A notable shift over the past decade is that patients are increasingly diagnosed early in their disease course, as cancer detection has dramatically improved with the advent of enhanced imaging and surveillance methods.3,4 As a result, prognoses are often favorable with early-stage disease in many cancer types, including breast cancer. Consequently, preserving the quality of life (QoL) during and after cancer treatments has become an issue of paramount importance.1-4 Minimizing cutaneous adverse events (cAEs) is central to maintaining their QoL during treatment and survivorship.2,5-14
SCOPE
The current algorithm addresses the prevention and management of acute radiation dermatitis (RD) using behavioral interventions, diagnostic interventions, prevention measures, and a skincare regimen involving hygiene, moisturization, and sun protection measures.7 The algorithm aims to reduce inflammation and promote healing skin areas affected by RD by applying topical treatments and skincare. By determining the best approach for oncology skincare programs in the US, the multidisciplinary panel comprised of oncodermatologists and a radiation oncologist hypothesized that the broad application of the algorithm would reduce cAEs and improve QoL in patients receiving RT.
METHODS
A modified Delphi process was used for the algorithm's development, following the AGREE II instrument.15,16 The modified Delphi method is a communication technique for interactive decision-making for medical projects.16 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.17 On October 9, 2021, 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. Finally, a consensus was obtained on the algorithm by all panelists.
LITERATURE REVIEW
The searches focused on the literature describing current bestpractice in improving health during radiotherapy, reducing inflammation, and promoting healing of skin areas affected by acute RD. The search topics were deemed clinically relevant to the algorithm and included guidelines, consensus papers, reviews, and publications describing current best-practice in acute RD in the English language from January 2010 to September 2021. In addition, a dermatologist (TE) and a physician associate/scientist (AA) conducted searches on PubMed and Google Scholar as a secondary source of the English-language literature. Search terms included radiation dermatitis (RD); skincare and topical regimes for prevention, treatment, and maintenance of acute RD; QoL of patients with acute RD; adjunctive skincare use; education of staff and patients; communication strategies; adherence; concordance; efficacy; safety; tolerability; skin irritation.
The initial search on these terms yielded 122 publications. Two independent reviewers (TE and AA) 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 = 50] such as other subjects, low quality), 72 papers remained. These 72 comprised 1 guideline, 1 algorithm, 18 systematic reviews, 5 review articles, and 47 clinical studies. Of the clinical studies, 22 were randomized controlled trials.
Radiation Therapy for the Management of Cancer
Approximately 50% of cancer patients receive radiotherapy (RT), either as a single modality or in combination with cytotoxic therapy, immunotherapy or other targeted therapies.4,5,18-22 The intent of RT can be curative, neoadjuvant, adjuvant, or palliative.6-10,20-22 The biophysical effects of RT are not selective to tumor cells and may damage surrounding organs and tissues. As a result, nearly all patients who receive RT will develop some form of RD, although the severity of RD depends on a multitude of host-, disease-, and treatment-specific factors, such as the individual's genotype, target, dose, fractionation regimen, and modality of RT.5-11 The ultimate reason that RT overall benefits patients lies in the inherent difference in how tumors have a defective repair response to DNA damage, whereas normal tissues can repair themselves, thereby creating a therapeutic ratio that maximizes tumor eradication while minimizing damage to normal organs.20-24
Acute RD occurs within 1 to 4 weeks of treatment, whereas subacute and chronic RD lasts beyond 4 weeks to years after treatment.10 The vast majority of patients eventually recover from mild to moderate cases of RD.5-11 Acute RD can significantly impact a patient’s quality of life. This was best shown in a prospective study conducted from July 2017 to June 2018 in 83 cancer patients (breast cancer 49%, head and neck cancer 45%, and anus cancer 6%) receiving RT.5 The Skindex-16, a validated instrument for assessing dermatologic-related QoL, was administered pre-and post-RT. All patients developed RD (59% grade 1, 33% grade 2, and 8% grade 3).10 The median composite pre-treatment Skindex-16 score was 0 vs 34 post-RT, demonstrating a markedly negative impact on QoL immediately following RT.5
Despite the cAEs of RT, providers have no consensus on how to optimally prevent and manage RD. To address this unmet clinical need, the US Cutaneous Oncodermatology Management (USCOM) decision-based algorithm was developed to offer
The initial search on these terms yielded 122 publications. Two independent reviewers (TE and AA) 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 = 50] such as other subjects, low quality), 72 papers remained. These 72 comprised 1 guideline, 1 algorithm, 18 systematic reviews, 5 review articles, and 47 clinical studies. Of the clinical studies, 22 were randomized controlled trials.
Radiation Therapy for the Management of Cancer
Approximately 50% of cancer patients receive radiotherapy (RT), either as a single modality or in combination with cytotoxic therapy, immunotherapy or other targeted therapies.4,5,18-22 The intent of RT can be curative, neoadjuvant, adjuvant, or palliative.6-10,20-22 The biophysical effects of RT are not selective to tumor cells and may damage surrounding organs and tissues. As a result, nearly all patients who receive RT will develop some form of RD, although the severity of RD depends on a multitude of host-, disease-, and treatment-specific factors, such as the individual's genotype, target, dose, fractionation regimen, and modality of RT.5-11 The ultimate reason that RT overall benefits patients lies in the inherent difference in how tumors have a defective repair response to DNA damage, whereas normal tissues can repair themselves, thereby creating a therapeutic ratio that maximizes tumor eradication while minimizing damage to normal organs.20-24
Acute RD occurs within 1 to 4 weeks of treatment, whereas subacute and chronic RD lasts beyond 4 weeks to years after treatment.10 The vast majority of patients eventually recover from mild to moderate cases of RD.5-11 Acute RD can significantly impact a patient’s quality of life. This was best shown in a prospective study conducted from July 2017 to June 2018 in 83 cancer patients (breast cancer 49%, head and neck cancer 45%, and anus cancer 6%) receiving RT.5 The Skindex-16, a validated instrument for assessing dermatologic-related QoL, was administered pre-and post-RT. All patients developed RD (59% grade 1, 33% grade 2, and 8% grade 3).10 The median composite pre-treatment Skindex-16 score was 0 vs 34 post-RT, demonstrating a markedly negative impact on QoL immediately following RT.5
Despite the cAEs of RT, providers have no consensus on how to optimally prevent and manage RD. To address this unmet clinical need, the US Cutaneous Oncodermatology Management (USCOM) decision-based algorithm was developed to offer
