Voice analysis after cancer treatment with organ preservation

Because several sequelae of oral communication may occur after treatment of head and neck cancer, research in this area is important to better describe the symptoms and adequately control the treated patients [1]. Costa Bandeira et al. [2], studying the quality of life and communication, voice and swallowing alterations of radiotherapy-treated tongue cancer patients, found voice and swallowing alterations and low quality of life scores after 1 year, stating the important role played by the speech therapist in the radiotherapy team.

This study aimed to analyze the voice pattern, through subjective and objective measurements, and the quality of life of head and neck cancer patients submitted to an organ-preservation protocol. The Voice Handicap Index (VHI) was used to measure voice quality [3].

None of our subjects reported professional voice use (singing or speech). Yet 36% reported voice use in the working environment and 84% in daily life conversation.

During the study period, the following frequencies referred to the year of diagnosis/treatment: 8% (2000); 20% (2002); 12% (2003); 20% (2004); 12% (2005); and 28% (2006). Our sample had no case referring to the year 2001.

79% of the subjects complained of hoarseness preceding their diagnosis. After radiotherapy, the patients complained of: throat clearing (56%), hoarseness (40%), hearing impairment (40%), and fatigue and vocal effort (8%). No patient reported aphony. As for vocal symptoms grading, 42.9% had grade I dysphonia and 47.6% had grade II dysphonia. The most frequent resonance type was laryngeal (56%). In spite of the large number of communication complaints, only 32% were referred to speech therapy.

Table 3 shows the vocal characterization of the 25 subjects who underwent organ preservation protocols.

On bivariate analysis, there was no association between acoustic analysis and sex (p = 0.385), or between acoustic analysis and GIRBAS scale (p = 0.391). GIRBAS worsened according to anatomical location (p = 0.002) and year of treatment (p = 0.017), and speech therapy increased the likelihood of GIRBAS = 1 (p = 0.048). It is noteworthy that implementation of speech therapy was influenced by sex (p = 0.057).

The main results of VHI indicated that the quality of life showed mild physical, functional and emotional handicaps. As for difficulty to be understood, 80% reported moderate difficulty, and 12% always or almost always had to repeat what they had just said, in order to be understood. Notwithstanding, 64% considered themselves talkative or extremely talkative. 40% considered their voices to have a rough pitch, 24% found their voices to be unpredictably clear, and 12% always or almost always had to make an effort to speak. In 20% the voice disappeared halfway through conversation, 8% felt embarrassed when speaking, and 8% always or almost always felt incompetent when speaking.

According to epidemiological data, age is one of the main risk factors for cancer development, a finding that points to an increase in cancer incidence with gains in life expectancy. 76% of our patients were males, with mean age of 64 years. Besides genetic factors, smoking and alcohol use increase the chances of head and neck cancer, with squamous cell carcinoma as the predominant histological type. In our sample, 64% were former smokers and 32% former alcohol users, with 44% present alcohol users. Mean alcohol and tobacco use time was 40 years, with 4 doses and 15 cigarettes a day, on average.

Recent studies have shown good results with organ preservation approaches that use radiochemotherapy. Although survival time is not affected, laryngeal function is not always preserved, as state Hirsch et al [10]. In our study, radiochemotherapy was used in 56% of the subjects, followed by radiotherapy alone in 44%. A 7000 Gy dose was applied to 64%, with a 5000 Gy fossa dose in 81%. Treatment was curative in 88%.

We chose to use a combination of objective and subjective measurements, according to Leeper et al [11]. Those authors concluded that, although subjective measurements of voice quality are important, objective measurements are necessary to assess subtle voice changes with time.

According to Behrman, Abramson and Myssiorek [12], 80% of prospectively studied patients had changes in their voice quality 1 year after radiotherapy. 40% of our patients still complained of hoarseness, and 56% of throat clearing, even 3 years after treatment.

Carrara-de Angelis et al. [13] concluded that of 15 patients who had received radiochemotherapy for laryngeal cancer, 33% had adequate voice quality or mild dysphonia, 40% moderate dysphonia, and 27% severe dysphonia. In a study of patients treated for glottic tumor, Caminero et al. [14] reported that 11% had normal voices, 44% had mild dysphonia, 28% had moderate dysphonia, and 17% had severe dysphonia. Those authors also reported VHI results that were close to normal. Our results were slightly better, with the following characteristic voices: hoarse (76%), hoarse-breathing (12%), rough (20%), and crepitating (16%). On the GIRBAS scale, 24% had normal voice, 40% mild dysphonia, and 36% moderate dysphonia.

Our study showed that although most subjects had mild physical, functional and emotional handicaps, several aspects of communication were impaired.

The communication problems identified in our study were: moderate difficulty to be understood, need to repeat what had been said, poor voice quality, need to make an effort to speak, and difficulty to socialize (embarrassment to speak and feeling of incompetence when speaking).

Voice quality was associated with speech rehabilitation in our study. The same finding was reported by Van Gogh et al. [15], who concluded that speech therapy was effective for patients complaining of voice impairment after treatment for early glottic carcinoma. Improvement was significant with VHI analysis, and was also confirmed through the objective voice parameters assessed.

Our study results cannot be generalized, because of the small number of patients meeting the inclusion criteria and a possible survival bias that may have overestimated the perception of voice and quality of life. Yet our results suggest an important reflection on radiotherapy and its sequelae. Communication and quality of life after treatment for head and neck cancer are an important issue, once longer survival should assume satisfactory community interaction.

Our findings revealed that even after years of cancer treatment completion, there remain voice symptoms able to interfere with the quality of life. Chemio-radiation organ preservation protocols in the patients studied may leave the organ but with reduced function. Therefore, the integration of the speech therapist in the head and neck cancer treatment teams should bring techniques that will ease patient communication.