Dysphagia Risk Stratification in Head and Neck Cancer via Two-Stage PRO-Clinical Stacking
Authors: Siyuan Zhao, Eric Ababio Anyimadu, Zachary G. Brumm, Yue Ma, Clifton David Fuller, Xinhua Zhang, G. Elisabeta Marai, Guadalupe Canahuate
Organizations: Department of Computer Science, University of Illinois Chicago, Chicago, IL, USA · Electrical and Computer Engineering, University of Iowa, Iowa City, IA, USA · Department of Otolaryngology, University of California, San Francisco, San Francisco, CA, USA · Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
Abstract
Dysphagia is a debilitating late effect of head and neck cancer (HNC) treatment, yet timely identification of at-risk patients remains challenging in survivorship care. Definitive assessment relies on videofluoroscopic imaging, as captured by the Dynamic Imaging Grade of Swallowing Toxicity (CTCAE-DIGEST), which, while validated, requires specialized equipment, trained personnel, and significant patient burden, limiting its routine use in surveillance. Patient-reported outcomes (PROs), by contrast, are low-cost, scalable, and easily collected at any clinical encounter, making them an attractive alternative signal for identifying patients who may warrant further evaluation. However, a clear clinical framework for translating PRO responses into actionable interventions is still evolving. In particular, uncertainty remains regarding when a patient's self-reported symptom burden should prompt escalation of care. This study addresses this gap by formulating a single-visit PRO-clinical prediction framework and introducing a clinically interpretable two-stage stacking model to predict swallowing impairment risk using PRO responses and structured clinical variables, without requiring videofluoroscopic imaging. The proposed framework quantifies the independent contributions of patient-reported symptoms and clinical factors within a unified and interpretable risk assessment model. Our findings demonstrate that individual MDADI responses contain predictive information beyond that captured by composite or global summary scores, while interpretability analyses reveal symptom patterns and clinical risk factors associated with swallowing impairment. Together, these results support the use of structured PRO-clinical integration as a practical, imaging-free approach for dysphagia risk stratification in HNC survivorship.
Background: Early prediction of distant metastasis (DM) risk in head and neck cancer (HNC) can enable timely interventions that may improve treatment outcomes. Many current machine learning methods rely on prior knowledge of the region of interest such as tumor segmentations, which require expert knowledge, is time-consuming and introduces user-dependent variability. Medical image-based foundation models have recently been developed for specific imaging modalities to streamline down-stream prediction tasks by extracting modality-relevant features. Purpose: In this study, we evaluate the effectiveness of using a foundation model as the feature extractor to predict DM risk in HNC patients and compare its performance with traditional approaches that require prior knowledge on the regions of interest. Methods: Preoperative CT images of 2327 patients from the RADCURE dataset were used. Three features-sets were created including radiomics, deep-learning based features, and CT Foundation derived features. The feature-sets were used individually in a multi-layer perceptron (MLP) to predict DM risk. Results: The model using CT Foundation embeddings outperformed the radiomics and deep learning-based models, achieving a Receiver Operating Characteristic Area Under the Curve (AUC) of 0.791, compared to AUC values of 0.772 and 0.753 for the radiomics and deep learning-based models, respectively. The CT Foundation based model had similar performance to a model that combined the use of radiomics and deep learning-based features that achieved an AUC of 0.794. Conclusions: Features based on foundation models offer a promising alternative to traditional radiomics while reducing the need for domain expertise and extensively annotated datasets. Their minimal preprocessing requirements also make them a more accessible and scalable option.
For head and neck cancer (HNC) patients, prognostic outcome prediction can support personalized treatment strategy selection. Improving prediction performance of HNC outcomes has been extensively explored by using advanced artificial intelligence (AI) techniques on PET/CT data. However, the interpretability of AI remains a critical obstacle for its clinical adoption. Unlike previous HNC studies that empirically selected explainable AI (XAI) techniques, we are the first to comprehensively evaluate and rank 13 XAI methods across 24 metrics, covering faithfulness, robustness, complexity and plausibility. Experimental results on the multi-center HECKTOR challenge dataset show large variations across evaluation aspects among different XAI methods, with Integrated Gradients (IG) and DeepLIFT (DL) consistently obtained high rankings for faithfulness, complexity and plausibility. This work highlights the importance of comprehensive XAI method evaluation and can be extended to other medical imaging tasks.
Baoqiang Ma, Djennifer K. Madzia-Madzou, Rosa C. J. Kraaijveld +1
This work investigates the interpretability of a Wav2Vec 2.0based speech intelligibility assessment model for oral and oropharyngeal cancer patients through canonical correlation analysis. By measuring the correlation between the model embeddings and eGeMAPS low-level descriptors (LLDs) as an interpretable reference, we analyze how acoustic information is encoded across the model layers. The analysis is conducted at two levels: individual LLDs layer-wise, and group-level: prosodic, spectral, and voice quality. Results show that the learned representations are most strongly correlated with spectral and prosodic features, with the first MFCC coefficient yielding the highest correlations across all layers. At the group level, spectral and prosodic groups achieve correlations of 0.77 and 0.71 respectively, while voice quality reaches 0.65. Beyond model interpretability, this work also offers practical guidance on acoustic feature selection for pathological speech assessment.