Skip to main content
SpringerLink
Log in

Risk Model and Nomogram for Dysphagia and Xerostomia Prediction in Head and Neck Cancer Patients Treated by Radiotherapy and/or Chemotherapy

  • Original Article
  • Published:
Dysphagia Aims and scope Submit manuscript

Abstract

In our randomized trial on hyperbaric oxygen (HBO), it was shown that HBO could reduce dysphagia and xerostomia, which are frequently encountered after (chemo-) radiotherapy (RT) and/or surgery for head and neck cancer (HNC). A risk model and nomogram are developed to select those patients who most likely will respond to HBO treatment. A total of 434 HNC patients treated from 2000 to 2008 were analyzed and filled out the EORTC QLQC-30 and H&N35 questionnaires. Age, gender, chemotherapy, T and N stages, site, radiotherapy technique, RT boost, surgery of the primary tumor and neck, bilateral RT, and dose were analyzed in a statistical model. The discriminative value of the model was evaluated based on receiver operating characteristics (ROC), the area under the curve (AUC), sensitivity, specificity, and proportion of correctly classified measures. Significant factors in predicting swallowing problems are age, follow-up duration, tumor site, chemotherapy, surgery of the primary tumor and neck, and dose. For dry mouth, the significant factors are age, gender, tumor site, N stage, chemotherapy, and bilateral irradiation. For dysphagia and xerostomia, the area under the ROC curve is 0.7034 and 0.7224, respectively, with a specificity of 89/77 %, sensitivity of 27/58 %, and a positive predictive value of 83/67 % for dysphagia and xerostomia, respectively. The developed predictive risk model could be used to select patients for costly hyperbaric oxygen treatment to prevent or reduce severe late side effects of HNC treatment. Our model serves as a guideline for the Department of Radiation Oncology to reduce costs by excluding patients not amenable to hyperbaric oxygen protocols. The nomogram presented is a useful tool for clinicians in assessing patient risks when deciding on follow-up strategies (e.g., hyperbaric oxygen treatment) after RT or surgery for HNC.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Teguh DN, Levendag PC, Noever I, van Rooij P, Voet P, Van der Est H, Sipkema D, Sewnaik A, de Jong RJ, de la Bije D, Schmitz PI. Treatment techniques and site considerations regarding dysphagia-related quality of life in cancer of the oropharynx and nasopharynx. Int J Radiat Oncol Biol Phys. 2008;72:1119–27.

    Article  PubMed  Google Scholar 

  2. Sanguineti G, Gunn GB, Parker BC, Endres EJ, Zeng J, Fiorino C. Weekly dose-volume parameters of mucosa and constrictor muscles predict the use of percutaneous endoscopic gastrostomy during exclusive intensity-modulated radiotherapy for oropharyngeal cancer. Int J Radiat Oncol Biol Phys. 2011;79:52–9.

    Article  PubMed  Google Scholar 

  3. Li B, Li D, Lau DH, Farwell DG, Luu Q, Rocke DM, Newman K, Courquin J, Purdy JA, Chen AM. Clinical-dosimetric analysis of measures of dysphagia including gastrostomy-tube dependence among head and neck cancer patients treated definitively by intensity-modulated radiotherapy with concurrent chemotherapy. Radiat Oncol. 2009;4:52.

    Article  PubMed  Google Scholar 

  4. Semrau S, Waldfahrer F, Lell M, Linke R, Klautke G, Kuwert T, Uder M, Iro H, Fietkau R. Feasibility, toxicity, and efficacy of short induction chemotherapy of docetaxel plus cisplatin or carboplatin (TP) followed by concurrent chemoradiotherapy for organ preservation in advanced cancer of the hypopharynx, larynx, and base of tongue. Early results. Strahlenther Onkol. 2011;187:15–22.

    Article  Google Scholar 

  5. Caudell JJ, Schaner PE, Meredith RF, Locher JL, Nabell LM, Carroll WR, Magnuson JS, Spencer SA, Bonner JA. Factors associated with long-term dysphagia after definitive radiotherapy for locally advanced head-and-neck cancer. Int J Radiat Oncol Biol Phys. 2009;73(2):410–5.

    Article  PubMed  Google Scholar 

  6. Peponi E, Glanzmann C, Willi B, Huber G, Studer G. Dysphagia in head and neck cancer patients following intensity modulated radiotherapy (IMRT). Radiat Oncol. 2011;6:1.

    Article  PubMed  Google Scholar 

  7. Gunn GB, Endres EJ, Parker B, Sormani MP, Sanguineti G. A phase I/II study of altered fractionated IMRT alone for intermediate T-Stage oropharyngeal carcinoma. Strahlenther Onkol. 2010;186:489–95.

    Article  PubMed  Google Scholar 

  8. Feng FY, Kim HM, Lyden TH, Haxer MJ, Feng M, Worden FP, Chepeha DB, Eisbruch A. Intensity-modulated radiotherapy of head and neck cancer aiming to reduce dysphagia: early dose-effect relationships for the swallowing structures. Int J Radiat Oncol Biol Phys. 2010;28(16):2732–8.

    Google Scholar 

  9. Schwartz DL, Hutcheson K, Barringer D, Tucker SL, Kies M, Holsinger FC, Ang KK, Morrison WH, Rosenthal DI, Garden AS, Dong L, Lewin JS. Candidate dosimetric predictors of long-term swallowing dysfunction after oropharyngeal intensity-modulated radiotherapy. Int J Radiat Oncol Biol Phys. 2010;78:1356–65.

    Article  PubMed  Google Scholar 

  10. Dijkema T, Raaijmakers CP, Ten Haken RK, Roesink JM, Braam PM, Houweling AC, Moerland MA, Eisbruch A, Terhaard CH. Parotid gland function after radiotherapy: the combined Michigan and Utrecht experience. Int J Radiat Oncol Biol Phys. 2010;78:449–53.

    Article  PubMed  Google Scholar 

  11. Caudell JJ, Schaner PE, Desmond RA, Meredith RF, Spencer SA, Bonner JA. Dosimetric factors associated with long-term dysphagia after definitive radiotherapy for squamous cell carcinoma of the head and neck. Int J Radiat Oncol Biol Phys. 2010;76:403–9.

    Article  PubMed  Google Scholar 

  12. Deasy JO, Moiseenko V, Marks L, Chao KS, Nam J, Eisbruch A. Radiotherapy dose-volume effects on salivary gland function. Int J Radiat Oncol Biol Phys. 2010;76:S58–63.

    Article  PubMed  Google Scholar 

  13. Rancati T, Schwarz M, Allen AM, Feng F, Popovtzer A, Mittal B, Eisbruch A. Radiation dose-volume effects in the larynx and pharynx. Int J Radiat Oncol Biol Phys. 2010;76:S64–9.

    Article  PubMed  Google Scholar 

  14. Teguh DN, Levendag PC, Sewnaik A, Hakkesteegt MM, Noever I, Voet P, Van der Est H, Sipkema D, Van Rooij P, Baatenburg de Jong RJ, Schmitz PI. Results of fiberoptic endoscopic evaluation of swallowing vs. radiation dose in the swallowing muscles after radiotherapy of cancer in the oropharynx. Radiother Oncol. 2008;89:57–63.

    Article  PubMed  Google Scholar 

  15. Dirix P, Abbeel S, Vanstraelen B, Hermans R, Nuyts S. Dysphagia after chemoradiotherapy for head-and-neck squamous cell carcinoma: dose-effect relationships for the swallowing structures. Int J Radiat Oncol Biol Phys. 2009;75:385–92.

    Article  PubMed  CAS  Google Scholar 

  16. Feng FY, Lyden TH, Kim HM, Haxer MJ, Feng M, Yang Y, Chepeha DB, Ten Haken RK, Eisbruch A. IMRT aimed at reducing dysphagia: Early dose-volume-effect relationships for swallowing structures. Int J Radiat Oncol Biol Phys. 2006;66:S44–5.

    Article  Google Scholar 

  17. Tang Y, Shen Q, Wang Y, Lu K, Wang Y, Peng Y. A randomized prospective study of rehabilitation therapy in the treatment of radiation-induced dysphagia and trismus. Strahlenther Onkol. 2011;187:39–44.

    Article  PubMed  CAS  Google Scholar 

  18. Teguh DN, Levendag PC, Noever I, Voet P, Van der Est H, van Rooij P, Dumans AG, de Boer MF, van der Huls MP, Sterk W, Schmitz PI. Early hyperbaric oxygen therapy for reducing radiotherapy side effects: early results of a randomized trial in oropharyngeal and nasopharyngeal cancer. Int J Radiat Oncol Biol Phys. 2009;75:711–6.

    Article  PubMed  Google Scholar 

  19. Cankar K, Finderle Z, Jan J. The effect of hyperbaric oxygenation on postradiation xerostomia and saliva in patients with head and neck tumours. Caries Res. 2011;45:136–41.

    Article  PubMed  CAS  Google Scholar 

  20. Mayer R, Hamilton-Farrell MR, van der Kleij AJ, Schmutz J, Granstrom G, Sicko Z, Melamed Y, Carl UM, Hartmann KA, Jansen EC, Ditri L, Sminia P. Hyperbaric oxygen and radiotherapy. Strahlenther Onkol. 2005;181:113–23.

    Article  PubMed  Google Scholar 

  21. Iasonos A, Schrag D, Raj GV, Panageas KS. How to build and interpret a nomogram for cancer prognosis. J Clin Oncol. 2008;26:1364–70.

    Article  PubMed  Google Scholar 

  22. Levendag PC, Al-Mamgani A, Teguh DN. Contouring in Head & Neck Cancer. New York: Elsevier Professional Education, 2009, ISBN: 978-3-437-59904-0.

  23. Teguh DN, Levendag PC, Kolkman-Deurloo IK, van Rooij P, Schmitz PI. Quality of life of oropharyngeal cancer patients treated with brachytherapy. Curr Oncol Rep. 2009;11:143–50.

    Article  PubMed  Google Scholar 

  24. Nourissat A, Bairati I, Samson E, Fortin A, Gelinas M, Nabid A, Brochet F, Tetu B, Meyer F. Predictors of weight loss during radiotherapy in patients with stage I or II head and neck cancer. Cancer. 2010;116:2275–83.

    PubMed  Google Scholar 

  25. Frowen J, Cotton S, Corry J, Perry A. Impact of demographics, tumor characteristics, and treatment factors on swallowing after (chemo)radiotherapy for head and neck cancer. Head Neck. 2010;32:513–28.

    PubMed  Google Scholar 

  26. Teguh DN, Levendag PC, Voet PW, Al Mamgani A, Han X, Wolf TK, Hibbard LS, Nowak P, Akhiat H, Dirkx ML, Heijmen BJ, Hoogeman MS. Clinical validation of atlas-based auto-segmentation of multiple target volumes and normal tissue (swallowing/mastication) structures in the head and neck. Int J Radiat Oncol Biol Phys. 2011;81(4):950–7.

    Article  PubMed  Google Scholar 

  27. Poulsen MG, Riddle B, Keller J, Porceddu SV, Tripcony L. Predictors of acute grade 4 swallowing toxicity in patients with stages III and IV squamous carcinoma of the head and neck treated with radiotherapy alone. Radiother Oncol. 2008;87:253–9.

    Article  PubMed  Google Scholar 

  28. Best SR, Ha PK, Blanco RG, Saunders JR Jr, Zinreich ES, Levine MA, Pai SI, Walker M, Trachta J, Ulmer K, Murakami P, Thompson R, Califano JA, Messing BP. Factors associated with pharyngoesophageal stricture in patients treated with concurrent chemotherapy and radiation therapy for oropharyngeal squamous cell carcinoma. Head Neck. 2011;33(12):1727–34.

    Article  PubMed  Google Scholar 

  29. Langendijk JA, Doornaert P, Rietveld DH, Verdonck-de Leeuw IM, Leemans CR, Slotman BJ. A predictive model for swallowing dysfunction after curative radiotherapy in head and neck cancer. Radiother Oncol. 2009;90:189–95.

    Article  PubMed  Google Scholar 

  30. Schallenkamp JM, Miller RC, Brinkmann DH, Foote T, Garces YI. Incidence of radiation pneumonitis after thoracic irradiation: Dose-volume correlates. Int J Radiat Oncol Biol Phys. 2007;67:410–6.

    Article  PubMed  Google Scholar 

  31. Dehing-Oberije C, De Ruysscher D, van Baardwijk A, Yu S, Rao B, Lambin P. The importance of patient characteristics for the prediction of radiation-induced lung toxicity. Radiother Oncol. 2009;91:421–6.

    Article  PubMed  Google Scholar 

  32. Kattan MW, Eastham JA, Stapleton AM, Wheeler TM, Scardino PT. A preoperative nomogram for disease recurrence following radical prostatectomy for prostate cancer. J Natl Cancer Inst. 1998;90:766–71.

    Article  PubMed  CAS  Google Scholar 

  33. Abu-Rustum NR, Zhou Q, Gomez JD, Alektiar KM, Hensley ML, Soslow RA, Levine DA, Chi DS, Barakat RR, Iasonos A. A nomogram for predicting overall survival of women with endometrial cancer following primary therapy: toward improving individualized cancer care. Gynecol Oncol. 2010;116:399–403.

    Article  PubMed  CAS  Google Scholar 

Download references

Conflict of interest

The authors have no conflicts of interest to declare.

Author information

Authors and Affiliations

  1. Radiation Oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, Netherlands

    David N. Teguh, Peter C. Levendag & Stefan L. S. Kwa

  2. Trials & Statistics-HOVON Data Center, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, Netherlands

    Wendimagegn Ghidey & Kees van Montfort

  3. Erasmus MC-Daniel den Hoed Cancer Center, Groene Hilledijk 301, 3075 EA, Rotterdam, Netherlands

    David N. Teguh

Authors
  1. David N. Teguh
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Peter C. Levendag
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Wendimagegn Ghidey
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Kees van Montfort
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Stefan L. S. Kwa
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to David N. Teguh.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Teguh, D.N., Levendag, P.C., Ghidey, W. et al. Risk Model and Nomogram for Dysphagia and Xerostomia Prediction in Head and Neck Cancer Patients Treated by Radiotherapy and/or Chemotherapy. Dysphagia 28, 388–394 (2013). https://doi.org/10.1007/s00455-012-9445-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00455-012-9445-6

Keywords

Search

Navigation