Mr K and Dr U were interviewed by a Perspectives editor 3 months after completion of Mr K's radiation therapy.
MR K: I had followed up with my surgeon's associate once or twice a year and was disappointed to find that the cancer had returned last year. Over the years, once in a while, they had done biopsies, but they always came back negative; this time it was positive. When I had the earlier surgery in 1999, it affected my ability to speak and eat normally. I also had concerns about the pain involved in recovering from the surgery. This time the surgery was much more extensive. I had 3 successive surgeries this time. After the second surgery, the postoperative tests revealed that there was cancer in the jawbone, which required another operation. The second and third surgeries were only a month apart.
DR U: Mr K has a long history of both oral dysplasia as well as oral cancer…He had been treated here at the oral medicine clinic and then had been treated by another surgeon in the department of oral and maxillofacial surgery for a cancer. After a number of years, he developed a new cancer and that's when he was referred to me.
The new cancer that he developed was more significant than the previous ones that he'd had, so he was referred to me for surgical management. It was in his tongue, floor of mouth, and on his gums. I told him that surgery would involve removal of a portion of his tongue, floor of mouth, and probably a portion of his lower jaw…He ended up having "positive margins," which means that there was additional cancer. So, he required a further resection and, in the end, he had a quite significant removal of his lower jaw and floor of mouth. He then required postoperative radiation therapy. I think he's had some of the typical problems, and he's had some of the more extreme problems along the continuum of what patients with oral cancer deal with. One of the primary problems for patients with oral cancer is high recurrence rate…This patient has gone through that. He's had multiple operations, which I know have been very taxing on him emotionally. He's suffered all the sequelae that go along with surgery, primarily radiation, which seemed to be much harder on him than the surgery, which is usual for the patients with oral cancer.
Palliative Care for Patients With Head and Neck Cancer
Palliative care is interdisciplinary care that provides support for the physical, emotional, and psychological suffering1 of patients with any advanced illness, regardless of age, diagnosis, or life expectancy. The goal is to prevent and relieve suffering and to improve quality of life for people facing severe, complex illness. It differs from traditional hospice or end-of-life care in that patients who receive palliative care can also continue to receive curative or life-prolonging treatments. This distinction is particularly important in the case of patients with head and neck cancers because they often have a relapsing course that is marked by periods of freedom from disease and symptoms, interspersed with bouts of serious illness, debility, and numerous physical and psychological symptoms, including pain, dysphagia, weight loss, disfigurement, depression, and xerostomia. Suggestions for treatment of symptoms discussed herein come from a comprehensive search of both PubMed and the Cochrane Review databases.
Epidemiology of Head and Neck Cancer
An estimated 35 000 people are diagnosed as having head and neck cancers annually in the United States, and approximately 7500 individuals die of these cancers annually.2,3 The phrase head and neck cancer refers to a diverse group of diseases that include primary malignancies of the oral cavity, oropharynx, larynx, sinuses, and skull base. These cancers primarily affect men (with a ratio of nearly 2:1) and are strongly associated with cigarette smoking and alcohol consumption.2,4-6 There has been increasing evidence in the last several years of an epidemiologic link between human papillomavirus and head and neck cancers, even in the absence of cigarette smoking or alcohol consumption.7-9
Although treatment options for head and neck cancer have evolved rapidly during the last 30 years, prognosis for patients with locally advanced disease still remains poor.10,11 Five-year survival rates for patients with head and neck cancer (all types and stages combined) is 59%.3 The mainstay of current therapies involves a combination of surgery, radiation, and chemotherapy; the sequence and timing of these interventions depend on both the origin of the malignancy and its stage.10 Although these treatment modalities have increased the disease-free interval for patients with head and neck cancers, cure rates have not significantly changed during the last 50 years. In other words, although the cure rates have not improved, patients are living longer with quiescent, subclinical disease.12 (A comprehensive outline of interventions and survival rates based on cancer type and stage is available elsewhere.13) As patients live longer with the consequences of the disease and its treatment, primary care physicians need to be familiar with the common adverse effects and ways to alleviate them.
Physical Symptoms in Patients With Head and Neck Cancer
DR U: I told him that there would be 2 kinds of restriction of oral function and [adverse] effects. There would be short-term effects, from the healing of the surgery. There would be consequences of [his radiation therapy as well], most of which would be temporary, primarily pain, mucositis, difficulty swallowing, loss of taste, and change of speech. He would also have some long-term effects. Those would be a change in his speech pattern, and, from the radiation therapy in particular, he would have xerostomia because of the damage to the salivary glands.
MR K: Essentially, the main drawbacks were the side effects and the fact that I am still not eating very well. Most of my nutrition is taken through a tube. It affects me because I can't travel a very far distance [from home] without having to deal with the tube feeding. It is cumbersome and somewhat messy. So, I don't want to go too far.
Patients with head and neck cancer can have a variety of physical symptoms, including pain, xerostomia, mucositis, difficulties with swallowing, and changes in speech and taste (Table 18-1).24 These symptoms may result from the tumor, acute adverse effects from treatments, or long-term sequelae of therapies.23
Table 18-1Common Symptoms Encountered in Patients With Head and Neck Cancer and Suggested Treatmentsa |Favorite Table|Download (.pdf) Table 18-1 Common Symptoms Encountered in Patients With Head and Neck Cancer and Suggested Treatmentsa
|Symptom ||Treatment ||Notes |
|Pain ||Opioids ||May need to be given via alternate route (eg, transdermal fentanyl patches, morphine elixir via gastrostomy tube).14 |
|Mucositis || |
Granulocyte-macrophage colony-stimulating factor
Human placental extract
|Evidence supporting use of these agents is weak.15 |
|Dysphagia || |
Consultation with speech and language pathologist16
Artificial hydration and nutrition17
Degree of dysphagia depends on origin of tumor and types of treatments.
May be transient or permanent, may be severe and lead to dehydration or malnutrition.
|Xerostomia || |
Frequent intake of water, ice chips18
Use of sugarless candy or gum18
Pilocarpine (starting dose of 2.5 mg enterally 3 times daily)19,20
Based on common practice but evidence is weak; should be left to patient preference within boundaries of what is deemed medically indicated (eg, avoid water if significant aspiration risk).
Pilocarpine has multiple adverse effects, which may limit its use, particularly in elderly patients.21
|Change in speech || |
Consultation with speech and language pathologist16,22
Adaptive devices (eg, amplifier)23
|Many patients can relearn speech so this symptom does not always interfere with long-term function, but speech may not return to baseline patterns.23 |
|Decreased quality of life ||Supportive treatments, including counseling and psychotherapy ||In many patients, quality of life will return to baseline level over the long term.24-26 |
|Depression || |
Referral to psychotherapy, counseling, antidepressant medications27
|May be transient or prolonged; if patients are treated with antidepressants, adverse effects and interactions with other medications should be considered when selecting the medications. |
|Anxiety || |
Referral to psychotherapy, counseling28
|Anxiolytics can be associated with fatigue, delirium. |
MR K: Radiation included rather unpleasant side effects. It's painful and I got burns around my chin and neck. I had pain medication, and I put topical solutions on the areas of skin that were affected. I also had ulcers on my lips and yeast infections in my mouth. There was also bleeding in my mouth.
Although all patients with cancer may experience pain, individuals with head and neck cancer often have causes and pathophysiologic mechanisms for pain that differ from other cancers. Pain in the mouth or neck may be a presenting symptom,29 and it also may be a marker of recurrence. Pain resulting from the tumor itself can be nociceptive, related to destruction of tissue such as the tongue or jaw, as well as neuropathic, related to tumor damaging or traveling along nerves.30 Although a discussion of treatment modalities for nociceptive vs neuropathic pain is beyond the scope of this article, distinguishing between the 2 is vital because they are treated with different medications and dosing intervals.30,31 Nociceptive pain is treated with opioid medications, whereas neuropathic pain is often treated with anticonvulsants, tricyclic antidepressants, local anesthetics, and other medications.32 Principles for treating pain among patients with head and neck cancers are similar to that of other cancers, but patients may be unable to take certain formulations of medications due to difficulty swallowing. Therefore, transdermal preparations for patients on a stable dose of opioids (eg, fentanyl patches) or liquids that enable easier dosing via gastrostomy tubes (eg, liquid morphine) may offer better options.14 Although medications used commonly to treat neuropathic pain do not come in liquid preparations, consultation with a pharmacist is beneficial to determine which classes of medication can be crushed and either mixed with food or given via gastrostomy tube. Dermatitis and soft tissue damage of the face or neck are often seen in patients who receive radiation therapy. These symptoms begin 2 to 3 weeks after initiation of radiation treatment and can be quite severe.17 Usually beginning with erythema, the field exposed to radiation may become edematous and eventually blister, ulcerate, and slough. Acute radiation-induced changes begin to heal about 2 weeks after the cessation of treatment. Patients whose scalp is included in the field of radiation should be instructed to wash gently and use mild shampoos to help prevent skin reactions. Topical agents, such as low-potency steroid creams, topical acid-containing creams (such as hyaluronic or ascorbic acid), and aloe vera, have been studied for both the prevention and treatment of acute radiation-induced skin reactions, but a systematic review found no benefit from these agents.33 As such, clinical experience suggests that initial use of a plain, nonscented, lanolin-free hydrophilic cream may be helpful for patients with skin discomfort due to radiation, but these creams should be discontinued if skin breakdown occurs.33 Itching resulting from radiation may be treated with low-potency topical steroids, but caution is warranted because these agents may lead to skin thinning if used for a prolonged period. Severe pain resulting from radiation may be managed with systemic opioids if necessary.33 Long-term complications can occur within 2 to 4 months after completion of treatment and include changes in skin texture, fibrosis, and atrophy of soft tissues. Chronic pain in the radiation field can occur but is not common.22 Skin changes may be more severe if chemotherapy is added to the treatment regimen.10
Sialorrhea and Xerostomia
MR K: Prior to the radiation, it seemed that I had an excess of saliva and mucus in my mouth. Because part of the jawbone in the front was removed, my bottom lip is not attached the way it was previously, so I tended to drool a bit. The radiation dries up the saliva, so I drink lots of water. If I don't drink lots of water, it's very difficult to continue speaking. Eventually, the saliva will return, but it will be several months before that happens.
Problems with controlling excessive saliva (sialorrhea) and producing saliva are troublesome treatment complications of head and neck tumors. Indeed, Mr K reported drooling postoperatively because of the loss of the normal architecture of his mouth caused by a resection of a portion of his mandible. Even though these hypersecretory symptoms can sometimes be addressed solely by swallowing and speech techniques taught by a speech pathologist, patients may benefit from pharmacologic treatment with anticholinergic medications (eg, glycopyrrolate, hyoscyamine) to dry secretions. In older adults, caution is warranted in using these medications because of their multifaceted adverse effects profile (eg, orthostasis, constipation, urinary retention) and their propensity to induce delirium.21
As Dr U mentioned, xerostomia is also a complication of these cancers, particularly in patients who undergo radiation therapy. The addition of chemotherapy to radiotherapy further increases the likelihood of developing xerostomia.34 Saliva is necessary for speech and eating, and it also serves to clean the mouth and reduce cavities. As such, the loss of saliva production can lead to difficulty eating and swallowing, trouble with speech, development of dental caries, and decreased quality of life.19 Because the radiation therapy destroys the glands that make saliva, higher doses are associated with more severe changes, which may be irreversible.35 Commonly used palliation for xerostomia includes drinking water frequently to keep the mouth lubricated, use of ice chips, and artificial saliva, which combines water with lubricants.18 Sucking on sugarless candy or chewing gum can also stimulate salivary flow.18 Pilocarpine, started at a dose of 2.5 mg by mouth 3 times daily that can be titrated up to 10 mg 3 times a day, is a parasympathomimetic compound that has been shown to improve patients' symptoms to a certain extent,19,20 but its adverse effect profile (eg, sweating, rhinorrhea, urinary frequency) may limit its use.36
DR U: He had quite severe radiation-induced mucositis. He developed very severe ulcerations in his mouth and significant pain in the midst of his radiation therapy, at about 2 weeks in.
Mucositis is an inflammation of the mucosal membranes lining the gastrointestinal tract and frequently affects the mouth and pharynx of patients with head and neck cancer who undergo radiation therapy.37 As with xerostomia, the prevalence increases with the addition of chemotherapy,34 and recent data show that the prevalence of mucositis may be as high as 100% in patients who undergo radiation treatment.38 The condition is caused by both direct toxicity of the agents to the oral mucosa and their systemic myelosuppressive effects.39 Mucositis can be extremely painful and result in the inability to eat, swallow, or speak. The discomfort can be so significant that it interrupts treatment plans.40 This condition can occur in either the mouth or pharynx and typically begins about 10 to 14 days after the commencement of radiation treatment (which is the length of time needed for the oral mucosa to regenerate, a process impeded by radiotherapy).23 The condition usually begins to abate 4 to 6 weeks after the completion of radiation.17 Clinically, the mucosal tissue may appear white and patchy at first and then may progress to erythema and, at times, ulcer formation. Mucositis can be exacerbated by superinfection by either Candida or oral bacterial flora. Numerous agents have been used in attempts to prevent, reduce the severity of, or treat mucositis.15,41,42 These range from nonpharmacologic treatments, such as the use of ice chips, honey, and meticulous oral hygiene to local treatments (eg, topical lidocaine, sucralfate, "magic mouthwash"—a combination that varies by institution but often contains viscous lidocaine, diphenhydramine, and aluminum hydroxide43), to systemic treatments (eg, etoposide, granulocyte-macrophage colony-stimulating factor). Unfortunately, the data to support the use of many of these agents come from poorly designed studies whose results are often equivocal. In a comprehensive meta-analysis of agents to prevent or reduce the severity of mucositis published in 2007, the Cochrane Collaboration determined that only 2 interventions showed promise in patients with head and neck cancer: amifostine (a free radical scavenger dosed at 200 mg/m2 and given intravenously before radiation treatment44-46) and hydrolytic enzymes.42 In terms of treating mucositis, a different meta-analysis by the same group showed that 4 agents were statistically beneficial for the treatment of mucositis: allopurinol mouthwash, granulocyte-macrophage colony-stimulating factor, immunoglobulins, and human placental extract.15 However, in both prevention and treatment trials, the effect size for these agents is small and problems with study design often make these conclusions unreliable.15,42 In addition, some of these medications may be difficult to obtain and are available only in nontraditional medical settings (eg, health food stores, Chinese herbalists). Systemic opioids (given orally, intravenously, or transdermally) effectively treat the pain of mucositis15 and should be used aggressively if local treatments do not result in desired pain relief. Patients with severe mucositis need to be closely monitored to prevent malnutrition or dehydration and may require hospitalization if severe pain or dehydration requires intravenous medications or fluids.
Dysphagia and Odynophagia
MR K: I would very much like to eat real food again and converse as normally as possible.
Difficulties with swallowing are almost universal symptoms for patients with head and neck cancer and may stem from the primary tumor or develop as sequelae of surgery or radiation (eg, mucositis resulting in painful swallowing). Swallowing difficulties can take the form of either dysphagia or odynophagia. Artificial hydration and nutrition, most often delivered through a gastrostomy tube, are commonly used in patients as a temporary mechanism to ensure adequate nutrition and hydration during the healing process.17 Unlike patients with other forms of advanced disease for whom data demonstrate that artificial hydration and nutrition are not beneficial and may even be harmful,47-49 there is less controversy about the benefit of artificial hydration and nutrition in this population. Mr K's concerns about his inability to travel while using gastric feeding are common. Providing larger quantities of artificial hydration and nutrition for a short period at regular intervals (bolus feeding) can help liberate these patients from the use of a pump and the need to be attached to external encumbrances. Consultation with a nutritionist is essential to ensure that patients receive adequate intake of calories, protein, and water. In those patients with advanced disease who require large-scale resections or permanent tracheostomy, the need for artificial nutrition may be lifelong. In addition to addressing swallowing difficulties, artificial nutrition may be needed to supplement caloric intake for patients who experience severe anorexia due to alterations in smell or taste. Systemic opioids may also be effective for those patients with severe pain that restricts their ability to swallow.
DR U: His speech is intelligible, but it's been significantly affected. That's improved over time as he's improved the control of his saliva. Since we had to reconstruct a portion of his mouth using free microvascular tissue from his leg, as that replacement flap has shrunken in size to a more appropriate size, his speech has improved significantly. I would say that he's intelligible now, without question.
Depending on the nature of a patient's cancer and the surgical procedures necessary to treat it, changes in speech may be transient or permanent. Alterations to the lips, tongue, teeth, hard or soft palate, and larynx can all result in different patterns of speech or voice disorders.23 In the case of Mr K, although his voice will never return to its preoperative character and quality, he is able to speak without the use of an assistive device. For patients with more advanced disease or who require laryngeal resection, amplifying devices or alternate speaking techniques (eg, tracheoesophageal speech) must be used.23 Close collaboration with speech and language pathologists who specialize in the care of patients with head and neck cancers should begin early in a patient's treatment.22
Psychological Symptoms in Patients With Head and Neck Cancer
DR U: One of the primary problems for patients with oral cancer is the high recurrence rate. This patient has gone through that. He's had multiple operations, which I know have been very taxing on him emotionally…Having said that, he has been surprisingly good at getting back to normal life…His partner has been extremely supportive and helped him through therapy and the difficult decisions…I think that the support he has gotten from his partner has improved his quality of life.
MR K: Having cancer can be very depressing. I can't say that I had severe depression, but I did have some intermittent bouts of depression…While it is comforting that the cancer has been removed and the radiation will try to prevent the return, I would like a quick return to a normal lifestyle.
Body Image and Functional Outcomes
Although physical symptoms must be considered in the care of patients with head and neck cancers, the constellation of these symptoms and their impact on patients' body image and overall quality of life are equally important to consider. Mr K sums up well the frustrations experienced by this group of patients. Although cure is possible for many, patients encounter numerous setbacks while undergoing the procedures and healing necessary along the road to recovery. Changes in body appearance—and body image—are almost universal. Since the 1980s, when surgeons began to consider aesthetics and function as well as treatment, reconstructive procedures have improved significantly, in part because of collaboration between otolaryngologists and plastic surgeons. Patients who undergo surgery by a skilled surgical team may be left with little to no outward physical changes.50 The introduction of microvascular-free tissue transfer, a technique that transfers skin, muscle, bone, or all 3 from 1 part of the body to the neck for reconstruction of the tongue, jaw, and face, provided surgeons with the means to improve a patient's quality of life by improving both functional and cosmetic outcomes.50
New techniques of minimally invasive surgery for patients with head and neck tumors have been developed in the past several decades,51 and data continue to accrue about their impact on patients' quality of life and functional outcomes. Techniques such as robotic-assisted surgery and endoscopic techniques allow the resection of tumors without using the deforming facial incision that was commonplace for nearly a century. The use of robotic-assisted surgery is becoming particularly popular; it involves using a surgical system whereby the surgeon sits at a console adjacent to the patient and controls micromanipulators that are connected to a robotic cart at the patient's bedside. The central arm of this system carries a high-quality endoscope that allows the operator to see the surgical field in 3 dimensions, and the other 2 arms have miniaturized interchangeable instruments that move as directed by the surgeon's hands.52 Advantages of robotic-assisted surgery include decreased blood loss, shorter hospital length of stay, and fewer postoperative complications.53,54 In terms of patient functional outcomes, robotic-assisted surgery has been associated with fewer airway complications and improved swallowing, although most of these data are from small, single-site cohort studies.53,54 These systems have significant startup costs, but the use of robotic-assisted surgery for patients with head and neck cancers is an emerging alternative for selected patients with appropriate tumor location and size.
Quality of Life and Depression
Because patients see themselves every day in the mirror and the face is a key element in the way we express ourselves to the outside world, even small alterations in visage can have a large adverse impact on patients' body image and self-esteem.55 Likewise, because of difficulties with swallowing and nutrition, as well as the cachexia that is associated with cancer, these patients may lose a great deal of weight. Because of these changes in appearance and the impact that both the cancer and its treatments have on physical functioning and self-image, patients with head and neck cancer may experience a significantly worsened quality of life. Long-term studies of these patients, however, show that after a period of 12 to 36 months, self-rated quality of life may return to baseline in more than 50% of patients. A patient's best achievable quality of life is dependent on factors such as current disease state, stage at diagnosis, and surgical or medical interventions used.24-26 Despite this eventual return to satisfaction with their quality of life, the period from diagnosis to full recovery may be marked by symptoms of frustration, hopelessness, and depression.56 Studies have shown that 20% to 50% of patients with head and neck cancers may have moderate to severe depression at some point after diagnosis.57-59 Whether these symptoms are a true episode of major depression or an adjustment reaction with depressive features,60 the use of antidepressant medications often helps patients with head and neck cancers.27 Choice of specific medications (eg, selective serotonin reuptake inhibitors [SSRIs] vs norepinephrine and dopamine reuptake inhibitors) should be guided by patients' other physical symptoms and the medication's adverse effect profile. For example, patients with weight loss may benefit from the tetracyclic antidepressant mirtazapine, which has been shown to cause weight gain in some patients,61,62 and patients with xerostomia should not receive tricyclic antidepressants due to their anticholinergic properties.
In addition to depression, the high recurrence rate of head and neck cancers may result in a constant sense of anxiety relating to concerns about relapse. Mr K has lived with his cancer for more than a decade, a not-uncommon scenario for patients with head and neck cancer. The anxiety caused by this uncertainty can be particularly pervasive, affecting patients and their families in multiple areas of function.63-65 Psychotherapy and support groups may be beneficial to patients with head and neck cancer and their families.28 If this anxiety impairs function or quality of life, treatment of anxiety with medications such as benzodiazepines or SSRIs may be indicated. By asking patients about their concern of recurrence, clinicians can begin a discussion that allows patients to talk about their fears while at the same time offering therapeutic options.
For decades the epidemiologic links between head and neck cancers and both tobacco and alcohol consumption have been well established4-6 and are thought to be mediated through the creation of oncogenes and ultimately tumor formation.66 Although some patients may blame themselves and feel they caused their own illness,67 patients may also feel guilt about the toll that the illness takes on their family and caregivers. Eating is a major social, cultural, and religious ritual in society, and patients with head and neck cancer often cannot participate in this activity. Even going out to dinner can become an impossible task, and patients may often be concerned about the impact this has on their family. Likewise, facial disfigurement—even if only temporary—may make it emotionally difficult for patients to leave the house, which can change the dynamic between patients and their loved ones. Feelings of guilt and self-blame in patients with head and neck cancer are therefore not only related to their own role in their illness but also to the belief that they are to blame for the impact the illness has on the quality of life of their loved ones. Physicians can assist patients with these feelings by encouraging them to talk about them with their loved ones and even facilitating these conversations. For example, if a patient is accompanied to an office visit with a caregiver, the clinician can ask both of them, "What role has the illness taken on your relationship?" or even more directly, "Are you finding it difficult to eat out in public? How are you handling the changes imposed by the cancer on your social life or religious practices?"
Interdisciplinary and Supportive Services for Patients With Head and Neck Cancer
DR U: The other thing that I have found helpful is using staff like the speech, physical, and occupational therapists. The surgeon simply cannot do all of those jobs and does not have the expertise to do those jobs. So I try to get [all of these disciplines] involved very early.
MR K: [Oral communication] is a significant issue…I manage a group of employees and some of my employees are not colocated with me, so I have to talk to them by phone. Some of this is alleviated by modern communication, and I can communicate with them by e-mail, for example. I am going to a speech and swallowing therapist. She's given me certain exercises for my mouth, tongue, head, and neck. She gave me exercises to read aloud. I'm supposed to focus on pronouncing words and emphasizing certain syllables. I'm supposed to speak more slowly and use the same emphasis as I would normally. Some consonants are difficult for me to pronounce, so she showed me how to emphasize those. For example, a "C" or a "G" is difficult for me to pronounce because my tongue is no longer able to go to the places it used to in order to enunciate those sounds. She actually records video of my swallowing technique. I'm not sure what the device is called, but she runs a tube through my nose and down into my throat and records a video of how the swallowing looks. By studying that, she can then give me pointers as to how to improve my swallowing.
One of the fundamental principles of palliative care is that it is practiced within an interdisciplinary team, pooling the expertise of physicians, nurses, social workers, and chaplains to provide the best quality of care for patients and their families.1 For patients with head and neck cancer, this approach is key, but many other disciplines must be included to ensure optimal treatment and recovery for these patients.13,68,69 Although there is evidence that multidisciplinary palliative care teams improve outcomes for patients,70,71 no studies to date have examined their advantages in patients with head and neck cancers. In addition to otolaryngologist–head and neck surgeons and oncologists and radiation oncologists completing treatment, several other professionals play important roles. Dentists may create prostheses for the teeth or jaw if these are resected. Speech and language pathologists provide voice rehabilitation, including acoustic assistive devices, and teach patients modified swallowing techniques. Physical therapists and occupational therapists help patients adapt to reconstructive procedures involving the use of flaps. Clinical social workers can help coordinate care across settings, nutritionists help assist patients in obtaining adequate nutrition and hydration, and ophthalmologists or neurosurgeons may be involved, depending on the location of the cancer. Table 18-2 outlines the roles of the interdisciplinary team members involved in the care of patients with head and neck cancer.
Table 18-2Roles of Members of Interdisciplinary Team in Caring for Patients With Cancers of the Head and Necka |Favorite Table|Download (.pdf) Table 18-2 Roles of Members of Interdisciplinary Team in Caring for Patients With Cancers of the Head and Necka
|Clinician ||Role in Team |
|Otolaryngologist/head and neck surgeon ||The head and neck surgeon not only coordinates the interdisciplinary team but in many cases becomes the primary care physician who refers the patient to other specialists and oversees the plan of care. |
|Radiation oncologist ||Charged with creating plan for and managing radiotherapy. Must be familiar with various options for treatment (eg, brachytherapy, fractionated radiation therapy) to allow for maximal effectiveness while minimizing adverse effects. |
|Medical oncologist ||Works with team to provide chemotherapeutic agents, both antineoplastic agents and radiosensitizers to improve effectiveness of radiotherapy. |
|Plastic and reconstructive surgeon ||Assists head and neck surgeon in planning surgical resection and sometimes works side by side in operating room to ensure best possible cosmetic outcomes. |
|Dentist/prosthodontist ||Ensures adequate dental health before, during, and after interventions. May be called on to create prosthetics for patients undergoing resection of teeth or jaw. |
|Psychiatrist/psychologist ||Provides emotional and psychological support for patients and families, either individually or in group setting. May prescribe antidepressants or anxiolytics. |
|Neurosurgeon ||Consults with head and neck surgeon in cases in which resection or treatment plan involves major structures of the nervous system. |
|Ophthalmologist ||Consults with head and neck surgeon in cases in which cancer involves orbits or eyes. |
|Palliative care team ||Physicians, nurses, social workers, and chaplains with expertise in palliative care are necessary to provide relief of pain and other symptoms, assistance with decision making, and supportive care for these patients and their families. |
|Oncology nurse specialists ||Nurses with expertise in care of patients with head and neck cancer are necessary because of specialized interventions, such as tracheostomy and gastrostomy tubes. Also play a role in educating patient and caregiver on the use of these interventions. |
|Speech and language pathologists ||Provide assistance, therapies, and education for patients with difficulty swallowing or speaking. This includes providing voice rehabilitation, use of acoustic assistive devices, and teaching modified swallowing techniques. May also educate family in terms of techniques for meal preparation and improving communication. |
|Physical and occupational therapists ||Provide care for those patients with general debility or who have undergone resection or reconstructive procedures that interfere with daily function and ability to care for themselves. |
|Clinical social work ||Provide care coordination across settings and assist with discharge planning. Depending on background and training, may provide supportive care and counseling for patient and family. |
|Clinical nutritionist ||Ensure patients receive adequate hydration and nutrition, especially in cases in which patients have debility, cachexia, hypermetabolic states, or gastrostomy tubes. |
Early and regular contact among these members of the team is essential to ensure optimal care for patients with these cancers. At our medical center, weekly meetings of the Multidisciplinary Program for Treatment of Diseases of the Head and Neck include otolaryngologists, oncologists, radiation oncologists, speech pathologists, social workers, and palliative care clinicians who discuss each patient who is to be admitted to the hospital to clarify the treatment plan and determine which services an individual patient will need. The palliative care nurse practitioners follow up ambulatory patients in the head and neck clinic to assess symptoms and help coordinate care. This approach to care improves patient satisfaction and ensures safe and efficient transitions across care settings, a key quality indicator for the health care of patients with complex disease.69,72,73 In addition, integrating palliative care into the care plan at an earlier point in the patient's disease process may help to reinforce, for both patients and clinicians, the idea that palliative care is not the same as end-of-life care.74,75 (See also Chapter 37, Secondary and Tertiary Palliative Care in Hospitals.) (For more information about staffing or sustaining a successful palliative care program, including solutions to common administrative and financial difficulties, see information on the Center to Advance Palliative Care in Resources.) Given the relapsing nature of head and neck cancers, palliative care teams can use their expert skills in communication to help patients and their families understand the often chronic and incurable nature of the disease early in the patient's course.39 Conversations such as these can be beneficial to both patients and their families and have been shown to improve outcomes and quality of life in patients with advanced cancer.76
The team approach to care begins before surgery when a nutritionist and speech therapist provide patients with a series of pretreatment exercises that may improve swallowing and speech after surgery. Preoperative integrated care may also help patients develop expectations and reduce feelings of anxiety and helplessness.16
The interdisciplinary team also provides support for patients and their families, as well as promotes self-care and relieving stress and burnout among clinicians caring for these patients with serious illness.77 Studies have shown that caring for patients with serious illness takes a toll on the health of caregivers,78-80 and the high recurrence rate, along with high symptom burden and physical changes caused by head and neck cancer and its treatments, creates serial challenges for caregivers.81,82
Care of the Dying Patient With Head and Neck Cancer
Because of the unique nature of cancers of the head and neck, special consideration must be given to end-of-life care for these patients. As with all cancer patients, predicting when an individual is near the end of life can be difficult. Signs include being bed-bound, semicomatose, able to take only sips of fluid, and unable to take oral medications or tolerate artificial hydration and nutrition.83 At this point, clear communication with patients (when possible) and families is important so they understand that the patient has begun to enter the last phase of life. Referral to an inpatient palliative care unit or home hospice program should be considered to ensure excellent management of symptoms and to provide the needed emotional and psychological support.84,85 (See also Chapter 40, Referring a Patient and Family to High-Quality Palliative Care at the Close of Life.) Although artificial hydration and nutrition play a role for patients earlier in their disease, it may become burdensome near the end of life and lead to edema, nausea and vomiting, and pulmonary congestion. Thus, it may make patients more uncomfortable and serve to only prolong the dying process.86-88 As such, families should be educated about how this once beneficial treatment may now be a source of suffering and stopping it should be considered. One significant symptom that can occur for patients with head and neck cancer at the end of life is odor emanating from wounds that cannot be closed and will not heal due to the advanced nature of the disease. Tools to aid in treating malodorous wounds include metronidazole gel, systemic antibiotics, and charcoal dressings.39 Interarterial injection of chemotherapeutic agents directly into tumors may also help reduce wound odor.39 Another management issue for many patients with advanced head and neck cancer is the "carotid blowout" syndrome—a process by which the cancer erodes into the carotid artery (or other great vessel in the neck) leading to exsanguination. This process may take place gradually, with occult blood loss into the surrounding tissues or with rapid, massive blood loss from the neck. Although the prevalence of this dreaded complication is much rarer than in the past because of palliative surgical techniques,89 it can be frightening to both patients and their families. Patients with impending blowout should be managed in an inpatient setting, especially if children are present in the home. However, caregivers who understand the nature of this complication and wish to have the patient remain at home, as a practical issue, should keep dark towels (red or black) near the patient's bedside to absorb the significant amount of blood that may be lost.