Lorraine Fulman Advanced Practitioner Radiotherapy Information & Support

Transcription

1 The Patient Experience at NUH Advanced Practitioner Radiotherapy Information & Support

2 Aims To discuss the management of acute toxicities of head & neck cancers treated on the TomoTherapy unit at the Nottingham Radiotherapy Centre To outline service developments to improve the head & neck cancer patients experience at Nottingham University Hospitals Trust

3 TomoTherapy The TomoTherapy Hi Art (Highly Integrated Adaptive Radiotherapy System) Combines treatment planning, CT image-guided patient positioning and treatment delivery in an integrated system. A sophisticated way of delivering intensitymodulated radiotherapy (IMRT)

4 Introduction TomoTherapy clinical on 21st June 2011 Currently head and neck cancers only Majority receiving Chemo-Radiotherapy treatment 22 patients to date 8 patients completed treatment

5 Mask & headboard 5 point fixation for the mask Carbon Fibre headboard 65 Gy in 30# (2.17 Gy per #)

6 Preparations 31 day target Dental assessments/treatment Baseline audiogram RIG

7 Treatment Weekly review mouth care, oral assessment MDT - weekly Missed days compensated by 2# given in one day Caphosol commenced week one

8 Guidelines for the management of oral mucositis - NUH 2009

9 Grading (NCI CTCAE Version 3) Normal mucosa Erythema; minimal symptoms; normal diet; minimal respiratory symptoms but not interfering with function Patchy ulcerations or pseudo membranes; can eat and swallow modified diet Confluent ulcerations or pseudo membranes; bleeding with minor trauma; symptomatic and unable to adequately aliment or hydrate orally Tissue necrosis; significant spontaneous bleeding; symptoms associated with life-threatening consequences Death

10 Grade 1-2 oral mucositis Water or saline mouth rinse regularly using vigorous ballooning and sucking motion of the cheeks Alcohol-free commercial mouthwashes if patient prefers but there is no evidence of any benefit over and above water or saline Regular analgesia including aspirin or paracetamol gargles Oxetacaine and antacid suspension 10mls qds po before meals Close monitoring of nutritional status and hydration levels

11 Grade 2 oral mucositis In addition to above measures Gelclair 15mls up to tds forms a bio protective barrier that adheres to or pharyngeal mucosa; covers exposed nerve endings and reduces pain Caphosol oral rinse 4-10 times daily - supersaturated calcium and phosphate electrolyte solution; promotes tissue repair, maintains ph balance, helps dry mouth

12 Grade 3-4 oral mucositis Consider admission to hospital if nutritionally depleted or dehydrated Enteral feeding and hydration Reassess for oral infection as higher risk with severe mucositis Mouth swabs for MC+S, culture, virology Consider modification of treatment regimen

13 Skin Care Protocol for patients receiving Radiotherapy NUH 2011

14 RTOG Skin assessment tool 2001 RTOG1 Skin is sore, reddened and may be itchy/uncomfortable RTOG2a Bright or tender erythema, with or without dry desquamation RTOG2b Patchy moist desquamation, moderate oedema RTOG3 Confluent moist desquamation, pitting oedema

15 REACTION MEDICATION INTENTION EFFECTIVENESS Mild/moderate erythema Dry desquamation Aqueous cream Moisturise the skin, soothe mildly irritated skin. Aqueous cream is a water based cream. It has a low incidence of allergic sensitivity and is widely used in the management of radiation skin reactions. Tender, bright erythema Pruritis Continue with aqueous cream and add 1% hydrocortisone 2-3 times daily BNF Topical corticosteroids are used for the treatment of inflammatory skin conditions other than those caused by infections. They are indicated for the relief of symptoms and for suppression of the signs of the disorder when potentially less harmful measures are ineffective. Maintain the suppleness of the skin. Dry, tight skin is painful particularly in areas where there is movement. Reduce inflammation and itching.

16 Moist Release desquamation Mepitel +Release with light Mepilex Lite exudate. Moist PolyMem desquamation Intrasite gel in areas with moderate difficult to dress or heavy exudate Protect fragile skin from further trauma e.g. friction from clothes or between skin surfaces. Release is an absorbent low adherent dressing. Can be used as a primary or secondary dressing. Should be removed for treatment Mepitel is a non adherent silicone dressing for lightly exuding wounds, to be left in situ for up to 14days. Can be covered with a secondary dressing which should be changed as needed. Can be treated through after removal of the secondary dressing. Mepilex lite is a silicone wound contact dressing with foam film backing for low to moderate exuding wounds. It should be removed for treatment. Maintain warm moist environment PolyMem is a soft, absorbent, conformable for optimum healing. Absorb dressing with moisturising and wound cleansing exudate. ingredients. It can be left in place for several Provide maximum possible comfort days. It should be replaced when it reaches it for patient. maximum absorbency. It should be removed for treatment. The plain side goes next to the skin. Intrasite is a hydrogel dressing. It provides a moist environment and absorbs some exudate. It is non-adherent and does not harm viable tissue or skin surrounding wounds. Can be used alone where dressings are very difficult to fix

17 RTOG2b Polymem dressings have been used on patients with radiotherapy skin reactions and have been shown in clinical practice to: keep damaged skin clean provide anti-inflammatory effect positively support healing of damaged skin Non-Adhesive Roll Dressing 10cm X 61cm Roll 4 per Box, 2 Boxes per Case

18 Improving patients experience Thermo-plastic masks Timely dental assessment/treatment Consider suitability for RIGS Patient experience survey Evaluating Caphosol in oral mucositis for head & neck cancer patents receiving TomoTherapy Audit local practise Information prescriptions

19 Questions?

20 References 1 The Royal College of Radiographers, Summary of intervention for acute radiotherapy induced skin reactions in cancer patients, Nottingham Hospital Services Wound Care Formulary, NHSSB Wound Management Manual, Glean E. et. al. (2001). Intervention for acute radiotherapy induced skin reactions in cancer patients: the development of a clinical guideline recommended for use by the college of radiographers. Journal of Radiotherapy in Practice, 2, Brown A, Butcher M (2005). A guide to emollient therapy. Nursing Standard,19 (24), Best practice in emollient therapy. A statement for healthcare professionals (2007). Dermatological Nursing, Supplement 7 Maureen S. et.al. (2007). Randomized comparison of dry dressings versus hydrogel in management of radiation-induced moist desquamation. International Journal of Oncology Biology physics, 68 (3), Wickline M M. (2004). Prevention and treatment of acute radiation dermatitis: A literature review. Oncology Nursing Forum, 31 (2), Porock D, Kristjanson L (1999). Skin reactions during radiotherapy for breast cancer: the use and impact of topical agents and dressings. European Journal of Cancer Care, 8, Bruce S D, Quinn A (2007). The pain of oral mucositis. Touch briefings: US oncological disease 11 Keefe D M et al (2007). Updated clinical practice guidelines for the prevention and treatment of mucositis. Cancer col 109; no.5;

21 References 12 Multinational Association for supportive care in cancer/international society for oral oncology (MASCC/ISOO). (2005 update). Summary of evidence base clinical practice guidelines for care of patients with oral and gastro-intestinal mucositis 13 Peterson D E, Bensadoun R J and Roila F (2008). Management of oral and gastro-intestinal mucositis: ESMO clinical recommendations. Annals of Oncology 19 (supplement 2): II122II UK medicines information, medicines Q & A`s saliva substitutes: Choosing and prescribing the right product August 2011 accessed via 15 Innocenti M, Moscatelli G, Lopez (2002). Efficacy of Gelclair in reducing pain in palliative care patients with oral lesions: preliminary finding from an open pilot study. Journal of Pain and symptom management 24(5): Allen M. Chen et al (2009). Initial clinical experience with helical tomotherapy for head and neck cancer. Head & Neck 31 (12):