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Prevention and treatment of oral mucositis in patients with head and neck cancer treated with (chemo) radiation: report of an Italian survey

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Abstract

Purpose

There is a limited number of therapies with a high level of recommendations for mucositis, while several strategies are currently employed with a limited evidence for efficacy. A national survey among Italian oncologists who treat head and neck cancer (HNC) was conducted in order to assess the most common preventive and therapeutic protocols (including nutritional support and pain control) for oral mucositis (OM) in patients undergoing chemoradiotherapy.

Methods

From September to November 2012, a nationwide electronic survey with 21 focused items was proposed to chemotherapy and radiotherapy centers.

Results

We collected 111 answers. Common Terminology Criteria for Adverse Events (CTCAE) scale is employed by 55 % of the physicians in assessing mucosal toxicity. The most relevant predictive factors for OM development are considered smoke, alcohol use, planned radiotherapy, and concurrent use of radiosensitizing chemotherapy. Prophylactic gastrostomy is adopted in <10 % of the patients. Preventive antibiotics or antimycotics are prescribed by 46 % of the responders (mainly local or systemic antimycotic drugs). Alkalinizing mouthwashes or coating agents are frequently adopted (70 % of the cases). Among therapeutic interventions, systemic fluconazole is administered by 80 % of the physicians. Pain is mainly treated by weak followed by strong opioids.

Conclusions

A variety of preventive and therapeutic protocols for OM exists among the participating Italian centers, with some uniformity in respect to nutritional support, use of antimycotic and painkillers. There is an urgent need for well-conducted clinical trials aimed at assessing the best choices for OM prevention and treatment in HNC.

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References

  1. Boyle P, Ferlay J (2005) Cancer incidence and mortality in Europe. Annals Oncol 16:481–490

    Article  CAS  Google Scholar 

  2. Chaturvedi AK, Engels EA, Pfeiffer RM et al (2001) Human papillomavirus and rising oropharyngeal cancer incidence in the United States. J Clin Oncol 29:4294–4301

    Article  Google Scholar 

  3. Sonis ST (2011) Oral mucositis. Anti-Cancer Drugs 22:607–612

    Article  CAS  PubMed  Google Scholar 

  4. Pico JL, Avila-Garavito A, Naccache P (1998) Mucositis: its occurrence, consequences, and treatment in the oncology setting. Oncologist 3:446–451

    PubMed  Google Scholar 

  5. Brown CG, Wingard J (2004) Clinical consequences of oral mucositis. Semin Oncol Nurs 20:16–21

    Article  PubMed  Google Scholar 

  6. Elting LS, Keefe DM, Sonis ST, Garden AS, Spijkervet FK, Barasch A et al (2008) Patient-reported measurements of oral mucositis in head and neck cancer patients treated with radiotherapy with or without chemotherapy: demonstration of increased frequency, severity, resistance to palliation, and impact on quality of life. Cancer 118:2704–2713

    Article  Google Scholar 

  7. Maurer J, Hipp M, Schafer C et al (2011) Dysphagia—impact on quality of life after radio(chemo)therapy of head and neck cancer. Strahlenther Onkol 187:744–749

    Article  PubMed  Google Scholar 

  8. Elting LS, Cooksley CD, Chambers MS, Garden AS (2007) Risk, outcomes and costs of radiation-onduced oral mucositis among patients with head and neck malignancies. Int J Radiat Oncol Biol Phys 68:1110–1120

    Article  PubMed  Google Scholar 

  9. Russo G, Haddad R, Marshall Posner M, Machtay M (2008) Radiation treatment breaks and ulcerative mucositis in head and neck cancer. Oncologist 13:886–898

    Article  PubMed  Google Scholar 

  10. Poulsen M, Denham J, Spry N et al (1999) Acute toxicity and cost analysis of phase III randomized trial of accelerated and conventional radiotherapy for squamous carcinoma of the head and neck: a trans-tasman radiation oncology group study. Australas Radiol 43:487–494

    Article  CAS  PubMed  Google Scholar 

  11. Trotti A, Bellm LA, Epstein JB et al (2003) Mucositis incidence, severity and associated outcomes in patients with head and neck cancer receiving radiotherapy with or without chemotherapy: a systematic literature review. Radiother Oncol 66:253–262

    Article  PubMed  Google Scholar 

  12. http://www.mascc.org/mucositis-guidelines (accessed on October 18th, 2013)

  13. Brennan MT, Elting LS S, Spijkervet FKL (2010) Systematic reviews of oral complications from cancer therapies, Oral Care Study Group, MASCC/ISOO: methodology and quality of the literature. Support Care Cancer 18:979–984

    Article  PubMed  Google Scholar 

  14. Kostler WJ, Hejna M, Wenzel C, Zielinski CC (2001) Oral mucositis complicating chemotherapy and/or radiotherapy: options for prevention and treatment. CA Cancer J Clin 51:290–300

    Article  CAS  PubMed  Google Scholar 

  15. Hensley ML, Hagerty KL, Kewalramani T et al (2009) American society of clinical oncology 2008 clinical practice guideline update: use of chemotherapy and radiation therapy protectants. J Clin Oncol 27:127–145

    Article  CAS  PubMed  Google Scholar 

  16. Bensinger W, Schubert M, Ang KK et al (2008) NCCN Task Force Report. Prevention and management of mucositis in cancer care. J Natl Compr Canc Netw 6(Suppl 1):S1–S21

    CAS  PubMed  Google Scholar 

  17. National Cancer Institute (2009) Common terminology criteria for adverse events (CTCAE) version 4.0. U.S. Department of Health and Human Services, Bethesda, MD

    Google Scholar 

  18. Cox JD, Stetz J, Pajak TF (1995) Toxicity criteria of the Radiation Therapy Oncology Group (RTOG) and the European Organization for Research and Treatment of Cancer (EORTC). Int J Radiat Oncol Biol Phys 30:1341–1350

    Article  Google Scholar 

  19. World Health Organization. (1979) Handbook for reporting results of cancer treatment. pp. 15–22

  20. Denis F, Garaud P, Bardet E et al (2003) Late toxicity results of the GEORTEC 94-01 randomized trial comparing radiotherapy with concomitant radiochemotherapy for advanced stage oro-pharynx carcinoma: comparison of the LENT/SOMA, RTOG/EORTC and NCI-CTC: scoring systems. Int J Radiat Oncol Biol Phys 55:93–98

    Article  PubMed  Google Scholar 

  21. Fromme EK, Eilers KM, Mori M et al (2004) How accurate is clinician reporting of chemotherapy adverse effects? A comparison with patient-reported symptoms from the Quality-of-Life Questionnaire C30. J Clin Oncol 22:3485–3490

    Article  PubMed  Google Scholar 

  22. Loprinzi CL (2003) The Epstein/Schubert article reviewed. Oncology 17:1767–1779, discussion 1779–1782, 1791–1792

    Google Scholar 

  23. Nonzee NJ, Dandade NA, Patel U, Markossian T, Agulnik M, Argiris A, Patel JD, Kern RC, Munshi HG, Calhoun EA, Bennett CL (2008) Evaluating the supportive care costs of severe radiochemotherapy-induced mucositis and pharyngitis: results from a Northwestern University Costs of Cancer Program pilot study with head and neck and nonsmall cell lung cancer patients who received care at a county hospital, a Veterans Administration hospital, or a comprehensive cancer care center. Cancer 113(6):1446–1452, Erratum in: Cancer. 2009 Jun 15;115(12):2805

    Article  PubMed  Google Scholar 

  24. Jager-Wittenaar H, Dijkstra PU, Vissink A, van der Laan BF, van Oort RP, Roodenburg JL (2001) Malnutrition and quality of life in patients treated for oral or oropharyngeal cancer. Head Neck 33(4):490–496

    Article  Google Scholar 

  25. Langius J, Zandbergen MC, Eerenstein S et al (2013) Effect of nutritional interventions on nutritional status, quality of life and mortality in patients with head and neck cancer receiving (chemo)radiotherapy: a systematic review. Clin Nutr 32:671–678

    Article  PubMed  Google Scholar 

  26. Sanguineti G (2011) Effect of radiotherapy and chemotherapy on the risk of mucositis during intensity-modulated radiation therapy for oropharyngeal cancer. Int J Rad Oncol Biol Phys 86(5):805–807, 1

    Article  Google Scholar 

  27. Sanguineti G, Gunn GB, Parker BC et al (2011) Weekly dose-volume parameters of mucosa and constrictor muscles predict the use of percutaneous endoscopic gastrostomy during exclusive radiotherapy. Int J Radiat Oncol Biol Phys 79(1):52–59

    Article  PubMed  Google Scholar 

  28. Sonis ST (2004) The pathobiology of mucositis. Nat Rev Cancer 4(4):277–284

    Article  CAS  PubMed  Google Scholar 

  29. Busetto M, Fusco V, Corbella F, Bolzan M, Pavanato G et al. (2013) Predictive factors for oropharyngeal mycosis during radiochemotherapy for head and neck carcinoma and consequences on treatment duration. Results of mycosis in radiotherapy (MIR): a prospective longitudinal study. Radiother Oncol Aug 7. [Epub ahead of print]

  30. Corvò R, Amichetti M, Ascarelli A, Arcangeli G, Buffoli A et al (2008) Effects of fluconazole in the prophylaxis of oropharyngeal candidiasis in patients undergoing radiotherapy for head and neck tumour: results from a double-blind placebo-controlled trial. Eur J Cancer Care 17(3):270–277

    Article  Google Scholar 

  31. Mann PA, McNicholas PM, Chau AS, Patel R, Mendrick C, Ullmann AJ, Cornely OA, Patino H, Black TA (2009) Impact of antifungal prophylaxis on colonization and azole susceptibility of Candida species. Antimicrob Agents Chemother 53(12):5026–5034

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  32. Epstein JB, Schubert MM (2004) Managing pain in mucositis. Semin Oncol Nurs 20(1):30–37

    Article  PubMed  Google Scholar 

  33. Laird B, Colvin L, Fallon M (2008) Management of cancer pain: basic principles and neuropathic cancer pain. Eur J Cancer 44(8):1078–1082

    Article  CAS  PubMed  Google Scholar 

  34. Ling IS, Larsson B (2011) Individualized pharmacological treatment of oral mucositis pain in patients with head and neck cancer receiving radiotherapy. Support Care Cancer 19(9):1343–1350

    Article  PubMed  Google Scholar 

  35. Trotter PB, Norton LA, Loo AS et al (2012) Pharmacological and other interventions for head and neck cancer pain: a systematic review. J Oral Maxillofac Res 3:e1

    Article  PubMed Central  Google Scholar 

  36. Wong PC, Dodd MJ, Miaskowski C, Paul SM, Bank KA, Shiba GH, Facione N (2006) Mucositis pain induced by radiation therapy: prevalence, severity, and use of self-care behaviors. J Pain Symptom Manage 32(1):27–37

    Article  PubMed  Google Scholar 

  37. Ripamonti CI, Santini D, Maranzano E, Berti M, Roila F (2012) Management of cancer pain (2012) ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 23(Suppl 7):139–154

    Article  Google Scholar 

  38. Bhatnagar S, Upadhyay S, Mishra S (2010) Prevalence and characteristics of breakthrough pain in patients with head and neck cancer: a cross-sectional study. J Palliat Med 13(3):291–295

    Article  PubMed  Google Scholar 

  39. Friedland PL, Bozic B, Dewar J et al (2011) Impact of multidisciplinary team management in head and neck cancer patients. Br J Cancer 104:1246–1248

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  40. Loblaw DA, Prestrud AA, Somerfield MR, Oliver TK, Brouwers MC, Nam RK, Lyman GH, Basch E (2012) American Society of Clinical Oncology Clinical Practice Guidelines: formal systematic review-based consensus methodology. J Clin Oncol 30(25):3136–3140

    Article  PubMed  Google Scholar 

Download references

Conflict of interest

The authors have no conflicts of interest directly relevant to this article. The authors had full control of primary data; these are available upon request for review. We thank Luca Giacomelli, Ph.D, for the useful discussion.

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Authors and Affiliations

  1. Head and Neck Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy

    Paolo Bossi

  2. Medical Oncology, Azienda USL Valle d’Aosta, Aosta, Italy

    Gianmauro Numico

  3. Department of Oncology, Radiation Oncology Unit, University of Turin, S. Luigi Hospital, Orbassano, Italy

    Maria Grazia Ruo Redda & Alessia Reali

  4. Oncologia Medica 2,Città della Salute e della Scienza, Turin, Italy

    Mario Airoldi

  5. UOC Oncologia Radioterapica IRCCS AOU di San Martino, IST, Genoa, Italy

    Alamalina Bacigalupo

  6. IRCSS AOU di San Martino, IST Genoa, Genoa, Italy

    Liliana Belgioia

  7. Farmacia, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy

    Marta Mazzer & Gabriella Saibene

  8. Radioterapia 2 Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy

    Ester Orlandi

  9. Department of Translational Medicine, Radiotherapy, University “Sapienza”, Rome, Italy

    Vitaliana De Santis

  10. Unit of Head and Neck medical Oncology, IRCCS Istituto Europeo di Oncologia, Milan, Italy

    Maria Cossu Rocca

  11. Radiation Unit of Ospedale Santa Croce di Cuneo, Cuneo, Italy

    Elvio Russi

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  1. Paolo Bossi
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  2. Gianmauro Numico
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Correspondence to Paolo Bossi.

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Bossi, P., Numico, G., De Santis, V. et al. Prevention and treatment of oral mucositis in patients with head and neck cancer treated with (chemo) radiation: report of an Italian survey. Support Care Cancer 22, 1889–1896 (2014). https://doi.org/10.1007/s00520-014-2166-7

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  • DOI: https://doi.org/10.1007/s00520-014-2166-7

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