Interventions for preventing oral mucositis for patients with cancer receiving treatment

Worthington HV, Clarkson JE, Bryan G, Furness S, Glenny A-M, Littlewood A, McCabe MG, Meyer S, Khalid T

Published Online:

April 13, 2011

Treatment for cancer (including bone marrow transplant) can cause oral mucositis (severe ulcers in the mouth). This painful condition can cause difficulties in eating, drinking and swallowing, and may also be associated with infections which may require the patient to stay longer in hospital. Different strategies are used to try and prevent this condition, and the review of trials found that some of these are effective. Two interventions, cryotherapy (ice chips) and keratinocyte growth factor (palifermin®) showed some benefit in preventing mucositis. Sucralfate is effective in reducing the severity of mucositis, and a further seven interventions, aloe vera, amifostine, intravenous glutamine, granulocyte-colony stimulating factor (G-CSF), honey, laser and antibiotic lozenges containing polymixin/tobramycin/amphotericin (PTA) showed weaker evidence of benefit. These were evaluated in patients with different types of cancer, undergoing different types of cancer treatment. Benefits may be restricted to the disease and treatment combinations evaluated.

Abstract (click to read)

Background:

Treatment of cancer is increasingly more effective but is associated with short and long term side effects. Oral side effects remain a major source of illness despite the use of a variety of agents to prevent them. One of these side effects is oral mucositis (mouth ulcers).

Objectives:

To evaluate the effectiveness of prophylactic agents for oral mucositis in patients with cancer receiving treatment, compared with other potentially active interventions, placebo or no treatment.

Search strategy:

Electronic searches of Cochrane Oral Health Group and PaPaS Trials Registers (to 16 February 2011), CENTRAL (The Cochrane Library 2011, Issue 1), MEDLINE via OVID (1950 to 16 February 2011), EMBASE via OVID (1980 to 16 February 2011), CINAHL via EBSCO (1980 to 16 February 2011), CANCERLIT via PubMed (1950 to 16 February 2011), OpenSIGLE (1980 to 2005) and LILACS via the Virtual Health Library (1980 to 16 February 2011) were undertaken. Reference lists from relevant articles were searched and the authors of eligible trials were contacted to identify trials and obtain additional information.

Selection criteria:

Randomised controlled trials of interventions to prevent oral mucositis in patients receiving treatment for cancer.

Data collection and analysis:

Information regarding methods, participants, interventions, outcome measures, results and risk of bias were independently extracted, in duplicate, by two review authors. Authors were contacted for further details where these were unclear. The Cochrane Collaboration statistical guidelines were followed and risk ratios calculated using random-effects models.

Main results:

A total of 131 studies with 10,514 randomised participants are now included. Overall only 8% of these studies were assessed as being at low risk of bias. Ten interventions, where there was more than one trial in the meta-analysis, showed some statistically significant evidence of a benefit (albeit sometimes weak) for either preventing or reducing the severity of mucositis, compared to either a placebo or no treatment. These ten interventions were: aloe vera, amifostine, cryotherapy, granulocyte-colony stimulating factor (G-CSF), intravenous glutamine, honey, keratinocyte growth factor, laser, polymixin/tobramycin/amphotericin (PTA) antibiotic pastille/paste and sucralfate.

Authors' conclusions:

Ten interventions were found to have some benefit with regard to preventing or reducing the severity of mucositis associated with cancer treatment. The strength of the evidence was variable and implications for practice include consideration that benefits may be specific for certain cancer types and treatment. There is a need for further well designed, and conducted trials with sufficient numbers of participants to perform subgroup analyses by type of disease and chemotherapeutic agent.

This record should be cited as:

Worthington HV, Clarkson JE, Bryan G, Furness S, Glenny A-M, Littlewood A, McCabe MG, Meyer S, Khalid T. Interventions for preventing oral mucositis for patients with cancer receiving treatment. Cochrane Database of Systematic Reviews 2011, Issue 4. Art. No.: CD000978. DOI: 10.1002/14651858.CD000978.pub5

Assessed as up to date:

March 8, 2011

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Primary Review Group:

Oral Health Group

PEARLS - Practical Evidence About Real Life Situations (click to read)

Clinical question:

How effective are interventions for preventing oral mucositis in patients with cancer receiving treatment?

Bottom line:

Compared with either a placebo or no treatment, 9 interventions were found to have some benefit with regard to preventing or reducing the severity of mucositis associated with cancer treatment. For patients with head and neck cancer undergoing radiotherapy, oral mucositis may be prevented by aloe vera, honey or with polymixin/tobramycin/amphotericin (PTA) antibiotic pastilles/ paste. For patients with blood cancers undergoing chemotherapy or stem cell transplant, cryotherapy (ice chips) may be effective. Another 5 interventions were found to be effective in groups of patients with a range of different types of cancer undergoing a range of different treatments. These interventions were allopurinol, amifostine, intravenous glutamine, keratinocyte growth factor and laser treatment.

Caveat:

The patient groups studied were diverse, the associated treatment modalities were varied and the strength of the evidence of effectiveness was variable. As some interventions were studied exclusively in certain patient groups receiving specific treatment modalities, generalisation of the results to other tumour types and treatment modalities must be done with caution – some benefits may be specific to certain cancer types and treatments.

Context:

Treatment for cancer (including bone marrow transplant) can cause oral mucositis. This painful condition can cause difficulties in eating, drinking and swallowing, and may also be associated with infections which may require the patient to stay longer in hospital.

Cochrane Systematic Review:

Worthington, HV et al. Interventions for preventing oral mucositis for patients with cancer receiving treatment. Cochrane Reviews, 2010, Issue 12. Article No. CD000978. DOI: 10.1002/14651858.CD000978.pub4. This review contains 131 studies involving 10,514 participants.

Authored by:

Brian R McAvoy

Cochrane Primary Health Care Field

Health topics:

Cancer > Generic cancer care > Oral care for cancer patients

Dentistry & oral health > Oral cancer > Oral care for cancer patients

Complementary & alternative medicine > Cancer > Generic cancer care

Complementary & alternative medicine > Dentistry & oral health > Oral cancer

Complementary & alternative medicine > Dentistry & oral health > Oral mucositis

Dentistry & oral health > Oral mucositis

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Interventions for preventing oral mucositis for patients with cancer receiving treatment

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