Transcript Pall Care in Head and Neck Cancer

Palliative Care in Head and Neck
Cancer
Presented By: Genevieve C. Stewart, MD, MPH
Date: September 9, 2016
Objectives
Participants will be able to:
• Define palliative care
• Describe how palliative care can be integrated into the
care of patients with head and neck cancer
• Refer a patient with head and neck cancer to Outpatient
Palliative Care Services
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What is Palliative Care?
Palliative Care: specialized medical care
for patients with serious illness designed
to improve quality of life
• Complex pain and other symptom
management
• Work with patients to set treatment plans
that are aligned with their goals and values
• Psychosocial support for patients and
families
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Palliative Care in Head and
Neck Cancer: Physical and
Psychosocial Symptoms
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Common Symptoms in Patients with Head and
Neck Cancer
Retrospective chart review of
patients dying of HN cancer
treated at Mayo Clinic
between 1999 and
2001(N=93)
Symptoms in last 6 months
evaluated based on chart
reviews
• Pain 62%
• Dysphagia 45%
• Anorexia and weight loss 43%
• Fatigue/weakness 39%
• Dyspnea 39%
• Mental status changes 29%
• Pneumonia/chest congestion 20%
• Nausea/vomiting 17%
• Cough 15%
• Dysphonia 14%
• Bleeding 14%
• Airway obstruction 13%
• Xerostomia 13%
Price KA: J Pall Med 2009;12 (2):117-118
Psychosocial Distress in Head and Neck Cancer
Depression scores over time using the HADS-D and BDI-II scales
Pre-RT
Mean
Score
Post-RT
Follow Up
HADS-D
BDI-II
HADS-D
BDI-II
HADS-D
BDI-II
8.4
12.6
11.2
18
10.7
16.9
HADS-D: 0-7 no depression
BDI-II:
< 13 no depression
8-10 mild depression
14-19 mild-moderate depression
11-14 moderate depression
20-28 moderate to severe depression
15-21 severe depression
29-63 severe depression
Abbreviations: RT=Radiation therapy; HADS-D = Hospital Anxiety and Depression Scale;
BDI = Beck Depression Inventory;
Chen AM et al. Prospective study of psychosocial distress among patients undergoing
radiotherapy for head and neck cancer. Int J Radiation Oncology Biol. Phys. 2009: 73(1): 187193
Depression in HN Cancer Patients Undergoing
RT
Predictors of post-RT depression:
• Pre-RT depression
• Age < 55 years
• No partner (single or separated)
• Living alone
• Working prior to onset of therapy
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Symptom Management
Strategies for Patients with HN
Cancer
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Approach to Pain Management in HN Cancer
Ongoing and Frequent Assessment: OPQRST
• Onset: sudden, gradual or part of ongoing, chronic pain
• Provocation or Palliation: Movement, pressure, rest or
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other external factors make the problem better or worse
Quality: patient’s description—sharp, dull, crushing,
burning, tearing, etc. Pattern may be constant,
intermittent, throbbing, etc.
Region and Radiation: where the pain is located and
whether it radiates
Severity: Usually on a numeric scale, 0-10 with zero = no
pain and 10 = worst pain imaginable
Time: How long has the pain been going on and has it
changed since its onset
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Approach to Pain Management in HN Cancer
Define Patient Context:
• Pain history: prior analgesic use, history of chronic
pain
• Medical History: PMH, other medications
• Good physical Exam
• Diagnostics if warranted: for example, evaluation
for new metastatic disease
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Approach to Pain Management in HN Cancer:
Type and Etiology of Pain
• Nociceptive Somatic Pain: tissue injury,
inflammation. Described as dull, gnawing, aching,
localized to one area.
• NSAIDs
• Opiates
• Steroids (bone pain)
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Approach to Pain Management in HN Cancer:
Type and Etiology of Pain
• Nociceptive Visceral pain: poorly localized,
described as pressure-like, cramping, squeezing,
colicky.
• Decompression
• Opiates
• Sympathetic Axis blocks
• Celiac plexus block: upper abdominal pain
• Superior hyogastric block: descending
colon to rectum as well as urogenital
system
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Approach to Pain Management in HN Cancer:
Type and Etiology of Pain
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Neuropathic Pain: nerve irritation or injury with abnormal
somatosensory processing. Described as burning, shocklike, dysesthetic.
• Tricyclic antidepressants
• SSRIs
• Opioids
• Topical anesthetics (capsicin cream)
• NMDA antagonists (methadone)
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Approach to Other Symptoms in HN Cancer
Symptom
Treatment
Notes
Mucositis
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Ice chips
Meticulous mouth hygiene
Magic Mouthwash (varies by
institution, but usually
contains viscous lidocaine,
diphenhydramine, aluminum
hydroxide)
Systemic opioids
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Consultation with
Speech/language therapist
Artificial nutrition and
hydration
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Degree of dysphagia
depends on origin of the
tumor and types of
treatments. May be transient
or permanent, may be
severe and lead to
dehydration and malnutrition
Frequent intake of water, ice
chips
Use of sugarless candy or
gum
Artificial saliva
Pilocarpine (start at 2.5 mg
enterally tid)
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Evidence is weak, treatment
choices should include
patient preference in context
of medical indication (eg,
avoid water if aspiration
risk). Pilocarpine has
significant SE including
rhinorrhea, sweating, urinary
frequency that limit its use.
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Dysphagia
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Xerostomia
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May be accompanied by
candida
Other treatments proposed
but not supported by the
evidence include allopurinol
mouthwash, GM-CSF,
Immunoglobulins
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Palliative Care in Head and
Neck Cancer: Management of
Depression and Anxiety
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Management of Depression/Anxiety in HN
Cancer
Diagnosis: low mood or anhedonia for 2 weeks and at
least 4/9 SIGECAPS sx
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Sleep
Interest
Guilt
Energy
Concentration
Appetite
Psychomotor
Suicidal
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Management of Depression/Anxiety in HN
Cancer
Treatment Options
• Provide support and referral to community resources
• First line agents: SSRIs
• Consider other meds based on other symptoms:
eg, mirtazipine (tetracyclic) for anorexia, benzos for
severe anxiety
• Evaluate efficacy
• If no response at 3 weeks, rotate agents
• If partial response, increase dose
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SJ Outpatient Palliative Care
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SJ Outpatient Palliative Care
The clinic shares space with the IHA Heme-Onc
Practice
• Providers include APNs with backup from Palliative
Care physician on the inpatient consult service
• Clinic runs Monday from 8:00AM to noon and
Thursdays from 8:00AM to 5:00PM
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SJ Outpatient Palliative Care: What to Expect
All initial visits will include a full Palliative Care
consultation with a focus on the reason for referral
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Assessment of patient and family understanding of treatment options in
order to help patients and families make decisions which align their
treatment with their goals and values
Assessment and management of pain and other symptoms
Assessment of functional status, social support, emotional and spiritual
state
Review of medications, particularly those used for symptom
management
Discussion of advance care plan and instructions for completion of forms
Assessment of hospice eligibility if appropriate
Discussion of code status
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SJ Outpatient Palliative Care: Referral Process
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Outpatient Palliative Care Clinic Phone Number is 734-712-PALL
(7255)
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Triage RN is available Monday-Friday from 7:30AM to 4:00PM to answer
questions and provide support for the clinic
The Triage RN screens patients to ensure that their symptoms fall
into the palliative care scope of practice
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Examples of patients who would not be a good fit for palliative care: chronic
musculoskeletal pain, patients with complex mental health or addiction issues
Palliative Care team handles medication refills, including opiates for
patients who are followed by palliative care for symptom
management
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Palliative Care NP works with patients to initiate a reasonable therapeutic plan
Symptom management is then be transitioned back to the PCP or primary
oncologist
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