Swallowing exercises during radiation and chemotherapy for head and neck cancer help preserve function early on, a small clinical trial showed.

Among 26 patients with head and neck cancer, functional scores turned out better at 3 and 6 months after the prophylactic intervention than after usual care (P=0.03 and P=0.009), Tamar Kotz, MS, CCC-SLP, of Mount Sinai Medical Center in New York City, and colleagues found.

But both groups improved to a similar degree over the longer-term at 9 and 12 months, the researchers reported in the April issue of Archives of Otolaryngology - Head & Neck Surgery.

Still, the short-term benefit is likely to be meaningful for patients, Kotz noted in an interview with MedPage Today.

“It means the difference between, for some, having to be fed through feeding tubes in their stomach rather than being able to eat by mouth,” she explained. For others, it meant being able to “just tolerate sipping small amounts of water or [being able to] go to a restaurant and order something off the menu and eat it.”

The small trial wasn’t powered to show a difference in clinical endpoints like tube feeding.

But scores on the Eating in Public and Normalcy of Diet portions of a head and neck cancer performance status scale came out significantly better at 3 and 6 months post radiation with the prophylactic exercises (all P

<0.05).

Many centers have already started using the exercises for their patients because it intuitively makes sense, Kotz noted.

With the promising trial data, "we are hoping that patients will be referred to a speech pathologist at the time of diagnosis so that these exercises can begin as early as possible rather than waiting for the swallowing dysfunction from treatment becoming so severe," she told MedPage Today.

The study used a combination of five exercises:

  Effortful swallow, squeezing hard with all muscles
  Super supraglotic swallow, holding breath tightly and bearing down as swallowing, then cough to finish
  Tongue-hold maneuver, gently holding tongue in between front teeth while swallowing saliva
  Tongue retraction, pulling the back of the tongue to the back of the mouth and holding it there
  Mendelsohn maneuver, swallowing saliva while paying attention to the neck and trying not to let Adam’s apple drop for several seconds

Patients randomized to the intervention at the tertiary care academic medical center were to perform 10 repetitions of each exercise three times a day, varying the order.

However, the exercise regimen was rigorous, and 69% of patients assigned to that arm of the study had stopped doing them by week five of radiation.

“While implementing a rigorous prophylactic swallowing program clearly shows some benefit in terms of swallowing outcomes after treatment, we must not lose sight of the additional demand this places on the individual patient and remain sensitive to how much some patients can or cannot endure,” the researchers cautioned.

Nevertheless, even without good adherence there were “clinically and statistically meaningful” benefits.

Ability to eat by mouth was significantly better at months 3 and 6 after chemoradiation in the prophylactic swallowing exercise group versus usual care, which meant referral for swallowing assessment and treatment if symptoms were present after completion of cancer treatment.

The scores on the on the seven-point Functional Oral Intake Scale were, respectively:

  No different immediately after radiation (median 3 versus 4, P=0.88)
  Better at 3 months after radiation (median 7 versus 5, P=0.03)
  Better at 6 months after radiation (median 7 versus 6, P=0.009)
  Similar at month 9 after treatment (median 7 versus 6, P=0.24)
  No different at 12 months (median 6 versus 6, P=0.93)

Performance status scores followed the same pattern with significant benefit to the intervention only at months 3 and 6.

Tube feeding didn’t differ between groups, with an insertion rate of 46% and median time to removal after completion of therapy of 3 months in both study arms.

However, “this is likely unrelated to the presence or absence of swallowing exercise performance but rather is an expected result of the acute sequelae of the chemoradiation therapy, including mucositis and odynophagia, which the swallowing exercises would not be expected to influence,” the researchers wrote.

“In addition, the numbers of patients in the PEG [percutaneous endoscopic gastrostomy] group were too small to assess whether prophylactic exercise could have an impact on hastening PEG removal,” they added.

How the exercises might impact swallowing function is not entirely clear but might involve reduction of post-radiation fibrosis or strengthening nonfibrotic tissue to compensate, the researchers suggested.

Aside from the small sample size, another limitation of the study was lack of videofluoroscopic evaluations as a more sensitive measure impact on swallowing function, they noted.

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By Crystal Phend, Senior Staff Writer, MedPage Today