palliative care

1. PALLIATIVE CARE IN
HEAD AND NECK CANCER
DR. SNEHA CHANDRA SEKHAR

2. W.H.O DEFINITION
• “an approach that improves the quality of life of patients and their
families facing the problems associated with life threatening illness,
through the prevention and relief of suffering by means of early
identification and impeccable assessment and treatment of pain and
other problems , physical, psychosocial and spiritual”
• Palliate – meaning to ‘cloak’ (Greek)

3. • Different from “Terminal care”
• Though both are aimed at providing comfort and relief
• Terminal care : when patient has less than 6 months to live
• Palliative care can begin as early as the time of diagnosis

4. Palliative care can begin at any point along the cancer care continuum
Hospice: when curative treatment is no longer the goal and the sole focus is quality of life.

5. CHARACTERISTICS OF PALLIATIVE CARE
• Provides relief from pain and other distressing symptoms
• Affirms life and regards death as a normal process
• Intends neither to hasten nor post pone death
• Integrates the psychosocial and spiritual aspects of care
• Offers support system to help patients live as actively as
possible until death

6. CHARACTERISTICS OF PALLIATIVE CARE
• Uses a team approach to address needs of patients and their
families
• Will enhance quality of life and may also positively
influence the course of the illness
• Is applicable early in the course of illness in conjunction
with other therapies that are intended to prolong life

7. MULTI- DISCIPLINARY TEAM
• Doctors ( surgeon/ oncologist / radiation oncologist )
• Nurses
• Speech and Swallow Therapists
• Nutritionists
• Social workers / volunteers

8. PALLIATIVE CARE IN INDIA
• Introduced in mid 1980s
• Palliative care first initiated in Gujrat : Gujrat cancer and research
institute
• 1986 : first Hospice – Shanti Avedna Ashram in Mumbai by Dr.
D’Souza
• Indian Association of Palliative Care : 1994 in association With WHO
• CanSupport: 1st free palliative home care support service in North
india 1997 , Delhi
• At present <3% of cancer patients have access to adequate pain relief

9. COMMON PROBLEMS IN HEAD AND NECK
CANCER
• Pain
• Dysphagia
• Malnutrition
• Airway obstruction
• Retained secretions
• Chemoradiation: mucositis/ xerostomia

10. PAIN
• Most common complain
• Pain is an unpleasant sensory and
emotional experience associated with
actual / potential tissue damage or is
described in terms of such damage

11. PAIN
• Nociceptive pain: due to activation of afferent nerves by a noxious stimuli
Somatic pain : piercing pain, tissue damage : eg skin, muscle, mucosa.
Visceral pain : constant pressing type. Thoracic, abdominal, pelvic viscera
• Non – nociceptive pain : neuropathic pain , plexus infiltration by the
tumour/ post chemoradiotherapy
Burning pain
In cancer patients : mixed type of pain

12. PAIN MANAGEMENT
• Goal of optimum pain management : relieve pain to a level that allows
quality of life that is acceptable to the patient
• Weigh the risks and benefits to maximise quality of life
• Pharmacological : mainstay
• Others : Radiotherapeutic/ surgical/ physiotherapy
psychological / spiritual and social intervention also play a role

13. ASSESSMENT
• First step
• Comprehensive detailed history/ examination and pain severity

14. BRIEF PAIN INVENTORY
Also translated in HINDI

15. WHO : ADMINISTRATION
• BY MOUTH : orally preferable
• BY THE CLOCK : At regular interval
• BY THE LADDER: based on severity and response to treatment
• FOR THE INDIVIDUAL : correct dose is the dose that relieves the patients
pain to an acceptable level
• ATTENTION TO DETAILS : Patient must be warned regarding adverse effects

16. Mild pain: (1-3)
Paracetamol / NSAIDS
Moderate pain (4-6) : weak
opiods
Severe pain(7-10) : strong
opioids
Adjuvants : antidepressants /
anticonvulsants

17. PHARMACOLOGICAL
• NON OPIOIDS : PARACETAMOL
NSAIDs : Ibuprofen, diclofenac, celecoxib, ketorolac
• OPIOIDS : WEAK OPIOIDS tramadol, Codeine, hydrocodone
STRONG OPIOIDS : Morphine, oxycodone,
hydromorphone, fentanyl, methadone
• ADJUVANTS : ANTI-DEPRESSANTS: Amitriptyline
ANTICONVULSANTS: Gabapentin / pregabalin

18. • BREAKTHROUGH : transient flare
• short acting / Immediate release morphine : oxynorm or
oramorph
• Fentanyl : sublingual tablet / intranasal spray
• Transdermal patch : after adequate pain control has been
achieved
changed every 72 hours
Fentanyl , Buprenorphine

19. Parenteral route
Subcutaneous preferred over I.M
subcutaneous : morphine,
oxycodone, fentanyl or alfentanil
if patient requires regular
injections : subcutaneous
infusion pump CSCI (end of life)

20. DYSPHAGIA
• Associated with the disease / post surgical / chemoradiation
• Maybe a cause of malnutrition , dehydration , aspiration
• Swallowing assessment in suspected aspiration : (FEES/VFSS)
• Targeted swallowing exercises and oral intake encouraged
• Diet modification : change food texture

21. • Manoeuvres :
• Effortful swallow : increase pressure generated by pharynx and
oral musculature
• Supraglottic swallow : adduct vocal cords longer during swallow
• Super supraglottic swallow : close airway before, during and
after swallow
• Mendelsohn manoeuvre : Prolongs the opening & diameter of
cricopharyngeal sphincter

22. • Exercises :
 Masako ( tongue – holding )
 Shaker (head lift)
• Postures : Chin tuck, head turn, head tilt, chin up
• Enteral tube feeding

23. MALNUTRITION
• Decreased oral intake
• Pain/ dysphagia : management discussed
• Cachexia: mediated by cytokines : TNF α, IL1,6 γInterferon
• Rx. Glucocorticoids , megestrol acetate, dronabinol
• Nutritional assessment by a dietician
• Nutritional support : fortifying foods with macronutrients,
oral nutritional supplements

24. • Enteral tube feeding : inadequate oral intake
• Nasogastric tube : short term feeding <4weeks
• Gastrostomy/ jejunostomy : long term feeding
• Parenteral nutrition rarely required in Head and neck cancers as
most have functioning GI tract

25. RESPIRATORY TRACT SECRETION
To manage retained secretions
Anti secretory : Glycopyrronium , Hyoscine hydro, hyoscine
butylbromide
Transdermal hyoscine patch : scopolamine

26. MUCOSITIS
• Painful and can interfere with food intake
• Symptomatic management: Oral hygiene /saline/
bicarbonate mouth rinses/ topical anaesthesia
• Benzydamine hydrochloride (nsaid) approved in
Europe for topical application

27. XEROSTOMIA
• c/o dryness/ increased thirst/ mouth burning/ dental caries
• At doses above 54 Gy Xerostomia is irreversible
• Measures: plenty of water, Pilocarpine or Cevimeline
artificial saliva ( rises/ spray )
• Amifostine: prior to radiotherapy

28. TERMINAL HEMORRHAGE
• 3-5% patients have carotid artery blow out post major head and neck
resections
• Neck Radiation most important risk factor
• Exposed into oral cavity / externally through skin breakdown / tumor invasion
• Impending CBS in terminally ill patients
caregiver must be present to reduce anxiety
keep dark towels
anxiolytics

29. PALLIATIVE SURGERY
• Refers to surgery that is non curative by intent
• Airway obstruction ( Tracheostomy )
• Tumour debulking
• Nutritional: Gastrostomy
• Reconstructive procedure : Orocutaneous/ Pharyngocutaneous fistula/
Osteoradionecrosis

30. PALLIATIVE RADIOTHERAPY
• To reduce symptom burden due to progressive local disease
• Conventional radiotherapy : 2 Gy/day for 5 days a week i.e 5
fractions per week for 7 weeks
• In palliative RT : Hypofractionation with reduced overall time: > 2
Gy/day
• Regimens : 30 Gy in 10 fractions
35 Gy in 15 fractions
20 Gy in 5 fractions

31. PALLIATIVE CHEMOTHERAPY
• Single agent / combination cytotoxic drugs
• Single agent activity : cisplatin/ taxanes/ 5-FU / gemcitabine/
etoposide/ irinotecan/ methotrexate
• Combination : cisplatin + 5-FU , addition of cetuximab

32. ACUPUNCTURE
• Modality of Chinese medicine
• Needles to stimulate certain
points in body that
correspond to energy
meridians
• Clinical trials: found to be
effective in chemotherapy
induced nausea and
vomiting

34. MEDICAL MARIJUANA
Pain, nausea and reduced appetite
Country : legal in 20 states of USA, Canada, Spain,
Portugal, Austria, Finland, Germany, Israel, Italy
Medicinal cannabis (plant form) :
smoked/ingested
Oral medication : Nabilone, Nabiximol
Dronabinol (synthetic THC) FDA approved as anti
emetic and appetite stimulant /

35. HOLISTIC CARE
• Spiritual issues
• Depression
• Care givers needs

36. THANK YOU