Supporting a patient during cancer treatment is a challenge. From symptom management to psychosocial considerations, each patient’s needs vary and must be reevaluated frequently. This is especially true for patients with head and neck cancer.

Head and neck cancers often result in serious quality of life issues. Surgical resection of the affected area can cause disfigurement that not only affects function (eating, drinking, speaking, etc) but also leads to self-image concerns and depression. Radiation therapy and chemotherapy may cause a variety of unpleasant adverse effects, including burns, xerostomia, dental caries, and mucositis. Below are some considerations to help guide nursing care for this patient population.

National Comprehensive Cancer Network guidelines recommend early involvement of a dentist, a dietitian, and a speech therapist to help address pre- and posttreatment concerns and preserve quality of life for people with head and neck cancer. The benefits of multidisciplinary collaboration for these complex cases are many but may also result in confusion and information overload for your patient. As the healthcare team provides care, you can help explain the rationale for interventions and assist them with keeping track of recommendations. Additionally, you have a team of experts you can call on when specific issues present themselves during treatment.

A lot goes on in the life of a patient with head and neck cancer, which means everyday activities like oral and skin care may fall a little lower on their priority list. Performing frequent assessments and assisting with hygiene is vital to preserving and improving quality of life, for example:

Help your patients use a handheld mirror to examine their mouth and throat.

Ensure that oral care products don’t contain alcohol or other ingredients that can irritate sensitive tissue.

Educate your patients about self-care, and guide them toward performing independent dressing changes and surgical site care.

Encourage your patients to report any new adverse effects or concerns so they can be addressed promptly.

Several factors contribute to malnutrition associated with head and neck cancers. Pain related to mucositis or radiation burns decreases the likelihood that a patient will maintain adequate oral intake. Functional changes following surgery can lead to dysphagia that impairs a patient’s ability to safely receive nutrition and medication by mouth.

To ensure adequate nutrition, many patients with head and neck cancer receive a percutaneous endogastric (PEG) tube prior to beginning treatment. It’s imperative that the patient, the dietitian, and the nursing staff maintain an open line of communication and work together to meet nutritional needs. The patient will likely struggle with losing the ability to taste food and the satisfaction of choosing what they want to eat, so it’s important to allow them to control when they want to receive tube feedings and to follow up frequently to ensure the feedings are being tolerated.

When administering medication via PEG, pay close attention to administration instructions and drug interactions. Extended-release and sustained-release medications should never be crushed and given via PEG. Each medication should be crushed and administered individually, followed by a flush of room-temperature or lukewarm water. If a patient has several medications scheduled at the same time, assess whether administration times can be changed or allow enough time to administer them slowly to avoid patient discomfort related to a high volume of fluid. Lastly, pay attention to whether medication should be administered on a full or empty stomach and coordinate medication administration with tube feedings accordingly.

Although nurses can’t eliminate the hardship that patients will face during treatment for head and neck cancer, we can support them by providing compassionate and thorough care.

 is a clinical content developer for Carevive Systems, Inc.

Balusik B. Management of dysphagiat in patients with head and neck cancer. 

 2014;18(2):149-150. doi: 10.1188/14. CJON.149-150.

Nam J. Oral impairment linked to reduced QOL in posttherapy head and neck cancer. 

 oncologynurseadvisor.com/headand- neck-cancer/oral-impairment-linked-reduced-qol-posttherapy-hnc/ article/740696/. Published January 31, 2018. Accessed Feb. 16, 2018.

NCCN Clinical Practice Guidelines in Oncology. Head and neck cancers, version 1.2018 National Comprehensive Cancer Center website. nccn.org/professionals/physician_gls/pdf/head-and-neck.pdf. Published February 15, 2018. Accessed February 15, 2018.

Articles

Fast Facts for the Frontline

Performing frequent assessments and assisting with hygiene is vital to preserving and improving quality of life.

Supportive Care for Patients With Head and Neck Cancer

What is the value of maintenance therapy in patients with lung or breast cancers, and how and when should it be used?

Within the research community, debate continues as data demonstrating improved health outcomes are weighed against the costs of treatment.

Oncology nurses have the same concerns, but on a more granular level. More and more, as the use of maintenance therapy (MT) increases, they’re tasked with monitoring how the strategy is working for specific patients.

The trend means nurses must be aware of the side effects that can arise with the long-term use of such medications, and be prepared to step in and help, two oncology nurses said.

Fatigue is a common side effect of MT for patients with lung cancer, whether they’re taking a cytotoxic drug such as gemcitabine or a targeted therapy such as erlotinib, said Susan J. Keen, RN, OCN, a thoracic nurse navigator at Thomas Johns Cancer Hospital in Richmond, Virginia. And bevacizumab MT in patients with lung cancer can spark hypertension, added Deborah L. Selm-Orr, RN, MS, CRNP, AOCN, of Cancer Treatment Centers of America at Eastern Regional Medical Center in Philadelphia.

“Nurses need to know what the potential side effects are, how to manage them, and what types of teaching the patient will need in order to be aware and empowered,” Selm-Orr said.

Monitoring such patients can present challenges for oncology nurses, who must find creative ways to ensure that MT outpatients remember to take their medications and report side effects, Selm-Orr said.

“Most people have a smart phone with a camera, so if they say their feet are hurting, I ask them to take a picture of their feet so I can see what they look like,” she said.

Checking in on patients can also mean helping them deal with their frustrations about cancer treatment, including uncertainty about how long they’ll be on a medication like bevacizumab, for which the timing of MT is not fixed, Selm-Orr said.

In fact, patients often question whether to begin such a therapy at all, questioning whether MT will make a difference in the course of their disease and be worth the side effects that come with it, said Keen, who helps to facilitate a survivors’ group for patients with lung cancer.

“I always tell my patients to try it, so they know what the results will be,” she said. “But if they’re on the therapy and they’re miserable, it’s not worth it.”

Admittedly, MT is a tough adjustment for many patients, Keen said. “They say, ‘I hate that I can’t do the things I used to.’ We discuss that it’s a new normal, and that everybody has those in their lifetime, even just with age.”

But when MT works, Keen said, patients are typically glad they tried it.

“Those who are on the drug and can manage the side effects say ‘I’m glad I’m above the earth and not below,’” she said. “They’re glad they can still have extra time with their families, see grandchildren or children graduate, or go on a trip they’ve always planned. They have these goals, and as long as they can get out of the bed, they’re OK with it.”

Cover Story

More and more, as the use of maintenance therapy increases, oncology nurses are tasked with monitoring how the strategy is working for specific patients.

Nurses Have Key Role in Managing Side Effects of Maintenance Therapy

		Lisa Schulmeister, RN, MN, APRN-BC, OCN®, FAAN

Oncology Nursing Consultant, Adjunct Assistant Professor of Nursing

		Louisiana State Health Sciences Center in New Orleans, Louisiana

Survivorship is the new buzzword in cancer care. In 2012, there were an estimated 13.7 million adult cancer survivors in the United States, and this number is predicted to exceed 18 million in the next decade. The increase in the number of cancer survivors is attributed to earlier detection, an increase in cancer incidence as the population ages, and more effective cancer treatment. Although the number of survivors is impressive, survivorship also brings challenges, as many cancer survivors experience long-term physical and psychosocial effects of the disease and its treatment.

According to the National Coalition of Cancer Survivorship, people are considered cancer survivors from the time of diagnosis through the balance of their lives. Although this definition conflicts with the public perception that survivorship begins when treatment ends, it provides hope and optimism for those diagnosed with cancer, and alerts healthcare providers about the need to initiate a survivorship plan upon an individual’s diagnosis of cancer.

There is now an overwhelming amount of information and research findings on survivorship, and the task of sorting it all out is daunting. Fortunately, in March 2013, the National Comprehensive Cancer Network (NCCN) issued its first version of adult Survivorship Guidelines (the Children’s Oncology Group previously issued survivorship guidelines for children).

The NCCN is well recognized for its evidence-based and consensus guidelines on cancer treatment and side-effect management. The survivorship guidelines were designed to provide a framework for managing the long-term and late effects of cancer and its treatment, and encompass the survivor’s health, physical and mental status, health behaviors, and psychosocial needs.

The NCCN recommends a periodic assessment of all survivors to identify their needs, and to identify reversible or contributing causes for symptoms, such as prior cancer treatment, disease status, comorbid conditions, functional status, and medications. The NCCN Survivorship Guidelines include a baseline assessment of concerns: anxiety and depression; cognitive function; exercise; fatigue; immunizations and infections; pain; sexual function; and sleep disorders. A sample survivorship care survey lists 19 questions addressing these key areas, and for each of these key areas, general background information and evidence-based or consensus recommendations are presented.

The information for some of the key areas will be familiar. For exercise, all patients should be encouraged to be physically active. Other sections, such as immunizations and infections, contain less-well-known, detailed information on vaccines and considerations for cancer and transplant survivors. An example is the use of inactivated vaccines (eg, influenza), purified antigen vaccines (eg, pneumococcus), vaccines with bacterial components (eg, DPT), or recombinant vaccines (eg, hepatitis B). The primary concern with the use of these vaccines that do not contain live organisms is whether or not a protective immune response will be generated. NCCN recommends vaccination using usual doses and administration schedules. They caution, however, that the effectiveness of these vaccines may be suboptimal.

The NCCN Survivorship Guidelines also include a five-question sexual health inventory for men and a four-question sexual symptom checklist for women. These assessment tools are straightforward and easy to complete. Sexual function and health is noted to be integral to an individual’s overall physical and emotional well-being, and the NCCN has included algorithms for responding to sexual health concerns.

Another area of the Survivorship Guidelines that is particularly well done is the section on sleep disorders. In addition to the usual areas of concern, such as insomnia and excessive sleepiness, this section also includes obstructive sleep apnea, restless legs syndrome, and parasomnias (eg, sleepwalking).

The Survivorship Guidelines conclude with a comprehensive list of survivorship resources for healthcare professionals and patients. The list includes the specific survivorship-related programs offered by various organizations and includes website and helpline information.

Back in 2005, the Institute of Medicine and National Research Council delineated essential components of survivorship care. They include prevention of new and recurrent cancers, cancer surveillance, assessment of late physical and psychosocial effects, intervention, and coordination of care. The NCCN Survivorship Guidelines (available at 

) are a much-needed step in effectively implementing survivorship care. 

Nurse's Notes

Although the number of survivors is impressive, survivorship also brings challenges, as many cancer survivors experience long-term physical and psychosocial effects of the disease and its treatment.

What's New From the NCCN? Survivorship Guidelines!

		Assistant Professor, Duquesne University School of Nursing

	Over the past decade, evidence has mounted recognizing sleep disturbances and fatigue as common occurrences in children with cancer during treatment, after treatment, and in long-term survivors.

	An investigation of nighttime sleep disruptions in hospitalized children with cancer found that school-aged children experienced limited sleep cycles due to a variety of environmental conditions, such as sound and light, as well as clinical care interruptions (ie, medication dosing).

 An earlier study of this population noted that parents or staff entered or exited a patient’s room 3-22 times per night (11:00pm - 7:00am), resulting in a disturbance of the child’s sleep 1-14 times during each night shift.

	Medication side effects and schedules have been implicated in sleep disturbances and fatigue in children with acute lymphoblastic leukemia (ALL) during chemotherapy.

 In this study, problematic and disturbed sleep scores were associated with greater fatigue in the majority of children and some of their parents. Another multisite study identified sleep and fatigue as behavioral responses to maintenance dexamethasone treatments, with the authors concluding that their “findings indicate that pediatric patients receiving dexamethasone for ALL have fewer actual sleep minutes, stay in bed longer, but have poorer sleep quality than well children, children, with chronic illnesses, or pediatric patients hospitalized for illnesses other than cancer.

	Research has also documented the psychological and social impact sleep disturbances and fatigue may have on the child and the family, suggesting that sleep disturbance during cancer treatment may impair a child’s quality of life.

 Researchers also have identified a correlation between fatigue and depressive symptoms in children receiving chemotherapy,

 and family functioning may also be altered alongside that of the child who is experiencing sleep disruption.

	There is scant research on specific, appropriate, and effective interventions to improve sleep in children with cancer; however, educating hospital staff, educating clinicians in outpatient clinics, and providing anticipatory guidance to parents on the myriad factors that can place children at risk for sleep problems can be the first step in prevention. Knowing the expected norm for the type and amount of sleep within a certain age group can help both parents and clinicians establish realistic expectations and goals. For example, preschool children average 9-10 hours of sleep during the night, and eventually transition from one nap to no naps. Preschool children typically have 90-minute sleep cycles with high levels of slow-wave sleep, the period during which it is most difficult to awaken.

Commonly Practiced Sleep Hygiene Techniques

			A consistent sleep schedule to maintain and regulate the internal clock

			Use of “zeitgebars” or environmental cues to help entrain the internal clock by lowering the lights in evening and providing early-morning light exposure

			Eliminating screen time several hours before bed to allow natural effects of melatonin, a hormone that rises in response to decreased light and helps to induce sleepiness

			The bedroom should be cool, dark, quiet, and comfortable

			A dim nightlight and a security object can be helpful to decrease anxiety

			Regulating daytime activities with consistent mealtimes, snacks, exercise, and therapies earlier in the day followed by quiet evening activities

			Being aware of and eliminating caffeinated drinks and energy foods

	Parents should be provided knowledge and given specific help regarding chemotherapeutic agents that result in sleep disruption (ie, dexamethasone) or sedation (ie, beta interferon); malignancies involving the central nervous system and subsequent radiation that can predispose a child to be at high risk for sleep-wake schedule disruption (eg, central apnea); particular side effects of treatment that may result in pain, nausea, or sedation and appropriate options that can minimize these secondary conditions (eg, hypnotherapy); and the need for counseling and mental health support should the insomnia be a symptom of anxiety or depression.

	Finally, staff and parents should view themselves as advocates for promoting overall quality of life within the hospital by limiting the number of patient room entrances and exits, lowering the lights early in the evening, and advocating for optimal timing of medication for best clinical results as well as sleep enhancement.

	Many children with cancer experience disturbed sleep, and this can negatively affect the healing process and quality of life—not only for the child but also for caregivers. Although causal pathways vary, understanding the root cause or causes can help direct an individualized intervention to promote sleep and minimize fatigue.

				Linder LA, Christian BJ. Nighttime sleep disruptions, the hospital care environment and symptoms in elementary school-age children with cancer. 

				Hinds PS, Hockenberry M, Rai SN, et al. Nocturnal awakenings, sleep environment interruptions, and fatigue in hospitalized children with cancer. 

				Zupanec S, Jones H, Stremler R. Sleep habits and fatigue of children receiving maintenance chemotherapy for ALL and their parents. 

				Hinds PS, Hockenberry MJ, Gattuso JS, et al. Dexamethasone alters sleep and fatigue in pediatric patients with acute lymphoblastic leukemia. 

				van Litsenburg RL, Huisman J, Hoogerbrugge PM, Egeler RM, Kaspers GJ, Gemke RJ. Impaired sleep affects quality of life in children during maintenance treatment for acute lymphoblastic leukemia: an exploratory study. 

				Hockenberry MJ, Hooke MC, Gregurich M, McCarthy K, Sambuco G, Krull K. Symptom clusters in children and adolescents receiving cisplatin, doxorubicin, or ifosfamide. 

				Gedaly-Duff V, Lee KA, Nail LM, Nicholson HS, Johnson KP. Pain, sleep disturbance, and fatigue in children with leukemia and their parents: a pilot study. 

				McGrath P, Rawson-Huff N. Corticosteroids during continuation therapy for acute lymphoblastic leukemia: the psycho-social impact.

Partner Perspectives

Rebecca Kronk, PhD, CRNP, MSN, writes about evidence recognizing sleep disturbances and fatigue as common occurrences in children with cancer during treatment, after treatment, and in long-term survivors.

Promoting Sleep in Children With Cancer

The decision about whether to get tested for a genetic mutation that may predispose a person to certain cancers is a difficult one for many patients to make. Even more difficult for mutation carriers is deciding whether to undergo a prophylactic surgical procedure.

How would cancer genetics specialists themselves make these tough choices? Have their perspectives changed over the years, with increased knowledge about genetic testing, surveillance, and treatment?

Ellen T. Matloff, MS, CGC, director of the Yale Cancer Genetic Counseling Program at the Yale School of Medicine/ Yale Cancer Center, in New Haven, Connecticut, shed light on these questions at the 2013 annual meeting of the American College of Medical Genetics and Genomics, held March 19-23 in Phoenix, Arizona. She presented findings of a follow-up survey of 216 active members of the National Society of Genetic Counselors’ Special Interest Group in Cancer.

“We originally conducted this study in 1998, when cancer genetic testing and counseling was in its infancy, and we had little or no data to tell us what would be the efficacy of prophylactic surgery, surveillance, or chemoprevention for carriers,” explained Matloff.

The follow-up, Internet-based, anonymous survey was conducted in July 2012; male respondents were asked to answer questions as they would for a close female relative.

Much has changed in the 14 years since the 1998 survey—notably, the fact that now 58.3% of the specialists surveyed said that they would opt for bilateral prophylactic mastectomy if they tested positive for a deleterious 

 mutation at age 35. When that question was asked in 1998, only approximately 25% said that they would choose to have their breasts removed if they were found to be 

Table. Survey of Cancer Genetic Specialists

					Would you undergo testing if you had a 50% risk of carrying a mutation?

					Would you have your breasts removed if you tested positive for a mutation at age 35?

 If you tested positive for a deleterious mutation at age 35, would you:

					Have your uterus removed prophylactically?

					Have your ovaries removed prophylactically?

Updates

Genetic Experts' Views Shift on Testing, Prophylactic Surgery

	Assistant Professor, Michigan State University College of Nursing

In 2012, nearly 13.7 million Americans were living with a history of cancer, and an estimated 1.6 million Americans are facing a diagnosis of cancer in 2013. Clearly, surviving cancer and making it through cancer treatment is a tremendous triumph. Most cancer survivors actively seek out strategies to prevent recurrence and optimize health and well-being.

The benefits of exercise for the general population are well documented. Moreover, exercise is now being recognized as an important strategy in the fight against cancer.

Several studies suggest that higher levels of physical activity are related to lower risk of recurrence and longer survival. In addition, exercise has many of the same benefits for cancer survivors as it does for the general population, including improved fitness, greater muscle strength, a leaner body mass, improved mental well-being, greater self-esteem, decreased risk associated with cardiovascular disease and diabetes, and improvements in hypertension, arthritis, chronic obstructive lung disease, and more.

Likewise, there is evidence that exercise can be beneficial to manage symptoms such as fatigue from cancer and its treatment, as w ell as to improve functional status. This is important since nearly 25% of people wit h chronic illness such as cancer have one or more daily activity limitations, and people want to engage in activities they enjoy.

	When should a person start exercising after cancer diagnosis and treatment?

The response I often give is: “As soon as possible.” It is important to note that mounting evidence has yielded a short and important message for cancer survivors: Avoid inactivity.

Unfortunately, research as well as my observation in clinical practice has shown that after a diagnosis of cancer, people slow down due to many factors, such as reports of distress; feelings of sadness and being upset; feeling sick from cancer and its treatment, and fatigue.

In addition, despite today’s best evidence, many healthcare providers continue to recommend rest or “taking it easy” over exercise for the treatment of fatigue. In contrast, for those persons undergoing active treatment and for those who have completed treatment, the general exercise guidelines for cancer survivors include:

		Returning to normal daily activities as quickly as possible after surgery

		Continuing normal daily activities and exercise as much as possible during and after nonsurgical treatments

	How do patients and survivors get started?

The advice I give is to make a plan, because like anything else: 

. Consequently, the following are some general strategies we can suggest to our patients who want to initiate regular exercise:

 Create an exercise plan that starts at the patient’s level of ability. This means that unless a patient has continued to be active, he or she should start light, with achievable goals, and gradually increase the level of exercise. Exercise is a marathon and not a race. Gradual changes lead to permanent, positive results.

. Ask the patient to identify an enjoyable activity where he or she finds richness in the exercise environment. Encourage the patient to include a friend to increase motivation. Have the patient identify a time that is conflict-free, making it easy to maintain a routine exercise plan.

 The patient should build in planned breaks to rest, recover, re-motivate, and reward, and take breaks during injury or illness.

. Suggest that patients identify the best exercise activity for them. Have the patient schedule exercise during their most energetic part of the day. Have the patient identify time slots and make regular exercise a reality, enlisting support from their family and friends.

 An exercise specialist can assist in tailoring the right exercise plan.

Amy Hoffman, MSN, PhD, RN, from Michigan State University's College of Nursing, offers practical tips to help initiate a regular exercise strategy for cancer patients and survivors. 

May 2013

Supportive Care for Patients With Head and Neck Cancer

Nurses Have Key Role in Managing Side Effects of Maintenance Therapy

What's New From the NCCN? Survivorship Guidelines!

Promoting Sleep in Children With Cancer

Genetic Experts' Views Shift on Testing, Prophylactic Surgery

Making the Move to Exercise