Status of the Nordic European Cutaneous Oncodermatology Management Project
The NECOM project aims to improve cancer patient outcomes by offering tools for preventing and managing cAEs. A review paper (NECOM 1) explored clinical insights in cAEs and focused on skincare regimens involving hygiene, moisturization, sun protection, and camouflage products.6 The NECOM 2 publication discussed a skincare algorithm for patients with cancer and survivors to promote healthy skin and reduce cancer treatment-related cAEs.7 Oncology nurses are central to the cancer treatment ecosystem, bridging patients and other healthcare professionals (HCPs).7
Scope of the Nordic European Cutaneous Oncodermatology Management 3 Algorithm
The NECOM 3 publication presents a practical algorithm for preventing and managing ARD using behavioral interventions, diagnostic interventions, prevention and treatment measures, and a skincare regimen involving hygiene, moisturization, and sun protection measures.6 The algorithm aims to reduce inflammation and promote healing skin areas affected by ARD by applying topical treatments and skincare. In addition, the panel aims to reduce the ARD of patients receiving RT by determining the best approach for oncology skincare programs in Nordic European countries.
MATERIALS AND METHODS
A modified Delphi process was used for the algorithm's development, following the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument.8-10 The process entailed preparing the project, selecting the advisors, conducting systematic literature searches, summarizing the literature search results, grading the literature, and drafting the algorithm.8-10 On September 9, 2022, the panel convened to discuss the systematic literature review results and draft the algorithm by integrating evidence and the clinical expertise of the panelists. A further online process was to refine the algorithm and prepare and review the publication. Even though the current algorithm is adapted to Nordic European countries, it could be applied worldwide to support all healthcare providers treating oncology patients, including physicians, nurses, pharmacists, and advanced providers.
Literature Review
The searches focused on the literature describing current best practices in improving cutaneous health during RT, reducing inflammation, and promoting healing of skin affected by ARD. The search topics were deemed clinically relevant to the algorithm and included guidelines, consensus papers, reviews, and publications describing the current best practice in ARD in the English language from January 2010 to August 2022. A dermatologist and a physician associate/scientist conducted searches on September 6 and 7, 2022, on PubMed and Google Scholar as secondary sources of the English-language literature. Search terms included: Acute radiation dermatitis AND patients' quality of life OR skincare efficacy, safety, tolerability OR skin irritation OR topical regimes OR prevention OR treatment OR adjunctive skincare for treatment, maintenance OR education of staff and patients.
The initial search on these terms yielded 122 publications. Two independent reviewers evaluated the literature review results and resolved any discrepancies by discussion. After excluding duplicates and articles that fell outside of the eligibility criteria for the algorithm ([n = 52] such as other subjects, low quality), 70 papers remained. These 70 comprised 1 guideline, 2 algorithms, 18 systematic reviews, 5 review articles, and 45 clinical studies. Of the clinical studies, 18 were randomized controlled trials (Figure 1).
Cancer Treatment With Radiation Therapy
Approximately 50% of cancer patients receive RT as a single modality or combined with cytotoxic therapy, immunotherapy, or targeted therapy.11-17 RT can be given for curative, neoadjuvant, adjuvant, or palliative cancer treatment.11-17
Breast cancer mortality, the most common malignancy in women, has markedly reduced due to earlier screening and improved treatment.18,19 The standard treatment to reduce breast cancer's local recurrence comprises adjuvant RT combined with surgery.12,20 This treatment approach has demonstrated efficacy for patients with early-stage breast cancer undergoing breast-conserving surgery or locally advanced breast cancer with positive lymph nodes undergoing a modified radical mastectomy.12,20 The effects of RT are not selective to tumor cells and may damage surrounding organs and tissues.21-30 As a result, nearly all patients who receive RT will develop some form of RD.21-30
ARD may range from mild erythema to wet desquamation reactions; ulcers and necrosis can occur in severe cases.22 The severity of RD depends on the host, disease, and treatment-specific factors, such as the individual's genotype, target dose, fractionation regimen, and RT modality.5-11 ARD can significantly impact patients' quality of life (QoL), as demonstrated in a prospective study in 83 cancer patients (breast cancer, 49%, head, and neck cancer, 45%, and anus cancer, 6%) receiving RT.13 All patients developed ARD [59% grade 1, 33% grade 2, and 8% grade 3].13,32 The Skindex-16, a validated instrument for assessing dermatologic-related QoL, was administered pre- and post-RT.13 The median composite pre-treatment Skindex-16 score was 0 vs 34 post-RT, demonstrating a markedly negative impact on QoL following RT.13 Another study of patients with breast cancer receiving RT reported that related cAEs negatively impacted physical well-being, body image, emotional and functional well-being, and treatment satisfaction.31
Acute Radiation Dermatitis
ARD is an acute cutaneous inflammatory reaction and oxidative stress induced by exposure to biologically effective levels of ionizing radiation.16,21-26,29,33 Inflammatory markers involved in acute inflammation secondary to ionizing radiation, including IL-1, IL-6, tumor necrosis factor-alpha (TNF-alpha), and transforming growth
