Long-Term, Prospective Performance of the MD Anderson Dysphagia Inventory in "Low-Intermediate Risk" Oropharyngeal Carcinoma After Intensity Modulated Radiation Therapy

Dysphagia in Head and Neck Cancer

Dysphagia is a common symptom in patients with head and neck cancer that can significantly impact health outcomes and quality of life. The origin of dysphagia in these patients is often multifactorial, making diagnosis and management especially complex. The evaluating otolaryngologist should be well versed with the patient's neoplasm, comorbidities, and treatment history alongside dysphagia-specific imaging modalities. Management is often dynamic, requiring frequent monitoring, interprofessional collaboration, and a variety of supportive and invasive measures to achieve optimal outcomes.

The timed 100 mL water swallow test for patients with head and neck cancer: What constitutes a clinically significant difference?

OBJECTIVES

Swallowing function in patients with head and neck cancer (HNC) is often assessed pre-treatment, during and at intervals post-treatment to identify those with dysphagia as early as possible. This study aims to investigate the minimal clinical important difference (MCID) for the 100 mL water swallow test (100 mL WST) to increase its utility in clinical practice and in clinical trials.

METHODS

Data from 211 HNC patients, treated by either single or combined modality were included. Patients completed both the 100 mL WST and M.D. Anderson Dysphagia Inventory (MDADI) at baseline (i.e., prior to treatment) and 12 months post-treatment. The MCID for the 100 mL WST was calculated using two approaches of the anchor-based method (using the MDADI), including mean change, and ROC curve. Additionally, the distribution-based method was used utilizing the half standard deviation approach.

RESULTS

In the anchor-based method, a 4 mL/s in the 100 mL WST was defined as an MCID for deterioration, with a sensitivity of 75% and a 1-specificity of 46%. In contrast, a change of 5 mL/s was deemed as an MCID for improvement, based on the distribution-based method.

CONCLUSION

The findings showed that deterioration of 4 mL, or an increase of 5 mL from baseline to 12 months post-HNC treatment equates to an MCID from the patients' perspective. Based on these findings, it may be beneficial to increase the utilization of the 100 mL WST in clinical practice to observe the changes, and in clinical trials to interpret and compare different study arms.

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

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

A Hard Truth to Swallow: Critically Evaluating the MD Anderson Dysphagia Inventory (MDADI) as an Endpoint in Human Papillomavirus-associated Oropharyngeal Cancer Trials

The MD Anderson Dysphagia Inventory (MDADI), a measure of swallowing-related quality of life, has become the preferred patient-reported outcome measure (PROM) in contemporary clinical trials evaluating the experience of human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPVOPSCC) survivors. With many potentially practice-changing studies using the MDADI composite score as either a primary or coprimary endpoint, or as a key secondary endpoint, it is important to understand its psychometric properties as judged by contemporary PROM standards, with a particular focus on its application to contemporary HPVOPSCC populations. In this critical review, we evaluate contemporary HPVOPSCC studies reporting MDADI outcomes, followed by a detailed evaluation of the psychometric properties of the MDADI. Although the focus of this review was the MDADI, the issues discussed are not unique to the MDADI and have broader applicability to the evaluation and assessment of other PROMs currently in use. First, it may be possible to improve administration of the instrument, as related to missing items, scoring, and the number of items required. Second, although in many instances, the MDADI has been intended as a direct or surrogate measure of swallowing physiology, the MDADI composite score captures a broader health-related quality of life construct affected by both swallowing and eating, the latter of which may be affected by a range of nonswallowing treatment-related toxicities. Finally, a clinically meaningful change of 10 in the MDADI composite score, widely accepted and applied to the clinical trial setting, represents an undoubtably clinically relevant difference in unselected head and neck cancer survivors. However, the smallest difference that might be clinically important to a highly functional HPVOPSCC cohort remains uncertain. Understanding the purpose and properties of the MDADI instrument and furthering the sophistication with which we apply it in this population would improve its interpretation in clinical trials.

Moving from conventional to adaptive risk stratification for oropharyngeal cancer

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

Pharyngeal Constrictor Dose-Volume Histogram Metrics and Patient-Reported Dysphagia in Head and Neck Radiotherapy

AIMS

Head and neck radiotherapy long-term survival continues to improve and the management of long-term side-effects is moving to the forefront of patient care. Dysphagia is associated with dose to the pharyngeal constrictors and can be measured using patient-reported outcomes to evaluate its effect on quality of life. The aim of the present study was to relate pharyngeal constrictor dose-volume parameters with patient-reported outcomes to identify prognostic dose constraints.

MATERIALS AND METHODS

A 64-patient training cohort and a 24-patient testing cohort of oropharynx and nasopharynx cancer patients treated with curative-intent chemoradiotherapy were retrospectively examined. These patients completed the MD Anderson Dysphagia Inventory outcome survey at 12 months post-radiotherapy to evaluate late dysphagia: a composite score lower than 60 indicated dysphagia. The pharyngeal constrictor muscles were subdivided into four substructures: superior, middle, inferior and cricopharyngeal. Dose-volume histogram (DVH) metrics for each of the structure combinations were extracted. A decision tree classifier was run for each DVH metric to identify dose constraints optimising the accuracy and sensitivity of the cohort. A 60% accuracy threshold and feature selection method were used to ensure statistically significant DVH metrics were identified. These dose constraints were then validated on the 24-patient testing cohort.

RESULTS

Existing literature dose constraints only had two dose constraints performing above 60% accuracy and sensitivity when evaluated on our training cohort. We identified two well-performing dose constraints: the pharyngeal constrictor muscle D63% < 55 Gy and the superior-middle pharyngeal constrictor combination structure V31Gy < 100%. Both dose constraints resulted in ≥73% mean accuracy and ≥80% mean sensitivity on the training and testing patient cohorts. In addition, a pharyngeal constrictor muscle mean dose <57 Gy resulted in a mean accuracy ≥74% and mean sensitivity ≥60%.

CONCLUSION

Mid-dose pharyngeal constrictor muscle and substructure combination dose constraints should be used in the treatment planning process to reduce late patient-reported dysphagia.

Quality of life and swallowing outcomes following major glossectomy: A prospective single-center experience

BACKGROUND

There exists a lacuna in the structured reporting of swallowing dysfunction and quality of life (QoL) outcome following major glossectomy.

METHODS

Prospective cohort study to assess the swallowing dysfunction and QoL following STG (subtotal glossectomy) or NTG (near total glossectomy) over a 6-month period using FEES and PAS scale, MDADI, and FACT-HN.

RESULTS

Twenty-four patients were available for analysis. The pre- and post-adjuvant evaluation revealed a statistically significant improvement in the composite MDADI and FACT-HN scores. Subscale analysis of FACT-HN scores revealed maximum deficit in the head and neck cancer-specific score domain followed by functional domain and social well-being domain, with serial improvement noted in the post-adjuvant setting.

CONCLUSION

This study showed serial improvement in terms of swallowing dysfunction although social and functional well-being domains related to QoL continued to reveal major deficits. Better outcomes were seen with preservation of bilateral base of tongue and mandible.

Longitudinal changes in swallowing function after surgery and proactive swallowing therapy for oral cancer

BACKGROUND

This study aimed to describe and explore the longitudinal changes in swallowing function among patients with oral cancer who underwent surgery and proactive swallowing therapy from baseline to 1-year postoperation.

METHODS

We retrospectively studied 118 patients over a 4.5-year duration. Swallowing functional assessment including 10-item Eating Assessment Tool (EAT-10), Functional Oral Intake Scale (FOIS), M. D. Anderson Dysphagia Inventory, and Modified Barium Swallow Impairment Profile (MBSImP™) was performed at baseline, 1-month, 6-month, and 1-year postoperatively.

RESULTS

All swallowing parameters worsened 1-month postoperation. EAT-10, FOIS, and MBSImP™ oral and pharyngeal impairment scores improved significantly compared with 1-month postoperation at 6 months. Other swallowing parameters, except for weight, did not differ significantly from baseline at 6 months. The rate of tube-feeding dependency was 11.5% and 5.6% at 1 and 6 months postoperation, respectively.

CONCLUSIONS

Periodic swallowing functional assessments help delineate the longitudinal changes in swallowing functional outcomes.

Pilot randomized, controlled, preoperative intervention for nutrition trial in head and neck cancer

BACKGROUND

Several prospective studies report improved outcomes with pretreatment nutrition interventions prior to radiation therapy for head and neck cancer (HNC), but none have assessed similar interventions before surgery for HNC.

METHODS

POINT, a pilot randomized controlled trial, was conducted to evaluate a multimodal nutrition intervention. Patients undergoing primary surgery with free flap reconstruction for HNC were randomly assigned to the control arm or a preoperative multimodal nutrition intervention.

RESULTS

POINT included 49 patients. Nutrition risk scores did not change significantly for either the intervention or control group. Control patients had a significant decrease in body weight in the preoperative period (p < 0.001). Conversely, weight among intervention patients did not significantly decrease (p = 0.680). The intervention mitigated weight loss in patients with dysphagia (p = 0.001).

CONCLUSIONS

Preoperative nutrition optimization shows potential to reduce weight loss normally experienced by patients with head and neck cancer prior to surgical extirpation, especially among those with subjective dysphagia.

Improvement in Dysphagia Outcomes Following Clinical Target Volume Reduction in the De-ESCALaTE Study

AIMS

The De-ESCALaTE study showed an overall survival advantage for the administration of synchronous cisplatin chemotherapy with radiotherapy in low-risk oropharyngeal cancer when compared with synchronous cetuximab. During the trial, a radiotherapy quality assurance protocol amendment permitted centres to swap from the original radiotherapy contouring protocol (incorporating the whole oropharynx into the high-dose clinical target volume (CTV); anatomical protocol) to a protocol that incorporated the gross tumour volume with a 10 mm margin into the CTV (volumetric protocol). The purpose of this study was to examine both toxicity and tumour control related to this protocol amendment.

MATERIALS AND METHODS

Overall survival and recurrence at 2 years were used to compare tumour control in the two contouring cohorts. For toxicity, the cohorts were compared by both the number of severe (grades 3-5) and all grades acute and late toxicities. In addition, quality of life and swallowing were compared using EORTC-C30 and MD Anderson Dysphagia Inventory, respectively.

RESULTS

Of 327 patients included in this study, 185 were contoured according to the anatomical protocol and 142 by the volumetric protocol. The two cohorts were well balanced, with the exception of significantly more patients in the anatomical cohort undergoing prophylactic feeding tube insertion (P < 0.001). With a minimum of 2 years of follow-up there was no significant difference in overall survival or recurrence between the two contouring protocols. Similarly, there was no significant difference in the rate of reported severe or all grades acute or late toxicity and no sustained significant difference in quality of life. However, there was a significant difference in favour of volumetric contouring in several domains of the MD Anderson Dysphagia Inventory questionnaire at 1 year, which persisted to 2 years in the dysphagia functional (P = 0.002), dysphagia physical (P = 0.009) and dysphagia overall function (P = 0.008) domains.

CONCLUSION

In the context of the unplanned post-hoc analysis of a randomised trial, measurable improvement in long-term dysphagia has been shown following a reduction in the CTV. Further reductions in the CTV should be subject to similar scrutiny within the confines of a prospective study.

Predictors of severe dysphagia following radiotherapy for head and neck cancer

OBJECTIVE

To investigate if severe dysphagia following radiotherapy for head and neck cancer (HNC) could be predicted by patient and tumor characteristics, feeding tube use, weight factors, jaw opening function, and saliva secretion.

METHODS

Data was collected from 94 HNC patients 6 to 36 months post radiotherapy. Swallowing function was assessed by videofluroscopy (VFS). Severe dysphagia was defined by Penetration Aspiration Scale (PAS) as PAS≥5 or a total score ≤60 on the M. D. Anderson Dysphagia Inventory (MDADI).

RESULTS

Thirty-three patients (35%) had PAS ≥5 and 19 (20%) a MDADI ≤60, that is, presented with severe dysphagia. Univariable logistic regression analysis (UVA) gave that tumor of the tonsil, overweight at time of VFS and each unit increase in Body Mass Index (BMI) predicted less risk of PAS ≥5. Dependency of feeding tube at time of VFS and each month's continued use and weight loss ≥7.5% since treatment to time of VFS predicted increased risk of PAS ≥5. Predictive variables from the UVA of PAS ≥5 (tumor of the tonsil, overweight, and total duration of feeding tube), were analyzed by multivariate logistic regression analysis. All retained power as independent predictors. UVA for MDADI showed that use of feeding tube at time of VFS predicted MDADI ≤60 with the risk increasing each month. Each increasing unit of BMI decreased risk of MDADI ≤60.

CONCLUSION

Long time users of feeding tube and higher weight-loss are at risk of severe dysphagia. This makes collaboration between professionals working with dysphagia an important step in detecting severe dysphagia.Level of Evidence: 3.

Long-term swallowing-related outcomes in oral cancer patients receiving proactive swallowing therapy

OBJECTIVES

The present study aimed to evaluate the impact of proactive swallowing rehabilitation on swallowing function and quality of life (QoL) in oral cancer patients in the first two years after definitive treatment.

MATERIALS AND METHODS

Consecutive adult patients with locally advanced oral cancer who received radical surgery, free flap reconstruction, and adjuvant radiotherapy were recruited prospectively, to whom proactive swallowing rehabilitation was provided. Body weight (BW); fiberoptic endoscopic evaluation of swallowing (FEES), functional oral intake scale (FOIS), and diet level; 10-item eating assessment tool (EAT-10), and MD Anderson Dysphagia Inventory (MDADI); and adherence at baseline, 1, 3, 6, 12, and 24 months were evaluated.

RESULTS

A total of 104 patients were included during May 2018 to July 2020. Compared to the baseline, significant deterioration in BW, FOIS, and MDADI was noted at one month. However, a trend of recovery was observed in FOIS from one month, and in BW and MDADI from three months. A total of 94% patients were free of tube feeding at 12 months but with a diet requiring special preparations or compensation. Safe swallowing could be achieved in approximately 90% of the participants after six months with diet modification or compensatory maneuvers. BW at 18 and 24 months did not differ significantly from baseline.

CONCLUSION

Proactive swallowing therapy is feasible for patients with locally advanced oral cancer receiving definitive treatments. It facilitates safe oral intake and adequate nutrition. Patients who performed swallowing exercises had a faster and better recovery in swallowing function and swallowing-related QoL.

Evaluating dysphagia and xerostomia outcomes following transoral robotic surgery for patients with oropharyngeal cancer

BACKGROUND

We assessed long-term patient-reported dysphagia and xerostomia outcomes following definitive surgical management with transoral robotic surgery (TORS) in patients with oropharyngeal cancer (OPC) via a cross-sectional survey study.

METHODS

Patients with OPC managed with primary oropharyngeal surgery as definitive treatment at least 1 year ago between 2015 and 2019 were identified. The M. D. Anderson Dysphagia Inventory (MDADI) and Xerostomia Inventory (XI) scores were compared across treatment types (i.e., no adjuvant therapy [TORS-A] vs. adjuvant radiotherapy [TORS+RT] vs. adjuvant chemoradiotherapy [TORS+CT/RT]).

RESULTS

The sample had 62 patients (10 TORS-A, 30 TORS+RT, 22 TORS+CT/RT). TORS-A had clinically and statistically significantly better MDADI scores than TORS+RT (p = 0.03) and TORS+CT/RT (p = 0.02), but TORS+RT and TORS+CT/RT were not significantly different. TORS-A had clinically and statistically significantly less XI than TORS+RT (p < 0.01) and TORS+CT/RT (p < 0.01).

CONCLUSIONS

Patients with OPC who have undergone TORS+RT or TORS+CT/RT following surgery face clinically worse dysphagia and xerostomia outcomes relative to patients who undergo TORS-A.

Optimizing oropharyngeal cancer management by using proton beam therapy: trends of cost-effectiveness

BACKGROUND

Proton beam therapy (PBT) is a new-emerging cancer treatment in China but its treatment costs are high and not yet covered by Chinese public medical insurance. The advanced form of PBT, intensity-modulated proton radiation therapy (IMPT), has been confirmed to reduce normal tissue complication probability (NTCP) as compared to conventional intensity-modulated photon-radiation therapy (IMRT) in patients with oropharyngeal cancer (OPC). Herein, we evaluated the cost-effectiveness and applicability of IMPT versus IMRT for OPC patients in China, aiming at guiding the proper use of PBT.

METHODS

A 7-state Markov model was designed for analysis. Base-case evaluation was performed on a 56-year-old (median age of OPC in China) patient under the assumption that IMPT could provide a 25% NTCP-reduction in long-term symptomatic dysphagia and xerostomia. Model robustness was examined using probabilistic sensitivity analysis, cohort analysis, and tornado diagram. One-way sensitivity analyses were conducted to identify the cost-effective scenarios. IMPT was considered as cost-effective if the incremental cost-effectiveness ratio (ICER) was below the societal willingness-to-pay (WTP) threshold.

RESULTS

Compared with IMRT, IMPT provided an extra 0.205 quality-adjusted life-year (QALY) at an additional cost of 34,926.6 US dollars ($), and had an ICER of $170,082.4/ QALY for the base case. At the current WTP of China ($33,558 / QALY) and a current IMPT treatment costs of $50,000, IMPT should provide a minimum NTCP-reduction of 47.5, 50.8, 55.6, 63.3 and 77.2% to be considered cost-effective for patient age levels of 10, 20, 30, 40 and 50-year-old, respectively. For patients at the median age level, reducing the current IMPT costs ($50,000) to a $30,000 level would make the minimum NTCP-reduction threshold for "cost-effective" decrease from 91.4 to 44.6%, at the current WTP of China (from 69.0 to 33.5%, at a WTP of $50,000 / QALY; and from 39.7 to 19.1%, at a WTP of $100,000 / QALY).

CONCLUSIONS

Cost-effective scenarios of PBT exist in Chinese OPC patients at the current WTP of China. Considering a potential upcoming increase in PBT use in China, such cost-effective scenarios may further expand if a decrease of proton treatment costs occurs or an increase of WTP level.

Deintensification Strategies Using Proton Beam Therapy for HPV-Related Oropharyngeal Cancer

Oropharyngeal cancers related to the human papillomavirus are a growing segment of head and neck cancers throughout the world. These cancers are biologically and demographically unique with patients presenting at younger ages and with more curable disease. This combination of factors heightens the importance of normal tissue sparing because patients will live a long time with treatment sequelae. Proton therapy has demonstrated benefits in reducing normal tissue exposure, which may lead to less toxicity, a higher quality of life, less immunologic suppression, and lower cost. Research investigating deintensified radiation volumes and doses are also underway. These deintensification studies synergize well with the beam characteristics of proton beam therapy and can decrease that already reduced normal tissue exposure enabled by proton therapy. Future studies should refine patient selection to best allow for volume and dose reduction paired with proton therapy.

Adaptation and Validation of the Dynamic Imaging Grade of Swallowing Toxicity for Flexible Endoscopic Evaluation of Swallowing: DIGEST-FEES

Purpose While flexible endoscopic evaluation of swallowing (FEES) is a common clinical procedure used in the head and neck cancer (HNC) population, extant outcome measures for FEES such as bolus-level penetration-aspiration and residue scores are not well suited as global patient-level endpoint measures of dysphagia severity in cooperative group trials or clinical outcomes research. The Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) was initially developed and validated for use during videofluoroscopic evaluations as a way to grade safety, efficiency, and overall pharyngeal swallowing impairment. The purpose of this study was to adapt and validate DIGEST for use with FEES. Method A modified Delphi exercise was conducted for content validation, expert consensus, adaptation, and operationalization of DIGEST-FEES. Three blinded, expert raters then evaluated 100 de-identified post-HNC treatment FEES examinations. Intra- and interrater reliability were tested with quadratic weighted kappa. Criterion validity against the MD Anderson Dysphagia Inventory, Functional Oral Intake Scale, Secretion Severity Scale, and Yale Residue Rating Scale was assessed with Spearman correlation coefficients. Results Interrater reliability was almost perfect for overall DIGEST-FEES grade (κ_w = 0.83) and safety grade (κ_w = 0.86) and substantial for efficiency grade (κ_w = 0.74). Intrarater reliability was excellent for all raters (0.9-0.91). Overall DIGEST-FEES grade correlated with MD Anderson Dysphagia Inventory (r = -.43, p < .0001), Functional Oral Intake Scale (r = -.43, p < .0001), Secretion Severity Scale (r = .47, p < .0001), Yale Vallecular Residue (r = .73, p < .0001), and Yale Pyriform Sinus Residue (r = .65, p < .0001). Conclusion DIGEST-FEES is a valid and reliable scale to describe the severity of pharyngeal dysphagia in patients with HNC. Supplemental Material https://doi.org/10.23641/asha.14642787.

Patient-reported quality of life and symptom burden measures in human papillomavirus associated oropharyngeal cancer - A review of the literature and PRO methodology

The emergence of human papillomavirus-associated oropharyngeal cancer (HPVOPC) has resulted in an explosion of clinical research offering reduced toxicity and improved health-related quality of life (HRQL) through treatment de-escalation. At the heart of this objective are patient-reported outcomes (PROs) which aim to quantify the patient experience, usually through the measurement of HRQL or symptom burden. A number of PRO measures (PROMs) are available to HNC researchers and selection of the optimal instrument relies on a detailed understanding of their content and psychometric properties matched to the clinical endpoint of interest. As PROMs become increasingly favoured as the primary or co-primary endpoints of interest in HNC clinical trials, particularly those focussed on HPVOPC, future treatment paradigms will be determined by these measures and it is imperative that they are applied with sophistication and rigor. This review draws attention to the limitations and challenges our specialty faces in PRO application, analysis and reporting. These shortfalls typically include a reliance on statistical rather than clinically relevant differences, multiple hypothesis testing, a lack of evidence-based minimal clinically important differences for the commonly used tools, as well as variations in PROM selection. The aim of this review is to provide: (1) an overview of PRO/PROM terminology and methodology in the HNC setting; (2) to provide a summary of HRQL and symptom burden reports in the HPVOPC literature; and (3) to draw attention to the unmet research need of refining PROM development, application and interpretation to guide our treatment decisions based on what matters to patients.

Psychometric Properties of the MDADI-A Preliminary Study of Whether Less is Truly More?

The MD Anderson Dysphagia Inventory (MDADI) is a 20-item dysphagia-specific QOL questionnaire with four subscales: global, emotional, functional, and physical. It is widely used in clinical practice and in research; however, its psychometric properties have been under-researched. We aim to evaluate the organisation of the MDADI subscales and identify any redundant items. The MDADI is a routinely collected outcome measure at two centres in northeast England. Questionnaires completed at three months following treatment were extracted from these existing databases. Factor analysis was carried out with the aim of reducing redundancy among the set of questionnaire items. Cases with missing values were excluded. A total of 196 complete patient questionnaires were used in factor analysis. A one-factor model accounted for around 50% of the total variance in item responses. The top five endorsed items (abbreviated by the questionnaire item keywords: Excluded, Irritate, Esteem, Social, and Why) in this one factor appeared in three (emotional, functional, and physical) of the four supposed MDADI subscales, i.e. global, emotional, functional, and physical. Our results suggest an overlap of three MDADI subscales across the top five endorsed items. The content of the top five questions all appear related to the psychosocial aspects of swallowing. This implies some redundancy of the items in the original subscales of the questionnaire. Using the most endorsed items, it appears feasible to abbreviate the 20-item MDADI questionnaire to a 5-item “MiniDADI” questionnaire, which is likely to have greater utility in routine clinical practice outside of research settings.

Comparison of Bazaz scale, Dysphagia Short Questionnaire, and Hospital for Special Surgery-Dysphagia and Dysphonia Inventory for Assessing Dysphagia Symptoms After Anterior Cervical Spine Surgery in Chinese Population

Dysphagia is one of the most common complaints after anterior cervical spine surgery. The Bazaz scale, the Dysphagia Short Questionnaire (DSQ), and the Hospital for Special Surgery-Dysphagia and Dysphonia Inventory (HSS-DDI) were patient-reported outcome measures assessing the patients' perceptions of their swallowing functions after surgery. This prospective diagnostic test study aimed to compare these surveys' psychometric properties in the Chinese population. We evaluated 150 consecutive patients after anterior cervical spine surgery with the Bazaz scale, DSQ, HSS-DDI, and M.D. Anderson Dysphagia Inventory (MDADI). The reliability and validity of the Bazaz scale, DSQ, and HSS-DDI were compared. Receiver operating characteristic (ROC) curves of the DSQ, Bazaz scale, and HSS-DDI were constructed using the MDADI as a reference criterion. Their areas under the curve (AUCs) were further analyzed. In total, 132 participants completed all of the surveys. The results showed that all surveys were significantly correlated with each other. The HSS-DDI and HSS-Dysphagia subscale showed near-perfect reliability (Cronbach α = 0.969 and 0.957, respectively). ROC curves showed both HSS-DDI and HSS-Dysphagia subscale had greater accuracy (AUCs > 0.9) in detecting mild dysphagia and moderate/severe dysphagia. The HSS-Dysphagia subscale achieved higher accuracy in assessing the dysphagia symptoms after anterior cervical spine surgery. The Bazaz scale was considered less accurate than other scales. Our results provided guidance for selecting the appropriate measuring tool during clinical and research practices.

Prospective Evaluation of Swallowing Symptoms in Human Papillomavirus-Associated Oropharynx Cancer

To demonstrate that the lack of significant swallowing-related symptoms in patients with human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma is attributable to smaller mucosal primaries. A validated dysphagia symptom questionnaire and eating assessment tool was prospectively provided to patients presenting with untreated human papillomavirus-associated oropharyngeal cancer at the University of Maryland from July 2017 to December 2018. A 10-item Eating Assessment Tool (EAT-10) was completed by each patient prior to intervention. All EAT-10 data were collected prospectively. Patient demographic and oncologic characteristics were also obtained. Seventy consecutive patients were enrolled and included in the study. This study cohort included 66 (94%) male patients. Sixty (86%) of patients were Caucasian. The mean EAT-10 score was 3.77 (95% CI 2.04, 5.50). Fifty-two (74.3%) patients presented with normal swallowing (EAT-10 scores less than 3). Spearman correlation indicated there was a significant positive association between tumor size and EAT-10 score (r(68) = 0.429, p < 0.005), with larger tumors associated with increased swallowing-related symptoms. The majority of patients presenting with HPV-associated oropharyngeal squamous cell carcinoma do not report any swallowing difficulties. Dysphagia-related symptoms are associated with large size tumors when they do occur.

Surgical rehabilitation of swallowing with polydimethylsiloxane injections after open partial horizontal laryngectomy: Long-term functional results and quality of life

BACKGROUND

Swallowing disorders are common problems after partial laryngectomy. The aim of this study is to illustrate the long-term functional results of rehabilitation of swallowing by polydimethylsiloxane (PDMS) injection.

METHODS

Twenty-eight patients with dysphagia after partial laryngectomy who underwent injection of PDMS for rehabilitation of swallowing were included in the study. Impairment of swallowing and quality of life (QoL) were investigated with questionnaires: M. D. Anderson Dysphagia Inventory (MDADI) and Performance Status Scale for Head and Neck Cancer (PSS-HNC). Functional results at fiberoptic endoscopic evaluation of swallowing (FEES) were analyzed using a modified penetration-aspiration scale.

RESULTS

Mean follow-up was 8.5 years. Twenty-six patients showed an improvement at questionnaires (p < 0.001). Median improvement was 6 (p < 0.001) in the modified penetration-aspiration scale. Total laryngectomy was required in one patient.

CONCLUSIONS

PDMS injection is a good option for rehabilitation of swallowing in case of dysphagia after partial laryngectomy. It improves QoL and the results persist after a long follow-up period.

Conditional survival among patients with oropharyngeal cancer treated with radiation therapy and alive without recurrence 5 years after diagnosis

BACKGROUND

Risk of recurrence among patients with oropharyngeal cancer (OPC) who survive 5 years is low. The goal of this study was to assess long-term survival of patients with OPC alive without recurrence 5 years after diagnosis.

METHODS

This study included newly diagnosed patients with OPC, who had been treated with radiation and were alive without recurrence 5 years after diagnosis. Overall survival (OS) probabilities beyond 5 years were estimated using the Kaplan-Meier method. Factors associated with OS were determined using Bayesian piecewise exponential survival regression. Standardized mortality ratios for all-cause death were estimated controlling for study year, age, and sex in the US general population.

RESULTS

Among 1699 patients, the additional 2-year, 5-year, and 10-year OS probabilities were 94%, 83%, and 63%, respectively, and were lower than those in the general population. Patients who were older, were current or former smokers, had other than tonsil or base of tongue tumors, or had T4 tumors had a higher risk of death. Patients who had base of tongue tumors and had received intensity-modulated radiation therapy (IMRT) or lower-radiation doses had a lower risk of death. Standardized mortality ratios were higher among current and heavy smokers and lower among recipients of IMRT and lower radiation doses.

CONCLUSIONS

In this large cohort, long-term survival among patients with OPC was good but lower than predicted for the general population. Patients treated with IMRT and those with less tobacco exposure had better outcomes.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

1.

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

BACKGROUND AND PURPOSE

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

METHODS AND MATERIALS

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

RESULTS

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

CONCLUSIONS

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

Transoral robotic surgery and neck dissection for HPV-positive oropharyngeal carcinoma: Importance of nodal count in survival

BACKGROUND

In this study we determine the survival in patients with HPV-positive oropharyngeal carcinoma treated with transoral robotic surgery (TORS), neck dissection and risk-adapted adjuvant therapy.

METHODS

We retrospectively identified 122 patients with HPV-positive oropharyngeal carcinoma treated with TORS and neck dissection between 2011 and 2018. Survival probability was calculated. We determined the effect of the type of neck dissection performed (modified radical neck dissection-MRND vs. selective neck dissection - SND), extranodal extension (ENE), margin status, and presence of ≥ 5 metastatic nodes on survival.

RESULTS

Our patient population had a five-year overall survival of 91.0% (95% C.I. 85-97%). The five-year probability of recurrence or cancer-associated death was 0.0977 (95% C.I. 0.0927-0.1027). The five-year probability of cancer-associated death was 0.0528 (95% C.I. 0.048-0.0570). All patients who died of their disease had distant metastasis. Our PEG dependence rate was 0%. Patients with ENE and positive margins who underwent adjuvant chemoradiation did not have worse survival. Presence of ≥ 5 metastatic nodes portended worse survival after controlling for age, positive ENE and margins. Low yield (<18 nodes) on neck dissection worsened DFS on multivariable analysis. Furthermore, patients who underwent SND did not have worse OS than those who underwent MRND.

CONCLUSION

Our study demonstrates that surgery could be simplified by performing TORS with SND rather than MRND. The one true poor prognostic factor in HPV-positive oropharyngeal carcinoma patients who undergo surgery is high nodal burden. Patients with high nodal burden are much more likely to die from their disease.

Organ Preservation and Late Functional Outcome in Oropharyngeal Carcinoma: Rationale of EORTC 1420, the "Best of" Trial

Dysphagia represents one of the most serious adverse events after curative-intent treatments with a tremendous impact on quality of life in patients with head and neck cancers. Novel surgical and radiation therapy techniques have been developed to better preserve swallowing function, while not negatively influencing local control and/or overall survival. This review focuses on the current literature of swallowing outcomes after curative treatment strategies. Available results from recent studies relevant to this topic are presented, demonstrating the potential role of new treatment modalities for early- and intermediate-stage oropharyngeal cancers. Based on this, we present the rationale and design of the currently active EORTC 1420 "Best of" trial, and highlight the potential of this study to help prioritizing either surgery- or radiation-based treatment modalities for the treatment of oropharyngeal cancer in the future.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

4 Laryngoscope, 130:2153-2159, 2020.

Swallowing-related outcomes associated with late lower cranial neuropathy in long-term oropharyngeal cancer survivors: cross-sectional survey analysis

BACKGROUND

The purpose of this study was to quantify the association of late lower cranial neuropathy (late LCNP) with swallowing-related quality of life (QOL) and functional status among long-term oropharyngeal cancer (OPC) survivors.

METHODS

Eight hundred eighty-nine OPC survivors (median survival time: 7 years) who received primary treatment at a single institution between January 2000 and December 2013 completed a cross-sectional survey (56% response rate) that included the MD Anderson Dysphagia Inventory (MDADI) and self-report of functional status. Late LCNP events ≥3 months after cancer therapy were abstracted from medical records. Multivariate models regressed MDADI scores on late LCNP status adjusting for clinical covariates.

RESULTS

Overall, 4.0% (n = 36) of respondents developed late LCNP with median time to onset of 5.25 years post-treatment. LCNP cases reported significantly worse mean composite MDADI (LCNP: 68.0 vs no LCNP: 80.2; P < .001). Late LCNP independently associated with worse mean composite MDADI (β = -6.7, P = .02; 95% confidence interval [CI], -12.0 to -1.3) as well as all MDADI domains after multivariate adjustment. LCNP cases were more likely to have a feeding tube at time of survey (odds ratio [OR] = 20.5; 95% CI, 8.6-48.9), history of aspiration pneumonia (OR = 23.5; 95% CI, 9.6-57.6), and tracheostomy (OR = 26.9; 95% CI, 6.0-121.7).

CONCLUSIONS

In this large survey study, OPC survivors with late LCNP reported significantly poorer swallowing-related QOL and had significantly higher likelihood of poor functional status. Further efforts are necessary to optimize swallowing outcomes to improve QOL in this subgroup of survivors.

Xerostomia-related quality of life for patients with oropharyngeal carcinoma treated with proton therapy

PURPOSE

We report longitudinal patient-reported quality-of-life (QoL) outcomes related to xerostomia in patients with oropharyngeal cancer treated with intensity-modulated proton therapy (IMPT).

MATERIALS AND METHODS

Patients treated from May 2012 through December 2016 at a single institution for AJCC7 stage III-IV, M0 oropharyngeal cancer were given the 15-item Xerostomia-Related QoL Scale (XeQoLS) before, during, and for up to 2 years after treatment. We evaluated the evolution of xerostomia-related QoL over that time, and examined potential associations between those measures with clinical characteristics.

RESULTS

Sixty-nine patients had XeQoLS scores at baseline and at least once either during or after treatment. The mean (±SD) XeQoLS score (0-4) was 0.24 ± 0.57 at baseline. Subsequent scores were 2.00 ± 1.01 at 6 weeks on treatment, and 1.03 ± 0.76, 0.97 ± 0.78, 0.82 ± 0.69, and 0.70 ± 0.75 at 10 weeks, 6 months, 1 year, and 2 years after treatment, respectively. All were statistically different from baseline (p < 0.001). Univariate analyses demonstrated associations between XeQoLS score and time (p < 0.0001 for each interval), baseline XeQoLS score (p < 0.0001), stage (p = 0.008), N status (p = 0.006), and mean oral cavity dose (p = 0.038), but not for age, sex, T status, receipt of chemotherapy, smoking history, disease site, laterality of neck irradiation, mean parotid dose, or mean submandibular dose. Multivariate analysis suggested that baseline XeQoLS scores, phase of treatment, and N status were associated with XeQoLS scores measured during treatment and recovery.

CONCLUSIONS

Patients receiving IMPT reported the greatest xerostomia-related QoL impairment at 6 weeks on treatment, with a 49% improvement by 10 weeks after treatment; however, XeQoLS scores remained above baseline after 2 years. As we aim to establish the value of IMPT in oropharyngeal tumors to de-intensify treatment over conventional therapy, these data help inform discussions about xerostomia-related quality of life for patients with oropharyngeal cancer treated with IMPT.

Long-Term Aspects of Quality of Life in Head and Neck Cancer Patients Treated With Intensity Modulated Radiation Therapy: A 5-Year Longitudinal Follow-up and Comparison with a Normal Population Cohort

Purpose

Knowledge of long-term health-related quality of life (HRQOL) in patients with advanced head and neck cancer treated with intensity modulated radiation therapy is scarce.

Methods and Materials

HRQOL in 126 patients with advanced head and neck cancer treated with intensity modulated radiation therapy was followed longitudinally from diagnosis to 5 years after treatment with the European Organization for Research and Treatment of Cancer's QLQ-C30, the European Organization for Research and Treatment of Cancer's Head and Neck Cancer Module, and the M.D. Anderson Dysphagia Inventory. The survivors' HRQOL was compared with an age- and sex-matched normal population cohort.

Results

At 5 years, 73 of the 95 surviving patients had completed the study. Significant reductions in general pain (29 vs 12), head and neck (HN) pain (22 vs 14), and feeling ill (20 vs 10) were found, and emotional functioning (70 vs 83) and global quality of life (67 vs 74) improved, compared with baseline values. Conversely, dry mouth (19 vs 56), senses (8 vs 27), teeth problems (10 vs 22), opening mouth (19 vs 56), and sticky saliva (15 vs 40) were markedly worse, although significant improvements had occurred over time after treatment. Anderson Dysphagia Inventory scores >80 at 5 years indicated good swallowing function. In a subgroup analysis, dry mouth and senses were significantly better in patients treated with chemoradiotherapy. Comparison to a normal population cohort's HRQOL shows that the study group experienced a wide array of symptoms affecting their quality of life.

Conclusions

The results of this large, long-term follow-up study show that a majority of patients report a reasonable quality of life 5 years after treatment and that there seems to be continuous improvement over time. Comparison with a normal population cohort, however, underlines the fact that classical side effects remain, even with improved radiation techniques. Additional emphasis on normal-tissue-sparing radiation therapy is warranted, with close attention devoted to HRQOL outcomes.

Rates of Dysphagia-Related Diagnoses in Long-Term Survivors of Head and Neck Cancers

OBJECTIVE

To estimate long-term prevalence of new dysphagia-related diagnoses in a large cohort of head and neck cancer survivors.

STUDY DESIGN

Retrospective cohort.

SETTING

Population based.

SUBJECTS AND METHODS

In total, 1901 adults diagnosed with head and neck cancer between 1997 and 2012 with at least 3 years of follow-up were compared with 7796 controls matched for age, sex, and birth state. Prevalence of new dysphagia-related diagnoses and procedures and hazard ratio compared to controls were evaluated in patients 2 to 5 years and 5 years and beyond after diagnosis. Risk factors for the development of these diagnoses were analyzed.

RESULTS

Prevalence of new diagnosis and hazard ratio compared to controls remained elevated for all diagnoses throughout the time periods investigated. The rate of aspiration pneumonia was 3.13% at 2 to 5 years, increasing to 6.75% at 5 or more years, with hazard ratios of 9.53 (95% confidence interval [CI], 5.08-17.87) and 12.57 (7.17-22.04), respectively. Rate of gastrostomy tube placement increased from 2.82% to 3.32% with hazard ratio remaining elevated from 51.51 (13.45-197.33) to 35.2 (7.81-158.72) over the same time period. The rate of any dysphagia-related diagnosis or procedure increased from 14.9% to 26% with hazard ratio remaining elevated from 3.32 (2.50-4.42) to 2.12 (1.63-2.75). Treatment with radiation therapy and age older than 65 years were associated with increased hazard ratio for dysphagia-related diagnoses.

CONCLUSION

Our data suggest that new dysphagia-related diagnoses continue to occur at clinically meaningful levels in long-term head and neck cancer survivors beyond 5 years after diagnosis.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

2b.

Single-item discrimination of quality-of-life-altering dysphagia among 714 long-term oropharyngeal cancer survivors: Comparison of patient-reported outcome measures of swallowing

BACKGROUND

Two patient-reported outcomes (PROs) of swallowing and their correlation to quality of life (QOL) were compared in long-term survivors of oropharyngeal cancer (OPC).

METHODS

Scores on the single dysphagia item from the 28-item, multisymptom MD Anderson Symptom Inventory-Head and Neck (MDASI-HN-S) were compared with scores on the dysphagia-specific composite MD Anderson Dysphagia Inventory (MDADI) and the EuroQol visual analog scale (EQ-VAS) in 714 patients who had received definitive radiotherapy ≥12 months before the survey. An MDASI-HN-S score ≥6 and an MDADI composite score <60 were considered representative of moderate/severe swallowing dysfunction.

RESULTS

Moderate/severe dysphagia was reported by 17% and 16% of respondents on the MDASI-HN-S and the composite MDADI, respectively. Both swallow PROs were predictive of QOL, and the MDASI-HN-S model was slightly more parsimonious for the discrimination of EQ-VAS scores compared with MDADI scores (Bayesian information criteria, 6062 vs 6076, respectively). An MDASI-HN-S cutoff score of ≥6 correlated best with a declining EQ-VAS score (P < .0001) and was associated with increased radiotherapy dose to several normal swallowing structures.

CONCLUSIONS

In this cohort, the single-item MDASI-HN-S performed favorably for the discrimination of QOL compared with the multi-item MDADI. A time-efficient model for PRO measurement of swallowing is proposed in which the MDADI may be reserved for patients who score ≥6 on the MDASI-HN-S.

Objective and subjective hyposalivation after treatment for head and neck cancer: Long-term outcomes

OBJECTIVES/HYPOTHESIS

This study examined saliva weight over time and its association with diet and patient-rated swallowing, dry mouth, sticky saliva, and dysgeusia quality of life in head and neck cancer (HNCA) patients treated with surgery plus adjuvant chemoradiotherapy (CRT), or primary CRT.

STUDY DESIGN

Prospective cohort study in an outpatient HNCA center setting.

METHODS

Patients were seen pretreatment, and 1, 3, 6, 12, 24, and 36 + months post-treatment. All had newly diagnosed oral, oropharynx, nasopharynx, larynx/hypopharynx cancer from 2010 to 2016 and were to undergo surgery + CRT or primary CRT. Stimulated saliva weight was assessed with the Saxon test. Diet, eating, dry mouth, and dysgeusia quality of life were assessed and correlated with saliva weight, treatment modality, and tumor site.

RESULTS

Saliva weight decreased the most within the first 3 months across treatment groups, except for the surgery + CRT group, which continued to decline. Similar trends were seen by tumor site. Performance Status Scale (PSS) Normalcy of Diet and all quality-of-life scores declined following treatment. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Head and Neck-35 (EORTC QLQ-H&N35); Eating Assessment Tool (EAT-10); M. D. Anderson Dysphagia Inventory (MDADI) Composite, Global, and subdomain scores; and PSS Diet were significantly correlated with saliva weight.

CONCLUSIONS

Saliva weight worsened post-treatment across groups and tumor site, with improvement by 36 + months. Saliva weight correlated with diet, eating quality of life and perception of dysgeusia across time points. Despite dose-sparing intensity-modulated radiation therapy, newer technologies are needed to preserve saliva production and maintain higher quality of life.

LEVEL OF EVIDENCE

2b Laryngoscope, 128:2732-2739, 2018.

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

PURPOSE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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