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American Cancer Society key recommendations for head and neck cancer survivorship care


The American Cancer Society published key recommendations for head and neck cancer (HNC) survivorship care. These are important recommendations that can improve patients’ care that includes surveillance for HNC recurrence, Assessment and management of physical and psychosocial long-term and late effects of HNC and its treatment (i.e. GERD, aspiration, fatigue, lymphedema, hypothyroidism, oral and dental care, taste problems, muscle dysfunction, speech and hearing ), psychological issues (Distress/depression/anxiety) , and nutrition.

These are the main recommendations for primary care physicians:

Surveillance for HNC recurrence

History and physical

Clinicians should : a) individualize clinical follow-up care provided to HNC survivors based on age, specific diagnosis, and treatment protocol as recommended by the treating oncology team; b) conduct a detailed cancer-related history and physical examination every 1–3 month for the first year after primary treatment, every 2–6 month in the second y, every 4–8 moth in y 3–5, and annually after 5 y ;10 c) confirm continued follow-up with otolaryngologist or HNC specialist for HN-focused examination.






Surveillance education

Clinicians should: a) educate and counsel all HNC survivors about the signs and symptoms of local recurrence.); b) refer HNC survivors to an HNC specialist if signs and symptoms of local recurrence are present.


Screening and early detection of second primary cancers 

Clinicians should screen HNC survivors for: a) other cancers as they would for patients in the general population; b) lung cancer with annual lung cancer screening also based on smoking history; c) another HN and esophageal cancer as they would for patients of increased risk.







Assessment and management of physical and psychosocial long-term and late effects of HNC and its treatment

Clinicians should assess for long-term and late effects of HNC and its treatment at each follow-up visit.


Spinal accessory nerve (SAN) palsy

Clinicians should refer HNC survivors with SAN palsy occurring postradical neck dissection to a rehabilitation specialist to improve range of motion and ability to perform daily tasks.




Spinal accessory nerve


Cervical dystonia/muscle spasms/neuropathies

Clinicians should: a) assess HNC survivors for cervical dystonia (spasmodic torticollis) , which is characterized by painful dystonic spasms of the cervical muscles and can be caused by neck dissection, radiation, or both; b) refer HNC survivors to a rehabilitation specialist for comprehensive neuromusculoskeletal management if cervical dystonia or neuropathy is found; c) prescribe nerve-stabilizing agents, such as pregabalin, gabapentin, and duloxetine, or refer to a specialist for botulinum toxin type A injections into the affected muscles for pain management and spasm control as indicated.




Cervical dystonia 

Shoulder dysfunction

Clinicians should: a) conduct baseline assessment of HNC survivor shoulder function posttreatment for strength, range of motion, and impingement signs, and continue to assess as follow-up for ongoing complications or worsening condition; b) refer HNC survivors to a rehabilitation specialist for improvement to pain, disability, and range of motion where shoulder morbidity exists.





Trismus

Clinicians should: a) refer HNC survivors to rehabilitation specialists and dental professionals to prevent trismus and to treat trismus as soon as it is diagnosed; b) prescribe nerve-stabilizing agents to combat pain and spasms, which may also ease physical therapy and stretching devices.




Dysphagia/aspiration/stricture

Clinicians should: a) refer HNC survivors presenting with complaints of dysphagia, postprandial cough, unexplained weight loss, and/or pneumonia to an experienced speech-language pathologist for instrumental evaluation of swallowing function to assess and manage dysphagia and possible aspiration; b) recognize potential for psychosocial barriers to swallowing recovery and refer HNC survivors to an appropriate clinician if barriers are present; c) refer to a speech-language pathologist for videofluoroscopy as the first-line test for HNC survivors with suspected stricture due to the high degree of coexisting physiologic dysphagia; d) should refer HNC survivors with stricture to a gastroenterologist or HN surgeon for esophageal dilation.






Gastroesophageal reflux disease (GERD)

Clinicians should: a) monitor HNC survivors for developing or worsening GERD, as it prevents healing of irradiated tissues and is associated with increased risk of HNC recurrence or secondary primary cancer; b) should counsel HNC survivors on an increased risk of esophageal cancer and the associated symptoms; c) should recommend PPIs or antacids, sleeping with a wedge pillow or 3-inch blocks under the head of the bed, not eating or drinking fluids for 3 h before bedtime, tobacco cessation, and avoidance of alcohol ; d) should refer HNC survivors to a gastroenterologist if symptoms are not relieved by treatments.




Lymphedema

Clinicians should: a) assess HNC survivors for lymphedema using the NCI CTCAE v.4.03, or referral for endoscopic evaluation of mucosal edema of the oropharynx and larynx, tape measurements, sonography, or external photographs; b) should refer HNC survivors to a rehabilitation specialist for treatment consisting of Manual lymphatic massage and if tolerated, compressive bandaging.




Fatigue

Clinicians should: a) assess for fatigue and treat any causative factors for fatigue, including anemia, thyroid dysfunction, and cardiac dysfunction; b) should offer treatment or referral for factors that may impact fatigue (eg, mood disorders, sleep disturbance, pain, etc) for those who do not have an otherwise identifiable cause of fatigue; c) should counsel HNC survivors to engage in regular physical activity and refer for cognitive behavior therapy as appropriate.





Altered or loss of taste

Clinicians should refer HNC survivors with altered or loss of taste to a registered dietitian for dietary counseling and assistance in additional seasoning of food, avoiding unpleasant food, and expanding dietary options.




Hearing loss, vertigo, vestibular neuropathy

Clinicians should refer HNC survivors to appropriate specialists (ie, audiologists) for loss of hearing, vertigo, or vestibular neuropathy related to treatment.




Sleep disturbance/sleep apnea

Clinicians should: a) screen HNC survivors for sleep disturbance by asking HNC survivors and partners about snoring and symptoms of sleep apnea; b) refer HNC survivors to a sleep specialist for a sleep study (polysomnogram) if sleep apnea is suspected ; c)manage sleep disturbance similar to patients in the general population); d) recommend nasal decongestants, nasal strips, and sleeping in the propped-up position to reduce snoring and mouth-breathing; room cool-mist humidifiers can aid sleep as well by keeping the airway moist; e) refer to a dental professional to test the fit of dentures to ensure proper fit and counsel HNC survivors to remove dentures at night to avoid irritation.




Speech/voice

Clinicians should: a) assess HNC survivors for speech disturbance; b) should refer HNC survivors to an experienced speech-language pathologist if communication disorder exists.





Hypothyroidism

Clinicians should evaluate HNC survivor thyroid function by measuring TSH every 6–12 months.




Oral and dental surveillance

Clinicians should: a) counsel HNC survivors to maintain close follow-up with the dental professional and reiterate that proper preventive care can help reduce caries and gingival disease; b) counsel HNC survivors to avoid tobacco, alcohol (including mouthwash containing alcohol), spicy or abrasive foods, extreme temperature liquids, sugar-containing chewing gum or sugary soft drinks, and acidic or citric liquids; c) refer HNC survivors to a dental professional specializing in the care of oncology patients.





Caries

Clinicians should: a) counsel HNC survivors to seek regular professional dental care for routine examination and cleaning and immediate attention to any intraoral changes that may occur; b) should counsel HNC survivors to minimize intake of sticky and/or sugar-containing food and drink to minimize risk of caries; c) should counsel HNC survivors on dental prophylaxis, including brushing with remineralizing toothpaste, the use of dental floss, and fluoride use (prescription 1.1% sodium fluoride toothpaste as a dentifrice or in customized delivery trays.


Periodontitis

Clinicians should: a) refer HNC survivors to a dentist or periodontist for thorough evaluation; b) should counsel HNC survivors to seek regular treatment from and follow recommendations of a qualified dental professional and reinforce that proper examination of the gingival attachment is a normal part of ongoing dental care.


Xerostomia (dry mouth)

Clinicians should: a) encourage use of alcohol-free rinses if an HNC survivor requires mouth rinses; b) should counsel HNC survivors to consume a low-sucrose diet and to avoid caffeine, spicy and highly acidic foods, and tobacco; c) encourage HNC survivors to avoid dehydration by drinking fluoridated tap water, but explain that consumption of water will not eliminate xerostomia.



Dry mouth

Osteonecrosis

Clinicians should: a) monitor HNC survivors for swelling of the jaw and/or jaw pain, indicating possible osteonecrosis; b) should administer conservative treatment protocols, such as broad-spectrum antibiotics and daily saline or aqueous chlorhexidine gluconate irrigations, for early stage lesions; c) refer to an HN surgeon for consideration of hyperbaric oxygen therapy for early and intermediate lesions, for debridement of necrotic bone while undergoing conservative management, or for external mandible bony exposure through the skin.




Oral infections/candidiasis

Clinicians should: a) refer HNC survivors to a qualified dental professional for treatment and management of complicated oral conditions and infections; b) should consider systemic fluconazole and/or localized therapy of clotrimazole troches to treat oral fungal infections.



Oral candidiasis

Body and self-image

Clinicians should: a) assess HNC survivors for body and self-image concerns; b) should refer for psychosocial care as indicated.


Distress/depression/anxiety

Clinicians should: a) assess HNC survivors for distress/depression and/or anxiety periodically (3 mo posttreatment and at least annually), ideally using a validated screening tool; b) offer in-office counseling and/or pharmacotherapy and/or refer to appropriate psycho-oncology and mental health resources as clinically indicated if signs of distress, depression, or anxiety are present; c) refer HNC survivors to mental health specialists for specific concerns.




Health promotion


Information

Clinicians should: a) assess the information needs of the HNC survivor related to HNC and its treatment, side effects, other health concerns, and available support services ; b) provide or refer HNC survivors to appropriate resources to meet identified needs).






Healthy weight

Clinicians should counsel HNC survivors: a) to achieve and maintain a healthy weight ; b) on nutrition strategies to maintain a healthy weight for those at risk for cachexia; c) if overweight or obese to limit consumption of high-calorie foods and beverages and increase physical activity to promote and maintain weight loss.






Physical activity

Clinicians should counsel HNC survivors to engage in regular physical activity and specifically should: a) avoid inactivity and return to normal daily activities as soon as possible after diagnosis; b) aim for at least 150 min of moderate or 75 min of vigorous aerobic exercise per week; (c) include strength training exercises at least 2 d/wk.




Nutrition

Care clinicians should: a) counsel HNC survivors to achieve a dietary pattern that is high in vegetables, fruits, and whole grains, low in saturated fats, sufficient in dietary fiber, and avoids alcohol consumption; b) refer HNC survivors with nutrition-related challenges to a registered dietician or other specialist.






Tobacco cessation

Clinicians should counsel HNC survivors to avoid tobacco products and offer or refer patients to cessation counseling and resources.





Personal oral health

Clinicians should: a) counsel HNC survivors to maintain regular dental care, including frequent visits to dental professionals, early interventions for dental complications, and meticulous oral hygiene; b) test fit dentures to ensure proper fit and counsel HNC survivors to remove them at night to avoid irritation; c) counsel HNC survivors that nasal strips can reduce snoring and mouth-breathing and that room humidifiers and nasal saline sprays can aid sleep as well; d) should train HNC survivors to do at-home HN self-evaluations and be instructed to report any suspicions or concerns immediately.





Care coordination and practice implications


Survivorship care plan

Clinicians should consult with the oncology team and obtain a treatment summary and survivorship care plan.


Communication with other providers

Clinicians should: a) maintain communication with the oncology team throughout diagnosis, treatment, and posttreatment care to ensure care is evidence-based and well-coordinated; b) should refer HNC survivors to a dentist to provide diagnosis and treatment of dental caries, periodontal disease, and other intraoral conditions, including mucositis and oral infections, and communicate with the dentist on follow-up recommendations and patient education; c) should maintain communication with specialists referred to for management of comorbidities, symptoms, and long-term and late effects.






Inclusion of caregivers

Clinicians should encourage the inclusion of caregivers, spouses, or partners in usual HNC survivorship care and support.


The recommendation were published in CA Cancer J Clin American Cancer Society.

(Cohen EE, LaMonte SJ, Erb NL, Beckman KL, Sadeghi N, Hutcheson KA, Stubblefield MD, Abbott DM, Fisher PS, Stein KD, Lyman GH, Pratt-Chapman ML. Head and Neck Cancer Survivorship Care Guideline. CA Cancer J Clin American Cancer Society. 2016)

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