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The benefits of early intervention to improve speech clarity, voice quality, safe swallow, and quality of life in head and neck cancer patients

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The benefits of early intervention to improve speech clarity, voice quality, safe swallow, and quality of life in head and neck cancer patients

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The Benefits of Early Intervention to Improve Speech Clarity, Voice Quality, Safe Swallow,
and Quality of Life in Head and Neck Cancer Patients

Laishyang Ouyoung

University of Southern California

A Dissertation presented to the faculty of Rossier School of Education
in partial fulfillment of the requirements for the degree of
Doctor of Education

August 2023

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Laishyang Ouyoung
Copyright 2023
All rights Reserved

The Committee for Laishyang Ouyoung certifies the approval of this Dissertation

Dr. Mark Robison
Dr. Lawrence Picus
Dr. Uttam Sinha
Dr. Ruth Chung, Committee Chair

Rossier School of Education
University of Southern California
2023

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Abstract
Patients with head and neck cancer are at risk for developing aspiration pneumonia,
dysphagia, speech, and voice challenges after surgery, during and after the chemoradiation
(CRT) management. While advances in surgical and radiation therapy have drastically improved
oncologic outcomes, there are not without risks. The side effects of cancer treatment causing
aspiration, speech impairment, voice impairment and dysphagia have significantly decreased
patients' quality of life. (Kraaijenga et al., 2015; Hutcheson et al., 2012). This quantitative
correlational study was conducted to evaluate the benefits of early intervention to speak with
clear voice quality, to swallow safely and to improve quality of life by using a patient's self-
reported survey questionnaire after cancer treatment. The results indicated that early speech and
swallowing intervention significantly improved patients’ ability to speak with clarity without
being hoarse and to eat with safety. This study also confirmed the benefits of early speech, voice
and swallowing intervention have improved patients' quality of life in their ability to speak, to
voice, to swallow, and to taste foods with more saliva flow. Patients can participate in daily
activities without feeling fatigue. Early speech, voice, and swallowing intervention within six
months of cancer treatment are essential for all care providers to make referrals to speech
pathologists so that HNC patients can speak with clarity and with good vice quality, to eat safely
for the years to come after the cancer treatment.
Keywords: head and neck cancer, early speech, voice, and swallow intervention, quality
of life, aspiration pneumonia.

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Acknowledgements
It takes a village to raise a child, and it appears the same is true to complete a dissertation.
I would like to take this moment to acknowledge my village and to thank them for their
encouragement and support. To begin, I would like to thank my chair, Dr. Ruth Chung. I could
not have done this without your encouragement, patience, and folders filled with guides and
examples. Thank you for enlightening me with your knowledge and clearing my questions. I
would also like to thank the members of my dissertation committee, Dr. Robison, Dr. Picus, and
Dr. Sinha, who pushed me to see beyond my initial thoughts and dig deeper to strengthen this
study.
I would also like to thank my USC classmates: JP, Lisa, Jimmy, Adam, and Peter. Your
timely encouragement and technical support to assist me to overcome computer challenges and
willingness to help me in the classes and during the overseas trips. Your timely support in
helping me navigating the stairs and in walking long distance was much appreciated. Ms.
Queenie and Omowale provided me the insight of Black race struggle and how you will make
the significant contributions to your race; Sedda, Daisy and Susan, I enjoyed outings with you, so
fun to be with young people. I enjoyed the time when we were in-person classes doing projects
and presenting our point of view backed up by evidence. Interacting and learning from my
cohorts with different fields of expertise and knowledge, I have broadened my dimensions of
learning and understanding in the field of education policies and implementation of written
policies. I can relate my healthcare field to the domain of education. I enjoyed the energy,

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positive social interactions, and ideas exchanges both in the classes and in our field trips. Those
happy moments I will cherish for a long time.
I would not be who I am today without my loving husband, Tony. Thank you for
inspiring me to pursue my dream to become a doctor and leave you without proper meals when I
make multiple international trips. During Covid time, I lost my dear mother, and I could not go
back home to be with her during her last moment. I will dedicate my success and my
achievement to my dear mother who sacrificed her own wellbeing for the benefit of her daughter.

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Table of Contents
Abstract .......................................................................................................................................... iv
Acknowledgements ......................................................................................................................... v
List of Tables ................................................................................................................................. ix
List of Figures ................................................................................................................................. x
Chapter One: Introduction to the Study .......................................................................................... 1
Purpose of the Study and Research Questions ............................................................................ 4
Importance of the Study .............................................................................................................. 4
Theoretical Framework and Methodology .................................................................................. 6
Terms and Definitions..................................................................................................................... 9
Chapter Two: Literature Review .................................................................................................. 10
Aspiration Pneumonia ............................................................................................................... 10
Side Effects of Cancer Treatment ............................................................................................. 15
Early Intervention for Head and Neck Cancer Patients ............................................................ 20
Chapter Three: Methodology ........................................................................................................ 29
Participants and Procedure ........................................................................................................ 29
Data Collection and Instrumentation......................................................................................... 32
Chapter Four: Results ................................................................................................................... 36
Chapter Five: Discussion .............................................................................................................. 44
Discussion of Main Findings .................................................................................................... 44

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Implications for Practice for Healthcare Education .................................................................. 49
Limitations of the Study................................................................................................................ 52
Recommendations for Future Studies ....................................................................................... 53
Conclusion ................................................................................................................................. 54
References ..................................................................................................................................... 56
Appendix A: Speech Handicap Index ........................................................................................... 84
Appendix B: Eating Assessment Tool (EAT-10) ......................................................................... 90
Appendix C: Voice Handicap Index-10 ........................................................................................ 91
Appendix D: University of Washington Quality of Life Questionnaire ....................................... 92
Appendix E: Figure 1 Quality Health Outcomes Model………………………………………. 95

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List of Tables
Table 1: Clinical Profile of Patients Participated in This Survey ................................................. 31
Table 2: Participants Cancer Treatment and Intervention ............................................................ 31
Table 3: Means and Standard Deviations for Speech Impairment by Timing of Speech Treatment
Speech Handicap Index scores...................................................................................................... 37
Table 4: Means and Standard Deviations for Voice Impairment by Timing of Voice Treatment
Voice Handicap Index -10 scores ................................................................................................. 38
Table 5: Means and Standard Deviations for Swallowing Impairment by Timing of Swallow
Treatment EAT-10-swallow scores .............................................................................................. 39
Table 6: Means and Standard Deviations for Physical Function and Social Emotional Function
by Timing of Speech Treatment ................................................................................................... 40
Table 7: Means and Standard Deviations for Physical Function Scale by Timing of Swallow
Treatment ...................................................................................................................................... 42

x
List of Figures
Figure 1: Quality Health Outcomes Model. .................................................................................... 8

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Chapter One: Introduction to the Study
Head and neck cancers (HNC) constitute the sixth most frequently diagnosed cancers
worldwide (Heron &Thomas, 2011) and survival rates continue to improve. However, little is
known about how the side effects of cancer treatment affect their speech clarity, voice quality,
swallowing safety, and quality of life for the approximately 50% who survive 5 years. The long-
term effect of early speech and swallowing intervention on HNC survivors is limited. Multiple
researchers documented that HNC survivors continue struggling with the effects of their disease
and treatment past 5-year survival (Hutcheson et al., 2013; Kraaijenga et al., 2015). There is
growing evidence of the potential benefits of early intervention among HNC patients undergoing
chemoradiation treatment (Shinn et al., 2013; van der Molen et al., 2011). Therefore, it is vital to
understand the benefits of early intervention for HNC patients to improve their speech, voice,
and swallowing skills within six months after the cancer treatment. It is crucial to keep HNC
patients eating orally, speaking with a clear voice, and maintaining HNC patients’ quality of life.
This study hopes to contribute to a growing body of evidence demonstrating the benefits of early
intervention and urge physicians to refer patients within six months of cancer treatment so that
their quality of life may be enhanced, especially in the domain of speech, voice, and swallowing
abilities.
Background of the Problem
Impairment of speech function is a common sequel of head and neck cancer (HNC). It is
estimated that up to two-thirds of head and cancer survivors report some degree of posttreatment
speech impairment (Rinkel et al., 2008). The authors indicated that HNC survivors can have
permanent alterations in their ability to communicate with others. The authors concluded that
speech intelligibility deficits persist among many long-term HNC survivors regardless of cancer

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site, cancer stage, or type of treatment. Decreased word intelligibility is associated with a greater
number of quality-of-life measures than decreased sentence intelligibility (Meyer et al., 2004).
This may result in withdrawal from social interactions, consequently leading to psychosocial
problems and poor quality of life (Dwivedi et al., 2009). Early intervention is critical to improve
voice quality. Kraaijenga et al. (2015) reported that HNC patients had voice changes including
breathiness and hoarseness. They also reported that HNC patients had increased vocal effort
when talking. Limited studies were done to address the effect of early speech intervention to
improve speech clarity. There is growing evidence to support early speech and swallowing
intervention: Shinnet al. (2013), van der Molen et al. (2013), and Hutcheson et al. (2013)
reported the positive association of maintenance of oral intake throughout radiotherapy or
chemoradiotherapy for pharyngeal cancers and swallowing exercise adherence with long-term
swallowing outcomes. Ouyoung et al. (2015) reported that use of a multimodality voice therapy
program-ABCLOVE on HNC patients with 2-times weekly swallowing treatment for 8 weeks
within one month of cancer treatment had improved patients voice quality significantly.
Dysphagia is a common and widely reported complication after surgery and or after
chemoradiotherapy for HNC patients and can persist for a long period of time (Hutcheson et al.,
2018). There is evidence of continued deterioration of swallowing function after chemoradiation
due to fibrosis in swallowing musculature. More than 50% of HNC patients have posttreatment
dysphagia; 23–43% will have chronic dysphagia. Similarly, 20–40% of patients will have silent
aspiration leading to pneumonia and repeated hospitalization (Hutcheson et al., 2012). Available
data in the literature indicate that swallowing rehabilitation can improve outcomes and it also
depicts that early intervention appears to be superior to delayed intervention. Gupta et al. (2015)
demonstrated that swallowing exercises, if administered from the first week of chemo-radiation

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and continued till six months, resulted in significant improvement in swallowing function and
quality of life. Kraaijenga et al. (2015) did a 10-year plus follow up with the HNC patients
treated with concurrent chemoradiotherapy for advanced head and neck cancer, results indicated
that 54% of the patients had moderate to serious swallowing issues, 14% of whom were feeding
tube dependent, 55% of patients had developed trismus (mouth opening <35 mm), which
significantly associated with aspiration. Regarding the ability to swallow safely, HNC patients
usually take more time to finish their meals or choke on food leading to embarrassment with
other family members (Kraaijenga et al., 2015). In addition, excessive scar formation and edema
in the neck leads to the feeling of disfigurement and leading to embarrassment with other family
members (Kraaijenga et al., 2015). However, the timing of swallowing intervention, the specific
swallowing exercises, the dose, and frequencies of training are lacking and unclear.
Literature indicated that Quality of Life (QoL) in head and neck cancer (HNC) patients
encompasses a range of issues, including the presence of negative treatment side effects and
toxicities as well as aspects more challenging to measure, such as changes in social, physical,
and emotional functioning, distress, depression, and the patients’ perspective of overall QoL
(Taylor & Singer, 2019; Buchmann et al., 2013; Chen et al., 2017). Untreated depression
significantly affects QoL, treatment compliance, and survival (Chen et al., 2014). Ekberg et al.
(2002) observed social isolation among those affected with dysphagia. Malnutrition leads to
decreased physical activity, weight loss, and lethargy. These patients have feelings of frustration,
anger, lack of self-esteem and confidence. Rogers et al. (2009) found that patients rated speech,
chewing, and swallowing as the most important quality of life domains.

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Purpose of the Study and Research Questions
The purposes of this study are as follows: 1) to assess the prevalence of speech and
swallowing impairment and quality of life of HNC survivors post cancer treatment; and 2) to
examine the benefits of early intervention (within six months of cancer treatment) as reflected in
functional gains in speech, voice, and swallowing skills as compared to late and no intervention
groups (post six months of cancer treatment). Three groups of patients were recruited in this
study, one was early intervention for speech, voice, and swallowing services, another two were
late and no intervention groups. The research questions that guide the study include:
1. Is there a difference between early, late and no intervention groups in patients' ability to
speak clearly and with a good voice post cancer treatment?
2. Is there a difference between early, late and no intervention groups in patients' ability to
swallow safely post cancer treatment?
3. Is there a difference between early, late and no speech intervention groups in their
quality-of-life post cancer treatment in the domain of speech?
4. Is there a difference between early, late and no swallowing intervention groups in their
quality-of life post cancer treatment in the domain of swallowing?
Importance of the Study
The ability to eat a regular diet, communicate with clear speech clarity, voice quality, and
maintain quality of life are essential for everyone. However, head and neck cancer patients suffer
tremendously in those four domains. Speech is a powerful social interaction tool, and speech
deficit can hamper a person’s day-to-day activities, resulting in a poor quality of life (QoL)
(Dwivedi et al., 2009). In accord with recent estimates, posttreatment speech problems are seen

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in 63.8% of patients with head and neck cancer. (Suarez-Cunqueiro et al., 2008). Despite the
extensive work on functional assessment and assessment of QoL in patients with head and neck
cancer, evaluation of speech remains largely unsystematic and is generally overlooked.
Dysphonia (voice disorder) related to head and neck cancer is unique, and demands treatment
tailored to its unique pathology. However, studies that focus on dysphonia in head and neck
cancer patients are sparse. Ouyoung et al. (2015) indicated the positive clinical outcome by using
the ABCLOVE voice program for HNC patients. In that study, 29 HNC patients were enrolled in
this specific voice program two times per week for 8 weeks training within one month of cancer
treatment. The results were positive for voice improvement.
Dysphagia or swallowing dysfunction is one of the negative consequences of head and
neck cancer due to cancer-related side effects and long-term sequelae or toxicity from systemic
therapies such as chemotherapy and radiation. Multiple studies reported the positive effect of
swallowing intervention had the highest rate of return to a regular diet and shortest duration of
gastrostomy dependence (Hutcheson et al., 2013; 2016; Kwon et al., 2021). However, the
rehabilitation timing, exercise type, dose, duration of treatment, and outcomes associated with
rehabilitation varied across different studies. Kwon et al. (2021) and Ouyoung et al. (2020)
indicated that swallowing intervention within six months of cancer treatment had yielded better
functional outcomes and had highlighted the need for early referral and engagement in swallow
rehabilitation after treatment of oropharyngeal cancers.
The quality of life of HNC survivors suffers, causing social isolation, depression, fatigue,
dry mouth, and pain after cancer treatment (Ackerstaff et al., 2011; Kraaijenga et al., 2015;
Taylor & Singer, 2019). There is inequality for HNC survivors due to their Socioeconomic
Status (SES). Patients who have a Health Maintenance Organization Plan (HMO) may have

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difficulty in accessing specialty care in terms of coverage of their treatment, prolonged time for
approval or being denied speech and swallowing treatment. Multiple studies also confirmed
inequality in HNC survivors with low socioeconomic status (SES) who had tumors of higher
stage, worse comorbidities, or poorer access to health care (Peterson et al., 2002).
The focus of this study was to understand the consequences of cancer treatment and
compare three groups of patients, one receiving early intervention (within six months post cancer
treatment), the second group of patients receiving speech and swallowing intervention post six
months of cancer treatment. The third group of patients did not have any treatment. Patients
would report three major functional status in speech, voice, swallowing and quality of life
ranging from six months to two years after the cancer treatment in survey questions. The
outcome data was calculated and analyzed. It is my hope that this study can provide a positive
outcome to indicate the benefits of early intervention and improve the awareness of the
importance of early referrals from physicians and healthcare providers so that patients can
benefit from the early intervention. HNC patients deserve and have the right to enjoy the benefits
of early intervention and have a better quality of life after cancer treatment. (Kraaijenga et al.,
2015; Ouyoung et al., 2015; Taylor et al., 2019; Kwon et al., 2021; Ouyoung et al., 2021).
Theoretical Framework and Methodology
The Quality Health Outcomes Model (QHOM; Echevarria et al., 2012) provided a
framework for studying the quality of health care and described relationships among
interventions, patient characteristics, health care system characteristics, and patient outcomes.
The QHOM was developed to encourage researchers to view the practice of health care as an
active process that is impacted by both contextual and client factors. The relationships in the

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model were presented with bidirectional influence, suggesting that interventions impact and were
impacted by both context and client characteristics in producing desired outcomes. In addition,
the connection between context and client suggested that no single intervention acted directly
through either context or client alone. In essence, the effect of an intervention was mediated by
client or context characteristics but was not thought to have an independent direction effect on
outcomes. The QHOM model was a dynamic and linear model. It was the structure-process-
outcome model which extended to indicate reciprocal directions of influence. This model
included four elements: system, interventions, outcomes, and clients. The first element was -
system, such as a hospital or provider network the researcher wanted to study. The second
element was- interventions, which were clinical processes both direct and indirection
interventions and related activities by which they were delivered. The third element was- client
characteristics. Outcomes would be directly affected by the characteristics of the clients to whom
the interventions were directed. Variables such as differing states of client health, demographics,
and disease risk factors would influence the outcome. The last element was outcomes, which
Lahr (1988) described in terms of “Five Ds”-death, disability, dissatisfaction, disease, and
discomfort. Health-related quality of life (HRQOL) measures had added the patient-perceived
dimensions of physical, social and role functioning, mental health, and overall health perception
to more widely used clinical data. Since the purpose of this study was to examine how early
intervention could shape a patient's quality of life, ability to speak with clarity and good voice
quality and to swallow safely, this framework was well-suited for this study.

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Figure 1:
Quality Health Outcomes Model.
This model proposed two-direction relationships among components, with interventions
always acting through characteristics of the system and of the client.

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Terms and Definitions
Below are definitions of key terms used within this study.
Aspiration pneumonia (AP) is an infection caused by specific microorganisms, whereas
chemical pneumonitis is an inflammatory reaction to irritative gastric contents. (Mandel et al.,
2019).
Head and Neck Cancers (HNC) are malignancies occurring in the upper aerodigestive
tract including the oral cavity, oropharynx, hypopharynx, and larynx (Langius et al., 2013).

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Chapter Two: Literature Review
Head and neck cancer (HNC) treatment usually includes surgery, radiation, and or
chemoradiation. HNC patients are often confronted with HNC specific changes in facial
appearance, voice, speech, and swallowing problems and related social withdrawal and
emotional distress (Abendstein et al., 2005; Nordgen et al., 2008). The quality of life of HNC
patients is compromised at the time of diagnosis and becomes worse during the first year after
treatment. The medical consequences (e.g., feeding-tube, dependency, malnutrition, dysphagia,
aspiration pneumonia) have a major negative impact on daily functioning and health-related
quality of life (QoL). The QoL of HNC patients is compromised at the time of diagnosis and
becomes worse during the first year after treatment.
This chapter reviewed literature regarding aspiration pneumonia, the relationship between
aspiration pneumonia and dysphagia and why head and neck cancer treatment had the elevated
risk of developing aspiration pneumonia. This will be followed by a discussion of the risk factors
of malnutrition, quality of life related to head and neck cancer patients and inequality concerns
for access and treatment. Finally, early detection and intervention to prevent aspiration
pneumonia, to improve HNC patients' quality of life will be reviewed. The benefits of
multidisciplinary team collaboration and ongoing monitoring swallowing safety for HNC
survivors to decrease incidences of aspiration and improve quality of life will be reviewed.
Aspiration Pneumonia
Overview of Aspiration Pneumonia
Aspiration pneumonia (AP) is an infection caused by specific microorganisms, whereas
chemical pneumonitis is an inflammatory reaction to irritative gastric contents. (Mandel et al.,

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2019). AP is defined as subject to the fulfillment of the following three criteria. First, the
presence of at least two of the following symptoms—fever, cough, or breathlessness. Second, the
presence of features of pneumonia on imaging or clinical examination like crepitations or
bronchial breathing. Third, the presence of aspiration is suspected either clinically (in history) or
on Videofluoroscopic imaging. The time to develop AP is the duration between the start of
chemoradiation to the diagnosis of AP. The time to resolution is the time from diagnosis of AP to
the date of the resolution of clinical symptoms which are lasting for >72 hours. (Shirasu et al.,
2020). AP can be associated with high mortality rates, higher financial burden to the facility,
longer hospital stays, use of mechanical ventilation, intensive care stays, expensive antibiotics,
increased laboratory tests, as well as increased imaging studies. Expected mortality among
patients with AP are higher than that of other forms of pneumonia (Mandell, 2019). AP can be
prevented with patient risk assessment screening and preventative strategies. AP is a recognized
complication for hospitalized patients, leading to sepsis, lung abscess, shock, respiratory failure,
and mortality (Komiya et al., 2013 & 2020). According to the literature, AP can be the result of a
central nervous system compromise, resulting in dysphagia (Cipra, 2019). If specific
interventions are implemented to recognize and screen patients for the risk of dysphagia, AP can
be prevented.
Early screening is important for AP prevention. Patients are at considerable risk for the
development of AP if they have one or more of the following conditions: altered mental status,
poor oral hygiene, neurologic disorders, vomiting, gastric obstruction, drug abuse, alcoholism,
seizures, general anesthesia, dementia, and gastroesophageal disorders. The clinical symptoms
paired with the diagnostic testing such as Modified Barium Swallowing Video Study (MBSS),
Fiberoptic Endoscopic Evaluation of Swallowing (FEES) can early detect considerable risk for

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developing aspiration pneumonia and action can be taken to reduce the incidence of AP (Seo et
al., 2021). Santos et al. (2021) reviewed interventions to prevent aspiration pneumonia in older
adults. Only 13 out of 703 articles identified met the eligibility criteria and were included. Six
studies focused on pharmacological interventions, three studies focused on dietary interventions
and compensatory strategies, one study focused on oral care, two studies focused on
multidisciplinary intervention, and one study assessed a screening method. The conclusions of
this study revealed modest to poor methodological quality. The development of larger well-
designed trials on this topic is needed. There was limited evidence relating to sole use of one of
nonpharmacologic approaches such as swallowing rehabilitation, thickening feeds, oral hygiene,
gastroesophageal reflux management, and a head-up position. They strongly recommended that
combining both pharmacologic and nonpharmacologic methods may be of value in high-risk
patients.
Aspiration Pneumonia in Head and Neck Cancer Patients
The causes of AP for head and neck cancer (HNC) patients are influenced by different
sites of head and neck cancer diagnoses and the extent of cancer treatment. HNC patients are
also prone to have dysphagia due to cancer treatments such as surgery, radiation, and/or chemo
treatment. Surgery is performed to remove the cancer in the oral, pharyngeal or esopharyngeal
area which affects swallowing function causing dysphagia. Surgery treatment affects patients'
swallowing skills due to anatomical changes after surgery such as partial or total removal of a
tongue. The side effects of radiation or chemo treatment including mucositis, lymphedema or
fibrosis affecting a patient's swallowing function and cause dysphagia. Dysphagia-related
pneumonia is caused by frank or silent aspiration, which occurs in 17% to 81% patients admitted
to the hospital (Nguyen et al., 2006; Stenson et al., 2000; Langerman et al., 2007). Multiple

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complications were associated with these treatments that increased the risk of dysphagia and
subsequent aspiration. The rate of AP in HNC patients ranged from 5.4% to 23% pending on
different studies. Furthermore, AP was a poor prognostic factor for HNC patients and accounted
for 19% of non-cancer-related deaths. Pneumonia complicates HNC treatment and can occur
during or after treatment. Development of pneumonia has long-term implications on morbidity
and mortality. Mucositis is the side effect of chemoradiation during and after cancer treatment.
Different grades of mucositis such as oral soreness and erythema will affect the patient's ability
to eat orally which causes dysphagia. Researchers recommend assessing the swallowing function
before and after cancer treatment and closely monitoring patients who have aspiration (Kwon et
al., 2021). Patients with baseline dysphagia need to be educated about the signs and symptoms of
AP and the importance of immediate treatment. In summary, HNC patients with dysphagia are
predisposed to an elevated risk to develop AP as indicated by various studies. Inequality for
HNC survivors and the side effects of cancer treatment such as malnutrition, dysphagia, speech
and voice challenges, and a compromised quality of life will be reviewed next.
Inequality For Head and Neck Cancer Survivors
Ingarfield et al. (2021) reported that inequality in survival of people with cancer is well
documented globally. Socioeconomic inequalities in survival of HNC patients specifically have
had limited attention and are not well understood. Explanations for inequality in survival of
people with HNC included those participants who were at a socioeconomic disadvantage
presented with cancers at a more advanced stage, or that they presented more frequently with
additional comorbidities (Paterson et al., 2002). Inequality in the survival of people with HNC
have been observed for several measurements of socioeconomic status (SES) including highest
education level, number of years spent in education, annual household income, proportion of

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income from benefits, and financial concerns of living with, or after, cancer. The results of
Ingarfield et al. (2021) indicated that half of the cohort had attained an education level of up to
secondary school, and one third of participants had spent 10 years or less in full-time education.
More than half of the cohort earned less than 29,000 British pounds per year, one third of the
cohort earned at least some of their income from benefits, and 34.3%(n=1181) of people had
financial concerns of living with, or after, cancer. People with lower SES status had tumors of
higher stage, worse comorbidities, or poorer access to health care due to lack of access to
preventive care (Peterson et al., 2002). Conway et al. (2015) also confirmed in a large
multinational study that lower education status and lower income were associated with increased
risk for HNC development. People with lower education status and lower levels of income have
less access to quality care and early detection of cancer or delay of treatment due to financial
restraint. More education to this population is needed to develop pathways to develop more
tailored preventive approaches in the future. The following section reviews current management
of AP and multidisciplinary team collaboration contributing to positive outcomes and reduced
occurrence of aspiration pneumonia in HNC patients. Early detection and intervention, especially
management of dysphagia to prevent AP, has become the top priority for clinical management of
HNC patients. In summary, HNC patients may have a lower education level to access
information and education regarding early detection of cancer and early signs of symptoms. They
may also have lower income and insurance coverage to cover the cost of quality of cancer
management. Short-term rehabilitation and long- term follow up to manage the side effects of
cancer treatment also would be compromised.

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Side Effects of Cancer Treatment
HNC patients with dysphagia are at considerable risk of developing aspiration
pneumonia. Dysphagia may happen immediately after surgery, during or after radiotherapy or
chemotherapy. The effect of dysphagia may continue to develop after years of after-HNC
treatment due to fibrosis or muscle atrophy. Dysphagia also may cause HNC patients not to eat
enough food by mouth, difficulty in gaining weight, or choking on liquids. Negative impact on
HNC after cancer treatment such as malnutrition, dysphagia both acute and long term,
compromised quality of life, inequality of HNC survivors will be reviewed in the next section.
Malnutrition
The prevalence of malnutrition is high in head and neck cancer patients and nutritional
status is altered in half of the cases (Khan et al., 2011; Mehanna et al., 2016). Anatomical
location of the tumors can result in dysphagia, odynophagia, dysgeusia, chewing difficulties, and
pain (Mehanna et al., (2006) which contributes to malnutrition. Numerous studies have
suggested that in comparison to well-nourished patients, malnourished patients experience worse
outcomes such as prolonged length of stay (LOS) in hospital, increased readmissions, and
mortality. (Friedmann et al., 2011). Patients who have dysphagia have difficulty in eating orally
to fulfill their nutritional needs. Patients’ inadequate oral intake or nutrition results in
malnutrition. Malnutrition is a condition in which a person has deficiencies, excesses, or
imbalance of energy and or nutrition intake. A full nutritional assessment and intervention can be
provided with patients identified as experiencing malnutrition. Several studies have reported that
there is an association between AP and dental decay, periodontal diseases, poor oral hygiene, the
need for assistance when eating, and swallowing problems (Langmore et al., 1998). Simon et al.,
(2022) reported that the cause of malnutrition is multifactorial. Malnutrition associated with

16

cancer is a global public-health problem and is associated with a reduction in quality of life,
tolerance to treatment, and therapeutic efficacy. For HNC patients, the risk of malnutrition
increased during the tumor treatment and after the treatment. Tumors caused impaired
swallowing function and adverse effects of HNC treatment. In patients with oropharyngeal
dysphagia, it affects oral intake (64%) of the HNC patients, also causing AP. Patients with pre-
existent compromised nutritional status due to unhealthy lifestyle (drinking, tobacco and a diet
lacking various nutrients) would exacerbate the nutrition status. Lack of adequate nutrition and
weight loss increases HNC patients’ morbidity, and mortality. A study in HNC treated with
chemoradiotherapy reported 20% of the patients presented a moderate or elevated risk of
malnutrition during oncological follow-up. Another study done by Simon et al. (2021) reported
that 81.3% of head and neck cancer patients who were on an oral diet were at elevated risk of
malnutrition. The researchers recommended early nutritional screening in dysphagic HNC
patients and checking patients’ nutritional status after oncological treatment and during long-
term follow-up is important. HNC survivors even with a normal Body Mass Index (BMI) also
needed to be screened for nutritional status. Patients need to refer to a dietician for additional
nutritional assessment, diagnosis of malnutrition, and nutritional support even when their BMI is
within normal range. In the next section, dysphagia both in the acute stage and long term will be
reviewed.
Dysphagia both Acute and Long-Term
Dysphagia is a common and widely reported complication after surgery and or after
chemoradiotherapy for head and neck cancer patients and can persist for an extended period
(Francis et al., 2010; Hutchson et al., 2012; Nguyen et al., 2006, Rosenthal et al., 2006). There is
evidence of continued deterioration of swallowing function after chemoradiation due to fibrosis

17

in swallowing musculature. More than 50% of HNC patients have posttreatment dysphagia; 23–
43% will have chronic dysphagia. Similarly, 20–40% of patients will have silent aspiration
leading to pneumonia and repeated hospitalization (Patil et al., 2021). Available data in the
literature indicate that swallowing rehabilitation can improve outcomes and it also depicts that
early intervention appears to be superior to delayed intervention. Kumar et al. (2015) and
Ouyoung et al. (2020) demonstrated that swallowing exercises, if administered from the first
week of chemoradiation and continued till six months, results in significant improvement in
swallowing function and quality of life. Kraaijenga et al. (2015) did a 10-year plus follow up
with the HNC patients treated with concurrent chemoradiotherapy for advanced head and neck
cancer, results indicated that 54% of the patients had moderate to serious swallowing issues, 14%
of whom were feeding tube dependent, 55% of patients had developed trismus (mouth opening
<35 mm), which significantly associated with aspiration.
Speech and Voice Challenges
Speech clarity is essential for social communication, and speech impairment can hamper
a person’s day-to-day activities, resulting in an inferior quality of life (QOL) (Dwivedi et al.,
2009; Vartanian et al., 2004). In accord with recent estimates, posttreatment speech problems are
seen in 34% to 65% of patients with head and neck cancer. (Thomas et al., 2009; Ringgit et al.,
2008). Meyer et al. (2004) concluded that speech intelligibility deficits persist among many long-
term HNC survivors regardless of cancer site, cancer stage, or type of treatment. Decreased word
intelligibility is associated with a greater number of quality-of-life measures than decreased
sentence intelligibility. Among non-laryngectomy HNC survivors, objective speech indelibility
deficits are significantly associated with oral function quality of life domains. Lazarus (2007)
indicated voice changes following radiotherapy may include reduced vocal loudness, low modal

18

speaking pitch, reduced phonic breath support, vocal roughness, breathiness, hoarseness, and
vocal fatigue (Lazarus et al., 2009). Kraaijenga et al. (2016) concluded that HNC, both the tumor
and its treatment with combined chemoradiotherapy (CRT), could adversely impact voice and
speech outcomes. In patients with cancers of the oral cavity and oropharynx, destructive effects
of the tumor would affect patients’ articulation and /or speech, whereas in laryngeal cancer
patients, the tumor often has negative effects on voice quality (van de Molen et al., 2012;
Kraaijenga et al., 2015). The effects of voice rehabilitation on HNC patients undergoing
chemoradiation have only been evaluated in laryngeal malignancies (van Gogh et al., 2006
&2012). Kraaijenga et al. (2015) reported that HNC patients indicate voice changes due to
increased vocal effort, breathiness, and hoarseness 5 years post cancer treatments. From HNC
patients’ self-report survey, 63.8% of patients reported speech problems (Jacobi et al., 2010) and
patients reported effortful speech made communication more difficult, and survivors had to
decide whether to spend their energy communicating or use that energy in other ways. When
radiation or chemoradiation is used for the treatment of laryngeal cancers, significant changes in
voice quality and communication occur; these can last up to a year (Verdonck-de Leeuw et al.,
1999). The compromised quality of life after HNC treatment and inequality of HNC survivors
will be reviewed next.
Compromised Quality of Life
Quality of Life (QoL) in head and neck cancer patients encompasses a range of issues,
including the presence of negative treatment side effects and toxicities as well as aspects more
challenging to measure, such as changes in social, physical, and emotional functioning and the
patients’ perspective of overall QoL (Taylor & Singer, 2019). Buchmann et al. (2013) reported
that HNC patients experienced an elevated level of baseline distress. They need emotional

19

support and psychosocial intervention. 58% of HNC patients had mild to severe depression
before radiotherapy. Depression increased to 67% at the final day of radiotherapy (Chen et al.,
2014). Untreated depression significantly affects QoL, treatment compliance, and survival (Chen
et al., 2014). Ekberg et al. (2002) observed social isolation among those affected with dysphagia.
Malnutrition leads to decreased physical activity, weight loss, and lethargy. These patients have
feelings of frustration, anger, lack of self-esteem and confidence. These patients usually take
more time to finish their meal leading to embarrassment with other family members. In addition,
excessive scar formation and edema in the neck leads to the feeling of disfigurement and leading
to embarrassment with other family members. In addition, excessive scar formation and edema
in the neck leads to the feeling of disfigurement and low self-esteem (Ekberg et al., 2002). Meyer
et al. (2004) indicated that HNC survivors can have permanent alterations in their ability to
communicate with others. The authors concluded that speech intelligibility deficits persist among
many long-term HNC survivors regardless of cancer site, cancer stage, or type of treatment.
Decreased word intelligibility is associated with a greater number of quality-of-life measures
than decreased sentence intelligibility. Recent studies have documented the importance to
survivors of effective communication. Rogers et al. (2010) found that patients rated speech,
chewing, and swallowing as the most important quality of life domains. In both the Taylor &
Singer (2019) and Bashir (2020) studies, researchers reviewed literature regarding QoL in HNC.
QoL worsened after cancer directed treatment in all domains due to acute and subacute adverse
effects of chemotherapy and radiotherapy in treatment courses. Pain, swallowing, speech, and
mouth problems worsened. HNC survivors (5-10 years) after a HNC diagnosis struggle with dry
mouth, sticky saliva, swallowing functions, sleep issues, fatigue, reduced enjoyment and interest
in sex, pain, and dyspnea (Taylor & Singer, 2019; Bashir, 2020). These patients will need

20

psychological support to help mitigate some of the debilitating side effects of the treatment in the
long-term and alleviate negative consequences of cancer treatment.
Early Intervention for Head and Neck Cancer Patients
Oral care, nutritional support, diet modification, dysphagia screening and treatment, and
body positioning have been proposed and tried with some success in managing aspiration
pneumonia. Echevarria et al. (2012) indicated that prevention of hospital-associated infections is
a national priority. They proposed an evidenced-based screening tool and care protocol which
was developed to identify patients with elevated risk for AP and implement appropriate
preventative interventions. Protocols, clinical pathways, and screening tools are examples of
processes which have improved standardization for the identification, assessment, and treatment
of hospitalized patients with dysphagia. Early detection of high-risk patients and providing
timely intervention are key factors to reduce AP. Mandell (2019) suggested routine antibiotic
treatment and prevention intervention strategies such as promoting oral feeding, dysphagia
screening, diet management, nutritional support, appropriate feeding position and good oral care
to prevent AP. In the next section, early nutritional support, oral care, early dysphagia screening
and management of head and neck cancer patients will be presented.
Early Nutritional Support
Patients with head and neck cancer are at increased risk of experiencing malnutrition,
which is associated with poor outcomes. Advances in the treatment of HNC’s have resulted in
improved outcomes that are associated with severe toxic oral side effects, placing patients at an
even greater risk of malnutrition. Side effects of this chemoradiotherapy (CRT), for example,
pain, dysphagia, mucositis, taste alteration, xerostomia, sticky saliva and nausea, impaired oral

21

nutritional intake (Bressan et al., 2016; Mulasi et al., 2020). As a consequence, these patients are
at high risk of malnutrition (Bressan et al., 2016). Nutritional support can be implemented by
prophylactic placement of a percutaneous endoscopic gastrostomy (PEG), or use of nasogastric
tubes or providing nutritional support during cancer treatment. The outcomes of nutritional
support depend on the stages of cancer, timing of nutritional intervention and patients’ adherence
to nutritional supplements (Hutcheson et al., 2013. Langius et al.2013 concluded that the
beneficial effects of individualized dietary counseling on nutritional status and improved quality
of life. Kok et al. (2020) showed substantial variation in dietetic practice, especially in the use of
a gastrostomy for tube feeding, between the HNC patients. There is a need for concise dietetic
guidelines. Simon et al. (2021) study emphasized the importance of early nutritional screening in
dysphagic HNC patients, as almost half of these patients presented a high risk of malnutrition. It
is better to screen the nutritional status after oncological treatment and during long term follow-
up in all HNC survivors. Lee et al. (2021) found improvement in oral health and the quality of
life in HNC patients with comprehensive oral care intervention by dental professionals.
Ongoing Oral Care
Nawata et al.(2019) study indicated that continual professional oral healthcare
intervention by a dental hygienist may improve severe aspiration pneumonia. There were a few
studies on the application of oral preventive programs for HNC patients undergoing radiotherapy
(Oton-Leite et al., 2013&2015). Lee et al. 2021 found out that oral care intervention by dental
professionals and nurses can improve patient’s oral care, prevent dental decay, and decrease
severe aspiration pneumonia. Radiotherapy is the most used method for the treatment of HNC.
This therapy is frequently associated with significant short- and long-term complications
including mucositis, dysgeusia, dysphagia, weight loss, malnutrition, hypo-salivation, increased

22

risk of dental caries, increased risk of progression of periodontal disease, dental hypersensitivity,
infections, mucosal atrophy, trismus, neuropathic pain, and osteoradionecrosis (Lee et al., 2021).
Lee et al. 2021 and Harding, 2023 stressed the fact that comprehensive oral care intervention
could prevent dental cavities and provide increased quality of life in HNC patients. Radiation
induced oral side effects are frequent complications and may generate significant impact on
HNC patients’ long-term and overall QoL. To enable optimal dental care for HNC patients
before, during, and after radiotherapy, close interdisciplinary communication and cooperation
among radiation oncologists, dentists, medical oncologists, and oral surgeons is essential.
Clinicians should be equipped with knowledge about signs and symptoms of the oral cavity so
that appropriate clinical assessment and timely treatment referral can be made. Clinicians need to
inform and educate HNC patients about 1) potential risk of oral side effects after radiation-based
therapy; and 2) preventative strategies, for example, treatment of xerostomia (dry mouth) related
complaints, meticulous oral hygiene, diet adaptation, control of cariogenic flora, and use of
prescription-strength fluoride. Compliance with preventative strategies must be reinforced by the
health care team.
Early Dysphagia Screening and Management
The occurrence of AP in HNC patients can be prevented by use of aspiration prevention
protocol. James-Petteay’s 2020 study indicated that increasing nurses' ability to recognize high
risk patients and implementing preventative aspiration pneumonia protocol would promote
positive social change by improving patient outcomes and decreasing financial loss for the
facility. In Sekhon’s 2019 study, the researcher used both DePaul Hospital Swallow Screen
(DHSS) and/or Burke three-ounce water test to assess patient’s aspiration risk to reduce hospital
acquired pneumonia (HAP). The result was encouraging as the rate of HAP dropped from 12.6%

23

to 2.7% over the two months. Arnold et al. (2016) used Dysphagia screening such as DePaul
hospital Swallow Screen (DHSS) or Gugging Swallowing Screen (GUSS) to screen the patients
for dysphagia and identify the high risks to develop AP. Dysphagia or swallowing dysfunction is
one of the negative consequences of head and neck cancer due to cancer-related side effects and
long-term sequelae or toxicity from systemic therapies such as chemotherapy and radiation.
Rehabilitation is essential from the beginning of diagnosis of cancer, hospitalization for surgery,
during and after radiation and to the home or clinic intervention. The purposes of targeted
interventions are aimed to reduce the incidence and severity of current and future impairments.
There is growing evidence of the potential benefits of prophylactic exercises among HNC
patients undergoing chemoradiation. (Shinn et al., 2013; Kotz et al., 2012; van der Molen et al.,
2011). Both Carroll et al. (2007) and Hutcheson et al. (2013) reported the positive treatment
effects and maintenance of oral intake throughout radiotherapy or chemo radiotherapy. Patients
who either eat or do swallowing exercises are far better than those who do neither. Patients who
both eat and do swallow exercise have the highest rate of return to a regular diet and shortest
duration of gastrostomy dependence. Adherence to evidence-based swallowing therapy and
home-based exercises are key to optimizing functional outcomes (Cnossen et al., 2016;
Hutchinson et al., 2013).
In another study by Loewen et al. (2021), they investigated rehabilitation (early
intervention), and mixed results of benefits were reported. Mixed results due to lacking
consensus across most areas related to rehabilitation in HNC. The variability of rehabilitation
timing, exercise type, dose, duration of treatment, and outcomes associated with rehabilitation.
The authors recommended a regimen of ten repetitions, three times a day, and supplementing
these exercises with increased physical activity. The program should begin as close to cancer

24

diagnosis as possible and be followed by early rehabilitation. Sinha et al. (2019) indicated that
self-esophageal dilation for head and neck cancer patients was safe and feasible in combining
with swallowing treatment. Patients who received intervention for less than a year had improved
functional oral intake scores. Sinha et al.’s 2022 study indicated the patients should undergo
traditional swallow therapy and neuromuscular swallow therapy to restore molecular
homeostasis in the cervical-pharyngeal muscles. Ouyoung et al. (2020) reported that using
exercises-based dysphagia boot camp (DBC) impacted functional swallowing outcomes after
surgical management of oropharyngeal cancer. Kwon et al. (2021) reported improved swallow
outcomes with early intervention using combined swallow therapy in advanced oropharyngeal
carcinoma. Swallowing treatment started two weeks after surgery and continued during
chemoradiation therapy. The regimen of ten repetitions, three times a day and follow-up with
home exercises was effective in restoring swallowing in their patients. Combined therapy
consisting of traditional swallow exercises and transcutaneous neuromuscular electrical
stimulation were used in Kwon et al. (2021). This positive outcome has suggested early
dysphagia intervention before, during, and after radiation therapy and using a combined
approach can achieve a positive outcome. Another study by Yang et al. (2021) also concluded
that preventive swallowing interventions may be effective at reducing aspiration, improving
swallowing function, and restoring oral intake.
Early Speech/Voice Intervention
Speech is a powerful social interaction tool, and deviant speech can hamper a person’s
day-to-day activities, resulting in an inferior QoL (Dwivedi et al., 2009). In accord with recent
estimates, posttreatment speech problems are seen in 40% of patients with head and neck cancer.
(Cnossen et al.,2011). Despite the extensive work on functional assessment and assessment of

25

QoL in patients with head and neck cancer, evaluation of speech remains unsystematic and is
overlooked. Dysphonia (voice disorder) related to head and neck cancer is unique, and demands
treatment tailored to its unique pathology. Van Gogh et al. (2006) reported that voice therapy
proved to be effective in patients who had voice problems after treatment for early glottic
carcinoma. Van Gogh et al. (2012) documented the beneficial effect of voice therapy was not
just a short-lived voice improvement but may result in a better voice for a period of at least one
year. Ouyoung et al. (2015) reported that use of a multimodality voice therapy program-ABC
LOVE- Activate exercises, Breathing, Counseling, Laryngeal manipulation, Oral resonance,
Vocal exercises, and Elimination of habits on HNC patients showed positive outcome. Sreenivas
et al. (2021) reported vocal rehabilitation offered at one month after cancer treatment ameliorates
chemoradiation-induced dysphonia within six months.
Multidisciplinary Team Approach
To improve dysphagia management and decrease aspiration pneumonia among HNC
patient requires a multidisciplinary team approach. Team approaches with the cooperation of
various professionals have the power to improve the quality of medical care, utilizing the
specialized knowledge and skills of each profession (Middleton et al., 2011). For head and neck
cancer patients, a multidisciplinary approach during various stages of cancer treatment is even
more critical. Bossi and Alfieni (2016) examined the benefit of a multidisciplinary team (MDT)
to the patients treated with chemoradiation for HNC. Kaderbay et al., (2018) indicated that early
identification of HNC with high risks required a multidisciplinary team approach.
They indicated that HNC patients experience a significant variety of symptoms and early
and late toxicities of the treatment itself. HNC patients need several types of expertise to manage
swallowing problems. Improved HNC survival rates and clinical outcome with MDT have been

26

reported (Friedland et al., 2011.; Prades et al., 2015.; Tsai, 2015; Liao, 2016). Team members'
motivation, peer mentoring and training are the foundation to implement an early intervention to
decrease aspiration pneumonia. Communicating and cooperating between the healthcare
professionals is needed to raise the quality of health care services for HNC patients’ cancer
treatment. Multidisciplinary team collaboration and training have shown position contribution to
decrease the rate of aspiration pneumonia. Ongoing monitoring for the wellbeing of head and
neck cancer survivors to decrease the side effect of cancer treatment will be reviewed next.
Ongoing Monitoring of Swallowing, Speech, and Voice Changes
Dysphagia, speech, and voice challenges are the sequels of cancer treatment. Ongoing
assessment and monitoring are essential to ensure a better quality of life. Mehanna and Morton
(2006) reported quality of life deteriorated at 5- year follow on a mixed HNC cohort of 43
patients. HNC survivors complained about head and neck pain, shoulder and arm pain, speech
difficulty, swallowing problems and cough compared to baseline and the first year of treatment.
More than 10-years after organ-preservation treatment, voice and speech problems are common
in this patient cohort, as assessed with perceptual evaluation, automatic speech recognition, and
with validated structured questionnaires. There were fewer complaints in patients treated with
IMRT than with conventional radiotherapies (Kraaijenga et al., 2016), These authors reported
that for head and neck cancer survivors at 8-11 years post-diagnosis, their quality of life such as
social functioning, swallowing, speech, taste/smell, dry mouth, sticky saliva, and coughing
worsened. Scores on overall quality of life, psychological distress, and all HNC cancer
symptoms deteriorated at long-term follow-up compared to baseline and the first year of
treatment. At time of treatment, the need for ongoing monitoring of swallowing safety was the
highest for a dental hygienist, a physical therapist, a speech therapist, a dietician, and a dietician.

27

At long-term follow-up, the need for supportive care was limited to a dental hygienist and a
physical therapist. It is not surprising that, in general, the supportive care needs of patients
treated for locally advanced oral and oropharyngeal cancer are substantial in the treatment and
immediate post-treatment period. During this time, patients often suffer from weight loss,
xerostomia, speech, and swallowing problems. In conclusion, long-term survivors of head and
neck cancer continue to experience negative treatment effects that are associated with quality of
life. There is evidence that survivors struggle with dry mouth, sticky saliva, eating functions,
sleep issues, fatigue, and swallowing problems. Kraaijenga et al. (2015) published voice-and
speech-related outcomes of HNC patients 10-years after cancer treatment. Voice and speech
problems were common in HNC survivors, with 68% and 77% of the 22 evaluated patients
reporting voice and speech problems in daily life. Dwivedi et al. (2009) suggested that speech
should be evaluated prospectively with adequate intervals. A pretreatment sample followed by 1,
6-, 12-, 18- and 24-months post-treatment speech sample will be adequate for all treatment
modalities. Ongoing monitoring of patients’ physical condition, swallowing, nutrition, speech
/voice status, and timely referrals to specialized team members is critical to ensure and promote
patients’ quality of life.
This chapter examined the existing literature regarding aspiration pneumonia, inequality,
and side effects of cancer treatment. The side effects of cancer treatment place HNC patients at a
high risk for malnutrition, affecting their ability to swallow and ability to speak with a clear
voice in their lives after cancer treatment. HNC’s quality of life is severely compromised after
the cancer treatment. Furthermore, increased studies indicating the benefits of early intervention
in nutrition, oral care, speech, voice and swallowing to improve HNC survivors’ quality of life
with multidisciplinary team effort also were reviewed.

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Head and neck cancer survivors continue experiencing both speech and swallowing
difficulties after cancer treatment. Various research has demonstrated the benefits of early
intervention for swallowing deficits caused by radiation treatment. Only a few studies focus on
speech rehabilitation during cancer treatment. However, the frequency of both speech, voice and
swallowing intervention, the specific exercises, the dosage of exercises and the length of training
varied in many studies. The purpose of this study was to examine the benefits of early
intervention as reflected in improved both speech and swallowing functional status in
comparison between the early intervention group versus late intervention group. Three groups of
patients were recruited in this study, one was the early group, the second group was late group,
and the third group was no intervention group for speech, voice, and swallowing services. The
independent variable was early intervention and dependent variables were speech, voice,
swallowing and quality of life of head and neck cancer patients after cancer treatment.

29

Chapter Three: Methodology
A cross-sectional correlation quantitative method was used in this study to examine the
relationships between early, late and no intervention groups regarding their ability to speak with
clarity and with good voice quality and swallow safely when early intervention has been
provided within six months of their cancer treatment. Their quality of life with early, late and no
intervention was studied. This study hopes to contribute to a growing body of evidence
demonstrating the benefits of early intervention to improve speech, voice and swallowing
functional abilities in head and neck cancer patients and provide quantitative data to urge
physicians and other related professionals to refer patients for early intervention. The research
questions that guided the study were: 1) Is there a difference between early, late and no
intervention groups in ability to speak clearly post cancer treatment? 2) Is there a difference
between early, late and no intervention groups in ability to swallow safely post cancer treatment?
3) Is there a difference between early, late and no speech intervention groups in their quality-of-
life post cancer treatment in the domain of speech? 4). Is there a difference between early, late
and no swallow intervention groups in their quality-of-life post cancer treatment in the domain of
swallow?
This chapter describes the methodology used to conduct the study, including participants,
instruments used, and procedures for data collection and analysis.
Participants and Procedure
Participants included current head and neck cancer patients in the otolaryngology clinic
and a speech outpatient clinic. Participants were recruited in two ways. First, the researcher sent
out a survey via online Qualtrics to 1064 head and neck cancer patients. The survey included a
description of the study with a link to the survey. When the participants voluntarily participated

30

in the survey, they filled out the survey questions. One follow-up reminder email was sent a
week later thanking those who had answered the survey and again asking those that had not to
please answer the survey by filling in a survey link. In addition to emailing patients, participants
were recruited during clinic visits. The nurse navigator distributed the survey links to the
patients. A total of 135 patients were recruited into this study. There were 103 male patients and
32 female patients. The mean age was 66 years old. The response rate was 12%. There were 94
white, 16 Asians and 16 Hispanic patients, only 5 patients were Black, 4 missing data. The most
frequent cancer was oral cancer, followed by oral-pharyngeal and larynx cancer. Cancer
treatment could be provided by single modality such as surgery or by radiation or by combined
treatment such as surgery+radiation, surgery+ chemotherapy, or sugery+radiation+chemo
treatment. 113 patients received surgery only, 59 patients received both surgery and radiation
treatment, 55 patients received both surgery and chemoradiotherapy, and 41 patients only
received radiation treatment. There were 34 patients who received cancer treatment for less than
six months, 33 patients received cancer treatment post 1 year, 62 patients post 2 years. There
were 45 patients who received early speech intervention (within six months of cancer treatment),
42 patients received late intervention (post six months of cancer treatment), and 46 patients
received no treatment. In the swallowing intervention group, there were 45 patients in the early
group, 34 patients in the late group and 51 patients in the no treatment group. (See Table 1 &2).

31

Table 1
Clinical Profile of Patients Participated in This Survey
Total number=135, Age=66 years, SD± 10.77
Clinical Variable
Number %
Sex
Male 103 76.3
Female 32 23.7
Race
White 94 69
Asian 16 11
Hispanic 16 11
Black 5 3.7
Site of HNC
Oral cancer 42 31.1
Nasopharynx 2 1.5
Oral-pharyngeal 27 20
Larynx 10 7.4
Other 52 38.5
Total number=135, Age=66 years, SD± 10.77
Table 2
Participants Cancer Treatment and Intervention
Clinical Variable Number %
Surgery only 113 83.7
Surgery+radiation 59 43.7
Surgery+chemoradiotherapy 55 40.7
Radiation only 41 30.4
Post cancer treatment
<6 months 34 26.3
One year 33 25.5
>2 years 62 48.0

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Speech intervention group 133
Early (<6 months) 45 33.8
Late (>6 months) 42 31.6
No treatment 46 34.6
Swallow intervention group 130
Early (<6 months) 45 34.6
Late (>6 months) 34 26.2
No treatment 51 39.2

Data Collection and Instrumentation
The methods of data collection chosen to support the quantitative nature of the study
were surveys, analyzing documents and artifacts. The use of survey techniques was used to
gather participants' perception of the cancer treatment impact on their speech, voice, swallowing
and quality of life. The survey design follows Creswell and Creswell’s (2018) description of a
survey purpose to understand relationships between variables in a descriptive and predictive
manner over cancer treatment. The document review technique was used to compare the
outcome of swallowing, voice and speech intervention and quality of life between early, late and
no intervention groups. Both approaches relate directly to answering the research questions using
quantitative methods. The survey contains 62 items divided into five sections: 1) Demographic
information, 2) Eating Assessment Tool, 3) Voice Handicap Index, 4) Speech Handicap Index,
5) the University of Washington Quality of Life Questionnaire. Details about each instrument
used were provided in the following sections.
Eating Assessment Tool (EAT-10)
The Eating Assessment Tool (EAT-10) is a 10-item instrument created by Peter Beflafsky
who is an expert in dysphagia management. It is used to measure symptom-specific outcomes for
dysphagia. It consists of ten statements that a patient rates on a scale of 0-4, with 0=no problem

33

to 4=severe problem. A summated EAT-10 total score ranges from 0 to 40, with a score ≥ 3
indicative of dysphagia. Beflafsky et al, 2008 documented the EAT-10 displayed excellent
internal consistency, test-retest reproducibility, and criterion-based validity. A total of 629
surveys were administered to 482 patients. The internal consistency (Cronbach alpha) of the final
instrument was 0.960. The test-retest intra-item correlation coefficients ranged from 0.72 to 0.91.
The normative data suggests that an EAT-10 score of 3 or higher is abnormal. The instrument
may be utilized to document the initial dysphagia severity and monitor the treatment response in
persons with a wide array of swallowing disorders.
Speech Handicap Index (SHI)
The SHI is used to measure speech-related quality of life assessment, originally
developed for measuring the psychosocial speech impact in patients with oral or pharyngeal
cancer. SHI has 30 items on speech problems that were developed and validated in 92 patients
with cancer of the oral cavity or pharynx and 110 healthy subjects. SHI is a reliable and valid
questionnaire for assessing speech problems. (Rinkel et al., 2008). Dwivedi et al., (2011)
reported on the reliability and validity of SHI in a cohort of sixty-three English-speaking HNC
patients. He reported internal consistency and test-retest reliability were assessed using
Cronbach’s alpha and Spearman’s correlation coefficient, respectively. Construct and group
validity were determined using the Spearman’s correlation coefficient and Mann-Whitney U-test,
respectively. The results indicated that the internal consistency reliability for Total SHI and SHI
speech domain as calculated by Cronbach’s alpha coefficient was 0.98 and 0.95, respectively.
For SHI psycho-social domain alpha coefficient was 0.98. The test-retest reliability of Total SHI
and the speech domain as calculated by Spearman's rank correlation coefficients were 0.92 and
0.88, respectively. For SHI psycho-social domain the coefficient was 0.89.

34

Voice Handicap Index -10 (VHI-10)
The VHI-10 is a 10-item, shortened version of the original 30-item Vocal Handicap
Index.4,8,10. It is used to measure the degree of voice quality affecting daily communication. It
is developed to assess patients’ perception of the severity of their voice disorder. There are 10
statements that many people have used to describe their voices and the effects of their voices on
their lives. Participants will circle the responses that indicate how frequently they have the same
experience, 0=never, 1=almost never, 2=sometimes, 3=almost always, 4=always. The total score
is used to indicate the severity of the voice disorders for the patient (maximum score 40,
minimum score 0). The Cronbach alpha of the VHI-10 was 0.89, indicating high internal
consistency (Deary. 2004).
The University of Washington Quality of Life Questionnaire (UW-QOL) v4
The UW-QOL is a head and neck cancer specific questionnaire with 12 domains, each
domain being scaled from 0 (worse) to 100 (best) according to the hierarchy of response. The
UW-QOL has two subscale composite scores, i.e., 'Physical Function' and 'Social-Emotional
Function' each have a single 6-point 'overall' QOL measure. ' Physical Function' is the simple
average of the swallowing, chewing, speech, saliva, taste, and appearance domain scores whilst
'Social-Emotional Function' is the simple average of the activity, recreation, pain, mood, anxiety,
and shoulder domains. Regarding the single-items overall QOL scale, participants were asked
not only physical and mental health, but also other factors, such as family, friends, spirituality,
and of personal leisure activities important to their enjoyment of life (Rogers, et al.,2017). It is
one of the more commonly used questionnaires in head and neck cancer. The UW-QOL v4 has
high validity and reliability. It has strong internal consistency (Cronbach's alpha=0.86), and the
exclusion of any domain did not change the alpha coefficients significantly (Rogers et al., 2002).

35

This study has several limitations, First, the head and neck cancer survivors were limited
to this institution and the response rate was 10%. The sample size was small to include patients
treated in the hospital, ENT clinic. For generalizable findings, a sizable sample of patients from
each of the types of institutions was needed. This study is a non-experimental study, only
association between the independent and dependent variables, and no cause-and-effect
relationships, could be implied from the study results. Secondly, the study design and data
collection relied on patients' subjective responses on a self-report survey. The answers were
based on patients' subjective impressions of their cancer treatment. Thirdly, 69% of survey
respondents were white, while only 11% respondents were Hispanic or Asian and only 3.7%
respondents were Black. Small sampling of different racial groups led to study participants being
not well represented in this study. A larger study sample would have allowed the researcher to
examine group differences between different racial groups. Additionally, the limitation of the
instrument tool to measure outcome variables in this study exists. In this study, the researcher
used EAT-10 to measure the swallowing impairment but not addressing the level of diet level
and consistencies which patients could eat and whether patients needed G-tube or supplements to
provide their nutritional support.

36

Chapter Four: Results
The purpose of the study was to investigate the benefits of early intervention (Tx) to
speak with clarity and with a good voice quality, to swallow safely and improve quality of life in
head and neck cancer patients. Additional exploratory analysis also examined the relationship
between two subscales in University of Quality-of-Life Scale (UW-QOL), Physical Function
Scale and Social-Emotional Scale in terms of timing of both speech and swallowing intervention.
This chapter reviews the findings of the study in response to the four research questions.
Analysis of Research Question 1: Is there a difference between early, late, and no
intervention groups in patients' ability to speak clearly post cancer treatment?
Because the dependent variable of speaking clearly was measured by two separate
measures, two separate ANOVAs were conducted. For the dependent variable of Speech
Handicap Index (SHI), the result of the 1-way ANOVA showed a significant difference between
intervention groups (early, late, no intervention) on speech impairment level [F (2,109) = 12.869,
p< .001]. Post-hoc analysis revealed that the early group reported significantly less speech
impairment on average than both late (p =< .001) and no treatment groups (p = <.001). There
was no significant difference between the late and no treatment group. These findings indicated
that early speech intervention was associated with significant improvement in ability to speak
with clarity in patients with head and neck cancer (See Table 3).

37

Table 3
Means and Standard Deviations for Speech Impairment by Timing of Speech Treatment Speech
Handicap Index scores
Group
M SD N
Early 1.30 .63 36
Late 2.18 .98 38
No Tx 2.41 1.05 38

Note. Speech Handicap Index scores: 0=never, 1=almost never, 2=sometimes, 3=almost always,
4=always having speech problems.

For the dependent variable of Voice Handicap Index (VHI) a 1-way ANOVA was
conducted with timing of voice intervention as the independent variable. The result of the 1-way
ANOVA showed a significant difference between intervention groups (early, late, no
intervention) on voice impairment level; [F (2,114) =12.243, p=<.001]. Post-hoc analysis
revealed that the early group reported significantly less voice impairment on average than both
late (p=<.001) and no treatment groups (p=<.001). There was no significant difference between
late and no treatment group. These findings indicated that early voice intervention was associated
with significant improvement in ability to speak with good voice quality. Means and standard
deviation for voice impairment by timing of treatment is provided in Table 4.

38

Table 4
Means and Standard Deviations for Voice Impairment by Timing of Voice Treatment Voice
Handicap Index -10 scores
Group
M SD N
Early 1.41 .67 41
Late 2.21 .94 38
No Tx 2.26 .96 38

Note. Voice Handicap Index-10 scores: 0=never, 1=almost never, 2=sometimes, 3=almost
always, 4=always having voice problems.

Analysis of Research Question 2: Is there a difference between early, late, and no
intervention groups in patients' ability to swallow safely post cancer treatment?
A 1-way ANOVA was conducted for the dependable variable swallowing handicap as
measured by EAT-10. The result indicated that there was a significant difference between timing
of swallowing intervention groups (early, late, no intervention) on swallowing handicap; [F
(2,119) = 11.12, p= < .001]. Post hoc analysis to determine the exact location of group
differences revealed that the early swallowing intervention had lower EAT-10 score than both
the late (p= < .001) and no intervention group (p = < .001). The group means and standard
deviations are provided in Table 5.

39

Table 5
Means and Standard Deviations for Swallowing Impairment by Timing of Swallow Treatment
EAT-10-swallow scores
Group
M SD N
Early 1.90 1.04 40
Late 3.13 1.19 33
No Tx 2.82 1.28 49

Note. EAT-10 scores: 0=no problem 1=minimum problem, 2=mild problem, 3=moderate problem,
4-severe problem.
Research Question 3: Is there a difference between early, late and no speech intervention
groups in their quality-of-life post cancer treatment in the domain of speech?
To determine if there is a difference between early, late and no speech intervention
groups patients' reported quality of life as measured by Washington Quality of Life (UW-QOL),
a 1-way MANOVA was conducted for the 2 subscales of-Physical Function (appearance,
swallowing, chewing, speech, taste and saliva 6 items) and Social-Emotional Function (activity,
recreation, pain, mood and anxiety, 5 items). The overall MANOVA was significant for Physical
Function, [Wilks' Lambda, F (2,216) =.655, p. =<.001]. Subsequent univariate analysis revealed
significant group differences for Physical Function subscale. Speech (p=.001), taste (p=.005),
and saliva(p=.001) domains were significant, the remaining domains such as swallowing,
chewing and appearance were not significant. The overall MANOVA was significant for Social-
Emotional Function [Wilks' Lambda, F (2,218) =1.954, p=.040). Subsequent univariate analysis

40

revealed significant group difference for activity domain(p=.028), but not for pian, mood,
anxiety, and recreation). Mean and standard deviation for Physical Function Scale are provided
in Table 6.
Table 6
Means and Standard Deviations for Physical Function and Social Emotional Function by Timing
of Speech Treatment
Speech
M SD
Early 10.54 14.51
Late 30.71 26.35
No Tx 30.27 27.73
Saliva M SD
Early 22.70 27.45
Late 46.67 32.59
No Tx 44.32 31.93
Taste M SD
Early 24.59 30.23
Late 46.43 32.59
No Tx 44.32 31.93
Activity M SD
Early 21.79 23.77
Late 35.98 23.08
No Tx 31.94 25.07

41

Note. UW-QOL domain significant problem trigger criteria: Speech, saliva, and taste >30 scores,
higher score=more impairment
Speech score 30= Only my family and friends can understand me
Saliva score 30= I have too little saliva
Taste score 30=I can taste some foods

Analysis of Research Question 4: Is there a difference between early, late, and no
swallowing intervention groups in their quality-of-life post cancer treatment in
swallowing?
To determine if there was a difference between early, late and no swallowing intervention
in patients' quality of life as measured by Washington Quality of Life (UW-QOL) with 2
subscales of Physical Function and Social-Emotional Function scale, one-way MANOVA was
run for dependable variables-Physical Function Scale (PF) and Social-Emotional Scale (SE). For
the dependent variable, PF, there was a statistically significant effect between timing of
swallowing intervention on dependent variables, [Wilks' Lambda F (12,212) =2.836, p =.001].
The overall MANOVA model was NOT significant for SE subscale. Subsequent univariate
analysis revealed significant group differences for PF -swallowing(p=.005) and PF-
saliva(p=<.001), but not significant for appearance, chewing, speech and taste. Post-hoc analysis
revealed the significant group differences for swallowing(p=0.005) and saliva (p=<.001). There
was a significant difference between early swallowing treatment effect on saliva flow as
compared to no swallowing treatment. (p=<.001). (See Table 7).

42

Table 7
Means and Standard Deviations for Physical Function Scale by Timing of Swallow Treatment
Saliva
M SD
Early 25.00 29.08
Late 47.94 33.28
No Tx 51.40 31.74
Swallow M SD
Early 22.70 27.45
Late 46.67 32.59
No Tx 44.32 31.93

Note. UW-QOL domain significant problem trigger criteria: swallow, saliva >30 scores, higher
score=more impairment
Swallow score >30=" I can only swallow liquid food" or " I cannot swallow because it
"goes down the wrong way and chokes me".
Saliva score >30= " I have too little saliva" or " I have no saliva"
Taste score 30=I can taste some foods

In the University of Washington Quality of Life Questionnaire, patients identified critical
issues during the past 7 days were both speech and saliva, followed by taste, pain, and activity
level. When asked about HR-QoL compared to a month before they had cancer, a total of 118
patients rated as follows: 43% patients rated much better and somewhat better, 23% rated about

43

the same and 12% rated worse. Regarding the QoL-health-related during the past 7 days, 70%
patients reported above good, only 10% patients reported poor.

44

Chapter Five: Discussion
Patients with head and neck cancer have encountered multiple challenges with speech,
voice, and swallow function prior to, during, or following cancer treatment. The ability to speak
clearly and with a good voice quality are essential for successful communication and social
interaction. Being able to swallow easily and without choking have been taken for granted. When
patients lose the ability to speak, produce a clear voice or ability to swallow safely, then, the
quality of life will be severely compromised. It is increasingly evident that counseling patients to
do swallowing exercises after surgery, during and after radiation is essential to reduce the side
effects of cancer treatment which may include aspiration pneumonia, G-tube feedings,
malnutrition and speech and voice impairment.
The purpose of this study was to investigate if early intervention for speech, voice and
swallowing would affect patients' ability to speak with a good voice, to eat and to live an
improved quality of life. This study strategically focused on early speech, voice and swallowing
intervention provided within six months of cancer treatment and used validated tools to measure
the effect on patients' speech, voice, swallowing skills, and their quality of life in the physical
and social-emotional function domains. This chapter covers the main findings of this study and
describes the overall outcome based upon the four research questions. Following the discussion
of the findings, this chapter reports on the implications for current practice and proposes action
plans to improve current head and neck cancer management. The limitations and the
recommendations for future studies will also be included in this chapter.
Discussion of Main Findings
Regarding Research Question 1: whether early speech intervention was related to patients'
ability to speak with clarity and with good voice quality, the results showed significant

45

relationship findings between early speech/voice intervention and speech/voice impairment level
measured by the Speech Handicap Index (SHI) and the Voice Handicap Index (VHI-10). Patients
who received speech/voice intervention within six months of cancer treatment reported having
the lowest handicap level as compared with the late group and no therapy group. Furthermore,
this result indicated that patients who received early speech intervention reported almost never
having speech problems as compared to late group patients who reported that they still
sometimes had speech problems. In terms of voice quality, patients who received early voice
intervention reported they had almost never had voice problems as compared to late intervention
patients who reported they sometimes had voice problems. Both findings indicated that early
speech and voice intervention provided within six months of cancer treatment was associated
with a significantly reduced patients' speech and voice impairment level. These findings support
the work of Sreenivas et al., (2021), Ouyoung et al., (2015) and Van Gogh et al., (2012). Van
Gogh et al. (2006) reported that voice therapy proved to be effective in patients who had voice
problems after treatment for early glottic carcinoma. Van Gogh et al. (2006) further documented
the beneficial effect of voice therapy was not just a short-lived voice improvement but may result
in a better voice for a period of at least 1 year. Ouyoung et al. (2015) were the first authors to use
the specific voice therapy titled “ABCLOVE”, specific frequency of voice treatment (2 times per
week for 8 weeks), and early voice intervention (within one month after cancer treatment to treat
HNC patients with improved voice outcome. Furthermore, Sreenivas et al (2021) confirmed that
voice therapy offered at 1 month after cancer treatment ameliorated chemoradiation-induced
dysphonia within six months.
In response to Question 2: whether early swallowing intervention was related to patients'
ability to swallow safely, the results showed a significant relationship between early swallowing

46

intervention and the level of swallowing impairment measured by the EAT-10 score. Patients
who received swallowing intervention within six months of cancer treatment had minimum
problem in eating compared to the late intervention patients reported moderate problem in eating.
The findings indicated early swallow intervention was associated with reduced swallowing
problems. These findings are in line with the work of multiple researchers (Shinn et al., 2013;
Kotz et al., 2012; van der Molen et al., 2011; Ouyoung et al., 2020; Hutcheson et al., 2013;
Kwon et al., 2021 and Yang et al., 2021). Hutcheson et al. (2013) reported that proactive
swallowing therapy during radiotherapy (RT) or chemoradiotherapy (CRT) for pharyngeal
cancers was beneficial to maintain patients’ oral intake when patients followed a regimen of
targeted swallowing exercises. Kumar et al. (2015) demonstrated that swallowing exercises, if
administered from the first week of chemoradiation and continued till six months, results in
significant improvement in swallowing function and quality of life. Hutcheson et al (2021)
further confirmed that the Eat-All Through Radiation Therapy (EAT-RT) program could
facilitate oral intake in patients with head and neck cancer throughout radiation therapy.
Ouyoung et al. (2020) reported that early Dysphagia Boot Camp therapy was associated with
increased improvement in Functional Oral Intake Scale Scores. This study highlighted the need
for early referral and engagement in swallow rehabilitation after treatment of oropharyngeal
cancers. Kwon et al. (2021) reported improved swallow outcomes with early intervention using
combined swallow therapy in advanced oropharyngeal carcinoma. Another author, Yang et al.
(2021), provided the evidence of the potential benefits of prophylactic swallowing exercises
among HNC patients undergoing chemoradiation treatment within six months of cancer
treatment. My current study findings further indicate the specific time limit for early swallowing
intervention need to be within six months after cancer treatment so that swallowing function can

47

be maintained and possible side effects of cancer treatment including aspiration and G-tube
placement can be avoided.
In response to Research Question 3: whether early speech intervention was clearly related
to patients' quality-of-life in both physical and social-emotional domains, the results showed a
significant relationship between early speech intervention and patients' physical function domain
such as their speech ability, saliva flow and their taste of foods. Patients could speak better, have
more saliva, less dry mouth and they could taste foods more. In the social-emotional domain,
patients reported that they could participate in their daily activity with more energy.
In response to Question 4: whether early swallowing intervention was related to patients'
quality-of- life in both the physical and social-emotional domain, the results showed a significant
relationship between early swallowing intervention and patients' ability to swallow and the saliva
flow in the physical function domain. Patients who received early swallow treatment reported
better saliva flow and better swallowing ability. Multiple studies reported long term survivors of
HNC suffered side effects of cancer treatment in speech, swallowing, dry mouth (lack of saliva
flow) and low activity level to participate in social events (Mehanna and Morton, 2006;
Kraaijenga et al., 2015). Kraaijenga et al. (2016) reported that for HNC survivors at 8–11-years
post-diagnosis, their quality of life such as social functioning, swallowing, speech, taste/small,
dry mouth, sticky saliva, and coughing worsened. Kraaijenga et al (2015) published voice-and-
speech-related outcomes of HNC patients 10-years after cancer treatment. Voice and speech
problems were common in HNC survivors, with 68% and 77% of the 22 evaluated patients
reporting voice and speech problems in daily life. The findings of this study suggested that early
speech and swallowing treatment could improve speech clarity and swallow better, taste more

48

foods and improve patient’s activity level to participate in social events. Long-term
consequences of side effects could be prevented by early intervention.
In the University of Washington Quality of Life Questionnaire, HNC patients identified
critical issues during the past seven days were both speech and saliva, followed by taste, pain,
and activity level. The above finding was expected, since 83.7% of the survey respondents
received surgery and radiation treatment which affected their ability to speech with clarity and
the saliva flow. The above findings were consistent with the studies done by Karnell et al. (2000)
and Rogers et al. (2002) indicating that speech and eating domains best predicted quality of life
scores and HNC patients rated speech, chewing, and swallowing as the most important quality of
life domains. Abendstein et al. (2005) reported persistent side effects for cancer treatment were
dryness of the mouth, difficulty in opening of the mouth creating swallowing difficulty and
sticky saliva between one and five years after cancer treatment. When asked about HR-QOL
compared to a month before they had cancer, a total of 118 patients rated as follows: 43%
patients rated much better and somewhat better, 23% rated about the same and 12% rated worse.
These findings indicate that 75% of the patients’ quality of life would go back to the same
quality of life after cancer treatment due to the natural healing process. In the Ackerstaff et al.
(2011) and Kraaijenga al. (2016) studies, they reported that dry xerostomia (dry mouth),
swallowing, speech, taste/smell, and sticky saliva and coughing worsened for HNC survivors
after cancer treatment. Regarding voice quality, 33% of the patients after one year of cancer
treatment remarked that their voice was worse and 39% of patients reported they had voice
problems. Reviewing the current literature regarding the time limit for early intervention, the
conclusion was not consistent pending on tumor size and individuals’ reaction to the side effects
of treatment, but one recommendation most of the researchers made was to provide early

49

intervention as soon as possible. Without timely intervention, the side effects of radiation would
worsen. This study results indicated that early intervention within six months of cancer treatment
had significant relationship with the ability to speak, voice, swallow, and improved quality of life
by participating daily activities with more energy, improved saliva flow and taste foods better.
Implications for Practice for Healthcare Education
The current study was designed to investigate the effects of benefits of early
intervention in speech, voice and swallowing for head and neck cancer (HNC) patients and
whether early intervention would affect their quality of life in both physical function and social-
emotional function domains. The results indicated the patients who received early intervention
could enjoy the benefits of speaking with clarity, good voice quality and eating safely with
minimum problems. Their quality of life would improve with improved speech clarity, better
saliva flow and better taste of food after speech/voice/swallow intervention. Specifically, patients
who received early swallow treatment would have better swallowing skills and improved saliva
flow. In this survey, patients identified speech and saliva were their major concerns over the past
7 days. Patients' concerns could be immediately addressed by early speech and swallowing
intervention. This study revealed that it was critical to provide early intervention within six
months of cancer treatment to reduce aspiration pneumonia, to improve speech, voice, and
swallow skills before, during and after cancer treatment. This study contributes to the limited
studies to document the benefits of early referral for speech, voice, and swallowing intervention,
but there are many obstacles to let HNC patients receive early intervention.
The results of this study have important implications for healthcare providers who are
interested in improving current HNC management by providing collaborative effort to make the

50

early referral for speech/voice and swallowing intervention. Healthcare providers can include
nurses, speech pathologists, dietitians, and other healthcare providers such as physical therapists
and occupational therapists. Patients and patients' family members need to be educated regarding
the benefits of early intervention and advocate for themselves to seek early intervention. In the
effort to further educate the above stakeholders about the benefits of early speech, voice, and
swallowing interventions, it is necessary and critical to launch a series of professional
development training courses and add the essential education components in the professional
curriculum. The training courses need to be tailored to specific disciplines and their roles in the
six months of a patient's cancer journey. A clinical pathway for HNC management needs to be
developed to cover the initial diagnosis of cancer, admission to the hospital for surgery and six
months after the discharge from the hospital. Different educational handouts need to be
developed for doctors, nurses, other healthcare providers and patients/family members so that
each discipline and patient/family members can be aware of early signs of speech, voice and
swallowing symptoms and refer for timely treatment.
According to the literature, aspiration pneumonia in HNC patients ranged from 5.4% to
23%, furthermore, AP was a poor prognostic factor for HNC patients. Patil et al. (2021)
indicated that 28.3% of HNC patients developed aspiration pneumonia. Working in a medical
center managing HNC patients for the past 17 years, I find room for improvement in current
HNC management. The medical center should enhance current aspiration pneumonia prevention
protocol, improve training and education for nurses to identify high-risk patients for management
at inpatient care. Close collaboration between speech pathologists, nurses, dietitians, and other
team members is essential to prevent aspiration pneumonia in the hospital setting. When patients
are at the outpatient settings such as doctor's office or outpatient clinics, physicians and

51

healthcare providers can have a checklist for detecting early signs of speech, voice and
swallowing difficulties and make early referrals for treatments. Patients and family members
need to be educated by speech pathologists regarding possible side effects of cancer treatment
and advocate for their care. A patient education handout can be provided and reviewed with the
patients and patients’ family during the first consult with speech pathologists. This will empower
patients and family members to take a proactive action to ask for a doctor's referral when the
early signs of speech, voice and swallowing occur. Based on the data gathered in this study,
training needs to be developed to provide for the following professionals for healthcare
education
Nurses
ICU nurses need to have the knowledge, motivation, and competency to administer Yale
Swallow Screening and make early referrals to speech pathologists for evaluation, and monitor
patients eating at the bedside. The aims of training courses for nurses need to include
administration of Yale Swallow Screening, collaboration with speech pathologists to follow
aspiration pneumonia protocol and dieticians to monitor patient's nutritional status. Furthermore,
nurses can monitor patients swallowing safely by using swallowing guidelines. Quarterly review
of aspiration pneumonia cases with nurses in the staff meeting to reinforce the compliance of
aspiration prevention protocol will be beneficial for continuous improvement of conducting the
policy.
Physicians
A screening checklist can be distributed to all physicians to detect early signs of speech,
voice, and swallowing severities. The summary of early intervention literature can be shared
with all physicians to trigger early referrals. It is important to include the content of aspiration

52

pneumonia and HNC cancer management and early intervention in the curriculum of medical
students or residents.
Dieticians
Early nutritional screening in dysphagia HNC patients and checking patients' nutritional
status after oncological treatment and during long term follow-up is important. Speech
pathologists can collaborate with dieticians to establish daily communication regarding patients’
nutritional status, diet consistencies and oral intake. Regular joint meetings between the two
disciplines are needed to discuss cases and exchange ideas and perspectives on how to manage
patients better. Malnutritional screen and dietician consultation are essential to maintain patients’
nutritional status. At an outpatient clinic, speech pathologists can refer patients to a dietician
consultation when patients lose weight or do not meet their nutritional needs.
Speech Pathologists
The senior speech pathologist who has experience working with HNC patients can
provide ongoing training to junior staff on HNC clinical pathway and the early intervention
program and patients’ education during the radiation or chemoradiation period. Monthly case
discussions will enhance learning and current practice at the department meetings.
Patients and Family Members
Patients' education handouts will be provided to the patients both at inpatient and
outpatient locations. Both nurses and speech pathologists can jointly design inpatient handouts
while patients are in the hospital. Speech pathologists should develop outpatient education
handouts to include simple checklists at the various stages of cancer treatment, pre-radiation
education and ongoing speech, voice, and swallowing exercises.
Limitations of the Study

53

While the study had significant findings, there were limitations that should be considered.
Firstly, this study employed a non-random sampling method to recruit study participants. Using a
sample of convenience, the researcher recruited patients treated in the hospital, speech outpatient
clinic and Ear, Nose and Throat (ENT) clinic. The sample size was small to include patients
treated in the hospital, ENT clinic and speech clinic. This was only a small fraction of head and
neck cancer patients treated over the past 17 years since 50% of the patients had recurrent cancer
or were deceased. For generalizable findings, a sizable sample of patients from each of the types
of institutions was needed. This study was a non-experimental study, only association between
the independent and dependent variables, and no cause-and-effect relationships, could be implied
from the study results. Secondly, the study design and data collection relied on patients'
subjective responses on a self-report survey. The answers were based on patients' subjective
impressions of their cancer treatment. Thirdly, 69% of survey respondents were white, while
only 11% respondents were Hispanic or Asian and only 3.7% respondents were Black. Small
sampling of different racial groups led to study participants being not well represented in this
study. A larger study sample would have allowed the researcher to examine group differences
between different racial groups. Additionally, the limitation of the instrument tool to measure
outcome variables in this study existed. In this study, the researcher used the EAT-10 to measure
the swallowing impairment but not addressing the level of diet level and consistencies which
patients could eat and whether patients needed G-tube or supplements to provide their nutritional
support. Finally, to claim generalizable findings on the ability to speak with clear, good voice
and their quality of life would improve after early speech intervention need to be explored.
Recommendations for Future Studies

54

Although there is a plethora of research-based practices for both speech and swallowing
treatment outcome, the need for more research and data analysis is needed in the early speech,
voice, and swallowing domain. This study aimed to explore the relationship between the early
intervention in relationship with their speech, voice, swallowing and quality of life domain
according to patients' own report in the survey questions. Future studies should recruit more
diverse racial groups, bigger samples, and consider the staging of head and neck cancer, the site
of tumor, and the tumor size affecting the patient's outcome. The time limit of early intervention
provided at three months, six months or nine months after cancer treatment should be
investigated and compared in terms of clinical outcome in speech, voice, swallowing and quality
of life. The early education of patients and patients’ family members regarding awareness of side
effects of cancer treatment to trigger them to take an active role to seek out early referral from
their attending doctors should be explored in the future studies. The selection of measurement
tools needs to be explored to provide specific measurement information. Future researchers can
also assess the benefits of using oral hygiene products, oral nutritional supplements designed for
the HNC population and specific rehabilitation techniques on speech, voice and swallowing
muscles and the intensity, frequency of treatment regimen will provide a more robust analysis to
improve current HNC management and improve patients’ quality of life.
Conclusion
The goal of this study was to explore the benefits of early intervention related to their
ability to speak with clarity, a good voice, to swallow safely and to improve their quality of life
through a self-reported survey questionnaire. The study findings indicated early intervention
provided within six months of cancer treatment was significantly associated with patients’ ability
to speak with clarity, with a good voice, and to swallow safely. Furthermore, improved patients'

55

quality of life such as speech, swallow, saliva flow, taste, and activity function were significantly
associated with early speech and swallow intervention. This study focused on early intervention
provided within six months of cancer treatment, team collaboration and ongoing education and
training to all professional team members throughout patient's cancer journey. Speech
pathologists play a significant role in patients' education and training regarding the early signs of
speech, voice, and swallowing problems so that patients can take an active role in seeking out the
early referrals from their attending doctors to continue eating by mouth with adequate nutrition,
speaking with clarity and a good voice and enjoying improved quality of life after the cancer
treatment. I hope this study can contribute to the current literature and trigger early intervention
for HNC patients.

56

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Appendix A: Speech Handicap Index
These are some statements that many people may have used to describe their speech and
the effects of their speech on their lives. Please tick the response that indicates how frequently
you have the same experience.

NEVER ALMOST
NEVER
SOMETIMES ALMOST
ALWAYS
ALWAYS
1 My speech makes
it difficult for
people to
understand me.

2 I run out of air
when I speak.

3 The intelligibility
of my speech
varies throughout
the day.

4 My speech makes
me feel
incompetent.

85

5 People ask me
why I’m hard to
understand.

6 I feel annoyed
when people ask
me to repeat.

7 I avoid using the
phone.

8 I’m tense when
talking to others
because of my
speech.

9 My articulation is
unclear.

10 People have
difficulty
understanding me
in a noisy room.

86

11 I tend to avoid
groups of people
because of my
speech.

12 People seem
irritated with my
speech.

13 People ask me to
repeat myself
when speaking
face-to-face.

14 I speak with
friends and
neighbors or
relatives less
often because of
my speech.

15 I feel as though I
have to strain to
speak.

87

16 I find other
people don’t
understand my
speaking
problem.

17 My speaking
difficulties
restrict my
personal and
social life.

18 The intelligibility
is unpredictable.

19 I feel left out of
conversations
because of my
speech.

20 I use a great deal
of effort to speak.

88

21 My speech is
worse in the
evening.

22 My speech
problem causes
me to lose
income.

23 I try to change
my speech to
sound different.

24 My speech
problem upsets
me.

25 I am less
outgoing because
of my speech
problem.

89

26 My family has
difficulty
understanding me
when I call them
throughout the
house.

27 My speech makes
me feel
handicapped.

28 I have difficulties
to continue a
conversation
because of my
speech.

29 I feel
embarrassed
when people ask
me to repeat.

30 I’m ashamed of
my speech
problem.

90

Appendix B: Eating Assessment Tool (EAT-10)

91

Appendix C: Voice Handicap Index-10

92

Appendix D: University of Washington Quality of Life Questionnaire

93

94

95

Appendix E: Figure 1: Quality Health Outcomes Model

Abstract (if available)

Abstract Patients with head and neck cancer are at risk for developing aspiration pneumonia, dysphagia, speech, and voice challenges after surgery, during and after the chemoradiation (CRT) management. While advances in surgical and radiation therapy have drastically improved oncologic outcomes, there are not without risks. The side effects of cancer treatment causing aspiration, speech impairment, voice impairment and dysphagia have significantly decreased patients' quality of life. (Kraaijenga et al., 2015; Hutcheson et al., 2012). This quantitative correlational study was conducted to evaluate the benefits of early intervention to speak with clear voice quality, to swallow safely and to improve quality of life by using a patient's self-reported survey questionnaire after cancer treatment. The results indicated that early speech and swallowing intervention significantly improved patients’ ability to speak with clarity without being hoarse and to eat with safety. This study also confirmed the benefits of early speech, voice and swallowing intervention have improved patients' quality of life in their ability to speak, to voice, to swallow, and to taste foods with more saliva flow. Patients can participate in daily activities without feeling fatigue. Early speech, voice, and swallowing intervention within six months of cancer treatment are essential for all care providers to make referrals to speech pathologists so that HNC patients can speak with clarity and with good vice quality, to eat safely for the years to come after the cancer treatment.

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Asset Metadata

Creator Ouyoung, Laishyang (author)

Core Title The benefits of early intervention to improve speech clarity, voice quality, safe swallow, and quality of life in head and neck cancer patients

School Rossier School of Education

Degree Doctor of Education

Degree Program Education

Degree Conferral Date 2023-08

Publication Date 08/28/2023

Defense Date 08/27/2023

Publisher Los Angeles, California (original), University of Southern California (original), University of Southern California. Libraries (digital)

Tag and swallow intervention,aspiration pneumonia.,early speech,Keywords: head and neck cancer,OAI-PMH Harvest,Quality of life,voice

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Chung, Ruth (committee chair), Picus, Lawrence (committee member), Robison, Mark (committee member), Sinha, Uttam (committee member)

Creator Email louyoung@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC113302368

Unique identifier UC113302368

Identifier etd-OuyoungLai-12285.pdf (filename)

Legacy Identifier etd-OuyoungLai-12285

Document Type Dissertation

Format theses (aat)

Rights Ouyoung, Laishyang

Internet Media Type application/pdf

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Source 20230830-usctheses-batch-1088 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

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