Clinical setting-specific guidance was provided in a recently updated version of the Multinational Association for Supportive Care in Cancer/International Society for Oral Oncology (MASCC/ISOO) clinical practice guidelines on the management of cancer treatment-related mucositis, and published in the journal Cancer.
Mucositis is a common adverse effect of cancer treatments, including chemotherapy, radiotherapy (RT), and chemoradiotherapy (chemoRT), and intensive conditioning therapy administered in the setting of hematopoietic stem cell transplantation (HSCT). It is characterized by inflammation and ulceration of the mucosal lining of the gastrointestinal tract and can be associated with substantial morbidity, as well as early interruption of cancer therapy and a higher rate of opioid use in patients with cancer.
Following a recently conducted, rigorous, systematic review of the related medical literature, the MASCC/ISOO Mucositis Study Group issued the fourth version of its guidelines on the prevention and treatment of mucositis secondary to chemotherapy, RT, chemoRT, or HSCT. MASCC/ISOO guidelines were first published in 2004.
Of note, although mucositis has also been identified as a potential adverse effect of some targeted therapies and immunotherapies used in the treatment of cancer, these guidelines do not address management of mucositis in those settings.
Although the guidelines cover both prevention and treatment, the emphasis of these updates was on interventions for preventing mucositis and its potentially serious complications in patients undergoing cancer therapy.
Some of the key recommendations issued by the Study Group regarding mucositis secondary to chemotherapy, RT, chemoRT, and/or HSCT include:
- Multiagent combination oral care was suggested for patients treated with chemotherapy, those with head and neck cancer undergoing RT, and those undergoing HSCT (Level III Evidence).
- Mouthwash containing the nonsteroidal anti-inflammatory drug (NSAID) benzydamine was suggested for patients with head and neck cancer treated with RT (Level I Evidence) or chemoRT (Level II Evidence).
- Intraoral photomodulation therapy (PBT) was recommended for patients undergoing HSCT (Level I Evidence) and patients with head and neck cancer treated with RT (Level II Evidence) or chemoRT (Level I Evidence).
- Oral cryotherapy was recommended for patients undergoing conditioning therapy with melphalan associated with autologous HSCT (Level II Evidence) and those receiving bolus 5-fluorouracil chemotherapy (Level II Evidence).
- Intravenous keratinocyte growth factor-1 (KGF-1) was recommended for patients with hematologic cancer undergoing HSCT (Level I Evidence).
- Honey was suggested for patients with head and neck cancer treated with RT or chemoRT (Level II Evidence).
Regarding professional oral care for the prevention of mucositis in patients with cancer undergoing treatment and the use of misoprostol mouthwash in patients with head and neck cancer treated with RT, the Study Group noted that only limited, high-quality evidence exists in these areas, hence no related guideline recommendations were issued on those topics.
However, recommendations were issued against prophylactic use of both topical granulocyte macrophage colony-stimulating factor (GM-CSF) in patients undergoing HSCT and chlorhexidine rinses in those with head and neck cancer undergoing RT.
Regarding treatment of mucositis, the guidelines suggested topical 0.2% morphine mouthwash for patients with pain related to oral mucositis secondary to the treatment of head and neck cancer with chemoRT (Level III Evidence). However, a recommendation was made against using combined topical and systemic sucralfate to treat oral mucositis-related pain in those with head and neck cancer receiving RT and those with solid tumors treated with chemotherapy.
“The ultimate goal of these guidelines is to improve the supportive care for patients with cancer and provide direction for future trials. As new research is conducted, new evidence will become available,” the guideline authors noted in their concluding remarks. To this end, the MASCC/ISOO Mucositis Study Group plans to continue periodically updating its guidelines.
Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.
Elad S, Cheng KKF, Lalla RV, et al; Mucositis Guidelines Leadership Group of the Multinational Association of Supportive Care in Cancer and International Society of Oral Oncology (MASCC/ISOO). MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer. Published online July 28, 2020. doi:10.1002/cncr.33100