Patients Blame H&N Therapy for Lasting Speech Issues

SCOTTSDALE, Ariz. — Patients with oropharyngeal cancer reported significant voice and speech impairment for up to 2 years after chemoradiation therapy, but most of their doctors saw no evidence of it, data from a prospective study showed.

Two years after treatment, a fourth of patients said their voice and speech remained below baseline levels, whereas none of their clinicians noted any impairment. At no time did as many as 10% of clinicians report patients with speech and voice issues, whereas the proportion of patients reporting problems ranged as high as 56%.

The likelihood of patient-reported difficulties with oral communication increased with the radiation dose to the glottic larynx, reported Jeffrey M. Vainshtein, MD, and colleagues at theMultidisciplinary Head and Neck Cancer Symposium.

“Our findings highlight the critical role of patient-reported outcomes in identifying areas of improvement of our current therapies, which may ultimately translate into improvements in quality of life for our patients,” Vainshtein, of the University of Michigan in Ann Arbor, said during a press briefing.

Dysphagia and xerostomia are recognized adverse effects of chemoradiation for head and neck cancer and have been studied extensively in recent years. In contrast, a paucity of information exists relative to the effects of chemoradiation on voice and speech quality, Vainshtein said.

To examine the issue, investigators assessed voice and speech outcomes in 93 patients who underwent chemoradiation for oropharyngeal cancer, using intensity-modulated radiation therapy (IMRT). At baseline, and then every 3 to 6 months after finishing treatment, patients completed two validated questionnaires: Head and Neck Quality of Life (HNQOL) and University of Washington Quality of Life (UWQOL).

At the same intervals, the patients’ physicians reported their assessments in accordance with the Common Terminology Criteria for Adverse Events.

All of the patients had locally advanced stage III/IV oropharyngeal cancer and received treatment in two clinical trials of organ-sparing IMRT. Radiation therapy protocols were designed to minimize the radiation dose to the pharyngeal constrictors, salivary glands, oral cavity, glottic larynx, supraglottic larynx, and esophagus.

Vainshtein and colleagues analyzed patient questionnaires to identify factors associated with voice and speech impairment, in addition to the frequency of impairment.

By the HNQOL communication domain and speech impairment domain of the UWQOL, radiotherapy-induced speech impairment reached a maximum in the first month after treatment. Impairment then decreased in subsequent assessments, stabilizing at 12 to 18 months.

The proportion of patients reporting post-treatment speech and voice impairment followed a time pattern consistent with speech impairment reflected in answers to the questionnaires. By the HNQOL, 68% of patients said their voice and speech quality were impaired versus baseline, decreasing to 56% at 3 months, 46% at 6 months, 33% at 12 months, 31% at 18 months, and 24% at 24 months.

By the UWQOL, the proportion of patients reporting worsening of voice and speech quality after treatment was 41%, 26%, 29%, 28%, 15%, and 22% at the assessments from 1 to 24 months after finishing therapy.

In contrast, few physicians included voice and speech impairment in their adverse event reports. Vainshtein said 7% of physicians reported grade 1 toxicity with respect to worsening of voice and speech at 3 months, 5% at 6 months, and 0% thereafter.

Comparing treatment characteristics and patient-reported voice quality worsening, investigators found an association between radiation dose to the larynx and patient-reported impairment at 6 and 12 months. Reported impairment at 6 months increased from 25% with a cumulative radiation dose of <20 Gy to 59% at >30-40 Gy, 50% at 40-50 Gy, and 64% with laryngeal doses >50 Gy (P=0.02).

A similar pattern emerged from the analysis of 12-month outcomes, as the proportion of patients reporting worsening of voice quality from baseline increased from 10% for laryngeal radiation doses <20 Gy to 63% of patients for cumulative doses >50 Gy (P=0.011).

“We observed similar findings for patient-reported voice quality worsening and speech impairment,” Vainshtein said. “The results were independent of other patient and treatment factors.”

Press briefing moderator Mitchell Machtay, MD, said he found the study eye opening.

“If you looked at radiation dose to larynx, not the area where the tumor was, I was struck by how doses of 20 to 30 Gy, which we don’t normally consider as very toxic high doses that can damage the voicebox, still caused a fair amount of damage,” said Machtay, of University Hospitals Case Medical Center in Cleveland.

The magnitude of disconnect between patient and physician assessments was one of the more surprising findings in the study.

“I don’t think it’s unique to head and neck cancer. I don’t think it’s unique to our study. I don’t think it’s unique to medicine,” Vainshtein said. “I think physicians tend to underestimate the effect of their treatment — whatever it is — on our patients.”

Some adverse effects can be subtle and do not become apparent during conversations with physicians, he continued. When the patients express their sentiments in a more formal manner, such as a questionnaire, the effects do emerge.

Some of the disconnect reflects differences in patients’ approaches to their illness and adverse effects of treatment, said Wade Thorstad, MD, of Washington University in St. Louis.

“There’s a group of patients, when you’re interviewing them about their symptoms, will tell it like it is and really explain things well,” said Thorstad, another participant in the press briefing. “There’s another group that is stoic, and they really underplay their issues before [their physician]. However, when they are filling out a questionnaire about their feelings about quality of life, I think you get a more honest assessment.”

Vainshtein and co-authors reported no relevant relationships with industry.

http://www.medpagetoday.com/MeetingCoverage/MHNCS/44439

 

 

Cochlear implants without external hardware? New chip looks promising

 

Cochlear implants – devices that help people who would otherwise be deaf have some limited hearing – currently require hardware mounted on the outside of the skull to accommodate a recharger and microphone. Now, researchers in the US have developed a new low-powered chip that offers the prospect of eliminating these bulky, visible externals.

The new chip is the work of engineers in the Microsystems Technology Laboratory at Massachusetts Institute of Technology (MIT) together with team members from Harvard Medical School and the Massachusetts Eye and Ear Infirmary.

They are presenting a paper about their work at the 2014 IEEE international Solid-State Circuits Conference being held in San Francisco, CA, this week.

Cochlear implants are used by hundreds of thousands of people worldwide whose hearing is impaired because sensory hair cells in their cochleas, within the inner ear, do not pass on sound vibrations to the brain.

In the US, around 70,000 people have them, many of them children. The device works by electrically stimulating the auditory nerve to receive sound signals that pass from an external microphone into the ear.

Current designs mean that users have to wear a 1-inch diameter disk-shaped transmitter on the skull, attached by a wire to a microphone and power source inside what looks like a large hearing aid around the ear.

But the new low-powered signal-processing chip could lead to a new implant design that eliminates the need for any external hardware, say the researchers. The implant could be wirelessly charged – it could run for about 8 hours between charges – and instead of an external microphone, it could pick up sound using the natural microphone chamber of the inner ear, which is often intact in implant users.

One of the researchers, Anantha Chandrakasan, a professor of electrical engineering at MIT, says:

“The idea with this design is that you could use a phone, with an adaptor, to charge the cochlear implant, so you don’t have to be plugged in. Or you could imagine a smart pillow, so you charge overnight, and the next day, it just functions.”

Lawrence Lustig, director of the Cochlear Implant Center at the University of California at San Francisco (UCSF), who describes the device as “very cool,” says people often experience more stigma with hearing loss than vision loss, so “people would be very keen on losing the externals for that reason alone.”

And, he says, there would also be practical benefits, such as “not having to take it off when you’re near water or worrying about components getting lost or broken or stolen.”

Design is based on middle-ear implant mechanism

The researchers based their new design on the mechanism of a middle-ear implant. The idea is to pick up the sound vibrations in the delicate bones of the middle ear and instead of conveying them to the cochlea, send them to a microchip implanted in the ear that converts them to electrical signals passed to an electrode in the cochlea.

Lowering the power requirements of the chip was the key to eliminating the need for the external skull-mounted hardware, say the researchers.

The device has been tested on patients already with cochlear implants to check it does not affect ability to hear. And the researchers showed the chip can pick up and process speech played into the middle ear.

Lustig says such a device would require more complex surgery to implant than existing designs. A current operation takes about an hour – the new design would probably need about 3 to 4 hours of surgery but would still be a relatively straightforward procedure.

“I don’t anticipate putting a lot of extra risk into the procedure,” he adds.

Medical News Today recently reported a study that showed short stays in darkness can boost hearing. Another US team working with mice found that preventing sight for as little as a week was enough to help the brain process sound more effectively.

http://www.medicalnewstoday.com/articles/272439.php

Picture courtesy to wikipedia