All You Need To Know About Radiation Mucositis

-Dr. Tejinder Kataria, Chairperson, Radiation Oncology, Cancer Institute, Medanta, the Medicity, Gurgaon

Radiation therapy is the treatment with high-energy X-Rays given to various cancers with the intent of either cure, downstage cancer, or palliation of painful/compressive symptoms.

The inner surface of the mouth, throat, food pipe, stomach, intestines, colon, and rectum is called mucosa or mucosal surface. When patients receive radiation to the cancers located in these areas, besides tumour breakdown the acute side-effect of inflammation of mucosa sets in. It is apparent by about 11-15th fraction of treatment or by the beginning of the third or fourth week of radiation. The inflammation of the mucosal surface is called mucositis.

The initial symptoms that the patient may have are irritation in the mouth or throat or difficulty in swallowing hard foods. Doctors can see either a reddening of the inner surface or the appearance of a white coating in the mouth or throat. Whilst on treatment, patients are seen once or twice a week by the doctors to keep a watch for the appearance of mucositis and appropriate medication. Depending upon the site of cancer the patient may have, symptoms can last from 2-6 weeks before resurfacing of normal mucosa and disappearance of symptoms.

The patients need to be made aware of this acute condition which is self-limiting as well as recovers within a specified time. Present day advanced supportive care can be managed at home. Less than 10% patient may need hospital care during radiation mucositis especially if they start losing weight or are afraid to swallow medicines to ease the pain to maintain nutrition.

The symptom complex experienced by the patient may include:

Increased sensitivity to hot and spicy foods
Inability to chew & swallow hard foods
Loss of taste
Dryness of mouth
Pain while swallowing

Remedies for these symptoms

Take soft, well-cooked, low salt, non-spicy foods such that there is no weight loss. A chat with the dietician, prior to treatment, is helpful. Preferably a chart of adequate proteins, carbohydrates/fats with enough micronutrients during different weeks for solids, semi-solids and liquid diet is recommended. Natural foods, prepared at home are preferred over preserved foods.
Take 3 liters of fluid including sweetened water, supplemental diets if there is no restriction to water intake (patients with heart and kidney disease need to consult their specialist for the daily water intake recommendation).
Pain medication as advised by the treating team. Patient is advised not to skip medicines as breakthrough pain is difficult to control.
Frequent mouth rinsing with nonalcoholic mouth cleansers and plain water/salt-water to prevent food residue remaining in mouth. Bacteria can overgrow in mouth over the remaining food particles in mouth and teeth and increase pain and delay mucosal resurfacing/healing.
Pre-treatment dental clearance & use of fluoride mouth rinses to prevent tooth decay. Tooth extractions should be done 4-7 days before radiation to allow for adequate healing. Tooth extraction is not recommended for one year after oral cavity treatment with radiation to prevent bone breakdown osteo-radio-necrosis).
Mouth sprays help to clean and moisten the mouth & gels are prescribed that can anesthetize the surface during feeding

Food pipe and stomach –Patient may have

Difficulty in swallowing hard food
Nausea or vomiting
Pain in upper abdomen
Feeling of fullness after small amount of food

Remedies

Include soft & liquid diet, small frequent (3 hourly), meals
Anti-nausea medicine
Not to lie down immediately after meal, either sit straight or in reclining position not below 45 degrees. Dinner should be taken at least 2 hours before sleep time.
Taking periodic walks – do not walk immediately after meals. Wait for 30-45 minutes.
May need antacids

Small-intestine, colon & rectum

Radiation to the small & large bowel can lead to symptoms of
Nausea &/or vomiting
Loose motions
Crampy pain abdomen

Remedies

Anti nausea medicine
Avoid plain milk
Take well cooked, soft foods
Avoid raw juices or cut fruits that have been lying around for more than one hour
Medication may be required if patient get >2-3 bowel movements or if the crampy pain is not controlled with change in diet.
Take about 3 liters of fluids including with electrolytes to avoid dehydration

The most important caveat is to understand radiation mucositis is a graded response of mucosa to radiation and heals by 2-6 weeks after radiation unless there are complications like infection or tooth extractions.