Clinical trial NCT03455608: PRO-ACTIVE: Prophylactic Swallow Intervention for Patients Receiving Radiotherapy for Head and Neck Cancer
Official title: PRO-ACTIVE: Comparing The Effectiveness of Prophylactic Swallow Intervention for Patients Receiving Radiotherapy for Head and Neck Cancer
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: NA
Conditions: Dysphagia
Keywords: dysphagia
swallowing disorder
speech pathology
swallowing therapy
head and neck cancer
radiotherapy
toxicity
supportive care
Lead sponsor: University Health Network, Toronto
Sponsor class: OTHER
Collaborators: name: M.D. Anderson Cancer Center
name: Applied Health Research Centre
name: Qualitative Health Research Consultants, LLC
name: Patient-Centered Outcomes Research Institute
First posted: 2018-03-06
Enrollment: 952
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: TREATMENT

Brief summary: Dysphagia (difficulty swallowing) is a common and potentially life-threatening toxicity of radiotherapy (RT) for patients with head and neck cancer (HNC). HNC survivors have a 20-24 percent lifetime risk of pneumonia after RT, which is associated with a 42 percent excess risk of death in survivorship. Moreover, dysphagia predisposes individuals to malnutrition, and at least half of HNC patients require feeding tubes during RT.

Patients are commonly referred for swallowing therapy with a speech pathologist. Some patients receive early intervention, before a swallowing problem begins-PRO-ACTIVE therapy. Other patients are monitored and prescribed dysphagia interventions only if and when a swallowing problem occurs-RE-ACTIVE therapy. Thus, REACTIVE therapy aims to reverse an already impaired swallowing ability, whereas PRO-ACTIVE therapy aims to prevent or reduce severity of dysphagia. These two broad categories of therapy represent the most common types of intervention offered to HNC patients across North America. Although there is single-institution evidence to support each practice, it is yet unknown which is most effective.

To address this gap, the primary aim of this international, multi-site 3-arm pragmatic randomized clinical trial is to compare the effectiveness of PRO-ACTIVE (high and low intensity) versus RE-ACTIVE swallowing therapy among 952 patients with HNC planning to undergo RT, using duration of feeding tube dependence after RT as the primary outcome. Our secondary aim proposes to compare the relative benefit or harm of these swallowing interventions on secondary outcomes considered relevant to our stakeholder partners.

Detailed description: Swallowing therapy is commonly provided as a behavioral treatment to lessen the risk or severity of dysphagia in head and neck cancer (HNC) patients; however, best practice is not established. This multi-site, international randomized clinical trial (RCT) will compare the effectiveness of PRO-ACTIVE (high and low intensity) versus RE-ACTIVE swallowing interventions in 952 HNC patients undergoing radiotherapy (RT). The 3 study arms represent alternate timing and intensity of swallowing therapy delivered by a speech language pathologist: 1) RE-ACTIVE, 2) PRO-ACTIVE EAT, and 3) PRO-ACTIVE EAT + EXERCISE.

The primary aim of the PRO-ACTIVE trial is to compare the effectiveness of PRO-ACTIVE versus RE-ACTIVE swallowing interventions among patients with HNC planned to undergo RT. We hypothesize that the combined PRO-ACTIVE therapies are more effective than RE-ACTIVE therapy; and, if so, that more intensive PRO-ACTIVE (EAT + EXERCISE) is superior to less intensive PRO-ACTIVE (EAT). Effectiveness will be measured based on reduced duration of feeding tube dependency as the primary endpoint, an outcome valued equally by patients, caregivers and clinicians.

The secondary aim of the PRO-ACTIVE trial is to compare the relative benefit or harm of swallowing therapy arms on secondary outcomes including videofluoroscopic swallowing evaluations, functional status measures, health status measures, and patient-reported outcomes.

Eligibility criteria: Inclusion Criteria:

* Adults ≥ 18 years of age diagnosed with head and neck malignancy;
* RT treatment planned for curative intent;
* Dispositioned to receive external beam radiotherapy dose ≥60 gray to bilateral fields at participating institution;
* Sufficient fluency in written English, French, Spanish or Simplified Chinese to be able to complete the study patient reported outcome questionnaires

Exclusion Criteria:

* Distant metastasis at enrollment; or
* Prior or planned total laryngectomy; or
* Moderate/severe dysphagia at enrollment per baseline videofluoroscopy DIGEST grade ≥2 (as graded per central laboratory review)
* Previously seen by speech language pathologist for swallowing therapy for the current head and neck cancer
* Diagnosis of second primary non-head and neck cancers in the thorax or the central nervous system at enrollment
* Head and neck radiotherapy for thyroid or cutaneous/skin primary tumors, regardless of neck fields

Primary outcomes:
measure: Duration of feeding tube dependence
timeFrame: Baseline - 12 months
Secondary outcomes:
measure: The MD Anderson Dysphagia Inventory (MDADI)
timeFrame: Baseline, Week 6/7, 3 months, 12 months
measure: The MD Anderson Symptom Inventory for Head and Neck Cancer (MDASI-HN)
timeFrame: Baseline, Week 2, Week 4, Week 6/7, 3 months, 12 months
measure: Dynamic Imaging Grade of Swallowing Toxicity (DIGEST)
timeFrame: Baseline, 3 months, 12 months
measure: Pharyngeal Constriction Ratio (PCR)
timeFrame: Baseline, 3 months, 12 months
measure: Penetration-Aspiration Scale (PAS)
timeFrame: Baseline, 3 months, 12 months
measure: Peak esophageal opening
timeFrame: Baseline, 3 months, 12 months
measure: Performance Status Scale Head and Neck (PSS-HN)
timeFrame: Baseline, Week 2, Week 4, Week 6/7, 3 months, 12 months
measure: Medical Outcome of Dysphagia (MOD)
timeFrame: Baseline, 3 months, 12 months
measure: Cancer Behavior Inventory (CBI-V3)
timeFrame: Baseline, 3 months, 12 months
measure: EQ-5D-5L
timeFrame: Baseline, 3 months, 12 months
measure: Medical History
timeFrame: Baseline, Week 6/7, 3 months, 12 months
measure: Pain Medications
timeFrame: Baseline; Week 6/7, 3 Month, and 12 Months
measure: Mouth Opening/Trismus
timeFrame: Baseline; 3 Month and 12 Months
measure: Hospitalization/Emergency Department (ED) Presentation
timeFrame: Baseline, Week 6/7, 3 months, 12 months
Other outcomes:
Locations:
city: Miami
country: United States
facility: University of Miami
state: Florida
city: Orlando
country: United States
facility: Orlando Health
state: Florida
city: Baltimore
country: United States
facility: Greater Baltimore Medical Center
state: Maryland
city: Boston
country: United States
facility: Boston University Medical Center
state: Massachusetts
city: Detroit
country: United States
facility: Henry Ford Health System
state: Michigan
city: New York
country: United States
facility: Memorial Sloan Kettering Cancer Center
state: New York
city: Cincinnati
country: United States
facility: University of Cincinnati
state: Ohio
city: Cleveland
country: United States
facility: Cleveland Clinic
state: Ohio
city: Houston
country: United States
facility: University of Texas MD Anderson Cancer Center
state: Texas
city: Madison
country: United States
facility: University of Wisconsin Hospitals and Clinics
state: Wisconsin
city: London
country: Canada
facility: London Health Sciences Centre
state: Ontario
city: Toronto
country: Canada
facility: University Health Network
state: Ontario
city: Montréal
country: Canada
facility: Jewish General Hospital
state: Quebec
Study officials:
affiliation: University Health Network, Toronto
name: Rosemary Martino, PhD
role: PRINCIPAL_INVESTIGATOR
affiliation: M.D. Anderson Cancer Center
name: Kate Hutcheson, PhD
role: PRINCIPAL_INVESTIGATOR
References:
citation: Krisciunas GP, Sokoloff W, Stepas K, Langmore SE. Survey of usual practice: dysphagia therapy in head and neck cancer patients. Dysphagia. 2012 Dec;27(4):538-49. doi: 10.1007/s00455-012-9404-2. Epub 2012 Mar 29.
citation: Xu B, Boero IJ, Hwang L, Le QT, Moiseenko V, Sanghvi PR, Cohen EE, Mell LK, Murphy JD. Aspiration pneumonia after concurrent chemoradiotherapy for head and neck cancer. Cancer. 2015 Apr 15;121(8):1303-11. doi: 10.1002/cncr.29207. Epub 2014 Dec 23.
citation: Hunter KU, Lee OE, Lyden TH, Haxer MJ, Feng FY, Schipper M, Worden F, Prince ME, McLean SA, Wolf GT, Bradford CR, Chepeha DB, Eisbruch A. Aspiration pneumonia after chemo-intensity-modulated radiation therapy of oropharyngeal carcinoma and its clinical and dysphagia-related predictors. Head Neck. 2014 Jan;36(1):120-5. doi: 10.1002/hed.23275. Epub 2013 Jun 1.
citation: Hutcheson KA, Bhayani MK, Beadle BM, Gold KA, Shinn EH, Lai SY, Lewin J. Eat and exercise during radiotherapy or chemoradiotherapy for pharyngeal cancers: use it or lose it. JAMA Otolaryngol Head Neck Surg. 2013 Nov;139(11):1127-34. doi: 10.1001/jamaoto.2013.4715.
citation: Setton J, Lee NY, Riaz N, Huang SH, Waldron J, O'Sullivan B, Zhang Z, Shi W, Rosenthal DI, Hutcheson KA, Garden AS. A multi-institution pooled analysis of gastrostomy tube dependence in patients with oropharyngeal cancer treated with definitive intensity-modulated radiotherapy. Cancer. 2015 Jan 15;121(2):294-301. doi: 10.1002/cncr.29022. Epub 2014 Oct 6.
citation: Mortensen HR, Jensen K, Aksglaede K, Lambertsen K, Eriksen E, Grau C. Prophylactic Swallowing Exercises in Head and Neck Cancer Radiotherapy. Dysphagia. 2015 Jun;30(3):304-14. doi: 10.1007/s00455-015-9600-y. Epub 2015 Feb 19.
citation: Ohba S, Yokoyama J, Kojima M, Fujimaki M, Anzai T, Komatsu H, Ikeda K. Significant preservation of swallowing function in chemoradiotherapy for advanced head and neck cancer by prophylactic swallowing exercise. Head Neck. 2016 Apr;38(4):517-21. doi: 10.1002/hed.23913. Epub 2015 Jun 16.
citation: van der Molen L, van Rossum MA, Rasch CR, Smeele LE, Hilgers FJ. Two-year results of a prospective preventive swallowing rehabilitation trial in patients treated with chemoradiation for advanced head and neck cancer. Eur Arch Otorhinolaryngol. 2014 May;271(5):1257-70. doi: 10.1007/s00405-013-2640-8. Epub 2013 Jul 28.
citation: Carroll WR, Locher JL, Canon CL, Bohannon IA, McColloch NL, Magnuson JS. Pretreatment swallowing exercises improve swallow function after chemoradiation. Laryngoscope. 2008 Jan;118(1):39-43. doi: 10.1097/MLG.0b013e31815659b0.
citation: Shaw SM, Flowers H, O'Sullivan B, Hope A, Liu LW, Martino R. The effect of prophylactic percutaneous endoscopic gastrostomy (PEG) tube placement on swallowing and swallow-related outcomes in patients undergoing radiotherapy for head and neck cancer: a systematic review. Dysphagia. 2015 Apr;30(2):152-75. doi: 10.1007/s00455-014-9592-z. Epub 2015 Mar 4.
citation: MD Anderson Head and Neck Cancer Symptom Working Group. Beyond mean pharyngeal constrictor dose for beam path toxicity in non-target swallowing muscles: Dose-volume correlates of chronic radiation-associated dysphagia (RAD) after oropharyngeal intensity modulated radiotherapy. Radiother Oncol. 2016 Feb;118(2):304-14. doi: 10.1016/j.radonc.2016.01.019. Epub 2016 Feb 17.
citation: Eisbruch A, Kim HM, Feng FY, Lyden TH, Haxer MJ, Feng M, Worden FP, Bradford CR, Prince ME, Moyer JS, Wolf GT, Chepeha DB, Ten Haken RK. Chemo-IMRT of oropharyngeal cancer aiming to reduce dysphagia: swallowing organs late complication probabilities and dosimetric correlates. Int J Radiat Oncol Biol Phys. 2011 Nov 1;81(3):e93-9. doi: 10.1016/j.ijrobp.2010.12.067. Epub 2011 May 17.
citation: Hutcheson KA, Lewin JS, Barringer DA, Lisec A, Gunn GB, Moore MW, Holsinger FC. Late dysphagia after radiotherapy-based treatment of head and neck cancer. Cancer. 2012 Dec 1;118(23):5793-9. doi: 10.1002/cncr.27631. Epub 2012 May 17.
citation: Rubin EB, Buehler AE, Halpern SD. States Worse Than Death Among Hospitalized Patients With Serious Illnesses. JAMA Intern Med. 2016 Oct 1;176(10):1557-1559. doi: 10.1001/jamainternmed.2016.4362. No abstract available.
citation: Siegel RL, Miller KD, Jemal A. Cancer statistics, 2016. CA Cancer J Clin. 2016 Jan-Feb;66(1):7-30. doi: 10.3322/caac.21332. Epub 2016 Jan 7.
citation: National Cancer Institute. SEER cancer statistics factsheets: Larynx cancer. http://seer.cancer.gov/statfacts/html/laryn.html. Accessed December 12, 2016.
citation: Canadian Cancer Society's Advisory Committee on Cancer Statistics. Canadian cancer statistics 2016. 2016; http://www.cancer.ca/en/cancer-information/cancer-101/canadian-cancer-statistics-publication/?region=on. Accessed December 12, 2016.
citation: Chaturvedi AK, Engels EA, Pfeiffer RM, Hernandez BY, Xiao W, Kim E, Jiang B, Goodman MT, Sibug-Saber M, Cozen W, Liu L, Lynch CF, Wentzensen N, Jordan RC, Altekruse S, Anderson WF, Rosenberg PS, Gillison ML. Human papillomavirus and rising oropharyngeal cancer incidence in the United States. J Clin Oncol. 2011 Nov 10;29(32):4294-301. doi: 10.1200/JCO.2011.36.4596. Epub 2011 Oct 3.
citation: Ang KK, Harris J, Wheeler R, Weber R, Rosenthal DI, Nguyen-Tan PF, Westra WH, Chung CH, Jordan RC, Lu C, Kim H, Axelrod R, Silverman CC, Redmond KP, Gillison ML. Human papillomavirus and survival of patients with oropharyngeal cancer. N Engl J Med. 2010 Jul 1;363(1):24-35. doi: 10.1056/NEJMoa0912217. Epub 2010 Jun 7.
citation: Weinberger PM, Yu Z, Haffty BG, Kowalski D, Harigopal M, Brandsma J, Sasaki C, Joe J, Camp RL, Rimm DL, Psyrri A. Molecular classification identifies a subset of human papillomavirus--associated oropharyngeal cancers with favorable prognosis. J Clin Oncol. 2006 Feb 10;24(5):736-47. doi: 10.1200/JCO.2004.00.3335. Epub 2006 Jan 9.
citation: Roe JW, Carding PN, Rhys-Evans PH, Newbold KL, Harrington KJ, Nutting CM. Assessment and management of dysphagia in patients with head and neck cancer who receive radiotherapy in the United Kingdom - a web-based survey. Oral Oncol. 2012 Apr;48(4):343-8. doi: 10.1016/j.oraloncology.2011.11.003. Epub 2011 Nov 29.
citation: McEwen S, Rodriguez AM, Martino R, Poon I, Dunphy C, Rios JN, Ringash J. "I didn't actually know there was such a thing as rehab": survivor, family, and clinician perceptions of rehabilitation following treatment for head and neck cancer. Support Care Cancer. 2016 Apr;24(4):1449-53. doi: 10.1007/s00520-015-3021-1. Epub 2015 Nov 18.
citation: Martino R, Beaton D, Diamant NE. Using different perspectives to generate items for a new scale measuring medical outcomes of dysphagia (MOD). J Clin Epidemiol. 2009 May;62(5):518-26. doi: 10.1016/j.jclinepi.2008.05.007. Epub 2008 Aug 22.
citation: Nund RL, Ward EC, Scarinci NA, Cartmill B, Kuipers P, Porceddu SV. Carers' experiences of dysphagia in people treated for head and neck cancer: a qualitative study. Dysphagia. 2014 Aug;29(4):450-8. doi: 10.1007/s00455-014-9527-8. Epub 2014 May 21.
citation: List MA, Mumby P, Haraf D, Siston A, Mick R, MacCracken E, Vokes E. Performance and quality of life outcome in patients completing concomitant chemoradiotherapy protocols for head and neck cancer. Qual Life Res. 1997 Apr;6(3):274-84. doi: 10.1023/a:1026419023481.
citation: Chen AY, Frankowski R, Bishop-Leone J, Hebert T, Leyk S, Lewin J, Goepfert H. The development and validation of a dysphagia-specific quality-of-life questionnaire for patients with head and neck cancer: the M. D. Anderson dysphagia inventory. Arch Otolaryngol Head Neck Surg. 2001 Jul;127(7):870-6.
citation: Rosenthal DI, Mendoza TR, Chambers MS, Asper JA, Gning I, Kies MS, Weber RS, Lewin JS, Garden AS, Ang KK, S Wang X, Cleeland CS. Measuring head and neck cancer symptom burden: the development and validation of the M. D. Anderson symptom inventory, head and neck module. Head Neck. 2007 Oct;29(10):923-31. doi: 10.1002/hed.20602.
citation: Cleeland CS, Mendoza TR, Wang XS, Chou C, Harle MT, Morrissey M, Engstrom MC. Assessing symptom distress in cancer patients: the M.D. Anderson Symptom Inventory. Cancer. 2000 Oct 1;89(7):1634-46. doi: 10.1002/1097-0142(20001001)89:73.0.co;2-v.
citation: Martino R, Ringash J, Durkin L, Greco E, Huang SH, Xu W, Longo CJ. Feasibility of assessing patient health benefits and incurred costs resulting from early dysphagia intervention during and immediately after chemoradiotherapy for head-and-neck cancer. Curr Oncol. 2017 Dec;24(6):e466-e476. doi: 10.3747/co.24.3543. Epub 2017 Dec 20.
citation: Greco E, Simic T, Ringash J, Tomlinson G, Inamoto Y, Martino R. Dysphagia Treatment for Patients With Head and Neck Cancer Undergoing Radiation Therapy: A Meta-analysis Review. Int J Radiat Oncol Biol Phys. 2018 Jun 1;101(2):421-444. doi: 10.1016/j.ijrobp.2018.01.097. Epub 2018 Feb 6.
citation: Martino R, Fitch MI, Fuller CD, Hope A, Krisciunas G, Langmore SE, Lazarus C, Macdonald CL, McCulloch T, Mills G, Palma DA, Pytynia K, Ringash J, Sultanem K, Theurer J, Thorpe KE, Hutcheson K. The PRO-ACTIVE trial protocol: a randomized study comparing the effectiveness of PROphylACTic swallow InterVEntion for patients receiving radiotherapy for head and neck cancer. BMC Cancer. 2021 Oct 13;21(1):1100. doi: 10.1186/s12885-021-08826-0.