Management of Radiation Dermatitis for Breast Cancer Patients: Comparison
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The importance of holistic, patient-centered assessments, interventions, and education during RT should not be understated in its value of promoting patients’ physical and emotional comfort. The implementation of a skin care plan is an opportunity for patients to fully engage in self-care, not only promoting their skin health, reducing RT-associated side effects, and promoting the restoration of skin integrity, but can enhance their sense of control with the stressful context of cancer treatments. Ultimately, a patient-centered approach with implementation of a skin care plan may avert a delay in treatment or discontinuation of RT due to RD and afford breast cancer patients the greatest chance for long-term survival.

  • breast cancer
  • skin care
  • radiation therapy
  • radiotherapy
  • radiation dermatitis

1. Background

Radiation treatments affect the skin’s anatomy and physiology depending on the dose, fraction size, volume of tissue, duration, energy and type of radiation, or bolus doses. The epidermis of the skin includes a cornified outer layer and a deeper basal layer. The epidermis is continuously renewed through a production of new skin cells from the basal layer in response to the shedding of skin cells at the outer layer. Radiation disrupts the balance between the production of new cells and the shedding of cells, resulting in mild to severe radiation dermatitis (RD). In addition, there are inflammatory responses with the release of histamine and serotonin, and vascular responses leading to capillary dilation in the dermis, which is the layer underneath the epidermis, in which there are nerve endings, blood vessels, and hair follicles. The skin responds to radiation with redness (erythema), changes in skin pigmentation, hair loss, and sweat and sebaceous gland destruction [1].
Varying degrees of RD occur within 1 to 4 weeks of radiation treatment and persist for 2 to 4 weeks following treatment. Transient erythema may occur within 24 h of treatment where the skin appears red, warm, and rash-like, and the patient experiences a sense of skin tightness and sensitivity. As the radiation doses increase to 20 Gy, the patient may experience dry desquamation, in which the skin becomes dry, itchy, or flaking. At doses of 30 to 40 Gy, extracapillary cell damage occurs with increasing edema. At doses 45 to 60 Gy, moist desquamation may occur in which the area may blister, bleed, slough, and ooze serous fluid with possible crusting [2].
For patients treated with RT, up to 95 percent are at risk for radiation dermatitis (RD) [3][4][5][6]. When RD progresses to acute radiation dermatitis (ARD), moist desquamation of the skin increases the possibility of infection [7][8][9].
Healthcare professionals often use a universal radiation therapy oncology group (RTOG) assessment tool to describe RD with a range of grades from 0–4. Rosenthal, Israilevich, and Moy [5] described the clinical presentation of RD based on the RTOG from grade 0 (normal skin) to grade 4 (ulceration and necrosis) which is the most acute dermatitis. However, the RTOG scale does not assess symptom severity such as pain. An additional assessment tool developed by the National Cancer Institute [10] is the Common Terminology Criteria for Adverse Events that rates the progressive severity of RD from grade 1 to grade 5, in which grade 1 is erythema or dry desquamation, while grades 2 and 3 represent moist desquamation with increasing discomfort and pain and grades 4 and 5 indicate skin ulceration and necrosis. Once RD begins, tissue damage builds with every subsequent radiation dose which further delays healing [11]. The consistent use of assessment tools is important to document the severity of RD and respond with appropriate therapeutic interventions. As it has been reported that RD grading by clinical assessments, such as the RTOG criteria, does not correlate well with patient-reported outcomes, there is a need for improved RD symptom assessment that includes both patient and clinician components [12]. Over the past 50 years, multiple risk factors have also been identified with RD, including individual/patient related factors and treatment related factors. While some of the risk factors are modifiable, others are not. Individual factors may include older age, smoking status, body mass index (BMI), type 2 diabetes mellitus, chronic immunosuppression, autoimmune disease, tumor histology and state, concurrent treatment with chemotherapy or hormonal therapy, compromised nutritional state, breast volume, initial darker skin, or chronic sun exposure [13][14][15]. Treatment factors may include whole breast fractionation schedule and dose, tumor bed boost dose, location of the tumor, duration of treatment, and type of energy used [6][13][14]. Newer radiation techniques may lower the incidence and severity of radiation skin reactions. For example, intensity-modulated radiation therapy (IMRT) results in only small volumes of normal tissue receiving the full treatment dose [2]. On a psychological level, patients receiving RT often express a loss of control, sleep disturbance, anxiety, depression, and issues with body image which are equally important to address as physical complications of treatment [16]. On a functional level, treatment related skin reactions may also lead to discomfort in wearing clothing and undergarments and in performing activities of daily living [17]. Prevention and reduction of RD are therefore extremely important. As RD progresses to severe ARD, not only is the condition very painful and debilitating, negatively impacting patient’s quality of life, but may result in patients’ or physicians’ decisions to terminate radiation treatment early or a patient’s decision not return for follow up appointments [7][8][9]. Beyond quality of life, a breast cancer patient’s survival from the disease is in significant jeopardy over time. Clinicians’ knowledge regarding the assessment and management of skin reactions caused by radiation therapy is critical to promoting the comfort of breast cancer patients receiving RT. A holistic approach to care is important as radiation therapy impacts not only patients’ physical adjustment, but emotional and functional adjustment to cancer and its treatment. Throughout the course of RT, the goals of care include maintaining skin integrity, reduction of pain, protection from trauma, prevention and management of skin infections, and promoting a healing environment to the wound bed [2]. Beyond physical healing, it is important for clinicians to provide a healing environment in which the patient feels understood, listened to, and supported through a patient-centered approach throughout their treatment experience. This can be achieved by use of a stress-reduction approach during all interactions with patients, including guiding patients in self-care, reducing their stress, and promoting a healthy lifestyle during and following radiation treatment [18] while being mindful of the economic costs of treatment, access, and ease of following a skin care plan.

2. Management of Radiation Dermatitis for Breast Cancer Patients

Clinicians caring for breast cancer patients receiving RT are positioned to promote the translation of research results into practice. Based on the literature and coupled with clinical judgment, the following Clinician Guide (Box 1), and Evidence-based Skin Care Plan (Box 2) are proposed in the care of breast cancer patients receiving RT.

Box 1. A Clinician Guide to Promoting Comfort of Breast Cancer Patients Receiving RT.
Week 1 (First Visit)
  • Build a Trusting Patient-Clinician Relationship:
    ○
    Introduce the patient to members of the radiation therapy team and provide contact information to respond to questions.
    ○
    Express the value of a holistic, patient-centered care and the importance of individualizing the approach to care dependent on their values and preferences.
    ○
    Determine patients’ individual learning needs and styles and provide additional information in the format preferred, such as written materials, videos, possible Apps, and psycho-educational information through consultation with staff during each visit.
    ○
    Encourage open communication with the clinician and health team members.
    ○
    Discuss the patient’s physical, emotional, social, spiritual, and functional adjustment to the illness and the treatment.
  • Box 2
  • ) to prevent and manage RD and promote comfort.
Week 2 to Week 5 (Second and Subsequent Visits)
  • Conduct a Physical Assessment:
    ○
    At each visit by consistent staff, if feasible, to determine changes in the skin color, texture, moisture, and breaches in skin integrity, as well as assessment of signs of infection, and evaluation of symptoms such as pain, itching, sleep disturbance, anxiety, depression, and concerns about body image.
  • Provide Emotional Care and Support:
    ○
    Assess and address patient’s fears and concerns regarding cancer and RT, with a reassuring, supportive approach.
  • Provide holistic care:
    ○
    Evaluate the patients’ overall adjustment to the illness and treatment.
    ○
    Check-in with the patient following the first treatment to offer reassurance and engage them in their care. Development of a trusting provider-patient relationship fosters open communication and a positive clinical experience.
  • ○
    Discuss positive coping strategies within the context of the illness and treatment experience.
    Promote Social Support:
    ○
    Determine the need for additional support of family or friends in coming and returning home from treatments.
    ○
    Discuss how treatments will occur within the context of lifestyle and other possible roles and responsibilities.
  • Reinforce healthy lifestyles, including adequate nutrition and hydration, sleep, and avoidance of tobacco, alcohol or other substances.
Box 2. Comfort Guidelines: Evidence-based Skin Care Plan to Follow During and After Radiation.
During radiation therapy, many people experience a skin reaction called radiation dermatitis (RD) ranging from slight to severe. The goal is to work with you to protect your skin during RT and improve your comfort.
FOLLOW THIS SKIN CARE PLAN THROUGHOUT TREATMENT AND FOR TWO WEEKS FOLLOWING TREATMENT
  • A clinician will see you weekly or more often if needed. For immediate assistance between visits, you can receive help 24/7 by calling (name and/or phone number). _____________________________
  • Keep a daily diary of skin changes/reactions to be shared with your radiation team members at each visit.
    • Skin red or pink color    ___     Areas that blister, weep, or peel ___
    • Tanned color of skin   ___     Signs of crusting        ___
    • Dry, itching, or flaking    ___      Signs of ulceration       ___
    • Tender to touch       ___      Exudate/Discharge       ___
    • Decrease in sweat      ___      Blackening of the skin      ___
  • Encourage patient engagement:
  • ○
    Remind the patient to perform daily skin checks and record daily skin care changes and practices. A diary may be suggested.
    ○
    Learn the diary at each visit to address patients’ individual questions and concerns, while attempting to normalize the experience, yet providing support and reassurance.
    ○
  • Report symptoms of pain, burning, or itching so that your clinician can prescribe oral medications to alleviate symptoms and promote your comfort.
  • Please follow the directions below to prevent or lessen radiation dermatitis.
  • Protect the skin in the treatment area from sun and cold.
  • Do NOT use hot packs, cold packs, or heating pads on the treatment area.
  • DO NOT take baths, use hot tubs, or swim in lakes or pools if your skin is not intact.
    Continue to summarize the Skin Care Plan, as described in 
    Box 1
    .


    ○
    Encourage self-care, which may include the use of a guided imagery, relaxation techniques, hobbies of interest, use of distraction such as music, positive self-affirmations, prayer, need for additional professional support, support from family and friends, or in support groups with others who have successfully completed RT. Each strategy may increase a sense of emotional and spiritual well-being and promote comfort.
    ○
  • Educate the Patient:
    ○
    Discuss the value of radiation therapy (RT), how RT works in destroying cancer cells, skin changes associated with RT, when skin reactions may start, and the importance of protecting healthy cells and tissues in the affected area.
  • Wear soft, loose comfortable cotton clothing. Avoid underwire bras during the remainder of treatment.
    ○
    Learn the expected procedures that will occur during radiation therapy to reduce uncertainty and promote emotional comfort.
    ○
    Inform the patient that the radiation therapy team will assess any effects of radiation therapy through use of standardized assessment tools, which will be compared with patient-reported symptoms, with the goal of prevention and early management of radiation skin reactions.
    ○
    Provide a step-by-step guide of the Skin Care Plan (refer to
  • Do not rub or scratch the skin in the treatment area. Avoid shaving the armpit with a straight razor. May use an electric razor or do not shave if preferred.
  • Perform Standard Washing and Skin Care: Shower before each treatment with a mild unscented soap (i.e., Dove, Neutrogena, or baby soap) and warm water.
    ▪
    Wash affected area and gently remove the skin product and deodorant during the shower. Do NOT scrub.
    ▪
    Dry treatment area with a clean, soft towel. Gently pat dry.
    ▪
    Apply an emollient cream, such as Aquaphor or Eucerin, to moisturize the skin in the treated area following a shower.
  • You may use a non-metallic or metallic deodorants/antiperspirants as they promote comfort and do not cause harm. Use of deodorants is based on your preference.
  • From the day of your first treatment until two weeks after treatment, apply a thin layer of mid to high potency topical steroid cream (e.g. Over the Counter: Hydrocortisone 1% (twice a day); Prescription: Betamethasone 0.1% (once or twice a day); Fluticasone 0.05% (twice a day), Triamcinolone 0.1% (twice a day), Mometasone furoate 0.1% (once a day), Clobetasol 0.05% (twice a day) to the radiation area after treatment. (Over the counter or prescription steroid creams may be used). NOTE: When using a topical steroid, apply moisturizer after the topical steroid. Use topical steroids only on intact skin.
  • Speak with your clinician if your skin is NOT intact for additional skin treatments.
  • Use no other skin care product on the irradiated area throughout treatment, including perfume or make-up.
  • Avoid the use of tape and adhesives in the treatment area.
  • Realize that fatigue may occur during radiation treatment; however, report to your clinician signs of systemic illness, such as fever, chills, or generalized weakness.
  • Eat a healthy well-balanced diet to promote skin healing and increase your energy.
  • Discuss with your clinician any physical, emotional, social, spiritual or functional issues you are experiencing.
  • Make notes below as a reminder of issues to discuss with your clinician.
 

References

  1. Bray, F.; Simmons, B.; Wolfson, A.; Nouri, K. Acute and chronic cutaneous reactions to ionizing radiation therapy. Radiother. Oncol. 2016, 59, 257–265.
  2. McQuestion, M. Evidence-based skin care management in radiation therapy: Clinical Update. Semin. Oncol. Nurs. 2011, 27, e1–e17.
  3. Bauer, C.; Laszewski, P.; Magnan, M. Promoting adherence to skin care practices among patients receiving radiation therapy. Clin. J. Oncol. Nurs. 2015, 19, 196–203.
  4. Chan, R.; Webster, J.; Chung, B.; Marquart, L.; Abmed, M.; Garantziotis, S. Prevention and treatment of acute radiation-induced skin reactions: A systematic review and meta-analysis of randomized controlled trials. BMC Cancer 2014, 14, 53.
  5. Rosenthal, A.; Israilevich, R.; Moy, R. Management of acute radiation dermatitis: A review of the literature and proposal for treatment algorithm. J. Am. Acad. Dermatol. 2019, 81, 558–567.
  6. Yee, C.; Wang, K.; Asthana, R.; Drost, L.; Lam, H.; Lee, J.; Vesprini, D.; Leung, E.; DeAngelis, C.; Chow, E. Radiation-induced skin toxicity in breast cancer patients: A systematic review of randomized trials. Clin. Breast Cancer 2018, 18, e825–e840.
  7. Bazire, L.; Fromantin, I.; Diallo, A.; de la Lande, B.; Pernin, V.; Dendale, R.; Kirova, Y. Hydrosorb® versus control (water-based spray) in the management of radio-induced skin toxicity: Results of multicenter controlled randomized trial. Radiother. Oncol. 2015, 117, 229–233.
  8. Kodiyan, J.; Amber, K.T. Topical antioxidants in radiodermatitis: A clinical review. Int. J. Palliat. Nurs. 2015, 21, 446–452.
  9. O’Donovan, A.; Coleman, M.; Harris, R.; Herst, P. Prophylaxis and management of acute radiation –induced skin toxicity: A survey of practice across Europe and the USA. Eur. J. Cancer Care 2015, 24, 425–435.
  10. National Cancer Institute. Common Terminology Criteria for Adverse Events (CTCAE) (Version 5.0). 2017. Available online: https://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/CTCAE_v5_Quick_References_8.5x11.pdf (accessed on 5 August 2021).
  11. Censabella, S.; Claes, S.; Robijns, J.; Bulens, P.; Mebis, J. Photobiomodulation for the management of radiation dermatitis: The DERMIS trial, a pilot study of MLS® laser therapy in breast cancer patients. Support. Care Cancer 2016, 24, 3925–3933.
  12. Behroozian, T.; Milton, L.; Zhang, L.; Lam, E.; Wondg, G.; Szumacher, E.; Chow, E. How do patient-reported outcomes compare with clinician assessments? A prospective study of radiation dermatitis in breast cancer. Radiother. Oncol. 2021, 159, 98–105.
  13. Parker, J.; Rademaker, A.; Donnelly, E.; Choi, J. Risk factors for the development of acute radiation dermatitis in breast cancer patients. Int. J. Radiat. Oncol. 2017, 99, E40–E41.
  14. Sharp, L.; Johansson, H.; Hatchek, T.; Bergenmar, M. Smoking as an independent risk factor for severe skin reactions due to adjuvant radiotherapy for breast cancer. Breast 2013, 22, 634–638.
  15. Bohner, A.; Koch, D.; Schmeel, F.; Rohner, R.; Schoroth, F.; Sarria, G.; Abramian, A.; Baumert, B.; Giordano, F.; Schmeel, L. Objective evaluation of risk factors for radiation dermatitis in whole-breast irradiation using the spectrophotometric L*a*B color-space. Cancers 2020, 12, 2444.
  16. Sherman, D.W.; Rosedale, M.; Haber, J. Reclaiming life on one’s own terms: A grounded theory study of breast cancer survivorship. Oncol. Nurs. Forum 2012, 39, 258–268.
  17. Montpetit, C.; Singh-Carlson, S. Engaging patients with radiation related skin discomfort in self-care. Can. Oncol. Nurs. J. 2018, 28, 191–200.
  18. Dendaas, N. Toward evidence and theory-based skin care in radiation oncology. Clin. J. Oncol. Nurs. 2012, 16, 520–525.
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