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.
- 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
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
Practice patterns in transoral robotic surgery: results of an American head and neck society survey.
Journal of robotic surgery
To understand perioperative practices for transoral robotic surgery (TORS) among academic medical centers. An electronic cross-sectional survey was distributed to fellows and program directors participating in 49 American Head and Neck Society fellowships. Operative decisions, medical and swallowing management, and disposition planning were assessed. Thirty-eight responses were collected (77.6%). Twenty-three centers (60.5%) performed>25 cases annually with the remainder performing fewer. The da Vinci Si was the most commonly used platform (n=28, 73.7%). A majority of institutions advocated tailored resection to adequate margins (n=27, 71.1%) over fixed subunit-based resection (n=11, 28.9%). Most surgeons (n=29, 76.3%) performed neck dissection concurrent with TORS, and 89.5% (n=34) routinely ligated external carotid artery branches. A minority of institutions (n=17, 45.9%) endorsed a standardized TORS care pathway. Antibiotic choices and duration varied, the most common choice being ampicillin/sulbactam (n=21, 55.3%), and the most common duration being 24h or less (n=22, 57.9%). Multimodal analgesia was used at 36 centers (94.7%), steroids at 31 centers (81.6%), and pharmacologic venous thromboembolic prophylaxis at 29 centers (76.3%). Nasogastric feeding tubes were placed during surgery at 20 institutions (54.1%). Speech-language pathologists routinely performed postoperative swallow evaluations at 29 (78.4%) sites. Practice patterns are variable among institutions performing TORS. While certain surgical and postoperative practices were quite common, many institutions reported no standard TORS care pathway. Further understanding of the impact of individual practices on outcomes is necessary to develop evidence-based perioperative protocols for TORS.
View details for DOI 10.1007/s11701-022-01448-z
View details for PubMedID 35933632
Assessment of Measures of Head and Neck Lymphedema Following Head and Neck Cancer Treatment: A Systematic Review.
Lymphatic research and biology
Purpose: Head and neck lymphedema is a common condition following head and neck cancer (HNC) treatment, with substantial functional morbidity. This systematic review aimed to (1) identify tools used to assess head and neck lymphedema in HNC patients and (2) determine their validity and reliability. Methods: Electronic and hand searches of Prospero, MEDLINE, Cochrane Library, and Embase were searched from their inception until April 2021, and hand searches were independently screened by two reviewers. Studies were included if they were available in English and measured lymphedema in adult HNC patients (aged ≥18 years). Data including psychometric characteristics were extracted and synthesized narratively, with the Quality Assessment of Diagnostic Accuracy Studies-2 and the COnsensus-based Standards for the selection of health Measurement INstruments checklists used to assess risk of bias. Results: Thirty-three studies, reporting 38 assessment tools, were included. Assessments included clinician rating scales, symptom inventories, size measures, measures of internal edema, radiographic and ultrasonographic measures, and quality-of-life measures. Of the 38 measures cited, only 11 had any degree of validation and reliability testing. Risk of bias varied among the different assessment tools. Conclusion: While many tools are used in the assessment of head and neck lymphedema, the majority of these tools lack validation and reliability data. Only one tool, the Head and Neck Lymphedema and Fibrosis Symptom Inventory, met criteria for strong quality assessment. Further efforts to establish a core set of metrics for this complex condition are warranted.
View details for DOI 10.1089/lrb.2021.0100
View details for PubMedID 35679595
The American Broncho-Esophagological Association Position Statement on Swallowing Fluoroscopy.
OBJECTIVES: To develop an expert consensus statement on the clinical use of swallowing fluoroscopy in adults that reduces practice variation and identifies opportunities for quality improvement in the care of patients suffering from swallowing impairment.METHODOLOGY: A search strategist reviewed data sources (PubMed, Embase, Cochrane, Web of Science, Scopus) to use as evidence for an expert development group to compose statements focusing on areas of controversy regarding swallowing fluoroscopy. Candidate statements underwent two iterations of a modified Delphi protocol to reach consensus.RESULTS: A total of 2184 publications were identified for title and abstract review with 211 publications meeting the criteria for full text review. Of these, 148 articles were included for review. An additional 116 publications were also included after reviewing the references of the full text publications from the initial search. These 264 references guided the authors to develop 41 candidate statements in various categories. Forty statements encompassing patient selection, fluoroscopic study choice, radiation safety, clinical team dynamics, training requirements, videofluoroscopic swallow study and esophagram techniques, and interpretation of swallowing fluoroscopy met criteria for consensus. One statement on esophagram technique reached near-consensus.CONCLUSIONS: These 40 statements pertaining to the comprehensive use of swallowing fluoroscopy in adults can guide the development of best practices, improve quality and safety of care, and influence policy in both the outpatient and inpatient settings. The lack of consensus on some aspects of esophagram technique likely reflects gaps in knowledge and clinical practice variation and should be a target for future research. Laryngoscope, 2022.
View details for DOI 10.1002/lary.30177
View details for PubMedID 35543231
We would like to express our gratitude to the Toole Family Foundation, whose continuous generosity supports us in our battle against HPV related cancers.