Survey of usual practice: dysphagia therapy in head and neck cancer patients

Speech and swallowing intervention following oral cancer treatment: A survey of speech-language pathologists in Australia and New Zealand

PURPOSE

Treatment for oral cancer has debilitating effects on speech and swallowing, however, little is known about current speech-language pathology practice.

METHOD

An online survey of speech-language pathologists (SLPs) was disseminated via emails to speech pathology departments, social media platforms, and professional online forums. Survey questions captured demographics, service delivery, type and timing of speech and swallowing interventions, and influences and barriers to practice.

RESULT

Forty-three SLPs working in Australia (n = 41) and New Zealand (n = 2) completed the survey. SLPs recommended speech and swallowing compensatory strategies significantly more frequently than active intervention. Swallowing outcomes measures were either instrumental (n = 31, 94%) or performance ratings (n = 25, 76%), whereas speech was measured informally with judgements of intelligibility (n = 30, 91%). SLPs used a range of supports for their decision making, particularly expert opinion (n = 81, 38.2%). They reported time and staffing limitations (n = 55, 55%) and a lack of relevant evidence (n = 35, 35%) as the largest barriers to evidence-based service delivery.

CONCLUSION

There is variability amongst SLPs in Australia and New Zealand regarding rehabilitation of speech and swallowing for people with oral cancer. This study highlights the need for evidence-based guidelines outlining best practice for screening processes, active rehabilitation protocols, and valid outcome measures with this population.

The Acceptability of Behavioural Swallowing Interventions for Head and Neck Cancer Patients During Radiotherapy: A Qualitative Study Exploring Experiences of Clinical Trial Speech-Language Pathologists

The PRO-ACTIVE randomized clinical trial offers 3 swallowing therapies to Head and Neck Cancer (HNC) patients during radiotherapy (RT) namely: reactive, proactive low- ("EAT-RT" only) and high-intensity ("EAT-RT + exercises"). Understanding the experiences of the trial Speech-Language Pathologists (SLPs) will be useful to inform clinical implementation. This study assessed SLP opinions of acceptability and clinical feasibility of the 3 trial therapies. 8 SLPs from 3 Canadian PRO-ACTIVE trial sites participated in individual interviews. Using a qualitative approach, data collection and thematic analysis were guided by the Theoretical Framework of Acceptability. Member checking was conducted through a follow-up focus group with willing participants. Seven themes were derived: intervention coherence, burden, barriers/facilitators, self-efficacy, attitude, ethicality, and perceived effectiveness. SLPs felt all 3 therapies had potential benefit yet perceived more advantages of proactive therapies compared to reactive. Compared to exercises, SLPs particularly endorsed the EAT-RT component. A major barrier was keeping patients motivated, which was impacted by acute toxicity and sometimes conflicting instructions from the healthcare team. Strategies utilized by to overcome barriers included: scaling exercises and/or diet up/down according to the changing patient needs and communicating therapy goals with healthcare team. A model was derived describing the perceived acceptability of the swallowing therapies according to SLPs, based on the interconnection of main themes. Proactive therapies were perceived as more acceptable to trial SLPs, for facilitating patient engagement. The perceived acceptability of the swallowing therapies was related to seven interconnected aspects of providers' experience. These findings will inform the implementation and potential uptake of the PRO-ACTIVE swallowing therapies in clinical practice.

Implementing flexible endoscopic evaluation of swallow screening within annual cancer surveillance appointments to monitor for late-stage radiation-induced dysphagia: A feasibility study

BACKGROUND

Late-stage progressive decline of swallowing function after radiotherapy for head and neck cancer (HNC) is often difficult to monitor. This study examined the feasibility and clinical outcomes of speech-language pathology implementing flexible endoscopic evaluation of swallow (FEES) screening during annual cancer surveillance visits to monitor late-stage swallowing function.

METHODS

Patients >2 years post treatment who attended routine oncological visits underwent FEES screening. Feasibility (service data, stakeholder survey) and swallowing outcomes (oral intake, secretions, internal lymphedema, penetration-aspiration, and residue) were collected.

RESULTS

Screening was completed with 70% (50/71) of eligible patients. Medical staff and speech-language pathologists indicated the protocol was worthwhile and achievable to incorporate into practice. Almost all patients were willing to complete the protocol annually. FEES outcomes identified 84% with dysphagia versus only 26% self-reported dysphagia.

CONCLUSION

Findings indicate FEES screening incorporated into annual oncological reviews is feasible and effective at monitoring late-stage swallowing function following HNC.

Speech-Language Pathologist's Pattern of Practice in the Rehabilitation of Head and Neck Cancer patients across Hospitals in India

OBJECTIVE

India has a significant burden of Head and Neck cancer (HNC) patients. Patients afflicted with HNC often encounter difficulties in speech, voice, and swallowing, either due to the disease itself or the treatment they receive. The rehabilitation of HNC patients is crucial, and Speech and Language Pathologists (SLPs) have a significant role in it. The current study aimed to understand the practices followed by SLPs in India while rehabilitating HNC patients.

METHODS

A questionnaire was developed and validated by five Speech-language pathologists, before circulation as an E-survey. The target participants were SLPs working in hospitals across India. The final online version of the questionnaire remained open for eight weeks.

RESULT

A total of 75 Hospital-based SLPs working in India participated in the survey. The responses depict notable trends and differences in the assessment and management approaches. HNC patients who had undergone surgery were more likely to be referred for rehabilitation than those who received non-surgical treatments. Only 36% of the SLPs reported getting pre-operative referrals for HNC patients. The time point for initial assessment and intervention, as well as the protocols used, varied across different hospitals. About 50% of participants had instrumental swallow evaluation facilities in their hospitals, and the majority of hospitals only used instrumental swallow evaluation for 1-3 assessments per week.

CONCLUSION

Variability exists in several aspects of SLP practice for HNC patients offered across Hospitals in India. All HNC patients do not get access to speech-language pathology services. Developing standardized protocols towards early evaluation, intervention and enhancing compliance could improve SLP-led rehabilitation of HNC patients in India.

Distribution pattern of medial group retropharyngeal lymph nodes and its implication in optimizing clinical target volume in nasopharyngeal carcinoma

Purpose

This study aimed to determine the diagnostic value of diffusion-weighted imaging (DWI) and to elucidate the clinical characteristics of medial group retropharyngeal lymph nodes (RLNs) based on multi-modal imaging. Also, we intended to explore the feasibility of optimizing the CTV60 boundary based on the characteristics of medial group RLNs.

Methods

A total of 549 patients with nasopharyngeal carcinoma received magnetic resonance imaging (MRI), DWI, and contrast-enhanced computed tomography (CT) to detect and evaluate clinical characteristics of medial group RLNs. [18F]Fluorodeoxyglucose positron emission tomography/computed tomography was utilized to identify fluorodeoxyglucose uptaking and contrast-enhanced CT to ensure the reliability of CTV optimization during radiotherapy. The DESdC (Drinking, Eating, Swallowing Difficulties, and Coughing while Eating or Drinking) score was utilized to evaluate swallowing disability.

Results

Fourteen of 549 patients had medial group RLNs with a transverse diameter of 2.0-19.0 mm, which distributed between the upper margin of 1st cervical vertebra (C1) and the upper one-third of C3. Lasso regression and Pearson chi-square test suggested that its occurrence was associated with stage N, bilateral cervical lymph node metastases, especially when the transverse diameter of cervical lymph nodes was > 3 cm. The sensitivity of DWI, T2 STIR, and contrast-enhanced CT was 100%, 57.1%, and 21.4%, respectively. We optimized CTV60 of medial group RLNs from the base of skull to the upper edge of C2 excluding specific cases. For patients with CTV60 optimization, radiation dose and volume of swallowing structures decreased obviously. Based on our radiotherapy strategy on CTV60, acute toxicities of enrolled patients were well tolerated. Ninety-six of 549 patients had scores with DESdC score. Eighty-three patients scored 1, seven patients scored 2, one patient scored 3, and three patients scored 4. The median interval from the onset of symptoms was 72 (4-114) months. The 5-year overall survival, progression-free survival, local recurrence-free survival, and distant metastasis-free survival were 87%, 80%, 93%, and 85%, respectively. None of the patients with regional recurrence happened in the optimized region.

Conclusion

DWI possesses superiorities in displaying lymph nodes. Based on the low incidence of the medial RLNs, CTV60 of medial group RLNs from the base of skull to the upper edge of C2 is feasible and has dosimetric advantages for protecting swallowing structures.

Longitudinal Effects of Base of Tongue Concurrent Chemoradiation Therapy in a Pre-Clinical Model

BACKGROUND/OBJECTIVES

Base of tongue (BOT) dysfunction is common following oropharyngeal concurrent chemoradiation therapy (CCRT). We present a clinically relevant animal model quantifying the effects of CCRT on tongue strength and elasticity over time.

METHODS

Fifty-three male and 53 female Sprague-Dawley rats were randomized to control or experimental groups. Experimental animals received cisplatin, 5-fluorouracil, and 5 fractions of 7 Gy directed to the BOT. Controls received no intervention. At 2 weeks, 5 months, or 10 months after CCRT, animals underwent non-survival surgery to measure twitch and tetanic tongue strength, which were analyzed using multivariate linear mixed effects models. Tongue displacement, a surrogate for tongue elasticity, was also determined via stress-strain testing and analyzed via a multivariate linear mixed effects model.

RESULTS

Reporting the combined results of both sexes, the estimated experimental group mean peak twitch forces became more divergent over time compared to controls, being 8.3% lower than controls at 2 weeks post-CCRT, 15.7% lower at 5 months, and 31.6% lower at 10 months. Estimated experimental group mean peak tetanic forces followed a similar course and were 2.9% lower than controls at 2 weeks post CCRT, 20.7% lower at 5 months, and 27.0% lower at 10 months. Stress-strain testing did not find CCRT to have a significant effect on tongue displacement across experimental timepoints.

CONCLUSIONS

This study demonstrates an increasing difference in tongue strength over time between controls and animals exposed to CCRT. Tongue elasticity was not significantly affected by CCRT, suggesting that changes in strength may not be caused by fibrosis.

LEVEL OF EVIDENCE

NA Laryngoscope, 133:1455-1461, 2023.

Swallowing Function After Treatment of Laryngeal Cancer

Dysphagia is a common functional outcome following treatment of laryngeal cancer. Despite curative advances in both nonsurgical and surgical approaches, preserving and optimizing swallowing function is critical. Understanding the nature and severity of dysphagia depending on initial tumor staging and treatment modality and intensity is crucial. This chapter explores current evidence on the acute and chronic impacts of treatments for laryngeal cancer on swallow function, as well as the medical and nonmedical management of dysphagia in this population.

Enhancing speech-language pathology head and neck cancer service provision in rural Australia: Using a plan, do, study, act approach

PURPOSE

People with head and neck cancer (HNC) require ongoing speech-language pathology (SLP) services into the post-acute recovery phase of care. However, there are recognised service inequities/barriers for people from rural areas who are unable to access SLP services locally, necessitating travel to metropolitan centres. This study implemented strategies to assist rural speech-language pathologists to work to full scope of practice and support post-acute rehabilitation services for people with HNC.

METHOD

The study involved five SLP departments within a rural health referral network (one tertiary cancer centre, four rural sites). It involved a Plan-Do-Study-Act (PDSA) method, across two six month cycles, to achieve implementation of a model to support local SLP delivery of HNC care. Data collected included service activity, consumer feedback from people accessing local care, staff perceptions of the model and changes to local SLP service capabilities.

RESULT

Staff identified four objectives for change across the two PDSA cycles including resource development, upskilling/training and improving communication, and handover processes. In cycle 1, multiple resources were developed such as an eLearning program for training and skill development. In cycle 2, a pilot trial of a shared-care model was implemented, which successfully supported a transfer of care to local services for eight people with HNC. The majority of consumers accessing HNC care locally were satisfied with the service and would recommend future people with HNC receive similar care.

CONCLUSION

The PDSA process supported development and implementation of a model enabling local speech-language pathologists to offer post-acute care for people with HNC. This model helps rural people with HNC to access care closer to home by supporting rural clinicians to work to full scope of practice.

Effect of Intensive Oropharyngeal Training on Radiotherapy-Related Dysphagia in Nasopharyngeal Carcinoma Patients

OBJECTIVE

To evaluate the effect of intensive oropharyngeal functional training on swallowing in patients with dysphagia after radiotherapy for nasopharyngeal carcinoma.

METHODS

Fourteen patients with nasopharyngeal carcinomas and dysphagia after radiotherapy received intensive oropharyngeal training for two weeks. The Functional Oral Intake Scale (FOIS) and videofluoroscopic swallowing studies (VFSS) were used to evaluate swallowing function before and after intensive oropharyngeal training. Spatiotemporal parameters of the VFSS were analyzed using a digital image analysis system.

RESULTS

After training, the FOIS, Rosenbek penetration-aspiration score, DIGEST, normalized residue ratio scale, and spatiotemporal parameters of VFSS were significantly improved (P < 0.05).

CONCLUSIONS

This study indicated that intensive oropharyngeal training improves swallowing function after radiotherapy in patients with nasopharyngeal carcinoma.

Using dosimetric information to guide dysphagia management in patients with head and neck cancer: Clinicians' knowledge and experiences

Purpose: The use of dosimetric information to guide the management of dysphagia related to head and neck cancer (HNC) treatment is an emerging area of practice. In order to better meet the needs of people with dysphagia in HNC, it is important to explore how clinicians use this information to guide practice and also to identify factors that influence/discourage the use of dosimetric information.Method: A descriptive qualitative method was chosen and purposeful sampling with additional snowball sampling were used to recruit clinicians working within Australian cancer centres. To facilitate participation, clinicians were offered either a focus group or individual interview as a means to collect their perspectives. A total of 20 clinicians with varying years of clinical experience (range 2.5 - 29 years) were recruited. Eight participants took part in a focus group and 12 elected to participate in an individual interview. Content analysis was used to analyse transcripts.Result: Three main themes emerged from the transcripts: (1) clinician factors such as experience, confidence and knowledge and (2) clinical service factors such as staffing levels, clinical management pathways and system access influence use of dosimetric information; (3) patient factors such as demographics, surgical history and education needs influence dysphagia management plans.Conclusion: Speech-language pathologists' (SLPs') use of dosimetric information within HNC settings to direct patient management is emerging and varies between clinicians and workplaces. Given that dosimetric information potentially enables specialised dysphagia management planning for patients during their radiotherapy treatment, further education and training for speech-language pathologists in this area should be prioritised.

Oral Health Management and Rehabilitation for Patients with Oral Cancer: A Narrative Review

Surgery is the current first choice for oral cancer treatment. Intensity-modulated radiation therapy, molecular targeted drugs, and immune checkpoint inhibitors are still used as adjuvant therapy for advanced cancer. In addition, postoperative rehabilitation and multidisciplinary treatment have also been developed in recent years. Multidisciplinary team approaches and supportive care in oral cancer treatment reportedly shorten the time to treatment and improve outcomes. Although there is enough evidence confirming the role of oral and maxillofacial surgeons, dentists, and dental hygienists in supportive care in oral cancer treatment, there are very few systematic studies. In particular, oral health management is a concept that encompasses oral function management, oral hygiene management, and oral care during oral cancer treatment. We provide a narrative review focusing on oral health management from a multidisciplinary and supportive care perspective, applicable in oral cancer treatment.

The effect of the Shaker head‐lift exercise on swallowing function following treatment for head and neck cancer: Results from a randomized, controlled trial with videofluoroscopic evaluation

Background

Dysphagia is common following treatment for head and neck cancer (HNC) and intervention to improve swallowing function is warranted. This study aimed to evaluate the efficacy of the Shaker head‐lift exercise (HLE) to improve dysphagia in HNC patients.

Methods

Patients treated for HNC with radiochemotherapy and with subsequent dysphagia were randomly assigned to intervention (HLE, n = 25) and control (standard dysphagia management, n = 27) groups. Videofluoroscopic evaluation of penetration‐aspiration, initiation, residue, movement of selected structures, and self‐perceived swallowing function, before and after 8 weeks of treatment, were compared.

Results

Although adherence to training was high, no statistically significant differences in objectively measured swallowing function between the groups or within‐group changes were found. Self‐perceived swallowing function improved in the intervention group.

Conclusions

In this HNC population, neither HLE nor standard dysphagia management improved objectively measured swallowing function as evaluated after 8 weeks. Future research focusing on finding effective interventions for dysphagia is warranted.

Adherence to Home-Based Swallowing Therapy Using a Mobile System in Head and Neck Cancer Survivors

Purpose A large knowledge gap related to dysphagia treatment adherence was identified by a recent systematic review: Few existing studies report on adherence, and current adherence tracking relies heavily on patient self-report. This study aimed to report weekly adherence and dysphagia-specific quality of life following home-based swallowing therapy in head and neck cancer (HNC). Method This was a quasi-experimental pretest-posttest design. Patients who were at least 3 months post-HNC treatment were enrolled in swallowing therapy using a mobile health (mHealth) swallowing system equipped with surface electromyography (sEMG) biofeedback. Participants completed a home dysphagia exercise program across 6 weeks, with a target of 72 swallows per day split between three different exercise types. Adherence was calculated as percent trials completed of trials prescribed. The M. D. Anderson Dysphagia Inventory (MDADI) was administered before and after therapy. Results Twenty participants (75% male), with an average age of 61.9 years (SD = 8.5), completed the study. The majority had surgery ± adjuvant (chemo)radiation therapy for oral (10%), oropharyngeal (80%), or other (10%) cancers. Using an intention-to-treat analysis, adherence to the exercise regimen remained high from 84% in Week 1 to 72% in Week 6. Radiation therapy, time since cancer treatment, medical difficulties, and technical difficulties were all found to be predictive of poorer adherence at Week 6. A statistically significant improvement was found for composite, emotional, and physical MDADI subscales. Conclusions When using an mHealth system with sEMG biofeedback, adherence rates to home-based swallowing exercise remained at or above 72% over a 6-week treatment period. Dysphagia-specific quality of life improved following this 6-week treatment program.

The PRO-ACTIVE trial protocol: a randomized study comparing the effectiveness of PROphylACTic swallow InterVEntion for patients receiving radiotherapy for head and neck cancer

BACKGROUND

Swallowing therapy is commonly provided as a treatment to lessen the risk or severity of dysphagia secondary to radiotherapy (RT) for head and neck cancer (HNC); however, best practice is not yet established. This trial will compare the effectiveness of prophylactic (high and low intensity) versus reactive interventions for swallowing in patients with HNC undergoing RT.

METHODS

This multi-site, international randomized clinical trial (RCT) will include 952 adult patients receiving radiotherapy for HNC and who are at high risk for post-RT dysphagia. Participants will be randomized to receive one of three interventions for swallowing during RT: RE-ACTIVE, started promptly if/when dysphagia is identified; PRO-ACTIVE EAT, low intensity prophylactic intervention started before RT commences; or, PRO-ACTIVE EAT+EXERCISE, high intensity prophylactic intervention also started before RT commences. We hypothesize that the PRO-ACTIVE therapies are more effective than late RE-ACTIVE therapy; and, that the more intensive PRO-ACTIVE (EAT + EXERCISE) is superior to the low intensive PRO-ACTIVE (EAT). The primary endpoint of effectiveness is duration of feeding tube dependency one year post radiation therapy, selected as a pragmatic outcome valued equally by diverse stakeholders (e.g., patients, caregivers and clinicians). Secondary outcomes will include objective measures of swallow physiology and function, pneumonia and weight loss, along with various patient-reported swallowing-related outcomes, such as quality of life, symptom burden, and self-efficacy.

DISCUSSION

Dysphagia is a common and potentially life-threatening chronic toxicity of radiotherapy, and a priority issue for HNC survivors. Yet, the optimal timing and intensity of swallowing therapy provided by a speech-language pathologist is not known. With no clearly preferred strategy, current practice is fraught with substantial variation. The pragmatic PRO-ACTIVE trial aims to specifically address the decisional dilemma of when swallowing therapy should begin (i.e., before or after a swallowing problem develops). The critical impact of this dilemma is heightened by the growing number of young HNC patients in healthcare systems that need to allocate resources most effectively. The results of the PRO-ACTIVE trial will address the global uncertainty regarding best practice for dysphagia management in HNC patients receiving radiotherapy.

TRIAL REGISTRATION

The protocol is registered with the US Patient Centered Outcomes Research Institute, and the PRO-ACTIVE trial was prospectively registered at ClinicalTrials.gov , under the identifier NCT03455608 ; First posted: Mar 6, 2018; Last verified: Jun 17, 2021. Protocol Version: 1.3 (January 27, 2020).

Speech pathology service enhancement for people with head and neck cancer living in rural areas: Using a concept mapping approach to inform service change

BACKGROUND

Speech pathology (SP) services provide swallowing and communication intervention to people with head and neck cancer (HNC) across the continuum of care. However, difficulties exist with access and delivery of services in rural areas. The study aim was to identify actionable goals for SP change, utilizing a concept mapping approach.

METHODS

Eleven SP staff from two regional/remote services completed the concept mapping process. Multivariate analysis and multidimensional scaling were used to develop a final set of prioritized goals for change.

RESULTS

Between the two participating health services, 30 actionable goals were identified within the "green-zone" on the go-zone graph of importance and changeability. Among the most highly rated areas for change was the need to deliver and receive more support for training, mentoring, and supervision to consolidate skills.

CONCLUSIONS

This methodology enabled identification of prioritized, actionable changes to improve SP services for people with HNC living in regional/remote areas.

Introduction of a speech-language pathology assistant role for swallow screening in a head and neck radiotherapy clinic

PURPOSE

Optimal care suggests that all moderate-high risk head and neck (H&N) cancer patients should receive speech pathology assessment, education and management when commencing radiotherapy. However this is not always feasible due to high patient numbers and limited staffing. The aim of this study was to investigate the implementation of a speech-language pathology assistant (SLP-A) role for swallowing screening and education in a multidisciplinary H&N treatment clinic.

METHOD

A detailed model of care and training module were developed to up-skill the SLP-A in the screening and education to be undertaken. A pre-test post-test design compared outcomes in two separate groups prior to and following SLP-A role implementation. Outcomes included: optimal care compliance, speech-language pathology time spent with complex patients, swallowing-related admissions and patient satisfaction.

RESULT

Twenty-six patients were included pre-implementation and 35 post-implementation, with 16 (46%) patients receiving SLP-A screening/education post-implementation. The proportion of eligible patients seen by speech-language pathology pre-implementation was 62%, compared to 94% seen by speech-language pathology or SLP-A post-implementation (p = 0.002). There was a (non-significant) increase in speech-language pathology time spent with complex patients post-implementation (total minutes per patient: mean 252, SD = 144 vs. 279, SD = 115). There was no increase in swallowing-related admissions, and a (non-significant) increase in patient satisfaction post-implementation, indicating no compromise to patient safety or satisfaction.

CONCLUSION

Implementing a speech-language pathology assistant role for screening patients within the H&N treatment clinic allowed delivery of optimal care and increased time for speech-language pathologists to spend with complex patients, without compromising patient safety or satisfaction.

Level of Awareness, Knowledge, and Involvement of Malaysian Medical and Dental Practitioners in Dysphagia Management of Head and Neck Cancer Patients

Head and neck cancer patients are at high risk of developing dysphagia from undergoing cancer treatment. It is essential for medical and dental practitioners to recognize speech-language pathologists' role and dysphagia symptoms to provide a timely referral to speech-language pathologists. This study aims to determine the level of awareness, knowledge, and involvement of medical and dental practitioners in dysphagia management. A total of 391 medical and dental practitioners from 22 government hospitals across Malaysia participated in this cross-sectional study. Participants completed the questionnaire specifically on the level of involvement, knowledge, awareness regarding the role of SLP and dysphagia symptoms. The results revealed a statistically significant relationship between the level of awareness of the role of SLP, χ² (4, 391) = 9.87, p = 0.043 and the level of involvement of medical and dental practitioners, χ² (8, 391) = 27.68, p = 0.001 and percentage of referring head and neck cancer patients. The odds of referring head and neck cancer patients for pre-treatment assessment increased three times for each one unit of the participation of medical and dental practitioners [OR] 3.65 (1.56, 8.51) p = 0.003 among those who are already highly involved in dysphagia management. These findings compel healthcare practitioners in head and neck cancer to revisit their collaborative practices. Head and neck cancer patients should receive swallowing management from speech-language pathologists to improve their swallowing function and avoid further complications such as dehydration, malnutrition, and death.

Resilience: an essential element in head and neck cancer survivorship and quality of life

PURPOSE

Individuals with head and neck cancer (HNCa) face myriad biopsychosocial challenges. Even after treatment completion, these challenges may cause continued disablement and diminished quality of life (QoL). Resilience may serve to minimize the disabling impact of HNCa and, in turn, maximize QoL. The purpose of this study was to formally assess resilience in HNCa survivors and explore its relationship with QoL.

METHODS

A cross-sectional descriptive study was conducted. Forty HNCa survivors completed three validated, self-report questionnaires pertaining to the collection of resilience and QoL data. Descriptive and correlational analyses were performed.

RESULTS

Resilience was identified in HNCa survivors and a positive correlation was found between resilience and QoL.

CONCLUSIONS

Data suggest that resilience may buffer the influence of HNCa on QoL. Thus, screening for reduced levels of resilience may proactively facilitate identification of those who are most vulnerable to the psychosocial impact of HNCa. Interventions that foster resilience may ameliorate the challenges of HNCa and maximize QoL.

Effects of high-frequency speech therapy on speech-related quality of life and objective speech intelligibility of oral cancer patients

To analyze objective and subjective progression of speech intelligibility in oral cancer patients undergoing high-frequency speech therapy during early rehabilitation. Oral cancer patients in the Department of Maxillofacial Surgery, University Hospital of Schleswig-Holstein, Kiel, Germany, participated in the study from March 2016 to November 2017. Speech intelligibility was analyzed preoperatively (t1), post radiation (t2), and post speech therapy (t3). Objective measures were the Munich Intelligibility Profile (Online) and the Frenchay Dysarthria Assessment-2 (FDA-2). Subjective measures were the Speech Handicap Index (SHI), the speech subscale of the EORTC QLQ-C30&HN35, and the WHO-5 Index II. For nine patients with complete data, progression analyses showed a non-existent-to-low intelligibility impairment at t1 (means/SDs: e.g. FDA-2: 8.96/0.11, SHI: 17.5/15.15), increasing towards t2 (means/SDs/p-values for difference from t1: e.g. FDA-2: 7.40/0.80/0.000, SHI: 21.7/14.24/0.213), and then decreasing towards t3, without ever reaching the initial level (means/SDs/p-values for difference from t1: e.g. FDA-2: 8.22/0.60/0.005, SHI: 23.5/15.85/0.481). The objective changes in intelligibility were significant; the subjective changes were not. Overall, the ability to speak intelligibly after oral cancer treatment follows a typical pattern. Therefore, high-frequency speech therapy in the early rehabilitation phase might be recommendable. It might help patients to adapt to their situation after surgery, and facilitates compensating for possible functional deficits.

Clinical Practices in Head and Neck Cancer: A Speech-Language Pathologist Practice Pattern Survey

OBJECTIVE

Clinical practices of speech-language pathologists (SLP) treating head and neck cancer (HNC) patients range widely despite literature trending toward best practices. This survey study was designed to identify current patterns and assess for gaps in clinical implementation of research evidence.

METHOD

A web-based survey was distributed to SLPs via listserv and social media outlets. Descriptive statistics and group calculations were completed to identify trends and associations in responses.

RESULTS

Of 152 received surveys, the majority of respondents were hospital-based (86%) and had greater than 5 years of experience (65%). There was group consensus for the use of prophylactic exercise programs (95%), recommendations for SLP intervention during HNC treatment (75%), and use of maintenance programs post-treatment (97%). Conversely, no group consensus was observed for use of pre-treatment swallow evaluations, frequency of service provision, and content of therapy sessions. Variation in clinical decision making was noted in use of prophylactic feeding tubes and number of patients taking nothing by mouth during treatment. No associations were found between years of experience and decision-making practices, nor were any associations found between practice setting and clinical decision making.

CONCLUSION

Despite the growing body of literature outlining evidence-based treatment practices for HNC patients, clinical practice patterns among SLPs continue to vary widely resulting in inconsistent patient care across practice settings. As compared to prior similar data, increased alignment with best practices was observed relative to early referrals, implementation of prophylactic intervention programs, and intervention with the SLP during the period of HNC treatment.

A comparison of the head lift exercise and recline exercise in patients with chronic head and neck cancer post-radiation

BACKGROUND

Patients who undergo surgery and adjuvant radiation treatment for head and neck cancer often develop dysphagia as a result of this treatment. Improvements in swallow function may be achieved with exercise. The goal of this pilot study was to compare the effectiveness and perceived difficulty of using the head lift exercise and the recline exercise to activate the suprahyoid musculature in 8 individuals with a history of head and neck cancer.

METHOD

Muscle activation using surface electromyography was examined to determine if the recline exercise activates the suprahyoid muscle groups to the same degree as the head lift exercise. Participants also rated the exertion they experienced to assess how easily patients are able to complete the exercises.

RESULTS

The majority of participants completed both exercises in their entirety on their first attempt. However, ratings of perceived exertion were significantly lower for the recline exercise than the head lift exercise. The head lift exercise activated the suprahyoid musculature to a significantly greater degree than the recline exercise.

CONCLUSION

The recline exercise, in comparison with the head lift exercise, is easier for participants to complete and results in significantly reduced perceptions of fatigue. Results of this study indicate that the recline exercise may be a good potential substitute for the head lift exercise in patient populations that are incapable of performing the head lift exercise, but that the head lift exercise should be prescribed whenever it is viable as it activates target musculature more effectively than the recline exercise.

Drooling in children with neurodisability: A survey of Australian speech-language pathologists' practice

Purpose: In the absence of evidence-based guidelines, this study sought to understand current speech-language pathologists' (SLPs) practice when treating drooling in children with a neurodisability.Method: Descriptive research using cross-sectional survey methodology. Online survey methods were used to obtain specific information on Australian SLPs' self-reported assessment and treatment practices relative to working with children with neurodisability who drool. Questions focussed on level of expertise, treatment approaches and barriers to evidence-based practice (EBP) in this area. Participants were sourced through three targeted associations/organisations. Data were analysed using descriptive and non-parametric statistics.Result: Participants were Australian SLPs who had recent experience working with children with neurodisability who drool (n = 68). They favoured informal rather than formal methods for assessment. Preferred treatment techniques included behavioural intervention methods (46-53%) and modifying positioning (43.3%). Client suitability dominated reasoning regarding treatment selection (60%) with 57% of SLPs reporting EBP barriers.Conclusion: Drooling was perceived to be a complex practice area for which SLPs desire additional education. Despite availability, valid and reliable assessments of drooling were not commonly used. Clinicians have limited evidence to support their practice: further research is needed to establish evidence-based treatments for drooling.

Eat All Through Radiation Therapy (EAT-RT): Structured therapy model to facilitate continued oral intake through head and neck radiotherapy-User acceptance and content validation

BACKGROUND

To develop and examine user acceptance and content validity of a structured program to facilitate safe but challenging oral intake during radiotherapy (RT) delivered by a speech language pathologist (SLP)-the Eat-All Through Radiation Therapy (EAT-RT) program.

METHODS

EAT-RT was developed through expert consensus of SLPs at the Princess Margaret Cancer Centre (Canada) and M D Anderson Cancer Center using a conceptual framework of a diet hierarchy and a mealtime routine. EAT-RT was refined by practicing SLPs, and then disseminated for a 4-week clinical pilot at seven sites who were subsequently invited to participate in an online survey.

RESULTS

Twelve SLPs from six sites piloted EAT-RT therapy with a median of eight patients (IQR: 2-15) before and/or during RT. All SLPs reported EAT-RT added value to their practice, harmonized well with exercises, and its content was helpful; 11 (92%) reported EAT-RT facilitated patient understanding and indicated the desire to continue using EAT-RT.

CONCLUSION

The EAT-RT program was accepted by North American SLPs. The findings support the content and value of EAT-RT to facilitate oral intake in patients with head and neck cancer throughout RT.

Adherence to Dysphagia Treatment Recommendations: A Conceptual Model

Purpose Conceptual models of complex health problems are useful when designing targeted clinical interventions and focused research studies. Understanding and studying patient adherence often involves interplay among many factors that influence whether a patient successfully follows recommendations or completes a therapy program. Functional frameworks serve to arrange these factors visually, increasing interpretability and allowing for empirical testing of relationships among concepts. The purpose of this article is to integrate relevant factors from the literature into a comprehensive framework that describes adherence to dysphagia treatment. Method Using peer-reviewed, published guidelines regarding conceptual model construction, the authors created a list of potential factors that influence patient adherence to dysphagia-related treatment recommendations. During model construction, following extensive review of the literature and existing theories that have been applied in other areas of health care, factors were identified and grouped into conceptually similar domains (clusters). Clusters were arranged into larger categories that emerged during model optimization. Ultimately, two models were created: one that illustrates the interrelated factors of patient adherence and another that illustrates a subset of modifiable risk factors that a clinical speech-language pathologist may influence when developing a dysphagia treatment plan. Results Three general categories from 14 factors emerged based on relationships between factors and aspects of patient care: health factors, individual patient factors, and contextual factors. A second model consisting of modifiable risk factors included access, treatment type, patient perceptions, self-efficacy, health literacy, support factors, and provider bias. Conclusions This conceptual model allows clinicians and researchers to identify and explore the mechanisms driving adherence. Continual refinements of this model should be made as future studies uncover how the interconnectedness of factors affects adherence in dysphagia management. The models we have presented here are ready for clinical application and should also serve researchers as they generate hypotheses and design targeted research questions.

Effects of Tongue Exercise Frequency on Tongue Muscle Biology and Swallowing Physiology in a Rat Model

Age-related changes in muscle composition and function are often treated using exercise, including muscles of the tongue to treat swallowing impairments (dysphagia). Although tongue exercise is commonly prescribed, optimal tongue exercise doses have not been determined. The purpose of this study was to evaluate effects of varying tongue exercise frequency on tongue force, genioglossus muscle fiber size, composition and metabolism, and swallowing in a rat model. We randomized 41 old and 40 young adult Fischer 344/Brown Norway rats into one of four tongue exercise groups: 5 days/week; 3 days/week; 1 day/week; or sham. Tongue force was higher following all exercise conditions (vs sham); the 5 day/week group had the greatest change in tongue force (p < 0.001). There were no exercise effects on genioglossus (GG) fiber size or MyHC composition (p > 0.05). Significant main effects for age showed a greater proportion of Type I fibers in (p < 0.0001) and increased fiber size of IIa fibers (p = 0.026) in old. There were no significant effects of citrate synthase activity or PGC-1α expression. Significant differences were found in bolus speed and area (size), but findings were potentially influenced by variability. Our findings suggest that tongue force is influenced by exercise frequency; however, these changes were not reflected in characteristics of the GG muscle assayed in this study. Informed by findings of this study, future work in tongue dose optimization will be required to provide better scientific premise for clinical treatments in humans.

Study protocol for a randomized controlled trial: prophylactic swallowing exercises in head-and-neck cancer patients treated with (chemo)radiotherapy (PRESTO trial)

Background

Dysphagia is a common and serious complication after (chemo)radiotherapy (CRT) for head-and-neck cancer (HNC) patients. Prophylactic swallowing exercises (PSE) can have a significantly positive effect on post-treatment swallowing function. However, low adherence rates are a key issue in undermining this positive effect. This current randomized trial will investigate the effect of adherence-improving measures on patients’ swallowing function, adherence and quality of life (QOL).

Methods

This ongoing trial will explore the difference in adherence and swallowing-related outcome variables during and after PSE in HNC patients performing the same therapy schedule, receiving different delivery methods. One hundred and fifty patients treated in various hospitals will be divided into three groups. Group 1 performs PSE at home, group 2 practices at home with continuous counseling through an app and group 3 receives face-to-face therapy by a speech and language pathologist. The exercises consist of tongue-strengthening exercises and chin-tuck against resistance with effortful swallow. The Iowa Oral Performance Instrument and the Swallowing Exercise Aid are used for practicing. Patients are evaluated before, during and after treatment by means of strength measurements, swallowing and QOL questionnaires.

Discussion

Since low adherence rates undermine the positive impact of PSE on post-treatment swallowing function, there is need to develop an efficient PSE protocol maximizing adherence rates.

Trial registration

ISRCTN, ID: ISRCTN98243550. Registered retrospectively on 21 December 2018.

Prophylactic swallowing therapy for patients with head and neck cancer: A three-arm randomized parallel-group trial

BACKGROUND

Intensive prophylactic swallowing therapy can mitigate dysphagia in patients with oropharyngeal (OP) SCC, however, presents service challenges. This trial investigated the clinical efficacy of three service models delivering prophylactic swallowing therapy during (chemo)radiotherapy ([C]RT).

METHODS

Patients (n = 79) with OPSCC receiving (C)RT were were randomized to: (a) clinician-directed face-to-face therapy (n = 26); (b) telepractice therapy via "SwallowIT" (n = 26); or (c) patient self-directed therapy (n = 27). Swallowing, nutritional, and functional status were compared at baseline, 6-weeks, and 3-months post-(C)RT. Patients' perceptions/preferences for service-delivery were collated posttreatment.

RESULTS

Service-delivery mode did not affect clinical outcomes, with no significant (P > .05) between-group differences or group-by-time interactions observed for swallowing, nutrition, or functional measures. Therapy adherence declined during (C)RT in all groups. SwallowIT and clinician-directed models were preferred by significantly (P = .002) more patients than patient-directed.

CONCLUSIONS

SwallowIT provided clinically equivalent outcomes to traditional service models. SwallowIT and clinician-directed therapy were preferred by patients, likely due to higher levels of therapy support.

Association of a Proactive Swallowing Rehabilitation Program With Feeding Tube Placement in Patients Treated for Pharyngeal Cancer

Importance

A proactive speech and language pathology (SLP) program is an important component of the multidisciplinary care of patients with head and neck squamous cell carcinoma (HNSCC). Swallowing rehabilitation can reduce the rate of feeding tube placement, thereby significantly improving quality of life.

Objective

To evaluate the initiation of a proactive SLP rehabilitation program at a single institution and its association with rates of feeding tube placement and dietary intake in patients with HNSCC.

Design, Setting, and Participants

Cohort study at a tertiary care and referral center for patients with HNSCC serving the northern Chicago region. Patients were treated for squamous cell carcinomas of the hypopharynx, oropharynx, and nasopharynx from 2004 to 2015 with radiation or chemoradiation therapy in the definitive or adjuvant setting. Patients who received less than 5000 cGy radiation or underwent reirradiation were excluded.

Interventions

A proactive SLP program for patients with HNSCC was initiated in 2011. Study cohorts were divided into 2 groups: 2004 through 2010 and 2011 through 2015.

Main Outcomes and Measures

Primary outcome variables were SLP referral placement and timing of the referral. Secondary outcomes were feeding tube placement and ability to tolerate any oral intake.

Results

A total of 254 patients met inclusion criteria (135 before and 119 after implementation of SLP program; median age, 60 years [range, 14-94 years]; 77% male). With the initiation of a proactive SLP program, pretreatment evaluations increased from 29 (21.5%) to 70 (58.8%; risk ratio [RR], 2.74; 95% CI, 1.92-3.91), and rate of referral overall at any time increased from 60.0% to 79.8% (RR, 1.33; 95% CI, 1.13-1.57). Feeding tube placement rates decreased from 45.9% (n = 62) to 29.4% (n = 35; RR, 0.64; 95% CI, 0.46-0.89). Among patients receiving a swallow evaluation, feeding tube requirements were less frequent for those receiving a pretreatment evaluation (31 of 99 [31%]) than for those referred during (11 of 18 [61%]) or after (38 of 59 [64%]) treatment. The rate of tolerating any oral intake at the end of treatment improved from 71.1% (n = 96) in the preimplementation period to 82.4% (n = 98; RR, 1.16; 95% CI, 1.01-1.33).

Conclusions and Relevance

A proactive SLP program can be successfully established as part of the multidisciplinary care of patients with HNSCC and improve patient quality of life.

Utilization of rehabilitation services in patients with head and neck cancer in the United States: A SEER-Medicare analysis

BACKGROUND

Head and neck cancer (HNC) and its treatment lead to functional impairments. Rehabilitation by speech-language pathology (SLP) and occupational/physical therapy (OT/PT) can decrease morbidity.

METHODS

The Surveillance, Epidemiology and End Results-Medicare data for patients with HNC diagnosed between 2002 and 2011 was utilized to evaluate posttreatment rehabilitation.

RESULTS

In 16 194 patients, the overall utilization rate was 20.7% for SLP and 26.2% for OT/PT services. Treatment modality was significantly associated rehabilitation utilization. Compared to patients treated with primary surgery, those treated with primary radiotherapy had significantly lower odds of OT/PT utilization. Patients treated with surgery plus adjuvant treatment and primary concurrent chemoradiation had higher odds of SLP utilization compared to patients treated with surgery alone.

CONCLUSIONS

Rehabilitation services appeared to be underutilized by patients with HNC in the United States and vary with treatment modality. There is a need to improve integration of rehabilitation services into the HNC care continuum.

SUMMARY

Rehabilitation services are underutilized by patients with HNC during posttreatment surveillance in the United States. Treatment modality significantly impacts rehabilitation utilization patterns.

Early Postoperative Oral Exercise Improves Swallowing Function Among Patients With Oral Cavity Cancer: A Randomized Controlled Trial

Dysphagia remains an unsolved problem for patients with oral cavity cancer who have undergone surgery. This randomized controlled trial was conducted to determine the effect of oral exercise in addition to standard general care and diet counseling on the physiology of swallowing. Fifty patients (25 in each group) with oral and oropharyngeal cancer who underwent tumor resection, neck dissection, and reconstruction were enrolled in this study. The Rosenbek penetration-aspiration scale and modified barium swallow study were administered at 1 and 4 month(s) postoperatively. We observed significant improvements in the intervention group regarding the penetration-aspiration scale (P = .037), and oral and pharyngeal residue with thickened boluses (Nectar P < .001, Honey P < .001, and Pudding P < .001). In conclusion, oral exercise significantly improves the postoperative swallowing function of patients with oral cavity cancers.

Application of Manual Therapy for Dysphagia in Head and Neck Cancer Patients: A Preliminary National Survey of Treatment Trends and Adverse Events

BACKGROUND

Radiation-associated dysphagia is a common and debilitating consequence of treatment for head and neck cancer (HNC). Since commonly employed dysphagia therapy programs for HNC patients still lack authoritative efficacy, some speech-language pathologists (SLPs) have started employing manual therapy (MT) techniques in an attempt to prevent or rehabilitate dysphagia in this patient population. However, exceptionally little is known about the use of MT in this patient population.

OBJECTIVES

The purpose of this study was to describe practice patterns as well as the rate, type, and severity of adverse events associated with SLP provision of MT to HNC patients.

METHODS

An Internet-based questionnaire geared toward SLPs who practice MT was developed and sent to SLPs practicing in the United States, 3 times, through 3 national listservs (American Speech Language Hearing Association [ASHA] Special Interest Division 13, ASHA Special Interest Division 3, and University of Iowa Voiceserv), over the course of 4 weeks.

RESULTS

Of the 255 respondents, 116 (45.5%) performed MT on HNC patients. Of these 116 SLPs, 27.6% provided proactive MT during radiation, 62.1% provided 1 to 2 sessions per week, and 94.8% prescribed a MT home program. The rate, type, and severity of reported adverse events were similar between HNC and non-HNC patients.

CONCLUSION

This preliminary survey demonstrated that SLPs provide MT to HNC patients during and after cancer treatment, and that reported adverse events paralleled those experienced by noncancer patients. However, these results should be taken with caution, and a well-designed prospective study is needed to formally establish the safety and the preliminary efficacy of this novel clinical intervention.

Nutrition and Swallowing Therapy in Head and Neck Cancer: Utilization of Care and Preventative Efficacy

PURPOSE

To examine the impact of ethnicity, Spanish language preference, socioeconomic status, and treatment setting on utilization of supportive services before radiotherapy (RT) among head and neck cancer patients and to determine whether a lack of these services is associated with an increased rate of adverse events.

METHODS AND MATERIALS

Demographic, staging, and treatment details were retrospectively collected for patients treated at a safety-net hospital (n = 56) or adjacent private academic hospital (n = 183) from January 1, 2014, to June 30, 2016. Supportive care services evaluated were limited to speech/swallowing therapy and nutrition therapy. Adverse events and performance measures examined included weight loss during RT, gastric tube placement, emergency department visits, hospital admissions, and missed RT days.

RESULTS

On multivariable analysis, patients receiving treatment at the safety-net hospital were less likely to receive speech/swallowing services. Receiving speech/swallowing therapy before treatment was associated with less weight loss during treatment, and in conjunction with nutrition therapy, was associated with fewer missed RT days.

CONCLUSION

Safety-net hospital treatment was associated with a lack of utilization of pre-RT speech/swallowing therapy which in turn was associated with increased weight loss. Interventions aimed at improving utilization of these services would improve treatment tolerance and patient outcomes.

Radiotherapy for cutaneous head and neck cancer and parotid tumours: a prospective investigation of treatment-related acute swallowing and toxicity patterns

PURPOSE

Reports of acute treatment-related dysphagia and toxicities for patients with parotid tumours or cutaneous head and neck cancer (HNC) are limited. This study aimed to describe the severity and timing of dysphagia and related toxicities experienced during radiotherapy for cutaneous HNC and parotid tumours, to inform the nature of future speech pathology (SP) service models required during treatment.

METHODS

Prospective study of 32 patients with parotid tumours and 36 with cutaneous HNC undergoing curative non-surgical management. Dysphagia and acute toxicity data was collected weekly during treatment and at 2, 4 and 12 weeks post-treatment using the Functional Oral Intake Scale, diet descriptors and CTCAE v4.0.

RESULTS

In both groups, minimal treatment toxicities (grades 0-1) were observed. Xerostomia and dysgeusia were the most frequently reported grade 2 toxicities. Only 3% of parotid patients and 6% with cutaneous HNC experienced grade 3 dysphagia. Full or soft texture diets were maintained by > 70% of patients in both groups. Symptoms peaked in the final week of treatment and rapidly improved thereafter. Apart from xerostomia < 10% of patients had any grade 2 toxicity at 12 weeks post-treatment.

CONCLUSION

Patients in these subgroups of HNC experienced minimal treatment-related toxicity during radiotherapy. As such, the need for supportive symptom management by SP is low. Models that involve interdisciplinary surveillance of symptoms with referral to SP only when required may be best suited for these individuals to ensure issues are identified whilst minimising patient burden created by unnecessary routine SP appointments.

Establishing a Multidisciplinary Head and Neck Clinical Pathway: An Implementation Evaluation and Audit of Dysphagia-Related Services and Outcomes

Head and neck cancer (HNC) guidelines recommend regular multidisciplinary team (MDT) monitoring and early intervention to optimize dysphagia outcomes; however, many factors affect the ability to achieve these goals. The aims of this study were to explore the barriers/facilitators to establishing and sustaining a MDT HNC care pathway and to examine the dysphagia-related speech-language pathology (SLP) and dietetic components of the pathway. Using the Consolidated Framework for Implementation Research (CFIR), a mixed methods study design was used to evaluate an established MDT HNC pathway. Ten MDT members provided perceptions of facilitators/barriers to implementing and sustaining the pathway. Patients attending the SLP and dietetic components of the pathway who commenced treatment between 2013 and 2014 (n = 63) were audited for attendance, outcome data collected per visit, and swallowing outcomes to 24-month post-treatment. Dysphagia outcomes were compared to a published cohort who had received intensive prophylactic dysphagia management. Multiple CFIR constructs were identified as critical to implementing and sustaining the pathway. Complexity was a barrier. Patient attendance was excellent during treatment, with low rates of non-compliance (< 15%) to 24 months. Collection of clinician/patient outcome tools was good during treatment, but lower post-treatment. Dysphagia outcomes were good and comparable to prior published data. The pathway provided patients with access to regular supportive care and provided staff opportunities to provide early and ongoing dysphagia monitoring and management. However, implementing and sustaining a HNC pathway is complex, requiring significant staff resources, financial investment, and perseverance. Regular audits are necessary to monitor the quality of the pathway.

Dysphagia therapy post stroke: An exploration of the practices and clinical decision-making of speech-language pathologists in Australia

PURPOSE

A variety of dysphagia management options are available for the treatment of dysphagia following a stroke, however, it is unknown which of these approaches are most commonly utilised by Australian speech-language pathologists (SLPs) and whether particular factors influence decision-making.

METHOD

The aim of this study was to investigate, through an online survey, the treatment practices of SLPs in Australia for the treatment of dysphagia post-stroke and identify the factors influencing treatment decisions.

RESULT

A total of 118 SLPs completed the online survey. Descriptive statistics identified large variability in the dysphagia treatments utilised, with all 24 therapies listed in the online survey reported as being routinely used. Compensatory therapies were ranked as being utilised more frequently than rehabilitative approaches, with six of the seven highly utilised therapies being compensatory in nature. A client's cognitive capacity was the most prominent factor influencing SLPs' treatment decisions.

CONCLUSION

This study provides insight into the practices of SLPs in Australia for the treatment of dysphagia following stroke and discusses potential for shifts in practice. It highlights the complexity involved in the decision-making process and that clinicians consider evidence, as well as client, clinician and service factors, when selecting between the range of options available.

Feasibility of assessing patient health benefits and incurred costs resulting from early dysphagia intervention during and immediately after chemoradiotherapy for head-and-neck cancer

Background

Resource limitations affect the intensity of speech-language pathology (slp) dysphagia interventions for patients with head-and-neck cancer (hnc). The objective of the present study was to assess the feasibility of a prospective clinical trial that would evaluate the effects on health and patient costs of early slp dysphagia intervention for hnc patients planned for curative concurrent chemoradiotherapy (ccrt).

Methods

Patients with hnc planned for curative ccrt were consecutively recruited and received dysphagia-specific intervention before, during, and for 3 months after treatment. Swallowing function, body mass index, health-related quality of life (qol), and out-of-pocket costs were measured before ccrt, at weeks 2 and 5 during ccrt, and at 1 and 3 months after ccrt. Actuarial percutaneous endoscopic gastrostomy (peg) removal rates and body mass index in the study patients and in a time-, age-, and disease-matched cohort were compared.

Results

The study enrolled 21 patients (mean age: 54 years; 19 men). The study was feasible, having a 95% accrual rate, 10% attrition, and near completion of all outcomes. Compared with the control cohort, patients receiving dysphagia intervention trended toward a higher rate of peg removal at 3 months after ccrt [61% (32%-78%) vs. 53% (23%-71%), p = 0.23]. During ccrt, monthly pharmaceutical costs ranged between $239 and $348, with work loss in the range of 18-30 days for patients and 8-12 days for caregivers.

Conclusions

We demonstrated the feasibility of comparing health and economic outcomes in patients receiving and not receiving early slp dysphagia intervention. These preliminary findings suggest that early slp dysphagia intervention for hnc patients might reduce peg dependency despite worsening health. Findings also highlight effects on financial security for these patients and their caregivers.

Flow and Grit by Design: Exploring Gamification in Facilitating Adherence to Swallowing Therapy

PURPOSE

Delivery of swallowing therapy is faced with challenges regarding access to in-clinic services and adherence to prescribed home programs. Mobile health (mHealth) technologies are being developed at a rapid pace to address these difficulties. Whereas some benefits to using these modern tools for therapy are obvious (e.g., electronic reminders), other advantages are not as well understood. One example is the potential for mHealth devices and apps to enhance adherence to treatment regimens.

METHOD

This article introduces a number of psychological concepts that relate to adherence and that can be leveraged by mHealth. Elements that contribute to flow (optimal experience) during an activity and those that reinforce grit (perseverance to achieve a long-term goal) can be used to engage patients in their own rehabilitation.

RESULTS

The experience of flow can be targeted by presenting the rehabilitation exercise as an optimally challenging game, one that offers a match between challenge and ability. Grit can be supported by reinforcing routine and by varying the therapy experience using different games.

CONCLUSIONS

A combination of hardware and software design approaches have the potential to transform uninteresting and repetitive activities, such as those that make up swallowing therapy regimens, into engaging ones. The field of gamification, however, is still developing, and gamified mHealth apps will need to withstand scientific testing of their claims and demonstrate effectiveness in all phases of outcome research.

Treatment of late sequelae after radiotherapy for head and neck cancer

Radiotherapy (RT) is used to treat approximately 80% of patients with cancer of the head and neck. Despite enormous advances in RT planning and delivery, a significant number of patients will experience radiation-associated toxicities, especially those treated with concurrent systemic agents. Many effective management options are available for acute RT-associated toxicities, but treatment options are much more limited and of variable benefit among patients who develop late sequelae after RT. The adverse impact of developing late tissue damage in irradiated patients may range from bothersome symptoms that negatively affect their quality of life to severe life-threatening complications. In the region of the head and neck, among the most problematic late effects are impaired function of the salivary glands and swallowing apparatus. Other tissues and structures in the region may be at risk, depending mainly on the location of the irradiated tumor relative to the mandible and hearing apparatus. Here, we review the available evidence on the use of different therapeutic strategies to alleviate common late sequelae of RT in head and neck cancer patients, with a focus on the critical assessment of the treatment options for xerostomia, dysphagia, mandibular osteoradionecrosis, trismus, and hearing loss.

Expiratory muscle strength training for radiation-associated aspiration after head and neck cancer: A case series

OBJECTIVE/HYPOTHESIS

Expiratory muscle strength training (EMST) is a simple, inexpensive, device-driven exercise therapy. Therapeutic potential of EMST was examined among head and neck cancer survivors with chronic radiation-associated aspiration.

STUDY DESIGN

Retrospective case series.

METHODS

Maximum expiratory pressures (MEPs) were examined among n = 64 radiation-associated aspirators (per penetration-aspiration scale score ≥ 6 on modified barium swallow). Pre-post EMST outcomes were examined in a nested subgroup of patients (n = 26) who enrolled in 8 weeks of EMST (25 repetitions, 5 days/week, 75% load). Nonparametric analyses examined effects of EMST on the primary endpoint MEPs. Secondary measures included swallowing safety (Dynamic Imaging Grade of Swallowing Toxicity [DIGEST]), perceived dysphagia (M.D. Anderson Dysphagia Inventory [MDADI]), and diet (performance status scale for head and neck cancer patients [PSSHN]).

RESULTS

Compared to sex-matched published normative data, MEPs were reduced in 91% (58 of 64) of aspirators (mean ± standard deviation: 89 ± 37). Twenty-six patients enrolled in EMST and three patients withdrew. MEPs improved on average 57% (87 ± 29 to 137 ± 44 cm H₂ O, P < 0.001) among 23 who completed EMST. Swallowing safety (per DIGEST) improved significantly (P = 0.03). Composite MDADI scores improved post-EMST (pre-EMST: 59.9 ± 17.1, post-EMST: 62.7 ± 13.9, P = 0.13). PSSHN diet scores did not significantly change.

CONCLUSION

MEPs were reduced in chronic radiation-associated aspirators relative to normative data, suggesting that expiratory strengthening could be a novel therapeutic target to improve airway protection in this population. Similar to findings in neurogenic populations, these data also suggest improved expiratory pressure-generating capabilities after EMST and translation to functional improvements in swallowing safety in chronic radiation-associated aspirators.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:1044-1051, 2018.

Contemporary management of advanced laryngeal cancer

The treatment of advanced laryngeal cancer has undergone a paradigm shift in recent years, with an increase in chemoradiation for organ preservation and a decrease in primary surgery. This review will summarize the contemporary management of advanced laryngeal cancer and discuss treatment‐related toxicity and strategies to improve outcomes.

Level of Evidence

NA.

Prophylactic Swallow Therapy for Patients with Head and Neck Cancer Undergoing Chemoradiotherapy: A Randomized Trial

Evidence supporting prophylactic swallow exercises for patients with head and neck cancer (HNC) has not been universally demonstrated. This RCT examined diet level, feeding tube use, swallow function, and quality of life (QOL) of patients undergoing chemoradiotherapy who performed prophylactic swallowing exercises. Sixty HNC patients were randomized into exercise versus control groups. Swallowing, oromotor, toxicity, and QOL data were recorded (baseline, 3, 6, 12, 24 months). Physiological swallow function was examined at baseline and 3 months. Swallow exercises were completed twice daily. Oral intake at 3 months was 10% better in the exercise group, which was not statistically significant (p = 0.49). Significant (p < 0.05) differences in secondary outcomes including oromotor function, pharyngeal impairment, oral pharyngeal swallow efficiency, and incisal opening were noted at early time points (3–6 months) in the exercise group. Possible positive early improvements in swallow function are associated with swallowing exercises, although these improvements are not significant longer term.

Comparing dysphagia therapy in head and neck cancer patients in Australia with international healthcare systems

PURPOSE

The Australian healthcare system has invested heavily in multidisciplinary cancer care teams. Despite such investments, guidelines that clearly delineate standard of care dysphagia treatment are lacking and services provided to Head and Neck Cancer (HNC) patients are not always consistent. There is little consensus regarding the frequency and intensity of dysphagia therapy. This is largely due to a lack of well-designed clinical trials that establish the efficacy of any dysphagia therapy in this patient population. The aim of this study was to evaluate HNC dysphagia therapy patterns among Australian speech-language pathologists (SLPs).

METHOD

A 22 question internet-based survey was administered to a web-based professional interest group. Results were analysed by institution type and individual clinical experience.

RESULT

A response rate of 46% was achieved (67 out of 144 surveyed). This survey identified several aspects of dysphagia management that were provided uniformly in addition to many aspects of care that showed a lack of consensus.

CONCLUSION

By comparing the results of this survey with existing international best-evidence treatment guidelines, the development of uniform Australian guidelines may be facilitated. However, more authoritative data on dysphagia treatment efficacy is needed to provide uniform evidence-based HNC dysphagia treatment guidelines.

The "Comprehensive ICF Core Set for Head and Neck Cancer": a Delphi consensus survey among German speaking speech and language therapists

The "Comprehensive ICF Core Set for Head and Neck Cancer" (ICF-HNC) is an application of the "International Classification of Functioning, Disability and Health" (ICF), representing the characteristic spectrum of issues in patients with head and neck cancer (HNC). Our primary aim was to evaluate which categories of the ICF-HNC are dealt with by speech and language therapists (SLTs) in Germany, Austria, and Switzerland. The secondary aim was to identify outcome measures used by SLTs to measure the categories of the ICF-HNC in clinical practice. SLTs experienced in the treatment of HNC patients evaluated the categories of the ICF-HNC in a three-round Delphi survey. They were asked whether the listed categories represented issues treated by SLTs in HNC patients, and what outcome measures were used to assess them. Altogether, 31 SLTs completed the survey. 47 of 108 previously selected categories of the ICF-HNC achieved the cut-off value. Out of these, 40.4% were derived from the component "Body Functions", 36.2% from "Body Structures", 12.8% from "Environmental Factors", and 10.6% from "Activities and Participation". Altogether, 82 of the mentioned outcome measures were considered as reasonable from the perspective of SLTs. Of these, only 37 achieved more than 50% approval. This study emphasises the importance of "Body Structures" and "Body Functions" for SLTs in Germany and Switzerland in treating patients with HNC. Moreover, the results highlighted the need to agree on evidence-based outcome measures in speech and language therapy.