Head and Neck Cancer:
The Impact of Speech Language Pathology
on Quality of Life
Presented by: Autumn Bjornstad, MA, CCC-SLP
Learning Objectives
• By the end of this presentation, the
listener will:
– Identify three quality of life (QOL) benefits to the
involvement of speech language pathology in the
care of patients with head and neck cancer.
– Identify the most effective timing of dysphagia
treatment in this population.
Birthdays
Graduations
Promotions
Weddings
Anniversaries
Holidays
Quality of Life
• Common themes:
– Food
– Drink
– Words to celebrate – singing happy birthday,
reciting vows, speeches, toasting the
newlyweds, prayers at family meals
Speech Language Pathology Role
• American Speech Language Hearing Association’s
(ASHA) Scope of Practice (2007) outlines the role
of a speech pathologist as:
– “the professional who engages in clinical services,
prevention, advocacy, education, administration, and
research in the areas of communication and
swallowing across the life span from infancy through
geriatrics”
– Clinical services include the assessment, treatment
and collaboration with other professionals in the
areas of swallowing, speech, language and voice.
Quality of Life Indicators
• Major themes in the literature for
measures of QOL after treatment for headneck cancer include:
– Swallowing
• Dysphagia
– Speech Intelligibility/Communication
• Dysarthria
• Voice: Aphonia/Dysphonia/Alaryngeal speech
Dysphagia
• Standard of care:
– Assessment of swallow function pre-treatment to determine
baseline
– Providing prophylactic treatment
(Carroll, Locher, Canon, Bohannon, McColloch
& Magnuson, 2008)
– Ongoing assessment and treatment of dysphagia during
and post radiation, chemoradiation or surgical intervention
(Rosenthal, Lewin, & Eisbruch 2006)
– Primary Goal: Keep the swallow moving and avoid any
prolonged NPO periods for the best long term swallowing
outcome (Gellespie, 2004)
Dysphagia Assessment
•
Assessment of dysphagia is best completed with a combination of
tools including objective measures (videoswallow or modified
barium swallow) and more subjective QOL measures
•
Use of QOL tools that assess emotional and social aspects of
dysphagia
– M. D. Anderson Dysphagia Inventory (MDADI): was studied and found to be
a reliable and validated questionnaire with the purpose to assess dysphagia
effects on the QOL of patients with head and neck cancer. It includes global,
emotional, functional, and physical subscales in relation to dysphagia.
•
•
–
(Chen, Frankowski, Bishop-Leone, Herbert, Leyk, Lwein, & Goepfert, 2001)
(Gellespie, Brodsky, Day, Lee, & Martin-Harris, 2004)
Gellespie (2004) states that diet texture alone is not an adequate measure of
dysphagia severity and impact on QOL
• Though 88% of patients in the study were on a normal or soft solid diet at
least 1 year post treatment of stage III or IV squamous cell carcinoma of
the oropharynx, larynx and hypopharynx, only 10% of these patients
scored within the area of normal or mild impairment on the MDADI
• Many of these patients were found to continue with a soft diet despite
significant difficulties in effort needed to swallow, increased time to eat, s/s
aspiration, avoidance of social situations involving eating, and weight loss
due to dysphagia
• These patients despite being on a reasonably normal textured diet may
still benefit from dysphagia therapy to make eating more comfortable,
enjoyable and safe
Dysphagia Assessment
•
Rosenthal (2006)
– Found that patients often have poor perception of
dysphagia and under-report difficulty. This can
contribute to more long term/chronic swallowing
impairments and supports the importance of
videofluoroscopic studies pre- and post- radiation
and chemo/radiation to accurately document swallow
function
•
Kendell, Kosek & Tanner (2014)
– Also highlight the importance of objective measures of
swallowing function in assessment and treatment
– Study compared quality of life scores to objective measures
of swallowing after chemo/radiation: Findings indicate that
a combination of subjective measures (QOL tools, bedside
swallow assessments) as well as objective studies
(videoswallow, modified barium, FEES) , pre, during and
post treatment is the most effective way to accurately
evaluate and treat dysphagia and reduce long term
swallowing deficits
Prophylactic Treatment
Swallow
(Eat/Drink)
Use it
or lose
it!
Exercise
(Hutchenson, 2012)
Prophylactic Treatment
•
Kulbersh, Rosenthal, McGrew, Duncan, McColloch, Carroll &
Magnuson (2006)
–
–
–
•
State that post-tx (radiation or chemoradiation) dysphagia occurs in 50-60% of patients
Dysphagia treatment in this study included swallowing education and initiation of a home
exercise program 5x/day. Exercises began 2 wks pre-treatment (focusing on hylolaryngeal
excursion, tongue base retraction, vocal fold closure, UES opening), with follow up 2 wks into
treatment, 6 wks into treatment and then 6+ months post tx
A group of 37 patients were studied undergoing primary radiation or chemoradiation. The
group receiving pre-treatement therapy for dysphagia showed a statistically significant
improvement on dysphagia QOL measurements in areas of physical, emotional and global.
This was in comparison to a control group which received dysphagia therapy after radiation or
chemoradiation was initiated.
Carroll (2008)
–
–
Study showed improved swallow function 3 months after completion of chemoradiation in
group receiving dysphagia therapy and exercises prior to initiation of tx for advanced
squamous cell carcinoma of the oropharynx, hypopharynx, and larynx, compared to control
group receiving only post treatment dysphagia therapy.
Improved outcomes in areas of epiglottic inversion and tongue base retraction for the pretreatment swallowing therapy group
Prophylactic Treatment
•
Rosenthal, Lewin & Eisbruch (2006)
–
–
Reported that early speech therapy intervention (prior to radiation
treatment) focusing on ROM maintenance, strength and precision of
movement is the best indicator of safe, functional post treatment
swallowing.
Recovery of swallow function 6 months post tx most indicative of
long term swallowing function
•
Barbon & Steele (2014) found that the temporary use of
postural changes and thickened liquids can reduce aspiration
during the course of treatment for head and neck cancer
•
The take home message in the literature is that the sooner the
dysphagia treatment is initiated the better the overall outcome
for swallowing both subjectively by the patients and objectively
via videofluoroscopy.
Passy Muir Speaking Valve (PMSV)
•
Even for temporary tracheostomy, PMSV can improve
quality of life during hospital stay and in the home
environment .
– Facilitates better communication with family, staff and
provides a sense of normalcy to be able to use “voice”
to communicate.
– Provides more functional/sustainable voice compared to a
fenestrated trach tube alone
– Other benefits include improved sensation for secretion
management and swallowing, as well as reduction of
aspiration (Dettelbach, Gross, Mahlmann, & Eibling, 1995)
– Contraindicated if tumor or swelling is causing upper airway
obstruction
•
These benefits, in turn, have a positive impact on QOL
Dysarthria
•
Though it may seem like common sense to slow your speech rate, increase loudness,
reduce background noises, use context, support speech with gestures; when speech
is less intelligible, patients often need to be educated regarding these compensatory
strategies, environment modifications, guided through a hierarchy, provided with
feedback and supported to obtain the best possible results (Yorkston, Strand & Kennedy,
1996)
•
A study in 1998 found decreased tongue mobility and speech intelligibility post
operatively after intraoral tumor resection with flap repair. The severity of speech
deficit was directly related to the post-op quality of life reported by patients on the
functional living cancer index.
–
–
•
If the speech was minimally effected, improved QOL was seen post op, while no
improvement was reported for those with a substantial reduction in intelligibility.
(Shliephake, Schmelzeisen, Schonweiler, Schneller, & Alternbernd, 1998)
For patients s/p total glossectomy or with presence of other severe post-surgical
dysarthria, text to speech apps on smartphones can be trained in addition to use of
Alternative & Augmentative Communication (AAC) devices. Speech sound
approximations can also be trained to increase intelligibility.
–
–
–
Furia, Kowalski, Latorre, Angelis, Martins, Barros, & Ribiero (2001)
Rodriguez & Rowe (2010)
Happ, Roesch, & Kagan (2005)
Laryngectomy
•
Pre-Operative Counseling/Education:
–
–
•
Alaryngeal speech
–
–
–
•
Meet and greet, provide general education regarding anatomy changes, post
surgical alaryngeal speech options and expectations, as well as dysphagia
Zeine & Larson (1999) found that up to 21% of patients/spouses surveyed
reported they were unaware that the laryngectomy surgery would result in loss
of voice
Electrolarynx – immediate gratification post-op
TEP – primary or secondary
Esophageal Speech
Dysphagia
–
–
Compenstory strategies for dysphagia, xerostomia, lack of taste, etc
Screen for dysphagia or strictures
•
•
–
Often need to ask the right questions: Instead of “Do you have any trouble
swallowing?” ask other probing questions such as “Do foods stick or come back up
after you eat or drink?”, “Do you avoid eating in public?”, “What types of food do you
avoid?”
Medical management of strictures, GERD, etc are going to be more successful if
caught and treated early on
Patient education
Knowledge is Power
• To improve quality of life in regards to speech and
swallowing, education may be one of the most
powerful tools we can provide to our patients with
head and neck cancer.
• It allows them to be proactive in their own care and
be best prepared for inevitable changes and
fluctuations in speech/swallowing, as well as
understand the importance of early intervention
and compensation to achieve the best possible
outcomes.
In Closing
• Speech Language Pathology services can improve
the QOL of patients with head and neck cancer
through proper evaluation and treatment of
dysphagia, dysarthria, voice impairments, use of
speaking valves, training alaryngeal speech and
educating and empowering the patient and family.
Thank You!
References
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American Speech-Language-Hearing Association. (2007). Scope of practice in speech-language pathology
[Scope of Practice]. http://www.asha.org/policy/SP2007-00283/, Retrieved on March 19th 2015
Barbon, C. E., & Steele, C. M. (2014). Efficacy of thickened liquids for eliminating aspiration in head and
neck cancer a systematic review. Otolaryngology--Head and Neck Surgery, 0194599814556239.
Carroll, W. R., Locher, J. L., Canon, C. L., Bohannon, I. A., McColloch, N. L., & Magnuson, J. S. (2008).
Pretreatment swallowing exercises improve swallow function after chemoradiation. The Laryngoscope,
118(1), 39-43.
Chen, A. Y., Frankowski, R., Bishop-Leone, J., Hebert, T., Leyk, S., Lewin, J., & Goepfert, H. (2001). The
development and validation of a dysphagia-specific quality-of-life questionnaire for patients with head and
neck cancer: the MD Anderson dysphagia inventory. Archives of Otolaryngology–Head & Neck Surgery,
127(7), 870-876.
Dettelbach, M. A., Gross, R. D., Mahlmann, J., & Eibling, D. E. (1995). Effect of the passy‐muir valve on
aspiration in patients with tracheostomy. Head & Neck, 17(4), 297-302.
Furia, C. L., Kowalski, L. P., Latorre, M. R., Angelis, E. C., Martins, N. M., Barros, A. P., & Ribeiro, K. C.
(2001). Speech intelligibility after glossectomy and speech rehabilitation. Archives of Otolaryngology–Head
& Neck Surgery, 127(7), 877-883
Gillespie, M. B., Brodsky, M. B., Day, T. A., Lee, F. S., & Martin‐Harris, B. (2004). Swallowing‐related quality
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Hutcheson, K. (2012, Sept). Introduction to normal swallow & application to H&N cancer radiotherapy.
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http://www.medicaldosimetry.org/pub/39816b99-2354-d714-5159-a6ab9f5085d1
Kendall, K. A., Kosek, S. R., & Tanner, K. (2014). Quality‐of‐life scores compared to objective measures of
swallowing after oropharyngeal chemoradiation. The Laryngoscope, 124(3), 682-687
References Continued
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Kulbersh, B. D., Rosenthal, E. L., McGrew, B. M., Duncan, R. D., McColloch, N. L., Carroll, W. R., &
Magnuson, J. S. (2006). Pretreatment, preoperative swallowing exercises may improve dysphagia
quality of life. The Laryngoscope, 116(6), 883-886.
Markkanen‐Leppänen, M., Mäkitie, A. A., Haapanen, M. L., Suominen, E., & Asko‐Seljavaara, S.
(2006). Quality of life after free‐flap reconstruction in patients with oral and pharyngeal cancer. Head &
Neck, 28(3), 210-216.
McDonough, E. M., Varvares, M. A., Dunphy, F. R., Dunleavy, T., Dunphy, C. H., & Boyd, J. H. (1996).
Changes in quality‐of‐life scores in a population of patients treated for squamous cell carcinoma of the
head and neck. Head & Neck, 18(6), 487-493.
Rodriguez, C., & Rowe, M. (2010, March). Use of a speech-generating device for hospitalized
postoperative patients with head and neck cancer experiencing speechlessness. In Oncology Nursing
Forum (Vol. 37, No. 2, pp. 199-205). Oncology Nursing Society.
Rosenthal, D. I., Lewin, J. S., & Eisbruch, A. (2006). Prevention and treatment of dysphagia and
aspiration after chemoradiation for head and neck cancer. Journal of Clinical Oncology, 24(17), 26362643
Schliephake, H., Schmelzeisen, R., Schönweiler, R., Schneller, T., & Altenbernd, C. (1998). Speech,
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