Prognostic value of baseline modified barium swallow for perioperative dysphagia in oropharyngeal cancer: Secondary analysis of ECOG-ACRIN E3311

Background Transoral surgery (TOS) for HPV-related oropharyngeal cancer (OPC) demonstrated excellent oncologic outcomes, but early postoperative dysphagia remains common and clinically consequential. Identifying patients at increased risk before surgery is critical to guide early supportive care. We examined whether baseline swallowing impairment assessed by modified barium swallow (MBS) predicts early post-TOS dysphagia. Methods In this retrospective, exploratory secondary analysis of a selected subset of Phase II ECOG-ACRIN E3311 trial, 89 patients with paired baseline and post-TOS MBS (before adjuvant therapy) underwent blinded central review using the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST). The primary outcome was moderate-to-severe post-TOS dysphagia (DIGEST ≥ 2); secondary outcomes were any dysphagia (DIGEST ≥ 1) and worsening DIGEST. The prognostic value of baseline DIGEST ≥ 1 was assessed with Firth penalized logistic regression adjusted for age, sex, race, T/N stage, and primary site. Results At baseline, 80% had no dysphagia and 17% had mild dysphagia (DIGEST = 1); moderate-to-severe impairment was rare (3%). Postoperatively, 45 patients (51%) worsened by ≥ 1 DIGEST grade, and 16% developed moderate-to-severe dysphagia. Baseline DIGEST ≥ 1 was independently associated with post-TOS DIGEST ≥ 2 (adjusted OR 4.69; 95% CI 1.32–16.64), with an absolute risk difference of 23.8% (95% CI 2.6–48.8%) and moderate optimism-corrected discrimination (AUC 0.75; 95% CI 0.59–0.88). Conclusions Baseline mild swallowing impairment identified on MBS was associated with high-grade acute postoperative dysphagia following TOS for HPV-related OPC. Preoperative imaging-based swallowing assessment before surgery may help risk-stratify patients for targeted pre-habilitation, nutritional support, and early postoperative swallowing imaging in 1 in 5 patients to mitigate postoperative swallowing morbidity.