Making Headway in Speech and Language Therapy Services

The 4th and Final Blog in the Cancer Rehabilitation #Takeover Series

by Julie Ellis, Specialist Speech and Language Therapist in NHS Tayside

Background

I commenced my post as Specialist Speech and Language Therapist (SLT) in Head and Neck Cancer / Oncology in September 2012. Prior to my appointment, there was no dedicated service offered to this population in Tayside.  Limited input was provided from the general SLT team to asses and treat patients post surgically, however there was no SLT service for patients undergoing radiotherapy and/or chemotherapy; and no provision for SLTs to attend routine clinic reviews.

These gaps had long been recognised and in light of this, and the fact there are increasing numbers of younger patients presenting with aggressive tumours, funding was received from cancer services and ENT. Together this ensured the SLT post would be a permanent post.

Evidence

As was mentioned in last weeks blog, cancer and its treatments can have long-lasting negative effects on an individual. An unavoidable consequence of head and neck cancer, and its treatment, is acute or chronic dysphagia. The extent of which will vary, however studies report 50-80% of those affected may have a significant dysphagia.

Swallowing problems, prolonged mealtimes and texture modified diet, along with pain and taste changes can negatively affect quality of life, and can lead to feelings of social isolation.  To this end, authors such as Robbins suggest “mucositis and dysphagia are a barrier to wining the battle with head and neck cancer”, which is another example of “Cured – but at what cost?”, as was discussed in last weeks blog.

Improving long-term swallowing outcomes has been discussed in the literature, particularly with regards to early interventions and prophylactic swallowing exercises (Roe et al, 2011).  Maintaining oral intake throughout treatment, to avoid reliance on alternative feeding has also been discussed, with Langmore et al (2012) suggesting this improves long-term swallowing outcomes.

Both SIGN guidelines and NICE guidelines recommend all patients with head and Neck cancer should have access to SLTs prior to treatment that may result in swallowing and/or communication difficulties.  Also stating patients should have regular access throughout treatment.

What have I achieved?

It’s been a busy year.  We’ve established a basic service which includes being available to patients at all stages of treatment.

We have now set up an SLT service for patients undergoing radiotherapy and/or chemotherapy.  I attend the Consultant-led Head and Neck cancer clinic and Maxillofacial clinic, providing an assessment and advice service as part of the multi-disciplinary team (MDT).

I also provide support during the Clinical Nurse Specialist (CNS)-led clinic for regular radiotherapy reviews.

Attending these clinics allows me to obtain baseline measures in terms of communication status and swallowing status, whilst offering education and support.

Is it enough?

Following results of local focus groups, held in Tayside, Angus and Perth, and the results of a survey across Tayside, Fife and Forth Valley (conducted by Prof Mary Wells) we became aware that our review clinics did not meet the need of all patients.  The feedback suggested reviews were often very short, rushed affairs with too many people in the treatment room.

Subsequently we have set up an MDT clinic staffed by myself, specialist dietitian and CNS.  The pilot commenced in September 2013.

The MDT clinic has two distinct roles: New Diagnosis Clinics and Review Clinics.

New Diagnosis

Patients are invited to attend the MDT clinic, with family members, one week post initial diagnosis.  This session allows them to meet the team and ask any questions.  It enables us to provide information, education and support to the family group about the treatment and the toxicities associated with it.  We set time lines of what to expect and also try to prepare people to expect a “new normal” following treatment.

I also fully assess communication and swallowing on this visit.

Review

The second group of patients, who attend the review clinic, have completed treatment and are either commencing follow-up review or are in an established review phase.

Review appointments alternate between the Consultant-led clinic and the MDT clinic.  This change has to date, resulted in longer consultations and shorter waiting times; and our aim is to address all issues associated with the late-effects of cancer. We also hope to continue to support those affected by cancer as they adapt to the changes associated with treatment.

It is too early to audit the success of this clinic, however we have received positive feedback from all patients.

What next?

I have much more to do and could take up 3 blogs listing it all! I am keen to hear from others with similar experiences and I am happy to share my experiences in more detail with anyone who wants to get in touch. I plan to continue to review the impact of our service developments and look forward to sharing our outcomes in the future. I would also like to encourage others to share their outcomes so that we can advance services more quickly and build the case for SLT involvement in head and neck cancer together.

In the mean time, I think it is fair to say that we have made a good start and our main aim is to continue to support people to live with cancer and the consequences of treatment; through promoting self-care, rehab and recovery.

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