Head and neck oncological patients suffer from various functional, physical, and emotional impairments due to both the primary illness and the secondary consequences of the tumor treatment [
In order to assist people with dysphagia to adjust to and live successfully with the sequelae of the primary condition, speech pathologists managing this caseload need to ensure posttreatment services are available [
Evidence-based practice (EBP) is hailed to be paramount in the practice of speech pathology [
Several reviews have been published about the outcomes after radiotherapy and/or chemotherapy in HNC patients (e.g., Frowen and Perry [
A systematic review was conducted to describe the effects of radiotherapy and/or chemotherapy on functions of the upper aerodigestive tract in patients with HNC and examined the evidence of interventions by speech pathologists.
A systematic literature search was performed by two independent reviewers. The electronic biomedical databases PubMed and Embase were used (search period from start of database until 5 May 2016). The searches were limited to English language publications. In PubMed the MeSH terms
Search strategies per literature database.
Database and search terms | Limits | Number of records | |
---|---|---|---|
Subject headings |
|
English | 201 |
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|||
Subject headings |
|
Adult: 19+ years |
304 |
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Free text |
|
Publication date: last year | 397 |
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Free text |
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Publication date: |
148 |
In Embase the thesaurus terms
To identify the most recent publications, the search was complemented by free text words in PubMed and Embase (for the period after April 2015 until May 2016). Truncation symbols and wildcards were used to search for variant forms of words or word extensions:
Only articles presenting both pre- and postintervention data of the upper aerodigestive tract functions of the participants were included. Review articles and studies with a population sample of less than 20 patients were excluded, as well as experiments on animals or articles not published in English. Furthermore, studies published before 1990, case reports, expert opinions, and articles describing combinations of therapy including surgical interventions were excluded.
Final decisions on inclusion were made based on the original articles by consensus between two expert reviewers in accordance with the PRISMA statement [
Using MeSH or thesaurus terms, 304 articles were located in PubMed and 201 in Embase. Free text word searches resulted in another 148 articles in PubMed and 397 in Embase. The combination of these searches, without overlap, yielded 947 articles. Figure
PRISMA flowchart.
Table
Methodological quality based on QualSyst critical appraisal tool by Kmet et al. 2004 [
Reference | Kmet score (%) | Methodological quality |
NHMRC level of evidence |
---|---|---|---|
Aaltonen et al. 2014 [ |
25/28 (89%) | Strong | II |
Ackerstaff et al. 2009 [ |
22/28 (79%) | Good | II |
Agarwal et al. 2009 [ |
19/24 (79%) | Good | III-2 |
Agarwal et al. 2011 [ |
17/20 (85%) | Strong | III-3 |
Akst et al. 2004 [ |
17/20 (85%) | Strong | III-3 |
Al-Mamgani et al. 2012 [ |
19/20 (95%) | Strong | III-3 |
Al-Mamgani et al. 2012 [ |
21/22 (95%) | Strong | III-3 |
Al-Mamgani et al. 2013 [ |
21/22 (95%) | Strong | III-3 |
Al-Mamgani et al. 2015 [ |
21/22 (95%) | Strong | III-3 |
Bansal et al. 2004 [ |
14/24 (58%) | Adequate | III-3 |
Bibby et al. 2008 [ |
18/22 (82%) | Strong | III-2 |
Bottomley et al. 2014 [ |
24/28 (86%) | Strong | II |
Buchbinder et al. 1993 [ |
14/26 (54%) | Adequate | III-1 |
Caudell et al. 2010 [ |
21/22 (95%) | Strong | III-3 |
Christianen et al. 2015 [ |
21/22 (95%) | Strong | III-3 |
Cohen et al. 2006 [ |
19/20 (95%) | Strong | III-3 |
Dornfeld et al. 2007 [ |
17/22 (77%) | Strong | III-3 |
Dijkstra et al. 2007 [ |
19/22 (86%) | Strong | III-3 |
Feng et al. 2007 [ |
19/22 (86%) | Strong | III-3 |
Feng et al. 2010 [ |
20/20 (100%) | Strong | III-3 |
Frowen et al. 2010 [ |
22/22 (100%) | Strong | III-2 |
Haderlein et al. 2014 [ |
17/20 (85%) | Strong | III-3 |
Hutcheson et al. 2014 [ |
18/20 (90%) | Strong | III-3 |
Jacobi et al. 2016 [ |
17/18 (94%) | Strong | III-3 |
Karlsson et al. 2015 [ |
26/28 (93%) | Strong | II |
Karlsson et al. 2016 [ |
18/20 (90%) | Strong | III-3 |
Kazi et al. 2008 [ |
17/20 (85%) | Strong | III-2 |
Kerr et al. 2015 [ |
19/20 (95%) | Strong | III-2 |
Kotz et al. 2012 [ |
24/28 (86%) | Strong | II |
Kraaijenga et al. 2014 [ |
19/20 (95%) | Strong | III-3 |
Kumar et al. 2014 [ |
19/20 (95%) | Strong | III-2 |
Lazarus et al. 2014 [ |
19/20 (95%) | Strong | III-3 |
List et al. 1999 [ |
15/18 (83%) | Strong | III-3 |
McLaughlin et al. 2010 [ |
19/20 (95%) | Strong | III-3 |
Mittal et al. 2001 [ |
16/20 (80%) | Strong | III-3 |
Murry et al. 1998 [ |
11/20 (55%) | Adequate | III-3 |
Niedzielska et al. 2010 [ |
17/20 (85%) | Strong | III-2 |
Nourissat et al. 2010 [ |
23/26 (88%) | Strong | III-3 |
Ottoson et al. 2014 [ |
19/22 (86%) | Strong | III-3 |
Pauli et al. 2013 [ |
19/22 (86%) | Strong | III-3 |
Pauloski et al. 2006 [ |
18/20 (90%) | Strong | III-3 |
Rademaker et al. 2003 [ |
17/20 (85%) | Strong | III-3 |
Remmelts et al. 2013 [ |
18/20 (90%) | Strong | III-3 |
Salama et al. 2008 [ |
17/20 (85%) | Strong | III-3 |
Sanguineti et al. 2014 [ |
19/20 (95%) | Strong | III-3 |
Scrimger et al. 2007 [ |
18/20 (90%) | Strong | III-3 |
Spector et al. 1999 [ |
17/22 (77%) | Good | III-3 |
Starmer et al. 2014 [ |
18/20 (90%) | Strong | III-3 |
Stenson et al. 2010 [ |
16/20 (80%) | Strong | III-3 |
Strigari et al. 2010 [ |
17/20 (85%) | Strong | III-3 |
Tuomi et al. 2015 [ |
18/20 (90%) | Strong | III-2 |
Urdaniz et al. 2005 [ |
18/20 (90%) | Strong | III-2 |
Vainshtein et al. 2015 [ |
20/24 (83%) | Strong | III-3 |
van der Molen et al. 2011 [ |
24/26 (92%) | Strong | II |
van der Molen et al. 2012 [ |
16/20 (80%) | Strong | III-3 |
van der Molen et al. 2013 [ |
19/20 (95%) | Strong | III-3 |
Verdonck-de Leeuw et al. 1999 [ |
18/20 (90%) | Strong | III-2 |
Verdonck-de Leeuw et al. 2014 [ |
16/20 (80%) | Strong | III-2 |
Vlacich et al. 2014 [ |
18/20 (90%) | Strong | III-3 |
Wilson et al. 2011 [ |
18/20 (90%) | Strong | III-3 |
All 60 studies focused on different functions of the upper aerodigestive tract following radiotherapy and/or chemotherapy for HNC. The following constructs were evaluated across the different studies: communication (voice and speech), functions of the digestive tract (oral intake, weight loss, dysphagia, trismus, xerostomia, and tube dependency), QoL, and overall survival rates.
Table
Overview of included observational and intervention studies (
Reference | Subjects | Carcinoma | Staging | Topic | Evaluation technique | Treatment(s) | Follow-up | Key findings/author’s conclusions |
---|---|---|---|---|---|---|---|---|
Aaltonen et al. 2014 [ |
|
Glottic = 56 (100%) | T1a = 56 (100%) | V | Videolaryngostroboscopy |
Group 1: laser surgery ( |
6, 24 months | Similar overall voice quality for both groups. Laser surgery yielded more breathiness compared to RT |
|
||||||||
Ackerstaff et al. |
|
Oral cavity = 40 (19%) |
T3 = 65 (31%) |
V |
EORTC QLQ-C30 |
Group 1: intra-arterial cisplatin 4 weekly ( |
7 weeks; 3 months; 1, 2, 5 years | Both groups showed improved oral intake and voice quality, at 1-year follow-up often better compared to baseline |
|
||||||||
Agarwal et al. |
|
Glottic = 50 (100%) | T1 = 33 (66%) |
V | Voice analysis |
RT | 3–6 months | A trend for improvement in voice quality following RT was found |
|
||||||||
Agarwal et al. |
|
Oropharyngeal |
T1 |
D | Videofluoroscopy |
CRT | 2, 6, 12 months | Significant impairment of swallowing was found: most frequently residue and aspiration |
|
||||||||
Akst et al. |
|
Oral cavity = 12 (6%) |
T1 = 15 (8%) |
D | Presence of feeding tube |
CRT | 3, 6, 12, 24 months | A majority of patients did not need a tracheotomy but need a feeding tube during treatment. At 1-year follow-up most patients had a (nearly) normal oral intake. Patients with tumor stage IV and age ≥ 60 had prolonged feeding tube use and slower recovery |
|
||||||||
Al-Mamgani et al. |
|
Supraglottic = 121 (71%) |
T3 = 170 (100%) | V |
EORTC QLQ-C30 |
Group 1: CRT ( |
2, 4, 6 weeks; 3, 6, 12 months | Adding chemotherapy to RT did not diminish QoL or voice handicap |
|
||||||||
Al-Mamgani et al. |
|
Hypopharyngeal = 176 (100%) | T1 = 18 (10%) |
D |
Tube dependency |
Group 1: CRT ( |
2, 4, 6 weeks; 3, 6 months; 1, 2 years | CRT significantly improved functional outcome. Acute toxicity increased but late radiation side effects did not increase |
|
||||||||
Al-Mamgani et al. |
|
Glottic = 1050 (100%) | T1a = 551 (52%) |
V |
EORTC QLQ-C30 |
RT | 4, 6 weeks; 3, 6, 12, 18, 24, 36, 48 months | Excellent outcome with good QoL and VHI scores |
|
||||||||
Al-Mamgani et al. |
|
Glottic = 30 (100%) | T1a = 30 (100%) | V | Laryngoscopy |
Single vocal cord RT | 4, 6, 12 weeks; 6, 12, 18 months | Single vocal cord RT showed better voice quality compared to whole larynx RT |
|
||||||||
Bansal et al. |
|
Base of tongue = 20 (44%) |
Stage III = 17 (38%) |
V |
Acute and late morbidity scoring of skin, oropharyngeal mucosa, salivary glands, larynx, and oesophagus (LENT/SOMA) |
RT | 1, 4 months | During RT a decline in all QoL domains was found. QoL improved after 1 month but did not reach pre-RT levels |
|
||||||||
Bibby et al. |
|
Glottic = 30 (100%) | T1 = 21 (70%) |
V |
Voice analysis |
RT | 3, 6, 12 months | After RT expert-rated perceptual auditory outcomes, patient self-rated VAS and all subscales of VR-QoL showed significant improvement |
|
||||||||
Bottomley et al. |
|
Laryngeal |
T2 |
QoL | EORTC QLQ-C30 |
Group 1: sequential CRT ( |
6, 12, 18, 24, 36, 48 months | The HRQoL scores of the majority of patients returned to baseline after therapy. No group differences were found |
|
||||||||
Buchbinder et al. |
|
No details provided | No details provided | D | MIO | Group 1: RT + unassisted exercise |
2, 4, 6, 8, 10 weeks | The highest increase in MIO was reached in group 3 |
|
||||||||
Caudell et al. |
|
Nasal cavity = 3 (4%) |
Tx-2 = 28 (34%) |
D | Videofluoroscopy |
Group 1: CRT ( |
12 months | Mean dose to the larynx greater than 41 Gy and a receiving volume greater than 24% showed association with increased PEG dependency and aspiration |
|
||||||||
Christianen et al. |
|
Nasopharyngeal = 8 (3%) |
T1-T2 = 161 (68%) |
D | Grade of swallowing dysfunction according to the RTOG/EORTC Late Radiation Morbidity Scoring Criteria | Group 1: conventional RT ( |
6, 12, 18, 24 months | Patterns of swallowing dysfunction may be caused by radiobiological mechanisms of radiation induced damage and recovery. No group differences were found |
|
||||||||
Cohen et al. |
|
Oral cavity = 14 (26%) |
T0 = 3 (6%) |
D |
PSS-HN |
CRT | 3, 6, 12, 18, 24, 36, 48, 60 months | Most patients returned to pretreatment function (QoL and performance) by 12 months |
|
||||||||
Dornfeld et al. |
|
Oral cavity = 1 (4%) |
Tx = 2 (7%) |
V |
Weight |
CRT | 1 year | Speech, diet, and QoL outcomes showed an inverse relationship with the delivered radiation dose to the larynx |
|
||||||||
Dijkstra et al. |
|
Parotid = 4 (14%) |
No details provided | D | MIO | RT | 12–48 weeks | Increase in mouth opening was significantly less in the group of patients with trismus related to head and neck cancer and is difficult to treat with exercise therapy |
|
||||||||
Feng et al. |
|
Base of tongue = 19 (53%) |
T1 = 2 (5%) |
D |
Videofluoroscopy |
CRT | 3 months | Statistically significant dose-volume effect relationships for dysphagia and aspiration were found. Reducing the doses to the swallowing structures may improve swallowing |
|
||||||||
Feng et al. |
|
Base of tongue = 38 (52%) |
T1 = 9 (12%) |
D | Videofluoroscopy |
CRT | 3, 6, 12, 18, 24 months | Long-term measures of swallowing were slightly worse than pretherapy measures |
|
||||||||
Frowen et al. |
|
Base of tongue = 19 (24%) |
T1 = 11 (14%) |
D | Videofluoroscopy | Group 1: CRT ( |
3, 6 months | Swallowing in both groups was best at baseline; a decline at 3 months and an improvement at 6 months after therapy were shown. Baseline levels were not reached. Predictors for swallowing outcome were intoxications, tumor size, RT technique, and baseline level of swallowing. Patients who received conformal RT had a very low risk of penetration and aspiration of liquids by 6 months after treatment |
|
||||||||
Haderlein et al. |
|
Oropharyngeal = 3 (7%) |
T2 = 15 (33%) |
D |
PEG dependency |
CRT | 3–6- month intervals | Almost 50% of patients had deterioration of swallowing function after CRT |
|
||||||||
Hutcheson et al. |
|
Nasopharyngeal = 1 (2%) |
T1 = 16 (34%) |
D | Videofluoroscopy |
Group 1: RT ( |
6, 12, 24 months | Two years after therapy, mild deterioration of swallowing without chronic aspiration was found |
|
||||||||
Jacobi et al. |
|
Nasopharyngeal = 6 (18%) |
T1 = 6 (18%) |
V | Speech analysis | CRT | 10 weeks; 1 year | Received dose to tongue and velopharynx were most relevant for speech and voice quality |
|
||||||||
Karlsson et al. |
|
Laryngeal = 74 (100%) | T0 = 1 (1%) |
V |
EORTC QLQ-C30 |
Group 1: CRT + voice rehabilitation ( |
1, 6 months | Patients treated with voice rehabilitation experienced benefits of therapy on communication and HRQoL |
|
||||||||
Karlsson et al. |
|
Laryngeal = 40 (100%) | Tis = 2 (5%) |
V |
EORTC QLQ-C30 |
RT (1 subject received concomitant chemotherapy) | 1, 6, 12 months | One year after treatment most outcomes showed no significant improvements compared to baseline measurements |
|
||||||||
Kazi et al. |
|
Hypopharyngeal = 8 (38%) |
Stage III |
V | Voice analysis |
CRT | 1, 6, 12 months | Patients treated with CRT had a better voice quality compared to patients after total laryngectomy |
|
||||||||
Kerr et al. |
|
Tongue base = 77 (38%) |
T0-T1 = 42 (21%) |
V |
KPS |
Group 1: 3DCRT ( |
3, 6, 12, 24 months | IMRT showed better functional outcomes compared to 3DCRT, both 3–6 and 12–24 months after treatment |
|
||||||||
Kotz et al. |
|
Nasopharyngeal = 1 (4%) |
T2 = 1 (4%) |
D | PSS-HN (eating in public and normalcy of diet) |
Group 1: CRT + prophylactic swallowing therapy ( |
3, 6, 9, 12 months | Prophylactic swallowing therapy improves swallowing at 3 and 6 months; later there were no group differences |
|
||||||||
Kraaijenga et al. |
|
Nasopharyngeal = 4 (18%) |
T1 = 5 (23%) |
V |
Videofluoroscopy |
CRT | 2, 6 years | Functional swallowing and voice problems at 6 years after treatment were minimal, possibly due to preventive swallowing rehabilitation programs |
|
||||||||
Kumar et al. |
|
Tonsil = 19 (41%) |
T0 = 2 (4%) |
D | Videofluoroscopy | CRT | From <6 to >18 months | Aspiration and penetration were associated with dose and volume delivered to the floor of mouth muscles |
|
||||||||
Lazarus et al. |
|
Nasopharyngeal = 3 (10%) |
Stage I = 2 (7%) |
D |
Tongue strength, jaw ROM, and tongue ROM |
CRT | 3, 6 months |
Patients performed worse in oral outcomes, performance status, and QoL after treatment |
|
||||||||
List et al. |
|
Nasopharyngeal = 1 (2%) |
Stage III = 4 (6%) |
D |
KPS |
CRT | 1, 3, 6, 9, 12 months | Decline of QoL and functional aspects resolved 1 year after treatment; however, oral intake stayed restricted |
|
||||||||
McLaughlin et al. |
|
Nasopharyngeal = 9 (10%) |
Stage II = 1 (1%) |
D | Weight loss |
CRT | 6, 12 months | Patients treated with CRT could be managed without nutritional support via G-tube. Dysphagia at baseline and advanced tumor stage are associated with increased risk of longer G-tube dependency |
|
||||||||
Mittal et al. |
|
Nasopharyngeal = 4 (10%) |
Stage III = 5 (13%) |
D |
Videofluoroscopy |
Group 1: CRT with TDC ( |
3 months | Patients treated with TDC had better oral intake, swallowing function, and articulation |
|
||||||||
Murry et al. 1998 [ |
|
Oropharyngeal = 19 (52%) |
T3 |
D | HNRQ |
CRT | 6 months | During treatment QoL and swallowing function decreased acutely and significantly. Six months after therapy QoL exceeded pretreatment level. Recovery was site-specific: oropharyngeal tumor patients had poorest outcome, whereas hypopharyngeal tumor patients showed most rapid recovery. Physical recovery followed psychosocial recovery. Organ preservation treatment may improve swallowing after treatment |
|
||||||||
Niedzielska et al. |
|
Laryngeal = 45 (100%) | T1 = 24 (53%) |
V | Videolaryngostroboscopy |
RT | 1–3 years | All irradiated patients showed reduced vibration of the vocal cords. Except for some of the acoustic parameters, most data were comparable to a healthy control group ( |
|
||||||||
Nourissat et al. |
|
Oral cavity = 63 (12%) |
T1 = 329 (61%) |
D |
Weight |
RT | Direct posttherapy | The occurrence of adverse effects of RT appeared to be one of the main reasons for weight loss. Correlations were found between genetic factors associated with the adverse effects of cancer treatments |
|
||||||||
Ottoson et al. |
|
Oral cavity = 20 (20%) |
T1 = 11 (10%) |
D | Videofluoroscopy |
RT | 5 years | Dysphagia with aspiration was related to unintentional weight loss and a lower BMI |
|
||||||||
Pauli et al. |
|
Sinus, nose = 6 (8%) |
T0 = 5 (7%) |
D |
MIO |
Group 1: surgery ( |
3, 6, 12 months | Trismus was a major side effect of the treatment of head and neck cancer and deteriorates HRQoL |
|
||||||||
Pauloski et al. |
|
Nasopharyngeal = 8 (5%) |
Stage IV = 122 (72%) |
D | Videofluoroscopy |
Group 1: CRT ( |
1, 3, 6, 12 months | In both groups limitations in oral intake and diet after cancer treatment were significantly related to reduced laryngeal elevation and reduced cricopharyngeal opening due to treatment |
|
||||||||
Rademaker et al. |
|
Nasopharyngeal = 13 (5%) |
Stage II = 16 (6%) |
D | Percentage of oral intake |
CRT | 1, 3, 6, 12 months | Eating ability decreased during treatment and improved 12 months after treatment to near pretreatment levels |
|
||||||||
Remmelts et al. |
|
Glottic = 248 (100%) | Tis = 26 (10%) |
V | VHI (physical subscale) |
Group 1: RT ( |
12 months | VHI scores were comparable for both groups. Regarding laryngeal preservation surgery is the treatment of first choice |
|
||||||||
Salama et al. |
|
Nasopharyngeal = 4 (4%) |
Tx = 7 (7%) |
D | Videofluoroscopy |
CRT | 1-2 months | Improvement of swallowing ability compared to baseline was associated with advanced tumor stage |
|
||||||||
Sanguineti et al. |
|
Base of tongue = 54 (43%) |
T0 = 8 (6%) |
V | CTCAE |
Group 1: CRT ( |
3, 6, 12, 18, 24, 36, 48, 60 months | Mild voice changes were common and strictly correlated to mean dose to larynx and should be kept under 50 Gy |
|
||||||||
Scrimger et al. |
|
Nasopharyngeal = 10 (21%) |
T0 = 2 (4%) |
D |
Mouth saliva flow |
Group 1: RT ( |
3, 6, 12 months | Nonsurgery resulted in better QoL questionnaire scores compared to surgery. Patients with good saliva production did not exhibit better QoL after RT than patients with less saliva production |
|
||||||||
Spector et al. |
|
Glottic = 659 (100%) | T1 = 659 (100%) | V | Voice preservation | Group 1: low-dose RT ( |
5 years | Groups 2–4 had similar unaided laryngeal voice preservation rates; however group 1 had significant lower unaided laryngeal voice preservation |
|
||||||||
Starmer et al. |
|
Oropharyngeal = 71 (100%) | T1 = 24 (34%) |
D | Videofluoroscopy |
Group 1: CRT ( |
1–18 months | Patients undergoing nonsurgical treatment for oropharyngeal tumors were at risk for posttreatment dysphagia |
|
||||||||
Stenson et al. 2010 [ |
|
Buccal = 4 (3%) |
T1 = 9 (8%) |
D | Videofluoroscopy |
Group 1: CRT ( |
2, 4, 6, 8, 10, 12, 16, 20, 24, 30, 36 months | Ninety-two percent of all patients were able to maintain weight via oral route. |
|
||||||||
Strigari et al. |
|
Nasopharyngeal = 44 (70%) |
T1-T2 = 17 (23%) |
D | Saliva flow |
RT | 3, 6, 12, 18, 24 months | The mean score on the xerostomia related questionnaire increased (worsened) after RT and decreased (improved) over time in all patients |
|
||||||||
Tuomi et al. |
|
Supraglottic = 13 (19%) |
Tis = 2 (3%) |
V |
Acoustic analysis |
RT | 1 month | Patients treated for supraglottic tumors experienced more problems in eating and swallowing prior to therapy compared to glottic tumors and demonstrated significant HRQoL reduction after treatment. In contrast, glottic tumors presented with inferior voice quality |
|
||||||||
Urdaniz et al. |
|
Paranasal sinuses = 3 (5%) |
T2 = 2 (3%) |
QoL | EORTC QLQ-C30 |
Group 1: hyperfractionated concomitant boost RT + cisplatin ( |
1 month | QoL in both groups was relatively good. QoL improved in the follow-up period |
|
||||||||
Vainshtein et al. |
|
Base of tongue = 18 (45%) |
T1 = 8 (20%) |
D |
HNQoL |
CRT | 1, 3, 6, 12, 18, 24 months | At 6.5 years after therapy patients showed a stable or improved HRQoL in most domains comparable with baseline and 2 years after therapy |
|
||||||||
van der Molen et al. |
|
Nasopharyngeal = 7 (14%) |
T1 = 8 (16%) |
D | Videofluoroscopy |
Group 1: standard rehabilitation ( |
10 weeks | (Preventive) rehabilitation |
|
||||||||
van der Molen et al. |
|
Nonlaryngeal = 36 (65%) |
T1 = 8 (15%) |
V |
Acoustic analysis |
CRT | 10 weeks; 1 year | CRT effects 10 weeks after therapy were worse than 1 year after therapy, and both were worse than baseline |
|
||||||||
van der Molen et al. |
|
Nasopharyngeal = 7 (13%) |
T1 = 8 (15%) |
D | Videofluoroscopy |
CRT | 10 weeks; 1 year | A correlation between doses and structures was found for dysphagia and trismus |
|
||||||||
Verdonck-de Leeuw et al. |
|
Glottic = 60 (100%) | T1 = 60 (100%) | V | Videolaryngostroboscopy Voice quality rating |
RT | 0.5–10 years | Voice and its characteristics improved after treatment but did not reach pretreatment levels in half of the patients |
|
||||||||
Verdonck-de Leeuw et al. |
|
Oral/oropharyngeal = 95 (58%) |
No details provided | QoL | EORTC QLQ-C30 |
CRT | 6 weeks; 6, 12, 18, 24 months | Significant difference in HRQoL between survivors and nonsurvivors in favor of survivors was found |
|
||||||||
Vlacich et al. |
|
Sinus/nasal cavity = 2 (1%) |
Stage III = 42 (30%) |
D | PEG requirement | CRT | 12 months | IMRT dose to the inferior constrictor correlated with persistent dysphagia requiring prolonged PEG use |
|
||||||||
Wilson et al. |
|
Nasopharyngeal = 5 (3%) |
T1 = 37 (22%) |
D |
MDADI |
Group 1: CRT ( |
3, 6, 12 months | HRQoL deteriorated significantly after treatment. Little improvement may be expected 3 to 12 months after treatment |
3DCRT: 3D conformal radiotherapy; BMI: body mass index; CRT: chemoradiotherapy; CTCAE: common terminology criteria for adverse events; D: digestive tract; ECOG: Eastern Cooperative Oncology Group; EORTC QLQ-C30: European Organization for Research and Treatment of Cancer Quality of Life Questionnaire; EORTC QLQ-H&N35: European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Module Head and Neck Cancer; FACT-HN: functional assessment of cancer therapy-head and neck; FOIS: functional oral intake scale; GRBAS: grade, roughness, breathiness, asthenia, strain scale; HADS: hospital anxiety and depression scale; HNCI: head and neck cancer inventory; HNQoL: head and neck quality of life; HNRQ: head and neck radiotherapy questionnaire; HRQoL: health-related quality of life; IMRT: intensity-modulated radiation therapy; KPS: Karnofsky performance status scale; LENT/SOMA: late effects normal tissue-subjective, objective, management, analytic scales; MDADI: MD Anderson dysphagia inventory; MIO: maximum incisal opening; NOS: not otherwise specified; PEG: percutaneous endoscopic gastrostomy; PSS-HN: performance status scale for head and neck cancer patients; QoL: quality of life; RBHOMS: Royal Brisbane Hospital outcome measure for swallowing; ROM: range of motion; RT: radiotherapy; RTOG: Radiation Therapy Oncology Group; S-SECEL: Swedish version of the self-evaluation of communication experiences after laryngeal cancer; SPS: swallowing performance status scale; TDC: tissue/dose compensation; UWQoL: University of Washington Quality of Life Questionnaire; V: voice and/or speech; VAS: visual analog scale; VHI: voice handicap index; VHI-10: voice handicap index-10; VR-QoL: voice-related quality of life; XQoL: xerostomia questionnaire.
Twenty-four studies evaluated voice and/or speech function [
Nine studies [
All the studies reported good to excellent outcomes for voice quality at long-term follow-up. Some studies specifically reported pre- to posttreatment improvements of voice or speech quality following radiotherapy and/or chemotherapy [
Forty studies [
With regard to nutritional status, five studies [
Follow-up times in these studies range from immediately after therapy [
Nine studies reported impaired swallowing function following radiotherapy and/or chemotherapy [
Five studies [
Ackerstaff et al. [
Twenty-five studies [
Although three studies [
We assessed the speech pathology interventions against the following criteria: (a) whether a detailed description of the intervention was provided; (b) whether the authors provided a description of treatment duration and intensity; and (c) what the speech pathology intervention outcomes were. The reported efficacy of 14 speech pathology intervention studies aimed at addressing problems in dysphagia, speech, voice, and trismus is summarised in Table
Overview of speech pathology interventions aimed at addressing problems in dysphagia, speech, voice, and trismus (
Reference | Topic | General description of intervention and treatment intensity/duration | Description of specific exercises | Conclusions specific to therapy |
---|---|---|---|---|
Agarwal et al. |
Voice | All patients received counseling and voice therapy by a trained speech pathologist |
No description of exercises provided | Forty-seven of 50 patients showed compliance to the therapy. No specific conclusions of influence of provided therapy on primary outcomes described |
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Akst et al. |
Swallowing | Swallowing evaluation and intervention when clinically indicated | No description of exercises provided | No specific conclusions of influence of provided therapy on primary outcomes described |
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Buchbinder et al. |
Trismus | Six to 10 exercise sessions per day for a 10-week period | Group 1: unassisted exercises: reach maximum MIO and closing, jaw motion to left, right, and protrusively |
The first four weeks no differences between groups were found. After week 4 minimal improvements in groups 1 and 2 were found and group 3 still improved. The highest increment in MIO was reached in group 3 |
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Dijkstra et al. |
Trismus | Physical therapy for trismus, median of 4 sessions | Physical therapy consisting of |
MIO increases significantly after physical therapy. History of HNC decreases the effect of physical therapy, compared to other trismus patients |
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Frowen et al. |
Swallowing | All patients were seen by a speech pathologist as an aspect of regular care | No description of exercises provided | No specific conclusions of influence of provided therapy on primary outcomes described |
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Hutcheson et al. |
Swallowing | All patients received prophylactic swallowing therapy to avoid nothing by mouth periods during treatment |
Targeted swallowing exercises | No specific conclusions of influence of provided therapy on primary outcomes described |
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Karlsson et al. |
Voice | Group 1: voice therapy group received 10 × 30-minute sessions over 10 weeks |
Group 1: voice therapy consisting of relaxation, respiration, posture, and phonation exercises |
Patients treated with voice therapy experienced greater improvements compared to patients that only received vocal hygiene advice. Group 1 showed a significant better functional communication and HRQoL |
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Kotz et al. |
Swallowing | Group 1: weekly treatment by speech pathologist and daily 3 × 10 home sessions of exercises. Group 2: swallowing assessment and treatment if necessary after treatment | Group 1: prophylactic swallowing therapy consisting of effortful swallow, tongue base retraction exercises, super supraglottic swallow, and the Mendelssohn maneuver |
Prophylactic swallowing therapy improves swallowing at 3 and 6 months; later there were no group differences found |
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Kraaijenga et al. |
Swallowing and voice | Daily practice from the start of the treatment until 1 year after treatment | Two combined groups: TheraBite System and standard logopedic swallowing exercises (the same cohort as van der Molen et al. 2011 [ |
Minimal voice and swallowing difficulties were found 60 months after treatment in patients treated with prophylactic swallowing exercises |
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Sanguineti et al. |
Voice | 75.8% of the patients received speech therapy. No therapy was provided to 30 patients |
No description of exercises provided | No specific conclusions of influence of provided therapy on primary outcomes described |
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Starmer et al. |
Swallowing | Patients received prophylactic swallowing and trismus exercises | No description of exercises provided | No specific conclusions of influence of provided therapy on primary outcomes described |
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van der Molen et al. |
Swallowing | Patients received instructions in advance of their oncological treatment. Three times daily exercises | Group 1: range-of-motion exercises and three strengthening exercises, that is, the effortful swallow, the Masako maneuver, and the super supraglottic swallow. Stretch holding for 10–30 seconds at a point of mild discomfort |
Similar outcomes in both groups were found. Preventive rehabilitation can improve early posttreatment functional outcomes |
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van der Molen et al. |
Voice | No specific speech or voice therapy | N/A | N/A |
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van der Molen et al. |
Swallowing and trismus | Study was aimed at describing dose-effect relationships in two treatment groups described in earlier study. References to other published study where treatment regime is described | Group 1: standard exercises |
Any possible difference between the two included treatment groups is not described, nor possible influence of the respective treatments |
HNC: head and neck cancer; HRQoL: health-related quality of life; MIO: maximum incisal opening; ROM: range of motion.
Of the 60 articles included in this review, 14 studies [
The three studies that investigated the treatment of trismus [
Of the eight studies on swallowing disorders, only Kotz et al. [
In total, 60 studies met the inclusion criteria. The studies described the effects of radiotherapy and/or chemotherapy on the functions of the upper aerodigestive tract in patients with HNC. The articles yielded by this systematic review vary in their findings regarding tumor characteristics and treatment modalities. As a result of this variability, no statistical pooling was possible. We also set out to investigate the involvement of speech pathologists in treating patients with HNC.
When considering treatment outcomes, voice quality worsened at the start of radiotherapy and/or chemotherapy but eventually improved after therapy finished. Dysphagia can be a major side effect of HNC and its treatment. The high incidence of dysphagia in this study population can cause serious secondary consequences, such as malnutrition, dehydration, an increased risk of aspiration, and, at worst, death [
The general description of the study population in Table
Additionally, a large range of outcome measures were used, some of which are not validated. This calls into question the reliability of results reported in some of the studies. The use of validated and standardised assessments in future research would provide more robust findings.
When considering the functional outcomes of radiotherapy and/or chemotherapy, one of the most important factors is whether the patient had received voice or swallowing therapy. Interestingly, only 14 of the 60 included studies reported whether the patients received any speech therapy. Thus, in 46 articles functional results, such as voice quality, are presented with no specification of whether the patient received therapy. As some of these studies have a follow-up of >2 years, it is fair to assume that patients sought help for voice or swallowing problems. Therefore, the involvement of speech therapy may be underreported, suggesting that the presented outcomes in these studies are biased and raise questions about their reliability.
When information was provided about treatment, only six articles [
To enable the objective reporting of the effectiveness of radiation and/or chemotherapy, baseline measurements of different aspects of voice quality and swallowing are required. To manage expectations, healthcare professionals and patients need to be made aware that some aspects of both voice and swallowing commonly do not recover to the level prior to the oncological intervention [
When describing aspects of swallowing function, both fiber optic endoscopic evaluation of swallowing and videofluoroscopy are considered to be the gold standard in dysphagia assessment [
Additional research is needed to develop clinical practice guidelines to support evidence-based practice in the area of dysphagia, speech, voice, and trismus following radiotherapy and/or chemotherapy in patients with head and neck carcinoma. These practice guidelines should bring together the best available current evidence within a specific clinical area, formulating evidence-based recommendations for clinicians and present choices between different interventions that have an impact on health and use of resources [
The studies included in this systematic review described a wide variety of outcomes in patients with HNC following radiotherapy and/or chemotherapy. The findings about the long-term functional implications of radiotherapy and/or chemotherapy in patients with HNC are inconclusive as a result of the wide range of outcome measures used and the possible influence of underreported speech therapy.
Future researchers need to consider targeting more homogeneous groups using standardised treatment protocols to improve the treatment outcomes, thereby decreasing the side effects of the oncological treatments. Findings of these studies need to inform the decision-making process in the treatment of HNC so complications can be better predicted with due consideration of the possible negative side effects to the upper aerodigestive tract. Although the main objective of most studies was to determine curing rates, the importance of the functional implications of the side effects of oncology treatments should not be overlooked, particularly their impact on QoL. Finally, more research is needed to gain a full understanding of the complexity and variety in the effects of radiotherapy and/or chemotherapy on the functions of the upper aerodigestive tract following HNC.
All authors declare no competing interests or financial disclosures.