 | Author(s) | | | Sonis, S.T. Elting, L.S. Keefe, D. Peterson, D.E. Schubert, M. Jauer-Jensen, M. Bekele, B.N. Raber-Durlacher, J. Donnelly, J.P. Rubenstein, E.B. |
| Publication | | | Cancer |
| Reference | | | 100, S9: pages 1995-2025 |
| Publication Date | | | 2004 |
|  |  Relevant to nurses who care for patients undergoing chemotherapy and radiotherapy
What is the problem and what is known about it so far?
Oral and gastro-intestinal mucositis are commonly reported side-effects of radiotherapy, high dose chemotherapy, and haemopoietic stem cell transplant (HSCT). Mucositis can be exceedingly painful, requiring the use of opioid analgesia post transplant, reducing food and fluid intake, and for those with neutropenia significantly increasing the risk of infection and the development of septicaemia. It is reported by patients as one of worst symptoms following transplant. However, there is a paucity of robust evidence on which to base practice related to the prevention, assessment and treatment of mucositis.
How was the study done?
An international, multidisciplinary panel of experts reviewed the medical literature between January 1996 and May 2002. Biological processes, assessment, incidence, and cost of mucositis were reviewed.
What were the findings?
Biological processes
Recently new insights into the complex biological mechanisms underpinning the development of mucositis have been demonstrated.
Traditionally, mucositis has been thought to be due to the effects of chemotherapy or radiotherapy on the rapidly dividing epithelial cells reducing cell renewal and resulting in mucosal atrophy and ulceration. However, the development of mucositis is now perceived to be much more complex. Five phases are outlined: initiation, up-regulation of a series of genes and generation of messenger signals, signalling and amplification, ulceration with inflammation and healing. Mucosal injury develops very quickly and the phases occur simultaneously.
It is suggested that the 5 phase model is best demonstrated in the oral mucosa but is similar in the rest of the gastro-intestinal tract. Details of the biological processes involved are detailed in the paper.
A genetic risk predisposing to mucositis is also proposed as an explanation for individual susceptibility to this treatment side-effect.
Mucositis Assessment Scales
An objective means of assessing mucositis is important in clinical practice to ensure that assessment is consistent between different health care professionals. It is suggested that the ideal mucositis scoring system should be: objective, reliable, valid and reproducible across all clinical applications and settings. The review concluded that no such scale currently exists.
Scales based on the National Cancer Institute-Common Toxicity Criteria or the World Health Organisation toxicity scale are perceived to be the most relevant oral mucositis scales for clinical practice. However, the importance of training to improve the accuracy and consistency of assessment is emphasised.
The frequency at which oral assessment should be conducted remains inconclusive.
Incidence
The incidence of mucositis proved difficult to determine as most data are derived from studies of chemo or radiotherapy regimens and mucositis is only reported as a toxicity of treatment. Incidence rates varied depending on the treatment regime. However, high rates of mucositis were noted following HSCT (30-50% without total body irradiation (TBI) and >60% with TBI).
Costs of Mucositis
Only a few studies specifically examine the financial implications of mucositis. However, additional days of fever, use of antibiotics, analgesics and parenteral nutrition and extended hospital stays are all likely to increase the cost of treatment.
What are the limitations?
It is unclear how levels of evidence were determined in the study.
Implications for Practice
This is an important paper as it brings together existing literature. Recommendations are made from the higher levels of evidence and expert consensus reached on best practice from lower level evidence. Gaps in the evidence base are identified as a guide for future research. New insights into the biological processes underpinning mucositis may help in determining future preventative and treatment strategies. Clinical guidelines have also been developed from this paper.
Mucositis Study Section of the Multinational Association of Supportive Care in Cancer and the International Society for Oral Oncology.
Comment by: Maggie Grundy, Senior Lecturer at the Robert Gordon University, Aberdeen
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