The concerns a family might have when a loved one develops squamous cell carcinoma of the oral cavity might seem obvious: fear that the patient will have a shorter life due to advanced disease, empathy for her pain, and a feeling of isolation in facing a rare presentation of cancer.
What might not immediately come to mind is a disturbingly bad smell.
But that smell, emanating from a rare oral wound caused by squamous cell carcinoma, is exactly what one patient and her family experienced. When Jerri Drain, BSN, RN, CWOCN, was contacted for suggestions, it occurred to her that active leptospermum honey (ALH)—which is safe to eat and has antibacterial and anti-inflammatory properties—could help resolve the problem.
That brainstorm sparked success and led to a poster on the use of honey for such wounds, written by Drain and Michael O. Fleming, MD, FAAFP, and presented at the 2015 Annual ONS Congress.
The presentation was one of many at the conference focused on integrative medicine for patients with cancer, including a study of group acupuncture as an effective and inexpensive means of relieving cancer-related symptoms; a clinical trial comparing chamomile and brassica oleracea extract in preventing radiodermatitis in women with breast cancer; and a look at the effects of music and nature sounds on pain and anxiety in hospice patients with cancer.
A Sweet Solution
The nurse in Drain’s case study was contacted by the patient, an 80-year-old woman, and her caregivers because of a “rotting flesh smell that permeated the entire house” and was so strong that family members were considering removing the patient from the home. The patient also had an external facial wound with bone protrusion that was “angry and inflamed” with “purulent drainage,” according to an abstract about the case.
In the abstract, Drain, regional wound program manager of Amedisys, Inc, in Baton Rouge, Louisiana, noted that “Palliative management of malignant malodorous wounds occurring in the oral cavity can be difficult, due the limited dressing and products that provide symptom management and are safe for ingestion.” The family had tried several measures to treat their home for the smell, including cat litter, vinegar, and air freshener, but when those didn’t work, Drain suggested application of leptospermum honey to the wound because of the product’s antimicrobial, deodorizing, and anti-inflammatory activity.
“In the literature, ALH has been used before in the treatment of oral conditions such as radiation mucositis and oral lesions associated with Stevens-Johnson Syndrome, but it had not been used, that I could find, for odor control in an oral cavity,” Drain said. “I suggested it because I knew it had been used safely in oral conditions and was safe for ingestion, and that ALH is routinely used to help with odor in external wounds.”
ALH paste was applied twice daily to the oral cavity, and honey-impregnated calcium alginate gel was administered for the external facial wound.
“After one week of ALH use, the odor could no longer be detected, and furthermore, drainage from the external wound was no longer purulent, and redness and inflammation was decreased. After 3 months, the patient was discharged to self-management with ALH and continued to report no odor, no noted inflammation, and no purulence,” Drain wrote in the abstract.
She concluded that ALH can be a safe, effective, and easy-to-use treatment for malignant mouth wounds.
Patients with such wounds can buy and self-administer this treatment, but should look specifically for ALH paste, which is harvested in Manuka, New Zealand and gamma-irradiated for safety and efficacy. It is available over the counter and on the Internet, and is safe for ingestion unless a patient has a condition such has diabetes or allergy, Drain said.
Drain would like to see ALH studied for use in treating stomatitis and periodontal conditions.
The study on group acupuncture considered whether this lower-cost therapy worked to alleviate symptoms in patients receiving outpatient treatment for cancer. The findings—that the program helped alleviate pain, neuropathy, and digestive problems—were presented in a poster by Cindy Tofthagen, PhD, ARNP, AOCNP, FAANP, of the University of South Florida, and colleagues.
“Most studies of acupuncture have involved individual settings, but most of the data is with nausea and vomiting and hot flashes, and there is very limited data on neuropathy,” Tofthagen said. “There’s quite a bit (of study on acupuncture) for pain, but this is first study that evaluates group acupuncture for cancer-related symptoms.”
Acupuncture is less expensive in a group setting because patients need to lie quietly after needles are inserted, allowing the acupuncturist to treat others in the interim. The acupuncturist involved in the study charges $75 for an individual session and $20 per person for a group session, Tofthagen said.
The study included 43 patients who underwent at least four group acupuncture sessions over as many weeks through an integrative oncology program at a large community oncology practice in West Central Florida, and completed short assessments of seven cancer-related symptoms. The mean age of participants was 66.4 years, and they were primarily white, non-Hispanic and female.
Symptom improvement was not seen until the fourth treatment, when patients reported significantly less pain/numbness and problems with digestion. While there were no significant improvements in sleep, fatigue, or dry mouth, trends toward improvement were seen in all those symptoms. No reduction of headache was experienced.
“The next step is that we’re (testing) four weeks of acupuncture twice a week, because (the acupuncturist) feels that’s ideal,” Tofthagen said. “Then we’ll evaluate the results at completion and two months later, to see if there are any sustained effects once patients are off the program. If we can show some efficacy over time after the acupuncture is finished, that would be really useful.”
In the clinical trial that compared the powers of two plant-based products to prevent radiation dermatitis in women with breast cancer, both were found to be similarly effective. And though mild radiodermatitis seemed to develop slightly earlier with chamomile, investigators nevertheless preferred the flower-derived product for their low-income patients because it is more cost-effective than brassica oleracea, or cabbage/collard green extract.
Enough chamomile for a course of 40 radiation treatments costs about $3 in Brazil, while brassica oleracea for the same period costs $37, said lead author Dalete Mota, PhD, of the Federal University of Goias, in Brazil, during a research podium session.
Chamomile tea compresses are already used in Brazil to prevent radiodermatitis because of their calming and anti-inflammatory properties and low cost. The authors wanted to see how brassica oleracea stacked up because it has demonstrated results for some types of wounds, but hadn’t been tested as a preventive treatment for radiodermatitis, Mota explained.
Conducted between October 2013 and September 2014, the trial included women with no history of radical mastectomy or breast reconstruction and without tumor infiltration into the skin. Twenty-three were randomized to take chamomile, and 20 to take brassica oleracea.
Assessments were conducted at the first radiation session and at every five sessions thereafter, for a total of at least 25 sessions. Investigators found no statistically significant difference between groups regarding the incidence or severity of their skin toxicity while using the two preventives.
Although all of the women developed grade 1 or 2 skin lesions during the study, “The result obtained shows that both interventions tested were satisfactory for the prevention of radiodermatitis, since no woman developed grade 3 or 4 skin lesions,” the authors wrote.
Chamomile was administered by putting one teabag in 200 milliliters of hot water, allowing the water to reach room temperature, and then soaking a clean washcloth in the tea and applying it to the skin around the breast for 30 minutes twice a day. Alternatively, a fingertip’s worth of brassica oleracea cream was applied to the area twice a day.
In the hospice study, presented as an abstract and a poster, investigators found that music and nature sounds can ease the pain and anxiety often experienced by patients with cancer in the last days or weeks of their lives.
The aim of the study was to complement the use of analgesics and to perhaps avoid larger doses of the drugs, which “can increase suffering and decrease quality of life,” according to the researchers from Taiwan and Case Western Reserve University, in Ohio.
Lead author Ling-Chun Chiang, PhD, RN, of HungKuang University in Taiwan, and colleagues conducted a four-arm randomized, controlled trial that included approximately 120 patients with cancer who were in hospice units at two large hospitals. For 20 minutes a day over 3 days, patients in three of the groups listened to sedative music of their choice (most often Taiwanese folk music), nature sounds (most typically forest sounds), or a combination of the two. Those in the control arm sat or lay quietly as data were collected about their levels of pain and anxiety, but were offered a CD of their choice afterwards.
The researchers measured pain and anxiety after the interventions using written patient self-reports. They found that patients in the three experimental groups experienced significantly less pain and anxiety than those in the control group (P
“Music and the combination had medium-to-large effect sizes on pain and anxiety. Nature sounds had small-to-large effect sizes for pain and small-to-medium for anxiety,” the authors wrote. “The interventions provide hospice cancer patients physical comfort, decreased emotional distress, and add to their pleasure as the end-of-life approaches.”
The researchers suggested that nurses select culturally and age-appropriate soundtracks and offer choices, providing portable, lightweight equipment that is easy for patients to use.
They recommend further testing of these interventions for periods longer than 3 days, and extending the study to families and home settings.
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