Effective communication is vital to maintaining relationships with friends, family members, and the community. Hearing is a critical part of the communication process. Auditory impairment, whether pre-existing or secondary to medical therapies, can significantly disrupt communication with a person's support system and health care providers. This is especially problematic when a patient is diagnosed with a life-threatening illness since communication with care providers and support systems is a crucial component in choosing the best care pathway. Ultimately, a disconnect in communication may lead to reduced patient adherence to the treatment plan and poorer patient outcomes.
OTOTOXICITY IN ONCOLOGY TREATMENT
Ototoxic auditory impairment occurs when chemotherapeutic agents (particularly platinum-based medications like cisplatin or high-dose carboplatin) or cranial irradiation treatments damage cochlear hair cells. Ototoxic cochlear effects from chemotherapy are often bilateral and originate from higher frequencies. Cranial irradiation treatments may cause conductive hearing loss, from an outer and/or middle ear pathology, and sensorineural hearing loss from cochlear damage. The personal risk for otologic damage is variable. Deterioration of hair cells can be progressive or treatment dose-dependent, and the degree of progression is confounded by pre-existing hearing loss or additional treatment with other ototoxic medications like diuretics or aminoglycoside antibiotics. These cancer therapies may cause hearing loss during treatment or produce delayed effects, which appear months or years after treatment. A common and poorly addressed issue affecting cancer survivors is that when they are free of their primary disease, they often find themselves dealing with the lasting side effects of cancer treatment. Between 2016 and 2040, the number of cancer survivors in the United States is projected to increase from an estimated 15.5 million (a total population of 324 million) to 26.1 million (a total population of 380 million) across all age groups. Specifically, in 2040, cancer survivors aged 65–74 years old will account for 24 percent of all survivors, those 75–84 years old will account for 31 percent of all survivors, and those 85 and older will represent 18 percent of all survivors.1 It is well established that as we age, the potential for developing hearing loss and tinnitus rises. Older adults comprise most cancer survivors and will continue to lead the survivor population. Audiologists must consider the great risk older adults in the survivor population face in developing hearing loss and tinnitus, which we are well positioned to manage.
UNTREATED HEARING LOSS AMONG CANCER PATIENTS
Sensory impairments like hearing loss have negative consequences for community-dwelling older adults, and individuals with impairments have poorer functional status, cognition, and psychological well-being, as well as poorer survival.2-5 Studies have shown specifically that uncorrected hearing loss leads to an increased feeling of isolation and reduced social activity, leading to an increased prevalence of depression.6 Hearing loss is an invisible deficit, and the resulting handicap often goes underrecognized and untreated. Reed and colleagues in 2019 reported that untreated hearing loss is associated with over $22,000 or 46 percent higher health care costs over 10 years in older adults compared with those without hearing loss.7 They also noted 50 percent more inpatient stays with a 44 percent greater risk for hospital readmission within 30 days. With acquired hearing loss, older adults deal with the loss of audibility and clarity, as well as other associated negative impacts such as increased hospitalization, higher likelihood of adverse events, and augmented overall burden of disease.8-9
Many major U.S. medical centers are members of the National Comprehensive Care Network (NCCN), which develops guidelines for adult cancer survivors. Despite a multitude of published research showing the lasting effects of ototoxicity on the auditory system, this information is not included in the NCCN guidelines for the monitoring and continued management of hearing loss during cancer treatment and in survivorship. Additionally, a 2018 study indicated that older adults with cancer are more likely to have functional, cognitive, and psychological deficits, including anxiety and depression.10 This is concerning since estimates show that by 2029, the number of adults who have lived five or more years after a cancer diagnosis is projected to increase by approximately 33 percent, to 15.1 million.1 Medical advances enable more individuals to live with cancer and beyond. The knowledge and experience of audiologists in managing hearing impairment and its impact on communication are unique, placing our profession in an ideal position to help cancer patients and survivors.
Pearson and colleagues explored and analyzed the experiences of cancer patients with chemotherapy-induced ototoxicity by reviewing posts in public online health forums, and found a significant number of posts that expressed concerns about the lack of information on the risk of ototoxicity. They also found that tinnitus and hearing loss were associated with distress, fear, and employment issues. Those with pre-existing hearing loss and tinnitus reported impacts on their quality of life and expressed fear that symptoms will worsen.11-12
Health literacy is defined by the Institute of Medicine as the “degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”13 Researchers have shown that low health literacy is a stronger predictor of health outcomes than age, income, or race, and that low health literacy is statistically linked to poorer health and quality of life.14 Optimized patient-provider communication for patients with ototoxic effects is imperative to implementing appropriate care and critical to patient well-being. Appropriate management of hearing loss has the potential to provide health care savings by reducing the risk of preventable adverse events, especially among cancer survivors who may have related health care needs throughout their lifespan. Hearing communication should be addressed to improve health literacy, patient compliance, motivation, health-related decision-making, and overall health outcomes.
Interventional audiology is (1) the delivery of audiology services at an earlier stage of auditory impairment and (2) the provision of treatment for hearing loss and tinnitus in cases wherein these are not the primary concerns but may negatively impact health outcomes if not addressed. As shown in Figure 1, offering early intervention may increase auditory rehabilitation options.
Audiologists aid in assessing the personal risk for hearing loss by performing a baseline hearing evaluation before treatment and consulting with oncologists regarding the ototoxic potential of recommended therapies. Throughout treatment, audiologists complement patient care by monitoring any decline in auditory function and counseling on hearing loss and tinnitus before and if changes occur. If a significant change is noted, the best practice is to consult the referring oncologist and refer the patient to an otolaryngologist for medical management. Potentially, oncologists may be able to adapt the therapy plan if adjusting the plan will not negatively impact the treatment of the primary disease. At present, the U.S. Food and Drug Administration does not have an approved otoprotective agent for a sudden change in hearing; however, research is ongoing in this area. Moreover, audiologists should play a key role in the multidisciplinary team to recommend hearing communication management options.
Auditory rehabilitative services aid in the management of hearing loss and tinnitus by developing a treatment plan that addresses their physical and psychosocial consequences. Person-centered rehabilitation helps individuals cope with lifestyle changes inherent in living with the chronic condition of auditory impairment. Hence, audiology services contribute to ensuring patients’ adherence to their overall treatment plan, improving patient outcomes, and increasing patients’ health-related quality of life.
THINKING OUTSIDE THE BOX
At the Vanderbilt Bill Wilkerson Center, our vision for audiology care is “A World without Barriers from Deafness and Dizziness.” We look to the future to accomplish this lofty goal by integrating our services into other health delivery models, providing services in a variety of patient and clinical settings, and ensuring a continuum of audiology care across the lifespan. As cancer facilities move toward a model of “survivorship care centers,” audiologists are essential members of the multidisciplinary team from the start of treatment and throughout survivorship. As experts in the management of auditory impairment, audiology services are invaluable in keeping patients informed and providing rehabilitative services for hearing loss and tinnitus, which can adversely affect health outcomes and an individual's overall health throughout his or her lifetime. It is time for audiologists to step out of the sound booth and look beyond the audiogram and hearing aids in the management of the chronic conditions of hearing loss and tinnitus. Continued research is needed to quantify the effects of auditory impairment specific to cancer patients and survivors. Research should also aim to obtain randomized controlled trials to evaluate the impact of audiologic interventions like counseling and hearing assistive technologies on this population.
As cancer treatments improve and more patients are living longer, we need to better manage cancer survivors’ burden from ototoxicity and the inherent effects on quality of life. Treatment of the primary disease is always the paramount goal, yet health care providers and audiologists should not lose sight of offering hearing communication services to adults battling cancer or living beyond their diagnosis.
1. Bluethmann S, Mariotto A, Rowland, J. Anticipating the ‘ ‘Silver Tsunami’: Prevalence Trajectories and Comorbidity Burden among Older Cancer Survivors in the United States. Cancer Epidemiol Biomarkers Prev
2. Crews JE, Campbell VA. Vision impairment and hearing loss among community-dwelling older Americans: implications for health and functioning. Am J Public Health
. 2004; 94:823–829.
3. Kiely KM, Anstey KJ, Luszcz MA. Dual sensory loss and depressive symptoms: the importance of hearing, daily functioning, and activity engagement. Front Hum Neurosci
4. Pinto JM, Wroblewski KE, Huisingh-Scheetz M, et al. Global Sensory Impairment Predicts Morbidity and Mortality in Older U.S. Adults. J Am Geriatr Soc.
5. Raina P, Wong M, Massfeller H. The relationship between sensory impairment and functional independence among elderly. BMC Geriatr
. 2004; 4:3.
6. Arlinger, S. Negative Consequences of Uncorrected Hearing Loss- a review. International Journal of Audiology
. 2003; 42 (suppl 2):S17-20.
7. Reed, N. Altan, A. Deal, J. Yeh, C. Kravetz, A. Wallagen, M. Lin, F. Trends in Health Care Costs and Utilization Associated with Untreated Hearing Loss Over 10 Years. JAMA Otolarynology-Head & Neck Surgery
. 2019; 145(1): 27-34.
8. Genther DJ, Frick KD, Chen D, Betz J, Lin FR. Association of hearing loss with hospitalization and burden of disease in older adults. JAMA
9. Bartlett, G., Blais, R., Tamblyn, R., Clermont, R.J., & MacGibbon, B. (2008). Impact of patient communication problems on the risk of preventable adverse events in acute care settings. Canadian Medical Association Journal
10. Soto-Perez-de-Celis E, Sun CL, Tew WP, et al. Association between patient-reported hearing and visual impairments and functional, psychological, and cognitive status among older adults with cancer. Cancer
11. Pearson, et al. Exploring the experiences of cancer patients with chemotherapy induced ototoxicity: a qualitative study using online health forums. JMIR Cancer
. 2019; 5:e10883.
12. Pearson S, Taylor J, Patel P, Baguley D. (2019) Cancer survivors treated with platinum-based chemotherapy affected by ototoxicity and the impact on quality of life: a narrative synthesis systematic review, International Journal of Audiology
, 58:11, 685-695.
13. Institute of Medicine. 2004. Health Literacy: A Prescription to End Confusion. Washington, DC: The National Academies Press. https://doi.org/10.17226/10883
14. Berkman ND, Sheridan, SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: An updated systematic review. Ann Intern Med.