Head and neck cancer includes cancers of the mouth, nose, sinuses, salivary glands, throat and lymph nodes in the neck. Those who survive and become disease free frequently have altered appearances and/or disabilities associated with treatment ¹ ,and that results in significant medical and psychosocial consequences.

Patients at the National Cancer Centre are counseled before surgery. The patients who undergo head and neck surgery are followed up by a trained staff nurse who identifies new issues that arise, provides counseling, and ensures that the patients are followed up by appropriate health professionals. She refers patients to the medical social worker for counseling, support and financial aid. The patient is introduced to a support group that meets monthly.

After a laryngectomy, the speech therapist helps in voice restoration. The options include the electrolarynx, oesophageal speech and tracheo-esophageal speech. The patients are taught effective communication in terms of phrase groups and coordination for the first two groups. Patients using tracheo-esophageal speech are assisted in the management of the prosthesis and in using it for communication. The most common form of voice rehabilitation after total laryngectomy is the artificial larynx. Although the tracheoesophageal puncture is a technique deemed as superior to other options of voice restoration, only a relatively small number of patients are successfully rehabilitated long term. ²

Aspiration rate following chemotherapy and radiotherapy for the treatment of head and neck cancer is an underreported occurrence. ³ Dysphagia is a significant morbidity of head and neck cancer treatment, and the severity of dysphagia correlated with a compromised quality of life, anxiety and depression. ⁴ The speech therapist play a big role in the rehabilitation and supportive care of these patients. They teach the patients compensatory techniques for swallowing and swallowing therapy has been shown to improve dysphagia severity and reduce the need for tube feedings. ⁵ The patients are also advised on the long-term side effects of radiotherapy, including xerostomia, fibrosis and trismus. Exercises for the oral and neck muscles are taught to prevent further fibrosis.

The prosthodontist is another health professional involved in the care of this group of patients. The patient may be rendered edentulous by cancer treatment or dentures may no longer fit due to gum atrophy or change of the anatomy of the jaw. They may need implants or prosthesis such as a palatal obturator. (Fig.1)

Fig.1: (a) to (c) before and after insertion of palatal obturator, (d) palatal lift appliance

Having cancer and dealing with the residual effects of treatment can be time-consuming, energy and emotionally draining. The patient needs to make adjustments in many ways, including adopting a healthier lifestyle. Smoking and drinking are risk factors for head and neck cancers and these patients may return to these habits in times of distress. Patients need help with smoking cessation, and the avoidance of alcohol. . They need support from their families and significant others in eating more healthily, exercising and coping more healthily with stress. Their closed ones need education, in order to support the patient in various ways needed.

Cancer-related fatigue is a late medical effect of cancer, and occurs in those who have been cured. It is easily overlooked. A cancer rehabilitation physician screens for and treats cancer-related fatigue. The contributing causes are identified and reversible factors are treated, for example anaemia , sleep disorders, depression and endocrine disorders such as hypopituitarism. Sleep apnoea often occurs after upper airway surgery, and should be investigated and addressed. Treatment of cancer-related fatigue include starting an exercise program, teaching the patient to prioritise and pace his daily activities as well as sleep restoration. Methylphenidate is used in the treatment of cancer-related fatigue. There is evidence that it can improve fatigue scores and it has an effect on overall well-being and quality of life scales ⁶ It improves one’s functional status.


Rehab Team Meeting

Quality of life includes dimensions such as physical , functional, psychologic and social wellbeing. Other dimensions include spirituality, sexuality and so on. In a study on head and neck cancer survivors, despite some improvements in physical changes and activities of daily living eventually, patients report a decline in certain quality of life domains. They report declines specifically in areas of marital and sexual functioning. ¹

An involvement of the rehabilitation physician is essential for a multidisciplinary approach to the management and supportive care of cured head and neck patients. The rehabilitation physician assesses and coordinates the multidisciplinary care amongst various health professionals and continues to follow up the patient when the patient no longer has surgical issues nor require follow-up for cancer treatment. He deals with the residual effects of cancer and its treatment, including cancer-related fatigue, depression, neuropathic pain, and helps to reintegrate the patient back into family/society , looking into issues such as sexuality, employment and other dimensions in life that is meaningful to the patient.

Dr Tay San San
Registrar,
Dept of Rehabilitation Medicine, SGH


References

1.	First Year after Head and Neck Cancer: Quality of Life. Ellen R Gritz et al. Journal of Oncology. Vol 17(1): 1999: 352-360.
2.	Voice rehabilitation after total laryngectomy and postoperative radiation therapy. William M Mendenhall et al. Journal of clinical Oncology, Vol 20,(10), 2002: p2500-2505.
3.	Aspiration rate following chemoradiation for head and neck cancer: and underreported occurrence. Nguyen NP et al. Radiother Oncol 2006 Sep;80(3):302-6.
4.	Impact of dysphagia on quality of life after treatment of head and neck cancer. Nguyen NP et al. Int J Radiat Oncol. Biol Phys. 2005 Mar1;61(3):772-8.
5.	Impact of swallowing therapy on aspiration rate following treatment for locally advanced head and neck cancer. Ngyuyen NP et al. Oral Oncol 2007 Apr;43(4)_:352-7.
6.	Patient-controlled methylphenidate for the management of fatigue in patients with advanced cancer: a preliminary report. Eduardo Bruera et al. Journal of Clinical Oncology 2003; 21(23): 4439-4443.

Data from National Cancer Registry Publication 2002.