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Best Practice for Communication and Swallowing: Hope for Head and Neck Cancer Survivors

Introduction to Head and Neck CancerWYOMING SPEECH-LANGUAGE-HEARING ASSOCIATION CONVENTIONOCTOBER 10, 2019BRIDGET GUENTHER, MS, CCC-SLP, BCS-S

Disclosures Financial Disclosure: ◦ Ms. Guenther is employed by Atos Medical, Inc. and Atos

Medical paid for her travel to present at the conference

Non Financial Disclosure: ◦ Ms. Guenther is a member of the following organizations: ◦ American Speech Language and Hearing Association (ASHA)◦ American Board of Swallowing and Swallowing Disorders (AB-

SSD))◦ Dysphagia Research Society (DRS)◦ New Mexico Speech Language and Hearing Association

(NMSHA)

Overview of our 2 day journey

Thursday, October 10◦ Intro to HNC (Bridget)◦ Evaluation of Dysphagia in HNC patients

(Melissa)◦ Intro to Lymphedema (Joy)◦ Application of Knowledge, Case Studies

and Panel discussion (All)

Friday, October 11◦ Intro to Treatment of Total

Laryngectomee (Bridget)◦ Treatment of Dysphagia in HNC patients

(Melissa)◦ Treatment of Lymphedema (Joy)◦ Application of Knowledge, Case Studies

and Panel discussion (All)

GOAL: To improve knowledge surrounding the care of patients with head and neck cancer to improve lives and treatment outcomes

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Objectives (Additional to the ones listed on course outcomes)

After this section, participants will be able to:

List 3 causes of Head and Neck Cancer (HNC)

Describe differences in incidence of Oropharyngeal, Pharyngeal, and Laryngeal cancers

Identify 3 different treatment options for HNC

Explain the importance of incorporating Quality of Life (QOL) in evaluation and treatment of patients with HNC

OVERVIEWHead and Neck Cancers

Treatment Options

Deficits by Cancer Site

Interdisciplinary HNC Care Team

SLP Scope and Role

Quality of Life (QoL)

Laryngectomy◦ Anatomical Changes◦ PreOp Evaluation and Counseling

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“Head and neck cancer strikes at the most basic human functions-the ability to communicate, eat, and interact socially”Assessing quality of life in head and neck cancer.Gotay CC, Moore TD.Qual Life Res. 1992 Feb;1(1):5-17

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Head and Neck CancerIncidence vs. PrevalenceStatisticsSymptomsLocation

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Image approved for reuse by Atos Medical, Inc.

Incidence vs. PrevalenceINCIDENCE

RISK OF CONTRACTING CANCER

or

A PERSON’S PROBABILITY OF BEING DIAGNOSED

or

THE NUMBER OF NEWLY DIAGNOSED CASES

PREVALENCE HOW WIDESPREAD CANCER

IS

or

NUMBER OF CASES EXISTING IN A POPULATION DIVIDED BY

THE POPULATION.

Source: https://www.health.ny.gov/diseases/chronic/basicstat.htm

INCIDENCEHead and neck cancer accounts for about 4% of all cancers in the US

Risk of oral cavity/pharynx cancer: 1.2% (2014-2016 data)Risk of laryngeal cancer: 0.3% (2014-2016 data)

PREVALENCE ALL HEAD & NECK CANCERS2019 (Estimates): ◦ 65,410 adults diagnosed (4%

of all cancers) ◦ 14,620 deaths (1.6% of all

cancer deaths)◦ 3:1 men:women for

diagnosis and deaths

Source: https://www.cancer.net/cancer-types/head-and-neck-cancer/statistics

Image labeled for reuse https://commons.wikimedia.org/wiki/File:Diagram_showing_the_parts_of_the_pharynx_CRUK_334.svg )

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WYOMING INCIDENCE

Source: www.seer.gov (information available by state)

Change in Cancer INCIDENCE – WYOMING 2013-2019Source: www.seer.gov (information available by state)

SURVIVAL

5 YEAR OVERALL SURVIVAL RATESIncludes ALL stages (Stage I through Stage IV)(2009-2014) Latest Data

Oral Cavity: ◦65.3%

Larynx: ◦60.3%

Images purchased from iStock

Source: https://www.cancer.net/cancer-types/head-and-neck-cancer/statistics

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But not all SURVIVAL RATES ARE EQUAL…

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Larynx Cancer example

Source: https://seer.cancer.gov/statfacts/html/laryn.html

General Trends across the US From Epidemiological Trends of Head and Neck

Cancer in the United States: A SEER Population Study (2017)

From 2002-2012: 149,301 cases of HNC Overall rate decreased by 0.22% per year Rate of laryngeal cancer decreased by 1.9% per year Rate of oropharyngeal (HPV-related) cancer increased

by 2.5% per year HNC rates: increased significantly in Kentucky and Connecticut decreased in California HPV-related cancers increased significantly in all states

except Georgia, Hawaii, and Michigan Laryngeal cancer rates decreased in California,

Georgia, New Jersey, and New Mexico

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Mourad, M., Jetmore, T., Jategaonkar, A. A., Moubayed, S., Moshier, E., & Urken, M. L. (2017). Epidemiological Trends of Head and Neck Cancer in the United States: A SEER Population Study. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons, 75(12), 2562–2572. doi:10.1016/j.joms.2017.05.008

General Trends across the US (cont’d) From Epidemiological Trends of Head and

Neck Cancer in the United States: A SEER Population Study (2017)

From 2002-2012: Conclusion: ◦Overall incidence of HNC is decreasing in the US

◦ Increasing incidence of HPV-related cancers of the oropharynx

◦Overall increase in HPV-related cancer in patients older than 50 years.

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Mourad, M., Jetmore, T., Jategaonkar, A. A., Moubayed, S., Moshier, E., & Urken, M. L. (2017). Epidemiological Trends of Head and Neck Cancer in the United States: A SEER Population Study. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons, 75(12), 2562–2572. doi:10.1016/j.joms.2017.05.008

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CausesSmoking / DrinkingHerbal useViral (HPV, EBV)Environmental exposureRole of Genetics?Unknown

Symptoms

A lump in the neck Change in voice A growth in the mouth Bringing up blood Swallowing problems Changes in the skin Persistent earache

17Images labeled for reuse: https://tinyurl.com/y2duln93https://tinyurl.com/y2sgdlz3

Location of Head and Neck Cancers

Anywhere in the head or neck:◦Nasopharynx, sinus and nasal cavity◦Oral / Oropharyngeal◦Larynx / Hypopharynx◦Salivary glands◦Lymph nodes (Locoregional metastasis)NOT …. Thyroid, Blood Cancers, Skin Cancers

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Location of HNC by site

Approximate distribution of head and neck cancer:

Oral cavity, 44%; Larynx, 31%; andPharynx, 25%

Image: labeled for reuse: https://tinyurl.com/y6r8xrq7

https://oncologypro.esmo.org/content/download/113133/1971849/file/2017-ESMO-Essentials-for-Clinicians-Head-Neck-Cancers-Chapter-1.pdf

Let’s take a look at some images of Head and Neck Cancer

Staging(and why should the SLP care?)

What is staging?How is Head and Neck Cancer staged?

T= TumorN= NodesM= Metastasis

24Image: Labeled for Reuse https://commons.wikimedia.org/wiki/File:Cervical_lymph_nodes_and_levels.png

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AJCC and NCCNAmerican Joint Committee on Cancer (AJCC) staging system, 8th Edition (2018)Drives staging decisionsMost recent edition with considerations to the differences of

HPV+ and HPV- Cancers

National Comprehensive Cancer Network (NCCN) Guidelines then drive treatment protocol recommendations based on staging Sign up for Free Account to view the recommendations by

NCCN GuidelinesHead and Neck Cancer last updated 9/2019https://www.nccn.org/professionals/physician_gls/pdf/head-and-neck.pdf

Why SLPs should care about staging

Predicted survival is related to site of cancer, staging, HPV status, and other clinical and pathologic factorsPatient presentation and function is direct correlate of stagingTreatment is driven by staging and acute toxicity increases as treatment protocols escalate

Inability to eatresults in loss of muscle mass and malnutrition (reduced functional reserves)

Results in worsening dysphagia (the role of prophylactic swallowing treatment and remember best exercise for eating is eating)

Pain can be overwhelmingreduced ability to f/through on treatment protocols/PO intake

Reduced PO intake and hydration

Mental Health is impactedimpaired ability to participate in decision making/go to appointments

Staging combined with evaluation, in depth interviewing, and patient reported surveys/outcome measures drives treatment

So the patient has a cancer staging…now to cancer treatment decision making

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Treatment OptionsChemotherapyRadiation Therapy

- As treatment option (for cure or control)- Post surgical protocol (planned or (+) surgical margins)Surgical Intervention

- As treatment (for cure)- As Pre radiation protocolCombination of ChemoRadiation (CRT) +/- SurgeryNo treatment as a decisionInnovations in Treatment

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ChemotherapyThree primary roles:◦Neoadjuvant or induction chemotherapy before locoregional treatment with surgery or radiation◦Concurrent chemotherapy and radiotherapy for advanced disease◦Adjuvant post-op chemotherapy usually with radiation

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Side EffectsXerostomia MucositisDysgeusia (Change in taste)Nausea / Vomiting Generalized weakness and fatigue Dysphagia / Odynophagia / Loss of AppetiteHair LossHearing Loss

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Lalla, R. V., Sonis, S. T., & Peterson, D. E. (2008). Management of oral mucositis in patients who have cancer.Dental clinics of North America, 52(1), 61–viii. doi:10.1016/j.cden.2007.10.002Groher M.E. & Crary, M.A. (2010) Dysphagia: Clinical management in adults and children. Mosby/Elsevier Press. Maryland Heights MO

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Otologic Effects of ChemoPrimary drugs for H&N Ca that are ototoxic are -platin drugs (Cisplatin, Carboplatin)Higher dose given less often = greater chance of ototoxicityResults in high frequency lossCase for monitoring to establish baseline, during treatment, and again post treatment

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Radiotherapy aka Radiation Therapy or RT or XRT

Three primary roles:◦Post-operative radiotherapy (RT)◦Definitive RT (for Cure)◦Combined Modality = Chemoradiation therapy (CRT)

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Radiation Therapy Uses highly charged ionizing particles

that interact with cells Traditional and IMRT are daily (M-F) for

up to 7 weeks varies based on STAGING

Technological advances related to focus of radiation include higher dosing but less frequent treatment (IMRT) or Proton

Often require pre-xrt extractions / repair of those teeth that are in the radiation field (may try to keep Maxillary teeth but many get osteoradionecrosis)

35Image Labeled for Reuse https://commons.wikimedia.org/wiki/File:RT_Mask_Oropharyngeal_cancer.jpg

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https://www.youtube.com/watch?v=W_ClcBF6a0IEXAMPLE OF RADIATION THERAPY

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Side EffectsSHORT TERM

(ACUTE/SUBACUTE)Redness / Burns / Skin reactionsLymphedemaIrritation

Sores in the mouthXerostomia (dry mouth)Thickened saliva and other secretions (such as cerumen)DysphagiaChanges in or loss of tastePain, infectionMucositis

LONG TERM (CHRONIC/LATE)

DysphagiaLymphedemaTrismus

Nerve Damage (resulting in weakness, discoordination, reduced ROM) (Peripheral Neuropathy)Mild to Severe Organ DysfunctionCarotid Artery Occlusion

HypothyroidismFibrosis

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Lalla, R. V., Sonis, S. T., & Peterson, D. E. (2008). Management of oral mucositis in patients who have cancer.Dental clinics of North America, 52(1), 61–viii. doi:10.1016/j.cden.2007.10.002 and Groher M.E. & Crary, M.A. (2010) Dysphagia: Clinical management in adults and children. Mosby/Elsevier Press. Maryland Heights, MO.

Otologic Effects of XRT

May result in conductive, sensorineural or mixed hearing loss Up to 40% of patients have acute middle ear side effects during xrt that includes acoustic structures (in the field); 33% develop late SNHL (Jereczek-Fossa et al, 2003)Effect depends on xrt dosage and tumor location

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Jereczek-Fossa, Barbara A et al. Radiotherapy-induced ear toxicity Cancer Treatment Reviews, Volume 29, Issue 5, 417 – 430

Bhandare, N., Jackson, A., Eisbruch, A., Pan, C. C., Flickinger, J. C., Antonelli, P., & Mendenhall, W. M. (2010). Radiation therapy and hearing loss. International journal of radiation oncology, biology, physics, 76(3 Suppl), S50–S57. doi:10.1016/j.ijrobp.2009.04.096

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Otologic Effects of XRT N = 325 patients treated for primary extracranial head and

neck tumors with curative intent who received radiotherapy between 1964 and 2000 (median follow-up, 5.4 years)

Dose incidence varying between 60 Gy to 66 Gy. Total dose to organ seems to be a significant factor though

fractionation and chemo-radiation may contribute to ototoxicities.

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Bhandare, N., Jackson, A., Eisbruch, A., Pan, C. C., Flickinger, J. C., Antonelli, P., & Mendenhall, W. M. (2010). Radiation therapy and hearing loss. International journal of radiation oncology, biology, physics, 76(3 Suppl), S50–S57. doi:10.1016/j.ijrobp.2009.04.096

Surgical Interventionas initial treatment procedure

o To remove tumor/malignancy (for debulking or for cure)

o To remove affected lymph nodesConsiderations:◦ Concomitant medical conditions◦ Metastasis◦ Goal of Surgery?◦ Post surgical function and rehabilitation◦ Pt and family wishes

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Side EffectsTrismusNerve Damage resulting in weakness, incoordination, reduced ROM (Short or Long Term)Complete dysfunction of the structureDysphonia/AphoniaDysphagiaPain, infection, etc

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Immediate post surgical rehabilitation

Speech intervention and the involvement of a competent, caring SLP may be the most important aspect in a patient’s recovery

Imperative that SLP communicates daily with the surgeons while the pt is inpatient

Frequent SLP intervention (eval/tx) to maximize gains

Focus on functional communication to ensure patient can participate in ongoing

care needs and treatment planning return to PO intake as soon as possible to maintain nutritional needs with

eventual transition to returning to as close to prior function as possible

43Image labeled for reuse: http://www.picpedia.org/highway-signs/b/bias.html

Treatment of No treatmentoThe SLP provides information but not necessarily an opinion regarding which choice is “better” or “best”

oUltimate decision rests with pt with the knowledge that SLP will remain part of their care team regardless of the path they choose◦ There is a role for SLP to continue to work on maximizing

communication and swallowing throughout the continuum of disease progression

oHealthcare, cultural and religious beliefs may play a role

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https://www.youtube.com/watch?v=hQwlckZyIxE

DR. COHEN (MEDICAL ONCOLOGIST, ASSOCIATE DIRECTOR, TRANSLATIONAL SCIENCE, MOORESCANCER CENTER, PROFESSOR OF MEDICINE) DISCUSSING IMMUNOTHERAPY

47FUTURE VIEWING for INFO: https://www.youtube.com/watch?v=0l7tNg36kc0

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Interdisciplinary HNC Care Team

ENT SurgeonSpeech Language Pathologist

Cancer Care Coordinator (Case manager – RN or Mid Level or Social Worker)Dentist / Oral Surgeon

PCPDietician

Radiation OncologistHematologist/Oncologist (chemo)

Physical TherapistImage labeled for reuse: https://www.piqsels.com/en/public-domain-photo-jrdte

Role of the SLPEvaluation and treatment (pre, during, post)DysphagiaVoice disordersTracheotomy managementPre-surgical counselingPost-surgical / post-treatment rehabilitation

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Pre-surgical Evaluation and Counseling• Speak with the ENT Surgeons if possible (or have

a copy of their note to refer to surgical plan) • Explain changes to Anatomy, Swallowing,

Speech and Voice• Have models, pamphlets/ brochures, and

significant other/caregiver available during this counseling

• Consider informal/formal evaluation of cognition

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Special Considerations for Dysphagia Evaluation Evaluation◦ Frequency of evaluation (best is

ongoing)◦ Role of Quality of Life Indicators

(ongoing)◦ Putting the pieces together on Clinical

/ FEES / MBS

Quality of Life (QoL) Measures

Examined 57 QoL measures from publications 1990-2010

Most commonly used: ◦ European Organisation for Research

and Treatment of Cancer Quality of Life Questionnaire Head and Neck Module (EORTC QLQ-H&N35)

◦ University of Washington QOL (UW-QOL)

◦ Functional Assessment of Cancer Therapy - Head & Neck cancerFACT-HN40

◦ University of Michigan Head and Neck QOL

◦ MD Anderson Symptom Inventory Head and Neck

Ojo, B., Genden, E. M., Teng, M. S., Milbury, K., Misiukiewicz, K. J., & Badr, H. (2012). A systematic review of head and neck cancer quality of life assessment instruments. Oral oncology, 48(10), 923–937. doi:10.1016/j.oraloncology.2012.03.025

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3406264/pdf/nihms-368340.pdf

PROLONG LIFE not DELAY DEATH

“In conclusion, the impact of the diagnosis and treatment of HNC on physical and psychosocial functioning and overall well-being can not be overstated; and the research body on QOL assessment in HNC patients is growing exponentially to address the significant issue of QOL in HNC patients. It is no longer enough to assess mortality and objective morbidity when evaluating treatment alternativesThe patient's QOL is important in the assessment of survival because the goal of optimal patient care is to prolong life not to delay death at the expense of physical and psychosocial suffering. However, the science of QOL assessment has yet to merge with its clinical application.”

• Emphasis is mine• Ojo et al. from previous page

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University of Washington Quality of Life (UW-QoL)

Domains: Physical, Functional, EmotionalResources listed below are open sourceQuestionnaire: https://www.entnet.org/sites/default/files/uw_qol_r_v4.pdfScoring: https://www.entnet.org/sites/default/files/uw_qol_r_v4_scoring.pdfScoring Update: http://www.hancsupport.com/sites/default/files/assets/pages/UW-QOL-update_2012.pdf

Role of Alternative Nutrition in patients with Head and Neck cancer

Alternative nutrition◦ Lab values (Albumin vs. Prealbumin)

PEG / PEJ or Nasogastric Tube ◦Do PEGs cause Dysphagia in HNC ? (Let’s ask Melissa later)

Prophylactic vs. Acute / Urgent placementRole of continued PO intake

ORAL CANCER

ANTICIPATED DEFICITS AND EVALUATION FOCUS:◦ Trismus◦ Swallow ◦ Oral Phase across the board◦ Speech

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GLOSSECTOMY

ANTICIPATED DEFICITS AND EVALUATION FOCUS Severity depends on glossectomy surgery (partial

vs. near total):◦ Swallow◦ Oral Phase with focus on bolus control, poor

timing, residue◦ Speech

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FOM RESECTION +/-RECONSTRUCTION

ANTICIPATED DEFICITS AND EVALUATION FOCUS◦ Swallow◦ Oral Phase with focus on bolus control, poor

timing, residue (from lip, lingual,tongue deficits)◦ Potential for prolonged NPOdecreased muscle

function/inefficiency in pharyngeal swallow◦ Speech

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BOT/FAUCIAL PILLAR/TONSIL

ANTICIPATED DEFICITS AND EVALUATION FOCUS◦ Swallow◦ Oral Phase related to containment/bolus control

and timing◦ Pharyngeal Phase deficits possible◦ Speech not nearly as impacted

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PALATE/VELUM/SINUS CANCER

ANTICIPATED DEFICITS AND EVALUATION FOCUS◦ Swallow◦ Oral Phase related to containment/bolus control◦ Nasal Regurgitation ◦ Fitting for obturator / palatal lift◦ Pharyngeal Phase deficits possible (residue if

reduced ability to create drive on tail of bolus)◦ Speech deficits can range from non-existent to

severe

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PHARYNGEAL/HYPOPHARYNGEAL CANCER ANTICIPATED DEFICITS AND EVALUATION FOCUS

◦ Swallow◦ Pharyngeal Phase deficits ◦ Speech deficits much less likely

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LARYNGEAL CANCER

ANTICIPATED DEFICITS AND EVALUATION FOCUS◦ Impacts swallowing to varying degrees◦ Dependent on treatment choice and size of

tumor◦ Impacts communication to varying degrees◦ Again dependent on treatment choice and

tumor◦ Evaluation focuses on both voice and swallowing

initially and continues PRN

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TREATMENT CONSIDERATIONS:

◦ ROM exercises / Prophylactic treat

◦ Speech therapy to address precision in articulation

◦ Maneuvers & Strategies (Diet Modification, Postures, use of assistive devices)

◦ Evidence Based Dysphagia Intervention to maximize current function and potential for return to maximum post treatment function

◦ More on treatment from Melissa and Joy tomorrow

Brief Introduction to Laryngectomy

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Laryngectomee vs Laryngectomy

Images from Atos Medical

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Pre-Laryngectomy

1. Breathing occurs through nose and mouth2. Any dust or particles get trapped in your nose and

coughed/sneezed out3. Nose and mouth moisten, filter and heat air before it

enters lungs4. Nose and mouth are connected to both esophagus

and trachea5. When food, liquid or saliva are swallowed, each can

go down the “right” pipe (esophagus) or “wrong pipe” (trachea)

6. Coughing results in mucus/saliva coming up into throat which is subsequently swallowed down into stomach

7. Vocal Cords have multiple jobs:1. close during swallowing to protect food or liquid

from entering lung2. Close off for breat holding

8. Articulators: tongue, teeth, roof of mouth and lips turn the sound into words

Images from Atos Medical

Post Laryngectomy

1. No longer breathe through nose and mouth2. Vocal cords are removed3. Breathe directly into trachea through stoma

(opening) in the neck4. Stoma is a permanent opening5. Filtering, heating and moistening of air no longer

occur6. Mouth no longer connected to the airway, so

during swallowing, food can no longer go down the wrong pipe

7. During coughing, mucus will come out of stoma8. To breath hold, the stoma must be covered9. An alternative sound source to speak (AL, TEP,

Esophageal Speech)10.Swimming and playing wind instruments will be

difficult

Images from Atos Medical

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Total Laryngectomy

Before Laryngectomy After Laryngectomy

Images from Atos Medical

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TerminologyStoma: aka tracheostoma. It is the hole in the neck made by redirecting the windpipe forward and creating a permanent opening. After the surgery, air will move in and out of the lungs through the stoma TEP: Tracheoesophageal Puncture and Prothesis(TE) Fistula: hole (puncture) where the TE Prosthesis lies in the common party wall between the trachea and the esophagus

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Functional ChangesSwallowingHumidificationSecretion ManagementShoweringSwimmingEmergency CareSexual functioning

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Pre-operative Education and Evaluation: Standard of Care

Establish rapportAlways ask, “What has the doctor told you about your surgery?”General overview of impact of total laryngectomy on function:

Pulmonary and CommunicationProvide overview of rehabilitation processPulmonary CommunicationSwallowing Initiate a functional communication alternativeLaryngectomee visitation if appropriate

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Images from Atos Medical

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Pre-operative Education, Counseling and ScreeningEducation and CounselingAnatomical Changes, Breathing, Swallowing, Communication, Self-Care Requirements

ScreeningCognition, vision, dexterity, support system, esophageal factorsPatients receive educational materialsPossible peer laryngectomy counseling/meetingTentative d/c plans are identified

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Images from Atos Medical

Preop Counseling and Its Affect on Length of Stay and Readmissions

Counseling session by SLP and surgery performed by high volume surgeon reduces length of stay (LOS)

d/c to rehab facility actually increases risk of ED visit (Shenson et al ,2017)

“The best care for the head and neck patient is likely given by a team of treating members who address both the oncologic and the functional challenges of treatment“ (Dr. Liu, commentary on Shenson et al, 2017)

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Images from Atos Medical; purchased from iStock

The Pre/Post TL Communication and Pulmonary Plan of Care

Short-term and long-term communication options: Timing or puncture planned preoperativelyPulmonary rehabilitation: Begins in the ORAccess to supplies: Planning begins preoperatively

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Communication OptionsMust involve the patientNot limited to just one optionEducate pt on all forms of alaryngealvoice restoration (i.e. artificial larynx- AL, TEP, esophageal speech) Not all patients are a candidate for a TEPImportant that the patient and healthcare team are on the same page

Post-Operative Communication GoalsReplace: Independent functional form of

communicationReduce: Patient dependence on clinicianImprove: Social engagement and QOLEnable: Patient to engage in care and

management of any devices required for communication

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Patient Goals

Able to be heard and understood by everyoneAchieve social acceptanceAchieve self acceptanceAchieve hands free with TEP

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Images from Atos Medical

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In-Hospital Communication OptionsGesturesAugmentative communication Writing (Boogie Board®, dry erase boards)Smartphone applicationsElectrolarynxTEP (only used when cleared by MD ~ POD 14)

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What we covered…

Head and Neck Cancers

Treatment Options

Deficits by Cancer Site

Interdisciplinary HNC Care Team

SLP Scope and Role

Quality of Life (QoL)

Laryngectomy◦ Anatomical Changes◦ PreOp Evaluation and Counseling

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THANKS!

Contact Info

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Bridget Guenther(505) 484-8001Atos Medical, Inc.Bridget.Guenther@atosmedical.com

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