Symptom Burden Associated With Late Lower Cranial Neuropathy in Long-term Oropharyngeal Cancer Survivors

Aggarwal, Puja; Zaveri, Jhankruti; Goepfert, Ryan P.; Shi, Qiuling; Du, Xianglin L.; Swartz, Michael D.; Gunn, G. Brandon; Lai, Stephen Y.; Fuller, Clifton D.; Hanna, Ehab Y.; Rosenthal, D.I.; Lewin, Jan S.; Piller, Linda B.; Hutcheson, Katherine A.

doi:10.1001/jamaoto.2018.1791

Cited by 25 publications

(61 citation statements)

References 44 publications

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“…Large and statistically significant differences in functional metrics by LCNP status also support our findings of high functional morbidity among LCNP cases. Our study results also support a previous survey analysis in this study population, which used complete case analysis of MDASI‐HN, with low attrition of cases due to missing data and demonstrated a strong impact of LCNP on swallowing, choking, mucus, fatigue, and voice symptoms …”

Section: Discussionsupporting

confidence: 89%

“…However, another cohort study reported 14% incidence of LCNP in 10‐year survivors of HNC, suggesting that risk increases over time . Our previous report confirmed high symptom burden among OPC survivors who developed LCNP, with largest effect sizes (coefficient, 2.3 of 10) on swallowing‐related symptoms . This phenomenon is also clinically recognized, but previous work has failed to quantify the impact of LCNP on individual swallowing domains and functional metrics.…”

Section: Discussionsupporting

confidence: 53%

“…Late LCNP was the primary exposure for this analysis. Late LCNP case status was ascertained by a detailed review of medical records of survivors as previously described . For this study, late LCNP was defined as a clinical evidence of neuropathy of at least one of the glossopharyngeal (IX), vagus (X), and hypoglossal (XII) nerves ≥3 months after the end of cancer treatment .…”

Section: Methodsmentioning

confidence: 99%

“…Among LCNP cases, onset of neuropathy preceded quantifiable, clinically significant decline in both patient‐reported (per MD Anderson Dysphagia Inventory; MDADI) and clinician‐rated (per Modified Barium Swallow Study; MBS) swallowing function . Likewise, the investigators recently published a large survey of 889 long‐term OPC survivors in which LCNP was significantly associated with excess symptom burden and had the greatest impact on swallowing/ chewing and voice/speech symptoms among the 22 symptom items rated using the MD Anderson Symptom Inventory Head and Neck Cancer Module (MDASI‐HN), a validated multi‐symptom survey instrument …”

Section: Introductionmentioning

confidence: 99%

“…1 Likewise, the investigators recently published a large survey of 889 long-term OPC survivors in which LCNP was significantly associated with excess symptom burden and had the greatest impact on swallowing/ chewing and voice/speech symptoms among the 22 symptom items rated using the MD Anderson Symptom Inventory Head and Neck Cancer Module (MDASI-HN), a validated multi-symptom survey instrument. 25 Previous literature also specifically implicates LCNP as a major contributor to late radiation associated dysphagia (late-RAD). 20,21 Patients with late RAD often have clinically detectable LCNP with unilateral paralysis, muscle wasting leading to atrophy of lingual and pharyngeal musculature with clinical series supporting a prominent role of nerve injury in the functional decline experienced by these patients.…”

Section: Introductionmentioning

confidence: 99%

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Swallowing‐related outcomes associated with late lower cranial neuropathy in long‐term oropharyngeal cancer survivors: cross‐sectional survey analysis

et al. 2019

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Background The purpose of this study was to quantify the association of late lower cranial neuropathy (late LCNP) with swallowing‐related quality of life (QOL) and functional status among long‐term oropharyngeal cancer (OPC) survivors. Methods Eight hundred eighty‐nine OPC survivors (median survival time: 7 years) who received primary treatment at a single institution between January 2000 and December 2013 completed a cross‐sectional survey (56% response rate) that included the MD Anderson Dysphagia Inventory (MDADI) and self‐report of functional status. Late LCNP events ≥3 months after cancer therapy were abstracted from medical records. Multivariate models regressed MDADI scores on late LCNP status adjusting for clinical covariates. Results Overall, 4.0% (n = 36) of respondents developed late LCNP with median time to onset of 5.25 years post‐treatment. LCNP cases reported significantly worse mean composite MDADI (LCNP: 68.0 vs no LCNP: 80.2; P < .001). Late LCNP independently associated with worse mean composite MDADI (β = −6.7, P = .02; 95% confidence interval [CI], −12.0 to −1.3) as well as all MDADI domains after multivariate adjustment. LCNP cases were more likely to have a feeding tube at time of survey (odds ratio [OR] = 20.5; 95% CI, 8.6‐48.9), history of aspiration pneumonia (OR = 23.5; 95% CI, 9.6‐57.6), and tracheostomy (OR = 26.9; 95% CI, 6.0‐121.7). Conclusions In this large survey study, OPC survivors with late LCNP reported significantly poorer swallowing‐related QOL and had significantly higher likelihood of poor functional status. Further efforts are necessary to optimize swallowing outcomes to improve QOL in this subgroup of survivors.

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Section: Discussionsupporting

confidence: 89%

Section: Discussionsupporting

confidence: 53%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Swallowing‐related outcomes associated with late lower cranial neuropathy in long‐term oropharyngeal cancer survivors: cross‐sectional survey analysis

et al. 2019

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Dysphagia After Primary Transoral Robotic Surgery With Neck Dissection vs Nonsurgical Therapy in Patients With Low- to Intermediate-Risk Oropharyngeal Cancer

Hutcheson

Warneke

Yao

et al. 2019

JAMA Otolaryngol Head Neck Surg

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for the MD Anderson Head and Neck Cancer Symptom Working Group IMPORTANCE A major goal of primary transoral robotic surgery (TORS) for oropharyngeal cancer is to optimize swallowing outcomes by personalized treatment based on pathologic staging. However, swallowing outcomes after TORS are uncertain, as are the outcomes compared with nonsurgical options. OBJECTIVES To estimate rates of acute dysphagia and recovery after TORS and to compare swallowing outcomes by primary treatment modality (TORS or radiotherapy). DESIGN, SETTING, AND PARTICIPANTSThis case series study was a secondary analysis of prospective registry data from 257 patients enrolled from March 1, 2015, to February 28, 2018, at a single academic institution who, according to the AJCC Staging Manual, 7th edition TNM classification, had low-to intermediate-risk human papillomavirus-related oropharyngeal squamous cell carcinoma possibly resectable by TORS. EXPOSURE Patients were stratified by primary treatment (75 underwent TORS and 182 received radiotherapy). MAIN OUTCOMES AND MEASURESModified barium swallow (MBS) studies graded per Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) and the MD Anderson Symptom Inventory-Head and Neck Module (MDASI-HN) questionnaires were administered at standard intervals. Prevalence and severity of dysphagia were estimated per DIGEST before and after TORS and 3 to 6 months after treatment. Moderate-severe dysphagia (DIGEST grade Ն2) was assessed using logistic regression and compared by primary treatment group. The MDASI swallowing symptom severity item scores during and after radiotherapy were compared using generalized estimating equations by treatment status at the start of radiotherapy, after induction, and after TORS. RESULTS A total of 257 patients (mean [SD] age, 59.54 [9.07] years; 222 [86.4%] male) were included in the study. Dysphagia severity (per DIGEST) was significantly worse after TORS (r = −0.63; 95% CI, −0.78 to −0.44): 17 patients (22.7%; 95% CI, 13.8%-33.8%) had moderate-severe (DIGEST grade Ն2) acute post-TORS dysphagia significantly associated with primary tumor volume (odds ratio, 1.43; 95% CI, 1.11-1.84). DIGEST improved by 3 to 6 months but remained worse than that at baseline; at 3 to 6 months, the number of patients with DIGEST grade 2 or higher dysphagia was 5 (6.7%; 95% CI, 2.2%-14.9%) after primary TORS and 29 (15.9%; 95% CI, 10.9%-22.1%) after radiotherapy. At the start of radiotherapy, MDASI swallowing symptom severity item scores were significantly worse in the post-TORS group compared with postinduction (mean [SD] change, 2.6 [1.1]) and treatment-naive (mean [SD] change, 1.7 [0.3]) patients. This result inverted at radiotherapy end, and all groups converged at 3 to 6 months.CONCLUSIONS AND RELEVANCE Subacute swallowing outcomes were similar regardless of primary treatment modality among patients with low-to intermediate-risk oropharyngeal squamous cell carcinoma.

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Radical Radiotherapy Should Remain the Standard of Care for Carcinoma Oropharynx—Reply

Hutcheon

Gross

Fuller

2020

JAMA Otolaryngol Head Neck Surg

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Symptom Burden Associated With Late Lower Cranial Neuropathy in Long-term Oropharyngeal Cancer Survivors

Cited by 25 publications

References 44 publications

Swallowing‐related outcomes associated with late lower cranial neuropathy in long‐term oropharyngeal cancer survivors: cross‐sectional survey analysis

Swallowing‐related outcomes associated with late lower cranial neuropathy in long‐term oropharyngeal cancer survivors: cross‐sectional survey analysis

Dysphagia After Primary Transoral Robotic Surgery With Neck Dissection vs Nonsurgical Therapy in Patients With Low- to Intermediate-Risk Oropharyngeal Cancer

Radical Radiotherapy Should Remain the Standard of Care for Carcinoma Oropharynx—Reply

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