A systematic review of interventions for eating and drinking problems following treatment for head and neck cancer suggests a need to look beyond swallowing and trismus

The Acceptability of Behavioural Swallowing Interventions for Head and Neck Cancer Patients During Radiotherapy: A Qualitative Study Exploring Experiences of Clinical Trial Speech-Language Pathologists

The PRO-ACTIVE randomized clinical trial offers 3 swallowing therapies to Head and Neck Cancer (HNC) patients during radiotherapy (RT) namely: reactive, proactive low- ("EAT-RT" only) and high-intensity ("EAT-RT + exercises"). Understanding the experiences of the trial Speech-Language Pathologists (SLPs) will be useful to inform clinical implementation. This study assessed SLP opinions of acceptability and clinical feasibility of the 3 trial therapies. 8 SLPs from 3 Canadian PRO-ACTIVE trial sites participated in individual interviews. Using a qualitative approach, data collection and thematic analysis were guided by the Theoretical Framework of Acceptability. Member checking was conducted through a follow-up focus group with willing participants. Seven themes were derived: intervention coherence, burden, barriers/facilitators, self-efficacy, attitude, ethicality, and perceived effectiveness. SLPs felt all 3 therapies had potential benefit yet perceived more advantages of proactive therapies compared to reactive. Compared to exercises, SLPs particularly endorsed the EAT-RT component. A major barrier was keeping patients motivated, which was impacted by acute toxicity and sometimes conflicting instructions from the healthcare team. Strategies utilized by to overcome barriers included: scaling exercises and/or diet up/down according to the changing patient needs and communicating therapy goals with healthcare team. A model was derived describing the perceived acceptability of the swallowing therapies according to SLPs, based on the interconnection of main themes. Proactive therapies were perceived as more acceptable to trial SLPs, for facilitating patient engagement. The perceived acceptability of the swallowing therapies was related to seven interconnected aspects of providers' experience. These findings will inform the implementation and potential uptake of the PRO-ACTIVE swallowing therapies in clinical practice.

Speech Language Pathology interventions in the areas of breathing, chewing, swallowing and speaking: a scoping review

There are several types of approaches that can be used to achieve therapeutic goals in disorders related to the functions of mastication, swallowing, speech, and breathing. However, the literature lacks evidence to support their use in speech-language clinical practice. The objective of this review was to map the syntheses of evidence on speech-language pathology intervention in the areas of breathing, mastication, swallowing and speech in adults and the elderly. Only studies classified by their authors as a systematic review, studies that addressed therapy for orofacial disorders in individuals over 18 years of age were included. The procedures performed included: electronic and manual search; selection of studies; data extraction; evaluation of the quality of studies and data analysis. It was possible to observe different types of interventions mainly aimed at the swallowing function, ranging from traditional therapy to the use of devices. However, due to the limitations of the studies, the data must be interpreted with caution.

Managing eating problems after cancer

Cancer treatment can cause food-limiting eating problems that persist or arise months or years after treatment, with negative consequences for the survivor's nutritional status, physical and social function, and quality of life. Hence, post-treatment follow-up and cancer rehabilitation services should aim to support the survivor in managing treatment-related eating problems. This narrative review summarizes the evidence on and provides an overview of interventions to manage eating problems after cancer. Interventions are grouped into four: 1) food-based interventions, including alternating food/fluids and experimenting through the trial-and-error strategy to find tolerated foods; 2) eating behavioral interventions, including instructions on swallowing techniques, posture, and utensils; 3) psychosocial support interventions, including group-based interventions and interventions including relatives; and 4) physical interventions, including exercises to improve dysphagia or trismus. While physical interventions are supported by evidence from several intervention studies, few studies evaluating the effect of other types of interventions in survivors were identified. Instead, qualitative and observational data providing insights on experiences of and coping strategies applied by survivors with eating problems underpin the need for the other types of interventions. Since existing research primarily focuses on survivors of head and neck cancer, future studies on the organization and effects of interventions aimed at managing eating problems among different groups of survivors are relevant.

The Change in Social Eating over Time in People with Head and Neck Cancer Treated with Primary (Chemo)Radiotherapy: The Role of Swallowing, Oral Function, and Nutritional Status

This study aimed at investigating the change in social eating problems from diagnosis to 24 months after primary (chemo)radiotherapy and its associations with swallowing, oral function, and nutritional status, in addition to the clinical, personal, physical, psychological, social, and lifestyle dimensions. Adult patients from the NETherlands QUality of life and BIomedical Cohort (NET-QUBIC) treated with curative intent with primary (chemo)radiotherapy for newly-diagnosed HNC and who provided baseline social eating data were included. Social eating problems were measured at baseline and at 3-, 6-, 12-, and 24-month follow-up, with hypothesized associated variables at baseline and at 6 months. Associations were analyzed through linear mixed models. Included patients were 361 (male: 281 (77.8%), age: mean = 63.3, SD = 8.6). Social eating problems increased at the 3-month follow-up and decreased up to 24 months (F = 33.134, p < 0.001). The baseline-to-24 month change in social eating problems was associated with baseline swallowing-related quality of life (F = 9.906, p < 0.001) and symptoms (F = 4.173, p = 0.002), nutritional status (F = 4.692, p = 0.001), tumor site (F = 2.724, p = 0.001), age (F = 3.627, p = 0.006), and depressive symptoms (F = 5.914, p < 0.001). The 6-24-month change in social eating problems was associated with a 6-month nutritional status (F = 6.089, p = 0.002), age (F = 5.727, p = 0.004), muscle strength (F = 5.218, p = 0.006), and hearing problems (F = 5.155, p = 0.006). Results suggest monitoring social eating problems until 12-month follow-up and basing interventions on patients' features.

Patient-Reported Outcomes in Adolescent and Young Adult Head and Neck Cancer Survivors Treated with Radiotherapy

Purpose: There are few studies of adolescent and young adult (AYA) head and neck (H&N) cancer survivors treated with radiotherapy. A recall of AYA H&N survivors was performed and this article evaluates their cross-sectional patient-reported outcomes. Methods: AYA H&N cancer survivors who had received radiotherapy in British Columbia between 1970 and 2010 participated in this study. Participants completed the Psychosocial Screen for Cancer-Revised (PSSCAN-R), Research and Development (RAND)-36 health-related quality of life, and the Vanderbilt Head and Neck Symptom Survey, version 2.0 (VHNSS 2.0), to evaluate late effects from treatment. Results: There were 36 participants in the study. Severe symptoms (greater than or equal to 4/10) were reported on the VHNSS 2.0 by 51% of participants for xerostomia, 35% for dysphagia, and 37% for dental/mucosal sensitivity. On the PSSCAN-R, 35% had moderate/high anxiety scores and 48% had moderate/high depression scores. The mean RAND-36 participant scores were as follows: physical functioning, 86.1; physical role functioning, 71.4; emotional role functioning, 75.1; energy/fatigue, 56.6; emotional well-being, 74.6; social functioning, 76.3; bodily pain, 71.7; and general health, 65.6. Conclusions: AYA survivors in our study reported significant late effects from H&N radiotherapy and high depression and anxiety scores, but generally high health-related quality of life. Prospective evaluation of psychosocial needs and H&N-related complications is warranted in this subgroup at high risk of late effects from treatment.

Quality of Life and Aesthetic Satisfaction in Patients Who Underwent the “Commando Operation” with Pectoralis Major Myocutaneus Flap Reconstruction—A Case Series Study

The “commando operation” is an extensive surgical procedure used to treat patients with oral squamous carcinoma and metastasis in the cervical lymph nodes. While the procedure can be curative, it is also very mutilating, which consequently has a major impact on the patient’s quality of life. Several studies showed that the procedure is associated with loss of certain functions, such as impairments in speech, chewing, swallowing, and loss of taste and appetite. Furthermore, some of these impairments and their degree depend on the reconstruction method. However, the data regarding the functional impairments and aesthetic results in patients who underwent the “commando operation” along with the pectoralis major myocutaneus flap reconstruction are still inconclusive. This study included 34 patients that underwent partial glossectomy, ipsilateral modified radical neck dissection, pectoralis major myocutaneus flap reconstruction, and adjuvant radiotherapy. A structured questionnaire was used to evaluate aesthetical results and functional impairments as well as to grade the level of satisfaction with the functional and aesthetic outcomes both by the patients and by the operator. Most of the patients stated that their speech (N = 33; 97%) and salivation (N = 32; 94.2%) severely changed after the operation and that they cannot chew (N = 33; 97%) and swallow (N = 33; 97%) the same as before the operation. Moreover, almost half of the patients (N = 16; 47%) reported that they have severe sleep impairments. However, only few of the included patients stated that they sought professional help regarding the speech (N = 4; 11.7%), eating (N = 5; 14.7%), and sleeping (N = 4; 11.7%) disturbances. Additionally, there was a statistically significant difference between the operator and the patients in the subjective assessment of the aesthetic results (p = 0.047), as operators gave significantly better grades. Our results imply that this procedure and reconstructive method possibly cause impairments that have an impact on the patients’ wellbeing. Moreover, our outcomes also suggest that patients should be educated and rehabilitated after the “commando operation” since most of them were reluctant to seek professional help regarding their impairments. Lastly, sleep deficiency, which was observed after the procedure, should be further explored.

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.

The role of folded fibular flap in patients' reconstruction of mandibular defects: a retrospective clinical study

This study has analyzed 41 patients with mandibular ameloblastoma who underwent a partial mandibulectomy and reconstruction by folding the free fibular flap. In the preoperative and postoperative (6 months and 24 months after surgery), the Quality of Life (QOL) of these patients was assessed by using the University of Washington Quality of Life Questionnaire (UW-QOL) and the medical outcome study short form-36 (SF-36) questionnaires. SPSS 20.0 statistical software was used to conduct statistical analysis on the base data of the two groups of patients. Independent sample t test was conducted for sf-36 and UW-QOL scores at two time points in each group. The SF-36 survey showed that body pain (54.54 ± 8.10), general health (55.27 ± 7.54), and health changes (58.29 ± 9.60) decreased significantly at 6 months after surgery, but the mean score at 24 months after surgery all exceeded the preoperational level. At 24 months after the surgery, the vitality (80.41 ± 3.74), social function (81.61 ± 4.07), emotional role (82.39 ± 4.07), psychological health (81.66 ± 4.37) and total score (704.00 ± 31.53) all returned to the preoperative level, which was statistically significant compared with 6 months after surgery. However, there was no significant difference compared with the preoperative level. The UW-QOL survey showed that chewing (56.68 ± 7.23), speech (54.54 ± 7.7) and taste (62.29 ± 10.15) have significantly changed at 6 months after the surgery, and the difference was statistically significant at 24 months after surgery. Saliva generation decreased slightly (80.76 ± 3.35) at 6 months after surgery, but quickly returned to the preoperative level (81.59 ± 4.06). The total score of the patients almost recovered to the preoperative level at 24 months after surgery. The folded the fibular flap can not only repair the defects of soft tissue and bone tissue, but also restore the height of the alveolar ridge to, avoid the imbalance of crown and root ratio after implantation and reduce the occurrence of peri-implant inflammation, so that a true functional reconstruction can be realized.

Adherence to Home-Based Swallowing Therapy Using a Mobile System in Head and Neck Cancer Survivors

Purpose A large knowledge gap related to dysphagia treatment adherence was identified by a recent systematic review: Few existing studies report on adherence, and current adherence tracking relies heavily on patient self-report. This study aimed to report weekly adherence and dysphagia-specific quality of life following home-based swallowing therapy in head and neck cancer (HNC). Method This was a quasi-experimental pretest-posttest design. Patients who were at least 3 months post-HNC treatment were enrolled in swallowing therapy using a mobile health (mHealth) swallowing system equipped with surface electromyography (sEMG) biofeedback. Participants completed a home dysphagia exercise program across 6 weeks, with a target of 72 swallows per day split between three different exercise types. Adherence was calculated as percent trials completed of trials prescribed. The M. D. Anderson Dysphagia Inventory (MDADI) was administered before and after therapy. Results Twenty participants (75% male), with an average age of 61.9 years (SD = 8.5), completed the study. The majority had surgery ± adjuvant (chemo)radiation therapy for oral (10%), oropharyngeal (80%), or other (10%) cancers. Using an intention-to-treat analysis, adherence to the exercise regimen remained high from 84% in Week 1 to 72% in Week 6. Radiation therapy, time since cancer treatment, medical difficulties, and technical difficulties were all found to be predictive of poorer adherence at Week 6. A statistically significant improvement was found for composite, emotional, and physical MDADI subscales. Conclusions When using an mHealth system with sEMG biofeedback, adherence rates to home-based swallowing exercise remained at or above 72% over a 6-week treatment period. Dysphagia-specific quality of life improved following this 6-week treatment program.

Effect of Physical Therapy Modalities on Quality of Life of Head and Neck Cancer Survivors: A Systematic Review with Meta-Analysis

The objective was to describe the effectiveness of different physical therapy modalities to improve Quality of Life (QoL) in Head and Neck Cancer (HNC) survivors. PubMed, Scopus, Web of Science, CINAHL and Cochrane Library were searched for randomized clinical controlled trials published until 30 April 2020. Risk of bias assessment and meta-analysis were conducted using the Cochrane tools. A total of 251 records were retrieved, and 10 met the inclusion criteria. Interventions whose parameters focus on a 12-week exercise programs of aerobic activity (walking) or Progressive Resistance Training (PRT) for the whole body are effective and safe modalities improving QoL in HNC survivors. Electrophysical agents did not show significant results between groups. As for the assessment of methodological quality, 4 of the 10 articles included had a high risk of overall bias. Only five articles provided sufficient information to conduct a meta-analysis for exercise program intervention on QoL, showing a tendency in favor of intervention group, even when the global results did not show statistically significant improvements (pooled Cohen's d 0.15; 95% CI: -0.25 to 0.54; I² 45.87%; p heterogeneity = 0.10). The present review and meta-analysis identified meaningful benefits of exercise on QoL of HNC survivors; this has been confirmed in a meta-analysis. This review adds evidence supporting exercise interventions on Head and Neck Cancer population whose opportunities for successful recovery after medical treatment are more limited.

The combination of traditional and auricular acupuncture to prevent xerostomia and anxiety in irradiated patients with HNSCC: a preventive, parallel, single-blind, 2-arm controlled study

OBJECTIVE

The purpose of the present study was to investigate the effect of acupuncture on xerostomia in irradiated patients with head and neck squamous cell carcinoma (HNSCC).

STUDY DESIGN

A preventive, 2-arm, parallel, single-blind trial was performed. Patients with HNSCC (N = 296) were checked for eligibility, and 107 patients were enrolled in the study. The study comprised 1 group that did not receive the intervention (n = 55) and the interventional group that received traditional and auricular acupuncture (n = 52). The primary outcome was the reduction of the patients' xerostomia after treatment. In addition, the secondary outcome was the reduction of anxiety.

RESULTS

The current acupuncture protocol reduced the xerostomia score and increased saliva volume and density without changing salivary pH. Additionally, acupuncture decreased the Beck Anxiety Inventory (BAI) score after radiation therapy.

CONCLUSION

Combining traditional and auricular acupuncture reduced xerostomia and increased saliva volume without changing the saliva's pH in irradiated patients with HNSCC. Additionally, the combination of traditional and auricular acupuncture reduced BAI scores.

Head and Neck Cancer Treatments from Chemotherapy to Magnetic Systems: Perspectives and Challenges

BACKGROUND

Cancer is one of the diseases causing society's fears as a stigma of death and pain. Head and Neck Squamous Cell Carcinoma (HNSCC) is a group of malignant neoplasms of different locations in this region of the human body. It is one of the leading causes of morbidity and mortality in Brazil, because these malignant neoplasias, in most cases, are diagnosed in late phases. Surgical excision, chemotherapy and radiotherapy encompass the forefront of antineoplastic therapy; however, the numerous side effects associated with these therapeutic modalities are well known. Some treatments present enough potential to help or replace conventional treatments, such as Magnetic Hyperthermia and Photodynamic Therapy. Such approaches require the development of new materials at the nanoscale, able to carry out the loading of their active components while presenting characteristics of biocompatibility mandatory for biomedical applications.

OBJECTIVE

This work aims to make a bibliographical review of HNSCC treatments. Recent techniques proven effective in other types of cancer were highlighted and raised discussion and reflections on current methods and possibilities of enhancing the treatment of HNSCC.

METHOD

The study was based on a bibliometric research between the years 2008 and 2019 using the following keywords: Cancer, Head and Neck Cancer, Chemotherapy, Radiotherapy, Photodynamic Therapy, and Hyperthermia.

RESULTS

A total of 5.151.725 articles were found, 3.712.670 about cancer, 175.470 on Head and Neck Cancer, 398.736 on Radiotherapy, 760.497 on Chemotherapy, 53.830 on Hyperthermia, and 50.522 on Photodynamic Therapy.

CONCLUSION

The analysis shows that there is still much room for expanding research, especially for alternative therapies since most of the studies still focus on conventional treatments and on the quest to overcome their side effects. The scientific community needs to keep looking for more effective therapies generating fewer side effects for the patient. Currently, the so-called alternative therapies are being used in combination with the conventional ones, but the association of these new therapies shows great potential, in other types of cancer, to improve the treatment efficacy.

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.

Impact of exercise with TheraBite device on trismus and health-related quality of life: A prospective study

Trismus is a common symptom in patients with head and neck cancer that affects many aspects of daily life negatively. The aim of this study was to investigate the impact of structured exercise with the jaw-mobilizing device TheraBite on trismus, trismus-related symptomatology, and health-related quality of life (HRQL) in patients with head and neck cancer. Fifteen patients with trismus (maximum interincisal opening [MIO] ≤35 mm) after oncologic treatment for head and neck cancer, underwent a 10-week exercise program with the TheraBite device and were followed regularly. Time between oncologic treatment and start of TheraBite exercise ranged from 0.7 to 14.8 years (average 6.2 years). MIO, trismus-related symptoms, and HRQL was assessed before and after exercise and after 6 months. A significant improvement in MIO was observed post-exercise (3.5 mm, 15.3%, p = 0.0002) and after 6-month of follow-up (4.7 mm, 22.1%, p = 0.0029). A statistically significant correlation was found between increased MIO and fewer trismus-related symptoms. In conclusion, exercise with TheraBite improved MIO and trismus-related symptoms in patients with trismus secondary to head and neck cancer. Structured exercise with the jaw-mobilizing device seems to be beneficial for patients with trismus independent of time since oncologic treatment.

Efficacy of stress management program for depressive patients with advanced head and neck cancer: A single-center pilot study

Background/Objective

Patients with head and neck cancer (HNC) have some problems such as dysfunction of breathing, eating, and/or speaking. The aim of this study was to examine efficacy of the stress management program for HNC patients (SMAP-HNC) compared with usual care (UC).

Method

We conducted a pilot study of SMAP-HNC for depressive HNC patients between January 2016 and March 2018. The program contains psychoeducation, stress coping training, and operant reinforcement. The outcome measure was the Hospital Anxiety and Depression Scale (HADS), Functional Assessment of Cancer Therapy (FACT), and Brief Coping Inventory (COPE).

Results

Twenty patients were randomly assigned to SMAP-HNC and UC group. Although a small sample sizes, there was no significant difference of depression score change between SMAP-HNC and UC group (Hedges’d g -0.83; 95% CI -1.80 to 0.13).

Conclusions

It was the first study to conduct stress management program for HNC patients. Unfortunately, our trial designed as a randomized controlled trial is underpowered to make conclusion as to the efficacy of SMAP-HNC. However, there are some valuable suggestions to modify the stress management program in future.

Head and Neck Cancers, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology

Treatment is complex for patients with head and neck (H&N) cancers with specific site of disease, stage, and pathologic findings guiding treatment decision-making. Treatment planning for H&N cancers involves a multidisciplinary team of experts. This article describes supportive care recommendations in the NCCN Guidelines for Head and Neck Cancers, as well as the rationale supporting a new section on imaging recommendations for patients with H&N cancers. This article also describes updates to treatment recommendations for patients with very advanced H&N cancers and salivary gland tumors, specifically systemic therapy recommendations.

Social participation in head and neck cancer survivors with swallowing disorder: World Health Organization Disability Assessment Schedule 2.0 study

BACKGROUND

Social function and quality of life were negatively impacted by the sequelae of treatment for the disease in the head and neck cancer survivor with swallowing disorder.

METHOD

Data from a total of 1023 survivors between July 2012 and November 2017 were collected from the Taiwan Data Bank of Persons with Disability. Nonparametric rank F test was used to analyze the influence of different variables on social participation.

RESULTS

(a) All WHODAS (World Health Organization Disability Assessment Schedule) 2.0 scores revealed significantly increased difficulty when swallowing impairment increased (P < .001). (b) Unemployment, institutionalization, severity of swallowing impairment, cancer sites, and WHODAS 2.0 score of domains 1 to 4 were negatively related to social participation, while living in rural area is related to increased social participation.

CONCLUSIONS

Social participation was negatively affected by many variables in this population. Among these variables, cancer sites and WHODAS 2.0 score of domains 1 to 4 were the strongest factors.

Interactive website for head and neck cancer patients: Adherence and coping program to prevent dysphagia after radiation

INTRODUCTION

Pharyngeal and laryngeal cancers are highly curable; however survivors are at high risk for long-term dysphagia after radiation. To address lack of access to preventive care in community settings, we developed a responsive web-based application to help patients adhere to preventive swallowing exercises and cope with radiation side effects. We conducted an interim study analysis to determine website usage characteristics and to examine the effect size for future trials.

METHODS

Pharyngeal and laryngeal cancer patients were recruited for enrollment by speech language pathologists before primary radiation and introduced to the interactive website. The program (English and Spanish) features tracking logs for preventive exercises, instructional videos, patient stories and search features. Patients' self-reported swallowing function was assessed with the MD Anderson Dysphagia Inventory (MDADI) at baseline and at 6 months. Adherence to preventive exercises was assessed during the 10 week intervention. Number of unique website visits, total duration of website exposure, and rankings of the most popular webpages were calculated. Preliminary regression models were run using adherence and MDADI as outcomes.

RESULTS

Of the 160 enrolled, 96 had 10-week adherence data and 61 had 6-month MDADI data. The average age was 63 (SD = 12.26), 49.4% were from rural counties, 44% had a high school education or lower, and 42% reported annual income of $30,000 or less. The average number of visits was 5.49 (SD = 9.96) and the average total time spent with the website was 41.09 min (SD =88.48). Preliminary analyses indicated that number of unique visits to the website was independently associated with increased adherence to preventive exercises (p = .001-.008).

CONCLUSION

Our website showed significant effects in promoting adherence to swallowing exercises. However, our return visit rate showed that the platform needs improvement in navigability and usability for this older population undergoing challenging treatment in community settings with low resources.

Patients' Perspectives on What Makes a Better Care Experience While Undergoing Treatment for Oropharyngeal Dysphagia Secondary to Head and Neck Cancer

Patients' perceptions on what makes a better care experience for head and neck cancer (HNca) have not been widely sought. Patients' perceptions can play a crucial role in shaping quality care and client involvement. To investigate patients' perspectives on what makes a better care experience while undergoing rehabilitation for oropharyngeal dysphagia secondary to HNca. Qualitative data were collected in the form of semi-structured interviews from eight patients after they had undergone rehabilitation for HNca. The data were thematically analysed by two researchers independently. Six themes, plus subthemes, were identified. These themes were Supportive network is essential; Reassurance from staff professionalism; Access to service; Using own motivation and resilience; Receiving the right information and Ongoing shock and adjustment. Results are discussed in context of the literature and clinical implications and future research are recommended. Collation of patients' perspectives is valuable to increase insight into what makes a better rehabilitative journey for patients with HNca. Rehabilitation that is holistic, specialised and patient-specific is highly valued by patients with HNca.

Efficacy of exercise therapy during radiotherapy to prevent reduction in mouth opening in patients with head and neck cancer: A randomized controlled trial

OBJECTIVE

The aim of this study was to compare the efficacy of 2 protocols of exercise therapy to avoid reduction in mouth opening (MO) in patients undergoing radiotherapy for head and neck cancer.

STUDY DESIGN

This was a randomized, controlled, double-blind, 3-arm, parallel-group, prevention clinical trial. Ninety patients were randomized into 3 groups to perform exercises during radiotherapy treatment: intervention group 1 (G1); intervention group 2 (G2); and control group (CG). Maximum MO was measured before (T0), immediately after (T1), and at 12 months (T2) after completion of radiotherapy treatment. Generalized estimating equations model complemented by the least significant difference test was applied to group comparisons.

RESULTS

There was no significant difference in MO measure between the groups at the 3 assessment time points (P = .264). The difference in MO measure from baseline to 12 months after having completed radiotherapy was -1 mm in CG (95% confidence interval [CI] -4.0 to 2.0); 1.3 mm in G1 (95% CI -1.7 to 4.3); and 0.5 mm in G2 (95% CI -3.4 to 4.4).

CONCLUSIONS

It was not possible to conclude that the exercise protocols performed in this study are more effective than the usual guidance to prevent reduction in MO in patients undergoing radiotherapy for head and neck cancer.

Evaluation of velopharyngeal function using high-speed cine-magnetic resonance imaging based on T2-weighted sequences: a preliminary study

The objective was to introduce a new technique for visualizing the three-dimensional (3D) movements of velopharyngeal-related muscles using high-speed cine-magnetic resonance imaging (MRI) based on T2-weighted sequences. The evaluation of phonation- and water swallowing-related events was performed in 11 healthy subjects. Specifically, whether cine-MRI could precisely visualize normal velopharyngeal function during these two events was examined. The 3D movements of the soft palate, superior pharyngeal constrictor muscles, and levator veli palatini muscles were visualized in all 11 subjects. A noteworthy finding was that the magnetic resonance signals of the superior constrictor pharyngeal muscles and the levator veli palatini muscles were significantly higher during phonation and during water swallowing than at rest. This initial study suggests that the 3D movements of velopharyngeal-related muscles can be successfully and precisely visualized without side effects. The magnetic resonance signal changes seen in the superior pharyngeal constrictor and levator veli palatini muscles using the technique described here should be useful to develop better methods of evaluation of velopharyngeal function.

To eat is to practice-managing eating problems after head and neck cancer

PURPOSE

The purpose of this qualitative study was twofold: (1) to explore head and neck cancer (HNC) survivors' experiences of everyday life with eating problems after cancer treatment and (2) to explore their experiences of participating in a multidisciplinary residential rehabilitation program with a primary focus on physical, psychological, and social aspects of eating problems after treatment.

METHODS

Semi-structured focus group interviews were conducted with 40 Danish HNC survivors who participated in a 5-day residential rehabilitation program with follow-up after 3 months. The transcribed interviews were analyzed through qualitative content analysis.

RESULTS

Physical nutrition impact symptoms and unmet needs for support were frequent. Participants experienced a feeling of loss due to impaired eating abilities. Eating had become an obligation or a training situation, and the eating problems challenged the relationship with their relatives when well-meaning encouragement was perceived as a pressure. Social eating was a challenge, and this often led to social withdrawal. The residential program was a safe and supportive environment to practice eating skills, and participants benefited from meeting peers. The program provided participants with knowledge and skills that many of them had been missing during and after treatment.

CONCLUSIONS

Eating problems after treatment have substantial effects on the everyday life of HNC survivors. A multidisciplinary residential rehabilitation program may be beneficial to meet their rehabilitation needs.

IMPLICATIONS FOR CANCER SURVIVORS

The results are useful for future planning of rehabilitation services and clinical studies that may contribute to improving current clinical practice and benefit HNC survivors.

Effects of jaw exercise intervention timing on outcomes following oral and oropharyngeal cancer surgery: Pilot study

BACKGROUND

Common in head and neck cancer patients, trismus can make speech and swallowing difficult and can compromise quality of life (QOL). Jaw range of motion exercise therapy may prevent or treat trismus in surgical patients. While the importance of these exercises is well-documented, there is little literature regarding the optimal timing of exercise initiation.

METHODS

A prospective pilot study investigated the effects of early vs late jaw exercise intervention on postoperative jaw opening and QOL measures, which were examined descriptively.

RESULTS

Timing of exercise intervention was not found to significantly impact the measured outcomes. However, provisional, descriptive findings showed that jaw opening was significantly associated with multiple QOL measures, with greater jaw opening associated with improved QOL. For certain QOL measures, this positive association was stronger at earlier time points than at later time points.

CONCLUSIONS

The exploratory findings of this pilot study support further research into possible benefits of early jaw exercise intervention.

Using experience-based co-design to improve the pre-treatment care pathway for people diagnosed with head and neck cancer

BACKGROUND

Recent studies have highlighted that people diagnosed with head and neck cancer (HNC) have complex information needs. They are subject to multiple clinical appointments with numerous healthcare professionals in preparation for their treatment. Speech and language therapists (SLTs) are core members of the HNC multidisciplinary team, providing assessment, prehabilitation and counselling regarding potential treatment effects on the critical functions, including swallowing and communication. We believed the purpose of the pre-treatment speech-language therapy (SLT) consultation within this pathway is not well understood by patients. Whilst the benefits of prophylactic swallowing exercise prescriptions continue to be explored, adherence is a frequently cited challenge in clinical trials. We sought to enhance pre-treatment dysphagia services for patients with head and neck cancer (HNC) undergoing chemoradiation.

METHODS

A participatory action research approach called experience-based co-design (EBCD) was undertaken at a tertiary cancer hospital in the UK. People who had previous radical radiation treatment for head and neck cancer and staff members within the head and neck unit were recruited to take part in in-depth, one-to-one interviews about their experiences of the pre-treatment SLT head and neck radiation clinic. Patient interviews were video-recorded, analysed and edited down to a 30 min 'trigger' film. At a subsequent patient feedback event, the film was shown and an 'emotional mapping' exercise was undertaken. Through facilitated discussion, patient priorities for change were agreed and recorded. At a staff feedback event, key themes from the staff interviews were discussed and priority areas for change identified. The project culminated in a joint patient and staff event where the film was viewed, experiences shared and joint priorities for change agreed. Task and finish groups were developed to implement these changes.

RESULTS

Seven patients and seven staff members participated. All seven patients had undergone radical (chemo-) radiation for HNC. At least 2 months had elapsed since their final treatment date and all participants were within 9 months of their definitive treatment. Staff members comprised a radiation oncologist, two clinical nurse specialists, two head and neck dietitians and two speech-language therapists. Patients reported that overall, their experience of the pre-treatment clinic is positive. Patients value experienced staff, consistency of staff and the messages they provide and a team approach. Patients highlighted the need for different information methods including online/digital information resources and further information regarding the longer-term effects of treatment. Patients valued the purposes of prophylactic exercises and again advocated for supporting resources to be available in a range of online/digital media. Staff members raised the need for flexibility in appointment times and clearer messaging as to the rationale for a pre-treatment SLT appointment, including a rebranding of the SLT service. Seven key areas for improvement were identified jointly by patients and staff members including revision of patient and carer information, development of a patient experience video, information on timelines for recovery, a buddy system for patients before, during and after treatment, flexibility of appointment scheduling, seamless transfer of care between settings and SLT department rebranding. Joint patient and staff task and finish groups were initiated to work on these seven priority areas.

CONCLUSIONS

We have worked in partnership with patients to co-design pre-treatment dysphagia services which are accessible and meet the individuals' needs. Task and finish groups are ongoing with staff and patients are working together to address priority areas for change. This work provides a good example for other centres who may wish to engage in similar activities.

The experience of head and neck cancer survivorship (including laryngectomy): an integrated biopsychosocial model

PURPOSE OF REVIEW

The head and neck cancer (HNC) survivorship experience is unique among cancer populations. This review seeks to explore the HNC survivor experience associated with altered upper aerodigestive tract (UADT) function using principles of survivorship.

RECENT FINDINGS

HNC survivors experience complex physical, functional, and psychosocial challenges related to UADT dysfunction. Interventions need to address all of these dimensions being mindful of the survivor experience. Studies reveal related unmet needs of both HNC survivors and their family members. An expose of the HNC survivorship experience is timely since 2016/2017 contains the release of landmark position papers and guidelines in the field. These address the unique challenges faced by the HNC population, their management, and the triad psychosocial, functional, and physical survivor burden. Such developments will drive future care.

SUMMARY

The head and neck survivorship experience is characterized by complex changes with broad impact when examined in an experiential framework. HNC survivor care demands clinical excellence from multiple disciplines that are positioned to enact recent HNC guidelines and adopt survivorship principles. Future research in this population that explores experiential aspects of altered UADT function would be valuable in informing clinical practice. A biopsychosocial framework is presented for conceptualizing the HNC survivorship experience.

Impact of a behavior change program and health education on social interactions in survivors of head and neck cancer: Randomized controlled trial

OBJECTIVE

The purpose of this study of survivors of head and neck cancer was to evaluate the effects of a behavior change program and health education on depression, fear of social interactions, avoidance of social interactions, physical function, and social-emotional function.

METHODS

This was a randomized controlled trial of 100 subjects, in which changes in the scores of several psychometric scales were recorded for an experimental group (behavior change program and health education) and a control group (routine care only). Assessments were performed at baseline (T0), and at 1 month (T1), 2 months (T2), and 3 months (T3) after completing the intervention.

RESULTS

After the intervention, the experimental group reported significantly less fear of social interactions, less avoidance of social interactions, and better physical function than the control group. The experimental group also had less depression at T3 than at T0, although there was no such change in the control group. Analysis of physical function indicated that both groups experienced improvements from T0 to T1, slight declines from T1 to T2, and slight declines from T2 to T3; however, both groups had significantly better physical function at T3 than at T0.

CONCLUSIONS

Head and neck cancer patients who received a behavior change program and health education reported less fear of social interactions, less avoidance of social interactions, and improved physical function during the 3 months after this intervention.

Electronic Swallowing Intervention Package to Support Swallowing Function in Patients With Head and Neck Cancer: Development and Feasibility Study

Background

Many patients undergoing treatment for head and neck cancer (HNC) experience significant swallowing difficulties, and there is some evidence that swallowing exercises may improve outcomes, including quality of life. This feasibility study developed an evidence-based, practical Swallowing Intervention Package (SiP) for patients undergoing chemoradiotherapy (CRT) for HNC. As part of the study, an electronic version of SiP (e-SiP) was concurrently developed to support patients to self-manage during treatment. This paper reports on the e-SiP component of this work.

Objective

The objective of our study was to develop and conduct a preliminary evaluation of an electronic support system (e-SiP) for patients undergoing CRT for HNC.

Methods

The study was conducted using a recognized mHealth development and evaluation framework and involved health professionals and patients who were undergoing CRT for HNC. The scoping stage of e-SiP development investigated the potential usefulness of the app, exploring how e-SiP would look and feel and what content would be appropriate to provide. Patient and carer focus groups and a health professionals’ consensus day were used as means of data gathering around potential e-SiP content. A repeat focus group looked at an outline version of e-SiP and informed the next stage of its development with regard to refining the requirements for the tool. This was followed by further development and a testing stage of e-SiP that involved the coding of a prototype, which was then evaluated using a series of steering group meetings, semistructured interviews with both patients and health care professionals, and analysis of e-SiP log data.

Results

Feedback from focus groups and health professional interviews was very positive, and it was felt e-SiP use would support and encourage patients in conducting their swallowing exercises. However, of the 10 patients who were offered e-SiP, only 2 opted to use it. For these patients, the aspects of the e-SiP app were considered useful, in particular, the ease of keeping a diary of exercises performed. Interviews with users and nonusers suggested significant barriers to its use. Most significantly, the lack of flexibility of the platform on which e-SiP could be accessed appeared a dominant factor in deterring e-SiP use.

Conclusions

The results suggest that further research needs to be conducted around the implementation of e-SiP. This involves evaluating how e-SiP can be better integrated into usual care and through patient training and staff engagement, can be perceived as a beneficial tool to help support patients in conducting swallowing exercises.

Altered eating: a definition and framework for assessment and intervention

Background

Eating can be a significant challenge for cancer survivors; however, to date there is no systematic way of assessing and addressing food related quality of life in this group. The purpose of our study was to develop a framework for doing so.

Methods

Over the course of 6 years in participant-led food workshops, we worked alongside 25 head and neck cancer (HNC) survivors and their partners, employing video-reflexive ethnographic (VRE) methods. The current study reports on data from the two summative workshops of this series where we worked with participants to cohere the emergent themes. Video and transcripts were reviewed and coded with participants and stakeholders according to domains of life that were affected by food. Three of the authors, one of whom is both survivor and researcher, arrived at the consensus framework.

Results

Seven areas of life were identified as affecting, or being affected by, altered eating. Three were physiological: anatomical, functional and sensory. Two captured the cognitive and behavioural labour of eating. Social life and identity were altered. The foregoing had an enduring emotional impact.

Conclusions

Altered eating has physical, emotional and social consequences. The altered eating framework provides a systematic way of exploring those consequences with individual survivors. This framework has the potential to improve both the assessment and treatment of altered eating, to benefit food-related quality of life.

Patient adherence to swallowing exercises in head and neck cancer

PURPOSE OF REVIEW

A younger population and improved treatments for head and neck cancer (HNC) mean that more people are now living longer with the consequences of treatment, including long-term swallowing problems (dysphagia). Exercises aim to improve swallowing function, however highly variable adherence rates are currently reported, with no standard measure of adherence.

RECENT FINDINGS

Measuring adherence to swallowing exercises depends on the definition of 'adherence', the tools used to measure adherence, and the acceptable threshold that is used to constitute adherence or nonadherence. Particular barriers to swallowing exercise adherence include the burden of treatment, the commitment required to undertake a home-based exercise programme and the difficulty in motivating patients to exercise before swallowing problems have become apparent. Findings from the wider literature on general exercise interventions highlight the importance of external and patient-related factors on adherence, including patient beliefs, social support, self-regulation and goal setting.

SUMMARY

Key barriers and motivators to adherence are presented, which will have implications for the design of future swallowing exercise interventions. The relevance of behaviour change theory in facilitating adherence is highlighted, with ongoing studies used to exemplify how behaviour change components and analysis of patient beliefs can be incorporated into intervention development.

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.

Treatment of late sequelae after radiotherapy for head and neck cancer

Radiotherapy (RT) is used to treat approximately 80% of patients with cancer of the head and neck. Despite enormous advances in RT planning and delivery, a significant number of patients will experience radiation-associated toxicities, especially those treated with concurrent systemic agents. Many effective management options are available for acute RT-associated toxicities, but treatment options are much more limited and of variable benefit among patients who develop late sequelae after RT. The adverse impact of developing late tissue damage in irradiated patients may range from bothersome symptoms that negatively affect their quality of life to severe life-threatening complications. In the region of the head and neck, among the most problematic late effects are impaired function of the salivary glands and swallowing apparatus. Other tissues and structures in the region may be at risk, depending mainly on the location of the irradiated tumor relative to the mandible and hearing apparatus. Here, we review the available evidence on the use of different therapeutic strategies to alleviate common late sequelae of RT in head and neck cancer patients, with a focus on the critical assessment of the treatment options for xerostomia, dysphagia, mandibular osteoradionecrosis, trismus, and hearing loss.

Development and pre-testing of a rehabilitation planning consultation for head-and-neck cancer

BACKGROUND

In contrast with other major chronic conditions such as heart disease and stroke, cancer care does not routinely integrate evidence-based rehabilitation services within the standard continuum. The objectives of the present project were to develop a rehabilitation planning consultation (rpc) for survivors of head-and-neck (hn) cancer, to test its feasibility, and to make refinements.

METHODS

Using intervention mapping, the rpc-alpha was developed by examining potential theoretical methods and practical applications relative to the program objectives. During feasibility testing, a single case series was conducted with survivors of hn cancer who had completed their cancer treatment within the preceding 11 months; iterative refinements were made after each case.

RESULTS

The rpc-alpha was led by a rehabilitation professional and was based on self-management principles. The initial consultation included instruction in a global cognitive strategy, goal-setting, introduction to available resources, action planning, and coping planning. A follow-up consultation was conducted a few weeks later. Of 9 participants recruited, 5 completed post-intervention assessments. Participants reported that the rpc helped them to make rehabilitation plans.

CONCLUSIONS

The rpc was feasible to use and satisfactory to a small group of hn cancer survivors. A pilot test of the refined version is in process.

Self-management strategies used by head and neck cancer survivors following completion of primary treatment: A directed content analysis

OBJECTIVE

Head and neck cancer (HNC) survivors encounter unique challenges following treatment. This study aimed to identify self-management strategies that HNC survivors use to overcome these posttreatment challenges.

METHODS

Twenty-seven individuals from 4 designated cancer centres in Ireland were interviewed about self-management strategies that helped them overcome challenges following HNC treatment. Interviews were audio-recorded, transcribed, and analysed using directed content analysis.

RESULTS

Twenty self-management strategy types (encompassing 77 specific strategies) were identified. The most frequently used self-management strategy types were self-sustaining (used by 26 survivors), self-motivating (n = 25), and proactive problem solving (n = 25). The most frequently used specific strategies were adaptive approaches to ongoing physical consequences of HNC and its treatment (n = 24), customising dietary practices (n = 24), and maintaining a positive outlook (n = 22).

CONCLUSIONS

The study identified strategies that helped HNC survivors to self-manage posttreatment challenges. This information could inform the design/development of self-management interventions tailored towards HNC survivors.

Behaviour change technique taxonomy: a method of describing head and neck cancer dysphagia intervention delivery

PURPOSE OF REVIEW

The purpose of the review is to examine the current state of the art of dysphagia intervention delivery description and to propose use of a new tool to facilitate this: the behaviour change technique taxonomy version 1 (BCTTv1).

RECENT FINDINGS

Describing intervention delivery is difficult, and published research in the field of speech and language therapy (SLT) does not include detail on this key aspect of research protocols. Interventions themselves are often poorly delineated, and a way is needed of classifying how these interventions are delivered in practice.

SUMMARY

Use of the BCTTv1 would facilitate clarity and transparency in intervention delivery description and have positive implications for research, clinical practice and undergraduate teaching if employed by the SLT profession.

Swallowing therapy and progressive resistance training in head and neck cancer patients undergoing radiotherapy treatment: randomized control trial protocol and preliminary data

BACKGROUND

Head and neck cancer (HNC) patients are often challenged by treatment induced dysphagia and trismus. Traditionally, rehabilitation is initiated when loss of function has already occurred. There is increasing evidence that it is of benefit to patients to initiate an early rehabilitation process before and during treatment. HNC patients have a unique set of functional challenges such as pre- and post-treatment dysphagia, pain and weight loss. The aim of the trial is to investigate the effects of swallowing and mouth-opening exercises combined with progressive resistance training (PRT) during radiotherapy. This report presents the protocol, interim inclusion and feasibility data.

MATERIAL AND METHODS

The trial (clinicaltrials.gov NCT02385929) is a multicenter randomized controlled trial (RCT) with a parallel-group randomization (1:1). The planned sample size of 240 HNC patients is randomly assigned to either (1) twice weekly PRT and three times weekly swallowing exercises by physio- and occupational therapists, respectively, as well as daily home exercises throughout radiotherapy or (2) standard care. Inclusion criteria are patients with cancer in the larynx, pharynx, oral cavity, or unknown primary tumor who are referred to radiotherapy with curative intent. Outcomes are measured at end-of-treatment and two, five, and 12 months post-treatment. Interim results: In 16 months, 321 HNC patients were screened for eligibility. Of these, 131 (41%) were eligible according to inclusion criteria. One-hundred-and-fifteen patients were invited to participate of which 69 (60%) were enrolled in the trial and randomized for either intervention or control group with 10 drop-outs (14%). The six pilot patients adhered more than 90% to the program.

CONCLUSION

Preliminary results show that exercise according to protocol is tolerable and feasible.

Swallowing interventions for the treatment of dysphagia after head and neck cancer: a systematic review of behavioural strategies used to promote patient adherence to swallowing exercises

BACKGROUND

Dysphagia is a significant side-effect following treatment for head and neck cancers, yet poor adherence to swallowing exercises is frequently reported in intervention studies. Behaviour change techniques (BCTs) can be used to improve adherence, but no review to date has described the techniques or indicated which may be more associated with improved swallowing outcomes.

METHODS

A systematic review was conducted to identify behavioural strategies in swallowing interventions, and to explore any relationships between these strategies and intervention effects. Randomised and quasi-randomised studies of head and neck cancer patients were included. Behavioural interventions to improve swallowing were eligible provided a valid measure of swallowing function was reported. A validated and comprehensive list of 93 discrete BCTs was used to code interventions. Analysis was conducted via a structured synthesis approach.

RESULTS

Fifteen studies (8 randomised) were included, and 20 different BCTs were each identified in at least one intervention. The BCTs identified in almost all interventions were: instruction on how to perform the behavior, setting behavioural goals and action planning. The BCTs that occurred more frequently in effective interventions, were: practical social support, behavioural practice, self-monitoring of behaviour and credible source for example a skilled clinician delivering the intervention. The presence of identical BCTs in comparator groups may diminish effects.

CONCLUSIONS

Swallowing interventions feature multiple components that may potentially impact outcomes. This review maps the behavioural components of reported interventions and provides a method to consistently describe these components going forward. Future work may seek to test the most effective BCTs, to inform optimisation of swallowing interventions.

Informational and Support Needs of Patients with Head and Neck Cancer: Current Status and Emerging Issues

The objective of this article is to review and summarize the extant literature on head and neck cancer (HNC) patients’ informational needs and to characterize emerging issues in this patient population in order to define priorities for future research. HNC patients may undergo challenging treatment regimens and experience treatment-related alterations in primary daily functions such as speech and eating. These changes often persist following treatment and may lead to significant deficits in quality of life and interpersonal relations. Despite empirical evidence demonstrating that receipt of adequate information and support is predictive of improved outcomes post-treatment, relatively limited attention has been paid to the informational and support needs of HNC patients. This review focuses primarily on three topic domains: (1) managing treatment-related side effects; (2) addressing alcohol and tobacco dependence; and (3) informational needs in the areas of human papillomavirus (HPV) and clinical trials. While there is increasing awareness of the rehabilitation and survivorship needs in this patient population, patients note that the impact of treatment on social activities and interactions is under-discussed and of key concern. In addition, there is a significant gap in addressing communication and informational needs of caregivers and family members who are integral for promoting healthy behaviors and self-care post-treatment. Greater integration of programs that address tobacco or alcohol dependency within a comprehensive treatment and support plan may increase patient motivation to seek help and enhance patient success in maintaining long-term abstinence. Finally, emerging patient-provider communication needs, particularly in the context of decision making about clinical trials or surrounding an HPV-related diagnosis, have been noted among both patients and healthcare providers. Future research on the development of novel programs that offer feasible and acceptable methods for addressing unmet informational and support needs is warranted and may yield benefit for improving patient-reported outcomes.

Prophylactic exercises among head and neck cancer patients during and after swallowing sparing intensity modulated radiation: adherence and exercise performance levels of a 12-week guided home-based program

The background and purpose of this paper is to investigate adherence, exercise performance levels and associated factors in head and neck cancer (HNC) patients participating in a guided home-based prophylactic exercise program during and after treatment [swallowing sparing intensity modulated radiation therapy (SW-IMRT)]. Fifty patients were included in the study. Adherence was defined as the percentage of patients who kept up exercising; exercise performance level was categorized as low: ≤1, moderate: 1–2, and high: ≥2 time(s) per day, on average. Associations between 6- and 12-week exercise performance levels and age, gender, tumour site and stage, treatment, intervention format (online or booklet), number of coaching sessions, and baseline HNC symptoms (EORTC-QLQ-H&N35) were investigated. Adherence rate at 6 weeks was 70% and decreased to 38% at 12 weeks. In addition, exercise performance levels decreased over time (during 6 weeks: 34% moderate and 26% high; during 12 weeks: 28% moderate and 18% high). The addition of chemotherapy to SW-IMRT [(C)SW-IMRT] significantly deteriorated exercise performance level. Adherence to a guided home-based prophylactic exercise program was high during (C)SW-IMRT, but dropped afterwards. Exercise performance level was negatively affected by chemotherapy in combination with SW-IMRT.

Therapeutic intervention in oropharyngeal dysphagia

Oropharyngeal dysphagia is a frequent consequence of several medical aetiologies, and even considered part of the normal ageing process. Early and accurate identification provides the opportunity for early implementation of dysphagia treatments. This Review describes the current state of the evidence related to dysphagia therapies - focusing on treatments most clinically utilized and of current interest to researchers. Despite successes in select studies, the level of evidence to support the efficacy of these treatments remains limited. Heterogeneity exists across studies in both how interventions are administered and how their therapeutic value is assessed, thereby making it difficult to establish external validation. Future work needs to address these caveats. Also, to be most efficacious, dysphagia therapies need to account for influences from pre-morbid patient characteristics as these factors have potential to increase the risk of dysphagia and the resulting complications of aspiration, malnutrition and psychological burden. Dysphagia therapies therefore need to incorporate the medical aetiology that is at its root, the resulting swallow physiology captured from comprehensive clinical and/or instrumental assessments, and the existing needs and supports of patients.

Trismus in oral cancer patients undergoing surgery and radiotherapy

OBJECTIVE

The aim of this study was to determine the incidence of trismus before and after surgery and subsequent radiotherapy for patients of oral cancer and to determine the risk factors for the same.

METHODS

30 patients diagnosed with oral cancer were included. Maximum mouth opening was measured for each patient as the inter incisal distance and was measured on 4 occasions - preoperatively at the time of diagnosis, post-operatively at discharge from the hospital, post-radiotherapy and at 6 months follow-up. The site of cancer, staging and grading of the malignancy, the surgical treatment performed, method of reconstruction, details of radiotherapy and compliance to physiotherapy were recorded, to evaluate the risk factors for developing trismus.

RESULTS

Trismus was observed in 53.3% patients at the time of diagnosis which increased significantly post-surgery (86.7%) and post-radiotherapy (85.7%) and gradually decreased (65.4%) at 6 months. The use of flaps for reconstruction, delay in radiotherapy post-surgery and non-compliance of patients to physiotherapy were the risk factors for developing trismus, showing statistical significance (p < 0.05).

CONCLUSION

Trismus is a significant complication of oral malignancies or its surgical and radiotherapy treatment, or both. Consideration must be given to its early diagnosis, to help in timely intervention and planning of preventive strategies.

Development and feasibility of a Swallowing intervention Package (SiP) for patients receiving radiotherapy treatment for head and neck cancer-the SiP study protocol

Background

Head and neck cancer (HNC) is the sixth most common cancer worldwide, and the functional, psychological and social consequences of HNC cancer and its treatment can be severe and chronic. Dysphagia (swallowing problems) affects up to two thirds of patients undergoing combined chemoradiotherapy. Recent reviews suggest that prophylactic swallowing exercises may improve a range of short- and long-term outcomes; however, the importance of psychological and behavioural factors on adherence to swallowing exercises has not been adequately studied. This study aims to develop and test the feasibility of a Swallowing intervention Package (SiP) designed in partnership with patients, speech and language therapists (SLTs) and other members of the head and neck multi-disciplinary team (MDT), for patients undergoing chemoradiotherapy (CRT) or radiotherapy (RT) for head and neck cancer.

Methods/design

This feasibility study uses quantitative and qualitative research methods, within a quasi-experimental design, to assess whether patients will tolerate and adhere to the SiP intervention, which aspects of the intervention can be implemented and which cannot, whether treatment fidelity can be achieved across different contexts, whether study processes and outcome measures will be feasible and acceptable and to what extent the intervention is likely to have an impact on swallowing dysfunction and quality of life. Patients are being recruited from five sites in Scotland and England (three interventions and two usual care). The SLT based in the relevant intervention centre teaches the exercise programme and provides supporting materials. A combination of patient-reported outcome measures (PROMs), adherence measures and clinical swallowing assessments are used prior to intervention (baseline), at the end of treatment, 3 and 6 months post-treatment.

Discussion

This collaborative study has taken a unique approach to the development of a patient-centred and evidence-based swallowing intervention. The introduction of an e-SiP app provides an exploration of the use of technology in delivering this intervention. The study provides an opportunity to examine the feasibility of delivering and participating in a supported swallowing intervention across several different NHS sites and will provide the evidence needed to refine intervention and study processes for a future trial.

Trial registration

NCRI portfolio, 18192 & 20259