Clinical practice guideline for the prevention of oral and oropharyngeal mucositis in pediatric cancer and hematopoietic stem cell transplant patients: 2021 update

Oral Hygiene Management of Hematologic Patients Undergoing Auto-Transplantation: An Observational Study

Background/Objectives: The present study evaluated the effectiveness of a prevention protocol involving oral hygiene, instructions, and motivation in patients eligible for hematopoietic stem cell transplantation (HSCT). Methods: Consecutive patients scheduled for HSCT were enrolled. All patients received a complete dental examination aimed at assessing periodontal health status through periodontal charting and registration of the levels of plaque and inflammation. Subsequently, patients received professional oral hygiene care and were instructed on and motivated toward oral prophylaxis prior to HSCT. Upon engraftment, patients received dedicated instructions to improve oral hygiene maneuvers. After HSCT, patients were re-evaluated for periodontal clinical parameters. The Oral Health Impact Profile-14 (OHIP-14) questionnaire was also administered to evaluate perceived oral health status. Results: Thirty-five patients (18 males and 17 females, with a mean age of 43.28 ± 11.73 years) were enrolled. An overall improvement was noted in periodontal parameters. However, despite plaque reduction, inflammation was still present because of the treatment. The OHIP-14 score slightly worsened after HSCT. Conclusions: Professional oral hygiene and prophylaxis proved effective in improving the oral health status of patients undergoing HSCT, potentially impacting post-treatment outcomes. Further assessment is needed to validate these results.

Managing strategies of chemotherapy and radiotherapy-induced oral mucositis

Radiotherapy and chemotherapy are widely employed as primary non-surgical cancer treatments; however, their non-selective cytotoxicity often leads to adverse events such as oral mucositis (OM), particularly in head and neck cancer therapies. International guidelines provide recommendations for managing chemoradiotherapy-induced OM in various clinical contexts. Subsequently, emerging researches have introduced evidence supporting novel approaches or existing regimens for OM prevention and treatment. The repurposing of established drugs has garnered significant interest due to its shorter development timeline, improved safety profiles, and lower costs compared to new drug development. For example, clinical trials assessing established drugs such as melatonin, clonidine, and pentoxifylline indicate promising potential for managing OM. Additionally, several emerging pharmacological interventions have demonstrated considerable efficacy; SAMITAL and rhIL-11 are supported by phase II clinical trials and prospective studies, while probiotics like Streptococcus salivarius K12 and curcumin have shown effectiveness in randomized clinical trials. Furthermore, recent high-level studies have reinforced the efficacy of non-pharmacological interventions, such as photobiomodulation (PBM) and cryotherapy, over the past two years. In all, given the evidence supporting different strategies, PBM and oral cryotherapy are highly recommended for managing OM when feasible. Topical clonidine, melatonin, oral pentoxifylline, topical SAMITAL or rhIL-11, oral SsK12, and curcumin may also be utilized but would benefit from validation in larger trials. Besides, Verbascoside, Palifermin, Amifostine, and Avasopasem manganese can be suggested for OM management, while the side effects should be monitored. The accessibility and cost/effectiveness of specific managing strategies of OM should be considered when selecting appropriate options.

Potentiality of Curcumin Against Radio-Chemotherapy Induced Oral Mucositis: A Review

In recent era, cancer is a major global health hazard and is mostly treated with either radio or chemotherapy. The above treatment procedure induces a secondary concern named as oral mucositis (OM). The disorder OM is specifically associated with oral mucosa and leads to bleeding, pain, difficulty in swallowing of solids, as well as fluids and speech difficulty. Curcumin is explored for prevention as well as treatment of OM. The article was organized via collection of enormous literatures by using the keywords like oral mucositis, chemotherapy, anti-inflammatory, curcumin, and clinical trials from search engines of different domains like Scopus, PubMed/MEDLINE, Science Direct, and Google Scholar with an increasing order of their year of publications. A numerous antineoplastic therapies resulted OM, as a devastating side effect. Moreover, the expanded pathogenesis of the disease permits a sound predictability over the patient's risk, thereby directing its adaptability and management protocols towards the achievement of novel therapeutics. An augmented interest towards curcumin as a potential therapeutic emerged because of its easy accessibility, antioxidant, anti-inflammatory, antiulcer, antimicrobial, and wound-healing abilities along with reduced side effects. Curcumin can potentially alter OM and OM-induced weight loss but showed a great heterogeneity.

Graphical Abstract

Photobiomodulation Therapy in the Prevention of Chemotherapy Induced Oral Mucositis in Children with Acute Myeloid Leukemia: A Randomized, Double-blind, Clinical trial

BACKGROUND

Many preventive modalities have been advocated to reduce the incidence and severity of chemotherapy-induced Oral Mucositis (OM). Photobiomodulation, also known as Low-Level laser. Therapy, has shown promising results. This clinical trial was performed to evaluate the effectiveness of Photobiomodulation (PBM) for the prevention of chemotherapy-induced oral mucositis (OM) in children with Acute Myeloid Leukemia (AML).

PATIENTS AND METHODS

A double-blinded randomized clinical trial was performed, including forty-two children diagnosed with Acute Myeloid Leukemia (AML) admitted to receiving chemotherapy (CT) at Children's Cancer Hospital 57357, Cairo, Egypt. Patients were randomly assigned to either the control or test group. Both groups followed the standard preventive protocol for oral mucositis. In the control group I sham therapy, while in the Laser group I had Photobiomodulation sessions for five consecutive days once a day performed by Diode laser (Sirrolaser Blue ™, USA) 660nm, 15watt, 10 s. Laser sessions began on day 1 of chemotherapy and were repeated on days 2,3, 4, and 5. The response to both groups was evaluated according to the development of oral mucositis; graded using the classification criteria of the World Health Organization (WHO) and the National Cancer Institute scale (NCI - Common Terminology Criteria for Adverse Events, version 4.0). Incidence of oral mucositis was evaluated from baseline to 5, 12, 19, and 30 days after treatment.

RESULTS

A clinical significant difference between the laser and control group was observed. The laser group showed a higher prevalence of no oral mucositis with decreased incidence of OM, while on day 12, the control group showed a higher prevalence of grades I and II (P-value <0.001, effect size = 0.796). However, the laser group showed higher prevalence of mucosa free of OM; on day 19, the control group showed higher rates of grades II and III, (P-value <0.001, effect size = 0.670). while on day 30 there was higher rates of grades I and II (P-value <0.001, effect size = 0.576) with higher rates of healthy oral mucosa in the laser group.

CONCLUSION

Photobiomodulation effectively reduces the incidence and severity of chemotherapy-induced oral mucositis in pediatric patients diagnosed with AML.

Interventions to reduce the risk of side-effects of cancer treatments in childhood

INTRODUCTION

Childhood cancers as a group affect around 1 in 500 children but each individual diagnosis is a rare disease. While research largely focuses on improving cure rates, the management of side effects of treatment are high priority for clinicians, families and children and young people.

AREAS COVERED

The prevention and efficient management of infectious complications, oral mucositis, nausea and vomiting and graft-vs-host disease illustrated with examples of implementation research, translation of engineering to care, advances in statistical methodologies, and traditional bench-to-patient development. The reviews draw from existing systematic reviews and well conducted clinical practice guidelines.

EXPERT OPINION

The four areas are driven from patient and family priorities. Some of the problems outlined are ready for proven interventions, others require us to develop new technologies. Advancement needs us to make the best use of new methods of applied health research and clinical trial methodologies. Some of the greatest challenges may be those we're not fully aware of, as new therapies move from their use in adult oncological practice into children. This will need us to continue our collaborative, multi-professional, multi-disciplinary and eclectic approach.

Effectiveness of cryotherapy in preventing oral mucositis in pediatric cancer patients in Jordan: a randomized controlled trial

PURPOSE

The study aimed to evaluate the effectiveness of cryotherapy in preventing oral mucositis in pediatric patients receiving chemotherapy.

METHODS

An evidence-based practice project utilized a randomized control trial design with two groups (experimental and control groups). Fifty-nine pediatric patients with cancer in Jordan, aged 8-18 years, were randomly assigned to the experimental group (n=29) or the control group (n=30). The intervention was conducted from June 2022 to December 2022. The severity of oral mucositis among pediatric cancer patients was assessed using the World Health Organization oral mucositis grade.

RESULTS

There were no significant differences in sex or disease type among the groups. On days 7, 14, and 21, we observed notable between-group differences in treatment responses and the intensity of oral mucositis, highlighting the efficacy of cryotherapy in diminishing the severity of oral mucositis.

CONCLUSION

This study supports the use of cryotherapy as a preventive measure for oral mucositis among pediatric oncology patients in Jordan. The findings suggest that cryotherapy effectively reduces the severity of oral mucositis. Further research is necessary to investigate the broader impacts of cryotherapy.

Enhancing Standardized Practices for Oral Mucositis Prevention in Pediatric Hematopoietic Stem Cell Transplantation: A Best Practice Implementation Project

Background

Oral mucositis (OM) poses a significant challenge in children undergoing hematopoietic stem cell transplantation (HSCT). There is a gap between clinical practice and the evidence, and nursing practices is not standardized.

Objective

This study aims to evaluate the effectiveness of applying the evidence for preventing HSCT chemotherapy-induced OM in children and to elevate the nurses' compliance to the evidence.

Methods

Following the clinical evidence practice application model of the Joanna Briggs Institute (JBI) evidence-Based Care Center. The process included reviewing literature, extracting evidence, identifying gaps, developing audit criteria, conducting a baseline audit, creating an action plan, implementing evidence-based interventions, and assessing outcomes.

Results

After the evidence implementation, 6 out of 12 audit criteria with poor compliance are significantly improved, with statistically significant differences (P<0.05). The incidence of OM decreases, with a statistically significant difference (66.6% vs 36.7%, P=0.02). The incidence of grade I, II, III, and IV OM also decreases (30% vs 23.3%, 23.3% vs 13.4%, 10% vs 0%, and 3.3% vs 0%). Ultimately, the standardized oral care practice routine and workflows to prevent OM were established.

Conclusion

Bridging the gap between evidence and clinical practice can standardize nurse behavior, decrease the incidence of OM, and lower the OM severity in children undergoing HSCT.

Enteral Nutritional Therapy in Pediatric Autologous Transplantation: A Descriptive Cohort Study

Introduction: Pediatric hematopoietic stem cell transplantation requires individualized nutritional therapy, and the use of early enteral nutrition is beneficial. This study aims to analyze the use of enteral nutrition therapy in pediatric patients undergoing autologous transplantation. Methods: This is a descriptive cohort study conducted with data from electronic medical records of pediatric patients undergoing autologous transplantation from 2017 to 2022, using enteral nutrition. Nutritional and clinical variables and biochemical markers were assessed at four time points: day 0, day +5, day +10 and day +15. Results: The sample consisted of 50 patients. On average, the nasoenteral tube was inserted on D-4 and the enteral feeding started on D-3. On D0, most patients used a normocaloric polymeric enteral formula, but on D + 10, when diarrhea (p = 0.017) and mucositis (p < 0.001) worsened, the most commonly used enteral formula was a hypocaloric pediatric semi-elemental formula. On D + 15, 35% of patients were receiving parenteral nutrition. At discharge, the patient's nutritional status had worsened compared to admission (p < 0.001). Discussion: Early use of enteral nutrition was observed, as adopted in other transplant centers and recommended in the literature. Protocols and guidelines are needed to support enteral nutritional therapy in pediatric transplantation.

Recent advances in cancer therapy-associated oral mucositis

Oral mucositis (OM) is a common and debilitating toxicity of cancer treatments - chemotherapy, radiotherapy, hematopoietic cell transplant, or combinations. OM is associated with severe oral pain and has negative impacts on patient function and quality of life. Additionally, OM has accompanying systemic complications that may have critical implications. These local and systemic consequences can alter cancer treatment, and add an economic burden. This review covers the clinical presentation and course of OM, differential diagnosis, clinical and economic impacts, pathogenesis, risk factors, assessment measures, biomarkers and prediction of OM, management, research advances in the development of new drugs and treatments, and big data.

Implementation of a light therapy team to administer photobiomodulation therapy: A standardized protocol to prevent and treat oral mucositis in the pediatric hematopoietic stem cell transplant population

BACKGROUND

Oral mucositis (OM) is a painful and common complication of hematopoietic stem cell transplant (HSCT). The Children's Oncology Group recently published guidelines recommending photobiomodulation (PBM) for preventing and treating OM in pediatric HSCT patients. However, this is a rarely used intervention in pediatric hospitals.

PROCEDURE

Patients undergoing allogeneic HSCT, or autologous HSCT for a neuroblastoma diagnosis, had PBM administered from the first day of conditioning to transplant Day +20. We successfully developed a standardized treatment protocol and workflow to ensure consistent and uniform delivery of PBM. In addition, clinical patient data were compared before and after PBM implementation.

RESULTS

The administration of PBM at our center was feasible, but required dedicated staff. A registered nurse (RN) was determined to be the best fit to deliver PBM. Sixty-two patients received PBM from October 2022 to September 2023; patients from 2021 before PBM implementation were used for comparison. Patients receiving PBM were more likely (p = .03) to engage in teeth brushing (56/62 = 90%) compared to baseline (61/81 = 75%). Mean days of OM decreased from 11.3 to 9 days; patients who received PBM were less likely (p < .001) to be discharged on total parental nutrition (TPN) (11/62 = 18%) compared to baseline (50/82 = 61%). OM-related supportive care costs (TPN and patient-controlled anesthesia [PCA]) were lower (p = .02) for those who received PBM (median cost = $31,229.87 vs. $37,370.66).

CONCLUSION

PBM, as the standard of care in the pediatric HSCT population, is safe, feasible, and well-tolerated. At our center, a dedicated RN was critical to providing standardized treatment and ensuring sustainability.

Oral Mucositis Management in Children under Cancer Treatment: A Systematic Review

Children undergoing antineoplastic treatment often present severe side effects due to the dosage and duration of treatments, with oral mucositis emerging as one of the most prevalent and painful inflammatory conditions. There is a growing body of evidence on therapeutic interventions such as cryotherapy, low-level laser therapy, and natural compounds for this condition. The aim of this systematic review was to identify and compare therapies for the management of cancer treatment-induced oral mucositis in pediatric patients. From 2655 articles obtained in initial searches, 39 articles were considered in this systematic review, after applying inclusion/exclusion criteria. Low-level laser therapy, palifermin, honey, and zinc demonstrated reductions in oral mucositis incidence, duration, severity, and pain reported by the patient. Although there are several therapies in place for the prevention and treatment of oral mucositis in children, evidence of their efficacy is still inconclusive to establish accurate clinical protocols.

Utilization of Photobiomodulation for the Prevention and Treatment of Oral Mucositis

Background: Oral mucositis is a significant and common toxicity experienced by patients who receive high-dose chemotherapy as a preparatory regimen for a hematopoietic cell transplant (HCT). Photobiomodulation (PBM) has been found to be feasible with significant efficacy in preventing the progression of oral mucositis in adult patients undergoing HCT. The purpose of this study was to determine the feasibility and efficacy of PBM in pediatric oncology patients undergoing HCT. Method: Forty children and adolescents admitted to the transplant unit for an allogeneic HCT for acute lymphoblastic leukemia or acute myeloid leukemia were treated daily at six sites until day + 20 or engraftment. Results: There were 1,035 patient encounters, with successful treatment of four or more sites during 979 patient encounters for a feasibility 93.3% CI [0.926, 0.039]. We had estimated a meaningful effect size of 20% for PBM and estimated 51% of patients treated with PBM would have at least one day or more of Grade 3 mucositis. The rate of patients who received PBM and developed Grade 3 mucositis was 20% CI [0.091, 0.356]. Patients treated with PBM had fewer days of hospitalization (p = .009) and less severe mucositis in comparison to the matched control group (p = .03). Conclusion: PBM is feasible and effective in preventing and treating oral mucositis and is now supported by the Children's Oncology Group for prevention and treatment of oral mucositis in patients undergoing an allogeneic HCT or receiving head/neck radiation.

Cryotherapy for oral mucositis in cancer: review of systematic reviews and meta-analysis

BACKGROUND

One of the most common side effects of cancer treatment is oral mucositis. Although studies have shown that oral cryotherapy has a favourable effect on oral mucositis, the reliability of the results is questionable.

OBJECTIVE

The goal of this umbrella review was to provide insight into the effects of oral cryotherapy against oral mucositis in patients with cancer, as well as to assess the certainty of this evidence.

METHOD

Studies were searched for through PubMed, Scopus and Web of Science, with no restrictions until August 2021. The risk ratio (RR) and 95% CI for each meta-analysis were recalculated using a random-effects model, and the certainty of the evidence was judged using Grading of Recommendations Assessment, Development and Evaluation.

RESULTS

Ten meta-analyses including 25 original RCTs that fit our inclusion criteria were included. The use of oral cryotherapy markedly reduced the occurrence of overall (RR 0.72, 95% CI 0.64 to 0.83, n=20 trials), moderate to severe (RR 0.60, 95% CI 0.45 to 0.80, n=16 trials) and severe oral mucositis (RR 0.48, 95% CI 0.34 to 0.67, n=16 trials), as well as average severity score of oral mucositis (standardised mean difference=-0.94, 95% CI -1.28 to -0.59, n=4 trials) in comparison to a control group; however, the certainty of evidence for all outcomes was rated very low.

CONCLUSION

In patients with cancer, oral cryotherapy appears to greatly lower the severity and occurrence of oral mucositis, but, with very low certainty of evidence.

Effectiveness of Nutrition Support Team Intervention in Pediatric Patients with Cancer

Malnutrition in children with cancer is associated with poor prognosis. This study aimed to determine whether nutritional support team (NST) interventions prevent adverse events and improve the nutritional status in pediatric patients admitted for cancer treatment. This was a historical cohort study of pediatric patients with acute lymphocytic leukemia, acute myeloid leukemia, neuroblastoma, or brain tumor who received chemotherapy or underwent hematopoietic stem cell transplantation. Patients admitted between June 2013 and October 2014 were classified into the intervention group. Those admitted between January 2011 and December 2012 were classified into the control group. We created a homogeneous probability model using the inverse probability of treatment weighting method, and compared outcomes. A total of 75 patients were included in the study (38 and 37 in the intervention and control groups, respectively). The intervention group had significantly fewer incidents of nothing by mouth (nil per os [NPO]) (p=0.037) and days of NPO (p=0.046) than the control group. There was no significant difference between the intervention and control groups regarding the change in body mass index z-score between admission and discharge (p=0.376). NST interventions for children with cancer were associated with a reduction in the number of NPO occurrences and NPO days. These findings suggest that NST interventions contribute to continued oral intake.

Mechanisms and Potential Clinical Implications of Oral Microbiome in Oral Squamous Cell Carcinoma

Microorganisms in the oral cavity are abundant in the human body. At present, more than 700 species of oral microorganisms have been identified. Recently, a lot of literature has indicated that the oral microbiota plays an important role in the occurrence, development, and prognosis of oral squamous cell carcinoma (OSCC) through various mechanisms. And researchers are now trying to utilize oral microbiota in cancer diagnosis and treatment. However, few articles systematically summarize the effects of oral microbes in the diagnosis, treatment, and disease outcomes of oral cancer. Herein, we made a summary of the microbial changes at cancerous sites and placed more emphasis on the mechanisms by which the oral microbiome promotes cancerization. Moreover, we aimed to find out the clinical value of the oral microbiome in OSCC.

Bibliometric Analysis to Global Research Status Quo on Photobiomodulation

Background: Photobiomodulation (PBM) becomes a remedial technology with growing popularity. The primary goal of this article is to conduct a PBM literature review, providing an overall systematic understanding of current and future trends. Methods: A dataset was made with topic retrieval, concerning PBM research retrieved from the Web of Science Core Collection. We analyzed to forecast research frontiers in this field using the softwares: VOSviewer, CiteSpace, and Biblioshiny. Results: Four thousand five hundred thirty pieces of literature were retrieved from our database. Current trends were characterized by keywords of "light," "spinal cord injury," "skeletal muscle," and so on. Future trends were characterized probably by six cutting-edge terms: "wound healing," "pain," "oral mucositis," "Alzheimer's disease," "Parkinson's disease," and "orthodontics." Conclusions: This study finds that the inadequacy of in-depth reliable interpretation of current clinical data calls for molecular biological mechanisms together with well-designed, large-sample, multicenter clinical trials. The study of oral, wound, and neural-related mechanisms and the exploration of therapeutic effects may be the popular trend at present and in the next few years.

Monte Carlo based dosimetry of extraoral photobiomodulation for prevention of oral mucositis

Photobiomodulation therapy (PBMT) is recommended for prevention and treatment of oral mucositis, a painful condition that occurs in cancer patients. Intraoral PBMT is limited to treating distal oral mucosa and oropharynx. Extraoral PBMT may provide a more efficient intervention. The goal of this study was to develop a clinically viable protocol for extraoral PBMT. Monte Carlo modeling was used to predict the distribution of 850 nm light for four treatment sites, using anatomical data obtained from MRI and optical properties from the literature. Simulated incident light power density was limited to 399 mW/cm2 to ensure treatment safety and to prevent tissue temperature increase. The results reveal that total tissue thickness determines fluence rate at the oral mucosa, whereas the thickness of individual tissue layers and melanin content are of minor importance. Due to anatomical differences, the fluence rate varied greatly among patients. Despite these variations, a universal protocol was established using a median treatment time methodology. The determined median treatment times required to deliver efficacious dose between 1 and 6 J/cm2 were within 15 min. The developed PBMT protocol can be further refined using the combination of pretreatment imaging and the Monte Carlo simulation approach implemented in this study.

Children's Oncology Group's 2023 blueprint for research: Cancer control and supportive care

The objective of the Cancer Control and Supportive Care (CCL) Committee in the Children's Oncology Group (COG) is to reduce the overall morbidity and mortality of therapy-related toxicities in children, adolescents, and young adults with cancer. We have targeted five major domains that cause clinically important toxicity: (i) infections and inflammation; (ii) malnutrition and metabolic dysfunction; (iii) chemotherapy-induced nausea and vomiting; (iv) neuro- and oto-toxicty; and (v) patient-reported outcomes and health-related quality of life. Subcommittees for each domain prioritize randomized controlled trials and biology aims to determine which strategies best mitigate the toxicities. The findings of these trials are impactful, informing clinical practice guidelines (CPGs) and directly leading to changes in the standard of care for oncology practice. With the development of new therapies, there will be new toxicities, and the COG CCL Committee is dedicated to developing interventions to minimize acute and delayed toxicities, lessen morbidity and mortality, and improve quality of life in pediatric and young adult patients with cancer.

Protective effect of cryotherapy against oral mucositis among allogeneic hematopoietic stem cell transplant recipients using melphalan-based conditioning

PURPOSE

Oral cryotherapy is an effective method to prevent oral mucositis (OM) induced by chemotherapeutic agents, such as melphalan (Mel). However, there is limited data about cryotherapy in allogeneic hematopoietic stem cell transplantation (allo-HSCT) recipients; thus, the current study aimed to examine the efficacy of cryotherapy among allo-HSCT recipients treated with Mel-containing regimens.

METHODS

Medical records of 78 consecutive allo-HSCT recipients were retrospectively analyzed. Baseline characteristics and clinical courses between the patients who received cryotherapy (cryotherapy group, n = 42) and those who did not (control group, n = 36) were compared, especially focusing on methotrexate (MTX) use as a part of graft-versus-host disease (GVHD) prophylaxis.

RESULTS

Binary logistic regression analysis revealed that a higher dose of Mel (OR, 3.82; 95%CI, 1.085-13.46; P = 0.037) or MTX use (OR, 7.61; 95% CI, 2.41-23.97; P < 0.001) was associated with the incidence of OM. MTX use was also significantly associated with the duration of OM (β = 0.515; 95% CI, 9.712-21.636; P < 0.001). Among 31 patients without MTX use, cryotherapy was associated with a significant reduction of OM development (0% in the cryotherapy group vs 35% in the control group, P = 0.021). We did not find such an association in 47 patients with MTX use.

CONCLUSION

Cryotherapy was useful to prevent the incidence of OM in allo-HSCT recipients in the cases without MTX for GVHD prophylaxis.

The Critical Exploration into Current Evidence behind the Role of the Nutritional Support in Adult Patients Who Undergo Haematogenic Stem Cell Transplantation

Haematopoietic stem cell transplantation (HSCT) is a treatment option for many haematological conditions in patients of all ages. Nutritional support is important at each stage of treatment, but particular nutritional needs and dictated support occur during the preparatory (conditioning regimen) and post-transplant periods. Patients may require nutritional treatment by the enteral or parenteral route. The quantitative and qualitative composition of meals may change. Vitamin requirements, including vitamin D and vitamin C, might also be different. An adequately composed diet, adapted to the needs of the patient, may influence the occurrence of complications such as graft-versus-host disease (GvHD), gastrointestinal disorders, infections, and reduced survival time. Haematological diseases as well as transplantation can negatively affect the intestinal flora, with negative consequences in the form of mucosal inflammation and disorders of a functional nature. Currently, aspects related to nutrition are crucial in the care of patients after HSCT, and numerous studies, including randomized trials on these aspects, are being conducted. This study serves the critical analysis of current scientific evidence regarding nutritional support for patients after HSCT.

Rethinking Antigen Source: Cancer Vaccines Based on Whole Tumor Cell/tissue Lysate or Whole Tumor Cell

Cancer immunotherapies have improved human health, and one among the important technologies for cancer immunotherapy is cancer vaccine. Antigens are the most important components in cancer vaccines. Generally, antigens in cancer vaccines can be divided into two categories: pre-defined antigens and unidentified antigens. Although, cancer vaccines loaded with predefined antigens are commonly used, cancer vaccine loaded with mixed unidentified antigens, especially whole cancer cells or cancer cell lysates, is a very promising approach, and such vaccine can obviate some limitations in cancer vaccines. Their advantages include, but are not limited to, the inclusion of pan-spectra (all or most kinds of) antigens, inducing pan-clones specific T cells, and overcoming the heterogeneity of cancer cells. In this review, the recent advances in cancer vaccines based on whole-tumor antigens, either based on whole cancer cells or whole cancer cell lysates, are summarized. In terms of whole cancer cell lysates, the focus is on applying whole water-soluble cell lysates as antigens. Recently, utilizing the whole cancer cell lysates as antigens in cancer vaccines has become feasible. Considering that pre-determined antigen-based cancer vaccines (mainly peptide-based or mRNA-based) have various limitations, developing cancer vaccines based on whole-tumor antigens is a promising alternative.

Clinical use of photobiomodulation for the prevention and treatment of oral mucositis: the real-life experience of MASCC/ISOO members

AIM

To assess clinical use and patient outcome of photobiomodulation (PBM) for oral mucositis (OM) prevention and treatment among specialized practitioners.

METHODS

A poll was emailed to the members of the Mucositis Study Group of MASCC/ISOO. The PBM parameters used by the respondents were analyzed using exploratory statistical methods to identify combinations of PBM parameters (patterns) that characterize the variance in the protocols (principal component analysis).

RESULTS

Responses were received from 101 MSG members, with 78 providing analyzable data. Most of the responders were dental practitioners or oral medicine specialists. PBM was used by 59% of the responders for OM or targeted therapy stomatitis. Technical parameters varied widely. Most responders used wavelengths ∼650 nm intra-orally. The spot-size and distance from the tissue were the main factors driving the variation. All PBM users noted that PBM relieved pain, either immediately or a delayed effect. High likelihood of pain relief (measured as responder's report of pain relief in 67-100% of patients) was reported by 22% and 19% of PBM users for immediate pain relief and delayed pain relief, respectively. The most common reported barriers to using PBM were financial considerations, time constraints, lack of training or experience and concern about the potential for malignant transformation or increased risk of cancer recurrence.

CONCLUSIONS

The use of PBM for OM prevention or treatment is in early phases of adoption in practices, facing some obstacles to implement it. A wide variation in technical parameters was found. Nonetheless, responses indicate that PBM provided pain relief.

Interventions for the Prevention of Oral Mucositis in Patients Receiving Cancer Treatment: Evidence from Randomised Controlled Trials

Oral mucositis is a common and most debilitating complication associated with cancer therapy. Despite the significant clinical and economic impact of this condition, there is little to offer to patients with oral mucositis, and the medications used in its management are generally only palliative. Given that mucositis is ultimately a predictable and, therefore, potentially preventable condition, in this study we appraised the scientific literature to evaluate effective methods of prevention that have been tested in randomised controlled trials (RCTs). Published high-level evidence shows that multiple preventative methods are potentially effective in the prevention of oral mucositis induced by radiotherapy, chemotherapy, or both. Anti-inflammatory medications (including benzydamine), growth factors and cytokines (including palifermin), cryotherapy, laser-and-light therapy, herbal medicines and supplements, and mucoprotective agents (including oral pilocarpine) showed some degree of efficacy in preventing/reducing the severity of mucositis with most anticancer treatments. Allopurinol was potentially effective in the prevention of radiotherapy-induced oral mucositis; antimicrobial mouthwash and erythropoietin mouthwash were associated with a lower risk of development of severe oral mucositis induced by chemotherapy. The results of our review may assist in highlighting the efficacy and testing the effectiveness of low-cost, safe preventative measures for oral mucositis in cancer patients.

A Novel Oncodental Collaborative Team: Integrating Expertise for Central Line-Associated Bloodstream Infection Prevention in Pediatric Oncology Patients

PURPOSE

Pediatric oncology and bone marrow transplant patients are at high risk of infection, and limitations to dental expertise among medical providers render patients vulnerable to central line-associated bloodstream infections from oral pathogens. Traditionally, oral health maintenance relied on patients and bedside nurses; however, routine methods are often suboptimal to prevent central line-associated bloodstream infection in high-risk patients. Limited overlap of medical and dental expertise, and limited dental resources in typical oncology units, prevent optimal oral care for children with cancer, requiring novel solutions to better integrate specialties.

METHODS

Here, we outline the creation of a novel Pediatric oncodental team to address oral-systemic infection prevention strategies for high-risk patients.

RESULTS

Our oncology and dental teams created a systematic approach for increasing oral surveillance and treatment in select high-risk patients. Supervised pediatric dental residents participated in scheduled oncology rounds, and a permanent oral health educator with a background in dental hygiene was also hired as a dedicated dental professional within our oncology department.

CONCLUSION

Our pediatric oncodental team aims to sustain optimal oral complication prevention strategies to reduce the risk of infection, provide education on the significance of the oral-systemic link in cancer care, and improve access and continuity of care.

Randomized cross-over study investigating the tolerability and side effects of an intra-oral air-cooling device compared to ice in healthy volunteers

Oral cryotherapy (OC) is a common preventive treatment of oral mucositis (OM) and is recommended in international guidelines. Ice and air OC have previously been shown to result in temperature reductions of 8.1-12.9 °C, and 14.5 °C, respectively, in healthy volunteers. However, no direct comparison between these two modalities has been performed. The primary aim was to investigate the tolerability and side effects of air OC using an intra-oral air-cooling (IOAC) device compared with ice OC. The secondary aim was to evaluate the temperature reduction in the mouth for the two respective methods. Cross-over study with randomization to order of treatment, in 15 healthy volunteers. We evaluated the self-reported intensity, frequency, and discomfort for 13 pre-defined side effects used in previous studies. All participants were able to complete both OC sessions, although one participant required reduced airflow in the air OC arm. The subjects reported more discomfort from being cold, having sensitive teeth, and numbness in the ice OC group, while they reported more discomfort from swallowing when subjected to air OC. No significant difference in the median temperature reduction was detected in the two modalities, except for the dorsal posterior part of the tongue where temperature reduction was larger in the ice OC group. We found that oral cooling using a new IOAC device was tolerated and seems to be safe in healthy volunteers.

High morbidity and mortality associated with primary bloodstream infections among pediatric patients with cancer at a Guatemalan tertiary referral hospital

Infectious complications remain major contributors to adverse outcomes in patients treated for non-communicable disease, particularly in resource limited settings. We performed a 5-year retrospective study of primary bloodstream infections at a dedicated pediatric oncology center in Guatemala. Two hundred and twelve episodes occurring in 194 unique patients qualified for inclusion. Patients required intensive care unit admission in 55% of episodes and death occurred in 24% of episodes. Despite subspecialty support in infectious diseases, poor outcomes, including prolonged hospitalization and mortality, were frequent. Our findings suggest that investments in laboratory and clinical data collection are critical to understanding the contributors to poor outcomes and therefore to improving the quality of bloodstream infection management in resource limited settings.

Use of Honey in the Management of Chemotherapy-Associated Oral Mucositis in Paediatric Patients

Background

Oral mucositis (OM) is a critical condition during chemotherapy in both adult and child cancer patients. Paediatric cancer patients have a higher prevalence of OM than adult cancer patients. Honey is a natural product that has been reported to have the best tissue healing properties. The present mini-review focused on the evaluation of the effectiveness of oral care with honey products in the treatment and prophylaxis of chemotherapy-induced OM in child patients.

Methods

A network of electronic English databases including CINAHL, CENTRAL, EMBASE, MEDLINE and PubMed, were used for primary search from April 2010 to April 2020. We have also considered data collected from ClinicalTrials.gov, Web of Science and Google Scholar. PRISMA software was used to build collective data. Controlled trials were included in this review and were critically appraised by Down and Black. The narrative synthesis was performed.

Results

A total number of 346 data of children and adolescents with cancer were considered in this short review. All patients were from three randomized controlled trial articles and two were non-randomised controlled trial articles. Based on the evidence so far revealed, honey may show an effect in the treatment and prophylaxis of OM. The analysis of collected data revealed that the probability value P<0.05. The honey enhanced recovery time and severity of OM were significantly compared with those without honey treatment receiving group of pediatric patients.

Conclusion

Honey not only has been shown to have the capability for healing injured tissues but it is also a more economical treatment, and it has fewer side effects compared to synthetic drugs. Honey or honey products can prevent chemotherapy-induced OM (CIOM) and be the best treatment to grade I, II and III CIOM. However, it is disappointing that studies involving children as patients were few, and limited data available so far.

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Photobiomodulation therapy in management of cancer therapy-induced side effects: WALT position paper 2022

Disclaimer

This article is based on recommendations from the 12th WALT Congress, Nice, October 3-6, 2018, and a follow-up review of the existing data and the clinical observations of an international multidisciplinary panel of clinicians and researchers with expertise in the area of supportive care in cancer and/or PBM clinical application and dosimetry. This article is informational in nature. As with all clinical materials, this paper should be used with a clear understanding that continued research and practice could result in new insights and recommendations. The review reflects the collective opinion and, as such, does not necessarily represent the opinion of any individual author. In no event shall the authors be liable for any decision made or action taken in reliance on the proposed protocols.

Objective

This position paper reviews the potential prophylactic and therapeutic effects of photobiomodulation (PBM) on side effects of cancer therapy, including chemotherapy (CT), radiation therapy (RT), and hematopoietic stem cell transplantation (HSCT).

Background

There is a considerable body of evidence supporting the efficacy of PBM for preventing oral mucositis (OM) in patients undergoing RT for head and neck cancer (HNC), CT, or HSCT. This could enhance patients’ quality of life, adherence to the prescribed cancer therapy, and treatment outcomes while reducing the cost of cancer care.

Methods

A literature review on PBM effectiveness and dosimetry considerations for managing certain complications of cancer therapy were conducted. A systematic review was conducted when numerous randomized controlled trials were available. Results were presented and discussed at an international consensus meeting at the World Association of photobiomoduLation Therapy (WALT) meeting in 2018 that included world expert oncologists, radiation oncologists, oral oncologists, and oral medicine professionals, physicists, engineers, and oncology researchers. The potential mechanism of action of PBM and evidence of PBM efficacy through reported outcomes for individual indications were assessed.

Results

There is a large body of evidence demonstrating the efficacy of PBM for preventing OM in certain cancer patient populations, as recently outlined by the Multinational Association for Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO). Building on these, the WALT group outlines evidence and prescribed PBM treatment parameters for prophylactic and therapeutic use in supportive care for radiodermatitis, dysphagia, xerostomia, dysgeusia, trismus, mucosal and bone necrosis, lymphedema, hand-foot syndrome, alopecia, oral and dermatologic chronic graft-versus-host disease, voice/speech alterations, peripheral neuropathy, and late fibrosis amongst cancer survivors.

Conclusions

There is robust evidence for using PBM to prevent and treat a broad range of complications in cancer care. Specific clinical practice guidelines or evidence-based expert consensus recommendations are provided. These recommendations are aimed at improving the clinical utilization of PBM therapy in supportive cancer care and promoting research in this field. It is anticipated these guidelines will be revised periodically.

Natural Products for the Prevention and Treatment of Oral Mucositis-A Review

Cancer, a major world public health problem, is associated with chemotherapy treatments whose administration leads to secondary concerns, such as oral mucositis (OM). The OM disorder is characterized by the presence of ulcers in the oral mucosa that cause pain, bleeding, and difficulty in ingesting fluids and solids, or speaking. Bioactive compounds from natural sources have arisen as an effective approach for OM. This review aims to summarize the new potential application of different natural products in the prevention and treatment of OM in comparison to conventional ones, also providing a deep insight into the most recent clinical studies. Natural products, such as Aloe vera, Glycyrrhiza glabra, Camellia sinensis, Calendula officinalis, or honeybee crops, constitute examples of sources of bioactive compounds with pharmacological interest due to their well-reported activities (e.g., antimicrobial, antiviral, anti-inflammatory, analgesic, or wound healing). These activities are associated with the bioactive compounds present in their matrix (such as flavonoids), which are associated with in vivo biological activities and minimal or absent toxicity. Finally, encapsulation has arisen as a future opportunity to preserve the chemical stability and the drug bioa vailability of bioactive compounds and, most importantly, to improve the buccal retention period and the therapeutic effects.

An exploration of the use of photobiomodulation for management of oral mucositis in children and young people undergoing cancer treatment in the UK

PURPOSE

Oral mucositis affects up to 80% of children and young people (CYP) receiving chemotherapy. This can result in pain, reduced oral intake and, in severe cases, hospitalisation for parental nutrition and pain relief. Photobiomodulation is recommended by multiple bodies for mucositis management for those undergoing cancer treatments. The current use of photobiomodulation within the UK, and the barriers and facilitators to implementation is unknown.

METHOD

An online mixed-methods survey was administered to representatives from the Children's Cancer and Leukaemia Group (CCLG) between October 2021 and March 2022. This explored: use of photobiomodulation, planned future use, barriers and facilitators to implementation and dental assessment. Quantitative data underwent descriptive statistics. Barriers and facilitators to the implementation of photobiomodulation were analysed using the Theoretical Domains Framework (TDF).

RESULTS

All UK CCLG centres responded (n = 20, a response rate of 100%). Two units in Scotland were delivering photobiomodulation. A further four units were planning to implement a service. Most units, 65% (n = 13) utilised specialist Paediatric Dentistry services for dental assessment. In the TDF analysis, five domains were most frequently populated: knowledge, skills, environmental context and resources, social influences, and social/professional role and identity.

CONCLUSION

Photobiomodulation was only available in Scotland in two children's cancer units. Lack of knowledge and skills, and insufficient environmental resources were identified as barriers. Collaboration with paediatric dental services was identified as a facilitator. The establishment of a national network of Paediatric Dentists and Oncologists would promote collaboration to standardise protocols and to address the identified barriers to wider implementation of photobiomodulation.