Disclosures Educating, Evaluating, and Treating Patients With Head and Neck Cancer

• Brittany Davis has no financial or nonfinancial disclosures • Keri Cullen has no financial or nonfinancial disclosures

Brittany Davis, M.Ed. CCC-SLP Keri Cullen, M.Ed. CCC-SLP

Learning Objectives • Participants will be able to – identify and discuss both initial and delayed side effects of chemo and radiation therapy for head and neck cancer. – identify and discuss research related to speech and swallowing impairments associated with head and neck cancer. – discuss treatment options, including exercises, strategies, postural changes, and diet modifications.

Overview of HNC • Anatomical structures of HNC: – Oral cavity, including lips, front two-thirds of the tongue, gums, lining inside the cheeks and lips, floor of the mouth, hard palate, and gums behind the wisdom teeth. – Pharynx, including nasopharynx, the oropharynx, and the hypopharynx. – Larynx, including cricoid, thyroid, epiglottis, and vocal folds. – Paranasal sinuses and nasal cavity. – Salivary glands. (National Cancer Institute, 2015)

Overview of HNC

Etiology

• Prevalence: Approximately 3% of all cancers in the US. – Twice as common among men – Usually presents in people over 50 years in age (National Cancer Institute, 2015).

• Survival rate: • 65% with just over 20% mortality within a year of treatment and 30% mortality after two years of treatment.

• 90% of malignancies within the head and neck region are squamous cell carcinomas (Hamilton, Khan, O’Hara, & Paleri, 2015). – Squamous cells are the cells that line the moist and mucosal surfaces of the mouth, nose, and throat. (National Cancer Institute, 2015).

• At least 75% of HNC are caused by use of tobacco and alcohol – A rapidly growing risk factor for HNC includes cancer-causing types of the human papillomavirus (HPV), most specifically HPV-16 (National Cancer Institute, 2015).

• In recent years, overall decline in the incidence of all HNC in the UK, however the incidence of oropharyngeal tumors has increased by 51%. (Hamilton, Khan, O’Hara, & Paleri, 2015). • Other risk factors for HNC include the following: – – – – – – –

Paan (betel quid), Mate (a tea-like beverage) preserved or salted foods oral health occupational exposure radiation exposure, Epstein-Barr virus, and ancestry (Asian and Chinese are higher risk) (National Cancer Institute, 2015).

(Hamilton, Khan, O’Hara, & Paleri, 2015; National Cancer Institute, 2015)

(National Cancer Institute, 2015; Hamilton, Khan, O’Hara, & Paleri, 2015)

Signs and symptoms •

– – – –

•

Diagnosis

Most common: Persistent sore throat A lump or sore that does not resolve Difficulty with swallowing Hoarse vocal quality

• MD reviews a patient’s medical history • Performs a physical exam • Diagnostic tests dependent on the patient’s symptoms:

Additional signs/symptoms – – – – – – – – – – – –

Trouble breathing or speaking Persistent pain in the neck or throat that does not resolve Frequent headaches Ringing in the ears Trouble hearing Chronic sinus issues that do not clear Swelling in the chin or jaw Numbness or pain in the face Bleeding through the nose Trouble with the eyes Unexplained weight loss, Coughing up blood.

– – – – – – –

(National Cancer Institute, 2015)

PET-CT scan MRI **Biopsy Endoscopy Laryngoscopy Oral brush exam HPV test

(National Cancer Institute, 2015)

HNC Staging • •

Medical Treatment

TNM System Primary Tumor (T) – TX: Primary tumor cannot be evaluated – T0: No evidence of primary tumor – Tis: Carcinoma in situ (CIS; Abnormal cells are present but have not spread to neighboring tissue. Although not cancer, CIS may become cancer and is sometimes called preinvasive cancer.) – T1, T2, T3, T4: Size and/or extent of the primary tumor

•

Regional Lymph Nodes (N) – NX: Regional lymph nodes cannot be evaluated – N0: No regional lymph node involvement – N1, N2, N3: Degree of regional lymph node involvement (number and location of lymph nodes)

•

Distant Metastasis (M) – MX: Distant metastasis cannot be evaluated – M0: No distant metastasis – M1: Distant metastasis is present

• Highly variable from patient to patient dependent on the location of the tumor, the stage of the cancer, and the patient’s overall health and age. • Main established treatment options for HNC: – Radiation • The two types of external radiation therapy include intensitymodulated radiation therapy (IMRT) and stereotactic radiosurgery. – IMRT is a 3-D radiation therapy that provides thin beams of radiation in varying intensity toward the tumor at different angles.

– Chemotherapy – Surgery – Targeted therapy • Causes less harm to normal cells than other cancer treatments do. • Utilizes drugs and/or other substances to attack specific cancer cells. – Example: monoclonal antibodies (National Cancer Institute, 2015)

(National Cancer Institute, 2015)

Side Effects of HNC Treatment

Side Effects of HNC Treatment • Chemotherapy

RADIATION

Mucositis Ulcers Changes in taste

– Exacerbates the effects of radiation – Increase in fatigue – Nausea

DELAYED EFFECTS OF

IMMEDIATE EFFECTS OF RADIATION

Xerostomia

Dysphagia

Tooth decay Osteoradionecrosis

Changes in smell

Trismus

Oral pain

Change in hearing

Viral/fungal infections

Fibrosis

(National Cancer Institute, 2014)

Side Effects of HNC Treatment • Anatomical changes

SLP Evaluation • Detailed medical history – Location of tumor, including if the patient is cancer free – Treatment of tumor (surgery, XRT, chemotherapy, combination of treatments) – Start and end dates of treatment for XRT and CXRT – Current oral intake (i.e., diet and liquid consistency)/Nutrition status – Current activity level, including if the patient is still working – Respiratory status, including history of PNA – Past SLP treatment, including results of MBS/FEES

SLP Evaluation • Oral motor examination – – – – – – –

Oral integrity (moisture/hygiene) Structures (ROM) Function of Cranial Nerves ( V, VII, IX/X, XII) Mucositis Trismus Ulcers Changes in taste/smell

• Assessment/Screening of Voice • Assessment/Screening of Speech • Assessment/Screening of Cognition

SLP Evaluation • Swallowing – Secretion management – Ice chips, water trial, puree, and solids as tolerated at bedside – Cough function – Diagnostic testing (depending on facility) • MBSS vs FEES

• Quality of Life Measures – Example: SWAL-QOL; EROTC QLQ-H&N35

Case Study • • • • • • • • •

71 y.o. Male PMH: heart surgery (AVR), GERD, Coagulation defect, sensorineural hearing loss (asymmetrical), BPH, chronic kidney disease, aortic stenosis, R inguinal hernia, colon polyp, hyperlipidemia, basal cell carcinoma of chest wall, arthritis, arrhythmia, pacemaker Initial complaint: pain and difficulty with swallowing after AVR surgery. Dx: ENT work-up revealed R tongue base cancer HNC TX (1): Radiation x 33 and chemo x 6. NPO with PEG during XRT/Chemo Patient returned to regular diet + thin liquids; continued with odynophagia, returned to ENT Dx: Biopsy completed revealing additional cancer HNC TX (2): Partial resection of tongue with resection completed by route of neck. Trach. NPO with PEG since December 2014. SLP MBS (3/13/15) revealed: moderate-severe pharyngeal dysphagia; decreased movement of all pharyngeal structures resulting in moderate-severe valleculae and pyriform sinus residue. Penetration during the swallow of all consistencies 2/2 reduced hyolaryngeal movement and reduced airway closure. Repeated penetration and eventual aspiration with all consistencies after the swallow 2/2 residue. Occasional silent aspiration and occasional cough reflex. R Head turn was trialed and proved successful – –

Trach removed (March 2015), however patient with unclosed stoma site. Initial NOMS: SwallowingLevel 1: Patient is not able to swallow anything safely by mouth. All nutrition and hydration is received through nonoral means.

SLP Treatment- ORAL PHASE Impairment

Exercise

Strategies

Trismus

Oral motor exercises; passive motion/ROM device (example: Therabite)

n/a

Labial seal

Labial exercises

• •

Place food/drink on strong side of oral cavity; Use of straw

Bolus formation 2/2 to Xerostomia

n/a

• • •

Change diet texture Increase water intake Oral moisturizers/saliva substitute

Posterior propulsion 2/2 resection of tongue, weakness, and/or ROM

Lingual ROM IOPI device if available

•

Place food on strong side of oral cavity. Use of glossectomy spoon Change texture of liquid/food Postural change (posterior head tilt)

• • • Oral residue 2/2 reduced ROM and lingual strength

Lingual ROM IOPI device if available

• •

Lingual sweep Oral care after PO

Poor oral intake 2/2 to pain

n/a

•

Pain management per MD (typically 3x a day before meals; example: Carafate) Oral intake after pain management

• Poor intake 2/2 to dysgeusia

n/a

• • •

Trial variety of foods Experiment with seasoning and temperature Address xerostomia

SLP Treatment • After initial evaluation, involvement of multidisciplinary team – Medical Doctor Team (ENT, Radiation Oncologist, GI) – Physical Therapy ---myofascial release – Medical Psychology – Nutritionist

SLP Treatment- ORAL PHASE • Langmore and Krisciunas (2010) – Type of Study: Literature review – Population: HNC patients s/p XRT or CXRT – Findings: Fibrosis and muscle tension related to radiation led to decreased ROM and underlying weakness. Liquids more easily cleared than puree or solids.

• Knott and Lewin (2013) – Type of Study: Literature review – Population: HNC patients s/p total glossectomy – Findings: Posterior head tilt improved bolus clearance through oral cavity in combination with supraglottic swallow to prevent airway compromise due to premature spillage

SLP Treatment-Pharyngeal phase dysphagia prevention

SLP Treatment- ORAL PHASE • May, Hiner, and Feldman (2013) – Type of Study: Literature review – Population: Various treatment after HNC – Findings:

• Recommend prophylactic swallowing exercises before and during radiation • Avoid NPO intervals • Frazier Free Water Protocol as appropriate for each patient

• Oral care after eating stimulated swallowing reflex, muscle function, and saliva secretion as well as cleared oral residue. • Increased risk to develop limited ROM, strength, and late effect fibrosis without jaw mobilization program

• Meier (2015) – Type of Study: Case Study. – Population: Patient with SCC of tongue – Findings: Improved lingual strength and diet tolerate after lingual resistance training with both traditional lingual exercises and IOPI.

NPO

SLP Treatment-Pharyngeal phase dysphagia prevention • Kotz, Federman, Kao, Milman, Packer, Lopez-Prieto, Forsythe, and Genden (2012) • Type of Study: Randomized control trial • Population: 26 patients with HNC receiving CXRT • Findings: – Prophylactic exercises resulted in improved swallowing after CXRT – Improved swallow function at 3 and 6 months after CXRT – No significant difference noted at 9 and 12 months after CXRT compared to control group (after CXRT the controls were then referred for swallowing treatment)

SLP Treatment-Pharyngeal phase dysphagia prevention • • • •

Hutcheson and Lewin (2013) Type of Study: Literature Review Population: Patients with oral cavity and oral pharyngeal cancers Findings: Improved QOL, outcomes, and superior diet levels up to 1 year post XRT in patients who avoided NPO intervals

SLP Treatment- PHARYNGEAL PHASE Impairment

Exercise

Maneuvers

Strategies

Tongue base retraction

Masako, Effortful

Mendolsohn Maneuver

• • • •

Diet modifications Liquid wash Alternate solids+liquids Additional dry swallows

Pharyngeal wall constriction

Effortful swallow

n/a

• • • • •

Diet modifications Liquid wash Alternate solids+liquids Additional dry swallows Head turn (evident on MBS)

Supra- super glottic swallow

• • • • •

Diet modifications Liquid wash Alternate solids+liquids Additional dry swallows Head turn (evident on MBS)

Super-supraglottic swallow

• • • • •

Diet modifications Liquid wash Alternate solids+liquids Additional dry swallows Head turn (evident on MBS)

• • • • •

Diet modifications Liquid wash Alternate solids+liquids Additional dry swallows Head turn (evident on MBS)

Decreased hyoid/laryngeal elevation and excursion

Mendolsohn, Effortful swallow, Chin Tuck Against Resistance (CTAR)

Impaired laryngeal closure/vocal fold closure

Impaired UES opening

Shaker exercise Chin Tuck Against Resistance

SLP Treatment- PHARYNGEAL PHASE • Langmore and Krisciunas (2010) – Type of study: Literature review – Results: Patients treated for HNC have more difficulty swallowing solids due to dental status and xerostomia, however liquid wash improved pharyngeal clearance.

• Logemann (2006) – Type of study: Literature review – Results: Improved pharyngeal swallow outcomes with use of masako maneuver, Mendelsohn, supraglottic swallow, and shaker exercise

Biofeedback in conjunction with swallow treatment has a high rate of returning to PO intake (Crary and Groher, 2000).

SLP Treatment- PHARYNGEAL PHASE • Yoon, Khoo, and Liow (2013) – Type of study: Repeated measures – Population: 40 healthy adults – Results: increase in activation of the suprahyoid muscles while completing chin tuck against resistance exercises.

• Hutcheson, Bhayani, Beadle, Gold, Shinn, Lai, and Lewin (2013) – Type of study: Retrospective observational study – Population: 497 HNC patients s/p XRT or CXRT – Results: patients who were able to eat and exercise during treatment had the highest rate of return to a regular diet than those who were not able to do either.

FYI… • Swallowing exercises should be completed to point of fatigue with increasing load as strength and endurance improve (Burkhead, 2004). • Mucositis, trismus, xerostomia, fibrosis, and nausea may limit ability to participate in exercises • Neuromuscular Electrical Stimulation (NMES) should be used with caution due to possibility of depressing the hyoid (Humbert, 2011)

• Initial exercises given included Effortful swallow, masako maneuver, and mendolsohn. • Limited ability to complete

Case Study • • • • • • • • •

– Initially completing Effortful swallow x 6,Masako x 10, Mendolsohn x 5

71 y.o. Male PMH: heart surgery (AVR), GERD, Coagulation defect, sensorineural hearing loss (asymmetrical), BPH, chronic kidney disease, aortic stenosis, R inguinal hernia, colon polyp, hyperlipidemia, basal cell carcinoma of chest wall, arthritis, arrhythmia, pacemaker Initial complaint: pain and difficulty with swallowing after AVR surgery. Dx: ENT work-up revealed R tongue base cancer HNC TX (1): Radiation x 33 and chemo x 6. NPO with PEG during XRT/Chemo Patient returned to regular diet + thin liquids; continued with odynophagia, returned to ENT Dx: Biopsy completed revealing additional cancer HNC TX (2): Partial resection of tongue with resection completed by route of neck. Trach. NPO with PEG since December 2014. SLP MBS (3/13/15) revealed: moderate-severe pharyngeal dysphagia; decreased movement of all pharyngeal structures resulting in moderate-severe valleculae and pyriform sinus residue. Penetration during the swallow of all consistencies 2/2 reduced hyolaryngeal movement and reduced airway closure. Repeated penetration and eventual aspiration with all consistencies after the swallow 2/2 residue. Occasional silent aspiration and occasional cough reflex. R head turn trialed on MBS and proved successful in reducing residue –

• 13 sessions consisting of exercise tolerance; PO trials with strategy (R head turn) • Repeat MBS completed 6/24/15: unable to swallow with head in neutral position 2/2 odynophagia. With R head turn patient able to tolerate thin and puree trials. MBS revealed: decreased tongue base retraction, decreased anterior hyoid movement, diminished posterior pharyngeal wall constriction, partial epiglottic inversion, decreased laryngeal elevation, residue in vallecula and pyriform. Aspiration 2/2 residue. Independent cough that cleared aspirated material. Swallow study discontinued 2/2 patient pain. Unable to continue to swallow. • Discharged on puree/mechanical soft snacks and thin liquids with head turn. HEP provided. Discharged mainly because of pain levels and inability to continue

Trach removed (March 2015), however patient with unclosed stoma site.

References • • • • • • • •

Burkhead, L. M. (2004). Applications of exercise science in dysphagia rehabilitation. Sig 13, Perspectives on Swallowing and Swallowing Disorders, 18, 43-48. doi:10.1044/sasd18.2.43 Hamilton, D., Khan, M., O’Hara, J., & Paleri, V. (2015). Re-emergence of surgery in the management of head & neck cancer. SIG 13 Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 24, 79-88. doi:10.1044/sasd24.3.79 Hutcheson, K. A., Bhayani, M. K., Beadle, B. M., Gold, K. A., Shinn, E. H., Lai, S. Y., Lewin, J. (2013). Eat and exercise during radiotherapy or chemoradiotherapy for pharyngeal cancers use it or lose it. JAMA Otolaryngology Head and Neck Surgery, 139(11), 1127-1134 Hutcheson, K. A. & Lewin, J. S. (2013). Functional assessment and rehabilitation—How to maximize outcomes. Otolaryngologic Clinics of North America, 46(4), 657-670. Humbert, I. (2011). Point/Counterpoint: Electrical stimulation for dysphagia: The argument against electrical stimulation for dysphagia. Sig 13, Perspectives on Swallowing and Swallowing Disorders, 20, 102-108. doi:10.1044/sasd20.4.102 Knott, J. K. & Lewin, J. S. (2013). Dysphagia rehabilitation following total glossectomy. SIG 13, Perspectives on Swallowing and Swallowing Disorders, 22, 73-80. DOI:10.1044/sasd22.2.73 Kotz , T., Federman, A. D., Kao, J., Milman, L., Packer, S., Lopes-Prieto, C., Forsythe, K., & Genden, E. M. (2012). Prophylactic swallowing exercises in patients with head and neck cancer undergoing chemoradiation. Archives of Otolaryngology—Head and Neck Surgery, 138(4), 376-382 Langmore, S. E. & Krisciunas, G. P. (2010). Dysphagia after radiotherapy for head and neck cancer: Etiology, clinical presentation, and efficacy of current treatments. SIG 13, Perspectives on Swallowing and Swallowing Disorders, 19, 32-38. DOI: 10.1044/sasd19.2.32

References • • • • • • • •

Logemann, J. A. (2006). Protocol for swallowing management in patients treated for head and neck cancer. SIG 13, Perspectives on Swallowing and Swallowing Disorders, 15, 22-26. doi:10.1044/sasd15.2.22 May, A. H., Hiner, E. D., & Feldman, E. (2013). Oral integrity related to head and neck cancer treatment. Sig 13, Perspectives on Swallowing and Swallowing Disorders, 21, 28-33. doi:10.1044/sasd21.1.28 Meier, A. (2015). Lingual strengthening: Success in an outpatient setting. Sig 13, Perspectives on Swallowing and Swallowing Disorders, 24, 71-74. doi:10.1044/sasd24.2.71 National Cancer Institute (2014). Oral complications of chemotherapy and head/neck radiation–for health professionals (PDQ®). Retrieved from http://www.cancer.gov/about-cancer/treatment/side-effects/mouth-throat/oral-complications-hp-pdq National Cancer Institute (2015). Cancer staging. Retrieved from http://www.cancer.gov/about-cancer/diagnosis-staging/staging/staging-fact-sheet National Cancer Institute. (2015). Head and neck cancers [Data file]. Retrieved from http://www.cancer.gov/types/head-and-neck/head-neck-factsheet National Cancer Institute. (2015). Oropharyngeal cancer treatment (PDQ) [Data file]. Retrieved from http://www.cancer.gov/types/head-andneck/patient/oropharyngeal-treatment-pdq Yoon, W. L., Khoo, J. K. P., & Liow, S. J. R. (2013). Chin tuck against resistance (CTAR): New method for enhancing suprahyoid muscle activity using a shaker-type exercise. Dysphagia, 29, 243–248. DOI 10.1007/s00455-013-9502-9