Case Study: Oral Cancer and Yoga


R. is a 43 year old woman from the Northern Territory, married with four (4) children. She is a Ward Clerk, working in hospital administration for more than seven (7) years. In July 2015, she visited her dentist with symptoms of a sore tongue, culminating in an oral cancer diagnosis requiring surgical excision of half her tongue and 31 lymph nodes from her neck.

Timeline

13 July 2015

Consulted dentist with a sore tongue – no diagnosis, no treatment, recommended to come back in two weeks.

14 July 2015

Second dental opinion sought – no diagnosis, ground teeth to ensure no impact, referred to specialist

20 July 2015

Following difficulty with specialist availability - consulted Maxillofacial team, two painful biopsies taken under local.

27 July 2015

Results indicated low grade abnormality - scheduled for further biopsy under general anaesthetic. However, following consultation R. was scheduled for surgery.

30 July 2015

Surgery removed a cyst and further samples

5 August 2015

Diagnosed with Squamous Cell Carcinoma (SCC) and scheduled for further surgery

13 August 2015

Hemi Glossectomy and right radical neck dissection removed half of the tongue and 31 lymph nodes from the neck.

28 September –

6 November 2015

Radiation Therapy

Medical History


R. has a history of mild asthma since she was a teenager. She is not taking any preventative asthma medication and uses Ventolin rarely.
She was diagnosed with mild high blood pressure when pregnant with her first child in 1993 and was prescribed Preindopril 2mg daily in June 2015. The rare side effects of this drug include swelling of the face and tongue, and a sore throat. [1] However, the drug was used for a short period prior to diagnosis.

There is a history of prior minor tongue injury with a bite and abrasion from cracked teeth around 2007. Otherwise R. was quite well without any specific stress or trauma prior to diagnosis.

There is a family history of bowel cancer affecting both her grandfather and father. However there is no other oral cancer history identified in the family.

Lifestyle Factors

R. is overweight with a high BMI. However, prior to diagnosis, she was moderately fit, regularly walking eight (8) floors of stairs at work during lunchtime.

R. is a non-smoker and does not use recreational drugs. She was a moderate to heavy drinker, consuming 18-28 units of alcohol on an average per week, although this has reduced since the diagnosis. The weekly recommended allowance for women is 18 units.

R. has experienced a high degree of sun exposure due to her life in the Northern Territory.

Her diet was balanced, included meat and avoided junk food. However, it may have been high in sodium prior to diagnosis.

Nature of the Condition

Oral cancer is an uncontrolled growth of cells in the mouth. It can affect lips, tongue, gums, inner cheeks or soft palate. There were 4520 new cases of head and neck cancer in Australia in 2015, representing 3.6% of all new cancer diagnoses. [2]

More than 90% of oral cancer is Squamous Cell Carcinoma (SCC), with lymphoma, melanoma and cancer of the salivary glands more rare. [3] R.’s case was diagnosed as SCC of the tongue.

Cause of the Condition

Although causes remain undetermined, oral cancer is linked to tobacco (smoking and chewing), alcohol, sun exposure (particularly on the lip), and a weakened immune system. Human Papillomavirus (HPPV) is also linked to the condition.

R. did not smoke, chew tobacco, or have HPPV, she does have history of alcohol consumption and sun exposure. However, the site (tongue) was not exposed to the sun.

Physical Effects of the Condition & Intervention

Initial symptoms of the condition were limited to soreness of the tongue, prompting R. to seek the initial dental opinion.

The subsequent intervention was painful, particularly at biopsy. Immediately following surgery, R. reported that the tongue was, perhaps surprisingly, the least painful part of recovery. Blood clots at the back of the throat and the wound from the removal of the lymph nodes from the right neck did cause significant pain and discomfort.

Scarring is evident from behind R.’s right ear to under the chin and she experienced numbness in the right neck and shoulder following surgery. Sensation is slowly returning to this area. However, sensitivity of the tongue and throat has been further diminished by radiation therapy.

As might be expected, speech and taste have been strongly impacted by the intervention. Pain medication, as well as radiation, has resulted in fatigue and constipation. Radiation caused ulcers in the mouth and throat, and burns on the neck but, overall, has not increased tenderness in this area.

Nutrition and diet have changed significantly since the surgery. Meals need to be predominantly liquidised. Post-operative care has stipulated mild flavours and avoiding salt. Since approximately two weeks after completing the course of radiation therapy, R. has been able to return increasing amounts of vegetable solids to her diet.

Mind Body Assessment

Understandably, there have been wider effects on R.’s sense of wellbeing. Diagnosis and intervention caused significant stress and anxiety. In addition, R. has been unable to work since August, affecting her career, finances and personal identity. Her relationships and self-esteem have suffered, not the least because her ability to communicate was impaired. Although R. already describes herself as an introvert, this experience has brought a further sense of isolation and a feeling of not being understood. She finds herself worrying about the future and struggles to read a book without her mind wandering.

Breathing and sleep have not been significantly affected. R.’s sense of smell is unaffected. Self-assessed positive impacts are identified in the areas of creativity and self-expression, as well as spiritual connection.

R. has sought acupuncture to support the medical intervention and is undergoing speech therapy. No psychological support or counselling has been offered or sought.

Findings & Recommendations

When asked, R. is already clear about her immediate goals to: regain her health and fitness; improve her speech and confidence; and return to employment.

In consideration of this and complementary to her medical care, the goals of a supporting Yoga program might be:

Short Term
  • Reduce current tension and anxiety
  • Return mobility to the throat neck and shoulder, and
  • Improve immediate quality of life
  • Medium Term
  • Improve communication
  • Increase confidence, and
  • Build skills in self-care and stress management
Long Term
  • Improve systemic balance to support weight reduction, and
  • Reduce the need for blood pressure medication, as approved by R.’s physician.
In the West, Yoga is often regarded as a purely a physical therapy. However, a support program would ideally emphasise the complete yoga system, [4] offering:

  • Philosophy and Self-Study
  • Reading list
  • Journal
  • Physical Postures
  • During radiotherapy, restorative postures such as:
  • Restorative backbends using props such as a bolster to relax and release areas of the neck, shoulder and throat.
  • After radiotherapy, gradual return to strength focusing on system balance and mobility in neck and shoulder including (in order of intensity):
  • Gentle mobility sequence (Pawanmuktasana);
  • Seated head rolls (Greeva Sanchalana) with caution for effects on blood pressure;
  • Lion Pose (Simhasana) where the tongue is extended, with vocalisation when comfortable;
  • Shoulderstand (Salamba Sarvangasana) where the posture encourages the throat bind (Jalandhara Bandha) and encourages blood flow once released;
  • Appropriate variations of Fish Pose (Matsyasana) where the head is extended backwards.
  • Breathing exercises
  • During radiotherapy, self-soothing techniques for calming the nervous system
  • Diaphragmatic breathing
  • After radiotherapy, reclaiming some voluntary control of the airway
  • Alternate nostril breathing (Nadi Shodan)
  • Gentle retentions (Viloma)
  • Humming Bee’ breath (Bhramari), when appropriate
  • Relaxation
  • During radiotherapy and ongoing, Yoga Nidra with a customised intention (sankalpa) focused on the throat chakra
  • Customised aromatherapy, topical, if approved by her physician, for radiation burns and diffusing to reduce nausea and anxiety
  • Meditation
  • After radiotherapy, mindfulness and concentration techniques
  • Voice release through chanting
  • Building time in silent meditation
Depending on the degree of damage to the vagus and related nerves under the chin, there may also be an opportunity to work with other postures that gently stimulate this area. Regardless, alternatives for increasing parasympathetic nervous (relaxation) response and decreasing sympathetic (stress) nervous response should be incorporated.

In addition to the specific condition of the tongue, asthma and hypertension indicate a pre-existing propensity for tension and anxiety. Cultivating skills to manage stress is the central focus of the program. In energetic terms, these types of conditions can correlate to desire for freedom of expression, to make her own decisions, find her voice, and feel heard. Therefore, activities promoting non-goal oriented creativity are also recommended.

It is also appropriate to pay attention to the sounds R. surrounds herself with, language, music and ambient noise, choosing positive, soothing sounds and messages whenever possible. Energetic interpretations of throat conditions may also suggest a truth or secrecy element to the condition related to possible past trauma. [5] Counselling may support recovery.

A continued sattvic (mild, nourishing) diet is recommended to minimise irritation and support recovery.

Positive results have been observed with the use of Yoga Nidra during Radiotherapy and recovery. R. has found it soothing, promoting relaxation when faced with pain and uncertainty. This is just the beginning of her recovery. Subscribe for future updates on R.'s progress.

[1] “Drugs, Herbs & Supplements: Perindopril”, Medline Plus, US National Library of Medicine, Web, 15 August 2015.
[2] "Head and Neck Cancer," Cancer Australia, Australian Government, Web, 18 December 2015.
[3] "Mouth Cancer (Oral Cancer)", BUPA, Web, 30 July 2011.
[4] Johnson, Lori, and Roberta Bourgon. "Complementary and Integrative Modalities." Core Curriculum for Oncology Nursing (2015): 315.
[5] This is indicated in energetic studies such as Judith, A, Eastern Body, Western Mind, Celestial Arts, 1996 and Hay, L, You Can Heal Your Life, Specialist Publications, 1984.

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