Prevention: follow-up, smoking, alcohol use, thrush, vaccination, influenza, COVID-19

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 well being 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

•        Not smoking 

•        Using proper techniques for caring of airways (e.g., using sterile saline 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 ( for those who received radiation treatment), and oncologist (for those who received chemotherapy), is very important. As time passes after the initial diagnosis and surgery, followup occurs with less frequency. In general, the intensity of follow-up is highest in the first two to four years because about 80-90% of all recurrences after treatment occur within this time frame.  However, surveillance beyond five years is generally recommended because there is an elevated risk of late recurrences and a second primary malignancy for at least 10 years.

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 and neck examination 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 examination. 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 physical examination, scans and other tests according to a schedule. The individual follow-up schedule depends 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 recommendation for patients with locoregionally advanced disease are;

      ·       If there is clinical concern for residual disease or progression, CT of primary site and neck with contrast and/or MRI with contrast may be considered at 4–8 weeks after treatment.

• If there is no concern for residual disease, post-treatment imaging may be performed with CT or MRI with contrast at 3–4 months after completion of treatment.
• For those patients in which PET/CT is used for follow-up, PET/CT should be performed within 3–6 months after definitive treatment

Post-treatment, consider obtaining radiographic imaging of primary site (and neck, if treated) within 3–4 months to establish a new baseline for surveillance following surgery, definitive radiation, or chemoradiation.

Further radiographic imaging may be indicated based on worrisome signs or symptoms, smoking history, and areas inaccessible to clinical examination (i.e., salivary glands, nasopharynx, and skull base).

Routine annual radiographic imaging is often employed for HNC difficult to visualize including salivary glands, nasopharynx, or skull base.

Chest CT with or without contrast as clinically indicated for patients with a smoking history (NCCN Guidelines for Lung Cancer Screening).

Carotid ultrasound screening may also be considered every 2–5 years for patients who received neck irradiation.

These recommendations, however, are not based on studies and are merely the opinion or consensus among the specialists. https://onlinelibrary.wiley.com/doi/full/10.1002/lio2.702  

 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

Avoiding smoking and limiting alcohol consumption are crucial for preventing and improving survival in head and neck cancer.

Smoking:

• Smoking is a major risk factor for developing head and neck cancer. Current smokers at the time of diagnosis have a significantly higher mortality risk compared to never-smokers, even after adjusting for important prognostic factors like tumor stage and HPV status.
• The risk of mortality increases with higher smoking intensity. Heavy smokers have a 2 -7 times higher risk of death compared to never-smokers
• Patients who continue to smoke while receiving radiation therapy have a lower long-term survival rate than those who do not smoke.
• 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.
• Quitting smoking is strongly recommended, as it can improve treatment outcomes and reduce the risk of second primary tumors. 

Alcohol:

Heavy alcohol consumption is an established risk factor for head and neck cancer, with a dose-dependent increase in risk for light, moderate, and heavy drinkers.

The evidence on alcohol's prognostic role after diagnosis is conflicting. Some studies found no association between alcohol intake at diagnosis and survival, while others suggest alcohol may adversely affect survival, especially with certain treatments or tumor sites.

Limiting alcohol to moderate levels (≤2 drinks/day for men, ≤1 drink/day for women) is generally recommended to reduce cancer risk. 

Combined Effects:

Tobacco and alcohol have a greater than multiplicative joint effect on head and neck cancer risk, meaning their combined impact is larger than the product of their individual effects.

Tobacco and alcohol decrease the effectiveness of treatment for laryngeal cancer.

Up to 35% of head and neck cancers may be attributable to the combined effects of smoking and alcohol.

In summary, 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. Avoiding smoking and limiting alcohol are crucial preventive measures. For diagnosed patients, quitting smoking is strongly advised to improve survival, while the role of alcohol cessation needs further research.

Preventing and treating 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.

Treatment includes topical agents or systemic antifungal therapy. Topical treatment with suspension (mycostatin), troches (clotrimazole) or mucoadhesive oral tablets (miconazole) is recommended for mild thrush. Azoles (i.e., fluconazole) are administered in tablets for systemic treatment.

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.

Laryngectomees are directly exposed to airborne respiratory pathogens (i.e., viruses, bacteria) because the air they inhale is no longer filtered by the nasal mucosa. This makes them more susceptible to lower respiratory tract and other infections that access the body through the respiratory tract. This is why it is very important to get vaccinated against all respiratory tract pathogens. 

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

COVID-19 Vaccines 

COVID-19 vaccines are effective at keeping people from getting COVID-19. Getting a COVID-19 vaccine will also help keep one from getting seriously ill even if one do get COVID-19. It typically takes 2 weeks after vaccination for the body to build protection against the virus that causes COVID-19. That means it is possible a person could still get COVID-19 before or just after vaccination and then get sick because the vaccine did not have enough time to build protection. People are considered fully vaccinated 2 weeks after their second dose of the Pfizer-BioNTech or Moderna COVID-19 vaccines, or 2 weeks after the single-dose Johnson & Johnson’s Janssen COVID-19 vaccine.

Individuals with medical conditions or those taking medicines that weaken their immune system, should talk to their healthcare provider. They may need to keep taking all precautions to prevent COVID-19 disease.

More information about the vaccines is available at the CDC website. 

Influenza (flu) 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. 

It is very important to  do this especially during the COVD-19 pandemic to prevent another respiratory infection due to influenza virus. Getting infection with both virus may generate a serious medical condition.

There are several variations of the quadrivalent flu shot, meaning they protect against four common strains of the seasonal influenza virus. Options include:

• The standard inactive flu vaccine grown in chicken eggs for people ages six months to 64 years.
• Inactive egg-free vaccines for people ages four years and up.
• High-dose inactive vaccines for people ages 65 and over, which create a stronger immune response.
• A nose spray containing trace amounts of the live virus for non-pregnant people ages two through 49 years.

A new vaccine for influenza is prepared for every new winter 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 (Streptococcus pneumoniae) 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.

Vaccination for Haemophilus Influenzae Type b (Hib)

Hib vaccine prevents serious infections caused by the Haemophilus influenzae type b bacteria. Such infections include meningitis, pneumonia, and epiglottitis. Children older than five years and adults usually do not need Hib vaccine. However, it may be recommended for older children or adults with no spleen or sickle cell disease, or following a bone marrow transplant. Because of the increased risk of laryngectomees to be infected with respiratory tract pathogens the administration of this vaccine may be considered.

Vaccination for Neisseria meningitidis

Meningococcal Disease is a type of illness caused by Neisseria meningitidis bacteria. There are three types of meningococcal vaccines. There are two types of meningococcal vaccines available in the United States: Meningococcal conjugate vaccines and Serogroup B meningococcal vaccines. The CDC recommends that all 11 to 12 year olds should be vaccinated with a meningococcal conjugate vaccine. A booster dose is recommended at age 16 years. Teens and young adults (16 through 23 year olds) also may be vaccinated with a serogroup B meningococcal vaccine. In certain situations, other children and adults could be recommended to get meningococcal vaccines. Because of the increased risk of laryngectomees to be infected with respiratory tract pathogens the administration of this vaccine may be considered.

Vaccination for Shingles (Herpes zoster) 

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. 

In 2017 the Food and Drug Administration approved a second shingles vaccine (Shingrix) that offered greater protection than the previous vaccine. The vaccine consists of a lyophilized recombinant varicella zoster virus (VZV) glycoprotein E antigen combined with an adjuvant that enhances its efficacy. 

Vaccination for Human Papillomavirus

The incidence of Human Papillomavirus (HPV)‐related oropharyngeal squamous cell carcinoma (OPSCC), has increasing dramatically in the past 30 years , with HPV now being observed in over 70% of these tumors.

Several prophylactic vaccines ( Cervarix, Gardasil® and Gardasil®9 ) have been approved by the FDA to protect from HPV infection as well as HPV-associated diseases such as genital warts and cancer.

Based on the observed link between HPV infection and the majority of OPSCC, and the safety and efficacy of the HPV vaccines in preventing HPV infection, the American Academy of Otolaryngology‐ Head and Neck Surgery and the American Head and Neck Society strongly encourage HPV vaccination of both boys and girls for prevention of OPSCC and anogenital cancers.

Preventing respiratory infections (i.e., corona and influenza viruses)

Laryngectomees are more susceptible to respiratory infection because the air they inhale is not filtered by passing through the nose. Consequently, they are at increased risk of inhaling respiratory pathogens (viruses, bacteria, and fungi) directly into their lungs. Therefore, laryngectomees have to vigilant and protect themselves from respiratory all pathogens during the influenza season and other viral epidemics.

•                 Respiratory pathogens most commonly spread from an infected person to others through:

•                 The air by coughing and sneezing and rarely, fecal contamination

•                 Close personal contact, such as touching or shaking hands

Touching an object or surface with the pathogen on it, then touching the stoma, mouth, nose, or eyes before washing hands.

Laryngectomees can protect themselves by getting vaccinated (when a vaccine is available) and:

•           Wearing HME 24/7 especially when being around other people. HME with greater filtering ability would work better in reducing the risk of inhaling the virus ( i.e., Provox Micron TM, Atos Medical's XtraMoist). Provox Micron, has an electrostatic filter and >99.9% filtration rate and it’s cover prevents direct finger contact of the stoma. Wearing it protects other individuals from becoming  infected when the laryngectomee is infected.

•           Wearing hands free HME (because it does not require touching when speaking)

•           Wearing a facemask (preferably N95 respirator) (picture 5) over the stoma (see pictures below how to modify the mask). Wearing an additional facemask (preferably N95 respirator) over the stoma Men should shave their facial hair prior to wearing facemask or respirator. 

•           Those who use a regular HME should wash their hands before touching their HME.

•           Washing hands often with soap and water for at least 20 seconds. Use an alcohol-based hand sanitizer that contains at least 60% alcohol if soap and water are not available. This especially important before managing their stoma, and touching their HME when speaking using tracheoesophageal speech.

•           Avoiding touching the stoma, HME, eyes, nose, and mouth with unwashed hands.

•           Avoiding close contact with sick people.

•           Cleaning and disinfecting frequently touched objects and surfaces.

A facemask with four strings can be modified to fit over the stoma. One of the strings can be extended with extra string; and the lower pair of strings can be tied behind the back. (See pictures below)

If worn properly, a facemask can help block large-particle droplets, splashes, sprays or splatter that may contain germs (viruses and bacteria). Facemasks may also help reduce exposure of the wearer’s respiratory secretions to others.

While a facemask may be effective in blocking splashes and large-particle droplets, it does not filter or block very small particles in the air that may be transmitted by coughs, and sneezes. Facemasks also do not provide complete protection from germs and other contaminants because of the loose fit between the surface of the facemask and the skin over the stoma.

Some facemasks (i.e., N95) offer greater filtering abilities of germs and small dust particles. However, neck breathers and people with chronic respiratory, cardiac, or other medical conditions that make breathing difficult should check with their healthcare provider before using a N95 facemask because it can make it more difficult for the wearer to breathe.

                                                 

Modifying the surgical mask by extending one of the strings. 

Front view of the surgical mask covering the stoma.

Back view of the surgical mask

Managing antiplatelet agents (i.e., plavix, aspirin) when changing voice prosthesis, caring of lower airways, and undergoing esophageal dilatation

Antiplatelet agents (Blood thinners) increase the risk of bleeding. Antiplatelet agents are used in patients who have a history of or who are at risk for cerebrovascular events, acute coronary syndromes, percutaneous coronary or vascular interventions with stenting, or peripheral arterial disease.

Laryngectomees receiving these agents are more likely to experience local bleeding around the tracheoesophageal fistula site after a voice prosthesis is inserted. They can also have petechial hemorrhage in their trachea after manual wiping of their tracheal secretions.

For esophageal dilatation in patients at low thrombotic risk, the European Society of Gastrointestinal Endoscopy recommends discontinuing P2Y12 receptor antagonists (i.e., Plavix) five days before the procedure. In patients on dual antiplatelet therapy, they suggest continuing aspirin. For esophageal dilatation in patients at high thrombotic risk, they recommend continuing aspirin and consulting with a cardiologist about the risk/benefit of discontinuation of P2Y12 receptor antagonists. 

It is best to consult with the clinician who manages the patient's long-term anticoagulation (e.g., cardiologist, neurologist) to estimate the laryngectomee’s thrombotic risk and to determine if antiplatelet therapy can be safely interrupted.

It is best to inform one’s speech therapists and otolaryngologists that one is receiving blood thinners prior to changing their voice prosthesis, and esophageal dilatation. Exercise caution when removing tracheal secretion can reduce the risk of developing upper tracheal bleeding.

Bleeding from the tracheo-esophageal fistula site after changing a voice prosthesis.