Predicting two-year longitudinal MD Anderson Dysphagia Inventory outcomes after intensity modulated radiotherapy for locoregionally advanced oropharyngeal carcinoma

Developing and validating multi-omics prediction models for late patient-reported dysphagia in head and neck radiotherapy

Background and purpose. To investigate models developed using radiomic and dosiomic (multi-omics) features from planning and treatment imaging for late patient-reported dysphagia in head and neck radiotherapy.Materials and methods. Training (n = 64) and testing (n = 23) cohorts of head and neck cancer patients treated with curative intent chemo-radiotherapy with a follow-up time greater than 12 months were retrospectively examined. Patients completed the MD Anderson Dysphagia Inventory and a composite score ≤60 was interpreted as patient-reported dysphagia. A chart review collected baseline dysphagia and clinical factors. Multi-omic features were extracted from planning and last synthetic CT images using the pharyngeal constrictor muscle contours as a region of interest. Late patient-reported dysphagia models were developed using a random forest backbone, with feature selection and up-sampling methods to account for the imbalanced data. Models were developed and validated for multi-omic feature combinations for both timepoints.Results. A clinical and radiomic feature model developed using the planning CT achieved good performance (validation: sensitivity = 80 ± 27% / balanced accuracy = 71 ± 23%, testing: sensitivity = 80 ± 10% / balanced accuracy = 73 ± 11%). The synthetic CT models did not show improvement over the plan CT multi-omics models, with poor reliability of the radiomic features on these images. Dosiomic features extracted from the synthetic CT showed promise in predicting late patient-reported dysphagia.Conclusion. Multi-omics models can predict late patient-reported dysphagia in head and neck radiotherapy patients. Synthetic CT dosiomic features show promise in developing successful models to account for changes in delivered dose distribution. Multi-center or prospective studies are required prior to clinical implementation of these models.

Moving from conventional to adaptive risk stratification for oropharyngeal cancer

Oropharyngeal cancer (OPC) poses a complex therapeutic dilemma for patients and oncologists alike, made worse by the epidemic increase in new cases associated with the oncogenic human papillomavirus (HPV). In a counterintuitive manner, the very thing which gives patients hope, the high response rate of HPV-associated OPC to conventional chemo-radiation strategies, has become one of the biggest challenges for the field as a whole. It has now become clear that for ~30-40% of patients, treatment intensity could be reduced without losing therapeutic efficacy, yet substantially diminishing the acute and lifelong morbidity resulting from conventional chemotherapy and radiation. At the same time, conventional approaches to de-escalation at a population (selected or unselected) level are hampered by a simple fact: we lack patient-specific information from individual tumors that can predict responsiveness. This results in a problematic tradeoff between the deleterious impact of de-escalation on patients with aggressive, treatment-refractory disease and the beneficial reduction in treatment-related morbidity for patients with treatment-responsive disease. True precision oncology approaches require a constant, iterative interrogation of solid tumors prior to and especially during cancer treatment in order to tailor treatment intensity to tumor biology. Whereas this approach can be deployed in hematologic diseases with some success, our ability to extend it to solid cancers with regional metastasis has been extremely limited in the curative intent setting. New developments in metabolic imaging and quantitative interrogation of circulating DNA, tumor exosomes and whole circulating tumor cells, however, provide renewed opportunities to adapt and individualize even conventional chemo-radiation strategies to diseases with highly variable biology such as OPC. In this review, we discuss opportunities to deploy developing technologies in the context of institutional and cooperative group clinical trials over the coming decade.

A randomized controlled study evaluating the head-lift exercise in head and neck cancer patients with radiation-induced dysphagia: effect on swallowing function and health-related quality of life over 12 months

PURPOSE

Dysphagia is common after radiotherapy for head and neck cancer (HNC) and can affect health-related quality of life (HRQL). This randomized controlled trial aimed to evaluate the effect of the head-lift exercise (HLE) over 12 months in HNC patients with radiation-induced dysphagia.

METHODS

Sixty-one patients with dysphagia were randomized to intervention group (n = 30) and control group (n = 31) at 6-36 months after completion of radiotherapy for HNC. Dysphagia-specific HRQL was measured with the MD Anderson Dysphagia Inventory (MDADI); general and HNC-specific HRQL was measured with the European Organization for Research and Treatment of Cancer Quality of Life questionnaire Core 30 (EORTC QLQ-C30) and QLQ-H&N35. Measurements were made at baseline, and at 8 weeks and 12 months after start of intervention.

RESULTS

Adherence to the intervention was good throughout the year. When comparing change from baseline reports to each follow-up no statistically significant differences between the groups were found in any of the HRQL instruments. There were some statistically significant changes within groups compared to baseline. The intervention group improved self-rated swallowing function on the MDADI at 8 weeks (emotional domain, p = 0.03; functional domain, p = 0.007; total score, p = 0.01) and the control at twelve months (emotional domain, p = 0.03; functional domain, p = 0.02; physical domain, p = 0.004; total score, p = 0.002).

CONCLUSION

In this randomized control study, no effect was observed short term or at 12 months on HRQL after use of the HLE as rehabilitation for radiation-induced dysphagia.

Decisional regret, symptom burden, and quality of life following transoral robotic surgery for oropharyngeal cancer

BACKGROUND

Transoral robotic surgery (TORS) has equivalent oncologic control to radiotherapy with potential for improved quality of life (QOL) and lower patient-reported decisional regret.

METHODS

Cross-sectional study between 2016 and 2021 of TORS patients with early-stage oropharyngeal squamous cell carcinoma who completed the Decision Regret Scale (DRS), M. D. Anderson Dysphagia Inventory (MDADI), and University of Washington Quality of Life (UW-QOL). The median time from treatment to questionnaire completion was 1.8 years (IQR 1.4-3.3, range 1.0-5.6).

RESULTS

Of 65 patients, 84.6% expressed no or mild decisional regret. Regret was not associated with clinical parameters or adjuvant treatment but was correlated with MDADI (τavg = -0.23, p < 0.001) and UW-QOL (τavg = -0.27, p < 0.001). Worse MDADI was associated with older age and worse UW-QOL was associated with multi-site operation and shorter time to survey.

CONCLUSIONS

Overall, the TORS cohort expressed very limited decisional regret. DRS scores were unaffected by clinicodemographics or additional adjuvant therapies, but decision regret was correlated with worse QOL and worse swallowing.

A Novel Risk Model for Predicting Dysphagia after Tongue Reconstruction: A Retrospective Multicenter Study in Japan

BACKGROUND

There is no consensus on the postoperative outcomes of tongue reconstruction. Therefore, the authors developed a novel risk model for predicting dysphagia after tongue reconstruction.

METHODS

This retrospective study was conducted by the Oral Pharyngeal Esophageal Operation and Reconstruction Analytical, or OPERA, group across 31 cancer centers and university hospitals in Japan. A total of 532 patients [390 (73.3%) men and 142 (26.7%) women; median age at surgery, 60 years (range, 15 to 88 years)] who were diagnosed with oral tongue squamous cell carcinoma and underwent tongue reconstruction following glossectomy between 2009 and 2013 were included. Independent risk factors were identified using univariate regression analysis and converted to a binary format for multivariate analysis. An integer value was assigned to each risk factor to calculate a total score capable of quantifying the risk of feeding tube dependence.

RESULTS

Overall, 54 patients (10.2%) required a feeding tube at the time of evaluation. Predictive factors for feeding tube dependence were advanced age, lower American Society of Anesthesiologists physical status, low body mass index, lower serum albumin, comorbid hypertension and diabetes, extended tongue defect, resection beyond the tongue, laryngeal suspension, postoperative radiation therapy, and no functional teeth. In multivariate logistic regression analysis, age greater than or equal to 58.5 years, postoperative radiation therapy, wider tongue defect, and body mass index less than 21.27 kg/m 2 earned 6, 4, 3, and 2 points, respectively, for a maximum total score of 15.

CONCLUSION

The authors' risk model provides a mathematical tool for estimating the individual risk of postoperative feeding tube dependence before tongue reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Temporal Trends in Clinician-Assessed and Patient-Reported Swallowing Outcomes in Oropharyngeal Cancer Patients

BACKGROUND

Dysphagia is a consequence of oropharyngeal squamous cell carcinoma (OPSCC) treatments and often results in a devastating reduction in quality of life (QoL; Nguyen et al., 2005; Pauloski, 2008).

OBJECTIVES

This study aimed to report temporal trends in swallowing outcomes using the Modified Barium Swallow Impairment Profile (MBSImP) and the M.D. Anderson Dysphagia Inventory (MDADI) and to study the relationship between these two measures.

METHOD

This was a retrospective review of clinical data collected in January 2013 to December 2017 from a tertiary care center. MBSImP PI scores and MDADI composite scores were collected pretreatment and 1, 6, and 12 months posttreatment. Data were analyzed in aggregate and stratified by treatment modality. To address the primary objective, descriptive statistics were used. To address the secondary objective, four Spearman tests were run between MBSImP PI and MDADI composite scores.

RESULTS

A total of 123 OPSCC participants were included. With respect to trends, MBSImP PI scores worsened 1 month posttreatment and remained impaired at 6 and 12 months. For MDADI composite scores, patient reports worsened 1 month posttreatment and subsequently improved at 6 and 12 months. MBSImP PI and MDADI composite scores were weakly negatively correlated (i.e., in agreement) at the pre- and 12-month posttreatment appointments.

CONCLUSIONS

Swallowing outcomes in OPSCC patients have distinct yet predictable trends for both clinician-assessed and patient-reported swallowing outcomes during the first year following cancer treatment. However, unlike previous findings, these two types of measures were in agreement at the pretreatment and 12 months posttreatment appointments.

Patient-Reported Outcomes After Swallowing (SWOARs)-Sparing IMRT in Head and Neck Cancers: Primary Results from a Prospective Study Endorsed by the Head and Neck Study Group (HNSG) of the Italian Association of Radiotherapy and Clinical Oncology (AIRO)

OBJECTIVES

To prospectively investigate changes in M.D. Anderson Dysphagia Inventory (MDADI) scores in patients affected by naso- and oropharynx cancer after definitive radiochemotherapy (ChemoRT) using swallowing organs at risk (SWOARs)-sparing IMRT.

METHODS

MDADI questionnaires were collected at baseline and at 6 and 12 months after treatment. MDADI scores were categorized as follows: ≥ 80 "optimal," 80-60 "adequate," < 60 "poor" deglutition-related quality of life (QoL) group, and dichotomized as "optimal" vs "adequate/poor" for the analysis. A mean MDADI composite (MDADI-C) change of 10 points was considered as minimal clinically important difference (MCID).

RESULTS

Sixty-three patients were enrolled of which 47 were considered for the analysis. At baseline, 26 (55%) were "optimal" and 21 (45%) were "adequate/poor." The mean baseline MDADI-C score was 93.6 dropping to 81 at 6 months (p = 0.013) and slightly rising to 85.5 at 12 months (p = 0.321) for the "optimal" group. Indeed, the mean baseline MDADI-C score was 64.3 rising to 77.5 at 6 months (p = 0.006) and stabilizing at 76 at 12 months (p = 0.999) for the "adequate/poor" group. A statistically significant but not clinically relevant worsening of the MDADI-C score was reported for the "optimal" group, whereas both a statistically significant and clinically meaningful improvement of the MDADI-C score were reported for the "adequate/poor" group from before to post-treatment.

CONCLUSION

Our results suggest a doubly clinical benefit of dose optimization to SWOARs to minimize the RT sequalae in patients with a baseline "optimal" deglutition-related QoL and to recover from cancer dysphagia in those with a baseline "adequate/poor" deglutition-related QoL.

Photobiomodulation in the management of oral mucositis for adult head and neck cancer patients receiving irradiation: the LiTEFORM RCT

BACKGROUND

Oral mucositis is a debilitating and painful complication of head and neck cancer irradiation that is characterised by inflammation of the mucous membranes, erythema and ulceration. Oral mucositis affects 6000 head and neck cancer patients per year in England and Wales. Current treatments have not proven to be effective. International studies suggest that low-level laser therapy may be an effective treatment.

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of low-level laser therapy in the management of oral mucositis in head and neck cancer irradiation. To identify barriers to and facilitators of implementing low-level laser therapy in routine care.

DESIGN

Placebo-controlled, individually randomised, multicentre Phase III superiority trial, with an internal pilot and health economic and qualitative process evaluations. The participants, outcome assessors and therapists were blinded.

SETTING

Nine NHS head and neck cancer sites in England and Wales.

PARTICIPANTS

A total of 87 out of 380 participants were recruited who were aged ≥ 18 years and were undergoing head and neck cancer irradiation with ≥ 60 Gy.

INTERVENTION

Random allocation (1 : 1 ratio) to either low-level laser therapy or sham low-level laser therapy three times per week for the duration of irradiation. The diode laser had the following specifications: wavelength 660 nm, power output 75 mW, beam area 1.5 cm², irradiance 50 mW/cm², exposure time 60 seconds and fluence 3 J/cm². There were 20-30 spots per session. Sham low-level laser therapy was delivered in an identical manner.

MAIN OUTCOME MEASURE

The mean Oral Mucositis Weekly Questionnaire-Head and Neck Cancer score at 6 weeks following the start of irradiation. Higher scores indicate a worse outcome.

RESULTS

A total of 231 patients were screened and, of these, 87 were randomised (low-level laser therapy arm, n = 44; sham arm, n = 43). The mean age was 59.4 years (standard deviation 8.8 years) and 69 participants (79%) were male. The mean Oral Mucositis Weekly Questionnaire-Head and Neck Cancer score at 6 weeks was 33.2 (standard deviation 10) in the low-level laser therapy arm and 27.4 (standard deviation 13.8) in the sham arm.

LIMITATIONS

The trial lacked statistical power because it did not meet the recruitment target. Staff and patients willingly participated in the trial and worked hard to make the LiTEFORM trial succeed. However, the task of introducing, embedding and sustaining new low-level laser therapy services into a complex care pathway proved challenging. Sites could deliver low-level laser therapy to only a small number of patients at a time. The administration of low-level laser therapy was viewed as straightforward, but also time-consuming and sometimes uncomfortable for both patients and staff, particularly those staff who were not used to working in a patient's mouth.

CONCLUSIONS

This trial had a robust design but lacked power to be definitive. Low-level laser therapy is relatively inexpensive. In contrast with previous trials, some patients found low-level laser therapy sessions to be difficult. The duration of low-level laser therapy sessions is, therefore, an important consideration. Clinicians experienced in oral cavity work most readily adapt to delivering low-level laser therapy, although other allied health professionals can be trained. Blinding the clinicians delivering low-level laser therapy is feasible. There are important human resource, real estate and logistical considerations for those setting up low-level laser therapy services.

FUTURE WORK

Further well-designed randomised controlled trials investigating low-level laser therapy in head and neck cancer irradiation are needed, with similar powered recruitment targets but addressing the recruitment challenges and logistical findings from this research.

TRIAL REGISTRATION

This trial is registered as ISRCTN14224600.

FUNDING

This project was funded by the National Institute for Health and Care Research ( NIHR ) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 46. See the NIHR Journals Library website for further project information.

The Feasibility of Home-Based Treatment Using Vibratory Stimulation in Chronic Severe Dysphagia

PURPOSE

Previously, externally placed vibratory laryngeal stimulation increased rates of swallowing in persons with and without dysphagia. This study examined the feasibility of using a vibratory device on the skin over the thyroid cartilage for home-based swallowing rehabilitation in long-standing dysphagia.

METHOD

Only participants with long-standing dysphagia (> 6 months) following cerebrovascular accident or head/neck cancer who had not previously benefited from dysphagia therapy participated. The device had two modes used daily for 90 days. In automatic mode, participants wore the device when awake, which vibrated for 4-8 s every 5 min to trigger a volitional swallow. In manual mode, participants practiced by activating vibration while swallowing rapidly. Study-related adverse events, such as pneumonia, and device-recorded adherence were tracked. Swallowing function on a modified barium swallow study was assessed at baseline and after 3 months of device use. Outcome measures included the Dysphagia Outcome and Severity Scale (DOSS), Penetration-Aspiration Scale (PAS), and swallowing timing measures. Participants' perceptions of the vibratory device and training were obtained.

RESULTS

The intent to treat analysis showed seven of 11 participants completed the study, all with severe chronic dysphagia. Of those seven participants completing the study, two developed respiratory complications (possibly due to pneumonia) that cleared after antibiotic intervention. For prescribed practice trials, adherence was 80% or greater in four of seven participants (57%) whereas prescribed automatic stimulations were met in only two of seven participants (29%). Three participants (43%) had a modest benefit on DOSS. The time to vestibule closure after the bolus passed the ramus was reduced in five participants (71%) on the modified barium swallow study.

CONCLUSION

Overall, the results have indicated that intensive home-based practice with stimulation may provide limited functional benefits in severe chronic dysphagia.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21498591.

The course of swallowing problems in the first 2 years after diagnosis of head and neck cancer

INTRODUCTION

Head and neck cancer (HNC) and its treatment often negatively impact swallowing function. The aim was to investigate the course of patient-reported swallowing problems from diagnosis to 3, 6, 12, and 24 months after treatment, in relation to demographic, clinical, and lifestyle factors.

METHODS

Data were used of the Netherlands Quality of Life and Biomedical Cohort Study in head and neck cancer research (NET-QUBIC). The primary outcome measures were the subscales of the Swallowing Quality of Life Questionnaire (SWAL-QOL). Linear mixed-effects models (LMM) were conducted to investigate changes over time and associations with patient, clinical, and lifestyle parameters as assessed at baseline.

RESULTS

Data were available of 603 patients. There was a significant change over time on all subscales. Before treatment, 53% of patients reported swallowing problems. This number increased to 70% at M3 and decreased to 59% at M6, 50% at M12, and 48% at M24. Swallowing problems (i.e., longer eating duration) were more pronounced in the case of female, current smoking, weight loss prior to treatment, and stage III or IV tumor, and were more prevalent at 3 to 6 months after treatment. Especially patients with an oropharynx and oral cavity tumor, and patients receiving (C)RT following surgery or CRT only showed a longer eating duration after treatment, which did not return to baseline levels.

CONCLUSION

Half of the patients with HNC report swallowing problems before treatment. Eating duration was associated with sex, smoking, weight loss, tumor site and stage, and treatment modality, and was more pronounced 3 to 6 months after treatment.

Adhering to Eat and Exercise Status During Radiotherapy for Oropharyngeal Cancer for Prevention and Mitigation of Radiotherapy-Associated Dysphagia

Importance

Previously published work reported independent benefit of maintenance of oral intake (eat) and swallowing exercise adherence (exercise) during radiotherapy (RT) on diet and functional outcomes. The current study seeks to validate the authors' previously published findings in a large contemporary cohort of patients with oropharynx cancer (OPC) and address limitations of the prior retrospective study using prospective, validated outcome measures.

Objective

To examine the longitudinal association of oral intake and swallowing exercise using validated, clinician-graded and patient-reported outcomes.

Design, Setting, and Participants

Secondary analysis of a prospective OPC registry including patients who underwent primary RT/chemoradiotherapy (CRT) or primary transoral robotic surgery plus RT/CRT for OPC at a single-institution comprehensive cancer center.

Exposures

Adherence to speech pathology swallowing intervention during RT coded as (1) eat: oral intake at end of RT (nothing by mouth [NPO]; partial oral intake [PO], with feeding tube [FT] supplement; full PO); and (2) exercise: swallowing exercise adherence (nonadherent vs partial/full adherence).

Main Outcomes and Measures

Feeding tube and diet (Performance Status Scale for Head and Neck Cancer) patient-reported swallowing-related quality of life (MD Anderson Dysphagia Inventory; MDADI) and clinician-graded dysphagia severity grade (videofluoroscopic Dynamic Imaging Grade of Swallowing Toxicity; DIGEST) were collected at baseline, 3 to 6 months, and 18 to 24 months post-RT.

Results

A total of 595 patients (mean [SD] age, 65 [10] years; 532 [89%] male) who underwent primary RT (111 of 595 [19%]), CRT (434 of 595 [73%]), or primary transoral robotic surgery plus RT/CRT (50 of 595 [8%]) were included in this cohort study. At the end of RT, 55 (9%) patients were NPO, 115 (19%) were partial PO, 425 (71%) were full PO, and 340 (57%) reported exercise adherence. After multivariate adjustment, subacute return to solid diet and FT were independently associated with oral intake (odds ratio [OR], 2.0; 95% CI, 1.0-4.1; OR, 0.1; 95% CI, 0.0-0.2, respectively) and exercise (OR, 2.9; 95% CI, 1.9-4.5; OR, 0.3; 95% CI, 0.1-0.5, respectively). Subacute MDADI (β = 6.5; 95% CI, 1.8-11.2), FT duration (days; β = -123.4; 95% CI, -148.5 to -98.4), and less severe dysphagia per DIGEST (OR, 0.6; 95% CI, 0.3-1.0) were independently associated with oral intake, while exercise was independently associated with less severe laryngeal penetration/aspiration per DIGEST-safety (OR, 0.7; 95% CI, 0.4-1.0). DIGEST grade associations with oral intake were not preserved long-term; however, exercise was associated with a higher likelihood of solid diet intake and better swallow safety per DIGEST.

Conclusions and Relevance

The findings of this cohort study extend the authors' previously published findings that oral intake and swallowing exercise during RT are associated with favorable functional outcomes, now demonstrated with broader domains of function using validated measures. Patterns of benefit differed in this study. Specifically, better subacute recovery of swallow-related quality of life and less severe dysphagia were found among patients who maintained oral intake independent of exercise adherence, and shorter FT utilization and better long-term diet and swallowing safety were found among those who exercised independent of oral intake.

Swallowing After Primary TORS and Unilateral or Bilateral Radiation for Low- to Intermediate-Risk Tonsil Cancer

OBJECTIVE

The primary course of treatment for patients with low- to intermediate-risk tonsil cancer has evolved with a shift toward primary transoral robotic surgery (TORS) or radiation therapy (RT). While favorable outcomes have been reported after deintensification via unilateral TORS or RT (uniRT), comparisons of functional outcomes between these treatments are lacking. We compared clinical outcomes (Dynamic Imaging Grade of Swallowing Toxicity [DIGEST] and feeding tube [FT]) and patient-reported swallowing outcomes (MD Anderson Dysphagia Inventory [MDADI]) based on primary treatment strategy: TORS, uniRT, or bilateral RT (biRT).

STUDY DESIGN

Secondary analysis of prospective cohort.

SETTING

Single institution.

METHODS

The study sample comprised 135 patients with HPV/p16+ T1-T3, N0-2b (American Joint Committee on Cancer, seventh edition), N0-1 (eighth edition) squamous cell carcinoma of the tonsil were sampled from a prospective registry. Modified barium swallow studies graded per DIGEST, FT placement and duration, and MDADI were collected.

RESULTS

Baseline DIGEST grade significantly differed among treatment groups, with higher dysphagia prevalence in the TORS group (34%) vs the biRT group (12%, P = .04). No significant group differences were found in DIGEST grade or dysphagia prevalence at subacute and longitudinal time points (P = .41). Mean MDADI scores were similar among groups at baseline (TORS, 92; uniRT, 93; biRT, 93; P = .90), subacute (TORS, 83; uniRT, 88; biRT, 82; P = .38) and late time points (TORS, 86; uniRT, 86; biRT, 87; P = .99). FT placement and duration significantly differed among primary treatment groups (FT [median days]: TORS, 89% [3]; uniRT, 8% [82]; biRT, 37% [104]; P < .001).

CONCLUSION

While TORS and uniRT offer optimal functional outcomes related to dysphagia, results suggest that no measurable clinician-graded or patient-reported differences in swallow outcomes exist among these primary treatment strategies and biRT. Aside from baseline differences that drive treatment selection, differences in FT rate and duration by primary treatment strategy likely reflect diverse toxicities beyond dysphagia.

Longitudinal Analysis of Swallowing Displacement Kinematics After Oropharyngeal Cancer Treatment

BACKGROUND/OBJECTIVE

Quantitative swallowing displacement kinematics evolve in patients treated for oropharyngeal squamous cell carcinoma (OPSCC). We aimed to longitudinally assess these measurements and correlate them with functional swallowing outcomes.

METHOD

A retrospective review was conducted on patients with OPSCC treated with definitive (chemo)radiation ([C]RT) or surgery with adjuvant (chemo)radiation (S-[C]RT) who completed at least two videofluoroscopic swallow studies (VFSS). Longitudinal analysis was accomplished via mixed-effects logistic regression for the Functional Oral Intake Scale (FOIS), and Penetration Aspiration Scale (PAS), and mixed-effects linear regression for kinematic measures. Spearman's correlation was conducted between changes in FOIS/PAS and kinematic measures.

RESULTS

Ninety-seven patients (76 males; mean age 61) completed 245 VFSS studies. A total of 94% had human papillomavirus (HPV)/p16 positive OPSCC and 74% were T0-T2. Sixty-four patients underwent [C]RT while 33 patients underwent S-[C]RT. After treatment, posterior pharyngeal wall at hold (PPWhold) increased 3.2 standard deviation (SD) between 0 and 6 months (p < 0.001), then decreased 2.2 SD between 6 and 12 months (p < 0.001) and did not return to baseline. Hyoid-to-larynx (HL) (p = 0.046) and maximal hyoid displacement (Hmax) + HL (p = 0.042) increased between 6 and 12 months. Hmax (p = 0.020) and Hmax + HL (p < 0.001) decreased between 12-24 months beyond baseline values. The decrease in HL and increase in PPWhold (p < 0.05) correlated with an increase in PAS. From baseline, increased pharyngeal constriction ratio correlated with decreased FOIS and PPWhold (p < 0.05).

CONCLUSIONS

Quantitative swallowing kinematic measures can effectively track changes in swallowing physiology. Increased PPWhold and restricted hyolaryngeal movement were seen in patients with OPSCC after treatment and correlated with a change in swallowing outcome, emphasizing the need for serial VFSS monitoring and targeted intervention.

LEVEL OF EVIDENCE

3 Laryngoscope, 2022.

Swallowing Function Following Neoadjuvant Chemotherapy and Transoral Robotic Surgery for Oropharyngeal Carcinoma: A 2-Year Follow-up

OBJECTIVE

To evaluate 2-year follow-up swallowing function in patients with human papillomavirus-related oropharyngeal squamous cell carcinoma (HPV+ OPSCC) who completed neoadjuvant chemotherapy and transoral robotic surgery (NAC+S).

STUDY DESIGN

Retrospective analysis of patients with OPSCC treated with NAC+S between 2010 and 2021.

SETTING

A single academic institution.

METHODS

This is a cross-sectional study of patient-reported swallowing function, assessed with the MD Anderson Dysphagia Inventory (MDADI) at least 2 years after completion of treatment. The inclusion criteria are patients with HPV+ OPSCC who underwent NAC+S at least 2 years ago. Those requiring adjuvant radiation or chemoradiation or experiencing relapse were excluded from the study.

RESULTS

Completed MDADIs were received from 37 patients at a median 3.8 years posttreatment (interquartile range, 2.0-8.6 years). Of those, 94.6% (n = 35) were male and 81.1% (n = 30) were White. The median age at OPSCC diagnosis was 59.0 years (interquartile range, 41-80 years). The most frequent primary subsite of OPSCC was the base of the tongue (n = 20, 54.1%), followed by the tonsils (n = 16, 43.2%). In addition, 75.7% (n = 28) had stage IVa disease (TNM seventh edition), and 29 (78.4%) had scores ≥80, classified as optimal function. When compared with patients who received bilateral neck dissection, patients who received unilateral neck dissection were associated with an age <65 years old (P = .036) and lower clinical TNM stage (P = .04), as well as higher composite, emotional, functional, and physical MDADI scores (P = .017, .046, .013, and .05, respectively).

CONCLUSION

Patients with OPSCC who were treated with NAC+S achieved satisfactory long-term swallowing outcomes. Unilateral neck dissection was significantly associated with higher MDADI scores in this patient cohort.

Using Ultrasound to Document the Effects of Expiratory Muscle Strength Training (EMST) on the Geniohyoid Muscle

Expiratory muscle strength training (EMST) is an exercise program designed to strengthen the muscles of expiration by increasing expiratory load during breathing exercises using either resistive or pressure threshold devices. Previous research has shown that EMST may increase submental suprahyoid muscle activity as measured with surface electromyography. The impact of EMST on submental muscles is of interest to those who treat dysphagia. The purpose of this study was to determine whether the cross-sectional area of the geniohyoid muscle changes as observed with ultrasound during a 5-week EMST program performed at 75% of maximum expiratory strength using the EMST150 device in healthy adults. Ten healthy adults participated in the 5-week program. Maximum expiratory pressure (MEP) and cross-sectional area of the geniohyoid muscle were measured weekly. Geniohyoid cross-sectional area was measured from ultrasound images recorded in the coronal plane. Repeated Measures ANOVA was used to determine whether there were significant changes among the dependent variables over the study period. Both MEP and geniohyoid area increased significantly in response to a 5-week program of EMST. EMST in healthy adults is effective at strengthening the geniohyoid muscle as reflected by significantly increased cross-sectional area measured with B-mode ultrasound. This is the first study to document weekly change in muscle morphology as a result of EMST. Increasing geniohyoid muscle mass and consequent strength through a program of EMST may be beneficial for persons with pharyngeal stage dysphagia resulting from reduced hyolaryngeal elevation, reduced laryngeal closure, or reduced UES opening.

Dysphagia, trismus and speech impairment following radiation-based treatment for advanced stage oropharyngeal carcinoma: a one-year prospective evaluation

OBJECTIVE

The objective was to assess swallowing, mouth opening and speech function during the first year after radiation-based treatment (RT(+)) after introduction of a dedicated preventive rehabilitation program for stage III-IV oropharyngeal carcinoma (OPC).

METHODS

Swallowing, mouth opening and speech function were collected before and at six- and twelve-month follow-up after RT(+) for OPC as part of ongoing prospective assessments by speech-language pathologists .

RESULTS

Objective and patient-perceived function deteriorated until 6 months and improved until 12 months after treatment, but did not return to baseline levels with 25%, 20% and 58% of the patients with objective dysphagia, trismus and speech problems, respectively. Feeding tube dependency and pneumonia prevalence was low.

CONCLUSION

Despite successful implementation, a substantial proportion of patients still experience functional limitations after RT(+) for OPC, suggesting room for improvement of the current rehabilitation program. Pretreatment sarcopenia seems associated with worse functional outcomes and might be a relevant new target for rehabilitation strategies.

Dysphagia and its impact on the quality of life of head and neck cancer patients: institution-based cross-sectional study

Objective

Impaired swallowing is a primary medical concern in head and neck cancer (HNC) patients. Swallowing therapy and supportive care to relieve swallowing problems among HNC patients are recommended. However, no data shows the effect of dysphagia on the quality of life (QoL) among Ethiopian patients. This cross-sectional study aimed to assess swallowing function and its impact on QoL.

Results

The sample included 102 HNC patients who visited oncology clinics at Tikur Anbessa Specialized Hospital. Majority were male (53.90%), employed (70.6%), single (57.80%), and completed some level of formal education (66.60%) with a mean age of 42.58 years (SD ± 14.08). More than half of the patients (69.6%) medical expenses were covered by the government. Most were suffering from advanced stage HNC (59.80%), squamous cell carcinoma (62.70%), and the most prevalent tumor location was nasopharynx (40.20%). The mean MDADI score was 53.29 (SD ± 15.85). Being female, low income, suffering from laryngeal cancer, advanced tumor, and undergoing a single modality therapy were crucial determinants of poor QoL related to swallowing problems. It is recommended to assess swallowing related QoL of patients using a validated tool and be included in treatment protocols.

A longitudinal study of the Swedish MD Anderson Dysphagia Inventory in patients with oral cancer

OBJECTIVE

The aim of this study was to investigate whether the Swedish MD. Anderson Dysphagia Inventory (MDADI) is able to detect changes in dysphagia symptoms over time for patients with head and neck cancer (HNC).

METHODS

One hundred and forty-two patients with resectable tumors of the oral cavity were included prior to treatment. The patients filled out the MDADI, European Organization for Research and Treatment of Cancer Quality of Life questionnaire Core 30 (EORTC QLQ-C30) and the HNC module (H&N35) at baseline and at least one follow-up at 6 and/or 12 months after oncologic treatment. A control group without dysphagia (n = 115) was included.

RESULTS

Self-perceived swallowing function decreased in all domains at 6 months, and improved between 6 and 12 months. The changes were similar to the changes of the EORTC domains, indicating a sensitivity to change. However, even if improvements were seen at 12 months, the values were still inferior compared to baseline values, and the values of a control group without dysphagia. Convergent validity was found with values of the MDADI and EORTC domains producing similar results, and moderate correlations as hypothesized. Patients with moderate-severe dysphagia according to the MDADI (<60 points) demonstrated inferior values of the EORTC domains compared to patients with scores above 60 points.

CONCLUSION

The Swedish MDADI was found to be sensitive to change, and showed convergent results when compared to other established instruments. The threshold value for the MDADI (<60 points) indicating moderate-severe dysphagia may be a valuable addition in the clinical use.

LEVEL OF EVIDENCE

1.

The natural history of weight and swallowing outcomes in oropharyngeal cancer patients following radiation or concurrent chemoradiation therapy

PURPOSE

Patients treated for oropharyngeal cancer (OPC) are at increased risk for functional decline due to cancer-related impairments and treatment toxicities, often leading to recommendations for enteral nutritional support. This study investigated the natural history of weight and swallowing outcomes in patients with and without feeding tube (FT) placement.

METHODS

Data were collected from electronic medical records of OPC patients treated with (chemo)radiotherapy at a single regional cancer center between January 2013 and December 2015. Weight measurements, Functional Oral Intake Scale (FOIS) scores, Performance Status Scale for Head and Neck Cancer (PSS-HN) normalcy of diet scores, and M.D. Anderson Dysphagia Inventory (MDADI) composite scores were gathered at baseline and at 3-, 6-, and 12-months post-treatment. Patients were grouped based on FT placement and change over time was assessed using linear mixed effects analysis.

RESULTS

Of 122 eligible patients, 38 (31.1%) received a FT (FT group). Compared with baseline, weight decreased significantly at 3 and 6 months in both groups and at 12 months for patients without a FT (NFT group). Swallowing-related quality of life (QoL) decreased significantly at 3 and 6 months only in the NFT group.

CONCLUSION

OPC patients experience clinically relevant decreases in weight and swallowing-related QoL in the first-year post-treatment irrespective of FT placement. These findings will contribute to improved patient monitoring and communication within the clinical setting which may ultimately lead to better outcomes for those with OPC.

Prospective longitudinal patient-reported outcomes of swallowing following intensity modulated proton therapy for oropharyngeal cancer

BACKGROUND AND PURPOSE

With an enlarging population of long-term oropharyngeal cancer survivors, dysphagia is an increasingly important toxicity following oropharynx cancer treatment. While lower doses to normal surrounding structures may be achieved with intensity modulated proton therapy (IMPT) compared to photon-based radiation, the clinical benefit is uncertain.

METHODS AND MATERIALS

Seventy-one patients with stage III/IV oropharyngeal cancer (AJCC 7th edition) undergoing definitive IMPT on a longitudinal prospective cohort study who had completed the MD Anderson Dysphagia Inventory (MDADI) at pre-specified time points were included.

RESULTS

The majority of patients had HPV-positive tumors (85.9%) and received bilateral neck radiation (81.4%) with concurrent systemic therapy (61.8%). Mean composite MDADI scores decreased from 88.2 at baseline to 59.6 at treatment week 6, and then increased to 74.4 by follow up week 10, 77.0 by 6 months follow up, 80.5 by 12 months follow up, and 80.1 by 24 months follow up. At baseline, only 5.6% of patients recording a poor composite score (lower than 60), compared to 61.2% at treatment week 6, 19.1% at follow up week 10, 13.0% at 6 months follow up, 13.5% at 1 year follow up, and 11.1% at 2 years follow up.

CONCLUSIONS

Patient reported outcomes following IMPT for oropharyngeal cancer demonstrates decreased swallowing function at completion of treatment with relatively rapid recovery by 10 weeks follow up and steady improvement through 2 years. The results are comparable to similar longitudinal studies of photon-based radiotherapy for oropharynx cancer, and suggest that IMPT confers no additional excess toxicity related to swallowing.

Assessing patient-reported symptom burden of long-term head and neck cancer survivors at annual surveillance in survivorship clinic

BACKGROUND

This study reports long-term head and neck cancer (HNC) patient-reported symptoms using the MD Anderson Symptom Inventory Head and Neck Cancer Module (MDASI-HN) in a large cohort of HNC survivors.

METHODS

MDASI-HN results were prospectively collected from an institutional survivorship database. Associations with clinicopathologic data were analyzed using χ² , Mann-Whitney, and univariate regression.

RESULTS

Nine hundred and twenty-eight patients were included. Forty-six percent had oropharyngeal primary tumors. Eighty-two percent had squamous cell carcinoma. Fifty-six percent of patients had ablative surgery and 81% had radiation therapy as a component of treatment. The most severe symptoms were xerostomia and dysphagia. Symptom scores were worst for hypopharynx and varied by subsite. Patients treated with chemoradiation or surgery followed by radiation ± chemotherapy reported the worst symptoms while patient treated with surgery plus radiation ± chemotherapy reported the worst interference.

CONCLUSION

HNC survivors describe their long-term symptom burden and inform efforts to improve care many years into survivorship.

Gastrostomy Utilization by Oropharyngeal Cancer Patients Is Partially Driven by Swallowing Function

OBJECTIVE

Oropharyngeal squamous cell carcinoma (OPSCC) incidence is rapidly increasing, as are survival rates, in large part due to the human papillomavirus (HPV). Treatment intensity, however, has remained unchanged, making treatment-related toxicity (i.e., dysphagia) a critical problem for an increasing number of patients. The primary objective of this study was to determine whether pretreatment objective swallowing measures can predict percutaneous fluoroscopic guided gastrostomy tube (PFG) utilization during OPSCC treatment.

METHODS

Forty-one newly diagnosed OPSCC patients treated with radiation underwent evaluation of swallow function with modified barium swallow study (MBSS) prior to and at completion of radiation treatment using the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST); a subset of patients were evaluated using the MD Anderson Dysphagia Inventory (MDADI).

RESULTS

Patients were male (100%), primarily Caucasian (85.4%) and p16 positive (85.4%) with mean age of 65.7 years. PFG were placed in 70.7% patients (n = 29) and used by 63.4% (n = 26). Pre- and post-treatment DIGEST scores were associated with T-classification (t = -2.9, p = .001, t = -2.7, p = .01) and indicated deteriorating swallow function during treatment (mean change = 0.46 [t = -2.7, p = .01]). DIGEST and MDADI scores were generally not associated with patient PFG utilization. DIGEST and MDADI scores were significantly correlated prior to, but not following completion of treatment.

CONCLUSION

Pre-treatment DIGEST and patient reported swallowing outcomes (MDADI) can be useful in identifying patients with unsafe and/or grossly inefficient swallowing function. However, objectively measured swallow function was not associated with PFG utilization. Development of PFG placement algorithms (reactive vs. prophylactic) therefore require additional inputs/metrics.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:2153-2159, 2020.

Very late xerostomia, dysphagia, and neck fibrosis after head and neck radiotherapy

BACKGROUND

Acute and late toxicity after intensity-modulated radiotherapy (IMRT) for head and neck cancer (HNC) impacts on patient quality of life; yet, very late toxicity data remain scarce. This study assessed dysphagia, xerostomia, and neck fibrosis 3-8 years after IMRT.

METHODS

A retrospective analysis using generalized estimated equations was performed on 60 patients with HNC treated with fractionated IMRT between 2000 and 2015 who had a follow-up ≥8 years. Toxicity was scored using LENT-SOMA scales.

RESULTS

A trend towards a nonlinear global time effect (P = .05) was noted for dysphagia with a decrease during the 5 years post-treatment and an increase thereafter. A significant decrease in xerostomia (P = .001) and an increase in neck fibrosis (P = .04) was observed until 8 years.

CONCLUSIONS

Dysphagia, xerostomia, and neck fibrosis do not appear stable over time and remain highly prevalent in the very late follow-up. Our findings support the need for prospective trials investigating very late toxicity in patients with HNC.

Chronic radiation-associated dysphagia in oropharyngeal cancer survivors: Towards age-adjusted dose constraints for deglutitive muscles

•

Age at treatment for OPSCC is a strong predictor of chronic radiation associated dysphagia (RAD).

•

For swallowing regions of interest (ROIs), dose to ROI and age impact patients’ risk of chronic RAD.

•

For patients at high risk for RAD more intense prophylactic swallowing therapies may be warranted.

Objectives

We sought to model chronic radiation-associated dysphagia (RAD) in patients given intensity-modulated radiation therapy (IMRT) for oropharyngeal squamous cell cancer (OPSCC) as a function of age and dose to non-target swallowing muscles.

Methods

We reviewed 300 patients with T1-T4 N0-3 M0 OPSCC given definitive IMRT with concurrent chemotherapy. Chronic RAD was defined as aspiration or stricture on videoflouroscopy/endoscopy, gastrostomy tube, or aspiration pneumonia at ≥12 months after IMRT. Doses to autosegmented regions of interest (ROIs; inferior, middle and superior constrictors, anterior and posterior digastrics, mylo/geniohyoid complex, intrinsic tongue, and gengioglossus) were obtained from DICOM-RT plans and dose-volume histograms. The probability of chronic RAD as a function of mean ROI dose, stratified by age (<50, 50–59, 60–69, or ≥70 years), was estimated with logistic probability models and subsequent unsupervised nonlinear curves.

Results

Chronic RAD was observed in 34 patients (11%). Age was a significant correlate of chronic RAD, both independently and with dose for all muscle groups examined. Distinct muscle-specific dose–response profiles were observed as a function of age (e.g., 5% of patients in their 50 s [but 20% of those 70 + ] who received 60 Gy to the superior constrictor had chronic RAD). This effect was stable across all observed muscle ROIs, with a false discovery rate-corrected p < 0.05, for all dose/muscle/age models, suggesting that including age as a covariate improves modeling of chronic RAD.

Conclusions

Age at treatment moderates the probability of chronic RAD after chemo-IMRT for OPSCC, with aging muscles showing lower dose thresholds. Uniform dose constraints may not predict toxicity in older patients.

Swallowing Function in Survivors of Oropharyngeal Cancer Is Associated With Advanced T Classification

OBJECTIVES

The incidence of oropharyngeal squamous cell carcinoma (OPSCC) is rapidly increasing in the United States. The aim of this study was to characterize the functional status of OPSCC survivors to identify predictors of swallowing dysfunction in this patient population.

METHODS

OPSCC survivors (n = 81) treated at the Michael E. DeBakey Veterans Affairs Medical Center between 2005 and 2015 with at least 2 years of clinical follow-up were reviewed. Functional status was ascertained using (1) gastrostomy and tracheostomy placement and retention, (2) gastrostomy use at last follow-up, (3) patient-reported diet, and (4) modified barium swallow.

RESULTS

Median follow-up duration was 5.6 years; 67% of patients had ≥10-pack-year tobacco exposure; 96% of tumors for which p16 data were available were p16 positive. At last follow-up, 82% of patients reported a regular diet, and only 9 patients required gastrostomy use. Gastrostomy use at last follow-up was higher in patients with T3 and T4 tumors compared with those with T1 and T2 tumors (P = .01). The relationship between T classification and gastrostomy use persisted even when the analysis was limited to p16+ tumors and p16+ tumors with ≥10-pack-year history of tobacco exposure.

CONCLUSIONS

Advanced T classification at presentation is a critical predictor of gastrostomy use in long-term OPSCC survivors irrespective of p16 status or tobacco exposure history.

LEVEL OF EVIDENCE

2b.

Revisiting the dose constraints for head and neck OARs in the current era of IMRT

Head and neck cancer poses a particular challenge in radiation therapy, whilst being an effective treatment modality it requires very high doses of radiation to provide effective therapy. This is further complicated by the fact that the head and neck region contains a large number of radiosensitive tissues, often resulting in patients experiencing debilitating normal tissue complications. In the era of intensity-modulated radiation therapy (IMRT) treatments can be delivered using non-uniform dose distributions selectively aimed at reducing the dose to critical organs-at-risk while still adequately covering the tumor target. Dose-volume constraints for the different risk organs play a vital role in one's ability to devise the best IMRT treatment plan for a head and neck cancer patient. To this end, it is pivotal to have access to the latest and most relevant dose constraints available and as such the goal of this review is to provide a summary of suggested dose-volume constraints for head and neck cancer RT that have been published after the QUANTEC reports were made available in early 2010.

Patient-reported outcomes in head and neck cancer: prospective multi-institutional patient-reported toxicity

Purpose

Head and neck cancer is occurring in an increasingly younger patient population, with treatment toxicity that can cause significant morbidity. Using a patient guided, Internet-based survivorship care plan program, we obtained and looked at patterns of patient-reported outcomes data from survivors seeking information after treatment for head and neck cancer.

Methods

The Internet-based OncoLife and LIVESTRONG Care Plan programs were employed, which design unique survivorship care plans based on patient-reported data. Care plans created for survivors of head and neck cancer were used in this evaluation. Demographics, treatment modality, and toxicity were included in this evaluation. Toxicity was further analyzed, grouped into system-based subsets.

Results

A total of 602 care plans were created from self-identified head and neck cancer survivors, from which patient-reported outcome data were attained. A majority of patients were Caucasian (96.2%) with median age at diagnosis of 55 years, living in suburban locations (39.9%), with ~50% receiving care within 20 miles of their residence. There was an equal distribution of education levels from high school only to graduate school. The majority of patients received care through cancer centers (96.7%), with a split between academic and non-academic centers. Ninety-three percent of patients had radiation therapy as part of their treatment modality, with 70.3% having chemotherapy and 60.1% having surgery. The most common system toxicities affected the oropharynx, followed by epithelium (skin/hair/nail), and then general global health. Specifically, the most common side effects were difficulty swallowing (61.5%) and changes in skin color/texture (49.7%). One third of patients experienced hearing/tinnitus/vertigo, xerostomia, loss of tissue flexibility, or fatigue.

Conclusion

The current work demonstrates the ability to obtain patient-reported outcomes of head and neck cancer survivors through an Internet-based survivorship care plan program. For this group dysphagia and dermatitis were the most commonly reported toxicities, as was expected; however, global effects of therapy, such as fatigue, were also significant and should be addressed in future survivorship planning.

Radiotherapy dose-volume parameters predict videofluoroscopy-detected dysphagia per DIGEST after IMRT for oropharyngeal cancer: Results of a prospective registry

PURPOSE

Our primary aim was to prospectively validate retrospective dose-response models of chronic radiation-associated dysphagia (RAD) after intensity modulated radiotherapy (IMRT) for oropharyngeal cancer (OPC). The secondary aim was to validate a grade ≥2 cut-point of the published videofluoroscopic dysphagia severity (Dynamic Imaging Grade for Swallowing Toxicity, DIGEST) as radiation dose-dependent.

MATERIAL AND METHODS

Ninety-seven patients enrolled on an IRB-approved prospective registry protocol with stage I-IV OPC underwent pre- and 3-6 month post-RT videofluoroscopy. Dose-volume histograms (DVH) for swallowing regions of interest (ROI) were calculated. Dysphagia severity was graded per DIGEST criteria (dichotomized with grade ≥2 as moderate/severe RAD). Recursive partitioning analysis (RPA) and Bayesian Information Criteria (BIC) were used to identify dose-volume effects associated with moderate/severe RAD.

RESULTS

31% developed moderate/severe RAD (i.e. DIGEST grade ≥2) at 3-6 months after RT. RPA found DVH-derived dosimetric parameters of geniohyoid/mylohyoid (GHM), superior pharyngeal constrictor (SPC), and supraglottic region were associated with DIGEST grade ≥2 RAD. V61 ≥ 18.57% of GHM demonstrated optimal model performance for prediction of DIGEST grade ≥2.

CONCLUSION

The findings from this prospective longitudinal registry validate prior observations that dose to submental musculature predicts for increased burden of dysphagia after oropharyngeal IMRT. Findings also support dichotomization of DIGEST grade ≥2 as a dose-dependent split for use as an endpoint in trials or predictive dose-response analysis of videofluoroscopy results.

Predictors of Patient-Reported Dysphagia Following IMRT Plus Chemotherapy in Oropharyngeal Cancer

The aim of this cross-sectional study is to evaluate the factors associated with patient-reported dysphagia in patients affected by locally advanced oropharyngeal cancer (OPC) treated with definitive intensity-modulated radiation therapy (IMRT) and concurrent chemotherapy (CHT), with or without induction CHT. We evaluated 148 OPC patients treated with IMRT and concurrent CHT, without evidence of disease and who had completed their treatment since at least 6 months. At their planned follow-up visit, patients underwent clinical evaluation and completed the M.D. Anderson dysphagia inventory (MDADI) questionnaire. The association between questionnaire composite score (MDADI-CS) and different patients' and tumor's characteristics and treatments (covariates) was investigated by univariable and multivariable analyses, the latter including only covariates significant at univariable analysis. With a median time from treatment end of 30 months [range 6-74 months, interquartile range (IQR) 16-50 months], the median (IQR) MDADI-CS was 72 (63-84). The majority of patients (82.4%) had a MDADI-CS ≥ 60. At multivariable analysis, female gender, human papilloma virus (HPV)-negative status, and moderate and severe clinician-rated xerostomia were significantly associated with lower MDADI-CS. Patient-perceived dysphagia was satisfactory or acceptable in the majority of patients. HPV status and xerostomia were confirmed as important predictive factors for swallowing dysfunction after radiochemotherapy. Data regarding female gender are new and deserve further investigation.

Tracheoesophageal Prosthesis Use Is Associated With Improved Overall Quality of Life in Veterans With Laryngeal Cancer

OBJECTIVES

Veterans have an increased risk of laryngeal cancer, yet their oncologic and functional outcomes remain understudied. We sought to determine the longitudinal impact of tracheoesophageal puncture and voice prosthesis on quality-of-life measures in veterans following total laryngectomy (TL).

METHODS

We performed a cross-sectional analysis of TL patients (n = 68) treated at the Michael E. DeBakey Veterans Affairs Medical Center using the Voice Handicap Index (VHI), MD Anderson Dysphagia Index (MDADI), and University of Washington Quality of Life Index (UW-QOL).

RESULTS

Using tracheoesophageal (TE) speech was associated with significantly better VHI, MDADI, and UW-QOL scores compared to other forms of communication. The association between TE speech use on VHI, MDADI, and UQ-QOL persisted even when the analysis was limited to patients with >5-year follow-up and was maintained on multivariate analysis that accounted for a history of radiation and laryngectomy for recurrent laryngeal cancer.

CONCLUSIONS

Using tracheoesophageal speech after total laryngectomy is associated with durable improvements in quality of life and functional outcomes in veterans. Tracheoesophageal voice restoration should be attempted whenever technically feasible in patients that meet the complex psychosocial and physical requirements to appropriately utilize TE speech.