Lisette van der Molen

Functional outcomes and rehabilitation strategies in patients treated with chemoradiotherapy for advanced head and neck cancer: a systematic review

Organ preservation with radiotherapy and concomitant chemotherapy has become an accepted treatment modality in advanced head and neck cancer. Unfortunately, organ preservation is not synonymous with function preservation. The aim of this review was to systematically assess the effects of the disease and chemoradiotherapy (CRT) on functions such as swallowing, mouth opening, nutrition, pain and quality of life in patients with head and neck cancer. Another aim was to search for (evidence-based) techniques or strategies known to alleviate or rehabilitate the loss of function(s) associated with CRT. Two databases were searched (time period, January 1997 to August 2007) for the terms head and neck cancer, chemotherapy or cisplatin and radiotherapy, and the functional outcomes swallowing, trismus, nutrition, pain and quality of life or a variation of those words. In total, 15 relevant articles were identified that met the inclusion criteria. The majority of the studies that met the criteria focused on the outcomes swallowing, quality of life, and nutrition. Two studies reported on the outcome pain, but no paper reported on the outcome trismus. Only two papers mentioned rehabilitation options, but specific information was lacking. Further long-term prospective research is essential, not only to determine the function impairment caused by the tumor and CRT, but also to assess the effects of known and newly developed rehabilitation measures. Therefore, in September 2006, the Netherlands Cancer Institute started a randomised clinical trial (RCT): Prevention of trismus, swallowing and speech problems in patients treated with chemoradiotherapy for advanced head and neck cancer. This systematic review was carried out to collect the baseline information for the future outcomes of this RCT.

Dysphagia and trismus after concomitant chemo-Intensity-Modulated Radiation Therapy (chemo-IMRT) in advanced head and neck cancer; dose-effect relationships for swallowing and mastication structures

BACKGROUND AND PURPOSE Prospective assessment of dysphagia and trismus in chemo-IMRT head and neck cancer patients in relation to dose-parameters of structures involved in swallowing and mastication. MATERIAL AND METHODS Assessment of 55 patients before, 10-weeks (N=49) and 1-year post-treatment (N=37). Calculation of dose-volume parameters for swallowing (inferior (IC), middle (MC), and superior constrictors (SC)), and mastication structures (e.g. masseter). Investigation of relationships between dose-parameters and endpoints for swallowing problems (videofluoroscopy-based laryngeal Penetration-Aspiration Scale (PAS), and study-specific structured questionnaire) and limited mouth-opening (measurements and questionnaire), taking into account baseline scores. RESULTS At 10-weeks, volume of IC receiving ≥60 Gy (V60) and mean dose IC were significant predictors for PAS. One-year post-treatment, reported problems with swallowing solids were significantly related to masseter dose-parameters (mean, V20, V40 and V60) and an inverse relationship (lower dose related to a higher probability) was observed for V60 of the IC. Dose-parameters of masseter and pterygoid muscles were significant predictors of trismus at 10-weeks (mean, V20, and V40). At 1-year, dose-parameters of all mastication structures were strong predictors for subjective mouth-opening problems (mean, max, V20, V40, and V60). CONCLUSIONS Dose-effect relationships exist for dysphagia and trismus. Therefore treatment plans should be optimized to avoid these side effects.

A cost-effectiveness analysis of a preventive exercise program for patients with advanced head and neck cancer treated with concomitant chemo-radiotherapy

BackgroundConcomitant chemo-radiotherapy (CCRT) has become an indispensable organ, but not always function preserving treatment modality for advanced head and neck cancer. To prevent/limit the functional side effects of CCRT, special exercise programs are increasingly explored. This study presents cost-effectiveness analyses of a preventive (swallowing) exercise program (PREP) compared to usual care (UC) from a health care perspective.MethodsA Markov decision model of PREP versus UC was developed for CCRT in advanced head and neck cancer. Main outcome variables were tube dependency at one-year and number of post-CCRT hospital admission days. Primary outcome was costs per quality adjusted life years (cost/QALY), with an incremental cost-effectiveness ratio (ICER) as outcome parameter. The Expected Value of Perfect Information (EVPI) was calculated to obtain the value of further research.ResultsPREP resulted in less tube dependency (3% and 25%, respectively), and in fewer hospital admission days than UC (3.2 and 4.5 days respectively). Total costs for UC amounted to €41,986 and for PREP to €42,271. Quality adjusted life years for UC amounted to 0.68 and for PREP to 0.77. Based on costs per QALY, PREP has a higher probability of being cost-effective as long as the willingness to pay threshold for 1 additional QALY is at least €3,200/QALY. At the prevailing threshold of €20,000/QALY the probability for PREP being cost-effective compared to UC was 83%. The EVPI demonstrated potential value in undertaking additional research to reduce the existing decision uncertainty.ConclusionsBased on current evidence, PREP for CCRT in advanced head and neck cancer has the higher probability of being cost-effective when compared to UC. Moreover, the majority of sensitivity analyses produced ICERs that are well below the prevailing willingness to pay threshold for an additional QALY (range from dominance till €45,906/QALY).

Treatment of myogenic temporomandibular disorder: a prospective randomized clinical trial, comparing a mechanical stretching device (TheraBite®) with standard physical therapy exercise

Abstract Aims: To compare in a randomized controlled clinical trial (RCT) the application of the TheraBite® (TB) Jaw Motion Rehabilitation System with a standard physical therapy (PT) exercise regimen for the treatment of myogenic temporomandibular disorder (TMD). Methodology: Myogenic TMD patients were randomized for the use of the TB device or for standard PT. Mandibular function was assessed with the mandibular function impairment questionnaire (MFIQ). Pain was evaluated using a visual analog scale, and maximum inter-incisor (mouth) opening (MIO) was measured using the disposable TB range of motion scale. Results: Of the 96 patients randomized (46 TB, 50 standard PT exercises), 38 actually started with the TB device and 41 with the standard PT exercises. After six-week follow-up, patients using the TB device reported a significantly greater functional improvement (MFIQ score) than the patients receiving regular PT exercises (P = 0·0050). At 6 weeks, no significant differences in pain, and active or passive MIO were found between the two groups. At 3 months, patients in both treatment groups did equally well, and showed a significant improvement in all parameters assessed. Conclusions: This RCT on myogenic TMD treatment, comparing standard PT with passive jaw mobilization using the TheraBite Jaw Motion Rehabilitation System®, shows that both treatment modalities are equally effective in relieving myogenic TMD symptoms, but that the use of the TB device has the benefit of achieving a significantly greater functional improvement within the first week of treatment.

Efficacy of a novel swallowing exercise program for chronic dysphagia in long‐term head and neck cancer survivors

The efficacy of rehabilitative exercises for chronic dysphagia treatment in head and neck cancer survivors has not been studied extensively and is ambiguous.

The cost-effectiveness of TheraBite® as treatment for acute myogenic temporomandibular disorder

Abstract Objective: Temporomandibular disorder (TMD) is a very common and costly pain problem concerning the temporomandibular joint. A previous study has shown that for the treatment of acute myogenic TMD, TheraBite® (TB) offers a faster and greater effect than usual care consisting of physical therapy (PT). This study estimates the cost-effectiveness of TB compared to PT. Methods: Differences in costs and quality-adjusted life-years (QALYs) between TB and PT are analyzed using a decision model. Results: The point estimate for the incremental cost-effectiveness ratio is −28,068 EUR (−30,191 USD) per QALY (dominant) for TB versus PT. At the willingness-to-pay ratio of 20,000 EUR (21,513 USD) per QALY, TB has a 97% probability of being cost-effective compared to PT. Conclusion: TB is expected to be cost-effective compared to PT for the treatment of acute myogenic TMD, offering faster recovery of quality of life for patients, at a lower cost to society.

Feasibility and potential value of lipofilling in post‐treatment oropharyngeal dysfunction

Head and neck cancer (HNC) patients may develop oropharyngeal dysfunction as result of volume loss or muscle atrophy of the tongue or pharyngeal musculature following treatment with surgery and/or chemoradiotherapy. If intensive swallowing therapy offers no further improvement, and the functional problems persist, transplantation of autologous adipose tissue (lipofilling) might restore functional outcomes by compensating the existing tissue defects or tissue loss.

Bidirectional associations between oral and systemic health

Many systemic diseases have associated oral manifestations Systemic inflammatory processes are associated with oral inflammatory disease Dysphagia may occur due to locoregional diseases, vascular, neurologic, and autoimmune diseases and medical management An interprofessional approach is important for dysphagia screening and management The preservation of periodontal health is a key component of oral and overall health