Author: Heather Bolan, MA, CCC-SLP Edited by: Ainsley Martin, MS, CCC-SLP
Working with cancer patients was always a career goal of mine. However, it can be challenging to get our foot in Oncology- whether it be because of healthcare professionals stuck in their ways, physicians who don’t see our value, or simply not having the desired experience on our resumes. The face of head and neck cancer (HNC) is changing, shifting away from tobacco-related carcinogenesis to a strong correlation of squamous cell carcinoma (SqCC) and the human papillomavirus (HPV) (1). Management is shifting in favor of organ preservation treatment resulting in greater use of treatments such as chemo and radiation therapy, making mucositis and dysphagia the new “barriers to winning the battle with HNC” (3).
According to the World Health Organization (WHO) the economic impact of cancer is significant and increasing, with the total annual economic cost of cancer in 2010 being $1.16 trillion (2). Having the SLP as a part of the multidisciplinary team (MDT) can lead to countless benefits including improved communication between healthcare professionals, better coordination and continuity of care, and better clinical outcomes. Yet, the SLP continues to fight to be apart of the MDT.
A 2012 survey of SLPs in the US revealed that only 18.3% intervene proactively and see HNC patients prior to cancer treatment (4).
Are you interested in changing this statistic? Ready to start a HNC prophylactic/rehabilitative program in your network, but not sure where to begin? Wondering how we start getting those referrals BEFORE that base of tongue cancer patient starts chemoradiation (CRT)?
Lucky for you I built my program from the ground up and did all the research for you. In this article, I will guide you through the need for SLPs to be involved in oncology, optimal timing for initiating treatment, considerations for assessment and treatment, and lastly educational resources for the aspiring Oncology SLP. Time to dig deep, know our worth, and advocate for best practice for our patients!
Why do we need SLP in Oncology?
Dysphagia in HNC can result from the disease process/infiltration (i.e. existing tumor), edema and pain, and neuropathy (5). There are significant discrepancies between patient perception of swallowing difficulties and objective measures such as instrumental evaluations of swallowing (6).
In fact, researchers found that 80% of HNC patients at baseline were on unrestricted diets although the majority of patients had some atypical findings on videofluoroscopic swallowing study (VFSS), with 80% demonstrating pharyngeal residue (6).
And this is before we start adding in any treatment toxicities! The radiation-induced morbidities of xerostomia, chemosensory acuity changes, mucositis, etc. come together as symptom clusters, causing a cascading effect of disuse atrophy and worsening dysphagia.
Radiotherapy (XRT) alone can lead to the following muscle changes from fibrosis and edema…. (7)
Impaired neural transmission
Impaired muscle contraction
Fewer muscle fibers and reduced fiber size
Replacement of muscle with connective and fibrotic tissue
Reduced sensation to larynx and trachea with reduced cough reflex
Neuropathies, specifically to the hypoglossal nerve
When XRT is concurrent with chemoradiotherapy (CRT) our patients are associated with higher rates of SEVERE early and late mucosal and pharyngeal toxicities (8), leading to similar disorders with more severe dysfunctions (9). Why? Most likely due to the large amounts of radiation volume and doses given to eradicate more advanced tumors (8). CRT accentuates radiotherapy side effects and adds more side effects of nausea, vomiting, dehydration, and neutropenia which severely compromise nutritional status.
These factors WILL impact swallowing, making intensive and supportive early intervention crucial to maintain the oropharyngeal swallow mechanism.
Dysphagia after CRT has been shown to lead to disordered swallows characterized by; (10)
Increased oral transit times
Decreased tongue base retraction to the posterior pharyngeal wall
Reduced hyolaryngeal excursion
Increased pharyngeal residue
Abnormal upper esophageal sphincter opening
When Should We Intervene?
Unfortunately there is no standardized dysphagia rehabilitation practice with dysphagia post radiation (11). Traditional rehabilitation timing initially started after treatment was completed or only when the patient had an aspiration complication with the rationale that radiated tissue would be too fragile for intervention, leading the clinician to wait until after toxicities have resolved. PEG tubes were also placed prophylactically to maintain intake of nutrition and hydration.
In 2015 Dr. Langmore found that dysphagia worsens over time and better outcomes are seen when therapy is provided earlier than 6 months after XRT as opposed to therapy several years later (12). We also know that late dysphagia in long term survivors has abnormal examination findings of:
dysarthria/dysphonia (76%)
trismus (38%)
pharyngeal residue and aspiration in all cases with 86% developing pneumonia, half of those requiring hospitalization
66% of patients being G-tube dependent (13).
The paradigm shift from reactive to preventative dysphagia management started with the study Pharyngocise, which was developed to minimize the long-term effects of radiation on swallowing function. Researchers Dr. Crary and Dr. Carnaby hypothesized that high-intensity swallowing therapy during the duration of CRT would facilitate maintenance of oropharyngeal muscle function. Guess what- they were right.
Pharyngocise prophylactic intervention showed better outcomes than traditional care with a reduction in muscle deterioration, dysgeusia (taste impairment), dysosmia (disordered smell perception), unintended weight loss, and improved mouth opening (14).
New research further supports the idea that early intervention can improve diet tolerance, airway protection, and overall nutrition. Kate Hutcheson and colleagues at MD Anderson Cancer Center completed a retrospective review of eating and exercise during radiation to evaluate the independent effects of maintaining oral intake by implementing preventive swallowing exercise with 497 patients treated with RT or CRT. The study showed that patients who both eat and exercise during RT/CRT have the highest chance of returning to a regular diet and have reduced PEG dependence (15).
Proactive swallowing therapy has lead to…
Improved QOL- measured by the MD Anderson Dysphagia Inventory (MDADI) (16)
Improved base of tongue retraction and epiglottic movement (17)
Shorter duration and dependence of a PEG (18)
Significant preservation of muscle mass found by MRI (14)
Improved jaw range of motion/mouth opening (19)
Reduced aspiration and hospitalizations (20)
As always, you should receive clearance from the patient's physician/surgeon before beginning any intervention.
Initial Evaluation Measurements
As previously discussed there is no standardized intervention that exists in the literature.
My network has standing orders for a Modified Barium Swallow Study (MBSS) and an initial pretreatment counseling session with goals of...
Establishing baseline swallow function
Assessing for any pre-existing dysphagia/current functional impact
Taking baseline measurements of jaw opening, DIGEST, etc
Determining patient’s understanding of upcoming treatment and expectations in regards to side effects from toxicities impacting swallow function
Defining recovery and rehabilitation pathways
Discussing potential outcomes with voice, speech, and swallowing post tx
Initiating prophylactic exercise and oral care routines.
Listed below are validated, objective measurements frequently utilized throughout the HNC research and in Oncology clinics in the US.
MD Anderson Dysphagia Inventory (MDADI): A patient-based reliable questionnaire used to assess how patients perceive the outcome of their swallowing ability as a result of treatment, as well as the impact of swallowing dysfunction on their Quality of Life (QOL). It is comprised of 20-items with three subscales including: emotional, functional, and physical. This can be filled out by the patient. (21)
Eating Assessment Tool (EAT-10): Self-administered, symptom-specific outcome instrument for dysphagia. The questionnaire asks 10 questions related to swallowing with a score of 0 equating to no problem and a score of 4 equating to severe problem. (22)
Mann Assessment of Swallowing Ability-Cancer (MASA-C): A physiology based assessment tool for measuring swallowing performance in HNC patients with and without dysphagia. This validation has proven to lead to earlier identification of patients with swallowing difficulties and allow a more efficient allocation of resources for dysphagia management. (23)
Performance Status Scale- Head and Neck Cancer (PSS-HN): Measures patient performance in terms of degree of mobility, ability to maintain employment, live at home, and care for oneself. This is a clinician-rated, semi-structured interview consisting of 3-items on: understandability of speech, normalcy of diet, and eating in public. (24)
Dynamic Imaging Grade of Swallowing Toxicity (DIGEST): Utilized as a supplemental tool to VFSS to rate (global) pharyngeal dysphagia severity through 5-point severity staging benchmarks. It takes into account safety of swallow (pen/asp) with efficiency (residue) interaction. A standard criteria is applied to assign a grade of the dysphagia which aligns to the common framework for grading toxicities of cancer. This allows the clinician to profile the patient’s safety and efficiency of swallow. (25)
Currently there is no standardized trismus assessment in the US. The Gothenburg Trismus Questionnaire (GTQ) has been validated in Sweden with plans to validate in English (stay tuned)! We should still be taking interincisal (i.e. mm between the bottom of the upper teeth to the top of the upper teeth) and lateral excursion measurements at baseline and throughout treatment to monitor for onset of trismus. This can be done by utilizing measuring tape or MIO scale measuring device from OraStretch or Therabite.
Initial pre-treatment counseling sessions should allow plenty of time to ensure the patient fully understands the recommended prophylactic care and provide additional time to process and ask for clarification as needed.
Managing HNC in Rehab Post-Radiation
Optimization Phase…
This phase should be utilized in order to strengthen or structure the swallow prior to the initiation of intensive functional rehabilitation. Some of the optimization may overlap in the functional phase of intervention depending on each individual patient’s needs. Treatments and procedures in the optimization phase may include:
Any medical/surgical intervention (i.e. esophageal dilation, vocal fold medialization, botox, etc)
Dental rehabilitation involving dentures or implants
Therabite/jaw range of motion- if the patient is unable to tolerate large boluses secondary to trismus the functional intervention will be unable to progress.
Manual therapy for lymphedema- swelling and pain can have implications such as decreased ability to safely participate in tx, worsening dysphagia, and potential airway patency concerns.
Behavioral interventions focusing on manual therapy or strengthening the swallow
Expiratory Muscle Strength Training (EMST): This resistive expiratory strengthening paradigm should be offered to patients that demonstrated reduced airway protection on the MBSS prior to the initiation of boot camp. A recent study examined the effectiveness of an intensive 8 week EMST exercise program for chronic HNC aspirators and found EMST offered significant improvements in maximum expiratory pressures, swallow safety on MBSS, an improvement in DIGEST scores! (26)
Iowa Oral Performance Instrument (IOPI): Objectively measures lip and tongue strength and endurance.
Functional Phase…
This phase consists of clinician-driven intensive functional swallowing intervention focused on challenging the swallow physiology by providing progressive overload. Both device and bolus options are available. This section of therapy should consist of intensive daily sessions for 2-3 weeks with 100 or more swallows per session and should include the following interventions:
McNeil Dysphagia Therapy Program (MDTP)
sEMG biofeedback swallows
bioFEESback (use of flexible endoscopic evaluation of swallowing as biofeedback)
Recommended Educational Development
Most big name HNC hospital programs (i.e. MD Anderson, Kessler Institute, Moffit, Stanford, etc) have SLPs that are trained in...
Lymphedema Therapy
McNeil Dysphagia Therapy Program (MDTP)
Myofascial Release
Amplification, Resistance, & Kinetics of the Jaw (ARK-J) Program
There are also observer programs through MD Anderson Cancer Center that vary from six days up to 90 days dependent on the goals and objects of the trainee and the resources of the department! A colleague of mine attended and I can say the benefits of her attending have been astronomical.
Starting this program at my network has been so fulfilling and rewarding for our rural community. One of the patients I was able to pick up for therapy has had recurrent cancer with extensive chemoradiation and surgical history, leaving her dependent on PEG with pleasure feeds and severe trismus impacting her dysphagia and speech intelligibility. Prior to beginning this program, she had to drive two hours one way, once a week to attend SLP treatment. This placed a significant burden on her, as she had begun working full time recently and could not get the amount of care she needed. Now my patient is only has to drive 50 minutes one way to come see me and we are going to look at increasing her treatment frequency to start intensive intervention for her trismus and dysphagia.
If you are interested in learning more about the role of SLPs in oncology or are simply looking to expand your skill set in this area, please see our review of The ARK-J Program and RMST for the Med SLP. As always, stay tuned for our upcoming reviews of courses specific to Oncology including Myofascial Release and the ever elusive McNeil Dysphagia Therapy Program!
References:
1. Li G., Sturgis E.M. (2006) The role of human papillomavirus in squamous cell carcinoma of the head and neck. Current Oncology Reports, 8, 130-139.
2. Stewart BW, Wild CP, editors. World cancer report 2014 Lyon: International Agency for Research on Cancer; 2014.
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5. Sullivan, Paula (2019). Management of HNC Throughout the Continuum of Care: Addressing Swallowing Challenges [PowerPoint Slides]. Retrieved from http://www.northernspeechservices.com
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