Prophylactic Oral Vitamin D and Zinc for Radiation-Induced Oral Mucositis in Head and Neck Cancer

Most head and neck cancers are derived from the mucosal epithelium in the oral cavity, pharynx and larynx and are known collectively as head and neck squamous cell carcinoma (HNSCC). Oral cavity and larynx cancers are generally associated with tobacco consumption, alcohol abuse or both, whereas pharynx cancers are increasingly attributed to infection with human papillomavirus (HPV), primarily HPV-16. Thus, HNSCC can be separated into HPV-negative and HPV-positive HNSCC.

As a major histological type of HNC, head and neck squamous cell carcinoma (HNSCC) is the sixth most common cancer worldwide. Totally, 53,000 new cases and 10,860 HNC-related deaths were observed in the U.S. in 2019. According to the estimation of the World Health Organization, 439,000 mouth and oropharynx cancer will be observed in 2030.

The main treatment options are surgery, radiation therapy, chemotherapy, targeted therapy, and immunotherapy.

Treatment options and recommendations depend on several factors, including the type and stage of head and neck cancer, possible side effects, and the patient's preferences and overall health.

Radiation therapy (RT) plays a key role in curative-intent treatments for head and neck cancers. Its use is indicated as a sole therapy in early stage tumors or in combination with surgery or concurrent chemotherapy in advanced stages. Recent technologic advances have resulted in both improved oncologic results and expansion of the indications for RT in clinical practice.

Chemotherapy is a treatment for head and neck cancer that uses powerful drugs to attack cancer cells. Often chemotherapy drugs are given before or during radiation to improve the effectiveness of care. Other drug therapies target the genetic mutations found in tumors or stimulate the immune system to fight the cancer.

Approximately 60% of head and neck cancer patients who were instructed to receive radiotherapy will suffer from oral mucositis. More importantly, the incidence of oral mucositis increases to 90% when patients underwent concurrent chemotherapy 19% of the latter will be hospitalized and will experience a delay in antineoplastic treatment for high-grade mucositis management.

Oral mucositis is a common side-effect associated with systemic chemotherapy and radiation of the head and neck region. It is characterized as an inflammation of the oral mucous membranes accompanied by many complex mucosal and submucosal changes. Ulcerative oral mucositis can cause significant oral pain, impair nutritional intake, lead to local or systemic infection, and cause significant economic cost. In addition, it may necessitate interruptions in cancer therapy, resulting in a reduction of the quality of life, a worse prognosis and an increase in patient management costs, thus adversely affecting patient prognosis.

vitamin D is a fat soluble vitamin which has important calcemic roles in the body regarding bone homeostasis and calcium/phosphorus balance. Recently, the non-calcemic roles of vitamin D as anti-inflammatory, anti-oxidant and immuno-regulatory functions have been widely reported.So, we tried to use it for prevention of radiation induced oral mucositis

Oral mucositis scale Vitamin D supplementation significantly improved erythema, lichenoid, edema, ulceration and pain in patients with inoperable/unresectable oral cancer.

Hypovitaminosis D could increase risk of developing OSCC from OPMDs, thus altering the immune response and it is associated with a lower survival rate in patients with OSCC, a greater recurrence of tumors in patients who underwent surgical treatment, and an increase in adverse reactions to chemotherapy. The use of vitamin D supplements can be a complement to primary therapy to prevent the recurrence of lesions and reduce adverse events associated with treatment.

Vitamin D supplementation has a role in reducing treatment-related toxicities, especially in advanced cancer.

Zinc sulfate is beneficial in decreasing the severity of radiation-induced mucositis and oral discomfort. These results should be confirmed by additional evaluation in randomized studies with a larger number of patients.

zinc has the potential of relieving oxidant damage and the progression of reactive oxygen species (ROS)-induced disease.

The World Health Organization has developed a grading system for mucositis based on clinical appearance and functional status.

The WHO scale is dependent on both objective and subjective variables, and measures anatomical, symptomatic as well as functional components of oral mucositis.

WHO Oral Mucositis Grading Scale Grade Description 0 (none) None I (mild) Oral soreness, erythema II (moderate) Oral erythema, ulcers, solid diet tolerated III (severe) Oral ulcers, liquid diet only IV (life-threatening) Oral alimentation impossible