Head and neck cancer patients receiving radiation are less likely to experience worsening of diet, need a gastronomy tube, or have stenosis if they follow specific “swallow-preservation” exercises throughout therapy, according to a study now available online ahead of print in the journal Otolaryngology—Head and Neck Surgery (doi: 10.1177/0194599813502310).
The protocol “is an essential component of a comprehensive multidisciplinary treatment program for head and neck cancer patients,” the senior author, Marilene Wang, MD, Professor-in-Residence in the Department of Head and Neck Surgery at UCLA's David Geffen School of Medicine and member of the Jonsson Comprehensive Cancer Center Signal Transduction and Therapeutics Program Area, said via email.
Patients need to be aware of the potential adverse effects of chemotherapy and radiation on swallowing and be encouraged to regularly exercise the appropriate muscles to avoid losing their swallowing ability. “Even though it may be difficult, tedious, and painful, every effort should be made to keep these muscles active,” she said. “Just like with other muscles in the body, lack of use will lead to weakness and eventually total loss of function.”
The Wang et al study is one of the better studies performed to date showing the promise of such a protocol during treatment of head and neck cancer, commented M. Boyd Gillespie MD, Msc, Professor of Otolaryngology-Head and Neck Surgery at Medical University of South Carolina. Many prior studies assessed only the use of speech therapists after treatment, he noted.
Oncologists are curing an increasing number of cases of head and neck cancer with aggressive multimodality therapy, and survival is often associated with a cost to quality of life and swallowing function, he continued. Consequently, physicians need to integrate such swallowing exercises into their treatment plans.
Wang and her colleagues at UCLA—first author is Victor M. Duarte, MD—conducted a retrospective database analysis of head and neck cancer patients who received radiation or chemoradiation and who used the swallow preservation protocol (SPP) before, during, and after treatment between 2007 and 2012. Patients had a mean age of 60, and 74 percent were male.
As part of the SPP, a speech-language pathologist evaluated all patients referred for radiation therapy two weeks before treatment. Patients also received education about their cancer and treatment side effects and underwent a pretreatment assessment for dysphagia. Swallowing exercises were introduced to maintain range of motion of the mouth and neck muscles and to counter radiation fibrosis. Exercises included gargling liquid for 10 seconds (repeated 20 times), tongue protrusion (10 times), and tongue press (10 times), among several others—nearly all of which were performed three times a day.
Compliance was based on the patient's self-report at weekly visits to UCLA and defined as the performance of at least one full set of exercises per day. Noncompliance was considered to be less than that. Both compliant and non-compliant groups had similar baseline characteristics, including gender, age, weight, tumor type, treatment type, and pretreatment diet.
At one month 57 patients were categorized as SPP compliant and 28 as noncompliant. A significantly higher percentage of patients tolerated a regular chewable diet in the compliant group than in the noncompliant group (54% vs. 21%).
Compliant patients also had a significantly lower G-tube dependence (about 23% vs. 54%) and a higher rate of maintaining or improving their diet (54% vs. 25%) compared with noncompliant patients. The researchers also reported a significant difference in stenosis between the two groups, with four patients in the compliant group and nine in the noncompliant group experiencing the symptom. No difference in pain was reported between the two groups
At two months, there was a 44 percent dropout rate in the compliant patients compared with 14 percent in the noncompliant group. Assuming that all individuals who left the study before two months were tolerating a form of oral diet, significantly more compliant than noncompliant patients were on an oral diet (84% vs. 57%).
Also asked for her opinion for this article, Tamar Kotz, MS, CCC, SLP, a head and neck cancer speech pathologist in the Department of Otolaryngology at Mount Sinai Hospital, said that the study reflects the importance and difficulty of compliance in this patient population.
Patients undergoing chemoradiation are experiencing serious negative side effects, which makes maintaining swallowing exercises throughout their cancer treatment very difficult—“It's a lot to ask of them,” she said. “The swallowing exercises are difficult and rigorous.”
During treatment, patients may experience significant inflammation, swelling, and pain of the tissues in the head and neck, Wang noted. Patients also frequently feel fatigued, overwhelmed, and depressed. “This may lead to discouragement and failure to keep scheduled appointments for swallowing therapy,” she said.
Furthermore, financial, insurance and social issues may affect patients' ability to keep their appointments, negatively impacting their compliance.
Another challenge is that swallowing exercises need to be conducted over the long-term, Kotz added. Radiation can decrease blood supply to structures in the head and neck over time, “so we're seeing patients years out of treatment with significant problems swallowing.”
Wang noted that although her group does not have long-term data on the SPP, the hope is that patients who were introduced to the program will at least have the information available to them, and be able to access these resources at later time periods if needed.
Helping With Compliance
“A team approach for head and neck cancer patients to help with compliance is important,” Kotz said. “We need medical oncologists, nutritionists, radiation oncologists, and speech pathologists to be clear in giving patients the same message about the importance of swallowing exercises.”
Communication among all of the providers before, during, and after treatment will help improve compliance with SPP, Wang agreed. Additionally, oncologists and health providers should inform patients about the potential swallowing sequelae of chemotherapy and radiation well in advance of starting treatment, so they will know what to expect.
Patients should be strongly encouraged to persist with the recommended exercises and appointments, even when it is difficult or inconvenient to do so, she added. “Otherwise, they may face the unfortunate situation of having their cancer cured but being unable to eat and swallow.”
If patients are made aware that following a relatively benign protocol will make them less likely to need a feeding tube long-term, compliance may improve, Gillespie said.
Establishing an SPP
Also asked for his opinion, Avraham Eisbruch, MD, a head and neck radiation oncologist and Professor of Radiation Oncology at the University of Michigan Medical School, said that there are financial challenges to establishing a swallowing preservation protocol. Level 1 evidence is needed to convince Medicare and other payers to support the use of an SPP so hospitals can hire speech pathologists and make the protocol part of routine therapy, he said.
Establishing an SPP can be challenging, Wang agreed: “It takes a collaborative effort between head and neck surgeons, radiation and medical oncologists, and speech and swallowing therapists.”
Establishing a successful SPP can depend on the volume of head and neck cancer patients a center treats, Gillespie said. “Most academic care centers with departments of otolaryngology, head and neck surgery, and radiation oncology are going to be able to provide these swallowing programs because they have the resources. But it may be tougher for smaller cancer programs that treat fewer head and neck cancer patients, which may not have the experience or resources.”
Health care providers need to fight for the appropriate level of support for their hospital speech and language programs because budgets are often stretched, Gillespie continued. Insurers may view such programs as ancillary and not provide adequate compensation.
Eisbruch said that ideally, health care providers need a large randomized clinical trial comparing patients who participate in a swallowing exercise protocol and those who do not. The Wang et al study doesn't answer why individuals do or do not comply with this therapy—for example, patients with larger tumors, worse swallowing, or who do not perceive an immediate benefit may be less compliant, while those with better performance status or who are nonsmokers may be more compliant.
Wang said that more research also needs to be done on the longer-term effects of an SPP to prevent swallowing problems at later stages following chemotherapy and radiation. Studies on improving compliance with an SPP and removing obstacles that patients face in their efforts to follow a program are also needed.
Determining the appropriate “dosage” of exercise is also important, Kotz said. “If we give patients a huge laundry list of exercises to complete, there's less chance that they will comply. We need to focus only on targeted exercises, and more research is needed to determine how much is necessary to achieve the swallowing benefits without over-taxing our patients.”