Mannix, C.M., Bartholomay, M.M., Doherty, C.S., Lewis, M., & Bilodeau, M.L. (2012). A feasibility study of low-cost, self-administered skin care interventions in patients with head and neck cancer receiving chemoradiation. Clinical Journal of Oncology Nursing, 16(3), 278–285. 

DOI Link

Study Purpose

To evaluate a low-cost, patient-administered skin care regimen for minimizing skin toxicities in patients with head and neck cancer receiving chemoradiation

Intervention Characteristics/Basic Study Process

A skin care algorithm was created that included a radiation dermatitis assessment (subjective and objective data and pertinent medical history); a skin toxicity grading; and the management of skin toxicities based on patients' grades. Patients were given laminated cards with specific skin care instructions and were provided with verbal instructions. Teaching included: wash daily with mild soap (e.g., Dove) and warm water TID; be gentle (do not scrub); pat skin dry; apply Aveeno® moisturizer to skin in treated area; do not apply lotions within four hours of radiation treatment; keep skin moist; keep well hydrated; maximize nutrition; provide loose clothing; avoid friction; and protect skin from sun (e.g., sunscreen with SPF 30 and lip balm with sunscreen). For skin toxicities of grade 2 or higher, a consult was made to a clinical nurse specialist with consideration for a consult to a burn clinic for alternative skin products. Data were collected at baseline and at weekly intervals. At least three clinicians reviewed and compared both the National Cancer Institute (NCI) grades and digital photographs to reach 100% inter-rater agreement.

Sample Characteristics

  • N = 100
  • MEAN AGE = 57 years
  • MALES: 87%, FEMALES: 13%
  • KEY DISEASE CHARACTERISTICS: Patients with head and neck malignancies receiving concurrent chemoradiation
  • OTHER KEY SAMPLE CHARACTERISTICS: Eligibility criteria included patient age of 21-years-old or older. The subjects were all English-speaking and had a mean of 15 years of education. 64% were married, 82% were Caucasian, 55% were former smokers, and 69% used ethanol at the time of the trial. Most subjects (90/100) received chemotherapy and/or biotherapy regimens, including carboplatin and paclitaxel (34%), carboplatin and etoposide (21%), and carboplatin (17%). Only 4% of the subjects received a carboplatin, paclitaxel, and panitumumab regimen. Most of the subjects (90/100) received radiation treatment regimens including photon (67%), proton (12%), and photon and proton (11%).

Setting

  • SITE: Single-site  
  • SETTING TYPE: Outpatient  
  • LOCATION: Boston, MA

Phase of Care and Clinical Applications

  • PHASE OF CARE: Active antitumor treatment
  • APPLICATIONS: Elder care 

Study Design

Prospective, descriptive study design

Measurement Instruments/Methods

Investigators developed a demographic data collection form and a weekly skin care diary. Skin grading was assessed using the NCI Common Terminology Criteria for Adverse Events (CTCAE v3.0) grading scale for dermatitis associated with chemoradiation.

Results

In week 6, 93% of subjects (n = 89) had NCI grades of 0–2 (mean grade = 1.74). During week 7, 81% of patients (n = 74) had NCI grades of 0–2 (mean grade = 1.93). 
 
The correlation between radiation dose and NCI grade was significant at week 6 (p = 0.003) and was small and insignificant at week 7. This may be related to the smaller number of patients being treated in week 7.   
 
There was a consistently high adherence to washing and moisturizing throughout the subjects' course of treatment with a greater than 80% adherence rate in weeks 6 and 7. Less grade 2 and grade 3 skin toxicities were noted in the adherent group (63% and 4.4%, respectively) as compared to the non-adherent group (74% and 11%, respectively). Due to the high number of subjects who adhered throughout treatment and the low number of subjects in the non-adherent group, no statistical significance was noted between levels of adherence in relation to NCI skin grades in weeks 6 or 7.  

Conclusions

The verbal instructions and laminated skin care instructions provided to the subjects in this study proved to be an affordable regimen to which patients could easily adhere. These interventions, combined with increased patient–provider interaction at weekly assessments, most likely contributed to the high level of adherence.

Limitations

  • Risk of bias (no control group) 
  • Risk of bias (sample characteristics)
  • Unintended interventions or applicable interventions that would influence results not described 
  • Key sample group differences that could influence results
  • Selective outcomes reporting
  • Other limitations/explanation: Products were provided to patients free of charge; this may have increased patient adherence. Some patients reported using other moisturizing products, which may have influenced outcomes.

Nursing Implications

Nurses can promote positive patient outcomes through proactive patient education, the early initiation of a skin care regimen, and the ongoing reinforcement of skin care interventions that may be beneficial in minimizing skin toxicities. Empowering patients to become active participants in their care may also contribute to positive outcomes. It is within nursing scope-of-practice to provide educational cards to patients for education and to promote skin care during treatment.