Treatment Protocols for Individuals Undergoing Organ Preservation Treatment Heather Starmer, M.S., CCC-SLP 1 Donna C. Tippett, M.P.H., M.A., CCC-SLP 1,2 Department of Otolaryngology—Head and Neck Surgery 1 Department of Physical Medicine and Rehabilitation 2 Johns Hopkins University
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Treatment Protocols for Individuals Undergoing
Organ Preservation Treatment
Heather Starmer, M.S., CCC-SLP1
Donna C. Tippett, M.P.H., M.A., CCC-SLP1,2
Department of Otolaryngology—Head and Neck Surgery1
Department of Physical Medicine and Rehabilitation2
Johns Hopkins University
Learner objectives
• Explain treatment protocol from pre- to post-treatment
• Describe therapeutic interventions that may be beneficial
• Discuss current literature influencing clinical decision making
• Surgical oncology• Radiation oncology• Medical oncology• Speech-language pathology• Nursing• Social work• Dietary• Research coordinator• Clinical care coordinator
Multidisciplinary Care
• 2008 Practice guidelines consider multidisciplinary care as standard of care for head and neck cancer patients– NCCN (National Comprehensive Cancer Network)– ESMO (European Society of Medical Oncology)– AHNS (American Head and Neck Society)
Multidisciplinary Care
• Blair & Callender, 1994– Collaboration and communication of
multidisciplinary teams have had a profound effect on the treatment of head and neck cancer
– “Essential for positive outcomes”
Potential Benefits of Multidisciplinary Assessment
• Westin & Stalfords, 2008– Built in second opinion for treatment planning– Education– Increased consideration of ethics and QOL– Cost efficiency– Coordination of care– Improved patient outcomes
Additional Benefits of Multidisciplinary Approach
• Increased recruitment for research (McNair et al, 2008)
• Fewer missed visits (Dwyer et al, 2008; Kremp et al, 2008)
Tumor Board Conferences
• Weekly
• Confirm diagnosis and stage
• Treatment planning
• Referrals
• Multidisciplinary
Tumor Board Conferences
• Head and neck surgeons• Medical oncologists• Radiation oncologists• Oral pathologists• Oncology nurses• Otolaryngology nurses
• Videostroboscopic findings– Increased supraglottic tension– Pooling of thick secretions– Impaired mobility– Glottic incompetence– Irregularity of leading edge of vocal fold– Asymmetry and inadequate amplitude and mucosal
wave
Fung et al, Journal of Otolaryngology, 2001Meleca et al, Laryngoscope, 2003
Organ Preservation Approachesand Dysphonia
Voice Handicap Index findings• 27% reported significant handicap• Self-perceived handicap greater in younger
individuals• Handicap increased as a function of time post-
treatment
Fung et al, Journal of Otolaryngology, 2001
Meleca et al, Laryngoscope, 2003
Organ Preservation Approachesand Dysphonia
Acoustic/aerodynamic findings• Lower fundamental frequency for females• Elevated jitter and shimmer• Reduced MPT• Elevated subglottic pressure and glottal resistance
Fung et al, Journal of Otolaryngology, 2001Meleca et al, Laryngoscope, 2003
Xerostomia and Voice
• Roh et al, Journal of Clinical Oncology, 2005– Wide field radiation had greatest impact on salivary
flow (four fold difference)– Increased voice disturbance (elevated but not
significant)– Increased abnormalities under videostroboscopy
(supraglottic activity, dryness of vocal folds, stickiness of secretions)
– Reduced voice related quality of life (moderate or greater impairment on VHI)
Voice Therapy
• Improve vocal hygiene
• Improve glottic valving
• Balance respiratory, phonatory, and resonant systems
• Improve pliability and pitch variability
• Reduce supraglottic constriction
• Compensate
Voice Intervention
• vanGogh et al, Cancer, 2006– Efficacy of voice therapy following treatment
for laryngeal cancer– Findings:
• Voice Handicap Index– Average improvement of 15 points post-treatment
• Acoustic parameters– Improvement in NHR and jitter post-treatment– Subjective reduction in perception of vocal fry
• Pauloski et al, Head & Neck, 2006– Prospective cohort study– VFSS pre- and post tx– N = 170 with head/neck SCCA– Identified multiple decompensations– Limitations in oral intake and diet post tx were
significantly related to:• Reduced laryngeal elevation• Reduced CP opening• Rating of nonfunctional swallow on at least 1 bolus type
Recovery
• Goguen et al, 2006
Months % Soft or Regular Diet
% GT Removed
3 17 27
6 53 63
9 70 80
12 80 81
24 97 90
Recovery
• Dworkin et al, Dysphagia, 2006– N = 14 with Stage III/IV laryngeal SCCA– <12 months: 43% regular/near normal diet– >12 months: 86% regular/near normal diet
Regular diet 3
Near normal diet 6
Puree 3
Gastrostomy tube
2
Recovery
• Pauloski et al, 2006
% with <50% oral intake
% with non-normal diet
Pre-tx 5.1 37.8
1 mos post 39.5 74.4
3 mos post 25.9 63.6
6 mos post 19.1 56.0
12 mos post 12.5 40.3
Exercise Principles
• Goal selection• Specificity of training• Overload/progression
Clark, AJSLP, 2003
Exercise Principles
• Goal selection
• Specificity of training
• Overload/progression
Clark, AJSLP , 2003
Exercise Principles
• Goal selection
• Specificity of training
• Overload/progression
• Clark, AJSLP , 2003
Therapy Targets
• BOT retraction
• Tongue strength
• Laryngeal elevation
Goguen et al, 2006
Logemann et al, 2006
Pauloski et al, 2006
Oral Care as Treatment
• Pneumonia, febrile days and death from pneumonia significantly decreased in patients with oral care than those without oral care
Adachi et al, Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 2002Yoneyama et al, J Am Geriatr Soc, 2002
Medical/Surgical Tx for Dysphagia/Dysphonia
• Dilatation– Surgical– Chemical
• Cricopharyngeal myotomy/Botox• Vocal fold medialization by injection• Medialization thyroplasty
• Body Mass Index (BMI) effects– Low BMI associated with:
• Higher probability of recurrence• Lower overall survival
McRackan et al, 2008
To tube or not to tube…
• Patients at greatest risk for weight loss during treatment– Nasopharynx or tongue base primary– Addition of chemotherapy to radiation– Hyperfractionated radiotherapy– Significant pre-treatment weight loss (>10% of weight 6
months prior to treatment)– Eating difficulties prior to treatment– Unpartnered male patients
Beaver et al, 2001; Larsson et al, 2005; Konski et al, 2006; Piquet et al, 2002
To tube or not to tube…
• Positive effects of prophylactic tube feeding– Reduction in weight loss for elective,
prophylactic tube feeds in contrast to therapeutic tube feeds or no tube (Chen et al, 2008)
– Reduction in admissions for dehydration during treatment (Scolapio et al, 2001, Beaver et al, 2001)
– Avoidance of treatment interruptions
To tube or not to tube…
• Mekhail et al, Cancer, 2001– Those with NGFT
• Less long term dysphagia• Shorter FT duration• Less need for dilatation
– Stenting function– Motivate patients to swallow sooner
To tube or not to tube…
• Negative side effects of tube– Increased discomfort at tube site– Tube blockage– Tube migration or dislodgement– Peritonitis, perforation, tumor seeding
(Rosenthal et al, 2006)
– May lead to patient over-reliance• Scar and stricture formation (Caudell et al, 2008)
How We Address It
• Patient education
• Patient encouragement
• Regular follow up in high risk patients
• Suggest prophylactic tube for patients in high risk groups
To stim or not to stim…
• Pro– Combine with other tx techniques
• Effortful swallow
– Use as a resistance exercise• Mendelsohn
– May decrease fibrosis
To stim or not to stim…
• Con– Cannot stimulate deep muscles– Contraindicated in SCCA