Two Novel Treatments for the Prevention and Treatment of ...• The wound cleansing properties of...
Transcript of Two Novel Treatments for the Prevention and Treatment of ...• The wound cleansing properties of...
Introduction
• Askincareworkingpartywassetuptoproduceevidencebasedpracticeskincareguidelines,includingrecommendationsforthetreatmentandpreventionofmoistdesquamation.Anauditof259patientsin2008revealedthat7%ofpatientsdevelopedmoistdesquamation.
• Aliteraturesearchbymembersoftheskincareworkingpartyfoundseveralstudieslookingatthepreventionofskinreactions1-6.Oneofthesestudieslookedintotheuseofcavilonnostingbarrierfilm(CNSBF)inpostmastectomytreatments6.TheresultsfromthestudysuggestedthattheuseofCNSBFcouldreducetheincidenceofmoistdesquamationinthisgroupofpatients.Anin-houseauditwasdevisedtoassesstheeffectivenessofCNSBFinotherpatientgroups.
• Numerousstudieshavepreviouslylookedatthetreatmentofmoistdesquamation7-11.Noonetreatmentinterventionhasbeenprovensuperiortoanyother9.
• Howeverourexistingclinicalpracticeneededupdatingtofollowbestpracticemoistwoundhealingprinciples.
• PolyMemdressingwaschosenandassessedforitsefficacyinthetreatmentofmoistdesquamation.Itsappealingpropertiesincludedodourreduction,nonadherence,absorbency,woundcleansingaswellashealingandpainrelief.
Methods and Materials
• 40patientswereidentifiedathighriskofdevelopingfrictionrelatedmoistdesquamation(RTOGscore2bandabove)usingtheresultsgainedfromthepreviousaudit(seetable1).
• These40patientsweregivenCNSBFtoapplyduringtheirtreatment.Theapplicationstartedtwiceweekly.OnceRTOG2bwasreached,theapplicationswereincreasedtoeveryotherday.TheirRTOGscorewasinitiallyrecordedweekly,thenincreasedtotwiceweeklyonce2bwasreached.Eachpatientwasissuedwitha28mLspraybottleandgivenverbalinstructionsforuse.
• 20patientswhodevelopedRTOG2bweregivenPolyMemdressingsappliedasperthemanufacturersinstructionsandtheirRTOGscorerecordedtwiceweekly.TheirpainscorewasrecordedbeforeandafterapplicationusingthefollowingadaptedpainmeasurementscalebyMcCaffreyandBeebe(1989)assuppliedbyActivaHealthcareLtd.
Table 1: Patient groups identified as being at high risk of developing RTOG 2b skin reactions
Results - CNSBF
• Ofthe40patientsidentifiedasbeingathighrisk,17(42.5%)patientsdevelopedstage2borgreaterskinreactions,3oftheselaterdevelopedstage3andnoneofthepatientsinthestudydevelopedstage4(Graph1).
• Stage2bwasnotobservedinanyofthecasesuntilweek3.Table2showsasummaryoftheweeklyskinreactionsover2bobservedindifferentpatientgroupsincludingriskfactorsassociatedwiththesepatients.8ofthesepatientswentfrom0to2binthespaceofaweek,3from1to2band2from2ato3.
• TheRadiographersobservedamarkedimprovementintheskinreactionsgenerallyandinparticularforpatientstreatedforanalcarcinomathatusedCNSBFwherethe2bareatendedtobelimitedtotheperinealregion.Intwoanalcarcinomapatientstheirgroinandgenitalareasweremissedintheapplicationprocess,stage2bwasreachedatweek3intheseareas,comparedtoweek5fortheperineum.
• Someskinreactionsdidnotfollowtheusualgradualprogressionthroughstage1,2a,2b,andinsteadwentstraightto2aor2b.
• TwopatientsreportedasensitivitytoCNSBF-amilderythematousrashdevelopedintheapplicationareaearlyoninthestudy-thereforeallpatientsweretestedforsensitivityoutsidethetreatmentarea24hoursbeforeCNSBFwasapplied,afurther2patientssubsequentlyshowedsensitivityreactionsandwereexcludedfromthestudy.
Table 2:- RTOG weekly score
PolyMem
• Ofthe17patientsreachingstage2b+intheCNSBFaudit,11weregivenPolyMemtouse(onepatientwasnoncompliantandasecondpatientdidnotlikethedressingandthereforedidnotuseit.TheremainingpatientsweregivengentianviolettoapplybytheclinicianbeforePolyMemcouldbeused).
• Atotalof20patientsweregiventhedressing.Table3showsatwhichRTOGscorePolyMemdressingswereinstigatedandtowhichsites.
• PolyMemwasgenerallyusedafterthepatienthadreceivedaminimumof20Gy.
• PolyMemwasfoundtohavereducedpainscoresbetween1and4pointsin14ofthe19patientsstudied.WilcoxonSignedRanksTestshowedthatthisisasignificantreduction(p<0.001).
Table 3:- RTOG score and number of patients* issued withnPolyMem dressing(*NBsomepatientsusedthedressinginmultiplesites)
Discussion
• Fromtheresultsofthestudythereappearstobeadelayinthepresentationofacuteskinreactions.Thisishighlightedintwoanalcarcinomapatientswherestage2bwasreachedinareasmissedbytheCNSBFapplication2weeksbeforetheareasthathadCNSBFapplied.
• 57.5%ofhighriskpatientsdidnotreachtheexpected2bskinreactionsnegatingtheneedforfurtherinterventions,overallthismayreducethecostintreatingthesepatientsskinreactionslongtermaswellasimprovingoverallcosmeticresultsandthepatientsexperienceoftreatment.
• Weareunabletoofferanexplanationastowhytheskinreactionsappearedtomissstagesofreactions.
• InitiallypatientswereaskedtoapplytheCNSBFthemselves,howeverRadiographersnotedabettercoverageandconsequentlyabetterreactioniftheCNSBFwasappliedbyRadiographers,thisalsoencouragedRadiographerstoassesstheskinreactionmorefrequentlyandinterveneearlierwithPolyMem.
• Theapplicationprocesstakes30secondsandduetothesmallnumberofpatientsrequiringapplication,thishasnooverallimpactontreatmentunitthroughput.
• InsomepatientstherewasabuildupofCNSBFwhenthepatientwasunabletoadequatelywashthetreatmentareaalthoughthisdidnotappeartoeffecttheoverallresults.OnebreastpatientstoppedusingCNSBFasherperfusesweatingcausedabuildupoffluidbeneaththefilmcausingdiscomfort.
PolyMem
• Thereisasignificantpainreductionformanypatients.Thisisduetoaninhibitionbythepolymericmembraneofthedressingonthenociceptorreaction,whichhasalsobeenproventoreduceinflammation,bruisingandoedema13,14onbothbrokenandintactskin.
• Thewoundcleansingpropertiesofthedressingensuredthattheriskofinfectionwasreducedwhilethedressingwasinplaceaswellasensuringeaseofdressingchangesandthetimerequiredwasminimised.
• Woundhealingcommencedinsomepatientsevenwhilstcontinuingwithradiotherapytreatment.
• PolyMemalsoactedasananti-inflammatorywhenitwasinstigatedatstage2a,particularlyintheanal/perinealregion.
• Feedbackfrompatientswaspositive,fromeaseofusetopainandodourrelievingproperties.Nopatientsshowedsignsofsensitivity.
• Someareasstillremaindifficulttodressandensurethedressingissecuree.g.scrotal,vulvalregions.Oftenthiswaseffectivelymanagedbyencouragingpatientstousescrotalsupportsandnettolastpants.
Cost implications
(asperOctober2009NHSsuppliescatalogueprices)
• 1bottleofspray(£8.26)lastedfor4weeksofapplication(18patients).22patientsrequiredanotherbottle.
• Ofthese40patients,11receivedPolyMemdressings.Twosizeswereordered(10x61cmroll(£12.21perroll)and13x13cmdressings(£4.21perdressing)),bothdressingswerecuttosizeasrequiredandchangeddaily.Totalcostperpatientwasdependantonwhenthedressingwasissuedthemaximumcostforasinglepatientwasfor5rolls(£61.05).AsthedressingisfreelyavailableinthecommunityG.P.swereabletoprescribethedressingforthepatientsonceitseffectivenesswasestablishedwithonly1dressingneedingtobeissuedbythedepartment.
Conclusion
• DuetotheeffectivenessoftheCNSBFitisnowroutinelyappliedbyRadiographerstopre-identifiedhighriskpatients,howeverallpatientsaretestedforsensitivitypriortoitsapplication.
• CNSBFisalsousedtopreserveskinmarksrequiredforsuperficialx-rayandelectrontreatments.
• PolyMemisnowissuedbyRadiographerstoallpatientspresentingwith2bskinreaction.
• Inpatientsbeingtreatedforlowerrectal/analcancerstheauthorswouldrecommendtheinstigationofPolyMemat2askinreactions,particularlywhenthepatienthasaheavymucosaldischargeandthereforetheskinislikelytomacerateandbreakdown.
• FuturestudiesarewarrantedintheuseofCNSBFwherepatientsareusedastheirowncontroltofullyestablishCNSBFeffectivenessinthepreventionofacuteradiotherapyinducedmoistdesquamation.
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Treatmentsiteisintheanal-genitalareae.g.vulva,vagina,penis,scrotum,anus,groins
Radicallimbs
Obeseradicalpelvispatients(withskinfoldsintreatmentarea)
Breastpatientsneedingorfitimmobilisationbras
Radicalfaceandneckhavingconcurrentchemotherapyorbolus
Week Number
RTOG Score Diagnosis Risk factors
3 2b3xBreast2xAnus
Largecupsize,tangentialpair,ParallelPair,bolus,concurrentchemo
4 2b2xAnus1xRectum1xVulva
AsAbove(samepts)Concurrentchemo,Parallelpair,bolus,concurrentchemo
5
2b
5xAnus3xRectum1xPenis1xGroin
AsaboveConcurrentchemo,Parallelpair,concurrentchemoHightotaldose,bolus,vacbag
31xVulva1xGroin/scrotum
Parallelpair,bolus,concurrentchemoHighdose,electrons
6
2b4xAnus1xGroin
AsaboveSameptaswk5
31xVulva1xGroin/scrotum1xAnus
Sameptaswk5Sameptaswk5
7 2b1xGroin1xFemur/groin
Sameptaswk5+6Hightotaldose,vacbag
RTOG Score No. of Patients Site
0 0
1 21–Inframammaryfold
1–Genitalarea
2a 61–Inframammaryfold5–Anal/perinealarea
2b 13
1–Axilla1–Inframammaryfold1–Scrotum2–Underabdominalfold4–Groin4–Anal/perinealarea
3 1 1–Anteriorcommisure
Two Novel Treatments for the Prevention and Treatment of Radiation Induced Moist Desquamation Authors: Claire Bode1 Helen Woodman2, Radiotherapy Department, Queen Elizabeth Hospital, Birmingham, B15 2TH 1 – Training and education Facilitator, 2 – Macmillan Paediatric Liaison Radiographer