Psychological effects of cetuximab-induced cutaneous rash in advanced colorectal cancer patients

Dermatological Side Effects of Cancer Treatment: Psychosocial Implications-A Systematic Review of the Literature

Cancer is a leading cause of mortality and morbidity all over the world and the second major cause of death in Portugal. Dermatological side effects resulting from cancer treatment have a psychosocial impact on patients' lives, such as quality of life (QoL), body image, cognitive fusion and social inhibition. This systematic review aimed to explore and synthesize the psychosocial impact of dermatological side effects of cancer treatment, answering the following research objectives: (i) Do the dermatological side effects of the cancer treatment present any psychosocial impact for the patients? (ii) How does the psychosocial impact of the dermatological toxicities of the cancer treatment manifest in patients' lives? Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed and guided a systematic search through the PubMed, Cochrane Library and PyscNet databases. The considered studies correlate dermatological side effects of cancer treatments and their psychological/psychosocial outcomes. The studies found were all published in peer-reviewed journals. The results obtained established that cancer treatment causes the most varied skin changes, consequently reducing self-esteem and QoL; disturbing body image; and contributing to cases of stress, depression and anxiety. There is still limited literature that profoundly investigates the experience of living with these skin toxicities. The development of research lines to improve knowledge in this field will allow for significant improvements in healthcare for patients undergoing cancer treatment who need to focus more on the psychosocial implications of skin toxicities. The novelty of this review lies in adding knowledge summarizing the psychosocial implications of dermatological side effects of cancer treatment to support healthcare providers in the development of integrative therapeutic strategies for these patients in their clinical practice.

Nursing care and management of adverse events for patients with BRAFV600E-mutant metastatic colorectal cancer receiving encorafenib in combination with cetuximab: a review

Encorafenib is a B-Raf proto-oncogene serine/threonine-protein kinase (BRAF) inhibitor, approved in the EU and USA, in combination with the epidermal growth factor receptor (EGFR) inhibitor cetuximab, for the treatment of patients with BRAF^V600E-mutant metastatic colorectal cancer (mCRC). In the pivotal BEACON CRC trial, patients achieved longer survival with encorafenib in combination with cetuximab vs. conventional chemotherapy. This targeted therapy regimen is also generally better tolerated than cytotoxic treatments. However, patients may present with adverse events unique to the regimen and characteristic of BRAF and EGFR inhibitors, which produce their own set of challenges. Nurses play an essential role in navigating the care of patients with BRAF^V600E-mutant mCRC and managing adverse events that patients may experience. This includes early and efficient identification of treatment-related adverse events, subsequent management of adverse events and education of patients and their caregivers around key adverse events. This manuscript aims to provide support to nurses managing patients with BRAF^V600E-mutant mCRC receiving encorafenib in combination with cetuximab, by summarising potential adverse events and providing guidance on how to manage them. Special attention will be paid to the presentation of key adverse events, dose modifications that may be required, practical recommendations and supportive care measures.

Exploring a multi-disciplinary model of supportive cancer care for monoclonal antibody treatment-related dermatological symptoms

CONTEXT AND OBJECTIVES

The present study examined the perspectives of healthcare providers (HCPs) in designing a multi-disciplinary model of supportive cancer care for the relief of dermatology-related symptoms caused by monoclonal antibody therapies.

METHODS

The study employed a mixed research methodology, with qualitative research embedded within a pragmatic prospective study of a registry protocol study. Patients undergoing oncology therapy with MoAB, anti-HER2, and anti-PD-L1 monoclonal antibodies were identified among a cohort of patients referred to an integrative oncology (IO) consultation for symptom relief and improved quality of life (QoL). Case studies with significant dermatology-related concerns were selected and presented to a panel of 6 HCPs trained in medical oncology, oncology nursing, family medicine, supportive cancer care, and IO. HCP narratives were qualitatively analyzed and assessed using ATLAS.Ti software for systematic coding.

RESULTS

Of the 924 patients referred to the IO consultation, 208 were treated with monoclonal antibodies, from which 50 were selected for further evaluation. Of these, 7 cases were presented to the HCP team who were asked to identify treatment gaps requiring a multi-disciplinary approach. Qualitative analysis identified 3 major themes: a biophysical perspective; a psycho-social-spiritual perspective; and the implementation of integrated care.

DISCUSSION

There is a need for a multi-disciplinary approach when treating patients suffering from monoclonal antibody treatment-related skin toxicities. HCP-reported themes highlight the need to identify patients for whom such an approach is warranted; conditions in which a psycho-social-spiritual perspective should be considered, in addition to a bio-physical approach; and considerations of who should be designated as the patient's primary case manager.

Quality of Life in Patients With Severe Skin Reactions in Course of First-Generation Epidermal Growth Factor Receptor Inhibitors Monoclonal Antibodies (Our Experience With Cetuximab)

Background

Metastatic colorectal cancer (mCRC) with wild type expression of RAS and RAF genes can be treated with anti-epidermal growth factor receptor (EGFR) monoclonal antibodies, such as cetuximab, in combination with chemotherapy. Skin toxicity represents the most serious and frequent side effect in these patients. Skin manifestations occur in approximately 80% of patients. In this study, we investigated the consequences on body image and quality of life (QoL) of patients with severe skin toxicity.

Methods

One hundred patients were enrolled with mCRC. All patients signed informed consent and completed questionnaires to assess QoL and body discomfort. Toxicity was assessed on Common Terminology Criteria for Adverse Events (CTCAEs).

Results

The greatest impact on QoL was represented by difficulties in managing skin rash-related side effects. Data showed a significant impact in psychological sphere and social relationships.

Conclusions

Skin side effects, particularly rash, influence QoL and social relationships, compromising therapeutic compliance.

Relationships between quality of life and skin toxicities of epidermal growth factor receptor inhibitors in cancer patients: A literature review

AIM

Epidermal growth factor receptor (EGFR) inhibitors are used as treatments for various cancers, but the associated skin toxicities affect quality of life (QoL). The aim of this review is to document the relationship between skin toxicity and QoL of cancer patients, and to identify implications for clinical practice and subjects for future studies.

METHODS

Electronic databases were searched systematically and all studies examining aspects of health-related QoL in patients receiving EGFR inhibitor treatments for cancer.

RESULTS

A total of 25 published studies met the criteria for inclusion. Some cancer patients maintained their health conditions by recognizing that skin toxicities are correlated with the efficacy of EGFR inhibitor therapy, yet QoL declined in all functional evaluations. In particular, QoL was low in patients above 81 years of age and in those under 50 years of age.

CONCLUSION

Improved understanding of the pain due to skin toxicity is required in all age groups, particularly in elderly and young cancer patients. In addition, further studies are required to define long-term changes in QoL among patients receiving EGFR inhibitors for cancer. Healthcare professionals need to help patients to maintain subjective health conditions by understanding relationships between skin toxicity and therapeutic effects. To this end, assessments of patients who are prone to QoL decline due to skin toxicity are critical so that skin management can be started during early stages.

A Review of Patient-Reported Outcomes Labeling for Oncology Drugs Approved by the FDA and the EMA (2012-2016)

OBJECTIVES

To compare US Food and Drug Administration (FDA) and European Medicines Agency (EMA) labeling for evidence based on patient-reported outcomes (PROs) of new oncology treatments approved by both agencies.

METHODS

Oncology drugs and indications approved between 2012 and 2016 by both the FDA and the EMA were identified. PRO-related language and analysis reported in US product labels and drug approval packages and EMA summaries of product characteristics were compared for each indication.

RESULTS

In total, 49 oncology drugs were approved for a total of 64 indications. Of the 64 indications, 45 (70.3%) included PRO data in either regulatory submission. No FDA PRO labeling was identified. PRO language was included in the summary of product characteristics for 21 (46.7%) of 45 indications. European Organisation for Research and Treatment of Cancer and Functional Assessment of Cancer Therapy measures were used frequently in submissions. FDA's comments suggest that aspects of study design (eg, open labels) or the validity of PRO measures was the primary reason for the lack of labeling based on PRO endpoints. Both agencies identified missing PRO data as problematic for interpretation.

CONCLUSIONS

During this time period, the FDA and the EMA used different evidentiary standards to assess PRO data from oncology studies, with the EMA more likely to accept data from open-label studies and broad concepts such as health-related quality of life. An understanding of the key differences between the agencies may guide sponsor PRO strategy when pursuing labeling. Patient-focused proximal concepts are more likely than distal concepts to receive positive reviews.

The Management of Skin Toxicity during Cetuximab Treatment in Advanced Colorectal Cancer: How much does it Cost? A Retrospecive Economic Assessment from a Single-Center Experience

Aims and background

Skin rash is a predictable and manageable side effect of anti-EGFR therapy such as cetuximab. The aim of this study is to estimate the costs for the foreseeable management of skin toxicity in patients treated with cetuximab in our institute in order to assess the direct medical economic impact.

Methods and study design

We retrospectively analyzed all consecutive patients with advanced colorectal cancer treated with cetuximab at our institute from June 2006 to May 2011. We evaluated the severity and mean duration of skin rash for each grade and we identified the costs for the different therapeutic interventions. Patients were treated according to the general consensus management of skin toxicity associated with cetuximab treatment.

Results

We evaluated 31 patients. The median follow-up was 28.95 months (range, 1.84–75.49). At last follow-up 10 patients (32.3%) were alive with metastases, 18 patients (58.1%) had died, 1 patient (3.2%) was alive without evidence of disease, and 2 patients (6.5%) were lost to follow-up. The median progression-free survival was 8.26 months and the median overall survival 32.89 months. Nineteen patients (61.3%) developed skin toxicities: 7 patients (22.6%) grade 1, 9 patients (29.0%) grade 2, 3 patients (9.7%) grade 3; no grade 4 skin toxicity was observed. The median duration of grade 1 toxicity was 79 days (no specific treatments were started), of grade 2 toxicity 95 days (cost range, € 199.50–294.50) and of grade 3 toxicity 64 days (cost range, € 159.42–233.90).

Conclusions

Our experience, through the analysis of nonselected cases, showed that the management of skin toxicities related to cetuximab is not so expensive. We recommend proper care of low-grade toxicities in order to reduce progression to highgrade toxicities and the resulting risk of hospitalization, which really impacts on costs.

Dermatologic Toxicity Occurring During Anti-EGFR Monoclonal Inhibitor Therapy in Patients With Metastatic Colorectal Cancer: A Systematic Review

Monoclonal antibody inhibitors of the epidermal growth factor receptor (EGFR) have been shown to improve outcomes for patients with metastatic colorectal cancer (mCRC) without RAS gene mutations. However, treatment with anti-EGFR agents can be associated with toxicities of the skin, nails, hair, and eyes. Because these dermatologic toxicities can result in treatment discontinuation and affect patient quality of life, their management is an important focus when administering anti-EGFR monoclonal antibodies. The present systematic review describes the current data reporting the nature and incidence of, and management and treatment options for, dermatologic toxicities occurring during anti-EGFR treatment of mCRC. A search of the National Library of Medicine PubMed database from January 1, 2009, to August 18, 2016, identified relevant reports discussing dermatologic toxicity management among patients with mCRC receiving anti-EGFR therapy. The studies were grouped by type and rated by level of evidence using the GRADE approach developed by the Agency for Healthcare Research and Quality. Overall, 269 reports were reviewed (nonrandomized trials, n = 120; randomized trials, n = 31; retrospective studies, n = 15; reviews, n = 39). Dermatologic toxicity of any grade occurs in most patients who receive anti-EGFR therapy; approximately 10% to 20% of patients experienced grade 3/4 toxicity. The most common dermatologic toxicities include papulopustular/acneiform rash, xerosis, and pruritus; however, nail changes, hair abnormalities, and ocular conditions also occur. Guidance for managing these toxicities includes the use of inexpensive emollient ointments and moisturizers, avoidance of sun exposure, avoidance of irritants, and the use of short showers. Several studies also found that preemptive treatment was more effective than reactive treatment at limiting the incidence and severity of skin toxicity. With appropriate treatment, the dermatologic toxicities associated with anti-EGFR monoclonal antibody therapy can be managed, minimizing patient discomfort and the need for therapy interruption and/or discontinuation. Additionally, preemptive treatment can reduce dermatologic toxicity severity, ultimately yielding better quality of life.

Management of adverse events during treatment of gastrointestinal cancers with epidermal growth factor inhibitors

The epidermal growth factor receptor (EGFR) is involved in development and progression of some gastrointestinal cancers, and is targeted by monoclonal antibodies (mAbs) and tyrosine kinase inhibitors (TKIs) used to treat these conditions. Targeted agents are generally better tolerated than conventional chemotherapy, but have characteristic toxicities that can affect adherence, dosing, and outcomes. Skin conditions are the most common toxicities associated with EGFR inhibitors, particularly papulopustular rash. Other common toxicities include mucosal toxicity, electrolyte imbalances (notably hypomagnesaemia), and diarrhoea, while the chimaeric mAb cetuximab is also associated with increased risk of infusion reactions. With appropriate prophylaxis, the incidence and severity of these events can be reduced, while management strategies tailored to the patient and the degree of toxicity can help to ensure continuation of anti-cancer therapy. Here, we review the main toxicities associated with EGFR-inhibiting mAbs and TKIs in patients with gastrointestinal cancers, and provide recommendations for prophylaxis and treatment.

Differences in symptom occurrence, severity, and distress ratings between patients with gastrointestinal cancers who received chemotherapy alone or chemotherapy with targeted therapy

BACKGROUND

Approximately 28% of patients with gastrointestinal (GI) cancers will receive targeted therapy (TT) because of the associated increases in survival. Only four studies have examined the symptom experience of these patients. To date, no studies have evaluated for differences in symptom occurrence, severity, and distress between patients who received chemotherapy (CTX) alone (n=304) or CTX with TT (n=93).

METHODS

Patients completed self-report questionnaires, approximately one week after they received CTX. A modified version of the Memorial Symptom Assessment Scale (MSAS) was used to obtain data on symptom occurrence, severity, and distress. Binary logistic regression analyses were used to test for differences in symptom occurrence rates between the two treatment groups. Ordinal logistic regression analyses were used to test for differences in severity and distress ratings between the two treatment groups.

RESULTS

Patients who received CTX with TT were significantly younger (P=0.009); were diagnosed with cancer longer (P=0.004); had a higher number of prior treatments (P=0.024); had metastatic disease, specifically to the liver (P<0.001); had a diagnosis of anal, colon, rectum, or colorectal cancer (CRC) (P<0.001); and were positive for detection of B-Raf proto-oncogene, serine/threonine kinase (BRAF) and Kirsten rat sarcoma viral oncogene homolog (KRAS) mutations (both P<0.001). In addition, CTX treatment regimens were significantly different between the two groups (P<0.001). After controlling for significant covariates, patients who received TT reported lower occurrence rates for lack of energy, cough, feeling drowsy, and difficulty sleeping (all, P<0.05). Patients who received TT reported lower severity scores for dry mouth (P=0.034) and change in the way food tastes (P=0.035). However, they reported higher severity scores for "I don't look like myself" (P=0.026). No differences in symptom distress scores were found between the two treatment groups.

CONCLUSIONS

This study is the first to evaluate for differences in the symptom experience of GI cancer patients who received CTX alone or CTX with TT using a multidimensional symptom assessment scale. While between group differences in patients' symptom experiences were identified, both treatment groups warrant ongoing assessments to optimally manage their symptoms.

Observational study on quality of life, safety, and effectiveness of first-line cetuximab plus chemotherapy in KRAS wild-type metastatic colorectal cancer patients: the ObservEr Study

Cetuximab improves efficacy when added to chemotherapy for metastatic colorectal cancer (mCRC). Effective management of skin reactions from cetuximab improves quality of life (QoL), and treatment compliance in clinical trials. No data are available from real-world settings. The ObservEr observational, multicenter, prospective study evaluated QoL, the incidence of skin reactions, and management of chemotherapy plus cetuximab in first-line for mCRC. The primary endpoint was QoL measured with the Dermatology Life Quality Index (DLQI) and EORTC QLQ-C30. Secondary endpoints were the incidence of skin and serious adverse events, median overall and progression-free survival, tumor response, and resection rates. Between May 2011 and November 2012, 228 patients with KRASwt mCRC were enrolled at 28 Italian centers, 225 evaluable, median age 65 years. QoL did not change during treatment and was not affected by the choice of prophylactic or reactive skin management. The incidence of cetuximab-specific grade ≥3 skin reactions was 14%, with no grade 4/5 events. Skin reactions correlated with survival (P = 0.016), and their incidence was influenced by chemotherapy regimen (oxaliplatin vs. irinotecan-Incidence rate ratio [IRR] 1.72, P < 0.0001) and gender (male vs. female-IRR 1.38, P = 0.0008). Compliance at first postbaseline evaluation was 97.75%. Median overall survival was 23.6 months, median progression-free survival 8.3 months. Cetuximab plus chemotherapy did not compromise QoL in the routine clinical setting when patients receive close monitoring plus prophylactic or reactive management of skin reactions. We observed the same correlation between overall survival (OS) and skin reactions reported in controlled clinical trials, also in this setting.

Dermatologic events from EGFR inhibitors: the issue of the missing patient voice

Purpose

As epidermal growth factor receptor (EGFR) inhibitors are associated with a variety of dermatologic adverse events (dAEs), the purpose of this study was to develop an overview of current knowledge of dAEs associated with EGFR inhibitors and to identify knowledge gaps regarding incidence, treatment, impact on quality of life (QOL), and patient acceptance.

Method

A structured literature search was conducted using MEDLINE/PubMed (January 1983 to January 2014). In total, 71 publications published from 2004 to 2014 were identified for consideration in the final evidence review.

Results

The majority of published articles concentrate on the incidence of skin reactions, duration, treatment, and prevention strategies. Different grading systems based on the symptoms of skin rash or on health-related QOL (HRQOL) are used. An additional topic is the possible correlation between acneiform rash and efficacy of EGFR inhibitors. Knowledge gaps identified in the literature were how dAEs impact QOL compared with other AEs from a patient’s perspective, patients’ acceptance of dAEs (willingness to tolerate), and the impact of physician-patient communication on treatment decisions.

Conclusions

Research is needed on the impact of dAEs on patients’ acceptance of cancer treatments. Systematic studies are missing that compare the impact of dAEs with other toxicities on therapy decisions from both physician’s and patient’s view, and that investigate the balance between efficacy and avoidance of acneiform rash in treatment decisions. Such studies could provide deeper insights into the acceptance of the risk of untoward dermatologic events by both physicians and patients when treating advanced cancers.

Electronic supplementary material

The online version of this article (doi:10.1007/s00520-016-3419-4) contains supplementary material, which is available to authorized users.

Nursing Management of Cutaneous Toxicities From Epidermal Growth Factor Receptor Inhibitors

BACKGROUND

Personalized targeted therapies have become an emerging paradigm in cancer treatment. Although generally more tolerable than other chemotherapeutic agents, one therapy, epidermal growth factor receptor inhibitors (EGFRIs), commonly results in the formation of cutaneous toxicities, which can negatively affect patients' treatment adherence and quality of life.

OBJECTIVES

The aim of this article is to review nursing management strategies for EGFRI-related cutaneous toxicities.

METHODS

A systematic literature review was performed, including database searches in PubMed/MEDLINE®, CINAHL®, Cochrane Library, PsycINFO®, and Web of Science.

FINDINGS

Nurses are essential to the management of EGFRI-related cutaneous toxicities and are in an ideal position to provide supportive care throughout the course of the EGFRI treatment. The aim of nursing management is to maintain patients' treatment adherence and quality of life by employing a preemptive and proactive approach. Patient education is the most frequently reported management strategy. However, treatment options and management strategies are largely anecdotal and based on individual reports and expert opinions. Although no evidence-based management strategies exist, nurses can rely on existing assessment tools and guidelines to provide patients with symptom management and supportive care.

Impact of Skin Toxicities Associated with Targeted Cancer Therapies on Body Image: A Prospective Study

BACKGROUND AND OBJECTIVE

Body-image issues associated with dermatological side effects induced by anticancer-targeted therapies have not been specifically explored until now despite growing literature about their impact on quality of life. Prospective and longitudinal investigations were needed. The aim of our study was to describe body-image changes occurring with cutaneous toxicities and their psychosocial impact on patients.

PATIENTS AND METHODS

Thirty-three patients were evaluated four times during the first 3 months of targeted therapy in terms of body satisfaction, physical attitudes and depression with validated and ad hoc questionnaires. The NCI-CTCAE V4.0 was used to grade adverse dermatological events. Descriptive and inferential analyses were conducted with SPSS 14.0 software.

RESULTS

Ninety-four per cent of the patients developed skin toxicities. Body satisfaction remained stable and slightly better than average over this period. About one-third of the patients reported body-image issues at baseline. Body satisfaction and depression levels at baseline appeared to be significantly associated with body-image issues after 3 months of therapy.

CONCLUSION

In the framework of regular dermatological monitoring, skin toxicities did not appear to be associated with body-image issues. Body satisfaction and depressive symptoms at the beginning of targeted therapy emerged as critical factors that practitioners should consider in order to prevent deterioration of body image that could impact on quality of life and compromise compliance.

Skin toxicity and quality of life during treatment with panitumumab for RAS wild-type metastatic colorectal carcinoma: results from three randomised clinical trials

Purpose

Epidermal growth factor receptor inhibitors such as panitumumab are associated with characteristic skin toxicities. We summarise data from three panitumumab clinical trials to investigate the potential impact of skin toxicity on quality of life (QoL) in patients with metastatic colorectal cancer (mCRC).

Methods

The studies were randomised, open-label trials comparing standard treatment (first-line FOLFOX4 [n = 456], second-line FOLFIRI [n = 381], or best supportive care [n = 114]) with or without panitumumab in adults with KRAS/NRAS (RAS) wild-type mCRC. QoL was assessed using the EuroQoL 5-domain health state index (HSI) and overall health rating (OHR) measures. Impact of skin toxicity on changes in QoL scores was estimated using a linear mixed-effects model. Worst skin toxicity was defined in separate models as a subgroup variable or as a measure over time.

Results

Regardless of analysis method, there were no statistically significant differences between the panitumumab and comparator arms in any of the studies in terms of change in HSI or OHR scores. There were no statistically significant differences in QoL outcomes between patients with worst skin toxicity grade <3 and those with grade ≥3. In addition, there were no statistically significant differences between the panitumumab and comparator arms in subgroups of patients with worst skin toxicity of grade <3 and ≥3.

Conclusions

Addition of panitumumab to chemotherapy in RAS wild-type mCRC has no statistically significant negative effect on overall QoL, despite skin toxicity. Skin toxicity of worst grade ≥3 appeared to have similar impact on QoL as skin toxicity of grade <3.

Electronic supplementary material

The online version of this article (doi:10.1007/s11136-016-1288-4) contains supplementary material, which is available to authorized users.

Quality of life during first-line FOLFOX4±panitumumab in RAS wild-type metastatic colorectal carcinoma: results from a randomised controlled trial

Introduction

Metastatic colorectal cancer is rarely curable. Improving quality of life is therefore a key treatment goal. We report quality of life for patients with RAS wild-type metastatic colorectal cancer in the PRIME study.

Methods

A randomised phase 3 open-label study of first-line panitumumab+FOLFOX4 vs FOLFOX4 enrolled adults with untreated metastatic colorectal cancer and an Eastern Cooperative Oncology Group performance status of 0–2. This analysis includes patients with wild-type RAS tumours (n=505). Quality of life (prespecified end point) was assessed using the EuroQoL 5-domain health state index and overall health rating in all patients and by early tumour shrinkage status (≥30% reduction in size by week 8; exploratory end point). Differences in quality of life were assessed using analysis of covariance and a mixed-effect piecewise linear model, and were also analysed by skin toxicity severity.

Results

There were no statistically significant differences between treatment arms from baseline to progression or to discontinuation. Grade 3+ skin toxicity was reported by 38% of patients receiving panitumumab+FOLFOX4 and 2% receiving FOLFOX4 alone. There were no significant differences in quality of life between patients with grade 0–2 skin toxicity and those with grade 3+ skin toxicity. More patients receiving panitumumab+FOLFOX4 vs FOLFOX4 had early tumour shrinkage (p<.001). In patients with tumour symptoms at baseline, there were statistically significant improvements in quality of life in those with early tumour shrinkage versus those without early tumour shrinkage.

Conclusions

Addition of panitumumab to FOLFOX4 in first-line therapy for metastatic colorectal cancer prolongs survival and has no negative effect on overall quality of life compared with FOLFOX4 alone. Specific quality of life assessments for skin toxicity should be included in study designs to better define the direct effect of these adverse events.

Trial registration number

NCT00364013.

Impact of dermatologic adverse events induced by targeted therapies on quality of life

BACKGROUND

Investigations about the impact of dermatologic adverse events on quality of life in the context of targeted therapies are quite recent and results vary in some dimensions. This article aims to summarize the existing data and to clarify needs in terms of clinical management and future research.

METHODS

A literature review was done with Pubmed, Medline, Scopus and PsycInfo databases and it combined the empirical studies published in English and in French over the past ten years.

RESULTS AND CONCLUSIONS

Dermatologic adverse events globally have a low to moderate impact on quality of life, mainly in the physical and emotional domains. Reasons for inter-individual variations in adjustment and long-term impact are still not well known. Making quality of life assessments systematic, making early referrals of patients to dermatology consultations and giving more attention to individual experience were identified as measures that could help prevent deterioration in quality of life.

Early skin toxicity predicts better outcomes, and early tumor shrinkage predicts better response after cetuximab treatment in advanced colorectal cancer

Cetuximab-containing treatments for metastatic colorectal cancer have been shown to have higher overall response rates and longer progression-free and overall survival than other systemic therapies. Cetuximab-related manifestations, including severe skin toxicity and early tumor shrinkage, have been shown to be predictors of response to cetuximab. We hypothesized that early skin toxicity is a predictor of response and better outcomes in patients with advanced colorectal carcinoma. We retrospectively evaluated 62 patients with colorectal adenocarcinoma who had unresectable tumors and were treated with cetuximab in our institution. Skin toxicity grade was evaluated on each treatment day. Tumor size was evaluated using computed tomography prior to treatment and 4-8 weeks after the start of treatment with cetuximab.Patients with early tumor shrinkage after starting treatment with cetuximab had a significantly higher overall response rate (P = 0.0001). Patients with early skin toxicity showed significantly longer overall survival (P = 0.0305), and patients with higher skin toxicity grades had longer progression-free survival (P = 0.0168).We have shown that early tumor shrinkage, early onset of skin toxicity, and high skin toxicity grade are predictors of treatment efficacy and/or outcome in patients with advanced colorectal carcinoma treated with cetuximab.

A prospective observational study to examine the relationship between quality of life and adverse events of first-line chemotherapy plus cetuximab in patients with KRAS wild-type unresectable metastatic colorectal cancer: QUACK Trial

We have planned a multicentre prospective study to examine the relative impact of the efficacy and adverse events of cetuximab plus first-line chemotherapy on the quality of life in Japanese patients with KRAS wild-type unresectable colorectal cancer. The Dermatology Life Quality Index and the European Organization for Research Treatment of Cancer Quality of Life Questionnaire Core 30 will be used to assess dermatology-specific and health-related quality of life. The severity of adverse events will be assessed by using the National Cancer Institute Common Terminology Criteria for adverse Events ver. 4.0. The endpoints will be the following associations: adverse events, including skin toxicity and quality of life; efficacy and skin toxicity; efficacy and quality of life; and skin-related quality of life and health-related quality of life. A total of 140 patients are considered to be appropriate for inclusion in this study. The results of this study will provide more information to both patients and physicians regarding the practical use of cetuximab and its impact on quality of life in patients with unresectable colorectal cancer in Japan. This study was registered at the University Hospital Medical Information Network Clinical Trial Registry as UMIN000010985.

Pilot clinical trial on the efficacy of prophylactic use of vitamin K1-based cream (Vigorskin) to prevent cetuximab-induced skin rash in patients with metastatic colorectal cancer

BACKGROUND

Cetuximab is an effective option for the treatment of metastatic colorectal cancer in the first and subsequent lines of treatment; among its side effects, acneiform skin rash is one of the major causes of treatment delay, reduction, or interruption, with a negative effect on quality of life. No effective strategy to prevent skin rash induced by epidermal growth factor receptor inhibitors is available; however, encouraging results have come from vitamin K1, phytomenadione, applied as a topical formulation. Available studies have been conducted in heterogeneous populations and are mainly focused on the use of vitamin K1-based cream for the treatment, rather than the prophylaxis, of acneiform rash.

PATIENTS AND METHODS

Forty-one consecutive patients from a single center all affected by metastatic colorectal cancer and receiving cetuximab, alone or combined with chemotherapy, applied vitamin K1-based cream to prevent the occurrence of acneiform skin rash. The cream was applied twice a day on the face and trunk from the first day of administration of cetuximab.

RESULTS

The application of the cream was well tolerated. No grade 4 rash was reported. The proportion of grade 3 skin rash in the first 8 weeks of treatment in this population was 15%, at the lower limit of values reported in the literature, and the proportion of patients with grade 2 rash was reduced (22.5%).

CONCLUSION

This experience confirms available data in a homogeneous population, suggesting a possible benefit of topical vitamin K1 as prophylaxis for cetuximab-induced skin rash in patients with metastatic colorectal cancer.

A review of cutaneous toxicities from targeted therapies in the treatment of colorectal cancers

Currently there are three targeted therapies approved for the treatment of colorectal cancers. These include the epidermal growth factor receptor (EGFR) inhibitors, cetuximab and panitumumab, and the multikinase inhibitor regorafenib. It is important to understand and recognize the common presentations of cutaneous toxicity that result from these agents to effectively manage symptoms and prevent premature discontinuation of anticancer treatment.

[Impact of cutaneous toxicities associated with targeted therapies on quality of life. Results of a longitudinal exploratory study]

Targeted therapies represent a promising option in cancer treatment, which have shown tumor control and patients survival benefits. But these drugs have systemic side effects, in particular frequent and various cutaneous effects. Few data have been published about the impact of these symptoms on patients' quality of life, particularly for psychological and social aspects. That is why we wished to evaluate this impact in order to propose a preventive management and optimize patients' care. Twenty-seven patients participated in both evaluation times of a longitudinal quantitative pilot study. They completed the same set of psychological questionnaires before taking treatment and 30 days after. Patients were mainly men with a metastatic lung, digestive or cutaneous cancer. Analyses showed that dermatological symptoms in 22 patients were associated for a majority of them with a decrease of quality of life, characterized by difficulties in houseworks and leisure activities, and a social functioning impairment. Adverse skin events did not seem to affect emotional state. These results must be confirmed by further investigations in a larger-scale prospective research.

Psychosocial impact of cutaneous toxicities associated with epidermal growth factor receptor-inhibitor treatment

Epidermal growth factor receptor inhibitors (EGFRIs) are an increasingly important class of anticancer agents. Cutaneous toxicities, the most common adverse effects of EGFRI therapy, require dose modification or treatment cessation when moderate or severe and may compromise treatment compliance. To date, assessment has focused on physical symptoms associated with cutaneous toxicities; however, the psychosocial impact of those effects requires greater consideration. This article reviews current knowledge of assessment of cutaneous toxicities and identifies gaps in evidence, with particular focus on the psychosocial impact of cutaneous toxicities. Promising new assessment tools and approaches including the use of electronic patient-reported outcome measures are discussed, as well as implications for research in evaluating psychosocial interventions.

Management of skin toxicity associated with cetuximab treatment in combination with chemotherapy or radiotherapy

BACKGROUND

Cetuximab was demonstrated by clinical trials to improve response rate and survival of patients with metastatic and nonresectable colorectal cancer or carcinoma of the head and neck. Appropriate management of skin toxicity associated with epidermal growth factor receptor inhibitor (EGFR-i) therapy is necessary to allow adequate drug administration and to improve quality of life and outcomes.

METHODS

A group of Italian Experts produced recommendations for skin toxicity management using the RAND/UCLA Appropriateness Method. Statements were generated on the basis of a systematic revision of the literature and voted twice by a panel of 40 expert physicians; the second vote was preceded by a meeting of the panelists.

RESULTS

Skin toxicity included skin rash, skin dryness, pruritus, paronychia, hair abnormality, and mucositis. Recommendations for prophylaxis and therapeutic interventions for each type of toxicity were proposed.

CONCLUSIONS

Interventions that were considered appropriate to improve compliance and outcomes of cancer patients treated with EGFR-i were identified.

Health-related quality of life and colorectal cancer-specific symptoms in patients with chemotherapy-refractory metastatic disease treated with panitumumab

PURPOSE

Panitumumab monotherapy is approved for chemotherapy-refractory wild-type KRAS metastatic colorectal cancer (mCRC). Patient-reported outcomes-although important in the palliative setting-have not been reported in this patient population.

METHODS

In a phase 3 trial (n = 463), patients with chemotherapy-refractory mCRC were randomized 1:1 to panitumumab plus best supportive care (BSC) or BSC alone. Patient-reported outcomes were assessed using the NCCN/FACT CRC Symptom Index (FCSI) and EQ-5D Index. KRAS tumor status was analyzed in a prospectively defined, retrospective analysis. Average difference in change from baseline between treatment groups was evaluated using linear mixed and pattern-mixture models.

RESULTS

KRAS tumor status and post-baseline patient-reported outcomes were available for 363 patients. Linear mixed models indicated significant differences in the FCSI score (difference in least-squares [LS] adjusted means [95% CI]; 5.62 [2.38, 8.86]) and the EQ-5D Index (difference in LS adjusted means [95% CI]; 0.22 [0.12, 0.32]) favoring panitumumab over BSC in patients with wild-type KRAS mCRC. By pattern-mixture analysis, the advantage of panitumumab over BSC was more pronounced in those patients with wild-type KRAS mCRC who did not drop out of the study early. In patients with mutant KRAS mCRC, no differences were observed between groups.

CONCLUSIONS

Panitumumab-treated patients with wild-type KRAS mCRC maintained better control of CRC symptoms and quality of life compared with BSC alone, extending our understanding of the benefits of panitumumab treatment beyond improvements in progression-free survival.

Quality of life in colon cancer patients with skin side effects: preliminary results from a monocentric cross sectional study

BACKGROUND

Epidermal growth factor receptor inhibitors are widely prescribed anticancer drugs. Patients treated commonly develop dermatologic adverse drugs reactions, but rarely they are involved in systematic evaluation of their quality of life. This monocentric cross sectional study is carried out to assess quality of life in colon cancer patients experienced skin side effects due to anti epidermal growth factor receptor inhibitors therapy.

METHODS

Consecutive patients with skin side effects to therapy treated at Fondazione Poliambulanza were enrolled in this study. Quality of life was evaluated with the Italian validated version of Skindex-29 questionnaire, exploring three dimensions: symptoms, emotional, and physical functioning. Skindex-29 was administered one time between the eighth and the twelfth week of the treatment.

RESULTS

Forty-five consecutive patients, mainly with metastatic colon cancer (29 female, 16 male), with an average age of 59.31 years (ranging from 34-78) were included in the study and analyzed. Patients showed a great impact of skin side effects on symptoms (mean 43), followed by emotional (mean 30), and functioning (mean 26) scales. In general women, the 55-65 age class, and patients with partial remission reported the worst quality of life.

CONCLUSIONS

Epidermal growth factor receptor inhibitors' skin side effects have an important impact on quality of life in advanced colon cancer patients; symptoms scale is the most effect respect to emotional and functioning scales.