Narrative review of the management of oral mucositis during chemoradiation for head and neck cancer

Association of Insomnia and Obstructive Sleep Apnea with Worse Oral Mucositis and Quality of Life in Head and Neck Cancer Patients Undergoing Radiation Therapy

BACKGROUND

Patients with head and neck cancer (HNC) undergoing radiation therapy (RT) often experience sleep disturbances that may contribute to oral mucositis (OM) and quality of life (QOL).

METHODS

Patients with HNC treated with RT at a single institution were examined. Sleep questionnaires were given on the first day of RT to assess for insomnia and obstructive sleep apnea (OSA). Patient-reported QOL and oral mucositis were assessed during RT. Associations between insomnia and OSA with QOL were assessed using the Mann-Whitney U test. Linear mixed models assessed associations with OM.

RESULTS

Among 87 patients, 34 patients (39%) had subthreshold or greater insomnia and 47 patients (54%) screened positive for OSA. Upon RT completion, patients with subthreshold or greater insomnia had worse physical function (p = 0.005), fatigue (p = 0.01), insomnia (p < 0.001), and sticky saliva (p = 0.002). Patients screening positive for OSA had worse physical function (p = 0.01), sticky saliva (p = 0.02), fatigue (p = 0.007), insomnia (p = 0.009), and pain (p = 0.005). Upon linear mixed model evaluation, subthreshold or greater insomnia (p = 0.01) and positive OSA screen (p = 0.002) were associated with worse OM.

CONCLUSION

Insomnia and OSA are highly prevalent in patients with HNC undergoing RT. These sleep disturbances are associated with worse QOL and OM during treatment.

Management of radiation-induced oral mucositis in head and neck cancer patients: a real-life survey among 25 Italian radiation oncology centers

AIM

Radiation-induced oral mucositis (RIOM) is the most frequent side effect in head and neck cancer (HNC) patients treated with curative radiotherapy (RT). A standardized strategy for preventing and treating RIOM has not been defined. Aim of this study was to perform a real-life survey on RIOM management among Italian RT centers.

METHODS

A 40-question survey was administered to 25 radiation oncologists working in 25 different RT centers across Italy.

RESULTS

A total of 1554 HNC patients have been treated in the participating centers in 2021, the majority (median across the centers 91%) with curative intent. Median treatment time was 41 days, with a mean percentage of interruption due to toxicity of 14.5%. Eighty percent of responders provide written oral cavity hygiene recommendations. Regarding RIOM prevention, sodium bicarbonate mouthwashes, oral mucosa barrier agents, and hyaluronic acid-based mouthwashes were the most frequent topic agents used. Regarding RIOM treatment, 14 (56%) centers relied on literature evidence, while internal guidelines were available in 13 centers (44%). Grade (G)1 mucositis is mostly treated with sodium bicarbonate mouthwashes, oral mucosa barrier agents, and steroids, while hyaluronic acid-based agents, local anesthetics, and benzydamine were the most used in mucositis G2/G3. Steroids, painkillers, and anti-inflammatory drugs were the most frequent systemic agents used independently from the RIOM severity.

CONCLUSION

Great variety of strategies exist among Italian centers in RIOM management for HNC patients. Whether different strategies could impact patients' compliance and overall treatment time of the radiation course is still unclear and needs further investigation.

Prophylactic High-Dose Gabapentin Reduces Opiate Use during Radiation Therapy for Head and Neck Squamous Cell Carcinoma

Background: The role of prophylactic high-dose gabapentin for the management of oral mucositis during radiation therapy for head and neck squamous cell carcinoma (HNSCC) remains controversial. Methods: A retrospective cohort analysis was performed on primary HNSCC patients treated at our institution. Kruskal–Wallis and Fisher’s exact tests were used to compare the patients’ baseline characteristics. Multivariate competing risk and logistic regressions were performed to evaluate time to first opioid use and feeding tube placement. Results: In total, 480 consecutive HNSCC patients were included. Within this cohort, 186 patients received 3600 mg gabapentin, 182 received 300 to 3200 mg gabapentin, and 112 received no gabapentin. The time to first opioid use was greater in the 3600 mg group compared with the no gabapentin group (34.3 vs. 23.9 days, p < 0.001) and to the 300 to 3200 mg group (28.0 days, p < 0.001). The proportion of patients requiring opioids at any point during RT was lower in the 3600 mg gabapentin group compared with the no gabapentin group (31.8% vs. 60.1%, p < 0.001) and with the 300 to 3200 mg group (63.8%, p < 0.001). Conclusions: Prophylactic use of 3600 mg gabapentin was well tolerated, halved overall opioid use, and delayed the time to first opioid use during radiation therapy.

Efficacy of kangfuxin liquid on radiotherapy-induced oral mucositis for patients with head and neck squamous cell carcinoma and its effect on salivary glands and immune function

OBJECTIVE

To observe the efficacy of Kangfuxin liquid on radiotherapy-induced oral mucositis for patients with head and neck squamous cell carcinoma and its effects on salivary glands and immune function.

METHODS

A total of 97 patients with head and neck squamous cell carcinoma receiving radiotherapy in Guigang City People's Hospital from January 2019 to June 2021 were retrospectively analyzed and divided into a control group and a test group according to different treatment plans. The two groups received the same radiation therapy. Patients in the control group (n=46) were given borax-containing gargles, while those in the test group (n=51) were treated with Kangfuxin liquid. We observed the incidences and grades of oral mucositis and oral pain, changes in saliva flow rate, pH of saliva, levels of epidermal growth factor (EGF) and amylase, levels of CD4⁺/CD8⁺, CD19⁺/CD69⁺ and natural killer (NK) cells, and serum cytokine (TGF-β1, IL-6 and C-reactive protein (CRP)) levels in the two groups before radiotherapy, and after 21 d and 42 d of radiotherapy. Quality of Life Instruments for Cancer Patients-Head and Neck Cancer (QLICP-HN) scores were compared in both groups before radiotherapy, and after 42 d of radiotherapy.

RESULTS

No oral mucositis or oral pain was found before radiotherapy in both groups. The incidences of oral mucositis and oral pain after 21 d and 42 d of radiotherapy in the test group were not significantly different from those in the control group (all P>0.05). The grades of oral mucositis and oral pain in the test group after 21 d and 42 d of radiotherapy were lower than those in the control group (all P<0.05). The test group had higher saliva flow rate, pH of saliva, levels of EGF and amylase, and levels of CD4⁺/CD8⁺, CD19⁺/CD69⁺ and NK cells. The test group had lower serum levels of TGF-β1, IL-6, and CRP than the control group after 21 d and 42 d of radiotherapy (all P<0.05). The scores of each item of the QLICP-HN scale and total scores in the test group were higher than those of the control group after 42 d of radiotherapy (all P<0.05).

CONCLUSION

Kangfuxin liquid effectively prevents the occurrence of radiotherapy-induced oral mucositis for patients with head and neck squamous cell carcinoma, reduces oral mucosal reactions and oral pain, improves salivary gland function, reduces inflammatory response, promotes cellular immune function, improves quality of life, and improves prognosis.

Disadvantaged Subgroups Within the Global Head and Neck Cancer Population: How Can We Optimize Care?

Within the global head and neck cancer population, there are subgroups of patients with poorer cancer outcomes independent from tumor characteristics. In this article, we review three such groups. The first group comprises patients with nasopharyngeal cancer in low- and middle-income countries where access to high-volume, well-resourced radiotherapy centers is limited. We discuss a recent study that is aiming to improve outcomes through the instigation of a comprehensive radiotherapy quality assurance program. The second group comprises patients with low socioeconomic status in a high-income country who experience substantial financial toxicity, defined as financial hardship for patients due to health care costs. We review causes and consequences of financial toxicity and discuss how it can be mitigated. The third group comprises older patients who may poorly tolerate and not benefit from intensive standard-of-care treatment. We discuss the role of geriatric assessment, particularly in relation to the use of chemotherapy. Through better recognition and understanding of disadvantaged groups within the global head and neck cancer population, we will be better placed to instigate the necessary changes to improve outcomes and quality of life for patients with head and neck cancer.

Efficacy of the Nourishing Yin and Clearing Heat Therapy Based on Traditional Chinese Medicine in the Prevention and Treatment of Radiotherapy-Induced Oral Mucositis in Nasopharyngeal Carcinomas: A Systematic Review and Meta-Analysis of Thirty Randomized Controlled Trials

This study aimed to evaluate the efficacy of nourishing Yin and clearing heat therapy (NYCH therapy) based on traditional Chinese medicine (TCM) in the treatment of radiotherapy-induced oral mucositis (RTOM) in nasopharyngeal carcinomas (NPCs). A total of eight online databases were searched from inception to September 2021 for randomized controlled trials (RCTs). The control group was treated with Western medicine (WM) alone, whereas the experimental group was treated with a combined NYCH and WM therapy. A total of 30 RCTs involving 2562 participants were ultimately included. NYCH therapy combined with conventional WM delayed the onset time (days) of RTOM (MD = 10.80, p < 0.001), and at that time, a higher cumulative radiotherapy dose (Gy) (MD = 5.72, p < 0.001) was completed in the experimental group. The combination regimen also reduced the incidence of severe oral mucositis (Grade III–IV) (RR = 0.25, p < 0.001). In addition, the treatment efficacy of the experimental group was significantly better than that of the control group (RR = 1.31, p < 0.001). Compared with the patients in the control group, the experimental group had lower xerostomia scores (MD = -1.07, p < 0.001) and more saliva (MD = 0.36, p < 0.001). NYCH combined with WM improved the efficacy of treating RTOM in NPC. This study provides a sufficient basis for conducting further large RCTs to prove the efficacy of NYCH.

State of Rehabilitation Research in the Head and Neck Cancer Population: Functional Impact vs. Impairment-Focused Outcomes

PURPOSE OF REVIEW

Management of head and neck cancer (HNC) typically involves a morbid combination of surgery, radiation, and systemic therapy. As the number of HNC survivors grows, there is growing interest in rehabilitation strategies to manage HNC-related comorbidity. In this review, we summarize the current state of HNC rehabilitation research.

RECENT FINDINGS

We have organized our review using the World Health Organization's International Classification of Function (ICF) model of impairment, activity, and participation. Specifically, we describe the current research on rehabilitation strategies to prevent and treat impairments including dysphagia, xerostomia, dysgeusia, dysosmia, odynophagia, trismus, first bite syndrome, dysarthria, dysphonia, lymphedema, shoulder syndrome, cervicalgia, cervical dystonia and dropped head syndrome, deconditioning, and fatigue. We also discuss the broader impact of HNC-related impairment by exploring the state of rehabilitation literature on activity, participation, psychosocial distress, and suicidality in HNC survivors. We demonstrate that research in HNC rehabilitation continues to focus primarily on impairment-driven interventions. There remains a dearth of HNC rehabilitation studies directly examining the impact of rehabilitation interventions on outcomes related to activity and participation. More high-quality interventional studies and reviews are needed to guide prevention and treatment of functional loss in HNC survivors.