Transcript Support of the Head and Neck patient during Radiotherapy

Support of the Head and
Neck patient during
Radiotherapy/Combined
Chemo-Radiation(CRT)
Anne Hope
Head and Neck CNS
RSCH
AIMS
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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
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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 ProblemsPsycho-social
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Withdrawn
Depression
Anxiety
Inability to work
Sexuality/Body Image
Loss of role in family/relationship
Financial difficulty
Common ProblemsClinical
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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
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Pain/Discomfort
Ulceration
Erythema
Dysphagia
Bleeding
Necrotic/sloughy ulceration
Prevention
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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 starts –
Activates inflammatory
response
Treatment completed- Takes
10-21 days for basal cells to
recover &new skin to grow.
No New cells to replace dead cellsMoist desquamation
Radiotherapy
Cycle
10-14/Days damaged basal
cells migrate to skin surface.
Erythema develops.
Further skin damage.
New Cells reproduce before old dead cells shedDry desquamation .
RTOG Grading Scale
Assessment / Observation Effects of
Radiotherapy on Skin Cells
RTOG 0
No visible change to skin
RTOG 1
Faint or dull erythema. Mild
tightness of skin and itching
may occur
RTOG 2
Bright erythema / dry
desquamation. Sore, itchy and
tight skin
RTOG 2.5
Patchy moist desquamation
Yellow/pale green exudate.
Soreness with oedema
RTOG 3
Confluent moist desquamation.
Yellow/pale green exudate.
Soreness with oedema
RTOG 4
Ulceration, bleeding, necrosis
(rarely seen)
Cetuximab Reaction
Management
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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
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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
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Good oral hygiene.
Regular rinsing…..saline mouth washes.
?? Sodium Bicarbonate Rinses.
Steam Inhalation.
Nebulisers.
Conclusion
Promote
patient comfort
Control
Symptoms
Complete
proposed
treatment.
Reduce/control
pain
Avoid
admission
Holistic
Assessment
Maintain
nutrition
intake
Avoid
Infection
Avoid
aspiration/maintain
safe swallow
Psychological
support
MDT
Working
Avoid further
trauma to
skin/oral
mucosa