Supportive Care in Cancer

https://doi.org/10.1007/s00520-021-06068-1

ORIGINAL ARTICLE

Impact of rehabilitation treatment on swallowing during adjuvant

radiotherapy following surgery in patients with oral
and oropharyngeal cancer
Nao Hashida 1 & Hironari Tamiya 1 & Takashi Fujii 2

Received: 11 June 2020 / Accepted: 9 February 2021

# The Author(s), under exclusive licence to Springer-Verlag GmbH, DE part of Springer Nature 2021

Abstract
Background Patients with advanced oral or oropharyngeal cancer sometimes require surgery and adjuvant postoperative radio-
therapy (PORT), which may cause dysphagia. However, the efficacy of rehabilitation treatment for PORT-induced dysphagia
remains unclear. This study aimed to determine whether rehabilitation treatment during PORT after surgery is effective for
dysphagia.
Methods We retrospectively studied 55 patients with oral or oropharyngeal cancer who received PORT. Of these, 25 received
rehabilitation treatment for swallowing during PORT. The Functional Oral Intake Scale (FOIS) score at 6 months after treatment
was used as the swallowing outcome. We performed multivariate linear regression and stratified analyses using the FOIS score
(poor oral intake group: FOIS score <5, good oral intake group: FOIS score ≧5) before PORT.
Results The median (interquartile range) FOIS scores at 6 months post-PORT were 6 (5–6) and 6 (4–7) in the non-rehabilitation
and rehabilitation groups, respectively. Multivariate linear regression revealed that rehabilitation treatment was a significant
independent factor for a better FOIS score. Stratified analysis of the changes in the FOIS score from pre-PORT values to those
obtained 6 months after treatment showed a significant difference in the good oral intake group between the rehabilitation and
non-rehabilitation groups. There was no significant difference in the FOIS score from pre-PORT values to those obtained 6
months after treatment between the rehabilitation and non-rehabilitation groups in the poor oral intake group.
Conclusion Rehabilitation treatment during PORT may achieve better swallowing outcomes in patients with advanced oral or
oropharyngeal cancer.

Keywords Dysphagia . Head and neck cancer . Radiotherapy . Rehabilitation treatment

Introduction organs for communication, swallowing, and breathing, the

Head and neck cancer (HNC), which consists mainly of squa-
mous cell carcinoma of the mouth, pharynx, and larynx, is
increasingly prevalent worldwide. Although the number of
new HNC diagnoses was approximately 700,000 in 2005,
more than 900,000 new patients were diagnosed with HNC
in 2015 [1]. Since the head and neck region contains important
* Nao Hashida
hashida1223@gmail.com
1
Department of Rehabilitation, Osaka International Cancer Institute,
3-1-69, Otemae, Chuo-ku, Osaka City 541-8567, Japan
2
Department of Head and Neck Surgery, Osaka International Cancer
Institute, Osaka City, Japan
treatment of HNC requires a balance between treatment effi-
cacy and side effects. Treatment for HNC, including surgery,
radiotherapy (RT), and chemoradiotherapy (CRT), often
causes dysphagia, which may affect the quality of life
(QOL) or lead to a poor prognosis [2, 3]. Patients with ad-
vanced HNC, especially oral cancer or oropharyngeal cancer,
and a high risk of recurrence sometimes require surgery plus
adjuvant postoperative radiotherapy (PORT) or CRT to im-
prove survival rate [4]. However, surgery and PORT may
result in poor swallowing function, including aspiration, oral
and pharyngeal residue, chewing dysfunction, and a high risk
of developing malnutrition [5–7]. Swallowing dysfunction af-
ter surgery and PORT may necessitate diet modification or
restriction of food intake, leading to poor QOL [8].
Rehabilitation treatment for patients with swallowing dys-
function after HNC treatment is often provided by a multi-

disciplinary team including speech-language pathologists
(SLPs) [2]. Treatment of dysphagia includes nutritional as-
sessment and management, assessment and recommendation
of appropriate food preparation techniques, and assessment of
the risk of aspiration as well as therapeutic rehabilitation and
adapted swallowing techniques [3, 9]. Recent reports have
detailed the impact of rehabilitation treatment on dysphagia
caused by RT/CRT [10–12]. However, the effect of rehabili-
tation treatment for HNC patients during PORT remains
unclear.
Therefore, this study aimed to determine whether rehabili-
tation treatment that includes exercises, assessment of dyspha-
gia and nutritional status, nutritional management, and recom-
mendations of food texture during PORT is useful for patients
with dysphagia who underwent surgery and PORT for oral or
oropharyngeal cancer.
Materials and methods
Patients
We conducted a retrospective cohort study of patients who
underwent surgery and PORT for oral or oropharyngeal can-
cer in the Department of Head and Neck Surgery at Osaka
International Cancer Institute between 1 January 2014 and 31
December 2019. Patients were eligible if they were over 20
years old, had completed a full dose (≥50Gy) of PORT, and
required tube feeding after surgery. All patients were provided
with rehabilitation treatment by SLPs after surgery for HNC
during hospitalization; some were also provided with rehabil-
itation treatment during adjuvant PORT. We excluded pa-
tients with a history of dysphagia induced by prior treatment
for HNC, cerebrovascular disease, and Parkinson’s disease.
Patients who underwent surgeries that do not typically affect
swallowing (i.e., neck dissection without primary tumor re-
section or endoscopic submucosal dissection), those who
underwent total laryngectomy, and those who refused to par-
ticipate were also excluded from the study.
Age, sex, tumor location, tumor size (T stage), lymph node
stage, surgical procedure, dentition (Eichner Index (EI) clas-
sification A or B/C), radiotherapy procedures (dose, fraction-
ation, presence of chemotherapy with radiotherapy), treatment
plan (three-dimensional conformal radiation therapy,
intensity-modulated radiotherapy, or volumetric modulated
arc therapy), and radiation field (unilateral or bilateral irradia-
tion, presence of the irradiation to the pharyngeal constrictors
muscles and/or the base of the tongue) were recorded. This
study was approved by the ethics committee of the Osaka
International Cancer Institute (approval number 20056). The
committee waived the need for informed consent in view of
the retrospective nature of the study. Instead, an opt-out tech-
nique through an announcement on the hospital webpage was
Support Care Cancer
used to provide an opportunity for patients to withdraw from
the study. General consent regarding the possibility of using
their clinical data was obtained from all patients at the time of
operation.
Assessments of swallowing outcome
As the primary outcome, swallowing outcome was assessed
using the Functional Oral Intake Scale (FOIS) score, which is
a seven-point scale comprising level 1 (nothing by mouth),
level 2–3 (tube depending), level 4 (total oral intake with a
single consistency), level 5 (total oral diet with multiple con-
sistencies but requiring special preparation or compensations),
level6 (total oral diet with multiple consistencies without spe-
cial preparation, but with specific food limitations), and level
7 (total oral diet with no restrictions) [13]. The FOIS scores
were assessed by a SLP. Although the FOIS score has no
direct correlation with oropharyngeal dysphagia, it reflects
the swallowing outcome of patients who undergo surgery
and PORT for oral or oropharyngeal cancer, which can cause
difficulty with oral transport or mastication [14]. In addition,
among Japanese HNC patients, the FOIS score is correlated
with the MD Anderson Dysphagia Inventory, a validated and
reliable self-completion questionnaire for assessing QOL in-
duced by dysphagia in patients with HNC [15, 16]. We
assessed the FOIS score before and 6 months after PORT.
Swallowing rehabilitation treatment
The purpose of the swallowing rehabilitation treatment is to
maintain the range of motion of the oral, pharyngeal, and
laryngeal structures involved in swallowing and to counteract
the radiation-induced fibrosis that leads to a restricted range of
motion and dysphagia.
Swallowing rehabilitation treatment includes swallowing
exercises, assessment of dysphagia and nutritional status,
management and recommendations of food texture, and en-
couragement of patients to continue oral intake as much as
possible. The swallowing exercises consisted of neck and oral
range of motion exercises, lingual resistance exercises, breath-
ing training, the shaker maneuver, and the Mendelsohn ma-
neuver. The patients were taught the swallowing exercises and
the rest of the interventions by SLPs and instructed to perform
them at home. They were given the swallowing exercises face
to face at the hospital at least once a week to assist with
compliance with therapy.
Statistics analysis
The patients were not randomized owing to the retrospective
nature of the study. The rehabilitation and non-rehabilitation
groups differed in variables influencing pre-PORT
swallowing ability, such as tumor size, tumor site, and
Support Care Cancer
swallowing ability. Multivariate linear regression analysis was
performed and adjusted for age, pre-PORT FOIS score, tumor
site (oral cavity or oropharynx) (model 1), model 1 with ad-
justment for tumor size (model 2), and model 1 adjusted for
the presence of chemotherapy (model 3) was used to assess
the effect of rehabilitation during PORT for the FOIS score at
6 months post-PORT.
We also performed post hoc stratified analysis of the changes
in the FOIS score from the values obtained before PORT to those
obtained 6 months after PORT using a study group (poor oral
intake group: FOIS score <5, good oral intake group: FOIS score
≥5) to assess whether the impact of rehabilitation varied between
patients with poor and good baseline swallowing ability.
Parametric data are presented as mean ± standard deviation,
non-parametric data are shown as median and interquartile range
(IQR), and categorical data are shown as percentages. Fisher’s
exact test and the Mann-Whitney U-test were used to examine
rehabilitation treatment-dependent differences. P values of less
than 0.05 were considered statistically significant.
All statistical analyses were performed using EZR (Saitama
Medical Center, Jichi Medical University, Saitama, Japan), a
graphical user interface for R (The R Foundation for Statistical
Computing, Vienna, Austria) [17]. More precisely, it is a mod-
ified version of R Commander that was designed to add sta-
tistical functions frequently used in biostatistics.
Results
A total of 92 patients with oral or oropharyngeal cancer met
the inclusion criteria in this study. Of the 92 patients, 37 were
excluded from the study because of death, recurrence, or loss
to follow-up (Fig. 1).
Table 1 compares the patient characteristics between the
groups. The mean patient age was 61 ± 11 and 61 ± 14 years,
male patients were 18 and 18, while the median pre-PORT FOIS
score was 5 (5–6) and 4 (3–5) in the non-rehabilitation and re-
habilitation groups, respectively. All patients were Asian.
The median FOIS score at 6 months post-PORT was 6 (5–
6) and 6 (4–7) in the non-rehabilitation and rehabilitation
groups, respectively. Table 2 shows the results of the multi-
variate linear regression of the FOIS score at 6 months post-
PORT. In the three models, the rehabilitation group was an
independent positive factor for FOIS score at 6 months after
PORT (model 1: coefficient, 0.56, 95% confidence interval
(CI), 0.02 to 1.10, P = 0.042; model 2: coefficient, 0.54,
95% CI, 0.01 to 1.07, P = 0.048; model 3: coefficient, 0.56,
95% CI, 0.02 to 1.11, P = 0.042).
Table 3 shows the results of the stratified analysis of the
changes in the FOIS score. In the good oral intake group, there
was a significant difference between the rehabilitation and
non-rehabilitation groups. However, there was no significant
difference in the poor oral intake group.
Discussion
This retrospective cohort study included patients who
underwent surgery and PORT for oral or oropharyngeal can-
cer and aimed to determine whether dysphagia rehabilitation
during PORT leads to better swallowing outcomes. There
were two important findings of this study. First, rehabilitation
treatment for swallowing during PORT is likely to lead to a
positive swallowing outcome. Second, the swallowing func-
tion might improve from the beginning of PORT (after sur-
gery) to 6 months post-PORT.
The results showed that rehabilitation treatment during
PORT may achieve better swallowing outcomes. In patients
who undergo RT/CRT, dysphagia may occur due to poor
retraction of the base of the tongue, poor epiglottic reflection,
reduced laryngeal elevation, delayed pharyngeal transit, and/
or poor coordination of swallowing muscles [18]. In patients
who undergo surgery plus PORT, PORT has an additional
negative impact on swallowing function by increasing fibrosis
of the irradiated head and neck tissues as well as surgical
influence [19]. On the other hand, in a randomized clinical
trial, swallowing exercises during CRT for HNC affect
swallowing ability and muscle maintenance [10]. In addition,
in patients who underwent surgery plus adjuvant RT/CRT,
swallowing exercises may have enabled the ingestion of solid
foods compared with the control group [20]. In a study using
both videofluorography and fiberoptic endoscopic evaluation
of swallowing, patients had worse penetration aspiration
scores and pharyngeal residue scores in solid bolus
swallowing after RT for HNC. This may be due to a reduction
in the posterior movement of the tongue and pharyngeal con-
traction [21]. Therefore, swallowing exercises during PORT
may contribute to preventing swallowing impairment. The
mechanism underlying the impact of swallowing exercise on
swallowing function remains elusive. However, there are
some reports on the effect of swallowing exercise on
swallowing function in patients who received CRT [22].
Carroll et al. reported that in patients who received CRT for
HNC, swallowing exercise improved the tongue base to pos-
terior pharyngeal wall approximation and led to better epiglot-
tic inversion while Carnaby-Mann et al. reported that the
swallowing exercise called pharyngocise contributed to
preventing swallowing muscle atrophy [10, 22]. Moreover,
the effect of oral exercise on dry mouth was reported [23].
Since dry mouth has a negative impact on swallowing func-
tion after RT, swallowing exercise may contribute to dry
mouth and swallowing function. Therefore, rehabilitation
treatment including swallowing exercises during PORT is
likely to have a positive impact on swallowing ability.
The post hoc stratified analysis showed a significant differ-
ence between the rehabilitation and non-rehabilitation sub-
groups in the good oral intake group; however, there was no
significant difference in the poor oral intake group. There was

Fig. 1 Flowchart of the cohort
a possibility that compared with those with good pre-PORT
swallowing function, patients with worse pre-PORT
swallowing function tended to undergo surgery that was more
likely to affect swallowing function. Patients who undergo
wide resection of oral or oropharyngeal cancer have a high
risk of chewing or transportation of bolus, which causes lim-
ited food texture and a low FOIS score [2, 6]. Therefore, the
impact of rehabilitation during PORT may be smaller in the
poor oral intake group than in the good oral intake group. In
contrast, most patients in the good oral intake group
underwent rehabilitation, but most patients in the poor oral
intake group did not undergo rehabilitation and the pre-
PORT FOIS score was 5 (5–6) and 4 (3–5) in the non-
rehabilitation and rehabilitation groups, respectively. One
possible explanation is that patients with a poor oral intake
ability might have had more hope of rehabilitation. This result
shows that rehabilitation treatment is needed for better
swallowing function after PORT despite a good pre-PORT
swallowing function.
Comprehensive intervention, which includes early
swallowing exercise during PORT as well as nutritional manage-
ment and food recommendation, was likely to have a positive
impact on the swallowing ability. Within 4 to 5 weeks of starting
RT, patients suffer from mucositis, pain, copious mucous pro-
duction, xerostomia, and edema of the soft tissues, which may
cause aspiration, malnutrition, and feeding tube dependency
[11]. Side effects, especially pain, make it difficult for patients
to perform swallowing exercises [24]. As such, starting rehabil-
itation treatment early during PORT when patients do not have
pain is likely to lead to superior base of the tongue retraction,
epiglottic inversion, and muscle maintenance resulting in im-
proved swallowing function [25, 26]. Moreover, our
Support Care Cancer
rehabilitation treatment included the assessment of dysphagia
and nutritional status, food texture management and recommen-
dations, and swallowing exercises. Poor swallowing ability
resulting from RT/CRT-induced malnutrition requires rehabilita-
tion and nutritional management [7, 18, 27]. In addition, eating
orally as much as possible during RT/CRT for HNC benefits
patients’ swallowing function owing to the continuous use of
the swallowing musculature [25, 28]. There is also a report that
recommended swallowing of maximal tolerated volumes as a
swallowing exercise during PORT [26]. Dysphagia after PORT
was attributed to various factors including prior surgery,
swallowing musculature fibrosis, and malnutrition. Although
continuing swallowing exercises for pain may be difficult, a
comprehensive approach may help prevent poor swallowing
function.
The results also suggested that the swallowing outcome
assessed by the FOIS score improved after cancer treatment,
including surgery and PORT. It is well known that RT/CRT
may worsen swallowing function [2]. However, the
swallowing outcomes evaluated by the FOIS score were better
at 6 months post-PORT (6 [5–6] and 6 [4–7]) in the non-
rehabilitation and rehabilitation groups, respectively than at
pre-PORT (5 [5–6] and 4 [3–5]) in the non-rehabilitation
and rehabilitation groups, respectively. PORT is reportedly a
factor of poor swallowing function at 1 year after treatment,
and patients who received PORT demonstrated only slight
swallowing improvements [29, 30]. On the other hand,
Lazarus et al. reported that, in patients with oral or oropharyn-
geal cancer, the swallowing function and tongue strength were
reduced after CRT but improved at 6 and 12 months after
CRT [31]. In the present study, swallowing ability was im-
proved in patients who had dysphagia due to surgery and/or
Support Care Cancer

Table 1 Patients’ characteristics

Non-rehabilitation Rehabilitation
(n = 30) (n = 25)

Male 18 (60.0) 18 (72.0)

Female 12 (40.0) 7 (28.0)
Age (mean ± SD) 61.3 ± 11.4 61.9 ± 13.9
Primary site
Oral cavity 23 (76.7) 20 (84.0)
Tongue 13 (43.3) 15 (60.0)
Lower gingiva 4 (13.3) 1 ( 4.0)
Floor of mouth 2 ( 6.7) 1 ( 4.0)
Buccal mucosa 3 (10.0) 2 ( 8.0)
Retromolar trigone 1 ( 3.3) 1 ( 4.0)
Oropharynx 7 (23.3) 5 (20.0)
Tonsil 2 ( 6.7) 4 (16.0)
Base of the tongue 1 ( 3.3) 0 ( 0.0)
Others 4 (13.3) 1 ( 4.0)
T stage
T1 1 ( 3.3) 0 ( 0.0)
T2 13 (43.3) 6 (24.0)
T3 4 (13.3) 10 (40.0)
T4 12 (40.0) 9 (36.0)
N stage
N0 11 (36.7) 2 ( 8.0)
N1 3 (10.0) 0 ( 0.0)
N2 15 (50.0) 18 (72.0)
N3 1 ( 3.3) 5 (20.0)
Surgery
Oral cavity resection without reconstruction 1 ( 3.3) 1 ( 4.0)
Partial glossectomy 0 (0.0) 1 ( 4.0)
Others 1 ( 3.3) 0 (0.0)
Oral cavity resection with reconstruction 17 (56.7) 17 (68.0)
Partial glossectomy 1 ( 3.3) 0 ( 0.0)
Hemiglossectomy 5 (16.7) 7 (28.0)
Subtotal glossectomy 6 (20.0) 7 (28.0)
Total glossectomy 1 ( 3.3) 1 ( 4.0)
Others 4 (13.3) 2 ( 8.0)
Segmental mandibulectomy with reconstruction 3 (10.0) 1 ( 4.0)
Segmental mandibulectomy without reconstruction 2 ( 6.7) 1 ( 4.0)
Oropharynx resection without reconstruction 1 ( 3.3) 0 ( 0.0)
Oropharynx resection with reconstruction 6 (20.0) 5 (20.0)
Tonsilectomy 2 ( 6.7) 4 (16.0)
Others 4 (13.3) 1 ( 4.0)
Eichner Index
A 15 (50.0) 10 (40.0)
B/C 15 (50.0) 15 (60.0)
PORT procedures
Dose (median [IQR]) 66 [59.4, 66] 66 [66, 66]
Fractionation 33 33
Presence of chemotherapy
Radiotherapy alone 14 (46.7) 11 (44.0)
 Support Care Cancer

Table 1 (continued)

Non-rehabilitation Rehabilitation
(n = 30) (n = 25)

Chemo-radio therapy 16 (53.3) 14 (56.0)

Treatment plan
VMAT 30 (100.0) 25 (100.0)
Radiation field
Pharyngeal constrictors muscles and/or base of the tongue 18 (60.0) 21 (84.0)
Unilateral irradiation 21 (70.0) 15 (60.0)
Bilateral irradiation 9 (30.0) 10 (40.0)
FOIS before PORT (median [IQR]) 5.00 [5.00, 6.00] 4.00 [3.00, 5.00]

SD, standard deviation; IQR, interquartile range; VMAT, volumetric modulated arc therapy; FOIS, Functional Oral Intake Scale; PORT, post-operative
radiotherapy

PORT. Therefore, the swallowing outcome is likely to be addition, more effective medicines for HNC have been devel-
improved, and this finding is useful for predicting the oped, which are expected to improve prognosis. Thus, im-
swallowing ability of patients who require surgery plus adju- proving the swallowing ability is important for survival and
vant RT/CRT. In addition, FOIS is one of the most common QOL. In addition, as our intervention method does not always
scales and is sensitive to changes in functional oral intake and require a face-to-face session, we believe it is feasible.
is associated with patients’ QOL [8, 32]. Consequently, reha- This study has several limitations. First, although our insti-
bilitation treatment during PORT may be useful for patients’ tute is among the largest cancer centers treating HNC, a small
QOL as well as for improving swallowing ability. number of patients were included because nearly half of the
Patients with advanced cancer who undergo surgery and patients dropped out for recurrence or death due to advanced
PORT for HNC may live longer after treatment. In this study, HNC. Thus, there are concerns such as insufficient adjustment
among the 92 patients, 55 did not show recurrence. In of background factors in multivariate analysis and the possi-
bility of low statistical power in post hoc stratified analysis.
This is in addition to the inherent limitation of post hoc strat-
Table 2 Multivariable linear regression for FOIS at 6 months follow-up ified analysis. Second, we used the FOIS score as a
swallowing outcome, but it does not directly assess dysphagia,
Coefficients (Β) 95 % CI P value unlike videofluorography [33]. However, we believe that the
FOIS score is useful for evaluating swallowing ability and
Model 1
swallowing-related QOL. Third, since our rehabilitation ses-
Age −0.02 −0.04 to 0.01 0.146
sions were not always face-to-face, we did not have correct
FOIS before PORT 0.78 0.57 to 0.99 < 0.001
information about patient compliance to the swallowing exer-
Primary Site (Oral cavity) −0.32 −0.99 to 0.36 0.351
cises. In a Cochrane review, low compliance to swallowing
Rehabilitation 0.56 0.02 to 1.10 0.042
therapy was reported to be due to pain following RT [24].
Model 2
Considering low compliance after week four or five, our re-
Age −0.02 −0.04 to 0.01 0.122
habilitation program included other interventions in addition
FOIS before PORT 0.73 0.51 to 0.95 < 0.001
Primary Site (Oral cavity) −0.17 −0.88 to 0.53 0.627
Rehabilitation 0.54 0.01 to 1.07 0.048 Table 3 Stratified analysis of FOIS score’s changes from pre-PORT to
T stage −0.20 −0.49 to 0.08 0.157 PORT between with rehabilitation and without rehabilitation
Model 3
n Mean ± SD P value
Age −0.02 −0.04 to 0.01 0.187
FOIS before PORT 0.79 0.58 to 1.00 < 0.001 FOIS<5 Rehabilitation 16 1.25 ± 1.18 0.304
Primary Site (Oral cavity) −0.33 −1.02 to 0.36 0.342 Non rehabilitation 7 0.71 ± 0.95
Rehabilitation 0.56 0.02 to 1.11 0.042 FOIS≧5 Rehabilitation 9 1.00 ± 0.70 0.006
CRT 0.13 −0.35 to 0.62 0.587 Non rehabilitation 23 0.21 ± 0.67

FOIS, Functional Oral Intake Scale; PORT, post-operative radiotherapy; FOIS, Functional Oral Intake Scale; n, number of patients; SD, standard
CRT, chemoradiotherapy deviation
Support Care Cancer
to swallowing exercises; hence, it is likely to have a positive
impact. Finally, since this was a retrospective study, there is a
possibility that some factors are unevaluated, such as dry
mouth, desire to eat, or social factors. Therefore, a randomized
clinical trial is needed to validate our findings.
In conclusion, rehabilitation treatment during PORT may
be useful to achieve better swallowing outcomes. SLPs should
focus on the swallowing function of patients with advanced
HNC who undergo PORT, and we believe that providing
comprehensive rehabilitation treatment, including manage-
ment of nutrition, food texture, dysphagia, and swallowing
exercise, is important for HNC patients.
Code availability N/A
Author contribution N.A., H.T., and T.F. were involved in the study
design, data analysis, and data interpretation. N.A drafted the work.
N.A., H.T., and T.F. revised it critically for important intellectual content.
N.A., H.T., and T.F. approved the version to be published and agreed to
be accountable for all aspects of the work in ensuring that questions
related to the accuracy or integrity of any part of the work are appropri-
ately investigated and resolved.
Data availability Due to the nature of this research, participants of this
study did not agree for their data to be shared publicly, so supporting data
is not available.
Declarations
Ethics approval This study was approved by the ethics committee of the
Osaka International Cancer Institute (approval number 20056).
Consent to participate The committee waived the need for informed
consent in view of the retrospective nature of the study. Instead, an opt-
out technique through an announcement on the hospital webpage was
used to provide an opportunity for patients to withdraw from the study.
General consent regarding the possibility of using their clinical data was
obtained from all patients at the time of operation.
Consent to publication The committee waived the need for informed
consent in view of the retrospective nature of the study. Instead, an opt-
out technique through an announcement on the hospital webpage was
used to provide an opportunity for patients to withdraw from the study.
General consent regarding the possibility of using their clinical data was
obtained from all patients at the time of operation.
Conflict of interest The authors declare no competing interests.
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