ORIGINAL ARTICLE

Interpretation of the Swedish Self Evaluation of Communication Experiences after

Laryngeal cancer: Cutoff levels and minimum clinically important differences

Lisa Tuomi, PhD,1* Mia Johansson, PhD, MD,2 Paulin Andrell, PhD, MD,3 Caterina Finizia, MD1

1
Department of Otorhinolaryngology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden,
2
Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden, 3Depart-
ment of Molecular and Clinical Medicine/Multidisciplinary Pain Center, Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospi-
tal, Gothenburg, Sweden.

Accepted 6 December 2014

Published online 26 May 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.23955

ABSTRACT: Background. The purpose of this study was to establish
minimum clinically important difference (MCID) scores for the Swedish
Self-Evaluation of Communication Experiences after Laryngeal Cancer
(S-SECEL) in order to facilitate clinical interpretation and identify cutoff
values for voice rehabilitation.
Method. One hundred nineteen patients with laryngeal cancer completed
the S-SECEL instrument and an anchor question regarding acceptability
Attitudinal 5 5), presenting acceptable sensitivity and specificity. Initial
MCID estimates were obtained for all domains; improvement of 213
points (p < .0001) or a deterioration of 18 points (p 5 .035) for the
Total domain.
Conclusion. MCID and cutoff scores for the S-SECEL have been identified
and may be used in clinical practice to help identify patients with laryn-
geal cancer in need of voice rehabilitation. V
C 2015 Wiley Periodicals, Inc.

of speech in a social context pretreatment and 12-month postoncologic Head Neck 38: 689–695, 2016
treatment. Receiver operating characteristic (ROC) curves analysis was
used for calculation of cutoff values. KEY WORDS: Swedish Self-Evaluation of Communication Experien-
ces after Laryngeal Cancer (S-SECEL), quality of life, laryngeal neo-
Results. Voice rehabilitation cutoff values were identified for all
plasms, voice, patient outcome assessment
domains (Total 5 20; General 5 4; Environmental 5 16, and

INTRODUCTION compared to pretreatment.8 Conversely, abnormal findings

regarding breathiness and pitch have been reported 10 to
Laryngeal cancer treatment can affect the voice and com-
15 years posttreatment.9 PRO adds the aspect of patient
munication. Approximately 40% to 80% of the patients
functioning in everyday life, whereas Agarwal et al10
experience some persisting voice problems in terms of
reported that 3 to 6 months postradiotherapy all patients
self-rated function up to 10 years after initial laryngeal
experience some improvement of voice quality. Bibby
cancer treatment.1,2 In order to properly assess voice
et al4 also demonstrated that for patients with laryngeal
function, the European Laryngological Society recom-
cancer at 12 months postcurative radiotherapy, the voice
mends a multidimensional approach including, but not
quality had improved significantly when measuring self-
limited to, perceptual, acoustical, and patient-reported
perceived voice function. These findings indicate that
outcome (PRO) measures.3 When using acoustic meas-
some spontaneous improvement of voice quality occurs,
ures, voice improvement after radiotherapy is reported but
although many patients still experience considerable voice
does, however, not reach normal levels.4–6 Regarding per-
problems after laryngeal cancer treatment.1,2
ceptually rated voice quality, there are contradicting
PRO instruments have been developed to measure out-
results in which patients with laryngeal cancer are per-
comes from the patient’s own perspective. There are sev-
ceived as having more strained voices 1-year postonco-
eral instruments, both general and disease-specific, such
logic treatment compared to pretreatment,7 whereas 24
as the European Organisation for Research and Treatment
months postradiotherapy the qualities of a strained and
of Cancer Core Quality of Life Questionnaire and the
breathy voice have been reported to improve significantly
Head and Neck module.11,12 These instruments, however,
only include a few items about voice and communication,
which is why an instrument addressing the specific com-
*Corresponding author: L. Tuomi, Department of Otorhinolaryngology, Head munication challenges faced by the laryngeal cancer pop-
and Neck Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.
E-mail: lisa.tuomi@gu.se
ulation is needed.13 There are several instruments used to
measure voice function after treatment for laryngeal can-
Contract grant sponsor: Mary von Sydows Foundation; Assar Gabrielsson Foun-
dation, Cancer Foundation; The Health & Medical Care Committee of the
cer8,14,15 including the Voice Handicap Index16 and the
Regional Executive Board; Region V€astra G€otaland; The Sahlgrenska University Voice Related Quality of life.17 Nevertheless, these
Hospital, Gothenburg University instruments do not assess the specific voice and

HEAD & NECK—DOI 10.1002/HED MAY 2016 689

TUOMI ET AL.
communication problems experienced by patients with
laryngeal cancer. In order to assess communication dys-
function after laryngeal cancer, specific voice and com-
munication instruments have been developed. The Self-
Evaluation of Communication Experiences after Laryn-
gectomy (SECEL)18 has been translated and validated
into several languages.19,20 It has also been adapted and
validated in Swedish (ie, the Swedish Self-Evaluation of
Communication Experiences after Laryngeal cancer [S-
SECEL]).21
Several PRO instruments provide guidelines regarding
clinical interpretation of the scores. However, for the S-
SECEL, guidelines for clinical interpretation of scales are
lacking. In clinical studies, small differences in a score
can be found to be statistically significant in a large
enough sample. Yet, a statistically significant score differ-
ence does not necessarily reflect a clinically relevant
change for the patient.22,23 The minimum clinically
important difference (MCID) score is a threshold value
that defines a change that the patient experiences as
worthwhile or meaningful.22 Guidelines of MCID have
been reported for the European Organisation for Research
and Treatment of Cancer Core Quality of Life Question-
naire,24 which was developed using the patient’s own per-
ception of significant changes of health. An issue
regarding MCIDs for deterioration is presented in a study
by Osoba et al24 in which they found that fewer patients
reported “worse” health-related quality of life (HRQOL)
ratings than patients who reported “better” HRQOL rat-
ings. This resulted in greater variability of results in the
group of patients who reported “worse” and unclear non-
significant results.
In the original version of the SECEL,18 guidelines
regarding interpretation of results with a cutoff value
were presented, where patients who scored above this
value would be in need of rehabilitation. However, nei-
ther cutoff values nor MCID have been previously pre-
sented for the S-SECEL version. The purpose of this
study was to identify the S-SECEL’s MCID in order to
facilitate clinical interpretation and identify cutoff values
for voice rehabilitation.
MATERIALS AND METHODS
Patients and settings
All patients with newly diagnosed as well as recurrent
laryngeal cancer in the Western region of Sweden are dis-
cussed at a weekly head and neck cancer conference at
the Otolaryngology Department at the Sahlgrenska Uni-
versity Hospital. At the conference, treatment options are
discussed and decided upon. All patients diagnosed with
laryngeal cancer who received treatment with curative
intent were asked to participate. Patient inclusion criteria
were: sufficient cognitive ability and general health, as
well as adequate knowledge of the Swedish language to
be able to independently complete the questionnaires.
Patients participating in other concurrent studies were
excluded. The patients completed the study instruments
before the start of treatment, 1 month, 2 months, 3
months, 6 months, and 12 months after the start of treat-
ment. Comparisons in this study were made between the
pretreatment and 12 months posttreatment occasions,
690 HEAD & NECK—DOI 10.1002/HED MAY 2016
because a change of communicative function was
expected between these timepoints.4
Vocally healthy control group
Vocally healthy volunteers (n 5 35) were recruited
from people accompanying patients to the Otorhinolar-
yngology Clinic, Sahlgrenska University Hospital. Their
larynx status was assessed as normal, and they all per-
ceived their voices as being normal. The vocally healthy
control group filled out the S-SECEL as well as the
anchor question about acceptability of speech on one
occasion.
Patient-reported outcome instruments
Swedish Self-Evaluation of Communication Experiences after
Laryngeal cancer. The SECEL is a voice and communica-
tion instrument developed to assess the challenges of
communication for laryngectomees.18 It has been trans-
lated to Swedish and adapted to assess communication for
all patients with laryngeal cancer, regardless of what
treatment they receive.21 The Swedish version (S-SECEL)
has shown high construct and convergent validity and has
demonstrated sensitivity to change over time.13,25
The instrument consists of 35 items addressing commu-
nication experiences and dysfunction after laryngeal can-
cer. Thirty-four of the items are divided into 3 domains.
The General (5 items) domain addresses attitudes about
being calm or relaxed in general and acknowledgment of
the sickness and treatment. The second domain, the Envi-
ronmental (14 items), focuses on how the patients experi-
ence their voice in different settings. The third domain,
the Attitudinal (15 items), describes attitudes regarding
speech, feelings about self-perception, and perceptions of
others. Each item is rated on a 4-point categorical Likert
scale ranging from 0 (never) to 3 (always) and addresses
the previous 30 days. Scoring of a domain and total score
is performed through addition. Summary scores therefore
range from 0 to 15 for the General domain, 0 to 42 for
the Environmental domain, 0 to 45 for the Attitudinal
domain, and 0 to 102 for the Total domain. A higher
score indicates a greater communicative dysfunction. The
last item “Do you talk the same amount now as before
your laryngeal cancer?” has 3 response alternatives (Yes/
More/Less) and is not included in the scoring system.
Anchor question regarding acceptability of speech
The patients were asked to rate their communication
with the following question: “Is your speech acceptable
in a social context?” on a Likert scale ranging from 0 to
3 (3 indicates always good acceptability, 2 5 often,
1 5 sometimes, and 0 5 never). This item has been used
in previous studies and was found to detect differences
over time as well as differences between patient groups
who had been treated with different modalities.26,27 For
this study, answers 0 to 1 were considered indicative of
the need of rehabilitation and 2 to 3 were indicative of
acceptable communication.
Statistical methods
Correlation analysis between dependent and independ-
ent variables was performed with Spearman correlation
 INTERPRETATION OF THE SWEDISH SELF EVALUATION OF COMMUNICATION EXPERIENCES AFTER LARYNGEAL CANCER

TABLE 1. Patient characteristics. than 50% of the items in the domain were filled in. Total
score was calculated with the imputed score. If a patient
Patient Included No. of Dropouts No. of did not fill in the instruments at the 12-month occasion,
characteristics patients 5 119 (%) patients 5 7 (%)
then the last observation carried forward was applied. The
Mean age, y 66.0 74.4 data was analyzed using the SAS system, version 9
Sex (Copyright 2002–2010 SAS Institute).
Female 17 (14) 1 (14)
Male 102 (86) 6 (86) Ethical aspects
Localization
Glottic 90 (75.5) 2 (29) The study was approved by the Regional Ethical
Supraglottic 20 (17) 4 (57) Review Board in Gothenburg, Sweden, and was con-
Subglottic 6 (5) 0 ducted in accordance with the Declaration of Helsinki.
Transglottic 3 (2.5) 1 (14) All participants gave their informed consent before inclu-
Stage sion in the study.
0 4 (3.5) 1 (14.5)
I 68 (57) 2 (28.5) RESULTS
II 30 (25) 2 (28.5)
III 10 (8.5) 0 Patients and controls
IV 7 (6) 2 (28.5)
Treatment In total, 126 patients with laryngeal cancer chose to
Total laryngectomy 8 (7)* 0 enroll in the study and 155 patients did not enter the
Radiotherapy 115 (97) 7 (100) study for the following reasons: declined participation
Chemotherapy 7 (6) 0 (n 5 41), poor general health or impaired cognitive abil-
Smokers 39 (33) 5 (71) ities (n 5 77), insufficient knowledge of Swedish
(n 5 14), participation in other studies (n 5 20), and
* Two laryngectomies only, 2 in combination with chemotherapy, 4 in combination with unknown reason (n 5 3). One hundred nineteen patients
radiotherapy. treated for laryngeal cancer were included in the analysis
because 7 patients (6 men and 1 woman) chose to discon-
tinue their participation after inclusion. Two patients with
analysis. For the cutoff calculation, receiver operating recurrent disease were included in this study. Patient
characteristic (ROC) curves were calculated using logistic characteristics and oncologic treatment regimens for
regression with the acceptability score as dependent and laryngeal cancer are presented in Table 1. Five of the lar-
the S-SECEL domains as predictors. The cutoff value yngectomized patients were using voice prosthesis and 2
was chosen to be the score where the total amount of sen- were using an electrolarynx. The vocally healthy control
sitivity and specificity was the greatest. The S-SECEL group consisted of 35 participants, 6 women and 29 men,
scores, 12 months posttreatment, were used for these cal- with a mean age of 66 years. Thirteen of the vocally
culations. Correct classification was calculated in the healthy controls were smokers.
vocally healthy control group where the S-SECEL scores Last observation carried forward was performed for
were set to predict the acceptability of speech as 2 to 3 24% (n 5 29) of the patients included in the analysis. The
(often-always good acceptability). If the S-SECEL score item response rate was 99.5% (ie, only 0.5% of items
was below the cutoff and acceptability of speech was 2 or were imputed by mean imputation method).
3, it was considered to be a correct classification.
Evaluation of the MCID scores used both anchor-based Correlations
and distribution-based approaches. For calculation of the
The Spearman rho between the S-SECEL Total score,
anchor-based MCID, the change from pretreatment to 12
General, Environmental, and Attitudinal score compared
months posttreatment was used. Patients who improved or
to the anchor question regarding acceptability of speech
deteriorated in 0, 1, 2, or 3 steps, respectively, on the
at 12 months posttreatment was 20.729, 20.574,
acceptability scale were divided into 7 groups. A change
20.683, and 20.676, respectively. All correlations were
on the acceptability scale was compared to the change in
statistically significant (p < .0001). The change of S-
the S-SECEL scores. Patients who remained unchanged
SECEL Total score, General, Environmental, and Attitu-
or improved or deteriorated 1 step on the anchor question
dinal domains were correlated with the change in anchor
regarding acceptability of speech from pretreatment to 12
score as follows: 20.571, 20.416, 20.533, and 20.526,
months posttreatment are presented. Patients who showed
also statistically significant (p < .0001).
greater improvement or deterioration on the anchor item
were excluded from this analysis, because the calculation
of MCID focuses on minimal change. Testing between Cutoff values
the 2 occasions within each group was carried out using The cutoff value for the S-SECEL Total score was set
the Wilcoxon signed rank test. Distribution-based meth- to 20 points. For this cutoff value, sensitivity was 0.86,
ods were used as a complement to the anchor-based specificity was 0.79, and the estimated area under the
approach; 0.5 and 0.3 of the SDs at the 12-month follow- ROC curve was 0.892. Cutoff values for all the domains
up were calculated. of the S-SECEL are presented in Table 2 and illustrated
All significance tests were 2-sided and conducted at the in the ROC curves in Figure 1A to 1D. According to this
5% significance level. In case of missing items, simple classification, 71 patients (60%) were above the cutoff for
mean imputation within the domain was used if more the Total score (ie, in need of rehabilitation at the start of

HEAD & NECK—DOI 10.1002/HED MAY 2016 691

TUOMI ET AL.

TABLE 2. Cutoff values of the Swedish Self-Evaluation of Communication Experiences after Laryngeal Cancer when compared to the anchor question
regarding acceptability of speech.

Laryngeal cancer Control group

Domain Sensitivity Specificity Cutoff value AUC Correct classification Incorrect classification

Total 0.86 0.79 20.0 0.892 33 (94.3%) 2 (5.7%)

General 0.89 0.60 4.0 0.825 15 (42.9%) 20 (57.1%)
Environmental 0.75 0.93 16.0 0.887 34 (97.1%) 1 (2.9%)
Attitudinal 0.75 0.76 5.0 0.842 34 (97.1%) 1 (2.9%)

Abbreviation: AUC, area under the curve.

The cutoff values for all domains of the Swedish Self-Evaluation of Communication Experiences after Laryngeal Cancer (S-SECEL) showed high values for the AUC as well as high sensitivity and
specificity measures.

the study) and 43 patients (36%) were in need of vocal
rehabilitation 1 year after the start of oncologic treatment.
The vocally healthy control group was used to test the
construct validity of the cutoff values and results from
these calculations are also presented in Table 2. Correct
classification implies that the patient scored below or
equal to the cutoff (ie, 20 points for the Total score and
at the same time scored 2 or 3 on the acceptability ques-
tion), or the inverse; the patient scored above 20 points
and scored 0 to 1 on the acceptability question. For the
Total score, correct classification was found in 94% of
the healthy controls.
Minimum clinically important difference
MCID for the 4 domains of the S-SECEL instrument
are presented in Table 3. The MCID indicating improve-
ment in the S-SECEL total score was 213 points
(p < .0001) and deterioration was 8 points (p 5 .035).
Deterioration in the General and Environmental domains
did not reach statistical significance. The patients who

FIGURE 1. (A) Total score.

Receiver operating characteris-
tic (ROC) curves – domains of
the Swedish Self-Evaluation of
Communication Experiences
after Laryngeal Cancer (S-
SECEL) as predictor, anchor
question about acceptability as
dependent. The circle indicates
the cutoff point. (B) General
score. ROC curves – domains of
the S-SECEL as predictor,
anchor question about accept-
ability as dependent. The circle
indicates the cutoff point. (C)
Environmental score. ROC
curves – domains of the S-
SECEL as predictor, anchor
question about acceptability as
dependent. The circle indicates
the cutoff point. (D) Attitudinal
score. ROC curves – domains of
the S-SECEL as predictor,
anchor question about accept-
ability as dependent. The circle
indicates the cutoff point.

692 HEAD & NECK—DOI 10.1002/HED MAY 2016

 INTERPRETATION
TABLE 3. Minimum clinically important differences.
Deterioration
No. of p value within
patients 5 13 group*
Domain Mean (SD)
Total 8.7 (12.3) .035
General 1.1 (4.2) .329
Environmental 2.5 (7.2) .174
Attitudinal 5.1 (4.3) .002
Change in scores for the Swedish Self-Evaluation of Communication Experiences after Laryngeal Cancer (S-SECEL) domains related to 1-step change for the anchor question regarding acceptability.
Distribution-based methods using 0.5 and 0.3 of the SD of values at 12-month follow-up.
* Significance analysis made with the Wilcoxon signed rank test for changes within the patients who remained unchanged/deteriorated/improved 1 step for the question on acceptability of speech.
Six patients deteriorated more than 1 step for Acceptability, 18 patients improved more than 1 step on the Acceptability question and are therefore not presented in the table.
rated their acceptability of speech as unchanged were
found to improve significantly regarding the General
domain (mean improvement 21.3; p 5 .002). Six patients
deteriorated more than 1 step for acceptability and 18
patients improved more than 1 step on the acceptability
question and are therefore not presented in Table 3. All
differences calculated are between 5% and 13% of their
domain score range.
MCID using 0.5 as well as 0.3 SD (ie, the distribution-
based approach) are shown in Table 3.
DISCUSSION
The present study assessed patients with laryngeal can-
cer pretreatment and postoncologic treatment according to
the S-SECEL. The purpose of the study was to determine
cutoff values for identifying voice rehabilitation need and
present guidelines on how to interpret the results of the
S-SECEL in the clinical setting through preliminary esti-
mation of the MCID scores. The correlations between the
S-SECEL domains and the acceptability scores were mod-
erate to strong, indicating high convergent validity (ie,
comparisons between the 2 measures were possible).
The results of the cutoff values for all domains of the
S-SECEL showed reasonably high values for the area
under curve as well as high sensitivity and specificity
measures (0.75–0.93). Sensitivity refers to the proportion
of correctly classified positives and specificity describes
the proportion of correctly classified negative individuals.
However, the General domain of the S-SECEL showed
somewhat weaker results where the proportion of cor-
rectly classified individuals in the healthy control group
was low (43%). The General domain also showed inferior
results, where patients who rated their acceptability of
speech as unchanged simultaneously showed a statisti-
cally significant change in S-SECEL General score. The
General domain has previously been discussed as subopti-
mal20,21 and should perhaps, in a future version of the
instrument, be adapted or excluded. However, in the pres-
ent study, the S-SECEL’s Environmental, Attitudinal, and
Total domain showed promising results, suggesting that
the cutoff values from these domains may be clinically
useful.
For the original version of the SECEL, Blood18 has
proposed a cutoff score for the Total domain, where
OF THE SWEDISH SELF EVALUATION OF COMMUNICATION EXPERIENCES AFTER LARYNGEAL CANCER
No change Improvement Distribution-based
No. of p value within No. of p value within No. of
patients 5 43 group* patients 5 39 group* patients 5 119
Mean (SD) Mean (SD) 0.5/0.3 SD
20.8 (12.6) .331 213.0 (12.3) < .0001 8.1/4.8
21.3 (2.7) .002 22.0 (2.2) < .0001 1.4/0.8
20.3 (0.7) .706 27.0 (7.2) < .0001 4.1/2.5
0.8 (6.5) .958 24.0 (5.8) < .0001 3.6/2.2
results above 60 points are considered to represent the
need for in-depth communication rehabilitation. The large
discrepancy between this cutoff score and the one sug-
gested (20 points) in the present study might be explained
partly by the fact that Blood18 included laryngectomees
solely, whereas in the current work all patients receiving
oncologic treatment for laryngeal cancer were included.
Furthermore, the methods used to calculate the cutoffs
scores differ between the 2 studies, where Blood18 based
the cutoff score obtained with the Psychosocial Adjust-
ment to Illness Scale-Self Report.
Van Gogh et al2 found that 40% of patients after treat-
ment for early glottic cancer experience persisting voice
problems. The present study supports this number,
because according to the classification of need for voice
rehabilitation, 36% of our patients are above the cutoff
value for the total score on the S-SECEL 1 year after the
start of treatment. This could indicate that the cutoff
value identified in this study is relevant to use in a laryn-
geal cancer population. The van Gogh study reported
results for patients up to 10 years postoncologic treat-
ment, which indicated that the problems persist over a
long time. Moreover, in a study by Morgan et al,9 the
voices of patients with laryngeal cancer were still rated as
abnormal 10 to 15 years after treatment. These findings
further support the need for voice rehabilitation.
To find the MCID, one of the most common methods
is to use an anchor-based approach where an external cri-
terion other than the instrument itself is used (ie, an
anchor).28 A global assessment scale is commonly used,
where patients rate themselves as “better,” “unchanged,”
or “worse,” and the MCID can be calculated as the mean
change of the patients who answered “better” and the
mean change who answered “worse,” respectively.22
Other methods to find the MCID are distribution-based,
for example, using the SEM, the SD or effect sizes. The
distribution-based approaches can be recommended as
complements to anchor-based methods to the calculation
of MCID values.23
The anchor-based MCID presented in this study
included the patients who improved or deteriorated 1 step
on the anchor question regarding acceptability of speech.
For the patients who reported an increased function on
the question “Is your speech acceptable in a social con-
text?” 1 year posttreatment, the results were statistically
HEAD & NECK—DOI 10.1002/HED MAY 2016 693
TUOMI ET AL.
significantly different than at pretreatment for all
S-SECEL domains. However, for the patients who rated
their communication as being worse according to the
acceptability question, not all domains showed statisti-
cally significant results from pretreatment to 12-month
follow-up (Table 3). This could be due to the fact that
there were only 13 patients in this group. Osoba et al24
presented a similar issue, where fewer patients reported
deterioration of HRQOL than improvement of HRQOL,
which resulted in unclear, nonsignificant results. This is
also the case in the present study, which is why results
regarding deterioration should be interpreted with caution.
The distribution-based estimates of MCID, and particu-
larly the 0.5 SD, showed results close to the estimates for
deterioration, and somewhat smaller than the estimates
for improvement derived from the anchor-based approach.
On the other hand, the estimates based on 0.3 SD appa-
rently resulted in too small values for the patient to find
it meaningful, which is in concordance with a review by
Norman et al29 who found that a change that is detectable
by the patient is approximately 0.5 SD. Barrett et al30
states that 7% to 10% differences were found as clinically
relevant over several studies and scales studied, a finding
in line with the anchor-derived estimates found in this
study where the MCIDs are within or above this percent-
age change: 5% to 13% change of domain scores.
This study may be limited in generalizability by the
fact that 155 patients declined participation or were
excluded. In addition, the sample size is somewhat small
in terms of psychometric studies. A limitation could also
be that only 1 anchor item was included. Additionally,
further studies including patients with more advanced
laryngeal cancer as well as different treatment modalities
might strengthen the findings further. To confirm the fea-
sibility and use of cutoff and MCID estimates in this
study, further studies are needed.
Clinical implications
It has previously been shown that voice problems per-
sist up to 15 years posttreatment for laryngeal cancer.2,9
The S-SECEL is a simple instrument consisting of 35
items and the cutoff levels (20 points for the Total score)
stated in this study are provided as guidelines for voice
rehabilitation. The MCID stated can be used as a comple-
ment to clinical assessments and acoustic measurements,
both in clinical practice as well as in research, to assess
the success of voice rehabilitation (a change of either 18
or 213 points for the Total domain). Using this instru-
ment might be of benefit in enhancing motivation, allow-
ing patients themselves to see the documented change
and become more involved in their management. The S-
SECEL instrument might be useful in systematic follow-
up for patients with laryngeal cancer who have completed
oncologic treatment, facilitating identification of those in
need of voice rehabilitation, and allow for better use of
resources. Further research, however, is needed to evalu-
ate these aims.
CONCLUSION
Cutoff values indicating the need for voice rehabilita-
tion in a laryngeal cancer population have been stated for
694 HEAD & NECK—DOI 10.1002/HED MAY 2016
the S-SECEL. There are also recommended levels of
MCID for improvement or deterioration based on anchor
and distribution-based approaches. Possible application of
these guidelines includes use in the clinical setting and in
research to identify patients in need of rehabilitation as
well as documentation of the treatment.
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