Pitt Dental and UPMC Clinic Help Survivors of Head and Neck Cancer

 

by Keightley Amen, ELS

 

DENTAL CARE ALONG THE CANCER CONTINUUM

Many people have untreated dental problems, which can become particularly problematic during treatment for head and neck cancer, said Dr. Elizabeth Pawlowicz, Director of the General Practice Dental Residency Program at UPMC Montefiore, who serves as the dental clinician at the Head and Neck Cancer Survivorship Clinic. Plus, treatment for head and neck cancer can cause new dental issues. Chemotherapy and radiation can change bone, disintegrate teeth, and affect the pH of saliva (from a neutral 7 to an acidic 4 or 5), so head and neck cancer survivors are prone to gum disease, tooth decay, fungal infections, dysphagia, trismus, loss of taste, xerostomia, mucositis, swallowing difficulties, aspiration, significant weight loss, and other difficulties. Dr. Pawlowicz’s role at the clinic, she screens and evaluates patients for issues before, during, and after treatment for cancer. At pretreatment visits, Dr. Pawlowicz educates patients about dental health in survivorship. She explains the changes to expect in teeth, enamel, and saliva. She prescribes high-fluoride toothpaste, often applies a fluoride varnish, and advises patients to get dental cleanings every three months. If resection is part of the plan, then Dr. Pawlowicz discusses possible reconstruction options that can later be performed by maxillofacial prosthodontists. Subsequently, during treatment and follow-up, she screens patients for problems that arise and continues to educate them about the importance of dental care. At any point in the continuum, when patients need dental services, such as impressions or extractions, Dr. Pawlowicz prepares a treatment plan, which is carried out through expedited referral to the dental service at Montefiore or by the patient’s own dentist. Because a general dentist may only see a few patients with head and neck cancer over an entire career, Dr. Pawlowicz serves as a resource to patients’ dentists whenever needed. “Head and neck cancer is very survivable, but it leaves a tremendous impact,” Dr. Pawlowicz said. “For so long, surviving cancer was enough. But now, we can focus more on quality of life and productivity. We don’t want our patients to just survive, we want them to thrive.”

A VISIT TO THE CLINIC

The Head and Neck Cancer Survivorship Clinic opens at 8 am every Thursday at the UPMC Eye and Ear Institute. When a patient arrives, he completes a questionnaire on an iPad, which screens for oral health, swallowing issues, neck disability, depression and anxiety, health literacy, and more. Within minutes, Drs. Johnson and Nilsen review the patient’s results to determine which clinicians the patient should see that day—and in what order, depending on the symptoms the patient indicates are most important. An audiology assistant also performs a brief hearing screening; sometimes a visit starts with something as simple as a hearing-aid repair so that a patient can better understand the important information covered during the rest of the visit, Dr. Johnson said. An appointment can take as long as two hours, as a patient visits each clinician indicated. Along the way, the healthcare providers document screening data, treatments, actions, and referrals in the patient’s electronic health record so progress can be tracked. Data also have been used to inform research, which is now being published and presented. Between Thursdays, the clinicians continue advocating for patients— arranging follow-up appointments, planning for new cases, and discussing current cases. The clinic welcomes 25–30 patients per day. To date, it has seen 1,000 unique patients for 1,600 patient encounters.

“ONE VISIT, ONE CLINIC, ONE COPAY”

The healthcare providers involved are passionate about easing the burden on patients with head and neck cancer, as they often have significant and complex needs that dramatically affect essential activities of daily living. Dr. Johnson stressed that the clinic model eases the financial toxicity of cancer survivorship. “Being sick is expensive,” he said. Many patients spend thousands of dollars to overcome cancer, and they often cannot return to work or have to scale back. With this model—“one visit, one clinic, one copay”—patients don’t have to “burn through their credit cards,” he said, or “chase around the region for different specialists,” Dr. Pawlowicz added. The model is financially sustainable thanks to some grants, fundraising, and significant support from clinics that are partnerships between the University of Pittsburgh Schools of Health Sciences and UPMC. “It really takes a team to look at these problems and figure out how to solve them,” Dr. Nilsen said. “It works so well because we have such passionate providers. The team is very engaged.”

THE CLINIC’S FUTURE

The UPMC clinicians expect copycats—and welcome them. They want to spread the word beyond UPMC, so that more patients can benefit from the interdisciplinary care model. “We are a resource for anyone who needs help—patients, physicians, therapists,” Dr. Pawlowicz said. “We are happy to speak with anyone.” The clinic often has difficulty seeing all the patients who need care, Dr. Nilsen said, so perhaps expansion is in the future. In the meantime, the team would like to add a mental health clinician, raise awareness of the magnitude of head and neck cancer, encourage head and neck cancer screening, increase vaccinations against the cancer-causing human papillomavirus, and attain additional funding to support care for more patients. And, as more research emerges from the clinic population, Dr. Johnson looks forward to “proving that this clinic model saves and improves lives.”


About the Head and Neck Cancer Survivorship Clinic

Head and neck cancer is the sixth common cancer worldwide, diagnosed in about 60,000 Americans every year. Long-term survival is becoming more and more common, with almost half a million survivors living in the United States.*

UPMC and the University of Pittsburgh Department of Otolaryngology operate a unique, dedicated clinic to manage the ongoing and complex needs of these patients from initial diagnosis, through treatment, and beyond. The multidisciplinary, comprehensive clinic includes a head and neck surgeon, dentist, speech language pathologist, audiologist, physical therapist, and nurse—all of whom have specialized training in the needs of patients with head and neck cancer. In addition, a primary care physician often volunteers to help the team address anxiety, depression, and polypharmacy common in the patient population.

The clinic was designed and founded by Marci Nilsen, PhD, RN, Assistant Professor in the School of Nursing, and Jonas Johnson, MD, Chair of the Department of Otolaryngology at the University of Pittsburgh. As soon as they got the green light to open the clinic in December 2016, they knew dentistry had to be a part of the team.

*American Cancer Society. American Cancer Society Head and Neck Cancer Survivorship Care Guideline. CA Cancer J Clin. 2016;66:203-39. doi: 10.3322/caac.21343