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Zhang J, Wu HY, Shan XF, Cai ZG, Zhang L, Yang Y. Effects of personalized oral exercises on swallowing function among patients with oral cancer after free flap transplantation: a cluster randomized controlled trial. Int J Oral Maxillofac Surg 2024; 53:355-363. [PMID: 38143220 DOI: 10.1016/j.ijom.2023.12.002] [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: 11/16/2022] [Revised: 12/04/2023] [Accepted: 12/06/2023] [Indexed: 12/26/2023]
Abstract
Dysphagia is a common complication in patients with oral cancer who have undergone free flap transplantation. The aim of this cluster randomized controlled trial was to evaluate the effect of personalized oral exercises on swallowing function in this group of patients. Eligible patients were randomly assigned to the intervention (n = 34) or control (n = 34) group. Intervention group patients received personalized oral exercises starting on day 6 after surgery. Swallowing function was evaluated on days 6 and 15, and at 1 month postoperative using the Mann Assessment of Swallowing Ability-Oral Cancer tool (MASA-OC). On day 15 and at 1 month after surgery, the total MASA-OC score (P = 0.003, P < 0.001) and the mouth opening (P = 0.001, P < 0.001) and lip seal (both P < 0.001) item scores showed a significantly greater improvement in the intervention group than in the control group. Moreover, the changes in salivation (P < 0.001) and tongue movement (P = 0.025) scores at 1 month after surgery were significantly greater in the intervention group than in the control group. There was no significant difference between the groups in the change in tongue strength scores on day 15 or at 1 month postoperative (P = 0.476, P = 0.223). Personalized oral exercises can improve swallowing function in patients with oral cancer after free flap transplantation.
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Affiliation(s)
- J Zhang
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology and National Center of Stomatology, Beijing, China.
| | - H-Y Wu
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology and National Center of Stomatology, Beijing, China.
| | - X-F Shan
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology and National Center of Stomatology, Beijing, China.
| | - Z-G Cai
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology and National Center of Stomatology, Beijing, China.
| | - L Zhang
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology and National Center of Stomatology, Beijing, China.
| | - Y Yang
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology and National Center of Stomatology, Beijing, China.
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Wu HY, Shan XF, Cai ZG, Zhang J, Li PJ, Zhang L, Yang Y. Early swallowing training after free flap surgery in oral cancer: A randomized controlled trial. Oral Dis 2024; 30:1970-1980. [PMID: 37392422 DOI: 10.1111/odi.14660] [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: 10/07/2022] [Revised: 05/01/2023] [Accepted: 06/14/2023] [Indexed: 07/03/2023]
Abstract
OBJECTIVE To explore the effect of early swallowing training on postoperative outcomes of patients who had undergone oral cancer surgery plus free flap reconstruction. SUBJECTS AND METHODS In this prospective, randomized controlled trial, 121 patients who had undergone oral cancer surgery plus free flap reconstruction were randomly assigned to the control (n = 59) or intervention group (n = 62). The control group underwent routine nursing measures. The intervention group received swallowing training on the sixth postoperative day. On the 15th day and 1 month after surgery, the swallowing function (Mann Assessment of Swallowing Ability-Oral Cancer [MASA-OC] score), weight loss rate, time of nasogastric tube removal, and quality of life were evaluated. RESULTS Patients in the intervention group had higher MASA-OC scores and better weight loss rates than those in the control group on the 15th day (MASA-OC: p = 0.014, weight loss: p < 0.001) and 1 month (both p < 0.001) after surgery. The time of nasogastric tube removal and the quality of life was statistically significant between groups (p < 0.001). CONCLUSION Early swallowing training improves the swallowing function, nutritional status, and quality of life and shortens the indwelling time of nasogastric tube of patients who have undergone oral cancer surgery plus free flap reconstruction.
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Affiliation(s)
- Hong-Yun Wu
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology & National Center of Stomatology, Beijing, China
| | - Xiao-Feng Shan
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology & National Center of Stomatology, Beijing, China
| | - Zhi-Gang Cai
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology & National Center of Stomatology, Beijing, China
| | - Jing Zhang
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology & National Center of Stomatology, Beijing, China
| | | | - Lei Zhang
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology & National Center of Stomatology, Beijing, China
| | - Yue Yang
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology & National Center of Stomatology, Beijing, China
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Kuenzel J, Duerr S, Vester S, Zeman F, Huppertz G, Koller M, Pfleger G, Woertgen A, Salloum H, Klinkhammer-Schalke M, Pukrop T, Kummer P. The effects of Phoniatric PREhabilitation in Head and Neck Cancer patients on Aspiration and Preservation of Swallowing (PREHAPS): study protocol of a monocentric prospective randomized interventional outcome-blinded trial. Trials 2024; 25:211. [PMID: 38519961 PMCID: PMC10958950 DOI: 10.1186/s13063-024-08010-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 02/22/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND Dysphagia, with its negative impact on life expectancy and quality of life, is a major side effect of head and neck squamous cell carcinoma (HNSCC). In a typical Head and Neck Cancer Center, more than half of patients are affected. Improving treatment, and ideally prevention respectively prehabilitation, therefore seems more than desirable. METHODS The study is planned as a monocentric, prospective, outcome-blinded, randomized interventional study comparing an advanced phoniatric-logopedic prehabilitation with a control (standard of care). Seventy patients (30 control group, 30 intervention group, 10 drop-out rate of 15%) with an initial diagnosis of invasive HNSCC and curative treatment intention will be included over a period of 17 months. In addition to the previous standard, both groups will undergo both detailed subjective assessment of swallowing function and quality of life by means of various questionnaires and objective analyses by bioelectrical impedance measurements and phoniatric endoscopic swallowing examinations. In the intervention group, risk-related nutritional counseling (face-to-face) and phoniatric-logopedic prehabilitation are provided: detailed counseling with video demonstration and exercises to strengthen and improve the range of motion of the oral, pharyngeal, and laryngeal muscles (guided by exercise diary). Controls are performed at 6 weeks, 3 and 6 months, and 9 or 12 months after the end of therapy during the regular tumor follow-up. Primary study endpoints are swallowing function and emotional distress at 6 weeks of control visit. DISCUSSION Prehabilitation measures have already proven successful in other patient groups, e.g., transplant patients. In the field of head and neck oncology, interest in such concepts has increased significantly in recent years. However, usually, only subgroups, e.g., patients with swallowing problems after radiochemotherapy alone, are in focus. Our study aims to investigate the general benefit of prehabilitation with regard to swallowing function, which is so important for protection of aspiration and quality of life. TRIAL REGISTRATION German Clinical Trials Register DRKS00029676 . International Clinical Trials Registry Platform DRKS00029676 . Registered on 19 July 2022.
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Affiliation(s)
- Julian Kuenzel
- Department of Otorhinolaryngology, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, Regensburg, 93053, Germany.
| | - Stephan Duerr
- Department of Otorhinolaryngology, Section Phoniatrics and Pediatric Audiology, University Hospital Regensburg, Regensburg, Germany
| | - Sarah Vester
- Department of Otorhinolaryngology, Section Phoniatrics and Pediatric Audiology, University Hospital Regensburg, Regensburg, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | - Gunnar Huppertz
- Center for Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | - Michael Koller
- Center for Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | - Gerda Pfleger
- Department of Otorhinolaryngology, Section Phoniatrics and Pediatric Audiology, University Hospital Regensburg, Regensburg, Germany
| | - Annika Woertgen
- Department of Otorhinolaryngology, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, Regensburg, 93053, Germany
| | - Hazem Salloum
- Department of Otorhinolaryngology, Section Phoniatrics and Pediatric Audiology, University Hospital Regensburg, Regensburg, Germany
| | - Monika Klinkhammer-Schalke
- Institute for Quality Management and Health Services Research, University Hospital Regensburg, Regensburg, Germany
| | - Tobias Pukrop
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Regensburg, Germany
| | - Peter Kummer
- Department of Otorhinolaryngology, Section Phoniatrics and Pediatric Audiology, University Hospital Regensburg, Regensburg, Germany
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Vester S, Muhr A, Meier J, Süß C, Kummer P, Künzel J. Prehabilitation of dysphagia in the therapy of head and neck cancer- a systematic review of the literature and evidence evaluation. Front Oncol 2023; 13:1273430. [PMID: 38188284 PMCID: PMC10766849 DOI: 10.3389/fonc.2023.1273430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 11/27/2023] [Indexed: 01/09/2024] Open
Abstract
Background Prehabilitation is becoming increasingly important in oncology because of the significant survival benefits that the reduction of malnutrition provide. Specifically, tumor- and therapy-related dysphagia leads to malnutrition in more than half of head and neck tumor patients. Studies describe the positive effects of an early onset of swallow-specific prehabilitation on the protection of the swallowing function. This paper intents to evaluate the existing evidence on the efficacy of preventive forms of swallowing therapy. Methods A systematic literature search was performed in February 2022 in the Cochrane Library, MEDLINE via PubMed, and ClinicalTrials.gov databases for randomized controlled trials investigating preventive swallowing therapy in head and neck tumor patients. This Procedure complies with the PRISMA statement. The RCTs were evaluated by using the PEDro Scale and the Cochrane Risk of Bias tool RoB2. Results Five randomized-controlled trials with 423 participants were identified. Four Studies showed moderate to high quality in the PEDro analysis, one showed less. The risk of bias was high in all studies because there was no possibility for blinding and there were high dropout rates. Heterogeneity in interventions, measurement instruments, measurement time points, and outcomes limits a general statement about which swallowing exercises are suitable for the prevention of dysphagia in head and neck tumor patients. Evidence is provided for short-term effects (≤24 months) on functional aspects of swallowing and quality of life. Overall, a decreasing adherence over time was observed in the intervention groups. Discussion Initial studies describe swallowing-specific prehabilitation programs in head and neck tumor patients as effective, at least in the short term, whereas long-term effects need to be further investigated. At the current time the evidence base for clear recommendations does not appear to be sufficiently high and studies share a high risk of bias. Further well-designed research, especially considering the conditions in the national health care system, is needed. Other There was no funding and no registration.
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Affiliation(s)
- Sarah Vester
- Department of Otorhinolaryngology, Department of Phoniatrics and Pediatric Audiology, Hospital of the University of Regensburg, Regensburg, Germany
| | - Anna Muhr
- Department of Otorhinolaryngology, Department of Phoniatrics and Pediatric Audiology, Hospital of the University of Regensburg, Regensburg, Germany
| | - Johannes Meier
- Department of Oral and Maxillofacial Surgery, Regensburg Hospital of the University of Regensburg, Regensburg, Germany
| | - Christoph Süß
- Department of Radiotherapy, Hospital of the University of Regensburg, Regensburg, Germany
| | - Peter Kummer
- Department of Otorhinolaryngology, Department of Phoniatrics and Pediatric Audiology, Hospital of the University of Regensburg, Regensburg, Germany
| | - Julian Künzel
- Department of Otorhinolaryngology, Hospital of the University of Regensburg, Regensburg, Germany
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Mathew A, Lockwood MB, Steffen A, Tirkey AJ, Pavamani SP, Patil CL, Doorenbos AZ. Symptom Cluster Experiences of Patients Operated for Oral Cancer: A Mixed Methods Study. Semin Oncol Nurs 2023; 39:151407. [PMID: 37024322 PMCID: PMC10258150 DOI: 10.1016/j.soncn.2023.151407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 02/20/2023] [Accepted: 03/01/2023] [Indexed: 04/08/2023]
Abstract
OBJECTIVE This convergent mixed methods study aimed to obtain a comprehensive understanding of symptom cluster experiences in patients with oral cancer. Survey and phenomenological interviews were conducted in parallel to identify distinct patient subgroups based on symptom cluster experiences along with their predictors and explore experiences of living with symptom clusters, respectively. DATA SOURCES A convenience sample of 300 patients with oral cancer who had completed surgery provided the quantitative data, and a maximum variation purposive subsample of 20 participants, drawn from the survey sample, provided the qualitative data. Agglomerative hierarchical cluster analysis was used to identify subgroups, multivariate analyses were done to identify predictors, and thematic analysis was used for patient narratives. CONCLUSION Almost 94% of the survey participants had two or more co-occurring symptoms. The four most severe and prevalent symptoms were dysphagia, problems with teeth or gums, speech difficulty, and dry mouth. A distinct subgroup consisting of 61% of patients reported severe dysphagia and teeth problems, which was associated with age, oral cancer stage and site. Interviews revealed the causes and the context influencing the perception and response to these symptoms. Thus, the quantitative data provided information on severity and patient subgroups based on symptom cluster experiences, while the qualitative data validated these conclusions and additionally provided in-depth details and meaningful insight on perceived causes and contextual influences of their experiences. This comprehensive picture of symptom cluster experiences can aid in the development of patient-centered interventions for people with oral cancer. IMPLICATIONS FOR NURSING PRACTICE An interdisciplinary approach to targeting concurrent symptoms incorporating psychological and physical interventions is necessary. Older patients treated for Stage IV cancers and for buccal mucosa tumors are at high-risk of having severe dysphagia postoperatively, and these patients should be targeted for dysphagia interventions. The contextual factors play an important role in developing patient-centered interventions.
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Affiliation(s)
- Asha Mathew
- PhD Scholar, College of Nursing, University of Illinois Chicago, US; Professor, College of Nursing, Christian Medical College Vellore, Tamil Nadu, India
| | - Mark B Lockwood
- Assistant Professor, College of Nursing, University of Illinois Chicago, US
| | - Alana Steffen
- Research Associate Professor, College of Nursing, University of Illinois Chicago, US
| | - Amit Jiwan Tirkey
- Professor, Department of Head and Neck Surgery, Christian Medical College Vellore, Tamil Nadu, India
| | - Simon P Pavamani
- Professor, Department of Radiation Oncology, Christian Medical College Vellore, Tamil Nadu, India
| | - Crystal L Patil
- Professor, College of Nursing, University of Illinois Chicago, US
| | - Ardith Z Doorenbos
- Professor, College of Nursing, University of Illinois Chicago, US; Director of Palliative Care, University of Illinois Cancer Center, Chicago, US.
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Zhang J, Li Q, Wu HY, Yang Y. A Systematic Review of Swallowing Training Measures for Postoperative Oral Cancer Patients. Dysphagia 2022; 37:1839-1850. [PMID: 35435477 DOI: 10.1007/s00455-022-10445-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 03/28/2022] [Indexed: 12/24/2022]
Abstract
Swallowing disorder is one of the most common postoperative complications for oral cancer patients and seriously influences quality of life. Limited attention has been paid to evaluating swallowing training measures in postoperative oral cancer patients. This study systematically reviewed swallowing training measures for these patients. A comprehensive search strategy was undertaken across various databases for studies published between database inception and 15 June 2021. Raters independently judged titles, abstracts and full articles for selection according to inclusion and exclusion criteria. The included literature was evaluated for quality and data were extracted. Meta-analyses were conducted using RevMan 5.3. Ten intervention studies (four randomized controlled trials and six quasi-experimental studies) involving 588 patients were identified. Across the studies, most started in the early postoperative stage; however, there were differences in starting time, training time and duration, and type of training. We summarized four training methods: oral exercise, oral sensory stimulation, compensatory strategies and protective airway manoeuvres. The meta-analysis indicated that swallowing training could improve patients' swallowing function and quality of life in the short term, but the long-term effects were not obvious. Swallowing training mostly occurred in the early postoperative period and training measures were often used in combination. The timing, frequency and content of interventions varied between studies, and the effectiveness of any single measure was unclear. High-quality randomized controlled trials are necessary to study the efficacy and clinical applicability of various training measures, to provide a theoretical basis for their optimal selection and to develop a standardized training programme for postoperative oral cancer patients.
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Affiliation(s)
- Jing Zhang
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology & National Center of Stomatology, Beijing, 100081, China
| | - Quan Li
- Tianjin Medical University Eye Hospital, Tianjin, 300384, China
| | - Hong-Yun Wu
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology & National Center of Stomatology, Beijing, 100081, China
| | - Yue Yang
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology & National Center of Stomatology, Beijing, 100081, China.
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Zhang J, Wu HY, Lu Q, Shan XF, Cai ZG, Zhang L, Wei L, Yang Y. Effects of personalized swallowing rehabilitation in patients with oral cancer after free flap transplantation: A cluster randomized controlled trial. Oral Oncol 2022; 134:106097. [PMID: 36126603 DOI: 10.1016/j.oraloncology.2022.106097] [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: 06/20/2022] [Revised: 08/16/2022] [Accepted: 08/23/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Dysphagia is a common and serious complication in patients with oral cancer after free flap transplantation (OC-FFT), which seriously affects their quality of life. Studies have found swallowing rehabilitation can improve the swallowing ability of these patients, but the studies have design deficiencies. This study's purpose was to test the effectiveness of personalized swallowing rehabilitation for this patient population. MATERIALS AND METHODS This is a cluster randomized, non-blind, controlled clinical trial. Participants were 68 OC-FFT patients randomly assigned to intervention (n = 34) or control (n = 34) groups. The control group received routine nursing and health education, while the intervention group received personalized swallowing rehabilitation twice a day for 10 days, based on the results of the Mann Assessment of Swallowing Ability-Oral Cancer (MASA-OC). On the 6th and 15th days and 1 month after the operation, MASA-OC scores and percentage weight loss were measured, and the removal time to nasogastric tube was also recorded. The quality of life was evaluated 1 month after the operation. RESULTS On day 15 and 1 month after the operation, MASA-OC scores were higher and the percentage weight loss was lower in the intervention group than the control group (P < 0.05). The removal time of the nasogastric tube was shorter (P < 0.05), and the quality of life at 1 month was better in the intervention group (P < 0.05). CONCLUSION Personalized swallowing rehabilitation can improve patients' swallowing after OC-FFT, promote the early removal of the nasogastric tube, and improve nutritional status and quality of life.
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Affiliation(s)
- Jing Zhang
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology & National Center of Stomatology, Beijing 100081, China.
| | - Hong-Yun Wu
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology & National Center of Stomatology, Beijing 100081, China.
| | - Qian Lu
- Peking University School of Nursing, Beijing 100191, China.
| | - Xiao-Feng Shan
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology & National Center of Stomatology, Beijing 100081, China.
| | - Zhi-Gang Cai
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology & National Center of Stomatology, Beijing 100081, China.
| | - Lei Zhang
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology & National Center of Stomatology, Beijing 100081, China.
| | - Li Wei
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology & National Center of Stomatology, Beijing 100081, China.
| | - Yue Yang
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology & National Center of Stomatology, Beijing 100081, China.
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Lehner U, Zaretsky E, Goeze A, Wermter L, Stuck BA, Birk R, Neff A, Fischer I, Ghanaati S, Sader R, Hey C. [Pre-treatment dysphagia in head-and-neck cancer patients]. HNO 2022; 70:533-539. [PMID: 35122104 PMCID: PMC9242961 DOI: 10.1007/s00106-021-01128-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2021] [Indexed: 12/03/2022]
Abstract
BACKGROUND The swallowing and nutritional status of head-and-neck cancer patients after oncological therapy have been extensively researched. However, the same topics are seldom scrutinized before the onset of oncological therapy, although they can influence treatment success in the long term. OBJECTIVE This study focusses on a systematic assessment of swallowing function and nutritional status in head-and-neck cancer patients prior to oncological therapy. MATERIALS AND METHODS In 102 patients, penetration/aspiration (PA scale), limitations of oral intake (Functional Oral Intake Scale, FOIS), and the need for further intervention (NFI) were endoscopically assessed to objectively quantify swallowing function. The subjective evaluation of swallowing function was carried out with the gEAT-10 (German EAT-10) questionnaire, nutritional status was assessed by body mass index (BMI). Possible impact factors for swallowing function and BMI were analyzed by univariate and multivariate methods. RESULTS PAS, FOIS, and NFI values were abnormal in ≤ 15% of patients. BMI was more often too high than too low. Objectively assessed swallowing functions depended predominantly on tumor stage and showed moderate correlations with gEAT-10. The latter mostly yielded a "fail" result. The nutritional status depended on the patients' biological sex and NFI. CONCLUSION In the pre-treatment setting, neither dysphagia nor malnutrition were found in most patients. Impaired swallowing was associated with higher tumor stages, malnutrition with female sex and NFI. A systematic pre-treatment assessment of swallowing and nutritional status in head-and-neck cancer patients appears necessary for modern oncological therapy and optimal patient outcome.
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Affiliation(s)
- Uta Lehner
- Abteilung für Phoniatrie und Pädaudiologie, HNO, Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Philipps-Universität Marburg, Baldingerstr. 1, 35043, Marburg, Deutschland
| | - Eugen Zaretsky
- Abteilung für Phoniatrie und Pädaudiologie, HNO, Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Philipps-Universität Marburg, Baldingerstr. 1, 35043, Marburg, Deutschland.
| | - Almut Goeze
- Abteilung für Phoniatrie und Pädaudiologie, HNO, Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Philipps-Universität Marburg, Baldingerstr. 1, 35043, Marburg, Deutschland
| | - Laura Wermter
- Abteilung für Phoniatrie und Pädaudiologie, HNO, Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Philipps-Universität Marburg, Baldingerstr. 1, 35043, Marburg, Deutschland
| | - Boris A Stuck
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Philipps-Universität Marburg, Marburg, Deutschland
| | - Richard Birk
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Philipps-Universität Marburg, Marburg, Deutschland
| | - Andreas Neff
- Klinik und Poliklinik für Mund‑, Kiefer- und Gesichtschirurgie, Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Philipps-Universität Marburg, Marburg, Deutschland
| | - Ingo Fischer
- Klinik und Poliklinik für Mund‑, Kiefer- und Gesichtschirurgie, Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Philipps-Universität Marburg, Marburg, Deutschland
| | - Shahram Ghanaati
- Klinik für Mund‑, Kiefer‑, Plastische Gesichtschirurgie, Universitätsklinikum Frankfurt/Main, Goethe-Universität Frankfurt/Main, Frankfurt/Main, Deutschland
| | - Robert Sader
- Klinik für Mund‑, Kiefer‑, Plastische Gesichtschirurgie, Universitätsklinikum Frankfurt/Main, Goethe-Universität Frankfurt/Main, Frankfurt/Main, Deutschland
| | - Christiane Hey
- Abteilung für Phoniatrie und Pädaudiologie, HNO, Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Philipps-Universität Marburg, Baldingerstr. 1, 35043, Marburg, Deutschland
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Examination of Suprahyoid Muscle Resection and Other Factors Affecting Swallowing Function in Patients With Advanced Oral Cancer After Surgical Resection and Reconstruction. J Craniofac Surg 2022; 33:e840-e844. [PMID: 36409859 PMCID: PMC9612680 DOI: 10.1097/scs.0000000000008770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 04/04/2022] [Indexed: 11/05/2022] Open
Abstract
Dysphagia is one of the most common adverse effects associated with oral cancer therapy and could greatly impair postoperative quality of life. The objective of this study was to analyze postoperative swallowing outcomes and factors influencing postoperative swallowing function in patients with advanced oral cancer who underwent primary reconstruction after surgical resection to identify patients at risk of experiencing severe dysphagia after immediate reconstruction of surgical defects, and to determine an ideal approach to provide appropriate perioperative interventions. The swallowing status was evaluated at 4 week postoperatively using the Functional Oral Intake Scale. We also analyzed the effects of patient, tumor, surgical, and other factors on postoperative swallowing function. The study included 67 patients. At 4 weeks postoperatively, 11 patients showed reduced swallowing function, whereas 56 patients showed good swallowing function. The number of resected suprahyoid muscles (odds ratio, 1.55; 95% confidence interval, 1.03-2.32; P=0.035) was an independent factor influencing postoperative swallowing function. Thus, among patients who underwent radical resection of oral cancer with primary reconstruction, those with extensive resection of the suprahyoid muscles were at higher risk of developing postoperative dysphagia. These findings are expected to facilitate increased vigilance for dysphagia, better counseling, and appropriate rehabilitation interventions.
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10
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Tooth extractions prior to chemoradiation or bioradiation are associated with weight loss during treatment for locally advanced oropharyngeal cancer. Support Care Cancer 2022; 30:5329-5338. [PMID: 35278135 PMCID: PMC9046292 DOI: 10.1007/s00520-022-06942-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 02/26/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE Prior to radiotherapy combined with chemotherapy (CRT) or biotherapy (BRT) for oropharyngeal squamous cell carcinoma (OPSCC), teeth with poor prognosis that pose a risk for post-RT osteoradionecrosis (ORN) are removed. The effect of tooth loss on body weight loss and tube feeding (TF) dependency during CRT/BRT is unknown. This study aimed to evaluate the effect of incomplete dentition, tooth extractions prior to CRT/BRT, and the subsequent loss of functional units on (1) weight loss during CRT/BRT and (2) the need for TF during CRT/BRT for OPSCC. METHODS OPSCC patients treated with CRT/BRT between 2013 and 2016 were included in this retrospective cohort study. Dental status was determined during the dental assessment at first visit and after tooth extractions prior to the start of CRT/BRT. Weight loss during CRT/BRT was scored dichotomously, comparing weight loss > 5% to stable or increased weight. Potential factors associated with weight loss were identified, including patient, tumor, and treatment characteristics. RESULTS Seventy-seven OPSCC patients were included. Forty patients (52%) experienced weight loss > 5% during CRT/BRT. Extractions were performed in 66% of the OPSCC patients. The mean number of extracted teeth was 4.1 ± 5.6 per patient. Tooth extractions prior to CRT/BRT were associated with weight loss > 5% during CRT/BRT (HR 1.130 (95% CI 1.011-1.262), p = 0.031). None of the dental status-related parameters showed any significant associative value for TF during CRT/BRT. CONCLUSIONS Pre-CRT/BRT tooth extractions intended to reduce the risk of ORN, are a risk factor for weight loss during CRT/BRT for OPSCC. TRIAL REGISTRATION NUMBER This study was approved by the medical ethics committee of the MUMC + (METC 2020-1589) on July 28, 2020.
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Bschorer M, Schneider D, Goppold K, Sperling J, Schön G, Bschorer R. Quality of life and survival rate after primary surgical treatment of oral squamous cell carcinoma: A retrospective study with 18 years of follow-up. J Craniomaxillofac Surg 2021; 50:170-177. [PMID: 34625373 DOI: 10.1016/j.jcms.2021.09.016] [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: 05/11/2020] [Revised: 07/25/2021] [Accepted: 09/26/2021] [Indexed: 10/20/2022] Open
Abstract
The aim of this study is to evaluate the long-term survival rates and assess the long-term quality of life (QoL) of patients treated for oral squamous cell carcinoma (OSCC). Patients, who underwent primary surgical tumor resection for OSCC at a single hospital center in Germany between 1998 and 2016, were eligible for inclusion in this analysis of survival rates and QoL parameters. The University of Washington-QoL version 4 (UW-QoL v4) questionnaire was administered to the patients in the years 2015 and 2016. The cases of 145 patients with the histological diagnosis of OSCC were included in this study. Despite a common distribution of tumor stage, the 1-year survival rate was 88.0% and the 5-year survival rate was 70.0%. The QoL questionnaire item, 'pain' (84) was selected most frequently. Chewing (50) and swallowing (58) yielded the lowest score. Chewing and swallowing impairment correlated significantly with an increase in tumor size, higher tumor stages, and the use of radio (chemo-)therapy (p < 0.001). In this retrospective study, patients reported significant long-term dysphagia and difficulty chewing. These parameters should be investigated in prospective studies to evaluate methods that could reduce the risk of suffering from these impairments.
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Affiliation(s)
- Maximilian Bschorer
- Department of Oral and Maxillofacial Surgery, Helios Kliniken Schwerin, Germany.
| | - Daniel Schneider
- Department of Oral and Maxillofacial Surgery, Helios Kliniken Schwerin, Germany
| | - Kai Goppold
- Department of Oral and Maxillofacial Surgery, Helios Kliniken Schwerin, Germany
| | - Juliane Sperling
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Germany
| | - Gerhard Schön
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Reinhard Bschorer
- Department of Oral and Maxillofacial Surgery, Helios Kliniken Schwerin, Germany
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Matsuda Y, Okui T, Karino M, Aoi N, Okuma S, Hayashida K, Sakamoto T, Kanno T. Postoperative oral dysfunction following oral cancer resection and reconstruction: A preliminary cross-sectional study. Oral Oncol 2021; 121:105468. [PMID: 34314945 DOI: 10.1016/j.oraloncology.2021.105468] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 07/17/2021] [Accepted: 07/20/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Oral cancer treatment reportedly causes decreased oral function, but few studies have examined the effects of oral cancer treatment on oral function in depth. This study aimed to comprehensively evaluate the oral function after treatment and classify the conditions related to oral dysfunction in patients with oral cancer. MATERIALS AND METHODS We recruited participants, collected their background data, and evaluated their oral function from September 2019 to March 2021. Principal component analysis was used to identify the components of oral function measurement and oral health perception. Receiver operating characteristic analysis was performed to investigate the accuracy of oral function measurements in predicting oral intake and nutritional status. RESULTS Fifty patients treated for oral cancer, including 33 (66.0%) males and 17 (34.0%) females, were included. Their median age was 71.0 years (interquartile range: 63.0-76.0). There were significant differences in oral dryness between males and females, occlusal force among different age groups, tongue pressure based on the tumor stage and performance of reconstructive procedures, and masticatory function and Eating Assessment Tool scores based on whether radiotherapy was performed (P < 0.05). The principal component analysis proposed that oral function measurements and subjective oral health perception could be divided into three main components (transport, oral hygiene, and occlusion type), which explain 61.5% of the variance of the phenomenon. CONCLUSION A significant decrease in oral function after oral cancer treatment should be diagnosed as postoperative oral dysfunction. Postoperative oral dysfunction can be classified into three types, each of which may present with different pathologies.
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Affiliation(s)
- Yuhei Matsuda
- Department of Oral and Maxillofacial Surgery, Shimane University Faculty of Medicine, Izumo, Shimane, Japan.
| | - Tatsuo Okui
- Department of Oral and Maxillofacial Surgery, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Masaaki Karino
- Department of Oral and Maxillofacial Surgery, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Noriaki Aoi
- Department of Otolaryngology, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Satoe Okuma
- Department of Oral and Maxillofacial Surgery, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Kenji Hayashida
- Department of Plastic and Reconstructive Surgery, Shimane University Hospital, Izumo, Shimane, Japan
| | - Tatsunori Sakamoto
- Department of Otolaryngology, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Takahiro Kanno
- Department of Oral and Maxillofacial Surgery, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
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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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de Vicente JC, Rúa-Gonzálvez L, Barroso JM, Fernández Del Valle-Fernández Á, de Villalaín L, Peña I, Cobo JL. Functional results of swallowing and aspiration after oral cancer treatment and microvascular free flap reconstruction: A retrospective observational assessment. J Craniomaxillofac Surg 2021; 49:959-970. [PMID: 33994072 DOI: 10.1016/j.jcms.2021.04.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 03/20/2021] [Accepted: 04/26/2021] [Indexed: 10/21/2022] Open
Abstract
This study aimed to assess the functional swallowing outcomes in cohort of oral cancer patients treated with tumor resection and reconstruction by means of microvascular free flaps. Duration from onset to the last examination was classified into three periods: less than 12 months, from 13 to 24 months, and more than 24 months. Type of feeding, dysphagia, and laryngeal aspiration were the dependent variables, and the study was mainly focused on the data from the multivariate analysis. Fifty-one patients were included in the study. Twenty-one patients had dysphagia, 11 showed stasis in vallecula and pyriform sinuses, 9 experienced laryngeal penetration, and 8 aspirations. Surgery combined with radiochemotherapy was associated with a higher prevalence of dysphagia (p = 0.03). Frequency of dysphagia was higher in the first year after treatment and less frequent after 24 months (p = 0.003). Dysphagia was associated with laryngeal penetration (p = 0.001), and this with aspiration (p < 0.0005). In conclusion, as it seems that the method of reconstruction has a major influence on swallowing, when there are relevant alternatives in the way the reconstruction is done, always the approach should be chosen that reduces dysphagia to a minimum.
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Affiliation(s)
- Juan Carlos de Vicente
- Department of Oral and Maxillofacial Surgery, Hospital Universitario Central de Asturias (HUCA). C/ Carretera de Rubín, S/n, 33011, Oviedo, Asturias, Spain; Department of Surgery, University of Oviedo, Asturias, Spain; Instituto de Investigación Sanitaria Del Principado de Asturias (ISPA), Instituto Universitario de Oncología Del Principado de Asturias (IUOPA), Universidad de Oviedo. C/ Carretera de Rubín, S/n, 33011, Oviedo, Asturias, Spain.
| | - Laura Rúa-Gonzálvez
- Department of Oral and Maxillofacial Surgery, Hospital Universitario Central de Asturias (HUCA). C/ Carretera de Rubín, S/n, 33011, Oviedo, Asturias, Spain
| | - José María Barroso
- Phoniatrician. Department of Rehabilitation, Hospital Universitario Central de Asturias, Oviedo, Asturias (HUCA). C/ Carretera de Rubín, S/n, 33011, Oviedo, Asturias, Spain
| | - Álvaro Fernández Del Valle-Fernández
- Department of Oral and Maxillofacial Surgery, Hospital Universitario Central de Asturias (HUCA). C/ Carretera de Rubín, S/n, 33011, Oviedo, Asturias, Spain; Instituto de Investigación Sanitaria Del Principado de Asturias (ISPA), Instituto Universitario de Oncología Del Principado de Asturias (IUOPA), Universidad de Oviedo. C/ Carretera de Rubín, S/n, 33011, Oviedo, Asturias, Spain
| | - Lucas de Villalaín
- Department of Oral and Maxillofacial Surgery, Hospital Universitario Central de Asturias (HUCA). C/ Carretera de Rubín, S/n, 33011, Oviedo, Asturias, Spain; Instituto de Investigación Sanitaria Del Principado de Asturias (ISPA), Instituto Universitario de Oncología Del Principado de Asturias (IUOPA), Universidad de Oviedo. C/ Carretera de Rubín, S/n, 33011, Oviedo, Asturias, Spain
| | - Ignacio Peña
- Department of Oral and Maxillofacial Surgery, Hospital Universitario Central de Asturias (HUCA). C/ Carretera de Rubín, S/n, 33011, Oviedo, Asturias, Spain; Instituto de Investigación Sanitaria Del Principado de Asturias (ISPA), Instituto Universitario de Oncología Del Principado de Asturias (IUOPA), Universidad de Oviedo. C/ Carretera de Rubín, S/n, 33011, Oviedo, Asturias, Spain
| | - Juan Luis Cobo
- Department of Oral and Maxillofacial Surgery, Hospital Universitario Central de Asturias (HUCA). C/ Carretera de Rubín, S/n, 33011, Oviedo, Asturias, Spain
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von Allmen D, Tang A, Takiar V, Zender C, Romeo S, Masch J, Casper K, Patil Y, Wilson K, Khosla S, Niu L, Altaye M, Tabangin M, Howell RJ. Modified Head and Neck Swallow Scale: Using EORTC-QLQ-H&N35 to Predict Overall Survival. Laryngoscope 2021; 131:2478-2482. [PMID: 33894000 DOI: 10.1002/lary.29559] [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: 11/17/2020] [Revised: 03/24/2021] [Accepted: 03/30/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS Dysphagia is a treatment-related complication of head and neck cancer (HNCA). We demonstrate the predictive value of a modified head and neck swallow scale (m-HNSW) adapted from the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Head and Neck 35 (EORTC-QLQ-H&N35). STUDY DESIGN Retrospective Cohort Study. METHODS Retrospective, single-center cohort study utilizing a prospectively collected database of HNCA patients in a high-volume tertiary referral center. 736 HNCA patients more than 2 years from completion of treatment were identified. EORTC-QLQ-H&N35 data collected from at least one of three defined episodes of care were used. The m-HNSW uses three questions to form a 9-point dysphagia scale. A Cox proportional hazards model was used to determine the effect of the m-HNSW while controlling for demographics, tumor staging, site, and treatment. RESULTS Using data from 3, 6, 12 months from treatment, we analyzed a subset that included 328 patients. Three months after the completion of therapy, the m-HNSW score had a significant association with 1 (HR = 1.24, P = .0005) and 5 year survival (HR = 1.19, P = .0002) after accounting for body mass index. Six (HR = 1.14, P = .014) and 12 month (hazard ratio (HR) = 1.33, P < .0001) scores post completion of therapy predict 5-year survival. An increase of the m-HNSW score by 1 point was associated with an increase in death by 24%, and 19% at 1 and 5 years following therapy. CONCLUSIONS The m-HNSW is a simple assessment of dysphagia using previously validated EORTC-QLC-H&N35 data that when taken at 3, 6, and 12 months after completion of therapy is predictive of overall survival. LEVEL OF EVIDENCE 4 Laryngoscope, 2021.
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Affiliation(s)
- Douglas von Allmen
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Alice Tang
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Vinita Takiar
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Chad Zender
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Stephen Romeo
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Jessica Masch
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Keith Casper
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, College of Medicine, Ann Arbor, Michigan, U.S.A
| | - Yash Patil
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Keith Wilson
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Siddarth Khosla
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Liang Niu
- Department of Biostatistics and Bioinformatics, University of Cincinnati, Cincinnati, Ohio, U.S.A
| | - Mekibib Altaye
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Meredith Tabangin
- Department of Biostatistics and Bioinformatics, University of Cincinnati, Cincinnati, Ohio, U.S.A
| | - Rebecca J Howell
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
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