Caphosol, a therapeutic option in case of cancer therapy-induced oral mucositis in children?

A Narrative Review of Pain in Pediatric Oncology: The Opioid Option

Opioid therapy is the mainstay for managing pain in pediatric oncology. This narrative review describes the current literature regarding opioids for pediatric cancer pain. The review explores the multifaceted landscape of opioid utilization in this population, including the role of opioids in certain clinical circumstances, modalities of opioid delivery, unique opioids, outpatient and at-home pain management strategies, and other key concepts such as breakthrough pain. This review highlights the importance of individualized dosing and multimodal approaches to enhance efficacy and minimize adverse effects. Drawing from a wide range of evidence, this review offers insights to optimize pediatric oncology pain management.

Oral Mucositis Management in Children under Cancer Treatment: A Systematic Review

Children undergoing antineoplastic treatment often present severe side effects due to the dosage and duration of treatments, with oral mucositis emerging as one of the most prevalent and painful inflammatory conditions. There is a growing body of evidence on therapeutic interventions such as cryotherapy, low-level laser therapy, and natural compounds for this condition. The aim of this systematic review was to identify and compare therapies for the management of cancer treatment-induced oral mucositis in pediatric patients. From 2655 articles obtained in initial searches, 39 articles were considered in this systematic review, after applying inclusion/exclusion criteria. Low-level laser therapy, palifermin, honey, and zinc demonstrated reductions in oral mucositis incidence, duration, severity, and pain reported by the patient. Although there are several therapies in place for the prevention and treatment of oral mucositis in children, evidence of their efficacy is still inconclusive to establish accurate clinical protocols.

Efficacy of polyacrylate silver salt/polyvinylpyrrolidone-based liquid oral gel in management of concurrence chemoradiotherapy-induced oral mucositis

BACKGROUND/PURPOSE

Acute oral mucositis (OM) is a painful complication of concurrent chemoradiotherapy (CCRT). This severe adverse symptom may impact on patient's quality of life, lead to malnutrition. Thus, finding more effective methods in OM management is very important. The purpose of this study is to evaluate the efficacy of polyacrylate silver salt/Polyvinylpyrrolidone-based liquid oral gel (named as polyacrylate silver salt oral gel) in improving the symptomatic relief of CCRT-induced oral mucositis and oral dysfunction in neck and head cancer patients.

METHODS

In this study, 24 oral cancer patients underwent CCRT and having OM grade 2 or higher were randomly assigned into the test group and the control group. Both groups followed Multinational Association of Supportive Care in Cancer and International Society of Oral Oncology (MASCC/ISOO) clinical practice guidelines for the management of mucositis, but adding rinsing with 15 g oral gel right after oral hygiene treaded the test group. Clinical OM and oral function were assessed weekly for 4 consecutive weeks till 5-10 days after the completion of radiotherapy. For evaluation, Common Terminology Criteria for Adverse Events (CTCAE) v3.0 was used for collecting the data of OM grade.

RESULTS

The results showed that polyacrylate silver salt oral gel had better effect for relieving the oral mucositis. There were statistically significant differences in OM grades (1.59 vs. 2.8, p < 0.0001) between the test group and the control group.

CONCLUSION

Our clinical studies demonstrated that polyacrylate silver salt oral gel is an effective interventional option in terms of rapid mucositis healing.

[Chemo-induced mucositis in pediatric oncology: Perspectives?]

Mucositis is defined as inflammatory and/or ulcerative lesions of the oral and/or gastrointestinal tract. It occurs in approximately 40% to 50% of adults patients receiving conventional chemotherapy and up to 75% of patients receiving high dose chemotherapy as conditioning for hematopoietic stem cell transplantation. It is a toxic side effect, which strongly impairs quality of life and leads to refractory pain, increasing risk of infection and even therapeutic modifications. Despite improvements made, the management of mucositis remains a challenge and is still not consensual. A multicentric survey of practices concerning the preventive and curative management of chemo-induced mucositis in pediatric oncology department in France was carried out using a standardized questionnaire. Results confirm heterogeneous practices and the small progress made during the last decade. This national survey and an analysis of the recent literature leads to propose guidelines for the prevention and treatment of oral mucositis in children receiving treatment for cancer.

Similar effectiveness of Fomukal and Caphosol in oral mucositis treatment after allogeneic hematopoietic stem cell transplantation

Objective: Oral mucositis occurs in 75% to 100% of allogeneic HSCT recipients can cause pain, facilitate infections, delay discharge, and threaten life. The aim of the study was to evaluate prophylaxis with the remineralizing mouthwash solution of supersaturated calcium phosphate rinse (SCPR) with Fomukal on measures of severity of mucositis and consequent interventions and complications, in comparison to Caphosol, already evaluated post-transplant. Materials/Methods: In this prospective, randomized, non-inferiority trial, 46 patients undergoing allogeneic HSCT were equally randomized to Fomukal or Caphosol, each administered four times daily from initiation of conditioning until the granulocyte count ≥0.2 G/L. Hematologist measured the daily severity of mucositis according to a WHO scale and patients self-assessed its symptoms. Need for analgesics, anti-infectious drugs, total parenteral nutrition (TPN) and incidence of complications were also assessed. Results: Fomukal vs. Caphosol groups had the same all following indicators: median measures of WHO oral mucositis reduction (0 vs. 2; P = NS), length of disease course (0 vs. 6 days; P = NS), peak and mean mouth (1 vs. 2; P = NS and 0.06 vs. 1; P = NS) and throat pain (1 vs. 1; P = NS and 0.22 vs. 0.31; P = NS), and peak and mean swallowing problems (1 vs. 1; P = NS and 0.19 vs. 0.25; P = NS). Analgesics need (7 vs. 10 patients; 0 vs. 0 days; P = NS) and the need for antifungals (1 vs. 2 drugs; P = NS) were not different, while the need for antibiotics and antivirals (3.5 vs. 5 drugs; P = 0.011 and 1 vs. 2 drugs; P = 0.023) were lower in the Fomukal group. Measures of complications: infections (7 vs. 12 patients, P = NS) and a GVHD (13 vs. 14 patients, P = NS, grade 1 vs. 1, P = NS) did not differ. Discussion: Both SCPR mouth rinses, Fomukal and Caphosol, were associated with similar effectiveness in reducing severity of oral mucositis.

MASCC/ISOO clinical practice guidelines for the management of mucositis: sub-analysis of current interventions for the management of oral mucositis in pediatric cancer patients

OBJECTIVE

The aim of this sub-analysis was to highlight the MASCC/ISOO clinical practice guidelines for the management of oral mucositis (OM) in pediatric patients and to present unique considerations in this patient population.

METHODS

This sub-analysis of the pediatric patient population is based on the systematic review conducted by the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISSO) published in 2019/2020. Studies were scored and assigned a level of evidence based on previously published criteria. Data regarding adverse effects and compliance was collected from the original publications.

RESULTS

A total of 45 papers were included and assessed in this sub-analysis, including 21 randomized controlled trials (RCTs). Chewing gum was demonstrated to be not effective in preventing OM in pediatric cancer patients in 2 RCTs. The efficacy of all other interventions could not be determined based on the available literature.

CONCLUSION

There is limited or conflicting evidence about interventions for the management of OM in pediatric cancer patients, except for chewing gum which was ineffective for prevention. Therefore, currently, data from adult studies may need to be extrapolated for the management of pediatric patients. Honey and photobiomodulation therapy in this patient population had encouraging potential. Implementation of a basic oral care protocol is advised amid lack of high level of evidence studies.

Randomized controlled and double-blinded study of Caphosol versus saline oral rinses in pediatric patients with cancer

BACKGROUND

Oral mucositis (OM) is a significant side effect of cancer treatment. The purpose of this study was to compare topically administered Caphosol to saline rinses in the prevention of mucositis in pediatric cancer patients.

PROCEDURE

A controlled, double-blinded, and randomized clinical crossover study recruited patients between 2 to 17.99 years of age who were diagnosed with a malignancy and were receiving either high-dose methotrexate (≥1 g/m² ), anthracycline, or cisplatin chemotherapy (NCT0280733). All patients received two 7-day cycles of the mouth rinses; that is, one cycle of Caphosol and one cycle of saline in a randomized order. Oral changes and symptoms were evaluated using the World Health Organisation (WHO) toxicity scale and the Children's International Mucositis Evaluation Scale (ChIMES). The primary endpoint was the frequency and severity of OM and oral symptoms.

RESULTS

A total of 56 patients were recruited to the study, of whom 45 were randomized with a median age of 6.5 years (range 2.1-17.1 years). No cases of severe OM were observed. Grade ≥ 3 oral symptoms were present at least once in six (13%) patients during the Caphosol cycle and 13 (29%) patients during the saline cycle (P = .12). The peak of symptom scores was evident at around day 4-7 after administration of the chemotherapy with no marked differences between the rinse solutions. Multivariable regression analysis did not indicate a benefit of using Caphosol over the saline solution.

CONCLUSIONS

No difference in prevention of oral mucositis was observed between the use of Caphosol or saline rinses.

Oncological-Therapy Related Oral Mucositis as an Interdisciplinary Problem-Literature Review

Oral mucositis is a toxic side effect of non-surgical cancer treatments: chemotherapy and radiotherapy, which strongly impair quality of life and can not only cause strong pain, but also lead to problems with basic physiological needs as eating and swallowing. Development of oral mucositis is associated with type, dosage, and schedule of radiation or chemotherapy and other factors related to patients. Management of oral mucositis is a valid problem, requiring topical application of anesthetics, coating agents, cryotherapy, low level laser therapy, pharmacological methods as usage of keratinocyte growth factors, supplementation of vitamins, and a proper diet. Another approach to oral mucositis measurement includesphotobiomodulation, which brings analgesic and anti-inflammatory effects.Although oral mucositis is a general health issues, the role of proper dental care is essential. It should include elimination of all potential sources of mucosal injury and microorganisms inhabiting theoral cavity through oral hygiene education,professional management ofdental plaque,and treatment of the caries and periodontium, which are necessary to reduce the risk of inflammation in the oral cavity. This paper describes the possibilities of monitoring oral mucositis,taking into account the latest therapeutic achievements.

Systematic review of natural and miscellaneous agents for the management of oral mucositis in cancer patients and clinical practice guidelines-part 1: vitamins, minerals, and nutritional supplements

PURPOSE

To update the clinical practice guidelines for the use of natural and miscellaneous agents 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 78 papers were identified within the scope of this section, out of which 29 were included in this part, and were analyzed with 27 previously reviewed studies. A new Suggestion was made for oral glutamine for the prevention of OM in head and neck (H&N) cancer patients receiving radiotherapy with concomitant chemotherapy. The previous Recommendation against the use of parenteral glutamine for the prevention of OM in hematopoietic stem cell transplantation (HSCT) patients was re-established. A previous Suggestion for zinc to prevent OM in H&N cancer patients treated with radiotherapy or chemo-radiotherapy was reversed to No Guideline Possible. No guideline was possible for other interventions.

CONCLUSIONS

Of the vitamins, minerals, and nutritional supplements studied for the management of OM, the evidence supports a Recommendation against parenteral glutamine in HSCT patients and a Suggestion in favor of oral glutamine in H&N cancer patients for the management of OM.

Management of oral mucositis in pediatric patients receiving cancer therapy: A systematic review and meta-analysis

BACKGROUND

One of the most common complications of cancer chemotherapy is oral mucositis (OM). OM affects more than 75% of patients undergoing chemotherapy and represents a significant burden to patients and caregivers. We performed a systematic review and meta-analysis of published studies to investigate the effects of agents and techniques in reducing OM.

PROCEDURE

This systematic review investigated, critically appraised, and rated the evidence on agents used to manage OM in children undergoing cancer therapy. A comprehensive search of the relevant literature was performed from January 2006 to December 2017. MEDLINE, Scopus, the Cochrane Database of Systematic Reviews, EMBASE, and the Web of Science were searched. Nine eligible studies were identified. Using random-effects models, standardized mean difference was estimated between treated and control groups across all studies. The Cochran test and the I2 index were performed for heterogeneity between studies. The significance level was set at P = 0.05.

RESULTS

Palifermin reduced the incidence (OR = 4.131, P = 0.000), duration (St diff mean = 0.803, P = 0.000), and severity (St diff mean = 0.637, P = 0.000) of OM in pediatric cancer patients significantly. However, the laser did not show significant efficacy in decreasing the incidence rate of OM (OR = 2.870, P = 0.364).

CONCLUSION

This review provided a comprehensive examination of available options for children who have OM. The results support the possibility of a positive effect of palifermin on reducing OM in children receiving cancer therapy.

Adjunctive Treatments for the Prevention of Chemotherapy- and Radiotherapy-Induced Mucositis

Background: Chemoradiotherapy-associated mucositis can manifest as pain, inflammation, dysphagia, diarrhea, weight loss, rectal bleeding, and infection. Mucositis is a major dose-limiting side effect of chemotherapy, affecting nutritional intake and oral and intestinal function. Despite several interventions being available, there is a need for safe and effective preventative and treatment options for treatment-induced mucositis. The goals of this review are to discuss interventions based on foods and natural products and present the research to date. Methods: A narrative literature review identified 60 clinical studies examining various nutritional compounds and 20 examining probiotics. 9 studies on probiotics for the prevention of diarrhea were also assessed on methodological quality and limitations identified. Results: Several compounds have been posited as useful adjuvants for cancer treatment–related mucositis. Probiotics demonstrate efficacy for the prevention and treatment of chemoradiotherapy-induced gastrointestinal toxicity without significant side effects. Glutamine and activated charcoal were reported to reduce chemotherapy-induced diarrhea but not radiation-induced intestinal mucositis. Honey has been reported to decrease treatment interruptions, weight loss, and delays the onset of oral mucositis. Zinc, glutamine, and topical vitamin E were demonstrated efficacy for oral mucositis. Conclusion: There is plausible clinical evidence for the administration of several adjunctive treatments for the prevention and treatment of mucositis. Probiotics were reported to reduce the burden of intestinal mucositis and treatment-induced diarrhea. Activated charcoal and glutamine are beneficial for chemotherapy-induced diarrhea, whereas the administration of honey, zinc, and glutamine reduce the risk of developing oral mucositis during chemotherapy or radiotherapy.

Challenges in the local delivery of peptides and proteins for oral mucositis management

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.

Dental Management of Patients Who Have Undergone Oral Cancer Therapy

Oral cancer therapies are associated with orofacial complications that could result in dose-limiting cancer treatment and consequent suboptimal tumor control. Oral cancer treatment complications include oral mucositis, salivary gland hypofunction, odontogenic infections, pain, dermatitis, neurotoxicity, soft tissue fibrosis, trismus, osteoradionecrosis, and potential cancer recurrence. These complications significantly affect cancer survivorship, quality of life, and psychosocial status. Effective dental management of patients with oral cancer involves the coordination of care among several health care professionals before, during, and after cancer therapy. The goal is to minimize complications, and establish optimal quality of life for survivors.

Oral Mucositis: Melatonin Gel an Effective New Treatment

The current treatment for cervico-facial cancer involves radio and/or chemotherapy. Unfortunately, cancer therapies can lead to local and systemic complications such as mucositis, which is the most common dose-dependent complication in the oral cavity and gastrointestinal tract. Mucositis can cause a considerably reduced quality of life in cancer patients already suffering from physical and psychological exhaustion. However, the role of melatonin in the treatment of mucositis has recently been investigated, and offers an effective alternative therapy in the prevention and/or management of radio and/or chemotherapy-induced mucositis. This review focuses on the pathobiology and management of mucositis in order to improve the quality of cancer patients' lives.

Caphosol for prevention of oral mucositis in pediatric myeloablative haematopoietic cell transplantation

BACKGROUND

The primary objective was to determine whether topically administered Caphosol, rinsed orally four times daily at the initiation of conditioning, reduces the duration of severe oral mucositis (OM) compared with placebo among children and adolescents undergoing haematopoietic cell transplantation (HCT).

METHODS

This was a Children's Oncology Group multicentre randomised double-blinded placebo-controlled clinical trial. Patients between the ages of 4 and 21 years who were scheduled to undergo myeloablative HCT for any indication were randomised to Caphosol or placebo saline rinses four times daily from initiation of conditioning through day +20. Subjects were assessed daily for OM using the World Health Organisation (WHO) Oral Toxicity Scale, Mouth Pain Categorical Scale (0-10) and the Oral Mucositis Daily Questionnaire (OMDQ). The primary end point was duration of severe OM (WHO ⩾3).

RESULTS

The study enrolled 220 participants with a median age of 13.7 years (range 4.0-21.9); 163 (74%) received allogeneic HCT. The mean (±s.d.) duration of severe OM was not reduced among Caphosol (4.5±5.0 days) vs placebo (4.5±4.8; P=0.99) recipients. The incidence of severe OM in the Caphosol and placebo arms was 63% (57 out of 91) and 68% (62 out of 91), respectively (P=0.44). There were no significant differences in any of the secondary end points between the groups.

CONCLUSIONS

Caphosol did not reduce severe OM when compared with placebo among children and adolescents undergoing myeloablative HCT. Studies to identify effective interventions for OM are needed in this population.

Pharmacotherapy for the management of cancer regimen-related oral mucositis

INTRODUCTION

Oral mucositis is a frequent and devastating toxicity secondary to cancer treatment, which may affect 20-40% of patients receiving conventional chemotherapy and 60-85% of patients undergoing hematopoietic stem cell transplantation. The pathobiology of mucositis includes a complex cascade of biologic events in which pro-inflammatory cytokines, ROS, second messengers, and the oral microbiome contribute to tissue damage of the oral mucosa. Management strategies to oral mucositis secondary to chemotherapy include preventative measures and therapeutic approaches.

AREA COVERED

A literature search of published animal and clinical studies was perform to review the epidemiology, pathophysiology and treatment options for cancer regimen-induced mucositis. We also discuss new data coming from recent pertinent clinical trials.

EXPERT OPINION

Mucositis is one of the most common debilitating toxicities secondary to cancer treatment and can adversely affect patients' quality of life. Epidemiological data for mucositis are often under-reported. Research efforts have shown that genetics plays a major role in the development of this toxicity. Although few therapeutic agents are available, several promising drugs are under investigations.

Mucositis: pathobiology and management

PURPOSE OF REVIEW

Oral mucositis remains a frequent debilitating toxicity associated with drug and radiation regimens used to treat cancer. This review highlights the recent understanding of the biological basis, risk factors for, and management for oral mucositis.

RECENT FINDINGS

Prevalence and incidence data for mucositis are inconsistent and often underreported. The pathogenesis of mucositis encompasses a sequence of biological events possibly influenced by the oral microbiome and environment. Despite its frequency and severity, there is currently no effective treatment available for the majority of patients at risk. However, with the better understanding of the pathogenesis of mucositis a number of new drugs and biological agents are under investigation. Genome-wide risk prediction tools will allow the identification of patients at risk of developing mucositis.

SUMMARY

Oral mucositis is a common complication of cancer treatment that may negatively impact the patient's cancer treatment outcome. Despite its frequency and consequences, the lack of effective interventions has frustrated patients and caregivers. Fortunately, a broad range of mechanistically targeted compounds are being developed.

Mineral derivatives in alleviating oral mucositis during cancer therapy: a systematic review

Objectives. Oral mucositis (mouth ulcers) is a cancer therapy side effect. Costly treatment interventions are often neglected in favor of cost-effective agents. This review assessed the general efficacy of mineral derivatives (a cost-effective agent) in alleviating oral mucositis (OM) during cancer therapy compared to the standard care, or placebo-including a decision tree to aide healthcare workers. Data Sources. Electronic searches of MEDLINE via OVID, EMBASE, CENTRAL, CANCERLIT via PubMed, and CINAHL via EBSCO (year 2000 to 11 September 2014) were undertaken for randomised controlled trials. A meta-search strategy extracted content from aggregate online databases. Review Methods. Randomized controlled trials were assessed (participants, intervention, outcome, results, and risk of bias) for inclusion. The author abstracted binary and continuous data synthesised to Hedges' g in a random effects model. The primary outcome measures were severity (incidence of peak oral mucositis, duration of oral mucositis, and time to onset); secondary outcome measures were the incidence of pain, and analgesic use. Serum mineral levels, total parenteral nutrition, and adverse events were discussed. The decision tree was mapped using sensitivity, specificity, pre-test and post-test Bayesian probability. Results. 1027 citations were identified and 16 studies were included (n = 1120; mean age 49 years). Cancer therapies consisted of chemotherapy, radiotherapy, chemo-radiotherapy, or hematopoietic stem cell transplantation. Outcome mineral derivatives were zinc (n = 549), calcium phosphate (n = 227), povidone-iodine (n = 228), or selenium (n = 116). Severity was measured across variable OM grading systems: In 13 studies, individuals in treatment groups (n = 958) experienced peak OM less than controls (g = -0.47, 95% CI -0.7 to -0.2, p = 0.0006); time to OM onset was significantly delayed in treatment than controls (g = -0.51, 95% CI-0.8 to -0.2, p = 0.0002; five studies); OM mean duration, pain incidences, or analgesics use was not significant. The decision analysis favored selenium. Conclusion. The general positive effect trend suggests individuals taking mineral derivatives during cancer therapies are less likely to experience peak OM than those without. However, significant bias and heterogeneity indicates the need for developing further methods in account of diverse protocols and include novel recordings (serum mineral levels and cell signals) in estimating a uniform true effect.