Proactive, Team-Based Approach Leads to Better Care, Fewer Treatment Delays for Head and Neck Cancer Patients

Head and Neck Cancer

A multidisciplinary team led by oncology nurses can reduce both hospitalization and treatment breaks for patients with head and neck cancer, according to Helena C. Viveiros, RN, BSN, OCN.

Viveiros discussed this topic and provided an overview of an analysis of the intervention at her own institution at the 2016 ONS Annual Congress.

Viveiros, from Saint Anne’s Hospital in Fall River, Massachusetts, said the inception of the program started with a woman in her 30s who had completed chemotherapy and radiation therapy for head and neck cancer. Six months later, the woman was still not eating and had to remain on a feeding tube.

Viveiros and her colleagues soon noticed a trend—about 60% of patients with head and neck cancer were not completing treatment or were being hospitalized—and knew something had to change.

The team categorized patient issues into three groups: pre-existing, treatment, and post-treatment. From there, they determined that a new multidisciplinary team would need to include many members: oncology/radiation nurses, medical/radiation oncologists, surgeons, social workers, visiting nurses, dieticians, dentists, radiologists, speech therapist, and family/caregivers.

To implement this new multidisciplinary team, Viveiros and her colleagues added chart review (to identify cause of hospitalizations and treatment delays), a speech therapy referral program (which was previously underutilized), and a collaborative effort with gastrointestinal physicians.

The most important piece of the puzzle, though, was adding home care to the treatment plan.

“Home care is what made the biggest difference in getting people to comply,” Viveiros said in an interview with Oncology Nursing News. Home care allowed nurses to address infections with feeding tubes, speech therapy, and skin irritation, among other issues, before they became larger problems.

Bi-weekly nursing visits were “triggered,” Viveiros said, if a patient needed a new feeding tube, concurrent chemotherapy or experienced dysphagia or weight loss.

Education as part of home care, too, was key. Viveiros and her team created a single page handout—many patients get overwhelmed with multiple pages of information, she said—explaining oral care and what to expect during and after chemotherapy, radiation therapy, and surgery.

“We needed them to know how bad this was going to get,” Viveiros said, explaining that the handout was nitty-gritty and to the point but also graphic when necessary.

Once the team and plan were put into place, patient outcomes changed almost immediately. At baseline, 6 months, and 1 year, respectively, 74, 28, and 44 patients were analyzed. The proportion of patients requiring treatment break without hospitalization changed from 30% (n = 22) at baseline to 11% (n = 3) at 6 months to 18% (n = 8) at 1 year. The proportion of patients requiring hospitalization changed from 30% (n = 22) at baseline to 14% (n = 4) at 6 months to 20% (n = 9) at 1 year.

In total, the interventions led to a 34% absolute reduction in hospitalizations and treatment breaks.

“Before, [care] was all scattered and all over the place and [patients] weren’t introduced to a lot of these team members until there was a problem,” Viveiros said.

In addition to making introductions to new team members easier, Viveiros acknowledges that even more work can and should be done to improve care. She said that adding physical therapy to their program would allow more patients to build the strength to endure surgery.

Ultimately, the goal is for every patient diagnosed with head and neck cancer to receive care that reflects a team-based approach.

“There's no such thing as ‘perfect,’ but we want to give them all the resources they need upfront for them to get through the treatment,” Viveiros said.