Oral complications: an overview DR ANDREW DAVIES FRCP CONSULTANT IN PALLIATIVE MEDICINE ROYAL SURREY COUNTY HOSPITAL, GUILDFORD, UK

Transcription

1 Oral complications: an overview DR ANDREW DAVIES FRCP CONSULTANT IN PALLIATIVE MEDICINE ROYAL SURREY COUNTY HOSPITAL, GUILDFORD, UK

2 Introduction

3 Introduction Outline: Epidemiology Aetiology Clinical features Management Conclusion

4 Epidemiology

5 Epidemiology Oral complications: All types of cancer All stages of disease All types of treatment

6 Epidemiology Oral complications: 10% receiving adjuvant chemotherapy 40% receiving primary chemotherapy 80% receiving myeloablative chemotherapy 100% receiving head & neck radiotherapy National Cancer Institute, 2008

7 Epidemiology

8 Epidemiology Prevalence xerostomia recorded in clinical notes (patients referred to specialist palliative care services): 16% total Joint 10 th most common symptom Potter et al, 2003

9 Epidemiology Prevalence xerostomia elicited by Memorial Symptom Assessment Scale (patients referred to specialist palliative care services): 78-82% total 2 nd / 4 th most common symptom Davies, 2000 Tranmer et al, 2003

10 Epidemiology 10 Healthcare professionals may not enquire about a symptom if: a) they perceive the symptom to be uncommon b) they perceive the symptom to be unimportant c) they perceive there is no treatment d) time does not permit

11 Epidemiology Patients may not volunteer a symptom if: a) they perceive the symptom to be inevitable b) they perceive there is no treatment c) they sense that healthcare professional is uninterested (in the symptom) d) other symptoms predominate

12 Aetiology

13 Aetiology Direct effect of cancer Indirect effect of cancer Direct/indirect effect of cancer treatment Direct/indirect effect of supportive care interventions Related to co-existent oral condition Related to co-existent physical condition Related to co-existent psychological condition Direct/indirect effect of treatment for other conditions Combination of factors*

14 Direct effect cancer Oral tumours Disseminated tumours

15 Indirect effect cancer Paraneoplastic syndromes Physiological effects

16 Effect cancer treatment Direct effect Indirect effect

17 Local radiotherapy Oral complication Oral mucositis Oral infections - fungal, bacterial Taste disturbance Salivary gland dysfunction Osteonecrosis Soft tissue necrosis Soft tissue fibrosis - trismus Dental/skeletal developmental problems* Induction of second malignancies Comment Acute complication Acute/chronic complication Acute/chronic complication Acute/chronic complication Chronic complication Chronic complication Chronic complication Chronic complication Chronic complication

18 Local radiotherapy Conventional head & neck radiotherapy: 66.5% dysgeusia (during radiotherapy) 37.4% oral candidosis (during radiotherapy) 24.1% dental caries (post radiotherapy) 25.4% trismus 7.4% osteonecrosis [80% oral mucositis] Oral Care Study Group of MASCC / ISOO, 2010

19 Local radiotherapy Conventional head & neck radiotherapy: 81.4% xerostomia (during radiotherapy) 83.8% xerostomia (1-2 yr post radiotherapy) Intensity modulated radiation therapy (IMRT): 100% xerostomia (during radiotherapy) 66% xerostomia (1-2 yr post radiotherapy) Oral Care Study Group of MASCC / ISOO, 2010

20 Systemic chemotherapy 20 Oral complication Oral mucositis Oral infections - viral, fungal, bacterial Taste disturbance Salivary gland dysfunction Neuropathy - jaw pain (vinca alkaloids) Haemorrhage Dental/skeletal developmental problems* Induction of second malignancies Comment Acute complication Acute complication Acute complication Acute complication Acute complication Acute complication Chronic complication Chronic complication

21 Systemic chemotherapy Conventional chemotherapy: 56.3% dysgeusia (during chemotherapy) 38.0% oral candidosis (during chemotherapy) 37.3% dental caries (post chemotherapy) 49.9% xerostomia (during chemotherapy) [40% oral mucositis] Oral Care Study Group of MASCC / ISOO, 2010

22 Chemo-radiotherapy Oral Complication Dysgeusia (during Rx) Oral candidosis (during Rx) Dental caries (post Rx) Chemotherapy Radiotherapy Chemoradiotherapy 56.3% 66.5% 76.0% 38.0% 37.4% 66.7% 37.3% 24.1% 21.4% Oral Care Study Group of MASCC / ISOO, 2010

23 Haematopoietic stem cell transplant Complications of chemotherapy Complications of radiotherapy Complications of stem cell transplant Complications of immunosuppression [Complications of supportive treatment]

24 Haematopoietic stem cell transplant Acute GVHD: 50-70% allogeneic transplants 35-60% oral involvement (Systemic disease) Tongue, buccal mucosa, labial mucosa Hyperkeratotic, erythematous, ulcerative, desquamative

25 Haematopoietic stem cell transplant Chronic GVHD: 30-50% allogeneic transplants Up to 80% oral involvement (Systemic disease) Similar agvhd; mucocoeles; stiffness oral tissues; SGD; malignancy

26 Haematopoietic stem cell transplant Ciclosporin: Infections Malignancies Gingival hyperplasia (1-10%)

27 Haematopoietic stem cell transplant Palifermin: Dysgeusia (> 10%) Oral paraesthesia (1-10%) Oral mucosal / tongue hypertrophy (> 10%) Oral mucosal / tongue discolouration Lip swelling (1-10%) Oral / tongue oedema

28 Novel agents Drug Bortezomib (Velcade ) proteasome inhibitor Sunitinib (Sutent ) protein kinase inhibitor Very common side effects ( 1/10 patients) Common side effects ( 1/100 1/10 patients) - Mucositis Oral ulceration Taste disturbance Xerostomia Mucositis Taste disturbance Glossodynia Xerostomia Oral pain Uncommon side effects ( 1/1000 1/100 patients) Oral pain Jaw pain Gingival bleeding Coated tongue Discoloured tongue Hypersalivation -

29 Novel biological agents Drug Bevacizumab (Avastin ) monoclonal Ab against VEGF Trastuzumab (Herceptin ) Monoclonal Ab against HER2 Very common side effects ( 1/10 patients) Mucositis Taste disturbance Mucositis Taste disturbance Common side effects ( 1/100 1/10 patients) (Gingival bleeding) Xerostomia - Uncommon side effects ( 1/1000 1/100 patients) -

30 Supportive care agents 30

31 Medication (general) Oral side effects of frequently prescribed drugs : 79% - oral side effects 63% - xerostomia 37% - dysgeusia 27% - stomatitis 20% - glossitis 9% - coated tongue Smith & Burtner, 1994

32 Medication (oral care)

33 Medication (oral care) Chlorhexidene: Discolouration teeth Discolouration tongue Calculus formation Dysgeusia Parotid gland swelling Mucosal dryness Mucosal irritation [Inactivation nystatin]

34 Paediatrics

35 Paediatrics

36 Clinical features

37 Clinical features Variable - frequency, intensity, bothersomeness - clinical presentation Cause direct morbidity Cause indirect morbidity

38 Clinical features

39 Clinical features

40 Clinical features 40

41 Clinical features Xerostomia dysphagia poor oral intake malnutrition fatigue depression ETC!

42 Clinical features Directly result in mortality oral infection/colonisation leading to systemic infection Indirectly result in mortality alteration chemotherapy leading to reduction in chemotherapy response

43 Management

44 Management Multi-disciplinary teams Evidence based practice [Common sense]

45 Management

46 Management Screening Prevention* Treatment

47 Management Assessment Treatment - definitive - symptomatic Re-assessment

48 Conclusion

49 Oral complications Oral problems are common in cancer patients, and are a significant cause of morbidity and impaired quality of life in this group of patients. Moreover, in some patients they can prevent administration of potentially life-saving treatment, whilst in other patients they can themselves cause potentially lifethreatening complications. Oral complications of cancer and its management, 2010

50 Oral complications Oral problems are usually predictable, and may be prevented or ameliorated by appropriate interventions. However, even when it is not possible to prevent the oral problem, it is usually possible to treat / palliate the oral problem (and so to prevent or ameliorate the associated complications). Oral complications of cancer and its management, 2010