Paul Gibson, MD Pediatric Oncologist Children s Hospital, London Health Sciences Centre. On Behalf of: The POGO Mucositis Prevention Panel

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1 Guideline for the Prevention of Oral and Oro-pharyngeal Mucositis in Children Receiving Treatment for Cancer or Undergoing Hematopoietic Stem Cell Transplantation Paul Gibson, MD Pediatric Oncologist Children s Hospital, London Health Sciences Centre On Behalf of: The POGO Mucositis Prevention Panel

2 Preaching to the Choir

3 Oral Mucositis is Important in Pediatric Cancer/HSCT Pain Inability to eat and drink Hydration, TPN Provides a portal of entry for bacteria Dose limiting toxicity QoL Economic burden In 2014, POGO Supportive Care Panel recognized the need for a mucositis prevention CPG

4 Approach Multidisciplinary panel including Oncologists, Nursing, Pharmacist and Dentist >130 RCTs mucositis prevention in adult and pediatric cancer Interventions effective in adult populations likely to have a similar effect in children Evaluate both adult and pediatric literature with emphasis on appraisal of pediatric studies

5 Finding the Evidence: Recommended/suggested by MASCC/ISOO for prevention of oral mucositis Evidence of benefit in Cochrane systematic review Cryotherapy Low level laser therapy (LLLT) Keratinocyte growth factor (KGF) Additional reviews restricted to pediatric patients All RCTs of any intervention to prevent oral mucositis Any primary study type of KGF use

6 Good Practice Statements 1. Good oral hygiene important in all children Regular tooth brushing Dental evaluation and treatment 2. Need for mucositis screening and measurement Several valid instruments ChIMES SSPEDI

LLLT Low level light or LED most 630-670 nm applied daily (5 days/week) to

7 LLLT Low level light or LED most nm applied daily (5 days/week) to oral mucosa No thermal generation Internal or external Widely used in Brazil

8 Recommendation 1.2: We suggest that LLLT may be offered to cooperative children receiving chemotherapy or HSCT conditioning with regimens associated with a high rate of mucositis. Weak Recommendation, High Quality Evidence Remarks: High value possibly effective intervention, low risk harm Weak recommendation feasibility, specialized equipment Ideal treatment parameters and cost-effectiveness unknown

9 Keratinocyte growth factor Epithelial growth factor - 28-kD, heparin binding member of the family of fibroblast growth factors Palifermin - recombinant human KGF 11 RCTs, 1,470 patients 9/11 reported a benefit of KGF 4 non-randomized Pediatric trials all HSCT - Allogeneic 3 - Autologous 1

10 Recommendation 1.3: We suggest that KGF may be offered to children receiving HSCT conditioning with regimens associated with a high rate of severe mucositis. Weak Recommendation, High Quality Evidence Remarks: High value evidence efficacy adult trials Weak recommendation indirectness, particularly potential for harm in pediatric cancers and costs

Oral Cryotherapy Placing ice cubes or ice chips in the mouth and continually replenishing fresh ice during the period of cytotoxic treatment (typically 30 to 60 minutes)

11 Oral Cryotherapy Placing ice cubes or ice chips in the mouth and continually replenishing fresh ice during the period of cytotoxic treatment (typically 30 to 60 minutes) Effect presumed to be related to vasoconstriction and reduced delivery of chemotherapy to mucosa 14 RCTs, 1,301 patients 12/14 RCTs reported benefit Only 1 with Children

12 RCTs of Cryotherapy vs No Cryotherapy for Reduction Severe Oral Mucositis RR % CI 0.30 to 0.71 P=0.0005

13 Recommendation 1.1: We suggest that cryotherapy may be offered to cooperative children receiving chemotherapy or HSCT conditioning with regimens associated with a high rate of mucositis. Weak Recommendation, Moderate Quality Evidence Remarks: High value possibly effective intervention, low risk harm Weak recommendation indirectness, limitations study design Regimens appropriate for cryotherapy restricted to agents with a short infusion time and short half-life

Implications for Practice Cryotherapy only feasible if

short half-life Flavoured ice popsicles, ice slushy drinks or

children Challenge identify regimens that a) Have significant

14 Implications for Practice Cryotherapy only feasible if chemotherapy is administered as a short infusion and has short half-life Flavoured ice popsicles, ice slushy drinks or freezies are likely to be more acceptable than plain ice to children Challenge identify regimens that a) Have significant risk of mucositis b) Have drug infusion times that make cryotherapy feasible

15 Where MIGHT Cryotherapy Help Short infusion anthracycline infusions - ALL Induction/Delayed Intensificaiton - AML Induction - Sarcoma Regimens (Ewings, Non-Rhabdo) - Hodgkin Disease Capizzi Methotrexate Regimens MOST outpatient chemo regimens

16 When cryotherapy is NOT feasible High Dose Methotrexate - Burkitt Lymphoma - High Risk ALL/LL Continuous infusion anthracycline - Neuroblastoma - Osteosarcoma Transplant Regimens Need more/better options and evidence!

17 Conclusions Mucositis routine care should include good oral hygiene, monitoring and dental evaluation Consider cryotherapy implementation Future work should look to consider feasibility of LLLT in Ontario and safety of KGF in Pediatric malignancy (Or Google POGO Practice Guidelines )

18 For Full Guideline: Sung L, Robinson P, Treister N, Baggott T, Gibson P, Tissing W, Wiernikowski J, Brinklow J, Dupuis LL: Guideline for the prevention of oral and oropharyngeal mucositis in children receiving treatment for cancer or undergoing haematopoietic stem cell transplantation. BMJ Supportive and Palliative Care 2015: Early view: Mar 27, 2015 Open access: full.pdf+html

19 Suggested implementation approach for the prevention of oral mucositis guideline recommendations Child can comply with both cryotherapy and LLLT (and LLLT available) Chemotherapy amenable to cryotherapy Chemotherapy not amenable to cryotherapy Consider cryotherapy and/or LLLT Consider LLLT High risk of mucositis Child can comply with LLLT but not cryotherapy (and LLLT available) Chemotherapy amenable to cryotherapy Consider LLLT Consider cryotherapy Child can comply with cryotherapy but not LLLT (or LLLT is not available) Chemotherapy not amenable to cryotherapy and child is undergoing HSCT with high risk of severe mucositis Consider KGF, if available, and if prevention of severe mucositis outweighs risks and costs Child cannot comply with either cryotherapy or LLLT (or LLLT is not available) and child is undergoing HSCT with high risk of severe mucositis Consider KGF, if available, and if prevention of severe mucositis outweighs risks and costs

Review. copyright. For numbered affiliations see end of article.

Review. copyright. For numbered affiliations see end of article. Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/ bmjspcare-2014-000804). For numbered affiliations see end of article. Correspondence to