MP is a 79-year-old male being treated in the oncology clinic for recurrent squamous-cell head and neck cancer. He is very active and still works in the family business a few days a week. He goes to the gym and walks every day to stay healthy. He states he has been doing this since he was first diagnosed with cancer, and it helped him get though his previous treatments. He was originally diagnosed in 2002 and treated with induction chemotherapy, surgery (including left neck dissection), and adjuvant radiation. In October 2007, he experienced right mandibular osteoradionecrosis and fracture after a tooth removal in addition to an orocutaneous fistula. He received hyperbaric oxygen therapy as treatment to help heal his wound.
In March 2018 he had a recurrence. An MRI of the neck and a PET/CT scan were performed and showed a right mandibular mass consistent with biopsy-proven carcinoma with positive neck nodes. There was no evidence of distant metastatic disease.
The surgeon discussed options, including palliative therapy, noninvasive therapy (systemic therapy or radiation), and surgery, which would be extensive and require reconstruction. He said that the best option for cancer control would be surgery but noted that due to his prior radiation therapy, MP was at higher risk of healing complications. After much discussion with his family and healthcare team, MP decided to proceed with immunotherapy only versus immunotherapy and surgery. He wanted to proceed with immunotherapy first and delay surgery so he could celebrate his upcoming birthday with his family. In his discussion, he stated that quality of life was most important for him, and he was hoping to have prolongation of life in a meaningful way and wanted to limit adverse effects. He felt that this treatment would allow him to achieve some of his bucket list items, such as celebrating a milestone birthday with his family at a vacation resort.
He met with the medical oncologist, who discussed immunotherapy with him, and she recommended he start pembrolizumab. Immunotherapy is a new treatment option for patients with head and neck cancer that has recurred. It was recently approved for the treatment of several types of cancer, including head and neck cancer.
What Is Immunotherapy?
Immunotherapy is a form of cancer treatment that boosts the body’s natural defenses to fight cancer. It uses substances made by the body or in a laboratory to improve or restore immune system function, thereby stopping or slowing the growth of cancer cells. In MP’s case, pembrolizumab was used as second- line therapy because he had been heavily pretreated. Pembrolizumab in particular targets the programmed cell death protein 1 receptor of lymphocytes.
MP met with his nurse navigator (NN) to assess his needs as he started treatment. He stated that he was having pain and hoped the immunotherapy would help with pain control. He was on pain medications, but upon assessment the NN would follow up with his team for some adjustments, as he was clearly uncomfortable. He told the NN that his pain was an 8 of 10. He was referred to palliative care to help with his pain and symptom management as he embarked on treatment. The NN spoke with him to ascertain his understanding of his disease and to assess for barriers to care, such as transportation or lodging, that could affect compliance. MP had a good understanding of his disease and a lot of family support, so getting back and forth to treatments would not be a problem.
MP told his navigator that he was taking tincture of marijuana along with his pain medication to help with his pain and appetite, but he felt that it made him slightly off balance, and he expressed concern for his safety as he did not want to fall. He had a discussion with his NN regarding his use of marijuana, and she advised him to stop taking it until he saw the palliative care team, because they would be adjusting his pain regimen to get him more comfortable. In addition, she was concerned about the possible interaction with his immunotherapy, because that might make it difficult to determine if the cause of any neurotoxicities was related to this immunotherapy. MP asked what side effects he might experience from his immunotherapy, because the side effects from the chemotherapy were awful.
His NN explained that the side effects from immunotherapy are very different than those from chemotherapy, and that these drugs are usually well tolerated. Many of the side effects are related to the inflammatory response because these drugs stimulate the immune system. Among patients receiving immunotherapy, the most commonly affected parts of the body are the skin, colon, endocrine system, liver, lungs, heart, musculoskeletal system, and central nervous system. MP was also aware that he would have labs drawn prior to each infusion to monitor for any potential problems.
The NN discussed with MP that he needed to be aware of the symptoms that might suggest an adverse event related to his immunotherapy. He was instructed to report any of the following to his medical team: any skin sores such as blisters, rashes, or itchy skin; nausea or vomiting; diarrhea or abdominal pain; dyspnea or chest pain; headaches or dizziness; fainting; or severe and persistent joint pain. He should also report any symptoms of an infection, such as fever, fatigue, malaise, and generalized aches and pains. As with any infusion, there is the possibility of an infusion reaction.
He was provided with contact information for his team with instructions to call with any questions.
Prior to starting treatment, MP met with the palliative care team, who made adjustments in his pain management regimen, and he was much more comfortable and did not resume taking his tincture of marijuana. He reported his pain was now a 2 of 10.
MP started his treatment, and at the third cycle he developed a rash on his upper body and face. He was prescribed a medicated skin cream to apply twice a day. MP called a few days later stating the rash was worse with intense itching, and he came to the clinic for an evaluation. He was started on steroids. MP asked if he would have to stop treatment due to his rash. He was told no, and that his rash was mild and an expected reaction to his immunotherapy. His NN reviewed skin care with him and instructed him to avoid the sun and to wear a hat when he was out walking. These self-care strategies will also be important for him to follow when he goes on vacation with his family.
MP’s rash was improved at his next visit, and he continued on therapy without any further toxicities. He also continued to report that his pain was well managed as the pain had decreased since starting treatment. Follow-up scans showed he was responding to therapy, for which he was very grateful as he will be celebrating his 80th birthday with his family.
MP told his NN that immunotherapy has been much easier on him than his previous treatments, and despite his rash he has been able to enjoy life and cross off things on his bucket list, which were goals that were important for him to achieve knowing his diagnosis.
The future looks bright as new treatment modalities such as immunotherapy are developed, giving patients many more options than ever before.