Heather Starmer Research Lab
Head & Neck Surgery
In addition to providing state of the art clinical care for communication and swallowing, our speech-language pathology team is engaged in clinical research to determine strategies to improve patient outcomes after a diagnosis of head and neck cancer. Our team recognizes the difficulties of going through cancer treatment and has particular interest in developing strategies to help patients make it through their treatment doing the therapies that will provide the best long-term outcomes. We collaborate closely with our surgeons, radiation oncologists, medical oncologists, and other team members to investigate how we can improve the patient experience of head and neck cancer care.
"Nothing would be more tiresome than eating and drinking if God had not made them a pleasure as well as a necessity.
Our objective is to improve swallowing outcomes and patient satisfaction with swallowing after treatment for head and neck cancer.
Swallowing disorders are a common consequence of head and neck cancers and the treatments used to eradicate it. Swallowing issues may be related to the removal of structures in the mouth or throat, scarring or fibrosis of the mouth and throat, or swelling of the mouth, throat, or neck. Swallowing problems after head and neck cancer are cited as being the primary determinant of poor quality of life and may be associated with poor nutrition and development of aspiration pneumonia. Given this reality, our work seeks to identify practical strategies to minimize dysphagia and it’s complications.
Harnessing the Power of Technology
Technology has the potential to influence healthcare in many different ways. Approximately 10 years ago, Professor Starmer initiated work on a mobile application to support patients with head and neck cancer undergoing radiation therapy. This application, called The Head and Neck Cancer Virtual Coach™, provides patients with access to video workouts to perform to maintain the strength and mobility of their swallowing muscles, high-quality content about how to manage side effects during treatment, recipes and videos of foods that are well tolerated during treatment, and reminders to perform important therapy tasks. The impact of The Head and Neck Virtual Coach™ on patient outcomes and their experiences during treatment is currently under investigation at Stanford, Massachusetts Eye and Ear Infirmary, and the Fox Chase Cancer Center.
The Head and Neck Cancer Virtual Coach™ application screenshots.
Starmer HM, Klein D, Montgomery A, et al. Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation [published online ahead of print, 2022 Aug 12]. Dysphagia. 2022;10.1007/s00455-022-10506-5. doi:10.1007/s00455-022-10506-5.
- Jennifer Kizner (Stanford University)
- Jocelen Hamilton (Stanford University)
- Dr. Beth Beadle (Stanford University)
- Dr. F. Christopher Holsinger (Stanford University)
- Vibrent Health
- Dr. Jeremy Richmon (Massachusetts Eye and Ear Infirmary)
- Tessa Goldsmith (Massachusetts Eye and Ear Infirmary)
- Barbara Ebersole (Fox Chase Cancer Center)
Effective Treatment Requires Precision Diagnostics
The ability to effectively manage swallowing disorders depends on diagnostic precision. Swallowing is typically evaluated using either fluoroscopy, an x-ray movie, or endoscopy. Both of these tools rely on an experienced clinician interpreting their images. Without use of reliable, standard rating systems, these interpretations can be subjective and lead to poorer patient outcomes and inadequate communication between clinicians. Further, research of advanced cancer treatments requires the ability to accurately assess the functional impact of the treatment. To address these challenges, our lab strives to establish and validate measurement tools to be used in patients with swallowing disorders. This work has resulted in the development of the DIGEST-FEES tool, which allows swallowing clinicians to reliably rate the safety and efficiency of an individual’s swallow using endoscopic assessment of swallowing.
Endoscopic Evaluation of Swallowing.
Dr. Katherine Hutcheson (MD Anderson Cancer Center)
ADAPTATION AND VALIDATION OF THE DYNAMIC IMAGING GRADE OF SWALLOWING TOXICITY FOR FLEXIBLE ENDOSCOPIC EVALUATION OF SWALLOWING: DIGEST-FEES. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR Starmer, H. M., Arrese, L., Langmore, S., Ma, Y., Murray, J., Patterson, J., Pisegna, J., Roe, J., Tabor-Gray, L., Hutcheson, K. 2021: 1-9
Purpose While flexible endoscopic evaluation of swallowing (FEES) is a common clinical procedure used in the head and neck cancer (HNC) population, extant outcome measures for FEES such as bolus-level penetration-aspiration and residue scores are not well suited as global patient-level endpoint measures of dysphagia severity in cooperative group trials or clinical outcomes research. The Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) was initially developed and validated for use during videofluoroscopic evaluations as a way to grade safety, efficiency, and overall pharyngeal swallowing impairment. The purpose of this study was to adapt and validate DIGEST for use with FEES. Method A modified Delphi exercise was conducted for content validation, expert consensus, adaptation, and operationalization of DIGEST-FEES. Three blinded, expert raters then evaluated 100 de-identified post-HNC treatment FEES examinations. Intra- and interrater reliability were tested with quadratic weighted kappa. Criterion validity against the MD Anderson Dysphagia Inventory, Functional Oral Intake Scale, Secretion Severity Scale, and Yale Residue Rating Scale was assessed with Spearman correlation coefficients. Results Interrater reliability was almost perfect for overall DIGEST-FEES grade (kappaw = 0.83) and safety grade (kappaw = 0.86) and substantial for efficiency grade (kappaw = 0.74). Intrarater reliability was excellent for all raters (0.9-0.91). Overall DIGEST-FEES grade correlated with MD Anderson Dysphagia Inventory (r = -.43, p < .0001), Functional Oral Intake Scale (r = -.43, p < .0001), Secretion Severity Scale (r = .47, p < .0001), Yale Vallecular Residue (r = .73, p < .0001), and Yale Pyriform Sinus Residue (r = .65, p < .0001). Conclusion DIGEST-FEES is a valid and reliable scale to describe the severity of pharyngeal dysphagia in patients with HNC. Supplemental Material https://doi.org/10.23641/asha.14642787.
View details for DOI 10.1044/2021_JSLHR-21-00014
View details for PubMedID 34033498
Lymphedema can occur following surgery or radiotherapy for head and neck cancer. Internal lymphedema can contribute to swallowing, voice and breathing difficulties. Unlike external edema, there is no method currently available to measure internal edema. In conjunction with researchers in the United Kingdom, our lab is working to develop a scale that can be used to quantify the severity of internal edema impacting the throat and voice box.
Dr Joanne Patterson (University of Liverpool)
Starmer, Heather, Mary Gemma Cherry, Joanne Patterson, Bridget Young, and Jason Fleming. “Assessment of Measures of Head and Neck Lymphedema Following Head and Neck Cancer Treatment: A Systematic Review.” Lymphatic Research and Biology, June 9, 2022, lrb.2021.0100. https://doi.org/10.1089/lrb.2021.0100.
DEVELOPMENT AND RELIABILITY OF THE REVISED PATTERSON EDEMA SCALE. CLINICAL OTOLARYNGOLOGY : OFFICIAL JOURNAL OF ENT-UK ; OFFICIAL JOURNAL OF NETHERLANDS SOCIETY FOR OTO-RHINO-LARYNGOLOGY & CERVICO-FACIAL SURGERY Starmer, H. M., Drinnan, M., Bhabra, M., Watson, L., Patterson, J. 2021
OBJECTIVE: The Patterson Edema scale was developed in 2007 to address the lack of a reliable, sensitive scale to measure laryngeal and pharyngeal edema in patients with head and neck cancer. The objective of this study was to revise the existing Patterson scale to improve its reliability and utility.DESIGN: Prospective investigation SETTING: Academic medical center PARTICIPANTS: Speech-Language Pathologists, Otolaryngologists, and Radiation Oncologists MAIN OUTCOME MEASURES: Ratings using the Revised Patterson Edema Scale METHODS: A consensus group reviewed existing literature regarding the performance of the original Patterson scale and revised the existing scale in regard to items to be included and descriptors for each severity level. The scale was then utilized by 18 speech language pathologists from the US and UK with >2 years-experience working with dysphagia and dysphonia with endoscopy. Each SLP rated a total of eight parameters (epiglottis, vallecula, pharyngoepiglottic folds, aryepiglottic folds, arytenoids, false vocal folds, true vocal folds, and pyriform sinuses) using the Revised Patterson Edema Scale. Feedback was solicited from raters regarding areas where clarity was lacking for further scale revision. Scale revisions were completed and additional ratings were completed by otolaryngologists, radiation oncologists, and less experienced SLP providers to establish reliability across disciplines. Quadratic weighted Kappa values were obtained to establish interrater reliability.RESULTS: Feedback received from raters included suggestions for clarification of how to rate unilateral edema, use of a standard task battery to visualize and rate structures consistently, and clarification of true vocal fold edema rating parameters. Overall interrater reliability was established using quadratic weighted Kappa with good agreement noted for the epiglottis, vallecula, arytenoids, andfalse vocal folds; moderate agreement noted for aryepiglottic folds, pharyngoepiglottic folds and pyriform sinuses; and fair agreement noted for true vocal folds.CONCLUSIONS: The Revised Patterson Edema Scale demonstrates moderate-substantial interrater reliability for most parameters across multiple disciplines and experience levels, with the exception of the true vocal folds where agreement was fair. We believe the Revised Patterson Edema Scale provides a reliable tool for clinicians and researchers to rate edema in the supraglottic larynx and pharynx following treatment for head and neck cancer.
View details for DOI 10.1111/coa.13727
View details for PubMedID 33529494
Expert Consensus Statement: Management of Dysphagia in Head and Neck Cancer Patients.
Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery
2023; 168 (4): 571-592
To develop an expert consensus statement (ECS) on the management of dysphagia in head and neck cancer (HNC) patients to address controversies and offer opportunities for quality improvement. Dysphagia in HNC was defined as swallowing impairment in patients with cancers of the nasal cavity, paranasal sinuses, nasopharynx, oral cavity, oropharynx, larynx, or hypopharynx.Development group members with expertise in dysphagia followed established guidelines for developing ECS. A professional search strategist systematically reviewed the literature, and the best available evidence was used to compose consensus statements targeted at providers managing dysphagia in adult HNC populations. The development group prioritized topics where there was significant practice variation and topics that would improve the quality of HNC patient care if consensus were possible.The development group identified 60 candidate consensus statements, based on 75 initial proposed topics and questions, that focused on addressing the following high yield topics: (1) risk factors, (2) screening, (3) evaluation, (4) prevention, (5) interventions, and (6) surveillance. After 2 iterations of the Delphi survey and the removal of duplicative statements, 48 statements met the standardized definition for consensus; 12 statements were designated as no consensus.Expert consensus was achieved for 48 statements pertaining to risk factors, screening, evaluation, prevention, intervention, and surveillance for dysphagia in HNC patients. Clinicians can use these statements to improve quality of care, inform policy and protocols, and appreciate areas where there is no consensus. Future research, ideally randomized controlled trials, is warranted to address additional controversies related to dysphagia in HNC patients.
View details for DOI 10.1002/ohn.302
View details for PubMedID 36965195
Internal oedema and dysphagia characteristics in patients with head and neck cancer.
Clinical otolaryngology : official journal of ENT-UK ; official journal of Netherlands Society for Oto-Rhino-Laryngology & Cervico-Facial Surgery
View details for DOI 10.1111/coa.14046
View details for PubMedID 36918287
Letter to the Editor re: Intra and interobserver agreement of the Dynamic Imaging Grade of Swallowing Toxicity Scale (DIGEST) in fiberoptic endoscopic evaluation of swallowing (FEES): the importance of observer-tailored training.
European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery
View details for DOI 10.1007/s00405-023-07902-4
View details for PubMedID 36912933
Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation.
Dysphagia is a common consequence of head and neck radiation and may be mitigated by performance of swallowing exercises during radiation treatment. Given historically poor adherence to such exercise protocols, we created a mobile health application, HNC Virtual Coach as an adjunct to standard clinical care. This randomized control trial investigated the impact of HNC Virtual Coach on adherence as well as swallowing outcomes by comparing those using the mobile app to those receiving only standard clinical care and paper logs. Both treatment groups were provided with the same exercise protocol as well as the same baseline educational information. Outcome measures included adherence rates, physiologic measures obtained during a Modified Barium Swallow Study (PAS, MBS-ImP, DIGEST), patient-reported outcomes (MDADI), diet levels (FOIS, PSS-HN), and quality of information received (INFO-25). Patients using the HNC Virtual Coach tended to have better adherence to treatment recommendations during radiation therapy. Increased adherence was associated with better patient-reported quality of life, but not physiologic function 2-3months following completion of radiation. Results suggest that a mobile health application may provide benefit for some patients undergoing head and neck radiation.
View details for DOI 10.1007/s00455-022-10506-5
View details for PubMedID 35960394
Transoral Robotic Surgery for Recurrent Tumors of the Upper Aerodigestive Tract (RECUT): An International Cohort Study.
Journal of the National Cancer Institute
BACKGROUND: Transoral robotic surgery (TORS) is an emerging minimally invasive surgical treatment for residual, recurrent, and new primary head and neck cancers in previously irradiated fields, with limited evidence for its oncological effectiveness.METHODS: A retrospective observational cohort study of consecutive cases performed in 16 high-volume international centers before August 2018 was conducted (registered at clinicaltrials.gov [NCT04673929] as the RECUT study). Overall survival (OS), disease-free survival, disease-specific survivals (DSS), and local control (LC) were calculated using Kaplan-Meier estimates, with subgroups compared using log-rank tests and Cox proportional hazards modeling for multivariable analysis. Maximally selected rank statistics determined the cut point for closest surgical resection margin based on LC.RESULTS: Data for 278 eligible patients were analyzed, with median follow-up of 38.5months. Two-year and 5-year outcomes were 69.0% and 62.2% for LC, 71.8% and 49.8% for OS, 47.2% and 35.7% for disease-free survival, and 78.7% and 59.1% for disease-specific survivals. The most discriminating margin cut point was 1.0mm; the 2-year LC was 80.9% above and 54.2% below or equal to 1.0mm. Increasing age, current smoking, primary tumor classification, and narrow surgical margins (≤1.0mm) were statistically significantly associated with lower OS. Hemorrhage with return to theater was seen in 8.1% (n=22 of 272), and 30-day mortality was 1.8% (n=5 of 272). At 1 year, 10.8% (n=21 of 195) used tracheostomies, 33.8% (n=66 of 195) used gastrostomies, and 66.3% (n=53 of 80) had maintained or improved normalcy of diet scores.CONCLUSIONS: Data from international centers show TORS to treat head and neck cancers in previously irradiated fields yields favorable outcomes for LC and survival. Where feasible, TORS should be considered the preferred surgical treatment in the salvage setting.
View details for DOI 10.1093/jnci/djac130
View details for PubMedID 35944904
We would like to express our gratitude to the Toole Family Foundation, whose continuous generosity supports us in our battle against HPV related cancers.
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