Page 105 - Functional impairment and cues for rehabilitation of head and neck cancer patients -

Long-term function after CRT and preventive rehabilitation
While the benefit of IMRT over conventional RT is not disputed, it has been challenging to substantiate the benefit of preventive rehabilitation in clinical research. Recently, a Cochrane review by Perry et al. on preventive exercises was published (13). They concluded that the evidence supporting the effectiveness of preventive exercises on functional outcomes post treatment was not yet convincing. The lack of convincing evidence is not necessarily due to the lack of observed effectiveness, but is caused by the limited sample sizes of the included studies, resulting in limited power and therefore imprecise estimates of effect, and the impossibility of meta-analysis due to the dissimilarities in outcome measures used. An important issue with this review is that it did not consider the relevance of patient compliance to the exercises. Individual studies do suggest positive effects of preventive exercises with superior swallowing function when compared to (historical) controls (6-9, 11, 14). Moreover, patients who maintain their oral intake during CRT have favorable outcomes compared to patients who become tube dependent (55, 56). These findings support the preposition that both the exercises and the maintenance of oral intake prevent decreased use, and thereby they may prevent non-use atrophy of swallowing muscles, which is the rationale behind preventive strategies.
Limitations
The main limitation of this study is the small sample size, with only 14 of the 22 patients at the six-year follow-up still alive and evaluable at ten-year plus. It is, however, not an uncommon sample size given the survival rate in advanced HNC. Also, DIGEST grades were assessed on the videofluoroscopy studies including only four bolus trials instead of ten bolus trials on which the grading system was validated.
CONCLUSION
Functional status and quality of life of patients treated for advanced HNC with state-of-the-art CRT and preventive rehabilitation exercises who have survived ten or more years is reasonably well-maintained. Swallowing, trismus and speech related outcomes only moderately deteriorated from six- to ten-years, with a perceived excellent overall quality of life.
ACKNOWLEDGEMENTS
Catherine Middag from the imec-IDLAB in Gent is greatly acknowledged for performing the speech analyses in ASISTO. The NKI-AVL receives a research grant from ATOS Medical Sweden, which contributes to the existing infrastructure for health-related, quality-of-life research in the Department of Head and Neck Oncology and Surgery.
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