51 Palliative Care/Considerations for Metastatic Oral Cavity Cancers
Head and neck cancer patients face unique challenges in symptom management and maximization of quality of life throughout their course of treatment. Multidisciplinary engagement in delivery of palliative care, as well as addressing palliative concerns earlier in the course of treatment, can enhance patient’s quality of life, and potentially lead to improvement of other clinical outcomes. Much of what is known about palliative care and best practices for its delivery stems from studies in other cancers, providing numerous opportunities for meaningful research into symptom- and quality of life-related issues and delivery of palliative care in head and neck cancer.
Palliative care is an approach to delivery of health care interventions that focus on improving quality of life and minimizing pain as well as other distressing symptoms, whether they be physical or psychosocial. 1 Palliation may be provided early on in the course of a chronic illness such as oral cancer, in conjunction with treatment with curative intent, and may take on a more prominent role later in a patient’s treatment trajectory. 1 – 3 As such, it is a misconception to view palliation as synonymous with hospice care, which attends to needs exclusively during the end-of-life period. 1 With regards to the care of the oncologic patient, studies have shown unmet palliative needs exist throughout a patient’s cancer treatment trajectory, not just in the end-of-life phase. 3 – 5 In this chapter, we aim to provide an overview of the most common palliative needs of oral cancer patients, as well as demonstrate the need for early integration of palliative care services in the multidisciplinary health care team for these patients. Finally, we consider some ethical quandaries relevant to palliative care for oral cancer patients.
51.2 Surgeons as Frontline Providers of Palliation in Oral Cancer
Head and neck cancer surgeons typically serve as primary coordinators of care for their cancer patients amongst multidisciplinary team members. As such, oral cancer surgeons are charged with the task of identifying and addressing symptomatic concerns for their patients, requiring a basic knowledge of palliative concerns of oral cancer patients. 2 Widespread implementation of communication aids such as standardized surveys enquiring about patients’ feelings about treatment and prognosis, quality of life, and end-of-life concerns may prove useful in identifying palliative needs and may itself help to address patients’ anxiety. 6 A considerable amount of research delves into the unique symptomatology of oral cancer, including the specific challenges of oral cancer pain, as well as quality of life concerns such as the ability to breathe without distress, to chew and/or swallow or otherwise maintain adequate nutrition, to communicate, and to manage sequelae of treatments such as xerostomia and trismus. 7 , 8
51.3 Challenges in Pain Control for Oral Cancer Patients
Pain is one of the top concerns for patients with advanced cancer of the oral cavity and is distinct from other types of oncologic pain in its severity and intrusiveness. Pain has been found to be a primary concern for roughly 80% of terminally ill head and neck cancer patients. 7 , 9 – 11 In a meta-analysis investigating prevalence of pain among cancer patients, head and neck cancer pain was more widely prevalent than gynecologic, gastrointestinal, lung, and breast cancers. 12 These patients’ cancer pain is experienced with a unique keenness due to the anatomy and functional demands of the oral cavity. Specifically, in contrast to the visceral pain derived from solid tumors in the abdomen, for example, the pain experienced by patients with advanced cancer in the oral cavity can be sharply localized due to trigeminal nerve innervation. 9 Additionally, the oral cavity is responsible for numerous specialized functions, including mastication, swallowing, and speech; these mechanical requirements further stimulate function-related pain. 9 , 13 Furthermore, the molecular biology of oral cavity squamous cell carcinoma (SCC) directly contributes to the pain experienced by patients: nociceptive mediators such as endothelin-1 (ET-1), proteases and protease-activated receptors (PAR1 to PAR4), and nerve growth factor (NGF) are secreted by oral SCC cells, leading to sensitization and stimulation of nociceptors in the tumor microenvironment. 9 , 14
51.3.1 Airway Management
A report showed 43% of head and neck cancer patients have respiratory difficulties in the end-of-life period. 15 In one study by Timon and Reilly, one-fifth to one-sixth of patients were deemed to need tracheostomy tube placement for airway concerns. 7 As discussed by Shuman et al, airway concerns are an integral part of head and neck cancers, particularly as a patient’s disease progresses and evolves. 16 Preparation for the possibility and in some cases eventuality of airway obstruction in head and neck cancer patients is of utmost importance; health care providers must ensure adequate patient education and discussion of preferences for urgent/emergent airway interventions should the need arise. 16 Alternatives to emergency airway management include supportive care and medications that help to mitigate air hunger and dyspnea as well as the anxiety associated with breathing symptoms. 16
Functional Impairments in Mastication, Swallowing, and Speech
In addition to the pain elicited during mastication and swallowing mentioned previously, functional limitations in these actions pose significant challenges to maintaining adequate nutrition. 17 Alternative feeding routes often must be sought to prevent or treat malnutrition and cachexia, with 25% patients requiring percutaneous gastrostomy placement in one study of head and neck cancer patients in general. 7 Furthermore, mastication and swallowing dysfunction narrows the range of therapeutic options to treat patients’ pain, necessitating delivery through alternative feeding routes (if any have been established) or devising alternate pain regimens.
Patients benefit from multidisciplinary team coordination of adjunctive therapy with speech therapy and nutrition services. 18 Additionally, communication barriers that often result from treatment should prompt health care providers to initiate early discussions of patient’s wishes regarding his/her care in order to achieve a more thorough and nuanced understanding, particularly regarding end-of-life/resuscitative preferences. 19
51.3.2 Gustatory Alterations
Xerostomia, altered taste sensation, and trismus are common side effects of radiotherapy that can have a significant impact on patients’ quality of life. 8 Oral mucositis, experienced by more than 80% of head and neck cancer patients, often limits their ability to endure full planned courses of radiotherapy as a result of the oral pain, bleeding, dysphagia, and resultant decreased nutritional intake, infections, and hospitalizations. 11 , 20 Interventions to prevent or decrease severity of oral mucositis include proper oral care and hygiene, regular assessment by care providers using one of several validated scales (from the National Cancer Institute [NCI], Radiation Therapy Oncology Group [RTOG], European Organization for Research and Treatment of Cancer [EORTC]), limiting alcohol/tobacco use, and employing radiotherapeutic precautions when possible. 20
Additionally, osteoradionecrosis is a major complication resulting from radiation treatments which may require preemptive full dental extraction. 8 Therefore, because pretreatment evaluation by dental team may help prevent posttreatment complications (such as osteoradionecrosis) and symptom management (such as avoidance of dental infections by removing diseased dentition), involvement of dentist at an early stage is advisable for improved symptom control in the long term. 8 , 21
51.3.3 Psychosocial Distress
Oral cavity cancers and their treatment may cause distressing psychological symptoms because of their unique location and functional impact. Compared to treatments for other types of cancers, e.g., pneumonectomy, prostatectomy, and bowel resection, interventions for head and neck cancer are easily visible to others, altering patients’ appearance and interactions with others in an especially debilitating way, particularly in the context of intimate relationships with loved ones. 22 , 23 Disfigurement of the face resulting from treatments or the malignancy itself may feel socially isolating and can provoke a sense of losing one’s identity at the very moment of grappling with one’s existence. 22 , 23
Evidence suggests that patients with advanced oral cancers experience greater emotional and psychological distress than patients with other malignancies including other head and neck cancers. 17 , 24 , 25 Studies estimate that overall 30-40% of head and neck cancer patients experience significant depression and anxiety, which also amplifies the perception of pain. 24 – 26 In fact, in a study by Misono et al, patients with cancers of the oral cavity and pharynx were found to have the third highest suicide rate when ranked by anatomic location of patients’ cancers, and a rate three to four times higher than that of the general US population. 27 It is difficult to determine whether this elevated risk of depression and suicide is due to the nature of head and neck cancer itself or common comorbidities such as tobacco and alcohol abuse, but the resultant psychosocial distress requires management nonetheless. 16 , 27
Strategies to address these psychosocial symptoms include support network, education, emotional support, and psychotherapy (e.g., cognitive behavioral therapy), as well as providing patients with a sense of control. 17 , 24 , 25 Additionally, a collaborative care approach involving multidisciplinary teams of specialists, primary care providers, and care management in conjunction with psychopharmacology is a systems-based strategy that decreases cancer patients’ depression, which in turn can affect length of hospital stay and treatment compliance in addition to quality of life. 28