Head and neck cancer part 2: the patient journey Stephanie Hackett Oliver Jones Despoina Chatzistavrianou David Newsum Dental Update 2024 46:9, 707-709.
Specialist in Prosthodontics, Specialty Registrar in Restorative Dentistry, Birmingham Dental Hospital and University of Birmingham School of Dentistry, Birmingham Community Healthcare NHS Trust, Birmingham, UK
Consultant in Restorative Dentistry, BDS, MFD RCS, MSc, MRCPS, MRD RCSEd, FDS(Rest Dent) RCSEd, Birmingham Dental Hospital and School of Dentistry, Birmingham Community Healthcare NHS Foundation Trust, Birmingham, UK
This is the second paper in a three-part series to discuss head and neck cancer diagnosis, treatment and rehabilitation. Following a confirmed diagnosis of head and neck cancer, patients will begin a long and often challenging pathway that will involve clinicians from a multidisciplinary team (MDT). This paper will summarize the role of individual MDT members involved in patient care, diagnostic and treatment phases for head and neck cancer and common side-effects encountered. By gaining an insight into this part of the patient's journey, dental practitioners should feel more comfortable and confident engaging in the care and support for head and neck cancer patients.
CPD/Clinical Relevance: This paper aims to provide readers with an insight into the journey that patients will undertake after being diagnosed with head and neck cancer.
Article
Stephanie Hackett
Care for head and neck cancer patients in England and Wales was reformed in 1995 following the Calman Hine Report.1 In this report, a patient-centred framework for the commissioning and provision of cancer services was proposed to ensure that treatment received was of a uniformly high standard.1 The quality and availability of care has improved immeasurably over the past decades with improved training, multidisciplinary working and treatment modalities,2 leading to improved survival rates.
The Cancer Reform Strategy (2007)3 set out the 62-day patient pathway for treatment of cancers in the UK (Figure 1). Following a suspected cancer referral, the patient is seen within 14 days by the accepting unit. Specifically for head and neck cancers, arrangements will be made to see the patient on a ‘fast track’ head and neck clinic by a consultant in head and neck surgery from the fields of Oral and Maxillofacial Surgery, Plastic Surgery and Ear, Nose and Throat Surgery. Diagnostic tests, including biopsies and imaging, are implemented within the next phase and a decision to treat must be made by MDTs within 31 days. The patient's first exposure to treatment of the cancer will be made within the following 31 days, concluding that the first treatment for the patient pathway should be started within 62 days of the referral being received.
Figure 1. 62-day timeline from cancer diagnosis to implementation of treatment (adapted from Department of Health, 2007).3
Diagnostic phase
Biopsies of suspicious lesions are vital in the grading and staging of cancers, giving an indication of the type, prognosis and rate of spread of the lesion.4 This is generally more straightforward with oral and skin lesions and will involve an incisional or excisional biopsy. For lesions that are less accessible, such as lesions of the vocal cords, biopsies will be taken under general anaesthetic. Other diagnostic techniques that can be utilized include fine needle aspiration cytology5 and core biopsies.
Large developments in cross-sectional imaging modalities over the last two decades have contributed significantly to aid more accurate cancer management decisions. Imaging will identify local spread of the primary tumour, spread to locoregional lymph nodes, metastasis and detection of synchronous primary tumours.6 Head and neck cancer patients routinely undergo computed-tomography (CT), magnetic resonance imaging (MRI), positron emission tomography-computerized tomography fusion scan (PET-CT) and chest imaging in their work-up to discussion of the required treatment plan at MDT meetings (Table 1).6
Imaging Modality
Clinical Reason
Computerized Tomography (CT)
Allows visualization of tumours based on changes in morphology and alteration of normal anatomy. Good at detecting hard tissue changes
Magnetic Resonance Imaging (MRI)
Allows visualization of tumours based on differences in tissue biochemistry between normal and cancerous tissue
PET–CT has specific value in evaluating patients with metastatic lymph nodes and an unknown primary. It maps the levels of glucose metabolism within tissues, with cancerous tissues showing more activity
Ultrasound
Useful to assess undiagnosed neck lumps and to guide a fine needle aspirate allowing cell cytology
Chest Imaging
Mandatory to assess for metastatic disease in the lungs
Dental Plain Films
To diagnose dental disease, tooth prognosis and aid in rendering the patient dentally fit
Further tests to determine the patient's ASA grade (eg lung capacity tests) will also be performed to enable decision-making between curative or palliative treatment and treatment modality. In addition, health-related quality of life indicators are utilized at the treatment planning stage, throughout treatment and follow-up to ensure personalized support of the patient.7
The multidisciplinary team and decision to treat
The multidisciplinary team (MDT) takes overall responsibility for the assessment, treatment planning and rehabilitation of head and neck cancer patients. They provide support and advice to those healthcare professionals outside of the MDT who may also be involved with the care pathway of the patient, such as the General Dental and Medical Practitioners.8
MDT members (Table 2)8 utilize their individual expertise to ensure prompt, appropriate and effective patient care. Patients will have immediate contact with a cancer nurse specialist from initial diagnosis who will co-ordinate special investigations, planning and provide emotional support to patients and their relatives.8
Member of the MDT
Role
Surgeons – Maxillofacial/ENT/Plastic
Plan the site and extent of surgery depending on staging and grading of cancer
Clinical Oncologist
Decide appropriateness, type and dose of radiotherapy and/or chemotherapy
Pathologist
Diagnose and grade cancersAssessment of excisional margins after surgery to give final grading and staging
Radiologist
To discuss relevant imaging that will aid in treatment planning and staging
Anaesthetist
Identification of the degree of airway difficulty, risk stratification and optimization of comorbidities within the limited timeframe prior to surgeryFormulation of a plan for peri-operative care
Cancer Nurse Specialist
Liaises between members of the MDT and acts as a first port of call for patients and relatives
Restorative Dentist
Pre- and post-operative planning for dental stability and rehabilitation
Dietitian
Ensures patients are nutritionally maintained during and following treatment
Speech and Language Therapist
Assesses swallowing ability and safety during and after treatment. Advises the MDT on the need for bypassing feeding techniques such as nasogastric tubes or gastrostomy
Head and neck MDT meetings generally run once weekly to discuss results from diagnostic tests, decide upon the staging of the tumour and consequently the most appropriate treatment modalities for patients. The MDT must balance the likely prognosis for survival with quality of life after treatment. Often these can be difficult decisions and the information is delivered to the patient in a supportive environment.8
Extended members of the MDT may also include psychiatrists, physiotherapists, maxillofacial technicians and dental hygienists.8
Dental assessment
Guidance from the British Association of Head and Neck Oncologists states that all patients whose oral cavity, teeth, salivary glands and jaws will be affected by treatment should have a pre-treatment dental assessment by a Consultant in Restorative Dentistry.9 The assessment will be arranged to allow for necessary dental treatment to be completed prior to, but without delaying, the treatment for head and neck cancer. The aims of a dental assessment are outlined as follows:9
To render the patient dentally fit prior to starting treatment;
To avoid interruptions part way through treatment;
To offer preventive advice and treatment;
To offer pre-prosthetic planning;
To plan for extractions of doubtful prognosis teeth in the radiotherapy fields;
To plan for restoration of remaining teeth.
High priority patients for pre-treatment assessment are those who require oral rehabilitation after treatment (especially if oral anatomy is going to be altered), dentate patients requiring radiotherapy to the jaws or salivary glands, patients who are at risk of post-operative infections (patients receiving chemotherapy) and those with specific dental concerns or issues.10
Patients requiring treatment for head and neck cancer often have poorly maintained dentitions11,12 and high levels of dental disease. In one study, 71% of patients who were to undergo treatment for head and neck cancer had periodontal disease and 61% had dental caries.11 A recent local audit found that only 66% of patients presenting to a head and neck MDT have a general dental practitioner (GDP).13
Special consideration is given to teeth in the radiotherapy fields, teeth with poor prognosis or apical pathology and strategically important teeth. The benefits of keeping specific teeth for function and aesthetics should be weighed up against the risk of loss of the tooth in the future. If extractions are to be performed, they should be completed a minimum of 10 days prior to the patient starting radiotherapy.14 However, there is limited evidence regarding dental extractions prior to radiotherapy and many decisions are based upon clinical expertise.15,16
The dental assessment is also an opportune time to discuss the importance of optimal oral hygiene and prevention regimens with patients. There is a burden on the patient after treatment to be able to keep teeth disease free owing to side-effects, including decreased saliva function, altered anatomy and trismus. The GDP has an important role in prevention and maintaining stability to head and neck cancer patients. The role of the GDP will be discussed in detail in the next paper of the series.
Overview of treatment
The main three treatment modalities in head and neck cancer are:
Surgical;
Radiotherapy;
Chemotherapy.
The aim for treatment will be either curative or palliative, once the staging and comorbidities are considered. Patients will undergo a single treatment modality or a combination therapy, depending on the size, site and type of the lesion. Radiotherapy and surgery are the two most frequently used therapeutic modalities in head and neck cancer. Early stage tumours (T0–T2) are most commonly treated with either radiotherapy or surgery alone, with both having similar cure rates.17 Consideration between the two will be based on patient-related factors, preservation of organs, speech, swallowing and function of the surrounding muscles, including the tongue.17
Surgery
Surgical management of larger and more extensively infiltrated head and neck tumours will often involve a combination of resection of the tumour (including soft tissue and bone if required), unilateral or bilateral neck dissection (to remove lymph nodes and potentially invaded structures) and reconstruction.
Reconstruction is achieved by primary soft tissue closure or with a local or regional flap, skin graft or free tissue transfer. Flaps are used to repair structural defects and are often composed of dermis, connective tissue, muscle and sometimes bone, depending on the size, location and shape of the defect (Figure 2). If the flap is taken from a distant site, the patient may have been provided with a skin graft to replace large areas of skin tissue. Depending on the cancer diagnosis and recommended treatment, patients may have their surgical treatment staged with resection and ablation of the tumour first, followed by reconstruction at a later date. In some cases, a prosthesis or external fixation device will be provided until the reconstruction can be provided. Increasingly, implants to restore dental function may be placed at primary ablative surgery or at secondary surgery following healing and, if required, radiotherapy.
Figure 2. Reconstruction of floor of mouth with a radial free forearm flap, following partial glossectomy and floor of mouth resection, partial mandibular rim resection and bilateral neck dissections.
Reconstruction is defined as mandibular or maxillary and classified based on the extent of the surgical defect and therefore the rehabilitation site.18,19 The reconstructive need following ablative surgery is unique to the patient and requires attention to form and function.
Radiotherapy
For advanced squamous cell carcinomas of the head and neck, the combined use of surgery and post-operative radiotherapy or combined chemotherapy and radiation frequently offers the highest chance of achieving cure.17 These treatment modalities are planned at pre- and post-treatment MDT and this enables the Restorative Dentist to consider further dental assessment and preventive regimens with this in mind.
Intensity-modulated radiotherapy (IMRT) is a newer form of radiation therapy which allows better control of radiation dose delivery to the head and neck. In a randomized trial performed in the UK, IMRT has been shown to reduce radiation-induced xerostomia from 75% to 39% at 12 months following treatment and it has been suggested that this is offered to all patients.17
Chemotherapy
Chemotherapy alone cannot cure head and neck cancer but it has a role in the treatment of advanced disease adjunct with radiotherapy. It can be delivered either before treatment (neoadjuvant or induction), concurrently with radiotherapy or after (adjuvant). It has been shown to improve local control and improve survival rates but at the price of greater acute and late toxicity.20 Chemotherapy is not routinely offered to patients above the age of 70 years.
For patients who are unfit for chemotherapy, the use of monoclonal antibody systemic treatment, Cetuximab, may be given concurrently with radiotherapy, which competitively inhibits the cell-surface epidermal growth factor receptor (EGFR). This has been shown to improve locoregional control and overall survival at 3 and 5 years over radiotherapy alone in a study of patients with locally advanced (Stage III/IV) head and neck cancer.20 Patients may be on a Cetuximab or Denusomab regimen long term and it is therefore likely that dentists in primary care may come into contact with these for general dental care. Toxicities of Cetuximab include rash and hypersensitivity reactions, but it does not increase the rate of severe radiation-related mucositis.20 Long term Denusomab use is associated with increased risk of osteonecrosis of the jaws21 and guidance should be sought with regards to prevention and its management. The Scottish Dental Clinical Effectiveness Programme have recently produced guidance on medication-related osteonecrosis of the jaws (MRONJ) which includes Denusomab use.22
It is also important to appreciate that some patients may be on long-term enteral feeding regimens for either full or partial nutritional or medicinal support. Those feeding orally may require supplementary nutrition with high calorie drinks. These can be a detriment to oral health and pose patients at high risk of caries, particularly for those who have undergone radiotherapy. Common supplement drinks are Fortisip (Nutricia), Ensure Plus (Abbott) and Fresubin Energy (Fresenius Kabi). These products provide a range of 6.7 to 18.8 g of sugar per 100 ml. Patients typically have a 200 ml serving, up to four times per day as prescribed by their dietitian. Dentists can liaise with the patient's dietitian to discuss frequency of quantity of sugar intake.
Oral and dental complications of treatment
Each of the cancer treatment modalities have commonly associated short- and long-term side-effects. It has been reported that 78% of patients experience severe difficulties in mastication following major head and neck surgery with implications for normal social adaptation.23Table 3 outlines the common problems associated with each treatment modality.
Treatment Modality
Short-term side-effects
Long-term side-effects
Surgery
Loss of functionSwellingPainInfectionFlap issues – failure, dehiscence, failure to integrateReduced manual dexterityReduced mobility to perform daily oral careTrismusLoss of taste/altered taste
Altered anatomyReduced or complete loss of functionMastication difficultiesTrismusPsychologicalNutritional
Radiotherapy
Mucositis and ulcerationPainOral candidal infectionsLoss of taste/altered taste
ScarringXerostomiaDental cariesPredisposition to osteoradionecrosis of the jawsTrismusOral candidal infections
Chemotherapy
MucositisReduced ability to perform daily oral careInfection-bacterial, viral or fungalLoss of taste/altered tasteIncreased risk of bleeding
For patients on long-term maintenance therapy – InfectionMucositisMedication-related osteonecrosis of the jawsPain
Short-term side-effects
Patients who have surgical resection with or without flap reconstruction often have prolonged hospital stays lending to significant impediment on their daily mobility and hygiene abilities. Resection of tumours will leave patients with obvious functional deficits and often loss of teeth. In the short to medium term, they can expect to have pain, swelling and possibly infection which will affect their ability to function and swallow.
Patients will often be provided with nutritional support through naso-gastric tubes or elective gastrostomy. Gastrostomies usually take the form of either percutaneous endoscopic gastrostomy (PEG) or radiologically inserted percutaneous gastrostomy (RIG), both of which can be used temporarily during and after cancer treatment, or are to be permanently inserted for feeding. RIGs are often preferred over PEGs in head and neck cancer patients as patients sometimes have dysphagia or oropharyngeal obstruction, preventing insertion of the PEG sensor for its placement.
Patients will liaise with speech and language therapists and dietitians who assess their safe swallow and nutritional needs during and after their hospital stay. With all treatment modalities, patients often suffer from aguesia/dysguesia (taste loss/altered taste), which can be debilitating, however it is often reversible with time.10
Inflammation and ulceration of the oral cavity and oropharynx is a major side-effect seen particularly in radiotherapy and chemoradiotherapy patients. Oral mucositis impedes quality of life and patients often require opioid analgesia for the management of the severe pain (Figure 3). In addition, oral mucositis may inhibit effective oral hygiene regimens due to the pain suffered from physical trauma to the mucosa and strong flavours of dental products.24 Mucositis most commonly occurs within the first two weeks of chemoradiotherapy treatment and resolves by six weeks after treatment.24 The management of this will be discussed in the next article in this series.
Figure 3. Oral mucositis affecting labial mucosa in a radiotherapy patient.
Long-term side effects
Patients who have had surgical resection of tumours will have altered anatomy, including microstomia, facial discrepancies and trismus. This will have implications on providing dental treatment and will reduce patients' ability to maintain adequate oral hygiene. Complex cases will likely be managed in secondary care centres for their oral rehabilitation but GDPs will be expected to provide routine dental care for these patients.
Radiotherapy aimed at or near the salivary glands will cause irreversible scarring of the glands and reduced ability to produce adequate saliva. As a result, patients can suffer from long-term xerostomia (the subjective feeling of a dry mouth as a consequence of hyposalivation), pain and difficulty with speech and mastication. Reduced saliva output will position the patient at greater risk of dental caries as a result of impaired buffering capacity, reduced clearance and lowered pH.25 The consistency of the saliva may also become more viscous.25 Patients should be managed with the available prevention strategies which are outlined in the next paper.
Osteoradionecrosis (ORN) is defined as an exposed area of bone of at least 3 months' duration in an irradiated site and not due to tumour recurrence.17 It is caused by trauma to irradiated hypovascularized bone leading to necrosis, however, it can sometimes also be spontaneous. Patients will experience induced or spontaneous mucosal breakdown and non-healing wounds. Figure 4 shows a non-healing necrotic lesion with associated mucosal breakdown lingual to LL7 in a patient who has previously received chemoradiotherapy to the head and neck. Patients who continue to smoke during radiotherapy treatment are at heightened risk of developing ORN.9 Avoidable ORN caused by trauma from dental extractions or invasive treatment on or near the periodontium can be prevented at the pre-assessment stage and by providing adequate oral hygiene instruction, fluoride supplements, smoking cessation and removal of teeth of poor prognosis. Patients are particularly at risk of ORN when tooth extractions are undertaken both immediately before and after radiotherapy.24
Figure 4. Osteoradionecrosis of the jaws affecting lingual bone adjacent to LL7.
In one study, the prevalence of ORN with conventional radiotherapy was found to be 7.4%, with intensity-modulated radiotherapy it was 5.1% and with chemoradiotherapy was 6.8%.26 There are currently no clear recommendations for the prevention or treatment of osteoradionecrosis.26
Conclusion
The patient journey for head and neck cancers can be rapid and it is important for dental practitioners to be able to recognize and support their patients through this. Oral and dental complications can be devastating to the patient, but minimization of these can be achieved through thorough dental pre-assessment and oral prevention regimens in both primary and secondary care. In the third, and final, part of this series the accepted preventive regimens for patients, management of treatment side-effects and specific cases of primary and secondary care dental management of head and neck cancer patients will be discussed.
