Pretreatment Dysphagia Research Articles

275. SAFETY AND TREATMENT RESULTS OF SELF-EXPANDABLE METAL STENT (SEMS) PLACEMENT FOR ESOPHAGEAL DISEASE

Abstract Background Self-expandable metal stent (SEMS) placement for esophageal strictures and fistulas caused by malignant tumors has been reported from various institutions as a relatively minimally invasive and safe palliative treatment. SEMS placement is often selected for cancer-bearing patients whose general condition has already deteriorated, but there are many unknowns regarding the risks and benefits of placement. Methods We retrospectively examined swallowing scores, oral intake status, complications and prognosis for 41 cancer-bearing patients who underwent SEMS placement in our hospital from 2011 to 2023. Results There were 29 men and 12 women, with a median age of 77 years. The types of cancer were esophageal cancer / gastric cancer / lung cancer / others in 22/12/3/4 cases, respectively. The reason for stent placement was stricture / fistula in 39/2 cases. Stent placement was successful in 40 cases (97.6%), and complications were observed in 7 cases (17.1%), including bleeding, displacement, and aspiration pneumonia in 2, 3, and 2 cases, respectively. Three patients underwent second stent placement for restenosis, and the median time to restenosis was 57 days. After stent placement, dysphagia score improved in 30 cases (78.9%). After stent placement 35 patients (87.5%) chose palliative treatment and the median survival time (MST) was 1.7 months (0.2-10.8). Comparing patients with PS≦2 and PS≧3 using performance status (PS) at the time of stent placement, patients with PS≦2 significantly ate more after stent placement (median amount of oral intake; 80 % vs. 40%, p=0.037), and the survival period was longer (MST; 3.1 months vs. 1.3 months, p=0.0018). Univariate analysis on the risk of complications by stent placement showed that chemotherapy history, radiotherapy history, and pretreatment dysphagia score were not risk factors, but poor PS (≥3) was the only significant risk factor (Odds ratio: 12.5, 95% CI:1.3-117, p=0.027). Conclusion Esophageal stents are less invasive treatment than any other palliative methods, like esophageal bypass or radiation therapy for patients who strongly desire oral intake. However in patients with poor general condition the risk of complications is high and the survival period is not long, so it should be performed after fully explaining the risks and benefits.

Prevalence and Predicting Factors of Pretreatment Dysphagia in Veterans With Head and Neck Cancer: A Pilot Study

Background: Dysphagia is a common sequela in individuals with a diagnosis of head and neck cancer. However, the prevalence and predicting factors for pretreatment dysphagia have not been well identified in the literature. A priori knowledge of the presence of a pretreatment dysphagia is advantageous and can have clinically significant implications for management of this patient population. The ability to predict pretreatment dysphagia in this population would allow more targeted interventions and potential improvements in clinical outcomes. Participants: This pilot study investigated the prevalence and predicting factors of pretreatment dysphagia in 67 veterans with head and neck cancer through the West Haven, CT, Veterans Affairs cancer database. Method: Data for this study were acquired via retrospective medical record review. Results: The prevalence of pretreatment dysphagia in our sample was found to be 49.3%. Age and pretreatment percutaneous endoscopic gastrostomy placement were found to have a statistically significant relationship with pretreatment dysphagia. Stage of cancer diagnosis and the diagnosis of pretreatment dysphagia were found to have a statistically significant relationship with posttreatment dysphagia. Conclusions: Findings offer important preliminary data and clinical considerations about this issue and serve as a foundation for future research. There are a limited number of factors associated with pretreatment dysphagia, and clinicians should consider a conservative referral approach when considering the need for dysphagia assessment prior to the initiation of oncologic treatment.

Long-Term Swallowing Outcome and Dysphagia in Advanced Staged Head and Neck Squamous Cell Carcinomas after Radiotherapy.

Objective: To evaluate the impact of radiotherapy (RT) on dysphagia and long-term swallowing outcome in patients with stage III and IV head and neck squamous cell carcinomas (HNSCCs). Material and Methods: Between 2005 and 2008, 189 patients with HNSCCs underwent primary or adjuvant RT in a curative setting. Long-term swallowing outcome was evaluated in 50 patients. Among them, 26 were further eligible for prospective analysis of long-term swallowing and dysphagia outcome. Medical charts were retrospectively reviewed regarding pre- and post-treatment dysphagia (3 months after last irradiation setting) as well as persisting long-term dysphagia (2019–2021). Results: Pre-treatment dysphagia was observed in 24 (48%) of 50 patients, particularly in oropharyngeal or hypopharyngeal stage III–IV tumors (OR 9.3; p = 0.003). Conversely, 46 patients (92%) complained about post-treatment dysphagic symptoms, which were more commonly seen in patients with positive neck nodes (OR 10.5; p = 0.037). The post-treatment dysphagia rate dropped from 92% to 24% (p < 0.001) during surveillance, which was significantly linked to xerostomia (OR 5.77; p = 0.019), dysgeusia (OR 9.9; p = 0.036) and free flap reconstruction (OR 6.1; p = 0.022). Conclusion: Pretreatment dysphagia is common in advanced stage HNSCCs and almost all patients complain about dysphagia at the end of RT. Importantly, applied RT protocols did not affect long-term dysphagia, which improves significantly in the majority of patients over time. Meeting Information: Preliminary results have been presented at the 65th Annual Meeting of the Austrian Society of Otorhinolaryngology, 22–26 September 2021, Austria.

Pre-treatment dysphagia in head-and-neck cancer patients

HintergrundSowohl der Schluck- als auch der Ernährungsstatus bei Kopf-Hals-Tumor(KHT)-Patienten nach einer onkologischen Therapie sind gut untersucht. Prätherapeutisch werden sie aber selten thematisiert, obwohl diese den Erfolg einer onkologischen Therapie nachhaltig beeinflussen können.Ziel der ArbeitZiel dieser Arbeit ist die systematische Erfassung des Schluck- und Nutritionsstatus von KHT-Patienten vor Beginn einer onkologischen Therapie.Material und MethodenBei 102 Patienten wurden zur objektiven Erfassung des Schluckvermögens endoskopisch die Penetration/Aspiration via PA-Skala (PAS), die Oralisierungseinschränkung (Functional Oral Intake Scale, FOIS) und die Versorgungsrelevanz (VRS) erhoben. Die subjektive Einschätzung des Schluckvermögens erfolgte via Fragebogen gEAT-10 („German EAT-10“), die orientierende Erfassung des Nutritionsstatus via Body-Mass-Index (BMI). Schluckvermögen und BMI wurden uni- und multivariat auf mögliche Einflussfaktoren geprüft.ErgebnisseAuffällige PAS-, FOIS- und VRS-Werte wurden bei ≤ 15 % der Patienten festgestellt. Der BMI war häufiger zu hoch als zu niedrig. Das objektiv erfasste Schluckvermögen war v. a. vom Tumorstadium abhängig und korrelierte mittelstark mit gEAT-10. Der gEAT-10-Gesamtscore war auffällig. Der Nutritionsstatus war von Patientengeschlecht und VRS abhängig.SchlussfolgerungPrätherapeutisch zeigte sich bei der Mehrzahl der Patienten keine Dysphagie oder Malnutrition. Ein auffälliges Schluckvermögen war mit höheren Tumorstadien assoziiert, eine Malnutrition mit weiblichem Geschlecht und Versorgungsrelevanz. Nichtsdestotrotz sollte hinsichtlich moderner onkologischer Therapie der Schluck- und Nutritionsstatus bei KHT-Patienten bereits prätherapeutisch systematisch erfasst werden, um ein optimales Patienten-Outcome zu erzielen.

Chemoradiotherapy but Not Radiotherapy Alone for Larynx Preservation in T3. Considerations from a German Observational Cohort Study.

Simple SummaryFor advanced laryngeal carcinoma, primary radiotherapy with or without chemotherapy (pCRT or pRT) is used as an alternative to total laryngectomy (TL) to preserve a functional larynx. For advanced laryngeal cancer (T4), poorer survival has been reported after nonsurgical treatment. Is there a need to fear worse survival in moderately advanced tumors (T3)? The outcomes after pRT, pCRT, or surgery were evaluated in 121 patients with T3 laryngeal cancers. pCRT and TL with risk-adopted adjuvant (chemo)radiotherapy (TL ± a(C)RT) yielded results without a significant survival difference. However, after pRT alone, survival was significantly poorer than after TL ± a(C)RT. Thus, according to our data and supported by the literature, pCRT instead of pRT alone is recommended for T3 laryngeal cancers. According to the literature, this recommendation also applies to bulky tumors (6–12 mm), vocal cord fixation, at least minimal cartilage infiltration, and advanced N stage. TL ± a(C)RT instead of larynx preservation should be considered if any of these factors is present and chemotherapy is prohibited; in cases with a tumor volume > 12 mm, severe forms of vocal cord fixation or cartilage infiltration; or when the patient needs a feeding tube or a tracheotomy before the onset of therapy.For advanced laryngeal cancers, after randomized prospective larynx preservation studies, nonsurgical therapy has been applied on a large scale as an alternative to laryngectomy. For T4 laryngeal cancer, poorer survival has been reported after nonsurgical treatment. Is there a need to fear worse survival also in T3 tumors? The outcomes of 121 T3 cancers treated with pCRT, pRT alone, or surgery were evaluated in an observational cohort study in Germany. In a multivariate Cox regression of the T3 subgroup, no survival difference was noted between pCRT and total laryngectomy with risk-adopted adjuvant (chemo)radiotherapy (TL ± a(C)RT) (HR 1.20; 95%-CI: 0.57–2.53; p = 0.63). However, survival was significantly worse after pRT alone than after TL ± a(C)RT (HR 4.40; 95%-CI: 1.72–11.28, p = 0.002). A literature search shows that in cases of unfavorable prognostic markers (bulky tumors of 6–12 ccm, vocal cord fixation, minimal cartilage infiltration, or N2–3), pCRT instead of pRT is indicated. In cases of pretreatment dysphagia or aspiration requiring a feeding tube or tracheostomy, gross or multiple cartilage infiltration, or tumor volume > 12 ccm, outcomes after pCRT were significantly worse than those after TL. In these cases, and in cases where pCRT is indicated but the patient is not suitable for the addition of chemotherapy, upfront total laryngectomy with stage-appropriate aRT is recommended even in T3 laryngeal cancers.

Effect of Pretreatment Dysphagia on Postchemoradiation Swallowing Function in Head and Neck Cancer.

Chemoradiation therapy (CRT) for head and neck cancer can have profound effects on swallowing function. Identification of risk factors for development of swallowing dysfunction after CRT may improve allocation of preventive strategies. The purpose of this study is to determine the association between pre-CRT dysphagia and post-CRT swallowing dysfunction. Retrospective cohort study. Academic medical center. Patients with head and neck cancer were evaluated before and 3 months after CRT. Dysphagia was assessed with the Eating Assessment Tool (EAT-10). Swallowing dysfunction was evaluated by a videofluoroscopic swallow study and the Penetration-Aspiration Scale and swallowing safety was evaluated by the Functional Oral Intake Scale. The association between pre-CRT EAT-10 scores and post-CRT swallowing dysfunction was evaluated. The mean ± SD post-CRT Functional Oral Intake Scale score was 6.5 ± 1.2 for individuals with a pre-CRT EAT-10 score <3 and 5.3 ± 1.9 for those with a pre-CRT EAT-10 score ≥3 (P < .001). The mean post-CRT Penetration-Aspiration Scale score was 2.2 ± 1.5 for individuals with a pre-CRT EAT-10 score <3 and 3.8 ± 2.6 for those with a pre-CRT EAT-10 score ≥3 (P < .001). After multivariate analysis adjusting for age, tumor subsite, T classification, and primary surgery, pre-CRT dysphagia (EAT-10 ≥3) was an independent predictor of post-CRT aspiration (odds ratio, 4.19 [95% CI, 1.08-16.20]; P = .04) and feeding tube dependence (odds ratio, 3.54 [95% CI, 1.01-12.33]; P = .04). The presence of dysphagia before chemoradiation for head and neck cancer is an independent predictor of swallowing dysfunction after completion of therapy. These results may help target intervention toward preventing swallowing dysfunction in high-risk individuals.

Factors Influencing the Development of Pneumonia in Patients With Head and Neck Cancer: A Meta-analysis.

The aim of this study was to identify factors that are associated with the occurrence of pneumonia in patients with head and neck cancer (HNC) after treatment. PubMed, Scopus, OVID, and Cochrane Library from inception to November 26, 2019. A systematic review in accordance with the PRISMA guidelines and an assessment of bias were performed. Included studies reported on the risk factors of pneumonia development after HNC treatment via odds ratios and subdistribution hazard ratios from regression analysis. Fifteen studies were included, comprising 30,962 patients with a mean age of 70 years (range, 19-95 years). Of these, 71.6% are male. The results of our study indicate that the following were independent risk factors contributing to the development of pneumonia: male sex, habitual alcohol consumption, poor oral hygiene before treatment, pretreatment dysphagia, hypopharynx and nasopharynx tumor sites, use of radiotherapy with or without chemotherapy versus surgery alone, addition of chemotherapy to radiotherapy, reirradiation, neck dissection, increased duration of tracheotomy, and use of sedatives for sleeping. Multiple patient-, tumor-, and treatment-specific risk factors were identified in predicting pneumonia. Recognition of these risk factors early on may help prevent or at least detect pneumonia in this vulnerable group of patients.

Palliative Radiotherapy Versus Esophageal Stent Placement in the Management of Patients With Metastatic Esophageal Cancer.

Patients with advanced esophageal cancer often experience pain and dysphagia, yet the optimal palliative management remains unclear. This retrospective study evaluated outcomes and adverse effects of palliative radiotherapy (RT) compared with esophageal stenting among a cohort of U.S. veterans with metastatic esophageal cancer. We identified 1,957 veterans in the United States with metastatic esophageal cancer who received palliative RT to the esophagus or esophageal stenting, and assessed the risks of severe adverse effects, including esophageal fistula formation, perforation, obstruction, hemorrhage, and esophagitis. We determined palliative efficacy by evaluating pain and dysphagia scores before and after intervention. Multivariable analyses were used to control for potential confounding factors. In our cohort, 1,593 patients underwent RT and 364 underwent esophageal stenting. The cumulative incidence of any severe adverse effect at 6 months was higher among patients who received stents compared with those who received RT (21.7% vs 12.4%; P<.0010). In multivariable analysis, patients who received stents had an increased risk of any severe adverse effect, including fistula, perforation, and hemorrhage (all P<.0500). Multivariable analysis also showed that, compared with stenting, RT was associated with more rapid and durable pain relief (P<.0010) with no difference in relief of dysphagia over time when accounting for pretreatment dysphagia scores (P=.1029). Compared with esophageal stenting, RT was associated with a decreased risk of adverse effects, greater pain relief, and equivalent relief of moderate to severe dysphagia over time. Unmeasured patient- or tumor-related factors could have influenced the choice of intervention, thereby impacting our study outcomes. To our knowledge, this is the largest study to date analyzing the comparative risks and benefits of palliative RT and esophageal stenting among patients with metastatic esophageal cancer.

Using experience-based co-design to improve the pre-treatment care pathway for people diagnosed with head and neck cancer.

Recent studies have highlighted that people diagnosed with head and neck cancer (HNC) have complex information needs. They are subject to multiple clinical appointments with numerous healthcare professionals in preparation for their treatment. Speech and language therapists (SLTs) are core members of the HNC multidisciplinary team, providing assessment, prehabilitation and counselling regarding potential treatment effects on the critical functions, including swallowing and communication. We believed the purpose of the pre-treatment speech-language therapy (SLT) consultation within this pathway is not well understood by patients. Whilst the benefits of prophylactic swallowing exercise prescriptions continue to be explored, adherence is a frequently cited challenge in clinical trials. We sought to enhance pre-treatment dysphagia services for patients with head and neck cancer (HNC) undergoing chemoradiation. A participatory action research approach called experience-based co-design (EBCD) was undertaken at a tertiary cancer hospital in the UK. People who had previous radical radiation treatment for head and neck cancer and staff members within the head and neck unit were recruited to take part in in-depth, one-to-one interviews about their experiences of the pre-treatment SLT head and neck radiation clinic. Patient interviews were video-recorded, analysed and edited down to a 30min 'trigger' film. At a subsequent patient feedback event, the film was shown and an 'emotional mapping' exercise was undertaken. Through facilitated discussion, patient priorities for change were agreed and recorded. At a staff feedback event, key themes from the staff interviews were discussed and priority areas for change identified. The project culminated in a joint patient and staff event where the film was viewed, experiences shared and joint priorities for change agreed. Task and finish groups were developed to implement these changes. Seven patients and seven staff members participated. All seven patients had undergone radical (chemo-) radiation for HNC. At least 2months had elapsed since their final treatment date and all participants were within 9months of their definitive treatment. Staff members comprised a radiation oncologist, two clinical nurse specialists, two head and neck dietitians and two speech-language therapists. Patients reported that overall, their experience of the pre-treatment clinic is positive. Patients value experienced staff, consistency of staff and the messages they provide and a team approach. Patients highlighted the need for different information methods including online/digital information resources and further information regarding the longer-term effects of treatment. Patients valued the purposes of prophylactic exercises and again advocated for supporting resources to be available in a range of online/digital media. Staff members raised the need for flexibility in appointment times and clearer messaging as to the rationale for a pre-treatment SLT appointment, including a rebranding of the SLT service. Seven key areas for improvement were identified jointly by patients and staff members including revision of patient and carer information, development of a patient experience video, information on timelines for recovery, a buddy system for patients before, during and after treatment, flexibility of appointment scheduling, seamless transfer of care between settings and SLT department rebranding. Joint patient and staff task and finish groups were initiated to work on these seven priority areas. We have worked in partnership with patients to co-design pre-treatment dysphagia services which are accessible and meet the individuals' needs. Task and finish groups are ongoing with staff and patients are working together to address priority areas for change. This work provides a good example for other centres who may wish to engage in similar activities.

Utility of a Clinical Decision Support System in Weight Loss Prediction After Head and Neck Cancer Radiotherapy.

To evaluate the utility of a clinical decision support system (CDSS) using a weight loss prediction model. A prediction model for significant weight loss (loss of greater than or equal to 7.5% of body mass at 3-month post radiotherapy) was created with clinical, dosimetric, and radiomics predictors from 63 patients in an independent training data set (accuracy, 0.78; area under the curve [AUC], 0.81) using least absolute shrinkage and selection operator logistic regression. Four physicians with varying experience levels were then recruited to evaluate 100 patients in an independent validation data set of head and neck cancer twice (ie, a pre-post design): first without and then with the aid of a CDSS derived from the prediction model. At both evaluations, physicians were asked to predict the development (yes/no) and probability of significant weight loss for each patient on the basis of patient characteristics, including pretreatment dysphagia and weight loss and information from the treatment plan. At the second evaluation, physicians were also provided with the prediction model's results for weight loss probability. Physicians' predictions were compared with actual weight loss, and accuracy and AUC were investigated between the two evaluations. The mean accuracy of the physicians' ability to identify patients who will experience significant weight loss (yes/no) increased from 0.58 (range, 0.47 to 0.63) to 0.63 (range, 0.58 to 0.72) with the CDSS ( P = .06). The AUC of weight loss probability predicted by physicians significantly increased from 0.56 (range, 0.46 to 0.64) to 0.69 (range, 0.63 to 0.73) with the aid of the CDSS ( P < .05). Specifically, more improvement was observed among less-experienced physicians ( P < .01). Our preliminary results demonstrate that physicians' decisions may be improved by a weight loss CDSS model, especially among less-experienced physicians. Additional study with a larger cohort of patients and more participating physicians is thus warranted for understanding the usefulness of CDSSs.

Short‐ and long‐term outcomes of oropharyngeal cancer care in the elderly

To examine associations between pretreatment variables, short-term and long-term swallowing and airway impairment, and survival in elderly patients (age > 65 years) treated for oropharyngeal squamous cell cancer (SCCA). Retrospective analysis of Surveillance, Epidemiology, and End Results (SEER)-Medicare data. Longitudinal data from 666 patients diagnosed with oropharyngeal SCCA from 2004 to 2007 were evaluated using cross-tabulations, multivariate logistic regression, and survival analysis. Dysphagia (odds ratio [OR] = 1.3, 1.0-1.7), esophageal stricture (OR = 5.5, 2.6-11.9), and airway obstruction (OR = 1.6, 1.1-2.2) increased 1 year after treatment. The odds of airway obstruction, esophageal stricture, and pneumonia increased over subsequent years, with significantly increased risk at 5 years for airway obstruction (OR = 3.0, 1.4-6.4), pneumonia (OR = 4.5, 1.8-11.2), and stricture (OR = 5.5, 1.8-17.6). Pretreatment dysphagia was a significant predictor of long-term dysphagia, airway obstruction, and pneumonia. Chemoradiation, advanced stage disease, high-volume hospital care, male sex, and salvage surgery were significant predictors of long-term gastrostomy use. Long-term dysphagia, gastrostomy or tracheostomy dependence, weight loss, airway obstruction, and pneumonia were associated with poorer survival, with tracheostomy dependence (hazard ratio [HR] = 2.2, 1.7-2.9) and pneumonia (HR = 2.0, 1.7-2.4) associated with the greatest risk of late mortality. Airway and swallowing impairment is common after treatment of oropharyngeal SCCA in elderly patients, increases over time, and is associated with poorer survival. Patients with pretreatment dysphagia, advanced stage disease, initial treatment with chemoradiation, and salvage surgery represent a high-risk group with an increased risk of disability and death. 2c. Laryngoscope, 128:2084-2093, 2018.

Pretreatment Dysphagia in Esophageal Cancer Patients May Eliminate the Need for Staging by Endoscopic Ultrasonography

Neoadjuvant therapy is commonly administered to patients with localized disease who have T3-4 esophageal disease as staged by endoscopic ultrasound (EUS). Previously, we noted that patients who present with dysphagia have a higher EUS T stage. We hypothesized that the presence of dysphagia is predictive of EUS T3-4 disease and that staging EUS could be forgone for esophageal cancer patients with dysphagia. We performed a prospective, intent-to-treat, single-cohort study in which patients with potentially resectable esophageal cancer completed a standardized four-tier dysphagia score survey. EUS was performed as part of our standard evaluation. To determine whether the presence of dysphagia predicted EUS T3-4 disease, the dysphagia score was compared with EUS T stage. The study enrolled 114 consecutive patients between August 2012 and February 2014: 77% (88 of 114) received neoadjuvant therapy, 18% (20 of 114) did not, and 5% (6 of 114) pursued treatment elsewhere. In total, 70% (80 of 114) underwent esophagectomy; of these, 54% (61 of 114) had dysphagia and 46% (53 of 114) did not. Dysphagia scores were 66% (40 of 61) grade 1, 25% (15 of 61) grade 2, and 10% (6 of 61) grade 3 to 4. Among patients with dysphagia, 89% (54 of 61) had T3-4 disease by EUS; among those without dysphagia, only 53% (28 of 53) had T3-4 disease by EUS (p < 0.001). The presence of dysphagia in patients with esophageal cancer was highly predictive of T3-4 disease by EUS. On the basis of this finding, approximately 50% of patients currently undergoing staging EUS at our institution could potentially forgo EUS before neoadjuvant therapy. Patients without dysphagia, however, should still undergo EUS.

Impact of baseline patient-reported dysphagia on acute gastrostomy placement in patients with head and neck squamous cell carcinoma undergoing definitive radiation.

Dysphagia-related symptoms in patients with head and neck cancer are common before treatment. We hypothesized greater self-reported baseline dysphagia would predict gastrostomy placement during primary radiation. Swallowing-specific/general surveys (SwalQOL/EuroQOL) collected prospectively before definitive radiation were analyzed for associations with gastrostomy placement. Prophylactic gastrostomy was recommended at the discretion of a multidisciplinary team blinded to the surveys. Of 84 patients in the cohort, 42 patients (50%) received feeding tubes. Eleven patients (13%) who underwent prophylactic feeding tube placement reported the greatest pretreatment dysphagia, whereas those who avoided gastrostomies reported the least. Prophylactic gastrostomy was more strongly associated with patient-reported measures than other clinical criteria. Controlling for stage IV, T3 to T4 classification, smoking, chemotherapy, and pretreatment weight loss, baseline dysphagia remained an independent predictor of feeding tube placement (odds ratio [OR] = 0.12; 95% confidence interval [CI] = 0.05-0.55; p = .01). Patients without gastrostomies during treatment avoided persistent gastrostomy dependence. Baseline dysphagia-related symptoms before radiation are independent predictors of gastrostomy placement. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1318-E1324, 2016.

Pretreatment Dysphagia Inventory and videofluorographic swallowing study as prognostic indicators of early survival outcomes in head and neck cancer.

The prognostic role of swallowing-related, pretreatment subjective and objective findings has not been investigated in detail. The authors evaluated the association between pretreatment MD Anderson Dysphagia Inventory (MDADI) or videofluorographic swallowing study (VFSS) results and standard outcomes, including early recurrence and survival, in patients with treatment-naïve head and neck squamous cell carcinoma (HNSCC). Patients with HNSCC (n = 191) who received treatment at the authors' institution and were examined by self-administered MDADI questionnaires and VFSS were prospectively enrolled. MDADI and VFSS findings were analyzed in correlation with clinicopathologic variables, and factors that predicted 2-year disease-free survival (DFS) and overall survival (OS) were identified using a Cox proportional-hazards regression model. The 2-year OS and DFS rates were 80.1% and 77.5%, respectively. Clinical tumor (T) and lymph node (N) classifications, overall TNM stage, sex, tumor site, and educational level were significantly associated with specific MDADI subdomains, whereas Karnofsky performance score was significantly associated with all MDADI subdomains. After controlling for clinical factors, total scores, global assessment scores, and emotional and physical MDADI subscores were significantly predictive of 2-year OS and DFS (P < .05 for each). VFSS findings were not significantly associated with survival (P > .05). The current results provide evidence of the prognostic role of the MDADI in predicting early survival outcomes in patients with HNSCC. The MDADI may be a practical and noninvasive method for the identification of patients at risk who would benefit from close follow-up.

Short- and long-term outcomes of laryngeal cancer care in the elderly.

To examine associations between pretreatment variables, short-term and long-term swallowing and airway impairment, and survival in elderly patients treated for laryngeal squamous cell cancer (SCCA). Retrospective analysis of Surveillance, Epidemiology, and End Results-Medicare data. Longitudinal data from 2,370 patients diagnosed with laryngeal SCCA from 2004 to 2007 were evaluated using cross-tabulations, multivariate logistic regression, and survival analysis. Dysphagia (odds ratio [OR] = 1.5 [1.2-1.7]), weight loss (OR = 1.3 [1.1-1.6]), esophageal stricture (OR = 3.8 [2.5-5.9]), airway obstruction (OR = 1.9, [1.6-2.3]), tracheostomy (OR = 1.5 [1.2-1.9]), and pneumonia (OR = 1.8 [1.4-2.2]) increased 1 year after treatment. The odds of airway obstruction, esophageal stricture, and pneumonia increased over subsequent years, with significantly increased risk at 5 years for airway obstruction (OR = 3.3 [1.8-5.8]) and pneumonia (OR = 5.2 [2.5-10.7]). Pretreatment dysphagia, chemoradiation, and salvage surgery were significant predictors of long-term dysphagia, weight loss, tracheostomy, and gastrostomy, with pretreatment dysphagia and salvage surgery also associated with pneumonia. Surgery and postoperative radiation was associated with long-term dysphagia (OR = 1.4 [1.0-1.9]) but reduced odds of long-term pneumonia (OR = 0.7 [0.5-0.9]). Long-term dysphagia, gastrostomy or tracheostomy dependence, weight loss, airway obstruction, and pneumonia were associated with poorer survival, with pneumonia associated with the greatest risk of death at 5 years (hazard ratio = 2.6 [2.4-2.9]). Airway and swallowing impairment is common after laryngeal SCCA treatment in elderly patients, increases over time, and is associated with poorer survival-with pneumonia associated with the highest risk of long-term mortality. Patients with pretreatment dysphagia, initial treatment with chemoradiation, and salvage surgery represent a high-risk group with an increased risk of disability and death.

Combination External Beam Radiotherapy and Intraluminal Brachytherapy for Non-radical Treatment of Oesophageal Carcinoma in Patients not Suitable for Surgery or Chemoradiation

AimsThis single-centre retrospective study evaluated combination external beam radiotherapy and high dose rate brachytherapy for patients in whom radical treatment was appropriate but comorbidity or frailty excluded this as an option. Materials and methodsIn total, 59 patients were selected for a combined approach and treated between October 2000 and October 2011; 68% were male. The median age was 77 years (range 53–88 years); 66% had adenocarcinoma, 31% squamous cell carcinoma. Tumour stage: I: 20%, II: 43%, III: 32% and IV: 3%. External beam radiotherapy doses of either 27 Gy/six fractions or 30 Gy/10 fractions were delivered, followed by high dose rate brachytherapy at doses of either 10 or 15 Gy utilising an iridium 192 source at 1 cm. ResultsThe median overall survival of all treated patients was 12.3 months; 1, 2 and 3 year survival rates were 51, 19 and 7%, respectively. Patients with stage I disease had a median survival of 16 months compared with 10 months for patients with stage III disease (P = 0.036). The pretreatment dysphagia score was associated with survival (P = 0.021). ConclusionsThis study shows the value of a purely radiation-based approach in a selected population. Treatment is deliverable with excellent compliance and the median survival compares favourably with unselected patients treated palliatively in our institution.

Combination external beam radiotherapy and brachytherapy for radical treatment of esophageal carcinoma in patients not suitable for surgery or chemoradiation.

115 Background: Standard curative therapy for esophageal cancer is surgery or chemoradiotherapy. Many patients are not suitable for this approach due to significant co-morbidity.This study evaluates a combination of external beam radiotherapy and High-Dose-Rate (HDR) brachytherapy as a sole modality of treatment for patients in whom tumour characteristics would indicate radical treatment was appropriate. All patients had previously been discussed in a multi-disciplinary setting in which standard radical therapies had been discounted. Methods: 59 patients were treated between October 2000 and October 2011. 40 (58%) were male. Median age was 77 (53 – 88). 39 (66%) adenocarcinoma, 19 (31%) SCC and 1 undifferentiated tumour. 49 (83%) were lower third esophagus. Tumour stage: 1 12(20%), 2 25(43%), 3 19(32%) and 4 2(3%). 30 (50%) had Adult Comorbidity Score – 27 (ACE) of 2 or 3. External beam radiotherapy was conformally planned. Doses of either 27 Gy/6F or 30 Gy/10F were delivered. HDR brachytherapy was delivered utilising an Ir 192 source dosed at 1cm. Doses of either 10 or 15 Gy were delivered. Results: The Median OS, of all treated patients estimated by the Kaplan Meier methods was 373 days (12.3 months). (Fig 1) The 1-, 2- and 3-year survival rates for treated patients were 51%, 19% and 7% respectively. Patients with stage I disease had a median survival of 16 months compared with 10 months for patients with stage III disease. Review of pre treatment dysphagia score demonstrated that patients with no dysphagia prior to treatment (score =0) had a median survival of 17 months compared to 12.5 months and 10 months for patients with scores of 2 and 3 respectively. Conclusions: This demonstrates the value of a purely radiation based approach in a population unsuited to other radical approaches. The median survival exceeds by several months that seen in patients treated palliatively. Treatment is deliverable without significant co-morbidities and offers a survival advantage comparable to radical chemoradiotherapy.

Intraluminal high-dose-rate brachytherapy for palliation of dysphagia in cancer of the esophagus: initial experience at a single UK center

Esophageal cancer tends to present with advanced disease, and the majority of patients are suitable only for palliative treatment at diagnosis. Dysphagia is the most common presenting symptom and significantly undermines quality of life. High-dose-rate intraluminal brachytherapy (ILBT) has been an option for the palliation of dysphagia for many years and has been used at our center since 2006. Experience was presented in terms of improvement of dysphagia and survival. Patients were identified from the local radiotherapy database. Original treatment sheets and clinical notes were reviewed retrospectively to obtain treatment details, pretreatment and post-treatment dysphagia scores, and survival information. Between January 2006 and January 2010, 21 patients of median age 77 years with a mean pretreatment dysphagia score of 2.5 underwent ILBT for esophageal cancer. All received 12 Gy in a single fraction. Thirteen (62%) had adenocarcinoma and eight (38%) squamous cell carcinoma. Four (19%) tumors were in the mid-esophagus and 17 (81%) in the lower esophagus. Eight had extension of tumor into the gastroesophageal junction. Seven patients (33%) received chemotherapy as first-line treatment prior to brachytherapy. Nineteen patients had clear documentation of dysphagia scores both pretreatment and post-treatment, and the improvement overall was significant (P= 0.04). Ten patients (53%) had an improvement in dysphagia score. Five of these (50%) went on to require further endoscopic intervention due to disease progression. Median duration of response was 4 months. Of the nonresponders, six (67%) went on to require further endoscopic intervention. No patients experienced documented toxicity aside from a short-lived acute esophagitis. Median survival from date of diagnosis was 12 months and from treatment date was 5 months (1-32 months). In our series of elderly patients with significant dysphagia, ILBT was a well-tolerated and effective treatment. It should be considered as a palliative option in esophageal cancer.

The clinical value of dysphagia preassessment in the management of head and neck cancer patients

To review the aims and clinical value of a pretreatment dysphagia assessment in head and neck cancer patients. Studies show that the majority of head and neck cancer patients have a functional swallow, before they commence treatment. However, those with advanced and/or pharyngeal cancer are more likely to show signs of aspiration. Changes to swallowing performance can be observed on clinical tests and a number of biomechanical differences are seen on instrumental assessment. New evidence has demonstrated that swallowing assessment prior to the commencement of treatment is predictive of swallowing difficulties up to 1 year posttreatment. The type of surgical or oncological treatment seems to be an important factor for long-term swallowing dysfunction. A swallowing evaluation is multidimensional and tests include both the clinical and the patient perspective. A pretreatment dysphagia assessment is important for identifying swallowing difficulties and highlighting patients who are likely to develop chronic dysfunction. Predictive indicators can be used to tailor patient information for the likely functional impact of treatment.

Examination of laryngoesophageal dysfunction‐free survival as an endpoint in nonsurgical treatment of squamous cell carcinomas of the larynx and hypopharynx

A recently published consensus guideline suggested a new endpoint for clinical trials involving cancer of the larynx and hypopharynx: laryngoesophageal dysfunction-free survival (LEDFS). The authors of this report examined LEDFS in the context of definitive radiotherapy alone (RT) or with concurrent chemoradiotherapy (CRT). Patients with a stage III to IVB squamous cell carcinomas of the larynx or hypopharynx who received definitive radiotherapy were included. Consensus guidelines also suggested analysis of the following: tumor classification, lymph node status, pretreatment tracheotomy, pretreatment swallowing dysfunction, and subsite. LEDFS was assessed using Kaplan-Meier survival analyses. Eighty-five patients (73.9%) received CRT, and 30 patients (26.1%) received RT. For the entire cohort, the 3-year LEDFS rate was 28.9%. CRT was associated with an improved LEDFS at 3 years (32.2% vs 20%; P = .02). Pretreatment dysphagia (P = .06) and N2 or N3 lymph node status (P = .09) demonstrated a trend toward poorer LEDFS, but patients who had T4 tumors had an LEDFS similar to that of patients who had T2 and T3 tumors. LEDFS was superior in patients who received CRT compared with patients who received RT alone. T4 status was not associated with a worse LEDFS.