Oral mucositis is a common and distressing complication of cancer treatment. A 2011 Cochrane review by Worthington et al found weak evidence that low energy laser therapy (LLLT) may be beneficial in preventing severe mucositis and a recent guideline from The Multinational Association of Supportive Care in Cancer (MASCC) and the International Society of Oral Oncology (ISOO) recommended LLLT.

The aim of this review was to determine whether prophylactic LLLT reduces the overall risk of severe mucositis in children and adults with cancer or undergoing hematopoietic stem cell transplantation (HSCT) as compared to placebo or no therapy.

Methods

Searches were conducted in Medline, Embase, Cochrane Central Register of Controlled Trials ( CENTRAL) , CINHAL, Web of Science, Scopus, and LILACS. This was supplemented by searches of the conference proceedings of the International Society of Paediatric Oncology, American Society of Clinical Oncology, American Society of Hematology, American Society of Pediatric Hematology and Oncology, and Multinational Association of Supportive Care in Cancer and the reference lists of identified studies. Randomised controlled trials (RCTs) and quasi-RCTs were considered. Two reviewers independently selected studies and extracted data. Risk of bias was assessed using the Cochrane collaboration’s tool. Meta-analysis used a random effects model.

Results

• 18 RCTs involving 1144 patients were included.
• 4 studies were at low risk of bias across all domains.
•  Prophylactic LLLT reduced the overall risk of severe mucositis (risk ratio (RR) 0.37, 95% confidence interval (CI) 0.20 to 0.67; P = 0.001).
•  LLLT also reduced the following outcomes when compared to placebo/no therapy:
  • severe mucositis at the time of anticipated maximal mucositis (RR 0.34, 95% CI 0.20 to 0.59),
  • overall mean grade of mucositis (SMD -1.49, 95% CI -2.02 to -0.95),
  • duration of severe mucositis (WMD -5.32, 95% CI -9.45 to -1.19) and
  • incidence of severe pain (RR 0.26, 95% CI 0.18 to 0.37).

Conclusions

The authors concluded

Prophylactic LLLT reduced severe mucositis and pain in patients with cancer and HSCT recipients. Future research should identify the optimal characteristics of LLLT and determine feasibility in the clinical setting.

Commentary

This review has a good methodology and is well reported. They point to the difference in primary outcome considered by this review of, overall incidence of severe mucositis throughout the observation period with that of the earlier Cochrane review of mucositis evaluation on day 28 of therapy. The authors also highlight two potential biases which they feel could result in an over estimation of the effectiveness, the lack of allocation concealment and the possibility of publication bias.

Links

Oberoi S, Zamperlini-Netto G, Beyene J, Treister NS, Sung L. Effect of prophylactic low level laser therapy on oral mucositis: a systematic review and meta-analysis. PLoS One. 2014 Sep 8;9(9):e107418. doi: 10.1371/journal.pone.0107418. eCollection 2014. PubMed PMID: 25198431; PubMed Central PMCID: PMC4157876.

Worthington HV, Clarkson JE, Bryan G, Furness S, Glenny AM, Littlewood A, McCabe MG, Meyer S, Khalid T. Interventions for preventing oral mucositis for patients with cancer receiving treatment. Cochrane Database of Systematic Reviews 2011, Issue 4. Art. No.: CD000978. DOI: 10.1002/14651858.CD000978.pub5.

Lalla RV, Bowen J, Barasch A, Elting L, Epstein J, Keefe DM, McGuire DB, Migliorati C, Nicolatou-Galitis O, Peterson DE, Raber-Durlacher JE, Sonis ST, Elad S; Mucositis Guidelines Leadership Group of the Multinational Association of Supportive Care in Cancer and International Society of Oral Oncology (MASCC/ISOO). MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer. 2014 May 15;120(10):1453-61. doi: 10.1002/cncr.28592. Epub 2014 Feb 25. Review. PubMed PMID: 24615748; PubMed Central PMCID: PMC4164022.