Abstract
Background
Skin reactions and pain are commonly reported side effects of radiation therapy (RT).
Objective
To characterize RT-induced symptoms according to treatment site subgroups and identify skin symptoms that correlate with pain.
Methods
A self-report survey, adapted from the MD Anderson Symptom Inventory and the McGill Pain Questionnaire, assessed RT-induced skin problems, pain, and specific skin symptoms. Wilcoxon Sign Ranked tests compared mean severity of pre- and post-RT pain and skin problems within each RT-site subgroup. Multiple linear regression (MLR) investigated associations between skin symptoms and pain.
Results
Survey respondents (n=106) were 58% female and on average 64 years old. RT sites included lung, breast, lower abdomen, head/neck/brain, and upper abdomen. Only patients receiving breast RT reported significant increases in treatment site pain and skin problems (p≤0.007). Patients receiving head/neck/brain RT reported increased skin problems (p<0.0009). MLR showed that post-RT skin tenderness and tightness were most strongly associated with post-RT pain (p=0.066 and p=0.122, respectively).
Limitations
Small sample size, exploratory analyses, and non-validated measure.
Conclusions
Only patients receiving breast RT reported significant increases in pain and skin problems at the RT site, while patients receiving head/neck/brain RT had increased skin problems, but not pain. These findings suggest that the severity of skin problems is not the only factor that contributes to pain, and interventions should be tailored to specifically target pain at the RT site, possibly by targeting tenderness and tightness. These findings should be confirmed in a larger sampling of RT patients.
Keywords: radiation-induced skin reactions, pain, pain management
1. Introduction
Radiation-induced skin reactions or radiation dermatitis is reported in 95% of cancer patients undergoing radiation therapy (RT) [1–3]. These skin changes range from mild erythema to dry or moist desquamation. Pain is often the cause for premature discontinuation of RT, which may impair control of disease and quality of life [1–5]. Various treatments have been tested for prevention and treatment of radiation dermatitis, including aloe vera, hyaluronate cream, corticosteroids, antimicrobials, and dressings [1, 6]. Although “washing with a mild soap” is still considered the most effective treatment for radiation dermatitis, interventions that increase moisture at the treatment site have shown some promise for decreasing moist desquamation, but not pain [1, 6, 7]. Little research has been dedicated to assessing the incidence and severity of pain associated with radiation-induced skin reactions at various RT sites.
The severity of radiation-induced skin reactions is most commonly assessed using the Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer (RTOG/EORTC) scoring system and the National Institutes of Health Common Toxicity Criteria-Adverse Event (NIH CTCAE) [2, 3]. These scoring systems, however, do not evaluate the pain or quality of life that is associated with these skin reactions. Further, established skin evaluation tools like the Skindex [8] and Skin Toxicity Assessment Tool (STAT) [9] evaluate quality of life, but not pain and skin symptoms simultaneously. Studies that do assess pain employ the standard 11-point, 0 to 10 Numeric Rating Scale (NRS) for pain severity, but do not relate the pain level to the treatment site, skin, or type of skin symptoms [10, 11]. A new assessment tool that simultaneously assesses skin symptoms and pain would benefit research studies in radiation dermatitis.
The purpose of this study was to simultaneously obtain specific information on pain and skin problems experienced by patients receiving RT for cancer at various sites using a new survey instrument, the Pain and Skin Problem Survey (PSP), which was adapted from the McGill Pain Questionnaire-Short Form (MPQ-SF) [12] and the MD Anderson Symptom Inventory (MDASI) [13–16].
2. Methods
2.1 Study population and design
Eligible patients were ≥18 years of age, of any gender and ethnicity, able to read and understand English, had any cancer diagnosis, and were scheduled to receive RT for cancer at the University of Rochester Cancer Center. The University of Rochester Institutional Review Board approved this clinical protocol and written informed consent was obtained from each patient. Patients were consented prior to or within four days of the start of RT. Once enrolled, patients completed the pre-treatment portion of the PSP either before or within four days of the start of their prescribed course of RT. For patient convenience, the post-treatment survey could be completed any time after but within one month of their last RT session. Patients were asked to consider their pain and skin problems on the last day of their RT when completing the survey no matter what date it was actually completed and returned.
2.2 Assessment
The PSP is a new instrument based on the MPQ-SF [12] and the MDASI [13–16]. It was developed to evaluate pain and skin problems associated with radiation therapy. The pre-treatment portion was completed before or at the start of RT, while the post-treatment portion was completed after the completion of RT. The PSP involved a series of 6-point, 0 to 5 Likert Scales. Patients were asked to rate the severity of pain and skin problems at the treatment site on a 6-point scale anchored by 0 = “Not Present” and 5 = “Very Severe”. Patients were also asked to describe the feeling or appearance of their skin problems at the treatment site using eight specified descriptive symptoms: itchy, throbbing/aching, tenderness, hot-burning, tightness/splitting, redness/discolored, flaking/peeling, and bumpy/spotted. Subjects rated the severity of the symptom on a similar Likert Scale. A chart review was also performed to determine which participants were prescribed opioid pain medications during radiation treatment. If the medication was prescribed between the dates that the subject completed the pre- and post- treatment surveys, it was considered “prescribed during treatment.”
2.3 Statistical Analyses
In this exploratory analysis, differences in mean severity between pre- and post-RT pain, skin problems, and skin symptoms at the RT site were assessed using Wilcoxon Signed Rank tests within each treatment site subgroup. Treatment site subgroups were defined by body region to assess how skin in different regions responded to RT. For analyses of changes in severity of pain and skin problems at treatment sites, significant p-values were set using the Holm-Bonferroni correction method accounting for five RT site subgroups (first p-value = 0.01). For analyses regarding changes in severity of specific skin symptoms, the first significant p-value for the Holm-Bonferroni method was set to correct for the eight skin symptoms investigated (first p-value = 0.00625). Multiple linear regression (MLR) analysis was used to determine predictors of post-treatment pain and skin problems. Independent variables included pre-treatment pain or skin problems, age, gender, RT-site (breast or head/neck/brain vs. other), total number of radiation treatments, and total dose of radiation. MLR analysis was used to assess how strongly the severity of each skin problem descriptor correlated with the severity of pain or skin problems at the treatment site (p<0.05 considered significant for MLR). All statistical analyses were performed in JMP 10.
3. Results
3.1 Patient Characteristics
A total of 154 patients was recruited and consented to participate in the study. Of these 154 patients, 111 completed both the pre- and post-treatment portions of the PSP. Thus, the overall response rate was 72%. Five participants were excluded for incorrect completion of the post-treatment survey. The analyses reported herein were conducted on the 106 patient who completed both pre- and post-treatment surveys. The majority of patients were white (96%) and female (62%) with an average age of 64 years. Approximately half of the patients had advanced cancer (48%), and the majority of patients had previous surgery (55%) or chemotherapy (58%) (Table 1). The most common primary cancer diagnoses were lung (26%), breast (18%), alimentary/gastrointestinal (17%), hematologic (11%), and genitourinary (7.5%). RT site subgroups included lung (30%), breast (16%), lower abdomen (14%), head/neck/brain (13%), and upper abdomen (12%), and “other” (14%). The lower abdomen group included irradiations for genitourinary, colorectal, and prostate cancers. The upper abdomen group included irradiations for esophageal, gall bladder, pancreas, and liver cancers. The head/neck/brain group consisted of patients with head/neck tumors (n = 2), brain tumors (n = 8), or metastatic lesions in the brain (n = 2). The “other” group included patients receiving RT for hematologic cancers, melanoma, sarcomas, and spinal irradiations for metastatic cancer. The mean total number of RT sessions was 20 and the mean total dose was 54 Gy (Table 1).
Table 1.
Subject Demographics.
| Characteristic | Mean (SD) or % n = 106 |
|---|---|
|
| |
| Age | 64 (13) |
|
| |
| Race | |
| White | 96% |
| Other | 4% |
|
| |
| Gender | |
| Female | 65% |
| Male | 35% |
|
| |
| Cancer Diagnosis | |
| Lung | 26% |
| Breast | 18% |
| Alimentary | 17% |
| Hematological | 11% |
| Genitourinary | 7.5% |
| Other | 20.5% |
|
| |
| RT site | |
| Lung | 30% |
| Breast | 16% |
| Lower abdomen | 14% |
| Head/Neck/Brain | 13% |
| Upper GI | 12% |
| Other | 14% |
|
| |
| Previous Txt | |
| Surgery | 55% |
| Radiation | 26% |
| Chemo | 58% |
| None | 14% |
|
| |
| Cancer Severity | |
| Early stage/local | 52% |
| Advanced cancer | 48% |
|
| |
| Total # of Txts | 20 (11) |
|
| |
| Total Dose (Gy) | 54 (25) |
|
| |
| Days between last txt and post survey completion | 6.6 (7.99) |
3.2 Report of pain, skin problems, and skin symptoms at treatment site
Patients receiving RT to the breast reported the largest and only significant increase in severity of pain at the treatment site (mean change = 1.35, 95% CI = 0.43, 2.28, p=0.01). Patients receiving RT to the breast or the head/neck/brain region reported significant increases in skin problems at the treatment site (breast: mean change = 2.18, 95% CI = 1.62, 2.73, p<0.0001; head/neck/brain: mean change = 1.54, 95% CI 0.77, 2.30, p=0.004) (Figure 1). MLR was used to identify predictors of the severity of post-treatment pain and skin problems. Independent predictors in the models included pre-treatment pain or skin problems, age, gender, RT site (breast cancer or head/neck/brain vs. other), total number of RT sessions, total dose of radiation, and cancer severity (early vs. late stage). RT to the breast was the only significant predictor of increased post-treatment pain (b = 1.029, 95% CI = 0.217, 1.896, p = 0.014) (Table 2). There was a trending association between pre- and post-treatment pain at the treatment site (b = 0.235, 95% CI = −0.023, 0.493, p = 0.073). Predictors of increased post-treatment skin problems were a greater number of total RT sessions (b = 0.031, 95% CI = 0.005, 0.056, p=0.017) and receiving RT to the breast (b = 1.629, 95% CI = 0.900, 2.358, p<0.0001) or head/neck/brain region (b = 0.882, 95% CI = 0.144, 1.620, p = 0.020) (Table 2).
Figure 1.
Changes in severity of pain and skin problems by RT site. *P<0.01 was considered significant based on the Holm-Bonferroni correction method.
Table 2.
Multiple linear regression model for predictors of post-RT pain and skin problems. Models also adjusts for age, gender, total radiation dose, and cancer severity (early vs. advanced stage).
| Model Outcome: post-RT pain | ||
|---|---|---|
| Predictor | b [95 % CI] | p-value |
| Pre-RT pain | 0.235 [−0.023, 0.493] | 0.07 |
|
| ||
| Total # of RT Txts | 0.021 [−0.007, 0.050] | 0.143 |
|
| ||
| RT site | ||
| (Breast Vs. Other) | 1.029 [0.217, 1.896] | 0.014 |
| (HNB Vs. Other) | −0.018 [−0.828, 0.792] | 0.965 |
|
| ||
| Adjusted R2 =0.122, obs = 102 | ||
| Model Outcome: post-RT skin problems | ||
|---|---|---|
| Predictor | b [95 % CI] | p-value |
| Pre-RT skin problems | 0.168 [−0.131, 0.468] | 0.268 |
|
| ||
| Total # of RT Txts | 0.031 [0.005, 0.056] | 0.017 |
|
| ||
| RT site | ||
| (Breast Vs. Other) | 1.629 [0.900, 2.358] | <0.0001 |
| (HNB Vs. Other) | 0.882 [0.144, 1.620] | 0.020 |
|
| ||
| Adjusted R2 = 0.3358, obs = 103 | ||
RT-induced changes in the severity of skin redness, itching, hotness, tenderness, flaking, tightness, throbbing, and bumpiness were examined in each RT site subgroup. Significant increases were observed in specific skin symptoms only in patients receiving RT to the breast when using the Holm-Bonferroni method for multiple comparisons. Patients receiving RT to the breast reported significant increases in skin redness (mean change = 2.17, 95 CI = 1.30, 3.05, p = 0.0002), itching (mean change = 1.88, 95% CI = 1.11, 2.65, p = 0.0002), hotness (mean change = 1.47, 95% CI = 0.58, 2.36, p =0.004), tenderness (mean change 1.25, 95% CI = 0.54, 1.96, p = 0.002), flaking (mean change = 1.31, 95% CI = 0.65, 2.00, p = 0.002), throbbing (mean change = 0.94, 95% CI = 0.41, 1.47, p = 0.004), tightness (mean change = 0.81, 95% CI = 0.25, 1.37, p = 0.014), and bumpiness (mean change = 0.94, 95% CI = 0.25, 1.63, p = 0.014). Patients receiving RT to the head/neck/brain region did not report significant increases in any individual skin symptom (Table 3).
Table 3.
Changes in skin symptoms at the treatment site after radiation therapy in patients receiving RT to the breast of head/neck/brain region.
| Skin symptom | Breast RT | Head/Neck/Brain RT | Holm-Bonferroni adjusted p-value | ||
|---|---|---|---|---|---|
| Mean change [95% CI] | p-value | Mean change [95% CI] | p-value | ||
| Redness | 2.18 [1.3, 3.05] | 0.0002* | 1.31 [0.45, 2.14] | 0.016 | 0.0065 |
| Itching | 1.88 [0.36, 2.65] | 0.0002* | 1.08 [−0.01, 2.17] | 0.125 | 0.007 |
| Flaky | 1.32 [0.65, 1.98] | 0.002* | 1.08 [0.24, 1.91] | 0.047 | 0.013 |
| Tenderness | 1.25 [0.53, 1.97] | 0.002* | 0.45 [0.09, 2.08] | 0.063 | 0.01 |
| Hot | 1.47 [0.42, 2.36] | 0.004* | 0.82 [−0.02, 1.66] | 0.125 | 0.008 |
| Throbbing | 0.94 [0.41, 1.47] | 0.004* | 0.54 [−0.27, 1.36] | 0.250 | 0.025 |
| Tightness | 0.81 [0.26,1.37] | 0.014* | 0.36 [−0.09, 0.82] | 0.250 | 0.016 |
| Bumpy | 0.94 [0.25, 1.63] | 0.014* | 0.58 [[−0.33, 1.5] | 0.250 | 0.05 |
MLR analysis demonstrated that the severity of skin redness (p < 0.0001), itching (p=0.0009), and tenderness (p=0.013) significantly correlated with the reported severity of “skin problems at treatment site” (adjusted R2=0.776). Although no skin symptoms were significantly correlated with pain at the treatment site, the severity of skin tenderness (p = 0.07) and tightness/splitting (p = 0.12) showed trending associations with the severity of pain at the treatment site (adjusted R2=0.457) (Table 4). These data suggest that specific skin symptoms may be linked to patients’ reported pain at their radiation treatment site.
Table 4.
Multiple linear regression analysis of skin symptom characteristics associated with skin problems and pain.
| Skin Problems | Pain | |||
|---|---|---|---|---|
| Skin description | b [95% CI] | p-value | b [95% CI] | p-value |
| Redness | 0.379 [0.200, 0.556] | <0.0001 | −0.117 [−0.388, 0.154] | 0.393 |
| Itching | 0.287 [0.122, 0.452] | 0.0009 | 0.021 [−0.237, 0.278] | 0.874 |
| Hotness | 0.030 [−0.175, 0.236] | 0.769 | 0.086 [−0.222, 0.395] | 0.581 |
| Tenderness | 0.300 [0.065, 0.535] | 0.013 | 0.336 [−0.022, 0.695] | 0.066 |
| Throbbing | −0.230 [−0.486, 0.031] | 0.062 | 0.132 [−0.260, 0.525] | 0.504 |
| Flaking | −0.007 [−0.492, 0.156] | 0.156 | 0.134 [−0.112, 0.380] | 0.281 |
| Bumpy | 0.118 [−0.051, 0.287] | 0.163 | 0.127 [−0.082, 0.683] | 0.324 |
| Tightness | 0.106 [−0.148, 0.360] | 0.408 | 0.301 [0.011, 0.689] | 0.122 |
| Adjusted R2 = 0.776, obs = 92 | Adjusted R2 = 0.441, obs = 90 | |||
3.3 Opioids prescribed during RT are inadequate
Patients who had an increase of ≥2 units of pain from before to after completion of their RT were more likely to have opioids prescribed during the course of RT than those with a pain increase <2 (42.9% vs. 15.2%, respectively, p<0.03) (data not shown). Despite the prescription of opioids to patients during RT, increased pain at the treatment site was reported by patients. These data suggest that opioid prescription is not sufficient to control pain associated with RT-induced skin reactions.
4. Discussion
Radiation-induced skin problems are among the most frequently reported side effects of cancer treatment. Approximately 10% of patients will experience moist desquamation and ulceration, which may result in treatment delays [17], decreased quality of life, and pain [4, 5]. These skin reactions are most common in breast, head and neck, lung cancer, and sarcoma patients [18, 19]. However, little research has specifically investigated the skin-associated pain experienced by patients receiving RT to each of these sites. In this study, only patients receiving RT to the breast reported significant RT-induced skin problems and pain at the treatment site. Patients receiving RT to the head/neck/brain region reported increased skin problems, but not pain at the treatment site. Of the symptoms investigated, tenderness and tightness/splitting of the skin were most closely associated with radiation-induced pain at the treatment site. Only patients receiving RT to the breast reported significant increases in individual skin symptoms, including tenderness and tightness.
The fact that patients receiving RT to the head/neck/brain region report increased severity of skin reactions, but not pain, suggests that the severity of skin reactions is not the only factor that is related to pain experienced with RT. Our data suggest that the RT site is an important predictive factor for RT-induced pain. MLR showed that while the total number of RT sessions and the site of RT (breast or head/neck/brain vs. other sites) predicted the severity of the skin problems, only RT of the breast predicted increased pain at the treatment site. These data demonstrate that it is important to evaluate both pain and skin problems when investigating interventions for radiation dermatitis and not to assume that pain will increase at the same rate for different RT sites as the severity of skin reactions increases. Future research should investigate if this disparity between RT-induced pain and skin problems exists when radiation dermatitis is evaluated objectively using a clinical skin toxicity scale.
The fact that the PSP is a non-validated survey instrument is a limitation of this study. However, the survey was developed with 8 pre-test iterations with feedback from a panel including two nurses, four physicians, five researchers, and one full time student prior to implementation for this study. The Chronbach’s alpha for all of the survey sections was above 0.9, supporting the internal validity of this new assessment tool. The PSP was adapted from two validated instruments, the MPQ-SF and the MDASI, which are self-report questionnaires for pain and symptom severity, as well as pain type. Our study demonstrated that the new PSP can identify changes in pain and skin problems in populations receiving RT to the breast and head/neck/brain regions. Further, trending associations between pain and specific skin symptoms were identified using this survey that would likely be significant in a larger sample size.
Currently, no instruments exist that simultaneously evaluate pain and skin problems in radiation dermatitis, highlighting the need for one such survey. Although the Skindex and the STAT tools are useful to assess acute radiation skin toxicity and which symptoms are most bothersome to patients, these tools do not incorporate pain assessment [9, 20]. Future research should confirm the external validity of this new measure in RT patients by administration with the Skindex, MPQ, and clinical skin toxicity scales. The combination of the clinical scoring scales and patient-report surveys would further support the validity and accuracy of our survey instrument and provide insight into which skin symptoms are most troublesome and painful for patients.
Recent trials testing interventions for radiation dermatitis have not assessed pain. For example, Schmuth et al examined the effects of a topical corticosteroid cream on radiation dermatitis. The cream did not prevent radiation dermatitis, but did reduce the severity of the skin reactions [20]. Unfortunately, the measures used in this trial (Skindex, SF-36) did not evaluate pain [20]. Neben-Wittich et al compared the Skindex-16, STAT, and NIH CTC-AE in a phase III clinical trial testing mometasone cream versus placebo for radiation dermatitis in breast cancer patients [21]. The patient-reported Skindex-16 and STAT did not correlate with the physician-reported NIH CTC-AE scores. The study concluded that the two patient-reported questionnaires provided additional information about the skin reaction that was not captured by the clinical rating.
While these studies provide insight the complicated nature of assessing skin reactions and quality of life, none of these studies explored radiation skin toxicity in the context of pain or pain type. Bostrom et al did assess skin toxicity, skin symptoms and pain in breast cancer patients receiving mometasone cream or placebo [22]. The study asked patients to rate the severity of itching, burning, and pain on a 0 to 10 scale. No statistically significant differences were observed in these symptoms between groups [22]. However, itching and burning are not the only symptoms descriptors for radiation dermatitis. Our PSP incorporates commonly reported symptoms of radiation dermatitis, based on MPQ-SF, such as hot-burning, tightness, tenderness, throbbing, in addition to itching and pain. Thus, we expect the PSP to provide another dimension to the subjective assessment of pain and skin problems in patients receiving RT and insight into effective amelioration of skin problems and skin-associated pain.
Other limitations of this study include its exploratory nature and relatively small sample size. Although the associations between tenderness and tightness/splitting with pain at the treatment site were at least two times larger in magnitude than next strongest association of the other skin symptoms with pain, the associations between tenderness and tightness/splitting with pain were trending, but not significant (p = 0.07 and p = 0.12, respectively), even though the model accounted for 44% of the variance. This is likely due to the relatively small sample size for a model with eight independent variables. This study needs to be repeated with a larger sample and a priori hypotheses to confirm these trending associations.
Although the overall response rate (72%) is acceptable for a longitudinal survey in cancer patients [23–25], another limitation of this study is the post-treatment survey non-response rate (28%). The distribution of RT sites, total radiation dose, and total number of radiation treatments were similar between patients that completed only the first survey and those that completed both surveys (p > 0.15). Since radiation dose and RT site were the characteristics associated with severity of pain and skin reactions but were similar between completers and non-completers of the second survey, we estimate a low level of non-response bias from missing data. A higher percentage of patients with advanced cancer completed only the first survey compared to both surveys (71% vs. 48%, p = 0.009). Other research has also shown that survey response rates are lower in metastatic cancer patients [23, 25]. However, cancer severity was not associated with pain or skin problems, and therefore not likely to contribute to non-response bias either. Possible differences in unmeasured characteristics associated with pain and skin problems can always cause non-response bias, which should be considered when interpreting these results.
Although patients were asked to think about their pain and skin problems on the last day of their RT treatment, they were allowed to complete the survey up to one month after RT completion. The ability to detect a difference between pre-RT and post-RT pain and skin problems is limited by the error induced by this protocol flexibility. Thus, statistical differences in groups other than breast and head/neck/brain may have been missed. Nevertheless, the fact that differences were detected in the breast and head/neck/brain groups in spite of this error suggests that these groups are important research targets for RT-induced pain and skin reactions. This is especially true considering ANOVA showed similar elapsed time between RT and post survey across groups (mean time elapsed = 6.8 days, p = 0.3) and therefore, we expect similar magnitudes of error across groups. Further, Brauer et al has reported that retrospective reports on pain severity are extremely reliable for up to three months after the time of event [26]. Our results suggest possible therapeutics for painful radiation dermatitis should be investigated in patients receiving RT to the breast; however, a larger study with equal representation of RT sites could reveal other important target populations.
The fact that tenderness and tightness are the symptoms most closely associated with pain suggests that future studies should investigate topical interventions with analgesic and moisturizing components for radiation-induced skin damage. Graham et al. [7] found that a No-sting barrier film, which increases moisture at the treatment site, reduced incidence and duration of moist desquamation, but did not improve pain or itching. This study suggests that moisturizing alone is not sufficient to control the pain and itching associated with radiation therapy, which supports the concept of a combined topical with moisturizing and analgesic properties.
The need for a novel treatment to control RT-induced pain is highlighted by the fact that prescription opioids did not control RT-induced pain. Patients with the largest increase in pain between pre- and post-RT were more likely to be prescribed opioids during treatment, suggesting that clinicians and patients are attempting to control the pain, but that opioids are insufficient. The interpretation of these results is limited by the fact that the chart review method cannot determine if patients actually took the prescribed opioids. Future prospective studies that monitor type, dose, and compliance with prescribed pain medications would clarify some of these questions. Regardless of whether the opioids were taken or not, this research suggests that prescription of these medications is not sufficient to control pain associated with RT-induced skin reactions. Research regarding new interventions tailored toward skin tenderness and tightness, which showed trending associations with pain at the treatment site, is warranted. Topical applications specifically would be advantageous to avoid opioid-associated systemic side effects, which could prevent patients from taking recommended doses.
4.1 Conclusion
This study provides insight into the difficulty of assessing and treating radiation-induced pain and skin problems in cancer patients. It highlights the importance of assessing pain and skin reactions simultaneously and targeting pain specifically, not only by attempting to decrease skin reactions. Specific RT-induced skin symptoms that correlate with increases in patient-reported pain provide possible avenues for targeted interventions. More information on radiation-induced pain and skin problems is clearly needed. These findings support future studies using the new PSP to address uncontrolled radiation-induced pain and skin reactions, as well as targeted therapies to ameliorate these side effects.
Acknowledgments
Funding Source The National Cancer Institute (R25CA10618 and U10CA37420). The funding source played no role in the study design; collection, analysis, and interpretation of the data; writing the report; or the decision to submit the manuscript.
We thank the patients for their time. A special thanks goes to Kassie Haitz, Prianca Naik, and Shilpa Cheela for their work with recruiting patients.
Abbreviations
- b
Beta
- CI
Confidence interval
- GI
Gastrointestinal
- MDASI
MD Anderson Symptom Inventory
- MLR
Multiple linear regression
- MPQ-SF
McGill Pain Questionnaire-Short Form
- NIH CTCAE
National Institutes of Health Common Toxicity Criteria-Adverse Event
- NRS
Numeric rating scale
- PSP
Pain and Skin Problem Survey
- RDS
Radiation Dermatitis Severity Scale
- RT
Radiation therapy
- RTOG/EORTC
Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer
- STAT
Skin Toxicity Assessment Tool
- Txt
Treatment
Footnotes
Conflicts The authors have no conflicts to report.
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