IMPROVING QUALITY OF LIFE:

CLINICAL GUIDELINE
IMPLEMENTATION FOR HEAD
AND NECK CANCER
Jamie A Meyer
Mercy
University of Detroit
INTRODUCTION
Head and neck cancer is a category of multiple types of cancers that include the
oral cavity, pharynx, nasal cavity, paranasal sinuses, salivary glands, and larynx.
head and neck cancer accounts for about 3% of all cancers in the United States with an
estimated 61,760 (45,330 men and 16,430 women) individuals developing head and neck
cancer this year.
Depending on the location of head and neck cancer the 5-year survival rate ranges from
30-90%; an estimated 13,190 deaths (9,800 men and 3,390 women) will occur this year
(American Society of Clinical Oncology, 2015).
Advances in technology and clinical trials that provide evidence-based medications
to treat this disease: patients who are being successfully cured of their disease
An important aspect to consider when caring for these patients is quality of life.
Diagnosis of cancer can leave patients frightened and vulnerable, and often unable
to understand the full implications of the treatment required; which affects their
definition of quality of life (Webber, 2008).
BACKGROUND/SIGNIFICANCE
A multidisciplinary treatment plan is often complex
Countless hours are spent providing emotional support, education, guidance,
and reinforcement
in my role as head and neck nurse navigator within Mercy Health Saint Marys
Head and Neck Cancer Program, quality of life is not consistently being
included into treatment considerations or baseline assessments.
guiding behaviors at Mercy Health Saint Marys is to treat the patient using a holistic
approach (mind, body, and spirit),
The quality of life assessment: subjective suffering of the patient and on his
or her individual needs and wishes; based on the context in which the patient
lives (Singer, Langendijk, & Yarom, 2013).
 BACKGROUND/SIGNIFICANC
E, CONT.
Assessment of the head and neck quality of life and overall quality of life in head and
neck cancer patients should be a standard of care that drives education and appropriate
interventions towards improving quality of life outcomes and the response to treatment.
By focusing on patient preferences, needs, and values health outcomes will improve;
reduction in emergency hospital admissions and emergency department visits (ED).
Two hydration related complications
Three decline in nutritional status
Three aspiration pneumonia
Three thrush requiring IV antifungal
Two uncontrolled pain due to mucositis or radiation dermatitis

Patients admitted to hospital due to side effects from treatment they endure further
financial implications.
CLINICAL QUESTION/AIM
An opportunity exits to improve assessment, diagnosis, and management
of head and neck cancer patientsby integrating a clinical guidelineto
assist the provider and patient in decisions about appropriate healthcare
that impacts the quality of life of patients receiving radiation and/or
chemotherapy. The process starts at diagnosis and continues through
survivorship. Success will be measured by maintaining self-reported quality
of life in 75% of head and neck cancer patients.
LITERATURE REVIEW
An important component of the patients care is to assess their quality of life
by the use of an evidence based questionnaire, which enables the provider to
identify the patients ever changing needs during the prescribed cancer
treatment period and beyond (Ehrsson, Sundberg, Laurell, & Langius-Eklof,
2015).
These patients have multiple, unique, and challenging symptoms due to
their disease and treatment side effects such as xerostomia, taste
disturbances, dietary restrictions, dysphagia and pain, fatigue, distortion of
physical appearance, permanent disfigurement and infirmity which has an
impact on the patients quality of life, thus, the concept of quality of life is
extremely important for these patients(Shavi et al., 2015, p. 23).
Quality of life is a multidimensional construct because it is compromised by
clinical and sociodemographic factors (Sterba et al., 2016).
LITERATURE REVIEW, CONT.
Extremely expensive to treat, have high morbidity, and of those individuals that
survive only 48% return to work (Jacobson et al., 2012, p 1).
multimodality treatment has twice the cost of single modality; three treatments modality can
cost from $96,520 in the Medicare population to $153,892 in the commercial insurance
population.
Assessing quality of life and symptoms in head and neck patients will help
practitioners and nurses best manage the debilitating problems with swallowing,
speech, and hearing, as well as the psychological effects of loss of function and
change in body image (Leung et al., 2011).
Tools need to be multi-dimensional incorporating physical, psychological, social, financial, and
emotional functional domains (Leung et al., 2011; Shavi et al., 2015; Singer et al., 2013).
The European Organization for Research and Treatment of Cancer Quality of Life
Questionnaire Core-30 (EORTC QLQ-C30) and head and neck module (QLQ_H&N35) are two of
the best questionnaires that need to be used together to assess quality of life in head and
neck cancer patients (Oliveira et al, 2014; Leung et al. 2011; Shavi et al. 2015; Kovacs et al.
2015; Dinescu et al. 2015).
THEORETICAL FRAMEWORK
Middle Range Theory
Model: AACN Synergy Model for Patient Care
Reconceptulized model of certified practice
Providing the best quality of care to head and neck cancer patients by focusing on
the quality of life aspect the needs and concerns of patients will influence and drive
characteristics of nurses
Focusing on the quality of life

Per the AACN synergy model, synergy results when the needs and
characteristics of a patient, system are matched with nurse's competencies.
Goal of this model is to restore a patient to an optimal level of wellness as
defined by the patient, which is reaching towards the patients definition of
his/her quality of life (AACN, 2015).
CONCEPTUALIZE THE CONCEPTS
WITH IN THE THEORY
Nurses need to be proficient in multiple dimensions on the nursing
continuum
Both patient and nurse characteristics
Recognize patients vulnerability

8 nursing competencies
Patterns of Knowing
Empirical
Esthetics
Personal Knowledge
AACN SYNERGY rg
y

MODEL FOR PATIENT Sy

ne
o ved
pr lity e
CARE Im ua ar
Q fC
O

Nurse Advocacy Resilienc

Competency y

Vulnerability

Clinical
Judgment

Resource
Caring Availabilit
practices y

Nurse
PatientCharacteristics
Characteristics
System
Participation in
Facilitation Thinking
care
of
Learning
Clinical
Inquiry
Stabilit
y
Patient
Collaboration
System Competency
PURPOSE STATEMENT
The purpose of this project is toimplement a clinical guideline to
directcare that is respectful and responsive to individual patients
preferences, needs, and values and ensures that patient values guide all
decisions within the Mercy Health St. Marys Head and Neck Cancer
Program over a 6-month period.
 ORGANIZATIONAL

ASSESSMENT
Leadership support
Strength

Weakness
Communication barriers between departments
Head and Nurse Navigator coordinating best care for Three different physician practices managing patients during
patients treatment
Team members of multidisciplinary team with a wide Staff reluctant to change practice
range of experience and knowledge

Opportunities Threats
Improve communication between departments Decrease quality of care without improvement
Create a team-orientated culture Change management has to be effective for the process to
Improve patient center care work
Increase patient satisfaction and involvement/engagement Overwhelm patients
in care Potential reimbursement cuts
Decrease hospital and ED admissions Unstable financial climate
Decrease morbidity related to treatment related symptoms
METHODS:
DESIGN/SETTING/SAMPLE
Design:
Quality improvement project
Implementation of a head and neck quality of life and site-specific symptom-
screening tool for patients receiving radiation and/or chemotherapy
A rapid-cycle quality improvement process to improve screening and symptom
management.
Patient reported quality of life and symptom screening information will be
obtained as an aggregate
METHODS:
DESIGN/SETTING/SAMPLE
Setting and sample
Mercy Health Saint Marys Lacks Cancer Center Radiation Oncology Unit in Grand Rapids,
Michigan
Target population includes all head and neck cancer patients receiving radiation therapy
and/or chemotherapy
averages three new consults a month with approximately five patients on treatment a week
Population Served: White Americans, Black Americans, Hispanic, and Asians. Age: Adults 18 years
and older, Gender: Male and Female
Project will include a sample size of 12 patients all diagnosed with head and neck cancer as
identified by the National Comprehensive Cancer Network guidelines.
Inclusion criteria
Adults 18 years or older
able to fluently speak, read, and understand English
receiving radiation treatment at Mercy Health Saint Marys
Recruitment: begin in January 2017 until 12 patients are identified.
IMPLEMENTATION PLAN
Patients data will be abstracted from paper and electronic medical records
(EMR)
Placed into the Access Database
Patient baseline data demographics, smoking and/or alcohol history, and
comorbidities obtained from the Radiation Oncology EMR
The European Organization for Research and Treatment of Cancers Quality of Life
Questionnaire, Core-30-version 3 (EORTC QLQ-C30) and specific module Head
and Neck (EORTC QLQ_H&N35) questionnaires used at different intervals during
the treatment trajectory to provide more comprehensive assessment of patient
reported difficulties (Loorents, Rosell, Wiliner & Borjeson, 2016, para. 10).
Patients will be approach at consultation
IMPLEMENTATION PLAN,
CONT.
Nurse clinicians and physicians in the radiation oncology department provided
education prior to the start
how to administer the questionnaires
Information outlining the project, risks and consent process
When to assess patients
Baseline measurement of patient reported symptoms at consultation prior to radiation treatment
start
Weekly on-treatment visit, last day of radiation, one month follow up, and three month follow up
appointment.
Surveys will drive patient specific education, provide appropriate interventions, and
manage site-specific side effects
oral care, nutritional aspects, pain management, and radiation site effects
speech therapy, social worker consultation, physical therapy referral, and medications will be
ordered for patients depending on their specific needs
DATA ANALYSIS
Quality of life and symptom management scores will be analyzed and
calculated according to the EORTC QLQ-C30 scoring manual
EORTC scale and single item score measures converted to a scale ranging
from 0 to 100
Data entered into an Access database
An SPSS system will provide the statistical analyses
The Mann-Whitney U test will be used to investigate differences.
NEXT STEPS
Potential for sustainability
Increase patient outcomes, patient satisfaction, targeted interventions

Dissemination Ideas
Poster Presentation at National Conference, Journal Article

Committee Development
Oncology Specialist, Data Specialist, DNP prepared Nurse
 REFERENCE
American Society of Clinical Oncology (2015). Head and neck cancer. Retrieved from http://www.cancer.net/cancer-types/head-and-neck-cancer/statistics

AACN. (2015). The AACN Synergy Model of Patient Care. Retrieved from www.aacn.org

Dinescu, F., Tiple, C., Chirila, M., Muresan, R., Drugan, T., & Cosgarea, M. (2015). Evaluation of health-related quality of life with EORTC QLQ-C30 and

QLQ- H&N35 in Romanian laryngeal cancer patients. European Archives of Otorhinolarngolpgy. 10, 1-6. Doi:10.1007/s00405-015-3809-0

Ehsson, Y., Sundberg, K., Laurell, G., & Langius-Eklof, A. (2015). Head and neck cancer patients perceptions of quality of life and how it is affected by the

disease and enteral tube feeding during treatment. Upsala Journal of Medical Sciences, 120, 280-289.

Gilbert, J., Murphy, B., Jackson, L., Brocksten, B., Ganz, P., Brizel, D., & Fried, M. (2015). Quality of life in head and neck cancer. Retrieved from

http://www.uptodate.com/contents/quality-of-life-in-head-and-neck-cancer
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Jacobson, J., Epstein, J., Eichmiller, F., Gibson, T., Carls, G., Vagtmann, E., Wang, S., & Murphy, B. (2012). The cost burden of oral, oral pharyngeal, and

salivary gland cancers in three groups: Commercial insurance, Medicare, and Medicaid. Head & Neck Oncology, 4(15), 1-17.

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Specialist, 332-342.

Kovacs, A., Stefenelli, U. & Thorn, G. (2015). Long-term quality of life after intensified multi-modality treatment of oral cancer including intra-arterial

induction chemotherapy and adjuvant chemoradiation. Annals of Maxillofacial Surgery, 5(1), 26-31.

Leung, S., Lee, T., Chien, C., Chao, P., Tsai, W., & Fang, F. (2011). Health-related quality of life 640 head and neck cancer survivors after radiotherapy

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Shavi, G., Thakur, B, Bhambal, A., Jain, S., Singh, V., & Shukla, A. (2015) Oral health related quality of life in patients of head and neck cancer attending

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