Triological Society Best Practice
Is speech language pathologist evaluation necessary in the nonoperative treatment of head and neck cancer?
The authors have no funding, financial relationships, or conflicts of interest to disclose.
Send correspondence to Christine G. Gourin, Johns Hopkins Outpatient Center, Department of Otolaryngology–Head and Neck Surgery, 601 N. Caroline Street, Suite 6260, Baltimore, MD 21287. E-mail: firstname.lastname@example.org
Dysphagia is a common sequelae of head and neck cancer (HNCA) and its treatment. While surgery is expected to result in predictable long-term alterations in swallowing function, the increased use of nonoperative treatment for organ preservation in recent years has led to a growing awareness of dysphagia associated with chemoradiation (CRT) secondary to radiation fibrosis and changes in innervation of the muscles of swallowing. Dysphagia can lead to poor nutrition/hydration, pulmonary complications, gastrostomy tube placement, and substandard quality of life. Evaluation and management of dysphagia is typically the purview of the speech-language pathologist (SLP). Despite the expertise of SLPs serving HNCA surgical patients, there continues to be some discord regarding the role and timing of speech-language pathology care in patients undergoing CRT. Historically, this lack of consensus was related to suboptimal evidence regarding the role of the SLP in nonsurgical care of the HNCA population; however, recent evidence provides a clearer direction for inclusion of this important care provider.
In the pretreatment state, patients with HNCA have elevated risk for dysphagia. van der Molen and colleagues in 2009 reported on the pretreatment swallow function of 55 individuals with HNCA. All patients in their series were candidates for chemoradiation with curative intent for advanced stage malignancies. Swallowing function in their series was evaluated with quality-of-life measures, the Functional Oral Intake Scale (FOIS), and videofluoroscopic swallowing study (VFSS). They found that 80% of subjects were on unrestricted diets prior to treatment; however, the majority of patients demonstrated some atypical findings on VFSS. Pharyngeal residue was observed in >80% of subjects, and penetration/aspiration was noted in 18% of subjects. All patients had at least one swallowing-related abnormality and 75% of patients had three or more swallowing abnormalities, whether patient reported or clinician documented. There was significant discrepancy between patient perception of swallowing difficulties and objective measures, with 30% of subjects with penetration/aspiration denying any difficulty swallowing. These findings support the importance of pretreatment, instrumental swallowing evaluations to identify existing swallowing abnormalities, minimize risk for aspiration and its sequelae during nonoperative treatment, and allow for targeted therapeutic interventions by the SLP during treatment. Swallowing questionnaires and intake questions do not appear adequate for identification of pretreatment swallowing changes.
A retrospective case control study by Carroll and colleagues demonstrated the therapeutic value of initiating therapy prior to CRT. Nine individuals receiving prophylactic intervention prior to CRT were matched with patients receiving swallowing therapy after the completion of CRT. Patients completed a series of exercises targeting the tongue base, pharyngeal constrictors, and laryngeal elevators and then completed a videofluoroscopic swallowing study 3 months after completion of CRT. Individuals performing exercises prior to and during CRT demonstrated more normal tongue base apposition to the posterior pharyngeal wall during swallowing (P = .025) as well as more normal epiglottic inversion (P = .02). Although a preliminary pilot study, this study suggests the superiority of prophylactic swallowing therapy for maintaining more normal swallowing physiology.
Three randomized controlled clinical trials demonstrate the efficacy and effectiveness of initiating preventive swallowing therapy before the start of nonoperative treatment of head and neck cancer. In a randomized, controlled trial of preventive swallowing exercises compared to standard care, van der Molen and colleagues demonstrated the feasibility of initiating prophylactic swallowing therapy during CRT and patient adherence to treatment recommendations. In their series, 69% of subjects were able to immediately implement therapeutic exercises following training, and an additional 31% were able to follow through within the first week of SLP treatment. Following completion of CRT, 57% of subjects were judged to be “very familiar” with their exercises, supporting patient reported adherence with home exercises. On average, their patients performed exercises 4 days per week, and 14% completed all exercises daily.
Kotz and colleagues performed a randomized control trial investigating the efficacy of prophylactic swallowing therapy. Swallowing outcomes were assessed using the FOIS and the Performance Status Scale for Head and Neck Cancer Patients (PSS-H&N). Significant differences in FOIS scores and “eating in public” and “normalcy of diet” scores on the PSS-H&N were noted between those individuals receiving prophylactic swallowing therapy and those receiving post-CRT swallowing therapy at 3 and 6 months post-CRT, with those patients receiving pretreatment swallowing therapy faring better than their counterparts.
Finally, objective functional data regarding the clinical impact of preventive swallowing therapy in HNCA patients undergoing CRT were recently published by Carnaby-Mann and colleagues. Six-month post-CRT muscle size/composition on magnetic resonance imaging was the primary outcome with functional swallowing ability, diet, chemosensory function, salivation, nutritional status, and complications from dysphagia serving as secondary outcomes. Patients were randomly assigned to standard care, sham treatment, and active treatment groups. In the active treatment arm where patients performed swallowing exercises twice daily over the duration of treatment, there was less structural change in the genioglossus, hyoglossus, and myohyloid muscles than in the other two treatment groups. Further, there was less deterioration of swallowing function, chemosensory function, and salivation in the active treatment group. Individuals in the active treatment group were more likely to continue oral diet during treatment than those in the usual care group (42% vs. 14%). Reduction of oral aperture was also less in the active treatment group. A composite measure was designed to designate a favorable swallowing related outcome and included weight loss <10%, maintenance of oral diet, and a change of <10 points on the Mann Assessment of Swallowing Ability. In the active treatment arm, 86% of patients achieved this desirable outcome, whereas only 47% of those who were not actively engaged in treatment achieved this (P = .009).
The best evidence strongly supports an active role for SLPs in the nonoperative management of HNCA patients that begins at the point of cancer diagnosis. Pretreatment instrumental swallowing assessments are indicated to identify silent dysphagia to optimize safe and efficient oral intake during treatment and to tailor interventional strategies. Based upon the available evidence, SLP evaluation and prophylactic swallowing intervention should be considered standard of care in the pretreatment setting for patients undergoing organ preservation treatment for HNCA to prevent dysphagia and optimize functional outcomes. Further, long-term follow-up appears appropriate given the potential for long-term sequelae following treatment.
LEVEL OF EVIDENCE
The best available evidence regarding the role of the SLP in the management of individuals undergoing CRT for HNCA includes three single-institution, randomized, controlled, clinical trials (level 1B), one case-control study (level 3b), and one case series (level 4).