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Radiotherapy skin care: a survey of practice in the uk
Contents lists available at Radiotherapy skin care: A survey of practice in the UK Rachel Harris ,Heidi Probst ,Charlotte Beardmore Sarah James ,Claire Dumbleton ,Amanda Bolderston Sara Faithfull ,Mary Wells ,Elizabeth Southgate , a The Society and College of Radiographers, 207 Providence Square, Mill Street, London SE1 2EW, UKb Faculty of Health and Wellbeing, Shefﬁeld Hallam University, UK c The Society and College of Radiographers, UKd Fraser Valley Cancer Centre, British Colombia, Canadae Faculty of Health and Medical Sciences, University of Surrey, UKf School of Nursing and Midwifery, University of Dundee, UKg Birmingham Cancer Centre, Queen Elizabeth Hospital, Birmingham, UK Aim: The primary objective of the survey was to evaluate clinical skin care practice in radiotherapy Received 27 May 2011 departments across the United Kingdom.
Received in revised form Methods and Sample: A questionnaire containing sixty-one questions grouped into eight themed sections was developed and a link to an on-line survey, using the Survey MonkeyÔ tool, was e-mailed to all Accepted 20 October 2011 radiotherapy department managers in the United Kingdom (N ¼ 67). Each recipient was invited to Available online xxx provide one response per department.
Key results: Fifty-four departments responded within the allocated timeframe giving a ﬁnal response rate of 81%. Products and their use for skin conditions varied and some outdated and unfounded practices were still being used which did not always reﬂect the current evidence base. The amount of data routinely collected on skin toxicity was limited making it difﬁcult to quantify the extent of skin morbidity Radiation dermatitis Conclusion: The survey demonstrated variability in skin care practice in radiotherapy departments across Evidence based practice the UK, with limited practice based on evidence or on skin toxicity measurement and monitoring.
Ó 2011 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
intensity modulated radiotherapy (IMRT) has been shown to offerthe opportunity to reduce skin toxicity in some cases, especially the The Society and College of Radiographers (SCoR) last reviewed rates of dry and moist desquamation when treating cancers in the UK radiotherapy centre skin care practice in 2000 and produced head and neck region.
guidelines for radiotherapy A decade later it was Despite changes in practice and published timely to re-assess what was actually happening in clinical practice radiotherapy skin care appears to have changed little over the with the aim of assessing current practices and subsequently years, with departments caring for their patients' skin in different updating the information.
ways. Consequently, a plethora of agents is being used on the skin Skin reactions from external beam radiotherapy are one of the in a non-standardised fashion.
most common side-effects from treatment and a factor which can Faithfull et note ‘a growing awareness of the need for limit radiation dose. Megavoltage linear accelerators with skin evidence based practice in radiotherapy' but that there are ‘well sparing capabilities have signiﬁcantly reduced the severity of documented disparities between clinical practice and research reactions from radiotherapyhowever accelerated dose schedules ﬁndings which could underpin care'; reﬂecting that supportive care with combined radiation chemotherapy regimenshave increased is often based on no, little, or poor evidence. Comparing data across the condition. The most severe reactions tend to be in seen in those radiotherapy skin care studies is difﬁcult as often the methods used patients receiving high doses to large ﬁelds. Recently the use of are unclear, patient allocations differ, different skin assessmentscales are used, and follow-up data is inconsiste Although it is unlikely that radiation reactions can be * Corresponding author. Tel.: þ44 020 77407 250; fax: þ44 020 7740 7204.
completely prevented, the current driver in clinical practice is to E-mail address: (R. Harris).
minimise and delay the onset of symptoms.
In collaboration with the Department of Psychology, University of Exeter.
1078-8174/$ e see front matter Ó 2011 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
doi: Please cite this article in press as: Harris R, et al., Radiotherapy skin care: A survey of practice in the UK, Radiography (2011), doi:10.1016/j.radi.2011.10.040 R. Harris et al. / Radiography xxx (2011) 1e7 The extent of skin reaction is often dependent upon the clinical existing are helpful indicators of how appropriate site being treated. For example, patients undergoing radiotherapy a product will be for future use.
for head and neck cancer require immobilisation and often receivecombination chemotherapy. This can make these patients very vulnerable to intensiﬁed skin reactions and it is known that inter-ruptions in radiotherapy for this category can have a detrimental A panel of experts was consulted for the issues they felt required effect on treatment outcome.
investigation in a survey of skin care practice. The panel consisted of The use of an effective evidence-based skin care protocol and a team from the Society and College of Radiographers, two leading monitoring syswould assist in a researched approach to nursing professionals, the Chair of the SCoR Research Group, and the radiation skin care management, aiding product evaluation and authors of the recent systematic reviews. Initially the survey was justiﬁcation of practice.
large and unfocussed as panel members had different aspects of carethey felt required exploration. Two previous surveinto radiotherapy skin care practice aided this survey construction andfocus, as did an examination of the relevant literature.
In Barkham's 1993 assessment of radiotherapy skin reactions D'haese et alevaluated skin care during radiotherapy practice and associated treatments,52% of UK radiotherapy departments by nurses in Flanders. They designed a 58 item questionnaire reported dry desquamation as a common event and 85% of structured into 4 main sections: preventative advice, advice for departments reported moist desquamation as an occasional event.
erythema, dry desquamation and moist desquamation. Dividing However, as Glean et noted, the incidence of skin reactions has the questionnaire into these key sections seemed a logical easy to not been accurately quantiﬁed in departments and practices have follow format which the project team adapted.
changed since Barkham's survey.
Swamy et adeveloped a questionnaire to explore variations in Turesson et demonstrated that the number of basal cells in radiation oncologist practice across the USA in managing breast the epidermis declines during fractionated radiotherapy due to cancer, speciﬁcally related to skin reactions. Their main questions increased cell cycle arrest and reduced mitosis. The reduction in the focussed on prophylactic skin care, risk factors, topical products basal cells causes a thinning of the epidermis and an inﬂammatory used, and percentages of patients with skin reactions. These themes reaction. The variation in the reaction appears to be a genetic were also built into the survey tool.
predisposition due to individual DNA repair capacity,genetic This ﬁnal survey comprised of 61 questions, grouped into 8 radiosensitivity,eand/or intravascular thrombin generation.
Speciﬁc genetic tests could therefore be used to predict those An advanced draft of the survey tool was reviewed by the SCoR patients most likely to develop a severe radiotherapy r Public and Patient Liaison Group and was also piloted at one radio- Certain clinical factors can also help to predict the possibility of therapy department. Comments returned were minor and around a radiation reactionExtrinsic factors are treatment related, i.e.
clarity. These were incorporated and the survey tool ﬁnalised.
dose; volume; fractionation; adjuvant treatment; treatment in a skin The ﬁnal survey is a comprehensive tool which is relevant to UK fold area (e.g. inframammary fold or rectal cleft); use of bolus mate- rial; type of immobilisation; treatment techniqueThese factorsneed to be under constant review with changing work practices; forexample, with the introduction of IMRT. Intrinsic factors are indi- vidual patient related, e.g. larger breast sizhigher body massindex (BMIpre-existing conditions (e.g. psoriasis)Such A link to an on-line survey, using the Survey MonkeyÔ tool, was intrinsic factors may enhance a skin reaction and therefore should be e-mailed to all radiotherapy department managers in the United recorded as a baseline and closely monitored Kingdom (N ¼ 67) and they were invited to provide one response Gosselinnotes that some skin care products did show prom- per department. A ‘back-up' pdf ﬁle was also provided which could ising results but comparing data across studies is difﬁcult because be printed off and a hard copy returned if required (2 departments of the wide variety of differing assessment tools. By utilising skin used this option). Anonymity was maintained for all respondents.
assessment tools on at least a weekly review basis, it would be Fifty-four departments responded within the allocated time- possible to monitor and record a patient's skin reaction throughout frame with a ﬁnal response rate of 81%.
the treatment stage.
Naylor and Malletundertook a literature review to investigate the products being used for radiotherapy skin reactions and theevidence base behind their use. They identiﬁed certain products Not all departments responded to all questions, therefore n where evidence contraindicated use: values stated for each result are associated with the number ofresponses to each particular question, as opposed to the number of Petroleum as it may create a build up effect and is returned responses.
difﬁcult to remove; Topical antibiotics unless there is a proven infection; Topical steroids on broken skin due to the adverse effect on the Distribution of survey questions.
Number of questions Gentian Violet due to potential carcinogenic Pre-treatment e assessment Pre-treatment e prophylactic skin care Another important aspect of skin care during radiotherapy is During treatment e assessment that of patient well being. It may not be possible to stop or even During treatment skin care e erythema reduce the rates of skin reaction from occurring, but there may be During treatment skin care - dry desquamation comfort and psychosocial beneﬁts that skin care products provide, During treatment skin care e moist desquamation Post-treatment e assessment and skin care such as empowerment and control.Recording of patient accept- Review of guidelines ability/satisfaction and compliance (as incorporated into some Please cite this article in press as: Harris R, et al., Radiotherapy skin care: A survey of practice in the UK, Radiography (2011), doi:10.1016/j.radi.2011.10.040 R. Harris et al. / Radiography xxx (2011) 1e7 Table 2Prophylactic skin care products.
Question 16 If yes, which prophylactic skin care product(s) does yourdepartment recommend? (please tick all that apply) Response percent Response count Chamomile and Almond oil Skin sealant or barrier product i.e. Cavilon If other, please specify answered question Graph 1. Which guideline does your department follow.
Pre-treatment: prophylactic skin care All departments (n ¼ 54) stated they provide verbal and written information to patients on how they should care for their skin Twenty six (n ¼ 38 ¼ 68%) departments use aqueous cream as during their course of radiotherapy. Forty six (n ¼ 52 ¼ 88%) a prophylactic treatment departments stated they had skin care guidelines and protocols.
Five (n ¼ 38 ¼ 13%) departments recommend aloe vera for Twenty seven (n ¼ 52 ¼ 52%) departments use their own locally prophylactic skin care.
developed guidelines or adaptations of existing national guidelines Nine (n ¼ 38 ¼ 23%) use a range of other products, for example: calendula; diprobaseÒ; sucralfateÒ; skin sealant.
Sixteen (29%) departments chose not to answer this question.
Thirty eight (70%) departments stated that skin assessment prior to radiotherapy would be conducted by a radiographer.
During treatment: assessment Only thirteen (24%) use a skin assessment tool on all patients prior to radiotherapy; with 30 departments (55%) using no The range of responses to the questions on assessment of assessment tool at all patients' skin during treatment was varied, demonstrating no The Radiotherapy Oncology Group (RTOG) skin assessment single clear practice was followed by the majority of departments.
The one area where it was possible to identity practice that was (n ¼ 30 ¼ 66%); 24 departments chose not to answer this question.
comparable in several departments was the advice on using soap Thirty six respondents (67%) reported no formal documentation and deodorant, as shown below.
and 22 (41%) do not review skin care products that a patient Forty-two (77%) departments specify the type of soap to use: currently uses.
‘simpleÒ', ‘doveÒ' or ‘none' being the most common answers.
Forty two departments (77%) stated they knew their hospital Nine (16%) specify the type of deodorant to use: ‘PitrokÒ'or had a tissue viability nurse (TVN), or equivalent, but liaison with a non-metallic being the most common answers.
this person was not commonplace.
Thirteen (24%) state no deodorant to be used.
During treatment: erythema Aqueous cream is used by 49 (n ¼ 50 ¼ 98%) departments as a product to alleviate erythema ().
Aloe vera is used by 8 (n ¼ 50 ¼ 16%) departments.
A variety of other products are also used to a lesser extent.
Evaluation and cost effectiveness Only 1 (n ¼ 49) department is conducting a randomised controlled trial into the clinical effectiveness of a topical agent forerythema.
There were no assessments into the cost effectiveness of using creams and topical agents for erythema.
During treatment: dry desquamation Twenty four (n ¼ 44 ¼ 54%) departments are using hydrocor- tisone 1% for dry desquamation A variety of other products are used to a lesser extent.
Graph 2. Use of a skin assessment tool.
Ten (18%) departments chose not to answer this question.
Please cite this article in press as: Harris R, et al., Radiotherapy skin care: A survey of practice in the UK, Radiography (2011), doi:10.1016/j.radi.2011.10.040 R. Harris et al. / Radiography xxx (2011) 1e7 Skin care products for erythema.
Skin care products for moist desquamation.
Question 29 If yes, which skin care product(s) does your department Question 45 If yes, which skin care product(s) does your department recommend for erythema? (please tick all that apply) recommend for moist desquamation? (please tick all that apply) Response percent Response count Parafﬁn or Lanolin Gauze Chamomile and Almond oil Hydrocolloid dressing Silicone dressing e.g. Mepitel Skin sealant or barrier product i.e. Cavilon If other, please specify If other, please specify answered question answered question Limitations of the survey During treatment: moist desquamation There are certain limitations to the survey that need to be rec- ognised and which may have affected results.
A variety of products and dressings are used for moist desqua- As the survey was sent to each radiotherapy departmental manager and they selected who completed the survey and anon- (n ¼ 45 ¼ 73%) departments using them ymously returned data, it is unknown who and what department The various other products used included: 18 departments use answered. Therefore, it is also unknown if the responses expressed hydrocolloid dressings (n ¼ 45 ¼ 40%); 21 silicone dressings are individual views or departmental policy.
(n ¼ 45 ¼ 46%); 7 lyofoam Ò (n ¼ 45 ¼ 15%).
It is not possible to know if each question was fully understood Three departments (n ¼ 45 ¼ 6%) use lanolin and 2 (n ¼ 45 ¼ 4%) in the manner intended as there was no ‘face to face' follow up. The gentian violet.
disparity in results could be owing to misinterpretation of a ques- Nine (16%) departments chose not to answer this question.
tion, although the authors believe this reﬂects the unknown Twenty nine (n ¼ 47 ¼ 61%) departments stated that those statistics as many departments do not routinely record this data.
undertaking care of moist desquamation have received additional It is unknown if all questions were answered honestly or if the training in wound care management ().
survey was given the answer the respondent felt was correct. For Only 3 (n ¼ 46 ¼ 6%) departments are conducting randomised example, do more departments use gentian violet in reality but felt controlled trials into the clinical effectiveness of a topical agent for this was an incorrect response to declare? moist desquamation.
There is one on-going assessment into the cost effectiveness of The survey highlights the need for departments to undertake Post-treatment: assessment and skin care a baseline assessment of the patient's current skin condition.
Despite papers emphasising the potential risk factwhich 37 (n ¼ 47 ¼ 78%) departments stated they supplied post radiotherapy moist desquamation skin care products for up to twoweeks (2e3 days being the most common answer) after which theywould expect the community nurse to continue supply and care.
Table 4Skin care products for dry desquamation.
Question 37 If yes, which skin care product(s) does your departmentrecommend for dry desquamation? (please tick all that apply) Hydrocortisone 1% Mometasone Furoate cream If other, please specify answered question Graph 3. Training in wound care management.
Please cite this article in press as: Harris R, et al., Radiotherapy skin care: A survey of practice in the UK, Radiography (2011), doi:10.1016/j.radi.2011.10.040 R. Harris et al. / Radiography xxx (2011) 1e7 may exacerbate a skin reaction these are not routinely recorded.
Gentian violet and lanolin are still used (10% of respondents Over two thirds of the respondents to this survey did not routinely reported using these products) despite contraindications for assess and formally record the patient's skin prior to radiotherapy.
In a small randomised controlled trial (n ¼ 30) comparing Without the collection of such data it is difﬁcult to attain gentian violet and hydrogel dressings for moist desqthe a complete picture of the extent of radiotherapy induced reactions, gentian violet was signiﬁcantly less effective (p ¼ 0.0003) and also which will be essential for improved research and skin care studies.
less well tolerated by patients.
Furthermore, over a third of respondents failed to assess and record This again demonstrates our propensity to continue with skin care products currently being used by patients, hence it is familiar traditional practice rather than an openness to test the possible that unsuitable skin care practices may be being used effectiveness of products.
unmonitored by the health care team; potentially exacerbating There were no assessments into the cost effectiveness of using radiotherapy skin reactions.
creams and topical agents for erythema or dry desquamation and The importance of linking with other sectors of care, especially only one assessment of a product for moist desquamation.
a Tissue Viability Nurse (TVN), or equivalent, would strengthen With the introduction of more expensive skin care treatments to improved communication, understanding and consistency of a vulnerable clientele market, health care professionals need to radiotherapy skin care across the care pathway thereby avoiding consider if such products are more effective than their cheaper patient and staff It is disheartening that many departments did not know if their hospital had a TVN and did not another.This is an important facet of modern health care collaborate on skin care with this person.
with the necessity for justiﬁcation for actions and seems to have A main area of variation across departments relates to washing been almost totally overlooked.
instructions and the use of soap and deodorant (also conﬁrmed by There may be problems with product supply and continuity of other studi). The traditional patient advice of not to wash the care after treatment. Not all departments routinely supplied skin affected area with soap and water, or even use water alone is still care products for moist desquamation post-treatment. For those given, despite updated evidence that this is unnecessaryand that did, the majority provided products for up to 2e3 days post there should be no restriction to using a speciﬁc type of soapOver two thirds of respondents in this survey reported providers would then take over skin care following this period.
washing restrictions (i.e. either no soap, or limited to speciﬁc brands This means that about 20% of responding departments did not such as ‘simpleÒ' and ‘doveÒ'), this has the potential to unnecessarily provide skin care products post radiotherapy. Therefore, in the control choices and preferences an individual may have.
period when most skin reactions build up to their maximum Still referencing traditional practice 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 An evaluation into the treatment after care requires review to control they have in their Additionally, we need to consider ensure local continuity of care across the pathway; a general need whether or not patients actually comply with these instructions.
highlighted by a recent Department of Health cancer patient The survey illustrates that there are numerous products for experience survey.It is essential that the whole health care radiotherapy skin care available and there is no consensus as to the pathway of a patient is considered and reviewed to ensure best best practice, causing an inconsistency of As noted by if the underlying cause of a radiation reaction is physiological and the extent is genetically predisposed topical agents are unlikely to realistically have any signiﬁcant effect.
Currently the quality and quantity of studies evaluating topical The survey appears to indicate that skin care advice to patients agents appears to be insufﬁcient to support or refute any speciﬁc undergoing radiotherapy in the UK is varied. Currently, some of the prand the survey indicated there were minimal on-going skin care provided may not alleviate the problem and indeed may assessments into skin care products; therefore it would appear even compound the effect. This area of patient care is time progress into understanding what actually may work will be slow.
consuming and expensive, therefore it is important to understand Aqueous cream is commonly recommended by most depart- what is being done and why.
ments and is a relatively cheap readily available moisturising agent, As Kedgenoted, and as the results of this survey show, the and recommended by the recently withdrawn College of Radiog- College of Radiographers (CoR) guidelineneed updating, paying rapher's 2000 guidelines.However, the evidence base indicates particular attention to advice about deodorant use, aqueous that type of regime applied preventatively and to erythema appears cream for erythema, use of hydrocortisone 1% for dry desqua- to have no inﬂuence in a skin reaction . Therefore, mation, and the use of hydrogels and hydrocolloids for moist there needs to be further debate about this aspect of care and the desquamation. Given that the survey shows that the CoR 2000 evidence base supporting actions. Furthermore, 16% of responding guidelinwere followed by the majority of departments, it is departments reportedly advise patients to use topical aloe vera reasonable to assume that revised guidelines would be followed which may incur a substantial cost either to the institution or to the and so provide an appropriate base for future evaluation of skin individual, yet there is limited as to any beneﬁt obtained care practices.
using this agent over another and therefore no justiﬁcation without The results indicate that not all radiotherapy departments are further detailed studies for this recommendation to monitoring and documenting skin morbidity in a systematic way.
Hydrocortisone 1% is frequently used (over 50% of respondents Departments need to routinely monitor, assess and document skin reported using this cream) for dry desquamation reactions, in line reactions using standard grading systems, and noting intrinsic and with the College of Radiographer's 2000 guidThis is despite extrinsic related factors. Although the majority of skin reactions current contradictory evidefurther illustrating how tend to subside after a few weeks, some can be prolonged, clinical practice has not kept pace with emerging research evidence.
uncomfortable and distressing, thereby affecting a patient's quality Product use varies considerably, hydrogels are the most of life.As Gosselin et al noted, ‘patients prefer to take action commonly used (over 70% of respondents) but there is conﬂicting rather than do nothing'so the focus for skin care should be on evidence as to their effect on wound healing.
alleviating symptoms and providing comfort.
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