Patient reported swallowing outcome after treatment for head and neck cancer

The aim of this study is to evaluate feasibility, reliability, and validity of the SWAL-QOL (a questionnaire on swallowing problems in daily life), and defining sample size calculations and a clinically relevant cut-off score.

102 patients treated for cancer of the oral cavity or pharynx and 111 healthy subjects completed the SWAL-QOL and the EORTC H&N35 questionnaire. A randomly selected subset of patients (n=29) completed the SWAL-QOL twice to asses test-retest stability. For the patient sample, data on tumor site (oral or oropharyngeal) and stage (I-IV), treatment modality (surgery, radiation, surgery + radiation, chemoradiation), and presence of a PEG tube were abstracted from medical records.

Reliability of the SWAL-QOL was high with high internal consistency and test-retest stability. Feasibility was good, except for patients with tube feeding, of whom 38% did not complete the questionnaire (versus 9% of those with oral feeding).

A cut-off score of 14 points (or higher) was defined regarding the total SWAL-QOL score to identify patients with swallowing problems with 94% sensitivity and 84% specificity.

A difference score of 12 points or more is proposed to be used in study designs with multiple groups. It can be concluded that the SWAL-QOL is a feasible, reliable, and valid questionnaire to assess patients’ swallowing impairment. It can be used in future comparative studies for oral and oropharyngeal cancer and in clinical practice to identify patients in need of further diagnostics and/or swallowing rehabilitation services.

The SWAL-QOL is used in clinical practice and in other research projects. In a study for instance the SWAL-QOL was used regarding on patient reported swallowing outcome among 55 patients (response rate 85%) who had been treated with chemoradiation for a head and neck tumor, at least 6 months after the start of treatment. 90% of the patients had a deviant total score on the SWAL-QoL-NL (15 or higher). The scores on the SWAL-QoL-NL were high, irrespective of the months after treatment.

AmsterdamUMC, location VUmc, department of Otolaryngology – Head & Neck Surgery.


  • Rinkel RN, Verdonck-de Leeuw IM, Doornaert P, Buter J, de Bree R, Langendijk JA, Aaronson NK, Leemans CR. Prevalence of swallowing and speech problems in daily life after chemoradiation for head and neck cancer based on cut-off scores of the patient-reported outcome measures SWAL-QOL and SHI. Eur Arch Otorhinolaryngol. 2016 Jul;273(7):1849-55.
  • Rinkel RN, Verdonck-de Leeuw IM, de Bree R, Aaronson NK, Leemans CR. Validity of patient-reported swallowing and speech outcomes in relation to objectively measured oral function among patients treated for oral or oropharyngeal cancer. Dysphagia. 2015 Apr;30(2):196-204.
  • Rinkel RN, Verdonck-de Leeuw IM, van den Brakel N, de Bree R, Eerenstein SE, Aaronson N, Leemans CR. Patient-reported symptom questionnaires in laryngeal cancer: voice, speech and swallowing. Oral Oncol. 2014 Aug;50(8):759-64.
  • Cnossen IC, de Bree R, Rinkel RN, Eerenstein SE, Rietveld DH, Doornaert P, Buter J, Langendijk JA, Leemans CR, Verdonck-de Leeuw IM. Computerized monitoring of patient-reported speech and swallowing problems in head and neck cancer patients in clinical practice. Support Care Cancer. 2012 Nov;20(11):2925-31.
  • Rinkel RN, Verdonck-de Leeuw IM, Langendijk JA, van Reij EJ, Aaronson NK, Leemans CR. The psychometric and clinical validity of the SWAL-QOL questionnaire in evaluating swallowing problems experienced by patients with oral and oropharyngeal cancer. Oral Oncol. 2009 Aug;45(8):e67-71.

For questions, please contact Rico N.P.M. Rinkel, MD, ENT-specialist, laryngologist via s.biemans@amsterdamumc.nl