Management of oral mucositis in cancer patients
Dr Odette Spruyt - Peter MacCallum Cancer Centre, Melbourne, Australia
What is oral mucositis and how does it occur?
This is an inflammatory condition of the mucosa of the mouth. It varies a little bit from stomatitis which includes also inflammation of the periodontium and the dentition as well as the oral mucosa. It’s an extremely important condition in that it’s one of the most distressing adverse effects of chemotherapy and other cancer treatments and certainly regarded by patients as one of the most distressing aspects of their treatment. Very common in chemotherapy management, it’s estimated up to around 40% of people who have chemotherapy will develop oral mucositis, often within a week or so of their treatment starting and it can continue for some period of time. In certain groups, people who are having induction therapy for stem cell transplants, people who are having radiation or radiotherapy to the head and neck, are very prone to developing this condition and may develop it to a very severe degree.
How can the severity of the condition be assessed?
There are scales developed to assess the severity of oral mucositis which are primarily focussed on what’s happening in the mouth. They don’t generally include the wider patient experience and I think we have to bring that into our clinical management very strongly. So what is the impact on this person’s quality of life, their relationships, their diet, just their social interaction and their self-image? All of these are very important to bring into our assessment as well as what is actually happening in the mouth – oedema, erythema, presence of ulceration and whether there is still saliva being produced and so forth. So most of these scales that have been developed to assess oral mucositis will include those sorts of factors.
How can oral mucositis be managed?
Looking then at considering the management of the condition, we can think about oral care, mouth care and hygiene, how to keep the mouth clean and debride any hard secretions that might be forming on the inside of the mouth. Looking for the presence of any infection and trying, perhaps, to prevent infections from developing because of the damage to the mucosa. Also a lot of attention is being paid to how to prevent this condition from occurring so prophylaxis and the prevention of bleeding complications, especially in patients who are thrombocytopenic. The final, very important aspect is pain management.
Are there any guidelines related to the management of oral mucositis?
In 2013 MASCC, the Multinational Association for Supportive Care in Cancer, produced guidelines, evidence-based guidelines, on the management of oral mucositis. Key outcome was that the oral care protocol is the only recommendation that encompasses all types of oral mucositis so it really highlights the importance of excellent oral care. The MASCC guidelines certainly encourage excellent oral mouth care and they also identify that palifermin, which is a keratinocyte growth factor, reduces the incidence and severity of oral mucositis in patients having stem cell replacements, however that agent is extremely expensive, something in the region of A$10,000 per dose and really limited to a very select group of patients who are having stem cell transplantation and identified as being at very high risk of possibly life-threatening complications from oral mucositis. Another therapy which is useful is cryotherapy and also laser therapy has been shown to be of benefit. While the guidelines are certainly important, we are still left with making careful clinical judgements about what treatments to use in individual patients and also to always remember the subjective experience of the patient and support them through this condition.