NUTRITION INTERVENTIONS FOR ORAL MUCOSITISJUSTINE CHARLTON — MONTANA DIETETIC INTERN 2017-2018

OBJECTIVES

Understand the research that is available for nutrition interventions

Recognize the negative impact oral mucositis may have on a patient’s treatment and quality of life

WHAT IS MUCOSITIS?

¡ Effects the epithelial lining of the gastrointestinal tract (5,6,7,10)

¡ Common side effect of chemotherapy/radiation therapy (8,9,10)

¡ 40% of patients undergoing chemotherapy develop oral mucositis (9)

¡ 30-60% head and neck cancer patients treated with radiation develop oral mucositis (9)

¡ May lead to decrease tolerance of chemotherapy/radiation therapy (7,8,9)

¡ May lead to malnutrition and cachexia (1)

¡ Increased risk for infection (6,11)

¡ Economic impact (8)

WORLD HEALTH ORGANIZATION GRADING OF MUCOSITIS (8,12)

0. No oral mucositis

1. Painless ulcers, erythema, or mild soreness

2. Painful erythema, edema, or ulcers but can eat

3. Painful erythema, edema, or ulcers and cannot eat

4. Requires parenteral or enteral support

NCI COMMON TERMINOLOGY CRITERIA FOR ADVERSE EVENTS (8)

Clinical Grading (8)

¡ 1. Erythema of the mucosa

¡ 2. Patchy ulcerations of pseudomembranes

¡ 3. Confluent ulcerations or pseudomembranes; bleeding with minor trauma

¡ 4. Tissue necrosis; significant spontaneous bleeding; life-threatening

¡ 5. Death

Functional/Symptomatic (8)

¡ 1. Minimal symptoms, normal diet

¡ 2. Symptomatic but can eat and swallow modified diet

¡ 3. Symptomatic and unable to adequately aliment or hydrate orally

¡ 4. Symptoms associated with life-threatening consequences

¡ 5. Death

NUTRITION COMPLICATIONS

¡ Inadequate intake

¡ Unplanned weight loss

¡ Cancer patients with oral mucositis had >5% weight loss compared to those who did not have mucositis (8)

¡ Malnutrition

¡ Malnutrition occurs in 15% to 80% of all cancer patients (3)

¡ Decreased nutritional status can increase risk for developing oral mucositis(5)

¡ Malnourished patients are more likely to develop infections (3)

¡ Rate of infection during cycles with mucositis was more than twice compared to those without (8)

ECONOMIC IMPACT

¡ In a retrospective random study it was found:

¡ Patient’s hospitalized for solid tumors or lymphoma without mucositis cost: ~$3893 (8)

¡ Patient’s hospitalized for solid tumors/lymphoma with oral mucositis cost: ~$6277 (8)

¡ Patient’s hospitalized for solid tumors/lymphoma with both oral and GI mucositis cost: ~$9132 (8)

¡ In the same study an increase in severity of mucositis led to an increase in TPN days, among other increased needs (8)

¡ Total: an additional ~$25,000 in hospital charges due to mucositis (8)

NUTRITION CARE PROCESS

¡ Nutrition Assessment

¡ Nutritional status

¡ History of mucositis

¡ Oral hygiene prior to treatment

¡ Nutrition focused physical exam

¡ Nutrition Diagnosis

¡ Inadequate intake

¡ Unintended weight loss

¡ Inadequate calorie/protein intake

¡ Biting/Chewing (masticatory) difficulty

NUTRITION INTERVENTIONS

Meals and Snacks:Small frequent mealsEating warm/room temperature foodsSoft diet and liquid nutritional supplements (12)

Using a straw to avoid coming in contact with ulcersAvoid acidic foods i.e. tomatoes, grapes, apple juices, spicy foodsEnergy-modified diet

Collaboration with other providers: Gastrostomy tube placed prophylactically (8)

Enteral and Parental Nutrition (9)

Feeding Assistance: Mouth Care (6)

THERAPEUTIC INTERVENTIONS

¡ Cryotherapy(8)

¡ Topical vitamin E (11)

¡ Mouth wash combinations: saline, lidocaine + anesthetics (8)

¡ Recombinant human keratinocyte growth factor (KGF) (8,11)

¡ Palifermin

¡ Chemocare.com

MONITORING &EVALUATION

¡ BMI

¡ Weight

¡ Nutrition-focused physical findings:

¡ Subjective oral mucositis pain

¡ Muscle wasting, fat loss

¡ Food/beverage intake

¡ Enteral and parenteral nutrition intake

CONCLUSION

¡ Communicating with the patient and healthcare team- RDs may not be the first point of contact with a patient

¡ Knowing when to recommend and implement nutrition interventions

¡ Performing in a proactive manner

¡ Encouraging a good nutritional status prior to and during treatment

¡ There is a need for further research

HELPFUL RESOURCES:

CHEMOCARE.COMA.S.P.E.N.ACADEMY OF NUTRITION AND DIETETICS: ONCOLOGY NUTRITIONNATIONAL CANCER INSTITUTE

THANK YOU

QUESTIONS?

REFERENCES1. Aapro, M., Arends, J., Bozzetti, F., Fearon, K., Grunberg, S., Herrstedt, J., … Strasser, F. (2014). Early recognition of malnutrition and cachexia in the cancer patient: a position paper of a European School of Oncology Task

Force. Annals of Oncology, 25(8), 1492-1499. Doi: 10.1093/annonc/mdu085.

2. Arends, J., Bachmann, P., Baracos, V., Barthelemy, N., Bertz, H., Bozzetti, F., … Preiser, J.C. (2017). ESPEN guidelines on nutrition in cancer patients. Clinical Nutrition, 36 (1) 11-48. doi: https://doi.org/10.1016/j.clnu.2016.07.015

3. Bratton, S., & Iannotta, Jessica A, MS, RD,C.S.O., C.D.N. (2017). Nutritional interventions for managing adverse effects. Oncology Nurse Advisor, , 22-26. Retrieved from https://search-proquest-com.proxybz.lib.montana.edu:3443/docview/1973390471?accountid=28148

4. Chagas T.R., Borges D.S., de Oliveira P.F., Mocellin M.C., Barbosa A.M., Camargo C.Q. , Del Moral J.Â.G., Poli A., Calder P.C., Trindade E.B.S.M. & Nunes E.A. (2017) Oral fish oil positively influences nutritional-inflammatory risk in patients with haematological malignancies during chemotherapy with an impact on long-term survival: a randomised clinical trial. J Hum Nutr Diet. 30, 681–692 doi: 10.1111/jhn.12471

5. D. E. Peterson, R.-J. Bensadoun, F. Roila, On behalf of the ESMO Guidelines Working Group; Management of oral and gastrointestinal mucositis: ESMO Clinical Practice Guidelines, Annals of Oncology, Volume 22, Issue suppl_6, 1 September 2011, Pages vi78–vi84, https://doi.org/10.1093/annonc/mdr391

6. Georgiou, M., Patapatiou, G., Domoxoudis, S., Pistevou-Gompaki, K., & Papanikolaou, A. (2012). Oral Mucositis: understanding the pathology and management., 16(3), 215–216

7. Knox, J.J., Puodziunas A.L.V., Feld, R. (October 2000). Chemotherapy-Induced Oral Mucositis. Drugs & Aging, volume 17. pp 257-267. doi: https://doi-org.proxybz.lib.montana.edu:3443/10.2165/00002512-200017040-00002

8. Lalla, R.V., Sonis, S.T., Peterson, D.E. (2009). Management of Oral Mucositis in Patients with Cancer. Dent Clin North Am., 52 (1):61-viii. doi: 10.1016/j.cden.2007.10.002

9. Naidu, M. U. R., Ramana, G. V., Rani, P. U., Mohan, I. K., Suman, A., & Roy, P. (2004). Chemotherapy-Induced and/or Radiation Therapy-Induced Oral Mucositis—Complicating the Treatment of Cancer. Neoplasia (New York, N.Y.), 6(5), 423–431

10. National Institutes of Health. (May 29, 2012). R-CHOP, National Cancer Institute. Retrieved from: https://www.cancer.gov/about-cancer/treatment/drugs/R-CHOP

11. Negrin, R.S., Toljanic, J.A. (2017). Oral toxicity associated with chemotherapy. UpToDate. Retrieved from: https://www.uptodate.com/contents/oral-toxicity-associated-with-chemotherapy

12. Okada, T., Nakajima, Y., Nishikage T., Ryotokuji T., Miyawaki, Y., Hoshino, A., Tokairin, Y., Kawada, K., Nagai, K., Kawano T. (2017). A prospective study of nutritional supplementation for preventing oral mucositis in cancer patients receiving chemotherapy. Asia Pac J Clin Nutr, 26 (1): 42-48. doi:http://dx.doi.org.proxybz.lib.montana.edu/10.6133/apjcn.112015.03