Combination Prevention And Treatment Nursing Essay

Nelson Lung B. Sc.

This manuscript is original, is not under consideration by another journal, has not been previously published, and has been approved by all authors.

There are not conflicts of interest.

The occurrence of mucositis is a very common side effect from chemotherapy and radiotherapy in cancer patients. Around 40% of patients that receive standard-dose chemotherapy and up to 100% of patients getting high-dose chemotherapy and hematopoietic stem cell transplantation (HSCT) or radiation for head and neck cancer can develop mucositis <1>. Gastrointestinal (GI) mucositis is associated with many symptoms which include pain, ulceration, abdominal bloating, nausea and vomiting, diarrhea and constipation. This can then lead to a decreased dose or worse yet a discontinuation in treatment which can reduce the likelihood of curing the patient. Furthermore, this can cause further strain on the healthcare system and patient’s quality of life by increasing hospitalization, increasing cost of treatments, use of opioids for pain management, increased chance of infection and increase of morbidity and mortality in general <1>.

There are many factors that may predispose a person to developing mucositis. The obvious one would be treatment-related which include the type, intensity, area of the body and route of delivery of cancer therapy that patients were to receive. Additionally when there is a combination of therapies, it appears to increase the chance and severity of mucositis as well. Patient-related risk factors include non-modifiable risk factors like genetic polymorphisms, age and gender; where younger and female patients are more susceptible to developing mucositis. There are also modifiable factors like malnutrition. Compared to oral mucositis, GI mucositis is harder to visualize and thus harder to assess and treat. There is a World Health Organization (WHO) scale for oral mucositis and the National Cancer Institute (NCI) has a scale for Common Terminology Criteria for Adverse Events (CTCAE) to grade the severity of oral mucositis where oral symptoms and signs of functional disturbances are noted <1>. GI mucositis can’t be directly observed and can only indirectly be measured by outcomes of mucosal injury like diarrhea. However there can be many confounding factors that cause diarrhea. Therefore any new drug or indication for an old drug for the prevention or treatment for GI mucositis that proves useful is crucial.

The last update to the clinical practice guidelines for prevention and treatment of cancer therapy-induced oral and mucositis was in September 2011. Since then there has been more studies that have looked at the effectiveness of new modalities, further studies on current agents in guidelines to see if they should be revised as well as research on previously inconclusive strategies to see if new guidelines can be made for them. In general, basic bowel care is recommended in all patients which includes proper hydration and consideration of the possibility of temporary lactose intolerance and presence of pathogens when receiving treatment <1>.

Combination prevention and treatment

For prevention of GI mucositis in concomitant chemotherapy and radiotherapy the only previous guideline was for the use of IV amifostine for the prevention of esophagitis in patients getting combination therapy for nonsmall cell lung carcinoma <1>. There have been a few studies that both support and conflict with this guideline. Koukourakis et al. showed 65% of the 31 patients were able to tolerate amifostine which supports the guidelines <2>. Hans et al. compared amifostine with epoetin-alpha where amifostine was associated with greater side effects. However the trial size was only 76 patients. Additionally, of the 76 patients, 36 were assigned to amifostine and 40 to epoetin-alpha but due to a lack of supply of amifostine, 15 of the 36 did not receive treatment <3>. Movsas et al. had 243 patients in their trial; 120 received amifostine, 122 did not. Amifostine was associated with higher rates of acute nausea, vomiting, cardiovascular toxicity, infection or febrile neutropenia without any significance in reducing esophagitis <4>. Therefore because of the small sample sizes amifostine is still recommended in this setting. There has been more research into probiotic treatment especially those with Lactobacillus spp. to help prevent diarrhea in patients with pelvic malignancies. Although a certain dose has not been determined yet, three randomized control studies with moderately sized patient populations <5-7> showed that patients treated with probiotics had significantly less episodes of diarrhea as well as lower severity than those that were not.

Radiotherapy prevention and treatment

In the prevention in those receiving just radiotherapy 500 mg sulfasalazine oral twice a day showed benefit in preventing and decreasing the severity of radiation-induced enteropathy in patients receiving external beam radiotherapy in the pelvic region. IV amifostine at a dose ≥ 340 mg/m2 prior to radiotherapy was also shown to prevent radiation proctitis in those with rectal cancer. Not recommended are oral sucralfate which actually could cause more rectal bleeding and 5-amino-salicylic acid and related compounds which could possibly cause more diarrhea <1>. There is a new guideline regarding misoprostol suppositories which state that they should not be used to prevent acute radiation-induced proctitis since it did not show any difference in efficacy in prostate patients and had significantly more rectal bleeding <8, 9>. Something that will require more research into is the treatment of patients depending on their circadian rhythm to minimize toxicity. A single and decent sized trial showed that patients treated in the morning compared to the evening had significantly worse mucositis overall. Additionally, there was no difference in patient response to treatment which is very crucial <10>. Since this was just one trial, a guideline cannot be created yet but it shows promise.

The single recommended treatment for GI mucositis caused by chronic radiation induced proctitis and who have rectal bleeding are sucralfate enemas. There however have been numerous studies that shows hyperbaric oxygen may be used to help treat radiation-induced proctitis. Although cost may be an issue, many studies have shown that it has aided in the resolution of radiation induced proctitis <11>.

Chemotherapy prevention and treatment

Ranitidine or omeprazole orally is recommended for the prevention of epigastric pain after standard dose of cyclophosphamide, methotrexate and 5-FU or just 5-FU with or without folinic acid <1>. Previously, glutamine was not recommended due to severe toxic effects however due to a few new randomized double blinded control trials have come out that did not show this toxicity and efficacy. However the trials were small so a definite change to recommend glutamine can still not be made. Blijlevens et al. showed that patients receiving stem cells transplants and received glutamine parenterally had better gut scores <12>. Sornsuvit et al. showed that those on glutamine parentally could maintain their nutritional status <13>. Finally Li et al. showed that glutamine helped avert intestinal permeability and symptoms of GI toxicity <14>.

To treat diarrhea induced by standard or high dose chemotherapy related to HSCT, at least 100 ug of octreotide SC twice a day can be used if loperamide fails <1>. There have not been any new strong trials that suggest a particular agent can be used in this category.

As you can see, after 2 years, there has only been enough evidence to really affect four guidelines. Glutamine is no longer not recommended however a guideline regarding its use cannot be determined due to conflicting studies. Hyperbaric oxygen can help prevent acute radiation-induced proctitis. Misoprostol suppositories are not recommended to prevent acute radiation induced proctitis. And finally probiotics with Lactobacillus spp. are suggested to be beneficial in preventing chemotherapy and radiotherapy-induced diarrhea when treating a pelvic malignancy.