NEW ORLEANS – Skin conditions in cancer patients often are serious enough to result in a reduction or discontinuation of chemotherapy or radiation treatments, and yet only a small number of oncologists routinely refer their patients to dermatologists, said Dr. Mario E. Lacouture of Memorial Sloan-Kettering Cancer Center in New York.
Dr. Lacouture added that the skin conditions can severely impact patients’ quality of life and even lead to a worsening of their disease. "In a sense, the skin becomes an innocent bystander to cancer, with far-reaching psychosocial, physical, and financial implications for patients," he said at a press briefing during the annual meeting of the American Academy of Dermatology.
About 1.5 million Americans are diagnosed with cancer each year, and there are some 10.5 million survivors. About 900,000 of those diagnosed will undergo chemotherapy and 700,000 will get radiation, said Dr. Lacouture. Before starting, some 45% have pre-existing skin conditions, such as skin infections, severe dry skin, or itchy skin, he said. Chemotherapy suppresses the immune system and prevents normal cell growth, which can aggravate these underlying conditions.
He estimated that half of patients will develop a treatable skin, nail, or hair condition. Among those most commonly seen are acneiform rash, mouth sores, nail changes, dry skin, itching, hair problems, and hand-foot syndrome.
And yet, only about 8% of oncologists refer their patients to a dermatologist, Dr. Lacouture said in an interview after the briefing.
These side effects are burdensome because they can make the cancer visible to others, which is upsetting to patients, said Dr. Lacouture. Treatments for the skin conditions can be expensive and might not be covered by insurance. And once the skin barrier is broken, it creates a greater susceptibility to infection. The skin conditions also can affect a patient’s ability to sleep or function, thereby lessening quality of life.
Most importantly, oncologists might stop or decrease the chemotherapy dose, Dr. Lacouture said. A survey he and colleagues conducted a few years ago found that two-thirds of oncologists modify chemotherapy regimens and up to a third will stop because of certain dermatologic side effects, he said.
Patients also have been surveyed. In a study by Dr. Lacouture and his colleagues, 379 cancer patients were asked about side effects (Support. Care Cancer 2010;11:1461-8). Skin irritation and dry skin were listed as present by as many people as had difficulty with diarrhea, insomnia, and fatigue. Almost half the patients said that dry skin and skin irritation had a negative impact – more than for any other side effect.
Targeted therapies have not decreased the incidence of dermatologic conditions, said Dr. Lacouture. For instance, 70%-90% of patients taking cetuximab, erlotinib, and panitumumab experience an acneiform rash, he said.
Sloan-Kettering has begun an interdisciplinary program – the Skin and Eye Reactions to Inhibitors of EGFRs and Kinases Clinic – to treat these patients rapidly, as soon as the day or the day after they present with the side effects.
When cancer patients present with side effects, "they cannot wait for several weeks to be seen because it’s imperative that they continue their treatment," said Dr. Lacouture.
But the goal now is to keep the patients from having to be referred. Many are given a prophylactic regimen of moisturizers, sunscreen, topical steroid cream, and doxycycline before they are started on a targeted therapy. The regimen was tested in the STEPP (Skin Toxicity Evaluation Protocol With Panitumumab) trial led by Dr. Lacouture (J. Clin. Oncol. 2010;28:1351-7).
Taxanes, used for breast, lung, head and neck, and prostate cancer, can cause inflammation, leading the nails to fall off. This affects up to 80% of patients taking the taxanes, he said. At Sloan-Kettering, patients are given cold pack gloves and slippers during infusion to prevent the side effect.
Many cancer institutions have adopted programs similar to those at Sloan-Kettering to reduce these dermatologic side effects, said Dr. Lacouture.
Dr. Lacouture reported that he has received honoraria from, or been a consultant or speaker with, Amgen, Bayer Pharmaceuticals, Bristol-Myers Squibb, Exelixis, Genentech, Hana Biosciences (now Talon Therapeutics), GlaxoSmithKline, ImClone, Lindi Skin, Onyx Pharmaceuticals, OSI Pharmaceuticals Inc., Pfizer, Roche, and Sanofi-Aventis.