One of the greatest challenges I find in treating patients with cancer of the head and neck is managing oral mucositis (OM). Patients with head and neck cancer are at the highest risk of OM, with a 100 percent guarantee of occurrence in those treated with combined modality therapy utilizing chemotherapy plus radiation.
The chemotherapy chosen is often a doublet regimen including a platinum-based drug (e.g., Cisplatin) (NCCN, 2012). Platinum agents carry some of the highest risk for OM (Daly & Quinn, 2011). These agents, along with radiation, rapidly destroy dividing epithelial cells of the mucous membranes, leading to progressive inflammation and subsequent pain.
As clinicians, we often find ourselves upping a patients' opioid dose in an effort to control the extreme localized pain they experience in their mouths. This often leads to secondary problems of constipation, nausea, and increased sedation. We also attempt to alleviate their pain with "magic" suspensions -- compounding medications like viscous lidocaine, Maalox, diphenhydramine, and corticosteroids, along with Nystatin if oral candidiasis is involved. Other formulations may also include antifungals and/or antibiotics. The effectiveness of such rinses has not been well established, however (Yarbro, Frogge, & Goodman, 2005).
Anyone who has cared for these patients knows OM is just the beginning of what can be a downward spiral in their quality of life. Along with pain, OM leads to taste changes and dry mouth, which in turn affects their ability to eat. A large number of patients start out or end up with feeding tubes. Living in a society where food is very much connected to our happiness and well being, it is easy to see how this can lead to emotional and psychosocial distress.
When we first meet these patients in our practice, we spend careful time reviewing potential side effects of therapy and ways to manage them as they arise. For this unique population, we cannot stress enough the importance of good oral care up front. This includes at the very least:
- Seeing a dentist prior to starting any therapy.
- Brushing with a soft-bristled toothbrush or mouth sponge.
- Continuing, meticulous care of partials or dentures, often leaving these out once ulcerations or inflammation exist.
- Using bland rinses such as sodium bicarbonate plus salt water.
- Avoiding alcohol-based mouth rinses.
- Avoiding spicy or acidic foods, tobacco products, and alcohol.
A more proactive approach I'm seeing some patients take is using fluoride trays prescribed by their dentists. With the decreased production of saliva in the oral cavity, this can increase the likelihood of cavity formation and demineralization of the teeth. Thus prescription fluoride can play an important role to avoid further complications.
In our practice we have begun using a promising new agent called MuGard (Access Pharmaceuticals, Inc.). This mucoadhesive is showing exciting results in Phase IV clinical trials, including delay of onset of OM and decreased amount of weight loss for study patients versus controls (Hughes, 2012).
One important point not to be overlooked is that OM can be a dose-limiting or treatment-halting toxicity. Sadly, I've had more than one patient hospitalized or at least debilitated to the point where chemotherapy, and more importantly, radiation, had to be withheld. This delay in therapy is a huge risk for what can often be a recurring and deadly disease if not treated aggressively up front.
As healthcare providers, whether you're a nurse or advanced practice clinician, the best thing we can do for these patients is educate them extensively at the outset and provide proactive strategies to prevent or delay OM.
So, what you are doing in your oncology care settings to help these patients manage OM and the problems that can result? Are there other approaches you are taking? Have any patients given you tips from their experience that we could all benefit from hearing?
- Carr, Ellen (2005). Head and Neck Malignancies. In Yarbro, C.H., Frogge, M.H., & Goodman, M. (Eds.), Cancer Nursing, Principles and Practice, (6th ed) (1317-1319). Sudbury, MA: Jones & Bartlett.
- Daly, C.F., & Quinn, A.M. (2011). Oral Mucositis: addressing the causes, challenges, and clinical management. Journal of the Advanced Practitioner in Oncology, 2(1), 4-12.
- Hughes, D. (2012). Novel mouth rinse reduces oral mucositis in patients with head and neck cancer undergoing chemoradiation. Retrieved from http://www.chemotherapyadvisor.com.
- National Comprehensive Center Network. (2012). NCCN Chemotherapy Order Templates. Retrieved from http://www.nccn.org/ordertemplates/default.asp?did=112.