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Saito Y, Takekuma Y, Takeshita T, Oshino T, Sugawara M. Impact of systemic dexamethasone dosage on docetaxel-induced oral mucositis in patients with breast cancer. Sci Rep 2023; 13:10169. [PMID: 37349388 PMCID: PMC10287713 DOI: 10.1038/s41598-023-37285-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 06/19/2023] [Indexed: 06/24/2023] Open
Abstract
Oral mucositis (OM) is a common adverse effect of docetaxel-containing treatment. This study aimed to assess whether dexamethasone (DEX) dose-dependently attenuates docetaxel-induced OM and dysgeusia. We retrospectively analyzed medical records of patients with breast cancer receiving docetaxel-containing regimens at Hokkaido University Hospital between June 2015 and June 2022. The patients were divided into low-dose and high-dose groups (DEX 4 or 8 mg/day on days 2-4, respectively), and incidence of OM and dysgeusia, and risk factor(s) for OM incidence were evaluated. The incidence of all-grade OM in the first cycle was 57.8% in the low-dose group and 19.2% in the high-dose group (P = 0.0002), which met our primary endpoint. The incidence of OM in all treatment cycles was also significantly lowered by DEX-dose increase (P = 0.01). In contrast, the incidence of dysgeusia was similar between the two groups in the first and all cycles (P = 0.50 and P = 0.28, respectively). These results were also confirmed in a propensity score-matched population. Multivariate logistic regression analysis also suggested that lower DEX dosage was a singular risk factor for all-grade OM incidence. In conclusion, our study suggests that DEX dose-dependently reduces the incidence of OM in docetaxel-containing regimens for breast cancer treatment.
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Affiliation(s)
- Yoshitaka Saito
- Department of Pharmacy, Hokkaido University Hospital, Kita 14-jo, Nishi 5-chome, Kita-ku, Sapporo, 060-8648, Japan
| | - Yoh Takekuma
- Department of Pharmacy, Hokkaido University Hospital, Kita 14-jo, Nishi 5-chome, Kita-ku, Sapporo, 060-8648, Japan
| | - Takashi Takeshita
- Department of Breast Surgery, Hokkaido University Hospital, Kita 14-jo, Nishi 5-chome, Kita-ku, Sapporo, 060-8648, Japan
| | - Tomohiro Oshino
- Department of Breast Surgery, Hokkaido University Hospital, Kita 14-jo, Nishi 5-chome, Kita-ku, Sapporo, 060-8648, Japan
| | - Mitsuru Sugawara
- Department of Pharmacy, Hokkaido University Hospital, Kita 14-jo, Nishi 5-chome, Kita-ku, Sapporo, 060-8648, Japan.
- Laboratory of Pharmacokinetics, Faculty of Pharmaceutical Sciences, Hokkaido University, Kita 12-jo, Nishi 6-chome, Kita-ku, Sapporo, 060-0812, Japan.
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Impact of systemic dexamethasone administration on oral mucositis induced by anthracycline-containing regimens in breast cancer treatment. Sci Rep 2022; 12:12587. [PMID: 35869165 PMCID: PMC9307799 DOI: 10.1038/s41598-022-16935-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 07/18/2022] [Indexed: 11/09/2022] Open
Abstract
AbstractOral mucositis (OM) is one of the most common complications associated with chemotherapy. Here, we evaluated whether systemic dexamethasone (DEX) dosage in prophylactic antiemetics affected the incidence of OM in anthracycline-containing regimens. Patients receiving anthracycline-containing regimens for breast cancer were divided into high- and low-DEX dose groups and retrospectively evaluated. The incidence of all-grade OM in the first cycle in the high- and low-dose groups was 27.3% and 53.5%, respectively, and was significantly lowered by increasing the DEX dose (P < 0.01); thus, the study met its primary endpoint. The result in all treatment cycles was also significant (P = 0.02). In contrast, the incidence of dysgeusia was similar between the high- and low-dose groups in the first and all cycles (13.6% and 16.3% in the first cycle [P = 0.79] and 27.3% and 34.9% in all cycles [P = 0.42], respectively). Multivariate analysis revealed that low DEX dosage was an independent risk factor for all-grade OM development. In conclusion, our study suggests that DEX attenuates OM in anthracycline-containing regimens for breast cancer treatment in a dose-dependent manner. Further evaluation of OM prophylaxis, including DEX administration, is required for better control.
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Logan RM, Al-Azri AR, Bossi P, Stringer AM, Joy JK, Soga Y, Ranna V, Vaddi A, Raber-Durlacher JE, Lalla RV, Cheng KKF, Elad S. Systematic review of growth factors and cytokines for the management of oral mucositis in cancer patients and clinical practice guidelines. Support Care Cancer 2020; 28:2485-2498. [PMID: 32080767 DOI: 10.1007/s00520-019-05170-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 11/05/2019] [Indexed: 01/05/2023]
Abstract
PURPOSE To update the clinical practice guidelines for the use of growth factors and cytokines for the prevention and/or treatment of oral mucositis (OM). METHODS A systematic review was conducted by the Mucositis Study Group of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO). The body of evidence for each intervention, in each cancer treatment setting, was assigned an evidence level. The findings were added to the database used to develop the 2014 MASCC/ISOO clinical practice guidelines. Based on the evidence level, the following guidelines were determined: recommendation, suggestion, and no guideline possible. RESULTS A total of 15 new papers were identified within the scope of this section and were merged with 51 papers that were reviewed in the previous guidelines update. Of these, 14, 5, 13, 2, and 1 were randomized controlled trials about KGF-1, G-CSF, GM-CSF, EGF, and erythropoietin, respectively. For the remaining agents there were no new RCTs. The previous recommendation for intravenous KGF-1 in patients undergoing autologous hematopoietic stem cell transplantation (HSCT) conditioned with high-dose chemotherapy and TBI-based regimens is confirmed. The previous suggestion against the use of topical GM-CSF for the prevention of OM in the setting of high-dose chemotherapy followed by autologous or allogeneic stem cell transplantation remains unchanged. CONCLUSIONS Of the growth factors and cytokines studied for the management of OM, the evidence supports a recommendation in favor of KGF-1 and a suggestion against GM-CSF in certain clinical settings.
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Affiliation(s)
- Richard M Logan
- Adelaide Dental School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, 5005, South Australia, Australia
| | - Abdul Rahman Al-Azri
- Adelaide Dental School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, 5005, South Australia, Australia. .,Dental and OMFS Department, Oral Pathology and Medicine, Al-Nahdha Hospital, Ministry of Health, Muscat, Oman.
| | - Paolo Bossi
- Medical Oncology, University of Brescia, ASST-Spedali Civili, Brescia, Italy
| | - Andrea M Stringer
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia.,Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, 5005, South Australia, Australia
| | - Jamie K Joy
- Clinical Pharmacy, Cancer Treatment Centers of America, Boca Raton, FL, USA
| | - Yoshihiko Soga
- Okayama University Hospital, 2-5-1, Shikata-cho, Kita-ku, Okayama, Japan
| | - Vinisha Ranna
- Department of Oral and Maxillofacial Surgery, The Mount Sinai Hospital, New York, NY, USA
| | - Anusha Vaddi
- Oral Medicine, Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, NY, USA.,Division of Oral and Maxillofacial Diagnostic Sciences, University of Connecticut School of Dental Medicine, Farmington, CT, USA
| | - Judith E Raber-Durlacher
- Department of Oral Medicine, Academic Centre for Dentistry Amsterdam, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,Department of Oral and Maxillofacial Surgery, Amsterdam UMC, University of Amsterdam , Amsterdam, Netherlands
| | - Rajesh V Lalla
- Division of Oral and Maxillofacial Diagnostic Sciences, University of Connecticut School of Dental Medicine, Farmington, CT, USA
| | - Karis Kin Fong Cheng
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Sharon Elad
- Oral Medicine, Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, NY, USA
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Altundag K. Is there any association between use of granulocyte colony-stimulating factor and chemotherapy-induced oral mucositis? Eur J Cancer Care (Engl) 2019; 27:e12921. [PMID: 30485603 DOI: 10.1111/ecc.12921] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 06/16/2018] [Accepted: 08/19/2018] [Indexed: 01/14/2023]
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Campos JC, Cunha JD, Ferreira DC, Reis S, Costa PJ. Challenges in the local delivery of peptides and proteins for oral mucositis management. Eur J Pharm Biopharm 2018; 128:131-146. [PMID: 29702221 DOI: 10.1016/j.ejpb.2018.04.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 04/21/2018] [Accepted: 04/23/2018] [Indexed: 12/20/2022]
Abstract
Oral mucositis, a common inflammatory side effect of oncological treatments, is a disorder of the oral mucosa that can cause painful ulcerations, local motor disabilities, and an increased risk of infections. Due to the discomfort it produces and the associated health risks, it can lead to cancer treatment restrains, such as the need for dose reduction, cycle delays or abandonment. Current mucositis management has low efficiency in prevention and treatment. A topical drug application for a local action can be a more effective approach than systemic routes when addressing oral cavity pathologies. Local delivery of growth factors, antibodies, and anti-inflammatory cytokines have shown promising results. However, due to the peptide and protein nature of these novel agents, and the several anatomic, physiological and environmental challenges of the oral cavity, their local action might be limited when using traditional delivering systems. This review is an awareness of the issues and strategies in the local delivery of macromolecules for the management of oral mucositis.
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Affiliation(s)
- João C Campos
- UCIBIO, REQUIMTE, Laboratory of Pharmaceutical Technology, Department of Drug Sciences, Faculty of Pharmacy, University of Porto, Portugal(1).
| | - João D Cunha
- UCIBIO, REQUIMTE, Laboratory of Pharmaceutical Technology, Department of Drug Sciences, Faculty of Pharmacy, University of Porto, Portugal(1)
| | - Domingos C Ferreira
- UCIBIO, REQUIMTE, Laboratory of Pharmaceutical Technology, Department of Drug Sciences, Faculty of Pharmacy, University of Porto, Portugal(1)
| | - Salette Reis
- LAQV, REQUIMTE, Department of Chemical Sciences, Faculty of Pharmacy, University of Porto, Portugal(1)
| | - Paulo J Costa
- UCIBIO, REQUIMTE, Laboratory of Pharmaceutical Technology, Department of Drug Sciences, Faculty of Pharmacy, University of Porto, Portugal(1)
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Riley P, Glenny A, Worthington HV, Littlewood A, Fernandez Mauleffinch LM, Clarkson JE, McCabe MG. Interventions for preventing oral mucositis in patients with cancer receiving treatment: cytokines and growth factors. Cochrane Database Syst Rev 2017; 11:CD011990. [PMID: 29181845 PMCID: PMC6486203 DOI: 10.1002/14651858.cd011990.pub2] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Oral mucositis is a side effect of chemotherapy, head and neck radiotherapy, and targeted therapy, affecting over 75% of high-risk patients. Ulceration can lead to severe pain and difficulty with eating and drinking, which may necessitate opioid analgesics, hospitalisation and supplemental nutrition. These complications may disrupt cancer therapy, which may reduce survival. There is also a risk of death from sepsis if pathogens enter the ulcers of immunocompromised patients. Ulcerative oral mucositis can be costly to healthcare systems, yet there are few preventive interventions proven to be beneficial. Cytokines and growth factors may help the regeneration of cells lining of the mouth, thus preventing or reducing oral mucositis and its negative effects. OBJECTIVES To assess the effects of cytokines and growth factors for preventing oral mucositis in patients with cancer who are receiving treatment. SEARCH METHODS Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (searched 10 May 2017); the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 4) in the Cochrane Library (searched 10 May 2017); MEDLINE Ovid (1946 to 10 May 2017); Embase Ovid (7 December 2015 to 10 May 2017); CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to 10 May 2017); and CANCERLIT PubMed (1950 to 10 May 2017). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. SELECTION CRITERIA We included parallel-design randomised controlled trials (RCTs) assessing the effects of cytokines and growth factors in patients with cancer receiving treatment. DATA COLLECTION AND ANALYSIS Two review authors independently screened the results of electronic searches, extracted data and assessed risk of bias. For dichotomous outcomes, we reported risk ratios (RR) and 95% confidence intervals (CI). For continuous outcomes, we reported mean differences (MD) and 95% CIs. We pooled similar studies in random-effects meta-analyses. We reported adverse effects in a narrative format. MAIN RESULTS We included 35 RCTs analysing 3102 participants. Thirteen studies were at low risk of bias, 12 studies were at unclear risk of bias, and 10 studies were at high risk of bias.Our main findings were regarding keratinocyte growth factor (KGF) and are summarised as follows.There might be a reduction in the risk of moderate to severe oral mucositis in adults receiving bone marrow/stem cell transplantation after conditioning therapy for haematological cancers (RR 0.89, 95% CI 0.80 to 0.99; 6 studies; 852 participants; low-quality evidence). We would need to treat 11 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 6 to 112). There might be a reduction in the risk of severe oral mucositis in this population, but there is also some possibility of an increase in risk (RR 0.85, 95% CI 0.65 to 1.11; 6 studies; 852 participants; low-quality evidence). We would need to treat 10 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 5 to prevent the outcome to 14 to cause the outcome).There is probably a reduction in the risk of moderate to severe oral mucositis in adults receiving radiotherapy to the head and neck with cisplatin or fluorouracil (RR 0.91, 95% CI 0.83 to 1.00; 3 studies; 471 participants; moderate-quality evidence). We would need to treat 12 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 7 to infinity). It is very likely that there is a reduction in the risk of severe oral mucositis in this population (RR 0.79, 95% CI 0.69 to 0.90; 3 studies; 471 participants; high-quality evidence). We would need to treat 7 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 5 to 15).It is likely that there is a reduction in the risk of moderate to severe oral mucositis in adults receiving chemotherapy alone for mixed solid and haematological cancers (RR 0.56, 95% CI 0.45 to 0.70; 4 studies; 344 participants; moderate-quality evidence). We would need to treat 4 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 3 to 6). There might be a reduction in the risk of severe oral mucositis in this population (RR 0.30, 95% CI 0.14 to 0.65; 3 studies; 263 participants; low -quality evidence). We would need to treat 10 adults with KGF in order to prevent one additional adult from developing this outcome (95% CI 8 to 19).Due to the low volume of evidence, single-study comparisons and insufficient sample sizes, we found no compelling evidence of a benefit for any other cytokines or growth factors and there was no evidence on children. There did not appear to be any serious adverse effects of any of the interventions assessed in this review. AUTHORS' CONCLUSIONS We are confident that KGF is beneficial in the prevention of oral mucositis in adults who are receiving: a) radiotherapy to the head and neck with cisplatin or fluorouracil; or b) chemotherapy alone for mixed solid and haematological cancers. We are less confident about a benefit for KGF in adults receiving bone marrow/stem cell transplant after conditioning therapy for haematological cancers because of multiple factors involved in that population, such as whether or not they received total body irradiation (TBI) and whether the transplant was autologous (the patients' own cells) or allogeneic (cells from a donor). KGF appears to be a relatively safe intervention.Due to limited research, we are not confident that there are any beneficial effects of other cytokines and growth factors. There is currently insufficient evidence to draw any conclusions about the use of cytokines and growth factors in children.
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Affiliation(s)
- Philip Riley
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of ManchesterCochrane Oral HealthJR Moore BuildingOxford RoadManchesterUKM13 9PL
| | - Anne‐Marie Glenny
- The University of ManchesterDivision of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and HealthJR Moore BuildingOxford RoadManchesterUKM13 9PL
| | - Helen V Worthington
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of ManchesterCochrane Oral HealthJR Moore BuildingOxford RoadManchesterUKM13 9PL
| | - Anne Littlewood
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of ManchesterCochrane Oral HealthJR Moore BuildingOxford RoadManchesterUKM13 9PL
| | - Luisa M Fernandez Mauleffinch
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of ManchesterCochrane Oral HealthJR Moore BuildingOxford RoadManchesterUKM13 9PL
| | - Jan E Clarkson
- University of DundeeDivision of Oral Health SciencesDental Hospital & SchoolPark PlaceDundeeScotlandUKDD1 4HR
| | - Martin G McCabe
- The University of ManchesterDivision of Cancer SciencesManchester Academic Health Science CentreManchesterUK
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Stokman MA, Spijkervet FKL, Boezen HM, Schouten JP, Roodenburg JLN, de Vries EGE. Preventive Intervention Possibilities in Radiotherapy- and Chemotherapy-induced Oral Mucositis: Results of Meta-analyses. J Dent Res 2016; 85:690-700. [PMID: 16861284 DOI: 10.1177/154405910608500802] [Citation(s) in RCA: 108] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The aim of these meta-analyses was to evaluate the effectiveness of interventions for the prevention of oral mucositis in cancer patients treated with head and neck radiotherapy and/or chemotherapy, with a focus on randomized clinical trials. A literature search was performed for reports of randomized controlled clinical studies, published between 1966 and 2004, the aim of which was the prevention of mucositis in cancer patients undergoing head and neck radiation, chemotherapy, or chemoradiation. The control group consisted of a placebo, no intervention, or another intervention group. Mucositis was scored by either the WHO, the National Cancer Institute-Common Toxicity Criteria (NCI-CTC) score, or the absence or presence of ulcerations, or the presence or absence of grades 3 and 4 mucositis. The meta-analyses included 45 studies fulfilling the inclusion criteria, in which 8 different interventions were evaluated: i.e., 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 with an odds ratio (OR) = 0.61 (95% confidence interval [CI], 0.39–0.96); GM-CSF, OR = 0.53 (CI: 0.33–0.87); oral cooling, OR = 0.3 (CI: 0.16–0.56); and amifostine, OR = 0.37 (CI: 0.15–0.89). To date, no single intervention completely prevents oral mucositis, so combined preventive therapy strategies seem to be required to ensure more successful outcomes.
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Affiliation(s)
- M A Stokman
- Departments of Oral and Maxillofacial Surgery, University of Groningen and University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands.
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8
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Chaveli-López B, Bagán-Sebastián JV. Treatment of oral mucositis due to chemotherapy. J Clin Exp Dent 2016; 8:e201-9. [PMID: 27034762 PMCID: PMC4808317 DOI: 10.4317/jced.52917] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 01/08/2016] [Indexed: 11/05/2022] Open
Abstract
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.
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Affiliation(s)
- Begonya Chaveli-López
- DDS. Stomatology Department, Faculty of Medicine and Dentistry, University of Valencia, Spain
| | - José V Bagán-Sebastián
- MD, DDS, PhD. Head of the Department of Stomatology and Maxillofacial Surgery. Chairman of Oral Medicine. University of Valencia, Spain
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Hosseinjani H, Hadjibabaie M, Gholami K, Javadi M, Radfar M, Jahangard-Rafsanjani Z, Hosseinjani E, Shabani N, Vaezi M, Ghavamzadeh A. The efficacy of erythropoietin mouthwash in prevention of oral mucositis in patients undergoing autologous hematopoietic SCT: a double-blind, randomized, placebo-controlled trial. Hematol Oncol 2015; 35:106-112. [PMID: 26310513 DOI: 10.1002/hon.2250] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Revised: 07/14/2015] [Accepted: 07/14/2015] [Indexed: 11/11/2022]
Abstract
Oral mucositis (OM) as a complication of high-dose chemotherapy is frequently occurred in hematopoietic stem cell transplantation (HSCT) settings. Erythropoietin (EPO) has anti-inflammatory, antioxidant and wound-healing properties and therefore could have an important role in the prevention of OM. We conducted a double-blind, randomized, placebo-controlled trial to evaluate the EPO mouthwash effect on OM incidence and severity in 80 patients with non-Hodgkin's lymphoma, Hodgkin disease (HD) or multiple myeloma, undergoing autologous hematopoietic stem cell transplantation. Patients received either EPO mouthwash (50 IU/ml, 15 ml four times a day) (n = 40) or placebo (n = 40) from the starting day of high-dose chemotherapy until day +14 after transplantation or until the day of discharge from the hospital, whichever occurred first. OM was evaluated daily for 21 days after transplantation or until resolution of OM according to World Health Organization oral toxicity scale. The incidence of OM (grades 1-4) in the EPO mouthwash group and control group was significantly different (27.5% vs 77.5%, p < 0.001). The mean ± SD of two other parameters of OM including maximum intensity OM score (0.60 ± 1.06 vs 1.67 ± 1.27) and average intensity OM score (0.47 ± 0.80 vs 1.28 ± 0.86) was significantly lower in the intervention group (p < 0.001). Moreover, the mean ± SD duration of OM was also significantly shorter among the EPO mouthwash recipients (1.92 ± 3.42 days vs 5.42 ± 3.86 days, P < 0.001). Also, the duration of neutropenic fever was significantly shorter in the intervention group (2.12 ± 2.42 days vs 3.95 ± 4.01 days, p = 0.016). It is concluded that EPO mouthwash can reduce the incidence and duration of OM. Copyright © 2015 John Wiley & Sons, Ltd.
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Affiliation(s)
- Hesamoddin Hosseinjani
- Clinical Pharmacy Department, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Molouk Hadjibabaie
- Clinical Pharmacy Department, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran.,Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
| | - Kheirollah Gholami
- Clinical Pharmacy Department, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran.,Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Javadi
- Clinical Pharmacy Department, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran.,Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
| | - Mania Radfar
- Clinical Pharmacy Department, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | | | | | - Nazanin Shabani
- Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Vaezi
- Hematology-Oncology and Stem Cell Transplantation Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ardeshir Ghavamzadeh
- Hematology-Oncology and Stem Cell Transplantation Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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10
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Raber-Durlacher JE, von Bültzingslöwen I, Logan RM, Bowen J, Al-Azri AR, Everaus H, Gerber E, Gomez JG, Pettersson BG, Soga Y, Spijkervet FKL, Tissing WJE, Epstein JB, Elad S, Lalla RV. Systematic review of cytokines and growth factors for the management of oral mucositis in cancer patients. Support Care Cancer 2012; 21:343-55. [PMID: 22987094 DOI: 10.1007/s00520-012-1594-5] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Accepted: 08/30/2012] [Indexed: 11/30/2022]
Abstract
PURPOSE The aim of this project was to review the literature and define clinical practice guidelines for the use of cytokines and growth factor agents for the prevention or treatment of oral mucositis induced by cancer chemotherapy or radiotherapy. METHODS A systematic review was conducted by the Mucositis Study Group of the Multinational Association of Supportive Care in Cancer/International Society for Oral Oncology (MASCC/ISOO). The body of evidence for each intervention, in each cancer treatment setting, was assigned an evidence level. Based on the evidence level, one of the following three guideline determinations was possible: Recommendation, Suggestion, No guideline possible. RESULTS Sixty-four clinical studies across 11 interventions were evaluated. A recommendation was made for the use of recombinant human KGF-1 (palifermin) at a dose of 60 μg/kg per day for 3 days prior to conditioning treatment and for 3 days post-transplant for prevention of oral mucositis in patients receiving high-dose chemotherapy and total body irradiation followed by autologous stem cell transplantation for hematological malignancies. A suggestion was made against using granulocyte macrophage colony-stimulating factor mouthwash for the prevention of oral mucositis in the setting of high-dose chemotherapy followed by autologous or allogeneic stem cell transplantation. No guideline was possible for any other cytokine or growth factor agents due to inconclusive evidence. CONCLUSIONS Of the cytokine and growth factor agents studied for oral mucositis, the evidence only supports use of palifermin in the specific population listed above. Additional well-designed research is needed on other cytokine and growth factor interventions and in other cancer treatment settings.
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Affiliation(s)
- Judith E Raber-Durlacher
- Department of Periodontology ACTA (Academic Centre for Dentistry Amsterdam), University of Amsterdam and VU University Amsterdam, Gustav Mahlerlaan 3004, 1081 LA Amsterdam, The Netherlands.
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11
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Worthington HV, Clarkson JE, Bryan G, Furness S, Glenny AM, Littlewood A, McCabe MG, Meyer S, Khalid T. Interventions for preventing oral mucositis for patients with cancer receiving treatment. Cochrane Database Syst Rev 2011; 2011:CD000978. [PMID: 21491378 PMCID: PMC7032547 DOI: 10.1002/14651858.cd000978.pub5] [Citation(s) in RCA: 125] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
- Helen V Worthington
- Cochrane Oral Health Group, School of Dentistry, The University of Manchester, Coupland III Building, Oxford Road, Manchester, UK, M13 9PL
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Role of bone marrow-derived monocytes/macrophages in the repair of mucosal damage caused by irradiation and/or anticancer drugs in colitis model. Mediators Inflamm 2011; 2010:634145. [PMID: 21274263 PMCID: PMC3022216 DOI: 10.1155/2010/634145] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2010] [Revised: 11/18/2010] [Accepted: 12/07/2010] [Indexed: 12/31/2022] Open
Abstract
Mucosal damage is a common side effect of many cancer treatments, especially radiotherapy and intensive chemotherapy, which often induce bone marrow (BM) suppression. We observed that acetic acid- (AA-) induced mucosal damage in the colon of mice was worsened by simultaneous treatment with irradiation or 5-FU. However, irradiation 14 days prior to the AA treatment augmented the recovery from mucosal damage, suggesting that the recovery from BM suppression had an advantageous effect on the mucosal repair. In addition, BM transplantation also augmented the recovery from AA-induced mucosal damage. We further confirmed that transplanted BM-derived cells, particularly F4/80+Gr1+ “inflammatory” monocytes (Subset 1), accumulated in the damaged mucosal area in the early healing phase, and both of Subset 1 and F4/80+Gr1− “resident” monocytes (Subset 2) accumulated in this area in later phases. Our results suggest that monocytes/macrophages contribute to the mucosal recovery and regeneration following mucosal damage by anticancer drug therapy.
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Worthington HV, Clarkson JE, Bryan G, Furness S, Glenny AM, Littlewood A, McCabe MG, Meyer S, Khalid T. Interventions for preventing oral mucositis for patients with cancer receiving treatment. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2010. [DOI: 10.1002/14651858.cd000978.pub4] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Worthington HV, Clarkson JE, Bryan G, Furness S, Glenny AM, Littlewood A, McCabe MG, Meyer S, Khalid T. Interventions for preventing oral mucositis for patients with cancer receiving treatment. Cochrane Database Syst Rev 2010:CD000978. [PMID: 21154347 DOI: 10.1002/14651858.cd000978.pub3] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
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 1 June 2010), CENTRAL (The Cochrane Library 2010, Issue 2), 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 2005) 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 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. Nine 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 nine interventions were: allopurinol, aloe vera, amifostine, cryotherapy, glutamine (intravenous), honey, keratinocyte growth factor, laser, and polymixin/tobramycin/amphotericin (PTA) antibiotic pastille/paste. AUTHORS' CONCLUSIONS Nine 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.
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Affiliation(s)
- Helen V Worthington
- Cochrane Oral Health Group, School of Dentistry, The University of Manchester, Coupland III Building, Oxford Road, Manchester, UK, M13 9PL
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von Bültzingslöwen I, Brennan MT, Spijkervet FKL, Logan R, Stringer A, Raber-Durlacher JE, Keefe D. Growth factors and cytokines in the prevention and treatment of oral and gastrointestinal mucositis. Support Care Cancer 2006; 14:519-27. [PMID: 16775647 DOI: 10.1007/s00520-006-0052-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2006] [Accepted: 02/21/2006] [Indexed: 10/24/2022]
Abstract
GOALS OF WORK Growth factors and cytokines may be useful in preventing chemotherapy (CT)- and radiotherapy (RT)-induced oral and gastrointestinal mucositis. Two systematic reviews of the medical literature on growth factors and cytokines for the amelioration of CT- and RT-induced mucositis throughout the alimentary tract were performed by the Mucositis Study Group of the Multinational Association of Supportive Care in Cancer/International Society for Oral Oncology. The aim of these evidence-based scientific reviews was to critically evaluate the literature and create evidence-based guidelines for the use of growth factors and cytokines in the prevention or treatment of CT- and RT-induced mucositis. METHOD The two reviews covered articles on clinical trials from January 1966 through May 2002 and preclinical studies from June 2002 through May 2005, respectively. The systematic review process was based on a well-established method for evaluating scientific literature. MAIN RESULTS The number of articles in the first review was 29. In the second review, 23 articles were evaluated, 14 preclinical and 9 clinical studies. It was concluded from the first review that there was no sufficient evidence to provide any recommendations for clinical practice guidelines regarding growth factors and cytokines. From the second review, a guideline could be presented recommending the use of recombinant human keratinocyte growth factor-1 (palifermin) to prevent oral mucositis in patients receiving high-dose CT and total body irradiation followed by stem cell transplantation for haematological malignancies. A guideline could also be provided suggesting that granulocyte macrophage colony-stimulating factor mouthwash not be used for the prevention of oral mucositis in the transplant setting with high-dose CT and autologous or allogeneic stem cell transplantation. CONCLUSIONS These systematic reviews have provided clarity and shown exciting new results. Further studies will provide new options for this debilitating side-effect of cancer therapy.
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Affiliation(s)
- Inger von Bültzingslöwen
- Department of Oral Medicine, Sahlgrenska Academy, Göteborg University, P.O. Box 450, 405 30, Göteborg, Sweden.
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Worthington HV, Clarkson JE, Eden OB. Interventions for preventing oral mucositis for patients with cancer receiving treatment. Cochrane Database Syst Rev 2006:CD000978. [PMID: 16625538 DOI: 10.1002/14651858.cd000978.pub2] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
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 The Cochrane Oral Health Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE were searched. Reference lists from relevant articles were scanned and the authors of eligible studies were contacted to identify trials and obtain additional information. Date of most recent searches: April 2004. SELECTION CRITERIA Trials were selected if they met the following criteria: design - random allocation of participants; participants - anyone with cancer receiving chemotherapy or radiotherapy treatment for cancer; interventions - agents prescribed to prevent oral mucositis; outcomes - prevention of mucositis, pain, amount of analgesia, dysphagia, systemic infection, length of hospitalisation, cost and patient quality of life. DATA COLLECTION AND ANALYSIS Information regarding methods, participants, interventions and outcome measures and results were independently extracted, in duplicate, by two review authors. Authors were contacted for details of randomisation and withdrawals and a quality assessment was carried out. The Cochrane Oral Health Group statistical guidelines were followed and risk ratios (RR) calculated using random-effects models. MAIN RESULTS Two hundred and two studies were eligible. One hundred and thirty two were excluded for various reasons, usually as there was no useable information on mucositis. Of the 71 useable studies all had data for mucositis comprising 5217 randomised patients. Interventions evaluated were: acyclovir, allopurinol mouthrinse, aloe vera, amifostine, antibiotic pastille or paste, benzydamine, beta carotene, calcium phosphate, camomile, chlorhexidine, clarithromycin, folinic acid, glutamine, GM-CSF, honey, hydrolytic enzymes, ice chips, iseganan, keratinocyte GF, misonidazole, oral care, pentoxifylline, povidone, prednisone, propantheline, prostaglandin, sucralfate, traumeel and zinc sulphate. Of the 29 interventions included in trials, 10 showed some evidence of a benefit (albeit sometimes weak) for either preventing or reducing the severity of mucositis. Interventions where there was more than one trial in the meta-analysis finding a significant difference when compared with a placebo or no treatment were: amifostine which provided minimal benefit in preventing moderate and severe mucositis RR = 0.84 (95% confidence interval (CI) 0.75 to 0.95) and 0.60 (95% CI 0.37 to 0.97), antibiotic paste or pastille demonstrated a moderate benefit in preventing mucositis RR = 0.87 (95% CI 0.79 to 0.97), hydrolytic enzymes reduced moderate and severe mucositis with RRs = 0.52 (95% CI 0.36 to 0.74) and 0.17 (95% CI 0.06 to 0.52), and ice chips prevented mucositis at all levels RR = 0.63 (95% CI 0.44 to 0.91), 0.43 (95% CI 0.23 to 0.81), 0.27 (95% CI 0.11 to 0.68). Other interventions showing some benefit with only one study were: benzydamine, calcium phosphate, honey, oral care protocols, povidone and zinc sulphate. The number needed to treat (NNT) to prevent one patient experiencing moderate or severe mucositis over a baseline incidence of 60% for amifostine is 10 (95% CI 7 to 33), antibiotic paste or pastille 13 (95% CI 8 to 56), hydrolytic enzyme 4 (95% CI 3 to 6) and ice chips 5 (95% CI 3 to 19). When the baseline incidence is 40%/90% the NNTs for amifostine are 16/7, for antibiotic paste or pastille 19/7, for hydrolytic enzyme 5/3 and for ice chips 7/3. The general reporting of RCTs was poor. However, the assessments of the quality of the randomisation improved when the authors provided additional information. AUTHORS' CONCLUSIONS Several of the interventions were found to have some benefit at 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 well designed and conducted trials with sufficient numbers of participants to perform subgroup analyses by type of disease and chemotherapeutic agent.
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Affiliation(s)
- H V Worthington
- School of Dentistry, University of Manchester, MANDEC, Higher Cambridge Street, Manchester, UK, M15 6FH.
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Valcárcel D, Sanz MA, Sureda A, Sala M, Muñoz L, Subirá M, Laborda R, Clopés A, Sierra J. Mouth-washings with recombinant human granulocyte-macrophage colony stimulating factor (rhGM-CSF) do not improve grade III-IV oropharyngeal mucositis (OM) in patients with hematological malignancies undergoing stem cell transplantation. Results of a randomized double-blind placebo-controlled study. Bone Marrow Transplant 2002; 29:783-7. [PMID: 12040477 DOI: 10.1038/sj.bmt.1703543] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2001] [Accepted: 02/19/2002] [Indexed: 11/08/2022]
Abstract
We investigated whether daily oral washings with recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF) solution improved grade III-IV oropharyngeal mucositis (OM) in patients with hematological malignancies undergoing stem cell transplantation. Forty-one consecutive patients (21 males and 20 females, median age (range) 44 (16-69) years) were prospectively randomized to perform daily mouth-washes with either a 400 microg rhGM- CSF (Molgramostin, Schering-Plough) solution (group A, n = 18) or with a saline solution (group B, n = 23). Primary end-points were the intensity of OM, night rest quality and characteristics of food intake. Secondary end-points were need for and duration of parenteral nutrition, oral and intravenous analgesic requirements, incidence of viral or fungal oral infections and development of neutropenic fever. No differences were found between the placebo and rhGM-CSF-treated groups regarding overall duration of OM, maximum grade, reduction in at least one grade of OM (nine patients (56%) in group A vs 13 patients (68%) in group B), reduction of spontaneous or swallowing-induced pain, improvement in oral food intake, use of parenteral nutrition or use of systemic analgesics. In conclusion, mouth-washings with a 400 microg of rhGM-CSF solution do not improve severe OM in hematological patients undergoing stem cell transplantation.
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Affiliation(s)
- D Valcárcel
- Clinical Hematology Division, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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18
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Abstract
Oropharyngeal mucositis is a painful, often dose-limiting side effect of both radiotherapy and chemotherapy. To reduce the intensity of pain and prevent systemic infection via the compromised mucosa, agents such as antiseptic mouthwashes, anti-ulcer compounds, sodium bicarbonate, saline, and allopurinol have been traditionally used with limited success. The new agents that show promise are granulocyte macrophage colony-stimulating factor (GM-CSF) and granulocyte colony-stimulating factor (G-CSF). However, best results, dosage, and means of administration still have to be determined. Other agents such as sucralfate, tretinoin, glutamine, and misoprostol are also being tested. The results reported from different testing centers are often contradictory and confusing. Basic requirements in prevention and control of mucositis are good oral hygiene, mechanical débridement of the oral tissues, and hydration.
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Affiliation(s)
- W Carl
- Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, USA
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Dodd MJ, Miaskowski C, Dibble SL, Paul SM, MacPhail L, Greenspan D, Shiba G. Factors influencing oral mucositis in patients receiving chemotherapy. CANCER PRACTICE 2000; 8:291-7. [PMID: 11898146 DOI: 10.1046/j.1523-5394.2000.86010.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE Oral mucositis is a painful complication of chemotherapy and can greatly affect patients' morbidity and mortality. Findings from two previous studies suggested a decrease in the prevalence of chemotherapy-induced mucositis in patients with solid tumors. The purposes of this study were to follow a large cohort of outpatients to determine the prevalence of mucositis and to identify whether certain clinical factors were significant in the development of mucositis. DESCRIPTION OF STUDY In this prospective study, a convenience sample of 199 outpatients was followed for three cycles or until mucositis developed. The clinical factors monitored included the following: pretreatment dental examination/repair; initial standard chemotherapy dosage; prophylactic use of colony-stimulating factors; and use of preventive mouthwashes or other prophylactic measures. RESULTS Oral mucositis developed in 50 patients (25.1%). Prechemotherapy dental examination/repair and initial standard chemotherapy dosage were equivalent among both groups. Of the 48 patients in whom mucositis developed, 10 (20.8%) received prophylactic colony-stimulating factors. Of 134 patients in whom mucositis did not develop, 46 (34.3%) received prophylactic colony-stimulating factors. This difference was statistically nonsignificant. CLINICAL IMPLICATIONS Differences in the clinical factors investigated could not explain the lower prevalence of oral mucositis among the current patient cohort. The reason for the diminishing prevalence of this side effect remains unclear, and additional parameters, particularly detailed oral hygiene practices, should be evaluated. In the meantime, oncology clinicians should consider the teaching of patients and urging them to use good oral hygiene practices as necessary and potentially preventive measures against chemotherapy-induced mucositis.
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Affiliation(s)
- M J Dodd
- University of California, San Francisco, Department of Physiological Nursing, Box 0610, San Francisco, CA 94143-0610, USA
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20
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Abstract
Oral mucositis is a frequent and potentially severe complication of chemotherapy which has a considerable impact on patient quality of life. While the management of other chemotherapy-related toxicities has improved, the incidence of mucositis is increasing. A critical review of the literature published between 1985 and 1999 reveals very few strategies or agents with proven efficacy, leaving few recommendations for the standard care in the prevention and treatment of mucositis at this time. Recommendations that can be made include: reducing patient risk factors, implementing proven preventative interventions such as utilising oral ice chips with fluorouracil chemotherapy, and optimising supportive care practices individualised to the patients' needs and symptoms. Progress in understanding the pathophysiology of mucositis at the molecular level has led to the evaluation of a number of new investigational agents, specifically those directed to the epithelial mucosa, such as mitogens and epithelial growth factors. These appear to be very promising in preclinical studies. Randomised clinical trials with these agents may finally demonstrate an impact on the clinical practice of mucositis management in the coming years.
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Affiliation(s)
- J J Knox
- Department of Medical Oncology, Princess Margaret Hospital/University Health Network, Toronto, Ontario, Canada
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Abstract
Oral mucositis is a distressing toxic effect of systemic chemotherapy with many commonly utilized drugs and of head and neck irradiation in patients with cancer. The agents and methods that have been used and studied in chemotherapy- and radiotherapy-induced oral mucositis, their mechanisms of action, and the current knowledge of their efficiency to reduce the incidence, severity or shorten the duration of oral mucositis are reviewed in this article. Oral cooling is a cheap and available method to lower the severity of bolus 5-fluorouracil-induced oral mucositis. However, more effective methods are needed. Results of studies with granulocyte-macrophage colony-stimulating factor or granulocyte colony-stimulating factor are promising. Lasers are partly beneficial, but equipment-demanding. Modification of the chemotherapy regimen resulting in shortening of the exposition time to chemotherapy agents or chronomodulation of chemotherapy has been shown to lower mucosal toxicity of some regimens. Results of animal studies with locally applied transforming growth factor beta 3 and interleukin-11 are also promising. Based on the findings of the role of the inflammatory cascade in the response of normal tissues to chemotherapy and radiotherapy, anti-inflammatory drugs might be beneficial. At the present time, no agent has been shown to be uniformly efficacious and can be accepted as standard therapy of chemotherapy- and radiotherapy-induced oral mucositis. Further intensive research is needed.
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Affiliation(s)
- P Plevová
- Department of Radiotherapy, University Hospital of Ostrava, Ostrava-Poruba, Czeck Republic.
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McCarthy GM, Awde JD, Ghandi H, Vincent M, Kocha WI. Risk factors associated with mucositis in cancer patients receiving 5-fluorouracil. Oral Oncol 1998; 34:484-90. [PMID: 9930359 DOI: 10.1016/s1368-8375(98)00068-2] [Citation(s) in RCA: 91] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Oral mucositis is a dose-limiting toxicity of 5-fluorouracil (5-FU). This prospective cohort study investigated factors associated with mucositis in patients receiving 5-FU for cancer of the digestive tract. Sixty-three patients (mean age 65 years) completed self-administered questionnaires and had interviews, oral examinations and unstimulated whole salivary flow measurements at baseline and follow-up appointments. The duration of follow-up was 2 months. Predictor variables included sociodemographic data, body surface area, diabetes, smoking, alcohol consumption, salivary flow, oral hygiene, presence of prostheses, performance status, regimen of cytotoxic drugs, hematological data, and herpes simplex virus antibody titer. Forty-six per cent of patients developed at least one episode of oral mucositis during cytotoxic treatment. Pearson's chi-square analysis showed that mucositis was significantly associated with xerostomia at baseline, xerostomia during chemotherapy, and lower baseline neutrophil counts (P < or = 0.05). Multiple logistic regression analysis indicated that xerostomia at baseline (odds ratio, OR = 10.0), or baseline neutrophil level under 4000 cells/mm3 (OR = 3.9) were significant predictors of mucositis. Taking into account the effect of neutrophil level at baseline, xerostomia during chemotherapy (OR = 4.5) was also a significant predictor of mucositis. The results showed that xerostomia and lower baseline neutrophil levels are significantly associated with oral mucositis. These variables should be taken into consideration in the design of intervention studies to reduce the frequency and severity of mucositis. More research is required to investigate the role of saliva and neutrophils in the pathogenesis of chemotherapy-induced mucositis.
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Affiliation(s)
- G M McCarthy
- Department of Epidemiology and Biostatistics, Faculty of Medicine & Dentistry, University of Western Ontario, Canada.
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Ibrahim EM, Al-Mulhim FA, Al-Muhanna FA, Al-Amri A. Effect of granulocyte-macrophage colony-stimulating factor on chemotherapy-induced oral mucositis in non-neutropenic cancer patients. J Family Community Med 1998; 5:37-43. [PMID: 23008581 PMCID: PMC3437118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE The study was designed to assess prospectively the efficacy of granulocyte-macrophage colony-stimulating factor (GM-CSF) in the management of chemotherapy-induced oral mucositis in non-neutropenic cancer patients. MATERIAL AND METHODS In a prospective open study, adult cancer patients with chemotherapy-induced, neutropenia-independent oral mucositis were treated with GM-CSF (Schering Plough Corporation, Kenilworth, NJ) prepared as mouthwash solution (5 to 10 μgm /ml). GM-CSF was administered within 24 hours of occurrence of oral mucositis at a frequency of 4 to 6 times daily. Systemic GM-CSF was not permissible. Oral mucositis was graded according to the modified Radiation Therapy Oncology Group criteria. RESULTS Forty-nine patients were recruited but nine were subsequently excluded as they experienced neutropenia during GM-CSF therapy. The remaining 40 patients were all evaluable. Most patients had either Grade 3 or 4 gross (71%) or functional (70%) mucositis. The mean ± SEM gross oral mucositis scores for all 40 patients combined decreased from 3.3 ± 0.11 at baseline to 2.1 ± 0.12 (p<0.0001) after 2 days, 0.95 ± 0.11 (p<0.0001) after 5 days and 0.23 ± 0.07 (p <0.0001) after 10 days of therapy. Likewise, the mean ± SEM functional oral mucositis scores decreased from 3.03 ± 0.13 at baseline to 1.58 ± 0.13 (p<0.0001) after 2 days, 0.68 ± 0.11 (p<0.0001) after 5 days, and 0.15 ± 0.06 (p<0.0001) after 10 days of therapy. The duration of severe oral mucositis was also shortened as Grade 0 or 1 (gross mucositis grading score) was evident in 12 (30%), 29 (73%), and 40 (100%) patients by the 2(nd), 5(th) and 10(th) day of therapy, respectively. Similarly, Grade 0 or 1 (functional mucositis grading score) reported in 19 (48%), 31 (78%), and 40 (100%) patients by the 2(nd), 5(th) and 10(th) day of therapy, respectively. The use of GM-CSF mouthwash was not associated with any apparent ill effect. CONCLUSION GM-CSF mouthwash as used in this study has a significant recuperative efficacy on the severity, morbidity, and duration of chemotherapy-induced oral mucositis. A large randomized, placebo-controlled study is warranted to ascertain that benefit and determine the optimal dosage and schedule.
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Affiliation(s)
- Ezzeldin M. Ibrahim
- Department of Internal Medicine, College of Medicine and Medical Sciences, King Faisal University, Saudi Arabia,Correspondence to: Prof. Ezzeldin M. Ibrahim, Professor of Medicine and Oncology, King Fahd Hospital of the University, P.O. Box 40004, Al-Khobar 31952, Saudi Arabia
| | - Fatma A. Al-Mulhim
- Department of Radiology, College of Medicine and Medical Sciences, King Faisal University, Saudi Arabia
| | - Fahd A. Al-Muhanna
- Department of Internal Medicine, College of Medicine and Medical Sciences, King Faisal University, Saudi Arabia
| | - Ali Al-Amri
- Department of Internal Medicine, College of Medicine and Medical Sciences, King Faisal University, Saudi Arabia
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Cohen G, Elad S, Or R, Galili D, Garfunkel AA. The use of tretinoin as oral mucositis prophylaxis in bone marrow transplantation patients: a preliminary study. Oral Dis 1997; 3:243-6. [PMID: 9643220 DOI: 10.1111/j.1601-0825.1997.tb00049.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The examination of prophylactic efficacy of tretinoin on oral mucositis, post bone marrow transplantation (BMT). PATIENTS AND METHODS The study population consisted of 11 patients undergoing BMT. Six tretinoin topically-treated patients (0.25 mg daily of 0.1% tretinoin cream) were matched with five non-treated control patients comparing mucositis severity, duration and analgetic (morphine) requirements. Concomitant follow-up included conditioning parameters associated with mucositis and engraftment. RESULTS The mean of oral mucositis peak scores was significantly lower in the tretinoin-treated patients vs the non-treated patients (score 1.5 vs 3.6; P < 0.02). In the majority of cases the duration of the most severe phase of oral mucositis was shorter in the tretinoin-treated group as compared with the control. Only one patient in the experimental group required morphine analgesics compared with four patients in the control group. CONCLUSIONS This preliminary study indicates that the severity of oral mucositis, both objective and subjective, in BMT patients may be reduced by 0.1% topical tretinoin cream, 0.25 mg, administered daily from the beginning of the BMT conditioning regimen until marrow engraftment.
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Affiliation(s)
- G Cohen
- Hospital Oral Medicine Department, Hadassah, Hebrew University, School of Dental Medicine, Jerusalem, Israel
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Ibrahim EM, al-Mulhim FA. Effect of granulocyte-macrophage colony-stimulating factor on chemotherapy-induced oral mucositis in non-neutropenic cancer patients. Med Oncol 1997; 14:47-51. [PMID: 9232612 DOI: 10.1007/bf02990946] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The aim of this study was to assess prospectively the efficacy of granulocyte-macrophage colony-stimulating factor (GM-CSF) in the management of chemotherapy-induced oral mucositis in non-neutropenic cancer patients. In a prospective open study, 30 cancer patients with chemotherapy-induced, neutropenia-independent oral mucositis were treated with GM-CSF (Schering Plough Corp, Kenilworth, NJ) prepared as a mouthwash solution (5-10 micrograms ml-1). GM-CSF was administered within 24 hours of occurrence of oral mucositis x 4 to 6 times daily. Systemic GM-CSF was not permissible. Oral mucositis was graded according to the modified Radiation Therapy Oncology Group criteria. Six patients were subsequently excluded as they experienced neutropenia during GM-CSF therapy. The remaining 24 patients were all evaluable. Most patients had either Grade 3 or 4 gross (76%) or functional (54%) mucositis. The mean +/- SEM gross oral mucositis scores for all 24 patients combined decreased from 3.08 +/- 0.18 at baseline to 2.04 +/- 0.19 (p < 0.0001) after 2 days, 0.92 +/- 0.16 (p < 0.0001) after 5 days, and 0.25 +/- 0.09 (p < 0.0001) after 10 days of therapy. Likewise, the mean +/- SEM functional oral mucositis scores decreased from 2.71 +/- 0.18 at baseline to 1.58 +/- 0.19 (p < 0.0001) after 2 days, 0.75 +/- 0.16 (p < 0.0001) after 5 days, and 0.17 +/- 0.08 (p < 0.0001) after 10 days of therapy. The duration of severe oral mucositis was also shortened as Grade 0 or 1 (gross mucositis score) was evident in seven (29%), 20 (83%), and 24 (100%) patients by the 2nd, 5th, and 10th day of therapy, respectively. Similarly, Grade 0 or 1 (functional mucositis score) reported in 13 (54%), 19 (79%), and 24 (100%) by the 2nd, 5th, and 10th day of therapy respectively. It was found that GM-CSF mouthwash as used in this study has a significant recuperative efficacy on the severity, morbidity, and duration of chemotherapy-induced oral mucositis. A large randomized, placebo-controlled study is warranted to ascertain that benefit and determine the optimal dosages and schedule.
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Affiliation(s)
- E M Ibrahim
- Division of Oncology, College of Medicine and Medical Sciences, King Faisal University, Kingdom of Saudi Arabia
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