HOW SPEECH PATHOLOGISTS CAN BETTER SERVE THE HEAD

HOW SPEECH PATHOLOGISTS CAN BETTER SERVE

THE HEAD AND NECK CANCER POPULATION

A Thesis

Presented to the faculty of the Department of Speech Pathology and Audiology

California State University, Sacramento

Submitted in partial satisfaction of the requirements for the Degree of

MASTER OF SCIENCE in

Speech Pathology by

Jamie Roberta Gomes

Spring 2014

© 2014

Jamie Roberta Gomes

ALL RIGHTS RESERVED

HOW SPEECH PATHOLOGISTS CAN BETTER SERVE

THE HEAD AND NECK CANCER POPULATION

A Thesis by

Jamie Roberta Gomes

Approved by:

_________________________________________________________, Committee Chair

Ann Blanton, Ph.D., CCC-SLP

_________________________________________________________, Second Reader

Robert Pieretti, Ph.D., CCC-SLP

___________________

Date iii

Student: Jamie Roberta Gomes

I certify that this student has met the requirements for format contained in the

University format manual, and that this thesis is suitable for shelving in the Library and credit is to be awarded for the thesis.

_________________________________, Department Chair __________

Ann Blanton Date

Department of Speech Pathology and Audiology iv

Abstract of

HOW SPEECH PATHOLOGISTS CAN BETTER SERVE THE HEAD AND

NECK CANCER POPULATION by

Jamie Roberta Gomes

Statement of Problem

This preliminary investigation examined potential barriers to effective assessment and treatment of patients who undergo radiotherapy in the head and neck cancer (HNC) population. The focus of the study was to determine whether oral or vocal hygiene is discussed with HNC patients during pre-radiation and post-radiation consultations, and if there is a need for oral and vocal hygiene protocols for HNC patients treated with radiotherapy. Physiological effects of radiotherapy, and hygiene protocols and their potential effect on reduction of radiotherapy symptom severity are discussed.

Sources of Data

A total of 15 Otolaryngologists—Ear, Nose, and Throat (ENT) physicians—and 15

Speech-Language Pathologists (SLPs) responded to a web-based survey regarding clinical services and information provided to HNC patients in the pre-radiation and post-radiation stages of the radiotherapy treatment process. v

Conclusions Reached

Respondents from both ENT and SLP groups indicated that consultations with HNC patients prior to radiotherapy were conducted less frequently than after radiotherapy, and that it would be beneficial to have an oral or vocal hygiene protocol for HNC patients.

_______________________, Committee Chair

Dr. Ann Blanton

_______________________

Date vi

TABLE OF CONTENTS

Page

List of Table .................................................................................................................. ix

List of Figures ................................................................................................................ x

Chapter

1. INTRODUCTION .................................................................................................. 1

Problem ......................................................................................................... 1

Purpose ......................................................................................................... 2

2. REVIEW OF THE LITERATURE ........................................................................ 4

Background ................................................................................................... 4

Physiologic Effects of Radiotherapy .......................................................... 5

Hydration of Tissue ...................................................................................... 8

Patient Experience ........................................................................................ 9

Rehabilition Efforts and Recovery ............................................................... 10

Conclusions and Future Directions .............................................................. 13

3. METHODOLOGY ................................................................................................. 15

Participants ................................................................................................. 15

Materials ...................................................................................................... 15

Disbursement and Collection of Data ........................................................... 16

Privacy Protection and Anonymity of Survey Correspondents .................... 16

Statistical Methodology ............................................................................... 17 vii

Page

4. ANALYSIS OF THE DATA ......................................................................................... 18

Organization of Data ................................................................................... 18

Survey Responses ......................................................................................... 25

ENT Survey Results ..................................................................................... 25

SLP Survey Results ...................................................................................... 44

Disbursement and Collection of Data ........................................................... 16

5. DISCUSSION ................................................................................................................. 63

6. CONCLUSIONS AND FUTURE DIRECTIONS ......................................................... 67

Appendix A. Sample Consent Letter .............................................................................. 70

Appendix B. Sample Ear, Nose, and Throat Doctor Survey ......................................... 71

Appendix C. Sample Speech and Language Pathologist Survey ................................... 75

References ..................................................................................................................... 78 viii

LIST OF TABLES

Page

Table 1 Ear, Nose, and Throat Physician Survey Responses .................................... 19

Table 2 Speech Language Pathologist Survey Responses ........................................ 22

ENT Table 1 .............................................................................................................. 27

ENT Table 2 .............................................................................................................. 32

ENT Table 3 .............................................................................................................. 33

ENT Table 4 .............................................................................................................. 36

ENT Table 5 .............................................................................................................. 38

ENT Table 6 .............................................................................................................. 41

SLP Table 7 ............................................................................................................... 45

SLP Table 8 ............................................................................................................... 49

SLP Table 9 ............................................................................................................... 53

SLP Table 10 ............................................................................................................. 55

SLP Table 11 ............................................................................................................. 59

SLP Table 12 ............................................................................................................. 61 ix

LIST OF FIGURES

Page

ENT Figure 1 ................................................................................................ 28

ENT Figure 2 ................................................................................................ 29

ENT Figure 3 ................................................................................................ 31

ENT Figure 4 ................................................................................................ 34

ENT Figure 5 ................................................................................................. 36

ENT Figure 6 ................................................................................................. 38

ENT Figure 7 ................................................................................................. 40

ENT Figure 8 ................................................................................................. 42

ENT Figure 9 ................................................................................................. 43

SLP Figure 10 ................................................................................................ 46

SLP Figure 11 ................................................................................................ 47

SLP Figure 12 ................................................................................................ 50

SLP Figure 13 ................................................................................................ 52

SLP Figure 14 ................................................................................................ 56

SLP Figure 15 ................................................................................................ 58

SLP Figure 16 ................................................................................................ 60 x

1

CHAPTER 1

INTRODUCTION

Problem

The use of radiotherapy is well established and proven to be effective in the treatment of some head and neck cancers. However, due to the radiation administered during treatment, physiological changes occur not only to cancer cells, but to the healthy tissues surrounding them as well (Sieracki, Voelz, Johannik, Kopaczewski, &

Hubert, 2009). The extent of those changes may be related to frequency of treatment, dosage, and the sites exposed to radiation (Grandi, Silva, Streit, & Wagner, 2007), but any change may have a negative impact on the function of the oral and laryngeal regions of individuals receiving treatment. For example, tissue changes due to radiotherapy may impair a patient’s ability to drink or eat, which could cause weight loss (Rose-Ped, Bellm, Epstein, Trotti, Gwede, & Fuchs, 2002) that subsequently leads to a reduction in the ability to recover fully. This reduction results not only from the lack of caloric intake, but from the distress caused by loss of quality of life.

Because of these physiological changes, oral care and vocal hygiene protocols in which oral and vocal hygiene techniques are used with specified frequencies may be recommended by physicians or SLPs to increase hydration of the oral cavity and laryngeal tissues. These practices may help to normalize tissue function, or at least somewhat alleviate the effects of radiotherapy. Hydration and healthier tissues

2 contribute to more normal voice production, swallowing, taste, and chewing.

Restoring tissue function is an important part of ensuring that a patient can be a functional communicator in a variety of environments. Unfortunately, there is limited research examining whether the use of an oral and/or vocal hygiene protocol preradiotherapy for head and neck cancer (HNC) patients can impact the outcome or severity of oral and laryngeal symptoms after treatment. It is important to investigate the use of oral and/or vocal hygiene techniques prior to radiotherapy treatment, as they might reduce physiological changes, especially those that affect oral and laryngeal function, which affects quality of life.

Purpose

The purpose of this survey was twofold: (1) to determine whether oral and/or vocal hygiene is discussed with HNC patients during pre-radiation and post-radiation consultations, and (2) to determine if there is a need for an oral and/or vocal hygiene protocol that instructs HNC patients in specific hygiene techniques. An oral and/or vocal hygiene protocol may include techniques or regimens that maintain hydration of the tissue, reduce stress on the tissue, and/or eliminate exposure to harmful substances.

Oral and vocal hygiene protocols can be crucial components of vocal health that promote the production of mucus and enable the nose, mouth, throat, and airway of a patient to remain lubricated.

Throughout Chapter 2, the effects of radiotherapy, oral and vocal symptoms associated with HNC patients after radiotherapy, the importance of early rehabilitative efforts and oral care regimens, and the impact of hydration on oral and vocal tissue

health are discussed in more depth. Chapter 3 describes the participants, materials,

3 design and procedures used to conduct the survey. The results from this survey are presented and discussed in Chapter 4. Finally, Chapters 5 and 6 present a discussion of the survey results in terms of how Speech-Language Pathologists can better serve the HNC population through collaboration with other members of a multidisciplinary treatment team by utilizing pre-radiation consultations, pre-radiation baseline evaluation, and long-term evaluation in hopes of reducing effects on speech, swallowing, and quality of life as a result of radiotherapy.

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CHAPTER 2

REVIEW OF THE LITERATURE

Background

Radiation is the combined processes of emission, transmission, and absorption of radiant energy. Radiotherapy is the medical use of ionizing radiation in order to control or kill malignant cells within a focused location. It is a standard treatment method used for HNC patients in the United States. Both malignant cancer cells and healthy cells are exposed to radiation during treatment. Therefore, both types of cells may be affected by radiotherapy, causing changes in skin and soft tissue in the areas where radiation doses are administered. Speech-Language Pathologists (SLPs) who work with HNC patients serve as important members of a multidisciplinary team involving physicians, nurses, pharmacists, and oral medicine specialists who rehabilitate swallowing, voice, and oral complications sustained by HNC patients

(Rose-Ped et al., 2002).

This research was conducted using a survey distributed to Ear, Nose, and

Throat Physicians (ENTs) and SLPs, including members and affiliates of the

American Speech-Language-Hearing Association (ASHA) accessed through the

ASHA database of research survey participants.

5

Physiologic Effects of Radiotherapy

Radiotherapy causes physiological changes that can negatively affect tissues on a cellular level and potentially result in swallowing, voice, and oral complications.

These changes can lead to a variety of side-effects such as reduced saliva production, infections, limitation of mouth opening, hardening of tissue, difficulty tasting food and swallowing, weight loss, mouth sores, and/or vocal fatigue as a result of postradiotherapy treatment (Lazarus et al., 2010). Shortly after treatment, a significant number of patients encounter swallowing limitations, speech deterioration, and psychological problems that can result in a decrease in their quality of life

(Borggreven, Leeus, Langedjik, et al., 2005).

Damage from radiotherapy is done to both cancer cells and healthy cells due to the fact that most treatments for cancer cannot differentiate between them (Sieracki, et al., 2009). Normal tissue function of the pharynx, larynx, and other oral cavity sites is greatly decreased because of this damage. Sieracki et al. state that adherence to an oral care protocol can aid in the reduction and severity of oral symptoms. Thus, an oral care regimen may be related to a patient’s rate of recovery.

Tissues of the respiratory tract affected by radiotherapy can include those of the oral cavity, nasopharynx, larynx, pharynx, and the laryngopharynx. Bacterial laryngitis, biopsy of the irradiated larynx, and/or damage to the perichondrium may increase the risk of radiation-induced osteochondronecrosis, an uncommon complication of radiotherapy for laryngeal carcinoma, in which some cell death of bone and cartilage in the irradiated area is sustained (Becker, Schroth, Zbaren,

Delavelle, Greiner, Vock et al., 1997). Changes to the mucosa, including oral mucositis (inflammation and ulcer formation), erythema (redness of the skin), and

6 desquamation—a condition in which outer layers of the skin slough away—are common following radiotherapy to the oral cavity and oropharynx (Arcuri &

Schneider, 1993). A study by Orlikoff and Krauss (1996) revealed that radiation is damaging to salivary and mucus glands. They noted that the initiation and maintenance of phonation is impacted by vocal fold lubrication and hydration.

Complications and side effects are contributing factors that can result in communication disorders affecting the HNC population.

The M. D. Anderson Symptom Inventory for Head and Neck Cancer (MDASI-

HN) patients was developed in 2007. Its purpose was to develop an overall symptom inventory for HNC patients (University of Texas M.D. Anderson Cancer Center,

2012). Data collected by development of this tool aimed to evaluate the overall symptom burden on a patient’s daily life, as well as the occurrence and severity of those symptoms. Data collected by the MDASI-HN included 205 participants with a mean age of 56.9 years. Diagnoses most commonly included diseases of the pharynx, larynx, tongue, and other oral cavity sites. The MDASI was used as a multi-symptom assessment tool where patients indicated the presence and severity of every symptom on a scale of 0-10. A score of 0 indicated the patient thought the symptom was “not present” and a score of 10 indicated the patient thought the symptom was “as bad as they could imagine.”

The MDASI also measured “symptom interference.” This was a measure of the degree to which symptoms interfered with major aspects of a patient’s daily life.

7

This measurement was aimed at obtaining the relationship of post-treatment symptoms to the patients’ quality of life. The items related to HNC patients were ranked in order from highest to lowest in terms of mean severity for the sample. These symptoms included: difficulty swallowing or chewing; problems with mucus; problems with tasting food; difficulty with voice or speech; mouth or throat sores; problems with teeth or gums; choking or coughing; constipation; hair loss; and skin pain, burning or rash. Clusters of closely related symptoms were considered to be indicative of common etiologic factors for such symptoms. (Gaskell, 2010).

The MDASI presents a list of symptoms, definitions of every symptom, and common treatments for those symptoms. Treatments for several symptoms, specifically those that involve salivary gland dysfunction, may be similar. The literature indicates that the following symptoms can be clustered together in HNC patients post-radiotherapy: oral mucositis, xerostomia ( a condition in which the salivary glands do not produce enough saliva or “dry mouth”), hypo-salivation and increase in saliva viscosity, trismis (limitation of mouth opening), opportunistic infections, dyseuaia (decreased sensation of taste), vocal fatigue, and local discomfort

(University of Texas M.D. Anderson Cancer Center, 2012). This clustering of symptoms could indicate that they are closely related, and may be reduced by an oral and vocal hygiene regimen (Gaskell, 2010). Other side effects may include fibrosis, which is the formation of fine scar-like structures that cause tissues to harden.

Fibrosis increases the rigidity of tissues, which reduces the flow of fluids through those tissues. Fibrosis in the tissues also affects the function and nature of the tissues

8 in these structures and may result in trismus (Becker, Schroth, Zbaren, Delavelle,

Greiner, Vock et al., 1997).

Hydration of Tissue

Systemic and surface body dehydration is reflected in the vocal fold mucosa, increasing its viscosity and reducing mucosa mobility (Franca & Simpson, 2009).

Viscosity is a measure of resistance to flow. Viscoelastic properties of mucosa are crucial to the normal function of the oral cavity, pharyngeal, and laryngeal regions.

Functioning soft tissues typically have a healthy layer of mucus covering them.

Keeping the vocal folds moist and lubricated is crucial to vocal health. This lubrication enables the soft tissues to glide past each other with minimal resistance

(Mossman, Shatzman, & Chencharick, 1982). Phlegm, another term for mucus, is part of the hydration system that allows the nose, mouth, throat, and airway to remain lubricated. The lubrication moistens the tissue surfaces, thereby promoting the movement of particles and sensory feedback while reducing friction between tissues

(Baroody, 1998). A coating of mucus should be present on soft tissues to keep it smooth and soft (Stemple, Glaze, & Klaben, 2000). Xerostomia caused by radiotherapy is known to be associated with thick mucus accumulation, fissured or cracked epithelium, and a dry, burning sensation in the mouth (Orlikoff & Kraus,

1996). Dehydrated vocal folds are likely to show epithelial changes that make them vibrate irregularly, making them more susceptible to damage and inflammation.

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Further laryngeal irritation could lead to increased throat clearing, coughing, and increased drying of the tissues.

Patient Experience

Patients of radiotherapy have stated that they were prepared for the “big things” commonly associated with radiation treatments. However, they were not prepared for oral and laryngeal difficulties (Miller, Taylor, Kearnery, Patersno, Wells et al., 2007). HNC patients reported that obtaining information on how to manage oral symptoms, when to seek advice from health professionals, and the impact of oral problems on their enjoyment of life were also issues of concern.

Other difficulties HNC patients encounter include limited financial resources, increased levels of stress, and a limited family or social support system. Difficulties in these areas can cause emotional reactions such as anxiety or depression. Depression, anger, coping with loss, insurance access barriers, and frustration are psychosocial struggles common among the HNC population (Clarke, Sigler, & Logemann, 1998) that contribute to a decline in a patient’s quality of life.

Managed care has contributed to decreased hospital stays, thereby decreasing time for effective clinical interventions before the patient is discharged (Clarke et al.,

1998). Education and prevention efforts outside of the primary care facility are often regulated based on the patient’s insurance provider. Unfortunately, insurance providers may impose limits on the amount of care a patient may receive that is covered by insurance. This insurance limitation can leave patients responsible for the expense of continued treatment, which may further contribute to a decrease in a

10 patient’s quality of life. Borggreven et al. (2003) stated that a patient’s quality of life after treatment gradually improves in the first year, but he/she may still experience speech and swallowing difficulties.

Clarke et al. (1998) state that pretreatment evaluations provide baseline information for current levels of functioning in patients about to undergo radiotherapy.

Baseline information is important in establishing a rehabilitation plan for the HNC population. Short-term and long-term rehabilitative goals may be more effective when decided with consideration of baseline measurements (Watson, 1992). Success in restoring a patient’s quality of life can be ensured by instituting rehabilitation plans that address psychosocial issues, and focus on restoring function of the oral cavity, pharyngeal, and laryngeal regions.

Rehabilitation Efforts and Recovery

According to Clarke et al., the SLP conducts initial assessments of oral structures, voice, swallowing, articulation and jaw mobility after a patient’s healing is ensured (1998). Rehabilitation typically involves post-radiation follow-up consultations until the patient’s rehabilitation potential has been reached. However, rehabilitative efforts should not wait until completion of a patient’s primary medical treatment (Orlikoff & Kraus, 1996).

According to Orlikoff and Kraus, dramatic anatomic and physiologic changes can occur as a result of radiotherapy treatment (1996). But, basic concepts in vocal function and hygiene can be discussed with the patient in preparation for subsequent rehabilitative efforts and follow-up care for the patient prior to radiotherapy treatment.

Rose-Ped et al. (2002) state that an emphasis must be placed on frequent and meticulous oral care as an important part of any treatment approach to reduce the

11 severity of oral complications in patients. A multidisciplinary team which may include SLPs, physicians, nurses, pharmacists, mental health professionals, and oral medicine specialists should be involved during initial cancer diagnosis to establish a damage prevention regimen. This prevention regimen is an integral part of the cancer treatment (Jansama, Vissink, Spijkervet, Roodenburg, Panders et al., 1992).

Jansama et al. (1992) proposed a protocol for the prevention and treatment of oral sequelae resulting from head and neck radiation. The protocol was noted to be especially applicable in centers operating with dental teams due to the wide range of preventive and treatment measures available in such facilities. Pre-radiation patient issues were identified as screening, consequential treatment, explication, patient motivation, and initiation of preventive measures. Of 33 HNC treatment patients who had undergone radiotherapy, 65% had received recommended prophylactic oral care, or were prescribed some type of oral product such as a saline solution (Rose-Ped et al.,

2002).

Vocal care regimens may include protocols for the following: reducing exposure to harmful substances; reducing vocal stressors, such as yelling; stress reduction techniques; relaxation exercises; a decrease in the patient’s amount of daily caffeine intake; and an increase in the patient’s amount of daily water intake. Speech therapy that focuses on a patient’s ability to sustain voicing, vocal quality, pitch and loudness, or increasing pressure from the lungs during speech is also recommended.

Vocal care regimens may be beneficial in the reduction of oral, pharyngeal, and laryngeal symptoms sustained by HNC patients. Examples of specific oral care protocol techniques may include: brushing of the patient’s teeth for 90 seconds four

12 times a day, flossing once a day, rinsing the mouth with normal saline for 30 seconds a day, and sucking ice cubes during the day (Sieracki et al., 2009). These techniques aim to increase hydration of the tissue and therefore increase function and viscosity of the vocal fold mucosa.

Collaborative efforts between the SLP and other team members may increase the frequency of the oral care a patient receives, and the education level of the patient in regards to the importance of following an oral care regimen. Multidisciplinary team members could include SLPs, ENTs, nurses or clinical nurse specialists, radiation oncologists, pharmacists, physical therapist, clinical dietitian, and social workers.

Rose-Ped et al. (2002) discuss the importance of nurses being involved in managing, assessing, and educating patients about self-care. They should be attentive to the acute and long-term effects of radiotherapy, including mucositis (ulcer formations in the mouth). Every team member perceives the impact of laryngeal hydration on the success and recovery rate of post treatment HNC patients differently. Therefore, each team member’s knowledge of the disease and the specialized needs of the patient is a crucial component to a patient’s successful recovery (Clarke, 1998). However, oral care and vocal hygiene protocol regimens are highly dependent upon the type of facility in which the patient receives therapy. Clarke et al. (1998) state that specialized treatment services are commonly offered in large medical centers or

university settings but some HNC patients are treated in facilities that may not have

13 access to specialized treatment services.

Conclusions and Future Directions

This review of the literature indicates that HNC patients often suffer from difficulty with swallowing and oral health secondary to physiological changes caused by radiotherapy. These changes cause a decline in their quality of life. The MDASI-

HN found that the most common affected sites were the pharynx, larynx, tongue, and other oral cavity sites. Further, as a result of radiotherapy, it is typical for members of the HNC population to sustain varying degrees of swallowing, voice, and oral difficulties. SLPs who work with HNC patients are important members of a multidisciplinary team that works to alleviate communication disorders created in

HNC patients during treatment.

Oral regimens can help increase a crucial component of vocal health, and that is promoting the production of mucus that enables the nose, mouth, throat, and airway of patients to remain lubricated. Research suggests an oral care regimen and its use can prove beneficial to a patient’s recovery by promoting hydration of the tissues affected. Therefore, adherence to an oral care protocol prior to beginning radiotherapy treatment, as opposed to having the instruction during post-radiotherapy treatment only, may significantly reduce the severity of oral symptoms after radiotherapy.

A survey was administered in an attempt to answer the question of whether or not new education methods are needed for professionals involved in treating the HNC population, or if current methods are sufficient to prevent as much damage as possible

14 and to maintain patient oral and vocal health during radiotherapy treatment. The survey aimed to discover: (1) whether professionals discuss vocal hygiene with HNC patients during pre-radiation and post-radiation consultations, and from those results

(2) to determine if there is a need for a vocal hygiene protocol that instructs HNC patients in oral or vocal hygiene techniques. This study may prove to be an important starting point from which to increase awareness by professionals, such as SLPs, of the need for pre-consultations and oral and vocal care protocols for HNC patients about to undergo radiotherapy. Professionals in this diverse field should be aware of the benefits of such protocols to reduce the severity of communication disorders associated with radiotherapy treatment for cancer in the head and neck region.

CHAPTER 3

METHODOLOGY

Participants

Participants in this study were 15 Otolaryngologists a.k.a. Ear, Nose, and

Throat Physicians (ENTs), and 15 Speech Language Pathologists (SLPs) who are

15 members or affiliates of the ASHA database of research survey participants. Contact information of ENTs and SLPs contained in the database are accessible to ASHA members for a fee. ENTs listed in this database may hold national board certifications, and/or be members with groups such as FACS (Fellow, American

College of Surgeons), American Board of Otolaryngology, Ear, Nose, & Throat

Association, or other affiliations. SLPs listed in the database may possess Certificates of Clinical Competence, a Speech Language Pathology services credential, and/or

Speech Language Pathology licensure.

Materials

Materials for this study included an electronic survey, an electronic cover letter, an electronic statement of confidentiality, and the survey questions. The cover letter described the purpose of the survey, the approximate time needed to complete the survey, and the examiner’s contact information in case participants had any questions.

The cover letter contained a link to the survey questions. Subjects gave their consent to participate in the survey by following a link leading to the survey questions.

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Disbursement and Collection of Data

The survey packets were electronically dispersed to 30 ENTs and 30 SLPs (of which half from each group responded as delineated above). Once the surveys were returned to the student researcher, results and data were analyzed. Appendix A illustrates the sample survey distributed to ENTs. Appendix B is the survey distributed to SLPs. An email address was created specifically for obtaining information pertaining to this study. After submission and approval of research, the email account was deleted.

Privacy Protection and Anonymity of Survey Correspondents

Privacy protection and destruction of the data were ensured in several ways.

Because the respondents participated in an online survey, identifiable information was not present on printed materials.

The electronic survey distribution method used was www.surveymonkey.com.

The subjects’ names were not used in the data analysis. Rights to privacy and safety were also protected because personal information such as address, telephone numbers, or any other identifiable information was not gathered or used in the analysis of the results. After opening the email requesting participation in the survey, participants received a notice prior to participating in the survey. The notice informed the participants that the survey was a request for their participation in a research study.

Participants were informed that this was an attempt to collect data regarding oral and vocal hygiene in the HNC population during pre-consultations, and to determine if there is a need for an oral and vocal hygiene protocol to teach hygiene techniques to

HNC patients prior to radiotherapy. Participants were also informed that no personally identifiable information would be released. Once the student researcher

17 obtained the minimum number of data responses required (15 ENT, and 15 SLP), the survey was discontinued and deleted from the online database.

Statistical Methodology

Survey question responses were presented in a Likert Scale, which is an ordinal data format. Ordinal data denotes a nonparametric ranking or ordering of responses that cannot determine whether the distances between the consecutive values of the data are equal. For example, it cannot be determined to what extent “slightly disagree” and “disagree” differ quantitatively. For the purposes of this survey, Likert items (answer choices) varied depending on the question posed. Answer choices were ranked as follows: “yes,” “no;” “very often,” “regularly,” “sometimes,” “never;”

“slightly agree,” “agree,” “strongly agree,” “disagree,” “slightly disagree;” “agree,”

“strongly agree,” “strongly disagree,” “disagree,” “slightly disagree,” “very often,”

“regularly,” “sometimes,” “once or twice,” and “never.” Responses obtained are reported separately from ENT and SLP groups as a frequency count, indicating how many respondents out of the total correspondents selected each answer choice. A comparison of responses between the groups was made when appropriate. However, due to the qualitative nature of ordinal data, no statistical significance could be determined when making comparisons.

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CHAPTER 4

ANALYSIS OF THE DATA

Organization of Data

Data collected in this study is organized in the following tables by respondent group and in chronological order. Table 1, titled Ear, Nose, and Throat Physician

Survey Responses , indicates the survey questions, answer choices, and responses obtained for each answer choice from Ear, Nose, and Throat Physicians (ENTs).

Table 2, titled Speech Language Pathologist Survey Responses , indicates the survey questions, answer choices, and responses obtained for each answer choice from

Speech Language Pathologists (SLPs). Of 15 SLP respondents, 4 did not answer survey questions number 2-6, and 8-10. Skipped responses are reported as “no response.”

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Table 1

Ear, Nose, and Throat Physician Survey Responses

Question 1. It would benefit my patients to have an oral care protocol packet readily available.

Yes

No

15

0

Total 15

Question 2. I regularly advise patients about risk factors involved with radiotherapy.

Risk Factors

Answer Choice ↓

Very Often

Regularly

Physical Health

Side-Effects

3

9

Oral Cavity

Side-

Effects

3

10

Swallowing

Side-Effects

7

8

Quality of Life

Side-Effects

1

7

Sometimes

Once or Twice

Never

Total

3

0

0

15

2

0

0

15

0

0

0

15

7

0

0

15

Question 3. My patients are informed of all the possible oral side effects of radiotherapy.

Answer Choice Responses

Very Often

Regularly

Sometimes

6

9

0

Once or Twice

Never

0

0

Total 15

Question 4. It is not my responsibility to teach vocal hygiene protocols to my patients.

Answer Choice

Slightly Agree

Agree

Strongly Agree

Responses

4

1

1

Strongly Disagree 5

Disagree 1

Slightly Disagree 3

Total 15

20

Question 5. A vocal hygiene protocol for head and neck cancer patients is medically justified.


Slightly Agree

Agree

0

7

Strongly Agree 8

Strongly Disagree 0

Disagree 0

Slightly Disagree 0

Total 15

Question 6. I use an oral hygiene protocol for a majority of my patients.


Slightly Agree

Agree

3

9

Strongly Agree 3

Strongly Disagree 0

Disagree 0

Slightly Disagree 0

Total 15


Answer Choice

Agree

Responses

8

Strongly Agree 7

Strongly Disagree 0

Disagree 0

Slightly Disagree 0

Total 15

Question 8. If an oral care protocol packet based on patients’ symptoms was at my disposal, I would distribute the packet to each of my patients accordingly.

Answer Choice

Slightly Agree

Agree

Strongly Agree

Responses

3

5

7

Strongly Disagree 0

Disagree 0

Slightly Disagree 0

Total 15

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Question 9. I refer a majority of my patients to a Speech Language Pathologist preradiation.


Very Often

Regularly

Sometimes

Once or Twice

2

4

8

1

Never

Total

0

15

*Additional comments submitted by 9 of 15 ENT respondents stated that a pre-radiation referral was dependent upon the patient’s insurance provider.

Question 10. I refer a majority of my patients to a Speech Language Pathologist postradiation.

Answer Choice

Very Often

Responses

6

Regularly

Sometimes

5

4

Once or Twice

Never

0

0

Total 15

Table 1. Survey questions, answer choices, and responses from Ear, Nose, and Throat Physicians regarding the head and neck cancer population .

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Table 2

Speech Language Pathologist Survey Responses



Yes

No

15

0

Total 15

Question 2. I regularly advise patients about risk factors involved with radiotherapy.

Risk Factors

Answer Choice

↓

Very Often

Regularly

Sometimes

Never

Total

No Response

Physical Health

Side-Effects

2

5

2

2

11

4

Oral Cavity

Side-Effects

3

4

2

2

11

4

Swallowing

Side-Effects

5

3

1

2

11

4

Quality of Life

Side-Effects

2

5

2

2

11

4

Question 3. I recommend and review a vocal hygiene protocol with a majority of my patients.

Answer Choice

Very Often

Responses

3

Regularly

Sometimes

Once or Twice

Never

2

3

2

1

Total

No Response

11

4

Question 4. It is not my responsibility to teach vocal hygiene protocols to my patients.


Slightly Agree 0

Agree

Strongly Agree

1

1

Strongly Disagree 8

Disagree 1

Slightly Disagree 0

Total

No Response

11

4

23

Question 5. A vocal hygiene protocol for head and neck cancer patients is medically justified.


Slightly Agree

Agree

0

6

Strongly Agree 5

Strongly Disagree 0

Disagree 0

Slightly Disagree 0

Total 11

No Response 4

Question 6. I use an oral hygiene protocol for a majority of my patients.

Answer Choice

Slightly Agree

Responses

1

Agree

Strongly Agree

3

5

Strongly Disagree 1

Disagree 0

Slightly Disagree 1

Total

No Response

11

4



Agree

Strongly Agree

1

9

Strongly Disagree 0

Disagree 0

Slightly Disagree 0

Total

No Response

10

5

24

Question 8. If an oral care protocol packet based on patients’ symptoms was at my disposal, I would distribute the packet to each of my patients accordingly.


Slightly Agree

Agree

0

2

Strongly Agree 8

Strongly Disagree 0

Disagree 1

Slightly Disagree 0

Total 11

No Response 4

Question 9. I consult a majority of my patients pre-radiation.

Answer Choice

Slightly Agree

Responses

0

Agree

Strongly Agree

2

3

Strongly Disagree 2

Disagree 4

Slightly Disagree 0

Total

No Response

11

4

Question 10. I consult a majority of my patients post-radiation


Slightly Agree

Agree

1

4

Strongly Agree 4

Strongly Disagree 0

Disagree 2

Slightly Disagree 0

Total 11

No Response 4

Table 2. Survey questions, answer choices, and responses from Speech Language Pathologists regarding the head and neck cancer population.

25

Survey Responses

The surveys were designed to obtain information about how often ENTs and

SLPs recommend and review an oral or vocal hygiene protocol with HNC patients and the type of information discussed with HNC patients, including risk factors and side effects of radiotherapy. The survey also obtained some information on how often

ENTs refer HNC patients pre-radiation and post-radiation to SLPs for consultations, and how often SLPs consult HNC patients pre-radiation and post-radiation. Views of how ENTs and SLPs regard their responsibilities as a multidisciplinary team members working with HNC patients were also investigated.

ENT Survey Results

In response to survey question number 1, which asked whether participants thought it would benefit HNC patients to have an oral care protocol packet readily available, 15 out of 15 ENTs responded “yes,” and 0 out of 15 responded “no.”

To obtain data regarding HNC patient education and consultation information discussed with patients about to undergo radiotherapy, survey question number 2 asked ENT participants to rank how often they advised patients about risk factors of radiotherapy including physical health, oral cavity, swallowing, and quality of life side effects. Data is listed in Table 1, ENT Table 1. I Regularly Advise Patients About

Risk Factors Involved With Radiotherapy , and Figure 1 illustrates the results obtained from this survey question, which is titled ENT Figure 1. I Regularly Advise Patients

About Risk Factors Involved With Radiotherapy .

In regards to the physical health side

26 effects of radiotherapy, 3 of 15 ENTs reported that they advise patients “very often,” 9 of 15 reported that they advise patients “regularly,” and 3 out of 15 reported that they advise patients “sometimes.” Of 15 participants, 0 reported that they advise patients

“once or twice,” and “never” regarding the physical health side effects. When asked to rank a response regarding how often participants advise patients of the oral cavity side effects of radiotherapy, 3 out of 15 respondents reported they advise patients

“very often,” with 10 out of 15 respondents reported “regularly,” and 2 out of 15 reported “sometimes.” Out of 15 respondents, 0 reported advising patients “once or twice” and “never” regarding the oral cavity side effects of radiotherapy. When asked to respond to how often participants advise patients of the swallowing side effects of radiotherapy, 7 out of 15 respondents indicated “very often,” and 8 out of 15 respondents indicated “regularly,” with 0 respondents indicating “sometimes, once or twice,” and “never.” In regards to the quality of life side effects, 1 out of 15 ENT respondents stated they advise patients “very often,” 7 out of 15 respondents stated they advise patients “regularly,” and 7 out of 15 respondents stated they advise patients “sometimes.” Out of 15 ENT participants, 0 indicated that they advise patients “once or twice” and “never” regarding the quality of life side effects of radiotherapy.

27

ENT Table 1

I Regularly Advise Patients About Risk Factors Involved With Radiotherapy

Answer Choice ↓

Very Often

Regularly

Sometimes

Risk Factors

Physical Health

Side-Effects

3

9

3

Oral Cavity

Side-Effects

3

10

2

Swallowing

Side-Effects

7

8

0

Quality of Life

Side-Effects

1

7

7

Once or Twice

Never

0

0

0

0

0

0

0

0

Total 15 15 15 15

Table 1. Potential risk factors patients about to undergo radiotherapy treatment may encounter, and how often Ear, Nose, and Throat Physicians reported advising patients regarding the risk factors.

ENT Figure 1


28

Never

Sometimes Quality of Life Side-

Effects

Swallowing Side- Effects

Oral Cavity Side- Effects

Regularly

Very Often

0 2 4 6 8 10 12

Figure 1. Potential risk factors patients about to undergo radiotherapy treatment may encounter, and how often Ear, Nose, and Throat Physicians reported advising patients regarding the risk factors.

Survey question number 3 asked ENTs to rank how often they informed HNC patients of the possible oral side effects of radiotherapy. Figure 2, titled ENT Figure

2. My Patients Are Informed of all the Possible Oral Side Effects of Radiotherapy , illustrates ENT responses to this survey question .

Out of 15 respondents, 6 stated they

inform patients of the side effects “very often” and 9 stated they inform patients

“regularly.” No respondents indicated that they inform patients of the possible oral

29 side effects of radiotherapy “sometimes,” “once or twice,” and “never.”

ENT Figure 2

My Patients Are Informed of all the Possible Oral Side Effects of Radiotherapy

0

0

0

9

6

Very Often

Regularly

Sometimes

Once or Twice

Never

Figure 2. Frequency in which Ear, Nose, and Throat Physicians reported advising patients of all the possible oral side effects of radiotherapy.

30

Figure 3 illustrates responses from ENTs that rank to what extent they agree or disagree that it is their responsibility as a multidisciplinary team member working with

HNC patients to teach vocal hygiene protocols to their patients in survey question number 4. Figure 3 is titled ENT Figure 3. It is Not My Responsibility to Teach Vocal

Hygiene Protocols to My Patients . Table 2 lists responses to this question, and is titled ENT Table 2. It is not My Responsibility to Teach Vocal Hygiene Protocols to

My Patients.

This question stated: “It is not my responsibility to teach vocal hygiene protocols to my patients.” Out of 15 respondents, 4 reported that they “slightly agreed” that it was not their responsibility to teach the protocols to patients. Fewer respondents (1 out of 15) said they “agreed” and the same number (1 out of 15) stated they “strongly agreed” it was not their responsibility. Of 15 respondents, 5 out of 15 reported they “strongly disagreed,” with only 1 out of 15 reporting they “disagreed” that it was not their responsibility to teach vocal hygiene protocols to HNC patients.

Furthermore, 3 out of 15 reported they “slightly disagreed” that teaching vocal hygiene protocols was not their responsibility. Overall, 6 out of 15 ENTs reported they “agreed to some extent,” and 9 out of 15 stated they “disagreed to some extent” that it was not their responsibility to teach vocal hygiene protocols to their HNC patients.

Survey question number 5 asked ENT participants to rank to what extent they agreed or disagreed as to whether a vocal hygiene protocol for HNC patients is medically justified. Out of 15 respondents to number 5, 7 indicated they “agreed” and

8 indicated they “strongly agreed.” None of the respondents indicated they “slightly

5

4

3

2

1 agreed,” “strongly disagreed,” or “slightly disagreed.” The results indicate that overall, 15 out of 15 ENT respondents agreed to some extent that a vocal hygiene

31 protocol for HNC patients is medically justified.

ENT Figure 3

It Is Not My Responsibility to Teach Vocal Hygiene Protocols to My Patients

6

0

Slightly Agree Agree Strongly Agree Strongly Disagree Slightly

Disagree Disagree

Table 2. Extent to which Ear, Nose, and Throat doctors agree or disagree that it is their responsibility as a multidisciplinary team member working with head and neck cancer patients to teach vocal hygiene protocols to their patients.

32

ENT Table 2

It Is Not My Responsibility to Teach Vocal Hygiene Protocols to My Patients.

Answer Choice

Slightly Agree

Agree

Strongly Agree

Strongly Disagree

Responses

4

1

1

5

Disagree

Slightly Disagree

1

3

Total 15

Table 6. Extent to which Ear, Nose, and Throat doctors agree or disagree that it is their responsibility as a multidisciplinary team member working with head and neck cancer patients to teach vocal hygiene protocols to their patients.

ENT participants were also asked to rank to what extent they used an oral hygiene protocol for a majority of their patients in survey question number 6. Table 3 is titled ENT Table 3. I Use an Oral Hygiene Protocol for a Majority of My Patients , and presents the results in a chart format. Figure 4, titled ENT Figure 4. I Use an

Oral Hygiene Protocol for a Majority of My Patients , illustrates responses to this survey question. Of 15 respondents, no respondents stated they “strongly disagreed,”

“disagreed,” or “slightly disagreed.” All (15 out of 15) ENT respondents stated that they agreed to some extent that they did use an oral hygiene protocol for a majority of their patients. Of the 15 respondents, 3 stated they “slightly agreed,” 9 stated they

“agreed,” and 3 stated that they “strongly agreed” to using an oral care protocol for a majority of their patients.

ENT Table 3

I Use an Oral Hygiene Protocol for a Majority of My Patients

Answer Choice

Slightly Agree

Agree

Strongly Agree

Strongly Disagree

Responses

3

9

3

0

Disagree

Slightly Disagree

0

0

Total 15

Table 3. Extent to which Ear, Nose, and Throat Physicians agree or disagree that they use an oral hygiene protocol for a majority of their patients.

33

34

ENT Figure 4


Strongly Agree

Agree

Slightly Agree

0 1 2 3 4 5 6 7 8 9 10

Figure 4. Extent to which Ear, Nose, and Throat Physicians agree or disagree that they use an oral hygiene protocol for a majority of their patients. Of 15 respondents, none reported they disagree to any extent.

Survey question number 7 asked ENT participants to rank to what extent they agreed or disagreed that it would benefit patients to have an oral care protocol packet readily available. In response to this question, 8 out of 15 respondents said they

“agreed,” and 7 out of 15 said they “strongly agreed.” Of the 15 ENT respondents, 0 reported they “strongly disagreed,” “disagreed,” and “slightly disagreed” that it would

35 benefit their patients to have an oral care protocol packet readily available. Therefore, results indicate that all (15 out of 15) respondents did agree to some extent that it would benefit patients to have an oral care protocol packet readily available.

ENT participants were asked to rank to what extent they agreed or disagreed that they would distribute oral care protocol packets based on patients’ symptoms in survey question number 8. Responses from this question are listed in Table 4, which is titled

ENT Table 4. If an Oral Care Protocol Packet Based on Patients’ Symptoms

Was at My Disposal, I Would Distribute the Packet to Each of My Patients

Accordingly

. Figure 5 illustrates the results of ENT respondents’ answers to this question, and is titled ENT Figure 5. If an Oral Care Protocol Packet Based on

Patients’ Symptoms Was at My Disposal, I Would Distribute the Packet to Each of My

Patients Accordingly . All 15 respondents indicated they agreed to some extent, with none indicating they disagreed to some extent. Of the 15 respondents indicating they agreed to some extent that they would distribute oral care protocol packets based on patients’ symptoms, 3 indicated they “slightly agreed,” 5 indicated they “agreed,” and

7 indicated they “strongly agreed.”

36

ENT Table 4

If an Oral Care Protocol Packet Based on Patients’ Symptoms Was at My Disposal, I

Would Distribute the Packet to Each of My Patients Accordingly

Answer Choice

Slightly Agree

Agree

Strongly Agree

Strongly Disagree

Disagree

Slightly Disagree

Responses

3

5

7

0

0

0

Total 15

Table 4. Extent to which Ear, Nose, and Throat Physicians agree or disagree that they would distribute an oral care protocol packet based on their patients’ symptoms.

ENT Figure 5



0

0

0

3

7

Slighlty Agree

Agree

Stongly Agree

Strongly Disagree

Disagree

Slightly Disagree

5

Figure 5. Extent to which Ear, Nose, and Throat Physicians agree or disagree that they would distribute an oral care protocol packet based on their patients’ symptoms.

37

Survey question number 9 aimed to obtain data regarding how often ENTs make pre-radiation patient referrals to SLPs. Results obtained from ENTs in regards to this question are listed in Table 5, which is titled ENT Table 5. I Refer a Majority of My Patients to a Speech Language Pathologist Pre-Radiation . An illustration of these findings is presented in Figure 6, titled ENT Figure 6. I Refer a Majority of My

Patients to a Speech Language Pathologist Pre-Radiation . Out of 15 ENT respondents, few respondents (2 out of 15) reported they refer patients to an SLP prior to radiotherapy treatment “very often.” More respondents (4 out of 15) reported they referred patients “regularly,” with the majority of respondents (8 out of 15) reporting they refer patients “sometimes.” Of the 15 respondents, 1 out of 15 reported they refer patients to SLPs prior to radiotherapy “sometimes,” and 0 out of 15 reported they

“never” refer patients pre-radiotherapy. In addition to ranking how often preradiotherapy referrals were made, 9 out of 15 respondents submitted additional comments stating that a pre-radiation referral to an SLP was dependent upon the patient’s insurance provider.

8

7

6

5

4

3

2

1

ENT Table 5

I Refer a Majority of My Patients to a Speech Language Pathologist Pre-Radiation

Answer Choice

Very Often

Regularly

Sometimes

Once or Twice

Responses

2

4

8

1

Never

Total

0

15

Table 12. Frequency in which Ear, Nose, and Throat Physicians reported referring head and neck cancer patients to a Speech Language Pathologist prior to radiotherapy. *Additional comments submitted by 9 of 15 ENT respondents stated that a pre-radiation referral was dependent upon the patient’s insurance provider.

ENT Figure 6


9

38

0

Very Often Regularly Sometimes Once or Twice Never

Figure 6. Frequency in which Ear, Nose, and Throat Physicians reported referring head and neck cancer patients to a Speech Language Pathologist prior to radiotherapy.

39

When classifying answer choices together in terms of frequency of referrals to determine whether referrals are consistent or inconsistent, “very often” and “regularly” may indicate referrals are made on a consistent basis. In contrast, rankings of

“sometimes,” “once or twice,” and “never” may indicate that referrals are made inconsistently. Therefore, results may indicate that out of 15 ENT respondents, 6 of

15 ENTs refer HNC patients to an SLP prior to radiation “consistently,” but more (9 out of 15) pre-radiotherapy patient referrals are made “inconsistently.” Data presented in Figure 7 illustrates ENT responses regarding frequency of referrals made to SLPs pre-radiation, and is ranked by classifications of “consistent” and “inconsistent.” An illustration of these findings is presented in Figure 7, which is titled ENT Figure 7.

I

Refer a Majority of My Patients to a Speech Language Pathologist Pre-Radiation .

ENT Figure 7


40

6

Consistent

Inconsistent

9

Figure 7. Frequency in which Ear, Nose, and Throat Physicians reported referring head and neck cancer patients to a Speech Language Pathologist prior to radiotherapy. Answer choices of “very often,” “regularly” are classified as consistent referrals; answer choices of “sometimes,” “once or twice,” and “never” are classified as inconsistent referrals.

Survey question number 10 aimed to obtain data regarding how often ENTs make post-radiation patient referrals to SLPs. Data is listed in Table 6, titled ENT

Table 6. I Refer a Majority of My Patients to a Speech Language Pathologist Post-

Radiation. An illustration of the results from this question is presented in Figure 8, titled ENT Figure 8. I Refer a Majority of My Patients to a Speech Language

Pathologist Post-Radiation. Most respondents (6 out of 15) indicated they refer patients following radiotherapy treatment “very often,” followed by 5 out of 15 respondents indicating they referred patients “regularly.” Of 15 ENT respondents, 4

41 out of 15 indicated they referred patients post-radiation “sometimes,” with 0 respondents indicating they made post-radiation referrals “once or twice,” and

“never.”

ENT Table 6

I Refer a Majority of My Patients to a Speech Language Pathologist Post-Radiation

Answer Choice

Very Often

Regularly

Sometimes

Once or Twice

Never

Responses

6

5

4

0

0

Total 15

Table 6. Frequency in which Ear, Nose, and Throat Physicians reported referring head and neck cancer patients to a Speech Language Pathologist after radiotherapy.

6

5

4

3

ENT Figure 8


7

42

2

1

0

Very Often Regularly Sometimes Once or Twice Never

Table 6. Frequency in which Ear, Nose, and Throat Physicians reported referring head and neck cancer patients to a Speech Language Pathologist after radiotherapy.

When classifying answer choices together in terms of frequency of referrals to determine whether referrals are consistent or inconsistent, “very often” and “regularly” may indicate referrals are made on a consistent basis. In contrast, rankings of

“sometimes,” “once or twice,” and “never” may indicate that referrals are made inconsistently. Therefore, results may indicate that out of 15 ENT respondents, 11 of

15 ENTs refer HNC patients to an SLP after radiation therapy “consistently,” and

43 fewer (4 out of 15) HNC patient referrals to SLPs after radiotherapy treatment are made inconsistently. An illustration of these findings is presented in Figure 9, titled

ENT Figure 9. I Refer a Majority of My Patients to a Speech Language Pathologist

Post-Radiation .

ENT Figure 9


4

Consistent

Inconsistent

11

Figure 9. Frequency in which Ear, Nose, and Throat Physicians reported referring head and neck cancer patients to a Speech Language Pathologist after radiotherapy treatment. Answer choices of

“very often,” and “regularly” classified as consistent referrals; answer choices of “sometimes,” “once or twice,” and “never” classified as inconsistent referrals.

SLP Survey Results

In response to survey question number 1, which asked whether participants believed it would benefit HNC patients to have an oral care protocol packet readily available, 15 out of 15 SLPs responded “yes,” and 0 out of 15 responded “no.”

44

Survey question number 2, aimed at obtaining data regarding HNC patient education and consultation information discussed with patients about to undergo radiotherapy, asked SLP participants to rank how often they advised patients about risk factors of radiotherapy including physical health, oral cavity, swallowing, and quality of life side effects. Data is listed in Table 1, SLP Table 7. I Regularly Advise

Patients About Risk Factors Involved With Radiotherapy , and Figure 1 illustrates the results obtained from this survey question and is titled SLP Figure 10. I Regularly

Advise Patients About Risk Factors Involved With Radiotherapy . Of 15 SLP survey participants, 4 did not respond to this question, making 11 SLPs the total number of respondents for each side effect in this question. In regards to the physical health side effects of radiotherapy, 2 of 11 SLPs stated that they advise patients “very often,” 5 of

11 stated that they advise patients “regularly,” and 2 out of 11 stated that they advise patients “sometimes” and “never.” Of the 11 SLP respondents asked to rank how often they advise patients of the oral cavity side effects of radiotherapy, 3 out of 11 respondents reported they advised patients “very often,” and 10 out of 15 respondents reported “regularly.” The same number of SLP respondents (2 out of 11) stated that they “sometimes” and “never” advise patients of the oral cavity side effects of radiotherapy. When asked to respond to how often SLPs advise patients of the

swallowing side effects of radiotherapy, 5 out of 11 respondents indicated “very often,” and 3 out of 11 respondents indicated “regularly,” with 1 out 15 indicating

45

“sometimes.” Of the 11 SLP respondents, 2 indicated that they “never” advise patients about the swallowing side effects of radiotherapy. In regards to the quality of life side effects, 2 out of 11 ENT respondents indicated they advise patients “very often,” 5 out of 11 respondents stated they advise patients “regularly.” Out of the 11 respondents, 2 stated they advise patients “sometimes,” with the same number of respondents (2) indicating that they “never” advise patients regarding the quality of life side effects of radiotherapy.

SLP Table 7


Answer Choice ↓

Very Often

Regularly

Sometimes

Never

Total

Risk Factors

Physical Health

Side-Effects

2

5

2

2

11

Oral Cavity

Side-Effects

3

4

2

2

11

Swallowing

Side-Effects

5

3

1

2

11

Quality of Life

Side-Effects

2

5

2

2

11

No Response 4 4 4 4

Table 7. Potential risk factors patients about to undergo radiotherapy treatment may encounter, and how often Speech Language Pathologists reported advising patients regarding the risk factors. Of 15 participants, 4 participants did not answer this question.

SLP Figure 10


46

No Response

Never

Sometimes

Regularly

Quality of Life Side- Effects

Swallowing Side- Effects

Oral Cavity Side- Effects

Physical Health Side- Effects

Very Often

0 1 2 3 4 5 6

Figure 10. Potential risk factors patients about to undergo radiotherapy treatment may encounter, and how often Speech Language Pathologists reported advising patients regarding the risk factors. Of 15 participants, 4 participants did not answer this question.

Survey question number 3 asked SLPs to rank how often they recommend and review a vocal hygiene protocol with a majority of their HNC patients. Figure 11, titled SLP Figure 11. I Recommend and Review a Vocal Hygiene Protocol With a

Majority of My Patients , illustrates results of SLP survey respondents. Out of 15 SLP

2

1

4

3 participants, 4 did not respond to this question, making the total number of survey

47 responses 11 for this survey question. Out of 11 SLP respondents, 3 stated they recommend and review a protocol “very often” and 2 out of 11 stated they inform patients “regularly.” Scattered results to this question left 3 respondents stating they recommend and review a protocol with patients “sometimes,” and 2 out of 11 indicating “once or twice,” with 1 out of 11 indicating they “never” recommend and review a vocal hygiene protocol with HNC patients.

SLP Figure 11

I Recommend and Review a Vocal Hygiene Protocol With a Majority of My Patients

5

0

Very Often Regularly Sometimes Once or Twice Never No Response

Figure 11. Frequency in which Speech Language Pathologists reported recommending and reviewing a vocal hygiene protocol packet with their head and neck cancer patients; 4 out of 15 participants did not answer this question.

48

SLPs were asked to rank to what extent they agree or disagree that it is their responsibility as a multidisciplinary team member working with head and neck cancer patients to teach vocal hygiene protocols to their patients in survey question number 4.

Table 8 lists data in chart format and is titled SLP Table 8. It Is Not My Responsibility to Teach Vocal Hygiene Protocols to My Patients. An illustration of the results is presented in Figure 12, which is titled SLP Figure 12. It Is Not My Responsibility to

Teach Vocal Hygiene Protocols to My Patients. Out of 15 participants, 4 did not respond to this question. Out of 11 SLP respondents, 0 of 11 reported they “slightly agreed,” and 1 out of 11 reported they “agreed” that it was not their responsibility to teach the protocols to patients. Few respondents (1 out of 11), reported they “strongly agreed” that it was not their responsibility, with the most (8 out of 15) indicating they

“strongly disagreed.” Of 11 respondents, 1 reported that he/she “disagreed” that it was not his/her responsibility to teach the protocols to HNC patients, with 0 out of 11 answering “slightly disagreed.” Overall, 2 out of 11 SLP respondents answered they agreed to some extent, and 9 out of 11 said they disagreed to some extent that it was not their responsibility to teach vocal hygiene protocols to their HNC patients.

49

SLP Table 8


Answer Choice

Slightly Agree

Agree

Strongly Agree

Strongly Disagree

Responses

0

1

1

8

Disagree

Slightly Disagree

Total

1

0

11

No Response 4

Table 8. Extent to which Speech and Language Pathologists agree or disagree that it is their responsibility as multidisciplinary team members working with head and neck cancer patients to teach vocal hygiene protocols to their patients. Of 15 participants, 4 participants did not answer this question.

50

SLP Figure 12


9

6

5

4

8

7

3

2

1

0

Slightly Agree Agree Strongly

Agree

Strongly

Disagree

Disagree Slightly

Disagree

No Response

Figure 12. Extent to which Speech and Language Pathologists agree or disagree that it is their responsibility as multidisciplinary team members working with head and neck cancer patients to teach vocal hygiene protocols to their patients. Of 15 participants, 4 participants did not answer this question.

Survey question number 5 asked participants to rank to what extent they agreed or disagreed that a vocal hygiene protocol for HNC patients is medically justified. Out of 15 participants, 4 did not respond to this question, making the total number of respondents 11 for this survey question. Out of the 11 SLP respondents, none reported that they “slightly agreed.” A majority of respondents (6 out of 11) indicated they “agreed,” followed by most respondents (5 out of 11) indicating they

“strongly agreed” that a vocal hygiene protocol for HNC patients is medically justified. None of the respondents indicated that they “strongly disagreed,”

“disagreed,” or “slightly disagreed” that a vocal hygiene protocol is medically justified. Results indicate that all of the SLP respondents (11 out of 11) agreed to some extent that a hygiene protocol for HNC patients is medically justified.

51

SLP participants were also asked to rank to what extent they agreed or disagreed that they used an oral hygiene protocol for a majority of their patients in survey question number 6; 4 SLPs did not respond to this question. Results from this question are illustrated in Figure 13 which is titled , SLP Figure 13. I Use an Oral

Hygiene Protocol for a Majority of My Patients.

Table 9, titled SLP Table 9. I Use an

Oral Hygiene Protocol for a Majority of My Patients , presents results from this question. Most respondents (5 out of 11) reported they “strongly agreed.” Of the 11

SLP respondents indicating to what extent they agreed or disagreed that they use an oral hygiene protocol with HNC patients, 1 out of 11 reported he/she “slightly agreed,” 3 out of 11 reported they “agreed,” and 1 out of 11 reported he/she “strongly disagreed.” None of the respondents reported they “disagreed,” but 1 out of 11 SLP respondents answered “slightly disagree” that he/she uses an oral hygiene protocol for a majority of his/her patients. Therefore, out of the 11 SLP respondents, 9 out of 11 reported that they agree to some extent that they use an oral hygiene protocol for a majority of their HNC patients, with only 2 out of 11 reporting they disagree to some extent.

52

SLP Figure 13


No Response

Slightly Disagree

Disagree

Strongly Disagree

Strongly Agree

Agree

Slightly Agree

0 1 2 3 4 5

Figure 13. Extent to which Speech Language Pathologists agree or disagree that they use an oral hygiene protocol for a majority of their patients. Of 15 participants, 4 participants did not answer this question.

6

53

SLP Table 9


Answer Choice

Slightly Agree

Agree

Strongly Agree

Strongly Disagree

Responses

1

3

5

1

Disagree

Slightly Disagree

Total

0

1

11

No Response 4

Table 9. Extent to which Speech Language Pathologists agree or disagree that they use an oral hygiene protocol for a majority of their patients. Out of 15 participants, 4 did not respond to this question.

Survey question number 7 asked SLP participants to rank to what extent they agreed or disagreed that it would benefit patients to have an oral care protocol packet readily available. In response to this question, 5 SLP participants did not respond to the question. Out of the 10 SLP respondents, 1 out of 10 respondents “agreed,” and 9 out of 10 reported they “strongly agreed” that it would benefit patients to have an oral care packet available. Of the 10 respondents, 0 reported “strongly disagreed,”

“disagreed,” or “slightly disagreed” that it would benefit patients to have an oral care protocol packet readily available. Overall, 10 out of 10 SLP respondents did agree to some extent that patients would benefit from an oral care protocol packet.

54

SLP participants were asked to what extent they agreed or disagreed that they would distribute oral care protocol packets based on patients’ symptoms in survey question number 8. Table 10 lists the results of this question and is titled SLP Table

10. If an Oral Care Protocol Packet Based on Patients’ Symptoms Was at My

Disposal, I Would Distribute the Packet to Each of My Patients Accordingly.

Figure

14 illustrates findings of this survey question, and is titled SLP Figure 14. If an Oral

Care Protocol Packet Based on Patients’ Symptoms Was at My Disposal, I Would

Distribute the Packet to Each of My Patients Accordingly . Of 15 SLP participants, 4 did not respond to this question, making the total number of SLP respondents to this question 11. None of the respondents indicated that they “slightly agreed,” but 2 out of 11 indicated they “agreed.” Of the 11 respondents, a majority (8 out of 11) indicated they “strongly agreed,” with 1 out of 11 indicating he/she “disagreed” that he/she would distribute protocol with 0 out of 11 indicating they “strongly disagreed,” or “slightly disagreed.” Results indicate that 10 out of 11 SLP respondents agree to some extent, with only 1 out of 11 respondents stating they disagree to some extent.

55

SLP Table 10



Answer Choice

Slightly Agree

Responses

0

Agree

Strongly Agree

Strongly Disagree

2

8

0

Disagree

Slightly Disagree

Total

No Response

1

0

11

4

Table 10. Extent to which Speech Language Pathologists agree or disagree that they would distribute an oral care protocol packet based upon their patients’ symptoms. Of 15 participants, 4 did not answer this question.

56

SLP Figure 14



3

4

0

0

0

5

Slightly Agree

Agree

Strongly Agree

Strongly Disagree

Disagree

Slightly Disagree

No Response

7

Figure 14. Extent to which Speech Language Pathologists agree or disagree that they would distribute an oral care protocol packet based on their patients’ symptoms. Of 15 participants, 4 did not answer this question.

Survey question number 9 aimed to obtain data regarding to what extent SLPs agree or disagree that they consult with patients during pre-radiation treatment. Figure

15 shows results of this survey question, and is titled SLP Figure 15.

I Consult a

Majority of My Patients Pre-Radiation with Table 11 listing the responses to the question, titled SLP Table 11. I Consult a Majority of My Patients Pre-Radiation. Out

57 of 15 SLP respondents, 4 did not respond to this question, making the total number of respondents to this question 11. Of the 11 SLP respondents, 0 out of 11 responded

“slightly agreed,” or “slightly disagreed” he/she consulted patients prior to radiotherapy. Few respondents (2 out of 11) reported they “agreed” with 3 out of 11 stating they “strongly agreed” that they consult patients pre-radiation. Out of the 11 respondents indicating to what extent they agree or disagree that they consult patients pre-radiation, 2 out of 11 said they “strongly disagreed,” and 4 out of 11 “disagreed.”

These results indicate that out of 11 respondents, fewer (5 out of 11) SLPs did agree to some extent that they consult HNC patients prior to radiotherapy treatment than those who disagree (6 out of 11) to some extent that they consult patients prior to radiotherapy.

58

SLP Figure 15

I Consult a Majority of My Patients Pre-Radiation

4,5

4

3,5

3

2,5

2

1,5

1

0,5

0


Agree

Strongly

Disagree

Disagree Slightly

Disagree

No Response

Figure 14. Extent to which Speech Language Pathologists agreed or disagreed to consulting with head and neck cancer patients prior to radiotherapy treatment; 4 out of 15 participants did not answer this question.

59

SLP Table 11

I Consult a Majority of My Patients Pre-Radiation

Answer Choice

Slightly Agree

Agree

Strongly Agree

Strongly Disagree

Responses

0

2

3

2

Disagree

Slightly Disagree

Total

4

0

11

No Response 4

Table 11. Extent to which Speech Language Pathologists agreed or disagreed to consulting with head and neck cancer patients prior to radiotherapy treatment; 4 out of 15 participants did not answer this question.

Illustrating data from survey question number 10, Figure 16 is titled SLP

Figure 16. I Consult a Majority of My Patients Post-Radiation . Survey question number 10 aimed to obtain data regarding to what extent SLPs agree or disagree that they consult with patients during post-radiation treatment. Table 12 lists results of respondents’ answers, and is titled SLP Table 12. I Consult a Majority of My Patients

Post-Radiation . Out of 15 SLP respondents, 4 did not respond to this question, making the total number of respondents to this question 11. Of the 11 SLP respondents, 1 out of 11 answered that they “slightly agreed,” with 0 out of 11 stating that they “slightly disagreed” to consulting with patients after radiotherapy treatment.

The same number of respondents (4 out of 11) said they “agreed” and “strongly

60 agreed” that they consulted with patients post-radiation. None of the respondents said they “strongly disagreed.” Few respondents (2 out of 11) answered that they

“disagreed” when reporting the extent to which they agreed or disagreed that they consulted a majority of their patients post-radiation. Overall, more SLP respondents

(9 out of 11) indicated they agree to some extent that they consult with HNC patients after radiotherapy treatment than those who indicated they disagree to some extent (2 out of 11).

SLP Figure 16

I Consult a Majority of My Patients Post-Radiation

4,5

4

3,5

3

2,5

2

1,5

1

0,5

0


Agree

Strongly

Disagree

Disagree Slightly

Disagree

No Response

Figure 16. Extent to which Speech Language Pathologists agreed or disagreed to consulting with head and neck cancer patients after radiotherapy treatment; 4 out of 15 participants did not answer this question.

61

SLP Table 12

I Consult a Majority of My Patients Post-Radiation

Answer Choice

Slightly Agree

Agree

Strongly Agree

Strongly Disagree

Responses

1

4

4

0

Disagree

Slightly Disagree

Total

2

0

11

No Response 4

Table 12. Extent to which Speech Language Pathologists agreed or disagreed to consulting with head and neck cancer patients after radiotherapy treatment; 4 out of 15 participants did not answer this question.

Based on data in response to SLP survey questions number 9 and 10, findings may reveal that fewer HNC patients receive consultations with SLPs before radiotherapy treatment begins than after radiotherapy treatment has taken place. The results show that fewer SLPs (5 out of 11) indicated they agree to some extent that they consult HNC patients pre-radiation, with more SLPs (9 out of 11) indicating they agree to some extent that they consult HNC patients post-radiation. Results also show that more SLPs (6 out of 11) disagreed to some extent that they consult HNC patients

62 post-radiation, than those who disagreed to some extent that they consult patients postradiation (2 out of 11).

63

CHAPTER 5

DISCUSSION

Complications during and after radiotherapy treatment must be managed by a multidisciplinary team that includes ENTs, SLPs, nurses, pharmacists, and oral medicine specialists who rehabilitate swallowing, voice, and oral complications sustained by head and neck cancer patients (Rose-Ped et al., 2002). This study focused on the perceived need to educate HNC patients by using protocols that could help limit the severity of the side effects of radiotherapy treatment. The education of

HNC patients prior to radiotherapy treatment is an important component to maintaining patients’ quality of life because of the overall prevalence of communicative disorders in this population. In addition to education, counseling and pre-treatment information are all within the SLP’s scope of practice to some degree in the management of HNC complications.

Previous research indicates that head and neck cancer patients about to undergo radiotherapy treatment do not always receive a pre-evaluation baseline measurement of the condition of oral and vocal structures against which to determine the extent of damage done by radiotherapy. According to Ames, Sulima, and Wallen, lack of baselines may be because, “No oral assessment scale has been identified that is appropriate in all clinical settings,” (2011).

64

The literature shows that oral care provided by patient care units may be based upon inadequate evaluations of patient condition, and they may not be evidence-based.

The results of this study combined with previous research revealed that there is not a standardized assessment measure for pretreatment evaluation. It is important to have a baseline measurement before radiation has altered tissues of the larynx. The role of an

SLP should not be limited to post-radiation evaluation and treatment of HNC patients.

The SLP’s role should include educating patients about the importance of adhering to a protocol before, during and after radiotherapy in order to have the best outcome possible during and after treatment. This is especially important because the current rehabilitative efforts seems not to be focused on restoring patients to their baseline levels—baselines do not exist for many patients—but rather restoring them to a functional state before discharging them from therapy. The findings of this study are that 9 out of 15 ENT respondents referred patients to an SLP prior to radiotherapy based upon their insurance provider’s requirements. Establishing a pre-radiation baseline and protocol may save insurance companies expenses during post-radiation speech therapy. A baseline evaluation can provide a stopping point for treatment providers and allow for a patient to be discharged once baseline levels are restored.

Other major findings included recognition that there is a difference between the number of ENTs and SLPs who believe it is their responsibility to teach vocal hygiene protocols to their parents. Of 15 ENT respondents, 6 indicated they agreed to some extent that it was not their responsibility to instruct patients in protocols; in contrast, very few (2 out of 11) of SLP respondents indicated they agreed to some

extent that it was not their responsibility. For efficiency in the treatment of HNC

65 patients, it would be appropriate for multidisciplinary team members to accept responsibility for an area of treatment and care including education, maintenance, and prevention of symptom outcomes for the HNC population. Determining team members’ areas of interest may be a significant factor in determining how they may better serve the HNC population.

It is important that each member of a multidisciplinary team working with

HNC patients who undergo radiotherapy collaborate to maximize the amount of support the patient receives within each team member’s scope of practice. The compartmentalization of services will benefit the HNC population to some extent, but facilitating multidimensional aspects within each professional’s scope of practice will likely prove most beneficial to the patient. For example, a social worker may not be responsible for teaching oral and vocal hygiene techniques to HNC patients who undergo radiotherapy treatment, but it is within the scope of practice for ENTs, SLPs, nurses, and oral medicine specialists to discuss this component of care with the HNC population.

Lewin (2005) noted that the Speech-Language Pathologist has a significant role during radiation treatment in helping the patient throughout the treatment while also aiming to minimize long-term effects on speech and swallowing. A review of the literature indicates that SLPs may have consultations with patients during the preradiation period less often than they do during post-radiation. Findings also indicate that SLPs do not consistently perform evaluations prior to radiotherapy for the purpose

of establishing pre-radiation baseline levels. Findings in this study support the trend

66 revealed in a study by The University of Texas, M.D. Anderson Cancer Center (2012) that patients may experience a lack of motivation and will sometimes avoid prevention and repair. Educating the HNC population prior to treatment in regard to the possible physical health side effects, oral cavity side effects, swallowing side effects, and quality of life side effects, may increase their quality of life and motivation to seek treatment.

67

CHAPTER 6

CONCLUSIONS AND FUTURE DIRECTIONS

The purpose of this survey was twofold: (1) to determine whether oral and/or vocal hygiene is discussed with HNC patients during pre-radiation and post-radiation consultations, and (2) to determine if there is a need for an oral and/or vocal hygiene protocol that instructs HNC patients in specific hygiene techniques. This study revealed important implications for the field of Speech-Language Pathology and for the HNC population. In this study, the views of SLPs and ENTs regarding the roles and responsibilities of multidisciplinary team members showed differences. The respondents also indicated that they believe a vocal hygiene protocol is medically justified in an attempt to increase the patient’s quality of life long-term, reducing symptom severity, and as a preventative maintenance regimen. Overall, it was found that 15 out of 15 respondents from both SLP and ENT survey participants believe it will benefit HNC patients to receive an oral care protocol packet. Majority responses from both ENT (15 out of 15) and SLP (10 out of 11) survey participants reported that they would distribute packets based upon patients’ symptoms. Results of this study revealed that the number of patients referred to SLPs during pre-radiotherapy consolations by ENTs was lower than those referred in post-radiotherapy. Data also revealed that the number of pre-radiotherapy patients consulting with Speech-

Language Pathologists was lower than the number of post-radiotherapy patients.

The review of literature relative to HNC patients, ENTs and SLPs roles in service delivery and the results of this study revealed a need for further investigation

68 of factors affecting the HNC population. Future research questions pertaining to the

HNC population may include the following:

1.

Is a patient’s psychosocial response as severely impacted for HNC patients who receive a pre-radiation consultation with an SLP as it is for those who do not receive pre-radiation consultations?

2.

Does a pre-radiation consultation with an SLP increase a patient’s understanding of the head and neck tissues and their functions, and how treatment may affect the ability of the patient to communicate or swallow?

3.

How does intervention from the SLP impact the recovery of mucosal surfaces in the head, neck, nose, and throat that have been negatively affected by cellular changes during radiotherapy?

4.

What effect does establishing a pre-radiation baseline for oral, pharyngeal, and laryngeal function have on the frequency, duration, or efficacy of establishing short- and long-term post-radiation speech therapy treatment goals for the patient?

69

APPENDICES

70

APPENDIX A

Consent to Participate in Research Survey

This is a request for your participation in a research study. We are collecting data to determine whether vocal hygiene is discussed with head and neck cancer patients during pre-consultations, and to determine if there is a need for a vocal hygiene protocol which instructs vocal hygiene techniques to head and neck cancer patients. No personally identifiable information will be released. Furthermore, all findings and results will be reported in the aggregate without the release of identifiable information. Estimated completion time for this survey is 2–5 minutes. Your participation and help in the completion of our study is appreciated.

You may withdraw by simply not completing or submitting the survey, but once the survey has been submitted we are no longer capable of removing your data.

By choosing to continue with the survey, you consent to participate in the described study.

Thank you,

Jamie Gomes

For questions regarding this survey, please contact:

Jamie Gomes, Student Researcher hncsurvey@gmail.com

Ann Blanton, PhD, CCC-SLP Faculty Advisor blantona@csus.edu

California State University, Sacramento

6000 J Street

Sacramento, CA 95819

Phone: 916-278-6601

Office: Shasta Hall, 166

Email: blantona@csus.edu

APPENDIX B

71

72

73

APPENDIX C

74

75

76

77

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