Dysphagia’s Effects on Quality of Life, Functional Disabilities, and Psychological Distress in Head and Neck Cancer Patients: Outcomes of Cancer Rehabilitation from an Observational Single-Centre Study

Dysphagia’s Effects on Quality of Life, Functional Disabilities, and Psychological Distress in Head and Neck Cancer Patients: Outcomes of Cancer Rehabilitation from an Observational Single-Centre Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Dysphagia’s Effects on Quality of Life, Functional Disabilities, and Psychological Distress in Head and Neck Cancer Patients: Outcomes of Cancer Rehabilitation from an Observational Single-Centre Study Špela Matko, Christina Knauseder, David Riedl, Vincent Grote, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5352887/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Many patients with head and neck cancer (HNC) suffer from speech or swallowing disorders. We investigated the effects of dysphagia on health-related quality of life (HRQoL), functioning, and distress in HNC survivors, and the extent to which rehabilitation can alleviate these effects. Methods Cancer survivors undergoing inpatient cancer rehabilitation at an Austrian rehabilitation centre were asked to complete electronic patient-reported outcomes before admission (T0) and at discharge (T1). The EORTC QLQ-C30 questionnaire was assessing HRQoL, symptoms, and functioning, and the Hospital Anxiety and Depression Scale (HADS) to assess psychological distress. Results Of 63 HNC patients, 22 had dysphagia, 23 did not need speech therapy (control group C1), and 18 without dysphagia needed speech therapy (control group C2). Before rehabilitation, HRQoL, physical, social, and emotional functioning were significantly lower in dysphagia patients than in controls. Dysphagia patients suffered from more severe general symptoms, including fatigue, pain, sleep disturbances, nausea/vomiting, diarrhoea, and financial worries. In addition, emotional and social functioning of C2 patients who needed speech therapy but did not show dysphagia was significantly worse than of C1 patients. Social, emotional, and role functioning, fatigue, nausea/vomiting, insomnia, and appetite loss significantly improved by T1 in all HNC patients. Improvements in HRQoL were most noticeable in dysphagia patients. Psychooncological counselling reduced depression in dysphagia and in C2 patients to levels seen in the general population. Conclusion Dysphagia patients suffer severely from impaired functioning and systemic symptoms, but benefit substantially from cancer rehabilitation. Patient-reported outcomes speech therapy psychooncology fatigue depression Figures Figure 1 Figure 2 1. Introduction The global incidence of head and neck cancer (HNC) is the seventh highest of all cancers [ 1 ]. Between 2020 and 2022, Austria recorded 1,378 new diagnoses for ICD-10 codes C00–C14, with a mortality rate of 559.7 [ 2 ]. Additionally, 334 laryngeal carcinomas (C32) were diagnosed, with a mortality rate of 134.3 [ 2 ]. The incidence of HNC is three to five times higher in men than in women [ 3 ]. Its primary causes are chronic alcohol and nicotine abuse, as well as human papillomavirus infection, particularly types 16, 18, and 31 [ 1 ]. Patients with HNC often display lumps in the neck, open and painful sores in the mouth and throat, plaques, swelling, difficulty swallowing (i.e. dysphagia), or changes in their voice and speech (e.g. hoarseness) [ 4 ]. These patients suffer from the considerable physical and psychological consequences of the disease [ 3 , 5 , 6 ], including a fear of its recurrence, depression, and difficulties affecting their family, social environment, and return to work. The symptom of dysphagia alone can cause nutritional deficiency, weight loss, or feeding tube dependency, increasing the risk of life-threatening aspiration [ 7 , 8 ]. Worse health-related quality of life (HRQoL) was found for female patients and patients with low income, laryngeal cancer, and advanced tumour stage [ 9 ]. Treatment of HNC is multimodal, involving surgery, radio(chemo)therapy, or systemic therapy [ 10 ]. Many HNC survivors experience impaired HRQoL and oral function [ 11 ]. Other adverse treatment effects include skin changes, oedema, pain in the head, neck, or shoulder girdle, a loss of taste, saliva, and appetite, thrush, or mucositis. Localised symptoms such as xerostomia, impaired movement, tissue induration, fibrosis, necrosis, and trismus can specifically affect the patient’s voice and ability to swallow. Dysphagia and aspiration are frequently underestimated [ 12 , 13 ]. These symptoms may appear several years after treatment, thereby making them difficult to address [ 8 , 14 , 15 ]. Three-quarters of HNC patients experience long-term morbidity and experience at least two treatment side effects ≥ 5 years after diagnosis; therefore, it is important to provide speech therapy targeting swallowing and oral functions for effective rehabilitation [ 11 ]. This rehabilitation should enhance patient HRQoL and participation by addressing functional limitations and alleviating psychological distress [ 16 , 17 ]. Patient-reported outcomes (PROs) have been utilised to identify unmet needs and evaluate HRQoL in addition to physical, psychological, and social functioning [ 18 , 19 ]. These measures provides valuable insights into patient perspectives and often highlights discrepancies between patient self-assessment and evaluations by healthcare professionals [ 20 ]. PROs are valuable tools for planning rehabilitative therapies, as they enable healthcare professionals to identify the patient’s specific needs and assess the effectiveness of interventions [ 18 , 21 ]. In previous studies, we utilised PROs to compare the effectiveness of rehabilitation in different tumour entities and age groups [ 22 , 23 ]. In this study, we assessed HRQoL using the EORTC QLQ-C30 [ 24 ], and psychological distress using the Hospital Anxiety and Depression Scale (HADS) [ 25 , 26 ]. Both questionnaires are validated and widely used. The aims of this study were to investigate the specific effects of dysphagia on HRQoL, functioning, and distress in HNC survivors and to evaluate the effectiveness of cancer rehabilitation in dysphagia patients. 2. Materials and Methods 2.1. Patients and methods Data were collected at the Austrian Rehabilitation Centre St. Veit im Pongau during a 21-day cancer rehabilitation programme. In cases of severe impairment, patients could extend their stays for seven days. The treatment costs were covered by Austrian pension funds, which stipulated the respective therapy frequencies and the minimum total treatment time (1800 minutes). According to pension fund guidelines, patients needed to have completed active oncological treatment and to be in a condition suitable for active participation in therapeutic interventions. All patients admitted to the rehabilitation centre between 01/01/2019 and 08/31/2021 were screened. Inclusion criteria comprised ICD-10 tumour diagnoses, C00-C14, C30-C32, or C76. To avoid the risk of bias, only the first rehabilitation stay per patient was included in the case of multiple rehabilitations. Exclusion criteria comprised an early discharge (i.e. ≤ three days), an interval of > 56 days between the first assessment and treatment initiation, and incomplete data sets. A single speech therapist conducted a clinical swallowing function examination (CSE) on all HNC patients, employing a standardised manual approach. This involved a thorough medical history review and clinical assessment of structures involved in swallowing, utilising tests with foods of various consistencies and bolus sizes [27]. Based on the CSE and logopaedic anamnesis results, patients were classified into three predefined groups: Dysphagia group (Dys): patients who needed speech therapy to treat swallowing disorders affecting ingestion, preparation, or transport of food Control group 1 (C1): patients who needed speech therapy Control group 2 (C2): patients without dysphagia symptoms who needed speech therapy due to impairments (e.g. xerostomia, dysgeusia, dysphonia, dysglossia, dyspnoea, painful hardening of throat and muscles) 2.2. Assessment procedures Data were acquired with a web-based patient portal utilising the Computer-based Health Evaluation System (CHES) [23,28]. Patients were asked to complete electronic PROs before admission (T0). We explained that these questionnaires would help pre-plan treatments to meet their specific needs. For those who had not completed the questionnaires upon arrival, administration staff provided technical assistance. A second assessment was conducted upon discharge (T1), employing identical questionnaires. 2.3. Ethics approval Upon admission, patients were informed about the study and asked to provide their written informed consent for the scientific use of their data. If they declined, the data were used for routine care only. This study was reviewed by the Ethics Committee of the State of Salzburg (vote no. 415-EP/73/706-2017, from 01/18/2017), which waived the necessity for formal approval, as the study was observational and non-interventional. The study was conducted according to the principles of the Declaration of Helsinki. 2.4. Outcome assessment Functions and symptoms were assessed using the QLQ-C30 (German version) [57], a 30-item questionnaire organised into scales for global HRQoL, functioning (physical, social, role, emotional, cognitive), and symptomatic scales (fatigue, nausea/vomiting, pain, dyspnoea, sleep disturbances, appetite loss, constipation, diarrhoea, financial impact). Scoring adhered to EORTC manual guidelines, which recommends the transformation of raw scores into values on a 0–100 scale, where 100 represents the worst symptom and the best functioning score [29]. The HADS, a 14-item questionnaire, was used to assess anxiety and depression. A total score ranging 0–42 is generated, with sub-scores for anxiety and depression. Clinical cases of anxiety or depression are defined by scores of ≥ 11 [26]. 2.5. Multimodal rehabilitation Patients underwent multidisciplinary therapies, receiving guidance and treatment from physicians, nursing staff, physiotherapists, sports therapists, psychologists, dieticians, and speech therapists. Interventions included aerobic and resistance training, psychological and social counselling, relaxation exercises, nutritional advice, and educational presentations. Patients could also receive occupational therapy, remedial massage, thermotherapy, hydrogymnastics, electrotherapy, and counselling for lifestyle modification or smoking cessation. Speech therapy was offered to all patients with dysphagia or other logopaedic dysfunctions. Techniques such as functional dysphagia therapy and manual swallowing therapy were used to enhance the range of motion and strengthen muscles essential for swallowing, including those of lips, tongue, and larynx [3,30]. Compensatory manoeuvres like the super-supraglottic swallow and the Mendelsohn manoeuvre were individualised, and additional guidance was provided on posture, movement, xerostomia management, and adaptive strategies. 2.6. Statistical analyses Mean differences were compared using χ 2 -tests and independent sample t -tests. Baseline differences (T0) between groups were analysed using univariate analysis of variance (ANOVA). Changes in symptoms or functioning during rehabilitation were evaluated by repeated measures ANOVA. Mean values for QLQ-C30 and HADS at T1 were compared with published reference values from the Austrian general population [26,29]. Effect sizes were determined for multivariate and univariate analyses using partial eta squared (η²) values, categorised as negligible (η² 0.14) [31]. A priori calculations indicated that a total sample size of n = 42 patients was needed to detect mean pre-post assessment differences in a three-group setting with moderate effect size (α = 0.05, 1-β = 0.80; f = 0.25). Post hoc tests (PHC) were performed despite the absence of a statistically significant interaction according to the omnibus test, as supported by previous research [32]. The significance threshold was set at p < 0.05. In case of multiple comparisons, Bonferroni corrections were applied to control for Type I error rate inflation. Analyses were repeated by applying a multivariate approach (3x2 design with two-way ANOVA, i.e. repeated measures). The within-subject factors included time points T0 and T1 to capture temporal intervention effects. This approach enabled us to simultaneously analyse multiple dependent variables, including HADS and QLQ-C30 summary scores, and comprehensively understand the intervention's effects across different PRO dimensions. It also allowed us to assess changes over time within subjects while accounting for the correlations among the dependent variables. All calculations were performed using IBM SPSSv27. 3. Results Of 2,730 patients with various forms of cancer, 113 with HNC were identified. Subsequently, 50 patients were excluded due to, e.g. incomplete data (Table 1a). The remaining 63 participants were stratified into three groups and analysed. The cohort consisted predominantly of males (76.2%) with an average age of 60.9 ± 9.2 years (Table 1b). Half of the patients (49.2%) had stage IV HNC according to UICC criteria, and cancer recurrence was evident in 12.7% of these. Notably, no significant differences were identified between the groups regarding gender, age, cancer stage, and recurrence status. Please add table 1 here 3.1. Mean baseline HRQoL differences between the three groups At the initial measurement point (T0), significant between-group differences were observed across several domains of functioning, and patients with dysphagia (Dys) consistently exhibited poorer outcomes than control groups (C1 and C2). A significant group effect was observed for global HRQoL ( p = 0.002, η² = 0.184), and PHC indicate that the Dys have a notably lower HRQoL than C1. A similarly significant group effect was observed for physical functioning ( p = 0.030, η² = 0.110), where the Dys exhibited lower physical functioning than C1 members. Social functioning also significantly differed between the groups ( p = 0.001, η² = 0.197): C1 scores are significantly higher than those of the Dys and C2. With regard to emotional functioning, a significant group effect was observed ( p = 0.024, η² = 0.117), and PHC indicate that the Dys exhibit significantly lower emotional functioning than C1. Furthermore, a significant group effect was observed for the total functional scale (TFS) ( p = 0.011, η² = 0.141). The PHC scores for the Dys are significantly inferior to those for C1. No significant group effects were identified for role functioning ( p = 0.068) or cognitive functioning ( p = 0.101). With regard to the symptoms, a group effect was indicated for fatigue ( p = 0.071, η² = 0.084), although this difference did not achieve statistical significance in PHC. No significant group effects were identified for other symptoms (e.g. nausea/vomiting, pain, dyspnoea, sleep disturbances, appetite loss, constipation, diarrhoea, or financial impact). Please add figure 1 here 3.2. Improvement during rehabilitation across groups Following rehabilitation, considerable time and group effects were evident across numerous functioning domains, accompanied by notable group-by-time interactions. The global HRQoL significantly improved over time in the Dys ( p = 0.002, η² = 0.361) and C2 ( p = 0.018, η² = 0.287). Furthermore, findings of the PHC indicate that the Dys and C2 improved more significantly over time than C1. A significant time effect was observed in C2 for role functioning ( p < 0.001, η² = 0.625), with the PHC indicating that C2 improved more than the Dys and C1. Social functioning demonstrated a significant time effect for all groups ( p < 0.05), and the PHC indicate that both the Dys and C2 improved more significantly than C1. Significant improvements were also observed over time in all groups for emotional functioning ( p < 0.05), and the PHC confirm that the Dys made larger significant gains than C1. The TFS significantly improved in the Dys ( p < 0.001, η² = 0.427) and C2 ( p < 0.001, η² = 0.604), and the PHC indicate that the Dys and C2 improve significantly more than C1. No significant time effect was observed for physical functioning; however, the PHC demonstrate the improvement seen in the Dys and C1 significantly differ. Regarding the observed symptoms, a statistically significant reduction in fatigue was observed across all groups ( p < 0.05). The PHC indicate that the Dys experienced a significantly greater reduction in fatigue than C1. Notable enhancements were discerned in terms of sleep disturbances in both the Dys ( p = 0.006, η² = 0.310) and in C2 ( p = 0.004, η² = 0.397). A significant group-by-time interaction was observed for sleep disturbances ( p = 0.034, η² = 0.106), as the PHC indicate the Dys and C2 improved considerably more than C1. Additionally, appetite loss notably and significantly improved over time in the Dys ( p = 0.047, η² = 0.175) and in C2 ( p = 0.035, η² = 0.237). The total symptom score (TSS) displayed statistically significant improvement over time in the Dys ( p = 0.041, η² = 0.184) and in C2 ( p = 0.001, η² = 0.476). The HRQoL of our study population was compared to data for the normal Austrian population [34]. At T1, the emotional functioning of C1 patients was equal to that of the normal population, while patients who needed speech therapy displayed lower values. Other functioning levels were below those of the normal population. All symptom scores remained above the level of the normative data, except for the score for diarrhoea, which was below this level in C1 and C2 (Figures 1A and 1B). Please add table 2 here Please add table 3 here 3.3. Psychological distress Before rehabilitation, anxiety and depression levels were higher in the Dys and C2 than in C1, although these differences were not statistically significant (Table 3, Figure 2). At T1, the Dys displayed statistically significantly lower anxiety ( p = 0.015, η² = 0.251) and depression ( p = 0.008, η² = 0.291). C2 also demonstrated a statistically significant decrease in depression ( p = 0.040, η² = 0.225) between T0 and T1. In the Dys and C2, these differences reached clinically relevant levels [33]. Conversely, the improvements in anxiety observed in C2, and in anxiety and depression in C1, were not statistically significant. Please add table 4 here A comparison with normative data revealed that the anxiety levels measured at T1 in our study groups aligned with those observed in the normal population (Figure 2) [26]. Notably, depression levels in C1 were even lower than in the normal population. An analysis of group-by-time interactions revealed no statistically significant differences in improvement between the three groups. Please add figure 2 here 3.4. Multivariate analysis A multivariate analysis and univariate tests were conducted to detect relationships among the various outcome measures and control for the influence of multiple variables simultaneously. The results indicate significant time effects across all outcome measures (Supplemental Table 5). The multivariate analysis results highlight the holistic impact of the intervention on multiple outcomes with high effect sizes. This intervention had many effects, and contributed most notably to improvements in functional aspects, a reduction of psychological distress, and a promotion of overall well-being in HNC patients. 4. Discussion Impact of dysphagia and speech disorders on HRQoL and functioning The study investigated the effects of oncological rehabilitation on the HRQoL of HNC survivors by utilising routinely collected PROs. The questionnaires completed before rehabilitation helped us to identify patients’ unmet needs. The Dys had significantly poorer HRQoL than other HNC patients and the general Austrian population. This was associated with a lower TFS, mainly due to poorer physical, emotional, and cognitive functioning. The Dys also reported higher TSS, characterised by increased fatigue, nausea/vomiting, pain, diarrhoea, and financial concerns. Late adverse effects were observed in more than half of the HNC survivors, including fatigue, joint pain and muscle aches, problems staying asleep, feeling cold, and neurocognitive symptoms [34]. Fatigue may persist in the long term, especially after radiotherapy [36]. Our findings corroborate previous reports indicating that disorders of speech or swallowing are associated with impaired HRQoL [7,34]. Dysphagia has also been associated adverse effects such as coughing, sleep disorders, and reduced mouth opening [36], additionally increasing the risk of dehydration, malnutrition, aspiration, and pneumonia, [3,37]. Our study findings demonstrate that dysphagia has specific, systemic consequences that extend beyond the swallowing function, affecting various aspects of physical, mental, and social health. We initially planned to compare dysphagia patients to patients without impaired swallowing. However, the control group was heterogeneous, necessitating an alternative approach. C2 displayed markedly lower HRQoL and emotional and social functioning scores than C1. These patients were more strongly affected by fatigue and gastrointestinal symptoms. The Dys and C2 displayed more severe symptoms (except pain) than C1 and the general population [29]. Hence, while speech and swallowing disorders lead to general impairments, our study findings suggest that dysphagia is a specific risk factor for patients with severe, systemic symptoms. The Dys had higher levels of anxiety and depression than C1 and C2. These findings are consistent with those of a previous study, which reported that 23% of HNC patients exhibited significant depression [38]. Another recent investigation revealed that many HNC survivors suffer from persistent psychological distress, namely 15.1% treated with irradiation reported experiencing depression and 10.0% anxiety after 24 months [40]. In our previous study comparing various forms of cancer, we noticed elevated depression levels in HNC patients, although their anxiety levels were similar to all cancer survivors [23]. Our current study data demonstrate that the HNC survivor population is not homogeneous, and that those with speech or swallowing dysfunctions experience severe distress, including higher anxiety levels. We hypothesise that the risk of aspiration and pneumonia causes anxiety. Effects of cancer rehabilitation The effectiveness of the rehabilitation was analysed by comparing PROs from admission and discharge. Analyses of group-by-time effects were conducted to identify between-group differences regarding rehabilitation benefits. All three HNC subgroups showed significant improvements in global HRQoL, TFS, and TSS, particularly in the Dys and C2. Social and emotional functioning improved across all groups with large effect sizes, and reductions were seen in fatigue, insomnia, and appetite loss, contributing to the overall increase in HRQoL. We and others have reported that cancer rehabilitation improves HRQoL and mental, social, and physical functions of survivors with different forms of cancer [23,41]. Our results indicate that among HNC patients, those with the greatest need for rehabilitation (i.e. dysphagia patients) benefit the most. Cancer rehabilitation is performed in a multimodal fashion, and speech therapy is highly relevant for HNC patients. Research has demonstrated the small to moderate effectiveness of exercises for swallowing and mouth opening in HNC patients [41]. These interventions may mitigate local symptoms, while observed improvements in systemic symptoms and social functioning are expected as a result of interactions between therapeutic modalities [42]. Notable improvements in anxiety and depression were observed in the Dys and C2. Adverse effects of dysphagia on emotional and mental health have been reported [43]. This underlines the need for dysphagia patients to receive psychosocial support and provides evidence for the efficacy of psychological counselling in rehabilitation. Depression levels in the sample of patients with dysphagia were reduced even below the level of the general population. These forms of support have been shown to alleviate distress in survivors of other forms of cancer [22,23,40,44]. A clinically significant correlation between social functioning, depression, and HRQoL of HNC patients has been reported [38]. Reducing psychological distress in dysphagia patients contributes in meaningful ways to their rehabilitation success. Strengths and limitations A notable strength of our study is that we directly compare different subgroups of HNC survivors. This allows us to draw conclusions about each group’s burden and their response to therapeutic interventions. Our cohort of previously unselected cancer survivors in rehabilitation provides a valuable source of real-world data on unmet needs. To control for Type I error rate inflation, i.e. false positive results in multiple hypothesis testing, we applied Bonferroni corrected p -values and conducted a multivariate analysis; these results support the initial findings. One potential limitation of the study is the relatively small sample size of 63 patients, which may have observed effect sizes. Although the a priori sample size calculation indicated the study was sufficiently powered, additional subset analyses of the importance of UICC stage, severity of dysphagia, and type of oncological therapy were not feasible. Firstly, numbers of evaluable patients were lower than expected due to restricted admission to the rehabilitation centre, including its temporary closure during the COVID-19 pandemic. Secondly, this single-centre analysis ensures the standardised assessment of patients and therapies, but it might not be possible to generalise the results to other centres or countries. Thirdly, the ECOG status of most patients was 0–2 because the Austrian pension fund does not refer patients in a poor general condition to the rehabilitation centres. Fourthly, QLQ-C30 was used as a part of routine rehabilitation procedures, but neither a dysphagia-specific questionnaire nor objective measures were used, such as the fibreoptic endoscopic evaluation of swallowing (FEES) and structured dysphagia therapy programmes [45]. This was not feasible in the setting of a general cancer rehabilitation without a sole focus on HNC patients. Nonetheless, our study demonstrates the benefits of general oncological rehabilitation for these patients. 5. Conclusion Dysphagia and to lesser extent other disabilities requiring speech therapy lead to a poorer HRQoL for HNC patients. Speech or swallowing disabilities are associated with multiple systemic impairments, which are more severe if dysphagia is present. Impaired functioning affects physical, emotional, and social functioning, mainly due to cancer-related fatigue, sleep disturbances, and appetite loss. Rehabilitation results in a conspicuous improvement in emotional and social functions. Although the cancer rehabilitation was not specifically designed to meet the needs of dysphagia patients, these particularly disabled and distressed patients benefited from this rehabilitation even more than other HNC survivors. Declarations Funding information This research received no external funding. Author Contribution Conceptualization: Thomas Licht; Data curation: Christina Knauseder, Michael Fischer and Thomas Licht; Formal analysis: Špela Matko; Methodology,: Špela Matko, David Riedl, Vincent Grote and Karin Pfaller-Frank; Resources,:Vincent Grote, Michael Fischer, Wilhelm Frank and Thomas Licht; Supervision: Thomas Licht; Visualization: Špela Matko; Writing – original draft, Christina Knauseder, Špela Matko and Thomas Licht; Writing – review & editing,:David Riedl, Vincent Grote, Michael Fischer and Samuel Vorbach. Acknowledgement We thank Bernhard Holzner and Gerhard Rumpold for the use of CHES software and valuable suggestions. Alain Nickels counselled the patients as a psychologist and participated in collection of PROs. References Barsouk, A., et al., Epidemiology, Risk Factors, and Prevention of Head and Neck Squamous Cell Carcinoma . Med Sci (Basel), 2023. 11(2). Austria, S. 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Support Care Cancer, 2019. 27(8): p. 2893–2902. Spratt, D.E., et al., Time course and predictors for cancer-related fatigue in a series of oropharyngeal cancer patients treated with chemoradiation therapy . Oncologist, 2012. 17(4): p. 569–76. Sasegbon, A. and S. Hamdy, The anatomy and physiology of normal and abnormal swallowing in oropharyngeal dysphagia . Neurogastroenterol Motil, 2017. 29(11). Kuhn, M.A., et al., Expert Consensus Statement: Management of Dysphagia in Head and Neck Cancer Patients . Otolaryngol Head Neck Surg, 2023. 168(4): p. 571–592. Patterson, J.M., et al., Associations between markers of social functioning and depression and quality of life in survivors of head and neck cancer: Findings from the Head and Neck Cancer 5000 study . Psychooncology, 2022. 31(3): p. 478–485. van Beek, F.E., et al., The course of symptoms of anxiety and depression from time of diagnosis up to 2 years follow-up in head and neck cancer patients treated with primary (chemo)radiation. Oral Oncol, 2020. 102: p. 104576. Pergolotti, M., et al. Impact of Real-World Outpatient Cancer Rehabilitation Services on Health-Related Quality of Life of Cancer Survivors across 12 Diagnosis Types in the United States . Cancers, 2024. 16, DOI: 10.3390/cancers16101927 . Banda, K.J., et al., Swallowing exercises for head and neck cancer patients: A systematic review and meta-analysis of randomized control trials . Int J Nurs Stud, 2021. 114: p. 103827. Stubblefield, M.D., K.H. Schmitz, and K.K. Ness, Physical functioning and rehabilitation for the cancer survivor . Semin Oncol, 2013. 40(6): p. 784–95. Agrawal, N., et al., Depression correlates with quality of life in people with epilepsy independent of the measures used . Epilepsy Behav, 2016. 62: p. 246–50. Klocker, J., et al., Long-term improvement of the bio-psycho-social state of cancer patients after 3 weeks of inpatient oncological rehabilitation: A long-term study at the Humanomed Zentrum Althofen . Wien Med Wochenschr, 2018. 168(13–14): p. 350–360. Wood, L., A review on adherence management in patients on oral cancer therapies . Eur J Oncol Nurs, 2012. 16(4): p. 432–8. Tables Table 1 to 4 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table14.docx ONKOsuppl.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5352887","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":375522559,"identity":"a61a3809-b9fe-43b6-967f-da79c060d875","order_by":0,"name":"Špela Matko","email":"","orcid":"","institution":"Ludwig Boltzmann Institute for Rehabilitation Research","correspondingAuthor":false,"prefix":"","firstName":"Špela","middleName":"","lastName":"Matko","suffix":""},{"id":375522560,"identity":"71f13682-47a2-486c-b236-e806f31e14d2","order_by":1,"name":"Christina Knauseder","email":"","orcid":"","institution":"Oncological Rehabilitation Center","correspondingAuthor":false,"prefix":"","firstName":"Christina","middleName":"","lastName":"Knauseder","suffix":""},{"id":375522561,"identity":"3c685812-95c1-4cdd-93ef-607a7be5955c","order_by":2,"name":"David Riedl","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA60lEQVRIie2QsQrCMBCGTwRdgl1TEH2FuLn5KjkKTg6CSweVSiEuPoIP4phSsEvANZNYBCeHioujKYo6Rd0E83FDOP6P/wiAw/GLSDMEwEww2+XRdwrGDKPn1qqUeQMK+pHSyFRHHmHb9OooQlxNwJvLyrmwKL4asGQJI+IvcqFRZUAVr1JbC5N9nhLghGk0ilgDaAC7sjnclJ7JD0ulraF6sSo6kLcWisL8wNhsoGZt8fVeJkvGCVV5TFFJ0lEousqiNDYYF8eQ97x5kBSn1bTVytJUhxblft7jZY6ESvRWeGX6VdrhcDj+gyu0y1fysoV7iAAAAABJRU5ErkJggg==","orcid":"","institution":"Ludwig Boltzmann Institute for Rehabilitation Research","correspondingAuthor":true,"prefix":"","firstName":"David","middleName":"","lastName":"Riedl","suffix":""},{"id":375522562,"identity":"3772be17-2c1b-438d-9dbb-e937233c4602","order_by":3,"name":"Vincent Grote","email":"","orcid":"","institution":"Ludwig Boltzmann Institute for Rehabilitation Research","correspondingAuthor":false,"prefix":"","firstName":"Vincent","middleName":"","lastName":"Grote","suffix":""},{"id":375522563,"identity":"eacddbd9-0d8b-475d-abfc-a518259299f5","order_by":4,"name":"Michael J. Fischer","email":"","orcid":"","institution":"Ludwig Boltzmann Institute for Rehabilitation Research","correspondingAuthor":false,"prefix":"","firstName":"Michael","middleName":"J.","lastName":"Fischer","suffix":""},{"id":375522564,"identity":"8563a558-6fd8-458a-a4c2-0c20105c9904","order_by":5,"name":"Samuel Moritz Vorbach","email":"","orcid":"","institution":"Department of Radiation-Oncology, Medical University of Innsbruck","correspondingAuthor":false,"prefix":"","firstName":"Samuel","middleName":"Moritz","lastName":"Vorbach","suffix":""},{"id":375522565,"identity":"6f4d5a77-98e3-47cc-80c5-e024d218c218","order_by":6,"name":"Karin Pfaller-Frank","email":"","orcid":"","institution":"University for Continuing Education Krems","correspondingAuthor":false,"prefix":"","firstName":"Karin","middleName":"","lastName":"Pfaller-Frank","suffix":""},{"id":375522569,"identity":"399e0c94-953f-4d9b-846a-52958b193fb9","order_by":7,"name":"Wilhelm Frank","email":"","orcid":"","institution":"University for Continuing Education Krems","correspondingAuthor":false,"prefix":"","firstName":"Wilhelm","middleName":"","lastName":"Frank","suffix":""},{"id":375522572,"identity":"1272d625-eaa8-4d9f-853c-44ef14a39676","order_by":8,"name":"Thomas Licht","email":"","orcid":"","institution":"Ludwig Boltzmann Institute for Rehabilitation Research","correspondingAuthor":false,"prefix":"","firstName":"Thomas","middleName":"","lastName":"Licht","suffix":""}],"badges":[],"createdAt":"2024-10-29 09:23:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5352887/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5352887/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":70924847,"identity":"43f5ff1e-7787-4752-a1f0-dd55ec283ead","added_by":"auto","created_at":"2024-12-09 09:07:33","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1248306,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparison of patients after rehabilitation (T1) with the general population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1a.\u003c/strong\u003e\u003cem\u003e\u003cstrong\u003e \u003c/strong\u003e\u003c/em\u003eHRQoL functioning scales values after rehabilitation (T1) compared to general population normative data. The stars represent significant differences between the group and normative data: *\u003cem\u003ep \u003c/em\u003e≤ 0.05; **\u003cem\u003ep \u003c/em\u003e≤ 0.01; ***\u003cem\u003ep \u003c/em\u003e≤ 0.001.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1b.\u003c/strong\u003e\u003cem\u003e\u003cstrong\u003e \u003c/strong\u003e\u003c/em\u003eHRQoL symptom scales values after rehabilitation (T1) compared to general population normative data. The stars represent significant differences between the group and normative data: *\u003cem\u003ep \u003c/em\u003e≤ 0.05; **\u003cem\u003ep \u003c/em\u003e≤ 0.01; ***\u003cem\u003ep \u003c/em\u003e≤ 0.001.\u003c/p\u003e","description":"","filename":"floatimage173.png","url":"https://assets-eu.researchsquare.com/files/rs-5352887/v1/1215d1a5cedcfc9d32dffff0.png"},{"id":70924851,"identity":"52b55f72-64fe-4383-ad00-f500ff3f637d","added_by":"auto","created_at":"2024-12-09 09:07:33","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":65661,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePsychological distress at admission and discharge\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHADS mean values at admission (T0) and discharge (T1) compared to general population normative data (a-b). The stars represent significant differences between the group and normative data: *\u003cem\u003ep \u003c/em\u003e≤ 0.05; **\u003cem\u003ep \u003c/em\u003e≤ 0.01; ***\u003cem\u003ep \u003c/em\u003e≤ 0.001.\u003c/p\u003e","description":"","filename":"floatimage348.png","url":"https://assets-eu.researchsquare.com/files/rs-5352887/v1/584143426ec0b23bba0537d4.png"},{"id":73111659,"identity":"95fafd6a-880f-42b6-90ae-7e3c504ac519","added_by":"auto","created_at":"2025-01-06 22:31:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1481452,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5352887/v1/c74d82db-7a2b-461b-8a8e-3d045a35cc97.pdf"},{"id":70926729,"identity":"7bc4dd5e-de18-4d77-953e-9955d4cc4b27","added_by":"auto","created_at":"2024-12-09 09:15:33","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":48048,"visible":true,"origin":"","legend":"","description":"","filename":"Table14.docx","url":"https://assets-eu.researchsquare.com/files/rs-5352887/v1/dd1c6c09657ff65e6926e856.docx"},{"id":70927124,"identity":"6b5e85b8-1260-4b4c-8f20-bc25c0fabb34","added_by":"auto","created_at":"2024-12-09 09:24:02","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":15922,"visible":true,"origin":"","legend":"","description":"","filename":"ONKOsuppl.docx","url":"https://assets-eu.researchsquare.com/files/rs-5352887/v1/c22bd4061e0d921bb7a43450.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Dysphagia’s Effects on Quality of Life, Functional Disabilities, and Psychological Distress in Head and Neck Cancer Patients: Outcomes of Cancer Rehabilitation from an Observational Single-Centre Study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eThe global incidence of head and neck cancer (HNC) is the seventh highest of all cancers [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Between 2020 and 2022, Austria recorded 1,378 new diagnoses for ICD-10 codes C00\u0026ndash;C14, with a mortality rate of 559.7 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Additionally, 334 laryngeal carcinomas (C32) were diagnosed, with a mortality rate of 134.3 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The incidence of HNC is three to five times higher in men than in women [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Its primary causes are chronic alcohol and nicotine abuse, as well as human papillomavirus infection, particularly types 16, 18, and 31 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Patients with HNC often display lumps in the neck, open and painful sores in the mouth and throat, plaques, swelling, difficulty swallowing (i.e. dysphagia), or changes in their voice and speech (e.g. hoarseness) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese patients suffer from the considerable physical and psychological consequences of the disease [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], including a fear of its recurrence, depression, and difficulties affecting their family, social environment, and return to work. The symptom of dysphagia alone can cause nutritional deficiency, weight loss, or feeding tube dependency, increasing the risk of life-threatening aspiration [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Worse health-related quality of life (HRQoL) was found for female patients and patients with low income, laryngeal cancer, and advanced tumour stage [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTreatment of HNC is multimodal, involving surgery, radio(chemo)therapy, or systemic therapy [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Many HNC survivors experience impaired \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eHRQoL\u003c/span\u003e and oral function [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Other adverse treatment effects include skin changes, oedema, pain in the head, neck, or shoulder girdle, a loss of taste, saliva, and appetite, thrush, or mucositis. Localised symptoms such as xerostomia, impaired movement, tissue induration, fibrosis, necrosis, and trismus can specifically affect the patient\u0026rsquo;s voice and ability to swallow. Dysphagia and aspiration are frequently underestimated [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. These symptoms may appear several years after treatment, thereby making them difficult to address [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Three-quarters of HNC patients experience long-term morbidity and experience at least two treatment side effects\u0026thinsp;\u0026ge;\u0026thinsp;5 years after diagnosis; therefore, it is important to provide speech therapy targeting swallowing and oral functions for effective rehabilitation [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis rehabilitation should enhance patient HRQoL and participation by addressing functional limitations and alleviating psychological distress [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Patient-reported outcomes (PROs) have been utilised to identify unmet needs and evaluate HRQoL in addition to physical, psychological, and social functioning [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. These measures provides valuable insights into patient perspectives and often highlights discrepancies between patient self-assessment and evaluations by healthcare professionals [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePROs are valuable tools for planning rehabilitative therapies, as they enable healthcare professionals to identify the patient\u0026rsquo;s specific needs and assess the effectiveness of interventions [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In previous studies, we utilised PROs to compare the effectiveness of rehabilitation in different tumour entities and age groups [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In this study, we assessed HRQoL using the EORTC QLQ-C30 [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], and psychological distress using the Hospital Anxiety and Depression Scale (HADS) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Both questionnaires are validated and widely used. The aims of this study were to investigate the specific effects of dysphagia on HRQoL, functioning, and distress in HNC survivors and to evaluate the effectiveness of cancer rehabilitation in dysphagia patients.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cp\u003e\u003cem\u003e2.1.\u0026nbsp;Patients and methods\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eData were collected at the Austrian Rehabilitation Centre St. Veit im Pongau during a 21-day cancer rehabilitation programme. In cases of severe impairment, patients could extend their stays for seven days. The treatment costs were covered by Austrian pension funds, which stipulated the respective therapy frequencies and the minimum total treatment time (1800 minutes). According to pension fund guidelines, patients needed to have completed active oncological treatment and to be in a condition suitable for active participation in therapeutic interventions.\u003c/p\u003e\n\u003cp\u003eAll patients admitted to the rehabilitation centre between 01/01/2019 and 08/31/2021 were screened. Inclusion criteria comprised ICD-10 tumour diagnoses, C00-C14, C30-C32, or C76. To avoid the risk of bias, only the first rehabilitation stay per patient was included in the case of multiple rehabilitations. Exclusion criteria comprised an early discharge (i.e.\u0026nbsp;\u0026le;\u0026nbsp;three days), an interval of \u0026gt; 56 days between the first assessment and treatment initiation, and incomplete data sets. A single speech therapist conducted a clinical swallowing function examination (CSE) on all HNC patients, employing a standardised manual approach. This involved a thorough medical history review and clinical assessment of structures involved in swallowing, utilising tests with foods of various consistencies and bolus sizes\u0026nbsp;[27]. Based on the CSE\u0026nbsp;and logopaedic anamnesis results, patients were classified into three predefined groups:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDysphagia group (Dys):\u003c/strong\u003e patients who needed speech therapy to treat\u0026nbsp;swallowing disorders affecting ingestion, preparation, or transport of food\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eControl group 1 (C1):\u003c/strong\u003e patients who needed speech therapy\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eControl group 2 (C2):\u003c/strong\u003e patients without dysphagia symptoms who needed speech therapy due to impairments\u0026nbsp;(e.g. xerostomia, dysgeusia, dysphonia, dysglossia, dyspnoea, painful hardening of throat and muscles)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.2.\u0026nbsp;\u003c/em\u003e\u003cem\u003eAssessment procedures\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eData were acquired with a web-based patient portal utilising the \u003cem\u003eComputer-based Health Evaluation System\u003c/em\u003e (CHES)\u0026nbsp;[23,28]. Patients were asked to complete electronic PROs before admission (T0). We explained that these questionnaires would help pre-plan treatments to meet their specific needs. For those who had not completed the questionnaires upon arrival, administration staff provided technical assistance. A second assessment was conducted upon discharge (T1), employing identical questionnaires.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.3.\u0026nbsp;\u003c/em\u003e\u003cem\u003eEthics approval\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eUpon admission, patients were informed about the study and asked to provide their written informed consent for the scientific use of their data. If they declined, the data were used for routine care only. This study was reviewed by the Ethics Committee of the State of Salzburg (vote no. 415-EP/73/706-2017, from 01/18/2017), which waived the necessity for formal approval, as the study was observational and non-interventional. The study was conducted according to the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.4.\u0026nbsp;\u003c/em\u003e\u003cem\u003eOutcome assessment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFunctions and symptoms were assessed using the QLQ-C30 (German version)\u0026nbsp;[57], a 30-item questionnaire organised into scales for global HRQoL, functioning (physical, social, role, emotional, cognitive), and symptomatic scales (fatigue, nausea/vomiting, pain, dyspnoea, sleep disturbances, appetite loss, constipation, diarrhoea, financial impact). Scoring adhered to EORTC manual guidelines, which recommends the transformation of raw scores into values on a 0\u0026ndash;100 scale, where 100 represents the worst symptom and the best functioning score\u0026nbsp;[29]. The HADS, a 14-item questionnaire, was used to assess anxiety and depression. A total score ranging 0\u0026ndash;42 is generated, with sub-scores for anxiety and depression. Clinical cases of anxiety or depression are defined by scores of \u0026ge; 11\u0026nbsp;[26].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.5.\u0026nbsp;Multimodal rehabilitation\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePatients underwent multidisciplinary therapies, receiving guidance and treatment from physicians, nursing staff, physiotherapists, sports therapists, psychologists, dieticians, and speech therapists. Interventions included aerobic and resistance training, psychological and social counselling, relaxation exercises, nutritional advice, and educational presentations. Patients could also receive occupational therapy, remedial massage, thermotherapy, hydrogymnastics, electrotherapy, and counselling for lifestyle modification or smoking cessation. Speech therapy was offered to all patients with dysphagia or other logopaedic dysfunctions. Techniques such as functional dysphagia therapy and manual swallowing therapy were used to enhance the range of motion and strengthen muscles essential for swallowing, including those of lips, tongue, and larynx\u0026nbsp;[3,30]. Compensatory manoeuvres like the super-supraglottic swallow and the Mendelsohn manoeuvre were individualised, and additional guidance was provided on posture, movement, xerostomia management, and adaptive strategies.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.6. Statistical analyses\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMean differences were compared using \u0026chi;\u003csup\u003e2\u003c/sup\u003e-tests and independent sample \u003cem\u003et\u003c/em\u003e-tests. Baseline differences (T0) between groups were analysed using univariate analysis of variance (ANOVA). Changes in symptoms or functioning during rehabilitation were evaluated by repeated measures ANOVA. Mean values for QLQ-C30 and HADS at T1 were compared with published reference values from the Austrian general population\u0026nbsp;[26,29]. Effect sizes were determined for multivariate and univariate analyses using partial eta squared (\u0026eta;\u0026sup2;) values, categorised as negligible (\u0026eta;\u0026sup2; \u0026lt; 0.01), small (\u0026eta;\u0026sup2; = 0.01\u0026ndash;0.06), moderate (\u0026eta;\u0026sup2; = 0.06\u0026ndash;0.14), or large (\u0026eta;\u0026sup2; \u0026gt; 0.14)\u0026nbsp;[31].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eA priori\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003ecalculations indicated that a total sample size of \u003cem\u003en\u003c/em\u003e = 42 patients was needed to detect mean pre-post assessment differences in a three-group setting with moderate effect size (\u0026alpha; = 0.05, 1-\u0026beta; = 0.80; \u003cem\u003ef\u003c/em\u003e = 0.25). \u003cem\u003ePost hoc\u003c/em\u003e tests (PHC) were performed despite the absence of a statistically significant interaction according to the \u003cem\u003eomnibus\u003c/em\u003e test, as supported by previous research\u0026nbsp;[32]. The significance threshold was set at \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05. In case of multiple comparisons, Bonferroni\u003cem\u003e\u0026nbsp;\u003c/em\u003ecorrections were applied to control for Type I error rate inflation. Analyses were repeated by applying a multivariate approach (3x2 design with two-way ANOVA, i.e. repeated measures). The within-subject factors included time points T0 and T1 to capture temporal intervention effects. This approach enabled us to simultaneously analyse multiple dependent variables, including HADS and QLQ-C30 summary scores, and comprehensively understand the intervention\u0026apos;s effects across different PRO dimensions. It also allowed us to assess changes over time within subjects while accounting for the correlations among the dependent variables. All calculations were performed using IBM SPSSv27.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eOf 2,730 patients with\u0026nbsp;various forms of cancer, 113 with HNC were identified. Subsequently, 50 patients were excluded due to, e.g. incomplete data (Table 1a). The remaining 63 participants were stratified into three groups and analysed. The cohort consisted predominantly of males (76.2%) with an average age of 60.9\u0026nbsp;\u0026plusmn;\u0026nbsp;9.2 years (Table 1b). Half of the patients (49.2%) had stage IV HNC according to UICC criteria, and cancer recurrence was evident\u0026nbsp;in 12.7% of these. Notably, no significant differences were identified between the groups regarding gender, age, cancer stage, and recurrence status.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePlease add table 1 here\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3.1.\u0026nbsp;\u003c/em\u003e\u003cem\u003eMean baseline HRQoL differences between the three groups\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAt the initial measurement point (T0), significant between-group differences were observed across several domains of functioning, and patients with dysphagia (Dys) consistently exhibited poorer outcomes than control groups (C1 and C2). A significant group effect was observed for global HRQoL (\u003cem\u003ep\u003c/em\u003e = 0.002, \u0026eta;\u0026sup2; = 0.184), and PHC indicate that the Dys have a notably lower HRQoL than C1. A similarly significant group effect was observed for physical functioning (\u003cem\u003ep\u003c/em\u003e = 0.030, \u0026eta;\u0026sup2; = 0.110), where the Dys exhibited lower physical functioning than C1 members. Social functioning also significantly differed between the groups (\u003cem\u003ep\u003c/em\u003e = 0.001, \u0026eta;\u0026sup2; = 0.197): C1 scores are significantly higher than those of the Dys and C2. With regard to emotional functioning, a significant group effect was observed (\u003cem\u003ep\u003c/em\u003e = 0.024, \u0026eta;\u0026sup2; = 0.117), and PHC indicate that the Dys exhibit significantly lower emotional functioning than C1. Furthermore, a significant group effect was observed for the total functional scale (TFS) (\u003cem\u003ep\u003c/em\u003e = 0.011, \u0026eta;\u0026sup2; = 0.141). The PHC scores for the Dys are significantly inferior to those for C1. No significant group effects were identified for role functioning (\u003cem\u003ep\u003c/em\u003e = 0.068) or cognitive functioning (\u003cem\u003ep\u003c/em\u003e = 0.101).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWith regard to the symptoms, a group effect was indicated for fatigue (\u003cem\u003ep\u003c/em\u003e = 0.071, \u0026eta;\u0026sup2; = 0.084), although this difference did not achieve statistical significance in PHC. No significant group effects were identified for other symptoms (e.g. nausea/vomiting, pain, dyspnoea, sleep disturbances, appetite loss, constipation, diarrhoea, or financial impact).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePlease add figure 1 here\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3.2.\u0026nbsp;\u003c/em\u003e\u003cem\u003eImprovement during rehabilitation across groups\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFollowing rehabilitation, considerable time and group effects were evident across numerous functioning domains, accompanied by notable group-by-time interactions. The global HRQoL significantly improved over time in the Dys (\u003cem\u003ep\u003c/em\u003e = 0.002, \u0026eta;\u0026sup2; = 0.361) and C2 (\u003cem\u003ep\u003c/em\u003e = 0.018, \u0026eta;\u0026sup2; = 0.287). Furthermore, findings of the PHC indicate that the Dys and C2 improved more significantly over time than C1. A significant time effect was observed in C2 for role functioning (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001, \u0026eta;\u0026sup2; = 0.625), with the PHC indicating that C2 improved more than the Dys and C1. Social functioning demonstrated a significant time effect for all groups (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026lt; 0.05), and the PHC indicate that both the Dys and C2 improved more significantly than C1. Significant improvements were also observed over time in all groups for emotional functioning (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05), and the PHC confirm that the Dys made larger significant gains than C1. The TFS significantly improved in the Dys (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001, \u0026eta;\u0026sup2; = 0.427) and C2 (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001, \u0026eta;\u0026sup2; = 0.604), and the PHC indicate that the Dys and C2 improve significantly more than C1. No significant time effect was observed for physical functioning; however, the PHC demonstrate the improvement seen in the Dys and C1 significantly differ.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding the observed symptoms, a statistically significant reduction in fatigue was observed across all groups (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05). The PHC indicate that the Dys experienced a significantly greater reduction in fatigue than C1. Notable enhancements were discerned in terms of sleep disturbances in both the Dys (\u003cem\u003ep\u003c/em\u003e = 0.006, \u0026eta;\u0026sup2; = 0.310) and in C2 (\u003cem\u003ep\u003c/em\u003e = 0.004, \u0026eta;\u0026sup2; = 0.397). A significant group-by-time interaction was observed for sleep disturbances (\u003cem\u003ep\u003c/em\u003e = 0.034, \u0026eta;\u0026sup2; = 0.106), as the PHC indicate the Dys and C2 improved considerably more than C1. Additionally, appetite loss notably and significantly improved over time in the Dys (\u003cem\u003ep\u003c/em\u003e = 0.047, \u0026eta;\u0026sup2; = 0.175) and in C2 (\u003cem\u003ep\u003c/em\u003e = 0.035, \u0026eta;\u0026sup2; = 0.237). The total symptom score (TSS) displayed statistically significant improvement over time in the Dys (\u003cem\u003ep\u003c/em\u003e = 0.041, \u0026eta;\u0026sup2; = 0.184) and in C2 (\u003cem\u003ep\u003c/em\u003e = 0.001, \u0026eta;\u0026sup2; = 0.476).\u003c/p\u003e\n\u003cp\u003eThe HRQoL of our study population was compared to data for the normal Austrian population\u0026nbsp;[34]. At T1, the emotional functioning of C1 patients was equal to that of the normal population, while patients who needed speech therapy displayed lower values. Other functioning levels were below those of the normal population. All symptom scores remained above the level of the normative data, except for the score for diarrhoea, which was below this level in C1 and C2 (Figures 1A and 1B).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePlease add table 2 here\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePlease add table 3 here\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3.3.\u0026nbsp;Psychological distress\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBefore rehabilitation, anxiety and depression levels were higher in the Dys and C2 than in C1, although these differences were not statistically significant (Table 3, Figure 2). At T1, the Dys displayed statistically significantly lower anxiety (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 0.015, \u0026eta;\u0026sup2; = 0.251) and depression (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 0.008, \u0026eta;\u0026sup2; = 0.291). C2 also demonstrated a statistically significant decrease in depression (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 0.040, \u0026eta;\u0026sup2; = 0.225) between T0 and T1. In the Dys and C2, these differences reached clinically relevant levels \u0026nbsp;[33]. Conversely, the improvements in anxiety observed in C2, and in anxiety and depression in C1, were not statistically significant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePlease add table 4 here\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA comparison with normative data revealed that the anxiety levels measured at T1 in our study groups aligned with those observed in the normal population (Figure 2)\u0026nbsp;[26]. Notably, depression levels in C1 were even lower than in the normal population. An analysis of group-by-time interactions revealed no statistically significant differences in improvement between the three groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePlease add figure 2 here\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3.4.\u0026nbsp;Multivariate analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA multivariate analysis and univariate tests were conducted to detect relationships among the various outcome measures and control for the influence of multiple variables simultaneously. The results indicate significant time effects across all outcome measures (Supplemental Table 5). The multivariate analysis results highlight the holistic impact of the intervention on multiple outcomes with high effect sizes. This intervention had many effects, and contributed most notably to improvements in functional aspects, a reduction of psychological distress, and a promotion of overall well-being in HNC patients.\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003e\u003cem\u003eImpact of dysphagia and speech disorders on HRQoL and functioning\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study investigated the effects of oncological rehabilitation on the HRQoL of HNC survivors by utilising routinely collected PROs. The questionnaires completed before rehabilitation helped us to identify patients\u0026rsquo; unmet needs. The Dys had significantly poorer HRQoL than other HNC patients and the general Austrian population. This was associated with a lower TFS, mainly due to poorer physical, emotional, and cognitive functioning. The Dys also reported higher TSS, characterised by increased fatigue, nausea/vomiting, pain, diarrhoea, and financial concerns.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLate adverse effects were observed in more than half of the HNC survivors, including fatigue, joint pain and muscle aches, problems staying asleep, feeling cold, and neurocognitive symptoms\u0026nbsp;[34]. Fatigue may persist in the long term, especially after radiotherapy\u0026nbsp;[36]. Our findings corroborate previous reports indicating that disorders of speech or swallowing are associated with impaired HRQoL\u0026nbsp;[7,34]. Dysphagia has also been associated adverse effects such as coughing, sleep disorders, and reduced mouth opening\u0026nbsp;[36], additionally increasing the risk of dehydration, malnutrition, aspiration, and pneumonia,\u0026nbsp;[3,37].\u0026nbsp;Our study findings demonstrate that dysphagia has specific, systemic consequences that extend beyond the swallowing function, affecting various aspects of physical, mental, and social health.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe initially planned to compare dysphagia patients to patients without impaired swallowing. However, the control group was heterogeneous, necessitating an alternative approach. C2 displayed markedly lower HRQoL and emotional and social functioning scores than C1. These patients were more strongly affected by fatigue and gastrointestinal symptoms. The Dys and C2 displayed more severe symptoms (except pain) than C1 and the general population\u0026nbsp;[29]. \u0026nbsp;Hence, while speech and swallowing disorders lead to general impairments, our study findings suggest that dysphagia is a specific risk factor for patients with severe, systemic symptoms.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Dys had higher levels of anxiety and depression than C1 and C2. These findings are consistent with those of a previous study, which reported that 23% of HNC patients exhibited significant depression\u0026nbsp;[38]. Another recent investigation revealed that many HNC survivors suffer from persistent psychological distress, namely 15.1% treated with irradiation reported experiencing depression and 10.0% anxiety after 24 months\u0026nbsp;[40]. In our previous study comparing various forms of cancer, we noticed elevated depression levels in HNC patients, although their anxiety levels were similar to all cancer survivors\u0026nbsp;[23]. Our current study data demonstrate that the HNC survivor population is not homogeneous, and that those with speech or swallowing dysfunctions experience severe distress, including higher anxiety levels. We hypothesise that the risk of aspiration and pneumonia causes anxiety.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEffects of cancer rehabilitation\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe effectiveness of the rehabilitation was analysed by comparing PROs from admission and discharge. Analyses of group-by-time effects were conducted to identify between-group differences regarding rehabilitation benefits. All three HNC subgroups showed significant improvements in global HRQoL, TFS, and TSS, particularly in the Dys and C2. Social and emotional functioning improved across all groups with large effect sizes, and reductions were seen in fatigue, insomnia, and appetite loss, contributing to the overall increase in HRQoL. We and others have reported that cancer rehabilitation improves HRQoL and mental, social, and physical functions of survivors with different forms of cancer\u0026nbsp;[23,41]. Our results indicate that among HNC patients, those with the greatest need for rehabilitation (i.e. dysphagia patients) benefit the most.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCancer rehabilitation is performed in a multimodal fashion, and speech therapy is highly relevant for HNC patients. Research has demonstrated the small to moderate effectiveness of exercises for swallowing and mouth opening in HNC patients\u0026nbsp;[41]. These interventions may mitigate local symptoms, while observed improvements in systemic symptoms and social functioning are expected as a result of interactions between therapeutic modalities\u0026nbsp;[42].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNotable improvements in anxiety and depression were observed in the Dys and C2. Adverse effects of dysphagia on emotional and mental health have been reported\u0026nbsp;[43]. This underlines the need for dysphagia patients to receive psychosocial support and provides evidence for the efficacy of psychological counselling in rehabilitation. Depression levels in the sample of patients with dysphagia were reduced even below the level of the general population. These forms of support have been shown to alleviate distress in survivors of other forms of cancer\u0026nbsp;[22,23,40,44]. A clinically significant correlation between social functioning, depression, and HRQoL of HNC patients has been reported\u0026nbsp;[38]. Reducing psychological distress in dysphagia patients contributes in meaningful ways to their rehabilitation success. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStrengths and limitations\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA notable strength of our study is that we directly compare different subgroups of HNC survivors. This allows us to draw conclusions about each group\u0026rsquo;s burden and their response to therapeutic interventions. Our cohort of previously unselected cancer survivors in rehabilitation provides a valuable source of real-world data on unmet needs. To control for Type I error rate inflation, i.e. false positive results in multiple hypothesis testing, we applied Bonferroni corrected \u003cem\u003ep\u003c/em\u003e-values and conducted a multivariate analysis; these results support the initial findings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOne potential limitation of the study is the relatively small sample size of 63 patients, which may have observed effect sizes. Although the \u003cem\u003ea priori\u003c/em\u003e sample size calculation indicated the study was sufficiently powered, additional subset analyses of the importance of UICC stage, severity of dysphagia, and type of oncological therapy were not feasible. Firstly, numbers of evaluable patients were lower than expected due to restricted admission to the rehabilitation centre, including its temporary closure during the COVID-19 pandemic. Secondly, this single-centre analysis ensures the standardised assessment of patients and therapies, but it might not be possible to generalise the results to other centres or countries. Thirdly, the ECOG status of most patients was 0\u0026ndash;2 because the Austrian pension fund does not refer patients in a poor general condition to the rehabilitation centres. Fourthly, QLQ-C30 was used as a part of routine rehabilitation procedures, but neither a dysphagia-specific questionnaire nor objective measures were used, such as the fibreoptic endoscopic evaluation of swallowing (FEES) and structured dysphagia therapy programmes [45]. This was not feasible in the setting of a general cancer rehabilitation without a sole focus on HNC patients. Nonetheless, our study demonstrates the benefits of general oncological rehabilitation for these patients.\u003c/p\u003e"},{"header":"5. Conclusion","content":" \u003cp\u003eDysphagia and to lesser extent other disabilities requiring speech therapy lead to a poorer HRQoL for HNC patients. Speech or swallowing disabilities are associated with multiple systemic impairments, which are more severe if dysphagia is present. Impaired functioning affects physical, emotional, and social functioning, mainly due to cancer-related fatigue, sleep disturbances, and appetite loss. Rehabilitation results in a conspicuous improvement in emotional and social functions. Although the cancer rehabilitation was not specifically designed to meet the needs of dysphagia patients, these particularly disabled and distressed patients benefited from this rehabilitation even more than other HNC survivors.\u003c/p\u003e "},{"header":"Declarations","content":"\u003ch2\u003eFunding information\u003c/h2\u003e \u003cp\u003eThis research received no external funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConceptualization: Thomas Licht; Data curation: Christina Knauseder, Michael Fischer and Thomas Licht; Formal analysis: Špela Matko; Methodology,: Špela Matko, David Riedl, Vincent Grote and Karin Pfaller-Frank; Resources,:Vincent Grote, Michael Fischer, Wilhelm Frank and Thomas Licht; Supervision: Thomas Licht; Visualization: Špela Matko; Writing \u0026ndash; original draft, Christina Knauseder, Špela Matko and Thomas Licht; Writing \u0026ndash; review \u0026amp; editing,:David Riedl, Vincent Grote, Michael Fischer and Samuel Vorbach.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe thank Bernhard Holzner and Gerhard Rumpold for the use of CHES software and valuable suggestions. Alain Nickels counselled the patients as a psychologist and participated in collection of PROs.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBarsouk, A., et al., \u003cem\u003eEpidemiology, Risk Factors, and Prevention of Head and Neck Squamous Cell Carcinoma\u003c/em\u003e. Med Sci (Basel), 2023. 11(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAustria, S. \u003cem\u003eKrebserkrankungen - Statistik Austria\u003c/em\u003e. 22.01.2024; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.statistik.at/statistiken/bevoelkerung-und-soziales/gesundheit/krebserkrankungen\u003c/span\u003e\u003cspan address=\"https://www.statistik.at/statistiken/bevoelkerung-und-soziales/gesundheit/krebserkrankungen\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. 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Eur J Oncol Nurs, 2012. 16(4): p. 432\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 to 4 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Patient-reported outcomes, speech therapy, psychooncology, fatigue, depression","lastPublishedDoi":"10.21203/rs.3.rs-5352887/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5352887/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eMany patients with head and neck cancer (HNC) suffer from speech or swallowing disorders. We investigated the effects of dysphagia on health-related quality of life (HRQoL), functioning, and distress in HNC survivors, and the extent to which rehabilitation can alleviate these effects.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eCancer survivors undergoing inpatient cancer rehabilitation at an Austrian rehabilitation centre were asked to complete electronic patient-reported outcomes before admission (T0) and at discharge (T1). The EORTC QLQ-C30 questionnaire was assessing HRQoL, symptoms, and functioning, and the Hospital Anxiety and Depression Scale (HADS) to assess psychological distress.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOf 63 HNC patients, 22 had dysphagia, 23 did not need speech therapy (control group C1), and 18 without dysphagia needed speech therapy (control group C2). Before rehabilitation, HRQoL, physical, social, and emotional functioning were significantly lower in dysphagia patients than in controls. Dysphagia patients suffered from more severe general symptoms, including fatigue, pain, sleep disturbances, nausea/vomiting, diarrhoea, and financial worries. In addition, emotional and social functioning of C2 patients who needed speech therapy but did not show dysphagia was significantly worse than of C1 patients. Social, emotional, and role functioning, fatigue, nausea/vomiting, insomnia, and appetite loss significantly improved by T1 in all HNC patients. Improvements in HRQoL were most noticeable in dysphagia patients. Psychooncological counselling reduced depression in dysphagia and in C2 patients to levels seen in the general population.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eDysphagia patients suffer severely from impaired functioning and systemic symptoms, but benefit substantially from cancer rehabilitation.\u003c/p\u003e","manuscriptTitle":"Dysphagia’s Effects on Quality of Life, Functional Disabilities, and Psychological Distress in Head and Neck Cancer Patients: Outcomes of Cancer Rehabilitation from an Observational Single-Centre Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-09 09:07:28","doi":"10.21203/rs.3.rs-5352887/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"07de6bda-1e62-4189-b8cd-24a159d746b8","owner":[],"postedDate":"December 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-01-06T22:23:15+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-09 09:07:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5352887","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5352887","identity":"rs-5352887","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}