Assessment of xerostomia and its impact on quality of life in head and neck cancer patients undergoing radiotherapy, and validation of the Taiwanese version of the xerostomia questionnaire

Salivary toxicity from PSMA-targeted radiopharmaceuticals: What we have learned and where we are going

Clinical trials of prostate-specific membrane antigen (PSMA) targeted radiopharmaceuticals have shown encouraging results. Some agents, like lutetium-177 [177Lu]Lu-PSMA-617 ([177Lu]Lu-PSMA-617), are already approved for late line treatment of metastatic castration-resistant prostate cancer (mCRPC). Projections are for continued growth of this treatment modality; [177Lu]Lu-PSMA-617 is being studied both in earlier stages of disease and in combination with other anti-cancer therapies. Further, the drug development pipeline is deep with variations of PSMA-targeting radionuclides, including higher energy alpha particles conjugated to PSMA-honing vectors. It is safe to assume that an increasing number of patients will be exposed to PSMA-targeted radiopharmaceuticals during the course of their cancer treatment. In this setting, it is important to better understand and mitigate the most commonly encountered toxicities. One particularly vexing side effect is xerostomia. In this review, we discuss the scope of the problem, inventories to better characterize and monitor this troublesome side effect, and approaches to preserve salivary function and effectively palliate symptoms. This article aims to serve as a useful reference for prescribers of PSMA-targeted radiopharmaceuticals, while also commenting on areas of missing data and opportunities for future research.

Acupuncture for Chronic Radiation-Induced Xerostomia in Head and Neck Cancer: A Multicenter Randomized Clinical Trial

Importance

Patients with head and neck cancer who undergo radiotherapy can develop chronic radiation-induced xerostomia. Prior acupuncture studies were single center and rated as having high risk of bias, making it difficult to know the benefits of acupuncture for treating radiation-induced xerostomia.

Objective

To compare true acupuncture (TA), sham acupuncture (SA), and standard oral hygiene (SOH) for treating radiation-induced xerostomia.

Design, Setting, and Participants

A randomized, blinded, 3-arm, placebo-controlled trial was conducted between July 29, 2013, and June 9, 2021. Data analysis was performed from March 9, 2022, through May 17, 2023. Patients reporting grade 2 or 3 radiation-induced xerostomia 12 months or more postradiotherapy for head and neck cancer were recruited from community-based cancer centers across the US that were part of the Wake Forest National Cancer Institute Community Oncology Research Program Research Base. Participants had received bilateral radiotherapy with no history of xerostomia.

Interventions

Participants received SOH and were randomized to TA, SA, or SOH only. Participants in the TA and SA cohorts were treated 2 times per week for 4 weeks. Those experiencing a minor response received another 4 weeks of treatment.

Main Outcomes and Measures

Patient-reported outcomes for xerostomia (Xerostomia Questionnaire, primary outcome) and quality of life (Functional Assessment of Cancer Therapy-General) were collected at baseline, 4 (primary time point), 8, 12, and 26 weeks. All analyses were intention to treat.

Results

A total of 258 patients (201 men [77.9%]; mean [SD] age, 65.0 [9.16] years), participated from 33 sites across 13 states. Overall, 86 patients were assigned to each study arm. Mean (SD) years from diagnosis was 4.21 (3.74) years, 67.1% (n = 173) had stage IV disease. At week 4, Xerostomia Questionnaire scores revealed significant between-group differences, with lower Xerostomia Questionnaire scores with TA vs SOH (TA: 50.6; SOH: 57.3; difference, -6.67; 95% CI, -11.08 to -2.27; P = .003), and differences between TA and SA (TA: 50.6; SA: 55.0; difference, -4.41; 95% CI, -8.62 to -0.19; P = .04) yet did not reach statistical significance after adjustment for multiple comparisons. There was no significant difference between SA and SOH. Group differences in Functional Assessment of Cancer Therapy-General scores revealed statistically significant group differences at week 4, with higher scores with TA vs SOH (TA: 101.6; SOH: 97.7; difference, 3.91; 95% CI, 1.43-6.38; P = .002) and at week 12, with higher scores with TA vs SA (TA: 102.1; SA: 98.4; difference, 3.64; 95% CI, 1.10-6.18; P = .005) and TA vs SOH (TA: 102.1; SOH: 97.4; difference, 4.61; 95% CI, 1.99-7.23; P = .001).

Conclusions and Relevance

The findings of this trial suggest that TA was more effective in treating chronic radiation-induced xerostomia 1 or more years after the end of radiotherapy than SA or SOH.

Trial Registration

ClinicalTrials.gov Identifier: NCT02589938.

A prospective study of patient-reported xerostomia-related outcomes after parotidectomy

OBJECTIVE

There is a paucity of data on patient-reported outcome measures regarding xerostomia after parotidectomy surgery. Although salivary flow rates after parotidectomy have been previously studied, they do not correlate with subjective xerostomia. This study was designed to evaluate if unilateral parotidectomy increases patient-reported xerostomia.

METHODS

A prospective cohort of patients undergoing unilateral partial, superficial, or total parotidectomy for benign or low-grade malignant pathology without postoperative radiation at a tertiary care academic center was studied. We analyzed patient-reported outcome measures of xerostomia using the Xerostomia Questionnaire (XQ) preoperatively and postoperatively. We compared pre- and postoperative cumulative and individual XQ scores using Wilcoxon signed-rank tests. We stratified patients by the weight in grams (g) of the parotid tissue excised, pathology, smoking status, and xerostomia-related medication use.

RESULTS

Twenty-two adults with benign or low grade malignant unilateral parotid tumors were included. Postoperative questionnaires were completed at a median of 10.2 months (interquartile range [IQR] 8.6-11.9) after unilateral parotidectomy. Mean preoperative and postoperative cumulative XQ scores, on a 100-point scale, with higher scores representing worse symptoms, were 10.33 (95% CI: 4.46-16.20) and 10.54 (95% CI: 5.10-15.98), respectively, with a mean change of +0.21 (p = 0.472). There were no statistically significant changes in individual XQ symptom scores. Neither type of parotidectomy, resection specimens weighing over 10 g, smoking habits, xerostomia-related medication use, nor malignant pathology were associated with worse symptom scores.

CONCLUSION

Based on these data, unilateral parotidectomy does not appear to definitely, or at least consistently, increase xerostomia per patient reporting. More extensive parotid resections are not associated with worse symptom scores. These data can help guide preoperative counseling and postoperative expectations for parotidectomy.

LEVEL OF EVIDENCE

2b.

Assessment of Radiation-Induced Xerostomia: Validation of the Xerostomia Questionnaire in Chinese Patients With Head and Neck Cancer

BACKGROUND

Xerostomia is a common complication in patients with head and neck cancer (HNC) during and after radiotherapy. The lack of a simply-administered and well-validated self-reported instrument has hampered the assessment and management of xerostomia for research and clinical purposes in China.

OBJECTIVE

This study aimed to evaluate the content validity and psychometric properties of the Xerostomia Questionnaire (XQ) in Chinese patients with HNC undergoing radiotherapy.

METHODS

This psychometric evaluation study enrolled 80 patients and was conducted in 2 stages: translation and evaluation of content validity and psychometric evaluation. Cognitive interviews (n = 10) were conducted using the Participant Interview Form. The psychometric evaluation (n = 80) included score distribution, homogeneity (interitem and item-total correlations), factor structure (exploratory factor analysis), internal consistency (Cronbach's α), criterion-related validity (person correlation), and test-retest reliability (intraclass correlations).

RESULTS

Content validity was supported by cognitive interviews. The factor analysis resulted in a 1-factor solution with strong factor loadings (0.84-0.91) that explained 75.6% of the total variance. The internal consistency was excellent, with a Cronbach's α of .95. The XQ correlated strongly with other measures of xerostomia (0.70-0.80), which supports criterion-related validity. The test-retest reliability was excellent (intraclass correlation coefficient = 0.92).

CONCLUSIONS

The result provides evidence for the validity and reliability of the XQ in a sample of Chinese patients with HNC.

IMPLICATIONS FOR PRACTICE

The XQ can be used in both clinical practice and research as a valuable tool to screen for problems with xerostomia, monitor the xerostomia level, and evaluate the effects of treatment and interventions among patients with HNC.

Intensity-modulated proton therapy for oropharyngeal cancer reduces rates of late xerostomia

BACKGROUND AND PURPOSE

To determine rates of xerostomia after intensity-modulated radiotherapy (IMRT) or intensity-modulated proton therapy (IMPT) for oropharyngeal cancer (OPC) and identify dosimetric factors associated with xerostomia risk.

MATERIALS AND METHODS

Patients with OPC who received IMRT (n = 429) or IMPT (n = 103) from January 2011 through June 2015 at a single institution were studied retrospectively. Every 3 months after treatment, each patient completed an eight-item self-reported xerostomia-specific questionnaire (XQ; summary XQ score, 0-100). An XQ score of 50 was selected as the demarcation value for moderate-severe (XQs ≥ 50) and no-mild (XQs < 50) xerostomia. The mean doses and percent volumes of organs at risk receiving various doses (V5-V70) were extracted from the initial treatment plans. The dosimetric variables and xerostomia risk were compared using an independent-sample t-test or chi-square test.

RESULTS

The median follow-up time was 36.2 months. The proportions of patients with moderate-severe xerostomia were similar in the two treatment groups up to 18 months after treatment. However, moderate-severe xerostomia was less common in the IMPT group than in the IMRT group at 18-24 months (6% vs. 20%; p = 0.025) and 24-36 months (6% vs. 20%; p = 0.01). During the late xerostomia period (24-36 months), high dose/volume exposures (V25-V70) in the oral cavity were associated with high proportions of patients with moderate-severe xerostomia (all p < 0.05), but dosimetric variables regarding the salivary glands were not associated with late xerostomia.

CONCLUSION

IMPT was associated with less late xerostomia than was IMRT in OPC patients. Oral cavity dosimetric variables were related to the occurrence of late xerostomia.

Evaluating the measurement properties of patient-reported outcome measures in radiotherapy-induced xerostomia

OBJECTIVE

Radiotherapy-induced xerostomia (RIX) is one of the most common adverse effects of radiotherapy to the head and neck, and a major determinant of survivors' quality of life. A number of patient-reported outcome measures (PROMs) have been used in clinical trials of therapeutic interventions for RIX; however, little is known regarding their measurement properties and methodological quality.

METHODS

We conducted a systematic literature search in Embase, MEDLINE and PsycINFO for articles published up to May 2019 and evaluating at least one measurement property of PROMs relevant to RIX. The COSMIN guidelines were used to assess relevant measurement properties and methodological quality.

RESULTS

Nine validations studies were identified reporting on four PROMs relevant to RIX. The Xerostomia Questionnaire (XQ) showed overall high-quality evidence for structural validity and internal consistency, but low-quality evidence supporting reliability. The methodological quality of the Groningen Radiotherapy-Induced Xerostomia scale (GRIX), Xerostomia Inventory (XI) and the Xerostomia Quality of Life Scale (XeQoLS) was relatively low for all measurement properties.

CONCLUSIONS

The XQ was found to have the highest potential to capture changes in RIX according to COSMIN guidelines. Additional validation studies are required to further understand the methodological quality of the XI, GRIX and XeQoLS.

Validating the Xerostomia Inventory in a radiation-induced xerostomia population in German language

OBJECTIVES

Though xerostomia is a frequent oral symptom, there is no validated disease-specific questionnaire in German. The purpose of this study was to translate and validate versions of the Xerostomia Inventory and the Summated Xerostomia Inventory in a German-speaking population.

PARTICIPANTS AND METHODS

Thirty-nine patients including 18 patients suffering from radiation-induced xerostomia enrolled in this study. Both questionnaires were translated into German language according to international accepted guidelines. For validation, we evaluated reliability, validity, and responsiveness using the COSMIN manual for cross-cultural adaptation.

RESULTS

Cronbach's α was 0.92 for XI and 0.91 for SXI, showing both high internal consistency. Patients suffering from xerostomia showed significantly higher average scores demonstrating its discriminant validity. Confirmatory factor analysis showed excellent "goodness-of-fit" values for SXI and good to moderate values for XI, confirming the assumed factor structures. The Xerostomia Inventory and its summated version both showed excellent test-retest reliability in the non-xerostomia group (ICC = 0.85 and 0.84).

CONCLUSIONS

The XI and SXI in their cross-cultural adapted versions are the first validated self-report assessments for xerostomia in German language. They are characterized by practical design and can be easily interpreted by the treating physician.

Long-Term Quality of Life and Nutritional Status of Patients with Head and Neck Cancer

Disease and therapy of head and neck cancer impair quality of life (QOL). QOL varies profoundly during therapy and follow-up.

AIM

We sought to monitor QOL and nutritional status of patients before, during and after therapy (AT).

PATIENTS AND METHODS

This study evaluates QOL by using the EORTC-questionnaires QLQ-C30 and H&N35, body weight and plasma albumin up to two years AT.

RESULTS

Chemoradiotherapy is the period of the most profound QOL-impairment. Postoperative QOL almost reaches preoperative levels just before adjuvant therapy and does not differ significantly from pretherapeutic QOL. Long-term QOL is not significantly deteriorated. Patients have an average weight loss of 17%. Nutritional supplements are used continuously. Xerostomia and sticky saliva are chronic symptoms that persist AT.

CONCLUSIONS

QOL is an important parameter for the evaluation of therapy success. Head and neck cancer and its therapy cause permanent xerostomia, sticky saliva and need of nutritional supplements. Adequate patient information, psychooncological counseling, analgesia and nutritional support may alleviate QOL impairment.

Initial clinical experience performing sialendoscopy for salivary gland protection in patients undergoing 225Ac-PSMA-617 RLT

PURPOSE

The main side effect of prostate-specific membrane antigen targeting alpha therapy (PSMA TAT) is dry mouth syndrome. Inflammation of the salivary glands and consequent reduced salivary function have been reported in patients after radioiodine therapy. The beneficial effects of sialendoscopy on radiation-induced inflammation in tissue are well known. Thus sialendoscopy with dilatation, saline irrigation and steroid injections (prednisolone) was performed before and after ²²⁵Ac-PSMA-617 TAT to reduce inflammatory effects in the salivary glands and to improve or prevent xerostomia.

METHODS

Eleven men with metastatic castration-resistant prostate cancer (mean age 68.5 years, range 58-80 years) underwent sialendoscopy, dilatation, saline irrigation and steroid injection of both submandibular and both parotid glands before or after every cycle of ²²⁵Ac-PSMA-617 TAT. Sialendoscopy and steroid injection were performed by a senior ENT physician. Quality of life was evaluated using two health-related quality of life (HRQOL) questionnaires, the Xerostomia Questionnaire (XQ) and the Xerostomia Inventory (XI) before and 3 months after the intervention.

RESULTS

In all 11 patients both parotid and both submandibular glands were affected by radiation sialadenitis and sialendoscopy was performed. The patients experienced no complications after sialendoscopy, and showed a significant improvement in HRQOL as measured using the XQ and XI. After sialendoscopy the XQ score decreased significantly from 77.7 ± 13.6 to 42.7 ± 14.8 (p = 0.003) and the XI score decreased from 44.5 ± 6.9 to 25.8 ± 12.8 (p = 0.003). Due to the limited number of patients we only report tendencies.

CONCLUSION

Sialendoscopy with dilatation, saline irrigation and steroid injection had beneficial effects on salivary gland function and HRQOL in patients undergoing ²²⁵Ac-PSMA-617 RLT. However, even with sialadenoscopic support after multiple cycles of TAT, salivary gland function was reduced and xerostomia was present. Therefore, not only inflammation but also the direct effect of radiation is a putative cause of dry mouth. Further research is necessary to determine the main side effects of PSMA TAT.

Salivary hypofunction: An update on therapeutic strategies

OBJECTIVE

To perform a literature review addressing the therapeutic strategies for salivary hypofunction.

BACKGROUND

Qualitative and quantitative salivary dysfunctions predispose to changes in the oral mucosa and teeth, cause impairment to oral functions and negative impact on quality of life.

MATERIALS AND METHODS

A MEDLINE/PubMed search was conducted using the terms "Xerostomia" AND, "Saliva Artificial" OR, "Citric Acid," "Malic Acid," "Chewing Gum," "Acupuncture" OR, "Pilocarpine" OR, "Bethanechol" OR, "Cevimeline" OR, "Hyperbaric Oxygen Therapy" OR, "Stem Cell Therapy" OR "Genetic Therapy" and their Mesh Terms.

RESULTS

We selected 25 clinical trials investigating the effects of salivary substitutes, chewing gum, malic and citric acids, pilocarpine, cevimeline, bethanechol, acupuncture, hyperbaric oxygen therapy and regenerative therapies on salivary hypofunction. In most studies, the number of participants was low and the follow-up times short. The therapeutic modalities were classified according to the level of evidence on salivary dysfunction.

CONCLUSIONS

Pilocarpine and cevimeline had the strongest evidence of beneficial effect on salivary hypofunction. Citric and malic acids increase salivary flow but also increase the risk of erosion and dental caries. There are no controlled clinical trials supporting the efficacy of acupuncture, stem cell therapy and gene therapy on salivary dysfunction, although clinical observations suggest a promising effect. There is no evidence supporting salivary substitutes, chewing gum, bethanechol or hyperbaric oxygen on the treatment of salivary hypofunction.

Symptom burden and patient characteristics: Association with quality of life in patients with head and neck cancer undergoing radiotherapy

BACKGROUND

Patients with head and neck cancer (HNC) experience diminished quality of life (QOL) during and after treatment. This study examined which characteristics were associated with QOL over time.

METHODS

One hundred thirty-three patients with HNC from a study of 534 oncology patients rated physical and mental QOL using the Short Form-12 5 times from the initiation of radiotherapy (RT) through the following 6 months. Linear mixed model analyses examined changes over time and associated characteristics.

RESULTS

The QOL deteriorated during RT and gradually improved after completion. Less social support was negatively associated with both physical and mental QOL. Older age, more comorbidities, more psychological symptoms, and concomitant chemotherapy (CTX) were negatively associated with physical QOL. Male sex, less physical symptoms, surgery before RT, and concomitant chemotherapy were positively associated with mental QOL.

CONCLUSION

Clinicians can use knowledge on time course and associated characteristics to identify and inform patients at higher risk for diminished QOL.

Impact of a sodium carbonate spray combined with professional oral hygiene procedures in patients with Sjögren's syndrome: an explorative study

OBJECTIVES

The aim of this study was to make an initial estimation on the effects of a sodium bicarbonate and xylitol spray (Cariex^® ), associated with non-surgical periodontal therapy, in participants with primary Sjögren's syndrome.

BACKGROUND

Sjögren's syndrome (SS) is a multisystem autoimmune disease that predominantly involves salivary and lachrymal glands, with the clinical effect of dry eyes and mouth.

MATERIALS AND METHODS

A prospective cohort of 22 women and two men has been evaluated. They were randomized into three groups (eight patients each): Group A) those treated once with non-surgical periodontal therapy, education and motivation to oral hygiene, associated with the use of Cariex^® ; Group B) treated only with Cariex^® ; Group C) treated only with non-surgical periodontal therapy, education and motivation to oral hygiene. Clinical variables described after treatment were unstimulated whole salivary flow, stimulated whole salivary flow, salivary pH, reported pain (using Visual Analogue Scale) and the Periodontal Screening and Recording index.

RESULTS

Salivary flow rate improved in all groups, but the difference was statistically significant only in those treated with Cariex^® , alone or in combination with periodontal therapy. Gingival status improved in participants who underwent periodontal non-surgical therapy while remained unchanged in those only treated with Cariex^® . Reported pain decreased in all groups, showing the best result in participants treated with periodontal therapy together with Cariex^® .

CONCLUSIONS

We propose a practical approach for improving gingival conditions and alleviating oral symptoms in patients with SS. Future randomized and controlled trials are however required to confirm these results as well as larger population, and also assessing other parameters due to oral dryness, possible oral infections and more comprehensive periodontal indices.

Oral complications of cancer and cancer therapy: from cancer treatment to survivorship

Answer questions and earn CME/CNE Oral complications resulting from cancer and cancer therapies cause acute and late toxicities that may be underreported, underrecognized, and undertreated. Recent advances in cancer treatment have led to changes in the incidence, nature, and severity of oral complications. As the number of survivors increases, it is becoming increasingly recognized that the aggressive management of oral toxicities is needed to ensure optimal long-term oral health and general well-being. Advances in care have had an impact on previously recognized oral complications and are leading to newly recognized adverse effects. Here, the authors briefly review advances in cancer therapy, including recent advances in surgery, oral care, radiation therapy, hematopoietic cell transplantation, and medical oncology; describe how these advances affect oral health; and discuss the frequent and/or severe oral health complications associated with cancer and cancer treatment and their effect upon long-term health. Although some of the acute oral toxicities of cancer therapies may be reduced, they remain essentially unavoidable. The significant impact of long-term complications requires increased awareness and recognition to promote prevention and appropriate intervention. It is therefore important for the primary oncologist to be aware of these complications so that appropriate measures can be implemented in a timely manner. Prevention and management is best provided via multidisciplinary health care teams, which must be integrated and communicate effectively in order to provide the best patient care in a coordinated manner at the appropriate time.

A systematic review of salivary gland hypofunction and xerostomia induced by cancer therapies: management strategies and economic impact

PURPOSE

This systematic review aimed to assess the literature for management strategies and economic impact of salivary gland hypofunction and xerostomia induced by cancer therapies and to determine the quality of evidence-based management recommendations.

METHODS

The electronic databases of MEDLINE/PubMed and EMBASE were searched for articles published in English since the 1989 NIH Development Consensus Conference on the Oral Complications of Cancer Therapies until 2008 inclusive. For each article, two independent reviewers extracted information regarding study design, study population, interventions, outcome measures, results, and conclusions.

RESULTS

Seventy-two interventional studies met the inclusion criteria. In addition, 49 intensity-modulated radiation therapy (IMRT) studies were included as a management strategy aiming for less salivary gland damage. Management guideline recommendations were drawn up for IMRT, amifostine, muscarinic agonist stimulation, oral mucosal lubricants, acupuncture, and submandibular gland transfer.

CONCLUSIONS

There is evidence that salivary gland hypofunction and xerostomia induced by cancer therapies can be prevented or symptoms be minimized to some degree, depending on the type of cancer treatment. Management guideline recommendations are provided for IMRT, amifostine, muscarinic agonist stimulation, oral mucosal lubricants, acupuncture, and submandibular gland transfer. Fields of sparse literature identified included effects of gustatory and masticatory stimulation, specific oral mucosal lubricant formulas, submandibular gland transfer, acupuncture, hyperbaric oxygen treatment, management strategies in pediatric cancer populations, and the economic consequences of salivary gland hypofunction and xerostomia.

A systematic review of salivary gland hypofunction and xerostomia induced by cancer therapies: prevalence, severity and impact on quality of life

PURPOSE

This systematic review aimed to assess the literature for prevalence, severity, and impact on quality of life of salivary gland hypofunction and xerostomia induced by cancer therapies.

METHODS

The electronic databases of MEDLINE/PubMed and EMBASE were searched for articles published in English since the 1989 NIH Development Consensus Conference on the Oral Complications of Cancer Therapies until 2008 inclusive. Two independent reviewers extracted information regarding study design, study population, interventions, outcome measures, results and conclusions for each article.

RESULTS

The inclusion criteria were met by 184 articles covering salivary gland hypofunction and xerostomia induced by conventional, 3D conformal radiotherapy or intensity-modulated radiotherapy in head and neck cancer patients, cancer chemotherapy, total body irradiation/hematopoietic stem cell transplantation, radioactive iodine treatment, and immunotherapy.

CONCLUSIONS

Salivary gland hypofunction and xerostomia are induced by radiotherapy in the head and neck region depending on the cumulative radiation dose to the gland tissue. Treatment focus should be on optimized/new approaches to further reduce the dose to the parotids, and particularly submandibular and minor salivary glands, as these glands are major contributors to moistening of oral tissues. Other cancer treatments also induce salivary gland hypofunction, although to a lesser severity, and in the case of chemotherapy and immunotherapy, the adverse effect is temporary. Fields of sparse literature included pediatric cancer populations, cancer chemotherapy, radioactive iodine treatment, total body irradiation/hematopoietic stem cell transplantation, and immunotherapy.

The influence of nursing in head and neck cancer management

PURPOSE OF REVIEW

Nurses can play an essential role in the treatment of head and neck cancer and the care of patients and their families. The role and influence of nursing is dependent on available evidence to fulfill that role and on the sociopolitical and organizational factors that shape the context for nursing and interdisciplinary practice.

RECENT FINDINGS

Nurses influence treatment for head and neck cancer through symptom management and tobacco cessation to improve quality of life and patient-reported outcomes. Nurses and interdisciplinary teams in the United States and Europe report successful, novel nurse-led care models that optimize influence on management.

SUMMARY

Current research suggests that nurses can influence head and neck cancer treatment through emphasis on symptom management, tobacco and alcohol cessation, and on patient and family education and care coordination. Nonetheless, evidence for practice remains scant. Only continued research, employing qualitative and quantitative approaches, conducted by nurse and interdisciplinary investigator teams will advance head and neck cancer management and optimize influence of nursing within it. Novel models for nursing care that are well fit into the organizations and society in which care is delivered may further improve care and patient outcomes. Evaluation of such models is further required to document improvements.