support of the head and neck patient during radiotherapy/combined chemo-radiation(crt ) anne hope...

Support of the Head and Neck patient during

Radiotherapy/Combined

Chemo-Radiation(CRT)

Anne HopeHead and Neck CNS

RSCH

AIMS• Gain an understanding treatment

implications/toxicities of RT/CRT .• The Role of the Holistic Needs Assessment.• Involvement of MDT • Evidence Based symptom control/supporting

patient.

The Current Practice• Increase in use of combined Chemo-radiation –

HPV RELATED ?• Overall increase in 100% over past year.• Most common sites treated:

Oropharynx/Hypopharynx/Tongue/Larynx.• Cisplatin /Carboplatin/Cetuximab.• 5/10/20/30 # RT (Depending on goal/disease)

Pre - Treatment Support

• Introduce to the MDT – attend MPC.• Holistic Assessment• Patient Information/Education• BUDDY ?• Referrals to necessary support services.

Holistic Assessment

Holistic Assessment

• Cancer Reform Strategy (CRS) (2007), Nice Guidance in supportive and palliative care(2004), Cancer Action Team (2007).

• Buzz word in Cancer Care • Peer Review Measure• Enables MDT approach/Team work• Encouraged at key points of the Patient journey.

Common Problems- Psycho-social

• Withdrawn• Depression• Anxiety• Inability to work• Sexuality/Body Image• Loss of role in family/relationship• Financial difficulty

Common Problems- Clinical

• Oral Mucositis• Skin Reaction• Pain• Xerostomia• Dysphagia• Copious/thick secretions• Aspiration• Fatigue• ORN

Oral Mucositis

Presentation• OM defined as ‘ Inflammation of the mucosal

membrane, often characterised by ulceration resulting in the impairment of the ability to talk, pain and dyshagia.’ (Rubenstein et al, 2004)

• 40 % of patients undergoing chemotherapy for solid tumours.

• 97% receiving RT to H&N will suffer with OM.

Presentation …contd• Pain/Discomfort• Ulceration• Erythema• Dysphagia • Bleeding• Necrotic/sloughy ulceration

Prevention

• Little evidence/ no avoidance.• Dental Assessment pre treatment.• Necessary dental extractions.• Avoidance alcohol/smoking/spicy foods.• Oral brushing/rinsing after every meal.• Soft tooth brush/Flossing.• High Fluoride Toothpaste.

Management• Manage symptom e.g pain WHO ladder.• Use of recognised oral assessment Guide e.g

WHO Oral Toxicity Scale.• Consistent Assessment…..Daily ?• Saline mouth rinses QDS/Sodium bicarbonate.• Asprin Gargles 300mg QDS.• Topical Agents, e.g Gelclair/Mugard• Difflam/Corsodyl.• Preventative Rinses- Caphosol?• Manage Infections/Candida.

Skin Care

Presentation

• 85% Patient receiving external beam RT will experience moderate –severe skin reaction.

• 10 % Moist Desquamation.• Usually seen 10-14 days following first fraction.• Is not a burn ! – Reaction differs /damage to skin

with RT migrates upwards and effects epidermal layer only.

• Usually increases up to 7-10 following last treatment.

• 4-6 weeks following completion of treatment skin healing well.

Radiotherapy Cycle

Radiotherapy starts – Activates inflammatory response

10-14/Days damaged basal cells migrate to skin surface. Erythema develops.

Further skin damage.New Cells reproduce before old dead cells shed- Dry desquamation .

No New cells to replace dead cells- Moist desquamation

Treatment completed- Takes 10-21 days for basal cells to recover &new skin to grow.

Assessment / Observation Effects of Radiotherapy on Skin CellsRTOG 0No visible change to skinRTOG 1Faint or dull erythema. Mildtightness of skin and itchingmay occurRTOG 2Bright erythema / drydesquamation. Sore, itchy andtight skinRTOG 2.5Patchy moist desquamationYellow/pale green exudate.Soreness with oedemaRTOG 3Confluent moist desquamation.Yellow/pale green exudate.Soreness with oedemaRTOG 4Ulceration, bleeding, necrosis(rarely seen)

RTOG Grading Scale

Cetuximab Reaction

Management• Priority – To avoid treatment breaks – delays• Maintain comfort/function• Maintain skin integrity.• Reduce pain.• Promote hydrated skin.• To avoid /reduce Infection.• Reduce risk of complications/further trauma.

Management…..contd• Avoid tight fitting clothing.• General moisturisers stop-if skin broken.• Hydrocolloid gel –skin breakdown.e.g Intrasite Gel.• Non adhesive dressings- moist desquamation.• Soft silicone dressings e.g Polymem, Meplilex lite.

Recommendations • Wash Daily with a simple soap and water.• Avoid rubbing/irritating affected area.• Moisturise skin twice daily- Product choice little

evidence.• However do avoid SLS, Lanolin, products with

high levels of paraffin/petroleum.• Aquamax- RSCH preference.• Avoid wet shaving/waxing/hair removal creams.• Pliazon cream for cetuximab reaction.• Aveeno cream.

Secretions• Most Difficult symptom to manage.• Distressing for patient and carers.• Causes Halitosis.• Unsociable !• Thick tenacious phlegm.• Source of infection/aspiration. • Maintains healthy PH oral cavity.• Main cause or nausea/retching.

Mangement• Good oral hygiene.• Regular rinsing…..saline mouth washes.• ?? Sodium Bicarbonate Rinses.• Steam Inhalation.• Nebulisers.

ConclusionPromote patient comfort

Avoid Infection

Complete proposed

treatment.Reduce/

control pain

Maintain nutrition

intake

Psychological support

Avoid aspiration/maintai

n safe swallow

Avoid further trauma to skin/oral mucosa

Control Symptoms

Avoid admission

Holistic Assessment

MDT Working