Prospective Validation of the Use It or Lose It Paradigm: Secondary Analysis of Sub-Acute Dietary Outcomes by Eat and Exercise Status During Oropharyngeal Radiotherapy

Abstract

<h3>Purpose/Objective(s)</h3> The investigators' 2013 use it or lose it study suggested functional benefit of two pharyngeal activities during head and neck radiotherapy (RT) – maintenance of oral intake (EAT) and swallowing exercise. EAT and EXERCISE independently associated with better odds of resuming a regular diet in long term survivorship and shorter duration of gastrostomy (FT) dependence. The prior work is limited by the retrospective nature of the dataset and historically far higher FT utilization. Our aim was to validate the previous work in a contemporary cohort of oropharyngeal cancer (OPC) survivors treated with RT using prospectively acquired validated outcome measures. <h3>Materials/Methods</h3> Endpoints included subacute diet after RT per the performance status scale for head and neck cancer (PSS-HN; solid food diet coded as ≥60 and no FT) and length of FT-dependence in days. Primary independent variables included oral intake (PO) at the end of RT (nothing per oral/NPO; partial PO; full PO) and swallow exercise adherence. Multiple linear regression and logistic regression models were analyzed adjusting for tumor location, baseline diet, chemotherapy and N and T stage. <h3>Results</h3> Analysis included 595 patients treated with primary radiotherapy (RT; 19% 111) /chemoradiation (CRT; 73% 434) or primary TORS + CRT (8% 50) for OPC (base of tongue/glossopharyngeal sulcus [46% 276]; tonsil [44% 263]; other [9% 56]). At the end of RT 9% of patients were NPO (55), 19% partial PO (115), 71% full PO (425). Statistically significant (<i>P</i> < 0.05) covariates for EAT and/or EXERCISE included tumor location, chemotherapy, N and T stage. Fifty-seven percent of patients (340) reported adherence to swallow exercises. Overall, 66% (394) of patients returned to a solid diet by 3-6 months. In adjusted models, EAT and EXERCISE during RT were independently, significantly (<i>P</i> < 0.01) associated with sub-acute diet recovery and FT duration. Patients who maintained full PO during RT were 2.5 times more likely to eat a solid diet by 3-6 months (OR 2.5, 95% CI: 1.3, 5) when compared to those who were NPO during treatment. Patients who exercised were 2.9 times more likely to return to a solid diet (OR 2.9, 95% CI: 1.8, 4.4) relative to those who did not. Thirty-eight percent of patients received a FT (231) and the median duration of tube dependence was 89 days (IQR: 28-142). EAT was independently associated with FT duration (<i>P</i> < 0.001, Coefficient, -123.6, 95% CI: -148.7, -98.4), while EXERCISE was not (<i>P</i> = .73). <h3>Conclusion</h3> These prospective registry data validate prior work that indicate independent benefit of EAT and swallowing EXERCISE adherence during RT on subacute functional outcomes. Patients who maintained full PO and/or exercise were more likely to eat solid foods by 3-6 months after treatment, while patients who EAT during treatment expectedly have the shortest feeding tube dependence.