Mepitel Film for the Prevention of Acute Radiation Dermatitis in Breast Cancer: A Randomized Multicenter Open-Label Phase III Trial

Cuproptosis nanoprodrug-initiated self-promoted cascade reactions for postoperative tumor therapy

Cancer metastasis and recurrence remain a regular cause of postoperative death in patients, implying that extra consolidation treatment strategies are needed. Here, a cuproptosis nanoprodrug, termed as Lipo@CP@DQ NPs, is developed to initiate self-promoted cascade reactions to achieve the combinational effect of cuproptosis, in situ chemotherapy, and oxidative stress amplification for effectively suppressing tumor recurrence and metastasis after postoperative treatment. Lipo@CP@DQ NPs are fabricated by loading copper peroxides (Cu2O2, CP) and hydrogen peroxide (H2O2)-repsonsive prodrug DQ into liposomal nanoparticles. Lipo@CP@DQ NPs rapidly dissociate in the acidic tumor microenvironment to release copper ions, H2O2, and prodrug DQ. Subsequently, the excessive accumulation of Cu ions induces cuproptosis and produces highly cytotoxic hydroxyl radicals (•OH). Meanwhile, the self-supplied H2O2 catalyzes the decomposition of DQ to diethyldithiocarbamate (DTC), which is chelated with self-supplied Cu ions to form the anticancer compound, Cu(DTC)2. The another decomposition product, quinone methide (QM), acts as a glutathione (GSH) scavenger for oxidative stress amplification. The synergistic effect of Lipo@CP@DQ NPs-mediated cuproptosis, in situ chemotherapy, and oxidative stress amplification effectively inhibits the growth and postoperative recurrence of triple-negative breast cancer. This work furnishes a strategy for developing cuproptosis-based nanomedicines for effective antitumor treatment after surgery.

Modified Delphi Consensus on Interventions for Acute Radiation Dermatitis in Breast Cancer: A Canadian Expert Perspective

PURPOSE

Acute radiation dermatitis (ARD) is a prevalent adverse effect of radiotherapy in patients with breast cancer, and there is a lack of high-quality data regarding its prevention and management. This study employs a systematic and iterative process to compile the perspectives of Canadian radiation oncology, nursing, and dermatology experts, aiming to establish consensus-based recommendations for the prevention and management of ARD in breast cancer patients.

METHODS AND MATERIALS

A modified Delphi consensus was conducted with the participation of 19 experts from across Canada. The process involved a systematic review of existing literature on the prevention and treatment of ARD in breast cancer, from January 1946 to September 2023. After review of the literature, participants first provided their opinions on the strength and quality of the evidence for the identified interventions. A second round assessed the degree to which the interventions would be recommended in either low- and/or high-risk settings. Two more rounds consolidated consensus.

RESULTS

After the four rounds, consensus for recommendation was reached for 3 prevention interventions in both low- and high-risk patients: prevention care education, moisturizing, and washing. For high-risk settings, 2 additional prevention interventions reached consensus: Mepitel Film and mometasone furoate. With regards to the management of ARD, there was consensus for recommendation of Mepilex Lite, betamethasone valerate, mometasone furoate, saline soaks/cold compresses and barrier creams.

CONCLUSIONS

This pan-Canadian modified Delphi consensus provides expert-reviewed and evidence-based recommendations for interventions to prevent and manage acute radiation dermatitis in patients with breast cancer. The endorsed interventions offer valuable guidance for clinicians and their patients, highlighting areas where consensus among experts has been achieved.

Mepitel® film versus standard care for the prevention of skin toxicity in breast cancer patients treated with adjuvant radiotherapy: A randomized controlled trial

Background & purpose

Radiotherapy plays a key role in breast cancer treatment however, radiation-induced dermatitis can impact on treatment delivery and patient quality of life.The primary outcome was to compare Mepitel® Film versus standard treatment in preventing radiotherapy skin toxicity onset.

Methods

A multicentre randomised controlled phase III study compared standard treatment (aqueous-urea cream - Excipial U hydrolotion applied at the beginning of radiotherapy and antiseptic cream - Flammazine or Ialugen Plus applied at the onset of moist desquamation) versus Mepitel® Film in patients with breast cancer undergoing post-operative radiotherapy. The primary outcome was the proportion of moist desquamation (RTOG score ≥ 2) in the experimental and control groups.

Results

During the study (2016-2020), 161 patients were randomized, 154 (95.7 %) were evaluable. Skin toxicity Radiation Therapy Oncology Group (RTOG) score ≥ 2 was observed in 9.5 % and 13.9 % of experimental and control groups respectively (Relative Risk = 0.68, 95 %CI 0.28-1.66; p = 0.393). RTOG scores > 0 were 90.5 % and 94.9 % in experimental and control groups respectively (Relative Risk = 0.95, 95 %CI 0.87-1.04; p = 0.294).Multivariable analysis, controlled for age, diabetes, BMI and smoking exposure, showed a risk reduction of RTOG > 0 of 38 % (HR = 0.62 95 %CI 0.49-0.96, p = 0.028), and a risk reduction of RTOG > 1 of 33 % (HR = 0.67 95 %CI 0.26-1.76, p = 0.420) in the experimental group.The median time to recovery from RTOG grade > 0 toxicity was 17 and 32 days for experimental and control groups, respectively (p = 0.027). At multivariable analysis, time to recovery was 38 % faster in the experimental group (HR = 1.38 95 %CI (0.99-1.93) p = 0.059).

Conclusions

Although the study did not demonstrate a statistically significant reduction in RTOG > 2 skin toxicity, there was evidence of a reduction in the rate of skin toxicity and an improvement in time to recovery. The device was well tolerated by patients.

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.

Xenogeneic platelet-rich plasma lotion for preventing acute radiation dermatitis in patients with breast cancer undergoing radiotherapy: An open-label, randomized controlled trial

Background

Breast cancer patients experience acute radiation dermatitis (ARD) during radiation therapy (RT). This study investigated the prophylactic effect of a newly developed xenogeneic platelet-rich plasma (PRP) lotion on ARD for breast cancer patients.

Methods

This study enrolled patients with ductal carcinoma in situ and early-stage invasive breast cancers after breast-conserving surgery. Hypofractionated whole-breast RT (42.5 Gy in 16 fractions) followed by tumour bed boost (10 Gy in 5 fractions) was used. The patients were randomly assigned to XONRID® gel (n = 48) or PRP lotion (n = 52) groups. We recorded the skin toxicity weekly during RT and at 2 weeks after RT. ARD was graded on the basis of the RTOG definition by two senior radiation oncologists, and the numerical rating scale (NRS) for pain and Dermatology Life Quality Index (DLQI) were subjectively scored by patients.

Results

Grade 3-4 ARD was noted in three (6 %) patients in the XONRID® gel group and no patients in the PRP lotion group (p < 0.001). One patient did not complete RT in the XONRID® gel group due to intolerable pain and refused to complete the weekly questionnaires and follow-ups. Compared with the XONRID® gel group, the PRP lotion group had significantly reduced and delayed progression of mean ARD (p = 0.001), lower mean NRS for pain value (p = 0.021) and lower mean DLQI (p = 0.048).

Conclusions

This randomized controlled trial is the first to use xenogeneic PRP lotion for ARD prevention. This lotion has prophylactic effects against ARD and thus improves quality of life of patients undergoing RT.

Use of Radiation Therapy in the Management of Vulvar Cancers-Identification and Management of Acute and Late Toxicities

Radiation therapy plays a critical role in the management of locally advanced vulvar cancers but can lead to a unique spectrum of side effects, with >25% of patients experiencing high-grade toxicities. The treatment phase requires meticulous perineal skincare and may require pharmacologic management of dysuria and cystitis, diarrhea, nausea, and dermatitis/mucositis. The addition of chemotherapy warrants close laboratory monitoring for hematologic and metabolic derangements.

"When Less is More": Paradigm Shifts in Radiation Treatment for Early-Stage Breast Cancer

OPINION STATEMENT

Recent advancements in the treatment of early-stage breast cancer have significantly shifted the radiotherapy landscape. Traditionally, the standard of care included lumpectomy followed by endocrine therapy and 3-5 weeks of adjuvant radiation targeting the entire unilateral breast. This review summaries modern trials, emphasizing data reported since 2019 that have changed radiation treatment paradigms. Ultra-hypofractionated treatment regimens have enabled radiation oncologists to deliver the total radiation dose in as few as 5 treatments over 1 week for select patients. Partial breast irradiation, treating only the breast tissue nearest to the lumpectomy cavity, has also emerged as an effective and well-tolerated treatment. Furthermore, a growing body of evidence supports the safety of omitting radiation completely for certain older adults with low-risk disease. Ongoing research in areas such as precision cancer care, treatment de-escalation, and toxicity prevention and management reflects a broader shift toward shared decision-making in medicine and individually tailored treatment paradigms. As research progresses, treatment options will continue to evolve. Advances in radiation oncology will give the oncology team a growing array of tools to custom treatment plans to individual patient risks and toxicity concerns. Knowledge of radiation advances should be used to facilitate shared decisions with patients about the balance of treatment efficacy, toxicity, and quality of life, with the ultimate goal of promoting high-quality, personalized, and patient-centered cancer care.

Therapeutic Potential of Hydrogen as a Radioprotective Agent for the Prevention of Radiation Dermatitis

Radiation dermatitis (RD) is a common side effect in patients receiving radiotherapy. Currently, clinical skincare approaches for acute RD vary widely among institutions and lack consensus. Hydrogen molecules, acting as radioprotective agents by selectively scavenging free radicals, have the potential to protect against RD. In this study, we demonstrate that hydrogen reduces double-strand breaks, mitochondrial depolarization, and inflammatory cytokines induced by irradiation damage in HaCaT cells. Furthermore, in vivo experiments reveal that exposing irradiated skin areas to a hydrogen gas environment alleviates RD. Assessment of skin appearance grade and histology staining revealed that direct transdermal application of hydrogen can prevent radiation-induced follicle damage, dermal thickening, and leukocyte infiltration, thereby reducing the severity of RD. In addition, hydrogen enhances the skin's antioxidant capacity, leading to a reduction in the Bcl-2-associated X protein/B-cell lymphoma 2 (Bax/Bcl-2) ratio, the number of apoptotic cells, and the expression of pro-inflammatory cytokines. Our data demonstrate that hydrogen possesses antioxidant, anti-inflammatory, and anti-apoptotic properties, and could be a preventive strategy for RD.

Correlation of CTCAE and patient-reported breast radiation dermatitis symptom scores

BACKGROUND AND PURPOSE

Clinicians use the CTCAE scale to grade radiation dermatitis (RD) based on edema, erythema, and desquamation. The purpose of this study was to correlate the CTCAE scores with the severity of patient-reported symptoms using a skin symptom assessment (SSA) and the Radiation-Induced Skin Reaction Assessment Scale (RISRAS).

MATERIALS AND METHODS

This is a secondary analysis of a randomized controlled trial involving 376 patients receiving Mepitel Film or standard-of-care for RD prophylaxis. The highest symptom categories for SSA and patient-component RISRAS assessments were selected from all time points, and a summary analysis and Spearman correlation coefficient was calculated for patients with CTCAE Grades 0, 1, 2, 3, and Grade 2/3, respectively. Analyses were conducted across all patients, within each treatment arm, and between arms in patients with only Grade 2 or 3 toxicity.

RESULTS

Weak correlations between CTCAE scores and all patient-reported skin symptoms were found across the entire cohort and each treatment arm (p < 0.05). Patients with Grade 2 (n = 72) and Grade 3 RD (n = 24) reported similar rates of patient-reported moderate-to-severe skin symptoms (11-72% vs 14-79%), with no significant difference in rates of individual moderate-to-severe symptom between these cohorts (p > 0.05). Between treatment arms, rates of patient-reported moderate-to-severe scores were similar for most symptoms.

CONCLUSION

CTCAE RD scores are weakly correlated with patient-reported skin symptoms and cannot distinguish between patients with severe patient-reported outcomes. Clinicians should consider the limitations of CTCAE grading and incorporate patient-reported outcomes within clinical practice.

Concordance of patient- and clinician-reported outcomes of acute radiation dermatitis in breast cancer

BACKGROUND AND PURPOSE

The study evaluated the concordance between patient-reported outcomes (PRO) and clinician-reported outcomes (CRO) of acute radiation dermatitis (RD) symptoms following adjuvant radiotherapy for early-stage and locally advanced breast cancer.

MATERIAL AND METHODS

This is a secondary analysis of a multi-center randomized phase 3 trial (376 patients). Ordinal logistic regression analysis was used to compare the Skin Symptom Assessment (SSA) independently reported by both patients and clinicians. Concordance between patient- and clinician-reported SSAs for RD symptoms was measured by percent concordance, concordance index (C-statistic), and Cohen's Kappa. Analyses were performed across all patients in the original modified intention-to-treat analysis and those with only grade 2-3 (CTCAE) RD.

RESULTS

PROs were significantly more severe than CROs across all RD symptoms (Odds Ratio [OR] > 1; p < 0.0001). Pigmentation (OR 5.4), blistering/peeling (OR 4.0), and pain/soreness (OR 3.9) were the most differentially reported symptoms. Poor-to-low concordance was noted between patient- and clinician-reported SSAs for all RD symptoms for the entire cohort (percent concordance < 50%, C-statistic 0.52-0.63, Cohen's Kappa 13.9-23.4%) and those with grade 2-3 RD (percent concordance < 50%, C-statistic 0.56-0.66, Cohen's Kappa 2.0-24.5%). Similarly, poor-to-low concordance was noted in both Mepitel film and standard-of-care arms.

CONCLUSION

PROs and CROs have poor concordance in breast RD, and patients report worse outcomes than clinicians, regardless of RD severity or prophylaxis. PROs must be further integrated into routine clinical practice and clinical trial design to reduce the risk of underreporting symptoms.

Barrier films or dressings for the prevention of acute radiation dermatitis in breast cancer: a systematic review and network meta-analysis

BACKGROUND

Barrier films or dressings were reported to be effective in preventing radiation dermatitis (RD) in breast cancer patients, but their comparative efficacy is unknown.

METHODS

A systematic literature search was performed on Embase, MEDLINE and Cochrane CENTRAL Registry of Clinical Trials from inception to October 20, 2023. Randomised controlled trials (RCTs) comparing barrier films or dressings to the standard of care (SOC) or other interventions were included. We estimated summary odds ratios and mean differences using network meta-analysis with random effects. This study was registered with PROSPERO (ID: CRD42023475021).

RESULTS

Fourteen RCTs met inclusion criteria. Six interventions were analysed: 3M™ Moisturizing Double Barrier Cream (MDBC), 3M™ No Sting Barrier Film (BF), Hydrofilm® (HF), Mepitel® Film (MF), Silver Leaf Nylon Dressing and StrataXRT®. HF, MF and StrataXRT® reduced the incidence of moist desquamation compared to SOC (HF: OR = 0.08; p = 0.02; MF: OR = 0.31 p < 0.01; StrataXRT®: OR = 0.22, p = 0.04). The ranking of agents from most to least effective in preventing moist desquamation according to P-scores was HF (92.5%), MF (78.5%), StrataXRT® (70.1%), BF (46.4%), Silver Leaf Nylon Dressing (24.9%), MDBC (22.9%) and SOC (14.7%). Only four RCTs on HF and MF included patient-reported outcome (PRO) assessments that allowed pooling for analysis. HF and MF were more effective in reducing pain, itchiness and burning sensation compared to SOC (p < 0.01 for all symptoms).

CONCLUSION

HF and MF were effective in preventing RD in breast cancer. Future RCTs should compare these interventions to effective cream preparations, such as topical corticosteroids.

Validation of the Skin Symptom Assessment (SSA) questionnaire for the evaluation of radiation dermatitis in breast cancer patients

PURPOSE

Radiation dermatitis (RD) is a painful side effect of radiation therapy (RT). The objective of this analysis was to investigate the validity and reliability of the Skin Symptom Assessment (SSA) questionnaire in evaluating the severity of patient- and clinician-reported outcomes for RD in breast cancer patients by comparing it to a validated assessment tool, the Radiation-Induced Skin Reaction Assessment Scale (RISRAS) questionnaire.

METHODS

This study compared patient and clinician-reported outcomes for RD from previous clinical trials conducted in a Canadian cancer centre. The analysis included 376 and 38 patients in the two trials using Mepitel Film (doi.org/10.1200) and StrataXRT (clinicaltrials.gov identifier: NCT05594498), respectively. Patients in both studies completed the SSA and RISRAS questionnaires at baseline, 2-weeks post-RT, and 3 months after completion of RT. Clinician SSA and RISRAS assessments were collected at baseline and 2-weeks post-RT. These time points were analyzed longitudinally to investigate the SSA's validity in RD symptom assessment.

RESULTS

The majority of patient-reported items on the SSA and RISRAS assessments demonstrated positive significant associations between symptoms of itchiness, between pain/soreness and pain/discomfort, and between blistering or erythema with burning sensation items. All items in the clinician-reported SSA and clinician component of RISRAS showed positive statistical significance between items measuring erythema, pigmentation or edema with dry desquamation, and blistering/peeling with moist desquamation.

CONCLUSIONS

The SSA has been validated for assessing patient- and clinician-reported symptoms of RD accurately as outcomes correlate well with the previously validated RISRAS assessment.

StrataXRT for the prevention of acute radiation dermatitis in breast cancer: a pilot study

PURPOSE

Previous literature has produced heterogeneous results on StrataXRT for prevention of acute radiation dermatitis (RD) in breast cancer. This pilot study aimed to assess the feasibility and efficacy of StrataXRT in a cancer center.

METHODS

The study consisted of five cohorts: (1) patients with large breasts treated with local radiation therapy (RT) either in the supine position or (2) the prone position, (3) patients receiving locoregional breast RT with any breast size, and (4) patients receiving chest wall RT, either locally or (5) locoregionally. The primary endpoint of the study was RD grade as assessed using the Common Terminology Criteria for Adverse Events. Secondary endpoints included incidence of moist desquamation (MD), patient- and clinician-reported skin assessments, patient quality of life as assessed by the Skindex-16, and patient satisfaction. These outcomes were compared with those from a published trial from the same institution assessing standard of care and Mepitel Film (MF) as prevention of breast RD.

RESULTS

Forty-five patients receiving RT to the breast or chest wall were enrolled. Two withdrew, leaving 43 evaluable patients. Overall, two (4.7%) patients had grade 3 RD, 14 (32.6%) had grade 2 RD, and 27 (62.8%) had grade 1 RD. Ten patients (23.3%) developed MD during/after RT.

CONCLUSION

StrataXRT is effective in preventing grade 3 RD in patients, and the most promising results were observed within the prone cohort. Further research includes evaluating the efficacy of StrataXRT against the standard of care for the prophylaxis of RD.

TRIAL REGISTRATION

The study protocol was registered at ClinicalTrials.gov (identifier: NCT05594498) on October 13, 2022.

Mepitel film for the prevention of radiation dermatitis: A comprehensive review of its efficacy, side effects, physics measurements, patient- and clinician-reported outcomes

Objective

This review aimed to summarize the benefits, side effects, physics measurements, and patient- and clinician-reported outcomes of Mepitel film (MF) in preventing radiation dermatitis (RD) for cancer patients.

Methods

The online database PubMed was searched from inception to April 15, 2024 with the search terms "Mepitel film" or "Mepitel." Articles of any study design evaluating MF for the prevention of RD were included. Non-human studies were excluded.

Results

The database search identified 119 articles and 13 of them were included in this review. Across these studies, MF was found to be beneficial in reducing RD and improved patient- and clinician-reported outcomes in breast and head and neck cancers. Side effects of MF included itchiness, acne, allergic reaction, tightness, discomfort, and poor film adherence, but patient dropouts were uncommon. MF did not cause a bolus effect or increased skin dose in physics measurements.

Conclusions

MF is a safe and effective intervention for preventing acute RD. It should be recommended in breast cancer patients where the data is more robust. Further research is needed to evaluate MF's efficacy on patients with different skin tones, its cost-effectiveness, and identifying patients who most benefit from MF relative to other effective interventions.

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.

Comparison of the efficacy among different interventions for radiodermatitis: A Bayesian network meta‑analysis of randomized controlled trials

BACKGROUND

Radiation dermatitis (RD) is a prevalent and difficult-to-manage consequence of radiation therapy (RT). A variety of interventions have been proven effective in preventing and treating RD. However, the optimal approach remains unclear. This network meta-analysis (NMA) conducted a comparison and ranking of the effectiveness and patient-reported outcomes (PROs) of the interventions currently utilized in RD.

METHODS

PubMed, Web of Science, Embase, and Cochrane Library were searched to identify pertinent randomized controlled trials (RCTs) focused on the prevention and treatment of RD. The primary outcome measures included the incidence of grade≥2 RD (i.e., percentage of moist desquamation) and RD score. The secondary outcome measures encompassed patients' subjective assessment scores of pains, itching and burning sensations.

RESULTS

Our meta-analysis encompassed 42 studies and 4884 participants. Regarding the primary outcomes, photobiomodulation treatment (PBMT) ranked first in surface under curve cumulative ranking area (SUCRA:0.92) for reducing the incidence of grade≥2 RD. It demonstrated a significant difference when compared to Trolamine (OR 0.18,95%CrI 0.09-0.33) and Xonrid® (OR 0.28,95%CrI 0.12-0.66). Mepitelfilm (SUCRA: 0.98) achieved the highest rank in reducing the RD score, demonstrating superiority over StrataXRT® (MD -0.89, 95% CrI -1.49, -0.29). Henna (SUCRA: 0.89) demonstrated the highest effectiveness in providing pain relief, with a significant difference compared to Hydrofilm (MD -0.44, 95% CrI -0.84, -0.04) and Mepitelfilm (MD -0.55, 95% CrI -0.91, -0.19). Hydrofilm (SUCRA: 0.84) exhibited the fewest itching sensations, demonstrating superiority over Mepitelfilm (MD -0.50, 95% CrI -0.84, -0.17). No statistically significant difference was observed among various interventions in the assessment of burning sensations.

CONCLUSION

PBMT and Mepitelfilm demonstrated better efficacy in reducing the incidence of grade≥2 RD and RD score, respectively. In terms of PROs, Henna and Hydrofilm had fewer complaints in pain and itching sensations, respectively. However, studies with larger sample size on different interventions are warranted in the future.

TRIAL REGISTRATION

PROSPERO registration number CRD42023428598.

Pharmaceutical management of acute radiation dermatitis in the German speaking radiation oncology community

BACKGROUND

Radiation dermatitis (RD) remains the most common side effect in radiation therapy (RT) with various pharmaceutical options available for prevention and treatment. We sought to determine pharmaceutical management patterns of radiation dermatitis among radiation oncology professionals.

METHODS

We conducted a survey on RD among the German-speaking community of radiation oncologists inquiring for their opinion on preventive and therapeutic pharmaceutical approaches for acute RD.

RESULTS

244 health professionals participated. Dexpanthenol lotion is the agent most widely used both for prevention (53.0%) and treatment (76.9%) of RD, followed by urea (29.8%) for prevention and corticosteroids (46.9%) for treatment. A wide range of substances is used by participants, though the overall experience with them is rather limited. 32.5% of participants do generally not recommend any preventative treatment. 53.4% of participants recommend alternative medicine for RD management. While seldomly used, corticosteroids were considered most effective in RD therapy, followed by dexpanthenol and low-level laser therapy. A majority of participants prefers moist over dry treatment of moist desquamation and 43.8% prescribe antiseptics.

CONCLUSIONS

Pharmaceutical management of RD in the German-speaking radiation oncology community remains controversial, inconsistent, and partially not supported by evidence-based medicine. Stronger evidence level and interdisciplinary consensus is required amongst practitioners to improve these care patterns.

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.

Pharmazeutische Behandlung der akuten Radiodermatitis in der deutschsprachigen strahlentherapeutischen Gemeinschaft: Pharmaceutical management of acute radiation dermatitis in the German speaking radiation oncology community

Hintergrund

Die Radiodermatitis (RD) ist die häufigste Nebenwirkung der Strahlentherapie (RT), wobei verschiedene pharmazeutische Optionen zur Vorbeugung/Behandlung zur Verfügung stehen. Unser Ziel war, die pharmazeutischen Behandlungsmuster für die RD unter strahlentherapeutischen Fachleuten zu ermitteln.

Methodik

Wir haben eine Umfrage zum Thema RD in der deutschsprachigen radioonkologischen Gemeinschaft durchgeführt und ihre Meinung zu präventiven und therapeutischen pharmazeutischen Therapieansätzen betreffend die akute RD erfragt.

Ergebnisse

244 Angehörige zugehöriger Gesundheitsberufe nahmen teil. Dexpanthenol‐Lotion ist das am häufigsten verwendete Mittel sowohl zur Vorbeugung (53%) als auch zur Behandlung (76,9%) der RD, gefolgt von Harnstoff (29,8%) zur Vorbeugung und Kortikosteroiden (46,9%) zur Behandlung. Die Teilnehmer verwenden eine breite Palette an Substanzen, haben aber insgesamt wenig Erfahrung mit diesen. 32,5% der Teilnehmer empfehlen generell keine präventive Behandlung. 53,4% der Teilnehmer empfehlen Alternativmedizin. Obwohl selten eingesetzt, wurden Kortikosteroide als wirksamstes Behandlungsmittel angesehen, gefolgt von Dexpanthenol und Low‐Level‐Lasertherapie. Die Mehrheit der Teilnehmer bevorzugt die feuchte gegenüber der trockenen Behandlung der feuchten Desquamation und 43,8% verschreiben Antiseptika.

Schlussfolgerungen

Die pharmazeutische Behandlung der RD in der deutschsprachigen strahlentherapeutischen Fachwelt ist nach wie vor umstritten, sowie mitunter inkonsistent und nicht durch evidenzbasierte Medizin gestützt. Ein interdisziplinärer Konsens ist erforderlich, um die bestehenden Behandlungskonzepte zu verbessern.

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.

Toward a Skin Dose-Area Metric Predictive of Moist Desquamation Using In Vivo Skin Dosimetry and Skin Assessments

Purpose

Moist desquamation (MD) is a concerning acute side effect of radiation therapy for breast cancer, often seen in skin folds for patients having large or pendulous breasts. In vivo skin dosimetry, clinical assessments, and patient-reported skin reactions were used to determine a relationship between dose-area metrics and the development of MD, to lend insight into skin tolerances and possibly guide future treatment planning dose constraints.

Methods and Materials

Skin dose was measured using GafChromic film on the inner surface of an early prototype carbon-fiber accessory for breast support to remove the inframammary fold in 20 patients at high risk of developing MD undergoing adjuvant whole breast radiation therapy. Prescribed doses were 42.5 Gray (Gy) in 16 fractions or 50 Gy in 25 fractions using 6 to 15 MV x-rays. To account for fraction size differences, analysis was performed using the equivalent dose in 2 Gy fractions using α/β = 11 (EQD211). MD was assessed out to 2 weeks post radiation therapy by trained therapists and by a patient-reported outcome questionnaire.

Results

Statistically significant differences in areas receiving 30 to 48 Gy (EQD211) were observed between patients who did and did not develop MD in the inframammary area. Patients receiving EQD211 maximum dose ≤ 46 Gy and ≥ 38 Gy to ≤ 50 cm2 of their breast skin did not develop MD.

Conclusions

The findings of this study offer insight into the relationship between skin toxicity and areas of skin irradiated to doses up to 50 Gy. Potential skin dose constraints to test in future studies to prevent MD are suggested.

Perceptions of healthcare professionals on the use of Mepitel Film for the prevention of acute radiation dermatitis in breast cancer

INTRODUCTION

Randomized clinical trials support Mepitel Film (MF) as a prophylactic treatment for radiation dermatitis (RD) in patients undergoing breast radiotherapy. Although several studies have canvassed the opinion of patients on using MF, no such studies have been done to investigate the perception of healthcare professionals (HCPs). The objective of this study was therefore to investigate the perceptions of HCPs on MF as a treatment option for RD.

METHODS

Anonymized responses to a web-based survey sent to HCPs at a single institution managing patients using MF during breast radiotherapy were analyzed.

RESULTS

Of the 28 HCPs contacted, 22 completed the survey, including 6 radiation oncologists (ROs), 11 radiation therapists (RTTs), and 5 nurses. Most HCPs reported MF was better at preventing severe RD than the standard of care and improved radiation-induced skin reactions (n = 20/22, 91%, and n = 19/22, 86%, respectively). MF was recommended for mastectomy patients without reconstruction (n = 15/21, 71%). The majority of HCPs believed that patients' families could be trained to apply and remove MF (n = 19/22, 86%). Many HCPs perceived that implementation of MF would be difficult in terms of maintaining patient flow and wide-scale implementation within their institution (n = 11/22, 50%, and n = 10/22, 46%, respectively). Most HCPs perceived that fewer than 50% of their patients could afford MF if priced at $100 CAD (n = 15/20, 75%).

CONCLUSION

These findings provide insights into the possibility of MF to be incorporated into standard practice of care for RD. Although most HCPs were satisfied with MF as a prophylactic treatment for RD, there are concerns about its resource-intensive operationalization and financial accessibility to patients. Future research should focus on ways to improve HCP experience with MF and to improve its implementation into clinical settings as standard of care.

Do Barrier Films Impact Long-Term Skin Toxicity following Whole-Breast Irradiation? Objective Follow-Up of Two Randomised Trials

Purpose: Hydrofilm, a polyurethane-based barrier film, can be used to prevent acute radiation dermatitis (RD) in adjuvant whole-breast irradiation (WBI) for breast cancer. This cost-effective prophylactic measure is currently being recommended to a growing number of patients, yet long-term safety data and its impact on late radiation-induced skin toxicity such as pigmentation changes and fibrosis have not been investigated. Methods: We objectively evaluated patients who were previously enrolled in either of two intrapatient-randomised (lateral versus medial breast halve) controlled trials on the use of Hydrofilm for RD prevention (DRKS00029665; registered on 19 July 2022). Results: Sixty-two patients (47.7% of the initial combined sample size) provided consent for this post-hoc examination, with a median follow-up time (range) of 58 (37-73) months. Following WBI, there was a significant increase in yellow skin tones of the entire breast when compared to baseline measurements before WBI (p < 0.001) and a significant increase of cutis, subcutis, and oedema thickness (p < 0.001, p < 0.001, and p = 0.004, respectively). At follow-up, there were no significant differences in either pigmentation changes or skin fibrosis between the Hydrofilm and standard of care breast halves. Conclusion: These data suggest that Hydrofilm can be safely used in the context of acute RD prevention, without affecting late side effects, supporting its widespread use.

Risk of Radiation Dermatitis in Patients With Skin of Color Who Undergo Radiation to the Breast or Chest Wall With and Without Regional Nodal Irradiation

PURPOSE

Acute radiation dermatitis (ARD) is common after radiation therapy for breast cancer, with data indicating that ARD may disproportionately affect Black or African American (AA) patients. We evaluated the effect of skin of color (SOC) on physician-reported ARD in patients treated with radiation therapy.

METHODS AND MATERIALS

We identified patients treated with whole breast or chest wall ± regional nodal irradiation or high tangents using 50 Gy in 25 fractions from 2015 to 2018. Baseline skin pigmentation was assessed using the Fitzpatrick scale (I = light/pale white to VI = black/very dark brown) with SOC defined as Fitzpatrick scale IV to VI. We evaluated associations among SOC, physician-reported ARD, late hyperpigmentation, and use of oral and topical treatments for RD using multivariable models.

RESULTS

A total of 325 patients met eligibility, of which 40% had SOC (n = 129). On multivariable analysis, Black/AA race and chest wall irradiation had a lower odds of physician-reported grade 2 or 3 ARD (odds ratio [OR], 0.110; 95% confidence interval [CI], 0.030-0.397; P = .001; OR, 0.377; 95% CI, 0.161-0.883; P = .025), whereas skin bolus (OR, 8.029; 95% CI, 3.655-17.635; P = 0) and planning target volume D0.03cc (OR, 1.001; 95% CI, 1.000-1.001; P = .028) were associated with increased odds. On multivariable analysis, SOC (OR, 3.658; 95% CI, 1.236-10.830; P = .019) and skin bolus (OR, 26.786; 95% CI, 4.235-169.432; P = 0) were associated with increased odds of physician-reported late grade 2 or 3 hyperpigmentation. There was less frequent use of topical steroids to treat ARD and more frequent use of oral analgesics in SOC versus non-SOC patients (43% vs 63%, P < .001; 50% vs 38%, P = .05, respectively).

CONCLUSIONS

Black/AA patients exhibited lower odds of physician-reported ARD. However, we found higher odds of late hyperpigmentation in SOC patients, independent of self-reported race. These findings suggest that ARD may be underdiagnosed in SOC when using the physician-rated scale despite this late evidence of radiation-induced skin toxicity.

Shedding light on the management of acute radiation dermatitis: insight from the MASCC Oncodermatology study group

This paper highlights a collection of eleven recently published manuscripts on the prevention and management of acute radiation dermatitis. These meta-analyses provide additional evidence for the updated clinical practice guidelines by the Multinational Association of Supportive Care in Cancer (MASCC) Oncodermatology study group for prevention and management of acute radiation dermatitis. The collection of papers elucidate the currently available evidence on acute radiation dermatitis, highlighting consolidated knowledge, effective treatments, and proposed areas for future clinical trials. Overall, a total of 51 randomized controlled trials were retrieved and included for quantitative analysis of an initial systematic review of literature from 1946 to January 2023. Discussion of the clinical impact of various therapeutic interventions include: antiperspirant and deodorant use, barrier films and dressings, natural and miscellaneous agents, photobiomodulation therapy, topical corticosteroids, topical non-steroidal agents, skin hygiene and washing, as well as StrataXRT and Mepitel film in breast cancer patients. The comprehensive nature of the meta-analyses and their related findings may help reduce the discrepancies in in treatment of acute radiation dermatitis and facilitate consistency of therapeutic interventions employed in clinical practice worldwide.

Effect of treatment interruptions on overall survival in patients with triple-negative breast cancer

INTRODUCTION

Currently, there are no data regarding the impact of treatment interruptions during radiotherapy for breast cancer. In this study, we examine the correlation between treatment interruptions during radiotherapy and outcomes in triple-negative breast cancer patients.

METHODS

A total of 35 845 patients with triple-negative breast cancer treated between 2010 and 2014 were identified and analyzed from the National Cancer Database. The number of interrupted radiotherapy treatment days was calculated as the difference between the total elapsed days from the start to end of radiation treatment (both initial treatment and boost treatment, when boost was administered) and the total number of expected treatment days, defined as the number of expected treatment days with an addition of 2 weekend days for every multiple of 5 treatment days. Binomial multivariate regression analysis was used to detect correlates of treatment interruptions, and propensity-score matched multivariable Cox proportional hazard models were used to evaluate the association between treatment interruption and overall survival (OS).

RESULTS

When modeled as a continuous variable, longer treatment duration was associated with poorer OS (hazard ratio [HR] = 1.023, 95% confidence interval [CI] = 1.015 to 1.031). In reference to 0-1 days of interruption, patients with 2-5 interrupted days (HR = 1.069, 95% CI = 1.002 to 1.140 interrupted days), 6-10 interrupted days (HR = 1.239, 95% CI = 1.140 to 1.348 interrupted days), and 11-15 interrupted days (HR = 1.265, 95% CI = 1.126 to 1.431 interrupted days) experienced increasing likelihood of mortality.

CONCLUSION

In the first study of its kind, we report a correlation between treatment interruptions during adjuvant radiotherapy in triple-negative breast cancer and OS.

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.

Multinational Association of Supportive Care in Cancer (MASCC) clinical practice guidelines for the prevention and management of acute radiation dermatitis: international Delphi consensus-based recommendations

Acute radiation dermatitis is a frequent adverse effect of radiotherapy, but standardisation of care for acute radiation dermatitis is lacking. Due to the conflicting evidence and variability in current guidelines, a four-round Delphi consensus process was used to compile opinions of 42 international experts on care for people with acute radiation dermatitis on the basis of the evidence in existing medical literature. Interventions for acute radiation dermatitis prevention or management that reached at least 75% consensus were recommended for clinical use. Six interventions could be recommended for the prevention of acute radiation dermatitis: photobiomodulation therapy and Mepitel film in people with breast cancer, Hydrofilm, mometasone, betamethasone, and olive oil. Mepilex Lite dressings were recommended for the management of acute radiation dermatitis. Most interventions were not recommended due to insufficient evidence, conflicting evidence, or lack of consensus to support use, suggesting a need for further research. Clinicians can consider implementing recommended interventions in their practice to prevent and manage acute radiation dermatitis until additional evidence becomes available.