Collaboration between dermatologists and oncologists is crucial.
As Director of Oncodermatology at Montefiore Einstein Center for Cancer Care, I have witnessed, firsthand, the improved patient satisfaction and better adherence to cancer therapy that can occur when oncologists and dermatologists work well together.
Collaboration between dermatologists and oncologists is crucial. Dermatologic toxicities have been described from the earliest days of radiation and chemotherapy use for cancer treatment. Over recent years with the increasing development of targeted agents, the importance of dermatologic care in cancer patients has only increased. Additionally, the presence and severity of several skin-related chemotherapy toxicities, including the papulopustular eruption secondary to epidermal growth factor receptor (EGFR) inhibitors, alopecia, hand foot syndrome, and nail toxicities, have been linked to improved survival.
It has never been more important to try to keep patients on effective treatments at optimum doses while addressing uncomfortable dermatologic adverse events. Here are six important steps dermatologists and oncologists can take to improve patient care and outcomes:
1. Evaluation by a dermatologist when appropriate
In one survey of cancer patients, 84% reported they were never referred to a dermatologist and over half said they would have felt better had they seen dermatologists. Patients may underreport their dermatologic concerns for many complex reasons: fear they will be perceived as trivial or fear that their treatment may need to be interrupted or changed. Oncology providers should offer patients dermatology evaluation. However, one large barrier to dermatologic care in cancer patients continues to be long wait times for dermatology appointments. Dermatologists interested in caring for these patients must accommodate urgent visits, especially when evaluation could affect cancer therapy decisions.
2. Communicate well
Being able to communicate effectively and using the same terminology can facilitate a team approach to patient care. Dermatologists should attempt to use standard grading scales to communicate severity of adverse events —- most commonly the National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE), which can be easily and quickly accessed online. Reporting severity of dermatologic problems using this system back to the referring oncologist can help oncologists make decisions about treatment and document adverse events for patients enrolled in clinical trials. Similarly, when oncologists can use accurate dermatologic terminology to describe skin problems, dermatologists are more accurately able to triage patient referrals.
3. Prevent skin problems when possible
In some cases, a prophylactic approach can prevent severe skin toxicities. For example, beginning a tetracycline antibiotic, sun protection, and topical corticosteroid can prevent and decrease severity of the papulopustular eruption due to EGFR inhibitors. Cooling of the hands and feet using cold gloves or ice packs during taxane infusion can significantly prevent nail toxicity and possibly hand foot syndrome. Often a good skin care regimen with gentle products and emollients can help prevent severely dry skin due to many chemotherapeutic agents. It often can be easier to treat these problems preemptively rather than waiting for toxicities to develop.
4. Recognize the importance of dermatologic toxicities on patients’ well-being
Often, the psychological impact of common and expected adverse events, such as alopecia, can be overlooked as providers focus on more life-threatening problems. Alopecia has become even more important to patients as better treatments have become available for other adverse events such as nausea. Although more research is needed to determine how to best prevent alopecia, patients often appreciate being told about things like minoxidil for the scalp and topical bimatoprost for the eyelashes, which can speed up hair growth. Adverse events that may have been minor in patients who were only receiving treatments for a short period of time become more important in patients who remain on medications long-term. For example, acneiform eruptions, paronychia, xerosis, and pruritus can be disabling in patients on EGFR inhibitors attempting to carry on their normal lives during cancer treatment.
5. Include dermatologic evaluation in clinical trials
Dermatologists should be included in chemotherapy clinical trials, when possible, so potential dermatologic toxicities can be classified and studied earlier in the drug investigation. Often these toxicities are underreported or documented generically as “rash.” Potential prophylactic and therapeutic strategies for adverse events related to the skin, hair, and mucous membranes could be developed sooner — hopefully resulting in more patients remaining on an optimum dose of chemotherapy – if dermatologists were regularly part of clinical trials from the early phases.
6. Incorporate dermatology care in survivorship plans
Dermatologic care is important for cancer survivors, especially those who have received radiation as part of their cancer therapy. Studies of survivors of childhood cancers have revealed a significantly increased risk of secondary skin cancers in radiated skin and routine dermatologic evaluation is currently recommended for survivors of childhood cancers. Annual full skin examination by a dermatologist should also be considered in survivorship plans for appropriate adult patients.