Quality Assessment of PBM Protocols for Oral Complications in Head and Neck Cancer Patients: Part 1

The supportive use of photobiomodulation on salivary glands: a narrative review and meta-analysis

PURPOSE

Radiotherapy is one of the main strategies used in the treatment of cancer patients and it can cause early or late xerostomia and/or hyposalivation. Therapeutic management of xerostomia includes oral hygiene, sialogenic agents among others.

METHODS

This study reviews the use of extra-oral salivary glands photobiomodulation in treating xerostomia and/or hyposalivation after radiotherapy and performs a meta-analysis of this data.

RESULTS

After a broad search of the literature, eight clinical studies were selected.

DISCUSSION

In a safe way, the studies found that extra-oral stimulation of the salivary glands has benefits in the hyposalivation and changes in salivary flow resulting from lesions by radiotherapy. A meta-analysis found significant values in pain comparing the pre- and post-treatment moments (MD - 3.02, I2 95%, IC - 5.56; - 0.48) and for stimulated salivary flow at 30 days after the end of radiotherapy (MD 2.90, I2 95%, IC 1.96; 3.84).

CONCLUSION

The most promising parameters comprise wavelengths between 630 and 830 nm, radiant exposure from 2 to 10 J/cm2, two-to-three times a week, before the radiotherapy damage, and homogeneously in the glands. Therefore, Light-Emitting Diode (LED) stimulation of larger areas than the punctual stimulation of small millimeters of the Low-Level Laser Therapy (LLLT) appears to be promising.

Emerging pharmacotherapy trends in preventing and managing oral mucositis induced by chemoradiotherapy and targeted agents

INTRODUCTION

The introduction of targeted therapy and immunotherapy has tremendously changed the clinical outcomes and prognosis of cancer patients. Despite innovative pharmacological therapies and improved radiotherapy (RT) techniques, patients continue to suffer from side effects, of which oral mucositis (OM) is still the most impactful, especially for quality of life.

AREAS COVERED

We provide an overview of current advances in cancer pharmacotherapy and RT, in relation to their potential to cause OM, and of the less explored and more recent literature reports related to the best management of OM. We have analyzed natural/antioxidant agents, probiotics, mucosal protectants and healing coadjuvants, pharmacotherapies, immunomodulatory and anticancer agents, photobiomodulation and the impact of technology.

EXPERT OPINION

The discovery of more precise pathophysiologic mechanisms of CT and RT-induced OM has outlined that OM has a multifactorial origin, including direct effects, oxidative damage, upregulation of immunologic factors, and effects on oral flora. A persistent upregulated immune response, associated with factors related to patients' characteristics, may contribute to more severe and long-lasting OM. The goal is strategies to conjugate individual patient, disease, and therapy-related factors to guide OM prevention or treatment. Despite further high-quality research is warranted, the issue of prevention is paramount in future strategies.

Preventive versus curative photobiomodulation for oral mucositis in patients with multiple myeloma undergoing hematopoietic stem cell transplantation: which approach is more effective?

PURPOSE

There is increasing evidence that photobiomodulation (PBM) therapy is both an effective and safe approach in hematopoietic stem cell transplantation (HSCT) for both prevention and management of oral mucositis (OM), but its use in clinical practice is still limited and the timing of application is under discussion. The aim of this retrospective study was to evaluate possible differences between patients treated either with preventive or curative PBM therapy.

METHODS

The retrospective case series included 24 patients suffering from multiple myeloma who underwent the same conditioning and transplantation protocol. Patients were treated either with preventive PBM starting from the first day of conditioning up to two days post-HSCT or with curative PBM (starting at OM onset for four consecutive days). OM score, pain, and functional parameters were recorded.

RESULTS

All patients developed OM. Preventive PBM was significantly more effective in reducing OM severity (p < 0.0001) and pain (p < 0.0001) post-HSCT than curative PBM. Furthermore, we found a lower number of patients reporting discomfort in all subjective parameters (pain during swallowing, chewing, and speaking) in the preventive PBM group. No adverse events related to PBM therapy were recorded in both groups.

CONCLUSION

The timing for PBM therapy in patients undergoing HSCT is crucial: when started on the first day of conditioning, it significantly reduces both pain and OM severity, providing an important benefit also in subjective oral functions such as speaking, swallowing, and chewing, thus increasing the overall adherence to the oncological therapies.

Efficacy of photobiomodulation therapy combined with mobile health education in patients with head and neck cancer suffering from chronic xerostomia after radiotherapy: protocol for a three-arm, randomised, placebo-controlled, double-blinded study

INTRODUCTION

The role of photobiomodulation (PBM) therapy for oral tissue damage induced by cancer treatment is currently unclear, and there is low-quality to moderate-quality evidence supporting the use of this approach for treating xerostomia and/or hyposalivation. Consequently, patients with head and neck cancer increasingly turn to basic oral hygiene to alleviate salivary gland dysfunction, and their adherence can be improved by mobile health (mHealth) education. The primary objective of this study will be to analyse the effects of different doses of PBM therapy (7.5 J/cm2 vs 3 J/cm2) plus mHealth education on quality of life (QoL), oral health, salivary secretion and salivary gland ultrasound assessment at postintervention and at the 6-month follow-up in patients with head and neck cancer after radiotherapy compared with those in control group.

METHODS AND ANALYSIS

A prospective, three-arm, randomised, placebo-controlled, double-blinded study will be conducted among patients with head and neck cancer suffering from chronic xerostomia. A total of 20 patients per arm will be included and randomly assigned to receive 7.5 J/cm2 of PBM, 3 J/cm2 of PBM or placebo therapy. PBM therapy will be applied during 24 sessions at 22 points extra and intraorally two times per week for 3 months, combined with a mobile application (https://www.laxer.es). The assessments will be recorded at the beginning of the study, at postintervention and at the 6-month follow-up. The primary outcomes will be QoL, oral health, salivary secretion and salivary gland ultrasound. The pain pressure threshold, functional performance, mood and sleep quality will be secondary indicators.

ETHICS AND DISSEMINATION

This study received ethics approval from the Andalusian Biomedical Research Ethics Portal (2402-N-21 CEIM/CEI Provincial de Granada) according to the Declaration of Helsinki for Biomedical Research. The results of this study will be presented at national and international conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT05106608.

Quality assessment of PBM protocols for oral complications in head and neck cancer patients: part 2

PURPOSE

To investigate the role of photobiomodulation (PBM) in patients undergoing head and neck cancer (HNC) treatment. We focused on the consequences of the main complications, such as quality of life (QoL), analgesia, functional impairment, and nutritional status, as well as on the impact on survival/ recurrences, radiotherapy (RT) interruption, adherence, cost-effectiveness, safety, feasibility, and tolerability.

METHODS

An electronic search in PubMed and Scopus databases was performed. Full texts were carefully assessed, and data were assimilated into a tabular form for discussion and consensus among the expert panel.

RESULTS

A total of 22 papers were included. Overall, a beneficial effect of PBM was evidenced in the amelioration of QoL, nutritional status, the reduction of pain, and functional impairment. Preventive PBM may reduce the incidence and duration of RT interruptions, potentially contributing to improved cancer treatment outcomes. PBM treatments are safe and recommended for routine use, with the caveat of avoiding direct tumor exposures where feasible. However, it does not appear to impact cancer survivorship/recurrences directly. Despite additional clinical efforts involving routine PBM use, the individual and public health benefits will positively impact oncology care.

CONCLUSIONS

Quality of life, pain and functional impairment, nutritional status, and survival may be effectively improved with PBM. Given its established efficacy also in reducing RT interruptions and its safety, feasibility, and tolerability, PBM should be included in the field of supportive cancer care in HNC patients. Improved understanding of PBM mechanisms and precise dose parameters is enabling the generation of more robust, safe, and reproducible protocols; thus, it is imperative to support further clinical implementation as well as both applied and basic science research in this novel field.

Photobiomodulation therapy for the prevention of acute radiation dermatitis: a systematic review and meta-analysis

PURPOSE

Approximately 95% of patients undergoing radiotherapy (RT) experience radiation dermatitis (RD). Evidence has suggested that photobiomodulation therapy (PBMT) can stimulate skin renewal and minimize RD. The aim of the present paper was to investigate the efficacy of PBMT in RD prevention through a comprehensive literature review.

METHODS

A literature search of Ovid MEDLINE, Embase, and Cochrane databases was conducted from 1980 to March 2021 to identify RCT on the use of PBMT for RD prevention. Forest plots were developed using RevMan software to quantitatively compare data between studies.

RESULTS

Five papers were identified: four in breast and one in head and neck cancer patients. Patients receiving PBMT experienced less severe RD than the control groups after 40 Gray (Gy) of RT (grade 3 toxicity: Odds Ratio (OR): 0.57, 95% CI 0.14-2.22, p = 0.42) and at the end of RT (grade 0 + 1 vs. 2 + 3 toxicity: OR: 0.28, 95% CI 0.15-0.53, p < 0.0001). RT interruptions due to RD severity were more frequent in the control group (OR: 0.81, 95% CI 0.10-6.58, p = 0.85).

CONCLUSION

Preventive PBMT may be protective against the development of severe grades of RD and reduce the frequency of RT interruptions. Larger sample sizes and other cancer sites at-risk of RD should be evaluated in future studies to confirm the true efficacy of PBMT, also in preventing the onset of RD and to finalize a standardized protocol to optimize the technique. At present, starting PBMT when RT starts is recommendable, as well as performing 2 to 3 laser sessions weekly.