Preventive measures for the progression of dysphagia in patients with cancer of head and neck subjected to radiotherapy: a systematic review with meta-analysis

Beuren, Amanda Guterres; Paim, Émille Dalbem; Flores, Nathália da Silva; Martins, Vera Beatris; Macagnan, Fabricio Edler

doi:10.1590/2317-1782/20232021246pt

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Systematic Review • CoDAS 35 (2) • 2023 • https://doi.org/10.1590/2317-1782/20232021246en linkcopy

Preventive measures for the progression of dysphagia in patients with cancer of head and neck subjected to radiotherapy: a systematic review with meta-analysis

Authorship SCIMAGO INSTITUTIONS RANKINGS

Purpose To identify the effects of prophylactic, non-pharmacological measures on the progression of dysphagia in patients with head and neck cancer undergoing radiotherapy.

Research strategies The search was performed in Medline (via PubMed), Scopus, and Embase databases, as well as in the gray literature.

Selection criteria Randomized clinical trials were included, with adult patients (≥ 18 years old) and diagnosed with head and neck cancer, treated with radiotherapy (with or without surgery and chemotherapy), and submitted to non-pharmacological protocols for the prevention of dysphagia.

Data analysis The risk of bias was assessed using the PEDRO scale and the overall quality of evidence was assessed using the GRADE instrument.

Results Four studies were considered eligible, and of these, two were included in the meta-analysis. The result favored the intervention group, with a mean difference of 1.27 [95% CI: 0.74 to 1.80]. There was low heterogeneity and the mean score for risk of bias was 7.5 out of 11 points. The lack of detail in the care with selection, performance, detection, attrition, and reporting biases contributed to the judgment of the quality of the evidence, considered low.

Conclusion Prophylactic measures to contain dysphagia can promote important benefits on the oral intake of patients with head and neck cancer when compared to those who did not undergo such a therapeutic measure during radiotherapy.

Keywords:
Prophylaxis; Preventive Measures; Dysphagia; Head and Neck Neoplasms; Radiotherapy

PEDRO CLASSIFICATION / PAPERS		Carnaby-Mann et al.(¹¹)	Messing et al.(¹⁸)	Mortensen et al.(¹⁹)	Kotz et al.(²⁰)
External Validity	1 Inclusion criteria	Y	Y	Y	Y
(Max = 1)	1 Inclusion criteria	Y	Y	Y	Y
Internal Validity	2 Random allocation	Y	Y	Y	Y
	3 Secret allocation	N	Y	N	N
	4 Similar group at the start of the study	Y	Y	Y	Y
	5 Blinding of the participants	N	N	N	N
	6 Blinding of the therapists	N	N	N	N
(Max=8)	6 Blinding of the therapists	N	N	N	N
	7 Blinding of the assessment	N	Y	N	N
	8 Analysis of 86% of the sample	Y	Y	Y	Y
	9 Analysis of the treatment goal	Y	Y	Y	Y
Interpretation of the outcomes	10 Comparison between groups	Y	Y	Y	Y
Interpretation of the outcomes	11 Measures of central and dispersion trend	Y	Y	Y	Y
(Max=2)	11 Measures of central and dispersion trend	Y	Y	Y	Y
Total of scores	-	7	9	7	7
(Max = 11)	-	7	9	7	7

AUTHOR/YEAR	SAMPLE	AGE (mean)	ANTINEOPLASTIC TREATMENT	RT	INTERVENTION PERIOD	IG x CG	FREQUENCY	DURATION
Carnaby-Mann et al.(¹¹)	40	56.5	RT + QT	Conventional (45%)	Throughout the 4 cycles of antineoplastic treatment up to 6 weeks	Exercises x Usual Care	2x/day	45 minutes / session
	(20 IG and 20 CG)			IMRT (55%)
	82.5%/M
Messing et al.(¹⁸)	60	57.5	RT + QT	Conventional* and IMRT*	During the CRT (Except the interval week on the 4^th week) and up to 3 months after the CRT	Exercises x Stretching	2x/day	20-30 minutes / session
	(30 IG and 30 CG)						7 days/week
	90%/M
Mortensen et al.(¹⁹)	39	58	RT + QT	Conventional* and IMRT*	Start before the RT up to 11 months	Exercises x Usual Care	3x/day	10-15 minutes / session
	(19 IG and 20 CG)						7 days/week
	87%/M
Kotz et al.(²⁰)	26	59	RT + QT	Conventional	?	Exercises x Usual Care	3x/day	?
	(13 IG and 13 CG)						7 days/week
	77%/M

AUTHOR/YEAR	IG PROTOCOL	CG PROTOCOL	SWALLOWING FUNCTION	ORAL INTAKE	VAA	NUTRITIONAL STATE
Carnaby-Mann et al.(¹¹)	Falsetto, swallowing with effort, tongue counter-resistance, and therabite	Usual Care *	All groups showed a deterioration in the muscle composition	The FOIS score decreased during the treatment in both groups, indicating a greater impairment of the swallowing function	Lower ADV índex in the IG	There was no difference between groups
	+		Three muscles related to the swallowing function showed greater conservation in the IG	The IG showed a higher FOIS median after the treatment, indicating a potential benefit of the intervention
	Adaptation of diet consistency		The relaxing time was better in the IG than in the CG	The lower degree of dysphagia in the IG, with greater maintenance of the oral nutrition and mouth opening
			There was no difference between the groups regarding the predominance of aspiration
Messing et al.(¹⁸)	Therabite	07/07/2007	The IG presented greater efficacy in swallowing three months after the treatment with less impairment of the PP and TPT	60.6% of the patients needed to change their diet consistency throughout the treatment, with some improvement 6 months after the end of the treatment	There was no significant difference between the groups regarding the use of an alternative route for the diet, mucositis, pain, or weight
	+	(7 stretching exercises passive of movement amplitude, with 7 repetitions, 7 times a day)
	Exercises of strength/ oromotor stretching and swallowing maneuvers
Mortensen et al.(¹⁹)	Exercises of movement amplitude and resistance	Usual Care *	There was no difference between the groups regarding the swallowing function	?	There was no difference between the groups over the 11 months of tracking	There was no difference between the groups
Mortensen et al.(¹⁹)	Exercises of movement amplitude and resistance	Usual Care *	Most of the participants (31/39) developed severe dysphagia over the treatment	?		There was no difference between the groups
Kotz et al.(²⁰)	Swallowing with effort, tongue mobility, supraglottic maneuvers, and Mendelsohn	Usual Care *	There was no difference between the groups immediately after the treatment.	There was no difference between the groups (qualitative analysis through the LQQ)	There was no difference between the groups	?
Kotz et al.(²⁰)		Usual Care *		The IG showed a significant difference in the FOIS in the 3^rd and 6^th months of follow-up	The average time for the removal of the ADV encompassed 3 months in both groups	?

Population: patients com cancer of the head and neck
Context: outpatient
Intervention: prophylactic swallowing exercises
Comparison: usual care
Outcomes	Nº of participants analyzed (Nº of studies)	Studies included	Statistical heterogeneity (I² )	Effect size (IC95%)	Quality of evidence (GRADE)	Interpretation
Functional Oral Intake Scale (FOIS) ^a	33 (2)	(¹¹,²⁰)	0%	MWD	⨁⨁◯◯ LOW ^c,d	Evidence of low quality suggests that prophylactic swallowing exercises decrease the progression of dysphagia according to the FOIS
Functional Oral Intake Scale (FOIS) ^a	33 (2)	(¹¹,²⁰)	0%	1.27 (0.74 to 1.80)
Progression of Dysphagia assessed based on the FOIS ^b	165 (4)	(¹¹,¹⁸-²⁰)	NA	Two studies demonstrate benefits and two absence of effect

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[1] Caption: Y = yes; N = no; Max = maximum