Swallowing outcomes after radiotherapy for head and neck cancer: A systematic review

Profiling of swallowing function in head and neck cancer patients prior to radiation therapy-Findings from a tertiary hospital in South India

Purpose

Head and neck cancer (HNC) patients often face difficulties with swallowing, which can be due to the cancer itself or the treatment modalities like radiation therapy. The presentation of HNC can vary between developing and developed countries due to socioeconomic factors. The current study aimed to profile the swallowing function of HNC patients before starting radiation therapy in a tertiary hospital in India.

Method

This cross-sectional observational study examined patients with HNC who were scheduled for radiation therapy. The Functional Oral Intake Scale (FOIS) and Karnofsky Performance Status Scale were used to assess the patients' swallowing status and functional abilities, respectively. The study also evaluated the relationship between swallowing function and clinical-demographic factors.

Results

Our assessment of 162 HNC patients found that the cancer site significantly affects swallowing. Although 92% of patients had an oral diet, 64% made dietary modifications. Patients with non-oral intake had either oral or pharyngeal cancer, and over 80% of oral cancer patients and 60% of those with pharyngeal cancer had already made changes to their diet. Patients with laryngeal cancer had a better oral intake, with 58% reporting no swallowing issues.

Conclusion

Patients with HNC scheduled for radiation therapy may experience varying degrees of swallowing difficulty. Early intervention and teaching of safe swallowing strategies are crucial to prepare for the potential worsening of swallowing difficulties resulting from the treatment. Advanced tumor stages and oral/pharyngeal cancers increase the risk of significant swallowing issues.

Clinical Swallowing Profile Change in HNC Patients Treated with C/RT

OBJECTIVES/HYPOTHESIS

To demonstrate utility of the Mann Assessment of Swallowing Ability-Cancer (MASA-C) to describe change in swallowing ability in a cohort of HNC patients from pre-C/RT to post-C/RT to follow up at 3 months post-C/RT. An exploratory analysis compared patients treated with radiotherapy (RT) only to patients treated with chemoradiation (CRT).

STUDY DESIGN

Prospective Cohort.

METHODS

The MASA-C and Functional Oral Intake Scale (FOIS) were completed on 85 HNC patients within the first 5 days of CRT initiation, at the completion of C/RT (6 weeks), and 3 months after completion of C/RT. MASA-C total scores and clinical profiles were used to describe change in swallowing performance at each time point.

RESULTS

MASA-C and FOIS scores were significantly lower at 6 weeks and 3 months compared to baseline. Patients treated with CRT demonstrated more frequent and more severe dysphagia. Post C/RT items demonstrating the most deterioration included taste, diet level, oral mucosa, saliva, weight loss, and pharyngeal functions. Significant recovery was observed between 6 weeks and 3 months on both the MASA-C and FOIS. MASA-C items revealing the greatest recovery included taste, diet level, oral mucosa, tongue movement, weight loss, oral transit, voice, and pharyngeal phase. Few significant differences were noted between RT and CRT cases at 3 months.

CONCLUSIONS

Swallowing functions deteriorate significantly following C/RT with incomplete recovery at 3 months. Few differences were noted between RT and CRT treated patients at 3 months. Clinical profiling with the MASA-C provides a standard, simple method to document swallow function change over time in these patients.

LEVEL OF EVIDENCE

2 Laryngoscope, 131:E1873-E1880, 2021.

Deglutition disorders as a consequence of head and neck cancer therapies: a systematic review and meta-analysis

PURPOSE

In this study, we aimed to estimate the frequency of deglutition disorders in patients pre- and post-treatment for head and neck cancer (HNC).

METHODS

Search strategies were developed for the following databases: LILACS, PubMed, SpeechBITE, LIVIVO, Web of Science, and Scopus. Additionally, the gray literature was searched using Google Scholar, OpenGrey, and ProQuest. Only studies that conducted an evaluation of deglutition before and after cancer treatment and had sufficient quantitative data were included. We conducted a proportion of random effects meta-analysis using R statistical software.

RESULTS

Seventeen studies were included. Aspiration showed a high frequency in the period less than 3 months post-treatment, with 28.6% (total sample = 229). Penetration of fluids above the vocal folds and reduced laryngeal elevation were more frequent in the period less than 6 months post-treatment.

CONCLUSION

The frequency of deglutition disorders and its complications, such as aspiration, appears to be higher in the immediate to 6-month post-treatment period in patients with HNC. The parameter pharyngeal residue continued to increase through the period analyzed.

Impact of choice of feeding tubes on long-term swallow function following chemoradiotherapy for oropharyngeal carcinoma

Background: Prior reports have raised concerns that a prophylactic gastrostomy may be detrimental to long-term swallow function. This study evaluates patient-reported swallow function following chemoradiotherapy for oropharyngeal carcinoma in relation to the use of a prophylactic gastrostomy or nasogastric (NG) tube as required. Material and methods: The MD Anderson Dysphagia Inventory (MDADI) was posted to 204 disease-free patients at least 2 years following chemoradiotherapy for oropharyngeal carcinoma between 2010 and 2014. Results: Overall, 181/204 (89%) patients returned questionnaire at a median of 34 months post-treatment. 97/181 (54%) and 84/181 (46%) were managed with an approach of a prophylactic gastrostomy or NG tube as required, respectively. A prophylactic gastrostomy was associated with higher rates of enteral feeding (92% vs. 58%, p < .001), lower median percentage weight loss (7.0% vs. 9.4%, p < .001), increased duration of enteral feed (median 3.3 vs. 1.1 months, p < .001). There was no significant difference in patient-reported swallow function measured by MDADI summary scores and subscales for patients managed with an approach of prophylactic gastrostomy or NG as required. Duration of enteral feed correlated negatively with composite MDADI scores. A subgroup of 116/181 (64%) patients were documented as having been offered a choice of enteral feeding approach and therefore can be considered to represent clinical equipoise; there were no significant differences in MDADI scores according to route. Conclusions: Despite concern regarding the use of a prophylactic gastrostomy in prior studies, the approaches of using a prophylactic gastrostomy or an NG tube as required to support patients during/after chemoradiotherapy for oropharyngeal carcinoma were associated with similar long-term swallow outcomes.

Society of Behavioral Medicine position statement: Society of Behavioral Medicine supports oral cancer early detection by all healthcare providers

In response to the increasing incidence of certain oral and oropharyngeal cancers, the Society of Behavioral Medicine (SBM) calls on healthcare providers and legislators to expand awareness of oral and oropharyngeal cancer risk factors, increase early detection, and support policies that increase utilization of dental services. SBM supports the American Dental Association's 2017 guideline for evaluating potentially malignant oral cavity disorders and makes the following recommendations to healthcare providers and legislators. We encourage healthcare providers and healthcare systems to treat oral exams as a routine part of patient examination; communicate to patients about oral/oropharyngeal cancers and risk factors; encourage HPV vaccination for appropriate patients based on recommendations from the Advisory Committee on Immunization Practices; support avoidance of tobacco use and reduction of alcohol consumption; and follow the current recommendations for evaluating potentially malignant oral cavity lesions. Because greater evidence is needed to inform practice guidelines in the primary care setting, we call for more research in collaborative health and dental services. We encourage legislators to support policies that expand Medicaid to cover adult dental services, increase Medicaid reimbursement for dental services, and require dental care under any modification of, or replacement of, the Affordable Care Act.

Diagnosis and treatment of oropharyngeal dysphagia after total laryngectomy with or without pharyngoesophageal reconstruction: Systematic review

Background

This systematic review qualitatively summarizes the current literature on diagnosis and treatment of oropharyngeal dysphagia (OD) after total laryngectomy (TLE).

Methods

Electronic databases PubMed, Embase, and the Cochrane Library were used. Two independent reviewers carried out the literature search and assessed the methodological quality of the included studies using a critical appraisal tool.

Results

Forty‐four articles met the inclusion criteria. Of these, 35 studies were on diagnosis, four on therapy, and five on both diagnosis and treatment of OD following TLE. Study aims, swallowing‐assessment methods, and main findings of the included studies were summarized and presented.

Conclusions

The reviewers found heterogeneous outcomes and serious methodological limitations, which prevented us from pooling data to identify trends that would assist in designing best clinical practice protocols for OD following TLE. Further research should focus on several remaining gaps in our knowledge on diagnosis and treatment interventions for OD following TLE.

Patient perceptions of living with head and neck lymphoedema and the impacts to swallowing, voice and speech function

Head and neck lymphoedema (HNL) is common following head and neck cancer (HNC) treatment, and may contribute to numerous physical, functional and psychological symptoms. However, its impact on swallowing, voice and speech is less well understood. The aim of this study was to use interpretive description to explore patient perceptions relating to the impact of HNL on swallowing, voice and speech. Twelve participants, >3 months post HNC treatment and experiencing some form of HNL, participated in individual, semi-structured interviews. Transcribed interviews underwent thematic analysis using an inductive approach, with subsequent member checking. Most participants felt their HNL impacted their swallowing and some had impacts on speech; although the impact on voice was less clear. Four themes emerged, including three themes relating to HNL and its impact on swallowing and speech: "it feels tight;" "it changes throughout the day;" "it requires daily self-monitoring and management;" and a fourth general theme "it affects me in other ways." Participants perceived direct impacts from HNL to swallowing and speech. They often experienced daily symptom fluctuations that required additional strategies during times of increased difficulty. Findings highlight the need to improve patient education regarding the functional impacts of HNL and the importance of self-management.

Changes in Patient-reported Swallow Function in the Long Term After Chemoradiotherapy for Oropharyngeal Carcinoma

AIMS

To assess long-term patient-reported swallow function after chemoradiotherapy for oropharyngeal carcinoma and to evaluate the frequency of deterioration/improvement over years.

MATERIALS AND METHODS

Fifty-nine patients with oropharyngeal carcinoma treated with parotid-sparing intensity-modulated radiotherapy and concurrent chemotherapy between 2010 and 2012 had previously completed the MD Anderson Dysphagia Inventory (MDADI) at a median of 34 months (range 24-59) after treatment. An MDADI was posted to 55 alive and disease-free patients after a 30 month interval; 52/55 replies were received, a median of 64 months (range 52-88) after treatment; 27/52 (52%) had been managed with a prophylactic gastrostomy. A 10 point or greater change in the MDADI scores was defined as clinically significant.

RESULTS

Overall, in the whole cohort, patient-reported swallow function showed a small absolute improvement in MDADI composite score on the second MDADI questionnaire (>5 years after treatment) compared with the first MDADI (>2 years after treatment); mean 68.0 (standard deviation 19.3) versus 64.0 (standard deviation 16.3), P = 0.021. Using the composite score, swallow function was stable over time in 29/52 (56%) patients; a clinically significant improvement in swallow function over time was noted in 17/52 (33%) patients; conversely 6/52 (12%) patients experienced a clinically significant deterioration with time. Abnormality of pre-treatment diet and a prophylactic gastrostomy correlated with an inferior MDADI composite score on the later questionnaire (P = 0.029 and P = 0.044, respectively).

CONCLUSIONS

Long-term dysphagia is prevalent >5 years after treatment. Although long-term swallow function is stable in most patients, it is not static in a minority. On MDADI composite summary scores, 33% of patients experienced an improvement, whereas 12% deteriorated with time. Further investigation is needed to determine underlying mechanisms behind these divergent outcomes.

Transcutaneous Electrical Nerve Stimulation (TENS) on hyposalivation induced by radiotherapy in the head and neck region: a preliminary study

PURPOSE

To verify the acute effect of electrostimulation on the salivary flow of patients with hyposalivation.

METHODS

Uncontrolled clinical trial evaluating 15 patients with hyposalivation induced by radiotherapy (RT) used for head and neck cancer treatment. Mean age of the patients was 56.8 ± 6.46 years. Males outnumbered females (73%). Transcutaneous Electrical Nerve Stimulation (TENS) was adjusted with 50Hz of frequency and 250μs of pulse width. Intensity was adjusted over a 20-minute period according to maximum tolerance. The electrodes were attached bilaterally on the region of the salivary glands. Evaluation of the salivary flow was performed through sialometry before and immediately after application of TENS.

RESULTS

The most prevalent region for RT was the oropharynx (80.0% of cases). The mean dose used in RT was 64.6 ± 7.27 Gy. After TENS, salivary flow increased significantly (p = 0.0051) from 0.05 (0.00; 0.40) mL/min to 0.10 (0.07: 0.40) mL/min. The response to TENS was directly correlated with the intensity of the tolerated electric current (r = 0.553; p = 0.032) and the dose used in RT (r = -0.514; p = 0.050).

CONCLUSION

TENS was able to increase the salivary flow rate of patients with RT-induced hyposalivation.

Patient Adherence to Dysphagia Recommendations: A Systematic Review

Patient adherence to treatment recommendations is an important issue for healthcare providers, in a multitude of specialties, and is critical when assessing the efficacy and effectiveness of a particular treatment approach. Patients who have swallowing impairment often require complex and specific interventions requiring altered daily patterns of behavior. Patients with dysphagia who do not follow recommendations or prescribed exercises may not receive maximum benefit of an intervention. Poor adherence also makes it more difficult to evaluate efficacy of a treatment both clinically and in experimental settings. Further, swallow safety can be compromised if certain recommendations are not followed. Our purpose was to systematically review the literature to understand what is known about adherence within the field of dysphagia treatment. We systematically identified 12 studies that tracked and reported patient-specific adherence. In this review, we found that the average adherence rate from these studies ranges between 21.9 and 51.9%. Adherence to prophylactic treatment recommendations for patients with head and neck cancer was the focus in 9/12 studies. The findings of this review identify a large gap in knowledge regarding adherence to dysphagia treatment. Few studies account for adherence within their study designs. When planning dysphagia treatment studies, it is imperative that investigators include information regarding patient adherence to accurately interpret findings. Given the variable adherence rates found in this review, factors influencing patient adherence with dysphagia treatments should be identified to increase adherence in future trials.

Impact of prophylactic gastrostomy or reactive NG tube upon patient-reported long term swallow function following chemoradiotherapy for oropharyngeal carcinoma: A matched pair analysis

OBJECTIVES

The purpose of this matched pair analysis is to assess patient-reported long term swallow function following chemoradiotherapy for locally advanced oropharyngeal cancer in relation to the use of a prophylactic gastrostomy or reactive nasogastric (NG) tube.

MATERIALS AND METHODS

The MD Anderson Dysphagia Inventory (MDADI) was posted to 68 consecutive patients with stage III/IV oropharyngeal squamous cell carcinoma who had completed parotid sparing intensity modulated radiotherapy with concurrent chemotherapy between 2010 and 2012, had not required therapeutic enteral feeding prior to treatment, minimum 2years follow up post treatment, and who were disease free. 59/68 replies were received, and a matched pair analysis (matching for T and N stage) was performed for 52 patients, 26 managed with a prophylactic gastrostomy and 26 with an approach of an NG tube as needed.

RESULTS

There were no significant differences in patient demographics, pre-treatment diet and treatment factors between the two groups. Patient-reported swallowing function measured using the MDADI was superior for patients managed with an NG tube as required compared with a prophylactic gastrostomy: overall composite score 68.1 versus 59.4 (p=0.04), global score 67.7 versus 60 (p=0.04), emotional subscale 73.5 versus 60.4 (p<0.01), functional subscale 75.4 versus 61.7 (p<0.01), and physical subscale 59.6 versus 57.1 (p=0.38).

CONCLUSIONS

Compared with an approach of an NG tube as required, the use of a prophylactic gastrostomy was associated with inferior long term patient-reported long term swallow outcomes.

DARS: a phase III randomised multicentre study of dysphagia- optimised intensity- modulated radiotherapy (Do-IMRT) versus standard intensity- modulated radiotherapy (S-IMRT) in head and neck cancer

BACKGROUND

Persistent dysphagia following primary chemoradiation (CRT) for head and neck cancers can have a devastating impact on patients' quality of life. Single arm studies have shown that the dosimetric sparing of critical swallowing structures such as the pharyngeal constrictor muscle and supraglottic larynx can translate to better functional outcomes. However, there are no current randomised studies to confirm the benefits of such swallow sparing strategies. The aim of Dysphagia/Aspiration at risk structures (DARS) trial is to determine whether reducing the dose to the pharyngeal constrictors with dysphagia-optimised intensity- modulated radiotherapy (Do-IMRT) will lead to an improvement in long- term swallowing function without having any detrimental impact on disease-specific survival outcomes.

METHODS/DESIGN

The DARS trial (CRUK/14/014) is a phase III multicentre randomised controlled trial (RCT) for patients undergoing primary (chemo) radiotherapy for T1-4, N0-3, M0 pharyngeal cancers. Patients will be randomised (1:1 ratio) to either standard IMRT (S-IMRT) or Do-IMRT. Radiotherapy doses will be the same in both groups; however in patients allocated to Do-IMRT, irradiation of the pharyngeal musculature will be reduced by delivering IMRT identifying the pharyngeal muscles as organs at risk. The primary endpoint of the trial is the difference in the mean MD Anderson Dysphagia Inventory (MDADI) composite score, a patient-reported outcome, measured at 12 months post radiotherapy. Secondary endpoints include prospective and longitudinal evaluation of swallow outcomes incorporating a range of subjective and objective assessments, quality of life measures, loco-regional control and overall survival. Patients and speech and language therapists (SLTs) will both be blinded to treatment allocation arm to minimise outcome-reporting bias.

DISCUSSION

DARS is the first RCT investigating the effect of swallow sparing strategies on improving long-term swallowing outcomes in pharyngeal cancers. An integral part of the study is the multidimensional approach to swallowing assessment, providing robust data for the standardisation of future swallow outcome measures. A translational sub- study, which may lead to the development of future predictive and prognostic biomarkers, is also planned.

TRIAL REGISTRATION

This study is registered with the International Standard Randomised Controlled Trial register, ISRCTN25458988 (04/01/2016).

Dysphagia, Speech, Voice, and Trismus following Radiotherapy and/or Chemotherapy in Patients with Head and Neck Carcinoma: Review of the Literature

Introduction. Patients with head and neck cancer suffer from various impairments due to the primary illness, as well as secondary consequences of the oncological treatment. This systematic review describes the effects of radiotherapy and/or chemotherapy on the functions of the upper aerodigestive tract in patients with head and neck cancer. Methods. A systematic literature search was performed by two independent reviewers using the electronic databases PubMed and Embase. All dates up to May 2016 were included. Results. Of the 947 abstracts, sixty articles met the inclusion criteria and described one or more aspects of the sequelae of radiotherapy and/or chemotherapy. Forty studies described swallowing-related problems, 24 described voice-related problems, seven described trismus, and 25 studies described general quality of life. Only 14 articles reported that speech pathologists conducted the interventions, of which only six articles described in detail what the interventions involved. Conclusion. In general, voice quality improved following intervention, whereas quality of life, dysphagia, and oral intake deteriorated during and after treatment. However, as a consequence of the diversity in treatment protocols and patient characteristics, the conclusions of most studies cannot be easily generalised. Further research on the effects of oncological interventions on the upper aerodigestive tract is needed.

Therapeutic exercises for affecting post-treatment swallowing in people treated for advanced-stage head and neck cancers

BACKGROUND

Head and neck cancer treatment has developed over the last decade, with improved mortality and survival rates, but the treatments often result in dysphagia (a difficulty in swallowing) as a side effect. This may be acute, resolving after treatment, or remain as a long-term negative sequela of head and neck cancer (HNC) treatment. Interventions to counteract the problems associated with dysphagia include swallowing exercises or modification of diet (bolus texture, size), or both.

OBJECTIVES

To determine the effects of therapeutic exercises, undertaken before, during and/or immediately after HNC treatment, on swallowing, aspiration and adverse events such as chest infections, aspiration pneumonia and profound weight loss, in people treated curatively for advanced-stage (stage III, stage IV) squamous cell carcinoma of the head and neck.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the ENT Trials Register; Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 6); MEDLINE; PubMed; Embase; CINAHL; LILACS; KoreaMed; IndMed; PakMediNet; Web of Science; ClinicalTrials.gov; ICTRP; speechBITE; Google Scholar; Google and additional sources for published and unpublished trials. The date of the search was 1 July 2016.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) of adults with head and neck cancer (stage III, stage IV) who underwent therapeutic exercises for swallowing before, during and/or immediately after HNC treatment to help produce safe and efficient swallowing. The main comparison was therapeutic exercises versus treatment as usual (TAU). Other possible comparison pairs included: therapeutic exercises versus sham exercises and therapeutic exercises plus TAU versus TAU. TAU consisted of reactive management of a patient's dysphagia, when this occurred. When severe, this included insertion of either a percutaneous endoscopic gastroscopy or nasogastric tube for non-oral feeding.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. Our primary outcomes were: safety and efficiency of oral swallowing, as measured by reduced/no aspiration; oropharyngeal swallowing efficiency (OPSE) measures, taken from videofluoroscopy swallowing studies; and adverse events, such as chest infections, aspiration pneumonia and profound weight loss. Secondary outcomes were time to return to function (swallowing); self-reported changes to quality of life; changes to psychological well-being - depression, anxiety and stress; patient satisfaction with the intervention; patient compliance with the intervention; and cost-effectiveness of the intervention.

MAIN RESULTS

We included six studies (reported as seven papers) involving 326 participants whose ages ranged from 39 to 83 years, with a gender bias towards men (73% to 95% across studies), reflecting the characteristics of patients with HNC. The risk of bias in the studies was generally high.We did not pool data from studies because of significant differences in the interventions and outcomes evaluated. We found a lack of standardisation and consistency in the outcomes measured and the endpoints at which they were evaluated.We found no evidence that therapeutic exercises were better than TAU, or any other treatment, in improving the safety and efficiency of oral swallowing (our primary outcome) or in improving any of the secondary outcomes.Using the GRADE system, we classified the overall quality of the evidence for each outcome as very low, due to the limited number of trials and their low quality. There were no adverse events reported that were directly attributable to the intervention (swallowing exercises).

AUTHORS' CONCLUSIONS

We found no evidence that undertaking therapeutic exercises before, during and/or immediately after HNC treatment leads to improvement in oral swallowing. This absence of evidence may be due to the small participant numbers in trials, resulting in insufficient power to detect any difference. Data from the identified trials could not be combined due to differences in the choice of primary outcomes and in the measurement tools used to assess them, and the differing baseline and endpoints across studies.Designing and implementing studies with stronger methodological rigour is essential. There needs to be agreement about the key primary outcomes, the choice of validated assessment tools to measure them and the time points at which those measurements are made.

Racial differences in head and neck squamous cell carcinomas among non-Hispanic black and white males identified through the National Cancer Database (1998-2012)

PURPOSE

Head and neck squamous cell carcinoma (HNSCC) incidence is increasing, and evidence suggests survival disparities between non-Hispanic (nH) black and white males. However, temporal changes in HNSCCs and factors contributing to survival differences have not been examined at the national level.

METHODS

National Cancer Database (NCDB) cases were used to evaluate temporal trends in HNSCC anatomical sites and site groupings (i.e., oral cavity, oropharyngeal, non-oropharyngeal), and to estimate incidence ratios (IRs) comparing nH black and white males in demographic and clinical characteristics.

RESULTS

Between 1998 and 2012, 18,443 (11 %) nH black males and 145,611 (89 %) nH white males were diagnosed with HNSCCs. Cases rose from 9094 diagnosed in 1998 to 13,838 in 2012, driven by increases in oropharyngeal tumors, particularly tumors of the tonsil and tongue. Annual percent changes in nH black males and nH white males were 1.93 and 3.17, respectively. Additionally, nH black males had higher incidence of the more aggressive non-oropharyngeal tumors (p < .0001) and distant-stage tumors (76 vs. 64 %, p < .0001). However, nH white males had higher incidence of high-risk HPV types (IRs range from 1.68, 95 % CI 1.50-1.88 in oropharyngeal tumors to 3.03, 95 % CI 1.11-8.25 in non-oropharyngeal tumors).

CONCLUSIONS

Incidence of oropharyngeal tumors has risen in both nH black and white males. However, nH white males have higher incidence of HPV, and nH black males have higher incidence of more aggressive and advanced HNSCCs. Racial differences in clinical characteristics associated with poorer survival exist, and future studies should determine factors associated with these differences.

Comparing the Performance Status Scale and MD Anderson Dysphagia Inventory as swallowing outcome measures in head and neck cancer: a prospective cohort study

OBJECTIVES

To examine the relationship between the two disease-specific measures currently in use to assess swallowing outcomes following treatment in patients with head and neck cancer: the Performance Status Scale (PSS) and MD Anderson Dysphagia Inventory (MDADI).

DESIGN

A prospective cohort study.

SETTING

Four head and neck cancer multidisciplinary clinics in the North of England Cancer Network.

PARTICIPANTS

114 patients with cancers of the upper aerodigestive tract.

MAIN OUTCOME MEASURE

Measures of swallowing function administered prospectively across 4 timepoints

RESULTS

Spearman's correlation coefficients were used to measure the relationship between the two scales. There was statistically significant correlation between the two tools at pre-treatment (rs = 0.428, P < 0.000), 3 months post-treatment (rs = 0.454, P < 0.002), 6 months post-treatment (rs = 0.551, P < 0.000) and 12 months post-treatment (rs = 0.680, P < 0.000).

CONCLUSION

This is the first prospective study comparing the MDADI and PSS questionnaires at multiple time points. Our study shows that these different instruments have a good relationship in measuring swallowing function in patients with head and neck cancer in short and medium term after treatment.

[Retrospective Study of Induction Chemotherapy and Concurrent Chemoradiation Therapy for Oropharyngeal Cancer]

We carried out this study to clarify the treatment outcomes and problems associated with induction chemotherapy (using taxotere, cisplatin and 5-FU [TPF therapy]) and chemoradiotherapy in patients with oropharyngeal cancer. The data of 44 patients receiving their initial treatment for oropharyngeal cancer (including 2, 9 and 33 patients with stage II, stage III and stage IV disease, respectively, and 31, 8 and 3 patients with side wall, front wall and upper wall (soft palate and uvula) involvement) were examined. Of the 44 patients, 33 received induction chemotherapy and 11 received chemoradiotherapy. The feasibility, incidence of neutropenia, response rate, and 3 year disease-specific survival rate in the induction chemotherapy group vs. chemoradiotherapy group were 70%, 88%, 82% and 73%, respectively, vs. 63%, 91%, 82% and 55%, respectively. A statistically significant difference in the 3-year disease-specific survival rate was seen between the p16-positive and p16-negative patients in the induction chemotherapy group: while the rate was 100% in the p16-positive patients, it was only 51% in the p16-negative patients (p=0.004). Of the patients undergoing chemoradiotherapy, 3 developed mandibular osteomyelitis, which was considered as one of the important problems associated with this therapy.

Swallowing performance and tube feeding status in patients treated with parotid-sparing intensity-modulated radiotherapy for head and neck cancer

BACKGROUND

The purpose of this prospective study was to evaluate the swallowing performance of patients with head and neck cancer treated with parotid-sparing intensity-modulated radiotherapy (IMRT).

METHODS

Sixty-two patients were recruited. Data were collected before and up to 12 months after treatment. Measures included the Performance Status Scale for head and neck cancer (PSS-HN Normalcy of Diet and Eating in Public subscales), tube feeding status, and 100 mL water swallow test (WST) volume and capacity scores.

RESULTS

There was a significant reduction in PSS-HN and WST scores from baseline to 3 months (p < .001). Significant improvements were observed up to 12 months on the PSS-HN. Swallowing volume and capacity scores recovered but did not reach statistical significance. Tube feeding was not required in 47% of the patients.

CONCLUSION

IMRT significantly impacts on swallowing performance, although there is a trend for improvement up to 12 months after treatment. Our data support a case-by-case approach to tube feeding. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1436-E1444, 2016.

Prevalence of swallowing and speech problems in daily life after chemoradiation for head and neck cancer based on cut-off scores of the patient-reported outcome measures SWAL-QOL and SHI

The objective of this study is to assess swallowing and speech outcome after chemoradiation therapy for head and neck cancer, based on the patient-reported outcome measures Swallowing Quality of Life Questionnaire (SWAL-QOL) and Speech Handicap Index (SHI), both provided with cut-off scores. This is a cross-sectional study. Department of Otolaryngology/Head and Neck Surgery of a University Medical Center. Sixty patients, 6 months to 5 years after chemoradiation for head and neck squamous cell carcinoma. Swallowing Quality of Life Questionnaire (SWAL-QOL) and SHI, both validated in Dutch and provided with cut-off scores. Associations were tested between the outcome measures and independent variables (age, gender, tumor stage and site, and radiotherapy technique, time since treatment, comorbidity and food intake). Fifty-two patients returned the SWAL-QOL and 47 the SHI (response rate 87 and 78 %, respectively). Swallowing and speech problems were present in 79 and 55 %, respectively. Normal food intake was noticed in 45, 35 % had a soft diet and 20 % tube feeding. Patients with soft diet and tube feeding reported more swallowing problems compared to patients with normal oral intake. Tumor subsite was significantly associated with swallowing outcome (less problems in larynx/hypopharynx compared to oral/oropharynx). Radiation technique was significantly associated with psychosocial speech problems (less problems in patients treated with IMRT). Swallowing and (to a lesser extent) speech problems in daily life are frequently present after chemoradiation therapy for head and neck cancer. Future prospective studies will give more insight into the course of speech and swallowing problems after chemoradiation and into efficacy of new radiation techniques and swallowing and speech rehabilitation programs.

The Value of Qualitative Research in Dysphagia in the Head and Neck Cancer Population: What Can We Learn From the Survivors' Perspective?

Dysphagia is a common acute and long-term side effect of curative, non-surgical treatment for head and neck cancer (HNC). Despite what is known about dysphagia associated with HNC treatment in terms of its prevalence, severity, physiological characteristics, and the associated effects on quality of life (QoL), our understanding of the key factors which impact on HNC survivors is only just emerging. Whilst quantitative research studies have demonstrated that most people experience dysphagia in the early post-treatment period, and that many people continue to have ongoing swallowing issues for months and years following treatment, emerging qualitative research in this field has provided insights into the extent to which the presence of dysphagia impacts on the everyday lives of people with HNC. By exploring issues from the perspectives of people living with dysphagia, qualitative research has highlighted those factors that have the greatest impact on oral intake, raised issues for service provision, and highlighted the need for additional professional involvement and better long term supportive care.

Physiological changes to the swallowing mechanism following (chemo)radiotherapy for head and neck cancer: a systematic review

Emerging research suggests that preventative swallowing rehabilitation, undertaken before or during (chemo)radiotherapy ([C]RT), can significantly improve early swallowing outcomes for head and neck cancer (HNC) patients. However, these treatment protocols are highly variable. Determining specific physiological swallowing parameters that are most likely to be impacted post-(C)RT would assist in refining clear targets for preventative rehabilitation. Therefore, this systematic review (1) examined the frequency and prevalence of physiological swallowing deficits observed post-(C)RT for HNC, and (2) determined the patterns of prevalence of these key physiological deficits over time post-treatment. Online databases were searched for relevant papers published between January 1998 and March 2013. A total of 153 papers were identified and appraised for methodological quality and suitability based on exclusionary criteria. Ultimately, 19 publications met the study’s inclusion criteria. Collation of reported prevalence of physiological swallowing deficits revealed reduced laryngeal excursion, base-of-tongue (BOT) dysfunction, reduced pharyngeal contraction, and impaired epiglottic movement as most frequently reported. BOT dysfunction and impaired epiglottic movement showed a collective prevalence of over 75 % in the majority of patient cohorts, whilst reduced laryngeal elevation and pharyngeal contraction had a prevalence of over 50 %. Subanalysis suggested a trend that the prevalence of these key deficits is dynamic although persistent over time. These findings can be used by clinicians to inform preventative intervention and support the use of specific, evidence-based therapy tasks explicitly selected to target the highly prevalent deficits post-(C)RT for HNC.

Efficacy of thickened liquids for eliminating aspiration in head and neck cancer: a systematic review

OBJECTIVE

To appraise the current videofluoroscopic evidence on the reduction of aspiration using thickened liquids in the head and neck cancer population.

DATA SOURCES

Search terms relating to deglutition or dysphagia or swallow and neoplasms and oncology or head and neck cancer and viscosity or texture and apira or residu* were combined with honey or nectar, xerostomia, and respiratory aspiration using Boolean operators.

REVIEW METHODS

A multiengine literature search identified 337 nonduplicate articles, of which 6 were judged to be relevant. These underwent detailed review for study quality and qualitative synthesis.

RESULTS

The articles reviewed in detail predominantly described heterogeneous study samples with small sample sizes, making for difficult interpretation and generalization of results. Rates of aspiration were typically not reported by bolus consistency, despite the fact that a variety of stimulus consistencies was used during a videofluoroscopic swallowing study. Studies confirmed that aspiration is a major concern in the head and neck cancer population and reported a trend toward more frequent aspiration after (chemo)radiotherapy.

CONCLUSION

Overall, the literature on thickened liquids as an intervention to eliminate aspiration in the head and neck cancer population is limited. Because aspiration is known to be prevalent in the head and neck cancer population and thickened liquids are known to eliminate aspiration in other populations, it is important to determine the effectiveness of thickened liquids for reducing aspiration in the head and neck cancer population.

Patient-reported outcomes following parotid-sparing intensity-modulated radiotherapy for head and neck cancer. How important is dysphagia?

OBJECTIVES

Swallowing can be significantly affected during and following radiotherapy for head and neck cancer (HNC). The purpose of this study was to understand: (1) the trajectory of swallowing recovery following parotid-sparing intensity-modulated radiotherapy (IMRT) and (2) overall physical and social-emotional wellbeing and how patients prioritise swallowing following treatment.

MATERIALS AND METHODS

Sixty-one HNC patients completed questionnaires as part of a prospective study exploring patient-reported swallowing outcomes following parotid-sparing IMRT. Participants were asked to complete the M.D. Anderson Dysphagia Inventory (MDADI) and University of Washington Quality of Life Questionnaire (UW-QoL) v.04 before treatment and 3, 6 and 12months after treatment. Given the rise in human papilloma virus (HPV) and associated oropharyngeal cancers, we completed a sub analysis of the data in those participants.

RESULTS

There was a significant reduction in the MDADI composite scores 3months after completion of treatment. Improvements were observed by 12months, however, scores did not recover to baseline. The recovery in physical function was limited in comparison to social-emotional recovery at 12months. When oropharyngeal cancer scores were analysed, there was not a substantial difference to the whole group results. There was a shift in priorities following treatment. Swallowing was highlighted as a concern by 44% of HNC patients up to 12months after treatment with swallowing-related factors (saliva, taste and chewing) rated highly.

CONCLUSIONS

Patient reported swallowing outcomes were significantly affected from baseline to all follow-up time points and remained a priority concern at 12months following treatment. Overall social-emotional functioning does improve, suggesting that patients have the potential to adapt to their "new normal" following IMRT for HNC.

Effects of 2 different swallowing exercise regimens during organ-preservation therapies for head and neck cancers on swallowing function

BACKGROUND

This study investigated the effects of 2 different swallowing exercise regimens performed during radiation therapy with/without chemotherapy on swallowing function.

METHODS

Fifty patients were recruited prospectively to 2 groups (the exercise group, n = 26 and the repetitive swallow group, n = 24). Functional Oral Intake Scale (FOIS) scores and percutaneous endoscopic gastrostomy (PEG) placements were compared at posttreatment and at 3 months.

RESULTS

The exercise group eliminated significantly more PEG tubes at 3 months posttreatment compared to the swallow group (16% vs 50%). Among patients who received both radiation and chemotherapy, the exercise group had significantly less PEG tubes immediately posttreatment as well as 3 months posttreatment (35% and 10%), compared to the swallow group (69% and 50%).

CONCLUSION

Findings indicate significant benefits of the exercise group's exercise regimen in reducing PEG dependence and oral intake difficulties.

Shoulder pain, functional status, and health-related quality of life after head and neck cancer surgery

Head and neck cancer (HNC) patients experience treatment-related complications that may interfere with health-related quality of life (HRQOL). The purpose of this study was to describe the symptom experience (shoulder pain) and functional status factors that are related to global and domain-specific HRQOL at one month after HNC surgery. In this exploratory study, we examined 29 patients. The outcome variables included global HRQOL as well as physical, functional, emotional, and social well-being. Symptom experience and functional status factors were the independent variables. In the symptom experience variables, shoulder pain distress was negatively associated with physical well-being (R (2) = 0.24). Among the functional status variables, eating impairment was negatively related to global HRQOL (R (2) = 0.18) and physical well-being (R (2) = 0.21). Speaking impairment and impaired body image explained a large amount of the variance in functional well-being (R (2) = 0.45). This study provided initial results regarding symptom experience and functional status factors related to poor HRQOL in the early postoperative period for HNC patients.

Assessment of functional outcomes in patients with head and neck cancer according to the International Classification of Functioning, Disability and Health Core Sets from the perspective of the multi-professional team: results of 4 Delphi surveys

BACKGROUND

The International Classification of Functioning, Disability and Health Core Set for Head and Neck Cancer (ICF-HNC) covers the typical spectrum of problems in functioning in head and neck cancer. This study is part of a multistep process to develop practical guidelines in Germany. The purpose of this study was to identify instruments for the assessment of functioning using the ICF-HNC as reference.

METHODS

Four Delphi surveys with physicians, physiotherapists, psychologists, and social workers were performed to identify which aspects of the ICF-HNC are being treated and which assessment tools are recommended for the assessment of functioning.

RESULTS

Ninety-seven percent categories of the ICF-HNC were treated by healthcare professionals participating in the current study. Altogether, 33 assessment tools were recommended for therapy monitoring, food intake, pain, further organic problems/laboratory tests, and psychosocial areas.

CONCLUSION

Although the ICF-HNC is being currently implemented by the head and neck cancer experts, several areas are not covered regularly. Additionally, validated tools were rarely recommended.

Preservation of organ function in head and neck cancer

Preservation of function is a crucial aspect for the evaluation of therapies applied in the field of head and neck cancer. However, preservation of anatomic structures cannot automatically be equated with preservation of function. Functional outcome becomes increasingly important particularly for the evaluation of alternative treatment options with equivalent oncological outcomes.AS A RESULT, PRESENT STUDIES TAKE INTO ACCOUNT THREE TOPIC AREAS WITH VARYING EMPHASIS: (1) the effects of cancer therapy on essential physiological functions, (2) additional therapy-induced side-effects and complications, and (3) health-related quality of life. The present article summarizes vital aspects of clinical research from recent years. Functional outcomes after surgical and non-surgical treatment approaches are presented according to tumor localization and staging criteria. Additional methodological aspects relating to data gathering and documentation as well as challenges in implementing the results in clinical practice are also discussed.

Swallowing dysfunction in cancer patients

PURPOSE

Dysphagia (swallowing dysfunction) is a debilitating, depressing, and potentially life-threatening complication in cancer patients that is likely underreported. The present paper is aimed to review relevant dysphagia literature between 1990 and 2010 with a focus on assessment tools, prevalence, complications, and impact on quality of life in patients with a variety of different cancers, particularly in those treated with curative chemoradiation for head and neck cancer.

METHODS

The literature search was limited to the English language and included both MEDLINE/PubMed and EMBASE. The search focused on papers reporting dysphagia as a side effect of cancer and cancer therapy. We identified relevant literature through the primary literature search and by articles identified in references.

RESULTS

A wide range of assessment tools for dysphagia was identified. Dysphagia is related to a number of factors such as direct impact of the tumor, cancer resection, chemotherapy, and radiotherapy and to newer therapies such as epidermal growth factor receptor inhibitors. Concomitant oral complications such as xerostomia may exacerbate subjective dysphagia. Most literature focuses on head and neck cancer, but dysphagia is also common in other types of cancer.

CONCLUSIONS

Swallowing impairment is a clinically relevant acute and long-term complication in patients with a wide variety of cancers. More prospective studies on the course of dysphagia and impact on quality of life from baseline to long-term follow-up after various treatment modalities, including targeted therapies, are needed.

Nutrition support for head and neck squamous cell carcinoma patients treated with chemoradiotherapy: how often and how long?

Background. Oral intake of many patients with locally advanced head and neck cancer (LAHNC) decrease during chemoradiotherapy (CRT). Although prophylactic percutaneous endoscopic gastrostomy (PEG) is recommended, not a few patients complete CRT without using PEG tube. Patients and Methods. The subjects were patients with LAHNC who received CRT. We retrospectively investigated the incidence and duration of nutritional support during and after CRT, and predicting factors of nutritional support. For patients who required nutritional support, we also checked the day of initiation and the duration of nutritional support. Results. Of 53 patients, 29 patients (55%) required nutritional support during and/or after CRT. While no clear relation between requirement of nutritional support and variables including age, T stage, N stage, clinical stage and chemotherapy regimen, there could be some relationships between tumor primary sites and the requirement and duration of nutritional support. 17 (77%) of 22 patients with oropharynx cancer(OP) required nutritional support and prolonged for 4.4 months, and 11 (46%) of 24 patients with hypopharynx cancer(HP) required nutritional support and prolonged for 21.9 months. Conclusion. Nutritional support is indicated many HNC patients treated with CRT and primary sites may have some relation to its indication and duration.

Changing the perspective: current trends in the assessment of functional outcome in patients with head and neck cancer

Functional outcome and quality of life have become frequent outcome measures in head and neck cancer (HNC) clinical trials. Many thoroughly validated outcome measures are available. Still, there is a low degree of standardization and comparability among measures. It seems difficult to fully translate the new insights into clinical routine. The aims of this paper are 1) to acknowledge the diversity of outcome measures and many of the past milestones that have been reached, but also 2) to capture a growing need to concentrate and reach consensus. The hypothesis is to gain more benefit from changing the perspective toward consensus rather than diversity in functional outcome assessment. The next steps are to adopt a unique "language" to describe functional outcome and implement clear end points that assist clinical decision making. The International Classification of Functioning, Disability, and Health was adopted by the WHO and offers an internationally accepted classification to describe disability in HNC.

Effects of sensory or motor nerve deafferentation on oromotor function in mice

OBJECTIVE

To investigate the effect of sensory or motor nerve damage to the tongue using a mouse model.

STUDY DESIGN

Animal study.

SETTING

Research laboratory.

SUBJECTS AND METHODS

Adult male and female mice from inbred strains B6 (n = 19) and D2 (n = 25). Following lick training, bilateral lingual-chorda tympani nerve cuts (LX) (n = 6 B6, n = 7 D2), unilateral hypoglossal nerve cuts (HX) (n = 7 B6, n = 9 D2), or sham surgery (n = 6 B6, n = 9 D2) was performed. Mice were lick tested postsurgically with both water and sucrose (4 days total). Following testing, post mortem dissections and microscopic analysis of tongue papillae were performed.

RESULTS

In both strains, HX and LX mice demonstrated a significant reduction in volume per lick (VPL) in the surgical groups relative to shams. Neither motor nor sensory nerve transection affected local lick rate. In most LX mice in both strains, taste papillae were reduced compared with HX or sham mice.

CONCLUSION

Mice of either strain with either a sensory or a motor nerve injury have a significant loss of VPL during ingestion of either a neutral (water) or preferred (sucrose) stimulus. This reduction in VPL reflects a deficit in licking. Lick rate was not affected by deafferentation. A reduction in fungiform papillae following LX but not HX mice was noted.

Objective assessment of swallowing function after definitive concurrent (chemo)radiotherapy in patients with head and neck cancer

The aim of this study was to objectively assess swallowing function and factors impacting it after curative intent definitive (chemo)radiotherapy (CRT) for head and neck squamous cell carcinoma (HNSCC). Swallowing function was studied in a cohort of 47 patients with locoregionally advanced (T1-4, N0-3) HNSCC treated with definitive CRT. Objective assessment of swallowing function was done using modified barium swallow (MBS) at baseline (pre-CRT) and subsequent follow-ups. Scoring of MBS was done using penetration-aspiration scale (PAS). Abnormal swallowing was defined in terms of incidence and severity of penetration-aspiration, pharyngeal residue, postural change, and regurgitation. Aspiration, residual, postural change, and regurgitation were present on baseline pre-CRT assessment in 9 (19%), 11 (23%), 10 (21%), and 5 (10%) patients that increased to 11 (29%), 11 (29%), 12 (32%), and 10 (26%) patients, respectively, at 6-month post-CRT evaluation. The proportion of patients with high PAS scores (3-7) increased from 27% at baseline to 37% at 6-month post-CRT evaluation. Among patients (n = 34) with low PAS scores (≤2) at baseline, additional impairment of swallowing function was seen in 53 and 46% at 2- and 6-month assessment, respectively. Residue (44%) and aspiration (18%) domains were impaired in a higher proportion of patients after CRT. Thin and thick barium had higher aspiration and residue function impairment, respectively. Patients with pre-CRT poor subjective swallowing function (P = 0.004), hypopharyngeal primary (P = 0.05), and large tumor volume (P = 0.05) had significantly worse objective swallowing function at baseline as demonstrated by pretreatment PAS scores. This study provides useful information regarding patterns of objective swallowing dysfunction in patients treated with definitive (chemo)radiotherapy. There is significant impairment of objective swallowing function in all domains following CRT, with residue and aspiration domains being affected most significantly.

A prospective investigation of swallowing, nutrition, and patient-rated functional impact following altered fractionation radiotherapy with concomitant boost for oropharyngeal cancer

Altered fractionation radiotherapy for head and neck cancer has been associated with improved locoregional control, overall survival, and heightened toxicity compared with conventional treatment. Swallowing, nutrition, and patient-perceived function for altered fractionation radiotherapy with concomitant boost (AFRT-CB) for T1-T3 oropharyngeal squamous cell carcinoma (SCC) have not been previously reported. Fourteen consecutive patients treated with AFRT-CB for oropharyngeal SCC were recruited from November 2006 to August 2009 in a tertiary hospital in Brisbane, Australia. Swallowing, nutrition, and patient-perceived functional impact assessments were conducted pretreatment, at 4-6 weeks post-treatment, and at 6 months post-treatment. Deterioration from pretreatment to 4-6 weeks post-treatment in swallowing, nutrition, and functional impact was evident, likely due to the heightened toxicity associated with AFRT-CB. There was significant improvement at 6 months post-treatment in functional swallowing, nutritional status, patient-perceived swallowing, and overall function, consistent with recovery from acute toxicity. However, weight and patient perception of physical function and side effects remained significantly worse than pretreatment scores. The ongoing deficits related to weight and patient-perceived outcomes at 6 months revealed that this treatment has a long-term impact on function possibly related to the chronic effects of AFRT-CB.

Objective assessment of swallowing function after definitive concurrent (chemo)radiotherapy in patients with head and neck cancer

The aim of this study was to objectively assess swallowing function and factors impacting it after curative intent definitive (chemo)radiotherapy (CRT) for head and neck squamous cell carcinoma (HNSCC). Swallowing function was studied in a cohort of 47 patients with locoregionally advanced (T1-4, N0-3) HNSCC treated with definitive CRT. Objective assessment of swallowing function was done using modified barium swallow (MBS) at baseline (pre-CRT) and subsequent follow-ups. Scoring of MBS was done using penetration-aspiration scale (PAS). Abnormal swallowing was defined in terms of incidence and severity of penetration-aspiration, pharyngeal residue, postural change, and regurgitation. Aspiration, residual, postural change, and regurgitation were present on baseline pre-CRT assessment in 9 (19%), 11 (23%), 10 (21%), and 5 (10%) patients that increased to 11 (29%), 11 (29%), 12 (32%), and 10 (26%) patients, respectively, at 6-month post-CRT evaluation. The proportion of patients with high PAS scores (3-7) increased from 27% at baseline to 37% at 6-month post-CRT evaluation. Among patients (n = 34) with low PAS scores (≤2) at baseline, additional impairment of swallowing function was seen in 53 and 46% at 2- and 6-month assessment, respectively. Residue (44%) and aspiration (18%) domains were impaired in a higher proportion of patients after CRT. Thin and thick barium had higher aspiration and residue function impairment, respectively. Patients with pre-CRT poor subjective swallowing function (P = 0.004), hypopharyngeal primary (P = 0.05), and large tumor volume (P = 0.05) had significantly worse objective swallowing function at baseline as demonstrated by pretreatment PAS scores. This study provides useful information regarding patterns of objective swallowing dysfunction in patients treated with definitive (chemo)radiotherapy. There is significant impairment of objective swallowing function in all domains following CRT, with residue and aspiration domains being affected most significantly.

Functional organ preservation in patients with locoregionally advanced head and neck squamous cell carcinoma treated by platinum-based multidrug induction chemotherapy and concurrent chemoradiotherapy

BACKGROUND

The objective of this study was to evaluate the feasibility, safety, and efficacy in terms of functional organ preservation of multidrug induction chemotherapy and concurrent chemoradiotherapy (IC-CCRT) protocol in patients with locoregionally advanced head and neck squamous cell carcinoma (LA-HNSCC).

PATIENTS AND METHODS

Patients with previously untreated, inoperable, histologically proven nonmetastatic stage III or IV HNSCC were eligible. Following one cycle of IC, two cycles of cisplatinum and 5-fluorouracil CCRT with conventional fractionated radiotherapy up to a dose of 66-70 Gy were administrated.

RESULTS

Between January 2000 and July 2007, a total of 139 patients were candidates to receive IC-CCRT for LA-HNSCC. Overall, 83% of the patients completed the treatment. Three-year overall survival estimate was 68% [95% confidence interval (CI) 57% to 79%]. Three-year progression-free survival (PFS) estimate was 62% (95% CI 50% to 74%). Three-year functional PFS was 57% (95% CI 44% to 69%). There were no cases of treatment-related deaths. The most frequent severe acute toxicity was pharyngeal mucositis.

CONCLUSIONS

Cisplatinum-based multidrug IC-CCRT can result in functional organ preservation and curative treatment in most patients with LA-HNSCC. The toxicity profile and patients' compliance to treatment confirmed the safety and tolerability of this approach.