Expanding Access to Photobiomodulation Treatment for Paediatric Oncology Patients in Glasgow

Oral mucositis (OM) is one of the most frequent side effects of cancer treatment. It is associated with intense oral pain, eating and swallowing difficulties, bacteraemia, opioid prescription, increased enteral or parenteral nutrition requirements, extended in-patient hospital stays, interruptions to cancer treatment, and a higher 100-day mortality [1, 2]. Photobiomodulation treatment (PBM) refers to the application of a range of non-ionising red and near-infrared light sources to positively influence cellular metabolism. PBM has an anti-inflammatory effect, wound healing properties, and promotes analgesia in patients with OM [3]. PBM is recommended for use in children by the Paediatric Oncology Group of Ontario (POGO) in clinical practice guidance in OM prevention [4]. The Royal Hospital for Children, Glasgow (RHC) is a Principal Treatment Centre for paediatric oncology, led by oncologists and haematologists, with Advanced Nurse Practitioners (ANPs) having a vital role in the patient's treatment journey. RHC was an early adopter of PBM in the United Kingdom [5], with treatment delivered by the paediatric dentistry team using a class 3B laser since 2012 primarily on an inpatient basis. It has been empirically embraced by paediatric oncology patients, parents, and staff who report it to be easy and beneficial, with frequent requests for treatment and positive feedback from families [6]. The LaserPen from Reimers & Janssen GmbH is operated in continuous wave (CW) mode at a wavelength of 810 nm with an output power of 500 mW. At the time of writing, PBM is delivered at RHC as a treatment for established mucositis rather than for prevention. The local protocol for delivery of PBM is dictated by mucositis severity according to the World Health Organisation (WHO) oral mucositis scale. The protocol specifies the total laser energy (J) to be delivered to each mucositis-affected area of the mouth and throat. Full details of this protocol have been published previously [6]. Class 3B lasers are potentially harmful to the eyes, and safety precautions must be taken. Locally, the agreed standards include laser safety training for PBM providers, eye protection for all people present for PBM delivery, and designated laser-safe rooms with window coverings and signage on external doors. Existing guidance does not specify which staff groups should deliver PBM and this has been highlighted as a barrier to its use [5]. At the outset of this evaluation, PBM was delivered solely by the paediatric dentistry team, limited to 9-5 pm Monday to Friday (excluding public holidays). Patient/parent feedback through local service questionnaire, indicated desire for wider access to PBM—‘Usually [my son's] mucositis would occur at [the] weekend and I just wish it [PBM] was available at the weekends as he's in pain all weekend then has instant relief after receiving laser. Laser is invaluable but with weekend availability then he would not have to go through days of pain’. To evaluate the demand for and use of PBM in RHC for the treatment of OM in paediatric oncology patients. Data were subsequently collected prospectively over a 6-month period from December 2023 to June 2024 to re-evaluate the service following the implementation of changes, with additional data collected pertaining to job role. Over a 6-month period, 31 patients received 145 episodes of PBM treatment for established OM. The minimum, median and maximum number of treated intraoral and/or extraoral sites per session were 1, 3 and 10, respectively. As shown in Table 1, there was a large variation in the number of PBM episodes delivered per patient, ranging between 1 and 22. Modal delivery days occurred at the beginning of the week, on Mondays and Tuesdays, with no service available on weekends or public holidays due to the working pattern of the dental team. To expand access to PBM, three ANPs in the paediatric oncology team who had working patterns inclusive of weekends and public holidays received PBM training. There was a greater number of PBM episodes in Evaluation 2, with 52 patients treated over 312 episodes of care (Table 1). Over 50 PBM treatments (16.1%) were delivered by ANPs. To allow comparison of utilisation, Figure 1 shows the proportion of total PBM episodes delivered on each day of the week in each cycle. With the introduction of ANP provided PBM, 7.7% (n = 24) of all PBM episodes were delivered on a Sunday, with proportionally less treatment delivered on Mondays. The training of ANPs also enabled 13 episodes of PBM to be delivered on public holidays. Despite PBM being available 7 days a week, only two episodes were delivered on Saturdays. The service will be re-evaluated in 6 months' time to assess change over time, service demands, and any need for further staff training. Service development is ongoing to support delivery of PBM on a preventative basis to patients, in line with existing guidance [4]. The first evaluation showed that the most common days for PBM treatment were at the start of the week. This was thought to be related to the lack of access to this service over the weekend and supported patient/parent concerns regarding the impact of limited weekend access. This finding resulted in multidisciplinary collaboration to train oncology ANPs to provide PBM. During the second evaluation, 26 patients received PBM treatment on weekends and 13 patients on public holidays, respectively—something that was not possible previously due to the weekday schedule for dentists at RHC. Additionally, the three PBM-trained ANPs delivered a notable proportion (16%; n = 51) of all paediatric PBM treatments delivered in RHC in this period, including on weekdays. Between the cycles, a change in modal delivery day was observed. While both rounds show similar demand for PBM on Tuesdays through to Fridays, a reduction in utilisation of PBM on Mondays occurred in evaluation 2, with a new demand for delivery on Sundays. The lack of utilisation on Saturdays may indicate that a single day PBM treatment gap is acceptable to patients (compared to a 2 day weekend break in service), or may reflect other unobserved, competing service demands on Saturdays that affect PBM delivery. PBM treatment remains in high demand at RHC. Indeed, there was a 115% increase in the number of episodes of PBM between evaluations (145–312), with the median number of episodes of PBM per patient increasing from 3.5 to 5. This may be related to the expansion of the service outside of standard hours, including through the weekend and over holiday periods. Additionally, the wider staff training has allowed for increased flexibility within the PBM service, supporting the paediatric dentistry team where there is a shortage of dental staff (e.g., staff illness or study days) which would have previously limited delivery. The service evaluation supported a response to patient and family concerns, improving treatment access and consistency for paediatric oncology patients with OM. It addressed unwarranted variation in availability of care, providing continuity and enhancing patients' quality of life. The service development highlights the importance of collaborative, adaptive healthcare in addressing patient needs, delivering a more resilient and flexible service by utilising ward-based staff. The authors greatly appreciate the hard work and dedication of the oncology ANPs in RHC. The authors declare no conflicts of interest.