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Results and the evidence base

(N = 67)
Response rate = 54 ( 81%)

Fifty-four departments responded within the allocated timeframe with a final response rate of 81%. This was considered to be an excellent response rate. A typical response rate for an electronic survey is 50% or less58, therefore at 81% we consider this sample is likely to be representative of radiotherapy departments across the United Kingdom.

Due to the size of the survey, only the key results are reported in this paper.

Section 1 - Pre-treatment: Assessment

All departments stated that they provide verbal and written information to patients on how to care for their skin during radiotherapy. Forty-six departments stated that they had skin care guidelines/protocols for staff. Twenty-seven departments use their own guidelines or an adaptation of existing guidelines, most of which have been updated in the last two years.

Graph 1: Question 3

Response count = 52

The evidence base for guidelines and protocols

The provision of patient information and guidelines for staff should aid consistency of information and compliance of health professionals, especially when staff transfer from one department to another20.

D’haese et al56 compared their 2009 and 2005 data59 to determine if the principles of a specifically developed protocol had been followed and if outdated techniques, such as using talcum powder and gentian violet, had ceased. Overall results indicated that, despite introducing guidelines after the first survey, there were still some recommendations that had not been transferred into practice and there were still some discrepancies in skin care which could cause confusion.

This SCoR survey indicates that some of the College’s 2000 guidelines1 are actually being followed; however these are now outdated and need urgent revision.

Consistency of care and liaison

Forty two departments stated they knew their hospital had a Tissue Viability Nurse (TVN), or equivalent, but liaison with this person was not commonplace. This may be a factor which will limit the introduction and assessment of products.

Cumming and Routsis60 discuss the importance of linking with other sectors of care to ensure improved communication and understanding and note the importance of consistency of care across the care pathway to avoid patient and staff confusion61.

Skin assessment

Thirty eight departments stated that skin assessment prior to radiotherapy would be conducted by a radiographer.

McIlroy et al62 note the importance of a dedicated and consistent treatment review.

Graph 2: Question 6

Response count = 54

Thirty departments do not use a skin assessment tool prior to radiotherapy despite recent NHS Quality Improvement Scotland guidelines12 emphasising the need for a baseline assessment of the patient’s current skin condition.

The Radiation Therapy Oncology Group (RTOG) skin assessment tool63 is the most commonly used by 20 departments. An evaluation of different scoring systems by Lopez et al24 favoured the RTOG system63 overall. A few of the other available systems are: ‘RISRAS’;53 photographic;64 Skin Toxicity Assessment Tool (STAT) system;65 Spectrophotometric NIR spectroscopy;66 laser Doppler perfusion imaging and digital photo67-70.

Despite numerous papers emphasising the potential risk factors36, 37 which may exacerbate a skin reaction, 36 respondents (67%) reported no formal documentation and 22 (41%) do not review skin care products that a patient currently uses.

Section 2 - Pre-treatment: Prophylactic skin care

Table 2: Question 16

Prophylactic skin care

Twenty six departments use aqueous cream as a prophylactic treatment. Wells et al’s39 findings did not find sufficient evidence to support aqueous or sucralfate for prophylactic use.

Tsang and Guy71 found that in people with healthy skin, use of aqueous cream was associated with reduced stratum corneum thickness and increase in transepidermal water. Their study suggests that more research is needed into the effect of aqueous cream and also the sodium lauryl sulphate it contains, which is known as a skin irritant.

Five departments recommend Aloe vera for prophylactic skin care. Richardson et al’s43 systematic review of Aloe vera use for prophylactic skin care concludes there is no evidence to recommend this product.

Swamy et al57note 75 % of their respondents agreed on the importance of using a prophylactic agent despite the lack of prospective trial data to support this practice.

The products most commonly used were those that would be used for the treatment of reactions when they occurred.

Section 3: During treatment: Assessment

Forty-two departments specify the type of soap to use: ‘Simple®’, ‘Dove®’ or ‘none’ being the most common answers.

Nine specify the type of deodorant to use: ‘none’ or ‘Pitrok®’72 being the most common answers.

D’haese et al56 note that the main areas of variations across departments in their study related to washing instructions and the use of soap. This is also confirmed by earlier studies by Barkham13 and Lavery73. The traditional patient advice of not washing the affected area with soap and water or even using water alone is also questioned by Porock and Kristjanson37. Campbell and Illingworth74 conducted a randomised controlled trial of 99 patients receiving breast radiotherapy and recorded no significant differences across cohorts (this is also confirmed in other studies.75, 76) Roy’s76 study concluded that those patients who washed actually had lower rates of skin reaction than those who were advised not to wash.

Bolderston et al’s54 systematic review reflects that the evidence indicates that gentle skin and hair washing should be unrestricted for patients and there should be no restriction to using a specific type of soap74, 76-80.

Some departments insist that deodorant should not be used, in line with the College’s 2000 guidelines1, despite the availability of more updated evidence72, 80-85. Bolderston et al’s54 systematic review highlights that the traditional reasons for not using soap and deodorant were:

1. a bolus effect
2. a secondary radiation effect on the skin due to metallics.

Burch et al82 note no real increase in surface dose due to skin care products or deodorants but emphasise that there may be chemical irritants within products that can cause a reaction.

Keeping our traditional advice may be a factor affecting patient social well being. For example, breast cancer patients who are advised not to use a deodorant often cite this as one less area of control they have in their life86. Additionally, we need to consider whether or not patients actually comply with these instructions44.

Section 4 - During treatment: Erythema

Table 3: Question 29

Products used for skin reactions

Aqueous cream is used by 49 departments as a product to alleviate erythema. This is a relatively cheap readily available moisturising agent, and is currently recommended by the College’s 2000 guidelines1.

Aloe vera is used by 8 departments. Even with a seemingly harmless substance like Aloe vera there is conflicting evidence ie Kaufman et al87 concludes that Aloe vera slowed down the wound healing process.

Evaluation and cost effectiveness

Only 1 department is conducting a randomised controlled trial into the clinical effectiveness of a topical agent for erythema.

There are no assessments of the cost effectiveness of using creams and topical agents for erythema. Swamy et al57 reflected that little work had been conducted on the cost effectiveness of practice41, 88, 89. With the introduction of more expensive skin care treatments to a vulnerable clientele market, health care professionals need to consider if such products are more effective than their cheaper comparators and why centres choose one product over another.

The extent of erythema

Maddocks-Jennings90 citing Fisher et al41 state that 87% of patients will experience a moderate to severe skin reaction to radiotherapy. Porock and Kristjanson37, based on work from King et al91 and De Conno et al92 state that 95% of patients will experience some degree of skin reaction. Butcher and Williamson’s93 systematic review also states this figure of 95 %37,43. Recent published results from Gosselin et al19 record 95 % of women receiving radiotherapy for breast cancer actually experienced a skin reaction, this occurring usually by week four.

The results from the SCoR survey tend to indicate that the extent of the erythema is actually unknown as it is unquantified. So what is the extent of the problem?

Graph 3: Question 35

Response count = 50

Section 5 - During treatment: Dry desquamation

Table 4: Question 37

Twenty four departments are using hydrocortisone 1 % for dry desquamation in line with the CoR 2000 guidelines1; this is despite current contradictory evidence18, 48, 94, 95. Kaufman et al87 conclude that 1% hydrocortisone cream may be effective owing more to its moisturising action rather than the anti-inflammatory effect and that it may reduce itching45,47. Bolderston et al’s54 systematic review concluded that no study reported significant differences in resultant skin reaction.

Section 6 - During treatment: Moist desquamation

Table 5: Question 45

Moist desquamation skin care

A variety of products and dressings are used for moist desquamation but hydrogels still seem to be most popular with 33 departments using them, in line with the CoR 2000 guidelines1.

Dyson et al96 investigated moist versus dry care of irradiated skin and documented more rapid vascularisation with moist wound care. Field and Kerstein97 also noted that maintaining a moist wound environment facilitates the wound healing process. Momm et al98 conclude that using a moist skin care product, such as 3% urea lotion, delays both the occurrence and severity of acute skin reactions. However, later work by Macmillan et al99 concludes that the use of hydrogels for moist desquamation is not supported and that hydrocolloid dressings or hydrogels may actually exacerbate the condition and delay wound healing99, 100.

Lanolin and gentian violet are still in use despite the evidence to contraindicate this practice16, 101.

Graph 4: Question 46

Response count = 45

It is interesting that management of moist desquamation appears to be shared almost equally between radiographers and nurses.

Graph 5: Question 47

Response count = 47

It is welcoming to note that 29 departments stated that those undertaking care of moist desquamation have received additional training in wound care management.

Only three departments are conducting randomised controlled trials into the clinical effectiveness of a topical agent for moist desquamation.

There is one on-going assessment into the cost effectiveness of a product.

Graph 6: Question 52

Response count = 46

Kedge’s55 systematic review notes the extent of moist desquamation seems to be unknown as varying figures are quoted37, 41, 102. The results of this survey would seem to confirm that view.

Section 7 - Posttreatment: Assessment and skincare

Nurses in the community are frequently expected to continue with moist desquamation care after radiotherapy. Most departments stated they supply 2-3 days worth of moist desquamation products to a patient at the end of radiotherapy. Therefore, there may be problems with product supply and continuity of care.

Graph 7: Question 54

Response count = 46

An evaluation of the treatment after care requires a review to ensure local continuity of care across the pathway, a general need highlighted by a recent Department of Health cancer patient experience survey103.

Section 8 - Review of Guidelines

Table 6: Question 58

Most departments have recently reviewed and updated their skin care advice. This is encouraging to note, although it is unknown if the guidelines have been reviewed in line with current evidence.

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