Prevalence of swallowing and speech problems in daily life after chemoradiation for head and neck cancer based on cut-off scores of the patient-reported outcome measures SWAL-QOL and SHI
Eur Arch Otorhinolaryngol (2016) 273:1849–1855
DOI 10.1007/s00405-015-3680-z
HEAD AND NECK
Prevalence of swallowing and speech problems in daily life
after chemoradiation for head and neck cancer based on cut-off
scores of the patient-reported outcome measures SWAL-QOL
and SHI
Rico N. Rinkel1 • Irma M. Verdonck-de Leeuw1 • Patricia Doornaert2 •
Jan Buter3 • Remco de Bree1 • Johannes A. Langendijk4 • Neil K. Aaronson5 •
C. René Leemans1
Received: 21 August 2014 / Accepted: 31 May 2015 / Published online: 14 June 2015
Ó The Author(s) 2015. This article is published with open access at Springerlink.com
Abstract The objective of this study is to assess swallowing and speech outcome after chemoradiation therapy
for head and neck cancer, based on the patient-reported
outcome measures Swallowing Quality of Life Questionnaire (SWAL-QOL) and Speech Handicap Index (SHI),
both provided with cut-off scores. This is a cross-sectional
study. Department of Otolaryngology/Head and Neck
Surgery of a University Medical Center. Sixty patients,
6 months to 5 years after chemoradiation for head and
neck squamous cell carcinoma. Swallowing Quality of Life
Questionnaire (SWAL-QOL) and SHI, both validated in
Dutch and provided with cut-off scores. Associations were
tested between the outcome measures and independent
variables (age, gender, tumor stage and site, and radiotherapy technique, time since treatment, comorbidity and
food intake). Fifty-two patients returned the SWAL-QOL
and 47 the SHI (response rate 87 and 78 %, respectively).
Swallowing and speech problems were present in 79 and
55 %, respectively. Normal food intake was noticed in 45,
35 % had a soft diet and 20 % tube feeding. Patients with
soft diet and tube feeding reported more swallowing
problems compared to patients with normal oral intake.
Tumor subsite was significantly associated with swallowing outcome (less problems in larynx/hypopharynx compared to oral/oropharynx). Radiation technique was
significantly associated with psychosocial speech problems
(less problems in patients treated with IMRT). Swallowing
and (to a lesser extent) speech problems in daily life are
frequently present after chemoradiation therapy for head
and neck cancer. Future prospective studies will give more
insight into the course of speech and swallowing problems
after chemoradiation and into efficacy of new radiation
techniques and swallowing and speech rehabilitation
programs.
Keywords Swallowing Speech Patient-reported
outcomes Quality of life Head and neck cancer
Chemoradiation
Introduction
& Irma M. Verdonck-de Leeuw
1
Department of Otolaryngology/Head and Neck Surgery, VU
University Medical Center, Amsterdam, The Netherlands
2
Department of Radiation Oncology, VU University Medical
Center, Amsterdam, The Netherlands
3
Department of Medical Oncology, VU University Medical
Center, Amsterdam, The Netherlands
4
Department of Radiation Oncology, University Medical
Center Groningen/University of Groningen, Groningen,
The Netherlands
5
Division of Psychosocial Research and Epidemiology, The
Netherlands Cancer Institute, Amsterdam, The Netherlands
Advanced head and neck cancer is increasingly being
treated with organ-preservation protocols such as
chemoradiation therapy (CHRT). Organ-preservation protocols aim, next to the foremost goal to cure the disease,
also at maintenance of respiration, deglutition, speech,
phonation and cosmetics. However, literature reviews
revealed that organ-preservation protocols often result in
swallowing impairment; also speech problems may occur
but these are investigated less often [1–5]. Most of the
studies included in these reviews focused on swallowing
impairment using videofluoroscopy, fiberoptic endoscopic
evaluation of swallowing (FEESTM),or toxicity grading
protocols, but recent studies involve patient-reported
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outcomes measures as well [6–10]. Information from
objective imaging techniques regarding swallowing
impairment is important but does not necessarily relate to
patient-reported swallowing outcomes [11–14]. There is
broad range of variety of questionnaires used to evaluate
swallowing and speech outcomes and the impact on quality
of life [2, 15]. The head and neck cancer modules
accompanying the EORTC and FACT Quality of Life
Questionnaires or the University of Washington Quality of
Life Questionnaire are often used. Studies using specific
swallowing and speech-specific questionnaires like the MD
Anderson Dysphagia Index (MDADI) [16] or the Swallowing Questionnaire on Quality of Life (SWAL-QOL)
[17, 18], or the Speech Handicap index (SHI) [19] to assess
speech or swallowing problems in daily life after
chemoradiation therapy are less often reported.
The goal of the present cross-sectional study was to
assess the prevalence of patient-reported speech and
swallowing outcome after chemoradiation therapy for
head and neck cancer. Measures were chosen that are
provided with clear cut-off values: the Dutch versions of
the Swallowing Quality of Life Questionnaire (SWALQOL) and the Speech Handicap Index (SHI), which
enables quantification of patient-reported speech and
swallowing problems in daily life [18, 19]. Furthermore,
insight will be obtained regarding the association of
sociodemographic (age and gender) and clinical factors
{comorbidity [Adult Comorbidity Evaluation 27 (ACE27)] [20], tumor site and stage, radiotherapy scheduling,
time since treatment} and food intake (normal, soft diet,
or tube feeding) with patient-reported speech and swallowing outcome.
Materials and methods
Eur Arch Otorhinolaryngol (2016) 273:1849–1855
Data on age, gender, comorbidity, and tumor and
treatment characteristics [site and stage (according to
UICC)], radiation technique, time since treatment, placement and removal of gastrostomy tube were collected from
the medical records. Comorbidity was assessed with the
Adult Comorbidity Evaluation 27 (ACE-27) [20]. The
ACE-27 includes 27 comorbid conditions, including cardiovascular, respiratory, gastro-intestinal, renal, endocrine,
neurological, immunological, psychiatric and rheumatologic disorders, previous or synchronous malignancy,
alcohol abuse and excessive body weight. The ACE-27 was
designed specifically for cancer patients and classifies
patients into 4 grades of comorbidity [none (grade 0), mild
(grade 1), moderate (grade 2), severe (grade 3)].
During a time span of 8 months, 52 out of 60 patients
returned the SWAL-QOL (response rate 87 %) and 47, the
SHI (response rate 78 %). An overview of patient characteristics is provided in Table 1. Median age of the patients
was 58 years (range 36–75). Thirty-five (67 %) of the
patients were male. No comorbidity was observed in 16
patients, 24 patients had grade 1, 8 patients grade 2 and 4
patients grade 3. Primary tumor locations were oral cavity
(n = 5), oropharynx (n = 30), nasopharynx (n = 4), larynx (n = 10) and hypopharynx (n = 3) and these were
categorized into oral cavity/oropharynx/na (...truncated)
