Vitamin E is a fat-soluble vitamin found in seeds, nuts, leafy vegetables, and vegetable oils. It is a type of antioxidant and helps prevent cell damage caused by free radicals (highly reactive chemicals). It is being studied in the prevention and treatment of some types of cancer. Vitamin E has been used as an oral or parenteral supplement and as a solution for topical application. Vitamin E has been examined in management of diarrhea, mucositis, peripheral neuropathy, skin effects, cognitive impairment, and hot flashes.
Clarkson, J.E., Worthington, H.V., Furness, S., McCabe, M., Khalid, T., & Meyer, S. (2010). Interventions for treating oral mucositis for patients with cancer receiving treatment. Cochrane Database of Systematic Reviews, 8, CD001973.
To assess the effectiveness of interventions for treatment of oral mucositis or its associated pain for patients receiving chemotherapy or radiation therapy
Databases searched were MEDLINE, CancerLIT, EMBASE, CINAHL, LILACS (Latin American and Caribbean Health Sciences Literature), Cochrane Oral Health Group and PaPaS Trials Registers, Cochrane Central Register of Controlled Trials (CENTRAL), OpenSIGLE, and Current Controlled Trials. Handsearching carried out by the Cochrane Collaboration was included. Reference lists from relevant articles were searched and the authors of eligible trials were contacted to identify trials and obtain additional information.
Search keywords were (neoplasm* OR leukemia OR leukaemia OR lymphoma* OR plasmacytoma OR “histiocytosis malignant” OR reticuloendotherliosis OR “sarcoma mast cell” OR “LettererSiwe disease” OR “immunoproliferative small intestine disease” OR “Hodkin disease” OR “bone marrow transplant*” OR cancer* OR tumor* OR malignan* OR netropeni* OR carino* or Adenocarcinoma* OR radioth* OR radiat* OR radiochemo* OR irradiat* OR chemo*) AND (stomatitis OR “Stevnes Johnson syndrome” OR “candidiasis oral” OR mucositis OR (oral AND (cand* OR mucos* OR fung*)) OR mycosis OR mycotic OR thrush. Extensive appendices are provided with specific search strategies used for each database.
Studies were included in the review if they
The final assessment incorporated 32 studies. Out of an initial 95 eligible studies, 64 were excluded because of study design issues, protocol violations, lack of useable data, or no relevant outcomes.
Treatment of mucositis
Summary of data from single trials showed the following interventions to demonstrate statistically significant benefit (p < 0.05).
Other interventions for treatment of mucositis evaluated included chlorhexadine versus salt and soda, Gelclair verus sucralfate and mucaine,”Magic” mouthwash versus salt and soda, sucralfate versus placebo and versus salt and soda, and tetrachlorodecaoxide.
Management of pain with mucositis
The following interventions demonstrated statistically significant benefit in managing pain (p < 0.05).
The lack of independent duplication of studies investigating the same intervention limits the strength of evidence and ability to generalize results.
Most studies reviewed had small sample sizes and may have been underpowered to demonstrate significant differences in outcomes.
Different scoring systems for mucositis were used, and, in some studies, the method of scoring was not defined.
The need for further well-designed trials to evaluate the effectiveness of interventions continues.
Adoption of standard clinical outcome measures should be considered, including patient-based measures and inclusion of the cost of interventions.
Khurana, H., Pandey, R., Saksena, A., & Kumar, A. (2012). An evaluation of vitamin E and pycnogenol in children suffering from oral mucositis during cancer chemotherapy. Oral Diseases.
Evaluate and compare effectiveness of topical vitamin E and pycnogenol (pine bark extract) in treatment of chemotherapy-induced oral mucositis.
Children were randomly assigned to the use of vitamin E, pycnogenol, or sterile water rinses. All were also to follow a uniform oral care protocol, including brushing with a soft tooth brush and chlorhexidine mouth rinse 3 times/day. All study interventions were applied topically three times a day using a dropper. Medications were stored in a refrigerator before usage. The medication was kept in the patient’s mouth for 30 seconds and then swallowed. Patients were blinded to the treatment group. Patients were followed for seven days.
The study was comprised of 72 patients, with a mean age of 9.25 and a range of 6-15 years.
MALES 79%, FEMALES 21%
KEY DISEASE CHARACTERISTICS: All had hematological cancers, including ALL, AML, and NHL, and all were in induction or intensification phases of treatment.
SITE: Single site
SETTING TYPE: Multiple settings
PHASE OF CARE: Active antitumor treatment
Single, blind, randomized placebo controlled
Mucositis grades in those receiving either vitamin E or pine bark extract were significantly lower than those on placebo (p </= 0.006). OMAS scores declined significantly and consistently across days 1-7, while these scores remained the same in the placebo group. There was significant improvement in pain scores in both intervention groups from day 4 onward, compared to placebo. There were no significant differences in study outcomes between those treated with vitamin E or pine bark.
Topical vitamin E and pine bark extract (pycnogenol) were of benefit in reducing severity of mucositis and pain associated with mucositis in these patients.
Topical vitamin E and pine bark extract may have some promise for the management of oral mucositis. Further research on these interventions is warranted.
Sung, L., Tomlinson, G.A., Greenberg, M.L., Koren, G., Judd, P., Ota, S., & Feldman, B.M. (2007). Serial controlled N-of-1 trials of topical vitamin E as prophylaxis for chemotherapy-induced oral mucositis in paediatric patients. European Journal of Cancer, 43, 1269–1275.
Eight hundred mg vitamin E was diluted with corn oil (volume = 2 mL). Patients swished for at least 30 seconds then spat it out. The control group received corn oil only. Subjects did not rinse mouths for 30 minutes after spitting out the solution. Forty-five cycles of the study drug were administered (one cycle: four patients, two cycles: five patients, three cycles: one patient, four cycles: four patients, six cycles: five patients; vitamin E = 22 cycles, placebo = 23 cycles).
Compliance was 84% with no statistically significant findings. Vitamin E was not associated with reduction in pain VAS scores or swallowing difficulty. WHO mucositis scores were similar for vitamin E and placebo cycles. No differences for the additional secondary outcomes between vitamin E and placebo cycles were found. Authors noted that vitamin E should not be used in this context. N-of-1 study design was found to be a potentially effective design method.
Yarom, N., Ariyawardana, A., Hovan, A., Barasch, A., Jarvis, V., Jensen, S.B., . . . Mucositis Study Group of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO). (2013). Systematic review of natural agents for the management of oral mucositis in cancer patients. Supportive Care in Cancer, 21, 3209–3221.
PURPOSE: Review evidence and provide guidelines for use of natural agents in the prevention and management of oral mucositis in cancer
TYPES OF PATIENTS ADDRESSED: Patients receiving chemotherapy, radiation therapy, or stem cell transplant
RESOURCE TYPE: Evidence-based guideline
PROCESS OF DEVELOPMENT: Systematic review of evidence, quality rating using Hadorn criteria, and level of evidence classified via Somerfield criteria
DATABASES USED: MEDLINE
KEYWORDS: Alternative, complementary, homeopathic, aloe vera, beta carotene, chamomile, chines herbal, folic acid, and numerous other specific natural agents
INCLUSION CRITERIA: Not specified, other than use of a natural agent
EXCLUSION CRITERIA: Not specified
PHASE OF CARE: Active antitumor treatment
Ninety-nine papers were identified, and, of these, 49 papers were included in the review.
Findings do not support efficacy of currently studied natural herbal agents and other agents for prevention of oral mucositis. Systemic zinc supplementation may be helpful for patients with oral cancer receiving treatment. Glutamine is not recommended in patients undergoing cell transplant. Further, well-designed research in this area continues to be needed.