HEAD neck cancers are devastating for patients, because surgery can mean the loss of a vital function such as speech, and some disfigurement.
A multi-disciplinary team can better prepare patients for surgery and provide comprehensive, customised care, while taking their concerns and preferences into account when deciding on treatment.
At the SingHealth Duke-NUS Head & Neck Centre, a 30-member team like this has been in place since last year.
It includes clinicians such as general surgeons, ENT (ear, nose and throat) surgeons, plastic surgeons, medical oncologists, radiation oncologists and dental specialists from the maxillofacial service. Also in the team are allied health professionals such as speech therapists, physiotherapists, occupational therapists, dietitians, clinical psychologists and social workers.
Head and neck cancers are a mixed group of conditions which no single clinician can handle, said the Centre’s previous Head, Dr Tan Hiang Khoon, currently Chairman, Division of Surgery, Singapore General Hospital (SGH). He also noted that the vital pre-operation assessment of patients by allied health team members puts patients’ minds at ease, prepares them better for surgery, and allows doctors to modify surgery in line with patients’ needs and preferences.
The entire team does combined weekly ward rounds to see patients, discuss cases, update one another and share input. Patients can also consult specialists at the Centre at the same time. Previously, they saw them at different times and in different clinics. There is also a pre-operation allied health clinic, where complex cases admitted to hospital are referred for counselling before surgery.
The Centre currently operates at both the National Cancer Centre Singapore (NCCS) and SGH but there are plans to house it in one place when the new NCCS opens in 2020.
The Centre’s recently appointed new Head, Dr Gopal Iyer, said: “The different specialists may have differing opinions, but are united by a common outlook and desire to work in the best interest of patients.”
His job is listening, directing and allowing the team to give the best from their own specialties to get the optimum outcome for patients.
“Each has an important role to play in the treatment and rehabilitation of patients and I need to ensure that everyone gets a platform to contribute.”
The advantage of having everyone on-site is that they can leverage on one another’s strengths, he said. More resources mean they can reduce delays in treating people with aggressive cancers, as these delays can be damaging.
Doctors can also get information from social workers and practice nurses on what resources are available in the community, before they discharge patients there.
And clinical psychologists can provide clinicians with critical input on the real worries of patients, their social background, and the family structures they will return to after surgery.
After surgery, the team helps patients – including those who have had reconstructive surgery – recover and integrate back into society. “Studies show that most patients, at diagnosis, are most concerned about not dying. But a significant number do survive beyond five years, and so have to return to normal life. Taking care of how they can look and function there, is also important,” said Dr Iyer.
“Patients who are reluctant to confide their worries to doctors are helped by the pre-operation counselling and assessment,” said Dr Constance Teo, Consultant and the Centre’s Director of Clinical Services. She said they can have their nutritional status optimised before surgery, and get psychosocial support, an understanding of the rehabilitation process, as well as advice and assistance with stepdown care arrangements, all in one visit at the combined allied health clinic.
“The multi-disciplinary approach is the only way forward in caring for cancer patients in the 21st century,” said Dr Tan Ngian Chye, Senior Consultant and Director, Education, SingHealth Duke-NUS Head & Neck Centre.
“It allows those with debilitating cancers to be treated in a holistic and organised manner. Previously, they may not have been as well-prepared mentally, physically and emotionally.”
“The main issues after surgery for head and neck cancer, especially if their voice box is removed, are not being able to speak and having a permanent opening in the neck,” said Ms Elizabeth Roche, Senior Principal Speech Therapist, SGH. Patients have to rely on gestures, facial expressions and mouthing words to communicate, and are fed through a tube until their wound heals in about two weeks. They worry about going back to work and interacting with people. Those who cannot read or write are more anxious than others.
For some, the reality of the opening in the neck only hits home after the operation. “They ask if and when it will close up. They don’t always take it in, even though the surgeon would have told them before.”
A speech therapist helps patients regain their ability to eat and speak well. To restore speech, patients need a voice prosthesis which the surgeon can insert in selected patients by creating another opening in the throat. Patients use their thumb to close the opening in the neck, thus letting air flow through tissues in the throat, to create vibrations that produce sounds. This serves as their new voice.
A hands-free feature can be added later.
Other methods include using an electronic artificial larynx (an external electronic device) or learning oesophageal speech (swallowing and trapping air in the throat to produce speech).
Patients may get depressed after surgery. “I encourage them to meet others who’ve had similar surgeries and experienced similar difficulties. This often shows them that there is light at the end of the tunnel. One patient who had suicidal thoughts was a changed man after learning to speak again with a voice prosthesis.”
“It is important for patients to have a thorough psychosocial assessment before surgery,” said Mrs Tan Yee Pin, Clinical Psychologist and Medical Social Worker, Head, Department of Psychosocial Oncology, NCCS.
She assesses what psychological, social and spiritual resources patients and their families have to deal with their needs, challenges, anxieties and fears. Knowing these helps the team prepare them psychologically and socially for treatment, its aftermath and long-term recovery.
She said that after diagnosis, patients are in a crisis-like situation. They worry about many things – treatment, finances, the uncertainty ahead, how they will function, speak, eat, work, cope with disfigurement and feeding tubes, or become a burden to others.
For instance, a taxi driver may be anxious about how he will speak to passengers, and an illiterate, elderly person living alone will fear not being able to call for help or manage tube feeding at home.
“In the past, without this assessment and problems not being pre-empted, it felt like we were fighting fires. Now, the whole team is aware of the challenges patients face, so we can pre-empt and address them.”
Clinical psychologists also work with medical social workers, who assess and help patients with practical things such as interim financial aid and work with families to harness social support to help in the recovery process.
One strategy to integrate patients back into the community is by setting up a routine. “We work out a schedule and encourage them to take small, incremental steps to go out of their homes, until they’re more able to deal with their anxieties and less conscious of stares. Each little success can motivate them to take on more challenging tasks.”
Ms Peh Hui Yee, Dietitian, SGH, ensures that patients get adequate nourishment before, during and after surgery. She assesses their nutritional status and recommends intervention to ensure optimum nutrition because malnutrition may lead to slower recovery and a risk of infection.
She guides patients and caregivers through specific dietary strategies to help maximise their oral intake and minimise symptoms that may arise from treatment, especially while on a modified texture diet. “Before surgery, many patients find it difficult maintaining adequate nutrition because of the disease itself. They may have pain in the mouth or throat, swallowing difficulties, or suffer from weight loss,” she said.
“Immediately after surgery, many are unable to eat and often put on nasogastric tube feeding. Some can eat after a week but still need tube feeding, a modified texture diet, or both. Those who need further radiotherapy or chemo-radiotherapy may have pain, weakness and nausea that prevent them from eating enough, so their intakes are closely monitored.”
• This story was first published in Singapore Health, Mar-Apr 2016 issue.