Interventions for treating oral mucositis for patients with cancer receiving treatment

Hypoxanthine Reduces Radiation Damage in Vascular Endothelial Cells and Mouse Skin by Enhancing ATP Production via the Salvage Pathway

An effective method that can protect radiation-damaged tissues from apoptosis and promote tissue repair has not been reported to date. Hypoxanthine (Hx) is an intermediate metabolite in the purine degradation system that serves as a substrate for ATP synthesis via the salvage pathway. In this study, we focused on the transient decrease in intracellular ATP concentration after radiation exposure and examined the protective effect of Hx against radiation-induced tissue damage. Human umbilical vein endothelial cells were X irradiated, and the cell viability and incidence of apoptosis and DNA double-strand breaks (DSBs) were evaluated at different Hx concentrations. We found that in the presence of 2-100 μM Hx, the percentages of DSBs and apoptotic cells after 2, 6 and 10 Gy dose of radiation significantly decreased, whereas cell viability increased in a concentration-dependent manner. Moreover, the addition of Hx increased the levels of AMP, ADP, and ATP in the cells at 2 h postirradiation, suggesting that Hx was used for adenine nucleotide synthesis through the salvage pathway. Administration of a xanthine oxidoreductase inhibitor to a mouse model of radiation dermatitis resulted in increased blood Hx levels that inhibited severe dermatitis and accelerated recovery. In conclusion, the findings provide evidence that increasing the levels of Hx to replenish ATP could be an effective strategy to reduce radiation-induced tissue damage and elucidating the detailed mechanisms underlying the protective effects of Hx could help develop new protective strategies against radiation.

Interventions for preventing oral mucositis for patients with cancer receiving treatment

BACKGROUND

Treatment of cancer is increasingly more effective but is associated with short and long term side effects. Oral side effects remain a major source of illness despite the use of a variety of agents to prevent them. One of these side effects is oral mucositis (mouth ulcers).

OBJECTIVES

To evaluate the effectiveness of prophylactic agents for oral mucositis in patients with cancer receiving treatment, compared with other potentially active interventions, placebo or no treatment.

SEARCH STRATEGY

Electronic searches of Cochrane Oral Health Group and PaPaS Trials Registers (to 16 February 2011), CENTRAL (The Cochrane Library 2011, Issue 1), MEDLINE via OVID (1950 to 16 February 2011), EMBASE via OVID (1980 to 16 February 2011), CINAHL via EBSCO (1980 to 16 February 2011), CANCERLIT via PubMed (1950 to 16 February 2011), OpenSIGLE (1980 to 2005) and LILACS via the Virtual Health Library (1980 to 16 February 2011) were undertaken. Reference lists from relevant articles were searched and the authors of eligible trials were contacted to identify trials and obtain additional information.

SELECTION CRITERIA

Randomised controlled trials of interventions to prevent oral mucositis in patients receiving treatment for cancer.

DATA COLLECTION AND ANALYSIS

Information regarding methods, participants, interventions, outcome measures, results and risk of bias were independently extracted, in duplicate, by two review authors. Authors were contacted for further details where these were unclear. The Cochrane Collaboration statistical guidelines were followed and risk ratios calculated using random-effects models.

MAIN RESULTS

A total of 131 studies with 10,514 randomised participants are now included. Overall only 8% of these studies were assessed as being at low risk of bias. Ten interventions, where there was more than one trial in the meta-analysis, showed some statistically significant evidence of a benefit (albeit sometimes weak) for either preventing or reducing the severity of mucositis, compared to either a placebo or no treatment. These ten interventions were: aloe vera, amifostine, cryotherapy, granulocyte-colony stimulating factor (G-CSF), intravenous glutamine, honey, keratinocyte growth factor, laser, polymixin/tobramycin/amphotericin (PTA) antibiotic pastille/paste and sucralfate.

AUTHORS' CONCLUSIONS

Ten interventions were found to have some benefit with regard to preventing or reducing the severity of mucositis associated with cancer treatment. The strength of the evidence was variable and implications for practice include consideration that benefits may be specific for certain cancer types and treatment. There is a need for further well designed, and conducted trials with sufficient numbers of participants to perform subgroup analyses by type of disease and chemotherapeutic agent.

Interventions for treating oral mucositis for patients with cancer receiving treatment

BACKGROUND

Treatment of cancer is increasingly effective but associated with short and long term side effects. Oral side effects, including oral mucositis (mouth ulceration), remain a major source of illness despite the use of a variety of agents to treat them.

OBJECTIVES

To assess the effectiveness of interventions for treating oral mucositis or its associated pain in patients with cancer receiving chemotherapy or radiotherapy or both.

SEARCH STRATEGY

Electronic searches of Cochrane Oral Health Group and PaPaS Trials Registers (to 1 June 2010), CENTRAL via The Cochrane Library (to Issue 2, 2010), MEDLINE via OVID (1950 to 1 June 2010), EMBASE via OVID (1980 to 1 June 2010), CINAHL via EBSCO (1980 to 1 June 2010), CANCERLIT via PubMed (1950 to 1 June 2010), OpenSIGLE (1980 to 1 June 2010) and LILACS via the Virtual Health Library (1980 to 1 June 2010) were undertaken. Reference lists from relevant articles were searched and the authors of eligible trials were contacted to identify trials and obtain additional information.

SELECTION CRITERIA

All randomised controlled trials comparing agents prescribed to treat oral mucositis in people receiving chemotherapy or radiotherapy or both. Outcomes were oral mucositis, time to heal mucositis, oral pain, duration of pain control, dysphagia, systemic infection, amount of analgesia, length of hospitalisation, cost and quality of life.

DATA COLLECTION AND ANALYSIS

Data were independently extracted, in duplicate, by two review authors. Authors were contacted for details of randomisation, blindness and withdrawals. Risk of bias assessment was carried out on six domains. The Cochrane Collaboration statistical guidelines were followed and risk ratio (RR) values calculated using fixed-effect models (less than 3 trials in each meta-analysis).

MAIN RESULTS

Thirty-two trials involving 1505 patients satisfied the inclusion criteria. Three comparisons for mucositis treatment including two or more trials were: benzydamine HCl versus placebo, sucralfate versus placebo and low level laser versus sham procedure. Only the low level laser showed a reduction in severe mucositis when compared with the sham procedure, RR 5.28 (95% confidence interval (CI) 2.30 to 12.13).Only 3 comparisons included more than one trial for pain control: patient controlled analgesia (PCA) compared to the continuous infusion method, therapist versus control, cognitive behaviour therapy versus control. There was no evidence of a difference in mean pain score between PCA and continuous infusion, however, less opiate was used per hour for PCA, mean difference 0.65 mg/hour (95% CI 0.09 to 1.20), and the duration of pain was less 1.9 days (95% CI 0.3 to 3.5).

AUTHORS' CONCLUSIONS

There is weak and unreliable evidence that low level laser treatment reduces the severity of the mucositis. Less opiate is used for PCA versus continuous infusion. Further, well designed, placebo or no treatment controlled trials assessing the effectiveness of interventions investigated in this review and new interventions for treating mucositis are needed.

Comparing pain control and ability to eat and drink with standard therapy vs Gelclair: a preliminary, double centre, randomised controlled trial on patients with radiotherapy-induced oral mucositis

GOAL OF THE WORK: Oral mucositis (OM) is a functionally destructive complication of aggressive head and neck cancer therapy, often resulting in intense pain, an inability to eat and drink and secondary malnutrition and dehydration. The barrier-forming properties of Gelclair have shown promise in relieving such symptoms. The aim of this randomised-controlled trial was to evaluate the efficacy of Gelclair, as compared to standard therapy, as a means of short-term symptom control for patients suffering from radiotherapy-induced OM.

MATERIALS AND METHODS

Twenty patients, with radiotherapy-induced OM seen in two oncology centres in Devon, were randomised to either standard therapy (Sucralfate and Mucaine) or Gelclair and assessed over 24 h. Both treatments were taken four times during the 24-h period, 30 min before meals.

MAIN RESULTS

No significant difference was found between the Gelclair and standard therapy arms in terms of general pain (F = 1.512, df = 1, 17, ns). There did appear to be a trend towards pain improvement initially after the use of Gelclair, but this did not last for the full 24-h assessment period. There was no significant reduction in pain on speaking (F = 0.261, df = 1, 17, ns) nor an improvement in capacity to eat and drink, although the effects of standard therapy did appear to last longer than the Gelclair.

CONCLUSION

This study indicates that Gelclair is no more effective than current standard practice in relieving the pain associated with radiotherapy-induced OM. Nevertheless, observations from this preliminary study warrant further investigation, with a view to shaping the way forward for head and neck cancer practice on a national level.

Prevention of oral mucositis in cancer patients treated with chemotherapy or radiotherapy

DATA SOURCES

The Medline, Embase and CINAHL databases were used to source studies, along with the reference lists of identified articles.

STUDY SELECTION

Studies were restricted to randomised controlled trials (RCT), written in English, where the outcome of mucositis was recorded using the World Health Organization score or the NCI-CTC (National Cancer Institute-Common Toxicity Criteria) score, the absence or presence of ulcerations, or the presence or absence of grades 3 and 4 mucositis.

DATA EXTRACTION AND SYNTHESIS

A total of 45 studies was included in a meta-analysis. When the included studies showed heterogeneity regarding the effect estimates, the results of the meta-analyses were based on the random-effects models; otherwise, the results were based on the fixed-effects models.

RESULTS

The search yielded 109 publications, 45 articles being included in the meta-analyses. These evaluated eight different interventions: local application of chlorhexidine; iseganan; PTA (polymyxin E, tobramycine and amphotericin B); granulocyte macrophage-colony-stimulating factor/ granulocyte colony-stimulating factor (GM-CSF/ G-CSF); oral cooling; sucralfate and glutamine; and systemic administration of amifostine and GM-CSF/G-CSF. Four interventions showed a significant preventive effect on the development or severity of oral mucositis: PTA [odds ratio (OR), 0.61; 95% confidence interval (CI), 0.39-0.96]; GM-CSF (OR, 0.53; 95% CI, 0.33-0.87); oral cooling (OR, 0.3; 95% CI, 0.16-0.56); and amifostine (OR, 0.37; 95% CI, 0.15-0.89).

CONCLUSIONS

From current data, it can be concluded that no single intervention is capable of completely preventing oral mucositis. Future studies should evaluate a combination of interventions for the prevention of oral mucositis. In contrast, novel therapies could be developed that will improve outcomes and be used as single agents.

Clinical effects of flurbiprofen tooth patch on radiation-induced oral mucositis. A pilot study

BACKGROUND

Mucositis is an oral sequela of radiotherapy. In the development of mucositis several mechanisms play a role, such as inflammation and the effect of radiation on the high proliferation rate of oral basal epithelial cells. Therefore, administration of a drug with antiinflammatory and antiproliferative properties might delay the disorder and/or alleviate the severity of oral mucositis. The aim of this pilot study was to evaluate the effect of flurbiprofen in a tooth patch on the development, severity and duration of pseudomembranous mucositis in patients treated with curative head and neck radiotherapy.

METHODS

The study group comprised 12 patients with a malignant tumor in the head and neck region to be treated with primary curative or postoperative radiotherapy. Patients applied once a day before sleep a flurbiprofen tooth patch to a natural tooth or upper denture during the full course of radiotherapy, starting 1 week before the onset of radiotherapy. Oral mucositis, pain, feeding, body weight and viability and maturation of epithelial cells were assessed. The results were compared with the findings in a historical control group.

RESULTS

No differences were found for severity and duration of pseudomembranous mucositis between the two groups. The onset of pseudomembranous/ulcerative mucositis occurred later in the flurbiprofen group (14.6+/-3.8 days, mean+/-SD) than in the historical control group (11+/-3.5 days; P<0.05).

CONCLUSION

This study shows that the flurbiprofen 15 mg tooth patch cannot prevent the development of pseudomembranous mucositis and has no influence on the duration of oral mucositis.