Page 93 - Functional impairment and cues for rehabilitation of head and neck cancer patients -

Long-term function after CRT and preventive rehabilitation
INTRODUCTION
Advanced stage head and neck cancer (HNC) is commonly treated with chemoradiotherapy (CRT) (1). Although CRT is an organ preserving treatment modality, it is associated with substantial toxicities (2). Despite efforts to reduce radiotherapy dose on swallowing related structures (i.e., with intensity modulated radiotherapy (IMRT)), toxicities such as dysphagia are still a serious burden for survivors of advanced HNC (3).
Currently, strategies to preserve or strengthen swallowing musculature before, during or after treatment are making their way into regular care. Although the evidence is limited, some studies with good patient compliance have suggested benefit of preventive rehabilitation (4- 16). At our institute, a randomized controlled trial (RCT) was performed, comparing preventive rehabilitation with and without the TheraBite Jaw Motion Rehabilitation SystemTM (Atos Medical, Sweden, Malmö)(6). Functional outcomes and quality of life after treatment up until six-year follow-up were comparable in both groups, besides less trismus in the TheraBite arm (6, 10, 17). A cost-effectiveness study using data of this study suggested that preventive rehabilitation, with or without TheraBite, is more cost-effective than usual care (18).
Due to increased survival of patients treated for HNC because of changing etiology and continuously improving treatment strategies, knowledge on long-term functional outcomes is essential (19). Functional outcomes of our preventive rehabilitation cohort have been described up until six years post treatment (6, 10, 17). Up until that time, functional outcomes were comparable between the two exercise groups. In both groups functional impairments were limited and more or less stable with no patients being feeding tube dependent at both two- and six-year follow-up. At two- and six-year follow-up 3 (10%) and 0 (0%) patients had a modified diet, respectively, and 2 (7%) and 1 (5%) patient(s) had trismus. Data from earlier studies on toxicities beyond this period have suggested that functional impairment after (C)RT may develop or worsen during the years after the end of treatment, possibly due to continued fibrosis of swallowing structures (20-22). Since preventive rehabilitation strategies are now applied more broadly, long-term outcomes may have improved, which could be relevant to medical decision making. Data on long-term functional outcomes after CRT with preventive swallowing rehabilitation are, however, currently lacking.
The objective of this study was to explore the functional outcomes and quality of life of the patients now more than ten years after CRT with preventive rehabilitation (with and without TheraBite), whose one-, two- and six-year data were assessed earlier (17). Functional outcomes at ten year- plus follow-up will be compared to those at six-year follow-up.
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