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FUTURE PERSPECTIVES
The results of the studies presented in this thesis all warrant implementation into clinical practice to a greater or lesser extent.
The clinical pro- and retrospective results discussed in Chapters 2 (on patient-reported swallowing function after surgery and radiotherapy for stage I and II oropharyngeal carcinoma), 4 (on long-term results after CRT and preventive rehabilitation) and 5 (on the one-year results after (C)RT for oropharyngeal carcinoma) are quite relevant for current clinical practice. They have broadened our insight in the short- and long-term issues following treatment, and the success rate of the implementation of a dedicated rehabilitation program. These results are valuable for further improving patient counselling and optimization of (preventive) rehabilitation strategies. They also underline that continued follow-up and audit are indispensable for maintaining and improving patient care standards.
The SPEAD-test, discussed in Chapter 3, is a likely candidate for clinical implementation. It is an easily manageable test, requiring minimal equipment, time, and money to execute and which provides a reproducible value (in grams per second) for the swallowing capacity. Ideally, after further validation and optimization of the test, integration into regular care is justified with multiple possible applications. It might be useful for pretreatment work-up to enable (early) identification of swallowing impairment, and act accordingly, as well as to determine baseline function to be able to further monitor deteriorations or progress during and after treatment. The test might also be useful in already treated patients. Moreover, the SPEAD-test might also be a useful test to evaluate swallowing capacity in patients with dysphagia caused by diseases other than HNC.
Now that we know that relevant (swallowing) muscles are targeted (Chapter 6) with the SEA, and the SEA has shown potential value in improving swallowing function, future studies should target the optimization of this exercise tool (e.g., optimizing protocol length and exercise frequency) and the assessment of its effects in randomized settings. In our institute, we are planning to not only evaluate the effect of the SEA in a randomized clinical trial comparing the SEA-based exercise protocol versus standard care, but also focus on laryngectomized patients with dysphagia. After total laryngectomy, some important muscles involved in swallowing are removed or transected with a high postoperative prevalence of dysphagia as a result (15-17). Within the planned studies, the effectiveness of maintenance exercises will also be evaluated in order to optimize the exercise protocol for a maximal and sustainable effect. Today, efforts are being made to further optimize the versatility and ergonomics of the tool and to make it more widely available.
Another obvious implementation concerns our clinical prediction model (Chapter 7), which would aid in estimating the risk for prolonged tube feeding during CRT for HNC into regular pretreatment work-up, to decide on the timing for tube feeding during CRT treatment. In
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