Dysphagia Risk Stratification in Head and Neck Cancer via Two-Stage PRO-Clinical Stacking

Siyuan Zhao, Eric Ababio Anyimadu, Zachary G. Brumm, Yue Ma, Clifton David Fuller, Xinhua Zhang, G. Elisabeta Marai, Guadalupe Canahuate

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.