Interventions for preventing oral mucositis for patients with cancer receiving treatment

Assessment of cancer therapy-induced oral mucositis using a patient-reported oral mucositis experience questionnaire

Objectives

Treatment of oral mucositis (OM) is challenging. In order to develop and test useful treatment approaches, the development of reliable, reproducible and simpler methods than are currently available for assessment of OM is important. A Patient-Reported Oral Mucositis Symptom (PROMS) scale was assessed in patients with head and neck cancer to determine if the patient-reported OM experience, as determined by using the PROMS scale, correlate with OM assessed by clinician-based scoring tools.

Materials and Methods

Fifty patients with head and neck cancer and undergoing radiotherapy consented to participate. They were examined before cancer treatment and twice weekly during 6–7 weeks of therapy and once 4–6 weeks after therapy. Signs of OM were evaluated using the 3 clinician-based scoring tools; NCI-CTCAE v.3, the OMAS criteria and the Total VAS-OMAS. The participants' OM experiences were recorded using PROMS-questionnaires consisting of 10 questions on a visual analogue scale. Spearman rank correlation test were applied between the PROMS scale values and the clinician-determined scores. Repeated measures mixed linear models were applied to appraise the strengths of correlation at the different time points throughout the observation period.

Results

Thirty-three participants completed all stages of the study. The participant experience of OM using the PROMS scale demonstrates good correlations (Spearman's Rho 0.65–0.78, p<0.001) with the clinician-determined scores on the group level over all time points and poor to good correlations (Spearman's Rho -0.12–0.70, p<0.001) on the group level at different time points during and after therapy. When mouth opening was problematic, i.e. during the 6^th and 7^th week after commencing cancer treatment, the Spearman's Rho varied between 0.19 and 0.70 (p<0.001).

Conclusion

Patient experience of OM, as reported by the PROMS scale may be a feasible substitute for clinical assessment in situations where patients cannot endure oral examinations.

Efficacy of cryotherapy associated with laser therapy for decreasing severity of melphalan-induced oral mucositis during hematological stem-cell transplantation: a prospective clinical study

Melphalan followed by hematopoietic stem-cell transplantation (HSCT) is the standard treatment for multiple myeloma and other hematopoietic neoplasms. However, high doses of melphalan cause severe oral mucositis (OM). The objective was to verify the efficacy of cryotherapy plus laser therapy on reduction of OM severity. HSCT patients undergoing melphalan chemotherapy (n = 71) were randomly divided into two groups according to OM treatment: oral cryotherapy performed with ice chips for 1 h 35 min followed by low-level laser therapy (InGaAIP, 660 nm, 40 mW, 6 J/cm(2) ) (n = 54) and laser therapy alone with the same protocol (n = 17). A control group (n = 33) was composed of HSCT patients treated with melphalan who received no specific treatment for OM. OM scores and clinical information were collected from D0 to D + 11. The cryotherapy/laser therapy group showed the lowest OM scores (maximum Grade I) and the lowest mean number of days (8 days) with OM in comparison with the other groups (p < 0.001). OM Grades III and IV were present with high frequency only in the control group. The association of cryotherapy with laser therapy was effective in reducing OM severity in HSCT patients who underwent melphalan conditioning.

Prevention and treatment of oral mucositis in patients receiving chemotherapy

Oral mucositis is one of the most common side effects of cancer treatment (chemotherapy and/or radiotherapy). It is an inflammatory process that affects the mucosa of the oral cavity, giving rise to erythematous areas in combination with ulcers that can reach a large size. The true importance of oral mucositis is the complications it causes - fundamentally intense pain associated to the oral ulcers, and the risk of overinfection. This in turn may require reduction or even suspension of the antineoplastic treatment, with the risk of seriously worsening the patient prognosis. This points to the importance of establishing therapeutic tools of use in the prevention and/or treatment of mucositis. The present study offers a literature review of all the articles published over the last 10 years referred to the prevention and/or treatment of oral mucositis associated to chemotherapy. Key words:Oral mucositis, management, prevention, treatment, chemotherapy.

A randomized placebo-controlled trial of manuka honey for radiation-induced oral mucositis

BACKGROUND

Few treatments have the potential to reduce the severity of radiation-induced mucositis in head and neck cancer patients. Some small studies have suggested that organic honey may be a useful preventive treatment.

METHODS

This investigator-initiated double-blind randomized placebo-controlled trial investigated whether honey reduced the severity of radiation-induced oral mucositis (ROM). One hundred six head and neck cancer patients from the Vancouver and Sudbury Cancer Centers in Canada were randomized to swish, hold, and swallow either 5 ml of irradiated organic manuka honey or a placebo gel, four times a day throughout radiation treatment, plus seven more days. Severity of oral mucositis according to the Radiation Therapy Oncology Group (RTOG), World Health Organization (WHO), and Oral Mucositis Assessment Scale scales, weight, and subjects' symptom severity and quality of life were assessed weekly. Sialometry was performed at baseline and at the last study visit.

RESULTS

One hundred six patients were recruited. Twenty-four did not attend any mucositis assessments. One was removed from the study because of off-study consumption of store-bought manuka honey. The remaining 81 patients had at least one mucositis assessment and were included in the analysis. Sixty-two percent of subjects received concurrent chemotherapy; 81 % were male. The groups were well-matched, and blinding was excellent. Dropouts were mostly due to nausea and were similar in both arms, with 78 % being able to tolerate the study products for more than 1 week. The dropout rate was 57 % in those who received honey and 52 % in those who received placebo gel. The dropout rate in those who had concurrent chemotherapy was 59 % and in those who only received radiation was 47 %. There was no statistically significant difference between the honey and placebo arms in any of the outcome indicators. Those who completed the study in both treatment arms had low rates of RTOG greater than or equal to grade 3 mucositis; 35 % in the honey group and 43 % in the placebo group.

CONCLUSION

Despite promising earlier reports, manuka honey was not tolerated well by our patients and, even when used as directed, did not have a significant impact on the severity of ROM.

A survey of chinese medicinal herbal treatment for chemotherapy-induced oral mucositis

Oral mucositis is one of the common side effects of chemotherapy treatment with potentially severe implications. Despite several treatment approaches by conventional and complementary western medicine, the therapeutic outcome is often not satisfactory. Traditional Chinese Medicine (TCM) offers empirical herbal formulas for the treatment of oral ulceration which are used in adaptation to chemotherapy-induced mucositis. While standard concepts for TCM treatment do not exist and acceptance by conventional oncologists is still low, we conducted a review to examine the evidence of Chinese herbal treatment in oral mucositis. Eighteen relevant studies on 4 single herbs, 2 combinations of 2 herbs, and 11 multiherbal prescriptions involving 3 or more compounds were included. Corresponding molecular mechanisms were investigated. The knowledge about detailed herbal mechanisms, especially in multi-herbal prescriptions is still limited. The quality of clinical trials needs further improvement. Meta-analysis on the existent database is not possible but molecular findings on Chinese medicinal herbs indicate that further research is still promising for the treatment of chemotherapy-induced oral mucositis.

Prevention and management of treatment-induced pharyngo-oesophageal stricture

Pharyngo-oesophageal stricture (PES) is a serious complication that occurs in up to a third of patients treated with external beam radiotherapy or combined chemoradiotherapy for head and neck cancer. This entity is under-reported and as a result, our understanding of the pathophysiology and prevention of this complication is restricted. This Review presents the knowledge so far on radiation-related and non-radiation-related risk factors for PES, including tumour stage and subsite, patient age, and comorbidities. The interventions to decrease this toxicity are discussed, including early detection of PES, initiation of an oral diet, and protection of swallowing structures from high-dose radiation. We discuss various treatment options, including swallowing exercises and manoeuvres, endoscopic dilatations, and for advanced cases, oesophageal reconstruction. Study of the subset of patients who develop this toxicity and early recognition and intervention of this pathological change in future trials will help to optimise treatment of these patients.

Understanding CAM Natural Health Products: Implications of Use Among Cancer Patients and Survivors

Herbs, vitamins, and other natural health products are being used by cancer patients and survivors with increasing prevalence in the United States. These complementary and alternative medicine (CAM) products, which are also referred to as natural health products in Canada and abroad, are used during cancer treatment and the survivorship period to ease the burden of symptoms such as pain, fatigue, insomnia, anxiety, and depression and hence improve overall quality of life. Data indicate that while patients choose these products for self-treatment, they often do not inform their health-care providers, thereby presenting the potential for negative interactions. This article gives an overview of CAM natural health products, including discussion of herbs, vitamins, and other supplements such as minerals, enzymes, and more. Related research is presented, and implications for advanced practitioners are discussed. Insights into guiding safe and effective use among patients as well as appropriate decision-making strategies are explored.

Evidence to support the use of honey for prevention of oral mucositis in cancer patients is limited

DATA SOURCES

PubMed, Medline, Embase, CINAHL via EBSCO and Cochrane library databases were searched.

STUDY SELECTION

Randomised controlled trials that investigated the protective effects of honey in head and neck cancer patients undergoing radiation therapy that used either the Radiation Therapy Oncology Group (RTOG) or World Health Organisation (WHO) criteria for evaluating the severity of the radiation mucositis were included. Risk of bias was assessed using the Cochrane methodology.

DATA EXTRACTION AND SYNTHESIS

A meta-analysis was conducted using a fixed-effects model. Heterogeneity was assessed using the I² statistic.

RESULTS

Three randomised trials involving a total of 120 patients were included. The overall relative risk of developing mucositis was almost 80% lower (risk ratio, 0.19; 95% CI, 0.098 - 0.371) in the honey treatment group than in the control group.

CONCLUSIONS

Despite promising results, the weaknesses of the individual studies highlight the need for further, more rigorous, randomised controlled trials. Future studies need to address the weakness of available studies by adequately describing the method of randomisation and allocation concealment.

Alteration of the oral environment in patients undergoing esophagectomy during the perioperative period

OBJECTIVE

During the perioperative period, oral ingestion is changed considerably in esophagectomy patients. The aim of this study was to investigate oral environment modifications in patients undergoing esophageal cancer treatments due to changes in dietary intake and swallowing functions.

MATERIAL AND METHODS

Thirty patients who underwent operation for removal of esophageal cancer in Tokushima University Hospital were enrolled in this study.

RESULTS

It was found that 1) the flow rate of resting saliva decreased significantly at postoperative period by deprived feeding for one week, although it did not recover several days after oral ingestion began, 2) the accumulation of dental plaque and the number of mutans streptococci in saliva decreased significantly after operation, while both increased relatively quick when oral ingestion began, and 3) the swallowing function decreased significantly in the postoperative period.

CONCLUSIONS

These results suggest that dental professionals should emphasize the importance of oral health care and provide instructions on plaque control to patients during the perioperative period of esophageal cancer treatment.

Systematic review of laser and other light therapy for the management of oral mucositis in cancer patients

BACKGROUND

The aim of this study was to review the available literature and define clinical practice guidelines for the use of laser and other light therapies for the prevention and treatment of oral mucositis.

METHODS

A systematic review was conducted by the Mucositis Study Group of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology. The body of evidence for each intervention, in each cancer treatment setting, was assigned an evidence level. Based on the evidence level, one of the following three guideline determinations was possible: recommendation, suggestion, and no guideline possible.

RESULTS

A new recommendation was made for low-level laser (wavelength at 650 nm, power of 40 mW, and each square centimeter treated with the required time to a tissue energy dose of 2 J/cm(2) (2 s/point)) for the prevention of oral mucositis in adult patients receiving hematopoietic stem cell transplantation conditioned with high-dose chemotherapy, with or without total body irradiation. A new suggestion was made for low-level laser (wavelength around 632.8 nm) for the prevention of oral mucositis in patients undergoing radiotherapy, without concomitant chemotherapy, for head and neck cancer. No guideline was possible in other populations and for other light sources due to insufficient evidence.

CONCLUSIONS

The increasing evidence in favor of low-level laser therapy allowed for the development of two new guidelines supporting this modality in the populations listed above. Evidence for other populations was also generally encouraging over a range of wavelengths and intensities. However, additional well-designed research is needed to evaluate the efficacy of laser and other light therapies in various cancer treatment settings.

The impact of hospitalization on dental plaque accumulation: an observational study

AIM

To investigate the effect of hospitalization on oral health as assessed by dental plaque.

MATERIALS AND METHODS

Observational study in a critical care unit (CCU). Participants were recruited within 24 h of admission. Dental plaque amount was assessed at baseline, 1 and 2 weeks using the Debris index-soft deposits (Greene & Vermillion 1960).

RESULTS

Fifty participants were recruited with 36 available for outcome assessment at 1 week and 10 at 2 weeks. The principal reason for losses was early discharge with no evidence of a difference between patients present only at baseline and those present at 1 week. The median value for dental plaque at baseline was 4 (95% CI: 4, 6). The median dental plaque increase from baseline to week 1 was 1.5 (95% CI: -1, 4), and this was statistically significant (p = 0.04). The median increase from week 1 to week 2 was 1.0 (95% CI -8, 6) and not statistically significant (p = 0.68).

CONCLUSIONS

Oral health as assessed by dental plaque deteriorates following hospitalization in CCU. Such change could lead to impairment of quality of life and well-being as well as to increasing the risk of important healthcare-associated infections such as nosocomial pneumonia.

Urban legends series: lichen planus

Oral Diseases (2012) Lichen planus (LP) is a common disorder affecting the oral cavity (OLP) and skin. Despite intensive research, LP/OLP etiology and treatment remain controversial. We investigated four controversial topics: (i) Is hepatitis C virus (HCV) infection associated with LP and involved in its pathogenesis? (ii) Should all patients with LP be screened for HCV? (iii) Should patients with OLP have all their amalgam restorations removed? (iv) Are there any new treatments for OLP? Results from extensive literature searches suggested that: (i) Robust evidence from three meta-analyses indicate that HCV is associated with LP and might be involved in OLP pathogenesis (ii) It would be prudent to screen patients with LP/OLP at significant risk with an ELISA for HCV antibodies using country-specific screening strategies (iii) There is no evidence that either OLP or oral lichenoid lesions patients would routinely benefit from having all their amalgam restorations replaced. Weak evidence from potentially very biased, small, non-randomized, unblinded studies suggests that a small fraction of patients may benefit from targeted amalgam replacement. (iv) There is weak evidence that, among new OLP treatments, topical pimecrolimus, aloe vera, and oral curcuminoids may be useful. The development of specific formulations for oral delivery of topical medications is a promising field.

The risk of skin rash and stomatitis with the mammalian target of rapamycin inhibitor temsirolimus: a systematic review of the literature and meta-analysis

OBJECTIVE

We conducted a systematic review of the literature and performed a meta-analysis to determine the risk of developing skin rash and stomatitis among patients receiving temsirolimus.

METHODS

Databases from PubMed and Web of Science from January, 1998 until June, 2011 and abstracts presented at the American Society of Clinical Oncology annual meetings from 2004 through 2011 were searched to identify relevant studies. The incidence and relative risk (RR) of skin rash and stomatitis were calculated using random-effects or fixed-effects model depending on the heterogeneity of included studies.

RESULTS

A total of 779 patients from 10 clinical trials were included in this analysis. The overall incidence of all-grade rash was 45.8% (95% confidence interval (CI): 35.6-56.3%), with a RR of 7.6 (95%CI: 4.4-13.3; p<0.001). The overall incidence of high-grade rash was 3.3% (95%CI: 1.9-5.6%), with a RR of 13.70 (95%CI: 0.82-227.50, p=0.07). The overall incidence of all-grade stomatitis was 44.3% (CI: 32.1-57.1%), with a RR of 11.10, 95%CI: 5.60-22.00; p<0.001). The overall incidence of high-grade stomatitis was 3.2% (95%CI: 1.9-5.4%), with a RR of 13.2 (95%CI: 0.80-218.50, p=0.07).

CONCLUSION

There is a significant risk of developing skin rash and stomatitis in cancer patients receiving temsirolimus. The risk is independent of underlying tumour. Adequate monitoring and early intervention are recommended to prevent debilitating toxicity and suboptimal dosing.

Pediatric supratentorial subdural empyemas: a retrospective analysis of 65 cases

AIM

Intracranial subdural empyemas (SDEs), the majority of which are supratentorial in location, are common neurosurgical emergencies in developing countries, especially in the pediatric age group. They result in significant morbidity and mortality despite improvements in neuroimaging, surgical techniques and antibiotic therapy. In the present study, we retrospectively analyze our experience with operated cases of intracranial supratentorial SDEs in the pediatric age group.

PATIENTS AND METHODS

65 pediatric patients (age <or=18 years) with supratentorial SDEs were treated in our institute between January 1988 and May 2006, and the case records analyzed with respect to clinical, radiological, bacteriological and surgical complications and outcome data.

RESULTS

There was a slight male preponderance (55%), with mean age being 9.54 +/- 6.43 years (range 3 months to 18 years). Otogenic source was the most common identifiable etiology, followed by postmeningitic and rhinogenic sources. The initial surgical intervention, burr holes (44 patients; 67.7%) and craniotomy (21 patients; 32.3%), varied with individual cases and surgeon preference. Initial craniotomy was associated with lesser repeat procedures, and slightly better clinical outcome. The majority (83.3%) of patients with significant residual requiring repeat surgery were found to have undergone burr hole evacuation initially. The mortality rate in the present series was 10.8%. Follow-up was available for 41 patients (70.7%) with an average follow-up of 10.4 months. 88% of patients showed good outcomes (Glasgow Outcome Scores of 4 or 5) at the latest follow-up.

CONCLUSION

Pediatric supratentorial SDEs, although rapidly fatal if not identified promptly, can be effectively managed with early surgical drainage (preferably craniotomy), eradication of the source, and sensitive broad-spectrum antibiotics (i.v.) with good outcomes.