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*
food selection*
eating duration
eating desire
fear of eating
mental health*
social function*
symptom frequency
(fatigue)
(sleep)
(communication)
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
COUGH - FOOD STUCK
DRIBBLE FROM NOSE
Site
DRIBBLE FROM MOUTH
Worst QoL
FOOD STICKMOUTH
*
FOOD STICK THROAT
Gender
PROBLEM CHEWING
DROOLING
CLEAR THROAT
EXCESS SALIVA, PHLEGM
GAGGING
THICK SALIVA, PHLEGM
CHOKE ON LIQUID
CHOKE ON FOOD
*
COUGHING
SOCIAL FX
MENTAL HEALTH
FEAR OF EATING
EATING DESIRE
T stage
EATING DURATION
FOOD SELECTION
GENERAL BURDEN
Pre-treatment
Best QoL
* *
Female
Male
*
1 or 2
3 or 4
*
Oral
Oropharyngeal
Nasopharyngeal
COUGH - FOOD STUCK
DRIBBLE FROM NOSE
DRIBBLE FROM MOUTH
Worst QoL
FOOD STICKMOUTH
Treatment
FOOD STICK THROAT
Site
PROBLEM CHEWING
DROOLING
CLEAR THROAT
EXCESS SALIVA, PHLEGM
GAGGING
THICK SALIVA, PHLEGM
Gender
CHOKE ON LIQUID
CHOKE ON FOOD
COUGHING
SOCIAL FX
MENTAL HEALTH
FEAR OF EATING
EATING DESIRE
EATING DURATION
FOOD SELECTION
GENERAL BURDEN
6 months post treatment
Best QoL
*
Female
Male
T stage
1 or 2
3 or 4
*
Oral
Oropharyngeal
Nasopharyngeal
*
Surgery
Surgery & Radiotherapy
Chemoradiotherapy
Radiotherapy
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, SWALQOL, 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
45
40
35
%
30
25
20
15
10
5
0
h
y
w
iet
ec
llo
x
e
a
an
sp
sw
in
pa
m
d
oo
a
liv
a
s
n
wi
e
ch
g
i
tiv
c
a
Domain
ty
er
ce
on
i
d
n
t
l
a
a
ou
ar
re
h
e
c
s
p
re
ap
ste
ta
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
Chemoradiotherapy
Performance Status Scale pre to 3 month difference
100
90
Score difference
80
70
60
50
40
30
20
10
0
NPC
Unknown
Orophx
Site
Hypophx
Larynx
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
100
90
% aspiration 80
70
60
50
40
30
20
10
0
Nguyen
Kotz
Smith
Pauloski Graner Eisbruch Chang
% Aspiration pneumonia
Aspiration Pneumonia
100
90
80
% pneumonia
70
60
50
40
30
20
10
0
Kendall
Nguyen
Chang
Studies
Wu
Eisbruch
Swallowing Efficiency
• Residue
• Oropharyngeal swallowing efficiency
• Water swallow test
Mean time to swallow 100mLs
water pre-treatment
18
16
14
12
10
8
6
4
2
0
Un
kn
ow
n
La
ry
nx
Mean
Site
16
14
12
Mean time
yn
x
Mean time
O
ro
ph
ar
Hy
po
ph
ar
yn
x
Time
Mean time
10
8
6
Mean
4
2
0
T1
T2
T3
Tumour stage
T4
Tx
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%)
10
42
16
68
Total
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