https://doi.org/10.33698/NRF0227 -Bankerlin B.Lynser, Neena Vir Singh, Sukhpal Kaur
Abstract : Introduction : Oral mucositis is one of the common side effects of radiotherapy in patients of head and neck cancer. It is painful and also affects the quality of life and nutrition of most patients. Objective : To assess the predictors of radiotherapy induced mucositis. Methodology : A descriptive study was carried out. Thirty patient suffering from head and neck cancer and undergoing radiotherapy for the first time were enrolled in this study. The oral mucosa of the subjects was assessed by using the WHO oral mucositis grading scale. Four follow ups were done at the interval of five days. Results: The results indicated that 93.7% of the patients developed radiation induced oral mucositis. There is an association of gender, educational status, occupation, proposed duration of radiotherapy, planned radiotherapy fractions and total planned radiation dose (p<0.05) with development of Radiation induced Mucositis. It was seen that there is no association between oral hygiene with the Radiation induced mucositis (p>0.05). Conclusion: The predictors of Radiation induced oral mucositis are gender, educational status, occupation, proposed duration of radiotherapy, planned radiotherapy fractions and total planned radiation dose.
Keywords
Mucositis, Radiotherapy
Correspondence at
Neena Vir Singh
Lecturer
National Institute of Nursing Education (NINE) PGIMER, Chandigarh.
Introduction
Cancer is a disease in which the normal mechanisms for control of growth and proliferation of cells have been altered. The options for treatment include chemotherapy, radiotherapy and surgery, according to tumour type, stage and availability of resources. More than 60% of all patients with cancer receive radiation therapy or radiotherapy during the course of their disease. Radiotherapy uses high energy ionizing radiation in order to treat different types of cancers.1 A common complication of cancer treatment is mucositis. It significantly affects the mucosa.
Oral mucositisis often referred to the ulcerative and erythematous lesions of the oral mucosa, which is commonly seen in those patients undergoing treatment of cancer. It is painful and it also affects the quality of life and nutrition of most patients.2 Assessment of the oral cavity is very crucial for all patients in order to manage any oral complications. It can be assessed by using the oral assessment guide (OAG), the World Health Organization (WHO) grading scale, the cancer and leukemia group B (CALGB) assessment guide etc. These assessment tools have their own strengths and weaknesses. The WHO design proved to be the most relevant assessment scale for clinical management.3
Presently management of oral mucositis mainly comprises of the control of pain, palliation of dry mouth, oral decontamination, nutritional support, oral mucosa bleeding management, and some intensive oral care in patients with and without total body irradiation where the observed risk of mucositis was reduced in the subjects and moderate/severe mucositis was lower.5 Oral mucositis in itself is painful and affects the compliance of treatment in patients receiving radiotherapy thus leading to high mortality rate of head and neck cancer patients. There is a limited literature on the predictors of Radiation induced oral mucositis. Hence the present study was undertaken.
Objective
To find out the predictors of radiation induced oral mucositis.
Material and method
A descriptive study was carried out in patients attending Radiotherapy OPD (Out Patient Department), PGIMER, Chandigarh. The study was conducted after getting ethical clearance from Institute Ethics Committee. Data was collected in the month of July- October, 2016. The sample population are the patients > 18 years of age suffering from head and neck cancer, undergoing radical radiotherapy for the first therapeutic treatment.2 Patients with oral time. An information sheet providing the cavity cancer suffer from oral mucositis and related symptoms during aggressive radiotherapy or chemo-radiotherapy.4 Studies have shown the superiority of details of the study was provided to the subjects and the nature of the study was also explained and written consent was taken from the subjects. Purposive sampling technique was used in this study. The number of subjects taken in this study calculated to describe the data. The inferential statistic that was used was Chi were 30. The subjects follow their daily square test and Fisher’s exact test.
The routine care. Assessment of the oral mucosa was done by using the WHO oral grading scale which comprises of five grade, Grade 0, Grade 1, Grade 2, Grade 3, Grade 4. Four follow ups was done at an interval of 5 days. Analysis of data was done to assess the association of variables with the radiation induced oral mucositis. In descriptive statistics, percentage, mean, standard deviation, median range was findings of the study were presented with the help of tables.
Result
Table 1 shows the prevalence of oral mucositis among the 30 patients enrolled in the study. Out of the 30 patients, 28 (93.3%) developed oral mucositis. This shows that patients receiving radiotherapy have high chance of developing oral mucositis.
Table 1: Prevalence of Oral mucositis
N=30
| Mucositis |
Total |
||
|
Yes |
No |
||
| Subjects | 28(93.3) | 2(6.7) | 30(100) |
Table 2 depicts the association of the demographic variables with presence of radiation induced oral mucositis. More patients of the age >50 years develops mucositis. There is an association in the gender, educational status and Occupation (p<0.05) with development of Radiation induced Mucositis. This shows that the males, literate and working subjects were more prone to develop radiation induced oral mucositis as compared to their counterparts
Table 2: Association of sociodemographic variables with development of mucositis.
N=30
| Mucositis | 2
z , df, p value |
||
| No % | Yes % | ||
| Age*
<50 ≥50 |
1(10.0) 1(5.3) |
10(90.9) 18(94.7) |
0.16
1 0.60 |
| Gender
Female Male |
2(40.0) |
3(60.0) 25(100) |
10.71
1 0.02** |
| Marital status
Married |
2(6.7) |
28(93.3) |
– |
| Educational status Illiterate Literate |
2(40.0) |
3(60.0) 25(100) |
10.71
1 0.02** |
| Habitat
Rural Urban |
2(10.0) |
18(90.0) 10(100) |
1.07
1 0.43** |
| Occupation
Housewife/Not working Working |
2(40.0) |
3(60.0) 25(100) |
10.71
1 0.02 |
| Family income (Rs.)
<10000 ≥10000 |
2(11.8) |
15(88.2) 13(100) |
1.63
1 0.313** |
*Mean ±SD age of the subjects in years: 54.67±11.27; RANGE: 30-72 years
**Fisher’s exact test
Table 3 depicts the association of the clinical diagnosis with the presence of radiation induced oral mucositis. There is no association between clinical diagnosis with Radiation induced Mucositis. This implies that patients having any clinical diagnosis may develop oral mucositis and it is not specific to any type of clinical diagnosis.
Table 3: Association of clinical diagnosis with development of mucositis
N=30
| Variables | Mucositis | Fisher exact test
df, p value |
|
| No % | Yes % | ||
| Diagnosis
Ca Base of Tongue Ca Oropharynx Ca Glottis Ca Tonsil Ca Larynx Ca Alveolus |
0(0) 0(0) 2(40) 0(0) 0(0) 0(0) |
13(100) 7(100) 3(60) 3(100) 1(100) 1(100) |
10.71 5 0.06 |
| Treatment plan Radiotherapy only Radiotherapy with chemotherapy |
2(8.0) 0(0) |
23(92.0) 5(100) |
0.53 2 0.76 |
Table 4 depicts the association of treatment profile with presence of radiation induced oral mucositis. There is an association proposed duration of radiotherapy, planned radiotherapy fractions and total planned radiation dose (p<0.05). This shows that the more the radiation dose the patients gets, the more chance it is for them to develop radiation induced oral mucositis.
Table 4: Association of treatment profile with development of mucositis.
N=30
| Variables | Mucositis | Fisher’s Exact Test
df, p value |
|
| No % | Yes % | ||
| Proposed duration of
Radiotherapy (weeks) 4 4.5 5 6 |
1(3.7) 0(0) 0(0) 1(100) |
26(96.3) 1(100) 1(100) 0(0) |
14.52 3 0.01 |
| Planned radiotherapy fractions
20 23 25 30 |
1(3.7)
0(0) 0(0) 1(100) |
26(96.3)
1(100) 1(100) 0(0) |
14.52
3 0.01 |
| Total planned radiation dose (Gy)
40 45 46 60 |
1(3.7) 0(0) 0(0) 1(100) |
26(96.3) 1(100) 1(100) 0(0) |
14.52 3 0.01 |
| Types of radiation rays
Gamma X rays |
2(8.3) 0(0) |
22(91.7) 6(100) |
0.53
1 0.46 |
Table 5 shows the association of oral hygiene with the mucositis. There is no significant association between oral hygiene with the Radiation induced mucositis (p>0.05).
Table 5: Association of Oral hygiene with development of mucositis.
N=30
| Mucositis | Fisher’s exact test
df, p value |
||
| No % | Yes % | ||
| Brushing teeth
No Yes |
0(0) 2(9.5) |
9(100) 19(90.5) |
0.92
1 0.48 |
| Frequency of brushing teeth
Many times Once Twice |
0(0) 2(15.4) 0(0) |
1(100) 11(84.6) 7(100) |
2.80 3 0.42 |
| Time of brushing teeth
After meals Before meals Both before and after meals |
0(0) 2(10.5) 0(0) |
1(100) 17(89.5) 1(100) |
1.24 3 0.74 |
| Flossing
No |
2(6.7) |
28(93.3) |
— |
| Rinsing the mouth
No Yes |
0 2(6.9) |
1(100) 27(93.1) |
0.07
1 0.93 |
| Frequency of rinsing the mouth
Many times Once Twice |
2(8.7) 0(0) 0(0) |
21(91.3) 1(100) 5(100) |
0.65 3 0.88 |
| Time of rinsing the mouth
After meals Before meals Both before and after meals |
1(4.5) 1(50) 0(0) |
21(95.5) 1(50) 5(100) |
6.62 3 0.08 |
Table 6 depicts the association between diet, tobacco chewing, smoking, and alcohol consumption with presence of radiation induced oral mucositis.
Table 6: Association of diet, tobacco & alcohol consumption with development of mucositis.
N=30
| Variables | Mucositis | Fisher’s exact test
df, p value |
|
| No % | Yes % | ||
| Diet | 0.08 | ||
| Vegetarian | 1(5.6) | 17(94.4) | 1 |
| Non-Vegetarian | 1(8.3) | 11(91.7) | 1.00 |
| History of tobacco chewing | 0.53 | ||
| No | 2(8.3) | 22(91.7) | 1 |
| Yes | 0(0) | 6(100) | 1.00 |
| History of smoking | 0.03 | ||
| No | 1(7.7) | 12(92.3) | 1 |
| Yes | 1(5.9) | 16(94.1) | 1.00 |
| History of alcohol consumption | |||
| No | 2(14.3) | 12(85.7) | 2.44 |
| Occasional | 0(0) | 10(100) | 2 |
| Yes | 0(0) | 6(100) | 0.29 |
Discussion
Oral mucositis is a common side effect which develops in patients of head and neck cancer undergoing radiation therapy. It is painful and affects the quality of life and nutrition of most patients. Its management comprises of the control of pain, dry mouth and oral decontamination, nutritional support and some therapeutic treatment.2 There is a limited literature on the predictors of Radiation induced oral mucositis. The objective of this study was to find out the predictors of the development of radiation induced oral mucositis.
Head and neck cancer is seen to be the 8th common type of cancer in UK, where in males it is the 4th and in females it is the 12th most common cancer. The male female ratio is 22:10.6 The present study reveals that there are more male (83.3%) subject enrolled than female (16.7%) subjects which implies that there are more males suffering from head and neck cancer thus there exist an association in gender and the development of mucositis.
The present study shows that almost all of the patients (93.3%) develop radiation induced oral mucositis. This shows that patients receiving radiotherapy are having a risk of development of oral mucositis. This study shows that there is an association between the gender of the subjects, Educational status and Occupation (p<0.01) with the Radiation induced mucositis. In a study conducted by Satheesh K P S et al. it was noted that proper oral care also reduced oral toxicity of radiation therapy. Maintenance of good oral hygiene can reduce the severity of oral mucositis.2 Although in the present study there is no association in oral hygiene and development of mucositis, it is still a good practice to maintain oral hygiene throughout the treatment and it is believe that it delays the development of mucositis by reducing the bacterial load in the oral mucosa.
Patients with higher levels of education and economic status deal better with the diagnosis of cancer and follow medical and nursing instructions and prescriptions more rigorously, such as for oral hygiene among those with oral mucositis.7 Routine mouth care needed and Patient education is very important in managing chemotherapy- induced and/or radiation-induced mucositis.8 In the present study most of the subjects have educational status of primary and secondary. Thus these patients can understand the needs of oral hygiene in order to prevent oral mucositis.
Patients treated with radiation therapy for head and neck cancer typically receive an approximately 200 cGy daily dose of radiation, five days per week, for 5–7 continuous weeks. Almost all such patients will develop some degree of oral mucositis. The incidence of oral mucositis was especially high in those who received a total dose over 5000 cGy.9 The present study shows that there exist an association between the proposed duration of radiation, planned radiation fraction and total proposed tumor dose of radiation of 40 Gy with the development of mucositis (p<0.05). The subjects in the study receive a total tumor dose ranging from 40 Gy to 60Gy.
The present study was focussed to find the predictors of development of radiotherapy induced oral mucositis. About 93.3% of the patients enrolled in this study developed oral mucositis. This shows how the patients receiving radiotherapy are at risk of developing oral mucositis which is painful and this in turn affects the quality of life and nutritional status of the patients. The study shows that there is an association between the development of radiation induced oral mucositis with age, gender, educational status, occupation, proposed duration of radiation, planned radiation fraction and total proposed tumor dose. Thus we can conclude that these variables are the predictors of radiation induced oral mucositis. Knowing the predictors of radiation induced oral mucositis will help us to take certain precautions towards these predictors. Thus it is recommended more such studies should be conducted and they can be conducted on a larger population.
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