Answer questions and earn CME/CNE The American Cancer Society Head and Neck Cancer Survivorship Care Guideline was developed to assist primary care clinicians and other health practitioners with the care of head and neck cancer survivors, including monitoring for recurrence, screening for second primary cancers, assessment and management of long-term and late effects, health promotion, and care coordination. A systematic review of the literature was conducted using PubMed through April 2015, and a multidisciplinary expert workgroup with expertise in primary care, dentistry, surgical oncology, medical oncology, radiation oncology, clinical psychology, speech-language pathology, physical medicine and rehabilitation, the patient perspective, and nursing was assembled. While the guideline is based on a systematic review of the current literature, most evidence is not sufficient to warrant a strong recommendation. Therefore, recommendations should be viewed as consensus-based management strategies for assisting patients with physical and psychosocial effects of head and neck cancer and its treatment. CA Cancer J Clin 2016;66:203-239. © 2016 American Cancer Society.

IMPORTANCE Major weight loss is common in patients with head and neck squamous cell carcinoma (HNSCC) who undergo radiotherapy (RT). How baseline and posttreatment body composition affects outcome is unknown. OBJECTIVE To determine whether lean body mass before and after RT for HNSCC predicts survival and locoregional control. DESIGN, SETTING, AND PARTICIPANT Retrospective study of 2840 patients with pathologically proven HNSCC undergoing curative RT at a single academic cancer referral center from October 1, 2003, to August 31, 2013. One hundred ninety patients had computed tomographic (CT) scans available for analysis of skeletal muscle (SM). The effect of pre-RT and post-RT SM depletion (defined as a CT-measured L3 SM index of less than 52.4 cm2 /m2 for men and less than 38.5 cm2 /m2 for women) on survival and disease control was evaluated. Final follow-up was completed on September 27, 2014, and data were analyzed from October 1, 2014, to November 29, 2015. MAIN OUTCOMES AND MEASURES Primary outcomes were overall and disease-specific survival and locoregional control. Secondary analyses included the influence of pre-RT body mass index (BMI) and interscan weight loss on survival and recurrence. RESULTS Among the 2840 consecutive patients who underwent screening, 190 had whole-body positron emission tomography–CT or abdominal CT scans before and after RT and were included for analysis. Of these, 160 (84.2%) were men and 30 (15.8%) were women; their mean (SD) age was 57.7 (9.4) years. Median follow up was 68.6 months. Skeletal muscle depletion was detected in 67 patients (35.3%) before RT and an additional 58 patients (30.5%) after RT. Decreased overall survival was predicted by SM depletion before RT (hazard ratio [HR], 1.92; 95% CI, 1.19–3.11; P = .007) and after RT (HR, 2.03; 95% CI, 1.02–4.24; P = .04). Increased BMI was associated with significantly improved survival (HR per 1-U increase in BMI, 0.91; 95% CI, 0.87–0.96; P < .001). Weight loss without SM depletion did not affect outcomes. Post-RT SM depletion was more substantive in competing multivariate models of mortality risk than weight loss–based metrics (Bayesian information criteria difference, 7.9), but pre-RT BMI demonstrated the greatest prognostic value. CONCLUSIONS AND RELEVANCE Diminished SM mass assessed by CT imaging or BMI can predict oncologic outcomes for patients with HNSCC, whereas weight loss after RT initiation does not predict SM loss or survival.

Background Changing trends in head and neck cancer (HNC) merit an understanding of late effects of therapy, but few studies examine dysphagia beyond 2 years of treatment. Methods A case series was examined to describe the pathophysiology and outcomes in dysphagic HNC survivors referred for modified barium swallow (MBS) studies ≥5 years after definitive radiotherapy or chemoradiotherapy (01/2001–05/2011). Functional measures included the Penetration-Aspiration Scale (PAS), Performance Status Scale-Head and Neck (PSS-HN), Swallowing Safety Scale (NIH-SSS), and MBSImp. Results Twenty-nine patients previously treated with radiotherapy (38%) or chemoradiotherapy (62%) were included (median years post-treatment: 9, range: 5–19). The majority (86%) had oropharyngeal cancer; 52% were never smokers. Seventy-five percent had T2-T3 disease; 52% were N+. Median age at diagnosis was 55 (range: 38–72). Abnormal late examination findings included: dysarthria/dysphonia (76%), cranial neuropathy (48%), trismus (38%), and radionecrosis (10%). MBS studies confirmed pharyngeal residue and aspiration in all dysphagic cases owing to physiologic impairment (median PAS: 8; median NIH-SSS: 10; median MBSImp: 18) whereas stricture was confirmed endoscopically in 7 (24%). Twenty-five (86%) developed pneumonia, half requiring hospitalization. Swallow postures/strategies helped 69% of cases, but no patient achieved durable improvement across functional measures at last follow-up. Ultimately 19 (66%) were gastrostomy dependent. Conclusions Although functional organ preservation is commonly achieved, severe dysphagia represents a challenging late effect that may develop or progress years after radiation-based therapy for HNC. These data suggest that novel approaches are needed to minimize and better address this complication that is commonly refractory to many standard dysphagia therapies.

Objective Proactive swallowing therapy promotes ongoing use of the swallowing mechanism during radiotherapy through 2 goals: eat and exercise. The purpose of this study was to evaluate the independent effects of maintaining oral intake throughout treatment and preventive swallowing exercise. Design Retrospective observational study. Setting The University of Texas MD Anderson Cancer Center, Houston. Patients The study included 497 patients treated with definitive radiotherapy (RT) or chemoradiation (CRT) for pharyngeal cancer (458 oropharynx, 39 hypopharynx) between 2002 and 2008. Main Outcome Measures Swallowing-related endpoints were: final diet after RT/CRT and length of gastrostomy-dependence. Primary independent variables included per oral (PO) status at the end of RT/CRT (nothing per oral [NPO], partial PO, 100% PO) and swallowing exercise adherence. Multiple linear regression and ordered logistic regression models were analyzed. Results At the conclusion of RT/CRT, 131 (26%) were NPO, 74% were PO (167 [34%] partial, 199 [40%] full). Fifty-eight percent (286/497) reported adherence to swallowing exercises. Maintenance of PO intake during RT/CRT and swallowing exercise adherence were independently associated (p<0.05) with better long-term diet after RT/CRT and shorter length of gastrostomy dependence in models adjusted for tumor and treatment burden. Conclusions Data indicate independent, positive associations between maintenance of PO intake throughout RT/CRT and swallowing exercise adherence with long-term swallowing outcomes. Patients who either eat or exercise fare better than those who do neither. Patients who both eat and exercise have the highest return to a regular diet and shortest gastrostomy dependence.

OBJECTIVE Summarize functional outcomes after transoral robotic surgery (TORS) ± adjuvant therapy for oropharyngeal cancer (OPC). STUDY DESIGN A systematic review was conducted. The MEDLINE database was searched (MeSH terms: transoral robotic surgery, pharyngeal neoplasms, oropharyngeal neoplasms). METHODS Peer-reviewed human subject papers published through December, 2013 were included. Exclusion criteria were: 1) case report design (n<10), 2) review article, or 3) technical, animal or cadaver studies. Functional outcomes extracted included feeding tube dependence, swallow examination findings, speech ratings, velopharyngeal insufficiency, pneumonia, and oral intake measures. RESULTS Twelve papers comprising 441 patients with OPC treated with TORS ± adjuvant therapy were included. Feeding tube rates were the most commonly reported functional outcome. Excluding prophylactic placement, 18% to 39% of patients required gastrostomy placement, typically during adjuvant therapy. Chronic gastrostomy dependence ranged from 0% to 7% (mean follow-up: 11–26 months), regardless of disease stage. Composite MD Anderson Dysphagia Inventory (MDADI) scores ranged from 65.2 to 78 (89 patients, 3 series, mean follow-up: 12–13 months). Videofluoroscopic swallowing studies were not systematically reported. Incidence of postoperative pneumonia was 0% to 7%. Predictors of swallowing function included baseline function, T-stage, N-stage, tongue base primary tumors, and adjuvant chemoradiation. Rates of transient hypernasality were 4% to 9%. A single study suggested dose-dependent effects of adjuvant therapy (none, radiation alone, chemoradiation) on diet scores at 6- and 12-months. CONCLUSIONS Crude endpoints of functional recovery after TORS ± adjuvant therapy suggest promising swallowing outcomes, depending on the functional measure reported.

Radiotherapy (RT) is used to treat approximately 80% of patients with cancer of the head and neck. Despite enormous advances in RT planning and delivery, a significant number of patients will experience radiation-associated toxicities, especially those treated with concurrent systemic agents. Many effective management options are available for acute RT-associated toxicities, but treatment options are much more limited and of variable benefit among patients who develop late sequelae after RT. The adverse impact of developing late tissue damage in irradiated patients may range from bothersome symptoms that negatively affect their quality of life to severe life-threatening complications. In the region of the head and neck, among the most problematic late effects are impaired function of the salivary glands and swallowing apparatus. Other tissues and structures in the region may be at risk, depending mainly on the location of the irradiated tumor relative to the mandible and hearing apparatus. Here, we review the available evidence on the use of different therapeutic strategies to alleviate common late sequelae of RT in head and neck cancer patients, with a focus on the critical assessment of the treatment options for xerostomia, dysphagia, mandibular osteoradionecrosis, trismus, and hearing loss.

Purpose NCI’s Common Terminology Criteria for Adverse Events (CTCAE) is the universal framework for toxicity reporting in oncology trials. We sought to develop a CTCAE-compatible modified barium swallow (MBS) grade for the purpose of grading pharyngeal dysphagia as a toxicity endpoint in cooperative group organ preservation trials for head and neck cancer (HNC). We hypothesized that a 5-point CTCAE-compatible MBS grade (“DIGEST”) based on the interaction of pharyngeal residue and laryngeal penetration/aspiration ratings is feasible and psychometrically sound. Methods A modified Delphi exercise was conducted for content validation, expert consensus, and operationalization of DIGEST criteria. Two blinded raters scored 100 MBS conducted before or after surgical or non-surgical organ preservation. Intra- and inter-rater reliability were tested by weighted Kappa. Criterion validity against OPSE, MBSImP™©, MDADI, and PSS-HN was assessed with one-way ANOVA and post hoc pairwise comparisons between DIGEST grades. Results Intra-rater reliability was excellent (weighted Kappa=0.82–0.84) with substantial to almost perfect agreement between raters (weighted Kappa=0.67–0.81). DIGEST significantly discriminated levels of pharyngeal pathophysiology (MBSImP™©: r=0.77, p<0.0001), swallow efficiency (OPSE: r=−0.56, p<0.0001), perceived dysphagia (MDADI: r=−0.41, p<0.0001), and oral intake (PSS-HN diet: r=−0.49, p<0.0001). Conclusions With the development of DIGEST, we have adapted MBS rating to the CTCAE nomenclature of ordinal toxicity grading used in oncology trials. DIGEST offers a psychometrically sound measure for HNC clinical trials and investigations of toxicity profiles, dose-response, and predictive modeling.

Background Due to its physical properties, intensity-modulated proton therapy (IMPT) used for oropharyngeal carcinoma patients has the ability to reduce the dose to organs at risk compared to intensity-modulated radiotherapy (IMRT) while maintaining adequate tumor coverage. Our aim was to compare the clinical outcomes of these two treatment modalities. Methods We performed a 1:2 matching of IMPT to IMRT patients. Our study cohort consisted of IMPT patients from a prospective quality of life study and consecutive IMRT patients treated at a single institution during the period 2010–2014. Patients were matched on unilateral/bilateral treatment, disease site, HPV status, T and N stages, smoking status and receipt of concomitant chemotherapy. Survival analyzes were performed using a Cox model and binary toxicity endpoints using a logistic regression analysis. Results Fifty IMPT and 100 IMRT patients were included. The median follow-up time was 32 months. There were no imbalances in patient/tumor characteristics with the exception of age (mean age of 56.8 years for IMRT patients and 61.1 years for IMPT patients, p-value = 0.010). Statistically significant differences were not observed in overall survival (hazard ratio (HR) = 0.55; 95% confidence interval (CI): 0.12–2.50, p-value = 0.44) or in progression free survival (HR = 1.02; 95% CI: 0.41–2.54; p-value = 0.96). The age-adjusted odds ratio (OR) for the presence of a Gastrostomy (G)-tube during treatment and at 3 months post-treatment are respectively (OR = 0.53; 95%CI: 0.24–1.15; p-value = 0.11) and (OR = 0.43; 95%CI: 0.16–1.17; p-value = 0.10). When considering the pre-planned composite endpoint of grade 3 weight loss or G-tube presence, the odds ratios at 3 months and 1 year were respectively (OR = 0.44; 95%CI: 0.19–1.0; p-value = 0.05) and (OR = 0.23; 95%CI: 0.07–0.73; p-value = 0.01). Conclusion Our results suggest that IMPT is associated with reduced rates of feeding tube dependency and severe weight loss without jeopardizing outcome. Prospective multicenter randomized trials are needed to validate such findings.