Background
Recent studies have highlighted that people diagnosed with head and neck cancer (HNC) have complex information needs. They are subject to multiple clinical appointments with numerous ...healthcare professionals in preparation for their treatment. Speech and language therapists (SLTs) are core members of the HNC multidisciplinary team, providing assessment, prehabilitation and counselling regarding potential treatment effects on the critical functions, including swallowing and communication. We believed the purpose of the pre-treatment speech-language therapy (SLT) consultation within this pathway is not well understood by patients. Whilst the benefits of prophylactic swallowing exercise prescriptions continue to be explored, adherence is a frequently cited challenge in clinical trials. We sought to enhance pre-treatment dysphagia services for patients with head and neck cancer (HNC) undergoing chemoradiation.
Methods
A participatory action research approach called experience-based co-design (EBCD) was undertaken at a tertiary cancer hospital in the UK. People who had previous radical radiation treatment for head and neck cancer and staff members within the head and neck unit were recruited to take part in in-depth, one-to-one interviews about their experiences of the pre-treatment SLT head and neck radiation clinic. Patient interviews were video-recorded, analysed and edited down to a 30 min ‘trigger’ film. At a subsequent patient feedback event, the film was shown and an ‘emotional mapping’ exercise was undertaken. Through facilitated discussion, patient priorities for change were agreed and recorded. At a staff feedback event, key themes from the staff interviews were discussed and priority areas for change identified. The project culminated in a joint patient and staff event where the film was viewed, experiences shared and joint priorities for change agreed. Task and finish groups were developed to implement these changes.
Results
Seven patients and seven staff members participated. All seven patients had undergone radical (chemo-) radiation for HNC. At least 2 months had elapsed since their final treatment date and all participants were within 9 months of their definitive treatment. Staff members comprised a radiation oncologist, two clinical nurse specialists, two head and neck dietitians and two speech-language therapists. Patients reported that overall, their experience of the pre-treatment clinic is positive. Patients value experienced staff, consistency of staff and the messages they provide and a team approach. Patients highlighted the need for different information methods including online/digital information resources and further information regarding the longer-term effects of treatment. Patients valued the purposes of prophylactic exercises and again advocated for supporting resources to be available in a range of online/digital media. Staff members raised the need for flexibility in appointment times and clearer messaging as to the rationale for a pre-treatment SLT appointment, including a rebranding of the SLT service. Seven key areas for improvement were identified jointly by patients and staff members including revision of patient and carer information, development of a patient experience video, information on timelines for recovery, a buddy system for patients before, during and after treatment, flexibility of appointment scheduling, seamless transfer of care between settings and SLT department rebranding. Joint patient and staff task and finish groups were initiated to work on these seven priority areas.
Conclusions
We have worked in partnership with patients to co-design pre-treatment dysphagia services which are accessible and meet the individuals’ needs. Task and finish groups are ongoing with staff and patients are working together to address priority areas for change. This work provides a good example for other centres who may wish to engage in similar activities.
Summary Objectives: Swallowing can be significantly affected during and following radiotherapy for head and neck cancer (HNC). The purpose of this study was to understand: (1) the trajectory of ...swallowing recovery following parotid-sparing intensity-modulated radiotherapy (IMRT) and (2) overall physical and social-emotional wellbeing and how patients prioritise swallowing following treatment. Materials and methods: Sixty-one HNC patients completed questionnaires as part of a prospective study exploring patient-reported swallowing outcomes following parotid-sparing IMRT. Participants were asked to complete the M.D. Anderson Dysphagia Inventory (MDADI) and University of Washington Quality of Life Questionnaire (UW-QoL) v.04 before treatment and 3, 6 and 12 months after treatment. Given the rise in human papilloma virus (HPV) and associated oropharyngeal cancers, we completed a sub analysis of the data in those participants. Results: There was a significant reduction in the MDADI composite scores 3 months after completion of treatment. Improvements were observed by 12 months, however, scores did not recover to baseline. The recovery in physical function was limited in comparison to social-emotional recovery at 12 months. When oropharyngeal cancer scores were analysed, there was not a substantial difference to the whole group results. There was a shift in priorities following treatment. Swallowing was highlighted as a concern by 44% of HNC patients up to 12 months after treatment with swallowing-related factors (saliva, taste and chewing) rated highly. Conclusions: Patient reported swallowing outcomes were significantly affected from baseline to all follow-up time points and remained a priority concern at 12 months following treatment. Overall social-emotional functioning does improve, suggesting that patients have the potential to adapt to their “new normal” following IMRT for HNC.
Objectives
Laryngotracheal stenosis is a rare condition characterized by upper airway narrowing. Reconstructive surgical treatment aims to manage the area of stenosis to improve dyspnea and can ...impact voice and swallowing function. This article critically evaluates the literature about voice and swallowing outcomes in adults with laryngotracheal stenosis who undergo reconstructive surgery.
Study Design
Systematic review.
Methods
Six databases were searched for articles referring to voice and swallowing outcome measures following reconstruction procedures in adults with laryngotracheal stenosis. Screening was completed using predefined inclusion/exclusion criteria.
Results
A total of 143 s were reviewed, with 67 articles selected for full‐text review. Twenty studies met the inclusion criteria. Data extraction was completed with the Strengthening Reporting of Observational Studies in Epidemiology checklist with Oxford Centre for Evidence‐Based Medicine Level of Evidence used to indicate quality. Risk of bias was assessed using the Risk of Bias Assessment Tool for Non‐Randomized Studies. All studies scored a high risk of bias in at least one of the domains. Selection and timing of outcome measures was heterogenous, and there was limited information provided about rationale or reliability.
Conclusions
The literature acknowledges the importance of voice and swallowing outcomes following airway reconstruction. Studies show correlation between reconstructive surgery and deterioration in vocal function; there are no consistent data about swallowing outcomes. The lack of a core outcome measures set for adults with laryngotracheal stenosis limits the findings of this review. Further research is needed to establish clear criteria for robust and clinically relevant outcome measurement. Laryngoscope, 131:146–157, 2021
Background
Dysphagia can occur in advanced lung cancer due to direct tumour invasion or nerve compression. Anti-cancer treatments and co-morbid conditions may also cause or compound dysphagic ...symptoms. Speech and language therapy (SLT), medical and surgical interventions are available to address dysphagic symptoms in patients with lung cancer, however, management options are not described in national guidelines. Given the potentially short prognoses for patients with lung cancer, the aim of care should be to reduce symptom burden and maximise quality of life (QOL). Central to that aim is the identification and treatment of swallowing difficulties.
Purpose
This study sought to identify the prevalence and impact of dysphagia on QOL in patients with advanced lung cancer.
Methods
A single-site, prospective, exploratory study was undertaken. Previously validated patient-reported outcome measures of swallowing were used to identify the presence and impact of dysphagia on QOL: EAT-10 assessment and the SWAL-QOL assessment.
Results
Seventy-two participants were recruited with 18.1% identified as having dysphagia on completion of the EAT-10 assessment. On further evaluation using the SWAL-QOL, compromised quality of life was noted with increased fatigue and meal time duration, difficulties with food selection and reduced eating desire. Frequent throat clearing, coughing and perceived pharyngeal stasis were reported.
Conclusions
Dysphagia is a potential symptom in advanced lung cancer which may impact QOL. Patients, carers and healthcare professionals should be aware of this so that early referral to SLT can be expedited. More robust prevalence and interventional studies are required to inform optimal management of this distressing condition.
Summary Purpose A systematic review to establish what evidence is available for swallowing outcomes following IMRT for head and neck cancer. Methods Online electronic databases were searched to ...identify papers published in English from January 1998 to December 2009. Papers were independently appraised by two reviewers for methodological quality, method of swallowing evaluation and categorized according to the World Health Organisation’s International Classification of Health Functions. The impact of radiation dose to dysphagia aspiration risk structures (DARS) was also evaluated. Results Sixteen papers met the inclusion criteria. The literature suggests that limiting the radiation dose to certain structures may result in favourable swallowing outcomes. Methodological limitations included variable assessment methods and outcome measures and heterogeneity of patients. There are only limited prospective data, especially where pre-treatment measures have been taken and compared to serial post-treatment assessment. Conclusions Few studies have investigated the impact of IMRT on swallow function and the impact on everyday life. Initial studies have reported potential benefits but are limited in terms of study design and outcome data. Further well designed, prospective, longitudinal swallowing studies including multidimensional evaluation methods are required to enable a more comprehensive understanding of dysphagia complications and inform pre-treatment counselling and rehabilitation planning.
Head and neck cancer (HNC) and its treatment impacts profoundly on patients' functional abilities, emotional well being and social interactions. Communication and swallowing are fundamental to ...everyday life, and the Speech and Language Therapist (SLT) has a critical role for both patients and their carers. In clinical practice, patient-reported outcome measures (PROMs) are a key part of the armamentarium of the SLT. The purpose of the review is to summarize how these measures can be beneficial in the context of time pressured SLT outpatient consultations.
Unmet needs in HNC are common and impact negatively on quality of life. There is an ever-increasing number of articles in this area, and it can be a challenge to identify, distil and summarize those specific to SLT.
In this review, we discuss the scope of holistic evaluation, strengths and limitations of PROMs, the Patient Concerns Inventory-Head and Neck, barriers to the use of outcome measures, the carers perspective and surveillance. SLT are uniquely placed members of the multidisciplinary team and provide expert advice and intervention. The inclusion of PROMs in routine consultations provides a model of follow up, which helps address patients and carers complex and unmet needs, ultimately promoting better outcomes.
Summary We undertook a service evaluation to establish how oropharyngeal dysphagia is managed in head and neck cancer patients receiving radiotherapy in the United Kingdom. A web-based survey ...including 23 open and closed questions was distributed to Speech and Language Therapy (SLT) teams via a national network of Royal College of Speech and Language Therapists (RCSLT) special interest groups with members involved in head and neck cancer care. Forty-six teams responded to the survey and 89% completed the questionnaire fully. Fifty percent ( n = 21/42) of the SLT teams reported routinely seeing patients prior to commencing radiotherapy. Baseline oromotor assessment (85.7% ( n = 36/42)), clinical dysphagia assessment (90.5% ( n = 38/42)) and information provision on the potential treatment effects on swallowing (97.6% ( n = 41/42)) and communication ability (85.7% ( n = 36/42)) were the most common components of initial evaluation. In keeping with expert opinion and emerging evidence, prophylactic swallowing exercises were administered by 71.4% ( n = 30/42) of teams targeting specific aspects of swallowing, although the nature, intensity and duration of programmes varied. A range of measures are used to monitor progress during treatment. Our survey highlighted that resource limitations affect service provision with some teams managing the consequences of treatment rather than proactive multidisciplinary intervention prior to and during treatment. Cancer- and treatment-related dysphagia can impact significantly on a broad range of outcomes following radiotherapy. There is variability in dysphagia service provision to patients before, during and following treatment. Comprehensive evaluation of swallowing function prior to treatment and proactive management can yield benefits for patients, inform multidisciplinary case management and support those involved in clinical trials to accurately determine treatment effects.
Objectives
Airway reconstruction for laryngo tracheal stenosis (LTS) improves dyspnoea. There is little evidence relating to impact upon voice and swallowing. We explored voice and swallowing ...outcomes in adults with LTS before and after reconstructive surgery.
Design
Outcome measures were collected pre‐reconstructive surgery, two‐weeks post‐surgery and up to 4‐6 months post‐surgery.
Setting
Tertiary referral centre.
Participants
With ethical approval, twenty consecutive adult (≥18 years) LTS patients undergoing airway reconstruction were prospectively recruited.
Main outcome measures
These included physiological values (maximum phonation time (MPT) and fundamental frequency; penetration aspiration score, residue score), clinician‐reported (GRBAS, functional oral intake score, 100ml Water Swallow Test) and patient‐reported outcomes (Voice Handicap Index‐10, Reflux Symptoms Index, Eating Assessment Tool, Dysphagia Handicap Index).
Results
The observational study identified patient‐reported and clinician‐reported voice and swallow difficulties pre‐ and post‐surgery; median and interquartile range are reported at each time point: Voice Handicap Index‐10 23 (8‐31); 20.5 (9‐33.5), 24.5 (12.5‐29); Dysphagia Handicap Index 9 (0‐37); 13 (7‐44); 15 (4‐34); GRBAS grade 1(1‐2); 2 (1‐2.5); 2(1‐2); 100ml Water Swallow Test volume score 16.7 (11.1‐20); 14.3 (12.5‐16.7); 16.7 (14.3‐20.0); 100ml Water Swallow Test capacity score 16.3 ± 9.0; 11.0 ± 4.1; 12.5 ± 2.6.
Conclusions
We present the first prospective data on voice and swallowing outcomes in adults with LTS before and after reconstructive surgery. The variability of the outcomes was higher than expected but importantly, for many the voice and swallow outcomes were not within normal limits before surgery. The clinical value of the study demonstrates the need for individual assessment and management of LTS patients’ voice and swallowing.
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