Managing voice and speech side effects after oropharyngeal cancer treatment

Oropharyngeal cancer includes cancers of the tonsils, base of the tongue and other parts of the throat. It’s usually caused by the human papillomavirus (HPV). People who have successfully completed treatment for HPV-related oropharyngeal cancer often have a good prognosis and are able to return to their daily lives.

But survivors may go on to develop voice and speech symptoms years after treatment. Moderate to severe voice symptoms can include a voice that sounds hoarse, raspy or weak, and speech that sounds slurred, resembling drunken speech.

“It’s an important and understudied topic,” says Sanjay Shete, Ph.D., who led the first study to report risk factors associated with patient-reported voice and speech symptoms among long-term oropharyngeal cancer survivors. “The ability to communicate is important to quality of life. If patients are self-conscious about the way they sound, they may speak less, which can lead to feelings of isolation and other problems.”

Here are four steps patients can take to understand and address these symptoms.

1. Learn the causes and risk factors for voice and speech changes

Voice and speech symptoms in oropharyngeal cancer survivors are mostly caused by scarring or nerve damage from surgery or radiation therapy, including lower cranial neuropathy and fibrosis in the larynx.

“Radiation is the main contributor to larynx damage,” says Puja Aggarwal, Ph.D. “When chemotherapy is given with radiation, it sensitizes the area to radiation, and may cause more harm to areas involved in speaking. Sometimes that damage accumulates over time.”

What wasn’t known until recently was how often people were affected by these issues or who was at increased risk for developing late symptoms, years after treatment. In the recent study of more than 800 oropharyngeal cancer survivors, 12.8% reported moderate to severe voice and speech symptoms. The study found that total radiation dose, Black race, Hispanic ethnicity and current smoking status were all associated with moderate to severe symptoms.

The risk for developing symptoms also accumulated over time, so survivors were more likely to report symptoms as they aged. Those who had chemotherapy before and/or alongside radiation were also at increased risk for future symptoms. Newer, more targeted forms of radiation therapy, such as intensity-modulated radiation therapy (IMRT), were associated with a lower risk of developing voice and speech symptoms.

2. Quit smoking

While patients may not have control over all of the factors that put them at risk for voice and speech problems, they can lower their risk by quitting smoking. 

“Patients who quit smoking even after their diagnosis were able to lower their risk for voice and speech symptoms to the same point as patients who never smoked,” Shete says. “This is a huge silver lining and should motivate care teams to encourage patients to take advantage of tobacco cessation services.”

MD Anderson’s Tobacco Treatment Program offers free tobacco cessation services, including behavioral counseling and nicotine-replacement therapy, to MD Anderson patients. Texas residents who are not MD Anderson patients may be eligible to take part in remote tobacco cessation studies. Anyone can call 1-800-QUIT-NOW to be connected to free quitting resources in their state.

3. Ask for voice and/or speech therapy

“It’s important for patients and caregivers to know there are options available to help with voice and speech problems, as well as swallowing issues,” says Katherine Hutcheson, Ph.D. “If the problem is related to damage in the larynx, voice therapy can help, as long as you commit to practicing. If the problem is slurred speech and articulation issues, tongue strengthening therapy can help. And if the problem is vocal cord paralysis, implants or surgery may be an option, even in patients who had radiation to the larynx.”

All of these services are available to MD Anderson patients through the Head and Neck Center. New patients or long-term survivors who haven’t been seen recently are required to undergo a medical evaluation first to ensure the symptoms aren’t signs of new or recurrent disease.  

4. Participate in research studies for oropharyngeal cancer survivors

Current patients and long-term survivors both have opportunities to contribute to progress in understanding, treating and preventing long-term symptoms. Shete and Aggarwal’s study was based on a survey led by Dr. Hutcheson’s lab that asked oropharyngeal cancer survivors, who ranged from one to 16 years post-diagnosis, to rate their own symptoms. Their future research will look at other symptoms, including swallowing issues and fatigue, and study the role of genetics in symptom development.  

Hutcheson leads a large registry that’s following over 1,000 oropharyngeal cancer survivors to investigate how symptoms evolve and progress over time. Clinical trials are also underway to study strategies to de-escalate treatment for HPV-related oropharyngeal cancer and to  improve symptoms associated with late lower cranial neuropathy.

“We’re so grateful to the patients and families who make our research possible,” Hutcheson says. “Your participation can help us make progress toward improving quality of life for all survivors.”

Request an appointment at MD Anderson online or by calling 1-877-632-6789.