Impact of a Proactive Swallowing Rehabilitation Program on Feeding Tube Placement in Patients Treated for Head and Neck Cancer

Abstract

Previous evidence has shown active swallowing rehabilitation during treatment for head and neck cancer can reduce feeding tube placement and improve swallowing outcomes. We sought to evaluate the initiation of a proactive swallowing program at a single institution and its effect on feeding tube placement and dietary intake. This is a retrospective evaluation of patients treated for squamous cell carcinomas of the hypopharynx, oropharynx, and nasopharynx from 2004-2015. Initiation of regular speech pathology evaluations occurred after 2011, so treatment groups were divided into two groups: 2004-2010 and 2011-2015. Primary outcome variables were speech pathology referral placement and timing of the referral. Secondary outcome was feeding tube placement. We identified 192 patients meeting inclusion criteria. The mean age in our cohort was 61.6 years (range 35-94). A majority of patients had tumors of the oropharynx (78%; nasopharynx 8.3%; hypopharynx 13.5%) and also received chemotherapy (85.4%). Only a minority of patients (18.8%) received any surgery. This cohort included patients of stages I-IVc, mostly III (17.2%) or IVa (62.0%). There were no significant differences in any of these characteristics between patients diagnosed prior to program implementation and after (P>.05, all). A majority of patients received a speech pathology referral (76.0%, n=146), but only 45.8% (n=88) received a referral prior to initiating treatment. 38.5% (n=74) of patients received a g-tube at some point, most often during treatment. Prior to initiation of our proactive program, only 26.5% of patients received a pre-treatment evaluation. This increased to 60.6% in the post-implementation period (P<.001). Of note, there was also a non-significant increase in rate of referral to speech pathology overall at any time (from 69.9% to 80.7%, P=.08). We also observed a significant decrease in g-tube placement rates following program initiation, from 51.8% to 28.4% (P=.001). Among patients receiving a swallow evaluation, feeding tube requirements were lower for those receiving a pre-treatment evaluation (29.6%) than for those referred during (83.3%) or after (67.5%) treatment (P<.001). Ultimately, the rate of tolerating any oral (PO) intake at the end of treatment improved from 70.6% in the pre-implementation period to 92.1% (P=.005). Implementation of a proactive speech pathology referral program at our institution was associated with increased likelihood of a pre-treatment referral and a decreased need for feeding tube, with associated increase in tolerating PO intake at the end of treatment. These results highlight the importance of active swallowing rehabilitation programs as part of any multidisciplinary head and neck team.