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Oral cancer: risk factors, treatment and nursing care NS716 Foulkes M (2013) Oral cancer: risk factors, treatment and nursing care. Nursing Standard. 28, 8, 49-57. Date of submission: February 6 2013; date of acceptance: June 13 2013.
Abstract Oral cancer occurs in a range of anatomical sites within the oral cavity and pharynx. Although oral cancer is relatively rare in the UK, it can have a significant effect on individuals, with treatment being associated with eating, drinking, speaking and breathing difficulties. Treatment may also result in alterations to body image and functionality, which can lead to depression. Therefore, nurses need to have knowledge of associated risk factors, treatment and nursing care to improve patient outcomes and enhance quality of life.
Author Mark Foulkes Nurse consultant in cancer care and lead cancer nurse, Royal Berkshire NHS Foundation Trust, Berkshire Cancer Centre, Reading. Correspondence to: [email protected]
Keywords Cancer, chemotherapy, oral cancer, palliative care, radiotherapy, surgery
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
Aims and intended learning outcomes This article aims to enhance the reader’s awareness and understanding of oral cancer. After reading this article and completing the time out activities you should be able to: 4Identify the main types of oral cancer and the anatomical sites where they occur. 4Discuss the epidemiology of oral cancer and factors leading to its development. 4Explain the treatment of oral cancer in light of existing evidence. 4Recognise the nursing care and support required by patients with oral cancer.
Introduction Incidence of oral cancer varies worldwide. The disease is relatively rare in the UK, but the incidence is increasing in some populations. Treatment presents the nurse with a number of challenges in relation to supporting the patient both physically and psychologically. Surgery, radiotherapy and chemotherapy can all be used during treatment, and these modalities can result in short or long-term functional changes for the patient in terms of eating, drinking and communicating. Complete time out activity 1
Oral cancer Oral cancer is a sub-group of tumours of the head and neck, arising in the oral cavity (lips, teeth, gums, tongue, buccal mucosa, and soft and hard palate) and the pharynx (oropharynx, nasopharynx and laryngopharynx) (Figure 1). Typically, oral cancer and pharyngeal cancer are grouped
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CPD oncology together in oncology statistics because of uniformity in histology and risk factors. When combined, oral and pharyngeal cancer is the sixth most common type of cancer worldwide and accounts for about 400,000 cases, with two thirds of these occurring in the developing world (Warnakulasuriya 2009). With rising trends in some populations (Warnakulasuriya 2009), this is a serious and growing health problem. Oral cancer is more common in men than women and risk increases with age (Warnakulasuriya 2009). However, there is growing concern, particularly in developed countries, about the increasing incidence of oral cancer in people aged under 40 (Schantz and Yu 2002). Mackenzie et al (2000) suggested that the rise in the number of young people with oral cancer may be the result of increased exposure to risk factors such as smoking, alcohol consumption, and lack of fruit and vegetables in the diet. There is significant variation in the incidence of oral cancer worldwide. Areas of south and southeast Asia (Sri Lanka, India, Pakistan and Taiwan), western Europe (northern France), eastern Europe (Hungary, Slovenia and Slovakia), South America and the Caribbean (Brazil, Uruguay and Puerto Rico), and some Pacific regions (Papua New Guinea and Melanesia) have a higher incidence of oral cancer than neighbouring countries. The reasons for this are not yet fully understood, but are likely to be linked to combinations of the major risk factors, including tobacco use, alcohol consumption and exposure
to the human papillomavirus (HPV) (Warnakulasuriya 2009). The most common histological type of oral cancer is squamous cell carcinoma, which accounts for 90-95% of oral cancer (Warnakulasuriya 2009). The remaining 5-10% of oral cancer is made up of those arising from the salivary glands such as muco-epidermal cancers and adenoid cystic adenomas, sarcomas arising from bone, cartilage, muscle or fat, and lymphomas and melanomas (British Association of Otorhinolaryngology Head and Neck Surgery 2011). Like all squamous cell cancers, oral cancer typically arises from the cells that line body tissues and surfaces, in this case the oral cavity and pharynx. Tumours begin when cells proliferate abnormally as a result of a malfunction in normal cell division. Malfunction in cell division may be caused by genetic dysfunction initiated by substances absorbed by the cells. These substances are called carcinogens. Carcinogens can affect particular sections of the cells’ deoxyribounucleic acid (DNA). These susceptible sections are called proto-oncogenes and can be transformed into oncogenes by the action of carcinogens. Oncogenes are sections of DNA that can malfunction during cell division, causing cells to proliferate abnormally and become cancerous.
Risk factors Collins (2010) noted that more than 70% of all oral cancer is caused by tobacco use.
FIGURE 1 Anatomical location of the pharynx
Tongue epiglottis Nasopharynx
Trachea
Oropharynx
Laryngopharynx Oesophagus
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jOANNA CAmeRON
Cricoid cartilage
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Consumption of alcohol (Pelucchi et al 2011) and diet (Garavello et al 2008) have also been implicated. Therefore, it is important to examine factors that lead to the development of head and neck cancer generally and oral cancer in particular.
Tobacco use
In the UK, smoking accounts for 85% of deaths from oral cancer (Johnson 2001). In other countries, tobacco use is often implicated in increased incidence of oral cancer, but this may be because of the local preference for using non-smoked tobacco (tobacco used orally, such as chewing tobacco) as well as smoking. Many countries have a tradition of using tobacco by placing it in contact with mucous membranes. Examples include the use of oral snuff (powdered tobacco) in the United States and Scandinavia, and the use of toombak (tobacco compressed into blocks and chewed) in Sudan. Betel quid (paan), a blend of betel leaves, areca nut and, frequently, tobacco, is chewed by people throughout much of south and southeast Asia (Lin et al 2011). Evidence suggests that all forms of tobacco use increase the risk of oral cancer (Lin et al 2011). More than 300 carcinogens have been identified in tobacco smoke, and many of them are also present in non-smoked tobacco, particularly some nitrosamines that are specific to tobacco. These substances have been found in high quantities in the saliva of tobacco users (International Agency for Research on Cancer (IARC) 2007). It seems likely that tobacco-specific nitrosamines are absorbed into the cells of the oral cavity from affected saliva where they disrupt DNA replication, causing cancer. In addition, tobacco users tend to maintain high levels of nicotine, and hence high levels of carcinogens in saliva, because tobacco is an addictive substance (IARC 2007).
Alcohol consumption
Meta-analyses and reviews have shown that combined tobacco and alcohol use increase the risk of oral cancer (Franceschi et al 1990, Johnson 2001), although the relationship between the two is not fully understood. This may be because metabolism of ethanol produces the by-product acetaldehyde, which is a known carcinogen (Brooks and Theruvathu 2005). Other carcinogens may also be present in alcoholic beverages. In a UK study, Hindle (1997) demonstrated a link between trends in alcohol consumption and mortality associated with oral cancer
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throughout the 20th century. The author found significant circumstantial evidence that alcohol, rather than tobacco use, is the main factor in oral cancer mortality and incidence. There is no evidence that any particular type of alcoholic beverage is associated with an increased risk of cancer, but the number of alcoholic drinks consumed in one week is a significant risk factor. These risks are further increased if individuals smoke, while the number of cigarettes smoked in a week is also a factor (Johnson 2001).
Poor nutrition
A link has been made between diet and oral cancer (Petridou et al 2002, Boeing et al 2006). Findings suggest that a diet high in fruit and vegetables reduces the risk of oral cancer, and that a diet high in starchy root vegetables, cereals and olive oil may also have a protective effect (Petridou et al 2002). Abdulla and Gruber (2000) suggested that fruit and vegetables contain vitamins, trace elements and antioxidant molecules, which have a role in cancer prevention. This finding is supported by Pavia et al (2006), who concluded that a diet high in fruit and vegetables is associated with a reduced risk of developing oral cancer.
Other risk factors
There is a well-established link between prolonged exposure to sunlight and the development of cancer of the lip. In Greece, cancer of the lip accounts for more than 60% of oral cancer, while a person raised in New Zealand has five times the risk of developing lip cancer than a person raised in the UK (Johnson 2001) because of prolonged exposure to sunlight. The role of infections in the development of oral cancer is not yet understood. However, HPV and oral fungal infection appear to have a role in the development of some tumours, as well as in amplifying the carcinogenic effect of smoking in some individuals (Gillison 2004). Complete time out activities 2 out 3
Types of oral cancer Lip cancer
Two of the most common non-melanoma skin cancers affecting the lip are basal cell carcinoma and squamous cell carcinoma (Figure 2). Lip cancer is more common in fairskinned males and is often related to high levels of exposure to sunlight (Warnakulasuriya
1 Can you recall caring for a patient with oral cancer? If so, what were the patient’s nursing needs and were you able to meet them? If you have not cared for a patient with oral cancer, speak to a colleague who has been involved in providing this care and find out what particular needs these patients may have. 2 Consider the risk factors associated with developing oral cancer. Do you think health promotion in the UK is effective in reducing these risks? If not, what strategies could be implemented to make people more aware of their risk of developing oral cancer? 3 Consider whether oral cancer is easier to treat than other forms of cancer. List the main factors in determining whether treatment is successful.
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CPD oncology
Floor of mouth cancer
The floor of the mouth is the area under the tongue that runs in a crescent inside the lower jaw. This is a common site for the development of oral cancer, particularly in smokers and users of non-smoked tobacco. Cancer of the floor of the mouth often requires major surgery to ensure total excision, and tumours are likely to metastasise to the neck nodes (Neville and Day 2002).
Cancer of the buccal mucosa
The buccal mucosa is the lining of the cheeks running towards the margins of the lips and back towards the molars (Figure 3). Cancer of the buccal mucosa is rare in the UK, Europe and North America (Warnakulasuriya 2009). In Asia and South America, this type of cancer is more common, particularly in individuals who use betel or non-smoked tobacco (Warnakulasuriya 2009). Cancer of the buccal mucosa can be aggressive and grow rapidly. Early-stage cancer is characterised as being smaller and not having invaded deeply or metastasised to local lymph nodes, and is treated with surgery alone, while more advanced tumours – those characterised as having invaded deeply and metastasised to local lymph nodes – may require surgery, followed by radiotherapy and, sometimes, chemotherapy (Bachar et al 2012).
laryngopharynx (hypopharynx) and nasopharynx. The most common site for this cancer is the tonsil (Figure 5). In the UK, death from pharyngeal cancers is five times more common in the Indian migrant population than in the native British population (Warnakulasuriya 2009). Pharyngeal cancer is associated with poorer prognosis compared with other types of oral cancer because it typically presents when the cancer is more advanced, and is more difficult to treat surgically because of the anatomical location and proximity to major structures. There is debate about the best way to treat pharyngeal cancer, for example with primary surgery, or with primary radiotherapy and chemotherapy, reserving surgery for cases where primary treatment is not effective (Forastiere and Trotti 1999). Complete time out activity 4
Treatment Treatment of patients with oral cancer can vary considerably depending on the stage of disease, but the main treatment modalities are surgery,
FIGURE 2 Squamous cell carcinoma affecting the lip
SCieNCe pHOTO LiBRARy
2009). This type of cancer is easily detected and is generally treated successfully with surgery and/or radiotherapy. Cancer of the lip has the best prognosis of all oral cancer (British Association of Otorhinolaryngology Head and Neck Surgery 2011).
Tongue cancer
FIGURE 3 Cancer of the buccal mucosa
SCieNCe pHOTO LiBRARy
4 Patients with oral cancer may require a number of treatment modalities, for example surgery, chemotherapy and radiotherapy, over an extensive period. What are the main challenges associated with supporting a patient with oral cancer through a prolonged period of treatment?
Cancer of the tongue is the most common type of oral cancer (Warnakulasuriya 2009). It is typically caused by squamous cell cancer and can affect the oral tongue – the portion of the tongue that is mobile and can be seen in the mouth – and the tongue base, which forms part of the oropharynx, which cannot be seen and is immobile (Figure 4). Treatment depends on staging, with larger tumours requiring major surgery, often with input from reconstructive plastic surgeons, followed by radiotherapy and chemotherapy. If lymph nodes are also involved, more extensive surgery may be required to remove these (Harish 2005).
Pharyngeal cancer
Pharyngeal cancer can occur in all three regions of the pharynx: the oropharynx,
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radiotherapy and chemotherapy, sometimes used in combination. Chemotherapy can be used adjuvantly (post surgery), neo-adjuvantly (before surgery to make surgery easier) or palliatively (to reduce symptoms). The treatment of oral cancer, in common with other tumours of the head and neck, requires a multidisciplinary approach. This is because treatment may be associated with difficulties in eating, drinking, speaking and breathing. In addition, treatment may result in alterations to body image and functionality, which can lead to depression, particularly in patients with other psychological problems such as alcohol or nicotine dependence (Lydiatt et al 2009). Treatment options need to be discussed carefully by a range of specialist clinicians and presented to the patient in a clear and unambiguous manner. Following discussion, any treatment plan should be agreed with the patient and consent obtained.
curative option in advanced disease. The primary aim is to excise the tumour, with a good margin (removal of a portion of normal tissue around the tumour to reduce the risk of localised spread) to prevent recurrence and also remove any lymph nodes that are, or are likely to be, affected by the cancer. Any reduction in function needs to be minimised, and there are a number of techniques that can assist with this.
Mohs surgery
Cancer of the lip can be excised by using Mohs surgery. The technique allows the tumour to be removed piece by piece, while checking the margins of each excision during surgery. This allows damage to the lip to be kept to a minimum and promotes preservation of function.
Use of skin grafts and flaps
Surgery
The main treatment modality for most oral cancer is surgery, which is often the only
FIGURE 4
CORBiS
Squamous cell cancer on underside of tongue
FIGURE 5
Dissection of neck nodes
SCieNCe pHOTO LiBRARy
Squamous cell cancer of the tonsil
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Where a large tumour is removed with a margin to prevent recurrence, there may be considerable deficit or space left behind. This can be filled by using tissue from another part of the body. Skin grafts and flaps are used where a tongue or floor of the mouth tumour has been excised. Removal of all or part of the tongue (total or partial glossectomy) can be repaired by taking a section of skin and associated blood vessels and transplanting it into the deficit using microsurgery to connect the vessels. This ‘free flap’ is often taken from the forearm (Scully and Porter 2000). Where a tumour destroys some bone, as in a large tumour of the floor of the mouth involving the mandible, bone can be removed and replaced with bone grafted from elsewhere. This bone can be harvested from a range of locations, but commonly the iliac crest above the hip is used. These procedures are well established and achieve good cosmetic and functional effect in more than 90% of patients (Rana et al 2011). Lymphatic drainage of the oral region occurs via the lymph nodes in the neck. Therefore, if cancer is suspected or confirmed in the lymphatic system, removal of the lymph nodes in the neck is necessary. A ‘neck dissection’ is carried out by making an incision down the side of the neck; this can be carried out on one or both sides. The operation is not without risk or side effects. For example, if the accessory nerve is removed or damaged during the procedure, then the patient may have a stiff shoulder, and difficulty lifting the arm and carrying heavy objects. october 23 :: vol 28 no 8 :: 2013 53
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CPD oncology Radiotherapy
Patients with oral cancer commonly receive radiotherapy, which destroys cancer cells by disrupting the way in which cellular DNA replicates. However, healthy tissues may become inflamed and red, and may break down. Radiotherapy is usually used in the treatment of oral cancers in the following ways (British Association of Otorhinolaryngology Head and Neck Surgery 2011): 4Primary treatment in small tumours instead of surgery – radiotherapy can sometimes be delivered via radioactive implants into the tumour (brachytherapy) instead of the more commonly used external beam radiotherapy. 4Treatment after surgery – this allows for control of diseased tissue that might have been left behind or in areas where surgery would be difficult to perform. 4Palliative treatment in incurable cancer – radiotherapy can be used to control bleeding, reduce pain and offer temporary control of tumour growth.
Chemotherapy
The use of chemotherapy has been shown to be effective when combined with surgery and radiotherapy. Furness et al (2011) found that chemotherapy and radiotherapy following surgery improves survival rates by 16%. When surgery was not possible, chemotherapy and radiotherapy showed a 22% improvement in survival rates compared with radiotherapy alone. The most commonly used drugs are cisplatin, carboplatin, 5-fluorouracil and bleomycin, generally used in combinations of two. Cetuximab, a newer agent and an antibody that inhibits cell growth by blocking the action of epidermal growth factor receptor, was shown to extend overall survival in patients with head and neck cancer when compared with chemotherapy alone (Vermorken et al 2008). The National Institute for Health and Care Excellence (NICE) (2008) supports the use of cetuximab in conjunction with radiotherapy in patients who have locally advanced oral cancer.
Nursing care Patients with oral cancer require skilled nursing care regardless of the treatment modality. They should be offered support from a specialist nurse who deals with head and neck cancer, however general nurses will also be involved in their care and should have appropriate knowledge. On diagnosis, 54 october 23 :: vol 28 no 8 :: 2013
patients may be distressed and will require psychological support and good quality information to assist them in making decisions about their care and management. Symptom management and assessment is essential. Patients may experience pain, ranging from visceral pain to neuropathic pain caused by nerve damage. Poorly controlled pain can mean that the patient is unable to eat and drink, which can have a negative effect on recovery. Expert advice on symptom management may be necessary, particularly if the patient requires a lengthy period of treatment (Tadman and Roberts 2007).
Following surgery
Surgery for oral cancer may result in alterations to the patient’s appearance, and ability to speak, eat and drink. It may be difficult, or even impossible, for some people to come to terms with these effects, even if surgery is the only curative option. Nursing staff should provide information about the type of surgery required, associated side effects and the long-term implications. Nurses are well-placed to offer psychological support to patients and carers. Referral to a specialist nurse, dietitian, speech therapist and psychologist or counsellor will also be useful in helping patients adjust to any changes following surgery. In the immediate post-operative period, nursing care will need to be focused on avoidance of bleeding, airway obstruction and wound infection. Where surgical flap repairs have taken place, these will have to be carefully observed for signs of wound breakdown and remedial action taken swiftly, if necessary. Because of the specialist and complex nature of head and neck surgery, patients should only be cared for on specialist wards with appropriately trained staff (NICE 2004). Longer term post-operative nursing needs to focus on rehabilitation, adjustment to altered body image and function, particularly when oral function has been affected profoundly by surgery. Depression in patients following major oral surgery is common, with rates of major depressive illness between 15% and 50% (Lydiatt et al 2009). This may be caused by the effects of surgery, but could also be linked to the high levels of alcohol and tobacco use in this patient group. Duffy et al (2006) suggested that high levels of smoking and drinking are linked to high levels of depression, and organised and supportive programmes to help patients deal with alcohol and nicotine dependence will
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During chemotherapy
reduce its incidence. Nurses should be alert to the signs of depression post-operatively, such as low mood, lack of interest in activity and poor energy levels, and refer patients to psychological or psychiatry services.
Chemotherapy may be associated with a wide range of side effects, including fatigue, infection caused by a reduced white cell count, nausea and vomiting, and hair loss or thinning, depending on the chemotherapy agents used. Because patients with oral cancer may already have compromised dietary and fluid intake, side effects such as nausea, vomiting, diarrhoea or constipation require careful nursing and medical management. Chemoradiation (concurrent chemotherapy and radiotherapy) can amplify the side effects of both radiotherapy and chemotherapy, in particular effects on the mucous membranes and skin (Bernier and Cooper 2004). These patients will require close monitoring and responsive management to ensure that they are able to complete their course of treatment.
During radiotherapy
Radiotherapy is frequently used in the treatment of patients with oral cancer, particularly following surgery. Patients may experience a wide range of side effects, the most debilitating being skin reactions and a breakdown of the mucous membranes in the mouth (mucositis) (Cancer Research UK 2013) (Figure 6). The onset of mucositis typically starts three to 14 days into treatment and does not begin to resolve until ten to 14 days following the end of treatment (Wygoda et al 2013). Painful mucositis can mean that patients are not able to eat and drink. Therefore, patients should be given dietary advice and effective pain relief. They may need to be admitted for nutritional support via a nasogastric tube or gastrostomy. Patients receiving oral radiotherapy should be assessed regularly for pain, severity of mucositis, and dietary and fluid intake. Mucositis will typically resolve three to four weeks following treatment. However, xerostomia (dry mouth) can be a debilitating permanent side effect of radiotherapy targeted at the head and neck. If the salivary glands are irradiated within the treatment area, they will not regain normal function. This can be managed by the provision of a synthetic saliva spray or by carrying a bottle of water around at all times. With the advent of intensity modulated radiotherapy, which accurately targets the area to be treated, the effect on the salivary glands is minimised and dry mouth prevented (Feng et al 2010).
Psychosocial care
FIGURE 6
mediSCAN
Severe mucositis associated with radiotherapy
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Patients with oral cancer tend to be from low income and disadvantaged sections of society and ‘are also generally more exposed to avoidable risk factors such as environmental carcinogens... alcohol, infectious agents and tobacco use’ (Peterson 2009). NICE (2004) suggests that advice on managing finances, claiming disability and other benefits should be given to patients to ensure that they are able to maintain quality of life while receiving treatment for oral cancer. Psychological morbidity is common among adults with oral cancer, with one study showing that cancer of the tongue and pharynx accounted for 20% of all male suicides relating to cancer in one eight-year period (Farberow et al 1971). In more recent studies, increased psychological morbidity associated with oral, and head and neck cancer has also been highlighted (Baile et al 1992, Kilbourn et al 2013). Therefore, psychological support is an essential element of care for all patients with oral cancer. Altered body image and function can have a significant effect on patients’ intimate and sexual relationships (Lebel et al 2013). Nurses can help alleviate these effects by recognising a patient’s distress and speaking to the individual about any issues he or she may have, and referral to appropriate professionals. These might include the clinical nurse specialist in head and neck cancer, or a psychologist or counsellor. Complete time out activity 5
5 Can you think of any ethical issues that may be encountered when caring for a patient with advanced, incurable oral cancer? How might these be addressed?
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CPD oncology Palliative care The head and neck are anatomically complex areas, with major structures in close proximity. Blood vessels, nerves, the airway and brain tissue can be affected by advancing disease. Therefore, oral cancer may be associated with significant challenges for healthcare professionals working in the palliative care setting.
Inability to eat and drink
As the cancer advances it may be difficult and eventually impossible for the patient to eat and drink. Choices regarding nutritional support and the best way to achieve this will need to be made. Healthcare professionals caring for the patient may feel that it is not in the patient’s best interests to maintain artificial hydration and nutrition over extended periods. However, discussions of
this nature should take place with the patient, family members and carers. Early involvement of the palliative care team and advanced care plans may be useful.
Airway obstruction
The patient’s airway may be compromised, and eventually occluded, by advanced cancer. There are difficult ethical decisions that need to be made, in discussion with the patient’s family members and carers, about how this complication of the cancer can best be managed. For example, radiotherapy, chemotherapy or surgical treatment may not be appropriate because of the patient’s overall condition or, in the case of radiotherapy, extensive pre-treatment. A palliative care approach, encompassing symptom management, may have to be discussed with
References Abdulla m, Gruber p (2000) Role of diet modification in cancer prevention. Biofactors. 12, 1-4, 45-51. Bachar G, Goldstein dp, Barker e et al (2012) Squamous cell carcinoma of the buccal mucosa: outcomes of treatment in the modern era. Laryngoscope. 122, 7, 1552-1557. Baile WF, Gilbertini m, Scott L, endicott j (1992) depression and tumor stage in cancer of head and neck. Psycho-Oncology. 1, 1, 15-24. Bernier j, Cooper j (2004) Chemoradiation after surgery for high-risk head and neck cancer patients: how strong is the evidence? The Oncologist. 10, 3, 215-224. Boeing H, dietrich T, Hoffmann K et al (2006) intake of fruits and vegetables and risk of cancer of the upper aero-digestive tract: the prospective epiC-study. Cancer Causes & Control. 17, 7, 957-969. Brooks pj, Theruvathu jA (2005) dNA adducts from acetaldehyde: implications for alcohol-related carcinogenesis. Alcohol. 35, 3, 187-193.
British Association of Otorhinolaryngology Head and Neck Surgery (2011) Head and Neck Cancer: Multidisciplinary Management Guidelines. www. bahno.org.uk/docs/head_and_ neck_cancer.pdf (Last accessed: October 11 2013.) Cancer Research UK (2013) Mouth Cancer Radiotherapy Side Effects. tiny.cc/CRUK_ radiotherapy (Last accessed: October 8 2013.) Collins Fm (2010) Tobacco Cessation and the Impact of Tobacco Use on Oral Health. chfs.ky.gov/NR/rdonlyres/ 31d160F5-8270-4BB1-BB5FA4199108A499/0/ TobaccoCessation.pdf (Last accessed: October 11 2013.) duffy SA, Ronis dL, Valenstein m et al (2006) A tailored smoking, alcohol, and depression intervention for head and neck cancer patients. Cancer Epidemiology Biomarkers & Prevention. 15, 11, 2203-2208. Farberow NL, Ganzler S, Cutter F, Reynolds d (1971) An eight-year survey of hospital suicides.
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Life-Threatening Behavior. 1, 3, 184-202. Feng Fy, Kim Hm, Lyden TH et al (2010) intensity-modulated chemoradiotherapy aiming to reduce dysphagia in patients with oropharyngeal cancer: clinical and functional results. Journal of Clinical Oncology. 28, 16, 2732-2738. Forastiere AA, Trotti A (1999) Radiotherapy and concurrent chemotherapy: a strategy that improves locoregional control and survival in oropharyngeal cancer. Journal of the National Cancer Institute. 91, 24, 2065-2066. Franceschi S, Talamini R, Barra S et al (1990) Smoking and drinking in relation to cancers of the oral cavity, pharynx, larynx, and esophagus in northern italy. Cancer Research. 50, 20, 6502-6507. Furness S, Glenny Am, Worthington HV et al (2011) interventions for the treatment of oral cavity and oropharyngeal cancer: chemotherapy. Cochrane Database of Systematic Reviews. issue 4, Cd006386.
Garavello W, Giordano L, Bosetti C et al (2008) diet diversity and the risk of oral and pharyngeal cancer. European Journal of Nutrition. 47, 5, 280-284. Gillison mL (2004) Human papillomavirus-associated head and neck cancer is a distinct epidemiologic, clinical, and molecular entity. Seminars in Oncology. 31, 6, 744-754. Harish K (2005) Neck dissections: radical to conservative. World Journal of Surgical Oncology. 3, 1, 21. Harris dG, Noble Si (2009) management of terminal hemorrhage in patients with advanced cancer: a systematic literature review. Journal of Pain and Symptom Management. 38, 6, 913-927. Hindle i (1997) The epidemiology of oral cancer in england and Wales, 1901-1991. Unpublished phd thesis, University of London, London. international Agency for Research on Cancer (2007) IARC Monographs on the Evaluation of Carcinogenic Risks to Humans.
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the patient and carers. It is likely that such an approach will require skilled interventions by specialist clinicians in both head and neck cancer, and palliative care. It is vital that the patient’s views and dignity are respected throughout the decision-making process.
Catastrophic haemorrhage
Rarely, major arteries and veins can be eroded by cancer. It may be difficult to prevent this happening and it can result in a sudden and catastrophic bleed, which can be fatal (Harris and Noble 2009). This scenario can be discussed and planned for in the hospital, the patient’s home or in a hospice. Patient sedation in an emergency can be assisted by good advance care planning. In their literature review, Harris and Noble (2009) pointed out that management of catastrophic, terminal
haemorrhage is based on clinicians’ experience of managing this distressing event and that further research is necessary.
Conclusion Patients with oral cancer require effective management and support from the multidisciplinary team. Treatment may result in significant alterations to appearance, physical function and lifestyle. Care plans should be discussed by the specialist team and may involve specialist nursing, dietetics, speech therapy, psychological support, financial advice and access to specialist palliative care, with the aim of improving patient outcomes and quality of life NS Complete time out activity 6
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National institute for Health and Care excellence (2008) Cetuximab for the Treatment of Locally Advanced Squamous Cell Cancer of the Head and Neck. www.nice.org. uk/nicemedia/live/12006/ 40997/40997.pdf (Last accessed: October 11 2013.)
petridou e, Zavras Ai, Lefatzis d et al (2002) The role of diet and specific micronutrients in the etiology of oral carcinoma. Cancer. 94, 11, 2981-2988.
Kilbourn Km, Anderson d, Costenaro A, Lusczakoski K, Borrayo e, Raben d (2013) Feasibility of eASe: a psychosocial program to improve symptom management in head and neck cancer patients. Supportive Care in Cancer. 21, 1, 191-200. Lebel S, Castonguay m, mackness G, irish j, Bezjak A, devins Gm (2013) The psychosocial impact of stigma in people with head and neck or lung cancer. Psycho-oncology. 22, 1, 140-152. Lin Wj, jiang RS, Wu SH, Chen Fj, Liu SA (2011) Smoking, alcohol, and betel quid and oral cancer: a prospective cohort study. Journal of Oncology. doi: 10.1155/2011/525976.
between fruit and vegetable consumption and oral cancer: a meta-analysis of observational studies. American Journal of Clinical Nutrition. 83, 5, 1126-1134.
Neville BW, day TA (2002) Oral cancer and precancerous lesions. Cancer Journal for Clinicians. 52, 4, 195-215.
Rana m, Warraich R, Kokemüller H et al (2011) Reconstruction of mandibular defects – clinical retrospective research over a 10-year period. Head & Neck Oncology. 3, 23. doi: 10.1186/ 1758-3284-3-23.
pavia m, pileggi C, Nobile CG, Angelillo iF (2006) Association
Schantz Sp, yu Gp (2002) Head and neck cancer incidence trends
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6 Now that you have completed the article, you might like to write a practice profile. Guidelines to help you are on page 62.
in young Americans, 1973-1997, with a special analysis for tongue cancer. Archives of Otolaryngology Head & Neck Surgery. 128, 3, 268-274. Scully C, porter S (2000) Oral cancer. British Medical Journal. 321, 7253, 97-100. Tadman m, Roberts d (eds) (2007) Oxford Handbook of Cancer Nursing. Oxford University press, Oxford. Vermorken jB, mesia R, Rivera F et al (2008) platinum-based chemotherapy plus cetuximab in head and neck cancer. New England Journal of Medicine. 359, 11, 1116-1127. Warnakulasuriya S (2009) Global epidemiology of oral and oropharyngeal cancer. Oral Oncology. 45, 4-5, 309-316. Wygoda A, Rutkowski T, Hutnik m, Składowski K, Golen’ m, pilecki B (2013) Acute mucosal reactions in patients with head and neck cancer. Three patterns of mucositis observed during radiotherapy. Strahlentherapie und Onkologie. 189, 7, 547-551.
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4 Page 60
Oral cancer multiple choice questionnaire
CONTINUING PROFESSIONAL DEVELOPMENT
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Read Lisa Scott’s practice profile on depression
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Guidelines on how to write a practice profile
Oral cancer: risk factors, treatment and nursing care NS716 Foulkes M (2013) Oral cancer: risk factors, treatment and nursing care. Nursing Standard. 28, 8, 49-57. Date of submission: February 6 2013; date of acceptance: June 13 2013.
Abstract Oral cancer occurs in a range of anatomical sites within the oral cavity and pharynx. Although oral cancer is relatively rare in the UK, it can have a significant effect on individuals, with treatment being associated with eating, drinking, speaking and breathing difficulties. Treatment may also result in alterations to body image and functionality, which can lead to depression. Therefore, nurses need to have knowledge of associated risk factors, treatment and nursing care to improve patient outcomes and enhance quality of life.
Author Mark Foulkes Nurse consultant in cancer care and lead cancer nurse, Royal Berkshire NHS Foundation Trust, Berkshire Cancer Centre, Reading. Correspondence to: [email protected]
Keywords Cancer, chemotherapy, oral cancer, palliative care, radiotherapy, surgery
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
Aims and intended learning outcomes This article aims to enhance the reader’s awareness and understanding of oral cancer. After reading this article and completing the time out activities you should be able to: 4Identify the main types of oral cancer and the anatomical sites where they occur. 4Discuss the epidemiology of oral cancer and factors leading to its development. 4Explain the treatment of oral cancer in light of existing evidence. 4Recognise the nursing care and support required by patients with oral cancer.
Introduction Incidence of oral cancer varies worldwide. The disease is relatively rare in the UK, but the incidence is increasing in some populations. Treatment presents the nurse with a number of challenges in relation to supporting the patient both physically and psychologically. Surgery, radiotherapy and chemotherapy can all be used during treatment, and these modalities can result in short or long-term functional changes for the patient in terms of eating, drinking and communicating. Complete time out activity 1
Oral cancer Oral cancer is a sub-group of tumours of the head and neck, arising in the oral cavity (lips, teeth, gums, tongue, buccal mucosa, and soft and hard palate) and the pharynx (oropharynx, nasopharynx and laryngopharynx) (Figure 1). Typically, oral cancer and pharyngeal cancer are grouped
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CPD oncology together in oncology statistics because of uniformity in histology and risk factors. When combined, oral and pharyngeal cancer is the sixth most common type of cancer worldwide and accounts for about 400,000 cases, with two thirds of these occurring in the developing world (Warnakulasuriya 2009). With rising trends in some populations (Warnakulasuriya 2009), this is a serious and growing health problem. Oral cancer is more common in men than women and risk increases with age (Warnakulasuriya 2009). However, there is growing concern, particularly in developed countries, about the increasing incidence of oral cancer in people aged under 40 (Schantz and Yu 2002). Mackenzie et al (2000) suggested that the rise in the number of young people with oral cancer may be the result of increased exposure to risk factors such as smoking, alcohol consumption, and lack of fruit and vegetables in the diet. There is significant variation in the incidence of oral cancer worldwide. Areas of south and southeast Asia (Sri Lanka, India, Pakistan and Taiwan), western Europe (northern France), eastern Europe (Hungary, Slovenia and Slovakia), South America and the Caribbean (Brazil, Uruguay and Puerto Rico), and some Pacific regions (Papua New Guinea and Melanesia) have a higher incidence of oral cancer than neighbouring countries. The reasons for this are not yet fully understood, but are likely to be linked to combinations of the major risk factors, including tobacco use, alcohol consumption and exposure
to the human papillomavirus (HPV) (Warnakulasuriya 2009). The most common histological type of oral cancer is squamous cell carcinoma, which accounts for 90-95% of oral cancer (Warnakulasuriya 2009). The remaining 5-10% of oral cancer is made up of those arising from the salivary glands such as muco-epidermal cancers and adenoid cystic adenomas, sarcomas arising from bone, cartilage, muscle or fat, and lymphomas and melanomas (British Association of Otorhinolaryngology Head and Neck Surgery 2011). Like all squamous cell cancers, oral cancer typically arises from the cells that line body tissues and surfaces, in this case the oral cavity and pharynx. Tumours begin when cells proliferate abnormally as a result of a malfunction in normal cell division. Malfunction in cell division may be caused by genetic dysfunction initiated by substances absorbed by the cells. These substances are called carcinogens. Carcinogens can affect particular sections of the cells’ deoxyribounucleic acid (DNA). These susceptible sections are called proto-oncogenes and can be transformed into oncogenes by the action of carcinogens. Oncogenes are sections of DNA that can malfunction during cell division, causing cells to proliferate abnormally and become cancerous.
Risk factors Collins (2010) noted that more than 70% of all oral cancer is caused by tobacco use.
FIGURE 1 Anatomical location of the pharynx
Tongue epiglottis Nasopharynx
Trachea
Oropharynx
Laryngopharynx Oesophagus
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jOANNA CAmeRON
Cricoid cartilage
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Consumption of alcohol (Pelucchi et al 2011) and diet (Garavello et al 2008) have also been implicated. Therefore, it is important to examine factors that lead to the development of head and neck cancer generally and oral cancer in particular.
Tobacco use
In the UK, smoking accounts for 85% of deaths from oral cancer (Johnson 2001). In other countries, tobacco use is often implicated in increased incidence of oral cancer, but this may be because of the local preference for using non-smoked tobacco (tobacco used orally, such as chewing tobacco) as well as smoking. Many countries have a tradition of using tobacco by placing it in contact with mucous membranes. Examples include the use of oral snuff (powdered tobacco) in the United States and Scandinavia, and the use of toombak (tobacco compressed into blocks and chewed) in Sudan. Betel quid (paan), a blend of betel leaves, areca nut and, frequently, tobacco, is chewed by people throughout much of south and southeast Asia (Lin et al 2011). Evidence suggests that all forms of tobacco use increase the risk of oral cancer (Lin et al 2011). More than 300 carcinogens have been identified in tobacco smoke, and many of them are also present in non-smoked tobacco, particularly some nitrosamines that are specific to tobacco. These substances have been found in high quantities in the saliva of tobacco users (International Agency for Research on Cancer (IARC) 2007). It seems likely that tobacco-specific nitrosamines are absorbed into the cells of the oral cavity from affected saliva where they disrupt DNA replication, causing cancer. In addition, tobacco users tend to maintain high levels of nicotine, and hence high levels of carcinogens in saliva, because tobacco is an addictive substance (IARC 2007).
Alcohol consumption
Meta-analyses and reviews have shown that combined tobacco and alcohol use increase the risk of oral cancer (Franceschi et al 1990, Johnson 2001), although the relationship between the two is not fully understood. This may be because metabolism of ethanol produces the by-product acetaldehyde, which is a known carcinogen (Brooks and Theruvathu 2005). Other carcinogens may also be present in alcoholic beverages. In a UK study, Hindle (1997) demonstrated a link between trends in alcohol consumption and mortality associated with oral cancer
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throughout the 20th century. The author found significant circumstantial evidence that alcohol, rather than tobacco use, is the main factor in oral cancer mortality and incidence. There is no evidence that any particular type of alcoholic beverage is associated with an increased risk of cancer, but the number of alcoholic drinks consumed in one week is a significant risk factor. These risks are further increased if individuals smoke, while the number of cigarettes smoked in a week is also a factor (Johnson 2001).
Poor nutrition
A link has been made between diet and oral cancer (Petridou et al 2002, Boeing et al 2006). Findings suggest that a diet high in fruit and vegetables reduces the risk of oral cancer, and that a diet high in starchy root vegetables, cereals and olive oil may also have a protective effect (Petridou et al 2002). Abdulla and Gruber (2000) suggested that fruit and vegetables contain vitamins, trace elements and antioxidant molecules, which have a role in cancer prevention. This finding is supported by Pavia et al (2006), who concluded that a diet high in fruit and vegetables is associated with a reduced risk of developing oral cancer.
Other risk factors
There is a well-established link between prolonged exposure to sunlight and the development of cancer of the lip. In Greece, cancer of the lip accounts for more than 60% of oral cancer, while a person raised in New Zealand has five times the risk of developing lip cancer than a person raised in the UK (Johnson 2001) because of prolonged exposure to sunlight. The role of infections in the development of oral cancer is not yet understood. However, HPV and oral fungal infection appear to have a role in the development of some tumours, as well as in amplifying the carcinogenic effect of smoking in some individuals (Gillison 2004). Complete time out activities 2 out 3
Types of oral cancer Lip cancer
Two of the most common non-melanoma skin cancers affecting the lip are basal cell carcinoma and squamous cell carcinoma (Figure 2). Lip cancer is more common in fairskinned males and is often related to high levels of exposure to sunlight (Warnakulasuriya
1 Can you recall caring for a patient with oral cancer? If so, what were the patient’s nursing needs and were you able to meet them? If you have not cared for a patient with oral cancer, speak to a colleague who has been involved in providing this care and find out what particular needs these patients may have. 2 Consider the risk factors associated with developing oral cancer. Do you think health promotion in the UK is effective in reducing these risks? If not, what strategies could be implemented to make people more aware of their risk of developing oral cancer? 3 Consider whether oral cancer is easier to treat than other forms of cancer. List the main factors in determining whether treatment is successful.
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CPD oncology
Floor of mouth cancer
The floor of the mouth is the area under the tongue that runs in a crescent inside the lower jaw. This is a common site for the development of oral cancer, particularly in smokers and users of non-smoked tobacco. Cancer of the floor of the mouth often requires major surgery to ensure total excision, and tumours are likely to metastasise to the neck nodes (Neville and Day 2002).
Cancer of the buccal mucosa
The buccal mucosa is the lining of the cheeks running towards the margins of the lips and back towards the molars (Figure 3). Cancer of the buccal mucosa is rare in the UK, Europe and North America (Warnakulasuriya 2009). In Asia and South America, this type of cancer is more common, particularly in individuals who use betel or non-smoked tobacco (Warnakulasuriya 2009). Cancer of the buccal mucosa can be aggressive and grow rapidly. Early-stage cancer is characterised as being smaller and not having invaded deeply or metastasised to local lymph nodes, and is treated with surgery alone, while more advanced tumours – those characterised as having invaded deeply and metastasised to local lymph nodes – may require surgery, followed by radiotherapy and, sometimes, chemotherapy (Bachar et al 2012).
laryngopharynx (hypopharynx) and nasopharynx. The most common site for this cancer is the tonsil (Figure 5). In the UK, death from pharyngeal cancers is five times more common in the Indian migrant population than in the native British population (Warnakulasuriya 2009). Pharyngeal cancer is associated with poorer prognosis compared with other types of oral cancer because it typically presents when the cancer is more advanced, and is more difficult to treat surgically because of the anatomical location and proximity to major structures. There is debate about the best way to treat pharyngeal cancer, for example with primary surgery, or with primary radiotherapy and chemotherapy, reserving surgery for cases where primary treatment is not effective (Forastiere and Trotti 1999). Complete time out activity 4
Treatment Treatment of patients with oral cancer can vary considerably depending on the stage of disease, but the main treatment modalities are surgery,
FIGURE 2 Squamous cell carcinoma affecting the lip
SCieNCe pHOTO LiBRARy
2009). This type of cancer is easily detected and is generally treated successfully with surgery and/or radiotherapy. Cancer of the lip has the best prognosis of all oral cancer (British Association of Otorhinolaryngology Head and Neck Surgery 2011).
Tongue cancer
FIGURE 3 Cancer of the buccal mucosa
SCieNCe pHOTO LiBRARy
4 Patients with oral cancer may require a number of treatment modalities, for example surgery, chemotherapy and radiotherapy, over an extensive period. What are the main challenges associated with supporting a patient with oral cancer through a prolonged period of treatment?
Cancer of the tongue is the most common type of oral cancer (Warnakulasuriya 2009). It is typically caused by squamous cell cancer and can affect the oral tongue – the portion of the tongue that is mobile and can be seen in the mouth – and the tongue base, which forms part of the oropharynx, which cannot be seen and is immobile (Figure 4). Treatment depends on staging, with larger tumours requiring major surgery, often with input from reconstructive plastic surgeons, followed by radiotherapy and chemotherapy. If lymph nodes are also involved, more extensive surgery may be required to remove these (Harish 2005).
Pharyngeal cancer
Pharyngeal cancer can occur in all three regions of the pharynx: the oropharynx,
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radiotherapy and chemotherapy, sometimes used in combination. Chemotherapy can be used adjuvantly (post surgery), neo-adjuvantly (before surgery to make surgery easier) or palliatively (to reduce symptoms). The treatment of oral cancer, in common with other tumours of the head and neck, requires a multidisciplinary approach. This is because treatment may be associated with difficulties in eating, drinking, speaking and breathing. In addition, treatment may result in alterations to body image and functionality, which can lead to depression, particularly in patients with other psychological problems such as alcohol or nicotine dependence (Lydiatt et al 2009). Treatment options need to be discussed carefully by a range of specialist clinicians and presented to the patient in a clear and unambiguous manner. Following discussion, any treatment plan should be agreed with the patient and consent obtained.
curative option in advanced disease. The primary aim is to excise the tumour, with a good margin (removal of a portion of normal tissue around the tumour to reduce the risk of localised spread) to prevent recurrence and also remove any lymph nodes that are, or are likely to be, affected by the cancer. Any reduction in function needs to be minimised, and there are a number of techniques that can assist with this.
Mohs surgery
Cancer of the lip can be excised by using Mohs surgery. The technique allows the tumour to be removed piece by piece, while checking the margins of each excision during surgery. This allows damage to the lip to be kept to a minimum and promotes preservation of function.
Use of skin grafts and flaps
Surgery
The main treatment modality for most oral cancer is surgery, which is often the only
FIGURE 4
CORBiS
Squamous cell cancer on underside of tongue
FIGURE 5
Dissection of neck nodes
SCieNCe pHOTO LiBRARy
Squamous cell cancer of the tonsil
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Where a large tumour is removed with a margin to prevent recurrence, there may be considerable deficit or space left behind. This can be filled by using tissue from another part of the body. Skin grafts and flaps are used where a tongue or floor of the mouth tumour has been excised. Removal of all or part of the tongue (total or partial glossectomy) can be repaired by taking a section of skin and associated blood vessels and transplanting it into the deficit using microsurgery to connect the vessels. This ‘free flap’ is often taken from the forearm (Scully and Porter 2000). Where a tumour destroys some bone, as in a large tumour of the floor of the mouth involving the mandible, bone can be removed and replaced with bone grafted from elsewhere. This bone can be harvested from a range of locations, but commonly the iliac crest above the hip is used. These procedures are well established and achieve good cosmetic and functional effect in more than 90% of patients (Rana et al 2011). Lymphatic drainage of the oral region occurs via the lymph nodes in the neck. Therefore, if cancer is suspected or confirmed in the lymphatic system, removal of the lymph nodes in the neck is necessary. A ‘neck dissection’ is carried out by making an incision down the side of the neck; this can be carried out on one or both sides. The operation is not without risk or side effects. For example, if the accessory nerve is removed or damaged during the procedure, then the patient may have a stiff shoulder, and difficulty lifting the arm and carrying heavy objects. october 23 :: vol 28 no 8 :: 2013 53
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CPD oncology Radiotherapy
Patients with oral cancer commonly receive radiotherapy, which destroys cancer cells by disrupting the way in which cellular DNA replicates. However, healthy tissues may become inflamed and red, and may break down. Radiotherapy is usually used in the treatment of oral cancers in the following ways (British Association of Otorhinolaryngology Head and Neck Surgery 2011): 4Primary treatment in small tumours instead of surgery – radiotherapy can sometimes be delivered via radioactive implants into the tumour (brachytherapy) instead of the more commonly used external beam radiotherapy. 4Treatment after surgery – this allows for control of diseased tissue that might have been left behind or in areas where surgery would be difficult to perform. 4Palliative treatment in incurable cancer – radiotherapy can be used to control bleeding, reduce pain and offer temporary control of tumour growth.
Chemotherapy
The use of chemotherapy has been shown to be effective when combined with surgery and radiotherapy. Furness et al (2011) found that chemotherapy and radiotherapy following surgery improves survival rates by 16%. When surgery was not possible, chemotherapy and radiotherapy showed a 22% improvement in survival rates compared with radiotherapy alone. The most commonly used drugs are cisplatin, carboplatin, 5-fluorouracil and bleomycin, generally used in combinations of two. Cetuximab, a newer agent and an antibody that inhibits cell growth by blocking the action of epidermal growth factor receptor, was shown to extend overall survival in patients with head and neck cancer when compared with chemotherapy alone (Vermorken et al 2008). The National Institute for Health and Care Excellence (NICE) (2008) supports the use of cetuximab in conjunction with radiotherapy in patients who have locally advanced oral cancer.
Nursing care Patients with oral cancer require skilled nursing care regardless of the treatment modality. They should be offered support from a specialist nurse who deals with head and neck cancer, however general nurses will also be involved in their care and should have appropriate knowledge. On diagnosis, 54 october 23 :: vol 28 no 8 :: 2013
patients may be distressed and will require psychological support and good quality information to assist them in making decisions about their care and management. Symptom management and assessment is essential. Patients may experience pain, ranging from visceral pain to neuropathic pain caused by nerve damage. Poorly controlled pain can mean that the patient is unable to eat and drink, which can have a negative effect on recovery. Expert advice on symptom management may be necessary, particularly if the patient requires a lengthy period of treatment (Tadman and Roberts 2007).
Following surgery
Surgery for oral cancer may result in alterations to the patient’s appearance, and ability to speak, eat and drink. It may be difficult, or even impossible, for some people to come to terms with these effects, even if surgery is the only curative option. Nursing staff should provide information about the type of surgery required, associated side effects and the long-term implications. Nurses are well-placed to offer psychological support to patients and carers. Referral to a specialist nurse, dietitian, speech therapist and psychologist or counsellor will also be useful in helping patients adjust to any changes following surgery. In the immediate post-operative period, nursing care will need to be focused on avoidance of bleeding, airway obstruction and wound infection. Where surgical flap repairs have taken place, these will have to be carefully observed for signs of wound breakdown and remedial action taken swiftly, if necessary. Because of the specialist and complex nature of head and neck surgery, patients should only be cared for on specialist wards with appropriately trained staff (NICE 2004). Longer term post-operative nursing needs to focus on rehabilitation, adjustment to altered body image and function, particularly when oral function has been affected profoundly by surgery. Depression in patients following major oral surgery is common, with rates of major depressive illness between 15% and 50% (Lydiatt et al 2009). This may be caused by the effects of surgery, but could also be linked to the high levels of alcohol and tobacco use in this patient group. Duffy et al (2006) suggested that high levels of smoking and drinking are linked to high levels of depression, and organised and supportive programmes to help patients deal with alcohol and nicotine dependence will
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During chemotherapy
reduce its incidence. Nurses should be alert to the signs of depression post-operatively, such as low mood, lack of interest in activity and poor energy levels, and refer patients to psychological or psychiatry services.
Chemotherapy may be associated with a wide range of side effects, including fatigue, infection caused by a reduced white cell count, nausea and vomiting, and hair loss or thinning, depending on the chemotherapy agents used. Because patients with oral cancer may already have compromised dietary and fluid intake, side effects such as nausea, vomiting, diarrhoea or constipation require careful nursing and medical management. Chemoradiation (concurrent chemotherapy and radiotherapy) can amplify the side effects of both radiotherapy and chemotherapy, in particular effects on the mucous membranes and skin (Bernier and Cooper 2004). These patients will require close monitoring and responsive management to ensure that they are able to complete their course of treatment.
During radiotherapy
Radiotherapy is frequently used in the treatment of patients with oral cancer, particularly following surgery. Patients may experience a wide range of side effects, the most debilitating being skin reactions and a breakdown of the mucous membranes in the mouth (mucositis) (Cancer Research UK 2013) (Figure 6). The onset of mucositis typically starts three to 14 days into treatment and does not begin to resolve until ten to 14 days following the end of treatment (Wygoda et al 2013). Painful mucositis can mean that patients are not able to eat and drink. Therefore, patients should be given dietary advice and effective pain relief. They may need to be admitted for nutritional support via a nasogastric tube or gastrostomy. Patients receiving oral radiotherapy should be assessed regularly for pain, severity of mucositis, and dietary and fluid intake. Mucositis will typically resolve three to four weeks following treatment. However, xerostomia (dry mouth) can be a debilitating permanent side effect of radiotherapy targeted at the head and neck. If the salivary glands are irradiated within the treatment area, they will not regain normal function. This can be managed by the provision of a synthetic saliva spray or by carrying a bottle of water around at all times. With the advent of intensity modulated radiotherapy, which accurately targets the area to be treated, the effect on the salivary glands is minimised and dry mouth prevented (Feng et al 2010).
Psychosocial care
FIGURE 6
mediSCAN
Severe mucositis associated with radiotherapy
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Patients with oral cancer tend to be from low income and disadvantaged sections of society and ‘are also generally more exposed to avoidable risk factors such as environmental carcinogens... alcohol, infectious agents and tobacco use’ (Peterson 2009). NICE (2004) suggests that advice on managing finances, claiming disability and other benefits should be given to patients to ensure that they are able to maintain quality of life while receiving treatment for oral cancer. Psychological morbidity is common among adults with oral cancer, with one study showing that cancer of the tongue and pharynx accounted for 20% of all male suicides relating to cancer in one eight-year period (Farberow et al 1971). In more recent studies, increased psychological morbidity associated with oral, and head and neck cancer has also been highlighted (Baile et al 1992, Kilbourn et al 2013). Therefore, psychological support is an essential element of care for all patients with oral cancer. Altered body image and function can have a significant effect on patients’ intimate and sexual relationships (Lebel et al 2013). Nurses can help alleviate these effects by recognising a patient’s distress and speaking to the individual about any issues he or she may have, and referral to appropriate professionals. These might include the clinical nurse specialist in head and neck cancer, or a psychologist or counsellor. Complete time out activity 5
5 Can you think of any ethical issues that may be encountered when caring for a patient with advanced, incurable oral cancer? How might these be addressed?
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CPD oncology Palliative care The head and neck are anatomically complex areas, with major structures in close proximity. Blood vessels, nerves, the airway and brain tissue can be affected by advancing disease. Therefore, oral cancer may be associated with significant challenges for healthcare professionals working in the palliative care setting.
Inability to eat and drink
As the cancer advances it may be difficult and eventually impossible for the patient to eat and drink. Choices regarding nutritional support and the best way to achieve this will need to be made. Healthcare professionals caring for the patient may feel that it is not in the patient’s best interests to maintain artificial hydration and nutrition over extended periods. However, discussions of
this nature should take place with the patient, family members and carers. Early involvement of the palliative care team and advanced care plans may be useful.
Airway obstruction
The patient’s airway may be compromised, and eventually occluded, by advanced cancer. There are difficult ethical decisions that need to be made, in discussion with the patient’s family members and carers, about how this complication of the cancer can best be managed. For example, radiotherapy, chemotherapy or surgical treatment may not be appropriate because of the patient’s overall condition or, in the case of radiotherapy, extensive pre-treatment. A palliative care approach, encompassing symptom management, may have to be discussed with
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British Association of Otorhinolaryngology Head and Neck Surgery (2011) Head and Neck Cancer: Multidisciplinary Management Guidelines. www. bahno.org.uk/docs/head_and_ neck_cancer.pdf (Last accessed: October 11 2013.) Cancer Research UK (2013) Mouth Cancer Radiotherapy Side Effects. tiny.cc/CRUK_ radiotherapy (Last accessed: October 8 2013.) Collins Fm (2010) Tobacco Cessation and the Impact of Tobacco Use on Oral Health. chfs.ky.gov/NR/rdonlyres/ 31d160F5-8270-4BB1-BB5FA4199108A499/0/ TobaccoCessation.pdf (Last accessed: October 11 2013.) duffy SA, Ronis dL, Valenstein m et al (2006) A tailored smoking, alcohol, and depression intervention for head and neck cancer patients. Cancer Epidemiology Biomarkers & Prevention. 15, 11, 2203-2208. Farberow NL, Ganzler S, Cutter F, Reynolds d (1971) An eight-year survey of hospital suicides.
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Life-Threatening Behavior. 1, 3, 184-202. Feng Fy, Kim Hm, Lyden TH et al (2010) intensity-modulated chemoradiotherapy aiming to reduce dysphagia in patients with oropharyngeal cancer: clinical and functional results. Journal of Clinical Oncology. 28, 16, 2732-2738. Forastiere AA, Trotti A (1999) Radiotherapy and concurrent chemotherapy: a strategy that improves locoregional control and survival in oropharyngeal cancer. Journal of the National Cancer Institute. 91, 24, 2065-2066. Franceschi S, Talamini R, Barra S et al (1990) Smoking and drinking in relation to cancers of the oral cavity, pharynx, larynx, and esophagus in northern italy. Cancer Research. 50, 20, 6502-6507. Furness S, Glenny Am, Worthington HV et al (2011) interventions for the treatment of oral cavity and oropharyngeal cancer: chemotherapy. Cochrane Database of Systematic Reviews. issue 4, Cd006386.
Garavello W, Giordano L, Bosetti C et al (2008) diet diversity and the risk of oral and pharyngeal cancer. European Journal of Nutrition. 47, 5, 280-284. Gillison mL (2004) Human papillomavirus-associated head and neck cancer is a distinct epidemiologic, clinical, and molecular entity. Seminars in Oncology. 31, 6, 744-754. Harish K (2005) Neck dissections: radical to conservative. World Journal of Surgical Oncology. 3, 1, 21. Harris dG, Noble Si (2009) management of terminal hemorrhage in patients with advanced cancer: a systematic literature review. Journal of Pain and Symptom Management. 38, 6, 913-927. Hindle i (1997) The epidemiology of oral cancer in england and Wales, 1901-1991. Unpublished phd thesis, University of London, London. international Agency for Research on Cancer (2007) IARC Monographs on the Evaluation of Carcinogenic Risks to Humans.
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the patient and carers. It is likely that such an approach will require skilled interventions by specialist clinicians in both head and neck cancer, and palliative care. It is vital that the patient’s views and dignity are respected throughout the decision-making process.
Catastrophic haemorrhage
Rarely, major arteries and veins can be eroded by cancer. It may be difficult to prevent this happening and it can result in a sudden and catastrophic bleed, which can be fatal (Harris and Noble 2009). This scenario can be discussed and planned for in the hospital, the patient’s home or in a hospice. Patient sedation in an emergency can be assisted by good advance care planning. In their literature review, Harris and Noble (2009) pointed out that management of catastrophic, terminal
haemorrhage is based on clinicians’ experience of managing this distressing event and that further research is necessary.
Conclusion Patients with oral cancer require effective management and support from the multidisciplinary team. Treatment may result in significant alterations to appearance, physical function and lifestyle. Care plans should be discussed by the specialist team and may involve specialist nursing, dietetics, speech therapy, psychological support, financial advice and access to specialist palliative care, with the aim of improving patient outcomes and quality of life NS Complete time out activity 6
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6 Now that you have completed the article, you might like to write a practice profile. Guidelines to help you are on page 62.
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