INTRODUCTION

Head-and-neck cancer (H&NC) is an umbrella term used to describe malignancies encompassing the upper aerodigestive tract, paranasal sinuses, salivary glands, and nasal cavities.[1] It is the seventh most common cancer worldwide, with more than 40% of the cases occurring in South Asia.[2,3] H&NCs are multifactorial in origin.[2,4] They are primarily treated by surgery and radiotherapy (RT), with or without concurrent chemotherapy.[5] Although less radical, managing cancer through radiation therapy further elevates physical and emotional and has a catastrophic effect on a patient’s emotional and mental health.[6] The psycho-oncological domain in cancer pathogenesis and treatment is slowly gaining momentum. However, oral health physicians (OHP) remain unaware of the importance of the psychosocial aspect of H&NC treatment. The current review aims to:

Create awareness among OHP about the psychological effects of RT and its clinical implications

Familiarise oral physicians with the current screening tools and management approach being used in RT patients through a literature search

Recommend other measures that can be adopted to improve the dentist’s role in the psychological assessment of RT patients.

METHODS

The review has been written following the recommendations provided in the SANRA (quality assessment scale for narrative reviews).[7]

Information source and search strategies

A literature search of studies (full free texts) utilising various psychological distress tools in patients undergoing RT (exclusively) was performed. Medline, CINTHL, Google Scholar, Cochrane, and WOS databases were searched with the keywords ‘psychological distress’, ‘head-and-neck cancer’, ‘oral cancer’, ‘anxiety and depression’ and ‘radiotherapy’. A scoping search of the literature was done from the period of 2012–2022. First, the abstract and title were screened, followed by screening the complete text (from the selected articles). Furthermore, the reference articles pertaining to our area were included in the study [Table 1].

Table 1:: Literature review of the studies screening psychological distress.

S. No. Article Country of origin Sample size Type of study Tools used Result 1. Paula et al. (2012)[31] Brazil 41 Explorative and quantitative Beck’s Depression Inventory Rise in depression symptoms during treatment. 2. Badr et al. (2017)[32] U.S.A 93 Cross sectional PROMIS
(short form) Depression increased in survivors of RT patients. 3. Nikoloudi et al.
(2020)[33] Greece 55 Prospective Greek-HADS Distress symptoms worsen during the treatment and return to pre-treatment level after 3 months. 4. Schaller et al.
(2017)[34] Sweden 54 Cross sectional HADS Patients suffered minor anxiety and depression symptoms with worsening QoL. 5. Ninu (2015)[35] Italy 86 Cross sectional Distress thermometer Depressive symptoms were present, which accelerated in tracheostomy patients. 6. Britton et al. (2012)[36] Australia 58 Prospective HADS Patients with baseline depression suffered from malnutrition during RT. 7. Neilson et al. (2013)[37] Australia 101 Prospective HADS Depressive symptoms are proportional to physical symptoms. Anxiety increases during treatment and returns to pre-treatment level after 1 year. 8. Astrup et al. (2015)[38] Norway 37 Longitudinal CES-D Depression increased during RT treatment and waned post-treatment with time. 9. Siafaka et al. (2021)[39] Greece 50 Longitudinal HADS Known anxiety and depression before RT lead to impaired quality of life. Inclusion and exclusion criteria Inclusion criteria

The following criteria were included in the study:

Adult H&N cancer patients who were treated with RT exclusively

Prospective studies with follow-up

Free complete texts in the English language.

Exclusion criteria

The following criteria were excluded from the study:

Studies performed before the period

Review articles, cross-sectional studies, conference proceedings, grey literature, and books

Non-English and abstract-only papers

Patients suffering from carcinoma other than H&NC

Patients undergoing other treatment modalities

Low-quality papers. The quality of the studies was determined by the quality assessment tool for cohort studies by National Heart, Lung and Blood Institute 2013 [Figure 1].

Figure 1:: Quality assessment tool for observational cohort and cross-sectional studies. (Available from: https://www.nhlbi.nih.gov/health-topics/studyquality-assessment-tools).[8]

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DISCUSSION

Anxiety and depression are more prevalent among RT patients. This psychological stress ultimately affected their treatment outcome, nutrition status, and quality of life (QoL)

Effects of RT and its clinical implications

RT helps reduce a patient’s toxicity profile and locoregional spread. However, the practice of reirradiation, pain, financial burden, physical, cognitive, and functional adverse effects, apart from the multiple visits, puts the patient into an emotional and psychological tumult.[7,9]

According to National Comprehensive Cancer Network (NCCN), psychological distress ranges from ‘a feeling of vulnerability to problems that can become disabling, such as depression, anxiety, panic, social isolation, and existential and spiritual crisis’.[10] H&NC patients are more vulnerable to psychological distress due to its unresolved physical signs and symptoms, aesthetic flaws, treatment side effects, emotional and functional disturbances, fear of recurrence and eminent death, premorbid factors, the prognosis of the disease, pre-existent psychological condition, social stigma or isolation.[11-14]

However, psychological morbidity often remains undiagnosed due to normalising emotional distress and its social stigma.[15,16] The inability of health-care professionals to give importance to the psychosocial component of a disease further adds to the problem.[17]

The high psychological burden severely hampers a patient’s personality and QoL, resulting in patient attrition.[13] Depressed patients require extended hospital stays and have poor survival outcomes even after complete remission of the disease.[18]

Dentists’ and H&NC patients

Dentists and oral physicians play a key role in diagnosing malignant oral lesions.[19] They form an integral part of the palliative care team.[20] Oral surgeons are not only part of the surgical team; they also play a crucial role throughout the RT sessions (fabrication of patient fixation models) and in managing the complications of RT (xerostomia, mucositis, dental caries, etc.).[3,21] However, there needs to be more knowledge about the importance of the psychological assessment of RT patients among dentists. Definitive diagnosis and management of oral complications and associated psychological effects were considered imperative.[22]

Dentists’ role in RT patients can be divided into three stages

Pre-RT – In this stage, the patient’s overall oral health is evaluated and stabilisation of the oral disease is initiated several weeks before RT to prevent complications

During RT – During this phase, the dentist works with the radiation oncologists to alleviate and provide relief from the acute complications of RT

Post RT - Dentists treat late complications of RT due to its adverse effects on the musculature and salivary glands, hard and soft tissues of the oral cavity.[23]

Dentists’ Role in psychological assessment of RT Patients

General recommendations for oral health professionals while screening RT patients include:

Psychological screening of cancer patients

Dentists should screen all cancer patients throughout their course and even during their follow-up with validated screening tools should be encouraged. Psychological screening tools help ascertain a cancer patient’s psychological well-being at every step of the disease progression.[14] Andrea Vodermaier et al. categorised the tools into long (21–50), short (5–20), and ultrashort tools (1–5).[24] It also helps manage the patient’s distress and improve their QoL.[25] The most frequently used psychological screening tool was the hospital anxiety and depression scale [Table 2]. They can refer patients with early signs of psychological distress for further management to a specialist. The dental staff should be trained and empowered with communication skills essential to speak with empathy and address the emotional concerns of patients and caregivers from the initial stage of the diagnosis and even post-treatment survivors.

Table 2:: Frequently used psychological screening tools.

S. No. Screening tool Description 1. HADS (Zingmond and Snaith, 1983)[40] It is the most widely used 14-item scale for measuring anxiety and depression without measuring the somatic factors, especially in medically ill patients. Patients with a score more than or equal to 8 are considered to be suffering from distress. 2. CES-D (Radloff,
1977)[41] It was initially developed as a 20-item scale to measure psychological and somatic factors along with interpersonal relations, etc., in a large epidemiological sample. However, a shorter form with 10 items was developed in 1999 by Andersen et al. It had good reliability with a cutoff score of 10. 3. BDI (Ward, 1961)[42] It is the widely used subscale to measure depression in older adults quantitatively. The earlier scale was a 20-item questionnaire. Several modified subscale versions have been identified, with the shortest being the BDI-FS (Fast Screening for Medical Patients). 4. PROMIS[43] The United States National Institute of Health came about with PROMIS to measure patients’ state-of-the-art HRQoL. There are more than 100 HRQoL to measure various domains, with items on each scale ranging from 29 to 59. In addition, shorter forms evaluating the seven core domains in patients have been developed with 4, 6 and 8 items. 5. DT-PL[44] It is an 11-item thermometer used to determine psychological distress, with the lowest and the highest range being 0 and 10, respectively. Patients with high distress are also given a problem list. It consists of around forty questions comprising of various problems such as physical, family and emotional, with the primary purpose of the rating scale to acknowledge distress as the sixth sign of cancer care. 6. PHQ-9[45] PHQ is a self-administered questionnaire used in primary health-care settings to assess depression severity and other mental disorders. It can be used for the diagnosis of depression and to assess its severity.

Awareness about distress management guidelines – Dentists should know the various distress management guidelines outlined in the literature. It was first given by NCCN in 1997.[18] Besides the NCCN guidelines, countries such as Canada, Australia, the UK, and the USA have separate clinical guidelines.[25-28] European Head and Neck Society and the UK’s Head and Neck Association have given distress management guidelines specific to H&N cancer patients[27,28] [Tables 3 and 4].

Collaboration with the psychologists – After the initial evaluation of the patient for distress, dentists should work with psychologists and refer these patients for counselling. These therapies include:

Psychological education

Family and couples therapy

Pharmacologic mediations

Complementary therapy

Counselling

Spiritual guidance

Telehealth aids

Group discussions and counselling

Dyadic coping strategies and pre-treatment psychoeducation in H&N cancer patients undergoing RT have also shown positive and better survival outcomes in these patients[29,30]

Psychological and social interventions

Cognitive behavioural therapy

Adjuvant psychological therapy.

Dentistry – A bridge between RT and palliative care – Dentists’ role in psychological assessment and other treatments in various institutions providing palliative care for cancer patients should be invigorated.[21] Dentists can be paramount in bridging the gap between actual cancer treatment and palliative care. Frequent dental visits by the patient can help alleviate patients’ fear and encourage them to seek help for their mental health issues.

Table 3:: European head-and-neck society guidelines for emotional screening of cancer patients.

S. No. Stages Evaluation of emotional screening Steps to manage emotional stress 1. Before diagnosis Patients are in a happy and content state. Patients are mostly unaware of cancer. Provide awareness to the patient about the disease and its screening. Help enhance coping strategies. 2. At diagnosis Patient suffers with varied emotional behaviour ranging from shock, anxiety, depression, fear, uncertainty and hopelessness. Be empathetic towards the patient and discuss their problems openly. Screening of psychological distress should be performed. 3. During treatment Patients suffer from a sense of loss, isolation, anxiety and fear. Screen patients for anxiety and depression, and monitor for any maladaptive coping strategies. 4. Post treatment Patients are vulnerable and feel depressed. They suffer from constant fear of relapse and have low self-esteem. Help patient cope with maladaptive strategies. Propose treatments to manage sequalae and social rehabilitation.

Table 4:: The UK head-and-neck association recommendations for multidisciplinary management of cancer patients.

S. No. Recommendations 1. Discuss treatment options and outcomes along with adverse effects with patients and their caregivers. 2. Hospital staff should be taught to be sensitive to the patients and handle their patients with empathy. 3. Flexibility should be followed while managing patients with terminal illnesses depending on the circumstances. 4. Multidisciplinary teams should operate to ensure proper and timely information and support to the patient and the caregiver. 5. Mental health interventions should be part of the multiple treatments imparted to the patients. 6. Health-care professionals should be continuously educated to improve their communication skills while consulting difficult patients. Strengths and limitations

The current review gives a comprehensive and detailed insight into the psychological distress screening tools and management guidelines. It also discusses the initiatives that can be adopted in the dental setup for improving psychological screening. The few limitations of the study include its narrative style of writing. The study included patients treated with RT exclusively and inclusion of only English studies.

Future scope

Further prospective studies evaluating the psychological status of patients reporting to a dentist should be conducted. Dentists should be encouraged to have psychological screening of cancer patients as a routine procedure from the initial stage of diagnosis.

CONCLUSION

The world is recognising the need not only to eradicate cancer but also to improve the QoL in the survivors. Oral health-care professionals can be crucial in screening patients for their psychological problems. Availing the oral physician’s aid in psychological screening will help alleviate patients’ apprehensions to seek mental health intervention and is of paramount importance in the future.