Bruce H. Campbell, Kristine Spinelli, Anne M. Marbella, Katherine B. Myers, Joan C. Kuhn, Peter M. Layde. Aspiration, Weight Loss, and Quality of Life in Head and Neck Cancer Survivors. Arch Otolaryngol Head Neck Surg. 2004;130(9):1100–1103. doi:10.1001/archotol.130.9.1100
To determine associations between objective assessments (swallowing function and weight change) and subjective quality-of-life (QOL) measures.
Observational case series using clinical testing and questionnaires.
University hospital-based tertiary clinical practice.
Convenience sample of 5-year survivors of head and neck cancer (62 nonlaryngectomy survivors were studied).
Objective testing included examination, weight history, videofluoroscopic swallow studies (VFSS), and oropharyngeal swallowing efficiency (OPSE). Subjective testing included QOL questionnaires (University of Washington Quality-of-Life [UWQOL] Scale, Performance Status Scale for Head and Neck Cancer Patients [PSS-HN], Functional Assessment of Cancer Treatment–General [FACT-G] Scales, and Functional Assessment of Cancer Therapy–Head and Neck [FACT-H&N] Scale).
Main Outcome Measures
Aspiration (identified by VFSS), weight change, and QOL measures.
Aspiration was associated with the decreased QOL scores in chewing, swallowing, normalcy of diet, and additional concerns of the FACT-H&N Scale. No association was found between aspiration and willingness to eat in public, subjective understandability, or any of the FACT-G scales. Of the nonlaryngectomy survivors, 27 (44%) demonstrated some degree of aspiration during VFSS. Associations were found between aspiration, primary tumor T stage, weight change, and OPSE. Aspirators lost a mean of 10.0 kg from precancer treatment weight, while nonaspirators gained a mean of 2.3 kg (P<.001). Mean OPSE scores were 69 for nonaspirators and 53 for aspirators (P = .01).
Almost half of long-term nonlaryngectomy head and neck cancer survivors demonstrated at least some degree of aspiration. The presence of aspiration is associated with substantial weight loss, advanced initial tumor stage, diminished oropharyngeal swallowing efficiency, and lower scores on a variety of QOL scales.
The lingering effects of head and neck cancer treatment can have a lasting impact on the survivor's quality of life (QOL). Head and neck cancer survivors (ie, persons treated for cancers of the oral cavity, oropharynx, hypopharynx, larynx, and neck) often undergo a combination of surgery, radiation therapy, and chemotherapy. The treatment results in a variety of long-term effects including xerostomia (dry mouth), dental decay/loss, numbness, tissue loss, loss of taste, and fibrosis. As a result, some survivors experience persistent swallowing difficulties and aspiration long after completion of therapy. The combination of cancer and its treatment can have a significant impact on the survivor's ability to eat.
Persistent swallowing problems have been studied in the early posttreatment period. Pauloski et al1 described 38 patients who were studied with videofluoroscopy at 0, 1, 3, 6, and 12 months after oral cavity and oropharyngeal resections. Despite an expectation that there would be a steady improvement in swallowing efficiency, there was no progressive recovery seen. The function documented at 3 months was equivalent to that seen at 12 months. The investigators found that pharyngeal transit time increased at 1, 3, and 6 months and was back to baseline by 12 months. Oropharyngeal swallowing efficiency (OPSE) remained significantly diminished at 12 months. In another important study evaluating pharyngeal function in early cancer survivors, Lazarus et al2 demonstrated that pharyngeal motility was affected by chemotherapy and radiation therapy if the larynx and tongue base were included in the radiation port.
Long-term survivors can have demonstrable QOL effects years after treatment. Zelefsky et al3 received questionnaires from 29 survivors who had undergone surgery and radiation therapy for oral cavity and oropharyngeal cancers 7 years (median) prior to the survey. Advanced-stage cancer and tongue base primary tumor were associated with a persistent impact on QOL compared with early-stage and non–tongue base cancers.
In the present study, we determined the prevalence of aspiration among cancer-free 5-year survivors of head and neck cancer and then compared both objective and subjective measures of cancer treatment effects among the aspirators and nonaspirators.
A cross-sectional convenience sample of head and neck cancer survivors was recruited from the Medical College of Wisconsin [MCW] Department of Otolaryngology & Communication Sciences (located in the MCW & Froedtert Clinic, Milwaukee) and from the Zablocki Veterans Affairs Medical Center Otolaryngology Clinic, Milwaukee. Each survivor had been originally treated at least 5 years prior to entry and had been free of all cancer for at least 3 years. Each survivor had been evaluated at 1 of the 2 institutions prior to treatment and had been followed up subsequently.
This project was part of a larger study of the long-term effects of head and neck cancer treatment. Survivors underwent a battery of functional tests and QOL questionnaires. Each underwent a targeted physical examination, an oral cavity/dental evaluation, and a medical record review for stage, treatment, and weight history. Prior approval was obtained from the MCW Institutional Review Board and Human Research Review Committee. A team including an otolaryngologist, a speech pathologist, a gastrointestinal radiologist, an oral surgeon, and a research nurse performed the testing. Survivors were reimbursed for travel expenses and participation. For this portion of the study, survivors underwent a videofluoroscopic swallow study (VFSS) and videofluoroscopic evaluation with an oropharyngeal swallowing efficiency (OPSE) measurement.4 Subjective testing included a battery of QOL instruments as well as locally prepared questions querying concern about cancer recurrence and attitudes toward tobacco.
Four validated QOL scales were administered to the survivors following the format used in our prior study.5 The University of Washington Quality-of-Life (UWQOL) Scale6 is an instrument aimed primarily at head and neck cancer patients that provides a series of choices in several domains. The patient chooses the statement most closely reflecting his or her current situation in pain, disfigurement, activity, recreation/entertainment, employment, eating (chewing and swallowing), speech, and shoulder disability. The choices are then rescaled into a 0 to 100 format, with 100 representing the best possible function for that domain. The Performance Status Scale for Head and Neck Cancer Patients (PSS-HN)7 is a 3-domain questionnaire that gives the patient a series of statements to choose from describing eating in public, understandability of speech, and normalcy of diet. The Functional Assessment of Cancer Treatment–General (FACT-G) questionnaire8 is a general QOL instrument that asks the patient to rate whether a statement is "not at all" to "very much" true over the past 7 days. Domains of the FACT-G include physical well-being, social/family well-being, emotional well-being, and functional well-being. The Functional Assessment of Cancer Therapy–Head and Neck (FACT-H&N Scale)9 is a series of additional concerns related to the head and neck region that are written in the same style as the FACT-G questions. The additional concerns of the FACT-H&N Scale include oral comfort, breathing, voice, eating, appearance, tobacco, alcohol, and communication.
"Weight change" was calculated by comparing survivors' self-reported "usual" precancer treatment weight with the weight measured at the time they underwent the study.
A gastrointestinal radiologist and a speech and language pathologist, who were blinded to the results of the quality-of-life questionnaires, performed the VFSSs. Survivors were classified by the radiologist (K.S.) as being "aspirators" if there was any evidence of the swallowed bolus reaching or extending below the level of the vocal cords. Survivors were classified as being "nonaspirators" if there was no evidence of barium penetration into the larynx or if a small amount of the barium transiently enters the laryngeal vestibule without reaching the level of the vocal folds. The response to aspiration was classified as given in Table 1. Further analysis grouped all survivors into either "aspirators" or "nonaspirators."
As an extension of the VFSS, an oropharyngeal swallowing efficiency was calculated from the videotapes.4 Frame-by-frame video analysis was used to determine the measures needed for the calculations. A single speech and language pathologist (J.C.K.) calculated all of the OPSE scores. Periodically, studies were reviewed and rerated to assure consistency. Oropharyngeal swallowing efficiency is the ratio of the percentage of bolus swallowed to the total oral and pharyngeal swallowing times and is calculated as follows:
OPSE = 100 − (ORES + PRES + ASPB + ASPD)/ (OTT + PDT + PRT),
where ORES indicates oral cavity residue (the subjective estimate of the approximate percentage of bolus remaining in the oral cavity after completion of the first swallow of a bolus); PRES, pharyngeal residue (the subjective estimate of the approximate percentage of bolus remaining in the pharyngeal cavity after completion of the first swallow of a bolus); ASPB, aspiration before the swallow (the subjective estimate of the approximate percentage of aspiration before the swallow); ASPD, aspiration during the swallow (the subjective estimate of the approximate percentage of aspiration during the swallow); OTT, oral transit time (the time in seconds from the onset of bolus movement in the mouth until the bolus head reaches the point where the lower rim of the mandible crosses the tongue base [point A]); PDT, pharyngeal delay time (the time from point A to the first laryngeal elevation [point B]); and PRT, pharyngeal response time (the time from point B until the bolus tail passes through the cricopharyngeal region). Thus, the OPSE scores decrease as aspiration increases, as transit time increases, or as percentage of bolus swallowed decreases.
Comparisons of demographic and cancer characteristics between the aspirators and nonaspirators were performed. χ2 Tests were used to detect differences in the categorical variables such as race, sex, cancer site, initial primary tumor T stage, overall tumor stage, and treatment between aspirators and nonaspirators. Analyses of variance were calculated to compare the mean values of age, weight change, OPSE score, and QOL measures between the aspirators and nonaspirators.
A total of 62 nonlaryngectomy survivors were included in this analysis. Weight information was available for each of the survivors.
Table 1 gives the results of the VFSS examinations. Of the 62 nonlaryngectomy oral feeding survivors tested, 35 (56%) demonstrated no evidence of aspiration and 27 (44%) had at least some evidence of aspiration, 14 of whom demonstrated an appropriate cough to clear the barium. However, 13 had a diminished response to the aspiration, including 8 who demonstrated neither detection nor response to the penetration.
Table 2 gives demographic information on the 62 patients. Initial primary T stage showed an association between advanced stage and the likelihood of aspiration (P = .03). Using a χ2 analysis, there was no statistical difference between the "aspirators" and the "nonaspirators" by sex, tumor site, tumor treatment, or tumor stage.
Table 3 shows the associations between aspiration status and several objective and subjective measures. Higher scores reflect better function for all of the scales. The presence of aspiration was associated with objective measures of weight change and decreased OPSE. Aspiration was associated with lower subjective scores for UWQOL chewing, UWQOL swallowing, PSS-HN normalcy of diet, and the global score of additional head and neck concerns on the FACT-H&N Scale. Aspiration was not associated with objective measurement of age at the time of the study or length of time since completion of therapy. In addition, aspiration was not associated with several subjective measures of QOL including UWQOL pain, UWQOL sense of disfigurement, UWQOL activity level, UWQOL speech, PSS-HN willingness to eat in public, PSS-HN understandability of speech, or any of the FACT-G well-being scales.
The QOL for an individual head and neck cancer survivor can depend on simple pleasures such as the enjoyment of food, a decent night's sleep, and rewarding social interaction. The QOL of the survivor reflects the gap between the survivor's perceived reality and his or her expectations or wishes.10 The impact of cancer and its treatment on swallowing function can widen this gap substantially.
In the early months after completion of treatment, head and neck cancer survivors can expect a gradual return to baseline function of some of the parameters that are measured in standard QOL evaluations. Hammerlid et al11 demonstrated that measures of global QOL (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire 30 [EORTC QLQ-30]) and a head and neck–specific module (Quality of Life Questionnaire—Head and Neck 35 [QLQ-H&N 35]) in the first 3 years show improvement in mental distress, global QOL, and pain. Some of the scales more closely associated with specific functions do not show improvement; these include dry mouth, senses, teeth, and trismus. Further improvement beyond 3 years was not expected.
Cancer patients who have survived 5 years beyond treatment have not been systematically studied to any great extent. This project sought to identify lingering QOL concerns and to determine associations between subjective and objective measures. Several interesting findings emerged from the data that focused on swallowing.
Several subjective QOL questionnaire scales reflect difficulty with swallowing. The subjective questions that most directly reflect swallowing difficulties were associated with the objective discovery of aspiration on the VFSS. For example, decreased UWQOL chewing, the UWQOL swallowing, and the PSS-HN normalcy of diet scores were all associated with the presence of aspiration. Conversely, scales that reflect nonswallowing domains were appropriately not associated with aspiration. Worsened scores on the FACT-H&N additional concerns scale were also associated with aspiration. The scale includes a number of questions that cover swallowing issues as well as dryness, breathing, voice, disfigurement, tobacco, alcohol, and communication. The presence of this association might reflect the strength of the swallowing problems within the global scale and its relative importance to the individual.
An unexpectedly high proportion of oral feeding–dependent nonlaryngectomy survivors demonstrated significant laryngeal penetration on the VFSS. Of the 62 survivors, 27 (44%) had some degree of aspiration, and almost half of these displayed inadequate airway protection. The long-term physiologic effect of this degree of aspiration is not known. The presence of aspiration was associated with a higher tumor stage at the primary site, although no association was seen between aspiration and other demographic characteristics including site of the initial tumor, age, sex, and type of treatment. Of note, as was customary in the era when these individuals were first treated, none of the survivors in this analysis received chemotherapy during their initial therapy. The lack of associations between the various demographic groups and aspiration reflects either the small sample size available for study or the possibility of continued adaptation during the years after treatment.
Aspiration of barium on the VFSS was associated with weight change (ie, "usual" weight minus current weight). Survivors with any evidence of aspiration had a mean weight loss of 10.0 kg, while nonaspirators had a mean weight gain of 2.3 kg. This observation might allow clinicians to look more carefully at their patients in the future for evidence of aspiration.
Decreased OPSE scores were associated with aspiration as well. The OPSE reflects the ability of the individual to move a food bolus from the oral cavity to the cervical esophagus. This reflects a greater transit time, increased residue with each swallow, and a greater degree of aspiration.
In summary, chronic aspiration was associated with diminished subjective QOL for a number of domains and scales. In addition, weight loss and diminished OPSE were associated with persistent aspiration in head and neck cancer survivors. Finding such a high percentage of survivors who had evidence of persistent aspiration was unexpected. Persistent weight loss in long-term head and neck cancer survivors should alert the clinician to possible aspiration. The long-term physiologic effect of chronic aspiration in this group of patients is unknown. Interventions to reduce aspiration in head and neck cancer survivors might improve their QOL.
Correspondence: Bruce H. Campbell, MD, Department of Otolaryngology & Communication Sciences, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226-3522 (firstname.lastname@example.org).
Submitted for publication July 28, 2003; final revision received January 22, 2004; accepted March 2, 2004.
This study was supported by grant R01 CA78940 from the National Cancer Institute, Bethesda, Md.
This study was presented at "Cancer Survivorship: Resilience Across the Lifespan," National Cancer Institute; June 2, 2002; Washington, DC.
We gratefully acknowledge the contribution of the late Judith I. Kulpa, MS, CCC-SLP, who participated in many of the videofluoroscopic swallow studies.