MD Anderson Dysphagia Inventory Scores Research Articles

Study of Dysphagia in Patients with Advanced Oropharyngeal Cancer Subjected to an Organ Preservation Protocol Based on Concomitant Radiotherapy and Chemotherapy

Introduction:Organ preservation protocol (based on chemo-radiotherapy) for oropharyngeal tumors include dysphagia as a possible sequel leading to function impairment and changes in patient’s quality of life.Objectives:The aim of this study is to assess dysphagia severity after treatment in advanced oropharyngeal cancer patients treated with concurrent chemo-radiation.Methods:This prospective cross-sectional study included 64 participants who had been disease free for at least six months after primary treatment. Dysphagia severity was assessed by fibre-optic endoscopic evaluation of swallowing (FEES) and the Dysphagia Outcome and Severity Scale (DOSS); the occurrence of penetration/aspiration during swallowing was also investigated. All participants also completed the M. D. Anderson Dysphagia Inventory (MDADI). The correlation of FEES results with clinical-demographic variables and MDADI scores was assessed. Descriptive analysis was performed, and qualitative variables were compared using either the chi-square or Fisher’s exact test.Results:FEES revealed silent aspiration in 18.8% of the patients. Approximately 6.3% of the patients exhibited severe dysphagia (scores 1-2 in DOSS). Dysphagia severity was significantly associated with the MDADI physical domain scores. The participants with scores 5-7 in DOSS (no or mild dysphagia) exhibited less limitations in the MDADI physical domain (p=0.015).Conclusions:Silent aspiration was detected in one of every five patients treated with concurrent chemo-radiotherapy; almost half of the patients exhibit at least moderate dysphagia. Assessment of the participant’s quality of life via the MDADI revealed an association between the physical domain scores and dysphagia severity.

Associations between pre-, post-, and peri-operative variables and health resource use following surgery for head and neck cancer

ObjectiveWe examined associations between pre-, post-, and peri-operative variables and health resource use in head and neck cancer patients. MethodsPatients (N = 183) who were seen for a pre-surgical consult between January 2012 and December 2014 completed surveys that assessed medical history, a patient-reported outcome measure (PROM) of dysphagia, and quality of life (QOL). After surgery, peri-operative (e.g., tracheostomy, feeding tube) and post-operative (e.g., complications) variables were abstracted from patients’ medical records. ResultsMultivariate regression models using backward elimination showed that pre-surgical University of Washington Quality of Life (UW-QOL) Inventory and M.D. Anderson Dysphagia Inventory (MDADI) composite scores, documented surgical complications, and having a tracheostomy, were all significant predictors of hospital length of stay, explaining 57% of the total variance (F(5, 160) = 18.71, p < .001). Male gender, psychiatric history, and lower pre-surgical MDADI scores significantly predicted thirty-day unplanned readmissions (30dUR). Pre-surgical MDADI composite scores also significantly predicted emergencey department (ED) visits within 30 days of initial hospital discharge (p = .02). ConclusionsAssessment of PROMs and QOL in the pre-surgical setting may assist providers in identifying patients at risk for prolonged LOS and increased health resource use after hospital discharge.

Comparison of Functional Organ Preservation by Concomitant Boost Radiotherapy Versus Concurrent Chemoradiation in Locally Advanced Carcinoma of Larynx or Hypopharynx: A Prospective Randomized Study

Functional organ preservation is a major challenge in management of advanced laryngeal and hypopharyngeal carcinoma. Although ideal approach is a subject of much debate, radiotherapy with or without chemotherapy is most commonly used modality. This randomized study was conducted to compare functional organ preservation by chemoradiation (CRT) versus concomitant boost radiotherapy (CBRT). A total of 40 patients with advanced (stage III/stage IVa) laryngeal and hypopharyngeal cancer were randomized to receive either CRT (n = 20) to a dose of 66Gy in 33 fractions over 6.5weeks with concurrent cisplatin (100mg/m2 on days 1, 22 and 43) or CBRT (n = 20) to a dose of 67.5Gy in 40 fractions over 5weeks. Patients were assessed for organ preservation rate, toxicities, voice and swallowing functions utilizing Voice Related Quality of Life (VRQOL) and MD Anderson Dysphagia Inventory (MDADI) scores, respectively, for minimum follow up of 6months. Organ preservation rate (intact disease free larynx) at 6months post treatment was observed in 100% in CRT arm and 95% in CBRT arm. There was no significant difference in mucositis and dermatitis in two arms (p = 0.82 and 0.78, respectively). Dysphagia was observed more in CRT arm (n = 12 vs n = 6). Late toxicities grade 3 xerostomia, grade 2 dysguesia, were seen significantly more in CRT arm. There was no statistical difference between the two arms in terms of VRQOL (p = 0.55) and MDADI scores (p = 0.13). In CRT arm 13 patients complete response and in CBRT arm 12 patients had complete response. Accelerated fractionation with concomitant boost schedule is as effective as CRT in anatomical and functional preservation of larynx. The toxicities, voice and dysphagia related quality of life is comparable.

Patient-reported versus physiologic swallowing outcomes in patients with head and neck cancer after chemoradiation.

The primary objective of this project was to retrospectively investigate the relationship between patient-reported and physiologic swallowing measures after chemoradiation therapy for head neck cancer (HNC). Adult patients who underwent chemoradiation therapy for HNC and presented for videofluoroscopic swallow study were reviewed retrospectively. Surgically treated patients were excluded. Patient perception of swallowing-related outcomes was assessed via the MD Anderson Dysphagia Inventory (MDADI) on the same day that physiologic measures of swallow function were obtained. Using vidoefluoroscopic data, the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) scale yielded measures of safety (DIGEST-S: penetration/aspiration) and efficiency (DIGEST-E: residue). Statistical analysis for correlation coefficients was performed. Thirty patients met the inclusion criteria. The oropharynx was the most commonly affected site (70.0%), followed by the larynx (16.7%). The median radiation dose was 72 grays (Gy), and participants were assessed a mean of 4.6 (range 0-12) years following completion of treatment. There was no correlation between the MDADI and the DIGEST-E score (Pearson rho = -0.045, P = 0.812), DIGEST-S score (Pearson rho = 0.075, P = 0.695), or summary DIGEST grade (Pearson rho = 0.046, P = 0.810). MDADI scores did not change significantly with increasing time since radiation (P = 0.375), whereas the DIGEST-E scores, DIGEST-S score, and summary DIGEST grades worsened over time (P = 0.007, P = 0.002, and P = 0.0005, respectively). Assessment of swallowing physiology showed that function worsened after chemoradiation therapy, but this did not correlate with patient-reported quality-of-life measures. Reduced patient awareness of swallow dysfunction years after completion of chemoradiation has implications for management of dysphagia in the face of physiologic decline. 4 Laryngoscope, 129:2059-2064, 2019.

Prospective instrumental evaluation of swallowing, tongue function, and QOL measures following transoral robotic surgery alone without adjuvant therapy.

Transoral robotic surgery (TORS) has been utilized to deintensify treatment. No studies have measured swallow safety and efficiency, nor assessed the functional impact of TORS alone. This prospective cohort underwent baseline and 1-month postsurgery assessments including modified barium swallow evaluation, using the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) rating system, tongue range of motion assessment, the Performance Status Scale (PSS), and quality of life with the MD Anderson Dysphagia Inventory (MDADI). All DIGEST safety scores were 0 (normal) at both time points. DIGEST efficiency scores were mildly impaired in 2 of 10 patients postsurgery. PSS scores revealed all patients were on regular diets, were 100% understandable, and were eating in public at both time points. Tongue Range of Motion scores were 100 of 100 at both time points. MDADI scores were not significantly different across time points. Careful identification of patients can result in excellent outcomes following TORS. Future studies will examine longer follow-up of speech, swallowing, and tongue function in patients undergoing TORS surgery.

Functional Burden Associated with Late Lower Cranial Neuropathy in Long-Term Oropharyngeal Cancer Survivors Treated with Definitive Radiation Therapy

Lower cranial neuropathy (LCNP) is a rare potentially disabling late toxicity induced by damage due to radiotherapy (RT) and other cancer therapies. The objective of this paper was to examine the impact of late LCNP on functional burden and swallowing related QOL. We hypothesized that OPC survivors with late LCNP would report significantly worse swallowing-related QOL scores. A total of 882 OPC survivors (median survival time: 7 years) who received definitive RT at an institution between January 2000 – December 2013 completed a cross-sectional survey (56% response rate) that included the MD Anderson Dysphagia Inventory (MDADI). The 19-item composite MDADI score representing overall swallowing-related QOL was the primary outcome and composite emotional, physical and functional subscale scores were secondary outcomes. Late LCNP events defined by onset >3-months after cancer therapy were abstracted from medical records. Multivariate models regressed MDADI scores on late LCNP status adjusting for clinical covariates. A total of 3.9% (n=34) of respondents (median survival time: 11.5 years) developed late LCNP. Among them, 50% were treated with RT and concurrent chemotherapy and 32%with RT only. They were treated with a higher total mean RT dose (LCNP: 69.5 vs. 68.2 Gy, p<0.001), 64% received IMRT-SF and 26% received 3D Conformal RT. Patients with late LCNP reported significantly worse mean composites scores (LCNP: 67.6 vs. no LCNP: 79.8, p<0.001). Late LCNP was independently associated with worse mean composite scores (β= -7.6, p=0.007, 95%CI: -13.1, -2.0) adjusting for age, survival time, sex, education, treatment modality, T-stage, subsite, RT type, solid food at baseline and smoking. Subscale scores that were most severe, in rank order of means, included physical (LCNP: 62.0 vs. no LCNP: 75.5, p<0.001), global (LCNP: 64.1 vs. no LCNP: 80.8, p<0.001), emotional (LCNP: 69.9 vs. no LCNP: 80.6, p<0.001) and functional scores (LCNP: 73.8 vs. no LCNP: 85.5, p<0.001). Late LCNP was independently associated with worse physical (β = - 8.8, p=0.008, 95%CI: - 15.23, -2.29), global (β = -10.6, p=0.01, 95%CI: -18.6, - 2.5), emotional (β = -6.1, p=0.035, 95%CI: -11.7, -4.2) and functional scores (β = -7.5, p=0.009, 95%CI: -13.0, -1.9) adjusting for age, survival time, sex, education, treatment modality, T-stage, subsite, RT type, solid food at baseline and smoking. In our large survey study, OPC survivors with late LCNP reported significantly poor swallowing related QOL and higher levels of functional impairment. Late LCNP may lead to profound deficits in swallowing, extended placement of feeding tubes, tracheostomy tubes, and refractory aspiration that can lead to pneumonia and diminished QOL. Further efforts are necessary to alleviate the functional burden associated with this disabling late effect of cancer treatment experienced by OPC survivors.

Patient-Reported Outcome Measures of Long-Term Swallowing Function after Oropharyngeal Radiation Therapy: A Cross-Sectional Methods Comparison

Definitive radiation therapy (RT) plays an important role in the curative treatment of many patients with oropharyngeal cancer (OPC), but carries a risk of long-term toxicity including the development of severe dysphagia. Here we characterize the relationship of patient-reported outcomes (PRO) of swallowing to quality of life (QOL) and radiation dose in long-term OPC survivors following definitive RT. Patients with non-metastatic OPC treated with definitive RT at a single institution between January 2000 and April 2014 were examined. All patients completed the MD Anderson Symptom Inventory—Head and Neck (MDASI-HN), the MD Anderson Dysphagia Inventory (MDADI), and the EuroQol five dimension questionnaire (EQ-5D VAS) 12 months or more following end of RT in a cross-sectional survivorship survey. A single dysphagia question from MDASI-HN (designated MDASI-HN-S) was used. An MDASI-HN-S score ≥6 and composite MDADI score <60 were considered representative of moderate-severe swallowing dysfunction. The Bayesian information criteria (BIC) were used to test the predictive power of MDASI-HN-S and composite MDADI with QOL as measured by EQ-5D VAS. The modified Breiman recursive partitioning analysis (RPA) was used to identify an MDASI-HN-S cut off score for poor QOL. To assess validity of PRO cutpoints, the mean dose to candidate regions of interest (ROI) were compared in patients with and without moderate/severe dysphagia symptoms. A total of 714 patients met criteria for inclusion, with 91.9% treated with intensity modulated radiotherapy (IMRT) and a mean time from treatment of 6.7 years. Moderate/severe dysphagia was reported by 17% and 16% of respondents by MDASI-HN-S and composite MDADI, respectively. QOL as measured by EQ-5D VAS was lower in those with moderate/severe dysphagia per both MDASI-HN-S (63.4 vs 83.5, p<0.001) and composite MDADI scores (64.5 vs 83.2, p< 0.001). Although both inventories were predictive of QOL, the model including MDASI-HN-S was slightly more parsimonious for discrimination of EQ-5D VAS scores compared to composite MDADI (BIC of 6062 vs 6076). Recursive partitioning analysis showed that an MDASI-HN-S cutoff score of ≥6 correlated best with EQ-5D VAS decline (LogWorth 2.7, p<0.001). Among 320 patients with available DICOM-RT plans, a higher mean dose to the contralateral anterior digastric muscle, intrinsic tongue muscles, and larynx was associated with moderate-severe dysphagia by both MDASI-HN-S and composite MDADI (all p <0.05). In long-term survivors of OPC following definitive RT, the single item dysphagia MDASI-HN-S question performed as well as the 20-item MDADI for discrimination of patient-reported dysphagia and QOL. Dose-response relationships to candidate ROIs were similar for the two questionnaires.

Impact of Head and Neck Cancer Treatment on Survivors' Mealtime Experience.

The objectives of the study were to develop a mealtime experience self-assessment questionnaire that was head and neck cancer (HNC) survivors-driven and based on the International Classification of Functioning, Disability and Health (ICF) framework, and to identify common mealtime issues reported by HNC survivors. Outcomes research. Mealtime issues reported by HNC survivors in prior research was synthesized and classified using the ICF framework to develop the content and structure of the Head and Neck Cancer Survivors' Assessment of Mealtimes (HNSAM). A total of 122 HNC survivors completed both HNSAM and M.D. Anderson Dysphagia Inventory (MDADI) to assess for concurrent validity, whereas 51% of participants completed a second HNSAM for test-retest reliability. The HNSAM scores were significantly correlated with the MDADI scores. Dysphagic participants (n = 45) had significantly higher HNSAM scores than the nondysphagic participants (n = 77). Principal component analysis revealed three factors that matched with the HNSAM subscales. Good internal consistency (Cronbach's α = 0.72-0.96) and test-retest reliability (intraclass correlation = 0.76-0.91) were found. Both dysphagic and nondysphagic participants reported difficulties with saliva-related issues and were not able to enjoy food/drinks that they previously enjoyed. HNC survivors experience mealtime changes after cancer treatment. These initial validity data support the potential for the HNSAM to help HNC survivors' identify changes to the mealtime experience. Validation of the English version of the tool is now required. 2c Laryngoscope, 129:1572-1578, 2019.

Changes in Patient-reported Swallow Function in the Long Term After Chemoradiotherapy for Oropharyngeal Carcinoma

AimsTo assess long-term patient-reported swallow function after chemoradiotherapy for oropharyngeal carcinoma and to evaluate the frequency of deterioration/improvement over years. Materials and methodsFifty-nine patients with oropharyngeal carcinoma treated with parotid-sparing intensity-modulated radiotherapy and concurrent chemotherapy between 2010 and 2012 had previously completed the MD Anderson Dysphagia Inventory (MDADI) at a median of 34 months (range 24–59) after treatment. An MDADI was posted to 55 alive and disease-free patients after a 30 month interval; 52/55 replies were received, a median of 64 months (range 52–88) after treatment; 27/52 (52%) had been managed with a prophylactic gastrostomy. A 10 point or greater change in the MDADI scores was defined as clinically significant. ResultsOverall, in the whole cohort, patient-reported swallow function showed a small absolute improvement in MDADI composite score on the second MDADI questionnaire (>5 years after treatment) compared with the first MDADI (>2 years after treatment); mean 68.0 (standard deviation 19.3) versus 64.0 (standard deviation 16.3), P = 0.021. Using the composite score, swallow function was stable over time in 29/52 (56%) patients; a clinically significant improvement in swallow function over time was noted in 17/52 (33%) patients; conversely 6/52 (12%) patients experienced a clinically significant deterioration with time. Abnormality of pre-treatment diet and a prophylactic gastrostomy correlated with an inferior MDADI composite score on the later questionnaire (P = 0.029 and P = 0.044, respectively). ConclusionsLong-term dysphagia is prevalent >5 years after treatment. Although long-term swallow function is stable in most patients, it is not static in a minority. On MDADI composite summary scores, 33% of patients experienced an improvement, whereas 12% deteriorated with time. Further investigation is needed to determine underlying mechanisms behind these divergent outcomes.

Long term patient reported swallowing function following chemoradiotherapy for oropharyngeal carcinoma

Background and purposeLimited data are available to inform on long term swallowing outcomes following concurrent chemoradiotherapy for oropharyngeal carcinoma. The aims of this study are to determine long term patient-reported swallowing outcomes across two large UK centres in routine clinical practice and identify associated factors. Material and methodsAll patients treated for oropharyngeal squamous cell carcinoma with concurrent chemoradiotherapy, and irradiation of the bilateral neck, between 2011 and 2013 were identified. Those requiring therapeutic enteral feeding prior to treatment, or having subsequent disease relapse, were excluded from the study. Patients were sent postal invitations to complete the MD Anderson Dysphagia Inventory (MDADI), at least two years following completion of treatment. ResultsCompleted MDADI were received from 201/242 eligible patients (83%) at a median of 3.4 years (range 2–5) post treatment. Median composite MDADI score was 68.4. 64 (32%) had composite MDADI <60 classed as ‘poor’ function, 76 (38%) scores ≥60–<80 classed as adequate function, and 61 (31%) had scores ≥80 classed as optimal function. Patients with normal and abnormal pre-treatment diet had median composite MDADI scores of 70.5 versus 47.4 respectively. Patients who did not require enteral feeding during treatment and those who did had median composite MDADI scores of 76.3 versus 65.3 respectively. On multivariate analysis poorer performance status, abnormal pre-treatment diet, and use of enteral feeding during radiotherapy were all significantly associated with lower composite, global and subscale MDADI scores. ConclusionsPatient reported swallowing dysfunction remains common in the long term post-chemoradiotherapy. Impaired pre-treatment diet and use of enteral feeding during treatment are key factors associated with poorer swallowing outcomes.

Two-Year Prospective Patient Reported Outcomes Related to Dysphagia After Intensity Modulated Proton Therapy for Oropharyngeal Cancer

Characterize longitudinal change in swallowing related quality of life during and after intensity modulated proton therapy (IMPT) for oropharyngeal cancer. The MD Anderson Dysphagia Inventory (MDADI) was administered prospectively at baseline, end of IMPT, and 10 weeks, and 6 , 12, and 24 months after IMPT as part of a prospective proton therapy registry. MDADI 19-item composite and subscale scores were plotted longitudinally. Pairwise tests were Bonferroni corrected for multiple comparisons (P<.003). Sixty-six patients with a mean age of 62 were included. Almost all had stage III/IV disease (96%) and 71% were treated with concurrent chemotherapy. A majority had T1-T2 primary tumors (80%); 84% had p16 positive disease and 41% were never smokers. Mean composite MDADI was 88.2±13.4 at baseline, dropping significantly to a nadir of 59.4±14.2 at end of IMPT (P<.001) with significant partial recovery by 10 weeks post-IMPT to 74.9±14.2 (P<.001) with stable average performance thereafter through 2 years (P>.003 compared to previous time point). Poor MDADI (score<60) were reported in 7%, 61%, 20%, and 13% of patients at baseline, end-IMPT, 10 weeks, and 2 years after IMPT, with 14% of patients showing persistently depressed MDADI Δ>20 at 2 years. Physical subscale performed lower than emotional or functional subscales at all points. Herein, we provide novel, prospective benchmark data suggesting potentially early recovery of perceived swallowing per MDADI after IMPT in OPC survivors. Expected performance patterns lend support to validity of MDADI after proton therapy.

Relationship between swallowing-related quality of life and fiberoptic endoscopic evaluation of swallowing in patients who underwent open partial horizontal laryngectomy.

Several studies have previously analyzed the relationship between QOL and signs of dysphagia in patients treated for head and neck cancer and have reported heterogeneous findings. To the best of our knowledge, no study has previously investigated this relationship among patients who underwent open partial horizontal laryngectomy (OPHL). The aim of the study is to determine if patient-reported swallowing-related QOL can discriminate between safe and unsafe swallowing in OPHL patients. 92 type I, type II, and type III OPHL patients at least 6months postoperatively were recruited. Fiberoptic endoscopic evaluation of swallowing (FEES) was conducted using liquids, semisolids, and solids. FEES recordings were assessed through the penetration-aspiration scale, the pooling score and the dysphagia outcome and severity scale. All patients completed the MD Anderson dysphagia inventory (MDADI). Kruskal-Wallis test and post-hoc Mann Whitney U test were performed to compare MDADI scores among different level of airway invasion, post-swallow pharyngeal residue's degree and overall dysphagia severity. ROC curves were generated to determine diagnostic accuracy of the MDADI. Statistically significant differences in MDADI scores were found between level of airway invasion with semisolids and solids, degree of pharyngeal residue with solids, and severity of dysphagia. MDADI showed significant diagnostic accuracy only in the detection of moderate/severe pharyngeal residue and severe dysphagia; however, sensitivity and specificity were low. Investigating patients' perception of swallowing impairment and swallowing-related QOL is not sufficient to discriminate safe and unsafe swallowing in OPHL patients.

Voice and swallowing outcomes following reoperative anterior cervical discectomy and fusion with a 2-team surgical approach.

OBJECTIVE Dysphagia and vocal cord palsy (VCP) are common complications after anterior cervical discectomy and fusion (ACDF). The reported incidence rates for dysphagia and VCP are variable. When videolaryngostroboscopy (VLS) is performed to assess vocal cord function after ACDF procedures, the incidence of VCP is reported to be as high as 22%. The incidence of dysphagia ranges widely, with estimates up to 71%. However, to the authors' knowledge, there are no prospective studies that demonstrate the rates of VCP and dysphagia for reoperative ACDF. This study aimed to investigate the incidence of voice and swallowing disturbances before and after reoperative ACDF using a 2-team operative approach with comprehensive pre- and postoperative assessment of swallowing, direct vocal cord visualization, and clinical neurosurgical outcomes. METHODS A convenience sample of sequential patients who were identified as requiring reoperative ACDF by the senior spinal neurosurgeon at the University of Alabama at Birmingham were enrolled in a prospective, nonrandomized study during the period from May 2010 until July 2014. Sixty-seven patients undergoing revision ACDF were enrolled using a 2-team approach with neurosurgery and otolaryngology. Dysphagia was assessed both preoperatively and postoperatively using the MD Anderson Dysphagia Inventory (MDADI) and fiberoptic endoscopic evaluation of swallowing (FEES), whereas VCP was assessed using direct visualization with VLS. RESULTS Five patients (7.5%) developed a new postoperative temporary VCP after reoperative ACDF. All of these cases resolved by 2 months postoperatively. There were no new instances of permanent VCP. Twenty-five patients had a new swallowing disturbance detected on FEES compared with their baseline assessment, with most being mild and requiring no intervention. Nearly 60% of patients showed a decrease in their postoperative MDADI scores, particularly within the physical subset. CONCLUSIONS A 2-team approach to reoperative ACDF was safe and effective, with no new cases of VCP on postoperative VLS. Dysphagia rates as assessed through the MDADI scale and FEES were consistent with other published reports.

Two-Year Prospective Patient Reported Outcomes Related to Dysphagia After Intensity Modulated Proton Therapy for Oropharyngeal Cancer

Characterize longitudinal change in swallowing related quality of life during and after intensity modulated proton therapy (IMPT) for oropharyngeal cancer. The MD Anderson Dysphagia Inventory (MDADI) was administered prospectively at baseline, end of IMPT, and 10 weeks, 6-, 12- and 24-month after IMPT as part of a prospective proton therapy registry. MDADI 19-item composite and subscale scores were plotted longitudinally. Pairwise tests were Bonferroni corrected for multiple comparisons (p<0.003). Sixty six patients with a mean age of 62 were included. Almost all had stage III/IV disease (96%) and 71% were treated with concurrent chemotherapy. A majority had T1-T2 primary tumors (80%); 84% had p16 positive disease and 41% were never smokers. Mean composite MDADI was 88.2±13.4 at baseline, dropping significantly to a nadir of 59.4±14.2 at end of IMPT (p<0.001) with significant partial recovery by 10 weeks post-IMPT to 74.9±14.2 (p<0.001) with stable average performance thereafter through 2 years (p>0.003 compared to previous time point). Poor MDADI (score<60) were reported in 7%, 61%, 20%, and 13% of patients at baseline, end-IMPT, 10-weeks, and 2-years after IMPT, with 14% of patients showing persistently depressed MDADI Δ>20 at 2 years. Physical subscale performed lower than emotional or functional subscales at all points. Herein, we provide novel, prospective benchmark data suggesting potentially early recovery of perceived swallowing per MDADI after IMPT in OPC survivors. Expected performance patterns lend support to validity of MDADI after proton therapy.

Quantitative Evaluation of Head and Neck Cancer Treatment–Related Dysphagia in the Development of a Personalized Treatment Deintensification Paradigm

Totest the hypothesis that quantifying swallow function with multiple patient-reported outcome (PRO) instruments is an important strategy to yield insights in the development of personalized deintensified therapies seeking to reduce the risk of head and neck cancer (HNC) treatment-related dysphagia (HNCTD). Irradiated HNC subjects seen in follow-up care (April 2015 to December 2015) who prospectively completed the Sydney Swallow Questionnaire (SSQ) and the MD Anderson Dysphagia Inventory (MDADI) concurrently on the web interface to our Oncospacedatabase were evaluated. A correlation matrix quantified the relationship between the SSQ and MDADI. Machine-learning unsupervised cluster analysis using the elbow criterion and CLUSPLOT analysis to establish its validity was performed. We identified 89 subjects. The MDADI and SSQ scores were moderately but significantly correlated (correlation coefficient -0.69). K-means cluster analysis demonstrated that 3 unique statistical cohorts (elbow criterion) could be identified with CLUSPLOT analysis, confirming that 100% of variances were accounted for. Correlation coefficients between the individual items in the SSQ and the MDADI demonstrated weak to moderate negative correlation, except for SSQ17 (quality of life question). Pilot analysis demonstrates that the MDADI and SSQ are complementary. Three unique clusters of patients can be defined, suggesting that a unique dysphagia signature for HNCTD may be definable. Longitudinal studies relying on only a single PRO, such as MDADI, may be inadequate for classifying HNCTD.

One-Year Swallowing Outcomes in Patients Treated with Prophylactic Gabapentin During Radiation-Based Treatment for Oropharyngeal Cancer.

Recent investigations by our study team have demonstrated patients using gabapentin for pain management during chemoradiotherapy (CRT) do well maintaining swallowing during treatment with less need for narcotic pain medication, PEG dependence, weight loss, and short-term swallowing morbidity. The purpose of this investigation was to characterize the long-term swallowing function of these patients 1-year following treatment. Sequential patients receiving CRT for oropharyngeal cancer and concurrent gabapentin were evaluated 1-year following treatment for swallowing outcomes. Functional Oral Intake Scores (FOIS) were utilized to assess diet level. The MD Anderson Dysphagia Inventory (MDADI) was chosen to evaluate patient perception of swallowing function. Videofluoroscopic swallowing studies were completed approximately 1 year after treatment to assess physiologic outcomes as well as Penetration Aspiration Scores (PAS). Data from 26 consecutive participants were available for analysis. The majority of patients had advanced stage disease (Stage 3-4). No patients had a PEG tube 1-year following treatment, and the mean FOIS score was 6.83. Pharyngeal deficits were infrequent with reduced pharyngeal constriction and prominence/early closure of cricopharyngeus predominating. Mean PAS score was 1.5, indicating that the majority of patients had either no laryngeal penetration/aspiration, or transient penetration that was fully cleared. Mean MDADI score was 85.52, indicating that, in general, patients perceived their swallowing to be minimally impaired. Patients receiving gabapentin pain management as part of a comprehensive dysphagia prevention protocol during CRT have excellent long-term swallowing outcomes as reflected in diet levels, physiologic functioning, and patient-perceived quality of life.

Functional Outcomes after Salvage Transoral Laser Microsurgery for Laryngeal Squamous Cell Carcinoma.

Transoral laser microsurgery (TLM) has been increasingly used in lieu of total laryngectomy to treat malignancy after definitive radiation. There are few data in the literature regarding functional outcomes. We retrospectively reviewed voice and swallowing outcomes in patients who underwent TLM for recurrent laryngeal carcinoma. Case series with chart review. Tertiary care center. Forty-two patients were identified with recurrent squamous cell carcinoma of the larynx after definitive radiation therapy from 2001 to 2013: 28 patients with glottic recurrence and 14 with supraglottic recurrence. Swallowing outcomes were evaluated by gastrostomy tube dependence, the MD Anderson Dysphagia Inventory, and the Functional Oral Intake Scale. Voice outcomes were evaluated by the Voice Handicap Index and observer-rated perceptual analysis. No significant difference was noted between mean pre- and postoperative MD Anderson Dysphagia Inventory scores: 78.25 and 74.9, respectively (P = .118, t = 1.6955). Mean Functional Oral Intake Scale scores after TLM for supraglottic and glottic recurrences were 6.4 and 6.6, respectively. Of 42 patients, 17 (40.5%) required a gastrostomy tube either during radiation or in conjunction with the salvage procedure. Of 17 patients, 15 resumed sufficient oral diet for tube removal. Patients' mean Voice Handicap Index score did increase from 34.3 to 51.5 (P = .047), and their mean perceptual score did decrease from 60.0 to 45.3 (P = .005). However, at 1-year follow-up, there was no significant difference in perceptual score: 61.1 to 57.1 (P = .722). TLM is a successful surgical option for recurrent laryngeal cancer with acceptable functional outcomes.

Predicting two-year longitudinal MD Anderson Dysphagia Inventory outcomes after intensity modulated radiotherapy for locoregionally advanced oropharyngeal carcinoma.

To determine the factors associated with longitudinal patient-reported dysphagia as measured by the MD Anderson Dysphagia Inventory (MDADI) in locoregionally advanced oropharyngeal carcinoma (OPC) survivors treated with split-field intensity modulated radiotherapy (IMRT). Retrospective patient analysis. A retrospective analysis combined data from three single-institution clinical trials for stage III/IV head and neck carcinoma. According to trial protocols, patients had prospectively collected MDADI at baseline, 6, 12, and 24 months after treatment. OPC patients with baseline and at least one post-treatment MDADI were included. Longitudinal analysis was completed with multivariate linear mixed effects modeling. There were 116 patients who met inclusion criteria. Mean baseline MDADI composite was 88.3, dropping to 73.8 at 6 months, and rising to 78.6 and 83.3 by 12 and 24 months, respectively (compared to baseline, all P < .0001). Tumor stage and smoking status were significant predictors of longitudinal MDADI composite scores. Patients with T1, T2, and T3 tumors had 15.9 (P = .0001), 10.9 (P = .0049), and 7.5 (P = .0615), respectively, higher mean MDADI composite than those with T4 tumors, and current smokers had a 9.4 (P = .0007) lower mean MDADI composite than never smokers. Patients report clinically meaningful dysphagia early after split-field IMRT for locoregionally advanced OPC that remains apparent 6 months after treatment. MDADI scores recover slowly thereafter, but remain depressed at 24 months compared to baseline. Higher tumor stage and smoking status are important markers of patient-reported function through the course of treatment, suggesting these are important groups for heightened surveillance and more intensive interventions to optimize swallowing outcomes. 4 Laryngoscope, 127:842-848, 2017.

Long-Term, Prospective Performance of the MD Anderson Dysphagia Inventory in “Low-Intermediate Risk” Oropharyngeal Carcinoma After Intensity Modulated Radiation Therapy

To characterize long-term MD Anderson Dysphagia Inventory (MDADI) results after primary intensity modulated radiation therapy (IMRT) for oropharyngeal carcinoma (OPC) among patients with "low-intermediate risk" OPC who would be eligible for current trials (eg, ECOG 3311, NRG HN002, CRUK PATHOS). A retrospective pooled analysis combined data from 3 single-institution clinical trials for advanced-stage head and neck carcinoma. Inclusion criteria were clinical stage III/IV OPC (T1-2/N1-2b, T3/N0-2b) treated with definitive split-field IMRT and prospectively collected MDADI at baseline and at least 1 posttreatment interval available in trial databases. Patients were sampled to represent likely human papillomavirus (HPV)-associated disease (HPV+/p16+ or <10 pack-years if HPV/p16 unknown). The MDADI composite scores were collected at baseline and 6, 12, and 24months after treatment. Pairwise tests were Bonferroni corrected for multiple comparisons. Forty-six patients were included. All received bilateral neck irradiation with a median dose of 70Gy and systemic therapy (57% concurrent, 43% induction only). Overall the mean baseline MDADI composite score was 90.1, dropping to 74.6 at 6months (P<.0001) and rising to 78.5 (P<.0001) and 83.1 (P=.002) by 12 and 24months relative to baseline, respectively, representing a clinically meaningful drop in MDADI scores at 6months that partially recovers by 24months (6 vs 24months, P=.05). Poor MDADI scores (composite <60) were reported in 4%, 11%, 15%, and 9% of patients at baseline and 6, 12, and 24months, respectively. Fifteen percent of patients had a persistently depressed composite score by at least 20 points at the 24-month interval. "Low-intermediate risk" patients with OPC treated with laryngeal/esophageal inlet dose-optimized split-field IMRT are highly likely to report recovery of acceptable swallowing function in long-term follow-up. Only 15% report poor swallowing function and/or persistently depressed MDADI at 12months or more after IMRT. These data serve as a benchmark future trial design and endpoint interpretation.

Swallowing outcome measures in head and neck cancer – How do they compare?

Dysphagia is a common and debilitating side effect of chemoradiotherapy. Assessment is difficult; swallowing is multifactorial and studies choose from a range of dysphagia assessments. This study intended to investigate the relationship between swallowing assessments of dysphagia in a cohort of patients and to evaluate whether clinical swallowing measures can predict patient reported swallowing outcomes. One hundred and seventy-three head and neck cancer patients from two teaching hospitals were recruited prospectively over 25 months. At three months follow-up patients were assessed using Rosenbeck's Penetration-Aspiration Scale (PAS), The 100 ml Water Swallow Test (WST), The Performance Status Scale: Normalcy of Diet and the MD Anderson Dysphagia Inventory (MDADI). The highest correlation was observed between the MDADI and Normalcy of Diet (rho 0.68) and the lowest between the MDADI and the PAS (rho 0.34). Using multiple regression the PAS and WST accounted for 44% of the variance in the MDADI scores (R2 = 0.44, F = 37.8, p < 0.001). On stepwise regression, the model only retained the Normalcy of Diet scores (R2 = 0.42, F=107.9, p < 0.001). Separating the PAS into subgroups, those with no penetration or aspiration on the PAS scored significantly higher on the MDADI (p = <0.001). Patient reported swallowing outcomes were strongly aligned with diet restrictions but poorly aligned with clinical assessment. The WST, however, was more correlated than the PAS score, representing a more functional assessment. Clinical dysphagia, associated with significant morbidity, and patient reported dysphagia related to quality of life are not interchangeable and must be measured separately.