Forgotten patients: New guidelines help those with head-and-neck cancers

Source: www.fredhutch.org
Author: Diane Mapes and Sabrina Richards

Stigma, isolation and medical complexity may keep patients from getting all the care they need; recommendations aim to change that.

Like many cancer patients, Jennifer Giesel has side effects from treatment.

There’s the neuropathy in her hands, a holdover from chemo. There’s jaw stiffness from her multiple surgeries: an emergency intubation when she couldn’t breathe due to the golf ball-sized tumor on her larynx and two follow-up surgeries to remove the cancer. And then there’s hypothyroidism and xerostomia, or dry mouth, a result of the 35 radiation treatments that beat back the cancer but destroyed her salivary glands and thyroid.

“I went to my primary care doctor a couple of times and mentioned the side effects,” said the 41-year-old laryngeal cancer patient from Cleveland, who was diagnosed two years ago. “She was great but she didn’t seem too knowledgeable about what I was telling her. She was like, ‘Oh really?’ It was more like she was learning from me.”

Patients like Giesel should have an easier time communicating their unique treatment side effects to health care providers with the recent release of new head-and-neck cancer survivorship guidelines. Created by a team of experts in oncology, primary care, dentistry, psychology, speech pathology, physical therapy and rehabilitation (with input from patients and nurses), the guidelines are designed to help primary care physicians and other health practitioners without expertise in head-and-neck cancer better understand the common side effects resulting from its treatment. The goal is that they’ll then be able to better make referrals or offer a holistic plan for patients to get the support they need.

“Head-and-neck cancer survivors can have enormous aftereffects from the disease and treatment by virtue of the location of the primary tumor,” said Dr. Gary Lyman, a public health researcher with Fred Hutchinson Cancer Research Center who helped create the guidelines. “There are functional interruptions, like losing the ability to talk, eat or taste. And some of the surgeries can be disfiguring.

“I’m really glad the American Cancer Society decided to take this on,” he said. “These guidelines are sorely needed, long overdue and will serve cancer patients who are incredibly affected — both physically and emotionally.”

Currently, there are more than 430,000 head-and-neck cancer, or HNC, survivors in the U.S., accounting for around 3 percent of the cancer patient population.

As with many other cancers, HNC is an umbrella term for a number of different malignancies, including cancers that develop in or around the mouth, tongue, throat, nose, sinuses or larynx. Brain, thyroid and esophageal cancer are not considered head-and-neck cancers.

HNC has traditionally been linked to tobacco and alcohol use, and about 75 percent of HNC are related to these risk factors. Increasingly, though, human papillomavirus, or HPV, is causing a significant number of head-and-neck cancers (another reason why the HPV vaccine is such an important prevention tool).

An isolating group of diseases
For some patients with HNC, there can be a certain amount of stigma and isolation, due to its association with drinking and smoking. Treatment can also isolate patients since it sometimes mars a person’s appearance or alters their speech.

Some patients, literally, have no voice.

HNC’s complicated nature — it’s not one disease but several, all of which behave and respond to treatment differently — also results in very small patient populations, which can hinder research.

“Head-and-neck cancer patients have historically been somewhat ignored,” said Lyman, an oncologist with Seattle Cancer Care Alliance, Fred Hutch’s treatment arm. “Many view this as a lifestyle-associated cancer, like lung cancer, heavily influenced by tobacco exposure and [drinking] alcohol to excess. And people may have difficulty dealing with the appearance of some of the more severely affected patients.”

t’s a sentiment echoed by Dr. Eduardo Méndez, a Fred Hutch clinical researcher and head-and-neck cancer surgeon at SCCA.

“It’s in a location that affects your appearance, it affects your ability to speak and to swallow, and those are all things that you need to interact with others,” he said. “It can have an effect of shutting you down from the rest of society. Even the treatment for head-and-neck cancer can have consequences that affect those very same things that the tumor was affecting — swallowing, speech, appearance.”

Not surprisingly, many HNC survivors suffer from depression and/or body image and self-esteem issues after diagnosis and treatment.

“I struggle with body image issues every day,” said Beci Steelman, a 42-year-old court clerk from Bushnell, Illinois, who went through radiation and eight surgeries, including a total right maxillectomy (a surgery of the upper jaw), after being diagnosed with a rare head and neck tumor in 2010.

“You can see that my eye looks like someone’s pulling it halfway down my cheek,” she said. ”My mom and I just call it my googly eye and joke that I have ‘really good face days’ and others that are just ‘face days.’ Clearly something’s not right. When I smile, you can see a bit of metal from the obturator, this weird rubbery dental piece that plugs the hole in the roof of my mouth. Some days I just feel like I’m so ugly.”

Holistic approach benefits patients
There is good news with these cancers: most patients are diagnosed with HNC in its early, most curable stages.

“The majority will be completely functional and normal [after treatment],” said Dr. Christina Rodriguez, the medical oncologist who oversees the majority of HNC patient care at SCCA.

According to the National Comprehensive Cancer Network, around 80 to 90 percent of early stage patients (stage 1 and 2) go into remission after receiving surgery or radiation. Advanced stage patients (stage 3 and 4) receive more aggressive treatment and have lower cure rates, with the exception of patients with HPV-related head-and-neck cancers. Their 5-year cure rates are close to 90 percent.

But even those who go into remission may have to contend with a constellation of difficult side effects.

The head and neck area is “like a fine-tuned machine,” said Dr. Keith Eaton, a medical oncologist at SCCA and Fred Hutch who specializes in lung cancer and HNC. “There are so many dedicated structures that we can’t do without. If you get rid of half your liver, not a problem. If your epiglottis doesn’t work, you aspirate.”

In addition to trouble with swallowing and speech, stiffness in the jaw and problems with shoulder and neck mobility, HNC patients can be left with hypothyroidism, hearing loss, taste issues, periodontitis and lymphedema, the swelling that comes after lymph nodes are surgically removed, a common step in cancer treatment. Because of this complexity, patients need a holistic approach, said Méndez.

Steelman’s cancer extended to the orbital floor of her right eye which meant she had to undergo extensive surgery to her face including the removal of four back teeth, an incision to the roof of her mouth and the shortening of a jaw muscle.

“They got the tumor out and then put me back together,” she said. “I feel like Humpty Dumpty.”

She now wears a prosthetic (which requires daily maintenance) and has had injectable fillers to help with the atrophy around her right eye (an implant in the area became infected and had to be removed). She’s lost hearing in her right ear, her speech is sometimes “a little marble-y,” she has dry mouth from damage to her salivary glands and her jaw will not open as wide as it once did.

Steelman tapped a number of specialists to help her deal with these issues, including an otolaryngologist (ear, nose and throat doctor), speech pathologist, a prosthodontist (an expert in the restoration and replacement of teeth) and a plastic surgeon.

“You have to be your own advocate,” she said. “You learn that very quickly.”

Get help early
Physical therapists, speech pathologists, dietitians and providers with expertise in palliative and pain care (also called supportive care) can improve survivors’ quality of life enormously, especially when therapy is started early.

“Careful — and early — attention to side effects and treatment-related complications can help optimize survivors’ quality of life,” said Eaton, the SCCA oncologist.

Dr. Elisabeth Tomere, a physical therapist at SCCA, said she and her colleagues prescribe exercises that help patients regain strength, range of motion and tissue flexibility that surgery and/or radiation may have diminished. Some patients, for instance, need help building up their trapezius muscle to improve shoulder function they have lost after neck surgery. Others need to learn movements that strengthen the front of their necks and the muscles needed to maintain posture.

Patients with lymphedema in the face and neck — a common side effect from HNC treatments — can also benefit from early intervention by a physical therapist, said Tomere.

“These issues are all helpful to address as quickly as possible so they’re not ongoing,” she said, adding that it may take up to two years for patients to mentally and physically recover from treatment.

“We try to give people a realistic timeline,” she said.

The new ACS guidelines should help providers without expertise in head-and-neck cancers find the right specialists for their patients, she said.

Cancer physical therapy, while new, is becoming more standard. Both the American Physical Therapy Association and the Lymphology Association of North America allow providers or patients to search for specialized physical therapists near them — a boon to primary care providers who are not “connected to that world,” said Tomere.

Dietitians can play a key role, too, since many HNC patients struggle to eat. Treatments can cause dry mouth, taste changes or make chewing difficult. Food can become unappetizing or difficult to ingest.

“There’s an emotional component. Food becomes medicine,” said Linda Kasser, an SCCA dietitian and specialist in oncology nutrition. Patients must eat to keep their weight up, “but it can become exhausting … Sometimes they need to force themselves to eat. They feel pressured, which can contribute to family tensions and even food aversions.”

Dietitians can offer approaches to help patients maintain their weight and strength, from using new cooking strategies to make food more palatable to recommending temporary feeding tubes inserted into the stomach that help patients avoid the pain of chewing and swallowing altogether. They also help alleviate patients’ worries about food and separate “nutrition fallacy from fact,” said Kasser.

Not surprisingly, communication is strongly emphasized in the guidelines.

“We wanted to make sure that there is open communication between the providers and caregivers,” said Lyman. “That there’s a care plan that the patient understands and the caregiver understands. All the different specialists involved in the care should be on the same page.”

The new guidelines also emphasize lifestyle choices that will help to reduce the risk of HNC recurrence and secondary cancers: smoking cessation, limiting use of alcohol, regular exercise and good oral hygiene.

Exciting new research
Chemotherapy, radiation and surgery remain the standard of care for HNC — and drive many of the side effects covered by the new ACS care guidelines — but recent advances are making researchers like Méndez very optimistic for future care.

Thanks to advances in genomics, researchers now know that the mutations found in head and neck tumors vary widely.

“One size will not fit all,” said Méndez. “Treatment will have to be individualized.”

Méndez is leading efforts at Fred Hutch to develop tailored therapies based on the cancer’s genomic mutations, zeroing in on cancer cells’ “Achilles heels” — molecular pathways that tumor cells rely on to survive but that normal cells can do without. The approach is already paying dividends: Méndez is currently leading a clinical trial of a drug he and his team identified that exploits a vulnerability unique to head and neck tumors missing a key gene called p53.

“Once we understand the genotype driving tumor growth, strategies [for treatment] can become more targeted, more effective and less toxic,” he said.

New robotic-assisted surgery has also transformed the procedure for certain patients with tumors in the larynx and at the base of the tongue, allowing surgeons to perform fewer incisions and better preserve functions like swallowing and speech, he said.

Immunotherapy also looks like a very promising path to better HNC treatments.

“New immunotherapy drugs are getting FDA approval for head and neck cancer,” said Méndez. “I think in the next few years we will see it moving to a first-line therapy. It’s a very exciting time for head and neck cancer.”

For patients like Steelman and Giesel, that’s great news.

“I had a social worker who helped me get through the thick of [treatment], but nobody talked about what it would be like when treatment was over,” said Giesel, who had to teach herself how to swallow food a new way (she no longer has an epiglottis). “I thought I’d be returned to myself and I’d be fine, but it was not like that in any way.”

These new guidelines, she said, will help patients like her get the help they truly need.

“Primary care doctors need to know about the physical and emotional effects,” she said. ”I have a lot of good support and know how to ask for help, but I can’t imagine how [patients] who don’t know how to ask for help explain how they’re feeling.”

Do you or someone you love have a head-and-neck cancer? Join the conversation about treatment challenges and how the new guidelines might help on our Facebook page.

About the authors:
Diane Mapes is a staff writer at Fred Hutchinson Cancer Research Center. She has written extensively about health issues for NBC News, TODAY, CNN, MSN, Seattle Magazine and other publications. A breast cancer survivor and patient advocate, she writes the breast cancer blog doublewhammied.com and tweets @double_whammied. Reach her at dmapes@fredhutch.org.

Sabrina Richards is a staff writer at Fred Hutchinson Cancer Research Center. She has written about scientific research and the environment for The Scientist and OnEarth Magazine. She has a Ph.D. in immunology from the University of Washington, an M.A. in journalism and an advanced certificate from the Science, Health and Environmental Reporting Program at New York University. Reach her at srichar2@fredhutch.org.

1. Original article available at: http://www.fredhutch.org/en/news/center-news/2016/04/new-survivorship-guidelines-spotlight-head-and-neck-cancers.html

April, 2016|Oral Cancer News|

Improving QOL in head and neck cancer as survival improves

Source: www.medscape.com
Author: Zosia Chustecka

In patients undergoing radiation treatment for head and neck cancer, reducing the radiation to organs not affected by cancer is key to improving quality of life post-treatment.

Several studies presented here at the 2014 Multidisciplinary Head and Neck Cancer Symposium described new approaches to sparing radiation delivered to the salivary glands and to the voice box, without any loss of cancer control, but with a reported reduction in adverse effects, such as xerostomia (dry mouth), and an anticipated reduction in loss of voice and speech quality.

Improvements in such outcomes are becoming increasingly important as the epidemiology of head and neck cancer is changing, and the increase in human papillomavirus-positive disease means that patients are being diagnosed their 50s and will, in many cases, go on to live for decades after their definitive cancer treatment, researchers commented at a press briefing.

Xerostomia can make it difficult to speak, as well as chew and swallow, and can lead to dental problems. “Dry mouth might seem trivial, but it actually has a significant effect on quality of life,” commented Tyler Robin, PhD, an MD candidate in his final year at the University of Colorado Medical School in Denver.

To reduce this adverse effect, intensity-modulated radiation techniques are already directing the beam away from the parotid gland, which is responsible for stimulated saliva production, for example during eating. But for the rest of the time, saliva is produced unstimulated from the submandibular gland. “This gland actually produces the majority of saliva for the majority of the day,” he said.

“Historically, however, there had been hesitation to spare the submandibular gland from radiation because there are lymph nodes near the gland that also end up not getting treated,” he said. “While this seems worrisome because head and neck cancer spreads through the lymph nodes, it is well established that the risk of cancer involvement in the lymph nodes near the submandibular gland is exceedingly low, yet the benefit of sparing the gland for a patient’s quality of life is high.”

Dr. Robin presented data from 71 patients with advanced head and neck cancer who were treated with radiation that spared the contralateral submandibular gland in a collaborative study conducted at the University of Colorado and the Memorial Sloan-Kettering Cancer Center in New York City. The mean radiation dose delivered to the contralateral gland was 33.04 Gy./p>

At a median follow-up of 27.3 months, none had had cancer recurrences in the spared area.

This is preliminary evidence that submandibular gland-sparing radiotherapy is feasible technically, and that it is safe even in advanced-stage node-positive cancers, the researchers conclude. They suggest that these outcomes data “offer significant promise for decreasing morbidity.”

More data on this submandibular gland-sparing approach were presented at the meeting by Moses Tam, BS, an MB candidate in his final year at New York University School of Medicine in New York City, who was also an author on the previous presentation.

He reported data from 125 patients (median age, 57 years) with oropharyngeal cancer (53% base of tongue, 41% tonsil, 6% other), all of whom had node involvement (16% N1, 8% N2A, 48% N2B, and 28% N2C).

All patients underwent chemoradiation, but some patients had sparing radiation, with a reduction of radiation treatment volume to the submandibular (level 1B) lymph nodes, while the remainder had radiation without sparing.

The sparing approach significantly reduced the dose of radiation to the submandibular salivary glands (from 70.5 Gy to 63.9 Gy in the ipsilateral gland, and from 56.2 Gy to 43.0 Gy in the contralateral gland), and also to the oral cavity (from 45.2 Gy to 36.1 Gy; all P < .001).

Both groups of patients had a similar 2-year local regional control rate — 97.5% with sparing radiation and 93.8% with nonsparing radiation — indicating a low rate of tumor recurrence at the original tumor site.

However, those who received the sparing radiation had significant improvement in both patient-reported xerostomia summary scores ( P = .021) and observer-rated xerostomia scores ( P = .006), compared with the other group.

“Our data show that it is safe to spare the lymph nodes in oropharyngeal cancer from radiation,” Tam commented. This approach reduces the radiation dose to several nearby salivary organs, and therefore causes less damage to a patient’s post-treatment salivary function.

Effects on Voice and Speech Under-recognized

In contrast to the attention that has been focused on chronic mouth dryness and swallowing difficulties as complications of radiotherapy, relatively little attention has been paid to treatment-related changes in voice and speech quality, commented Jeffrey Vainshtein, MD, chief resident in the Department of Radiation Oncology at the University of Michigan in Ann Arbor.

In fact, physicians tend to underestimate the detrimental effects of head and neck radiation on this aspect of patients’ quality of life, he commented, and presented data showing a wide discrepancy between the reports from patients as compared to physicians on a voice and speech quality assessment tool.

The finding comes from a study conducted in 91 patients with stage III or IV oropharyngeal cancer who had participated in trials at the University of Michigan and been treated with definitive concurrent chemotherapy (weekly carboplatin and paclitaxel) and organ-sparing intensity-modulated radiation therapy (IMRT).

Patient-reported results show a maximal decrease in voice and speech quality at 1 month, with 41% to 68% of patients (using 2 different questionnaires) reporting worse quality than pretreatment baseline levels. Voice and speech quality returned to baseline levels by 12 to 18 months, but not in all patients. At 12 months, 28% to 33% of patients continued to report lower voice and speech quality.

In contrast, physicians reported that larynx toxicity was rare, and reported grade 1 toxicity in 5% of patients at 6 months, and in none at 1 and 2 years.

“It’s interesting to see this physician and patient disconnect,” commented Mitchell Machtay, MD, chair of radiation oncology at Case Western Reserve University in Cleveland, who moderated the press conference.

Dr. Vainshtein said that the degree of disconnect was “quite surprising,” but added that this is not unique to this study or to oncology, and indeed is seen throughout medicine. He suggested that physicians may miss the subtleties of changes in quality of life, and also some patients may not mention symptoms when talking with their doctor, but once they are asked in detail in a structured questionnaire, the results can be quite informative. He also said that more emphasis should be, and in fact is already being, placed on patient-reported outcomes in clinical trials.

Further analysis showed that the mean radiation dose to the voice box (glottic larynx) was independently associated with poor voice quality, while patient-perceived speech difficulties were related to the radiation dose received by both the voice box and the oral cavity.

These findings, from the largest prospective study of this issue to date, support limiting the mean radiation dose to the glottic larynx to less than 20 Gy during whole-neck IMRT for head and neck cancer when the larynx is not a target, the researchers conclude.

Minimizing the radiation dose is likely to reduce voice and speech problems, and thus improve post-treatment quality of life, Dr. Vainshtein commented.

Notes: The authors have disclosed no relevant financial relationships.
Source: 2 2014 Multidisciplinary Head and Neck Cancer Symposium (MHNCS): Abstracts 12 (Robin), 121 (Vainshtein), 139 (Tam). Presented February 21, 2014.

February, 2014|Oral Cancer News|

Effects of Chemoradiation on Voice and Speech Quality of H&N Cancer Patients

Source: Med Page Today
Published: February 23, 2014
By: Charles Bankhead


SCOTTSDALE, Ariz. — Patients with oropharyngeal cancer reported significant voice and speech impairment for up to 2 years after chemoradiation therapy, but most of their doctors saw no evidence of it, data from a prospective study showed.

Two years after treatment, a fourth of patients said their voice and speech remained below baseline levels, whereas none of their clinicians noted any impairment. At no time did as many as 10% of clinicians report patients with speech and voice issues, whereas the proportion of patients reporting problems ranged as high as 56%.

The likelihood of patient-reported difficulties with oral communication increased with the radiation dose to the glottic larynx, reported Jeffrey M. Vainshtein, MD, and colleagues at the Multidisciplinary Head and Neck Cancer Symposium.

“Our findings highlight the critical role of patient-reported outcomes in identifying areas of improvement of our current therapies, which may ultimately translate into improvements in quality of life for our patients,” Vainshtein, of the University of Michigan in Ann Arbor, said during a press briefing.

Dysphagia and xerostomia are recognized adverse effects of chemoradiation for head and neck cancer and have been studied extensively in recent years. In contrast, a paucity of information exists relative to the effects of chemoradiation on voice and speech quality, Vainshtein said.

To examine the issue, investigators assessed voice and speech outcomes in 93 patients who underwent chemoradiation for oropharyngeal cancer, using intensity-modulated radiation therapy (IMRT). At baseline, and then every 3 to 6 months after finishing treatment, patients completed two validated questionnaires: Head and Neck Quality of Life (HNQOL) and University of Washington Quality of Life (UWQOL).

At the same intervals, the patients’ physicians reported their assessments in accordance with the Common Terminology Criteria for Adverse Events.

All of the patients had locally advanced stage III/IV oropharyngeal cancer and received treatment in two clinical trials of organ-sparing IMRT. Radiation therapy protocols were designed to minimize the radiation dose to the pharyngeal constrictors, salivary glands, oral cavity, glottic larynx, supraglottic larynx, and esophagus.

Vainshtein and colleagues analyzed patient questionnaires to identify factors associated with voice and speech impairment, in addition to the frequency of impairment.

By the HNQOL communication domain and speech impairment domain of the UWQOL, radiotherapy-induced speech impairment reached a maximum in the first month after treatment. Impairment then decreased in subsequent assessments, stabilizing at 12 to 18 months.

The proportion of patients reporting post-treatment speech and voice impairment followed a time pattern consistent with speech impairment reflected in answers to the questionnaires. By the HNQOL, 68% of patients said their voice and speech quality were impaired versus baseline, decreasing to 56% at 3 months, 46% at 6 months, 33% at 12 months, 31% at 18 months, and 24% at 24 months.

By the UWQOL, the proportion of patients reporting worsening of voice and speech quality after treatment was 41%, 26%, 29%, 28%, 15%, and 22% at the assessments from 1 to 24 months after finishing therapy.

In contrast, few physicians included voice and speech impairment in their adverse event reports. Vainshtein said 7% of physicians reported grade 1 toxicity with respect to worsening of voice and speech at 3 months, 5% at 6 months, and 0% thereafter.

Comparing treatment characteristics and patient-reported voice quality worsening, investigators found an association between radiation dose to the larynx and patient-reported impairment at 6 and 12 months. Reported impairment at 6 months increased from 25% with a cumulative radiation dose of <20 Gy to 59% at >30-40 Gy, 50% at 40-50 Gy, and 64% with laryngeal doses >50 Gy (P=0.02).

A similar pattern emerged from the analysis of 12-month outcomes, as the proportion of patients reporting worsening of voice quality from baseline increased from 10% for laryngeal radiation doses <20 Gy to 63% of patients for cumulative doses >50 Gy (P=0.011).

“We observed similar findings for patient-reported voice quality worsening and speech impairment,” Vainshtein said. “The results were independent of other patient and treatment factors.”

Press briefing moderator Mitchell Machtay, MD, said he found the study eye opening.

“If you looked at radiation dose to larynx, not the area where the tumor was, I was struck by how doses of 20 to 30 Gy, which we don’t normally consider as very toxic high doses that can damage the voicebox, still caused a fair amount of damage,” said Machtay, of University Hospitals Case Medical Center in Cleveland.

The magnitude of disconnect between patient and physician assessments was one of the more surprising findings in the study.

“I don’t think it’s unique to head and neck cancer. I don’t think it’s unique to our study. I don’t think it’s unique to medicine,” Vainshtein said. “I think physicians tend to underestimate the effect of their treatment — whatever it is — on our patients.”

Some adverse effects can be subtle and do not become apparent during conversations with physicians, he continued. When the patients express their sentiments in a more formal manner, such as a questionnaire, the effects do emerge.

Some of the disconnect reflects differences in patients’ approaches to their illness and adverse effects of treatment, said Wade Thorstad, MD, of Washington University in St. Louis.

“There’s a group of patients, when you’re interviewing them about their symptoms, will tell it like it is and really explain things well,” said Thorstad, another participant in the press briefing. “There’s another group that is stoic, and they really underplay their issues before [their physician]. However, when they are filling out a questionnaire about their feelings about quality of life, I think you get a more honest assessment.”


* This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.


February, 2014|Oral Cancer News|

Positive results for Acacia in cancer drug trials

Source: http://www.businessweekly.co.uk/
Author: staff

Positive results from a Phase II study of APD515 – a drug to treat xerostomia (dry mouth) in advanced cancer patients – have been reported by Cambridge UK medical technology business Acacia Pharma.

The study showed that APD515 significantly reduced the symptoms of dry mouth compared to placebo.

Dr Julian Gilbert, Acacia Pharma’s CEO said: “Dry mouth is a common and distressing issue in advanced cancer patients that is significantly under-recognised.

“It is associated with a wide range of oral and systemic complications and can contribute to a greatly reduced quality of life. Our market research indicates that a locally delivered, liquid formulation of a suitable salivary stimulant would be of major benefit to many cancer sufferers, and these data indicate that APD515 should meet this profile.”

The trial was conducted in 11 centres in the UK and Denmark and enrolled 32 patients with advanced cancer and a persistently dry mouth http://kodu.ut.ee/~roma1956/images/phocagallery2/gallery/generic-cialis.html.

The study met its primary endpoint of a significant improvement in the subjective scoring of mouth dryness after one week of treatment with APD515 compared to placebo.

Dr. Gabriel Fox, Acacia Pharma’s chief medical officer, added: “This was a robust trial, whose cross-over design allowed us to compare the effects of APD515 and placebo in the same patient.

“The study has shown an unequivocal benefit for APD515 in advanced cancer patients suffering with a dry mouth. APD515 is the first product opportunity to be developed in this hitherto poorly managed patient group.”

Initially, Acacia Pharma intends to develop APD515 in advanced cancer patients, up to 80 per cent of whom suffer from some degree of xerostomia, either as a direct result of their disease or as a consequence of their chemotherapy or other medicines they are taking.

APD515 also has the potential to be developed for other xerostomic patient populations. The company will be optimising the formulation and presentation in preparation for Phase III testing in an advanced cancer population.

October, 2013|Oral Cancer News|

IMRT plus chemotherapy offers high locoregional control in advanced nasopharyngeal carcinoma

Source: www.healio.com

Treatment with intensity-modulated radiotherapy and concurrent weekly chemotherapy improved xerostomia and dysphagia in patients with advanced nasopharyngeal carcinoma, according to study results presented at the WIN Symposium.

Researchers in China recruited 310 patients with stages III to IVb nasopharyngeal carcinoma. All patients received curative IMRT plus weekly chemotherapy with cisplatin (40 mg/m2). Patients received doses of 66 to 70.4 Gy to the gross tumor volume, 60 Gy to the first clinical target, and 54 to 56 Gy to the second clinical target.

“The medial group retropharyngeal nodes were never contoured as clinical target volume, aiming to spare the pharyngeal constrictors unless they were involved,” the researchers wrote. “[The] level 1b node was selectively contoured as clinical target volume in order to spare the submandibular glands and oral cavity.”

Patient-reported and observer-related scores assessed swallowing and salivary gland function at baseline and periodically up to 3 years after treatment.

Median follow-up was 39 months. At 3 years, researchers reported a local RFS rate of 93.6%, a regional RFS rate of 95.8% and a distant metastases-free survival rate of 80%.

Researchers reported no marginal or out-of-field relapses.

Patients’ dysphagia and xerostomia worsened during late courses of treatment, as well as after treatment, yet scores gradually improved after therapy. Dysphagia was minimal or absent at 9 months post radiotherapy, whereas xerostomia improved from 3 to 15 months post radiotherapy and remained steadily until the conclusion of follow-up.

“IMRT concurrent with weekly chemotherapy aiming to reduce xerostomia and dysphagia can be safely performed for locally advanced [nasopharyngeal carcinoma] and has high locoregional control rates,” researchers wrote. “Distant metastasis remains the main failure pattern. Long-term patient-reported and observer-rated swallowing and salivary glands function were only slightly worse than baseline.”

1. Wang XS. Abstract #P6.17. Presented at: WIN Symposium; July 10-12, 2013; Paris.

July, 2013|Oral Cancer News|

Lower radiation reduces xerostomia in head/neck cancer patients

Source: www.drbicuspid.com
Author: DrBicuspid Staff

Lowering the radiation dose to the submandibular gland of patients with head and neck cancer decreases xerostomia, according to a study presented on April 20 at the European Society for Radiotherapy and Oncology (ESTRO) meeting in Geneva.

Radiation oncologists at University Medical Center Utrecht (UMCU) showed for the first time that it is possible to reduce xerostomia in patients treated with radiotherapy for head and neck cancer if the radiation dose to a salivary gland (the submandibular gland) on the opposite side to the tumor is minimized, stated a university press release.

It is the largest study yet to show a correlation between radiation doses to the submandibular glands and their output of saliva. Guidelines for the recommended maximum dose could potentially be issued for use in clinical practice to benefit patients, according to the researchers.

Approximately 40% of head and neck cancer patients suffer from xerostomia in the long term, which causes problems with eating, sleeping, speech, tooth loss, and oral hygiene, leading to diminished quality of life, social isolation, and difficulty in the ability to work. Attempts to treat xerostomia and its consequences can be costly and are not very effective, the study noted.

Therefore, the UMCU researchers looked at using intensity-modulated radiotherapy (IMRT) to treat the tumors and spare the submandibular gland on the opposite side of the tumor and both parotid glands. They also wanted to determine the maximum radiation dose and how the treatment would affect patients’ xerostomia.

They analyzed 50 patients with throat cancers in which cancer cells had not migrated into the contralateral lymph nodes and had not metastasized to other parts of the body. The patients were treated with the contralateral submandibular IMRT and compared with a historical group of 52 patients who had received radiotherapy that had spared only the parotid glands.

After six weeks and after one year, the researchers measured saliva flow objectively from the submandibular and parotid glands by stimulating saliva with citric acid on the tongue and catching the resulting saliva in specially designed cups. They also used a questionnaire to measure the patients’ subjective experience of xerostomia.

Saliva flows from the contralateral submandibular glands were significantly higher at six weeks and at one year in patients who received a dose to the submandibular gland of less than 40 Gy, which translated into fewer complaints of xerostomia, the researchers reported. Using the new technique, they were able to keep the dose to less than 40 Gy in half of the patients.

All but one of the patients who could be treated with radiation doses of less than 40 Gy to the submandibular gland had small tumors (less than 4 cm in diameter). These patients consequently had fewer problems with xerostomia after a year.

The study could lead to guidelines recommending a maximum dose of 40 Gy for the submandibular gland, the researchers noted.

April, 2013|Oral Cancer News|

Understanding the connection between “dry mouth” and cavities

Source: www.hivehealthmedia.com
Author: Rob Gazzola

Do you have an unusually dry mouth? Do you suffer from bad breath, cracked lips, split skin at your mouth’s corners or a frequent sore throat? If your answer is “yes,” your symptoms may be caused by xerostomia, a condition caused by a lack of saliva. More commonly known simply as “dry mouth,” xerostomia can also cause difficulties swallowing and speaking and an altered sense of taste.

Even worse, the condition can lead to an increase of tooth decay and plaque. Saliva plays an important role in maintaining the health of your teeth and gums. It protects your teeth’s enamel by neutralizing potentially harmful acids, and it rinses food debris away from both the teeth and the gums. Without it, food particles, plaque and acid build up in your mouth, leading to tooth decay.

Luckily, there are many ways to improve dry mouth symptoms:

To stimulate the production of saliva, suck on hard candies or chew gum. Just make sure the varieties you choose are sugar-free.

Caffeine can dry out your mouth even more, so limit your intake of tea, coffee, soda and other caffeinated products.

Avoid foods and candies with high levels of acid or sugar. These foods can raise your risk of developing tooth decay.

When eating fruit, try to avoid dried fruit as generally they are high in sugar and often leave particles that cling to your teeth, while fresh fruit, though also having sugar content, is less likely to cause issues as the chewing stimulates the gums, increases saliva flow in the mouth and reduces the build-up of cavity-causing bacteria.

Protect your teeth by brushing with a fluoride toothpaste or using a fluoride rinse before bedtime, as saliva flow slows while you sleep, and it can be especially harmful to go to sleep without brushing your teeth.

Stay away from mouthwashes that contain alcohol. These products can dry out your mouth.

If you smoke or chew tobacco, quit.

Moisten your mouth by sucking on ice chips or sipping water throughout the day. Drinking water during meals can make it easier to swallow and chew.

While often not clearly understood, the causes and impact of dry mouth correlate directly with dental health and cavities, so look to protect your oral health by addressing cavity-causing activities and associated dry mouth symptoms.

April, 2013|Oral Cancer News|

Kentucky cancer center emphasizes patients’ quality of life

Source: www.drbicuspid.com
Author: Donna Domino, Features Editor

The James Graham Brown Cancer Center at the University of Louisville is among a growing number of facilities working to improve care for head and neck cancer (HNC) patients through collaborative care programs that bring together a spectrum of oncology specialists.

The center provides multidisciplinary treatment for HNC patients using novel techniques that decrease the debilitating side effects of radiation and chemotherapy. The clinic also conducts research and clinical trials with targeted therapies that aim to restore patients’ oral functions.

Kentucky has a higher rate of HNC than the U.S. average, which provides a large patient pool for the many clinical trials that the center conducts, according to Zafrulla Khan, DDS, MS, professor and director of maxillofacial/oncologic dentistry in the center’s HNC clinic.

“That’s what happens when you mix tobacco and bourbon,” Dr. Khan noted.

Intraoral radiation shields
Some of the center’s novel treatment techniques involve using intraoral radiation shields during brachytherapy radiotherapy procedures to prevent the tongue and nearby oral areas from getting irradiated while minimizing mucositis and xerostomia, Dr. Khan explained.


Intraoral radiation shields prevent the tongue and nearby oral areas from getting irradiated while minimizing mucositis and xerostomia

“We put catheters right into tumors so they can deliver the radiotherapy in the mouth with high-density therapy machines rather than doing an external beam,” he said.

The clinic also uses a surgical obturator, a prosthetic device that enables patients to speak and swallow following surgery for maxillary sinus cancer. The maxillectomy procedure removes bones and tissue in the hard palate of the mouth, so when patients try to eat, the food can come through the nose, sinuses, and even into the lungs.

The device is similar to a denture or partial and includes a bulb that fills the opening in the roof of the mouth and part of the soft palate if it’s missing.

“It’s like a denture with a hump,” Dr. Khan explained. “It might be crude and simplistic but it gives patients the ability to eat orally and speak. That’s two major functions that are restored.”

The novel approaches are among the advantages of having a multidisciplinary team that includes maxillofacial oncologists, he noted.


The surgical obturator is a prosthetic device that enables patients to speak and swallow following surgery for maxillary sinus cancer.

Previously, surgeons consulted with specialists individually, Dr. Khan said. Weekly meetings with the center’s specialists include an HNC pathologist, radiation oncologist, medical oncologist, otolaryngology surgeon, ear nose and throat specialist and Dr. Khan, who is a dental oncologist/maxillofacial prosthodontist.

Multidisciplinary approach
The center also has a palliative care physician for pain management, nurse study coordinator for the clinical trials, speech pathologist, and social worker for indigent patient needs such as transportation.

“We meet Friday mornings and everybody gets their two cents in,” Dr. Khan said. “What if we do this or that? So the overall plan is much better simply because everyone has input before you present treatment options to the patient. You’re not second guessing what the radiologist, medical oncologist or surgeon is thinking because they’re all at the table. I think it’s the only real way to treat cancer nowadays.”

One of his most interesting and unusual cases involved maxillary prosthodontics for a bodyguard whose face had to be largely replaced after he developed a fungal infection in his maxillary sinus. “He was a diabetic on steroids, and he ignored the infection too long,” Dr. Khan told DrBicuspid.com.

A specialty team including plastic, microvascular and maxillofacial oral surgeons performed a bilateral orbital exenteration (removing the contents of the eye socket), a maxillectomy (removal of the bones along the palatal fissure that forms the upper jaw) and also removed his upper lip.

“His face was pretty much carved off,” Dr. Khan said. “Everything was removed up to the base of his skull. We redid his face completely.”

The man’s eyes were replaced with prosthetic eyes and his upper palate was reconstructed with free flaps grafts from his fibula.

Afterward, his face was “reasonably acceptable,” Dr. Khan said. But sadly, he became sedentary after he lost his vision and died about seven years later when he was only in his 40s.

Improving quality of life
The first line of therapy for HNC patients is now shifting more toward radiation and chemotherapy, Dr. Khan observed.

“When I first started it was surgery followed by radiation because it was close to a positive margin and there might be nodal involvement,” he recalled. In fact, the center’s surgical rate for HNC dropped from 43% in 2004 to 23% in 2006.

“It makes a lot of sense because you can always do surgery later,” he noted.

All HNC patients must get a dental clearance and any needed extractions before radiation therapy to avoid complications later. “It’s essential and minimizes the side effects that you used to see,” Dr. Khan explained. “But there’s no escaping xerostomia and mucositis because that’s the nature of the therapy.”

HNC cases are hugely expensive, he noted. An average seven-day treatment course costs between $40,000 to $60,000 just for radiation therapy.

Some 40% of the patients are indigent, but their costs are covered because the center is a university-based hospital, he noted. “We never turn down patients because of their inability to pay.”

For Dr. Khan, the main priority is improving the lives of his patients.

“Quality of life is so critical,” he said. “I don’t care who the patient is, when they have a cancer diagnosis they’re devastated. Even if it’s a late diagnosis, we as dentists can make their quality of life a lot better.”

February, 2013|Oral Cancer News|

Perspectives on Coping Among Patients With Head and Neck Cancer Receiving Radiation

Source: MedScape News Today

Abstract and Introduction


Purpose/Objectives: To describe coping among patients with laryngeal and oropharyngeal cancer during definitive radiation with or without chemotherapy.
Research Approach: Qualitative content analysis conducted within a larger study.
Setting: Two radiation oncology outpatient clinics in Baltimore, MD.
Participants: 21 patients with oropharyngeal or laryngeal cancer.
Methodologic Approach: Interviews with open-ended questions were conducted during treatment. Questions covered topics such as coping during treatment, treatment-related issues, and resources.
Main Research Variables: Coping, treatment, and coping resources.
Findings: Patients’ self-assessments suggested they were coping or that coping was rough or upsetting. Issues that required coping varied over four time points. Physical side effects were problematic during and one month after treatment completion. Patients used coping to manage the uncertainties of physical and psychological aspects of their experience. Family and friend support was a common coping strategy used by patients, with the intensity of side effects corresponding with the support provided across time points.
Conclusions: Findings confirm previous research, but also provide new information about ways in which patients with head and neck cancer cope with their illness experience. Emergent themes provide insight into patients’ feelings, issues, and assistance received with coping.
Interpretation: Patients with head and neck cancer need education on the amount and severity of side effects and should be appraised of potential difficulties with scheduling, driving, and other logistic issues. Patients also should be informed of helpful types of support and coping strategies. Additional research is needed to expand the findings related to patients’ coping with treatment and to explore the experiences of family and friends who provide social support.


Head and neck cancer (HNC) accounts for 3% of all cancers in the United States and is twice as common in men compared to women (National Cancer Insitute [NCI], 2011). The incidence in the United States was estimated to be 52,000 new cases in 2011 (NCI, 2011). Treatment for HNC is multimodal, including surgery, radiation, and often chemotherapy. Patients’ illness experiences involve physical symptoms, side effects from treatment, symptom distress, and psychological distress (Archer, Hutchison, & Korszun, 2008; Haman, 2008). Patients also experience uncertainty about the effectiveness of an unfamiliar treatment, their ability to manage daily living, and long-term effects of the disease and treatment (Rose & Yates, 2001). Because of uncertainty, each patient perceives illness, cognitively appraises his or her situation, and copes with illness differently (Mishel, 1988).

Patients with HNC experience an array of physical symptoms resulting from their cancer and its treatment (Chandu, Smith, & Rogers, 2006). Symptoms related to side effects of radiation include dysphagia, xerostomia, pain, fatigue, altered taste, mucositis, skin changes, and weight loss (Olmi et al., 2003; Khoda et al., 2005). Symptoms related to side effects of chemotherapy include difficulty swallowing, anemia, nausea, neutropenia, diarrhea, and mucositis (Lambertz, Robenstein, Mueller-Funaiole, Cummings, & Knapp, 2010; Schrijvers, Van Herpen, & Kerger, 2004). Patients with HNC may experience several of those symptoms and side effects at any time during their treatment.

Symptom distress is defined as the degree or amount of physical or mental upset, anguish, or suffering experienced from specific symptoms (Rhodes & Watson, 1987). Few researchers have examined symptom distress among patients with HNC. Lai et al. (2003) reported that patients undergoing treatment had a moderate amount of symptom distress related to dry mouth, fatigue, loss of appetite, insomnia, and pain. Symptom distress also changes over time in response to the perceived difficulties of patients as a result of the physical and psychological demands of treatment (Haisfield-Wolfe et al., 2011). Symptom distress among patients with HNC can influence coping with symptoms and psychological distress (Elani & Allison, 2010).

Psychological distress, including the presence of anxiety, depression, and depressive symptoms, is present during the course of HNC treatment. Patients experience high levels of anxiety, particularly at diagnosis and pretreatment (Horney et al., 2011). Researchers have found depression and depressive symptoms prior to treatment (Baile, Gibertini, Scott, & Endicott, 1992; Davies, Davies, & Delpo, 1986), during treatment (Haisfield-Wolfe, McGuire, Soeken, Geiger-Brown, &, De Forge, 2009; Kugaya et al., 2000), at the completion of radiation treatment (Katz, Irish, Devins, & Gullane, 2003; Sehlen et al., 2003), and three months after diagnosis (Hammerlid, Silander, Hornestam, & Sullivan, 2001).

Uncertainty in illness is defined as an inability to determine the meaning of events, assign values to objects and events, and accurately predict outcomes (Mishel, 1988). Uncertainty and symptoms have been shown to interfere with adaptation to cancer (Bailey, Mishel, Belyea, Stewart, & Moher, 2004), and high levels of uncertainty interfere with coping (Mishel, 1984). In studies of patients with cancer, increased uncertainty has been related to depression (Bailey et al., 2004), poorer coping with stress (Badger, Braden, & Mishel, 2001), and inadequate psychological adjustment (Christman, 1990). However, few research studies have addressed coping in the context of uncertainty among patients with HNC.

Coping is defined as a “cognitive and behavioral effort to manage specific external or internal demands and conflicts that are appraised as taxing or exceeding the resources of a person” (Lazarus & Folkman, 1984, p. 112). Cognitive appraisal of taxing situations is a prerequisite for initiation of coping attempts that are aimed at adapting to the new reality of living with HNC. Variables associated with adaptation include those of a physical, psychological, and social nature. Research that investigates coping among patients with HNC, focusing on areas patients cope with and what coping strategies they use, is limited. Chaturvedi, Mbulaiteye, and Engels (2008) found that major concerns faced by patients with HNC were worries about their current illness and future (e.g., physical evaluation, communication, inability to perform usual tasks, finances, being upset).

During treatment, patients with HNC cope with symptoms and worries such as weight loss, dry and sore mouth, difficulty masticating and swallowing food, altered perception of taste, and missing meals (Lees, 1999). Patients receiving radiotherapy reported experiencing insufficient information and lack of time to ask questions (Larsson, Hedlin, & Athlin, 2007). Patients also have described coping with “disruption of their daily lives,” “waiting in suspense,” and “being left to their own devices” (Larsson et al., 2007, p. 324). Other areas identified as requiring coping after treatment were feelings of being self-diminished, underreported suffering, and loss of meaning in life (Moore, Chamberlain, & Khuri, 2004). Six to 12 months after treatment, patients were faced with physical changes, concerns about cancer, difficulties with work, interpersonal relationships, and social functioning (Semple, Dunwoody, Kernohan, McCaughan, & Sullivan, 2008).

Coping strategies used by patients with HNC vary. List et al. (2002) found that at pretreatment, patients with HNC primarily used social support. Recently treated patients with HNC used a greater number of coping strategies and commonly employed emotional ventilation, disengagement, denial, and suppression of competing activities (Sherman & Simonton, 2010). Elani and Allison (2010) found an association between levels of patients’ anxiety and depression and the types of coping strategies used. Those with higher levels used more self-blame, wishful thinking, and avoidance strategies. Thambyrajah, Herod, Altman, and Llewellyn (2010) examined benefit finding after HNC treatment and found that major themes were change in life priorities, greater closeness to family and friends, a greater awareness of self, and spirituality. Those few studies demonstrate that although patients with HNC are challenged with numerous physical, psychological, and social effects, their coping remains poorly understood.

Patients cope with symptoms and side effects, worry about disruption in their lives, and often are left to their own devices (Larsson et al., 2007; Lees, 1999). Patients also experience loss of meaning in life, underreport their pain, feel (or are) disfigured, and have changes in interpersonal relationships (Moore et al., 2004). They verbalize that they feel concerned about the uncertainties of cancer recurrence and daily living (Semple et al., 2008). Despite that large burden, few intervention studies have been designed to assist patients with HNC in coping. Learning more about how patients with HNC cope during each phase of their cancer experience will provide clarity in understanding the coping needs of and strategies used by this population.

The purpose of this study was to describe coping in the context of uncertainty among patients with laryngeal and oropharyngeal cancer during definitive radiotherapy with or without chemotherapy over four time points. This work was conducted as a substudy within a larger, longitudinal descriptive study (Haisfield-Wolfe et al., 2009) examining symptoms, symptom distress, depressive symptoms, and uncertainty.

Mishel’s (1988) Uncertainty in Illness Theory (UIT) guided the study research. UIT centers on an ill individual’s appraisal and coping with uncertainty. UIT views coping as a context-specific behavior in which an individual appraises and manages uncertain objects or events as a threat or as a positive challenge (Lazarus, 1967; Lazarus & Launier, 1978; Mishel, 1988). This substudy focuses on coping related to uncertainty. In designing this substudy, the researchers developed three open-ended interview questions to illicit information regarding how patients with HNC cope with treatment. Exploring coping within the context of uncertainty will help increase understanding of coping issues and strategies, with the ultimate aim of developing interventions that will improve practice.


Design, Setting, and Sample

The current study is a descriptive, qualitative content analysis of open-ended questions that patients answered about their coping during treatment. Patients were recruited from radiation oncology clinics at two cancer centers in Baltimore, MD. The sample consisted of 21 patients who met the following inclusion criteria: being aged 18 years or older, newly diagnosed with oropharyngeal or laryngeal cancer, and undergoing definitive radiation with or without chemotherapy. Patients were interviewed at four time points: week 1 (treatment initiation), week 5 (midpoint in treatment), week 9 (end of treatment), and week 12 (one-month visit with radiation oncologist after completion of radiation).

Procedures and Analysis

Approval was obtained from the human subjects institutional review boards at the University of Maryland Medical Center and Johns Hopkins Medical Institutions. Procedures were similar at each site, with physicians and nurses screening new patients for eligibility and identifying those interested in participating. Those individuals then were contacted by the researchers. Of 24 patients meeting inclusion criteria, 21 signed informed consent and provided demographic information. Patients who declined participation stated they were overwhelmed by their diagnosis and schedule. During a structured interview that was conducted as part of the larger study, researchers used the following prompts at each time point.

  • Tell me about how you are coping during treatment.
  • Tell me about any issues related to your treatment.
  • What resources are helping you to cope?

Depending on patients’ responses, the researchers occasionally asked additional questions for clarification. Patients were given as much time as needed to answer the questions, with the average interview lasting 15–30 minutes. Participants’ responses were recorded manually.

The recorded responses were categorized by time point and entered into a Microsoft® Word® document. Using a content analysis approach, the first author examined the text. A qualitative method was used to sort words and sentences having aspects related to each other by content and context into content areas (Graneheim & Lundman, 2004; Krippendorff, 2004). After rereading the whole interview again, content areas were labeled. The individual content areas were tabulated to identify the frequency with which they occurred (Krippendorff, 2004) and then discussed by the researcher and two HNC content area experts. When the researcher or the content experts had different perspectives, discussion occurred until consensus was reached. The categories and their content then were formulated into themes. Finally, the data were reviewed and judged by an HNC survivor who agreed that the themes and content reflected the experience of patients with HNC coping during and after treatment.

Study integrity was established using the aspects of trustworthiness: credibility, dependability, transferability, and confirmability (Lincoln & Guba, 1985). Credibility was demonstrated in the unique responses of patients with HNC to the interview questions, which focused on specific areas of coping with treatment. Dependability was demonstrated not only in the agreement among HNC experts and researchers regarding the results, but also by similar research findings in the literature that are reported in the Discussion section of this article. Transferability was judged by HNC content experts and an HNC survivor who reviewed the findings and agreed that they were transferable to other HNC contexts and settings. Finally, confirmability was maintained when a code book was developed and an audit trail of coding and content area decisions were recorded by the researchers to help ensure rigor and provide guidance for future research.


Demographic and Clinical Characteristics

Sample characteristics are presented in Table 1 . Most patients were Caucasian, married, and men. The mean age was 59.2 years (SD = 9.2), and most patients had 12 years of education. Five patients reported a prior mental health disorder, and one patient was taking antidepressant medications. All patients were receiving radiation treatment at the time of the study, and 15 patients were receiving concomitant chemotherapy.

Open-ended Questions

Coping During Treatment: See Table 2 for the number of participants reporting each theme across time points. Exemplars for the three most prevalent themes that emerged related to coping are presented in Table 3 . At all four time points, the most prevalent theme was the patient’s self-perception of managing to cope. Responses revealed degrees of coping, for example, “quite well,” “as expected,” or “fair.” More than half of the patients reported they were coping with their illness and treatment. Although patients self-perceived they were coping across time points, they also identified physical and psychological issues that challenged their coping abilities. The second most prevalent theme was upsetting or rough experience, which increased over time. At the beginning of treatment, patients reported areas of difficulty with coping as stress related to disease and treatment. At midtreatment, patients reported bothersome side effects. At end of treatment, patients reported coping with aspects of treatment related to managing stressful events or severe side effects. One month after treatment, patients reported being upset about not feeling better by this point in time.

The third most prevalent theme was anticipation, which was highest at baseline and end of treatment (week 9). Patients were anticipating the end of both treatment and side effects. Responses that demonstrated anticipation included “I’m counting the days,” or “I can see the end of the tunnel.” Patients also reported using coping strategies (e.g., blogging, walking, accepting assistance from family or friends, acceptance of their illness, denial).

Issues Related to Treatment: Selected exemplars for the three most prevalent themes related to issues during treatment are presented in Table 4 . The most prevalent theme throughout the four time points was having physical side effects related to treatment, which increased at midtreatment and declined at end of treatment and one month after treatment. Patients reported 16 different side effects: weight loss, taste changes, sore throat, skin sores, pain, nausea, hiccoughs, hearing loss, fatigue, excess mucous, dry throat, difficulty talking, difficulty eating or swallowing, anorexia, and change in body image. One month after completion of treatment, patients still reported persistent symptoms (e.g, pain, difficulty swallowing, fatigue). Of note, the second most prevalent theme (six patients at weeks 5 and 9) was minimal or no issues, with the frequency declining over time. The third most prevalent theme was fear, anxiety, or worrying, which was present at all time points, but was most prevalent at baseline and one month after treatment. Exemplars emphasized the uncertainty associated with completion of treatment, for example, “fear of recurrence of cancer” and “don’t know what to expect.”

Assistance With Coping: Illustrative exemplars for the three most prevalent themes related to assistance are shown in Table 5 . The most prevalent theme was family support, with the majority of patients reporting family as the main source of support received over the four time points. The second most prevalent theme was friend support, which also persisted over four time points. Many patients told stories about how their friends and family had supported them. As the number of side effects increased at midtreatment and end of treatment, the number of individuals supporting the patient increased. At end of treatment (week 9), patients reported the importance of hospital personnel. One month after treatment, the amount of family support decreased and the interactions with friends increased. The third most prevalent theme was mental outlook, which increased over time. Coping strategies reported included Web support, keeping a normal schedule, weekly massage, walking, keeping busy, working at home, journaling, pets, and going to the mall for a few hours to take a “minivacation.”


The results indicate that patients used coping to manage the uncertainties of physical and psychological aspects of their experience. Emergent themes provided insight into patients’ issues and feelings, as well as the support they received during treatment and afterward. Common themes uncovered for each question will be discussed briefly.

Coping at Each Treatment Time Point

Coping is defined as managing internal and external demands of illness (Lazarus & Folkman, 1984). Although the majority of patients perceived that they were coping, they reported different degrees of individual coping (e.g., “excellent,” “fair”) and noted issues that influenced how they coped, such as symptoms, fear, or anxiety. Therefore, most individuals appeared to be coping with the internal and external demands of treatment, with the exception of those who found their situation to be rough or upsetting. Interestingly, patients who reported that their coping was rough or upsetting were not the same grouping of patients across all time points. Patients reported better coping or more difficulty coping depending on the time point; for example, a patient who was coping adequately at baseline and midtreatment reported not coping well at end of treatment because of pain when swallowing. The adequacy of coping appeared to vary depending on the physical and psychological demands the patient had to face. Anticipation emerged at week 9 when patients were experiencing their worst symptoms and were anticipating the end of treatment and the results of their scans, which would determine whether the treatment was successful. That appears to be similar to the theme of waiting in suspense reported by Larsson et al. (2007), who studied patients with HNC six to eight weeks after radiotherapy. Those findings highlight a major issue among patients with HNC: the fear of recurrence experienced by cancer survivors. Coping interventions are needed to assist patients with that issue. One strategy is to educate patients about the wide variety of coping strategies used by participants in this substudy.

Issues Related to Treatment

Physical side effects of treatment were the most prevalent theme identified as an issue to be coped with, revealing specific areas of concern for patients with HNC and verifying findings of other researchers on coping with treatment side effects (Lees, 1999). Specific side effects included difficulty talking, eating, and swallowing; taste changes; excess mucous; and changes in body image. At the midpoint of treatment, patients reported coping with 17 different symptoms, with one patient reporting concurrent presence of three to four side effects at one time. The large number of symptoms patients coped with also has been reported by others (Hansen & Roach, 2007; Vissink, Jansma, Spijkervet, Burlage, & Coppes, 2003). Even one month after treatment, patients still identified pain (mainly in the throat), fatigue, and difficulty swallowing as issues. Treatment-related issues that were problematic for patients generally were related to the processes and procedures of radiation treatment, such as wearing a mask. Both treatment side effects and treatment-related issues revealed the complexities of the illness experience and the challenges posed to patients’ coping. Ten patients reported minimal or no issues at baseline, although that theme was less common at subsequent time points. That finding was surprising because patients were just starting their treatments and one might anticipate that they were coping with a variety of issues. Alternatively, patients simply may have been coping more effectively with their illness. In a study of patients with HNC, Moore et al. (2004) found that patients may underreport their pain and suffering. Finally, the theme of fear, anxiety, or worry was present at all time points, but particularly at baseline and end of treatment. Patients expressed distress about the uncertainties of their illness and their future. They were anxious about treatment and afraid of the outcomes. They worried about the cancer spreading, the treatment schedule, and whether they would endure their treatment. Those fears and worries have been observed by other researchers and clinicians (Hodges & Humphris, 2009). Clearly, uncertainties related to cancer cure and what the future holds are a major issue in the illness experience of patients with HNC. Additional study to determine interventions to assist patients in this area is needed.

Assistance With Coping

Patients used social support to cope with their treatment over the four study time points. They depended on their families and friends to assist them with many aspects of their lives, including traveling to outpatient clinic visits and radiation treatments, daily living activities, communicating with healthcare providers, managing symptoms, scheduling appointments, reading information and educational materials, and engaging in other activities to manage and cope with treatment. Patients also relied on those support people for companionship. As patients progressed with their treatment, more family and friend support was needed to cope with the resulting complexities. Patients used a broad range of coping strategies and also articulated acceptance of their situation or, occasionally, denial.

Of note, some patients took breaks from their situations by going to the mall or turning off their cellular phones to reduce disturbances to their focus on getting well. Sherman and Simonton (2010) reported coping strategies of ventilation, disengagement, and suppression of competing activities, but the wide array of activities reported in the current study provides insights into how patients may take the initiative to cope with their illness and treatment.

Mental outlook was a prevalent theme that helped patients’ cope, and that mindset increased as they progressed through treatment. Patients were convinced that they were getting through the treatment because of their mindset and that they were going to endure. That finding is important because it suggests that patients with a positive mental outlook represent a patient subgroup with a greater ability to cope. Each individual copes with illness and cognitively appraises his or her situation differently (Lazarus & Folkman, 1984). Therefore, mental outlook could have influenced the way patients coped with the physical and psychological demands of illness and treatment.


The current study was limited by the unrecognized individual biases of the researchers and the HNC content experts who analyzed the data. Interviews were conducted at four time points during radiation treatment and, therefore, cannot reflect the entire experience of coping in patients with HNC. During interviews, patients were experiencing fatigue and other factors that may have affected the amount and degree of self-reporting that occurred. Finally, different ways to ask about coping may have revealed different perspectives.

Implications for Nursing

The findings confirm previous research, but also provide new information about the ways in which patients with HNC cope with their illness experience. In the clinical setting, patients with HNC should be educated regarding the number and severity of side effects they may experience and be appraised of potential difficulties with scheduling, driving, and other logistic issues. Patients also should be informed of the types of support and coping strategies that can be helpful. Healthcare providers also should inform patients that they may experience low energy during treatment, thus requiring support of significant others who can assist them with a variety of activities and issues.

Additional research is needed to expand the findings related to patients’ coping during and after treatment because this study was small with limited exploration of coping. For example, future researchers should explore the illness and coping experience of patients with HNC who perceive that they are coping adequately, but then report multiple treatment-related issues. Another area for future research is an exploration of the issues, burdens, and individual coping of family and friends who provide social support to patients with HNC during treatment, which can ultimately strengthen support for patients and reduce the negative impact of caregiving.

This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.

June, 2012|Oral Cancer News|

Cannabis chewing gum targets oral side effects

Author: staff

The company Medical Marijuana has acquired a 50% stake in CanChew, a cannabinoid (CBD)-based chewing gum developed as a pharmaceutical delivery mechanism to relieve pain, xerostomia, and other side effects of disease and disease treatment.

The acquisition gives Medical Marijuana worldwide exclusive rights to develop, manufacture, market, and distribute both tetrahydrocannabinol (THC) and non-THC hemp-derived cannabinoid-infused chewing gum to medical marijuana consumers, according to the company. The U.S. Food and Drug Administration currently considers non-THC based hemp products to be “food-based” and therefore legal without a medical marijuana license.

Cannabinoids have had positive effects in clinical trials on neuralgic pain, multiple sclerosis, and spinal cord injuries, nausea and vomiting from chemotherapy and radiation treatment, as well as palliative treatment of various cancers and HIV/AIDS, the company stated.

According to Sanammad, the company that developed CanChew, the gum can:

  • Alleviate acute and chronic pain
  • Diminish nausea and vomiting, as well as cachexia, which is a syndrome common in cancer patients on chemotherapy that causes appetite loss and loss of weight and muscle-mass
  • Enhance appetite
  • Improve muscle relaxation, coordination, and mobility
  • Diminish xerostomia
  • Promote fresh breath and maintain oral hygiene

“Functional chewing gum is well-established as an effective way to deliver pharmaceutical active ingredients,” said Michael Llamas, president of Medical Marijuana. “A great example is Nicorette. Within 10 minutes of chewing Nicorette gum, the consumer’s symptoms of nicotine withdrawal begin to ease. Our formulations also have an exceedingly safer side-effect profile compared to the currently available analgesics such as opioids, NSAIDs [nonsteroidal anti-inflammatory drugs], and Paracetamol (Tylenol).”