Implementation of an oral care standard for leukemia and transplantation patients

Current management of mTOR inhibitor-associated stomatitis

mTOR inhibitor-associated stomatitis (mIAS) is an adverse event associated with mTOR inhibitor treatment for advanced cancers. mIAS tends to occur within 2 weeks of treatment start and resolve within weeks of symptom onset. mIAS is usually mild in severity and often self-limiting. Nevertheless, inadequately controlled mIAS can negatively affect patient function and treatment adherence. This review summarizes efficacy and mIAS safety data of mTOR inhibitors, and discusses prevention and treatment of mIAS. Patient cases are used to illustrate important practice points. Although mIAS has been recognized as a cancer treatment-related adverse event only in the last decade, several clinical studies are ongoing. This raises the expectation that management of mIAS in the future will be guided by strong evidence.

Implementation of an Oral Care Protocol and Its Effects on Oral Mucositis

Oral complications are commonly seen in pediatric oncology patients. Induced by chemotherapy or radiation, oral mucositis is a debilitating side effect that has much clinical significance. Oral mucositis may decrease the effectiveness of treatment as well as decrease the quality of life in the pediatric oncology patient. Therefore, it is our responsibility as health care professionals to reduce the incidence and/or severity of mucositis as much as possible. One intervention that has been proven to be successful is basic oral hygiene implemented through an oral care protocol. It is important that nurses are educated on the significance of adequate dental hygiene and the process and need for institutional change of protocols. Nurses and other health care professionals can positively influence patient care by incorporating the evidence-based practice of an oral care protocol— improving consistency of care while promoting an intervention of proven benefit against oral mucositis.

Prevention and management of oral mucositis in patients with cancer

OBJECTIVES

To review current evidence that applies to the development of a nursing plan of care for the prevention and treatment of oral mucositis related to cytotoxic therapy.

DATA SOURCES

Research studies, review articles, evidence-based guidelines, web-based material, and clinical experience.

CONCLUSION

Although high-level research evidence regarding mucositis is limited, use of multiple types of evidence in developing a structured plan of care facilitates improved patient outcomes and the advancement of the current body of knowledge.

IMPLICATIONS FOR NURSING PRACTICE

Nurses play a key role in the identification and use of evidence to guide the care of patients at risk for cytotoxic therapy-related oral mucositis.

Nursing Interventions and Supportive Care for the Prevention and Treatment of Oral Mucositis Associated with Cancer Treatment

PURPOSE/OBJECTIVES

To review novel approaches to assessing and managing patients with cancer who are at risk for oral mucositis.

DATA SOURCES

Published research and review articles, books, conference presentations, and abstracts.

DATA SYNTHESIS

Oral mucositis is a major source of clinical morbidity among patients with cancer undergoing treatment, yet definitive management strategies continue to elude practitioners. A growing body of evidence suggests that a multifaceted, innovative, targeted approach to oral care provides an important foundation with which to reduce treatment-related morbidity.

CONCLUSIONS

Ongoing assessment and monitoring are critical to the effective management of oral mucositis. Targeted interventions that incorporate the basic principles of wound care with current knowledge about the temporal aspects of clinical manifestations, evidence-based standardized approaches to assessment, and utilization of novel therapeutics provide an important means by which to improve patient outcomes.

IMPLICATIONS FOR NURSING

Oral care protocols are essential components of oral mucositis management. Incorporating current knowledge of pathophysiology with a targeted, standardized approach may help to reduce overall morbidity and improve quality of life.

Chemotherapy-induced oral mucositis: new approaches to prevention and management

Oral mucositis is a common and significant toxicity of cancer chemotherapy. It is under-reported and not well treated, particularly in patients that receive high-dose therapy with an autologous or allogenic stem cell transplant. Two recently published retrospective analyses of patient complaints following stem cell transplantation have identified oral mucositis as the worst toxicity reported by patients, and what is more important is that patients indicated that oncology healthcare team members do a poor job of managing and providing methods of symptom relief. Twenty percent of patients surveyed indicated they received no symptom relief at all.

Evidence-based guidelines for the management of neutropenia following outpatient hematopoietic stem cell transplantation

Hematopoietic stem cell transplantation (HSCT) involves the transfer of stem cells to establish hematopoiesis in patients who have received myeloablative chemotherapy with or without whole body irradiation. Following high-dose therapy and HSCT, all patients experience a period of neutropenia. Outpatient care delivery models place expanded responsibilities on patients and their families for the management of this treatment side effect. Proactive management of neutropenia is critical to decrease the depth and duration of neutropenia following HSCT, limit exposure to opportunistic and nosocomial pathogens, and ensure prompt intervention should febrile neutropenia or infection develop. Patient and family education, psychosocial support, and coordination of care are key nursing responsibilities.

Clinical practice guidelines for the prevention and treatment of cancer therapy-induced oral and gastrointestinal mucositis

BACKGROUND

Oral and gastrointestinal (GI) mucositis can affect up to 100% of patients undergoing high-dose chemotherapy and hematopoietic stem cell transplantation, 80% of patients with malignancies of the head and neck receiving radiotherapy, and a wide range of patients receiving chemotherapy. Alimentary track mucositis increases mortality and morbidity and contributes to rising health care costs. Consequently, the Multinational Association of Supportive Care in Cancer and the International Society for Oral Oncology assembled an expert panel to evaluate the literature and to create evidence-based guidelines for preventing, evaluating, and treating mucositis.

METHODS

Thirty-six panelists reviewed literature published between January 1966 and May 2002. An initial meeting in January 2002 produced a preliminary draft of guidelines that was reviewed at a second meeting the same year. Thereafter, a writing committee produced a report on mucositis pathogenesis, epidemiology, and scoring (also included in this issue), as well as clinical practice guidelines.

RESULTS

Panelists created recommendations from higher levels of evidence and suggestions when evidence was of a lower level and there was a consensus regarding the interpretation of the evidence by the panel. Panelists identified gaps in evidence that made it impossible to recommend or not recommend use of specific agents.

CONCLUSIONS

Oral/GI mucositis is a common side effect of many anticancer therapies. Evidence-based clinical practice guidelines are presented as a benchmark for clinicians to use for routine care of appropriate patients and as a springboard to challenge clinical investigators to conduct high-quality trials geared toward areas in which data are either lacking or conflicting.

Educational issues in oral care

OBJECTIVE

To discuss the importance of patient, family, and health care professional education in enhancing oral care and adherence to treatment regimens.

DATA SOURCE

Textbooks, review articles, and research studies.

CONCLUSION

Oral complications of cancer therapy influence both patient outcomes and fiscal outcomes. Patient awareness of the importance of oral health improves adherence to the oral care standard. However, the lack of knowledge of health professionals is a barrier to implementing patient education and oral care standards.

IMPLICATIONS FOR NURSING PRACTICE

Curriculum should incorporate oral assessment and oral hygiene. Training of oncology nurses must include assessment, prevention, and treatment of oral mucositis.

Evidence-based guidelines for managing mucositis

OBJECTIVES

To discuss implementation of evidence-based clinical practice guidelines for mucositis.

DATA SOURCE

Published articles, book chapters, web sources, clinical experience, unpublished manuscripts.

CONCLUSION

Nurses can implement evidence-based guidelines but must include an evaluation component to determine effect on clinical outcomes.

IMPLICATIONS FOR NURSING PRACTICE

Nurses have an integral role implementing and evaluating evidence-based practice guidelines for managing mucositis. When evidence is lacking and guidelines have gaps, nurses can play important roles in research to overcome these gaps.

Assessment and measurement of oral mucositis

OBJECTIVE

To discuss the assessment and monitoring of mucositis and provide an overview of instruments available to assess or measure mucositis.

DATA SOURCE

Published journal articles, texts, and clinical experience.

CONCLUSION

The lack of consistent use of valid and reliable instruments for the assessment of mucositis have limited progress in the prevention and management of mucositis.

IMPLICATIONS FOR NURSING PRACTICE

Nurses play a key role in the assessment of oral cavity changes. Using valid and reliable measures will foster the ability to predict risk for mucositis and to test the effectiveness of protocols for its prevention and treatment.

Experiences of oral care in patients with haematological malignancies or head and neck cancer

The aim of the present study was to investigate cancer patients' experiences of oral hygiene information, oral care and self-care, information on oral complications, examination of the oral cavity, and ability to eat and drink during cancer treatment, and to explore patient attitudes to oral examination and oral hygiene. The sample consisted of 41 consecutive patients treated with radiotherapy for head and neck cancer (n = 18) or with chemotherapy for haematological malignancies (n = 23). Patients were interviewed at the end of radiotherapy or the second/third chemotherapy cycle. Compared with patients receiving chemotherapy, those who received radiotherapy had significantly more often visited hospital dentistry, been informed about oral complications and oral hygiene, received instructions in oral hygiene procedures, and been examined by hospital staff. More of the radiotherapy patients experienced oral symptoms and difficulties to eat and drink during treatment. There were no significant differences between the groups with regard to patient experiences of the oral hygiene procedures. Only one patient objected to having hospital staff discuss oral hygiene procedures, and three did not want hospital staff to examine their oral cavity. Patients undergoing radiotherapy or chemotherapy need to be monitored during treatment with regard to their oral status and oral symptoms and complications. There are no acceptable reasons for allowing patients to suffer from oral symptoms that can be reduced.

The 20 item oral mucositis index: reliability and validity in bone marrow and stem cell transplant patients

Precise quantification of oral complications in cancer patients receiving bone marrow and stem cell transplantation is essential when testing new treatment strategies for mucositis. Using 133 adult transplant patients, the authors evaluated the 20 item oral mucositis index (OMI), adapted from the 34 item OMI, to facilitate use by nondental health professionals. The OMI-20 consists of nine items measuring erythema, nine measuring ulceration, one measuring atrophy, and one measuring edema; all are scored from 0 = none to 3 = severe and summed for a total possible score of 0-60. The two sets of nine items measuring erythema and ulceration can also be summed separately to produce subscale scores ranging from 0 to 27. Results demonstrated internal consistency, test-retest, and inter-rater reliability, and strong evidence of construct validity. Provided that clinical examiners have appropriate training and experience, the OMI-20 can be used as a reliable, valid, and quantifiable measure of mucositis in clinical research.

More than a sore mouth: patients' experience of oral mucositis

PURPOSE/OBJECTIVES

To explore patients' experience of chemotherapy-induced oral mucositis.

DESIGN

Interpretive descriptive, phenomenologic.

SETTING

The cancer center of a metropolitan teaching hospital in South Australia.

SAMPLE

A purposive sample of six participants undergoing intensive cytotoxic therapy associated with autologous hematopoietic stem cell transplantation.

METHODS

Patients were interviewed at different stages of their treatment trajectory and asked to relate their experience of oral mucositis as it developed and resolved.

FINDINGS

Participants' reports indicated three distinct phases representing linear time in the course of their mucositis: the preparatory phase, the peak phase, and the persisting phase. Five themes further abstracted were the presence of nurses, therapeutic interventions, manifestations of mucositis, the distress of eating (and not eating), and whether the treatment was worthwhile.

CONCLUSIONS

Oral mucositis is much more than a sore mouth. The effects of mucositis are widespread and can have a marked effect on patients' psychological well-being.

IMPLICATIONS FOR NURSING

Care centers often focus on pain control through pharmacologic intervention and overlook the effects of other sequelae. Nurses' role in helping patients to cope with mucositis should encompass more than providing pharmacologic pain relief.

Mucosal tissue injury in cancer therapy. More than muscositis and mouthwash

PURPOSE

The purpose of this article is as follows: 1) to describe the characteristics and scope of mucosal tissue injury associated with cancer treatment; 2) to discuss recent advances in related basic and clinical science; and 3) to articulate research needs and opportunities to be addressed through collaborative interdisciplinary research.

OVERVIEW

Mucosal tissue injury is both a direct and indirect consequence of cancer therapy, with manifestations that include damage and a number of other potentially serious sequelae. Current research in mucosal tissue injury is focused on the biology, immunology, and genetics of mucosal injury; clinical problems; assessment and management; and processes and outcomes of care.

CLINICAL IMPLICATIONS

Results from these various areas of research enhance the understanding of the mechanisms of mucosal tissue injury, provide direction for the development of policy and for clinical practice, and help to define research needs and opportunities. Future research on the complex process of mucosal tissue injury will be interdisciplinary and will cross the boundaries among basic, translational, and clinical science.

Management of oral complications

OBJECTIVES

To explore what nurses were doing to prevent or treat oral complications related to cancer and cancer therapies.

DATA SOURCES

Review articles, research studies, consensus statements, and data collection.

CONCLUSIONS

Different practice patterns exist between physicians and nurses in providing oral care interventions. Nurses initiated less toxic and less costly interventions than those prescribed by physicians. Standard assessment parameters are used infrequently.

IMPLICATIONS FOR NURSING PRACTICE

Oral mucositis can be distressing by interfering with comfort, appetite, communication, and general well-being. Nurses need to initiate appropriate therapy for patient care.

Maintaining study validity in a changing clinical environment

BACKGROUND

Nurse scientists who conduct intervention research in a variety of clinical settings find themselves facing numerous challenges posed by today's changing and sometimes complex health care environment. Maintaining study validity thus becomes a major focus of interventional research, but existing literature does not fully address challenges to study validity nor offer potential solutions.

OBJECTIVES

The purposes of this paper are to 1) discuss methodologic challenges to maintaining study validity of intervention research that is conducted in a changing clinical environment, and 2) share strategies for maximizing study validity.

METHODS

A recently completed intervention study is used as an example to discuss two specific areas that affected study validity, provide examples of selected threats to validity, and outline strategies used to minimize these threats.

RESULTS

Careful definition of goals, thoughtful decision making, and implementation of specific strategies to maintain study validity helped increased the rigor of the research.

CONCLUSIONS

Investigators conducting intervention research in changing clinical settings can reduce threats to study validity and increase design rigor by considering clinical realities (e.g., clinician-researcher role conflict) when making methodologic decisions, becoming familiar with the setting, and involving clinicians in the research.