Its Oral Right, Honey!

Abstract

Pediatric Oncology remains a very challenging field despite improved outcomes in the last few decades, using the combined modalities of surgery, radiation therapy and chemotherapy. However, relatively few of these improved outcomes have been accompanied by introduction of new therapies in the armamentarium of chemotherapeutic agents. A case in point is Acute Lymphoblastic Leukemia (ALL) in children. A decade-wise analysis of sequential ALL trials by the Children’s Oncology Group (COG) showed dramatic improvements from a dismal 20% survival in the early 1970s, to 60% in the late 1970s, followed by incremental increases to well over 90% in the 2000s [1]. But there have been no new drugs used in the primary treatment of ALL since 1980. Similar success stories abound across the spectrum of pediatric cancers, with a few notable exceptions of recalcitrant tumors. The main treatment modality remains chemotherapy. While refinements in the use of these agents, better risk-stratification, and response-adapted therapy have contributed largely to the outcomes, the contribution of supportive care has been probably the biggest, though also the most difficult to measure. While we await newer miracle therapies, focus in developing countries like ours must remain on improving supportive care with low-cost interventions that reduce mortality or morbidity with locally relevant research [2]. In this context, the article in this issue by Singh et al., exploring the effectiveness of topical application of Honey for reducing morbidity of Oral Mucositis (OM), in children undergoing chemotherapy is notable. OM is a vexed issue in Pediatric Oncology often tipping the nutritional balance to negative in a populace that has endemic malnutrition even before being subjected to nauseating and emetogenic chemotherapy. Many strategies have been tried, though the most successful ones are not necessarily cheap, even though most are easily available compounds. A case in point is Casophol®, a super-saturated solution of Calcium and Phosphorus that proved very effective in transplant and standard chemotherapy settings [3]. Though not yet easily available in India, its price is listed upwards of INR 7000/− (unconfirmed). Singh et al., have settled, for reasons well explained in the article, on natural honey [4]. It is not for the first time this has been tried, and neither is it the only traditional compound that may have a role. Several others have been tried, though systematic reviews have found most such studies to be ill-designed [3, 5]. However, what the authors have shown in a simple open-label randomized study, in which the observer who measured outcomes was blinded, is that application of honey in addition to standard care significantly reduced severity of OM by day-3 and 7, though beyond that the two groups were comparable. So, what should we gather from this? Can it now become routine practice? From a purely scientific robustness viewpoint for widespread applicability, the answer would be ‘No’. The reasons for this would be several, chiefly among them the inclusion criteria, blinding procedure and sample size. Specifically, patients with grade 1 or 2 mucositis at study inclusion only were taken. This was justifiable for ethical reasons, for what is essentially a Phase-II study, in which administrator and patient are not blinded, even though the observer is. To make a wide recommendation of its use in general practice would be improper as it is subject to the same limitations for other such therapiesnatural and otherwise, as is pointed out in systematic reviews. Having said that, the natural appeal of Honey * Gaurav Narula [email protected]