A Multimodal Prophylactic Approach to Head and Neck Cancer-Related Dysphagia
Background on Dysphagia Secondary to Head and Neck Cancer
Dysphagia, or difficulty swallowing, is characterized based on the root pathology and the severity of the impairments identified with an instrumental evaluation. The role of the speech-language pathologist (SLP) includes uncovering and understanding the underlying issues resulting in swallowing disorders.
For individuals with head and neck cancer (HNC), dysphagia is highly prevalent and can occur at the onset of the disease. The severity of dysphagia prior to cancer treatment is dependent on the tumor stage and localization (Logemann et al., 2006; Nguyen et al., 2008; Pauloski et al., 2000). Research indicates that the prevalence of pre-treatment dysphagia ranges from 28% - 71.5% based on the staging and location of the disease (Nguyen et al., 2006; Pauloski et al., 2000). The treatment modalities utilized to eradicate the disease further the potential for acute and chronic swallowing issues. Radiation therapy, surgical interventions, and chemotherapy can each result in changes to swallow function. Acute and chronic ramifications of HNC related to swallow function can include mucositis, xerostomia, lymphedema, odynophagia, dysgeusia, trismus, fibrosis, general pain, fatigue, and more.
Due to the vast issues that people with HNC experience impacting swallow safety and efficiency, it is important that SLPs are well-versed in a variety of topics and have access to a collaborative interdisciplinary team. Based on the prevalence of toxicities that occur related to HNC, it is reasonable to hypothesize that many individuals with HNC will develop multiple issues impacting swallow function. When underlying pathologies are not identified, patients may not achieve success in the capacity that is possible had multiple aspects been addressed. For example, lymphedema is highly prevalent in people with HNC. Research demonstrates that 97% of individuals with HNC will develop some degree of lymphatic dysfunction (Jeans et al., 2021). If dysphagia is addressed with swallowing exercises and progressive overload via the use of oral intake, the patient will typically demonstrate improvement in oral intake (Carnaby-Mann et al., 2012; Hutcheson et al., 2013). However, if we utilize these approaches yet lymphedema remains unaddressed, it is likely that swallow dysfunction will develop over the course of time due to anatomical changes and systemic changes secondary to lymphedema and subsequent fibrosis development (Jackson et al., 2016; Stubblefield & Weycker, 2023). This is just one example of many demonstrating the vitality of considering multiple underlying issues and providing intervention options.
Protocol Development
In my clinical practice, I developed a proactive protocol based on current research and best practices. At the time of development, I had the honor of being part of a collaborative and supportive interdisciplinary team. After observing and tracking data related to the negative ramifications of referrals for therapeutic services after the completion of HNC, our team decided to implement a clinical pathway in both the outpatient and acute care settings. We aimed to ensure that anyone being treated for HNC within our system was provided education, counseling, and options to help address acute and chronic symptoms related to HNC, including dysphagia. This pathway implemented the protocol I developed, which utilizes a proactive, multimodal approach to address swallow dysfunction secondary to HNC. After seeing positive outcomes, our healthcare system worked towards implementing similar pathways district-wide.
When I first entered the field of speech pathology, my understanding of the various sequelae related to swallow dysfunction experienced by people with HNC was limited. In order to best serve the patients I worked with, I spent an immense amount of time seeking further education, training, and mentorship. Our team implemented the protocol specific to dysphagia based on these opportunities, in addition to input and clinical expertise from the interdisciplinary team. Our program was further developed and expanded upon with collaboration involving speech pathology, occupational therapy, lymphedema therapy, physical therapy, radiation oncology, radiologists, dietitians, ENT, and case management.
I am passionate about increasing the accessibility of information backed by evidence and person-centered care. It is my belief that SLPs can help facilitate the improvement of quality of life for people with HNC through improved understanding regarding the multiple underlying issues resulting in dysphagia for this patient population. Dysphagia is the highest driver of decisional regret for people with HNC (Goepfert et al., 2017). Both from a clinical and personal stance, it is my opinion that those diagnosed with HNC should be provided with all of the information to make informed decisions not only regarding disease eradication but also pertaining to ways to mitigate acute and chronic issues that impact their overall quality of life.
Upon entering this realm of healthcare, I only knew how to help people with HNC based on what I had learned in graduate school and via the limited resources that were available online at the time. Although many patients I worked with at the time did see a level of improvement, many often continued to struggle with numerous sequelae that I was ill-equipped to help address. Additionally, those referred post-HNC treatment or years after treatment had concluded often saw little progress or plateaued. When these situations arose, I would refer out to other SLPs in the area. My motivation and desire to do all that I can to learn about how to best serve people with HNC as an SLP was sparked after witnessing the severe ramifications related to dysphagia for these individuals such as isolation, recurrent hospitalizations, and suicidal ideations.
Based on current research, mentorship, interdisciplinary collaboration, as well as my own clinical experiences, I created a protocol specific for dysphagia that includes consideration of multiple pathologies. Throughout the course of my career, I have shared this protocol as a resource for healthcare teams throughout the United States who are interested in improving outcomes for people with HNC. As stated within the protocol, it is important to remember that each person with HNC is different - evaluation and treatment options should always be tailored to the person’s values, needs, and goals. That said, I wanted to make this protocol available here on my website as a resource for anyone interested in learning more about these topics.
Resource - Proactive Multimodal Protocol for HNC-Related Dysphagia
To download this complimentary resource, please click here.
Questions and Feedback
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References
Goepfert, R. P., Fuller, C. D., Gunn, G. B., Hanna, E. Y., Lewin, J. S., Zaveri, J. S., Hubbard, R. M., Barrow, M. P., & Hutcheson, K. A. (2017). Symptom burden as a driver of decisional regret in long-term oropharyngeal carcinoma survivors. Head & Neck, 39(11), 2151–2158. https://doi.org/10.1002/hed.24879
Jackson, L. K., Ridner, S. H., Deng, J., Bartow, C., Mannion, K., Niermann, K., Gilbert, J., Dietrich, M. S., Cmelak, A. J., & Murphy, B. A. (2016). Internal lymphedema correlates with subjective and objective measures of dysphagia in head and neck cancer patients. Journal of Palliative Medicine, 19(9), 949–956. https://doi.org/10.1089/jpm.2016.0018
Jeans, C., Brown, B., Ward, E. C., & Vertigan, A. E. (2021). Lymphoedema after head and neck cancer treatment: an overview for clinical practice. British Journal of Community Nursing, 26(Sup4), S24–S29. https://doi.org/10.12968/bjcn.2021.26.Sup4.S24
Logemann, J. A., Rademaker, A. W., Pauloski, B. R., Lazarus, C. L., Mittal, B. B., Brockstein, B., MacCracken, E., Haraf, D. J., Vokes, E. E., Newman, L. A., & Liu, D. (2006). Site of disease and treatment protocol as correlates of swallowing function in patients with head and neck cancer treated with chemoradiation. Head & Neck, 28(1), 64–73. https://doi.org/10.1002/hed.20299
Nguyen, N. P., Vos, P., Moltz, C. C., Frank, C., Millar, C., Smith, H. J., Dutta, S., Alfieri, A., Lee, H., Martinez, T., Karlsson, U., Nguyen, L. M., & Sallah, S. (2008). Analysis of the factors influencing dysphagia severity upon diagnosis of head and neck cancer. The British Journal of Radiology, 81(969), 706–710. https://doi.org/10.1259/bjr/98862877
Pauloski, B. R., Rademaker, A. W., Logemann, J. A., Lazarus, C. L., Newman, L., Hamner, A., MacCracken, E., Gaziano, J., & Stachowiak, L. (2002). Swallow function and perception of dysphagia in patients with head and neck cancer. Head & Neck, 24(6), 555–565. https://doi.org/10.1002/hed.10092
Stubblefield, M. D., & Weycker, D. (2023). Under recognition and treatment of lymphedema in head and neck cancer survivors - a database study. Supportive Care in Cancer: Official Journal of the Multinational Association of Supportive Care in Cancer, 31(4), 229. https://doi.org/10.1007/s00520-023-07698-3
Disclosure: The information provided here is for general informational purposes only and should not be construed as medical advice. Always consult with your healthcare provider or a qualified medical professional for advice specific to your situation. Your healthcare team is the best resource for personalized medical guidance and treatment recommendations.