What patients consider important: temporal variations by early and late stage oral, oropharyngeal and laryngeal subsites

Do Effects of Voice Rehabilitation in Patients Irradiated for Laryngeal Cancer Remain 5 Years Postradiotherapy?

PURPOSE

Laryngeal cancer treated by radiotherapy results in many patients being left with an abnormal voice long-term. This prospective study aims to report efficacy of voice rehabilitation 5years postradiotherapy completion.

METHODS

Seventy-seven patients were randomized into an intervention group (n = 37) or a control group (n = 40). Voice rehabilitation was administered postradiotherapy. Patients were followed at baseline, 12- and 60-month postradiotherapy with voice recordings assessed using GRBAS protocol (Grade, Roughness, Breathiness, Asthenia, Strain). Patients filled in the European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire Head and Neck 35 (EORTC QLQ-HN35) and the Swedish Self-Evaluation of Communication Experiences after Laryngeal Cancer (S-SECEL).

RESULTS

There were no statistically significant differences between the intervention and control group in scores reported on EORTC QLQ-HN35, S-SECEL or in perceptual evaluation at study end-point. The intervention group reported an improvement in EORTC QLQ-HN35 Speech between baseline-60months postradiotherapy. No significant changes between 12-60months were observed. The control group demonstrated significant improvement in domains Pain, Senses, Speech, Social eating and Sexuality from baseline-60months postradiotherapy, of which only Speech showed a statistically significant change between 12-60months postradiotherapy (P = 0.02). Both groups reported improved S-SECEL scores from baseline-60months, with no significant dynamic between the 12- and 60-month follow-up.

CONCLUSION

Previously observed positive effects of voice rehabilitation on patient communicative skills and perceptual evaluation are no longer noticeable at 5-year post voice therapy completion. Nevertheless, patients receiving voice rehabilitation experience a greater improvement within the first year, which in the control group takes a corresponding 5years.

Laryngectomy: Social media analysis of patient perception

BACKGROUND

Social media continues to grow as a relevant information source for the lay public and medical professionals.

METHODS

A search of posts on Facebook and Instagram was conducted using the hashtag #laryngectomy. Posts were categorized based upon perspective, media type, timeframe, topic, tone, and popularity.

RESULTS

Final analysis included 929 Instagram posts and 355 Facebook posts. Most Facebook posts were made by companies (38%) and physicians (17%) with information (30%) and advertisements (22%) being common topics. Patients (40%) were the largest group of Instagram authors with lifestyle (39%) being the most common topic. Greater than 90% of posts were either neutral or positive in tone across both platforms.

CONCLUSIONS

Patient perspective was most commonly represented on Instagram, whereas Facebook more commonly included posts by physicians and companies. The majority of posts carried a neutral or positive tone, which is consistent with positive quality of life patients have shown postoperatively.

Near-Infrared Photoimmunotherapy for Oropharyngeal Cancer

Human papillomavirus (HPV)-associated oropharyngeal cancer has a better prognosis than other head and neck cancers. However, rates of recurrence and metastasis are similar and the prognosis of recurrent or metastatic HPV-associated oropharyngeal cancer is poor. Near-infrared photoimmunotherapy (NIR-PIT) is a treatment involving administration of a photosensitizer (IRDye^®700DX) conjugated to a monoclonal antibody followed by activation with near-infrared light illumination. It is a highly tumor-specific therapy with minimal toxicity in normal tissues. Moreover, NIR-PIT is expected to have not only direct effects on a treated lesion but also immune responses on untreated distant lesions. NIR-PIT with cetuximab-IR700 (AlluminoxTM) has been in routine clinical use since January 2021 for unresectable locally advanced or locally recurrent head and neck cancer in patients that have previously undergone radiotherapy in Japan. NIR-PIT for head and neck cancer (HN-PIT) is expected to provide a curative treatment option for the locoregional recurrent or metastatic disease after radiotherapy and surgery. This article reviews the mechanism underlying the effect of NIR-PIT and recent clinical trials of NIR-PIT for head and neck cancers, treatment-specific adverse events, combination treatment with immune checkpoint inhibitors, illumination approach and posttreatment quality of life, and provides a case of series of two patients who receive NIR-PIT for oropharyngeal cancer at our institution.

Development of a Patient-Centered Functional Outcomes Questionnaire in Head and Neck Cancer

Importance

Incorporation of patient perspectives, or patient-reported outcomes, in functional outcome measures has been gaining prominence in the literature on reconstructive surgery.

Objective

To create and validate an instrument for measuring the main functional areas of concern for patients with head and neck cancer.

Design, Setting, and Participants

This 4-phase mixed-methods qualitative study was conducted from July 1, 2013, to June 30, 2016, in a quaternary head and neck oncology center in Edmonton, Alberta, Canada. Patients were recruited from 3 Head and Neck Research Network sites: University of Alberta (Edmonton, Canada), Mount Sinai Health Network (New York, New York), and University of Turku Hospital (Turku, Finland). The inclusion criteria included 18 years of age or older, diagnosis of squamous cell carcinoma involving the subsites of the head and neck (ie, oral cavity, oropharynx, hypopharynx, and larynx), and at least 1 year since treatment completion. Those patients who were undergoing additional active treatment or with evidence of disease recurrence were excluded. Data were analyzed from July 1, 2013, to June 30, 2016.

Main Outcomes and Measures

The primary outcome measures were the clinical correlation of the Edmonton-33 instrument scores with swallowing, speech, dry mouth, and chewing assessment outcomes.

Results

In total, 10 patients with head and neck cancer (mean age, 59.6 years; 6 men [60%]) were included in phase 1 of the study, 5 patients (mean age, 55.2 years) were included in phase 2, 10 patients were included in phase 3, and 25 patients with head and neck cancer (mean age, 62.6 years; 14 men [56%]) participated in the phase 4 validation. The Edmonton-33 instrument scores correlated strongly with the swallowing scores of the MD Anderson Dysphagia Inventory (r = 0.77; 95% CI, 0.49-1.0), the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Head and Neck 35 (EORTC QLQ-H&N35) (r = -0.73; 95% CI, -1.0 to -0.44), and the modified barium swallow test (r = -0.60; 95% CI, -0.94 to -0.25). The instrument scores were also strongly correlated with the Speech Handicap Index scores (r = -0.64; 95% CI, -0.97 to -0.31), word intelligibility scores (r = 0.61; 95% CI, 0.27-0.95), and sentence intelligibility scores (r = 0.55; 95% CI, 0.19-0.91). A moderate to strong correlation was observed between the Edmonton-33 instrument and the EORTC QLQ-H&N35 scores in the dry mouth (r = -0.54; 95% CI, -0.91 to -0.18) and chewing (r = -0.45; 95% CI, -0.84 to -0.06) domains. The factor loading values for the domains of swallowing, speech, dry mouth, and chewing were all greater than 0.3. The mean factor loading values for the items related to swallowing were 0.71 (95% CI, 0.62-0.80) and for the items related to speech were 0.76 (95% CI, 0.72-0.80). The mean factor loading values for the items related to dry mouth were 0.71 (95% CI, 0.59-0.83) and for those related to chewing were 0.77 (95% CI, 0.69-0.85).

Conclusions and Relevance

The Edmonton-33 appears to be a validated instrument that will allow patients with head and neck cancer to assess and report their own functional outcomes. It could serve as a single comprehensive measure for functional outcomes.

Quality of life after total laryngectomy: impact of different vocal rehabilitation methods in a middle income country

INTRODUCTION

The impact of advanced laryngeal cancer and its extensive surgical treatments cause significant morbidity for these patients. Total laryngectomy impacts essential functions such as breathing, communication and swallowing, and may influence the quality of life as well as affecting the social life of laryngeal cancer patients.

OBJECTIVE

Describe the quality of life and analyze the factors associated with the reduced quality of life in patients who have undergone total laryngectomy.

METHOD

Observational cross-sectional study was carried out to evaluate the quality of life of patients who had undergone total laryngectomy due to laryngeal cancer. The fourth version of the UW-QOL Quality of Life Assessment Questionnaire from Washington University, validated for Portuguese, was used.

RESULTS

The study population was 95 patients, and the mean composite score of the QOL was 80.4. In the subjective domains the majority of the patients (38.9%) reported they felt much better at present compared to the month before being diagnosed with cancer. When questioned about how they evaluated their health-related quality of life, there was a predominance of those who considered it good (43.2%), and most considered they had a good quality of life (46.3%) considering personal well-being. The overall quality of life was considered good to excellent by 83.2% of the patients. Patients with tracheoesophageal prosthesis reported a better quality of life, compared to patients using an electrolarynx or esophageal voice.

CONCLUSION

The high mean value of the composite score for quality of life revealed that the patients assessed their quality of life positively. The absence of vocal emission was the only variable associated with a lower quality of life within the composite score according to the UW-QOL questionnaire.

Assessing patient-reported symptom burden of long-term head and neck cancer survivors at annual surveillance in survivorship clinic

BACKGROUND

This study reports long-term head and neck cancer (HNC) patient-reported symptoms using the MD Anderson Symptom Inventory Head and Neck Cancer Module (MDASI-HN) in a large cohort of HNC survivors.

METHODS

MDASI-HN results were prospectively collected from an institutional survivorship database. Associations with clinicopathologic data were analyzed using χ² , Mann-Whitney, and univariate regression.

RESULTS

Nine hundred and twenty-eight patients were included. Forty-six percent had oropharyngeal primary tumors. Eighty-two percent had squamous cell carcinoma. Fifty-six percent of patients had ablative surgery and 81% had radiation therapy as a component of treatment. The most severe symptoms were xerostomia and dysphagia. Symptom scores were worst for hypopharynx and varied by subsite. Patients treated with chemoradiation or surgery followed by radiation ± chemotherapy reported the worst symptoms while patient treated with surgery plus radiation ± chemotherapy reported the worst interference.

CONCLUSION

HNC survivors describe their long-term symptom burden and inform efforts to improve care many years into survivorship.

Content analysis of rehabilitation goals for patients following non-surgical head and neck cancer treatment

PURPOSE

Following head and neck cancer (HNC) treatment, individuals experience an array of side effects which can impact on physical, emotional, and practical aspects of their lives. Responsive, supportive rehabilitation services are therefore essential to address ongoing survivorship needs. This study examined the nature of patient-reported goals from acute to long-term post-treatment, to inform design/delivery of future rehabilitation services.

METHODS

Using a cross-sectional cohort design, 91 patients between 2 weeks and 5 years of post non-surgical HNC treatment (acute n = 29; sub-acute n = 28; long-term n = 34), provided their top four rehabilitation goals considering any aspect of their lives. Content analysis was used to categorise responses at each time point.

RESULTS

Three core categories of patient goals were identified relating to: (1) treatment side effects (TSE), (2) overall health (OH), and (3) living life (LL). TSE goals were a priority during the acute and sub-acute phases, with less focus long-term. LL goals were prevalent across all time points, though increased in the long-term. Approximately a third of all goals at each time point related to OH.

CONCLUSIONS

A variety of rehabilitation goals were identified, and the focus shifted over time. These data highlight the importance of changing the focus of rehabilitation as patients' priorities vary over time. Early multidisciplinary care from allied health services is crucial to provide support with managing side effects and returning to daily activities. In the long-term, greater input from services to address health, nutrition, leisure, and fitness goals may be more beneficial.

Development and evaluation of oral Cancer quality-of-life questionnaire (QOL-OC)

Background

In this study scales and items for the Oral Cancer Quality-of-life Questionnaire (QOL-OC) were designed and the instrument was evaluated.

Methods

The QOL-OC was developed and modified using the international definition of quality of life (QOL) promulgated by the European Organization for Research and Treatment of Cancer (EORTC) and analysis of the precedent measuring instruments. The contents of each item were determined in the context of the specific characteristics of oral cancer. Two hundred thirteen oral cancer patients were asked to complete both the EORTC core quality of life questionnaire (EORTC QLC-C30) and the QOL-OC. Data collected was used to conduct factor analysis, test-retest reliability, internal consistency, and construct validity.

Results

Questionnaire compliance was relatively high. Fourteen of the 213 subjects accepted the same tests after 24 to 48 h demonstrating a high test-retest reliability for all five scales. Overall internal consistency surpasses 0.8. The outcome of the factor analysis coincides substantially with our theoretical conception. Each item shows a higher correlation coefficient within its own scale than the others which indicates high construct validity.

Conclusions

QOL-OC demonstrates fairly good statistical reliability, validity, and feasibility. However, further tests and modification are needed to ensure its applicability to the quality-of-life assessment of Chinese oral cancer patients.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4378-6) contains supplementary material, which is available to authorized users.

Long noncoding RNAs in head and neck cancer

Head and neck cancers (HNCs) include a series of malignant tumors arising in epithelial tissues, typically oral cancer, laryngeal cancer, nasopharynx cancer and thyroid cancer. HNCs are important contributors to cancer incidence and mortality, leading to approximately 225,100 new patients and 77,500 deaths in China every year. Determination of the mechanisms of HNC carcinogenesis and progression is an urgent priority in HNC treatment. Long noncoding RNAs (lncRNAs) are noncoding RNAs longer than 200 bps. lncRNAs have been reported to participate in a broad scope of biological processes, and lncRNA dysregulation leads to diverse human diseases, including cancer. In this review, we focus on lncRNAs that are dysregulated in HNCs, summarize the latest findings regarding the function and molecular mechanisms of lncRNAs in HNC carcinogenesis and progression, and discuss the clinical application of lncRNAs in HNC diagnosis, prognosis and therapy.

Current research on head and neck cancer-associated long noncoding RNAs

Head and neck cancers (HNC) are one of the ten leading cancers worldwide, including a range of malignant tumors arising from the upper neck. Due to the complex mechanisms of HNC and lack of effective biomarkers, the 5-year survival rate of HNC has been low and the mortality rate has been high in recent decades. Long noncoding RNAs (lncRNAs), noncoding RNAs longer than 200 bps, are a focus of current cancer research, closely related to tumor biology. LncRNAs have been revealed to be aberrantly expressed in various types of HNC, and the dysregulated lncRNAs participate in HNC progression and induce malignant behavior by modulating gene expression at diverse levels. This review will focus on the functions and molecular mechanisms of dysregulated lncRNAs in HNC tumorigenesis and progression, as well as their diagnostic, therapeutic or prognostic implications in HNC.

Nivolumab versus standard, single-agent therapy of investigator's choice in recurrent or metastatic squamous cell carcinoma of the head and neck (CheckMate 141): health-related quality-of-life results from a randomised, phase 3 trial

BACKGROUND

Patients with platinum-refractory recurrent or metastatic squamous cell carcinoma of the head and neck have few treatment options and poor prognosis. Nivolumab significantly improved survival of this patient population when compared with standard single-agent therapy of investigator's choice in Checkmate 141; here we report the effect of nivolumab on patient-reported outcomes (PROs).

METHODS

CheckMate 141 was a randomised, open-label, phase 3 trial in patients with recurrent or metastatic squamous cell carcinoma of the head and neck who progressed within 6 months after platinum-based chemotherapy. Patients were randomly assigned (2:1) to nivolumab 3 mg/kg every 2 weeks (n=240) or investigator's choice (n=121) of methotrexate (40-60 mg/m² of body surface area), docetaxel (30-40 mg/m²), or cetuximab (250 mg/m² after a loading dose of 400 mg/m²) until disease progression, intolerable toxicity, or withdrawal of consent. On Jan 26, 2016, the independent data monitoring committee reviewed the data at the planned interim analysis and declared overall survival superiority for nivolumab over investigator's choice therapy (primary endpoint; described previously). The protocol was amended to allow patients in the investigator's choice group to cross over to nivolumab. All patients not on active therapy are being followed for survival. As an exploratory endpoint, PROs were assessed at baseline, week 9, and every 6 weeks thereafter using the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-Core 30 (QLQ-C30), the EORTC head and neck cancer-specific module (EORTC QLQ-H&N35), and the three-level European Quality of Life-5 Dimensions (EQ-5D) questionnaire. Differences within and between treatment groups in PROs were analysed by ANCOVA among patients with baseline and at least one other assessment. All randomised patients were included in the time to clinically meaningful deterioration analyses. Median time to clinically meaningful deterioration was analysed by Kaplan-Meier methods. CheckMate 141 was registered with ClinicalTrials.org, number NCT02105636.

FINDINGS

Patients were enrolled between May 29, 2014, and July 31, 2015, and subsequently 361 patients were randomly assigned to receive nivolumab (n=240) or investigator's choice (n=121). Among them, 129 patients (93 in the nivolumab group and 36 in the investigator's choice group) completed any of the PRO questionnaires at baseline and at least one other assessment. Treatment with nivolumab resulted in adjusted mean changes from baseline to week 15 ranging from -2·1 to 5·4 across functional and symptom domains measured by the EORTC QLQ-C30, with no domains indicating clinically meaningful deterioration. By contrast, eight (53%) of the 15 domains in the investigator's choice group showed clinically meaningful deterioration (10 points or more) at week 15 (change from baseline range, -24·5 to 2·4). Similarly, on the EORTC QLQ-H&N35, clinically meaningful worsening at week 15 was seen in no domains in the nivolumab group and eight (44%) of 18 domains in the investigator's choice group. Patients in the nivolumab group had a clinically meaningful improvement (according to a difference of 7 points or greater) in adjusted mean change from baseline to week 15 on the EQ-5D visual analogue scale, in contrast to a clinically meaningful deterioration in the investigator's choice group (7·3 vs -7·8). Differences between groups were significant and clinically meaningful at weeks 9 and 15 in favour of nivolumab for role functioning, social functioning, fatigue, dyspnoea, and appetite loss on the EORTC QLQ-C30 and pain and sensory problems on the EORTC QLQ-H&N35. Median time to deterioration was significantly longer with nivolumab versus investigator's choice for 13 (37%) of 35 domains assessed across the three questionnaires.

INTERPRETATION

In this exploratory analysis of CheckMate 141, nivolumab stabilised symptoms and functioning from baseline to weeks 9 and 15, whereas investigator's choice led to clinically meaningful deterioration. Nivolumab delayed time to deterioration of patient-reported quality-of-life outcomes compared with single-agent therapy of investigator's choice in patients with platinum-refractory recurrent or metastatic squamous cell carcinoma of the head and neck. In view of the major unmet need in this population and the importance of maintaining or improving quality of life for patients with recurrent or metastatic squamous cell carcinoma of the head and neck, these data support nivolumab as a new standard-of-care option in this setting.

FUNDING

Bristol-Myers Squibb.

Predicting two-year longitudinal MD Anderson Dysphagia Inventory outcomes after intensity modulated radiotherapy for locoregionally advanced oropharyngeal carcinoma

OBJECTIVES/HYPOTHESIS

To determine the factors associated with longitudinal patient-reported dysphagia as measured by the MD Anderson Dysphagia Inventory (MDADI) in locoregionally advanced oropharyngeal carcinoma (OPC) survivors treated with split-field intensity modulated radiotherapy (IMRT).

STUDY DESIGN

Retrospective patient analysis.

METHODS

A retrospective analysis combined data from three single-institution clinical trials for stage III/IV head and neck carcinoma. According to trial protocols, patients had prospectively collected MDADI at baseline, 6, 12, and 24 months after treatment. OPC patients with baseline and at least one post-treatment MDADI were included. Longitudinal analysis was completed with multivariate linear mixed effects modeling.

RESULTS

There were 116 patients who met inclusion criteria. Mean baseline MDADI composite was 88.3, dropping to 73.8 at 6 months, and rising to 78.6 and 83.3 by 12 and 24 months, respectively (compared to baseline, all P < .0001). Tumor stage and smoking status were significant predictors of longitudinal MDADI composite scores. Patients with T1, T2, and T3 tumors had 15.9 (P = .0001), 10.9 (P = .0049), and 7.5 (P = .0615), respectively, higher mean MDADI composite than those with T4 tumors, and current smokers had a 9.4 (P = .0007) lower mean MDADI composite than never smokers.

CONCLUSIONS

Patients report clinically meaningful dysphagia early after split-field IMRT for locoregionally advanced OPC that remains apparent 6 months after treatment. MDADI scores recover slowly thereafter, but remain depressed at 24 months compared to baseline. Higher tumor stage and smoking status are important markers of patient-reported function through the course of treatment, suggesting these are important groups for heightened surveillance and more intensive interventions to optimize swallowing outcomes.

LEVEL OF EVIDENCE

4 Laryngoscope, 127:842-848, 2017.

Psychometric evaluation of the Swallowing Outcomes After Laryngectomy (SOAL) patient-reported outcome measure

BACKGROUND

The purpose of this study was to evaluate the psychometric properties of the Swallowing Outcomes After Laryngectomy (SOAL) in a large group of people who underwent a laryngectomy.

METHODS

We conducted a cross-sectional psychometric study of laryngectomy patients (minimum 3 months posttreatment) attending routine hospital follow-up for the psychometric evaluation of SOAL.

RESULTS

One hundred ten people participated in this study. Thirteen percent of the patients had a laryngectomy, 63% had laryngectomy with radiotherapy, and 24% had laryngectomy with chemoradiation therapy. The SOAL showed good quality of data (minimal missing data and floor effects); good internal consistency (α = 0.91); and adequate test-retest reliability (intra-class correlation coefficient = 0.73). In terms of validity, it differentiated people by treatment group (F(2,85) = 8.02; p = .001) and diet texture group (t(102) = -7.33; p < .001).

CONCLUSION

The SOAL demonstrates good validity and has potential for use in research. Further study is required to determine its clinical application. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1639-E1645, 2016.

Effects of voice rehabilitation on health-related quality of life, communication and voice in laryngeal cancer patients treated with radiotherapy: a randomised controlled trial

OBJECTIVE

This study aims to assess the effect of voice rehabilitation on health-related quality of life (HRQL) and communication experience for laryngeal cancer patients treated with radiotherapy.

METHOD

This prospective randomised controlled trial included 74 patients with Tis-T4 laryngeal cancer treated curatively by radiotherapy, of which 37 constituted the intervention group receiving voice rehabilitation and 37 patients as a control group. Patients were followed at one and six months post-radiotherapy, with voice rehabilitation conducted between these time-points. Endpoints included patient reported outcomes, including HRQL as measured by European Organisation for Research and Treatment of Cancer (EORTC) Core30 (C30) and Head & Neck35 (H&N35) as well as communication function as measured by Swedish Self-Evaluation of Communication Experiences after Laryngeal cancer (S-SECEL).

RESULTS

The intervention group reported statistically significant improvements in communication experience as measured by S-SECEL environmental, attitudinal and total score domains compared to the control group. Similar improvements were seen in EORTC H&N35 Speech domain and the EORTC C30 domain Global quality of life. Moderate correlations were noted (r = 0.51-0.59) between three of four S-SECEL domains and the EORTC domains Speech and Global quality of life.

CONCLUSION

Laryngeal cancer patients treated with radiotherapy who receive voice rehabilitation appear to experience beneficial effects on communication function and selected HRQL domains. Voice rehabilitation following radiotherapy is recommended but further research investigating potential target groups and long-term effects is required.

Identification of behaviour change components in swallowing interventions for head and neck cancer patients: protocol for a systematic review

BACKGROUND

Dysphagia (difficulty in swallowing) is a predictable consequence of head and neck cancer and its treatment. Loss of the ability to eat and drink normally has a devastating impact on quality of life for survivors of this type of cancer. Most rehabilitation programmes involve behavioural interventions that include swallowing exercises to help improve swallowing function. Such interventions are complex; consisting of multiple components that may influence outcomes. These interventions usually require patient adherence to recommended behaviour change advice. To date, reviews of this literature have explored whether variation in effectiveness can be attributed to the type of swallowing exercise, the use of devices to facilitate use of swallowing muscles, and the timing (before, during or after cancer treatment). This systematic review will use a behavioural science lens to examine the content of previous interventions in this field. It aims to identify (a) which behaviour change components are present, and (b) the frequency with which they occur in interventions deemed to be effective and non-effective.

METHODS/DESIGN

Clinical trials of behavioural interventions to improve swallowing outcomes in patients with head and neck cancers will be identified via a systematic and comprehensive search of relevant electronic health databases, trial registers, systematic review databases and Web of Science. To ascertain behaviour change intervention components, we will code the content for its theory basis, intervention functions and specific behaviour change techniques, using validated tools: the Theory Coding Scheme, Behaviour Change Wheel and Behaviour Change Technique Taxonomy v1. Study quality will be assessed for descriptive purposes only. Given the specialisation and focus of this review, a small yield of studies with heterogeneous outcome measures is anticipated. Therefore, narrative synthesis is considered more appropriate than meta-analysis. We will also compare the frequency of behavioural components in effective versus non-effective interventions, where effectiveness is indicated by statistically significant changes in swallowing outcomes.

DISCUSSION

This review will provide a synthesis of the behaviour change components in studies that currently represent best evidence for behavioural swallowing interventions for head and neck cancer patients. Results will provide some guidance on the choice of optimal behavioural strategies for the development of future interventions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015017048.

Brush biopsy with DNA-image cytometry: a useful and noninvasive method for monitoring malignant transformation of potentially malignant oral disorders

Oral and pharyngeal cancer is the sixth most common cancer worldwide, the 5-year survival rate has not yet increased. A key factor in rates not having improved is the lack of early detection. This study was undertaken to estimate the diagnostic accuracy of brush biopsy with DNA-image cytometry (a noninvasive method) for potentially malignant oral disorders compared with tissue biopsy pathology in China. Exfoliative cells were obtained using a cytobrush cell collector from oral mucosa of 52 subjects, followed by scalpel biopsy from the same region. Nuclear DNA contents (ploidy) were measured after Feulgen restaining, using an automated DNA image cytometer. Exfoliative cytology with DNA-image cytometry and histopathological diagnosis were performed separately at different institutions. Histological investigation was considered the gold standard. We reported that the sensitivity of DNA aneuploidy for the detection of cancer cells in potentially malignant oral disorders was 86.36 %, its specificity was 90.00 %, its positive predictive value was 86.36 %, and its negative predictive value was 90.00 %. Brush biopsy with DNA-image cytometry is a useful method for monitoring potentially malignant oral disorders.