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Hello,

We have an HBO candidate (ORN)
Pt was taking Cis-Platin and Bleomycin
Both were D/C in February of 2021

Also pt has a lesion in mouth that they suspect is cancer, (it is at the same initial site), his surgeon wanted to take a biopsy but the pt does not want a biopsy taken..
It just so happened that as Im taking my CHT class this morning the speaker spoke about thissubject, stating that a biopsy should be taken in order to know if pt is a true candidate for HBO?

Any information would be helpful…

Thank you

Lisa

Apr 15, 2022 by Lisa Fischer,
5 replies
Eugene Worth
MD, M.Ed., FABA, ABPM/UHM
Lisa:

I will add a physician perspective, in order to ensure that we are talking on the same frequencies ...

I'm not sure who your speaker was in your CHT class, but that blanket statement doesn't make sense. I agree, with the oral surgeon or ENT, that a biopsy needs to be performed in order to make a cancer determination. If there is cancer in the lesion, no amount of HBOT will "cure" the ORN. The cancer needs to be treated and gone. I would not knowingly 'treat' a patient with recurring cancer in HBOT. Re-treating an oral cancer with excision, chemotherapy ... and rarely more radiation ... is not uncommon and frequently does not worsen the ultimate outcome ... but the required information is ... Does this lesion have cancer?

The unspoken question is "Does HBOT make a cancer grow more quickly or make it more severe?" My colleague, Dr. John Feldmeier has performed research with cancer cell cultures under hyperbaric exposure. None of the cancers that he has tested have grown more quickly or been more aggressive. I'll leave this to you about finding the papers by Dr. Feldmeier ... or you can ask your CHT physician instructors ... this is basic knowledge and should be covered in your introductory class.

Whether or not this patient is a candidate for HBOT means that the patient has no other diseases that would worsen (or be absolute contraindications) with exposure to high concentrations of inhaled oxygen under varying atmospheric pressure. On my list, there are plenty of 'relative' contraindications, but only one 'absolute' contraindication; an UNTREATED pneumothorax. Again, this should be covered in your introductory course lectures. And, this is purely a physician medical evaluation perspective.

I hope this makes sense and good luck in your studies for CHT!

gene worth
Apr 15, 2022
Jeff Mize
RRT, CHT, UHMSADS
Lisa,
Thank you for your question. Dr. Worth has provided the great insight from the physician perspective. I thought it would be helpful to provide an overview of considerations for Cisplatin, Bleomycin and hyperbaric oxygen therapy.

Cisplatin (Cisplatin®, Platinol®) - Cisplatin has been used for a number of years in a variety of cancer treatment protocols. The therapeutic benefit of this drug is realized through its ability to inhibit DNA synthesis affecting fibroblast production and collagen synthesis. Concomitant use of Cisplatin is a relative contraindication in patients who suffer from chronic, non-healing wounds and should not be considered for hyperbaric oxygen therapy due to diminished wound healing. [1]

Bleomycin Sulfate (Blenoxane®, Blenomax®) - Bleomycin is a polypeptide which fights against a number of tumors. The exact mechanisms of action of this drug are not clear; however, its cytotoxic effects are likely mediated through inhibition of cell cycle progression and the synthesis of DNA and protein. The primary dose-limiting toxicity of Bleomycin is the development of pulmonary toxicity ranging from radiographic changes to pneumonitis and fatal pulmonary fibrosis. Controversy has surrounded the use of supplemental oxygen administration and perioperative patients who have received Bleomycin chemotherapy since 1978 due to oxygen-related risk to severe pulmonary complications. Despite the theoretical risk, there are no articles specifically stating that HBO should be prohibited after bleomycin administration. As late as 2008, prior bleomycin remained an absolute contraindication to HBO therapy. [1]

The UHMS Safety Committee posted the following response to a MEDFAQ question regarding Bleomycin and hyperbaric Oxygen therapy, originally published August 2, 2015: “The UHMS is unable to provide a stance on Bleomycin being a contraindication to hyperbaric oxygen therapy. As always, this is the treating physician's decision. There is no definitive study on this topic, however Duke University published an article on their research. Prudence would mandate a consult with a pulmonologist with PFTs and the patient’s oncologist. Factors influencing toxicity include patient's age at time of Bleomycin, dose and time since treatment”. [2]

Klaus et al reported a case series fourteen Bleomycin exposed patients receiving hyperbaric oxygen therapy at Duke
Center for Hyperbaric Medicine and Environmental Physiology from 1979 to 2010. Fourteen bleomycin-exposed patients received HBO2 at Duke under a special-precautions protocol. One was treated for DCS elsewhere. The protocol included: pre-treatment evaluation; chest radiograph; spirometry; blood gases; a single, 2-atmospheres absolute (atm abs),120-minute HBO2 treatment; and a gradual acceleration over one week to a twice-daily schedule contingent on clinical and laboratory findings. Median bleomycin-to-HBO2 latency was 34 months (range 1-279). Three patients received HBO2 within six months, and seven patients received HBO2 within two years of their last bleomycin exposure. There were no adverse pre-to-post HBO2 changes in: arterial blood gases, spirometry, chest radiograph findings or clinical reports. There were no persistent post-HBO2 pulmonary complications on follow-up. Post-HBO2 data were available for 40%, 53%, 87%and 100% of these parameters respectively. Bleomycin and oxygen can individually cause acute pulmonary toxicity. However, evidence for increased long-term susceptibility based on their synergy may be overstated. [4]

Reference
1. Hamm T, Mize J, Worth E, (2019). "Medications In The Hyperbaric Environment". In (Eds.) , WoundReference. Available from: https://woundreference.com/app/topic?id=medications-in-the-hyperbaric-environment. Retrieved on 4/15/22.
2. UHMS.orghttps://www.uhms.org/resources/medfaqs-frequently-asked-questions-faq/search/1-%20Search.html?yrfaqsearch=cis%platin. Retrieved on 4/15/22.
3. Baude J, Cooper JS. Hyperbaric Contraindicated Chemotherapeutic Agents. In: StatPearls. Treasure Island (FL): StatPearls Publishing; August 11, 2021.
4. Torp KD, Carraway MS, Ott MC, et al. Safe administration of hyperbaric oxygen after bleomycin: a case series of 15 patients. Undersea Hyperb Med. 2012;39(5):873-879.

I hope this helps. Thanks again for your questions.

Jeff
Apr 16, 2022
Dr. Worth and Jeff,

Thank you for the info. I probably worded my question wrong re: Cancer and "a true candidate" I apologize. It was a busy week for me and I had so much new info in my brain. I guess the only other thing that Dr. Chong and myself were wondering about was since the pt has been D/Cd from Bleomycin and Cisplatin for 13 months if that would cause any contraindication. We both read your response as the pt will be a candidate since his meds have been D/Cd?
Apr 18, 2022
Eugene Worth
MD, M.Ed., FABA, ABPM/UHM
Lisa, great question about Bleomycin. This is a topic where lions dare to tread. OK, so the patient has not received the drug for 13 months. That's fine, but the oxygen-induced pulmonary fibrosis is a lifetime penalty to bleomycin. Some patients can have oxygen exposure and some cannot.

I'm going to attach a file discussing this and the monitoring that you must commit to in order to care for the patient safely. The devil here is in the details.

My personal opinion is to steer clear of this patient unless you have a pulmonologist willing to back you up with the testing and interpretation of these tests as you treat this patient.

See what you think after you and your physician read these papers.

Apr 18, 2022
thank you so much!
Apr 18, 2022
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