2017 Section 7 Green Book
B. Sethugavalar et al. / Oral Oncology 59 (2016) 80–85
approach is preferable for long term swallow outcomes. We have examined a retrospective cohort of patients who all received con- current chemo-radiotherapy using whole-field parotid-sparing IMRT for locally advanced oropharyngeal carcinoma, using the MDADI as a validated patient-reported tool, with long term follow up of at least 2 years post-treatment. These data suggest that the use of a prophylactic gastrostomy results in statistically inferior overall MDADI scores, as well as in the global, emotional and func- tional subscales, with a small statistically non-significant benefit in the physical domain. The clinical significance of these results is dependent upon the extent to which these two groups of patients are comparable. All patients received concurrent chemotherapy and bilateral neck IMRT and did not require therapeutic enteral feeding prior to treatment. The matched pair analysis was performed to minimise differences in swallow outcome which may have been due to tumour stage, which are recognised to influence long term swallow function [2,7] . The selection of feeding route was dependent upon clinician and patient preference, and all patients were entered into routine programmes of dietetic and speech and language therapy support during and after treatment. There was no difference in baseline swallow function between these two groups of patients, measured using a simple dietetic consistency scale. In addition there were no significant differences in patient demographics, tumour stage, treat- ment details between the two groups. Despite this, it is not possible to completely exclude the possibility that baseline factors may have influenced the choice of approach to enteral feeding and conse- quently confound possible associations with swallow function. The T stage and N stage match involved grouping stages together e.g. N0 and N1, to allow an adequate number of patients to be matched for subsequent analysis. There was a higher number of N0 patients within the prophylactic gastrostomy group, although there was no significant difference between T and N stages, and N0 nodal stage might be expected to be associated with superior swal- lowing outcomes. A slightly higher proportion of patients in the pro- phylactic gastrostomy group received induction chemotherapy, possibly reflecting a perceived clinical preference for using a gas- trostomy to support patients through treatment involving induction and concurrent chemotherapy. There are some limitations to this study. We do not have human papilloma virus (HPV) status available for this a useful proportion of this historical cohort of patients as it was not being routinely tested at our institution in this era. However, it seems likely that HPV status is balanced across the two groups as the proportion with current or previous smoking status was similar, as was the proportion of patients with advanced nodal disease. There is no data to suggest that there are differences in the impact of chemora- diotherapy upon late dysphagia risk depending upon HPV status. It should also be noted that the mean parotid doses achieved with the compartmental outlining methods are considerably higher than we would currently expect with current volumetric outlining and more advanced IMRT delivery techniques; it is possible that this may have impacted upon the overall swallow function. Many factors may influence long term swallow recovery post- chemoradiotherapy, including patient characteristics, baseline swallow function, tumour factors, smoking status, and swallowing support and rehabilitation provided during and after treatment [2,10] . The timing and route of enteral feeding tube may be an important factor. This is an area in which previous randomised tri- als [36] have failed to adequately recruit, and institutional out- comes are important to inform practice. This matched pair analysis reinforces concern over the potential for a prophylactic Conclusion
gastrostomy to negatively impact upon long term swallow recovery.
Conflict of interest statement
We have no conflicts of interest.
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