Protecting the radiation-damaged skin from friction: a mini review

Mepitel Film Versus StrataXRT in Managing Radiation Dermatitis in an Intra-Patient Controlled Clinical Trial of 80 Postmastectomy Patients

BACKGROUND

Mepitel film decreases the severity of radiation dermatitis in breast cancer patients, but its application is resource-intensive. Many departments therefore use StrataXRT, a gel that patients apply themselves. We compared the protective effects of Mepitel film and StrataXRT on radiation dermatitis during and immediately after radiation therapy.

METHODS

This phase III multicentre randomised intra-patient-controlled clinical trial recruited breast cancer patients receiving radiation therapy following mastectomy in three New Zealand Hospitals. Lateral and medial aspects of the chest wall were randomised to either Mepitel film or StrataXRT. Overall skin reaction severity was measured using RISRAS and RTOG once a week during treatment and for 4 weeks after treatment completion. The primary outcome was moist desquamation (with a non-inferiority margin of 7.5%); secondary outcomes were overall skin reaction severity, patient tolerability, satisfaction and cost.

RESULTS

Between June 2021 and May 2024, 93 patients were recruited, and 80 patients completed the trial. The absolute difference in moist desquamation rates was 6% lower under Mepitel film (p = 0.413, 95% CI -5%, 18%). Overall skin reaction severity was significantly lower for Mepitel film (Researcher RISRAS: p = 0.022; RTOG: p = 0.011). Mepitel film was cheaper to apply but was less well tolerated, with poor skin adherence being an issue for many patients.

CONCLUSION

The study did not show non-inferiority for StrataXRT; overall skin reaction severity and costs were significantly lower under Mepitel film; however, StrataXRT was better tolerated.

TRIAL REGISTRATION

ACTRN12621000124831.

StrataXRT and Mepitel Film for Preventing Postmastectomy Acute Radiation Dermatitis in Breast Cancer: An Intrapatient Noninferiority Randomized Clinical Trial

PURPOSE

Acute radiation dermatitis (ARD) is a notable challenge for patients with breast cancer undergoing postmastectomy radiation therapy (RT). This study evaluates the efficacy, safety, and user experience of StrataXRT versus Mepitel Film for ARD prevention.

METHODS AND MATERIALS

This multicenter, noninferiority trial involved intrapatient randomization of 44 patients with histologically confirmed breast carcinoma who had undergone postmastectomy RT across 4 Australian hospitals from January 1 to December 31, 2017. Patients were randomly assigned to receive Mepitel Film and StrataXRT on alternate halves of the irradiated chest wall. Mepitel Film was applied by nurses and replaced every 1 to 2 weeks or as necessary, ensuring continuous coverage throughout RT. Conversely, patients self-applied StrataXRT daily to the opposite half, with adherence details recorded in patient diaries. The primary outcome was the mean difference in the time-weighted average (TWA) grade of ARD within designated rectangles in each half over 10 weeks from the commencement of RT.

RESULTS

Forty patients were analyzed per-protocol. Measurements using thermoluminescent dosimeters showed no significant dose differences between medial and lateral rectangles. StrataXRT was inferior to Mepitel Film in the primary outcome, with a mean difference in TWA grade of 0.19 (95% confidence interval, 0.12-0.26; P < .001). Secondary outcomes-mean difference in TWA grade in chest wall halves, worst ARD grade, and incidence of moist desquamation-showed noninferiority between treatments. Patient preferences were closely matched, with 37.5% favoring StrataXRT and 40% Mepitel Film. StrataXRT caused itching in 1 patient and Mepitel Film in 3, leading to 1 removal.

CONCLUSIONS

Although StrataXRT did not meet the noninferiority threshold in the primary outcome and is considered inferior, its ease of application and patient acceptance suggest that it may still be offered for ARD prevention in postmastectomy RT when Mepitel Film is not a practical option. Open discussion with patients and caregivers is recommended to determine the most appropriate skin protection agent, considering both efficacy and practicality.

The impact of a prophylactic skin dressing on surface-guided patient positioning in chest wall Radiation Therapy

INTRODUCTION

Surface-guided radiation therapy (SGRT) has emerged as a powerful tool to improve patient setup accuracy in radiation therapy (RT). Combined with the goal of increasing RT accuracy is an ongoing effort to decrease RT side effects. The application of a prophylactic skin dressing to the treatment site is a well-documented method of reducing skin-related side effects from RT. This paper aims to investigate whether the application of Mepitel, a prophylactic skin dressing, has an impact on the accuracy of surface-guided patient setups in chest wall RT.

METHODS

A retrospective analysis of daily image-guided Online Corrections (OLCs) from patients undergoing chest wall irradiation with SGRT was performed. Translational (superior-inferior, lateral, and anterior-posterior) OLC magnitude and direction were compared between patients treated with Mepitel applied and those treated without. Systematic and random errors were calculated and compared between groups.

RESULTS

OLCs from 275 fractions were analysed. Mean OLCs were larger for patients with Mepitel applied in the superior_inferior axis (0.34 vs. 0.22 cm, P = 0.049) and for the combined translational vector (0.54 vs. 0.43 cm, P = 0.043). Combined translational systematic error was slightly larger for patients with Mepitel applied (0.15 vs. 0.09 cm).

CONCLUSION

Mepitel can impact the accuracy of SGRT patient-positioning in chest wall RT. The variation however is small and unlikely to have any clinical impact if SGRT is coupled with image guidance and appropriate PTV margins. Further investigation is required to assess the effect of Mepitel on SGRT accuracy in other treatment sites, as well as any potential dosimetric impacts.

Decrease of radiation-induced skin reactions in breast cancer patients by preventive application of film dressings-a systematic review

PURPOSE

Radiation-induced skin reactions remain one of the most frequent side effects of adjuvant radiotherapy for breast cancer, which is the most common global malignancy. In individual cases, we observed a decrease in radiation dermatitis under film dressings used for skin marking purposes. Therefore, we decided to revise the available evidence regarding the prophylactic use of film dressings to reduce radiation dermatitis in breast cancer patients.

METHODS

On 20 March 2023, we conducted a systematic review of literature for randomized controlled trials published in the English, German, French, or Spanish language, available in the PubMed database.

RESULTS

Of 82 publications, 9 full texts were assessed and 6 randomized controlled trials were included in the final synthesis. Two trials analyzed the application of polyurethane film (Hydrofilm, Paul Hartmann AG, Heidenheim, Germany), the other four of silicone-based polyurethane film (Mepitel film, Molnlycke Health Care Limited, Milton Keynes, United Kingdom). The evaluation scales Common Terminology Criteria for Adverse Events (CTCAE), Radiation Therapy Oncology Group (RTOG), and the Radiation-Induced Skin Reaction Assessment Scale (RISRAS) were used for assessment. All six trials, with a total of 788 patients yielding data for analysis, demonstrate a significant decrease in radiation-induced skin reactions by use of the film (mainly p < 0.001).

CONCLUSION

Our analysis demonstrates a significant decrease in radiation-induced skin reactions by prophylactically applied film dressings in breast cancer patients. Consequent preventive use of film dressings might systematically reduce acute radiation-induced skin reactions in these patients.

Patient-reported experience with the use of Mepitel Film for prevention of acute radiation dermatitis in breast cancer

BACKGROUND AND PURPOSE

Mepitel Film (MF) has been demonstrated to reduce the severity of radiation dermatitis (RD) in patients receiving breast cancer radiotherapy (RT). The objective of this study was to characterize patient-reported experience with MF use, including its impact on daily activities and wellbeing.

MATERIALS AND METHODS

This single-institution study analyzed anonymized responses to a questionnaire completed by patients who used MF for the prevention of RD during breast cancer RT.

RESULTS

Of the 254 patients contacted, 192 patients completed the survey. Most patients disagreed or strongly disagreed that MF limited their ability to perform their daily activities, including household chores (88%, n = 169/191), their ability to work (83%, n = 157/189), or their ability to sleep (85%, n = 163/191). Furthermore, patients agreed or strongly agreed MF was comfortable on their skin (67%, n = 126/189) and protected their skin from rubbing against clothing (86%, n = 161/188). Some patients agreed or strongly agreed that MF affected their ability to shower (31%, n = 50/162), wear bras (28%, n = 51/185), and impacted their level of pruritus (35%, n = 67/189). However, most patients agreed or strongly agreed that their overall experience with MF was positive (92%, n = 173/189) and would recommend MF to a friend undergoing breast cancer RT (88%, n = 166/188).

CONCLUSION

MF use is associated with positive patient-reported experience during breast RT with minimal impact on daily activities.

Barrier films for the prevention of acute radiation dermatitis in breast cancer: A systematic review and meta-analysis of randomised controlled trials

PURPOSE

Radiation dermatitis (RD) is the most common side effect of adjuvant whole-breast or chest wall irradiation, majorly impacting quality of life in numerous patients. The use of barrier films (polyurethane dressings such as Hydrofilm® and Mepitel® film remaining on the skin for the duration of the radiation treatment) has been investigated as a prophylactic measure in several prospective trials. Here, we critically appraise the available evidence behind preventive barrier film application in the context of breast cancer treatment.

METHODS

International literature was reviewed and high-quality randomised controlled trials (RCTs) were included in this meta-analysis.

RESULTS

The results of 5 RCTs (663 patients; >90% Caucasian) were analysed. Overall, barrier films lead to improved clinician- and patient-reported outcomes: fewer grade ≥2 RD (11% vs. 42%; OR = 0.16; p < 0.001) and moist desquamation (2% vs. 16%; OR = 0.12; p = 0.006), as well as less patient-reported pain (standardised mean difference [SMD] -0.51; p < 0.001), itching (SMD -0.52; p = 0.001), burning (SMD -0.41; p = 0.011), and limitations in daily activities (SMD -0.20; p = 0.007). Furthermore, barrier films have a high acceptance rate among patients, as well as a favourable cost-benefit ratio. Possible side effects due to its application are mild and mostly self-limiting. Overall, there was a lack of information on the radiation treatment techniques used.

CONCLUSION

The evidence presented in this meta-analysis suggests that barrier films are an excellent tool in the prevention of RD among Caucasian patients receiving whole-breast or chest wall irradiation. Its use should therefore be considered routinely in these patients.

Mepitel Film for the prevention of acute radiation dermatitis in head and neck cancer: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

This systematic review and meta-analysis evaluates the efficacy of Mepitel Film in preventing acute radiation dermatitis (RD) in patients with head and neck cancer (HNC) across randomized controlled trials (RCTs).

METHODS

Embase, MEDLINE, and Cochrane Central Register of Controlled Trials were searched on 5 March 2023 to identify relevant RCTs. RD assessment tools and outcomes were compared across studies. Pooled effect sizes and 95% confidence intervals (CI) were estimated based on random-effects analysis using RevMan 5.4.

RESULTS

Three RCTs conducted between 2018 and 2020 were included. Mepitel Film decreased RD severity when compared to Sorbolene or Biafine but not when compared to mometasone. A per-protocol analysis of two of the trials revealed that, overall, Mepitel Film significantly reduced the incidence of grade 2-3 RD (odds ratio (OR), 0.24; 95% CI, 0.09-0.65; p = 0.005) and moist desquamation (OR, 0.21; 95% CI, 0.10-0.46; p < 0.0001) and decreased average patient, researcher, and combined components of the Radiation-Induced Skin Reaction Assessment Scale (the standardized mean difference (SMD) for patient ratings, - 2.56; 95% CI, - 3.15 to - 1.96, p < 0.00001; SMD for researcher ratings, - 3.47; 95% CI, - 6.63 to - 0.31, p = 0.03; SMD for combined scores, - 3.68; 95% CI, - 6.43 to - 0.92, p = 0.009). Noted issues with Mepitel Film included itchiness and poor adherence.

CONCLUSION

While there were discrepancies across studies, Mepitel Film demonstrated a decrease in the incidence of grade 2-3 RD and moist desquamation. These findings emphasize the need for further examining Mepitel Film's efficacy across diverse patient groups and the importance of standardizing RD severity assessment methodologies and control arms.

Mepitel film for the prevention and treatment of acute radiation dermatitis in breast cancer: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

This systematic review and meta-analysis aimed to evaluate the efficacy of Mepitel film in preventing or treating acute radiation dermatitis (RD) in patients with breast cancer in randomized controlled trials (RCTs).

METHODS

Embase, APA PsychInfo, Journals@Ovid Full Text, Ovid MEDLINE, PubMed, and Cochrane Trials were searched until December 12, 2022, to identify RCTs on the use of Mepitel film for preventing or treating acute RD from breast cancer radiotherapy. Per-protocol analysis was used to compare outcomes, calculate pooled effect sizes, odds ratio (OR), and 95% confidence intervals (CI), and to create forest plots using random effects analysis in RevMan 5.4.

RESULTS

Three RCTs were included in this review. Mepitel film significantly reduced the incidence of grade 3 RD (OR 0.15 95% CI 0.06, 0.37, p<0.0001) and grade 2 or 3 RD (OR 0.16 95% CI 0.04, 0.65, p=0.01) as scored on either the CTCAE or the RTOG scale. Additionally, Mepitel film significantly reduced RISRAS mean scores assessed by patients and combined researcher and patient (standardized mean difference (SMD) -7.59, 95% CI -14.42, -0.76, p=0.03; SMD -15.36, 95% CI -30.01, -0.71 p=0.04) but not the researcher component of the assessment tool (SMD -17.55, 95% CI -36.94, 1.84, p=0.08).

CONCLUSION

Mepitel film reduced the incidence of acute RD and improved patient-reported outcomes with minimal side effects, the main one being itchiness. Future research should assess the feasibility of Mepitel film with respect to specific patient-reported outcomes such as health-related quality of life issues associated with its use.

Differences in prophylactic performance across wound dressing types used to protect from device-related pressure ulcers caused by a continuous positive airway pressure mask

Prolonged use of continuous positive airway pressure masks, as often required for non-invasive ventilation, involves a risk for facial tissue breakdown due to the sustained deformations caused by tightening of the stiff mask surfaces to the head and the moist environment. The risk of developing mask-related facial injuries can be reduced through suitable cushioning materials placed at the skin-mask interfaces to spread the localised contact forces and disperse the surface and internal tissue stresses. Using an integrated experimental-computational approach, we compared the biomechanical protective performance of three popular foam-based wound dressings to that of a market-lead hydrocolloid dressing when applied to protect the facial skin under a mask. We measured the compressive stiffness properties of the four commercial dressing types in dry and moist conditions, and then fed those to an anatomically realistic finite element model of an adult male head, with an applied simulated mask. Through this process, we calculated the protective efficacy index of each dressing type, indicating the relative contribution of the specified dressing to alleviating facial soft tissue loads with respect to the no-dressing case. The foam-based dressings generally performed substantially better than the hydrocolloid, but foam dressings were also demonstrated to vary by their protective performance.

Barrier Films and Dressings for the Prevention of Acute Radiation Dermatitis: A Systematic Review and Meta-Analysis

PURPOSE

This systematic review and meta-analysis aimed to evaluate the efficacy of barrier films and dressings in preventing acute radiation dermatitis (RD).

METHODS

OVID Medline, Embase, and Cochrane databases were searched from 1946 to September 2020 to identify randomized controlled trials on the use of barrier films or dressings to prevent RD. For comparable outcomes between studies, pooled effect sizes and 95% confidence intervals (CI) were calculated using the random effects analysis in RevMan 5.4.

RESULTS

Fourteen and 11 studies were included in the qualitative and quantitative analyses, respectively. Five types of barrier films used for RD were identified: Hydrofilm, StrataXRT®, Mepitel® Film, 3 M™ Cavilon™ No-Sting Barrier Film, and silver leaf nylon dressing. Hydrofilm and Mepitel Film significantly reduced the development of RD grade ≥ 2 in breast and head and neck cancer patients (RR 0.32, 95%CI 0.19, 0.56, p < 0.0001; RR 0.21, 95%CI 0.05, 0.89, p = 0.03, resp.). Moreover, Hydrofilm had a beneficial effect on patient-reported outcomes (PROs) (SMD -0.75, 95%CI -1.2, -0.29, p = 0.001). The meta-analyses on the other barrier films did not show any significant effect.

CONCLUSION

This review and meta-analysis demonstrated that Hydrofilm and Mepitel Film could effectively reduce RD severity and improve PROs. The evidence is generally weak for all the studies on barrier films and dressings due to a limited study number, high risk of bias, small sample sizes, and minimal comparable outcome measures. It's potential has been proven, but future research in this field is recommended to confirm the efficacy of these products and assess real-world feasibility.

Comparison of clinical practice guidelines on radiation dermatitis: a narrative review

PURPOSE

Radiation dermatitis (RD) is a common side effect of radiation therapy (RT). While many different treatment strategies are currently used to address RD, there is a lack of consensus and RD prophylaxis and management guidelines have remained largely unchanged over the last 10 years. This review aims to formulate unambiguous supportive care interventions by comparing RD clinical practice guidelines published between 2010 and 2021 by several organizations: Multinational Association for Supportive Care in Cancer (MASCC), British Columbia Cancer Agency (BCCA), Cancer Care Manitoba (CCMB), Oncology Nursing Society (ONS), Society and College of Radiographers (SCoR), and International Society of Nurses in Cancer Care (ISNCC).

METHODS

Areas of agreement and discordance were assessed among the MASCC, BCCA, CCMB, ONS, SCoR, and ISNCC guidelines.

RESULTS

Treatment recommendations across guidelines for acute RD and chronic RT-induced skin toxicities have been summarized. The strongest agreement among the guidelines exists for the use of topical corticosteroids, silver sulfadiazine, washing, and deodorant. All guidelines recommend the use of topical corticosteroids, and washing with water and soap is consistently supported. There is minimal consensus on an optimal dressing or barrier film for RD prophylaxis or management. MASCC weakly recommends prophylactic use of silver sulfadiazine to reduce RD, while BCCA, CCMB, and SCoR recommend its use upon signs of infection. MASCC and CCMB recommend the use of a long-pulsed dye laser to manage telangiectasia, a late effect of RT.

CONCLUSIONS

Given the extent of discordance among guideline recommendations, further research is recommended to establish optimal treatments for RD prophylaxis and management.

Comparison of clinical practice guidelines on radiation dermatitis: a narrative review

PURPOSE

Radiation dermatitis (RD) is a common side effect of radiation therapy (RT). While many different treatment strategies are currently used to address RD, there is a lack of consensus and RD prophylaxis and management guidelines have remained largely unchanged over the last 10 years. This review aims to formulate unambiguous supportive care interventions by comparing RD clinical practice guidelines published between 2010 and 2021 by several organizations: Multinational Association for Supportive Care in Cancer (MASCC), British Columbia Cancer Agency (BCCA), Cancer Care Manitoba (CCMB), Oncology Nursing Society (ONS), Society and College of Radiographers (SCoR), and International Society of Nurses in Cancer Care (ISNCC).

METHODS

Areas of agreement and discordance were assessed among the MASCC, BCCA, CCMB, ONS, SCoR, and ISNCC guidelines.

RESULTS

Treatment recommendations across guidelines for acute RD and chronic RT-induced skin toxicities have been summarized. The strongest agreement among the guidelines exists for the use of topical corticosteroids, silver sulfadiazine, washing, and deodorant. All guidelines recommend the use of topical corticosteroids, and washing with water and soap is consistently supported. There is minimal consensus on an optimal dressing or barrier film for RD prophylaxis or management. MASCC weakly recommends prophylactic use of silver sulfadiazine to reduce RD, while BCCA, CCMB, and SCoR recommend its use upon signs of infection. MASCC and CCMB recommend the use of a long-pulsed dye laser to manage telangiectasia, a late effect of RT.

CONCLUSIONS

Given the extent of discordance among guideline recommendations, further research is recommended to establish optimal treatments for RD prophylaxis and management.

The Clinical Application of 3D-Printed Boluses in Superficial Tumor Radiotherapy

During the procedure of radiotherapy for superficial tumors, the key to treatment is to ensure that the skin surface receives an adequate radiation dose. However, due to the presence of the built-up effect of high-energy rays, equivalent tissue compensators (boluses) with appropriate thickness should be placed on the skin surface to increase the target radiation dose. Traditional boluses do not usually fit the skin perfectly. Wet gauze is variable in thickness day to day which results in air gaps between the skin and the bolus. These unwanted but avoidable air gaps lead to a decrease of the radiation dose in the target area and can have a poor effect on the outcome. Three-dimensional (3D) printing, a new rising technology named “additive manufacturing” (AM), could create physical models with specific shapes from digital information by using special materials. It has been favored in many fields because of its advantages, including less waste, low-cost, and individualized design. It is not an exception in the field of radiotherapy, personalized boluses made through 3D printing technology also make up for a number of shortcomings of the traditional commercial bolus. Therefore, an increasing number of researchers have tried to use 3D-printed boluses for clinical applications rather than commercial boluses. Here, we review the 3D-printed bolus’s material selection and production process, its clinical applications, and potential radioactive dermatitis. Finally, we discuss some of the challenges that still need to be addressed with the 3D-printed boluses.

Non-Healing Burn Wound Treatment With A Sterile Silicone Gel

Treatment of burn wounds can be complicated due to fluid and electrolyte loss and the increased chance of infectious complications. Silicone-based products have become increasingly used for non-healing wound treatment, but no study has specifically addressed its potential on burn patients. The purpose of this study was to compare the use of sterile silicone gel with conventional medication in improving the healing of burn wounds. Between November 2019 and March 2020, 12 patients with mid-deep and deep burn wounds were included in the present study (average TBSA approximately 29%, range 13-51%). Patient average age was 49 years (range 29-67 years), 7 were male. In each patient two clinically similar areas were identified and treated every 48 hours with topical application of silicone gel in the form of Stratamed® (Group 1) and conventional medication (Group 2). All the cases healed without requiring skin grafting. No secondary wound infection nor allergic reactions were found. The mean days from commencing the treatment to 95% re-epithelialization in Groups 1 and 2 were 5.4 and 12.5, respectively. Culture samples were negative for common pathogens. Silicone gel has shown to be particularly effective in speeding up the re-epithelialization process. The protective film formed by the silicone helps to reduce possible infectious complications. Finally, silicone gel is easy to apply and associated with greater pain control during medication.

Patient and radiographer acceptability of prophylactic skin care for breast patients receiving radiotherapy

INTRODUCTION

This study aimed to: • Address the lack of information surrounding patient preference within radiotherapy skin care. • Identify if prophylactic skin care is the preferred approach of patients and staff. • Establish if patients and staff are accepting of the use of a type of barrier film, such as 3M™ Cavilon™ No Sting Barrier Film.

METHODS

Twelve patients undergoing standard whole breast radiotherapy and four staff members who were based mainly on a breast-specific treatment unit were interviewed using semi-structured techniques. The interview transcripts were coded for areas of interest and a thematic map generated using the qualitative data analysis software (NVivo V12, QSR International).

RESULTS

One Hundred percent of patients (n = 12) would have preferred a proactive approach to skin care management over the reactive one currently implemented. Staff were also in favour of a proactive approach to skin care with 100% (n = 4) supportive of a trial into the film's effectiveness. Three key themes were identified: • Theme 1: Patient Ownership of Own care - all patients identified they preferred a prophylactic approach and that more specific skin care guidance from healthcare professionals would be beneficial. • Theme 2: Product Practicality - 93% of patients and 100% of staff accepted the product and would be open to the use of it clinically. • Theme 3: Staff Acknowledgement of Skin Care - all staff identified a patient group in need of prophylaxis and that Cavilon No Sting may be a product of interest.

CONCLUSION

Patients and staff were in support of prophylactic skin care, both approved of the proposed product. However, there is a significant lack of clinical evidence to support the use of any topical products within radiotherapy skincare due to the lack of high-quality studies.

IMPLICATIONS FOR PRACTICE

Changes to skin care practice could be considered due to patient preference in favour of proactive management.

An audit of radiation-induced skin reactions in the inframammary fold; does breast size impact on the severity of the reaction?

INTRODUCTION

Skin toxicity is a clinically significant side effect of external beam radiation; moist desquamation is particularly prevalent for breast patients, mainly in the axilla and inframammary fold (IMF). The aim of this audit was to assess if there is a correlation between patient breast size and the presence and extent of radiotherapy skin reaction in the IMF.

METHODS

Between 22/12/2017 and 31/05/2018 forty patients undergoing standard whole breast radiotherapy using 3D planned medial and lateral tangential fields had their skin reaction recorded weekly, whilst on treatment, using the Radiotherapy Oncology Group (RTOG) scoring system. Skin reactions were also documented at three and eight weeks post radiotherapy. A measurement of the patients IMF length and bra size were also noted. Statistical analysis was carried out using IBMÒ SPSS Statistics 24.

RESULTS

Six patients presented with grade ≥2 during week three of radiotherapy. The mean IMF length of six patients with adverse reactions 6.1 cm (±3.6 cm). As the length of the IMF increases, severity of skin reactions also increases; a positive correlation was identified between the two at both week three of radiotherapy and three weeks post radiotherapy (r = 0.401, n = 34, p = 0.05 and r = 0.671, n = 29, p = 0.00 respectively). Only one patient displayed grade 2 at eight weeks post radiotherapy (IMF length 7.5 cm).

CONCLUSION

The findings from this study would suggest that larger breasted patients do present earlier, and with more severe radiation-induced skin reactions.

IMPLICATIONS FOR PRACTICE

Changes to skin care practice could be considered for patients with larger breasts. This could be in the form of more frequent check-ups during treatment or proactive side effect management rather than reactive management.

Hydrofilm Polyurethane Films Reduce Radiation Dermatitis Severity in Hypofractionated Whole-Breast Irradiation: An Objective, Intra-Patient Randomized Dual-Center Assessment

Radiation-induced skin injury represents the most frequent side effect in breast cancer patients undergoing whole-breast irradiation (WBI). Numerous clinical studies on systemic and topical treatments for radiation dermatitis have failed to provide sustainable treatment strategies. While protective skin products such as dressings are undoubtedly the standard of care in wound care management, their utilization as preventive treatment in radiotherapy has been somewhat neglected in recent years. In this prospective, intra-patient randomized observational study, Hydrofilm polyurethane films were prophylactically applied to either the medial or lateral breast-half of 74 patients with breast cancer undergoing hypofractionated whole-breast irradiation following breast-preserving surgery. Maximum radiation dermatitis severity was assessed using Common Terminology Criteria for Adverse Events (CTCAE) v4.03 toxicity scores, photospectrometric erythema and pigmentation measurements and patient-assessed modified Radiation-Induced Skin Reaction Assessment Scale (RISRAS) scale. Phantom studies revealed a clinically negligible dose build-up of less than 0.1% with Hydrofilm. Compared to the control compartments physician-assessed radiation dermatitis severity was reduced in the hydrofilm compartments (mean 0.54 vs. 1.34; p = < 0.001). Objective photospectrometric skin measurements showed decreased erythema (p = 0.0001) and hyperpigmentation (p = 0.002) underneath Hydrofilm. Hydrofilm also completely prevented moist desquamation, and significantly reduced patients' treatment-related symptoms of itching, burning, pain, and limitations of day-to-day-activities. Significant beneficial effects were observed in terms of radiation dermatitis severity, erythema, hyperpigmentation as well as subjective treatment-related symptom experiences, while adverse reactions were rare and minor. Therefore, a prophylactic application of Hydrofilm polyurethane films can be suggested in hypofractionated WBI.

A single-blind, randomised controlled trial of StrataXRT® - A silicone-based film-forming gel dressing for prophylaxis and management of radiation dermatitis in patients with head and neck cancer

AIM

Investigate the effects of StrataXRT® versus 10% Glycerine (Sorbolene cream) for preventing and managing radiation dermatitis in patients with head and neck cancer receiving radical radiotherapy (≥50 Gy) with or without chemotherapy or biotherapy.

METHODS

A single-blind, randomised controlled, superiority trial was conducted. Patients either received StrataXRT® or Sorbolene (usual care). Skin toxicity, pain, itching and skin-related quality of life scores were collected from baseline, and up to four weeks post-treatment.

RESULTS

A total of 197 patients were randomised into the study. Skin toxicity was dependent on the treatment group with StrataXRT® patients experiencing lower mean skin toxicity at the end of the radiation treatment (P = 0.002). At the end of treatment, the StrataXRT® arm had a lower percentage of grade 2 (80%) and grade 3 (28%) skin toxicity compared to the sorbolene arm (91% and 45% respectively). After adjustment for Cetuximab, the StrataXRT® arm had a 12% lower risk of experiencing grade 2 skin toxicity (RRR = 0.876, 95% CI: 0.778-0.987, P = 0.031); and a 36% lower risk of experiencing grade 3 skin toxicity (RRR = 0.648, 95% CI: 0.442-0.947, P = 0.025). Cox regression analysis showed that patients receiving StrataXRT® had a 41.0% and 49.4% reduced risks of developing grade 2 and 3 skin toxicity respectively throughout treatment compared to the Sorbolene arm. There were no differences between groups in patient-reported outcomes. No treatment interruptions and study product related adverse events were reported in either arm.

CONCLUSION

StrataXRT® is effective for preventing, and delaying the development of grade 2 and 3 skin toxicity.

TRIAL REGISTRATION

ACTRN12616000511437.

Phase III Randomized Pair Comparison of a Barrier Film vs. Standard Skin Care in Preventing Radiation Dermatitis in Post-lumpectomy Patients with Breast Cancer Receiving Adjuvant Radiation Therapy

Introduction

Patients undergoing adjuvant radiotherapy to the breast often experience radiation dermatitis ranging from mild erythema to moist desquamation. In post-lumpectomy patients, the axilla and inframammary fold are at an increased risk for friction dermatitis. Dermatitis can impact patients’ quality-of-life and may require treatment break/cessation. Our objectives are to assess the efficacy of 3M Cavilon Barrier Film (BF) in preventing and/or delaying the onset of grade-two dermatitis and reducing patient-reported sensation scores.

Methods

A total of 55 patients were randomized to receive BF on the medial or lateral breast. BF was applied twice weekly during treatment. Skin toxicity was evaluated weekly by a blinded clinical investigator using the Skin Toxicity Assessment Tool (STAT) and the modified Radiation Therapy Oncology Group Visual Assessment Score (RTOG VAS). On day one, baseline photographs were taken; seven-to-ten days post-treatment, patients returned for photographs, the STAT/RTOG VAS, and patient-opinion questions in the form of the global questionnaire.

Results

The paired analysis found BF did not significantly reduce dermatitis either during or post-treatment. However, the unpaired analysis found significantly reduced RTOG VAS on the lateral compartment during treatment (BF:0.91 vs. Control:1.21, p = 0.0408). This difference resolved post-treatment. Additionally, BF was able to reduce pruritus (p = 0.047) on the medial components and burning sensations on the lateral components (p = 0.035). There was no significant difference between the time-to-onset or proportion of patients who developed grade-two dermatitis.

Conclusion

In an unpaired analysis, BF significantly reduced dermatitis on the lateral compartment during treatment. Additionally, BF significantly reduced pruritus and burning sensations. A larger study using a more reliable scoring method is required to clarify the effect of BF on radiation-associated skin toxicity.

Optimization of skin dose using in-vivo MOSFET dose measurements in bolus/non-bolus fraction ratio: A VMAT and a 3DCRT study

In‐phantom and in‐vivo three dimensional conformal radiation therapy (3DCRT) and volumetric modulated arc therapy (VMAT) skin doses, measured with and without bolus in a female anthropomorphic phantom RANDO and in patients, were compared against treatment planning system calculated values. A thorough characterization of the metal oxide semiconductor field effect transistor measurement system was performed prior to the measurements in phantoms and patients. Patients with clinical indication for postoperative external radiotherapy were selected. Skin dose showed higher values with 3DCRT technique compared with VMAT. The increase in skin dose due to the use of bolus was quantified. It was observed that, in the case of VMAT, the bolus effect on the skin dose was considerable when compared with 3DCRT. From the point of view of treatment time, bolus cost, and positioning reproducibility, the use of bolus in these situations can be optimized.

Breast cancer patients report reduced sensitivity and pain using a barrier film during radiotherapy - A Danish intra-patient randomized multicentre study

BACKGROUND AND PURPOSE

Radiodermatitis is a well-known toxicity of radiotherapy and barrier film has been shown to reduce the severity of radiodermatitis. We have validated prior findings in a Danish cohort, using a similar barrier film and patient reported outcomes.

MATERIALS AND METHODS

101 Danish breast cancer patients were included at three radiotherapy centres. Based on randomization either the lateral or medial part of their chest was covered by Mepitel film; making the patients their own control. The primary endpoint was patient reported symptoms and experience. A secondary endpoint was radiotherapy staff evaluation of dermatitis.

RESULTS

Within the skin area covered by film, the patients reported a statistical significant lower level of pain (p < .001), itching (p = 0.005), burning sensation (p = 0.005) as well as edema (p = 0.017) and reduced sensitivity (p < .001). Most patients (76%) would have preferred film on the entire treatment area (p < 0.001) and Mepitel Film as a standard treatment option (84%) (p < 0.001). Patients treated after mastectomy had a significantly lower severity of radiation-induced dermatitis with film at the end of RT compared to standard care (p = 0.005). However, in the blinded staff evaluation, no significant differences were found at follow-up.

CONCLUSIONS

Patients reported reduced symptoms from the skin with Mepitel Film and the majority would have preferred film as a standard offer to cover their entire treatment area. Especially women treated after mastectomy had a significantly lower level of radiodermatitis and preferred the film over standard care.

Prophylactically applied Hydrofilm polyurethane film dressings reduce radiation dermatitis in adjuvant radiation therapy of breast cancer patients

PURPOSE

Radiation-induced skin injury represents one of the most common side effects in breast cancer patients receiving adjuvant whole-breast radiotherapy. Numerous systemic and topical treatments have been studied in the prevention and management of radiation-induced skin injury without providing sustainable treatment strategies. While superficial barrier-forming skin products such as dressings are the standard of care in wound care management, their utilization as preventive treatment approach in radiotherapy has barely attracted attention.

METHODS

In this prospective, intra-patient randomized study, Hydrofilm polyurethane film dressings were applied prophylactically to either the medial or lateral breast half of 62 patients with breast cancer undergoing adjuvant radiation therapy following breast conserving surgery. The breast half contralateral to the film dressing was concurrently treated with 5% urea lotion as control skin care. Maximum severity of radiation dermatitis was assessed using RTOG/EORTC toxicity scores, photospectrometric erythema measurements and patient-assessed modified RISRAS scale.

RESULTS

In the Hydrofilm compartments, mean maximum RTOG/EORTC radiation dermatitis severity grades were significantly reduced from 1.33 to 0.35 and photospectrometric measurements showed significantly reduced erythema severity, as compared to the control compartments, with an overall response rate of 89.3%. Hydrofilm completely prevented moist desquamation and significantly reduced patients' subjective experience of itching and pain.

CONCLUSION

The obtained results along with a favorable cost-benefit ratio and an easy and quick application suggest a prophylactic application of Hydrofilm in adjuvant radiotherapy of breast cancer patients to reduce or even prevent radiation dermatitis.

Interest of Supportive and Barrier Protective Skin Care Products in the Daily Prevention and Treatment of Cutaneous Toxicity During Radiotherapy for Breast Cancer

Purpose:

As many as 50% of patients with cancer develop acute skin reactions to some degree with radiotherapy. Proactive skin care is often recommended to minimise these skin reactions and maintain the integrity of the epidermal barrier; nevertheless, no consensual guidelines are systematically used. This multicentre, observational, prospective study evaluated the tolerability and benefit of supportive and barrier protective skin care products in preventing radiotherapy-induced skin reactions in 253 women initiating radiotherapy (exclusive or adjuvant) for breast cancer.

Methods:

Patients received a kit of 5 commercially available skin care products before the first radiotherapy treatment. The following variables were assessed: cutaneous adverse events, investigator-assessed skin reactions (oedema, erythema, dryness, desquamation) before and after radiotherapy course, investigator, and patient opinion on products benefit. Results were analysed by frequency of product use (heavy versus low).

Results:

Average age was 60 years (range: 34-85). Over 92% of patients reported good to excellent tolerance on irradiated skin for each product. During the 6-week radiotherapy period, we observed that heavy product users had less skin reactions than the low users, particularly within 10 days of radiotherapy initiation (8% versus 18%; p = .031). Positive physician’s opinion on product use was more frequent for high (66.6%) versus low (32%) users. Patient-assessed patient benefit index was generally >1, indicating relevant treatment benefit, with a tendency for better benefit in high versus low users.

Conclusions:

These results support recommendations to use skin care products to minimise the impact of secondary cutaneous reactions with radiotherapy cancer treatment.

Protective effect of FGF-2 and low-molecular-weight heparin/protamine nanoparticles on radiation-induced healing-impaired wound repair in rats

We examined the effectiveness of localized administration of fibroblast growth factor-2 containing low-molecular-weight heparin/protamine nanoparticles (FGF-2&LMWH/P NPs) on apoptosis in vivo and on healing of radiation-induced skin injury in a rat model. FGF-2 binds onto LMWH/P NPs, which can significantly enhance and stabilize FGF-2 as a local carrier. X-irradiation at a dose of 25 Gy was administered to the lower part of the back (using a lead sheet with two holes) 1 h before the administration of FGF-2&LMWH/P NPs. Cutaneous full-thickness defect wounds were then formed in X-irradiated areas to examine the time-course of wound healing, and the wound tissues were microscopically and histologically compared and examined. Wound healing was significantly delayed by X-irradiation, but FGF-2&LMWH/P NPs administration prior to irradiation led to a significantly shorter delay compared with FGF-2 alone, LMWH/P NPs alone, and controls. Furthermore, terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) staining showed that the proportions of apoptotic dermal fibroblasts in X-irradiated skin were significantly lower in rats administered FGF-2&LMWH/P NPs than in controls. However, 8-hydroxy-2'-deoxyguanosine (8-OHdG) staining showed no differences. Thus, localized administration of FGF-2&LMWH/P NPs prior to irradiation may alleviate X-irradiation-induced healing-impaired wound repair in normal tissue.

The effect of Mepitel Film on acute radiation-induced skin reactions in head and neck cancer patients: a feasibility study

OBJECTIVE

Mepitel Film significantly decreases acute radiation-induced skin reactions in breast cancer patients. Here we investigated the feasibility of using Mepitel Film in head and neck cancer patients (ACTRN12614000932662).

METHODS

Out of a total of 36 head and neck cancer patients from New Zealand (NZ) (n = 24) and China (n = 12) recruited between June 2015 and December 2016, 33 patients complied with protocol. Of these, 11 NZ patients followed a management protocol; 11 NZ patients and 11 Chinese patients followed a prophylactic protocol. An area of the neck receiving a homogenous radiation dose of > 35 Gy was divided into two equal halves; one half was randomized to Film and the other to either Sorbolene cream (NZ) or Biafine cream (China). Skin reaction severity was measured by Radiation Induced Skin Reaction Assessment Scale and expanded Radiation Therapy Oncology Group toxicity criteria. Skin dose was measured by thermoluminescent dosimeters or gafchromic film.

RESULTS

Film decreased overall skin reaction severity (combined Radiation Induced Skin Reaction Assessment Scale score) by 29% and moist desquamation rates by 37% in the Chinese cohort and by 27 and 28%, respectively in the NZ cohort. Mepitel Film did not affect head movements but did not adhere well to the skin, particularly in males with heavy beard stubble, and caused itchiness, particularly in Chinese patients.

CONCLUSION

Mepitel Film reduced acute radiation-induced skin reactions in our head and neck cancer patients, particularly in patients without heavy stubble. Advances in knowledge: This is the first study to confirm the feasibility of using Mepitel Film in head and neck cancer patients.

Acute radiation dermatitis in breast cancer patients: challenges and solutions

Nearly all women who receive radiotherapy (RT) for breast cancer experience some degree of radiation dermatitis. However, evidence describing the appropriate management of radiation dermatitis is often lacking or contradictory. Here, we summarize the available literature regarding radiation dermatitis causes, the presentation and timing of symptoms, methods for dermatitis assessment and prevention, and review evidence-based management strategies.

A Review of the Use of Topical Calendula in the Prevention and Treatment of Radiotherapy-Induced Skin Reactions

Calendula is a topical agent derived from a plant of the marigold family Calendula Officinalis. Containing numerous polyphenolic antioxidants, calendula has been studied in both the laboratory and clinical setting for the use in treating and preventing radiation induced skin toxicity. Despite strong evidence in the laboratory supporting calendula's mechanism of action in preventing radiation induced skin toxicity, clinical studies have demonstrated mixed results. In light of the controversy surrounding the efficacy of calendula in treating and preventing radiodermatitis, the topic warrants further discussion.