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Evidence-Based Interventions for Cancer Treatment-Related Mucositis: Putting Evidence Into Practice

Evidence-Based Interventions for Cancer Treatment-Related Mucositis: Putting Evidence Into Practice - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Nursing Practice Guidelines











Guideline Title: Evidence-Based Interventions for Cancer Treatment-Related Mucositis: Putting
Evidence Into Practice
Effective Date: October, 2017
Approved By: Nursing Practice Guidelines Committee; Nursing Practice Council

I. Guideline Overview

Mucositis is an inflammatory process that affects the mucous membranes of the oral cavity and gastrointestinal
tract. ONS PEP resources focus on oral mucositis, which is estimated to occur in about 40% of patients secondary
to chemotherapy and almost 100% of those receiving radiation for head and neck cancer. Approximately 80% of
those undergoing hematopoietic stem cell transplantation will experience some level of oral mucositis. Oral
mucositis can range in degree from mild changes in sensation to severe oral pain, infection, and ulcerative bleeding
lesions. As a result of oral mucositis, patients can also experience anorexia, dehydration, weight loss, and
malnutrition because of difficulty eating and drinking.

Oral mucositis is a dose-limiting side effect of cancer treatment, with more than one-third of patients discontinuing
treatment because of the condition. Oral mucositis can be costly as well, necessitating hospitalization in 62% and
tube feedings in 70% of patients with this symptom.

Implications for Practice
• Assess for oral mucositis with a valid and reliable instrument as an initial step for prevention and
management.
• Develop evidence-based oral care protocols as the foundation for cancer-related mucositis care.
• Teach oral cavity self-management techniques for mucositis to patients and family members.

For more information, please see the complete guideline and the Oncology Nursing Society’s Putting Evidence Into
Practice (PEP) Mucositis website

II. Practice Recommendations


Agent Findings Studies Reviewed
Cryotherapy Topical application: ice water, ice
cubes, ice chips or ice lollipops
during chemotherapy infusion
Reduced symptoms, incidence,
severity and pain associated with
mucositis for patients receiving
chemotherapy agents with a short
half-life
Aisa et al., 2005; Karagözoglu & Filiz Ulusoy,
2005; Katranci et al., 2012; Kwong, 2004;
Lilleby et al., 2006; Migliorati et al., 2006; Mori
et al., 2006, 2008; Nikoletti et al., 2005;
Papadeas et al., 2007; Peterson et al., 2010;
Salvador et al., 2012; Svanberg et al., 2010;
Vokurka, Bystricka, et al., 2011; Worthington et
al., 2011
Oral care protocols To provide consistent frequent oral
hygiene, prophylactic mouth rinses,
and routine assessment for early
detection Decreased the incidence,
duration, and severity of mucositis
Structure and components of oral
care are important
Bhatt et al., 2010; Caplinger et al., 2010; Cheng
et al., 2001; Dodd et al., 2000; Hogan, 2009;
Kwong, 2004; McGuire et al., 2013; Peterson et
al., 2011; Qutob et al., 2013; Shih et al., 2002;
Yamagata et al., 2012
Sodium bicarbonate
mouth rinses
Shown to be effective in systematic
reviews
Potting et al., 2006; Shih et al., 2002


Recommended for Practice


University of Wisconsin Hospitals and Clinics
Nursing Practice Guideline At-a-Glance


Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Last Revised: 10/2017EArsenaultknudsen@uwhealth.org
Agent Findings Studies Reviewed
Prophylactic
Chlorhexidine mouth
rinses
Reduced incidence and pain
associated with oral mucositis in
three of five individual studies
Two systematic reviews reported
moderate support for prophylactic
use. Chlorhexidine is not
recommended as treatment for
existing mucositis.
Cheng et al., 2001, 2004; Dodd et al., 2000;
Donnelly et al., 2003; Pitten et al., 2003; Qutob
et al., 2013; Sorensen et al., 2008
Agent Remarks Studies Reviewed
Amifostine IV Seven studies
A systematic review showed
conflicting results, but associated
guidelines suggest use of amifostine.
Antonadou et al., 2002; Buentzel et al., 2006;
Gibson et al., 2013; Hwang et al., 2004;
Jantunen et al., 2002; Lorusso et al., 2003;
Nicolatou-Galitis et al., 2013a; Spencer et al.,
2005; Thieblemont et al., 2002
Glutamine (oral) Four RCTs
One retrospective study
Blijlevens et al., 2005; Cerchietti et al., 2006;
Peterson et al., 2006; Vidal-Casariego et al.,
2013; Ward et al., 2009
Honey (TA) Studies included children with low-
grade symptoms
Studies in adults showed mixed
results and had numerous design
limitations
Abdulrhman et al., 2012; Bardy et al., 2012;
Hawley et al., 2014; Jayachandran & Balaji,
2012; Maiti et al., 2012; Motallebnejad et al.,
2008; Rashad et al., 2009; Song et al., 2012;
Worthington et al., 2011; Yarom et al., 2013
Zinc or zinc
supplements
One systematic review and seven
individual studies
Arbabi-Kalati et al., 2012; Ertekin et al., 2004;
Lin et al., 2006, 2010; Mansouri et al., 2011;
Mehdipour et al., 2011; Sangthawan et al.,
2013; Yarom et al., 2013
Agent Remarks Studies Reviewed
Chlorhexidine
(nonprophylactic)
Did not improve existing mucositis
and is not recommended in
guidelines or systematic reviews for
adults or children
Nashwan, 2011; Niscola et al., 2009; Peterson
et al., 2010; Potting et al., 2006; Shih et al.,
2002; Worthington et al., 2011
A complete list of recommendations are found in the complete guideline and the Oncology Nursing Society’s Putting
Evidence Into Practice (PEP) Mucositis website
III. Pertinent Resources
A. Patient Education Resources
1. HFFY 4494: Cancer Related Treatment Mouth Sores: Mucositis
B. Clinical Tools
1. Mucositis Grading Scale
A. National Cancer Institute (2006). Gastrointestinal. Cancer Therapy Evaluation Program,
Common Terminology Criteria for Adverse Events, Version 3.0, DCTD, NCI, NIH, DHHS
March 31, 2003, p. 24. Retrieved from
https://ctep.cancer.gov/protocoldevelopment/electronic_applications/docs/ctcaev3.pdf
Likely to be Effective
Effectiveness not Established
Not Recommended for Practice

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Last Revised: 10/2017EArsenaultknudsen@uwhealth.org
2. Oncology Nursing Society’s Putting Evidence Into Practice (PEP) Mucositis website
IV. References
See full guideline document for complete list of references
Reference for full guideline: Eilers, J., Harris, D., Henry, K., & Johnson, L. A. (2014). Evidence-based interventions
for treatment-related mucositis: Putting evidence into practice. Clinical Journal of Oncology Nursing, 18(6), 80-96.
V. Rating Scheme For The Strength Of The Recommendations
Category Description
Recommended
for Practice:
Interventions for which effectiveness has been demonstrated by strong evidence
from rigorously-designed studies, meta-analyses, or systematic reviews, and for
which expectation of harms is small compared with the benefits
Likely to be
Effective:
Interventions for which the evidence is less well established than for those listed
under "recommended for practice"
Benefits
Balanced with
Harm:
Interventions for which clinicians and patients should weigh up the beneficial and
harmful effects according to individual circumstances and priorities
Effectiveness
Not
Established:
Interventions for which there are currently insufficient data or data of inadequate
quality
Effectiveness
Unlikely:
Interventions for which lack of effectiveness is less well-established than for those
listed under "not recommended for practice"
Not
recommended
for Practice:
Interventions for which ineffectiveness or harmfulness has been demonstrated by
clear evidence, or the cost or burden necessary for the intervention exceeds
anticipated benefit