Abstract
Background information The premise of this study was that hearing deterioration, associated with treatment for head and neck cancer, has a negative impact on patients’ quality of life. However, there have been no studies to assess this phenomenon in people receiving current UK treatment, and there is little information on the impact of subsequent hearing deterioration. Objective This study, conducted in one UK hospital, aimed to investigate the incidence and severity of hearing deterioration, and patient experience of it, following treatment for head and neck cancer. Design A sequential mixed methods explanatory design was chosen as it was the most appropriate for addressing the research aims. A critical realist framework underpinned the study. A prospective observational repeated measures design was employed to obtain quantitative data in Phase 1 of the study to assess changes in hearing at the end of treatment, and at 3-month follow-up post-treatment, using pre-treatment test level comparison. The Common Terminology Criteria for Adverse Events (version 4.03) were used to determine the incidence and severity of hearing deterioration. Results from Phase 1 were used to inform selection of participants for Phase 2 of the study. An approach informed by phenomenology using interview methodology, was used to explore patient experience of hearing deterioration. Study sample Fifty adults who had been diagnosed with head and neck cancer were recruited to Phase 1 of the study using a consecutive sampling approach. These participants were due to receive standard UK curative radiotherapy (intensity modulated radiotherapy) or chemoradiotherapy (including the use of cisplatin or carboplatin). From the 50 participants recruited, 13 who had hearing deterioration were selected using purposive sampling for one-to-one interviews to obtain in-depth information on their experience of hearing loss. Results The incidence of hearing deterioration was 57% in the 42 participants who completed testing at the end of treatment, and 50% percent in those who completed 3-month follow-up testing. At 3-month follow-up, 26% of participants had major (Grade 3) hearing deterioration in at least one ear. Patients who had chemoradiotherapy were more likely to experience hearing deterioration compared with those who had had radiotherapy only (p=0.01). Older patients were more at risk of hearing deterioration than younger participants (p=0.03), but if hearing deterioration occurred it appeared that younger patients suffered more severe deterioration than older patients (p=0.02). Aural change (including hyperacusis) experienced by some participants during treatment required a change in treatment regimen for them. Participants reporting either minor (Grade 1) or major hearing deterioration were adversely affected by their aural symptoms that manifested with treatment, and the impact of tinnitus (the incidence of which is not covered by existing studies), was extensive in head and neck cancer survivors. Another emerging finding in this study was that middle ear dysfunction, in the early post treatment phase, had a negative impact on patient experience. A further novel finding was that participants with bilateral mild-moderate or moderate severity, mid-high frequency sudden-onset hearing loss required lip-reading to assist their communication. There was evidence that some participants played down their aural symptoms, yet hearing deterioration had a negative impact on their overall quality of life, including generating a sense of loss (principally in older patients) and isolation (associated with younger patients). Finally, there was varied experience among participants receiving information on their hearing test results and on the process of receiving support for their hearing and tinnitus concerns. Conclusions and recommendations This current study provides evidence that could be used to increase awareness of the potential scale and impact of hearing deterioration following head and neck cancer treatment, in the early post treatment period. A larger multi-centre UK study would test the issues identified in the study to inform national policy, clinical practice and education. The study suggests a number of changes for consideration in improving current clinical practice when designing care provision of patients preparing for and recovering from radiotherapy or chemoradiotherapy for head and neck cancer. One key recommendation is for the adoption of a multidisciplinary approach in developing appropriate protocols to inform and support patients about hearing and tinnitus concerns that may occur with their treatment.