Treatment

Most patients with oral cancer are older people who abuse alcohol and tobacco. As a result, many have medical problems that complicate their condition. From alcohol abuse, these patients may have liver problems or diabetes. From smoking, they may have emphysema, chronic obstructive pulmonary disease (COPD), or hardening of the arteries (including the arteries in the neck, brain and heart).

The pain of oral cancer may make eating and swallowing difficult; therefore, many people with oral cancer suffer from malnutrition.

The complications that may accompany oral cancer often demand multidisciplinary care – care designed by specialists in many fields and delivered through their cooperation.

At UPMC, surgery is the mainstay of oral cancer treatment. Surgery is augmented as necessary by specialists who work together to help ensure that:

• the patient is ready for surgery
• surgical procedures are planned with rehabilitation in mind
• the most appropriate specialists participate in surgery
• the patient has the resources needed to make the most complete recovery possible

Patients with advanced cancers may need radiation and chemotherapy in addition to surgery. The UPMC Division of Medical Oncology and the Department of Radiation Oncology provide these services at UPMC Presbyterian.

Presurgical Rehabilitation Conferences

At UPMC, interdisciplinary planning for recovery often begins before surgery. Patients may visit specialists at the UPMC Regional Center for Maxillofacial Prosthetic Rehabilitation to address potential speaking and swallowing problems which are unavoidable consequences of oral cancer treatment. The staff at the center make recommendations that help the surgeons maximize oral cavity function. The maxillofacial rehabilitation specialists are able to provide prosthetic devices that can help correct postsurgical speaking and swallowing problems, and they can help the patient prepare mentally for the recovery period.

The UPMC Regional Center for Maxillofacial Prosthetic Rehabilitation is one of only six centers in the United States that train professionals in the highly specialized field of dental rehabilitation.

A Multidisciplinary Surgical Team

An oral cancer patient's surgical team should consist of head and neck surgeons (otolaryngologists) who may be assisted by oral and maxillofacial surgeons and plastic surgeons. Reconstruction of the jawbone and the soft tissues of the oral cavity are priorities in order to restore the patient's form and functions.

A Specialized Nursing Unit

After surgery, patients usually recover in our specialized nursing unit dedicated to the care of patients undergoing surgery of the head and neck. The nurses in this unit are specially trained to take care of patients with cancer of the head and neck and to manage the temporary openings in the windpipe (tracheostomies) that oral cavity surgery often necessitates. Patients who have major medical problems or who have had a lengthy surgical procedure are admitted to the Medical Intensive Care Unit before transfer to our head and neck nursing unit.

UPMC Swallowing Disorders Center

The UPMC Swallowing Disorders Center is staffed by speech pathologists, head and neck surgeons, and other swallowing disorder specialists. These clinicians provide expertise in helping patients to rehabilitate their swallowing functions. A nutritionist helps patients address the special dietary problems of oral cancer patients.

Other Types of Treatment

In addition to the medical treatment, other treatments are very important in these patients such as tobacco and alcohol cessation programs. While Alcoholics Anonymous is a well known and very important and effective means of alcohol cessation, most patients are not aware of smoking cessation programs, which in a formal setting, are also very effective. Many patients try themselves using nicotine patches and other means to stop but are usually not successful. The group therapy aspect of smoking cessation programs together with the use of chemical agents has been very effective. Our clinicians provide a very effective smoking cessation program.

Alcohol use among head and neck cancer patients is a common occurrence. Alcohol withdrawal syndrome (AWS) or delirium tremens (the most severe form of withdrawal) often causes significant problems for postoperative patients and those that provide their care. Patient problems include injury to self (falls), damage to surgical site, injury to staff , extended length of stay, and high cost due to transfer to an ICU for sedation and ventilation. Chronic alcohol use has a depressant effect on the central nervous system. When patients are admitted to the hospital for surgery their alcohol intake is suddenly stopped. Abrupt withdrawal from alcohol can result in signs and symptoms of central nervous system excitation.

The best approach to alcohol withdrawal is prophylaxis. We have found that if we treat the patient prior to admission for withdrawal, the patient will not experience the ill affects of AWS, costs will be significantly lower and the staff will not endure injury when working with these patients. The theory is simple, once alcohol is absent in the blood system for several days there is nothing to withdrawal from during the post op course. UPMC offers in patient pre-operative detoxification at UPMC Braddock. It typically takes 2-3 days to complete in-patient detoxification. Patients may also be treated at home by their PCP with decreasing doses of serax prior to admission. A family member must be available to stay with the patient to assure the patient is following the protocol. Educating patients and families to the severity of post operative AWS is key in helping patients understand the need for pre-operative treatment and the cessation of ETOH intake at least 1 week prior to surgery.

A protocol is also in place for those patients who failed to yield to the pre-operative treatment. Nurses' monitor for withdrawal symptoms utilizing the "Withdrawal Assessment Scale". Patients are given points based on the observed behavior and medical symptoms then given safe and effective doses of benzodiazepines. Since implementing the ETOH Withdrawal Protocol there has been an 80 percent decrease in patients' experiencing delirium tremors.

The ETOH Withdrawal protocol has been in place for 2 years. It has produced the following outcomes:

• Patient comfort/well being: Proper treatment avoids progression of AWS (AWS causes disorientation, frightening visual or auditory hallucinations etc.), prevent medical complications
  
  
• Decreased length of stay: Patients who experience DT's often have a length of stay of 2-3 weeks longer than anticipated. High costs of ICU care for those who need sedated and ventilated run into thousands of dollars over average charges
  
  
• Increase nurse job satisfaction: The alcoholic patient in withdrawal can be difficult to manage. Often the patient is physically abusive and uncooperative
  
  
• Staff safety: Patients are abusive to staff when they are disoriented or hallucinating
  
  
• Patient Safety: Patients have undone restraints and fell out of bed
  
  
• Provide safe and effective doses of sedatives/benzodiazepines
  
  
• Improved staff education on care of AWS/DT patients.

Access to Clinical Trials

Patients who are interested in pursuing experimental approaches to treatment may be candidates for clinical trials and other research conducted through the Oral Cancer Center. Among the treatments under study at the center are gene therapy and vaccines.

More information on Treatment:

• Treatment According to Stage of Disease