Treating Cancer-Related Aphasia When speech-language pathologists think of aphasia, the first type of patient that most likely comes to mind is one who has suffered an ischaemic or hemorrhagic stroke. But aphasia can also result from other brain conditions-traumatic brain injury, infections, and brain tumors. Neurological cancer is an understudied etiology of aphasia, ... Features
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Features  |   July 01, 2012
Treating Cancer-Related Aphasia
Author Notes
  • Noel Shafi, MS, is a master’s student in speech-language pathology at the Department of Communicative Disorders and Sciences at SUNY Buffalo. His research interests include adult neurogenic communicative disorders, poetry therapy, and neuroscience-based approaches to aphasia rehabilitation. Contact him at noelshaf@buffalo.edu.
    Noel Shafi, MS, is a master’s student in speech-language pathology at the Department of Communicative Disorders and Sciences at SUNY Buffalo. His research interests include adult neurogenic communicative disorders, poetry therapy, and neuroscience-based approaches to aphasia rehabilitation. Contact him at noelshaf@buffalo.edu.×
  • Linda Carozza, PhD, CCC-SLP, is an assistant professor in the Department of Communication Sciences and Disorders at St. John’s University. Her research interests include adult language and motor speech impairments, with secondary concentration in medical speech pathology. She is an affiliate of SIG 2, Neurophysiology and Neurogenic Speech Disorders. Contact her at carozzal@stjohns.edu.
    Linda Carozza, PhD, CCC-SLP, is an assistant professor in the Department of Communication Sciences and Disorders at St. John’s University. Her research interests include adult language and motor speech impairments, with secondary concentration in medical speech pathology. She is an affiliate of SIG 2, Neurophysiology and Neurogenic Speech Disorders. Contact her at carozzal@stjohns.edu.×
Article Information
Language Disorders / Aphasia / Features
Features   |   July 01, 2012
Treating Cancer-Related Aphasia
The ASHA Leader, July 2012, Vol. 17, online only. doi:10.1044/leader.FTR3.17092012.np
The ASHA Leader, July 2012, Vol. 17, online only. doi:10.1044/leader.FTR3.17092012.np
When speech-language pathologists think of aphasia, the first type of patient that most likely comes to mind is one who has suffered an ischaemic or hemorrhagic stroke. But aphasia can also result from other brain conditions-traumatic brain injury, infections, and brain tumors. Neurological cancer is an understudied etiology of aphasia, and derserves further attention.
A brain tumor is a mass of abnormal cells that can be benign (non-cancerous) or malignant (cancerous). A primary brain tumors emerges in the brain; a metastic tumor began in another part of the body before spreading to the brain.
Primary brain tumors are typically gliomas and are derived from glial cells, the non-neuronal, supportive tissue in the central nervous system. The majority of primary brain tumors are fast-growing and rapidly spreading high-grade gliomas. Brain tumors may cause a widerange of neurological dysfunctions, including aphasia, but the treatment strategy for this population is still understudied. In fact, one recent report notes that “[t]here is no current literature on strategies for persons with communication problems after [primary malignant brain tumors] but speech and language pathologists may successfully use strategies developed for use in stroke or brain injury populations” (Ford, Catt, Chalmers, & Fallowfield, 2012).
Aphasia secondary to cancer is referred to as neoplastic aphasia (Paratz, 2011) or tumor-associated aphasia (Recht, McCarthy, O’Donnell, Cohen, & Drachman, 1989) in the medical literature. In medical rehabilitation centers, brain tumor and stroke patients often present with similar personal and demographic data and with similar motor, sensory, and cognitive deficits (Greenberg, Treger, & Ring, 2006), and have a high rate of disability and mortality (Duncan, 1994; Siegel, Naishadham, & Jemal, 2012). However, the two clinical groups are quite different in terms of prevalence, incidence, assessment, and recovery from aphasia.
Prevalence and Incidence
About 30%–50% of patients with primary brain tumors experience aphasia (Davie, Hutcheson, Barringer, Weinberg, & Lewin, 2009). In contrast, the prevalence rate for poststroke aphasia seems to be lower than it is from cancer-related aphasia, ranging from 21% to 38% of acute stroke patients (Berthier, 2005).
The incident rates for poststroke and cancer-related aphasia are strikingly different. According to the American Cancer Society, there were an estimated 22,910 new cases of brain and other central nervous system cancers in 2012 (Siegel et al., 2012). However, only a subgroup of these cases may be experiencing aphasia. In contrast, according to a 2010 report by the American Heart Association, about 795,000 people experience a new or recurrent stroke every year (Lloyd-Jones et al., 2010). The National Aphasia Association (NAA) estimates that about 100,000 Americans acquire aphasia every year. Thus, although the prevalence rate of aphasia in cancer patients seems to be higher than it is in poststroke aphasia, the incidence rate of cancer-related aphasia is substantially lower than that of cardiovascular types of aphasia (see Table 2 [PDF]).
Cancer-related language disorders are considered secondary to brain cancer in the medical field and, therefore, are undertreated (see Paratz, 2011, for a review). In addition, cancer-related language disorder is not adequately highlighted in the aphasia literature, and SLPs may be called on to treat it without significant prior exposure. Because the language assessment, prognosis, and recovery patterns of aphasia relating to cancer or surgery may be different from those associated with stroke, it is important for SLPs working in medical settings to understand the clinical intervention and counseling needs of patients with brain tumors.
Language Symptoms
The most common subtype of language disorder in cancer-related aphasia is anomic aphasia (Davie et al., 2009). In contrast, global or unclassified aphasia is the most common subtype in poststroke aphasia (Godefroy, Dubois, Debachy, Leclerc, & Kreisler, 2002). Other major types of vascular aphasias are Broca’s, Wernicke’s, and transcortical aphasias (seeTable 1[PDF] for a frequency list of aphasia subtypes for both poststroke and cancer-related aphasia). Additionally, although cancer-related aphasia is typically transient and mild, poststroke aphasia is usually chronic and relatively severe (see Paratz, 2011).
In general, however, the symptoms related to cancer-related aphasia depend on the individual patient. Patients with brain tumors may have language disorders regardless of tumor type, location, and grade; as observed in poststroke aphasia, all modalities of language, including language production, comprehension, reading, and writing, are susceptible to language disorder in brain tumor patients. Therefore, language function in brain tumor patients is highly variable. Nevertheless, cancer-related aphasia is typically associated with tumors in the fronto-temporal region of the left hemisphere (Davie et al., 2009). However, it is still important to note that there are exceptions to this rule.
Assessment
When treating individuals with cancer-related aphasia, SLPs play an important role on a multidisciplinary medical team. Many members of the team-including neurosurgeons, neurologists, neuropsychologists, and psychometrists-may administer language testing to patients before, during, and after surgery to measure language function and recovery in brain tumor patients. Some studies report the use of standardized tests (Wu et al., 2011); others use clinician-made tests specifically tailored to the individual client (Meyer et al., 2001). The choice of tools may depend on the clinician’s clinical philosophy and the dominant language of the patient. The Boston Diagnostic Aphasia Examination, Western Aphasia Battery, Peabody Picture Vocabulary Test, and Token Test are among the assessments given to English-speaking patients before, during, and/or after brain surgery.
The speech and language assessments provide important clinical markers of language function and recovery. Preoperative and intraoperative language assessments have strong predictive value of postoperative language outcome for patients with brain tumors, and high clinical postoperative utility for speech and language rehabilitation.
Preoperative Procedures
Preoperative language assessments help establish a patient’s baseline, which can then be used as a reference point for postoperative language function. Clinicians also may localize the dominant hemisphere for language by administering preoperative language assessments in conjunction with functional neuroimaging, such as functional magnetic resonance imaging (Meyer et al., 2001) or positron emission tomography (Meyer et al., 2003). Preoperative identification of cognitive and linguistic deficits may also influence the surgical procedure, depending on the location and extent of the tumor.
Intraoperative Procedures
Neurosurgeons may perform awake craniotomy with the patient, and apply cortical electro-stimulation for language mapping, especially in cases in which a glioma is adjacent to language areas. Vassall, Le Bars, Moritz-Basser, Menjot, and Duffau (2010) noted that “awake craniotomy with intraoperative language mapping should be considered” in patients with language disturbances during pre-surgical assessment. Cortical electro-stimulation on a particular area of interest that elicits or inhibits a speech or motor response in the patient helps to establish the functional neuroanatomy of language in the brain. In addition, SLP-administered language tests-typically picture-naming tasks (Meyer et al., 2001)-assess expressive language skills while the surgeon pinpoints eloquent or language-related regions of the brain. Some tests may have implications for post-surgical functional outcome. Intraoperative cortical electrical stimulation, in combination with preoperative non-invasive functional neuroimaging techniques, permits minimization of definitive postoperative language deficits (Zhang et al., 2008).
Postoperative Procedures
Postoperative language assessment monitors language function and recovery. Using the preoperative baseline for comparison, clinicians can track changes in language functioning. If the tumor recurs, the aphasia may also return, and repeated speech and language assessments may be warranted. Long-term speech and language rehabilitation may be necessary if the language disorder persists after surgery.
Recovery and Prognosis
Aphasia secondary to cancer will present differently from poststroke aphasia in terms of language function and recovery. SLPs should consult with the neuro-oncologist for best treatment options, including functional maintenance, environmental supports, and augmentative strategies. Prime target areas for intervention may include group communication treatment aimed at social supports and quality-of-life adjustments.
Post-operative aphasia, in particular, is fundamentally different from post-stroke aphasia in terms of the pattern of language function and recovery. In poststroke aphasia, recovery typically occurs spontaneously within eight to 12 weeks, and peaks after one year with only minimal improvement thereafter (Berthier, 2005). In postoperative aphasia, several studies have shown that transient postoperative deficits in speech, memory, and motor function are not uncommon immediately after surgery, but the vast majority of patients experience considerable recovery of function within three months of surgery (Wu et al., 2011). Brain tumor-related aphasia is generally transient, but if the tumor is inoperable or recurrent, symptoms may continue to develop and worsen over time.
However, cerebral reorganization can occur in response to the tumor, initiating the redistribution of language. If the tumor is slow-growing and low-grade, reorganizational properties of the brain can shift language function to other regions outside the classic language areas. Language reorganization explains why surgical resection of a tumor can be performed without inducing post-operative aphasia, even if the tumor is localized in Broca’s area; this fact, therefore, demonstrates that neural plasticity in response to a neoplasm is possible, even in adult patients (Duffau, 2005).
A distinctive recovery process seems to occur in a patient with a brain tumor. According to Heiss, Thiel, Kessler, and Herholz (2003), the different in post-stroke and tumor-related aphasia could be interpreted as different compensatory mechanisms evolving during the development of the lesion. These patterns of recovery depend on the nature of the injury. For example, no expressive aphasia is observed in some cases when Broca’s area is removed after tumor resection (Plaza, Gatignol, Leroy, & Duffau, 2009). This ability indicates that brain plasticity may have occured in response to slow-growing tumors, shifting language functioning sites to areas adjacent to the lesion in the ipsilateral hemisphere, or to homologous areas in the contralateral hemisphere. However, language reorganization may not occur as efficiently in cases of fast-growing tumors, which displace and infiltrate neural tissue more quickly and aggressively.
Typically, post-operative language assessments administered within several weeks to months after surgery indicate that patients will recover many functions over time, particularly in the period of “spontaneous recovery” and beyond in many cases. Post-operative language function tends to improve over time, assuming no surgical complications or tumor recurrence.
Postoperative Rehabilitation
Patients exhibiting moderate to severe postoperative language deficits are potential candidates for long-term rehabilitation, because they are more likely to experience persistent language disorder. Although many patients seem to recover language function spontaneously within a short time, some patients suffer permanent language deficits long after surgery. Future studies should employ various treatments with this population to extrapolate further the clinical differences in functional outcome between tumor-related and poststroke aphasia using a variety of rehabilitation methods.
Acute rehabilitation for stroke and brain tumor patients is rather similar in terms of discharge rate but different in terms of length of stay. Patients recovering from stroke stay an average of 74 days in acute rehabilitation centers; those with brain tumors stay an average of 23 days. However, discharge rates are similar with about 88% for patients with stroke and 83% for those with brain tumors surviving (Greenberg et al., 2006).
Speech-language treatment for people with brain tumors may be useful not only in the short- and long-term rehabilitation phase, but also when patient recovery is no longer possible. Patients with gliomas that grow rapidly and spread quickly in the brain generally have a poor prognosis; in the end-of-life phase, about 51% experience progressive neurological symptoms, including speech and motor deficits (Sizoo et al., 2010). Speech-language services, including speech and swallowing treatment, assistive technology, or augmentive and alternative communication devices, should be considered for use with terminal patients (see Pollens, 2004).
Future Directions
SLPs in health care play a role in the perioperative process of patients at risk for aphasia secondary to cancer in language areas of the brain and those who acquire aphasia secondary to surgery. This under-explored area calls for increased education about treatment and counseling options. A team-based approach will be an important addition to the care of these patients, especially because the SLP will often take charge of the post-hospitalization portion of the patient’s recovery. Including information related to this area of neurosurgical and oncological medicine in SLPs’ graduate education and clinical practice information-in addition to the more common cerebral vascular conditions that may cause aphasia-will help SLPs in acute care settings.
Although “neuro-oncological” speech-language pathology is likely to remain a relatively rare specialty, SLPs in health care settings should be aware of aphasia secondary to cancer and the general protocol for treating this population. This protocol may include repeated longitudinal assessments, modified speech and language treatement, and use of assistive technology, depending on the presentation and/or reccurence of symptoms. As the incidence of primary brain tumors increases, particularly in older adults (Lowry, Snyder, & Lowry, 1998), and post-operative survival improves, preoperative and postoperative speech and language disorders secondary to cancer will also become more prevalent. This complex symptomology of language disorders in cancer patients demands a multidisciplinary medical team and a coordinated treatment effort.
Acknowledgements
The authors would like to thank Dr. Susan Behrens for her comments and critique of this manuscript. The first author would also like to acknowledge Professor Rosemary B. Lubinski for her guidance, the anonymous brain tumor patient who welcomed my observation during therapy, and Dr. Joseph R. Duffy for sharing his knowledge and expertise on cancer-related aphasia.
Recommended Resources

American Brain Tumor Association. (2004). A primer of brain tumors: A patient’s reference manual (8th ed). Des Plaines, IL: Author.

Mayer, J.F. (2009). Brain Tumors Frequently Encountered by Speech-Language Pathologists: A Review and Tutorial. Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders, 18: 129–136.

Miceli, G., Capasso, R., Monti, A., Santini, B., & Talacchi, A. (2012). Language testing in brain tumor patients. Journal of Neurooncology, 108: 247–252.

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July 2012
Volume 17, Issue 9