Barriers and Potential Solutions to Increase the Success of Ototoxicity Monitoring Programs
January 2018
Marilyn Dille
This paper provides a brief summary of some common barriers to adult ototoxicity monitoring programs (OMPs) that may be encountered during program development—and potential solutions to those barriers. Ototoxicity monitoring practices are common in the United States and have been widely adopted internationally, as well. However, many OMPs fail to thrive. Why is that?
Some drugs that are known to cause irreversible hearing loss during treatment for cancer and serious infections include (a) first- and second-generation platin drugs for late-stage cancer treatment (cisplatin and carboplatin, respectively) and (b) aminoglycoside antibiotics (gentamicin, tobramycin, amikacin) for the treatment of serious infections. We know that hearing loss can affect interpersonal communication, but having this adverse effect is particularly disheartening at a time when important health care decisions are discussed and, perhaps more important, when family and friends draw near. We also know that interactions with audiologists increase the potential that patients will seek hearing intervention during or following treatment. OMP best practices have been endorsed by governing bodies (AAA, 2009; ASHA, 1994) and are taught at most speech and hearing training institutions. Some common OMP beliefs and practices in the United States and internationally are provided in this article to give insight into barriers and potential solutions for ongoing programs or programs in development. The majority of providers in this report follow ASHA-recommended practice patterns. Provider solutions were added that have been found to work in our institution, the National Center for Rehabilitative Auditory Research (NCRAR) and others (Konrad-Martin et al., 2017).
Prior to initiating an OMP program, understanding the viewpoints of the OMP provider (audiologist) and of the program recipient (oncology or infectious disease providers) is important. Surveys of oncologists and audiologists in South Africa and New Zealand are reviewed to provide their insights. The purpose of these surveys was to identify beliefs about OMP and why they fail.
In New Zealand, there is no nationally accepted OMP practice pattern such that the state of monitoring is "poorly understood." Steffens et al. (2014) set out to survey oncology and audiology providers from 16 of 20 health districts to better understand the knowledge, attitudes, and practice patterns of OMP by both disciplines. Within these areas, 16 senior audiologists and eight senior medical oncologists were surveyed. Both disciplines were of one mind on the purpose of OMPs—that is, for early detection of hearing shifts and to provide timely provision of aural rehabilitation. All oncologists and 81% of audiologists called for better collaboration between the services. Oncologists reported that a major limitation for them, when cisplatin ototoxicity was found, was their perception that there were no effective alternative treatments, thereby limiting their options. Yet they still reported that information provided by audiologists guided oncology treatment decisions, when possible. However, audiologists suspected that their information was either not used or did not influence treatment decisions. Both groups emphasized the need for protocols that were evidence based, cost effective, and agreed upon by both professions. This 2014 survey suggested that improved collaboration and communication could improve their program. Although most programs in New Zealand used ASHA and AAA protocols, many patients did not get baseline and follow-up testing. Follow-up rehabilitation was found to be important to both disciplines. All oncologists and 81% of audiologists wanted improved collaboration—a hopeful sign. The survey provides important areas to emphasize when a new program is considered. The importance of close collaboration cannot be minimized to discuss aspects of the program such as procedures and rehabilitation, education on the importance of referrals for OMP especially prior to treatment, and plans to support ongoing communication.
South Africa has the highest incidence of cancer in all of Africa, with 1 of 4 males and 1 of 6 females having a lifetime risk. de Andrade, Khoza-Shangase, and Hajat (2009) surveyed 10 oncologists from two public hospitals in Gauteng, South Africa, to find the level of awareness oncologists had to the presence of an OMP in their hospital and to determine the beliefs about ototoxic events. All oncologists were aware that some chemotherapies had an impact on hearing, although 20% were not sure what that impact might be. Approximately 80% did not counsel their patients regarding the potential for ototoxicity despite 90% knowing that ototoxic chemotherapies could permanently change the structures in the ear. Clearly, oncologists need education about ototoxicity and its importance to successful post-treatment survivorship. When asked about audiology, oncologists were unsure as to their roles and that an audiologist can both manage as well as diagnose hearing loss. Half of oncologists believed that audiologists assessed only speech and hearing disorders, whereas the other half said that they managed only hearing loss. It is not surprising, then, that a large group of oncologists were unsure of the presence of an OMP in their hospital, and why and to whom to refer their patients for testing in the event of hearing loss complaints. Even in the United States, where audiologists can be found in nearly every hospital, we have found that oncologists and infectious disease physicians are not necessarily familiar with the diversity of an audiologist’s practice. Provider education may be an ongoing need, especially should the OMP be in a training hospital, in which physicians rotate in and out.
According to the American Cancer Society (ACS), an estimated 1.7 million people in the United States will be diagnosed this year with cancer, with most surviving (ACS, 2017). In the United States, death rate from the most deadly cancers—lung, bronchus, prostate, colorectal, and breast—have trended down dramatically between 1990 and 2014.
This survivorship suggests that hearing preservation is increasingly important. Our group at the Department of Veterans Affairs, National Center for Rehabilitative Auditory Research (Portland, OR) joined forces with the following organizations to more fully describe OMP practices and the barriers and facilitators to OMPs in their institutions:
- Department of Defense, Walter Reed National Medical Center, Division of Audiology (Bethesda, MD)
- Mayo Clinic, Department of Audiology (Rochester MN)
- Oregon Health and Sciences University, Cystic Fibrosis Clinic (Portland, OR)
- Yale University, Department of Audiology (New Haven, CT)
Although progress is being made, OMPs still need support to succeed. All of these institutions have OMPs in various stages of implementation. There is some variation in the programs that reflect individual institutional needs and variation in patient populations, but the goals of the OMPs are similar across these programs. All programs have adopted ASHA and AAA goals for OMPs. Populations include adult or pediatric hospitals only or a mix of children and adults.
The following are additional programmatic barriers encountered at these institutions (referred to above) and their potential solutions.
Scheduling Limitations
Scheduling remains a nearly universal problem for an audiology clinic. Patients with late-stage cancer are a priority and can receive immediate treatment for their cancers. This leaves little flexibility for baseline hearing testing to be done. As a result, opportunities can be missed. All institutions have found this to be a barrier to baseline testing, in particular. Each institution needs to develop a policy for how this might be managed. For example, a hearing test following the first treatment could be a solution, but we have seen hearing shifts even after the first treatment (although this is relatively rare). Collecting a thorough hearing history can be a partial solution, but hearing changes could be missed. For those patients who were not referred but could have been tested prior to treatment, a brief discussion with the treating oncologist is important. They may not know that the lack of a baseline test limits the ability to identify an early hearing shift—and the impact and importance of this shift. This discussion can accomplish two goals. First, it will inform them that an early hearing shift could be missed without a baseline test. Second, it will allow you to discuss the importance of a baseline test. However, be aware that the oncologist, in order to achieve remission of the cancer, may not have the luxury of waiting for hearing testing in these early stages of treatment. Once your program has had some time to develop, this problem tends to decrease as the oncology team comes to rely on hearing information.
Staffing and Equipment Limitations
Limitations related to staffing and equipment can also infringe on timely testing. Generally, audiometric booths are scheduled to capacity in most audiology clinics; thus, oncology patients may need to wait until an audiologist and booth are available on treatment day. However, most of these patients are not like the typical patient that comes to an audiology clinic. They are very often sick from their cancer or cancer drugs and have physical difficulty waiting for testing. Further, they have myriad other appointments on treatment day to complete before treatment begins (labs, radiation, visits with the oncologist and nursing prior to treatment, social work, speech therapy). Patients do not always have the flexibility to wait at the audiology clinic for their hearing test. We have found that portable equipment provides some flexibility to patient access and solves some of these barriers. However, portable equipment with extended high frequencies (> 8000 Hz for early detection of ototoxicity) is not always easy to obtain.
Inconsistent Referrals and Staff That Can Provide Assistance
Referrals to audiology can be inconsistent. Particularly in training institutions, oncologists may not consistently refer patients for hearing monitoring because residents and fellows rotate in and out of the hospital. These personnel can sometimes have strong opinions about hearing monitoring. For example, they may believe that there is no satisfactory substitute treatment for some cancers.
Some physicians want audiologists to independently find and test patients who are prescribed ototoxic medications, whereas others prefer to send referrals for monitoring. If physicians inconsistently refer patients or want an OMP to be independent, patients can be identified by other means. These include teaming with other services like pharmacy or nursing, or attending interdisciplinary medical staff meetings at which treatment plans are developed with input from oncologists, radiation oncologists, and surgeons—these meetings typically include discussions of medications to be prescribed.
Pharmacists may be willing to inform you when platins are prescribed. However, platins tend to be prepared just before treatment, so working with the pharmacy may require an ability to do baseline testing on short notice. Attending the interdisciplinary team meetings may be the best solution. The monitoring audiologist will receive an orientation on each patient’s treatment plan that includes type and stage of the cancer, prescribed medications, and planned radiation.
Oncology nursing staff can also be very helpful, as they are often knowledgeable about patients who will need upcoming medications of interest to your program and the approximate start date of treatment. Not only will this provide an opportunity to build relationships with nursing staff, but it may enable you to get the baseline test done and to schedule timely follow-ups.
Underutilization
OMPs are often underutilized in the early phases of the program. To address this, consider arranging meetings with the chairs of oncology and infectious disease services to introduce the audiology team and discuss the goals of the program. This will help to increase visibility of the program, to garner support, and to provide your contact information. It is also helpful to check in with oncology and medical clinic staff to ask if any patients are starting medication. Getting to know the clinic staff who are knowledgeable about patients on the appointment schedule helps gain support for your OMP. These facilitators (generally, nurse practitioners and oncology fellows) will prove helpful in building your program. However, the more independent you can be, the more likely your OMP will thrive.
A more extensive review of various programs and their limitations can be found in an upcoming edition of the International Journal of Audiology, which will be dedicated to ototoxicity monitoring.
Other Logistical Issues
Locations, Time, and Space Limitations
These remain ongoing barriers for most OMPs. For monitor testing, if you are able to find a quiet area (e.g., we have a sleep study lab next to our chemo unit and are allowed to test there), testing can be done during pre- or post-hydration (2 hours of fluid infusion). We have found that reliable hearing testing outside a hearing suite can be done if circumaural earphones are used, the room for testing is relatively quiet, and retesting is done to ensure that the thresholds are reliable. We use the sensitive range for ototoxicity, which is generally about 6000 Hz in adults. This has been shown to be the range of initial ototoxicity (Fausti et al., 1999). These frequencies can generally be tested reliably in a quiet room.
Because of time constraints on treatment days that include other appointments, several audiology services have adopted abbreviated testing protocols that are the minimal necessary to detect ototoxicity (Fausti et al., 1999). These are air conduction testing, otoscopy, and tympanometry. A full audiogram can be saved for the end of chemotherapy because bone conduction, otoacoustic emissions (OAE) testing, and speech audiometry do not provide additional information to the detection of ototoxicity for adults. These minimal tests are feasible, sensitive, and similar to those done for hearing conservation programs. If the number of chemotherapy patients referred is large at your facility, technicians could (conceivably) perform this testing. Again, retesting can ensure reliability of testing. If abbreviated testing is used, testing for ototoxicity can more easily be done at each treatment.
Results of the hearing test are time-sensitive, as treatment is approximately 2–3 hours after the patient arrives. Therefore, any changes in hearing need to be transmitted to the medical team quickly so that treatment decisions can be made. Important information for the medical team is (a) the presence of an ototoxic hearing shift as defined by ASHA (for adults); (b) a change in test frequencies, and (c) the significance of the hearing shift to hearing speech. Post-treatment testing should be comprehensive with aural rehabilitation recommendations planned.
About the Author
Marilyn Dille started her career in 1980 as an audiologist working for 12 years primarily at the VA Medical Center in Seattle, Washington. In 1999, she received her PhD from the University of Washington (UW) and subsequently accepted a position at UW as a clinical supervisor. She then accepted a position at the University of Arizona in Tucson as an assistant professor in audiology and director of their audiology clinic. She joined the National Center for Rehabilitative Auditory Research (NCRAR) in 2007. Her primary research was on the development and validation of an ototoxicity monitoring program for the Veterans Administration. Her publications have focused primarily on the auditory system effects of ototoxic medication, and on the development of all aspects of an evidence-based ototoxic monitoring program. She has worked closely with expert colleagues at the NCRAR who had similar interests, including Drs. Dawn Konrad-Martin, Stephen Fausti, Garnett McMillan, Patrick Feeney, Angela Garinis, Kelly Reavis, and Keri O’Connell. She has also worked closely with Kristin Knight, a pediatric audiologist at Doernbecker Childrens Hospital in Portland, Oregon, on the development of objective measures using otoacoustic emissions to detect ototoxicity in infants and young children treated for their cancers. Dr. Dille is now retired but plans to continue supporting grant preparation at the NCRAR with the goal of improving the lives of veterans with hearing loss.
References
American Academy of Audiology. (2009). Ototoxicity monitoring [Position Statement and Clinical Practice Guidelines]. Retrieved from https://www.audiology.org.
American Cancer Society. (2017). Cancer facts and figures, 2017. Retrieved from http://www.cancer.org.
American Speech-Language-Hearing Association. (1994). Guidelines for the audiologic management of individuals receiving cochleotoxic drug therapy. ASHA, 36, 11–19.
de Andrade, V., Khoza-Shangase, K., & Hajat, F. 2009. Perceptions of oncologists at two state hospitals in Gauteng regarding the ototoxic effects of cancer chemotherapy: A pilot study. African Journal of Pharmacy and Pharmacology, 3, 307–318.
Fausti, S. A., Henry, J. A., Helt, W. J., Phillips, D. S., Frey R. H., Noffsinger D, ...Fowler, C. G. (1999). An individualized, sensitive frequency range for early detection of ototoxicity. Ear and Hearing, 20, 497–505.
Konrad-Martin, D., Poling, G. L., Garinis, A. C., Ortiz, C. E., Hopper, J., O’Connell Bennett, K., & Dille, M. F. (2017). Applying U.S. national guidelines for ototoxicity monitoring in adult patients: Perspectives on patient populations, service gaps, barriers and solutions. International Journal of Audiology. Advance online publication. doi:10.1080/14992027.2017.1398421
Steffens, L., Venter, K., O'Beirne, G. A., Kelly-Campbell, R., Gibbs, D., & Bird, P. (2014). The current state of ototoxicity monitoring in New Zealand. The New Zealand Medical Journal, 127, 84–151.
