Swallowing Outcomes in Head & Neck Cancer

Jo Patterson

Macmillan Speech & Language Therapist/Research Fellow

Swallowing Outcomes

• Critique assessments

• Collector’s perspective

• Patient rated outcomes

• Clinical scales

• Clinical indicators

Patient reported outcomes

• SWAL-QOL / SWAL-CARE

• M.D.Anderson Dysphagia Inventory

SWAL-QOL (McHorney 2002)

• Devised from patient focus group (N=549, 14.5% head & neck cancer)

• Good correlation with UWQOL (Lovell 2005)

• Moderately related to pathophysiology

Measurement tool• SWAL-QOL 2002 (44 items, 11 domains)

general burden* (fatigue)food selection* (sleep)eating duration (communication)eating desirefear of eatingmental health*social function*symptom frequency

Data Sample

• N=65 (49 males; 16 females)

• Age 32-80y mean 60y

• Oral (31) oropharyngeal (30) NPC (4)

• T1-2 (35) T3-4 (30)

• Surgery (10) surgery & radiotherapy (36) chemoradiotherapy (13) radiotherapy (6)

• 35 completed pre & post SWAL-QOL

• Analysed using ANOVA

Pre-treatment

Worst QoL Best QoL

Gender * *Female

Male

T stage * * *1 or 23 or 4

Site *Oral

OropharyngealNasopharyngeal

GEN

ERAL

BUR

DEN

FOO

D SE

LECT

ION

EAT

ING

DUR

ATIO

N

EATI

NG D

ESIR

E

FEAR

OF

EATI

NG

MEN

TAL

HEAL

TH

SOCI

AL F

X

COUG

HING

CHO

KE O

N FO

OD

CHO

KE O

N LI

QUI

D

THIC

K SA

LIVA

, PHL

EGM

GAG

GIN

G

EXCE

SS S

ALIV

A, P

HLEG

M

CLEA

R TH

ROAT

DRO

OLI

NG

PRO

BLEM

CHE

WIN

G

FOO

D ST

ICK

THRO

AT

FOO

D ST

ICKM

OUT

H

DRIB

BLE

FRO

M M

OUT

H

DRIB

BLE

FRO

M N

OSE

COUG

H - F

OO

D ST

UCK

6 months post treatmentWorst QoL Best QoL

Gender *Female

Male

T stage1 or 23 or 4

Site *Oral

OropharyngealNasopharyngeal

Treatment *Surgery

Surgery & RadiotherapyChemoradiotherapy

Radiotherapy

GE

NE

RA

L B

UR

DE

N

FO

OD

SE

LE

CT

ION

EA

TIN

G D

UR

AT

ION

EA

TIN

G D

ES

IRE

FE

AR

OF

EA

TIN

G

ME

NT

AL

HE

AL

TH

SO

CIA

L F

X

CO

UG

HIN

G

CH

OK

E O

N F

OO

D

CH

OK

E O

N L

IQU

ID

TH

ICK

SA

LIV

A, P

HL

EG

M

GA

GG

ING

EX

CE

SS

SA

LIV

A, P

HL

EG

M

CL

EA

R T

HR

OA

T

DR

OO

LIN

G

PR

OB

LE

M C

HE

WIN

G

FO

OD

ST

ICK

TH

RO

AT

FO

OD

ST

ICK

MO

UT

H

DR

IBB

LE

FR

OM

MO

UT

H

DR

IBB

LE

FR

OM

NO

SE

CO

UG

H -

FO

OD

ST

UC

K

Collector’s perspective

• Author’s report 14 mins to complete – much longer needed

• Difficult to analyse – many components

• Good sections – includes symptoms

• Not to be done cross-sectional

M.D. Anderson Dysphagia Inventory (Chen 2001)

• 20 items (sub-groups emotion, physical, function)

• Devised from professionals (SALTs & Surgeons)• Good reliability• Correlates with UWQOL• No association with aspiration (Gillespie 2005)• Used as outcome for swallowing exercises

(Kulbersh 2006)

MDADI pre & post CRT Demographics

T1 T2 T3 T4 Tx

Orophx 6 9 7 24 -

Hypophx 2 3 6 6 -

Larynx 23 6 11 4 -

U/k 1° - - - - 9

Total = 116

Comparison pre & post

Collector’s perspective

• 10 mins to complete

• ‘no opinion’ poses difficulties

• Difficult to use on someone without swallowing difficulties

• Difficult to use on NBM patients

• One item complex double negative

Quality of Life Questionnaires

• University of Washington QOL Scales• DAHNO• Correlates with VFSS, HADS, MDADI, SWAL-

QOL, TOMS• Short, quick to complete• Wide research base• Difficult to find out how it was devised• Reproducible, reliable & valid• Originally intended for surgical group• Additions of taste, saliva, mood, anxiety• Speech & saliva difficult for people to answer

Pre-treatment priorities

University of Washington QOL pre-treatment

0

5

10

15

20

25

30

35

40

45

Domain

%

Clinical Scales

• Performance Status Scales (List ’90)

• Therapy Outcome Measures (TOMS)

• FIGS

Performance Status Scales (List 1990)

• Developed by surgeons, oncologists & SALTs• Purpose; research & clinical• Normalcy of diet, eating in public,

communication• Rated by ‘health professionals’• High reliability• Correlates with QOL• Included in DAHNO dataset

Diet scale pre vs. 3 months post ChemoradiotherapyPerformance Status Scale pre to 3 month difference

0

10

20

30

40

50

60

70

80

90

100

NPC Unknown Orophx Hypophx Larynx

Site

Sco

re d

iffe

ren

ce

Collectors perspective

• Quick

• Can be done by other staff

• Some diets difficult to grade

• Can give false positive results

• Gradations ?equal

• Large literature base for comparison

• ?swallowing outcome

Therapy Outcome Measures(Enderby ’77)

10 core patients specific scales

• ‘Laryngectomy’ only scale specific to H&NC

• Scales on voice, dysarthria, phonology & dysphagia

• Pilot study Radford et al 2003– Correlates with UWQOL scales– ?modification for H&NC

Functional Intraoral Glasgow Scale (FIGS)(Goldie 2006)

• Originated Canniesburn Hospital

• 3 scales – chew, swallow & speech

• Total score of all 3 items

Clinical Indicators

• Aspiration / penetration

• Residue

• Swallowing efficiency

• Feeding tube dependency

Aspiration / Penetration

• H&NC literature focuses on aspiration

• Penetration / aspiration scale (Rosenbek)– Increases reliability of findings– One score– Requires instrumental assessment– ?meaningful to clinical picture / patient

% Aspiration Post CRT

010

203040

506070

8090

100

Nguyen Kotz Smith Pauloski Graner Eisbruch Chang

% aspiration

% Aspiration pneumonia

Aspiration Pneumonia

0

10

20

30

40

50

60

70

80

90

100

Kendall Nguyen Chang Wu Eisbruch

Studies

% p

neu

mo

nia

Swallowing Efficiency

• Residue

• Oropharyngeal swallowing efficiency

• Water swallow test

Mean time to swallow 100mLs water pre-treatment

Mean time

02468

1012141618

Hypop

hary

nx

Oroph

aryn

x

Laryn

x

Unknown

Site

Tim

e

Mean time

Mean

0

2

4

6

8

10

12

14

16

T1 T2 T3 T4 Tx

Tumour stage

Mea

n t

ime

Mean

Tube feeding

NPC T.Base U/k 1° Total

No Peg 4 12 11 27(40%)

0-4week - 5 - 5(12%)

4-12wks 1 1 1 3(7%)

12-24wks 1 7 1 9(22%)

24-52wks 4 11 2 17(14%)

>52wks - 6 1 7(17%)

Total 10 42 16 68

DAHNO

• Was the patient seen for pre treatment SALT assessment?

• PSS Normalcy of Diet

• Weight

• Type & timing of nutritional support

Summary

• Choice of measures• One-dimensional, cross-sectional misleading• Needs to be longitudinal, set time points• Simple / collectable• What questions to ask of the data• It will require dedicated time• ?interventions• DAHNO