Prophylactic Swallowing Exercises in Head and Neck Cancer Radiotherapy

Systematic review of adherence to swallow and trismus exercises during radiation therapy for head and neck cancer

Understanding the barriers and facilitators for prophylactic swallowing and trismus exercises for patients undergoing radiation to the head and neck may help exercise adherence. The analysis reviews all published reports of exercise adherence with a critical appraisal following PRISMA guidelines. A total of 137 potential papers were identified; 20 studies met the inclusion criteria. The most commonly reported facilitators for swallowing and trismus exercises were regular clinician contact and online resources to reinforce instructions, set goals, and manage radiation toxicities. Social support and perceived benefit from exercises were also reported to be of help. The most common barriers to exercise were radiation toxicities, anxiety, feeling overwhelmed with information, and not understanding the reason for the exercises. Understanding facilitators and barriers to adherence is critical when designing exercise interventions for patients undergoing radiation for head and neck cancer.

Prehabilitation for Patients with Cancer Undergoing Radiation Therapy: a Scoping Review

AIMS

Prehabilitation is a process of identifying and assessing factors that could compromise the physical and psychological health of patients undergoing cancer treatment and implementing an intervention to combat such concerns. The use of prehabilitation in cancer surgery has yielded positive outcomes in rectal, lung and abdominal cancers. Prehabilitation strategies have potential to improve the management of patients receiving radiation therapy or chemoradiation. The aim of the present study was to map the evidence of the assessment and evaluation of prehabilitation for radiation therapy patients.

MATERIALS AND METHODS

A database search using EMBASE and PubMed was conducted. The PRISMA guidelines were adhered to. Keywords included prehabilitation, radiation therapy/radiotherapy, chemoradiotherapy/chemoradiation, intervention and exercise. Types of prehabilitation strategy, their purposes and impact, according to cancer site, were analysed.

RESULTS

Prehabilitation is most commonly evaluated in head and neck cancer, whereby unimodal, physical interventions manage dysphagia. Prehabilitation for lung cancer demonstrated its ability to widen treatment options for patients. Physical prehabilitation is administered to combat adverse effects of neoadjuvant chemoradiation therapy in patients with rectal cancer.

CONCLUSION

Prehabilitation is adaptive and tailored to specific patient and site needs; thus it is applied across a wide range of cancer sites. More interventions by which radiation therapy is the definitive treatment modality and larger sample sizes within these studies are warranted to increase prehabilitation utilisation for patients undergoing radiation therapy.

Prophylactic Swallowing Therapy During Head-and-Neck Cancer Radiotherapy: Effect of Service-Delivery Mode and Overall Adherence Level on Swallowing Function and Muscle Strength-the PRESTO Trial

Prophylactic swallowing exercises (PSE) during head-and-neck cancer (HNC) (chemo)radiotherapy (CRT) have a positive effect on swallowing function and muscle strength. Adherence rates to PSE are, however, moderate to low, undermining these effects. PRESTO already showed that the service-delivery mode (SDM), the way the exercises are offered, can influence adherence. The aim of this study was to investigate the effect of SDM on swallowing function and muscle strength during and post-CRT. In addition, the effect of overall adherence (OA), independent of SDM, was also investigated. A total of 148 HNC patients, treated with CRT, were randomly assigned to one of the three SDM's (paper-supported, app-supported, or therapist-supported PSE) and performed a 4-week PSE program. OA was calculated based on the percentage of completed exercises. Patients were divided into OA levels: the OA75+ and OA75- group performed respectively ≥ 75 and < 75% of the exercises. Swallowing function based on Mann Assessment of Swallowing Ability-Cancer (MASA-C), tongue and suprahyoid muscle strength during and up to 3 months after CRT were compared between the SDM's and OA levels. Linear Mixed-effects Models with post hoc pairwise testing and Bonferroni-Holm correction was used. No significant differences were found between the three SDMs. Significant time effects were found: MASA-C scores decreased and muscle strength increased significantly during CRT. By the end of CRT, the OA75+ showed significantly better swallowing function compared to OA75-. Muscle strength gain was significantly higher in the OA75+ group. SDM had no impact on swallowing function and muscle strength; however, significant effects were shown for OA level. Performing a high level of exercise repetitions is essential to benefit from PSE.Trial registration ISRCTN, ISRCTN98243550. Registered December 21, 2018-retrospectively registered, https://www.isrctn.com/ISRCTN98243550?q=gwen%20van%20nuffelen&filters=&sort=&offset=1&totalResults=2&page=1&pageSize=10&searchType=basic-search.

Rehabilitation Interventions in Head and Neck Cancer: A Scoping Review

OBJECTIVE

The aim of the study is to identify and appraise current evidence for rehabilitation interventions in head and neck cancer.

DESIGN

A previously published scoping review spanning 1990 through April 2017 was updated through January 11, 2023 and narrowed to include only interventional studies (Arch Phys Med Rehabil. 2019;100(12):2381-2388). Included studies had a majority head and neck cancer population and rehabilitation-specific interventions. Pairs of authors extracted data and evaluated study quality using the PEDro tool. Results were organized by intervention type.

RESULTS

Of 1338 unique citations, 83 studies with 87 citations met inclusion criteria. The median study sample size was 49 (range = 9-399). The most common interventions focused on swallow (16 studies), jaw (11), or both (6), followed by whole-body exercise (14) and voice (10). Most interventions took place in the outpatient setting (77) and were restorative in intent (65 articles). The overall study quality was fair (median PEDro score 5, range 0-8); none were of excellent quality (PEDro >9).

CONCLUSIONS

Most head and neck cancer rehabilitation interventions have focused on restorative swallow and jaw exercises and whole-body exercise to address dysphagia, trismus, and deconditioning. More high-quality evidence for head and neck cancer rehabilitation interventions that address a wider range of impairments and activity and social participation limitations during various cancer care phases is urgently needed to reduce head and neck cancer-associated morbidity.

Prehabilitation in radiation therapy: a scoping review

PURPOSE/OBJECTIVES

Radiation therapy (RT) is a central component of cancer treatment with survival and long-term quality-of-life benefits across a spectrum of oncologic diagnoses. However, RT has been associated with varying levels of fatigue, pain, weight loss, and changes in mental health both during and post-treatment. Prehabilitation aims to optimize health prior to anti-neoplastic therapy in order to reduce side effects, increase adherence to treatment, expedite post-treatment recovery, and improve long-term outcomes. Though prehabilitation has been studied in those undergoing cancer-related surgery, literature on prehabilitation in individuals undergoing RT has not been comprehensively explored. Thus, this scoping review aims to summarize the existing literature focused on prehabilitation interventions for patients receiving RT.

MATERIALS/METHODS

The PRISMA-ScR checklist for conducting scoping reviews was adopted to identify and evaluate studies investigating the efficacy of prehabilitation before and during RT for cancer over the past 21 years (10/2002-10/2022). A search of prehabilitation and RT was performed to identify studies investigating prehabilitation interventions in adult cancer patients undergoing RT.

RESULTS

A total of 30 articles met inclusion criteria, yielding 3657 total participants. Eighteen (60%) studies were randomized controlled trials (RCTs) with sample sizes ranging from 21 to 221. The most commonly studied populations were patients with head and neck cancer, followed by rectal, breast, and lung cancer. A majority (80%) of studies evaluated one prehabilitation intervention (i.e., unimodal). Targeted physical exercises were the most common intervention, followed by general physical exercises and technology/apps. Adherence/feasibility was the most common primary outcome, representing 30% of studies. All studies reported data on sex, and 5 (17%) reported data on race and/or ethnicity.

CONCLUSIONS

Prehabilitation interventions have been successfully implemented in patients with cancer undergoing surgical treatment. Based on limited current literature, prehabilitation appears to have a promising effect in reducing morbidity in adult cancer patients requiring RT. Though our review identified many RCTs, they were frequently small sample trials with primary outcomes focused on feasibility, rather than functional status or quality of life. Thus, there is a need for adequately powered, randomized controlled intervention trials to investigate the efficacy of prehabilitation and maximize the treatment outcomes for patients undergoing RT.

Pre-rehabilitation interventions for patients with head and neck cancers: A systematic review and meta-analysis

OBJECTIVE

To investigate the effect of pre-rehabilitation interventions such as nutrition and exercise for patients with head and neck cancer (HNC).

METHODS

Web of Science, PubMed, Scopus, Google Scholar, and Cochrane databases were searched up to December 2022. Quality of life, length of hospital stay, postoperative complications, change in body mass index or muscle mass, and functional assessments were the primary outcomes. PRISMA guidelines were adhered to, and the study was registered on PROSPERO. The Cochrane Collaboration tool and Newcastle Ottawa scale assessed the quality of included studies. Pooled data are presented as odds ratios (OR) and 95% confidence intervals (CI). Analysis was conducted using RevMan5.4.

RESULTS

A total of 31 articles were included for quantitative analysis and 15 for qualitative synthesis. Nutrition alone resulted in significant weight retention (2.60; 2.32, 2.88, p < 0.00001), length of stay (-4.00; -6.87, -1.13), p = 0.0006) and complications (0.64; 0.49, 0.83, p = 0.0009). Nutrition and psychoeducation resulted in a significant reduction in mortality rate (0.70; 0.49, 1.00, p = 0.05 and 0.60; 0.48, 0.74, p < 0.00001), and exercise resulted in a significant reduction in dysphagia (0.55; 0.35, 0.87, p = 0.01). Exercise with nutrition resulted in significant improvements in weight loss, length of stay, complications, and dysphagia. Randomized controlled trials (RCTs) had a moderate risk of bias and cohort studies were of fair to good quality.

CONCLUSION

Prehabilitation programs based on exercise, nutrition, or psychoeducation demonstrated improved post-interventional outcomes in HNC, such as quality of life, and mortality and morbidity. Studies with longer follow-ups and larger sample sizes, and investigations comparing nutritional supplements with exercise programs are needed.

Prehabilitation of dysphagia in the therapy of head and neck cancer- a systematic review of the literature and evidence evaluation

Background

Prehabilitation is becoming increasingly important in oncology because of the significant survival benefits that the reduction of malnutrition provide. Specifically, tumor- and therapy-related dysphagia leads to malnutrition in more than half of head and neck tumor patients. Studies describe the positive effects of an early onset of swallow-specific prehabilitation on the protection of the swallowing function. This paper intents to evaluate the existing evidence on the efficacy of preventive forms of swallowing therapy.

Methods

A systematic literature search was performed in February 2022 in the Cochrane Library, MEDLINE via PubMed, and ClinicalTrials.gov databases for randomized controlled trials investigating preventive swallowing therapy in head and neck tumor patients. This Procedure complies with the PRISMA statement. The RCTs were evaluated by using the PEDro Scale and the Cochrane Risk of Bias tool RoB2.

Results

Five randomized-controlled trials with 423 participants were identified. Four Studies showed moderate to high quality in the PEDro analysis, one showed less. The risk of bias was high in all studies because there was no possibility for blinding and there were high dropout rates. Heterogeneity in interventions, measurement instruments, measurement time points, and outcomes limits a general statement about which swallowing exercises are suitable for the prevention of dysphagia in head and neck tumor patients. Evidence is provided for short-term effects (≤24 months) on functional aspects of swallowing and quality of life. Overall, a decreasing adherence over time was observed in the intervention groups.

Discussion

Initial studies describe swallowing-specific prehabilitation programs in head and neck tumor patients as effective, at least in the short term, whereas long-term effects need to be further investigated. At the current time the evidence base for clear recommendations does not appear to be sufficiently high and studies share a high risk of bias. Further well-designed research, especially considering the conditions in the national health care system, is needed.

Other

There was no funding and no registration.

Interventions to improve quality of life in patients with head and neck cancers receiving radiation therapy: a scoping review

BACKGROUND

Quality of life (QOL) is impaired in patients with head and neck cancers (HNC) due to illness and treatment-associated morbidity. Although there is evidence from the studies on interventions' role in improving QOL receiving radiation therapy, these are not systematically synthesised. In this scoping review, we searched and synthesised the evidence on interventions to improve the QOL and its impact among patients with HNCs.

METHODS

This scoping review was conducted using the framework proposed by Arksey and O'Malley, and the extensions suggested by Levac et al. were incorporated. Two reviewers independently searched four electronic databases using key thesaurus and free-text terms, and the data was extracted, tabulated, synthesised and reported as categories.

RESULTS

Seventy-nine papers reported various interventions of diverse nature such as pharmacological, physical, nutritional, complementary and alternative therapies, psychosocial, oral care related, laser and photobiomodulation therapies, rehabilitative, educational, technology-based, surgical, device-related and nurse lead interventions. Most studies reported clinically meaningful impact of interventions on QOL, although the outcome differences were often statistically insignificant. Few studies reported a combination of interventions to address the multidimensional concerns faced by patients with HNCs. None of the studies examined the impact of interventions on QOL among long-term survivors of HNCs.

CONCLUSION

As QOL concerns in patients with HNCs are multifaceted, more extensive studies with complex multi-component interventions and robust research designs are warranted.

Quality of life and swallowing outcomes after early proactive swallowing rehabilitation by either transcutaneous neuromuscular electrical stimulation or exercise-based swallowing training in patients with nasopharyngeal carcinoma after radiotherapy

Background

Exercise-based swallowing training (EBST) and transcutaneous neuromuscular electrical stimulation (TNMES) are common modalities used to treat late dysphagia after radiotherapy for nasopharyngeal carcinoma (NPC). We aimed to investigate and compare the efficacies of EBST and TNMES as proactive treatments administered early after radiotherapy.

Methods

Patients with early post-radiotherapy NPC (n = 120) underwent either TNMES or EBST. Flexible endoscopic evaluation of swallowing (FEES), quality of life (QOL), and swallowing function questionnaires were completed before the intervention as well as immediately, 6, and 12 months after the intervention. Outcome measures included the scores for the swallowing function score (SFS), penetration and aspiration scale (PAS), dynamic imaging grade of swallowing toxicity (DIGEST), functional oral intake scale (FOIS), swallowing performance status scale (SPSS), pharyngeal motor impairment (PMI), pharyngeal function impairment (PFI), and functional assessment after cancer therapy-nasopharyngeal (FACT-NP) questionnaire.

Results

Three months after radiotherapy, 31 and 34 patients underwent TNMES and EBST, respectively, and completed swallowing assessments at all four assessment timepoints. All patients showed post-radiotherapy impairments in the SFS, PAS, DIGEST, PMI, and PFI. Compared with the EBST group, the TNMES group showed significant improvements in the PFI and PMI scores, with small-to-medium effect sizes. Additionally, compared with the EBST group, the TNMES group demonstrated a trend toward slightly better improvements in the PAS, DIGEST, FOIS, and SPSS scores immediately and 6 months after the intervention. The SFS scores improved from baseline in both groups; however, the TNMES group showed an earlier improvement. Finally, the TNMES group showed better QOL according to the FACT-NP than the EBST group.

Conclusion

Proactive TMNES and EBST are safe and feasible modalities for improving swallowing in patients with NPC when administered early after radiotherapy. Although TNMES showed better results than EBST, these results should be interpreted with caution given the study limitations.

Level of evidence

1B.

Nutritional prehabilitation in head and neck cancer: A systematic review of literature

BACKGROUND/SCOPE

Malnutrition is a common problem among patients with head and neck cancer and can have adverse effects on overall health and treatment outcomes. Nutritional and physical prehabilitation are potential strategies to optimize the nutritional status of these patients. This systematic review aimed to identify and describe prehabilitative interventions that can promote an improvement in nutritional status.

METHODS

A systematic review of the literature was conducted in the databases PubMed/Medline, Embase, CINAHL, Scopus and on the platform Web of Science and in Cochrane Library. The selected studies concern adults with head and neck tumours, not malnourished at the time of diagnosis, who undergo nutritional or physical prehabilitation.

RESULTS

Out of 1369 results, 7 studies were included. Multimodal prehabilitation interventions that combine nutritional counseling, oral nutritional supplements, and swallowing exercises to prevent dysphagia have shown positive outcomes in maintaining caloric intake, body weight, swallowing ability, and a reduced incidence of fibrosis in the upper gastrointestinal tract, as well as improving quality of life.

CONCLUSION

Despite the limited number of clinical studies available in the literature, the results suggest that nutritional and physical prehabilitation interventions have a positive effect on the nutritional status and clinical outcomes of patients with head and neck cancer, helping mitigate the risk of malnutrition and improve general well-being.

Swallowing Function After Treatment of Laryngeal Cancer

Dysphagia is a common functional outcome following treatment of laryngeal cancer. Despite curative advances in both nonsurgical and surgical approaches, preserving and optimizing swallowing function is critical. Understanding the nature and severity of dysphagia depending on initial tumor staging and treatment modality and intensity is crucial. This chapter explores current evidence on the acute and chronic impacts of treatments for laryngeal cancer on swallow function, as well as the medical and nonmedical management of dysphagia in this population.

Perioperative Assessment/Prehabilitation in Larynx Cancer

Head and neck cancer (HNC) survivorship is increasing, and with it, a shift in treatment practices has occurred. Radical surgical resections for the treatment of HNC have decreased, and organ preservation treatments have increased. Although effective in treating HNC, chemoradiation therapy toxicities can be detrimental to a patient's overall health, nutrition status, and quality of life (QOL). Considering that dysphagia is typically a driving element of dysfunction, speech-language pathologists are vital to the prehabilitation phase. Prehabilitation programs include a variety of components, with the primary goal being to improve functional and QOL outcomes posttreatment.

Feasibility and Cost of Telehealth Head and Neck Cancer Survivorship Care: A Systematic Review

OBJECTIVE

Evaluate the feasibility and cost-effectiveness of telehealth head and neck cancer (HNC) survivorship care.

DATA SOURCES

Ovid MEDLINE, Embase, Scopus, CINAHL.

REVIEW METHODS

A systematic search for peer-reviewed feasibility studies on telehealth models for HNC survivorship care published between 2005 and 2021 was conducted using the terms "head and neck cancer" and "telehealth" and their synonyms. Inclusion criteria were studies on telehealth survivorship program interventions for HNC patients with quantitative feasibility outcome measures (eg, enrollment, retention, attrition/dropout rate, adherence/task completion rate, patient satisfaction, cost).

RESULTS

Thirty-eight studies out of 1557 identified met inclusion criteria and were included for analysis. Feasibility outcomes evaluated were enrollment and attrition rates, adherence/task completion rates, patient satisfaction, and user feedback surveys in different survivorship domains. Patient enrollment ranged from 20.8% to 85.7%, while attrition ranged from 7% to 47.7%. Overall, adherence was 30.2% higher in the intervention group than in the control group (46.8% vs 16.6%). Studies with cost analysis found telehealth models of care to be statistically significantly less expensive and more cost-efficient than the standard model of care, with a $642.30 saving per patient (n = 3). Telehealth models also substantially reduced work time saving per visit (on average, 7 days per visit).

CONCLUSION

While telehealth survivorship programs are feasible and cost-effective and are associated with improved patient outcomes, they might not be ideal for every patient. Further investigations are needed to understand the role of telehealth in survivorship care, given the variability in study design, reporting, measures, and methodological quality.

Preventive measures for the progression of dysphagia in patients with cancer of head and neck subjected to radiotherapy: a systematic review with meta-analysis

PURPOSE

To identify the effects of prophylactic, non-pharmacological measures on the progression of dysphagia in patients with head and neck cancer undergoing radiotherapy.

RESEARCH STRATEGIES

The search was performed in Medline (via PubMed), Scopus, and Embase databases, as well as in the gray literature.

SELECTION CRITERIA

Randomized clinical trials were included, with adult patients (≥ 18 years old) and diagnosed with head and neck cancer, treated with radiotherapy (with or without surgery and chemotherapy), and submitted to non-pharmacological protocols for the prevention of dysphagia.

DATA ANALYSIS

The risk of bias was assessed using the PEDRO scale and the overall quality of evidence was assessed using the GRADE instrument.

RESULTS

Four studies were considered eligible, and of these, two were included in the meta-analysis. The result favored the intervention group, with a mean difference of 1.27 [95% CI: 0.74 to 1.80]. There was low heterogeneity and the mean score for risk of bias was 7.5 out of 11 points. The lack of detail in the care with selection, performance, detection, attrition, and reporting biases contributed to the judgment of the quality of the evidence, considered low.

CONCLUSION

Prophylactic measures to contain dysphagia can promote important benefits on the oral intake of patients with head and neck cancer when compared to those who did not undergo such a therapeutic measure during radiotherapy.

Increasing Adherence to Prophylactic Swallowing Exercises During Head and Neck Radiotherapy: The Multicenter, Randomized Controlled PRESTO-Trial

Background

Prophylactic swallowing exercises (PSE) during radiotherapy can significantly reduce dysphagia after radiotherapy in head and neck cancer (HNC). However, its positive effects are hampered by low adherence rates during the burdensome therapy period. Hence, the main goal of this multicenter randomized controlled trial (RCT) was to investigate the effect of 3 different service-delivery modes on actual patients’ adherence.

Methods

A total of 148 oropharyngeal cancer patients treated with primary (chemo)radiotherapy were randomly assigned to a 4 weeks PSE program, either diary-supported (paper group; n = 49), app-supported (app group; n = 49) or therapist-supported (therapist group; n = 50). Participants practiced 5 days/week, daily alternating tongue strengthening exercises with chin tuck against resistance exercises. Adherence was measured as the percentage of completed exercise repetitions per week (%reps). Statistical analysis was performed by means of SPSSv27, using Linear Mixed-effects Models with post hoc pairwise testing and Bonferroni-Holm correction.

Results

Adherence and evolution of adherence over time was significantly different between the three groups (p < .001). Adherence rates decreased in all three groups during the 4 training weeks (p < .001). During all 4 weeks, the therapist group achieved the highest adherence rates, whilst the app group showed the lowest adherence rates.

Conclusions

PSE adherence decreased during the first 4 radiotherapy weeks regardless of group, but with a significant difference between groups. The therapist group achieved the highest adherence rates with a rather limited decline, therefore, increasing the face-to-face contact with a speech-language therapist can overcome the well-known problem of low adherence to PSE in this population.

Trial Registration

Trial registration: ISRCTN, ISRCTN98243550. Registered December 21, 2018 – retrospectively registered, https://www.isrctn.com/ISRCTN98243550?q=gwen%20van%20nuffelen&filters=&sort=&offset=1&totalResults=2&page=1&pageSize=10&searchType=basic-search.

Systematic Review of Functional Outcomes in Cancer Rehabilitation

OBJECTIVE

To systematically review the evidence regarding rehabilitation interventions targeting optimal physical or cognitive function in adults with a history of cancer and describe the breadth of evidence as well as strengths and limitations across a range of functional domains.

DATA SOURCES

PubMed, Cumulative Index to Nursing and Allied Health Plus, Scopus, Web of Science, and Embase. The time scope was January 2008 to April 2019.

STUDY SELECTION

Prospective, controlled trials including single- and multiarm cohorts investigating rehabilitative interventions for cancer survivors at any point in the continuum of care were included, if studies included a primary functional outcome measure. Secondary data analyses and pilot/feasibility studies were excluded. Full-text review identified 362 studies for inclusion.

DATA EXTRACTION

Extraction was performed by coauthor teams and quality and bias assessed using the American Academy of Neurology (AAN) Classification of Evidence Scheme (class I-IV).

DATA SYNTHESIS

Studies for which the functional primary endpoint achieved significance were categorized into 9 functional areas foundational to cancer rehabilitation: (1) quality of life (109 studies), (2) activities of daily living (61 studies), (3) fatigue (59 studies), (4) functional mobility (55 studies), (5) exercise behavior (37 studies), (6) cognition (20 studies), (7) communication (10 studies), (8) sexual function (6 studies), and (9) return to work (5 studies). Most studies were categorized as class III in quality/bias. Averaging results found within each of the functional domains, 71% of studies reported statistically significant results after cancer rehabilitation intervention(s) for at least 1 functional outcome.

CONCLUSIONS

These findings provide evidence supporting the efficacy of rehabilitative interventions for individuals with a cancer history. The findings should be balanced with the understanding that many studies had moderate risk of bias and/or limitations in study quality by AAN criteria. These results may provide a foundation for future work to establish clinical practice guidelines for rehabilitative interventions across cancer disease types.

Oral Health Management and Rehabilitation for Patients with Oral Cancer: A Narrative Review

Surgery is the current first choice for oral cancer treatment. Intensity-modulated radiation therapy, molecular targeted drugs, and immune checkpoint inhibitors are still used as adjuvant therapy for advanced cancer. In addition, postoperative rehabilitation and multidisciplinary treatment have also been developed in recent years. Multidisciplinary team approaches and supportive care in oral cancer treatment reportedly shorten the time to treatment and improve outcomes. Although there is enough evidence confirming the role of oral and maxillofacial surgeons, dentists, and dental hygienists in supportive care in oral cancer treatment, there are very few systematic studies. In particular, oral health management is a concept that encompasses oral function management, oral hygiene management, and oral care during oral cancer treatment. We provide a narrative review focusing on oral health management from a multidisciplinary and supportive care perspective, applicable in oral cancer treatment.

The impact of dysphagia prehabilitation on swallowing outcomes post-chemoradiation therapy in head and neck cancer: A systematic review

INTRODUCTION

This study aimed to summarise research findings on dysphagia prehabilitation initiated before chemoradiation therapy (C)RT in head and neck cancer (HNC) including its impact on three swallow-related outcomes at distinct time points.

METHODS

A comprehensive search was completed in PubMed, Embase, Web of Science and CINAHL. Inclusion criteria were studies of adults with HNC with an exercise-based prehabilitation programme beginning before (C)RT. Methodological quality was rated using the Downs and Black checklist. The Template for Intervention Descriptions and Replication (TIDieR) checklist was used to evaluate how well studies were reported.

RESULTS

Eight studies (three randomised control trials) involving 295 adults with HNC were included. The largest participant group (63%) were Stage III/IV head and neck squamous cell carcinoma (HNSCC). Prehabilitation was completed independently at home (100%) and typically began 2 weeks before CRT (75%). Studies evaluated the impact of dysphagia prehabilitation across functional (n = 6), quality of life (n = 5) and physiological (n = 4) domains. Prehabilitation significantly altered physiological (25%), functional (66%) and quality of life (50%) outcomes. Fifty per cent of studies included long-term (>1 year) outcomes. Quality of included studies ranged from poor (25%) to good (38%). Six (75%) studies reported sufficient details of exercise programmes.

CONCLUSION

Limited evidence supports exercise-based dysphagia prehabilitation before (C)RT to improve swallow-related outcomes, and long-term benefits remain unclear. Further high-quality research using core outcome sets is required.

Improved Swallow Outcomes with Early Intervention using Combined Swallow Therapy in Advanced Oropharyngeal Carcinoma

Objective

To evaluate the impact of early intervention using combined swallow therapy, consisting of traditional swallow exercises and transcutaneous neuromuscular electrical stimulation, on patients with advanced oropharyngeal squamous cell carcinoma.

Methods

A cohort study of 60 prospectively enrolled patients was performed. Thirty patients with advanced oropharyngeal squamous cell carcinoma starting combined swallow therapy two weeks after surgery that continued throughout chemoradiotherapy were compared with a matched cohort of 30 patients starting combined swallow therapy after cancer treatment completion. Gastrostomy tube status, modified barium swallow, and Functional Oral Intake Scale scores were assessed before and after therapy.

Results

Both cohorts demonstrated a statistically significant improvement in Functional Oral Intake Scale scores. All patients in the early intervention cohort discontinued gastrostomy tube use, compared with one-third in the control cohort, with greater improvements in Functional Oral Intake Scale scores. The tongue base was the site of greatest improvement in the early intervention group.

Conclusion

Early initiation of combined swallow therapy may optimise swallow outcomes in patients with advanced oropharyngeal squamous cell carcinoma.

The PRO-ACTIVE trial protocol: a randomized study comparing the effectiveness of PROphylACTic swallow InterVEntion for patients receiving radiotherapy for head and neck cancer

BACKGROUND

Swallowing therapy is commonly provided as a treatment to lessen the risk or severity of dysphagia secondary to radiotherapy (RT) for head and neck cancer (HNC); however, best practice is not yet established. This trial will compare the effectiveness of prophylactic (high and low intensity) versus reactive interventions for swallowing in patients with HNC undergoing RT.

METHODS

This multi-site, international randomized clinical trial (RCT) will include 952 adult patients receiving radiotherapy for HNC and who are at high risk for post-RT dysphagia. Participants will be randomized to receive one of three interventions for swallowing during RT: RE-ACTIVE, started promptly if/when dysphagia is identified; PRO-ACTIVE EAT, low intensity prophylactic intervention started before RT commences; or, PRO-ACTIVE EAT+EXERCISE, high intensity prophylactic intervention also started before RT commences. We hypothesize that the PRO-ACTIVE therapies are more effective than late RE-ACTIVE therapy; and, that the more intensive PRO-ACTIVE (EAT + EXERCISE) is superior to the low intensive PRO-ACTIVE (EAT). The primary endpoint of effectiveness is duration of feeding tube dependency one year post radiation therapy, selected as a pragmatic outcome valued equally by diverse stakeholders (e.g., patients, caregivers and clinicians). Secondary outcomes will include objective measures of swallow physiology and function, pneumonia and weight loss, along with various patient-reported swallowing-related outcomes, such as quality of life, symptom burden, and self-efficacy.

DISCUSSION

Dysphagia is a common and potentially life-threatening chronic toxicity of radiotherapy, and a priority issue for HNC survivors. Yet, the optimal timing and intensity of swallowing therapy provided by a speech-language pathologist is not known. With no clearly preferred strategy, current practice is fraught with substantial variation. The pragmatic PRO-ACTIVE trial aims to specifically address the decisional dilemma of when swallowing therapy should begin (i.e., before or after a swallowing problem develops). The critical impact of this dilemma is heightened by the growing number of young HNC patients in healthcare systems that need to allocate resources most effectively. The results of the PRO-ACTIVE trial will address the global uncertainty regarding best practice for dysphagia management in HNC patients receiving radiotherapy.

TRIAL REGISTRATION

The protocol is registered with the US Patient Centered Outcomes Research Institute, and the PRO-ACTIVE trial was prospectively registered at ClinicalTrials.gov , under the identifier NCT03455608 ; First posted: Mar 6, 2018; Last verified: Jun 17, 2021. Protocol Version: 1.3 (January 27, 2020).

Rehabilitation Needs of Head and Neck Cancer Patients and Stakeholders: Case Study

Background

The incidents of Head and Neck Cancer (HNC) are rising worldwide, suggesting that this type of cancer is becoming more common. The foreseen growth of incidents signifies that future rehabilitation services will have to meet the needs of a wider population.

Objective

The aim of this paper is to explore the needs of patients, caregivers and healthcare professionals during HNC rehabilitation.

Methods

This paper reports the empirical findings from a case study that was conducted in a cancer rehabilitation center in Copenhagen to elicit the needs of HNC cancer patients, informal caregivers and healthcare professionals.

Results

Four areas of needs during the rehabilitation process were identified: service delivery, emotional, social and physical needs. Service delivery needs and emotional needs have been identified as the most prevalent.

Conclusions

Stakeholders' needs during the rehabilitation process were found to be interrelated. All stakeholders faced service delivery challenges in the form of provision and distribution of information, including responsibilities allocation between municipalities, hospitals and rehabilitation services. Emotional and social needs have been reported by HNC patients and informal caregivers, underlining the importance of inclusion of all actors in the design of future healthcare interventions. Connected Health (CH) solutions could be valuable in provision and distribution of information.

Review of prophylactic swallowing interventions for head and neck cancer

BACKGROUND

Head and neck cancer treatment destroys nerves and/or organs associated with swallowing. Previous studies have investigated the efficacy of exercises for muscles used in swallowing before treatment in reducing disuse atrophy and delaying the occurrence of muscle fibrosis. However, the rehabilitation effects of training and the optimal intervention strategy are unknown.

OBJECTIVES

To establish evidence for the efficacy of prophylactic swallowing interventions in reducing aspiration and restoring oral intake in patients with head and neck cancer with dysphagia.

METHODS

We searched electronic databases (PubMed, Embase, Cochrane and MEDLINE) for studies published up to June 2021 reporting outcomes following prophylactic swallowing interventions in patients with head and neck cancer with dysphagia and the related influencing factors. The methodological quality of the literature was assessed using the Joanna Briggs Institute appraisal tools.

RESULTS

The search identified 1468 articles, and 13 studies were eventually included. Four categories involving 12 different swallowing interventions were classified. Regarding the descriptive analysis of the rehabilitation effects across all studies, in terms of oropharyngeal safety, five studies showed that swallowing interventions reduced the risk of aspiration, penetration or residue. In terms of oral intake and tube feeding dependence, four studies demonstrated reduced time to return to oral intake in the intervention group compared with the control group. In terms of intervention adherence, three studies showed that speech-language pathologist- and nurse-supervised training was a potential promoter of adherence, and five studies showed that the negative factors affecting adherence included pain, fatigue, forgetting, smoking, decreased exercise motivation, side effects of radiotherapy and distance to the rehabilitation site.

CONCLUSIONS

Preventive swallowing interventions may be effective at reducing aspiration, improving swallowing function, and restoring oral intake. However, due to the lack of standardization and consistency of interventions and measurement results, which prevented the production of a best practice guide, future rigorous methodological trials will be needed to determine the most effective interventions for maximizing exercise adherence over the long term.

Level of Awareness, Knowledge, and Involvement of Malaysian Medical and Dental Practitioners in Dysphagia Management of Head and Neck Cancer Patients

Head and neck cancer patients are at high risk of developing dysphagia from undergoing cancer treatment. It is essential for medical and dental practitioners to recognize speech-language pathologists' role and dysphagia symptoms to provide a timely referral to speech-language pathologists. This study aims to determine the level of awareness, knowledge, and involvement of medical and dental practitioners in dysphagia management. A total of 391 medical and dental practitioners from 22 government hospitals across Malaysia participated in this cross-sectional study. Participants completed the questionnaire specifically on the level of involvement, knowledge, awareness regarding the role of SLP and dysphagia symptoms. The results revealed a statistically significant relationship between the level of awareness of the role of SLP, χ² (4, 391) = 9.87, p = 0.043 and the level of involvement of medical and dental practitioners, χ² (8, 391) = 27.68, p = 0.001 and percentage of referring head and neck cancer patients. The odds of referring head and neck cancer patients for pre-treatment assessment increased three times for each one unit of the participation of medical and dental practitioners [OR] 3.65 (1.56, 8.51) p = 0.003 among those who are already highly involved in dysphagia management. These findings compel healthcare practitioners in head and neck cancer to revisit their collaborative practices. Head and neck cancer patients should receive swallowing management from speech-language pathologists to improve their swallowing function and avoid further complications such as dehydration, malnutrition, and death.

Swallowing Exercise During Head and Neck Cancer Treatment: Results of a Randomized Trial

The diagnosis and treatment of head and neck cancer (HNC) can have substantial impact on swallowing function, nutritional balance, physical function and quality of life (QoL). Early initiated swallowing exercises are hypothesized to improve swallowing function in HNC patients. The aim was to investigate the effects of swallowing exercises and progressive resistance training (PRT) during radiotherapy on swallowing function, physical function and QoL in patients with pharynx-, larynx-, oral cavity cancer or unknown primary compared to usual care. In a multi-centre RCT participants were assigned to (a) twice-weekly PRT and daily swallowing exercises throughout treatment or (b) usual care. Outcomes were measured at end of treatment and 2, 6 and 12 months after. Primary outcome was penetration aspiration score (PAS). Data were analysed on an “intention-to-treat” basis by GEE logistic regression model, linear mixed effects model and cox regression. Of 371 invited HNC patients, 240 (65%) enrolled. Five participants were excluded. At 12 months follow-up, 59 (25%) participants were lost. Analyses showed significant effect on mouth opening, QoL, depression and anxiety at 12 months when comparing intervention to non-active controls. The trial found no effect on swallowing safety in HNC undergoing radiotherapy, but several positive effects were found on secondary outcomes when comparing to non-active controls. The intervention period may have been too short, and the real difference between groups is too small. Nevertheless, the need to identify long-lasting intervention to slow down or avoid functional deteriorations is ever more crucial as the surviving HNC population is growing.

Cost-utility and cost-effectiveness of a guided self-help head and neck exercise program for patients treated with total laryngectomy: Results of a multi-center randomized controlled trial

OBJECTIVES

The guided self-help exercise program called In Tune without Cords (ITwC) is effective in improving swallowing problems and communication among patients treated with a total laryngectomy (TL). This study investigated the cost-utility and cost-effectiveness of ITwC.

MATERIALS AND METHODS

Patients within 5 years after TL were included in this randomized controlled trial. Patients in the intervention group (n = 46) received access to the self-help exercise program with flexibility, range-of-motion and lymphedema exercises, and a self-care education program. Patients in the control group (n = 46) received access to the self-care education program only. Healthcare utilization (iMCQ), productivity losses (iPCQ), health status (EQ-5D-3L, EORTC QLU-C10D) and swallowing problems (SwalQol) were measured at baseline, 3- and 6-months follow-up. Hospital costs were extracted from medical files. Mean total costs and effects (quality-adjusted life-years (QALYs) or SwalQol score) were compared with regression analyses using bias-corrected accelerated bootstrapping.

RESULTS

Mean total costs were non-significantly lower (-€685) and QALYs were significantly higher (+0.06) in the intervention compared to the control group. The probability that the intervention is less costly and more effective was 73%. Sensitivity analyses with adjustment for baseline costs and EQ-5D scores showed non-significantly higher costs (+€119 to +€364) and QALYs (+0.02 to +0.03). A sensitivity analysis using the QLU-C10D to calculate QALYs showed higher costs (+€741) and lower QALYs (-0.01) and an analysis that used the SwalQol showed higher costs (+€232) and higher effects (improvement of 6 points on a 0-100 scale).

CONCLUSION

ITwC is likely to be effective, but possibly at higher expenses.

TRIAL REGISTRATION

NTR5255.

Clinical Practices in Head and Neck Cancer: A Speech-Language Pathologist Practice Pattern Survey

OBJECTIVE

Clinical practices of speech-language pathologists (SLP) treating head and neck cancer (HNC) patients range widely despite literature trending toward best practices. This survey study was designed to identify current patterns and assess for gaps in clinical implementation of research evidence.

METHOD

A web-based survey was distributed to SLPs via listserv and social media outlets. Descriptive statistics and group calculations were completed to identify trends and associations in responses.

RESULTS

Of 152 received surveys, the majority of respondents were hospital-based (86%) and had greater than 5 years of experience (65%). There was group consensus for the use of prophylactic exercise programs (95%), recommendations for SLP intervention during HNC treatment (75%), and use of maintenance programs post-treatment (97%). Conversely, no group consensus was observed for use of pre-treatment swallow evaluations, frequency of service provision, and content of therapy sessions. Variation in clinical decision making was noted in use of prophylactic feeding tubes and number of patients taking nothing by mouth during treatment. No associations were found between years of experience and decision-making practices, nor were any associations found between practice setting and clinical decision making.

CONCLUSION

Despite the growing body of literature outlining evidence-based treatment practices for HNC patients, clinical practice patterns among SLPs continue to vary widely resulting in inconsistent patient care across practice settings. As compared to prior similar data, increased alignment with best practices was observed relative to early referrals, implementation of prophylactic intervention programs, and intervention with the SLP during the period of HNC treatment.

Prehabilitation in head and neck cancer patients: a literature review

Background

Dysphagia is one consequence of head and neck cancer that has a significant impact on quality of life for head and neck cancer survivors. While survival rates continue to improve, focus has shifted to maximizing long-term function, with prevention or prehabilitation programs becoming more common. Prehabilitation programs typically include an exercise regime that specifies the exercise type, the number of repetitions to complete per set, the number of sets of each exercise to complete per day, as well as the length of the treatment block. Ideally, exercise programs are designed with principles of neuromuscular plasticity in mind.

Methods

Twenty-nine original research articles published between 2006 and 2020 were included in this state-of-the-art review and examined for program timing and details.

Results

Two definitions for prehabilitation were noted: one third of the studies defined prehabilitation as preventative exercises prior to the start of acute cancer treatment; the remaining two thirds defined prehabilitation as treatment concurrent prehabilitation. Exercises prescribed ranged from general stretching and range of motion exercises, to trismus and swallowing specific exercises. The most common swallowing specific exercise was the Mendelsohn’s maneuver, followed by the effortful swallow, Shaker, and Masako maneuver. The most common dose was 10 repetitions of an exercise, three times per day for the duration of radiation therapy. The most common measures were questionnaires, followed by g-tube dependence, mouth opening, and MBS reports.

Conclusion

This review of the literature has shed light on the variability of prehabilitation timing, exercise type, dose, duration of treatment, and outcomes associated with prehabilitation, making the selection of an optimal prehabilitation program difficult at this time.

Swallowing exercises for head and neck cancer patients: A systematic review and meta-analysis of randomized control trials

BACKGROUND

Extensive surgery and chemo/radiation therapy (C/RT) to manage head and neck cancer (HNC) patients affects their ability to swallow food and liquids, risk of aspiration and greatly influences their quality of life (QOL).

OBJECTIVES

Ascertain the effectiveness of swallowing exercises on improving swallowing function, performance status, mouth opening, risk of aspiration/penetration and QOL in HNC patients.

DESIGN

Systematic review and meta-analysis of randomized controlled trials DATA SOURCES: PubMed, Ovid-Medline, Embase, Cochrane Library, CINAHL and Web of Science and included all available RCTs.

REVIEW METHODS

We followed the PRISMA guidelines and standard methods for conducting a systematic review and meta-analysis. Comprehensive Meta-analysis 3.0 using the random effects model was used for data analysis.

RESULTS

In total, 19 RCTs with 1100 participants were identified and included in the current review. Swallowing exercises had significant small effect on swallowing function 0.33 (95%CI = 0.00-0.65) and moderate effect on mouth opening 0.60 (95%CI = 0.21-0.99) immediately after intervention and small effect at 6-month follow-up 0.46 (95%CI = 0.11-0.81). However, non-significant effects were observed on risk of aspiration/penetration, performance status and all domains of QOL.

CONCLUSION

Swallowing exercises demonstrated effectiveness in improving swallowing function and mouth opening in HNC patients undergoing multimodal treatment. This is the first comprehensive systematic review and meta-analysis of RCTs to assess the effect of swallowing exercises in HNC patients undergoing multimodal treatment. Nurses can play an important role in assisting the delivery of oropharyngeal swallowing exercises including jaw exercises, tongue exercises and swallowing maneuvers with assistance and guidance from speech pathologists to help improve HNC complications and QOL for HNC survivors.

Is EAT-10 Useful to Assess Swallowing during the Chemo-Radiotherapy Phase in Patients with Head and Neck Cancer? A Pilot Study

OBJECTIVE/HYPOTHESIS

The 10-item Eating-Assessment Tool (EAT-10) is a dysphagia screening test. In HNC patients, screening and diagnosis of dysphagia are not well-established. To determine the metrological properties of the EAT-10 compared with videofluoroscopy in non-surgical HNC-patients and to assess the relationship between EAT-10 scores and patients' self-reported symptoms.

STUDY DESIGN

Prospective cohort study.

METHODS

Forty-six HNC-patients recently diagnosed and referred to chemoradiotherapy (CRT). Main outcome was evidence of dysphagia according to EAT-10 score, self-perception on a Visual Analog Scale (VAS) of impaired swallowing, severity on the Penetration-Aspiration Scale (PAS), and the Functional Oral Intake Scale (FOIS). Patients were assessed at baseline, before-CRT, after-CRT, and at 3-month follow-up.

RESULTS

A strong baseline correlation between EAT-10, VAS, and FOIS was observed. All 3 values decreased in weeks 6 to 9 after CRT initiation; a poor correlation of EAT-10 with VAS was observed at 3-month follow-up. A receiver operating characteristic curve determined new cut-off points (sensitivity/specificity) for safe swallowing: baseline 3 (86%, 77%); post-CRT, 15 (62.5%, 80%); and 3-month follow-up, 4 (83%, 75%).

CONCLUSIONS

New safe-swallow EAT-10-points are suggested for this population during screening and the oncological follow-up. A poor correlation between EAT10-score and patient self-reported symptoms was observed at the end-RT and at 3-month follow-up, highlighting the need for an objective evaluation instrument.

Eat All Through Radiation Therapy (EAT-RT): Structured therapy model to facilitate continued oral intake through head and neck radiotherapy-User acceptance and content validation

BACKGROUND

To develop and examine user acceptance and content validity of a structured program to facilitate safe but challenging oral intake during radiotherapy (RT) delivered by a speech language pathologist (SLP)-the Eat-All Through Radiation Therapy (EAT-RT) program.

METHODS

EAT-RT was developed through expert consensus of SLPs at the Princess Margaret Cancer Centre (Canada) and M D Anderson Cancer Center using a conceptual framework of a diet hierarchy and a mealtime routine. EAT-RT was refined by practicing SLPs, and then disseminated for a 4-week clinical pilot at seven sites who were subsequently invited to participate in an online survey.

RESULTS

Twelve SLPs from six sites piloted EAT-RT therapy with a median of eight patients (IQR: 2-15) before and/or during RT. All SLPs reported EAT-RT added value to their practice, harmonized well with exercises, and its content was helpful; 11 (92%) reported EAT-RT facilitated patient understanding and indicated the desire to continue using EAT-RT.

CONCLUSION

The EAT-RT program was accepted by North American SLPs. The findings support the content and value of EAT-RT to facilitate oral intake in patients with head and neck cancer throughout RT.

SIP SMART: a parallel group randomised feasibility trial of a tailored pre-treatment swallowing intervention package compared with usual care for patients with head and neck cancer

BACKGROUND

Dysphagia or difficulty in swallowing affects quality of life for most patients with head and neck cancer. SIP SMART - [Swallowing Intervention Package: Self-Monitoring, Assessment, Rehabilitation Training] aims to improve post-treatment swallowing outcomes through a targeted and tailored pre-treatment intervention. This feasibility study assessed 1) recruitment and retention, 2) patient acceptability of randomisation and participation, 3) patient adherence, and 4) sought to identify a suitable primary outcome for a definitive trial, including sample size estimation.

METHODS

This two-arm parallel group non-blinded randomised feasibility trial took place within a head and neck centre at a teaching hospital in London, UK. Patients newly diagnosed with stage III/IV head and neck cancer were recruited and underwent 6-month follow-up. Patients were randomised to SIP-SMART or usual care via an online web-based system. SIP SMART comprised two 45-min consultations including a baseline clinical and instrumental swallowing assessment, relevant educational information, targeted swallowing exercises, and specific behaviour change strategies to increase exercise adherence. Usual care comprised a single session including a baseline clinical assessment and generic information about the likely impact of treatment on swallowing.

RESULTS

A total of 106 patients were identified at pre-screening, 70 were assessed for eligibility. Twenty-six patients did not meet eligibility criteria [0.37, 95% CI 0.27 to 0.49]. Five of 44 [0.11, 95% CI 0.05 to 0.24] eligible patients were not approached by researchers during clinic. Seven [0.18, 95% CI 0.08 to 0.33] of the 39 approached declined participation. Target recruitment (32 consented patients) was achieved within the timeframe. At 6-months 29/32 [0.91, 95% CI 0.76 to 0.97] patients remained in the trial. Acceptability of randomisation and participation in the intervention was favourable, and adherence to the exercises exceeded the pre-defined 35% minimum criterion. The MD Anderson Dysphagia Inventory swallow related quality of life measure was selected as the most suitable primary outcome for sample size estimation. No adverse effects arose from the intervention, or study participation.

CONCLUSIONS

A definitive trial of the SIP SMART intervention compared to usual care is feasible and can be undertaken with patients with head and neck cancer treated within the NHS.

TRIAL REGISTRATION

ISRCTN40215425, registered retrospectively.

Dose in Exercise-Based Dysphagia Therapies: A Scoping Review

BACKGROUND

Optimal exercise doses for exercise-based approaches to dysphagia treatment are unclear. To address this gap in knowledge, we performed a scoping review to provide a record of doses reported in the literature. A larger goal of this work was to promote detailed consideration of dosing parameters in dysphagia exercise treatments in intervention planning and outcome reporting.

METHODS

We searched PubMed, Scopus[Embase], CINAHL, and Cochrane databases from inception to July 2019, with search terms relating to dysphagia and exercises to treat swallowing impairments. Of the eligible 1906 peer-reviewed articles, 72 met inclusionary criteria by reporting, at minimum, both the frequency and duration of their exercise-based treatments.

RESULTS

Study interventions included tongue exercise (n = 16), Shaker/head lift (n = 13), respiratory muscle strength training (n = 6), combination exercise programs (n = 20), mandibular movement exercises (n = 7), lip muscle training (n = 5), and other programs that did not fit into the categories described above (n = 5). Frequency recommendations varied greatly by exercise type. Duration recommendations ranged from 4 weeks to 1 year. In articles reporting repetitions (n = 66), the range was 1 to 120 reps/day. In articles reporting intensity (n = 59), descriptions included values for force, movement duration, or descriptive verbal cues, such as "as hard as possible." Outcome measures were highly varied across and within specific exercise types.

CONCLUSIONS

We recommend inclusion of at least the frequency, duration, repetition, and intensity components of exercise dose to improve reproducibility, interpretation, and comparison across studies. Further research is required to determine optimal dose ranges for the wide variety of exercise-based dysphagia interventions.

Long-term swallowing, trismus, and speech outcomes after combined chemoradiotherapy and preventive rehabilitation for head and neck cancer; 10-year plus update

BACKGROUND

The objective of this study was to explore the 10-year plus outcomes of Intensity Modulated Radiotherapy with concomitant chemotherapy (CRT) combined with preventive swallowing rehabilitation (CRT+) for head and neck cancer (HNC).

METHODS

Subjective and objective swallowing, trismus, and speech related outcomes were assessed at 10-year plus after CRT+. Outcomes were compared to previously published 6-year results of the same cohort.

RESULTS

Fourteen of the 22 patients at 6-year follow-up were evaluable. Although objective swallowing-related outcomes showed no deterioration (eg, no feeding tube dependency and no pneumonia), swallowing-related quality of life slightly deteriorated over time. No patients had or perceived trismus. Voice and speech questionnaires showed little problems in daily life. Overall quality of life (QOL) was good.

CONCLUSIONS

After CRT with preventive rehabilitation exercises for advanced HNC, swallowing, trismus, and speech related outcomes moderately deteriorated from 6 to 10 years, with an on average good overall QOL after.

Effectiveness of a guided self-help exercise program tailored to patients treated with total laryngectomy: Results of a multi-center randomized controlled trial

OBJECTIVE

To investigate the effectiveness of a guided self-help exercise program on swallowing, speech, and shoulder problems in patients treated with total laryngectomy (TL).

MATERIALS AND METHODS

This randomized controlled trial included patients treated with TL in the last 5 years. Patients were randomized into the intervention group (self-help exercise program with flexibility, range-of-motion and lymphedema exercises and self-care education program) or control group (self-care education program). Both groups completed measurements before and 3 and 6-months after randomization. The primary outcome was swallowing problems (SWAL-QOL). Secondary outcomes were speech problems (SHI), shoulder problems (SDQ), self-management (patient activation: PAM) and health-related quality of life (HRQOL: EORTC QLQ-C30/H&N35). Adherence was defined as moderate-high in case a patient exercised >1 per day. Linear mixed model analyses were conducted to investigate the effectiveness of the intervention and to investigate whether neck dissection, treatment indication (primary/salvage TL), time since treatment, severity of problems, and preferred format (online/booklet) moderated the effectiveness.

RESULTS

Moderate-high adherence to the exercise program was 59%. The intervention group (n = 46) reported less swallowing and communication problems over time compared to the control group (n = 46) (p-value = 0.013 and 0.004). No difference was found on speech, shoulder problems, patient activation and HRQOL. Time since treatment moderated the effectiveness on speech problems (p-value = 0.025): patients within 6 months after surgery benefitted most from the intervention. Being treated with a neck dissection, treatment indication, severity of problems and format did not moderate the effectiveness.

CONCLUSION

The guided self-help exercise program improves swallowing and communication.

TRIAL REGISTRATION

NTR5255.

Prophylactic swallowing therapy for patients with head and neck cancer: A three-arm randomized parallel-group trial

BACKGROUND

Intensive prophylactic swallowing therapy can mitigate dysphagia in patients with oropharyngeal (OP) SCC, however, presents service challenges. This trial investigated the clinical efficacy of three service models delivering prophylactic swallowing therapy during (chemo)radiotherapy ([C]RT).

METHODS

Patients (n = 79) with OPSCC receiving (C)RT were were randomized to: (a) clinician-directed face-to-face therapy (n = 26); (b) telepractice therapy via "SwallowIT" (n = 26); or (c) patient self-directed therapy (n = 27). Swallowing, nutritional, and functional status were compared at baseline, 6-weeks, and 3-months post-(C)RT. Patients' perceptions/preferences for service-delivery were collated posttreatment.

RESULTS

Service-delivery mode did not affect clinical outcomes, with no significant (P > .05) between-group differences or group-by-time interactions observed for swallowing, nutrition, or functional measures. Therapy adherence declined during (C)RT in all groups. SwallowIT and clinician-directed models were preferred by significantly (P = .002) more patients than patient-directed.

CONCLUSIONS

SwallowIT provided clinically equivalent outcomes to traditional service models. SwallowIT and clinician-directed therapy were preferred by patients, likely due to higher levels of therapy support.

Association of a Proactive Swallowing Rehabilitation Program With Feeding Tube Placement in Patients Treated for Pharyngeal Cancer

Importance

A proactive speech and language pathology (SLP) program is an important component of the multidisciplinary care of patients with head and neck squamous cell carcinoma (HNSCC). Swallowing rehabilitation can reduce the rate of feeding tube placement, thereby significantly improving quality of life.

Objective

To evaluate the initiation of a proactive SLP rehabilitation program at a single institution and its association with rates of feeding tube placement and dietary intake in patients with HNSCC.

Design, Setting, and Participants

Cohort study at a tertiary care and referral center for patients with HNSCC serving the northern Chicago region. Patients were treated for squamous cell carcinomas of the hypopharynx, oropharynx, and nasopharynx from 2004 to 2015 with radiation or chemoradiation therapy in the definitive or adjuvant setting. Patients who received less than 5000 cGy radiation or underwent reirradiation were excluded.

Interventions

A proactive SLP program for patients with HNSCC was initiated in 2011. Study cohorts were divided into 2 groups: 2004 through 2010 and 2011 through 2015.

Main Outcomes and Measures

Primary outcome variables were SLP referral placement and timing of the referral. Secondary outcomes were feeding tube placement and ability to tolerate any oral intake.

Results

A total of 254 patients met inclusion criteria (135 before and 119 after implementation of SLP program; median age, 60 years [range, 14-94 years]; 77% male). With the initiation of a proactive SLP program, pretreatment evaluations increased from 29 (21.5%) to 70 (58.8%; risk ratio [RR], 2.74; 95% CI, 1.92-3.91), and rate of referral overall at any time increased from 60.0% to 79.8% (RR, 1.33; 95% CI, 1.13-1.57). Feeding tube placement rates decreased from 45.9% (n = 62) to 29.4% (n = 35; RR, 0.64; 95% CI, 0.46-0.89). Among patients receiving a swallow evaluation, feeding tube requirements were less frequent for those receiving a pretreatment evaluation (31 of 99 [31%]) than for those referred during (11 of 18 [61%]) or after (38 of 59 [64%]) treatment. The rate of tolerating any oral intake at the end of treatment improved from 71.1% (n = 96) in the preimplementation period to 82.4% (n = 98; RR, 1.16; 95% CI, 1.01-1.33).

Conclusions and Relevance

A proactive SLP program can be successfully established as part of the multidisciplinary care of patients with HNSCC and improve patient quality of life.

Nutrition and swallowing therapy strategies for patients with head and neck cancer

Patients with head and neck cancer experience many problems with eating which make them at high risk of malnutrition. Pre-habilitation swallowing exercises as overseen by a speech pathologist can improve swallowing function. A multidisciplinary approach to care, including effective nutritional screening, assessment and intervention has demonstrated improved outcomes in terms of meet nutritional requirements, improved nutritional status and quality of life. Nutritional recommendations are 1.2-1.5 g protein per kilogram per day and 125kJ/kg body weight per day but as these are guides close monitoring of intake and weight is important. Multidisciplinary teams and telehealth have shown better outcomes for nutrition and swallowing status for head and neck cancer patients and ongoing support is required for best patient care.

Adherence to preventive swallowing exercises for head and neck cancer patients undergoing (chemo)radiotherapy treatment

Background: In recent years, preventive swallowing exercises have been investigated as a means to limit dysphagia in head and neck cancer patients. However, adherence to exercise regimes has been poorly documented limiting the conclusions drawn on the effects of the interventions. We investigated adherence to a preventive swallowing exercise program and identified possible associations between adherence and four selected baseline factors: HPV status, partner status, concomitant chemotherapy and tumor site and between adherence to swallowing exercises and attendance to supervised training sessions. Material and methods: Forming part of an ongoing RCT (clinicaltrials.gov NCT02385929) adherence to intervention was based on participant provided training-logs. The exercise program consisted of 3 weekly supervised sessions of 30 min each and a home-based exercise program to be performed three times daily. Adherence was calculated as percentage of prescribed exercises completed and dichotomously as high (≥80%∼median) and low (<80%∼median) adherence. Associations between adherence and clinical/demographic factors (HPV, partner status, chemotherapy, tumor site or attendance level) were explored by logistic regression analyses. Results: Full adherence data were available from 45 (76%) participants. The total cohort median adherence to exercises was 78%. No association was found between any of the tested factors and adherence. Discussion: The study found a high adherence to preventive swallowing exercises in HNC patients undergoing (chemo)radiotherapy, both in home-based exercises and in supervised sessions, when compared to other studies, although median adherence to home-based exercises was below the defined 80% threshold. We acknowledge, that adherence in an RCT may be higher than in the everyday clinical situation due to surveillance bias. However, we find it reassuring that HNC patients comply with a preventive swallowing program, which requires some time investment from the patients.

Feasibility and outcomes of fibreoptic endoscopic evaluation of swallowing following prophylactic swallowing rehabilitation in head and neck cancer

OBJECTIVES

Investigate the feasibility and outcomes of fibreoptic endoscopic evaluation of swallowing (FEES) following a programme of prophylactic swallowing exercises in head and neck cancer (HNC) patients treated with radiotherapy.

DESIGN

Prospective, single cohort, feasibility study.

SETTING

Three head and neck cancer centres in Scotland.

PARTICIPANTS

Pre-radiotherapy HNC patients who consented to participate in a prophylactic swallowing intervention.

OUTCOME MEASURES

Fibreoptic endoscopic evaluation of swallowing recruitment and retention rates, assessment acceptability and compliance, qualitative process evaluation.

RESULTS

Higher rates of recruitment and retention were achieved in centres where FEES equipment was available on-site. Travel and anticipated discomfort were barriers to recruitment. Data completion was high for all rating scales, with good reliability. Following radiotherapy, swallowing safety significantly deteriorated for liquid boluses (P = 0.005-0.03); pharyngeal residue increased for liquid and semi-solid boluses. Pharyngo-laryngeal oedema was present pre-treatment and significantly increased post-radiotherapy (P = 0.001). Patients generally reported positive experience of FEES for their own learning and establishing a baseline.

CONCLUSIONS

Fibreoptic endoscopic evaluation of swallowing is an acceptable method of assessing patients for a prophylactic swallowing intervention and offers some additional information missing from VF. Barriers have been identified and should be taken into account in order to maximise recruitment for future trials.

Analysis of dysphagia in advanced-stage head-and-neck cancer patients: impact on quality of life and development of a preventive swallowing treatment

OBJECTIVES

Swallowing and voice dysfunctions are common side effects following head-and-neck squamous-cell carcinoma (HNSCC) treatment. Our aim was to analyze the relationships between quality of life, swallowing, and phonatory problems in patients with an advanced-stage HNSCC and to prospectively evaluate the effects of a prophylactic swallowing program.

METHODS

First, we retrospectively studied 60 advanced HNSCC patients treated with exclusive or adjuvant radiotherapy/chemoradiotherapy (RT/CRT). Subjects were classified according to general and clinical-therapeutic features. Outcome measures included EORTC QLQ-C30, EORTC QLQ-H&N35, Dysphagia Handicap Index (DHI), M.D.Anderson Dysphagia Inventory (MDADI), and Voice Handicap Index (VHI). Then, we conducted a prospective evaluation of a prophylactic swallowing counselling in 12 consecutive advanced-stage HNSCC patients by a two-arm case-control analysis. These patients were treated with exclusive or adjuvant RT/CRT.

RESULTS

71% of the retrospective population studied reported swallowing dysfunction as a major side effect. No differences were detected in the severity of dysphagia or dysphonia according to type of treatment or staging of the primary tumour, while hypopharyngeal and laryngeal cancer patients showed significantly better swallowing ability and better QoL compared to oral cavity and oropharyngeal localisation (p < 0.05). In addition, a relevant correlation between swallowing and voice problems emerged (p < 0.05). In the prospective part, while no statistical correlation was evident before the start of RT/CRT in the experimental group compared to the control one, the former showed better performances at MDADI (p = 0.006) and DHI (p = 0.002) test 3 months after its end.

CONCLUSION

Dysphagia is both an acute-and-long-term side effect which greatly affects QoL of HNSCC patients undergoing multimodality treatment. Our data show that a prophylactic swallowing program could actually produce a beneficial effect on patients' outcomes.

LEVEL OF EVIDENCE

1b and 2b.

Clinical factors impacting on late dysphagia following radiotherapy in patients with head and neck cancer

OBJECTIVE

Patient and treatment characteristics of patients with head and neck cancer (HNSCC) were correlated with dysphagia scored on swallowing-videofluoroscopy (VFS) and with patient- and physician-scored dysphagia.

METHODS

63 HNSCC patients treated with radiotherapy (RT) were evaluated at baseline, and 6 and 12 months post-RT. VFS was scored with Penetration Aspiration Scale (PAS) and Swallowing Performance Scale (SPS). Physician- and patient-scored dysphagia were prospectively recorded according to Common Terminology Criteria for Adverse Events scoring system, Radiation Therapy Oncology Group/EORTC scoring system and European Organization for Research and Treatment of Cancer Quality of Life questionnaire (EORTC-QLQ H&N35).

RESULTS

Univariable analysis revealed a significant association between tumour-subsite and higher SPS (p = 0.02) and patient-scored dysphagia (p = 0.02) at baseline. At 12 months, tumour-subsite was significantly associated with higher PAS and SPS. Multivariable analysis and pairwise comparison showed that hypopharyngeal cancer and carcinoma of unknown primary  were associated with higher SPS at baseline and at 12 months, respectively (p = 0.03 and p = 0.01). Upfront neck dissection (UFND) was significantly associated with higher SPS and physician-scored dysphagia in univariable analysis at all timepoints. At 12 months, there was also a significant association with higher PAS (p < 0.01) and patient-scored dysphagia (p < 0.01). After multivariable analysis, the association between UFND and higher PAS (p < 0.01) and SPS (p < 0.01) remained significant at 12 months.

CONCLUSION

Hypopharyngeal tumours and carcinoma of unknown primary were related to more dysphagia at baseline and at 12 months, respectively. Furthermore, UFND was associated with more severe dysphagia scored by physicians and patients and on VFS at 12 months. Advances in knowledge: This is the first paper reporting a significant link between UFND and late dysphagia scored with VFS. We advocate abandoning UFND and preserving neck dissection as a salvage option post-RT.

Feasibility and acceptability of combining cognitive behavioural therapy techniques with swallowing therapy in head and neck cancer dysphagia

BACKGROUND

Head and neck cancer squamous cell carcinoma (HNSSC) patients report substantial rates of clinically significant depression and/or anxiety, with dysphagia being a predictor of distress and poorer quality of life. Evidence-based dysphagia interventions largely focus on the remediation of physical impairment. This feasibility study evaluates an intervention which simultaneously uses a psychological therapy approach combined with swallowing impairment rehabilitation.

METHODS

This prospective single cohort mixed-methods study, recruited HNSCC patients with dysphagia, from two institutions. The intervention combined Cognitive Behavioural Therapy with swallowing therapy (CB-EST), was individually tailored, for up to 10 sessions and delivered by a speech and language therapist. Primary acceptability and feasibility measures included recruitment and retention rates, data completion, intervention fidelity and the responsiveness of candidate outcome measures. Measures included a swallowing questionnaire (MDADI), EORTC-QLQH&N35, dietary restrictions scale, fatigue and function scales and the Hospital Anxiety and Depression Scale (HADS), administered pre-, post-CB-EST with three month follow-up and analysed using repeated measures ANOVA. Qualitative interviews were conducted to evaluate intervention processes.

RESULTS

A total of 30/43 (70%) eligible patients agreed to participate and 25 completed the intervention. 84% were male, mean age 59 yrs. Patients were between 1 and 60 months (median 4) post-cancer treatment. All patients had advanced stage disease, treated with surgery and radiotherapy (38%) or primary chemoradiotherapy (62%). Pre to post CB-EST data showed improvements in MDADI scores (p = 0.002), EORTC-QLQH&N35 (p = 0.006), dietary scale (p < 0.0001), fatigue (p = 0.002) but no change in function scales or HADS. Barriers to recruitment were the ability to attend regular appointments and patient suitability or openness to a psychological-based intervention.

CONCLUSIONS

CB-EST is a complex and novel intervention, addressing the emotional, behavioural and cognitive components of dysphagia alongside physical impairment. Preliminary results are promising. Further research is required to evaluate efficacy and effectiveness.

Feasibility and acceptability of combining cognitive behavioural therapy techniques with swallowing therapy in head and neck cancer dysphagia

Background

Head and neck cancer squamous cell carcinoma (HNSSC) patients report substantial rates of clinically significant depression and/or anxiety, with dysphagia being a predictor of distress and poorer quality of life. Evidence-based dysphagia interventions largely focus on the remediation of physical impairment. This feasibility study evaluates an intervention which simultaneously uses a psychological therapy approach combined with swallowing impairment rehabilitation.

Methods

This prospective single cohort mixed-methods study, recruited HNSCC patients with dysphagia, from two institutions. The intervention combined Cognitive Behavioural Therapy with swallowing therapy (CB-EST), was individually tailored, for up to 10 sessions and delivered by a speech and language therapist. Primary acceptability and feasibility measures included recruitment and retention rates, data completion, intervention fidelity and the responsiveness of candidate outcome measures. Measures included a swallowing questionnaire (MDADI), EORTC-QLQH&N35, dietary restrictions scale, fatigue and function scales and the Hospital Anxiety and Depression Scale (HADS), administered pre-, post-CB-EST with three month follow-up and analysed using repeated measures ANOVA. Qualitative interviews were conducted to evaluate intervention processes.

Results

A total of 30/43 (70%) eligible patients agreed to participate and 25 completed the intervention. 84% were male, mean age 59 yrs. Patients were between 1 and 60 months (median 4) post-cancer treatment. All patients had advanced stage disease, treated with surgery and radiotherapy (38%) or primary chemoradiotherapy (62%). Pre to post CB-EST data showed improvements in MDADI scores (p = 0.002), EORTC-QLQH&N35 (p = 0.006), dietary scale (p < 0.0001), fatigue (p = 0.002) but no change in function scales or HADS. Barriers to recruitment were the ability to attend regular appointments and patient suitability or openness to a psychological-based intervention.

Conclusions

CB-EST is a complex and novel intervention, addressing the emotional, behavioural and cognitive components of dysphagia alongside physical impairment. Preliminary results are promising. Further research is required to evaluate efficacy and effectiveness.

Prophylactic Swallow Therapy for Patients with Head and Neck Cancer Undergoing Chemoradiotherapy: A Randomized Trial

Evidence supporting prophylactic swallow exercises for patients with head and neck cancer (HNC) has not been universally demonstrated. This RCT examined diet level, feeding tube use, swallow function, and quality of life (QOL) of patients undergoing chemoradiotherapy who performed prophylactic swallowing exercises. Sixty HNC patients were randomized into exercise versus control groups. Swallowing, oromotor, toxicity, and QOL data were recorded (baseline, 3, 6, 12, 24 months). Physiological swallow function was examined at baseline and 3 months. Swallow exercises were completed twice daily. Oral intake at 3 months was 10% better in the exercise group, which was not statistically significant (p = 0.49). Significant (p < 0.05) differences in secondary outcomes including oromotor function, pharyngeal impairment, oral pharyngeal swallow efficiency, and incisal opening were noted at early time points (3–6 months) in the exercise group. Possible positive early improvements in swallow function are associated with swallowing exercises, although these improvements are not significant longer term.