Audiologists often work with patients who are receiving ototoxic chemotherapy. When the patient is a child, many variables must be considered in the planning and provision of family-centered clinical care.
The audiologist plays a critical role as a member of the multi-disciplinary oncology team. Baseline and monitoring audiological evaluations must be completed as treatment timelines indicate, and must be reported accurately and expeditiously to all who are involved in the patient's care. Services must be flexible and adaptable to the ongoing needs and schedules of patients and their multiple caregivers.
Audiologists must understand and practice family-centered care, especially when working with the pediatric oncology population. This treatment philosophy considers the health care needs of the patient within his or her family unit and identifies factors that may influence a patient's outcomes and interventions.
Family-centered care ensures that providers are flexible in tailoring services to the needs, beliefs, and cultural values of the family unit (Committee on Hospital Care, 2003). Families of very young and fretful children, for example, may request that test results and recommendations be discussed privately, away from the patient. They also may ask that care providers not mention a new diagnosis of cancer to their children until they have determined the best time and way to discuss this with them.
When counseling older children and families, audiologists should include information about the nature and frequency of subsequent testing. The auditory and vestibular consequences of ototoxic chemotherapy also should be reviewed. Patients and families should be provided with educational materials and websites geared toward and easily understood by consumers. When possible, families should maintain continuity with the same examining audiologist to help ensure the development of a trusting relationship among the patient, family, and professional.
In providing family-centered care, the pediatric audiologist also may:
- Partner with an audiology assistant to distract patients during testing with age-appropriate, interesting activities (e.g., electronic toys, pet therapy).
- Coordinate testing times (avoid times that conflict with naps, for example, or that follow painful procedures).
- Encourage older patients to select the order of tests to be completed to enhance their feeling of control over their surroundings.
- Encourage an older child to participate in activities such as removing the probe tips used in testing.
- Maintain a stock of loaner hearing aids and assistive listening devices to ensure patients have immediate resources to maintain communication with family and caregivers.
- Include patients in decisions about hearing aid and earmold styles and colors.
- Celebrate milestones, such as finishing chemotherapy treatment, with patients and other oncology team members.
- Participate in oncology team community events, such as Cancer Survivor Day celebrations and Relay for Life walks.
- Participate in educational events offered to families.
- Seek opportunities to learn more about the grieving process and hospice care.
Baseline Evaluation and Monitoring
Prior to the administration of toxic chemotherapy agents, audiologists should provide baseline audiological evaluations, including high-frequency audiometry and distortion product otoacoustic emission testing when possible. A revised protocol may be necessary, depending on the patient's age, cognitive abilities, responsiveness, and middle-ear status. These variables may prevent the clinician from obtaining a full battery of test results. Frequency-specific threshold auditory brainstem response (ABR) testing may be an appropriate clinical tool to estimate hearing levels in the peripheral auditory system, and often can be coordinated with other planned medical procedures under anesthesia. This testing is objective, noninvasive, and painless. The audiologist must complete monitoring evaluations prior to each dose of ototoxic chemotherapy, or sooner if tinnitus or changes in hearing are suspected. Annual follow-up is recommended for all patients who have received ototoxic chemotherapy, even when hearing loss has not manifested, as hearing can worsen years after completion of treatment (Al-Khatib et al., 2010).
An ototoxicity incidence of up to 33% has been reported for patients receiving cisplatin. Hearing loss at higher frequencies is common, especially in patients receiving dosages greater than 60 mg/m2 every two weeks (Rademaker-Lakhai et al., 2006). Cisplatin has been found to be more ototoxic than carboplatin. Children treated with both often acquire significant hearing loss, and children who are younger than 5 years and/or have kidney dysfunction during treatment are at an increased risk (Knight, Kraemer, & Neuwelt, 2007). For young children, any hearing loss
has the potential to affect speech and language development negatively.
Various scales evaluate changes in hearing from administration of ototoxic chemotherapy agents, including those from the National Cancer Institute and Brock et al. (1991). Recently, Chang and Chinosornvatana (2010) proposed a grading system advocating pure-tone threshold shifts compared to baseline testing rather than the absolute level of hearing loss. These protocols often call for a reduction or discontinuation of ototoxic chemotherapy agents when changes in hearing occur. The treatment protocol chosen by the oncologist for each patient depends upon the type and stage of the disease. The audiologist must be in a position to report test results quickly, especially when a change in the use or dosage of the next planned round of ototoxic chemotherapy is indicated.
As part of a collaborative team, the pediatric audiologist must remain flexible in accommodating the scheduling needs of oncology patients. Families seeking oncology services often live far from the treatment facility. Coordinating audiological appointments on days patients are scheduled for other medical appointments is often necessary. Particularly when an initial cancer diagnosis is confirmed, baseline testing may be required with short notice. A department scheduling guideline that addresses this issue is critical and avoids treatment delays. Policy and procedure manuals should include specific information regarding flexible scheduling for this and other urgent audiologic needs to reduce delays. All members of the pediatric oncology team should understand and embrace the importance of prompt access to services.
The pediatric audiologist plays a vital role in the care of children receiving ototoxic chemotherapy. Clinicians who follow evidence-based practice, focus on family-centered care, actively participate on the multi-disciplinary team, adapt to the plan of care, and provide appropriate and convenient resources will successfully address the hearing health care needs of this population.