Direct stomatotoxic effects begin shortly after administration of either mucotoxic chemotherapy or within 2 weeks of beginning radiation. National Cancer Institute (NCI) clinical/functional OM toxicity grades categorize mild mucositis as grade 0–1, moderate as grade 2, and severe as grade 3–4.
Although most patients report clinical and functional grades of OM returning to normal after 1–3 months of radiation and shortly after stopping chemotherapy, delayed effects or impairments can linger. Oral discomfort such as dysphagia, dysgeusia, and odynophagia may continue for months and can have a negative impact on the patient’s quality of life.
At the conclusion of Mrs. J.’s combined chemoradiation for head/neck cancer, her NCI clinical/functional OM was grade 2. Mrs. J. followed the basic oral regimen previously described, including utilizing the calcium/phosphate rinse four times a day. She was able to maintain her nutritional status and her pain was controlled with minimal narcotics. Mrs. S. found that her OM was manageable after she utilized the calcium/phosphate oral rinse during her second cycle of therapy. She was able to focus on the radiation side effects associated with pelvic irradiation instead of side effects induced by chemotherapy (ie, OM).
Approximately 400,000 oncology patients experience treatment-related injury to the oral cavity. The case studies described in this article illustrate how OM can develop in the course of treating different cancer sites and the different modalities that can precipitate OM—that is, acute toxicity of OM is associated not only with irradiation of the head and neck, but it also can result from certain cytotoxic chemotherapies. OM affected several quality of life domains in both patients, as shown in Figure 3.
Several risk factors have an impact on development of OM. The site of malignancy will determine radiation treatment fields and/or chemotherapy agents. Poor oral hygiene, caries with associated periapical pathology, and periodontal disease all are associated with an increased risk of developing OM. Poor nutritional status has an impact on how treatment is tolerated by the patient and how quickly he or she recovers from therapy.
Education should begin with the first contact with the patient. Nutritional consults are essential. The patient must be shown how to brush and floss effectively, and must be evaluated by a dentist before, during, and after treatment.
Incorporating evidence into practice still remains challenging, as there are limited randomized controlled clinical trials with OM interventions. There are no guidelines from the NCCN or the American Society of Clinical Oncology (ASCO). The Multinational Association of Supportive Care in Cancer (MASCC) and the International Society for Oral Oncology offer general guidelines for OM. The Oncology Nursing Society’s Putting Evidence into Practice (PEP) card provides additional OM resources for nurses and also is available in a new PEP Resources textbook.
Prophylactic approaches to prevent or minimize the severity of OM are important. Oral cryotherapy—intraoral administration of ice chips by swishing with the chips for 30 minutes—has shown efficacy when patients are receiving 5-FU. The largest clinical trial was reported by Sorensen and colleagues, in which patients were randomized into three arms: cryotherapy (performed 10 minutes prior to administration of 5-FU and leucovorin and continuing for 35 minutes after treatment), chlorhexidine(Drug information on chlorhexidine) mouthwash, or a placebo mouthwash. Prevalence of grades 3 and 4 OM was significantly lower among patients using cryotherapy (11%, 13%, and 33% in the cryotherapy, chlorhexidine, and placebo arms, respectively).
Another double-blind, placebo-controlled trial was conducted in hematopoietic cell transplant patients using a regimen of a supersaturated calcium/phosphate oral rinse. Two arms of this study (the calcium phosphate(Drug information on calcium phosphate) rinse plus topical fluoride group and topical fluoride alone) demonstrated a statistically significant outcome with shorter days of OM, less pain, and less narcotic administration. MASCC does not currently recommend systemic use of glutamine to prevent OM, owing to limited controlled studies. Palifermin (keratinocyte growth factor-1; Kepivance) is recommended for prevention of OM in patients with hematologic malignancies who are receiving high-dose chemotherapy and total body irradiation with autologous stem cell transplantation, and research in patients with solid tumors is planned.
OM is the principal oral side effect of chemotherapy, radiation, and chemoradiation. Altered mucosa can predispose patients to bacterial, fungal, and viral superinfection, and OM often results in physiological/functional impairment and psychological distress, producing a negative impact on quality of life. Oncology nurses need to continue to seek evidence-based interventions that can alleviate OM and its potential complications.
Financial Disclosure: Marilyn Haas serves as a consultant for EUSA.