INTRODUCTION:

Cancers are a large family of diseases that involve abnormal cell growth with the potential to invade or spread to other parts of the body.

They form a subset of a neoplasm or tumor is a group of cells that have undergone unregulated growth, and will often form a mass or lump, but may be distributed diffusely. Cancer is also known as a malignant tumor or malignant neoplasm, is a group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body. Not all tumors are cancerous; benign tumors do not spread to other parts of the body. Possible signs and symptoms include: a new lump, abnormal bleeding, a prolonged cough, unexplained weight loss, and a change in bowel movements among others. While these symptoms may indicate cancer, they may also occur due to other issues. There are over 100 different known cancers that affect humans.¹

Tobacco use is the cause of about 22% of cancer deaths. Another 10% is due to obesity, a poor diet, lack of physical activity, and consumption of alcohol. Other factors include certain infections, exposure to ionizing radiation, and environmental pollutants. In the developing world nearly 20% of cancers are due to infections such as hepatitis B, hepatitis C, and human papillomavirus (HPV). These factors act, at least partly, by changing the genes of a cell. Typically many such genetic changes are required before cancer develops. Approximately 5–10% of cancers are due to genetic defects inherited from a person's parents. Cancer can be detected by certain signs and symptoms or screening test. It is then typically further investigated by medical imaging and confirmed by biopsy.¹

Chemotherapy and radiation therapy are the most widely used interventions for cancer treatment. Although these treatments are employed to improve the patient’s quality of life, they are associated with severe adverse effects. Oral mucositis is one of the most common adverse effects of chemotherapy and radiation therapy, especially in patients with head and neck cancer. Oral mucositis is the painful inflammation and ulceration of the mucous membrane lining the oral cavity.²

Interest in complementary alternative medicine has grown dramatically over the past several years. According to survey results 80% of patients repeated using some type of complementary alternative medicine, in that 54 % took herbal products and 30 % used relaxation techniques.³

Apitherapy is a type of complementary and alternative therapy which helps to reduce the degree of oral mucositis as a complication of radiation therapy. Apitherapy or bee therapy, is the product of the common honey bee for therapeutic purposes, which involves the medicinal use of bee stings the venom and it has a strong anti – inflammatory and pain relieve effect, soften scar tissue and to boost the body’s immune system. There by symptoms of oral mucositis being reduced.⁴

NEED FOR THE STUDY:

Globally cancer account for 5.1% of total disease burden and 12.5% of all deaths. In India they account for 3.3% of disease burden and 9.9% of all deaths. With the increasing prevalence of alcohol and tobacco consumption in the country, it is estimated that 10 lakh new cases will be diagnosed in 2016. Nearly 6,70,000 people are expected to die due to cancers in India in year 2016. Based on cancer registry there are about 8,00,000 new cancer case reported every year. Cancer sites to tobacco accounts for 30% to 35% cases in men and 17% in women.⁵

Head and neck cancer (HNC) is a term used to describe malignant tumours originating in the upper orodigestive tract, including the oral cavity, larynx, pharynx and nasopharynx. Majority (90%) of cancers are squamous cell carcinomas arising from epithelial mucus membrane. HNCs are among the ten most frequent cancers and are the sixth most common cancers worldwide. They constitute five percent of all cancers accounting for more than 550,000 cases annually. Incidence rate is more than twice as high in males and is showing an increase in most parts of the world.⁶

Radiotherapy for HNC is typically given in daily fractions of 180cGy (centi-Gray) to 200cGy, five days a week to a total dose of 6000cGy to 7000cGy. However radiotherapy causes DNA damage to cells of surrounding critical structures, resulting in acute side effects such as skin reactions, oral mucositis (OM) and xerostomia which can severely affect a patient’s nutritional status and quality of life (QOL). Concurrent chemo-radiotherapy is often used to improve loco regional control, organ preservation and overall survival in patients with advanced disease but at the expense of increased toxicity (fibrosis and dysphagia leading to feeding tube dependency).⁶

Oral mucositis is a distressing toxic effect of radiotherapy and systemic chemotherapy in cancer patients. Mucositis is characterized by atrophy of squamous epithelial tissue, vascular damage, and an inflammatory infiltrate concentrated at the basement membrane and is followed by ulceration. Oral mucositis is associated with significant morbidity characterized by pain, odynodysphagia, dysgeusia, malnutrition, dehydration and it also increases the risk for systemic infections in immunocompromised patients.⁷

Clinically OM develops within 10-14 days after start of radiotherapy, beginning at 15Gy, becomes full blown at 30Gy and may persist till 2-3 weeks after stopping treatment. Severe OM is associated with pain, erythema, ulcers and sores on oral mucosa (including gums, mouth or tongue), burning sensation in mouth, loss of taste, sensitivity to hot, cold or spicy food, difficulty in swallowing and talking owing to dryness of mouth and presence of ulcers, leading to impaired intake. This negatively impacts the patient’s QOL (Quality of Life) and often results in malnutrition, weight loss and depression.6Honey works differently from antibiotics, which attack the bacteria's cell wall or inhibit intracellular metabolic pathways. Honey is hygroscopic, it draws moisture out of the environment and thus dehydrates bacteria. Honey is used as a complementary therapy in oncology settings especially in patients with radiation or chemotherapy induced oral mucositis .Honey has antimicrobial and anti-inflammatory properties.⁸

Honey has high sugar content which hinders the growth of microbes. Honey reduces pain by sensitizing the nerve endings by prostaglandin produced in the process of inflammation. The low pH level of honey (3.4-5.5) and acidification of wounds speeds healing process .Natural honey is a product with rich nutritional qualities that could be pleasant, simple, and economic modality for the management of radiotherapy induced oral mucositis.⁸

Rashad UM did a study on honey as topical prophylaxis against radio chemotherapy induced mucositis in head and neck cancer in Assiut university Hospital, Egypt. 40 patients diagnosed with head and neck cancer were entered into the trial. Enrolled patients were randomized to either the treatment group, receiving concomitant chemotherapy and radiotherapy plus prior topical application of pure honey, or the control group, receiving concomitant chemotherapy and radiation therapy without honey. Patients were evaluated clinically every week to assess development of radiation mucositis. In the results in the treatment group, no patients developed grade four mecositis and only 3 patients (15%) developed grade three mucositis. In the control group 13 patients (65%) developed grade three or four mucositis (p< 0.05). As a conclusion this study shows that prophylactic use of pure natural honey was effective in reducing mucositis resulting from radio chemotherapy in patients with head and neck cancer.⁹

The investigator during her clinical experience had come across cancer patients radiation induced oral mucositis and need to do some intervention to reduce the oral mucositis among cancer patients undergoing radiation therapy. From the findings of literatures the investigator realized the importance of reducing the severity of radiation induced oral mucositis in cancer patients using Apitherapy and designed a study to evaluate the effectiveness of Apitherapy on oral mucositis among cancer patients undergoing radiation therapy.

OBJECTIVE:

· To assess the oral mucositis among cancer patients undergoing radiation therapy.

· To determine the effectiveness of Apitherapy in oral mucositis among cancer patients undergoing radiation therapy.

· To find the association between degree of oral mucositis after Apitherapy among cancer patients undergoing radiation therapy with their selected demographic variables.

HYPOTHESIS:

1. H₁: Apitherapy will be effective in reducing oral mucositis among cancer patients undergoing radiation therapy.

2. H₂: There will be a significant association between degree of oral mucositis after Apitherapy among cancer patients undergoing radiation therapy with their selected demographic variables.

MATERIAL AND METHODS:

Research Approach: Quantitative Approach

Research Design: Pre-Experimental Research Design, One-group pretest-posttest design.

Target Population: Cancer patients with oral mucositis admitted in selected hospital at Rajkot.

Accessible Population: Cancer patients with oral mucositis admitted in selected hospital at Rajkot.

Sampling Technique: Purposive Sampling Techniques

Data Collection Procedure: WHO oral mucositis Assessment Scale

Group: 40

Pretest Assessment of Oral mucositis: With WHO oral mucositis Assessment Scale on 1^stday.

Posttest Assessment of Oral mucositis: With WHO oral mucositis Assessment Scale after 7 days of Apitherapy

Data Analysis: Descriptive & Inferential Statistics

Criterion Measure: Grade Of Oral Mucositis

MAJOR FINDINGS:

A. Finding related to demographic variables of the study.

1. The majority of 12(30%) the sample’s age is between 31-40years.

2. The majority of 31(77.5%) the sample’s are males.

3. The majority of 24(60%) the sample’s had 3-4 weeks of radiation therapy.

4. The majority of 19(47.5%) the sample’s are on stage ll cancer.

5. The majority of 19(47.5%) the sample’s are on nasogastric tube feeding.

B. Findings according to assessment of oral mucositis among cancer patients undergoing radiation therapy.

The pre test reported 36(90%) moderate oral mucositis, 4(10%) severe oral mucositis and after the intervention Apitherapy in the post test the grade of oral mucositis were reported as 36(90%) mild oral mucositis, 4(10%) reported moderate oral mucositis.

C. Findings related to effectiveness of Apitherapy in oral mucositis among cancer patients undergoing radiation therapy.

The effectiveness of Apitherapy in oral mucositis reduction was revealed in the post test that there was significant improvement in the quality of life and reduction in degree of severity of oral mucositis with the application of Apitherapy. The obtained ‘t-test’ value for the grade of mucositis was 15.45 that was highly significant at p<0.001 level hence the hypothesis was accepted.

D. Findings related to association between demographic variables and post test.

With regard to association between degree of oral mucositis with their selected demographic variables age and stage of cancer are significant, other demographic variables such as gender, duration of radiation therapy, diet being taken, maintaining oral hygiene did not show significant association. Thus stated hypothesis is accepted and null hypothesis is rejected which shows there is significant association between effectiveness of Apitherapy and selected demographic variables.

CONCLUSION:

The main conclusion from this present study is that most of the cancer patients undergoing radiation therapy had moderate to severe grade of oral mucositis in pre test and mild, moderate grades of oral mucositis in post test. This shows the imperative need to understand the purpose of Apitherapy regarding reduction of degree of severity of oral mucositis among cancer patients undergoing radiation therapy and it will improve the quality of life which includes the stability in nutritional physiological, psychological, vocational and lifestyles aspects.

REFERENCES:

1. Wikipedia, the free Encyclopedia. Cancer. [Online] 2015. Available from: http://en./wikipedia.org/wiki/Cancer. [Accessed on 2^ndJune 2015].

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3. American cancer society. 2015. Available from: http://www.cancer.org/research/cancerfac -tstatistics/cancerfactsfigures2015/. [Accessed on 1st July 2015].

4. The American Apitherapy. [Online] 2015. Available from:http://www.apitherapy.org/. [Accessed on 30th June 2015].

5. Lewis SM, Heitkemper M, Dirksen SR, Bucher O’Brien. Chintamani (ed.). Medical- Surgical Nursing. 7^th edition. Philadelphia: Mosby Elsevier publications; 2011; 270-273.

6. Devgan RK, Kaur SJ, Singh J, Sharma DK. An evaluation of sucralfate and honey on Oral mucositis amongst patients of head and neck cancers receiving radiotherapy and concurrent chemotherapy:a comparitve study. International journal of healthcarescienc [Online] 2015: ISSN 2348-5728; (2); 202-209. Available from:http://www.researchpub lish.com. [Accessed on 30^thJune 2015].

7. Roopshree GJ, Jayanthii KR. Radiotherapy and chemotherapy induced oral mucositis- prevention and current therapeutic modalities: a descriptive study. NACD. [Online] 2013; vol(2) issue(2)/41. Available from: http://www.nacd.in/ijda/volume-02-issue-02 /41. [Accessed on 22^ndJune 2015].

8. Simson A, Traynor K, et al. Medical honey for wound care. Journal of Evidence Based Based Complementary and Alternative Medicine. [Online] 2009 June; 6 (2): 165 - 173. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2686636/. [Accessed on 12^th June].

9. Rashad UM, Gezaway Al, El Gezaway. [Online]. Honey as topical prophylaxis against Radiochemotherapy - induced mucositis in head and neck cancer : an interventional interventional study. NCBI [Online] 2009 Feb; 123(2): 223-8. DOI: 10. 1017/S0022215 108002478. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18485252 [Accessed on 22^nd June 2015

Received on 07.09.2016 Modified on 25.09.2016

Int. J. Nur. Edu. and Research. 2017; 5(1): 55-58.

DOI: 10.5958/2454-2660.2017.00012.6