Approaches to Assessment and Treatment of Patients with Head and Neck Cancer for the Speech- Language Pathologist Megan Hyers, MS, CCC-SLP Rebecca Schob,

Approaches to Assessment and Treatment of Patients with Head and Neck Cancer for the Speech-Language PathologistMegan Hyers, MS, CCC-SLPRebecca Schob, MsED, CCC-SLPProvidence Portland Cancer Center AmphitheaterMarch 29, 2014

Outline

• Overview of anatomy, staging, tumor size, and multidisciplinary team.  Treatment approaches of Head and Neck Cancer, and how they impact speech, swallowing, and voice

• Evaluation and Treatment approaches status post surgery.  Surgical reconstruction approaches, and impact on communication and swallowing.

Outline continue

• Evaluation and Treatment approaches during chemo-radiation, and impact on communication and swallowing

• Post treatment outpatient role • Evaluation and Treatment for patients with a

laryngectomy.  Focus on pre-operative, post-operative, and long-term treatment.  Discussion of communication options.

• Case studies and questions

Incidence

• Head and neck cancer accounts for 3-5% of all cancers in the United States

• 35,000 new oral and oralpharyngeal cancers• About 6,800 deaths

• 12,360 new laryngeal cancers• About 3,650 deaths

• More men than women will be affected• More common over the age of 50

Incidence (cont)

• Rate of new cases dropping past few decades

• Recent rise in cases of oral pharyngeal cancer related to Human Papilloma Virus (HPV)– Especially in white men under 50

• Rates vary among countries with much higher rates in Hungary and France

Cancer Staging

• Describes the extent or severity• TNM system (tumor, nodes, metastasis)

– For example T3N2M0– T=extent of tumor (0-4)– N=spread to nearby lymph nodes– M=whether any distant body parts are involved

• TNM corresponds to one of five stages (Stage 0-Stage IV)

Nasopharyngeal Cancer

• Nose and paranasal cavities including sinuses

• Different types of cancers can develop depending on the type of tissue

• Impacts smell, breathing, and resonance

Nasopharyngeal (cont)

• Rare, more common in other parts of the world (Asia)– Males from Kwangtung Province (Cantonese)

40 times that of US Caucasian males

• Twice as high in men than in women• Tends to occur in people between the

ages of 45-85• 54% of patients survive 5 years after

diagnosis

Oral Cancer

• Lips

• Cheeks

• Gums

• Floor of mouth

• Hard palate

Oral Cancer (cont.)

• Soft palate• Tongue• Tonsils• Mandible• Salivary glands

Oral Cancer (cont.)

• More than 90% are squamous cell carcinoma• Rates are more than twice as high in men

than women– Except women have a higher incidence of salivary

gland cancer

• 84% of patients survive at least 1 year after diagnosis– 59% survive 5 years– 48% survive 10 years

Laryngeal Cancers

• Larynx-including the vocal cords

• Epiglottis• Base of tongue• Pharyngeal walls

Laryngeal Cancers (cont.)

• Hypopharynx/Supraglottis-from the epiglottis to the arytenoids

• Subglottic-below the vocal cords• 95% are squamous cell carcinomas• One of the most common types of head and

neck cancer• 64% survive 5 years

Causes of Head and Neck Cancer

• Overwhelming majority of head and neck cancers are related to prolonged exposure to environmental factors

Causes (cont.)

• Tobacco: Tobacco contains many carcinogens- Pipe smoking associated with lip cancer- Cigarette smoking plays a causative role in

tongue, pharyngeal, laryngeal, esophageal, and lung cancer

- Reverse smoking (where the burning end of the cigarette is kept in the mouth), which is popular in parts of India, Sardinia, Venezuela, and Panama is associated with hard palate cancer

Causes (cont.)

• Sunlight-Lip cancer, skin cancer• Frequent and heavy alcohol consumption

– Synergistic with tobacco– Ethanol per se, not a carcinogen, other factors

implicated

• Occupational Factors-nickel workers, wood workers implicated in paranasal sinus cancer

Causes (cont.)

• Epstein-Barr Virus-possible etiological role in nasopharyngeal carcinoma

• Poor oral hygiene-oral cavity, especially floor of mouth, tongue, and alveolar ridge

• Nutritional deficiencies-specific role not established, but an area of research

• Reflux• Exposure to second hand smoke

Causes (cont.)

• Genetic factors– genetic link is not completely understood– some neoplasms have had recent chromosomal

identification

• Radiation- Ionizing radiation, which was used in the past to

treat acne, tonsillar hypertrophy, and enlarged thymus in newborns has led to increased risk of some cancers

• Weakened immune system• Human papillomavirus (HPV)

Human Papiloma Virus

• In 1970’s, HNSCC has decreased along similar trend to reduced cigarette smoking

• Large increase in HPV positive tumors since 1970s– HPV oralpharyngeal SCCC increased 225% between 1988-

2004

• 70% of new cases of oral cancers linked to HPV– Surpassed tobacco use as leading cause

• Usually diagnosed at higher stage

HPV continued• Population is different

– Younger• Oral HPV infections peaked in 30-34 year olds and 60-64

year olds

– Healthier– Mostly male

• 6-7 times more common in men as opposed to general oral cancers are 2 times more likely in men

• HPV tumors respond better to treatment and higher survival rates– 2-3 year survival is 80-95% (HPV negative is 57-62%)

Prevention of H + N Cancer

• According to WHO: “While tobacco use is the single largest causative factor -accounting for about 30% of all cancer deaths in developed countries and an increasing number in the developing world – dietary modification and regular physical activity are significant elements in cancer prevention and control. Overweight and obesity are both serious risk factors for cancer. Diets high in fruit and vegetables may reduce the risk for various types of cancer, while high levels of preserved and/or red meat consumption are associated with increased cancer risk.”

Multidisciplinary Team

• Surgeon

• Radiation Oncologist

• Medical Oncologist

• Speech Pathologist

• Physical Therapist

• Occupational Therapist

• Dentist

• Dietician• Social Worker• Respiratory

Therapist• Nursing

Treatment Options

• Surgery

• Radiation

• Chemotherapy

Surgery

Surgery types

• Most common types– Glossectomy/partial glossectomy– Tonsilar – Base of tongue– Floor of mouth– Mandible– Maxilla– Buccal– Laryngectomy

More surgery

• Radial forearm free flap (RFFF)

• Fibular free flap (FFF)

• Transoral Robotic Surgery (TORS)– Minimally invasive– Reduce need to split the jaw– Reduce infection risk– Shorted hospital stay, faster recovery

TORS

Protocols for Surgeries

• Unofficial

• MD’s will clarify for specific patients

• Surgeons: Drs Bell, Dierks, Bui, Petrisor, Ueeck

Neck Dissection Only

Neck Dissection Care

• Eating: ASAP– Start with clear liquids, advance as tolerated to

regular

• Shower: ASAP– Back to the shower head– Do not submerge wound for 2 weeks.– Light antibiotic ointment layer allows small amount

of water to trickle over wounds without problems

Neck Dissection Movement• Ambulate: ASAP, when awake and alert• Avoid exertion, heavy lifting/straining, bending for 2

weeks• Dictated by patient comfort, self-limiting for 2 weeks• Neck turning: initially guarded enough to make

driving and rapid reactions difficult• Spinal Accessory Nerve almost always spared• If injury to Spinal Accessory Nerve:

• Symptoms may not appear for 1 week post surgery

• Can take 6 months to reconnect

Spinal Accessory Nerve

Spinal Accessory Nerve and Neck Dissection • Goal of Radical Neck Dissection is to remove lymph

node metastasis in one or both sides of the neck, and removes the Spinal Accessory Nerve

• Modified Neck Dissection will spare the Spinal Accessory nerve

• Even when the SAN is spared, problems can arise with the shoulder

• SAN innervates the sternocleidomastoid muscle (tilts and rotates the head) and the trapezius muscle (several actions on the scapula, including shoulder elevation and adduction of the scapula)

Spinal Accessory Nerve• PT or OT help the patient to maintain or regain passive

ROM of the shoulder.

– This can limit or prevent stiffness of the shoulder capsule and ligaments that can arise with malalignment of the shoulder and adhesive capsulitis.

• Significant improvement in mobility, pain, quality of life, and return to previous occupation seen with patients receiving therapy.

– Early and prolonged therapy, beginning within 1 month of surgery and lasting, on average, 3 months.

Glossectomy, Hemiglossectomy

Glossectomy, Hemiglossectomy• Eating:

– Free Flap: 1-2 weeks before eating (tube feeding)– No Free Flap: eating ASAP

• Shower: same as Neck Dissection

• Movement: same as Neck Dissection

Base of Tongue

• Deficits depend on how much tissue is removed

• Can affect swallowing and speech

• Pain can limit intake

Radiation Therapy

Radiation Therapy

• Intensity-modulated radiation therapy (IMRT)– precise radiation doses to a malignant tumor

or specific areas within the tumor. – allows for the radiation dose to conform more

precisely to the three-dimensional (3-D) shape of the tumor

– allows higher radiation doses to be focused to regions within the tumor while minimizing the dose to surrounding normal critical structures.

• Spares healthy tissue and organs

IMRT

Chemotherapy

Chemotherapy

• Cisplatin– Cross links DNA, which ultimately triggers

apoptosis (programmed cell death)– Traditionally 100 mg/m² every 3 weeks– To attempt to reduce side effects, some

doctors using 33 mg/m² every week• The research has mostly been done on the

traditional method

Cisplatin Side Effects

• Kidney damage

• Nerve damage

• Nausea and vomiting

• Ototoxicity

• Electrolyte disturbances

• Decreased sense of taste

• Fatigue

Exercise in Dysphagia Rehabilitation

How common is dysphagia in H and N cancer?

Prevalence of Dysphagia in H + N Cancer• Patients with oral-pharyngeal dysphagia: 50.6% • Mostly to solid foods: 72.4% • Patients with total glossectomy and

chemoradiotherapy had the highest rate of dysphagia.

• Nutritional support: 57.1% • Malnutrition: 20.3%• Patients reported a decrease in their quality of life

due to dysphagia: 51%

Long-term prevalence of oropharyngeal dysphagia in head and neck cancer patients: Impact on quality of life, Garcia-Peris, P; Clinical Nutrition, Dec 2007

Swallowing disorders in head and neck cancer patients treated with radiotherapy and adjuvant chemotherapyLazarus, CL, et al, Laryngoscope; 1996, Sept, 106

• Study of 9 patients undergoing external beam radiation and chemo for H + N Cancer

• 7 of the 9 experienced reduced posterior tongue base movement toward the posterior pharyngeal wall and reduced laryngeal elevation during the swallow

• All 9 patients experienced reduced efficiency of their swallowing compared to normals

Do exercises help with swallowing?

Strength-Training Exercise in Dysphagia Rehabilitation: Principles, Procedures, and Direction for Future ResearchBurkhead, L, et al; Dysphagia 2007 (22)

• Muscles involved in mastication and swallowing exhibit unique fiber types, architecture, and composition, unlike any other human skeletal muscle.

• They undertake a wide spectrum of actions– respiration, speech, mastication, and swallowing

• Demand may shift rapidly from tonic contractions for maintaining airway patency during inhalation to rapid low-force movements during speech to forceful bursts during chewing.

• Contain Type I, IIa, and IIb fibers, with a predominance of Type II fibers.

Continue of Strength Training

• Simply swallowing food or liquid does not provide the degree of load needed to force adaptations in the neuromuscular system to increase strength

• Exercise programs usually involve non-swallowing strengthening with good results, but will have even greater effect when in conjunction with task-specific swallowing practice

Dysphagia treatment after surgery

Post-op Swallowing Exercises

• ALWAYS check MD’s restrictions prior to starting PO• Gentle in beginning secondary to tenderness and

pain• Related to location of surgery

– Jaw=opening/closing jaw– FOM=tongue, jaw– Tongue=see glossectomy exercises

• Stress good oral care• As surgery heals, exercises can be progressed

Glossectomy

• Must address tongue movement for mastication, swallow and articulation

• Total glossectomy will have difficulty with articulation, and manipulation of all boluses.– Compensatory strategies such as positioning, use

of buccal muscles

Glossectomy Continued

• More common for a partial glossectomy, leaving a remainder of the tongue.

– Radial Forearm Free Flap including skin and blood supply

– Flaps have no motor function, so they are unable to propel the bolus

– Sensation can vary, which will impact the ability to sense the bolus in the mouth

• The patient should also be taught self examination to insure that he/she is not damaging the remainder of the tongue while chewing

Partial glossectomy exercisesAdapted from Dennis Fuller, Ph. D

• Mandible opening; open mouth as far as possible. This is good exercise for stimulation of tongue base.

• With a tongue blade; push non-affected side of tongue against blade for count of three and relax.

• Attempt to lick alveolar ridge, left to right, then right to left.

• Attempt to lick lip, left to right , then right to left.

• Attempt to push non-affected cheek out and hold for count of three.

• With teeth together and lips closed, attempt to push tongue forward and hold for count of three.

• Repeat #6 but push tongue to roof of mouth for count of three.

Continue Glossectomy exercises

• For prevention of saliva pooling, pucker lips and do a strong suck-back and swallow.

• Any attempted articulation is good stimulation for tongue movement– Start with non-glossal sentences and then move into some

that have glossal movement. – i.e, "Why buy ham mom", "May I have more" and move to,

"Head light" "small hotdog"

• If the patient is not a risk for aspiration, any swallowing activity is good stimulation for tongue movement. Start with a consistency that is easy to manage such as pudding or honey and move to a thinner consistency.

What does chemoradiation do to swallowing?

Effects of Chemoradiotherapy on Tongue Function in Patients With Head and Neck CancerLazarus, CL, Perspectives on Swallowing and Swallowing Disorders, 18 55-60, June 2009

• Radiation can cause neuropathies, specifically, within the hypoglossal nerve

• Tongue strength has been found to be impaired following radiation to the head and neck. – Decrease in lingual strength can occur long after

completion of radiation and can have a negative effect on swallowing

• Exercise programs that target pharyngeal structures as well as the tongue may play a critical role in maintaining and improving swallow functioning

Do exercises help with swallowing for individuals with H and N cancer?

Pretreatment, Preoperative Swallowing Exercises May Improve Dysphagia Quality of LifeKulbersh, BD MD, et al, Laryngoscope, 116, 6. June 2006

• 25/37 patients were started on swallowing exercises 2 weeks prior to beginning radiation

• The M.D. Anderson Dysphagia Inventory (MDADI) was administered 14 months after treatment

• Those patients who completed the swallowing exercises, showed improved scores on the MDADI as compared the the control group

• Separate analysis demonstrated improved quality of life for those that did the exercises

Dysphagia treatment during Chemo-Radiation Treatment

Pretreatment Dysphagia Protocol for the Patient With Head and Neck Cancer Undergoing ChemoradiationMcColloch, NL, et al, Dysphagia, 19, June 2010

• Initial meeting: – Swallow evaluation– may include diet modifications, postural changes, and oral

motor exercises.• Ongoing contact with the patient during treatment is a

priority– reinforce the exercise protocol, – assess the risk of aspiration, – continually evaluate the patient’s hydration and mucous

status• Oral-motor exercises focus on maintaining tongue range

of motion and strength, hyolaryngeal elevation, vocal fold mobility, and rotary jaw motion.

Pretreatment Dysphagia Protocol

• Tongue exercises include passive range of motion and active assistive range of motion.

• Tongue Hold• Effortful Swallow• Laryngeal elevation exercises: pitch glides and

vocalizing /i/ at a high pitch. • Mendelhsohn Maneuver and Shaker Exercises • Jaw range of motion exercises: maintain rotary

movements of mastication and decrease the chance of trismus

Swallowing Treatment During Radiation

• Begin treatment at start of radiation, however patients will usually be tolerating PO

• Start oral-motor and swallowing exercises– Tongue press, Masako, Super Supraglottic have

been proven– Reinforce importance of continuing through

treatment and after• Educate on keeping moisture in mouth• Continue to treat through Radiation to assess diet

tolerance, continuing exercises, comfort measures– Swallowing will change as treatment progresses

Impact of disabilities on patients

Disability in Patients With Head and Neck CancerTaylor, J. C, MD, et al, Arch Otolaryngology Head Neck Surg. 2004;130:764-769

• More than half of the patients were disabled by their H + N cancer or treatment.– About half of those who underwent a neck

dissection, were unable to work afterward • Those undergoing chemotherapy or neck dissection

or have high pain scores are at increased risk • While undergoing chemo, they often develop

profound deconditioning or fatigue. They also often have mild to moderate neuropathies, dysphagia, loss of taste, and potentially other adverse effects

Physical Activity Correlates and Barriers in Head and Neck Cancer PatientsRogers, LQ, et al, Support Care Cancer, 2008, 16

• Physical activity improves cardio-respiratory fitness during and after cancer treatment, symptoms and physiologic effects during treatment, and vigor post-treatment

• Most prevalent barriers to physical activity include enjoyment, and treatment related difficulties – dry mouth or throat, fatigue, drainage in mouth or

throat, difficulty eating, shortness of breath, and muscle weakness.

• Efforts to enhance exercise adherence should focus on enjoyment and managing treatment barriers

Physical activity and quality of life in head and neck cancer survivorsRogers, LQ, et al; Support Care Cancer; 2006, Oct; 14

• 59 H + N survivors were given survey of physical, emotional, social and functional well being

• Few H + N Cancer survivors are participating in moderate or vigorous exercise. Over half are sedentary

• Meaningful associations between total exercise minutes, QoL, and fatigue were noted.

• Appears that an exercise program may benefit this survivor group.

Laryngectomy

Laryngectomy continue• Eating: NPO 2 weeks

– NG tube feedings– Cleared with a modified barium swallow study first

• Shower: Unique issues– Back to the shower head– Open hand, press anteriorly to protect the stoma

• No soaking in hot tub or bathtub

• No Chiropractor or cervical manipulations

Laryngectomy Communication Options

• Electrolarynx

• TEP (tracheo-esophageal prosthesis)

• Esophageal speech

Electrolarynx

• Usually taught to every patient post-laryngectomy.– Even if it is not their permanent communication

choice, it is a backup for emergencies• Ordered prior to leaving the hospital• Start with an oral adaptor because of swelling

Electrolarynx continue

• Oregon Telecommunication Devices Access Program

• Attached to the phone

• Must have a land line

• If patient lives alone, good option for emergencies

IPALPATAdapted from “Total Laryngectomy: SLP Survival Guide,” Benjamin, Meaghan Kane, Bunting, Glenn, and DeLassus Gress, Carla, ASHA Convention 2011

• I=Information– The patient is informed about the benefits of

artificial larynges and selection of the proper device– Influential factors:

• Purchase price

• Upkeep

• Availability

• Possible modifications

• Expediency

• Post-operative complications

• Patient preferences

IPALPAT continue• P=Placement

– Optimal placement of device to achieve the best clarity of sound and resonance

– With intra-oral devices appropriate placement of the intra-oral tubing to achieve the best clarity of sound and resonance

• Bend it about 45 degree angle• Lay upon tongue or up against roof of mouth• Usually lateral region along one side of tongue• May consider cheek placement if adequate resonance and tolerated

by patient• Insert only 1-2 inches of tubing with upward or downward orientation• Practice speaking around the tube, don’t hold it with lips, tongue or

teeth

IPALPAT continue• A=Articulation

– Shaping sound into speech using the tongue, teeth, lips, and palate for precise sound production

– Over articulation is recommended to improve overall intelligibility

– Placement of the artificial larynx should not result in obstruction of the mouth as some lip reading may be used by the listener

IPALPAT continue• A=Articulation continue

– Plosive and fricative voiceless features (p, t, k, s. sh, ch, f, th) must be produced with effort over the sound of the electrolarynx

– Keep it practical, avoid working on single words unless necessary for specific articulatory drills

– Voiced sounds are better perceived than voiceless

IPALPAT continue• T=Timing

– Effective use of on/off button to coincide with appropriate phrasing

– Biggest challenge is the learning curve to activate device as speech is initiated and turn off device at the end of the final word in a phrase

– Using 7-10 syllable phrases and training the patient to learn to phrase as they turn sound on and off is effective way of teaching this portion

IPALPAT continue• PAL=Pitch and Loudness

– The pitch of the electrolarynx is set by the SLP during the initial artificial larynx treatment session

• Adjusted to a level appropriate to the patient’s age and gender

– Loudness/Volume adjusted so that the patient can hear himself clearly

– Individuals can be taught to modulate pitch for more natural intonation patterns by manipulating the buttons on the external device

IPALPAT continue• PAL=Pitch and Loudness continue

– Instruction in basic volume adjustments specific to individual’s device should be offered within the first few treatment sessions

– Keep volume as low as possible– Keep pitch as low as acceptable

IPALPAT continue• Distracting behaviors

– Refer to any behavior that draws attention to the patient in a negative way

• Stoma blasting• Head tilted back• Grimaces• Atypical arm postures

– These behaviors should be addressed during each session

Other Communication Strategies

• When talking on the phone, hold receiver between mouth and nose

• Face communication partners

• Exaggerate facial expression to emphasize verbal expression

TEP (tracheo-esophageal prosthesis)• Most common communication choice

• Sounds more “normal”

• Not perfect choice for every one

Esophageal Speech

• Much less common

• Difficult to learn

• “Burp speech”

Post-laryngectomy stoma care

• Clean around the stoma multiple times per day– May require some cleaning with hemostats,

gauze, and saline spray to clear dried secretions

• Saline boluses– Use saline “bullets”– Start with small amount (3-5 ml)– Squirt directly into the stoma– Cough if able, or suction after– Do 2-3 times per day

Lary tubes and HMEs

• Lary tubes– Cleaned throughout the day– Rinsed under running water– Replaced using water based lubricant

• HME (Heat Moisture Exchange)– Do not use with trach mist– Worn as long as tolerated (trach mist if not on)– Change if coated or at least every 24 hours

Adhesive base plates

• Can be worn if lary tube is not tolerated, but always check with surgeon first

• Immediate post-op, only the optiderm

• Housing unit for HME

• Can stay on without HME in and trach mist on

Post-surgical issues

• Trach– Unable to have Valsalva-Open system

• Can impact ability to bear down for bowel movement (often issues with pain medications)

• Teach them to cover trach, if able, when having bm

• NG tube– Can be irritating when rubbing on post-surgical

tissue

Support Groups

• Head & Neck Cancer Support Group: Education and support for individuals and families coping with the – Impact of a head, neck or oral cancer

diagnosis.– Legacy Good Samaritan Medical Center: 1st

Thursday, 4-5:30 pm• Conference Room 219, Good Samaritan Building 3,

2nd floor• Contact Julia Robinson, MS CCC-SLP at

[email protected] or 503-413-2841

Support Groups continue

• Nu Voice Club– Meet at American Cancer Society

• 0330 SW Cury St, Portland, OR

– 1:00 3rd Saturday of each month– Call Blayne Graves 503-795-3918– Or Email [email protected]

Thank you for coming!