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