Dermatology Expert Discusses Challenges Facing Cancer Patients

Mario E. Lacouture, MD

Dermatologist

Memorial Sloan-Kettering

Cancer Center

New York, NY

Skin conditions can affect patients throughout their cancer trajectory, emerging or persisting even after treatment ends. Novel therapies also have heightened the need for clinicians to be well informed on potential skin-related adverse events to help ensure that patients adhere to their regimens and complete treatment.

Mario E. Lacouture, MD, dermatologist at Memorial Sloan-Kettering Cancer Center in New York, has focused on the impact that targeted therapies can have on patients. He founded the SERIES (Skin and Eye Reactions to Inhibitors of EGFR and kinases) Clinic at Northwestern University in Chicago, which brings together specialists in patient care, education, and research to help minimize adverse effects.

Lacouture is the author of a new book, Dr. Lacouture’s Skin Care Guide for People Living With Cancer, which offers practical information and resources for patients and providers, featuring answers to those questions patients can be expected to ask about dermatologic issues they may experience before, during, and after treatment.

In this interview, Lacouture discusses the role that members of the oncology treatment team play in helping patients with any skin care issues that may arise.

What are some of the considerations for ensuring access to dermatologic care?

Only about 8% of cancer patients with dermatologic conditions are sent to a dermatologist. In most dermatology offices, studies show that the median wait time for appointments is about one month, but patients with cancer need immediate attention, because many of the adverse events will determine whether or not patients can stay on therapy.

Just as hematopoietic and gastrointestinal adverse events are being addressed by oncologists and oncology nurses, dermatologic adverse events need to be addressed by these professionals because of the necessity for immediate attention; also, patients are tired, they are coming to the hospital every week, and many will not want to wait for another appointment for their issues to be addressed. Novel therapies also present new types of reactions, and oncology nurses and oncologists are on the front lines of addressing these adverse events.

The issue of availability of dermatologic care will be mitigated by increasing the knowledge of oncologists and oncology nurses. Ways to do that are varied, and include more pharmaceutical support for educational programs. Also, these types of toxicities are ideal for nurses to study as part of their research projects.

It only takes one person, be it the oncologist or the oncology nurse, who really believes in an approach that works⎯for example, that every patient who starts on an EGFR inhibitor like Tarceva [erlotinib] or Erbitux [cetuximab] be given antibiotics at the beginning of therapy to prevent the rash; they will always treat these patients prophylactically to prevent these adverse events.

You note in your book that patients are sometimes reluctant to bring up skin-related adverse events during their office visits, believing these issues are annoyances more than real problems. What accounts for this?

This issue hasn’t been formally studied, but I would like to study it. It was first brought to my attention by an oncology nurse. With any other disease, patients will tell you if a medication is causing them problems. In oncology, we’re in the unique situation where patients want to hide or underreport their adverse events because they don’t want their doctor to stop their therapy. Secondly, with everything else that is going on, patients want to focus on whether the drug is working or not.

One way to overcome this problem is that, at the beginning of therapy, the oncology nurse or oncologist assuage the patient’s concerns by telling them, “We have treatments for almost every type of dermatologic condition that may occur from your therapy, if you tell us early enough and you stick with the prescriptions that we give you.” I think that by telling patients this, we may be able to minimize patients’ unwillingness to report.

How can providers assist patients who experience dermatologic adverse events that appear or continue after the treatment ends, especially in the context of the growing number of cancer survivors?

This is a relatively new field. In dermatology, it’s important to keep in mind that this focus on cancer patients has really emerged in the last five years or so—that there are few dermatologists focusing only on cancer patients.

Here is just one example of the many issues affecting survivors: Many women have their ports placed on the chest for the delivery of chemotherapy. Once they complete their chemotherapy, the port is removed, but in many cases the way it is removed and the wound is closed leaves a wide, gaping scar in the chest. Many patients feel very uncomfortable about this, but don’t realize that these scars can be effectively reduced in size by either using topical steroids or laser treatments, or, in some cases, having a plastic surgeon revise the scar to make it smaller and less noticeable.

Some of the newer therapies have fewer adverse events when compared with cytotoxic chemotherapies in terms of complete hair loss, but they do cause alterations in hair that in many cases can be mitigated or are temporary. One recent analysis has demonstrated that women after breast cancer chemotherapy can develop persistent hair loss, and this is something that more people need to be aware of, including patients. Also, when patients are placed on tamoxifen or aromatase inhibitors for five or 10 years, they develop hair thinning, which may not be as severe, but some of them will argue that, “to reduce my risk of recurrence, I’d really rather have my hair for the next 10 years.” I’ve seen many patients who have actually turned down either hormonal therapy or, in some cases, some types of chemotherapy. We have certain interventions to try to improve upon this⎯for example, products and medications that have mostly been used in men for hair loss that occurs with age.

One study we just published (J Clin Oncol. 2012;30(20):2466-2474) showed that in childhood cancer survivors, persistent hair thinning and scarring were associated with depression and anxiety when these patients became teenagers or adults—and understandably so. The oncology nurse or oncologist, when he or she sees a survivor, could ask, “Is anything about your previous treatment still affecting you?” Persistent hair thinning or scars are perennial concerns, and they should refer the patient to a dermatologist.

What is your overarching message about dermatologic care in the oncology setting?

For the great majority of dermatologic conditions, there are interventions, either through medications or procedures that can minimize these conditions to such a point that they will not affect patients or their treatment. This is the biggest point of my book and for everything I do in my practice. There is almost always something that can be done to mitigate the majority of these adverse events.