People of all genders can get breast cancer but it is the most common cancer in women in Australia, with 1 in 7 women diagnosed with breast cancer in their lifetime. While not as common, men also experience breast cancer with 1 in 500 men receiving a diagnosis in their lifetime (National Breast Cancer Foundation,2023).
While the specific cause is not known there are some factors that are associated with a higher risk of prevalence
Increasing age - the older we get the higher the risk of cellular damage and mutations that can result in cancers
Family history - those with a first-degree relative such as a parent or sibling with breast cancer have an increased risk. Mutations of a gene associated with breast cancer BRCAI and BRCA2 are also linked to a family history.
Research also indicates other factors such as smoking, alcohol, and obesity have links to a higher risk of breast cancer (Australian Breast Cancer Research https://australianbreastcancer.org.au)
Treatment for breast cancer can include surgery such as lumpectomy or mastectomy to remove breast cancer as well as reconstructive techniques, chemotherapy, hormone therapy, and adjuvant radiation therapy. Treatment for breast cancer can have short and long-term impacts on skin health due to medications, surgery, and radiation therapy including skin changes such as dermatitis and fibrosis, scarring, and lymphoedema.
The overall 5-year survival rate according to Australian statistics for those that have breast cancer is now reported to be 92% and 86% for the 10-year survival rate. Early detection and diagnosis can make a significant impact with a 100% 5-year survival rate for those diagnosed with early stage 1 breast cancer (National Breast Cancer Foundation, 2023).
In this post, we will focus on research updates in the area of managing radiation dermatitis within the scope of practice for dermal clinicians.
What can happen to the skin with radiation therapy?
Radiation therapy is associated with acute and early skin changes that are usually transient and reversible, resolving after treatment is completed. Acute side effects are related to the dosages used and how frequent the treatments are. Chronic and long-term side effects may not resolve and may be permanent alterations to the structure and function of the skin.
Early skin response such as erythema, oedema, heat, and pain or tenderness is an inflammatory response to tissue irradiated relating to cellular damage and oxidative stress. It may feel a bit like a moderate to severe sunburn. Over a period of 1-4 weeks, symptoms can progress to include dry desquamation which can progress if not managed to wet desquamation or skin necrosis (ulceration).
Image courtesy of DermNetNZ.org
Acute radiation-induced skin changes are graded 1-4 according to the classification system created by the National Cancer Institute in the USA.
Grade 1 – Faint erythema or desquamation.
Grade 2 – Moderate to brisk erythema or patchy, moist desquamation confined to skin folds and creases. Moderate swelling.
Grade 3 – Confluent, moist desquamation greater than 1.5 cm diameter, which is not confined to the skin folds. Pitting oedema (severe swelling).
Grade 4 – Skin necrosis, bleeding or ulceration of full-thickness dermis (middle layer of skin).
Chronic and late skin changes
The skin that has been treated with radiation therapy will experience changes over a 6 -12 month period after treatment and these are usually irreversible.
These changes included alterations in skin pigmentation, fibrosis in the tissues, loss of hair follicles, dysfunction of the sebaceous glands, and telangiectasia. Radiation therapy can also be associated with skin necrosis and tumour genesis such as basal cell skin cancers.
Image courtesy of DermNetNZ.org
Research Publication Updates - Best Practice Guidelines and Global Consensus to Manage Acute Radiation Dermatitis.
Management of acute radiation dermatitis has experienced significant discrepancies around the world and within different clinical settings due to a lack of high-level evidence to support clinical practice. Recently several publications have been published to review literature and propose best practices through more definitive consensus recommendations. dermal (skin) health professionals should be aware of updates and changes in this area in order to translate and transmit accurate and current information.
Two research updates were published in 2023 by the Multinational Association of Supportive Care in Cancer (MASCC). MASCC is an international, non-profit, multidisciplinary organization that is dedicated to research into and education of supportive care for cancer patients. The Oncodermatology Study Group comprises experts in dermatology, medicine, radiation, dental/oral surgery, and supportive oncology, nursing. The research and the development of evidence-based guideline recommendations for the care of cancer-related dermatologic (skin, hair, nail) toxicities. This group provided a two-part publication series on the MASCC Clinical Practice Guidelines for the Prevention and Management of ARD, including a systematic review to highlight the available evidence on the prevention and management of acute radiation dermatitis and a Delphi-based expert consensus recommendations report.
Sherman and Walsh published their review titled Promoting Comfort: A Clinician Guide and Evidence-Based Skin Care Plan in the Prevention and Management of Radiation Dermatitis for Patients with Breast Cancer. This publication aimed to translate a review of current high-level evidence and assimilate findings into a protocol for clinicians.
A substantial number of prevention and management strategies were evaluated including topical, oral, and complementary/alternative therapies. It was determined that in many cases there is still insufficient evidence to support their use and couldn't be recommended as current best practice. A few interventions that were of note to discuss to inform practice included:
Topical corticosteroids including OTC and prescribed can be useful to prevent or manage itch and inflammation associated with radiation therapy. Most supported by consensus were Mometasone and Betamethasone. Non-steroidal agents weren't recommended based on inconclusive results.
Barrier film dressings including polyurethane film and silicone-based polyurethane films can be useful to manage acute radiation dermatitis.
Many moisturising and emollient agents were evaluated, those with the greatest consensus for recommendation by the experts were for the use of aqueous cream or olive oil. As this is a global working group it was flagged in their discussion that accessibility and affordability had to be a consideration for lower socioeconomic countries or groups. Products with calendula, turmeric, and silymarin-based products did not achieve consensus recommendations but were discussed to show promising results in the literature review.
The use of aluminum or aluminum-free deodorants in the literature review didn't show any negative impact on acute radiation dermatitis. However, there wasn't a consensus to recommend deodorants be used. Sherman & Walsh (2022) suggest to leave it to the patient's preference.
The use of photo-biomodulation or low-level light therapy was recommended by 79% of experts based on current evidence and their own experience in preventing acute radiation dermatitis with breast cancer. It is worth noting as well that use with head and neck cancer in this review did not achieve consensus and is not supported based on current evidence. There have been concerns about using PBM and cancer recurrence. A 5-year long-term follow-up study of 120 patients with breast cancer was undertaken by Robjins et al, 2022 to evaluate this question. In this study, it was reported that receiving PBM for acute radiation dermatitis during breast cancer treatment didn't have a statistically significant influence on local recurrence, development of new tumours, or overall survival. While more research is still underway, being published and evidence is still emerging these therapies should only be used when integrated with oncology specialists, and cancer management teams for risk assessment and decision-making.
(Behroozian et al, 2023; Behroozian et al, 2023; Sherman & Walsh, 2022 & Robjins et al, 2022)
Resources for patients receiving radiation therapy
The American Academy of Dermatology Association has created a resource page for assisting those receiving radiation therapy to manage their skin.
General Recommendations for Skin Health during Breast Cancer Treatment
Gentle washing with a gentle soap & fragrance-free cleanser. Don't scrub or rub, splash lukewarm water gently. Gently pat the area dry.
Apply emollient gently
If the skin is not intact avoid situations where the skin may become further damaged or infected for example spas, pools, lakes, or even hot baths.
Protect the area from damage from the sun, extremes of temperature, or friction. Covering the area with a dressing can be helpful. If on the face discuss options with your skin or health professional.
Don't use cold or hot packs in the area.
Avoid make-up, perfume, and adhesive products in the area.
If the skin becomes irritated, itchy or the skin is broken talk to the oncology medical health professionals about options to manage it.
Summary
Breast cancer is one of the most common cancers affecting women and radiation therapy is a mainstay therapy in its treatment. Radiation therapy is associated with short and long-term side effects. Skin management is an area that has been challenging with many options with practices being varied around the world and in different clinical settings. Dermal Clinicians should be informed about emerging and current best practices particularly as clients may ask about therapies within the Dermal Clinicians' expertise and skill set. Working in interprofessional or integrated oncology teams is an emerging area of practice due to the importance of skin health and integrity for those receiving radiation therapy.
Disclaimer
The information in this document is of a general nature only and is not, and is not intended to be advice. Before making any decision or taking any action, you should consult with appropriate accounting, tax, legal or other advisors. No warranty is given as to the correctness of the information contained in this publication, or of its suitability for use by you. To the fullest extent permitted by law, the Australian Society of Dermal Clinicians Inc. (ASDC) is not liable for any statement or opinion, or for any error or omission contained in this publication and disclaims all warranties with regard to the information contained in it, including, without limitation, all implied warranties of merchantability and fitness for a particular purpose. ASDC is not liable for any direct, indirect, special, or consequential losses or damages of any kind, or loss of profit, loss or corruption of data, business interruption, or indirect costs, arising out of or in connection with the use of this publication or the information contained in it, whether such loss or damage arises in contract, negligence, tort, under statute, or otherwise
References
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Behroozian T, Bonomo P, Patel P, Kanee L, Finkelstein S, van den Hurk C, Chow E, Wolf JR; Multinational Association of Supportive Care in Cancer (MASCC) Oncodermatology Study Group Radiation Dermatitis Guidelines Working Group. Multinational Association of Supportive Care in Cancer (MASCC) clinical practice guidelines for the prevention and management of acute radiation dermatitis: international Delphi consensus-based recommendations. Lancet Oncol. 2023 Apr;24(4):e172-e185. doi: 10.1016/S1470-2045(23)00067-0. PMID: 36990615.
Jinlong Wei, Lingbin Meng, Xue Hou, Chao Qu, Bin Wang, Ying Xin & Xin Jiang (2019) Radiation-induced skin reactions: mechanism and treatment, Cancer Management and Research, 11:, 167-177, DOI: 10.2147/CMAR.S188655
Sherman DW, Walsh SM. Promoting Comfort: A Clinician Guide and Evidence-Based Skin Care Plan in the Prevention and Management of Radiation Dermatitis for Patients with Breast Cancer. Healthcare (Basel). 2022 Aug 9;10(8):1496. doi: 10.3390/healthcare10081496. PMID: 36011153; PMCID: PMC9408725.
Ren Y, Kebede MA, Ogunleye AA, Emerson MA, Evenson KR, Carey LA, Hayes SC, Troester MA. Burden of lymphedema in long-term breast cancer survivors by race and age. Cancer. 2022 Dec 1;128(23):4119-4128. doi: 10.1002/cncr.34489. Epub 2022 Oct 12. PMID: 36223240; PMCID: PMC9879608.
Robijns J, Lodewijckx J, Claes M, Lenaerts M, Van Bever L, Claes S, Pannekoeke L, Verboven K, Noé L, Maes A, Bulens P, Mebis J. A long-term follow-up of early breast cancer patients treated with photobiomodulation during conventional fractionation radiotherapy in the prevention of acute radiation dermatitis. Lasers Surg Med. 2022 Dec;54(10):1261-1268. doi: 10.1002/lsm.23608. Epub 2022 Oct 2. PMID: 36183377.
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