Manage Late Effects From HPV-Positive Oropharyngeal Cancers

Studies have shown (https://doi.org/10.2105/AJPH.2014.302095) that HPV vaccination rates are lower in LGBTQ individuals: about 13% of gay and bisexual men have received any doses of the vaccine, less than half (https://www.contagionlive.com/news/hpv-vaccination-rates-on-the-rise-among-us-males) the rate of males in the general population (27%). Correspondingly, higher OPC incidence rates have been reported (https://doi.org/10.1200/JCO.2017.72.5465) in gay and bisexual men.

In their article in the April 2020 issue of the Clinical Journal of Oncology Nursing, Cerar et al. discussed (https://doi.org/10.1188/20.CJON.153-159) the nursing considerations for managing a new patient demographic in HPV-positive OPC and the long-term effects that younger patients may experience throughout survivorship.

HPV-Positive OPC

Since 1988, incidence of HPV-positive OPC increased by 225% and HPV-negative OPC decreased by 50%, Cerar et al. reported (https://doi.org/10.1188/20.CJON.153-159). Younger men in their 40s and 50s who do not smoke or drink, have a higher socioeconomic status, and participate in high-risk sexual behavior involving oral, genital, or anal contact are more likely to be diagnosed with HPV-positive OPC.

Symptoms are the same for both forms: nonhealing mouth sores, mouth pain, lumps or thickening of the cheeks, or white or red patches on the gums, tongue, tonsil, or mouth lining. Some patients report a sore throat, a feeling of having something caught in their throat, trouble chewing or swallowing, jaw swelling, or a lump in their neck, Cerar et al. said (https://doi.org/10.1188/20.CJON.153-159).

However, patients with HPV-positive OPC tend to have better outcomes than those with HPV-negative tumors, Cerar et al. reported (https://doi.org/10.1188/20.CJON.153-159). Survival rates are higher for HPV-positive disease at both five years (79% versus 42%, respectively) and 10 years (58% versus 29%). One study even showed that patients with HPV-positive OPC were less likely to die from their disease—or any cause at all—than those with HPV-negative disease.

Because of their younger age at diagnosis and significantly longer survival, patients with HPV-positive OPC will have to manage long-term and late effects of the disease and treatment throughout their lives. Oncology nurses can empower OPC survivors with management strategies that enable them to live more comfortably with lingering adverse effects.

Managing OPC Late Effects

Typically beginning about 90 days after the start of treatment, late effects from OPC can last as long as two years or may even become chronic or long-term, Cerar et al. wrote (https://doi.org/10.1188/20.CJON.153-159). The authors provided an overview of the common late effects from OPC and its treatment and how to educate patients to manage them.

Dental disease: Patients’ teeth may demineralize during treatment; educate patients about the importance of regular dental assessments before, during, and after treatment; using calcium and phosphorus supplements and fluoride rinses; and keeping their mouth moist with agents such as chlorhexidine and xylitol.

Dysphagia: Surgery and radiation therapy may affect patients’ ability to swallow, but physical therapy can help return function. Chronic fibrosis or lymphedema may result in a long-term decline in swallowing capability. Educate patients about functional therapies, chewing xylitol gum, and managing pain.

Lymphedema: Internal lymphedema involves the larynx, pharynx, and oral cavity, whereas external affects the face, submental region, and neck; both types result from damage from surgery or radiation-induced sclerosis. It may cause dysphagia, resulting in weight loss, dry mouth, facial disfiguration, hearing loss, and soft tissue damage. Refer patients to lymphedema therapists, speech pathologists, and physical therapists.

Osteoradionecrosis of the jaw: In some patients, bone may not heal after radiation therapy. Risk factors include radiation, oral surgery, short time between oral extractions and radiation therapy, dental and periodontal disease, tobacco or alcohol use, or comorbidities (e.g., diabetes, collagen vascular disease, poor nutrition). Remind patients about the importance of pretreatment dental assessments, dental hygiene, proper nutrition, and managing their comorbidities.

Ototoxicity: Hearing impairment is a common long-term effect; assess patients at each visit and refer them to hearing specialists as needed.

Taste disorders: Patients may experience loss, alteration, or increased sense of taste or tasting phantom flavors for as long as seven years post-treatment or even permanently, resulting in nutrition disorders. Risk factors include oral infection, poor oral hygiene, surgery, medication, or radiation. Educate patients about the importance of proper oral hygiene, managing dry mouth, and ongoing infection assessment.

Thyroid dysfunction: Radiation damage to the thyroid may result in hypothyroidism. Watch for signs and symptoms (e.g., increased thyroid-stimulating hormones, depression, lethargy, weakness, skin changes, cold intolerance, cognitive dysfunction, muscle cramps, constipation, weight gain) to intervene early with appropriate treatment. Educate patients about the need for lifelong thyroid monitoring.

Trismus: Damage to mastication muscles may limit the range of patients’ jaw motions, leading to difficulty speaking, chewing, and swallowing. It presents most often around six months after radiation therapy. Educate patients about range of motion exercises, using tongue blades and mouth-opening devices, and effective pain management. Refer patients to dentists and rehabilitation specialists as needed.

Xerostomia: Damage to salivary glands can lead to dry mouth, thick saliva, burning pain, mouth sores, difficulty chewing or swallowing, intolerance to dentures, halitosis, increased infection and dental caries, and changes in voice and taste. Educate patients about saliva stimulants, proper dental hygiene, decreasing consumption of sugar and caffeine, and tobacco cessation. Refer them to counseling as needed.

Long-Term Health and Wellness

Patients with OPC are highly motivated to learn more about staying healthy after treatment and likely to initiate new habits that may decrease the likelihood of cancer recurrence, Cerar et al. reported (https://doi.org/10.1188/20.CJON.153-159). As patient educators, oncology nurses can provide patients with resources from groups like the American Cancer Society and National Cancer Institute. In addition, ONS’s Get Up, Get Moving resources (ons.org/make-a-difference/quality-improvement/get-up-get-moving) can help patients incorporate healthy activity during and after treatment.

For more information on managing late effects from HPV-positive OPC, refer to the full article (https://doi.org/10.1188/20.CJON.153-159) by Cerar et al. ONS members can also receive free nursing continuing professional development credits by reading the article.