title: Patient-reported voice and speech outcomes after whole-neck intensity modulated radiation therapy and chemotherapy for oropharyngeal cancer: prospective longitudinal study.
abstract: OBJECTIVE
  To describe voice and speech quality changes and their predictors in patients with locally advanced oropharyngeal cancer treated on prospective clinical studies of organ-preserving chemotherapy-intensity modulated radiation therapy (chemo-IMRT).
  
  
  METHODS
  Ninety-one patients with stage III/IV oropharyngeal cancer were treated on 2 consecutive prospective studies of definitive chemoradiation using whole-field IMRT from 2003 to 2011. Patient-reported voice and speech quality were longitudinally assessed from before treatment through 24 months using the Communication Domain of the Head and Neck Quality of Life (HNQOL-C) instrument and the Speech question of the University of Washington Quality of Life (UWQOL-S) instrument, respectively. Factors associated with patient-reported voice quality worsening from baseline and speech impairment were assessed.
  
  
  RESULTS
  Voice quality decreased maximally at 1 month, with 68% and 41% of patients reporting worse HNQOL-C and UWQOL-S scores compared with before treatment, and improved thereafter, recovering to baseline by 12-18 months on average. In contrast, observer-rated larynx toxicity was rare (7% at 3 months; 5% at 6 months). Among patients with mean glottic larynx (GL) dose ≤20 Gy, >20-30 Gy, >30-40 Gy, >40-50 Gy, and >50 Gy, 10%, 32%, 25%, 30%, and 63%, respectively, reported worse voice quality at 12 months compared with before treatment (P=.011). Results for speech impairment were similar. Glottic larynx dose, N stage, neck dissection, oral cavity dose, and time since chemo-IMRT were univariately associated with either voice worsening or speech impairment. On multivariate analysis, mean GL dose remained independently predictive for both voice quality worsening (8.1%/Gy) and speech impairment (4.3%/Gy).
  
  
  CONCLUSIONS
  Voice quality worsening and speech impairment after chemo-IMRT for locally advanced oropharyngeal cancer were frequently reported by patients, underrecognized by clinicians, and independently associated with GL dose. These findings support reducing mean GL dose to as low as reasonably achievable, aiming at ≤20 Gy when the larynx is not a target.
authors.affiliation: Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
authors.forename: Jeffrey M
authors.initials: JM
authors.lastname: Vainshtein
authors.affiliation: Center for Cancer Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan.
authors.forename: Kent A
authors.initials: KA
authors.lastname: Griffith
authors.affiliation: Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
authors.forename: Felix Y
authors.initials: FY
authors.lastname: Feng
authors.affiliation: Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
authors.forename: Karen A
authors.initials: KA
authors.lastname: Vineberg
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan.
authors.forename: Douglas B
authors.initials: DB
authors.lastname: Chepeha
authors.affiliation: Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan. Electronic address: eisbruch@umich.edu.
authors.forename: Avraham
authors.initials: A
authors.lastname: Eisbruch
mesh_terms: D000328:Adult; D000368:Aged; D059248:Chemoradiotherapy / Q000009:adverse effects* / Q000379:methods; D005260:Female; D005931:Glottis / Q000187:drug effects / Q000528:radiation effects; D006801:Humans; D007830:Larynx / Q000187:drug effects / Q000528:radiation effects*; D008297:Male; D008875:Middle Aged; D037981:Neck Dissection / Q000009:adverse effects; D015588:Observer Variation; D059351:Organ Sparing Treatments / Q000009:adverse effects* / Q000379:methods; D011446:Prospective Studies; D011788:Quality of Life; D011879:Radiotherapy Dosage; D050397:Radiotherapy, Intensity-Modulated / Q000009:adverse effects* / Q000379:methods; D013060:Speech / Q000187:drug effects / Q000528:radiation effects*; D013064:Speech Disorders / Q000209:etiology; D014062:Tongue Neoplasms / Q000473:pathology / Q000628:therapy*; D014067:Tonsillar Neoplasms / Q000473:pathology / Q000628:therapy*; D014832:Voice Disorders / Q000209:etiology; D014833:Voice Quality / Q000187:drug effects / Q000528:radiation effects*