Advances in Head and Neck Cancers Yield New Clinical Implications for Nurses

Julie Scott, DNP, ANP-BC, AOCNP

Much has changed in the past decade in cancer treatments, and the management of head and neck cancers is no exception. The discovery of the impact the human papillomavirus (HPV) has on some oropharyngeal cancers led to new staging guidelines, and the introduction of immunotherapy for advanced disease has improved outcomes and quality of life for many individuals with head and neck cancer. In light of these changes, nurses have had to change and adapt their practice accordingly.

Treatments can be exhausting for patients with head and neck cancer and may lead to many temporary and long-term adverse events, such as dry mouth, dysphagia, and speech changes. When head and neck cancer is managed with intent to cure, aggressive treatments are offered for patients to obtain the best outcomes. Without management, head and neck cancers can grow quickly, and therefore there is usually a desire to initiate patients’ treatment quickly to prevent the spread of disease.¹

For many, multiple treatment modalities are offered, including surgery, radiation, and chemotherapy. The objective behind these treatments is not merely to eradicate the cancer, but also to preserve the function of the important structures nearby, which could affect a person’s ability to speak, swallow, and breathe without assistance.² Treatment planning for patients with head and neck cancers often depends on the stage of the cancer. But staging for HPV-positive cancers has changed.

HPV-Positive Staging Changes

Over the past decade, the number of individuals diagnosed with head and neck cancer associated with tobacco and alcohol use has been declining. However, cases of HPV-associated head and neck cancer have been on the rise.³ HPV-associated cancers also tend to be found in a younger population than those who have smoking- or alcohol-related cancers.

With the increased incidence of HPV-associated head and neck cancer came an updated staging system in 2017. It was observed that HPV-positive cancers had different characteristics and responses than those that were HPV negative. HPV-positive primary tumors were often smaller in size than HPV-negative ones but would spread to the lymph nodes more quickly. However, when compared with HPV-negative cancers with nodal disease, it was discovered that HPV-positive patients had better outcomes, despite the appearance of more advanced disease.⁴ This led to the American Joint Committee on Cancer changing the staging of HPV-positive head and neck cancers, with HPV-positive cancers showing improved prognosis over HPV-negative cancers.

It’s important to note that HPV positivity is considered only in the staging of oropharyngeal squamous cell head and neck cancers, which include cancers of the lip and mouth, tongue, base of tongue, and tonsils. ⁵

HPV-Positive Treatment Changes

Because of the improved response rate and outcomes for patients with HPV-positive cancer, there has been interest in deescalating therapy. Many clinical trials are ongoing to see if the possibility of less intensive treatment could avoid some of the longterm adverse effects from radiation, surgery, or chemotherapy but still provide successful survival outcomes.

Current clinical trials are evaluating the use of⁶:

• immunotherapy instead of cisplatin chemotherapy with radiation

• immunotherapy for neoadjuvant therapy followed by surgery

• reduced dose of radiation

• same radiation dose but no concurrent chemotherapy

• neoadjuvant chemotherapy followed by reduced dose radiation

• surgery followed by adjuvant therapy at reduced dose

The results of these trials may change the future of how HPV-positive oropharyngeal cancer is managed.

Immunotherapy

For patients with recurrent or metastatic head and neck cancers, the option of immunotherapy has become available within the past 10 years. Anti–PD-1 agents nivolumab (Opdivo) and pembrolizumab (Keytruda) are now widely used to treat this patient population. In studies that led to immunotherapy approval for use for metastatic head and neck cancers, participants who received single-agent nivolumab had improved overall survival when compared with those who received single-agent chemotherapy. KEYNOTE trials have shown pembrolizumab to be an effective treatment for patients with metastatic head and neck cancers that are PD-L1 positive.⁷

Nursing Implications

As management has changed for head and neck cancers, nurses have had to evolve and adapt to these changes as well.

Patient Experience

Nurses are well equipped to provide education to patients with head and neck cancer, and they understand the importance of including the patient’s family and caregivers in the conversation. In some clinics, the value of the nurse offering formal supportive care programs to the patient and their family has led to significant quality of life improvements. Patients have reported they were able to get their personal empowerment back and felt that they had a better sense of control over their situation as a direct result of nurse-led supportive programs.⁸

Immunotherapy

Especially in the era of immunotherapy, nurses have had to learn not only the safe administration of immunotherapy treatments but also the possible AEs of immunotherapy, which can be different from traditional chemotherapy AEs. Nurses have had to learn the mechanism of how immunotherapy treats cancer, along with how and why AEs from immunotherapy can occur. Nurses must think critically of the possibility that the cough their patient has may not be due to their chronic obstructive pulmonary disease but may be a manifestation of pneumonitis. The diarrhea that is so often experienced with chemotherapy may be colitis in a patient receiving immunotherapy and will require management with steroids, not antidiarrheal medications.⁹

Chemotherapy and radiation

The AEs of radiation for head and neck cancer can negatively affect a patient’s quality of life. Nurses are in a position to help manage AEs, identifying them quickly in order to be able to implement interventions to improve them. Oncology Nursing News® interviewed Julie Reback, a nurse practitioner in Baltimore, Maryland, to learn about her experience in caring for patients with head and neck cancer. As part of the standard of concurrent chemotherapy and radiation therapy, her clinic has implemented the practice of more frequent electrolyte monitoring and dehydration prevention. “We schedule fluids in the middle of the week following their chemotherapy, and check electrolytes and replace those if necessary,” she said. She also noted that “this practice has improved how well our patients are able to tolerate therapy, and we have found that patients are able to complete their full course of therapy, often feeling better. It’s also helped prevent dose reductions.”

Surgery

Surgery for head and neck cancers is a frequently used option. These complex surgeries can leave patients with permanent changes in their appearance, as well as changes to how they eat and speak. The hospitalizations can be prolonged if patients require additional time to recover. Long hospital stays can result in significant financial toxicity to the patient and health care system as a whole, as well as decrease the patient’s quality of life.¹⁰

An advanced practice provider (APP) team presented the findings of a quality improvement study at the 2022 Oncology Nursing Society Annual Congress. The team members found that through the interventions they provided prior to surgery, they were able to decrease the length of hospital admission for surgery. These interventions included¹¹:

• a presurgical APP visit held with the patient and their support system detailing the procedure, description of the patient’s hospital stay, wound care interventions, and education on any required feeding tubes or tracheostomy tube

• medical and cardiovascular clearance before surgery

• preoperative visit for speech and swallowing expectations and exercises with speech language pathology (SLP)

• preoperative evaluation for hypothyroidism

• standardization of inpatient physical therapy and SLP visits

The results of this project not only decreased the length of hospital stay but resulted in improved coordination between inpatient and outpatient teams. The implementation of this program improved outcomes in terms of increased patient satisfaction and improved patients’ mobility, speech, and swallowing functions. These interventions are a great example of how nurses may recognize an opportunity to improve patient outcomes in this setting.¹¹

Survivorship

Nurses are able to guide patients with head and neck cancer into the survivorship phase of their diagnosis.

Patients need continued education on what to expect. Education may be needed on how to start or improve healthy habits, such as changing the diet and increasing exercise.¹² Patients also may need nurses’ additional support and continued motivation for smoking and alcohol cessation. With some studies reporting smoking relapse rates of 14% to 60% after treatment ends, continued nursing education may help these patients continue to abstain and reduce their risk of secondary cancers or other diseases.¹²

Nurses also can play a role in the surveillance of short- and long-term AEs of treatment. Some of the AEs of head and neck cancer therapy are not experienced by those with other cancers. Monitoring patients for these effects and making recommendations for quick intervention to improve them is another area where nurses can help during survivorship. They will be on alert for the potential long-term effects that specific treatments may cause, especially as they relate to immunotherapy.

The landscape of head and neck cancer has changed significantly over the past 10 years, and nurses have played a big part in providing the care for this patient population. As additional research continues, nurses will continue to adapt to the changes so that they can provide excellent patient care.

References

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