Prehabilitation in head and neck cancer patients: a literature review

[Prehabilitation and sport in oncology]

Numerous randomized controlled trials confirm the clinical importance of exercise therapy in the management of side effects of cancer treatment. Physically active cancer patients also have a better prognosis. Since it has been known that the physical performance level before surgery is a strong prognostic factor for the occurrence of perioperative complications, the focus of interest has also been on exercise therapy-based prehabilitation. Studies in this field show that even very short interventions (2-4 weeks) can achieve lower perioperative complication rates, particularly for pulmonary complications. Even if the evidence is still limited, it can be concluded that every patient should be offered exercise therapy prehabilitation in preparation for major pulmonary or gastrointestinal surgical interventions. However, there are so far hardly any treatment structures that make this currently possible.

Comparison between adult comorbidity evaluation-27 and Charlson Comorbidity Index in head and neck oncology

OBJECTIVES

To determine whether Adult Comorbidity Evaluation-27 (ACE-27) or Charlson Comorbidity Index (CCI) is more accurate in predicting overall survival in head and neck squamous cell cancer (HNSCC) patients.

METHODS

A retrospective study was conducted on all patients with a primary HNSCC diagnosis and treatment between January 1st, 2010, and December 31th, 2013 at ErasmusMC, the Netherlands. Medical records were reviewed for patient data. The following covariables were considered: sex, age, subsite of the index HNSCC, treatment, TNM-stage, tobacco use and alcohol use. Significant covariables were identified with Kaplan-Meier analyses. Two Cox-regression models were made including the covariables and each comorbidity model. The primary endpoint was the c-statistic, with overall survival as the dependent variable and the covariables as the independent variables in the comorbidity models.

RESULTS

A total of 1,193 patients were included in the study, with an average age of 63.9 years (SD:10.7). In the Kaplan-Meier analysis, all variables, except sex, demonstrated a significant correlation with 5-year-overall survival. According to the Cox regression analysis, there was a HR of 2.462 (95 %CI:1.630-3.718) for a CCI of ≥ 5. The HR at an ACE-27 score of 3 was 1.969 (95 %CI:1.457-2.660). The model that incorporated the CCI score resulted in an average c-statistic of 0.6783 (range:0.6524-0.6935), while the mean c-statistic for the model with the ACE-27 was 0.6790 (range:0.6364-0.6973).

CONCLUSION

In individuals diagnosed with HNSCC, both the ACE-27 and CCI serve as independent factors that reflect overall survival. Their predictive capabilities are comparable, allowing for their interchangeable use in both clinical and research contexts.

The ReDyor study: Effects of prophylactic swallowing exercises on dysphagia and quality of life in patients with head and neck cancer receiving chemoradiation therapy, a randomized clinical trial

OBJECTIVE

To determine the best time to start rehabilitation to preserve swallowing function and enhance health-related quality of life in patients with head and neck cancer (HNC) undergoing chemoradiation therapy (CRT).

MATERIAL AND METHODS

Randomized single-blind controlled trial study conducted at a tertiary university hospital. Fifty-two HNC patients treated with CRT were randomized into early intervention (EIG, at diagnosis) and late intervention groups (LIG, post-radiotherapy). Interventions included Inspiratory and Expiratory Muscle Strength Training and standard swallowing exercises for 21 weeks, starting 2 weeks before RT in EIG and immediately after RT in LIG. Functional parameters, dysphagia severity, and HRQoL were assessed at baseline, RT completion, and post-RT follow-ups (3, 6, 12 months).

RESULTS

No significant differences were observed between groups, except for mouth interincisor opening at RT completion in EIG. At final assessment, PEmax% values recovered in EIG but deteriorated in LIG (p=0.028). Speech problems decreased in EIG (p=0.019) compared to baseline. PImax showed a positive trend in both groups. Both groups had isolated improvements in quality of life.

CONCLUSION

The effectiveness of rehabilitation was similar regardless of initiation timing, suggesting both early and late interventions are viable for preserving swallowing function and improving quality of life in HNC patients undergoing CRT.

The Ready for Safe Cancer Treatment (RESET) tool: enhancing quality and optimizing timely and safe discharge with transitional care adjustments for Head and Neck Cancer patients

<b>Introduction:</b> The Ready for Safe Cancer Treatment (RESET) tool is a structured, multimodal program designed to optimize hospitalization and enhance the quality of perioperative care for oncological patients. While RESET has been developed as a general framework for surgical oncology, its adaptation to Head and Neck Cancer (HNC) patients remains unexplored despite their unique physiological and psychological needs. HNC patients frequently face severe functional impairments affecting speech, swallowing, and respiration, as well as heightened nutritional deficiencies, sarcopenia, and psychological distress. This study explores the feasibility of tailoring the RESET tool to meet the specialized requirements of HNC patients. <br><br><b>Aim:</b> The aim of this study is to assess the feasibility of adapting the RESET to the specific needs of HNC patients. The research focuses on identifying key areas requiring modification to optimize perioperative care, including prehabilitation, nutritional support, functional rehabilitation, and psychological care. Epidemiological analysis, patient needs assessment, and a review of the core RESET modules will help determine effective strategies for improving treatment quality and recovery outcomes in this patient group. The ultimate goal is to develop a more personalized, evidence-based approach that could be implemented in oncology centers to enhance treatment outcomes for HNC patients. <br><br><b>Methods:</b> RESET is structured into four modules: pre-admission prehabilitation, advanced communication and need assessment upon admission, intra-hospital recovery optimization, and transitional care planning at discharge. This study includes a cross-sectional epidemiological assessment of HNC patient representation at two oncological centers in Poland, an analysis of prehabilitation requirements, a comparative evaluation of core RESET modules, and a gap analysis identifying necessary protocol enhancements. The proposed methodological approach integrates both quantitative and qualitative assessments to ensure a comprehensive evaluation of RESET's adaptation to HNC patients. <br><br><b>Results:</b> Data from 2023-2024 indicate that HNC patients constitute 11-25% of the total oncological population at the studied centers, demonstrating distinct demographic characteristics such as younger age distribution and extended hospitalization periods. Prehabilitation needs analysis underscores the importance of structured nutritional support, targeted muscle preservation strategies, and psychological interventions, including cognitive behavioral therapy. Additionally, core RESET module evaluations highlight the necessity of enhanced post-discharge transitional care, particularly for patients requiring tracheostomy or prolonged enteral nutrition support. The gap analysis identifies critical areas requiring reinforcement, such as comprehensive sarcopenia screening, specialized dysphagia management protocols, and a multidisciplinary approach to psychosocial rehabilitation. <br><br><b>Discussion:</b> HNC patients present unique challenges that demand tailored modifications to the RESET framework. Unlike other oncological cohorts, HNC patients are predisposed to functional impairments, high nutritional deficits, and significant psychosocial burdens. The inclusion of dedicated nutritional strategies, prehabilitation exercises, and psychological support within the RESET protocol may significantly improve treatment outcomes, reduce postoperative complications, and enhance the quality of life. Despite its structured approach, the main limitation of the RESET adaptation for HNC remains the need for dedicated funding and further validation through prospective clinical trials. <br><br><b>Conclusions:</b> Adapting the RESET tool to the needs of HNC patients has the potential to optimize perioperative care, ensuring a more individualized, evidence-based approach. The proposed modifications emphasize enhanced nutritional, physical, and psychological support, aligning RESET with the specific challenges faced by HNC patients. Further research and implementation studies are required to validate the effectiveness of this adapted framework in improving patient outcomes within oncological network hospitals.

Dysphagia, nutritional status, and quality of life in patients with head and neck cancer undergoing radiotherapy alone or combined with chemotherapy: an observational study

INTRODUCTION

Radiotherapy (RT) is the most common nonsurgical treatment for head and neck cancer (HNC) and may or may not be combined with chemotherapy (CT). Dysphagia, characterized by impaired swallowing function, is one of the most common side effects of RT, occurring during and after RT, and may persist long after treatment.

OBJECTIVE

To compare the evolution of dysphagia, nutritional status, and quality of life (QoL) in the periods immediately before and after RT for HNC in individuals who received only RT or combined RT/CT.

METHODS

Prospective longitudinal observational study performed in a hospital of the Brazilian public health system. The individuals were allocated into two groups: RG (n = 20), consisting of patients who received only RT for HNC, and RCG (n = 27), who received RT plus CT. The patients were evaluated before and after RT to identify and classify dysphagia (PARD protocol), anthropometric variables (BMI, triceps skinfold thickness, arm and calf circumferences, and manual dynamometry), and QoL (QLC-30 and H&N-35 questionnaires).

RESULTS

The groups were homogeneous in demographic characteristics and tumor stage. RCG showed a higher proportion of worsening dysphagia severity (p < 0.01) and worsening of anthropometric assessment (p < 0.05). A negative correlation was observed between the initial-final change in dysphagia and the change in BMI for the total sample (rho=-0.379, p < 0.05). QoL worsened in most domains evaluated, but RCG showed additional worsening in the domains of global health and nausea and vomiting (p < 0.05).

CONCLUSION

RT for HNC leads to the early development of dysphagia, which can adversely affect nutritional status and QoL. Including CT in the RT regimen leads to a more accentuated worsening of the evaluated parameters.

Compressed Sensing-Based Cine-MRI for Location of Dysphagia and Swallowing Function assessment in Patients with Head and Neck Cancer: A Comparative Study

Cine magnetic resonance imaging (Cine-MRI) may evaluate the swallowing function and locations of patients with dysphagia, which requires very fast imaging speed. Compressed sensing is a technique that allows for faster MRI imaging by sampling fewer data points and reconstructing the image via optimization techniques, crucial for capturing the rapid movements involved in swallowing. This study aimed to analyze swallowing function and locations in patients with head and neck cancer and healthy individuals using Cine-MRI based on compressed sensing. This comparative study enrolled 36 patients with dysphagia and 10 healthy controls at the Department of Radiology, Yunnan Cancer Hospital between June 2020 and January 2021. Significant correlations were found between primary tumor location and Cine-MRI parameters, and between swallowing function and Cine-MRI parameters. The areas under the receiver operating characteristic curve for the combined Cine-MRI-related parameters in predicting mild and severe dysphagia were 0.806 (95% CI: 0.662-0.949). Cine-MRI with compressed sensing may identify swallowing function and abnormal stages of the physiologic swallowing process in patients with dysphagia after treatment.

Assessing Long-Term Quality of Life Concerns Through Survivorship Clinic in Head and Neck Cancer Patients

OBJECTIVE

To characterize the concerns of head and neck cancer (HNC) patients and discern changes in quality-of-life (QoL) during long-term follow-up.

STUDY DESIGN

Retrospective review.

SETTING

Survivorship clinic at a tertiary academic center.

METHODS

A retrospective review was conducted on HNC patients seen in our survivorship clinic between 1/2020 and 1/2024 using the University of Washington Quality of Life (UW-QOL) Questionnaire.

RESULTS

Three hundred and forty-two patients were seen for 914 encounters. Patients were divided into 4 groups: pretreatment (n = 326), 0 to 12 months posttreatment (n = 247), 1 to 3 years posttreatment (n = 248), and more than 3 years posttreatment (n = 64). The average follow-up after treatment was 459 days (range: 0-5.2 years). Multivariable analysis revealed significant improvements in overall QoL, health-related QoL, social-emotional composite scores, activity, anxiety, appearance, chewing, mood, pain, speech, and recreation at more than 1-year posttreatment compared to less than 1-year posttreatment. However, declines were noted in saliva and taste scores. No differences in scores were observed between patients 1 to 3 years posttreatment and those >3 years posttreatment. At all timepoints before and after treatment, top concerns were pain, activity, and swallowing. Patients with oral cancer followed for more than 1-year posttreatment had worse scores in appearance, chewing, pain, and speech compared to those with oropharyngeal cancer.

CONCLUSIONS

Understanding the evolving concerns of HNC patients is imperative for enhancing care. Most QoL domains improve at 1-year posttreatment except for saliva, taste, swallowing, and shoulder function. QoL scores stabilize after 1-year post-treatment. Pain, activity, and swallowing remain the top concerns at all time points.

Prognostic value of serum 25-hydroxyvitamin D levels and malnutrition status on postoperative complications in patients following laryngectomy with neck dissection

BACKGROUND

Postoperative complications (PCs) following total laryngectomy remain a significant challenge, with recent investigations directed toward the impact of nutrition status and vitamin D deficiency.

OBJECTIVES

To elucidate the association between preoperative vitamin D level status, malnutrition risk score, and surgical and survival outcomes in patients with advanced laryngeal cancer following total laryngectomy.

STUDY DESIGN

Prospective cohort study.

METHODS

Sixty-four patients with advanced laryngeal carcinoma treated with total laryngectomy were included in the study. Serum levels of 25(OH) D3 were measured employing a commercial chemiluminescent immunoassay kit, while nutrition status was evaluated using the nutrition risk index (NRI) and Malnutrition universal screening tool (MUST).

RESULTS

The mean serum 25(OH) D level was 37.1 ± 19.4 nmol/L (range 11.0-100.6 nmol/L), with 47% of patients exhibiting vitamin D deficiency and 31% displaying insufficiency. Medium/high MUST score had 53% of patients, and moderate/severe NRI was verified in 48% of patients. Univariate logistic regression analysis identified MUST score, GPS score, neutrophil-to-lymphocyte ratio, and circulating 25(OH) D levels as predictive for the occurrence of PCs. In multivariate analysis, MUST score and circulating 25(OH) D levels remained significantly associated with PCs. Patients with high nutrition risk had significantly lower two-year OS rates compared to the medium and low nutrition risk groups, respectively (30% vs. 62% and 83%, p = 0.010).

CONCLUSION

Early identification of malnourished or patients with vitamin D deficiency and those who would benefit from specific nutritional support could be beneficial for minimizing the risk of development of surgical complications and help improve our clinical outcomes.

The association of frailty with morbidity and mortality following major mucosal head and neck surgery

OBJECTIVES

Frailty refers to a state of reduced physiological reserve and functional decline. We sought to analyse whether frailty, assessed using the 5-item modified frailty index (5mFI), was associated with increased morbidity and mortality following major mucosal head and neck surgery.

MATERIALS AND METHODS

We performed a retrospective study of patients undergoing major mucosal head and neck surgical resection over a 2-year period. Potential confounding variables were controlled by way of multivariable regression analysis.

RESULTS

There were 310 patients included with 77 (24.8 %) classified as frail. Most patients were male (219/310, 70.7 %), had a history of smoking (246/310, 79.4 %) and 151 patients (48.7 %) were older than 65 at time of surgery. Most surgeries related to oral cavity or oropharyngeal subsites (227/310, 73.2 %) and 150 patients (48.4 %) underwent microvascular free tissue reconstruction. On multivariable analysis, frail patients were more likely to suffer adverse outcomes such as a return to theatre (OR 3.47, 95 % CI 1.82-6.62, p < 0.001), a Clavien-Dindo grade IV complication (OR 6.23, 95 % CI 2.55-15.20, p < 0.001) or medical complications, such as respiratory complications (OR 2.61, 95 % CI 1.45-4.69; p = 0.001) or delirium (OR 5.05, 95 % CI 2.46-10.33; p < 0.001). Additionally, hospital length of stay was increased among frail patients (ß 16.46 days, 95 % CI 9.85-23.07 days; p < 0.001). Neither 90-day nor 1-year post-operative mortality was increased in frail patients.

CONCLUSION

Frailty assessed using the 5mFI was associated with greater post-operative morbidity, but not mortality following major mucosal head and neck surgery.

Swallowing rehabilitation of patients undergoing T-tube implantation for the treatment of laryngotracheal stenosis

OBJECTIVE

Patients with laryngotracheal stenosis (LTS) often have dysphagia after laryngotracheal reconstruction with T-tube insertion, which affects the quality of life. The purpose of this study is to observe the effect of swallowing rehabilitation therapy on the improvement of quality of life in patients of otolaryngology-head and neck surgery with dysphagia undergoing T-tube implantation treatment through longitudinal study.

METHODS

Thirty-eight patients with LTS who experienced dysphagia after laryngotracheal reconstruction and T-tube implantation were recruited. All patients received swallowing rehabilitation therapy. The assessment of swallowing function was performed using the 10-item Eating Assessment Tool (EAT-10), the 30 mL water swallow test (WST), and flexible endoscopic evaluation of swallow (FEES).

RESULTS

After swallowing rehabilitation therapy, timing of swallowing, grade of dysphagia, performance on FEES and 30 mL WST, and EAT-10 score all improved. Thirty-eight patients successfully transitioned to oral feeding and were able to remove their nasogastric tubes without experiencing any complications, including aspiration pneumonia.

CONCLUSION

For patients with LTS who experienced dysphagia after laryngotracheal reconstruction and T-tube implantation, swallowing rehabilitation therapy could improve swallowing function of the patients, so as to reduce the potential harm caused by the pain and complications of surgery experienced by patients.

Predicting short-term treatment toxicity in head and neck cancer through a systematic review and meta-analysis

INTRODUCTION

Frailty is a recognized condition associated with poorer outcomes in patients with head and neck cancer (HNC). The objective of this study was to ascertain the prognostic significance of various frailty metrics on short-term treatment toxicity in patients with HNC undergoing curative-intent therapy.

MATERIALS AND METHODS

A systematic review was performed searching multiple databases. An inverse-variation, random-effects model was used to perform the meta-analysis to evaluate the prognostic significance of various frailty metrics on short-term treatment-related toxicity in this population.

RESULTS

A total of 292,560 patients with HNC originating from 36 observational studies were analyzed. The most frequently reported frailty metrics were the modified frailty index (mFI), Geriatric 8 questionnaire (G8), Adjusted Clinical Groups (ACG), Groningen Frailty Indicator (GFI), and comprehensive geriatric assessment (CGA). The overall prevalence of frailty using any metric in all included studies was 7.5 %. The combined odds ratio (OR) for short-term treatment toxicity using the mFI was 2.60 (95 % CI of 1.81-3.72), G8 2.69 (95 % CI 1.37-5.28), ACG 3.43 (95 %CI 2.52-4.67), GFI 2.71 (95 % CI 1.11-6.62), and CGA 3.36 (95 % CI 1.18-9.53). The association of frailty with short-term treatment toxicity using various frailty metrics was more pronounced in patients with upfront surgery (OR 3.00, 95 %CI of 2.35-3.81) compared to definitive (chemo)radiotherapy 2.64 (95 % CI 1.04-6.68).

DISCUSSION

Various frailty metrics exists in the HNC literature, with the most common being the mFI, G8, ACG, GFI, and CGA. Patients with HNC and frailty are more than twice as likely to suffer a short-term treatment-related toxicity when undergoing curative-intent HNC treatment than patients without frailty. This effect is more pronounced in patients undergoing upfront surgery.

Head and Neck Cancer (HNC) Prehabilitation: Advantages and Limitations

Cancer prehabilitation is the process between the time of cancer diagnosis and the beginning of the active acute treatment; prehabilitation consists of various need-based interventions, e.g., physical activity, a nutritional program, and psychological support. It can be delivered as unimodal or multimodal interventions. Physical activity, including resistant exercise and aerobic activities, has to be tailored according to the patient's characteristics; nutritional support is aimed at preventing malnutrition and sarcopenia; while psychological intervention intercepts the patient's distress and supports specific intervention to address it. In addition, multimodal prehabilitation could have a potential impact on the immune system, globally reducing the inflammatory processes and, as a consequence, influencing cancer progression. However, many challenges are still to be addressed, foremost among them the feasibility of prehabilitation programs, the lack of adequate facilities for these programs' implementation, and the fact that not all prehabilitation interventions are reimbursed by the national health system.

Factors influencing quality of life and functional status in head and neck cancer patients

OBJECTIVE

To assess the quality of life (QoL) and functional status factors of patients at various stages of treatment for head and neck cancer.

STUDY DESIGN

Cross-sectional survey study.

SETTING

Outpatient.

METHODS

Patients over the age of 18 who received care at the Markey Head and Neck Cancer Center Clinic since 2015 were invited to complete the survey. Survey items included: demographic information, characteristics of the patient's disease and treatments, as well as an 18-item survey assessing quality of life and functional status. A follow-up for each factor asked patients to rate how important it was to them.

RESULTS

Patients reported greatest difficulties with physical activity (2.18), sleep (2.20), stress (2.26), and fatigue (2.26). Patients indicated that information (3.00), medication management (2.67), and sleep (2.62) were the most important. Multimodal therapy, marital status, and education level were all found to have statistically significant associations with several QoL measures.

CONCLUSION

Quality of life and functional status in patients who have undergone treatment for head and neck cancer are both affected by many factors, particularly multimodal treatment, partner support, and education level. Identifying patients who may be more affected by treatment and targeting them with additional support and resources may lead to improved QoL in patients and their caregivers. This study would suggest that efforts to support physical activity, sleep, and stress management could lead to the most significant impact.

Patient management with Head and Neck tumors-A nationwide data collection in oral and maxillofacial surgery

INTRODUCTION

This study analyzed oncologic patient management from initial tumor diagnosis to tumor follow-up in oral and maxillofacial surgery (OMFS) in Germany.

MATERIAL AND METHODS

A dynamic online questionnaire with a total of 44 questions was used to generate general and specific data regarding oncologic patient management with head and neck malignancies, supportive care, and (pre-) rehabilitation from initial tumor diagnosis to tumor follow-up and head and neck cancer center (HNCC) structures in OMFS in Germany. The questionnaire was sent to 81 OMFS departments affiliated with the German-Austrian-Swiss Working Group for Tumors of the Jaw and Facial Region (DÖSAK) and the German Association of Oral and Maxillofacial Surgery (DGMKG). Data analysis was conducted descriptively.

RESULTS

Forty-eight OMFS departments participated (response rate 59.26%), of which 36/48 (75%) were certified HNCC. 28/34 (82.4%) reported subjective improvements in oncologic care, most often interdisciplinary collaboration (21/33, 63.64%) and clinic structure changes (21/34, 61.76%). Nearly all OMFS departments present patients in multidisciplinary tumor boards (45/46, 97.83%) and aim for osseous reconstruction post-tumor resection (43/44, 97.73%). Significant discrepancies regarding the frequency of masticatory-functional dental rehabilitation following osseous reconstruction were observed. Before oncologic therapy, patients are offered various supportive services, mostly psychotherapy and psycho-oncological support (24/26, 92.31%). Post-therapy, speech therapy (43/43, 100%), physiotherapy (40/43, 93.02%), lymphatic drainage, and follow-up rehabilitation (39/43, 90.7%, respectively) are most often offered. 17/43 (39.53%) have oncological nursing staff. 36/40 (90%) manage patients and side effects during adjuvant therapy, while 5/41 (12.2%) provide proprietary palliative care. 36/41 (87.8%) offer counseling to patients and families.

CONCLUSION

Oncologic patient care in OMFS is highly standardized and potentially attributable to many certified HNCCs in Germany. Certain treatment aspects are handled differently, possibly due to institution-specific reasons.

CLINICAL RELEVANCE

The high homogeneity in treatment protocols reflects the widespread high and comparable treatment quality of head and neck malignancies in OMFS in Germany.

Study protocol for a single-site feasibility study evaluating the adoption and fidelity of Prep-4-RT: prehabilitation for head and neck cancer patients undergoing radiotherapy

INTRODUCTION

Prep-4-RT is a co-designed stepped-care multimodal prehabilitation program for people scheduled to receive radiotherapy for head and neck cancer (HNC). Prehabilitation, which occurs between diagnosis and treatment commencement, aims to improve a patient's health to reduce the incidence and severity of current and future impairments. HNC treatment can be distressing and has detrimental impacts on function and quality of life. HNC patients have increased social vulnerabilities including higher rates of socio-economic disadvantage and engagement in lifestyle habits which increase cancer risk. High levels of physical and psychological impacts of HNC treatment and increased social vulnerabilities of this population warrant investigation of optimal pathways of care, such as prehabilitation. This paper describes a research protocol to evaluate the feasibility of Prep-4-RT, which was designed to prepare HNC patients for the physical and psychological impacts of radiotherapy.

METHODS AND ANALYSIS

At least sixty adult HNC patients, scheduled to receive radiotherapy (with or without chemotherapy), will be recruited over a five-month period. All participants will receive access to Prep-4-RT self-management resources. Participants identified through screening as high-risk will also be offered individualised interventions with relevant allied health professionals prior to the commencement of radiotherapy (psychologists, dietitians, speech pathologists and physiotherapists). Participants will complete evaluation surveys assessing their experiences with Prep-4-RT resources and interventions. Clinicians will also complete program evaluation surveys. Primary feasibility outcomes include adoption (uptake and intention to try) and fidelity (adherence to the specialist prehabilitation pathway). Secondary feasibility outcomes include acceptability (patient and clinician) of and satisfaction (patient) with Prep-4-RT as well as operational costs. Feasibility outcome data will be analysed using exact binomial and one-sample t tests, as appropriate.

ETHICS AND DISSEMINATION

Ethics approval has been obtained at the Peter MacCallum Cancer Centre in Melbourne, Australia. Results will be presented at national conferences and published in peer-reviewed journal(s) so that it can be accessed by clinicians involved in the care of HNC patients receiving radiotherapy. If the model of care is found to be feasible and acceptable, the transferability and scalability to other cancer centres, or for other cancer types, may be investigated.

REGISTRATION DETAILS

ANZCTA (Australian New Zealand Clinical Trials Registry) ACTRN12623000770662.

Dysphagia in Head and Neck Cancer

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

Effectiveness of a Protocol Intervention for Aspiration Pneumonia Prevention in Patients With Esophageal Cancer During Concurrent Chemoradiotherapy: A Randomized Control Trial

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.

Top Ten Tips Palliative Care Clinicians Should Know About Physical Therapy, Occupational Therapy, and Speech Language Pathology

This article provides guidance on the integral role of physical therapy, occupational therapy (OT), and speech language pathology (SLP) in palliative care (PC), underlining the necessity for effective communication between physicians and therapists, the importance of caregiver education and support, the application of holistic treatment modalities in OT, the underutilization of resources in PC settings, the role of SLP professionals in feeding and nutrition, and the challenges in communication during the advanced stages of illness. The article draws on various studies and expert opinions to elucidate these issues, offering a valuable resource to health care professionals in ensuring high-quality patient-centered PC.

"Prehabilitation" for Pediatric Patients With Cancer Before Undergoing Hematopoietic Stem Cell Transplantation

Hematopoietic stem cell transplantation (HSCT) is associated with significant physical debility. Studies have suggested that physical activity can improve endurance and strength. However, studies have not yet investigated "prehabilitation," exercise before HSCT, to improve functional outcomes. We describe the impact of exercise therapy on physical debility in children undergoing HSCT to inform the implementation of prehabilitation. This review was conducted through a search of the electronic database PubMed. Articles included were those with original research, including randomized control trials, prospective studies, case controls, and retrospective studies. Eleven of the 191 resulting studies met our review criteria. None focused on prehabilitation, but instead on interventions during HSCT. Ten studies showed improvement or maintenance of strength, endurance, stretching, or aerobic fitness. This review shows that exercise therapy can positively affect outcomes in patients undergoing HSCT. Further investigations are needed to determine whether prehabilitation has better results than concurrent exercise.

Prehabilitation for Patients with Cancer Undergoing Radiation Therapy: a Scoping Review

AIMS

Prehabilitation is a process of identifying and assessing factors that could compromise the physical and psychological health of patients undergoing cancer treatment and implementing an intervention to combat such concerns. The use of prehabilitation in cancer surgery has yielded positive outcomes in rectal, lung and abdominal cancers. Prehabilitation strategies have potential to improve the management of patients receiving radiation therapy or chemoradiation. The aim of the present study was to map the evidence of the assessment and evaluation of prehabilitation for radiation therapy patients.

MATERIALS AND METHODS

A database search using EMBASE and PubMed was conducted. The PRISMA guidelines were adhered to. Keywords included prehabilitation, radiation therapy/radiotherapy, chemoradiotherapy/chemoradiation, intervention and exercise. Types of prehabilitation strategy, their purposes and impact, according to cancer site, were analysed.

RESULTS

Prehabilitation is most commonly evaluated in head and neck cancer, whereby unimodal, physical interventions manage dysphagia. Prehabilitation for lung cancer demonstrated its ability to widen treatment options for patients. Physical prehabilitation is administered to combat adverse effects of neoadjuvant chemoradiation therapy in patients with rectal cancer.

CONCLUSION

Prehabilitation is adaptive and tailored to specific patient and site needs; thus it is applied across a wide range of cancer sites. More interventions by which radiation therapy is the definitive treatment modality and larger sample sizes within these studies are warranted to increase prehabilitation utilisation for patients undergoing radiation therapy.

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

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.

Positive correlation between persistence of medical nutrition therapy and overall survival in patients with head and neck cancer

Background: Several factors can affect overall survival of head and neck cancer (HNC) patients, including characteristics of the cancer disease and response to treatments. However, patients' nutritional status and the effectiveness of medical nutrition therapy (MNT) can also impact overall survival. The primary goal of our research was to collect real-life data on the use of MNT in HNC patients and to specifically investigate the correlation between survival and the duration of uninterrupted (persistent) nutrition. Method: The data of this retrospective, analytical, cohort study was collected from electronic healthcare records from the Hungarian National Health Insurance Fund Management. Overall, 38,675 HNC patients' data of the period between 2012 and 2021 was used. We applied multi-step exclusions to identify patient groups accurately and to avoid biasing factors. Statistical analysis was done by the Kaplan-Meier method, log-rank test, and Cox regression analysis. Results: Throughout the investigated period 16,871 (64%) patients received MNT therapy out of 26,253 newly diagnosed patients (≥18 years). In terms of the persistence of MNT, we divided the patients into three groups (1-3; 4-6; ≥7-month duration of MNT). When comparing these groups, we found that patients receiving long-term (≥7 months) MNT had a significantly longer overall survival (p < 0.0001) than those who received MNT for a shorter duration, both in locally advanced and recurrent/metastatic cases. Conclusion: The main outcome of the study is that there is a positive correlation between the persistence of MNT and the overall survival in HNC patients when nutritional intervention lasts several months. It highlights the responsibility of the specialists during the patient journey to use MNT early and to continue its use for as long as it is beneficial to the patients.

Effectiveness of an evidence-based swallowing facilitation strategy for patients undergoing radiotherapy for head and neck cancer: a study protocol for a randomised controlled trial

INTRODUCTION

Dysphagia emerges as a frequent, persistent and enduring aftermath in individuals undergoing radiotherapy for head and neck cancer (HNC). Timely intervention becomes imperative to ameliorate prolonged dysphagia and curtail related complications. Among the evidence-grounded tactics, preventive swallowing training and proficient feeding management stand out as pivotal measures for precluding and mitigating dysphagia. However, past inquiries that amalgamated these dual interventions exhibited heterogeneous quality due to their restricted participant cohorts and a dearth of uniform, systematic and practicable procedural benchmarks.

METHOD/DESIGN

This randomised, parallel-controlled study enrols 94 patients diagnosed with HNC, who are undergoing radiotherapy either with or without concurrent chemotherapy. The patients will be randomly assigned to either the intervention group, which will receive a facilitation strategy to enhance swallowing function in conjunction with standard care, or the control group, which will receive typical radiotherapy care. Patient assessments will be conducted at three distinct time points: at the onset of radiotherapy (baseline), at the conclusion of radiotherapy and 3 months postradiotherapy. The primary outcome will revolve around measuring swallowing function, while secondary outcomes will encompass swallowing-related quality of life and nutritional status.

ETHICS AND DISSEMINATION

This research initiative received endorsement from the Shanghai Proton Heavy Ion Hospital Ethics Committee on 2 December 2 (Approval Number 2210-59-01). Throughout the recruitment process, patients will be acquainted with the primary aims and scope of the study. Their participation will be a voluntary choice, demonstrated by their informed consent form signatures. The outcomes of this study will be disseminated through publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

Clinical Trials.gov, ChiCTR2300067550, registered 11 January 2023.

Prehabilitation in radiation therapy: a scoping review

PURPOSE/OBJECTIVES

Radiation therapy (RT) is a central component of cancer treatment with survival and long-term quality-of-life benefits across a spectrum of oncologic diagnoses. However, RT has been associated with varying levels of fatigue, pain, weight loss, and changes in mental health both during and post-treatment. Prehabilitation aims to optimize health prior to anti-neoplastic therapy in order to reduce side effects, increase adherence to treatment, expedite post-treatment recovery, and improve long-term outcomes. Though prehabilitation has been studied in those undergoing cancer-related surgery, literature on prehabilitation in individuals undergoing RT has not been comprehensively explored. Thus, this scoping review aims to summarize the existing literature focused on prehabilitation interventions for patients receiving RT.

MATERIALS/METHODS

The PRISMA-ScR checklist for conducting scoping reviews was adopted to identify and evaluate studies investigating the efficacy of prehabilitation before and during RT for cancer over the past 21 years (10/2002-10/2022). A search of prehabilitation and RT was performed to identify studies investigating prehabilitation interventions in adult cancer patients undergoing RT.

RESULTS

A total of 30 articles met inclusion criteria, yielding 3657 total participants. Eighteen (60%) studies were randomized controlled trials (RCTs) with sample sizes ranging from 21 to 221. The most commonly studied populations were patients with head and neck cancer, followed by rectal, breast, and lung cancer. A majority (80%) of studies evaluated one prehabilitation intervention (i.e., unimodal). Targeted physical exercises were the most common intervention, followed by general physical exercises and technology/apps. Adherence/feasibility was the most common primary outcome, representing 30% of studies. All studies reported data on sex, and 5 (17%) reported data on race and/or ethnicity.

CONCLUSIONS

Prehabilitation interventions have been successfully implemented in patients with cancer undergoing surgical treatment. Based on limited current literature, prehabilitation appears to have a promising effect in reducing morbidity in adult cancer patients requiring RT. Though our review identified many RCTs, they were frequently small sample trials with primary outcomes focused on feasibility, rather than functional status or quality of life. Thus, there is a need for adequately powered, randomized controlled intervention trials to investigate the efficacy of prehabilitation and maximize the treatment outcomes for patients undergoing RT.

Pre-rehabilitation interventions for patients with head and neck cancers: A systematic review and meta-analysis

OBJECTIVE

To investigate the effect of pre-rehabilitation interventions such as nutrition and exercise for patients with head and neck cancer (HNC).

METHODS

Web of Science, PubMed, Scopus, Google Scholar, and Cochrane databases were searched up to December 2022. Quality of life, length of hospital stay, postoperative complications, change in body mass index or muscle mass, and functional assessments were the primary outcomes. PRISMA guidelines were adhered to, and the study was registered on PROSPERO. The Cochrane Collaboration tool and Newcastle Ottawa scale assessed the quality of included studies. Pooled data are presented as odds ratios (OR) and 95% confidence intervals (CI). Analysis was conducted using RevMan5.4.

RESULTS

A total of 31 articles were included for quantitative analysis and 15 for qualitative synthesis. Nutrition alone resulted in significant weight retention (2.60; 2.32, 2.88, p < 0.00001), length of stay (-4.00; -6.87, -1.13), p = 0.0006) and complications (0.64; 0.49, 0.83, p = 0.0009). Nutrition and psychoeducation resulted in a significant reduction in mortality rate (0.70; 0.49, 1.00, p = 0.05 and 0.60; 0.48, 0.74, p < 0.00001), and exercise resulted in a significant reduction in dysphagia (0.55; 0.35, 0.87, p = 0.01). Exercise with nutrition resulted in significant improvements in weight loss, length of stay, complications, and dysphagia. Randomized controlled trials (RCTs) had a moderate risk of bias and cohort studies were of fair to good quality.

CONCLUSION

Prehabilitation programs based on exercise, nutrition, or psychoeducation demonstrated improved post-interventional outcomes in HNC, such as quality of life, and mortality and morbidity. Studies with longer follow-ups and larger sample sizes, and investigations comparing nutritional supplements with exercise programs are needed.

Prehabilitation of dysphagia in the therapy of head and neck cancer- a systematic review of the literature and evidence evaluation

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.

Elective Revision Surgery in Head and Neck Cancer Patients: A Retrospective Analysis at an Oncology Centre in Porto, Portugal

Introduction Elective revision surgery in head and neck cancer is crucial for refining and optimizing outcomes, ensuring complete tumor removal, and enhancing both functional and aesthetic aspects, ultimately improving the overall quality of life for patients. The aim of this study is to analyze the overall survival (OS) of head and neck cancer patients who underwent elective revision surgery with or without adjuvant treatment between 2019 and 2022, reflecting on the practice between those years in IPO-Porto, Porto, Portugal. Methods This study included 58 patients who underwent 116 major neck surgeries. Multidisciplinary head and neck follow-up records were obtained for every patient. Overall survival and disease-specific survival (DSS) curves were calculated using the Kaplan-Meier method, and statistical significance was determined by the Log-Rank test. We did a retrospective study with an anterograde direction, evaluating the treatments that were previously done by the patients. Results The sample comprised 51 males (87.9%) and seven females (12.1%), with a mean age of 59.02±11.014 years. Head and neck pathology was mostly in the larynx (36.2%). The type of the first surgery was mainly directed to the primary tumor in 62.1% (n=36). In the other 37.9% (n=22), surgery was directed to the primary tumor in association with neck dissection. The type of the second surgery was mainly revision surgery. We found that T4 tumors (HR (hazard ratio) = 10.219, p = 0.006) and hypopharynx tumors (HR = 5.306, p =0.035) were significantly associated with inferior OS. Conclusion In our sample, we found that a T4 and a tumor located in the hypopharynx were significantly associated with inferior OS in elective head and neck oncologic revision surgery. Disease-free survival in patients undergoing revision surgery in our sample is generally poor. In our sample, there was a statistically significant difference in overall survival between the group who underwent surgery for microscopic evidence of persistent tumor (R1) versus clinical and imagiological tumoral persistency. In our sample, the time between the first and second surgeries wasn't linked with an inferior OS. Further studies with larger populations and prospective design, with longer follow-ups can be the road to a better understanding of this issue.

Nutritional status and post-operative complications in patients undergoing surgery for advanced pharyngeal or laryngeal cancer

PURPOSE

Malnutrition is an important prognostic indicator of post-operative outcomes in patients undergoing surgery for head and neck cancer, however, limited studies utilize validated nutrition assessment tools to accurately assess risk. The aim of this study was to determine the relationship between nutritional status on post-operative complications and length of stay for patients undergoing either a laryngectomy, pharyngectomy or pharyngolaryngectomy for head and neck cancer.

METHODS

Patients with head and neck cancer undergoing a laryngectomy, pharyngectomy or pharyngolaryngectomy at a tertiary hospital in Australia were eligible for this retrospective cohort study (n = 40). Nutritional status was assessed by the dietitian on admission using the validated Subjective Global Assessment tool. Clinical outcomes were collected via retrospective chart review and included length of stay and post-operative complications.

RESULTS

Pre-operative malnutrition incidence was 40%. Malnourished patients had higher incidences of any type of complication (57% vs 44%, p = 0.013) and pressure injury (86% vs 14%, p = 0.011) compared to well-nourished patients. Well-nourished patients had a clinically important shorter median length of stay compared to malnourished patients (17.5 vs 20 days).

CONCLUSION

Early identification and management of malnutrition is essential to minimize risk of post-operative complications and reduce length of stay and should be considered a key component of prehabilitation programs.

Multiphasic exercise prehabilitation for patients undergoing surgery for head and neck cancer: a hybrid effectiveness-implementation study protocol

Head and neck cancer (HNC) treatment often consists of major surgery followed by adjuvant therapy, which can result in treatment-related side effects, decreased physical function, and diminished quality of life. Perioperative nutrition interventions and early mobilization improve recovery after HNC treatment. However, there are few studies on prehabilitation that include exercise within the HNC surgical care pathway. We have designed a multiphasic exercise prehabilitation intervention for HNC patients undergoing surgical resection with free flap reconstruction. We will use a hybrid effectiveness-implementation study design guided by the RE-AIM framework to address the following objectives: (1) to evaluate intervention benefits through physical function and patient-reported outcome assessments; (2) to determine the safety and feasibility of the prehabilitation intervention; (3) to evaluate the implementation of exercise within the HNC surgical care pathway; and (4) to establish a post-operative screening and referral pathway to exercise oncology resources. The results of this study will provide evidence for the benefits and costs of a multiphasic exercise prehabilitation intervention embedded within the HNC surgical care pathway. This paper describes the study protocol design, multiphasic exercise prehabilitation intervention, planned analyses, and dissemination of findings. Trial registration: https://clinicaltrials.gov/NCT04598087.

Symptom clusters after chemoradiotherapy in discharged nasopharyngeal carcinoma patients

Objective

To investigate the incidence of complications and types of chemoradiotherepy induces symptom clusters in patients with nasopharyngeal carcinoma (NPC) who were first diagnosed after treatment and discharged from hospital.

Methods

After their discharge home, 130 NPC patients who had been treated with chemoradiotherapy were asked to complete a modified Chinese version of the Quality of Life Questionnaire-Head and Neck Module developed by the European Organization for the Research and Treatment of Cancer in the Head and Neck. Symptom clusters in patients were identified through exploratory factor analysis.

Results

The most serious symptoms for discharged NPC patients who had received chemoradiotherapy were dental problems, a sense of obstruction while swallowing, embarrassment in physical contact with family members and friends, difficulty in speaking with others, and embarrassment in public. The six symptom clusters identified through exploratory factor analysis were (1) painful eating, (2) social difficulties, (3) psychological disorders, (4) symptomatic shame, (5) teeth/throat injuries, and (6) sensory abnormalities. The total contribution rate of variance was 65.73%.

Conclusion

NPC patients who are treated with chemoradiotherapy can experience adverse symptom clusters that continue after discharge. Nurses should evaluate the patients' symptoms before discharge and provide targeted health education services which would reduce the patients' complications and improve the quality of life at home. Besides, medical staff should evaluate the complications in a timely and comprehensive manner and provide individualized health education for the affected patients to help them manage chemoradiotherapy side effects.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Management of Older Patients with Head and Neck Cancer: A Comprehensive Review

The projected increase in life expectancy over the next few decades is expected to result in a rise in age-related diseases, including cancer. Head and neck cancer (HNC) is a worldwide health problem with high rates of morbidity and mortality. In this report, we have critically reviewed the literature reporting the management of older patients with HNC. Older adults are more prone to complications and toxicities secondary to HNC treatment, especially those patients who are frail or have comorbidities. Thus, this population should be screened prior to treatment for such predispositions to maximize medical management of comorbidities. Chronologic age itself is not a reason for choosing less intensive treatment for older HNC patients. Whenever possible, also older patients should be treated according to the best standard of care, as nonstandard approaches may result in increased treatment failure rates and mortality. The treatment plan is best established by a multidisciplinary tumor board with shared decision-making with patients and family. Treatment modifications should be considered for those patients who have severe comorbidities, evidence of frailty (low performance status), or low performance status or those who refuse the recommendations of the tumor board.

Speech and Swallowing Rehabilitation Potentially Decreases Body Weight Loss and Improves Survival in Head and Neck Cancer Survivors

This retrospective observational cohort study aims to assess the outcomes and associated factors in head and neck cancer (HNC) survivors with dysphagia, and to investigate the relationship between outcomes and speech and swallowing rehabilitation (SSR). We enrolled patients who were diagnosed with HNC between October 2016 and July 2018; we included 393 patients who developed dysphagia after definite treatment and were referred to speech-language pathologists (SLPs). We then classified patients into groups according to whether they received SSR. We used the clinical variables-including age, sex, site of malignancy, cancer stage, treatment modality, SSR, initial ECOG score, initial KPS, initial body weight (BW), and initial BMI-to evaluate the association between the percentage of BW change and overall survival (OS). There were 152 (39%) and 241 (61%) patients who received and did not receive SSR, respectively. In multivariate linear regression, SSR was significantly associated with percentage change in BW at 3 months post-treatment. Having SSR was positively associated with the percentage change in BW and decreased the BW loss [β coefficient (95% CIs) = 2.53 (0.92 to 4.14)] compared to having no SSR. In the multivariate Cox regression, SSR was an independent factor for OS. Compared to no SSR, the hazard ratio (95% CIs) for patients who received SSR was 0.48 (0.31 to 0.74). SSR helps to avoid BW loss and increases overall survival. HNC patients who develop dysphagia after treatment should be encouraged to participate in SSR.

Expert Consensus Statement: Management of Dysphagia in Head and Neck Cancer Patients

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.

Perioperative Assessment/Prehabilitation in Larynx Cancer

Head and neck cancer (HNC) survivorship is increasing, and with it, a shift in treatment practices has occurred. Radical surgical resections for the treatment of HNC have decreased, and organ preservation treatments have increased. Although effective in treating HNC, chemoradiation therapy toxicities can be detrimental to a patient's overall health, nutrition status, and quality of life (QOL). Considering that dysphagia is typically a driving element of dysfunction, speech-language pathologists are vital to the prehabilitation phase. Prehabilitation programs include a variety of components, with the primary goal being to improve functional and QOL outcomes posttreatment.

Response to Neoadjuvant Targeted Therapy in Operable Head and Neck Cancer Confers Survival Benefit

PURPOSE

Neoadjuvant targeted therapy provides a brief, preoperative window of opportunity that can be exploited to individualize cancer care based on treatment response. We investigated whether response to neoadjuvant therapy during the preoperative window confers survival benefit in patients with operable head and neck squamous cell carcinoma (HNSCC).

PATIENTS AND METHODS

A pooled analysis of treatment-naïve patients with operable HNSCC enrolled in one of three clinical trials from 2009 to 2020 (NCT00779389, NCT01218048, NCT02473731). Neoadjuvant regimens consisted of EGFR inhibitors (n = 83) or anti-ErbB3 antibody therapy (n = 9) within 28 days of surgery. Clinical to pathologic stage migration was compared with disease-free survival (DFS) and overall survival (OS) while adjusting for confounding factors using multivariable Cox regression. Circulating tumor markers validated in other solid tumor models were analyzed.

RESULTS

92 of 118 patients were analyzed; all patients underwent surgery following neoadjuvant therapy. Clinical to pathologic downstaging was more frequent in patients undergoing neoadjuvant targeted therapy compared with control cohort (P = 0.048). Patients with pathologic downstage migration had the highest OS [89.5%; 95% confidence interval (CI), 75.7-100] compared with those with no stage change (58%; 95% CI, 46.2-69.8) or upstage (40%; 95% CI, 9.6-70.4; P = 0.003). Downstage migration remained a positive prognostic factor for OS (HR, 0.22; 95% CI, 0.05-0.90) while adjusting for measured confounders. Downstage migration correlated with decreased circulating tumor markers, SOX17 and TAC1 (P = 0.0078).

CONCLUSIONS

Brief neoadjuvant therapy achieved pathologic downstaging in a subset of patients and was associated with significantly better DFS and OS as well as decreased circulating methylated SOX17 and TAC1.

Trismus Occurrence and Link With Radiotherapy Doses in Head and Neck Cancer Patients Treated With Chemoradiotherapy

BACKGROUND

Chemoradiotherapy (CRT) for head and neck cancer (HNC) induces side-effects, including trismus, which impairs quality of life by causing difficulty to eat, speak, and maintain good oral hygiene, and by altering social life. Given the wide variation of reported trismus prevalence and as a first mandatory step for the preventive physiotherapy OPEN program (NCT03979924) this study evaluated trismus occurrence and its link with radiation doses.

METHODS

Study population was non-larynx HNC patients with epidermoid carcinoma treated with CRT, with or without surgery. A physiotherapist measured maximal interincisal distance before, during and after CRT, at 10 weeks and 6 months. The proportion of patients with trismus (with a 95% confidence interval) was estimated. Irradiation doses were analyzed between patients with and without trismus using non-parametric Kruskal-Wallis test.

RESULTS

We included 45 patients (77.8% male), median age 61 years (range 41-77). The proportion of trismus at baseline was 24.4%, 26.8% at 10 weeks and 37.1% at 6 months. During radiotherapy, it was 27.9% at week 3 and increased to 41.9% at week 6. Trismus occurrence at 10 weeks was higher when the radiation dose to the ipsilateral lateral pterygoid muscle was above the median value, that is, 36.8 grays.

CONCLUSION

Trismus occurrence differed according to radiation dose and cancer location. These findings highlight the necessity of early preventive physiotherapy programs to reduce trismus occurrence. The second step, of the interventional multicenter OPEN program, is currently evaluating the impact of preventive physiotherapy and patient education on trismus in a sample of 175 patients.

Improving compliance with swallowing exercise to decrease radiotherapy-related dysphagia in patients with head and neck cancer

Objective

Dysphagia, one of the most common complications in head and neck cancer (HNC) treated with radiotherapy, can severely affect patients' quality of life. Currently, because no "gold standard" treatment exists, swallowing exercise remains the main rehabilitation strategy for dysphagia. However, patients' compliance with long-term swallowing exercise is only 40%, thus, greatly compromising outcomes. This article aims to analyze thefactors influencing swallowing exercise compliance in patients with HNC and explains strategies developed to date for improved rehabilitation outcomes.

Methods

Research studies published between 2005 and 2022 were retrieved from seven databases: PubMed, Cochrane Library, Embase, CINAHL, CNKI, Wan Fang Database, and VIP Database, and 21 articles were shortlisted and systematically reviewed.

Results

The swallowing exercise compliance in patients with HNC undergoing radiotherapy was affected by multiple factors, including socio-demographic factors, illness-associated factors, treatment-associated factors, and psychosocial factors. Regarding the interventions, current strategies mainly address psychosocial issues via developing various education programs.

Conclusions

Different factors influencing swallowing exercise compliance are important and should be observed. Measures including developing multidisciplinary teams, applying innovative equipment, refining the intervention procedure, and applying systematic theory frameworks should be performed to achieve better outcomes of compliance interventions.

The Normal, the Radiosensitive, and the Ataxic in the Era of Precision Radiotherapy: A Narrative Review

(1) Background: radiotherapy is a cornerstone of cancer treatment. When delivering a tumoricidal dose, the risk of severe late toxicities is usually kept below 5% using dose-volume constraints. However, individual radiation sensitivity (iRS) is responsible (with other technical factors) for unexpected toxicities after exposure to a dose that induces no toxicity in the general population. Diagnosing iRS before radiotherapy could avoid unnecessary toxicities in patients with a grossly normal phenotype. Thus, we reviewed iRS diagnostic data and their impact on decision-making processes and the RT workflow; (2) Methods: following a description of radiation toxicities, we conducted a critical review of the current state of the knowledge on individual determinants of cellular/tissue radiation; (3) Results: tremendous advances in technology now allow minimally-invasive genomic, epigenetic and functional testing and a better understanding of iRS. Ongoing large translational studies implement various tests and enriched NTCP models designed to improve the prediction of toxicities. iRS testing could better support informed radiotherapy decisions for individuals with a normal phenotype who experience unusual toxicities. Ethics of medical decisions with an accurate prediction of personalized radiotherapy's risk/benefits and its health economics impact are at stake; (4) Conclusions: iRS testing represents a critical unmet need to design personalized radiotherapy protocols relying on extended NTCP models integrating iRS.

Perspectives on the Direction of Cancer Prehabilitation in the Pandemic and Beyond

Growing attention has been placed on cancer prehabilitation in the recent years as the number of publications increase. The real-world application of prehabilitation remains heterogeneous and its implementation has been challenging during the COVID-19 pandemic. However, the pandemic has also provided impetus for change-leveraging technology and digitalization. This paper will discuss the pre-existing models of care, adaptations that had taken place in the pandemic, the model of care in the author's institution, and the future direction of cancer prehabilitation.

Oral Dysfunction in Patients with Oral Cancer Could Occur Before Treatment and Require Early Nutritional Improvement: A Cross-Sectional Study

Patients with oral cancer have poor nutritional status before treatment. However, there have been no reports of the detailed evaluation of preoperative oral function in patients with oral squamous cell carcinoma (OSCC). Therefore, this study aimed to evaluate the preoperative oral function of patients with OSCC and examine the relationship with nutritional status. Oral function measurements (microorganisms, oral dryness, occlusal force, tongue pressure, masticatory function, Eating Assessment Tool, and Postoperative Oral Dysfunction Scale) and Mini Nutritional Assessment-Short Form (MNA-SF) data were collected from 51 patients with OSCC (men: 37, women: 14, mean age: 72.1 years) who visited the Shimane University Hospital, Department of Oral and Maxillofacial Surgery, from September 2019 to September 2021. The tongue was the most prevalent primary gingiva site [22 patients (43.1%)], and 36 patients (70.6%) had advanced cancer. Comparisons between nutritional status and each related factor revealed significant differences in the number of individuals in the household, cancer stage, presence of pulmonary disease, number of teeth, microorganisms (grade), and masticatory function (mg/dL) (p < 0.05). Multiple regression analysis using the total MNA-SF score as the dependent variable with adjustment for confounding factors showed significant association between oral dryness and tongue pressure (p < 0.05). No significant association was found for the Eating Assessment Tool or Postoperative Oral Dysfunction scale. Patients with OSCC may have decreased oral function because of the tumor at the time of diagnosis, which causes a decline in nutritional status. Preoperative interventions are necessary to improve nutrition based on the state of oral function.

Adhering to Eat and Exercise Status During Radiotherapy for Oropharyngeal Cancer for Prevention and Mitigation of Radiotherapy-Associated Dysphagia

Importance

Previously published work reported independent benefit of maintenance of oral intake (eat) and swallowing exercise adherence (exercise) during radiotherapy (RT) on diet and functional outcomes. The current study seeks to validate the authors' previously published findings in a large contemporary cohort of patients with oropharynx cancer (OPC) and address limitations of the prior retrospective study using prospective, validated outcome measures.

Objective

To examine the longitudinal association of oral intake and swallowing exercise using validated, clinician-graded and patient-reported outcomes.

Design, Setting, and Participants

Secondary analysis of a prospective OPC registry including patients who underwent primary RT/chemoradiotherapy (CRT) or primary transoral robotic surgery plus RT/CRT for OPC at a single-institution comprehensive cancer center.

Exposures

Adherence to speech pathology swallowing intervention during RT coded as (1) eat: oral intake at end of RT (nothing by mouth [NPO]; partial oral intake [PO], with feeding tube [FT] supplement; full PO); and (2) exercise: swallowing exercise adherence (nonadherent vs partial/full adherence).

Main Outcomes and Measures

Feeding tube and diet (Performance Status Scale for Head and Neck Cancer) patient-reported swallowing-related quality of life (MD Anderson Dysphagia Inventory; MDADI) and clinician-graded dysphagia severity grade (videofluoroscopic Dynamic Imaging Grade of Swallowing Toxicity; DIGEST) were collected at baseline, 3 to 6 months, and 18 to 24 months post-RT.

Results

A total of 595 patients (mean [SD] age, 65 [10] years; 532 [89%] male) who underwent primary RT (111 of 595 [19%]), CRT (434 of 595 [73%]), or primary transoral robotic surgery plus RT/CRT (50 of 595 [8%]) were included in this cohort study. At the end of RT, 55 (9%) patients were NPO, 115 (19%) were partial PO, 425 (71%) were full PO, and 340 (57%) reported exercise adherence. After multivariate adjustment, subacute return to solid diet and FT were independently associated with oral intake (odds ratio [OR], 2.0; 95% CI, 1.0-4.1; OR, 0.1; 95% CI, 0.0-0.2, respectively) and exercise (OR, 2.9; 95% CI, 1.9-4.5; OR, 0.3; 95% CI, 0.1-0.5, respectively). Subacute MDADI (β = 6.5; 95% CI, 1.8-11.2), FT duration (days; β = -123.4; 95% CI, -148.5 to -98.4), and less severe dysphagia per DIGEST (OR, 0.6; 95% CI, 0.3-1.0) were independently associated with oral intake, while exercise was independently associated with less severe laryngeal penetration/aspiration per DIGEST-safety (OR, 0.7; 95% CI, 0.4-1.0). DIGEST grade associations with oral intake were not preserved long-term; however, exercise was associated with a higher likelihood of solid diet intake and better swallow safety per DIGEST.

Conclusions and Relevance

The findings of this cohort study extend the authors' previously published findings that oral intake and swallowing exercise during RT are associated with favorable functional outcomes, now demonstrated with broader domains of function using validated measures. Patterns of benefit differed in this study. Specifically, better subacute recovery of swallow-related quality of life and less severe dysphagia were found among patients who maintained oral intake independent of exercise adherence, and shorter FT utilization and better long-term diet and swallowing safety were found among those who exercised independent of oral intake.

Assessing Risk of Severe Complications after Endoscopic Transnasal Transsphenoidal Surgery: A Comparison of Frailty, American Society of Anesthesiologists, and Comorbidity Scores

Objective  This study aimed to improve age-independent risk stratification for patients undergoing endoscopic transnasal transsphenoidal (TNTS) approach to pituitary mass resection by investigating the associations between frailty, American Society of Anesthesiologists (ASA), and comorbidity scores with severe complications following TNTS. Design  This study is a retrospective review. Setting  This review was conducted utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Participants  A total of 680 cases of TNTS identified from 2010 to 2013 were included in this study. Main Outcome Measures  The modified frailty index (mFI) was calculated to quantify frailty. ASA and Charlson's comorbidity index (CCI) scores were obtained as physiologic status and comorbidity-based prognostic markers. Severe complications were separated into intensive care unit (ICU)-level complications, defined by Clavien-Dindo grade IV (CDIV) criteria, and mortality. Results  Overall, 24 CDIV complications (3.5%) and 6 deaths (0.9%) were recorded. Scores for mFI ( p  = 0.01, R ²  = 0.97) and ASA ( p  = 0.04., R ²  = 0.87) were significantly correlated with CDIV complications. ASA scores were significantly correlated with mortality ( p  = 0.03, R ²  = 0.87), as well as independently associated with CDIV complication by multivariable regression models (odds ratio [OR] = 2.96, 95% confidence interval [CI]: 1.35-6.83, p  < 0.01), while mFI was not. CCI was not significantly associated with CDIV complications or mortality. A multivariable regression model incorporating ASA had a lower Akaike's Information Criteria (AIC; 188.55) than a model incorporating mFI (195.99). Conclusion  Frailty and physiologic status, as measured by mFI and ASA scores respectively, both correlate with ICU-level complications after TNTS. ASA scores demonstrate greater clinical utility than mFI scores; however, as they are more easily generated, uniquely correlated with mortality and independently associated with ICU-level complication risk on multivariable regression analysis.

Proactive Swallowing Rehabilitation in Patients with Recurrent Oral Cancer Receiving Salvage Treatment: Long-Term Swallowing-Related Outcomes

The present study aimed to evaluate the impact of proactive swallowing rehabilitation on swallowing function and quality of life in patients with recurrent oral cancer in the first 2 years after salvage treatment. Consecutive adult patients with recurrent oral cancer who received salvage surgery and free flap reconstruction were recruited prospectively, to whom proactive swallowing rehabilitation was provided. Body weight (BW); fiberoptic endoscopic evaluation of swallowing (FEES), functional oral intake scale (FOIS), and diet level; 10-item eating assessment tool (EAT-10), and MD Anderson Dysphagia Inventory (MDADI); and adherence at baseline, 1, 3, 6, 12, 18 and 24 months were evaluated. A total of 50 patients were included during May 2018 to July 2020. Compared to the baseline, significant deterioration in BW, FOIS, and MDADI was noted at one month. However, a trend of recovery was observed in BW and FOIS from one month, and in MDADI from three months. All patients were free of tube feeding at 18-24 months and tolerated diet with special preparations or compensation. Safe swallowing could be achieved in approximately 80% participants after 12 months of diet modification or compensatory maneuvers. Proactive swallowing therapy was feasible in patients with recurrent oral cancer receiving salvage treatment. Although this patient population might have pre-existing dysphagia from previous treatments, rehabilitation could facilitate safe per oral intake and maintain adequate nutrition with adaptive maneuvers or compensatory strategies. Patients who underwent proactive swallowing rehabilitation had better recovery in the functional oral intake level.

The Role of Exercise Before Cancer Treatment

OBJECTIVES

We aim to describe on the role of exercise in preparation for cancer treatments (prehabilitation) that include surgery and neoadjuvant or nonsurgical approaches. We discuss the evidence for the role of exercise and provide guidelines to exercise prescription and examples of the structure of prehabilitation exercise programs.

DATA SOURCE

We use peer-reviewed articles obtained through PubMed searches with search terms: exercise, oncology, cancer surgery, exercise physiology, respiratory exercises, prehabilitation, and behavior change.

CONCLUSION

The emergence of prehabilitation in preparing patients for cancer care has followed a rapidly upward trajectory over the past 20 years. Exercise prehabilitation remains the cornerstone of management, particularly in patients attending for major surgery. Multimodal approaches to supporting patients before cancer treatment are now well accepted and include screening and individualized treatments of functional, nutritional, and psychological impairments. Respiratory training before surgery and the addition of behavior change strategies to improve adherence to interventions and promote improved longer-term outcomes are now included in many prehabilitation programs. For exercise to be an effective treatment in improving fitness and strength, supervised aerobic and resistance exercises at moderate intensity are recommended. There remains debate regarding the use of higher-intensity exercise, the appropriate outcome to measure efficacy, and the mechanisms driving the efficacy of exercise.

IMPLICATIONS FOR NURSING PRACTICE

We provide background evidence and knowledge pertaining to the role and provision of exercise prehabilitation. Understanding screening, risk factors, and potential efficacy assists in knowing who to refer for prehabilitation and what the programs include. This enables more effective com munication with patients attending for cancer treatments.

A Qualitative Study of Patient and Healthcare Provider Perspectives on Building Multiphasic Exercise Prehabilitation into the Surgical Care Pathway for Head and Neck Cancer

Head and neck cancer (HNC) surgical patients experience a high symptom burden. Multiphasic exercise prehabilitation has the potential to improve patient outcomes, and to implement it into the care pathway, the perspectives of patients and healthcare providers (HCPs) must be considered. The purpose of this study was thus to gather feedback from HNC surgical patients and HCPs on building exercise into the standard HNC surgical care pathway. Methods: Semi-structured interviews were conducted with patients and HCPs as part of a feasibility study assessing patient-reported outcomes, physical function, and in-hospital mobilization. Interview questions included satisfaction with study recruitment, assessment completion, impact on clinical workflow (HCPs), and perceptions of a future multiphasic exercise prehabilitation program. This study followed an interpretive description methodology. Results: Ten patients and ten HCPs participated in this study. Four themes were identified: (1) acceptability and necessity of assessments, (2) the value of exercise, (3) the components of an ideal exercise program, and (4) factors to support implementation. Conclusion: These findings highlight the value of exercise across the HNC surgical timeline from both the patient and the HCP perspective. Results have informed the implementation of a multiphasic exercise prehabilitation trial in HNC surgical patients.

Anaesthesia for reconstructive free flap surgery for head and neck cancer

Head and neck cancer surgery presents significant challenges for the anaesthetist. A thorough multidisciplinary preoperative assessment and optimisation of the patient is essential, including nutritional and psychological evaluation. The incidence of a difficult airway is high, and the anaesthetist must be skilled in advanced airway techniques. Surgery is extensive, often requiring reconstructive surgery with either a pedicled or free flap. Detailed knowledge of flap physiology and anatomy is needed, and anaesthesia comprises careful management of mean arterial pressure, fluid administration, temperature control and oxygenation. The Enhanced Recovery after Surgery Society and the Society for Head and Neck Anaesthesia consensus recommendations provide guidance on current best practice. Despite continued debate, it now appears that this constitutes goal-directed fluid therapy, coupled with judicious vasopressor therapy sufficient to achieve an adequate mean arterial pressure. Emerging techniques such as prehabilitation and postoperative near-infrared spectroscopy flap monitoring provide hope of improved outcomes going forward.