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Dysphagia on the Rise with Chemoradiation

The number one quality-of-life complaint in head and neck cancer survivors is difficult and/or painful swallowing, or dysphagia. As adoption of chemoradiation therapy for organ preservation increases, so has the incidence of treatment-associated dysphagia.

“We believe that the incidence of dysphagia for these patients is underreported, and I think that’s because a lot of people don’t ask about it,” said laryngologist Nausheen Jamal, MD, associate professor and chief of otolaryngology-head and neck surgery and associate dean for graduate medical education at the University of Texas Rio Grande Valley.

In Tuesday’s session “Strategies to Manage Chemoradiation-Associated Dysphagia,” panelists outlined the problem of dysphagia and presented several case studies to explain dysphagia presentation and treatment.

Dysphagia prevalence is reported in 31 to 81 percent of head and neck cancer survivors, Dr. Jamal said. Thirty to 40 percent of survivors were dependent on feeding tubes during treatment.

Radiation can cause both short- and long-term dysphagia. Short-term dysphagia develops because of acute inflammation; eventually that can develop into fibrosis and scarring. Chemotherapy combined with radiation tends to add to the injuries, especially in hypopharyngeal primary cancer, Dr. Jamal said. Patients with cancer in the oropharynx and nasopharynx also seem to have higher rates of dysphagia. Other risk factors include advanced-stage disease and high-dose radiation.

Patients can be assessed both with instrumental and non-instrumental swallow tests. Non-instrumental includes the bedside swallow test, observing patients as they eat and drink. During this test, otolaryngologists should look for abnormal or prolonged chewing, difficulty initiating swallowing, throat clearing or wet voice quality afterward, Dr. Jamal said. However, this is still considered a weak test, she said. Patients can aspirate silently and not feel it; they may not cough or clear their throats.

Instrumental techniques include fiberoptic endoscopic evaluation of swallowing (FEES), transnasal esophagoscopy (TNE), sensory testing, and an esophagram or other barium radiologic testing.

A multidisciplinary approach

Patients who participate in a swallow preservation protocol during and after treatment can improve swallow function, quality of life, and weight maintenance, Dr. Jamal said. Ideally, patients would be treated by a multidisciplinary team that includes head and neck surgery, laryngology, and speech-language pathology.

“As otolaryngologists, we can do a lot for them, but we can do even more if we’re working in a team,” Dr. Jamal said.

A team approach helps identify issues early and promotes collaborative assessment. If possible, it’s beneficial to evaluate patients in an interdisciplinary clinic, Dr. Jamal said. Patients who are evaluated by an otolaryngologist and a speech-language pathologist seem to have better adherence to their treatment recommendations.

By showing a patient how many people would be involved in her treatment, a care team at UC San Diego Health’s Moores Cancer Center was able to convince the patient to undergo treatment for her cancer—instead of going to Mexico for zinc and vitamin C infusions and a no-sugar diet.

The 67-year-old woman had a mass in her right tonsil and right lymph node metastasis. She was referred to radiology oncology and had pre-treatment sessions with a dietician and speech-language pathologist. When she was told the plan for concurrent radiation and chemotherapy, she balked. “Sometimes, [patients] cry or look concerned,” said Liza Blumenfeld, MA, CCC-SLP, a speech-language pathologist at Moores Cancer Center. “This woman abruptly looked at us and said, ‘No, I’m not doing this. I’m gonna go to Mexico.’”

The clinicians realized that the patient had read some patient horror stories about the treatment online. “She was worried that we were going to strip her of her quality of life,” Blumenfeld said. The patient thought she’d lose her hearing and ability to eat, among other things.

To mitigate her concerns, the clinicians explained to her how their multidisciplinary care pathway works. They showed her a spreadsheet they developed that outlines the role and timing of all the providers involved in her care, including a patient navigator, nurse practitioner, and dental oncologist.

“Just showing her this one busy piece of paper was really a very compelling, cogent argument that allowed her to then follow through with what we recommended in the first place,” Blumenfeld said.

 

Questions to ask patients about dysphagia

Otolaryngologists need to ask patients the right questions to tease out any swallowing issues. These include:

  • Where was your cancer?
  • What type of radiation did you have? What was your dosage?
  • When did you finish treatment?
  • Have you had any cases of pneumonia and how many?
  • Have you ever had a feeding tube and when?
  • Do you take anything by mouth?
  • What do you eat?
  • Are there any foods you avoid or have trouble swallowing?

 

Tests to assess swallowing problems

Non-instrumental

  • Bedside swallow test

Instrumental

  • Fiberoptic endoscopic evaluation of swallowing (FEES)
  • Transnasal esophagoscopy (TNE)

Sensory testing

  • Esophagram
  • Modified barium swallow study (MBSS) or video-fluoroscopic swallow study (VFSS)
  • Esophageal manometry