Dysphagia in Head and Neck Cancer Patients: Pretreatment Evaluation, Predictive Factors, and Assessment during Radio-Chemotherapy, Recommendations

Abstract

Progress in head and neck cancer (HNC) therapies has improved tumor response, loco-regional control, and survival. However, treatment intensification also increases early and late toxicities. Dysphagia is an underestimated symptom in HNC patients. Impairment of swallowing process could cause malnutrition, dehydration, aspiration, and pneumonia. A comprehensive literature review finalized in May 2012 included searches of electronic databases (Medline, Embase, and CAB abstracts) and scientific societies meetings materials (American Society of Clinical Oncology, Associazione Italiana Radioterapia Oncologica, Associazione Italiana di Oncologia Cervico-Cefalica, American Head and Neck Society, and European Society for Medical Oncology). Hand-searches of HNC journals and reference lists were carried out. Approximately one-third of dysphagia patients developed pneumonia requiring treatment. Aspiration pneumonia associated mortality ranged from 20% to 65%. Unidentified dysphagia caused significant morbidity, increased mortality, and decreased the quality of life. In this review we underline definition, causes, predictive factors of dysphagia and report on pretreatment and on-treatment evaluation, suggesting some key points to avoid underestimation. A multi-parameter assessment of swallowing problems may allow an earlier diagnosis. An appropriate evaluation might lead to a better treatment of both symptoms and cancer.

Improving guideline sensitivity and specificity for the identification of proactive gastrostomy placement in patients with head and neck cancer

“…Treatment for head and neck cancer, particularly chemoradiotherapy, has been found to cause dysphagia or increase the severity of an existing swallowing impairment . A recent systematic review reported the incidence of dysphagia was 22% to 62% posttreatment . A further recent study has shown that patients with aspiration are also more likely to have had significant weight loss or a lower body mass index (BMI) …”

Prevalence of hospital malnutrition in cancer patients: a sub-analysis of the PREDyCES® study

“…On the other hand, in patients with neurodegenerative conditions, dementia and in very elderly patients, the presence of dysphagia and malnutrition could be both cause and consequence of functional decline, in a cycle in which dysphagia causes malnutrition, malnutrition contributes to functional decline, and functional decline aggravates dysphagia symptoms 8,13 . Dysphagia's most important complication is aspiration pneumonia [14][15][16] , which is responsible for 20% to 65% of deaths in head and neck cancer patients 17 , and is the most important cause of mortality in patients with neurodegenerative diseases 18 . Recent studies suggest that in very elderly patients deglutition rehabilitation could provide an improvement in nutritional status as well as a decrease in the incidence of pneumonia 19 .…”

Impact of weight loss in patients with head and neck carcinoma undergoing radiotherapy: is it an underestimated phenomenon? A radiation oncologist’s perspective

“…1,3,[32][33][34]37 Nonetheless, weight loss has not been properly considered during HN treatment plans. It is important that clinicians are capable to recognize patients at risk for critical weight loss with the goal of providing the proper supportive care.…”