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

Presence and duration of feeding tube in a 5-year cohort of patients with head and neck cancer treated with curative intensity-modulated radiation therapy

BACKGROUND

Our study assessed post-radiation therapy (RT) G-tube presence, duration, and clinical predictors in patients with head and neck cancer (HNC).

METHODS

We identified those 1-5-years post-RT with stage III/IV nasopharyngeal, oropharyngeal, hypopharyngeal, laryngeal, or unknown primaries. Logistic regression identified predictors of post-RT G-tube presence, Kaplan-Meier analysis estimated G-tube days, and log-rank test compared by tumor site.

RESULTS

The 977 patients had mean age 60.6 ± 11.6 years, 804 (82.3%) male, 764 (78.2%) stage IV, and 618 (63.3%) oropharyngeal primaries. All patients received intensity-modulated RT (IMRT), 571 (58.4%) received chemotherapy, and 698 (71.4%) prophylactic G-tube. G-tube prevalence 1- and 5-years post-IMRT was 7.1% and 4.8%, respectively. Median post-IMRT G-tube days were overall 63 (95%CI: 56-70), nasopharynx 119 (95%CI: 109-131), oropharynx 57 (95%CI: 51-68), hypopharynx 126 (95%CI: 77-256), larynx 53 (95%CI: 21-63), unknown 30 (95%CI: 17-55), of which hypopharynx was highest p < 0.001.

CONCLUSIONS

At an institution offering prophylactic G-tube for patients with advanced HNC, no differences were found in yearly G-tube use 1-5 years post-IMRT. Across all patients, median post-IMRT days with G-tube was 63 day but those with hypopharyngeal tumors registered the most days.

Routine Use of Swallowing Outcome Measures Following Head and Neck Cancer in a Multidisciplinary Clinic Setting

Introduction  Chemoradiotherapy treatment for head and neck cancer (HNC) can have a major impact on swallowing function and health-related quality of life.

The use of outcome measures in early detection of patients with swallowing problems provides the opportunity for targeting speech and language therapy (SLT) interventions to aid adaption and promote better clinical outcomes.

Objective  The purpose of the present study was to assess relationships between four outcomes measures over time, in a cohort of HNC patients, treated by (chemo-)radiotherapy.

Methods  Data were collected at 3 months and 12 months, on 49 consecutive patients with primary squamous cell cancer of the oropharynx, nasopharynx or hypopharynx stage T1–4, N0–2b, M0 disease.

Results  Out of 49 eligible patients, 45 completed assessment at 3 months and 20 at 12 months. The 3-month outcomes gave a strong indication of performance at 1 year. There were several strong correlations found between measures. The strongest was between the 3-month Performance Status Scale for Head and Neck Cancer (PSSHN) and the 12-month PSSHN (rs = 0.761, n  = 17), the 12-month PSSHN and the 12-month Functional Oral Intake Scale (FOIS) (rs = 0.823, n  = 20), and the 12-month University of Washington Head and Neck Quality of Life (UWQoL) swallow and the 12-month Water Swallow Test (WST) capacity (rs = 0.759, n  = 17).

Conclusion  The UW-QoL swallow item and WST are easy to incorporate into routine care and should be used as part of a standard assessment of swallow outcome. These measures can serve to help screen patients for dysfunction and focus allocation of resources for those who would benefit from more comprehensive assessment and intervention by SLT.

Late Effects of Organ Preservation Treatment on Swallowing and Voice; Presentation, Assessment, and Screening

The prevalence of head and neck cancer (HNC) survivors is on the rise. Treatments for HNC can have a major deleterious impact on functions such as swallowing and voice. Poor functional outcomes are strongly correlated with distress, low quality of life, difficulties returning to work and socializing. Furthermore, dysphagia can have serious medical consequences such as malnutrition, dehydration, and pneumonia. A conservative estimate of the percentage of survivors living with dysphagia in the long-term is between 50 and 60%. Evidence is emerging that functions can worsen over time, sometimes several years following treatment due to radiation-associated fibrosis, neuropathy, intractable edema, and atrophy. Muscles lose their strength, pliability, stamina, and range, speed, precision, and initiation of movements necessary for swallowing and voice functions. Late treatment effects can go unrecognized, and may only be identified when there is a medical complication such as hospitalization for aspiration pneumonia. In the routine healthcare setting methods of evaluation include a detailed case history, a thorough clinical examination and instrumental assessments. Interventions for late treatment effects are limited and it is imperative that patients at risk are identified as early as possible. This paper considers the role of screening tests in monitoring swallowing and detecting aspiration in the long-term. Further work is indicated for addressing this pressing and increasingly common clinical problem.

Patient Experiences of Swallowing Exercises After Head and Neck Cancer: A Qualitative Study Examining Barriers and Facilitators Using Behaviour Change Theory

Poor patient adherence to swallowing exercises is commonly reported in the dysphagia literature on patients treated for head and neck cancer. Establishing the effectiveness of exercise interventions for this population may be undermined by patient non-adherence. The purpose of this study was to explore the barriers and facilitators to exercise adherence from a patient perspective, and to determine the best strategies to reduce the barriers and enhance the facilitators. In-depth interviews were conducted on thirteen patients. We used a behaviour change framework and model [Theoretical domains framework and COM-B (Capability–opportunity–motivation-behaviour) model] to inform our interview schedule and structure our results, using a content analysis approach. The most frequent barrier identified was psychological capability. This was highlighted by patient reports of not clearly understanding reasons for the exercises, forgetting to do the exercises and not having a system to keep track. Other barriers included feeling overwhelmed by information at a difficult time (lack of automatic motivation) and pain and fatigue (lack of physical capability). Main facilitators included having social support from family and friends, the desire to prevent negative consequences such as long-term tube feeding (reflective motivation), having the skills to do the exercises (physical capability), having a routine or trigger and receiving feedback on the outcome of doing exercises (automatic motivation). Linking these findings back to the theoretical model allows for a more systematic selection of theory-based strategies that may enhance the design of future swallowing exercise interventions for patients with head and neck cancer.