10.14639/0392-100X-N1992
Objective. Patients with locally advanced laryngeal and hypopharyngeal cancer (LHC) are often treated with chemo-radiotherapy to avoid total laryngectomy, although voice problems may occur even if not markedly manifest. We sought to evaluate the impact of chemoradiation on voice and quality of life. Methods. We studied 21 patients with locally advanced LHC with tumour control at least two years after chemo-radiotherapy. None manifested clinical symptoms related to the treatment and maintained an activity considered as within normal limits. All patients had a voice handicap index (VHI) of less than 15. Voice function was evaluated by perceptual vocal analysis (CAPE-V) and aerodynamic and acoustic study. Quality of life was assessed with the EORTC-H&amp;N35 (voice items 46, 53 and 54). Results. Voice changes were frequent, with alterations in all CAPE-V attributes, and predominantly type II and III spectrograms in acoustic analysis (78%). The EORTC-H&amp;N35 scale showed a reduction in scores in 10-40% of items related to voice. Conclusions. Subclinical voice disorders are common after chemo-radiotherapy. Although patients consider vocal impairment to be very minor and to not interfere with their daily life, it may contribute to a reduced quality of life.
text/xml
1827-675X
1992
en
Juan Pablo Rodrigo
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
voice
Voice outcomes in patients with advanced laryngeal and hypopharyngeal cancer treated with chemo-radiotherapy
Text.Serial.Journal
https://www.actaitalica.it/
42
Laryngology
2022-06-30
2021-12-29
2022-07-26
2022-07-26
243-249
1
Juan Pablo Rodrigo
2022/06/30
10.14639/0392-100X-N1992
243
Department of Otorhinolaryngology, Head and Neck Surgery, Hospital Universitario Central de Asturias, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Instituto Universitario de Oncología del Principado de Asturias (IUOPA), University of Oviedo, CIBERONC-ISCIII, Oviedo, Spain
1827-675X
voice
en
249
Voice outcomes in patients with advanced laryngeal and hypopharyngeal cancer treated with chemo-radiotherapy
https://www.actaitalica.it/article/download/1992/824
42
ACTA OTORHINOLARYNGOLOGICA ITALICA 2022;42:243-249; doi: 10.14639/0392-100X-N1992




Laryngology


Voice outcomes in patients with advanced laryngeal and
hypopharyngeal cancer treated with chemo-radiotherapy
Risultati vocali in pazienti con cancro laringeo e ipofaringeo avanzato trattati
con chemio-radioterapia
César Álvarez-Marcos1,2, Andrea Vicente-Benito3, Águeda Gayol-Fernández3, Daniel Pedregal-Mallo1,2,
Paloma Sirgo-Rodríguez3, Liliana Santamarina-Rabanal3, José Luis Llorente1,2, Fernando López1,2, Juan Pablo Rodrigo1,2
1
  Department of Otorhinolaryngology, Head and Neck Surgery, Hospital Universitario Central de Asturias, Oviedo, Spain; 2 Instituto de
Investigación Sanitaria del Principado de Asturias (ISPA), Instituto Universitario de Oncología del Principado de Asturias (IUOPA), University
of Oviedo, CIBERONC-ISCIII, Oviedo, Spain; 3 Department of Speech Therapy, Faculty of Psychology, University of Oviedo, Oviedo, Spain


SUMMARY
Objective. Patients with locally advanced laryngeal and hypopharyngeal cancer (LHC) are
often treated with chemo-radiotherapy to avoid total laryngectomy, although voice prob-
lems may occur even if not markedly manifest. We sought to evaluate the impact of chemo-
radiation on voice and quality of life.
Methods. We studied 21 patients with locally advanced LHC with tumour control at least
two years after chemo-radiotherapy. None manifested clinical symptoms related to the
treatment and maintained an activity considered as within normal limits. All patients had
a voice handicap index (VHI) of less than 15. Voice function was evaluated by perceptual
vocal analysis (CAPE-V) and aerodynamic and acoustic study. Quality of life was assessed
with the EORTC-H&N35 (voice items 46, 53 and 54).
Results. Voice changes were frequent, with alterations in all CAPE-V attributes, and pre-
dominantly type II and III spectrograms in acoustic analysis (78%). The EORTC-H&N35
scale showed a reduction in scores in 10-40% of items related to voice.
Conclusions. Subclinical voice disorders are common after chemo-radiotherapy. Although
                                                                                                   Received: December 29, 2021
patients consider vocal impairment to be very minor and to not interfere with their daily life,
                                                                                                   Accepted: March 14, 2022
it may contribute to a reduced quality of life.
KEY WORDS: laryngeal and hypopharyngeal cancer, quality of life, organ-preservation                Correspondence
protocol, voice                                                                                    Fernando López
                                                                                                   Department of Otorhinolaryngology, Hospital
                                                                                                   Universitario Central de Asturias
RIASSUNTO                                                                                          Avenida de Roma s/n, 33011 Oviedo (Spain)
Obiettivo. I pazienti con cancro della laringe e dell’ipofaringe (LHC) localmente avanzato         E-mail: flopez_1981@yahoo.es
vengono spesso trattati con chemio-radioterapia per evitare la laringectomia totale, anche
se si possono presentare problemi disfonici. Abbiamo cercato di valutare l’impatto della
                                                                                                     How to cite this article: Álvarez-Marcos C,
chemioradioterapia sulla voce e sulla qualità della vita.                                            Vicente-Benito A, Gayol-Fernández A, et al.
Metodi. Abbiamo studiato 21 pazienti con LHC localmente avanzato, con controllo locale di            Voice outcomes in patients with advanced
malattia a 2 anni dal termine dei trattamenti chemio-radioterapici. Nessuno di essi lamenta          laryngeal and hypopharyngeal cancer treat-
sintomi clinici correlati a detto trattamento, essendo ritornati a una normale attività di vita.     ed with chemo-radiotherapy. Acta Otorhi-
Tutti i pazienti mostrano un indice di handicap vocale (VHI) inferiore a 15. La funzione vo-         nolaryngol Ital 2022;42:243-249. https://doi.
cale è stata valutata mediante analisi percettiva vocale (CAPE-V) e studio aerodinamico e            org/10.14639/0392-100X-N1992
acustico. La qualità della vita è stata valutata con l’EORTC-H&N35 (voci 46, 53 e 54).
Risultati. I cambiamenti di voce sono risultati essere frequenti, con alterazioni del CAPE-V e     © Società Italiana di Otorinolaringoiatria
                                                                                                   e Chirurgia Cervico-Facciale
spettrogrammi prevalentemente di tipo II e III nell’analisi acustica. (78%). La scala EORTC-
H&N35 mostra una riduzione del punteggio tra il 10-40% nelle voci relative alla funzione vocale.
                                                                                                                  OPEN ACCESS
Conclusioni. I disturbi della voce subclinici sono comuni dopo la chemio-radioterapia.
Sebbene i pazienti considerino la compromissione vocale di minore importanza, non inter-           This is an open access article distributed in accordance with
                                                                                                   the CC-BY-NC-ND (Creative Commons Attribution-Non-
ferendo tali alterazioni con la loro vita quotidiana, tali disturbi potrebbero contribuire a       Commercial-NoDerivatives 4.0 International) license. The
una ridotta qualità della vita.                                                                    article can be used by giving appropriate credit and mentio-
                                                                                                   ning the license, but only for non-commercial purposes and
PAROLE CHIAVE: cancro laringeo e ipofaringeo, qualità della vita, protocollo di conservazione      only in the original version. For further information: https://
dell’organo, voce                                                                                  creativecommons.org/licenses/by-nc-nd/4.0/deed.en




                                                                                                                                                           243
C. Álvarez-Marcos et al.




Introduction                                                    and neck area, including tracheostomy, those dependent on
                                                                a feeding tube or percutaneous endoscopic gastrostomy for
Treatment of head and neck cancer (HNC) usually ad-
                                                                nutritional support, or had received specific rehabilitation
versely affects voice and swallowing 1,2. Radiotherapy
                                                                by a speech therapist due to swallowing or voice disorders
(RT) or chemoradiotherapy (CRT) has become standard
                                                                were excluded. Moreover, patients diagnosed with chronic
for the management of locally advanced laryngeal and hy-
                                                                obstructive pulmonary disease and pharyngo-laryngeal re-
popharyngeal carcinomas (LHC) 3.
                                                                flux before the start of CRT, as well as those who continued
RT causes laryngeal muscle atrophy and/or stiffness, fibro-
                                                                to smoke at the time of the study, were also excluded. The
sis, insufficient lubrication of the laryngeal mucosa, hyper-
                                                                final sample consisted of 21 patients (25.6% of all patients
aemia, oedema and erythema 4. These changes can lead to
                                                                treated with CRT): 16 men (76%) and 5 women (24%),
impaired vocal fold function 5. In addition, the tissue ef-
                                                                with a mean age of 65 years (range 56-77 years). The se-
fects of RT are enhanced by chemotherapy 1,5.
                                                                lected patients underwent perceptual study, aerodynamic
Voice disorders are common in patients treated with CRT 5.
                                                                and acoustic analysis and QoL assessed with EORTC-
Following CRT treatment, patients may present with re-
                                                                H&N35 (voice items) between the second and third year
duced volume, low modal pitch, reduced phonic breath
                                                                after the CRT.
support, hoarseness and vocal fatigue. This is reflected in
                                                                All patients were or had been smokers and 15 (71%) had a
altered phonatory function tests in which impaired acoustic
                                                                history of alcohol consumption. All patients stopped smok-
and aerodynamic measures of the voice are observed. In ad-
                                                                ing after treatment. In 12 patients, the tumour was in the
dition, patients frequently complain that the voice is highly
                                                                larynx (8 stage III and 4 stage IVa; all T3) and in 9 pa-
variable and unpredictable after RT 4. All these disorders
                                                                tients in the hypopharynx (6 stage III and 3 stage IVa; 3 T2
can reduce speech intelligibility and impaired articulation
                                                                and 6 T3). All patients underwent endoscopic evaluation
can affect patients’ daily life activities and interactions,
                                                                of the larynx prior to treatment. Unilateral vocal fold pa-
which can be associated with severe functional and psy-
                                                                ralysis was observed in all patients with a paramedian posi-
chosocial problems that affect the quality of life (QoL) 6.
The presence of voice disorders after CRT in patients with      tion of the paralysed vocal fold and a glottic gap. Despite
advanced HCL has been studied by several authors 1,4. In        having vocal cord paralysis, no patient had been seen prior
general, it has been observed that the voice worsens during     to diagnosis of the tumour for dysphonia. The mean time
CRT, improves 1-2 months after the end of treatment and         since CRT was 31.52 months (range 24-36). None of the
reaches pre-treatment levels after 1 year or more.              patients reported symptoms related to CRT and stated that
Despite having an alteration in QoL, some patients with         their voice was like what it was before CRT. Endoscopic
laryngeal or hypopharyngeal carcinomas treated with CRT         examination after treatment revealed that laryngeal struc-
and controlled disease do not perceive an alteration in their   tures were well preserved. Ten patients had recovered vocal
voice. Our aim was to detect possible subclinical voice im-     cord mobility, 3 had vocal paresis and 8 had not recovered
pairment in these patients and to determine how it affects      vocal mobility.
their QoL.                                                      The treatment with CRT consisted of a single cycle of in-
                                                                duction chemotherapy (cisplatin, 100 mg/m2 on day 1 plus
                                                                5-fluorouracil, 1,000 mg/m2, for 5 days) followed by con-
Methods                                                         comitant CRT (70 Gy in 7 weeks plus cisplatin, 75 mg/m2,
Patients                                                        every 3 weeks, on days 1, 22 and 43) 8. All participants
Since 2012, our department has followed an organ pres-          were treated with volumetric intensity modulated radia-
ervation protocol with CRT for patients with locally ad-        tion therapy (IMRT) in volumetric modulated arc therapy
vanced LHC and, up to 2017, a total of 82 patients had been     (VMAT).
included. A cross-sectional observational cohort study was
designed. To be included in the study, patients must have       Evaluation of voice
been tumour-free at the time of the study and without tra-      Voice outcomes were assessed at least 2 years after CRT
cheostomy. None of the patients had any complaints about        with a maximum of 3 years. All recordings were made in a
their voice during follow-up. Voice was assessed by the         sound-treated room using a SONY ECM- DS70P condens-
Voice Handicap Index (VHI) 7. All patients had VHI score        ing microphone with a flat frequency response and a SONY
< 15. A cut-off score of 15 points has been established to      ICD-PX820 (16-bit) digital wave recorder with a sampling
identify patients with voice problems in daily life 4. The      frequency of 40 kHz. The distance from the mouth to the
minimum follow-up since the end of the treatment had to         microphone was kept constant at approximately 30 cm at a
be 2 years. Patients who had undergone surgery in the head      45° angle.



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                                                             Voice outcomes after chemo-radiotherapy in laryngeal and hypopharyngeal cancer




Perceptual evaluation                                             MPT is not diagnostic of laryngeal pathology, but it may
The Consensus Protocol for Auditory-Perceptual Voice              be useful as an indicator of laryngeal pathology and is fre-
Assessment (CAPE-V) is a test designed to promote a               quently used to monitor progress.
standardised approach to assess and document auditory-
perceptual judgments of vocal quality 9. CAPE-V assesses          Acoustic analysis
6 perceptual components of voice (general gravity, rough-         The /e/ sound was analysed at comfortable levels of inten-
ness, respiration, tension, pitch and loudness) and scores        sity and pitch in a soundproof environment. The computer
each component using a 100-mm line as a visual-analogue           captured 3 sec of the sound, selecting the most stable part
scale. Higher scores indicate more significant deviation          of the broadcast, avoiding its beginning and end. Once the
from normal in such a way that the scoring scale was di-          signal was digitised, the acoustic parameters were analysed
vided into normal (0 mm), mild (1-33 mm), moderate (34-           with the PRAAT 5.6.56 programme 13. The reference values
66 mm) and severe (67-100 mm). The CAPE-V test was                of the acoustic variables were taken from a healthy Span-
validated into Spanish from its initial version in English 10     ish population of the same age and gender range 14. The
and has 3 tasks that are evaluated using the visual-analogue      acoustic parameters obtained were fundamental frequency
scale of 0-100 mm: 1) a sustained vowel /e/ emitted three         F0 (Hertz, Hz), intensity (decibels, dB) and harmonic-noise
times during 3-5 seconds in a natural and comfortable tone,       ratio (HNR) (dB). The spectrographic analysis consisted of
selecting the highest quality; 2) 6 sentences of the adapt-       performing a narrow band spectrogram, using the Yanagi-
ed CAPE-V that evaluate specific and concrete aspects of          hara classification (grades I to IV) 15.
speech in a controlled linguistic environment that reveal
compromised phonetic situations (articulation, glottal at-        Evaluation of Quality of life (QoL)
tacks, vocal spasms, hypo-hypernasality); 3) natural speech       QoL was assessed using the European Organization for Re-
of 20 seconds versed in how the patient perceives his voice.      search and Treatment of Cancer - Head and Neck question-
The easiest task to perform this provides more consistent         naire 35 (EORTC-H&N35) consists in 7 subscales with 35
results in adults is the sustained vowel 11. If the quality of    items to assess QoL in head and neck cancer. It has been
all the tasks is uniform and does not show significant dis-       widely used especially in patients treated with CRT 16,17.
crepancies, CAPE-V can be scored with a single scale to           The subscale “speech problem” that includes three items
manage its results, using the highest values 10. Two expe-        is evaluated (46: Have you had problems with hoarseness?
rienced speech and language pathologists (SLP; P.S-R and          53: Have you had problems talking to other people? and
A. G-F), who regularly use the CAPE-V since its valida-           54: Have you had problems talking on the telephone?).
tion into Spanish in 2015 10, evaluated the voice recordings      Each item has four-point scale (from 0 to 4; best to worst).
randomly and independently. Ratings were established by           The scale score becomes a scale from 0 to 100 and a higher
direct observation of vocal output, and not by patient report     score indicates a greater alteration in QoL. We use the gen-
or other means. For overall analysis of perceptual evalua-        eral score of the subscale and the value of each item.
tion, average scores between the two raters’ mean opinion
scores were used to evaluate perceptual voice and speech          Statistical analysis
parameters. Recordings were coded to avoid patient iden-          All variables were analysed with SPSS 22.0 for Windows.
tification.                                                       Descriptive statistical data (mean, standard deviation,
                                                                  range, median, interquartile range) were obtained. Rela-
Aerodynamic analysis                                              tionships were established between the QoL questionnaire
The variable maximum phonation time (MPT) was used,               (EORTC- H&N35) and the categorical-ordinal variables of
which is a simple test of glottic efficiency 12. MPT is the       vocal alteration: perceptual (CAPE-V), aerodynamic and
longest period during which a patient can sustain phonation       acoustic analysis, with Pearson and Spearman correlations,
of a vowel sound, typically /a/. The vowel /a/ is emitted         the latter in asymmetric distributions. Values of p < 0.05
effortlessly for as long as possible after a deep inspiration     were considered statistically significant.
and time in seconds was measured with a chronometer.
Typically, with no laryngeal pathology, adult males can
sustain vowel sounds for between 25-35 seconds and adult
                                                                  Results
females between 15-25 seconds. In cases of vocal dysfunc-         Voice evaluation results
tion/laryngeal pathology, however, the MPT is considera-          Most of the participants had a mild to moderate degree
bly reduced. Arguably, therefore, MPT is of most use when         of alteration for overall severity, roughness, breathiness,
glottic efficiency is poor (an MPT of 10 seconds or less) 12.     strain, pitch and loudness with CAPE-V (Tab. I). No patient



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C. Álvarez-Marcos et al.




Table I. Perceptual values in degrees of affectation for CAPE-V.
                            Overall severity          Roughness                   Breathiness          Strain              Pitch         Loudness
 Normal (0)                            -                          -                 1 (4.8%)              -                    -             -
 Mild (1-33)                       9 (42.9%)                13 (61.9%)             16 (76.2%)        15 (71.4%)           17 (81%)      20 (95.2%)
 Moderate (34-66)                  9 (42.9%)                 7 (33.3%)             3 (14.2%)          6 (28.6%)            4 (19%)       1 (4.8%)
 Severe (67-100)                   3 (14.2%)                  1 (4.8%)              1 (4.8%)              -                    -             -



Table II. Aerodynamic and acoustic measurements.                                         ment with CRT and an organ preservation protocol. The
 Variables                  Mean         Standard                     Range              main criterion for selection was that patients had no com-
                                         deviation                                       plaints about their voice before treatment, despite having
 MPT* (s)                         13.57             5.74              5-23               vocal paralysis, and that they considered that their voice
 HNR** (dB)                       10.25             6.64           0.51-21.41            had not changed after CRT and was similar to their voice
 F0§ (Hz)                        153.71            91.29          80.43-488.83           before treatment. A cut-off score of 15 points in the VHI-
 Intensity (dB)                   79.19             2.32           71.90-83.31           30 (97% sensitivity and 86% specificity) was established
*MPT: maximum phonation time; ** HNR: harmonic-to-noise ratio; §F0: fundamental fre-     to identify patients with LHC and voice problems in daily
quency
                                                                                         life, as used by other authors 4. Vocal disability perceived
                                                                                         by all patients treated with CRT in our centre is classified
                                                                                         according to the VHI-30 as mainly mild (90%), as observed
showed normality values in the total of CAPE-V attributes.
                                                                                         in other studies 15,18.
Table II shows the measurements of aerodynamic and
                                                                                         It should be noted that the sample of our patients is homo-
acoustic parameters. In the classification of voices in the
                                                                                         geneous since all had similar location (LHC) and disease
Yanagihara scale, 4 cases (19%) showed grade I, 8 (38%)
                                                                                         stage (III-IV) and had been treated with the same organ
grade II and 9 (43%) grade III.
                                                                                         preservation protocol. This reduces the size of the sample
Quality of life                                                                          that we study compared with other larger series that in-
The values obtained for the voice items of the EORTC-                                    clude other HNC locations such as oropharynx, oral cavity
H&N35 questionnaire are shown in Table III. A decrease                                   and nasopharynx, with expected voice sequelae of differ-
in QoL was observed in the overall voice and in the three                                ent severity and importance 4. Furthermore, in our study
voice items separately, especially in item 46. Six patients                              there were no patients with previous surgeries in the up-
(28.6%) indicated “Not at all” in all the three items.                                   per aerodigestive tract, including tracheostomy, that could
Correlations were sought between the CAPE-V attributes                                   produce voice alterations. Another criterion that limited the
with the EORTC-H&N35 voice items and the aerodynamic                                     sample size was the exclusion of patients with known voice
and acoustic variables, without observing significant values                             disorders after CRT, rejecting those with severe mucositis
in any. Significant values were also not observed when cor-                              and who had undergone specific rehabilitation by speech
relating EORTC-H&N35 items with the aerodynamic and                                      therapist. Patients who manifested swallowing disorders
acoustic variables.                                                                      or had undergone a medical, instrumental, or rehabilita-
                                                                                         tive procedure for dysphagia were also excluded, since this
                                                                                         situation can cause a decrease in QoL. This must be con-
Discussion                                                                               sidered because VHI-30 assesses the vocal disability per-
Voice disorders are common sequelae after CRT treatment                                  ceived by the patient himself and QoL indirectly in relation
in HNC. In this work, a voice study was carried out in a                                 to voice disorders, but does not take into account swallow-
selected sample of patients with LHC who underwent treat-                                ing, eating and social and occupational disorders that af-


Table III. EORTC-HN35 (overall voice and items 46, 53 and 54).
 Variables                                   Mean                             Standard deviation                Median                 Range
 Overall voice                                      21.16                              26.26                      11.11                 0-89
 Item 46                                            39.68                              39.25                       50                  0-100
 Item 53                                            24.60                              33.58                        0                  0-100
 Item 54                                            10.31                              27.11                        0                  0-100




246
                                                               Voice outcomes after chemo-radiotherapy in laryngeal and hypopharyngeal cancer




fect global QoL. Therefore, the sample, although relatively         ed with CRT swallowing disorders affect QoL in a more
small, provides very concrete and specific information on           negative way than voice disorders 2,4,22,23, concluding that
LHC treated with CRT.                                               it is very possible that the impact of CRT on voice has not
The evaluation with the CAPE-V test showed a predomi-               been sufficiently clarified and is generally minimised. In
nance of mild and moderate degrees in the vocal charac-             this regard, it has been proposed to reduce these sequelae,
teristics of patients, as also observed by other authors 15.        both vocal and swallowing, through early rehabilitation ex-
The perceptual evaluation with this test through the phona-         ercises and extend their use once treatment with CRT has
tion of vowels in an adequate and comfortable tone allows           been completed 6.
the patient’s voice to be heard without influences of the           Acoustic analysis showed interesting data. On one hand, it
articulation of words or the beginnings and ends of phona-          is observed that mean F0 and vocal intensity were within
tion, in addition to serving to perform objective acoustic          normal range (154 Hz and 79 dB, respectively), although
analysis 11. This fact was adapted to our sample of patients,       with very wide dispersion values in F0. On the contrary,
since the field of RT affects the larynx and hypopharynx            spectrographic analysis of most patients showed grades II
where vocal articulation is less altered than other locations       (38%) and III (43%). These results are similar to those de-
(oral cavity and oropharynx), as observed by others 4,19.           scribed in other studies, which only observed grade IV in
Our work also reflects that the vocal perception of partici-        12% of patients 15.
pants is better (VHI < 15) than that collected by the re-           The QoL of the patients studied shows a worsening in both
searchers in the perceptual analysis with CAPE-V, as has            overall voice and in each individual item, ranging between
also been published 4. It has been reported that subjective         10 and 40%, as seen in Table III. Voice-related questions
tests (VHI-30, CAPE-V) show a lower perception of se-               are very general, and thus participants tend to answer them
verity compared to objective tests (acoustic analysis and           with a more favourable score on the EORTC-H&N35. How-
spectrogram) and that these tests do not usually correlate          ever, only 6 patients in the sample studied indicated “Not
with each other when evaluating different data 10,15,20,21. This    at all” in the three items. In the EORTC-H&N35 question-
discrepancy between patients and researchers is explained           naire, specific for HNC, only 3 of its 35 items are related
by the fact that the former tend to minimise the importance         to voice, while 20 are related to swallowing and feeding.
of vocal disability and its impact on QoL, since they re-           For this reason, it is difficult to determine to what extent
tain their voice. Patients undergoing CRT have particular           voice alterations intervene in QoL when they have so little
characteristics, since they assess their voice during a se-         weight in its global assessment. It would be beneficial if in
vere and potentially life-threatening cancer, the treatment         the global calculation of QoL of patients undergoing CRT
of which could be total laryngectomy. For this reason, it           the number of items that assess vocal disorders and swal-
is possible that at the end of a successful CRT treatment,          lowing disorders were more balanced 2,22,23, as for example
patients may show a tendency to rate their voice as normal          with the HADS (Scale of hospital anxiety and depression)
or slightly altered. Another aspect to be taken into account        that assesses anxiety/depression with 14 items (7 for each
is that most patients definitively gave up their usual work         disorder) 24.
activity after completion of CRT. The greatest alteration of        Other authors have compared QoL in patients with glottic
the voice during CRT has been reported to occur during its          laryngeal cancer and observed that those treated with RT
administration or just at the end of treatment 16,17. However,      have better QoL in the EORTC-H&N35 questionnaire in
our results in CAPE-V and acoustic-aerodynamic analysis             the areas of voice quality, emotional functioning and social
confirm that voice disorders are common, even after sev-            contact in relation to those treated with surgery, although
eral years, being more evident for researchers than for the         the items referred to “dry mouth” and “sticky saliva” are
patients themselves. This can be explained for several rea-         higher in patients with surgery 25.We have not been able
sons. The passage of time from the end of the CRT treat-            to establish significant correlations between CAPE-V at-
ment to the completion of the QoL questionnaires (mean:             tributes and QoL assessed with the EORTC-H&N35 voice
31.52, range: 24-36 months) favours adaptation to sequelae          items, nor between them and aerodynamic and acoustic
and the trend to positively judge having an intact voice.           variables. Other authors have observed a relationship be-
Other studies have shown that an adaptation mechanism               tween the functional and physical areas of symptoms of the
can occur over time, as seen in swallowing disorders in the         VHI-30 and EORTC-H&N35 16. However, one of the cri-
same LHC patients treated with CRT, where a self-admin-             teria established to select the sample studied was a VHI-30
istered test such as EAT-10 was normal, while other more            value < 15, and thus it is likely that the relationship of the
specific and objective parameters were altered 22. Several          subjective questionnaires that evaluate the voice is altered.
authors have pointed out that in patients with HNC treat-           There is much information in the literature on voice and



                                                                                                                                        247
C. Álvarez-Marcos et al.




swallowing in patients with HNC treated with CRT, but it            detect alterations that could be rehabilitated and thus avoid
is often at variance 2,4,22. This is due to the difficulty of ob-   future impact on the QoL.
taining uniform series in terms of tumour location, CRT
modality and evaluation time with respect to treatment              Conflict of interest statement
(during, early end, late end). In addition, other factors           The authors declare no conflict of interest.
such as having vocal rehabilitation, tracheostoma and con-
comitant surgery have an influence in functional outcomes,          Funding
making the data obtained in the different studies difficult         This study was supported by grants from CIBERONC
to compare. On the other hand, there are many subjective            (CB16/12/00390 to JPR), Ayudas a Grupos PCTI Principa-
questionnaires where items related to voice are usually             do de Asturias (IDI2018/155 to JPR), Fundación Bancaria
few and superficial. These questionnaires query patients’           Caja de Ahorros de Asturias-IUOPA and the FEDER Fund-
self-perception and assess their QoL. However, they do not          ing Program from the European Union.
necessarily detect the physical state or functioning of the
affected organs.                                                    Authors’ contributions
QoL of LHC patients treated with CRT is not only condi-             All authors contributed to the study conception and design.
tioned by functional swallowing or vocal alterations, but           Material preparation, data collection and analysis were per-
also by other factors that may be physical (tracheostoma,           formed by AV-B, AG-F, DP-M, PS-R nad LS-R. CAM
change in body scheme), emotional, cognitive and socio-             wrote the first draft of the manuscript and others authors
occupational. Therefore, the design of a questionnaire that         commented on previous versions of the manuscript. FL,
considers the main functional disorders in a balanced way           JPR and JLL wrote, supervised adn edited the manuscript.
would reflect the extent to which the alterations are related       All authors have read and agreed to the published version
to QoL and the therapeutic modality used, both surgical             of the manuscript.
(total laryngectomy, supraglottic) and CRT. They would
therefore be a guide to indicate different supportive and re-       Ethical consideration
habilitation therapies, as suggested by other authors 2,6,26.       All procedures were conducted in accordance with the
Our group is conducting a study similar to the present one          Declaration of Helsinki and approved by Institutional Eth-
in the same group of patients but with diagnostic instru-           ics Committee of the HUCA (285/18). Written informed
ments and QoL questionnaires for swallowing disorders 22.           consent was obtained from each patient.
Therefore, it would be necessary to design balanced QoL
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