Table 2.

Recommendations based on interviews

Recommendations for the Radiation Treatment Team	Recommendations for Psychosocial Care Providers	Recommendations for Radiation Researchers
Assess for women who may be at greater risk for skin toxicity-related distress due to the moderating factors described above, and tailor patient education and problem solving efforts accordingly.	Assess for women who may be at greater risk for quality of life impairment due to the moderating factors described above Psychosocial Interventions should be flexible enough to adapt to these factors. If resources are limited, interventions should perhaps be targeted to these groups.	Empirical testing of the potential moderators suggested here would improve our understanding of risk factors for quality of life impairments related to skin toxicity.
Avoid solely using the word “sunburn” to describe skin changes, as it may underestimate the experience for some, to invalidate it for others, and to be unfamiliar to darker skinned women. Instead, use a wider range of descriptors (e.g., itchy, hot).	Be attuned to patients’ language choice when discussing their skin changes. Very few participants used the word “pain” to describe their experience. Whenever possible, use patients’ own words during interventions.	Develop a multidimensional scale to assess the effect of skin toxicity on various dimensions of quality of life.
Set appropriate expectations for skin changes. The vast majority of women will experience skin changes during radiotherapy, and these changes tend to worsen throughout treatment. Provide this information honestly, but in a reassuring manner.	Avoid suggesting images of heat (e.g., sun, summer, warmth) in interventions involving imagery. Focus instead on images of coolness (e.g., cool washcloth, cool breeze, snow, mist, cool water).	Assess all affected domains of quality of life, not merely the physical domain.
Develop and distribute a “tip sheet” based on the participant-initiated coping strategies described here. Hand this out to each patient at either consultation or simulation (i.e., before treatment begins), so women can make practical preparations for the treatment. During each patient’s treatment, collect any new strategies they have found useful and add them to the list.	In any form of talk psychotherapy, be aware of the multitude of effects that skin changes can have on patients’ thoughts, feelings, and quality of life. Also, be aware that like many symptoms, it is the patient’s perceptions of and reactions to skin changes that are the most important intervention target. What a physician might rate as an RTOG score of 1 (mild redness) may be devastating or perceived as glaring to a given patient.	Include patient-rated measures in research on skin toxicity, so that the patient’s voice is reflected in the research.
Provide psychosocial interventions, or make referrals to such interventions, to help women manage the suffering associated with skin changes.	Participants were sensitive to and worried about the reactions of others to their skin changes. If a patient chooses to show you/talk about their skin changes, it is important to react in a sensitive, non-rejecting manner.	Qualitative and quantitative approaches could be used to further explore the influence of individual differences (e.g., culture) on patients’ experiences of skin toxicity.