Dear Editor,
Chronic radiation dermatitis and fibrosis (CRDF) has been defined as skin changes that develop more than 90 days after the cessation of radiation therapy. It encompasses dyspigmentation, epidermal thinning, dermal atrophy and telangiectasias. 1 As no consensus on standard of care exists, we created an international, multidisciplinary, consensus‐based approach for the terminology, risk factors, treatment and management of CRDF.
A multidisciplinary panel of 27 providers (25 physicians and two nurse practitioners) participated in the Delphi‐method survey, which consisted of two independent rounds of questionnaires followed by a consensus meeting between panellists. Of the 25 physicians, 19 were dermatologists and six were oncologists, two of whom were radiation oncologists. Strong consensus was achieved once ≥70% of respondents strongly agreed or agreed with a statement. Moderate consensus was achieved if 50–69% of respondents strongly agreed or agreed with a statement. Statements that achieved moderate consensus were reviewed in detail for modification and inclusion in the second Delphi round. Statements that failed to reach consensus (< 50% of participants agreeing or strongly agreeing) were dismissed unless a group member felt further discussion could benefit inclusion in the next round.
The first and second rounds in the Delphi process consisted of 63 and 27 questions or statements, respectively. We achieved strong consensus for 15 statements and moderate consensus for 16 statements. Thirty‐two statements failed to reach consensus and were eliminated. This process and the results are summarized in Table 1. Consensus points determined by this collaboration of physicians can be used to aid the decision making of clinicians treating patients with CRDF and are outlined below.
Table 1.
Topics reaching strong consensus among the panellists
| Topic | Statement or topic specified | Percentage consensus | |
|---|---|---|---|
| Initial survey | Second survey | ||
| Treatment of acute radiation dermatitis and fibrosis | Treat acute radiation dermatitis with topical steroids | 93% | NA |
| Factors increasing the likelihood of CRDF | Anatomical location | 86% | NA |
| Radiation dose | 89% | NA | |
| Reirradiation | 96% | NA | |
| Radiation volume | 86% | NA | |
| Underlying connective tissue diseases | 61% | 70% | |
| History of smoking | 68% | 90% | |
| Clinical presentation and morphologies included | Telangiectasias and vascular changes | 96% | NA |
| Skin fibrosis and induration | 100% | NA | |
| Dermal atrophy | 92% | NA | |
| Skin contractures | 77% | NA | |
| Epidermal atrophy | 77% | NA | |
| Hyperpigmentation | 96% | NA | |
| Hypopigmentation | 77% | NA | |
| Prophylactic treatment of CRDF | Sunscreen after radiation to protect the skin against ultraviolet‐induced radiation changes | 85% | |
| Laser therapies | Inclusion of laser therapy in the management of CRDF | NA | 96% |
| Vascular lasers for telangiectasias and vascular changes | 64% | 77% | |
| †Based on participants with expertise in laser therapy | †Fractional ablative laser for fibrosis and induration | NA | 75% |
| †Q‐switched laser for hyperpigmentation | NA | 100% | |
| †Fractional ablative laser for skin contractures | NA | 90% | |
| First‐line treatment | Laser therapy for telangiectasias and vascular changes | NA | 92% |
| Other | Significance of interdisciplinary discussions in patient management | 93% | NA |
| Forewarning patients with acute radiation dermatitis about the risk of CRDF | 79% | NA | |
| CRDF having negative impact on quality of life | 100% | NA | |
CRDF, chronic radiation dermatitis and fibrosis; NA, not applicable.
Treatment features increasing the likelihood of CRDF that reached strong consensus include reradiation, initial radiation dose and radiation volume. Furthermore, the risk of developing toxicity positively correlates with radiation dose. 2 Patient features increasing the likelihood of CRDF that reached strong consensus include anatomical location, underlying connective tissue diseases and a history of smoking. In the experience of the panellists, the head/neck and breast/chest were the anatomical sites associated with the greatest likelihood of CRDF. Smoking exacerbates CRDF via several mechanisms including impaired oxygenation and elevated carboxyhaemoglobin levels. 3
Most panellists agreed that CRDF begins 90 days after the cessation of radiation therapy and encompasses various morphologies ranging from dermal atrophy to vascular changes. Some panellists expressed frustration with the current all‐encompassing ‘chronic radiation dermatitis’ terminology and recommended the use of new terminology such as chronic radiotherapy changes of ‘specific morphology’, for example telangiectatic type. Although this nomenclature reached moderate consensus, there was concern that it would be confused with nonionizing radiation. Therefore, the modifier ‘radiotherapy’ in place of ‘radiation’ was recommended. Implementation of a more specific terminology would aid in better understanding by patients and physicians who are not exposed to CRDF in their everyday practice.
Although the panellists did not reach consensus concerning the increased likelihood of CRDF following excessive ultraviolet exposure after radiation, strong consensus was achieved concerning recommended sunscreen after radiotherapy to protect the skin against ultraviolet‐induced radiation changes.
Moderate consensus was achieved concerning the use of topical and/or intralesional corticosteroids (61%) and oral pentoxifylline (57%) in the management of CRDF. Fifty‐eight per cent of panellists also found physical therapy and a range of motion exercises to be helpful in the setting of contractures, fibrosis, epidermal atrophy and dermal atrophy. Combination therapy consisting of oral pentoxifylline, oral vitamin E and physical therapy achieved moderate consensus, with 54% of panellists supporting this first‐line approach for contractures, fibrosis, epidermal atrophy and dermal atrophy.
There was strong consensus (96%) regarding the inclusion of laser therapy in the management of CRDF. For vascular changes, 92% of all panellists felt that a vascular laser such as 595‐nm pulsed‐dye laser was an appropriate first‐line treatment. There was also strong consensus concerning the use of fractional ablative laser therapy for skin contractures (90%) and fibrosis or induration (75%).
Given that the care of patients experiencing CRDF may be spread across different centres and specialties, the panel recognized the value of interdisciplinary input and the importance of initiating discussions. The panellists are unanimous in their view that CRDF significantly impacts patient quality of life. 4 In their experience, CRDF has impacted patients’ self‐confidence and their ability to undergo and maintain breast implants, and served as a painful reminder of cancer history. Poor cosmesis, pain, recurrent wounds and limited range of motion resulting from CRDF further impact patient quality of life. 5 The panellists felt that any patient receiving a significant dose of radiation to the skin should discuss the possibility of developing CRDF. Thus, guidelines and best practices for the diagnosis, management and treatment of CRDF are useful, particularly in the context of multidisciplinary cancer care.
Author contributions
Britney Wilson: Conceptualization (equal); writing – original draft (lead); writing – review and editing (lead). Rohan Shah: Data curation (equal); investigation (equal); writing – original draft (equal); writing – review and editing (equal). Christian Menzer: Formal analysis (equal); methodology (equal); validation (equal); visualization (equal); writing – original draft (equal). Abdullah Aleisa: Conceptualization (equal); data curation (equal); investigation (equal); supervision (equal); validation (equal). Mary Daotung Sun: Data curation (equal); validation (equal); writing – original draft (equal). Bernice Kwong: Data curation (equal); investigation (equal); validation (equal); writing – review and editing (equal). Benjamin Harris Kaffenberger: Data curation (equal); methodology (equal); supervision (equal); visualization (equal). Lucia Seminario: Formal analysis (equal); funding acquisition (equal); investigation (equal); resources (equal); software (equal); supervision (equal). Christopher Barker: Data curation (equal); project administration (equal); supervision (equal); validation (equal). Michael Stubblefield: Resources (equal); validation (equal); visualization (equal). Paul Romesser: Funding acquisition (equal); methodology (equal); project administration (equal); software (equal); supervision (equal); writing – original draft (equal). Gabriella Fabbrocini: Conceptualization (equal); formal analysis (equal); project administration (equal); validation (equal). Murad Alam: Data curation (equal); investigation (equal); project administration (equal); supervision (equal). Farah Abdulla: Data curation (equal); funding acquisition (equal); methodology (equal); visualization (equal). Brittany Dulmage: Funding acquisition (equal); investigation (equal); project administration (equal); software (equal). Vincent Sibaud: Formal analysis (equal); methodology (equal); software (equal); visualization (equal). Milan J Anadkat: Formal analysis (equal); investigation (equal); methodology (equal); visualization (equal); writing – review and editing (equal). Jean‐Michael Mazer: Conceptualization (equal); funding acquisition (equal); methodology (equal); project administration (equal); visualization (equal). Dhwani Parikh: Formal analysis (equal); methodology (equal); software (equal); supervision (equal); validation (equal). Beth N. McLellan: Data curation (equal); formal analysis (equal); methodology (equal); software (equal); writing – original draft (equal). H. Cartier: Funding acquisition (equal); methodology (equal); project administration (equal); supervision (equal). Silvina Pulgies: Formal analysis (equal); investigation (equal); methodology (equal); software (equal); validation (equal). Albert Wolkerstorfer: Data curation (equal); funding acquisition (equal); validation (equal); visualization (equal). Hans Joachim Laubach: Conceptualization (equal); formal analysis (equal); investigation (equal). Nicole Leboeuf: Formal analysis (equal); methodology (equal); resources (equal); software (equal); visualization (equal). Jonathan S. Leventhal: Conceptualization (equal); data curation (equal); investigation (equal); visualization (equal); writing – review and editing (equal). Derrick Wan: Data curation (equal); formal analysis (equal); software (equal); supervision (equal); validation (equal). Jennifer Choi: Funding acquisition (equal); methodology (equal); resources (equal); software (equal); validation (equal). Tran Thanhnga: Data curation (equal); funding acquisition (equal); project administration (equal); supervision (equal). R.Rox Anderson: Data curation (equal); investigation (equal); methodology (equal); supervision (equal); validation (equal). Alina Markova: Funding acquisition (equal); methodology (equal); supervision (equal); validation (equal). Anthony Rossi: Conceptualization (lead); formal analysis (lead); funding acquisition (lead); methodology (lead); supervision (lead); writing – review and editing (lead).
Supporting information
Appendix S1 Full list of affiliations.
Appendix S2 Conflicts of interest.
Acknowledgments
we thank Andrew Zarski and Kwok Leung, data analysts from Digital Informatics and Technology Solutions (DigITs) at Memorial Sloan Kettering Cancer Center, for their assistance with data acquisition and developing the REDCap surveys.
Funding sources: this research was funded, in part, by NIH/NCI Cancer Center Support Grant P30 CA008748. The funder had no role in the design and conduct of the study; the collection, management, analysis and interpretation of the data; the preparation, review and approval of the manuscript; or the decision to submit the manuscript for publication.
Conflicts of interest: Conflicts of interest are listed in Appendix S2.
Data availability statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.
References
- 1. Rossi AM, Nehal KS, Lee EH. Radiation‐induced breast telangiectasias treated with the pulsed dye laser. J Clin Aesthet Dermatol 2014; 7:34–7. [PMC free article] [PubMed] [Google Scholar]
- 2. Bentzen SM, Agrawal RK, Aird EG et al. The UK Standardisation of Breast Radiotherapy (START) Trial A of radiotherapy hypofractionation for treatment of early breast cancer: a randomised trial. Lancet Oncol 2008; 9:331–41. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Seité S, Bensadoun R‐J, Mazer J‐M. Prevention and treatment of acute and chronic radiodermatitis. Breast Cancer (Dove Med Press) 2017; 9:551–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Leventhal J, Young MR. Radiation dermatitis: recognition, prevention, and management. Oncology (Williston Park) 2017; 31:885–7, 894–9. [PubMed] [Google Scholar]
- 5. Rossi AM, Blank NR, Nehal K et al. Effect of laser therapy on quality of life in patients with radiation‐induced breast telangiectasias. Lasers Surg Med 2018; 50:284–90. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Appendix S1 Full list of affiliations.
Appendix S2 Conflicts of interest.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.