A Comparison of Older and Younger Individuals Living after the Surgical Treatment of Laryngeal Cancer.

Introduction

Cancer of the larynx often necessitates the surgical removal of the larynx, resulting in communication and psychosocial problems for the individual surviving cancer. The median age of diagnosis for cancer of the larynx is between 50 and 60 years of age. An estimated 13,000 new cases of laryngeal cancer were diagnosed in 1990, and approximately 9,000 persons will survive (American Cancer Society, 1991). Early detection and high survival rates suggest that laryngeal cancer is becoming one of a growing number of "chronic, curable diseases" in the elderly. One of the primary aims of rehabilitation programs for individuals with laryngectomies (IWL) is functional communication.

Some studies have examined the psychosocial qualities of IWL and found post-surgery depression, sense of loss, problems in adjustment to the permanent hole in their neck, irritability, isolationism, and anxiety are present in some IWL (Blood & Blood, 1982; Manuel et al., 1987; Richardson & Bourque, 1985; West, 1977). Recently, Blood, et al. (1992) reported on the coping and adjustment of IWL. Results from 41 face-to-face interviews revealed that over 70% of the sample showed good adjustment to the cancer experience. The good copers used predominantly problem-focused and seeking-social support strategies to deal with their cancer. They perceived themselves to have positive self-esteem and higher scores on general well-being than poor copers.

Kane (1991) in describing psychological and social issues for older people with cancer suggests the major issues revolve around: multiple losses, reactions of others, arranging for care, learned helplessness, and loss of control. She indicated that learned helplessness in older people may result in depression, failure to recognize their control of events, and failure to exercise influence in their lives.

No studies have examined adjustment, communication traits, and activities in daily living of IWL using standardized scales. In fact, only a few studies have examined the issue of aging in laryngeal cancer survivors. It would seem important for counseling, as well as developing effective rehabilitation interventions in speech language pathology to determine if older laryngeal cancer survivors' adjustment styles, communication attributes, or functional capabilities in daily living activities differ from younger laryngeal cancer survivors' attributes. The present study is part of an ongoing series of investigations examining life after a laryngectomy. The specific aims were to 1) determine if differences exist between two age cohorts (IWL between 46 - 65 years and IWL 66 - 82 years of age) using standardized measures of adjustment, communication skills, and activities of daily living, and 2) determine if relationships exist between the variables of adjustment, communication, and activities of daily living for IWL.

Methods

Subjects

A questionnaire was mailed to 200 IWL who had volunteered to participate. The questionnaire contained items about communication, adjustment, voice restoration, and activities of daily living. Also included with the questionnaire were an explanation of the study, assurances of confidentiality and informed consent forms. A follow-up post card reminder was sent two weeks after the initial mailing to increase the response rate. One hundred and fifty-seven respondents (79% return rate) completed the questionnaire. Thirty-three subjects' data could not be used because of incomplete responses, failure to follow the directions, or incomplete demographic data. Therefore, the total number of subjects for this investigation was 124.

The 124 European American males with laryngectomies ranged in age from 46-82 years, with a mean age of 63 years. Subjects were divided into two age cohorts. Sixty-two subjects were placed in Group 1 (Younger Adult Group), and ranged in age from 46 - 65 years of age, with a mean of 52 years. Eighty-one percent (n=50) were married and six percent were widowed (n=4) and thirteen percent were divorced (n=8). Education level ranged from 7th grade to graduate school, with a mean of 12.8 years. Seventy-three percent of Group 1 were employed full time (n=45), sixteen percent (n=10) were employed part time, and eleven percent (n=7) were retired. Although all subjects had undergone total laryngectomies, surgical variations included flap procedures and radical neck dissections. Forty-eight percent (n=30) of the subjects were esophageal speakers, thirty-five percent (n=22) were tracheoesophageal speakers and sixteen percent (n=10) were artificial larynx speakers. Time from surgery to participation in the study ranged from 6 to 58 months, with a mean of 40 months.

Sixty-two subjects were included in Group 2 (Older Adult Group), and ranged in age from 66 - 82 years of age, with a mean of 73 years. Fifty-five percent (n=34) were married and thirty-eight percent were widowed (n=23) and eight percent were divorced (n=5). Education level ranged from 7th grade to graduate school, with a mean of 10.1 years. Sixteen percent of Group 2 were employed full time (n=10), nineteen percent (n=12) were employed part time, and sixty-five percent (n=40) were retired. Although all subjects had undergone total laryngectomies, surgical variations included flap procedures and radical neck dissections. Sixty-three percent (n=39) of the subjects were esophageal speakers, twenty-six percent (n=16) were tracheoesophageal speakers and eleven percent (n=7) were artificial larynx speakers. Time from surgery to participation in the study ranged from 9 to 64 months, with a mean of 48 months. The demographic variables were analyzed to determine similarities between the two groups. Significant differences were found between the two age groups for marital status and employment. A significantly greater number of subjects in the older group were widowed compared to the younger group (X2 (121) = 7.4, p [is less than] .01). No other significant differences were found between the two groups.

Validity and Reliability of Scales

There were four dependent measures: one for adjustment to cancer, one for activities in dally living, and two for communication abilities. These instruments were selected because they had either been previously used in studies with cancer survivors or they represented measures frequently reported in the literature for a particular construct.

1. Adjustment to cancer was measured by the seven subscales and resulting Total Score of The Psychosocial Adjustment to Illness Scale-Self Report PAIS-SR (Derogatis & Lopez, 1983). This scale has been used in a number of studies with cancer survivors, and has norms for cancer survivors. The PAIS-SR is a 46-item interview protocol that assesses the adjustment to a medical illness in seven different areas of functioning. The areas include: a) healthcare orientation, b) vocational adjustment, c) domestic environment, d) sexual relationships, e) extended family relationships, f) social environment, and g) psychological distress. The self-report inventory takes approximately 20 minutes per subject Scoring is rated on a four-point scale of adjustment (0-3). Higher ratings indicate poorer overall adjustment. Individual subscores for each of the subscales and a total score (T-score) were calculated. The manual indicated that total scores (T-scores) over 62 may signal adjustment problems and psychologic distress. Internal consistency for PAIS-SR scores on a normative sample of lung cancer and mixed cancer patients ranges from .68 to .93. Construct validity coefficients for the PAIS Total Score is 0.81.

2. Impaired functional capacities and the ability to live independently were assessed with the Activities of Daily Living-ADL (Filembaum, 1985). The ADL is a 5-item screening instrument which provides information on the capacity to live independently in the community. Items are scored 0, 1, or not answered. Items include: Can you get to places out of walking distance.... with some help (need someone to help you or go with you when you are traveling); Can you prepare your own meals..... without help (plan and cook full meals yourself); Can you handle your own money.... with some help (manage day to day buying, but need help managing your checkbook and paying your bills). Predictive and discriminant validity of the ADL has been reported with coefficients between .54 to .60 for physical and mental health measures. Normative data on random samples of 4,146 elderly persons between 65 and 85 years of age is provided. This instrument provides a rapid screener for functional independence in the elderly.

3. The Self Evaluation of Communication Experiences after Laryngectomy-SECEL (Blood, 1993) is a 35-item scale developed to address the communication needs of patients with laryngectomies. The scale development, factor structure, and data reduction are reported for 431 IWL. Factor analyses revealed three factors representing General, Environment, and Attitude Subscales. Scoring is rated on a four-point scale of adjustment (0-3). Higher ratings indicate greater problems with communication. Internal consistency for SECEL scores on a normative sample of 102 patients with laryngectomies ranges from .80 to .91 for the subscales and total SECEL score. Predictive validity was reported for the SECEL between 0.46 and 0.81. Well adjusted patients had mean scores of 36 with a standard deviation of 12. Recommendations for in depth counseling about communication and adjustment were suggested for subjects with scores above 60. The scale provides a useful measure of adjustment related to communication experiences of patients with laryngectomies.

4. The Opener Scale (Miller et al., 1983) is a 10-item scale designed to measure the tendency to "open-up", elicit intimate information from others, or disclose personal information. The scale is a measure of perceived awkwardness in communication. This 5-point Likert scale ranging from 0 (strongly agree) to 4 (strongly disagree) evaluates perceived reactions from others, interest in listening to others, and interpersonal communication skills. Scale validity and reliability measures were made on 740 college students. Significant correlations with shyness, self-disclosure indices, self-esteem, public self-consciousness ratings, perspective talking, and sociability have been reported from .30 to .74. Cronbach's alpha was reported for internal consistency at 0.79, and a six-week test-retest reliability was 0.69. One standard deviation from the mean for males and females was used to define "high" and "low" openers. High openers are more likely to engage in self-disclosure, encourage communication, possess good listener skills, and appear more attentive and responsive than low openers. The scale has recently been used as a measure of communication traits and skills in studies with aging adult singles.

Results

Reliability

Test-retest reliability was calculated for 30 subjects by mailing the scales at least two weeks but no more than 6 weeks after the initial questionnaires and scales were returned. Twenty-one subjects returned the scales and pearson product moment correlations were calculated. Results revealed correlation coefficients of 0.81, 0.73, 0.74, and 0.85 for the PAIS-SR, ADL, SECEL and Opener Scale, respectively.

Age Differences

The group mean Total Score for the PAIS-SR was 50.7 (SD=10.3) with a range of 31 to 75. This meant that IWL as a group were well adjusted on the Total Score of the PAIS-SR. Examination of the data revealed that 22% (27) of the subjects had scores higher than 62 indicating poor adjustment and psychosocial distress. The remaining 78% (97) of the subjects had Total Scores ranging from 31 to 59 indicating good overall adjustment. A t-test for independent samples was computed and revealed no significant difference between the younger group (mean = 51.3; standard deviation = 10.6) and for the older group (mean = 48.8; standard deviation = 9.5) with a T(122) = 1.03; p = .30.

A t-test for independent samples was also computed for the scores on the Al)L, and revealed no significant difference between the younger group (mean = 4.73; standard deviation = 0.61) and for the older group (mean = 4.53; standard deviation = 0.77) with a T(122) = 1.57; p = .12. This meant that as a group, younger and older IWL demonstrated similar functional capacities for independent living.

A combined (younger and older) group mean score for the SECEL was 32.7 with a standard deviation of 15.4. This indicated that as a group IWL perceive themselves as having a low number of problems with communication. Thirty percent (n=37) of the subjects' scores were above 60, indicating the need for in depth counseling and examination of communication attitudes and environment. A t-test for independent samples was computed and revealed no significant difference for the total problems endorsed between the younger group (mean = 31.9; standard deviation = 14.2) and the older group (mean = 33.5; standard deviation = 16.6) with a T(122) = 0.57; p = .56. The total group mean score of 30.5 (standard deviation of 5.1) for the Opener Scale revealed that IWL had a higher mean than the normative data for 253 male college students (mean = 28.0) and similar mean to the 487 college women (30.7). This indicated that IWL as a group tended to perceive themselves as high self-disclosers or "openers." A t-test for independent samples revealed no significant difference between the younger group (mean = 30.3; standard deviation = 4.6) and the older group (mean = 30.8; standard deviation = 5.7) with a T(122) = 0.45; p = .65.

Correlations Among Dependent Measures

To assess the extent to which adjustment, communication traits, and functional capabilities were related to one another, a series of correlations were performed. We were interested in determining if those subjects who were well adjusted according to their score on the PAIS-SR were also the subjects who functioned more independently, endorsed a fewer number of communication problems, and perceived themselves as high disclosers in communication dyads. Correlations among adjustment, communication, and activities of daily living are provided in Table 1. A high score on the PAIS-SR indicated poorer adjustment. Significant, positive relationships were obtained between adjustment and the SECEL (r = +.68). The more communication problems endorsed, the poorer was the adjustment score according to PAIS-SR score. Significant, negative relationships for the PAIS-SR and the Opener Scale (r = -.49) and the ADL (r = -.37) were found. IWL with higher (poorer) PAIS-SR scores had lower functional capacity scores and lower discloser scores. No other significant relations were found among the variables.

Table 1. Correlations among the four dependent variables for younger and older subjects combined.

PAIS-SR Total Score(1)      1.00   +0.68(*)    -0.49(*)    -0.37(*)
SECEL(2)                            1.00       -0.28       -0.21
Opener Scale                                    1.00       +0.09
ADL(3)                                                      1.00

(*) Significant correlation at p < .05 level of confidence.

(1) PAIS-SR Psychosocial Adjustment to Illness Scale - Self Report

(2) SECEL - Self Evaluation of Communication Experiences after Laryngectomy

(3) ADL-Activities of Daily Living

Discussion

Results from this study show that older IWL are as adjusted to their cancer as their younger counterparts. There were also no age-related differences in this study for communication traits and a measure of independent living. These results support other studies examining other types of cancer, and provide support that older IWL adapt as well or better to cancer than younger IWL (Silliman et al., 1989; Yancik et al., 1983). In fact, the older group reported a fewer number of distresses and communication problems than younger subjects, although not statistically significant. These findings have important clinical implications. Regardless of whether IWL are in their fifth decade or seventh decade of life, they appear to adjust to their cancer, report similar number of communication problems, and function independently. It would appear that age should not be a significant variable in determining psychosocial and communication treatment plans for laryngeal cancer survivors. Older people cope well with the diagnosis and treatment of laryngeal cancer.

Seventy-eight percent of the subjects showed no psychological distress. According to Meyerowitz et al., (1983) the extent and duration of problems for cancer patients may be strongly influenced by the methods patients use to cope with the disease. It appears that the good news is that the majority of laryngeal cancer survivors adjust to their laryngectomy and continue to lead healthy and fulfilling lives. Twenty-two percent of the people in this study reported they were not adjusting well to cancer and demonstrated a need for counseling. These IWL should be referred for counseling to rehabilitation counselors, psychologists, or social workers, for additional testing and treatment.

Approximately 70% of the subjects, regardless of age, reported some difficulties in their communication environment and/or attitudes. Some of these problems included not getting the attention of their listener, difficulties in yelling or calling out to people, or trouble speaking on the telephone. These types of problems could be discussed with speech language pathologists or other healthcare workers, and immediate solutions such as amplifiers, and nonverbal ways of getting attention could be offered. Other problems including frustration, depression, hesitation in meeting new people, or feeling left out of a group because of their speech may be addressed in voice therapy sessions, support group meetings, and psychological counseling sessions. Data presented here provide evidence that psychosocial distress, ability to function independently, and the ability to self-disclose may be related. Significant, positive correlations were found between psychosocial distress and the number reported communication problems. This finding in IWL suggests that healthcare professionals should be alert to the fact that communication problems may signal-potential psychosocial dysfunction in some IWL. The results of this study suggest that IWL are making appropriate decisions about recovery and continuing to live quality lifestyles after the diagnosis of laryngeal cancer.

Acknowledgements

This research was supported by John Scripps Research Grant, Head and Neck Cancer Rehabilitation Center, Indianapolis, Indiana; W. K. Kellogg Foundation National Leadership Fellowship; and Gerontology Center Initiation Grant at The Pennsylvania State University awarded to the first author.

Address for reprints: Gordon W. Blood, Ph.D., College of Health and Human Development, 108 Moore Building, Penn State University, University Park, PA, USA 1680A Telephone: [phone].

References

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Miller, L. C., Berg, J. H., & Archer, R. L. (1983). Openers: Individuals who elicit intimate self-disclosure. Journal of Personality and Social Psychology, 44, 1234-1244.

Richardson, J., & Bourque, L. (1985). Communication after laryngectomy. Journal of Psychosocial Oncology, 3, 89-97.

Silliman, R.A., Guadagnoli, E., Weitberg, A.B., & Mor, V. (1989). Age as a predictor of diagnostic and initial treatment intensity in newly diagnosed breast cancer patients. Journal of Gerontology, 44, 46-50.

West, D. (1977). Social adaptation patterns among cancer patients with facial disfigurement resulting from surgery. Archives of Physical Medicine and Rehabilitation, 58, 473-479.

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Received: August 1994

Revision: January 1995

Acceptance: February 1995

Gordon W. Blood
Ingrid M. Blood
Pennsylvania State University

Susan Kauffman
Hahnemann Hospital, Philadelphia , Pennsylvania

Susan C. Raimondi
Wheeling Hospital, Wheeling, West Virginia

Mary Dineen
Private Practice, Speech Pathology, Minneapolis, Minnesota

Gordon W. Blood, Ph.D., Department of Communication Disorders, The Pennsylvania State University, University Park, Pennsylvania 16802.