Putting Evidence Into Practice®: Evidence-Based Interventions for the Management of Oral Mucositis

Title: Chemotherapy-Induced Oral Complications and Prophylaxis Strategies

Cancer is currently a significant therapeutic challenge and is frequently connected with numerous adverse effects. Despite many improvements in chemotherapy, oral complications are common, leading to poor quality of life and chemotherapeutic dose reduction, which impair survival. This review summarizes the most common dental complications in patients receiving chemotherapy. We mainly focus on oral mucositis as it is a major cause of dose-limiting toxicity. Furthermore, oral candidiasis, viral infections, and xerostomia will be discussed. Conclusions: preventing complications is significantly more important than treating them. All patients beginning systemic anticancer treatment should undergo a thorough oral examination and get appropriate prophylaxis.

Effect of Honey on Pediatric Radio/Chemotherapy-Induced Oral Mucositis (R/CIOM): A Systematic Review and Meta-Analysis

Background

As a common side effect of radio/chemotherapy, oral mucositis severely affects patients' quality of life. Honey has been recommended for adults with radio/chemotherapy-induced oral mucositis (R/CIOM), but its effect for pediatric patients has not been systematically evaluated. Therefore, the aim of this systematic review and meta-analysis was to illuminate whether honey is effective in treating pediatric R/CIOM.

Methods

Two authors searched electronic databases including PubMed, Embase, the Cochrane Library, Web of Science, and Scopus to identify relevant studies, published in English. Then, the outcomes data was extracted from eligible studies and pooled in the meta-analysis.

Results

Totally, five studies containing 316 patients were included in our systematic review and meta-analysis. The result indicated that honey intervention significantly reduced the recovery time (MD = −5.10, 95% CI [−9.60, −0.61], P < 0.001, I² = 98%, random-effect model) in pediatric patients. Honey also reduced the occurrence of all grades of R/CIOM (RR = 0.19, 95% CI [0.12, 0.30], P < 0.001, I² = 0%, fixed-effect model) and the occurrence of grade III and grade IV R/CIOM (RR = 0.18, 95% CI [0.08, 0.41], P < 0.001, I² = 7%, fixed-effect model), and the sensitivity analysis showed the results were stable and robust.

Conclusion

Therefore, honey could be a competent candidate for the complementary treatment of pediatric R/CIOM.

Pathogenesis and Amelioration of Radiation-Induced Oral Mucositis

OPINION STATEMENT

Oral mucositis (OM) causes significant detriment to patient quality of life. Despite advances in RT, chemotherapy, and surgery for HNC which have led to improved local control and survival, management of certain toxicities such as OM have not kept pace. Numerous strategies have emerged with demonstrable benefit in preventing severe OM. However, ones which are not only effective, but practical and affordable to implement are rare. For example, infusion of growth factors or free radical scavengers, and daily treatment of intra-oral sites with lasers are supported by high-quality evidence but have not become widely adopted. It falls to familiarity of the physician with the available preventative measures and ultimately, patient preference in accepting which strategies for OM amelioration are used. In this review, we present a pathophysiological-based review of prevention techniques available for reducing the incidence and duration of severe OM.

Effects of nanomicelle curcumin capsules on prevention and treatment of oral mucosits in patients under chemotherapy with or without head and neck radiotherapy: a randomized clinical trial

BACKGROUND

One of the most prevalent complications of chemotherapy and radiotherapy is oral mucositis (OM) and manifests as erythema and ulceration. Curcumin is one of the components of turmeric and possesses anti-inflammatory and anti-oxidative features. Some of studies have proved the effectiveness of Curcumin in OM. This study aimed to investigate the effects of nanomicelle Curcumin on OM related chemotherapy and head and neck radiotherapy.

METHODS

In this clinical trial study, 50 patients underwent chemotherapy with or without head and neck radiotherapy were divided into study and control group. The study group was received Curcumin nanomicelle capsules 80 mg twice a day and the control group took placebo two times a day for 7 weeks and the severity and pain of OM was measured.

RESULTS

Oral mucositis severity in control group in the first (P = 0.010), fourth (P = 0.022) and seventh (P < 0.001) weeks were significantly more than the study group. Pain grade in study group was lower than control group only in the seventh week. (P = 0.001) Additionally, NRS incremental gradient in control group was more than study group. OM severity in patients who underwent only chemotherapy in the control group were significantly more than the study group in all weeks. In patients who were under chemotherapy and head and neck radiotherapy, OM in control group was significantly more intense than the study group only in the fourth and seventh weeks.

CONCLUSIONS

Nabomicelle Curcumin capsules is effective on prevention and treatment of head and neck radiotherapy and especially chemotherapy induced OM.

TRIAL REGISTRATION

Registered 12 February 2019 at Iranian Registry of Clinical Trials (IRCT). IRCT code: IRCT20100101002950N6 . https://en.irct.ir/trial/36665 . GUMS ethical code: IR.Gums.Rec.1397.296.

Clinical Outcome in Children with Chemotherapy-Induced Mucositis

OBJECTIVES

This study was conducted to assess the impact of oral mucositis on nutrition and performance status in pediatric cancer patients treated by chemotherapy.

DATA SOURCES

A total of 46 children were followed for mucositis episode, and their mean Oral Assessment Guide score was 20.2. Main concomitant disorders were hematological changes (86.9%), loss of appetite (60.7%), vomiting (28.3%), and diarrhea (10.9%).

CONCLUSION

Anthropometric changes were highlighted by a decrease in body mass index (P = .03) and a decrease of Waterlow score (P = .007). Most patients had a low Lansky Play Performance Scale (LPPS) ≤40 (86.9%). High mucositis grades (P = .007) and long hospital stay (P = .005) were associated with a significant reduction in Lansky Play Performance Scale. Patient's follow-up showed need for hospitalization (84.8%), delay in chemotherapy treatment (71.7%), use of opioides (34.8%), and use of parenteral nutrition (26.1%). Death occurred in 10.9% of the cases.

IMPLICATIONS FOR NURSING PRACTICE

These findings illustrate the impact of mucositis on nutrition and performance status in children undergoing chemotherapy, which considerable affected their outcome.

Oral Care in Hospital Settings: Breaking the Vicious Circle of Older Adult Deconditioning

Hospitalized older adults frequently develop aspiration pneumonia, swallowing dys-function (dysphagia), and sarcopenia. In the current study, we propose a framework that incorporates these three factors into a vicious circle that leads to deconditioning, a condition frequently experienced by this vulnerable population. Viewing aspiration pneumonia, dysphagia, and sarcopenia, along with their interrelationships through the lens of this vicious circle, illuminates the critical role that oral health plays in deconditioning. Moreover, this framework highlights oral care as a key nursing intervention for reducing deconditioning in hospitalized older adults. Supporting this view, several studies have shown that oral care can improve health outcomes for hospitalized older adults. However, despite oral care being an essential nursing intervention that restores oral function and promotes patient wellness, it is one of the most neglected nursing interventions. Missed oral care occurs due to staff's limited awareness of its significance for care-dependent older adults in hospital settings. We hope that this vicious circle paradigm helps raise awareness of the significance of oral care to prevent deconditioning in hospitalized older adults. [Journal of Gerontological Nursing, 47(6), 7-12.].

Development and Validation of the Oral Mucositis Risk Assessment Scale in Hematology Patients

OBJECTIVES

This study was conducted as a methodological study to develop a valid and reliable scale to evaluate the risk of developing oral mucositis in hematology patients.

DATA SOURCES

The universe and sample were comprised of one hundred eighty-seven in-patients who were taken to receive chemotherapy in the hematology clinics over a six-month period. The data were collected through the Patient Diagnosis Form, the World Health Organization's Mucositis Evaluation Form and Oral Mucositis Risk Assessment Scale in Hematology Patients developed. Risk of "taking high-dose chemotherapy regimen", "neutropenia", "dry mouth", "pain", "leukopenia", "parenteral feeding", "previous history of oral mucositis" and "chemotherapy or radiotherapy in the past" were found as an oral mucositis risk factor. We have added "using high-risk chemotherapeutic agents", "bone marrow transplant", " head-neck or mouth cancer" which we consider clinically important. The scale consists of 11 items. The sensitivity value is 0.941 and the selectivity value is 0.724.

CONCLUSION

We recommend that use the Oral Mucositis Risk Assessment Scale in Hematology Patients. Similar studies should be performed in oncology clinics and especially in patients receiving head and neck, oral radiotherapy.

IMPLICATIONS FOR NURSING PRACTICE

Oral mucositis is an important problem for hematology patients. nurses' risk assessment and early intervention to oral mucositis prevent the formation and complications of oral mucositis.

Managing the effects of cancer and cancer treatments on patients' nutritional status

Adequate nutrition is a basic requirement of the human body, supporting cell growth and optimal organ function. The nutritional requirements of patients with cancer can increase due to systemic inflammatory responses caused by cancer and cancer treatments. Nurses have an important role in providing nutritional interventions to patients undergoing treatment for cancer, through education and person-centred nutritional care. This article examines which nutritional interventions provided by nurses can relieve symptoms and side effects, improve nutritional status and enhance quality of life in patients with cancer.

Supportive care during pediatric hematopoietic stem cell transplantation: beyond infectious diseases. A report from workshops on supportive care of the Pediatric Diseases Working Party (PDWP) of the European Society for Blood and Marrow Transplantation (EBMT)

Hematopoietic stem cell transplantation (HSCT) is currently the standard of care for many malignant and nonmalignant blood diseases. As several treatment-emerging acute toxicities are expected, optimal supportive measurements critically affect HSCT outcomes. The paucity of good clinical studies in supportive practices gives rise to the establishment of heterogeneous guidelines across the different centers, which hampers direct clinical comparison in multicentric studies. Aiming to harmonize the supportive care provided during the pediatric HSCT in Europe, the Pediatric Diseases Working Party (PDWP) of the European Society for Blood and Marrow Transplantation (EBMT) promoted dedicated workshops during the years 2017 and 2018. The present paper describes the resulting consensus on the management of sinusoidal obstructive syndrome, mucositis, enteral and parenteral nutrition, iron overload, and emesis during HSCT.

Oral cryotherapy for oral mucositis management in patients receiving allogeneic hematopoietic stem cell transplantation: a prospective randomized study

PURPOSE

To explore the best schedule of oral cryotherapy for the prevention of oral mucositis in recipients of myeloablative hematopoietic stem cell transplantation (HSCT).

METHODS

A prospective randomized study was conducted to recruit allogeneic HSCT recipients, who were then randomly allocated into four arms to accept the following: oral cryotherapy during the whole course (arm A) or second half of the course (arm B) of cytotoxic agents administration, regular oral cryotherapy twice a day (arm C), or conventional oral care without cryotherapy (arm D). Status of oral mucositis was daily assessed from the first day of conditioning to the 15th day post-HSCT. A myeloablative conditioning regimen was used which was composed of busulfan, cyclophosphamide, and cytarabine.

RESULTS

Totally 160 cases were consecutively enrolled in this study, and 145 cases were eligible for oral mucositis assessment. Both arm A and arm B were associated with a lower incidence and short duration of severe mucositis (≥ grade 3), although no statistical difference was found between these two groups (p = 0.463, p = 0.678). The highest incidence of severe mucositis was observed in arm C. Recovery of mucositis also had a significant diversity among the 4 arms (F = 4.133, p = 0.008).

CONCLUSIONS

Risk and outcome of severe oral mucositis could be ameliorated by oral cryotherapy during the administration of cytotoxic agents for allogeneic HSCT patients receiving non-radiation myeloablative conditioning regimen, and a half-course schedule could acquire a comparable efficacy compared with the whole-course schedule.

Mucosal Injury during Anti-Cancer Treatment: From Pathobiology to Bedside

Mucositis is one of the most common debilitating side effects related to chemotherapy (CT), radiation therapy (RT), targeted agents and immunotherapy. It is a complex process potentially involving any portion of the gastrointestinal tract and injuring the mucosa, leading to inflammatory or ulcerative lesions. Mechanisms and clinical presentation can differ according both to the anatomic site involved (oral or gastrointestinal) and the treatment received. Understanding the pathophysiology and management of mucosal injury as a secondary effect of anti-cancer treatment is an important area of clinical research. Prophylaxis, early diagnosis, and adequate management of complications are essential to increase therapeutic success and, thus, improve the survival outcomes of cancer patients. This review focuses on the pathobiology and management guidelines for mucositis, a secondary effect of old and new anti-cancer treatments, highlighting recent advances in prevention and discussing future research options.

Back to Basics: CLABSI Reduction Through Implementation of an Oral Care and Hygiene Bundle

Children with cancer often undergo treatments that render them severely immunocompromised. Side effects of treatment place them at risk for developing oral mucositis (OM), which can potentially lead to infection and bacteremia. Staff nurses on an inpatient pediatric oncology unit noted inconsistent daily oral hygiene practices despite assessing OM consistently. Basic oral hygiene can reduce the severity of OM, and evidence-based bundled care has shown to increase consistency of practice. Based on findings and recommendations from the literature, an oral care and hygiene bundle was developed. The oral care bundle included a soft bristled toothbrush, fluoride toothpaste, twice-daily brushing and sodium bicarbonate rinses, lip balm, and oral moisturizer. The hygiene component consisted of a daily bath or shower and daily linen changes. Education on the rationale and purpose for the use of an oral care and hygiene bundle was provided to the inpatient direct care staff prior to implementation on two inpatient oncology units. Audits were performed to measure the adherence of the oral care and hygiene bundle. Central line–associated bloodstream infections were measured in collaboration with the quality and infection prevention departments. Since the oral care and hygiene bundle was implemented, laboratory-confirmed bloodstream infection rates decreased from 1.05 to 0.54 per 1,000 catheter days, while mucosal barrier injury rates decreased from 2.98 to 1.27 per 1,000 catheter days.

The post hoc analysis comparing the severity grades of chemoradiotherapy-induced oral mucositis scored between the central and local assessors in a multicenter, randomized controlled trial of rebamipide for head and neck cancer

BACKGROUND

In the treatment of head and neck cancer, severity of chemoradiotherapy-induced oral mucositis has been recognized as one of the key factors affecting the outcomes of the anticancer therapies. Therefore, the development of treatments mitigating oral mucositis would be of clinical significance, although the adequate assessment procedure for efficacy evaluation remains to be established. We conducted this post hoc study to assess the effect of objective evaluation of the severity grade on the outcomes of the clinical trial.

METHODS

In the original trial with rebamipide liquids (0, 2, and 4%) for chemoradiotherapy-induced oral mucositis, the investigators in local sites and independent central review separately determined the severity grades in accordance with Common Terminology Criteria of Adverse Events version 3.0 based on the Assessment Sheet scored by the investigators. The discordance in severity grades between the investigators and central review was analyzed on cross table.

RESULTS

The analysis revealed the discordance rate over the trial was 34%. While the incidences of severe oral mucositis in the placebo, rebamipide 2%, and 4% groups evaluated by the central review were 39%, 29%, and 25%, respectively, the respective values in the investigator's evaluation were 32%, 39%, and 44%.

CONCLUSION

In the clinical trial for the treatment of oral mucositis, it was strongly suggested that objective evaluation with a consistent scale would be required.

Global Health Journal Club: Is Honey Effective as a Treatment for Chemotherapy-induced Mucositis in Paediatric Oncology Patients?

Oral mucositis (OM) is an inflammatory response of mucosal epithelium to the cytotoxic effects of chemotherapy and radiotherapy causing severe oral pain and ulceration, which may complicate the management of cancer. The Mucositis Prevention Guideline Development Group has developed an international guideline for the prevention of mucositis in children receiving treatment for cancer or undergoing haematopoietic stem cell transplantation. Evidence-based preventative strategies include cryotherapy, low-level light therapy and keratinocyte growth factor. However, these strategies are often not available in resource-poor settings. There is some evidence that honey may be a suitable treatment for OM in adult patients. We performed a literature search of 11 databases to find papers exploring the use of honey to treat chemotherapy-associated mucositis in paediatric oncology patients. We found four papers, which provide Grade C evidence that honey is effective as a preventative and therapeutic measure for OM in paediatric oncology patients.

CE: Oral Care for Head and Neck Cancer Symptom Management

: An evidence-based practice change at a radiation oncology center in a large academic medical center was designed to reduce the severity of oral mucositis in adults receiving radiation treatment for head and neck cancer. In the intervention described, patients were given newly created oral care kits and educational materials to improve their oral hygiene. Evaluations were conducted at three points during the project (before radiation treatment, during week 4 to 5 of treatment, and one month after treatment). At week 4 to 5-when the severity of oral mucositis is expected to peak-patients reported improved oral hygiene practices and reduced oral mucositis severity. The authors conclude that the use of these oral care kits and educational materials lessened the effects of oral mucositis during and after radiation treatment.

Oral Care: Exploring Education, Attitudes, and Behaviors Among Nurses Caring for Patients With Breast Cancer

BACKGROUND

Patients treated for breast cancer often experience severe oral complications, such as mucositis, xerostomia, and infections, which can result in dose reductions and treatment delays, affecting treatment outcomes.
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OBJECTIVES

The purpose of this article is to explore oncology nurses' perceptions of their educational experiences, professional attitudes, and behavior related to providing oral healthcare education to patients with breast cancer.
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METHODS

The Oncology Nursing Society sent an email to 5,000 nursing team members who cared for patients with breast cancer, requesting participation in a web-based survey; 194 responses were received, with 164 meeting study eligibility.
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FINDINGS

More oral health-related education was received during clinical experiences than during formal or continuing education. Although patient-driven oral care and diagnostic efforts were frequent, actual behavior was less frequent. No major barriers to providing oral care were indicated. Increased oral health-related education and behavior correlated with the reported importance of increased oral health education for nurses.

The assessment and management of chemotherapy-related toxicities in patients with breast cancer, colorectal cancer, and Hodgkin's and non-Hodgkin's lymphomas: A scoping review

PURPOSE

The purpose of the eSMART (Electronic Symptom Management using the Advanced Symptom Management System (ASyMS) Remote Technology) study is to evaluate the use of mobile phone technology to manage chemotherapy-related toxicities (CRTs) in people with breast cancer (BC), colorectal cancer (CRC), Hodgkin's lymphoma (HL), and non-Hodgkin lymphoma (NHL)) across multiple European sites. One key objective was to review the published and grey literature on assessment and management of CRTs among patients receiving primary chemotherapy for BC, CRC, HL, and NHL to ensure that ASyMS remained evidence-based and reflected current and local practice.

METHODS

Three electronic databases were searched for English papers, with abstracts available from 01/01/2004-05/04/2014. For the grey literature, relevant clinical practice guidelines (CPGs)/evidence-based resources (EBRs) from the main international cancer organisations were reviewed as were symptom management (SM) protocols from the sites.

RESULTS

After full-text screening, 27 publications were included. The majority (n = 14) addressed fatigue and focused on BC patients. Relevant CPGs/EBRs were found for fatigue (n = 4), nausea/vomiting (n = 5), mucositis (n = 4), peripheral neuropathy (n = 3), diarrhoea (n = 2), constipation (n = 2), febrile neutropenia/infection (n = 7), palmar plantar erythrodysesthesia (PPE) (n = 1), and pain (n = 4). SM protocols were provided by >40% of the clinical sites.

CONCLUSIONS

A need exists for empirical research on SM for PPE, diarrhoea, and constipation. Research is needed on the efficacy of self-care strategies in patients with BC, CRC, HL, and NHL. In general, consistency exists across CPGs/EBRs and local guidelines on the assessment and management of common CRTs.

The impact of an oral hygiene education module on patient practices and nursing documentation

BACKGROUND

Oral hygiene is inconsistent among patients with cancer and is a national patient care issue. To promote comfort and nutritional status, oral hygiene for patients with cancer is important.

OBJECTIVES

The purpose of this study was to develop an evidence-based oral hygiene educational module (EM) for nursing and patient care technician (PCT) staff to promote consistent oral hygiene patient education; evaluate patient understanding of oral hygiene practices post-EM; and determine staff documentation frequency of oral hygiene care.

METHODS

Pre- and post-EM data were collected using a developed oral hygiene assessment tool; nursing documentation data were collected by chart review. Post-EM data were collected eight weeks post-EM. Data were analyzed using frequencies and the Mann-Whitney U test.

FINDINGS

Twenty-two patient documentation pairs were collected. Compared to pre-EM, admission teaching, patient education, and patient oral hygiene practices improved post-EM. Post-EM oral hygiene documentation and PCT teaching increased.

[Effects of special mouth care with an aroma solution on oral status and oral cavity microorganism growth in elderly stroke patients]

PURPOSE

This study was conducted to examine the effect of oral care with an aroma solution on oral status and oral cavity microorganism growth in elderly patients with stroke.

METHODS

A non-equivalent control group, with a pretest-posttest design was used in this study. The participants were assigned to the experimental group (n=30) that received oral care with an aroma solution or the control group (n=31) that received 0.9% saline solution. To identify the effect of the experimental treatments, objective/subjective assessments of oral status and oral cavity microorganism growth were performed using the oral assessment guide, oral perception guide, and oral swab culture. Data were analyzed using Chi-square test, Fisher's exact test, and t-test with the SPSS version 21.0 program.

RESULTS

The objective oral status was significantly lower in the experimental group than in the control group (t= -3.64, p<.001). There was no significant difference between the subjective oral status of the experimental group and control groups (t= -1.24, p=.109). Oral microorganism growth was significantly lower in the experimental group than in the control group (t= -7.39, p<.001).

CONCLUSION

These findings indicate that special mouth care using an aroma solution could be an effective oral health nursing intervention for elderly patients with stroke.

Role of Gabapentin in Managing Mucositis Pain in Patients Undergoing Radiation Therapy to the Head and Neck

BACKGROUND

Oral mucositis (OM) is a painful and debilitating side effect that affects 80%-100% of patients undergoing radiation therapy for head and neck cancer. This dose-limiting side effect may potentially lead to pain, dehydration, malnutrition, infection, and treatment breaks. Treatment breaks can lead to decreased disease control and suboptimal patient outcomes. No primary prevention exists for OM, and management is focused on pain control. Compelling evidence exists that OM pain has somatic and neuropathic components.

OBJECTIVES

This article reviews the existing literature on the use of gabapentin (Neurontin®) as a co-analgesic in treating the neuropathic pain in OM.

METHODS

A literature search was performed using CINAHL® and PubMed with the search terms gabapentin and oral mucositis. The selected articles were briefly screened for relevance, and three were included in this review.

FINDINGS

No systematic reviews exist on the role of gabapentin for neuropathic pain in radiation-induced OM. Two retrospective studies concluded that gabapentin reduced escalation of opioid doses and unplanned treatment breaks. One retrospective study demonstrated favorable swallowing outcomes. Pain and OM are nursing-sensitive outcomes that can be significantly affected by evidence-based nursing interventions.

Using Practice-Based Evidence to Improve Supportive Care Practices to Reduce Central Line–Associated Bloodstream Infections in a Pediatric Oncology Unit

Children with cancer are a subset of patients with central lines with distinct risk factors for infection including periods of prolonged neutropenia and compromised mucous membrane integrity. This article relates the implementation of principles of practice-based evidence to identify interventions in addition to best practice maintenance care bundles to reduce central line–associated bloodstream infections involving viridans group streptococci and coagulase-negative staphylococci on an inpatient pediatric oncology unit. Review of individual events combined with review of current clinical practice guided the development of structured protocols emphasizing routine oral care and general supportive cares. Key principles of the protocols emphasized a 1-2-3 mnemonic and included daily bathing, twice daily oral care, and out-of-bed activity 3 times daily. Poisson regression identified a significant main effect for time period for central line–associated bloodstream infection rates involving both viridans group streptococci and coagulase-negative staphylococci. Significant differences were present between the preintervention baseline and implementation of the supportive care protocols. Project outcomes demonstrate the added value of using principles of practice-based evidence to guide the development of interventions to improve clinical care when evidence-based sources are limited.

A morphometric study of the protective effect of cryotherapy on oral mucositis in cancer patients treated with 5-fluorouracil

We investigated cytological changes in oral mucosa smears from patients treated with cryotherapy to determine whether cryotherapy prevented mucositis caused by 5-fluorouracil (5-FU) therapy. Patients with gastrointestinal malignancies were divided into four groups; control patients before 5-FU therapy, patients after 5-FU therapy without cryotherapy, patients with cryotherapy before 5-FU therapy and patients with cryotherapy after 5-FU therapy. Oral mucosa samples from all patients were assessed at the beginning and on day 14 of chemotherapy. We used exfoliative cytology to evaluate cellular changes in the oral mucosa that were caused by 5-FU. Smears from each patient were stained using the Papanicolaou method and analyzed using stereology. Smears were taken from each group before and after 5-FU infusion. We found that nuclear volume was decreased significantly in cells of the 5-FU therapy after cryotherapy patients compared to the 5-FU therapy before cryotherapy patients. We also found significantly decreased cytoplasmic volumes in the 5-FU therapy after cryotherapy patients compared to the 5-FU therapy before cryotherapy patients. The results of cytomorphometric estimations revealed that cryotherapy may be used to prevent damage to oral tissue and may decrease the frequency and duration of oral mucositis caused by 5-FU.

Optimizing patient adherence to targeted therapies in renal cell carcinoma

The current standard of care for treating metastatic renal cell carcinoma is sequential therapy with vascular endothelial growth factor-targeted agents (i.e., axitinib, bevacizumab, pazopanib, sorafenib, and sunitinib) and mammalian target of rapamycin inhibitors (i.e., everolimus and temsirolimus). To maximize adherence to and persistence with targeted therapy, which should help improve clinical benefit, a clear understanding of the tolerability profiles of these agents and implementation of early, appropriately aggressive adverse event (AE) prevention and management strategies are key. Active and aggressive AE management should improve the quality of life of patients during the course of their treatment. Nurses are in a unique position to educate patients on the potential AEs they may experience and their prevention and management. This article reviews the safety and tolerability of currently available targeted therapies recommended for use in the second-line treatment setting, as well as their management in the context of maximizing clinical outcomes and patient quality of life.

Honey prevents oral mocositis in children undergoing chemotherapy: A quasi-experimental study with a control group

BACKGROUND

There are numerous pharmacological and non-pharmacological treatment options available in the treatment of oral mucositis. However, in spite of so many methods and products, medical professionals have not come to a consensus as to which of these offer the best results.

OBJECTIVES

This study was conducted to assess the effect of oral care with honey on children undergoing chemotherapy for the prevention and healing of oral mucositis.

METHODS

This quasi-experimental study was conducted on children undergoing chemotherapy. The study group consisted of 83 children who attended clinics and polyclinics for chemotherapy. All the children were included in the study period. The study was completed with a total of 76 children except for seven patients who were excluded from the study. The data were collected using a form and the World Health Organization Mucositis Assessment Index. The data were analyzed using percentage distributions, means, a chi-square test, a t-test, a variance analysis, and a Friedman test. Ethics approval of the study was obtained from the Institution Ethics Committee.

RESULTS

It was found that the severity of oral mucositis in the children in the experimental group was significantly less than the control group. The mucositis recovery period in the experimental group was significantly shorter than the control group.

CONCLUSION

Regular oral care with honey for children undergoing chemotherapy for hematological cancers prevents mucositis and also accelerates recovery of it when started after mucositis onset.

Increasing Activities of Daily Living Is as Easy as 1-2-3

Background: Human flora are the most common cause of bacteremia in immunocompromised patients. Activities of daily living (ADL), including oral care and daily chlorhexidine gluconate bathing, can lower the risk of infection. Methods: To address ADL compliance in our pediatric oncology and bone marrow transplant patients, we adopted the ADL 1-2-3 initiative: daily chlorhexidine gluconate bath and linen change, at least 2 activities per day, and oral care 3 times per day. Using the Model for Improvement we created a standardized ADL process that involved all providers. Interventions included addressing ADL 1-2-3 compliance during rounds, establishing accountability in care delivery, an oral care order set and algorithm, daily text message reminders, and physician intervention with noncompliant and high-risk patients. Results: With our interventions, we increased our median compliance with the all-or-none ADL 1-2-3 initiative from 25% to 66% in 90 days. We have sustained our median compliance to 75% sixteen months after implementation. The greatest impact on compliance was seen with text message reminders to staff to complete and document the ADL 1-2-3 components, designated roles and responsibilities, and physician discussion with noncompliant and high-risk patients. Discussion: Oral care algorithm and order set, daily text message reminders, and physician intervention with noncompliant and high-risk patients has improved our compliance. Units where compliance with ADL participation is low can benefit from incorporating elements from this ADL 1-2-3 initiative.

Treatment of oral mucositis due to chemotherapy

INTRODUCTION

The management of oral mucositis is a challenge, due to its complex biological nature. Over the last 10 years, different strategies have been developed for the management of oral mucositis caused by chemotherapy in cancer patients.

MATERIAL AND METHODS

An exhaustive search was made of the PubMed-Medline, Cochrane Library and Scopus databases, crossing the key words "oral mucositis", "prevention" and "treatment" with the terms "chemotherapy" and "radiotherapy" by means of the boolean operators "AND" and "NOT". A total of 268 articles were obtained, of which 96 met the inclusion criteria.

RESULTS

Several interventions for the prevention of oral mucositis, such as oral hygiene protocols, amifostine, benzidamine, calcium phosphate, cryotherapy and iseganan, among others, were found to yield only limited benefits. Other studies have reported a decrease in the appearance and severity of mucositis with the use of cytoprotectors (sucralfate, oral glutamine, hyaluronic acid), growth factors, topical polyvinylpyrrolidone, and low power laser irradiation.

CONCLUSIONS

Very few interventions of confirmed efficacy are available for the management of oral mucositis due to chemotherapy. However, according to the reviewed literature, the use of palifermin, cryotherapy and low power laser offers benefits, reducing the incidence and severity of oral mucositis - though further studies are needed to confirm the results obtained.

KEY WORDS

Chemotherapy-Induced Oral Mucositis Treatment.

The Effects of Oral Cryotherapy on Chemotherapy-Induced Oral Mucositis in Patients Undergoing Autologous Transplantation of Blood Stem Cells: A Clinical Trial

Background

Oral mucositis is one of the irritating side effects of chemotherapy in patients undergoing bone marrow transplantation. However, up until now, the common methods of oral mucositis therapy have failed to show significant effects.

Objectives

The aim of this study was to investigate the effects of local cryotherapy on the intensity of chemotherapy-induced oral mucositis in autologous bone marrow transplantation patients.

Patients and Methods

In this single, blinded, randomized clinical trial, 29 patients undergoing stem cell transplantation in Iran were selected by convenience sampling, and randomly allocated to control (n = 13) and intervention groups (n = 16). In the intervention group, cryotherapy was applied, while the control group received a normal saline mouthwash. The severity of the mucositis and neutrophil rate were investigated in five periods, based on the world health organization (WHO) scales. The data were analyzed using descriptive statistics, the Mann-Whitney test, repeated measures analysis of variance (ANOVA), and linear regression.

Results

In both groups, the mucositis reached its peak intensity on the 7th day, and the least intensity was obtained on the 21st day. The neutrophil rate reached the minimum value on the 7th day, then increased up to the 21st day. The two groups showed no significant differences between the mucositis severity on the 14th and 21st days (P = 0.164), while the severity of the mucositis in the cryotherapy group was significantly less than that in the saline mouthwash group (1.81 < 2.54 and 0.13 < 0.92, respectively) on the 7th and 14th days (P < 0.05). There was no significant difference in the neutrophil rate between the groups.

Conclusions

The results showed that cryotherapy is more effective than the saline mouthwash in reducing the severity of mucositis. This method is recommended for the prevention of mucositis in bone marrow transplantation.

Comparison of saliva interleukin-2 concentration to the condition of gums in children with acute lymphoblastic leukaemia during anti-tumour treatment

Purpose

Subjects undergoing chemotherapy often develop disorders in salivation and changes in salivary composition. Therefore, a tendency to inflammatory states developing within oral mucosa is often observed. The objective of the study was to assess the effect of disturbed immunity on the gum condition in children with acute lymphoblastic leukaemia (ALL) during anti-tumour treatment and to compare saliva interleukin-2 (IL-2) concentration in relation to the condition of gums oral mucositis—must be removed in children with ALL.

Methods

The study included 78 children with ALL in followed three examinations and a control group included 78 healthy children. Dental examination of the children with ALL and the control group included the evaluation of gingival condition by gingival index (GI). Children’s unstimulated saliva samples were taken, and IL-2 concentration was determined by Human IL-2 EIA.

Results

Mean GI higher than 1 was observed in 3.17 % children with ALL. The results found higher frequency of gingival inflammations in children with ALL on chemotherapy compared with the healthy controls. A comparison of results for a given patient during anti-tumour therapy with regard to salivary IL-2 showed significant differences between examination 2 and examination 3. The results indicated that IL-2 level in saliva was twice higher in a patient during chemotherapy.

Conclusions

An increase in salivary level of the proinflammatory IL-2 cytokine in ALL children during chemotherapy may cause pathological changes in the condition of the gums. An increase in salivary IL-2 level most probably results from a micro-injury of oral mucosa following administration of cytostatics, which in turn may cause oral mucositis in children with ALL.

Assessment and management of gastrointestinal toxicities and lab abnormalities related to targeted therapy

OBJECTIVES

To identify the most common gastrointestinal toxicities and laboratory abnormalities associated with targeted therapies, as well as the assessment and management necessary to minimize adverse events related to these side effects.

DATA SOURCES

Peer-reviewed articles and national guidelines for oncology practice.

CONCLUSION

Common toxicities of diarrhea, mucositis, and laboratory abnormalities are often associated with the use of targeted agents and require skilled assessment and early management interventions to prevent severe complications or treatment interruption.

IMPLICATIONS FOR NURSING PRACTICE

Emerging trends focused on targeted therapy increase the importance of the oncology nurse's role in assessment, education, and evidenced-based recommendations to meet patient needs.

The effect of royal jelly on oral mucositis in patients undergoing radiotherapy and chemotherapy

This study was conducted to evaluate the effect of royal jelly on oral mucositis in patients undergoing radiotherapy and chemotherapy. The study population consisted of 103 patients undergoing radiotherapy and chemotherapy. Oral mucositis was graded according to the World Health Organization criteria, and patients were divided into 2 groups. All patients received mouthwash therapy with benzydamine hydrochloride and nystatin rinses. In addition, patients in the experimental group received royal jelly. The mean resolution time of oral mucositis in the royal jelly group was significantly shorter than that of the control group. As a result, the study results demonstrate that royal jelly administrated by a certain procedure improved the signs and symptoms of oral mucositis and markedly shortened its healing time.

Clinical management of regorafenib in the treatment of patients with advanced colorectal cancer

Colorectal cancer is one of the most common tumors worldwide and at least 50 % of patients with this disease develop metastases. In this setting, additional treatment options are needed for patients presenting disease progression after exhausting all standard therapies. Regorafenib is an orally administered multikinase inhibitor which has been shown to provide survival benefits to patients with metastatic colorectal cancer (mCRC). Although most adverse events (AEs) associated with regorafenib may resolve within the first 8 weeks of treatment, some of them may require dose reduction or treatment interruption. Overall, while remaining aware of the safety profile of regorafenib and how to manage the most common toxicities related to its use, this drug should be considered a new standard of care for patients with pretreated mCRC. This review addresses practical aspects of its use, such as dosing, patient monitoring, and management of the most common regorafenib-related AEs.

Pain Management for Children during Bone Marrow and Stem Cell Transplantation

Pain management for children during bone marrow and stem cell transplantation is a significant clinical challenge for the health care team. Pain management strategies vary by institution. This paper reports on the use of a pediatric pain management service and patient- and caregiver-controlled analgesia for children undergoing transplant. This 2-year retrospective chart review examined the pain management practices and outcomes of children undergoing bone marrow and stem cell transplants in a large urban teaching hospital during 2008 and 2009. We concluded that patient- and caregiver-controlled analgesia is a well-tolerated modality for pain control during hospitalization for transplantation at this institution.

Managing toxicities associated with antiangiogenic biologic agents in combination with chemotherapy for metastatic colorectal cancer

Toxicities commonly associated with antiangiogenic agents include hypertension, proteinuria, wound-healing complications, bleeding or hemorrhage, thromboembolic events, hypersensitivity reactions, and gastrointestinal perforation; however, toxicities most often attributed to chemotherapy include nausea, vomiting, diarrhea, constipation, fatigue, neuropathy, mucositis, hand-foot syndrome, hypersensitivity reactions, and myelosuppression. Patients with metastatic colorectal cancer (mCRC) who receive an antiangiogenic agent in combination with chemotherapy may experience toxicities related to both chemotherapy and the antiangiogenic agent. If possible, evidence-based interventions should be used for the management of toxicities. Patient education about expected toxicities and optimal toxicity management can promote the optimal use of therapy to improve survival and quality of life. Oncology nurses are well positioned to educate patients and their families on anticipated treatment and management of side effects. This article summarizes the incidence of toxicities associated with the antiangiogenic biologic agents aflibercept and bevacizumab, in combination with chemotherapy for patients with mCRC, and provides strategies for managing these toxicities based on clinical practice guidelines.

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.

Prevention and management of radiation-induced dermatitis, mucositis, and xerostomia

Purpose

Current strategies for preventing and managing radiation-induced dermatitis, mucositis, and xerostomia are reviewed, with an emphasis on pharmacologic interventions.

Summary

Nearly two thirds of all patients with cancer receive radiation therapy during the course of treatment, frequently resulting in acute skin and mucosal toxicities. The severity of radiotherapy-associated toxicities varies according to multiple treatment- and patient-related factors (e.g., total radiation dose and dose fractionation schedule, volume of organ or tissue irradiated, use of concurrent versus sequential chemotherapy, comorbid conditions, functional performance status). Three major radiation toxicities encountered in clinical practice are (1) radiation dermatitis, typically managed with a variety of topical agents such as water-based moisturizing creams or lotions, topical steroids, antiinflammatory emulsions, and wound dressings, (2) radiation-induced oral mucositis, which can be managed through proper basic oral care practices, appropriate pain management, and the use of medicated mouthwashes and oral rinses and gels, and (3) radiation-induced xerostomia, which can be alleviated with saliva substitutes, moistening agents, and sialagogues. Pharmacists involved in the care of patients receiving radiotherapy can play an important role in optimizing symptom control, educating patients on self-care strategies, and adverse effect monitoring and reporting.

Conclusion

Radiation-induced dermatitis, mucositis, and xerostomia can cause significant morbidity and diminished quality of life. Pharmacologic interventions for the prevention and treatment of these toxicities include topical agents for dermatitis; oral products, analgesics, and palifermin for mucositis; and amifostine, saliva substitutes, and pilocarpine for xerostomia.

Management of adverse events in patients with hormone receptor-positive breast cancer treated with everolimus: observations from a phase III clinical trial

Everolimus is a mammalian target of rapamycin (mTOR) inhibitor approved for the treatment of advanced renal cell carcinoma, pancreatic neuroendocrine tumors, subependymal giant cell astrocytoma associated with tuberous sclerosis complex, renal angiomyolipoma and tuberous sclerosis complex, and, in combination with exemestane, for hormone receptor-positive HER2-negative advanced breast cancer after failure of treatment with letrozole or anastrozole. Results from the phase III BOLERO-2 trial demonstrated that everolimus in combination with exemestane provided significant clinical benefit to patients with advanced hormone receptor-positive breast cancer. Although everolimus is generally well tolerated, as with most therapies administered in an advanced cancer setting, drug-related adverse events (AEs) inevitably occur. Most common AEs observed in the everolimus studies include stomatitis, rash, infection, noninfectious pneumonitis, and hyperglycemia. Clinical awareness and early identification of such AEs by oncology nurses are essential to dosing (interruptions, reduction, and treatment discontinuation); quality of life; and, ultimately, patient outcomes. Because everolimus has already been shown to significantly improve clinical efficacy in patients with advanced breast cancer, a proactive approach to the practical management of AEs associated with this mTOR inhibitor as well as other most common AEs observed in this patient population has been reviewed and outlined here.

Drug reaction, skin care, skin loss

Stevens-Johnson syndrome is a rare, potentially fatal drug reaction that causes necrosis of epidermal cells. Early recognition of the syndrome is essential to prevent complications. This article discusses identification, complications, and treatment of Stevens-Johnson syndrome.

Incidence, severity and management of cancer chemotherapy related oral mucositis in Eastern Cape and Western Cape

This study explored the incidence, duration and severity of oral mucositis in patients receiving chemotherapy in the Eastern and Western Cape, how this symptom was managed and whether the patients considered the management to be effective. An exploratory, contextual, quantitative survey was conducted. The sampling method was convenience. One hundred and sixty patients were recruited, with 106, (66.3%) participating. Data were collected by means of self-reports, using a self-administered questionnaire. Oral mucositis was a common problem, with 71.7% (n = 76) reporting to have had mucositis. Pain was not effectively managed, as 69.8% (n = 53) of respondents experienced pain whilst only 17.1% (n = 13) reported to have used analgesics. More than half of the respondents used prescribed mouth and throat preparations, whilst 28.9% (n = 22) used non-prescribed self-care measures including potentially harmful products. A significant difference was found between using non-prescribed self-care measures and the duration of oral mucositis (χ² = 0.81; p = 0.01). The reported grade of mucositis did not influence the use of non-prescribed self-care measures, whilst the more pain patients experienced the less inclined they were to use these measures. The management of oral mucositis remains a challenge. Failure to palliate this distressing symptom can lead to the use of potentially harmful self-care measures. Die studie het die insidensie, tydsduur en intensiteit van orale mukositis in Oos en Wes Kaapse pasiënte wat kankerchemoterapie ontvang verken asook hoe hierdie simptoom hanteer is en die sukses hiervan volgens die pasiënte. ‘n Kwantitatiewe, ekploratiewe, kontekstuele opname is onderneem. ‘n Gerieflikheidsteekproef is gebruik om die deelnemers te verkry. Een hondered en sestig persone is genader en 66.3% (n = 106) het aan die studie deelgeneem. Die datainsamelingsmetode was self-rapportering met behulp van ’n vraelys en beskrywende statistiek is gebruik om die data te verwerk. Orale mukositis was ’n algemene probleem, aangesien 71.7% (n = 76) van die respondente die simptoom ondervind het. Pyn was nie goed beheer nie, aangesien 69.8% (n = 53) pyn ondervind het terwyl slegs 17.1% (n = 13) aangedui het dat hulle analgetika gebruik het. Meer as die helfte van die respondente het voorgeskrewe mond en keel preparate gebruik, terwyl 28.9% (n = 22) self gemedikeer het wat potensiële nadelige preparate ingesluit het. ’n Beduidende verskil is tussen die gebruik van nie voorgeskrewe medikasie en die duur van mukositis bevind (χ² = 0.81; p = 0.01). Die graad van die mukositis het nie die gebruik van die self-medikasie beinvloed nie. Hoe meer pyn ondervind is, hoe minder was die neiging om die mukositis self te behandel. Die hantering van orale mukositis bly ’n uitdaging. Die onsuksesvolle palliasie van hierdie simptoom kan tot die gebruik van potensieel nadelige self-sorg maatreëls lei.