Association of oral toxicity and taste changes during hematopoietic stem cell transplantation: a preliminary study

A liberalized diet does not improve caloric intake during neutropenia in patients undergoing hematopoietic stem cell transplants: A prospective randomized controlled trial

BACKGROUND

The neutropenic diet has been a long-standing approach to preventing infection in patients with hematopoietic stem cell transplants (HSCTs), although data on its efficacy are inconclusive and its restrictive nature might contribute to harm by reducing dietary intake in this patient population who typically experiences poor oral intake. The aim was to determine if a liberalized diet (LD), in comparison with a neutropenic hospital diet (ND), would improve energy intake and lessen weight loss during neutropenia in patients with HSCTs.

METHODS

A randomized controlled trial was conducted in a single-center HSCT/hematologic malignancy unit. The diet interventions were initiated when absolute neutrophil counts dropped to <500 cells/mm3; oral dietary intake was assessed during neutropenia until neutrophil recovery, which averaged 9.5 days.

RESULTS

Meal intake compliance (consuming at least 50% of meals/day) was not different between groups (LD, 47%; ND, 43%; P = 0.66). Of the 191 patients assessed (LD, n = 92; ND, n = 99), mean (SD) energy, 678 (349) vs 724 (393) kcal/d (P = 0.46), and protein, 30.3 (18.5) vs 30.4 (18.1) g/day (P = 0.89) did not differ between groups nor did weight change, 0.3 (2.5) vs 1.2 (4.1) kg (P = 0.22) during neutropenia. None vs higher than or equal to grade 1 mucositis, allogeneic vs autologous stem cell transplantation, and fewer days on intervention favored higher energy and protein intakes.

CONCLUSION

Energy intake during neutropenia did not improve with a LD encouraging fresh fruits and vegetables. Thus, alternative approaches to improving dietary intake, such as energy-dense and nutrient-dense foods with sensory characteristics acceptable to patients experiencing significant mucositis, require exploration.

Prevalence and risk factors of chemotherapy-induced taste alterations among cancer patients: A systematic review and meta-analysis

PURPOSE

Chemotherapy-induced taste alterations (CiTA) are significant predictors of gastrointestinal symptoms, malnutrition, and poor prognosis. However, the prevalence and risk factors of CiTA vary substantially between studies. This study aimed to synthesize the prevalence and risk factors of CiTA among cancer patients.

METHODS

Eight databases (Pubmed, Web of Science, Embase, ScienceDirect, Sinomed, China National Knowledge Infrastructure, Wanfang and Weipu database) were retrieved to collect observational studies regarding the prevalence or risk factors of CiTA published before June 1, 2024. The random effects meta-analysis was conducted to estimate the pooled prevalence. Subgroup analysis was conducted to identify heterogeneity across studies. For the same risk factor, the odds ratio and 95% confidence interval were calculated.

RESULTS

In total, 30 studies with 15,722 participants were included. The pooled prevalence of CiTA was 70.0% (95% CI: 59.1%-79.9%, I2 = 99.4%), ranging from 21.0% to 100.0%. Female (OR = 2.59, 95% CI: 1.59 to 4.22), patients with xerostomia (OR = 2.04, 95% CI: 1.48 to 2.81), oral mucositis/ulcers (OR = 3.72, 95% CI: 1.46 to 9.47), receiving not less than 2 chemotherapy cycles (OR = 3.95, 95% CI: 3.20 to 4.88) were more likely to develop CiTA.

CONCLUSIONS

The prevalence of CiTA among cancer patients was alarmingly high. Female, xerostomia, oral mucositis/ulcers, receiving not less than 2 chemotherapy cycles were significant risk factors of CiTA. Healthcare practitioners should identify high-risk patients and develop targeted interventions to manage CiTA based on identified risk factors.

Taste alterations after hematopoietic cell transplantation: a scoping review

PURPOSE

This review aimed to evaluate the prevalence and characteristics of dysgeusia after hematopoietic cell transplantation (HCT).

METHODS

A literature search (in PubMed, Embase.com and Web of Science) for clinical studies evaluating taste before and after HCT was performed up to June 22, 2023, in collaboration with a medical information specialist. After title and abstract review (N = 807) followed by full-text review (N = 61), articles that met the inclusion criteria were summarized in a table and synthesized narratively.

RESULTS

11 articles were analyzed in this review. All studies had a prospective design and patient populations included children (N = 3) and adults (N = 8) undergoing allogeneic or autologous HCT. Taste was assessed objectively (N = 6) and/or subjectively (N = 8) between baseline and 12 months after HCT. Before HCT, the self-reported (0-31%) and objective (2.4-10%) prevalence of dysgeusia was low. During the neutropenic phase, self-reported (20-100%) and objective (21.4%) dysgeusia was highest. In the post-engraftment period, the self-reported (18%) and objective (0-33%) prevalence of dysgeusia decreased. Different taste qualities were assessed in six studies including salt, sour, bitter, sweet, and umami.

CONCLUSIONS

Some patients undergoing HCT experience dysgeusia prior to treatment. During the neutropenic phase, they had highest complaints, with recovery occurring in the post-engraftment period. All basic tastes, except bitter, were affected. Umami and salt were most affected during treatment. These findings have implications for patient management.

Salivary flow rate, subjective oral dryness and dental caries 5 years after haematopoietic cell transplantation

BACKGROUND

The aim of this study was to describe salivary flow rate, subjective oral dryness and dental caries 5 years post haematopoietic cell transplantation (HCT).

METHODS

HCT survivors of a previous longitudinal observational cohort study in the Netherlands (the H-OME study) were invited to participate in this additional follow-up after 5 years (the HOME2 study). During the additional follow-up appointment, stimulated (SWS) and unstimulated whole saliva (UWS) was collected, participants rated subjective oral dryness on a 0 - 10 scale, and caries lesions were assessed. Furthermore, dental records, including treatments and radiographs, were requested for the 5 years preceding and the 5 years following transplantation. Paired t-tests were performed to determine changes in UWS and SWS flow rates and subjective oral dryness from pre-HCT, and to compare the number of caries-related dental treatments (restorations, endodontic treatments or extractions) before and after HCT. Hyposalivation of UWS (< 0.2 mL/min) and SWS (< 0.7 mL/min) at 3 and 12 months, was used to explore the predictive potential of hyposalivation on a high dental treatment need (> 3 treatments) over the 5 years post-HCT.

RESULTS

Five years post-HCT, 39 HCT survivors were included. The mean UWS flow rate was 0.36 mL/min (SD 0.26) and the mean SWS flow rate 1.02 (SD 0.57); survivors were diagnosed with a median of 0 dentine lesions (range 0 - 12) and 73% reported a subjective oral dryness score ≥ 1. Survivors underwent a median of 3 (range 0 - 20) dental treatments during the 5 years following transplantation. The mean difference in UWS 5 years post-HCT compared to pre-HCT was 0.03 (95% CI: -0.07 - 10.12), the mean difference for SWS was -0.18 (95% CI: -0.45 - 0.08) and for subjective oral dryness 1.2 (95% CI: 0.2 - 2.1). In the 5 years post-HCT, non-significantly more treatments were performed compared to the 5 years pre-HCT (mean difference: 0.5, 95%CI: -1.2 - 2.2). Seventy eight percent of patients with hyposalivation of SWS at 12 months had a high dental treatment need, compared with 38% with no hyposalivation.

CONCLUSIONS

Five years post-HCT, mean UWS and SWS flow rates were not significantly different from pre-HCT levels but subjective oral dryness scores were elevated.

Nutritional deficiency in patients with newly diagnosed diffuse large B-cell lymphoma Prevalence and approaches to correction

Background. Assessing nutritional status at the start of treatment for patients with diffuse large B-cell lymphoma allows us to plan adequate accompanying treatment for patients in whom early nutritional support can improve the results of antitumor treatment.

Aim. To assess the prevalence of nutritional deficiency, features of usual diet energy and protein composition in patients with diffuse large B-cell lymphoma who are starting antitumor treatment.

Materials and methods. The study included 96 adult patients (m = 61), average age 38.9 ± 16.8 years, with newly diagnosed diffuse large B-cell lymphoma of various localization and prevalence. Additional laboratory screening (total protein, albumin, C-reactive protein (CRP), total cholesterol, triglycerides, daily urea excretion), anthropometric measurements (height, body weight (BW), weight loss over 6 months, body mass index), questionnaire (considering the intake of nutrients during the previous 3 days, calculating the intake of protein and energy, nitrogen balance) were performed in all patients before the first course of antitumor treatment. GLIM (Global Leadership Initiative on Malnutrition) criteria were used to diagnose protein-energy malnutrition (PEM).

Results. In studied patients, energy intake was 27.92 ± 6.47 kcal/kg BW per day, protein 0.91 ± 0.18 g/kg BW per day, and nitrogen balance was –3.57 ± 2.94 g/day. Moderate PEM was diagnosed in 37 (38.5 %) patients. Differences in some laboratory parameters were revealed in patients with PEM and without nutritional disorders: CRP level (20.38 ± 14.69 mg/L versus 12.52 ± 5.66 mg/L; p = 0.0004), glucose (5.07 ± 1.09 mmol/L versus 4.57 ± 0.62 mmol/L; p = 0.005), total cholesterol (4.35 ± 1.27 mmol/L versus 5.36 ± 1.45 mmol/L), triglycerides (1.22 ± 0.51 mmol/L versus 2.02 ± 0.78 mmol/L; p = 0.001).

Conclusion. Moderate PEM is detected in more than a third of patients with diffuse large B-cell lymphoma who begin antitumor treatment. The leading symptom in this case is unintentional weight loss over the past 6 months. An increased CRP level, moderate hyperglycemia, and lower concentrations of total cholesterol and blood triglycerides also characterize PEM in this cohort of patients. With sufficient energy supply, the amount of protein in the natural diet of patients with PEM turned out to be low, and the nitrogen balance was negative, which in the future can lead to the development of sarcopenia and requires nutritional support.

Photobiomodulation minimizes taste changes during hematopoietic cell transplantation: A randomized clinical trial

Prevention and treatment protocols for taste changes observed during hematopoietic cell transplantation (HCT) are not well-established. The purpose of this study was to assess the efficacy of photobiomodulation (PBM) in relieving taste changes and preventing lingual papillae atrophy. HCT patients received PBM (n = 42) on the tongue dorsum using an InGaAIP laser (660 nm, 100 mW, 1.1 W/cm2, 8.8 J/cm2). During the HCT conditioning (T0), severe neutropenia (T1), and after neutrophil engraftment (T2), taste acuity for sweet, bitter, sour, and salty solutions, and clinical appearance of lingual papillae were compared with those of a placebo group (n = 43). PBM significantly reduced hypogeusia, ageusia, and parageusia at T1 and T2, and also successfully prevented papillae atrophy during all the analyzed HCT periods. In conclusion, PBM enhanced taste acuity during HCT. The decrease in papillae atrophy indicated a potential regenerative effect of this therapy on tongue mucosa.

Taste alterations in patients following hematopoietic stem cell transplantation: A qualitative study

Objective

This study aims to explore the experiences and consequences of taste alterations in patients undergoing HSCT, how they respond to these changes, and the factors that influence their responses.

Methods

In this descriptive qualitative study, face-to-face semi-structured individual interviews were conducted with 31 patients undergoing HSCT in a comprehensive hospital in Hubei, China. The interview data were transcribed and analyzed using Colaizzi's seven-step analysis. The Symptom Management Theory was applied to design the study and identify key themes.

Results

Three key themes were identified from the theory: (1) the complexity and diversity of taste experiences; (2) coping strategies; and (3) the multifaceted challenges of coping. Taste alterations in HSCT patients were characterized by diversity and dynamism. Patients employed three distinct coping styles in response to taste alterations: active coping, reluctant submission, and passive coping. These coping styles were influenced by various factors, including the specific treatment modalities of HSCT, individual patient characteristics, and the healthcare environment.

Conclusions

The experience of taste alterations among HSCT patients is intricate and varied, and the importance of addressing this symptom can easily be underestimated. Management of taste alterations is influenced by multiple factors. Nursing staff should give careful attention to taste alterations in HSCT survivors, enhance their expertise in managing taste alterations, provide robust health education, conduct regular screening and assessments, and formulate individualized intervention plans to assist patients in actively and effectively managing taste alterations.

The effect of conditioning regimen and prescribed medications on hyposalivation in haematopoietic cell transplantation (HCT) patients: an 18-month prospective longitudinal study

OBJECTIVES

Haematopoietic cell transplantation (HCT) preceded by a conditioning regimen is an established treatment option for (non)malignant haematologic disorders. We aim to describe the development of hyposalivation over time in HCT recipients, and determine risk indicators.

MATERIALS AND METHODS

A multi-centre prospective longitudinal observational study was conducted. Unstimulated (UWS) and stimulated (SWS) whole saliva was collected before HCT, early post-HCT, and after 3, 6, 12, and 18 months. The effect of type of transplantation (allogeneic vs autologous) and intensity (full vs reduced) of the conditioning regimen on hyposalivation (UWS < 0.2 mL/min; SWS < 0.7 mL/min) was explored.

RESULTS

A total of 125 HCT recipients were included. More than half of the patients had hyposalivation early post-HCT; a quarter still had hyposalivation after 12 months. The conditioning intensity was a risk indicator in the development of hyposalivation of both UWS (OR: 3.9, 95% CI: 1.6-10.6) and SWS (OR: 8.2, 95% CI: 2.9-24.6). After 3 and 12 months, this effect was not statistically significant anymore.

CONCLUSIONS

Hyposalivation affects the majority of patients early post-HCT. The conditioning intensity and the type of transplantation were significant risk indicators in the development of hyposalivation. The number of prescribed medications, total body irradiation as part of the conditioning regimen and oral mucosal graft-versus-host disease did not influence hyposalivation significantly.

CLINICAL RELEVANCE

Because of the high prevalence of hyposalivation, HCT recipients will have an increased risk of oral complications. It might be reasonable to plan additional check-ups in the dental practice and consider additional preventive strategies.

Weight loss post-allogeneic stem cell transplant is associated with increased transplant-related mortality

PURPOSE

Allogeneic stem cell transplant (allo-HSCT) patients are at risk of malnutrition and weight loss from impaired oral intake resulting from gastrointestinal toxicities, dysgeusia, and psychological effects.

METHODS

A retrospective review of 264 adult patients transplanted at Princess Margaret Cancer Centre who achieved relapse-free survival up to 3 months after allo-HSCT was performed.

RESULTS

Overall incidence of patients who experienced WL (WL) ≥ 10% from HSCT to 3-month post-transplant was 45.9% and from HSCT to 6 months was 56.6%. Patients with ≥ 10% WL from allo-HSCT at 3 months and 6 months had similar 2-year overall survival (OS) compared to those with < 10% WL, 55.7% vs 62.8% (HR = 1.38, p = 0.11) and 71.1% vs 77.2% (HR = 1.37, p = 0.27), respectively. Patients with ≥ 10% WL 3 and 6 months from allo-HSCT also had similar 2-year relapse-free survival (RFS) compared to those with < 10% WL, 48.1% vs 55.8% (HR = 1.26, p = 0.22), and 62.7% vs 69.8% (HR = 1.29, p = 0.31), respectively. The 2-year transplant-related mortality (TRM) was higher for those with ≥ 10% WL from allo-HSCT to 3 months, 35.4% vs 16.9% (HR = 2.39, p = 0.0007) and 6 months, 22% vs 8% (HR = 3.1, p = 0.0034). Although statistical significance was not observed for OS or RFS, patients who experienced ≥ 10% WL 3- and 6-months post allo-HSCT experienced higher 2-year TRM. These results highlight the importance of early intervention and close monitoring of weight post allo-HSCT.

CONCLUSION

Approaches to WL post allo-HSCT should be multifaceted and include members of the interdisciplinary team in order to decrease TRM.

The effect of hematopoietic stem cell transplantation on patient-reported subjective oral dryness: a systematic review focusing on prevalence, severity and distress

OBJECTIVE

The aim of the present systematic review is to assess the prevalence and severity of and distress caused by xerostomia over time in adult hematopoietic stem cell transplantation (HSCT) recipients.

METHODS

PubMed, Embase, and the Cochrane Library were searched for papers published between January 2000 and May 2022. Clinical studies were included if patient-reported subjective oral dryness was reported in adult autologous or allogeneic HSCT recipients. Risk of bias was assessed according to a quality grading strategy published by the oral care study group of the MASCC/ISOO, resulting in a score between 0 (highest risk of bias) and 10 (lowest risk of bias). Separate analysis focused on autologous HSCT recipients, allogeneic HSCT recipients receiving a myeloablative conditioning (MAC), and those receiving a reduced intensity conditioning (RIC).

RESULTS

Searches yielded 1792 unique records; 22 studies met the inclusion criteria. The quality scores ranged between 1 and 7, with a median score of 4. The prevalence, severity, and distress of xerostomia increased shortly after HSCT. Severity of xerostomia in allogeneic MAC recipients was higher compared to allogeneic RIC recipients 2-5 months post-HSCT (mean difference: 18 points on 0-100 scale, 95% CI: 9-27); after 1-2 years, there was no significant difference anymore.

CONCLUSION

The prevalence of xerostomia in HSCT recipients is high in comparison to the general population. The severity of complaints is raised during the first year post-HSCT. The intensity of the conditioning plays a key role in the short-term development of xerostomia, while factors affecting the recovery in the long term remain largely unknown.

A prospective study of dysgeusia and related symptoms in patients with multiple myeloma after autologous hematopoietic cell transplantation

BACKGROUND

Dysgeusia is a common but understudied complication in patients undergoing autologous hematopoietic cell transplantation (auto-HCT). We assessed the feasibility of using chemical gustometry (CG) to measure dysgeusia and explored its associations with symptom burden, nutrition, chemotherapy pharmacokinetics (PK), and the oral microbiome.

METHODS

We conducted a single-center, prospective feasibility study (NCT03276481) of patients with multiple myeloma undergoing auto-HCT. CG was performed longitudinally testing five flavors (sweet, sour, salty, bitter, umami) to calculate a total taste score (maximum score, 30). We measured caloric intake and patient-reported symptoms, assessing their correlation with oral microbiota composition and salivary and blood melphalan PK exposure.

RESULTS

Among all 45 patients, 39 (87%) completed at least four (>60%) and 22 (49%) completed all six CG assessments. Median total CG scores remained stable over time but were lowest at day +7 (27, range 24-30) with recovery by day +100. Symptom burden was highest by day +10 (area under the curve, 2.9; range, 1.0-4.6) corresponding with the lowest median overall caloric intake (1624 kcal; range, 1345-2267). Higher serum/salivary melphalan levels correlated with higher patient-reported dysgeusia and lower caloric intake. Oral microbiota α-diversity was stable early and increased slightly by day +100.

CONCLUSIONS

Assessment of dysgeusia by CG is feasible after auto-HCT. Most dysgeusia, symptom burden, and lowest caloric intake occurred during the blood count nadir. Higher melphalan concentrations correlated with more dysgeusia and poorer caloric intake. Future studies will aim to modulate melphalan exposure by PK-targeted dosing and characterize patient taste preferences to personalize diets for improved nutritional intake.

LAY SUMMARY

Taste changes after cancer treatments are very common. We used chemical gustometry (taste testing) to study taste changes and to better understand why patients with multiple myeloma experience this symptom after autologous hematopoietic cell transplantation. We found that taste testing was feasible, taste changes peaked when blood counts were lowest, and most patients recovered their taste by 100 days after transplantation. Taste changes correlated with lower food intake and with higher levels of chemotherapy in the body. Future work will focus on using personalized chemotherapy doses to reduce taste changes and to match patients' individual taste preferences with their diets.

Taste and smell disturbances in patients with chronic oral graft vs. host disease: An observational study

Background

A common complication of allogeneic hematopoietic stem cell transplantation (alloHSCT) is chronic oral graft vs. host disease (cGvHD). Oral cGvHD may present as mucosal lesions, salivary gland dysfunction, and trismus. Moreover, taste and smell ability may be affected, but the prevalence, nature and severity of altered taste and smell function, and their impact on quality of life (QoL) are understudied.

Aim

To identify the prevalence, nature, and severity of taste and smell disturbances, their impact on QoL and to assess whether altered taste/smell ability is associated with oral mucosal cGvHD or hyposalivation.

Materials and methods

AlloHSCT recipients at least 100 days post-HSCT and referred for oral cGvHD-related oral complaints were eligible for participation in this cross-sectional study. Manifestations of oral mucosal cGvHD were scored, the (un)stimulated salivary flow was measured, and objective taste and smell ability was evaluated. Subjective taste and smell alterations, and overall and oral health (OH)-related QoL were assessed.

Results

In total, 45 patients were included, of which objective reduced taste ability (hypogeusia) was identified in 68.9%; 28.9% had reduced smell ability and 11.1% had complete loss of smell. Nevertheless, only 31.1% of patients reported severe taste alterations and 22% reported moderate taste alterations indicating that not all the patients were aware of their altered taste sense. Taste/smell disturbances were not related to oral mucosal cGvHD or hyposalivation. Most alloHSCT recipients reported a decreased OH-related QoL. However, a relation between taste/smell ability and global or OH-related QoL could not be identified.

Conclusion

Taste and smell disturbances are prevalent among alloHSCT recipients. Most patients reported a decreased OH-related QoL, but the specific impact of taste and smell disturbances remains to be elucidated.

What is the relations between dysgeusia and alterations of the nutritional status? A metanarrative analysis of integrative review

BACKGROUND AND AIM

Dysgeusia is  an altered or damaged tasting perception of a multifactorial etiology, from polypharmacy, infections to chemotherapy and radiotherapy. Approximately 5% of the population suffer from a diminished taste sensation, which unfortunately remains underestimated by the affected person, creating the conditions for a dramatic underestimation of the incidence of the symptom. The aim of this study is to summarize the evidences present in literature on the relations between Dysgeusia and alterations of the nutritional status Methods: an integrative review with metanarrative analysis of the articles included was carried out in August 2020. PubMed, Scopus, Embase and CINAHL databases were examined with keywords and methodological strings. PRISMA flow-chart along with a qualitative evaluation grid (JBI-QARI) were applied in the selection of the studies with a time limitation to the last ten years.

RESULTS

10 articles resulted from the literature review process were divided into two macro-categories. Eight articles reported dysgeusia linked to weight loss. The second macro-category showed two studies relating to dysgeusia in patients with altered nutritional status associated with body weight gain.

CONCLUSIONS

this review represents an initial contribution to summarize the best evidence and knowledge in relation to dysgeusia, with the aim of enabling the identification and treatment of this symptom and facilitating targeted educational interventions.