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 Table of Contents  
Year : 2022  |  Volume : 7  |  Issue : 2  |  Page : 241-244

Pulmonary function tests, fatigue levels and functional capacity in head and neck cancer patients undergoing cancer therapy: An evaluation study

Department of Oncology Physiotherapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka, India

Date of Submission21-May-2021
Date of Decision24-May-2021
Date of Acceptance26-Jun-2021
Date of Web Publication09-Sep-2022

Correspondence Address:
Prasad Kharwandikar
Department of Oncology Physiotherapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/bjhs.bjhs_46_21

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BACKGROUND: The changes in pulmonary functions and fatigue; occurring in the months and years following cancer therapy have been well documented. The changes that occur in the hours of the cancer treatment are less clear.
AIMS AND OBJECTIVES: The changes detected in the early stage of cancer treatment may help to prevent late pulmonary & associated complications.
MATERIALS AND METHODS: The pre and post scores were taken after 3 days of treatment. PFT was recorded by vitalograph & peak flow meter, fatigue levels were assessed by FACIT-F scale and functional capacity was assessed by distance covered in 6- minute walk test.
RESULTS: One hundred and seventeen patients with head and neck cancer were recruited 108 were males and 09 females with mean age of 52.2 years; there is a significant statistical reliable difference between the pre & post treatment values, with P-value is 0.001< 0.05. It justifies the deuteriations in health outcome post intervention.
CONCLUSION: There is significant deterioration seen in the PFT, fatigue levels, functional capacity; could cause significant clinical problems. Early detection of all these changes can helps the patients as well as therapist to avoid or minimal late complications.

Keywords: Cancer therapy, fatigue, functional capacity, head-and-neck cancer, pulmonary function test

How to cite this article:
Pattanshetty R, Huddar V, Kharwandikar P. Pulmonary function tests, fatigue levels and functional capacity in head and neck cancer patients undergoing cancer therapy: An evaluation study. BLDE Univ J Health Sci 2022;7:241-4

How to cite this URL:
Pattanshetty R, Huddar V, Kharwandikar P. Pulmonary function tests, fatigue levels and functional capacity in head and neck cancer patients undergoing cancer therapy: An evaluation study. BLDE Univ J Health Sci [serial online] 2022 [cited 2023 Jun 3];7:241-4. Available from: https://www.bldeujournalhs.in/text.asp?2022/7/2/241/355853

Head-and-neck cancer (HNC) is the sixth most common cancer worldwide. It includes cancers of larynx, nasopharynx, oropharynx, salivary glands, and oral cancers.[1] The primary treatment options available for most of these cancers include surgery, chemotherapy, and radiation therapy or combination of all three. The choice of modality depends on patient factors, primary site, clinical stage, and respectability of the tumor. Radiation therapy, surgery, and chemotherapy are the most common treatment for HNCs.[2] These patients can be treated with complete surgical excision followed by postoperative radiation therapy and chemotherapy. These cancer therapies of the head-and-neck region cause both short-term and long-term complications because of adverse effect on the normal tissues.[2],[3]

Due to high radiation exposure during the treatment, it can harm the tissues around the lesion. Some of the postradiation symptoms include lethargy and weakness, fatigue, dry mouth, pain, sore throat, and breathlessness reported by patients. It leads to poor prognosis, and it affect the survival rate of the patients.[2] The complications include mucositis, dysphagia, radiation-induced lung damages such as pneumonitis, pulmonary fibrosis, and xerostomia.[4]

The adverse effect of radiotherapy on the normal lung and the syndromes of radiation pneumonitis and radiation fibrosis have been well described. These syndromes occur in the later weeks and months of cancer therapy. Interstitial pneumonitis and pulmonary fibrosis are recognized as some of the common radiation-induced lung damages. Other radiation-induced clinical syndromes have also been identified in various studies, which include alveolar lipoproteinosis, pulmonary veno-occlusive disease, hypersensitivity pneumonitis, noncardiogenic pulmonary edema, obliterative bronchiolitis, and pleural diseases.[4] Most of studies documenting changes in respiratory function following radiotherapy have been found first 3 days.[5] The pathological changes due to radiation toxicity to the lung are marked by damage to the capillary endothelium resulting in increased vascular permeability and congestion. Prominent hyperplasia of Type II alveolar lining cells with bizarre-shaped hyperchromatic nuclei and accumulation of neutrophils, macrophages, lymphocytes, and fibroblasts into the alveolar interstitium are noted.

The bilateral nature of radiation-induced pneumonitis was described in individual case history reports in the 1960s. In 1988, the changes in pulmonary function tests (PFT) were reported in patients who developed dyspnea after postoperative irradiation for cancer.[6] The evidence states that there is significant drop in forced-vital capacity, forced expiratory volume in 1 s (FEV1), and peak expiratory flow rate (PEFR) after radiation therapy in the first 0–72 h. Studies show that cancer patients undergoing radiotherapy present with increased level of fatigue during treatment, between the 4th/5th week of radiotherapy and 2 weeks after the end of treatment. The same studies highlight that the greater the fatigue present before radiotherapy and higher fatigue levels during treatment.[6] Another study found that fatigue affected almost all patients undergoing radiotherapy for HNC, reaches maximum fatigue score at the 6th week of radiotherapy and slowly decreases thereafter.[3] The previous studies were done on the bronchial carcinoma in which it was proven that pulmonary functions are decreased in the acute stage after treatment.[3]

The chemotherapy also plays an important role in cancer therapy, but the drug-induced lung injury and its adverse effect on lung functions are well documented. Gas exchange is compromised by all pulmonary toxic agents, and they may act synergistically. Studies reported that around 35%–55% of patients suffer from pulmonary toxicity.[7]

Postoperative pulmonary infections are common in patients undergoing major HNC surgery with tracheostomy. Poor pulmonary function and postoperative atelectasis emerged as significant risk factors for pulmonary infection following surgery. Forty-five percent of patients undergoing such major surgeries develop pulmonary complications, most of which occur in the first 5 days after surgery. The patients most at risk seem to be elderly people, especially those with comorbid respiratory disease, with poor clearance of lower respiratory secretions.[8] Although poor lung function due to various cancer therapy has been well documented, there are hardly any studies that have documented the PFT changes in initial 3 days posttreatment which would act as an indicator for early pulmonary dysfunctions. These indicators may also help the physical therapist to initiate an early pulmonary rehabilitation program, even during treatment or on the 1st day of cancer therapy itself. Hence, the present study was taken up to see the early changes in PFTs, fatigue, and functional capacity in HNC patients undergoing cancer therapy.

These complications affect the quality of life (QOL) and functional capacity of the patients. Therefore, the purpose of the study is to assess the pulmonary functions, fatigue level, and functional capacity in HNC patients undergoing cancer therapy.

  Materials and Methods Top

HNC patients were interviewed before starting the cancer treatment. The participants were selected according to the inclusion criteria set for the study.

Prior to the 1st session or cycle of cancer therapy, PFT, fatigue levels, and functional capacity were assessed using vitalograph, peak flow meter, FACIT–F scale, and 6-min walk test, respectively.[3],[8],[9],[10] In PFT, FEV1, FEV6, FEV1/FEV6 ratio, and PEFR were measured. Fatigue level was assessed using FACIT-F, the self-reported questionnaire. To measure the functional capacity, 6-min walk test was performed by calculating the distance covered (in meters). After 3 days of the session or cycle of the chemo/radio/surgery, all the outcome measures were assessed again. The data were collected and analyzed statistically. In the present study, we are focusing on the changes occurring in the first 3 days after the treatment.

  Results Top

One hundred and thirty-three patients were screened for the study, of which, 16 patients were excluded due to unstable vitals and lost to follow-up as they got discharged from the hospital. One hundred and seventeen participants were included in the study. The statistical analysis was done by using various statistical measures such as mean, standard deviation, and test of significance such as Wilcoxon test were used to analyzing the data.

Specific demographic characteristics, type of cancer is presented in [Table 1],[Table 2],[Table 3].
Table 1: Age and body mass index (male - 108)

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Table 2: Age and body mass index (female - 9)

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Table 3: Cancer diagnosis of all the participants in the study

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Comparison of the baseline PFT, fatigue levels, and functional capacity scores before and after treatment are presented in [Table 4].
Table 4: Pulmonary Function test, fatigue level and functional capacity of all the participants in the study

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A significant decrease of posttreatment PFT (FEV1, FEV6, FEV1/FEV6, and PEFR), fatigue scores, and distance covered in 6-min walk test was observed in patients treated with surgery, chemotherapy, and radiation therapy. The mean difference is positively indicating postscore has decreased after the medical intervention the P value of the all the variables are P < 0.001 (using Wilcoxon test) [Figure 1] and [Figure 2].
Figure 1: Pre and post difference in outcomes. FEV1 = Forced expiratory volume in 1st sec, FEV6 = Forced expiratory volume in 6 s, FEV1/FEV6 = Ratio of FEV1 to FEV6

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Figure 2: Pre and post difference in outcomes. PEFR = Peak expiratory flow rate, FACIT_F = Functional assessment of chronic illness therapy-fatigue, 6 MWD = Distance covered in 6 min

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Based on the results of the Wilcoxon test analysis at 5% significance level, there is a significant statistical reliable difference between the pre- and posttreatment values, with P value is less than the 5% significance level (i.e., 0.001 < 0.05) in terms of all the outcome measures in the study, and therefore, it justifies the deuteriations in health outcome postintervention.

  Discussion Top

The present study was conducted to evaluate the effect of cancer therapy in HNC patients. All participants who undergoing cancer therapy showed significant changes in the reduction of pulmonary functions, fatigue level, and functional capacity.

A study conducted by Hatton et al. on the bronchial carcinoma to check the effect of radiotherapy on pulmonary functions. It was concluded that, there was fall in the pulmonary functions within 72 h of the radiotherapy treatment.[3] Another study was concluded by Spyropoulou et al. in which pulmonary functions were assessed in breast cancer patients after radiotherapy, there was significant changes seen in the PFT functions.[11] Petrar et al. conducted a study on postoperative HNC population, it was found that patients with especially tracheostomy leads to poor bronchial hygiene and affects pulmonary functions. In the postoperative HNC patients, there are the chances of reduced pulmonary functions and postoperative atelectasis; this can further lead to pulmonary infections because of poor clearance of bronchial secretions.[8] Decreased in lung compliance can also be measured. The goal of the present study was to assess the effect of surgery, radiation, and chemotherapeutic agent on pulmonary functions.[8] Similar findings seen in the present study revealed that there was significant deuteriation in PFT findings in HNC patients. The results of the present study, the mean value show significant fall in the PFT and PEFR.

A study conducted by Sawada et al. on HNC patients in which fatigue, depression, and QOL were assessed during the cancer therapy, it was proved that the fatigue levels increases during cancer therapy and initial hrs of postchemoradiotherapy.[6] A study done on lung cancer patients with cachexia by Salsman et al. also reveals that there is significant improvement in fatigue levels.[9] Shannon and Price suggest that there is significant increased in the fatigue levels postsurgery.[4] Similarly, in the results of the present study showed increased in fatigue levels after initial hours of the treatment.

Samuel et al. conducted a study on the effect of exercise on functional capacity in HNC patients it was seen that there was significant drop in the functional capacity in terms of the 6-min walk test distance.[10],[12]

The oral health is important factor which is compromised during the head and neck treatment. Poor oral health leads to the decreased nutritional intake and weight loss which causes increased in fatigue levels.[5] The patients undergoing cancer therapy suffer from fatigue which causes decrease in functional capacity.[12] All these treatment protocols also affect the QOL, in most of the cases, cancer-related fatigue and difficulty in ADLs have been reported by the patients in the initial stages of the treatment. Therefore, the early detection of all these changes can helps the patients as well as therapist to avoid or minimal late complications.

  Conclusion Top

A number of patients with HNCs suffers from severe pulmonary complications and fatigue in the initial treatment hours. There is significant deterioration seen in the functional capacity could cause significant clinical problems.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Kulkarni MR. Head and neck cancer burden in India. Int J Head Neck Surg 2013;4:29-35.  Back to cited text no. 1
Rose-Ped AM, Bellm LA, Epstein JB, Trotti A, Gwede C, Fuchs HJ. Complications of radiation therapy for head and neck cancers. The patient's perspective. Cancer Nurs 2002;25:461-7.  Back to cited text no. 2
Hatton MQ, Nixon DL, MacBeth FR, Symonds RP. Acute changes in peak expiratory flow rate following palliative radiotherapy for bronchial carcinoma. Radiother Oncol 1997;44:31-4.  Back to cited text no. 3
Shannon VR, Price KJ. Pulmonary complications of cancer therapy. Anesthesiol Clin North Am 1998;16:563-86.  Back to cited text no. 4
Dirix P, Nuyts S, Van den Bogaert W. Radiation-induced xerostomia in patients with head and neck cancer: A literature review. Cancer 2006;107:2525-34.  Back to cited text no. 5
Sawada NO, de Paula JM, Sonobe HM, Zago MM, Guerrero GP, Nicolussi AC. Depression, fatigue, and health-related quality of life in head and neck cancer patients: a prospective pilot study. Support Care Cancer 2012;20:2705-11.  Back to cited text no. 6
McDonald S, Rubin P, Phillips TL, Marks LB. Injury to the lung from cancer therapy: clinical syndromes, measurable endpoints, and potential scoring systems. Int J Radiat Oncol Biol Phys 1995;31:1187-203.  Back to cited text no. 7
Petrar S, Bartlett C, Hart RD, MacDougall P. Pulmonary complications after major head and neck surgery: A retrospective cohort study. Laryngoscope 2012;122:1057-61.  Back to cited text no. 8
Salsman JM, Beaumont JL, Wortman K, Yan Y, Friend J, Cella D. Brief versions of the FACIT-fatigue and FAACT subscales for patients with non-small cell lung cancer cachexia. Support Care Cancer 2015;23:1355-64.  Back to cited text no. 9
Enright PL. The six-minute walk test. Respir Care 2003;48:783-5.  Back to cited text no. 10
Spyropoulou D, Leotsinidis M, Tsiamita M, Spiropoulos K, Kardamakis D. Pulmonary function testing in women with breast cancer treated with radiotherapy and chemotherapy. In Vivo 2009;23:867-71.  Back to cited text no. 11
Samuel SR, Maiya GA, Babu AS, Vidyasagar MS. Effect of exercise training on functional capacity and quality of life in head and neck cancer patients receiving chemoradiotherapy. Indian J Med Res 2013;137:515-20.  Back to cited text no. 12
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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4]


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