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Preventive care: follow-up, avoiding smoking and alcohol, preventing thrush, and vaccination (influenza, shingles, pneumococcal) in head and neck cancer patients


Preventive medical and dental care is essential for patients with cancer. Many individuals with cancer including those with head and neck tumors neglect to attend to other important medical problems and focus exclusively on their cancer. Neglecting other medical issues can lead to serious consequences that may influence wellbeing and longevity. It is important to remember as everyone else, cancer survivors are also susceptible to other ailments. This includes other types of gender and age related cancers (i.e., colon, prostate, breast, skin, etc.)


A lecture about life challenges after laryngectomy including preventive care can be viewed on YouTube.


The most important preventive measures for laryngectomees and other head and neck cancer patients include:

        Proper dental and oral care
        Routine examinations by family physician
        Routine follow-up by an otolaryngologist
        Getting appropriate vaccinations
        Stop smoking 
        Using proper techniques (e.g., using sterile water for stoma irrigation)
        Maintaining adequate nutrition

Routine dental follow up and dental preventive care are discussed in Dental issues and hyperbaric oxygen therapy page.

Using proper techniques for stoma care is presented in the Stoma Care page.

Adequate nutrition is discussed in the Eating, Swallowing and Smelling page.


Follow-up by family physician, internist and medical specialists

Continual medical follow-up by specialists, including the otolaryngologist, radiation oncologist (those who got radiation treatment), and oncologist (for those who received chemotherapy), is very important. As time passes from the initial diagnosis and surgery, followup occurs with less frequency. Most otolaryngologists recommend monthly follow-up examinations in the first year after diagnosis, and less often afterwards, depending on the patient’s condition. 
Patients should be encouraged to contact their physician whenever new symptoms arise.


Most major cancer medical centers in the US follow the National Comprehensive Cancer Network (NCCN) guidelines and recommendations for follow up of head and neck cancer patients. These guidelines are based on the potential risk of relapse and second primary cancers, treatment sequelae and toxicities to treatment.


They recommend a complete head & neck exam every 1-3 months for the first year after treatment and/or surgery, every 2-6 months for the 2nd year, every 4-8 months for the 3rd through 5th year, and then every 12 months after the fifth year. However, each patient’s head and neck surgeon, medical oncologist and/or radiation oncologist generally determines the frequency of follow-up visits based on the relative risk of recurrence, which depends on the site of the original tumor, the stage of the disease when first detected, and whether there was spread of the disease to lymph nodes in the neck or other organs in the body.

They also recommend baseline imaging of the tumor site and also the neck if it has been treated within 6 months of treatment, with further re-imaging as needed based on concerning signs/symptoms, smoking history and areas that can’t be seen on a clinical exam. Chest imaging is recommended for individuals with a smoking history based on the guidelines for lung cancer screening. It is  important to realize that imaging tests are not perfect and can miss a small tumor (less than one inch). A thorough physical examination should also accompany any scanning procedure.

They also recommend a thyroid checkup if the neck has been irradiated or the thyroid has been removed, smoking cessation and alcohol counseling if needed, dental evaluation, a nutritional evaluation and treatment until nutritional status is stabilized, speech/hearing evaluation and swallowing evaluation if needed, and ongoing surveillance for depression.

It is critical that one continues to be vigilant to find out if the cancer returns or if a secondary cancer has emerged. There is a higher probability of cancer returning (recurrence) or a new cancer occurring in the first few years after diagnosis. Early identification of recurrence increases survival; survival is 90% when the cancer is in stage I, and only 70% in stage ll.   

It is recommended to undergo periodic follow-up physicals, scans and other tests according to a schedule. The individual follow-up schedule depend on the cancer’s specific type, and the course of treatment given. 


Regular checkups ensure that any changes in health are noted and whenever a new problem emerges it is addressed and treated. The clinician will perform a careful examination to detect cancer recurrence. Checkups include a general examination of the entire body and specific examination of the neck, throat and stoma. Examination of the upper airway is performed using an endoscope or indirect visualization with a small, long-handled mirror to check for abnormal areas. Radiological and other studies may also be performed as needed.


The general recommendation is to perform fewer positron emission tomography/ computed tomography (PET/CT) scans the longer the elapsed time from the surgery that removed the cancer. Generally, PET/CT is performed every three to six months during the first year, then every six months during the second and then yearly throughout life. These recommendations, however, are not based on studies and are merely the opinion or consensus among the specialists. More scans are performed if there are concerns or suspicious findings. When scheduling a PET and/or CT scan any potential benefit gained by the information should be weighed against any potential deleterious effects of exposure to ionizing radiation and or X rays.
it is very important to be followed by an internist or family physician, as well as a dentist, to address other medical and dental issues. 





Avoiding smoking and alcohol

Smoking and/or excessive alcohol consumption are known risk factors for developing many types of head and neck cancer in addition to several other types of cancer in the body. Individuals with head and neck cancer should receive counseling about the importance of smoking cessation. In addition to being a major risk factor for head and neck cancer, alcohol consumption further enhances the risk of cancer. Smoking can also influence cancer prognosis. Patients with laryngeal cancer who continue to smoke and drink are less likely to be cured and are more likely to develop a second 
tumor. Continued smoking, either during or after radiation therapy, can increase the severity and duration of mucosal reactions, worsen dry mouth (xerostomia), and compromise patient outcome.
Smoking tobacco and drinking alcohol decrease the effectiveness of treatment for laryngeal cancer. Patients who continue to smoke while receiving radiation therapy have a lower long-term survival rate than those who do not smoke. 

Counseling services are available to help one stop smoking and/or alcohol consumption. There also are medications approved by the United States Food and Drug Administration (FDA) that can help stop smoking.




Preventing thrush

Thrush can occur as a result of radiation treatment, chemotherapy, high carbohydrate intake, antibiotic or steroid treatment, and poor oral hygiene. Oral thrush (also called oral candidiasis) is caused by the fungus Candida albicans. Candida is a normal inhabitant of the mouth that can overgrow and cause clinical symptoms such as thrush. Oral thrush causes creamy white lesions, usually on the tongue or inner cheeks. Sometimes oral thrush may spread to the roof of the mouth, gums, tonsils, and the back of the throat. Undergoing chemotherapy and/or radiation treatment, and having conditions that lead to a dry mouth predisposes to thrush.

One’s physician may recommend antifungal medication(s). These comes in several forms, including lozenges, tablets, or a liquid that one can swish in their mouth and then swallow.

There are several methods that help prevent yeast growth in the mouth:

  • Reduce the consumption of sugars in food and drinks, brush your teeth well after consuming sugary food and/or drinks.
  • Brush your teeth well after every meal and especially before going to sleep.
  • Diabetic should maintain adequate blood sugar levels.
  • Take antibiotics or corticosteroids only if they are needed
  • If one uses an oral suspension of an antifungal agent,, one should 
  • Wait for 30 minutes to let it work and then brush your teeth. This is because some of these suspensions contain sugar.
  • Consume probiotics by eating active-culture yogurt and/or a probiotic preparation.
  • Gently brush the tongue if it is coated with yeast (white plaques). Brushing should be avoided in those who have irradiation mucositis 
  • Replace the toothbrush after overcoming a yeast problem to prevent re colonization  with yeasts.




Oral thrush


Vaccinations

Vaccination is the most cost effective way by which infections can be prevented. It can protect the vaccinated person as well as those around them from becoming infected; reduce the need for antibiotics and antiviral agents; prevent hospitalizations and prolong life.  

It is important for laryngectomees to be vaccinated for respiratory infections caused by viruses (e.g., influenza) and bacteria (e.g., Streptococcus pneumoniae) and shingles (herpes zoster virus). Preventing or reducing the severity of these infections is recommended by the Center of Disease Control and Prevention (CDC).



Influenza vaccination

It is important for laryngectomees to be vaccinated for influenza regardless of age. Influenza can be more difficult to manage and vaccination is an important preventive tool

There are two types of influenza vaccine: an injection that is adequate for all ages and an inhalation (live virus) only given to individuals younger than 50 years who are not immuno-compromised.

Available vaccines include:
1. The "flu shot" - an inactivated vaccine (containing killed virus) given by a needle, usually in the arm. The flu shot is approved for persons in those older than six months, including healthy individuals and those with chronic medical conditions.
2. The nasal-spray flu vaccine - a vaccine made with live, weakened flu viruses that do not cause the flu (sometimes called LAIV for "live attenuated influenza vaccine" or FluMist®). LAIV (FluMist®) is approved for use in healthy individuals ages 2-49 years (with the exception of pregnant women).

A new vaccine for influenza is prepared for every new season. While the exact strains that cause influenza are unpredictable, it is likely that strains that caused the illness at other parts of the world will also cause illness in the U.S.  It is best to consult one's physician prior to vaccination to ensure that there is no reason why one should not be vaccinated (such as egg allergy). Information of the current recommendations about vaccination can be found in the Center of Disease Control Website.
 

How well the flu vaccine works (or its ability to prevent flu illness) can range widely from season to season. The vaccine’s effectiveness also can vary depending on who is being vaccinated. At least two factors play an important role in determining the likelihood that flu vaccine will protect a person from flu illness: 1) characteristics of the person being vaccinated (such as their age and health), and 2) the similarity or "match" between the flu viruses the flu vaccine is designed to protect against and the flu viruses spreading in the community. During years when the flu vaccine is not well matched to circulating viruses, it’s possible that no or only little benefit from flu vaccination may be observed.

The best way to diagnose Influenza is a rapid test of nasal secretions by one of the diagnostic kits.
Because laryngectomees have no connection between the nose and the lungs, it is advisable to test nasal secretions in addition to tracheal sputum (using a kit that was approved for sputum testing). 

Information about these tests can be found in the Center of Disease Control website.

One "advantage" of being a laryngecomee is that one generally gets fewer infections caused by respiratory tract viruses. This is because “cold” viruses generally first infect the nose and throat; from there they travel to the rest of the body, including the lungs. Because laryngectomees do not breathe through their nose; cold viruses are less likely to infect them.

It is still important for laryngectomees to receive yearly immunization for influenza viruses, to wear a Heat and Moisture Exchanger (HME) device to filter the air that gets into the lungs, and to wash their hands well before touching the stoma or the HME, or before eating. 
The Atos (Provox) Micron HME with electrostatic filter is designed to filtrate potential pathogens and to reduce susceptibility to respiratory infections.

The influenza virus is capable of spreading by touching objects. Laryngectomees who use a voice prosthesis and need to press their HME to speak may be at increased risk of introducing the virus directly to their lungs. Washing hands or using a skin cleanser can prevent the spread of the virus.




Vaccination against the pneumococcal bacteria

It is advisable that laryngectomees and other neck breathers get vaccinated against the pneumococcus bacterium which is one of the major causes of pneumonia. In the United States there are two types of vaccines against the pneumococcal bacteria: the pneumococcal conjugate vaccine (Prevnar 13 or PCV13) and the pneumococcal polysaccharaide vaccine - a 23-valent pneumococcal polysaccharide vaccine (Pneumovax or PPV23).

One should consult their physician about receiving the pneumococcal vaccination. The Center for Disease Control publishes the current vaccination guidelines.







Shingles (Herpes zoster) vaccination

Shingles (Herpes zoster) is a painful skin rash caused by the varicella (chicken post) zoster virus. Shingles usually appears in a band, a strip, or a small area on one side of the face or body.

Shingles is most common in older adults and people with weak immune systems because of stress, injury, certain medicines, or other reasons.  Vaccine for shingles (Zostavax®) is recommended by the Center for Disease Control (CDC) for people older than 60 years to prevent shingles and reduce pain after the infection in those who still get shingles. The vaccine reduced the risk of getting shingles by about half and the risk of pain along a nerve (neuralgia) in those that who still get shingle by 2/3. The older a person is, the more severe the effects of shingles typically are, so all adults older  than 60 years old or older should get the shingles vaccine regardless of whether they recall having had chickenpox or not. 

The shingles vaccine is not recommended to treat active shingles or post-herpetic neuralgia (pain after the rash is gone) once it develops.


Shingles vaccine should not be administered to those allergic to gelatin, neomycin, or any components of shingles vaccine; those with a weakened immune system (i.e., HIV/AIDS, leukemia, lymphoma, steroids, receiving radiation or chemotherapy), or pregnant. 

One should check with their physician to make sure they can be vaccinated. 







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