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DeAnna- Hey it’s Greg! Sorry I didn’t give my first name on my earlier post. I didn’t realize you are in triage now!
Kelly- we need Steph to reply here- I would love to hear about that trial!
Trish- I agree that I wish we had more options than just MMW for mucositis. I didn’t mean to make it sound like I don’t like MMW. On the contrary it is the one thing that enable some patients to tolerate PO intake, as you mentioned. I just wish we had more resources for support.
Hi, my name is Jennifer Clark, I am a nurse in the Clinical Treatment Unit. We do Phase I clinical trials here at The James.
1. What was the knowledge gained from the article?
Both articles were interesting. I was not aware that targeted therapies and immunotherapies cause a pathobiologically different type of oral mucositis. Developing trends in treatment are moving away from standard chemotherapies and towards these targeted therapies and immunotherapies so I feel like more emphasis needs placed on developing new treatments for oral mucositis. I have been in the CTU for the last 10 years and we have done several clinical trials for an oral mucositis treatment for the Head & Neck oncology population that were done in conjunction with radiation therapy. We have not participated in any clinical trials for the stem cell population, for whom the incidence of mucositis can be as high as 80%, or patients who receive targeted/immunotherapies. I believe the CTU is going to be opening another oral mucositis trial soon for Head & Neck oncology patients.2. Will the research/information in this article change or influence your practice?
I am the Lead RN on a trial that is opening soon for colorectal cancer patients that consists of an oral targeted therapy given in conjunction with SOC FOLFOX or FOLFIRI and includes a 5FU bolus. I will educate my patients to use oral cryotherapy during their treatment to hopefully lessen their incidence of mucositis.3. Do you agree or disagree with the conclusions of the author?
I do agree that interventions for oral mucositis are limited and new treatments need to be developed, especially as we are moving towards developing more immunotherapies.Trish, I agree that we need to improve our efforts to prevent and treat mucositis more successfully. I wonder if other large cancer centers are using Morphine suspension for pain relief.
Jeff, it is difficult to understand why effective treatments like benzydamine and keratinocyte growth factor-1 are not available for use in the United States. I know the one trial we did for mucositis was so complex that it would not be appropriate for administration in an infusion center. There are not alot of options for our patients.
Deanna-The population that I work with would be more of the digestion process and MMW would not be the prescribed treatment. The patients I work with would most likely be given a PPI, like omeprazole, and use for approximately 8 weeks and then return for another procedure to evaluate the response.
Jeff- I too see the frustration of seeing therapies being offered in other countries and not here in the United States. When those treatments show success and our patient population has reached the limit on what can be done for them, wouldn’t it be nice to have something else off label to offer?
Hello all! My name is Holly Smith from ambulatory JCRU. Thanks Trish for hosting this month’s journal club!
1. Knowledge gained: I, too, was surprised that some immunotherapies such as cetuximab and pantumumab can cause OM. I guess it makes sense since they can also cause pneumonitis, colitis, etc. I personally haven’t seen it, yet. I also found it interesting that women seem to be a higher risk for OM. I also hadn’t considered that bolus chemotherapy vs. infusions over a period of time would have a better response to cryotherapy. It was also notable that there didn’t seem to be a difference in efficacy for those using cryotherapy for 2 hours vs. 6 hours, which is nice for the patient. There was a lot of really interesting little tidbits of knowledge in these articles.
2. Change or influence practice: I think that it will likely change my practice in the way that I approach teaching with my patients with regard to cryotherapy and even oral hygiene. I know that I likely stress this more when I am caring for the head and neck population, but should focus on other disease lines since this can be a bigger issue than I previously understood.
3. Questions raised: I don’t recall reading much about the prevalence and prevention of thrush in these populations, as we know it can exacerbate pain and thus interfere with nutrition, and even oral hygiene adeherence.
4. Agree or disagree: I agree with the authors that OM is a huge issue overall and more studies and better teaching would benefit patients greatly.Jeff-I looked up the Benzydamine a little bit. It appears it has been used recreationally and in overdosages it acts as a deliriant and CNS stimulant. That would make sense why it wouldn’t be OTC, but it not being available in the US at all, seems silly since lots of medication in doses higher than intended can have similar side effects. Seems like some studies are warranted to determine efficacy, but unfortunately, they will have to be done outside of the US.
I also like the cryotherapy being built in to the plans. I have seen a few where it is built in, but not many.Trish-I agree that sometimes the MMW is effective, if a patient can actually get it. Many pharmacies do not compound and I have had several instances where the patient could not get the prescription filled locally, which is a big issue when they live far away. It makes sense that OM is worsened if patients aren’t adherent to a good oral hygiene program but I could see it being a viscious cycle-pain making them not want to perform oral hygiene, esp if they don’t have access to MMW readily.
1. What was the knowledge gained from the article?
I read a lot about other cancer treatments and symptom management that is not offered at The James but I have not seen anything on cryotherapy. I knew some chemo nurses that had patients swish ice water but I didn’t know it was an official symptom management tool.
2. Will the research/information in this article change or influence your practice? If so how?
I am not sure if it can change anything in the moment but I will certainly mention it and ask if The James is in the know about this and considering incorporating it in symptom management. I asked the chemo nurses at my clinic about it a while back and none of them knew anything about it as a treatment.
3. What other questions does the article raise about current practice?
If there is even a remote chance it could improve symptoms then why aren’t we doing it?
About 10 years ago I was on the chemo floor training to float there and for certain treatments, patients would swish ice water in their mouth to prevent mucositis- I have wondered ever since why no other chemo unit did that.
Obviously it would not be a good idea to use if the cancer was in the vicinity of where the ice water would be so the cancer cells would uptake the chemo. It wouldn’t have to be ice water that would travel down the gi tract- it could be those cocktail ice cubes that freeze inside a rubber cube or ball so it would melt but not go down the throat.Trish- when a patient calls in after hours, can’t you page the physician/resident on call and they can send a prescription after a phone assessment? Seems it would be the same as when someone calls in during the day.
Greg- It would be unrealistic to ask someone w/ an OBI to swish ice water the entire time but what about a short infusion or bolus given? Maybe treatment plans have changed and there aren’t boluses given anymore?
Whoever said it should be in the treatment plans, I agree 100%. Then without a doubt we would know if it is okay for that patient’s cancer location and treatment being given. I think that is something we could start asking about but we would probably need more than 2 research articles to state the request.
1. What was the knowledge gained from the article?
I was surprised to learn how high the statistics are for individuals who develop oral mucositis. I learned that oral mucositis is correlated with a higher mortality rate than patients who do not develop the side effect. I also learned about how to educate patients with oral mucositis on how spicy, acidic, and crunchy foods may increase their discomfort. Lastly, I learned how important it is to counsel patients on maintaining good nutrition while experiencing oral mucositis.
2. Will the research/information in this article change or influence your practice? If so, how?
Learning about how important nutrition is with oral mucositis has influenced my practice. I work at Mill Run with ovarian, cervical, and uterine cancers. I have seen patients with oral mucositis. Thankfully, there is an oncology nutritional consult providers can order to help support patients’ nutrition. I will be advocating for patients’ nutrition more when they start developing oral mucositis. The article touched on preventive interventions of oral hygiene practices and the use of honey in head and neck patients.
3. What other questions does the article raise about current practice?
It was interesting to learn how oral cooling has been shown to prevent oral mucositis with 5-FU. However, this is not the current population I work with. For oral cooling, it should be tested in other populations as well to determine its effectiveness. For the most part, in the GYN Onc clinic, most cases of oral mucositis use a steroid mouthwash (“magic mouthwash”). However, most treatments for oral mucositis aim to help manage the symptoms associated with the condition rather than preventing it from occurring.
4. Do you agree/disagree with the conclusions of the author? Why?
I agree with the authors’ conclusions. For oral cooling, it has been found to be a preventative treatment for oral mucositis in GI patients taking 5-FU. I also agree with the other article’s conclusion that prevention interventions will be an area of growth for oral mucositis, since most treatments only focus on symptom management. I hope there will be more research trials testing different populations with oral cooling, since it has shown benefits for the GI population.
Hi Jennifer,
Your insights into oral mucositis management within clinical trials at The James are enlightening. Understanding the distinct pathobiological challenges posed by targeted therapies and immunotherapies versus traditional chemotherapies highlights the evolving treatment landscape. Your proactive approach to incorporating oral cryotherapy in upcoming trials for colorectal cancer patients underscores a commitment to improving patient comfort and outcomes. I agree that with the rise of immunotherapies, there’s a critical need for innovative mucositis interventions. Your initiative in expanding trials to include diverse patient populations, such as those undergoing stem cell transplants or receiving targeted therapies, demonstrates a forward-thinking approach to patient care. Your efforts are pivotal in advancing treatments that align with emerging therapeutic modalities, ultimately enhancing patient quality of life.
Hello Jeff,
Your insights into managing oral mucositis in oncology patients are eye-opening, especially concerning its prevalence and impact on treatment outcomes. The article’s revelations about OM’s association with various cancer therapies, including newer modalities like immunotherapy, underscore the urgency for improved prevention and treatment strategies. I find the suggestion of adding low-dose Morphine to mouthwash formulations particularly intriguing for managing pain, especially in head and neck cancer patients. The idea of pre-ordering specialized mouthwashes for high-risk patients to avoid treatment delays in outlying areas seems practical and beneficial. I agree with your call for more research emphasis on OM prevention and treatment, considering its significant impact on patient quality of life and treatment continuity.
Hello my name is Patti (infusion nurse at SSCBC)
What was the knowledge gained from the article?
Efficacy of Oral Cryotherapy in the Prevention of Oral Mucositis Associated with Cancer Chemotherapy: Systematic Review with Meta-Analysis and Trial Sequential Analysis provided me with a good refresher oral mucositis. I had forgotten oral mucositis causes atrophy and destruction of the mucosal lining of the mouth leading to ulcer.
Targeted and immune therapies have shown to also cause mouth sores.
Will the research/information in this article change or influence your practice? If so how?
I will assess my targeted and immune therapies for mouth sores.
Do you agree/disagree with the conclusions of the author, why?
I do agree cryotherapy helps prevent mouth sores when receiving bolus IV chemos. We recommend all of our Adriamycin patients use cryotherapy while their adria is being administered.
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