Oncology - Head and neck cancers A team approach

A multidisciplinary approach is the key to effective management of head and neck cancer patients, writes Anne Murphy

Anne Murphy is an oncology nurse education facilitator at St. Luke's Hospital, Dublin.

HEAD and neck cancers account for approximately 5% of all cancer diagnosed worldwide. In Ireland, there were 526 new cases and 230 deaths from head and neck cancer recorded in 1997 alone.1

The crude overall five-year survival is 40%. This small percentage belittles the multiple challenges and severe complications to the physical, psychological and social wellbeing experienced by people with head and neck cancer. Few cancers are more obvious to the human eye than advanced head and neck cancer.

Distribution of cancers
  • Larynx 25%
  • Tongue 13%
  • Lips 11%
  • Oropharynx 10%
  • Floor of mouth 7%
  • Salivary 7%
  • Hypopharynx 5%
  • Nasopharynx 4%
  • Nose and sinus 4%
  • Buccal mucosa 4%
  • Gingiva 4%
  • Others 3%-5%

The key to effective management, however, is to adopt a multidisciplinary approach to care.2 This approach will help to achieve excellence in patient care, and contribute to one of the expected outcomes of treatment – a reasonable quality of life for this patient group.

Head and neck cancers comprise those that occur in the oral cavity, the pharynx, the larynx, the maxillary sinus, the salivary glands and the thyroid gland. The brain, skin and eyes are not included. Squamous cell carcINOmas account for 90%. The other 10% are adenocarcINOma, melanoma and tumours of the soft tissue.

Risk factors
The use of tobacco and tobacco products is the main aetiological factor in head and neck cancer. The other main factor is alcohol, but since many heavy drinkers smoke and vice versa, it is difficult to be precise on the actual contribution of either.3

Risk factors of head and neck cancer
  • Alcohol: Oral cavity, pharynx, oesophagus, larynx
  • Tobacco: Oral cavity, pharynx,oesophagus, larynx
  • Thorium dioxide: Paranasal sinuses
  • Chromium dust/fumes: Nasal cavity and sinuses
  • Leather working: Nasal cavity and sinuses
  • Nickel dust/fumes: Nasal cavity and sinuses
  • Wood dust: Nasal cavity and sinuses
  • Iron deficiency: Post cricoid carcINOma
  • Salt fish: Nasopharynx
Associated viruses
  • Human papilloma virus (HPV): Oral cavity, tonsil and larynx
  • Herpes simplex virus (HSV): Oral cavity, tonsil and larynx
  • Epstein-Barr virus (EBV): Nasopharyngeal carcINOma

There is also evidence to suggest that risk factors such as vitamin A and retINOid deficiency, poor nutritional status, poor oral hygiene, viruses such as herpes simplex and the human papilloma virus, and occupational exposure to textiles, leather and wood dusts may be other aetiological factors in head and neck cancer.4

Treatment regimes
The main treatment choices are surgery, radiotherapy and chemotherapy. Surgery will not be discussed here.

Radiotherapy
Radiotherapy is the treatment of tumours and a few non-neoplastic diseases with ionising radiation.5

In the treatment of head and neck cancers the patient may have to attend the radiotherapy centre on a few occasions for treatment planning. The first visit is to the mould room where an impression is made of the patient’s head. This is commonly known as the patient’s mask. This aid helps immobilise the head of the patient in the same position each day for treatment.

The patient may also attend the simulator room, which is similar to that of a treatment suite but it does not give radiotherapy. The simulator takes x-rays of the area to be treated and allows doctors to plan out where they are going to treat the patient. The treatment area is marked out on the patient’s mask. These marks act as a guide for the radiographer to position the patient correctly for treatment each day.

Treatment lasts only a few minutes each day and is given on a Monday to Friday basis. It lasts for approximately six weeks for head and neck cancers but this may vary depending on the tumour type.

National Radiotherapy Centre
On the first day of treatment at the National Radiotherapy Centre a clinical radiographer meets the patient and the treatment process is explained in detail.
Some patients find it difficult to wear the mask, particularly if they suffer from claustrophobia. The radiographer has the patient in view at all times through a television monitor and can talk to the patient through an intercom system. The doctor may also prescribe medication for the patient if necessary.

Each patient undergoing treatment will also be monitored closely by a radiotherapy nurse during treatment, and will have access to the clinical nurse specialist in head and neck cancer and will be reviewed by their doctor once a week.

A dietitian will also review the patient, usually on a weekly basis. Patients also have access to social work services, complementary therapy, pastoral care and a head and neck cancer support group that meets three to four times a year. This group is open to patients with head and neck cancer, their family, friends and carers. A clinical psychologist is also available to patients.

Side effects
The side effects experienced by patients are confined to the treatment area. The most common side effects are: mucositis; pain; infections, in particular oral thrush; skin reaction; and reduced nutritional intake due to oral mucositis. Constipation is also a common side effect caused by change of diet and medications.

Some patients experience odynophagia (pain on swallowing) and others experience total dysphagia. Enteral feeding is common for head and neck cancer patients. Some will require nasogastric feeding for a short period while others may be PEG (percutaneous endoscopic gastrostomy) dependent for a period of time.

Trismus (reduced mouth opening) is also a common side effect if the temporomandibular joint is in the radiotherapy treatment field. Fatigue is also a side effect that patients commonly experience.

Chemotherapy
Some patients will have both chemotherapy and radiotherapy for the treatment of their head and neck cancer. It is thought that chemotherapy given at the same time as radiotherapy may be of benefit in tumour reduction and disease-free survival.6

If patients are prescribed chemotherapy it is typically only given during their weeks of radiotherapy for most tumour types. The toxicities associated with radiotherapy are enhanced if the patient receives concomitant chemotherapy. Chemotherapy is also occasionally used for palliative treatment in advanced head and neck cancers.

Management post treatment
Side effects of head and neck cancer treatment do not generally heal for at least one month on completion of treatment. In fact for some people the two/three weeks post radiotherapy treatment is more difficult than during the treatment, particularly if they had concomitant chemotherapy.

It is at this time that intensive supportive therapy is required for the patient, be it in a convalescence home, their local hospital or if the patient is at home, support from their GP, public health nurse and clinical nurse specialist.

Head and neck cancer team
  • Otolaryngologist
  • Maxillofacial surgeon
  • Plastic surgeon
  • Medical oncologist
  • Radiotherapist
  • Clinical nurse specialist
  • Nursing team
  • Palliative care team
  • Dietitian
  • Speech therapist
  • Prosthetist/prosthodontist
  • Dentist/dental hygienist
  • Psychologist/counsellor
  • Physiotherapist
  • Social worker
  • Pastoral care

Usually patients are advised to continue on the same medications and feeding regimes until their first medical review post treatment. This is normally a month later. Recovery post radiotherapy to the head and neck area takes time and side effects can persist for a long time.

Head and neck cancer affects a small number of people so it is appropriate to consult with specialist nurses. Clinical nurse specialists in head and neck cancer are found in some major hospitals in Ireland, including Tullamore General Hospital, Co Offaly; Beaumont Hospital, Dublin; St Luke’s Hospital, Dublin and University College Hospital, Galway. There are head and neck cancer co-ordinators based in the Mater Hospital and St James’s Hospital, Dublin.

Anne Murphy is an oncology nurse education facilitator at St Luke’s Hospital, Dublin

References

  1. National Cancer Registry. Cancer in Ireland, 1997, Incidence and Mortality, National Cancer Registry Board, 2000
  2. British Association of Head and Neck Oncologists. Provision and quality assurance for head and neck cancer care in the United Kingdom: A Nationally Co-ordinated Multidisciplinary Approach, 1998
  3. Munro AJ. Head and Neck. In Price P, Sikora K eds. Treatment of Cancer, third edition, Chapman & Hall, London, 1995
  4. Epidemiology and risk factors for head and neck cancer, Seminars in Oncology, Spritz 1994; 21(3), 349-358
  5. Witt ME. Radiation and chemotherapy as combined treatment for advanced head and neck cancer. Medsurg Nursing 1998; 7(3): 159-165
  6. Department of Health and Children. The Development of Radiation Oncology Services in Ireland, The Stationery Office, Dublin, 2003

Patient information booklets

  1. Cancer of the larynx, Irish Cancer Society
  2. Cancers of the head and neck, Cancer Bacup, England (charge per booklet)
  3. Cancer of the thyroid, Cancer Bacup, England (charge per booklet)

Further information
Head and Neck Nurses Association Ireland (HANNA)
www.ncnm.ie


 Oncology - Head and neck cancers A team approach

 


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