Oral Cryotherapy for Prevention of Chemotherapy-Induced Oral Mucositis in Oncology Patients

Emily HuberUNC Lineberger-Lauterborn-Piver Oncology Nursing Fellow

About Me

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Overview

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• Research Question - PICO

• Definitions – Oral Mucositis & Oral Cryotherapy

• Review of a Cochrane study

• Results and Implications

• Final Thoughts

• Special Thanks

• References

Research Question - PICOIn adult oncology patients receiving chemotherapy treatment(s), how does oral cryotherapy compare to standard care (either saline mouth rinse or no treatment) in prevention of chemotherapy-induced oral mucositis?

▸ Population – Oncology patients receiving chemotherapy that induces oral mucositis (Bolus 5FU and Melphalan)

▸ Intervention – Oral cryotherapy (ice chips, ice-cold water, popsicles) during treatment

▸ Compared to – Standard care (saline mouth rinse or no treatment)▸ Outcome – Reduced incidence and severity of oral mucositis

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• A common complication secondary to cancer treatment

• Patients may experience…o severe paino Less able to eat or drink à dehydration and malnutritiono Increased risk for infection due to open sores in the oral mucosa

• Consequently, this may interrupt therapy, cause pain, increase the length of hospitalization, increase the use of antibiotics and narcotics, and increase the overall cost of treatment for patients.

The Burden of Oral Mucositis (OM)

(Lalla et al., 2008)

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The Burden of Oral Mucositis

FiGuRe 4 | World Health Organization's Oral Toxicity Scale. Republished with the permission of Dr. Patrick Stiff, Loyola University Medical Center, Maywood, IL, USA.

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• The first signs of mucositis usually begin with a feeling of mucosal irritation about 3-4 days after chemotherapy which is accompanied by ulcer development

• The lesions usually heal within 2-4 weeks of the last dose of chemo (Lalla et al., 2008)

• In a prospective study involving 298 patients treated with chemotherapy for solid

tumors (Shankar et al., 2017): o 40% of patients developed à WHO grade 1 (mild)o 5% of patients developed à WHO grade 2 (moderate)o 1% of patients developed à WHO grades 3–4 (severe)

The Burden of Oral Mucositis (OM)

• Mouth cooling using cold consumables

• Ice chips

• Ice cold water

• Popsicles

• Cold mouthpieces

(Riley et al., 2015, p. 1846)8

Oral Cryotherapy

Causes local vasoconstriction

Decreases blood flow to the oral mucosa

Decreased mucosa drug exposure

Decreased incidence and severity of OM

Cochrane Oral Health Group conducted a systematic review to determine whether

oral cryotherapy (ice, ice-cold water, ice cream or ice lollies/popsicles) during

chemotherapy can help prevent oral mucositis in patients receiving treatment.

• 14 RCT from 1991-2015

• 1316 randomized participants were to receive oral cryotherapy versus standard care (either

saline mouth rinses or no treatment)

• Patients receiving 5FU (bolus)• Received cryotherapy 5 minutes prior to treatment and continuing for 30 minutes

• Patients receiving Melphalan

• Received cryotherapy for longer periods of time (as long as 7 hours)

(Riley et al., 2015, p. 1846)

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Cochrane Review on Oral Cryotherapy

Key Results: Patients Receiving 5FU (bolus)

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Results

• Oral cryotherapy leads to large reductions in oral mucositis of all severities

(Riley et al., 2015, p. 1846)

Outcomes Comments

Oral Mucositis -any grade severity

Oral cryotherapy reduced the risk of developing oral mucositis by 39%

Oral Mucositis -moderate + severe

Oral cryotherapy reduced the risk of developing moderate to severe oral mucositis by 48%

Oral mucositis -severe

Oral cryotherapy reduced the risk of severe oral mucositis by 60%

Key Results: Patients Receiving Melphalan

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Results

• Oral cryotherapy reduce oral mucositis incidence and severity in adults receiving high-dose melphalan before bone marrow transplant but confidence intervals were wide.

(Riley et al., 2015, p. 1846)

Outcomes Comments

Oral Mucositis -any grade severity

41% reduction in the risk of developing oral mucositis [Confidence Interval or CI 1%-65%]

Oral Mucositis -moderate + severe

57% reduction in the risk of developing moderate to severe oral mucositis [CI 9%-83%]

Oral mucositis -severe

Oral cryotherapy reduced the risk of developing severe oral mucositis by 62%

MASCC GUIDELINESPrevention Recommendations

▸ The panel recommends…○ the use of intra-oral PBM therapy using low-level laser therapy for the prevention

of OM in adult patients receiving RT and CT for H&N cancer (LOE I)

○ that 30 minutes of oral cryotherapy be used to prevent OM in patients receiving

bolus 5FU chemotherapy (LOE II) ○ that recombinant human Keratinocyte Growth Factor-1 be used to prevent OM

in patients receiving high-dose CT and RT, followed by stem cell transplant, for a

hematological malignancy (LOE II).

○ that low-level laser therapy be used to prevent OM in patients receiving stem

cell transplant conditioned with high-dose CT, with or without RT (LOE II).

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(Multinational Association of Supportive Care in Cancer, 2019)

MASCC GUIDELINESPrevention Suggestions

▸ The panel suggests…○ the use of benzydamine mouthwash for the prevention of OM among H&N

cancer patients receiving RT-CT (LOE III)

○ the use of oral glutamine in H&N cancer patients undergoing RT-C (LOE III)

○ that oral care protocols be used to prevent oral mucositis in all age groups and

across all cancer treatment modalities (LOE III)

○ that oral cryotherapy be used to prevent oral mucositis in patients receiving

high-dose melphalan, with or without total body irradiation, as conditioning for

hematopoietic stem cell transplantation (LOE III)

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(Multinational Association of Supportive Care in Cancer, 2019)

• Safe with very low rates of minor side effects such as, headaches, chills,

numbness/taste disturbance, and tooth pain (Riley et al., 2015, p. 1846)

• Easily accessible (Riley et al., 2015, p. 1846)

• Cost-effective (Riley et al., 2015, p. 1846)

• Reduced incidence and severity of oral mucositis leading to…

• Decreased need for fluids and supplemental nutrition (Svanberg et al., 2010, p.

2148)

• Decreased incidence of interruptions to cancer treatment (Svanberg et al.,

2007, p. 1157)

• Decreased use of opioid analgesics and antibiotics (Svanberg et al., 2007, p.

1157)14

Benefits of Oral Cryotherapy

Special Thanks

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▶ Bob and Sylvia Lauterborn

▶ Laura and Warren Piver

▶ UNC Lineberger Comprehensive Cancer Center

▶ UNC School of Nursing

▶ Dr. Deborah Mayer and Dr. Ashley Bryant

▶ My fellow classmates Anna, Christie, and Jessie

▶ Cancer survivors and caregivers

▶ Claire Gillet and Susie Mason

References

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Correa, M. E. P., Cheng, K. K. F., Chiang, K., Kandwal, A., Loprinzi, C. L., Mori, T., Potting, C., Rouleau, T., Toro, J. J., Ranna, V., Vaddi, A., Peterson, D. E., Bossi, P., Lalla, R. V., &

Elad, S. (2019). Systematic review of oral cryotherapy for the management of oral mucositis in cancer patients and clinical practice guidelines. Supportive Care in Cancer, 28(5),

2449–2456. https://doi.org/10.1007/s00520-019-05217-x

Lalla, R. V., Sonis, S. T., & Peterson, D. E. (2008). Management of oral mucositis in patients with cancer. Dental clinics of North America, 52(1), 61–viii.

https://doi.org/10.1016/j.cden.2007.10.002

Multinational Association of Supportive Care in Cancer. (2019). Mucositis Guideline Publications. https://www.mascc.org/mucositis-guideline-publications

Riley, P., Glenny, A.-M., Worthington, H. V., Littlewood, A., Clarkson, J. E., & McCabe, M. G. (2015). Interventions for preventing oral mucositis in patients with cancer receiving

treatment: Oral cryotherapy. Cochrane Database of Systematic Reviews, 1465–1858. https://doi.org/10.1002/14651858.cd011552.pub2

Shankar, A., Roy, S., Bhandari, M., Rath, G., Biswas, A., Kanodia, R., Adhikari, N., Sachan, R. (2017). Current trends in management of oral mucositis in cancer treatment. Asian Pacific

Journal of Cancer Prevention, 18(8), 2019-2026. https://doi.org/10.22034/APJCP.2017.18.8.2019

Svanberg, A., Birgegård, G., & Öhrn, K. (2007). Oral cryotherapy reduces mucositis and opioid use after myeloablative therapy—a randomized controlled trial. Supportive Care in Cancer,

15(10), 1155–1161. https://doi.org/10.1007/s00520-007-0245-8

Svanberg, A., Öhrn, K., & Birgegård, G. (2010). Oral cryotherapy reduces mucositis and improves nutrition - a randomised controlled trial. Journal of Clinical Nursing, 19(15–16), 2146–

2151. https://doi.org/10.1111/j.1365-2702.2010.03255.x