support of the head and neck patient during radiotherapy/combined chemo-radiation(crt ) anne hope...
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Support of the Head and Neck patient during
Radiotherapy/Combined
Chemo-Radiation(CRT)
Anne HopeHead and Neck CNS
RSCH
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AIMS• Gain an understanding treatment
implications/toxicities of RT/CRT .• The Role of the Holistic Needs Assessment.• Involvement of MDT • Evidence Based symptom control/supporting
patient.
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The Current Practice• Increase in use of combined Chemo-radiation –
HPV RELATED ?• Overall increase in 100% over past year.• Most common sites treated:
Oropharynx/Hypopharynx/Tongue/Larynx.• Cisplatin /Carboplatin/Cetuximab.• 5/10/20/30 # RT (Depending on goal/disease)
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Pre - Treatment Support
• Introduce to the MDT – attend MPC.• Holistic Assessment• Patient Information/Education• BUDDY ?• Referrals to necessary support services.
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Holistic Assessment
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Holistic Assessment
• Cancer Reform Strategy (CRS) (2007), Nice Guidance in supportive and palliative care(2004), Cancer Action Team (2007).
• Buzz word in Cancer Care • Peer Review Measure• Enables MDT approach/Team work• Encouraged at key points of the Patient journey.
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Common Problems- Psycho-social
• Withdrawn• Depression• Anxiety• Inability to work• Sexuality/Body Image• Loss of role in family/relationship• Financial difficulty
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Common Problems- Clinical
• Oral Mucositis• Skin Reaction• Pain• Xerostomia• Dysphagia• Copious/thick secretions• Aspiration• Fatigue• ORN
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Oral Mucositis
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Presentation• OM defined as ‘ Inflammation of the mucosal
membrane, often characterised by ulceration resulting in the impairment of the ability to talk, pain and dyshagia.’ (Rubenstein et al, 2004)
• 40 % of patients undergoing chemotherapy for solid tumours.
• 97% receiving RT to H&N will suffer with OM.
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Presentation …contd• Pain/Discomfort• Ulceration• Erythema• Dysphagia • Bleeding• Necrotic/sloughy ulceration
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Prevention
• Little evidence/ no avoidance.• Dental Assessment pre treatment.• Necessary dental extractions.• Avoidance alcohol/smoking/spicy foods.• Oral brushing/rinsing after every meal.• Soft tooth brush/Flossing.• High Fluoride Toothpaste.
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Management• Manage symptom e.g pain WHO ladder.• Use of recognised oral assessment Guide e.g
WHO Oral Toxicity Scale.• Consistent Assessment…..Daily ?• Saline mouth rinses QDS/Sodium bicarbonate.• Asprin Gargles 300mg QDS.• Topical Agents, e.g Gelclair/Mugard• Difflam/Corsodyl.• Preventative Rinses- Caphosol?• Manage Infections/Candida.
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Skin Care
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Presentation
• 85% Patient receiving external beam RT will experience moderate –severe skin reaction.
• 10 % Moist Desquamation.• Usually seen 10-14 days following first fraction.• Is not a burn ! – Reaction differs /damage to skin
with RT migrates upwards and effects epidermal layer only.
• Usually increases up to 7-10 following last treatment.
• 4-6 weeks following completion of treatment skin healing well.
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Radiotherapy Cycle
Radiotherapy starts – Activates inflammatory response
10-14/Days damaged basal cells migrate to skin surface. Erythema develops.
Further skin damage.New Cells reproduce before old dead cells shed- Dry desquamation .
No New cells to replace dead cells- Moist desquamation
Treatment completed- Takes 10-21 days for basal cells to recover &new skin to grow.
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Assessment / Observation Effects of Radiotherapy on Skin CellsRTOG 0No visible change to skinRTOG 1Faint or dull erythema. Mildtightness of skin and itchingmay occurRTOG 2Bright erythema / drydesquamation. Sore, itchy andtight skinRTOG 2.5Patchy moist desquamationYellow/pale green exudate.Soreness with oedemaRTOG 3Confluent moist desquamation.Yellow/pale green exudate.Soreness with oedemaRTOG 4Ulceration, bleeding, necrosis(rarely seen)
RTOG Grading Scale
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Cetuximab Reaction
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Management• Priority – To avoid treatment breaks – delays• Maintain comfort/function• Maintain skin integrity.• Reduce pain.• Promote hydrated skin.• To avoid /reduce Infection.• Reduce risk of complications/further trauma.
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Management…..contd• Avoid tight fitting clothing.• General moisturisers stop-if skin broken.• Hydrocolloid gel –skin breakdown.e.g Intrasite Gel.• Non adhesive dressings- moist desquamation.• Soft silicone dressings e.g Polymem, Meplilex lite.
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Recommendations • Wash Daily with a simple soap and water.• Avoid rubbing/irritating affected area.• Moisturise skin twice daily- Product choice little
evidence.• However do avoid SLS, Lanolin, products with
high levels of paraffin/petroleum.• Aquamax- RSCH preference.• Avoid wet shaving/waxing/hair removal creams.• Pliazon cream for cetuximab reaction.• Aveeno cream.
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Secretions• Most Difficult symptom to manage.• Distressing for patient and carers.• Causes Halitosis.• Unsociable !• Thick tenacious phlegm.• Source of infection/aspiration. • Maintains healthy PH oral cavity.• Main cause or nausea/retching.
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Mangement• Good oral hygiene.• Regular rinsing…..saline mouth washes.• ?? Sodium Bicarbonate Rinses.• Steam Inhalation.• Nebulisers.
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ConclusionPromote patient comfort
Avoid Infection
Complete proposed
treatment.Reduce/
control pain
Maintain nutrition
intake
Psychological support
Avoid aspiration/maintai
n safe swallow
Avoid further trauma to skin/oral mucosa
Control Symptoms
Avoid admission
Holistic Assessment
MDT Working
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