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  1. Approaches to Assessment and Treatment of Patients with Head and Neck Cancer for the Speech-Language Pathologist Megan Hyers, MS, CCC-SLP Rebecca Schob, MsED, CCC-SLP Providence Portland Cancer Center Amphitheater March 29, 2014

  2. Outline • Overview of anatomy, staging, tumor size, and multidisciplinary team.  Treatment approaches of Head and Neck Cancer, and how they impact speech, swallowing, and voice • Evaluation and Treatment approaches status post surgery.  Surgical reconstruction approaches, and impact on communication and swallowing.

  3. Outline continue • Evaluation and Treatment approaches during chemo-radiation, and impact on communication and swallowing • Post treatment outpatient role • Evaluation and Treatment for patients with a laryngectomy.  Focus on pre-operative, post-operative, and long-term treatment.  Discussion of communication options. • Case studies and questions

  4. Incidence • Head and neck cancer accounts for 3-5% of all cancers in the United States • 35,000 new oral and oralpharyngeal cancers • About 6,800 deaths • 12,360 new laryngeal cancers • About 3,650 deaths • More men than women will be affected • More common over the age of 50

  5. Incidence (cont) • Rate of new cases dropping past few decades • Recent rise in cases of oral pharyngeal cancer related to Human Papilloma Virus (HPV) • Especially in white men under 50 • Rates vary among countries with much higher rates in Hungary and France

  6. Cancer Staging • Describes the extent or severity • TNM system (tumor, nodes, metastasis) • For example T3N2M0 • T=extent of tumor (0-4) • N=spread to nearby lymph nodes • M=whether any distant body parts are involved • TNM corresponds to one of five stages (Stage 0-Stage IV)

  7. Nasopharyngeal Cancer • Nose and paranasal cavities including sinuses • Different types of cancers can develop depending on the type of tissue • Impacts smell, breathing, and resonance

  8. Nasopharyngeal (cont) • Rare, more common in other parts of the world (Asia) • Males from Kwangtung Province (Cantonese) 40 times that of US Caucasian males • Twice as high in men than in women • Tends to occur in people between the ages of 45-85 • 54% of patients survive 5 years after diagnosis

  9. Oral Cancer • Lips • Cheeks • Gums • Floor of mouth • Hard palate

  10. Oral Cancer (cont.) • Soft palate • Tongue • Tonsils • Mandible • Salivary glands

  11. Oral Cancer (cont.) • More than 90% are squamous cell carcinoma • Rates are more than twice as high in men than women • Except women have a higher incidence of salivary gland cancer • 84% of patients survive at least 1 year after diagnosis • 59% survive 5 years • 48% survive 10 years

  12. Laryngeal Cancers • Larynx-including the vocal cords • Epiglottis • Base of tongue • Pharyngeal walls

  13. Laryngeal Cancers (cont.) • Hypopharynx/Supraglottis-from the epiglottis to the arytenoids • Subglottic-below the vocal cords • 95% are squamous cell carcinomas • One of the most common types of head and neck cancer • 64% survive 5 years

  14. Causes of Head and Neck Cancer • Overwhelming majority of head and neck cancers are related to prolonged exposure to environmental factors

  15. Causes (cont.) • Tobacco: Tobacco contains many carcinogens • Pipe smoking associated with lip cancer • Cigarette smoking plays a causative role in tongue, pharyngeal, laryngeal, esophageal, and lung cancer • Reverse smoking (where the burning end of the cigarette is kept in the mouth), which is popular in parts of India, Sardinia, Venezuela, and Panama is associated with hard palate cancer

  16. Causes (cont.) • Sunlight-Lip cancer, skin cancer • Frequent and heavy alcohol consumption • Synergistic with tobacco • Ethanol per se, not a carcinogen, other factors implicated • Occupational Factors-nickel workers, wood workers implicated in paranasal sinus cancer

  17. Causes (cont.) • Epstein-Barr Virus-possible etiological role in nasopharyngeal carcinoma • Poor oral hygiene-oral cavity, especially floor of mouth, tongue, and alveolar ridge • Nutritional deficiencies-specific role not established, but an area of research • Reflux • Exposure to second hand smoke

  18. Causes (cont.) • Genetic factors • genetic link is not completely understood • some neoplasms have had recent chromosomal identification • Radiation • Ionizing radiation, which was used in the past to treat acne, tonsillar hypertrophy, and enlarged thymus in newborns has led to increased risk of some cancers • Weakened immune system • Human papillomavirus (HPV)

  19. Human Papiloma Virus • In 1970’s, HNSCC has decreased along similar trend to reduced cigarette smoking • Large increase in HPV positive tumors since 1970s • HPV oralpharyngeal SCCC increased 225% between 1988-2004 • 70% of new cases of oral cancers linked to HPV • Surpassed tobacco use as leading cause • Usually diagnosed at higher stage

  20. HPV continued • Population is different • Younger • Oral HPV infections peaked in 30-34 year olds and 60-64 year olds • Healthier • Mostly male • 6-7 times more common in men as opposed to general oral cancers are 2 times more likely in men • HPV tumors respond better to treatment and higher survival rates • 2-3 year survival is 80-95% (HPV negative is 57-62%)

  21. Prevention of H + N Cancer • According to WHO: “While tobacco use is the single largest causative factor -accounting for about 30% of all cancer deaths in developed countries and an increasing number in the developing world – dietary modification and regular physical activity are significant elements in cancer prevention and control. Overweight and obesity are both serious risk factors for cancer. Diets high in fruit and vegetables may reduce the risk for various types of cancer, while high levels of preserved and/or red meat consumption are associated with increased cancer risk.”

  22. Multidisciplinary Team • Surgeon • Radiation Oncologist • Medical Oncologist • Speech Pathologist • Physical Therapist • Occupational Therapist • Dentist • Dietician • Social Worker • Respiratory Therapist • Nursing

  23. Treatment Options • Surgery • Radiation • Chemotherapy

  24. Surgery

  25. Surgery types • Most common types • Glossectomy/partial glossectomy • Tonsilar • Base of tongue • Floor of mouth • Mandible • Maxilla • Buccal • Laryngectomy

  26. More surgery • Radial forearm free flap (RFFF) • Fibular free flap (FFF) • Transoral Robotic Surgery (TORS) • Minimally invasive • Reduce need to split the jaw • Reduce infection risk • Shorted hospital stay, faster recovery

  27. TORS

  28. Protocols for Surgeries • Unofficial • MD’s will clarify for specific patients • Surgeons: Drs Bell, Dierks, Bui, Petrisor, Ueeck

  29. Neck Dissection Only

  30. Neck Dissection Care • Eating: ASAP • Start with clear liquids, advance as tolerated to regular • Shower: ASAP • Back to the shower head • Do not submerge wound for 2 weeks. • Light antibiotic ointment layer allows small amount of water to trickle over wounds without problems

  31. Neck Dissection Movement • Ambulate: ASAP, when awake and alert • Avoid exertion, heavy lifting/straining, bending for 2 weeks • Dictated by patient comfort, self-limiting for 2 weeks • Neck turning: initially guarded enough to make driving and rapid reactions difficult • Spinal Accessory Nerve almost always spared • If injury to Spinal Accessory Nerve: • Symptoms may not appear for 1 week post surgery • Can take 6 months to reconnect

  32. Spinal Accessory Nerve

  33. Spinal Accessory Nerve and Neck Dissection • Goal of Radical Neck Dissection is to remove lymph node metastasis in one or both sides of the neck, and removes the Spinal Accessory Nerve • Modified Neck Dissection will spare the Spinal Accessory nerve • Even when the SAN is spared, problems can arise with the shoulder • SAN innervates the sternocleidomastoid muscle (tilts and rotates the head) and the trapezius muscle (several actions on the scapula, including shoulder elevation and adduction of the scapula)

  34. Spinal Accessory Nerve • PT or OT help the patient to maintain or regain passive ROM of the shoulder. • This can limit or prevent stiffness of the shoulder capsule and ligaments that can arise with malalignment of the shoulder and adhesive capsulitis. • Significant improvement in mobility, pain, quality of life, and return to previous occupation seen with patients receiving therapy. • Early and prolonged therapy, beginning within 1 month of surgery and lasting, on average, 3 months.

  35. Glossectomy, Hemiglossectomy

  36. Glossectomy, Hemiglossectomy • Eating: • Free Flap: 1-2 weeks before eating (tube feeding) • No Free Flap: eating ASAP • Shower: same as Neck Dissection • Movement: same as Neck Dissection

  37. Base of Tongue • Deficits depend on how much tissue is removed • Can affect swallowing and speech • Pain can limit intake

  38. Radiation Therapy

  39. Intensity-modulated radiation therapy (IMRT) precise radiation doses to a malignant tumor or specific areas within the tumor. allows for the radiation dose to conform more precisely to the three-dimensional (3-D) shape of the tumor allows higher radiation doses to be focused to regions within the tumor while minimizing the dose to surrounding normal critical structures. Spares healthy tissue and organs Radiation Therapy

  40. IMRT

  41. Chemotherapy

  42. Chemotherapy • Cisplatin • Cross links DNA, which ultimately triggers apoptosis (programmed cell death) • Traditionally 100 mg/m² every 3 weeks • To attempt to reduce side effects, some doctors using 33 mg/m² every week • The research has mostly been done on the traditional method

  43. Cisplatin Side Effects • Kidney damage • Nerve damage • Nausea and vomiting • Ototoxicity • Electrolyte disturbances • Decreased sense of taste • Fatigue

  44. Exercise in Dysphagia Rehabilitation

  45. How common is dysphagia in H and N cancer?

  46. Patients with oral-pharyngeal dysphagia: 50.6% Mostly to solid foods: 72.4% Patients with total glossectomy and chemoradiotherapy had the highest rate of dysphagia. Nutritional support: 57.1% Malnutrition: 20.3% Patients reported a decrease in their quality of life due to dysphagia: 51% Long-term prevalence of oropharyngeal dysphagia in head and neck cancer patients: Impact on quality of life, Garcia-Peris, P; Clinical Nutrition, Dec 2007 Prevalence of Dysphagia in H + N Cancer

  47. Study of 9 patients undergoing external beam radiation and chemo for H + N Cancer 7 of the 9 experienced reduced posterior tongue base movement toward the posterior pharyngeal wall and reduced laryngeal elevation during the swallow All 9 patients experienced reduced efficiency of their swallowing compared to normals Swallowing disorders in head and neck cancer patients treated with radiotherapy and adjuvant chemotherapyLazarus, CL, et al, Laryngoscope; 1996, Sept, 106