3.2.2 : Qualité de vie
5.2 Forces et faiblesses
À notre connaissance, il s’agit de la plus grande étude prospective évaluant de façon systématique tous les facteurs de statut nutritionnel comme facteurs prédicteurs de la qualité de vie à long terme. Il s’agit aussi de la seule étude Québécoise, procurant ainsi des données locales. Celle-ci a d’ailleurs été effectuée dans un centre tertiaire en oncologie ORL, l’hôpital
Notre-Dame du CHUM, qui traite le plus grand nombre de patients atteints de cancer ORL dans la province (statistiques SARDO, 2011).
Il y a cependant des limites à nos résultats. Comme la qualité de vie est une variable multidimensionnelle et subjective, il est très difficile d’ajuster pour tous les facteurs de confusion. Nous avons donc décidé d’ajuster pour les facteurs étant les plus cliniquement pertinents et reconnus dans la littérature, soit l’âge, le sexe, le stade de cancer, le type de traitement, les comorbidités et la qualité de vie prétraitement. Nous retenons entre-autre le statut socioéconomique ainsi que le support social comme autres facteurs ayant potentiellement un impact sur nos résultats. De plus, afin d’ajuster pour la qualité de vie prétraitement, il était essentiel que tous les patients de l’étude aient remplis un questionnaire prétraitement. L’absence de ce questionnaire a donc été établie comme un critère d’exclusion dans l’étude, ce qui a représenté un total de 47 patients. Il est donc possible qu’un biais de sélection ait ainsi été introduit. Cependant, ces patients présentent des caractéristiques cliniques similaires à notre échantillon (tableau VIII), ce qui laisse supposer que le biais de sélection associé à leur exclusion est minimal. Finalement, comme il s’agit d’une étude prospective basée sur des données cliniques sous forme de questionnaires, il y a présence de données manquantes, de l’ordre de 2 à 34% selon les variables. Il y a notamment eu 24 décès en cours d’étude, ce qui représente 15,4% des patients. Une interprétation nuancée des résultats est donc recommandée.
Tableau VIII. Caractéristiques des patients exclus pour questionnaire prétraitement manquant Variable Nombre (%) Sexe Homme Femme 32 (68,1%) 49 (31,9%) Site de cancer Cavité orale Orophaynx Hypopharynx Larynx Nasopharynx Nasosinusal Primaire inconnu 17 (36,2%) 13 (27,6%) 2 (4,2%) 11 (23,4%) 0 (0%) 0 (0%) 4 (8,5%) Stade cancer I II III IV 10 (21,3%) 5 (10,6%) 5 (10,6%) 27 (57,4%) Variable Nombre (%) Age (années) 63,5 +/- 12,0 IMC (kg/m2) 25,9 +/- 4,8
5.3 Implications cliniques
Cette étude apporte un argument supplémentaire en faveur de la détection précoce de la dénutrition dans la population oncologique, ainsi que la prise en charge par une équipe multidisciplinaire. Cette étude permet de cibler le sous-groupe de patient le plus à risque d’une faible qualité de vie globale à long terme, soit ceux avec un faible IMC à leur visite initiale. Dans la littérature, la méthode de support nutritionnel la plus profitable en regard à son impact sur la qualité de vie n’est pas clairement définie102. Les différentes méthodes, tel que les suppléments oraux, le gavage par tube nasogastrique ou par gastrostomie, ainsi que les
implications des équipes de nutrition et d’orthophonie peuvent toutes potentiellement avoir un impact positif. De plus, les patients avec un faible IMC ont démontré une moins bonne fonction sociale-émotive à 12 mois. Ainsi, l’identification de ces patients à risque dès leur visite initiale, permet de les encadrer de façon plus importante lors de leur suivi, notamment en terme de support psychologique.
Conclusion
En conclusion, l’évaluation du statut nutritionnel est une composante essentielle des soins des patients avec carcinomes épidermoïdes de la tête et du cou. Un indice de masse corporelle bas est associé à une moins bonne qualité de vie à long terme. L’identification précoce de la dénutrition est importante. Elle permet une prise en charge multidisciplinaire rapide avec les équipes d’orthophoniste et de diététique. La prévention et le traitement de la dénutrition a donc le potentiel d’éviter les complications en terme de morbidité et mortalité, mais aussi en terme de fonction sociale-émotive et de qualité de vie globale à long terme des patients atteins de cancers de la sphère ORL.
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