Review Article

Skin Toxicity During Breast Irradiation: Pathophysiology and Management

Authors: Jennifer L. Harper, MD, Lynette E. Franklin, MSN, Joseph M. Jenrette, MD, Eric G. Aguero, MD

Abstract

Radiotherapy is a critical component in the treatment of breast cancer, a disease that is estimated to have affected 203,500 US women in 2002. According to the data from some series, an estimated 90% of patients treated with radiotherapy for breast cancer will develop a degree of radiation-induced dermatitis. This review describes the indications and techniques of radiotherapy for breast cancer. The pathophysiology, clinical presentation, and contributing factors of radiation-related skin injury are discussed. A review of recent clinical research addressing skin toxicity is provided.


Key Points


* Radiotherapy is a modality commonly incorporated in breast cancer therapy.


* Radiation-related skin injury frequently occurs, and is related to both treatment and patient factors.


* While there is a paucity of data to support the prophylactic use of topical agents during therapy, advances in radiation techniques hold promise for preventing severe injury.

This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Jemal A, Thomas A, Murray T, et al. Cancer statistics, 2002. CA Cancer J Clin 2002;52:23–47.
 
2. Fisher B, Anderson S, Bryant J, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer.N Engl J Med 2002;347:1233–1241.
 
3. Overgaard M, Hansen PS, Overgaard J, et al. Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy. Danish Breast Cancer Cooperative Group 82b Trial. N Engl J Med 1997;337:949–955.
 
4. Ragaz J, Jackson SM, Le N, et al. Adjuvant radiotherapy and chemotherapy in node-positive premenopausal women with breast cancer. N Engl J Med 1997;337:956–962.
 
5. Shimm D. The skin, in Cox J (ed): Moss’ Radiation Oncology: Rational, Techniques, Results. St. Louis, Mosby-Year Book, 1994, ed 7, pp 99–118.
 
6. Velkley DE, Manson DJ, Purdy JA, et al. Buildup region of megavoltage photon radiation sources.Medical Physics 1975;2:14–19.
 
7. Porock D, Kristjanson L. Skin reactions during radiotherapy for breast cancer: the use and impact of topical agents and dressings. Eur J Cancer Care (Engl) 1999;8:143–153.
 
8. Mettler F. Medical Effects of Ionizing Radiation. Philadelphia, W.B. Saunders Co., 1995, ed 2.
 
9. Bentzen SM, Turesson I, Thames HD. Fractionation sensitivity and latency of telangiectasia after postmastectomy radiotherapy: a graded-response analysis. Radiother Oncol 1990;18:95–106.
 
10. Porock D, Kristjanson L, Nikoletti S, et al. Predicting the severity of radiation skin reactions in women with breast cancer. Oncol Nurs Forum 1998;25:1019–1029.
 
11. Iannuzzi CM, Atencio DP, Green S, et al. ATM mutations in female breast cancer patients predict for an increase in radiation-induced late effects. Int J Radiat Oncol Biol Phys 2002;52:606–613.
 
12. Swift M, Morrell D, Cromartie E, et al. The incidence and gene frequency of ataxia-telangiectasia in the United States. Am J Hum Genet 1986;39:573–583.
 
13. Swift M, Morrell D, Massey RB, et al. Incidence of cancer in 161 families affected by ataxia-telangiectasia. N Engl J Med 1991;325:1831–1836.
 
14. Jackson W. Surface effect of high-energy x-rays at oblique angles. Br J Radiol 1971;44:109–115.
 
15. Archambeau J. Relative radiation sensitivity in the integumentary system dose response of the epidermal, microvascular, and dermal populations, in Lett J (ed): Advances in Radiation Biology Vol 12. San Diego, Academic Press, 1987, pp 147–203.
 
16. Archambeau JO, Pezner R, Wasserman T. Pathophysiology of irradiated skin and breast. Int J Radiat Oncol Biol Phys 1995;31:1171–1185.
 
17. Kupper TS. The activated keratinocyte: a model for inducible cytokine production by non-bone marrow-derived cells in cutaneous inflammatory and immune responses. J Invest Dermatol1990;94:146S–150S.
 
18. Hopewell JW. The skin: its structure and response to ionizing radiation. Int J Radiat Biol1990;57:751–773.
 
19. Canney PA, Dean S. Transforming growth factor beta: a promotor of late connective tissue injury following radiotherapy? Br J Radiol 1990;63:620–623.
 
20. Fisher J, Scott C, Stevens R, et al. Randomized phase III study comparing best supportive care to Biafine as a prophylactic agent for radiation-induced skin toxicity for women undergoing breast irradiation: Radiation Therapy Oncology Group (RTOG) 97–13. Int J Radiat Oncol Biol Phys2000;48:1307–1310.
 
21. Roy I, Fortin A, Larochelle M. The impact of skin washing with water and soap during breast irradiation: a randomized study. Radiother Oncol 2001;58:333–339.
 
22. Williams MS, Burk M, Loprinzi CL, et al. Phase III double-blind evaluation of an aloe vera gel as a prophylactic agent for radiation-induced skin toxicity. Int J Radiat Oncol Biol Phys 1996;36:345–349.
 
23. Spitalier J, Amalric M. Value of Biafine in the prevention and treatment of skin reactions following radiotherapy. 1973. Located at: Centre Regional Delutte Centre Le Cancer, Marsille, France, submitted for publication.
 
24. Coulomb B, Friteau L, Dubertret L. Biafine applied on human epidermal wounds is chemotactic for macrophages and increases the IL-1/IL-6 ratio. Skin Pharmacol 1997;10:281–287.
 
25. Beetz A, Messer G, Oppel T, et al. Induction of interleukin 6 by ionizing radiation in a human epithelial cell line: control by corticosteroids. Int J Radiat Biol 1997;72:33–43.
 
26. Bostrom A, Lindman H, Swartling C, et al. Potent corticosteroid cream (mometasone furoate) significantly reduces acute radiation dermatitis: results from a double-blind, randomized study.Radiother Oncol 2001;59:257–265.
 
27. Aref A, Thornton D, Youssef E, et al. Dosimetric improvements following 3D planning of tangential breast irradiation. Int J Radiat Oncol Biol Phys 2000;48:1569–1574.
 
28. Kestin LL, Sharpe MB, Frazier RC, et al. Intensity modulation to improve dose uniformity with tangential breast radiotherapy: initial clinical experience. Int J Radiat Oncol Biol Phys 2000;48:1559–1568.
 
29. Winter G. Formation of the scab and the rate of epithelialization of superficial wounds in the skin of the domestic pig. Nature 1962;193:293–294.
 
30. Mak SS, Molassiotis A, Wan WM, et al. The effects of hydrocolloid dressing and gentian violet on radiation-induced moist desquamation wound healing. Cancer Nurs 2000;23:220–229.