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Medical Care of the Irradiated Patient

last modified on: Mon, 03/04/2024 - 08:58

see also: Head and Neck Cancer Followup and Survivorship Clinic - Specifics

GENERAL CONSIDERATIONS OF RADIOTHERAPY FOR HEAD AND NECK CANCER

  1. Indications
    1. Primary radiotherapy
      1. Definitive course of treatment for early-stage cancer
      2. Definitive course of treatment for surgically less-assessable sites (eg, nasopharynx)
      3. Definitive course of treatment for medically inoperable or surgically unresectable patient
      4. Palliative course of treatment for advanced stage disease
    2. Preoperative (neoadjuvant radiotherapy)
      1. Borderline resectable disease
      2. Primary radiotherapy followed by a planned neck dissection for a small primary with large neck disease (>2 cm).
    3. Postoperative (adjuvant radiotherapy)
      1. Positive or close surgical margin
      2. Multiple involved lymph nodes
      3. Extracapsular extension
      4. Extensive capillary lymphatic space invasion
      5. Extensive perineural spread
      6. Locally advanced disease (T4)
      7. High-grade tumor (eg, parotid)
      8. Elective neck irradiation for high-risk patients
  2. Relative Contraindications
    1. Pregnancy
    2. Previous radiotherapy - re-irradiation may be indicated in selected cases

PRIOR TO RADIOTHERAPY

  1. Dental Evaluation
    1. For dentulous patients
      1. Thorough dental examination
      2. Panoramic and full series radiographs
      3. Dental photographs
      4. Caries control, restorative dentistry
      5. Dental prophylaxis, scaling, fluoride treatment, fluoride carrier preparation
      6. Extraction of unrestorable teeth
      7. Endodontics and periodontics
    2. For edentulous patients
      1. Panoramic radiograph to rule out intrabony pathology.
      2. Denture cleaning, polishing, and inspection to remove all potentially irritating areas of the dentures.
      3. Thorough cleaning of dentures to reduce denture-borne Monilia and the institution of an antifungal home care routine.
  2. Nutritional Support
    1. Dietitian consultation for nutritional counseling; especially for patients who need enteral nutrition.
    2. Prophylactic feeding tube placement for patients with advanced disease, compromised oral intake, and significant weight loss.

DURING RADIOTHERAPY

  1. Monitoring Radiotherapy
    1. Weekly weights and vital signs for evidence of malnutrition or dehydration.
    2. Weekly physical examination for acute radiation effects on the tumor and normal tissues:
      1. Tumoritis
      2. Disease regression or progression
      3. Inspection of the oral mucosa for mucositis and Candidiasis
      4. Monitoring the airway
      5. Cutaneous evaluation for evidence of desquamation or infection
      6. Monitoring all surgical sites for evidence of wound breakdown and fistula formation
    3. Weekly CBC in patients receiving combined chemo-radiotherapy or with pre-existing hematological disorders
  2. Management of Radiation Side Effects
    1. Oral mucositis
      1. Expected to occur near the end of second week of radiotherapy
      2. Often times presents with progressive severity
      3. Begins to resolve a few days after cessation of irradiation
      4. Severity may be magnified by concomitant chemotherapy, smoking, and superimposed infection (eg, Candidiasis, herpes, etc)
      5. Treatment
        1. Abstain from smoking
        2. Maintain good oral hygiene
        3. Encourage daily mouth care with salt and baking soda mouth rinse (1 tablespoon salt and baking soda mixed with 1 quart of water Q4-6 times daily)
        4. Avoid hot, acidic, spiced, coarse, and dry foods
        5. Avoid alcohol and caffeine
        6. Pain control (Tylenol with codeine or morphine elixir, or 2% viscous xylocaine)
        7. Special mouthwash swish and swallow 10 to 15 cc Q4-6H. Should retain in mouth for 3 minutes prior to swallow. There are a variety of formulations. The following is the Magic Mouthwash used in the past at the University of Iowa: 2% carboxymethyl cellulose, 12,000 units per ml nystatin, 1.25 mg per ml diphenhydramine, and 0.2 mg per ml hydrocortisone
          1. Also:
            1. Equal parts of nystatin 50,000 units per cc, diphenhydramine 5 mg per ml
            2. Equal parts of nystatin 50,000 units per cc, diphenhydramine 5 mg per ml, liquid Maalox and 4% lidocaine
            3. Equal parts of nystatin 50,000 units per cc, diphenhydramine 5 mg per ml, hydrocortisone 1.0 mg per ml, 8% carboxymethyl cellulose, and tetracycline 25 mg per ml
        8. Both topical and systemic treatments are available, and they can be used together for oral Candidiasis. Nystatin suspension is the classic topical treatment, but it has no prophylactic activity. Among systemic treatment, fluconazole (50 mg qd x 7 to 14 days) is possibly more effective than traditional treatments, such as nystatin and ketaoconazole.
        9. For more in depth contemporary discussion: Therapeutic Agents for Oral Mucosal Disease Treatment Strategies; Therapeutic Agents for Oral Candidiasis, Thrush, Candida, Oral Thrush
    2. Special care for tracheostoma
      1. No metal tubes during treatment (radiation scattering effect).
      2. Silastic stoma stents, airlon, or plastic tracheotomy cannula should be used.
      3. If possible, no tubes are preferable as their use may reduce some of the skin-sparing effects of high-energy radiotherapy.
    3. Skin care
      1. Radiation dermatitis and desquamation occur during the later phases of radiotherapy.
      2. Severity depends on radiation dose, modality and energy (photons vs. electrons or if bolus is used).
      3. Management
        1. Patients need to be taught about expected skin changes as the treatment progresses and how to care for their skin. There are a number of skin-care products that can be used effectively for symptomatic relief, such as Eucerin, Aquafor, RadiCare, and Biafine. It is important to use these products under physician's direction, and they should not be used immediately before each daily radiation treatment.
        2. Severe desquamation may require a treatment break for a few days.
        3. Apply Silvadene cream or Tegaderm to the area of moist desquamation.
    4. Xerostomia
      1. Patients treated with radiotherapy for head and neck cancer may suffer from dry mouth from the beginning of the treatment.
      2. Xerostomia could become severe and permanent.
      3. Management (Management of Xerostomia (Dry Mouth))
        1. Exclusion of 10 to 20% of the gland from the radiation field can minimize severe symptomatic xerostomia.
        2. Parasympathomimetic drugs such as Salagen may be considered (5mg PO TID or QID during radiotherapy and 3 to 6 months after treatment completed).
        3. Artificial saliva (such as Moi-ster, Salivart, or Xerolube) may be used.
        4. Bioten dry mouth products (such as alcohol-free mouthwash, toothpaste, chewing gum, moisturizing gel) may be used.
    5. Loss of taste
      1. Problem is caused by a temporary degeneration of the taste buds of the tongue.
      2. Loss of taste usually persists for approximately four to six months after the treatment; could be partial or complete.
      3. Management:
        1. Altered food preparation
        2. Improved salivation may facilitate recovery
        3. Zinc sulfate (200 mg BID) may increase taste perception and salivation
    6. Weight loss
      1. Weight loss is common during radiotherapy for head and neck cancer due to the disease process and treatment toxicity.
      2. Poor nutrition during radiotherapy may cause severe fatigue and higher incidence of complications.
      3. Management:
        1. Dietary counseling to help patients to maintain weight and increase protein and calorie intake is essential.
        2. Aggressive pain control should be used.
        3. When dysphagia from mucositis begins, switch medications to liquid if possible.
        4. Consider early placement of a nasogastric tube and institution of supplementation if rapid weight loss occurs or there is evidence of dehydration.
        5. Hospitalization may be needed to maintain hydration and nutritional support.
        6. Consider gastrostomy (PEG-tube) if long-term problems are anticipated.
    7. Airway compromise
      1. Laryngeal edema is common when the high larynx is receiving a high dose
      2. Laryngeal edema is usually temporary, but could become permanent
      3. Management:
        1. Careful treatment planning and monitoring are essential.
        2. Patient should abstaining from smoking.
        3. Low-dose steroids may be selectively prescribed.
        4. Tracheotomy may be necessary for impending airway compromise.

POST-RADIOTHERAPY

  1. Close follow-up to monitor response
  2. Watch for recurrence or second primary
  3. Monitoring long-term radiation after effects or complications; soft tissue fibrosis, lymphedema, permanent xerostomia, trismus, dental caries, ulceration, osteo- or chondroradionecrosis, and hypothyroidism
  4. Management
    1. Dental care
      1. Meticulous oral hygiene, daily fluoride application
      2. Endodontics and periodontics
      3. Restorative dentistry
      4. Nontraumatic prosthodontics
      5. Treatment of moniliasis and xerostomia
      6. Avoid routine extractions
      7. Avoid surgical procedures in bony sites
    2. Xerostomia
      1. Symptomatic relief with water
      2. Consider Salagen (5 mg PO TID or QID during radiotherapy and for the three months after treatment completed)
      3. Use of artificial saliva (Moi-ster, Salivart, Xerolube)
      4. Use of Bioten dry mouth products (alcohol-free mouthwash, toothpaste, chewing gum, moisturizing gel)
    3. Trismus
      1. May be permanent
      2. Exercise (may use stacked tongue depressors or TheraBite) may prevent progression
    4. Skin care
      1. Avoid direct sun exposure to irradiated skin
      2. Use sunscreen (SUV higher than 15)
      3. Use Vaseline for symptomatic dry skin (such as Eucerin, Aquafor, RadiCare)
    5. Hypothyroidism
      1. Monitoring symptomatology for hypothyroidism
      2. Check thyroid profile when hypothyroidism is suspected
      3. Begin replacement as needed

References

Manikantan K, Khode S, Dwivedi RC, Palav R, Nutting CM, Rhys-Evans P, Harrington KJ, Kazi R. Making sense of post-treatment surveillance in head and neck cancer: when and what of follow-up. Cancer Treat Rev. 2009 Dec;35(8):744-53. doi: 10.1016/j.ctrv.2009.08.007. Epub 2009 Sep 9. PMID: 19744793.

Shune SE, Karnell LH, Karnell MP, Van Daele DJ, Funk GF. Association between severity of dysphagia and survival in patients with head and neck cancer. Head Neck. 2012 Jun;34(6):776-84. doi: 10.1002/hed.21819. Epub 2011 Aug 30. PMID: 22127835; PMCID: PMC4304637.

Hanna GJ, Patel N, Tedla SG, Baugnon KL, Aiken A, Agrawal N. Personalizing Surveillance in Head and Neck Cancer. Am Soc Clin Oncol Educ Book. 2023;43:e389718. doi:10.1200/EDBK_389718

Berger BM, Hanna GJ, Posner MR, et al. Detection of Occult Recurrence Using Circulating Tumor Tissue Modified Viral HPV DNA among Patients Treated for HPV-Driven Oropharyngeal Carcinoma. Clin Cancer Res. 2022;28(19):4292-4301. doi:10.1158/1078-0432.CCR-22-0562

Carpenter DJ, Mowery YM, et al. The risk of carotid stenosis in head and neck cancer patients after radiation therapy. Oral Oncol. 2018 May;80:9-15. doi:10.1016/j.oraloncology.2018.02.021

Carpenter DJ, Patel P, et al. Long-term risk of carotid stenosis and cerebrovascular disease after radiation therapy for head and neck cancer. Cancer. 2023 Oct: https://doi.org/10.1002/cncr.35089

Randolph, W, & Dains, JE. Ultrasound Evaluation of carotid Artery Intima-media Thickness: Effective early marker of Carotid Artery Disease in Adult Head and Neck Cancer patients After neck Radiation? J Adv Pract Oncol. 2022 Sept; 13(7): 683-694. doi: 10.6004/jadpro.2022.13.7.4

U.S. Preventive Services Task Force. Final Recommendation Statement. Asymptomatic Carotid Artery Stenosis: Screening. February 2021.