sign in sign up
<<
Home , Head and neck cancer

Head and Neck

When, Why and How – Introduction of speech Sarah Smith has no therapy for patients undergoing surgical financial disclosures for intervention and this presentation.

Sarah Smith MCD, CCC-SLP

Table of Contents About Me ● Overview and terminology June August ● (HNC) 2014 2017 2017 Present ● ● Speech Therapy and for HNC ● Speech Therapy and Radiation Therapy ● Speech Therapy and ● Speech Therapy and ● Initial Evaluation Overview ● Resources Introduction to Cancer Common Terminology(2)

● Definition: “the name for a group of more than 100 diseases in ● Primary Lesion/Tumor: Original tumor which cells begin to grow out of control” (1) ● : The spread of cancer from one part of the body to another. ● Potential causes Tumors formed from cells that have spread are called ‘secondary tumors’ ○ Viral (HPV) and contain cells that are like those in the original (primary) tumor. ○ Exposure to (SCCa) ○ Genetics/Gene Mutations of tissue (Breast, Ovarian, Colon ● Lymph Nodes: Rounded mass of lymphatic tissue that is surrounded by a capsule of connective tissues...filter lymphatic fluid and store lymphocytes etc) (white blood cells). is vastly complex - different types of have different presentations and respond in different ways. ● : Growth or lump that be benign or malignant

Head and Neck Cancer (HNC)

Areas included in HNC(3): Areas NOT included in HNC:

● Oral cavity ● Brain ○ Includes and salivary glands ● Eyes ● ● ● ● ● and nasal cavity

May have metastasis to any other area of the body - considered part of the same lesion HNC Prevalence and Incidence

● HNC is the 6th leading cancer by incidence worldwide(4) ○ Annual incidence of 550,000 cases with around 300,000 deaths each year ● United States, over 65,000 new cases (not including cancer) are expected to be diagnosed each year (11.7 individuals per 100,000)(5) ○ GA = 12 individuals per 100,000 ● Twice as common in men as they are in women.(6) ● 90% of all cases are Squamous Cell (SCCa) ○ Viral or carcinogenic

Risk Factors for Developing HNC Cancer Staging - TNM ● “Sex, Drugs and Rock N’ Roll” ○ Substance Abuse ■ - Smoking, snuff, chew 75% of HNC caused by T: Tumor ■ combination(7) ○ Environmental Exposures ○ Oral Health N: Nodal Involvement ○ Foods (Processed) ○ Viral ■ HPV (type 16) M: Metastases ■ Epstein Barr Virus TNM Defined(8)

T: Rating of extent of

N: Extent to which the cancer is in nearby lymph nodes

M: Represents if the cancer has spread to distant sites (i.e. metastasized)

● Examples: ○ T1bN0M0 ○ T4aN2M1

Recommendations for Speech Therapy In HNC Treatment

“It is critical that multidisciplinary evaluation and treatment be coordinated and integrated prospectively by all disciplines involved in patient care before the initiation of any treatment.” ASHA - Scope of Practice(9) HNC - Need for Objective Data

● Clinical Scientists ○ Evidence based practice best leads plan of care (POC) ● Easier to communicate with MDs/surgeons ● Easier to communicate progress/regression with patients and family ● Ensure justification for services ● Evaluation ● Advocacy ● Education ● Counseling ● Source of Referral ● CEUs ● Decision making for functional management ● Interprofessional collaboration ● Treatment

Surgical Intervention Common Types of for HNC

● ● Definition: Treatment of injuries or disorders of the body by ● incision or manipulation, especially with instruments(10) ● Pharyngectomy

● ● May include a team of different surgical specialties ● Maxillectomy ○ Otolaryngology (ENT), Oral and Maxillofacial Surgery ● Mandibulectomy (OMFS), Dentistry, Plastic Surgeons ● Typical Course of Treatment: ○ MD assessment consent (dental extraction) surgery in-patient stay home health Transoral Robotic Surgery (TORS) Types of Surgery - Laryngectomy

● Supraglottic/Partial Laryngectomy ○ Incomplete resection of the larynx, in which the supraglottic portion is removed, preserving the

■ Hyoid and epiglottis typically excised ● Total Laryngectomy ○ Complete excision of the larynx ○ Creation of permanent tracheostoma for

Types of Surgery - Glossectomy

● Partial/Hemi Glossectomy

○ Excision of part of/lateral half of tongue ● Total Glossectomy ○ Excision of entire tongue (anterior/oral 2/3ds + base/posterior 1/3d)

● Often includes flap reconstruction Lateral hemiglossectomy with ■ Leg/pectoralis flap reconstruction ■ May continue to grow hair ■ May be anchored into floor of (FOM) or onto buccal surface ● Limited range of motion (ROM)/movement Types of Surgery - Cervical Types of Surgery - Jaw

● Pharyngectomy ● Maxillectomy ○ Excision of part of the pharynx ○ Resection of the upper jaw (maxilla) ○ May include flap reconstruction ○ May have significant facial deformity ● Neck Dissection after surgery ○ Neck is surgically opened to remove cancer/lymph nodes ○ Several different types ● Mandibulectomy ■ May be unilateral/bilateral ○ Resection of lower jaw (mandible) ○ May require hardware for replacement

Side Effects of HNC Surgery Dysphagia ● Changes to anatomy ○ SLPs should be familiar with changes to anatomy and how ● Dysphagia is only a symptom and evaluation is always necessary that may impact patient performance to determine Dx (s) ■ Thorough medical chart review ● Impact can range from decreased QOL and social isolation to ● Dysphagia* life-threatening aspiration Profound dysphagia has high degree of morbidity and mortality ● Lymphedema: edema (swelling) associated with build up of ● ○ Dehydration, malnutrition, aspiration pneumonia, and lymph fluid after removal or damage/blockage to lymph nodes or death passageways(10) ○ May interfere with Range of Motion (ROM), speech, swallowing, maximum interincisal opening (MIO) ○ Occupational Therapy (OT) referral to Lymphedema specialist SLP Pre-Surgical Evaluation ● Education ○ Review anticipated changes to anatomy ○ Changes to speech/swallowing ○ Use It or Lose It! ■ Teach post-surgical ROM exercises ■ Need for continual use of remaining structures ● Paperwork ○ Georgia Center for the Deaf and Hard of Hearing (GCDHH) electrolarynx application ○ Patient contact (consent) form ■ Atos/InHealth for TL ● Objective data Dysphagia due to Disuse Atrophy

Pre-Surgical Objective Data Lingual Strength Measurement

● Weight (kg) ● MBSS (MBSImP) vs. FEES ● Iowa Oral Performance Instrument (IOPI) vs. Tongueometer (kPa) ● MIO (mm) ● Overall intelligibility ○ Word list ● Quality of Life (QOL) assessments ○ EAT-10, M.D. Anderson Dysphagia Inventory, SAFE, Mann Assessment of Swallowing Ability (MASA) ○ Voice Handicap Index (VHI) SLP Post-Surgical Evaluation Post-Surgical Objective Data

● Weight (kg) ● Education ● MBSS (MBSImP) vs. FEES ○ Oral Care, per MD recommendations ● IOPI vs. Tongueometer (kPa) ■ Typically on prescription mouthwash/may have suction ● MIO (mm) ○ Surgical trachs are typically removed with decreased ● Stoma diameter (mm) swelling ● Overall intelligibility ○ Typically NPO until cleared by surgeons ○ Word list ○ Management of adaptive equipment ● Quality of Life (QOL) assessments ● Communication method ○ EAT-10, M.D. Anderson Dysphagia Inventory, SAFE, Mann ● Objective data Assessment of Swallowing Ability (MASA) ○ Voice Handicap Index (VHI)

Total Laryngectomy (TL) Considerations TL Prescriptions ● TL patients benefit from set-up prior to surgery ○ Communication Atos Medical InHealth Technologies ■ Boogie Board ■ Electrolarynx Offers free Coming Home Kit Cheapest option for patients ■ Voice (CHK) for new TLs paying out of pocket ● May be a primary or secondary placement ○ Surgical kits Create surgical kits Create surgical kits ○ Prescription for adaptive equipment Accepts most insurances Accepts most insurances ■ HMEs, extra larytube, neckbands, shower aid/guard ○ Consent forms ■ Company must have permission prior to TL to speak to family Overall, Atos Medical and InHealth Technologies manufacture the same size equipment and can interchanged. Post-Op Equipment for Total Laryngectomy Radiation Therapy (XRT)

Definition: The use of high energy penetrating particles such as X-Rays, Gama Rays, Proton Rays or Neutron Rays to destroy Voice Prosthesis Blom-Singer cancer cells and prevent Electrolarynx them from reproducing(10)

Atos Medical Pulmonary Kit

Radiation Therapy Treatment

● Typical Course of Treatment ○ 6-7 weeks of Mon-Fri treatments ■ 6 weeks for post-op XRT; 7 weeks definitive XRT ○ Fitted with radiation mask prior to treatment ○ Treatment is very quick ■ 10-20 minutes ■ XRT ~3 mins Radiation Therapy - Side Effects ● Radiation Fibrosis: fibrotic tissue Internal Lymphedema sclerosis that often occurs in response to radiation exposure from XRT

● Lymphedema: edema (swelling) associated with build up of lymph fluid after removal or damage/blockage to lymph nodes or passageways

● : tissue swelling in the Submental Lymphedema mouth/swelling of mucosa

Radiation Therapy - Side Effects

● Dysphagia: difficulty/disordered swallowing ○ May be oropharyngeal or esophageal

● : dry mouth

● Trismus: restriction in jaw ROM (<35 mm)(11)

● Radiation Burn: burn caused by radiation therapy - can be simple burn Xerostomia or cause radiation dermatitis Trismus Radiation Burn

Best treated with Do NOT use medical device lotions/oils (OroStretch vs. Therabite) Default to Avoid tongue depressors if possible(12)

Radiation Therapy - Risks

● Carotid blow-out syndrome: rupture of carotid artery in an uncommon complication of HNC, which can be rapidly fatal(13) ○ More frequent with re-radiation

● : serious complication of XRT, where irradiated bone becomes necrotic and exposed(10) ○ Always support MD recommendations for dental extractions, if indicated

Maxillary Osteoradionecrosis SLP Pre-XRT Evaluation SLP Post-XRT Evaluation

○ Hydration ● Gather objective information ● Gather baseline, objective information ■ 64-80 oz daily ● Thorough oromotor evaluation ● Thorough oromotor evaluation to assess for changes ■ Compensates for ○ Will benefit you when assessing for changes ○ If no baseline exam taken, assume patient was WNL unless possible changes to during treatment otherwise stated during patient interview salivation ● Education ● Assess for negative impact of XRT ○ Humidifier at night ○ Teach Swallowing Exercises ○ Fibrosis, trismus, dysphagia, mucositis/thrush, lymphedema, ○ Oral care 2-3x daily ■ Effortful Swallow, Masako, Mendelsohn, xerostomia, mastication patterns Shaker ■ Non-alcohol based ■ High intensity exercises mouthwash ■ (90/day of each/9 mins) ○ Stoma for Laryngectomy ○ Anticipated course of treatment/changes to Patients swallow ■ Patency, sizing

Post-XRT Objective Data Chemotherapy

● Definition ○ Treatment of cancer with anticancer drugs(10) ● MBSS (MBSImP) vs. FEES ● QOL Assessments ● Examples ● IOPI vs. Tongueometer (kPa) ○ EAT-10, M.D. Anderson ○ ● MIO (mm) Dysphagia Inventory, ■ Side Effects ● Number of tolerated swallowing exercises SAFE, Mann ● Hearing loss (Ototoxic) ● Weight (kg) Assessment of ● Change senses/appetite ● Stoma diameter (mm) Swallowing Ability ○ Taste, , , bowels, etc. ● Intelligibility (MASA) ● Xerostomia ○ Word list ○ Voice Handicap Index (VHI) ● Cognitive-linguistic changes SLP Chemotherapy Evaluation Chemotherapy Treatment

● Commonly 3 cycles ● Pre-chemotherapy evaluation and education ● Multidisciplinary Intervention ○ Address hydration and oral care ○ Audiology ○ Dietary ■ 64-80 oz H2O daily ■ Baseline audiogram/OAEs ■ Address changes to ■ Oral care 2-3x daily (assess ) taste/bowels/appetite; ● Non-alcohol based mouthwash ■ Secondary audiogram/OAEs nausea, vomiting ○ Objective data ○ Speech ■ Prophylactic PEG ■ Baseline cognitive-linguistic evaluation/screen ■ Works in conjunction with education ■ Weight (kg) dietary/audiology ■ Xerostomia ● Post-chemotherapy evaluation and education ■ Cognitive-linguistic changes ○ Re-assess objective data for comparison

ChemoXRT Immunotherapy

● Often completed after surgical intervention ● “A class of treatments that take advantage of a person’s own ● Adjuvant to help kill cancer cells.”(10) ○ Definition ● “Immuno-oncology is a form of cancer treatment that uses the ■ Therapy applied after the initial treatment of cancer to power of the body's immune system to prevent, control and prevent/suppress secondary tumor formation eliminate cancer.”(15) ● Concurrent (CCRT) ○ ○ Definition ● It is not eating/drinking clean diet to “cure” cancer (i.e. ■ “A standard treatment for patients with locally advanced homeopathy) squamous cell of head and neck” (14) ■ Improved 5-year survival rate by 8% compared with XRT alone SLP Treatment of HNC with Immunotherapy Approved for HNC

● May be in conjunction with chemotherapy ● Expect plan of care to be palliative ● Three types approved for HNC ○ Focus on preservation of function/pleasure ○ Targeted ● Survival rate (5+ years) for HNC patients on immunotherapy varies ■ based on staging of tumor ○ Immunomodulators ○ “At 6 months after initiation of treatment with keytruda [in ■ advanced HNC cancer], 58% of patients were alive, and 25% ■ of patients were alive with no progression of cancer.” (16)

Initial Evaluation Initial Evaluation - Gathering Objective Data

● Be upfront about your limitations as a clinician ○ Baseline Measurements ○ Be thoughtful about the language you use in front of the ■ QOL Assessment ■ IOPI vs. Tongueometer (kPa) patient ● EAT-10, MD Anderson ■ MIO (mm) ● Gather as much information as possible Dysphagia Inventory, SAFE, ■ Stoma diameter(mm) ○ Read the discharge paperwork Voice Handicap Index (VHI) ○ Does the patient have a previous hx of cancer? ■ MBSS vs. FEES

○ What type of equipment did the patient receive from the ■ Weight (kg) hospital? ■ Articulation assessment ○ Did the patient have an objective swallow study? ■ Number of completed swallowing exercises ○ Were there any complications during hospitalization? ● Degree of cuing ○ Does the patient have a TEP? What are they doing for communication/nutrition? Initial Evaluation - Utilizing Resources

● Use evidence-based resources to lead POC ○ ASHA (practical portal) Failure to collect objective data ○ GSHA may result in unnecessary patient ○ Calling referring MD or SLP and clinician distress! ○ Cancer Organizations ■ NCI, ACS, NCCN, AIRC etc. ○ Vendor CEUs ■ InHealth vs. Atos Medical ■ Passy Muir ■ CranioRehab ■ Tactile Medical vs. BioTAB Healthcare

SLP Treatment Overview GEORGIA CANCER CENTER NEEDS YOU!

● Don’t be afraid of making a mistake ○ HNC patients tend to be surprisingly resilient We are looking for qualified SLPs all over Georgia ● Work to build a rapport with your patient and South Carolina to refer patients to for: ● Do not give ultimatums or false hope 1) Home Health ● Forgive yourself for making mistakes and move on 2) Outpatient Therapy

When in doubt, refer. Please contact me at [email protected] for questions/comments or for a source of referral! Resources: Resources:

American Cancer Society: https://www.cancer.org/ “Riveting and powerful...Mukherjee’s National Comprehensive Center Network: https://www.nccn.org/ extraordinary book might stimulate a National Cancer Institute: https://www.cancer.gov/ wider discussion of how to wisely allocate Center of Disease Control: https://www.cdc.gov/ our precious health care resources.” -San ASHA: https://www.asha.org/ Francisco Chronicle Head and Neck Cancer Alliance: https://headandneck.org/ CranioRehab: https://www.craniorehab.com/ “Mukherjee brings an impressive balance Atos Medical: https://www.atosmedical.us/ of empathy and dispassion to this InHealth Technologies: https://inhealth.com/ instantly essential piece of medical International Association of Laryngetcomees: https://www.theial.com/ journalism.” -Time

Sources:

(1) “Information and Resources about for Cancer: Breast, Colon, , Prostate, .” American Cancer Society, 2020, www.cancer.org/. (2) Cancer of the Larynx, NCI (3) Head and Neck Cancers. (n.d.). Retrieved January 19, 2021, from https://www.cancer.gov/types/head-and-neck/head-neck-fact-sheet#what-are-cancers-of-the-head-and -neck (4) Home. (n.d.). Retrieved January 18, 2021, from https://www.headandneck.org/ (5) Vigneswaran, N., & Williams, M. D. (2014). Epidemiologic trends in head and neck cancer and aids in diagnosis. Oral and maxillofacial surgery clinics of North America, 26(2), 123–141. https://doi.org/10.1016/j.coms.2014.01.001 (6) USCS Data Visualizations - CDC. (n.d.). Retrieved January 18, 2021, from https://gis.cdc.gov/Cancer/USCS/DataViz.html (7) Comprehensive Cancer Information. (n.d.). Retrieved January 18, 2021, from https://www.cancer.gov/ (8) National Comprehensive Cancer Network. (n.d.). Retrieved January 18, 2021, from https://www.nccn.org/patients/resources/diagnosis/staging.aspx (9) Head and Neck Cancer. (n.d.). Retrieved January 18, 2021, from https://www.asha.org/Practice-Portal/Clinical-Topics/Head-and-Neck-Cancer/#collapse_4 (10) (n.d.). Retrieved January 18, 2021, from https://medical-dictionary.thefreedictionary.com/ (11) Dijkstra P.U., Huisman P.M. & Roodenburk J.L. (2006) Criteria for trismus in head and neck oncology. International Journal of Oral Maxillofacial Surgery. 35, 337-342 Sources Continued:

(12) Buchbinder D, Currivan RB, Kaplan AJ, Urken ML. Mobilization regimens for the prevention of jaw hypomobility in the radiated patient: a comparison of three techniques. Journal of Oral Maxillofacial Surgery 1993;51:863-867. (13) Suárez, C., Fernández-Alvarez, V., Hamoir, M., Mendenhall, W. M., Strojan, P., Quer, M., Silver, C. E., Rodrigo, J. P., Rinaldo, A., & Ferlito, A. (2018). Carotid blowout syndrome: modern trends in management. Cancer management and research, 10, 5617–5628. https://doi.org/10.2147/CMAR.S180164 (14) Machtay M, Moughan J, Trotti A, Garden AS, Weber RS, Cooper JS, Forastiere A, Ang KK. Factors associated with severe late toxicity after concurrent chemoradiation for locally advanced head and neck cancer: an RTOG analysis. J Clin Oncol. 2008 Jul 20;26(21):3582-9. doi: 10.1200/JCO.2007.14.8841. Epub 2008 Jun 16. PMID: 18559875; PMCID: PMC4911537. (15) Immunotherapy for Head and Neck Cancer. (n.d.). Retrieved from https://www.cancerresearch.org/immunotherapy/cancer-types/head-neck-cancer (16) Keytruda Precision Treatment for Head and Neck Cancer. (n.d.). Retrieved January 18, 2021, from https://news.cancerconnect.com/head-neck-cancer/keytruda-precision-cancer-immunotherapy-treatme nt-for-head-and-neck-cancer-A7uF7bH_90O_o_zVCOEIbw