US Cutaneous Oncodermatology Management (USCOM): A Practical Algorithm

September 2021 | Volume 20 | Issue 9 | Supplement Individual Articles | 3ss | Copyright © September 2021


Published online September 1, 2021

Mario E. Lacouture MD,a Jennifer Choi MD,b Alice Ho MD,c Jonathan Leventhal MD,d Beth N. McLellan MD,e Anneke Andriessen PhD,f Maxwell B. Sauder MD,g Edith Mitchell MDh

aOncodermatology, Memorial Sloan Kettering Cancer Center, New York, NY
bOncodermatology Program, Department of Dermatology, Northwestern University Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL
cRadiation Oncology, Massachusetts General Hospital, Memorial Sloan Kettering Cancer Center, New York, NY
dOncodermatology, Smilow Cancer Hospital at Yale, New Haven, CT
eMontefiore's Division of Dermatology and Montefiore Einstein Center for Cancer Care; Dermatology, Jacobi Medical Center, New York, NY fRadboud UMC, Nijmegen and Andriessen Consultants, Malden, The Netherlands
gOncodermatology, Princess Margaret Cancer Centre, Pigmented Lesion Clinic, Toronto Dermatology Disparities; Gastrointestinal Centre, Toronto, ON, Canada
hCenter to Eliminate Cancer Disparities, Gastrointestinal Oncology, Thomas Jefferson University Hospital and Jefferson Methodist Hospital, Philadelphia, PA

literature before the meeting. During the virtual meeting, the panel selected and fine-tuned six consensus statements from the draft list of twenty and further added three statements and revised them online after the meeting. Through blinded reiterations and votes, the USCOM panel defined the final statements. The panels' consensus, established as an 80% agreement, was obtained.

Development of the Algorithm
A concept algorithm based on the literature selected before the virtual conference was discussed and adopted using clinical evidence coupled with the panel's expert opinion and experience. An online procedure was then used to reach consensus through blinded reiterations and votes to define the final algorithm.

A clinical algorithm's function is to standardize and support medical decision-making, such as regulating the selection and use of treatment regimens.13 The best algorithms have inputs and outputs, precisely defined specific steps, and uniquely defined results that depend on the preceding steps used to solve a problem.16 For the development of the USCOM algorithm, the mnemonic RECUR (Reliable, Efficient, Clear instructions, Understandable, Remember easily) was used.16

The current algorithm focuses on preventing and managing cAEs that can benefit from skincare measures and has the following sections: Measures before, during, and after cancer treatment. Assessment includes evaluating the type and severity of the cAEs and describes the action to be taken (Figure 3).

Cancer-Treatment-Related cAEs
Statement 1: Dermatologic toxicities associated with cancer treatment are common.

Over the past decade, 5-year cancer survival rates have improved, especially for prostate and breast cancer.1 Earlier cancer diagnosis, more effective treatments, and enhanced prevention measures, such as anti-smoking measures, have contributed to more cancer patients surviving and living with cancer.1 Many of these patients suffer from disabling cAEs, which are frequently inadequately managed without the appropriate use of personal hygiene products and skincare.12,18

The current review and algorithm focus on a skincare regimen that prevents or reduces the severity of cAEs, treatment, and maintenance. For that reason, it gives only a summary of the cancer treatments and cAEs.

Depending on the type of cancer and cancer treatment, various cAEs may occur.5 Radiation therapy causes non-specific DNA damage that is limited to the area that received radiation. The damage is dependent on the target volume, dose, and radiation schedule and may affect one to four patients.20 Acute radiation dermatitis (ARD) may occur during radiation treatment, and subacute radiation dermatitis can persist months after treatment.19-22

Mild ARD presents with dry desquamation, mild erythema, and pruritus. Moderate ARD presents with moderate erythema, patchy moist desquamation in skin folds and creases, bleeding induced by minor trauma, and pruritus. Severe conditions show moist desquamation, spontaneous bleeding, severe pain, and even ulceration.19-22

Chronic radiation dermatitis ranges from persistent mild to severe pigmentary alteration, atrophy, necrosis, and telangiectasia.21

Chemotherapy aims to disrupt the cell cycle's specific phases in actively dividing cancer cells, causing significant effects while on treatment.23 The cAEs can be non-specific or agentspecific, and sequelae of therapy/metabolites can occur on uninvolved organs.23 Chemotherapy can be associated with reversible or permanent alopecia, hand and foot syndrome (HFS), nail changes (onycholysis, pigmentary alteration, brittle nails), and phototoxicity.23 HFS presents with erythema and tenderness, with or without blisters with a surrounded rim of erythema. Painful and thickened lesions can occur and are more pronounced in areas with increased pressure and friction.

Targeted therapies inhibit specific molecules involving tumor pathogenesis.24-27 Targeted therapy-related cAEs include papulopustular reactions, reversible alopecia hyperkeratosis (keratosis-pilaris like changes, keratoderma), nail changes (onycholysis, pigmentary alteration, brittle nails), paronychia (± pyogenic granulomas), phototoxicity, trichomegaly, and hirsutism.18,24-28

Immunotherapy aims to activate the host immune mechanisms by blocking immune-suppressing pathways. cAEs may occur at any time during and after treatment. These cAEs include pruritus, xerosis, lichenoid reactions, psoriasiform reactions, eczematoid eruptions, vitiligo, bullous diseases, etc.27-36

Hormonal therapy, for instance, treating breast and prostate cancer, may cause flushing, xerosis, vulvovaginal dryness, atrophy, alopecia, or pigmentary alterations.37,38 The panel developed an overview of the treatments and related cAEs, including a glossary to help identify frequently occurring cAEs relevant to the current algorithm.

Impact of Cutaneous Toxicities on the Patients' Quality of Life
Statement 2: Acute and chronic skin reactions can significantly