Implementing flexible endoscopic evaluation of swallow screening within annual cancer surveillance appointments to monitor for late‐stage radiation‐induced dysphagia: A feasibility study

Late‐stage progressive decline of swallowing function after radiotherapy for head and neck cancer (HNC) is often difficult to monitor. This study examined the feasibility and clinical outcomes of speech‐language pathology implementing flexible endoscopic evaluation of swallow (FEES) screening during annual cancer surveillance visits to monitor late‐stage swallowing function.


Conclusion:
Findings indicate FEES screening incorporated into annual oncological reviews is feasible and effective at monitoring late-stage swallowing function following HNC.

K E Y W O R D S
FEES, head and neck cancer, late dysphagia, screening, speech-language pathology

| INTRODUCTION
The acute, short-term effects of radiotherapy treatment for head and neck cancer (HNC) on swallowing function are well documented.Mucositis, dysphagia, dysgeusia, thick secretions, trismus, odynophagia, and reduced appetite are all early symptoms experienced by patients, 1 which can impact on an individual's ability to maintain adequate oral intake. 2 For a proportion of patients, symptom severity will largely resolve within a few months of treatment completion. 1,3However, for symptoms which remain at 3 months post treatment and beyond, such as dysgeusia and xerostomia, many patients compensate with specific swallowing or mealtime strategies in the long term. 3hile acute stage dysphagia is a well-recognized consequence of HNC treatment, chronic, late-stage radiation-induced dysphagia is increasingly being recognized as an additional significant, and difficult to manage, sequela of radiotherapy intervention. 4,50][11][12][13] Symptoms can also progress across different pathways over time.For some patients, swallowing function may progressively deteriorate over the months and years posttreatment at a very slow rate.Others may experience a more rapid, but later onset of dysphagia, preceded by a period of minimal or even no perceived swallowing difficulties. 13,14ate-stage dysphagia is complex in nature, with multiple impacting factors. 15,16Radiation fibrosis of the swallowing muscles is one of the key factors that can contribute to severe, late onset dysphagia. 4The continued development of fibrosis can cause restricted range and strength of movement of the swallowing musculature, which leads to inefficient and poorly coordinated swallowing. 8Radiation induced cranial neuropathy is a rare side effect which has been reported to affect 4.4% of patients with previous oropharyngeal cancer. 17It is associated with muscle atrophy which may also contribute to long-term dysphagia. 7,18,19Other factors, such as xerostomia impact on bolus formation and transit of certain foods which can influence long-term swallowing function. 31][22] Severity of dysphagia also correlates strongly with poor quality of life, has negative impacts on social interactions, and has been shown to contribute to depression and anxiety. 16,23,24Hence, there are clinical, psychosocial, and financial imperatives to mitigate the risks associated with dysphagia, and to ensure that services are available to promptly diagnose and optimally manage dysphagia when it occurs.
Although current speech-language pathology (SLP) services involve regular dysphagia assessment and management prior to and during the acute stages of treatment, [25][26][27] identification and management of patients experiencing late-stage swallowing changes remains challenging.This is largely because routine SLP services often cease within the first-year post treatment, with clinicians relying on patients to return to the service with any changes in swallow function.Due to the nature of progression of late radiation induced dysphagia, patients often re-present to SLP services only when they are experiencing significant problems swallowing, functional impacts such as prolonged mealtimes, diet modifications such as adding extra sauces to aid swallowing, nutritional compromise, and/or aspiration pneumonia.
To support long-term dysphagia management, a recent consensus review recommended early identification of patients at risk of developing dysphagia, along with a strategy for lifelong surveillance for swallowing problems post-treatment. 28In addition, studies suggest there may be a role for utilizing rehabilitation specialists in a HNC survivorship clinic to identify late treatment related dysfunction, including dysphagia. 29However, there is a lack of evidence regarding how to provide longterm SLP services, especially in often resource-limited hospital settings.To address the current challenges of long-term swallowing monitoring, and to be in line with recommendations from the recent dysphagia management consensus review, the study site developed and trialed a FEES screening service model conducted by SLPs when patients were attending their annual oncological surveillance visits post-treatment.The aims of this study were to examine the feasibility and clinical outcomes of implementing the FEES screening service model for patients who were >2 years post HNC treatment.If feasible, this type of service model could ultimately be used to enable annual instrumental swallow screening in long term post HNC care, supporting detection of late-stage changes to swallow function and assisting timely referral to SLP services.

| MATERIALS AND METHODS
A prospective, cross-sectional study design was used to recruit participants at, a tertiary cancer service in Sydney, New South Wales, Australia.Consecutive participants were recruited during the two periods of February 2021 to June 2021 and February 2022 to May 2022.Data collection was ceased in between these two collection periods due to COVID-19 restrictions on conducting nasendoscopic assessments.The research received ethical approval SESLHD HREC 2020/ ETH02940, and all participants provided informed, written consent.

| Participants
Three groups of participants were involved in this research: patients post HNC management, SLPs, and medical staff (radiation oncologists and Ear Nose and Throat surgeons [ENT]).Eligibility criteria for patient participants included all adults (>18 years) who received radiotherapy (+/À chemotherapy, +/À surgery) with curative intent for HNC a minimum of 2 years ago, and who attended a routine annual oncology review appointment during the study period.Exclusion criteria included a history of distant metastases, second primary or recurrent/residual disease, laryngectomy surgery, and any comorbidity that could impact swallowing function (e.g., stroke).All patients who undergo radiotherapy at the study site are seen by SLP prior to and during radiotherapy, with those presenting with post-treatment dysphagia, receiving ongoing outpatient swallowing management.Any patient still actively receiving SLP care for dysphagia at the time of their oncology review appointment was excluded, as they were already known to, and being managed by the SLP service.Potential patient participants were identified through regular reviews of the HNC clinic appointment schedule.Medical records were reviewed at least 1 week prior to scheduled oncology review appointments to determine eligibility and complete the consent processes.
SLP clinician participants were required to have experience in HNC care (>5 years), be active members of the HNC multi-disciplinary team, have completed competency training in technical scoping and/or conducting and interpreting FEES.Medical staff participants included consultant and registrar radiation oncologists and ENT surgeons who conducted the routine oncology review appointments.Any SLP or medical staff participants who were not involved in the new clinical model were excluded.

| Late-stage dysphagia screening model
In this clinical model, SLPs conducted a clinical review and then FEES screening to assess the current swallowing status of all eligible patients returning for their routine annual post-treatment oncological review appointment.Prior to commencing this new service model, key stakeholders from the HNC oncology clinics including nursing, allied health, medical and research staff, met with the research team to discuss the research objectives and problem-solve clinic workflow and resource requirements.Approximately 4 weeks after commencing the service model, further discussions were held to troubleshoot issues that had arisen and to refine the workflow for the clinic.The refined model, outlined below, was then implemented for the duration of the study trial.
The workflow began with SLP staff reviewing outpatient appointments to identify eligible patients scheduled for annual oncological review.For the purposes of research, all eligible patients were then contacted, advised of the study, and consented.Once patients were consented, the SLP staff then contacted the clinic nurses to ensure a suitable room and nasendoscopes were scheduled to be available for the appointment.A Karl Stortz, flexible CMOS Video-Rhino Laryngoscope with C-Mac monitor was used to allow multiple people to view, and to record the FEES footage and provide patient education during the visit.
On the day of the appointment the SLP was responsible for preparing all resources and foods/fluids required for the FEES procedure.When the patient attended their appointment, both the oncologist (or ENT) and SLP(s) were present.For the first part of the appointment, the medical staff completed their standard cancer surveillance procedures ending with the endoscopic assessment conducted with nasal decongestant (vs.local anesthetic).Then after the medical review, and with the scope still in situ, the SLP then led the FEES screening assessment.The FEES screen was completed either with or without the SLP taking over scoping, depending on their level of FEES competency and/or the preference of the medic scoping.A study-specific FEES screening protocol was developed, adapted from the full FEES assessment first published in 1988. 30Swallowing trials consisted of three liquid and three food boluses.Liquid swallows were conducted using milk dyed with blue food coloring (IDDSI Level 0).Food trials were either biscuit (IDDSI Level 7) or diced fruit with green food coloring (IDDSI Level 6), depending on patient capability/ current diet.Patient-initiated swallowing strategies were noted during the assessment.If strategies were ineffective, the SLP would prompt patients to undertake additional strategies to ensure patient safety.
The results of the FEES were later discussed while replaying the FEES recording with the participant.If swallowing issues were identified, further education and management was offered as appropriate.If the assessment revealed the swallow was within normal limits, patients were advised they would be reviewed again by a SLP at their next oncology review appointment (typically in 12 months).The FEES footage was formally analyzed for internal lymphedema, secretions, and swallowing function after the appointment by one of three clinicians (who may or may not have conducted the FEES).These three clinicians all had >4 years experience analyzing FEES assessments, and all had completed local FEES competency training.As this was a feasibility study, inter and intra rater reliability was not conducted.

| Feasibility and satisfaction
Feasibility and satisfaction of the model was explored using both service data and participant feedback.Service data included the proportion of FEES screenings completed with eligible participants at the oncological review appointments and reasons for failed completion.Participant feedback was collected at the end of each session via three different surveys designed for the patient, SLP and medical staff involved in that session.Surveys rated the feasibility, acceptability, and appropriateness of the clinical model using a 5-point scale with 1 = strongly disagree and 5 = strongly agree.There was opportunity to provide additional comments for any of the questions.

| Swallowing outcomes
Prior to the appointment, medical records were reviewed to record time since last contact with SLP services and the functional swallowing status reported at that time.During the appointment, the SLP discussed with the patient the regular diet/fluids tolerated at home and any strategies used to manage mealtimes.From this information, functional swallowing and diet levels were determined using (a) the Functional Oral Intake Scale (FOIS), 31 a 7-point scale ranging from 1 = nothing by mouth to 7 = total oral diet, and (b) the International Dysphagia Diet Standardisation Initiative (IDDSI) Framework, 32 which provides a common terminology to describe liquid thickness and food textures rated on a scale of 8 levels, with liquids measured from Level 0 = thin fluids to Level 4 = extremely thick fluids (most restrictive liquid), and foods measured from Level 3 = puree (most restrictive food texture) to Level 7 = a full regular or "easy to chew" regular diet.Prior to the FEES assessment, patients also answered three questions regarding their perceptions of their current swallowing function and associated impacts: (1) a single, purpose built question "I feel like I have a swallowing problem when I eat and drink right now" (scale of 1 = strongly disagree to 5 = strongly agree), (2) Question 2 from the SWAL-QoL 33 "It takes me longer to eat than other people" (scale of 0 = very much true to 4 = not at all true), and (3) Question 2 from the Performance Status Scale for Head and Neck Cancer (PSSH&N) 34 "Eating in public" (an incremental scale from 0 = always eats alone to 100 = no restrictions in place, food or company).
Pre-swallow FEES screening outcomes included recording internal lymphedema and secretion status.Internal lymphedema of the pharynx and larynx was rated using the revised Patterson Edema Scale. 35This scale indicates edema severity from 1 = normal to 4 = severe, for eight locations in the larynx and pharynx (epiglottis, valleculae, pharyngoepiglottic folds, aryepiglottic folds, arytenoids, false vocal cords, true vocal cords, and pyriform sinus).Secretions were rated using the New Zealand Secretion Scale (NZSS). 36This scale rates location, amount of, and response to secretions in the pyriform fossa and laryngeal vestibule.
All swallowing trials were rated using the Dynamic Imaging Grade of Swallowing Toxicity for Flexible Endoscopic Evaluation of Swallowing (DIGEST-FEES). 37The DIGEST-FEES calculates two grades: a safety grade which scores volume and frequency of penetration of food and fluid into the airway (ranges from 0 = no penetration/aspiration to 4 = profound/life threatening penetration/aspiration) and an efficiency grade measured by percentage of pharyngeal residue in the uncompensated swallow (ranges from Grade 0 = less than 10% residue to Grade 4 = >66% residue).An overall DIGEST-FEES score is calculated from these 2 scores (ranges from Grade 0 = no problem to Grade 4 = life threatening problem).Any patient-initiated and SLP-initiated strategies for bolus clearing (as needed) including dry swallow, fluid flush, and cough were noted.

| Feasibility and satisfaction
Over the study period a total of 71 patients met eligibility criteria and of these, 50 (70.4%)completed the FEES screening.The primary reason for not completing FEES screening was that a SLP was unable to attend the appointment (n = 11) which was often due to COVID rescheduling or staff unavailability (COVID leave).A further 5 were unable to tolerate the scope without topical anesthetic (n = 5), and 5 others declined to participate in the research.Of the 50 who completed FEES screening, the majority were males and ≥5 years post HNC treatment (Table 1).Analysis of the duration since each patient was last seen by SLP services identified 14% (n = 7) had been seen within 12 months prior to this FEES screening, 54% of patients (n = 27) seen between 1 and 3 years prior, and 32% of patients (n = 16), were greater than 3 years since (range 2 months to >190 months).
Twelve staff participants provided feedback on the model, including three SLPs, each with >5 years' experience in HNC care (>4 years FEES experience), and nine medical staff (three consultants and six registrars, 30% from ENT, 70% from Radiation Oncology).All patient, SLP, and medical staff participants were asked to complete a survey after each visit and results are presented in Table 2. Most patient participants reported that the FEES assessment was worthwhile and should be incorporated as part of their monitoring of swallowing over time (98%).Equally, most SLP surveys indicated the FEES screening service was appropriate (96%).However, for almost one third of sessions, clinicians indicated they did not have capacity to complete all of the formal outcome measures included within the research study protocol within 5 working days of the clinic.There was an opportunity for clinicians to provide more detail about the feasibility of the model in the survey comment section.Responses revealed that clinicians had difficulty completing the full internal lymphedema rating within 5 days of the clinic; however, it was able to be completed with additional time.In the future, perhaps replacing the full internal lymphedema reporting (i.e., grading each site by severity) with a simple binary rating of presence/absence of internal lymphedema conducted at the time of the FEES (with further detailed analysis conducted later only if required), could help improve the feasibility of reporting.Medical staff reported that completing the FEES was worthwhile (96%) and that the process did not impact on the time or efficiency of the clinic (94%).

| Clinical swallowing outcomes
At the time of assessment, all patients were on an exclusively oral diet.Regarding functional oral intake, 42% indicated they had no dietary restrictions (FOIS 7), 28% indicated requiring minor adjustments to food choices (FOIS 6), and 30% indicated requiring preparation and/or compensation strategies (FOIS 5).Classification of the foods and fluids consumed in regular meals using IDDSI revealed 74% managed Level 7 (52% on regular foods, 22% on regular easy to chew), 14% Level 6 (soft and bite sized), and 6% Level 5 (minced and moist).All participants managed Level 0 fluids (thin fluids), with no participants requiring thickened fluids.
In response to the study-specific question "I feel like I have a swallowing problem when I eat and drink right now," 66% indicated that they did not have a current swallowing problem (score 1 or 2; Figure 1).In response to the two clinical questions regarding their usual eating/ drinking, 46% reported it took them longer to eat than others (SWAL-QOL < 4).Although 58% of patients reported that they did not restrict any aspect of eating out in public (PSSH&N eating in public level 100), 36% reported they might restrict the types of food but not the location or company (level 75).

| Internal lymphedema
From the pre-swallow FEES observations, 90% of patients had internal lymphedema in at least one site, with 62% demonstrating lymphedema in four or more sites.One patient demonstrated lymphedema in all eight sites.The predominate sites for lymphedema were the epiglottis, pharyngoepiglottic folds, aryepiglottic folds, and arytenoids, with the majority rated as either mild or moderate in severity (Table 3).

| Secretions
Results of the NZSS revealed that most patients (90%) had no pre-swallow pooling of secretions in the pyriform sinuses or laryngeal vestibule (Location NZSS 0).For the remaining 10% of participants, all the preswallow secretions were identified in the pyriform Completing the FEES during this appointment did not impact on the time and efficiency in the clinic 94 (44) 0 (0) 6 (3)  sinuses only (Location NZSS 1).These secretions occupied 20%-80% of the available space (Amount NZSS 1), with attempts to clear being either absent or ineffective (Response NZSS 2&3).Vocal cord function was also assessed at this point by ENT or radiation oncologist, and all but one participant had normal vocal fold function on phonation.

| DIGEST-FEES swallowing outcomes
The outcomes of the FEES screen revealed 84% (n = 42) of the study cohort had dysphagia (DIGEST-FEES score of >0; Table 4).Of the 42 participants who presented with dysphagia, the majority was classified as mild (57%) or moderate (36%) in severity.Most difficulties were observed with residue remaining in the pharynx postswallow, with 84% scoring a DIGEST-FEES efficiency score >0.Thirty-four percent of participants had mildmoderate safety concerns indicating a potential aspiration risk (DIGEST-FEES safety score >0).As this is a cross-sectional sample, no conclusions can be made regarding dysphagia severity and duration post treatment.However, those who presented with either mild dysphagia (n = 24) or moderate (n = 15) dysphagia were 20-10 years post treatment, while those with severe deficits (n = 3) were between 4 and >10 years post treatment.
Direct comparison of the patient reported dysphagia and DIGEST-FEES scores revealed that 27 of the 33 participants (82%) who reported having no swallowing problems were classified as having dysphagia as observed on FEES (DIGEST-FEES score >0).All patients who reported having dysphagia showed evidence of dysphagia on FEES (Figure 1).

| Dysphagia management outcomes
Following FEES screening, 26% of the cohort required no further input from SLP services as no changes were required to their current oral intake or mealtime strategies.This included all patients who were noted to have a normal swallow on FEES as well as some who presented with a mild overall DIGEST-FEES score.Patients who were independently managing oral intake safely, including those with a DIGEST-FEES grade of 1, were planned for review at their next annual clinic visit.These patients were educated about their risk of possible declining swallowing function, were given strategies to assist with swallowing efficiency, and were encouraged to return to SLP services with any changes or concerns.The remaining 74% required some form of SLP intervention.This included 24% who received swallowing education regarding additional mealtime strategies to improve swallow safety (e.g., use of a fluid flush to clear solid residue), and 50% who required multiple levels of advice and education which included: texture modification, use of swallowing strategies, progression to further instrumental assessment (videofluoroscopy), and/or commencement of swallowing therapy.

| DISCUSSION
Early detection of late-stage swallowing changes in the HNC population is challenging as it is typically reliant on patients to self-refer to SLP services with reports of any changes.As such, late-stage dysphagia whether it is new in onset or a decline in existing function, often goes undetected until patients present with more severe symptom presentation and complications. 8The current study presents a model of incorporating an annual instrumental FEES screening into cancer surveillance appointments.Data confirmed that this FEES screening model was feasible to implement, and was well received by patients, SLPs, and medical staff.Furthermore, the FEES data confirmed the existence of dysphagia in 86% of patients, compared to only 26% identified by patient report alone.Finally, 74% of patients went on to receive some form of SLP services to support swallow safety.
Overall, this model appears to be both feasible and effective at identifying patients who would benefit from swallowing management after HNC treatment.
In the current study, the majority of patients who attended their routine oncological review appointment were also able to complete the FEES screening.Although 70% of eligible patients were seen within this model, 11 assessments (15%) were unable to be conducted because the SLP was not available to attend the appointment.This was largely due to multiple patients attending appointments at the same time, last-minute scheduling changes, and competing clinical priorities for the clinician.Although some of these missed appointments were exacerbated by COVID impacts to services and scheduling, the data highlights the importance of ensuring that appointments and scheduling between oncology and SLP services are optimized to help minimize this issue in the future.
Overall, there was good patient engagement and positive feedback about the service model.Patients felt the inclusion of a FEES screen was worthwhile, and almost all felt that the importance of the information they received about their current swallowing function outweighed the discomfort of the procedure.They valued the opportunity to be involved in the assessment and found that it enhanced their own understanding of their swallowing difficulties.This education and patient engagement may also lead to increasing patients' awareness of any changes in their swallowing over time, allowing for more timely referrals to SLP services in the future.
SLPs and medical staff also reported that this model did not adversely impact on their clinical time or efficiency and the medical teams agreed that this model could be integrated into routine oncology appointments.Early collaboration and consultation with the key stakeholders was integral to supporting implementation success of this model.However, SLPs reported the time required for collecting all outcome measures and formally scoring the FEES footage after the screen was not always achievable with competing clinical demands.It should be noted there were numerous outcome measures and formal FEES ratings which were included in the post-session analysis due to the nature of the research project, and it was primarily the lymphedema scoring which took slightly longer to complete.The extent of outcome measures and/or formal FEES ratings could be reduced or simplified once this model was incorporated into routine practice.Currently most services rely on patient report and/or self-referrals to detect any new onset or late-stage decline in swallow function. 25,29However, several studies have highlighted that patient-reported swallowing following HNC can differ from clinician assessment, with swallowing impairment often identified as significantly worse when examined on instrumental assessments compared to patient-report. 38,39This may relate to up to 50% of patients with radiation associated dysphagia experiencing pharyngeal/laryngeal sensory impairment, which may result in silent aspiration. 40,41For others, the insidious onset of dysphagia may result in patient-initiated compensations which are accepted as effective, however instrumental assessments of swallow function should be used to provide more accurate assessment of function. 28he recent Consensus Statement for Dysphagia Management 28 supports the use of instrumental assessments for optimal identification of dysphagia in HNC patients.The current study has also highlighted high rates of poor patient identification of dysphagia, with 27 of the 33 patients reporting normal swallow function but demonstrating swallow safety issues on FEES.These results highlight the issues with self-report/self-referral, and the benefit of establishing a proactive instrumental screening method to identify dysphagia more accurately.
A further advantage of the current FEES screening model was the ability for the SLP to view both the secretions and presence of internal lymphedema within the pharynx.The frequency of internal lymphedema within the cohort was high, with 90% of participants presenting with at least 1 of the 8 pharyngo-laryngeal structures assessed being affected by lymphedema.3][44][45] Information about the prevalence and resolution of internal lymphedema is emerging in the literature therefore, monitoring this as part of long-term patient management would help provide further insights into the link between internal lymphedema and dysphagia. 45,46key benefit of the current clinical model is its ability to enable regular review, and timely support, for patients with late changes to swallow safety.Most participants in this study had had their last contact with SLP services well over 12 months prior to the screening visit (32% were >3 years).Although their clinical model was different to the current study, Ebersole et al. 29 similarly found that most (37%) of the HNC patients attending their interdisciplinary quality of life clinic required onreferral for dysphagia, and the median time since prior instrumental swallow assessment was 6.1 years.The outcomes of FEES screening in the current model led to 74% of patients needing some form of swallowing management from SLP services, including 50% who required more complex care, including videofluoroscopy to investigate the phases of the swallow in more detail as well as active swallowing therapy.Although there is limited evidence for interventions which are effective for improving swallowing function in late-stage radiation induced dysphagia, 47 there is emerging evidence for techniques, such as Expiratory Muscle Strength Training (EMST), that may help improve swallow safety. 48By including an annual FEES screening model into routine care, there is increased potential to support early identification of people who may benefit from such late-stage therapy options.

| LIMITATIONS
This study has inherent limitations as it is only a descriptive, single site study.Although the current model was able to be successfully implemented in this specific service, further implementation, and evaluation of the model across other services is needed to provide a robust evaluation of service feasibility.It is recognized that the close location of SLP and oncology services assisted the successful implementation of this model.Hence, the service model may not be suitable in other contexts where SLP and oncology services are not closely located.The current study also had a limited sample size of 71 participants, which had to be recruited over two separate time periods due to COVID restrictions.Evaluation of the model across a longer study period with larger participant numbers is warranted.The study design was also cross sectional.Longitudinal data, following the same cohort of patients over the years post treatment would provide further insights into the ability of this model to detect change over time.
It is recognized that the FEES assessment implemented was a screening assessment only.This was intentional to ensure any swallowing issues were identified in a time efficient manner, with minimal impact to the oncology review appointment schedule.However, as the DIGEST-FEES severity rating was determined from a modified bolus protocol for screening purposes, of only three fluid and three solid trials, it is recognized that further assessment may be necessary to appropriately inform dysphagia severity and inform clinical management.Furthermore, in some services it may be necessary to complete a full FEES assessment for reimbursement purposes.This, and other cost considerations associated with staffing must be considered within the health service this model is to be implemented in.Finally, it is recognized that this model requires SLPs with relevant training and skills in both FEES assessment and internal lymphedema assessment, which may not always be possible in all services.

| CONCLUSION
With radiotherapy continuing to be one of the key curative approaches to managing HNC, it is important that known consequences of treatment, such as radiationinduced dysphagia, is promptly identified and managed in both the acute and long-term stages post care.The current study provides initial evidence to support the introduction of FEES screening by SLP services within routine oncology surveillance appointments, as an approach to long-term monitoring of dysphagia.This model allows for more timely referrals to, and tailored support from SLP services for patients with late-stage radiation induced dysphagia, with the potential to reduce the severity of long-term swallowing decline.Future studies to investigate the health care cost savings associated with this model, and long-term swallowing and quality of life outcomes is recommended.Finally, this current work, and the recent work by Ebersole et al. 29 has highlighted that dedicated screening/review models to detect late functional change in the years post HNC care are needed.Within the pathway of care for patients with HNC, establishing models that are both feasible to implement within local service capacity/demands, and which assist in the improved detection of dysphagia and other long term functional deficits is urgently needed for this population.
Patient, speech-language pathologist, and medical staff survey responses T A B L E 2

1
Patient reported versus observed swallowing difficulties [Color figure can be viewed at wileyonlinelibrary.com]T A B L E 3 Location and severity of internal lymphoedema