by Sheri B. Doniger, DDS
The leading cancer in women, regardless of race, is breast cancer. We see many reminders about performing self-examinations and taking our recommended mammograms. What happens when the examination proved to be positive and breast cancer was found? The National Cancer Institute estimates that one in eight women will develop breast cancer in their lifetime. With statistics like this, the likelihood of encountering patients who are undergoing chemotherapy post breast cancer treatment is high. We need to be aware of treatment protocols and possible ways we can help these patients cope with their treatments from a dental point of view.
The American Joint Committee on Cancer (AJCC) established a staging protocol for treatment of breast cancer with relation to prognosis. Staging is accomplished with the TMN classifications: tumor size, metastasis and affect on regional lymph node. Various ranges occur within the staging and TMN classifications. Treatment strategies are usually based on staging, in addition to other factors including tumor size and lymph node status. Treatments may include tamoxifen treatments alone, breast conserving surgery (lumpectomies) plus radiation therapy, mastectomy plus reconstruction, and mastectomy alone. The majority of these patients will also undergo varying forms of chemotherapy.
Chemotherapy can be either utilized as adjuvant therapy, in addition to surgery or radiation, or as a palliative treatment when the metastasis beyond the ability to surgically remove or radiologically shrink the lesion. Treatments are usually given intravenously over a twenty one or twenty eight day cycle, depending on the amount of drugs needed and the cancer that was presented. Multiple drugs may be utilized in these therapies. Some medications are given orally as well. The two drugs used most often are Adriamycin (doxorubicin) and Cytoxin (cyclophosphamide).
Chemotherapeutic agents, by nature, are cytotoxic. They do not kill only the "bad" tumor cells; they will affect the good cells as well. The healthy cells most affected are the fastest replicating ones. The destruction of both types of blood cells and platelets will cause different patient issues. Decreased ability to fight off infections and overgrowth of candida intraorally may occur from the decreased white blood cell production. Anemia and fatigue may occur due to the decreased red blood cell production. Anemia may be manifested in dizziness and shortness of breath, in some cases. Bruising or bleeding can occur due to the reduction in platelet production. Other cells affected will be mucosa lining the digestive tract, reproductive organs and hair follicles. Patients may experience alopecia, usually by the fifteenth day of treatment. Side effects will vary with each individual and may be dose related.
The effects of chemotherapy will also be cumulative. Patients receiving the first dose may not have as severe a reaction to the medications as they would with future treatments. Patients usually feel better by the second week after treatments, but there could be a lingering fatigue. Although exercise is recommended, they may not feel like moving. In addition to fatigue, patients may also have flu-like symptoms.
Patients undergoing chemotherapy are recommended not to receive dental prophylaxis during the treatments. Patients should be advised, by their oncologist, to have their preventive maintenance visits prior to the start of any drug intervention. This does not mean patient care ceases. Several oral side effects can occur due to the course of therapy. Xerostomia is not uncommon. Use of artificial saliva substitutes and saliva stimulating toothpaste, in addition to constant hydration, should be recommended. Use of lip balm for dryness may be suggested.
Many of the anticancer drugs will have other gastric side effects. Nausea and vomiting may occur, within days of the treatments. Patients are usually given several anti-nausea drugs to combat the side effects, even before they manifest themselves. Drugs may be taken prior to the beginning of the intravenous therapy session, in addition to be prescribed for use after the patient goes home. Antiemetic or antinausea drugs such as Zofran (ondansetron), Compazine (prochlorperazine), Decadron (dexamethasone), and transdermal scopolamine patches may all be given alone or in combination. Ativan (lorazepam) may be given for anxiety or insomnia. Antibiotics may also be recommended if a risk of infection is noted. All of these medications have side effects of their own, in addition to the ones from the chemotherapeutic agents. Each oncologist treats his/her patient differently, so the variety of adjunct medications utilized may not be the same in each patient. The majority of the side effects will be similar.
Stomatitis or mucosititis are common, again in concert with the decreased white blood cell counts. Intraoral lesions can occur, both viral and fungal in nature. Acyclovir (zovirax) or Nystatin (mycostatin) would be recommended, respectively, to alleviate symptoms and decrease the severity of the outbreak. The lesions may occur around the same time after each treatment. Additionally, oral mucosal and gingival sloughing may occur, along with an increase in gingival bleeding.
Care must be taken in performing personal oral hygiene due to the possible nausea, oral lesions, and xerostomia. Strong recommendations for the proper soft toothbrush and impeccable oral hygiene should be made. As previously stated, due to the chemotherapy, patients may exhibit nausea and their ability to perform their routine oral hygiene procedures will be diminished.
Patients are advised not to use alcoholic beverages or mouthwashes. Patients may need recommendations for mouthwashes that do not contain alcohol. Other patients may need lidocaine rinses if their intraoral lesions are severe. Patients need to be reminded not to utilize sugar based candies to alleviate their symptoms of xerostomia or nausea. We can offer suggestions of sugarless gum, candy and mints. Increasing the amount of fluids in smaller amounts may also help with the nausea and keep the oral tissues hydrated.
Good nutritional counseling prior to chemotherapy may offer suggestions as to the variety of foods patients should be eating. Diet may be altered due to the xerostomia or the ability to "keep foods down". Offering options of types of foods to be consumed, that will keep nutritional levels high and support the immune system, and will help the patient maintain health throughout the chemotherapeutic process. As mucosal sloughing could occur into the pharyngeal area, soft, cold or room temperature foods are suggested. Acidic foods, such as tomato and citrus fruits, overly spicy, salty or rough foods, such as chips or popcorn, should be avoided.
We can offer much to patients undergoing chemotherapy. With knowledge of the various side effects of treatment, we are able to counsel our patients and give them the support they truly need. Breast cancer can strike anyone. Until there is a cure, we need to be diligent in our own care. Remember your mammogram!
This article is dedicated to my dearest friend, Andi Nadulek, who has just completed her successful chemotherapeutic regimen and is now a true breast cancer survivor.
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Sheri B. Doniger, DDS, has been in private practice of family and preventive dentistry for 20 years. She is currently focusing on women's health and well-being issues. She can be contacted at (847) 677-1101 or [email protected].