Impact of a Head and Neck Cancer Chemoradiation (HNC CRT) Nurse Practitioner (NP) on Patient Outcomes

Purpose/Objective(s)

In addition to chemotherapy toxicities, most HNC patients receiving CRT experience moderate to severe radiation-induced pharyngitis. Management includes escalating analgesics, dietary modification, supplemental hydration, and feeding tubes for nutritional support as needed. Uncontrolled symptoms can interrupt or truncate curative intent treatment, impacting both quality of life and cancer outcomes. In 2014, a fulltime NP role dedicated to symptom management during and immediately post-CRT was initiated at our center. We assessed the impact on patient Emergency Department (ER) visits, hospitalizations and deaths.

Materials/Methods

Patients receiving definitive primary CRT with curative intent were identified during 12 month periods prior to (April 2012-March 2013) and three years after (April 2017-March 2018) initiation of the NP from records of H&N MDT case conferences. We hypothesized that ER visits and hospitalizations would be reduced with NP care. Effects on treatment delivery were secondary outcomes. Patient demographic, tumor, treatment, ER visit, hospital admission, and mortality data were extracted retrospectively from the electronic medical record. Unadjusted comparisons were done using the chi-square test for categorical variables and t-test for continuous variables with p<0.05 considered of significance. This project was approved by the institutional REB.

Results

105 and 120 patients were identified in the pre-NP and post-NP cohorts, respectively. Post-NP patients were younger (mean age 63.2 vs 67.3 years), more often had oropharyngeal cancer (81.5% vs 56.2%), did not receive weekly carboplatin (0.0% vs 8.6%), and received cisplatin scheduled q3weekly less often (45.0% vs 71.4%) and weekly more often (48.3% vs 16.2%). Patients received a mean of 3.6 visits and 4.3 phone calls with the NP. There was no difference in ER visits within 42 days of treatment between cohorts (55.2% vs 55.8%). However, hospital admissions were reduced (60.0% vs 45.8%, p=0.034). Length of stay was similar, and there was no difference in 90-day mortality (2.9% vs 2.5%).

Conclusion

This before-and-after study showed a 23.7% reduction in hospitalizations after introduction of the NP role, consistent with the findings of others (Terzo 2017). Over 50% of patients visited the ER at least once and 1 in 40 died in both cohorts. Time trends included a 14.3% increase in the number of patients receiving CRT; and shifts in patient age, cancer type and cisplatin schedule consistent with an increasing incidence of HPV-related oropharyngeal cancer. We cannot rule out effects of these trends or other interventions on our results. Additional limitations include inability to harmonize staging between cohorts and lack of quality of life and cost effectiveness data. Nevertheless, these data support the value of a NP role focused on HNC patients receiving CRT to optimize outcomes.