MUCOSITIS/STOMATITIS ORAL CHEMOTHERAPY EDUCATION Stomatitis (also known as mucositis or mouth sores) describes a common side effect of certain anti-cancer drugs (e.g., methotrexate, sunitinib, afatinib, cytarabine, fluorouracil), radiation therapy, or a combination of both. It causes swelling of the mouth and can affect the cheeks, lips, gums, tongue, throat, and the roof or floor of the mouth. Things that put you at risk: o Poor dental care o Dental prosthetics (e.g., dentures, dental bridges, implants) that do not fit o Gum diseases and fungal, bacterial, or viral infections o Open wound or cut in the mouth o Dehydration o Smoking o Other medications (opioids, steroids, antidepressants, anticholinergics, antihistamines, decongestants) What you may experience with mucositis/stomatitis: o Ulcers or sores in the mouth, including on the gums or tongue o Pain or discomfort in the mouth and throat, including when eating food o Reddening of the skin inside the mouth, usually in patches o Swelling of the mouth and gums o White patches in the mouth o Trouble talking and swallowing food or water Mucositis/stomatitis typically starts after 1 to 2 weeks of cancer treatment. It may go away on its own or require treatment recommended by your care team. What can you and your care team do to prevent and lessen the severity of mucositis/stomatitis? o Swish and spit with solutions that contain salt, baking soda, and warm water (one-half teaspoon of salt and one teaspoon of baking soda in 8 oz of water) every 4 hours. o Keep your mouth moisturized by using over the counter products for dry mouth. o Keep your lips moisturized and protected by using water-soluble, lanolin or oil-based lubricants. o Take good care of your teeth and gums and use a soft toothbrush when brushing your teeth. • You may buy a soft bristle toothbrush or run your toothbrush under hot water to soften the bristles. o If you are receiving anti-cancer drugs through your veins, ask your care team if you should swish ice chips in your mouth for 20 to 30 minutes around the time of cancer treatment (also referred to as “oral cryotherapy”). o Avoid alcohol (including drinking alcoholic beverages as well as mouthwashes that contain alcohol) and tobacco products. o Avoid eating foods that are sharp or rough, spicy, hot, acidic, citrus fruits, or require a lot of chewing. o Your doctor may prescribe you mouth washes to help with pain and healing. o Consider visiting your dentist for your routine follow ups. Call your care team if you are experiencing any pain or discomfort in your mouth or throat. MUCOSITIS/STOMATITIS ORAL CHEMOTHERAPY EDUCATION Important notice: The Association of Community Cancer Centers (ACCC), Hematology/Oncology Pharmacy Association (HOPA), National Community Oncology Dispensing Association, Inc. (NCODA), and Oncology Nursing Society (ONS) have collaborated in gathering information for and developing this patient educational supplement. This summarized information represents a brief summary of supportive care information and other resources. This supplement does not cover all existing information related to the possible directions, doses, precautions, interactions, adverse effects, or risks associated with specific medication or adverse events and should not substitute for the advice of a qualified healthcare professional. Provision of this supplement is for informational purposes only and does not constitute or imply endorsement, recommendation, or favoring of this side effect management by ACCC, HOPA, NCODA, or ONS, who assume no liability for and cannot ensure the accuracy of the information presented. The collaborators are not making any representations with respect to the clinical information presented whatsoever, and any and all decisions, with respect to such patient management, are at the sole risk of the individual consuming the medication. All decisions related to education and managing adverse events should be made with the guidance and under the direction of a qualified healthcare professional. Permission: Supplemental Oral Chemotherapy Education (OCE) sheets are provided as a free educational resource for patients with cancer in need of concise, easy-to-understand information about cancer topics and adverse event management. Healthcare providers are permitted to copy and distribute the sheets to patients as well as direct patients to the OCE website for information. However, commercial reproduction or reuse, as well as rebranding or reposting of any type, are strictly prohibited without permission of the copyright holder. Please email permission requests and licensing inquiries to This email address is being protected from spambots. You need JavaScript enabled to view it.. Copyright © 2022. All rights reserved. Additional instructions

ORAL ONCOLOGY TREATMENT TERMS ORAL CHEMOTHERAPY EDUCATION Chemotherapy treatment cycle A course of treatment that is repeated on a regular schedule with periods of rest between. For example, treatment for 2 weeks followed by 2 weeks of rest may be considered one treatment cycle. Hormone therapy This treatment affects hormone production. Hormones can cause certain cancers to grow (e.g., prostate and breast cancer). Hormones or other medicines may be given to block the body’s natural hormones, helping to slow or stop the growth of cancer. It is also called endocrine therapy, hormonal therapy, and hormone treatment. Medication adherence The extent to which patients take medicines as ordered by healthcare providers Oral chemotherapy Treatment with medicines given by mouth to kill cancer cells or stop them from growing Targeted therapy This type of treatment uses medicine to identify and attack specific types of cancer cells. It may cause less harm to healthy cells. There are many types of targeted therapies. Some block the action of certain enzymes, proteins, or molecules involved in the growth and spread of cancer cells. Other types help the immune system kill cancer cells or deliver toxic substances directly to cancer cells and kill them. Targeted therapies may have fewer side effects than other types of cancer treatment. Bibliography National Cancer Institute. (n.d.). National Cancer Institute dictionary of cancer terms. Retrieved from https://www.cancer.gov/publications/ dictionaries/cancer terms Osterberg, L., & Blaschke, T. (2005). Adherence to medication. New England Journal of Medicine, 353, 487–497. https://doi.org/10.1056/ NEJMra05010

SAFE HANDLING OF ORAL CHEMOTHERAPY ORAL CHEMOTHERAPY EDUCATION How should I handle my drug before I take it? ɋ Wash your hands before and after touching the drug. ɋ Only you or a caregiver should handle your chemotherapy. Do not let anyone else touch the drug. Ɉ If your caregiver handles your drug, he or she should wear gloves. ɋ Never break, crush, chew, or open your tablets or capsules unless your doctor tells you to do so. How should this drug be stored? ɋ Find a place in your home to store your oral chemotherapy that is separate from your other prescriptions and overthe counter medicines. ɋ Store your drug in a place with a controlled temperature that is not in direct sunlight. Be sure children and pets cannot reach your pills. ɋ Read the drug package and any included papers. Make sure to look for any storage instructions for your drug. Some drugs should be kept in the refrigerator. What should I do if another person or a pet swallows or is exposed to my drug? ɋ Keep calm. ɋ Flush the area with water, if the skin was exposed. ɋ Call the Poison Control Center immediately at 1 800 222 1222. What should I do with leftover drugs if my treatment is changed or stopped? ɋ Do not put chemotherapy drugs in the garbage* or down the toilet. ɋ Store your oral chemotherapy in a safe place until you can return it. ɋ State or local medication disposal sites or drop boxes are available as below: *If you need to dispose of oral chemotherapy quickly, follow these instructions: ɋ Mix whole pills (do not crush or open) in used coffee grounds or cat litter. ɋ Place the mixture in a container (e.g., empty laundry detergent or bleach bottle) and put the lid on tightly. Alternatively, double bag the mixture in plastic storage bags. ɋ Place the sealed container in your household trash. Additional instructions

SPECIALTY PHARMACY INSURANCE TERMS ORAL CHEMOTHERAPY EDUCATION Appeal An appeal is a request for your health insurance to go back and review a decision that denies a drug or service. It is often needed if your health insurance denies a prior authorization. Coinsurance This is the percent of the cost for a health service or drug that you pay after you’ve paid your deductible. For example, you may have to pay 20% coinsurance for each drug after you have paid your deductible. Copayment (“copay”) A copay is a fixed amount you pay for a covered healthcare service after you’ve paid your deductible. For example, you may have to pay a $20 copay for each prescription after you have paid your deductible. Deductible A deductible is the amount you pay for covered healthcare services before your insurance plan starts to pay for these same services. If you have a $1,000 deductible, you would need to pay $1,000 of the covered services before your insurance starts paying. Formulary A formulary is a list of preferred drugs covered by a health plan that offers drug benefits. It is also called a drug list. Grant Grants are given by nonprofit companies to help with the cost for drug coinsurance, copays, deductibles, health insurance premiums, and other selected out of pocket healthcare costs. The availability of these may vary based on the disease or medicine. Patient assistance program (PAP) These programs are created to help patients who lack health insurance or drug coverage or are unable to pay for their medicine. They often are offered by drug companies to give low cost or free medicines to patients who qualify and do not have Medicare or Medicaid. Prior authorization A prior authorization is a choice by your health insurance that a healthcare service, treatment plan, or prescription drug is medically needed. It may also be called preauthorization, prior approval, or precertification. Your health insurance may require this for certain services before you get them. It is not a promise that your health insurance will cover the cost. Bibliography Academy of Managed Care Pharmacy. (2016). The AMCP format for formulary submissions (version 4.0). Retrieved from http://www.amcp.org/ FormatV4/ American Pharmacists Association. (n.d.). Pharmacy benefit management. Retrieved from https://www.pharmacist.com/sites/default/files/files/ Profile 24 PBM SDS FINAL 090707.pdf HealthCare.gov. (n.d.). Glossary. Retrieved from https://www.healthcare.gov/glossary National Council on Patient Information and Education. (n.d.). Understanding prescription assistance programs (PAPs). Retrieved from http:// www.bemedwise.org/documents/paps.pd

UNDERSTANDING AND MANAGING TASTE CHANGES ORAL CHEMOTHERAPY EDUCATION Taste Changes Some people notice things taste differently during or after cancer treatment. Examples of these changes include: o Food tastes differently than before, mainly bitter, sweet, and/or salty foods. o Food smells different or certain smells are stronger. o Food may taste bland. o Every food may have the same taste. o A metallic or chemical taste in your mouth, especially after eating meat or other high-protein foods. What causes taste changes during cancer treatment? Taste changes can be caused by many things related to cancer treatment: o Medications to treat cancer • About half of people receiving cancer treatment have taste changes. • This usually stops 3 to 4 weeks after treatment ends. o Radiation treatment to the head or neck may affect taste buds and sense of smell. • This usually starts to improve 3 weeks to 2 months after treatment ends. • Taste changes may continue to improve for up to 1 year. o Other causes: • Surgery to the nose, throat, or mouth • Dry mouth • Mouth sores • Nausea and vomiting • Dehydration • Heartburn • Medications to help with side effects of cancer treatment How can taste changes be prevented or treated? There are no specific ways to prevent or treat taste changes from cancer treatment. To help, you can try the following: If you have a metallic taste in your mouth: • Use plastic forks, knives, and spoons. • Eat mints, chew gum, or chew ice. • Avoid red meat or try to marinate meat in fruit juices, Italian dressing, teriyaki sauce, sweet and sour sauce, or barbeque sauce. • Other sources of protein you can try are chicken, eggs, fish, peanut butter, beans, and dairy. If foods taste bland: • Brush your teeth before and after each meal. • Eat cold or room-temperature food because it may taste better than hot food. • Flavor food with herbs, spices, salad dressings, or sauces that you like. • Eat fresh or frozen fruits and vegetables instead of canned. • Eat small meals more often. Important notice: The Association of Community Cancer Centers (ACCC), Hematology/Oncology Pharmacy Association (HOPA), National Community Oncology Dispensing Association, Inc. (NCODA), and Oncology Nursing Society (ONS) have collaborated in gathering information for and developing this patient educational supplement. This summarized information represents a brief summary of supportive care information and other resources. This supplement does not cover all existing information related to the possible directions, doses, precautions, interactions, adverse effects, or risks associated with specific medication or adverse events and should not substitute for the advice of a qualified healthcare professional. Provision of this supplement is for informational purposes only and does not constitute or imply endorsement, recommendation, or favoring of this side effect management by ACCC, HOPA, NCODA, or ONS, who assume no liability for and cannot ensure the accuracy of the information presented. The collaborators are not making any representations with respect to the clinical information presented whatsoever, and any and all decisions, with respect to such patient management, are at the sole risk of the individual consuming the medication. All decisions related to education and managing adverse events should be made with the guidance and under the direction of a qualified healthcare professional. Permission: Supplemental Oral Chemotherapy Education (OCE) sheets are provided as a free educational resource for patients with cancer in need of concise, easy-to-understand information about cancer topics and adverse event management. Healthcare providers are permitted to copy and distribute the sheets to patients as well as direct patients to the OCE website for information. However, commercial reproduction or reuse, as well as rebranding or reposting of any type, are strictly prohibited without permission of the copyright holder. Please email permission requests and licensing inquiries to This email address is being protected from spambots. You need JavaScript enabled to view it.. Copyright © 2022. All rights reserved. Additional Instructions If foods taste salty: • Try low-salt versions of food or add a small amount of sugar to your food. • Drink plenty of clear liquids such as water, flavored water, sports drinks, broth, and decaffeinated tea. Avoid strong smells. • Use a fan, cook on an outdoor grill, or buy precooked food. • Cover drinks and use a straw. • Choose foods that do not need to be cooked. Your taste buds can change because of cancer treatment. Foods you did not like before may taste better. Your cravings may also be different. It is good to try new or different flavors and textures, even if they are something you did not like before. Can taste changes be harmful? Taste changes can lead to loss of appetite and weight loss. It can cause a strong dislike of certain foods, also called food aversions. Taste changes can make it hard for some people to eat healthy foods and maintain their weight. Relieving these side effects are an important part of cancer care and treatment. For more help, talk with your care team or a dietitian.