Page 225 - Functional impairment and cues for rehabilitation of head and neck cancer patients -

latter being especially relevant for prevention and/or treatment of trismus. The findings of this explorative study further support the potential of the SEA to improve swallowing rehabilitation.
In Chapter 7, a prediction model is developed to predict the risk for long-term feeding tube dependency before CRT for head and neck cancer, to select patients for proactive tube placement and to avoid unnecessary prophylactic tube placement. A retrospective study was performed in a consecutive cohort of HNC patients treated with primary CRT, for whom a reactive tube placement protocol was used. A prediction model was developed to prognosticate prolonged (> 90 days) feeding tube dependency. Model performance and clinical net benefit of the model were assessed. Of the 336 included patients, 229 (68%) needed a feeding tube during CRT and 151 (45%) were prolonged feeding tube dependent. The prediction model includes the parameters pretreatment BMI, weight loss, Functional Oral Intake Scale and T-stage. Discriminatory ability is fair (area under the ROC-curve of 0.69) and calibration is adequate (Hosmer and Lemeshow test p = .254). The model shows net benefit over current practice for probability thresholds from 35–80%. Therefore, the developed model can be used to select patients for proactive feeding tube placement during primary CRT for HNC. The presented nomogram with easily obtainable parameters is a useful tool for clinicians to support shared decision making regarding proactive tube placement.
Sarcopenia, loss of skeletal muscle mass, was hypothesized to be a relevant lead for optimization of head and neck cancer (HNC) patients’ condition before chemoradiotherapy to prevent long-term functional swallowing impairment, such as feeding tube dependency. To test this hypothesis, regression analyses were performed in Chapter 8 to assess the association between skeletal muscle mass index (SMI), as a measure of sarcopenia, and prolonged (> 90 days) feeding tube dependency in 128 HNC patients treated with primary CRT. Sixty-one patients (48%) became prolonged feeding tube dependent. Lower SMI increased the risk of prolonged feeding tube dependency in multivariable analysis (risk ratio 1.08; 95% confidence interval 1.02–1.14, p = .013) adjusted for body mass index, abnormal diet and socioeconomic status. Sarcopenia contributes to the risk of prolonged feeding tube dependency of HNC patients treated with primary CRT. Since sarcopenia might be a modifiable issue prior to treatment, it should be explored as a target for pretreatment optimization of patients’condition.
In Chapter 9 the results of these studies and related future perspectives are discussed. Although considerable effort has been put into minimalizing functional loss, functional limitations after treatment for HNC 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.
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