The Psychological Effect of Facial and Neck Surgery

Question 1

Describe head and neck cancer epidemiology.

Answer 1

60% men
40% women
-Main age group by proportion is 80+
-Of all cancers, heads and neck cancers are on the rise (due to link between smoking levels are quite resistant to change, esp. in women (started to decrease in men) + increase in HPV due to increase in sexual partners
-SHOULD start seeing decline in future thanks to vaccines against HPV in boys and girls

Question 2

Which UK country has the highest age standardised rate of head and neck cancers ?

Answer 2

Scotland

Question 3

Identify psychological factors of Head and Neck Cancer.

Answer 3

• Quality of life
• Psychological distress (depression, anxiety)
• Appearance
• Fears of recurrence

Question 4

Identify possible outcomes measured in cancer.

Answer 4

• Disease free interval
• Recovery
• Longevity
• Quality of life

Question 5

Identify tools to measure QOL in head and neck cancer.

Answer 5

– EORTC H&N
– FACT H&N
– UoW QoL H&N

Question 6

Why does QOL decrease in head and neck cancer patients ?

Answer 6

Decreases on diagnosis, and sinks because of pain, loss of function, worry.

Question 7

What is the trajectory of QOL as time goes on in head and neck cancer ?

Answer 7

As time goes on, trajectory of QOL improving (on average, patient come back to baseline QOL one year after surgery)

Question 8

Describe progression in survival rates from head and neck cancers in later years.

Answer 8

Survival rates for head and neck cancers have not improved (not enough resources + complex cancer)

Question 9

What is the trajectory of psychological distress as time goes on in head and neck cancer ?

Answer 9

On average, psychological distress all but gone one year after

Question 10

Identify factors which contribute to depression following head and neck cancer.

Answer 10

Pain management problems + possible swallowing difficulties (decreased independence, may have gastric tube)

Question 11

Why are people concerned about facial appearance ?

Answer 11

• Facial information is first to be available
• It is continuously available
• Facial appearance information does not require complex processing
• Increased incidence of meeting new people

Question 12

Identify psychological problems associated with requests for plastic surgery (following surgery from head and neck cancer).

Answer 12

Eating disorders

• anorexia bulemia
• bulemia nervosa
• compulsive eating

Sexual abuse

Familial / social estrangement

Question 13

Identify differences in response to stigmatizing reactions to the same physical characteristic (following head and neck cancer surgery).

Answer 13

Individual differences in response to stigmatizing reactions to the same physical characteristic:

Less stigma felt in those who are ‘resilient’:

• reduced sense of personal vulnerability
• high level of intelligence
• sense of humour
• stable childhood
• strong self-esteem

Question 14

Define handicapping dentofacial anomaly.

Answer 14

A handicapping dentofacial anomaly is one which causes disfigurement or which impedes function

Question 15

In which cases should an anomaly (in the context of head and cancer) be regarded as requiring treatment ?

Answer 15

An anomaly should be regarded as requiring
treatment if the disfigurement or functional defect is,
or is likely to be, an obstacle to the patients’ physical or emotional well-being “

Question 16

Identify psychological consequences of disfigurement.

Answer 16

Minor disfigurement

• unpredictable response from others
• increase in anxiety and helplessness
• increased scanning of face

Major disfigurement
-can anticipate response of others

LACK OF CORRELATION between disfigurement level and distress

Question 17

Describe psychiatric considerations in the context of appearance, following head and neck cancer surgery.

Answer 17

MONOSYMPTOMATIC HYPOCHONDRIAL PSYCHOSIS (MHP)

• Delusions of ugliness
• obsessional to obtain a “cure”
• anxious and vigilant
• rational about other things

BODY DYSMORPHIC DISORDER (BDD)
-nondelusional
-preoccupation with an imagined defect
-overvalued ideas that can be discussed rationally
coexists with depression, obsessive-compulsive
behaviour and social phobia

Question 18

Describe the process of assessing appearance concerns, for patients following head and neck cancer surgery.

Answer 18

• Careful and sensitive questioning to gauge level of difficulty that appearance concerns may have for patient
• Seek out family, carers or close friend’s opinions of possible patient concerns
• Rate intensity of concern and validate by effect on behaviour (avoidance of social situations)
• Rate depression and if necessary seek specialist assessment (clinical psychologist, liaison psychiatrist)

Question 19

Describe the link between illness concerns and psychological distress.

Answer 19

-Evidence for association between concerns and affective disorder

• Two alternative hypotheses
  1) Specific illness fears effect general distress
  2) General distress effects illness fears and other beliefs

Question 20

How may we measure fear of recurrence in a patient following head and neck cancer surgery ?

Answer 20

“Over the past month, how often have you worried about the possibility that cancer might come back?”

Question 21

What proportion of patients will want to talk to their consultant about the concern that the cancer might return ?

Answer 21

40% (including 10% who will have recurrence fears so great they will have difficulty getting back to work and will keep calling doctor etc)

Question 22

Why might patients have fears of recurrence ?

Answer 22

As part of recovery process, some sensations like pain, tingling, numbness, which can be interpreted as cancer returning

Question 23

Describe the trajectory of recurrence fears over time.

Answer 23

Recurrence fears appear to reduce slightly over time

Question 24

Describe the common sense model of illness.

Answer 24

↗ Illness Representation↘
Stimuli Coping ↣ Appraisal
↘ Emotional Response ↗

Question 25

Describe a structured intervention to reduce fears of recurrence in head and neck cancer patients.

Answer 25

AFTER intervention
•Focused on family beliefs, symptom reinterpretation,
checking behaviour,
•Exposure to anxiety and worry
•Based upon Self-Regulation Theory
•Includes questions such as whether he/she has compared themselves with other patients on the ward or out-patients + what comparisons he/she has made and what influence this process has had on his/her understanding of the illness and the treatment he/she received

Question 26

Describe the effect of the AFTER intervention on recurrence fears in head and neck cancer patients.

Answer 26

Decreased recurrence fear

Question 27

Identify carer Responses to Illness.

Answer 27

• Openness
– ‘the encouragement of emotional expression’
– Value of open and closed communication?
• Fears of recurrence
• Distress

Question 28

What should you answer if patient asks whether the cancer will come back ?

Answer 28

Do NOT give early reassurance

1) We’re checking you regularly
2) If feeling something, happy for you to come and see me
3) BUT need to wait before push panic button (two weeks for breast cancer)

Question 29

Briefly explain the carer’s importance in promoting recovery.

Answer 29

• Retain structure to daily life
• Assist with medication, treatments and adherence to medical recommendations
• Practical support
• Maintain emotional life (possible act as a safety valve)
• Family interactions are complex and not always supportive (‘toxic’ environment)

Question 30

Which of flap or non-flap surgery allows patient to maintain better appearance ?

Answer 30

Non-flap surgery

Question 31

State incidence and mortality of mouth cancer in the UK.

Answer 31

Incidence around 4000 per y

Mortality around 1600 per y