Early clinical factors associated with long-term impaired dysphagia-specific quality of life after free-flap reconstruction of oral cavity and oropharyngeal defects.

Presented by: Soroush Zaghi, MDResident Physician, PGY3UCLA Dept of Head and Neck SurgeryDavid Geffen School of Medicine at UCLALos Angeles, CA

Co-Authors: Doug Sidell, MD ; Keith Blackwell, MD ; Andrew Erman, MS; Vishad Nabili, MD

AHNS 8th International Conference on Head & Neck CancerToronto, CanadaSunday, July 22, 2012.

AHNS Disclosure Slide

• Soroush Zaghi, MD: Nothing to disclose.

• Doug Sidell, MD: Nothing to disclose.

• Keith Blackwell, MD: Nothing to disclose.

• Andrew Erman: Nothing to disclose.

• Vishad Nabili, MD: Nothing to disclose.

Dysphagia in head and neck cancer

• Dysphagia is a significant morbidity of head-and-neck cancer treatment.

• Dysphagia severity correlates with worsened QOL, increased anxiety and depression.

• Nutritional support, physical therapy, speech rehabilitation, pain management, and psychological counseling are available to help.

• Goal: Identification of patients at risk of dysphagia.

“Risk factors predicting aspiration after free flap reconstructionof oral cavity and oropharyngeal defects.”

Smith JE, Suh JD, Erman A, Nabili V, Chhetri DK, Blackwell KE. Archives of Otolaryngol ogy- Head Neck Surg. Nov 2008;134(11):1205-1208.

• 100 patients s/p resection of oral cavity or oropharyngeal tumors with immediate free flap reconstruction

• Modified barium swallow study (MBSS) at approximately one month post-operatively to assess dysphagia severity.

• High risk of having early postoperative aspiration after free flap reconstruction:– Patients with prior history of radiation therapy– Patients with resection of more than half of the tongue base

• Conclusion: Patients with h/o XRT or > 50% tongue base resection should be considered candidates for perioperative gastrostomy tube placement.

Limitations of Prior Study

• MBSS outcomes are a reliable indicator of swallowing function for the short-term post-operative setting (3-6 months).

• Immediate post-op MBSS results may not be a reliable predictor of long-term dysphagia outcomes.

• Progressive improvement in head and neck– dysphagia specific quality of life over a period of at least 12 months after the completion of treatment.

Objective

To further determine the subsequent dysphagia-specific quality of life among this population of patients at > 1 year follow-up after surgery.

To identify early clinical factors associated with poor long-term dysphagia outcomes.

Methods

• M.D. Anderson Dysphagia Inventory (MDADI) surveys were sent to the 100 patients included in the previously published study.

• Inclusion criteria: Patients who were (1) greater than or equal to 12 months post surgery and (2) gave complete responses to the survey questionnaire.

MD Anderson Dysphagia Inventory• Cross-validated questionnaire designed specifically to assess dysphagia QOL in patients with head and

neck cancer.

• 21 dysphagia-related statements, subdivided into four subscales:

– Global Score- single question: “my swallowing ability limits my day-to-day activities” (A general overall assessment.)

– Emotional Subset: emotional responses to dysphagia. (e.g. “I am embarrassed by my eating habits; I am upset by my swallowing problem”.)

– Functional Subset: impact of swallowing problem on daily activities. (e.g. “It takes me longer to eat because of my swallowing problem; my swallowing problem limits my social and personal life ”.)

– Physical Subset: represents self-perceptions of the swallowing difficulties (e.g.” swallowing takes great effort, I feel that I am swallowing a huge amount of food; I cough when I try to drink liquids”)

– Total Score: sum of Emotional, Functional, Physical subsets

MDADI scores set to scale: Higher score= better day to day functioning greater quality of life 0 = (extremely low functioning) 100 = (extremely high functioning)

Results• Twenty-two responses met the

inclusion criteria and were included in the analysis.

• MDADI surveys were completed between 524 to 1968 days after surgery (median: 820 days).

• MBSS was performed between 13 and 58 days post-operatively (median: 33 days).

• Of the 22 patients included in the analysis, 9.1% (n=2) still had a G-tube at the time of survey.

Primary Findings:- Prior h/o radiation therapy: Significantly associated with

lower MDADI scores at long-term follow up across ALL subscale domains.

- Greater than 50% tongue base resection: No significant association with any MDADI score.

E.g. Total Score- Yes (n=7) : 64.9 ± 7.5 vs. No (n=15): 63.3 ± 5.1, p=0.8628.

Secondary Findings:• Certain findings on early postoperative MBSS may be predictive of

long-term dysphagia outcomes.

– Specifically: evidence of aspiration and severely impaired oral phase swallowing.

– Other facets of the MBSS (e.g. oral preparatory phase, pharyngeal phase, penetration, aspiration risk), on the other hand, correlated poorly with long-term QOL outcomes

• Gender- Women were significantly more likely to report more critical self-perceptions of swallowing difficulties.

• Surgical Defect- Resection of lateral pharyngeal wall and/or soft palate may have long-term effect on post-op dysphagia.

Limitations• A large proportion of patients from the previous study were lost to

follow up. This phenomenon was expectedly true among patients with advanced T- stage malignancies.

• Small sample size- power limiting considerations. – Differences in quality of life scores corresponding to a 20% difference were

considered clinically significant (a sample size of 22 can be used to distinguish groups with a 20-point anticipated difference in means with power= 80%, Type 1 error= 0.05).

• Many of the associations reported were discovered with univariate exploratory analysis- inherent weakness in terms of Type I error, but good for hypothesis generation and identifying variables for future studies.

ConclusionPatients with:

history of radiation therapy, early post-operative evidence of aspiration, difficulty with oral phase of swallowing, defects at lateral pharyngeal wall/soft palate, women in general.

– Risk of of poor long-term dysphagia QOL MDADI outcomes

– Should be the subject of further dysphagia-related research – May be directed early on to multidisciplinary teams to help them overcome and

cope with swallowing dysfunction.