Denver, CO—The incidence of human papillomavirus (HPV)-associated oropharyngeal cancer is increasing. Patients treated for these cancers with radiation and chemotherapy are at increased risk for early and late side effects that diminish their quality of life, and nurses play a key role in coaching patients about living with these side effects.
“Symptoms and side effects of treatment affect quality of life, and we have to teach patients how to manage these. Nurse coaching on management of side effects should begin on day 1. Talk to patients, answer their questions, and help them understand what to expect throughout the course of care,” stated Jennifer Cerar, RN, CRRN, Rehabilitation Registered Nurse, Radiation Oncology, Moffitt Cancer Center, Tampa, FL.
HPV infects the skin and mucosa, and HPV 16 and 18 are linked to oropharyngeal cancer. These cancers are typically asymptomatic, and may present as a wart on the base of the tongue. HPV-positive oropharyngeal cancer typically occurs in younger patients, mostly men, and has a much better prognosis compared with HPV-negative oropharyngeal cancer. Oral sex is the major behavioral risk factor for HPV-positive oropharyngeal cancer.
The incidence of HPV-positive oropharyngeal cancer has increased 225% since 1984, Ms Cerar said.
“HPV-associated cancer has a better prognosis than HPV-negative cancer, and patients are living longer,” she noted.
Patients with HPV-positive cancer have several treatment options for early or locally advanced disease. These include surgery; surgery in combination with chemotherapy/biotherapy, radiation, or concurrent chemoradiation; and clinical trials.
Early side effects associated with radiation include fatigue, skin irritation, throat soreness, thick oral mucus, taste disorders, and changes in appetite. Late side effects of radiation include fatigue, xerostomia, chronic throat swelling, poor wound healing, dental disease, dysphagia, taste disorders, trismus, hypothyroidism, fibrosis, lymphedema, altered speech, and pain.
What Can Nurses Do?
Ms Cerar tackled issues related to several late side effects of radiation separately.
Trismus (ie, lockjaw) is the reduced ability to open the mouth and chew. Nurses can teach patients range-of-motion and stretching exercises to do at home, instruct them how to use custom mouth-opening devices, and refer them to physical therapy. Analgesics can be helpful. Trismus requires ongoing assessment, with the highest prevalence 6 months postradiation.
Taste disorders are common late effects of radiation, and can be managed with good oral hygiene, management of xerostomia, treatment of oral infections, increased seasoning in foods, and the use of gum and candy. Patients can be referred to a dietitian regarding nutrition and meal planning. Long-term assessment is needed for up to 7 years postradiation, and taste disorders may be permanent.
Hypothyroidism can appear up to 10 years postradiation, and may also be permanent. Patients should be alert for symptoms such as fatigue, weight gain, cold intolerance, cognitive dysfunction, muscle cramps, and depression. Patients may require lifelong thyroid hormone replacement therapy. Thyroid-stimulating hormone testing should be performed every 6 to 12 months.
Other late effects of radiation include dry mouth and tooth decay. The salivary glands stop functioning during radiation and may take a long time to recover. Some patients may have dry mouth permanently, and patients with little or no saliva are at increased risk for tooth decay. Patients should use non–alcohol-containing over-the-counter mouthwashes, and practice good dental hygiene. Products that mimic saliva are available at the pharmacy, and the pharmacist can recommend the best one to use.
Hearing changes can also occur 6 to 12 months after radiation. The risk for hearing changes is increased in patients who receive chemotherapy in addition to radiation. Hearing loss may be temporary or permanent.
Speech and swallowing difficulties should be addressed by a speech pathologist, Ms Cerar continued. The speech pathologist will develop a treatment plan for these late effects, as well as dietary and exercise recommendations.
Strategies to lessen radiation toxicity and enhance quality of life include reduced radiation and concurrent chemotherapy doses. Biologic therapy should be considered because it is associated with fewer side effects. Preradiation induction chemotherapy can be used to select the best responders who can be treated at lower doses.
Ms Cerar also mentioned TomoTherapy, a new radiation modality that targets the tumor itself and spares normal tissues. Patients should be aware that this treatment can lessen the side effects of radiation, she said.