Adjuvant breast radiotherapy (RT) is associated with acute skin toxicities including erythema and desquamation that may be associated with a detrimental impact on patients’ quality of life. Management of radiation-induced skin reactions (RISR) is contentious due to conflicting literature. There is a lack of evidence for the use of aqueous cream although this is commonly used in UK cancer centres. Alternative preparations such as Moogoo udder cream® are more expensive and may be more efficacious. The aim of this study was to investigate patient experience of RISRs and determine whether they would be willing to purchase a cream not provided on the NHS, should one be demonstrated to be more efficacious.
A single-centre questionnaire based study of 60 patients receiving adjuvant breast RT was designed to explore patients’ expectations regarding RISRs and their willingness to purchase a skin preparation, should one be demonstrated to be efficacious, in relation to age, smoking history, and financial status.
45 questionnaires (75%) were completed. Two thirds of all respondents were willing to purchase an efficacious skin preparation. Younger patients (30-49 years) all anticipated developing RISRs. In addition this age cohort was more likely to purchase a skin preparation compared to the older age cohorts (50-69; 70+ years). Current smokers were less likely to definitely purchase or consider purchasing a cream compared to ex-smokers and non-smokers.
There was a strong correlation between younger age, anticipation of RISRs, and willingness to purchase an effective cream, which is potentially due to increased access to additional sources of health information. Older patients (>70 years) had a lower expectation of RISRs which may be due to a combination of reduced consultation information recall and less access to additional information e.g. internet and online forums. Smokers experience a higher level of acute RT toxicities however expenditure on tobacco may explain reluctance to purchase a cream. Clear evidence based guidance is required to facilitate optimal management of this common RT toxicity.
Whole breast radiotherapy (RT) is the standard of care in patients with early breast cancer treated with breast conserving surgery. RT improves local control and confers a survival advantage in this patient group . However it has both acute and late toxicities which may be significant and impact on quality of life. Megavoltage RT promotes the skin sparing effect but, despite this, erythema, dry desquamation and moist desquamation are not uncommon. Intensity modulated RT (IMRT) is a more complex technique  which achieves a more homogenous dose throughout the whole breast tissue and has been demonstrated in a randomised clinical trial to reduce the incidence of moist desquamation .
The Edinburgh Cancer Centre treats approximately 950 patients with breast RT annually. At present, aqueous cream is provided routinely to patients at the end of their course of treatment. The optimal management, and prevention, of acute skin reactions is a contentious issue with limited published data.
A prospective audit was conducted to investigate breast cancer patients’ experiences of radiation induced skin reactions (RISRs) in order to understand patient attitudes to skin reaction management. The audit also sought to explore whether patients would be willing to purchase an alternative topical treatment for the management of RISRs, not provided on the NHS, should one be proved to be efficacious.
The study was approved by the University of Edinburgh College of Medicine. A questionnaire was developed by all authors and contributing authors and was circulated for 3 weeks to women undergoing breast RT at the Edinburgh Cancer Centre in February 2013. Questions were formulated through group discussion, taking into account the target group and study aims. The questionnaire was distributed to patients via their radiographer either at initiation of treatment or during treatment review appointments. Therefore, responses were acquired from women at all stages of RT treatment. Information collected included age, employment and economic status as well as smoking history, pre-existing skin conditions and perceived anticipation of skin toxicities. Anonymity was assured by providing a blank envelope in which completed questionnaires could be returned.
In addition, 4 qualitative interviews were conducted with patients currently undergoing treatment to gain a more patient-centred and comprehensive understanding of the results. The interviews were approximately 10 minutes in length and covered the key aspects of the questionnaire. They helped to minimise any possible confusion regarding questions in the questionnaire and allowed for more extensive answers. Further questions concerned the degree of information provided by the hospital regarding treatment. Patients’ opinions of this were recorded and details of their own independent research were discussed.
60 questionnaires were circulated, with 45 completed thus giving a response rate of 75%. The median age of respondents was in the 50-69 age bracket. 10 patients (22%) identified themselves as current smokers and 15 (33%) identified themselves as ex-smokers.
Figure 1 shows the proportions of patients willing to spend money on an efficacious product should one be identified. 20% of all patients stated that they would be willing to purchase a product (Figure 1). It was found that 60% of all respondents were willing to spend, or consider spending, money on a product; whereas 9% of respondents stated that they would definitely not pay (Figure 1).
Patients who identified themselves as current smokers were less likely to definitely buy a product to manage RISRs, should one be recommended, compared to both ex-smokers and those who had never smoked (Figure 2). 10% (1 of 10) of current smokers were definitely willing to purchase a product, compared to 20% (3 of 15) of ex-smokers and 25% (5 of 20) of those who never smoked.
Current smokers were also less likely to either definitely buy or consider purchasing a product compared to ex-smokers and those who had never smoked. In the current smokers group, 50% (5 of 10) would definitely buy or consider buying a product. Amongst the patients who used to smoke, 67% (10 of 15) of respondents were willing to pay, or consider paying, for a more effective product. Among those who had never smoked, the proportion was 60% (12 of 20).
However, 8% (2 of 25) of those who smoked or used to smoke definitely would not consider spending money on a recommended product; compared to 10% (2 of 20) of those who had never smoked.
Patients in the youngest age cohort (Figure 3) all anticipated developing a RISR. 31% of the group were aged 70+ (14 of 45), 51% were in the 50-69 age group (23 of 45) and the 30-49 age group was the least represented with 18% (8 of 45). All patients in the 30-49 age group anticipated RISRs. However, there was no significant trend in the 50-69 and 70+ age groups with 30% of the 50-69 group (7 of 23) and 29% (4 of 14) of the 70+ group anticipating RISRs.
Of the respondents aged 30-49 years, 88% (7 of 8) said that they would pay, or consider paying, for an alternative product – a result which was greater than both the 50-69 and the 70+ age groups (Figure 4). The percentage of patients who stated that they would definitely not purchase a product was the smallest in the 30-49 age group, as no patients answered with this, and was the highest in the 70+ age group with 14% (2 of 14).
The optimal management of acute radiotherapy skin reactions is unclear and remains a contentious issue .
It was expected that smokers and ex-smokers may be less likely to definitely pay for a cream due to the extra expense associated with smoking in comparison to those who had never smoked. However, this may apply primarily to those who perceive themselves to be of less favourable financial status. This was the case, as a lower proportion of current smokers said that they would definitely pay for an alternative product compared to ex-smokers and those who had never smoked. The proportion of current smokers that would either definitely purchase a recommended product or consider doing so was also lower than ex-smokers and those who had never smoked.
Smokers experience an increased incidence of RISRs  and therefore may feel an increased need for a product, such as a cream, to manage the symptoms. This could help explain why the proportion of ex-smokers willing to consider spending money on an alternative product, depending on its price, was higher than expected. As an example, Moogoo Skin Milk Udder Cream® costs around £8 per 120g [6, 7].
The proportion of those who had never smoked that stated they would definitely not purchase a product was slightly higher than those with a smoking history. This could be explained by the documented increased incidence of RISRs in smokers but the small sample size makes this result difficult to interpret.
All respondents aged 30-49 anticipated skin reactions and were more willing to purchase an alternative product compared to the older groups. This could be because younger adults are more likely to have Internet access , and thus could be better informed. However, all patients in the 30-49 age group had a skin reaction at the time of questionnaire distribution and were also in the later stages of RT. This could have allowed for bias and would thus be a point of improvement for future studies.
Differing stages of treatment introduced an additional variable. RISRs tend to develop a few weeks into radiotherapy  and therefore this could affect the validity of the results. Therefore, to improve, the sample size would need to be increased and the data analysed separately for women at different treatment stages. This would allow a greater understanding of whether this factor had significant bearing on the willingness to invest in cream.
There may be an increased trust in the NHS amongst the older population, with the elderly being more likely to prefer for the doctor to make the decisions . Therefore this could explain why fewer older patients were willing to pay for an alternative treatment.
It was difficult to assess the effect of financial status due to the subjectivity of both answering the questions and interpreting results. This could impact the amount of money that patients would consider spending on an alternative treatment. Results could have been skewed by personal perception of financial status, as comparative deprivation may have an impact . Future studies could look at this further.
Opinions from two Scotland-based dermatologists, Dr Susannah Fraser and Dr Megan Mowbray (NHS Fife), were also sought regarding the best cream for RISRs. One stated that they have omitted aqueous cream from their practice whereas the other believed it to be of some benefit for RISRs. Both indicated that aqueous cream would not be their first line treatment, as greasy emollients are thought to be generally better for dry or scaly skin. It was also mentioned that topical steroids are sometimes used if the skin is particularly red or inflamed. However, it is generally the oncology departments who deal with RISRs rather than dermatology with the best treatment generally depending on patient preference and overall ease of application.
The opinions ascertained, regarding the use of aqueous cream in RISRs, from the dermatologists were conflicting, reflecting the inconsistencies of advice in this field . For example, it has been suggested that using aqueous cream can cause more damage than benefit to the skin due to irritation . It has also been proposed that steroid cream could be an effective alternative to moisturisers. This could indicate an area for further research .
The results suggest the need for more consistent and comprehensive information regarding RISR management. Through reviewing the literature, great disparity in the advice given to patients following their radiotherapy treatment was noted. The study results show that the majority of the sample would be willing to spend their own money on cream and this suggests that a national list of NHS advised alternative products might be of use. However, the small sample size limits data analysis, in particular with respect to sub-groups. Furthermore, a study encompassing a more comprehensive analysis of the impact of financial status in this patient group would be of benefit. Thus it is clear more scientific research is needed in this area, providing a large scope for future work.
Acknowledgements: We thank Dr Fraser and Dr Megan Mowbray for their contribution.
Declarations: We have no financial interest in Moogoo udder cream®
1. Early Breast Cancer Trialists' Collaborative Group: Effects of radiotherapy on 10-year recurrence and 15- year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials. Lancet. 2011; 378:1707-1716. doi: 10.1016/S0140-6736(11)61629-2
2. Pignol J. et al. A Multicenter Randomized Trial of Breast Intensity-Modulated Radiation Therapy to Reduce Acute Radiation Dermatitis. J Clin Oncol. 2008; 28(13);2085-2092. doi: 10.1200/JCO.2007.15.2488
3. Freedman GM, Anderson PR, Li J, et al. Intensity modulated radiation therapy (IMRT) decreases acute skin toxicity for women receiving radiation for breast cancer. Am J Clin Oncol. 2006; 29:66–70.
4. Salvo, N. et al. Prophylaxis and management of acute radiation-induced skin reactions: a systematic review of the literature. Current Oncology. 2010; 17(4): 94-112.
5. Sharp L, Johansson H, Hatschek T, Bergenmar M. Smoking as an independent risk factor for severe skin reactions due to adjuvant radiotherapy for breast cancer. The Breast. 2013; 22(5):634-638. doi: 10.1016/j.breast.2013.07.047
6. MooGoo Skin Care [Internet]. Australia: MooGoo UK; c2015. Skin Milk Udder cream; 2015 Feb 22 [cited 2015 Feb 22]. Available from: http://moogooskincare.co.uk/udder-cream-skin-milk.html
7. Chan RJ, Keller J, Cheuk R, Blades R, Tripcony L, Keogh S. A double-blind randomised controlled trial of a natural oil-based emulsion (Moogoo Udder Cream®) containing allantoin versus aqueous cream for managing radiation-induced skin reactions in patients with cancer. Radiation Oncology. 2012; 7:121. Doi: 10.1186/1748-717X-7-121.
8. Smith Wagner L, Wagner TH. The Effect of Age on the Use of Health and Self-Care Information: Confronting the Stereotype. The Gerontologist. 2003; 43(3):318-324.
9. Coulter A. Paternalism or partnership? BMJ. 1999; 319(7212):719–720.
10. Liang J, Fairchild TJ. Relative Deprivation and Perception of Financial Adequacy Among the Aged. The Journal of Gerontology. 1979; 34(5):746-759. doi: 10.1093/geronj/34.5.746
11. Patel AN, Varma S, Batchelor JM, Lawton PA. Why Aqueous Cream should not be used in Radiotherapy-induced Skin Reactions. Clinical Oncology. 2013; 25:272-273. doi: 10.1016/j.clon.2012.11.011
12. Ulff E, Maroti M, Serup J, Falkmer U. A potent steroid cream is superior to emollients in reducing acute radiation dermatitis in breast cancer patients treated with adjuvant radiotherapy- a randomised study of betamethasone versus two moisturizing creams. Radiotherapy and Oncology. 2013; 108(2):287-292. doi: 10.1016/j.radonc.2013.05.033