Improving Dysphagia Quality of Life Outcomes in Patients Receiving Head and Neck Radiotherapy (original) (raw)
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Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology, 2015
To determine if acute symptoms during definitive radiotherapy (RT) or chemoradiation (CHRT) are prognostic factors for late dysphagia in head and neck cancer (HNC). This prospective cohort study consisted of 260 HNC patients who received definitive RT or CHRT. The primary endpoint was grade 2-4 swallowing dysfunction at 6months after completing RT (SWALM6). During treatment, acute symptoms, including oral mucositis, xerostomia and dysphagia, were scored, and the scores were accumulated weekly and entered into an existing reference model for SWALM6 that consisted of dose-volume variables only. Both acute xerostomia and dysphagia were strong prognostic factors for SWALM6. When acute scores were added as variables to the reference model, model performance increased as the course of treatment progressed: the AUC rose from 0.78 at the baseline to 0.85 in week 6. New models built for weeks 3-6 were significantly better able to identify patients with and without late dysphagia. Acute xeros...
Asian Journal of Oncology, 2015
Introduction: Dysphagia is a very common problem associated with head and neck cancer patients. Inspite of best of technologies like Intensity Modulated Radiotherapy (IMRT) or Image Guided Radiotherapy (IGRT), Dysphagia remains a major problem in locally advanced head and neck cancer patients. Materials and Methods: We randomized 50 head and neck cancer patients, including all sites and stages into two groups, 25 patients in each group. In Group-A dysphagia prevention exercises were done from the day of the onset of radiation therapy and continued till 6 months, while in Group-B no dysphagia interventions were given. We analyzed rate of dysphagia, aspiration rate and its impact on quality of life. We used M.D. Anderson Dysphagia Inventory (MDADI) which is a validated and reliable questionnaire designed specifically for evaluating impact of dysphagia on quality of life (QOL) in head and neck cancer patients. American Speech language Hearing Association (ASHA) scale was used for asses...
Radiation Oncology, 2014
Backgorund: The aim of this study was to evaluate dysphagia in patients with head and neck cancer (HNC) undergoing three-dimensional conformal radiation therapy using objective and subjective tools simultaneously and to associate the clinical correlates of dysphagia with dosimetric parameters. Methods: Twenty patients were included in the study. The primary tumor and the involved lymph nodes (LN) were treated with 66-70 Gy, the uninvolved LN were treated with 46-50 Gy. Six swallowing structures were identified: the superior pharyngeal constrictor muscle (SPCM), the middle pharyngeal constrictor muscle (MPCM), the inferior pharyngeal constrictor muscle (IPCM), the base of tongue (BOT), the larynx and the proximal esophageal sphincter (PES). Dysphagia was evaluated using videofluoroscopy and European Organization for Research and Treatment of Cancer (EORTC) QoL questionnaire (QLQ-C30) and supplemental EORTC QoL module for HNC (QLQ-H&N35). The evaluations were performed before treatment, at 3 months and at 6 months following treatment. Results: On objective evaluation, the D max for the larynx and the sub-structures of the PCM were correlated with impaired lingual movement, BOT weakness and proximal esophageal stricture at 3 months, whereas the V 65 , the V 70 and the D max for the larynx was correlated with BOT weakness and the V 65 , the V 70 , the D max or the D mean for the sub-structures of the PCM were correlated with impaired lingual movement, BOT weakness, reduced laryngeal elevation, reduced epiglottic inversion and aspiration at 6 months following treatment. On subjective evaluation, the V 60 , the D max and the D mean for SPCM were correlated with QoL scores for HNSO at 3 months, whereas the V 70 for SPCM were correlated with QoL scores for HNPA and the V 60 , the V 65 , the V 70 , the D max and the D mean for SPCM were correlated with QoL scores for HNSO at 6 months following treatment. Conclusions: The use of multiple dysphagia-related endpoints to complement eachother rather than to overlap with one another, as well as the use of multiple evaluations over time to represent a scale of early to late findings might provide a better insight in terms of the association of the clinical correlates of dysphagia with the dose-volume data for the dysphagia-related anatomical structures.
Dysphagia in head and neck cancer patients following intensity modulated radiotherapy (IMRT)
Radiation Oncology, 2011
Background: To evaluate the objective and subjective long term swallowing function, and to relate dysphagia to the radiation dose delivered to the critical anatomical structures in head and neck cancer patients treated with intensity modulated radiation therapy (IMRT, +/-chemotherapy), using a midline protection contour (below hyoid, level of vertebra 2/3). Methods: 82 patients with stage III/IV squamous cell carcinoma of the larynx, oropharynx, or hypopharynx, who underwent successful definitive (n = 63, mean dose 68.9Gy) or postoperative (n = 19, mean dose 64.2Gy) simultaneous integrated boost (SIB) -IMRT either alone or in combination with chemotherapy (85%) with curative intent between January 2002 and November 2005, were evaluated retrospectively. 13/63 definitively irradiated patients (21%) presented with a total gross tumor volume (tGTV) >70cc (82-173cc; mean 106cc). In all patients, a laryngo-pharyngeal midline sparing contour outside of the PTV was drawn. Dysphagia was graded according subjective patient-reported and objective observer-assessed instruments. All patients were re-assessed 12 months later. Dose distribution to the swallowing structures was calculated. Results: At the re-assessment, 32-month mean post treatment follow-up (range 16-60), grade 3/4 objective toxicity was assessed in 10%. At the 32-month evaluation as well as at the last follow up assessment mean 50 months (16-85) post-treatment, persisting swallowing dysfunction grade 3 was subjectively and objectively observed in 1 patient (1%). The 5-year local control rate of the cohort was 75%; no medial marginal failures were observed. Conclusions: Our results show that sparing the swallowing structures by IMRT seems effective and relatively safe in terms of avoidance of persistent grade 3/4 late dysphagia and local disease control.
Oral Oncology, 2018
In head and neck cancer (HNC) scenario, newer radiotherapy (RT) techniques, such as intensity modulated RT (IMRT), aim to reduce acute and late toxicity without impair tumor response and loco-regional control rates. However, late radiation-associated dysphagia (RAD) remains a major clinical problem and has gained a growing importance in the last few years, especially due to human papilloma virus (HPV)-related HNC favorable prognosis. The aim of this review was to provide clinical information about late RAD. The main anatomical structures involved in swallowing were described, in order to define potential organ at risk and available radiation-dose constraints in IMRT plan. Finally, possible rehabilitation strategies were proposed. This is expected to represent an opportunity for improved multidisciplinary management in HNC patients.
International Journal of Radiation Oncology*Biology*Physics, 2007
Purpose: To present initial results of a clinical trial of intensity-modulated radiotherapy (IMRT) aiming to spare the swallowing structures whose dysfunction after chemoradiation is a likely cause of dysphagia and aspiration, without compromising target doses. Methods and Materials: This was a prospective, longitudinal study of 36 patients with Stage III-IV oropharyngeal (31) or nasopharyngeal (5) cancer. Definitive chemo-IMRT spared salivary glands and swallowing structures: pharyngeal constrictors (PC), glottic and supraglottic larynx (GSL), and esophagus. Lateral but not medial retropharyngeal nodes were considered at risk. Dysphagia endpoints included objective swallowing dysfunction (videofluoroscopy), and both patient-reported and observer-rated scores. Correlations between doses and changes in these endpoints from pre-therapy to 3 months after therapy were assessed. Results: Significant correlations were observed between videofluoroscopy-based aspirations and the mean doses to the PC and GSL, as well as the partial volumes of these structures receiving 50-65 Gy; the highest correlations were associated with doses to the superior PC (p = 0.005). All patients with aspirations received mean PC doses >60 Gy or PC V 65 >50%, and GSL V 50 >50%. Reduced laryngeal elevation and epiglottic inversion were correlated with mean PC and GSL doses (p < 0.01). All 3 patients with strictures had PC V 70 >50%. Worsening patientreported liquid swallowing was correlated with mean PC (p = 0.05) and esophageal (p = 0.02) doses. Only mean PC doses were correlated with worsening patient-reported solid swallowing (p = 0.04) and observer-rated swallowing scores (p = 0.04). Conclusions: These dose-volume-effect relationships provide initial IMRT optimization goals and motivate further efforts to reduce swallowing structures doses to reduce dysphagia and aspiration. Ó
Dysphagia severity following chemoradiation and postoperative radiation for head and neck cancer
European Journal of Radiology, 2006
Objective: The purpose of the study is to evaluate dysphagia severity following chemoradiation and postoperative radiation for head and neck cancer, and particularly the aspiration risk because of its potential life-threatening consequence. Materials and methods: We reviewed retrospectively the modified barium swallow (MBS) results in 110 patients who complained of dysphagia following chemoradiation (57) and postoperative radiation (53) of their head and neck cancer. Patients were selected if they were cancer free at the time of the swallowing study. Dysphagia severity was graded on a scale of 1-7. Patients were grouped according to the dysphagia severity: mild (grades 2-3), moderate (grades 4-5), and severe (grades 6-7). Results: Mean and median dysphagia grades were 4.84/5 and 4.12/4 for chemoradiation and postoperative radiation respectively. The mean difference between the two groups is statistically significant (p = 0.02). Mild dysphagia occurred in 13 patients (22%) of the chemoradiation group and 17 (32%) of the postoperative group. Corresponding number for the moderate group was 25 (43%) and 25 (48%), respectively. Severe dysphagia was significant in the chemoradiation group (34%) compared to the postoperative group (19%). However, the difference was not statistically significant (p = 0.29). There was a higher proportion of patients with large tumor (T3-T4) in the chemoradiation group who developed severe dysphagia. Conclusion: Dysphagia remained a significant morbidity of chemoradiation and postoperative radiation for head and neck cancer. Dysphagia may be more severe in the chemoradiation group because of the higher proportion of patients with large tumor, the high radiation dose, and a high number of oropharyngeal tumors. Aspiration occurred in both groups. Diagnostic studies such as MBS should be part of future head and neck cancer prospective studies to assess the prevalence of aspiration, as it may be silent.
Evaluating and Reporting Dysphagia in Trials of Chemoirradiation for Head-and-Neck Cancer
International Journal of Radiation Oncology*Biology*Physics, 2010
Purpose-Reporting long-term toxicities in trials of chemo-irradiation (CRT) of head and neck cancer (HNC) has mostly been limited to observer-rated maximal grades ≥3. We evaluated this reporting approach for dysphagia by assessing 1) patient-reported dysphagia (PRD), and 2) objective swallowing dysfunction through videofluoroscopy (VF), in patients with various grades of maximal observer-reported dysphagia (ORD). Methods-62 HNC patients completed quality-of-life questionnaires periodically through 12m post-CRT. Five PRD items were selected: three dysphagia-specific questions, an Eating-Domain, and "Overall Bother". They underwent VF at 3m and 12m, and ORD (Common Terminology Criteria for Adverse Events) scoring every 2 months. We classified patients into four groups (0-3) according to maximal ORD scores documented 3-12 months post-CRT, and assessed PRD and VF summary scores in each group. Results-Differences in ORD scores among the groups were considerable throughout the observation period. In contrast, PRD scores were similar between Groups 2 and 3, and variable in Group 1. VF scores were worse in Group 3 compared to 2 at 3m but similar at 12m. In Group 1, PRD and VF scores from 3 through 12 months were close to Groups 2 and 3 if ORD score 1 persisted, but were similar to Group 0 in patients whose ORD scores improved by 12m. Conclusions-Patients with lower maximal ORD grades, especially if persistent, had similar rates of PRD and objective dysphagia as patients with highest grades. Lower ORD grades should therefore be reported. These findings may have implications for reporting additional toxicities besides dysphagia.