xerostomia

Perspectives on Coping Among Patients With Head and Neck Cancer Receiving Radiation

Source: MedScape News Today

Abstract and Introduction

Abstract

Purpose/Objectives: To describe coping among patients with laryngeal and oropharyngeal cancer during definitive radiation with or without chemotherapy.
Research Approach: Qualitative content analysis conducted within a larger study.
Setting: Two radiation oncology outpatient clinics in Baltimore, MD.
Participants: 21 patients with oropharyngeal or laryngeal cancer.
Methodologic Approach: Interviews with open-ended questions were conducted during treatment. Questions covered topics such as coping during treatment, treatment-related issues, and resources.
Main Research Variables: Coping, treatment, and coping resources.
Findings: Patients’ self-assessments suggested they were coping or that coping was rough or upsetting. Issues that required coping varied over four time points. Physical side effects were problematic during and one month after treatment completion. Patients used coping to manage the uncertainties of physical and psychological aspects of their experience. Family and friend support was a common coping strategy used by patients, with the intensity of side effects corresponding with the support provided across time points.
Conclusions: Findings confirm previous research, but also provide new information about ways in which patients with head and neck cancer cope with their illness experience. Emergent themes provide insight into patients’ feelings, issues, and assistance received with coping.
Interpretation: Patients with head and neck cancer need education on the amount and severity of side effects and should be appraised of potential difficulties with scheduling, driving, and other logistic issues. Patients also should be informed of helpful types of support and coping strategies. Additional research is needed to expand the findings related to patients’ coping with treatment and to explore the experiences of family and friends who provide social support.

Introduction

Head and neck cancer (HNC) accounts for 3% of all cancers in the United States and is twice as common in men compared to women (National Cancer Insitute [NCI], 2011). The incidence in the United States was estimated to be 52,000 new cases in 2011 (NCI, 2011). Treatment for HNC is multimodal, including surgery, radiation, and often chemotherapy. Patients’ illness experiences involve physical symptoms, side effects from treatment, symptom distress, and psychological distress (Archer, Hutchison, & Korszun, 2008; Haman, 2008). Patients also experience uncertainty about the effectiveness of an unfamiliar treatment, their ability to manage daily living, and long-term effects of the disease and treatment (Rose & Yates, 2001). Because of uncertainty, each patient perceives illness, cognitively appraises his or her situation, and copes with illness differently (Mishel, 1988).

Patients with HNC experience an array of physical symptoms resulting from their cancer and its treatment (Chandu, Smith, & Rogers, 2006). Symptoms related to side effects of radiation include dysphagia, xerostomia, pain, fatigue, altered taste, mucositis, skin changes, and weight loss (Olmi et al., 2003; Khoda et al., 2005). Symptoms related to side effects of chemotherapy include difficulty swallowing, anemia, nausea, neutropenia, diarrhea, and mucositis (Lambertz, Robenstein, Mueller-Funaiole, Cummings, & Knapp, 2010; Schrijvers, Van Herpen, & Kerger, 2004). Patients with HNC may experience several of those symptoms and side effects at any time during their treatment.

Symptom distress is defined as the degree or amount of physical or mental upset, anguish, or suffering experienced from specific symptoms (Rhodes & Watson, 1987). Few researchers have examined symptom distress among patients with HNC. Lai et al. (2003) reported that patients undergoing treatment had a moderate amount of symptom distress related to dry mouth, fatigue, loss of appetite, insomnia, and pain. Symptom distress also changes over time in response to the perceived difficulties of patients as a result of the physical and psychological demands of treatment (Haisfield-Wolfe et al., 2011). Symptom distress among patients with HNC can influence coping with symptoms and psychological distress (Elani & Allison, 2010).

Psychological distress, including the presence of anxiety, depression, and depressive symptoms, is present during the course of HNC treatment. Patients experience high levels of anxiety, particularly at diagnosis and pretreatment (Horney et al., 2011). Researchers have found depression and depressive symptoms prior to treatment (Baile, Gibertini, Scott, & Endicott, 1992; Davies, Davies, & Delpo, 1986), during treatment (Haisfield-Wolfe, McGuire, Soeken, Geiger-Brown, &, De Forge, 2009; Kugaya et al., 2000), at the completion of radiation treatment (Katz, Irish, Devins, & Gullane, 2003; Sehlen et al., 2003), and three months after diagnosis (Hammerlid, Silander, Hornestam, & Sullivan, 2001).

Uncertainty in illness is defined as an inability to determine the meaning of events, assign values to objects and events, and accurately predict outcomes (Mishel, 1988). Uncertainty and symptoms have been shown to interfere with adaptation to cancer (Bailey, Mishel, Belyea, Stewart, & Moher, 2004), and high levels of uncertainty interfere with coping (Mishel, 1984). In studies of patients with cancer, increased uncertainty has been related to depression (Bailey et al., 2004), poorer coping with stress (Badger, Braden, & Mishel, 2001), and inadequate psychological adjustment (Christman, 1990). However, few research studies have addressed coping in the context of uncertainty among patients with HNC.

Coping is defined as a “cognitive and behavioral effort to manage specific external or internal demands and conflicts that are appraised as taxing or exceeding the resources of a person” (Lazarus & Folkman, 1984, p. 112). Cognitive appraisal of taxing situations is a prerequisite for initiation of coping attempts that are aimed at adapting to the new reality of living with HNC. Variables associated with adaptation include those of a physical, psychological, and social nature. Research that investigates coping among patients with HNC, focusing on areas patients cope with and what coping strategies they use, is limited. Chaturvedi, Mbulaiteye, and Engels (2008) found that major concerns faced by patients with HNC were worries about their current illness and future (e.g., physical evaluation, communication, inability to perform usual tasks, finances, being upset).

During treatment, patients with HNC cope with symptoms and worries such as weight loss, dry and sore mouth, difficulty masticating and swallowing food, altered perception of taste, and missing meals (Lees, 1999). Patients receiving radiotherapy reported experiencing insufficient information and lack of time to ask questions (Larsson, Hedlin, & Athlin, 2007). Patients also have described coping with “disruption of their daily lives,” “waiting in suspense,” and “being left to their own devices” (Larsson et al., 2007, p. 324). Other areas identified as requiring coping after treatment were feelings of being self-diminished, underreported suffering, and loss of meaning in life (Moore, Chamberlain, & Khuri, 2004). Six to 12 months after treatment, patients were faced with physical changes, concerns about cancer, difficulties with work, interpersonal relationships, and social functioning (Semple, Dunwoody, Kernohan, McCaughan, & Sullivan, 2008).

Coping strategies used by patients with HNC vary. List et al. (2002) found that at pretreatment, patients with HNC primarily used social support. Recently treated patients with HNC used a greater number of coping strategies and commonly employed emotional ventilation, disengagement, denial, and suppression of competing activities (Sherman & Simonton, 2010). Elani and Allison (2010) found an association between levels of patients’ anxiety and depression and the types of coping strategies used. Those with higher levels used more self-blame, wishful thinking, and avoidance strategies. Thambyrajah, Herod, Altman, and Llewellyn (2010) examined benefit finding after HNC treatment and found that major themes were change in life priorities, greater closeness to family and friends, a greater awareness of self, and spirituality. Those few studies demonstrate that although patients with HNC are challenged with numerous physical, psychological, and social effects, their coping remains poorly understood.

Patients cope with symptoms and side effects, worry about disruption in their lives, and often are left to their own devices (Larsson et al., 2007; Lees, 1999). Patients also experience loss of meaning in life, underreport their pain, feel (or are) disfigured, and have changes in interpersonal relationships (Moore et al., 2004). They verbalize that they feel concerned about the uncertainties of cancer recurrence and daily living (Semple et al., 2008). Despite that large burden, few intervention studies have been designed to assist patients with HNC in coping. Learning more about how patients with HNC cope during each phase of their cancer experience will provide clarity in understanding the coping needs of and strategies used by this population.

The purpose of this study was to describe coping in the context of uncertainty among patients with laryngeal and oropharyngeal cancer during definitive radiotherapy with or without chemotherapy over four time points. This work was conducted as a substudy within a larger, longitudinal descriptive study (Haisfield-Wolfe et al., 2009) examining symptoms, symptom distress, depressive symptoms, and uncertainty.

Mishel’s (1988) Uncertainty in Illness Theory (UIT) guided the study research. UIT centers on an ill individual’s appraisal and coping with uncertainty. UIT views coping as a context-specific behavior in which an individual appraises and manages uncertain objects or events as a threat or as a positive challenge (Lazarus, 1967; Lazarus & Launier, 1978; Mishel, 1988). This substudy focuses on coping related to uncertainty. In designing this substudy, the researchers developed three open-ended interview questions to illicit information regarding how patients with HNC cope with treatment. Exploring coping within the context of uncertainty will help increase understanding of coping issues and strategies, with the ultimate aim of developing interventions that will improve practice.

Methods

Design, Setting, and Sample

The current study is a descriptive, qualitative content analysis of open-ended questions that patients answered about their coping during treatment. Patients were recruited from radiation oncology clinics at two cancer centers in Baltimore, MD. The sample consisted of 21 patients who met the following inclusion criteria: being aged 18 years or older, newly diagnosed with oropharyngeal or laryngeal cancer, and undergoing definitive radiation with or without chemotherapy. Patients were interviewed at four time points: week 1 (treatment initiation), week 5 (midpoint in treatment), week 9 (end of treatment), and week 12 (one-month visit with radiation oncologist after completion of radiation).

Procedures and Analysis

Approval was obtained from the human subjects institutional review boards at the University of Maryland Medical Center and Johns Hopkins Medical Institutions. Procedures were similar at each site, with physicians and nurses screening new patients for eligibility and identifying those interested in participating. Those individuals then were contacted by the researchers. Of 24 patients meeting inclusion criteria, 21 signed informed consent and provided demographic information. Patients who declined participation stated they were overwhelmed by their diagnosis and schedule. During a structured interview that was conducted as part of the larger study, researchers used the following prompts at each time point.

  • Tell me about how you are coping during treatment.
  • Tell me about any issues related to your treatment.
  • What resources are helping you to cope?

Depending on patients’ responses, the researchers occasionally asked additional questions for clarification. Patients were given as much time as needed to answer the questions, with the average interview lasting 15–30 minutes. Participants’ responses were recorded manually.

The recorded responses were categorized by time point and entered into a Microsoft® Word® document. Using a content analysis approach, the first author examined the text. A qualitative method was used to sort words and sentences having aspects related to each other by content and context into content areas (Graneheim & Lundman, 2004; Krippendorff, 2004). After rereading the whole interview again, content areas were labeled. The individual content areas were tabulated to identify the frequency with which they occurred (Krippendorff, 2004) and then discussed by the researcher and two HNC content area experts. When the researcher or the content experts had different perspectives, discussion occurred until consensus was reached. The categories and their content then were formulated into themes. Finally, the data were reviewed and judged by an HNC survivor who agreed that the themes and content reflected the experience of patients with HNC coping during and after treatment.

Study integrity was established using the aspects of trustworthiness: credibility, dependability, transferability, and confirmability (Lincoln & Guba, 1985). Credibility was demonstrated in the unique responses of patients with HNC to the interview questions, which focused on specific areas of coping with treatment. Dependability was demonstrated not only in the agreement among HNC experts and researchers regarding the results, but also by similar research findings in the literature that are reported in the Discussion section of this article. Transferability was judged by HNC content experts and an HNC survivor who reviewed the findings and agreed that they were transferable to other HNC contexts and settings. Finally, confirmability was maintained when a code book was developed and an audit trail of coding and content area decisions were recorded by the researchers to help ensure rigor and provide guidance for future research.

Results

Demographic and Clinical Characteristics

Sample characteristics are presented in Table 1 . Most patients were Caucasian, married, and men. The mean age was 59.2 years (SD = 9.2), and most patients had 12 years of education. Five patients reported a prior mental health disorder, and one patient was taking antidepressant medications. All patients were receiving radiation treatment at the time of the study, and 15 patients were receiving concomitant chemotherapy.

Open-ended Questions

Coping During Treatment: See Table 2 for the number of participants reporting each theme across time points. Exemplars for the three most prevalent themes that emerged related to coping are presented in Table 3 . At all four time points, the most prevalent theme was the patient’s self-perception of managing to cope. Responses revealed degrees of coping, for example, “quite well,” “as expected,” or “fair.” More than half of the patients reported they were coping with their illness and treatment. Although patients self-perceived they were coping across time points, they also identified physical and psychological issues that challenged their coping abilities. The second most prevalent theme was upsetting or rough experience, which increased over time. At the beginning of treatment, patients reported areas of difficulty with coping as stress related to disease and treatment. At midtreatment, patients reported bothersome side effects. At end of treatment, patients reported coping with aspects of treatment related to managing stressful events or severe side effects. One month after treatment, patients reported being upset about not feeling better by this point in time.

The third most prevalent theme was anticipation, which was highest at baseline and end of treatment (week 9). Patients were anticipating the end of both treatment and side effects. Responses that demonstrated anticipation included “I’m counting the days,” or “I can see the end of the tunnel.” Patients also reported using coping strategies (e.g., blogging, walking, accepting assistance from family or friends, acceptance of their illness, denial).

Issues Related to Treatment: Selected exemplars for the three most prevalent themes related to issues during treatment are presented in Table 4 . The most prevalent theme throughout the four time points was having physical side effects related to treatment, which increased at midtreatment and declined at end of treatment and one month after treatment. Patients reported 16 different side effects: weight loss, taste changes, sore throat, skin sores, pain, nausea, hiccoughs, hearing loss, fatigue, excess mucous, dry throat, difficulty talking, difficulty eating or swallowing, anorexia, and change in body image. One month after completion of treatment, patients still reported persistent symptoms (e.g, pain, difficulty swallowing, fatigue). Of note, the second most prevalent theme (six patients at weeks 5 and 9) was minimal or no issues, with the frequency declining over time. The third most prevalent theme was fear, anxiety, or worrying, which was present at all time points, but was most prevalent at baseline and one month after treatment. Exemplars emphasized the uncertainty associated with completion of treatment, for example, “fear of recurrence of cancer” and “don’t know what to expect.”

Assistance With Coping: Illustrative exemplars for the three most prevalent themes related to assistance are shown in Table 5 . The most prevalent theme was family support, with the majority of patients reporting family as the main source of support received over the four time points. The second most prevalent theme was friend support, which also persisted over four time points. Many patients told stories about how their friends and family had supported them. As the number of side effects increased at midtreatment and end of treatment, the number of individuals supporting the patient increased. At end of treatment (week 9), patients reported the importance of hospital personnel. One month after treatment, the amount of family support decreased and the interactions with friends increased. The third most prevalent theme was mental outlook, which increased over time. Coping strategies reported included Web support, keeping a normal schedule, weekly massage, walking, keeping busy, working at home, journaling, pets, and going to the mall for a few hours to take a “minivacation.”

Discussion

The results indicate that patients used coping to manage the uncertainties of physical and psychological aspects of their experience. Emergent themes provided insight into patients’ issues and feelings, as well as the support they received during treatment and afterward. Common themes uncovered for each question will be discussed briefly.

Coping at Each Treatment Time Point

Coping is defined as managing internal and external demands of illness (Lazarus & Folkman, 1984). Although the majority of patients perceived that they were coping, they reported different degrees of individual coping (e.g., “excellent,” “fair”) and noted issues that influenced how they coped, such as symptoms, fear, or anxiety. Therefore, most individuals appeared to be coping with the internal and external demands of treatment, with the exception of those who found their situation to be rough or upsetting. Interestingly, patients who reported that their coping was rough or upsetting were not the same grouping of patients across all time points. Patients reported better coping or more difficulty coping depending on the time point; for example, a patient who was coping adequately at baseline and midtreatment reported not coping well at end of treatment because of pain when swallowing. The adequacy of coping appeared to vary depending on the physical and psychological demands the patient had to face. Anticipation emerged at week 9 when patients were experiencing their worst symptoms and were anticipating the end of treatment and the results of their scans, which would determine whether the treatment was successful. That appears to be similar to the theme of waiting in suspense reported by Larsson et al. (2007), who studied patients with HNC six to eight weeks after radiotherapy. Those findings highlight a major issue among patients with HNC: the fear of recurrence experienced by cancer survivors. Coping interventions are needed to assist patients with that issue. One strategy is to educate patients about the wide variety of coping strategies used by participants in this substudy.

Issues Related to Treatment

Physical side effects of treatment were the most prevalent theme identified as an issue to be coped with, revealing specific areas of concern for patients with HNC and verifying findings of other researchers on coping with treatment side effects (Lees, 1999). Specific side effects included difficulty talking, eating, and swallowing; taste changes; excess mucous; and changes in body image. At the midpoint of treatment, patients reported coping with 17 different symptoms, with one patient reporting concurrent presence of three to four side effects at one time. The large number of symptoms patients coped with also has been reported by others (Hansen & Roach, 2007; Vissink, Jansma, Spijkervet, Burlage, & Coppes, 2003). Even one month after treatment, patients still identified pain (mainly in the throat), fatigue, and difficulty swallowing as issues. Treatment-related issues that were problematic for patients generally were related to the processes and procedures of radiation treatment, such as wearing a mask. Both treatment side effects and treatment-related issues revealed the complexities of the illness experience and the challenges posed to patients’ coping. Ten patients reported minimal or no issues at baseline, although that theme was less common at subsequent time points. That finding was surprising because patients were just starting their treatments and one might anticipate that they were coping with a variety of issues. Alternatively, patients simply may have been coping more effectively with their illness. In a study of patients with HNC, Moore et al. (2004) found that patients may underreport their pain and suffering. Finally, the theme of fear, anxiety, or worry was present at all time points, but particularly at baseline and end of treatment. Patients expressed distress about the uncertainties of their illness and their future. They were anxious about treatment and afraid of the outcomes. They worried about the cancer spreading, the treatment schedule, and whether they would endure their treatment. Those fears and worries have been observed by other researchers and clinicians (Hodges & Humphris, 2009). Clearly, uncertainties related to cancer cure and what the future holds are a major issue in the illness experience of patients with HNC. Additional study to determine interventions to assist patients in this area is needed.

Assistance With Coping

Patients used social support to cope with their treatment over the four study time points. They depended on their families and friends to assist them with many aspects of their lives, including traveling to outpatient clinic visits and radiation treatments, daily living activities, communicating with healthcare providers, managing symptoms, scheduling appointments, reading information and educational materials, and engaging in other activities to manage and cope with treatment. Patients also relied on those support people for companionship. As patients progressed with their treatment, more family and friend support was needed to cope with the resulting complexities. Patients used a broad range of coping strategies and also articulated acceptance of their situation or, occasionally, denial.

Of note, some patients took breaks from their situations by going to the mall or turning off their cellular phones to reduce disturbances to their focus on getting well. Sherman and Simonton (2010) reported coping strategies of ventilation, disengagement, and suppression of competing activities, but the wide array of activities reported in the current study provides insights into how patients may take the initiative to cope with their illness and treatment.

Mental outlook was a prevalent theme that helped patients’ cope, and that mindset increased as they progressed through treatment. Patients were convinced that they were getting through the treatment because of their mindset and that they were going to endure. That finding is important because it suggests that patients with a positive mental outlook represent a patient subgroup with a greater ability to cope. Each individual copes with illness and cognitively appraises his or her situation differently (Lazarus & Folkman, 1984). Therefore, mental outlook could have influenced the way patients coped with the physical and psychological demands of illness and treatment.

Limitations

The current study was limited by the unrecognized individual biases of the researchers and the HNC content experts who analyzed the data. Interviews were conducted at four time points during radiation treatment and, therefore, cannot reflect the entire experience of coping in patients with HNC. During interviews, patients were experiencing fatigue and other factors that may have affected the amount and degree of self-reporting that occurred. Finally, different ways to ask about coping may have revealed different perspectives.

Implications for Nursing

The findings confirm previous research, but also provide new information about the ways in which patients with HNC cope with their illness experience. In the clinical setting, patients with HNC should be educated regarding the number and severity of side effects they may experience and be appraised of potential difficulties with scheduling, driving, and other logistic issues. Patients also should be informed of the types of support and coping strategies that can be helpful. Healthcare providers also should inform patients that they may experience low energy during treatment, thus requiring support of significant others who can assist them with a variety of activities and issues.

Additional research is needed to expand the findings related to patients’ coping during and after treatment because this study was small with limited exploration of coping. For example, future researchers should explore the illness and coping experience of patients with HNC who perceive that they are coping adequately, but then report multiple treatment-related issues. Another area for future research is an exploration of the issues, burdens, and individual coping of family and friends who provide social support to patients with HNC during treatment, which can ultimately strengthen support for patients and reduce the negative impact of caregiving.

This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.

June, 2012|Oral Cancer News|

Cannabis chewing gum targets oral side effects

Source:
Author: staff

The company Medical Marijuana has acquired a 50% stake in CanChew, a cannabinoid (CBD)-based chewing gum developed as a pharmaceutical delivery mechanism to relieve pain, xerostomia, and other side effects of disease and disease treatment.

The acquisition gives Medical Marijuana worldwide exclusive rights to develop, manufacture, market, and distribute both tetrahydrocannabinol (THC) and non-THC hemp-derived cannabinoid-infused chewing gum to medical marijuana consumers, according to the company. The U.S. Food and Drug Administration currently considers non-THC based hemp products to be “food-based” and therefore legal without a medical marijuana license.

Cannabinoids have had positive effects in clinical trials on neuralgic pain, multiple sclerosis, and spinal cord injuries, nausea and vomiting from chemotherapy and radiation treatment, as well as palliative treatment of various cancers and HIV/AIDS, the company stated.

According to Sanammad, the company that developed CanChew, the gum can:

  • Alleviate acute and chronic pain
  • Diminish nausea and vomiting, as well as cachexia, which is a syndrome common in cancer patients on chemotherapy that causes appetite loss and loss of weight and muscle-mass
  • Enhance appetite
  • Improve muscle relaxation, coordination, and mobility
  • Diminish xerostomia
  • Promote fresh breath and maintain oral hygiene

“Functional chewing gum is well-established as an effective way to deliver pharmaceutical active ingredients,” said Michael Llamas, president of Medical Marijuana. “A great example is Nicorette. Within 10 minutes of chewing Nicorette gum, the consumer’s symptoms of nicotine withdrawal begin to ease. Our formulations also have an exceedingly safer side-effect profile compared to the currently available analgesics such as opioids, NSAIDs [nonsteroidal anti-inflammatory drugs], and Paracetamol (Tylenol).”

Dental oncology: Meeting a growing need

Source: Dr.Biscuspid.com

The good news is more cancer patients are surviving than ever before.

The bad news is it creates new challenges for the medical community to provide adequate and appropriate aftercare and treat the many short- and long-term side effects of cancer treatment.

For example, chemotherapy and radiation often cause oral problems such as mucositis, xerostomia, oral and systemic infections, and accelerated caries development. But many dentists refuse to treat cancer patients with these conditions due to the increased risk of osteonecrosis from radiation treatment or bisphosphonate use.

Enter Ryan Lee, DDS, MPH, MHA, who is finishing a postgraduate clinical fellowship in dental oncology at Memorial Sloan-Kettering Cancer Center in New York City. He hopes to help solve the shortage of dentists with the training to treat the growing number of cancer patients who need specialized oral care.

Ryan Lee, DDS, is one of a handful of dentists specializing in dental oncology.

Dr. Lee is one of two fellows in Sloan-Kettering’s dental oncology fellowship program, which has been offering the specialty training for at least a decade.

“All along I’ve liked working on medically complex cases with dental needs, so cancer fit into that niche very well,” he told DrBicuspid.com. “I’ve come to realize how much of a growing need it is and how little is available to meet that need,” he explained.

Currently, only two cancer hospitals offer fellowship training programs for dental oncology: the Memorial Sloan-Kettering Cancer Center and the University of Texas MD Anderson Cancer Center.

“Oncology training in the dental setting is a new and growing field, kind of a cottage industry,” Dr. Lee said. “When I went to dental school, cancer instruction was just a couple of lectures, and we learned mostly about oral cancer. We didn’t learn about the oral manifestations of systemic cancer that can be anywhere in the body.”

In fact, most of his patients don’t have oral cancers; most have breast or prostate cancer. And yet he sees hundreds of patients each month who present with cancer-related dental sequelae, including radiation-induced xerostomia, osteoradionecrosis, bisphosphonate-related osteonecrosis of the jaw, chemotherapy-related manifestations, oral (pre)cancerous lesions, and surgically resected jaws.

Dr. Lee also prescreens patients prior to bone marrow and stem cell transplants, head and neck radiation, and other cancer treatments.

“But we, as a dental profession, need to see these patients even when they’re outside the hospital setting,” he said. “The buzzword is oral systemic condition.”

An emotional toll

Some of Dr. Lee’s most difficult cases involve pediatric patients who have liquid tumors such as myeloma and often need chemotherapy and stem cell or bone marrow transplants.

“The effects of that are pretty severe in the mouth,” he said. “A lot of the children are missing teeth, and their adult teeth never fully develop so managing them throughout the course of their growth is a big issue — not only in clinical terms like chewing, eating, and smiling, but also the psychological impact.”

Treating cancer-stricken youngsters takes an emotional toll. “There’s nothing like seeing a bunch of kids with alopecia, and you know they’re going through cancer treatment,” Dr. Lee said. “It just breaks your heart.”

“Oncology training in the dental setting is a new and growing field, kind of a cottage industry.”
— Ryan Lee, DDS, Memorial
Sloan-Kettering Cancer Center

There are many physical challenges as well, he noted; for one, many patients must get a dental clearance before they start radiation therapy.

“When you get radiation to the jaw, it affects the blood vessels in such a way that you have nonhealing, so any dental extractions or oral surgery cannot be done after radiation to the mouth because of the risk of osteoradionecrosis,” Dr. Lee explained. “So we see a lot of those folks.”

Cancer patients also often need extensive oral surgery before they can be cleared for transplants.

“We often have patients that need 12 to 15 teeth extracted before they can go in for a transplant,” Dr. Lee said. Although the protocol calls for allowing three to four weeks for proper healing, sometimes they can’t wait due to the patient’s deteriorating condition and the urgent need for the transplant, he explained.

And during cancer treatment, a patient’s immunity is greatly diminished, which can result in abscesses and gingival inflammation, Dr. Lee said.

“You’ve got to manage these types of patients carefully, and these are the types of patients dentists on the outside really don’t want to deal with,” he noted.

Creative solutions

One of his most difficult cases involved a 29-year-old woman with fanconi anemia, an inherited blood disorder that leads to bone marrow failure. She subsequently developed squamous cell cancer in her mouth and has had multiple cycles of radiation, which puts her at a very high risk of osteoradionecrosis. She also has trismus (a contraction of the muscles of mastication), leaving her with limited ability to open her mouth because of the fibrosis, Dr. Lee explained.

“Because of her radiation history she has bursitis, and she’s full of mouth sores,” he said.

The woman is now missing a couple of front teeth and because of her fanconi anemia, she never developed adult teeth and now wants implants.

“Imagine performing oral surgery to place implants on someone who’s had that much radiation, who cannot open her mouth,” Dr. Lee said. “We can’t even take impressions because we can’t fit the tray into her mouth. That alone is an incredible challenge.”

He was forced to come up with creative solutions, including making customized smaller trays and using unusual materials.

“We’ve actually used butter just to be able to put a small impression tray in her mouth,” Dr. Lee said. “Having the tray in her mouth just hurts her so much because her gums are so inflamed.”

He is now focusing on dentures so she can stabilize the woman’s occlusion, but he must specifically measure how much radiation was given in the areas where the implants will be placed.

Fortunately, her illness is now in remission.

“She’s an incredibly smart person with such a great outlook, and she encourages me when I’m having a long day,” Dr. Lee said.

Influencing policymakers

Dr. Lee is encouraged by the work of Texas dentist Dennis Abbott, DDS, who specializes in oncology and has seen his practice grow quickly. Drs. Lee and Abbott met at a dental conference, and the two discussed the growing need for dentists who can treat cancer patients with specialized needs.

“It’s such a small, relatively unknown field,” Dr. Lee observed.

But Dr. Lee, who is working toward another doctorate in health policy, hopes to change that. In addition to becoming an academic-level dental oncologist, he would also like to practice part time treating the cancer-specific needs of patients.

“It would be nice to be able to influence policymakers and show them that dental oncology treatment is a medically necessary condition, that the effects on the mouth are severe,” Dr. Lee said.

This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.

June, 2012|Oral Cancer News|

Pig mucus effective at blocking viruses associated with cervical and oral cancer

Source: American Chemical Society

Scientists are reporting that the mucus lining the stomachs of pigs could be a long-sought, abundant source of “mucins” being considered for use as broad-spectrum anti-viral agents to supplement baby formula and for use in personal hygiene and other consumer products to protect against a range of viral infections. Their study appears in ACS’ journal Biomacromolecules.

In the report, Katharina Ribbeck and colleagues point out that mucus, which coats the inside of the nose, mouth and vagina, is the immune system’s first line of defense. The slimy secretion traps disease-causing microbes, ranging from influenza virus to HIV (which causes AIDS) before they can cause infection. That has led to consideration of mucin, the main component of mucus, for use as an anti-viral agent in a variety of products. However, existing sources of mucins, such as breast milk, cannot provide industrial-sized quantities. Large amounts of mucus exist in the lining of pigs’ stomachs, and the authors set out to determine if pig mucus – already used as a component of artificial saliva to treat patients with “dry mouth,” or xerostomia – has the same anti-viral activity.

They found that pig mucus is effective at blocking a range of viruses, from strains of influenza to the human papilloma virus, which is associated with cervical and oral cancer. They report that pig mucins could be added to toothpastes, mouthwashes, wound ointments and genital lubricants to protect against viral infections. “We envision porcine gastric mucins to be promising antiviral components for future biomedical applications,” the report says.

This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.

April, 2012|Oral Cancer News|

Oral Complications After Head/Neck Radiation ‘Underreported’

Source: Elsevier Global Medical News

Late oral effects of head and neck cancer therapy are “multiple, underreported, and under-appreciated. “That is the perspective of Joel Epstein, D.M.D., who has worked extensively with head and neck cancer patients experiencing severe dental and other oral problems following radiation therapy.

“The acute complications of head and neck cancer therapy are pretty well known, but the late complications are underappreciated,” Dr.  Epstein, director of oral medicine at City of Hope National Medical Center, Duarte, Calif., told attendees at the symposium. As head and neck cancer treatments have advanced and patients are living longer, the spectrum of treatment complications has shifted, he explained. In a 5-year, prospective longitudinal study of 122 patients with oral carcinoma, dry mouth, sticky saliva, speech changes, dental problems, and sleep disturbance were reported by all patients except those treated only with surgery. These complications persisted at 1 and 5 years and affected quality of life (Head Neck 2008;30:461-70).

According to Dr. Epstein, the data illustrate the need for better collaboration between oncologists and dentists. “While people discuss  the concept of multidisciplinary [and] interdisciplinary teams for the benefit of our patients, it is unfortunate that dentistry developed  separately from physicians and surgeons. So while we need to interact, we’re not really well prepared to do so, particularly in the  community,” he said.

Clinically, it’s important to evaluate oral care, including brushing, flossing, fluoride, and tobacco abstinence, at all head and neck cancer treatment follow-up visits. Patients should be assessed for xerostomia, speech, swallowing, mucosal sensitivity, and taste. Head and neck and oral exams should include assessments for saliva (wet mucosa), exposed bone, infection, and new lesions or recurrent cancer, and a dental exam (for plaque, caries, and periodontal health), Dr. Epstein recommended.

Dry mouth, in particular, can lead to a host of other chronic problems related to swallowing, eating, sleeping, and dental health. When the 50-item Vanderbilt Head and Neck Symptom Survey was administered to a total of 70 patients, 67 reported having dry mouth at more than 6 months’ follow up (Head Neck 2011 Aug. 24 [doi:10.1002/hed.21816]).

The majority reported that dry mouth makes chewing/swallowing difficult (65) and that it affects their ability to sleep (67) and  talk (64). With regard to eating and swallowing, similar majorities reported trouble eating solids (67) and drinking liquids (68), with food getting stuck in their mouth (66) and throat (67).

And, of concern, the same numbers of patients reported the sensation of choking or strangling on solids (66) and liquids (68). “The impact on function from the lack of saliva and the change in quality of saliva are issues we need to be more ready and willing to address,”  Dr. Epstein commented.

Taste and smell may also be profoundly altered. In the Vanderbilt survey, most patients reported altered taste (68), a decreased desire to eat (68), altered food choices (66), and a decrease in food eaten (66). A change in sense of smell was reported by 69 patients.

Such alterations often result in changes in diet, including decreased consumption of high-fiber food and of vitamins and other nutrients,  along with increased consumption of fats, caffeine, and sugar. All of these factors increase the risk for dietary deficiencies, as well as  dental caries.

Yet, altered taste sensation is not something patients might think to mention. “Half of patients experience altered taste sensation. But if  they think you’re not interested or you don’t ask, you may not know,”  Dr. Epstein commented.

Periodontal health is often compromised by hyposalivation, which can lead to inflammation, bone/attachment loss, oral infection, and necrosis. Dental demineralization and cavitation may develop as early as 2-3 months after cancer treatment and progress rapidly, leading to fractures of the gum line, tooth loss, and necrosis.

Demineralization appears as a change to white, which may not be recognized as a problem because of the belief that white teeth are  healthy. However, recognition at this stage is critical in order to prevent further dental damage, he said.

“The white change near the gum line and the tips of the teeth represent demineralization, and [in] time reversal can be accomplished  prior to structural breakdown. Once cavitation has occurred, fillings are needed and prevention must be instituted or the cavities will  recur and progress,” Dr. Epstein said in an interview.

In the Vanderbilt survey, reported dental problems included difficulty chewing because of teeth/dentures (54 of the 70 patients); tooth  sensitivity to hot, cold, or sweet foods (52); teeth feeling looser (51); teeth cracking/chipping (50); and trouble with dentures (24).

Oral candidiasis is another common problem, affecting approximately 39% of head and neck cancer patients during treatment and 33% afterward. One common clinical mistake is prescribing these patients antifungals that contain sugar, such as nystatin. “Nystatin is very high in sugar, and one of the [most commonly] used antifungals. The message is to avoid sugar-sweetened products in dry mouth patients and utilize alternatives,” Dr. Epstein said in the interview.

Mucosal sensitivity and pain is also frequent. In a meta-analysis of 22 studies published between 1990 and 2008, the prevalence of trismus was 25.4% in patients who received conventional radiotherapy and 5% for the few intensity-modulated radiation therapy studies that were included, suggesting that the newer radiation modality might diminish the problem (Support. Care Cancer 2010;18:1033-8).

Data suggest that the radiation effect on mandibular movement correlates with the radiation dose to the mastication muscles, with a  steep dose-response curve. Onset is typically 2-6 months post treatment and is ongoing. Concurrent chemotherapy may increase the  incidence and/or severity of mandibular immobility (Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 1999;88:365-73).

In the Vanderbilt survey, most patients reported burning in the throat or mouth (69); sensitivity to hot, spicy, or acid food (67);  sensitivity to dryness (69); and changes in food intake because of mucosal sensitivity (67); most patients also reported that mucosal  sensitivity prevents tooth brushing (63). “Mucosal sensitivity is a quality of life issue,” Dr. Epstein said.

The Vanderbilt survey was particularly illuminating, Dr. Epstein commented. Studies that utilize claims data probably underrepresent  the problem of long-term oral complications because dental and medical insurance are separate and the data are not easily combined, he added.

“Late oral effects are best diagnosed [and] managed in a multidisciplinary team with close communication between medical and  dental providers. … We really need to come together.”

The Multinational Association of Supportive Care in Cancer is developing tools to improve communication between dentistry and  medicine. These could be available for beta testing as early as this fall.

Dr. Epstein said he had no relevant financial disclosures.

This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.

 

March, 2012|Oral Cancer News|

IMRT provides better QOL in head and neck cancers

Source: www.oncologyreport.com/
AUthor: Miriam E. Tucker

Intensity-modulated radiotherapy is more expensive than 3-D–conformal radiotherapy is and has not been shown to improve standard outcomes in patients with head and neck cancer. But it results in better quality of life. These findings from two studies presented at the Multidisciplinary Head and Neck Cancer Symposium raise the question: Does improved quality of life justify the greater expense of intensity modulated radiotherapy (IMRT), which has been rapidly adopted for the treatment of head and neck cancer?

Because IMRT spares surrounding tissues, it reduces the likelihood of developing xerostomia, noted Dr. Nathan C. Sheets, who presented data on billing charges associated with IMRT, compared with 3-D–conformal radiotherapy (CRT). IMRT is reimbursed at a substantially higher level than CRT, however, and it is unclear how to assess this cost relative to other aspects of care in this population, said Dr. Sheets, a radiation oncology resident at the University of North Carolina, Chapel Hill.

A separate study presented by Dr. Allen M. Chen compared quality of life in patients who received IMRT vs. CRT. “There’s very little data to suggest IMRT is better than non-IMRT using traditional end points. But the question is: How do you define ‘better’?” said Dr. Chen, director of the radiation oncology residency training program at the University of California, Davis in Sacramento.

“IMRT might not particularly involve better cure rates, but it could make a difference in terms of other end points, such as quality of life, which we all know is very important to patients,” he said.

Gap Ranges from $5,000 to $6,000
The cost study analyzed data for 184 patients who had received definitive radiation therapy for head and neck squamous cell cancer at the University of North Carolina at Chapel Hill during 2000-2009 and for whom billing records were available.

The median year of treatment was 2004 for 89 patients treated with CRT, and 2007 for 95 IMRT patients, reflecting the shift to use of IMRT over time. The majority of patients – 87% of CRT and 94% of IMRT – received concurrent chemotherapy. More IMRT patients received positron emission tomography (PET) scans at any point (69% vs. 37%).

Over 36 months’ follow-up, locoregional control was nearly identical for the two patient groups (P = .73). Mean total costs, from the time of diagnosis through the first year of follow-up, were considerably higher for IMRT, at $50,502 vs. $38,977 for CRT. Outpatient costs accounted for the bulk of the difference ($35,418 IMRT vs. $22,696 CRT), whereas inpatient costs were similar, Dr. Sheets reported.

Multivariate analysis showed that factors associated with increased cost of radiotherapy included IMRT, recurrent disease, comorbidities, non-white race, and use of positron-emission scanning. After adjustment for inflation, each of these factors, including IMRT, independently increased the total cost by approximately $5,000-$6000. (Treatment failure was much more expensive, contributing about $14,274 to the total cost.)

Dr. Sheets ended his presentation with the question, “Do the benefits of IMRT outweigh the costs?”

QOL Improves Over 2 Years’ Follow-up
Dr. Chen’s quality of life study addressed that question. The study used the University of Washington Quality of Life instrument (UW-QOL), a previously validated, self-administered questionnaire given to patients returning for follow-up after completion of radiation therapy for head and neck cancer. The University of California, Davis, routinely uses the measure in clinical practice.

Scores on the UW-QOL were retrospectively reviewed for 155 patients with squamous cell carcinomas of the head and neck requiring bilateral neck irradiation for locally advanced disease. Only patients who were clinically without evidence of recurrent disease and with at least 2 years of follow-up were included in the analysis. Definitive radiation therapy was given to 82 patients (53%), while 73 (47%) underwent postoperative treatment.

IMRT was used in 84 patients (54%), with inclusion of the low neck in an extended field. The remaining 71 patients (46%) were treated with 3-D–CRT using opposed lateral fields matched to a low anterior neck field. Concurrent chemotherapy was administered with radiation therapy for 73 patients (47%).

The mean global quality of life scores for the IMRT patients were 67.5 at 1 year and 80.1 at 2 years, compared with 55.4 and 57.0, respectively, for the CRT patients (P less than .001). At 1 year after completion of radiation therapy, the proportion of patients who rated their global quality of life as “very good” or “outstanding” 51% of the IMRT patients, compared with 41% of those treated with CRT (P = .11).

Those numbers became statistically significant at 2 years, with “very good” or “outstanding” quality of life reported by 73% of the IMRT patients and 49% of the CRT group (P less than .001). At last follow-up, 80% of patients treated by IMRT reported that their health-related quality of life was “much better” or “somewhat better,” compared with the month before developing cancer, compared with 61% among patients treated by 3-D–CRT (P less than .001).

On multivariate analysis accounting for gender, age, radiation intent (definitive vs. postoperative), radiation dose, T stage, primary site, use of concurrent chemotherapy, and neck dissection, the use of IMRT was the only variable independently associated with improved quality of life (P = .01).

In 1- and 2-year analyses of factors contributing to the difference in UW-QOL score, only “saliva” was found to be significantly different between IMRT and CRT (P less than .001) for both time points. Other examined factors that did not affect the score included pain, appearance, activity, recreation, chewing, swallowing, speech, mood, and anxiety.

“Treatments for dry mouth are fairly primitive and ineffective at present, so preventing dry mouth is so critical. It’s a huge problem. Imagine not being able to make any saliva. And, there are health consequences with respect to things like oral hygiene and dental caries. There’s a cost associated with chronic dry mouth,” Dr. Chen said in the interview.

Increased Cost Not That Big
The increase in cost with IMRT isn’t that big, Dr. Bhisham Chera, the principal investigator for the cost study and a radiation oncologist at the University of North Carolina said in an interview.

“On average, it was about $5,000-$6,000 more total,” he said. “It is more expensive, but what was shocking to me is that it wasn’t much more expensive as some therapies – like newer chemotherapy drugs, compared to older ones, where there’s a hundred thousand dollar difference in cost and the survival improvement is only a few months.”

“We think the incremental increase in cost is justified because of the improvement in dry mouth. If you really compare it to other therapies such as using transperineal prostatectomy vs. robotic prostatectomy or cisplatin vs. cetuximab chemotherapy, the cost difference is vastly greater,” he added. “Here, the incremental difference is not that much. It is more expensive, but it’s not astronomically more expensive.”

Note: Dr. Sheets, Dr. Chen, and Dr. Chera all stated that they had no disclosures.

February, 2012|Oral Cancer News|

Review Finds Evidence Lacking for Dry Mouth Remedies

Source: Medscape Today

December 28, 2011 — There is not enough evidence to recommend any topical therapies for dry mouth, but that does not mean that they do not work, according to investigators who published a review of research on the therapies online December 4 in the Cochrane Library.

“There was very little evidence,” said Helen Worthington, PhD, a professor of evidence-based care at the University of Manchester, United Kingdom.

Dr. Worthington and colleagues scoured the literature for randomized controlled trials of topical therapies for dry mouth, or xerostomia. They found 36 studies of treatments such as lozenges, sprays, mouth rinses, gels, oils, chewing gum, and toothpaste.

Xerostomia often results from treatments for head and neck cancer that damage the salivary glands, as well as from Sjögren’s syndrome, an autoimmune disorder that also damages these glands. It is also a common adverse effect of many medications.

The authors cite an estimated prevalence of dry mouth of about 20% in the general population. This percentage may be increasing because people are living longer and suffering from more chronic illnesses for which the treatments can have xerostomia as an adverse effect.

It is possible to feel the sensation of dry mouth without having a clinically reduced saliva flow, the researchers point out.

The treatments in the review broke down into 2 broad categories: saliva substitutes, in which some other substance is intended to perform the role of the patient’s own saliva, and saliva stimulants, which are intended to activate the patient’s own mechanism for producing saliva.

Two of the trials compared saliva stimulants with placebos, 9 compared saliva substitutes with placebos, 5 compared saliva stimulants with saliva substitutes, 18 compared 2 or more saliva substitutes with each other, and 2 compared 2 or more saliva stimulants with each other.

The researchers found convincing evidence that 1 saliva substitute, oxygenated glycerol triester saliva spray, was more effective than another, an electrolyte spray (standardized mean difference, 0.77; 95% confidence interval, 0.38 – 1.15). This corresponded to an approximate mean difference of 2 points on a 10-point visual analog scale in which patients rate their mouth dryness.

However, this evidence did not actually prove that either substitute was useful for treating dry mouth, Dr. Worthington said.

The researchers concluded that an integrated mouth care system (toothpaste, gel, and mouthwash) looked promising, as did oral reservoir devices. Here again, however, the evidence was not quite strong enough to recommend either one.

Asked to comment on the review, Joel Napeñas, DDS, a specialist in saliva disorders at Carolinas Medical Center in Charlotte, North Carolina, told Medscape Medical News that it is still possible to treat dry mouth despite the lack of evidence for a particular therapy.

“There are a lot of nonrandomized controlled trials that do show variable results,” said Dr. Napeñas, who was not involved in the Cochrane review. “Since there is no strong evidence for any individual agent, we are left with trial and error on an individualized basis.”

Dr. Napeñas begins by measuring saliva flow: He has the patient spit into a cup and then asks the patient to suck on something like a piece of wax and spit again to see whether the sucking action increases the patient’s saliva flow.

If the saliva flow increases, this suggests that saliva stimulants may work. Barring contraindications, therefore, Dr. Napeñas prescribes systemic saliva stimulants, usually pilocarpine or cevimeline, often in combination with topical stimulants.

If the experiment does not increase saliva flow, Dr. Napeñas instead recommends various saliva substitutes. He also typically recommends that patients try a variety of topical therapies to see what works best. “Biotene-type products are some of the first we would go to,” he said.

Frequently sipping water and sucking on ice can help many patients, he said. He advises patients to avoid caffeine and alcohol, which can worsen symptoms, and he pointed out that patients with xerostomia should avoid many commercial mouth rinses because they contain alcohol.

Dr. Napeñas also initiates preventive measures to prevent caries, including topical fluoride, prescription fluoride products, and frequent recalls, because patients with low saliva flow are at high risk for caries.

“It’s a very difficult condition to treat,” he said. “The way I approach it is to throw everything I can at it.”

This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.

December, 2011|Oral Cancer News|

Consider dental issues before beginning cancer treatment

Soure: www.curetoday.com/
Author: Lacey Meyer

Dentists advise resolving tooth and gum issues before starting cancer treatment.

Bettye Davis admits she has never had very good teeth. But when she received a diagnosis of salivary gland cancer, she was surprised that her oncologist recommended she visit a dentist before beginning radiation treatments to her jaw.

“When we first saw her, she still had quite a few teeth, but she had severe periodontal disease and severe bone loss,” says Dennis Abbott, DDS, Davis’ dentist. Knowing radiation would do more damage, he recommended removing the remainder of her teeth and allowing time to heal before she began 33 radiation treatments.

“We knew that if we took the teeth out after radiation, we risked the bone not healing well, which would have meant osteonecrosis, dead bone in her mouth, and lots of systemic problems.”

According to the National Cancer Institute, eliminating pre-existing dental and mucosal infections and instituting a comprehensive oral hygiene protocol before and throughout therapy can reduce the severity and frequency of oral complications from cancer therapy. Abbott says the NCI recommendations, as well as an increasing number of studies, are bringing more recognition to the importance of dental issues before, during and after cancer treatment.

A Proactive Approach
Abbott’s goal is to help patients maintain healthy teeth and reduce the risk of future infection with an oral care plan that eliminates or stabilizes disease that could produce complications during or following therapy. These complications can range from irradiated bone and gums not healing properly to an oral bacterial infection spreading throughout the body due to chemotherapy-induced immunosuppression.

Radiation to the head and neck area can also cause severe dry mouth (xerostomia) and loss of the protective effects of saliva, which accelerates existing tooth decay and can damage tiny blood vessels in the bone that deliver nutrients and oxygen that allow the bone to grow. So any tooth extractions or invasive dental procedures in irradiated bone are likely to result in slow healing, leading to pain and infection.

Oral complications may be acute (developing during therapy) or chronic (developing or continuing long after therapy), with the most common and significant being oral mucositis (inflammation and ulcers in the lining of the mouth), salivary gland dysfunction, taste dysfunction, pain and dry mouth. Limited or no saliva can lead to increased risk of infections in the mouth, gum disease and dental disease, which can progress rapidly and be difficult to control.

Available medications to stimulate saliva production rely on residual salivary gland function, if enough function remains. Mouth gels, rinses and sprays can moisturize the mouth, but unlike natural saliva, they don’t contain antibodies; growth and repair factors; fluoride; and calcium phosphates that help keep teeth healthy and strong.

Abbott says this means patients must be proactive in caring for their teeth to prevent cavities. Topical antimicrobials or antiseptics can also help control infections, including dental decay related to acid-producing bacteria.

Oral Health and Overall Health
With radiation therapy directed at her salivary glands, Davis, 73, experienced extreme dry mouth, especially at night. But, she says, a mint-flavored antioxidant topical gel Abbott prescribed, AO ProVantage, effectively relieved this symptom. “It has really helped because it keeps your mouth refreshed, plus it helps you have more moisture in your mouth,” Davis says.

The decision to extract teeth prior to radiation, Abbott says, is based on the health of the tooth, the condition of the gums and bone around the tooth, the amount of radiation the bone around the tooth is scheduled to receive and the area that will be radiated. Gum disease is a cause for tooth extraction prior to therapy. Other causes include problems with previous root canals, tooth fractures and broken fillings that can’t be adequately restored.

“You can’t dismiss oral health because it affects systemic health,” Abbott says. “The mouth has a huge amount of bacteria, and if it’s not taken care of, there is the risk of that bacteria getting into the bloodstream.”

Catching Up to Get Ahead
The American Dental Association recommends all cancer patients schedule a dental exam at least two weeks before beginning treatment. This should involve a full comprehensive exam, gum probing around every tooth and X-rays. It may also include removal of local sites of irritation, such as broken teeth, or identifying chronic infections, such as gum disease.

“Those conditions need to be managed up front because we are very limited after treatment and the complication risk is so significant that not doing it before can lead to significant difficulties after,” says Joel Epstein, DMD, MSD, director of oral medicine services at City of Hope Cancer Center in Duarte, Calif.

Appropriate healing time for dental care prior to treatment is imperative, Epstein adds, because a surgically treated area in the mouth becomes vulnerable to bacteria. Patients with suppressed immune systems can develop infection, which could result in a treatment delay or dose reduction, ultimately affecting the treatment outcome and survival.

Epstein says two weeks of healing time is ideal, but the overall goal is to have the right dental treatment coordinated with medical therapy to avoid those types of risks. Therefore communication between the dentist and oncology team is key.

Dental Care During Treatment
Treating dental issues during cancer therapy is possible but can be difficult and can also lead to complications, such as infection in patients on immunosuppressing chemotherapy and delayed healing of affected oral tissue in patients receiving high-dose radiation.

If dental treatment is needed during a cycled chemotherapy, it must be coordinated between cycles and at a time when white cell counts are high, Epstein says.

For patients receiving radiation for head and neck cancers, the dentist needs to understand the risks for healing and communicate with the oncologist to understand which regions are involved in the radiation fields, Epstein says. The dentist should also be aware of any previous or ongoing bisphosphonate use and understand the associated risks.

“We function as a part of the oncology team for all of our patients,” Abbott says. “I understand the blood work that I get back, and I understand what it is that I need to look for in order to keep the patient safe and then develop my treatment plan around that.”

Preparation and Coordination
A less common but significant oral complication involves bone healing, or lack thereof. Because radiation can damage bone cells, limiting their ability to heal, any future trauma or surgery to irradiated bone can cause osteonecrosis, or bone death.

Bisphosphonates and the RANK ligand inhibitor Xgeva (denosumab)—used to maintain bone density and prevent fractures in people with bone metastases—have also been associated with increased risk for osteonecrosis of the jaw (ONJ), which can occur in 1 to 2 percent of patients on these therapies, according to a 2010 study published in the Journal of Clinical Oncology.

A study published in 2009 in Annals of Oncology showed that preventive dental measures can significantly decrease the risk of developing ONJ. In 2003 and 2004, the FDA updated inserts for the intravenous bisphosphonates Aredia (pamidronate) and Zometa (zoledronic acid) recommending a dental exam with preventive dentistry prior to cancer treatment.

“The main prevention is treatment of the at-risk dental conditions before you’ve had a long-term effect on the bone,” Epstein says. The FDA also warns against invasive dental procedures if possible during or following bisphosphonate use, noting that the majority of reported cases of ONJ have been associated with dental procedures, such as tooth extraction, and many had signs of local infection.

Whether a tooth is extracted from an irradiated area or following bisphosphonate use, Epstein says it must be done carefully. “You want a specialist surgeon to do that with coordination with the cancer center and with people who have supported this need before.”

Therapies Making “A Huge Difference”
After her diagnosis of metastatic renal cell carcinoma in 2009, Linda Morris had two extractions before starting Zometa. When an exposed jaw area wouldn’t heal, she developed osteonecrosis. After visiting six dentists over two years, the 67-year-old saw Abbott.

To prevent infection, Abbott had her apply AO ProVantage twice daily and rinse her mouth with non-alcoholic antibacterial chlorhexidine, as well as clean her teeth with a water flosser. To promote healing, Abbott removed necrotic tissue and performed a comprehensive cleaning every two weeks. For the first time, Morris began to see progress.

“The biggest problem I had was not being able to find the dental care I needed,” Morris says.

“The topically applied gel has made a huge difference in how we can treat this problem,” Abbott says. “We’ve had two cases where the necrotic bone has been totally resolved.”

December, 2011|Oral Cancer News|

Acupuncture can prevent radiation-induced chronic dry mouth

Source: http://www.virtualmedicalcentre.com
Author: staff

When given alongside radiation therapy for head and neck cancer, acupuncture has shown for the first time to reduce the debilitating side effect of xerostomia, according to new research from The University of Texas MD Anderson Cancer Center and Fudan University Shanghai Cancer Center.

The study, published in the journal Cancer, reported findings from the first randomised controlled trial of acupuncture for the prevention of xerostomia.

Xerostomia, or severe dry mouth, is characterised by reduced salivary flow, which commonly affects patients receiving radiotherapy for head and neck cancer. Most current treatments are palliative and offer limited benefit, according to Lorenzo Cohen, Ph.D., professor in MD Anderson’s Departments of General Oncology and Behavioral Science and director of the Integrative Medicine Program.

The condition impairs quality of life for patients, as it creates difficulties eating, speaking and sleeping, while also increasing the risk for oral infections.

“There have been a number of small studies examining the benefits of acupuncture after xerostomia develops, but no one previously examined if it could prevent xerostomia,” said Cohen, who is also the study’s principal investigator. “We found incorporating acupuncture alongside radiotherapy diminished the incidence and severity of this side effect.”

Cohen and his colleagues examined 86 patients with nasopharyngeal carcinoma, treated at Fudan University Shanghai Cancer Center. Forty patients were randomised to acupuncture and 46 to the standard of care. Those in the treatment arm received acupuncture therapy three times per week during the seven-week course of radiotherapy. Patients were evaluated before radiotherapy, weekly during radiotherapy, and then again one and six months later.

The results were based on data derived from two self-report questionnaires and measuring actual saliva flow. Patients completed the Xerostomia Questionnaire (XQ), an eight-item survey which assessed symptoms consistent with the condition. XQ scores under 30 corresponded to mild or no symptoms of xerostomia.

The second measure, MD Anderson Symptom Inventory Head and Neck (MDASI-HN), ranked the severity of cancer-related symptoms, other than xerostomia, and their interference with quality of life. The team also measured saliva flow rates using standardised sialometry collection techniques.

Benefits Noticed Quickly

“What was quite remarkable was that we started to see group differences as early as three weeks into radiotherapy for the development of xerostomia, cancer-related symptoms that interfere with quality of life, and saliva flow rates – an important objective measure,” said Zhiqiang Meng, M.D., Ph.D., co-principle investigator of the study and deputy chair of the Department of Integrative Oncology, Fudan University Shanghai Cancer Center.

The largest group differences in XQ scores were seen by the end of radiotherapy, but the differences persisted over time. By one month after the end of radiotherapy, 54.3 percent of the acupuncture group reported XQ scores greater than 30, compared to the control group at 86.1 percent. By six months after radiotherapy, the numbers dropped to 24.1 percent in the acupuncture group and 63.6 percent of the control group still reporting symptoms of xerostomia. Saliva flow rates were also greater in the acupuncture group, starting at three weeks into radiotherapy and persisting through the one and six month follow-up.

Acupuncture also helped cancer-related symptoms, other than xerostomia, as measured by the MDASI-HN questionnaire, with differences that emerged in week three and continued through six months.

“The medical implications are quite profound in terms of quality of life, because while chronic dry mouth may sound benign, it has a significant impact on sleeping, eating and speaking,” Cohen said. “Without saliva, there can be an increase in microbial growth, possible bone infection and irreversible nutritional deficits.”

Additional studies are needed to determine the mechanisms for the benefits of acupuncture, and while the study didn’t examine this issue, Cohen said it may have an impact on local blood flux, specifically at the parotid gland.

Further research is planned, including a large trial conducted at MD Anderson in collaboration with Fudan University Shanghai Cancer Center. Both centers will enroll 150 patients undergoing radiotherapy for head and neck cancer: 50 will receive acupuncture, 50 sham acupuncture and 50 will be enrolled in a control group. Researchers will also examine saliva constituents and a number of other measures to better determine the mechanisms of acupuncture.

Source: MD Andersen Cancer Center: Cancer

November, 2011|Oral Cancer News|

Proper dental care for cancer patients: why it is important

Source: newcanaan.patch.com
Author: Alan B. Sheiner DDS

Common side effects from radiation therapy are not stressed enough in dental schools, but they can be managed and even prevented.

A few weeks ago, I was contacted by a retired physician with whom I had not spoken for a number of years since he retired from practice to become a “gentleman farmer” in the country. While I was happy to hear from him, his news was not so good. He was calling because he had been treated for base of tongue cancer and his teeth were “coming apart”. His cancer treatment consisted of chemotherapy and radiation therapy. Unfortunately, he somehow “slipped through the cracks” and his oral cavity was now suffering from some of the side effects of the cancer therapy – fortunately he is currently cancer free.

The oral cavity, one of the most complex and visible organ systems in the body, is invariably compromised as a result of treatment for head and neck cancer. Whether the malignancy is to be treated by surgery, radiation therapy, chemotherapy or a combination of these modalities, the function, if not also the form, of the oral cavity will be impacted. Aside from the obvious physical changes after cancer surgery to the head and neck region, there are issues which usually accompany radiation therapy to the head and neck region.

There may be side effects from cancer therapy, some of which can be devastating, but preventable or manageable with proper precautions and care. The most common side effects for head and neck cancer patients who undergo radiation therapy are:

Dry Mouth (xerostomia)
Post Radiation Tooth Decay
Inability to open the mouth wide (Trismus)
Necrosis of soft tissue and bone (osteoradionecrosis)
Impaired ability to heal from wounds in the oral cavity

Prior to commencement of active treatment, each patient should be thoroughly evaluated by a dentist well versed in the management and care of the irradiated head and neck cancer patient. Unfortunately, this subject has not been stressed in dental school. Even if a dentist has had some instruction, his or her clinical experience might be quite limited. A real life example of this is a lady irradiated for a parotid gland tumor. The parotid gland (we have two) is a major salivary gland. Her general dentist provided her with fluoride applicators, but unfortunately this practitioner did not appreciate the importance of using a neutral pH fluoride gel. The acidulated fluoride gel, normally used when a dentist or hygienist gives a fluoride treatment, literally ate into the surfaces of this woman’s porcelain crowns. Now, in addition to having a dry mouth from radiation, she also has multiple crowns with surfaces like sandpaper. These expensive restorations could not be salvaged and required replacement. In short, the dentist remembered that radiated patients should have daily fluoride treatment. He just did not have a genuine understanding of how to accomplish the task properly.

The most common and profound side effects of irradiation to the head and neck region are: dry mouth (since the major salivary glands are almost always damaged by the therapy), post-irradiation dental caries (a preventable situation), the risk of osteoradionecrosis (non-healing chronic bone death in irradiated bone which has a compromised blood supply) and trismus (an inability to open the mouth fully).

As always, your dentist is the best resource and first person you should see for consultation.

October, 2011|Oral Cancer News|