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

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

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

4. 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

5. 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

6. 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

7. Pre-treatment

8. 6 months post treatment

9. 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

10. 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)

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

12. Comparison pre & post

13. 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

14. 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

15. Pre-treatment priorities

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

17. 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

18. Diet scale pre vs. 3 months post Chemoradiotherapy

19. 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

20. 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

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

22. Clinical Indicators Aspiration / penetration Residue
Swallowing efficiency
Feeding tube dependency

23. 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

24. % Aspiration Post CRT
% aspiration

25. % Aspiration pneumonia

26. Swallowing Efficiency
Residue
Oropharyngeal swallowing efficiency
Water swallow test

27. Mean time to swallow 100mLs water pre-treatment

28. 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

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

30. 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