Epidermiology And Management Of Radiation-induced Oral Mucositis Among Patients With Head-and-neck Tumors:a Survey Of Current Statues

Purpose:Radiotherapy(RT) is one of the most important treatments of head-and-neck tumors. Although the technique of RT is developing fast, oral mucositis(OM) is still the most common toxicity among patients with head-and-neck tumors. OM often leads to the pain of oral and oropharynx, and some patients may need opioids. Also, OM may affect oral diet, the quality of life and treatment schedules. Thus, cause the increase of hospital admissions and the costs for treatment. As important as OM is, it is not noticed enough in the daily medical care. The aim of this study is1) to investigate the incidence, risk and clinical outcomes of radiation-induced OM among patients with head-and-neck tumors;2) to study the current statues of diagnosis and management of OM;3) to study the attitude and the knowledge of OM among oncologists.Methods:1. From November2013to January2014, data of patients with head-and-neck tumors were collected, including gender, age, hight, weight, diagnosis and chemotherapy(CT). Use National Cancer Institute-Common Terminology Criteria for Adverse Events(NCI-CTCAE) to evaluate the OM once a week until the end of the treatment.2. Medical records of these patients were collected to analysis the diagnosis as well as the managements of OM based on MASCC/ISOO Clinical Practice Guidelines for the management of mucositis secondary to cancer therapy. 3. Questionnaires were used to investigate the knowledge of epidermiology, grading and management of OM among oncologist, and also to analysis their attitude towards OM and it’s guidelines.Results:1. Epidermiology study:(1) Totally101patients of head-and-neck tumors enrolled. OM occurred in93.1%of patients. In66.3%it was severe (≥grade3). The risk factors for severe OM include, patient related:nasopharynx primaries(OR=3.7,95%CI1.6～8.9), decreased white blood cells account during RT(OR=5.3,95%CI2.1～13.3), and treatment related: radiation dose≥70Gy(OR=18.4,95%CI2.4～143.2), induction CT(OR=5.7,95%CI1.6～20.1) and chemo-RT (OR=5.4,95%CI2.2～13.3).(2) On average, OM persisted for (5.0±1.4)weeks, and severe OM persisted for (3.3±0.8)weeks. OM persisted longer among patients with nasopharynx primaries (5.4±1.8w vs.4.5±1.9w, P=0.002) and those who received chemo-RT (5.3±0.8w vs.4.4±2.0w, P=0.001).(3) The mean weight loss of patients was (4.0±2.7)kg,50.5%of patients received parenteral nutrition support,33.7%of patients were admitted in hospital, and the mean time of hospitalization was (10.2.±6.9) days. Patients with sever OM were more likely to have weight loss(5.0±2.5kg vs.1.7±1.7kg, P=0.000), parenteral nutrition support(OR=7.4,95%CI2.8～19.5), prescription of opioids(OR=7.3,95%CI1.6～33.4) and risk for hospitalization(OR=14.6,95%CI3.2～66.0).2. The current statues of diagnosis and management of OM:(1)43.6%of patients were diagnosed or noted for OM in their medical records. Only11.7%were diagnosed, and only3patients (3.2%) were graded.(2) Many methods were used to prevent/treat OM, but the prevention were only given to7.7%of patients, and all of them were basic oral care. Top5interventions that used most frequently were:antibacterial agent (intravenous injection, iv.)(73.3%), basic oral care (52.5%), dexamethasone iv.(46.5%), aerosol inhalation (46.5%) and lidocaine mouthwash (35.6%).(3) Patients with severe OM had higher risks of antibacterial agent (OR=14.5,95%CI4.9～42.8) prescription.3. The attitude and understanding of OM among oncologists:(1)50%of oncologists agreed that the incidence of radiation-induced OM among patients with head-and-neck tumors was higher than80%. And nearly half of oncologists (48.3%) thought that OM has caused major influence to patients, but only58.6%of oncologists paid enough attention to it.(2) Only20.7%of oncologists would exam the oral cavity of patients more than once a week. The World Health Organization (WHO) scales was used by50.0%of oncologists. And only14.3%of oncologists known the grading scales for OM very well.(3) The preventive protocols would be prescribed by31.0%of oncologists. The top5preventions/treatments which oncologists though effective for OM were:basic oral care (94.7%), topical anesthetic (eg. lidocaine)(78.9%), dexamethasone (78.9%), nutrition support (78.9%), G(M)-CSF (68.4%). And top5measures that were considered to be not effective were:honey (36.8%), chlorhexidine mouthwash (21.1%), benzydamine mouthwash (21.1%), sucralfate mouthwash (15.8%) and low-level laser therapy (15.8%).(4)41.4%of oncologists didn’t know MASCC/ISOO Clinical Practice Guidelines for the management of mucositis secondary to cancer therapy. And most oncologists (62.1%) felt that they were not trained enough for the management of OM.Conclusions:1.Radiation-induced OM is a frequent, almost inevitable toxicity among patients with head and neck tumors. Nasopharynx primaries, induction CT, chemo-RT and decreased white blood cells account during RT are relevant to the severity of OM. And severe OM may lead to significant weight loss, parenteral nutrition support, prescription of opioids and increasement of hospitalization. 2. The diagnosis and treatment of radiation-induced OM in clinical practice is lack of standardization, and there is a high rate of missed diagnosis of OM. The management of OM is usually based on clinical experience, and the evidence-base medicine is not widely used in the management of OM.3. The questionnaire shows a lack of attention to OM. The oncologists has a poor understanding of diagnosis criteria and management of OM, as well as the knowledge of guidelines. It emphasizes that specific training of the management of OM is necessary.