Guidance on mucositis assessment from the MASCC Mucositis Study Group and ISOO: an international Delphi study

Abstract

Background: Mucositis is a common and highly impactful side effect of conventional and emerging cancer therapy and thus the subject of intense investigation. Although common practice, mucositis assessment is heterogeneously adopted and poorly guided, impacting evidence synthesis and translation. The Multinational Association of Supportive Care in Cancer (MASCC) Mucositis Study Group (MSG) therefore aimed to establish expert recommendations for how existing mucositis assessment tools should be used, in clinical care and trials contexts, to improve the consistency of mucositis assessment.

Methods: This study was conducted over two stages (January 2022-July 2023). The first phase involved a survey to MASCC-MSG members (January 2022-May 2022), capturing current practices, challenges and preferences. These then informed the second phase, in which a set of initial recommendations were prepared and refined using the Delphi method (February 2023-May 2023). Consensus was defined as agreement on a parameter by >80% of respondents.

Findings: Seventy-two MASCC-MSG members completed the first phase of the study (37 females, 34 males, mainly oral care specialists). High variability was noted in the use of mucositis assessment tools, with a high reliance on clinician assessment compared to patient reported outcome measures (PROMs, 47% vs 3%, 37% used a combination). The World Health Organization (WHO) and Common Terminology Criteria for Adverse Events (CTCAE) scales were most commonly used to assess mucositis across multiple settings. Initial recommendations were reviewed by experienced MSG members and following two rounds of Delphi survey consensus was achieved in 91 of 100 recommendations. For example, in patients receiving chemotherapy, the recommended tool for clinician assessment in clinical practice is WHO for oral mucositis (89.5% consensus), and WHO or CTCAE for gastrointestinal mucositis (85.7% consensus). The recommended PROM in clinical trials is OMD/WQ for oral mucositis (93.3% consensus), and PRO-CTCAE for gastrointestinal mucositis (83.3% consensus).

Interpretation: These new recommendations provide much needed guidance on mucositis assessment and may be applied in both clinical practice and research to streamline comparison and synthesis of global data sets, thus accelerating translation of new knowledge into clinical practice.

Funding: No funding was received.

Keywords: Gastrointestinal mucositis; Mucositis assessment tools; Oral mucositis; Patient-reported outcome measures.

Fig. 1

Flow chart demonstrating the stages of the Delphi process. MASCC, Multinational Association of Supportive Care in Cancer; MSG, Mucositis Study Group.

Fig. 2

Assessment tools ranked by preference in sample of MASCC MSG members and aggregated based on their use in clinical trials vs clinical practice. The respondents were asked to mark their preferred assessment tool, in clinical practice and in clinical trials. Hence for each assessment tool, the same respondents answered two questions. BSC, Bristol stool scale; DGS, daily gut score; FACIT-D, Functional Assessment of Chronic Illness Therapy Diaerrhoea subscale; NCI-CTCAE, National Cancer Institute-Common Terminology Criteria for Adverse Events; IBD-Q Score, Inflammatory Bowel Disease Questionnaire; OMAS, Oral Mucositis Assessment Scale; OMDQ, Oral Mucositis Daily Questionnaire; OMNI, Oral Mucositis Nursing Instrument. OMWQ, Oral Mucositis Weekly Questionnaire; PRO-CTCAE, Patient-reported outcome-Common Terminology Criteria for Adverse Events; RTOG, Radiation Therapy Oncology Group; WHO, World Health Organization.

Fig. 3

MASCC MSG member confidence in assessment tools with each tool ranked from 0 = no confident at all in using the tool to 10 = extremely confident in using the tool. BSC, Bristol stool scale; DGS, daily gut score; FACIT-D, Functional Assessment of Chronic Illness Therapy Diaerrhoea subscale; NCI-CTCAE, National Cancer Institute-Common Terminology Criteria for Adverse Events; IBD-Q Score, Inflammatory Bowel Disease Questionnaire; OMAS, Oral Mucositis Assessment Scale; OMDQ, Oral Mucositis Daily Questionnaire; OMWQ, Oral Mucositis Weekly Questionnaire; PRO-CTCAE, Patient-reported outcome-Common Terminology Criteria for Adverse Events; RTOG, Radiation Therapy Oncology Group; WHO, World Health Organization.

Fig. 4

Rates of agreement of each recommendation following the second round of the Delphi survey. Recommendations that did not reach consensus are marked in white.