What Special Considerations Are Needed in Patients With Head and Neck Cancer?

Introduction and Scope of the Problem

The term head and neck cancer (HNC) encompasses a diverse group of cancers that includes cancers of the skin, oral cavity, larynx, skull base, trachea, jaw, thyroid, and sinuses. Based on data from the national Surveillance Epidemiology and End Results (SEER) database from 2013 to 2017, the median age at diagnosis is 63 years, and this group of cancers is more common in males than females, with an incident rate of 17 cases per 100,000 males and 6 cases per 100,000 females. Overall 5-year survival rates from 2010 to 2016 SEER data were 66.2% (up from 60.8% from 2001 to 2007), with better survival for Whites and males as compared to Blacks and females, respectively.

These statistics do not accurately capture the unique challenges faced by patients with HNC. Because of tumor burden or side effects of cancer treatments, patients may have difficulty with basic daily actions such as speaking, self-expression, and eating and drinking. HNC primarily affects the face; thus disfigurement can be disturbing and emotionally destabilizing. Unlike other cancers in which body alterations might be hidden (such as amputation or colostomy), changes to the face are apparent to the public and often interfere with the ability and desire to socialize. The disease trajectory is relapsing and remitting, with periods when patients are symptom free and have no evidence of disease interspersed with times of higher symptom burden when the disease is active. As a result, patients with no evidence of disease may still have anxiety and concern about recurrence. Given their multiple needs, patients with HNC should receive palliative care as a core element of their oncological care, and early integration of such services is aligned with current clinical practice guidelines.

Relevant Pathophysiology and Prognosis

HNC tumors are primarily squamous cell carcinomas and affect males more than females. There is a strong and dose-dependent relationship with both alcohol and tobacco consumption, and these risk factors may be synergistic with human papillomavirus (HPV) in the development of HNC. Smoking- and alcohol-related HPV-negative cases are decreasing in older adults while more HPV-positive cases are being seen in younger adults, particularly White middle-aged males, likely due to variations in substance use and sexual behavioral patterns in the general population.

Palliative care clinicians must understand the role of HPV in HNC, as it has broad implications for clinical care. HPV has higher proclivity for certain tissue types, and up to 60% of oropharyngeal cancers are HPV-positive. HPV positivity is associated with improved response to treatment and a favorable prognosis both at diagnosis and at disease recurrence. Due to these observations, the 8th edition of the Tumor, Node, and Metastasis (TNM) staging system of the Union for International Cancer Control (UICC)/American Joint Committee on Cancer (AJCC) established separate staging for HPV-positive and HPV-negative oropharyngeal carcinomas. Staging remains unchanged for nonoropharyngeal carcinoma regardless of HPV status.

Antineoplastic treatment depends on multiple disease-specific factors. Treatment can include any combination of surgery, chemotherapy, immunotherapy, or radiation, and the plan often changes over time. For example, an initial plan for surgical resection alone may be modified to include adjuvant therapy if pathology reveals adverse prognostic features. Despite advances in treatment, most patients with HNC will have a disease recurrence, and recurrent or metastatic disease portends both a poor response to treatment and poor prognosis. Although palliative care specialists cannot grasp every nuance of oncological treatment, they must understand the complex landscape of antineoplastic treatments available and that patients may be offered enrollment in a clinical trial at any time during the disease. Upstream palliative care support can help patients navigate dynamically changing treatments throughout their disease course and make decisions that are concordant with their values.

Summary of Evidence Regarding Treatment Recommendations

Physical Symptoms and Treatment Strategies

Numerous physical symptoms can occur in patients with HNC related to tumor location or cancer-directed therapies. Adequate symptom control is important to optimize quality of life. For a summary of common symptoms and their treatments, see Table 49.1 .

Table 49.1

Common Symptoms in Patients With Head and Neck Cancer and Suggested Treatments ^a

Adapted from McPhee SJ, Winker MA, Rabow MW, et al (eds): Care at the Close of Life: Evidence and Experience . New York: McGraw-Hill; 2010; 233.

Symptom	Treatments ^a	Notes
Pain	Nonopioids Opioids Gabapentin	Consider nonoral administration routes (e.g., transdermal fentanyl patches, morphine elixir by gastrostomy tube)
Mucositis (see Table 49.2 for treatment recommendations)	Oral hygiene Nonmedicated mouthwashes Opioids Nonopioids	Uses of many agents are controversial, with conflicting data Weigh benefit-to-burden ratio for any treatment and consider a “time-limited trial” with plan for discontinuation if no appreciable improvement Gabapentin and tricyclic antidepressants can be useful
Dysphagia	Speech language therapy referral Artificial hydration and nutrition	May be transient or permanent May be severe and lead to dehydration or malnutrition Intended to be short term when benefits are clear
Xerostomia	Hydration, ice chips Sugarless candy, gum, artificial saliva Cholinergics	Should be left to patient preference within boundaries of what is medically indicated (e.g., avoid water if high aspiration risk) Evidence for use of artificial saliva substitutes is weak Cholinergics have multiple side effects that may limit use, particularly in older adults
Change in speech	Speech language therapy referral Adaptive devices (e.g., amplifier)	Many patients can relearn speech, so this symptom does not always interfere with long-term function Speech may not return to baseline patterns
Depression and/or anxiety	Emotional support Psychotherapy, counseling Antidepressants Anxiolytics	May be transient or prolonged, lasting years after treatment As with any medication, patients on antidepressants should be monitored for side effects and interactions with other medications Duration of anxiolytic use depends on side effects, prognosis, and overall balance of benefit vs. risk

a Treatments are not necessarily listed in order of efficacy and can be used according to patient and provider preference.

Pain

Pain in patients with HNC is often both nociceptive and neuropathic. Nociceptive pain may be managed with opioids, though the administration route depends on whether the patient can reliably take medications orally. For example, a patient may require both a transdermal opioid and liquid morphine via a gastrostomy tube. Neuropathy can result from the invasion of nerves by tumor or as a consequence of surgery and/or radiation and is optimally treated with adjuvant analgesics. Initiation of gabapentin during radiation is associated with less opioid use, shorter duration of gastrostomy tube use, and improved swallowing outcomes. Adjuvant analgesics may help limit treatment interruptions due to pain and potentially reduce long-term opioid use. Posttreatment pain is a significant issue in HNC and is particularly important in patients treated with curative intent at a young age who live with sequelae for decades. Approximately 15% to 40% of HNC survivors have chronic pain, many of whom report persistent pain that impacts quality of life more than 10 years after treatment. Pain management should be optimized to improve cancer treatment adherence and preserve functionality. Palliative care clinicians may not continue to be a part of the care team for patients in remission who develop chronic pain, but if needed can assist with down-titration of medications associated with long-term toxicity, such as opioids. Please see Chapter 10 for management of chronic nonmalignant pain.

Mucositis

Prevalence depends on the site of irradiation, though over 90% of HNC patients who undergo radiation will suffer from mucositis. Risk factors include female gender, younger age, poor oral hygiene, malnutrition, tobacco use, and the particular radiation treatment plan. Radiation directly damages cells and triggers an influx of inflammatory mediators. This damage is further exacerbated by poor salivary function and ulceration. Mucositis generally begins 2 weeks into radiation and plateaus 2 weeks after completion of therapy, with gradual improvement over the following 8 weeks. Because tissue damage extends over a period of months, effective management is essential to ensure mucositis does not interfere with oral intake or interrupt treatment, as every day of missed radiation corresponds to a 1.4% reduction in the likelihood of local disease control. Patients should take in at least three liters of hydration a day to account for insensible losses from mucositis. Those who cannot do so may require a gastrostomy tube or parenteral nutrition to prevent dehydration or malnourishment. Weekly examinations are recommended to ensure mucositis is optimally managed and to evaluate for superinfection.

Unfortunately, most data regarding best treatment modalities are low quality with conflicting recommendations. Consequently, there is no agent specifically approved by the FDA. Clinician recommendations for pharmacological treatments are often based on anecdotal experience and patient preference, and it is important to consider the cost and burdens of use in light of potentially limited benefit. Nondrug treatments are most strongly recommended. A general treatment categorization based on recent literature is provided in Table 49.2 .

Table 49.2

Summary of Mucositis Treatment Recommendations

Recommend	Oral hygiene: one of the most important and consistent recommendations (e.g., brush teeth with soft toothbrush 2–3 times daily, use saline or baking soda mouthwashes) Oral hydration Pretreatment dental evaluation Avoidance of alcohol, smoking, and acidic/spicy foods Morphine 2% mouthwash (swish and spit) Systemic pain control (opioids remain the mainstay) Role for adjuvants due to neuropathic component of pain
Cannot recommend	Magic mouthwash (no clinically significant benefit) Amifostine: not widely used due to optimization of radiation therapy and challenges with drug administration Chlorhexidine (for prevention or treatment) Benzydamine: study stopped early due to a negative analysis Glutamine: does not decrease mucositis Cryotherapy: concern for vasoconstriction decreasing radiation efficacy
Insufficient or conflicting evidence	Calendula, honey, aloe vera, ginseng: recommended by some authors, ^a while others specifically recommend against use Keratinocyte growth factor: although a recent review found evidence supporting use to prevent mucositis, practical use is limited by parenteral administration and cost, and other data are conflicting

a From Moslemi D, Nokhandani AM, Otaghsaraei MT, Moghadamnia Y, Kazemi S, Moghadamnia AA. Management of chemo/radiation-induced oral mucositis in patients with head and neck cancer: a review of the current literature. Radiother Oncol . 2016;120(1):13–20.

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