• 7/2/2004
  • Karis K. F. Kwong
  • Cancer Nurse, 27(3):183-205, 2004

Abstract and Introduction

Oropharyngeal mucositis is an acute and distressing toxic effect of chemotherapy and head and neck irradiation. This oral sequela significantly impairs the daily functioning and quality of life of patients. The biological basis of mucositis is quite complex, involving sequential interaction of chemotherapeutic drugs or irradiation on mitosis of proliferating epithelium, a number of cytokines, and elements of oral microbial environment. Various interventions based on biological attenuation have been tested for mucositis. Such interventions have been reviewed elsewhere; however, most reviews focus on biomedical outcomes. Little attention has been paid to mucositis outcomes with oral morbidity or psychosocial aspects. The purpose of this article is to review the current research studies on the prevention and treatment of oropharyngeal mucositis following chemotherapy, radiotherapy, and bone marrow transplantation with an emphasis on biomedical, oral symptomatic, and functional impairment outcomes. In addition, further avenues of mucositis management, including psychotherapeutic intervention and integrated and stage-based treatment approaches are discussed.

Oropharyngeal mucositis is a significant clinical problem afflicting most patients in cancer therapy. Its manifestations may range from generalized erythema to pseudomembranous degeneration, frank ulceration, and hemorrhage. Considerable effort has been expended in the past 10 years to identify etiopathophysiology and develop strategies to alleviate such an oral sequela. Various interventions based on biological attenuation have been investigated with different types of cancer patients. However, the majority of studies are tarnished by methodological shortcomings. At present, no intervention has been shown to be uniformly efficacious and can be accepted as evidence-based standard therapy. Mucositis interventions have been reviewed elsewhere[1-3]; however, most reviews focus on biomedical outcomes, such as onset, severity, and duration of mucositis. No review has produced a comprehensive evaluation of outcome measures. Accordingly, the present article aims at providing a review of the agents or measures to protect proliferating cells, stimulate basal cells proliferation and epithelization, as well as decrease inflammation, sepsis, and superinfection for mucositis with an emphasis on biomedical, oral symptomatic, and functional impairment outcomes. A Medline search was conducted from 1993 to 2003 to obtain a list of randomized controlled trials that evaluated mucositis interventions in patients treated with chemotherapy, radiotherapy, and bone marrow transplantation (BMT). In addition, this article discusses integrated and stage-based approaches of mucositis care. Areas of potential research that may improve the current knowledge and clinical management of mucositis is also indicated.

Prevalence of Oropharyngeal Mucositis

Given the wide variation in study populations, diagnoses, cancer treatments, time or types of scales used in assessment, and the methods of reporting, the true prevalence of mucositis is difficult to ascertain. In particular, the detection of mucositis depends on the method of assessment.[4] In literature, variable mucositis prevalence has been reported, with ranges from a low of 12% in patients receiving adjuvant chemotherapy to 99% in patients subjected to high-dose myeloablative chemotherapy for BMT.[5,6] The prevalence of mucositis in patients undergoing standard-dose chemotherapy is approximately 40%.[7] Karthaus et al indicated that mucositis affects more than 50% of patients on high-dose chemotherapy protocols.[8] In patients receiving chemotherapy for leukemia and solid tumors, the prevalence of mucositis is approximately 50% and 21% to 31%, respectively.[5,9,10] Approximately 60% and 90% of head and neck cancer patients receiving standard radiotherapy and chemoradiotherapy will develop severe mucositis, respectively.[11]