Trends in Reporting of Swallowing Outcomes in Oropharyngeal Cancer Studies: A Systematic Review

Head and Neck Cancer: A Study on the Complex Relationship between QoL and Swallowing Function

Head and neck squamous cell carcinoma (HNSCC) is linked to significant morbidity, adversely affecting survival and functional capacity. Post-treatment challenges such as pain, dysphonia, and dysphagia are common, prompting increased attention in survivorship research. Quality of Life (QoL) questionnaires, especially the MD Anderson Dysphagia Inventory (MDADI), are prevalent outcome measures in clinical studies but often lack parallel objective swallowing function evaluations, leading to potential outcome discrepancies. This study aimed to illuminate the relationship between subjective QoL (EQ-5D-5L and MDADI) measures and objective swallowing function (evaluated via Fiberoptic Endoscopic Evaluation of Swallowing, FEES) in patients with HNSCC. The analysis revealed a notable discordance between objective measures of swallowing function, such as the Penetration-Aspiration Scale (PAS) and residue ratings in the vallecula or piriform sinus, and patients' subjective QoL assessments (p = 0.21). Despite the lack of correlation, swallowing-related QoL, as measured by the MDADI, was more indicative of disease severity than generic QoL assessments. Generic QoL scores did not demonstrate substantial variation between patients. In contrast, MDADI scores significantly declined with advancing tumor stage, multimodal therapy, and reliance on feeding tubes. However, the clinical significance of this finding was tempered by the less than 10-point difference in MDADI scores. The findings of this study underline the limitations of QoL measures as standalone assessments in patients with HNSCC, given their reliance on patient-perceived impairment. While subjective QoL is a crucial aspect of evaluating therapeutic success and patient-centric outcomes, it may fail to capture critical clinical details such as silent aspirations. Consequently, QoL assessments should be augmented by objective evaluations of swallowing function in clinical research and practice to ensure a holistic understanding of patient well-being and treatment impact.

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.

Long-Term Swallowing Outcome and Dysphagia in Advanced Staged Head and Neck Squamous Cell Carcinomas after Radiotherapy

Objective: To evaluate the impact of radiotherapy (RT) on dysphagia and long-term swallowing outcome in patients with stage III and IV head and neck squamous cell carcinomas (HNSCCs). Material and Methods: Between 2005 and 2008, 189 patients with HNSCCs underwent primary or adjuvant RT in a curative setting. Long-term swallowing outcome was evaluated in 50 patients. Among them, 26 were further eligible for prospective analysis of long-term swallowing and dysphagia outcome. Medical charts were retrospectively reviewed regarding pre- and post-treatment dysphagia (3 months after last irradiation setting) as well as persisting long-term dysphagia (2019−2021). Results: Pre-treatment dysphagia was observed in 24 (48%) of 50 patients, particularly in oropharyngeal or hypopharyngeal stage III−IV tumors (OR 9.3; p = 0.003). Conversely, 46 patients (92%) complained about post-treatment dysphagic symptoms, which were more commonly seen in patients with positive neck nodes (OR 10.5; p = 0.037). The post-treatment dysphagia rate dropped from 92% to 24% (p < 0.001) during surveillance, which was significantly linked to xerostomia (OR 5.77; p = 0.019), dysgeusia (OR 9.9; p = 0.036) and free flap reconstruction (OR 6.1; p = 0.022). Conclusion: Pretreatment dysphagia is common in advanced stage HNSCCs and almost all patients complain about dysphagia at the end of RT. Importantly, applied RT protocols did not affect long-term dysphagia, which improves significantly in the majority of patients over time. Meeting Information: Preliminary results have been presented at the 65th Annual Meeting of the Austrian Society of Otorhinolaryngology, 22−26 September 2021, Austria.

Psychometric properties of patient-reported outcome measures for dysphagia in head and neck cancer: a systematic review protocol using COSMIN methodology

BACKGROUND

Dysphagia (swallowing difficulty) is one of the most common and debilitating sequelae of head and neck cancer (HNC). Patient-reported outcome measures (PROMs) are a fundamental component of dysphagia outcomes evaluation, as they inform treatment consequences that cannot be captured by objective clinician measures. Many PROMs for dysphagia in HNC are available, but their validity is unclear. As a consequence, the selection of the most appropriate PROM for dysphagia in HNC is complex and often based on the clinician's personal preferences, rather than on valid psychometric properties. This protocol describes a systematic review aiming at (1) identifying PROMs specific to dysphagia symptoms, swallowing functional status, swallowing-related health status, and swallowing-related quality of life in HNC, (2) mapping them to our conceptual framework of dysphagia-related PROs, and (3) appraising their psychometric properties using the Consensus Based Standards for the Selection of Health Measurement Instrument (COSMIN) methodology.

METHODS

Six electronic databases will be searched from inception to December 2020 for all primary studies in any language and design detailing PROM development, reliability, validity, feasibility, interpretability, and/or cross-cultural adaptation. Eligibility criteria will target PROMs for patients with HNC (≥ 90% of the study sample) with ≥ 20% of their items pertaining to swallowing. Two independent raters will screen abstract and full texts and a third rater will resolve discrepancies. Data will be extracted on study, sample and PROM characteristics, and results of psychometric testing. PROMs will be mapped to our conceptual framework. The methodological quality of included PROMs and their psychometric properties will be appraised using the COSMIN risk of bias checklist and evidence will be summarized using a modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

DISCUSSION

This systematic review will provide a summary of existing dysphagia-related PROMs for people with HNC and a comprehensive account of their psychometric properties. We will provide recommendations on PROMs selection which will aid healthcare professionals to the most appropriate PROM based on its validity, reliability, feasibility, interpretability and suitability for clinical and research settings. Further recommendations will be made on areas of measurement property requiring further testing.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration ID: CRD42021237877.

Swallowing Patterns in the HNC Population: Timing of Penetration-Aspiration Events and Residue

Objective

This study described swallowing patterns in a large head/neck cancer (HNC) cohort.

Study Design

In a retrospective review of data from a randomized controlled trial, we studied timing of penetration events as they related to aspiration and oral/pharyngeal residue.

Setting

Retrospective review of a multicenter randomized controlled trial.

Subjects and Methods

In total, 168 patients who were >3 months postradiation received baseline modified barium swallow evaluations. Retrospective analyses of data from these exams were studied, including Penetration-Aspiration Scale (PAS) scores and timing of these events (before, during, or after the swallow), as well as percentage of oral and pharyngeal residue.

Results

Aspiration occurred more frequently after than before or during the swallow ( P < .05). There were significantly more events of penetration that led to aspiration after the swallow (n = 260) when compared to events before (n = 6) or after (n = 81) the swallow. There was more pharyngeal (16%-25%) than oral residue (5%-20%). Weak correlations were found between thin liquid, nectar-thick liquid, pudding residue, and PAS scores, with varying significance (pharyngeal residue/PAS rs: .26*, .35*, .07*; oral residue/PAS rs: .21*, .16, .3; * P < .05).

Conclusion

The predominant pattern for this sample of postradiation patients with HNC with dysphagia was aspiration that occurred after the swallow, rather than before or during the swallow. The aspiration was directly caused by penetration events that occurred during the swallow, resulting in aspiration as the airway reopened. Patients demonstrated more pharyngeal residue than oral residue, but a weak relationship was found between residue and penetration/aspiration events. These results guide clinicians in targeting appropriate swallowing interventions.