Risk Factors of Adverse Voice and Speech Effects of Oropharyngeal Cancer Identified Through Patient Reported Surveys

Patients with long-term oropharyngeal cancer were surveyed regarding factors leading to severe effects on voice and speech.

Worse voice and speech adverse effects in patients with oropharyngeal cancer (OPC) were associated with high radiotherapy doses, multimodality therapy and continuation of smoking among other demographic factors, according to dating from a retrospective cohort study published in JAMA Otolaryngology-Head & Neck Surgery.

The study examined 881 OPC survivors of White, Black, and Hispanic ethnicity and of whom 12.8% had already reported moderate to severe voice and speech scores. Risk factors such as Black race, Hispanic ethnicity, current cigarette smoking at the time of the survey, and induction and concurrent chemotherapy were identified.

“To our knowledge, this study is the first to identify demographic and treatment-related risk factors that are associated with moderate to severe voice and speech symptoms,” wrote the investigators from The University of Texas MD Anderson Cancer Center in Houston.

The research team distributed surveys to patients who were treated between January 2000 and December 2013; this study took place between September 2015 and July 2016. Survivors (n = 1740) were contacted, resulting in a 56% participation rate. Only those who had been disease free for more than 1 year, were over 18, and who spoke English were permitted onto the study.

Investigators found longer survival time (odds ratio [OR], 1.17; 95% CI, 1.06-1.30), increasing radiation dose (OR, 1.16; 95% CI, 1.00-1.34), Black race (OR, 3.90; 95% CI, 1.02-14.89), Hispanic ethnicity (OR, 3.74; 95% CI, 1.50-9.35), current cigarette use (OR, 3.98; 95% CI, 1.56-10.18), receipt of induction and concurrent chemotherapy (OR, 1.94; 95% CI, 1.06-3.57), and late (OR, 7.11; 95% CI, 3.08-16.41) and baseline lower cranial neuropathy (LCNP; OR, 8.70; 95% CI, 3.01-25.13) were all associated with moderate-to-severe voice and speech effects.

The MD Anderson Symptom Inventory Head and Neck Cancer Module (MDASI-HN) survey was used and included 28 items: 13 items common across tumor types, 9 specific to head and neck cancer, and 6 items related to daily life. The head and neck portion included questions regarding difficulties with voice and speech, dry mouth, trouble chewing and swallowing, and any mucus in the mouth among others.

Those who identified as Black and Hispanic reported moderate-to-severe speech symptoms at rates of 31.2% and 27.3%, respectively. Of the patients with induction and concurrent chemotherapy, 20.6% reported effects considered to be moderate or severe.

By multivariate logistic regression analysis, increasing survival time (OR, 1.17; 95% CI, 1.06-1.30), higher radiotherapy dose (OR, 1.16; 95% CI, 1.00-1.34), Black race (OR, 3.90; 95% CI, 1.02-14.89), Hispanic ethnicity (OR, 3.74; 95% CI, 1.50-9.35), cigarette use (OR, 3.98; 95% CI, 1.56-10.18), combined treatment with induction and concurrent chemotherapy (OR, 1.94; 95% CI, 1.06-3.57), late LCNP (OR, 7.11; 95% CI, 3.08-16.41), and baseline LCNP (OR, 8.70; 95% CI, 3.01-25.13) were risk factors for moderate-to-severe speech symptoms.

Notably, the intensity modulated radiotherapy–split-field (IMRT-SF) treatment technique was found to lower the likelihood of symptoms (OR, 0.31; 95% CI, 0.12-0.80). The investigators noted that a radiotherapy dose increase by even 1 Gy may lead to a 17% increase of moderate-to-severe voice/speech effects.

Some limitations noted by the investigators included that a single question from the MDASI-HN was used to determine the level of voice/speech difficulty. There was also no availability of patients’ voice and speech scores prior to treatment.

“Consistent with other studies, we found that survivors of OPC who received more modern conformal RT regimens, such as IMRT-SF, were less likely than survivors who received older 3-dimensional conformal RT regimens to report moderate to severe voice and speech scores,” said the investigators.

The investigators concluded that preserving quality of life for long-term survivors with these factors in mind will likely require shared decision making regarding prioritization of therapy goals and lifestyle changes.


Aggarwal P, Hutcheson KA, Garden AS, et al. Association of Risk Factors With Patient-Reported Voice and Speech Symptoms Among Long-term Survivors of Oropharyngeal Cancer. JAMA Otolaryngol Head Neck Surg. May 6, 2021. doi:10.1001/jamaoto.2021.0698