Head and neck cancers are the seventh most common cancer globally, accounting for more than 660,000 new cases and 325,000 deaths annually (Sung et al., 2021). Several risk factors are associated with head and neck cancers, including tobacco smoking, alcohol consumption, human papillomavirus (type 16), and Epstein–Barr virus infection [International Agency for Research on Cancer (IARC), 2007; Warnakulasuriya, 2009], along with a broad spectrum of occupational exposures (Paget-Bailly et al., 2012a,b).

These cancers pose a significant clinical and social challenge due to their potential to compromise the delicate functions of crucial organs, with a marked impact on every aspect of a patient's quality of life (QoL). Head and neck cancers (HNCs) are particularly devastating due to the localization and visibility (Fingeret, 2010; Kangas et al., 2013; Fingeret et al., 2014). Patients not only suffer from a potentially lethal disease but also must cope with inevitable and sometimes drastic changes in their appearance, as well as the impairment of certain important and basic abilities. HNC patients may risk enduring permanent or temporary physical disfigurements and total or partial loss of some basic functions such as swallowing, chewing, breathing, and communicating, forcing them to adapt laboriously to a radically transformed internal and external reality. Consequently, HNC patients may experience psychological symptoms such as uncertainty, anxiety, depression, suicidal thoughts, feelings of worthlessness, irritability, fear of recurrence, and feelings of inferiority (Pruyn et al., 1986; Lang et al., 2013; Jimenez-Labaig et al., 2024).

These psychological effects can also impact patients' ability to work, particularly when the emotional consequences of a diagnosis emanate from occupational exposure. This situation is commonly faced by patients with certain types of head and neck cancers, such as sinonasal cancer (SNC), nasopharyngeal carcinoma (NPC), and larynx cancer.

According to the International Agency for Research on Cancer (IARC), there is sufficient evidence that SNCs are causally related to exposure to wood dust, leather dust, and nickel compounds as well as to working in the isopropyl alcohol manufacturing industry, which involves the use of strong acids. However, the evidence indicating a causal association for exposure to hexavalent chromium compounds, formaldehyde, and working in the carpentry, joinery, and textile manufacturing industry is limited [International Agency for Research on Cancer (IARC), 2023].

Occupational exposures to formaldehyde and wood dust have been classified by the IARC as potent carcinogenic agents with sufficient evidence of also causing NPC in humans [International Agency for Research on Cancer (IARC), 2012]. The IARC classified the following occupational agents as carcinogens for laryngeal cancer: asbestos (all forms), strong inorganic acid mists (with sufficient evidence of carcinogenicity), sulfur mustard and occupational exposure to hard bitumens and their emissions during mastic asphalt work and roofing, and working in the rubber manufacturing industry (with limited evidence) (Cogliano et al., 2011).

The role of occupational exposure as a determinant of the psychological impact of diagnosis of SNC, NPC, and laryngeal cancer in patients has been largely disregarded. Asbestos exposure primarily causes mesothelioma, making it a significant occupational hazard. Following mesothelioma, SNC is considered the second major disease caused by occupational exposure to asbestos, characterized by a high work-related attributable fraction (estimated to be in the range of 20%−46%) (Rushton et al., 2012; Slack et al., 2012). In Italy, SNC is monitored through a surveillance system that utilizes data regarding clinical and occupational exposure histories. These data are collected using standardized questionnaires, which is then recorded in the national registry (“Registro Nazionale Tumori Naso-Sinusali: ReNaTuNS”). A first report showed that 63% of SNCs were likely attributable to exposure to occupational hazards (Binazzi et al., 2018).

The network of ReNaTuNS interviewers has found that many contacted patients often refuse to be interviewed due to their disfigured faces or difficulties in speech. Therefore, a decision was made to explore the existing scientific literature on emotional distress in these patients. The research was extended to also include NPC and larynx cancer, which are also frequently caused by exposure to occupational agents, because a former experience with mesothelioma cancer patients had suggested an additional emotional burden due to their occupational etiology (Bonafede et al., 2020). Indeed, interviews of patients affected by mesothelioma have revealed that they face substantial physical and psychological difficulties resulting from the diagnosis of mesothelioma, which is recognized as a traumatic experience associated with depression and despair (Bonafede et al., 2020).

In this context, the purpose of the present study was to conduct a literature review to examine the emotional impact of receiving a diagnosis of SNC, NPC, and laryngeal cancer. Specifically, it sought to assess whether the impact differs according to their occupational etiology and to evaluate the instruments utilized for assessing the impact on the quality of life and psychological distress, with the goal of indentifying a suitable instrument to be employed in interviews with SNC patients contacted by the ReNaTuNS network interviewers.

We applied the Navigation Guide methodology for conducting systematic reviews in environmental and occupational health as our guiding methodological framework, wherever feasible. This methodology incorporates established systematic review methods from clinical medicine, such as the standard Cochrane methods for systematic reviews of interventions, to the field of environmental and occupational health to ensure systematic and rigorous synthesis of evidence on environmental and occupational risk factors, which reduces bias and maximizes transparency (Woodruff and Sutton, 2014).

Only electronic databases managed in English were selected. An electronic search of PubMed and Scopus databases from inception to 31 August 2021 was performed. Search strategies were conducted based on the following Medical Subject Headings (MeSH) terms: quality of life, post-traumatic stress disorder, mental health, nose neoplasms/psychology, and activities of daily living/psychology. These were then cross-referenced with the following terms: sinonasal tumor, sinonasal cancer, sinonasal neoplasm, head and neck tumor, head and neck cancer, head and neck neoplasm, and nose neoplasms.

The search terms used were as follows:

(“sinonasal tumor” OR “sinonasal cancer” OR” sinonasal neoplasm” OR “head and neck tumor” OR “head and neck cancer” OR “head and neck neoplasm” OR “Nose Neoplasms”) AND ((quality of life[mh]) or (Post traumatic stress disorder [mh]) or (Mental Health [mh]) OR (Nose Neoplasms/psychology[mh]) OR (Activities of Daily Living/psychology[mh])).

Although the search term “occupational etiology” was previously included, no research pertaining to a correlation with job-related factors or workplace exposures could be found. Therefore, this term was excluded.

Manual searches were performed for potentially eligible studies in the reference lists of previous reviews and included studies.

Two review authors independently and in duplicate screened titles and abstracts (phase 1) and then full texts (phase 2) of potentially relevant documents. A third review author resolved any disagreement between the two review authors. The selection of studies is presented in a flow diagram, according to the PRISMA guidelines (Liberati et al., 2009). The selected articles were then assessed for eligibility according to the following criteria.

This review intended to highlight the psychological impact of SNC, NPC, and laryngeal cancer diagnosis associated with the possible occupational etiology of these neoplasms and to explore the instruments that evaluate QoL, anxiety, and depression in these patients.

Only six studies met the eligibility criteria. Three studies provided limited information about employment status of the patients, but outcomes of QoL and distress were never associated with occupational characteristics.

The selected studies mainly included cases of laryngeal cancers. A very small number of patients affected by SNC and NPC were examined. Therefore, the results for these cancer types should be interpreted with caution, as they may have been affected by sampling variability. Moreover, the identified studies were designed in the mid-to-late 1990–2000s and may not reflect possible improvements in the therapies.

The EORTC QLQ-C30, EORTC QLQ-H&N35, and FACT questionnaires to assess the QoL and the HADS and CES-D questionnaires to evaluate anxiety and depression were identified in this review. These tools will be considered for future studies on the topic, although a review by Shunmugasundaram et al. highlights that the best tools to assess anxiety and depression in HNC patients are “The Patient Health Questionnaire-9, Zung Self-rating Depression, and Zung Self-rating Anxiety Scales” (Shunmugasundaram et al., 2020).

Regarding laryngeal cancers, the EORTC QLQ scores were consistent with the normative values of head and neck cancers at diagnosis (Fayers et al., 2001).

Normative values of EORTC QLQ-C30 were investigated in the general population of 15 countries in Europe and North America (Nolte et al., 2019). In terms of emotional functioning, in Swedish general population, the mean value was 76.7, comparable to those found in the present review by Hammerlid et al. (2001a,b) and Finizia et al. (2002) at diagnosis, which further improved at 1 year post diagnosis. In the Netherlands, the normative values were higher than those found by de Graeff et al. (2000), although these improved at 1 year post diagnosis, as it has also been observed in the Swedish studies. Therefore, the emotional impact appears more relevant at diagnosis than 1 year later (Hammerlid et al., 1999; Ronis et al., 2008).

The values of social functioning in the Swedish studies included in our review were slightly lower than the data for the same country (91.4), as found by Nolte et al. (2019) both at diagnosis (Hammerlid et al., 2001a,b; Finizia et al., 2002) and 1 year later, particularly for the nasopharynx (Hammerlid et al., 2001a). Similarly, the observed value in the Dutch study (de Graeff et al., 2000) was lower than the one reported by Nolte et al. (2019) (91.9).

Regarding global health status, the values in the Swedish and Dutch studies are comparable with the normative ones, except for the nasopharynx, which is much lower (Hammerlid et al., 2001a). At 1 year since diagnosis, values tended to be higher.

The QoL in the Indian study (Sharma et al., 2019) was evaluated using the FACT questionnaire, and the values of both emotional and social domains at diagnosis were higher than average normative reference scores (List et al., 1996), indicating that the QoL was preserved at diagnosis, but the emotional aspect worsened at 1 year since diagnosis.

In relation to the assessment of anxiety, our results indicate instead a higher prevalence, compared to the general population: in the Swedish study by Finizia et al. (2002), possible/probable anxiety was found to affect more than 30% of cancer patients and to decline 1 year since diagnosis to values similar to those of the general Swedish population (Lisspers et al., 1997). In addition, the proportion of the affected subjects in the study considered was more than double the reported rates for probable anxiety (HADS score higher than 10) in the general populations of Sweden (8%) (Lisspers et al., 1997), UK (10%) (Crawford et al., 2001), or Germany (men: 5.4%; women: 8.5%) (Hinz and Brähler, 2011).

For depression, a higher prevalence was found among laryngeal cancer patients compared to the Swedish general population, with reported proportions of possible/probable depression being ~8%−10% (Lisspers et al., 1997; Djukanovic et al., 2017). Similar results were observed in the studies conducted in other countries (Crawford et al., 2001; Nortvedt et al., 2006; Grav et al., 2012), although the study by Breeman et al. (2015) on the general Swedish population found a proportion of ~15% in both genders (Breeman et al., 2015). In the Dutch study assessing depression through the CES-D questionnaire (de Graeff et al., 2000), the percentage of laryngeal cancer patients with a total score ≥16 was 28.9% at the time of diagnosis, indicating a significant depressive symptomatology (Orme et al., 1986), and nearly, i.e., 15.6%, at 1 year since diagnosis. The prevalence at the time of diagnosis (28.9%) was more than double the rate of prevalence found in a sample of the healthy general Dutch population (12.5%), as determined using the same CES-D questionnaire with a cutoff score of 16 (Bouwman et al., 2010).

In contrast, the study by Verdonck-de Leeuw et al. (2009) reported a prevalence of high levels of distress (total HADS score >15) that was more marked at 1 year since diagnosis (32%) than at the time of diagnosis (5%), possibly as a result of the treatment's side effects, although other factors such as the stage and location of the tumor, any underlying distress, and individual personality traits can be reasonably involved. A similar prevalence of high levels of distress at 1 year since diagnosis (27% for both probable/possible anxiety and depression) was found in the study by Hammerlid et al. (2001b) (data not reported at diagnosis).

These results are consistent with those of a study that analyzed the prevalence of psychological distress among a large sample of ~4,500 cancer patients, which suggested that the prevalence rate of distress for head and neck tumors was 35.1%. This rate varied from 43.4% for lung cancer to 29.6% for gynecological tumors (Zabora et al., 2001).

Globally, psychological stressors associated with head and neck cancers mainly consist of uncertainty, obstacles to activities and communication, fear of recurrence, apprehension for disease and treatment, and the expected negative surgical consequences on the body aspects. The main challenge for these cancer patients indeed is their facial disfigurement. This aspect is more evident for SNCs, where the face can be seriously compromised by surgical interventions, implying considerable difficulties in managing their life. Many interviewers, involved in submitting the ReNaTuNS questionnaire, referred a deep psychological distress in the patients, often leading to the refusal of the interview. Suffering from facial deformity because of such type of cancers implies experiencing deep psychological trauma associated with a loss of self-esteem and awareness of limited attractiveness (Moadel et al., 1998). Moreover, decreased feelings of sexuality associated with humiliation and increased isolation have also been reported (Curtis and Zlotolow, 1980; Meyers et al., 1980) as well as greater social isolation (Strauss, 1989; Gritz et al., 1999). The most adopted coping strategies at diagnosis such as denial, behavioral disengagement, and self-blame were predictive of post-traumatic stress disorder symptoms and poor quality of life (Richardson et al., 2016). Regarding personality characteristics, the results of a review (Llewellyn et al., 2005) showed that the higher the patient's extraversion or optimism score, the higher his health-related quality of life (HR-QoL) score. In contrast, patients with a high score for neuroticism were more likely to have a low HR-QoL.

Psychological consequences resulting from illness or treatment have been observed in long-term cancer survivors (Brandenbarg et al., 2019), although often underdiagnosed and undertreated. They experience greater anxiety, pain, fatigue, psychological and social impacts (fear, alienation, and disfigurement), and feelings of guilt for lifestyle choices that may have impacted the cancer risk.

Although no suicide case was identified in the present review, all these stressors are considered reasons for the elevated risk of suicide observed in cancer patients. A study observed that the risk remains elevated in the first 6 months after diagnosis, with a suicide rate ~2.5 times higher than the expected rate in the general population (Saad et al., 2019).

In an effort to comprehend and cope with their condition, individuals diagnosed with cancer may formulate beliefs about the origin of their illness, and these attributions may influence their psychosocial adaptation. A review about causal attributions for breast cancer revealed a consistent belief among survivors that their breast cancer could be linked to family history, environmental factors, stress, fate, or chance (Dumalaon-Canaria et al., 2014). Comprehending and evaluating causal attributions and existential questions related to diagnosis can significantly enhance understanding of survivors' adaptation and psychosocial wellbeing (Ferrucci et al., 2011). Causal attributions may also include the occupational environment, and this aspect can impact cancer patients' quality of life and distress levels.

Not having specific data on work-related aspects related to emotional distress and quality of life represents a significant limitation, which should be addressed in further studies. The only work-related aspect considered is the return to work after the diagnosis and treatment of head and neck cancer patients. The percentage of those who were still working varies from 40% at 12 months post-diagnosis to over 80% 2 years after diagnosis (Buckwalter et al., 2007; Verdonck-de Leeuw et al., 2010). Furthermore, some of those who return to work tend to reduce the duration of their working hours (Harrison et al., 1997), change tasks, or change jobs (Verdonck-de Leeuw et al., 2010; Chang et al., 2012). Survivors of head and neck cancers express their desire for more information on returning to work during their health consultations, but they perceive it to be absent (Miller et al., 2023). Returning to work depends on the type of cancer and the specific treatment received. Head and neck cancer survivors were more likely to remain on sick leave at the beginning of the recovery period in comparison with breast cancer patients (So et al., 2022). Moreover, a study found that head and neck cancer survivors who experienced stronger negative impacts from their cancer took longer to return compared to breast, gynecological, and urological cancer survivors (Cooper et al., 2013).

A major strength of our review is that we included studies that presented data on the QoL and prevalence of anxiety and depression in SNC, NPC, and laryngeal cancer, both at diagnosis and 1 year later. On the basis of the results, the most relevant impact is represented by anxious and depressive experiences mainly at diagnosis. Focusing on symptoms' prevalence in these patients is essential for early intervention programs to address specific healthcare needs and treatments. Moreover, the review has highlighted the different questionnaires used for outcome assessment.

This review has the following limitations: the partial use of databases (only Scopus and PubMed were used) and the exclusion of gray literature. Moreover, only longitudinal studies were found, which are more vulnerable to bias due to unmeasured confounding factors. Moreover, most studies investigated QoL, and psychological health in head and neck cancers were not distinguished by the specific site of the tumor.

This review revealed a clear aspect of distress characterized by anxiety and depression at the time of diagnosis, which must be considered in a holistic perspective. This psychological suffering can also have peculiarities related to past/current exposure to occupational carcinogenic hazards since it is a group of cancers in which the occupational etiological fraction is high, and this aspect is not considered in the scientific literature.

The diagnosis of a head or neck tumor can have a significant impact on mental health, psychological distress, and quality of life of patients. It is important that they have access to comprehensive support not only for medical treatment but also for psychological and social assistance. Interventions such as individual or group therapy can help patients manage emotional stress, cope with challenges related to the illness, and improve their quality of life during and after treatment. Additionally, involvement of family members and caregivers is crucial to ensure adequate emotional and social support for patients. When patients' clinical history is collected, their employment history must be systematically investigated and the possible consequences of the awareness of an occupational etiology in the evaluation of the psychological distress also need to be considered. We suggest addressing these concerns in the design of future study protocols.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

MB: Writing – original draft, Writing – review & editing. Ad'E: Writing – review & editing. SR: Writing – review & editing. CM: Writing – review & editing. LM: Writing – review & editing. RC: Writing – review & editing. RG: Writing – review & editing. SP: Writing – review & editing. PM: Writing – review & editing. DV: Writing – review & editing. AB: Writing – original draft, Writing – review & editing.