What Should Head and Neck Cancer Patients Expect After Surgery?

A Keck Medicine of USC head and neck surgeon explains how she and her team prepare patients for potential challenges.

Preparing patients for what to expect after head and neck cancer surgery is critical. In the weeks after surgery and/or chemoradiation, patients can experience everything from swelling, facial numbness and sore throat to trouble swallowing and speaking.

Not all patients understand how daily activities can be affected after head and neck surgery. “If it’s tongue cancer, we’re removing a part of the tongue,” Tang explains. “If it’s laryngeal cancer, we’re removing a part of the larynx. So, eating can be affected. Speaking can be affected. It’s incredibly important to counsel patients and set their expectations before surgery, not only so they are mentally prepared but also so they can make all their postoperative care preparations at home,” Tang says.

Patients should know the range of possible complications. “For the simpler surgeries, we go through the possibilities of what recovery can look like if it goes perfectly — and what it can look like if it doesn’t,” Tang says. “For example, with thyroid and parathyroid surgeries, even though it rarely happens, we always talk about possible damage to the recurrent laryngeal nerve, which can lead to vocal cord paralysis, voice changes or difficulty swallowing. We also talk about the possibility of temporary low calcium levels, which can lead to numbness and tingling.”

Certain risk factors such as previous history of radiation, smoking and diabetes can make surgical recovery more challenging, so additional counseling needs to be provided. “For instance, if anyone was previously radiated, we warn them that they’re very likely to have wound-healing issues. They may need wound care afterward.”

Tang also advises patients about what to expect from more complex procedures. One example is if a patient is to undergo reconstructive flap surgery — for instance, reconstructing a significant portion of the tongue that was removed using tissue from the arm, leg or another part of the body.

“It’s a complicated surgery that takes about eight hours and requires connecting blood vessels from two different areas of the body,” Tang explains. “At least for the first couple of weeks, and especially during the first five days, recovery relies on the vessels you connected. If a clot happens in one of the connected vessels and we catch it early on, we can still save the flap — but if not, part or all of the flap can die. Even though this rarely happens, we always talk about the possibility so that patients can be mentally prepared should they need to return to the OR.”

Helping patients decide on treatment

Preparing patients for these scenarios isn’t just important for setting expectations but also for giving patients all the information they need to make the right treatment decisions for their situation.

Patients have the right to weigh the possible outcomes against their own goals and preferences. For instance, says Tang, “Sometimes after hearing about what recovery might entail and about the possible risks of treatment, some patients instead opt for palliative treatment to live out the rest of their lives in comfort.”

“Setting expectations is incredibly important because it all goes back to patient autonomy — what they want for themselves and the life they choose,” she adds. “If we don’t give them the correct information they need to choose, we’ve failed.”

Getting the message across

Some patients do have difficulty accepting the changes that surgery can bring, and as a result the patient may be resistant to a treatment plan at first.

“Younger patients, especially 20- or 30-year-olds, often have cancers that are more aggressive,” she says. “In the case of small tongue cancers, our treatment expectations are usually pretty aligned. Once we get to bigger tongue cancers, however, a lot of times our expectations are not aligned. Most recently, I had a conversation with a 20-year-old patient and his family. The tumor was affecting most of his tongue, and I told the family I had to remove his entire tongue, but they kept asking if I could only remove a small part of his tongue.”

She continues: “When we’re talking about surgery that removes function like the ability to talk or eat normally, patients and their families have a hard time accepting it. That being said, being really honest and trying to be clear and consistent is the key that usually gets the message across.”

Expert consensus also helps

Among the USC Head and Neck Center’s strengths for treating complex head and neck cancer cases is the fact that treatment plans are the result of the consensus of multidisciplinary experts who are all part of the academic health system of Keck Medicine of USC. Being able to convey to patients that a treatment plan has been shaped and vetted by numerous advanced specialists helps build credence.

“Our tumor boards are attended by five otolaryngologists, two medical oncologists specializing in head and neck cancers, two radiation oncologists, a radiologist and a pathologist,” Tang says. “So, when I present a plan to a patient, I can tell them, ‘We went through a tumor board with these experts. This is our consensus and expectations for treating you the best way we can and to get you the best outcome possible.’”

What happens when patients don’t follow advice?

There are, of course, instances when patients hamper their own healing post-surgery. One example is a patient who, after a larynx reconstruction, continues smoking or not following postoperative recommendations.

“The patient may decide to eat when we tell them they shouldn’t yet. This can stress the incision site and can sometimes cause the incision to break open, resulting in a leakage of saliva. Other times, the reason a patient isn’t healing well is because they do not stop smoking, even during the immediate postoperative recovery period. In these two cases, patients tend to understand that they’re inhibiting their own recovery.”

Transparency is the best policy

Ultimately, being as thorough and honest as possible in conveying information about potential risks and outcomes sets appropriate patient expectations, which benefits physicians, too. “Just be honest and consistent about your own numbers, your own complications and expectations for recovery,” Tang advises. “In general, patients are incredibly understanding. With good counseling, your expectations should be pretty aligned.”

And if patients aren’t healing as well as they’d hoped, Tang says, “I first tell them, ‘I’m really sorry. I understand that you’re frustrated and that you’re going through a really difficult process right now. You underwent a hugely complicated surgery, and you’re doing okay, but it will take a little bit of time for you to heal. Eventually, you will heal.’ Then we talk about what might be a new normal for them, and we also discuss if there are any other solutions we can try.”

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