Vol. 3 No.2
R e c o v e r y S t r a t e g i e s f r o m t h e O R t o H o m e
The Challenges of
In 2000, the American Cancer Society estimated that head and neck cancers accounted for 2.5%of cancer diagnoses with concomitant high mor- Postoperative
tality rate —2% of all cancer deaths. There are, however, indications that the rates of newly di-agnosed oral cancers have declined and the mor- Radiotherapy for
Bonus Issue
tality rates for oral cavity and oropharyngeal can- 1.6 C
cers have been decreasing since the early 1980s.
The treatment plan for these patients is individu- Post-surgical Head and
alized and depends on a number of variables.
The treatment may be surgery alone, radiationalone, or a combination of both. In general, head Neck Cancer Patients
and neck cancers when treated early are highly By Margaret Hickey RN, MSN, MS, OCN, CORLN
curable with radiation or surgery alone. Advancedcancers are candidates for treatment by a com-bination of surgery and radiation therapy.
Patients with more advanced cancers or in situ-ations where it was not possible to resect thelesion with adequate surgical margins will re-quire postoperative radiation therapy. In this ar-ticle, Ms. Hickey discusses the complex patientcare issues surrounding treatment of patients re-quiring postoperative external beam radio-therapy.
Head and neck cancer accounts these cancers rises. This ratio of men to Successful management demands the attention of a dedicated health-care team: radiation on- many to be the most dreaded site for can- vidualized for these patients with special cologist, otolaryngologist, radiation oncologynurse, radiation therapist, social worker and di- cer to occur, as both the disease and treat- size and location, patient’s physical condi- cers of the head and neck can arise in the tion, patient’s emotional status, treating Advisory Board
oral cavity, pharynx, or larynx. In 2000, the team’s experience, and available treatment Oncology Nurse Specialist, Oncology Memorial Hospital, Houston, TX, Adjunct Faculty, Trinity College of Nursing, Moline, IL cancers are treated early (stage I and II), Pulmonary Staff Nurse, Genesis Medical Center, Davenport, IA they are highly curable with radiation or Asst. Professor for Adult Acute and Critical Care Nursing Secretary/Treasurer, AACN Certification Corp. with the greatest risk are men over 40 years Nurse Practitioner/Specialist, Associate Professor of Nursing, by a combination of surgery and radiation.
Clinical Assistant Professor of Urology, University of Virginia, Department of Urology, Charlottesville, VA, Past-president SUNA because a history of excessive use of to- Victoria-Base Smith, PhD, MSN, CRNA, CCRN bacco and alcohol are contributing factors Clinical Assistant Professor, Nurse Anesthesia, to the development of this cancer. In the this group of patients, they should be con- Nurse Practitioner, Vascular Surgery, Harper Hospital, Detroit, MI Vice-president, Education and Professional Development, or in situations where it was not possible Executive Director, Cross Country University Supported by an educational grant from Dale Medical Products Inc.
Table 1: A guide to assessment of the oral cavity
Adapted from Beck SL, Yasko JM: Guidelines for Oral Care. 2nd ed. Crystal lake, IL;Sage,1993. to resect the lesion with adequate surgi- treatment. The cancer, surgical resection, cal margins will require postoperative ra- and cytotoxic effects of radiation therapy diation. This article will discuss the com- plex patient-care issues surrounding treat- in saliva production, xerostomia, another side effect of head and neck radiation to be discussed later in this paper, exacer-bates mucositis by causing changes to the Radiotherapy
therapy, particularly antimetabolites such death by eliminating the proliferation of adjuvant therapies for head and neck can- cer, heightens the risk of oral complica- it together. The cells are able to function eliminate their prior albeit unhealthy cop- Stomatitis is one of the earliest side ef- fects to manifest and may initially present directly related to the rate at which cells from 1 to 3 weeks into therapy. Early signs divide. This holds true for both tumor cells and normal cells. Injury occurs in normal tissues with rapid cell proliferation, such the stomatitis advances, ulcerative lesions do not.2 And, the risk of a second tumor is has significant side effects, both acute and Mucositis
begin an aggressive, prophylactic oral regi- the treatment site, dose, and patient’s re- care is essential during therapy to improve sponse. Acute side effects include mucosi- tis or stomatitis is an inflammatory reac- tis, xerostomia, taste changes, skin reac- mucositis. A dental evaluation and correc- tiple stressors, including cancer and its tion of any periodontal and dental disease patient has dentures, they must fit prop- rinses should be increased to every 2 hours flossing if pain, thrombocytopenia (plate- they irritate the mucosa and will exacer- are present. The soft toothbrush may need plenty of fluids to hydrate the mucosa.
Trauma to the oral cavity should be mini- mized; this goal can be achieved by avoid- need to be used, especially before eating.
ing foods that are too hot or cold, spicy or Topical analgesics include sprays, gels, and (Hurricaine®, Zilactin-B®, Orajel®). These Figure 1
done with each patient, using an oral mu- analgesics can be used alone or mixed with cositis grading system (Table 1). The pa- tient should be instructed to implement a equal proportions of xylocaine viscous 2%, the radiation field, a mucositis of the tra- diphenhydramine elixir, and an antacid; chea or tracheitis may result. The tracheal 15 cc are administered every 2 to 4 hours mucosa becomes inflamed, some blood streaking of the sputum may be noted, and A number of topical agents can be used there is a risk of infection. It can best be to protect the mucosa and to promote heal- prevented and managed by maintaining ■ brushing four times daily, 30 minutes ing. A sucralfate (carafate) suspension can adequate humidification. The patient can after eating and at bedtime, with a soft, also be used. The sucralfate adheres to and use a number of techniques to increase protects exposed proteins in the inflamed humidification. They include instilling ster- ile normal saline (1 to 2 cc) into the stoma, ■ removing and thoroughly cleaning den- three to four times a day; wearing a moist- ened stomal cover; using a bedside humidi- fier; and increasing fluid intake. Trauma ■ moistening the lips with a lip balm of spoons of salt or 1 teaspoon of baking soda, changes. If the patient has had a total la- or both. Oral rinses, such as chlorhexidien ryngectomy, the tube should coated with a mucosa and may stimulate prostaglandin water-soluble lubricant, and an obturator release.6,7 Orabase, a paste of carboxy- should be used when the tube is re-in- washes are to be avoided, as most contain methylcellulose, can be applied to the ir- serted after cleaning or no laryngectomy alcohol and, although initially refreshing, ritated areas but should not be used if an tube should be used at all. Whenever a tra- infection is present. Zilactin®, a cheostomy or laryngectomy tube is used, At the first sign of stomatitis, increase hydoxypropylcellulose gel, forms a protec- it is vital that the tube is well secured. Cot- the frequency of oral rinses with the solu- tive film that can last up to 8 hours. Vita- ton-twill tracheostomy tape or a manufac- min E oil extracted from a 400-mg cap- tured tracheostomy tube holder (Dale sule can be applied with a cotton-tip ap- Medical) can be used (Figure 1). The tra- plicator to oral lesions. If the oral cavity cheostomy tube holder contains an elastic the first sign of inflammation to prevent a needs debrided, a 1:4 hydrogen peroxide section that enables movement and accom- secondary fungal infection. Fungal infec- and water solution can be used; however, modates the cough reflex, while holding it should be discontinued when ulcers are the tube secure.
debrided, as prolonged use can inhibit tis- may be delayed if a fungal infection is as- Table 2: Radiation Therapy Oncology Group radiation morbidity scoring
sociated with the mucositis, but generally criteria: salivary gland
Acute Reactions
Mild mouth dryness/ slightly thickened saliva/ may have slightly altered taste, such asmetallic taste/ changes are not reflected by alteration in baseline feeding minor salivary glands. It is a natural lubri- Moderate to complete dryness/ thick, sticky saliva/ markedly altered taste in saliva begin the digestive process. Sa- Late Reactions
debris and bacteria, aids in taste, and is Slight dryness of mouth / good response on stimulation important for speech. Salivary glands pro-duce 1,000 to 1,500 ml of saliva each day.8 Moderate dryness of mouth / poor response on stimulation Complete dryness of mouth / no response on stimulation sult from radiation therapy to the head and neck region, certain chemotherapy agents, Source: Radiation Therapy Oncology Group (RTOG), American College of Radiology, Philadelphia, PA and surgery that involves removal of sali-vary gland(s). Radiotherapy-induced xe- maintain nutrition. The sensation of dry- rostomia results from radiation damage to ness is best alleviated with frequent oral the salivary glands. As radiation exposure equate oral care exacerbate the threat of rinses and sips of water or juice. Meticu- rostomia is noted. If the radiation dose ex- be initiated at the start of therapy as de- they will not recover.9 Some patients re- help to relieve symptoms temporarily. En- sleeping, speaking, and the ability to per- courage the patient to increase oral intake form physical exercise. There is a lack of tients’ ability to compensate for the sali- ropey, which makes it difficult to eat dry vary changes.10 Rating scales can be used such as Salivart® or MouthKote®. They are to describe the degree of xerostomia. The the need to take frequent sips of fluids, which may result in early satiety. Oral dry- than water alone. The use of sugarless gum ness alters the taste of food and smell. This help to increase the salivary flow. Sleep tive impact on the patient’s nutritional sta- tus. Saliva is also important for retention affect oral comfort, mucosal health, den- and stability of dentures. Sleep is inter- the mouth with a teaspoon of olive oil or tition, deglutition, the ability to chew nor- mally, and the ability to speak. The patient that the tongue is stuck to the roof of the lematic, especially at mealtime. Papain is tions, sore lip and tongue, ulcerations, ill- tions are impaired by the need to take sips fitting dentures, difficulty swallowing, and to dissolve tenacious secretions. The pa- abnormalities of taste and smell. Xerosto- der to articulate clearly; this necessity is tient may find some relief by eating papa- mia affects oral health, as it contributes to the development of dental caries, loss of teeth, mucositis, oral infections, and os- solution of meat tenderizer and water can teonecrosis. The patient is often instructed tended to provide comfort, to prevent and to use fluoride trays daily during treatment minimize stomatitis/oral infections, and to to help to dissolve the thick secretions.
tual or potential malnutrition. A lack of nutrition, and xerostomia interferes with oral intake should be anticipated. At the this goal. The lack of saliva interferes with chewing, digestion, and taste. Changes in ter therapy begins and continue for 14 to 21 days after its completion. Partial re- high-protein diets, oral supplements, food maintain nutrition. Soft, moist foods are ment; a complete recovery of normal taste preparation tips, and other suggestions to easier to eat. The use of gravies and sauces stimulate appetite. Despite this counsel- ing, patients may require the insertion of make it easier to chew and swallow. Avoid a feeding tube to maintain nutrition; it is dry, sticky foods like peanut butter. Alco- preferable to use the gastrointestinal tract and place a percutaneous gastric tube. The be avoided, as they further dry and irri- application of a G-tube holder will lower tube profile and help to discourage patient “pull-out.” It allows the patient to be more comfort and irritation caused by adhesive important for supportive care, as they di- treating anorexia and cachexia, related to can be used to stimulate salivary flow.
perience taste changes resulting from sur- Amifostine (Ethyol®) is a radioprotective gery, chemotherapy, and radiotherapy.
can be used to stimulate appetite include Surgery to the oral cavity and tongue lead mize the occurrence of acute and late xe- to a loss of sweet and salty receptors; pro- foods, small frequent meals, eliminate any rostomia, mucositis, and loss of taste.
cedures involving the palate lead to a loss unpleasant odors or add pleasant ones, use of sour and bitter receptors. Patients with Taste changes
exercise. To counteract changes to taste, altered olfactory component to taste, re- mary sensations: sweet, sour, bitter, and sulting from the diversion of airflow from salty. Taste buds, the receptors and con- lemon, and vanilla; avoid using hot spices, ductors of taste sensation, respond to all grees. Alterations in taste and smell have on appetite and contribute to nutritional well as moisten food. Maintaining the nu- dependent of treatment for their disease.11 deficits. People with cancer who lose 10% tritional status improves quality of life and not live as long as those with similar can- xerostomia. Taste alterations are believed Skin reactions
to result from both the loss of saliva and ished at diagnosis; this physical state is ex- the direct pathological effect of radiation affects swallow, taste, and appetite. Now, radiation dose beneath the skin surface.
the microvilli of the taste buds may be the as they face radiation and the multiple oral complications caused by stomatitis, xeros- tumor bed may be close to or even involve tomia, and taste changes, maintaining ad- the skin. Within the irradiated field, the sweet taste is least affected. This change skin will react to treatment. Melanocytes plaint of pain. Topical analgesics should electrolyte imbalance or dehydration, and struction exceeds the rate of repair, and be used, especially before meals. This pain can be quite severe and chronic. Narcotic posure of the dermis results. The loss of analgesics should be used, if warranted.
tance of exercise to alleviate fatigue is an the dermis are problematic but rarely does the site become infected. Healing is spon- Conclusion
fort. Use of long-acting opioids works well to control the chronic pain of stomatits. A number of agents are available, including include the collar line, clavicular area, and head and neck cancer. Patients experience changes, skin reactions, pain, and fatigue.
efits to this patient population, because it clothing on skin within the radiation field.
The tracheal stoma needs to be kept clean and is effective for 72 hours. As with any radiation oncologist, otolaryngologist, ra- and dry. If the patient has a metal tracheo- pist, social worker, and dietician. The team ing therapy. If there is a lot of drainage without the involvement and efforts of the patient and family. They must be provided dressing needs to be changed frequently.
plaint of patients with cancer. As many as tating; it is important to keep them clean 96% of patients report fatigue in conjunc- and dry and to avoid constriction. A tra- therapy.14 Like pain, fatigue can only be measured by the patient’s subjective re- and has a positive impact on the patient’s port. Multiple factors contribute to fatigue ment. These factors either disrupt oxygen neck cancer patients are “special people.” twill tape with a built-in elastic section to nutrition and hydration. Psychological fac- tors, such as anxiety and depression, also tial. The irritated skin needs to be treated of providing nursing care to this popula- with care. Skin within the radiation field of patients undergo radiotherapy.15 Treat- tion is equally special. Mary Jo Dropkin, ment-related fatigue has a clear temporal sionally, fatigue persists for a prolonged horrified, struggling to maintain pressure on a ruptured carotid artery, and shaving around a facial defect. It is being there out discussing them with the radiation or fatigue is to correct any potential contribu- for the first look in the mirror after sur- gery, appreciating laughter without sound, drugs, treatment of sleep disorders, effec- around the hall with one so severely dis- 16. Yuska CM. Introduction. Seminars in Oncology figured that he was afraid to venture out Cross Country University is an ac-credited provider of continuing edu- Suggested readings
truly beneficial only after the defect is ac- 1. Fleming ID, Cooper JS, Henson DE, Hutter RVP, et al. (eds.). AJCC Cancer Staging Handbook.
Philadelphia: Lippincott-Raven Publishers, 1997.
2. Fowler JF, Lindsstrom MJ. Loss of local control with After reading this educational offering, the reader
neck cancer patient is a direct encounter prolongation in radiotherapy. International Journal should be able to:
Review treatment modalities for head and neck cancer.
3. Hansen O, Overgaard J, Hansen HS, Overgaard M, 2. Describe prevention and management of mucositis in et al. Importance of overall treatment time for the References
a patient receiving radiation therapy to the head and outcome of radiotherapy of advanced head and neck 1. American Cancer Society, Cancer Facts and Figures carcinoma: dependency on tumor differentiation.
3. Discuss the management of xerostomia and its effects 2000, Radiotherapy and Oncology 1997,43(1):47-51.
on a patient receiving radiation therapy for head and 2. Browman GP, Wong G, Hodson I, Sathya J, Russell 4. Describe the treatment of skin reactions that may R, McAlpine L, Skingley P, Levine MN. Influence of cigarette smoking on the efficacy of radiationtherapy in head and neck cancer. New England 5. Describe pain management for the head and neck Journal of Medicine 1993,328(3):159-163.
3. Spitz MR. Epidemiology and risk factors for head 6. Discuss multidimensional causes and management of fatigue in patients receiving radiation therapy for head 4. Strohl RA. The etiology and management of acute To receive continuing education credit, simply do the
and late sequelae of radiation therapy in persons following:
with head and neck cancers. ORL Head and Neck ana. Her past experience includes the directorship 2. Complete the post-test for the educational offering.
5. Miller SE. Stomatitis and Esophagitis. In Yasko JM Mark an X next to the correct answer. (You may make (ed.). Nursing management of symptoms associated of Tulane Cancer Centre, Tulane University Hos- with chemotherapy. 4th edition. Bala Cynwyd,PA:Meniscus Health Care Communications, 1998, pital and Clinic, New Orleans, and the clinical di- rectorship of the General Clinical Research Cen- 4. Mail, fax, or send on-line the completed learner 6. Loprinzi CL, Ghosh C, Camoriano J, Sloan J, et al.
evaluation and post-test to the address below.
Phase III controlled evaluation of sucralfate to ter, University of Pittsburgh Medical Center, Pitts- 5. 1.6 contact hours will be awarded for this educational alleviate stomatitis in patients receiving fluoruracil- burgh, Pennsylvania. She is a past-president and offering through Cross Country University, an accredited based chemotherapy. Journal of Clinical Oncology active member of the Society of Otorhinolaryngol- provider of continuing education in nursing by the American Nurses Credentialing Center’s Commission on 7. Cengiz M, Ozyar E, Ozturk D, Akyol F, Atahan IL, Accreditation (ANCC) and an approved CE provider by Hayran M. Sucralfate in the prevention of radiation- the American Society of Radiologic Technologists, as it induced oral mucositis. Journal of Clinical Perspectives, a quarterly newsletter focusing on post- 6. To earn 1.6 contact hours of continuing education, you 8. Dreizen S, Brown LR, Handler S, Levy BM.
operative recovery strategies, is distributed free-of- must achieve a score of 75% or more. If you do not pass Radiation-induced xerostomia in cancer patients: charge to health professionals. Perspectives is pub- the test, you may take it again one time.
effect on salivary and serum electrolytes. Cancer lished by Saxe Healthcare Communications and is Your results will be sent within four weeks after the form funded through an education grant from Dale Medi- 9. Dreizen S, Brown LR, Daley TE. Short- and long- cal Products Inc. The newsletter’s objective is to pro- term effects of radiation-induced xerostomia in head 8. The administrative fee has been waived through an vide nurses and other health professionals with timely and neck cancer patients on salivary flow. Journal of educational grant from Dale Medical Products, Inc.
and relevant information on postoperative recovery 9. Answer forms must be postmarked by Jan. 7, 2006, strategies, focusing on the continuum of care from 10. Mossman K, Shatzman A, Chencharick J. Long- operating room to recovery room, ward, or home.
term effects of radiotherapy on taste and salivary Name _______________________________________ function in man. International Journal Radiation The opinions expressed in Perspectives are those of Credentials ___________________________________ Oncology Biology Physics 1982,8:991-997.
the authors and not necessarily of the editorial staff, 11. DeWys W, Walters K. Abnormalities of taste Position/title __________________________________ Cross Country University, or Dale Medical Products Inc.
sensations in cancer patients. Cancer 1975,36:1888- The publisher, Cross Country University and Dale Medi- Address _____________________________________ cal Corp. disclaim any responsibility or liability for such City _________________________ State __________ 12. Bender C. Taste alterations. In: Yasko JM (ed.).
Zip _________________________________________ Nursing management of symptoms associated with We welcome opinions and subscription requests Phone ______________________________________ from our readers. When appropriate, letters to the Fax _________________________________________ editors will be published in future issues.
License #: ____________________________________ 13. Ottery F. Supportive nutrition to prevent cachexia * Soc. Sec. No. ________________________________ and improve quality of life. Seminars in Oncology1995,22(Suppl. 3):98-111.
E-mail _______________________________________ 14. Portenoy RK, Itri LM. Cancer-related fatigue: Saxe Healthcare Communications
Guidelines for evaluation and management. The P.O. Box 1282, Burlington, VT 05402
Cross Country University
Fax; (802) 872-7558
15. Ream E, Richardson A. From theory to practice: 6551 Park of Commerce Blvd. N.W.
Designing interventions to reduce fatigue in patients Suite 200
Boca Raton, FL 33487-8218
or Fax: (561) 988-6301

1. Head and neck cancers occur more
8. Amifostine is a cytotoxic agent which
often in individuals who:
enhances the cell killing effects of
radiation therapy.
5. Tracheitis can be prevented/
minimized with adequate
9. Managing the impact of taste
2. Radiation alone or surgery alone
humidification and:
alterations on diet due to xerostomia
each has a high cure rate in stage I
and direct effects of radiation therapy
and II head and neck cancers.
to the taste buds can be best
managed by:
3. Early signs and symptoms of
b. Inserting a central line for total parental stomatitis include:
6. Xerostomia may not be reversible if
radiation dose exceeds 4000 cGy to
the salivary glands.
10. Healing of an area of moist
7. Xerostomia profoundly affects:
desquamation of the skin within the
4. Patient teaching regarding
radiation field is:
a. Eating, sleeping, speaking, and ability to appropriate preventative dental
hygiene for stomatitis includes:
b. Eating, speaking, hearing, and ability to weeks after radiation treatment iscompleted Oral self exam
ii. Rinsing with Listerine four times
c. Eating, sleeping, speaking, and ability to iii. Brushing after eating and at
c. Frequently treated by skin grafts after bedtime with a soft toothbrush
iv. Avoid flossing
Apply lip balm to keep lips moist
Mark your answers with an X in the box next to the correct answer
Participant’s Evaluation
1. What is the highest degree you have earned? Using 1 =Strongly disagree to 6= Strongly agree rating scale, please circle the number that best reflects the extent of your agreement to each statement.
Strongly Disagree
Strongly Agree
2. Indicate to what degree you met the objectives for this program: Review treatment modalities for head and neck cancer.
Describe prevention and management of mucositis in a patient receiving radiationtherapy to the head and neck region.
Discuss the management of xerostomia and its affects on a patient receivingradiation therapy for head and neck cancer.
Describe the treatment of skin reactions that may occur with head and neckradiation.
Describe pain management for the head and neck cancer patient.
Discuss multidimensional causes and management of fatigue in patients receivingradiation therapy for head and neck cancer.
3. Have you used home study in the past? ■ Yes ■ No4. How many home-study courses do you typically use per year? 5. What is your preferred format? ■ video ■ audio-cassette 6. What other areas would you like to cover through home study? Mail to: Cross Country University, 6551 Park of Commerce Blvd. N.W., Suite 200, Boca Raton, FL 33487-8218• or Fax: (561) 988-6301 Supported by an educational grant from Dale Medical Products Inc.



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