Radiation associated dysphagia
Dysphagia is a well-established consequence of head and neck cancer (HNCA) and its treatment. While surgery may result in predictable alterations in swallowing function based upon the structures resected, the increased use of non-operative treatment for organ preservation in recent years has led to a growing awareness of radiation associated dysphagia (RAD). The use of radiation and chemotherapy has been beneficial in sparing the consequences of surgical exposure and removal of tissues involved in swallowing. However, we now understand that organ preservation does not equate to preservation of function. Patients receiving non-surgical treatment for HNCA are at risk for both acute toxicities and long-term alteration of swallow function which may contribute to long-term decrements in health status and quality of life.1-8 Given the rise in HNCA associated with the human papilloma virus (HPV) and the preferential use of radiation based therapy in these patients who are typically young and healthy at diagnosis, a focus on RAD prevention is of paramount importance.
The importance of prophylactic swallowing therapy during non-operative HNCA treatments has received great attention in recent years. A retrospective case control study by Carroll and colleagues9 demonstrated the value of initiating prophylactic therapy prior to chemoradiotherapy (CRT). Patients in this study completed a series of exercises targeting the tongue base, pharyngeal constrictors, and laryngeal elevators and then completed a videofluoroscopic swallowing study 3 months after completion of CRT. Individuals performing exercises prior to and during CRT demonstrated more normal tongue base apposition to the pharyngeal wall as well as more normal epiglottic inversion than those patients who did not receive therapy. A randomized controlled trial by Kotz10 and colleagues further demonstrated that those patients receiving prophylactic swallowing therapy had more favorable diet levels 3-6 months following treatment completion. Additional support for preventative exercise came from Carnaby-Mann’s “Pharyngocise” paper.11 In this study, patients performing prophylactic swallowing exercises during radiation had less structural change in the genioglossus, hyoglossus, and myohyloid muscles than in the groups that did not receive direct therapy. Further, in the immediate period following radiation, patients receiving treatment had a more favorable composite outcome that took into account diet, weight maintenance, and performance on the Mann Assessment of Swallowing Ability. These papers together demonstrate that both physiology and function in the early period following radiation are optimized with application of preventative dysphagia exercises.
I often compare the purpose of our treatment to dental hygiene – you don’t brush your teeth once you get a cavity, you brush them to prevent the cavity. Similarly, we aren’t exercising to treat dysphagia, but rather to prevent it.
In addition to performance of swallowing exercises for prevention of RAD, there is growing evidence that maintenance of oral intake during treatment has a positive impact on swallowing outcomes. In Langmore’s paper12 “Does PEG cause dysphagia in head and neck cancer patients?” post-treatment diet level was significantly associated with oral intake during treatment in that those who maintained some oral intake had significantly more advanced diet levels following treatment. Additional evidence concerning feeding tube use and RAD was provided by Hutcheson et al13 in the “Eat and Exercise” manuscript. This report demonstrated that eating and exercising swallowing musculature during radiation provided patients with better post-treatment diet outcomes. For individuals not eating and not exercising, return to a normal diet was only enjoyed by 65% of patients. For those who ate and exercised during treatment, 92% returned to a normal oral diet after treatment completion.
Preventative Swallowing Intervention
Despite our understanding as care providers of the importance of eating and exercising during radiation, patients often have poor adherence to our treatment recommendations. A recent report from MD Anderson demonstrated that only 45% of patients were even partially adherent to treatment recommendations.14 HNCA treatment can be complicated and patient understanding of treatment recommendations can be lacking. Many patients cite not having a current dysphagia as the reason for their non-adherence. Increasing patient comprehension of the importance of preventative swallowing intervention is critical for improving adherence. I often compare the purpose of our treatment to dental hygiene – you don’t brush your teeth once you get a cavity, you brush them to prevent the cavity. Similarly, we aren’t exercising to treat dysphagia, but rather to prevent it.
SLP Integration into the Multidisciplinary Team
One technique to increase patient understanding of the role of the SLP may be integrating the SLP into the multidisciplinary head and neck cancer clinic.15 I believe that establishing a clinical relationship between the patient and the SLP from the time of diagnosis assists in the patient’s familiarity and comfort with that provider. Inclusion of the SLP as part of the team evaluation supports their legitimacy on the team, and I suspect that the emphasis on the importance of swallowing therapy during the multidisciplinary clinic is more salient to patients than an isolated recommendation by the oncology team. Sharing with patients in an easy to understand way the data cited above can be a powerful tool in increasing their understanding of the role of dysphagia prevention.
Managing Acute Side Effects
Another key to facilitating adherence is management of acute treatment toxicities. Individuals providing care to HNCA patients know that the acute side effects of treatment can be very difficult for patients to manage. Pain and fear of pain have been cited as reasons why patients do not adhere to their swallowing exercises.14,16 Our team has demonstrated that prophylactic administration of gabapentin (2700 mg/d) during radiation is associated with improved pain control, decreased total narcotic analgesic use, decreased time to use of narcotic analgesics, and less weight loss despite the decreased use of prophylactically placed PEG.17 Further, we found that when comparing patients treated prophylactically with gabapentin with historical controls, short term swallowing outcomes on VFSS and post-treatment diet level were more favorable in those receiving gabapentin.18. Controlling toxicity may significantly impact adherence in these patients.
My clinical practice
My practice has been developed using the evidence based medicine approach of integrating research, clinical experience, and patient preference. I assess and educate all patients undergoing radiation for HNCA. I review the current evidence regarding the importance of eating and exercising with my patients. I provide a series of exercises focusing on the regions impacted most by radiation. Commonly this includes effortful swallows, Masako exercises, Mendelsohn Maneuver, and effortful sirening. Based upon our best dose data provided in the Pharyngocise paper, I ask patients to complete 3 sets of 10 repetitions of each exercise twice daily. Patients are also provided with jaw stretches for trismus prevention, which they are asked to perform 15 times, three times per day. I do not routinely encourage prophylactic PEG placement, however if a patient is nutritionally depleted at baseline or has a substantial pre-radiation dysphagia, a prophylactic PEG may be warranted for nutritional support. It is emphasized that the patient should continue some form of oral intake despite PEG to continue recruiting the muscles of deglutition. I have found that a well-educated patient with good pain control is typically able to follow through with these recommendations. As a core member of the HNCA team, it is incumbent on SLPs to work with physician partners to optimize outcomes through toxicity management and thorough patient education.
- Kotz T, Costello R, Li Y, Posner MR. Swallowing dysfunction after chemoradiation for advanced squamous cell carcinoma of the head and neck. Head Neck 2004; 26(4): 365–72.
- Graner DE, Foote RL, Kasperbauer JL, et al. Swallow function in patients before and after intra-arterial chemoradiation. Laryngoscope 2003; 113(3): 573–9.
- Lazarus C. Tongue strength and exercise in healthy individuals and head and neck cancer patients. Semin Speech Lang 2006; 27(4): 260–7.
- Starmer HM, Tippett D, Webster K, et al. Swallowing outcomes in patients with oropharyngeal cancer undergoing organ preservation treatment. Head Neck 2014; 36: 1392-7.
- Gillespie M., Brodsky MB, Day TA, Sharma AK, Lee F, Martin-Harris B. Laryngeal Penetration and Aspiration During Swallowing After the Treatment of Advanced Oropharyngeal Cancer. Arch Otorhinolaryngology Head Neck Surg 2005; 131: 615-19.
- Eisbruch A, Kim HM, Feng FY, et al. Chemo-IMRT of oropharyngeal cancer aiming to reduce dysphagia: swallowing organs, late complication probabilities, and dosimetric correlates. Int J Radiat Oncol Biol Phys 2011; 81: e93-9.
- Hunter KU, Feng FY, Schipper M, et al. What is the clinical relevance of objective studies in head and neck cancer patients receiving chemoirradiation? Analysis of aspiration in swallowing studies vs. risk of aspiration pneumonia. Paper presented at American Society for Radiation Oncology (ASTRO) Annual Meeting. Miami FL, October 2-6, 2011.
- Hutcheson KA, Lewin JS, Barringer DA et al. Late dysphagia after radiotherapy-based treatment of head and neck cancer. Cancer 2012; 118(23): 5793-9.
- Carroll WR, Locher JL, Canon CL, et al. Pretreatment swallowing exercises improve swallow function after chemoradiation. Laryngoscope 2008; 118: 39-43.
- Kotz T, Federman AD, Kao J, et al. Prophylactic swallowing exercises in patients with head and neck cancer undergoing chemoradiation: a randomized trial. Arch Otolaryngol Head Neck Surg 2012; 138: 376-82.
- 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.
- Langmore S, Krisciunas GP, Miloro KV, et al. Does PEG cause dysphagia in head and neck cancer patients? Dysphagia 2012; 27(2): 251-9.
- Hutcheson KA, Bhayani MK, Beadle BM et al. Eat and exercise during radiotherapy or chemoradiotherapy for pharyngeal cancers. Use it or lose it. JAMA Otolaryngol Head Neck Surg 2013; 139(11):1127-34.
- Shinn EH, Basen-Engquist K, Baum G, et al. Adherence to preventative exercises and self-reported swallowing outcomes in post-radiation head and neck cancer patients. Head and Neck 2013; 35(12): 1707-12.
- Starmer HM, Sanguineti G, Marur S, Gourin CG. Multidisciplinary head and neck cancer clinic and adherence with speech pathology. Laryngoscope 2011; 121 (10): 2131-5.
- 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.
- Raval RR, Richardson ML, Yang WY, et al. Gabapentin therapy for prevention and management of the pain syndrome in oropharyngeal carcinoma patients treated with radiation. Paper presented at the American Society for Radiation Oncology (ASTRO) Annual Meeting. Boston MA, October 28-31, 2012.
- Starmer HM, Yang WY, Raval R, et al. Effect of gabapentin on swallowing during and after chemoradiation for oropharyngeal squamous cell cancer. Dysphagia 2014; 29(3): 396-402.