© The authors, 2026

Introduction

Oral squamous cell carcinoma (OSCC) is a significant public health concern in India, with a major contribution to cancer-related death and morbidity [1]. According to reports, the estimated incidence rate is 12.6% per 100,000 people, with a 30% local recurrence rate, a 10% regional recurrence rate, and a 20% distant metastasis rate [2].

Quality of life (QOL) is defined by WHO as an individual’s perception of their position in life in relation to their objectives, expectations, standards, and concerns in the context of the culture and value systems in which they live [3]. By assessment of the QOL, one can identify the disease's most distressing characteristic and help with treatment choices. As a result, therapeutic success can also be evaluated in addition to the lack of metastases and recurrence [4].

The European Organization for Research and Treatment of Cancer (EORTC) study group on Quality of Life had developed an oral cancer-specific QOL questionnaire (EORTC QLQ-C30) (Version 3.0) [5]. While several studies have evaluated QOL in OSCC patients shortly after treatment, few have examined survivors with a 5-year follow-up. Furthermore, limited Indian literature incorporates financial burden as a measurable symptom affecting QOL using standardized international tools.

Although the EORTC QLQ-C30 is a validated instrument widely used in oncology research, it is a generic cancer-specific questionnaire rather than head-and-neck specific. The EORTC also provides a dedicated head and neck module (QLQ-H&N35), which evaluates symptoms specific to oral and head-and-neck cancers. However, the present study focused on the core QLQ-C30 instrument to assess general cancer-related quality of life parameters.

Materials and methods

Study design and sample size (Fig. 1)

The cross-sectional study was conducted in the Oral Medicine and Radiology Department of a tertiary care hospital. From an initial cohort of 100 OSCC patients, only 47 met the inclusion criteria, and the rest were excluded due to postoperative mortality or loss to follow-up. Patients treated for OSCC between 2016 and 2017 were identified from hospital records. Recruitment of eligible patients for the present cross-sectional assessment was conducted in 2022 during their routine follow-up visits. Only patients who had completed approximately five years of post-treatment follow-up were included in the study.

Fig. 1 STROBE-compliant flow diagram showing screening, exclusion, and final inclusion of OSCC patients for quality-of-life assessment using the EORTC QLQ-C30 questionnaire.

Inclusion and exclusion criteria

All subjects with OSCC who underwent surgery as the primary treatment modality at the predefined time point 5 years back with or without adjuvant chemo or radiotherapy were included in the study. This is to ensure a homogeneous study cohort receiving standard, guideline-concordant management. Patients treated with chemotherapy or radiotherapy alone were excluded, as these modalities are typically reserved for unresectable disease, palliative intent, or patients unfit for surgery, which would introduce significant clinical heterogeneity and bias survival and quality-of-life outcomes. Exclusion of patients with perioperative mortality was necessary to avoid distortion of long-term survival analysis unrelated to disease biology or treatment effectiveness.

These criteria were designed to minimize selection bias and enhance the interpretability of long-term treatment-related outcomes in surgically managed OSCC patients. The purpose of the study was explained, and a duly filled informed consent was obtained from all the patients participating in the study.

Assessment tool

The present study used the standard EORTC Questionnaire QLQ-C30 (Version 3.0) to record patient-reported outcomes [5].

Principles of scoring

• The QLQ-C30 is composed of both multi-item scales and single-item measures, which include five functional scales, three symptom scales, a global health status/QoL scale, and six single items.

• Each of the multi-item scales includes a different set of items—no item occurs in more than one scale.

• All of the scales and single-item measures range in score from 0 to 100.

• A high scale score represents a higher response level.

(A high score for a functional scale represents a high/healthy level of functioning, and a high score for the global health status/QoL represents a high QoL, but a high score for a symptom scale/item represents a high level of symptomatology/problems.)

The questionnaire was provided to patients while waiting for routine checkups in the outpatient department of hospitals. For the convenience and comfort of the patients and better understanding of the questions, the questionnaire was made available in the Hindi (translated) and English languages. Great importance was laid on the point that no influence whatsoever should be exerted on the patient.

The impression emerged that the patient’s answers and objective evaluation of his condition were roughly similar. The analysis of the questionnaires was done in accordance with the EORTC guidelines [5,6].

The following clinical parameters were registered:

• Age

• Gender

• Site

• Tumor stage

• Treatment

• Present status

• Overall survival

Statistical analysis

Statistical analysis was conducted using SPSS Statistics for Windows, Version 21 (SPSS Inc., Chicago, IL, USA). For the questionnaire split, descriptive, Mann–Whitney, and Kruskal–Wallis tests were used for comparison of categorical data.

Since the sample size was relatively small and the quality-of-life scores did not follow a normal distribution, non-parametric tests were used. The Mann–Whitney U test was applied for comparison between two independent groups, while the Kruskal–Wallis test was used for comparison among more than two groups.

Results

Among 47 patients, 61.7% were over the age of 45, and 93.6% were males. The most commonly involved site was buccal mucosa (48.9%), followed by the tongue (34%). Regarding staging, 40.4% of patients presented with the T2 clinical stage, followed by 27.6% with moderately advanced disease (T4). The majority of the patients, 74.5%, received surgery along with chemotherapy and radiotherapy as the treatment modality (Table 1).

The mean global health score (GHS) was 45.88 ± 14.82. The mean functional score (FS) was 58.08 ± 19.53, and the mean Symptom Score (SS) was 39.97 ± 26.57 (Table 2). It can be seen that the age of the subject has a significant association with the functional scale and symptom scale, with subjects younger than 45 years old showing better quality of life scores, functional status, and symptom scores. The mode of treatment has an association with the global health scale, with subjects receiving both chemotherapy and radiotherapy after surgery showing a better quality of life. The site of the lesion shows a significant association with the symptom scale, with subjects having tongue involvement showing the least symptom scores. Although gender and stage of the lesion have no significant association, it can be seen that males and subjects with the T1 stage have a better quality of life as compared with females and those with T3 and T4 stages (Table 3).

The global health score of the study population showed average values. The distribution of global health status and functional scale scores across the study population is presented in Figure 2. The distribution of symptom scores among study participants is shown in Figure 3.

Fig. 2 The distribution of questionnaire scores for different functional scales and the global health score (GHS). Abbreviations: GHS, global health score; EF, emotional functioning; PF, physical functional; CF, cognitive functioning; RF, role functioning; SF, social functioning.

Fig. 3 Comparison of global health scales with various symptom scales.

Discussion

The present study adds a unique perspective by exploring long-term QoL outcomes five years post-treatment, capturing late-emerging symptoms and socioeconomic challenges that are often underreported in the literature, especially within Indian cohorts.

Demographic characteristics

The results of the present study showed that the majority of study subjects diagnosed with OSCC were elderly males. The observation can be attributed to the higher prevalence of established risk factors such as tobacco (both in smoking and smokeless form) and alcohol consumption. Prolonged exposure to these carcinogens over several decades leads to cumulative genetic mutations, epigenetic alterations, and field cancerization, thereby increasing the risk of malignant transformation with advancing age. Additionally, immunosenescence associated with aging may compromise the tumor surveillance mechanism, rendering the elderly population more susceptible to OSCC development. Aging is also associated with reduced DNA repair capacity and increased oxidative stress, which further contributes to carcinogenesis in oral epithelial tissues [7–11].

According to the present study, the buccal mucosa is the most common anatomical site, followed by the tongue. The site-specific distribution can be attributed to the prevalence of smokeless tobacco products, which are typically retained in the buccal vestibule for prolonged periods, resulting in sustained local exposure of the buccal mucosa to carcinogenic substances, including tobacco-specific nitrosamines. Furthermore, the widespread practice of betel quid chewing, with or without tobacco, predisposes individuals to oral submucous fibrosis—a recognized potentially malignant disorder—which significantly elevates the risk of OSCC development at this site. This pattern explains the predominance of buccal mucosa involvement observed in the present cohort and is consistent with reports from Indian and Southeast Asian populations [7-11].

The majority of study subjects were at the T2 stage, followed by the T4 stage, which highlights several challenges commonly encountered in developing countries such as India. Delayed presentation may also be attributed to limited awareness regarding early signs of oral cancer among the general population, inadequate opportunistic screening, and restricted access to specialized oncology services, particularly in rural and underserved areas. Additionally, fear of a cancer diagnosis and socioeconomic constraints may further contribute to postponement of healthcare-seeking behavior, resulting in a higher proportion of patients presenting with advanced-stage disease [8-10].

The present study demonstrated that the majority of patients received either surgery followed by radiotherapy or surgery combined with adjuvant radiotherapy and chemotherapy as the primary treatment modality. This treatment pattern is consistent with the National Comprehensive Cancer Network (NCCN) guidelines, which recommend surgical resection followed by adjuvant radiotherapy for early-stage, resectable OSCC (T1/T2) and multimodal treatment comprising surgery with concurrent chemoradiotherapy for patients with advanced-stage disease. Guideline-concordant management has been shown to improve locoregional control and survival outcomes in OSCC, underscoring the importance of multimodal therapy in appropriate clinical settings [10, 11].

The improved survival outcomes and better post-treatment health status observed in the present study may be attributed to the use of adjuvant therapy following primary surgical management in OSCC patients. From a biological perspective, adjuvant therapy may eliminate subclinical tumor remnants and address occult nodal metastases, which are common in OSCC, thereby improving survival outcomes. Similar benefits of adjuvant treatment following surgery in OSCC have been reported in previous studies, reinforcing the role of combined treatment modalities in achieving better prognosis [7-9].

The mean functional score for the present study was 58.08 ± 5, indicating an average ability to perform daily activities according to the present study, which is in concordance with the results of previous studies performed by Pierre et al. [12], Borggreven et al. [13], and Peisker et al. [14], respectively. According to the present study, the majority of OSCC study subjects showed uncompromised CF, RF, and PF. Peisker et al. showed better CF, RF, and PF with 84.5 ± 5, 68.3 ± 5, and 81.3 ± 5, respectively, in comparison with the present study in OSCC study subjects [14].

The mean symptom score, which allows an evaluation of complaints, was 26.57 ± 5 on a scale of 100, with 0 indicating no symptoms and 100 indicating the most symptoms. The mean (symptom score) SS showed comparatively higher scores for fatigue, pain, &and insomnia in comparison with general oncological symptoms like dyspnea, diarrhea, constipation, appetite loss, &and financial difficulties, in agreement with the results of previous studies by Rogers et al. [15] and Maciejewski et al. [16]. According to other studies, patients have the most difficulty with specific oral cavity symptoms (such as swallowing and speaking issues). Questions pertaining to eating and swallowing were typically rated the lowest, according to Kessler et al. [17] and Coelho et al. [18]. These outcomes are likely a result of the fact that, despite being feasible, total dental rehabilitation is not always an option for patients for social and financial reasons.

Financial issues were identified as serious issues by the present study group due to their extremely high mean score. In a recent paper, Rogers et al. [15] and Coelho et al. [18] examined the direct cost of OSCC care and arrived at the conclusion that there is a direct relationship between cancer staging and treatment cost, with early-stage OSCC management being relatively inexpensive and rising significantly with late-stage disease and multimodal therapy. In agreement with Thanvi et al. [19], Khandelwal et al. [20] proposed “recurrence of OSCC” as a significant factor increasing the costs and worsening the burden on the economy. As a result, when compared to early-stage cases, the overall survival rate further decreases. Early identification would therefore help to decrease treatment-related morbidity and financial burden while also increasing the survival rate.

The overall QOL (GHS) score of the present study is lower compared with other studies by Khandelwal et al. [20], Peisker et al. [14], and Anand et al. [21], indicating poorer perceived QOL of the participants. When the comparison was conducted using clinical parameters in combination with the functional, symptom, and global health scales, it is evident that a substantial correlation exists between a subject’s age and the corresponding functional scale and the symptom scale, with subjects under 45 years of age scoring higher on all three dimensions: quality of life, functional status, and symptom score.

Patients who receive both chemotherapy and radiotherapy after surgery have a greater quality of life than those who receive only one of the two forms of treatment. The person whose tongue was affected had the least symptom score, and the site of the lesion significantly correlated with the symptom scale. Although there is no correlation between gender and lesion stage, it can be noted that males and patients in the T1 stage have a higher quality of life than women and those in the T3 and T4 stages, respectively. Patients with small tumors responded much better than those with large tumors in terms of scores (better QOL). Klug et al. [22] reported findings that are comparable. In our group comparison, we investigated variations in QOL based on the amount of time since the treatment. The findings are consistent with those of Pierre et al. [12] and Rogers et al. [15], who discovered no additional changes in QOL after the first year following surgery. Comparison of the global health scale with the symptom scale showed that most of the study participants were suffering from financial burden and fatigue, followed by nausea, vomiting, and constipation, which highlights the economic concerns a patient faces along with decreased quality of life during and after the treatment.

Clinical implications and importance

This study is distinctive in that it integrates clinical staging, treatment modality, and socio-demographic factors with standardized QOL scoring tools, revealing critical correlations that can shape future survivorship care models. The findings of this study raise several important areas of thrust that need to be taken into consideration while dealing with cancer patients. There should be rehabilitation programs that focus on the psychosocial aspect of cancer survivors through counseling, support groups, and social reintegration programs. Another major concern is the high financial burden experienced by patients and their families, which highlights the need for re-evaluation and re-amendment of healthcare policies to reduce out-of-pocket expenses and increase affordability and accessibility to supportive care services. The extended follow-up duration offers a unique window into long-term survivorship challenges and delayed complications, especially in a resource-limited setting.

Global relevance

The findings of the present study—financial burden, functional limitations, and psychosocial distress—are not only relevant to the Indian subcontinent but are universal concerns that need to be addressed across healthcare systems for the maintenance of sustainability. The study has added to the evidence supporting patient-related outcomes in comprehensive cancer care.

Limitations

The present study was a hospital-based study; there is a need for more longitudinal studies with a larger sample size for validation of the results. There was a high chance of recall bias, survivorship bias, and responder bias. Another limitation of the study was that although patients treated with surgery alone were included in the eligibility criteria, none were enrolled due to random recruitment during routine 5-year follow-up visits, which might be due to their limited long-term follow-ups. A baseline QoL questionnaire can be done to further compare the pre- and post-treatment outcomes in patients. Another limitation is the use of EORTC QLQ-C30, which is a generic cancer-specific questionnaire rather than head-and-neck specific.

Conclusion

Patients’ QOL is significantly impacted by oral cancer. Despite maintaining higher levels of physical, role, emotional, cognitive, and social functioning, they experience a loss of global QOL of about 44.5%. In decreasing order of frequency, the general oncological symptoms are financial problems, fatigue, pain, appetite loss, and insomnia. The patients' QOL was significantly impacted by the tumor’s stage. Those with early-stage, small tumors had considerably higher quality of life (QOL) than those with advanced-stage, large tumors. The patients' QOL was significantly impacted by additional factors such as age, gender, tumor site, and time following the first year of treatment (1–5 years).

As in our study, a simple and explicit questionnaire aids in promptly assessing patients’ QOL and symptom burden. The delivery of improved symptom-directed therapies could certainly benefit from this. Our findings contribute unique data to the growing field of survivorship research in OSCC, particularly in low- and middle-income countries. By focusing on financial and psychosocial parameters at a 5-year interval, we address long-term unmet needs not covered in most existing Indian studies. Planning for treatment and rehabilitation should give significant consideration to the assessment of QOL.

Funding

This study was not supported by any funding.

Conflicts of interest

The authors declare that they have no conflict of interest.

Data availability statement

Data presented in this study are available on request from the corresponding author. The data are not publicly available due to patient data security.

Author contribution statement

Each author has contributed significantly and equally to the study’s conceptualization, design, data collection, analysis, and interpretation. They all actively participated in the manuscript’s creation and critical revisions, and they gave their approval for the final draft to be published.

Ethics approval

This observational study has been approved by the institutional ethical committee (Ethical Committee no. 3247 dated – 02/11/2020).

References

All Tables

All Figures

	Fig. 1 STROBE-compliant flow diagram showing screening, exclusion, and final inclusion of OSCC patients for quality-of-life assessment using the EORTC QLQ-C30 questionnaire.
In the text

	Fig. 2 The distribution of questionnaire scores for different functional scales and the global health score (GHS). Abbreviations: GHS, global health score; EF, emotional functioning; PF, physical functional; CF, cognitive functioning; RF, role functioning; SF, social functioning.
In the text

	Fig. 3 Comparison of global health scales with various symptom scales.
In the text