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Landry V, Sedillot-Daniel È, Ayad T, Leclerc AA. Strategies for CO 2 Laser Use in Laryngeal Microsurgery: A Systematic Review. Otolaryngol Head Neck Surg 2024; 171:353-367. [PMID: 38529664 DOI: 10.1002/ohn.734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/21/2024] [Accepted: 02/29/2024] [Indexed: 03/27/2024]
Abstract
OBJECTIVE We aim to systematically review the literature addressing perioperative practices for optimal use of the CO2 laser in laryngeal transoral laser microsurgery (TOLMS), with a focus on safety. DATA SOURCES A systematic review of publications indexed in Medline, Embase, and EBM reviews-Cochrane Central Register of Controlled Trials which evaluated perioperative strategies for the use of CO2 laser in laryngeal TOLMS was conducted. REVIEW METHODS Records obtained from the search strategy were assessed for eligibility in a 2-step process by 2 independent researchers using the Covidence software. RESULTS Among 2143 identified records, 103 were included in this study. The majority of studies (n = 25) focused on the use of the CO2 laser in oncologic resection, while 20 addressed the treatment of vocal cord paralysis, 16 discussed the treatment of pediatric or congenital pathologies, 11 detailed the management of benign lesions, and 31 studies tackled other surgical indications. Strategies for safe CO2 TOLMS were highly heterogeneous across studies and included preoperative measures (ie, related to the environment, staff preparation, patient protection, and ventilation), intraoperative precautions (ie, protection of nontarget structures, technical considerations, topical and systemic medications), and postoperative strategies (ie, related to airway protection, oral intake, vocal rest, hospitalization duration, drug regimen, and consultant follow-up). CONCLUSION The results provided in this study can be used as a framework to guide the creation of laser safety protocols across institutions, guide quality improvement initiatives, the development of simulation training activities, and as a tool to facilitate resident teaching and skill assessment.
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Affiliation(s)
- Vivianne Landry
- Faculty of Medicine, University of Montreal, Montréal, Quebec, Canada
- Division of Otolaryngology-Head and Neck Surgery, University of Montreal Hospital Center (CHUM), Montréal, Quebec, Canada
- Division of Otolaryngology-Head and Neck Surgery, Maisonneuve-Rosemont Hospital, Montréal, Quebec, Canada
| | - Ève Sedillot-Daniel
- Faculty of Medicine, University of Montreal, Montréal, Quebec, Canada
- Division of Otolaryngology-Head and Neck Surgery, University of Montreal Hospital Center (CHUM), Montréal, Quebec, Canada
- Division of Otolaryngology-Head and Neck Surgery, Maisonneuve-Rosemont Hospital, Montréal, Quebec, Canada
| | - Tareck Ayad
- Division of Otolaryngology-Head and Neck Surgery, University of Montreal Hospital Center (CHUM), Montréal, Quebec, Canada
- Division of Otolaryngology-Head and Neck Surgery, Maisonneuve-Rosemont Hospital, Montréal, Quebec, Canada
| | - Andrée-Anne Leclerc
- Division of Otolaryngology-Head and Neck Surgery, Maisonneuve-Rosemont Hospital, Montréal, Quebec, Canada
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Pauloski BR, Nitschke T, Schultz S, Bloedel S, Amman A, Kessler L, Lisowski K. Association of Tongue Strength and Maximum Incisal Opening with Oral Intake in Persons with Head and Neck Cancer Treated with Radiotherapy: A Retrospective Study. Dysphagia 2024; 39:726-734. [PMID: 38446254 DOI: 10.1007/s00455-023-10653-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 11/20/2023] [Indexed: 03/07/2024]
Abstract
Persons treated with radiotherapy (RT) for cancer of the head and neck (HNC) may experience limited oral intake at treatment completion. The purpose of this retrospective study was to examine the contributions of tongue strength and maximum incisal opening (MIO) to oral intake in a cohort of veterans treated for HNC. Medical records of veterans diagnosed with HNC treated with RT who were seen by the Speech Pathology Service prior to and throughout treatment per usual care were reviewed for this study; eighty-two records met the inclusion criteria for analysis. Tongue strength in kPa, MIO in mm, feeding tube status at completion of RT, and food and liquid consistencies consumed at completion of RT were among the data abstracted from the records. Most veterans (67%) did not have a feeding tube present at the completion of RT and reported drinking thin liquids (84.2%) at treatment completion. Eighteen percent reported including all food consistencies in their diet at the end of treatment. Both MIO and tongue strength decreased after treatment. Greater tongue strength during RT and larger MIO at the completion of RT were predictive of improved functional outcomes for oral intake at the end of treatment. This study provides evidence of the importance of increasing tongue strength and MIO during treatment with RT, and supports an important focus for intervention by speech-language pathologists.
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Affiliation(s)
- Barbara Roa Pauloski
- Department of Communication Sciences and Disorders, College of Health Professions and Sciences, University of Wisconsin Milwaukee, 2400 E. Hartford Avenue, Suite 840, Milwaukee, WI, 53211, USA.
- Clement J. Zablocki Veterans Administration Medical Center, Research Speech Pathologist, WOC, 5000 National Avenue, Room 8300, Building 111, Milwaukee, WI, 53295, USA.
| | - Terilynn Nitschke
- Clement J. Zablocki Veterans Administration Medical Center, Speech-Language Pathologist, 5000 National Avenue, Room 8300, Building 111, Milwaukee, WI, 53295, USA
| | - Stephanie Schultz
- Clement J. Zablocki Veterans Administration Medical Center, Speech-Language Pathologist, 5000 National Avenue, Room 8300, Building 111, Milwaukee, WI, 53295, USA
| | - Suzi Bloedel
- Clement J. Zablocki Veterans Administration Medical Center, Speech-Language Pathologist, 5000 National Avenue, Room 8300, Building 111, Milwaukee, WI, 53295, USA
| | - Adrienne Amman
- Clement J. Zablocki Veterans Administration Medical Center, Speech-Language Pathologist, 5000 National Avenue, Room 8300, Building 111, Milwaukee, WI, 53295, USA
| | - Laura Kessler
- Clement J. Zablocki Veterans Administration Medical Center, Speech-Language Pathologist, 5000 National Avenue, Room 8300, Building 111, Milwaukee, WI, 53295, USA
| | - Kara Lisowski
- Clement J. Zablocki Veterans Administration Medical Center, Speech-Language Pathologist, 5000 National Avenue, Room 8300, Building 111, Milwaukee, WI, 53295, USA
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Liu MY, Wang CH, Lee SH, Chang WC, Wu CE, Liu HE. Effectiveness of a Protocol Intervention for Aspiration Pneumonia Prevention in Patients With Esophageal Cancer During Concurrent Chemoradiotherapy: A Randomized Control Trial. Cancer Nurs 2024; 47:327-335. [PMID: 36696534 DOI: 10.1097/ncc.0000000000001205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Dysphagia is a leading cause of aspiration pneumonia and negatively affects tolerance of chemoradiotherapy in patients with esophageal cancer. OBJECTIVE This study aimed to assess a protocol for preventing the occurrence of aspiration pneumonia for adult patients with esophageal cancer experiencing swallowing dysfunction. METHODS This study tested a dysphagia intervention that included high-risk patients confirmed by the Eating Assessment Tool questionnaire and Water Swallowing Test. A protocol guide (Interventions for Esophageal Dysphagia [IED]) to prevent aspiration pneumonia during chemoradiotherapy was also implemented. Thirty participants were randomly assigned to an intervention or control group. The study period was 50 days; participants were visited every 7 days for a total of 7 times. Instruments for data collection included The Eating Assessment Tool, Water Swallowing Test, and personal information. The IED was administered only to the experimental group. All data were managed using IBM SPSS statistics version 21.0. RESULTS The IED significantly reduced the occurrence of aspiration pneumonia ( P = .012), delayed the onset of aspiration pneumonia ( P = .005), and extended the survival time ( P = .007) in the experimental group. CONCLUSION For patients with esophageal cancer undergoing chemoradiotherapy, this protocol improved swallowing dysfunction and reduced aspiration pneumonia. IMPLICATION FOR PRACTICE The IED protocol should be included in continuous educational training for clinical nurses to help them become familiar with these interventions and to provide these strategies to patients.
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Affiliation(s)
- Mei-Ying Liu
- Author Affiliations: Department of Nursing, Chang Gung Memorial Hospital, Linkou Branch (Mss MY Liu, Wang, and Lee); Department of Oncology, Chang Gung Memorial Hospital, Linkou Branch (Drs Chang and Wu); School of Nursing, College of Medicine, Chang Gung University (Ms HE Liu); Department of Rheumatology, Chang Gung Memorial Hospital (Ms HE Liu); and Department of Nursing, College of Nursing, Chang Gung University of Science and Technology (Ms HE Liu), Taoyuan, Taiwan
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Pan D, Chung S, Nielsen E, Niederman MS. Aspiration Pneumonia. Semin Respir Crit Care Med 2024; 45:237-245. [PMID: 38211629 DOI: 10.1055/s-0043-1777772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
Aspiration pneumonia is a lower respiratory tract infection that results from inhalation of foreign material, often gastric and oropharyngeal contents. It is important to distinguish this from a similar entity, aspiration with chemical pneumonitis, as treatment approaches may differ. An evolving understanding of the human microbiome has shed light on the pathogenesis of aspiration pneumonia, suggesting that dysbiosis, repetitive injury, and inflammatory responses play a role in its development. Risk factors for aspiration events involve a complex interplay of anatomical and physiological dysfunctions in the nervous, gastrointestinal, and pulmonary systems. Current treatment strategies have shifted away from anaerobic organisms as leading pathogens. Prevention of aspiration pneumonia primarily involves addressing oropharyngeal dysphagia, a significant risk factor for aspiration pneumonia, particularly among elderly individuals and those with cognitive and neurodegenerative disorders.
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Affiliation(s)
- Di Pan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Samuel Chung
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Erik Nielsen
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Michael S Niederman
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medical College, New York, New York
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Huynh TTM, Dale E, Falk RS, Hellebust TP, Astrup GL, Malinen E, Edin NFJ, Bjordal K, Herlofson BB, Kiserud CE, Helland Å, Amdal CD. Radiation-induced long-term dysphagia in survivors of head and neck cancer and association with dose-volume parameters. Radiother Oncol 2024; 190:110044. [PMID: 38061420 DOI: 10.1016/j.radonc.2023.110044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 11/19/2023] [Accepted: 11/29/2023] [Indexed: 02/20/2024]
Abstract
BACKGROUND Although dysphagia is a common side effect after radiotherapy (RT) of head and neck cancer (HNC), data on long-term dysphagia is scarce. We aimed to 1) compare radiation dose parameters in HNC survivors with and without dysphagia, 2) investigate factors associated with long-term dysphagia and its possible impact on health-related quality of life (HRQoL), and 3) investigate how our data agree with existing NTCP models. METHODS This cross-sectional study conducted in 2018-2020, included HNC survivors treated in 2007-2013. Participants attended a one-day examination in hospital and filled in patient questionnaires. Dysphagia was measured with the EORTC QLQ-H&N35 swallowing scale. Toxicity was scored with CTCAE v.4. We contoured swallowing organs at risk (SWOAR) on RT plans, calculated dose-volume histograms (DVHs), performed logistic regression analyses and tested our data in established NTCP models. RESULTS Of the 239 participants, 75 (31%) reported dysphagia. Compared to survivors without dysphagia, this group had reduced HRQoL and the DVHs for infrahyoid SWOAR were significantly shifted to the right. Long-term dysphagia was associated with age (OR 1.07, 95% CI 1.03-1.10), female sex (OR 2.75, 95% CI 1.45-5.21), and mean dose to middle pharyngeal constrictor muscle (MD-MPCM) (OR 1.06, 95% CI 1.03-1.09). NTCP models overall underestimated the risk of long-term dysphagia. CONCLUSIONS Long-term dysphagia was associated with higher age, being female, and high MD-MPCM. Doses to distally located SWOAR seemed to be risk factors. Existing NTCP models do not sufficiently predict long-term dysphagia. Further efforts are needed to reduce the prevalence and consequences of this late effect.
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Affiliation(s)
- Thuy-Tien Maria Huynh
- Faculty of Medicine, University of Oslo, Oslo, Norway; Department of Oncology, Oslo University Hospital, Oslo, Norway.
| | - Einar Dale
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | | | - Taran Paulsen Hellebust
- Department of Physics, University of Oslo, Oslo, Norway; Department of Medical Physics, Oslo University Hospital, Oslo, Norway
| | | | - Eirik Malinen
- Department of Physics, University of Oslo, Oslo, Norway; Department of Medical Physics, Oslo University Hospital, Oslo, Norway
| | | | - Kristin Bjordal
- Faculty of Medicine, University of Oslo, Oslo, Norway; Research support services, Oslo University Hospital, Oslo, Norway
| | - Bente Brokstad Herlofson
- Faculty of Dentistry, University of Oslo, Oslo, Norway; Department of Otorhinolaryngology, Head and Neck Surgery, Oslo University Hospital, Oslo, Norway
| | | | - Åslaug Helland
- Faculty of Medicine, University of Oslo, Oslo, Norway; Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Cecilie Delphin Amdal
- Department of Oncology, Oslo University Hospital, Oslo, Norway; Research support services, Oslo University Hospital, Oslo, Norway
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Ghazali SNA, Chan CMH, Nik Eezamuddeen M, Manan HA, Yahya N. Quality of Life for Head and Neck Cancer Patients: A 10-Year Bibliographic Analysis. Cancers (Basel) 2023; 15:4551. [PMID: 37760520 PMCID: PMC10526491 DOI: 10.3390/cancers15184551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/01/2023] [Accepted: 07/05/2023] [Indexed: 09/29/2023] Open
Abstract
Head and neck cancers (HNCs) have a profound impact on patients, affecting not only their physical appearance but also fundamental aspects of their daily lives. This bibliometric study examines the landscape of scientific research pertaining to the quality of life (QoL) among head and neck cancer (HNC) patients. By employing data and bibliometric analysis derived from the Web of Science Core Collection (WOS-CC) and employing R-package and VOSviewer for visualization, the study assesses the current status of and prominent areas of focus within the literature over the past decade. The analysis reveals noteworthy countries, journals, and institutions that have exhibited notable productivity in this research domain between 2013 and 2022. Notably, the United States, the Supportive Care in Cancer journal, and the University of Pittsburgh emerged as the leading contributors. Moreover, there was a discernible shift, with an increasing focus on the significance of QoL within the survivorship context, exemplified by the emergence and subsequent peak of related keywords in 2020 and the subsequent year, respectively. The temporal analysis additionally reveals a transition towards specific QoL indices, such as dysphagia and oral mucositis. Therefore, the increasing relevance of survivorship further underscores the need for studies that address the associated concerns and challenges faced by patients.
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Affiliation(s)
- Siti Nur Akmal Ghazali
- Diagnostic Imaging and Radiotherapy, CODTIS, Faculty of Health Sciences, National University of Malaysia, Jalan Raja Muda Aziz, Kuala Lumpur 50300, Malaysia
| | - Caryn Mei Hsien Chan
- Clinical Psychology and Behavioural Health Programme, REACH, Faculty of Health Sciences, National University of Malaysia, Jalan Raja Muda Aziz, Kuala Lumpur 50300, Malaysia
| | - Marfu’ah Nik Eezamuddeen
- Cancer Center MAKNA, Universiti Kebangsaan Malaysia Medical Centre, Cheras, Kuala Lumpur 56000, Malaysia
| | - Hanani Abdul Manan
- Functional Image Processing Laboratory, Department of Radiology, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia
- Department of Radiology and Intervention, Hospital Pakar Kanak-Kanak (Children Specialist Hospital), Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur 56000, Malaysia
| | - Noorazrul Yahya
- Diagnostic Imaging and Radiotherapy, CODTIS, Faculty of Health Sciences, National University of Malaysia, Jalan Raja Muda Aziz, Kuala Lumpur 50300, Malaysia
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Fong SC, Pandey R, Rajaretnam M, Delaibatiki M, Peel DN. Routine Prophylactic Percutaneous Endoscopic Gastrostomy in Head and Neck Cancers with Bilateral Neck Irradiation: A Regional Cancer Experience in New Zealand. J Med Radiat Sci 2023; 70:292-300. [PMID: 37403761 PMCID: PMC10500120 DOI: 10.1002/jmrs.699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 06/15/2023] [Indexed: 07/06/2023] Open
Abstract
INTRODUCTION Patients with head and neck cancer (HNC) are particularly susceptible to dysphagia and malnutrition. Prophylactic percutaneous endoscopic gastrostomy (PEG) placement is a method used to manage these issues, but practices vary among institutions. At Midcentral District Health Board, patients receiving radiotherapy to the primary and bilateral neck regions routinely undergo prophylactic PEG placement. This study aimed to review the nutritional and PEG-related outcomes of these patients. METHODS Records of 49 patients were retrospectively reviewed. Their demographics, tumour and treatment characteristics were recorded. We evaluated patient weight loss, non-elective hospitalisation, treatment interruption rates, PEG-related complications, usage, dependency rates and late dysphagia rates. RESULTS Oropharyngeal cancers were the most common primary site (61.2%), and 83.7% of patients received primary chemoradiotherapy. Mean weight loss at treatment completion was 5.6% ± 4.3 (4.6 kg ± 3.9). The rate of non-elective hospitalisations was 26.5%, and only 2% of patients had treatment interruptions. Peristomal infection was the most frequent PEG complication (20.4%). No PEG-related mortality was reported. Median duration of PEG dependency was 97 days (14-388 days). Two patients remained permanently dependent at 3 years due to grade 3 dysphagia, and six patients experienced grade ≥2 late dysphagia. CONCLUSION Our study showed that prophylactic PEG tube placement was relatively safe, with a high utilisation rate and low long-term dependence on PEG tubes after treatment completion. However, complications related to their use should be addressed through a multidisciplinary approach, with careful assessment by clinicians. The weight loss and hospitalisation rates observed were consistent with earlier studies that utilised prophylactic PEG tubes.
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Affiliation(s)
- Su Chen Fong
- Department of Radiation OncologyPalmerston North Hospital, Midcentral DHBPalmerston NorthNew Zealand
| | - Ramesh Pandey
- Department of Radiation OncologyPalmerston North Hospital, Midcentral DHBPalmerston NorthNew Zealand
- Department of Radiation OncologyAuckland HospitalAucklandNew Zealand
| | - Michelle Rajaretnam
- Department of Radiation OncologyPalmerston North Hospital, Midcentral DHBPalmerston NorthNew Zealand
| | - Miriama Delaibatiki
- Department of Radiation OncologyPalmerston North Hospital, Midcentral DHBPalmerston NorthNew Zealand
- Department of Radiation OncologyKathleen Kilgour Centre, Tauranga HospitalTaurangaNew Zealand
| | - David N.Y. Peel
- Department of Radiation OncologyPalmerston North Hospital, Midcentral DHBPalmerston NorthNew Zealand
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Kuhn MA, Gillespie MB, Ishman SL, Ishii LE, Brody R, Cohen E, Dhar SI, Hutcheson K, Jefferson G, Johnson F, Rameau A, Sher D, Starmer H, Strohl M, Ulmer K, Vaitaitis V, Begum S, Batjargal M, Dhepyasuwan N. Expert Consensus Statement: Management of Dysphagia in Head and Neck Cancer Patients. Otolaryngol Head Neck Surg 2023; 168:571-592. [PMID: 36965195 DOI: 10.1002/ohn.302] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 01/16/2023] [Accepted: 02/01/2023] [Indexed: 03/27/2023]
Abstract
OBJECTIVE To develop an expert consensus statement (ECS) on the management of dysphagia in head and neck cancer (HNC) patients to address controversies and offer opportunities for quality improvement. Dysphagia in HNC was defined as swallowing impairment in patients with cancers of the nasal cavity, paranasal sinuses, nasopharynx, oral cavity, oropharynx, larynx, or hypopharynx. METHODS Development group members with expertise in dysphagia followed established guidelines for developing ECS. A professional search strategist systematically reviewed the literature, and the best available evidence was used to compose consensus statements targeted at providers managing dysphagia in adult HNC populations. The development group prioritized topics where there was significant practice variation and topics that would improve the quality of HNC patient care if consensus were possible. RESULTS The development group identified 60 candidate consensus statements, based on 75 initial proposed topics and questions, that focused on addressing the following high yield topics: (1) risk factors, (2) screening, (3) evaluation, (4) prevention, (5) interventions, and (6) surveillance. After 2 iterations of the Delphi survey and the removal of duplicative statements, 48 statements met the standardized definition for consensus; 12 statements were designated as no consensus. CONCLUSION Expert consensus was achieved for 48 statements pertaining to risk factors, screening, evaluation, prevention, intervention, and surveillance for dysphagia in HNC patients. Clinicians can use these statements to improve quality of care, inform policy and protocols, and appreciate areas where there is no consensus. Future research, ideally randomized controlled trials, is warranted to address additional controversies related to dysphagia in HNC patients.
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Affiliation(s)
- Maggie A Kuhn
- Department of Otolaryngology-Head and Neck Surgery, University of California Davis, Sacramento, California, USA
| | - M Boyd Gillespie
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Stacey L Ishman
- Department of Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lisa E Ishii
- Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins University Medical Institute, Cockeysville, Maryland, USA
| | - Rebecca Brody
- Department of Clinical and Preventive Nutrition Sciences, Rutgers University, West Linn, Oregon, USA
| | - Ezra Cohen
- Moores Cancer Center at UC San Diego Health, La Jolla, California, USA
| | | | - Kate Hutcheson
- Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Center, Houston, Texas, USA
| | - Gina Jefferson
- Department of Otolaryngology-Head & Neck Surgery, Division of Head & Neck Surgical Oncology/Microvascular Reconstruction, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | | | - Anais Rameau
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York City, New York, USA
| | - David Sher
- UT Southwestern Medical Center, Dallas, Texas, USA
| | - Heather Starmer
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California, USA
| | - Madeleine Strohl
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Karen Ulmer
- Milton J Dance, Jr Head and Neck Cancer at GBMC, Baltimore, Maryland, USA
| | - Vilija Vaitaitis
- Department of Otolaryngology-Head and Neck Surgery, Louisiana State University Health Science Center, New Orleans, Charleston, South Carolina, USA
| | - Sultana Begum
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Misheelt Batjargal
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Nui Dhepyasuwan
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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Blake CL, Brown TE, Pelecanos A, Moroney LB, Helios J, Hughes BGM, Chua B, Kenny LM. Enteral nutrition support and treatment toxicities in patients with head and neck cancer receiving definitive or adjuvant helical intensity-modulated radiotherapy with concurrent chemotherapy. Head Neck 2023; 45:417-430. [PMID: 36433667 DOI: 10.1002/hed.27249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 09/10/2022] [Accepted: 11/11/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Enteral nutrition (EN) is often required in patients with head and neck cancer (HNSCC); however, initiation criteria is limited or inconsistent. This study aimed to describe the relationship of treatment toxicities and requirement for EN and investigate toxicity and baseline characteristics association with EN duration. METHODS Acute toxicities and baseline characteristics were collected from patients with HNSCC (n = 110) undergoing H-IMRT. Percentage EN contributing to estimated requirements and EN duration were measured. RESULTS The threshold for patients needing ≥50% of estimated requirements via EN increased from week 3 to 4 for grade ≥2 oral/pharyngeal mucositis, dysgeusia, thick saliva and nausea, and for grade 3 dysphagia. Patients with grade 2-3 dysphagia had a reduced risk of ceasing EN compared to those with grade 0-1 dysphagia. CONCLUSIONS Using acute toxicities in clinical practice may be a useful tool to inform prompt initiation of EN prior to decline in nutritional status and anticipate EN duration.
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Affiliation(s)
- Claire L Blake
- Department of Nutrition and Dietetics, Royal Brisbane & Women's Hospital, Brisbane, Queensland, Australia
| | - Teresa E Brown
- Department of Nutrition and Dietetics, Royal Brisbane & Women's Hospital, Brisbane, Queensland, Australia
| | - Anita Pelecanos
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Laura B Moroney
- Department of Speech Pathology and Audiology, Royal Brisbane & Women's Hospital, Brisbane, Queensland, Australia
| | - Jennifer Helios
- Department of Speech Pathology and Audiology, Royal Brisbane & Women's Hospital, Brisbane, Queensland, Australia
| | - Brett G M Hughes
- Cancer Care Services, Royal Brisbane & Women's Hospital, Brisbane, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Benjamin Chua
- Cancer Care Services, Royal Brisbane & Women's Hospital, Brisbane, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Lizbeth M Kenny
- Cancer Care Services, Royal Brisbane & Women's Hospital, Brisbane, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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10
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Joo HA, Lee YS, Jung YH, Choi SH, Nam SY, Kim SY. Risk Stratification of Dysphagia After Surgical Treatment of Hypopharyngeal Cancer. Front Surg 2022; 9:879830. [PMID: 35662815 PMCID: PMC9162264 DOI: 10.3389/fsurg.2022.879830] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 05/02/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveHypopharyngeal cancer is managed by either surgical resection or radiation therapy-based treatment. In choosing the treatment modality, the patient’s swallowing function should be considered to achieve optimal treatment outcomes. This study aimed to stratify the risk factors predictive of postoperative dysphagia in hypopharyngeal cancer.Study DesignRetrospective study.SettingTertiary referral center.MethodsWe enrolled 100 patients who were diagnosed with hypopharyngeal cancer and underwent curative surgery between January 2010 and December 2019, and retrospectively reviewed their medical records.ResultsPostoperative dysphagia occurred in 29 patients (29%) who required a tracheostomy tube or percutaneous gastrostomy tube for feeding or preventing aspiration; additionally, the overall survival rate was lower in those patients than in those without dysphagia. The univariate analysis revealed that postoperative dysphagia was associated with clinical T stage (p = 0.016), N stage (p = 0.002), and surgical resection extent of the larynx and pharynx (p < 0.001). Patients who underwent total laryngectomy with total/partial pharyngectomy were more likely to have dysphagia than those in the larynx-preserving pharyngectomy groups (odds ratio [OR] = 3.208, 95% confidence interval [CI] 1.283–8.024, p = 0.011). Concerning the posterior pharyngeal wall (PPW), which has an important role in swallowing, patients who underwent resection of ≥1/2 of the PPW were more likely to have dysphagia (OR = 7.467, 95% CI 1.799–30.994, p = 0.003).ConclusionsSurgical resection extent was proportionally associated with dysphagia in hypopharyngeal cancer patients. Patients with smaller lesions but no laryngeal invasion had better postoperative swallowing function than patients with larger lesions or laryngeal involved lesions. Preserving the larynx and hypopharyngeal mucosa (especially the PPW) as much as possible can help preserve postoperative swallowing function.
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Gawryszuk A, Bijl HP, van der Schaaf A, Perdok N, Wedman J, Verdonck-de Leeuw IM, Rinkel RN, Steenbakkers RJHM, van den Hoek JGM, van der Laan HP, Langendijk JA. Relationship between videofluoroscopic and subjective (physician- and patient- rated) assessment of late swallowing dysfunction after (chemo) radiation: Results of a prospective observational study. Radiother Oncol 2021; 164:253-260. [PMID: 34592362 DOI: 10.1016/j.radonc.2021.09.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 09/15/2021] [Accepted: 09/20/2021] [Indexed: 11/12/2022]
Abstract
BACKGROUND AND PURPOSE Primary (chemo)radiation (CHRT) for HNC may lead to late dysphagia. The purpose of this study was to assess the pattern of swallowing disorders based on prospectively collected objective videofluoroscopic (VF) assessment and to assess the correlations between VF findings and subjective (physician- and patient-rated) swallowing measures. MATERIAL AND METHODS 189 consecutive HNC patients receiving (CH)RT were included. Swallowing evaluation at baseline and 6 months after treatment (T6) encompassed: CTCAE v.4.0 scores (aspiration/dysphagia), PROMs: SWAL QOL/ EORTC QLQ-H&N35 (swallowing domain) questionnaires and VF evaluation: Penetration Aspiration Scale, semi-quantitative swallowing pathophysiology evaluation, temporal measures and oral/pharyngeal residue quantification. Aspiration specific PROMs (aPROMs) were selected. Correlations between late penetration/aspiration (PA_T6) and: clinical factors, CTCAE and aPROMs were assessed using uni- and multivariable analysis. RESULTS Prevalence of PA increased from 20% at baseline to 43% after treatment (p < 0.001). The most relevant baseline predictors for PA_T6 were: PA_T0, age, disease stage III-IV, bilateral RT and baseline aPROM 'Choking when drinking' (AUC: 0.84). In general aPROMs correlated better with VF-based PA than CTCAE scores. The most of physiological swallowing components significantly correlated and predictive for PA (i.e. Laryngeal Vestibular Closure, Laryngeal Elevation and Pharyngeal Contraction) were prone to radiation damage. CONCLUSION The risk of RT-induced PA is substantial. Presented prediction models for late penetration/aspiration may support patient selection for baseline and follow-up VF examination. Furthermore, all aspiration related OARs involved in aforementioned swallowing components should be addressed in swallowing sparing strategies. The dose to these structures as well as baseline PROMs should be included in future NTCP models for aspiration.
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Affiliation(s)
- Agata Gawryszuk
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, The Netherlands.
| | - Hendrik P Bijl
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Arjen van der Schaaf
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Nathalie Perdok
- Department of Otolaryngology, Speech Language Pathology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Jan Wedman
- Department of Otolaryngology, Speech Language Pathology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Irma M Verdonck-de Leeuw
- Department of Otolaryngology - Head & Neck Surgery, Amsterdam University Medical Centers, The Netherlands
| | - Rico N Rinkel
- Department of Otolaryngology - Head & Neck Surgery, Amsterdam University Medical Centers, The Netherlands
| | - Roel J H M Steenbakkers
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Johanna G M van den Hoek
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Hans Paul van der Laan
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Johannes A Langendijk
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, The Netherlands
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12
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Goeze A, Zaretsky E, Lehner U, Wermter L, Mayer M, Stuck BA, Birk R, Neff A, Fisher I, Stöver T, Kramer S, Ghanaati S, Sader R, Hey C. [Post-operative prevalence of dysphagia in head-and-neck cancer patients in the acute care units]. Laryngorhinootologie 2021; 101:320-326. [PMID: 34187052 DOI: 10.1055/a-1528-7584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Dysphagia constitutes a frequent post-operative functional impairment in head-and-neck cancer patients. This impairment can result in aspiration/penetration and limitations of oral intake. Therefore, often it requires a therapeutic intervention. In this study, prevalence of post-operative dysphagia and its associations with the tumour stage, localisation, patients' age, and biological sex were analysed for the inpatient treatment setting. MATERIAL AND METHODS A total of 201 adult head-and-neck cancer patients (mean age 63 years) were analysed prospectively by FEES in two university hospitals in regard to their penetration/aspiration, limitations of oral intake, and need for therapeutic interventions directly after the operative tumour treatment. Additionally, the influence of the same patients' characteristics on these three parameters were analysed by means of univariate and multivariate statistical methods. RESULTS Out of 201 patients, 66.7 % needed a therapeutic intervention because of their dysphagia, 57.2 % needed a nasogastral or PEG tube due to limitations of oral intake, 45.3 % had an aspiration. In the latter subgroup, 38.5 % had a silent aspiration. Higher tumour stage, patients' higher age and male sex were shown to be significant influence factors for dysphagia, tumour localisation showed only a marginally significant result. CONCLUSIONS The study demonstrated a clinical importance and relevance of the consequent and systematic treatment of post-operative dysphagia in head-and-neck cancer patients in the acute care units as a constituent of a modern oncological therapy.
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Affiliation(s)
- Almut Goeze
- Abt. für Phoniatrie und Pädaudiologie, KHNO,Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Philipps-Universität Marburg, Deutschland
| | - Eugen Zaretsky
- Abt. für Phoniatrie und Pädaudiologie, KHNO,Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Philipps-Universität Marburg, Deutschland
| | - Uta Lehner
- Abt. für Phoniatrie und Pädaudiologie, KHNO,Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Philipps-Universität Marburg, Deutschland
| | - Laura Wermter
- Abt. für Phoniatrie und Pädaudiologie, KHNO,Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Philipps-Universität Marburg, Deutschland
| | - Miriam Mayer
- Abt. für Phoniatrie und Pädaudiologie, KHNO,Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Philipps-Universität Marburg, Deutschland
| | - Boris A Stuck
- Klinik für Hals-, Nasen- und Ohrenheilkunde, Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Philipps-Universität Marburg, Deutschland
| | - Richard Birk
- Klinik für Hals-, Nasen- und Ohrenheilkunde, Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Philipps-Universität Marburg, Deutschland
| | - Andreas Neff
- Klinik und Poliklinik für Mund-, Kiefer- und Gesichtschirurgie, Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Philipps-Universität Marburg, Deutschland
| | - Ingo Fisher
- Klinik und Poliklinik für Mund-, Kiefer- und Gesichtschirurgie, Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Philipps-Universität Marburg, Deutschland
| | - Timo Stöver
- Klinik für HNO-Heilkunde, Universitätsklinikum Frankfurt/Main, Goethe-Universität Frankfurt/Main, Frankfurt, Deutschland
| | - Sabine Kramer
- Schwerpunkt für Phoniatrie und Pädaudiologie, Universitätsklinikum Frankfurt/Main, Goethe-Universität Frankfurt/Main, Frankfurt am Main, Deutschland
| | - Shahram Ghanaati
- Klinik für Mund-, Kiefer-, Plastische Gesichtschirurgie, Universitätsklinikum Frankfurt/Main, Goethe-Universität Frankfurt/Main, Frankfurt am Main, Deutschland
| | - Robert Sader
- Klinik für Mund-, Kiefer-, Plastische Gesichtschirurgie, Universitätsklinikum Frankfurt/Main, Goethe-Universität Frankfurt/Main, Frankfurt am Main, Deutschland
| | - Christiane Hey
- Abt. für Phoniatrie und Pädaudiologie, KHNO,Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Philipps-Universität Marburg, Deutschland
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13
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Hutchison AR, Wishart LR, Brown B, Ward EC, Hargrave C, Brown E, Porceddu S. Exploring the Interplay Between Radiotherapy Dose and Physiological Changes in the Swallowing Mechanism in Patients Undergoing (Chemo)radiotherapy for Oropharynx Cancer. Dysphagia 2021; 37:567-577. [PMID: 33966115 DOI: 10.1007/s00455-021-10307-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 04/20/2021] [Indexed: 11/26/2022]
Abstract
This study explored associative relationships between radiotherapy dose volumes delivered to the dysphagia aspiration risk structures (DARS) and swallowing physiological disturbance at 3 months post treatment in a homogenous cohort of patients who received (chemo)radiotherapy ((C)RT) for oropharyngeal head and neck cancer (HNC). Participants(n = 53) were a subgroup of patients previously recruited as part of a prospective randomised trial, and had undergone physiological swallowing assessment using videofluroscopic swallowing study (VFSS) at 3 months post (C)RT. The extended oral cavity (EOC), supraglottic larynx (SGL), glottic larynx (GL), cricopharyngeal inlet (CI), and pharyngeal constrictor muscles (PCM) were contoured as per international consensus guidelines and dose volume histograms (DVHs) were generated for each structure. Each DVH was analysed to reveal mean, maximum and partial radiotherapy doses of V40, V50 and V60 for each structure. Physiological swallowing function on VFSS was rated using the Modified Barium Swallow Impairment Profile (MBSImP). A binary logistic regression model was used to establish associative relationships between radiotherapy dose to the DARS and physiological changes within the swallowing mechanism. Structures that received the largest volumes of radiotherapy dose were the PCM and SGL. Significant relationships were found between the proportion of the EOC, SGL, GL and PCMs that received radiotherapy doses > 40 Gy, > 50 Gy and > 60 Gy and the likelihood of a moderate-severe physiological swallowing impairment (on the MBSImP). Whilst the current study was exploratory in nature, these preliminary findings provide novel evidence to suggest structure-specific associative relationships between radiotherapy dose and impacts to corresponding swallow physiology in patients with oropharyngeal HNC.
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Affiliation(s)
- Alana R Hutchison
- Division of Speech Pathology, School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, QLD, 4072, Australia.
- Centre for Functioning and Health Research, Queensland Health, Level 3, Centro Buranda, Ipswich Rd, PO Box 6053, Buranda, QLD, 4102, Australia.
| | - Laurelie R Wishart
- Division of Speech Pathology, School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, QLD, 4072, Australia
- Centre for Functioning and Health Research, Queensland Health, Level 3, Centro Buranda, Ipswich Rd, PO Box 6053, Buranda, QLD, 4102, Australia
| | - Bena Brown
- Centre for Functioning and Health Research, Queensland Health, Level 3, Centro Buranda, Ipswich Rd, PO Box 6053, Buranda, QLD, 4102, Australia
- Speech Pathology Department, Princess Alexandra Hospital, Ipswich Rd, Woolloongabba, QLD, 4102, Australia
| | - Elizabeth C Ward
- Division of Speech Pathology, School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, QLD, 4072, Australia
- Centre for Functioning and Health Research, Queensland Health, Level 3, Centro Buranda, Ipswich Rd, PO Box 6053, Buranda, QLD, 4102, Australia
| | - Catriona Hargrave
- Radiation Oncology Department, Princess Alexandra Hospital, Ipswich Road, Brisbane, QLD, 4102, Australia
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, QLD, 4000, Australia
| | - Elizabeth Brown
- Radiation Oncology Department, Princess Alexandra Hospital, Ipswich Road, Brisbane, QLD, 4102, Australia
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, QLD, 4000, Australia
| | - Sandro Porceddu
- Radiation Oncology Department, Princess Alexandra Hospital, Ipswich Road, Brisbane, QLD, 4102, Australia
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, QLD, 4000, Australia
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14
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Nilsen ML, Belsky MA, Scheff N, Johnson JT, Zandberg DP, Skinner H, Ferris R. Late and Long-Term Treatment-Related Effects and Survivorship for Head and Neck Cancer Patients. Curr Treat Options Oncol 2020; 21:92. [DOI: 10.1007/s11864-020-00797-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2020] [Indexed: 12/26/2022]
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15
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Krouse JH. Highlights from the Current Issue: October 2019. Otolaryngol Head Neck Surg 2020; 161:549-550. [PMID: 31571534 DOI: 10.1177/0194599819874819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- John H Krouse
- School of Medicine, University of Texas Rio Grande Valley, Edinburg, Texas, USA
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16
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Aylward A, Park J, Abdelaziz S, Hunt JP, Buchmann LO, Cannon RB, Rowe K, Snyder J, Deshmukh V, Newman M, Wan Y, Fraser A, Smith K, Lloyd S, Hitchcock Y, Hashibe M, Monroe MM. Individualized prediction of late-onset dysphagia in head and neck cancer survivors. Head Neck 2020; 42:708-718. [PMID: 32031294 DOI: 10.1002/hed.26039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 10/28/2019] [Accepted: 12/03/2019] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Limited data exist regarding which head and head and neck cancer (HNC) survivors will suffer from long-term dysphagia. METHODS From a population-based cohort of 1901 Utah residents with HNC and ≥3 years follow-up, we determined hazard ratio for dysphagia, aspiration pneumonia, or gastrostomy associated with various risk factors. We tested prediction models with combinations of factors and then assessed discrimination of our final model. RESULTS Cancer site in the hypopharynx, advanced tumor classification, chemoradiation, preexisting dysphagia, stroke, dementia, esophagitis, esophageal spasm, esophageal stricture, gastroesophageal reflux, thrush, or chronic obstructive pulmonary disease were associated with increased risk of long-term dysphagia. Our final prediction tool gives personalized risk calculation for diagnosis of dysphagia, aspiration pneumonia, or gastrostomy tube placement at 5, 10, and 15 years after HNC based on 18 factors. CONCLUSION We developed a clinically useful risk prediction tool to identify HNC survivors most at risk for dysphagia.
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Affiliation(s)
- Alana Aylward
- Department of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine and Huntsman Cancer Institute, Salt Lake City, Utah
| | - Jihye Park
- Cancer Control and Population Science, Huntsman Cancer Institute, Salt Lake City, Utah
| | - Sarah Abdelaziz
- Department of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine and Huntsman Cancer Institute, Salt Lake City, Utah
| | - Jason P Hunt
- Department of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine and Huntsman Cancer Institute, Salt Lake City, Utah
| | - Luke O Buchmann
- Department of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine and Huntsman Cancer Institute, Salt Lake City, Utah
| | - Richard B Cannon
- Department of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine and Huntsman Cancer Institute, Salt Lake City, Utah
| | - Kerry Rowe
- Intermountain Healthcare, Salt Lake City, Utah
| | - John Snyder
- Intermountain Healthcare, Salt Lake City, Utah
| | | | - Michael Newman
- University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Yuan Wan
- Pedigree and Population Resource, Population Sciences, Huntsman Cancer Institute, Salt Lake City, Utah
| | - Alison Fraser
- Pedigree and Population Resource, Population Sciences, Huntsman Cancer Institute, Salt Lake City, Utah
| | - Ken Smith
- Pedigree and Population Resource, Population Sciences, Huntsman Cancer Institute, Salt Lake City, Utah
| | - Shane Lloyd
- Department of Radiation Oncology, Radiation Oncology, University of Utah School of Medicine and Huntsman Cancer Institute, Salt Lake City, Utah
| | - Ying Hitchcock
- Department of Radiation Oncology, Radiation Oncology, University of Utah School of Medicine and Huntsman Cancer Institute, Salt Lake City, Utah
| | - Mia Hashibe
- Department of Family and Preventive Medicine, Division of Public Health, University of Utah School of Medicine, Salt Lake City, Utah
| | - Marcus M Monroe
- Department of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine and Huntsman Cancer Institute, Salt Lake City, Utah
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