Prevention and treatment of oral mucositis caused by chemo- and radiotherapy in head and neck cancer patients

Abstract

Background: Oral mucositis is a common and dose-limiting complication among head and neck cancer patients receiving radiotherapy (RT). The addition of chemotherapy (CT) has been shown to improve locoregional control and disease- free survival at the expense of increased incidence and severity of oral mucositis. Understanding the mechanisms of mucositis allowed development of therapies to target specific molecular events for radioprotective intervention. Objective: To perform a systematic review of therapeutic agents for the prevention and treatment of oral mucositis in head and neck cancer patients undergoing chemo-radiotherapy (CRT) or radiotherapy (RT). Methods: Electronic search via MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials was performed from 1994 until September 2016 for randomized controlled trials (RCTs) comparing medical therapeutic agents with placebo or standard care in patients with head and neck cancers undergoing CRT or RT. The primary outcome was the overall incidence of severe oral mucositis and the secondary outcome was the incidence of unplanned RT interruptions. Results: 14 RCTs were included for the final review. Eight agents were evaluated. They were glutamine, palifermin, amifostine, granulocyte-macrophage colony- stimulating factor, honey, benzydamine, chlorhexidine and aloe vera. Five interventions reported a significantly less incidence of severe oral mucositis, namely palifermin, glutamine, amifostine, benzydamine and honey. Seven studies compared the incidence of treatment delay due to oral mucositis between treatment arm and placebo arm. Less treatment interruptions, though not statistically significant, was observed with the use of glutamine, honey and aloe vera. Conclusions: This systematic review found that five interventions (glutamine, palifermin, amifostine, benzydamine and honey) were reported to be effective in reducing the incidence of severe oral mucositis. However, there is insufficient evidence to conclude whether the radioprotective agents could reduce radiotherapy interruption and impact on the survival.