For CTCAE grade 4 RD and any cAEs deemed possibly dangerous or life-threatening, such as skin necrosis, ulceration of the full-thickness dermis, or copious bleeding, further fractions of RT and/or bolus should be held off until the desquamated region is clinically improved.6,7,23,32,33,35,36 The decision to hold off RT must be made by the radiation oncologist, who will need to weigh the consequence of a treatment break for cutaneous healing vs potentially reducing the efficacy of RT.76-78 Treatment breaks may negatively impact prognosis in highly proliferative tumors, such as head and neck cancer and inflammatory breast cancer, which have high rates of local recurrence.76-78
Patients with large areas of moist desquamation, bleeding, or bullae should be referred to a wound-healing specialist or oncodermatologist.7 Breast cancer patients with a tissue expander or implant reconstruction and moist desquamation in any part of their chest wall or axilla should be carefully assessed for secondary infection of the prosthesis by their plastic surgeon.6,7 Adequate pain control is essential, with a low threshold for offering narcotic medications as needed. Mucosal involvement, thinning of a flap with exposure to a breast prosthesis, and the presence of systemic symptoms such as fever, uncontrolled pain, and laboratory abnormalities -- like elevated white blood cell counts or decreased hemoglobin and hematocrit -- signal urgent evaluation at an urgent care facility with subspecialty consultation by a dermatologist, plastic surgeon, infectious disease specialist, or wound-healing specialist.6,7
