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The Scope of the Problem
Over the past two decades, advances in the supportive care of oncology patients have permitted more aggressive treatment strategies that would otherwise not have been possible. However, the prevention and treatment of oral mucositis (OM) remains a dilemma. The American Cancer Society in 1999 estimated that approximately 400,000 patients annually will experience some type of oral complication as a result of their cancer treatment.1 The tissue trauma and associated pain of OM were identified as major clinical problems as far back as the 1970s, yet they remain a significant concern for the majority of patients undergoing cancer treatments.2 The National Cancer Institute estimated in 2005 that almost 100% of patients receiving radiation therapy for head and neck cancers experience OM, as do 80% of patients undergoing hematopoietic stem cell transplantation and 40% of patients receiving standard-dose chemotherapy.3
Most patients who have experienced OM report that it is the most bothersome side effect of their cancer treatment. OM is a multifaceted problem that can lead to a number of clinical complications. It can manifest itself in various ways, but pain is the hallmark symptom and may be the first indication that OM is developing. The inability to eat and drink can lead to problems with maintaining nutrition and subsequent weight loss. It may be necessary for patients to have a feeding tube placed to ensure adequate nutrition. Pain can significantly impact a patient’s quality of life and trigger a cluster of symptoms including fatigue and depression. OM is a doselimiting side effect that may result in treatment delays, dose reductions, or the stopping of treatment altogether. It is essential to have strategies in place to manage the pain associated with OM.
Recently, a survey enquiring about several aspects of OM was conducted at the 32nd Annual Oncology Nursing Society (ONS) Congress, which was held April 24–27, 2007 in Las Vegas, Nevada. Respondents were asked to rank the significance of OM in their clinical setting and against other supportive care issues; indicate if they had specific guidelines for the management of OM; and list first- and second-line OM pain management interventions and rate their effectiveness. A five-point Lickert scale was used, with responses from ‘not important’ to ‘very important.’ Not surprisingly, 89% of the 558 respondents identified OM as a significant problem. Pain was the primary issue identified by 93% of the respondents as ‘most important’ to their patients, followed by pain on swallowing (87%) and difficulty speaking (73%). Nurses ranked OM very high (92%) relative to other supportive care issues faced by cancer patients. Nurses were overwhelmingly identified (81%) as the healthcare professionals responsible for the initial evaluation and management of OM in their practice setting. Fifty-seven percent of respondents reported that they did not have specific institutional guidelines in place for the management of OM. The survey revealed myriad products used as first- and second-line agents in the management of OM pain (see Table 1). The multi-agent rinse ‘magic mouthwash’ (pharmacy compounded), oral pain medications, and sucralfate were the primary management strategies used in an attempt to alleviate the pain caused by OM. The effectiveness of these first-line agents in relieving the pain of OM was dismal, with 67% of the respondents rating them as only minimally effective. These survey results are not surprising. They reinforce the fact that OM remains a significant clinical problem that is currently being treated with ineffective agents. Many nurses still do not have specific clinical guidelines to assist them in the management of OM.