Assessing and Managing Chemotherapy-Induced Mucositis Pain

Guide for health professionals addressing oral care for individuals in oncological treatment based on scientific evidence

OBJECTIVE

Oncological treatment can cause changes in the oral cavity compromising oral functions. The aim of the study was, based on a systematic review, to draft a guide directed at the team of health professionals involved in the oral care of oncological patients.

METHODS

A systematic search of the literature was performed for articles published between 2000 and April 2017. Searches were made of electronic databases and hand search. The inclusion criteria were systematic reviews of randomized clinical trials (RCTs) and RCTs published in English, involving pediatric and adult oncological patients and focused on the prevention and treatment of oral complications as well as studies addressing the maintenance of oral health. Among the 1237 studies identified, 129 were pre-selected and 54 were selected to form the basis for the clinical guide.

RESULTS

The studies analyzed stress the need for oral assessments as well as preventive and curative actions prior to oncological treatment. To minimize the severity of oral problems, the studies emphasize daily oral care, the treatment of xerostomia with saliva substitute and hydration, and low-level laser therapy, nystatin, acyclovir, respectively, for the prevention and treatment of oral mucositis, oral candidiasis, and infection by herpes simplex virus. Thus, the guide produced addresses oral assessments and professional and home care before, during, and after oncological treatment.

CONCLUSION

The guide drafted has the function of assisting health professionals involved in the oral care of patients with cancer, enabling the prevention or treatment of oral complications stemming from oncological treatment.

Cancer treatment-induced mucositis pain: strategies for assessment and management

Mucositis pain is a major clinical problem associated with cancer treatment. Mucosal tissue injury is a dose-limiting side effect and also limits nutritional intake and oral function, resulting in weight loss and nutritional deficits for many patients. The pathophysiology of mucositis is thought to be a complex array of cytokine-mediated events, which begins with mucosal atrophy and eventually leads to the painful ulceration of the mucosa. This article reviews current research related to pain management for mucositis. Effective treatment for mucositis pain must be targeted at the various factors involved in the pain experience. Although a number of interventions aimed to prevent and treat mucositis have been studied, there is little evidence to recommend any one treatment modality. While current strategies for pain management rely on general treatment for acute pain, research developments are aimed at targeting the specific receptors and enzymes involved in mucositis. As these breakthroughs become available clinically, thorough assessment and timely directed interventions must be implemented in order to limit patient distress from mucositis. This article presents an assessment tool specific to mucositis pain, including physical, functional, and pain parameters.

Tratamento da mucosite em pacientes submetidos a transplante de medula óssea: uma revisão sistemática

OBJETIVO: Identificar as medidas terapêuticas para redução da gravidade da mucosite oral em pacientes adultos submetidos ao Transplante de Medula Óssea (TMO). MÉTODOS: Revisão sistemática nas bases de dados: LILACS, MEDLINE, CINAHL, EMBASE; CENTRAL (Cochrane Central) e DARE (Database of abstracts of reviews of effects), no período de 1972 a julho de 2010, utilizando os descritores mucositis, stomatitis e bone-marrow-transplantation. RESULTADOS: Identificaram-se 3.839 resumos, dos quais 22 foram incluídos na revisão sistemática que descreveram 14 intervenções tópicas e sistêmicas, dentre as quais oito com significância estatística para a redução dessa complicação. As terapias tópicas foram a crioterapia, clorexidine, glutamina, laser e Traumeel® e as sistêmicas, amifostine, Granulokine® e palifermin. CONCLUSÃO: A heterogeneidade dos resultados dessas intervenções e a falta de melhor elucidação para a prática assistencial indicam a necessidade de pesquisas mais precisas para identificar a efetividade de terapias tópicas para a reparação celular das mucosas.

A systematic review of oral assessment instruments: what can we recommend to practitioners in children's and young people's cancer care?

BACKGROUND

Observing and recording the signs and symptoms of oral mucositis are an important part of oral care, essential to the prevention and treatment of mucositis. Structured oral assessment enables a more informed and accurate identification of signs and symptoms and will enable early and individualized interventions.

OBJECTIVE

A United Kingdom-based mouth-care group conducted a systematic review of the published literature through to March 2004 and repeated in 2008. The goal of this review was to identify and evaluate the range of instruments used to assess oral mucositis to recommend in evidence-based guidelines the "best" instrument to use in the field of children's and young people's cancer care.

METHODS

Search sources included the Cochrane Library, MEDLINE, EMBASE, and CINAHL. Studies were selected using defined criteria and reviewed by 3 pairs of group members.

RESULTS

Fifty-four individual oral assessment instruments were identified with only 15 reporting evidence of reliability and validity testing. Only 3 articles reported on oral assessment exclusively in our population.

CONCLUSIONS

The guidelines recommend only 1 assessment instrument, the Oral Assessment Guide, or adaptations of this instrument, to be used in clinical practice. Five factors influenced this recommendation: purpose of assessment, population, outcomes assessed, and quality of the instrument and ease of use.

IMPLICATIONS FOR PRACTICE

The Oral Assessment Guide has been consistently judged to be user-friendly and appropriate for everyday clinical practice with both adults and children, as well as a useful research tool.

Advances in the management of acute myeloid leukemia in older adult patients

PURPOSE/OBJECTIVES

To update oncology nurses on new developments in the care of older adult patients with acute myeloid leukemia (AML).

DATA SOURCES

Clinical trial data, published guidelines, review articles, and conference proceedings.

DATA SYNTHESIS

Therapies for older adult patients with AML include cytarabine-based intensive-induction chemotherapy, investigational therapy, and supportive care. Nonmyeloablative allogeneic hematopoietic stem cell transplantation may provide the best opportunity for cure following remission if a human leukocyte antigen-matched hematopoietic stem cell donor is available. Careful assessment of patient- and disease-related factors is critical in determining the appropriate treatment modality for individuals. Assessment tools and algorithms may identify patients likely to be intolerant of intensive therapies. Supportive care may improve treatment tolerance and quality of life.

CONCLUSIONS

Survival outcomes have not improved significantly for older adult patients with AML. Novel therapies, coupled with better understanding of prognostic factors, may allow more highly individualized care. Performance status or comorbidity score may provide insights regarding outcome, particularly when combined with age, cytogenetic risk, or molecular markers. Efforts to improve transplantation safety may increase use in the older adult patient population.

IMPLICATIONS FOR NURSING

Nurses provide disease and treatment information, manage adverse effects, and offer emotional support. Knowledge of the key management issues for older adult patients with AML is critical in fulfilling this role.

[Descriptive study of nursing-sensitive outcomes in oncohematological patients and nursing interventions]

OBJECTIVE

To assess the main nursing-sensitive outcomes in oncohematological patients admitted to hospital and to evaluate nursing interventions.

MATERIAL AND METHODS

We performed a prospective, observational study in the oncohematological units of the Morales Meseguer Hospital. The sample included patients admitted from March 2006 to June 2007.

RESULTS

A total of 56 patients were studied. Of these, 39 patients (69.6%) had some degree of mucositis but only six patients (10.7%) were assessed objectively by nurses. Fifty-two patients (92.9%) received anti-emetic treatment, but there were no reports of nausea or vomiting in 27 (48.2%). Ten patients (17.9%) were referred to the nutritional unit. Anxiety levels and psychosocial impact decreased during hospital admission and patient satisfaction increased but family members experienced greater stress. Pressure ulcer developed in only one patient. Four catheters (8.2%) became infected and there were five cases of catheter-related bacteremia. There were 22 cases of catheter obstruction (39.9%).

CONCLUSIONS

The incidence of mucositis, pressure ulcer and catheter-related bacteremia was lower than in other studies. There was no standard assessment of pain, nausea or vomiting. Anxiety levels were lower than in other studies. Improvement and psychosocial adjustment suggested a process of adaptation to the disease. The increase in caregiver burden was related to the disease in the long term. Satisfaction with nursing care was 55 points on a 70-point scale.

Prevention and management of oral mucositis in patients with cancer

OBJECTIVES

To review current evidence that applies to the development of a nursing plan of care for the prevention and treatment of oral mucositis related to cytotoxic therapy.

DATA SOURCES

Research studies, review articles, evidence-based guidelines, web-based material, and clinical experience.

CONCLUSION

Although high-level research evidence regarding mucositis is limited, use of multiple types of evidence in developing a structured plan of care facilitates improved patient outcomes and the advancement of the current body of knowledge.

IMPLICATIONS FOR NURSING PRACTICE

Nurses play a key role in the identification and use of evidence to guide the care of patients at risk for cytotoxic therapy-related oral mucositis.

The importance of assessment rating scales for chemotherapy-induced oral mucositis

PURPOSE/OBJECTIVES

To review the literature related to chemotherapy-induced oral mucositis and highlight four empirically supported oral mucositis rating scales that oncology nurses can use.

DATA SOURCES

CINAHL and MEDLINE databases, published articles, and supplemental publications.

DATA SYNTHESIS

Various oral mucositis rating scales have been developed; however, a lack of consensus exists regarding their use in clinical practice.

CONCLUSIONS

To date, standards of practice for the assessment of oral mucositis do not exist, yet clinical measures are necessary for oncology nurses to manage the side effect effectively. The selection of a valid and reliable rating tool is necessary for routine oral assessment and for facilitating optimal patient outcomes related to oral mucositis.

IMPLICATIONS FOR NURSING

Knowing patient risk factors and the circumstances that exacerbate oral mucositis are keys to performing quality oral assessments. Oncology nurses should make performing oral assessments with a valid and reliable rating scale a priority. Further research regarding oral mucositis rating scales is needed.

The role of basic oral care and good clinical practice principles in the management of oral mucositis

BACKGROUND

The Basic Oral Care Group is one of eight subcommittees functioning within the Mucositis Study Group Guidelines Panel of the Multinational Association of Supportive Care in Cancer and International Society for Oral Oncology (MASCC/ISOO). The Basic Oral Care Group, comprised of the four authors of this paper, represented the disciplines of nursing (DBM, JJ), dentistry (MEPC), and pediatric dentistry (PW). This group reviewed research and clinical literature to update the original 2004 Mucositis Management Guidelines in the areas of basic oral care, bland rinses, protocols and education, and good clinical practices such as pain management, oral assessment, oral care, and dental care.

MATERIALS AND METHODS

Over 100 articles published between 2000 and 2005 were identified, and 32 of these were useful for the analysis. Each article was rated by at least two authors using a structured rating form and systematic determination of levels of evidence, based on the American Society of Clinical Oncology criteria. Discussion at the 2005 MASCC/ISOO Geneva pre-conference meeting of the Guidelines Panel resulted in the development of consensus on the interpretation of the literature.

RESULTS

Based on the literature and on Panel discussions, a revision of the original guidelines for protocols and education was produced by the group, and they developed a set of recommendations related to good clinical practices.

CONCLUSIONS

Although research remains scanty for components of basic oral care, bland rinses, protocols, and education, the original 2004 guidelines with the help of newer literature from 2000 to 2005 and expert consensus among the Guidelines Panel enabled the development of useful clinical practice guidelines for managing oral mucositis in patients receiving cancer treatment with radiation and/or chemotherapy.