Grading Dysphagia as a Toxicity of Head and Neck Cancer: Differences in Severity Classification Based on MBS DIGEST and Clinical CTCAE Grades

Abstract

Clinician-reported toxicity grading through common terminology criteria for adverse events (CTCAE) stages dysphagia based on symptoms, diet, and tube dependence. The new dynamic imaging grade of swallowing toxicity (DIGEST) tool offers a similarly scaled five-point ordinal summary grade of pharyngeal swallowing as determined through results of a modified barium swallow (MBS) study. This study aims to inform clinicians on the similarities and differences between dysphagia severity according to clinical CTCAE and MBS-derived DIGEST grading. A cross-sectional sample of 95 MBS studies was randomly selected from a prospectively-acquired MBS database among patients treated with organ preservation strategies for head and neck cancer. MBS DIGEST and clinical CTCAE dysphagia grades were compared. DIGEST and CTCAE dysphagia grades had "fair" agreement per weighted κ of 0.358 (95% CI .231-.485). Using a threshold of DIGEST ≥ 3 as reference, CTCAE had an overall sensitivity of 0.50, specificity of 0.84, and area under the curve (AUC) of 0.67 to identify severe MBS-detected dysphagia. At less than 6 months, sensitivity was 0.72, specificity was 0.76, and AUC was 0.75 while at greater than 6 months, sensitivity was 0.22, specificity was 0.90, and AUC was 0.56 for CTCAE to detect dysphagia as determined by DIGEST. Classification of pharyngeal dysphagia on MBS using DIGEST augments our understanding of dysphagia severity according to the clinically-derived CTCAE while maintaining the simplicity of an ordinal scale. DIGEST likely complements CTCAE toxicity grading through improved specificity for physiologic dysphagia in the acute phase and improved sensitivity for dysphagia in the late-phase.

High prevalence of malnutrition and nutrition impact symptoms in older patients with cancer: Results of a Brazilian multicenter study

“…In another study in head and neck cancer, patients had been subjected to multiple treatments, either in combination or isolated, and thus had a greater expectation of adverse effects of treatment, including problems with swallowing. 42 Moreover, the prevalence of dry mouth was significantly higher in older patients compared with those aged ≤50 years. Dry mouth is a common condition in older individuals; it has been associated with increasing age, female sex, and white race, 43,44 and it should be considered in the construction of nutritional therapeutic plans for food-quality adjustments.…”

Prospective instrumental evaluation of swallowing, tongue function, and QOL measures following transoral robotic surgery alone without adjuvant therapy

“…The DIGEST rating system is a reliable validated tool that is simple to score and can grade the degree of pharyngeal phase swallow impairment based on safety and efficiency components of the swallow. This scale offers a 5‐point ordinal summary grade similar to that used in the CTCAE, with fair agreement between the 2 scales . The PSS is a reliable validated tool to assess the impact of treatment on diet, ability to eat out, and speech understandability.…”

“…This scale offers a 5-point ordinal summary grade similar to that used in the CTCAE, with fair agreement between the 2 scales. 46 The PSS is a reliable validated tool to assess the impact of treatment on diet, ability to eat out, and speech understandability. This objective tool has been employed to measure these outcomes across head and neck tumor sites and treatments.…”

Patient‐reported versus physiologic swallowing outcomes in patients with head and neck cancer after chemoradiation

“…The DIGEST grading system of VFSS offers a novel and efficient way of characterizing the most important endpoints of swallow physiology. This method provides an effective means for standardizing VFSS analysis of safety and efficiency profiles of pharyngeal swallowing . Further studies are necessary in larger samples to assess DIGEST sensitivity to changes in swallow function over time, as well as its correlation with patient‐reported outcomes.…”

“…[22][23][24] In a longitudinal cluster analysis of 238 consecutive patients with HNC, varying patterns of swallowing dysfunction could be identified depending on time since RT; roughly 16% of these patients had substantial late burden of severe persistent or progressive dysphagia. 25 Due to the cross-sectional design of this study, we are unable to report changes in swallow function over time for each individual. Further investigation using repeated measures design in a larger cohort is warranted.…”