EPISODE 69

[INTRODUCTION]

[00:00:05] MBH: Thanks for joining us at Keys for SLPs, opening new doors for speech-language pathologists to better serve clients throughout the lifespan, a weekly audio course and podcast from SpeechTherapyPD.com. I'm your host, Mary Beth Hines, a curious SLP who embraces lifelong learning. Keys for SLPs brings you experts in the field of speech-language pathology, as well as collaborative professionals, patients, and caregivers to discuss therapy strategies, research, challenges, triumphs, and career opportunities. Engage with a range of practitioners from young innovators to pioneers in the field as we discuss a variety of topics to help the inspired clinician thrive.

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Welcome to this episode, Keys to the SLP's Role on a Head and Neck Cancer Team. This is part one of a two-part series. Here are the financial and non-financial disclosures. I am the host of Keys for SLPs, and receive compensation from SpeechTherapPD.com. No relevant non-financial disclosures exist. Heather Thompson is an SLP at Cedars-Sinai Medical Center. She receives compensation from SpeechTherapyPD.com for this episode. No relevant non-financial disclosures exist.

Our learning objectives for today are; one, to identify updates in head and neck cancer; two, explain the evidence of increased effectiveness of treating head and neck cancer as a multidisciplinary team; three, identify the SLP role in the head and neck cancer treatment and education throughout the continuum of care to facilitate quicker reintegration into the community. 

Now, we welcome our guest today. Heather Thompson, CCC, SLP is a speech-language pathologist at Cedars-Sinai Medical Center specializing in the evaluation and treatment of oral pharyngeal swallowing disorders, as well as head and neck cancer, speech and swallowing restoration. She is proficient in the management of voice prosthesis following the tracheoesophageal voice restoration after laryngectomy. Most recently, she presented at the Society of Physician's Assistants in Ear, Nose and Throat in Los Angeles, California. She co-authored a book chapter on the Role of SLP in Head and Neck Cancer Management. Currently, she's involved in research in the lung transplant population and participates in community outreach promoting speech language pathology.

[INTERVIEW]

[0:03:05] MBH: We are so happy to have you here on Keys for SLPs to talk about the SLP's role on the head and neck cancer team.

[0:03:12] HT: Thank you. Thank you so much, Mary Beth, for that kind introduction. Makes me sound more important than I think I am. 

[0:03:21] MBH: Well, I think you are very important, and we are so happy to have you here tonight with us. Thank you to all of our participants for joining us tonight. We're really Ð this afternoon for some of you. We're really excited to have you all here.

[0:03:36] HT: I'm very happy to be here. The head and neck cancer population and patient population is a population that I am very passionate about and I love working with. It doesn't really feel like a job to me. I really love this population. It's never the same. One of my mentors from way back told me, ÒIf you've seen one head and neck cancer patient, you've seen one head and neck cancer patient, because no two patients are ever the same.Ó My goal is just to kind of give tips and tricks for just managing and getting through.

[0:04:18] MBH: Well, thank you. That's so interesting that you say that because you never know how someone's head and neck cancer or any cancer is going to go. You can have what looks like the same diagnosis, and looks like the same course, and one goes in one direction, and the other goes in the other direction. For you to be in a role that you support people no matter what direction is truly a gift. How wonderful for you that you don't even feel like your work is work. 

[0:04:45] HT: Right.

[0:04:47] MBH: That's great. All right. Well, let's dig in. How did you get involved in head and neck cancer? Tell us a little bit about your journey as an SLP and how you landed in this specialized area.

[0:04:59] HT: My journey as an SLP is probably this roundabout circle that's not the same. I feel like I got out and I felt like I didn't know what I wanted to do. I was all over the map. I actually started doing pediatrics and adults. I slowly started going down doing more of the neuro path, the stroke, and that path. Then I did early intervention, and it was kind of okay, but then I was really drawn to that adult path. So then, I worked in long-term, acute, and I worked in skilled nursing, and then worked in acute care. Then at the hospital I'm at now, I just got an experience here and there on the acute side with the head and neck cancer population. 

Now, I was working out in the outpatient setting, actually with neuro and with voice, and we had a surgeon who wanted to start a head and neck cancer program. They said, "Who's interested?" I was like, "Why not?" So I was like, I have some experience from my graduate school days. I've done a little bit on acute, I'm willing to learn. I was like, "Why not? I'll jump in." That was about 10 years ago. So I just decided to jump in, and learn, and that's where I am now. It was kind of a sink or swim.

[0:06:33] MBH: Oh, that's great. Wow. What percent of your caseload is head and neck cancer?

[0:06:37] HT: Right now, my caseload is probably 80% head and neck cancer in the cancer population right now. It probably started initially 10 years ago being 10%, to now where it's 80% of my caseload at this time.

[0:06:59] MBH: Are you working in both outpatient and inpatient with head and neck cancer patients?
[0:07:04] HT: I'm primarily outpatient. I have an acute colleague, who I'll only cover if she's out on vacation, and she'll come over to outpatient and cover if I'm out, but I'm primarily in the outpatient setting.

[0:07:21] MBH: Okay.

[0:07:23] HT: Well, great. I can cross over but Ð

[0:07:25] MBH: Okay. One of the things we really thought it was important to cover is the updates in head and neck cancer over the past 20 years. You've really been in this area for about 10 years, and you've seen a lot of change. But if you look back 20 years, there have been significant changes in this area.

[0:07:43] HT: Well, I think that's kind of the very interesting part of it all too. Even in the 10 years where I started. Going back 20 years, when I first was in graduate school, head and neck cancer, the patients that the speech-language pathologist would see for head and neck cancer, for laryngectomy were due to smoking, tobacco-related more so. We can thank the government for some things, and that would be smoking awareness, and there was a decline in smoking. Since the decline was smoking in tobacco, there was a decline in head and neck cancer or oral pharyngeal cancers related to smoking. But there's now HPV, so now there is an increase. Head and neck cancer is on the rise because of HPV. 

Smoking is related to what's called HPV negative. Now we have HPV positive, and so it's kind of swung the other way. Smoking has gone down so you don't have those HPV negatives. Now, we have HPV positive, and that's what's actually on the rise. Just kind of some numbers that I looked up for this podcast is that the CDC reported in 2018, this is kind of the most current that I could find, that nearly 42 million people are currently infected with HPV in the United States, and about 30 million people including teens become infected with HPV each year. About 10% of men and 3.6% of women have oral HPV, and oral HPV infection is more common with the older age.

Then the other statistic that I thought was very interesting is that, according to the data that the CDC had from 2015 to 2019, there were an estimated 47,000 new cases of HPV associated cancers occurring in the United States each year, including 26,000 among women, and 21,000 among men. Then women had the higher cases of cervical, but men had the higher cases of the oral pharyngeal cancers. Kind of looping back to your question of what you were saying. Twenty years ago when I was in school, we weren't talking about oral pharyngeal cancers related to HPV. We were talking about oral cancers related to smoking. Now, we're talking about oral cancers related to HPV, which are on the rise right now. The good thing is, if they're HPV positive, there is like a 90% cure rate. The good bad part of it is, if you are HPV positive, there is that 90% cure in the oral pharyngeal cancer.

[0:11:11] MBH: So it is more curable?

[0:11:13] HT: It is more curable, but detection is key. Early detection is key. 

[0:11:18] MBH: Early, yes. In your research for this, have you come across any information about how the HPV vaccine in the younger generation, let's say, how long has that been around now? Maybe 15 years? 

[0:11:34] HT: Yes.

[0:11:35] MBH: Fifteen- to 30-year-olds. Are the numbers projected to go down because of the vaccine?

[0:11:41] HT: Well, that's what the hope is. When I was actually at that physician's assistant conference, they're starting to collect data on that, and they are starting to see some of those numbers flip. Because what I'd said earlier is, it infects the older generation, so you have to wait. It's only been out 20 years. Now would be the time where you would look to start to see that decline. But there is starting to get that research to show that the more people who are getting the vaccine, there should be that decline. We're seeing that go down; however, there's now also this increase with the vaping.

[0:12:30] MBH: I was thinking of the vaping, and oh, it makes me so sad.

[0:12:35] HT: So now we don't know where that's going to kind of go, if that will impact those oropharyngeal cancers. It's kind of this passing wave here.

[0:12:45] MBH: Right, right. Oh, I sure do hope that vaping is a trend that will decrease because it has been alarming to see the vaping in the past five to 10 years and the effects that that will have down the road, we don't know.

[0:13:01] HT: I do guest lecture and I have guest lectured at USC and Cal State, LA. I give the lecture every year, and I'm like, ÒWhen I was in school, you may or may not see a head and neck cancer patient if you were working outpatient in an adult clinic. Now, you will see a head and neck cancer patient.Ó I mean, the numbers for HPV are like one in three, it's at epidemic levels. So you're more than likely you will see someone who has it. I mean, that's how much it's changed. But there is the hope with the vaccine, that maybe in 20 years, you won't see. That's what I always say or the doctors will also say is there is also the hope that this is the one thing that we have to fight cancer.

[0:13:56] MBH: Yes. All right. Anything else you want to add as far as the update goes?

[0:14:03] HT: No. I mean, I think that's just kind of everything as of now. It's just kind of Ð I think the other thing to know now too, is that, talking about the vaccine, the CDC recommends for the vaccination to be between nine to 12. It's not necessarily recommended for anyone older than 26. However, it is recommended for adults ages 27 to 45. You may decide with a conversation with your doctor, you can have the vaccine so they increase the age to Ð you may have benefit in getting that vaccine. It used to be a hard stop at 26, and now they've extended the age to 45 for that. That is something that has changed. Adults 27 to 45, you can consider or discuss getting that HPV vaccine with the doctor. That's something new.

[0:15:04] MBH: That's good to know. Do you know why the vaccine had a limit?

[0:15:08] HT: It's because they don't know the effectiveness. The goal is for nine to 12, they want kids to get it before their first kiss, and their first sexual encounter, because it lies dormant. After 26, it reduces the effectiveness of the vaccine. However, with a discussion with your doctor, they may feel as though each person, depending upon sexual partners, and different factors, you could have benefit from the vaccine.

[0:15:47] MBH: Okay. Well, thank you for sharing. All right. Well, let's talk about that multidisciplinary team, and how a multidisciplinary team leads to better patient outcomes.

[0:15:58] HT: It's actually really interesting. I am part of a multidisciplinary team and I couldn't imagine not being part of a multidisciplinary team, because I feel like everything is always easier with a team. You carry it together. There's actually a research study that came out by Heather Starmer out of Stanford University in 2011 that actually looked at this. She found that patients evaluated in a multidisciplinary clinic are more likely to comply with the SLP recommendations. Right there, that gives you justification for your multidisciplinary team. I feel like you just kind of work as a support system together.

I know for myself, in general, we kind of all support each other. It's so overwhelming, when a patient gets the diagnosis, all they hear is cancer. Sometimes, to be able to go to you and have, "Okay. What am I doing? Why am I doing this?" and just kind of rehashing things and going through things over and over. I feel like not only, even though there's not research on this, compliance with the speech therapy recommendations, but compliance with overall getting through the program. Compliant, yes, you need to get through this. Yes, you're going to get through this. But then, also, there's also research that says, you eat, you drink, you swallow, you exercise during radiation treatment, you have better outcomes long-term. 

If they're hearing it from you, they're hearing it from the dietician, they're hearing it from a social worker, they're hearing it from the pain management, the oncologist, they're hearing it from everybody, they're more than likely going to buy into it. I know for me personally, if they've seen the ENT, they've seen the radiation oncologist, they've seen the oncologist, and they're coming for me for the evaluation, they already know why they're there. Patients will say at the very end of treatment, "You know, I was so overwhelmed in the beginning when I had to go to all of these people, but now I couldn't imagine getting through without having my person helping me through with all of this."

Even too, just last week, I had somebody email me and say, "You know, a friend of mine is going to another facility across the country. He doesn't have the dietician. Could you connect me with the dietician? I forgot her name. He needs help with knowing this." I think for patients to know, "This is your point person for this. This is your point person for that." They don't like it in the beginning, but knowing that they have this team supporting them, I think patients really do benefit from it at the end. They like having the team.

[0:19:26] MBH: Yes, it's encouraging. And they know that everyone is looking out for them too. 

[0:19:30] HT: Yes. 

[0:19:31] MBH: All right. Well, who are all those people on that team?

[0:19:35] HT: Well, our team is rather large. I think it varies from facility. Our team, we have the otolaryngologist or the surgeon. There also may be a laryngologist on board or the ENT, the nose and throat. We have the radiation oncologist, the doctor doing the radiation. Your oncologist who would be doing your chemo or your immunotherapy, those things. We have supportive medicine and pain management. They also serve as the role of the palliative doctor. They kind of set the goals of care as well for our patients, especially the elderly ones. But they also are there guiding the pain management too, because believe it or not, some people don't want to take pain medicine, and how much pain medicine because with the opioid crisis, they're worried and they have concerns with this. Also, with alternatives such as CBD, and marijuana, and guiding that. We're lucky to have that aspect.

We also have dieticians on board, we have a physical therapist, and some facilities have occupational therapists. They help with the lymphedema and the trismus as well. And speech therapy, which would be me. Social workers, and then also we have a dentist on board as well to also help as needed. He kind of floats in and out, but weÕre very fortunate to have a dentist as needed. That's kind of a novelty. A lot of places don't have that.

[0:21:42] MBH: Tell us a little bit about the role of the dentist.

[0:21:44] HT: The dentist actually, prior to treatment, he does the assessment to assess for any cavities, if there's anything that needs to be cleared, any root canals, gets that all clean. But then during treatment also is assessing for xerostomia, saliva, any of those kinds of things that could be impacting the mouth, taste, saliva. The dentist that we're actually working with now is actually doing research on light therapy to actually help with saliva stimulation in taste. Just all of those different things. But then also, fluoride treatments, trays. 

That they're also there as well to help keep an eye on the trismus. They also are there to kind of guide whether or not, and to help with referrals for obturators, palate tools, things like that too. Sometimes it's good to have a dentist because they can get you in Ð they may know a quicker prosthodontist or a route to that you need if you need that as well.

[0:23:07] MBH: Right, because it often takes a while to make those appointments. You don't have a while when youÕre in head and neck cancer treatment. You've been on the team for 10 years, how long has the dentist been part of the team?

[0:23:19] HT: The dentist has been a part of the team, I would say, that whole time. But he's there one to two times a week. A lot of times, we utilize him more so for the very Ð we've utilized him more throughout the years. It used to be like once a month, and it's become more and more, especially now as his research has kind of picked up with the saliva, and the taste, and all of those things. But it's really a benefit if they can get into this dentist, because he can measure the saliva, do the assessment on that, look at the teeth, and decide, ÒOkay, we need to pull,Ó and set realistic expectations for implants, dentures, all of those things. Because people want it quickly, but sometimes in the process of getting ready, and setting the trays, and fluoride treatments, and the oral care prior, sometimes in the process of trying to get the dentist set up, and starting radiation, it's just easier to get them started with their own dentist, and then switching over to the dentist that's part of our team later in the treatment.

[0:24:50] MBH: Okay. Well, thank you. Thank you for enlightening us on dentistry with head and neck.

[0:24:55] HT: Dentistry, yes.

[0:24:57] MBH: I have another question. You said supportive medicine and pain management. Are those two different individuals?

[0:25:03] HT: Well, our supportive medicine doctor takes the role of pain management. In some facilities, it's called the pain management doctor. In our facility, it's supportive medicine. Our supportive medicine doctor kind of fills the role of palliative and pain management. They will discuss the goals of the patient, ÒDo you want a feeding tube? Do you want a curative approach?Ó But then, they are also throughout treatment, managing pain. Because pain can also be the biggest obstacle for a lot of patients with getting through treatment. If pain is managed, then they typically can get through treatment a lot better. But also, you want pain managed, because for me, as the speech therapist, I want patients to stay oral as much and as often as possible. What's going to stop it is pain. 

[0:26:17] MBH: Exactly.

[0:26:18] HT: If they can manage their pain, they can stay oral longer. Of course, the dietitian is like, "Well, I want them to stay oral longer, because I don't want them to be on the feeding tube long, or I don't want them to be on the feeding tube at all.Ó

[0:26:35] MBH: Exactly. There really is some synergy when you have a whole team working together that really does lead to better patient outcomes. All right. Let's see. So you have a multidisciplinary approach all the way from diagnosis through treatment, and then follow up. So normally, the person comes to your team through which person on that team, the ENT? 

[0:27:00] HT: Typically, they come through Ð they'll usually meet with the ear, nose, and throat doctor first. I feel like for ear, nose and throat, when they present to ear, nose, and throat, it's always the same. It's either, ÒI've had a cold, or hoarse, and raspy throat that hasn't gone away.Ó Or for men, it's, "Oh, I was shaving and I noticed a lump, and it didn't go away." They'll present to ENT, and then the ear, nose, and throat doctor then typically presents them to the tumor board. The tumor board is an interdisciplinary team. That's when they meet with everybody all together. I feel as though if you're new, or you're starting at a cancer program, advocate as a speech-language pathologist, advocate to go to and be a part of these tumor boards. Because I feel like doctors are very good at thinking about the cure, and beating the cancer. That sometimes they forget the function and the long term. They're like, "Oh, yeah." 

Sometimes your input can change the course. They may be going down the path of surgery. Especially for us in Los Angeles, we have a lot of actors, we have a lot of voiceovers, we have a lot of singers, and there'll be going down this path of surgery, surgery, surgery. Then my colleague and I will be like, "Hold up, if you do this surgery, what is this going to look like? You do the surgery, you cut a piece of their tongue, they're not going to be able to say this sound anymore. That's going to impact their job, their livelihood.Ó Okay, then that switch, we're going to radiation for a curative approach. Or it switches the other way. You have that impact, because I feel like we have that impact on that function part. Because eating, drinking, and talking are very valuable for quality of life across the board for everybody.

[0:29:46] MBH: Absolutely. But as you said, for some, it really is their livelihood.

[0:29:49] HT: Yeah. And not just that. I'm just talking about it for actors and singers, but what about chefs? But then, we also just don't think about it in the fact of just people in their day to day. Their one goal may be to be able to go out to eat with family and friends, then eating is their main goal. So it switches and you're there to kind of advocate for those goals, for your patients.

[0:30:22] MBH: How often does the tumor board meet?

[0:30:24] HT: Our tumor board meets twice a month. So we meet twice a month. What they'll do is they'll bring up a case, and they just kind of go over Ð they present it, they show the tumor, they talk about the pros and cons, the pathology, the imaging, go back and forth. They'll go over all of that. Then once a month, we have a disease management team that is run by the radiation oncologist, and then we go through all the patients who are on active treatment, and how they are actually doing in the treatment process. Are they losing weight? How are they doing through radiation and chemo? How are they doing after surgery? Did they get the NG tube out? Do they need a G tube? Are they eating and drinking? Are they being compliant? Are they showing up? Are they taking their pain medicine? Also, are they seeing speech? Are they showing up to appointments?

[0:31:33] MBH: When you meet, dp you meet in person? I know a lot of things have changed in the last couple of years.

[0:31:38] HT: We used to meet in person. Now, we're Zoom and we're going to hybrid.

[0:31:45] MBH: And you go through all the patients and how long does that meeting last usually?

[0:31:49] HT: It's supposed to last an hour. But I feel like we always go over. It lasts an hour if everybody agrees.

[0:32:01] MBH: But you have a lot of smart people in one room or on one Zoom, and not everyone agrees, right?

[0:32:05] HT: Yeah. If everybody agrees, or if Ð but I feel like these cases are never straightforward, either. Because there's a lot of things to think about. In the cases that are brought forward, sometimes they're younger, and you really want the best cure, because they have young kids, and young families, and those things. But then, also too, sometimes they're older. So, do we go for everything or do we go for quality of life? How much time? You have to weigh out a lot of things?

[0:32:43] MBH: You really have to strike a balance. The team sees patients from diagnosis, through treatment, and through follow up. How long is the treatment on average, would you say? Is head and neck cancer a slow growing cancer? Does the treatment start very shortly after diagnosis? Is it okay to have some time to get that treatment plan together?

[0:33:10] HT: I feel like it Ð they move. I feel like with any cancer, you're going to move quick. It's a hurry up and wait kind of thing. They are going to move quickly with it. If it's a surgical approach, they're going to do surgery, and then they're probably going to wait till you heal from surgery, which is going to be like a four to six-week period, and then they're going to want to start radiation. Radiation, or radiation and chemo is usually a six to seven-week period. Then you have your recovery, which is usually Ð the quickest recovery, they usually feel better two weeks after. They start to feel better two weeks after, but it's a year recovery process.
I like the way our radiation oncologist explains it. He goes, "It's kind of like a mirror." You're seven weeks in, and you're seven weeks out." The first week after radiation is like the last week of radiation. The second week after radiation is like your next week Ð the next and the last week of radiation. It just kind of folds itself out. But it takes a year to completely recover from it, your body to kind of recover from the whole process. You slowly get your taste back, but they make the most recovery in those first three months. For me, personally, if it is a patient that I'm seeing, if it's a chemo radiation patient, I see them prior to chemo and radiation. You see them at chemo radiation, you get the baseline. And they tell you that they have no problems, "I don't know why I'm seeing you." Then you tell them, "It's going to get worse," and you prepare them every week. 

Then you're doing exercises for the head, the shoulder, the jaw, the larynx, anywhere that the radiation is going to hit. You're trying to prevent that lymphedema, that trismus, the pharyngeal strengthening, keeping them eating and drinking. Then about that fourth or fifth week when they're ready to be done, they're like, "Oh, you were right," and you're like, "But I didn't want to be right."

[0:35:44] MBH: ÒI'm sorry that I was right. I actually knew I was right, but I didn't want to be for your sake.Ó

[0:35:49] HT: Exactly. Then, I continue to follow them, and then I always say, "My goal is, you have to be where you were when you finished. If you started eating solid food, I need to watch you be able to eat solid food." Then after that, I follow them every three months for the first year to make sure that they're eating, and drinking, and swallowing. Because the most changes happen within that first year. If I'm able to get a baseline video swallow study, I try to do that. But sometimes it just moves so quickly that I'm not able to do that. Currently, we have a research study going, and those patients do have a baseline prior to radiation, and chemo, and post chemo radiation. 

[0:36:47] MB: Can you tell us a little bit about that study?

[0:36:48] HT: So yeah, that's kind of Ð hopefully, we'll see some good things. It's for surgical patients. I think if itÕs T1, T2, HPV positive  and I think if you have one or two lymph nodes involved, or no lymph nodes involved, then you get chemo and radiation, but you only get three weeks or five weeks. The hope is that it might change the radiation course from seven weeks, to three weeks, or five weeks, and hopefully reduce the side effects, and have better outcomes with speech or swallowing. Stay tuned. That's what the hope is.

[0:37:40] MBH: Two other things that you've mentioned are the lymphedema, and then the trismus. Can you tell us a little bit about those two?

[0:37:48] HT: The trismus would be the jaw range of motion. Typically, where HPV cancers like to live are in the tonsil, in the tonsil bed. The radiation, typically, the field typically hits that TMJ joint. So throughout radiation treatment, you have to keep that moving, and have them stretching, and moving that jaw. Because what happens is radiation is making it tighter, they're stretching it completely throughout the treatment. It's getting tighter, they're stretching it. Also, if they have a surgical resection through the TORS, which is the transoral robotic surgery, which is where the robot goes in and just stretches everything open, and moves everything out of place, it could displace that joint. So then, after surgery, it gets tight again. Then you have to work that joint. 

With trismus and radiation, it's not something that just gets tight overnight. It just goes down a millimeter, and a millimeter, and a millimeter, and a millimeter. If they're not doing these exercises, then what they'll notice is it's just tight and it could become painful. It's just keeping everything moving throughout to avoid that scar tissue from developing and avoiding that pain.

[0:39:32] MBH: Okay. Actual exercises as well as eating, chewing, and then of course speaking. You use your jaw for all three.

[0:39:40] HT: Yes. There's devices you can use. There's TheraBite, there's the OraStretch, there's good tongue depressors, fingers. I think I probably use a little bit of all depending upon the patient and also too, what the patient can afford and what the deficit is.

[0:40:08] MBH: Okay. Well, thank you. Then, the lymphedema.
[0:40:11] HT: Lymphedema is the swelling of the lymph glands. That's from the radiation treatment. You want to keep everything moving in the head, and the neck, because the radiation will make those lymph glands swollen, so you want to keep everything moving, and keep everything going so the muscles in the neck don't get tight and fibrotic. You want to keep everything moving, keep everything going, so that those muscles don't get tight and fibrotic. I myself personally am not a certified lymphedema therapist, so I just kind of do the stretches to get them through and keep everything kind of at a maintenance point.

Then, once they finish with treatment, and everything kind of settles down as far as with the radiation, what I do then is then refer to our physical therapist who is a certified lymphedema therapist. He will then work and do massage as soon as possible after treatment, as soon as he can touch the neck, to kind of work that down to stop that fluid from hardening, and getting thick, and hard within the net.

[0:41:27] MBH: Well, that is interesting. Who is qualified to earn a lymphedema certification?

[0:41:33] HT: I mean, speech therapists, OT, PT, and I think Walt Fritz, Brad Smith, they all do courses for head and neck lymphedema certifications for the head and neck. And then physical therapists as well as occupational therapists.

[0:41:55] MBH: Okay. Great. All right. Let's talk about specifically the SLP's role. We've touched upon it in conversation, but SLP has played that crucial role in educating, counseling, and treatment of speech and swallowing throughout the continuum of care. Let's dive into each stage. We've got the preoperative evaluation, post-surgery, post-radiation, post-reconstruction.

[0:42:21] HT: Your role in preoperative care is Ð you want to get your baseline Ð well, first of all, you want to get the baseline, but you also want to find out what their goals are. You want to set that realistic expectation of like, ÒThis is what it's going to be like, this is what's going to happen, and this is what to prepare for.Ó Education regarding the side effects that are going to happen, whether if it's surgery, you want to prepare them like, "Hey, look. Your speech is going to change,Ó or, ÒYou're not going to be able to talk after surgery. I can't change that. You're going to be on voice rest, but here's a text to speech app, or here's a writing tablet, or here's this. You're going to need a way to communicate. But four to six weeks after surgery, your speech should start to sound like this, these are the sounds that are going to be difficult."

Setting those realistic expectations, because I feel like the same thing with chemo and radiation, you know, ÒAt four weeks, your mouth won't be dry, you'll notice this, you'll notice this.Ó I feel like if people know what to expect and know the pathway, they're less anxious. They have an idea. It's when they go into surgery and, ÒNobody told me that this was going to happen,Ó setting those realistic expectations, I think are very important. You want to get the baseline, swallowing baseline voice, and then starting on speech and swallowing exercises as soon as you can. I mean, there's a lot of research out there about prophylactic speech and swallowing exercises and how that helps those long-term swallowing.

Also, you want to make any necessary referrals then. Because as soon as things start, it's too late, because then it's too overwhelming. So they need the dietician, get the dietician, get the social worker on board, any other referrals. Just go on and get those things going as soon as possible.

[0:44:41] MBH: On your team, they don't automatically see everyone on the team?

[0:44:44] HT: They typically do. But sometimes, there's just things like the doctor may look at somebody, and think that they're, "Oh, well this person looks overweight, so they probably don't need the dietitian,Ó but they're really dropping 10 pounds a week so yes, you need to see the dietician." But the doctor hasn't asked that question because the weight looks fine on the scale, or they're not telling the doctor they're on the modified diet. Or sometimes things may come up in your session, that aren't alerting the doctors right away for a social worker referral, or different referrals. Sometimes they may wait on them, and then they're like, "No, let's get these things going now." Sometimes, if there's some referrals, definitely for radiation, but sometimes, if it's pre op, they may need them earlier.

Then, for me, because I don't see them on the acute setting, I will say, ÒOkay, my colleagues name is Ð and you're going to see her on acute. This is the person you ask for, I'm going to talk to her.Ó Then they have that Ð and to have that handoff, so they know exactly what to expect, and what that next step will be. They kind of know what the process will be going forward.
[0:46:22] MBH: That's great. Well, so important to decrease any anxiety around the whole surgery, and any little thing that you can do, it can be very helpful.

[0:46:31] HT: Yeah, definitely. I will say too, I'm very fortunate that I have an acute colleague that I can tag-team with. Because literally, as soon as I do that, I call her and I'm like, "Okay. This is what's happening." Then when she sees them on acute, she can do, while they're in the hospital, if she can, she'll see them at bedside, but she can also get done any of those objective studies while they're there. They don't have to come back into it. They can do the video swallow studies, they can do the fiber optic exams, they can do all of those things. Then she can loop and she can tell me, "Hey, they're coming back to you." Then I know Ð so when they're coming post-op, I can schedule their post-op visit the same day. It makes a nice little loop. 

[0:47:25] MBH: Yeah, it sounds like you really focus on the continuum of care.

[0:47:30] HT: I feel like patients like it too. They like to know that people are talking. Sometimes they don't like to know that people are talking.

[0:47:37] MBH: Who said that? But for the most part, they like to know that they have that team working in their favor.

[0:47:44] HT: Exactly.

[0:47:45] MBH: All right. So post surgery then, they're in the hospital, and they're not speaking.

[0:47:53] HT: Well, they'll speak, they're usually communicating, it's just not at their baseline.

[0:47:58] MBH: Okay.

[0:47:59] HT: So the first day, if they have a resection, the doctor will want them to be on vocal rest, minimal communication. That's when they'll use a text to speech app, or they'll use a writing tablet to communicate with the nursing staff because they don't want things, if they did a reconstruction, they don't want it moving around. They want things to stay still for a little bit.

[0:48:25] MBH: Okay. So then at what point post surgery do they usually come back to you?

[0:48:29] HT: If everything goes well, knock on wood, sometimes it's like one to two weeks. They're usually talking pretty well, doing pretty well. Usually on a diet, but they have the swelling, so everything isn't perfect. I think it's setting that expectation. ÒYour tongue was cut. You had this oral surgery, you gotta let things heal.Ó But I think the bigger ones are the ones where the soft palate is involved, and they have the nasal regurgitation. They're like, ÒIt's my Ð and you're like, ÒSo that will get better.Ó Because I feel like people can get past their speech sounding awkward for a while. It's the liquid going through their nose, which I understand that. 

[0:49:24] MBH: Yes, and it hurts too.

[0:49:25] HT: Yes, well, it's just awkward and embarrassing.

[0:49:29] MBH: Okay. So if they've had their surgery before the radiation, they come back after surgery to you, and then they start radiation, and usually see you throughout the radiation.

[0:49:40] HT: Yeah, I see them. My goal is to see them every week. I'll see them every week, either before or after the radiation. I pick the same day, same time, and I see them. A lot of times, I tag-team with a dietitian, because a lot of what we say overlaps. We'll see them together. Because I think it gets confusing. I tell you the texture, she tells you what to eat. We kind of tag team that together. It also kind of works when we go on vacation. Because an idea of like, "Okay, remember, she said five shakes." She kind of knows like, "Remember the exercises?" I can't do what the dietitian does, but I know the language enough where they can't skirt around me. It kind of works really well because I do feel like speech and dietitians, sometimes they get us confused.

[0:50:46] MBH: Right. Well, as you said, it's similar information, but slightly different. 

[0:50:51] HT: Yes. Then if I make a diet change, if I say they need to thicken liquids, she's right there to tell them, ÒOkay. This is what you need to do. This is how you're going to get your hydration now, if you don't want to drink water.Ó Then, also too, with cultural things, she can say, ÒThese are the foods you need to have.Ó I'm like, ÒApple sauce,Ó and they're like, "Yeah, we don't need that."

[0:51:22] MBH: Okay. Then, post reconstruction.

[0:51:25] HT: I think that post reconstruction kind of goes with that kind of post surgery. It's all kind of hand in hand. Because during the surgery, they're going to do a reconstruction.

[0:51:41] MBH: Okay. The reconstruction is not going to come after the radiation? That reconstruction is part of that, they're taking out what they need to take out, and doing the reconstruction at the same time.

[0:51:50] HT: Yeah, they do it all. The other thing we're fortunate with too, is you want a good facial plastic reconstruction person. That's the other thing with the tumor board to say like, "Hey, look, please don't make this flap too big.Ó You know, ÒHow is this flap going to be able Ð don't make this sit down too long, that's going to impact the speech. If you're going to do that, we need to go for an obturator. Because it will impact your functional outcomes.Ó

[0:52:17] MBH: Can you explain what an obturator is?

[0:52:19] HT: An obturator, it's like a retainer, it just kind of sits up in your mouth. If somebody has a hole, or a fistula in the hard palate, they can make this retainer that would cover that hole so that food or liquid won't go up into that nasal passage, or so that it can sit down lower so that the tongue can have contact if they reconstruct, and the tongue is unable to lift as much, or the flap isn't able to lift as much. 

[0:52:57] MBH: That would be the dentist who makes the obturator?

[0:53:00] HT: Yes, or prosthodontist. 

[0:53:02] MBH: Or prosthodontist. Okay. All right. One point we had a note to talk about was post-transoral resection.

[0:53:08] HT: Transoral resection would be very similar. To me, it's kind of Ð surgery is very much surgery. I feel like when you're doing any head and neck cancer patient that is going through surgery, you have to prepare them for what the change is going to be with their speech, their swallowing, and all of those different things. If they're going to have a transoral resection, if they're going to have a flap reconstruction, you have to make sure that they know there are going to be changes to their speech, there are going to be changes to their swallowing. They need to know, ÒOkay, you may have a feeding tube, you're going to have an NG tube.Ó What does that look like? What are the diet levels? What is that going to look like? Realistic timelines for that.

I think knowing all of those kinds of things, but then I feel like too, for the transoral resection, that's the TORS, also knowing, like I talked about with the trismus, ÒThat robot is going to go in. That could stretch your jaw.Ó You have to know that you may wake up, and your jaw is going to feel a little tight. This is the reason why. But then, I feel like also reassuring, ÒWe know these things are going to happen, but this is why you're going to do these exercises. This is why my colleague is going to see you. This is why I'm going to see you afterwards.Ó I think making sure that they know why you have a plan in place. ÒYou might have a feeding tube after you have your resection, because it was done right back there where your tonsil was, or your base of tongue, but you're going to start with a liquid diet, then you may come see me, and you may be on pureed foods, and that's okay because your healing. Your speech may be different, because it's swollen, that's okay. You are healing, you have to be realistic. Things may go up your nose, because it goes back here. That's okay.Ó

I think just making sure that you're talking about all these things, making sure that they know, ÒYou may have trismus, your neck may be tight,Ó if they have to do a neck dissection to get everything out. But I think also being the cheerleader for the surgeon, but you have to remember the number one goal is for you to be cancer free. We can get all of these things after the surgery, but you've got to get through the surgery.

[0:56:22] MBH: Yes, exactly. Get rid of that cancer. All right. I know we're going to have part two and a little bit but I know you want to share a case study, so we have just a few minutes for you to share one case study, then we're going to see if we have any questions from our audience, and then we'll take a break and come back for part two. Share a case study. It doesn't matter which one, it's up to you.

[0:56:46] HT: This person, I find this case study very interesting because he's doing so well now. He's a 38-year-old male, and he was HPV negative with squamous cell carcinoma of the left tongue. He was a T2N2, which means the tumor was a T2, and the N2 means he had two lymph nodes that were involved. So he had the resection, and a reconstruction, and then he had chemo and radiation. He had a left hemiglossectomy, and a left radical neck dissection. They did a radical forearm free flap. They made the tongue here, reconstructed it, put it here, and then sent him off. 

If you think about somebody who, they took half of his tongue, reconstructed it, sent him off to chemo and radiation for seven weeks. Throughout, they were able to Ð the hypoglossal nerve, lingual nerve, they were all maintained during the surgery because they were able to kind of follow that. He did have the two lymph nodes removed. He was the patient that was the perfect patient. He was seen preoperative, he was seen during radiation treatment, chemo treatment, he ate, he drank throughout treatment, did all of his exercises, did his stretches. And then after radiation, his neck swelled, and he got lymphedema. He also had physical therapy afterwards.

He's now seven years out. He's cancer free, he does public speaking all the time. He's the patient that I showed to all of my other patients, and they're like, ÒI want to sound like him.Ó His articulation is perfect, [inaudible 0:59:14] every once in a while if he speeds up, or if he's tired. I feel like he is the perfect patient to show, like if you continue to eat, if you continue to drink, if you do the dietician. He didn't need a feeding tube. He was never admitted during the hospital because of dehydration or non-compliance, or didn't take his pain management. He did have the lymphedema, but he went to lymphedema therapy. 

He doesn't have all this fibrotic Ð you would have to look and see his tongue. When he talks, I show the students every year a clip of him talking. They read this case study and they're like, "Wow." I feel like, for me, it's just the perfect example of Ð if you get the patient that buys in, they can be the success story.

[1:00:13] MBH That's great. Well, thank you for sharing. It doesn't look like we have any questions at this time, so I think we can take our break and come back for part two. If you're coming back for part two, we're going to take about a 10-minute break. Part two is Keys to Rehabilitation After Laryngectomy. We talked a lot about head and neck cancer, but we really didn't speak specifically to Laryngectomy in part one. We're going to dive into that in part two. All right. Do you have anything else you'd like to add at this time, Heather?

[1:00:45] HT: No, I just feel like Ð well, I said no but I just want to thank everybody for joining too, and I probably rambled on a lot. I do feel like head and neck cancer is so deep and so broad. Just to go back to kind of what my mentor said, if you're new at seeing had a neck cancer, or you've done it forever, if you've seen one, you've seen one. It's just really having your toolbox of knowing, ÒOkay, I named my baseline, these are in my toolbox,Ó and reaching out to people who see it all the time, and having those support systems in place in those groups. Because it's a fun population, and it is a population you'll never get bored with. It's always changing, and the therapy, and the therapeutic immunotherapy wasn't on the table five years ago. Now, it's a treatment option, Reiki therapy. It's constantly changing.

[1:01:53] MBH: Well, that is exciting and hopeful. If someone wanted to reach out to you what would be the best way to get a hold of you?

[1:01:58] HT: I feel like email is probably the best for me. However, my phone number I think is available. It's 310-423-9295, but my email, which is heather.thompson@cshs.org is probably the best way to get in contact with me. Because during the day, it's a little chaotic, but when I sit down, I'm always able to return an email.

[1:02:33] MBH: Okay. Well, thank you. 

[OUTRO]

[1:02:36] MBH: Thanks for joining us here at Keys for SLPs, providing keys to open new doors to better serve our clients throughout the lifespan. Remember to go to SpeechTherapyPD.com to learn more about earning ASHA's CEUs for this episode and more. Thanks for your positive reviews and support. I would love for you to write a quick review and subscribe. Keep up the good work.

[END]
KFSP 69		Transcript

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