Video transcript
Innovations in Surgery Part C
The Head & Neck Cancer Innovations 2020 Video Series is brought to you by St Vincent’s Hospital Sydney & The Kinghorn Cancer Centre. In this episode we talk to A/Prof Julia Maclean, Clinical Specialist in Speech Pathology from the St George Swallow Centre Sydney about innovations in treatment for head & neck cancer patients, including long-term swallowing rehabilitation and support. 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
A/Prof Julia Maclean, Speech Pathologist, St George Swallow Centre Sydney
Julie McCrossin
Well, welcome back to our third section of our video on innovations in surgical care for head and neck cancer patients. And it’s part of a series of videos looking at improvements in care and in treatment that are improving both survival and, equally significantly for many of us, quality of life.
My name is Julie McCrossin. I’m a former patient. And when I was treated seven years ago for stage four cancer in my tonsils, tongue and throat, I lost speech all together for a number of months. And I worked for nearly a year with a speech pathologist. So it gives me great pleasure now to welcome a speech pathologist to our video today. Julia, welcome. Can you introduce yourself to our to our audience today keen to hear about speech pathology?
Julia MacClean
So I’m Julia MacLean and I’m a speech pathologist at St. George Hospital in Sydney. I’ve been there for 24 years and I work with the head and neck team down there. So I feel very lucky in my position. I get to see patients before their treatment and help them decide which treatment they’re going to have. And I see them during treatment, be it surgery or chemo radiation. And then, really importantly, I see them very long term, following their treatment, to deal with the side effects from whatever treatment they’ve had.
Julie McCrossin
Well, you’ll know from our patient Hans Ede at the beginning of this video, he was someone who’s had multiple surgeries and radiation, which many of us have both, and he was really crying out for long-term rehabilitation support. Let’s begin by talking about the Swallows Clinic at St George Hospital. When was it set up? What’s its purpose? And what are you able to offer people, particularly in that longer term?
Julia MacClean
So I’ve worked with our Professor Ian Cook, who’s a gastroenterologist, for the last 24 years and he set up The Swallow Clinic over 25 years ago at St George. And it was the first multidisciplinary swallowing clinic. And it’s quite unique because we have gastroenterologist. We have speech pathology. We work very closely with the radiation oncologists and the head and neck surgeons, but also with neurologists and other specialists, dieticians. Everyone who’s involved in people who have long-term swallowing difficulties.
Julie McCrossin
And how common is it? Do we have data on that? How many head and neck cancer patients, whatever their treatment type, will have difficulty swallowing long term?
Julia MacClean
So we know from our data that up to 60% of patients will have swallowing problems into the long term. And what’s really important is, we talk about following patients up for five years following treatment, but a lot of these late problems with swallowing come after that five years. So we certainly get involved. There are some people who do have difficulties early on in the piece and we certainly know that post-operatively or during chemo radiation, it can be very difficult to swallow. People then tend to recover over about a period of a year. And we work really hard to get patients to their best function at that time. But we know in the longer term that patients can end up with swallowing problems.
Julie McCrossin
So can you give us a sense of what you’re able to offer people longer term with the swallowing difficulties, and how long those difficulties may progress?
Julia MacClean
What’s really important is that we get really accurate assessment of a patient’s swallowing disorders. And we have some innovations down at St. George. We use special catheters that measure the pressure when people swallow. So we know many people who are watching this may have had what we call a modified barium swallow, which is an X ray of your swallowing. And that’s really helpful for speech pathologists to see what the anatomy is doing and checking that everything’s flowing down the right way and nothing is going down into the lungs.
But we have some technology, we’re actually able to measure the pressure in the throat. Because when people swallow, we want pressure where the muscles squeeze the food and fluid down into the stomach. But we don’t want a resistance to that flow at the top of the esophagus. And that’s a problem that we commonly see as a late effect of surgery, radiotherapy and chemotherapy in head and neck patients.
So for patients who have this resistance to flow, or what we often call a stricture, or a narrowing of the throat, we’re able to then work with our gastroenterology colleagues to open up that area to allow swallowing to be easier for patients. So we know as I said, about 60% of patients in the longer term can have difficulty with their swallowing, and about 20% of patients overall will develop a stricture.
What’s really important is that the treatment that we offer these patients, which is called dilatation, which is just stretching up the esophagus. We know that 80% of patients, if they’re well selected with this problem, will get a really big improvement. So this is fantastic. We get patients who haven’t been able to swallow, sometimes for some years, and we’re able to get people swallowing again. It may be that they can’t swallow everything, but even, you can imagine, if you went from swallowing nothing in a day, to being able to enjoy a cup of coffee, or a piece of cake with your family, that’s a huge improvement.
Julie McCrossin
That’s a huge thing. You mentioned the barium swallow test. Is that we call it? Because I’ve had one of those and if I could just say for people who might be really new, my understanding is that there’s two pipes. One pipe is where the food goes down to my stomach and the other pipe is where air goes into my lungs.
And that one of the problems that can happen is that food instead of going down or liquid going down the pipe into my stomach, might go into my lungs. And sometimes you can get a little bit of food in your lungs and you get pneumonia as a result. And that’s actually happened to me a couple of times. So with that particular issue, are you able to help people with that as well, because that can deteriorate over time?
Julia MacClean
Absolutely. And there’s two different reasons that, well, there’s a few different reasons that food and liquid can go into the lungs. It may be that the muscles aren’t pushing it down the right way. So there’s lots of remaining food and liquid staying in the throat of the swallow, and then it drips into the airway if you like.
But it can also be because of that resistance to flow that I talked about. So if you have a blocked drain, and the food and liquid, then back up and spill into the airway. So if we can open up that narrowing, we get better flow and we haven’t got that backflow into the airway.
Julie McCrossin
We’re talking about impacts on swallow and they are clearly a side effect of treatment. Are there any other side effects of treatment that you work with as a speech pathologist, either at The Swallow Clinic, or that other speech pathologists work on.
Julia MacClean
Absolutely. So communication is obviously the other really mainstay of our work. So, during treatment, there can be changes to patient’s ability to articulate or make the sounds. There can be problems with their voice. And so we work with all range of communication and voice problems post-operatively and after chemo or radiation as well,
Julie McCrossin
Julia, in our discussion so far, there’s been a lot of emphasis on multidisciplinary teams being very important for both patients who have surgery or radiation and chemo or both. Your service sounds innovative and comprehensive and it’s multidisciplinary. This is The Swallow Clinic at St George Hospital in in southern Sydney. How common are services like yours? You see people from all over New South Wales, but for people watching in other parts of Australia or New Zealand, can you get access to your sort of work?
Julia MacClean
I mean, certainly there are a lot of specialists who do the work that my team do. We’re unique because we’ve come together as a team to work together as a team. And there are some other swallowing teams that are certainly working together. Some with gastroenterology and some with ear, nose and throat doctors. I think like everything what’s important is that you find people with the expertise. So it might be a slightly different combination of members in that team. But what you want is people who are experienced with swallowing disorders and able to treat that as a team,
Julie McCrossin
And how can a patient or family find that sort of team? Is there, I know we’ve talked about BeyondFive which has a marvelous website beyondfive.org.au. It has amazing information on head and neck cancer and anatomical imagery, patients’ stories. They’re putting lists of support groups and so on. But is there any central point at which neck cancer patients longer term can get reliable evidence-based information about where good teams are working to help them with their problems?
Julia MacClean
I mean, certainly head and neck teams are listed through the Cancer Institute in New South Wales. But there’s not a really coordinated approach. And I think that particularly as our internet and all of those resources grow, that’s something that patients will want to see and should see, because not every center is good at doing everything.
And certainly I’ve seen a lot of patients who have said they’ve had excellent head neck cancer treatment at another centre, but they weren’t able to get the resources to help them with their long term swallow function.
So I think the really important message I would want to give to patients is if you have a problem, talk to your team and ask questions because we are fairly small networks in head neck cancer and we all do collaborate through society meetings and conferences. And so we do have a good idea of innovations that are going on across the state and across the country. And I think patients should seek out those areas of expertise if they need specific help.
Julie McCrossin
But does the profession, the cluster of professions, through organizations like BeyondFive, Cancer Council, need to put more work into providing one-stop shops with reliable, regularly updated information? Because if your doctor doesn’t help you, where do you go next?
Julia MacClean
Look? Absolutely. And I think it’s hard to keep things up to date. I’m very lucky, I’ve worked in a very established team, which has had very low level of stuff turnover, but that’s fairly unique. I mean, it’s common that a lot of members of the team change. So it has to be something that’s dynamic, and we have to keep that information up to date that I certainly agree it would be a fantastic resource.
Julie McCrossin
So in a nutshell, what are the key positive improvements you’ve seen in the care of head and neck cancer patients from a swallowing and speaking point of view? And then what more would you like to see?
Julia MacClean
So the key things that have got better for patients is, I think, the choice of what treatments to have. I think there’s a lot of innovations in every area of head neck cancer treatment. There’s the robot that we’ve talked about this morning. But there’s also with chemotherapy. We have targeted therapies in immunotherapy, which is a really exciting time. And in radiotherapy, we have much more targeted ways of delivering that radiotherapy and minimizing the side effects in the long term.
So I think the technology that we’ve seen over the last 10 years has been fantastic. And certainly, we will see those benefits long term in patients with hopefully a reduction in the long term side effects. But we still have a way to go because where head and neck cancers are, it’s in those vital structures of breathing and swallowing and speech. And we need to eradicate the cancer in the first place. So we will still see changes to all of those functions, unfortunately.
So I think, where we still need to go, is to work into the longer term. And I think Han Ede, as always, patients always say it best, we get to five years really well. But what about beyond that five now? And we need to look at long-term survivorship care for patients. And I think we need to look at, we have beautiful multidisciplinary care in head and neck, but how can we then involve other people into that multidisciplinary care in the longer term? So I think we still have a way to go in terms of bringing people in to treat the side effects, the really long-term side effects for our patients.
Julie McCrossin
Julia thank you so much. And I just want to say that the speech pathologists who worked for me, both acutely, and then another speech pathologist longer term to get my speech and swallowing working again, was also a tremendous psychological support.
I think speech pathologists get to spend quite a bit of time with us in the treatment that you do. And that was tremendously helpful for me. So thank you very much.
Julia MacClean
Thank you.
Julie McCrossin
Well, as you can see, I’ve got out of my scrubs to wish you farewell from the innovations in surgery video, as part of this head and neck cancer series of videos on innovations that improve survival and quality of care. I really want to thank Associate Professor Richard Gallagher, Suzie Flynn, our critical nurse who’s done such remarkable work with patients, and also speech pathologist, Julia Maclean.
Thank you so much for taking an interest in head and neck cancer. And remember Cancer Council 13 11 20 is the Information and Support Line. Cancer Council 13 11 20 . Free call anywhere in Australia. And the BeyondFive website, https://www.beyondfive.org.au. And thank you for taking an interest in innovations in head and neck cancer treatment.
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