Updates in the care of patients with mucositis
Tampa, Fla—Oral mucositis is a common side effect of both chemotherapy and radiation that patients find distressing, yet there are interventions that seem to help.
“This really hurts; the pain is tremendous,” said Colleen Lambertz, RN, MSN, MBA, FNP, a nurse practitioner at the St. Luke's Mountain States Tumor Institute in Boise, Idaho, at the Oncology Nursing Society's Institutes of Learning. “It is difficult to control even with high-dose opioids.”
Oral mucositis refers to erythematous and ulcerative lesions in the oral mucosa. Although prevalence is difficult to determine, Ms Lambertz estimated that 12% to 40% of chemotherapy patients and virtually all patients receiving radiation to the oral cavity develop mucositis.
Mucosal whitening and erythemia start at about the second week of radiation therapy, when the patient has received 1,000-2,000 cGy, with ulcerations beginning at 3,000 cGy. Chemoradiation regimens shorten the onset, increase severity, and prolong duration of the condition.
The lesions lead to changes to the sense of taste, painful swallowing, excessive secretions that pool in the back of the mouth, and nausea, vomiting, and gagging. Patients lose weight and may require enteral or parenteral nutrition, opioids to temper the pain, and hospitalization for symptom management.
“It's painful and leads to serious problems with infection,” added Marilyn Haas, PhD, RN, CNS, ANP-C, a nurse practitioner at Mountain Radiation Oncology in Ashville, NC (at left in photo; Colleen Lambertz is on the right).
Mucositis may lead to treatment breaks. Delays in radiation can decrease head and neck cancer patients' survival. The mean cost of treatment increases by about $3,000 to $4,000 for head and neck cancer when the patient develops mucositis. With hematopoietic stem cell transplantation, there is a 3.9 fold increase in 100-day mortality risk with ulcerative mucositis.
“Our primary goal is to avoid treatment breaks,” Ms Lambertz stated.
Evaluate risks and prevent
Younger patients, women, Caucasians, poor baseline nutrition, alcohol and tobacco use, certain types of cancer, and pretreatment oral conditions increase risk of developing mucositis. Multicycle chemotherapy; certain agents, such as cisplatin and 5-FU; induction therapy; and, possibly, afternoon or evening radiation also increase the risk.
Radiation shields and Intensity Modulated Radiation Therapy may help prevent radiation-associated mucositis, and cryotherapy and oral rinses may help prevent the condition when giving chemotherapy. With cryotherapy, the patient holds ice in the mouth for five minutes prior to administration of the drug and for 30 minutes afterwards.
Several products and home remedies exist. Chlorhexidine, a germicidal mouthwash, is marketed to prevent mucositis, but the Multinational Association of Supportive Care in Cancer (MASCC) guidelines do not recommend its use for prevention or treatment. The association does recommend palifermin for prevention of oral mucositis associated with stem-cell transplantation.
“There is no proven prevention,” Ms Lambertz said. “Studies have lagged behind the problem.”
Assess and manage
Nurses must complete a thorough oral assessment, checking for changes in the mucosa. Dr Haas advised wearing a medical headlight to keep hands free and to use two tongue blades to pull out both sides of the mouth. She warned that the lesions may mimic thrush, herpes, and graft vs host disease.
Management of oral mucositis involves good oral hygiene, including brushing with a soft toothbrush, gargling with salt and soda gargles, and avoiding alcohol, smoking and acidic, salty, or dry foods. Providers may prescribe Caphosol, Gelclair, Tetracaine lollipops, oral morphine rinses, Duke's Solution or Miracle Mouthwash, or UlcerEase. All of the products are swished around the mouth and then spit out.
Clinicians at St. Luke's Mountain States Tumor Institute began a daily “spray and weigh program” and found it beneficial. Nurses look in the mouth every day before or after radiation treatment and assess the oral mucosa, and then spray warm normal saline to cleanse the tissue and teeth and to manage secretions. In addition, the nurse weighs the patient to monitor nutritional status. The patient meets with a nutritionist at least weekly, and the nurse documents the intervention.
The program has led to fewer treatment breaks and hospitalizations related to mucositis, improved pain control, less weight loss and earlier diagnosis of infection.
“It's an easy program to set up,” Ms Lambertz said. “It takes nursing time, but we find it wildly popular.”
Nurses must also provide psychosocial support. Sexuality suffers. Patients often feel isolated due to fewer social interactions, and 90% of them report a negative effect on quality of life, with anxiety, depression, and poor self-esteem experienced by many.
To increase staff nurses' performance for managing oral mucositis, Haas recommends establishing competencies, such as knowing risk factors, identifying normal and abnormal oral structures and pathology, incorporating recommendations from the ONS Putting Research Into Practice reference materials (http://ons.metapress.com/content/v150275w23382r3g/), and using a clinical assessment tool and grading scale. Facilities also should encourage nurse-dentist collaboration and referral practices.