head and neck cancer survivors: dysphagia and quality of life jocelen gudgeon, m.a. ccc-slp...

Head and Neck Cancer Survivors:Dysphagia and Quality of Life

Jocelen Gudgeon, M.A. CCC-SLPSpeech-Language Pathologist

Department of Otolaryngology-Head & Neck Surgery

University of Iowa Hospitals and Clinics

Dysphagia and Quality of Life

Goals1. Discuss importance of swallowing exercises

for individuals going through radiation

2. Discuss the role of telemedicine dysphagia therapy

Head and Neck Cancer (HNC)

• Prevalence– 5th most common cancer worldwide– 3% of all malignancies in US

• Incidence– 53,000 new cases in US each year– 11,500 deaths in US per year

Stenson, 2013

Dysphagia: Any disruption in transport of food/liquid from the oral cavity

to the stomach

• Choking• Coughing• Gagging• Throat Clearing• Unintentional weight loss• Need for multiple swallows

• Wet or gurgly vocal quality• Sensation of food sticking in

throat• Food or liquids coming out of

tracheostomy• History of respiratory

infections or pneumonia

Signs and Symptoms

Causes:

Tumor Treatment

Surgery Radiation (+/- Chemo)

Dysphagia in HNC Survivors

+/-

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• Incidence of post-treatment dysphagia ranges from 50% to 60%

• Review of 416 HNC cases treated at UIHC revealed that 45.9% had dysphagia

Shune et al., 2012; Langendijk et al., 2009; Jensen et al., 2007; Eisbruch et al., 2007; Platteaux et al., 2010

Our experience has shown that all individuals undergoing radiation for HNC experience at least some

degree of dysphagia.

Common Side Effects of Radiation

Mucositis

Taste changes

Thick secretions

Pain with swallowing

Efforts to Increase Swallowing-Related Quality of Life

Provide Dysphagia InterventionDuring Radiation

andAfter Radiation

Intervention During Radiation (XRT)

• Complete swallowing assessment

• Implement prophylactic swallowing exercise program

• Provide recommendations to minimize impact of side effects on oral intake

Carbaby-Mann et al., 2012; Carroll, et al., 2008; Kulbersh et al. 2006

Bottom Line:

MOVE IT OR LOSE IT!Do exercises as much as can be

tolerated

KEEP SWALLOWING SOMETHING!

Water sips at a minimumGillespie et al., 2004

Intervention After XRT

• Re-assess swallowing function– Provide oral intake recommendations

• Recommend intensive swallowing therapy

Challenges to Obtaining Post-XRT Swallowing Therapy

• Difficult to return to hospital on regular basis to receive therapy

• Access to Speech-Language Pathologist – May not be available locally– May not have expertise in working with HNC

population

Telemedicine Approach to Dysphagia Therapy

Studied the feasibility of providing off-site therapy using video-chat software

Four subjects were enrolled• Completed at least one face-to-face session• Received two telemedicine sessions per week

for eight weeksKarnell et al., Submitted 2013

Patient and clinician ratings collected via questionnaires regarding:

1. Technical quality

2. Satisfaction with use of telemedicine approach

3. Equivalency of telemedicine approach to traditional on-site therapy

Results:

• Each participant said the telemedicine approach was satisfactory

• Each participant rated the telemedicine approach to be equivalent to or better than traditional face-to-face therapy

• Challenging area: Technical feasibility–Reliability of Internet connection

Additional Study Findings

Resource conservation

• Travel expenses and time savings

Patients saved an average 2,934 miles of travel

Des Moines

WaterlooDubuque

Burlington

UIHC

Therapy expenses

• None had insurance to pay for therapy at a local facility

• All had IowaCare– Therapy only obtainable at UIHC or Broadlawns in

Des Moines

Resource Conservation

Therapy Outcomes?

Study targeted feasibility not efficacy

Telemedicine approach facilitated more frequent therapy sessions

General consensus: – Two sessions/week increased compliance

with swallowing exercises

“Squeaky wheel gets the grease”

Communication

Allowed communication despite loss of voice• Patient with trach used the text box to type her

responsesTelemedParticipant 2: The tongue curls are the easiest it seems. The tongue hold hurts little on right side and tongue pull hurts both sides. But closer to meds the less it hurts

CommunicationFacilitated communication with other healthcare team members

• Encouraged to call RN/physician with concerns

• Facilitated contact with dietitian

Provide Support and Encouragement

TelemedParticipant 2: I tend to push it if it doesn't hurt at first then it hurts. Just a couple and stop would be betterTelemedParticipant 2: The I get to scared to do themTelemedParticipant 2: I am not scared of the swab anymoreTelemedParticipant 2: Dr encouraged me to try the self breathing more. and Dr Wehbe encouraged the swallowing