1. Support of the Head and Neck patient during Radiotherapy/Combined Chemo-Radiation(CRT ) Anne Hope Head and Neck CNS RSCH

2. 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.

3. 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)

4. Pre - Treatment Support Introduce to the MDT – attend MPC. Holistic Assessment Patient Information/Education BUDDY ? Referrals to necessary support services.

5. Holistic Assessment

6. 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.

9. Common Problems- Psycho-social Withdrawn Depression Anxiety Inability to work Sexuality/Body Image Loss of role in family/relationship Financial difficulty

10. Common Problems- Clinical Oral Mucositis Skin Reaction Pain Xerostomia Dysphagia Copious/thick secretions Aspiration Fatigue ORN

11. Oral Mucositis

15. 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.

16. Presentation …contd Pain/Discomfort Ulceration Erythema Dysphagia Bleeding Necrotic/sloughy ulceration

17. 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.

18. 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.

20. Skin Care

21. 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.

22. 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.

23. Assessment / Observation Effects of Radiotherapy on Skin Cells RTOG 0 No visible change to skin RTOG 1 Faint or dull erythema. Mild tightness of skin and itching may occur RTOG 2 Bright erythema / dry desquamation. Sore, itchy and tight skin RTOG 2.5 Patchy moist desquamation Yellow/pale green exudate. Soreness with oedema RTOG 3 Confluent moist desquamation. Yellow/pale green exudate. Soreness with oedema RTOG 4 Ulceration, bleeding, necrosis (rarely seen) RTOG Grading Scale

24. Cetuximab Reaction

25. 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.

26. 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.

27. 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.

29. 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.

30. Mangement Good oral hygiene. Regular rinsing…..saline mouth washes. ?? Sodium Bicarbonate Rinses. Steam Inhalation. Nebulisers.

31. Conclusion Promote patient comfort Avoid Infection Complete proposed treatment. Reduce/control pain Maintain nutrition intake Psychological support Avoid aspiration/maintain safe swallow Avoid further trauma to skin/oral mucosa Control Symptoms Avoid admission Holistic Assessment MDT Working