Quality of life in head and neck cancer patients: validation of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-H&N35.

PURPOSE: The aim of this study was to define the scales and test the validity, reliability, and sensitivity of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ)-H&N35, a questionnaire designed to assess the quality of life of head and neck (H&N) cancer patients in conjunction with the general cancer-specific EORTC QLQ-C30. PATIENTS AND METHODS: Questionnaires were given to 500 H&N cancer patients from Norway, Sweden, and the Netherlands as part of two prospective studies. The patients completed the questionnaires before, during (Norway and Sweden only), and after treatment, yielding a total of 2070 completed questionnaires. RESULTS: The compliance rate was high, and the questionnaires were well accepted by the patients. Seven scales were constructed (pain, swallowing, senses, speech, social eating, social contact, sexuality). Scales and single items were sensitive to differences between patient subgroups with relation to site, stage, or performance status. Most scales and single items were sensitive to changes, with differences of various magnitudes according to the site in question. The internal consistency, as assessed by Cronbach's alpha coefficient, varied according to assessment point and within subsamples of patients. A low overall alpha value was found for the speech and the senses scales, but values were higher in assessments of patients with laryngeal cancer and in patients with nose, sinus, and salivary gland tumors. Scales and single items in the QLQ-H&N35 seem to be more sensitive to differences between groups and changes over time than do the scales and single items in the core questionnaire. CONCLUSION: The QLQ-H&N35, in conjunction with the QLQ-C30, provides a valuable tool for the assessment of health-related quality of life in clinical studies of H&N cancer patients before, during, and after treatment with radiotherapy, surgery, or chemotherapy.

Tumor cytokinetic response to total parenteral nutrition in patients with head and neck cancers.

Refeeding of patients with malignant tumors may induce tumor-cell DNA synthesis. The present study was aimed at evaluating whether induction of altered cell-cycle kinetics could be induced by intravenous total parenteral nutrition (TPN) in tumor biopsies from head and neck cancers. Nine malnourished patients with squamous cell carcinoma in the head-and-neck area were investigated before and after 5-7 d of continuous TPN. Tumor biopsies were taken in both fasted and fed states for determination of 1) ornithine decarboxylase (ODC) activity, which is rate limiting for polyamine synthesis; 2) flow-cytometric-DNA-distribution measurements; and 3) the fraction of proliferating cells expressed as immunohistochemical reactivity with the monoclonal antibody Ki-67. The histopathological differentiation, the fraction of aneuploidic cells, ODC activity, and Ki-67 reactivity were not significantly related to each other, although the number of aneuploidic cells in replicative phases correlated with the number of cells expressing the Ki-67 antigen (r = 0.86, P less than 0.01). Tumor cytokinetics showed no evidence of being changed by TPN administration.

Ornithine decarboxylase activity in mouse tumour tissue in response to refeeding and diet components.

Ornithine decarboxylase (ODC) and S-adenosylmethionine decarboxylase activity (SAMD) were measured in tumour tissue in mice during periods of starvation (24 h) and refeeding. Starvation led to a 60% reduction in tumour ODC activity. Refeeding normalised the activity within 4 h. Restitution in ODC activity, representing de novo enzyme synthesis, preceded DNA resynthesis. SAMD activity continued to fall along the increase in ODC activity during refeeding, while difluoro-methyl-ornithine (DFMO) caused a compensatory increase in SAMD activity as expected. A fall and regain in ODC activity was associated with inhibition and regrowth of the tumour. Starvation-refeeding was not related to any decrease in tumour polyamine concentrations, while systemic DFMO blockade was. Glucose stimulated ODC when refed orally, but not when given systemically. Tumour ODC activity was not decreased in refed mice by anti-insulin, a procedure that antagonised insulin's bioactivity. Exogenous insulin did not stimulate tumour ODC activity. Our results suggest that gastrointestinal metabolism of carbohydrates stimulates the release of a factor, which initiates both ODC activity and DNA synthesis in tumour cells. This factor was not insulin.

Tumour purine nucleotides and cell proliferation in response to exercise in rats.

Voluntary physical exercise can delay the onset of anorexia and cachexia in tumour-bearing rats. A substrate deviation in the host which has been hypothesised as tumour burden is reduced despite an increase in food intake. Therefore, we determined the levels of purine nucleotides, the energy charge and the cell division rate in tumours from exercising animals in the postexercise period. Tumour content of purine nucleotides was analysed by HPLC. Tumour cell kinetics was studied by flow cytometry after incorporation of bromodeoxyuridine (BrdU) into DNA. Exercising animals demonstrated a 34.4% reduction in tumour volume (P < 0.05) but a 1.31-fold increase in energy charge in tumour tissue (P < 0.05). Labelling index (LI), DNA synthesis time (Ts) and potential doubling time (Tpot) were not significantly altered. These results suggest that the influence on tumour growth is closely related to the exercise period.

Effects of nandrolone propionate on experimental tumor growth and cancer cachexia.

We studied the tumor host response to excessive doses of an anabolic steroid (nandrolone propionate, 2.5 mg 20 g intraperitoneally every second day for 11 days) with respect to body composition and tumor cell kinetics in MCG 101 sarcoma-bearing mice (C57BL/6J) with progressive cachexia. Although survival and food intake were not affected, a significant weight gain was observed that was essentially attributed to water retention. Net protein content was increased only to a minor extent (15%), of which only the liver accounted for a significant part of the body compartments. Hepatic protein accumulation was obviously caused by decreased protein degradation, since hepatic RNA content was unchanged. After anabolic steroid administration, reduced histochemical staining of succinate dehydrogenase was observed in skeletal muscles rich in oxidative type 1 fibers, but it was not different from that of tumor-bearing control animals, which was also confirmed by measurements of citrate synthase and cytochrome c oxidase activities in skeletal muscle and liver tissue. The anabolic steroid had no significant effect on tumor growth in terms of weight progression, energy state, polyamine synthesis rate, cell division rate, and cell cycle cytocompartments. We conclude that anabolic steroid supplementation is not therapeutically beneficial in counteracting progressive weight loss in experimental cancer.

A prospective quality of life study of patients with oral or pharyngeal carcinoma treated with external beam irradiation with or without brachytherapy.

The aim of this longitudinal quality of life (QL) study, was to study tumour-related symptoms and treatment side-effects of patients with oral or oropharyngeal cancer and to determine whether an increased local dose of irradiation (brachytherapy affected QL. The European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30), a tumour-specific Head and Neck questionnaire and the Hospital Anxiety and Depression scale (HAD) were used repeatedly during 1 year. There were 105 patients, with a cumulative response rate of 89%. Most symptoms and problems were at their peak 2 or 3 months after the start of treatment. Nutrition and pain were found to be the major problems, and as many as 19-40% reported psychiatric distress. Patients having received additional brachytherapy did not report any increase in QL problems (except for pain) compared with those having had external radiation only. Quality of life does not seem to be affected by the increased irradiation local dose given when brachytherapy is included in the treatment regimen.

Evaluation of ornithine decarboxylase activity as a marker for tumor growth rate in malignant tumors.

Ornithine decarboxylase (ODC) is a rate-limiting enzyme in the synthesis of polyamines. Polyamines regulate DNA synthesis by a mechanism that is not fully understood. High levels of polyamines and ODC activity are associated with rapid cell growth, particularly in tumor tissues. The aim of this study was to determine whether ODC activity as a marker for rapid alterations in tumor growth could be used to investigate whether nutritional support in cancer patients stimulates tumor cell proliferation. Weight-losing head and neck cancer patients and tumor-bearing mice (MCG 101, C57/BL) were studied during different feeding regimens. The ODC activity in tumor tissue was investigated in relation to the following variables: (1) histopathologic differentiation; (2) DNA content; and (3) bromodeoxyuridine (BrdUrd) incorporation into DNA. After the animals were starved for 24 hours, a significant reduction of tumor growth was demonstrated in the experimental tumor along with a reduction of ODC activity, an accumulation of cells in the G0G1 phase, and a reduction of cells incorporating BrdUrd into DNA. Refeeding after 24 hours generated a response by all variables. Tumor biopsy specimens from patients with head and neck cancer malignancies demonstrated aneuploidy in the cells of 70% of the patients. High ODC activity in tumor tissue was demonstrated mainly among poorly differentiated tumors, and ODC activity was correlated with the compartment size of aneuploidic cells in the tumor. High ODC activity indicated a poor short-term survival (1 year). It was concluded that experimental tumor growth is highly dependent on host feeding. However, there was no evidence supporting the claim that nutritional support to cancer patients stimulates tumor cell proliferation. Determination of ODC activity may be used to monitor rapid changes in DNA synthesis and may have prognostic significance for survival.

Proliferative pattern of head and neck cancer.

Tumor growth is primarily dependent on the fraction size of growing cells, their growth and proliferative rate, and the fractional cell death. In the present study, we focused specifically on the proliferative characteristics of squamous cell carcinomas of the head and neck region by using monoclonal antibodies and immunohistochemical methods. We studied two normally occurring antigens representative of cell proliferation: (1) ribonucleotide reductase, which is an independent cytoplasmatic enzyme and is intimately integrated in DNA synthesis, and (2) Ki-67, which is a nuclear antigen being expressed only in replicative cells. We also used intravenously injected bromodeoxyuridine (BRDU) for specific detection of tumor cells in the S phase of the cell cycle. In addition, in vivo injections of BRDU were also given to tumor-bearing mice to illustrate tumor cell kinetics by means of flow cytometry. The main observation was morphologic heterogeneity, with a high frequency of proliferative cell clusters in the cancer specimens interspersed among quiescent cells, which was demonstrated by the three monoclonal antibodies independent of each other. The experimental studies clearly visualized the transfer of BRDU throughout the tumor cell cycle. We conclude that immunohistochemical analysis provides valuable qualitative information on the proliferative pattern of tumor growth and, together with dynamic flow cytometry, may improve the clinical basis for individualized management of the cancer patient.

Quality of life and voice in patients with laryngeal carcinoma: a posttreatment comparison of laryngectomy (salvage surgery) versus radiotherapy.

OBJECTIVES: This study was designed to compare the voice and the quality of life (QOL) of laryngeal cancer patients receiving treatment with radical radiotherapy with or without laryngectomy as salvage surgery. We also compared the patients' own perceptual ratings of their voice to the perceptual ratings of a group of listeners. STUDY DESIGN: Two groups of laryngeal cancer patients were studied. METHODS: Fourteen irradiated laryngeal speakers with preserved larynx were matched with 14 salvage surgery laryngectomized patients speaking with tracheoesophageal prosthesis (TEP). To measure patients' QOL, we used the European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30), the EORTC Head and Neck module (EORTC QLQ-H&N35), the Hospital Anxiety and Depression scale (HAD) and a study-specific questionnaire. For the perceptual speech evaluation we used visual analog scales. RESULTS: The perceptual ratings of speech intelligibility, voice quality, and speech acceptability showed a significant difference between the treatment groups. Both the patients who received treatment with radiotherapy and the listeners rated the irradiated laryngeal voices higher than the tracheoesophageal speech. The laryngectomized patients scored significantly better than the patients treated with radical radiotherapy on the question about hoarseness. No other significant difference was found for the QOL functions and symptoms. CONCLUSION: When patients treated with radiotherapy were compared with patients treated with laryngectomy as salvage surgery, QOL was similar, only small differences being found in the perceptual speech evaluation.

A prospective quality of life study of patients with laryngeal carcinoma by tumor stage and different radiation therapy schedules.

This study was designed to prospectively monitor the quality of life of laryngeal cancer patients, to compare the quality of life of patients with small tumors with that of patients with large tumors, and to test any quality of life difference in patients with small tumors treated with conventional versus hyperfractioned accelerated radiation therapy. Patients having had a laryngectomy within the study year were also analyzed separately. The European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Core Questionnaire (QLQ-C30), the EORTC Head and Neck Module (H&N-37), and the Hospital Anxiety and Depression (HAD) scale were administered six times during 1 year. These questionnaires were found to be suitable for measuring laryngeal cancer patients' quality of life longitudinally. The questionnaires were sensitive to differences in quality of life for small versus large tumors and showed that hyperfractioned accelerated radiation therapy was advantageous compared with conventional radiation therapy with respect to quality of life at the 1-year follow-up.

Overexpression of p53-related proteins predicts rapid growth rate of head and neck cancer.

OBJECTIVES/HYPOTHESIS: The p53 tumor suppressor gene plays an important role for cell cycle regulation and is the most frequent mutated gene in head and neck cancer. Controversy remains regarding the biological and clinical value of immunohistochemical identification of the proteins accumulated in association with inactivation of the p53 gene and increased tumor growth. Therefore, the objective of the present study was to perform a cell kinetic analysis of cases with untreated squamous cell carcinoma and to compare the result with immunostaining for p53-related proteins in the tumor cells. STUDY DESIGN: A prospective series of 32 patients presenting with various stages of untreated squamous cell carcinoma of the head and neck were included. Bromodeoxyuridine (BrdU) was injected as a tracer dose before tumor biopsy for cell kinetic analysis, and p53 protein accumulation was detected using two antibodies (DO7 and PAb 1801). RESULTS: Antibody DO7 showed the highest and the optimal immunoreactivity. Diploid tumors were found in 27 cases (84%), and the mean potential doubling time (Tpot) was 55 +/- 7 hours for these tumors. Positivity of DO7 (>1%) was demonstrated in 85% of the cases. However, a discrimination level exceeding 20% was required to obtain a significant negative relationship (Spearman's rank correlation coefficient test, P < or = .03) between Tpot and DO7 positivity. At that level, 33% of the tumors remained DO7-positive. The corresponding Tpot was not significantly different from the overall mean. The rates of metastatic disease and survival were not dependent on DO7 immunoreactivity or cancer cell kinetics. CONCLUSION: Accumulation of p53-related proteins is associated with an unrestrained growth of head and neck cancer.

A prospective study of quality of life in head and neck cancer patients. Part I: at diagnosis.

PURPOSE: A Swedish and Norwegian study was designed to examine health-related quality of life (HQL) in patients with head and neck cancer (head and neck) at diagnosis and during treatment and rehabilitation. The overall aim was to examine the impact on HQL at diagnosis depending on tumor location, stage, sex, and age (part I) and to describe HQL longitudinally and determine for which patients and during which period HQL deteriorated most (part II). This article presents the results at diagnosis. METHOD: Patients with head and neck cancer at five hospitals in Sweden and Norway were consecutively requested to participate. They were asked to answer the EORTC QLQ-C30 and QLQ-H&N35 (the European Organization for Research and Treatment of Cancer, Core 30 questionnaire and head and neck cancer module) repeatedly during 1 year. A total of 357 patients (mean age, 63 y; 72% males) were included. RESULTS: Patients with different tumor locations all had their special problems at diagnosis, for example, those with tumors in the larynx with communication, those with oral tumors with pain, and those with pharyngeal tumors with nutrition and pain. The patients with hypopharyngeal cancer reported the worst HQL. Stage appeared to have the strongest impact on HQL. Patients with a more advanced tumor stage reported significantly worse HQL scores for 24 of 32 variables reflecting functioning or problems. The females scored worse than the males for some areas, in particular, emotional functioning. The older patients scored significantly better for emotional and social functioning than patients <65 years but worse for physical functioning and various symptoms. The traditional way of grouping the tumor locations into oral, pharyngeal, laryngeal, and "other" tumors (salivary gland, sinus and nose, and unknown primary) was tested from a HQL point of view and found to be consistent. CONCLUSIONS: The chosen questionnaires differentiated between different sites of head and neck cancer at diagnosis. Tumor stage had the most powerful impact on HQL score.

A prospective study of quality of life in head and neck cancer patients. Part II: Longitudinal data.

OBJECTIVES: To evaluate the health-related quality of life (HRQL) of patients with head and neck cancer during and after treatment with radiotherapy, surgery, and chemotherapy. STUDY DESIGN: Prospective, descriptive study. METHODS: All new patients in four institutions in Norway and Sweden were asked to participate. Health-related quality of life was assessed at baseline and at 1, 2, 3, 6, and 12 months after start of treatment by means of the European Organization for Research and Treatment of Cancer (EORTC) Core Quality of Life Questionnaire and the EORTC head and neck cancer-specific questionnaire. Baseline results are described elsewhere; longitudinal results are presented in the current article. Three hundred fifty-seven patients with cancer in the oral cavity, pharynx, larynx, nose, sinuses, and salivary glands and neck node metastases from unknown primaries filled in the questionnaires at baseline. RESULTS: Seventy-eight percent of the patients who were alive after 12 months filled in all questionnaires (218/280). The general trend was that HRQL deteriorated significantly during treatment, followed by a slow recovery until the 12-month follow-up with few exceptions (senses, dry mouth, and sexuality). Patients who later died reported worse HRQL at each assessment point compared with patients who filled in all six questionnaires, whereas those who dropped out of the study for other reasons were quite similar to patients who filled in all questionnaires. The patients with pharyngeal cancer in general reported worse HRQL compared with the other groups and did not reach pretreatment values in several domains. Stage was also an important factor for HRQL in patients with head and neck cancer. CONCLUSION: Detailed knowledge about the differences between groups and changes over time may aid us in the communication with patients and in the design of intervention studies focusing on improvement of the support and rehabilitation of patients with head and neck cancer.

Mental depression is associated with malnutrition in patients with head and neck cancer.

We have studied the prevalence of mental disorder in a variety of patients with head and neck cancer in different stages of disease and treatment. All together, 59 patients were studied according to a comprehensive psychopathologic rating score and nutritional status. Six patients refused to answer the comprehensive psychopathologic rating score questionnaire. Of the remaining 53 patients, 13 patients were classified as mentally disordered. Five patients were classified as mentally depressed according to a specific comprehensive psychopathologic rating scale depression score. We found that depression was significantly linked to malnutrition. In total, 30% of our patients with cancer with weight loss demonstrated features that were consonant with depression. This suggests that mental depression is associated with physical improvement rather than with the malignant condition per se.

Acute traumatic tympanic membrane perforations. Cover or observe?

The influence of a paper prosthesis on healing in acute traumatic tympanic membrane perforations was studied in 60 patients randomly selected for a treatment group or a control group. The majority (42 [70%] ) were seen within two days. All patients were treated with oral antibiotics for ten days. The overall healing rate two months after the trauma was 94% (37 of 39 patients). No significant difference between the study group and the control patients was observed. Intermittent secretion was seen in six patients but did not influence the outcome. The perforations occurred in patients with normally sized mastoid air cell systems as seen on roentgenograms. We conclude that acute traumatic tympanic membrane perforations do not need to be treated routinely with paper patching.

Circulating levels of selenium and zinc in relation to nutritional status in patients with head and neck cancer.

There is evidence that selenium and zinc are involved in malignant neoplasia. The exact role of these trace elements, however, is not completely understood. For this reason, we studied circulating levels of selenium and zinc in relation to food intake and nutritional status in 14 patients with head and neck cancer. Six patients without cancer served as controls. The patients with cancer were in different stages of disease. They were untreated or in an initial phase of oncologic treatment. Five of these patients were severely cachectic according to weight loss and nutritional status, which included body mass index, anthropometric values, and serum albumin level. These patients also demonstrated decreased circulating levels of selenium and zinc. Plasma glutathione peroxidase (selenium-dependent enzyme) activity, however, was not significantly different when the cachectic patients with cancer were compared with controls. We found that the plasma selenium level was positively correlated to both short-term and long-term selenium intake when all 20 patients were accounted for. However, no significant correlation could be shown between plasma selenium and serum albumin levels. Although only one patient demonstrated a plasma value below the reference value, serum zinc was positively correlated to the serum albumin level. We conclude that plasma selenium concentrations are essentially related to food intake but not necessarily to weight loss. Low circulating levels of zinc are, rather, associated with the catabolic state of the patient with cancer.

Long-term sequelae after surgery for orbital floor fractures.

A surgical technique involving exact repositioning and rigid fixation is required for the reduction of fractures of the orbital floor. Even then, sequelae may be present long after the trauma. The aim of this study was to establish the frequency and type of sequelae after surgery for orbital floor fractures and to investigate the extent to which the method of surgery had any impact on the severity of the sequelae. A questionnaire was sent to all 107 patients (response rate 77%) 1 to 5 years after the injury. Further clinical data were obtained from the patients' charts. Eighty-three percent of the patients were affected by some kind of permanent sequelae in terms of sensibility, vision, and/or physical appearance. A high frequency of diplopia (36%) was related to the reconstruction of the orbital floor with a temporary "supporting" antral packing in the maxillary sinus, a technique which has now been abandoned at our department in favor of orbital restoration with sheets of porous polyethylene. Our conclusion is that, because long-term sequelae are common, the surgical technique must be subjected to continuous quality control to minimize future problems for this group of patients.

Long-term study of quality and safety of osseointegration for the retention of auricular prostheses.

The aim of this article is to describe the safety and quality of the osseointegrated implant technique for the retention of craniofacial prostheses, to present a protocol for collection of clinical data, and to discuss the impact of the procedure on the patient quality of life. A protocol was designed and used to study patients who had received auricular prostheses consecutively since 1979 at our department. The patients were asked to answer a questionnaire designed to describe symptoms and problems specific for someone wearing an auricular prosthesis. In total, 99 patients received 107 prosthetic ears (8 patients had bilateral defects) retained on 309 implants (2 to 4 implants/ear). Patients of all ages were represented, and only 9 discontinuities were reported. Most patients (95%) wear their prosthesis every day, in most cases more than 10 hours/day. The follow-up period ranged from 1 to 12 years, giving a total of 2624 postoperative observations of implants, with a 3% incidence of significant skin reaction. We conclude that the surgical technique for auricular prostheses retained on osseointegrated implants is simple and associated with a low rate of peroperative and long-term complications. It offers a high degree of stability and aesthetic satisfaction.

Quality-of-life effects of psychosocial intervention in patients with head and neck cancer.

METHODS: Two studies of psychosocial interventions in head and neck cancer patients at different stages of their disease were performed. We explored the feasibility and effectiveness of different approaches, offered for the first time to this population. The first study concerned long-term group psychological therapy for patients with newly diagnosed head and neck cancer. Quality of life was measured longitudinally for 1 year and compared with that of a control group. The second study comprised a short-term psychoeducational program 1 year after treatment for head and neck cancer. Quality-of-life assessments were made repeatedly from diagnosis until 1 month after the intervention. RESULTS: Thirteen patients started the psychological group therapy, and 8 of them completed both the intervention and evaluation procedure. The quality of life of the therapy group improved more than that of a control group in most areas measured during the study year, in particular psychiatric morbidity, social functioning, emotional functioning, and global quality of life. The results indicate benefits from the therapy, although the therapy group scored worse than the control group at diagnosis. Most of the variables representing functioning and symptoms improved after the 1-week psychoeducational program, especially items reflecting "trouble eating" and "problems enjoying your meals." Patients' judgments of the intervention quality indicated satisfaction with all separate elements, mostly education, about cancer and the opportunity to socialize with the other guests. CONCLUSION: These pilot studies suggest that head and neck cancer patients can benefit from different psychosocial interventions. Quality-of-life questionnaires were well accepted and sensitive to changes during the studies. Thus our early findings seem promising and would justify confirmation in larger studies.

Prospective, longitudinal quality-of-life study of patients with head and neck cancer: a feasibility study including the EORTC QLQ-C30.

Despite modern advances in the treatment of head and neck cancer, the survival rate fails to improve. Considering the different treatment modalities involved, quality of life has been thought of as an additional end point criterion for use in clinical trials. A Nordic protocol to measure the quality of life of head and neck cancer patients before, during, and after treatment was established. Before the study, a pilot study was done with this protocol. The main purpose of this pilot study was to find out whether this cancer population would answer quality-of-life questionnaires repeatedly (six times) over a 1-year period and whether the chosen questionnaires-a core questionnaire (European Organisation for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30)), a tumor-specific questionnaire, and a psychological distress measure (Hospital Anxiety and Depression scale (HAD))-were sensitive for changes to functions and symptoms during the study year. The results presented in this article all refer to the pilot study. Forty-eight consecutive patients agreed to participate in the study. The most common tumor locations were the oral cavity (17) and the larynx (12). Almost all patients received combined treatment: 45 of 48 radiation therapy, 18 of 48 chemotherapy, and 17 of 48 surgery. After the primary treatment, 40 patients had complete tumor remission. Four of the 48 patients did not answer any questionnaires and were therefore excluded from the study. Of the remaining 44 patients, 3 died during the study year, and another 6 withdrew for various reasons. Thirty-five (85%) of the 41 patients alive at the 1-year follow-up answered all six questionnaires and thus completed the study. Mailed questionnaires were used throughout the study. All questionnaires were well accepted and found to be sensitive to changes during the study year. The greatest variability was found for symptoms and functions related specifically to head and neck cancer. The symptoms were swallowing difficulties, hoarse voice, sore mouth, dry mouth, and problems with taste. They all showed the same pattern, with an increase of symptoms during and just after finishing the treatment. The HAD scale revealed a high level of psychological distress, with 21% probable cases of psychiatric morbidity at diagnosis. In conclusion, it was shown that the study design and questionnaires were feasible for the forthcoming prospective quality-of-life assessment of Swedish and Norwegian head and neck cancer patients.