Collaborative Dysphagia Care for Chemoradiation Patients Curative treatment of head and neck cancer (HNC) often requires multiple modalities: surgery, radiation, and chemotherapy. Although curative outcomes may improve with such treatments, acute toxicities also are heightened. A multi-disciplinary approach in the diagnosis and treatment of dysphagia is crucial during these critical treatments to optimize swallow capabilities and ... Features
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Features  |   October 01, 2011
Collaborative Dysphagia Care for Chemoradiation Patients
Author Notes
  • Rachael Kammer, MS, CCC-SLP, BRS-S, is a senior SLP in the Voice and Swallow Clinics, Division of Otolaryngology-Head and Neck Surgery, in University of Wisconsin-Madison School of Medicine and Public Health. She is a member of Special Interest Group 13, Swallowing and Swallowing Disorders. Contact her at kammer@surgery.wisc.edu.
    Rachael Kammer, MS, CCC-SLP, BRS-S, is a senior SLP in the Voice and Swallow Clinics, Division of Otolaryngology-Head and Neck Surgery, in University of Wisconsin-Madison School of Medicine and Public Health. She is a member of Special Interest Group 13, Swallowing and Swallowing Disorders. Contact her at kammer@surgery.wisc.edu.×
  • Peggy Wiederholt, RN, is the oncology nurse coordinator, Department of Human Oncology, University of Wisconsin-Madison School of Medicine and Public Health. Contact her at wiederholt@humonc.wisc.edu.
    Peggy Wiederholt, RN, is the oncology nurse coordinator, Department of Human Oncology, University of Wisconsin-Madison School of Medicine and Public Health. Contact her at wiederholt@humonc.wisc.edu.×
  • Molly Knigge, MS, CCC--SLP, BRS-S, is a senior SLP in the Voice and Swallow Clinics, Division of Otolaryngology-Head and Neck Surgery, in University of Wisconsin-Madison School of Medicine and Public Health. She is a member of Special Interest Group 13, Swallowing and Swallowing Disorders. Contact her at knigge@surgery.wisc.edu.
    Molly Knigge, MS, CCC--SLP, BRS-S, is a senior SLP in the Voice and Swallow Clinics, Division of Otolaryngology-Head and Neck Surgery, in University of Wisconsin-Madison School of Medicine and Public Health. She is a member of Special Interest Group 13, Swallowing and Swallowing Disorders. Contact her at knigge@surgery.wisc.edu.×
Article Information
Swallowing, Dysphagia & Feeding Disorders / Features
Features   |   October 01, 2011
Collaborative Dysphagia Care for Chemoradiation Patients
The ASHA Leader, October 2011, Vol. 16, online only. doi:10.1044/leader.FTR5.16122011.np
The ASHA Leader, October 2011, Vol. 16, online only. doi:10.1044/leader.FTR5.16122011.np
Curative treatment of head and neck cancer (HNC) often requires multiple modalities: surgery, radiation, and chemotherapy. Although curative outcomes may improve with such treatments, acute toxicities also are heightened. A multi-disciplinary approach in the diagnosis and treatment of dysphagia is crucial during these critical treatments to optimize swallow capabilities and oral intake. One of the most important goals is to keep patients eating throughout their treatment with a concomitant intact swallow at its completion. The relationship between oncology nurse coordinators and speech-language pathologists is particularly complementary, effective, and efficient for the management of oral intake and swallowing in HNC patients.
Treatment decisions depend on the site and staging of a lesion. Cancer staging identifies the size of the tumor and whether it has spread (metastasized) to nearby lymph nodes or to other parts of the body such as the lungs. Patients with locoregional disease receive treatment that may include primary surgery, followed by post-operative radiotherapy, and possibly concurrent chemotherapy, or primary radiotherapy, with or without concurrent chemotherapy. In some cases, patients require chemotherapy first to shrink the tumor so that it may be better managed with surgery or radiation. Patients with distant metastases are typically offered palliative (supportive) care, which may include chemotherapy.
Radiotherapy has toxicities that challenge oral intake, including mucositis (inflammation of the mucous membranes in the mouth and throat), xerostomia (dry mouth), dysgeusia (distorted sense of taste), and dysphagia. Research has demonstrated that the addition of chemotherapy to radiotherapy improves curative outcomes (Bourhis, Amand, & Pignon, 2004), but also amplifies these side effects (Trotti et al., 2003).
Mucositis causes pain, frequently requiring topical anesthetics and narcotics. Pain often increases with swallowing (odynophagia), and as a result, patients often eat less. Xerostomia occurs because at least one saliva gland receives radiation and therefore produces less saliva; patients report discomfort, an increase in thick secretions, and difficulty swallowing dry food. Xerostomia does improve after treatment, but may not fully resolve. For patients with dysgeusia, food may taste unpleasant have no taste at all, causing decreased motivation to eat. Dysphagia can be caused from mass effect of tumor, primary surgical resection causing altered anatomy, or radiotherapy causing edema (swelling) and fibrosis (thickening and scarring) of pharyngeal structures. Dysphagia and aspiration can be acute or chronic, and are often under-reported and underappreciated consequences of HNC and its treatment (Rosenthal, Lewin, & Eisbruch, 2006).
Collaboration between nursing and speech language-pathology in caring for HNC patients optimizes the management of side effects and oral intake, and ideally prevents chronic dysphagia. At the University of Wisconsin Hospital and Clinics, an oncology nurse coordinator (ONC) and an SLP follow all HNC patients as they move between clinics and through different stages of treatment. The ONC evaluates clinical and psychosocial needs, manages adverse side effects, identifies patients who either present with symptoms of dysphagia or aspiration or are at risk for developing swallow dysfunction, and facilitates timely referrals to the SLP. The SLP tracks all patients undergoing treatment and determines when visits to other members of the multidisciplinary team are needed.
Patient-Clinician Meetings
The members of the multidisciplinary team meet with patients at several points throughout treatment to gather specific information.
Pre-treatment
Prior to treatment, visits with patients and their families are important to determine expectations and responsibilities. Providing information in writing is essential so that patients have a resource as questions and issues develop. Families are often overwhelmed when information is initially presented verbally, and we have found anecdotally they are likely to be more attentive when they have time to review a written resource at home. A binder that includes basic information from multiple disciplines is optimal, with each discipline explaining its specialty and the services it provides. The binder also is an opportunity to list different tests and appointments the patient may encounter. Finally, the resource should list contact names and phone numbers for appropriate clinics.
The binder is introduced at the pre-treatment meeting with the ONC. The ONC presents the risk of swallow dysfunction and, as part of standard HNC care, refers the patient to an SLP. Patients who already exhibit swallowing problems are typically referred prior to the pre-treatment meeting. As part of the multidisciplinary team approach, the ONC also facilitates consultation with a nutritionist and referrals to a social worker or cancer psychologist to address any potential financial, insurance, or behavioral barriers.
Involvement of the SLP before, during, and after treatment, and initiation of preventive exercises and rehabilitative measures can potentially reduce or eliminate long-term swallowing dysfunction (Nguyen et al., 2004). An important aspect of the pre-treatment meeting with an SLP is to assess baseline swallow function. Some patients will have had initial surgery (e.g. partial glossectomy or mandibulectomy), resulting in dysphagia that may worsen during the course of (chemo) radiation treatment. Other patients are at higher risk for decompensation of their swallow function and aspiration pneumonia due to age, frailty, or advanced disease. These high-risk patients need to be identified, and the safety of oral intake clearly defined, possibly with an instrumental dysphagia evaluation. Such patients need to be monitored closely throughout treatment, and continually educated about the risk for aspiration. Education is particularly critical on the importance of continued daily oral intake to maintain swallow function (Rosenthal et al., 2006). Finally, prophylactic pharyngeal range-of-motion exercises may help to prevent fibrosis, thereby preventing dysphagia (Carroll et al., 2008). The SLP should present patients with exercises and allow patients to practice them during the meeting.
The challenges of oral intake during treatment may require some patients to use a gastrostomy tube to provide nutrition and hydration. However, swallow function may actually be better maintained if patients continue oral intake during treatment (Rosenthal et al., 2006). Placement of elective gastrostomy tubes can be controversial, as patients who have them may rely on them more than needed. Periods of nothing-by-mouth (NPO) as short as two weeks have been shown to predict dysphagia (Gillespie, Brodsky, Day, Lee, & Martin-Harris, 2004). Following pre-treatment visits, a joint decision on the need for gastrostomy tube placement, made by the physician, ONC, and SLP, is imperative. Factors affecting the decision are the site of the lesion, treatment modalities (single vs. combined), baseline swallow ability, age, and functional reserve. If patients have a gastrostomy tube placed for supplemental nutrition, it is typically recommended that they continue daily oral intake throughout treatment, at the maximally tolerated diet. Because some patients are able to sustain themselves on an oral diet throughout treatment, it is not recommended that an elective tube be placed in patients who have normal baseline swallow studies, are relatively robust, and are receiving radiotherapy only.
During Treatment
After (chemo)radiation begins, it is important for the ONC to meet with the patient weekly. Pain, nausea, dysgeusia, xerostomia, hydration, weight, tube feedings, fluids, bowels, and skin care are carefully monitored and managed to avoid breaks in treatment, prevent hospitalization, and achieve better long-term outcomes. In collaboration with the SLP, nursing must encourage the patient to maximize oral intake, even if a gastrostomy tube is in place.
SLP meetings occur concurrently as part of a coordinated, multidisciplinary team approach. Patients often are able to tolerate a general or mechanical soft diet through the first half of treatment. However, during the second half of treatment, toxicities escalate and oral intake becomes challenging. Patients often need to downgrade diet, and the SLP can assist in this process by providing diet suggestions for the consistencies tolerated. In general, patients should maximize oral intake of their tolerated diet. If patients are experiencing significant odynophagia, they should, at a minimum, eat daily snacks of puree and sip water. The SLP also monitors swallow function, as risk for aspiration may increase during treatment (Jones et al., 2006, Trottie et al., 2003). Finally, patients are reminded to continue daily prophylactic exercises.
During treatment, communication between the ONC and the SLP is crucial. The ONC will likely see the patient more frequently, and can help reinforce swallow objectives, particularly maximizing oral intake. Nursing also can monitor for signs of aspiration, either by patient report or by observation. If worsening dysphagia is suspected, nursing may contact the SLP and ask for the patient to be seen more urgently. The patient will have at least three to four scheduled visits during treatment with the SLP. Patients may report information to the SLP that is better handled by nursing; for example, they may report increased odynophagia because pain is not adequately covered. Communication between the SLP and ONC allows for improved pain coverage, which leads to improved oral intake.
Post-treatment
The ONC typically meets with patients about one week after treatment, when toxicities often continue to be overwhelming. The ONC evaluates symptoms and manages ongoing treatment-related side effects in collaboration with the treating physicians. Patients are encouraged to continue eating and drinking by mouth and guidelines are set for their recovery and rehabilitation.
Patients are seen by the SLP at one month post-treatment. Acute side effects should have decreased and oral intake should be easier. At this meeting, swallow is reassessed and residual dysphagia identified. Instrumental evaluation may be needed, and some patients will require compensatory strategies and/or initiation of swallow rehabilitation. Goals are set to advance diet, increase oral intake, and decrease tube feedings, if applicable. At the University of Wisconsin Hospital and Clinics we have determined in a quality assessment review that 18% of patients who undergo (chemo)radiation and who were followed by the ONC and SLP were found to have persistent dysphagia post-treatment, as defined by the need for an instrumental swallow examination. This outcome contrasts with that of Nguyen, Sallah, Karlsson, and Antoine (2002), who report that up to 50% of patients have dysphagia following (chemo)radiation. Further investigation is necessary to clarify clinical efficacy of this collaborative approach.
Collaboration between the SLP and ONC is especially important in weaning tube feedings. Safety of swallow function must be established to initiate and capitalize oral intake and diet advancement. Guidelines must be set to decrease tube feedings slowly while maintaining body weight. The decision to remove a gastrostomy tube, if applicable, should be made only with input from both clinicians and approval from the attending physician. Removal is indicated for patients who have functional swallow and maintain weight for two weeks without using the tube.
Support groups are very helpful for cancer patients before, during, and after treatment. An ONC and SLP are excellent professionals to coordinate such a group. Meetings provide education as well as peer support. Multiple disciplines can speak to group members and provide information on topics relevant to HNC. Most importantly, group members can learn from one another by sharing experiences. A patient just beginning treatment may gain confidence from meeting a patient who completed treatment years ago. Finally, it is helpful for patients to see clinicians working together as a unified team in a support-group effort.
A strong framework for following patients during HNC treatment is important for optimizing treatment success. Communication and teamwork between disciplines is required to manage side effects and complications most effectively. The ONC and SLP can jointly manage the challenges of oral intake during (chemo)radiation and potentially decrease the risk for chronic dysphagia.
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October 2011
Volume 16, Issue 12