Head and Neck Cancer

Question 1

Demographics

Answer 1

• 3% of all new cancer diagnoses
• ~60,000 new cases per year (11,000 HPV related SCC diagnosed each year)
• 3:1 male to female ratio
• 13,000 deaths per year

Question 2

Risk Factors

Answer 2

• Tobacco
• EtOH
• HPV infection (base of tongue, tonsil cancers)
• EBV infection (nasopharyngeal)
• Betel nut chewing
• History of leukoplakia or erythroplakia

Question 3

Types of Head & Neck Cancers

Answer 3

• Heterogeneous collection of tumors arising
• in the upper aerodigestive tract
• Oral Cavity
• Oropharynx
• Nasopharynx
• Larynx/hypopharynx
• Thyroid
• Nasal cavity/paranasal sinuses
• Salivary glands (major & minor)
• Skin of the H&N

Question 4

Signs & Symptoms

Answer 4

• Oral lesion
• New neck mass
• Globus sensation
• Dysphagia
• Odynophagia
• Otalgia
• Trismus
• Hoarseness
• Epistaxis
• Tongue deviation
• CN deficits

Question 5

Traditional Etiology

Answer 5

• HNC related to tobacco, Etoh use/abuse, reflux and poor socio-economic status –
• Oral Cavity
• Hypopharynx
• Larynx
• Supraglottis

Question 6

HPV + Etiology

Answer 6

• Tongue base, tonsil, soft palate, pharyngeal wall
• Increasing incidence of HPV infection as causative agent
  for tonsil and tongue base cancers (~70% nationwide)
• Non-smokers or former smokers (~2/3)
• Males (90%)
• Younger age (50-60s)
• Smaller tumors, larger lymph node metastases
• Much more favorable outcome than non-HPV related oropharyngeal cancer (HR 0.3-0.4 for death

Question 7

HNC Treatment -> Function

Answer 7

• General Treatment Paradigm
• Maximize likelihood of cure while minimizing
• overall toxicity burden of therapy
• Organ preservation
• Optimizing functional outcomes
• 2 primary modalities – surgery & XRT
• Chemotherapy enhances efficacy of XRT
• Goal is to minimize the number of total treatment modalities

Question 8

Dysphagia in HNC

Answer 8

Related to
* Tumor burden—damage to structure, CNs
* Surgery –damage to CN (peripheral neuropathy)
* Tracheostomy
* Radiotherapy (acute and late effects/toxicity)
* Chemoradiotherapy (acute and late effects/toxicity)
* Recurrence—skull base
* Disuse atrophy

Question 9

Patterns of deficit post chemoradiotherapy

Answer 9

• Tongue base retraction
• Laryngeal closure
• Hyolaryngeal elevation
• Pharyngeal clearance and contraction

Question 10

Swallowing Deficits

Answer 10

• Dysphagia support/treatment
• Initial evaluation of structures, ROM and function, overall status, aspiration risk and nutritional compromise risk
• Provision of swallowing exercise regimen to target tongue base, pharyngeal constrictors and laryngeal elevators, mandible (trismus)
• Carroll, et al.(2008) demonstrated benefit of initiating dysphagia exercises PRIOR to treatment; 3 RCTs demonstrated efficacy for pre-treatment exercise regimen (Carnaby- Mann, et al., 2012; Kotz, et al., 2012; van der Molen et al., 2011)
• Weekly assessment (adjustment) and treatment during course
• Scales, instrumentation, interview
• Long term follow-up –late onset dysphagia, radiation fibrosis particularly for patients with CCRT or triple modality

Question 11

History of PEGs in HNC

Answer 11

• Once upon a time…. Everyone got a PEG
• Then the pendulum swung in the opposite direction
• Now…varies based upon center, MD, number of modalities and perceived toxicity, performance status ?
• Evidence that PEGs may contribute to dysphagia in HNC
  patients (Langmore, et al, 2015)
• Do PEGs cause dysphagia in head and neck cancer patients?

Question 12

Who gets an upfront PEG?

Answer 12

• This prospective descriptive study will include 100 patients who will undergo primary chemoradiotherapy or postoperative chemoradiotherapy for head and neck cancer. Patients of both genders and all ethnic backgrounds ranging in age from 21 on up will
  be included in this study. Subjects will be followed for evaluation at 3 time-points: pre-treatment, half-way through treatment, 3 months, post-treatment
• Inclusion Criteria
• 100 subjects, male or female ages 21 and up
• Subjects who will undergo primary concomitant chemoradiotherapy treatment or postoperative chemoradiotherapy for newly diagnosed tumors of the head and neck and no induction chemotherapy.
• Tumor sites can include oral cavity, oropharynx, larynx, hypopharynx or nasopharynx. Subjects with local neck metastasis will be included.
• Patients who will not undergo PEG placement prior to treatment, based on the following criteria:
• No aspiration on pureed foods and thick liquids during baseline Modified Barium Swallow exam.
• % Usual Body Weight (%UBW) > 95%m, with UBW = current weight / usual weight x 100
• Body Mass Index (BMI) between greater than 18.5, with BMI = Current weight (kg)/ height2 (meters)
• Blood work that reveals no signs of malnutrition prior to chemoradiotherapy (i.e., BUN 7 to 20mg/DL; creatinine 0.8 to 1.4 mg/DL; Albumin 3.4 to 5.4g/DL

Question 13

Prophylactic Swallowing Exercises

Answer 13

• 2-4 x per day until fatigue
• Head and Neck Stretches

Airway Protection
* Supersupraglottic, VF adduction (tight breath hold)
* Cough, EMST, Inspiratory Spirometry

Tongue Base Retraction
* Masako, Effortful Swallow

Pharyngeal Clearance
* Mendelsohn Maneuver
* Effortful Pitch Glide

Question 14

Importance of Oral Care

Answer 14

• Oral health and hygiene is an essential component of patient safety. In fact, the importance of oral care in the prevention of aspiration pneumonia has been well established, particularly in the dysphagic population
• Langmore, et al (1998)—Predictors of aspiration PNA: How important is dysphagia?
• Landmark study
• Aspiration was not enough
• Needed poor oral care, # of decayed teeth, dependence on others for feeding, dependence on others for oral care