Most head/neck cancer patients experience this side effect associated with poor quality of life, worse outcomes

While most patients treated with radiation therapy for cancers of the head and neck develop oral mucositis, there is no standard approach for monitoring those patients for this often-debilitating side effect of cancer treatment or for measuring its severity. In new work published today by JAMA Network Open, a research team at Roswell Park Comprehensive Cancer Center shows that more patients than previously thought experience mucositis and can benefit from earlier diagnosis and intervention to address its effects.

Oral mucositis, a condition marked by inflammation after treatment for head and neck cancer, causes painful ulcers and bleeding of the mucosal tissue, often leading to difficulty talking, eating and swallowing. The condition can affect the patient’s quality of life profoundly, leading to weight loss, placement of a feeding tube, longer and more frequent hospitalization, increased use of opiates to relieve pain and financial difficulties due to additional treatment costs.

The results of most prior studies examining mucositis and clinical outcomes in patients with head/neck cancers may no longer be relevant: They were conducted when few of these patients received targeted chemoradiation, a treatment approach that combines radiation therapy and chemotherapy.

“We know that mucositis following chemoradiation is one of the major drivers of poor outcomes in patients undergoing treatment for head and neck cancers,” says the study’s principal investigator, Anurag Singh, MD, Director of Radiation Research and Director of Head & Neck and Lymphoma Radiation Services at Roswell Park. “Mucositis is often tied to more hospitalizations, treatment disruptions and other factors that are associated with worse treatment outcomes and worse quality of life.”

Austin Iovoli, MD, of Rowell Park’s Department of Radiation Medicine, is first author of the study, which is the largest and longest-term of its kind. Between 2015 and 2022, data were collected from 576 Roswell Park patients who received definitive or adjuvant intensity-modulated radiation therapy to treat primary head and neck cancer, either with or without adjuvant chemotherapy.

During the course of treatment, nearly all patients — 568 out of 576 (98.6%) — reported some degree of mouth and throat soreness. Of those, 360 (62.5%) experienced severe symptoms and were twice as likely as the others to be hospitalized (13.9% vs. 25.0%), typically to treat dehydration or malnourishment, or for pain control. More than half of all patients (56.8%) said they had moderate or severe difficulty swallowing; 69.4% reported moderate or severe difficulty eating; and 48.6%, moderate or severe difficulty drinking.

Because mucositis can be difficult to spot by visual examination of the treatment area, the Roswell Park team used a validated survey for patients to self-report mouth and throat soreness on a weekly basis, to help identify the problem earlier and make it possible to intervene in time to reduce the severity of symptoms. Symptoms were addressed promptly — for example, by increasing fluid intake — and that strategy cut the hospitalization rate in half.

Dr. Singh notes that the mucositis management plan at Roswell Park also includes educating patients about the need for practicing good oral hygiene, staying hydrated and maintaining good nutrition to protect against mucositis.

He adds that previous studies have shown that opioid use is associated with more severe OM symptoms, and that better pain-relief solutions are essential. For pain control, all eligible Roswell Park patients who receive chemoradiation for head and neck cancer are given gabapentin — a nonopioid — prophylactically, plus acetaminophen and non-steroidal anti-inflammatory drugs such as aspirin, on an alternating basis, before opioids are prescribed.

“This work demonstrates how critically important it is to seek and act on information from cancer patients about what they’re experiencing as they go through treatment,” says Dr. Singh. “It’s part of our longer-term vision for improving outcomes by understanding the patient factors that drive outcomes.

“By focusing on quality of life, we’ve learned a lot of things that continue to inform our practice and our clinical trials.”

The research was supported in part by a grant from the National Cancer Institute (award P30CA016056).