Exploring oral health care for patients undergoing cancer therapy of the head and neck region: a case study in the eThekwini District, KwaZulu-Natal.

Abstract

Oral health care is paramount for patients with head and neck cancer. There is currently no published evidence to ascertain these patients’ access to oral health care. The extent to which oral health planning in the province takes into account the specific oral health needs of patients with head and neck cancer is not known so far. Aim: The aim of this study was to assess the perceptions and oral health practices of patients undergoing therapy for cancer of the head and neck region, in the Ethekwini District, KwaZuluNatal, so as to inform oral health planning of the needs for this population. Method: This was a cross-sectional, descriptive and exploratory study using both quantitative and qualitative data to determine the perceptions and oral health practices of patients with head and neck cancer. The study population for the quantitative component of the study, consisted of purposively selected patients with head and neck cancer (n=235) from a public tertiary central referral hospital in the Ethekwini District, KwaZulu-Natal (KZN). Data collection included the use of two previously validated questionnaires that was combined, namely, The EORTC QLQC30 and the EORTC QLQ- H&N35. These combined questionnaires included both single and multiple item scales to assess self-reported treatment side effects and oral health–related symptoms (Aaronson et al., 1993). There were eleven single item questions (such as mouth opening, dry mouth, sticky saliva, teeth problems, feeling ill, cough, pain killers, nutritional supplements, use of feeding tube, weight loss/gain) and seven multiple item questions on pain, swallowing, sexuality, social contact, social eating, speech and senses (Aaronson et al., 1993; Sherman et al., 2000; López-Jornet et al., 2012). The quantitative data collected was captured in Microsoft excel spreadsheet and imported onto Statistical Package for Social Sciences software (SPSS) version 24 for analysis. The demographic details for the participants were calculated using descriptive statistics (mean, frequency, percentages, standard deviation). Pearson Chi-Square test was used to assess possible relationships between the independent and dependent variables. The p-value was set to less than 5% (p< 0.05) to be significant. For the qualitative component of the study, structured interviews were conducted with twelve voluntary patients (n=12) undergoing cancer therapy for the head and neck region. The purpose of the interview was to gain a better understanding of oral health-related challenges and opportunities facing these patients. The interview schedule comprised demographic questions related to the date of diagnosis, duration and type of treatment and past and present habits. Other questions included participant’s knowledge of oral health care in relation to one’s overall well-being, oral health self-care practices, perceived barriers and opportunities to access oral health care, and familial support. Another semi-structured interview was conducted with the Ethekwini oral health district coordinator using purposive sampling technique. The interview schedule comprised questions related to oral health strategies in place to support patients with head and neck cancer and the extent to which oral health care is covered in district health policy and planning for these patients. Other questions included the existent institutional support for oral health promotion activities such as risk factor intervention programmes or strategies to improve oral health awareness. Data analysis of the qualitative data incuded content analysis using a thematic process by following the steps described by Braun and Clarke (2006). The audio-recorded interviews were first transcribed verbatim and a data clean-up process was applied (Braun and Clarke, 2006; Theron, 2015). The narrative from each interview transcript was then coded and analysed based on the conventional thematic content analysis approach (Braun and Clarke, 2006; Theron, 2015). A code guide was developed to guide and support the coding process. Open nodes were generated in the open coding phase (Pateman et al., 2015). This form of coding thus allowed for inductive reasoning of the emergent themes (Theron, 2015). Results: The results from the quantitative component of the study indicated that head and neck cancer was most common among participants in the 61-70 (n=86; 36.6%) age group. Oral cavity cancer was most common type of cancer reported (n=91; 38.7%), followed by laryngeal cancer (n= 53; 22.6%). Males (n=50; 21.3%) were more affected by oral cavity cancer as compared to females (n=41; 17.4%). With regards to employment, 14.5% (n=34) of participants were

employed, while 46.4% (n=109) were unemployed because of cancer and 39.1% (n=92) were unemployed due to other reasons (old age, housewife). With respect to treatment, 20.4% of participants (n=48) were on radiotherapy, 28.5% (n=67) on chemotherapy and 9.8% (n=23) were on concurrent chemoradiotherapy, while 17.4% of participants (n=41) had already undergone surgery. Only 8.5% of participants (n=20) were recently diagnosed with cancer of the head and neck while 23.4% (n=55) were on follow up programme. There were noted differences in the self-reported severity and extent of oral complications in relation to the participants’ perceived oral health status. Xerostomia was found to be more common with increasing age. Pain in the jaw was experienced by 46.8% of participants while the majority of participants (n=125; 53.2%) did not report any pain in the jaw. Among those who perceived intra-oral discomfort, 13.8% females (n=13) and 7.8% males (n=11) experienced severe intraoral related pain and discomfort. More female participants (n=7; 7.4%) in the age group of 41- 60 reported severe difficulty in swallowing liquids than males of the same age group. Male participants who perceived severe difficulty to swallow liquids were all in the age group of 51- 70 years. Among those (n=100; 42.6%) who perceived difficulty to swallow pureed food, slightly more females (n=13; 13.8%) perceived severe difficulty in swallowing pureed foods than males (n=17; 12.1%, p=0.034). Most of the participants (n=148; 63.0%) had difficulty in swallowing solid foods. Similarly, the majority of participants experienced problems with their teeth (n=162; 69.0%) and reported xerostomia (n=159; 67.7%). A higher proportion of females (n=27; 28.7%) reported severe trismus as compared to male participants (n=33; 23.4%). Sticky saliva (increased viscosity in salivary flow) was reported by 34.0% (n=32) females and 29.8% males (n=42). Dysgeusia (altered sense of taste) was also reported by the majority of participants (n=131; 55.7%), among whom 22.3% females (n=21) reported severe dysgeusia as compared to 19.1% males (n=27). The majority of participants (n=138; 58.7%) perceived difficulty to eat, with 35.1% females among them (n=33) reporting of severe problem in eating as compared to 23.4% males (n=33). With reference to the qualitative data, six themes emanated from both interviews namely, knowledge and practices in oral health care, barriers in accessing oral health care, support for oral health care (includes both familial and institutional support), perceived opportunities to access oral health care, perceived precautions for outdoor activity and identified shortcomings in oral health service delivery at district level. Participants generally agreed that oral health was important for their overall well-being, with the exception of one participant. The reported oral hygiene practices included toothbrushing, mouthwash and dental floss. With reference to the perceived barriers, a lack of dental services in some areas of the province which consequently led to the need to travel long distances to access the nearest dental facility, was reiterated by some participants. The co-existence of other diseases in addition to cancer was perceived by one participant as being challenging to seek oral health services. The time taken by hospital staff to diagnose dental pathology was also seen as a barrier to access oral health care. Additionally, the fact that medical personnel fell short of informing patients about oral complications arising with chemotherapy was perceived as a shortcoming. Financial instability and failure of the local dental clinic to provide basic oral health care were reported to hamper access to oral health care. With regards to support, most participants reported that they had support, whether financially or morally from their families, with the exception of one participant who did not get any form of familial support. One interviewee reported that support was obtained through prayer. Participants also indicated the need to use protective clothing, hats and sunscreen. As for professional support, the oral health district coordinator reported that there was no specific support for oral health promotion activities from a policy perspective for head and neck cancer patients. However, he narrated that the pathway of referral patterns to oral and maxillofacial surgeons, ENT or oncology in cases of suspected malignancies was a form of oral health-related support for patients. Furthermore, he indicated that the district has many dental facilities with good infrastructure to offer services, such as oral prophylactic treatment and prosthetic services. Some of the opportunities perceived by head and neck cancer participants for improving oral health self-care practice included access to a dental hygienist, comprehensive explanation of the benefits and complications of cancer therapy, and clear referral patterns for further oral health management. Among the shortcomings identified to deliver oral health services at the district level was the absence of a specific oral health policy formulated for head and neck cancer patients and risk factor intervention programs. Conclusion: The results indicate that patients with cancer of the head and neck region reported limited access to professional oral health care. Oral health promotion services in the district, should take into account the specific needs for patients with cancer of the head and neck cancer region. There is an urgent need to prioritise oral health care for this vulnerable population in district oral health planning efforts.