Radiotherapy for cutaneous head and neck cancer and parotid tumours: a prospective investigation of treatment-related acute swallowing and toxicity patterns.

PURPOSE: Reports of acute treatment-related dysphagia and toxicities for patients with parotid tumours or cutaneous head and neck cancer (HNC) are limited. This study aimed to describe the severity and timing of dysphagia and related toxicities experienced during radiotherapy for cutaneous HNC and parotid tumours, to inform the nature of future speech pathology (SP) service models required during treatment. METHODS: Prospective study of 32 patients with parotid tumours and 36 with cutaneous HNC undergoing curative non-surgical management. Dysphagia and acute toxicity data was collected weekly during treatment and at 2, 4 and 12 weeks post-treatment using the Functional Oral Intake Scale, diet descriptors and CTCAE v4.0. RESULTS: In both groups, minimal treatment toxicities (grades 0-1) were observed. Xerostomia and dysgeusia were the most frequently reported grade 2 toxicities. Only 3% of parotid patients and 6% with cutaneous HNC experienced grade 3 dysphagia. Full or soft texture diets were maintained by > 70% of patients in both groups. Symptoms peaked in the final week of treatment and rapidly improved thereafter. Apart from xerostomia < 10% of patients had any grade 2 toxicity at 12 weeks post-treatment. CONCLUSION: Patients in these subgroups of HNC experienced minimal treatment-related toxicity during radiotherapy. As such, the need for supportive symptom management by SP is low. Models that involve interdisciplinary surveillance of symptoms with referral to SP only when required may be best suited for these individuals to ensure issues are identified whilst minimising patient burden created by unnecessary routine SP appointments.

UK survey of clinical consistency in tracheostomy management.

BACKGROUND: Many speech and language therapists (SLTs) work with patients who have a tracheostomy. There is limited information about their working practices and the extent to which recent publications and research have influenced the speech and language therapy management of the tracheostomized patient. AIMS: This study reviews the current patterns of clinical practice for SLTs in the management of adult tracheostomized patients in the UK. METHODS & PROCEDURES: An online questionnaire was completed by 106 SLTs with prior experience in tracheostomy management. The information from this was explored to determine patterns of practice across various areas of speech and language therapy tracheostomy management including clinical roles and responsibilities, management of communication disorders, and assessment and management of dysphagia and decannulation. These clinical patterns were then examined with respect to the current literature, emerging patterns in evidence-based practice and national practice guidelines. OUTCOMES & RESULTS: The results indicate a moderate to high level of clinical consistency in the majority of areas evaluated across the scope of tracheostomy management in speech and language therapy. Consistency in practice areas such as increased utilization of instrumental assessments and conservative use of the Modified Evans Blue Dye Test indicate clinical application in line with current research. Limited clinical consensus or inconsistencies in evidence-based services were identified in aspects of practice that are supported by conflicting or emerging research evidence. Such areas include involvement in cuff deflation regimes, adoption of specific decannulation procedures and participation in multidisciplinary team management. CONCLUSIONS & IMPLICATIONS: SLTs in the UK provide a moderate to high level of consistent practice in tracheostomy management. This study identifies areas of tracheostomy management that require further research in order to establish clinical practice guidelines and to address discrepancies between research evidence and clinical implementation.

Post-laryngectomy pulmonary and related symptom changes following adoption of an optimal day-and-night heat and moisture exchanger (HME) regimen.

BACKGROUND: This study examined post-laryngectomy pulmonary and related symptom changes following establishment of an optimal day/night regimen (all day/night wear of devices with improved humidification) using a new generation range of heat and moisture exchanger (HME) devices. METHODS: In Phase 1 (6 weeks), 42 post-laryngectomy HME users transitioned from their usual HME regime to equivalent new device/s (i.e., "like-for-like"). In Phase 2 (6 weeks) participants used the full range of HMEs to achieve an optimal day/night regimen. Pulmonary symptoms, device use, sleep, skin integrity, quality of life and satisfaction were examined at baseline, and weeks 2 and 6 of each Phase. RESULTS: From baseline to end of Phase 2, cough symptoms and impact significantly improved, as did sputum symptoms, sputum impact, duration and types of HMEs used, reasons for HME replacement, involuntary coughs, and sleep. CONCLUSION: The new HME range supported improved HME use, with pulmonary and related symptom benefits.

Preparation, clinical support, and confidence of speech-language therapists managing clients with a tracheostomy in the UK.

BACKGROUND: Literature regarding the education, training, clinical support and confidence of speech-language therapists (SLTs) working with patients with a tracheostomy is limited; however, it suggests that many clinicians have reduced clinical confidence when managing this complex population, many face role and team challenges practising in this area, and most are seeking more opportunities for professional development and training. AIMS: To investigate the education, training, clinical support and confidence of SLTs in the UK who manage patients with a tracheostomy in order to identify current challenges and inform the future clinical training needs of this professional group. METHODS & PROCEDURES: Via an online survey, the clinical training, clinical support and confidence of SLTs with more than one year of clinical experience was examined. A total of 106 SLTs from the UK completed the survey. Within the questionnaire, clinicians were also asked to identify if their workplace had a tracheostomy competency training programme (CTP) to allow further exploration of the preparation, clinical support and confidence of respondents with (43% of respondents) and without (32% of respondents) a CTP. OUTCOMES & RESULTS: Most SLTs (71%) were confident managing patients with a tracheostomy. The majority were accessing professional development and receiving expert support, though many identified specific areas where more support and training was needed. Less than half the group felt up to date with the current evidence. Only 35% of clinicians felt they worked in an optimal team for tracheostomy management, and poor recognition of the role of the SLT in managing dysphagia in patients with a tracheostomy was an issue for many clinicians, particularly on more general care wards. SLTs in workplaces with a CTP were found to have received significantly more expert support, on-the-job training, access to evidence-based practice and were significantly more confident in managing ventilator-assisted patients. CONCLUSIONS & IMPLICATIONS: SLTs are eager to access further professional development and training; however, such training needs to target specific areas of need. The significant difference in the preparation, support and confidence of SLTs with CTPs in their workplace highlights potential benefits that can be achieved through workplace training and support.

Helical intensity-modulated radiotherapy with concurrent chemotherapy for oropharyngeal squamous cell carcinoma: A prospective investigation of acute swallowing and toxicity patterns.

BACKGROUND: Conformal radiotherapy modalities may minimize treatment toxicities. The purpose of this study was to document the extent and timing of dysphagia and related toxicities during helical intensity-modulated radiotherapy (IMRT) with chemotherapy for oropharyngeal squamous cell carcinoma (SCC). METHODS: We conducted a prospective study of 76 patients with oropharyngeal SCC undergoing helical IMRT with chemotherapy. Dysphagia and acute toxicity data were collected weekly during treatment and at 2, 4, and 12 weeks posttreatment using the Functional Oral Intake Scale, diet descriptors, and Common Terminology Criteria for Adverse Events (CTCAE) version 4.0. RESULTS: Patients experienced maximum incidence of grade 3 dysphagia (61%), mucositis (30%), and thick saliva (38%), with grade 2 xerostomia (87%) and dysgeusia (97%). Only 14.5% were nil-by-mouth. Symptoms peaked in week 7 and improved thereafter. Grade 3 dysphagia was twice as common for T3 to T4 tumors compared with T2. CONCLUSION: Results confirm that patients with oropharyngeal SCC undergoing helical IMRT with chemotherapy continue to experience incidences of acute toxicities comparable with other conformal techniques, and need supportive cares.

Patterns of dysphagia and acute toxicities in patients with head and neck cancer undergoing helical IMRT±concurrent chemotherapy.

BACKGROUND: There is limited prospective data reporting the extent of treatment related toxicities associated with helical Intensity Modulated Radiotherapy (H-IMRT) for head and neck cancer (HNC). The study aim was to investigate severity, peak incidence and recovery patterns of dysphagia and related toxicities in patients undergoing H-IMRT±chemotherapy to examine when patients are experiencing symptoms requiring supportive clinical care. METHODS: Prospective study of 212 patients undergoing H-IMRT. Dysphagia and associated acute toxicities were monitored weekly during treatment and at weeks 2, 4 and 12 post treatment using the CTCAE v4, Functional Oral Intake Score and National Dysphagia Diet Descriptors. RESULTS: 75% experienced Grade 2-3 dysphagia. Over 70% had grade 2-3 dysguesia, xerostomia, and thick saliva, and >50% experienced grade 2-3 pharyngeal mucositis, oral mucositis, and nausea. 13% patients declined to NBM requiring complete enteral nutrition, 25% required enteral nutrition but maintained some form of oral intake. Symptoms peaked in final week of treatment, consistently improving thereafter, with the majority better than baseline by 12 weeks post-treatment. Concurrent chemotherapy at least doubles the odds of experiencing most symptoms excepting xerostomia, taste and fluid level. CONCLUSION: Despite advancements in radiation techniques, results confirm a high proportion of HNC patients experience dysphagia and related toxicities requiring supportive care during H-IMRT. Patients receiving H-IMRT alone experience a lower incidence of symptoms compared with those receiving concurrent chemotherapy. The data confirms the ongoing need for active on treatment monitoring with implications for the timing and intensity of patient support services.

Improving guideline sensitivity and specificity for the identification of proactive gastrostomy placement in patients with head and neck cancer.

BACKGROUND: Swallowing and nutrition guidelines for patients with head and neck cancer are available for identification of proactive gastrostomy placement in patients with high nutritional risk. The purpose of this study was to investigate improvements to the validity of these guidelines. METHODS: A multivariate analysis was fitted to the original dataset (n = 501) to examine the variables that may predict gastrostomy placement (eg, tumor site, treatment, sex, and age). Using these factors, the high risk category was modified and retrospectively validated in the same cohort to provide new measures of sensitivity and specificity. RESULTS: The following were positive predictors of gastrostomy placement: T3 (p = .01), T4 (p < .001), and chemoradiotherapy (p < .001). Laryngeal (p = .02) and skin cancer (p < .001) were negative predictors. Modification of the high risk definition improved sensitivity to 58% and maintained specificity at 92%. CONCLUSION: Minor modifications to the high risk definition in the guidelines have improved the guideline sensitivity for future use. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1163-E1171, 2016.

Swallowing outcomes and PEG dependence in head and neck cancer patients receiving definitive or adjuvant radiotherapy +/- chemotherapy with a proactive PEG: a prospective study with long term follow up.

OBJECTIVES: This study examined long term swallowing outcomes of a cohort of head and neck cancer (HNC) patients identified at high risk of experiencing significant side effects from cancer treatment and were provided with a proactive PEG. MATERIAL AND METHODS: Ninety-five HNC patients receiving definitive or adjuvant radiotherapy +/- chemotherapy were identified for proactive PEG placement using validated guidelines and followed for up to 3years. Functional swallowing status was recorded at regular time points and data were collected on PEG use and duration in situ. RESULTS: Mean duration of enteral feeding was 125days. PEGs remained in situ for approximately 7months. PEG removal was achieved by 52% by 6months and 86% by 1year. Only 3 (3%) remained PEG dependent at 3years. Over half (55%) had resumed a full non-texture modified diet by PEG removal. CONCLUSION: Proactive PEG placement did not lead to high proportion of long term tube dependence in this high risk group and the majority achieved good swallowing outcomes.

Decreased hospital stay and significant cost savings after routine use of prophylactic gastrostomy for high-risk patients with head and neck cancer receiving chemoradiotherapy at a tertiary cancer institution.

BACKGROUND: Evidence-based nutritional and swallowing guidelines were developed to identify patients at high risk of developing malnutrition during chemoradiation for head and neck cancer. These guidelines recommended a prophylactic gastrostomy and were actively implemented at our institution in January 2007. This study assesses the effect of this policy change on patient outcomes. METHODS: This retrospective cohort study was carried out for the years before (2005) and after (2007) implementation of these guidelines. RESULTS: In all, 165 patients were treated with radical chemoradiation for head and neck cancer at our institution in the years 2005 and 2007. Gastrostomy tube complications were low. Patients in 2007 had significantly fewer hospital admissions, unexpected admissions, and a shorter mean duration of hospital stay in comparison with those in 2005. CONCLUSIONS: Prophylactic gastrostomy tubes in patients with high-risk head and neck cancer resulted in a significant decrease in hospital admissions and length of stay, and led to increased bed availability.

Validated swallowing and nutrition guidelines for patients with head and neck cancer: identification of high-risk patients for proactive gastrostomy.

BACKGROUND: The "Swallowing and Nutrition Guidelines for Patients with Head and Neck Cancer" were developed to guide early identification and management of dysphagia and nutritional risk before, during, and after cancer treatment. The purpose of this study was to validate these guidelines. METHODS: Patients attending a Combined Head and Neck Clinic at a major tertiary hospital in 2007 to 2008 were assessed using the guidelines, with high-risk category patients recommended for proactive gastrostomy. Data were collected on guideline adherence, gastrostomy tube insertion, and weight. Sensitivity, specificity, and positive predictive value were calculated for validation. RESULTS: Proactive gastrostomy tubes were inserted in 173 of 501 patients (25%). Overall guideline adherence was 87%. High-risk category adherence was 75%. Validation outcomes were sensitivity 54%, specificity 93%, and positive predictive value 82%. CONCLUSION: The risk categories in the guidelines are valid to assist early identification of swallowing and nutritional risk and guide decision-making on proactive gastrostomy tube insertion.