© 2004 Foundation for Promotion of Cancer Research
Health-related Quality of Life Outcome for Oral Cancer Survivors after Surgery and Postoperative Radiotherapy
1 Department of Radiation Oncology, 3 Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, 4 Department of Public Health, Kaohsiung Medical University, Kaohsiung and 2 Department of Cosmetic Application and Management, Yung Ta Institute of Technology and Commerce, Pintung, Taiwan
For reprints and all correspondence: Fu-Min Fang, Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital, 123 Ta-Pei Rd, Niao Sung Hsiang, Kaohsiung Hsien, Taiwan. E-mail: a7323630{at}ms14.hinet.net
Received May 19, 2004; accepted August 8, 2004
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Abstract |
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 TOP Abstract INTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONReferences |
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Background: Health-related quality of life (HRQL) data are becoming an important supplement to information pertaining to treatment outcome for cancer patients. The purpose of this study was to evaluate the HRQL outcome for oral cancer survivors after surgery plus postoperative radiotherapy (RT) and to investigate the variables associated with their HRQL.
Methods: Sixty-six oral cancer patients with cancer-free survival after surgery plus postoperative RT of >2 years were enrolled. The Short Form-36 (SF-36) questionnaire in the Taiwan Chinese version was self-reported by all participants at the clinics. The linear regression model was used to analyze the socio-demographic and medical-related variables correlated with the physical component summary (PCS) and mental component summary (MCS) in SF-36.
Results: The mean scores of the eight functional domains in the SF-36 were markedly lower for oral cancer survivors compared with the Taiwanese and US norms. Those with older age, lower annual family income, more advanced cancer stage and flap reconstruction had significantly worse PCS, and those with lower annual family income, unemployment and more advanced cancer stage reported significantly worse MCS. This model accounts for 63% of variance in PCS, and 51% in MCS.
Conclusions: These results provided patient-reported evidence that oral cancer survivors lived with a worse HRQL compared with the general Taiwanese population. Socio-economic factors and cancer stage were important factors correlated with their HRQL.
Key Words: quality of life • oral cancer • postoperative radiotherapy • socio-economic factors
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INTRODUCTION |
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Squamous cell carcinoma of oral cancer is a prevalent disease in southern Taiwan, where the habit of betel quid chewing is common. The treatment modality of surgery combined with postoperative radiotherapy (RT) for advanced but curable cases has been well recognized. The 3-year actuarial survival rate for patients with oral cancer after surgery plus postoperative RT was 55% in our hospital (1). However, composite resection of oral cancers usually destroyed patients' facial looks, mouth opening, swallowing or speech functions, and subsequent adjuvant RT would further induce irreversible fibrosis of the organs irradiated, causing impaired taste and/or permanent xerostomia. Little research has been conducted to explore exclusively the way that oral cancer survivors live with the threat of cancer relapse and treatment morbidity, and the subsequent changes of their physical and mental functions after radical operation plus postoperative RT.
Health-related quality of life (HRQL) data are becoming an important supplement to information pertaining to treatment outcome for head-and-neck cancer patients (2–5). HRQL generally refers to the perception of the effects of disease and the impact on the patient's daily functioning. HRQL has two fundamental premises. First, it is a multidimensional survey incorporating the physical, psychological, social and emotional functional domains. Secondly, it is subjective and instruments must be self-reporting according to the patient's own experiences. With the use of HRQL, the manner in which patients perceive and cope with their disease could be usefully assessed. There are now a variety of well-validated HRQL instruments available for use in the field of oncology. Three types of methods have been categorized. They include the generic type, e.g. the Short Form-36 (SF-36), the cancer-specific type, e.g. the Functional Assessment of Cancer Treatment (FACT-G), the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30), and the cancer site-specific type, e.g. the FACT-HN or EORTC QLQ-H&N35 (6–10).
In this research, we compare the SF-36 scores of oral cancer survivors with the reported normative data of SF-36 for the Taiwanese and US populations (6,11,12). In addition, using a linear regression model, we analyze the socio-demographic and medical-related variables correlated with the physical component summary (PCS) and mental component summary (MCS) in SF-36 for these survivors.
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SUBJECTS AND METHODS |
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PATIENTS
From January 1995 to December 2001, there were 268 newly diagnosed oral squamous cell carcinoma patients treated with postoperative RT at the Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital. Sixty-six patients with cancer-free survival and receiving regular follow-up for >2 years were enrolled in this study. Patients revealing a history with a second primary cancer, tumor recurrence and/or a level of cognitive impairment were excluded from participation in this study. The cancer-free status was confirmed by results of clinical examinations and recent image studies. At the latest follow-up, these patients completed the questionnaire of the Taiwan Chinese SF-36 by themselves or with the assistance of a trained interviewer if they did not understand the Chinese characters.
Concerning the existence of selection bias, we also compared the distributions of socio-demographic characteristics (including age, gender, marital status and years of education) between oral cancer survivors in this study and the other surviving oral cancer patients found in the cancer registry database in the department. No statistically significant differences were found between them (data not shown).
PATIENT CHARACTERISTICS
Table 1 lists the socio-demographic and medical-related variables for the 66 oral cancer survivors. A summary of the primary cancer site included 16 cases (24.3%) of gum cancer, 28 (42.4%) of buccal mucosa cancer and 22 (33.3%) of oral tongue cancer. Most of these patients were male (91%) and derived from lower socio-economic levels of Taiwanese society. More than half of them (54.5%) received education <6 years, 60.6% had an annual family income <1 000 000 NTD (1 US$ = 33 NTD), 60.6% were unemployed and 27.3% lived without a spouse (unmarried or divorced).
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According to the clinical staging system of the American Joint Committee on Cancer (AJCC) in 1997 (13), there were 12 patients (18.2%) in stage II, 36 patients (54.5%) in stage III and 18 patients in stage IV (27.3%). Radical resections of the primary tumor combined with neck dissection were the standard procedures to treat these patients. At presentation for RT, 38 patients (57.5%) were operated on with a wide excision of the cheek mass, 21 patients (31.8%) with a marginal or segmental mandibulectomy, 22 patients (33.3%) with a partial or nearly total glossectomy, 42 patients (63.6%) with a flap reconstruction and 62 patients (93.9%) had undergone a functional or modified radical neck dissection.
The median time interval between surgery and postoperative RT was 6 weeks (range 4–9 weeks). Conventional fractionation of RT administering 1.8–2.0 Gy per day, with five fractions per week, was the standard therapeutic schedule of RT for oral cancer patients at our institution (1). Large-field irradiation was conducted to cover the entire tumor bed and regional lymphatics, followed by a boost-field irradiation to the risky tumor and nodal bed area. The median total dose was 61.2 Gy (range 57.2–70.2). Ten patients (15.2%) received systemic chemotherapy before surgery or combination with RT. The combination regimens of cisplatin and 5-fluorouracil (FU) via intravenous infusion were usually given. Fifty patients (75.8%) received pre-RT dental care, which included the removal of caries and molars and polish fluoridation. Twenty-two patients (33.3%) had at least one type of co-morbidity. The types of co-morbidity were defined in our previous publication (14). Survival time was calculated from the date when RT ended to that when the patient completed the questionnaire. The distributions of survival years were 50.0% for 2–4 years, 34.8% for >4–6 years and 15.2% for >6 years.
QUESTIONNAIRE
The SF-36, developed by the Medical Outcomes Study (MOS) group, was selected for use in this study. The reasons included (i) the validity of the SF-36 has been rigorously evaluated; (ii) the Taiwan Chinese version of the SF-36 is readily available (15); (iii) the SF-36 is suitable for the normal population, and the data of SF-36 for a variety of the normal population are available for comparison; (iv) the SF-36 provides a comprehensive health survey, which can be completed at clinics in 5–10 min; and (v) the data of the PCS and MCS in SF-36 could clearly demonstrate the outcome of physical and mental health. The SF-36 included 36 questions in eight functional domains, which were physical functioning (PF), role limitation due to physical functioning (RP), role limitation due to emotional problems (RE), social functioning (SF), bodily pain (BP), vitality (VT), mental health (MH) and general health perception (GH). Scores for each ranged from 0 to 100, with higher scores indicating a better status of the function domain. The two normalized component scale summaries (PCS and MCS) were calculated from the SF-36 data based on the normal population of the USA (6).
STATISTICS
The mean scores of the eight functional domains, PCS and MCS in SF-36 were calculated according to the SF-36 manual provided (6). For the purpose of the analysis, the patient characteristics such as age, years of education, annual family income, radiation dose, number of co-morbidities and survival years were analyzed as continuous data. The other characteristics were categorized into groups that were logical. The linear regression model was used to evaluate the associations between the dependent variable (PCS or MCS) and independent variables (socio-demographic and medical-related variables). The data were analyzed using the statistical package SPSS for Windows (SPSS Inc., Chicago, IL) (16).
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RESULTS |
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SF-36 OUTCOME
The mean scores (SD) of the SF-36 for these oral cancer survivors were as follows: 77.3 (22.9) in PF, 45.5 (44.9) in RP, 53.5 (46.7) in RE, 71.2 (18.2) in SF, 70.8 (21.6) in BP, 55.2 (18.9) in VT, 61.4 (16.8) in MH, 55.0 (19.4) in GH, 45.4 (8.5) in PCS, and 42.9 (9.8) in MCS. Figure 1 shows that oral cancer survivors had markedly lower mean scores on all the functional domains in SF-36 compared with the reported Taiwanese or US norms (6,12).
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VARIABLES CORRELATED TO PCS AND MCS
Table 2 lists the linear regression model that correlated the socio-demographic and medical-related variables with the PCS or MCS in SF-36 for oral cancer survivors. Statistically significant variables were age, annual family income, cancer stage and flap reconstruction for PCS, and annual family income, occupation status and cancer stage for MCS. Those with older age [regression coefficient (ß) = –0.306, P = 0.026], lower annual family income (ß = 0.568, P = 0.000), more advanced cancer stage (ß = –0.295, P = 0.007) and flap reconstruction (ß = –0.239, P = 0.040) had significantly worse PCS scores. On the other hand, those with lower annual family income (ß = 0.446, P = 0.002), unemployment (ß = 0.376, P = 0.026) and more advanced cancer stage (ß = –0.229, P = 0.012) reported significantly worse MCS. As regards the variables of gender, years of education, marital status, cancer site, radiation dose (<60 Gy/
60 Gy), combination with chemotherapy or not, number of co-morbidities, dental care and survival years, none of them were found to be correlated with the PCS or MCS with statistical significance. This model accounts for 63% of variance in PCS, and 51% in MCS.
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DISCUSSION |
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Acknowledging the relatively heterogeneous nature of oral cancer patients and experienced treatments including varying tumor stages, sites and the frequently diverse treatment modalities applied and administering institutions involved, the findings of HRQL outcome for oral cancer patients following treatment appear to be somewhat discordant and also complicated in the literature. Comparing 97 head-and-neck cancer patients with age-matched US norms, Terrell et al. found that most functional domains (except BP and GH) of the SF-36 after treatment were significantly worse (17). Funk et al. found the HRQL outcomes of 180 head-and-neck cancer patients at
6 months after treatment were significantly worse than age-matched US norms in most functional domains of the SF-36 (18). Rogers et al. evaluated 50 oral cancer patients following surgery alone or in combination with RT (44%) and found that their HRQL outcome at 12 months after surgery was lower than US norms in RP, RE and SF of the SF-36 (19). In contrast, Hammerlid and Taft compared the HRQL outcome in head-and-neck cancer survivors with Swedish norms, reporting no significant difference in most functional domains of the SF-36 (except RP), although the treatment-related or disease-specific symptomatic problems (e.g. swallowing, local pain and dry mouth) measured by EORTC QLQ-H&N35 were significantly worse than the norms (20). In the present study, we exclusively discern the HRQL of oral cancer survivors treated with surgery plus postoperative RT at a single institute. Our findings demonstrated that the mean scores of all the functional domains in the SF-36 were markedly worse for oral cancer survivors compared with Taiwanese norms. Several prospective studies have demonstrated the longitudinal changes in HRQL for head-and-neck cancer patients following treatments. In the series reported by Rogers et al., they found at the time of presentation that patients with oral cancer scored lower than the norms, particularly in RP, RE and SF. At 3 months following surgery, there was a considerable deterioration in PF, RP, VT and GH. One year after surgery, most of the SF-36 scores approached the pre-treatment level (19). de Graeff et al. prospectively evaluated the changes of HRQL for 107 head-and-neck cancer patients treated by surgery and/or RT by using the EORTC QLQ-C30 and QLQ-H&N35 questionnaire before treatment, and 6, 12, 24 and 36 months later. They found a limited deterioration of PF and RF and many head-and-neck symptoms at 6 months, which improved thereafter. After 36 months, only PF, taste/smell, dry mouth and sticky saliva were significantly worse, compared with baseline (21). Bjordal et al. also prospectively evaluated the HRQL of head-and-neck cancer patients treated with surgery, RT and/or chemotherapy by using the EORTC QLQ-C30 and QLQ-H&N35 at baseline and 1, 2, 3, 6 and 12 months later. They found the general trend was that HRQL deteriorated significantly during treatment, followed by a slow recovery until the 12 month follow-up, with a few exceptions (senses, dry mouth and sexuality) (22).
We found that oral cancer survivors with older age (ß = –0.306, P = 0.026), lower annual family income (ß = 0.568, P = 0.000), more advanced cancer stage (ß = –0.295, P = 0.007) and flap reconstruction (ß = –0.239, P = 0.040) had significantly worse PCS. On the other hand, those with lower annual family income (ß = 0.446, P = 0.002), unemployment (ß = 0.376, P = 0.026) and more advanced stage (ß = –0.229, P = 0.012) reported significantly worse MCS. With the heterogeneous nature of the materials in the literature, factors significantly correlated with the HRQL for head-and-neck cancer patients were also found to be diverse. In the series reported by Hammerlid and Taft, factors related to patients' age, gender and location of tumor appear to have bearing on the reported HRQL for head-and-neck survivors 3 years after treatment. They found that those with a tumor located at the larynx, aged below 65 years or female patients had significantly better SF-36 scores than their counterparts (20). In the series reported by de Graeff et al., female sex, higher cancer stage and combination treatment were found to be associated with more symptomatic problems and worse HRQL (21). Zelefsky et al. evaluated the long-term subjective functions by the performance status scale for 35 advanced oral cavity and oropharyngeal cancer patients after RT, and reported deterioration of subjective functional scores with increasing T stage and worse scores in patients with lesions in the base of tongue than in the mobile tongue, floor of the mouth or tonsils (23). Campbell et al. evaluated the HRQL for 72 head-and-neck cancer patients with a 3-year disease-free survival using the questionnaires of the University of Washington HRQL, the Performance Status Scale for Head and Neck Cancer (PSS-HN), the FACT-G scale and the FACT-HN. They found advanced cancer stage was significantly correlated with lower HRQL scores in the domains of disfigurement, chewing ability, speech and eating in public. Patients treated with RT alone had significantly better HRQL scores than those treated with combined surgery/RT in the pain, disfigurement, chewing and speech domains (24).
Socio-economic status is a well-known predictor of disease morbidity or mortality rates. Individuals lower in the socio-economic hierarchy suffer disproportionately more from almost every disease and have poorer prognosis than those with higher socio-economic status (25). Sprangers et al. evaluated the HRQL of 15 000 patients with chronic diseases using the SF-36. They found that patients who were older, with lower education levels and with at least one co-morbid condition generally had a lower level of HRQL (26). Similar results have been found in other cancer patients. Penson et al. reported that prostate cancer patients with lower socio-economic status had significantly lower scores of most functional domains in the SF-36 before and after treatment (27). Ramsey et al. reported that lower income status in survivors of colorectal cancer was associated with worse outcome for reported pain, ambulation, and social and emotional status (28). Ashing-Giwa et al. evaluated HRQL for 278 breast cancer survivors using the SF-36. The differences of HRQL outcomes were found to be attributable to their socio-economic and life-burden factors (29).
We did not find that any radiation-related parameters (radiation dose, combination with chemotherapy or not, or pre-RT dental care) had a significant correlation with PCS or MCS. However, it has been suggested that the specific target site of irradiation may affect the HRQL for head and neck cancer survivors (30). Quite a homogeneous content of the adjuvant therapy in our subjects might not demonstrate any significant differences in the HRQL detected by the SF-36.
In conclusion, our findings provided patient-reported evidence to demonstrate that oral cancer survivors lived with a worse HRQL compared with the general Taiwanese population. Socio-economic factors and cancer stage were important factors correlated with the HRQL. However, this study was a cross-sectional survey, and there were no pre-treatment HRQL data to investigate the changes of HRQL during the course of follow-up. Therefore, a prospective and longitudinal design with repeated measurements of HRQL before and following treatment will be planned in a further study.
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Acknowledgments |
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This study was supported by the grant NSC 90-2320-B-182A-006 from the National Science Council, Taiwan.
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References |
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TOPAbstractINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONReferences |
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1 Fang FM, Leung SW, Huang CC, Liu YT, Wang CJ, Chen HC, et al. Combined-modality therapy for squamous carcinoma of the buccal mucosa: treatment results and prognostic factors. Head Neck 1997;19:506–12.[CrossRef][Web of Science][Medline]
2 Ganz PA. Quality of life and the patient with cancer: individual and policy implications. Cancer 1994;74:1445–52.[CrossRef][Web of Science][Medline]
3 de Boer MF, McCormick LK, Pruyn JFA, Ryckman RM, van den Borne BW. Physical and psychosocial correlates of head and neck cancer: a review of the literature. Otolaryngol Head Neck Surg 1999;120:427–36.[CrossRef][Web of Science][Medline]
4 List MA, Stracks J. Evaluation of quality of life in patients definitively treated for squamous carcinoma of the head and neck. Curr Opin Oncol 2000;12:215–20.[CrossRef][Web of Science][Medline]
5 Rogers SN, Fisher SE, Woolgar JA. A review of quality of life: assessment in oral cancer. Int J Oral Maxillofac Surg 1999;28:99–117.[Web of Science][Medline]
6 Ware JE Jr, Kosinski M, Keller SD. SF-36 Physical and Mental Health Summary Scales: A User's Manual. Boston: The Health Institute, New England Medical Center, 1994.
7 Ware JE Jr, Sherbourne CD. The MOS 36-Item Short-Form Health Survey (SF-36). I. Conceptual framework and item selection. Med Care 1992;30:473–83.[Web of Science][Medline]
8 Aronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez KJ, et al. The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. J Natl Cancer Inst 1993;85:365–76.
9 Cella DF, Tulsky DS, Gray G, Sarafian B, Linn E, Bonomi A, et al. The functional assessment of cancer therapy scale: development and validation of general measure. J Clin Oncol 1993;11:570–79.
10 Bjordal K, Hammerlid E, Ahlner-Elmqvist M, de Graeff A, Boysen M, Evensen JF. Quality of life in head and neck cancer patients: validation of the EORTC H&N35. J Clin Oncol 1999;17:1008–19.
11 Lu JFR, Tseng HM, Tsai YJ. Assessment of health-related quality of life in Taiwan (I): development and psychometric testing of SF-36 Taiwan version. Taiwan J Public Health 2003;22:501–11.
12 Tseng HM, Lu JFR, Tsai YJ. Assessment of health-related quality of life in Taiwan (II): norming and validation of SF-36 Taiwan version. Taiwan J Public Health 2003;22:512–8.
13 American Joint Committee on Cancer. AJCC Cancer Staging Manual, 5th edn. 1993.
14 Fang FM, Chiu HC, Kuo WR, et al. Health-related quality of life for nasopharyngeal carcinoma patients with cancer-free survival after treatment. Int J Radiat Oncol Biol Phys 2002;53:959–68.[CrossRef][Web of Science][Medline]
15 New England Medical Center Hospital. IQOLA SF-36 Taiwan Standard Version 1.0. Boston: The Health Institute, New England Medical Center, 1996.
16 Norusis MJ. SPSS for Windows. Chicago, IL: SPSS Inc., 1993.
16 Terrell JE, Nanavati K, Esclamado RM, Bradford CR, Wolf GT. Health impact of head and neck cancer. Otolaryngol Head Neck Surg 1999;120:852–9.[CrossRef][Web of Science][Medline]
18 Funk GF, Karnell LH, Dawson CJ, Means ME, Colwill ML, Gliklich RE, et al. Baseline and post-treatment assessment of the general health status of head and neck cancer patients compared with United States population norms. Head Neck 1997;19:675–83.[CrossRef][Web of Science][Medline]
19 Rogers SN, Humphris G, Lowe D, Brown JS, Vaughan ED. The impact of surgery for oral cancer on quality of life as measured by the Medical Outcomes Short Form 36. Oral Oncol 1998;34:171–9.[CrossRef][Web of Science][Medline]
20 Hammerlid E, Taft C. Health-related quality of life in long-term head and neck cancer survivors: a comparison with general population norms. Br J Cancer 2001;84:149–56.[CrossRef][Web of Science][Medline]
21 de Graeff A, de Leeuw JRJ, Ros WJG, Hordijk, Blijham GH, Winnubst JAM. Long-term quality of life of patients with head and neck cancer. Laryngoscope 2000;110:98–106.[CrossRef][Web of Science][Medline]
22 Bjordal K, Ahlner-Elmqvist M, Hammerlid E, Boysen M, Evensen JF, Biorklund A, et al. A prospective study of quality of life in head and neck cancer patients part II: longitudinal data. Laryngoscope 2001;111:1440–52.[CrossRef][Web of Science][Medline]
23 Zelefsky MJ, Gaynor J, Kraus D, Strong EW, Shah JP, Harrison LB. Long-term subjective functional outcome of surgery plus postoperative radiotherapy for advanced stage oral cavity and oropharyngeal carcinoma. Am J Surg 1996;171:258–62.[CrossRef][Web of Science][Medline]
24 Campbell BH, Marbella A, Layde PM. Quality of life and recurrence concern in survivors of head and neck cancer. Laryngoscope 2000;110:895–906.[CrossRef][Web of Science][Medline]
25 Adler NE, Boyce WT, Chesney MA, Folkman S, Syme SL. Socioeconomic inequalities in health: no easy solution. J Am Med Assoc 1993;269:3140–5.
26 Sprangers MAG, de Regt EB, Andries F, van Agt HME, Bijl RV, de Boer JB, et al. Which chronic conditions are associated with better or poorer quality of life? J Clin Epidemiol 2000;53:895–907.[CrossRef][Web of Science][Medline]
27 Penson DF, Stoddard ML, Pasta DJ, Lubeck DP, Flanders SC, Litwin MS. The association between socioeconomic status, health insurance coverage, and quality of life in men with prostate cancer. J Clin Epidemiol 2001;54:350–8.[CrossRef][Web of Science][Medline]
28 Ramsey SD, Andersen MR, Etzioni R, Moinpour C, Peacock S, Potosky A, et al. Quality of life in survivors of colorectal carcinoma. Cancer 2000;88:1294–303.[CrossRef][Web of Science][Medline]
29 Ashing-Giwa K, Ganz PA, Petersen L. Quality of life of African-American and white long term breast carcinoma survivors. Cancer 1999;85:418–26.[CrossRef][Web of Science][Medline]
30 Huguenin PU, Taussky D, Moe K, Meister A, Baumert B, Lutolf UM, et al. Quality of life in patients cured from a carcinoma of the head and neck by radiotherapy: the importance of the target volume. Int J Radiat Oncol Biol Phys 1999;45:47–52.[CrossRef][Web of Science][Medline]
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