MANAGEMENT OF ADVERSE EVENT OF CHEMOTHERAPY:

STOMATITIS

DR ANKUR SHAHMEDICAL ADVISOR

WHAT IS CANCER? AND IS IT CURABLE? WHAT IS CHEMOTHERAPY?

A. Cancer is an umbrella term for a large group of diseases caused when abnormal cells divide and invade other tissue and organs.

A. Yes

A. Chemotherapy drugs kill rapidly growing cancer cells but can also harm perfectly healthy cells, causing side effects throughout the body.

The Side Effects of

Chemotherapy on the Body

WHAT IS MUCOSITIS?• Mucositis is inflammation of the

mucosal surfaces throughout the body.

• It typically involves redness and ulcerative sores in the soft tissues of the mucosa.

• Oral mucositis manifests as erythema, inflammation, ulceration, and hemorrhage in the mouth and throat.

Image from: Spielberger, Ricardo; KepivanceTM: A Breakthrough for Oral Mucositis Associated with Myeloablative Hematopoietic Stem Cell Transplantation; City of Hope National Medical Center, Department of Hematology and Bone Marrow Transplantation

RISK FACTORS Age ( young children and elderly)

Gender ( women are at greater risk for severe mucositis)

Oral health and oral hygiene

Reduced salivary function

High expression of cytokines

Altered drug metabolisms

Kills rapid growing cells (esp. mucus membrane)

Irritation to the Mucous membrane

Inflammation occurs

Ulceration occurs if notdetected or treated

Stomatitis

RISK FACTORS• Treatments (Chemotherapy and radiation therapy)• excessive alcohol intake• excessive tobacco use• hot and spicy food• cheek biting• poor oral hygiene• ill fitted oral appliances• nutritional deficiency

CAUSALITY• Mucositis is a frequent complication of anticancer

treatment, including chemotherapy and radiation therapy.

• Due to high-dose chemotherapy and/or radiation preconditioning, it is particularly common in patients preparing for bone marrow transplantation (BMT).

Source: Bellm LA, Epstein JB, Rose-Ped A, Martin P, Fuchs HJ. Patient reports of complications of bone marrow transplantation; Support Care Cancer. 2000 Jan;8(1):33-9

Source: http://symptomresearch.nih.gov/Chapter_17/sec2/cghs2pg1.htm

SITES OF MUCOSITIS• While the oral mucosa is the most frequent site of mucosal toxicity,

mucositis also is common along the entire alimentary tract:• Esophagus – duodenum – colon• Stomach – ileum/jejunum – rectum

• GI mucositis occurs via a mechanism similar to that in the oral mucosa, only the damage to the mucosal layer is more aggressive than in oral mucositis.

• Although less common, treatment of ovarian and nasopharyngeal cancer also can result in vaginal and nasal mucositis.

60%

40%

Mucositis ReportedMucositis Not Reported

20%

80%

25%

75%

EPIDEMIOLOGY• 40% of patients receiving standard-dose chemotherapy• 80% of patients receiving radiation therapy for head and neck cancer • 75% of all patients undergoing BMT

Source: Bellm et al. 2000

Mucositis Frequency: Standard-Dose Chemotherapy

Mucositis Frequency: Radiation for Head and Neck Cancer

Mucositis Frequency: BMT with High-Dose Chemotherapy and/or

Radiation Pre-Conditioning

CLINICAL CONSEQUENCESPainful condition that interferes significantly with patient functioning and tolerance for cancer therapy

Functional implications may include:• Inability to tolerate food or fluid intake• Difficulty or inability to talk*

*Borbasi S, Cameron K, Quested B, Olver I, To B, Evans E. More than a sore mouth: patients' experience of oral mucositis. Oncol Nurs Forum. 2002;29:1051-1057, and Bellm et al. 2000. **Bellm et al. 2000

CLINICAL CONSEQUENCES (CONTINUED)Hospital admission or extended hospitalization for total parenteral nutrition, iv analgesia, and iv antibiotics

• 62% of patients require hospitalization.* • 70% of patients with Grade 3-4 oral mucositis require feeding

tubes.*

Reduction or cessation (dose-limiting toxicity) of cancer treatment in 35% of patients*

*Sonis ST, Elting LS, Keefe D, Peterson DE, Schubert M. Perspectives on cancer therapy-induced mucosal injury. Cancer. 2004;100(9 Suppl):1995-2025

DIFFERENTIAL DIAGNOSIS AND TREATMENT

Mucositis is distinguishable from other forms of inflammatory disorders in terms of:

• causality• clinical presentation/lab findings• severity • treatment

The presence and severity of radiation- or chemotherapy-induced mucositis is routinely documented in clinical progress notes.

Local, Denture-Related Lesion Aphthous UlcerOral Thrush

Oral Mucositis*

* Spielberger, Ricardo; KepivanceTM: A Breakthrough for Oral Mucositis Associated with Myeloablative Hematopoietic Stem Cell Transplantation; City of Hope National Medical Center, Department of Hematology and Bone Marrow Transplantation

Because these conditions can coexist in immunocompromised patients, differential diagnosis is critical.

DIFFERENTIAL DIAGNOSIS: ORAL

NURSING MANAGEMENT•The nurse instructs the patient in the importance and techniques of preventive mouth care

•The nurse monitors the patients physical and psychological response to treatment

•Advise the patients to avoid dry, bulky and irritating foods and fluids, as well as alcohol and tobacco

•Encourage the patient to increase fluid intake

PHYSICIAN DUTIES• Some physician may be recommended a variety of dietary measures

to treat stomatitis.• Cottage• Cheese• Buttermilk• Yogurt

• Ask for history of radiation or chemotherapy regimen.

• Do oral exam noting evidence of lesions within the mouth and tongue.

STOMATITISStomatitis currently is a more specific diseases of the oral mucosa.

Stomatitis

Acute Necrotizing Ulcerative Stomatitis

Aphthous Stomatitis

Herpetic Stomatitis

GangrenousStomatitis

Oral Mucositis

Soreness± erythema

Erythema,ulcers; patient canswallowsolid food

Mucositisto the extentthat alimentationis not possible

Ulcers with extensive erythema; patient cannot swallow food

Grade 2 Grade 3

Severe Mucositis

Grade 1 Grade 4

World Health Organization’s Oral Toxicity Scale

WHO’s Oral Toxicity Scale

Severity Everolimus dose adjustments and management recommendations

Grade 1 Minimal symptoms, normal Diet

No dose adjustment is required Manage with saltwater (0.9%) or nonalcoholic mouthwash several

times a dayGrade 2Symptomatic but can eat and swallow modified food

Temporary dose interruption until recovery to grade <-1 Reinstate everolimus at the same dose If stomatitis recurs at grade 2, interrupt dose until recovery to grade <-

1. Reinitiate everolimus at a lower dose. Manage with topical analgesics mouth treatments (e.g. benzocaine)

with or without topical corticosteroids (i.e., triamcinolone oral paste)Grade 3Symptomatic and unable to adequate aliment and hydrate orally

Temporary dose interruption until recovery to grade <-1 Reinstate everolimus at the same dose Manage with topical analgesics mouth treatements (e.g. benzocaine)

with or without topical corticosteroids (i.e. triamcinolone oral paste)Grade 4Sypmtoms associated with life threatnening consequences

• Discontinue everolimus and treat with appropriate medical therapy

IMPLEMENT AN ORAL CARE PROTOCOL USING:

a. Non-irritating agents - Normal saline with or without baking soda, Sterile water, avoid mouth washes with alcohol.

b. Soft-bristle toothbrush

c. Floss

d. Use foam toothettes.

HEALTH TEACHINGS• Avoid commercial mouth washes, citrus fruit juices, spicy

foods, extremes in food temperature, crusty or rough foods

• Use straw to facilitate fluids bypassing inflamed lesions (if indicated)

• Use soft tooth brush or toothettes for oral care

• Check for proper fit of dentures

PATIENT EDUCATIONPatients and family care providers should learn about :a. The importance of oral care during cancer treatment to decrease

morbidity and mortality b. Systematic care of oral cavity—promote health and avoid

trauma

c. Assessment of the oral cavity (i.e., at least daily during therapy)

d. Signs and symptoms to report (i.e., changes in sensation or taste, presence of ulcerations and/or bleeding)

THE MOST IMPORTANT THING IN ILLNESS IS

NEVER TO LOSE HEART.