Transcription:
Getting Ahead After Head or Neck Cancer

Scott Webb: Welcome to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System. We put knowledge and care within reach, so you have everything you need to live your life to the fullest. This podcast is sponsored by the UM Rehab Network. I'm Scott Webb. And today, we're discussing head and neck cancer, diagnosis, treatment and rehab with Christine Hudacek, she's a physical therapist and certified lymphedema therapist at UM St. Joseph Medical Center, and Melissa Arasz, she's a speech language pathologist also at UM St. Joseph Medical Center.

So first off, I want to thank you both for joining me today. This is a really interesting topic and I can't wait to learn more and it's great to have the expertise of both of you. So as we get rolling here, I'll start with you Melissa. First off, can you give us a brief summary of what head and neck cancer consists of, the causes, symptoms, things that we can be on the lookout for?

Melissa Arasz: So the symptoms of head and neck cancer can actually really vary greatly from person to person. Sometimes people will have a sore that won't heal in their mouth. They'll find like a red or white patch on their tongue or somewhere else in their mouth that just doesn't seem to heal. Also, some people will notice like a lump or a bump in their neck or a sore throat that just doesn't go away even after being treated for more traditional things like an infection or something like that.

Other symptoms that can be an indication of cancer would be like voice changes or hoarseness or complete loss of voice without a good explanation, difficulty with chewing or swallowing. Some people report some ear pain or we can even have patients that some of their initial symptoms include like unintentional weight loss. We've had people that have reported like a foul mouth odor that just doesn't go away or persistent nasal congestion or difficulty breathing can also be some early symptoms.

In terms of stuff that can increase your risk of developing head and neck cancer, we know that tobacco and alcohol use can definitely increase your risk. Some studies also suggest that marijuana use can increase your risk of developing head and neck cancer, but there's still limited research on that. We know that men are more likely to develop head and neck cancer and that your risk increases after the age of 40. And recently, we've been seeing more and more patients develop head and neck cancer from an HPV infection. And poor dental hygiene and poor nutrition can also increase your risk of developing head and neck cancer as well.

Scott Webb: Thank you for all of that. And it's a lot to unpack and I'm sure that one of the complications as you're going through the possible symptoms is that many of those symptoms may mirror symptoms of other things. Is that one of the complications in diagnosing head and neck cancer, is that all these things could potentially be something else?

Melissa Arasz: Yes. And I think a lot of times, it takes a process to get to a diagnosis. And so we encourage our patients to stay persistent with their followup with their physicians. If they feel like things aren't improving with more traditional treatment, then it's time to start looking beyond that.

Scott Webb: Yeah. Awesome. And I want to bring in Christine now and just briefly discussing here some of the complications and diagnosing and getting to an accurate diagnosis. But let's say someone is diagnosed with this kind of cancer, in what ways does it affect people, physically, psychologically, ADLs, communication and so on?

Christine Hudacek: So a cancer diagnosis really does affect all aspects of a person's life. Physically, you're going to have treatment, which usually requires surgery, radiation. A lot of times it's reconstructive surgery and therefore the neck cancer or the treatment for it can cause pain, trouble swallowing, difficulty talking and eating and disfigurement, unfortunately, to a decent extent, depending on how extensive the surgery is that the person has to undergo. The more complicated reconstruction can be and the more involved that cancer is in the head and neck area, the more likely you will see more of a disfigurement that's going to happen afterwards.

Less commonly, depending on again, how maybe a reconstruction is done, sometimes they use grafting from an arm or a leg, or even sometimes the upper back area that can lead to some facial paralysis and some decreased range of motion or strength in the person's arms. And then oftentimes after surgery, a lot of these patients have to undergo radiation therapy as well. And one of the unfortunate side effects that occurs rather frequently when you have radiation therapy, especially to such a sensitive kind of small area such as the throat, lower face, jaw area is that you're going to develop the potential to develop what's called lymphedema. And this is swelling that occurs not only externally, that you'll see on the outer part of the face, but also internally and can really compromise your ability to then swallow and your voice and your speech at this point.

Another area, treatment can lead also to weight loss and fatigue. We see this a lot with the radiation therapy. A lot of the times they get burning on the inside of their throat area. And the fatigue is a part of this that can further impact a person's ability to do what we call like their ADLs or their activities of daily living. People also report sometimes brain fog. If they're receiving chemotherapy along with the radiation treatment, which is rather common when it comes to head and neck.

A lot of our patients will also report difficulty, being able to concentrate, being able to fully do their job, being more distractible. Patients can also experience changes obviously to their speech, voice, makes it difficult to communicate. Sometimes our patients have a trache that has to be placed in order to be able to establish an area for breathing and that then they lose sometimes their ability to be able to speak at this point. Or depending on how extensive some of the surgery can be, that can also interrupt their ability to be able to communicate with others and loved ones, which you can imagine is rather devastating for a lot of these patients.

Changes with the speech can include distortions to those that undergo a total laryngectomy, which requires a completely different mode of communication altogether. Melissa can probably touch on this a little bit at the end. And in many cases, patients undergo significant weight loss when they have a trache, or if they sometimes many times losing a lot of weight, they have to require a tube placement for feedings known as a PEG tube. If they cannot continue to maintain their ability to swallow and intake with their nutrition, they don't want them to obviously have their weight drop too drastically. So sometimes they have to perform these types of surgeries as well. So most of the time they are temporary, but sometimes a little bit more on a permanent basis for these patients.

Psychologically, patients are often dealing with obviously anxiety, depression related to their cancer treatment and diagnoses. Many of this can show forth in the way of body image, finances, and being able to pay for treatment, lack of control of their life and fear of dying or recurrence. Once unfortunately, they receive a cancer diagnosis, there's always this fear of what's going to come next or is it going to come back, which can weigh heavily on them. There's the concerns that then obviously affect the relationships, not only with their family, but with their friends and coworkers who sometimes struggle with ways that they can relate or help the patient throughout the treatment process.

An important thing to remember also I think for many patients is to let them know that our team is here to support them along their journey from diagnosis and going forward and beyond. If they're hopefully at a good place with us in therapy, if they ever stumble or have issues in the future, we're always curious to continue to support them and help them problem-solve ways that they can continue to move forward and return to a normal life as possible.

Many aspects of a person's life are impacted obviously by head and neck cancer. But they can be improved by participating in therapy and in rehabilitation. We work closely with our doctors and nurses who are part of our team. And we also have a wellness center here at our location and a dietician for patients who need help with not only social and emotional impacts, but also maybe with nutritional guidance and those things to help them with their physical symptoms or helping to regain weight.

Melissa Arasz: We often will help patients and support them regardless of the speech and voices changes that they undergo. That can look very different depending on what the final outcome is in terms of surgery, interventions and things like that. For patients who end up having a total laryngectomy, it means that their voice box is removed. So they're no longer able to use their traditional means of communicating. So we have a lot of different options for helping those patients still be able to communicate effectively. That also ties in with patients who may end up having a tracheostomy tube placed, which is a tube that's placed in the neck that helps maintain their airway and breathing, particularly if they end up having a lot of swelling in the throat area, sometimes that can cause difficulty with breathing, requiring that to be placed. But we can work with patients to learn ways to still verbally communicate even with the trache in place. And that includes something called a speaking valve that we can put on the end of the tracheostomy tube or teach them to use their finger to cover that opening when they want to speak to help them still be able to preserve their ability to communicate.

Scott Webb: Well, I can really see the value in having both of you to work with and the entire team there, because it's a lot, and a lot for patients, their families. And thankfully, they have all of you and your expertise. And Melissa, I read that the goal of rehabilitation for cancer patients is to keep or improve patient's ability to function as well as keep them as active and independent as possible. So how does this apply to head and neck cancer and what kinds of therapies might they need?

Melissa Arasz: The primary therapist from a rehab perspective that a person with head and neck cancer will probably need at some point during their treatment is likely a speech pathologist and then either a physical or occupational therapist that specializes in lymphedema treatment if the patient ends up developing lymphedema. So obviously, speech pathologists can work with patients even at the time of diagnosis to teach them some things to do to help maintain their voice and swallowing ability during treatment and then beyond into the recovery stage. And we know that sometimes even just having something that you can hold onto to say, "I know I'm doing something to help promote my own health while you're feeling like you have such limited control over what's happening to your body" can psychologically also just have some really good impacts. But research also shows that doing these exercises at the beginning of diagnosis through treatment as much as possible and then beyond have the best outcomes in terms of helping people return to eating by mouth and maintaining a relatively normal diet after surgery.

We also know that from a physical therapy perspective, we can teach patients some exercises and range of motions that are going to help maintain the movement of their head and neck during treatment, and also help promote some drainage to try to help prevent any swelling or issues post intervention. We also have physical therapists who can help work with patients to help prevent deconditioning so they can maintain their energy levels and their strength and endurance, which is going to be really important for allowing them to continue to do their daily tasks. And that also ties into teaching patients energy conservation techniques. If we know that fatigue is an expected side effect of treatment itself, what are the ways that we can teach you to still be able to maximize your day and get all of the important things done and still feel like you're able to do that independently and not relying on others to help you as much as possible?

Scott Webb: Yeah. And you mentioned physical therapy there. And I was just thinking, most of us probably have some experience with physical therapy or maybe even occupational therapy, but this is a whole new world for me. And I want to ask you, Christine, what kinds of therapists would a patient work with and what exactly would they be doing?

Christine Hudacek: The patients will be working with a physical or occupational therapist who has had specialized training in treating lymphedema. And this is usually an extensive course that they would go to. Lymphedema is the swelling in any part of the body. But obviously in this case, we're talking about the head, the neck, the facial area. And so patients benefit from working with either PT or OT weekly in order to be able to teach them a specialized massage technique, which is known as manual lymphatic drainage. And what this massage does is it helps move the fluid from the area of swelling down to the chest area and then over to the armpits where there's other healthy functioning lymph nodes that can pick up this excess fluid. And we work with patients generally at least two to three times a week to be able to do this massage. And then we teach it to the patient and to their family members if they need assistance, to be able to do this at home.

We also work a lot on using specific scar techniques. These patients have had surgery in the neck area, or I'd mentioned before with reconstruction, you're obviously going to be seeing incisions and scar healing that we can help increase the mobility of these scars, because a lot of times this is the area where the drainage is being blocked. We can help move that fluid and get it over to other areas of the body where they can pick up this excess fluid and help reduce it from the area of swelling.

Certified lymphedema therapists can also help in the area if patient needed a compression garment. There are special facial garments that you can get for different patients depending to target the different areas of swelling. And we also work with one specific company that makes a compression pump for the head and neck lymphedema patient population, which works amazingly well for these patients. And this allows them to then be able to do treatment at home on a daily basis which is huge, because a lot of times it's going to take several months. And unfortunately with lymphedema, there's not always a cure. They're not going to be able to fully maybe reduce all this swelling. So it's a chronic condition that we have to help the patients manage as they go forward in their life.

Another thing physical and occupational therapists do, as I mentioned before, sometimes patients have difficulty not only with their swelling, but also with range of motion of their arms, especially in some cases where they happen to have to cut one of the nerves, they can lose some of their full use of their shoulder range of motion. So if they're having issues with moving their arms or, in many cases, with their neck range of motion as well, then we also intervene on this end too to help work with patients to help regain as much range of motion in their neck area or with their upper extremities, to be able to allow them to get back to doing, you know, all their daily activities or their work activities and the things they like to do with their life.

Melissa Arasz: Patients who undergo any treatment that can alter their speech, voice or swallowing would also benefit from working with a speech pathologist who specializes in the treatment of those areas. Obviously, the head and the neck are very integral in all of those things that a speech pathologist would treat. And our therapists would focus on teaching patients exercises before their treatment, like we've mentioned before to help maintain their swallowing function during treatment itself. And we know that research supports that those exercises can have huge impacts on their outcomes after treatment is completed in terms of returning to eating the way that they did before treatment began.

Sometimes we will require more of an in-depth assessment of a patient's following ability after treatment. And if that's the case, we have the ability to collaborate with radiologists to conduct swallowing studies that are called modified barium swallow studies. And these tests or studies help us to better assess the patient's swallowing ability. And in fact, they also help us identify, like which exercises are most optimal for a patient, as well as if there's any like strategies that we can teach them to keep them more safe or more comfortable when they're eating in terms of the way that they posture their body or their head. And it helps us know what textures or consistencies of food and drink are the best for the patient at the time.

We can also help patients who experience any speech or voice changes by teaching them some different strategies to adjust for any tissue changes after treatment and to target any weakness that may have resulted from their treatment for head and neck cancer.

Scott Webb: So Melissa, if someone is diagnosed with head or neck cancer, are there things that they can do to stay as healthy as possible during treatments so that essentially they need less therapy?

Melissa Arasz: Yes. I think the best thing that we can tell patients ahead of time, is that meeting with your team of support following diagnosis and even before treatment can really be the best for the patient themselves during treatment and beyond. And that team we've touched on can consist of a lot of different players, but we know that it will likely include a rehab member, like a physical therapist and/or a speech pathologist and nutritionist. Obviously, your nurses and your doctors who are involved in your treatment as well, and then adding any of those other support staff along the way as we need. Like we've mentioned, we've got a wellness center that kind of looks at holistic approach to managing some of those psychological and social symptoms and helping collaboratively treat a patient as they go through this journey.

And we know that doing things ahead of time and really helping you grapple with the diagnosis before you even get started with treatment can really just help you along the way. I think also knowing what side effects to expect and having the therapist intervene early to help you address things that you can do to help prevent any more severe side effects and preserve your function as much as possible is really key. Obviously, we know that eating healthy and staying active is important and we're here to help make sure that that is something that someone can continue to do during treatment.

Scott Webb: Yeah, it's really amazing learning about this and just the size and the scope and the comprehensive ways in which you help patients for everything, including you were mentioning there about , just understanding the side effects, knowing what to be on the lookout for and so on. So a really amazing work. I wanted to give you both a chance, final takeaways for listeners. I'll start with you, Christine. What would be your final takeaways, the things that you really want folks to know about head and neck cancer, rehabilitation, and how you can help them?

Christine Hudacek: One of the key things patients just need to know is that, when they get this diagnosis, I think any cancer diagnosis is overwhelming for patients. They don't know where to go. They don't know what to do. They're frozen by that diagnosis, that there are so many resources available. And that they're not alone in this journey. As Melissa said, it kind of takes a village to help patients be able to really walk their way through the upcoming surgeries or treatments, radiation, whatever it might be. And, you know, she and I often, you know, talk and say it about a patient like, "Oh, if only we maybe had seen them beforehand or we could have taught them how to do this beforehand..." I think that maybe that pre-visit, which a lot of patients don't get is so key to having patients learn certain skills, to be able to help not only keep some of the functions that they have with their speech and their swallowing. But for me, I think on the same end of many patients have never even heard of the word lymphedema

And so they don't even know what that is. They have no clue what I'm talking about or "What do you mean I might get swelling if I have radiation treatment or just from surgery?" And I think just knowing that if they start to see those sorts of things and being able to intervene earlier is better. And for any patient, I think if you can find a rehabilitation team that has both either occupational, if they're lymphedema trained or physical therapists and speech pathologists that are all in the same location, I think can be huge. Melissa and I are constantly mentioning patients. Often, I will see a patient first in our treatment so that I can help work on reducing some of that swelling before they then go to Melissa for speech treatment, whether it be for swallowing or for voice training. And they're able to just I think accomplish a lot more in her sessions if they've seen me first and there's many times she'll get a referral and then come to me and be like, "I think this person has lymphedema. Why don't you come pop in and take a look at them and tell me what you think?" And I think just that collaboration for both of us is huge and being able to really give the best care to our patients.

Scott Webb: Last word to you, Melissa, what would be your takeaways for listeners as they unfortunately maybe confront head and neck cancer or the rehabilitation that we've discussed today? What would you most like them to know?

Melissa Arasz: Christine really touched on this, but that you're not alone in this journey. I think a cancer diagnosis of any kind can feel really isolating. And even though people can find really good support with friends and family, I think just knowing that all of these resources are available and not hesitating to take advantage of them is the biggest thing I would hope that people would take away from this.

And again, like Christine mentioned, I think not just having all those resources, but finding a team that really relies heavily on each other and can help guide you in making those decisions. And I feel like I do the same thing with Christine and with our dietician, if I have questions about what are your daily calorie needs, we know you can eat safely and also meeting those calorie needs each day to help optimize your recovery and having those resources readily available and a team that's not afraid to reach out to those other team members can be a really important aspect of your recovery process.

Scott Webb: Yeah, I see what you mean. And I think just sort of one of my takeaways from today is really how important the education is and the communication and getting the word out and I feel like we've done that today. So thank you both for your time. You both stay well.

Melissa Arasz: Thanks. You too.

Christine Hudacek: Thank you so much for having us.

Scott Webb: And this episode is sponsored by the University of Maryland Rehabilitation Network. Offering a full range of physical rehabilitation services, the UM Rehab Network brings together a committed team of experts from across Maryland to help patients recover from illness or injury, such as stroke, joint replacement, or traumatic injury.

The University of Maryland Rehabilitation Network, bringing world-class comprehensive rehabilitation services directly to your neighborhood. And find more shows like this one at umms.org/podcast. And thank you for listening to Live Greater, a health wellness podcast brought to you by the University of Maryland Medical System. We look forward to you joining us again.