Innovations in Radiation Therapy Part B
The Head & Neck Cancer 2020 Innovations Video Series is brought to you by St Vincent’s Hospital Sydney & The Kinghorn Cancer Centre. In this episode we talk to speech pathologist Therese Dodds about innovations in treatment for head & neck cancer patients who have radiation therapy, including to manage swallowing problems. For more information please visit our website or our You Tube channel. The podcast versions can be found on our SoundCloud channel.
Julie McCrossin, Head & Neck Cancer Survivor
Therese Dodds, Speech Pathologist, St Vincent’s Private Hospital Sydney. Director, Eastern Suburbs Speech Pathology.
Well welcome back to this video on innovations in radiation therapy. We’ve just heard from Dion Forstner all about the perspective of a radiation oncologist and now it gives me great pleasure to welcome a speech pathologist. Can you introduce yourself and give us a sense of your experience, particularly with head and neck cancer patients?
So my name is Therese Dodds. I’m a speech pathologist with 15 years of experience in fact, working in head and neck oncology. I’ve spent time working across both the public and the private sectors. At the moment you’ll find me working through my private clinic Eastern Suburbs Speech Pathology, which has a lovely partnership with GenesisCare. We do a lot of work in Darlinghurst, Hurstville and also here at Concord. In addition to that, we look after the service for St Vincent’s Private Hospital Sydney,
And for the totally uninitiated, when you’re dealing with head and neck cancer patients who’ve had radiation therapy, and I realized they may have had surgery as well, but what’s your primary goal? What are your absolute “must do’s” in terms of what you achieve with those patients?
Certainly. So the primary goal is to understand who the patient is, what matters to them, and what’s going to be very, very important for them once they get through the treatment period. And once I have a good understanding of that, I can work with them carefully to look at ensuring I’m providing the right sort of education in terms of communication and swallowing changes that they may face during and post that treatment period. And also what kinds of therapies that myself and my team can institute for that person so that we have, I guess, the least impact from some of those side effects that I know we’ve talked about a little bit earlier through Dion.
From a speech pathologists point of view, what are the key common side effects? And then I’ll talk to you about what are some of the innovations to try and help us with those dilemmas?
Sure. So I’ll speak to swallowing first, as with all head and neck cancers, the specific I guess challenges or side effects do depend a lot on the location of that tumour and also the treatment modality or modalities that they receive.
But from a swallowing point of view, we are often dealing with acute changes that include mucositis. So some angry tissues on the inside of the mouth and the throat, that can sometimes cause pain that can then limit oral intake.
We’re also looking at particular structures that receive radiation therapy that are really vital to the safe ability to swallow. So a key example might be the base of tongue when somebody is receiving treatment to that area that can have a really key impact on someone’s ability to safely bring food and fluid back into the throat. And then obviously, first of all, get the nutrition and hydration they need, but also that enjoyment factor that is part of being human and enjoying eating and drinking.
Just speaking for myself, I lost speech as the result of my radiation treatment – 30 sessions of radiation. And I managed to keep swallowing liquid food. I didn’t have to have a PEG tube or a nasogastric tube. But I could only swallow liquid food and it took a very long time to swallow. So what do speech pathologists do to help us get our speech back and get our swallowing back so we can return to normal eating?
Sure. So the first comment I’ll make is the best therapy or treatment for swallowing is swallowing. So to speak to your example there Julie, the fact that you were able to maintain the intake of liquids is a far better place to be than somebody finding themselves in a scenario where they become quite dependent only on alternative feeding. So that’s what we try to avoid the most.
So listening to the symptoms that people are experiencing is important. So, for example, if pain is becoming more of an issue, throughout the course of therapies, we are able to then speak with the broader multidisciplinary team and review the medications, so that the doctors can be prescribing the right pain relief, so that we can then be encouraging the right type of oral intake. So whether that’s liquids or foods that are slightly modified alongside the implementation of the right sorts of therapies.
So to speak to therapies for a moment, if I may, a key innovation in the space of treatment for swallowing problems in the head neck cancer field is the use of what’s called an EMST device, or Expiratory Muscle Strength Training. It’s an exciting area where we’re learning more and more about the fact that if somebody can work with a device, just like this one, where there’s changes in the amount of resistance that somebody breaths against, and then back in with, we find that that we can target in a fairly comfortable way strengthening of key muscles that are involved in swallowing but also in voice.
So is that a way of treating? Can you just explain how it helps if you use it?
Yeah, sure. So the way it treats the body is that it works on increasing the strength of somebody’s ability to both breathe in and breathe out against resistance. Now people might think, why would I be working on breathing if I’m looking at working on swallowing? But if we think about the intricacies of the anatomy of the head and neck, our ability to actually close and open the vocal folds for breath, we close and open the vocal folds for voice and also swallowing as well.
There are also key muscle groups that sit in this area here. Okay. The tricky term is the suprahyoid muscles that basically, it’s like the pulley system that sits above the vocal folds. When we can target those muscles through a device like this, and also other more traditional therapies, we know that we are going to be working on creating the strongest swallow possible.
Thank you, are there any other innovations you’d like to mention?
The other key innovation I’d mention today relates to the use of Telehealth. It’s been obviously a huge area of work through this pandemic period. But I can absolutely see the application of offering patients the ability to access services across the multidisciplinary team, including speech pathology, from the comfort of their own home.
It’s done a lot to reduce patient anxieties in, you know, sort of being out and about in the community through the short term period. But likewise what I’m finding is people are having to sit in waiting rooms for shorter periods of time, I guess accessing the services they need. There’s less burden through an already burdensome period.
And I guess too, for people in rural and remote areas, Telehealth may prolong their access to speech pathology support, because they’re able to do it through Telehealth and not have to travel.
That’s right and I will be the first speech pathologist to take my hat off to my rural and remote colleagues who absolutely do the best work they can, knowing that they are having to work with a very broad range of patients through their clinical practice.
And where through my practice, we’ve been able to use Telehealth, it’s not only being able to treat patients directly, okay, who have been associated with the practice through their treatment, but also supporting some of our rural and remote colleagues, so that they get to access some of the skill set I suppose that we offer, knowing that we work in head neck oncology all the time.
Look thank you. Can you go to this question of speaking loss? When people have radiation therapy do we all lose speech? And then what can you do to help us regain our speech?
And as I’m speaking to you, I’m involved with some Facebook groups, as many patients are. And I’ve made friends with a woman who’s just been treated in New York, who’s an actor. And she is working very, very hard at the moment to get precision of speech back or she will lose her job. So give us a sense of what you can do with voice?
Yeah, most definitely. So, to answer the first part of the question. No, thank goodness, not everybody who receives radiation treatment will suffer from changes with their speech. What we tend to find are those patients who have needed combined therapies, so surgery plus radiotherapy, we tend to see those sort of patients having more difficulties.
You know, there’s a sort of a spectrum, I suppose, of difficulties patients will face. To talk to dry mouth, that most anybody who is going through radiation therapy will experience, that can cause difficulties with articulation, because the movement in our mouth is so rapid for speech sound creation, if we’re a bit dry, it’s so much more difficult to be really nice and clear. So to talk to that, sort of, let’s say milder end of the spectrum, making sure that the mouth is as moist as possible. So we try various products that are available, as well as obviously making sure someone’s well hydrated.
So that’s probably the milder end of the spectrum, all the way through to the more severe end to talk to voice changes, where somebody is receiving direct radiotherapy to the larynx, okay? The larynx being the voice box. That group of patients is obviously at the greatest risk, let’s say of voice change and through the therapy period, so the radiation therapy period, what we work hard to do is balance good general voice care.
So for example, is a patient getting a good balance between gentle voice use, voice rest and good hydration? And then on the other hand, what kind of direct therapies can we provide? So, for example, gentle vocal function exercises that keep that most precious part of our anatomy mobile and as healthy as possible, so that not only somebody can I guess, vocally or verbally communicate during treatment, but what can we do to ensure that somebody’s voice is as healthy as possible, on the other side.
Look that’s so helpful and I’ll just say for people who are perhaps at the beginning of their treatment, when I did lose my voice, I began by writing notes to my partner who claimed that I could interrupt her, even though I couldn’t speak, with a note. But then my daughter who was a bit more high tech, gave me an app on a computer where I could write with a little rubber pencil and I could write my notes on that. But I just want to say, just before I leave voice.
I saw you in my acute phase and got a lot of help and then, because I really wanted my voice to come back as close as possible to normal, because I had been working as a radio broadcaster, I spent a good year with another speech pathologist doing lots of tests, and then lots of exercises, and I got a lot of emotional support from that person as well.
So are there a proportion of patients who do need quite long-term help to regain good quality voice?
The answer is yes, Julie and I think what it often comes down to are what is somebody’s personal, what are somebody’s personal goals. So for example, somebody like yourself, where your work is so very reliant on your communication, and particularly your voice, and your I guess inspiration and your need to regain voice to a particular level, might be different to somebody else.
So to speak to other groups of patients, I can’t tell you how many wonderful gents I’ve worked with who may be in their 70s and 80s, who’ve gone through a very successful period of radiation therapy for the treatment of a variety of cancers. Their voices have improved with direct therapies. But ,their motivation to continue, you know, for sort of six and 12 months after the fact is going to be less, so it’s certainly been my experience that it’s less than a working professional. Let’s say.
What I will say though is that every patient’s personal goals are treated with the utmost level of respect and if somebody has got a very mild change with their voice, but to them, it’s very troublesome and they would like to work on that they can be certain that the services are available to them, should they wish to work on that longer term.
And in terms of access publicly without fees, or privately with fees, is it possible to generalize about that?
Not really. To be honest with you, what I will say to my knowledge, there are excellent public and private services, wherever a patient is presenting for their care. What I would encourage people to do is find out what model is best for them. Find out what’s available. And from there, that will help I think, with the right sort of decision-making around what group let’s say is most appropriate to treat them.
And I’ll let you know that Cancer Council have an Information and Support Line that’s a free call anywhere in Australia 13 11 20 if you want to ask questions about speech pathology or any other aspect of radiation therapy care in a multidisciplinary team. Obviously your own team is your first point of call, but Cancer Council 13 11 20 are there as well. And the BeyondFive website, www.beyondfive.org.au.
Is there anything else you’d like to add?
I guess, Julie, what I would add to the group who’s listening is to understand that there are a broad array of services that are available for people who are newly diagnosed with head neck cancers, but also for those people who have survived and are going on five years plus.
Although we might not be working with you quite so regularly, kind of at their five-year-plus mark, we are still there for you. And if you would like to access our services again, please use your GP or your treating specialists…so whether that’s your radiation oncologist or your head and neck surgeon…as that first point of call. And from there, we’ll be linked in together.
And Therese before I let you go, I’m lucky, while I did get a very dry mouth, my radiation oncologist promised me my saliva would come back and it did to a very significant degree. It’s not normal, I do still occasionally have difficulty eating. I certainly always have water, seven years later, near me when I’m eating and I do occasionally choke if I eat and get excited while I’m talking.
So I’ve still got some impact, but I’m a very lucky person. But I know there’ll be people watching this, who even years later have got very significant dry mouth. Any word for them on how you can manage that and, you know, achieve the best result possible? Because it does cause considerable distress, doesn’t it?
That’s it. From a quality of life point of view, dry mouth or xerostomia is a big deal. I wish I had a whole lot of fancy things to share. What I will mention is making sure that people do have that bottle of water with them all the time tends to be the first point of reference. If somebody can be well hydrated from the inside out, that sets people up to be as comfortable orally as possible.
Beyond that, there are products available that are readily purchasable from either the pharmacy, Coles or Woolies. Things like Biotene. For example, we’ve got lovely toothpastes and mouth washes and mouth sprays. And there are other brands out there as well that are also very, very good.
It’s never the same as saliva. It’s just not. But it offers the most comfort possible.
Well Therese Dodds thank you so much. I really, really learned a lot. And Therese has been talking from the perspective of a speech pathologist.
Stay with us because in just a moment, we’re going to hear from an expert dietitian.
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