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Supportive Care and Long-Term Quality of Life in HNSCC

Insights From: Ezra Cohen, MD, UC San Diego Moores Cancer Center; Robert L. Ferris, MD, PhD, FACS, University of Pittsburgh Cancer Institute; Jared Weiss, MD, University of North Carolina School of Medicine
Published: Monday, Jun 27, 2016


Transcript:

Jared Weiss, MD:
Heck and neck cancer patients suffer. Chemoradiotherapy is an extremely rough thing to get through. Following chemoradiotherapy, patients have quality-of-life issues that can dog them for the rest of their lives, and these same issues are relevant to the palliative care of our head-and-neck patients. So, let’s start talking about them. The first, and most obvious, is pain. Chemoradiotherapy hurts. In particular, mucositis can be a very, very big problem. Some practitioners have found that the neuropathic agents, like pregabalin and gabapentin, can be helpful in these situations.

Regardless of their use though, most patients will require opioid management, and this is very advanced opioid management. You need to be continuously readjusting both the PRN medicine and the long-acting medicine as you go. Because these patients can’t swallow, very often we need to use Fentanyl patches for them. It’s important to know that Fentanyl patients are not always absorbed well in emaciated patients, and so you have a population for whom you most want to use it who you know can’t. I will say that in the situation where the patient isn’t absorbing the Fentanyl patch, but the patient has trouble swallowing pills, there’s really only one liquid long-acting pain medicine, and that’s methadone. And I would say that methadone should be used only by practitioners with heavy expertise in its use for pain. It can be a problematic medicine, but for certain patients, it can be a godsend. In particular, it has the wonderful characteristic of a very long half-life and has the wonderful characteristic of causing less fatigue relative to pain relief as compared to the other opioids.

The other thing that can help a lot for mucositis-type pain are magic mouthwashes. So, lidocaine-containing mixtures can cause a local numbing that can help patients to get brief relief and sometimes to even allow them to eat during that time. We spoke about the trouble swallowing in reference to long-acting pain medicines. This is a problem in and of itself. Nutrition is a massive problem in our world. During chemoradiotherapy, it’s hard for patients to get enough nutrition in, and following it can be a big problem. Many patients simply require a PEG tube, a feeding tube. These are easy in, easy out, very low-risk, short surgical procedures to place these—less of a big deal than it sounds at first glance. And it can really make it quite a bit easier for patients to get through treatment and to recover after the treatment.

Once a tube is in though, that’s not an automatic checkmark to good nutritional health for the patient. Patients then require advanced nutritional management, and this is where you really need a nutritionist with expertise in management of this particular class of patients to do it right for you. And just like the pain medicines, that nutritional plan needs to be regularly re-evaluated to see if you’re meeting goals.

Patients suffer from dry mouth, both during treatment and sometimes permanently thereafter. In my practice, I found some of the saline rinses, like Biotene, to be helpful. In addition, there’s a product called XyliMelts that some of my patients have found extremely helpful.

In a lot of ways, palliative ways for the HPV-positive patient is rather similar to that for the HPV-negative patient. What’s different is that these patients are often younger, and so the quality-of-life issues that we’ve known for a long time can harm patients for the rest of their lives, affect these patients for a longer time. So, we know that patients can have dry mouth for the rest of their lives. We know that patients can have permanent Peg tube dependence. But the way a patient will look at this, how they’ll feel about these things, is a little bit different for a 40-year-old patient as compared to a 70-year-old patient. There are ways to address this. There are novel radiotherapy techniques that, for select patients, they may be able to avoid hitting the salivary glands as much, and that can preserve salivary function. I think in terms of swallowing, regardless of age, it’s good to encourage a patient to keep swallowing some during treatment. Even if they have a feeding tube, using those muscles does help some.

And then there are all kinds of approaches out there about de-intensifying the treatment for these patients. We don’t yet have long-term data. We have no randomized data to say whether that’s safe in terms of preserving the cure rate. But those studies are planned and ongoing. There’s a lot of investigation in that realm. And if we can go down on the radiation dose, that could be very promising for preserving long-term quality of life.

In terms of managing quality of life, a dental evaluation prior to chemoradiotherapy can avoid a lot of the problems up front. And then both during therapy and following, speech and swallowing therapy can help to improve these functions.

Robert L. Ferris, MD, PhD, FACS: One of the important issues, as I alluded to earlier, was not only using treatment selection for cure and optimizing the chance of survival, but understanding and segregating patients into risk stratification. Because it’s important once you cure the patient to make sure that they have a life that they want to live based on the treatments that were selected.

Often, the choice at the front end of therapy makes a dramatic impact on long-term quality of life. In head and neck cancer, we often will decide on a surgical approach or a nonsurgical approach based on the risk stratification, recognizing that we have this increasing population of HPV-positive patients who are, at worst, intermediate-risk, but often are low-risk, and therefore we can achieve cure with an eye toward quality of life and avoiding long-term functional side effects. Because if you have a cure rate over 90% for an individual who is, on average, 50 or 55 years of age, they’ve got another three, four, five decades to live with, and experience, the side effects and/or enjoy the quality of life of an appropriately designed treatment plan that can cure the cancer but retain the organs of speaking, breathing, and swallowing—trying to avoid xerostomia, and fibrosis, and swallowing dysfunction. And so, it’s really a composite decision that a multidisciplinary team undergoes with experts from all modalities, recognizing that a low-risk patient really needs to have just the right therapy but not too much and that a high-risk patient may tolerate treatment intensification and side effects because their survival is no better than 50%, and therefore we have to maintain that level.

Transcript Edited for Clarity
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Transcript:

Jared Weiss, MD:
Heck and neck cancer patients suffer. Chemoradiotherapy is an extremely rough thing to get through. Following chemoradiotherapy, patients have quality-of-life issues that can dog them for the rest of their lives, and these same issues are relevant to the palliative care of our head-and-neck patients. So, let’s start talking about them. The first, and most obvious, is pain. Chemoradiotherapy hurts. In particular, mucositis can be a very, very big problem. Some practitioners have found that the neuropathic agents, like pregabalin and gabapentin, can be helpful in these situations.

Regardless of their use though, most patients will require opioid management, and this is very advanced opioid management. You need to be continuously readjusting both the PRN medicine and the long-acting medicine as you go. Because these patients can’t swallow, very often we need to use Fentanyl patches for them. It’s important to know that Fentanyl patients are not always absorbed well in emaciated patients, and so you have a population for whom you most want to use it who you know can’t. I will say that in the situation where the patient isn’t absorbing the Fentanyl patch, but the patient has trouble swallowing pills, there’s really only one liquid long-acting pain medicine, and that’s methadone. And I would say that methadone should be used only by practitioners with heavy expertise in its use for pain. It can be a problematic medicine, but for certain patients, it can be a godsend. In particular, it has the wonderful characteristic of a very long half-life and has the wonderful characteristic of causing less fatigue relative to pain relief as compared to the other opioids.

The other thing that can help a lot for mucositis-type pain are magic mouthwashes. So, lidocaine-containing mixtures can cause a local numbing that can help patients to get brief relief and sometimes to even allow them to eat during that time. We spoke about the trouble swallowing in reference to long-acting pain medicines. This is a problem in and of itself. Nutrition is a massive problem in our world. During chemoradiotherapy, it’s hard for patients to get enough nutrition in, and following it can be a big problem. Many patients simply require a PEG tube, a feeding tube. These are easy in, easy out, very low-risk, short surgical procedures to place these—less of a big deal than it sounds at first glance. And it can really make it quite a bit easier for patients to get through treatment and to recover after the treatment.

Once a tube is in though, that’s not an automatic checkmark to good nutritional health for the patient. Patients then require advanced nutritional management, and this is where you really need a nutritionist with expertise in management of this particular class of patients to do it right for you. And just like the pain medicines, that nutritional plan needs to be regularly re-evaluated to see if you’re meeting goals.

Patients suffer from dry mouth, both during treatment and sometimes permanently thereafter. In my practice, I found some of the saline rinses, like Biotene, to be helpful. In addition, there’s a product called XyliMelts that some of my patients have found extremely helpful.

In a lot of ways, palliative ways for the HPV-positive patient is rather similar to that for the HPV-negative patient. What’s different is that these patients are often younger, and so the quality-of-life issues that we’ve known for a long time can harm patients for the rest of their lives, affect these patients for a longer time. So, we know that patients can have dry mouth for the rest of their lives. We know that patients can have permanent Peg tube dependence. But the way a patient will look at this, how they’ll feel about these things, is a little bit different for a 40-year-old patient as compared to a 70-year-old patient. There are ways to address this. There are novel radiotherapy techniques that, for select patients, they may be able to avoid hitting the salivary glands as much, and that can preserve salivary function. I think in terms of swallowing, regardless of age, it’s good to encourage a patient to keep swallowing some during treatment. Even if they have a feeding tube, using those muscles does help some.

And then there are all kinds of approaches out there about de-intensifying the treatment for these patients. We don’t yet have long-term data. We have no randomized data to say whether that’s safe in terms of preserving the cure rate. But those studies are planned and ongoing. There’s a lot of investigation in that realm. And if we can go down on the radiation dose, that could be very promising for preserving long-term quality of life.

In terms of managing quality of life, a dental evaluation prior to chemoradiotherapy can avoid a lot of the problems up front. And then both during therapy and following, speech and swallowing therapy can help to improve these functions.

Robert L. Ferris, MD, PhD, FACS: One of the important issues, as I alluded to earlier, was not only using treatment selection for cure and optimizing the chance of survival, but understanding and segregating patients into risk stratification. Because it’s important once you cure the patient to make sure that they have a life that they want to live based on the treatments that were selected.

Often, the choice at the front end of therapy makes a dramatic impact on long-term quality of life. In head and neck cancer, we often will decide on a surgical approach or a nonsurgical approach based on the risk stratification, recognizing that we have this increasing population of HPV-positive patients who are, at worst, intermediate-risk, but often are low-risk, and therefore we can achieve cure with an eye toward quality of life and avoiding long-term functional side effects. Because if you have a cure rate over 90% for an individual who is, on average, 50 or 55 years of age, they’ve got another three, four, five decades to live with, and experience, the side effects and/or enjoy the quality of life of an appropriately designed treatment plan that can cure the cancer but retain the organs of speaking, breathing, and swallowing—trying to avoid xerostomia, and fibrosis, and swallowing dysfunction. And so, it’s really a composite decision that a multidisciplinary team undergoes with experts from all modalities, recognizing that a low-risk patient really needs to have just the right therapy but not too much and that a high-risk patient may tolerate treatment intensification and side effects because their survival is no better than 50%, and therefore we have to maintain that level.

Transcript Edited for Clarity
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