Swallowing is one of those functions, like breathing, that you don’t think about unless it doesn’t work.
Problems swallowing may feel like a nuisance, but can be debilitating for some people. Like many symptoms, there’s not much to see. In antiquity, a lump in the throat sensation in the absence of physical symptoms was uncharitably called globus hystericus, suggesting a psychological cause. Later, a more neutral term, globus pharyngeus, was adopted, but clinicians remain perplexed about this particular symptom. Make no mistake, however: in the right context, a person’s experience of their swallowing provides information that surpasses our most sophisticated medical testing.
Patients with certain kinds of cancers experience a problem swallowing. In some cases, the cancer causes the problem; in other cases, it is related to cancer treatment. As cancer doctors, our mission is to cure cancer, but also to improve the lives of survivors. For head and neck cancer, that means understanding the physiology of swallowing and how the patient experiences it.
A few years ago, we tried to determine how people experienced their swallowing before and after treatment for head and neck cancers, including cancers of the mouth, throat and larynx or voice box. By using validated questionnaires relating to swallowing and quality of life, we were able to measure the effort patients felt they were putting into maintaining their nutrition.
This measure proved to be highly predictive of subsequent outcomes. For example, people with cancer who reported swallowing was a great burden were more likely to require placement of a feeding tube at some point during their treatment. No other cancer-related or medical testing was as accurate in its predictions. More importantly, patients who reported the greatest swallowing problems and greatest effort in maintaining nutrition were far more likely to go on to die from their cancer.
The information provided by the patients was not reflected in any of the sophisticated medical testing performed prior to treatment. The virulence of a cancer is contained within its genetic blueprint. Our findings suggested that patients were directly experiencing virulence of the cancer, which was not appreciated on the physical examination or picked up in other testing. This has since been confirmed by other studies.
Swallowing related problems may persist for cancer survivors. Rehabilitation programs in swallowing initiated early after diagnosis can help preserve function.
While innovations in cancer treatment may increase cures with fewer side effects, results are usually incremental rather than dramatic. Consequently, we turn to our patients to study whether an innovation is an advance over older treatments. The best means by which to measure swallowing outcomes continues to be an active area of investigation.
Physicians have always known that obtaining careful histories from patients can provide important information. Some patients may pass away from small, painful oral cancers while others with extensive, even inoperable, but non-tender cancers are cured. Our studies help validate patient experiences of their symptoms. We anticipate that in the future, we will be able to formally use information derived from the patient to provide better cancer care.
Miriam N. Lango, MD is an associate professor at the Fox Chase Cancer Center Head and Neck Surgery Section.
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