Swallowing outcomes following Intensity Modulated Radiation Therapy (IMRT) for head & neck cancer - A systematic review

Head and Neck Unit, The Royal Marsden Hospital NHS Foundation Trust, Fulham Road, London SW3 6JJ, United Kingdom.
Oral Oncology (Impact Factor: 3.61). 10/2010; 46(10):727-33. DOI: 10.1016/j.oraloncology.2010.07.012
Source: PubMed


A systematic review to establish what evidence is available for swallowing outcomes following IMRT for head and neck cancer.
Online electronic databases were searched to identify papers published in English from January 1998 to December 2009. Papers were independently appraised by two reviewers for methodological quality, method of swallowing evaluation and categorized according to the World Health Organisation's International Classification of Health Functions. The impact of radiation dose to dysphagia aspiration risk structures (DARS) was also evaluated.
Sixteen papers met the inclusion criteria. The literature suggests that limiting the radiation dose to certain structures may result in favourable swallowing outcomes. Methodological limitations included variable assessment methods and outcome measures and heterogeneity of patients. There are only limited prospective data, especially where pre-treatment measures have been taken and compared to serial post-treatment assessment.
Few studies have investigated the impact of IMRT on swallow function and the impact on everyday life. Initial studies have reported potential benefits but are limited in terms of study design and outcome data. Further well designed, prospective, longitudinal swallowing studies including multidimensional evaluation methods are required to enable a more comprehensive understanding of dysphagia complications and inform pre-treatment counselling and rehabilitation planning.

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    • "There are currently many measures of dysphagia, including instrumental tests of swallowing impairment, swallowing specific quality of life questionnaires and surrogate measures such as diet texture scales and presence of a feeding tube. There is no consensus for a preferred method, which does not allow for easy data comparison between studies as identified in systematic reviews [4] [6] Patient reported outcome measures (PROMs) have begun to be valued and integrated into HNC trials as important end points [7]. If PROMs are employed to assess the impact of interventions, it is important to understand the relationship between measures to better interpret findings and which factors might facilitate or predict an "
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    ABSTRACT: Objectives: Dysphagia is a common and debilitating side effect of chemoradiotherapy. Assessment is difficult; swallowing is multifactorial and studies choose from a range of dysphagia assessments. This study intended to investigate the relationship between swallowing assessments of dysphagia in a cohort of patients and to evaluate whether clinical swallowing measures can predict patient reported swallowing outcomes. Materials and methods: One hundred and seventy-three head and neck cancer patients from two teaching hospitals were recruited prospectively over 25months. At three months follow-up patients were assessed using Rosenbeck's Penetration-Aspiration Scale (PAS), The 100ml Water Swallow Test (WST), The Performance Status Scale: Normalcy of Diet and the MD Anderson Dysphagia Inventory (MDADI). Results: The highest correlation was observed between the MDADI and Normalcy of Diet (rho 0.68) and the lowest between the MDADI and the PAS (rho 0.34). Using multiple regression the PAS and WST accounted for 44% of the variance in the MDADI scores (R(2)=0.44, F=37.8, p<0.001). On stepwise regression, the model only retained the Normalcy of Diet scores (R(2)=0.42, F=107.9, p<0.001). Separating the PAS into subgroups, those with no penetration or aspiration on the PAS scored significantly higher on the MDADI (p=<0.001). Conclusion: Patient reported swallowing outcomes were strongly aligned with diet restrictions but poorly aligned with clinical assessment. The WST, however, was more correlated than the PAS score, representing a more functional assessment. Clinical dysphagia, associated with significant morbidity, and patient reported dysphagia related to quality of life are not interchangeable and must be measured separately.
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    • "Thus, studies aimed at identification of the dysphagia/aspiration-related structures (DARSs) (Eisbruch et al., 2004) (e.g., the pharyngeal constrictors, tongue base, and larynx), altered-mastication-related structures or (AMRSs) (Teguh et al., 2008; Johnson et al., 2010; Van der Molen et al., 2011, 2013) (e.g., the masseter and pterygoid muscles, the temporo-mandibular joints, and the oral cavity), and xerostomia-related structures or XRSs (Van de Water et al., 2009; Jellema et al., 2005) (e.g., the major and minor salivary glands) have been undertaken in recent years. As a consequence, RT techniques sparing the above-mentioned structures have been employed and they seem to improve patients' health-related quality of life (HRQoL) (Pow et al., 2006; Nutting et al., 2011; Bhide et al., 2009), even when RT is combined with CT (Hancock et al., 2003; Roe et al., 2010; Van der Laan et al., 2012). Yet, few studies report the exact dose-volume correlation for each individual DARS, AMRS and XRS (Nutting et al., 2011; Caudell et al., 2010; Eisbruch et al., 2011; Jensen et al., 2007; Levendag et al., 2007; Li et al., 2009; Bhide et al., 2012), and the majority of these are retrospective. "
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    ABSTRACT: Radiotherapy alone or in combination with chemotherapy and/or surgery is the typical treatment for head and neck cancer patients. Acute side effects (such as oral mucositis, dermatitis, salivary changes, taste alterations, etc.), and late toxicities in particular (such as osteo-radionecrosis, hypo-salivation and xerostomia, trismus, radiation caries etc.), are often debilitating. These effects tend to be underestimated and insufficiently addressed in the medical community. A multidisciplinary group of head and neck cancer specialists met in Milan with the aim of reaching a consensus on clinical definitions and management of these toxicities. The Delphi Appropriateness method was used for developing the consensus, and external experts evaluated the conclusions. This paper contains 10 clusters of statements about the clinical definitions and management of head and neck cancer treatment sequels (dental pathologies and osteo-radionecroses) that reached consensus, and offers a review of the literature about these topics. The review was split into two parts: the first part dealt with dental pathologies and osteo-radionecroses (10 clusters of statements), whereas this second part deals with trismus and xerostomia. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
    Full-text · Article · Aug 2015 · Critical reviews in oncology/hematology
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    • "The inconsistency between objective swallowing outcomes and patient-reported outcomes observed in these studies demonstrates that measuring the impact of dysphagia through instrumental assessments in this population alone does not provide a holistic picture of functioning. It has become increasingly apparent that to fully explore and understand the complexity of dysphagia post HNC, clinicians need to take a multidimensional assessment approach incorporating multiple outcome measures designed to provide greater insight into the impact of dysphagia on people with HNC (Frowen & Perry, 2006; Roe et al., 2010). This holistic approach is consistent with the International Classification of Functioning, Disability and Health (ICF), which emphasises the importance of viewing health conditions using a biopsychosocial perspective (World Health Organization, 2001). "

    Full-text · Article · Jun 2015 · Perspectives on Swallowing and Swallowing Disorders (Dysphagia)
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