Effect of an oral mucositis protocol on quality of life of patients with head and neck cancer treated with radiation therapy

Interventions to improve quality of life in patients with head and neck cancers receiving radiation therapy: a scoping review

BACKGROUND

Quality of life (QOL) is impaired in patients with head and neck cancers (HNC) due to illness and treatment-associated morbidity. Although there is evidence from the studies on interventions' role in improving QOL receiving radiation therapy, these are not systematically synthesised. In this scoping review, we searched and synthesised the evidence on interventions to improve the QOL and its impact among patients with HNCs.

METHODS

This scoping review was conducted using the framework proposed by Arksey and O'Malley, and the extensions suggested by Levac et al. were incorporated. Two reviewers independently searched four electronic databases using key thesaurus and free-text terms, and the data was extracted, tabulated, synthesised and reported as categories.

RESULTS

Seventy-nine papers reported various interventions of diverse nature such as pharmacological, physical, nutritional, complementary and alternative therapies, psychosocial, oral care related, laser and photobiomodulation therapies, rehabilitative, educational, technology-based, surgical, device-related and nurse lead interventions. Most studies reported clinically meaningful impact of interventions on QOL, although the outcome differences were often statistically insignificant. Few studies reported a combination of interventions to address the multidimensional concerns faced by patients with HNCs. None of the studies examined the impact of interventions on QOL among long-term survivors of HNCs.

CONCLUSION

As QOL concerns in patients with HNCs are multifaceted, more extensive studies with complex multi-component interventions and robust research designs are warranted.

Update on Prevalence of Pain in Patients with Cancer 2022: A Systematic Literature Review and Meta-Analysis

Experiencing pain and insufficient relief can be devastating and negatively affect a patient's quality of life. Developments in oncology such as new treatments and adjusted pain management guidelines may have influenced the prevalence of cancer pain and severity in patients. This review aims to provide an overview of the prevalence and severity of pain in cancer patients in the 2014-2021 literature period. A systematic literature search was performed using the databases PubMed, Embase, CINAHL, and Cochrane. Titles and abstracts were screened, and full texts were evaluated and assessed on methodological quality. A meta-analysis was performed on the pooled prevalence and severity rates. A meta-regression analysis was used to explore differences between treatment groups. We identified 10,637 studies, of which 444 studies were included. The overall prevalence of pain was 44.5%. Moderate to severe pain was experienced by 30.6% of the patients, a lower proportion compared to previous research. Pain experienced by cancer survivors was significantly lower compared to most treatment groups. Our results imply that both the prevalence of pain and pain severity declined in the past decade. Increased attention to the assessment and management of pain might have fostered the decline in the prevalence and severity of pain.

The effect of navigation programme on the management of symptoms related to head and neck radiotherapy

BACKGROUND

This study aims to determine the effect of navigation programme in the management of symptoms related to head and neck cancer (HNC) radiotherapy.

METHODS

This randomized, controlled and experimental study was conducted between November 2018 and March 2020 with the participation of 88 patients with HNC receiving radiotherapy. Referring to the pre-prepared randomization checklist, 41 people were randomized to the experimental group and 47 to the control group. While the standard treatment approaches of the hospital were applied to all patients, the patients in the experimental group were applied an additional nursing navigation program. At the beginning of the navigation program, the patients were given a 30-minute visual training on the first day of radiotherapy and a handbook related to the expected adverse effects. Throughout subsequent seven weeks, the patient continued to be followed up via phone reminders, providing daily counseling and a weekly follow-up. Patient identification form, CTCAE v5.0 toxicity criteria and EORTC QLQ-30, H&N35 assessment questionnaires were used in the study. The first result was the difference observed in quality of life scores at the beginning, middle and end of radiotherapy.

RESULTS

Data obtained from the study revealed that the quality of life scores (p < 0.05) improved while the navigation program reduced the severity of symptoms such as mucositis, dysphagia, oral pain and weight loss (p < 0.05).

CONCLUSION

It was concluded that navigation programme is an effective approach for patients receiving head and neck radiotherapy.

TRIAL REGISTRATION

NCT04857749.

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

Oral mucositis (OM) can be a significant problem for patients undergoing radiation or chemoradiation for head and neck cancer. In modern clinical trials, grade 3-4 OM can be seen in over 40% of patients and can cause a significant impact on their quality of life (QOL). Despite this fact, strategies for the prevention and treatment of OM vary widely, with options including both lifestyle modifications and pharmaceuticals. Here we evaluate and summarize the current clinical interventions for the management of radiation-induced OM. The majority of the current evidence focuses on reducing OM related pain. These agents are detailed over multiple clinical trials including treatment modalities such as: GC4419, doxepin mouthwash, diphenhydramine-lidocaine-antacid (DLA) mouthwash, gabapentin, and methadone. While several strategies have been employed to prevent radiation-induced OM, there is currently no strong evidence for the routine use of these agents in the clinic. After summarization of these treatments, we offer practical guidance for the treatment of OM in the clinic. We recommend a multiagent approach of pharmacological and non-pharmacological treatments including oral rinses, home humidification, escalating doses of gabapentin, doxepin or DLA mouthwash, over the counter analgesics, and lastly methadone. These interventions are tailored to address the expected increase of severity of symptoms during the course of head and neck radiotherapy.

Nurse-Delivered Telephone Intervention to Reduce Oral Mucositis and Prevent Dehydration

PROBLEM STATEMENT

This study evaluates the feasibility of a nurse-delivered telephone intervention to reduce oral mucositis severity and prevent dehydration in patients with lung or head and neck cancer undergoing chemotherapy and radiation therapy.

DESIGN

This study used a two-phase, qualitatively driven, mixed-methods descriptive design.

DATA SOURCES

11 participants were recruited from an academic cancer center in southern Florida. Participants received symptom management education followed by twice-weekly tailored nurse coaching telephone calls.

ANALYSIS

Questionnaires measuring symptom severity, health-related quality of life, perceived self-efficacy, and symptom self-management were administered at four data points. Data on unscheduled medical visits were collected. Guided interviews were conducted four weeks post-treatment and analyzed qualitatively using content analysis.

FINDINGS

Participants found the intervention to be acceptable. Oral mucositis symptom severity was minimized, and dehydration was avoided. The intervention enabled symptom self-management and improved perceived self-efficacy.

IMPLICATIONS FOR PRACTICE

Emotional support provided by the nurse was crucial, exemplifying improvement over an automated system.

Honey Against Radiation-induced Oral Mucositis in Head and Neck Cancer Patients. An Umbrella Review of Systematic Reviews and Meta- Analyses of the Literature

Backround: Oral mucositis (OM) consists of a major side effect of radiotherapy (RT) in head and neck (H-N) cancer patients and natural honey is gaining more and more scientific interest due to its beneficial effects in tissue repair.

OBJECTIVE

The aim of this review is to better clarify the preventive/therapeutic role of honey in the management of OM in patients with H-N cancer undergoing RT with or without chemotherapy (CT).

METHODS

We used the PubMed database to retrieve journal articles and the inclusion criteria were only reviews and meta-analyses that illustrated the effective use of honey for either the prevention or treatment of OM in H-N cancer patients receiving either RT alone or in combination with CT.

RESULTS

Our search resulted in 92 citations, of which 12 eventually fulfilled the inclusion criteria of our study. Decreased incidence and severity of OM, extended time of occurrence of mucositis, less weight loss and less treatment interruptions were occasionally documented with conventional honey use in the included reviews and meta-analyses. In contrast to conventional honey, manuka honey proved to be weak in improving OM management in the small number of included reviews in our search.

CONCLUSION

Conventional honey might constitute a highly promising natural product against OM attracting much scientific interest due to its easy accessibility and low financial cost. Hence, the lack of studies with high evidence requires further advanced research to enhance the existing knowledge about the potential value of honey in radiation-induced OM in H-N cancer patients.

Financial and socio-economic factors influencing pre- and post-cancer therapy oral care

PURPOSE

The primary objective of this study is to evaluate how attendance at dental visits may change as cancer patients move through pre-diagnosis, diagnosis, and into survivorship.

METHODS

The Health and Retirement Study consists of longitudinal survey data collected biannually detailing financial and health information in subjects over 51 years old. We assessed a subset of 4195 patients who received a new cancer diagnosis during the study period. The odds of reporting a dental visit were examined using a mixed effects logistic regression model. A propensity score weighted analysis of the association between dental attendance and survival was also undertaken.

RESULTS

The odds of attending a dental visit were substantially lower in the peri-diagnosis period OR = 0.784 (0.700, 0.876) and the post-diagnosis period OR = 0.734 (0.655, 0.823) compared to pre-diagnosis. This effect persisted in patients who survived for at least 2 years indicating that the decline in oral health visits was not due to low expected survival. After propensity score weighting, patients who attended a dental visit in the peri-diagnosis period demonstrated a reduced hazard of all-cause mortality HR = 0.825 (0.681, 0.979) compared with those with no attendance.

CONCLUSIONS

Dental attendance decreases by a statistically and clinically significant amount both during and after cancer therapy despite guideline recommendations encouraging dental referral and monitoring for many types of cancer therapy. Attendance at dental appointments during cancer therapy is associated with improved survival, which is likely due to a combination of direct and indirect effects.

Efficacy of Plantago major, chlorhexidine 0.12% and sodium bicarbonate 5% solution in the treatment of oral mucositis in cancer patients with solid tumour: A feasibility randomised triple-blind phase III clinical trial

PURPOSE

Oral mucositis is one of the most common adverse effects of chemotherapy and radiotherapy. The aim of this study was to compare the efficacy of Plantago major extract versus chlorhexidine 0.12% versus sodium bicarbonate 5% in the symptomatic treatment of chemotherapy-induced oral mucositis in solid tumour cancer patients.

METHOD

Multicentre randomised controlled trial estimated sample of 45 solid tumour patients with grade II-III mucositis. The participants were randomised to one of three treatments, consisting of sodium bicarbonate 5% aqueous solution together with: an additional dose of sodium bicarbonate 5% aqueous solution, Plantago major extract, or chlorhexidine 0.12%. The primary outcomes were severity of mucositis, pain intensity, oral intake capacity and quality of life. The independent variable was treatment group, and confounders included sociodemographic data, neutrophil count, chemotherapy drug and dose received.

RESULTS

Of the 50 patients enrolled, 68% (n = 34) achieved grade 0 mucositis (none), with those using the double sodium bicarbonate rinse healing in five days on average (95% CI 3.9, 6.5) versus seven days (95% CI 5.3, 9,0) for the chlorhexidine group and seven days (95% CI 5.3, 8.5) for the Plantago major group. The pain experienced by the participants lessened over the 14 days of treatment, but differences in pain intensity between the three groups did not show statistical significance (p = 0.762).

CONCLUSIONS

Healing time was shorter with the double sodium bicarbonate solution compared to the other two rinses, but the differences were not significant. Our results suggest it may be time to reconsider the use of Plantago major extract in the management of oral mucositis.

Effect of Tempol on the prevention of irradiation-induced mucositis in miniature pigs

OBJECTIVE

The goals of this study were to (i) establish a useful miniature pig (minipig) model for irradiation-induced oral mucositis and (ii) evaluate the effect of Tempol to prevent its development.

METHODS AND MATERIALS

Minipigs were irradiated with 6 Gy for five consecutive days targeting the entire oral cavity. To prevent radiation damage, minipigs were treated with 30 mg kg^-1 Tempol 10 min before irradiation (n = 4), while the radiation-alone group was similarly injected with saline (n = 4). Lesions were graded using an oral mucositis score and visual inspection every 3 days, and biopsy of multiple sites was performed at day 18. Weight and chest and abdominal circumferences were measured every 3 days.

RESULTS

Lesions began about 12 days after the first irradiation fraction and healed about 30 days after irradiation. Epithelial thickness was calculated on the lingual and buccal mucosa on the 18th day after the first irradiation fraction. Tempol provided modest protection from ulceration after irradiation using this treatment strategy.

CONCLUSIONS

This study established a useful large animal model for irradiation-induced oral mucositis and showed modest beneficial effects of Tempol in limiting tissue damage. The latter finding may be potentially valuable in preventing oral mucositis in patients receiving irradiation for head and neck cancers.

Role of Gabapentin in Managing Mucositis Pain in Patients Undergoing Radiation Therapy to the Head and Neck

BACKGROUND

Oral mucositis (OM) is a painful and debilitating side effect that affects 80%-100% of patients undergoing radiation therapy for head and neck cancer. This dose-limiting side effect may potentially lead to pain, dehydration, malnutrition, infection, and treatment breaks. Treatment breaks can lead to decreased disease control and suboptimal patient outcomes. No primary prevention exists for OM, and management is focused on pain control. Compelling evidence exists that OM pain has somatic and neuropathic components.

OBJECTIVES

This article reviews the existing literature on the use of gabapentin (Neurontin®) as a co-analgesic in treating the neuropathic pain in OM.

METHODS

A literature search was performed using CINAHL® and PubMed with the search terms gabapentin and oral mucositis. The selected articles were briefly screened for relevance, and three were included in this review.

FINDINGS

No systematic reviews exist on the role of gabapentin for neuropathic pain in radiation-induced OM. Two retrospective studies concluded that gabapentin reduced escalation of opioid doses and unplanned treatment breaks. One retrospective study demonstrated favorable swallowing outcomes. Pain and OM are nursing-sensitive outcomes that can be significantly affected by evidence-based nursing interventions.