Managing Dysphagia During Radiotherapy for Head and Neck Cancer

Dysphagia (difficulty swallowing) is a common side effect of head and neck cancer and its radiotherapeutic treatment. It can be caused by tumor obstruction, radiation fibrosis damage to the nerves and muscles involved in swallowing, or narrowing (stenosis) of the pharynx and esophagus.^1-4 Dysphagia can make it difficult or painful to eat and drink, and can lead to malnutrition, dehydration, and weight loss. It tends to worsen throughout treatment once it occurs, and in severe cases, can lead to cachexia muscle wasting, anorexia, and anemia.^1-3 

There are 4 types of dysphagia, reflecting the anatomy of damage and swallow dysfunction: oropharyngeal, esophageal, esophagogastric, and paraesophageal.¹ Patients often describe dysphagia as involving difficulty swallowing, chest pain, and “food sticking,” and they can point to where these occur on their body.¹ (Dysphagia should be differentiated from a lump-like sensation in one’s throat called globus hystericus, described as a sense of upper esophageal “fullness.”¹)

Patients face higher risks of developing dysphagia during head and neck radiotherapy if they are overweight or obese, older, have a history of smoking or alcohol use, are receiving concurrent systemic chemotherapy, if their treatment includes long-term use of feeding tubes, or they have experienced pronounced weight loss.^5,6

Patients should be asked explicitly during and after treatment if they experience pain or difficulty swallowing, and if so, in what way and whether swallowing difficulty occurs when eating solid food, drinking liquids, or both.¹

Obstructive dysphagia typically involves greater difficulty with swallowing solids, whereas damage to nerves or muscle function tends to be associated with greater or equal difficulty swallowing liquids.¹ Patients should be asked when difficulty swallowing began, if it is painful, and to localize it.¹

One validated tool for asking patients about dysphagia symptoms and detecting changes over time in the severity of dysphagia is the MD Anderson Dysphagia Inventory (MDADI).⁷ MDADI assesses 4 domains of dysphagia:

• Global How much the patient’s swallowing ability limits their day-to-day activities.
• Physical Effort required to swallow.
• Emotional How the patient feels about their swallowing ability.
• Functional How swallowing ability affects the patient’s ability to eat, drink, and socialize.

Treatments range from anti-inflammatory and pain medication to dietary modifications, speech and swallowing therapy, and assistive medical devices such as straws or feeding tubes. When dysphagia occurs, nutrition referrals, assessments, monitoring, and interventions are also indicated and should not be delayed.⁸

But cancer care teams should not wait for symptoms to appear to address dysphagia. Prophylactic interventions to reduce the risk of radiation dysphagia in patients undergoing radiotherapy for head and neck cancer include swallowing exercises (typically taught by speech language therapists) and tissue-sparing radiotherapy planning and delivery modalities, and prophylaxis should be undertaken at the start of treatment planning and throughout radiotherapy.^2,3,8-13 Some cancer centers, such as UCLA Health in Los Angeles, California, have swallow preservation programs or teams whose work is integrated with that of a patient’s radiotherapy and clinical oncology teams.