Predictive factors associated with radiation dermatitis in breast cancer

Predictive factors associated with acute radiation dermatitis in patients with breast cancer: a retrospective cohort study

Background

Radiation therapy (RT) is a primary postsurgical treatment for breast cancer; however, it can cause acute radiation dermatitis (ARD), which can severely impair quality of life. The aim of this study was to identify predictive factors associated with moderate to severe ARD.

Materials and Methods

In this retrospective analysis, we utilized data from Chulabhorn Hospital's Health Information System that was collected between January 2017 and December 2022. A radiation oncology specialist assessed ARD in a cohort of 635 patients using the Radiation Therapy Oncology Group (RTOG) ARD grading scale. The patients were classified into two groups based on the maximum grade recorded: mild (grade < 2) and moderate to severe (grade ≥ 2). Various factors were examined, including demographic characteristics (age, body mass index (BMI), comorbidities) and treatment-related variables (surgical history, adjuvant chemotherapy, hormone therapy, targeted therapy, fractionation, boost treatments, and bolus application). Logistic regression was used to perform the statistical analysis.

Results

Among the 635 patients, the average age was 54.2 ± 10.9 years, and 32% were classified as having moderate to severe ARD. Multiple logistic regression analysis identified BMI ≥ 30 kg/m2 (adjusted odds ratio (AOR) = 2.33; 95% confidence interval (CI) [1.36-3.98]; p-value = 0.002), localized boost treatments (AOR = 2.09; 95% CI [1.08-4.06]; p-value = 0.029), and bolus application (AOR = 2.08; 95% CI [1.02-4.24]; p-value = 0.044) as significant risk factors for moderate to severe ARD. Conversely, hypofractionated RT (AOR = 0.31; 95% CI [0.16-0.57]; p < 0.001) and hormonal therapy (AOR = 0.60; 95% CI [0.42-0.86]; p-value = 0.005) were associated with a decreased risk. However, radiation to both the primary site and regional lymph nodes (AOR = 0.81; 95% CI [0.41-1.59]; p-value = 0.538) and targeted therapy (AOR = 0.72; 95% CI [0.43-1.20]; p-value = 0.210) did not significantly affect the risk of moderate to severe ARD.

Conclusions

We have identified key risk factors for moderate to severe ARD, including obesity and treatment modalities such as localized boost treatments and bolus application. Hormone therapy and hypofractionated RT appear to reduce ARD severity. These findings have implications for the development of treatment plans and the mitigation of the risk of ARD in patients undergoing RT.

Non-invasive physical plasma for preventing radiation dermatitis in breast cancer: study protocol for a phase 3 randomised double-blind placebo-controlled trial (NIPP-RD III)

BACKGROUND

Radiation dermatitis (RD) is the most common side effect of breast irradiation, yet only few potent preventative and therapeutic options are available. Following encouraging results from a phase 1 and 2 trial on the topical use of non-invasive physical plasma (NIPP), a very well-tolerated physical treatment option to promote tissue regeneration generated from ambient air, we now present the study protocol for a planned phase 3 trial.

METHODS

In this randomised double-blind placebo-controlled trial, patients with breast cancer will be randomised (1:1) to receive either 120 s of NIPP or sham treatment with an identical device daily during hypofractionated breast irradiation following breast-conserving surgery. Standard skin care with urea lotion will be applied twice daily to the whole breast by all patients. Acute skin toxicity will be assessed weekly and includes clinician- (CTCAE v5.0) and patient-reported (modified RISRAS), and objective (spectrophotometry) assessments. The trial has started enrolment in the first quarter of 2024 and is projected to recruit 140 patients over 36 months.

DISCUSSION

This randomised controlled trial will recruit a homogeneous patient collective in terms of RD risk and aims to unequivocally establish the impact of NIPP on RD by employing a robust trial design, incorporating both the patient's perspective and validated objective outcome measures. If the addition of NIPP proves useful, it might reduce both physical and psychological distress caused by RD in numerous breast cancer patients and beyond.

TRIAL REGISTRATION

German Clinical Trial Registry DRKS00032560 (January 9th 2024).

A critical review of randomized controlled trials on topical corticosteroids for the prevention of radiation dermatitis in breast cancer

INTRODUCTION

Topical steroids have shown effectiveness in preventing radiation dermatitis (RD) in breast cancer patients in randomized controlled trials (RCTs). This review provides an in-depth analysis of the study methodology of these RCTs to review whether topical steroids should be employed in routine clinical practice.

METHODS

A systematic literature search of MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials was conducted from database inception until May 31, 2024. RCTs comparing topical steroids with moisturizers or placebo for the prophylaxis of RD in breast cancer patients were included. The methodology of the RCTs, including how topical steroids were applied, whether crossover in the control arm was allowed, if stratification factors were employed, and the reporting of side effects was evaluated.

RESULTS

Twelve RCTs met inclusion criteria. Four different topical steroids were used, including betamethasone 0.1%, mometasone 0.1%, hydrocortisone 1%, and beclomethasone. Eleven studies (92%) showed that topical steroids were effective in reducing incidence or delaying occurrence of grade 2 or above RD with a relative risk of 0.69 (range, 0.19 to 0.98). In all RCTs, topical steroids were consistently used from the start of radiotherapy (RT) until completion to 3 weeks post-RT. Five RCTs (42%) provided patient education on topical steroid application. Six (50%) reported on subsequent management if moist desquamation occurred. Four studies (33%) stratified potential risk factors of RD during randomization. No studies reported any long-term side effects of topical steroids.

CONCLUSION

Topical steroids are effective in reducing the incidence of RD. However, heterogeneity was observed among the RCTs with regard to how and when the topical steroids were applied. The long-term safety profile of topical steroids is not well studied. In the context of modern radiotherapy planning techniques and increased use of hypofractionation radiation schedules, a repeat RCT addressing these methodological concerns may provide more guidance to clinicians.

Development and performance evaluation of medical radiation-reducing creams using eco-friendly radiation-shielding composites

To ensure the safety of medical personnel in healthcare organizations, radiation-shielding materials like protective clothing are used to protect against low-dose radiation, such as scattered rays. The extremities, particularly the hands, are the most exposed to radiation. New materials that can be directly coated onto the skin would be more cost-effective, efficient, and convenient than gloves. We developed protective creams using eco-friendly shielding materials, including barium sulfate, bismuth oxide, and ytterbium oxide, to avoid harmful effects of heavy metals like lead, and tested their skin-protective effects. Particularly, the radiation-shielding effect of ytterbium oxide was compared with that of the other materials. As shielding material dispersion and layer thickness greatly affect the efficacy of radiation-shielding creams, we assessed dispersion in terms of the weight percentage (wt%). The effective radiation energy was reduced by 20% with a 1.0-mm increase in cream thickness. Ytterbium oxide had a higher radiation-shielding rate than the other two materials. A 28% difference in protective effect was observed with varying wt%, and the 45 wt% cream at 63.4 keV radiation achieved a 61.3% reduction rate. Higher content led to a more stable incident energy-reducing effect. In conclusion, ytterbium oxide shows potential as a radiation-shielding material for creams.

Utilizing radiomics and dosiomics with AI for precision prediction of radiation dermatitis in breast cancer patients

PURPOSE

This study explores integrating clinical features with radiomic and dosiomic characteristics into AI models to enhance the prediction accuracy of radiation dermatitis (RD) in breast cancer patients undergoing volumetric modulated arc therapy (VMAT).

MATERIALS AND METHODS

This study involved a retrospective analysis of 120 breast cancer patients treated with VMAT at Kaohsiung Veterans General Hospital from 2018 to 2023. Patient data included CT images, radiation doses, Dose-Volume Histogram (DVH) data, and clinical information. Using a Treatment Planning System (TPS), we segmented CT images into Regions of Interest (ROIs) to extract radiomic and dosiomic features, focusing on intensity, shape, texture, and dose distribution characteristics. Features significantly associated with the development of RD were identified using ANOVA and LASSO regression (p-value < 0.05). These features were then employed to train and evaluate Logistic Regression (LR) and Random Forest (RF) models, using tenfold cross-validation to ensure robust assessment of model efficacy.

RESULTS

In this study, 102 out of 120 VMAT-treated breast cancer patients were included in the detailed analysis. Thirty-two percent of these patients developed Grade 2+ RD. Age and BMI were identified as significant clinical predictors. Through feature selection, we narrowed down the vast pool of radiomic and dosiomic data to 689 features, distributed across 10 feature subsets for model construction. In the LR model, the J subset, comprising DVH, Radiomics, and Dosiomics features, demonstrated the highest predictive performance with an AUC of 0.82. The RF model showed that subset I, which includes clinical, radiomic, and dosiomic features, achieved the best predictive accuracy with an AUC of 0.83. These results emphasize that integrating radiomic and dosiomic features significantly enhances the prediction of Grade 2+ RD.

CONCLUSION

Integrating clinical, radiomic, and dosiomic characteristics into AI models significantly improves the prediction of Grade 2+ RD risk in breast cancer patients post-VMAT. The RF model analysis demonstrates that a comprehensive feature set maximizes predictive efficacy, marking a promising step towards utilizing AI in radiation therapy risk assessment and enhancing patient care outcomes.

A topical BRAF inhibitor (LUT-014) for treatment of radiodermatitis among women with breast cancer

Background

Modern radiotherapy is associated with dermatitis (RD) in approximately one-third of patients treated for breast cancer. There is currently no standard for treating RD.

Objective

The objective of this study was to determine whether LUT014, a topical BRAF inhibitor which paradoxically activates mitogen-activated protein kinase, can safely improve RD.

Methods

A phase I/II study was designed to first follow a small cohort of women with grade 2 RD regarding toxicity and response. Then, 20 patients were randomized to compare LUT014 to "vehicle" relative to safety and response (measured with common terminology criteria for adverse events, Dermatology Life Quality Index).

Results

No substantial toxicity (eg, 0 serious adverse event) was associated with LUT014. All 8 women receiving LUT014 achieved treatment success (5-point Dermatology Life Quality Index reduction at day 14) compared to 73% (8/11) on the placebo arm (P = .591). The time to complete recovery was shorter in the treatment arm.

Limitations

The sample size was limited. Only 2 hospitals were included.

Conclusions

Topical LU014 is tolerable and may be efficacious for grade 2 RD.

Effectiveness of glutamine for the treatment of radiodermatitis in cancer patients: a meta-analysis of randomized controlled trials

BACKGROUND

After receiving radiation therapy, 60%-95% of patients with cancer develop radiodermatitis, which causes pain, wound infection, and poor quality of life. Glutamine is a popular nutritional supplement for patients with cancer. Several studies examined the usefulness of glutamine for reducing radiodermatitis. However, there is still no consolidated evidence for clinical use.

METHODS

We searched PubMed, Embase, Cochrane Library, CINAHL PLUS, and the China Knowledge Resource Integrated Database for the relevant literature published up to March 2023, without language restrictions. Two reviewers screened, filtered, and appraised these articles independently, and their data were pooled using a random-effects model.

RESULTS

Five randomized controlled trials (RCTs) with 218 participants were analyzed. The incidence of radiodermatitis in the glutamine group (89/110) was significantly lower than in the placebo group (99/108; risk ratio [RR], 0.90; 95% CI, 0.81-1.00; p = 0.05; I2 = 7%). The incidence of moderate to severe radiodermatitis was significantly lower in the glutamine group than in the placebo group (RR, 0.49; 95% CI, 0.32-0.76; p = 0.001; I2 = 52%). Moreover, subgroup analysis demonstrated heterogeneity (I2 = 52%) for moderate to severe radiodermatitis, the risk of which might be significantly reduced by a glutamine dose of 20-30 g/day (RR, 0.60; 95% CI, 0.41-0.87; I2 = 0%).

CONCLUSION

The meta-analysis indicate that glutamine might lead to a lower incidence of radiodermatitis, and that a glutamine dose of 20-30 g/day might decrease the incidence of moderate to severe dermatitis. Thus, the serious impact of radiodermatitis on treatment follow-up makes the clinical use of glutamine even more important. PROSPERO number: CRD42021254394.

Non-invasive physical plasma for preventing radiation dermatitis in breast cancer: Results from an intrapatient-randomised double-blind placebo-controlled trial

Background and Purpose

To investigate the effect of topical non-invasive physical plasma (NIPP), a volatile mix generated out of ambient air, on prevention of acute radiation dermatitis (RD) during and after whole-breast irradiation (WBI).

Materials and Methods

Lateral and medial breast halves were randomised within each patient to receive either 120 s of NIPP or sham treatment daily during WBI. Standard skin care with urea lotion was applied to the whole breast. Blinded acute skin toxicity was assessed weekly for each breast half separately and included clinician- (CTCAE) and patient-reported (modified RISRAS), and objective (spectrophotometry) assessments. As an additional external control, a comparable standard of care (SoC) patient collective from a previous prospective trial was used.

Results

Sixty-four patients were included. There were no significant differences between breast halves. Post-hoc comparison with a similar SoC control collective revealed OR = 0.28 (95% CI 0.11-0.76; p = 0.014) for grade ≥ 2 RD upon WBI completion, along with less hyperpigmentation (p < 0.001), oedema (p = 0.020), dry (p < 0.001) and moist desquamation (p = 0.017), pain, itching, and burning (p < 0.001 for each). Tolerability of NIPP was excellent and side effects were not observed.

Conclusion

Even though there were no differences between intrapatient-randomised breast halves, the overall incidence and severity of acute radiation-induced skin toxicity were considerably lower when compared to a prospectively collected SoC cohort. Our data suggest the potential benefit of NIPP in RD prevention. A randomised trial with a physical control group is warranted to confirm these promising results (DRKS00026225).

Quality-of-life outcomes following topical melatonin application against acute radiation dermatitis in patients with early breast cancer: A double-blind, randomized, placebo-controlled trial

The aim of this double-blind, placebo-controlled, randomized study was to investigate whether topical melatonin administered during radiation therapy could increase the quality of life in patients with primary breast cancer. Patients were followed from the first radiation fraction until 3 weeks after the last. The patients applied 1 g of cream to the irradiated area of the skin twice daily, consisting of either 25 mg/g melatonin and 150 mg/g dimethyl sulfoxide, or a placebo cream. Outcomes were the European Organisation for Research and Treatment of Cancer's quality-of-life questionnaires for breast cancer (QLQ-C30 and QLQ-BR23) on the last day of radiation therapy. As a secondary outcome, we evaluated the breast symptom (BS) scores over the entire duration of the trial in a repeated measures linear model. We included 65 patients and had 17 drop-outs, thus totaling 26 and 22 patients in the melatonin and placebo groups, respectively. BS scores on the last day of radiation did not differ between groups (p = .333). However, the linear model analyzing BS for the entire duration showed that melatonin significantly decreased the symptoms (p = .001). There was no difference in the BS score on the last day of radiation, however, we found that the patients in the melatonin group had significantly lower BS scores over the entire duration of the trial.

The effect of recombinant human epidermal growth factor on radiation dermatitis in rectal and anal cancer patients: a self-controlled study

Background

Our previous study reported that recombinant human epidermal growth factor (rhEGF)-triggered EGFR internalization promoted radioresistance. Here, we aimed to evaluate the effect of rhEGF on the skin protection of rectal and anal cancer patients receiving radiotherapy.

Methods

One hundred and ninety-three rectal and anal cancer patients who received radiotherapy were prospectively enrolled from January 2019 to December 2020. To perform self-controlled study, the left and right pelvic skin area (separated by midline) were randomly assigned to the rhEGF and control side. The association between radiation dermatitis and factors including rhEGF, the dose of radiotherapy and tumor distance from anal edge were analyzed.

Results

Among 193 enrolled patients, 41 patients (21.2%) did not develop radiation dermatitis, and 152 patients (78.8%) suffered radiation dermatitis on at least one side of pelvic skin at the end of radiotherapy. For the effect on radiation dermatitis grade, rhEGF had improved effect on 6 (4.0%) patients, detrimental effect on 2 (1.3%) patients, and no effect on 144 (94.7%) patients. Whereas for the effect on radiation dermatitis area, rhEGF showed improved effect on the radiation dermatitis area of 46 (30.2%) patients, detrimental effect on 15 (9.9%) patients, and no effect on 91 (59.9%) patients. The radiation dermatitis area of rhEGF side was significantly smaller than that of control side (P = 0.0007).

Conclusions

rhEGF is a skin protective reagent for rectal and anal cancer patients receiving radiotherapy.

Trial registration

Chinese Clinical Trial Registry identifier: ChiCTR1900020842; Date of registration: 20/01/2019.

Assessment of Tissue Oxygenation and Radiation Dermatitis Pre-, During, and Post-Radiation Therapy in Breast Cancer Patients

Over 95% of breast cancer patients treated with radiation therapy (RT) undergo an adverse skin reaction known as radiation dermatitis (RD). Assessment of severity or grading of RD is clinically visual and hence subjective. Our objective is to determine sub-clinical tissue oxygenation (oxygen saturation) changes in response to RT in breast cancer patients using near-infrared spectroscopic imaging and correlate these changes to RD grading. A 4-8 week longitudinal pilot imaging study was carried out on 10 RT-treated breast cancer patients. Non-contact near-infrared spectroscopic (NIRS) imaging was performed on the irradiated ipsilateral and the contralateral breast/chest wall, axilla and lower neck regions before RT, across the weeks of RT, and during follow-up after RT ended. Significant changes (p &lt; 0.05) in oxygen saturation (StO2) of irradiated and contralateral breast/chest wall and axilla regions were observed across weeks of RT. The overall drop in StO2 was negatively correlated to RD scaling (in 7 out of 9 cases) and was higher in the irradiated regions when compared to its contralateral region. Differences in the pre-RT StO2 between ipsilateral and contralateral chest wall is a potential predictor of the severity of RD. The subclinical recovery of StO2 to its original state was longer than the visual recovery in RD grading scale, as observed from the post-RT assessment of tissue oxygenation.

A Chitosan-Coated Chamomile Microparticles Formulation to Prevent Radiodermatitis in Breast: A Double-blinded, Controlled, Randomized, Phase II Clinical Trial

PURPOSE

The aim was to evaluate the effect of a topical formulation containing chitosan-coated Chamomilla recutita (L.) rauschert microparticles regarding the incidence, grade, and days for the appearance of radiodermatitis (RD) in women with breast cancer.

METHODS

A double-blinded, controlled, randomized, phase II clinical trial developed with women diagnosed with breast cancer who will receive radiation therapy. The participants were randomly divided into 2 groups: control and treatment. They were followed up until the end of the treatment or the appearance of grade III RD.

RESULTS

Fifty-four women were included in the study. There is no significant difference between the groups in the incidence (88.9% vs. 88.9%, P=1.0) or time to develop any grade of RD (3 days of difference, P=0.300). A significant reduction was observed in the incidence (P=0.03) and in the time to appearance (7 d of difference, P=0.01) grade 2 or >RD. In the follow-up evaluation (15 d after the end of treatment), the Chamomile group presented a superior skin recovery than the control group (P=0.0343). High-intensity local symptoms as pain, and pruritus were significantly reduced in the Chamomile group.

CONCLUSIONS

Although no effect was observed with chamomile to reduce any grade of RD, it was effective to reduce grade 2 or >toxicity, to improve skin recovery and to diminish high-intensity local symptoms.

TRIAL REGISTRATION

Brazilian Registry of Clinical Trials (ReBEC): RBR-9hnftg, April 29, 2019.

Estimation of the Surface Dose in Breast Irradiation by the Beam Incident Angle and the 1 cm Depth Dose

To develop a method of estimating surface dose in whole breast irradiation, we used an anthropomorphic phantom with accessories for the simulation of different breast sizes. The surface points, which are measured by TLDs, are set along with two main directions, superior-inferior and medial-lateral. The incident angle between the photon beam and the surface and the doses at 1 cm beneath the surface at every point are assessed by a computerized treatment planning system (cTPS). With the prescription dose of 200 cGy, the average surface doses under tangential irradiation are 97.73 (±14.96) cGy, 99.90 (±10.73) cGy, and 105.26 (±9.21) cGy for large, medium, and small breast volumes, respectively. The surface dose increased in the model of small breast volume without significance (p = 0.39). The linear analysis between surface dose and the incident angle is y = 0.5258x + 69.648, R² = 0.7131 (x: incident angle and y: surface dose). We develop the percentage of skin surface dose with reference to a depth of 1 cm (PSDR1cm) to normalize the inhomogeneous dose. The relationship between incident angle and PSDR1cm is y = 0.1894x + 36.021, R² = 0.6536 (x: incident angle and y: PSDR1cm) by linear analysis. In conclusion, the surface dose in whole breast irradiation could be estimated from this linear relationship between PSDR1cm and incident angle in daily clinical practice by cTPS. Further in vivo data should be studied to verify this formula.

Radiation induced skin reactions during and following radiotherapy: A systematic review of interventions

INTRODUCTION

Radiation induced skin reactions (RISR) are a common adverse effect of radiotherapy that can impact on patient quality of life. The aim of this systematic review was to identify new research evidence on interventions for RISR to guide health practitioners on best practice skin care for people receiving radiotherapy.

METHODS

A narrative systematic review was adopted including published research since 2014. The MESH search terms used in the 2014 College of Radiographers skin care systematic review were supplemented with terms identified through a pearl growing search technique.

RESULTS

Thirty-three studies were identified and reviewed, 13(39.4%) were assessed as having a high risk of bias 6(18.2%) moderate risk of bias, and 13(39.4%) low risk of bias; one pilot study was not assessed. Twenty-one of the studies were randomised controlled trials, 2 feasibility studies, 9 non-randomised trials, and 1 a pilot study.

CONCLUSION

Evidence from well conducted studies identified prophylactic use of steroid cream for patients, at high risk of RISR, as being the most efficacious in reducing acute skin reactions. Further research is needed on photo biomodulation therapy, studied within standard dose fractionation schedules, before it is recommended for use in practice. There is insufficient evidence to support the use of barrier films or any topical emollients currently in practice to reduce RISRs. Despite the number of new studies in this area there is limited good comparative research of RISR that accounts for predictive risk and new radiotherapy techniques.

IMPLICATIONS FOR PRACTICE

Practitioners are encouraged to risk assess patients prior to radiotherapy to guide interventions and record and monitor patient skin toxicity regularly during treatment, comparing toxicity changes with scores recorded at baseline and support patient self-monitoring of skin reactions.