Exploring Health Professionals' Perceptions and Clinical Manifestations of Chemotherapy and Radiation Therapy-Related Oral and Oropharyngeal Mucositis

Abstract

Background: Oral and oropharyngeal mucositis (OM) refers to inflammation caused by certain chemotherapy (CT) agents and radiation therapy (RT) to mucosal structures. CT-induced OM is usually a manifestation of widespread mucosal inflammation, whereas RT-induced OM only affects irradiated mucosa. Health professionals (HPs) caring for cancer patients may have varying understanding of OM. This may result in variations in assessment, management and patient outcomes.

Aims: 1) Determine HPs’ perceptions of oral mucositis, including clinical presentation of CT-induced vs RT-induced oral mucositis, its assessment and management. 2) Document differences in clinical manifestation of CT and RT-induced OM.

Methods: 2 studies were undertaken to address each aim respectively: Study 1: HPs involved in the care of head and neck cancer (HNC) patients receiving RT, and haematology patients receiving mucositis-inducing CT regimens were invited to participate in a custom 20-question online survey. Themes included oral mucositis presentation, assessment tools and management. Study 2: Clinical presentation of OM was mapped using a modified Oral Mucositis Assessment Scale (OMAS). Patients undergoing RT for HNC and receiving oral cavity/oropharynx irradiation, as well as haematopoietic stem cell transplantation (HSCT) patients undergoing mucositis-inducing CT were invited to participate.

Results: Study 1: The HPs survey had an 81.4% response rate. Most respondents were nurses (33%) and specialist doctors/dentists (25%). The majority identified as part of the Haematology (45%) or Radiation Oncology (32%) services. Most HPs (89% from haematology and 70% from radiation oncology) agreed/strongly agreed that oral mucositis impacted patients’ ability to complete treatment. There was a strong association (p<0.01) between HPs’ specialty and their perceptions of oral mucositis clinical manifestations. Most Radiation Oncology (85%) and all Oral Medicine HPs agreed/strongly agreed that clinical manifestations of CT-induced and RT-induced oral mucositis were different, whereas Haematology HPs varied in their perceptions (11% disagreed, 41% were neutral and 48% agreed/strongly agreed). There was uncertainty regarding differences in management of CT vs RT-induced oral mucositis: 30% of Haematology HPs and 45% Radiation Oncology HPs agreed/strongly agreed but most (52% and 45% respectively in each group) responded “neutral”.

Study 2: Although there was an increase in OMAS scores during treatment and decreasing back to baseline over time in both groups, the time course in which these changes occurred were different. There was a shorter duration for the CT group compared to the RT group. The maximum mucositis coverage score was higher in the RT group (5.50) compared to the CT group (3.06). All the highest OMAS scores occurred between days 10-12 post stem cell infusion for the CT group, and occurred at week 6 and week 8 for the RT group. OM developed predominantly on the non-keratinised mucosa for the CT group, whereas a greater portion of RT participants developed OM on keratinised mucosa (10% CT participants and 44% RT participants developed OM on keratinised mucosa).

Conclusions: Study 1: OM was recognised by HPs to adversely impact HSCT and HNC RT patients’ ability to complete treatment. There were differences in HPs’ perceived understanding of OM manifestations and management. Interventions to address these may reduce unwanted variations in patient care and outcomes, such as when HPs rotate between services or provide inter-disciplinary care. Study 2: Differences in clinical presentation of OM were observed between RT and CT groups including duration of OM, as well as OM location. Further data analysis may improve understanding of OM relating to its aetiopathogenesis, allow development of different management strategies between the RT and CT groups and ultimately optimise cancer treatment outcomes for patients.