Cancer can manifest in many different ways one of which is head and neck cancer (HNCA). HNCA and its treatment can result in significant swallowing difficulties in which speech-language therapists play a key role. Head and neck cancer can refer to cancers of:
- The mouth
- The throat
- The voice box
- Nasal cavity
- Salivary glands
Stats and facts:
Although the incidence of head and neck cancers represent only 2.5% of all cancers in NZ, the epidemiology of which appears to be changing. Historically HNCA has largely been attributed to people over 50yrs old and mainly as a result of smoking and alcohol intake. However, there has been an increase of HNCA in young adults. Recent unpublished data from the Auckland regional Head and Neck Service indicates that over 75% of oropharyngeal cases are human papillomavirus (HPV)-positive. Treatment can involve either, or a combination of, surgery, radiotherapy, and chemotherapy. Although surgical options may induce predictable swallowing difficulties, (HVP)-positive tumors are commonly treated with radiotherapy which can lead to a very different presentation of dysphagia. Radiotherapy has been shown to be effective in treating HPV-positive oropharyngeal cancers, meaning that younger people are surviving HNCA and living long after treatment with the post-radiation effects. Radiation can cause long term effects, which in turn impact on swallowing and can increase aspiration risk, and significantly affect quality of life. Some effects include tightening of the jaw (trismus), tightening of the radiated tissues (fibrosis), dry mouth (xerostomia), thick secretions, ulcerations and inflammation (mucositis), painful swallowing (odynophagia), and swelling (oedema). Radiation fibrosis syndrome is a condition whereby the radiated tissues become fibrosed and tight which then also progressively worsens over time causing significant swallowing difficulties. This condition does not happen to everyone but is the reality for some.
Role of the SLT:
SLT’s work as part of the whole team of professionals (MDT) required to help this population.
SLT’s are key team players in the journey of someone with HNCA. Evidence tells us that prophylactic therapy programs such as ‘pharyngocise’ implemented pre, during, and post treatment can increase positive swallowing outcomes. This type of therapy is aimed at ‘preventing’ dysphagia during and after treatment rather than ‘treating’ it. The commitment to preventative treatment is life-long after radiation and is something SLT’s can support you with to incorporate into your daily routines.
An SLT can implement a series of swallowing techniques and safe swallowing strategies to help with eating and drinking if dysphagia has developed.
If compensatory strategies alone do not completely help with swallowing safety and ease then an SLT may assess to see if a modified diet and/or liquids might be appropriate.
Alternate feeding options:
If swallowing safety continues to be compromised despite all above efforts then the medical team may need to consider alternative feeding options such as a feeding tube (PEG).
If you have had radiation for head and neck cancer in the past and feel like your swallowing has worsened, it might be time to contact your GP and/or SLT for advice.
For more information about signs and symptoms of head and neck cancer head on over to the Cancer Society Website.
By Renee Taylor (SLT)
Carroll WR, Locher JL, Canon CL, et al. Pretreatment swallowing exercises improve swallow function after chemoradiation. Laryngoscope 2008; 118: 39-43.
Carnaby-Mann G and Lagorio L. Preventing dysphagia in head and neck cancer. Paper presented at American Speech Language and Hearing Association (ASHA) Annual Convention. Atlanta, GA, November 15-17, 2012.
Carnaby-Mann G, Crary MA, Schmalfus I, Amdur R. “Pharyngocise”: Randomized control trial of preventative exercises to maintain muscle structure and swallowing function during head and neck chemoradiotherapy. Int J Rad Onc Bio Phys 2012; 83: 210-9
Curado MP, Hashibe M. 2009. Recent changes in the epidemiology of head and neck cancer. Current Opinion in Oncology 21: 194–200National Head and Neck Cancer Tumour Standards Working Group. 2013.
Standards of Service Provision for Head and Neck Cancer Patients in New Zealand - Provisional. Wellington: Ministry of Health.