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Impact of dysphagia on quality of life after treatment of head-and-neck cancer
Int. J. Radiation Oncology Biol. Phys., Vol. 61, No. 3, pp. 772–778, 2005 Copyright © 2005 Elsevier Inc. Printed in the USA. All rights reserved 0360-3016/05/$–see front matter
doi:10.1016/j.ijrobp.2004.06.017
CLINICAL INVESTIGATION
Head and Neck
IMPACT OF DYSPHAGIA ON QUALITY OF LIFE AFTER TREATMENT OF HEAD-AND-NECK CANCER NAM P. NGUYEN, M.D.,*† CHERYL FRANK, M.A.,‡ CANDACE C. MOLTZ, M.S.,‡ PAUL VOS, PH.D.,§ HERBERT J. SMITH, M.D.,¶ ULF KARLSSON, M.D., PH.D.,㛳 SURESH DUTTA, M.D.,# ALLAN MIDYETT, M.D.,¶ JESSICA BARLOON, M.S.,** AND SABAH SALLAH, M.D.†† †
*Department of Radiation Oncology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX; Departments of Radiation Oncology, ‡Audiology and Speech Pathology, ¶Radiology, and **Dietetic Service, Veterans Affairs North Texas Health Care System, Dallas, TX; Departments of §Biostatistics and 㛳Radiation Oncology, East Carolina University, Greenville, NC; # Department of Radiation Oncology, University of Southern California, Los Angeles, CA; ††Division of Hematology/Oncology, Louisiana State University, Shreveport, LA Purpose: To evaluate the quality of life (QOL) associated with dysphagia after head-and-neck cancer treatment. Methods and Materials: Of a total population of 104, a retrospective analysis of 73 patients who complained of dysphagia after primary radiotherapy (RT), chemoradiotherapy, and postoperative RT for head-and-neck malignancies were evaluated. All patients underwent a modified barium swallow examination to assess the severity of dysphagia, graded on a scale of 1–7. QOL was evaluated by the University of Washington (UW) and Hospital Anxiety and Depression questionnaires. The QOL scores obtained were compared with those from the 31 patients who were free of dysphagia after treatment. The QOL scores were also graded according to the dysphagia severity. Results: The UW and Hospital Anxiety and Depression scores were reduced and elevated, respectively, in the dysphagia group compared with the no dysphagia group (p ⴝ 0.0005). The UW scores were also substantially lower among patients with moderate-to-severe (Grade 4 –7) compared with no or mild (Grade 2–3) dysphagia (p ⴝ 0.0005). The corresponding Hospital Anxiety (p ⴝ 0.005) and Depression (p ⴝ 0.0001) scores were also greater for the moderate-to-severe group. The UW QOL subscale scores showed a statistically significant decrease for swallowing (p ⴝ 0.00005), speech (p ⴝ 0.0005), recreation/entertainment (p ⴝ 0.0005), disfigurement (p ⴝ 0.0006), activity (p ⴝ 0.005), eating (p ⴝ 0.002), shoulder disability (p ⴝ 0.006), and pain (p ⴝ 0.004). Conclusion: Dysphagia is a significant morbidity of head-and-neck cancer treatment, and the severity of dysphagia correlated with a compromised QOL, anxiety, and depression. Patients with moderate-to-severe dysphagia require a team approach involving nutritional support, physical therapy, speech rehabilitation, pain management, and psychological counseling. © 2005 Elsevier Inc. Dysphagia, Quality of life, Head-and-neck cancer treatment.
a gastrostomy tube. However, prolonged unnatural feeding may induce severe psychological distress, because it causes discomfort and distorts the patient’s self-image (4). Therefore, it is important for the clinician to assess the severity of dysphagia objectively in cancer survivors and to recognize its impact on their quality of life (QOL). The purpose of this study was to provide an objective basis for management of this debilitating side effect/complication.
INTRODUCTION Normal swallowing is a complex process requiring the perfect coordination of different nerve, muscle, and joint groups, beginning with mastication of the food, followed by transfer of the bolus to the pharynx, and closure of the larynx and velopharynx to avoid aspiration and nasal reflux (1). The destruction of normal tissues by head-and-neck malignancies, surgery, inflammation, and/or radiation-induced fibrosis of the pharyngeal muscles are potential mechanisms responsible for dysphagia in head-and-neck cancer patients (2). When aspiration occurs because of compromise of the swallowing reflex, pneumonia and respiratory failure may lead to death (3). The risk of aspiration is reduced by feeding through
The study population comprised 104 patients treated for headand-neck malignancies between January 1995 and March 2003 at
Reprint requests to: Nam P. Nguyen, M.D., Department of Radiation Oncology, University of Texas Southwestern Medical Center at Dallas, Veterans Affairs North Texas Health Care System, S. Lancaster Rd., Dallas, TX 75216. Tel: (214) 8570142; Fax: (214) 857-0145; E-mail: NamPhong.Nguyen@
med.va.gov Acknowledgments—The authors thank Brenda M. Lewis and Randy Stewart in the preparation of this manuscript. Received Nov 10, 2003, and in revised form Jun 8, 2004. Accepted for publication Jun 25, 2004.
METHODS AND MATERIALS Study population
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the Veterans Affairs North Texas Health Care System. Of these 104 patients, 73 with swallowing difficulties underwent a modified barium swallow (MBS) study to assess the severity of the dysphagia after definitive treatment for head-and-neck cancer. Their primary care or ear, nose, and throat physician referred these patients because of continued weight loss, difficulty with oral feeding ⬎3 months after treatment, or clinical suspicion of aspiration. All 73 patients were men. Of the 73 patients, 5 had undergone surgery, 8 primary RT, 30 postoperative RT, and 30 concurrent chemoradiotherapy. The disease site was the oropharynx in 29, larynx in 21, oral cavity in 10, hypopharynx in 6, and nasopharynx in 3; it was unknown in 4. The disease stage was Stage I in 2, Stage II in 8, Stage III in 22, Stage IV in 36, and recurrence in 5. The TNM stage was Tx in 5, T1 in 7, T2 in 27, T4 in 13, and recurrence in 5. The cancer was squamous cell carcinoma in 72 and chondrosarcoma in 1 patient. In the surgery-alone group, 2 patients had undergone wide local excision, 2 total laryngectomy and bilateral neck dissection, and 1 bilateral neck dissection only. Eight patients underwent definitive RT alone for laryngeal (n ⫽ 5), oropharyngeal (n ⫽ 2), and hypopharyngeal (n ⫽ 1) malignancy. The tumor dose was 7000 cGy. The indications for postoperative RT were positive cervical lymph nodes and close or positive resection margins. The postoperative radiation dose was 5940 – 6600 cGy. In the group who underwent concurrent chemoradiotherapy for locally advanced tumors, chemotherapy (5-fluorouracil and cisplatin) was delivered in Weeks 1 and 4 of RT. Patients with nasopharyngeal tumors received cisplatin in Weeks 1, 4, and 7 of RT. The radiation dose as 6600 –7020 cGy. Radiotherapy was delivered by a cobalt unit or a 6-MV linear accelerator using the standard technique (two lateral and one supraclavicular beam, off cord at 3960 – 4000 cGy, at 180 –200 cGy/fraction) and covering the tumor and regional lymph nodes.
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Table 1. Patient characteristics Characteristic Disease site (n) Oropharynx Larynx Hypopharynx Nasopharynx Oral cavity Unknown Sinus cavity Histologic type (n) Squamous Chondrosarcoma Stage (n) I II III IV Recurrence Treatment (n) Surgery Radiotherapy Chemoradiotherapy Postoperative radiotherapy Gender (n) Male Female Race (n) Black Hispanic White Follow-up (mo) Mean Median
Study group (n ⫽ 71)
Control group (n ⫽ 31)
29 19 6 3 10 4 0
8 12 1 0 7 2 1
70 1
31
2 7 21 36 5
0 4 8 15 4
4 7 30 30
7 1 5 18
71 0
30 1
11 1 59
3 0 28
30 24
50 48
Control population Of the 104 patients, 31 had no or minimal dysphagia. These patients were not matched for age, stage, disease site, or treatment compared with the dysphagia group. They did not undergo the MBS study. Their age range was 46 –75 years (median, 59 years); 30 were men and 1 was a woman. The tumor location was the larynx in 12, oropharynx in 8, oral cavity in 7, hypopharynx in 1, and paranasal sinus in 1. All patients had squamous carcinoma. The disease stage was Stage II in 4, Stage III in 8, Stage IV in 15, and recurrence in 4. Treatment was RT alone in 1, chemoradiotherapy in 5, surgery in 7, and postoperative RT in 18. The RT technique and chemotherapy were the same as described above for the dysphagia group. Table 1 summarizes the patient characteristics.
MBS study The severity of the dysphagia was assessed by the MBS technique (5). During the MBS procedure, the patients were either sitting or standing and viewed in the frontal and lateral planes. The fluoroscopy tube was positioned to view the oral cavity anteriorly, soft palate superiorly, posterior pharyngeal wall posteriorly, and seventh cervical vertebra inferiorly. In this way, the oral preparatory and oral, pharyngeal, and cervical esophageal phases of deglutition could be assessed and viewed simultaneously. Seven consistencies of food and liquid were introduced by teaspoon to the patient. Water, liquid barium, applesauce, mashed potatoes, green beans, ground meat, and sliced meat mixed with barium
paste were used in the assessment. With each swallow, the patients were instructed to hold the material in their mouth until told to swallow. The fluoroscope remained focused on the oral cavity and pharynx during and after each swallow. The patient was then repositioned in the AP position and presented with at least two additional consistencies, usually liquid barium and mashed potatoes introduced by teaspoon. Finally, at the completion of swallowing, the patient was instructed to vocalize on “a” and count to 5 while being videotaped with fluoroscopy. A number of observations were made during each swallow. Residue on the tongue or in the pharynx after the swallow, penetration or aspiration during or after the swallow, backflow, esophageal–pharyngeal reflux, delayed onset of pharyngeal swallow, and disordered peristalsis in the pharynx or esophagus were noted. The findings for each patient were scored using the Swallowing Performance Scale (6), as described below. The performance scale had been previously validated to be an accurate assessment of dysphagia severity by combining clinical and radiographic information (7–10). Grade 1: normal. Grade 2: within functional limits—abnormal oral or pharyngeal stage but able to eat a regular diet without modifications or swallowing precautions.
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Table 2. Dysphagia severity ⱖ3 months after treatment and grouping for statistical analysis (n ⫽ 104) Grade
Patients (n)
Group
Severity
Reason for severity group
0 and 1 2 3 4 5 6 7
31 (controls) 7 17 11 14 4 20
1 2 2 3 3 4 4
None Mild Mild Moderate Moderate Severe Severe
No swallowing precautions No swallowing precautions Swallowing precautions needed Swallowing precautions needed Enteral feeding support needed Enteral feeding support needed
Grade 3: mild impairment—mild dysfunction in oral or pharyngeal stage, modified diet required without need for therapeutic swallowing precautions. Grade 4: mild-to-moderate impairment with need for therapeutic precautions—mild dysfunction in oral or pharyngeal stage, modified diet and therapeutic precautions required to minimize aspiration risk. Grade 5: moderate impairment—moderate dysfunction in oral or pharyngeal stage, aspiration noted on examination, modified diet and swallowing precautions required to minimize aspiration risk. Grade 6: moderate-to-severe dysfunction—moderate dysfunction in oral or pharyngeal stage, aspiration noted on examination, modified diet and swallowing precautions required to minimize aspiration risk, supplemental enteral feeding support needed. Grade 7: severe impairment—severe dysfunction with significant aspiration or inadequate oropharyngeal transit to esophagus, nothing by mouth, primary enteral feeding support required.
or after the swallowing study at their follow-up visit. The severity of dysphagia found on the MBS was correlated with the scores obtained after completion of the questionnaire. The MBS grade may or may not have been known at the follow-up visit. The MBS was performed by Speech Pathology Service staff who were unaware of the QOL scores. Patients in the control group also filled out the questionnaire during their follow-up visit. The median follow-up for the dysphagia and control group was 24 and 48 months, respectively. Because of the high number of patients, the QOL questionnaires were given routinely to all head-and-neck cancer patients after treatment to improve their quality of care. However, only one-half of the patients were compliant with returning the questionnaire. Statistical analysis was performed to assess whether a correlation existed between the severity of the dysphagia and the QOL scores. Patients with a high level of anxiety and depression were referred for psychological counseling.
In addition to a modified diet, patients were instructed about safe eating techniques and the swallowing maneuvers designed to facilitate the safest swallow. The rehabilitation technique was individualized for each patient who was then followed at regular intervals by the speech pathologist. An MBS examination was repeated if deemed necessary by the team. A traditional radiographic barium swallow was also obtained to complement the MBS if abnormal structural integrity of the pharynx and esophagus were suspected by the team. The patient’s weight and nutritional status were also monitored by a dietitian who provided enteral nutritional support recommendations as needed.
Statistical analysis
QOL assessment Quality of life was assessed with the University of Washington (UW-QOL) (11) and Hospital Anxiety-Depression (HAD-QOL) (12) questionnaires. The UW-QOL questionnaire tests nine specific areas relating to the head-and-neck cancer patient: pain, disfigurement, activity, recreation/entertainment, employment, speech, chewing, swallowing, and shoulder disability. A composite score is calculated by summing the nine domains and dividing by 9 to give a scale from 0 (for poor health) to 100 (good health). Each item is also scaled from 0 to 100. Hospital Anxiety-Depression-QOL comprises two scales, one for anxiety (seven questions) and one for depression (seven questions). High scores indicate a high level of anxiety and depression. Cutoffs have been established for when to regard a patient as a probable (⬎10 points on one scale) or possible (8 –10 on one scale) case of psychiatric illness. Patients in the study group completed the questionnaire before
Statistical analysis was performed using the Fisher’s exact test. Differences with values of p ⬍ 0.05 were considered statistically significant.
RESULTS Dysphagia severity After the MBS study, the degree of dysphagia was graded as Grade 2 in 7, Grade 3 in 17, Grade 4 in 11, Grade 5 in 14, Grade 6 in 4, and Grade 7 in 20. For statistical analysis, we classified the patients into four groups: Group 1, no dysphagia (control group); Group 2, mild dysphagia (Grade 2–3); Group 3, moderate dysphagia (Grade 4 –5); and Group 4, severe dysphagia (Grade 6 –7). Table 2 summarizes the dysphagia prevalence ⱖ3 months after treatment and the grouping for statistical analysis. QOL scores The mean UW score for the four dysphagia groups was 76.52, 70.62, 62, and 53.08 for Groups 1 through 4, respectively. The corresponding UW median scores were 75, 70, 64, and 53.5. The mean and median HA score was 4.29, 6.13, 7.68, and 10.22 and 3, 7, 8, and 9 for Groups 1 through 4, respectively. The mean and median HD score was 3.74, 5.96, 7.84, and 10.13 and 3, 5, 8 and 10 for Groups 1 through 4, respectively. The mean and median score for Groups 2– 4 combined was 61.9, 8, and 7.97 and 75, 8, and 8 for the UW, HA, and HD questionnaires, respectively. A
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Table 3. Mean/median quality-of-life domain scores for dysphagia patients Group Domain
1
2
3
4
Pain Disfigurement Activity Recreation/entertainment Employment Eating Swallowing Speech Shoulder disability Anxiety Depression
86.45/80 78.06/80 76.77/80 80.65/80 47.74/40 70/60 90.32/100 81.45/75 81.45/75 4.39/3 3.74/3
73.33/80 80.83/80 66.67/60 74.17/80 32.5/20 70/60 76.04/75 85.42/75 84.58/100 6.13/7 5.96
73.6/80 66.4/60 64/60 62.4/60 39.2/40 53.6/60 61/75 70/75 67/75 7.68/8 7.84/8
63.33/60 66.67/60 54.17/60 60.83/60 30/20 35/20 44.79/50 57.29/50 68.75/62.5 10.22/9 10.13/10
statistically significant difference was found between the UW, HA, and HD scores for Group 1 and those for Groups 2– 4 (p ⫽ 0.0005). Table 3 summarizes the UW-QOL domain and HAD-QOL scores for the four dysphagia groups. To simplify the statistical analysis, because the QOL scores for Groups 1 and 2 and Groups 3 and 4 were close, we compared the scores of these two groups. A statistically significant difference was found for the UW scores between Group 1–2 and Group 3– 4. Patients with no or mild dysphagia experienced a greater QOL compared with those with moderate or severe dysphagia (p ⫽ 0.0005). They also had less anxiety (p ⫽ 0.005) and depression (p ⫽ 0.0001). An analysis of the UW domain scores showed statistically significant low scores affecting eight of nine domains in Group 3– 4 patients. The odds ratio was greatest for swallowing, followed by speech, recreation/entertainment, eating, disfigurement, pain, shoulder disability, and activity. No difference in employment was noted between the two groups. Table 4 summarizes the p values, odds ratios, and Table 4. Statistical analysis demonstrating statistically significant low University of Washington and high anxiety and depression scores for patients with moderate–severe dysphagia Variable HA HD UW Pain Disfigurement Activity Recreation/ entertainment Employment Eating Swallowing Speech Shoulder disability
p
OR
95% CI
0.005 0.0001 0.00005 0.004 0.0006 0.004 0.00005
0.23 0.15 11.02 3.44 4.39 3.43 8.12
0.07–0.69 0.04–0.45 2.89–60.80 1.36–8.86 1.73–11.35 1.38–8.76 3.10–21.66
0.12 0.002 0.00005 0.00005 0.006
2.45 6.85 23.11 19.87 3.53
0.72–9.59 1.76–38.54 5.96–126.64 4.23–181.62 1.37–9.33
Abbreviations: OR ⫽ odds ratio; CI ⫽ confidence interval; HA ⫽ Hospital Anxiety; HD ⫽ Hospital Depression; UW ⫽ University of Washington.
95% confidence intervals between Groups 1–2 and 3– 4. Patients in the control group did not undergo MBS because they had minimal or no dysphagia; therefore, we could not exclude the possibility that some of them might have had silent aspiration. To exclude that possibility, we reanalyzed the QOL data for the 73 patients who had undergone the MBS. The p value for the UW, HA, and HD scores between Groups 2, 3, and 4 was 0.0001, 0.009, 0.002, respectively. To assess whether the tumor size played a significant role in inducing dysphagia through destruction of normal tissues and affecting QOL, we compared the dysphagia severity among those with Stage T1–T4. The mean and median dysphagia grade was 4.7, 4.7, 4.8, and 5 and 5, 5, 5, and 5 for Stage T1, T2, T3, and T4, respectively. However, the number of patients was too small to make any meaningful conclusion. We also raised the question of the effect of surgery on the QOL compared with organ-preserving modalities such as RT and chemoradiotherapy. Of the UW subscales, only shoulder disability was significantly affected by surgery (p ⫽ 0.006). We found no statistically significant differences in the scores between the surgical and nonsurgical patients for the other UW domains.
DISCUSSION In all cultures, mealtime is a social event, at which sharing symbolizes friendship, closeness, and warmth (13, 14). Therefore, the inability to eat represents a social handicap affecting not only our physical, but also our mental wellness (15). In a survey of 360 elderly patients with diverse medical conditions, Ekberg et al. (16) observed social isolation among those affected with dysphagia. The patients reported that they avoided eating with others because of the discomfort. Malnutrition, in turn, leads to decreased activity, inducing weight loss and lethargy. Elmstahl et al. (17) also reported the deleterious consequences of dysphagia in stroke patients. After an aggressive treatment regimen with
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oral motor exercise, diet modification, and different swallowing techniques, these patients eventually recovered. Treatment of head-and-neck cancer usually involves surgery, RT, and chemoradiotherapy or a combination (18). Regardless of the treatment involved, dysphagia is a common complication among cancer survivors. Three years after surgery, 42% of laryngectomy and 50% of pharyngolaryngectomy patients in the study by Ward et al. (19) experienced long-term dysphagia requiring a modification of their diet or tube feeding. Dysphagic patients described a feeling of anger, frustration, lack of confidence, and poor self-esteem. Even among patients who managed to eat a normal diet, compensatory techniques such as taking additional time to complete a meal led to embarrassment and affected their interaction with family members. Radiotherapy for the head and neck may lead to xerostomia, trismus, fibrosis of pharyngeal muscles, and, in severe cases, pharyngeal stenosis (20). When combined with chemotherapy, the severity of dysphagia increases and may lead to aspiration, requiring prolonged gastric tube feeding (21). In our preliminary observation, the dysphagia grade was independent of the T stage, suggesting this is a direct consequence of the treatment rather than the destructive effect of tumor on normal tissue. However, because of the small number of patients and the lack of a baseline MBS study, no firm conclusion could be made. The consequences of dysphagia may be socially debilitating. Only 10 of 18 patients in the study by Ackerstaff et al. (22) were able to return to work 1 year after chemoradiotherapy for advanced head-and-neck cancer. Gustafsson and Tibbling (23) also observed that dysphagia affected all aspects of life, including a reduction in self-esteem, exercise, and leisure activity. Despite its known impact on the QOL in other disease conditions, few studies have correlated the severity of dysphagia on the QOL for head-and-neck cancer patients. MBS remains the reference standard to assess dysphagia severity after treatment (24). The MBS has two objectives. The first is to define the anatomy and physiology of the patient’s oropharyngeal swallow of solid food and liquid by introducing increasing amounts of barium-coated thin and thicker food. Once an abnormality of the patient’s swallowing mechanism is identified, various strategies (postural techniques, increased sensory input, voluntary swallowing maneuvers) may be introduced by the speech therapist to decrease the risk of aspiration and improve the efficiency of swallowing. MBS can be used for a range of conditions characterized by dysphagia, such as stroke, head-and-neck injury, and treatment of oropharyngeal malignancies, in patients of all ages. The validity of its grading system has been tested by many studies (7–10, 24 –26). In our study, 49 patients had moderate-to-severe dysphagia (Groups 3 and 4). Their QOL was significantly lower than those with no or minimal dysphagia (Groups 1 and 2) as measured by the UW-QOL scores. They also experienced significantly increased anxiety and depression, such as was observed in previous dysphagia studies (11, 12, 15). Anal-
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Table 5. Summary of treatment within each dysphagia group Treatment
None (n ⫽ 31)
Postoperative 18 radiotherapy Chemoradiotherapy 5 Surgery 7 Radiotherapy 1
Mild (n ⫽ 24)
Moderate (n ⫽ 25)
Severe (n ⫽ 24)
8
10
11
9 4 3
13 1 1
8 1 4
ysis of the treatment received among the four treatment groups showed a high number of patients with postoperative RT in the no dysphagia group. The number of patients receiving postoperative RT and chemoradiotherapy was similar among those with mild, moderate, and severe dysphagia. This possibly reflected the treatment policy in our institution. Postoperative RT was the primary treatment offered to patients with locally advanced head-and-neck malignancy. Concurrent chemotherapy and RT has become more popular in the past 4 years for increased organ preservation. The number of patients who underwent chemoradiotherapy was smaller and they had had a shorter followup. Table 5 summarizes the treatment modality within each dysphagia group. Analysis of the UW-QOL scores revealed almost all domains were affected except for employment. The results indicated no statistically significant difference in employment between the two dysphagic groups. This has been because our patients mainly were from a population of retired veterans. The eating difficulty of the participants in this study was not surprising given the severity of their dysphagia. For example, in the study by Pauloski et al. (27), patients with severe dysphagia resulting from head-and-neck cancer often limited their oral intake unconsciously. It was more difficult to explain why patients with severe dysphagia also had frequent pain, disfigurement, speech impediment, and shoulder problems. An analysis of their treatment modality showed a statistically significant impact of surgery on shoulder disability (p ⫽ 0.006). However, no statistically significant difference was found in the scores between patients who had undergone surgery vs. organpreserving modalities for the other UW domains. We postulate that excessive fibrosis was responsible for the severe dysphagia and also produced nerve entrapment. Abnormal stimulation of sensory nerves and their endings may result in severe pain (22). Extraneural fibrosis is commonly observed after surgery and is responsible for recurrent peripheral nerves problems secondary to nerve compression (28). Similar lesions were observed after RT, producing femoral nerve compression syndrome (29). Radiation-induced neuropathy was dose dependent. Optic neuropathy seldom developed for radiation dose ⬍5000 cGy, but its prevalence increased to 30% for a dose ⬎6000 cGy (30). Cranial nerve palsy was also a well-known complication of nasopharyngeal cancer after high-dose head-and-neck RT. The nerves commonly involved were the vagal and hypoglossal nerves,
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but all cranial nerves might be affected. Even though in our study patients who developed shoulder disability were more likely to have undergone surgery, such an event might occur if the accessory nerve became involved (31, 32). In the study by Lin et al. (31), 12 of 19 patients who developed cranial nerve dysfunction after nasopharyngeal RT had marked neck fibrosis, suggesting that collagen deposition might play an important role in the etiology of radiationinduced nerve injury. In addition, excessive scar formation in the neck and secondary facial edema after RT might contribute to the sensation of disfigurement (33). Prolonged edema and laryngeal fibrosis have been observed with high doses of radiation to the larynx, producing hoarseness of the voice as late as 22 years after RT (34). In severe cases, the laryngeal edema, cervical fibrosis, trismus, and tissue necrosis induced by RT may lead to a patient’s death (35). Because excessive fibrosis was produced by hyperactivation of transforming growth factor-1 at the molecular level, an antagonist of transforming growth factor-1, such as interferon-␥, may be helpful to alleviate these symptoms (36).
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The limitations of our study included its retrospective nature, because only patients who became symptomatic after treatment underwent MBS, and the very heterogeneous patient population. Nevertheless, we hope our findings will encourage other prospective studies to use MBS as an investigative tool to assess the severity of dysphagia after treatment and its impact on patients’ QOL. CONCLUSION Moderate and severe dysphagia complications after definitive treatment of head-and-neck cancer are significantly associated with a poor QOL, regardless of the treatment modality. Patients experience anxiety and depression related to their dysphagia. The resulting weight loss, pain, speech deficit, and shoulder problems affect their well being. Management of dysphagia in head-and-neck cancer survivors requires a team approach. Nutritional assessment, pain control, antidepressive and/or anxiolytic medications, psychological counseling, and speech and physical rehabilitation are needed to help these patients overcome their handicap.
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agement of patients with dysphagia. Otolaryngol Head Neck Surg 1997;116:335–338. Rasley A, Logemann JA, Kahrilas PJ, et al. Prevention of barium aspiration during videofluoroscopic swallowing studies: Value of change in posture. AJR Am J Roentgenol 1993; 160:1005–1009. Pauloski BR, Logemann JA, Rademaker A, et al. Speech and swallow function after anterior tongue and floor of mouth resection with distal flap reconstruction. J Speech Hear Res 1993;36:267–276. Pauloski BR, Rademaker AW, Logemann JA, et al. Swallow function and perception of dysphagia in patients with head and neck cancer. Head Neck 2002;24:555–565. McCall TD, Grant GA, Britz GW, et al. Treatment of recurrent peripheral nerve entrapment problems: Role of scar formation and its possible treatment. Neurosurg Clin North Am 2001;12:329 –339. Laurent E. Femoral nerve compression syndrome with paresis of the quadriceps muscle caused by radiotherapy of malignant tumours. Acta Orthop Scand 1975;46:804 – 808. Jiang GL, Tucker SL, Guttenberger R, et al. Radiation induced injury to the visual pathway. Radiother Oncol 1994;30:17–25. Lin YS, Jen YM, Lin JC. Radiation related cranial nerve palsy
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in patients with nasopharyngeal carcinoma. Cancer 2002;15:404 – 409. Kang MY, Holland JM, Stevens KR. Cranial neuropathy following curative chemotherapy and radiotherapy for carcinoma of the nasopharynx. J Laryngol Otolaryngol 2000;114: 308 –310. Leung SF, Zheng Y, Choi CY, et al. Quantitative measurement of post irradiation neck fibrosis based on the young modulus: Description of a new method and clinical results. Cancer 2002;95:656 – 662. Berger G, Freeman JL, Briant TD, et al. Late postradiation necrosis and fibrosis of larynx. J Otolaryngol 1984;13:160 – 164. Nguyen TD, Panix X, Froissard D, et al. Analysis of late complications after rapid hyperfractionated radiation therapy in advanced head and neck cancer. Int J Radiat Oncol Phys Biol 1988;14:23–25. Hirota S, Tsujino K, Oshitani T, et al. Subcutaneous neck fibrosis after whole neck radiation. Int J Radiat Oncol Phys Biol 2002;52:937–943. Nguyen NP, Antoine JE, Dutta S, et al. Current concept in radiation enteritis and implications for future clinical trials. Cancer 2002;95:1151–1163.
doi:10.1016/j.ijrobp.2004.06.017
CLINICAL INVESTIGATION
Head and Neck
IMPACT OF DYSPHAGIA ON QUALITY OF LIFE AFTER TREATMENT OF HEAD-AND-NECK CANCER NAM P. NGUYEN, M.D.,*† CHERYL FRANK, M.A.,‡ CANDACE C. MOLTZ, M.S.,‡ PAUL VOS, PH.D.,§ HERBERT J. SMITH, M.D.,¶ ULF KARLSSON, M.D., PH.D.,㛳 SURESH DUTTA, M.D.,# ALLAN MIDYETT, M.D.,¶ JESSICA BARLOON, M.S.,** AND SABAH SALLAH, M.D.†† †
*Department of Radiation Oncology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX; Departments of Radiation Oncology, ‡Audiology and Speech Pathology, ¶Radiology, and **Dietetic Service, Veterans Affairs North Texas Health Care System, Dallas, TX; Departments of §Biostatistics and 㛳Radiation Oncology, East Carolina University, Greenville, NC; # Department of Radiation Oncology, University of Southern California, Los Angeles, CA; ††Division of Hematology/Oncology, Louisiana State University, Shreveport, LA Purpose: To evaluate the quality of life (QOL) associated with dysphagia after head-and-neck cancer treatment. Methods and Materials: Of a total population of 104, a retrospective analysis of 73 patients who complained of dysphagia after primary radiotherapy (RT), chemoradiotherapy, and postoperative RT for head-and-neck malignancies were evaluated. All patients underwent a modified barium swallow examination to assess the severity of dysphagia, graded on a scale of 1–7. QOL was evaluated by the University of Washington (UW) and Hospital Anxiety and Depression questionnaires. The QOL scores obtained were compared with those from the 31 patients who were free of dysphagia after treatment. The QOL scores were also graded according to the dysphagia severity. Results: The UW and Hospital Anxiety and Depression scores were reduced and elevated, respectively, in the dysphagia group compared with the no dysphagia group (p ⴝ 0.0005). The UW scores were also substantially lower among patients with moderate-to-severe (Grade 4 –7) compared with no or mild (Grade 2–3) dysphagia (p ⴝ 0.0005). The corresponding Hospital Anxiety (p ⴝ 0.005) and Depression (p ⴝ 0.0001) scores were also greater for the moderate-to-severe group. The UW QOL subscale scores showed a statistically significant decrease for swallowing (p ⴝ 0.00005), speech (p ⴝ 0.0005), recreation/entertainment (p ⴝ 0.0005), disfigurement (p ⴝ 0.0006), activity (p ⴝ 0.005), eating (p ⴝ 0.002), shoulder disability (p ⴝ 0.006), and pain (p ⴝ 0.004). Conclusion: Dysphagia is a significant morbidity of head-and-neck cancer treatment, and the severity of dysphagia correlated with a compromised QOL, anxiety, and depression. Patients with moderate-to-severe dysphagia require a team approach involving nutritional support, physical therapy, speech rehabilitation, pain management, and psychological counseling. © 2005 Elsevier Inc. Dysphagia, Quality of life, Head-and-neck cancer treatment.
a gastrostomy tube. However, prolonged unnatural feeding may induce severe psychological distress, because it causes discomfort and distorts the patient’s self-image (4). Therefore, it is important for the clinician to assess the severity of dysphagia objectively in cancer survivors and to recognize its impact on their quality of life (QOL). The purpose of this study was to provide an objective basis for management of this debilitating side effect/complication.
INTRODUCTION Normal swallowing is a complex process requiring the perfect coordination of different nerve, muscle, and joint groups, beginning with mastication of the food, followed by transfer of the bolus to the pharynx, and closure of the larynx and velopharynx to avoid aspiration and nasal reflux (1). The destruction of normal tissues by head-and-neck malignancies, surgery, inflammation, and/or radiation-induced fibrosis of the pharyngeal muscles are potential mechanisms responsible for dysphagia in head-and-neck cancer patients (2). When aspiration occurs because of compromise of the swallowing reflex, pneumonia and respiratory failure may lead to death (3). The risk of aspiration is reduced by feeding through
The study population comprised 104 patients treated for headand-neck malignancies between January 1995 and March 2003 at
Reprint requests to: Nam P. Nguyen, M.D., Department of Radiation Oncology, University of Texas Southwestern Medical Center at Dallas, Veterans Affairs North Texas Health Care System, S. Lancaster Rd., Dallas, TX 75216. Tel: (214) 8570142; Fax: (214) 857-0145; E-mail: NamPhong.Nguyen@
med.va.gov Acknowledgments—The authors thank Brenda M. Lewis and Randy Stewart in the preparation of this manuscript. Received Nov 10, 2003, and in revised form Jun 8, 2004. Accepted for publication Jun 25, 2004.
METHODS AND MATERIALS Study population
772
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the Veterans Affairs North Texas Health Care System. Of these 104 patients, 73 with swallowing difficulties underwent a modified barium swallow (MBS) study to assess the severity of the dysphagia after definitive treatment for head-and-neck cancer. Their primary care or ear, nose, and throat physician referred these patients because of continued weight loss, difficulty with oral feeding ⬎3 months after treatment, or clinical suspicion of aspiration. All 73 patients were men. Of the 73 patients, 5 had undergone surgery, 8 primary RT, 30 postoperative RT, and 30 concurrent chemoradiotherapy. The disease site was the oropharynx in 29, larynx in 21, oral cavity in 10, hypopharynx in 6, and nasopharynx in 3; it was unknown in 4. The disease stage was Stage I in 2, Stage II in 8, Stage III in 22, Stage IV in 36, and recurrence in 5. The TNM stage was Tx in 5, T1 in 7, T2 in 27, T4 in 13, and recurrence in 5. The cancer was squamous cell carcinoma in 72 and chondrosarcoma in 1 patient. In the surgery-alone group, 2 patients had undergone wide local excision, 2 total laryngectomy and bilateral neck dissection, and 1 bilateral neck dissection only. Eight patients underwent definitive RT alone for laryngeal (n ⫽ 5), oropharyngeal (n ⫽ 2), and hypopharyngeal (n ⫽ 1) malignancy. The tumor dose was 7000 cGy. The indications for postoperative RT were positive cervical lymph nodes and close or positive resection margins. The postoperative radiation dose was 5940 – 6600 cGy. In the group who underwent concurrent chemoradiotherapy for locally advanced tumors, chemotherapy (5-fluorouracil and cisplatin) was delivered in Weeks 1 and 4 of RT. Patients with nasopharyngeal tumors received cisplatin in Weeks 1, 4, and 7 of RT. The radiation dose as 6600 –7020 cGy. Radiotherapy was delivered by a cobalt unit or a 6-MV linear accelerator using the standard technique (two lateral and one supraclavicular beam, off cord at 3960 – 4000 cGy, at 180 –200 cGy/fraction) and covering the tumor and regional lymph nodes.
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Table 1. Patient characteristics Characteristic Disease site (n) Oropharynx Larynx Hypopharynx Nasopharynx Oral cavity Unknown Sinus cavity Histologic type (n) Squamous Chondrosarcoma Stage (n) I II III IV Recurrence Treatment (n) Surgery Radiotherapy Chemoradiotherapy Postoperative radiotherapy Gender (n) Male Female Race (n) Black Hispanic White Follow-up (mo) Mean Median
Study group (n ⫽ 71)
Control group (n ⫽ 31)
29 19 6 3 10 4 0
8 12 1 0 7 2 1
70 1
31
2 7 21 36 5
0 4 8 15 4
4 7 30 30
7 1 5 18
71 0
30 1
11 1 59
3 0 28
30 24
50 48
Control population Of the 104 patients, 31 had no or minimal dysphagia. These patients were not matched for age, stage, disease site, or treatment compared with the dysphagia group. They did not undergo the MBS study. Their age range was 46 –75 years (median, 59 years); 30 were men and 1 was a woman. The tumor location was the larynx in 12, oropharynx in 8, oral cavity in 7, hypopharynx in 1, and paranasal sinus in 1. All patients had squamous carcinoma. The disease stage was Stage II in 4, Stage III in 8, Stage IV in 15, and recurrence in 4. Treatment was RT alone in 1, chemoradiotherapy in 5, surgery in 7, and postoperative RT in 18. The RT technique and chemotherapy were the same as described above for the dysphagia group. Table 1 summarizes the patient characteristics.
MBS study The severity of the dysphagia was assessed by the MBS technique (5). During the MBS procedure, the patients were either sitting or standing and viewed in the frontal and lateral planes. The fluoroscopy tube was positioned to view the oral cavity anteriorly, soft palate superiorly, posterior pharyngeal wall posteriorly, and seventh cervical vertebra inferiorly. In this way, the oral preparatory and oral, pharyngeal, and cervical esophageal phases of deglutition could be assessed and viewed simultaneously. Seven consistencies of food and liquid were introduced by teaspoon to the patient. Water, liquid barium, applesauce, mashed potatoes, green beans, ground meat, and sliced meat mixed with barium
paste were used in the assessment. With each swallow, the patients were instructed to hold the material in their mouth until told to swallow. The fluoroscope remained focused on the oral cavity and pharynx during and after each swallow. The patient was then repositioned in the AP position and presented with at least two additional consistencies, usually liquid barium and mashed potatoes introduced by teaspoon. Finally, at the completion of swallowing, the patient was instructed to vocalize on “a” and count to 5 while being videotaped with fluoroscopy. A number of observations were made during each swallow. Residue on the tongue or in the pharynx after the swallow, penetration or aspiration during or after the swallow, backflow, esophageal–pharyngeal reflux, delayed onset of pharyngeal swallow, and disordered peristalsis in the pharynx or esophagus were noted. The findings for each patient were scored using the Swallowing Performance Scale (6), as described below. The performance scale had been previously validated to be an accurate assessment of dysphagia severity by combining clinical and radiographic information (7–10). Grade 1: normal. Grade 2: within functional limits—abnormal oral or pharyngeal stage but able to eat a regular diet without modifications or swallowing precautions.
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Table 2. Dysphagia severity ⱖ3 months after treatment and grouping for statistical analysis (n ⫽ 104) Grade
Patients (n)
Group
Severity
Reason for severity group
0 and 1 2 3 4 5 6 7
31 (controls) 7 17 11 14 4 20
1 2 2 3 3 4 4
None Mild Mild Moderate Moderate Severe Severe
No swallowing precautions No swallowing precautions Swallowing precautions needed Swallowing precautions needed Enteral feeding support needed Enteral feeding support needed
Grade 3: mild impairment—mild dysfunction in oral or pharyngeal stage, modified diet required without need for therapeutic swallowing precautions. Grade 4: mild-to-moderate impairment with need for therapeutic precautions—mild dysfunction in oral or pharyngeal stage, modified diet and therapeutic precautions required to minimize aspiration risk. Grade 5: moderate impairment—moderate dysfunction in oral or pharyngeal stage, aspiration noted on examination, modified diet and swallowing precautions required to minimize aspiration risk. Grade 6: moderate-to-severe dysfunction—moderate dysfunction in oral or pharyngeal stage, aspiration noted on examination, modified diet and swallowing precautions required to minimize aspiration risk, supplemental enteral feeding support needed. Grade 7: severe impairment—severe dysfunction with significant aspiration or inadequate oropharyngeal transit to esophagus, nothing by mouth, primary enteral feeding support required.
or after the swallowing study at their follow-up visit. The severity of dysphagia found on the MBS was correlated with the scores obtained after completion of the questionnaire. The MBS grade may or may not have been known at the follow-up visit. The MBS was performed by Speech Pathology Service staff who were unaware of the QOL scores. Patients in the control group also filled out the questionnaire during their follow-up visit. The median follow-up for the dysphagia and control group was 24 and 48 months, respectively. Because of the high number of patients, the QOL questionnaires were given routinely to all head-and-neck cancer patients after treatment to improve their quality of care. However, only one-half of the patients were compliant with returning the questionnaire. Statistical analysis was performed to assess whether a correlation existed between the severity of the dysphagia and the QOL scores. Patients with a high level of anxiety and depression were referred for psychological counseling.
In addition to a modified diet, patients were instructed about safe eating techniques and the swallowing maneuvers designed to facilitate the safest swallow. The rehabilitation technique was individualized for each patient who was then followed at regular intervals by the speech pathologist. An MBS examination was repeated if deemed necessary by the team. A traditional radiographic barium swallow was also obtained to complement the MBS if abnormal structural integrity of the pharynx and esophagus were suspected by the team. The patient’s weight and nutritional status were also monitored by a dietitian who provided enteral nutritional support recommendations as needed.
Statistical analysis
QOL assessment Quality of life was assessed with the University of Washington (UW-QOL) (11) and Hospital Anxiety-Depression (HAD-QOL) (12) questionnaires. The UW-QOL questionnaire tests nine specific areas relating to the head-and-neck cancer patient: pain, disfigurement, activity, recreation/entertainment, employment, speech, chewing, swallowing, and shoulder disability. A composite score is calculated by summing the nine domains and dividing by 9 to give a scale from 0 (for poor health) to 100 (good health). Each item is also scaled from 0 to 100. Hospital Anxiety-Depression-QOL comprises two scales, one for anxiety (seven questions) and one for depression (seven questions). High scores indicate a high level of anxiety and depression. Cutoffs have been established for when to regard a patient as a probable (⬎10 points on one scale) or possible (8 –10 on one scale) case of psychiatric illness. Patients in the study group completed the questionnaire before
Statistical analysis was performed using the Fisher’s exact test. Differences with values of p ⬍ 0.05 were considered statistically significant.
RESULTS Dysphagia severity After the MBS study, the degree of dysphagia was graded as Grade 2 in 7, Grade 3 in 17, Grade 4 in 11, Grade 5 in 14, Grade 6 in 4, and Grade 7 in 20. For statistical analysis, we classified the patients into four groups: Group 1, no dysphagia (control group); Group 2, mild dysphagia (Grade 2–3); Group 3, moderate dysphagia (Grade 4 –5); and Group 4, severe dysphagia (Grade 6 –7). Table 2 summarizes the dysphagia prevalence ⱖ3 months after treatment and the grouping for statistical analysis. QOL scores The mean UW score for the four dysphagia groups was 76.52, 70.62, 62, and 53.08 for Groups 1 through 4, respectively. The corresponding UW median scores were 75, 70, 64, and 53.5. The mean and median HA score was 4.29, 6.13, 7.68, and 10.22 and 3, 7, 8, and 9 for Groups 1 through 4, respectively. The mean and median HD score was 3.74, 5.96, 7.84, and 10.13 and 3, 5, 8 and 10 for Groups 1 through 4, respectively. The mean and median score for Groups 2– 4 combined was 61.9, 8, and 7.97 and 75, 8, and 8 for the UW, HA, and HD questionnaires, respectively. A
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Table 3. Mean/median quality-of-life domain scores for dysphagia patients Group Domain
1
2
3
4
Pain Disfigurement Activity Recreation/entertainment Employment Eating Swallowing Speech Shoulder disability Anxiety Depression
86.45/80 78.06/80 76.77/80 80.65/80 47.74/40 70/60 90.32/100 81.45/75 81.45/75 4.39/3 3.74/3
73.33/80 80.83/80 66.67/60 74.17/80 32.5/20 70/60 76.04/75 85.42/75 84.58/100 6.13/7 5.96
73.6/80 66.4/60 64/60 62.4/60 39.2/40 53.6/60 61/75 70/75 67/75 7.68/8 7.84/8
63.33/60 66.67/60 54.17/60 60.83/60 30/20 35/20 44.79/50 57.29/50 68.75/62.5 10.22/9 10.13/10
statistically significant difference was found between the UW, HA, and HD scores for Group 1 and those for Groups 2– 4 (p ⫽ 0.0005). Table 3 summarizes the UW-QOL domain and HAD-QOL scores for the four dysphagia groups. To simplify the statistical analysis, because the QOL scores for Groups 1 and 2 and Groups 3 and 4 were close, we compared the scores of these two groups. A statistically significant difference was found for the UW scores between Group 1–2 and Group 3– 4. Patients with no or mild dysphagia experienced a greater QOL compared with those with moderate or severe dysphagia (p ⫽ 0.0005). They also had less anxiety (p ⫽ 0.005) and depression (p ⫽ 0.0001). An analysis of the UW domain scores showed statistically significant low scores affecting eight of nine domains in Group 3– 4 patients. The odds ratio was greatest for swallowing, followed by speech, recreation/entertainment, eating, disfigurement, pain, shoulder disability, and activity. No difference in employment was noted between the two groups. Table 4 summarizes the p values, odds ratios, and Table 4. Statistical analysis demonstrating statistically significant low University of Washington and high anxiety and depression scores for patients with moderate–severe dysphagia Variable HA HD UW Pain Disfigurement Activity Recreation/ entertainment Employment Eating Swallowing Speech Shoulder disability
p
OR
95% CI
0.005 0.0001 0.00005 0.004 0.0006 0.004 0.00005
0.23 0.15 11.02 3.44 4.39 3.43 8.12
0.07–0.69 0.04–0.45 2.89–60.80 1.36–8.86 1.73–11.35 1.38–8.76 3.10–21.66
0.12 0.002 0.00005 0.00005 0.006
2.45 6.85 23.11 19.87 3.53
0.72–9.59 1.76–38.54 5.96–126.64 4.23–181.62 1.37–9.33
Abbreviations: OR ⫽ odds ratio; CI ⫽ confidence interval; HA ⫽ Hospital Anxiety; HD ⫽ Hospital Depression; UW ⫽ University of Washington.
95% confidence intervals between Groups 1–2 and 3– 4. Patients in the control group did not undergo MBS because they had minimal or no dysphagia; therefore, we could not exclude the possibility that some of them might have had silent aspiration. To exclude that possibility, we reanalyzed the QOL data for the 73 patients who had undergone the MBS. The p value for the UW, HA, and HD scores between Groups 2, 3, and 4 was 0.0001, 0.009, 0.002, respectively. To assess whether the tumor size played a significant role in inducing dysphagia through destruction of normal tissues and affecting QOL, we compared the dysphagia severity among those with Stage T1–T4. The mean and median dysphagia grade was 4.7, 4.7, 4.8, and 5 and 5, 5, 5, and 5 for Stage T1, T2, T3, and T4, respectively. However, the number of patients was too small to make any meaningful conclusion. We also raised the question of the effect of surgery on the QOL compared with organ-preserving modalities such as RT and chemoradiotherapy. Of the UW subscales, only shoulder disability was significantly affected by surgery (p ⫽ 0.006). We found no statistically significant differences in the scores between the surgical and nonsurgical patients for the other UW domains.
DISCUSSION In all cultures, mealtime is a social event, at which sharing symbolizes friendship, closeness, and warmth (13, 14). Therefore, the inability to eat represents a social handicap affecting not only our physical, but also our mental wellness (15). In a survey of 360 elderly patients with diverse medical conditions, Ekberg et al. (16) observed social isolation among those affected with dysphagia. The patients reported that they avoided eating with others because of the discomfort. Malnutrition, in turn, leads to decreased activity, inducing weight loss and lethargy. Elmstahl et al. (17) also reported the deleterious consequences of dysphagia in stroke patients. After an aggressive treatment regimen with
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oral motor exercise, diet modification, and different swallowing techniques, these patients eventually recovered. Treatment of head-and-neck cancer usually involves surgery, RT, and chemoradiotherapy or a combination (18). Regardless of the treatment involved, dysphagia is a common complication among cancer survivors. Three years after surgery, 42% of laryngectomy and 50% of pharyngolaryngectomy patients in the study by Ward et al. (19) experienced long-term dysphagia requiring a modification of their diet or tube feeding. Dysphagic patients described a feeling of anger, frustration, lack of confidence, and poor self-esteem. Even among patients who managed to eat a normal diet, compensatory techniques such as taking additional time to complete a meal led to embarrassment and affected their interaction with family members. Radiotherapy for the head and neck may lead to xerostomia, trismus, fibrosis of pharyngeal muscles, and, in severe cases, pharyngeal stenosis (20). When combined with chemotherapy, the severity of dysphagia increases and may lead to aspiration, requiring prolonged gastric tube feeding (21). In our preliminary observation, the dysphagia grade was independent of the T stage, suggesting this is a direct consequence of the treatment rather than the destructive effect of tumor on normal tissue. However, because of the small number of patients and the lack of a baseline MBS study, no firm conclusion could be made. The consequences of dysphagia may be socially debilitating. Only 10 of 18 patients in the study by Ackerstaff et al. (22) were able to return to work 1 year after chemoradiotherapy for advanced head-and-neck cancer. Gustafsson and Tibbling (23) also observed that dysphagia affected all aspects of life, including a reduction in self-esteem, exercise, and leisure activity. Despite its known impact on the QOL in other disease conditions, few studies have correlated the severity of dysphagia on the QOL for head-and-neck cancer patients. MBS remains the reference standard to assess dysphagia severity after treatment (24). The MBS has two objectives. The first is to define the anatomy and physiology of the patient’s oropharyngeal swallow of solid food and liquid by introducing increasing amounts of barium-coated thin and thicker food. Once an abnormality of the patient’s swallowing mechanism is identified, various strategies (postural techniques, increased sensory input, voluntary swallowing maneuvers) may be introduced by the speech therapist to decrease the risk of aspiration and improve the efficiency of swallowing. MBS can be used for a range of conditions characterized by dysphagia, such as stroke, head-and-neck injury, and treatment of oropharyngeal malignancies, in patients of all ages. The validity of its grading system has been tested by many studies (7–10, 24 –26). In our study, 49 patients had moderate-to-severe dysphagia (Groups 3 and 4). Their QOL was significantly lower than those with no or minimal dysphagia (Groups 1 and 2) as measured by the UW-QOL scores. They also experienced significantly increased anxiety and depression, such as was observed in previous dysphagia studies (11, 12, 15). Anal-
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Table 5. Summary of treatment within each dysphagia group Treatment
None (n ⫽ 31)
Postoperative 18 radiotherapy Chemoradiotherapy 5 Surgery 7 Radiotherapy 1
Mild (n ⫽ 24)
Moderate (n ⫽ 25)
Severe (n ⫽ 24)
8
10
11
9 4 3
13 1 1
8 1 4
ysis of the treatment received among the four treatment groups showed a high number of patients with postoperative RT in the no dysphagia group. The number of patients receiving postoperative RT and chemoradiotherapy was similar among those with mild, moderate, and severe dysphagia. This possibly reflected the treatment policy in our institution. Postoperative RT was the primary treatment offered to patients with locally advanced head-and-neck malignancy. Concurrent chemotherapy and RT has become more popular in the past 4 years for increased organ preservation. The number of patients who underwent chemoradiotherapy was smaller and they had had a shorter followup. Table 5 summarizes the treatment modality within each dysphagia group. Analysis of the UW-QOL scores revealed almost all domains were affected except for employment. The results indicated no statistically significant difference in employment between the two dysphagic groups. This has been because our patients mainly were from a population of retired veterans. The eating difficulty of the participants in this study was not surprising given the severity of their dysphagia. For example, in the study by Pauloski et al. (27), patients with severe dysphagia resulting from head-and-neck cancer often limited their oral intake unconsciously. It was more difficult to explain why patients with severe dysphagia also had frequent pain, disfigurement, speech impediment, and shoulder problems. An analysis of their treatment modality showed a statistically significant impact of surgery on shoulder disability (p ⫽ 0.006). However, no statistically significant difference was found in the scores between patients who had undergone surgery vs. organpreserving modalities for the other UW domains. We postulate that excessive fibrosis was responsible for the severe dysphagia and also produced nerve entrapment. Abnormal stimulation of sensory nerves and their endings may result in severe pain (22). Extraneural fibrosis is commonly observed after surgery and is responsible for recurrent peripheral nerves problems secondary to nerve compression (28). Similar lesions were observed after RT, producing femoral nerve compression syndrome (29). Radiation-induced neuropathy was dose dependent. Optic neuropathy seldom developed for radiation dose ⬍5000 cGy, but its prevalence increased to 30% for a dose ⬎6000 cGy (30). Cranial nerve palsy was also a well-known complication of nasopharyngeal cancer after high-dose head-and-neck RT. The nerves commonly involved were the vagal and hypoglossal nerves,
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but all cranial nerves might be affected. Even though in our study patients who developed shoulder disability were more likely to have undergone surgery, such an event might occur if the accessory nerve became involved (31, 32). In the study by Lin et al. (31), 12 of 19 patients who developed cranial nerve dysfunction after nasopharyngeal RT had marked neck fibrosis, suggesting that collagen deposition might play an important role in the etiology of radiationinduced nerve injury. In addition, excessive scar formation in the neck and secondary facial edema after RT might contribute to the sensation of disfigurement (33). Prolonged edema and laryngeal fibrosis have been observed with high doses of radiation to the larynx, producing hoarseness of the voice as late as 22 years after RT (34). In severe cases, the laryngeal edema, cervical fibrosis, trismus, and tissue necrosis induced by RT may lead to a patient’s death (35). Because excessive fibrosis was produced by hyperactivation of transforming growth factor-1 at the molecular level, an antagonist of transforming growth factor-1, such as interferon-␥, may be helpful to alleviate these symptoms (36).
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The limitations of our study included its retrospective nature, because only patients who became symptomatic after treatment underwent MBS, and the very heterogeneous patient population. Nevertheless, we hope our findings will encourage other prospective studies to use MBS as an investigative tool to assess the severity of dysphagia after treatment and its impact on patients’ QOL. CONCLUSION Moderate and severe dysphagia complications after definitive treatment of head-and-neck cancer are significantly associated with a poor QOL, regardless of the treatment modality. Patients experience anxiety and depression related to their dysphagia. The resulting weight loss, pain, speech deficit, and shoulder problems affect their well being. Management of dysphagia in head-and-neck cancer survivors requires a team approach. Nutritional assessment, pain control, antidepressive and/or anxiolytic medications, psychological counseling, and speech and physical rehabilitation are needed to help these patients overcome their handicap.
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