Page 216 - Functional impairment and cues for rehabilitation of head and neck cancer patients -

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Chapter 9
addition, as sarcopenia has proven to also be relevant in predicting this risk, we propose to add this parameter (measured as neck skeletal muscle index (SMI) on routine CT-scans) to the decision-making process (Chapter 8). A proposed flow chart is presented in figure 1. Within this protocol, first, the risk for prolonged feeding tube dependence is estimated on the basis of the identified clinical parameters (T-stage, BMI, and pretreatment weight loss and dysphagia). In case of an estimated risk below 30%, no additional action would be needed, except for encouraging and supporting the patient to optimally maintain oral intake. In case of an estimated risk between 30% and 60% measurement of the neck SMI is advised. Pretreatment optimization of the patient’s condition in case of a neck SMI below 12.7 might be beneficial and can therefore be discussed with the patient. In case of an estimated risk above 60%, pretreatment optimization of the patient’s condition might be beneficial regardless neck SMI. Additional research still has to be performed to (externally) validate this or a comparable protocol, and especially the suggested cut-off percentages.
Regarding the association between sarcopenia and feeding tube risk, one has to keep in mind that this does not immediately imply that when skeletal muscle mass throughout the body increases, functions of the head and neck area also improve. It could be that the association only works one way: when swallowing function decreases, oral intake is less, and skeletal muscle mass also decreases, and not the other way around: more skeletal muscle mass increases swallowing function.
In conclusion, after treatment for HNC, people, including Peter de Valença – whos story is depicted above – have to live with functional sequelae of the treatment. Although considerable effort has been put into minimalizing functional loss, these limitations still cannot be prevented or cured. Preventive as well as reactive rehabilitation, including swallowing muscle exercises with for example the SEA, most likely will continue to play an important role in preserving and improving the functional endresult by targeting swallowing as well as mouth opening mechanisms. By using adequate tools to assess swallowing status, including the newly developed SPEAD-test, and prediction models (including sarcopenia), the risk for functional impairment later on can be anticipated and timely and proper action can be taken, including proactive placement of a feeding tube or initiation of (SEA) rehabilitation.