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Stage One - Literature Review

The aim of the survey was to explore skin care practice in radiotherapy departments across the United Kingdom. Prior to the survey production, an extensive literature review was undertaken of published articles from 1980 to October 2010.

Keywords in the literature search were: ‘dermis’ ‘skin reaction’ ‘radiation effects’ ‘adverse effects’ ‘radiation dermatitis’ ‘erythema’ ‘moist desquamation’ ‘wound management’ combined with search terms ‘radiotherapy’ and ‘radiation therapy’ - combining using Boolean logic.

Databases used were: MEDLINEPubmed, CINAHL, PreMEDLINE, EBSCO EJS, Science Direct, ISI Web of Science.

Other search strategies were: reference chaining; following up references from reference lists of relevant articles; hand searching of key radiotherapy/cancer journals and conference proceedings with ready professional access and reference feedback by subject indexing key references.

Two recently published (ie within the last five years) systematic reviews of skin care literature54, 55 proved invaluable in determining the more robust evidence base and highlighted key randomised controlled trials for inclusion and consideration.

In addition, skin care manufacturers’ leaflets, websites and magazine/newspaper articles were considered as these provide readily available information for patients and staff which might influence practice.

Stage Two – Survey Production

A panel of experts was consulted regarding issues it felt required investigation in a survey of skin care practice. The panel consisted of a team from the Society and College of Radiographers, two leading nursing professionals, the Chair of the SCoR Research Group and the authors of the recent systematic reviews. Initially the survey was large and unfocussed as panel members had different aspects of care they felt required exploration. Two previous surveys into radiotherapy skin care practice aided the survey construction and focus.

D’haese et al56 evaluated skin care during radiotherapy practice by nurses in Flanders, Belgium. They designed a 58 item questionnaire structured into 4 main sections: preventative advice; advice for erythema; dry desquamation and moist desquamation. Dividing the questionnaire into these key sections seemed a logical and easy format which the SCoR project team adapted.

Swamy et al57 developed a questionnaire to explore variations in radiation oncologist practice across the USA in managing breast cancer that was specifically related to skin reactions. Their main questions focussed on prophylactic skin care, risk factors, topical products used and percentages of patients with skin reactions. These themes were also built into the SCoR questions.

The final SCoR survey comprised 61 questions grouped into 8 sections (Table 1). Questions varied in type with a mixture of yes/no/don’t know, multiple choice, and open ended/add comments.

A draft was reviewed by the SCoR Public and Patient Liaison Group and their comments were used to adapt certain questions. The survey was also piloted at one radiotherapy department prior to launch to discover if there were any inherent design and functionality flaws and to determine if the questions were answerable. Consequently, two questions were adapted due to pilot site feedback. The pilot site reported that the survey would take a maximum of thirty minutes to complete, which the panel felt was acceptable given the importance of the topic and relevance to everyday clinical practice.

Section Number of questions
Pre-treatment – assessment 14
Pre-treatment - prophylactic skin care 6
During treatment – assessment 7
During treatment skin care – erythema 8
During treatment skin care - dry desquamation 8
During treatment skin care - moist desquamation 9
Post treatment - assessment and skin care 5
Review of guidelines 4

Distribution of survey questions

A link to an on-line survey, using the Survey MonkeyTM tool, was e-mailed to all radiotherapy departmental managers in the United Kingdom (N = 67) and they were invited to provide one response per department. A ‘back-up’ pdf file was also provided which could be printed off and a hard copy sent in to SCoR headquarters if required (2 departments used this option). Anonymity was maintained for all respondents.

The survey was originally intended to run for 4 weeks with a ‘reminder to complete’ e-mail sent after 3 weeks. To aid a higher response rate, the survey remained open for a further 2 weeks after the deadline, ie a total of 6 weeks access.

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