcomes in head andneck cancer patients. World J Surg 2003;27:884–889.

4. Portenoy RK, Spebner KT. Quality of life issues in patientswith head and neck cancer. In: Harrison LB, Sessions RB,Hong WK, editors. Head and neck cancer. 2nd ed. Philadel-phia: Lippincott Williams & Wilkins: 2004. p. 165–177.

5. Presant CA. Quality of life in cancer patients: Who measureswhat? Am J Clin Oncol 1984;7:571.

6. Kahn SB, Hums PS, Harding SP. Quality of life and patientswith cancer: A comparative study of patients versus physi-cians perceptions and its implications for cancer education.

7. Cengiz M, Chao KSC, Perez CA. Intensity-modulated radio-therapy (IMRT) with concurrent cisplatin chemotherapyyields superior therapeutic outcome than conventional tech-niques with or without chemotherapy in locally advanced naso-pharyngeal carcinoma. Int J Radiat Oncol Biol Phys 2000;48(Suppl. 3):325.

8. Yu CL, Fielding R, Chan CL. The mediating role of optimismon post-radiation quality of life in nasopharyngeal carcinoma.Qual Life Res 2003;12:41–51.

9. Yu CL, Fielding R, Chan CL, et al. Chinese nasopharyngealcarcinoma patients treated with radiotherapy. Cancer 2001;92:2126–2135.

0. McMillan AS, Pow ENH, Leung WK, et al. Oral healthrelated quality of life in southern Chinese following radiother-apy for nasopharyngeal carcinoma. J Oral Rehab 2004;31:600–608.

1. Talmi YP, Horowitz Z, Bedrin L, et al. Quality of life of naso-pharyngeal carcinoma patients. Cancer 2002;94:1012–1017.

2. Fang FM, Chiu HC, Kuo WR, et al. Health related quality of

1

1

1

1

1

1353Quality of life of nasopharyngeal carcinoma patients ● M. CENGIZ et al.

life for nasopharyngeal carcinoma patients with cancer-freesurvival after treatment. Int J Radiat Oncol Biol Phys2002;53:959–968.

3. Aaronson NK, Ahmedzai S, Bergman B, et al. The Euro-pean Organization for Research and Treatment of CancerQLQ-C30: A quality-of-life instrument for use in interna-tional clinical trials in oncology. J Natl Cancer Inst 1993;85:365–376.

4. Bjordal K, de Graeff A, Fayers PM, et al. 12 country fieldstudy of the EORTC QLQ-C30 (version 3.0) and the head andneck cancer specific module (EORTC QLQ-H&N35) in headand neck patients. EORTC Quality of Life Group. Eur JCancer 2000;36:1796–1807.

5. Sherman AC, Simonton S, Adams DC, et al. Assessing quality

of life in patients with head and neck cancer: Cross-validationof the European Organization for Research and Treatment ofCancer (EORTC) quality of life head and neck module(QLQ-H&N35). Arch Otolaryngol Head Neck Surg 2000;126:459–467.

6. Bjordal K, Hammerlid E, Ahlner-Elmqvist M, et al. Quality oflife in head and neck cancer patients: Validation of the Euro-pean Organization Research and Treatment of Cancer qualityof life questionnaire—H&N 35. J Clin Oncol 1999;17:1008–1019.

7. Huguenin PU, Thaussky D, Moe K, et al. Quality of life inpatients cured from a carcinoma of the head and neck byradiotherapy: The importance of the target volume. Int J

Radiat Oncol Biol Phys 1999;45:47–52.