Nursing researchers illuminate symptom relief for mucositis

Reviewing her patient’s chart, Brittany Bedard, RN, combed through the details of an intricate diagnosis and treatment plan. As is common for many patients at St. Jude, the case was complex; the patient had a rare, metastatic tumor requiring substantial treatment that would leave him susceptible to side effects. Chief among them was esophageal mucositis, a painful inflammation of the protective mucosa (mucous membrane) lining the gastrointestinal tract, specifically in the esophagus. If left unchecked, mucositis can result in an inability to eat and can require a feeding tube to maintain nutrition.

As a nurse, Bedard was familiar with the impact of care. She understood that treatment for rare diseases could be rough on the body, especially for patients receiving radiation therapy, with whom she spends the bulk of her time. While survival is the ultimate goal for each child she treats, she is keenly focused on improving her patients’ quality of life. With that aim, Bedard sought out any literature she could find on alleviating the worst symptoms of mucositis.

Mucositis commonly occurs in patients undergoing radiation therapy or bone marrow transplantation. Because mucositis-affected tissues usually heal themselves after intense therapy, mucositis symptoms are traditionally treated with pain management. However, Bedard knew that her colleagues at St. Jude regularly used photobiomodulation, commonly referred to as “red light therapy,” to prevent and mitigate oral mucositis in patients undergoing bone marrow transplantation. The procedure uses small discs placed on the affected site that emit red light to stimulate the cells and promote healthy regeneration. She had also seen it used effectively with her own patients in Radiation Oncology to treat dermatitis. Perhaps, she hoped, there was research to support its use in this new context.

Published research on treating esophageal mucositis offered Bedard negligible insight as to whether photobiomodulation therapy could be effective in helping her patient. “I found nothing,” said Bedard. “The type of tumor is so rare; the treatment is so rare. So that’s when it went from ‘What can I find?’ to ‘If it’s not going to hurt, why not try?’”

Determined to find a solution for her patient, Bedard turned to her colleagues in the Division of Nursing Research for guidance.

A painful problem, a gentle solution

The mucosa experiences rapid cell turnover, allowing the membrane to revitalize itself, remove harmful particles and pathogens, and heal quickly. However, therapies designed to target rapidly dividing cancer cells, such as chemotherapy and radiation, cannot distinguish healthy cell turnover from unfettered growth. Thus, these therapies affect healthy mucosa cells along with cancer cells. This leads to painful inflammation of the tissue, loss of appetite and greater vulnerability to infections.

Photobiomodulation applies specific wavelengths of low-level light to the affected mucosa sites to reduce oxidative stress and induce cellular repair — without causing pain.

In a 2024 study led by Belinda Mandrell, PhD, RN, Division of Nursing Research director, St. Jude researchers used photobiomodulation therapy to prevent and reduce oral mucositis in patients who received a bone marrow transplant. Ninety-three percent of the study’s participants saw a significant reduction in mucositis, including reduced severity and duration of mucositis and fewer days admitted to the hospital. It was a watershed moment, ushering in a new standard of preventative care for all bone marrow transplant patients that has rapidly expanded to other treatment areas at St. Jude and other pediatric hospitals across the United States.

 “It’s not uncommon now for me to attend an outside meeting, and they’re talking about a photobiomodulation program they’re starting,” said Mandrell. “We were really on the forefront and the first to get this started and really show that, within pediatrics, photobiomodulation is feasible and it has significant efficacy. From that, the program has just exploded.”

With their expertise in photobiomodulation, Bedard knew her colleagues in the Division of Nursing Research were her best bet in getting her red-light therapy proposal for her patient off the ground. So, she turned to Mandrell and Hannah Clugh, RN, Light Therapy Program coordinator, to help develop the protocol. Like Bedard, neither Mandrell nor Clugh unearthed any additional existing research. Instead, they relied on their extensive knowledge and experience working with photobiomodulation equipment and designing research studies to light the way.

The team determined, based on the previous success of the bone marrow transplantation light therapy study, that the therapy needed to occur concurrently with primary treatment. However, they would have to adjust the light therapy equipment to accommodate the likely location and intensity of the mucositis. The small discs commonly used for cheek placement in oral mucositis cases had too small a surface area to use for an esophageal case, nor were they necessarily strong enough to penetrate the membranous tissue in the throat. The team needed a larger paddle that would encompass the affected area and offer stronger light waves that were still gentle enough for a child to tolerate the treatment well. For Bedard, pain reduction was key.

Throughout his combined light therapy and primary treatment, the team monitored the child for increased pain and difficulties with eating and digestion. The child reported none; instead, he maintained his weight and was able to enjoy meals as normal, without supplemental feeding. Additionally, his therapy progressed uninterrupted by toxicities associated with mucositis.

“I knew the projection for him was that he was probably going to have an NG [nasogastric] tube because he wasn’t going to be able to eat — it was going to be that significant. So, I hoped, maybe we could avoid the NG tube. Maybe there would be some pain, but not so bad that he couldn’t eat,” Bedard said. “We probably couldn’t take away all his discomfort, but could we make it so that he could eat even if his throat was sore or he had indigestion? That was my goal, so I was surprised and happy when he had next-to-no pain.”

The lack of pain and the relative normalcy it brings to patients and their families during challenging treatment is a frequent and gratifying datapoint for Clugh. “I think we are probably the most well-liked program, where children are concerned, because we offer things that don’t hurt and things that can be fun.”

The ripple effect

The National Institutes of Health created a task force to ensure nursing research had a seat at the table of biomedical research and established the National Institute of Nursing Research in 1986. St. Jude has shared this value, opening its first roles in nursing research in 1985 and maintaining a strong presence in the space ever since.

Since its inception, the Division of Nursing Research has built a robust infrastructure to support nursing staff at St. Jude pursuing research endeavors, ranging from mentorship in protocol design to evidence-based practice fellowships to poster-development workshops. For Mandrell and the Nursing Research staff, bolstering the confidence and research skills of nursing personnel is paramount to continuing the crucial role nurses play in clinical research and improving patient outcomes.

“A lot of nurses can feel hesitant — like they don’t think they’re capable of changing practice on their unit,” said Clugh. “Nursing Research is constantly endorsing and mentoring nurses, encouraging them to initiate evidence-based practice projects.”

That level of support was invaluable to Bedard, opening her eyes to possibilities she had not initially considered when she first pursued nursing. “A lot of times, the difference you feel you make as a nurse is on a more personal level. ‘What can I do with your care that gives you the trust to know I’m going to take care of your kid as if they were my own?’” explained Bedard. “But I felt like just asking a question led to something bigger than I even dreamed it would.”

That question led Bedard to a much better outcome for one child, but the information she and her colleagues learned will continue to help children down the road. The growing interest in the Light Therapy Program is a testament to that. “I get calls from families at other institutions, wanting to know what they can do to help their child when that hospital may not have a light therapy program,” said Mandrell. “We probably get a call at least once a week from another institution that’s interested in bringing this on board for their hospital.”

Reflecting on the program’s rapid growth and the role the Division of Nursing Research played, Clugh cannot help but smile. “It’s miraculous how, from that small study and from what we’re doing, it has had such an impact and has created such curiosity with other people. It’s quite something, quite special to be a part of it.”