, Volume 33, Issue 2, pp 185–191 | Cite as

Grading Dysphagia as a Toxicity of Head and Neck Cancer: Differences in Severity Classification Based on MBS DIGEST and Clinical CTCAE Grades

  • Ryan P. Goepfert
  • Jan S. Lewin
  • Martha P. Barrow
  • Carla L. Warneke
  • Clifton D. Fuller
  • Stephen Y. Lai
  • Randal S. Weber
  • Katherine A. Hutcheson
Original Article


Clinician-reported toxicity grading through common terminology criteria for adverse events (CTCAE) stages dysphagia based on symptoms, diet, and tube dependence. The new dynamic imaging grade of swallowing toxicity (DIGEST) tool offers a similarly scaled five-point ordinal summary grade of pharyngeal swallowing as determined through results of a modified barium swallow (MBS) study. This study aims to inform clinicians on the similarities and differences between dysphagia severity according to clinical CTCAE and MBS-derived DIGEST grading. A cross-sectional sample of 95 MBS studies was randomly selected from a prospectively-acquired MBS database among patients treated with organ preservation strategies for head and neck cancer. MBS DIGEST and clinical CTCAE dysphagia grades were compared. DIGEST and CTCAE dysphagia grades had “fair” agreement per weighted κ of 0.358 (95% CI .231–.485). Using a threshold of DIGEST ≥ 3 as reference, CTCAE had an overall sensitivity of 0.50, specificity of 0.84, and area under the curve (AUC) of 0.67 to identify severe MBS-detected dysphagia. At less than 6 months, sensitivity was 0.72, specificity was 0.76, and AUC was 0.75 while at greater than 6 months, sensitivity was 0.22, specificity was 0.90, and AUC was 0.56 for CTCAE to detect dysphagia as determined by DIGEST. Classification of pharyngeal dysphagia on MBS using DIGEST augments our understanding of dysphagia severity according to the clinically-derived CTCAE while maintaining the simplicity of an ordinal scale. DIGEST likely complements CTCAE toxicity grading through improved specificity for physiologic dysphagia in the acute phase and improved sensitivity for dysphagia in the late-phase.


Deglutition and deglutition disorders Head and neck cancer Toxicity grading Clinical trials 



This work was accomplished with support of the MD Anderson Institutional Research Grant Program. Dr. Hutcheson received funding support from the National Cancer Institute (R03CA188162-01). Drs. Hutcheson, Lai, and Fuller received funding support from the National Institutes of Health (NIH)/National Institute for Dental and Craniofacial Research (1R01DE025248-01/R56DE025248-01). Dr. Fuller has received speaker travel funding from Elekta AB.


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Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  • Ryan P. Goepfert
    • 1
  • Jan S. Lewin
    • 1
  • Martha P. Barrow
    • 1
  • Carla L. Warneke
    • 2
  • Clifton D. Fuller
    • 3
  • Stephen Y. Lai
    • 1
  • Randal S. Weber
    • 1
  • Katherine A. Hutcheson
    • 1
  1. 1.Department of Head and Neck SurgeryThe University of Texas M.D. Anderson Cancer CenterHoustonUSA
  2. 2.Department of BiostatisticsThe University of Texas M.D. Anderson Cancer CenterHoustonUSA
  3. 3.Department of Radiation OncologyThe University of Texas M.D. Anderson Cancer CenterHoustonUSA

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