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Head and Neck Cancer Head and Neck Cancer When, Why and How – Introduction of speech Sarah Smith has no therapy for patients undergoing surgical financial disclosures for intervention and radiation therapy this presentation. Sarah Smith MCD, CCC-SLP Table of Contents About Me ● Overview and terminology June August ● Head and Neck Cancer (HNC) 2014 2017 2017 Present ● Cancer Staging ● Speech Therapy and Surgery for HNC ● Speech Therapy and Radiation Therapy ● Speech Therapy and Chemotherapy ● Speech Therapy and Immunotherapy ● 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) ● Metastasis: 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 carcinogens (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). Oncology is vastly complex - different types of cancers have different presentations and respond in different ways. ● Nodule: 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 tongue and salivary glands ● Eyes ● Nasal Cavity ● Esophagus ● Pharynx ● Larynx ● Paranasal Sinuses 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 thyroid 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 Carcinomas (SCCa) ○ Viral or carcinogenic Risk Factors for Developing HNC Cancer Staging - TNM ● “Sex, Drugs and Rock N’ Roll” Substance Abuse ○ ■ Tobacco - Smoking, snuff, chew 75% of HNC caused by T: Tumor ■ Alcohol 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 primary tumor 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 Surgeries for HNC ● Laryngectomy ● Definition: Treatment of injuries or disorders of the body by ● Glossectomy incision or manipulation, especially with instruments(10) ● Pharyngectomy ● Neck Dissection ● 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 biopsy 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 vocal cords ■ Hyoid and epiglottis typically excised ● Total Laryngectomy ○ Complete excision of the larynx ○ Creation of permanent tracheostoma for breathing 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 mouth (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 Prosthesis (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 ● Mucositis: tissue swelling in the Submental Lymphedema mouth/swelling of mucosa Radiation Therapy - Side Effects ● Dysphagia: difficulty/disordered swallowing ○ May be oropharyngeal or esophageal ● Xerostomia: 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 radiation oncologist Avoid tongue depressors if possible(12)
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