Aspects of nursing care for patients with head and neck cancer receiving radiation therapy

Abstract: Head & Neck (H&N) cancer accounts for approximately 3 % of all cancer in Sweden. The treatment options include radiotherapy (RT), surgery and/or chemotherapy. Both the disease and the treatment cause side effects that often have great impact on the patients. Many H&N cancer patients have limited social networks and have been found to have a worse general health compared with the general population. A majority of these patients are smokers and many also have other types of substance abuse. The general aim of this thesis was to improve the nursing care for H&N cancer patients undergoing RT. The four studies included, predominantly focus on information and communication (paper I), immobilization and reproducibility during RT for H&N cancer (paper II) and smoking cessation (paper III and IV). In paper I, the helpfulness of a care diary, aiming to improve information and communication, was evaluated through anonymous questionnaires from H&N cancer patients, family members and clinicians. The results indicate that the overall impression of the care diaries were good or very good among 85 % (n = 99) of the responders. The evaluation gave information on the usefulness of the diaries, suggestions for improvements in layout and content and also indicated difficulties, such as lack of involvement and information among some clinicians. In paper II, two types of thermoplastic face masks (Posicast ®) for immobilization during RT were compared, regarding reproducibility of patient position over time, radiation skin reactions and the patients' subjective experiences of using the masks. In this trial, 260 patients were randomised to one of the two types of face mask. One hundred and forty one patients were evaluated. We found no difference in reproducibility, pain, fit, discomfort or possibility to move the head within the mask during RT between the two types of masks. However, patients using the longer head and shoulder mask (HSM) experienced significantly more claustrophobia (p = 0.023). Patients allocated to HSM and receiving > 60 Gy were also found to have more radiation skin reaction, according to the WHO scale for acute or sub acute toxicity. In paper III, H&N cancer patients and nurses experience of a nurse-led smoking cessation program was explored. In this qualitative study, data was collected from diary notes (kept by six patients and two nurses) concerning 13 H&N cancer patients, focusing on the smoking cessation process. Data was analysed using the Framework approach. The most important finding was the therapeutic value of the patient-nurse relationship, described by both patients and nurses. The results were presented in three major categories; patient-nurse relationship, factors facilitating and hindering behaviour change and drug (ab)use. In paper IV, the effectiveness (proportion of smoke-free patients) of the nurse-led smoking cessation program for 50 H&N cancer patients planned for curative RT was evaluated, with one-year follow-up. Thirtyseven (74 %) of the patients were tested (measuring carbon monoxide in expired air) smoke free weekly during RT, and of the 41 patients alive after one year 28 (68 %) were reported and tested smoke free at the one-year follow-up. Care diaries seem to be a useful tool in communication between H&N cancer patients, their families and clinicians. We recommended that the care diaries should be implemented in the standard care for H&N cancer patients after improvements but a more sophisticated evaluation on a larger sample in needed. When choosing an immobilization device for H&N cancer patients undergoing RT, a more individual approach is recommended and the shorter head mask (HM) is suggested as first choice, to reduce the risk severe skin toxicity, especially for patients receiving > 60 Gy and/or with previous experiences of claustrophobia. Smoking cessation could be implemented into standard cancer care and even H&N cancer patients with a heavy nicotine addiction and multi drug abuse could successfully quit smoking with systematic support from the multidisciplinary team. However, to more accurately evaluate the effect of this nurse-led intervention program, farther studies are on going, involving larger groups of patients and suitable control groups.