Modeling symptom drivers of oral intake in long-term head and neck cancer survivors

  • Mona Kamal
  • Martha P. Barrow
  • Jan S. Lewin
  • Alicia Estrella
  • G. Brandon Gunn
  • Quiling Shi
  • Theresa M. Hofstede
  • David I. Rosenthal
  • Clifton David Fuller
  • Katherine A. HutchesonEmail author
  • MD Anderson Head and Neck Cancer Symptom Working Group
Original Article



This study examined the relationship between self-reported symptom severity and oral intake in long-term head and neck cancer (HNC) survivors.


An observational survey study with retrospective chart abstraction was conducted. HNC patients who had completed an MD Anderson Symptom Inventory-Head and Neck (MDASI-HN) questionnaire and also had clinician graded oral intake ratings (Functional Oral Intake Scale [FOIS]) were included. Correlation coefficients were computed. FOIS scores were regressed on MDASI-HN symptom items using stepwise backwards elimination for multivariate models.


One hundred and fifty-two survey pairings were included in the analysis (median 44 months follow-up, range 7–198). Per FOIS, 28% of survivors maintained a total oral diet with no restrictions, 67% reported a restricted oral diet (without tube), 3% were partially tube-dependent with some oral intake, and 2% were NPO. Of the 22 symptom items, the most severe items in decreasing order were dry mouth, difficulty swallowing\chewing, problems with mucus, tasting food, and choking/coughing. Significant bivariate correlations, after Bonferroni correction for multiple comparisons, were present for 8 of 22 symptoms with FOIS. On multivariate analysis, symptom severity for difficulty swallowing and problems with teeth/gums remained significantly associated with FOIS.


Oral intake in HNC survivorship is a multidimensional issue and functional outcome that is impacted not only by dysphagia but also by dental status. Symptom drivers of oral intake likely differ in acute survivorship. Nonetheless, these findings highlight the lack of specificity in this end point and also the need for multidisciplinary supportive care to optimize oral intake in survivors.


Oral intake Head and neck cancer Survivors Symptom drivers Toxicity Functional outcomes 



This work was completed with support of the MD Anderson Oro pharynx Program Patient-Reported Outcomes/Function Core.

Author contributions

All listed co-authors performed the following:

1. Substantial contributions to the conception or design of the work or the acquisition, analysis, or interpretation of data for the work

2. Drafting the work or revising it critically for important intellectual content

3 Final approval of the version to be published

4. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved

Specific additional individual cooperative effort contributions to study/manuscript design/execution/interpretation, in addition to all criteria above are listed as follows:

MK, MPB, AE—Drafted manuscript and supervised analysis and interpretation of data

KH—Corresponding author; primary investigator; conceived, coordinated, and directed all study activities; responsible for data collection, project integrity, data collection infrastructure, programmatic oversight, direct oversight of classified personnel, manuscript content and editorial oversight and correspondence

GBG, JSL, DIR, QS, TH, CDF—Co-investigators; direct patient care provision, direct toxicity assessment and clinical data collection; interpretation and analytic support

MPB, MK, AE—Data coordination, collection, curation, and analysis


This work was supported in part by infrastructure support from the National Institutes of Health Cancer Center Support (Core) Grant CA016672 to The University of Texas MD Anderson Cancer Center. These listed funders/supporters played no role in the study design, collection, analysis, interpretation of data, manuscript writing, or decision to submit this manuscript for publication. Dr. Hutcheson receives grant support from the Patient-Centered Outcomes Research Institute (PCORI), the MD Anderson Institutional Research Grant Program, and the National Cancer Institute (R03 CA188162). Drs. Fuller and Hutcheson receive funding support from the National Institute for Dental and Craniofacial Research (ROl DE025248 and 1R56DE025248-0l). Dr. Fuller received/receives grant and/or salary support from the National Institutes of Health/National Cancer lnstitute’s Paul Calabresi Clinical Oncology Award Program (K12 CA088084-06) and Clinician Scientist Loan Repayment Program (L30 CA136381-02); the SWOG/Hope Foundation Dr. Charles A. Coltman, Jr., Fellowship in Clinical Trials; the NCI QUBBD (1R01CA225190-01); NCI Early Phase Clinical Trials in Imaging and Image-Guided Interventions Program (1R01CA218148-01); a General Electric Healthcare/MD Anderson Center for Advanced Biomedical Imaging In-Kind Award; an Elekta AB/MD Anderson Department of Radiation Oncology Seed Grant; the Center for Radiation Oncology Research at MD Anderson Cancer Center; and the MD Anderson Institutional Research Grant Program. Family of Paul W. Beach is providing direct salary support for Dr. Kamal.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Supplementary material

520_2018_4434_MOESM1_ESM.pdf (301 kb)
ESM 1 MDASI-HN symptom items correlations to Diet score of PSS-HN. Abbreviations: PSSHN, the Performance Scale of Head and Neck Cancer; MDASI-HN, MD Anderson Symptom Inventory-Head and Neck questionnaire (PDF 301 kb)
520_2018_4434_MOESM2_ESM.docx (13 kb)
ESM 2 (DOCX 12 kb)
520_2018_4434_MOESM3_ESM.docx (13 kb)
ESM 3 (DOCX 13 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Mona Kamal
    • 1
    • 2
  • Martha P. Barrow
    • 3
  • Jan S. Lewin
    • 3
  • Alicia Estrella
    • 3
  • G. Brandon Gunn
    • 1
  • Quiling Shi
    • 4
  • Theresa M. Hofstede
    • 3
  • David I. Rosenthal
    • 1
  • Clifton David Fuller
    • 1
    • 5
  • Katherine A. Hutcheson
    • 1
    • 3
    Email author return OK on get
  • MD Anderson Head and Neck Cancer Symptom Working Group
  1. 1.Departments of Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonUSA
  2. 2.Department of Clinical Oncology and Nuclear Medicine, Faculty of MedicineAin Shams UniversityCairoEgypt
  3. 3.Departments of Head and Neck Surgery Unit 1445The University of Texas MD Anderson Cancer CenterHoustonUSA
  4. 4.Departments of Symptom ResearchThe University of Texas MD Anderson Cancer CenterHoustonUSA
  5. 5.MD Anderson Cancer Center/UTHealth Graduate School of Biomedical SciencesHoustonUSA

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