May 28 – 30, 2015, Montréal, Québec

Standards for Skin Care in Radiation Therapy

Amanda Bolderston, MRT(T), MSc, FCAMRT

Radiation Therapy Provincial Professional Practice & Academic Leader, BCCA

@AmandaBoldersto

Disclosure Statement: No Conflict of Interest

May 28 – 30, 2015, Montréal, Québec

I do not have an affiliation, financial or otherwise, with a pharmaceutical company, medical device or communications organization.

I have no conflicts of interest to disclose (i.e. no industry funding received or other commercial relationships).

I have no financial relationship or advisory role with pharmaceutical or device-making companies, or CME provider.

I will not discuss or describe in my presentation at the meeting the investigational or unlabeled ("off-label") use of a medical device, product, or pharmaceutical that is classified by Health Canada as investigational for the intended use.

Today’s objectives

• To examine the significance of radiation induced skin reactions (RISR) in external beam radiotherapy

• To identify current practice trends in the prevention and management of RISR

• To review available evidence in the prevention and management of RISR using the recent Society and College of Radiographers guidelines

AcknowledgementsDr Heidi Probst, Reader in Radiotherapy, Sheffield Hallam University

Dr Rachel Harris, Professional & Education Manager, Society & College of Radiographers

Charlotte Beardmore, Director of Professional Policy, Society & College of Radiographers

Gemma Burke, Senior Lecturer & Prof. Development Facilitator, Sheffield Hallam University

Sarah James, Prof. Officer for Radiotherapy, Society & College of Radiographers

Claire Bennett, Program Lead for Radiotherapy & Oncology, University of the West of England

Samantha Bostock, Superintendent Radiographer, Gloucestershire Oncology Centre

Carole Downs, Breast Cancer Specialist Radiographer, Northern Centre for Cancer Care

Professor Sara Faithfull, Strategic Lead for Innovation & Enterprise, University of Surrey

Sonja Hoy, Nurse Specialist for Head & Neck, The Royal Marsden NHS Foundation Trust

Audrey Scott, Macmillan Head & Neck CNS, Mount Vernon Cancer Centre

Dr Diana Tait, Consultant Clinical Oncologist, The Royal Marsden NHS Foundation Trust

Ellen Trueman, Senior Radiotherapy Sister, St James's Institute of Oncology

Professor Mary Wells, Professor of Cancer Nursing Research & Practice, University of Stirling

Angela Cashell, Clinical Educator, Princess Margaret Cancer Centre, Toronto, Ontario

Radiation Induced Skin Reaction

• One of the most common side effects

• Can limit treatment in severe cases

• Source of patient discomfort/distress

Brown and Rzucidlo, 2011; Ryan, 2012

Image: UICC “Radiotherapy in Cancer Care”

Radiation Induced Skin Reaction

•Frequency < with IMRT, hypofractionation

•RISR is genetically related to the individual’s DNA repair capacity

•But other clinical factors can > RISR

Chang-Claude et al., 2005; Pinar et al., 2007; Andreassen and Alsner, 2009 and Russell et al., 1994; Russell 2010

Blausen gallery 2014. Wikiversity Journal of Medicine. DOI:10.15347/wjm/2014.010. ISSN 20018762.

RTOG 0: No visible skin reaction.RTOG 1: Faint or dull erythema, heat, pain sometimes with itching and edema.RTOG 2a: Tender or bright erythema with or without dry desquamationRTOG 2b: Patchy, moist desquamation, moderate erythema.RTOG 3: Confluent, moist desquamation and pitting edema

Radiotherapy Oncology Group Stages

Stages: Erythema

Image: SCoR guidelines PPT (Appendix 10)

Stages: Dry desquamation

Image: SCoR guidelines PPT (Appendix 10)

Stages: Moist desquamation

Image: SCoR guidelines PPT (Appendix 10)

Goals of care

• Delay RISR onset

• Minimise severity

• Reduce symptom-related discomfort

• Prevent further complications

“Radiation treatment techniques are the most promising intervention in

reducing the degree of skin reaction” (McQuestion et al., 2012)

Two problems!

1. There is a considerable evidence-practice gap in many departments

2. The evidence available is limited and it’s often hard to compare data across studies

2013 provincial skin care survey (n=14)

•Skin care guidelines (12/14):– BC Cancer Agency – CCO guidelines “to some extent”– NCIC RISR assessment tool– In-house by interprofessional group– “We have department guidelines but

physicians are not consistent”

Ontario practice

Used with permission: Ontario Provincial Radiation Therapy Skin Care Working Group

•All (14/14) allowed gentle washing

•All recommended “unscented mild soap”

•Half (7/14) said “no deodorant”

•Most (10/14) asked patients to avoid creams 2 hours prior to treatment

Ontario practice

Used with permission: Ontario Provincial Radiation Therapy Skin Care Working Group

• Topical prevention, erythema and dry desquamation recommendations:– Glaxal– Calendula cream– Aloe Vera– Lubriderm– Cavillon barrier spray– Hydrocortisone– Flamazine– Proshield– Baby powder/cornstarch

Ontario practice

Used with permission: Ontario Provincial Radiation Therapy Skin Care Working Group

• Recommendations for moist desquamation:

– Hydrogels– Tefla/non adherent dressings– Hydrocolloids– Saline or burosol soaks– Flamazine– Polysporin (may be mixed with xylocaine)– Mepilex/Mepitel dressings– Proshield– Hydrofibres

Ontario practice

Used with permission: Ontario Provincial Radiation Therapy Skin Care Working Group

World Wide Radiation Therapist FB group

General recommendationsTo reduce friction and irritation:

•Loose clothing•Avoid extremes of heat and cold•Gentle washing, pat dry•Use electric razor for shaving•Minimise sun exposure, high SPF sunblock•Avoid adhesive tape•No make up, perfume or aftershave in treated area

Current evidence: SCoR

Phase 1: Extensive literature review of > 300 articles from 1980 to 2010

– Included 2 systematic reviews of skin care literature (Bolderston et al., 2006; Kedge 2009)

Phase 2: 2014 systematic review to uncover latest evidence.

– Included 3 systematic reviews of skin care literature (Butcher and Williamson, 2012; Schnur et al., 2013; Chan et al., 2014)

• Topical antibiotics unless proven infection. (Sitton, 1992; Campbell and Lane, 1996; Korinko and Yurick, 1997)

• Topical steroids on broken skin due to the adverse effect on wound healing. (Blackmar, 1997; Rice, 1997; Jones, 1998)

• Gentian Violet due to potential carcinogenesis. (Campbell and Lane, 1996; Rice,1997; Boot-Vickers and Eaton, 1999)

Contraindicated

Washing:

“Gentle skin and hair washing should be unrestricted for patients with no restriction to a particular type of soap.”

SCoR Review summary

Campbell and Illingworth, 1992; Burch et al., 1997; Westbury et al., 2000; Roy et al., 2001; Rudd and Dempsey, 2002; Aistars, 2006; Bolderston et al., 2006; Aistars and Vehlow, 2007; Butcher and Williamson 2012.

Deodorant:•Normal deodorant – discontinue if irritation occurs

SCoR Review summary

Bennett, 2009; Butcher and Williamson, 2012; Watson et al., 2012; Wong et al., 2013; Lewis et al.,2014

“Breast cancer patients who are advised not to use a deodorant often cite this as one less area of control they have in their life and they note

concern regarding body odour.” (Komarnicki, 2010)

Topical products:

“Overall, the evidence base is not strong enough to either support or refute the use of any particular product

for topical application.”

•Use a product that is sodium lauryl sulphate free. (Tsang and Guy, 2013; Patel et al., 2013)

SCoR Review summary

Wells et al., 2004; Richardson et al., 2005; Russell, 2010; Gosselin, 2010

Steroids:

•MASCC guidelines recommend steroids to < itching and discomfort (Wong et al., 2013)

•However – past studies are mixed pro and con for steroid use (Sitton, 1992; Dunne-Daly,1995; Sperduti et al., 2006; Bostrom et al., 2001; Miller et al., 2011; El Madani et al., 2012; Hindley and Dunn, 2013)

SCoR Review summary

Films:•Promising work on the use of Mepitel film to < friction (Herst et al., 2014; Diggelmann et al., 2010; MacBride et al., 2008)

– Not included in SCoR guidelines as a recommendation due to limited evidence/methodological issues

Restrictions on cream/lotion application:•“Bolus effect” minimal for normal application – no need to remove/restrict application (Morley et al., 2014)

Editorial comments!

Moist desquamation:

•Use appropriate dressing/product on broken skin to < further trauma and infection.

– non-adhesive, silicone low adhesion– non or low paraffin/petroleum jelly based.

•Avoid prophylactic antibiotics unless proven infection

SCoR Review summary

Image: SCoR guidelines PPT (Appendix 10)

Other practice recommendations:

•Importance of assessments (Richardson et al., 2005; Fisher et al., 2006; NHS Scotland, 2010)

– Baseline assessment of patient’s current skin condition and care– Baseline should include what skin products are used currently– Assessment/review of the skin should continue throughout

treatment

•Health promotion strategies/interventions pre-treatment (e.g. nutritional advice and smoking cessation) are beneficial (Wells et al., 2004; Wan et al., 2012; Sharp et al., 2013)

SCoR Review summary

Further research:– Dept audits assessing numbers of patients that develop

different RTOG graded reactions across different sites

– New high quality trials with assessor blinding and comparators should include ‘current best evidence practice' or 'no intervention'

– Evaluation into wet vs dry shaving, perfume and make-up

– Patient preferences and compliance

– Evaluation of aftercare to ensure local continuity and consistency of care across the patient pathway

SCoR Review summary

What’s next?

Dr Rachel Harris, RTT, Professional & Education Manager, Society and College of Radiographers, London, UK

Angela Cashell, RTT, Clinical Educator, Radiation Medicine Program, Princess Margaret Cancer Centre, Ontario

Maurene McQuestion, RN, Clinical Nurse Specialist / Advanced Practice NurseH&N Site Group, Princess Margaret Hospital, University Health Network, Ontario

Clare Summers, RTT, Nova Scotia Cancer Centre, Halifax

Michele Cardoso, RTT, Clinical Specialist RT, Juravinski Cancer Centre, Ontario

• E-survey examining Canadian practice• Collecting responses from RTTs, RNs• Using SCoR survey tool for comparison

www.sor.org