A UK multi‐centre pilot study of speech and swallowing outcomes following head and neck cancer

Speech and swallowing are important components of health‐related quality of life following head and neck cancer treatment. The aim of this study was to demonstrate the value of prospective multi‐centre evaluation by Speech and Language Therapists and to compare health‐related quality of life with speech and swallowing impairments. The University of Washington Head and Neck questionnaire version 4 (UW‐QOL) and Therapy Outcome Measures (TOM) were rated before and 6 months after cancer treatment in 95 patients from 12 centres. There was deterioration in TOM scores at 6 months. Pretreatment UW‐QOL swallowing was ranked equal first, with speech fourth. At 6 months speech was first and swallowing second. There were positive correlations between UW‐QOL swallowing and TOM dysphagia and between UW‐QOL speech and TOM laryngectomy, voice, phonology and dysarthria disorders. Both outcome measures are suitable for routine practice. Adaptation of TOM scales for use with head and neck cancer patients may improve sensitivity, validity and therapist compliance.     

Quality of life in advanced oropharyngeal carcinoma after chemoradiation versus surgery and radiation

OBJECTIVE: The objective of this cohort study from a tertiary academic university practice was to identify differences in patients' perceived quality of life after either chemoradiation or surgery and radiation for advanced-stage oropharyngeal carcinoma. METHODS: From institutional databases, thirty-five patients were identified who had undergone either primary chemoradiation or primary surgery and postoperative radiation for advanced oropharyngeal cancer (stage II-IV). Patients voluntarily responded by mail using the University of Washington quality-of-life instrument version 4 (UW-QOL). Data were analyzed using chi and Wilcoxon tests. RESULTS: There were 17 patients who underwent chemoradiation and 18 patients who underwent surgery and postoperative radiation. All surgical patients had undergone free-flap reconstruction. Patients completed the UW-QOL an average of 25 months after treatment. There was no statistically significant difference between the two groups with regard to any specific domain, including pain, appearance, swallowing, chewing, speech, saliva, or mood. There was a trend toward significance for taste (P = .07) with chemoradiation patients reporting poorer taste function. The lack of difference in the patients' perception of appearance and swallowing was rather surprising given the vastly different treatment modalities. Respondents reported equivalent overall quality of life in response to global quality-of-life questions. CONCLUSION: Most patients with advanced oropharyngeal carcinoma report good quality of life after treatment, regardless of treatment modality. Although the short-term side effects of treatment may be different between the groups, long-term quality of life is remarkably similar whether the patients choose primary chemoradiation or surgery with postoperative radiation.     

Speech intelligibility and quality of life in head and neck cancer survivors

OBJECTIVE: Poor speech intelligibility adversely affects quality of life self-assessment in long term survivors of head and neck cancer treatment. STUDY DESIGN: Observational case series including both objective clinical speech testing and subjective quality of life questionnaire administration. METHODS: Five-year head and neck cancer survivors were recruited to study the association between speech intelligibility and quality of life. Survivors were analyzed as an entire group, and also subdivided into laryngectomees and non-laryngectomees. Objective testing included sentence and word intelligibility. Subjective testing included quality of life questionnaires (UWQOL, FACT, FACT-head and neck, and PSS-HN) and a locally prepared "cancer concern" question. Associations were sought between intelligibility, quality of life and demographics. RESULTS: Sixty-two survivors underwent testing. Lower sentence intelligibility and word intelligibility scores were associated with diminished self-perceived UWQOL Speech (P = .0001 and P = .0001, respectively) and PSS-HN Understandability of Speech (P = .009 and P = .005). Decreased word intelligibility was additionally associated with decreased UWQOL Chewing (P = .003), UWQOL Swallowing (P = .02), UWQOL Recreation (P = .05), PSS-HN Willingness to Eat in Public (P = .03), and PSS-HN Normalcy of Diet (P = .0001). The associations continued even after patients who had undergone laryngectomy were excluded. CONCLUSIONS: Long-term survivors of head and neck cancer continue to have both objective and subjective deficits in speech parameters five years after treatment. Objective deficits are associated with subjective concerns about speech, eating, and recreation. Understanding how communication deficits affect quality of life in long-term head and neck cancer survivors may allow more effective therapies to modulate these concerns in the recovery period.     

An evaluation of functional outcomes (speech,swallowing) in patients attending speech pathology after head and neck cancer treatment(s): results and analysis at 12 months post-intervention

We have earlier reported establishing a computerized database to audit functional outcomes in patients who underwent head and neck cancer treatment in Victoria, Australia and attended speech pathology services from April 1997-April 1999. This paper presents the statistical analyses and results from this study. Speech pathologists collected, prospectively, functional outcome data on 293 patients who underwent head and neck cancer treatment, and sent these for analysis to La Trobe University. Clinician and patient assessments of outcomes: speech, swallowing, activity, pain, employment, health, QOL status were made. Initial data on 293 patients were collected and data on mortality and morbidity were compiled at three, six and 12 months post-treatment. Within twelve months, 74 patients had died. Three, six and/or 12-month follow-up data was available on 219 patients, with both clinician and patient assessments of status completed. The status forms are presented as appendices to this paper. Complete status forms on 179 patients at 12 months were obtained. This clinical audit of functional outcomes represents the first study of this kind, collecting data from speech pathologists and patients in a multi-centre study of patients with head and neck cancer. We present data to demonstrate optimal recovery of function at six months, such that this may represent a good reference point for reporting and comparison of functional outcomes.     

The development and validation of a dysphagia-specific quality-of-life questionnaire for patients with head and neck cancer: the M. D. Anderson dysphagia inventory.

OBJECTIVE: To design a reliable and validated self-administered questionnaire whose purpose is to assess dysphagia's effects on the quality of life (QOL) of patients with head and neck cancer. DESIGN: Cross-sectional survey study. METHODS: Focus groups were convened for questionnaire development and design. The M. D. Anderson Dysphagia Inventory (MDADI) included global, emotional, functional, and physical subscales. One hundred consecutive adult patients with a neoplasm of the upper aerodigestive tract who underwent evaluation by our Speech Pathology team completed the MDADI and the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). Speech pathologists completed the Performance Status Scale for each patient. Validity and reliability properties were calculated. Analysis of variance was used to assess how well the MDADI discriminated between groups of patients. RESULTS: The internal consistency reliability of the MDADI was calculated using the Cronbach alpha coefficient. The Cronbach alpha coefficients of the MDADI subscales ranged from 0.85 to 0.93. Test-retest reliability coefficients of the subscales ranged from 0.69 to 0.88. Spearman correlation coefficients between the MDADI subscales and the SF-36 subscales demonstrated construct validity. Patients with primary tumors of the oral cavity and oropharynx had significantly greater swallowing disability with an adverse impact on their QOL compared with patients with primary tumors of the larynx and hypopharynx (P<.001). Patients with a malignant lesion also had significantly greater disability than patients with a benign lesion (P<.001). CONCLUSIONS: The MDADI is the first validated and reliable self-administered questionnaire designed specifically for evaluating the impact of dysphagia on the QOL of patients with head and neck cancer. Standardized questionnaires that measure patients' QOL offer a means for demonstrating treatment impact and improving medical care. The development and validation of the MDADI and its use in prospective clinical trials allow for better understanding of the impact of treatment of head and neck cancer on swallowing and of swallowing difficulty on patients' QOL.     

Treatment considerations for head and neck cancer in the elderly

As life expectancy increases, surgeons can expect an increasing number of geriatric patients. In turn, the number of elderly patients presenting with head and neck cancer is likely to increase. Management of this subpopulation has become a source of debate because there is a paucity of randomized data regarding the effect of age on treatment response and morbidity associated with the treatment of head and neck cancer. The management of head and neck cancer in the elderly depends on the patient's age and general condition, the stage of disease, the effects of treatment on quality of life (such as speech and swallowing), patient and family wishes, and active physician participation in continued care. Elderly patient's comorbid conditions need appropriate attention especially if surgery is to be undertaken. The aim of this review is to examine the current literature in an attempt to develop an approach to the treatment of the elderly patient with head and neck cancer and to define the pertinent issues that require further study.     

Impact of neck dissection on quality of life.

OBJECTIVES: For decades, the gold standard for treatment of cervical metastasis was radical neck dissection (RND). Current oncologic philosophy allows for treatment of appropriately staged neck disease with modified radical neck dissection (MRND) or selective neck dissection (SND). The purposes of this study were to determine the impact of various forms of neck dissection on patients' quality of life (QOL) and to evaluate the responsiveness of the University of Washington (UW) QOL shoulder domain. STUDY DESIGN: Prospective accumulation of QOL data from patients treated for head and neck cancer at UW. METHODS: Eighty-four patients were identified from the UW QOL registry who had undergone neck dissection and had completed pretreatment and posttreatment QOL questionnaires at 6 and 12 months. RESULTS: Compared with pretreatment scores, the MRND and RND groups reported worse shoulder function at 6 and 12 months (P<.0005). The MRND group reported greater shoulder disability at 6 months compared with the SND group (P = .002), but by 12 months, there was no difference between the two groups. Shoulder function for the RND group was worse than the SND group at 6 and 12 months (P = .004). There was a trend toward decreased pain after treatment in the SND and MRND groups. There were no significant differences in subjective appearance, activity, recreation, chewing, swallowing, or speech in the three groups after treatment. CONCLUSIONS: Consistent with findings of published functional studies, this study confirmed that the three forms of neck dissection affect patients' QOL differently. This study demonstrates that the UW QOL shoulder domain is a responsive instrument in assessing the effect of neck dissection on shoulder function.     

Quality of life in tongue cancer treated patients before and after speech therapy: a randomized clinical trial

IntroductionTongue cancer is one of the most common subtypes of head and neck cancer. The aggressive effects of treatment cause aesthetic, psychosocial and functional deficits, especially dysphagia, which affects patient quality of life. Rehabilitation, which is essential for functional maximum recovery, helps patients deal with new and altered structures and has a positive impact on quality of life.ObjectiveTo verify the impact of speech therapy on swallowing quality of life in tongue cancer patients after treatment.MethodsThis parallel randomized clinical trial was conducted at a public hospital in Porto Alegre, RS, Brazil. Before and after the intervention, a quality of life questionnaire (the Deglutition Handicap Index) was employed, dysphagia severity was assessed with fiberoptic endoscopic evaluation of swallowing, and the Functional Oral Intake Scale carried out. The experimental group underwent four-week sessions of speech therapy over one month, while the control group received the institution’s usual follow-up.ResultsThirty individuals treated for tongue cancer were divided into a study and a control group. Deglutition Handicap Index scores decreased significantly (approximately 40 points) (p < 0.001) after the intervention in the study group. There was a significant correlation between improved quality of life, reduced dysphagia severity and increased in Functional Oral Intake Scale scores (p < 0.001).ConclusionAfter speech therapy, quality of life scores related to deglutition and dysphagia severity improved in patients treated for tongue cancer.     

Quality of life evolution in patients after surgical treatment of laryngeal, hypopharyngeal or oropharyngeal carcinoma

IntroductionThe assessment of quality of life in patients with head and neck cancer is dependent on many variables.ObjectiveThe aim of this study was to evaluate the differences in quality of life among patients treated with conservative or radical surgery for laryngeal, oropharyngeal or hypopharyngeal cancer, evaluated before and at 3 and 6 months after definitive therapy.Material and methodProspective study between November 2008 and June 2009 on 53 patients diagnosed and treated for head and neck carcinoma with surgery: partial (n = 32) and radical (n = 21). Quality of life was evaluated using the European Organization of Research and Treatment of Cancer (EORTC) general questionnaire EORTC QLQ-C30 and its specific head and neck EORTC QLQ-H&;N35 before treatment, and at 3 and 6 months afterwards.ResultsNo significant differences were found in overall health. Patients experienced the greatest changes in functional scale. There were no changes in swallowing problems or feeling of disease, while evident phonation problems were present in both groups.Discussion and conclusionsThe routine application of quality of life questionnaires in cancer patients improves information regarding how and to what extent patients feel that treatment and its sequelae modify it, making it possible to adapt rehabilitation and support programs to their real needs. This data helps in choosing between different options depending on the results, delivering improved care to patients.     

Head and neck reconstructive surgery with free flaps and quality of life: a prospective study

OBJECTIVE: The aim of this prospective study is to evaluate functional results and quality of life after head and neck reconstructive surgery with free flaps. MATERIAL AND METHODS: All patients who have beneficed of head and neck reconstructive procedures with free flaps during the year 2004 were included in this study. EORTC quality of life questionnaire (QLQ-C30/H&N35) was used before and 6 months after surgery. A head and neck functional evaluation was realized 6 months after surgery. RESULTS: Thirty four patients were examinate 6 months after surgery. Global quality of life remained at its preoperative level (61.3% VS 62.8%). Physical, role and social functioning decreased significantly (p = 0.05), but emotional and cognitive functioning remained stable. Pain decreased considerably after treatment in the head and neck area (p = 0.001). Oral (eating: p = 0.05, speaking: p = 0.008) and sensorial functions (p = 0.001) decreased after treatment. All patients except one have recovered sufficient oral intakes, an intelligible speech and a good cosmetic result. CONCLUSION: Functional and cosmetic results after head and neck reconstructive surgery are the key factors of quality of life. Free flaps are considered actually as an indispensable technique to achieve an optimal reconstruction.     

Quality of life issues in cancer of the oral cavity

Quality of life issues in head and neck cancer have been portrayed increasingly in the medical literature in recent decades. Reports vary in sample size and study design but the majority are cross-sectional and suffer from inherent bias. Many of the patients' complaints in cancer of the head and neck manifest close linkage to problems related to the oral cavity. Frequent specific problems are trismus, pain, xerostomia, and speech and swallowing disorders. Although quality of life is multifactorial and subjective, some improvement may be achieved by recognizing and addressing problems during the course of treatment. More longitudinal long-term studies are indicated in order to better define quality of life along the time axis.     

An evaluation of the University of Washington Quality of Life swallowing domain following oropharyngeal cancer

Oropharyngeal cancer and its treatment have debilitating effect on swallowing function which can impact on quality of life. The aims of this study were to assess swallowing dysfunction in patients treated for oropharyngeal cancer by both patient and observer assessed tools and to assess the suitability of University of Washington Quality of Life (UW-QOL) swallowing domain as a potential screening tool in routine clinic practice. This was a cross-sectional study of disease free survivors following radical treatment for oropharyngeal squamous cell carcinoma at a tertiary care centre between 1999 and May 2005. Evaluation included three questionnaires—the M. D. Anderson Dysphagia Inventory (MDADI), the SWALQOL, the University of Washington Quality of Life (UWQOL) and Fibreoptic Endoscopic Evaluation of Swallowing (FEES). Of 117 patients 77 (66%) participated. On the UW-QOL, 18% could only swallow liquids whilst 11% could not swallow at all. There is a clear demarcation between UW-QOL levels and food consistency and texture as measured by the SWALQOL (r = ?0.86, P < 0.001). There was a graduation in respect to function with correlations of r = 0.61 with overall MDADI and SWALQOL and r = ?0.45 for FEES. Patients scoring 70 or better in the UW-QOL were notably better in MDADI and the SWALQOL hence a cut off of below 70 could be regarded as a quick screening tool for swallowing dysfunction.     

Quality of life during the first 3 months following discharge after surgery for head and neck cancer: prospective evaluation

OBJECTIVE: To identify patient groups that are prone to poorer quality of life (QoL) during the first 3 months following discharge from the hospital after surgery for head and neck cancer. DESIGN: Prospective evaluation of the QoL of surgically treated head and neck cancer patients measured with questionnaires at discharge and at 6 weeks and 3 months after discharge. SETTING: Department of Otolaryngology and Head and Neck Surgery of the Erasmus University Medical Centre, a tertiary health care centre in Rotterdam, The Netherlands. PARTICIPANTS: Ninety head and neck cancer patients who had undergone a total laryngectomy, neck dissection, or the commando procedure. MAIN OUTCOME MEASURES: Patients' quality of life in 22 different dimensions. RESULTS: Three patient characteristics associated with poorer QoL during the first 3 months following discharge from the hospital after surgery for head and neck cancer: laryngectomy, lower levels of education, and being single. QoL already improved in eight QoL dimensions during the first 3 months after discharge, but QoL in the dimensions "loss of control" and "physical self-efficacy" worsened during this same period. CONCLUSIONS: It is possible to identify patient groups that are prone to poorer QoL during the first 3 months following discharge from the hospital after surgery for head and neck cancer. The results of this study may help care providers working with head and neck cancer patients to tailor their rehabilitation programs.     

Pretreatment, preoperative swallowing exercises may improve dysphagia quality of life

OBJECTIVES: Dysphagia is commonly associated with head and neck cancer treatment. Traditional dysphagia management strategies focus on post-treatment therapy. This study evaluated the utility of pretreatment swallowing exercises in improving post-treatment swallowing quality of life (QOL). STUDY DESIGN: Prospective cohort study and cross-sectional QOL analysis. METHODS: This study includes 37 patients who underwent primary radiation or combined chemoradiation treatment for newly diagnosed hypopharyngeal, laryngeal, or oropharyngeal primary tumors at the University of Alabama at Birmingham. Of the 37, 25 patients underwent swallowing exercises beginning 2 weeks prior to the start of radiation. The M.D. Anderson Dysphagia Inventory (MDADI) was administered an average of 14 months after treatment to assess the success of the protocol. Analysis of QOL scores related to gender, primary site, stage, and race were obtained. RESULTS: Patients who performed pretreatment swallowing exercises (n = 25) showed improvement in the overall MDADI score (P = .0002) compared to the control population (n = 12) who underwent post-treatment therapy. Furthermore, a separate analysis of individual domains of the MDADI (global, emotional, functional, and physical) demonstrated improved quality of life. CONCLUSIONS: Implementation of pretreatment swallowing education and exercise may improve dysphagia-specific QOL in head and neck cancer patients undergoing radiation and/or chemoradiation therapy.     

Analysis of the performance characteristics of the University of Washington Quality of Life instrument and its modification (UW-QOL-R)

BACKGROUND: During a 5-year period, we analyzed 3 patient subsets from the University of Washington Quality of Life (UW-QOL) Registry and published the results. In each instance, editorial review has raised legitimate concerns regarding the UW-QOL instrument that deserve public comment. We present our response to these criticisms. Since our original publication (1993), we have added domains to the original UW-QOL instrument. These additions reflected our concern that we might be missing important elements in the spectrum of disease-specific response to treatment. Using the data we have accumulated in the last 5 years, we present an analysis of the internal consistency of the UW-QOL. We have identified those domains that are responsive (or not responsive) to treatment effect and have revised the UW-QOL accordingly to create the UW-QOL-R, which is recommended for future use. DESIGN: The project began January 1, 1993, after approval by the UW Human Subjects Committee. Critical comments offered by external review were collated and responded to. Internal consistency was evaluated by interitem correlation matrix (Cronbach alpha) testing. SUBJECTS: All new patients presenting to the UW Medical Center (Seattle) with a diagnosis of head and neck cancer were asked to participate in a prospective analysis of QOL changes during and after treatment. INTERVENTION: Patients completed the pretreatment QOL questionnaire on the day of their initial workup. The format for the pretreatment test was an interviewer-supervised self-administered test; the subsequent tests were self-administered and were completed at 3, 6, 12, 24, and 36 months. Other data entered for each patient included site, stage, treatment, histologic classification, reconstruction, and current status. A QOL registrar was responsible for patient follow-up, data collection, and collation. All data were entered into the departmental relational database. RESULTS: Criticisms by external review included the following: "it is improper to call it [UW-QOL] a measure of quality of life"; "the summary scale is problematic because it implies that each of the subscales are weighted or 'valued' equally"; "some domain questions relate to surgery specific issues. while others are specific to radiation"; "we were confused by the scoring"; and "the UW-QOL index does not specifically address the psychological impact of the disease and its treatment." After evaluation of internal consistency, the UW-QOL was modified by removing 2 domains that correlated poorly with the others. This resulted in a 10-item instrument (UW-QOL-R) with an overall internal consistency score of 0.85. CONCLUSIONS: The UW-QOL can be effectively and accurately used to compare treatment effects in the management of head and neck cancer. With this revised instrument, the 10 items appear to measure the domains of overall QOL in a highly consistent and reliable fashion over time.     

Long-term quality of life for surgical and nonsurgical treatment of head and neck cancer

OBJECTIVE: To compare the long-term, health-related quality-of-life outcomes in patients with advanced head and neck cancer (HNC) treated with surgery and postoperative radiation therapy (SRT) or concurrent chemotherapy and radiation therapy (CRT). DESIGN: Matched-pair study comparing patients with advanced HNC treated with SRT or CRT at least 12 months after treatment. Patients completed 2 validated surveys addressing HNC-specific outcomes and depressive symptoms and provided information on employment and tobacco and alcohol use. Results for the 2 groups were compared using paired-sample t test and chi2 analysis. SETTING: University-based study. PATIENTS: Patients with stage III or IV squamous cell carcinoma of the oropharynx, hypopharynx, and larynx who underwent SRT or received CRT. MAIN OUTCOME MEASURES: Head and neck cancer-specific health-related quality of life from the Head and Neck Cancer Inventory and level of depressive symptoms from the Beck Depression Inventory. RESULTS: The matching process resulted in 27 patients in each treatment group. The HNC-specific domain scores (with higher scores representing better outcomes) for CRT vs SRT were eating, 37.8 vs 40.8 (P = .69); speech, 65.1 vs 56.0 (P = .23); aesthetics, 80.3 vs 69.2 (P = .14); and social disruption, 69.7 vs 70.6 (P = .90). Overall health-related quality of life was 64.0 with SRT and 55.0 with CRT (P = .142). For the Beck Depression Inventory (with higher scores representing worse outcomes), patients who underwent SRT had a mean score of 9.6 compared with 11.6 for patients who received CRT (P = .42). CONCLUSION: As nonsurgical means of treating HNC have become more aggressive and surgical techniques have become more focused on function preservation and rehabilitation, the overall health-related quality of life resulting from these different approaches is similar.     

Ileocolic free flap reconstruction, concomitant chemotherapy and radiotherapy and assessment of speech and swallowing function during management of advanced cancer of the larynx and hypopharynx: preliminary report

CONCLUSION: The new technique of ileocolic free flap reconstruction provides a better quality of life in terms of swallowing and speech for patients who have undergone laryngopharyngectomy with concomitant chemotherapy and radiotherapy (CCRT). OBJECTIVES: To compare and contrast the swallowing and speech outcomes of patients who underwent total laryngopharyngectomy with ileocolic free flap reconstruction and to analyze the survival rate after surgery and CCRT. MATERIAL AND METHODS: This was a follow-up study of 12 patients with advanced (stages III, IVA and IVB) laryngeal and hypopharyngeal cancer who underwent major surgery, CCRT (with one exception) and ileocolic free flap reconstruction. RESULTS: All patients were able to tolerate single-stage combined management comprising total laryngopharyngectomy with or without radical neck dissection plus ileocolic free flap reconstruction and postoperative CCRT (with one exception), without immediate morbidity or mortality. Eleven patients were diagnosed with hypopharyngeal cancer and one with laryngeal cancer. The mean interval between surgery and CCRT was 34.1 days. The mean follow-up period was 16.5 months. Four patients died during the follow-up period as a result of local recurrence (n=2), distant metastasis (n=1) and suicide (n=1). One patient was alive with disease despite neck recurrence.     

Outcomes research in head and neck cancer

Quality of life (QOL) considerations are uniquely important in head and neck oncology outcomes research due to the multidimensional impact of these tumors and their treatment. Patient variables, tumor variables and treatment variables must be considered comprehensively in order to maximize the validity of QOL outcome measures. There are a multitude of QOL instruments, which can be classified into: (1) general measures of health-related QOL, (2) general QOL instruments for patients with cancer, (3) disease-specific instruments for patients with head and neck cancer, (4) treatment-specific instruments and (5) symptom-specific instruments. This article will highlight commonly used validated QOL instruments in head and neck oncology.