A Team Approach to Side Effect Management during Chemoradiotherapy for Head and Neck Cancer

Concurrent chemoradiation therapy can result in acute toxicities, primarily painful oral mucocitis, dermatitis, weight loss, dehydration , infection, fatigue, excessive oral secretions, fatigue and emotional and ecomomic strains.    Hospitalization and treatment breaks in radiation therapy often result. 1,2        A multidisciplinary team from the community cancer treatment center and acute care facility developed a comprehensive approach to better manage the side effects and minimize treatment breaks. The team consisted of members from radiation and medical oncology nursing , nutrition services, speech and language pathology, wound, ostomy, continence nursing and social work.  The NO SToPS approach focuses on management of Nutrition, Oral care, Skin care, Therapy for swallowing, jaw and neck mobility and lymphedema, Pain management  and Social Work support.     WOCN involvement begins during a radiation Treatment Learning Class where strategies related to minimizing skin reactions are discussed.    A topical gel containing aloe vera, hyaluronic acid and a moisturizing agent is provided for TID use, to reduce the intensity of skin reactions. 3   A skin care protocol based on the Radiation therapy Oncology Group (RTOG) acute toxicity scale was developed to guide the nursing staff in early intervetions.4  Symptom management for skin reactions may be needed by the third week of treatment for erythema, itching, burning, pain and dry or moist desquamation.  The WOCN nurse will be consulted for more complex wound care needs.        Patient education on care and use of a gastrostomy tube for enteral feeding ,that are routinely placed pre-treatment ,  is provided by the WOCN, home health nurses or clinic nurses depending on the patient's situation  and the timing of tube placement.  To standardize feeding tube education, a feeding tube toolkit is available at each of the four outpatient oncology clinics.  Education and tube site evaluation occurs on each clinic visit, in an effort to minimize feeding tube complications, leakage, irritant dermatitis of the skin and tube migration.        The role of the WOCN nurse on the oncology team is viewed as a valuable resource.   Preliminary feedback indicates improvement in pateint adherence to oral care and nutrition regimens, early identifiaction of oral infections and dehydration and improved pain control.  Evaluation of frequency of treatment breaks, hospitalizations for side effect-related complications and other outcomes is underway.