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Palliative Care for Patients With Head and Neck Cancer: Interview With Dr Nathan E. Goldstein
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Palliative Care for Patients With Head and Neck Cancer: Interview With Dr Nathan E. Goldstein
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>> Ed This is the second part of a two-part podcast regarding palliation of head and neck cancer. In the first podcast, Dr. David Goldstein and I discuss the very difficult process of how to talk to patients who have cancer and have a very limited life expectancy. In this podcast we discuss issues specific to delivering palliative care for patients with head and neck cancer. Why don't we move on to some of the specific issues regarding palliation for head and neck cancer patients? And in the chapter, there's a nice table that summarizes these things and I wonder if we could kind of review some of these concepts.
Obviously, one of the most important ones is management of pain. What's your general strategy for pain management in ENT cancer patients? Or do you have one? >> Dr. Goldstein You know, I think we have general pain management strategies for all patients, in that we use, you know, the World Health Organizations pain management ladder, which, you know, has three steps. One is the non-opioids, one is the combination agents, and the third step for patients with severe pain are the opioid analgesics.
Most of these patients will jump directly to step three in the WHO ladder, which is the opioid analgesics. For patients who are opioid naïve, we start on lower doses of either morphine or a morphine equivalent and for patients who have more advanced disease or have been on opioids, we can figure out kind of what their opioid equivalent dosing is and provide analgesia that way. The thing that can be quite complicated in patients with head and neck cancer is one, obviously difficult swallowing, so oral agents in many of these patients are difficult to give them.
And many of these patients will need either IV medications titrated in the hospital, and then we can put them on a transdermal system. However, many of the opioids can be given in liquid form, so both morphine and oxycodone, for example, come in liquid form, so we may need to use those because they may not be able to swallow pills, but we can give them liquids, drops that they can swallow or place underneath the tongue, and then many of these patients will have tubes for artificial hydration and nutrition, often a gastric tube or a jejunostomy tube and we can either use the liquid preparations in those or crush the shorter-acting medication.
Because of course, we can never crush the longer acting oral delivery systems. So, that's a long-winded answer, but I think basically the model that we use in head and neck cancer is the use of opioids like we do for all other cancers, but in head and neck cancers, we have to spend a little time thinking about how we're going to actually get the medication into the patient if they can't swallow safely. >> Ed So, in the table, there's also some very specific symptoms that have very specific and mechanical solutions, like mucositis, dysphagia, xerostomia, changes in speech and whatnot.
But one of them is decreased quality of life and depression, and what's your general approach for the depressed patient? >> Dr. Goldstein So, my general approach to the depressed patient first of all is to remind clinicians that depression is never normal. Like, so what I hear often is well, she has head and neck cancer, of course she's depressed. So, it's normal to be sad, it's normal to be disappointed, it's normal to cry. Depression includes symptoms such as lack of pleasure, hopelessness, uncontrollable crying, no longer getting pleasure in activities that used to give patients pleasure, and that is never normal.
So, when they say, she's really sad, that can be normal. When they say, well, she no longer wants to interact with her children or she no longer has hope, that's when we begin to get worried that patients might actually be depressed. In head and neck cancer, patients can have what we call an adjustment reaction to a medical condition with depressive features, or they actually may have an episode of major depression. But regardless, we can still treat them with either psychostimulants or anti-depressants.
The thing to remember about head and neck cancer is that it is one of the few cancers that is very difficult to hide. So, if a patient has pancreas cancer or colon cancer or lung cancer, until the very end stages, these patients can look normal or can cover their illness. So, a patient with colon cancer may have an ostomy, but obviously can hide it under a shirt.
A patient with pancreas cancer may lose weight, but until the end stages of the disease, won't look sick, so to speak. Head and neck cancers can often be quite disfiguring. Surgeries that we give for the therapies can ultimately have very good cosmetic outcomes, but it may take a while or they may need a staged procedure with a resection, then a period of healing, and then a flap, for example.
So, the disfigurement of head and neck cancer make these patients particularly prone to depression. If a patient has pancreas cancer, they can forget about it. If a patient has head and neck cancer, every time they look in the mirror, they're reminded. Every time they go to eat with their family to a restaurant, they're reminded. Head and neck cancers create an unusual set of problems coping that we don't see in other cancers and that's why these patients may be more prone to depression and why it's something that we need to be particularly on the lookout for.
>> Ed What about the opposite or what about anxiety? How do you deal with the anxious patient? >> Dr. Goldstein You know, I think again, because head and neck cancer does have such a relapsing and remitting course, we do see anxiety often in these patients. Even when patients are cured of their disease, particularly if they've had a relapse and the disease goes into remission, there's always a lingering anxiety that the disease may recur.
So, the answer that kind of depends on the severity of the anxiety and how much it's interfering with function. A low level of anxiety, you know, I'm worried the cancer may come back some day, what will it mean for me, can often be treated with supportive counseling or psychotherapy, whether that's from a social worker, a psychologist or a psychiatrist or some form of mental health professional. Anxiety that is debilitating and it's keeping patients from going back to work, from enjoying life, from interacting with their family, often needs medications, whether we're talking about the use of benzodiazepines or the use of SSRIs or SNRIs for longer term management of anxiety.
>> Ed That sort of leads into the next question. An aspect of disease management that you cover quite nicely in the chapter, which is the need and the composition of a multi-disciplinary care team. Could you tell us about that? >> Dr. Goldstein In palliative care, we always think about a multi-disciplinary team, which often includes physicians, nurses, and social workers. When we think about head and neck cancer, the interdisciplinary team is much, much larger than the standard interdisciplinary team.
It includes the head and neck surgeon, the radiation oncologist, the medical oncologist, a dentist, a plastic and/or reconstructive surgeon, though more and more head and neck surgeons are doing reconstructive surgeries themselves. It also can include ophthalmologists, speech and language therapists, physical and occupational therapists, as well as nutritionists. Almost 100% of these patients will have issues around speech and swallowing, so specialists that may seem optional, and I use air quotes around optional, in other diseases are essential in head and neck cancer, particularly nutrition and speech and language pathology are core members of the interdisciplinary team.
And that is pretty unusual to think of them, those specialties as core disciplines, but you really can't create a comprehensive treatment plan for patients with head and neck cancer without, for example, speech and language pathologists and clinical nutritionists. One of the things that I really seen in head and neck cancer is a real embracing of the entire team, you know, the medical oncologist and the head and neck surgeon will embrace a speech pathologist and the clinical nutritionist as a core member of that team because they really understand the needs of these patients in ways that other disciplines may not understand their importance in other patients with cancer.
>> Ed So, patients with head and neck cancers are always a challenge to manage because they can't eat very well. So, often times they need feeding tubes placed or gastrotomy tubes put in. How do you approach the head and neck cancer patients' nutritional and fluid requirements? >> Dr. Goldstein I think patients with head and neck cancer absolutely do have issues with swallowing. Whether it's from the disease itself, from the therapies we offer, surgery, mucositis from radiation or chemotherapy, you know, difficulty swallowing and keeping patients both adequately nourished and hydrated is a significant problem in this group.
In many of these patients, they prophylactically get gastric tubes inserted in case they need them in the future. Head and neck cancer is one of the few diseases where the evidence is crystal clear early in the disease that gastrostomy tubes can both improve outcomes and mortality. We're talking about patients who, for example, need four, six, eight weeks of artificial nutrition to recover from a surgery.
Or where patients, you know, may have very good cosmetic outcomes, may be disease free, but ultimately the surgery has left them in a state where they can't swallow safely. So, they may be completely functional, have years to live, but just swallow safely. So, that's a group of patients in whom gastric tubes are put in prophylactically and there's very clear evidence that they improve outcomes for these patients, including better quality of life and longer life.
However, the tricky thing about the use of artificial hydration and nutrition in these patients is that that can shift as the disease progresses. So, if we're talking about a patient early in their stages who needs time to recover from mucositis or recover from a particular surgery, then the use of a short-term feeding tube in those patients makes sense. As patients come closer to the end of their lives and the disease progresses, we then have to re-explain to patients and families that as the disease progresses, lack of appetite, weight loss, inability to swallow may be because they're approaching the end of their lives and the benefit/burden ratio of giving them artificial hydration and nutrition may change as they near the end of their lives.
That takes quite a bit of education because we actually then have to explain that a tube that once was very helpful may no longer be of the same benefit it once was. And that just takes often multiple conversations explaining that the difference in that benefit/burden analysis as a disease progresses. You know, the use of gastrostomy or artificial hydration and nutrition in patients with head and neck cancer is very different than for example, the patient with end-stage dementia who can no longer eat or drink safely.
That's a real sign of disease progression and that patients are nearing the end stages of their disease. Early in the disease course, patients with head and neck cancer can't swallow because they need surgery on their head and neck and clearly will benefit from the use of artificial hydration and nutrition and that's where discussions about artificial hydration and nutrition are unique in this group of patients as compared to many other groups where we talk about it. >> Ed Fortunately for the patients, speaking as a general surgeon, the technologies available for placing these tubes have vastly improved over the last 10 or 20 years and placing the feeding tubes is much more benign than it used to be.
So, I think you can feel comfortable in having a lower threshold putting them in or taking them out than we used to. It used to involve a laparotomy and a big tube, and it was a mess. >> Dr. Goldstein I think that's absolutely right and one of the things that we often say to patients early in their disease is, you know, we can put this tube in and if you get better, we can always take it out. You know it is not like the patient with, as I said before, end-stage dementia who once we put the tube in, that will be the way that they get nutrition and hydration for the rest of their lives.
Many of these patients will recover and they can have the tube removed. Sometimes we leave it in if they have concern about relapse, of course, but taking tubes out for artificial hydration and nutrition is always an option in these patients. >> Ed This is Ed Livingston and I've been speaking with Dr. Nathan Goldstein from the Mt. Sinai School of Medicine. In the first podcast, we discussed how to talk with patients and their families when the cancer prognosis is poor. In this podcast, we reviewed the specific medical issues related to palliative care for head and neck cancers.
Our full set of JAMA Evidence Podcasts can be found at jamaevidence.com. Please also listen to the JAMA Clinical Reviews Podcast, which can be found in the iTunes store and in Stitcher.
Segment:0 .
>> Ed This is the second part of a two-part podcast regarding palliation of head and neck cancer. In the first podcast, Dr. David Goldstein and I discuss the very difficult process of how to talk to patients who have cancer and have a very limited life expectancy. In this podcast we discuss issues specific to delivering palliative care for patients with head and neck cancer. Why don't we move on to some of the specific issues regarding palliation for head and neck cancer patients? And in the chapter, there's a nice table that summarizes these things and I wonder if we could kind of review some of these concepts.
Obviously, one of the most important ones is management of pain. What's your general strategy for pain management in ENT cancer patients? Or do you have one? >> Dr. Goldstein You know, I think we have general pain management strategies for all patients, in that we use, you know, the World Health Organizations pain management ladder, which, you know, has three steps. One is the non-opioids, one is the combination agents, and the third step for patients with severe pain are the opioid analgesics.
Most of these patients will jump directly to step three in the WHO ladder, which is the opioid analgesics. For patients who are opioid naïve, we start on lower doses of either morphine or a morphine equivalent and for patients who have more advanced disease or have been on opioids, we can figure out kind of what their opioid equivalent dosing is and provide analgesia that way. The thing that can be quite complicated in patients with head and neck cancer is one, obviously difficult swallowing, so oral agents in many of these patients are difficult to give them.
And many of these patients will need either IV medications titrated in the hospital, and then we can put them on a transdermal system. However, many of the opioids can be given in liquid form, so both morphine and oxycodone, for example, come in liquid form, so we may need to use those because they may not be able to swallow pills, but we can give them liquids, drops that they can swallow or place underneath the tongue, and then many of these patients will have tubes for artificial hydration and nutrition, often a gastric tube or a jejunostomy tube and we can either use the liquid preparations in those or crush the shorter-acting medication.
Because of course, we can never crush the longer acting oral delivery systems. So, that's a long-winded answer, but I think basically the model that we use in head and neck cancer is the use of opioids like we do for all other cancers, but in head and neck cancers, we have to spend a little time thinking about how we're going to actually get the medication into the patient if they can't swallow safely. >> Ed So, in the table, there's also some very specific symptoms that have very specific and mechanical solutions, like mucositis, dysphagia, xerostomia, changes in speech and whatnot.
But one of them is decreased quality of life and depression, and what's your general approach for the depressed patient? >> Dr. Goldstein So, my general approach to the depressed patient first of all is to remind clinicians that depression is never normal. Like, so what I hear often is well, she has head and neck cancer, of course she's depressed. So, it's normal to be sad, it's normal to be disappointed, it's normal to cry. Depression includes symptoms such as lack of pleasure, hopelessness, uncontrollable crying, no longer getting pleasure in activities that used to give patients pleasure, and that is never normal.
So, when they say, she's really sad, that can be normal. When they say, well, she no longer wants to interact with her children or she no longer has hope, that's when we begin to get worried that patients might actually be depressed. In head and neck cancer, patients can have what we call an adjustment reaction to a medical condition with depressive features, or they actually may have an episode of major depression. But regardless, we can still treat them with either psychostimulants or anti-depressants.
The thing to remember about head and neck cancer is that it is one of the few cancers that is very difficult to hide. So, if a patient has pancreas cancer or colon cancer or lung cancer, until the very end stages, these patients can look normal or can cover their illness. So, a patient with colon cancer may have an ostomy, but obviously can hide it under a shirt.
A patient with pancreas cancer may lose weight, but until the end stages of the disease, won't look sick, so to speak. Head and neck cancers can often be quite disfiguring. Surgeries that we give for the therapies can ultimately have very good cosmetic outcomes, but it may take a while or they may need a staged procedure with a resection, then a period of healing, and then a flap, for example.
So, the disfigurement of head and neck cancer make these patients particularly prone to depression. If a patient has pancreas cancer, they can forget about it. If a patient has head and neck cancer, every time they look in the mirror, they're reminded. Every time they go to eat with their family to a restaurant, they're reminded. Head and neck cancers create an unusual set of problems coping that we don't see in other cancers and that's why these patients may be more prone to depression and why it's something that we need to be particularly on the lookout for.
>> Ed What about the opposite or what about anxiety? How do you deal with the anxious patient? >> Dr. Goldstein You know, I think again, because head and neck cancer does have such a relapsing and remitting course, we do see anxiety often in these patients. Even when patients are cured of their disease, particularly if they've had a relapse and the disease goes into remission, there's always a lingering anxiety that the disease may recur.
So, the answer that kind of depends on the severity of the anxiety and how much it's interfering with function. A low level of anxiety, you know, I'm worried the cancer may come back some day, what will it mean for me, can often be treated with supportive counseling or psychotherapy, whether that's from a social worker, a psychologist or a psychiatrist or some form of mental health professional. Anxiety that is debilitating and it's keeping patients from going back to work, from enjoying life, from interacting with their family, often needs medications, whether we're talking about the use of benzodiazepines or the use of SSRIs or SNRIs for longer term management of anxiety.
>> Ed That sort of leads into the next question. An aspect of disease management that you cover quite nicely in the chapter, which is the need and the composition of a multi-disciplinary care team. Could you tell us about that? >> Dr. Goldstein In palliative care, we always think about a multi-disciplinary team, which often includes physicians, nurses, and social workers. When we think about head and neck cancer, the interdisciplinary team is much, much larger than the standard interdisciplinary team.
It includes the head and neck surgeon, the radiation oncologist, the medical oncologist, a dentist, a plastic and/or reconstructive surgeon, though more and more head and neck surgeons are doing reconstructive surgeries themselves. It also can include ophthalmologists, speech and language therapists, physical and occupational therapists, as well as nutritionists. Almost 100% of these patients will have issues around speech and swallowing, so specialists that may seem optional, and I use air quotes around optional, in other diseases are essential in head and neck cancer, particularly nutrition and speech and language pathology are core members of the interdisciplinary team.
And that is pretty unusual to think of them, those specialties as core disciplines, but you really can't create a comprehensive treatment plan for patients with head and neck cancer without, for example, speech and language pathologists and clinical nutritionists. One of the things that I really seen in head and neck cancer is a real embracing of the entire team, you know, the medical oncologist and the head and neck surgeon will embrace a speech pathologist and the clinical nutritionist as a core member of that team because they really understand the needs of these patients in ways that other disciplines may not understand their importance in other patients with cancer.
>> Ed So, patients with head and neck cancers are always a challenge to manage because they can't eat very well. So, often times they need feeding tubes placed or gastrotomy tubes put in. How do you approach the head and neck cancer patients' nutritional and fluid requirements? >> Dr. Goldstein I think patients with head and neck cancer absolutely do have issues with swallowing. Whether it's from the disease itself, from the therapies we offer, surgery, mucositis from radiation or chemotherapy, you know, difficulty swallowing and keeping patients both adequately nourished and hydrated is a significant problem in this group.
In many of these patients, they prophylactically get gastric tubes inserted in case they need them in the future. Head and neck cancer is one of the few diseases where the evidence is crystal clear early in the disease that gastrostomy tubes can both improve outcomes and mortality. We're talking about patients who, for example, need four, six, eight weeks of artificial nutrition to recover from a surgery.
Or where patients, you know, may have very good cosmetic outcomes, may be disease free, but ultimately the surgery has left them in a state where they can't swallow safely. So, they may be completely functional, have years to live, but just swallow safely. So, that's a group of patients in whom gastric tubes are put in prophylactically and there's very clear evidence that they improve outcomes for these patients, including better quality of life and longer life.
However, the tricky thing about the use of artificial hydration and nutrition in these patients is that that can shift as the disease progresses. So, if we're talking about a patient early in their stages who needs time to recover from mucositis or recover from a particular surgery, then the use of a short-term feeding tube in those patients makes sense. As patients come closer to the end of their lives and the disease progresses, we then have to re-explain to patients and families that as the disease progresses, lack of appetite, weight loss, inability to swallow may be because they're approaching the end of their lives and the benefit/burden ratio of giving them artificial hydration and nutrition may change as they near the end of their lives.
That takes quite a bit of education because we actually then have to explain that a tube that once was very helpful may no longer be of the same benefit it once was. And that just takes often multiple conversations explaining that the difference in that benefit/burden analysis as a disease progresses. You know, the use of gastrostomy or artificial hydration and nutrition in patients with head and neck cancer is very different than for example, the patient with end-stage dementia who can no longer eat or drink safely.
That's a real sign of disease progression and that patients are nearing the end stages of their disease. Early in the disease course, patients with head and neck cancer can't swallow because they need surgery on their head and neck and clearly will benefit from the use of artificial hydration and nutrition and that's where discussions about artificial hydration and nutrition are unique in this group of patients as compared to many other groups where we talk about it. >> Ed Fortunately for the patients, speaking as a general surgeon, the technologies available for placing these tubes have vastly improved over the last 10 or 20 years and placing the feeding tubes is much more benign than it used to be.
So, I think you can feel comfortable in having a lower threshold putting them in or taking them out than we used to. It used to involve a laparotomy and a big tube, and it was a mess. >> Dr. Goldstein I think that's absolutely right and one of the things that we often say to patients early in their disease is, you know, we can put this tube in and if you get better, we can always take it out. You know it is not like the patient with, as I said before, end-stage dementia who once we put the tube in, that will be the way that they get nutrition and hydration for the rest of their lives.
Many of these patients will recover and they can have the tube removed. Sometimes we leave it in if they have concern about relapse, of course, but taking tubes out for artificial hydration and nutrition is always an option in these patients. >> Ed This is Ed Livingston and I've been speaking with Dr. Nathan Goldstein from the Mt. Sinai School of Medicine. In the first podcast, we discussed how to talk with patients and their families when the cancer prognosis is poor. In this podcast, we reviewed the specific medical issues related to palliative care for head and neck cancers.
Our full set of JAMA Evidence Podcasts can be found at jamaevidence.com. Please also listen to the JAMA Clinical Reviews Podcast, which can be found in the iTunes store and in Stitcher.
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