Radiation Dermatitis and Breast Cancer

Introduction

Breast cancer is the most common female malignancy in the USA. Approximately 250,000 estimated new cases are diagnosed and over 40,000 annual deaths are reported each year. Breast cancer is the second leading cause of malignant deaths in American women. (1)

Nearly all Patients who receive radiotherapy (RT) for breast cancer experience some degree of radiation dermatitis and would need relief from radiation's effects on the skin. Breast cancer patients may receive radiation therapy for breast conservation or post mastectomy decrease recurrence rates and improve overall survival. (2) (3) (4) 

Patients undergoing radiation therapy to the intact breast or chest wall with or without lymph nodes typically receive 4–6 weeks of radiation. Radiation dermatitis is most common acute side effect. (5)

Anatomy and Skin Damage

Radiation affects the dermis, hair follicles and sebaceous (oil producing) glands. These are sensitive to relatively low doses of radiation and lead to the acute effects of hair loss and skin dryness. injury to the blood vessels. Damage to the structure of the skin induces a inflammatory response within the dermis ad contributes to both the acute and chronic skin effects of radiation. (6)

Assessing Your Skin During Radiation

Several grading scales exist to aid in the reproducible quantification of acute radiation dermatitis. In the United States, the CTCAE scale is most commonly used in clinical trials (7). It defines acute skin reactions to radiation as those occurring within the first 90 days after therapy. The scale encompasses five grades of reactions.

Grade 1: Faint erythema (superficial reddening of the skin, usually in patches) or dry desquamation (Dryness, itching, scaling, flaking and peeling and hyperpigmentation). This usually occurs within the first 2 to 4 weeks of treatment. These reactions cause skin redness and warmth and a rash like appearance. Patients may feel skin tightness or sensitivity.

Grade 2: Moderate to brisk erythema; patchy, moist desquamation usually confined to skin folds or creases. Moderate edema (swelling), dryness, pruritus (itchiness), and flaking of skin layers (dry desquamation) also may occur.

Grade 3: Moist desquamation in areas other than creases and skinfolds. Bleeding may arise from minor trauma, such as abrasion.

Grade 4: Life-threatening consequences, such as full-thickness skin ulcers, necrosis, and spontaneous bleeding. 

Risk Factors for Developing Radiation Dermatitis

Larger breast size was among the earliest patient characteristics to be identified as a risk factor for acute skin toxicity. Additional patient factors such as the degree of friction due to normal arm movement, texture and type of clothing items worn, and a build-up of perspiration can contribute to dermatitis. Racial differences and menopausal status were also been linked to radiation dermatitis risk, with higher rates of moist desquamation in black and postmenopausal women in one prospective study. (8)

Techniques utilized during radiation therapy all influence the development of radiation dermatitis. Modern techniques that deliver a more uniform, homogenous radiation dose across breast tissue result in significantly less acute and long-term skin toxicity. Three-dimensional (3D) treatment planning significantly diminishes radiation-induced skin reactions. Modern 3D techniques account for changes in breast contour above and below the central axis to reduce inherent radiation “hot-spots”. These “hot-spots” are known to increase the risk of radiation dermatitis.

Intensity-Modulated Radiation Therapy (IMRT) are two methods that allow for multiple smaller radiation fields to more evenly apply the radiation. The use of these techniques is now considered standard-of-care for all centers. trials of 3D/IMRT technique have shown improved rates of hyperpigmentation, edema, and moist desquamation. (9) (10) diminished durations and severity of radiation dermatitis reactions in the acute setting; (11) and have resulted in significantly reduced long-term skin changes and fibrosis that are associated with breast radiation.(12)

Radiation Dermatitis Management Challenges

Subsequently, additional studies have been added to the body of literature and have been informative for identifying general principles of skin care during RT treatment. While the available literature has not clearly defined optimal treatment of radiation dermatitis based on high-level evidence, it is important to recognize that recommendations in use today, in practice, have not been found to cause any harm or interact negatively with RT.

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