brooke beilman, ms, ccc-slp

6/30/2021

1

Head and Neck Cancer: Understanding the Role of the Speech Pathologist

B R O O K E B E I L M AN , M S , C C C - S L P

Time Ordered Agenda: Introduction and Objectives: 5:45 - 6:00 Statistics Regarding Head and Neck Cancer 6:00 - 6:15 Risk Factors for Head and Neck Cancer 6:15-6:30 Human Papillomavirus (HPV) and its Role in Development of Head and Neck Cancer 6:30-6:45 Treatment Modalities for Head and Neck Cancer 6:45 - 7:00 ASHA Scope of Practice Review -Prevention and Wellness: 7:00 - 7:15 Chronic and Progressive Edema: 7:15 -7:45 The Importance of Imaging: 7:45 - 8:00 Therapeutic Treatment Options: 8:00 -8:30 Gold Standard Protocols 8:30 - 8:45 Case Studies: 8:45 - 9:00

Disclosures and Introductions

Brooke Beilman, MS, CCC-SLP is a full-time member of Tactile

Medical's Oncology team, a board member for Dysphagia

Outreach Project, an affiliate for Medbridge, and has

previously worked with SpeechTherapyPD and Tactus

Therapy on affiliate projects. She is certified in NMES,

myofascial release, and MDTP. She is the recipient of the

ASHA ACE Award, co-founder of Servant Leadership, and

member of the Medical SLP Collective. Brooke has presented

at the state and national levels, has been a guest on the

Understanding Dysphagia Podcast: Episode 4., and has been

the host for continuing education webinars for both the

Medical SLP Collective and Tactile Medical.

1

2

3

6/30/2021

2

Contact Information Email: [email protected]

Social Media: Instagram - Brookebeilman Facebook - Brooke Renee

Intoductions and Opening Continued...

My "Why" for Head and Neck Cancer

According to Kam et al (2015)

"Patients with head and neck cancer have more than 3 times the incidence of suicide compared with the general US population."

4

5

6

6/30/2021

3

Course Objectives

Describe roles/responsibilities of the SLP in the evaluation and treatment of patients with head and neck cancer

Apply prevention and wellness activities in their clinical practice for early intervention

List tools to obtain information about swallow function for patients with head and neck cancer

Describe the impact chronic edema can have on swallow function and communication

Identify risk factors for the development of chronic edema

Apply information learned to provide education regarding the side effects of treatment for head and neck cancer and the impacts on communication and swallowing

Statistics Current Data:

Chaturvedi et al. (2011) tell us that increases in

the occurrence and survival rates of

oropharyngeal cancers in the United States are

caused by HPV.

Current data suggests that HPV will continue to

rise, and therefore, so will oropharyngeal and

possibly oral cancers.

Changes to Caseload

Younger patient population Increased prognosis for survival Longer survivorship

7

8

9

6/30/2021

4

Risk Factors According to Dhull et al. (2018) both alcohol and tobacco use are risk factors for the development of head and neck cancer.

According to the CDC (2018), the human papillomavirus (HPV) is the most common sexually transmitted infection and can cause many types of cancer including oropharyngeal and base of tongue. Cancer due to HPV can take years or even decades to develop.

Fakhry et al. (2018) state that the increasing rise of oropharyngeal squamous cell cancer is well established. This is correlated with the rise in HPV.

Human Papillomavirus Cleveland Clinic (2018)

79 million Americans currenlty have HPV.

CDC (2020)

Approximately 3,500 new cases of HPV associated

oropharyngeal cancers are diagnosed each year in

women, and 16,200 are diagnosed each year in men.

Burd (2003)

Tells us that HPV is categorized into high and

low risk.

Michaud et al. (2014)

Concluded that HPV16 presents with a high risk for oral cavity, pharyngeal and laryngeal

cancers. They also found that HPV 18, 33, and 52 were also associated with head and neck

squamous cell carcinoma cancers, which supports the role of HPV subtypes other than HPV16

in the development of cancer.

Treatment Modalities What kind of treatment did my patient receive?

Surgery

With reconstruction

Without reconstruction

Radiation

May also have surgical resection

Chemotherapy


Immunotherapy


10

11

12

6/30/2021

5

Treatment Modalities (cont'd) Important Information:

Surgery

Structures involved in treatment

Anatomical

Neural and vascular

Radiation

Radiation Dosing

Total dose

Number of fractions

Total duration of treatment

Chemotherapy

Type of drug administered and frequency

Total period of time the drug was utilized

Immunotherapy

Type and Timing

*Knowing this information can better help us predict prognosis and what challenges our patient may experience.

ASHA Scope of Practice

How do these apply for our patients with head and neck cancer?

Let's discuss.

Professional practice domains: Advocacy and outreach Supervision Education Administration/leadership Research Service delivery domains Collaboration Counseling Prevention and Wellness Screening Assessment Treatment Modalities, Technology, and Instrumentation Population and Systems

*The information on this slide comes directly from ASHA's website

American Speech-Language-Hearing Association (2016).

ASHA Scope of Practice: Prevention and Wellness

"SLPs are involved in prevention and wellness activities that are geared toward reducing the incidence of a new disorder or disease, identifying disorders at an early

stage, and decreasing the severity or impact of a disability associated with an existing disorder or disease. Involvement is directed toward individuals who are

vulnerable or at risk for limited participation in communication, hearing, feeding and swallowing, and related abilities. Activities are directed toward enhancing or

improving general well-being and quality of life. Education efforts focus on identifying and increasing awareness of risk behaviors that lead to communication disorders and

feeding and swallowing problems. SLPs promote programs to increase public awareness, which are aimed at positively changing behaviors or attitudes."

*The information on this slide comes directly from ASHA's website

American Speech-Language-Hearing Association (2016).

13

14

15

6/30/2021

6

Chronic and Progressive Swelling

What we're seeing....

What we're seeing....

16

17

18

6/30/2021

7

What issues do you think patients with

chronic edema (lymphedema) have?

According to Smith & Lewin (2010)....

Head and neck lymphedema can cause:

Reduced quality of life Impaired communication including speaking, reading, writing, and hearing Difficulty breathing Vision loss or changes Psychological effects Dysphagia ...and more

The Importance of Imaging

Photo courtesy of https://www.vumc.org/hearing-speech-continuing-ed/sites/default/files/public_files/MSP-VFSS-FEES-2020.pdf

19

20

21

6/30/2021

8

The Importance of Imaging

Starmer et al. (2011) state that patients may have dysphagia prior to treatment, and that instrumental evaluations are vital especially

for those with advanced stage tumors.

Example FEES Courtesy of Rebecca Brown, MS, CCC-SLP, CNT

FEES Used to assess secretion management Provides assessment tissue integrity Allows for evaluation vocal fold movement Provides visual feedback for the patient Can be conducted when patients are on mechanical ventilation FEES is preferred for spinal cord injuries or traumatically injured Can be performed on medically complex patients who are not able to transport to radiology Allows for the assessment of pharyngeal and laryngeal sensation Is beneficial for those who have difficulty sitting at 90 degrees or who have difficulty transferring Can be used with patients whose size impacts use of MBS Can assess for the presence of edema, foreign bodies, and more No coordination required between Radiology and Speech Pathology Use of real food and preferred items vs. use of barium No waiting to be cleared from isolation precautions SLP can conduct independently once deemed competent FEES studies can be recorded and entered into the EMR for team use/review Increased rate of reimbursement associated with FEES vs MBS ....and more!

22

23

24

6/30/2021

9

MBS/VFSS Used to assess for the presence oral dysphagia Evaluates the presence of esophageal dysphagia Can be used for patients with nasal trauma, nasal obstruction or bleeding disorders Can be utilized with patients who have hypersensitive gag-reflexes MBS may be more suitable for combative patients MBS is able to more thoroughly determine the extent of aspiration (trace, gross, etc.) Can evaluate the presence of cervical osteophytes, fistulas or diverticula Allows for collaboration with radiology colleagues ...and more!

Image courtesy of Kate Hoener, MA, CCC-SLP

Swallowing Impairments: What are we seeing and why?

Let's discuss.

Considerations for Instrumental Evaluations Regarding Recommendations Are the issues we are seeing due to....

Disuse atrophy? Related to lymphedema? Due to fibrosis? Cranial nerve involvement? ....and more.

When conducting instrumental evaluations, don't forget to consider the principles of exercise physiology, the Three Pillars of Aspiration Pneumonia, and the patient's wishes when making recommendations.

25

26

27

6/30/2021

10

Challenges for Patients with Head and Neck Cancer Patients with head and neck cancer experience both acute and chronic challenges. While the list below is not exhaustive, it does demonstrate some of the challenges these individuals face.

Mucositis - can cause pain, reductions/changes to oral intake, impact treatment, and more. Xerostomia - can cause increased difficulty with swallowing, reduction/changes in oral intake, and more. Radiation Fibrosis Syndrome - describes the multiple clinical manifestations of progressive fibrotic tissue. Trismus - causes reduced oral cavity range of motion. Head and Neck Lymphedema - can cause dysphagia, issues breathing, changes in voice, difficulty with communication, visual changes, and more. Dysphagia - is often chronic; signs and symptoms can include changes in vocal quality, coughing/throat clearing/gagging with oral intake, reflux, weight loss, increased duration of mealtimes, and more.

Therapeutic Treatment Options

Prevention Hutcheson et al. (2013) studied the effects of oral intake throughout treatment (chemotherapy or radiation) as well as implementation of preventative swallowing exercises.

Their Findings: Those who ate or conducted exercises did better than those who did neither

Those who did both had the highest rate of resuming a regular diet and shortest duration of gastrostomy dependence

28

29

30

6/30/2021

11

Prevention

Carnaby-Mann et al. (2012) investigated the impact of exercise during treatment (radiation and chemotherapy) for those with head and neck cancer. They found:

Those in the exercise group had less musculature deterioration.

Salivation rate and functional swallow deteriorated less for those in the exercise group.

Conclusions: Those completing swallowing exercise programs during cancer treatments had improved muscles maintenance and swallowing abilities.

Therapeutic Options Post Treatment Rehabilitative Programs/Tools

*Not an exhaustive list

Let's Discuss!

What treatment modalities have you found to be beneficial for your patients with head and neck

cancer?

31

32

33

6/30/2021

12

Gold Standard Protocols There are many members of the team some of which include:

Head and Neck Surgeon Plastics/Reconstructive Surgeon Dentist Oral-Maxillofacial Surgeon Radiation Oncologist Medical Oncologist Registered dietitian Speech Pathologist Physical Therapy Occupational Therapy Nurse Navigator Social Worker Palliative Care Psychiatry Physical Therapy

Gold Standard Protocols

Current research tells us that patients may have dysphagia, and therefore risk for aspiration prior to undergoing treatment for head and neck cancer. Starmer et al. (2011) tells us that instrumental evaluations prior to treatment are important due to risk for dysphagia prior to intervention for head and neck cancer, especially those with advanced tumors.

According to Ridner et al. (2016), 90% of patients with head and neck cancer will develop some form of lymphedema - whether that be internal, external, or both.

Gold Standard Protocols Sleigh and Manna (2021) state, "Lymphedema is a progressive disease, and early diagnosis and treatment are paramount. Therefore, it is critical to diagnose and treat both mild and early onset cases to halt the progression of this lifelong and often debilitating condition."

As previously stated, Carnaby-Mann and colleagues (2012) found that patients who continued to exercise throughout treatment demonstrated improvements in muscle maintenance as compared to those who did not.

Ridner et al. (2016) shows that 75% of patients with head and neck cancer are moderate/severe and 47% develop moderate/severe fibrosis.

34

35

36

6/30/2021

13

Gold Standard Protocols Based on current research, implementing the platinum standard (as coined by Theresa Richard and Karen Sheffler at ASHA 2018), utilizing both FEES and MBS may be warranted for this patient population.

We know that early identification of both dysphagia and lymphedema is key to help patients maintain oral intake and reduce the progression of chronic swelling.

Current literature also supports use of exercise and oral intake throughout treatment for head and neck cancer.

When developing protocols, consider what evaluation and treatment modalities may help our patients succeed not only throughout treatment, but also after.

Gold Standard Protocols

Based on what we just reviewed and your clinical experiences, let’s

discuss!

Case Studies

*Assistance in case study creation courtesy of Katie Gollin, MA, CCC-SLP and Madison Ericson, MA, CCC-SLP

37

38

39

6/30/2021

14

Case Study One:

Case Study Two:

A Patient's Perspective

40

41

42

6/30/2021

15

Resource List List compliments of Kelly Salmon, SLPD, CCC-SLP, BCS-S, CLT-LANA



43

44

45

6/30/2021

16




46

47

48

6/30/2021

17

Closing Thoughts and

Questions

References

Dhull, A. K., Atri, R., Dhankhar, R., Chauhan, A. K., & Kaushal, V. (2018). Major Risk Factors in Head and Neck Cancer: A Retrospective Analysis of 12-Year Experiences. World journal of oncology, 9(3), 80-84. https://doi.org/10.14740/wjon1104w

Fakhry, C., Lacchetti, C., Rooper, L. M., Jordan, R. C., Rischin, D., Sturgis, E. M., Bell, D., Lingen, M. W., Harichand-Herdt, S., Thibo, J., Zevallos, J., & Perez-Ordonez, B. (2018). Human Papillomavirus Testing in Head and Neck Carcinomas: ASCO Clinical Practice Guideline Endorsement of the College of American

Pathologists Guideline. Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 36(31), 3152-3161. https://doi.org/10.1200/JCO.18.00684

Hutcheson, K. A., Bhayani, M. K., Beadle, B. M., Gold, K. A., Shinn, E. H., Lai, S. Y., & Lewin, J. (2013). Eat and exercise during radiotherapy or

chemoradiotherapy for pharyngeal cancers: Use it or lose it. JAMA Otolaryngology Head and Neck Surgery, 139(11), 1127-1134.

doi:10.1001/jamaoto.2013.4715

Kam, D., Salib, A., Gorgy, G., Patel, T. D., Carniol, E. T., Eloy, J. A., Baredes, S., & Park, R. C. (2015). Incidence of Suicide in Patients With Head and Neck Cancer. JAMA otolaryngology-- head & neck surgery, 141(12), 1075-1081. https://doi.org/10.1001/jamaoto.2015.2480

Michaud, D. S., Langevin, S. M., Eliot, M., Nelson, H. H., Pawlita, M., McClean, M. D., & Kelsey, K. T. (2014). High-risk HPV types and head and neck cancer. International journal of cancer, 135(7), 1653-1661. https://doi.org/10.1002/ijc.28811

Ridner, S. H., Dietrich, M. S., Niermann, K., Cmelak, A., Mannion, K., & Murphy, B. (2016). A Prospective Study of the Lymphedema and Fibrosis

Continuum in Patients with Head and Neck Cancer. Lymphatic research and biology, 14(4), 198-205. https://doi.org/10.1089/lrb.2016.0001

Sleigh BC, Manna B. (2021).Lymphedema; StatPearls. StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537239/

Smith, B. G., & Lewin, J. S. (2010). Lymphedema management in head and neck cancer. Current opinion in otolaryngology & head and neck surgery, 18(3), 153-158. https://doi.org/10.1097/MOO.0b013e32833aac21

Starmer, H., Gourin, C., Lua, L. L., & Burkhead, L. (2011). Pretreatment swallowing assessment in head and neck cancer patients. The Laryngoscope, 121(6), 1208-1211. doi:10.1002/lary.21800

49

50

51

brooke beilman, ms, ccc-slp

Documents