Ni Hms 494089

A systematic review of patient-rated measures of radiodermatitis
in breast cancer radiotherapy

Julie B. Schnur, PhD
1
, Bianca Love, BA
1
, Bari L. Scheckner, BA
1
, Sheryl Green, MD
2
, A.
Gabriella Wernicke, MD
3
, and Guy H. Montgomery, PhD
1
1
Department of Oncological Sciences, Integrative Behavioral Medicine Program, Mount Sinai
School of Medicine, New York, NY
2
Department of Radiation Oncology, Mount Sinai School of Medicine, New York, NY
3
Department of Radiation Oncology, Weill Medical College of Cornell University, New York, NY
Abstract
During breast cancer radiotherapy, nearly all patients will experience radiodermatitis. Study
objectives were to: 1) systematically review the literature on radiodermatitis and breast cancer; 2)
summarize and describe patient-rated radiodermatitis measures; 3) determine whether consensus
exists regarding subjective radiodermatitis measurement; and 4) provide recommendations for
future research. PubMed and CINAHL were searched from their inception through August 2009.
Study inclusion/exclusion criteria were: full abstract available; manuscript in English; focused on
radiodermatitis resulting from breast cancer radiotherapy, and described a patient-rated empirical
assessment of radiodermatitis. Three reviewers examined abstracts, and decisions about inclusion
were reached by consensus. 22/237 mutually identified studies met selection criteria. Using a
standardized abstraction form, three authors independently extracted relevant information. Results
indicated that: 1) only 9% of the studies reviewed included a patient-rated measure; 2) generally,
extant scales are very brief and focus almost exclusively on physical reactions, and 3) there is no
gold standard measure of patient-rated radiodermatitis at this time. We conclude that
significantly more research is needed to determine the best (most valid, reliable, sensitive,
comprehensive) measure(s) to evaluate the experience of radiodermatitis from the patients
perspective, and that further scale development efforts are needed.
Keywords
breast neoplasms; radiodermatitis; radiotherapy; Patient Outcome Assessments
Introduction
Radiotherapy is a key element of curative breast cancer treatment, and it has been estimated
that 45% of all breast cancer patients receive radiotherapy
1
. During the course of breast
cancer radiotherapy, the vast majority of patients (74%100%) will experience
radiodermatitis, also referred to as skin toxicity
25
. The physical manifestations of
radiodermatitis can range from faint erythema (redness, warmth, rash-like appearance), to
dry desquamation (dryness, itching, peeling), to moist desquamation (moist, oozing, tender,
redness and exposure of the dermis) and necrosis
69
. After the conclusion of radiotherapy,
patients may experience cutaneous fibrosis, which involves changes in skin texture, skin
Corresponding Author Information: Julie B. Schnur, Ph.D., Mount Sinai School of Medicine, Department of Oncological Sciences,
Box 1130, 1425 Madison Avenue, New York, NY 10029. Fax: 212-849-2566; Phone: 212-659-5644; julie.schnur@mssm.edu.
NIH Public Access
Author Manuscript
Am J Clin Oncol. Author manuscript; available in PMC 2013 July 30.
Published in final edited form as:
Am J Clin Oncol. 2011 October ; 34(5): 529536. doi:10.1097/COC.0b013e3181e84b36.
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
retraction, discomfort, telangiectasia, pain, and itching
10
. But radiodermatitis not only
affects breast skin, it also affects the breast patient herself. Qualitative research and review
articles have suggested that radiodermatitis may be experienced by patients as itching,
sensitivity, pain, numbness, tenderness, warmth, tingling, throbbing, tightness, heaviness,
and burning
3, 11
, and that skin pain may be associated with fatigue, body image disturbance,
sleep problems, and emotional distress
12, 13
. Such qualitative data suggest that in order to
understand the impact of radiodermatitis on quality of life, it is critical to assess not only the
occurrence of skin reactions, but also patients subjective experience of such reactions
14
.
Unfortunately, there has been a paucity of research focused on the patients experience of
radiodermatitis, including the degree to which radiodermatitis impairs quality of life
(QOL)
15
, causes pain
16
, or causes distress
15
. Indeed, in regard to radiodermatitis, rarely
have studies considered patient comfort of primary importance (p. E9,
12
). Overall, the
effects of radiation-related skin reactions on quality of life are largely absent in the
literature (p. E11
12
). This lack of attention to the patients subjective experience is
inconsistent with the emphasis placed on QOL by major health organizations (World Health
Organization
17
, Institute of Medicine
18, 19
), as well as with the more widespread
recognition of the need to assess patient-rated symptoms in addition to observer-rated
measures (e.g.,
14, 2022
).
The lack of research on the patients subjective experience of radiodermatitis is problematic
for at least four reasons. First, two people with the same observer-rated level of
radiodermatitis (e.g., with the same Radiation Therapy Oncology Group (RTOG) score
6
)
may have very different subjective experiences. As Schmuth et al.
23
have noted (p. 987),
Clinical judgment and bioengineering techniques alone cannot reflect the potential impact
of a skin condition on patients lives. Second, if not inquired about, important symptoms
(e.g., pain, impaired body image, impaired functioning) may go unrecognized and
unmanaged, potentially leading to impaired patient quality of life, poor treatment
satisfaction, and social constraints
24
in the doctor-patient relationship. Third, breast cancer
patients cannot make fully informed treatment decisions (i.e., whether or not to undergo
radiotherapy) without data on how the treatment may affect their quality of life
14
. Fourth, if
patients are not provided with accurate information about radiotherapy side effects it can
inhibit their ability to cope with, understand and interpret their treatment experience;
increase feelings of uncertainty; and hinder problem solving
3
.
It has been suggested that research on radiodermatitis has been hampered by the absence of
a widely accepted and psychometrically sound scale to assess skin reactions
4, 11
. Although
there exist a number of commonly used and well-accepted observer-rated methods of
evaluating radiodermatitis (e.g.,
6
;
25
), as well as more technological approaches (e.g.,
reflectance spectroscopy), the patients experiences of symptoms and quality of life have
been given less attention
4
. In 1999, Noble-Adams
11
reviewed the literature on assessment
of radiation-induced skin reactions in general (not focused on breast), and found that the
most common assessment method at the time for radiodermatitis was physician-rated visual
observation scales, and that there existed no scale at the time that could be used to assess the
subjective symptoms of radiotherapy-induced skin reactions
26
. The goal of the present
paper is to: 1) provide an up-to-date systematic review of the literature on radiodermatitis
and breast cancer in order to learn which patient-rated instruments have been used to assess
subjective radiodermatitis; 2) summarize and describe patient-rated radiodermatitis
measures to inform future research efforts; 3) determine whether consensus exists regarding
subjective radiodermatitis measurement; and 4) to provide recommendations for the use of
current instruments as well as for future scale development in this area.
Schnur et al. Page 2
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
Method
The QUORUM checklist
27
guided the conduct and reporting of this systematic review.
Data Sources and Search strategy
Two electronic databases, PubMed and CINAHL were searched from their respective
inceptions through August 19, 2009.
For PubMed, the search terms were: "Radiodermatitis"[Mesh] AND ("Breast
Neoplasms"[Mesh] OR breast). Limits placed on the search required articles to be about
humans and in English. This search yielded 202 abstracts/titles.
For CINAHL, the search terms were: (breast neoplasms or breast) AND radiodermatitis.
The only limit placed on the search was that the article had to be in English. This search
yielded 35 abstracts/titles.
Study Selection Strategy
The abstracts/titles of all articles identified by electronic searches (237 in total) were
carefully screened by three of the authors to determine whether they met the following
inclusion criteria: (a) full abstract available online; (b) manuscript written in English; (c)
focused on or included breast cancer patients; (d) focused on radiotherapy for the treatment
of breast cancer (e.g., not other types of radiation); (e) focused on radiodermatitis resulting
from radiotherapy; (f) described a patient-rated empirical assessment of radiodermatitis
(e.g., excluded qualitative studies and other-rated measures); and (g) the study was not a
duplicate (i.e., if an article was cited in both PubMed and CINAHL, it was only used once).
Subsequent to abstract review, 46 manuscripts were obtained and read in full, independently
by three co-authors, each of whom completed a standardized form assessing the inclusion
criteria. These co-authors then met together to review these 46 manuscripts. Based on
consensus review by these reviewers, 22 of those 46 mutually identified studies met
selection criteria and were included in the meta-analysis. Reasons for exclusion are
identified in Figure 1 - QUORUM
27
Flow Chart.
Data Extraction and Study Characteristics
For each of the 22 papers included in the review, relevant data was extracted independently
by three of the authors using a standardized worksheet. Specifically, the standardized
worksheet was used to collect the following information: authors, publication year, sample
size, type of study (e.g., intervention study, descriptive study, scale development study),
type of radiation received, scale name (if provided), number of scale items related to
radiodermatitis, constructs measured, item rating method, and frequency of administration.
Any discrepancies were discussed among the authors with reference to the original
manuscript until consensus was reached.
It should be noted that: a) if a given paper reported both subjective and objective data (e.g.,
patient-rated and physician-rated), we focused only on the assessment items specifically
identified as patient-rated or subjective; b) if a given paper reported on both quantitative and
qualitative data, we only report on the quantitative data. Although both are critical pieces of
information, the goal of the present review is to survey empirical measures of subjective
radiodermatitis which could be used in future research; c) if a given paper had a mixed
cancer sample, we only report on the breast cancer patients; and d) only questions/
questionnaires pertaining to skin reactions and related quality of life were included. Other
types of questions (e.g., opinions about interventions, adverse effects related to creams
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
under investigation, skin products used) are not reported on in the present review. Again,
this decision was made in the interest of compiling questions/measures which could be used
in clinical settings and across radiodermatitis studies (e.g., intervention studies, longitudinal
studies, etc) in breast cancer.
Results
Description of Trial, Sample, and Intervention Characteristics
Table 1 presents the chief characteristics of each study and scale. The papers were published
between 1979 and 2009. Sample size ranged from 2 to 331, with 12/22 having fewer than 50
breast patients, 2/22 having 50100 breast patients, 3/22 having100200 breast patients, and
5/22 having greater than 200 breast patients. Three of the studies did not report the specific
type of radiation patients received; the rest involved external beam radiation. None was
specifically focused on alternative forms of radiation treatment (e.g., accelerated
hypofractionated radiation regimens, partial breast irradiation, etc.). The majority of the
studies (86%) were intervention studies (testing the effectiveness of various creams,
homeopathic treatments, mechanical massage, behavioral strategies). Only one
4
was
specifically focused on the development and validation of a radiodermatitis scale. The vast
majority of the studies focused on acute toxicity. Only 5/22 papers reported ethnicity data on
participants, and of those 5, all were greater than 85% White.
Data synthesis and Description of Scale Characteristics
The primary finding is that only 9% of the abstracts reviewed included any patient-rated
measure. In other words, 91% of the studies of radiodermatitis in breast cancer patients did
not ask patients about their symptom experience. The papers which did meet inclusion
criteria discussed 28 measures (some of which were single item measures). The depth of the
description of the measures varied greatly between manuscripts. In some manuscripts
measures are described in great detail, whereas in others the description is limited to one
sentence, making data synthesis difficult. However, based on our consensus reading of the
manuscripts, the results are as follows.
Tremendous heterogeneity was noted both in terms of scales used and items assessed. For
example, none of the previously developed, psychometrically sound scales included in these
papers (e.g., Skin Toxicity Assessment Tool, Spitzer quality of life, Radiation-Induced Skin
Reaction Assessment Scale, EORTC C-30 general module or BR-23 breast cancer-specific
module, Skindex, SF-36, or Dermatology quality of life index) was used more than once.
Furthermore, the only scales that did appear to be used more than once were pain visual
analog scales (k=4) and symptom diary cards (k=3). However, because only 1 of the 4 pain
visual analog scales reported their numerical and verbal anchors, we cannot be sure that
these four VASs are identical. In general, the data suggest that there currently exists no clear
consensus in the field in terms of measuring patient-rated radiodermatitis.
Heterogeneity was also noted in terms of specific items assessed (see Table 1, Constructs
Measured). This suggests that there is no well-accepted definition of the construct of
radiodermatitis from the patient perspective. Every study is, in effect, measuring its own
version of radiodermatitis. For one study it may mean cosmesis, for another pain, for
another, more comprehensive effects on quality of life. This diversity further makes it
difficult to compare across studies, and to build a knowledge base in this area.
Yet despite the heterogeneity, the following trends became apparent: 1) The vast majority of
the 28 scales were extremely brief. 79% were between 1 and 5 items. 2) The most
commonly asked items were erythema/redness, desquamation/peeling, burning, itching, and
pain. 3) Regarding dimensions of quality of life assessed, more than half (61%) focused
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
solely on physical well-being. A smaller subset of studies looked at both physical well-being
and functional well-being (25%). However, other domains of QOL were more rarely
examined, and only 11% took a more comprehensive approach (i.e., 3 or more domains of
quality of life assessed) to examining radiodermatitis effects on multiple domains of quality
of life
15, 23, 28
. 4) Clear empirical data describing scale properties (e.g., reliability, validity,
time to complete, reading level) was largely absent.
Discussion
This systematic review of the literature on patient-rated measures of radiodermatitis in
breast cancer radiotherapy provides an important snapshot of the current state of research in
this area, and revealed at least five important areas for future growth.
Our primary finding was that out of 237 abstracts/titles reviewed, only 9% actually asked
breast cancer patients about their experience of radiodermatitis. In other words, in studies of
radiodermatitis, an extremely common treatment side effect, the patients experience,
perceptions, suffering, and evaluations have generally been ignored by the breast
radiotherapy research literature. These results are quite similar to findings by Noble-Adams
from a decade ago
11
, and disappointingly suggest that little progress has been made in this
area. It seems impossible to comprehensively evaluate the success or failure of any new
radiotherapy technique, or any new symptom control intervention, without assessing
whether patients themselves are more comfortable, are more satisfied with their appearance,
feel less pain, are more satisfied with the texture of the breast, sleep better, or are more
satisfied with treatment. Of course we recognize that clinically, radiotherapy treatment
teams discuss these issues extensively with patients. However, if these factors are not
regularly assessed in research enterprises, treatment guidelines may be decided upon without
true consideration of the patient experience and without empirical data. In consequence, it is
our recommendation that all future prospective research on radiotherapy-induced skin
changes in breast cancer patients include at least one patient-rated measure. This will ensure
that quality of life is not ignored in this population.
Second, we noted that among those studies which did measure patient-rated radiodermatitis,
there was no clear agreement on which scale to use and little consistency regarding items
assessed. The high variability in assessment approaches is problematic, and makes it
difficult to develop norms or compare results across studies
28
. Moreover, the variability
suggests a lack of consensus not merely in terms of measurement, but in also terms of a
clear definition of the construct of patient-rated radiodermatitis. Our own qualitative work
13
suggests that in order to comprehensively account for patient experiences, a patient-rated
skin toxicity measure should at minimum include items about: a) nociceptive/tactile effects
(e.g., pain/discomfort, burning/heat, itching, tingling, pulling and heaviness, skin texture); b)
body image and satisfaction with skin color changes and skin texture; c) emotional
reactions; d) functional impairment (e.g., clothing/bra changes, sleep impairment, work
performance); and e) satisfaction with radiotherapy. Our general recommendation is that
more work (both quantitative and qualitative) be conducted to develop an operational
definition of radiodermatitis that accurately represents patients experiences and voices.
Third, we found that the scales in use were generally quite brief and limited in scope, and
focused almost exclusively on one particular aspect of quality of life physical well-being.
To address this limitation, we suggest that future research regularly address multiple
dimensions of quality of life. Among the scales already in use, the most comprehensive are
the Skindex, EORTC, SF-36, and DLQI. However, Wells et al.
15
raised some concerns
about the sensitivity of the DLQI, and more work is needed to determine the appropriateness
of each of these measures in the breast cancer radiotherapy setting. More broadly, we
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
recommend that significantly more research be conducted to develop a new, comprehensive,
radiodermatitis scale for breast cancer patients which is informed by qualitative research as
well as expert opinions. It should be noted that we recognize that skin toxicity scales may
exist, or may be used more frequently, in radiotherapy populations other than breast.
However, without sufficient testing and validation in breast samples, it is unclear whether
they are appropriate for this population.
Fourth, we strongly recommend that more attention (i.e., better reporting) be given to
descriptions of the scales, including description of supporting literature, wording/anchors,
number of items, and psychometric properties. Without such knowledge, it is difficult to
interpret the quality of the data collected
14
, and difficult to make informed decisions about
using the scale in future research. Consequently, we recommend that psychometric
properties of the scales be included in research reports on patient-rated radiodermatitis, and
that in the future, research focus on the development and use of psychometrically reliable
and valid scales.
Fifth, of those studies which did report ethnicity, samples were predominantly White. In
order to determine the appropriateness of these measures across ethnic groups, future
research should include more diverse samples of patients.
Of course, like any study, the present review has its limitations. First, the search strategy
was focused. The Mesh term radiodermatitis was the descriptor used to search for
radiotherapy-related skin toxicity. However, different search terms could lead to different
results. As a check on our search strategy, we examined two recent reviews in the area
29, 30
.
Out of the 38 studies included in these reviews, only three additional studies
3133
would
have met our inclusion criteria, and none of these three papers included a scale which was
not already reported on in Table 1. More specifically, one used a visual analog scale and the
other two rated itching/pain as none, mild, moderate, or severe. Thus, the information
provided by these additional manuscripts does not change the conclusions of the present
review, that the field lacks a gold standard patient-rated self-report measure of skin
changes associated with breast cancer radiotherapy. Second, the present review included two
databases PubMed and CINAHL, and was limited to published manuscripts in English. It
is possible that additional relevant papers exist outside of the present sample of papers.
Future work may wish to include more languages, include unpublished manuscripts, and use
a wider variety of search terms to confirm the generalizability of the present conclusions.
Third, we chose not to conduct quality appraisals of the included studies, as is suggested in
the QUORUM
27
guidelines. We chose not to do this because we were focused on the quality
of the measures, rather than the overall quality of the studies in which a measure was used.
We view study quality and measure quality as separate issues. Future research may wish to
rate both study and measure quality to be used as covariates in meta-analytic approaches.
In conclusion, this review suggests that although some important efforts have been made to
assess breast cancer patients experiences of radiodermatitis, the literature in this area is
relatively underdeveloped compared to the literature on other cancer-related symptoms, side
effects, and quality of life (e.g.,
20, 21, 3436
). With regard to radiodermatitis, it has been
stated that (
11
, p. 1140), Accurate assessment of both the subjective symptoms and the
observable signs of these reactions is a prerequisite in enabling an understanding of the
phenomenon and planning appropriate care. Until a holistic, valid and reliable tool is
developed the concept cannot be fully examined. It is our hope that the present review will
spur development of such a tool, and focus attention on the patient experience.
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
Acknowledgments
Sources of support: The project described was supported by Award Number K07CA131473 from the National
Cancer Institute and by RSGPB-04-213-01 from the American Cancer Society. The content is solely the
responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute,
the National Institutes of Health, or the American Cancer Society.
References
1. National Cancer Database (NCDB) / Commission on Cancer (CoC) NCDB Hospital Comparison
Benchmark Reports [database online]. Chicago, IL: American College of Surgeons; 2006.
2. Wengstrom Y, Haggmark C, Strander H, Forsberg C. Perceived symptoms and quality of life in
women with breast cancer receiving radiation therapy. Eur J Oncol Nurs. 2000; 4(2):7888.
[PubMed: 12849634]
3. Knobf MT, Sun Y. A longitudinal study of symptoms and self-care activities in women treated with
primary radiotherapy for breast cancer. Cancer Nurs. 2005; 28(3):210218. [PubMed: 15915066]
4. Berthelet E, Truong PT, Musso K, et al. Preliminary reliability and validity testing of a new Skin
Toxicity Assessment Tool (STAT) in breast cancer patients undergoing radiotherapy. Am J Clin
Oncol. 2004; 27(6):626631. [PubMed: 15577442]
5. Freedman GM, Li T, Nicolaou N, Chen Y, Ma CC, Anderson PR. Breast intensity-modulated
radiation therapy reduces time spent with acute dermatitis for women of all breast sizes during
radiation. Int J Radiat Oncol Biol Phys. 2009; 74(3):689694. [PubMed: 19362779]
6. Cox JD, Stetz J, Pajak TF. Toxicity criteria of the Radiation Therapy Oncology Group (RTOG) and
the European Organization for Research and Treatment of Cancer (EORTC). Int J Radiat Oncol
Biol Phys. 1995; 31(5):13411346. [PubMed: 7713792]
7. Harper JL, Franklin LE, Jenrette JM, Aguero EG. Skin toxicity during breast irradiation:
pathophysiology and management. South Med J. 2004; 97(10):989993. [PubMed: 15558927]
8. Mendelsohn FA, Divino CM, Reis ED, Kerstein MD. Wound care after radiation therapy. Adv Skin
Wound Care. 2002; 15(5):216224. [PubMed: 12368711]
9. McQuestion M. Evidence-based skin care management in radiation therapy. Semin Oncol Nurs.
2006; 22(3):163173. [PubMed: 16893745]
10. Bourgeois JF, Gourgou S, Kramar A, Lagarde JM, Guillot B. A randomized, prospective study
using the LPG technique in treating radiation-induced skin fibrosis: clinical and profilometric
analysis. Skin Res Technol. 2008; 14(1):7176. [PubMed: 18211604]
11. Noble-Adams R. Radiation-induced reactions. 1: An examination of the phenomenon. Br J Nurs.
1999; 8(17):11341140. [PubMed: 10897695]
12. MacBride SK, Wells ME, Hornsby C, Sharp L, Finnila K, Downie L. A case study to evaluate a
new soft silicone dressing, Mepilex Lite, for patients with radiation skin reactions. Cancer Nurs.
2008; 31(1):E8E14. [PubMed: 18176123]
13. Schnur JB, Ouellette SC, DiLorenzo TA, Green S, Montgomery GH. A qualitative analysis of skin
toxicity among breast cancer radiotherapy patients. Psychooncology. 2010 Mar 17. [Epub ahead of
print].
14. Kuroi K, Shimozuma K, Ohsumi S, Imai H, Ono M. Current status of health outcome assessment
of medical treatment in breast cancer. Breast Cancer. 2007; 14(1):7480. [PubMed: 17244999]
15. Wells M, Macmillan M, Raab G, et al. Does aqueous or sucralfate cream affect the severity of
erythematous radiation skin reactions? A randomised controlled trial. Radiother Oncol. 2004;
73(2):153162. [PubMed: 15542162]
16. Delaney G, Fisher R, Hook C, Barton M. Sucralfate cream in the management of moist
desquamation during radiotherapy. Australas Radiol. 1997; 41(3):270275. [PubMed: 9293679]
17. World Health Organization. [Accessed March 19, 2010] Constitution of the World Health
Organization. Available at: http://www.who.int/governance/eb/who_constitution_en.pdf
18. National Cancer Policy Board, Institute of Medicine. Meeting Psychosocial Needs of Women with
Breast Cancer. Washington, D.C.: National Academies Press; 2004.
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
19. National Cancer Policy Board, Institute of Medicine and National Research Council. Ensuring
Quality Cancer Care. Washington, D.C.: The National Academies Press; 1999.
20. Lipscomb, J.; Gotay, CC.; Snyder, C. Outcomes assessment in cancer: measures, methods and
applications. New York: Cambridge University Press; 2005.
21. Perry S, Kowalski TL, Chang CH. Quality of life assessment in women with breast cancer:
benefits, acceptability and utilization. Health Qual Life Outcomes. 2007; 5:24. [PubMed:
17474993]
22. Cella D, Wagner L, Cashy J, Hensing TA, Yount S, Lilenbaum RC. Should health-related quality
of life be measured in cancer symptom management clinical trials? Lessons learned using the
functional assessment of cancer therapy. J Natl Cancer Inst Monogr. 2007; (37):5360. [PubMed:
17951232]
23. Schmuth M, Wimmer MA, Hofer S, et al. Topical corticosteroid therapy for acute radiation
dermatitis: a prospective, randomized, double-blind study. Br J Dermatol. 2002; 146(6):983991.
[PubMed: 12072066]
24. Lepore SJ, Helgeson VS. Social constraints, intrusive thoughts, and mental health after prostate
cancer. J Soc Clin Psychol. 1998; 17(1):89106.
25. Cancer Therapy Evaluation Program (CTEP) of the National Cancer Institute (NCI). Common
Terminology Criteria for Adverse Events (CTCAE): Version 4.0. U.S. Department of Health and
Human Services, National Institutes of Health, National Cancer Institute; Published: May 28, 2009
(v4.02:Sept. 15, 2009)
26. Noble-Adams R. Radiation-induced skin reactions. 2: Development of a measurement tool. Br J
Nurs. 1999 Oct 14; 8(18):12081211. [PubMed: 10897708]
27. Moher D, Cook DJ, Eastwood S, Olkin I, Rennie D, Stroup DF. Improving the quality of reports of
meta-analyses of randomised controlled trials: the QUOROM statement. Quality of Reporting of
Meta-analyses. Lancet. 1999; 354(9193):18961900. [PubMed: 10584742]
28. Pignol JP, Olivotto I, Rakovitch E, et al. A multicenter randomized trial of breast intensity-
modulated radiation therapy to reduce acute radiation dermatitis. J Clin Oncol. 2008; 26(13):2085
2092. [PubMed: 18285602]
29. Bolderston A, Lloyd NS, Wong RK, Holden L, Robb-Blenderman L. The prevention and
management of acute skin reactions related to radiation therapy: a systematic review and practice
guideline. Support Care Cancer. 2006; 14(8):802817. [PubMed: 16758176]
30. Kedge EM. A systematic review to investigate the effectiveness and acceptability of interventions
for moist desquamation in radiotherapy patients. Radiography. 2009; 15:247257.
31. 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(3):333339. [PubMed: 11230896]
32. Campbell IR, Illingworth MH. Can patients wash during radiotherapy to the breast or chest wall?
A randomized controlled trial. Clin Oncol (R Coll Radiol). 1992; 4(2):7882. [PubMed: 1554631]
33. Lokkevik E, Skovlund E, Reitan JB, Hannisdal E, Tanum G. Skin treatment with bepanthen cream
versus no cream during radiotherapy--a randomized controlled trial. Acta Oncol. 1996; 35(8):
10211026. [PubMed: 9023388]
34. Minton O, Stone P. A systematic review of the scales used for the measurement of cancer-related
fatigue (CRF). Ann Oncol. 2009; 20(1):1725. [PubMed: 18678767]
35. Kirkova J, Davis MP, Walsh D, et al. Cancer symptom assessment instruments: a systematic
review. J Clin Oncol. 2006; 24(9):14591473. [PubMed: 16549841]
36. Hjermstad MJ, Fainsinger R, Kaasa S. Assessment and classification of cancer pain. Curr Opin
Support Palliat Care. 2009; 3(1):2430. [PubMed: 19365158]
37. Bennett C. An investigation into the use of a non-metallic deodorant during radiotherapy treatment:
a randomised controlled trial. J Radiother Pract. 2009; 8:39.
38. Glees JP, Mameghan-Zadeh H, Sparkes CG. Effectiveness of topical steroids in the control of
radiation dermatitis: a randomised trial using 1% hydrocortisone cream and 0.05% clobetasone
butyrate (Eumovate). Clin Radiol. 1979; 30(4):397403. [PubMed: 380872]
39. Graham P, Browne L, Capp A, et al. Randomized, paired comparison of No-Sting Barrier Film
versus sorbolene cream (10% glycerine) skin care during postmastectomy irradiation. Int J Radiat
Oncol Biol Phys. 2004; 58(1):241246. [PubMed: 14697444]
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
40. Halyard MY, McCombs KE, Wong WW, et al. Acute and chronic results of adjuvant radiotherapy
after mastectomy and Transverse Rectus Abdominis Myocutaneous (TRAM) flap reconstruction
for breast cancer. Am J Clin Oncol. 2004; 27(4):389394. [PubMed: 15289733]
41. Heggie S, Bryant GP, Tripcony L, et al. A Phase III study on the efficacy of topical aloe vera gel
on irradiated breast tissue. Cancer Nurs. 2002; 25(6):442451. [PubMed: 12464836]
42. Dische S, Warburton MF, Jones D, Lartigau E. The recording of morbidity related to radiotherapy.
Radiother Oncol. 1989; 16(2):103108. [PubMed: 2595009]
43. Macmillan MS, Wells M, MacBride S, Raab GM, Munro A, MacDougall H. Randomized
comparison of dry dressings versus hydrogel in management of radiation-induced moist
desquamation. Int J Radiat Oncol Biol Phys. 2007; 68(3):864872. [PubMed: 17363185]
44. Pommier P, Gomez F, Sunyach MP, D'Hombres A, Carrie C, Montbarbon X. Phase III randomized
trial of Calendula officinalis compared with trolamine for the prevention of acute dermatitis during
irradiation for breast cancer. J Clin Oncol. 2004; 22(8):14471453. [PubMed: 15084618]
45. 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(3):143153. [PubMed:
10763645]
46. Primavera G, Carrera M, Berardesca E, Pinnaro P, Messina M, Arcangeli G. A double-blind,
vehicle-controlled clinical study to evaluate the efficacy of MAS065D (XClair), a hyaluronic acid-
based formulation, in the management of radiation-induced dermatitis. Cutan Ocul Toxicol. 2006;
25(3):165171. [PubMed: 16980242]
47. Roper B, Kaisig D, Auer F, Mergen E, Molls M. Theta-Cream versus Bepanthol lotion in breast
cancer patients under radiotherapy. A new prophylactic agent in skin care? Strahlenther Onkol.
2004 May; 180(5):315322. [PubMed: 15127162]
48. Schlappack O. Homeopathic treatment of radiation-induced itching in breast cancer patients. A
prospective observational study. Homeopathy. 2004; 93(4):210215. [PubMed: 15532701]
49. Chren MM, Lasek RJ, Quinn LM, Mostow EN, Zyzanski SJ. Skindex, a quality-of-life measure for
patients with skin disease: reliability, validity, and responsiveness. J Invest Dermatol. 1996;
107(5):707713. [PubMed: 8875954]
50. Schnur JB, Montgomery GH. Hypnosis and cognitive-behavioral therapy during breast cancer
radiotherapy: a case report. Am J Clin Hypn. 2008; 50(3):209215. [PubMed: 18246853]
51. Szumacher E, Wighton A, Franssen E, et al. Phase II study assessing the effectiveness of Biafine
cream as a prophylactic agent for radiation-induced acute skin toxicity to the breast in women
undergoing radiotherapy with concomitant CMF chemotherapy. Int J Radiat Oncol Biol Phys.
2001; 51(1):8186. [PubMed: 11516855]
52. Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI)--a simple practical measure for
routine clinical use. Clin Exp Dermatol. 1994; 19(3):210216. [PubMed: 8033378]
53. Lewis V, Finlay AY. 10 years experience of the Dermatology Life Quality Index (DLQI). J
Investig Dermatol Symp Proc. 2004; 9(2):169180.
54. 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(2):
345349. [PubMed: 8892458]
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
Figure 1.
QUORUM Flow Chart.
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
T
a
b
l
e

1
S
t
u
d
y

a
n
d

S
c
a
l
e

C
h
a
r
a
c
t
e
r
i
s
t
i
c
s
.
A
u
t
h
o
r
/
Y
e
a
r
N
S
c
a
l
e

N
a
m
e
#

o
f

i
t
e
m
s
a
C
o
n
s
t
r
u
c
t
s
m
e
a
s
u
r
e
d
R
a
t
i
n
g
Q
O
L

a
s
p
e
c
t
a
s
s
e
s
s
e
d
F
r
e
q
u
e
n
c
y

o
f
a
d
m
i
n
i
s
t
r
a
t
i
o
n
B
e
n
n
e
t
t
(
2
0
0
9
)
3
7
1
9
0
S
k
i
n

A
s
s
e
s
s
m
e
n
t

F
o
r
m
-
P
a
t
i
e
n
t

O
b
s
e
r
v
a
t
i
o
n
s
4
-
E
r
y
t
h
e
m
a
-
D
e
s
q
u
a
m
a
t
i
o
n
-
a
r
e
a

o
f

s
k
i
n
r
e
a
c
t
i
o
n
-
a
n
y

a
d
d
i
t
i
o
n
a
l
s
y
m
p
t
o
m
s
R
a
t
i
n
g
s

f
o
r

e
r
y
t
h
e
m
a

a
n
d
d
e
s
q
u
a
m
a
t
i
o
n

w
e
r
e

b
a
s
e
d
o
n

t
h
e

R
T
O
G

s
c
a
l
e
(
g
r
a
d
e
s

0
3
)
.
P
W
B
W
e
e
k
l
y
B
e
r
t
h
e
l
e
t
(
2
0
0
4
)
4
2
7
S
k
i
n

T
o
x
i
c
i
t
y

A
s
s
e
s
s
m
e
n
t
T
o
o
l

(
S
T
A
T
)
5
-
b
u
r
n
i
n
g
-
i
t
c
h
i
n
e
s
s
-
p
u
l
l
i
n
g
-
t
e
n
d
e
r
n
e
s
s
-
o
t
h
e
r

c
o
m
p
l
a
i
n
t
s
0
5

v
i
s
u
a
l

a
n
a
l
o
g

s
c
a
l
e
P
W
B
W
e
e
k
l
y

a
n
d

2

w
e
e
k
s
a
f
t
e
r

R
T

c
o
m
p
l
e
t
i
o
n
B
o
u
r
g
e
o
i
s

e
t

a
l
.
(
2
0
0
8
)
1
0
2
0
Q
u
a
l
i
t
a
t
i
v
e

a
s
s
e
s
s
m
e
n
t

b
y
t
h
e

p
a
t
i
e
n
t
4
-
f
e
e
l
i
n
g

o
f

t
i
g
h
t
n
e
s
s
-
i
t
c
h
i
n
g
-
f
e
e
l
i
n
g

o
f
i
n
d
u
r
a
t
i
o
n

o
f

t
h
e
s
k
i
n
-
g
l
o
b
a
l

a
s
s
e
s
s
m
e
n
t
o
f

s
k
i
n

s
o
f
t
e
n
i
n
g
E
a
c
h

i
t
e
m

w
a
s

r
a
t
e
d

a
s
:
y
e
s
/
n
o
0
1
0

V
A
S
0
=
n
o
t

a
t

a
l
l
1
0
=
e
n
o
r
m
o
u
s
l
y
P
W
B
O
n

e
n
r
o
l
l
m
e
n
t
;

a
f
t
e
r
1
5

i
n
t
e
r
v
e
n
t
i
o
n
s

o
r
f
o
r

c
o
n
t
r
o
l

p
a
t
i
e
n
t
s
,
3
5

d
a
y
s
;

a
n
d

o
n
e
m
o
n
t
h

a
f
t
e
r

t
h
e

e
n
d
t
h
e

i
n
t
e
r
v
e
n
t
i
o
n

o
r
f
o
r

c
o
n
t
r
o
l

p
a
t
i
e
n
t
s
,
6
5

d
a
y
s
D
e
l
a
n
e
y

e
t

a
l
.
(
1
9
9
7
)
1
6
1
0
P
a
t
i
e
n
t

a
s
s
e
s
s
m
e
n
t
1
-
D
i
s
c
o
m
f
o
r
t

l
e
v
e
l
L
i
n
e
a
r

a
n
a
l
o
g
u
e

s
e
l
f
-
a
s
s
e
s
s
m
e
n
t

s
c
a
l
e
s
(
L
A
S
A
)
P
W
B
D
a
i
l
y

w
h
i
l
e
p
a
r
t
i
c
i
p
a
t
i
n
g

i
n

t
h
e
t
r
i
a
l

(
f
o
l
l
o
w
-
u
p

u
n
t
i
l
e
n
d

o
f

R
T

o
r

m
o
i
s
t
d
e
s
q
u
a
m
a
t
i
o
n
h
e
a
l
e
d
)
G
l
e
e
s

e
t

a
l
.
(
1
9
7
9
)
3
8
2
0
D
a
i
l
y

r
e
c
o
r
d

c
a
r
d
5
-
s
o
r
e
n
e
s
s
-
b
u
r
n
i
n
g
/
t
i
n
g
l
i
n
g
-
i
t
c
h
i
n
g
-
r
e
d
n
e
s
s
-
p
e
e
l
i
n
g
0

i
f

n
o
t

p
r
e
s
e
n
t
1

i
f

p
r
e
s
e
n
t
P
W
B
W
e
e
k
l
y
G
r
a
h
a
m

e
t

a
l
.

(
2
0
0
4
)
3
9
5
8
5
-
p
o
i
n
t

L
i
k
e
r
t

s
c
a
l
e
s
2
-
p
a
i
n
-
p
r
u
r
i
t
u
s
1
(
m
i
n
i
m
u
m
)

-
5
(
m
a
x
i
m
u
m
)
P
W
B
W
e
e
k
l
y

(
u
n
t
i
l

s
k
i
n
r
e
a
c
t
i
o
n

c
l
e
a
r
e
d

o
r

a
m
a
x
i
m
u
m

o
f

1
2
a
s
s
e
s
s
m
e
n
t
s
)
H
a
l
y
a
r
d

e
t

a
l
.
(
2
0
0
4
)
4
0
1
5
S
e
l
f
-
r
a
t
e
d

c
o
s
m
e
s
i
s
1
-
c
o
s
m
e
s
i
s
E
x
c
e
l
l
e
n
t
,

g
o
o
d
,

f
a
i
r
,

o
r
p
o
o
r
P
W
B
N
R
H
e
g
g
i
e

e
t

a
l
.
(
2
0
0
2
)
4
1
2
0
8
S
u
b
j
e
c
t
i
v
e

r
a
t
i
n
g
s

b
a
s
e
d

o
n
t
h
e

M
o
r
b
i
d
i
t
y

R
a
t
i
n
g
S
c
a
l
e
4
2
2
-
i
t
c
h
i
n
g
-
p
a
i
n
N
o
n
e
,

m
i
l
d
,

m
o
d
e
r
a
t
e
,

o
r
s
e
v
e
r
e
P
W
B
W
e
e
k
l
y

(
s
t
a
r
t
i
n
g

o
n
D
a
y

1

o
f

t
r
e
a
t
m
e
n
t
)
a
n
d

t
h
e
n

2

w
e
e
k
s
a
f
t
e
r

t
r
e
a
t
m
e
n
t
K
n
o
b
f

&

S
u
n
(
2
0
0
5
)
3
3
0
A
n

a
d
a
p
t
e
d

v
e
r
s
i
o
n

o
f

t
h
e
S
y
m
p
t
o
m

P
r
o
f
i
l
e

(
S
P
)
1
3
-
f
a
t
i
g
u
e
-
s
k
i
n

c
h
a
n
g
e
s
5
-
p
o
i
n
t

L
i
k
e
r
t
-
t
y
p
e

s
c
a
l
e
:
1
5
P
W
B
,

F
W
B
W
e
e
k
l
y

d
u
r
i
n
g
r
a
d
i
a
t
i
o
n

a
n
d
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
A
u
t
h
o
r
/
Y
e
a
r
N
S
c
a
l
e

N
a
m
e
#

o
f

i
t
e
m
s
a
C
o
n
s
t
r
u
c
t
s
m
e
a
s
u
r
e
d
R
a
t
i
n
g
Q
O
L

a
s
p
e
c
t
a
s
s
e
s
s
e
d
F
r
e
q
u
e
n
c
y

o
f
a
d
m
i
n
i
s
t
r
a
t
i
o
n
(
T
e
e
p
l
e
,

1
9
8
7
,

u
n
p
u
b
l
i
s
h
e
d
m
a
s
t
e
r
s

t
h
e
s
i
s
)
-
s
o
r
e

t
h
r
o
a
t
-
s
l
e
e
p

d
i
f
f
i
c
u
l
t
i
e
s
-
a
n
o
r
e
x
i
a
-
i
n
d
i
g
e
s
t
i
o
n
-
s
e
n
s
o
r
y

c
h
a
n
g
e
s
-
n
a
u
s
e
a
-
a
r
m

e
d
e
m
a
-
b
r
e
a
s
t

e
d
e
m
a
-
d
i
f
f
i
c
u
l
t
y

w
i
t
h

a
r
m
m
o
b
i
l
i
t
y
-
o
t
h
e
r

p
r
o
b
l
e
m
s
-
c
h
a
n
g
e
s

i
n

d
a
i
l
y
a
c
t
i
v
i
t
y

d
u
r
i
n
g
t
r
e
a
t
m
e
n
t
1
=
n
o
t

b
a
d

a
t

a
l
l
5
=
e
x
t
r
e
m
e
l
y

b
a
d
m
o
n
t
h
l
y

f
o
r

3
m
o
n
t
h
s

a
f
t
e
r
t
r
e
a
t
m
e
n
t
M
a
c
B
r
i
d
e

e
t

a
l
.
(
2
0
0
8
)
1
2
8
R
a
d
i
a
t
i
o
n

i
n
d
u
c
e
d

s
k
i
n
r
e
a
c
t
i
o
n

a
s
s
e
s
s
m
e
n
t
(
R
I
S
R
A
S
)
4
-
t
e
n
d
e
r
n
e
s
s
/
d
i
s
c
o
m
f
o
r
t
/
p
a
i
n

o
f
t
h
e

s
k
i
n
-
i
t
c
h
i
n
g

o
f

t
h
e

s
k
i
n
-
b
u
r
n
i
n
g

s
e
n
s
a
t
i
o
n
o
f

t
h
e

s
k
i
n
-
e
x
t
e
n
t

t
o

w
h
i
c
h
s
k
i
n

r
e
a
c
t
i
o
n

a
n
d
s
y
m
p
t
o
m
s

h
a
v
e
a
f
f
e
c
t
e
d

d
a
y

t
o

d
a
y
a
c
t
i
v
i
t
i
e
s
0
3
0
=
n
o
t

a
t

a
l
l
1
=
a

l
i
t
t
l
e
2
=
q
u
i
t
e

a

b
i
t
3
=
v
e
r
y

m
u
c
h
P
W
B
,

F
W
B
W
e
e
k
l
y

d
u
r
i
n
g

R
T
a
n
d

w
e
e
k
l
y

a
f
t
e
r
c
o
m
p
l
e
t
i
n
g
t
r
e
a
t
m
e
n
t

f
o
r

a
m
a
x
i
m
u
m

o
f

4
w
e
e
k
s
D
a
i
l
y

s
y
m
p
t
o
m

d
i
a
r
y

c
a
r
d
s
4
-
p
a
i
n
-
i
t
c
h
i
n
g
-
b
u
r
n
i
n
g
-
s
l
e
e
p

d
i
s
t
u
r
b
a
n
c
e
-
i
m
p
a
c
t

o
f

t
h
e
r
a
d
i
a
t
i
o
n

o
n

t
h
e
i
r
s
k
i
n

r
e
a
c
t
i
o
n
I
n
s
u
f
f
i
c
i
e
n
t

i
n
f
o
r
m
a
t
i
o
n
P
W
B
,

F
W
B
D
a
i
l
y
M
a
c
m
i
l
l
a
n

e
t

a
l
.
(
2
0
0
7
)
4
3
2
2
6
S
y
m
p
t
o
m

D
i
a
r
y

C
a
r
d
s
4
-
p
a
i
n
-
i
t
c
h
i
n
g
-
b
u
r
n
i
n
g
-
s
l
e
e
p

d
i
s
t
u
r
b
a
n
c
e
L
i
k
e
r
t

s
c
a
l
e

i
t
e
m
s

s
c
o
r
e
d
a
s
:
0
=
n
o
t

a
t

a
l
l
1
=
a

l
i
t
t
l
e

(
o
r

e
q
u
i
v
a
l
e
n
t
)
2
=
q
u
i
t
e

a

l
o
t
1
5
P
W
B
,

F
W
B
D
a
i
l
y
P
o
m
m
i
e
r

e
t

a
l
.

(
2
0
0
4
)
4
4
2
5
4
P
a
i
n

v
i
s
u
a
l

a
n
a
l
o
g

S
c
a
l
e
1
-
p
a
i
n
1
0

c
m

(
n
u
m
e
r
i
c
a
l

a
n
d
v
e
r
b
a
l

a
n
c
h
o
r
s

n
o
t
r
e
p
o
r
t
e
d
)
P
W
B
W
e
e
k
l
y
Q
u
e
s
t
i
o
n
n
a
i
r
e

t
o

a
s
s
e
s
s
s
a
t
i
s
f
a
c
t
i
o
n

w
i
t
h

p
a
i
n

a
n
d
d
e
r
m
a
t
i
t
i
s

r
e
l
i
e
f
I
n
s
u
f
f
-
i
c
i
e
n
t

i
n
f
o
r
-
m
a
t
i
o
n
-
s
a
t
i
s
f
a
c
t
i
o
n

w
i
t
h
p
r
e
v
e
n
t
i
o
n

o
f

p
a
i
n
-

s
a
t
i
s
f
a
c
t
i
o
n

w
i
t
h
p
r
e
v
e
n
t
i
o
n

o
f
e
r
y
t
h
e
m
a
I
n
s
u
f
f
i
c
i
e
n
t

i
n
f
o
r
m
a
t
i
o
n
P
W
B
,

T
r
e
a
t
m
e
n
t

S
a
t
i
s
f
a
c
t
i
o
n
A
t

t
h
e

e
n
d

o
f

t
h
e
s
t
u
d
y
P
o
r
o
c
k

&

K
r
i
s
t
j
a
n
s
o
n
(
1
9
9
9
)
4
5
1
2
6
V
i
s
u
a
l

A
n
a
l
o
g

S
c
a
l
e
1
-
p
a
i
n
0
=
n
o

p
a
i
n
1
0
=
w
o
r
s
t

p
a
i
n

t
h
e

p
a
t
i
e
n
t
c
o
u
l
d

i
m
a
g
i
n
e
P
W
B
W
e
e
k
l
y
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
A
u
t
h
o
r
/
Y
e
a
r
N
S
c
a
l
e

N
a
m
e
#

o
f

i
t
e
m
s
a
C
o
n
s
t
r
u
c
t
s
m
e
a
s
u
r
e
d
R
a
t
i
n
g
Q
O
L

a
s
p
e
c
t
a
s
s
e
s
s
e
d
F
r
e
q
u
e
n
c
y

o
f
a
d
m
i
n
i
s
t
r
a
t
i
o
n
P
r
i
m
a
v
e
r
a

e
t

a
l
.
(
2
0
0
6
)
4
6
2
0
P
a
t
i
e
n
t
s

v
i
e
w

o
f

i
t
c
h

a
n
d
p
a
i
n
2
-
i
t
c
h
i
n
g
-
p
a
i
n
V
i
s
u
a
l

N
u
m
e
r
i
c
a
l

S
c
a
l
e
(
0
c
m
-
1
0
c
m
)
P
W
B
B
e
f
o
r
e

R
T
,

w
e
e
k
l
y
d
u
r
i
n
g

R
T
,

f
o
r

2
w
e
e
k
s

a
f
t
e
r

R
T
c
o
m
p
l
e
t
i
o
n
R
o
p
e
r

e
t

a
l
.

(
2
0
0
4
)
4
7
2
0
I
t
c
h
i
n
e
s
s
1
-
i
t
c
h
i
n
g
0

3

s
c
a
l
e

(
n
o
n
e
,

f
a
i
n
t
,
m
o
d
e
r
a
t
e
,

s
t
r
o
n
g
)
P
W
B
A
t

t
h
e

b
e
g
i
n
n
i
n
g

o
f
R
T
,

a
t

d
o
s
e
s

o
f
3
0
/
3
0
.
6

G
y

a
n
d
5
0
/
5
0
.
4

G
y
S
c
h
l
a
p
p
a
c
k

(
2
0
0
4
)
4
8
2
5
V
i
s
u
a
l

A
n
a
l
o
g

S
c
a
l
e
1
-
i
t
c
h
i
n
g
1
0
0
m
m

l
e
n
g
t
h

(
0
m
m

=
n
o

p
r
o
b
l
e
m
,

1
0
0

m
m

=
s
e
v
e
r
e

p
r
o
b
l
e
m
)
P
W
B
B
e
f
o
r
e

p
r
e
s
c
r
i
p
t
i
o
n
o
f

h
o
m
e
o
p
a
t
h
i
c
m
e
d
i
c
i
n
e

a
n
d

a
t
f
o
l
l
o
w
-
u
p

e
v
a
l
u
a
t
i
o
n
S
c
h
m
u
t
h

e
t

a
l
.

(
2
0
0
2
)
2
3
1
7
S
k
i
n
d
e
x
4
9
6
1
5

s
u
b
s
c
a
l
e
s
:
-
d
i
s
c
o
m
f
o
r
t
-
l
i
m
i
t
a
t
i
o
n
s
-
c
o
g
n
i
t
i
v
e
-
s
o
c
i
a
l
-
e
m
o
t
i
o
n
a
l
(
i
n
c
l
u
d
i
n
g
d
e
p
r
e
s
s
i
o
n
,

f
e
a
r
,
e
m
b
a
r
r
a
s
s
m
e
n
t
,

a
n
d
a
n
g
e
r
)
I
t
e
m
s

1

4
8

r
a
t
e
d
:

n
e
v
e
r
,
r
a
r
e
l
y
,

s
o
m
e
t
i
m
e
s
,

o
f
t
e
n
,
a
l
l

t
h
e

t
i
m
e
O
t
h
e
r

i
t
e
m
s

r
a
t
e
d
:
s
t
r
o
n
g
l
y

d
i
s
a
g
r
e
e
,
d
i
s
a
g
r
e
e
,

s
l
i
g
h
t
l
y
d
i
s
a
g
r
e
e
,

s
l
i
g
h
t
l
y

a
g
r
e
e
,
a
g
r
e
e
,

s
t
r
o
n
g
l
y

a
g
r
e
e
S
k
i
n
-
D
i
s
e
a
s
e

S
p
e
c
i
f
i
c
H
e
a
l
t
h
-
R
e
l
a
t
e
d

Q
O
L
A
t

t
h
e

b
e
g
i
n
n
i
n
g

o
f
R
T

a
n
d

f
o
r
a
p
p
r
o
x
i
m
a
t
e
l
y

8
w
e
e
k
s

p
o
s
t

R
T
S
c
h
n
u
r

&

M
o
n
t
g
o
m
e
r
y
(
2
0
0
8
)
5
0
2
V
i
s
u
a
l

A
n
a
l
o
g

S
c
a
l
e
1
-
d
i
s
c
o
m
f
o
r
t
1
0
0

m
m

v
i
s
u
a
l

a
n
a
l
o
g
s
c
a
l
e

r
a
n
g
i
n
g

f
r
o
m

0
1
0
0
.
P
W
B
W
e
e
k
l
y

d
u
r
i
n
g

R
T
S
z
u
m
a
c
h
e
r

e
t

a
l
.
(
2
0
0
1
)
5
1
6
0
S
e
l
f
-
a
d
m
i
n
i
s
t
e
r
e
d
q
u
e
s
t
i
o
n
n
a
i
r
e

t
h
a
t

e
v
a
l
u
a
t
e
d
s
k
i
n

s
y
m
p
t
o
m
s
.
4
-
d
r
y
n
e
s
s

o
r

i
t
c
h
i
n
e
s
s
-
p
a
i
n

o
r

s
o
r
e
n
e
s
s
-
b
l
i
s
t
e
r
i
n
g

o
r
b
r
e
a
k
d
o
w
n

o
f

t
h
e
s
k
i
n
-
f
i
t
t
i
n
g

o
f

b
r
a
s
s
i
e
r
e
o
r

o
t
h
e
r

c
l
o
t
h
i
n
g
1
4

s
c
a
l
e

w
h
e
r
e

1

=

n
o
t

a
t
a
l
l

a
n
d

4

=

v
e
r
y

m
u
c
h
P
W
B
,

F
W
B
B
e
f
o
r
e

R
T
,

w
e
e
k
l
y
d
u
r
i
n
g

R
T
,

a
n
d

2
a
n
d

4

w
e
e
k
s

p
o
s
t
-
R
T
W
e
l
l
s

e
t

a
l
.

(
2
0
0
4
)
1
5
2
2
6
P
a
t
i
e
n
t

d
i
a
r
y

c
a
r
d
5
-
p
a
i
n
-
i
t
c
h
i
n
g
-
b
u
r
n
i
n
g
-
s
l
e
e
p

d
i
s
t
u
r
b
a
n
c
e
-
d
e
g
r
e
e

o
f
d
e
s
q
u
a
m
a
t
i
o
n
-
d
e
g
r
e
e

o
f

e
r
y
t
h
e
m
a
L
i
k
e
r
t

s
c
a
l
e

i
t
e
m
s

s
c
o
r
e
d
a
s
:
0
=
n
o
t

a
t

a
l
l
1
=
a

l
i
t
t
l
e

(
o
r

e
q
u
i
v
a
l
e
n
t
)
2
=
q
u
i
t
e

a

l
o
t
R
a
t
e
d

f
r
o
m

0
3
0
=
n
o

d
r
y

o
r

b
r
o
k
e
n

s
k
i
n
3
=
b
r
o
k
e
n

a
n
d
/
o
r

w
e
e
p
i
n
g
i
n

l
a
r
g
e

p
a
t
c
h
e
s
I
n
s
u
f
f
i
c
i
e
n
t

i
n
f
o
r
m
a
t
i
o
n
P
W
B
,

F
W
B
W
e
e
k
l
y

d
u
r
i
n
g

R
T
,
u
n
t
i
l

a
t

l
e
a
s
t

2

w
e
e
k
s
p
o
s
t

R
T

o
r

u
n
t
i
l

s
k
i
n
h
a
d

h
e
a
l
e
d
P
a
t
i
e
n
t
s

w
e
r
e
e
n
c
o
u
r
a
g
e
d

t
o

f
i
l
l

i
n
t
h
e

d
i
a
r
y

c
a
r
d

o
n

a
d
a
i
l
y

b
a
s
i
s
D
e
r
m
a
t
o
l
o
g
y

l
i
f
e

q
u
a
l
i
t
y
i
n
d
e
x
(
D
L
Q
I
)

5
2
,

5
3
1
0
D
o
m
a
i
n
s

i
n
c
l
u
d
e
:
-
i
t
c
h
i
n
g
/
s
t
i
n
g
i
n
g
/
p
a
i
n
-
e
m
b
a
r
r
a
s
s
m
e
n
t
-
d
o
m
e
s
t
i
c

d
u
t
i
e
s
-
c
l
o
t
h
i
n
g
E
a
c
h

q
u
e
s
t
i
o
n

i
s

s
c
o
r
e
d
f
r
o
m

0
3
0
=
n
o
t

a
t

a
l
l
3
=
v
e
r
y

m
u
c
h
P
W
B
,

E
W
B
,

F
W
B
,

B
o
d
y
i
m
a
g
e
,

S
o
c
i
a
l
/
S
e
x
u
a
l

w
e
l
l
-
b
e
i
n
g
,

T
r
e
a
t
m
e
n
t

S
a
t
i
s
f
a
c
t
i
o
n
W
e
e
k
l
y

u
n
t
i
l

a
t

l
e
a
s
t
2

w
e
e
k
s

a
f
t
e
r
c
o
m
p
l
e
t
i
o
n

o
f

R
T

o
r
u
n
t
i
l

a
n
y

s
k
i
n
r
e
a
c
t
i
o
n

h
a
d

t
o
t
a
l
l
y
h
e
a
l
e
d
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
N
I
H
-
P
A

A
u
t
h
o
r

M
a
n
u
s
c
r
i
p
t
A
u
t
h
o
r
/
Y
e
a
r
N
S
c
a
l
e

N
a
m
e
#

o
f

i
t
e
m
s
a
C
o
n
s
t
r
u
c
t
s
m
e
a
s
u
r
e
d
R
a
t
i
n
g
Q
O
L

a
s
p
e
c
t
a
s
s
e
s
s
e
d
F
r
e
q
u
e
n
c
y

o
f
a
d
m
i
n
i
s
t
r
a
t
i
o
n
-
s
o
c
i
a
l
/
l
e
i
s
u
r
e
a
c
t
i
v
i
t
i
e
s
-
s
p
o
r
t
s
-
w
o
r
k
/
s
t
u
d
y
-
r
e
l
a
t
i
o
n
s
h
i
p
s
-
s
e
x
-
s
k
i
n

t
r
e
a
t
m
e
n
t
s
W
i
l
l
i
a
m
s

e
t

a
l
.

(
1
9
9
6
)
5
4
1
9
1
S
k
i
n

r
e
a
c
t
i
o
n

q
u
e
s
t
i
o
n
n
a
i
r
e
3
-
m
a
x
i
m
u
m
d
e
r
m
a
t
i
t
i
s

s
e
v
e
r
i
t
y
-
t
i
m
e

t
o

o
c
c
u
r
r
e
n
c
e
o
f

s
e
v
e
r
e

d
e
r
m
a
t
i
t
i
s
-
d
u
r
a
t
i
o
n

o
f

s
e
v
e
r
e
d
e
r
m
a
t
i
t
i
s
S
e
v
e
r
i
t
y

r
a
t
e
d

a
s

n
o
n
e
,
m
i
l
d
,

m
o
d
e
r
a
t
e
,

o
r

s
e
v
e
r
e
P
W
B
A
t

s
t
u
d
y

i
n
i
t
i
a
t
i
o
n
a
n
d

w
e
e
k
l
y

u
n
t
i
l

1
m
o
n
t
h

a
f
t
e
r
c
o
m
p
l
e
t
i
o
n

o
f

R
T
N
o
t
e
:

E
W
B

=

E
m
o
t
i
o
n
a
l

W
e
l
l
-
B
e
i
n
g
;

F
W
B

=

F
u
n
c
t
i
o
n
a
l

W
e
l
l
-
B
e
i
n
g
;

N
R

=

n
o
t

r
e
p
o
r
t
e
d
;

P
W
B

=

P
h
y
s
i
c
a
l

W
e
l
l
-
B
e
i
n
g
;

Q
O
L

=

Q
u
a
l
i
t
y

o
f

L
i
f
e
;

R
T

=

R
a
d
i
o
t
h
e
r
a
p
y
;

R
T
O
G

=

R
a
d
i
a
t
i
o
n

T
h
e
r
a
p
y

O
n
c
o
l
o
g
y
G
r
o
u
p

Ni Hms 494089

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Ni Hms 494089

Uploaded by

Copyright:

Available Formats

A systematic review of patient-rated measures of radiodermatitis

in breast cancer radiotherapy

You might also like