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Appendix
What current evidence is there to
give the optimal skin care advice to
patients undergoing radical external
beam megavoltage radiotherapy?
Introduction
 Turesson et al. (1996) demonstrated that the number of basal
cells in the epidermis declines during fractionated RT due to
increased cell cycle arrest and reduced mitosis. This causes a
thinning of the epidermis and an inflammatory reaction and the
variation in the reaction appears to be a genetic
predisposition related to individual DNA repair capacity.
(Chang-Claude et al., 2005; Pinar et al., 2007; Andreassen and Alsner, 2009)
 Certain clinical factors can aid in the prediction of which patients
are more likely to experience a significant radiation reaction.
(Russell et al., 1994; Russell 2010)
Extrinsic and Intrinsic factors
52% of departments are not recording this data
Extrinsic factors
Intrinsic factors
Radiotherapy
Age
Bolus
Nutrition
Radiosensitisers
Smoking and alcohol
Chemicals/ thermals/ mechanical
irritants
Co-morbidities
Dose, fractionation, site, and modality of
radiotherapy.
Some Cytotoxic agents can increase the
severity of reaction e.g. Cisplatin, 5Flurouracil, Mitomycin C.
e.g. diabetes
Previous damage
Trauma
Obesity
Infection
UV exposure
Systematic Review
 An extensive literature review was undertaken of over 300
articles from 1980 to October 2010.
 Two systematic reviews of skin care literature proved
invaluable in determining the more robust evidence base.
(Bolderston et al., 2006; Kedge 2009)
 2014 systematic review undertaken using PICO method and
SIGN to determine if, since 2010 there has been any
additional evidence. Three systematic reviews also reviewed.
(Butcher and Williamson, 2012; Schnur et al., 2013; Chan et al., 2014)
Contraindicated products
Of significant note is the identification of certain products
contraindicated for use on radiotherapy skin reactions:
 Topical antibiotics, unless there is a proven infection. (Sitton,
1992; Campbell and Lane, 1996; Korinko and Yurick, 1997)
 Topical steroids on broken skin due to the adverse effect on
the wound healing process. (Blackmar, 1997; Rice, 1997; Jones, 1998)
 Gentian Violet due to potential carcinogenic
side effects. (Campbell and Lane, 1996; Rice, 1997;
Boot-Vickers and Eaton, 1999)
Consensus
There are two areas where a more general consensus on
guidance is closer to being achieved.
 Firstly with respect to the use of aqueous cream:
This has now been reclassified in the British National
Formulary (BNF) as a soap substitute and may be applicable
in this usage for patients undergoing radiotherapy.
However, it should not be used as a leave-on moisturiser.
 Secondly with respect to the use of deodorant, where a
much stronger evidence base refutes the adverse impact that
deodorants were once thought to have. (Bennett, 2009; Watson et
al., 2012; Wong et al., 2013)
2014 systematic review
 A number of studies have been undertaken investigating the
use of topical steroids and Wong et al. (2013) make strong
recommendations for the use of prophylactic topical
steroids. In spite of this some of the published research
recommends exercising a degree of caution, particularly
regarding any long term implications of using steroids.
 A plethora of agents is being used on the skin in a nonstandardised fashion.
 Overall, the evidence base is not strong enough to
either support or refute the use of any particular
product for topical application.
Prophylactic skin care (1)
A lack of evidence to support
prophylactic use of any specific product
(Wells et al., 2004; Richardson et al., 2005; Russell, 2010; Gosselin, 2010)
2011 survey
26 aqueous cream
5 aloe vera base
3 Diprobase®
2 Cavilon®
1 calendula base
2014 survey
17 aqueous cream
6 E45
2 Diprobase ®
2 Aquamax ®
1 Cavilon ®
1 patient use own
49% of departments do not assess
what a patient currently uses
Prophylactic skin care (2)
Evidence indicates that gentle skin and hair washing should be
unrestricted for patients and there should be:
no restriction to using a specific type of soap
(Roy et al., 2001; Bolderston et al., 2006; Aistars and Vehlow, 2007;
Butcher and Williamson, 2012)

2011 42 specified the type of soap to use: ‘Simple®’, ‘Dove®’ or
‘none’ being the most common answers.

2014
31 specified the type of soap.
74% of departments report washing restrictions
Prophylactic skin care (3)

2011
9 specified the type of deodorant to use: ‘none’ or ‘Pitrok®’
being the most common answers.

2014 19 departments stated patients could use a deodorant; 23 stated
they could not.
“If patient insists they prefer to use something then rock salt from
Holland and Barrett.”
55% departments are still saying ‘no deodorant’
Breast cancer patients who are
advised not to use a deodorant
often cite this as one less area
of control they have in their life
and they note concern
regarding body odour.
(Komarnicki, 2010)
Erythema
2011 survey
49 aqueous cream
8 aloe vera base
Erythema tends to occur
7 Diprobase®
at 2000-4000 cGy
4 Cavilon®
2014 survey
24 aqueous cream
6 E45 ®
4 Diprobase ®
4 Aquamax ®
4 aloe vera base
3 hydrocortisone 1%
3 BioOil ®
3 hydrogel product
29 ISSUED the product
15 products cited
aqueous cream may actually comprise skin integrity
(Tsang & Guy, 2010; Patel et al., 2013)
Dry desquamation
2011 survey
Dry desquamation occurs
mainly at 3000 cGy and
higher
35 aqueous cream
24 hydrocortisone 1%
despite some contradictory
evidence
(Sitton 1992; Bostrom et al., 2001;
Sperduti et al., 2006;
El Mandani et al., 2012)
2014 survey
16 aqueous cream
5 hydrogel product
5 Diprobase ®
4 hydrocortisone 1%
4 E45 ®
3 patient’s own
33 ISSUED the product
13 products cited
Moist desquamation
2011 survey
Moist desquamation tends
to occurs at 4000 cGy and
higher
33 hydrogel product
21 silicone dressing
i.e. Mepitel®
18 hydrocolloid base
7 lyofoam base
3 lanolin
2 gentian violet
1 second skin product
2014 survey
13 Intrasite ®
10 Mepilex ®
10 Polymem ®
10 hydrogel product
7 Flamazine ®
40 ISSUED the product
22 products cited
Recommendations (1)
Pre-treatment
 The various factors that influence how people react to
radiotherapy need to be considered. (Turesson, 1996; Porock et al.,
1998; Porock and Kristjanson, 1999; Richardson et al., 2005; Barnett et al.,
2011; McQuestion, 2011)
 Before radiotherapy begins, it is essential that a baseline
assessment of the patient’s current skin condition and care is
documented, including what skin products are being used
currently. Assessments and review of the skin should continue
for all patients on a regular basis throughout treatment.
(Richardson et al., 2005; Fisher et al., 2006; NHS Scotland, 2010)
 Education and health promotion strategies and interventions
given to patients pre-treatment such as nutritional advice
and smoking cessation would be beneficial and are advised.
(Wells et al., 2004; Wan et al., 2012; Sharp et al., 2013)
Recommendations (2)
 Wash the skin gently with soap and water and gently pat dry.
(Aistars, 2006; Bolderston et al., 2006; Aistars and Vehlow, 2007; Butcher and
Williamson, 2012)
 Use aqueous cream instead of soap if wished but it is NOT
recommended as a leave-on moisturiser.
(www.evidence.nhs.uk/formulary/bnf)
 Use a moisturiser that is sodium lauryl sulphate free. (Tsang
and Guy, 2013; Patel et al., 2013)
 Continue to use normal deodorant (unless this irritates the
skin), but discontinue if the skin is broken. (Bennett, 2009; Butcher
and Williamson, 2012; Watson et al., 2012; Wong et al., 2013)
Things to consider as an issuer
With a wide variety of products currently available there are
bound to be variations in product utilisation and availability;
therefore, careful assessment and justification is paramount.
? What are the variation of ingredients in products that use
the same generic name e.g. aloe vera, aqueous cream?
? Is a product actually worth the cost?
? How available and reliable is the supplier?
? How often does a product need to be applied?
? How easily is the product applied?
Recommendations (3)
On broken skin
 Use appropriate dressing/product on broken skin to reduce
further trauma and infection. Suitable products would be
non-adhesive, silicone low adhesion, non or low
paraffin/petroleum jelly based.
 NOT use Gentian Violet. (Campbell and Lane, 1996; Rice, 1997; BootVickers and Eaton, 1999)
Future research needed (1)
 New high quality trials are urgently required; enabling a
more consistent approach for patients receiving radiotherapy
and to inform guidelines.
 There is a need for further research of new products
before they are introduced on an ad-hoc basis, without
evidence, into radiotherapy skin care regimens.
 Future research should include designs that
allow assessor blinding and comparators should
include ‘current best evidence practice' or
'no intervention'.
Number of studies
2011 survey
 Only 1 (n= 49) department was conducting a RCT into the clinical
effectiveness of a topical agent for erythema. There were no
assessments into the cost effectiveness for erythema.
 Only 3 (n=46=6%) departments were conducting RCTs into the clinical
effectiveness of a topical agent for moist desquamation. There was one
on-going assessment into the cost effectiveness of a product.
2014 survey
 Only 4 (n=42=9%) departments stated they were conducting or had
conducted any trials or evaluation into efficacy of any skin care products
at any stage of skin reaction and only 4 (n=42=9%) had assessed cost
effectiveness.
“would like to be involved with RCT's but find it difficult to sustain with
clinical workload and other responsibilities” and “we would like to
undertake this sort of analysis but time and resources prohibit this”.
Future research needed (2)
 Assessment and quantification of the extent of
radiation induced skin reactions is needed as currently it is
unknown how many patients are affected and to what level.
Departments need to audit radiation induced skin reactions
locally to monitor proportions of patients that develop
different RTOG graded reactions across different treatment
sites:
1. To increase the quality of information that can be given to
patients;
2. To allow departments to monitor their
own practice and compare across centres.
The extent of the problem?
Approximately what percentage of patients in your department get
erythema
10
Don't know
91%-100%
81%-90%
71%-80%
61%-70%
51%-60%
41%-50%
31%-40%
21%-30%
11%-20%
0%-10%
8
6
4
2
0
Approximately what percentage of patients in your department get
moist desquamation
16
14
12
10
8
6
4
2
0
Don't know
91%-100%
81%-90%
71%-80%
61%-70%
51%-60%
41%-50%
31%-40%
21%-30%
11%-20%
0%-10%
Future research needed (3)
 Evaluation into wet versus dry shaving and perfume and
make-up use is needed.
 Evaluation of treatment aftercare requires review to ensure
local continuity and consistency of care across the patient
pathway.
 Further investigations into the skin care reactions:
superficial, orthovoltage, and proton beam
radiotherapy are required.
 Patient preferences and compliance.
The current position
 Overall, the evidence base is not strong enough to either
support or refute the use of any particular product for
topical application.
 Currently, some of the skin care provided may not actually
alleviate the problem and indeed may even compound the
effect.
 Are we actually providing skin care advice to patients based on
traditional knowledge and a paternalistic approach to
healthcare? (Harris, 2002)
The patient perspective
Health is:
" ... a state of complete physical, psychological, and social wellbeing, and not merely the absence of disease or infirmity.“
WHO (1978)
“ We are people, not just bodies.”
Patient 7: Harris (1995)
As Gosselin, et al. (2010) noted:
“patients prefer to take action rather than do nothing”
Conclusion
 The extent of skin conditions is largely unknown. Although
the majority of skin reactions subside after a few weeks,
some can be prolonged and affect a patient’s quality of life.
 It may not be possible to stop or even reduce the rates of
skin reaction from occurring, but there may be comfort and
psychosocial benefits that skin care products provide.
Working party
Dr Rachel Harris, Professional and Education Manager, SCoR
Charlotte Beardmore, Director of Professional Policy, SCoR
Amanda Bolderston, Provincial Professional Practice & Academic Leader, BCC Agency, Canada
Gemma Burke, Senior Lecturer and Professional Development Facilitator, SHU
Sarah James, Professional Officer for Radiotherapy, SCoR
Dr Heidi Probst, Reader in Radiotherapy, SHU
Claire Bennett, Programme Leader for Radiotherapy and Oncology programme, UWE
Samantha Bostock, Superintendent Radiographer, Gloucestershire Oncology Centre
Carole Downs, Breast Cancer Specialist Radiographer, Northern Centre for Cancer Care
Professor Sara Faithfull, Strategic Lead for Innovation and Enterprise, University of Surrey
Sonja Hoy, Nurse Specialist for Head & Neck, The Royal Marsden NHS Foundation Trust
Audrey Scott, Macmillan Head and Neck CNS, Mount Vernon Cancer Centre
Dr Diana Tait, Consultant Clinical Oncologist, The Royal Marsden NHS Foundation Trust
Ellen Trueman, Senior Radiotherapy Sister, St James's Institute of Oncology
Professor Mary Wells, Professor of Cancer Nursing Research & Practice, University of Stirling
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