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What Are We Really Measuring? A Content Comparison of Swallowing Outcome Measures for Head and Neck Cancer Based on the International Classification of Functioning, Disability and Health (ICF)

  • Rebecca Louise NundEmail author
  • Bena Brown
  • Elizabeth Celeste Ward
  • Julia Maclean
  • Justin Roe
  • Joanne M. Patterson
  • Rosemary Martino
Original Article


A combination of outcome measures are required to provide important information on the physiological profile and associated impact of dysphagia in head and neck cancer (HNC). Choosing the most appropriate tool can be a difficult and time-consuming process. The aim of this study was to identify and then compare the content of tools commonly used to assess swallowing post HNC care using the International Classification of Functioning Disability and Health (ICF) as a reference. A literature audit of 11 databases was conducted for relevant articles published between January 2004 and June 2017 and total of 502 papers met the inclusionary criteria. These papers were audited and 27 tools were identified which met the study criteria. The meaningful concepts contained in each tool were mapped to the ICF. Within the 27 tools, 898 meaningful concepts were identified and matched to 60 ICF categories. The most frequently matched ICF categories related to body functions, while comparatively few concepts matched to activity and participation and environmental factors. This study has identified that a large number of tools are currently being used in HNC research to measure swallowing outcomes. The sheer number of tools available to explore dysphagia post HNC highlights the lack of a uniform approach to outcome measurement which limits the potential to compare and combine research studies in order to strengthen treatment evidence. There is a need to develop an international consensus for a core outcome set of swallowing related measures, that capture the holistic impact of dysphagia, for HNC.


Deglutition Deglutition disorders Head and neck cancer ICF Outcome measures 


Compliance with Ethical Standards

Conflict of interest

The authors declared that they have no conflict of interest.

Supplementary material

455_2019_10005_MOESM1_ESM.docx (16 kb)
Supplementary material 1 (DOCX 15 kb)


  1. 1.
    Wall LR, Cartmill B, Ward EC, Hill AJ. Physiological changes to the swallowing mechanism following (chemo)radiotherapy for head and neck cancer: a systematic review. Dysphagia. 2013;28:481–93. Scholar
  2. 2.
    Hunter KU, et al. Aspiration pneumonia after chemo-intensity-modulated radiation therapy of oropharyngeal carcinoma and its clinical and dysphagia-related predictors. Head Neck. 2014;36:120–5. Scholar
  3. 3.
    Lazarus CL, et al. Functional outcomes and quality of life after chemoradiotherapy: baseline and 3 and 6 months post-treatment. Dysphagia. 2014;29:365–75. Scholar
  4. 4.
    Nund RL, Ward EC, Scarinci NA, Cartmill B, Kuipers P, Porceddu SV. The lived experience of dysphagia following non-surgical treatment for head and neck cancer. Int J Speech Lang Pathol. 2014;16:282–9. Scholar
  5. 5.
    Cancer Council Australia. Optimal care pathway for people with head and neck cancers. Accessed 9 Dec 2018.
  6. 6.
    National Institute for Health and Care Excellence (2018) Cancer of the upper aerodigestive tract: assessment and management in people aged 16 and over. NICE GUIDELINE 36. Accessed 9 Dec 2018.
  7. 7.
    Nekhlyudov L, et al. Head and neck cancer survivorship care guideline: American Society of Clinical Oncology clinical practice guideline endorsement summary. J Oncol Pract. 2018;14:167–71. Scholar
  8. 8.
    Martino R, et al. A systematic review of current clinical and instrumental swallowing assessment methods. Curr Phys Med Rehabil Rep. 2013;1:267–79. Scholar
  9. 9.
    Speyer R, et al. Psychometric properties of questionnaires on functional health status in oropharyngeal dysphagia: a systematic literature review. Biomed Res Int. 2014;2014:1–11. Scholar
  10. 10.
    Timmerman AA, Speyer R, Heijnen BJ, Klijn-Zwinjnenberg IR. Psychometric characteristics of health-related quality-of-life questionnaires in oropharyngeal dysphagia. Dysphagia. 2014;29:183–98. Scholar
  11. 11.
    Barnhart M, Robinson R, Simms V, Ward EC, Cartmill B, Chandler S, Smee R. Treatment toxicities and their impact on oral intake following non-surgical management for head and neck cancer: a 3 year longitudinal study. Support Care Cancer. 2018;26:2341–51. Scholar
  12. 12.
    Moroney LB, et al. Helical IMRT with concurrent chemotherapy for oropharyngeal SCC: a prospective investigation of acute swallowing and toxicity patterns. Head Neck. 2018;40:1955–66. Scholar
  13. 13.
    van der Molen L, van Rossum MA, Ackerstaff AH, Smeele LE, Rasch CR, Hilgers FJ. Pretreatment organ function in patients with advanced head and neck cancer: clinical outcome measures and patients’ views. BMC Ear Nose Throat Disord. 2009. Scholar
  14. 14.
    Patterson JM, McColl E, Wilson J, Carding P, Rapley T. Head and neck cancer patients’ perceptions of swallowing following chemoradiotherapy. Support Care Cancer. 2015;23:3531–8. Scholar
  15. 15.
    Chan KMK, Chan HKW, Siu JYL, Pu D, Nund RL, Ward EC. Impact of head and neck cancer treatment on survivors mealtime experience. Laryngoscope. 2018. Scholar
  16. 16.
    Hutcheson KA, Lewin JS. Functional assessment and rehabilitation: how to maximize outcomes. Otolaryngol Clin N Am. 2013;46:657–70. Scholar
  17. 17.
    World Health Organization. International Classification of Functioning, Disability and Health. Geneva: World Health Organization; 2001.Google Scholar
  18. 18.
    Nund RL, Ward EC, Scarinci NA, Cartmill B, Kuipers P, Porceddu SV. Application of the International Classification of Functioning, Disability and Health (ICF) to people with dysphagia following non-surgical head and neck cancer management. Dysphagia. 2014;29:692–703. Scholar
  19. 19.
    Tschiesner UM, Rogers SN, Harreus U, Berghaus A, Cieza A. Content comparison of quality of life questionnaires used in head and neck cancer based on the international classification of functioning, disability and health: a systematic review. Eur Arch Otorhinolaryngol. 2008;265:627–37. Scholar
  20. 20.
    Stucki A, Borchers M, Stucki G, Cieza A, Amann E, Ruof J. Content comparison of health status measures for obesity based on the international classification of functioning, disability and health. J Obes. 2006;30:1791–9. Scholar
  21. 21.
    Brockow T, Cieza A, Kuhlow H, Sigl T, Franke T, Harder M, Stucki G. Identifying the concepts contained in outcome measures of clinical trials on musculoskeletal disorders and chronic widespread pain using the International Classification of Functioning, Disability and Health as a reference. J Rehabil Med. 2004;44:30–6. Scholar
  22. 22.
    Granberg S, Moller K, Skagerstrand A, Moller C, Danermark B. The ICF Core Sets for hearing loss: researcher perspective, part II: linking outcome measures to the International Classification of Functioning, Disability and Health (ICF). Int J Audiol. 2014;53:77–87. Scholar
  23. 23.
    Cieza A, Brockow T, Ewert T, Amman E, Kolleritis B, Chatterji S, Ustun TB, Stucki G. Linking health-status measurements to the international classification of functioning, disability and health. J Rehabil Med. 2002;34:205–10.CrossRefGoogle Scholar
  24. 24.
    Cieza A, Geyh S, Chatterji S, Kostanjsek N, Ustun B, Stucki G. ICF linking rules: an update based on lessons learned. J Rehabil Med. 2005;37:212–8. Scholar
  25. 25.
    Belafsky PC, Mouadeb DA, Rees CJ, Pryor JC, Postma GN, Allen J, Leonard RJ. Validity and reliability of the eating assessment tool (EAT-10). Ann Otol Rhinol Laryngol. 2008;117:919–24. Scholar
  26. 26.
    List MA, D’Antonio LL, Cella DF, Siston A, Mumby P, Haraf D, Vokes E. The Performance Status Scale for Head and Neck Cancer patients and the Functional Assessment of Cancer Therapy-Head and Neck Scale. A study of utility and validity. Cancer. 1996;77:2294–301.CrossRefGoogle Scholar
  27. 27.
    Perry A, Skeat J. Australian therapy outcome measures (AusTOMs) for speech pathology. Victoria: La Trobe University; 2004.Google Scholar
  28. 28.
    Trotti A, Colevas AD, Setser A, Rusch V, Jaques D, Budach V, Rubin P. CTCAE v3. 0: development of a comprehensive grading system for the adverse effects of cancer treatment. Semin Radiat Oncol. 2003;13:176–81. Scholar
  29. 29.
    Silbergleit AK, Schultz L, Jacobson BH, Beardsley T, Johnson AF. The Dysphagia Handicap Index: development and validation. Dysphagia. 2012;27:46–52. Scholar
  30. 30.
    O’Neil KH, Purdy M, Falk J, Gallo L. The dysphagia outcome and severity scale. Dysphagia. 1999;14:139–45. Scholar
  31. 31.
    Bjordal K, et al. Development of a European Organization for Research and Treatment of Cancer (EORTC) questionnaire module to be used in quality of life assessments in head and neck cancer patients. Acta Oncol. 1994;33:879–85.CrossRefGoogle Scholar
  32. 32.
    Bjordal K, et al. Quality of life in head and neck cancer patients: validation of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-H&N35. J Clin Oncol. 1999;17:1008–19. Scholar
  33. 33.
    Crary MA, Mann GD, Groher ME. Initial psychometric assessment of a functional oral intake scale for dysphagia in stroke patients. Archiv Phys Med Rehabil. 2005;86:1516–20. Scholar
  34. 34.
    Salassa JR. A functional outcome swallowing scale for staging oropharyngeal dysphagia. Dig Dis. 1999;7:230–4. Scholar
  35. 35.
    Funk GF, Karnell LH, Christensen AJ, Moran PJ, Ricks J. Comprehensive head and neck oncology health status assessment. Head Neck. 2003;25:561–75. Scholar
  36. 36.
    Ho KF, Farnell DJ, Routledge JA, Burns MP, Sykes AJ, Slevin NJ, Davidson SE. Comparison of patient-reported late treatment toxicity (LENT-SOMA) with quality of life (EORTC QLQ-C30 and QLQ-H&N35) assessment after head and neck radiotherapy. Radiother Oncol. 2010;97:270–5. Scholar
  37. 37.
    Carnaby GD, Crary MA. Development and validation of a cancer-specific swallowing assessment tool: MASA-C. Support Care Cancer. 2014;22:595–602. Scholar
  38. 38.
    Martin-Harris B, et al. MBS measurement tool for swallow impairment–MBSImp: establishing a standard. Dysphagia. 2008;23:392–405. Scholar
  39. 39.
    Chen AY, Frankowski R, Bishop-Leone J, Hebert T, Leyk S, Lewin J, Goepfert H. The development and validation of a dysphagia-specific quality-of-life questionnaire for patients with head and neck cancer: the M. D. Anderson dysphagia inventory. Arch Otolaryngol Head Neck Surg. 2001;127:870–6.Google Scholar
  40. 40.
    Rademaker AW, Pauloski BR, Logemann JA, Shanahan TK. Oropharyngeal swallow efficiency as a representative measure of swallowing function. J Speech Hear Res. 1994;37:314–25.CrossRefGoogle Scholar
  41. 41.
    Rosenbek JC, Robbins JA, Roecker EB, Coyle JL, Wood JL. A penetration-aspiration scale. Dysphagia. 1996;11:93–8.CrossRefGoogle Scholar
  42. 42.
    List MA, D’Antonio LL, Cella DF, Siston A, Mumby P, Haraf D, Vokes E. The Performance Status Scale for Head and Neck Cancer patients and the Functional Assessment of Cancer Therapy-Head and Neck Scale: a study of utility and validity. Cancer. 1996;77:2294–301.CrossRefGoogle Scholar
  43. 43.
    Ward EC, Conroy AL. Validity, reliability and responsivity of the Royal Brisbane Hospital outcome measure for swollowing. Asia Pacific J Speech Lang Hear. 1999;4:109–29. Scholar
  44. 44.
    Cox JD, Stetz J, Pajak TF. Toxicity criteria of the Radiation Therapy Oncology Group (RTOG) and the European organization for research and treatment of cancer (EORTC). Int J Radiat Oncol Biol Phys. 1995;31:1341–6. Scholar
  45. 45.
    Dwivedi RC, et al. Validation of the Sydney Swallow Questionnaire (SSQ) in a cohort of head and neck cancer patients. Oral Oncol. 2010;46:e10–4. Scholar
  46. 46.
    McHorney CA, Robbins J, Lomax K, Rosenbek JC, Chignell K, Kramer AE, Bricker DE. The SWAL-QOL and SWAL-CARE outcomes tool for oropharyngeal dysphagia in adults: III documentation of reliability and validity. Dysphagia. 2002;17:97–114. Scholar
  47. 47.
    Terrell JE, Nanavati KA, Esclamado RM, Bishop JK, Bradford CR, Wolf GT. Head and neck cancer-specific quality of life. Arch Otolaryngol Head Neck Surg. 1997;123:1125–32.CrossRefGoogle Scholar
  48. 48.
    Rogers SN, Gwanne S, Lowe D, Humphris G, Yueh B, Weymuller EA Jr. The addition of mood and anxiety domains to the University of Washington quality of life scale. Head Neck. 2002;24:521–9. Scholar
  49. 49.
    Murphy BA, et al. Reliability and validity of the Vanderbilt Head and Neck Symptom Survey: a tool to assess symptom burden in patients treated with chemoradiation. Head Neck. 2010;32:26–37. Scholar
  50. 50.
    Patterson JM, Hildreth A, McColl E, Carding PN, Hamilton D, Wilson JA. The clinical application of the 100 mL water swallow test in head and neck cancer. Oral Oncol. 2011;47:180–4. Scholar
  51. 51.
    Henson BS, Inglehart MR, Eisbruch A, Ship JA. Preserved salivary output and xerostomia-related quality of life in head and neck cancer patients receiving parotid-sparing radiotherapy. Oral Oncol. 2001;37:84–93. Scholar
  52. 52.
    Chera BS, et al. Recommended patient-reported core set of symptoms to measure in head and neck cancer treatment trials. J Natl Cancer Inst. 2014;106:dju127-dju131. Scholar
  53. 53.
    Hutcheson KA, et al. Dynamic Imaging Grade of Swallowing Toxicity (DIGEST): scale development and validation. Cancer. 2017;123:62–70. Scholar
  54. 54.
    Bressan V, Bagnasco A, Aleo G, Catania G, Zanini MP, Timmins F, Sasso L. The life experience of nutrition impact symptoms during treatment for head and neck cancer patients: a systematic review and meta-synthesis. Support Care Cancer. 2017;25:1699–712. Scholar
  55. 55.
    Threats TT. Use of the ICF in dysphagia management. Semin Speech Lang. 2007;28:323–33. Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.School of Health and Rehabilitation SciencesThe University of QueenslandBrisbaneAustralia
  2. 2.Centre for Functioning and Health Research, Metro South Hospital and Health ServiceBurandaAustralia
  3. 3.Speech Pathology DepartmentPrincess Alexandra HospitalWooloongabbaAustralia
  4. 4.Cancer Care Centre, St George HospitalKogarahAustralia
  5. 5.University of New South WalesSydneyAustralia
  6. 6.Department of Speech and Language TherapyThe Royal Marsden NHS Foundation TrustLondonUK
  7. 7.Department of Otolaryngology, Head and Neck Surgery, Charing Cross HospitalImperial College Healthcare NHS TrustLondonUK
  8. 8.Department of Surgery and Cancer, Faculty of MedicineImperial College LondonLondonUK
  9. 9.Institute for Health and SocietyNewcastle UniversityNewcastle upon TyneUK
  10. 10.Speech and Language Therapy DepartmentSunderland Royal HospitalSunderlandUK
  11. 11.Department of Speech Language PathologyRehabilitation Sciences InstituteTorontoCanada
  12. 12.Department of Otolaryngology-Head & Neck Surgery, Faculty of MedicineUniversity of TorontoTorontoCanada
  13. 13.Krembil Research InstituteUniversity Health NetworkTorontoCanada

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