Page 104 - Functional impairment and cues for rehabilitation of head and neck cancer patients -

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Chapter 4
between December 1999 and November 2004 (29, 46, 47). During this time period IMRT was applied less often (50% vs. 100%) and no preventive rehabilitation interventions were offered. When our results are compared to that cohort, aspiration was observed less often (30% in our study vs. 68% in the study of Kraaijenga et al.), as well as contrast residue (70% vs. 100%). Also, less patients were feeding tube dependent (0% vs. 14%), had pneumonia the past six months (0% vs. 14%) and had an FOIS below 7 indicating a modified diet (0% vs. 55%). To properly appreciate the difference in functional outcomes, one should keep in mind that the patients of the historical cohort were somewhat older (median 63 (range 42–74) vs. 58 (range 39–66) in our study), and had more stage IV tumors (68% vs. 57%). Yet, the differences likely also reflect the improvement resulting from more advanced radiotherapy in combination with preventive rehabilitation.
Besides this historical cohort treated at our institute, other studies have also reported on long- term swallowing related outcomes after CRT for HNC without preventive rehabilitation (48-50). All of these studies report that severe late toxicity is common after CRT for HNC. Machtay et al. found that 99 of the 230 patients (34%) at a median follow-up of 3 years after CRT (no IMRT) for HNC experienced late toxicity (48). Rutten et al. concluded that 57% of the 77 analyzed CRT for HNC patients (of whom 17% received IMRT) had impaired swallowing and 23% had silent aspiration at a median follow-up of 3.7 years after CRT for HNC (49). Only 15.6% reported to have a normal diet. Frowen et al. analyzed 39 patients after CRT (no IMRT) for HNC and found that at 5 years after treatment, 2 patients (5%) were PEG tube dependent (50). Hutcheson et al. published results from the longest follow-up on swallowing function after CRT (7% IMRT) for HNC (21). They also reported a high prevalence of impaired swallowing at nine years post (C)RT, with 66% being gastrostomy dependent (21), although, this result might not be representative for all HNC patients receiving CRT, because the patients included in their analysis were complaining about dysphagia and specifically referred for a modified barium swallow.
Long-term speech related outcomes after CRT for HNC are scarce in literature (51). Results suggest that speech problems are common after CRT, but extensive long-term (10-year) evaluations are lacking (52, 53). Kraaijenga et al. published voice and speech related outcomes of the previously mentioned historical cohort ten-years after CRT (54). Voice and speech problems were common in that cohort, with 68% and 77% of the 22 evaluated patients reporting voice and speech problems in daily life, based on VHI and SHI scores above the cut-off values. In the present cohort, there were less patients with scores above the cut-off value (29% and 43% for VHI and SHI). Again, comparisons between these two different cohorts of the NKI-AVL should be interpreted with caution since differences might be caused by preventive rehabilitation strategies, but might also be due to differences in patient and tumor characteristics. The median intelligibility deteriorated from 85% to 75% in this cohort. This might be, just as the deterioration of swallowing function, caused by continuing fibrosis or the effects of ageing which both affect structures of the upper aerodigestive tract.