Swallowing Outcomes in Head & Neck Cancer Jo Patterson Macmillan Speech & Language Therapist/Research Fellow

Swallowing Outcomes Critique assessments Collector’s perspective Patient rated outcomes Clinical scales Clinical indicators

Patient reported outcomes SWAL-QOL / SWAL-CARE M.D.Anderson Dysphagia Inventory

SWAL-QOL (McHorney 2002) Devised from patient focus group (N=549, 14.5% head & neck cancer) Good correlation with UWQOL (Lovell 2005) Moderately related to pathophysiology

Measurement tool SWAL-QOL 2002 (44 items, 11 domains) general burden* (fatigue) food selection* (sleep) eating duration (communication) eating desire fear of eating mental health* social function* symptom frequency

Data Sample N=65 (49 males; 16 females) Age 32-80y mean 60y Oral (31) oropharyngeal (30) NPC (4) T1-2 (35) T3-4 (30) Surgery (10) surgery & radiotherapy (36) chemoradiotherapy (13) radiotherapy (6) 35 completed pre & post SWAL-QOL Analysed using ANOVA

Pre-treatment

6 months post treatment

Collector’s perspective Author’s report 14 mins to complete – much longer needed Difficult to analyse – many components Good sections – includes symptoms Not to be done cross-sectional

M.D. Anderson Dysphagia Inventory (Chen 2001) 20 items (sub-groups emotion, physical, function) Devised from professionals (SALTs & Surgeons) Good reliability Correlates with UWQOL No association with aspiration (Gillespie 2005) Used as outcome for swallowing exercises (Kulbersh 2006)

MDADI pre & post CRT Demographics Tx Orophx 6 9 7 24 - Hypophx 2 3 Larynx 23 11 4 U/k 1° Total = 116

Comparison pre & post

Collector’s perspective 10 mins to complete ‘no opinion’ poses difficulties Difficult to use on someone without swallowing difficulties Difficult to use on NBM patients One item complex double negative

Quality of Life Questionnaires University of Washington QOL Scales DAHNO Correlates with VFSS, HADS, MDADI, SWAL-QOL, TOMS Short, quick to complete Wide research base Difficult to find out how it was devised Reproducible, reliable & valid Originally intended for surgical group Additions of taste, saliva, mood, anxiety Speech & saliva difficult for people to answer

Pre-treatment priorities

Clinical Scales Performance Status Scales (List ’90) Therapy Outcome Measures (TOMS) FIGS

Performance Status Scales (List 1990) Developed by surgeons, oncologists & SALTs Purpose; research & clinical Normalcy of diet, eating in public, communication Rated by ‘health professionals’ High reliability Correlates with QOL Included in DAHNO dataset

Diet scale pre vs. 3 months post Chemoradiotherapy

Collectors perspective Quick Can be done by other staff Some diets difficult to grade Can give false positive results Gradations ?equal Large literature base for comparison ?swallowing outcome

Therapy Outcome Measures (Enderby ’77) 10 core patients specific scales ‘Laryngectomy’ only scale specific to H&NC Scales on voice, dysarthria, phonology & dysphagia Pilot study Radford et al 2003 Correlates with UWQOL scales ?modification for H&NC

Functional Intraoral Glasgow Scale (FIGS)(Goldie 2006) Originated Canniesburn Hospital 3 scales – chew, swallow & speech Total score of all 3 items

Clinical Indicators Aspiration / penetration Residue Swallowing efficiency Feeding tube dependency

Aspiration / Penetration H&NC literature focuses on aspiration Penetration / aspiration scale (Rosenbek) Increases reliability of findings One score Requires instrumental assessment ?meaningful to clinical picture / patient

% Aspiration Post CRT % aspiration

% Aspiration pneumonia

Swallowing Efficiency Residue Oropharyngeal swallowing efficiency Water swallow test

Mean time to swallow 100mLs water pre-treatment

Tube feeding NPC T.Base U/k 1° Total No Peg 4 12 11 27(40%) 0-4week - 5 5(12%) 4-12wks 1 3(7%) 12-24wks 7 9(22%) 24-52wks 2 17(14%) >52wks 6 7(17%) 10 42 16 68

DAHNO Was the patient seen for pre treatment SALT assessment? PSS Normalcy of Diet Weight Type & timing of nutritional support

Summary Choice of measures One-dimensional, cross-sectional misleading Needs to be longitudinal, set time points Simple / collectable What questions to ask of the data It will require dedicated time ?interventions DAHNO