Managing a Patient Receiving Radiotherapy for a Head and Neck Cancer

There are about 5% of head and neck cancer among all cancers and more than 500,000 new cases are diagnosed worldwide each year. It is important to understand that between 60-65% of patients with head and neck cancer can be cured with surgery or radiotherapy. However, according to Fortin (2001), the prognosis of a patient depends on the primary tumor site and its extension, the histologic type, nodal involvement, and even grading. An estimated 90% of head and neck cancer in the west has been of squamous cell origin.

Below is an example on the history of a head or neck cancer patient:

History of a head or neck cancer patient

Symptoms: Referred ear pain, Dysphagia for solids, Fear of growing cancer

In addressing the needs of the patient, an interdisciplinary team is expected to provide comprehensive management of the cancer patient. These include evaluation and treatment planning that incorporates the patient’s overall health, malignancy diagnosis, site and stage, psychosocial functioning, and cultural or socioeconomic status. The assessment and proper dissemination of information are very important and should be performed by the health team members as needed at the different stages of cancer therapy.

In HNC, the treatment team usually includes physicians, nurses, dieticians, speech-language pathologists, and pharmacists, dentists and dental hygienists with sufficient expertise in oral medicine.

The services of other healthcare workers such as physical therapists, social workers, and psychologists help in the improvement of the patient’s case. It is also necessary that the dental team treating cancer patients should have a wider knowledge of oral medicine, the non-surgical interface between dental medicine and medicine.

During the treatment for head and neck cancers, a temporary or permanent speechlessness may occur that lessens patients’ ability to report critical information in the post-operative period. Other patients undergo radical surgeries such as total laryngectomy and glossectomy and this could result in permanent loss of speech. In cases where patients experience temporary speechlessness due to upper airway edema, extended intubation with an endotracheal tube, or temporary tracheostomy may be resorted to.

The use of communication strategies tailored to the needs of one adult postoperative patient with head and neck cancer after glossectomy and laryngectomy surgery becomes necessary (Fox and Rau, 2001). Speech-language pathologists and a psychiatric nurse should work together to identify and implement strategies to facilitate the communication process between the patient and the health care team. In a 3-week post-surgical hospital stay, the patient’s communication priorities were mainly associated with properly informing physicians, nurses, rehabilitation staff, and colleagues from work.

In this stage, the aims are: to identify communication needs for non-speaking patients with H&N cancer during their acute care hospitalization after surgery and to explore whether family caregivers’ and nurses’ perceptions of what us communicated differ from those pointed out by these patients.

Nurses are in the best position to influence the communication process during the postoperative period considered critical. At most, the registered nurse or RN is the health care team member with whom patients had the most communication difficulties so that the use of augmentative and alternative communication strategies such as speech-generating devices and standardized writing tools or the provision of consistent methods of communication should be explored, specifically tailored to meet the individual needs of speechless postoperative patients.

Dentist

Radiation therapies always play an important role in the treatment of patients with head and neck cancer. The location of the malignancy usually determines the inclusion in the radiation treatment portals. The malignancy may be located in the primary tumor orlymph node metastases, the salivary glands, oral mucosa, and jaws. In the process, changes induced by exposure to radiation is expected in these tissues.

Vissink et al (2003) suggested that the resulting oral sequelae may cause substantial problems during and after radiation therapy and are major factors in determining the patient’s quality of life. Dental practitioners should be able to identify the potential oral problems of the HNC therapy and to provide efficacious measures for their prevention (National Institutes of Health, 1989). Likewise, it is important to provide information to the patients and their families about these problems to prepare them for tolerance for orodental complications of HNC therapy (Morton et al. 2004).

Dental health care providers shall advance their knowledge about HNC cancer therapy-related complications and their prevention and management options. Information should also be properly provided to the patients and their caregivers or family members involved (Macpherson et al. 2003).

A general dentist who recognizes the signs and symptoms of HNC therapy and provides dental management before, during and after the therapy plays an important role in the prevention and pallation of some of the potential side effects (Barker et al, 2005).

More recently, oral care programs’ objectives are: to remove mucosal-irritating factors, cleansing of the oral mucosa, maintaining the moisture of the lips and the oral cavity, relief of mucosal pain and inflammation, and prevention or treatment of infection (Scully and Epstein, 1996). It is important that plaque control and oral hygiene be maintained (Scully and Epstein, 1996). Scully and Epstein (1996) must aim limit or eliminate the use of tobacco, alcohol, and spicy and acidic foods to facilitate expedient recovery.

Dietician

Speilman (1998) pointed out that taste sensation is altered as a result of the direct effect of radiation on the taste buds and due to changes in the saliva. In most cases, taste gradually returns to normal or near-normal levels within one year after radiotherapy (Tomita and Osaki, 1990). Taste loss can result in weight loss making dietary counselling necessary (Erkurt et al. , 2000). It is encouraged that food with pleasing taste, color, and smell as well as substitution of food aromas for the sense of taste may improve food intake should be prepared. Dietary counselling helps in adapting to the taste of food, as many patients’ perception of the various flavours does not change to the same extent. Sometimes, food enjoyed by the patient before radiation treatment can often have a less pleasant taste after treatment (Vissink et al, 2003).

It is therefore important that a basic meal plan that includes supplementary feedings should be incorporated from the beginning of therapy. This should be continued with slight or major modifications during the whole treatment process. When the patients’ food intake starts improving or returns to normal, dietary counselling should still be continued until patient no longer express discontent as well as adapted to the new situation. In this stage, hyposalivation should also be closely observed. Insufficient moistening and lubrication of the oral tissues and food has a major negative impact on food intake and the ability of a patient to eat (Epstein et al, 1999).

Nutrition and Hydration

Dysphagia or the difficulty with swallowing is a regular symptom in malignant disease and affects 23% of patients with advanced disease (Regnard, 1995). This is often attributed to obstructive oropharyngeal dysphagia associated with head and neck cancers (Eckman S, 2005). The primary aims of the team are to restore safe and adequate eating and drinking. Otherwise, the method of fluid or nutritional intake that most enhances the patient’s quality of life should be adopted (Margtens L, 1990). Management requires a coordinated multi- disciplinary team involved with the patient family (Layne, 1990). The key worker, often a trained speech and language therapist, is responsible for the overall planning dysphagia rehabilitation programme.

The safety of oral feeding is decided by the multidisciplinary team – health, social and the family – based on the findings from the bedside or radiographic assessments. In cases where oral feeding is not safe, an alternative method of feeding should be considered. Even when a patient is perceived to be safe for oral feeding, the team has to decide whether oral intake will be sufficient to meet nutritional needs (ADA, 1980). A patient may not be at risk of aspixation, but the whole act of swallowing tyakes a lot of effort that calorie intake is not sufficient. The dietician may advise the team to pass a NG tube or suggest a PEG to supplement oral intake until such time that patients are able to meet their nutritional and hydrational needs orally.

Reference:

Fortin A, Couture C, Doucet R et al. (2001). “Does histologic grade have a role in the management of head and neck cancer?” J Clin Onco pp 4107-4116.

Fox, L.E., & Rau, M.T. (2001). “Augmentative and alternative communication for adults following glossectomy and laryngectomy surgery.” Augmentative and Alternative Communication, 17 (3), pp 161-166.

Vissink A, Jansma J, Spijkervet FKL, Burlage FR, Coppes RP (2003). “Oral sequelae of head and neck radiotherapy.” Critical Review Oral Biology Medicine 14, pp 199-212.

National Institutes of Health. (1989) “National institutes of health consensus development conference statement: oral complications of cancer therapies: diagnosis, prevention and treatment.” Journal of the American Dental Association 119, pp 179-183.

Morton R.P., Hay K.D. & Macann A. (2004) “On completion of curative treatment of head and neck cancer: why follow up?” Current Opinion in Otolaryngology and Head and Neck Surgery 12, p 142-146.

Macpherson L. M.D., McCann M.F., Gibson J., Binnie V.I.& Stephen K.W. (2003) “The role of primary health care professionals in oral cancer prevention and detection.” British Dental Journal 195, pp 277-281.

Barker G.J., Epstein J.B., Williams K.B., Gorsky M. & Raber-Durlacher J.E. (2005) “Current practice and knowledge of oral care for cancer patients: as survey of supportive health care providers.” Supportive Care in Cancer 13, pp 32-41.

Scully C, Epstein JB (1996). “Oral health care for the cancer patient.” Oral Oncology Journal Cancer 32B:281-292.

Spielman AI (1998). Chemosensory function and dysfunction. Crit Rev Oral Biol Med 9:267-291.

Tomita Y, Osaki T (1990). Gustatory impairment and salivary gland pathophysiology in relation to oral cancer treatment. Int J Oral Maxillofac Surg 19:299-304.

Erkurt E, Erkisi M, Tunali C (2000). Supportive treatment in weight losing cancer patients due to the additive adverse effects of radiation treatment. J Exp Clin Cancer Res 19:431-439.

Epstein JB, Emerton S, Kolbinson DA, Le ND, Philips N, Stevenson-Moore P, et al. (1999a). Quality of life and oral function following radiotherapy for head and neck cancer. Head Neck 21:1-11.

Regnard C. Dysphagia. In Regnard C. ed. Flow diagrams in advanced cancer and other diseases. Edward Arnold, 1995: 19-21.

Eckman S, Roe J. Speech and language therapists in palliative care: what do we have to offer? Int J Palliat Nurs 2005; 11(4):179-81.

Groher ME. Dysphagia: diagnosis and management, second edition. Boston: Butterworths, 1993.

Layne KA. Feeding strategies for dysphagic patient: a nursing perspective. Dysphagia 1990;5:84-88.

Logemann JA. Evaluation and Treatment of swallowing disorders. San Diego: College Hill Press, 1983.

Margtens L, Cameron T, Simonsen M, Effects of a multidisciplinary management programme on neurologically impaired patients with dysphagia. Dysphagia 1990; 5: 147-51 52 American Dietetic Association. Study Guide: Dysphagia. The dietitians role in patient care, 1980.