The breast advice for managing radiotherapy induced skin reactions

Transcription

1 15/05/2016 The breast advice for managing radiotherapy induced skin reactions Margaret Hjorth Nurse Unit Manager Epworth Radiation Oncology 1

2 15/05/2016 What is Radiotherapy? Use of high energy radiation to kill cancer cells or injure them so that they cannot multiply and grow The Aim Measured dose of radiation, delivered directly to the tumour whilst minimising injury to surrounding healthy tissue The Goal Balance between cancer cell kill and minimal damage to normal cells 2

3 Healthy skin regeneration Two layers Epidermis (Superficial layer) The epidermis protects against major environmental stresses, such as water loss and microorganism infection Dermis (Deep layer) Supportive structure Homeostasis achieved through process of desquamation and repopulation Epidermal repopulation takes approx. 4 weeks 3

4 Mechanism of action Radiotherapy utilizes radiation to kill cells via DNA damage in two ways: Direct Indirect 4

5 Effects of radiotherapy on the epidermis Basal layer High rate cell division = Cells are highly radiosensitive Repopulation impeded Skin integrity altered skin reaction occurs

6 Differences between a radiation induced skin reaction and a burn injury (adapted from Trueman and The Princess Royal Radiotherapy Review Team, 2011) Cause Radiation induced skin reaction Absorption of energy from ionizing radiation affects the process of regeneration Burn injury Trauma e.g. fire, hot liquids, corrosive chemicals, electrical current Time to reaction Delayed (days) Immediate (minutes) Skin layers affected Sequence of damage Epidermal layers Damaged basal cells migrate upwards towards surface of skin All layers can be affected (superficial to full-thickness burns) Damage occurs downwards from surface of skin in relation to degree and depth of burn 6

7 Skin reaction cycle Radiotherapy commences Activates inflammatory response Radiotherapy completed. Severity can increase for first 7-10 days days from first # - damaged basal cells migrate to surface (erythema) > 3 weeks Lack of new cells to replace dead cells (moist desquamation) 2 3 weeks Further skin changes due to new cells reproducing before dead cells shed (dry desquamation) 7

8 Long term skin changes Pigmentation changes Decreased tissue flexibility Telangiectasia Impaired wound healing 8

9 Pre-treatment Aim of skin care strategy Minimize radiotherapy induced skin reactions Promote and maintain comfort The strategy includes: Accurate, timely information Patient involvement Patient education Comfort Psychological support 9

10 Erythema - (Grade 1) Damage to basal layer of epidermis = inflammatory response Red & warm Itchiness Discomfort Tightness Severity Faint & dull Bright & tender 20 Gy 10

11 Management goals Promote hydrated skin Patient comfort Maintain skin integrity Itchy skin Reduce pain, soreness and discomfort 11

12 Dry desquamation (Grade 2 ) Increased rate of production of new skin cells (mitotic activity) = new skin cells produced faster that the old skin cells are shed Dry Flaky Scaly Damage to sweat and sebaceous glands in the dermis 30 Gy 12

13 Management goals Promote hydrated skin Patient comfort Maintain skin integrity Itchy skin Reduce pain, soreness and discomfort 13

14 Moist desquamation (Grade 3) Stem cells in basal layer affected = impaired ability to produce new cells to replace damaged cells Blisters Moist Oedematous Partial or widespread(confluent) Painful Tender Sensitive 40Gy 14

15 Management goals Promote comfort Reduce risk of infection/further trauma Reduce pain, soreness and discomfort Dressings Moist Simple Comfort Tailored Non-adhesive Frequent Cost effective 15

16 Factors influencing the severity of skin reactions Intrinsic factors: Nutritional status Smoking Co-existing disease Age Extrinsic factors: Dose & volume Size and location Fractionation Treatment technique 16

17 Consequences for patients Physical Discomfort Pain Changes in sensation Itchiness, sensitivity, tightness, heat Psychological/Social Activities of daily living Body image Stress/anxiety Work & social activities Treatment break 17

18 Assessment Baseline Change in patient status Regular intervals Consistent Timely Patient reported impact Assessment tools Validated Reliable Structured 18

19 Case study 63 years Presentation Redness tightness left breast Palpable lymph node left neck Large palpable axillary lymph node CT Confirmed loco regional disease Excluded distant metastatic disease Bone scan Clear 19

20 Biopsy Gr 3 invasive carcinoma of no specific type. ER+ 90%, PR+ 10%, HER-2- Lymph node biopsy also confirmed malignant disease. Diagnosis extensive, locally advanced left breast cancer enlarged palpable nodes in the axilla, left supraclavicular fossa and left posterior triangle 20

21 Treatment Neo-adjuvant chemotherapy AC x 6 cycles Left mastectomy Clear margins LVSI was present and extensive. Associated DCIS Left axillary node dissection 4 macro mets (largest 12mm) 3 micro mets 21

22 Treatment Adjuvant Radiotherapy left chest wall, left axilla, left supraclavicular fossa and left cervical chain up to the level of the mastoid. Clinical examination Left mastectomy scar healing well Overlying skin healthy and intact No concerning lesions Excellent range of movement of left shoulder No lymphedema present No palpable disease in the supraclav or left neck 22

23 Past history Osteoporosis, osteoarthritis, No past history of radiotherapy. Medications Panadol Osteo, Vitamin D, Celebrex. Allergies No known allergies. 23

24 Radiotherapy prescription L SCF & Axilla & L Chest Wall 60Gy/30# CT Planning 24

25 Completed treatment 04/04/16 Grade 1 Brisk erythema Skin intact Continue moisturiser 25

26 18/04/2016 (2 weeks post) Grade 2-3 Mixed dry areas/ moist areas 26

27 20/04/2016 Grade 3 Confluent moist desquamation 27

28 Dressing 28

29 22/04/2016 Grade 2-3 Mixed moist desquamation/healing 29

30 26/04/2016 (24 days post) Grade 2 Almost healed small patchy areas moist 30

31 04/05/16 (4 weeks post) Healed 31

32 15/05/2016 Overall goals of management Delay onset Minimize severity Reduce treatment related symptoms Prevent further damage Prevent complications Patient information 32

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34 References 1. Faithful, S. (2003). Suppoprtive care in radiotherapy. Radiation skin reactions (pp ). Edinbrhg: Churchill Livingstone Warnock, C., & Lee, N. (2014). Skin reactions from radiotherapy. Art & Science, 13 (9). Pp: Bostock, S., & Bryan, J. (2016). Radiotherapy-induced skin reactions: assessment and management. British Journal of Nursing, 25 (4). Pp: The Society and College of Radiographers (2015). Skin care advice for patients undergoing radical external beam megavoltage radiotherapy. (accessed 26 April, 2016) 5. Trueman, E. (2015). Management of radiotherapy-induced skin reactions. Journal of Palliative Nursing., 21 (4) pp: