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Conclusion

Faithfull et al106 note ‘a growing awareness of the need for evidence-based practice in radiotherapy’ but that there are ‘well documented disparities between clinical practice and research findings which could underpin care’; reflecting that supportive care is often based on no, little, or poor evidence. They also emphasise that although there are numerous products for radiotherapy skin care available, there is no consensus as to the best practice, causing an inconsistency of care61;  a view which has been confirmed by this survey.

McQuestion107 reviewed published studies for the prevention and management of radiotherapy skin reactions and note insufficient evidence to recommend any specific topical or oral product. Schreck et al108 found no benefit in either creams or powders and reflect that the lack of effect may be explained by underlying pathophysiological processes which cannot be influenced by topical agents35, 109 . Gosselin et al19 found none of the three care products they tested to be superior to a placebo of sterile water mist.

Bolderston et al54 and Wickline109 note that the quality and quantity of studies evaluating topical agents was not sufficient to support or refute any specific product. Many different products are in use across the United Kingdom, often at considerable expense, which may be difficult to justify. Therefore the body of evidence is insufficient to provide clinicians with comprehensive guidelines for the prevention and management of radiation induced skin reactions. For example, research is required to determine how often a treatment course is interrupted as a result of a patient’s skin reaction.

Although the majority of skin reactions tend to subside after a few weeks, some can be prolonged, uncomfortable and distressing, thereby affecting a patient’s quality of life102 . Therefore, a focus for skin care may need to be on alleviating symptoms and providing comfort. As noted by Gosselin et al ‘patients prefer to take action rather than do nothing’19.

Can radiotherapy skin care be improved? Yes, but there needs to be more evidence and documentation of practice. The College needs to urgently publish new guidelines based on the current evidence available to provide a foundation and radiotherapy departments need to routinely monitor, assess and document skin reactions using grading systems and noting intrinsic and extrinsic related factors, thus assisting in the overall data collection and management of irradiated skin.

Recommendations

All radiotherapy departments should monitor and document skin morbidity in a systematic way. Best practice should have standard pre-treatment assessment and baseline, and weekly reviews using a particular tool and process. Skin care practice should be agreed across the Cancer Network, in line with the requirement for agreed Radiotherapy protocols as recommended within the Cancer Peer Review Measures for Radiotherapy (England)110.

Further high quality trials to investigate interventions for dry or moist desquamation are urgently required. National Guidelines must be regularly reviewed and revised to ensure that they are consistent with emerging evidence. Evaluation into treatment aftercare should be reviewed to ensure local continuity of care across the pathway. Audit into patient preference and compliance with skin care information and products should be undertaken.

Acknowledgments

All the centres who took the time to participate in the survey Dr Ian Frampton, University of Exeter Professor Audrey Paterson, The Society and College of Radiographers

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