Restoring Speech after Head and Neck Cancer

Transcript

00:00 --> 00:03Funding for Yale Cancer Answers is
00:03 --> 00:06provided by Smilow Cancer Hospital.
00:06 --> 00:08Welcome to Yale Cancer Answers
00:08 --> 00:10with Doctor Anees Chagpar.
00:10 --> 00:11Yale Cancer Answers features
00:11 --> 00:13the latest information on cancer
00:13 --> 00:15care by welcoming oncologists and
00:15 --> 00:17specialists who are on the forefront
00:17 --> 00:18of the battle to fight cancer.
00:19 --> 00:20This week it's a conversation about
00:20 --> 00:22the role of speech pathology and head
00:22 --> 00:24and neck cancers with John Gerrity,
00:24 --> 00:26a speech pathologist at Yale
00:26 --> 00:27New Haven Hospital.
00:27 --> 00:29Doctor Chagpar is a professor of surgical
00:29 --> 00:32oncology at the Yale School of Medicine.
00:33 --> 00:35John, maybe we can start off by you
00:35 --> 00:37telling us a little bit more about
00:37 --> 00:38yourself and what it is you do.
00:39 --> 00:42As a speech language pathologist,
00:42 --> 00:44I'm a specialist who works
00:44 --> 00:45amongst others who can prevent,
00:45 --> 00:49diagnose, assess, and treat speech,
00:49 --> 00:51language, social communication,
00:51 --> 00:52cognitive communication,
00:52 --> 00:54voice and swallowing disorders.
00:54 --> 00:58And my work primarily is at an
00:58 --> 00:59outpatient or otolaryngology clinic,
00:59 --> 01:01treating patients with voice
01:01 --> 01:02and swallowing disorders.
01:02 --> 01:04And I also work with patients
01:04 --> 01:06who have voice swallowing and
01:06 --> 01:07speech disorders related to a
01:07 --> 01:09diagnosis of head and neck cancer.
01:09 --> 01:11And I do that work at Smilow Cancer
01:11 --> 01:13Hospital in a multispecialty clinic.
01:14 --> 01:16I mean, it seems like patients who
01:16 --> 01:19have head and neck cancers may well
01:19 --> 01:22have dysfunctions in speech and
01:22 --> 01:24language and swallowing and so on,
01:24 --> 01:27either because of the diagnosis
01:27 --> 01:30itself or because of the treatments
01:30 --> 01:32that may have side effects.
01:32 --> 01:34So can you talk a little bit about
01:34 --> 01:37some of the issues that patients
01:37 --> 01:39may have either from the cancer
01:39 --> 01:42itself or from the treatment and
01:42 --> 01:45what people can kind of anticipate?
01:46 --> 01:48Absolutely. So patients who have a
01:48 --> 01:50diagnosis of head and neck cancer,
01:50 --> 01:52primarily in the outpatient setting,
01:52 --> 01:55we're seeing them for assessment of
01:55 --> 01:57swallowing function because that can
01:57 --> 01:59very much be impacted for patients
01:59 --> 02:01with that diagnosis just because of the
02:01 --> 02:03presence of a mass that a patient has,
02:03 --> 02:05that can affect the timing,
02:05 --> 02:07the coordination of swallowing and
02:07 --> 02:09that can really put patients at a
02:09 --> 02:11risk for aspiration in which food or
02:11 --> 02:13liquid can go down towards the lungs,
02:13 --> 02:16creating risk of health complications.
02:16 --> 02:18So these patients will oftentimes
02:18 --> 02:20see them before they're undergoing
02:20 --> 02:23a surgery to see what their baseline
02:23 --> 02:24swallow function is.
02:24 --> 02:26We might be working with these patients
02:26 --> 02:28after they've had an operation to see
02:28 --> 02:30what their swallow function looks like.
02:30 --> 02:31And so there's definitely some impact
02:31 --> 02:34that can be had just from the presence of
02:34 --> 02:36the cancer or from surgical intervention.
02:36 --> 02:38We also work with patients who after
02:38 --> 02:40undergoing radiation treatment or
02:40 --> 02:42even during the process of radiation,
02:42 --> 02:44the effects of radiation that
02:44 --> 02:46set in including fibrosis.
02:46 --> 02:48So tightening of these structures
02:48 --> 02:49can impact swallowing.
02:49 --> 02:52So we try and provide therapy to make sure
02:52 --> 02:54that patients can safely take enough food,
02:54 --> 02:57nutrition and be able to maintain their
02:57 --> 02:59quality of life when it comes to eating.
02:59 --> 03:01As far as speech is concerned,
03:01 --> 03:03a patient can come in and we can
03:03 --> 03:05really help them in a variety of areas.
03:05 --> 03:07As it relates to speech and
03:07 --> 03:08the realm of speech pathology,
03:08 --> 03:10we talk about speech and voice
03:10 --> 03:11a little bit differently.
03:11 --> 03:13So for patients who have
03:13 --> 03:14undergone radiation treatment,
03:14 --> 03:15they can have some swelling or
03:15 --> 03:17inflammation of their vocal cords
03:17 --> 03:19giving them a horse vocal quality.
03:19 --> 03:20We can help them target that.
03:20 --> 03:22And for patients who've undergone
03:22 --> 03:24treatment where their articulatory
03:24 --> 03:25structures are impacted,
03:25 --> 03:27we can help them on
03:27 --> 03:29intelligibility strategies as well.
03:29 --> 03:30So that's just a real small subset of
03:30 --> 03:32the patients that we're working with.
03:33 --> 03:35In terms of swallowing,
03:35 --> 03:37when people have difficulty swallowing
03:37 --> 03:41either because of a mass or because of,
03:41 --> 03:45you know, infiltration of a tumor in
03:45 --> 03:47nerves or because they've had surgery
03:47 --> 03:52that may have caused some damage to those
03:52 --> 03:54structures or radiation with fibrosis,
03:54 --> 03:56certainly swallowing can be a real issue.
03:56 --> 03:59The question then is what
03:59 --> 04:00treatments are available?
04:00 --> 04:02I mean, how can patients make this better?
04:02 --> 04:05Do they ever get back to normal
04:05 --> 04:07swallowing and what does that entail?
04:08 --> 04:10Patients can get back to their
04:10 --> 04:11baseline diet with normal swallowing
04:11 --> 04:13and there are a bunch of different
04:13 --> 04:14factors that will impact that.
04:14 --> 04:17As far as you know, other treatments,
04:17 --> 04:19they've undergone the size or location
04:19 --> 04:21of a mass, so prognosis can be impacted.
04:21 --> 04:24But we start off by assessing
04:24 --> 04:26the swallowing type of disorder,
04:26 --> 04:27the severity of the disorder.
04:27 --> 04:29So we always begin by taking
04:29 --> 04:31a look at the swallow.
04:31 --> 04:34We do that by doing direct visualization
04:34 --> 04:37with fiber optical Laryngoscopy or a ear,
04:37 --> 04:38nose and throat camera where we
04:38 --> 04:40look right down in the throat or
04:40 --> 04:41we can do X-ray swallow tests.
04:41 --> 04:42And when we do that,
04:42 --> 04:44we get a great sense of how
04:44 --> 04:45the structures are moving,
04:45 --> 04:47how timing is, what strength is like,
04:47 --> 04:48what coordination is like.
04:48 --> 04:50And from there we give targeted
04:50 --> 04:52exercises that really try and help
04:52 --> 04:55either strengthen the swallow or get
04:55 --> 04:57some of these tightened structures to
04:57 --> 04:59begin moving a little bit better.
04:59 --> 05:01So patients can be coming to see us
05:02 --> 05:03usually once a week throughout
05:03 --> 05:04the course of treatment.
05:04 --> 05:06For intensive swallowing exercises,
05:06 --> 05:08we carry them through a regimen
05:08 --> 05:10and try and ensure that they're
05:10 --> 05:11following these exercises,
05:11 --> 05:13which will make sure they maintain their
05:13 --> 05:14swallow function or try and improve it.
05:15 --> 05:16That's really interesting.
05:16 --> 05:18I mean, I'm sure you know,
05:18 --> 05:21we often think about exercises like at
05:21 --> 05:24the gym where we're strengthening muscles.
05:24 --> 05:26I don't know that many of us have really
05:26 --> 05:28thought about exercises for swallowing.
05:28 --> 05:30Can you kind of give us a
05:30 --> 05:31sense of what that's like?
05:31 --> 05:33I mean, how do you train your
05:33 --> 05:35muscles in your esophagus?
05:36 --> 05:38When it comes to training all the
05:38 --> 05:40different muscles, we have a pretty,
05:40 --> 05:42pretty consistent set of exercises
05:42 --> 05:44that we use for patients just to
05:44 --> 05:46work on keeping the pharynx strong,
05:46 --> 05:49maintaining range of motion,
05:49 --> 05:50making sure that the airway stays
05:50 --> 05:51protected when you swallow.
05:51 --> 05:53So a lot of these exercises
05:53 --> 05:55have to do with range of motion.
05:55 --> 05:57So for patients undergoing radiation
05:57 --> 05:58treatment, moving the mouth,
05:58 --> 06:00moving your jaw, your tongue.
06:00 --> 06:02But then with the actual
06:02 --> 06:03swallowing exercises,
06:03 --> 06:05where you're physically swallowing,
06:05 --> 06:06it's using a lot of force.
06:06 --> 06:09Swallowing your saliva as hard as you can.
06:09 --> 06:10Or trying to swallow while you're holding
06:10 --> 06:12your tongue in between your teeth.
06:12 --> 06:14Or making sure that you're elevating
06:14 --> 06:16your voice box and holding your swallow
06:16 --> 06:18nice and high and tight as you're trying
06:18 --> 06:21to go through some of these exercises.
06:21 --> 06:23It's something that is
06:23 --> 06:25definitely not second nature.
06:25 --> 06:27A lot of patients need a lot of
06:27 --> 06:28repetition because it's a very
06:28 --> 06:30interesting way to target the swallow.
06:30 --> 06:31But what we're going on is
06:31 --> 06:32just the repetition,
06:32 --> 06:32this movement,
06:32 --> 06:33the strengthening,
06:33 --> 06:34that's what helps them
06:34 --> 06:35get that function back.
06:36 --> 06:38You know, while you were saying that
06:38 --> 06:39I just tried to swallow holding my
06:39 --> 06:41tongue in my teeth and it's pretty tough.
06:41 --> 06:43I'm sure all of our listeners just
06:43 --> 06:46tried that. It takes a lot of work.
06:47 --> 06:48That's a lot of feedback
06:48 --> 06:49I've gotten on that one too.
06:52 --> 06:53In terms of speech,
06:53 --> 06:55that's another one where
06:55 --> 06:58so many of these things we take as
06:58 --> 07:00second nature and then to try to
07:00 --> 07:04learn how to go about speaking,
07:04 --> 07:06especially when there may have
07:06 --> 07:08been damage to nerves or other
07:08 --> 07:10structures that really help us to
07:10 --> 07:13get the sounds out that we use for
07:13 --> 07:15speech might be really difficult.
07:15 --> 07:17Talk a little bit about some of
07:17 --> 07:19the therapies that are available
07:19 --> 07:21for patients who may have speech
07:21 --> 07:23issues after surgery or radiation or
07:23 --> 07:26as a result of a cancer directly.
07:26 --> 07:29With the therapy that's
07:29 --> 07:31involved with the tongue being our
07:31 --> 07:33most used articulator for speech,
07:33 --> 07:35we're typically working with a
07:35 --> 07:36lot of patients who've undergone
07:37 --> 07:38surgeries for a lingual cancer.
07:38 --> 07:40So we do have some patients who might have
07:40 --> 07:42had portion of their tongue removed due
07:42 --> 07:44to cancer and then replaced with a flap
07:44 --> 07:46to try and poke their tongue back up.
07:46 --> 07:48And for these patients,
07:48 --> 07:49they've been speaking a certain way
07:49 --> 07:51the entire course of their lives.
07:51 --> 07:52Then all of a sudden they've
07:52 --> 07:53undergone some intervention.
07:53 --> 07:55They've had cancer and they're used to
07:55 --> 07:58talking in their normal speech pattern,
07:58 --> 08:00but now it's not getting that clarity,
08:00 --> 08:02that articulation that they want.
08:02 --> 08:03So as speech pathologists,
08:03 --> 08:05what we'll do is we meet with these patients,
08:05 --> 08:06we assess their articulation,
08:06 --> 08:09we have them make a lot of different sounds.
08:09 --> 08:11We want to make sure that we're
08:11 --> 08:12covering all the sounds of the
08:12 --> 08:13English language and then we target
08:14 --> 08:16are there any strategies that you
08:16 --> 08:18can do to try and get your speech
08:18 --> 08:19stronger or clearer or more crisp?
08:19 --> 08:22As I like to say for a lot of
08:22 --> 08:24these patients and includes
08:24 --> 08:25compensatory strategies.
08:25 --> 08:27So sometimes that's over articulating,
08:27 --> 08:28moving your mouth more,
08:28 --> 08:30slowing your rate of speech,
08:30 --> 08:32trying to increase your volume in a healthy
08:32 --> 08:34way, using a lot of breath support.
08:34 --> 08:37These strategies can help intelligibility.
08:37 --> 08:39But then it's also some repetition,
08:39 --> 08:41some directed exercises with
08:41 --> 08:42different speech sounds.
08:42 --> 08:42All right,
08:42 --> 08:44let's make sure that your S,
08:44 --> 08:47your T is crisp right where we need it to be.
08:47 --> 08:48And then for other patients,
08:48 --> 08:50if we're noticing it has a lot to do
08:50 --> 08:52with scar tissue or if it has to do
08:52 --> 08:54a lot with our radiation fibrosis,
08:54 --> 08:56we can also offer them something
08:56 --> 08:58called myofascial release where
08:58 --> 09:00it's manual exercises that we can
09:00 --> 09:02try and teach patients to get their
09:02 --> 09:04tongue to be less tight so they're
09:04 --> 09:05able to move their articulators
09:05 --> 09:07better and usually get some better
09:07 --> 09:08speech along with it.
09:09 --> 09:11And so give us a sense of how
09:11 --> 09:13common these problems are after your
09:13 --> 09:15head and neck cancer treatment.
09:15 --> 09:18I mean, are we talking about the majority
09:18 --> 09:20of patients who need to undergo these
09:20 --> 09:22therapies or is it really just a few
09:23 --> 09:26when it comes to swallowing?
09:26 --> 09:28Every single patient who's
09:28 --> 09:29undergoing radiation treatment,
09:29 --> 09:32we try to see for swallowing therapy and
09:32 --> 09:34we do a lot of prophylactic exercises.
09:34 --> 09:36So if patients are going to be
09:36 --> 09:37getting radiation treatment,
09:37 --> 09:39we know that those side effects of
09:39 --> 09:41radiation can continue to impact
09:41 --> 09:43patients years and years down the line.
09:43 --> 09:46So being proactive in getting exercises
09:46 --> 09:48can help prevent patients from
09:48 --> 09:51potentially having issues later on.
09:51 --> 09:52So everybody essentially we
09:52 --> 09:54would love to come and see us for
09:54 --> 09:56swallowing exercises or any speech
09:56 --> 09:58pathologist who you have access to.
09:58 --> 09:59For patients who might have some
09:59 --> 10:02trouble with speech or articulation,
10:02 --> 10:03that's more related to those who
10:03 --> 10:05typically have a lot of involvement
10:05 --> 10:08in the base of their tongue or more
10:08 --> 10:10of their oral tongue as they're
10:10 --> 10:11undergoing cancer treatment or
10:11 --> 10:13other structures like their palate.
10:13 --> 10:15So it might not be very common as
10:15 --> 10:17far as the general population with
10:17 --> 10:19people who have had a neck cancer,
10:19 --> 10:21but by and large,
10:21 --> 10:22if those patients undergo any
10:22 --> 10:24intervention on those sites,
10:24 --> 10:25we'll be seeing them.
10:25 --> 10:26And then there are also patients
10:26 --> 10:27in a completely different subset
10:27 --> 10:29who will see for voice restoration.
10:30 --> 10:33Talk a little bit about the difference
10:33 --> 10:35between speech and voice restoration.
10:36 --> 10:37So with speech,
10:37 --> 10:39what we're really talking about is,
10:39 --> 10:41are those main articulators.
10:41 --> 10:44So we're looking at the the lips, the tongue,
10:44 --> 10:45how they impact the different structures,
10:45 --> 10:47your palate, your teeth.
10:47 --> 10:48When it comes to voice,
10:48 --> 10:50we are really focusing on the
10:50 --> 10:51vocal cords and how the vocal
10:51 --> 10:53cords vibrate to produce a clear,
10:53 --> 10:54steady, consistent voice.
10:54 --> 10:57Now for a lot of patients who undergo
10:57 --> 10:59radiation treatment and that radiation
10:59 --> 11:01field can impact the vocal cords,
11:01 --> 11:03they might end up having
11:03 --> 11:04a horse vocal quality.
11:04 --> 11:06They might have some stiffness to their
11:06 --> 11:07vocal cords and that might prevent
11:07 --> 11:10them from getting as clear or strong a voice.
11:10 --> 11:11Voice therapy,
11:11 --> 11:12which is similar to the
11:12 --> 11:15other types of therapy we do,
11:15 --> 11:16which is very highly repetitive,
11:16 --> 11:17different voice exercises,
11:17 --> 11:19ways to relax the throat,
11:19 --> 11:21get those vocal cords to stretch,
11:21 --> 11:23and that's what we can work on with people.
11:23 --> 11:25But we also have a very large patient
11:25 --> 11:27population that undergoes a procedure
11:27 --> 11:29due to a laryngeal cancer where they
11:29 --> 11:31actually might need their voice box removed.
11:31 --> 11:32And as part of that procedure,
11:32 --> 11:34they no longer have their
11:34 --> 11:34vocal cords present.
11:34 --> 11:36So we need to determine ways in which
11:36 --> 11:39we can help them get that voice back.
11:39 --> 11:40And that's one of the largest
11:40 --> 11:41patient populations we work with.
11:41 --> 11:42They're those who've undergone
11:42 --> 11:43a total laryngectomy.
11:43 --> 11:44So wait
11:44 --> 11:46a minute, I thought you need your
11:46 --> 11:48vocal cords in order to have a voice.
11:48 --> 11:51So if they've been removed and you
11:51 --> 11:53don't have them anymore, how exactly
11:53 --> 11:56are people going to still have a voice?
11:57 --> 11:59We are very fortunate just with
11:59 --> 12:01the technology that we have to help
12:01 --> 12:02people get that voice after surgery
12:02 --> 12:04and very skilled surgeons and the
12:04 --> 12:06whole care team really is involved
12:06 --> 12:08in the care of all our patients.
12:08 --> 12:10But you know
12:10 --> 12:11this patient population in particular,
12:11 --> 12:13when a patient undergoes a total
12:13 --> 12:15laryngectomy, what happens is
12:15 --> 12:17because that voice box is removed,
12:17 --> 12:19there is no longer a connection between
12:19 --> 12:21their airway and their food pipe.
12:21 --> 12:23So these patients have their airway
12:23 --> 12:25redirected and a permanent opening called
12:25 --> 12:27a stoma to the front of their necks.
12:27 --> 12:29Now, usually during the surgery in
12:29 --> 12:32which a total laryngectomy takes place,
12:32 --> 12:34the ear, nose and throat surgeon
12:34 --> 12:36who's completing this surgery will
12:36 --> 12:38actually insert what's called a
12:38 --> 12:39tracheoesophageal prosthesis,
12:39 --> 12:42or ATEP, into the wall between
12:42 --> 12:44the trachea and the esophagus.
12:44 --> 12:45So what this is,
12:45 --> 12:47is this is a valve that when
12:47 --> 12:49patients redirect air through it,
12:49 --> 12:51it vibrates tissue within the esophagus
12:51 --> 12:54and they can actually achieve a voice.
12:54 --> 12:55It's an esophageal speech,
12:55 --> 12:56but they're able to communicate
12:56 --> 12:57with their loved ones.
12:58 --> 12:59Well, that's very interesting.
12:59 --> 13:01So we're going to take
13:01 --> 13:02a quick medical minute.
13:02 --> 13:04But on the other side of the break,
13:04 --> 13:06we will learn more about that and
13:06 --> 13:08other aspects of speech, language,
13:08 --> 13:10pathology and head neck cancer
13:10 --> 13:12with my guest, John Gerrity.
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13:25 --> 13:28Find a Smilow location near you
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14:17 --> 14:20You're listening to Connecticut Public Radio.
14:21 --> 14:23Welcome back to Yale Cancer Answers.
14:23 --> 14:25This is Doctor Anees Chagpar,
14:25 --> 14:27and I'm joined tonight by my guest,
14:27 --> 14:28John Gerrity.
14:28 --> 14:29We're talking about the role of
14:29 --> 14:31a speech language pathologist,
14:31 --> 14:33particularly in patients who have
14:33 --> 14:35faced head and neck cancers.
14:35 --> 14:37And right before the break,
14:37 --> 14:39John, you were talking about
14:39 --> 14:41this population of patients who
14:41 --> 14:43may have had laryngeal cancers,
14:43 --> 14:45So cancers of the voice box,
14:45 --> 14:48where the voice box actually had to
14:48 --> 14:51be removed and how you can actually
14:51 --> 14:54help patients to get a voice back even
14:54 --> 14:56though they don't have a voice box.
14:56 --> 15:00So you were talking a little bit about
15:00 --> 15:02this tracheoesophageal prosthesis.
15:02 --> 15:05Tell us more about what exactly that is.
15:05 --> 15:08Is it like a metallic implant?
15:08 --> 15:10Is it your own tissue?
15:10 --> 15:14And how is it that patients learn to
15:14 --> 15:17make this thing vibrate even though
15:17 --> 15:21the air is coming from their esophagus
15:21 --> 15:23with the tracheoesophageal prosthesis?
15:23 --> 15:27So what that is, is it's a small silicon
15:27 --> 15:29type prosthesis and they're only about
15:29 --> 15:32on average a centimeter in length.
15:32 --> 15:34So it's a one way valve and this valve
15:34 --> 15:37is put right in the patient's tissue and
15:37 --> 15:39what the patient learns to do when they
15:39 --> 15:42want to talk is they breathe in and when
15:42 --> 15:45they breathe out they cover their stoma.
15:45 --> 15:48So that opening in the front of their throat,
15:48 --> 15:50that air travels through that one
15:50 --> 15:53way valve and it's going to vibrate
15:53 --> 15:54the tissue in their esophagus.
15:55 --> 15:58And so that's how that voice is produced.
15:58 --> 16:00Patients typically start using that as
16:00 --> 16:03soon as three weeks after
16:03 --> 16:05and it can be this very intense,
16:05 --> 16:08very life changing procedure.
16:08 --> 16:09And as we're working with these patients,
16:09 --> 16:11it's real hands on treatment.
16:11 --> 16:13Getting them to be able to inspect
16:13 --> 16:14this prosthesis,
16:14 --> 16:16knowing how to care for the prosthesis,
16:16 --> 16:18being able to occlude their own stoma with
16:18 --> 16:21their hands so they can produce a voice.
16:21 --> 16:23It's a lot of follow up with the speech
16:23 --> 16:25pathologist seeing us at least once
16:25 --> 16:27a week on the outpatient side to make
16:27 --> 16:29sure that you're able to communicate all
16:29 --> 16:30of your wants and all of your needs.
16:31 --> 16:35And so when you had mentioned that it's an
16:35 --> 16:38esophageal voice in part because
16:38 --> 16:41the sound I guess is coming from your
16:41 --> 16:43esophagus through this oneway valve,
16:43 --> 16:46how is that different from a tracheal voice?
16:46 --> 16:47I mean does it sound different?
16:48 --> 16:50It does sound different in quality,
16:50 --> 16:51but the clarity of it is actually great.
16:51 --> 16:53I have a lot of patients who say
16:53 --> 16:55that given how their voice might
16:55 --> 16:57have been before their surgery,
16:57 --> 16:59they might feel like they're better
16:59 --> 17:01understood after the surgery given how
17:01 --> 17:03healthy their esophagus was vibrating.
17:03 --> 17:05One of the main differences in voice
17:05 --> 17:07is that you're not going to be able
17:07 --> 17:09to have that pitch change or as
17:09 --> 17:11substantial a volume change as you
17:11 --> 17:15would with vocal cords because your
17:15 --> 17:18pitch changes depending
17:18 --> 17:20on how your vocal cords stretch and
17:20 --> 17:22change their tension and how much
17:22 --> 17:24valve your air to change your volume.
17:24 --> 17:26So these patients might have
17:26 --> 17:27trouble with changing their volume
17:27 --> 17:29as significantly and their pitch,
17:29 --> 17:31but their intelligibility is really great.
17:31 --> 17:34As long as though those articulation
17:34 --> 17:36structures for speech are still intact
17:36 --> 17:40and so, so they can, even though
17:40 --> 17:41they don't have a voice box,
17:41 --> 17:44they can continue to live
17:44 --> 17:46a productive life with a voice,
17:46 --> 17:48albeit a voice that they've
17:48 --> 17:50had to learn to manage.
17:51 --> 17:54And this patient population,
17:54 --> 17:56I've had a lot of patients go
17:56 --> 17:58on to continue to go back to
17:58 --> 17:59resuming their normal lives,
17:59 --> 18:02going back to work, enjoying
18:02 --> 18:04activities with friends and families.
18:04 --> 18:06And it's been very rewarding.
18:06 --> 18:08So you can definitely live a
18:08 --> 18:09pretty normal life.
18:09 --> 18:11You know when we think about these
18:11 --> 18:13patients who have gone through
18:13 --> 18:15head and neck cancers and they're
18:15 --> 18:17dealing with significant disruptions
18:17 --> 18:19or changes in what we all think of
18:19 --> 18:22as normal daily functions, right?
18:22 --> 18:25Our swallowing, our speech, our voice.
18:25 --> 18:28I can only imagine that for some of them,
18:28 --> 18:30even though
18:30 --> 18:34we have now technology where we can
18:34 --> 18:37make people learn how to swallow and
18:37 --> 18:39learn how to speak again and even
18:39 --> 18:41have a voice without a voice box,
18:41 --> 18:45that this may still be something
18:45 --> 18:47that is a little distressing.
18:47 --> 18:50Talk a little bit about the
18:50 --> 18:53psychosocial aspects of this and
18:53 --> 18:55effect of support groups
18:55 --> 18:58and trying to give people mutual support
18:58 --> 19:01as they go through this journey?
19:02 --> 19:05For the patients who I've worked with,
19:05 --> 19:06you know it's definitely phenomenal
19:06 --> 19:08and really remarkable just to
19:08 --> 19:10see the resilience, their resolve,
19:10 --> 19:12their strength and undergoing what
19:12 --> 19:14can be a life changing procedure
19:14 --> 19:15or life changing treatment.
19:15 --> 19:17And you're exactly right
19:17 --> 19:19with how the different,
19:19 --> 19:21the psychosocial impact and just
19:21 --> 19:23the impact on their quality of
19:23 --> 19:26life overall can be great.
19:26 --> 19:28And we're really fortunate in
19:28 --> 19:31that we do have support groups
19:31 --> 19:33where patients can come together,
19:33 --> 19:35really talk about what their experience
19:35 --> 19:38has been, to
19:38 --> 19:39share what their daily struggles
19:39 --> 19:42might be and how they're able to go
19:42 --> 19:44through each day just being able to
19:44 --> 19:46communicate and do the best that they
19:46 --> 19:50can to live as normal a life as they can.
19:50 --> 19:51What I really love about
19:51 --> 19:52one of our support groups,
19:52 --> 19:54which is a laryngectomy support group
19:54 --> 19:57that I'm part of is, you know,
19:57 --> 19:58you can really pose a question,
19:58 --> 20:00start the conversation and then
20:00 --> 20:01these patients are the ones who
20:01 --> 20:03living with these
20:03 --> 20:05diagnoses and they really
20:05 --> 20:06just take it from there.
20:06 --> 20:07They give each other insight,
20:07 --> 20:08they give each other tips,
20:08 --> 20:11they give each other reassurance
20:11 --> 20:12and having those resources and
20:12 --> 20:14just letting people come together
20:14 --> 20:16as a community has been
20:16 --> 20:18something that I'm really grateful
20:18 --> 20:20we've been able to do.
20:20 --> 20:22And in addition to that,
20:22 --> 20:23just whenever I have people coming
20:23 --> 20:25into clinic and I know that all the
20:25 --> 20:27providers are fantastic and trying
20:27 --> 20:28to make sure that patients are
20:28 --> 20:30set up with the right counseling
20:30 --> 20:31services that they may need or
20:31 --> 20:34even if they don't need it at that
20:34 --> 20:35time or would prefer maybe to talk
20:35 --> 20:37to somebody at a later time.
20:37 --> 20:39They always set them up with those
20:39 --> 20:40resources to make sure whether
20:40 --> 20:42it's social work or somebody
20:42 --> 20:44else who they can talk to that
20:44 --> 20:45these resources are in place.
20:45 --> 20:47I let my patients know who are
20:47 --> 20:49particularly undergoing a total
20:49 --> 20:51laryngectomy because we see these
20:51 --> 20:52patients so frequently for follow up.
20:52 --> 20:54You know we're here for you this
20:54 --> 20:56Cancer Center is here for you.
20:56 --> 20:57You become a friend with
20:57 --> 20:58my department for life.
20:58 --> 21:00Given how often we follow up with you and
21:01 --> 21:02if there's anything that we can
21:02 --> 21:03do to support you or point you
21:03 --> 21:04in the direction of support,
21:04 --> 21:05we're going to be here to do that.
21:06 --> 21:08Yeah. That that's so important.
21:08 --> 21:10And I'm sure that your patients
21:10 --> 21:12really love that kind of of support
21:12 --> 21:14as well as the support that they
21:14 --> 21:16get from other cancer survivors.
21:16 --> 21:18I can just imagine if you were newly
21:18 --> 21:20diagnosed and you're faced with this,
21:20 --> 21:22you are no longer
21:22 --> 21:23going to have a voice box.
21:23 --> 21:25You are going to have to learn
21:25 --> 21:27how to manage a prosthesis.
21:27 --> 21:29Just to hear from somebody who might
21:29 --> 21:31have gone through it before that this
21:31 --> 21:33is livable and that you can do this
21:33 --> 21:35and get through it and live a normal
21:35 --> 21:39and healthy life I'm sure is so reassuring.
21:39 --> 21:42The other piece though that I think
21:42 --> 21:44is really important is
21:44 --> 21:45one that you've kind of touched on,
21:45 --> 21:48which is that there are other people on
21:48 --> 21:50the team who are also there to support.
21:50 --> 21:52So whether that's social
21:52 --> 21:53workers or psychologists.
21:53 --> 21:54And you know,
21:54 --> 21:56even thinking about what we were
21:56 --> 21:58talking about before the break in
21:58 --> 22:00terms of learning how to swallow,
22:00 --> 22:01again, I'm sure that,
22:02 --> 22:05having relationships with dietitians
22:05 --> 22:06and nutritionists,
22:06 --> 22:08other physical therapists as well
22:08 --> 22:11as your medical team is really
22:11 --> 22:13important in terms of making sure
22:13 --> 22:14that you're getting the right
22:14 --> 22:16nutrition and when you should be
22:16 --> 22:18having more solid food and when
22:18 --> 22:20you should be having more pureed
22:20 --> 22:22food and so on and so forth.
22:22 --> 22:25Talk a little bit more about how that
22:25 --> 22:27multidisciplinary interaction occurs.
22:27 --> 22:29The multidisciplinary interaction
22:29 --> 22:31really starts off at the very
22:31 --> 22:33beginning of a diagnosis.
22:33 --> 22:36So if a patient's coming in to see
22:36 --> 22:38your nose and throat physician,
22:38 --> 22:42they just received the diagnosis of
22:42 --> 22:44cancer where the patients typically go
22:44 --> 22:46for direction of treatment after that
22:46 --> 22:48is a tumor board and that's something
22:48 --> 22:50where the staff meets weekly and we have
22:50 --> 22:52people from all different disciplines.
22:52 --> 22:54We have medical oncology,
22:54 --> 22:56radiation oncology, ear,
22:56 --> 23:00nose and throat dietitian speech pathology,
23:00 --> 23:02APRN's. It's a whole host of
23:02 --> 23:03members on the medical team.
23:03 --> 23:04And they really get together,
23:04 --> 23:07look at this patient's diagnosis,
23:07 --> 23:09look at what the testing has told
23:09 --> 23:11them and develop a treatment plan.
23:11 --> 23:12And typically that's where
23:12 --> 23:13patients would then come to me,
23:13 --> 23:15they get a referral for speech
23:15 --> 23:17because the physician might say,
23:17 --> 23:18all right, well,
23:18 --> 23:19we're anticipating swallowing
23:19 --> 23:21issues for this patient or this
23:21 --> 23:22patient's getting radiation.
23:22 --> 23:23Let's get them over to a speech
23:23 --> 23:25pathology for an assessment,
23:25 --> 23:27and at that point I complete my assessment.
23:27 --> 23:28I'm doing my therapy,
23:28 --> 23:29but throughout the course
23:29 --> 23:30of the patient's treatment,
23:30 --> 23:32I'm in constant communication
23:32 --> 23:34with our registered dietitians,
23:34 --> 23:35ensuring that the recommendations
23:35 --> 23:37I've made for eating and drinking
23:37 --> 23:39are ones that a patient can follow
23:39 --> 23:41and get nutrition and hydration.
23:41 --> 23:43I'm also letting the physicians
23:43 --> 23:45know how the patient's progressing,
23:45 --> 23:47where I think that I'm going to be
23:47 --> 23:49able to help them get to as far as
23:49 --> 23:51eating and drinking all throughout
23:51 --> 23:52the course of the treatment.
23:52 --> 23:53It's something where we're in
23:53 --> 23:55very close communication,
23:55 --> 23:56the staff collaborate great,
23:56 --> 23:57all the medical providers
23:57 --> 23:59that we're working with.
23:59 --> 24:00And the feedback that I've gotten
24:00 --> 24:02from patients is it's very nice how
24:02 --> 24:04open the lines of communication are
24:04 --> 24:06and how it seems like everybody's
24:06 --> 24:08really collaborating well to provide
24:08 --> 24:09a patient with the best care possible.
24:10 --> 24:12And then finally you know as
24:12 --> 24:15we talk about all of the newer
24:15 --> 24:18technologies that have really helped
24:18 --> 24:20patients in terms of for
24:20 --> 24:22example regaining voice and so on.
24:22 --> 24:25Can you talk a little bit about some of
24:25 --> 24:27the newer things coming down the Pike?
24:27 --> 24:29Is there research that goes on
24:29 --> 24:32in speech and language pathology
24:32 --> 24:33that patients should be aware of?
24:34 --> 24:36Of course, there is always new
24:36 --> 24:38research that's being
24:38 --> 24:40published for speech pathology in
24:40 --> 24:42the areas of voice, swallowing,
24:42 --> 24:44articulation, and a lot of that.
24:44 --> 24:48Evidence base is just all evidence base
24:48 --> 24:51is really what's driving our practice
24:51 --> 24:53as far as it goes with swallowing.
24:53 --> 24:55There's been a lot of research that's
24:55 --> 24:57come out and new technology for patients,
24:57 --> 24:58biofeedback.
24:58 --> 25:00So different machines that can measure
25:00 --> 25:02the strength of a patient swallow,
25:02 --> 25:05give them a visual readout of how
25:05 --> 25:07hard they're swallowing or how much
25:07 --> 25:09force they're using and encourage
25:09 --> 25:11them, coach them to practice with
25:11 --> 25:12a greater amount of intensity.
25:12 --> 25:15That's one piece of technology that's
25:15 --> 25:17been really beneficial for patients.
25:17 --> 25:19We also have different devices that might
25:19 --> 25:21help patients with their range of motion.
25:21 --> 25:24So some patients who I have with
25:24 --> 25:25difficulty with opening their jaw,
25:25 --> 25:27we have different devices that
25:27 --> 25:28can help their jaw open more,
25:28 --> 25:30find ways to do stretches and
25:30 --> 25:32not to mention just the whole
25:32 --> 25:34host of artificial intelligence,
25:34 --> 25:37different things with voice reproduction,
25:37 --> 25:37voice banking.
25:37 --> 25:39It's a constant change and
25:39 --> 25:41it's really taken off I think
25:41 --> 25:43exponentially with a lot of what
25:43 --> 25:45we're able to access for patients.
25:45 --> 25:48And with all the research that's being done,
25:48 --> 25:50I think we're just going to have more
25:50 --> 25:53and more to offer from a rehabilitative
25:53 --> 25:55perspective in the years to come.
25:56 --> 25:58So just a question, what
25:58 --> 26:00exactly is voice banking?
26:01 --> 26:02So voice banking is something
26:02 --> 26:05that if patients might have a
26:05 --> 26:06diagnosis of head and neck cancer,
26:06 --> 26:09they might have another diagnosis that
26:09 --> 26:10might impact their their communication
26:10 --> 26:12abilities or it might be degenerative
26:12 --> 26:14in nature for their communications.
26:14 --> 26:16So we'd expect their speech
26:16 --> 26:18and their voice to get worse.
26:18 --> 26:19There's software out there where
26:19 --> 26:21we can record a patient's voice.
26:21 --> 26:23And then given some of the
26:23 --> 26:24software that we have,
26:24 --> 26:26you can plug it into a device.
26:26 --> 26:28And that device speaks for the patient,
26:28 --> 26:29because they're able to program it,
26:29 --> 26:30it will sound like them.
26:30 --> 26:32So it'll continue to have their
26:32 --> 26:34voice even if they're not able
26:34 --> 26:36to produce it themselves anymore.
26:37 --> 26:38Wow, that's very cool.
26:38 --> 26:41So, but how does that work?
26:41 --> 26:42I mean, how does the device know
26:42 --> 26:44what the patient wants to say?
26:44 --> 26:46I mean, how does that work?
26:47 --> 26:49So that's augmentative and
26:49 --> 26:50alternative communications.
26:50 --> 26:52So these are different devices
26:52 --> 26:55similarly set up like a like a
26:55 --> 26:57smart tablet where the programs
26:57 --> 27:00that they have preset,
27:00 --> 27:02messages or they
27:02 --> 27:04might also have simple buttons
27:04 --> 27:06you can click which will end up
27:06 --> 27:07communicating a message for you.
27:07 --> 27:11So a variety of ways where just by the
27:11 --> 27:13click of a few buttons or even by eye
27:13 --> 27:16gaze and some of the advanced technology,
27:16 --> 27:17these these devices can
27:17 --> 27:18help patients communicate.
27:19 --> 27:22Very cool. And then for the biofeedback,
27:22 --> 27:25I can imagine that that's really helpful
27:25 --> 27:27as patients are going through their
27:27 --> 27:29training and and doing their exercises,
27:29 --> 27:33Is that like an app that they carry around
27:33 --> 27:35with them where it gives them feedback
27:35 --> 27:37or is that like external technology that
27:37 --> 27:39they need to hook up to themselves?
27:39 --> 27:41How does that work exactly?
27:42 --> 27:44So that's typically some external technology
27:44 --> 27:46that they'll hook up to themselves.
27:46 --> 27:47So we have different,
27:47 --> 27:50we have different devices that patients
27:50 --> 27:52can use and they can even sync it
27:52 --> 27:54to an application on their phone.
27:54 --> 27:55So if I'm working with a
27:55 --> 27:57patient on tongue strength,
27:57 --> 27:58what we might be able to do
27:58 --> 28:00is use a pressure bulb.
28:00 --> 28:01I'll have them try and
28:02 --> 28:03put as much pressure as
28:03 --> 28:05they can to try and work those
28:05 --> 28:06swallowing muscles and they'll get a
28:06 --> 28:08readout on their phone and that tells
28:08 --> 28:10them if they're getting into the
28:10 --> 28:12range that they need to be in or not.
28:12 --> 28:14With a lot of the patients
28:14 --> 28:15that we're working with,
28:15 --> 28:17sometimes sensation can really
28:17 --> 28:19be impacted given the surgery,
28:19 --> 28:21the radiation, the presence of cancer.
28:21 --> 28:23So having this biofeedback,
28:23 --> 28:24letting patients know how
28:24 --> 28:26hard their body's working,
28:26 --> 28:28how well they're doing the exercises,
28:28 --> 28:29that really provides them with
28:29 --> 28:31the benefit of knowing they're
28:31 --> 28:32working as hard as they can to
28:32 --> 28:33try and get the best end result.
28:34 --> 28:36John Gerrity is a speech language
28:36 --> 28:39pathologist at Yale New Haven Hospital.
28:39 --> 28:41If you have questions, the address
28:41 --> 28:43is Cancer Answers at Yale dot Edu.
28:43 --> 28:45And past editions of the program
28:45 --> 28:48are available in audio and written
28:48 --> 28:49form at yalecancercenter.org.
28:49 --> 28:51We hope you'll join us next week to
28:51 --> 28:53learn more about the fight against
28:53 --> 28:55cancer here on Connecticut Public Radio.
28:55 --> 28:57Funding for Yale Cancer Answers is
28:57 --> 29:00provided by Smilow Cancer Hospital.

Information

Restoring Speech after Head and Neck Cancer with guest John Gerrity August 13, 2023 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095