Management of Mucositis Secondary to Cancer Therapy
Publication Date: July 1, 2020
Guidelines
Basic Oral Care
The panel suggests that implementation of multiagent combination oral care protocols is beneficial for the prevention of OM during CT. (Level III)
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The panel suggests that implementation of multiagent combination oral care protocols is beneficial for the prevention of OM during H&N RT. (Level III)
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The panel suggests that implementation of multiagent combination oral care protocols is beneficial for the prevention of OM during HSCT. (Level III)
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No guideline was possible regarding the use of professional oral care for the prevention of OM in patients with hematologic, solid, or H&N cancers because of limited and inconsistent data. (Level III)
- An expert opinion complements this guideline: Although there was insufficient evidence to support the use of professional oral care for OM prevention, the panel is of the opinion that dental evaluation and treatment as indicated before cancer therapy are desirable to reduce risk for local and systemic infections from odontogenic sources.
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No guideline was possible regarding the use of patient education for the prevention of OM in patients with hematologic cancer during HSCT or CT because of limited and inconsistent data. (Level III)
- An expert opinion complements this guideline: The panel is of the opinion that educating patients about the benefits of BOC strategies is still appropriate because this may improve self-management and adherence to the recommended oral care protocol during cancer treatment.
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No guideline was possible regarding the use of saline or sodium bicarbonate rinses in the prevention or treatment of OM in patients undergoing cancer therapy because of limited data. (Level III)
- An expert opinion complements this guideline: Despite the limited data available for both saline and sodium bicarbonate, the panel recognizes that these are inert, bland rinses that increase oral clearance, which may be helpful for maintaining oral hygiene and improving patient comfort.
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The panel suggests that CHX not be used in the prevention of OM in patients undergoing H&N RT. (Level III)
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Anti-inflammatory Agents
The panel recommends benzydamine mouthwash for the prevention of OM in patients with H&N cancer receiving a moderate dose RT (<50 Gy). (Level I)
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The panel suggests the use of benzydamine mouthwash for the prevention of OM in patients with H&N cancer who receive RT-CT. (Level II)
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Photobiomodulation
The panel recommends the use of intraoral PBM therapy using low-level laser therapy for the prevention of OM in adult patients receiving HSCT conditioned with high-dose CT, with or without TBI, using one of the selected protocols listed in Table 2. (Level I)
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The panel recommends the use of intraoral PBM therapy using low-level laser therapy for prevention of OM in adults receiving RT to the H&N (without CT) (Table 2); safety considerations unique to patients with oral cancer should be considered. (Level II)
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The panel recommends the use of intraoral PBM therapy using low-level laser therapy for the prevention of OM in adults receiving RT-CT for H&N cancer (Table 2); safety considerations unique to patients with oral cancer should be considered. (Level I)
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For all PBM guidelines, it is recommended that the specific PTPs of the selected protocol will be followed for optimal therapy. ()
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Cryotherapy
The panel recommends using oral cryotherapy to prevent OM in patients undergoing autologous HSCT when the conditioning includes high-dose melphalan. (Level II)
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The panel recommends using 30 min of oral cryotherapy to prevent OM in patients receiving bolus 5-FU CT during the infusion of the CT. (Level II)
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Antimicrobials, coating agents, anesthetics, and analgesics
Topical morphine 0.2% mouthwash is suggested for the treatment of OM-associated pain in patients with H&N cancer who receive RT-CT. (Level III)
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Sucralfate (combined topical and systemic) is not recommended for the prevention of OM-associated pain in patients with H&N cancer who receive RT. (Level II)
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Sucralfate (combined topical and systemic) is not recommended for the treatment of OM-associated pain in patients with H&N cancer who receive RT. (Level II)
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Sucralfate (combined topical and systemic) is not recommended for the treatment of OM-associated pain in patients with solid cancer who receive CT. (Level II)
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Growth factors and cytokines
The use of KGF-1 intravenously is recommended for the prevention of OM in patients with hematologic cancer undergoing autologous HSCT with a conditioning regimen that includes high-dose CT and TBI. (Level I)
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The evidence suggests that topical GM-CSF should not be used for the prevention of OM in patients undergoing HSCT. (Level II)
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Natural and miscellaneous
The panel recommends against the use of glutamine (parenteral) for the prevention of OM in patients undergoing HSCT. (Level I)
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The panel suggests oral glutamine for the prevention of OM in patients with H&N cancer who receive receiving RT-CT. (Level II)
- The suggestion is with caution because of the higher mortality rate seen in patients undergoing HSCT who receive parenteral glutamine.
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Honey is suggested for the prevention of OM in patients with H&N cancer who receive treatment with either RT or RT-CT. (Level II)
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Chewing gum is not suggested for the prevention of OM in pediatric patients with hematological or solid cancer who receive CT. (Level III)
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Gastrointestinal Mucositis
The panel suggests that probiotics containing Lactobacillus spp. may be beneficial for the prevention of RT-induced or RT-CT–induced diarrhea in patients with pelvic malignancy. (Level III)
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The panel suggests that hyperbaric oxygen is an effective way to treat RT-induced proctitis in patients with pelvic malignancy. (Level II)
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Table 2. Recommended Intraoral Photobiomodulation Therapy Protocols for the Prevention of Oral Mucositis
| Cancer Treatment Modality | Wavelength, nm | Power Density (Irradiance), mW/cm2 | Time per Spot, s | Energy Density (Fluence), J/cm2 | Spot Size, cm2 | No. of Sites | Duration |
|---|---|---|---|---|---|---|---|
| HSCT | 632.8 | 31.25 | 40 | 1.0 | 0.8 | 18 | From the d after cessation of conditioning for 5 d |
| 650 | 1000b | 2 | 2.0 | 0.04 | 54-70 | From the first d of conditioning to d + 2 post-HSCT (for 7-13 d) | |
| RT | 632.8 | 24 | 125 | 3.0 | 1.00 | 12 | Entire RT course |
| RT-CT | 660 | 417b | 10 | 4.2 | 0.24 | 72 | Entire RT course |
| 660 | 625b | 10 | 6.2 | 0.04 | 69 | Entire RT course |
5-FU, 5-fluorouracil; BOC, basic oral care; CHX, chlorhexidine; CT, chemotherapy; GM-CSF, granulocyte-macrophage colony–stimulating factor; Gy, grays; H&N, head and neck; HSCT, hematopoietic stem-cell transplantation; KGF-1, keratinocyte growth factor 1; LoE, level of evidence; OM, oral mucositis; PBM, photobiomodulation; PTPs, photobiomodulation therapy parameters; RT, radiotherapy; TBI, total body irradiation.
Recommendation Grading
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Overview
Title
Management of Mucositis Secondary to Cancer Therapy
Authoring Organization
Multinational Association of Supportive Care in Cancer
Publication Month/Year
July 1, 2020
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Female, Male, Adult
Health Care Settings
Ambulatory, Hospital, Long term care
Intended Users
Social worker, physician, nurse, nurse practitioner, physician assistant
Scope
Management
Diseases/Conditions (MeSH)
D052016 - Mucositis
Keywords
Mucositis, secondary cancer therapy, erythema, Oral mucositis
Source Citation
Elad, S, Cheng, KKF, Lalla, RV, Yarom, N, Hong, C, Logan, R M., Bowen, J, Gibson, R, Saunders, DP, Zadik, Y, Ariyawardana, A, Correa, ME, Ranna, V, Bossi, P; for the Mucositis Guidelines Leadership Group of the Multinational Association of Supportive Care in Cancer and International Society of Oral Oncology (MASCC/ISOO). MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer. 2020: 126: 4423– 4431. https://doi.org/10.1002/cncr.33100
Supplemental Methodology Resources
Methodology
Number of Source Documents
271
Literature Search Start Date
January 1, 2011
Literature Search End Date
June 30, 2016