Improving Toxicity Grading and Management of Esophagitis for Radiotherapy Breast Cancer Patients

Purpose/Aim

An increase in the usage of prescriptions for pain-relieving mouthwash (PRM) for mild esophagitis has been noted in a population of breast cancer patients receiving radiotherapy with supraclavicular nodal irradiation in this institution. Between January 2023, to March 2024, 49% of patients were given PRM (either newly prescribed or were told to continue a previous prescription) to aid in altered eating/swallowing due to their radiation treatment. Typically, grade 2 esophagitis would require intervention, but this data showed PRM was given for grade 1 more commonly than grade 2. This is a problem as it goes against the standardized grading scale (CTCAE) guidelines and an expensive prescription which has a short shelf life should only be filled when necessary. The aim was to decrease the percentage of breast nodal radiotherapy patients with grade 1 esophagitis who are prescribed pain-relieving mouthwash from 58.3% to 15% within six months.

Methods/Process

An interdisciplinary team collaborated on how to improve congruency of prescribing based on the guidelines. An infographic was developed to guide radiotherapy team members in grading esophageal toxicities. Clinical educators reviewed it with both RNs and MRT(T)s and posted it in clinic areas. The study author led an education session, followed by a survey to gather feedback on the implementation. On weekly review, all breast nodal radiotherapy patients who were graded as grade 1 toxicity level and were given PRM were tracked. A comparison was made to the management and grading of patients treated during the few months preceding the study to determine trends after change ideas were implemented. The monthly percentage of patients prescribed PRM assessed at grade 1 esophagitis were graphed in a run chart.

Results or Benefits/Challenges

The benefit of this study is a reduction in unnecessary prescriptions following data driven quality improvement efforts. Staff were surveyed and reported empowerment with increased confidence in esophageal toxicity grading and sharpened toxicity assessment skills. The challenge of this study is that there is a small sample size that fluctuates based on the number of patients who are on active treatment for nodal breast radiotherapy in the department.

Conclusions/Impact

A discrepancy between the toxicity grading levels reported and the guidelines indicating when interventions are required was initially observed. Only one month after introducing the infographic, the percentage of breast nodal radiotherapy patients with grade 1 esophagitis who were prescribed PRM decreased to 33%. The study is ongoing and further reduction in the percentage of patients prescribed PRM outside of guidelines is expected in the coming months. Prescribing PRM less often could alleviate the financial burden for patients who were purchasing prescriptions for mouthwash before trying different management strategies and additionally reduce clinic disruptions. A potential impact of this study is to expand the usage of the infographic to other patient cohorts and to extend it to the provincial cancer care team.