Supportive Care in Cancer

, Volume 22, Issue 9, pp 2361–2369 | Cite as

Weight loss and body mass index in relation to aspiration in patients treated for head and neck cancer: a long-term follow-up

  • Sandra OttossonEmail author
  • Ulrika Lindblom
  • Peter Wahlberg
  • Per Nilsson
  • Elisabeth Kjellén
  • Björn Zackrisson
  • Eva Levring Jäghagen
  • Göran Laurell
Original Article



Persistent severe swallowing dysfunction with aspiration is a common and sometimes overlooked sequelae after treatment for squamous cell carcinoma of the head and neck (SCCHN) and may impact food intake and nutritional status. More knowledge is needed to increase the understanding of severe swallowing dysfunction as a risk factor for persistent nutritional deteriorations in SCCHN survivors. The purpose of the study was to investigate weight loss and body mass index (BMI) in relation to pharyngeal swallowing function in a long-term perspective in patients after SCCHN treatment.


Data from 101 patients were available for the analyses. Swallowing function was assessed by videofluoroscopy at a mean of 71.6 months after the start of radiotherapy (RT). Percent weight change (calculated with weight at the start of RT as the reference) and BMI at follow-up were the primary nutritional measures.


Aspiration was present in 48 of 101 patients (48 %). Patients with aspiration had a significantly higher mean weight loss and a lower BMI (−10.9 % and 23.1, respectively) at follow-up compared with patients without aspiration (−2.8 % and 26.0, respectively). Patients with aspiration were unable to gain weight after 23 months. Only ten of 101 patients (10 %) were underweight at follow-up.


Swallowing dysfunction with aspiration was related to long-term weight loss and reduced BMI. Few patients were underweight despite the high prevalence of swallowing dysfunction.


Fluoroscopy Swallowing dysfunction Head and neck cancer Weight loss Body mass index 



This study was supported by grants from the Swedish Cancer Society, Laryngfonden (Sweden), Lions Cancer Research Foundation at Umeå University, and the Cancer Research Foundation of Northern Sweden. The study was made possible by the commitment from the staff at the participating centers in the ARTSCAN trial and the SALU study-Umeå University Hospital, Sunderby Hospital, Sundsvall Härnösand Hospital, Östersund Hospital, Lund University Hospital, and Malmö University Hospital. The authors acknowledge Ola Gärskog for help with the data collection and Ove Björ for statistical advice.

Conflict of interest statement

The authors have no conflict of interest to disclose and have full control of all primary data and agree to accept the journal to review the data if requested.


  1. 1.
    Platteaux N, Dirix P, Dejaeger E, Nuyts S (2010) Dysphagia in head and neck cancer patients treated with chemoradiotherapy. Dysphagia 25:139–152PubMedCrossRefGoogle Scholar
  2. 2.
    Argiris A, Karamouzis MV, Raben D, Ferris RL (2008) Head and neck cancer. Lancet 371:1695–1709PubMedCrossRefGoogle Scholar
  3. 3.
    Mittal BB, Pauloski BR, Haraf DJ, Pelzer HJ, Argiris A, Vokes EE, Rademaker A, Logemann JA (2003) Swallowing dysfunction—preventative and rehabilitation strategies in patients with head-and-neck cancers treated with surgery, radiotherapy, and chemotherapy: a critical review. Int J Radiat Oncol, Biol, Phys 57:1219–1230CrossRefGoogle Scholar
  4. 4.
    Caudell JJ, Schaner PE, Meredith RF, Locher JL, Nabell LM, Carroll WR, Magnuson JS, Spencer SA, Bonner JA (2009) Factors associated with long-term dysphagia after definitive radiotherapy for locally advanced head-and-neck cancer. Int J Radiat Oncol, Biol, Phys 73:410–415CrossRefGoogle Scholar
  5. 5.
    Langendijk JA, Doornaert P, Rietveld DHF, Verdonck-de Leeuw IM, René Leemans C, Slotman BJ (2009) A predictive model for swallowing dysfunction after curative radiotherapy in head and neck cancer. Radiother Oncol 90:189–195PubMedCrossRefGoogle Scholar
  6. 6.
    Rosenthal DI, Lewin JS, Eisbruch A (2006) Prevention and treatment of dysphagia and aspiration after chemoradiation for head and neck cancer. J Clin Oncol 24:2636–2643PubMedCrossRefGoogle Scholar
  7. 7.
    Hughes PJ, Scott PMJ, Kew J, Cheung D, Leung SF, Ahuja AT, van Hasselt CA (2000) Dysphagia in treated nasopharyngeal cancer. Head Neck 22:393–397PubMedCrossRefGoogle Scholar
  8. 8.
    Chang YC, Chen SY, Tak Lui L, Wang TG, Wang TC, Hsiao TY, Li YW, Lien IN (2003) Dysphagia in patients with nasopharyngeal cancer after radiation therapy: a videofluoroscopic swallowing study. Dysphagia 18:135–143PubMedCrossRefGoogle Scholar
  9. 9.
    Zackrisson B, Nilsson P, Kjellén E, Johansson KA, Modig H, Brun E, Nyman J, Friesland S, Reizenstein J, Sjödin H (2011) Two-year results from a Swedish study on conventional versus accelerated radiotherapy in head and neck squamous cell carcinoma—the ARTSCAN study. Radiother Oncol 100:41–48PubMedCrossRefGoogle Scholar
  10. 10.
    Johansson KA, Nilsson P, Zackrisson B, Ohlson B, Kjellen E, Mercke C, Alvarez-Fonseca M, Billstrom A, Bjork-Eriksson T, Bjor O, Ekberg L, Friesland S, Karlsson M, Lagerlund M, Lundkvist L, Lofroth PO, Lofvander-Thapper K, Nilsson A, Nyman J, Persson E, Reizenstein J, Rosenbrand HO, Wiklund F, Wittgren L (2008) The quality assurance process for the ARTSCAN head and neck study—a practical interactive approach for QA in 3DCRT and IMRT. Radiother Oncol 87:290–299PubMedCrossRefGoogle Scholar
  11. 11.
    Eisbruch A, Lyden T, Bradford CR, Dawson LA, Haxer MJ, Miller AE, Teknos TN, Chepeha DB, Hogikyan ND, Terrell JE (2002) Objective assessment of swallowing dysfunction and aspiration after radiation concurrent with chemotherapy for head-and-neck cancer. Int J Radiat Oncol, Biol, Phys 53:23–28CrossRefGoogle Scholar
  12. 12.
    Nguyen N, Frank C, Moltz C, Vos P, Smith H, Bhamidipati P, Karlsson U, Nguyen P, Alfieri A, Nguyen L (2006) Aspiration rate following chemoradiation for head and neck cancer: an underreported occurrence. Radiother Oncol 80:302–306PubMedCrossRefGoogle Scholar
  13. 13.
    Nguyen N, Moltz C, Frank C, Vos P, Smith H, Karlsson U, Dutta S, Midyett F, Barloon J, Sallah S (2004) Dysphagia following chemoradiation for locally advanced head and neck cancer. Ann Oncol 15:383–388PubMedCrossRefGoogle Scholar
  14. 14.
    Pauloski BR, Rademaker AW, Logemann JA, Lazarus CL, Newman L, Hamner A, MacCracken E, Gaziano J, Stachowiak L (2002) Swallow function and perception of dysphagia in patients with head and neck cancer. Head Neck 24:555–565PubMedCrossRefGoogle Scholar
  15. 15.
    Chasen MR, Bhargava R (2009) A descriptive review of the factors contributing to nutritional compromise in patients with head and neck cancer. Support Care Cancer 17:1345–1351PubMedCrossRefGoogle Scholar
  16. 16.
    Jager-Wittenaar H, Dijkstra PU, Vissink A, van Oort RP, van der Laan BFAM, Roodenburg JLN (2011) Malnutrition in patients treated for oral or oropharyngeal cancer—prevalence and relationship with oral symptoms: an explorative study. Support Care Cancer 19:1675–1683PubMedCentralPubMedCrossRefGoogle Scholar
  17. 17.
    Sobin LH, Fleming ID (1997) TNM classification of malignant tumors. Cancer 80:1803–1804PubMedCrossRefGoogle Scholar
  18. 18.
    Palmer JB, Kuhlemeier KV, Tippett DC, Lynch C (1993) A protocol for the videofluorographic swallowing study. Dysphagia 8:209–214PubMedCrossRefGoogle Scholar
  19. 19.
    Logemann JA (1998) Evaluation and treatment of swallowing disorders. PRO-ED, IncorporatedGoogle Scholar
  20. 20.
    Kondrup J, Allison S, Elia M, Vellas B, Plauth M (2003) ESPEN guidelines for nutrition screening 2002. Clin Nutr 22:415–421PubMedCrossRefGoogle Scholar
  21. 21.
    Vallén C, Hagell P, Westergren A (2011) Validity and user-friendliness of the minimal eating observation and nutrition form-version II (MEONF-II) for undernutrition risk screening. Food Nutr Res. doi: 10.3402/fnr.v55i0.5801 Google Scholar
  22. 22.
    Campbell BH, Spinelli K, Marbella AM, Myers KB, Kuhn JC, Layde PM (2004) Aspiration, weight loss, and quality of life in head and neck cancer survivors. Arch Otolaryngol Head Neck Surg 130:1100–1103PubMedCrossRefGoogle Scholar
  23. 23.
    Teitelbaum D, Guenter P, Howell WH, Kochevar ME, Roth J, Seidner DL (2005) Definition of terms, style, and conventions used in ASPEN guidelines and standards. Nutr Clin Pract 20:281–285PubMedCrossRefGoogle Scholar
  24. 24.
    Silver HJ, Dietrich MS, Murphy BA (2007) Changes in body mass, energy balance, physical function, and inflammatory state in patients with locally advanced head and neck cancer treated with concurrent chemoradiation after low-dose induction chemotherapy. Head Neck 29:893–900PubMedCrossRefGoogle Scholar
  25. 25.
    Ottery FD (1996) Definition of standardized nutritional assessment and interventional pathways in oncology. Nutrition 12:15–19CrossRefGoogle Scholar
  26. 26.
    Dechaphunkul T, Martin L, Alberda C, Olson K, Baracos V, Gramlich L (2013) Malnutrition assessment in patients with cancers of the head and neck: a call to action and consensus. Crit Rev Oncol Hematol 88:459–476PubMedCrossRefGoogle Scholar
  27. 27.
    Stratton RJ, Hackston A, Longmore D, Dixon R, Price S, Stroud M, King C, Elia M (2004) Malnutrition in hospital outpatients and inpatients: prevalence, concurrent validity and ease of use of the ‘malnutrition universal screening tool’ (‘MUST’) for adults. Br J Nutr 92:799–808PubMedCrossRefGoogle Scholar
  28. 28.
    Berg MG, Rütten H, Rasmussen–Conrad EL, Knuijt S, Takes RP, Herpen CM, Wanten GJ, Kaanders JH, Merkx MA (2013) Nutritional status, food intake, and dysphagia in long–term survivors with head and neck cancer treated with chemoradiotherapy: a cross–sectional study. Head Neck. doi: 10.1002/hed.23265 PubMedGoogle Scholar
  29. 29.
    McQuestion M, Fitch M, Howell D (2011) The changed meaning of food: physical, social and emotional loss for patients having received radiation treatment for head and neck cancer. Eur J Oncol Nurs 15:145–151PubMedCrossRefGoogle Scholar
  30. 30.
    Tiblom Ehrsson YT, Langius-Eklof A, Laurell G (2011) Nutritional surveillance and weight loss in head and neck cancer patients. Support Care Cancer 20:757–765CrossRefGoogle Scholar
  31. 31.
    Newman LA, Vieira F, Schwiezer V, Samant S, Murry T, Woodson G, Kumar P, Robbins KT (1998) Eating and weight changes following chemoradiation therapy for advanced head and neck cancer. Arch Otolaryngol Head Neck Surg 124:589–592PubMedCrossRefGoogle Scholar
  32. 32.
    Ottosson S, Zackrisson B, Kjellén E, Nilsson P, Laurell G (2012) Weight loss in patients with head and neck cancer during and after conventional and accelerated radiotherapy. Acta Oncol 52:711–718PubMedCentralPubMedCrossRefGoogle Scholar
  33. 33.
    Silander E, Nyman J, Bove M, Johansson L, Larsson S, Hammerlid E (2011) Impact of prophylactic percutaneous endoscopic gastrostomy on malnutrition and quality of life in patients with head and neck cancer—a randomized study. Head Neck 34:1–9PubMedCrossRefGoogle Scholar
  34. 34.
    Nguyen NP, Moltz CC, Frank C, Vos P, Smith HJ, Karlsson U, Nguyen LM, Rose S, Dutta S, Sallah S (2006) Evolution of chronic dysphagia following treatment for head and neck cancer. Oral Oncol 42:374–380PubMedCrossRefGoogle Scholar
  35. 35.
    Payakachat N, Ounpraseuth S, Suen JY (2012) Late complications and long–term quality of life for survivors (>5 years) with history of head and neck cancer. Head Neck 35:819–825PubMedCrossRefGoogle Scholar
  36. 36.
    Bodin I, Jäghagen EL, Isberg A (2004) Intraoral sensation before and after radiotherapy and surgery for oral and pharyngeal cancer. Head Neck 26:923–929PubMedCrossRefGoogle Scholar
  37. 37.
    Kuhlemeier K, Yates P, Palmer J (1998) Intra-and interrater variation in the evaluation of videofluorographic swallowing studies. Dysphagia 13:142–147PubMedCrossRefGoogle Scholar
  38. 38.
    Lango MN, Egleston B, Fang C, Burtness B, Galloway T, Liu J, Mehra R, Ebersole B, Moran K, Ridge JA (2013) Baseline health perceptions, dysphagia, and survival in patients with head and neck cancer. Cancer. doi: 10.1002/cncr.28482 PubMedGoogle Scholar
  39. 39.
    Semenov YR, Starmer HM, Gourin CG (2012) The effect of pneumonia on short–term outcomes and cost of care after head and neck cancer surgery. Laryngoscope 122:1994–2004PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  • Sandra Ottosson
    • 1
    Email author
  • Ulrika Lindblom
    • 2
  • Peter Wahlberg
    • 2
  • Per Nilsson
    • 3
  • Elisabeth Kjellén
    • 3
  • Björn Zackrisson
    • 4
  • Eva Levring Jäghagen
    • 5
  • Göran Laurell
    • 6
  1. 1.Department of Clinical Sciences, OtorhinolaryngologyUmeå UniversityUmeåSweden
  2. 2.Department of Clinical Sciences, OtorhinolaryngologyLund UniversityLundSweden
  3. 3.Department of Oncology and Radiation PhysicsSkåne University Hospital, Lund UniversityLundSweden
  4. 4.Department of Radiation Sciences, OncologyUmeå UniversityUmeåSweden
  5. 5.Department of Odontology, Oral and Maxillofacial RadiologyUmeå UniversityUmeåSweden
  6. 6.Department of Surgical Sciences, Otolaryngology and Head & Neck SurgeryUppsala UniversityUppsalaSweden

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