Originally published in the May 2014 issue of Imaging & Therapy Practice.  The Society of Radiographers.

A Case Study Evaluation of GutLife Cream in Minimising Radiation-induced Skin Damage

Alice Macleod, Colorectal Advanced Nurse Practitioner, Liz Radford, Colorectal Oncology Clinical Nurse Specialist, Gail Marshall, Radiographer – Beatson West of Scotland Cancer Centre, Glasgow, Scotland

Download a PDF of the Case study here

Introduction

Colorectal cancer is the fourth most common cancer worldwide and the third most common cancer in the United Kingdom (UK) after lung and breast cancer [1]. Colorectal cancer is a collective term for cancer of the colon, rectum and anus.  Almost two-thirds (64%) of all colorectal cancers are cancers of the colon and over one-third (36%) are cancers of the rectum (including the anus). More than half of rectal cancer cases occur in men (60%), while colon cancer cases are approximately evenly divided between men and women (53% male) [1] 

Management

The treatment of colorectal cancer involves surgery, chemotherapy and radiotherapy. Radiotherapy in combination with chemotherapy is a major treatment modality in the management of rectal and anal cancer.  This paper will focus on the skin toxicity associated with chemoradiotherapy treatment for rectal and anal cancer.

All patients receiving external beam radiotherapy are at risk of skin damage.  More than 85% of patients treated with radiotherapy will experience a skin reaction ranging from mild to severe [3,4].

Although patients with anal and rectal cancer receiving concurrent chemoradiotherapy will experience a skin reaction, patients with anal cancer tend to have a more severe reaction due to a greater radiation dose to the skin [4,5].   This patient group subsequently experience a moist desquamation to the anorectal area, groins and genital area requiring appropriate active wound management products to provide soothing relief, as well as cleaning and de-sloughing [3-5].  In addition, such radiation reactions also require pain management with non-steroidal inflammatory analgesia and/or opiate analgesia and may occasionally require oral antibiotics.  It is crucial that patients with anal cancer do not have any treatment interruptions, which can impact on overall outcome, therefore skin care management is essential in this patient group to minimise secondary complications which may affect patients’ ability to cope with treatment [2]. 

GutLife for reduced severe skin reactions caused by anal cancer radiotherapy, reduced pain relief needs, improvement in daily activities

GutLife Cream

Although, a small sample of patients used Gutlife, they experienced a significant reduction in skin toxicity and more rapid resolution of skin damage post-treatment.  In addition, GutLife was well tolerated, compared with a bulky, difficult to secure, dressing.  A significant cost benefit was noticed with GutLife.

Results (anal cancer patients)

In the control patients, the maximum score on the RTOG scale was 3 (in all areas).  Patients had an adverse skin reaction from week 2 onwards which became progressively worse and spread to the entire anogenital region by week 3. Patients reported pain at week 3 (score 4) and week 2 (score 4) which became progressively worse reaching a maximum of 8 and 9 respectively. Polymem dressing (2 boxes per day) was required from week 3 onwards in both patients and for 4 weeks post-treatment.

One control patient was asked to consider admission; however she was very reluctant to do so. This could be due to her stoic attitude in addition to coping with a family member who was terminally ill.

In the GutLife patients, the maximum RTOG scores were 2A and 2B. In patient 3, symptoms (grade 1) occurred at week 3 in the vulval area and became progressively worse reaching grade 2A by week 5.  Symptoms (grade 1) in the groin and perineum occurred at week 6. In patient 4, a similar pattern was seen of worsening vulval symptoms from week 3 and grade 1 symptoms in the groin and perineum at week 6.

In patient 4 the maximum RTOG score was 2B; she required a catheter at week 5 and hospitalisation at week 6 for 10 days. The natal cleft and the anal area were not affected in the two GutLife patients. Patients reported pain at week 3 (score 3 and 4) which worsened reaching a maximum of 6 and 8. Patient 3 reported an alleviation of pain to score 4 by week 6. Polymem dressings were used in both GutLife patients, patient 3 required  1 box per  day at week 6 and 1 box per week for 1 week post-treatment. 

The patient’s skin discomfort improved considerably post-treatment so use reduced from 1 box per day to 1 box per week.   Patient 4 required Polymem 1 box per day from week 3 and 1 box per week for 2 weeks post-treatment.  In the GutLife group, both anal patients found the use of moist Polymem soothing for vulval irritation, and only required a small amount compared with anal patients in the control group. It is interesting to note that in both the anal cancer patients receiving GutLife, the vulval area was not treated and the main skin reaction was seen in the vulval area.

Table 4: Outcomes in anal cancer patients
ControlControlGutLifeGutLife
Patient 1 (female)Patient 2 (female)Patient 3 (female)Patient 4
(female)
Maximum RTOG score332A2B
LocationALL ALLPerineum (1)
Groins (1)
Vulval area (2A)
Perineum (1)
Groins (1)
Vulval area (2B)
Maximum pain score8968
Use of hydrogelNoNoYes, week 3No
Use of PolymemYes, from week 3
(2 boxes per day) and for 4 weeks post-treatment
Yes, from week 3
(2 boxes per day)
and for 4 weeks post-treatment
Yes, week 6
(1 box per day) and for 1 week post-treatment (1 box per week)
Yes, from week 3
(1 box per day) and 2 for weeks post-treatment (1 box per week)
MedicationNSAIDs, week 3
PPI, week 3
Opiates, week 3
Antibiotics, week 4
Opiates, week 2
Antibiotics, week 5
NSAIDs, week 6
PPI, week 6
Opiates, week 6
Antibiotics, week 6
NSAIDs, week 3
Opiates, week 5
Antibiotics, week 5
AdmissionNoNoNoYes, week 6

See full paper for results in rectal patients

Conclusion

In conclusion, the aim of our skin care management in rectal and anal patients receiving chemoradiation is to minimise secondary infection, control pain, achieve comfort and maintain a patients’ ability to cope with radiotherapy treatment. Acknowledging the lack of randomised controlled trials in radiation-induced skin damage, our practice is to treat established skin reactions in accordance with established guidelines.  Despite the current products available, there is no product that has been able to reduce the expected skin reactions associated with anal cancer treatment.  

 Although, a small sample of patients used Gutlife, they experienced a significant reduction in skin toxicity and more rapid resolution of skin damage post-treatment. In addition, GutLife was well tolerated, compared with a bulky, difficult to secure, dressing.  A significant cost benefit was noticed with GutLife, which with support from our clinical team, will allow us to progress an application to use this for our patient group. This will allow further evaluation of skin toxicity, use of adjuvant pain medication and gain valuable patient feedback regarding ease of use, comfort and pain control.

Download a PDF of the Case study here

References

  1. Cancer Research UK.   Available from http://www.cancerresearchuk.org
  2. Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of colorectal cancer. Edinburgh: SIGN; 2011. (SIGN publication no. 126). Available from http://www.sign.ac.uk
  3. Skin care of patients receiving radiotherapy. NHS Quality Improvement Scotland Best Practice Statement, March 2010.
  4. Harris R. Summary of interventions for acute radiotherapy skin reactions in cancer patients: A Clinical Guideline for use by The Society and College of Radiographers, 2011. Available from http://www.sor.org/learning/document-library/summary-interventions-acute-radiotherapy-induced-skin-reactions-cancer-patients-clinical-guideline
  5. Salvo N, Barnes E, Draanen JV et al. Prophylaxis and management of acute radiation-induced skin reactions: a systematic review of the literature. Current Oncology 2010;17(4) 94-112.