Nurse-led Oral Mucositis Management: Impact on Health Outcomes of Patients Receiving Radiotherapy for Head and Neck Cancer and Lung Cancer: A Prospective Study

doi:10.21203/rs.3.rs-1734361/v1

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Nurse-led Oral Mucositis Management: Impact on Health Outcomes of Patients Receiving Radiotherapy for Head and Neck Cancer and Lung Cancer: A Prospective Study

https://doi.org/10.21203/rs.3.rs-1734361/v1

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Purpose The study aimed to evaluate the impact of nurse-led OM management on the health outcomes of patients receiving radiotherapy for head and neck cancer and lung cancer.

Methods The radiotherapy nurse carried out evidence-based assessments for OM in patients diagnosed with head and neck cancer and lung cancer and scheduled to receive radiotherapy, during their visits to the radiotherapy unit. The study adopted a holistic approach involving the patient in the care process with the radiotherapy nurse screening OM complications, providing information on OM-related factors and integrating these factors into daily life. The prospective, longitudinal cohort study, 27 patients were assessed and monitored through the WHO Oral Toxicity Scale, OM Follow-up Form and educated on OM during their radiotherapy through the OM Prevention and Care Guide. At the end of radiotherapy, an Evaluation of the Radiotherapy Process was performed.

Results In this study, each patient was followed for six weeks from the start of radiotherapy (n=27). During RT, 23 patients had different grades of OM and 26 patients had esophagitis.The worst clinical data for OM and its variables emerged at week 6 of treatment. While the Nutrition Risk Screening (NRS) score increased over time, weight loss was observed to decrease. The mean stress level was 4.74±0.33 in the first week and 5.77±0.35 in the last week. It was observed that 24 out of 27 patients (88.9%) showed good adherence to the treatment.

Conclusion Involving the patient in the process of radiotherapy in nurse-led OM management contributes to better patient outcomes. Such an approach improves oral care management in patients receiving radiotherapy for head and neck and lung cancer, demonstrating its positive impact on additional patient-focused outcomes.

Head and neck cancer

Lung cancer

Radiotherapy

Oral mucositis

Nurse-led

Radiotherapy (RT), is often the choice of treatment for head and neck cancers (HNC), as well as lung cancer [1, 2]. The most common complications experienced by patients treated with radiotherapy include oral mucositis (OM), dry mouth, taste changes, pain in the mouth/throat, dysphagia, odynophagia, loss of appetite, nausea, vomiting and emotional disturbances, such as anxiety, depression, fear, stress, loneliness, and vertigo [3–5]. Among these complications, OM has probably the highest incidence, with a rate more than 90% in HNC patients undergoing radiotherapy [1,2,5.6]. OM is defined as inflammatory and/or ulcerative lesions in the oral and/or gastrointestinal tract [6, 7]. It occurs in the form of erythema and ulceration, especially 7–10 days after the commencement of treatment [8–10]. It prevents the patient from eating, drinking liquids, swallowing food and speaking, and it may lead to malnutrition, severe pain and opportunistic infections, thus increasing the need for parenteral nutrition and use of narcotic medication to control the pain [8.11,12]. In addition, as the radiation dose applied to the patient increases, the severity of radiation-induced OM increases,^3,10 and it is considered a dose-limiting side effect of cancer therapy, as one-third of patients may choose to forfeit the treatment due to severity of the condition [6, 14, 15]. In some cases, complications caused by OM also cause missed treatment days or reduction in the doses required for effective treatment, thus increasing mortality, morbidity, and health care costs[13–17], as well as severely impairing the patient’s quality of life[13, 14].

In the prevention of OM, the guidelines updated by the Multinational Association of Supportive Care in Cancer / International Society for Oral Oncology (MASCC/ISOO) in 2019 recommend implementing a basic oral care protocol in patients receiving chemotherapy (CT) and radiotherapy for HNC [16]. This protocol involves professional oral care, brushing with a soft toothbrush, changing toothbrush at regular intervals, use of dental floss, mouth-washing and moistening with soft solutions, and use of saline and sodium bicarbonate [14, 16]. It also encourages an interdisciplinary approach, the implementation of a regular and systematic oral care regimen, and patient education[16]. The use of chlorhexidine (Level of Evidence: III), the use of sucralfate (Level of Evidence: II) is not recommended to prevent OM in patients undergoing radiotherapy for HCT. On the other hand, benzydamine mouthwash is recommended in patients receiving moderate-dose radiotherapy (up to 50 Gy) (Level of Evidence: I), along with oral glutamine (Level of Evidence: II), and low-level laser therapy [14, 16].

However, no measure of quality in cancer care is more important than recognizing the patient’s beliefs and core values related to health and devising a care plan accordingly [18]. The subjective perception of an individual may differ from the clinical perception, which further complicates the evaluation of OM’s impact [5], therefore a multidisciplinary team and collaboration are required in the prevention and treatment of OM. In this context, nurses, who play a key role in such a team, can play a unique role in identifying and eliminating OM risk factors (such as poor oral health habits, smoking, and malnutrition) [2, 19–21]. Patients expect that healthcare professionals understand their ideals, beliefs, and values and design a treatment plan in line with those perceptions [18], so radiotherapy nurses should inevitably provide regular counseling and screening along with evidence-based care. Our study, therefore, aimed to explore the impact of nurse-led OM management (1) on the course of OM and associated factors and (2) on adherence to radiotherapy in patients with HNC and lung cancer.

Study design and setting

The research was designed as a prospective, observational, longitudinal cohort study in an attempt to examine the impact of OM management (such as assessing the presence, variables, comorbidities) and adherence to radiotherapy in patients with HNC and lung cancer. The radiotherapy nurse applied a holistic approach during patients’ visits to the radiotherapy unit, performing OM screening, OM-related factors and integrating these factors into daily life. In this holistic approach, the radiotherapy nurse ensured patient empowerment by encouraging joint decision-making with patients and supporting self-efficacy. She used an empathetic communication framework in the assessment and education process. Patients were recruited through the use of sequential sampling in a tertiary radiotherapy unit. The usual oral care involving oral hygiene and mouthwash/gargling had not been standardized in this setting. Patient education was irregular and consisted only of recommendation of mouthwash with salt and carbonated water, which patients were advised to perform at home. No randomized controlled study was conducted due to ethical concerns regarding the assignment of radiotherapy-treated patients to the group receiving no OM assessment/treatment.

Study procedures and data collection

The study continued six weeks from the commencement of radiotherapy. The oral cavities of the patients (with HNC and lung cancer) who were scheduled for radiotherapy were examined for mucositis by the researcher, radiation physician and radiotherapy nurse before the commencement of radiotherapy. The patients had a dental examination, and their dental problems were resolved by the dentist. “OM Prevention and Care Guideline for Patient” was explained to the patient and given as print material. In addition, patients were informed about basic oral care training, intraoral evaluation, regular dental examination, and signs and symptoms of oral comorbidity. Radiotherapy nurse, using the “OM and Related Factors Follow-up Form (OAFFF)”, OM grade, factors affecting OM (such as weight, laboratory finding, chemotherapy in the last 15 days), OM comorbidities and OM-related factors (stress level) and NRS rating) evaluated. From the beginning, OM training was repeated every week (during radiotherapy), evaluated, followed up, and personalized counseling was provided by including the patient in the process on the issues that the patient needed. From the previous week's notes, the radiotherapy nurse observed the changes at the patient's next clinic visit. By the last week (6th week), the radiotherapy was evaluated together with the patient. In our study, from the beginning of radiotherapy, the patient was included in the process led by the nurse, and training, counseling and follow-up tailored for the individual were provided to the patients within the scope of OM management every week (Table 1).

OM prevention and care guideline for patient

The guideline prepared by the researchers based on evidence-based guidelines included information on how to self-assess the patient's oral cavity, what and how to eat, how to perform oral care (time interval, material to be used/mouthwash), namely information designed to ensure OM prevention and recovery[14,16,20]. The contents of this guideline were evaluated and approved by six experienced oncology nurses and two academic nurses working in the field of oncology.

Data were collected face-to-face by the radiotherapy nurse, during radiotherapy (from initiation of radiotherapy to completion and at each visit of the patient). Demographic and disease-related characteristics, age, gender, diagnosis, and radiotherapy region were recorded through “Patient Information Form” by the radiotherapy nurse at the beginning.“OAFFF” was administered at baseline and once every week (every time the patient visited the unit for radiotherapy)

Participants

The sample consisted of a total of 27 patients with HNC and lung cancer attending to the radiotherapy unit for 6 months (September 2020-February 2021) meeting the inclusion criteria: >18 years of age, radiotherapy in the neck, upper thorax or both regions, newly diagnosed, ability to read, understand, and fill out the informed consent form, and no prior radiotherapy history for the neck and/or upper thorax region. During treatment, 1 patient whose treatment was interrupted and 2 patients with missing data were excluded from the study..

Instruments

Patient Information Form

Developed by the researchers based on the relevant data from the current literature, this form contained sociodemographic characteristics (such as age, gender, marital status) and disease variables (such as diagnosis, radiotherapy area and dose) [14,16, 20,22].

OM and Associated Factors Follow-up Form (OAFFF)

In the form developed by the researchers based on the literature, OM (grade), factors affecting OM (weight, laboratory findings, CT scan in the last 15 days), OM comorbidities, and OM-related factors (stress level and Nutritional Risk Screening-NRS scoring) were evaluated. [14,16,20,22]. WHO Oral Toxicity Scale;The grade of OM was evaluated with the most widely used scale in research and clinical fields. It allows grading OM in four grades: Grade 0 means no OM, Grade 1 mild (oral soreness, erythema), Grade 2 moderate (oral erythema, ulcers, solid diet is tolerated), Grade 3 severe (oral ulcers, only liquid diet is possible), and Grade 4 indicates life-threatening (oral alimentation is impossible) OM [6,8,9,23]. Stress Scoring;; The stress levels of the patients were scored by drawing a ruler from 0 to 10. NRS Scoring; Nutritional status was measured through a highly reliable assessment tool called NRS 2002, recommended by the European Society for Parenteral Nutrition (ESPEN), which reflects the nutritional risk of patients in a real and objective way[24]. Planning was created for each patient in the form of a 6-week evaluation, oral care and repetitive training. OM and related factors were re-evaluated every week.

Radiotherapy ProcessEvaluation Form

In the last week of the radiotherapy, the effects of radiotherapy on the general, daily, social, work, and sexual life of patient during the radiotherapy and the patient's compliance with the treatment were examined. In the Likert-type evaluation, the impact of radiotherapy was evaluated in three items (affected, slightly affected, not affected). The questions in this form were prepared by the researchers.

Statistical Analysis

Research data were analyzed on the SPSS 23.0 software package. Basic demographic data (such as age, education level) and disease characteristics (such as diagnosis, total radiation dose) were evaluated using percentages, means, and standard deviation. While OM status, grade, esophagitis status, NRS, weight and stress level by each week were calculated as frequencies and percentages, OM comorbidity status was calculated as frequencies and cumulative percentages.

Ethics

This study was carried out in accordance with the Declaration of Helsinki and approved by the University Ethics Committee (Approval no: 70904504/121) and the hospital chief physician. The patients were informed about the purpose and content of the study. All patients voluntarily participated in this study. Informed consent was obtained from all individual participants

Demographic and Clinical Information

A total of 27 patients completed the study, and a total of three patients were excluded because two patients lacked certain data and one patient could not complete the study period (death). The study lasted six weeks from the commencement of radiotherapy. OM monitoring and process follow-up were performed with 27 patients during the radiotherapy. The mean age of the patients was 59.14±1.69, and the male prevalence was 77.8%. About 88.9% of the patients were married, 55.6% were high school graduates and 29.6% were employed. 66.7% of the patients were diagnosed with HNC and 33.3% with lung cancer. Around 40.7% of these patients also received chemotherapy. In addition, 66.7% of patients received radiotherapy in the neck, while 33.3% received thorax radiotherapy. A total median radiation dose of 63 Gy (dose ranging from 45 to 70 Gy) was administered to the patients for 6 weeks through intensity-modulated radiation therapy (IMRT) technique. All patients were fed orally and 18.5% had a dental prosthesis. Tooth brushing and mouthwash were applied together by 88.9% of patients (Table 2).

OM and Associated Factors

In this study, 27 patients were followed, 23 patients had OM and 26 patients had esophagitis. OM development time was 12.30±1.44 days, esophagitis development time was 12.46±1.04 days. Grade IV OM was not seen in any of the patients. Grade III was observed in only three patients after week 5. The incidence of severe OM during radiotherapy was 11%. The worst OM comorbidities during the radiotherapy period occurred at week 6 (last week of radiotherapy). While there were only 8 patients with a NRS score greater than 3 (NRS>3) in the first week, there were 19 people in the 6th week. The mean weight was 75.72±2.64 kilos in the first week and 73.79±2.56 kilos in the last week. The mean stress level was 4.74±0.33 in the first week and 5.77±0.35 in the last week (Table 3). Percentage of patients with OM, esophagitis, NRS, and stress were shown for each treatment week (Fig 1).

Evaluation of Radiotherapy Process

Adherence to treatment during the radiotherapy period was measured, and 77.8% showed good adherence, while 11.1% of patients displayed a moderate level of adherence. As for the impact of radiotherapy on patient life, 92.6% reported that the process affected their overall life, 74.1% activities of daily living, 59.2% social life, 77.7% work life, and 81.5% sexual life. (Table 4).

This study explored the impact of nurse-led management of oral mucositis on patient outcomes in HNC and lung cancer patients undergoing radiotherapy. OM was detected in 23 patients and esophagitis was observed in 26 patients at any grade of radiotherapy. Mean OM development time was 12.30 ± 1.44 days, while mean esophagitis development time was 12.46 ± 1.04 days. Grade IV OM was not seen in any of the patients. Grade III was seen in 1 patient at week 5 and in 2 patients at week 6 (11%). We found that the incidence of advanced mucositis was relatively low. In the literature, the prevalence of OM in patients receiving radiotherapy for HNC is over 90% [1, 2, 5, 6]. In the study conducted in patients with HNC (n = 60) receiving radiotherapy, OM was observed in all of the patients [10]. In a review, it was reported that 56% of patients receiving radiotherapy with modified fractionation, 43% of patients receiving radiotherapy combined with chemotherapy, and 34% of patients receiving conventional radiotherapy experienced severe mucositis (Grade 3–4) [25]. We believe that the lower rate of severe OM in our study could be attributed to our regular monitoring of the patient every week along with nurse-led patient education and follow-up system. There is evidence in the literature that oral care measures reduce the incidence and severity of OM in patients with HNC receiving radiotherapy [26–28]. For instance, a study conducted in patients with HNC (n = 40) reported that guiding the patient according to the type of food to be swallowed during the radiotherapy reduced the severity and pain of mucositis [19]. In another study of cancer patients with OM, it was reported that only 27.2% of patients with severe mucositis received special guidance from nurses [11]. In patients treated with radiotherapy, various nutritional support products are given to patients through oral, enteral, and parenteral routes once they have developed OM [22]. In our study, the patients were given education about nutrition and oral/enteral support products, and OM was not observed in any of the patients at the level that would lead to the use of parenteral support products.

Progressing from the first week to the last week of radiotherapy, it was observed that the number of patients with OM and esophagitis, OM comorbidities increased, and the highest level was in the last week (week 6). The incidence of mucositis in the last week was 62.9%, and the rate of esophagitis was 81.5%. A study conducted in patients with HNC undergoing radiotherapy reported that OM and its comorbidities increased from the first week to the 6th week, with the highest level in the last week [29]. In another study conducted in patients receiving radiotherapy for HNC, it was observed that OM comorbidities increased significantly from the 3rd week [30]. In another study, a worse clinical picture of OM occurred at the 2nd and 5th weeks of treatment [5]. In a longitudinal study, it was stated that patients had an average of eight to nine nutritional comorbidities during treatment and at least three after completion of radiotherapy (dry mouth, dysphagia, change in taste) [31]. In our study, progressive worsening of OM and its comorbidities appear to be consistent with previous reports in the literature due to the treatment effect on the mucous layer of the oral cavity, but the worst comorbidities at 6 weeks indicates that we can achieve a partial improvement in patient outcomes.

Weight loss is an important prognostic factor [11]. Many patients undergoing radiation therapy face a high risk of weight loss due to tumor metabolism and the toxicities of the therapy[3, 32]. Studies have shown that more severe diet-related comorbidities are associated with greater weight loss [3, 31, 32]. Symptoms of OM, nutrition, and weight loss are closely related and occur simultaneously, and patient-specific evaluation and management should be a priority, rather than focusing on a single symptom [3, 11, 22]. In their study with a sample of 54 patients with HNC, who were divided into two groups, Wei et al. (2020) noted that the incidence of OM was significantly lower in the group receiving early nutritional intervention than the group receiving that intervention at a later period [33]. It has been shown that early nutrition and care intervention can improve OM and nutritional status of patients receiving radiotherapy.³ In the current study, there was an inverse relationship between NRS score and weight loss. It was determined that the weight loss decreased while the NRS score increased over the weeks, but no serious loss in body weight (5% or more) was observed in any of our patients.

In our study, the stress level was kept at moderate levels. The mean stress level and standard deviation were 4.74 ± 0.33 in the first week and 5.77 ± 0.35 in the last week. There was no obvious increase or decrease. It was clear that the patients had negative changes in OM-related eating. During the radiotherapy, increases in weight loss and NRS scores were observed as each week passed [32, 34, 35]. It has been reported in the literature that patients experience anxiety, fear, or sadness about how they can participate in the eating experience. Research has revealed that patients with oral cavity cancer may experience anxiety and worry as well as disruptions in physical areas [36]. As a result, we think that stress levels kept stable (at moderate levels) from the beginning through the end of radiotherapy in our study can be attributed to the nurse-led management approach. However, future research is needed to investigate whether stress levels can be further diminished through additional individual and motivational interviews.

Potential adverse effects of OM, OM comorbidities (such as taste change, dry mouth), weight loss, and nutritional change on adherence to treatment, quality of life, and clinical outcomes have been shown in the literatüre [29, 31, 32, 35]. It is important to understand the patient's internal relationships and to ensure timely and appropriate management [29]. Changes in dietary behavior may lead to loss of valuable relationships and social connections [34]. A study on patients with HNC receiving radiotherapy found that adherence to treatment was positively correlated with adherence to nutritional care [37]. In the current study, 77.8% of the patients had good adherence to the treatment during the radiotherapy, and 11.8% showed moderate levels of adherence. We can suggest that this high level of adherence among our patients was achieved thanks to the nurses’ efforts towards maintaining adherence (patient education, counseling, regular face-to-face visits). There is evidence that nurse-led follow-up approaches could improve care delivery, rendering it more efficient and functional, which could in turn increase patient satisfaction and adherence as they often receive tailored treatment according to their needs [20, 38, 39]. However, it was observed that this acute toxicity event also affected the general, sexual, work, daily and social life of the patients at high rates during radiotherapy. To address this issue, we suggest that patients need care that will touch their daily life in every aspect during neck-upper thorax radiotherapy, which is a rather disturbing procedure by nature.

Our study has some limitations. First, we did not include a control group receiving no OM management intervention. However, the results of our observational study in cancer care provided valuable insight into intensive mucositis management and its implications in daily radiotherapy practice. Second, our study sample was relatively small, which impairs the generalizability of our findings to a larger population. Therefore, larger cohort analyses may lead to more robust results. Third, we evaluated 6 weeks of the radiotherapy course to provide data on this acute condition, but future research involving longer follow-up periods should look at whether patients report clinical differences in the post-treatment period.

From the first week of the nurse-led radiotherapy, the process was systematized in line with the needs of each patient in an attempt to address the unmet needs and opportunities in OM management. Early recognition of OM by radiotherapy nurses, who provided appropriate and evidence-based care, improved treatment outcomes. Our study provided valuable insight into the field of radiation oncology as well as nursing care in the management of OM during the radiotherapy period for patients with HNC and lung cancer, offering nurses a chance to understand the process such patients are going through and their potential care needs.

Data Availability The data that support the fndings of this study are

available within the article.

Code availability Not applicable

Ethıcal approval

The patients were informed about the purpose and content of the study before treatment. All patients voluntarily participated in this study. Our study was carried out in accordance with the Declaration of Helsinki and approved by the University Ethics Committee (Approval no: 70904504/121) and the hospital chief physician.

Consent to participate

Informed consent was obtained from all individual participants included in the study.

Conflict of interest

The authors declare that they have no conflict of interest

Funding

None

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Table 1 Working flow chart in RT treatment process: Practice and evaluation criteria

RT Treatment Process	Practice	Evaluation
First Week (1)	* Basic Oral Care Training * Giving “OM Prevention and Care Guideline” to the patient	“ Patient Information Form” “OAFFF”
Process Weeks (2,3,4,5)	* Oral Care Training and Counseling by Grade	*“OAFFF”
Last Week (6)	* Oral Care Training and Counseling by Grade	“OAFFF” “ Radiotherapy Process Form”

OAFFF, OM and Associated Factors Follow-up Form

Table 2 Demographic characteristics of patients with OM (n = 27)

Characteristics	n	%
Age (Mean ± SD)= 59.14 ± 1.69
Gender
Women	6	22.2
Man	21	77.8
Marital status
Married	24	88.9
Single	3	11.1
Educational status
İlliterate	1	3.7
Primary school	15	55.6
High school	4	14.8
University	7	25.9
Working status
Working	8	29.6
Not working	19	70.4
Smoking habits
Yes	3	11.1
No	24	88.9
Comorbid chronic disease
Yes	11	40.7
No	16	59.3
Cancer type
Head and neck cancer*	18	66.7
Lung cancer	9	33.3
Receiving chemotherapy
Yes	11	40.7
No	16	59.3
Radiotherapy treatment site
Neck	18	66.7
Upper thorax	9	33.3
Dental prosthesis status
Yes	5	18.5
No	22	81.5
Oral care practice
Mouthwash	3	11.1
Brushing Teeth + Mouthwash	24	88.9
Information regarding radiation therapy	Median	Min/Max
Total radiation dose (Gy)	63	45–70
Treatment duration (day)	30	25-85

* Larynx :10, Skin : 1, Tonsil :1, Tongue :2, Nasal :1, Parotis :1, Esophagus: 2

Table 3 Evaluation of variables OM, stage, comorbidity, esophagitis, NRS, weight and stress level in the RT treatment process (n=27)

	Week 1		Week 2		Week 3		Week 4		Week 5		Week 6
Variables	n	%	n	%	n	%	n	%	n	%	n	%
OM (Mean ± SD) /day = 12.30 ± 1.44 (1-26)
OM Grades (n = 23)
Grade 0	25	92.6	19	70.4	11	40.7	11	40.7	9	33.3	10	37.0
Grade 1	2	7.4	8	29.6	15	55.6	9	33.3	12	44.4	12	44.4
Grade 2	-	-	-	-	1	3.7	7	25.9	5	18.5	3	11.1
Grade 3	-	-	-	-	-	-	-	-	1	3.7	2	7.4
OM Comorbidity (n= 27)*
Talking difficulties	6	35.3	6	28.6	5	20.8	9	39.1	8	33.3	10	38.5
Hoarseness	8	47.1	7	33.3	7	29.2	9	39.1	10	41.7	12	46.2
Eating difficulties	9	52.9	11	52.4	17	70.8	17	73.9	18	75.0	19	73.1
Pain	5	29.4	9	42.9	16	66.7	16	69.6	12	50.0	17	65.4
Burning	4	23.5	3	14.3	5	20.8	2	8.7	4	16.7	8	30.8
Loss of appetite	5	29.4	8	38.1	6	25.0	7	30.4	8	33.3	12	46.2
Taste change	9	52.9	8	38.1	9	37.5	12	52.2	15	62.5	14	53.8
Dry mouth	4	23.5	8	38.1	9	37.5	10	43.5	6	25.0	8	30.8
Bleeding	-	-	1	4.8	-	-	-	-	-	-	2	7.7
Oral Alım Bozukluğu	2	11.8	4	19.0	6	25.0	2	8.7	1	4.2	2	7.7
Esophagitis (Mean ± SD) /day = 12.46 ± 1.04 (5-28)
Esophagitis (n = 26)
Yes	-	-	7	25.9	22	81.5	22	81.5	20	74.1	22	81.5
No	27	100.0	20	74.1	5	18.5	5	18.5	7	25.9	5	18.5
NRS
NRS<3	19	70.4	16	59.3	11	40.7	10	37.0	7	25.9	8	29.6
NRS>	8	29.6	11	40.7	16	59.3	17	63.0	20	74.1	19	70.4
	Mean ±SD		Mean ±SD		Mean ±SD		Mean ±SD		Mean ±SD		Mean ±SD
Weight (Mean ± SD) = 74.73 ± 2.60	75.72	2.64	75.37	2.60	74.78	2.61	74.74	2.68	73.79	2.56	73.79	2.56
Stress Level (Mean ±SD) = 5.24 ± 0.24	4.74	0.33	4.85	0.28	5.14	0.24	5.29	0.27	5.62	0.30	5.77	0.35

* n is folded, the percentage is cumulative. SD: Standard Deviation RT:Radiotherapy, OM: Oral Mucosit, NRS: Nutritional Risk Screening

Table 4 Evaluation of radiotherapy process

	n	%
Adherence to Treatment
Good	21	77.8
Moderate	3	11.1
Bad	3	11.1
Overall Effect
Non Affected	2	7.4
Moderate Affected	19	70.4
Bad Affected	6	22.2
Activities of Daily Living Effect
Non Affected	7	25.9
Moderate Affected	14	51.9
Bad Affected	6	22.2
Social Life Effect
Non Affected	11	40.7
Moderate Affected	11	40.7
Bad Affected	5	18.5
Work Life Effect
Non Affected	6	22.2
Moderate Affected	10	37.0
Bad Affected	11	40.7
Sexual Life Effect
Non Affected	5	18.5
Moderate Affected	6	22.2
Bad Affected	16	59.3

No competing interests reported.

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Nurse-led Oral Mucositis Management: Impact on Health Outcomes of Patients Receiving Radiotherapy for Head and Neck Cancer and Lung Cancer: A Prospective Study

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