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2/19/2019 1 Dysphagia in Head and Neck Cancer Optimizing outcomes through standard pathways and evaluation protocols Kate A. Hutcheson, PhD Associate Professor Department of Head and Neck Surgery [email protected] MD Anderson Disclosures Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019) PCORI 1609-36195 NCI R01CA218148 NCI R03CA188162 NCI R01CA214825 NCI R21CA226200 NIDCR R01DE025248 MD Anderson Institutional Research Grant Program MD Anderson Survivorship Seed Monies Research Grant Program NCI CTEP NCORP Seed Monies Grant Program Charles & Daneen Stiefel MD Anderson Oropharynx Program Fund (PRO/Function Core) American Board Swallowing & Swallowing Disorders: non-financial MD Anderson Dysphagia is common in HNC Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019) Twoyear prevalence of dysphagia and related outcomes in head and neck cancer survivors: An updated SEERMedicare analysis (n=16,194, 2002 - 2011) Hutcheson KA, Lewis, CM, et al. Head Neck (e-pub 2019) multimodality single modality sx RT CRT SRT

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Page 1: 2019 Feb - Dysphagia HNC (Vanderbilt) handout€¦ · Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019) MD Anderson Dysphagia is top symptom associated with decisional

2/19/2019

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Dysphagia in Head and Neck CancerOptimizing outcomes through standard pathways and evaluation protocols

Kate A. Hutcheson, PhDAssociate Professor

Department of Head and Neck Surgery

[email protected]

MD Anderson

Disclosures

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

• PCORI 1609-36195

• NCI R01CA218148

• NCI R03CA188162

• NCI R01CA214825

• NCI R21CA226200

• NIDCR R01DE025248

• MD Anderson Institutional Research Grant Program

• MD Anderson Survivorship Seed Monies Research Grant Program

• NCI CTEP NCORP Seed Monies Grant Program

• Charles & Daneen Stiefel MD Anderson Oropharynx Program Fund (PRO/Function Core)

• American Board Swallowing & Swallowing Disorders: non-financial

MD Anderson

Dysphagia is common in HNC

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

Two‐year prevalence of dysphagia and related outcomes in head and neck cancer survivors: An updated SEER‐Medicare analysis

(n=16,194, 2002 - 2011)

Hutcheson KA, Lewis, CM, et al. Head Neck (e-pub 2019)

multimodality

single modality

sx

RT

CRT

SRT

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MD Anderson

Impact of dysphagia

Health QOL

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

Quality of life

r = 0.49 – 0.56, p<0.001(n = 72 OPC U Michigan swallowing-optimized IMRT trial)

Largest effect size of all toxicities (larger than xerostomia)

Hunter KU, Eisbruch A, et al. Int J Radiat Oncol Biol Phys (2013)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

Dysphagia is top symptom associated with decisional regret

Recursive partition with bootstrap re-sampling MDASI-HN symptoms by Decisional regret, (n=972, median 6Y disease-free survival time)

Goepfert, RP, Hutcheson KA, et al. Head Neck (e-pub 2017)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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MD Anderson

Aspiration pneumonia

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

SEER-Medicare2000-2009, n=3,513

chemoradiation for HNC

23.8% (5Y)

Xu B, Murphy JD, et al. Cancer (2014)

MD Anderson

Aspiration as source of late non-cancer deaths

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

n=116, 56% OPC, mean 33 mos FU

Szczesniak, MM, Cook, IJ, et al. Clin Oncol (2014)

MD Anderson

Dysphagia in HNC is complex….

Tumor• Site• Size

Patient• Age• Comorbidities• Psycosocial• Support• Function

Surgery• Approach• Site/size• Reconstruction

Radiation• Dose• Fields • Fractionation • Technique

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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MD Anderson

Distinct subsites

TNM staging

Different treatment modalities

Head & Neck CancerHead and neck cancer

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

What is the “Head & Neck”?

H&N

• “Upper aerodigestive tract”• Borders of the H&N:

• Superiorly: skull base• Inferiorly: trachea• Anteriorly: nose• Posteriorly: pharyngeal

wall

NOT H&N

• Esophagus• Cervical spine• Lungs• Trachea• Brain

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

Anatomic regions of H&N

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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Visualization of H&N Regions

a

dc

b

f

g

hi

a

h

e

i

b

d

f

e e

ih

g

Endoscopy Fluoroscopy

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

Key functions of the H&N region

Respiration

SwallowingSpeech

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

H&N structures: What are the functional correlates?

Larynx (voicebox)• supraglottis• glottis• subglottis

Oral Cavity (mouth)• oral tongue• floor of mouth• gums• mandible/maxilla• retromolar trigone• buccal / lip

Oropharynx (throat)• soft palate• tonsil• base of tongue• post pharyngeal wall

Hypopharynx (throat)• piriform sinuses• postcricoid region• post pharyngeal wall

Nasopharynx (throat)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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Review of CN functions

V• Sensory: hard/soft palate (V2), anterior tongue (V3)• Motor (V3): suprahyoid (anterior excursion), palate (VP closure), masticatory muscles

VII• Sensory: anterior tongue (taste)• Motor: labial, facial, posterior digastric (laryngeal elevation)

IX• Sensory: posterior tongue, faucial arches, oropharynx• Motor: stylopharyngeus

X• Sensory: SLN BOT, hypopharynx, supraglottis, glottis; RLN subglottis• Motor: pharynx, palate, intrinsic larynx, cricopharyngeus

XII• Motor: intrinsic & extrinsic tongue, hyolaryngeal excursion

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

12th most common malignancy (U.S.)

49,260 new cases 2010

11,000 deaths/year

Prevalence ~350K

>90% SCCA

Survival: 5-year ~60%

Head and neck cancer

Jemal A et al. CA Cancer J Clin (2010)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

Shifting epidemiology of HNC

↑ frequency of non-surgical organ preservationNCI SEER (2011)

Cooper JS, et al. Head Neck (2009)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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MD Anderson

HPV epidemic: impact on HNC incidence

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

HPV associated disease is different

Vidal & Gillison (2009)Chaturvedi AK, et al. JCO (2011)

Ang KK, et al. NEJM (2010)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

Primary site

http://www.nccn.org/professionals/physician_gls/pdf/head-and-neck.pdf

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Regional

http://www.nccn.org/professionals/physician_gls/pdf/head-and-neck.pdf

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

TNM Classification

T

(tumor)

Tumor size or extent of involvement

Varies some by site of primary tumor

TX: Primary tumor cannot be assessed

T0: No evidence of primary tumor

T1*: varies by site

T2*: varies by site

T3*: varies by site

T4*: varies by site, invades adjacent structures

*varies by site

N

(nodal status)Important predictor of survival

NX: Regional lymph nodes cannot be assessed

N0: No regional lymph nodes

N1*: Single ipsilateral node, ≤ 3 cm

N2a-c*: Single ipsilateral node 3-6 cm, or multiple nodes < 6 cm

N3*: >6cm (single or multiple)

Varies by site

M

(metastases) Rare at presentation (typically lung)

MX: Distant metastases cannot be assessed

M0: No distant metastases

M1: Distant metastases

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

AJCC Staging(non-NPC, non-OPC)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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MD Anderson

AJCC Staging, 8th edition (update)Oropharynx cancer

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

p16 (HPV) positive p16 (HPV) negative

Lydiatt, Patel, O’Sullivan, et al. Ca Cancer J Clin. (2017)

MD Anderson

Evolution of HNC treatment

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

1940 1950 1960 1970 1980 1990 2000Before1900

Surgery

Radiation Therapy

Chemotherapy

Biological Therapy (targeted therapy)

Courtesy of Dr. F. Christopher Holsinger

2010

Immunotherapy

MD Anderson

Single modality

Combined modality

Single versus Multi-modality

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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MD Anderson

Treatment options for oral cancers

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

• surgeryDefinitive

• Induction chemotherapy (preop)

• Postoperative radiation (± chemo)

Adjuvant

MD Anderson

Treatment options for oropharyngeal cancers

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

• radical surgeryHistorically

• Organ preservation (radiation/chemoradiation)1990’s

• Transoral surgery2000’s

• De-intensified RT (low-intermediate risk)

• Immunotherapy• Transoral surgery

2010’s

MD Anderson

Treatment options for oropharyngeal cancers

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

Current

Low-intermediate risk (HPV+) and

low T stage

Transoral surgery

RT +/- systemic

HPV- and advanced T stage

Chemoradiation(~70 Gy)

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MD Anderson

Treatment options for early laryngeal cancer

Single modality therapy

RT alone (narrow field)

SurgeryTLMS (laser)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

Treatment options for advanced laryngeal cancer

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

Multi-modality therapy

Laryngeal preservation ChemoRT (US standard)

Partial laryngectomy + PORT

Total laryngectomy+

PORT

MD Anderson

Treatment options for hypopharyngeal cancers

• RT ± chemo• eHNS – laser or robot

Early stage “larynx

preservation”

• Total laryngopharyngectomy• Postoperative RT ± chemo

Advanced stage

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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MD Anderson

Sources of dysphagia in HNC

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

Dysphagia in HNC is complex….

Tumor• Site• Size

Patient• Age• Comorbiditi

es• Psycosocial• Support• Function

Surgery• Approach• Site/size• Reconstruction

Radiation• Dose• Fields • Fractionation • Technique

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

Patient factors

Age• Sarcopenia • Frailty

Comorbidity Functional reserve

Psychosocial factors motivation, ability, adherence

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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Tumor-associated dysphagia

Primary site Lymph nodes

http://www.nccn.org/professionals/physician_gls/pdf/head-and-neck.pdf

T-stage

Site Volume Approach Closure Neck

Post‐surgical dysphagia

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

know what to look for

Managing postsurgical dysphagia

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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Surgical factors to consider

Surgical considerations Details that impact swallowing outcome

Location of resection • Normal function of structure(s)• Size defect (t-stage)• Adjacent structures

Approach • Open approach (transcervical, mandibulotomy)• Minimally invasive/transoral/endoscopic approaches

•Transoral laser microsurgery (TLM)• Transoral robotic surgery (TORS)

Closure • Healing by secondary intention• Primary closure (local suture)• Reconstruction:

• Regional flap• Free flap (plastic surgeon)

Neck dissection • Extent of ND• Levels (I-V)• Selective vs. radical

• Laterality (unilateral/bilateral)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

Partial glossectomy = RANGE OF MOTION

partial glossectomies + flaps: less ROM

partial glossectomies + 1° closure: betterROM

Healing by 2°intention: best ROM

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

(sub)Total glossectomy = bulk

Day of surgery 5 mos. postop

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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Protuberant

Semi-protuberant

Flat

Concave

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

Copyright © 2015 American Medical Association. All rights reserved.

From: Risk Factors Predicting Aspiration After Free Flap Reconstruction of Oral Cavity and Oropharyngeal Defects

Arch Otolaryngol Head Neck Surg. 2008;134(11):1205-1208. doi:10.1001/archotol.134.11.1205

Post-swallow aspiration residue Post-RT inefficiency BOT as “pump” (McConnel et al. Lscope 1988)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

Partial laryngectomy

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

post-cordectomy

post-vertical partial

post-supraglotticpost-supracricoid

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MD Anderson

Postop swallowing rehabilitation – a practical hierarchy

1. Saliva management

2. Re-introduce PO (safest, most efficient)MBS: rule out leak/assess safety (advanced-stage)

3. Increase volume of POmass practice

4. Increase complexity of PO

Hutcheson, KA, Lewin JS, In: HNC: Evidence-Based Treatment, Argiris, Ferris, & Rosenthal (2018)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

expect (and address) post-surgical edema

Postsurgical dysphagia

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

LymphedemaFunctional impact?

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

H&N Lymphedema Therapy ProgramIntensive Phase + home program

COMPLETE DECONGESTIVE TX1. Manual lymphatic drainage2. Compression therapy 3. Remedial exercise 4. Skin care

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

n=733

60% CDT responders

Adherence (p<0.001)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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Radiation-Associated Dysphagia “RAD”Safety Efficiency

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

“Organ preservation”Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

VA Laryngeal Cancer Study

68%68%64%

0

25

50

75

100

Larynx preservation Estimated 2-year survival

Pe

rce

nt

PF induction → RT (n=166)

Surgery + RT (n=166)

The Department of Veterans Affairs Laryngeal Cancer Study Group. N Engl J Med. 1991;324:1685.

Median follow-up = 2 years Median follow-up = 33 months

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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Laryngeal Preservation: RTOG 91-11%

P

R E

S E

R V

E D

0

25

50

75

100

YEARS FROM RANDOMIZATION0 1 2 3 4 5

ConcurrentInduction RT alone

88%

75%

69%

Induction vs Concurrent p= 0.0048Induction vs RT alone p= 0.27Concurrent vs RT alone p= 0.00012

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

51 studies

6,400 pooled patients

Compared 2 approaches:

• Surgery + PORT

• RT +/- chemotherapy

Equivalent survival and LRC

Complications in surgical group

Organ Preservation: OropharynxDefinitive surgery v. RT?

Parsons et al. Cancer (2002)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

The standard of care for organ preservation?

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

Chemoradiation

66-72 Gy

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MD Anderson

Organ preservation ≠ functional preservation

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

Radiation injury/toxicities

King SN, Pitts, T, et al. Dysphagia (2017)

Early

• Acute (<3M)• Subacute (3-6M)• Mucosal• Cell death• Inflammation

Late

• >3-6M• Deeper tissue• Vascular• Connective tissue• Salivary/oral

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

Toxicity GradingCommon Toxicity Criteria for Adverse Events (CTCAE)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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Patterns of Acute Toxiticies:MD Anderson Symptom Inventory (MDASI-HN)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

Gunn GB et al. Cancer (2014)

Patient‐reported symptoms during RT

MD Anderson

MBS PRO

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

Pharyngeal constrictor

dose>50 Gy

Laryngeal dose

>20-30 Gy

MD Anderson

Dale, Hutcheson, Fuller, et al MD Anderson Symptom Working Group. Head Neck (2016)

Floor of mouth (suprahyoid) muscle dose predicts RAD in OPC survivors (n=349)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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MD Anderson

Older patients tolerate less radiation dose to swallowing muscles before developing dysphagia

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

- Age: 70 – 79 - Age: 60 – 69 - Age: 50 – 59- Age: 40 – 49

Abbreviations: NTCP, normal tissue complication probability; ROIs, regions of interest; ADM, anterior digastric muscle; GGM, genioglossus muscle; IPC, inferior pharyngeal constrictor; ITM, intrinsic tongue muscle; MGM, mylo/geniohyoid muscles; MPC, middle pharyngeal constrictor; PDM, posterior digastric muscle; SPC, superior pharyngeal constrictors

Christopherson, Hutcheson, Fuller, et al MD Anderson Symptom Working Group. Unpublished (2019)

MD Anderson

Acute

(edema)

Chronic

(fibrosis)

Late

(denervation)

Dysphagia-Aspiration Related Structures (DARS): ↓ mobility

Eisbruch et al, IJROBP (2004)Hutcheson et al, Cancer (2012)

Early/ chronic

RAD

LateRAD

Pathophysiology RAD

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

RAD

MechanicsLaryngeal closure

Bolus push

Esophageal opening

Structure Edema

Defect

Stricture

Aspiration

Residue

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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MD Anderson

Dysphagia is not always stricture after RT

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

Wang, Goldsmith, et al. Head Neck (2012)

MD Anderson

Collaborative management: the esophagus

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

Rosenthal DI, Lewin JS, Eisbruch A. Prevention and treatment of dysphagia and aspiration after chemoradiation for head and neck cancer. J Clin Oncol 24(17):2636-2643, 6/2006.

MD Anderson

Gastroenterology (GI) or ENT/HNS

EGD w/ esophageal dilation:

• Bougie (“push”)

• Balloon dilation

• Rendevouz

Management of stricture

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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Esophageal dilation improves symptomatic stricture

- n = 41 HNC survivors

- ≥12M post RT NED

- Sham controlled RCT (EGD +/- dilation)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

Wu, P, Szczesniak M., Maclean J, et al. Disease Esophagus (2018)

75%76% 5%

Note: short term response rate in redStricture relapse rate = 50%

MD Anderson

When to suspect stricture

“Spit cup”

Can’t belch or vomit

High risk site + prolonged NPO

Solid-food dysphagia (sometimes)

Stricture: common symptoms

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

When to suspect stricture

Large volume liquid

AP (high density barium)

Oblique?

Pharyngeal function

Hyolaryngeal kinematics (frozen larynx?)

Stricture: evaluating on fluoro

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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MD Anderson

T2N1 SCCA Supraglottis 6M post chemoRTSternal recurrence 4M post re-RT

Pre-dilation Post-dilation

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

Lymphedema-Fibrosis continuum

n = 100 HNC with RTPre-RT to 18M post-RT

75% moderate-severe lymphedema47% grade ≥2 fibrosis

lymphedema external

lymphedema internal

fibrosis

Ridener SH, Murphy B, et al. Lymph Res Biol (2016)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

Lower cranial neuropathy (LCNP) as rare late effect of RT – 5% incidenceIX, X, XII nerves, median latency 8 years (n=59 IMRT OPC survivors)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

Hutcheson KA, et al. Head Neck (2017)

overall survival87% at 10 years

incidence LCNP5% (median FU 6 years)

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MD Anderson

Denervation source?

Chemotoxicity

Compressive (peripheral

axonal)

Brainstem nuclei

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

LCNP associated significantly worse cancer-related symptoms largest impact on swallow and voice/speech

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

n = 889 OPC survivors

Median 7 year survival time

4% incidence of LCNP

MD Anderson Symptom Inventory-Head and Neck Module (MDASI-HN) survey responses

Aggarwal P, et al. JAMA-Oto HNS (2018)

mucusswallowing

voice/speech

Late Dysphagia

“Late‐RAD”

Significant inefficiency

Refractory aspiration

Progressive dysfunction

Secondary pneumonia

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Late‐RAD

1 year 7 yearsPre‐RT

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

Acute

(edema)

Chronic

(fibrosis)

Late

(denervation)

Dysphagia-Aspiration Related Structures (DARS): ↓ mobility

Eisbruch et al, IJROBP (2004)Hutcheson et al, Cancer (2012)

LateRAD

Denervation (cranial neuropathy) common in late-RAD

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

LCNP associated with late functional decline

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

Hutcheson KA, et al. Head Neck (e-pub 2017)

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MD Anderson

MBS PRO

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

Pharyngeal constrictor

dose>50 Gy

Laryngeal dose

>20-30 Gy

MD Anderson

Dose-response varies over time

Christianen MEMC, Verdonck-de-Leeuw I, Langendijk JA, et al Radiotherapy Oncolog (2015)

Grade ≥2 Dysphagia (EORTC)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson Late-RADDose-dependent

n=38, (12 cases, 26 controls)

ROI:SPC, IPC,MPC

CP angleMedulla

Peripheral nerve tractFOMBOT

ParotidsLarynx

Palate (hard/soft)Retropharyngeal space

Intrinsic tongue

MVA adjusted for T-stage, total RT dose

Late RADCases: 70.5 Gy vs. Controls: 61.6 Gy

Lower cranial neuropathyCases: 71.1 Gy vs. Controls: 61.8 Gy

Awan MJ, Fuller CD, Hutcheson KA, et al, Oral Oncol(2014)

SPC mean dose

SPC mean dose

LCNPno LCNP

late-RADno late-RAD

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MD Anderson

Evolution of RAD

Acute“transient”

Chronic or persistent Late-onset

Edema Edema-fibrosis Fibrosis-neuropathy

High dose larynx High RT dose larynx, pharynx

Moderate dose upper pharynx

Goldsmith T & Jacobson M, Curr Opin Otolaryngol Head Neck Surg (2018)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

Evaluating dysphagia in HNC

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

What’s the pathophysiology?

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

Difficulty swallowing

SOLIDS

Poor propulsion (pharyngeal)

Stricture

Prep:

Mastication or saliva

Difficulty swallowing

LIQUIDS

Poor laryngeal (supraglottic)

closure

Residue

(propulsion v. stricture)

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MD Anderson

MDACC Swallowing Evaluation Protocol

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MBS• Efficiency• Penetration-aspiration• Pathophysiology

Patient-reported outcomes (PROs)• MDADI

Functional status scale• PSS-HN (Diet,

Eating in Public)

pre post

MD Anderson

Performance Status Scale – Head & Neck Cancer (PSS-HN)

Understand-ability of

Speech

• 100= Always understandable• 75= Usually understandable (occasional repetition)• 50= Sometimes understandable (face-to-face)• 25= Difficult to understand• 0= Never understandable

Normalcy of Diet

• 100= Full diet (no restriction)• 90= Full diet (liquid assist)• 80= All meat• 70= Raw vegetables• 60= Dry toast, cracker• 50= Soft, chewable• 40= Soft, nonchewable• 30= Pureed• 20= Liquid (warm)• 10= Liquid (cool)• 0= NPO

Eating in Public

• 100= No restriction (people, place, food)• 75= Restrict food in public• 50 = Certain people, certain places• 25 = At home, certain people• 0 = Always eats alone

• Clinician-rated

• Semi-structured interview

• 3-items

• NCCN recommended

• Best = 100, Worst = 0

• Don’t average the score

List M, et al. Cancer (1990)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

MD Anderson Dysphagia Inventory

Chen, A. et al. Arch Oto-HNS. (2001)

• 20-item PRO

• Scores:

• Best = 100

• Worst = 20

• 3 subscales:• Emotional

• Functional

• Physical

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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Quantifying MBS?

Function•Safety

•Efficiency

Pathophysiology•Kinematics

•Timing

Penetration/Aspiration Residue DIGEST

Leonard‐Kendall Logemann

Martin‐Harris (MBSImP) Pearson 

Steele (ASPEKT)Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP 

Course | 2019)

MD Anderson

Dynamic Imaging Grade of Swallowing Toxicity (DIGEST)

MBS tool: pharyngeal dysphagia severity (global)

5-point severity staging, CTCAE benchmarksgrade 0=none, 1=mild, 2=moderate, 3=severe, 4=life threatening/profound

Safety (Pen-Asp) x Efficiency (residue) interaction

For therapy profiling!

S3 E0 DIGEST3 versus S1 E3 DIGEST 3

Hutcheson KA, et al. (2017) Cancer

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

S0 S1 S2 S3 S4

E0

0 1 2 3 3

E1

1 1 2 3 3

E2

1 2 2 3 3

E3

2 2 3 3 4

E4

3 3 3 4 4

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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S0 S1 S2 S3 S4

E0

0 1 2 3 3

E1

1 1 2 3 3

E2

1 2 2 3 3

E3

2 2 3 3 4

E4

3 3 3 4 4

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

Dynamic Imaging Grade of Swallowing Toxicity (DIGEST)

MBS tool: pharyngeal dysphagia severity (global)

5-point severity staging, CTCAE benchmarks0=none, 1=mild, 2=moderate, 3=severe, 4=life threatening/profound

Safety (Pen-Asp) x Efficiency (residue) interaction

For therapy profiling! (ex: S1 E4 D3)

Hutcheson KA, et al. (2017) Cancer

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

DIGEST Grade 0

MD Anderson

Dynamic Imaging Grade of Swallowing Toxicity (DIGEST)

MBS tool: pharyngeal dysphagia severity (global)

5-point severity staging, CTCAE benchmarks0=none, 1=mild, 2=moderate, 3=severe, 4=life threatening/profound

Safety (Pen-Asp) x Efficiency (residue) interaction

For therapy profiling! (ex: S1 E4 D3)

Hutcheson KA, et al. (2017) Cancer

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

DIGEST Grade 0

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MD Anderson

Dynamic Imaging Grade of Swallowing Toxicity (DIGEST)

MBS tool: pharyngeal dysphagia severity (global)

5-point severity staging, CTCAE benchmarks0=none, 1=mild, 2=moderate, 3=severe, 4=life threatening/profound

Safety (Pen-Asp) x Efficiency (residue) interaction

For therapy profiling! (ex: S1 E4 D3)

Hutcheson KA, et al. (2017) Cancer

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

DIGEST Grade 1

MD Anderson

Dynamic Imaging Grade of Swallowing Toxicity (DIGEST)

MBS tool: pharyngeal dysphagia severity (global)

5-point severity staging, CTCAE benchmarks0=none, 1=mild, 2=moderate, 3=severe, 4=life threatening/profound

Safety (Pen-Asp) x Efficiency (residue) interaction

For therapy profiling! (ex: S1 E4 D3)

Hutcheson KA, et al. (2017) Cancer

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

DIGEST Grade 2

MD Anderson

Dynamic Imaging Grade of Swallowing Toxicity (DIGEST)

MBS tool: pharyngeal dysphagia severity (global)

5-point severity staging, CTCAE benchmarks0=none, 1=mild, 2=moderate, 3=severe, 4=life threatening/profound

Safety (Pen-Asp) x Efficiency (residue) interaction

For therapy profiling! (ex: S1 E4 D3)

Hutcheson KA, et al. (2017) Cancer

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

DIGEST Grade 3

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MD Anderson

Dynamic Imaging Grade of Swallowing Toxicity (DIGEST)

MBS tool: pharyngeal dysphagia severity (global)

5-point severity staging, CTCAE benchmarks0=none, 1=mild, 2=moderate, 3=severe, 4=life threatening/profound

Safety (Pen-Asp) x Efficiency (residue) interaction

For therapy profiling! (ex: S1 E4 D3)

Hutcheson KA, et al. (2017) Cancer

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

DIGEST Grade 4

MD Anderson

Other measures to consider: Oral Intake

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

Steele C, et al. Arch PMR (2018)

Level Description

Tube dependent

1 NPO

2 Tube dependent with minimal attempts of food or liquid

3 Tube dependent with consistent oral intake of food or liquid

Fully oral

4 Total oral diet of single consistency

5 Total oral diet of multiple consistencies, but requiring special preparations or compensations

6 Total oral diet with multiple consistencies without special preparation, but with specific food limitations

7 Total oral diet with no restrictions

Functional Oral Intake Scale (FOIS) IDDSI-Functional Diet Scale (IDDSI-FDS)

Crary M et al Arch PMR(1995)

MD Anderson

EAT-10

Sydney Swallow Questionnaire (SSQ)

SWAL-QOL

Other swallowing questionnaire options

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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MD Anderson

Tongue strength (MILS)

Mouth opening (MIO)

Cough (PCF)

Laryngoscopy

Adjunctive functional measures

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

Mucositis, odynophagia,

mucus↓ oral intake Disuse

atrophy?

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

Eat

Exercise

Use it or lose

it!

Preventive swallowing therapy

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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MD Anderson

Evidence for Proactive Swallowing Therapy: ExerciseStudy Outcomes

UAB Retrospective Superior MDADI (swallow-related QOL)1

Better BOT & epiglottic movement2

MDACC Retrospective Shorter duration PEG (OPC & HP)3

Adherence improves MDADI (swallow-related QOL)4

UF RCT Significant preservation muscle mass by MRI5

NKI RCT Improved mouth opening6

Mt Sinai RCT Superior diet levels (3-6M after CRT)7

Japan Retrospective Less aspiration8

Less PEG dependenceLess hospitalization

1. Kulbersh BD et al, Lscope (2006), 2. Carrol WR et al, Lscope (2008)3. Bhayani M et al, Head Neck (2013)4. Shinn E et al, Head Neck (2013)5. Carnaby-Mann G et al, IJROBP (2012)6. Van der Molen L et al, Dysphagia (2011)7. Kotz T et al, Arch Oto-HNS (2012)8. Ohba S et al, Head Neck (2014)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

Cochrane review (Perry, 2016) inconclusiveMeta-Analysis (Grecco, Martino, 2018) benefit

MD Anderson

Evidence for Proactive Swallowing Therapy: Eat

Gillespie B et al, Lscope (2004)

Part PO

NPO

End RT diet

MDADIscores ̅ 4.7± 3.4 yrs

100% PO

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

Langmore S et al, Dysphagia (2012)

MD Anderson

Use it or lose it:Eat and Exercise during Radiation (n=497, pharyngeal cancers 2002-2008)

Adherent58%

Non-adherent

42%

Fully PO40%

Partially PO34%

NPO26%

Eat

Exercise

Hutcheson, Bhayani, Beadle, Gold, Shinn Lai, Lewin.  JAMA‐OtoHNS (2013)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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MD Anderson

Use it or lose it study: EAT and Exercise are feasible during RT

MDACC retrospective review: Eat & Exercise during radiation (n=497, pharyngeal cancers 2002-2008)

Adherent58%

Non-adherent

42%Fully PO

40%

Partially PO

34%

NPO26%

EatExercise

Hutcheson, Bhayani, Beadle, Gold, Shinn Lai, Lewin.  JAMA‐OtoHNS (2013)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

Use it or lose it study: EAT and Exercise associated with greater chance of returning to regular diet long-termMDACC retrospective review: Eat & Exercise during radiation (n=497, pharyngeal cancers 2002-2008)

Hutcheson, Bhayani, Beadle, Gold, Shinn Lai, Lewin.  JAMA‐OtoHNS (2013)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

Use it or lose it: EAT and Exercise associated with shorter feeding tube dependenceMDACC retrospective review: Eat & Exercise during radiation (n=497, pharyngeal cancers 2002-2008)

Hutcheson, Bhayani, Beadle, Gold, Shinn Lai, Lewin.  JAMA‐OtoHNS (2013)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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mid-RT 6-8 weeks post end-

RT

3-6 monthspost end-RT

18-24 monthspost end-RT

5 yearspost end RT

PRE end-RT

Clinic Counsel exercise

Clinic H2O screen exercise

Clinic H2O screen exercise

Clinic CSE exercise

Clinic MBS FU

MDADI

MBS

MD Anderson Radiation Swallowing Pathway

MDADI

MBS

MDADI

MBS

MDADI

MBS

H&N cancer patients with cancers of oral cavity, larynx*, pharynx (OPC, NPC, or HP), or UPC dispositioned to receive bilateral neck RT ± chemo

*note: T1‐2 N0 TVF receiving narrow field excluded (unless age>80)

PSS-HN PSS-HN PSS-HN PSS-HN PSS-HN PSS-HN PSS-HN

Clinic MBS FU

Clinic MBS FU

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

Source: MD Anderson Cancer Center, Section Speech Pathology & Audiology

MD Anderson

Pathways work!

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

Dance Head and Neck PathwayGreater Baltimore Medical Center

Messing B, et al. Dysphagia (2018)

mid-RT 6-8 weeks post end-

RT

3-6 monthspost end-RT

18-24 monthspost end-RT

5 yearspost end RT

PRE end-RT

Clinic Counsel exercise

Clinic H2O screen exercise

Clinic H2O screen exercise

Clinic CSE exercise

Clinic MBS FU

MDADI

MBS

MD Anderson Radiation Swallowing Pathway

MDADI

MBS

MDADI

MBS

MDADI

MBS

H&N cancer patients with cancers of oral cavity, larynx*, pharynx (OPC, NPC, or HP), or UPC dispositioned to receive bilateral neck RT ± chemo

*note: T1‐2 N0 TVF receiving narrow field excluded (unless age>80)

PSS-HN PSS-HN PSS-HN PSS-HN PSS-HN PSS-HN PSS-HN

Clinic MBS FU

Clinic MBS FU

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

you are here

Source: MD Anderson Cancer Center, Section Speech Pathology & Audiology

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39

mid-RT 6-8 weeks post end-

RT

PRE end-RT

Clinic Counsel exercise

Clinic H2O screen exercise

Clinic H2O screen exercise

Clinic CSE exercise

MDADI

MBS

MD Anderson OPC and Radiation Swallowing Pathway

H&N cancer patients with cancers of oral cavity, larynx*, pharynx (OPC, NPC, or HP), or UPC dispositioned to receive bilateral neck RT ± chemo

*note: T1‐2 N0 TVF receiving narrow field excluded (unless age>80)

PSS-HN PSS-HN PSS-HN PSS-HN

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

Proactive exercise training

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

Mendelsohn Jaw/FOM stretch Supraglottic Masako Effortful

3 sets, 10 reps

Source: International Radiation Associated Dysphagia Working Group

MD Anderson

EAT – Eat All Through Radiation

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

EAT diet staircase (food hierarchy)

Mealtime routine

Source: International Radiation Associated Dysphagia Working Group

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40

mid-RT 6-8 weeks post end-

RT

3-6 monthspost end-RT

18-24 monthspost end-RT

5 yearspost end RT

PRE end-RT

Clinic Counsel exercise

Clinic H2O screen exercise

Clinic H2O screen exercise

Clinic CSE exercise

Clinic MBS FU

MDADI

MBS

MD Anderson Radiation Swallowing Pathway

MDADI

MBS

MDADI

MBS

MDADI

MBS

H&N cancer patients with cancers of oral cavity, larynx*, pharynx (OPC, NPC, or HP), or UPC dispositioned to receive bilateral neck RT ± chemo

*note: T1‐2 N0 TVF receiving narrow field excluded (unless age>80)

PSS-HN PSS-HN PSS-HN PSS-HN PSS-HN PSS-HN PSS-HN

Clinic MBS FU

Clinic MBS FU

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

Source: MD Anderson Cancer Center, Section Speech Pathology & Audiology

post RT

mid-RT 6-8 weeks post end-

RT

3-6 monthspost end-RT

18-24 monthspost end-RT

5 yearspost end RT

PRE end-RT

Clinic Counsel exercise

Clinic H2O screen exercise

Clinic H2O screen exercise

Clinic CSE exercise

Clinic MBS FU

MDADI

MBS

MD Anderson Radiation Swallowing Pathway

MDADI

MBS

MDADI

MBS

MDADI

MBS

H&N cancer patients with cancers of oral cavity, larynx*, pharynx (OPC, NPC, or HP), or UPC dispositioned to receive bilateral neck RT ± chemo

*note: T1‐2 N0 TVF receiving narrow field excluded (unless age>80)

PSS-HN PSS-HN PSS-HN PSS-HN PSS-HN PSS-HN PSS-HN

Clinic MBS FU

Clinic MBS FU

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

Source: MD Anderson Cancer Center, Section Speech Pathology & Audiology

If functional swallow:

“maintenance” education

MD Anderson

Maintenance exercise & education

Tips for Eating“You may feel solid foods stick abnormally in your throat while you eat. Although you may want to grab a drink to wash the food through the throat, try a hard, fast swallow instead to help clear the food. You may need to repeat this several times. It is good exercise for your throat when you swallow thick or heavy foods”

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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41

mid-RT 6-8 weeks post end-

RT

3-6 monthspost end-RT

18-24 monthspost end-RT

5 yearspost end RT

PRE end-RT

Clinic Counsel exercise

Clinic H2O screen exercise

Clinic H2O screen exercise

Clinic CSE exercise

Clinic MBS FU

MDADI

MBS

MD Anderson OPC and Radiation Swallowing Pathway

MDADI

MBS

MDADI

MBS

MDADI

MBS

H&N cancer patients with cancers of oral cavity, larynx*, pharynx (OPC, NPC, or HP), or UPC dispositioned to receive bilateral neck RT ± chemo

*note: T1‐2 N0 TVF receiving narrow field excluded (unless age>80)

PSS-HN PSS-HN PSS-HN PSS-HN PSS-HN PSS-HN PSS-HN

Clinic MBS FU

Clinic MBS FU

Biofeedback

If DIGEST ≥2:

Boot camp Device-

facilitated exercise

Biofeedback

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

Dysphagia Therapies

1980’s 1990’s 2000’s

Compensations

ExercisesBiofeedback Electrical

stimulation

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

Electrical stimulation for RAD?

R01 funded multi‐site RCT:• “Chronic” RAD (≥3 months post RT or CRT)• 2 arms:

– Swallow exercise & stretching + NMES– Swallow exercise & stretching + sham NMES

• 3 month intensive home program– BID, 6 days/week

Primary aim: NS effect NMES

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Efficacy of popular therapies for RAD

“home program therapies”

Persistent RAD is DIFFICULT to fix!

Secondary analyses NMES trial

• Efficacy home exercise:– Significant (small) gains diet, QOL

– NS effects MBS detected OPSE, PAS, hyoid excursion

• Time-dependent effects:

– >10 yrs post• Worst pre-therapy swallows

• Progressive deterioration despite therapy

– Threshold @ 2 years?

Langmore, Kriscuinas, et al. DRS (2015)

Limitations of home program

Static program (lack progression)

Rely solely on patient adherence

Low intensity

More structured and progressive swallowing therapy programs needed!

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

stimulate biofeedback

electrical stimulationBiofeedback assisted skill

trainingTongue press

“e-stim”“NMES”

“Vital Stim”“AmpCare”

resistance

“IOPI”“iPRO – Swallow Strong”

“RST”“bioFEESback”

“HRM”“sEMG”

strength skill

Expiratory training

“”EMST”

More intensive options for persistent/chronic/late dysphagia

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

stretch

mobility

ROM exerciseManual therapy

Myofascial release

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MD Anderson

Skill/strength training“Boot Camp”

McNeil

EFFICIENCY

Skill training

“RST”

Resp Pattern

SAFETY

Strength training

“EMST”

Exp M. Strength

SAFETY

Manual“MFR”

Myofascial release

MOBILITY

More intensive swallowing therapies for persistent/chronic/late dysphagia

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson Swallowing BOOT CAMP

Progressive resistive functional exercise program

sEMG Biofeedback“device-driven”

MDTP“bolus- driven”

“Mass practice”

Intensive, daily

QD or BID

2-3 weeks

FUNCTIONAL task = swallowing

Intensifies over time = progressive, resistive swallowing (exercise) paradigm

Home carry-over (min 6-8 wks)

MD Anderson

MDACC Boot Camp Experience

sEMG and/or MDTP (n=29)

Global Composite Emotional Physical Functional20

40

60

80

Me

an M

DA

DI

sco

res

Pre

PrePrePre

Pre

PostPost

PostPost Post

   

{p=.05 {

{

{

{p=.12

p=.08

p=.21

p=.22

Pre-Post MDADI Scores. Mean MDADI scores pre-post boot camp swallow therapy. Global MDADI significantly improved (Δ+11.1, p=0.049)

Pre-Post Pen-Asp Scores. Penetration aspiration scale scores pre-post boot camp (Δ0, p=0.999)

QOL improves(efficiency)(adaptation)

Aspiration persists

Hutcheson, Kelly, Barrow, Barringer, Perez, Little, Weber, Lewin. COSM 2014

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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MD Anderson

Airway protection

Downstream targets respiratory system?

Respiratory pattern training (Martin-Harris, 2014)

Expiratory muscle strength training - EMST (Sapienza, 2009)

Keep eating

Avoid pneumonia

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

Therapeutic target = airway protection

Adjustable spring-loaded expiratory valve

CLEARANCE: expiratory force

AIRWAY CLOSURE: hyolaryngeal lift

PUMP: velopharynx

Expiratory Muscle Strength Training (EMST)

Hutcheson K, et al. Laryngoscope. (2017)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)swallows

EMST exercise

MD Anderson

Expiratory Muscle Strength Training (EMST)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

Hutcheson K, et al. Laryngoscope (2017)

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MD Anderson

Maximum expiratory pressures significantly improve after EMST in post-RT HNC aspiratorspre-post 8 weeks of EMST (5-5-5, 75% individualized MEP, n=23)

57%↑, p<0.001

Hutcheson K, et al. Laryngoscope (2018)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

MBS resultsDIGEST safety profiles significantly improve after 8 weeks EMST (n=23)

Hutcheson K, et al. Laryngoscope. (2018)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

Less frequent or better cleared aspiration post-EMST

“no longer running to bathroom to regurgitate my food at restaurants”

“cough is stronger”

“less mucus in my throat”

“I bought the trainer for friends in my support group”

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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MD Anderson

Integration of Manual Therapy into Speech and Swallow Rehabilitation Program for Head and Neck Cancer: A Case Series (n=15)

15 HNC survivors; 59 combined MT sessions

RT ±surgery or chemotherapy

Primary endpoint: cervical range of motion (CROM)

Secondary outcomes: functional status interview

Lewin JS, Woodall HE, Porsche CB, Barrow MP, Hutcheson KA (2017, MDACC unpublished)

SexFemaleMale

2 (13%)13 (87%)

Age, median (range) 67 (53-79)

Survival time, median mos. (range)

98 (2-192)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

All 15 improved CROM

CROM significantly improved >10º on avg after one session

80% pts improved 4 planes, 60% in 5 planes

Lewin JS, Woodall HE, Porsche CB, Barrow MP, Hutcheson KA (2017, MDACC unpublished)

CROM significantly improved after single session

“lift your head as high as you can”

CROM extension

-2°

CROM extension

-50°

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

Myofascial release

Massage

Passive and Active ROM

Manual Therapy for Fibrosis-Related Late Effect Dysphagia in Head and Neck Cancer Survivors: The Pilot MANTLE trial (2018-0052, NCI R21CA226200)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

HNC survivor >2Y post-RT with late-

RAD

CROMMBSMRIPROs

Pre-MT

Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6

CROMMBSMRIPROs

Post-MTmanual therapy

6 weeks home

practice

washout

CROMMRIPROs

Post-washout

“lift your head as high as you can”

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MD Anderson

EVALUATION CONSENSUS

Therapy phase 1:

Optimize pre-boot camp

Therapy Phase II:

“Boot Camp”

MD Anderson’s work flow for implementing “Boot Camp”

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

Good therapy starts with comprehensive evaluationMDACC Swallowing Evaluation Standard

MBS• Efficiency• Penetration-aspiration• Pathophysiology

Patient-reported outcomes (PROs)• MDADI

Functional status scale• PSS-HN (Diet,

Eating in Public)

pre post

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

DIGEST

Hutcheson KA, et al. (2017) Cancer

MBS tool (pharyngeal dysphagia)

5-point severity staging

CTCAE benchmarks0=none, 1=mild, 2=moderate, 3=severe, 4=life threatening/profound

Safety (Pen-Asp) x Efficiency (residue) interaction

FOR BOOT CAMP profiling! (ex: S1 E4 D3)

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MD Anderson Evaluation…

Other data you need to plan boot camp

Treatment history – time post treatment

Disease status

Pneumonia history

Cranial nerve examination

Trismus

Wound issues/pain control (radionecrosis, ulcers, mucositis)

Prior therapy (and response)

Goal (priority!)

MD Anderson

Checklist for swallowing boot camp planning

Evaluation results:MBS date: __ / __ / __DIGEST grade: __ overall __safety __efficiencyMBS pathophysiology:PSS-HN diet:Tube status:MIO:Cranial nerve function:

Optimization phase: Dilation Botox VC medialization Therabite/jaw ROMManual therapy IOPI/lingual strengthening EMST Dental rehab (specify:_____)

Functional therapy phase (boot camp): McNeil Dysphagia Therapy Program (start level:

______) sEMG biofeedback swallows bioFEESback

History: Age: Comorbidity: HNC details: Pneumonia history: Prior swallowing therapy: Patient’s goal:

Candidacy: Cancer free Free active tissue issue (mucositis, ulcer, untreated ORN) Minimal/no oropharyngeal pain

History & evaluation Therapy plan

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

Checklist for swallowing boot camp planning

Evaluation results:MBS date: __ / __ / __DIGEST grade: __ overall __safety __efficiencyMBS pathophysiology:PSS-HN diet:Tube status:MIO:Cranial nerve function:

Optimization phase: Dilation Botox VC medialization Therabite/jaw ROMManual therapy IOPI/lingual strengthening EMST Dental rehab (specify:_____)

Functional therapy phase (boot camp): McNeil Dysphagia Therapy Program (start level:

______) sEMG biofeedback swallows bioFEESback

History: Age: Comorbidity: HNC details: Pneumonia history: Prior swallowing therapy: Patient’s goal:

Candidacy: Cancer free Free active tissue issue (mucositis, ulcer, untreated ORN) Minimal/no oropharyngeal pain

History & evaluation Therapy plan

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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MD Anderson

Checklist for swallowing boot camp planning

Evaluation results:MBS date: __ / __ / __DIGEST grade: __ overall __safety __efficiencyMBS pathophysiology:PSS-HN diet:Tube status:MIO:Cranial nerve function:

Optimization phase: Dilation Botox VC medialization Therabite/jaw ROMManual therapy IOPI/lingual strengthening EMST Dental rehab (specify:_____)

Functional therapy phase (boot camp): McNeil Dysphagia Therapy Program (start level:

______) sEMG biofeedback swallows bioFEESback

History: Age: Comorbidity: HNC details: Pneumonia history: Prior swallowing therapy: Patient’s goal:

Candidacy: Cancer free Free active tissue issue (mucositis, ulcer, untreated ORN) Minimal/no oropharyngeal pain

History & evaluation Therapy plan

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

Optimization Phase

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

Dilation Botox VC medialization Therabite/jaw ROMManual therapy IOPI/lingual strengthening EMST Dental rehab (specify:_____)

MD Anderson

Checklist for swallowing boot camp planning

Evaluation results:MBS date: __ / __ / __DIGEST grade: __ overall __safety __efficiencyMBS pathophysiology:PSS-HN diet:Tube status:MIO:Cranial nerve function:

Optimization phase: Dilation Botox VC medialization Therabite/jaw ROMManual therapy IOPI/lingual strengthening EMST Dental rehab (specify:_____)

Functional therapy phase (boot camp): McNeil Dysphagia Therapy Program (start level:

______) sEMG biofeedback swallows bioFEESback

History: Age: Comorbidity: HNC details: Pneumonia history: Prior swallowing therapy: Patient’s goal:

Candidacy: Cancer free Free active tissue issue (mucositis, ulcer, untreated ORN) Minimal/no oropharyngeal pain

History & evaluation Therapy plan

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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MD Anderson Swallowing BOOT CAMP

Progressive resistive functional exercise program

sEMG Biofeedback“device-driven”

MDTP“bolus- driven”

“Mass practice”

Intensive, daily

QD or BID

2-3 weeks

FUNCTIONAL task = swallowing

Intensifies over time = progressive, resistive swallowing (exercise) paradigm

Home carry-over (min 6-8 wks)

MD Anderson

Biofeedback driven BOOT CAMPsurface electromyography (sEMG)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

Reading amplitude of muscle activity (through skin)

Not stimulating contractions

Work at % of max, increase over time

With or without bolus

MD Anderson

Swallow “form”

Volume

Viscosity

Bolus-Driven Boot Camp

McNeill Dysphagia Therapy Program (MDTP)

Mass practice

Food hierarchy

Strengthening & coordination

Carnaby-Mann & Crary. Arch PMR (2008)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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MD Anderson

Device-driven(sEMG

biofeedback)

Bolus-driven

(McNeill“MDTP”)

Tube removal 27% 67%

Dysphagia recovery (per FOIS) 12% 75%

Continued aspiration

62% 35%

Comparing functional therapy options for boot camp

N=24

Chronic dysphagia (>6M)

75% HNC

Short-term outcomes assessment (end therapy)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

T2 N2 NPC

9 year survivorFlight attendant

chemoIMRT(70 Gy/33 fx, cis 100mg/m2)

Maintaining weightModerate dysphagia (DIGEST 2)

S0 E3 D2↓

Mild dysarthriaTongue “fatigue”

No pneumonia

MDADI = 55

PSSHN = 50

CN examhemitongue paresis, atrophy, fasciculation

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

Post‐boot camp (MDTP)5‐months later

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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MD Anderson

To my hero,

You make a difference! I came here 3 weeks ago with a life that was all but over. Yes, the cancer was gone but the inability to swallow/eat left me with a very shallow, empty life. All that is now changed. You didn’t give me a silver bullet, but rather you gave me the courage to try to take baby steps, to believe in miracles, the impossible. No, eating is not the same, but it is manageable. Thank you so much for your training, wisdom, knowledge, dedication, kindness, compassion, but most importantly your passion for serving and helping to heal others. You are a good woman! I pray nothing but the best for you in the future.

You make a difference!

Reflections on boot camp for late-RAD

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

https://www.cancer.org/health-care-professionals/american-cancer-society-survivorship-guidelines/head-neck-cancer-survivorship-care-guidelines.html

Xerostomia

Caries

ORN

Carotid stenosis

Hypothyroidism

Musculoskeletal

Dysphagia

Stricture

Pneumonia

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

Interdisciplinary considerations

Veteran’s Affairs Interdisciplinary Clinical Demonstration Project:

SLP therapy (device assisted tongue strengthening exercise)

Pulmonary monitoring (ID nurse practioner)

Nutrition monitoring (RD)

↓ hospital admission (56%, 7.3 mean bed days, $2.1M)

↓ pneumonia diagnoses (67%, 0.43 HR)

Rogus-Pulia N, Robbins J, et al. JAGS (2017)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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MD Anderson

Doing more for oral care?

A meta-analysis could only be done on 4 trials; this analysis showed a significant risk reduction

in pneumonia through oral care interventions(RRfixed, 0.61; 95% CI, 0.40-0.91; P=.02).

Kaneoka A, Pisegna J, Miloro K, Lo M, Saito H, Riquelme L, Langmore S. Inf Control Hosp Epi (2017)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

What about late-RAD?

Late-RAD responds poorly to “traditional” rehab?Traditional rehab = home program exercise ± dilation

Hutcheson KA, et al. Cancer (2014)

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson

Late-RAD: aspiration pneumonia

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

Hutcheson KA, et al. Cancer (2012)

86%

aspiration pneumonia rate in late-RAD cases (25/29 cases)

52% hospitalized 14% intubated/trach

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MD Anderson

“I cannot fix this”

Evaluation:• Videofluoroscopy MUST (>90% silent aspirators)• Cranial nerve exam prefer endoscopy• Manometry

Management:• Avoid pneumonia• Avoid NPO • Strategies, strategies, strategies biofeedback (FEES)• Myofascial release• “Home exercise” = not enough

Late-RAD

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

MD Anderson What else?

…elective TL

MD Anderson

100% resumed PO

74% regular or soft

70% TEP among whom, 88% successful

Considerations:

• Pre-TL function: CN exam, stricture, trismus

• Extent TL: flap?

Yes, you eliminate aspiration, but how do they function?

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)

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MD Anderson

• Dysphagia in HNC is common and complex

• Not all HNC impacts swallowing function similarly

• Standardized evaluation protocol and pathways offer a framework to optimize care

• Be pro-active use it or lose it

• Consider intensive, multi-disciplinary paradigms for persistent/chronic or late onset dysphagia

Conclusions

Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)