Supportive care during radiotherapy for head and neck cancer

• Prior to starting concurrent chemo-radiotherapy with cisplatin/carboplatin, the following medications should be stopped as there is an increased risk of acute kidney injury (AKI).
  • ACE inhibitors
  • Angiotensin II receptor blockers
  • NSAIDs
    Please refer to “Nephrotoxic drugs with cancer therapy” document on OOQS.
• If any medications have been stopped prior to or during treatment then asking for GP review regarding re-initiating these medications should take place following the end of treatment (most commonly anti-hypertensive medication)
• Gastrostomy feeding tubes can be inserted prior to or during treatment. Antiplatelet and anticoagulation medications must be stopped prior to this procedure.
  • Aspirin and LMWH = 24 hours before
  • Clopidogrel and warfarin = 7 days before
  • DOACs (edoxaban, apixaban etc) = refer to Suspected thromboses (RIG insertion carries minor bleeding risk)

Please discuss with Oncology Consultant responsible for patient if stopping warfarin to ascertain if cover with LMWH prior to procedure is required.

• Patients are advised not to use their own creams, lotions or ointments during radiotherapy treatment. We advise gentle or unperfumed soaps and to pat skin dry.
• Radiation doses for head and neck cancers have a BED of >45Gy therefore are considered high risk of radiation dermatitis.
• Emollients advised are Zerobase and topical steroid of either betamethasone 0.1% or fluocinolone acetonide 0.025%
• Refer to guidelines for management of radiation dermatitis and the prescription template for further information.
• Moist desquamation can often become infected. If this is suspected- swab and start empirical antibiotics (flucloxacillin 500mg QDS unless penicillin allergic in which case clarithromycin 500mg BD) for 5-10 days until results are back and alter as needed.
• For brisk erythema and patchy moist desquamation, Polymem dressings can be considered.

• Radiotherapy for head and neck cancer will result in mucositis and the distribution of this depends on site of treatment. Mucositis can lead to difficulties taking tablets therefore soluble or liquid preparations should be offered wherever possible.
• Many medications can also be given via gastrostomy tube if the patient is too sore or it is unsafe to swallow.
• Radiation induced mucositis is generally not expected until the 3rd or 4th week of radiotherapy but this varies between patients due to their sensitivity and whether they are also receiving chemotherapy. It is usually more gradual in onset therefore if there is a sudden increase in pain, consider oral infection as a potential cause.
• The analgesic ladder is a good reference point when aiming to optimise pain control. This must be taken as a guide only; clinical judgement must be taken into consideration.
• Please refer to Scottish palliative care guideline for information on pain management and choosing and changing opiates for further advice.

• Alcohol based mouthwashes should not be used during H&N radiotherapy.
• Patients should use sodium bicarbonate mouthwash, initially 4 x per day but frequency should increase as treatment progresses and secretions increase. This is prepared using a level teaspoon of bicarbonate of soda (from baking aisle of supermarket is fine) dissolved in a pint of tap water.
  We recommend making this up each morning and storing in the fridge to use throughout the day. Make a fresh batch daily. Sodium bicarbonate powder has been discontinued via pharmacy wholesalers. In the inpatient setting, where a patient has not brought their own supply with them, sodium chloride 0.9% 10ml ampoules can be opened and used a mouthwash as a short term alternative. This should be prescribed as other drug and topical route should be selected.
• Benzydamine hydrochloride 0.15% mouthwash has analgesic properties and often helps with oral mucositis. If used 10-15 minutes prior to oral intake it can help pain control facilitating eating and drinking. Ideally it should be held in the mouth for as long as possible (30-45 seconds) up to 4 x daily. It should not be swallowed.

• High dose radiotherapy to the H&N region causes the normal mucosa of the upper aerodigestive tract to make an increased volume of secretions. These can be difficult to expectorate. Optimizing secretion clearance regularly can reduce the risk of infections and also make eating and drinking easier. The use of regular sodium bicarbonate mouthwash will help with this.
• Secretions can frequently be blood stained due to the friable mucosa in the pharynx. This is entirely normal.
• Patients will often report that secretions increase the sensitivity of their gag reflex which results in retching. Reiteration of the importance of clearing secretions is the best advice for this. Humidified oxygen has been shown to improve comfort from this symptom. Providing nebulisers in some circumstances to patients who have this difficulty can aid their secretion clearance.
• Hyoscine can reduce secretions but as they increase the dryness of the mucosa they often can reduce patient comfort.

• Nausea and vomiting can be multi-factorial in nature. Timing in relation to SACT and or radiotherapy is often important. Radiotherapy itself will rarely be the cause of the nausea, except in nasopharyngeal tumors where the vomiting centre in the brainstem is likely to receive a higher dose.
• Prophylactic anti-emetics are given following SACT but delayed nausea after anti-emetics finish can occur and affected patients often benefit from a longer course with their next cycle.
• Increased secretions in the latter part of radiotherapy can lead to nausea and vomiting. Regular mouthcare as discussed previously is encouraged. Prochlorperazine can also help with these symptoms.
• Subcutaneous infusion of anti-emetics can be considered but isn’t always helpful therefore this should be discussed with the patient’s Oncologist in the first instance.
• Refer to SACT nausea and vomiting and Antiemetic guidance for patients undergoing radiotherapy for further advice

• SACT, anti-emetics and opiate analgesia can all cause constipation. Patients receiving concurrent treatment are given laxatives to take regularly but adherence to this can be variable.
• Macrogol 3350 is the preferred laxative as it can be given via gastrostomy when the oral route is not available. This should be prescribed once daily throughout chemoradiation or when starting opioids.
  In the event of faecal impaction, 6-8 sachets a day can be used in conjunction with PR treatments.

• Always exclude febrile neutropenia in patients receiving SACT. Patients are often on regular paracetamol which can mask a fever.
• Consider oral infections if there is a sudden increase in oral or oropharyngeal pain (this can be indicative of candida). Oral thrush should be treated with fluconazole 100mg OD for 1 week.
• In the case of malodorous breath consider anaerobic infection.

• Patient attends Oncology elective clerking clinic on Monday between 11:00 to 14:30hrs.
• Full clerking done by ANP/CNP or doctor covering clinic.
• Patient is clerked on TRAK using shortcode: \RIGOnc (clerking documentation)
• Patient’s own medications added to HEPMA.
• Patient’s pre/post RIG medications added to HEPMA using RIG insertion protocol.
• RIG insertion protocol medications will include:
  • Pre- RIG placement antibiotics (co-amoxiclav 1.2g IV, or teicoplanin 400mgs IV if penicillin allergic)
  • Post- RIG placement antibiotics to be given 8 to 10 hours after RIG insertion (coamoxiclav 1.2g IV, or teicoplanin 400mgs IV if penicillin allergic)
  • Sterile water 50mls TDS via RIG.
  • RIG rotation and clean (24 hours post insertion)
  • PRN paracetamol 500mgs – 1g orally/via RIG 4 to 6 hourly, max QDS
  • PRN morphine sulphate 2.5mgs – 10mgs s/c 1 hourly, max QDS
  • PRN morphine sulphate liquid (oramorph) 5 -10mgs orally/via RIG 1 hourly, max QDS
  • PRN hyoscine butylbromide 20mgs s/c 4 to 6 hourly, max QDS
  • PRN cyclizine 50mgs orally/via RIG s/c 6 to 8 hourly, max TDS.