Treatment of head and neck cancer often leaves patients with aftereffects that are bothersome at the very least and life-altering at their worst.
Colleen O’Leary, RN, MSN, AOCNS
Treatment of head and neck cancer (HNC) often leaves patients with aftereffects that are bothersome at the very least and life-altering at their worst. Oncology nurses should be prepared to address and help mitigate these conditions, speakers said at the Oncology Nursing Society 37th Annual Congress.
Colleen O’Leary, RN, MSN, AOCNS, Clinical Nurse Specialist at Arthur G. James Cancer Hospital of Ohio State University in Columbus, Ohio, said that to enhance survivorship in HNC, a multidisciplinary team is essential. “The different specialties tend to work in their own silos, but nurses can pull these all together and make sure the patient gets all he or she needs,” she said.
There are numerous “nursing-sensitive outcomes” for each mode of HNC treatment, she said. Post-operatively, these domains include pain, infection, hospital length of stay, and nutritional status. Chemotherapy-related outcomes include nausea and vomiting, mucositis, nutritional status and neutropenia. Those related to radiation therapy are xerostomia, mucositis, pain and nutritional status.
“Nurses should be advocates for survivorship,” she continued. This means facilitating rehabilitation, working to keep disease- and treatment-related costs down, addressing insurance issues - such as lack of coverage -and steering patients toward support groups.Jean Holland, MSN, RN, AOCN, Clinical Nurse of Radiation Oncology at Fox Chase Cancer Center in Philadelphia, discussed the management of treatment-related side effects especially related to HNC.
Mucositis, of some degree, occurs in essentially 100% of patients. It impairs eating, swallowing, taste, speech, and quality of life. She advised a dental evaluation prior to radiation therapy, weekly nurse assessments or more frequent assessments as needed, and good oral care as the best modes of prevention.
Patients should brush for 90 seconds after eating, floss daily, avoid irritants, and use a water-based moisturizer for the lips. Adequate hydration is critical and sometimes requires intravenous fluids. Oral rinses with saline or sodium bicarbonate with saline can help.
Pain management is an important component of mucositis management. In addition to non-steroidal anti-inflammatory agents and opioids, patients benefit from topical agents: “magic mouthwash” (applied only to a clean mouth), dyclonine, supersaturated calcium phosphate rinse, and mucoadhesive oral wound rinse. While some of these products can be expensive, patients find them soothing, she said.
Xerostomia is also quite disabling. In addition to the temporary swelling of the salivary glands, which alarms patients, the loss of saliva increases the likelihood of developing dental cavities and periodontal disease and makes chewing and swallowing difficult. Xerostomia can be permanent with radiation doses as low as 10 to 15 Gy to the parotid gland.
Management involves frequent rinses, humidifiers, artificial saliva products, increased fluid intake of 8-10 glasses a day, moist foods, sugar-free candies or gum, up to 30 mg of pilocarpine a day, and prescription-strength fluoride to protect tooth enamel.
“The goal with these measures is a 50% to 80% return of saliva,” Holland said.
Preventing dehydration, using a humidifier, and giving club soda, papaya enzyme, guaifenesin, scopolamine, and levsin can manage the occurrence of thick mucus. “Robitussin in the feeding tube, and having the patient swallow Mucinex, can also help,” she said.
When these side effects are severe, the consequences can be substantial, including malnutrition, dehydration, infection, prolonged hospitalization, and higher treatment costs. Feeding tubes are often necessary to prevent this decline, she said.
“We don’t want treatment breaks, as this compromises survival,” Holland emphasized. “It’s often necessary to hospitalize the patient, give him a feeding tube, and control his pain in order to keep him on treatment. Patients need to understand these side effects are usually temporary. Nurses can reassure them and help them get through this.”
“Radiotherapy, however, is the gift that keeps on giving,” she added. Late effects often occur, including xerostomia, osteoradionecrosis and soft tissue necrosis, soft tissue fibrosis, trismus or a condition the affects a person’s ability to open the mouth, dysphagia, esophageal stricture, hypothyroidism, ototoxicity, and secondary malignancies.
Stretching exercises can help prevent fibrosis and trismus. Tooth extraction of questionable teeth before treatment can help prevent osteonecrosis.
Patients are followed monthly for the first year post-treatment, then less frequently, but since late effects can occur years later it is important for nurses to see them at least annually, Holland said.