RTOG CRI TERI A TO EVALUATE ACUTE SKI N REACTI ON AND I TS RI SK FACTORS I N
PATI ENTS W I TH BREAST CANCER SUBMI TTED TO RADI OTHERAPY
Ana Mar ia Teix eir a Pir es1 Rober t o Ar au j o Segr et o2 Helena Regina Côm odo Segr et o2
Pir es AMT, Seg r et o RA, Seg r et o HRC. RTOG cr it er ia t o ev alu at e acu t e sk in r eact ion an d it s r isk f act or s in pat ien t s w it h br east can cer su bm it t ed t o radiot h er apy. Rev Lat in o- am En f er m agem 2 0 0 8 set em br o- ou t u br o; 1 6 ( 5 ) : 8 4 4 - 9 .
Pur pose: Ev aluat e and classify sk in r eact ions t hr ough t he Radiat ion Ther apy Oncology Gr oup ( RTOG) cr it er ia an d ch ar act er ize f act or s t h at can in t er v en e in t h ese r eact ion s. Met h od: Pr ospect iv e st u dy , w it h 8 6 w om en subm it t ed t o adj uvant br east r adiot her apy w it h a t ot al dose of 5040cGy, in a 6 MeV Linear Acceler at or . Per sonal dat a w er e collect ed and br east size w as m easur ed ( dist ance bet w een field separ at ion and br east height ) . The t r eat ed sk in ar ea w as ev alu at ed w eek ly . Resu lt s: Br east h eig h t an d t r eat m en t t ech n iq u e w er e sig n if ican t fact or s in t he univar iat e analysis for t he incidence of degr ee 3 skin r eact ions. How ever , only br east height w as a sign if ican t f act or in t h e m u lt iv ar iat e an aly sis f or t h e sev er it y of sk in r eact ion s. Th e ch an ces of occu r r in g degr ee 3 r eact ions incr ease 2. 61 t im es for each incr ease in height unit ( cm ) . These findings allow nur ses t o plan m or e adequat e and individualized pr ocedur es for each pat ient and cont r ibut e t o t he opt im izat ion of t r eat m ent . DESCRI PTORS: r adiot h er apy ; on cologic n u r sin g; r adioder m at it is; br east n eoplasm s
EVALUACI ÓN DE LAS REACCI ON ES AGUDAS DE LA PI EL Y SUS FACTORES DE RI ESGO EN
PACI ENTES CON CÁNCER DE MAMA SOMETI DOS A RADI OTERAPI A
El obj et iv o fue ev aluar y clasificar las r eacciones de la piel según los cr it er ios del Radiat ion Ther apy Oncology Gr oup ( RTOG) y car act er izar fact or es que puedan int er fer ir en esas r eacciones. Met odología: Est udio pr ospect ivo, con 86 m uj er es som et idas a la r adiot er apia en la m am a, dosis t ot al de 5040cGy , con Aceler ador Lineal de 6 MeV. Fuer on r ecolect ados dat os per sonales y m edido el t am año de la m am a ( dist ancia ent r e la separ ación de los cam pos y la alt ur a de la m am a) . La evaluación de la piel del ár ea de t r at am ient o fue r ealizada sem analm ent e. Result ados: La alt ur a de la m am a y la t écnica de t r at am ient o fuer on significat iv os en el análisis univ ar iado, p ar a in cid en cia d e r eacción d e p iel g r ad o 3 . Sin em b ar g o, solam en t e la alt u r a d e la m am a f u e el f act or significat iv o en el análisis m ult iv ar iado par a la gr av edad de la r eacción de la piel. La pr obabilidad de ocur r ir una r eacción gr ado 3 aum ent a 2, 61 v eces por cada aum ent o de 1 unidad de alt ur a en cm . Lo encont r ado le per m it e al en fer m er o plan ificar con du ct as m ás adecu adas e in div idu alizadas par a cada pacien t e y con t r ibu ir par a opt im izar el t r at am ient o.
DESCRI PTORES: r adiot er apia; en fer m er ía on cológica; r adioder m at it is; n eoplasias de la m am a
AVALI AÇÃO DAS REAÇÕES AGUDAS DA PELE E SEUS FATORES DE RI SCO EM PACI EN TES
COM CÂNCER DE MAMA SUBMETI DAS À RADI OTERAPI A
O obj et iv o dest e est udo foi av aliar e classificar as r eações de pele, segundo os cr it ér ios do Radiat ion Ther apy Oncology Gr oup ( RTOG) e car act er izar fat or es que possam int er fer ir nessas r eações. A m et odologia usada foi o est u d o p r osp ect iv o, com 8 6 m u lh er es su b m et id as à r ad iot er ap ia n a m am a, d ose t ot al d e 5 0 4 0 cGy , com Aceler ador Linear de 6 MeV. Colet ou- se dados pessoais e foi m edido o t am anho da m am a ( dist ância ent r e a se p a r a çã o d o s ca m p o s e a l t u r a d a m a m a ) . A a v a l i a çã o d a p e l e n a á r e a d e t r a t a m e n t o f o i r e a l i za d a sem analm ent e. Concluiu- se que a alt ur a da m am a e a t écnica de t r at am ent o for am significant es na análise univar iada, par a incidência de r eação de pele gr au 3. Por ém , apenas a alt ur a da m am a foi fat or significant e na an álise m u lt iv ar iada par a a gr av idade da r eação de pele. A ch an ce de ocor r er r eação gr au 3 au m en t a 2 , 6 1 v ezes a cad a au m en t o d e 1 u n id ad e d e alt u r a em cm . Esses ach ad os p er m it em ao en f er m eir o p r og r am ar condut as m ais adequadas e indiv idualizadas a cada pacient e e cont r ibuir par a a ot im ização do t r at am ent o.
DESCRI TORES: r adiot er apia; en f er m agem on cológica; r adioder m at it e; n eoplasias da m am a
1
M.Sc, Nur se, Radiot herapy Cent er, Hospit al Alem ão Osw aldo Cr uz, Brazil; 2 Associat e Pr ofesor, São Paulo Federal Univer sit y, Brazil.
I NTRODUCTI ON
R
ad i o t h er ap y h as b een u sed as ad j u v an t t h er apy in pat ien t s w it h br east can cer su bm it t ed t ocon ser v at iv e su r g er ies in in it ial st ag es. I t aim s t o
dim inish loco- regional recurrence and favor survival( 1- 2).
Sk in r eact ion is one of t he fr equent adv er se
r eact ion s t h at occu r in pat ien t s su bm it t ed t o br east
can cer r ad i o t h er ap y. Acu t e r ad i o d er m at i t i s b eg i n s
ar ou n d t h e secon d/ t h ir d w eek of t r eat m en t , du e t o
dest r uct ion of cells in t he epider m al basal layer ( loss
o f p e r m e a b i l i t y ) w i t h e x p o s u r e o f t h e d e r m i s
( i n f l a m m a t o r y p r o c e s s ) , a n d i s m a n i f e s t e d a s
er y t h em a, w h ich can eit h er p r og r ess t o ex u d at iv e
derm at it isor not( 3- 4).
I n 1 9 8 2 , t h e Ra d i a t i o n Th er a p y On co l o g y
Gr o u p ( RTOG) d e v e l o p e d t h e Ra d i a t i o n Mo r b i d i t y
Scor in g Cr it er ia t o classif y r ad iot h er ap y ef f ect s. I t
ident ifies degr ee 0 ( no r eact ion) , 1 ( faint er y t hem a,
dr y desquam at ion, epilat ion, dim inished sw eat ing) , 2
( m oder at e, br isk er y t h em a, ex u dat iv e der m at it is in
p l a q u e s a n d m o d e r a t e e d e m a ) , 3 ( e x u d a t i v e
d e r m a t i t i s, b e si d e s cu t a n e o u s f o l d s a n d i n t e n se
ed em a) an d 4 ( u lcer at ion , h em or r h ag e, n ecr osis) .
RTOG scor e has been w idely em ployed for m or e t han
2 5 y e a r s a n d i s a cce p t e d a n d a ck n o w l e d g e d b y
m edical and nur sing com m unit ies( 5).
The sever it y of skin r eact ions is at t r ibut ed t o
f act or s r elat ed t o r ad iat ion , su ch as t ot al d osag e,
f r a c t i o n i n g s c h e m e , r a d i a t i o n e n e r g y ( t y p e o f
eq u ip m en t ) , v olu m e of ir r ad iat ed t issu e an d r ad
io-sensit iv it y of t he t issue inv olv ed. I t is believ ed t hat
p a t i e n t - r e l a t e d f a c t o r s , s u c h a s a g e , s m o k i n g ,
c o e x i s t e n t c h r o n i c d i s e a s e s a n d c o n c o m i t a n t
ant ineoplast ic t reat m ent can int erfere in skin react ions
due t o t he alt er ed healing pr ocess( 3).
I t has been obser v ed t hat br east size is an
im p or t an t f act or f or st r on g er sk in r eact ion s. Lar g e
br east s r eceiv e lar ger ir r adiat ion doses on t h e sk in
t o assur e adequat e dosage in deeper st r uct ur es and
t issues( 6). Thus, a significant par t of t he skin and br east
fold is ex posed t o r adiat ion, incr easing t he ir r adiat ed
v o l u m e( 6 ). H o w e v e r, t h e r e i s n o m a t h e m a t i c a l
par am et er in lit erat ure t hat indicat es how m uch br east
si ze i n cr eases ch an ces o f m o r e sev er e acu t e sk i n
r eact ion s.
Accu r at e k n ow led g e on f act or s in h er en t t o
pat ient s, r elat ed t o t he disease and t o t he t r eat m ent
and t heir im por t ance for t he sever it y of skin react ions,
c a n c e r t a i n l y c o n t r i b u t e t o o r i e n t a t i o n a n d
in d iv id u alized car e, im p lem en t at ion of n u r sin g car e
a n d o p t i m i z a t i o n o f t r e a t m e n t . Re c o r d i n g t h i s
infor m at ion cont r ibut es t o evaluat e t he pat ient at any
m o m e n t , t o f o l l o w - u p t h e t r e a t m e n t i n a m o r e
com plex w ay and offer qualit y car e( 7).
Ther efor e, t his st udy aim ed t o ev aluat e and
classify sk in r eact ions accor ding t o t he RTOG cr it er ia
a n d ch a r a ct e r i ze p o t e n t i a l f a ct o r s r e l a t e d t o t h e
t r eat m en t an d t h ose in h er en t t o p at ien t s t h at can
int erfere in t he react ions of w om en w it h breast cancer
su bm it t ed t o r adiot h er apy.
B e c a u s e o f t h e a b o v e , o b s e r v a t i o n a n d
c l a s s i f i c a t i o n o f s k i n r e a c t i o n s c a u s e d b y
r ad i o t h er a p y, v er i f i cat i o n o f f act o r s r el at ed t o t h e
t r ea t m en t o r i n t r i n si c t o ea ch p a t i en t , w h i ch ca n
aggr av at e r eact ions, ar e r elev ant for or ient at ions t o
t h e se p a t i e n t s, so t h a t t h e y ca n t a k e a d e q u a t e
m easur es t o m inim ize and/ or t r eat t hem , opt im izing
t he t r eat m ent .
CASUI STI C AND METHOD
Th is p r osp ect iv e st u d y in v olv ed 8 6 w om en
w it h br east cancer diagnosis, w ho w er e subm it t ed t o
s u r g e r y ( s t a g e s I , I I a a n d I I b ) a n d a d j u v a n t
r a d i o t h e r a p y i n t h e Ra d i o t h e r a p y Ce n t e r s a t t h e
Fed er al Un iv er sit y of São Pau lo ( UNI FESP) an d t h e
Hospit al Alem ão Osw aldo Cr uz ( HAOC) . The Resear ch
Et h ics Com m it t ees f r om b ot h in st it u t ion s ap p r ov ed
t he st udy and all pat ient s signed t he fr ee and infor m ed
con sen t t er m . Dat a w er e collect ed accor din g t o t h e
ev aluat ion inst r um ent , w it h quest ions on hist ological
t y p e , a g e , c o e x i s t e n t d i s e a s e s ( d i a b e t e s ,
hy per t ension) , pr ev ious or concom it ant ant ineoplast ic
t r eat m en t ( sch em e an d d at e) , sm ok in g an d f am ily
cancer hist or y. Wom en older t han 18 year, w ho w er e
su b m it t ed t o q u ad r an t ect om y or m ast ect om y w it h
r e c o n s t r u c t i o n , w e r e i n c l u d e d i n t h e s t u d y.
Rad iot h er ap y w as p er f or m ed on t h e b r east r eg ion ,
t angent ial and parallel opposed fields, w it h a t ot al dose
of 5 0 4 0 cGy ( 1 8 0 cGy d ose/ d ay ) , w it h 6 MeV lin ear
accel er at o r. Tw o t r eat m en t t ech n i q u es w er e u sed :
Sour ce t o skin dist ance ( SSD) and isocent er. The br east
si ze w as o b t ai n ed f r o m t h e co n t o u r d r aw i n g . Th e
dist ance bet w een t he field separ at ion and t he br east
Figu r e 1 – Br east dist an ce m easu r e ( d) an d h eigh t
( h)( 8)
A l l t o p i c a l p r o d u c t s p r e s c r i b e d b y t h e
ph y sician s w er e also r ecor ded, t h ou gh , du e t o t h eir
var iet y, t hey w er e only consider ed as adj unct fact or s
in t he ir r adiat ion effect on t he skin.
Tw o o b ser v er s ( p h y si ci an an d r esear ch er )
ev alu at ed t h e t r eat ed sk in ar ea ev er y w eek d u r in g
t h e s i x w e e k s o f t r e a t m e n t a n d r e a c t i o n s w e r e
classified using t he RTOG scale. Br east s w er e m ar ked
in t h e f ollow in g r egion s: su per ior ex t er ior qu adr an t
( QSE) , su p e r i o r i n t e r n a l q u a d r a n t ( QSI ) , i n f e r i o r
ex t er n al q u ad r an t ( QI E) , in f er ior in t er n al q u ad r an t
( QI I ) , ce n t r a l q u a d r a n t ( QC) a n d i n f r a m a m m a r y
r egion ( I M) . React ion in t he I M region w as considered
only w hen lesion w as locat ed specifically in t his region,
w h ich d if f er en t iat es f r om alt er at ion in t h e in f er ior
q u ad r an t s.
D e g r e e s 1 a n d 2 w e r e g r o u p e d f o r
s t a t i s t i c a l a n a l y s i s b e c a u s e t h e y c a u s e m i l d
sy m p t o m s an d r eq u i r e si m p l e co n d u ct s, w h i ch d o
n ot lim it t h e con t in u it y of t r eat m en t . Fish er ’s t est
w as u sed t o an aly ze cat eg or ical v ar iab les an d t h e
n u m er ical v ar iab le ag e in r elat ion t o sk in r eact ion s.
To e v a l u a t e n u m e r i ca l v a r i a b l e s, b r e a st d i st a n ce
an d h eig h t , in r elat ion t o sk in r eact ion s, b ox - p lot s,
Fi sh e r ’ s t e st a n d Lo g i st i c Re g r e ssi o n w e r e u se d .
To j o i n t l y e v a l u a t e t h e p a r a m e t e r t e ch n i q u e a n d
b r east h eig h t in r elat ion t o sk in r eact ion s, b ox - p lot s
an d Log ist ical Reg r ession w er e u sed . All t est s w er e
f ix ed at a 5 % sig n if ican ce lev el.
RESULTS
Table 1 sh ow s t h e qu an t it y of pat ien t s w it h
degr ee 1, 2 and 3 skin r eact ions.
Ta b l e 1 – I n ci d e n ce o f d i f f e r e n t d e g r e e s o f sk i n
r eact ions due t o r adiot herap y. São Paulo, 2007
s n o i t c a e
R N %
2 d n a 1 s e e r g e
D 71 82.6% 3 e e r g e
D 15 17.4% l
a t o
T 86 100%
Table 2 show s t he st at ist ical result s of logist ic
r egr ession in r elat ion t o br east height .
Table 2 – Final m odel of logist ic r egr ession accor ding
t o br east height . São Paulo, 2007
l e d o
M Coefficient Coefficient r o r r e -d r a d n a t s e v i t p i r c s e D ) p ( l e v e l t n e i c i f f e o C l a i t n e n o p x e t h g i e
H 0.9586 0.2702 <0.001 2.61 t n a t s n o
C -8.5891 2.1120 <0.001 0.00
Chances of occurring degree 3 reactions (RTOG)
increase 2.61 at each increased height unit (cm ).
Th e p a r a m e t e r b r e a s t h e i g h t s h o w e d
st at ist ical significance for t he occur r ence of degr ee 3
r eact ions accor ding t o Figur e 2.
Figur e 2 – Br east height accor ding t o t he t ype of skin
r eact ion ( d1/ d2 e d3) . São Paulo, 2007
Figu r e 3 sh ow s t h e m u lt iv ar iat e an aly sis t o
ver ify t he r elevance of t r eat m ent t echnique and br east
Figure 3 – Height and t r eat m ent t echnique in r elat ion
t o t he t ype of skin r eact ion. São Paulo, 2007
DI SCUSSI ON
Br e a st sk i n r e a ct i o n d u r i n g r a d i o t h e r a p y,
t h ou gh r ev er sible in t h e m aj or it y of cases an d less
fr equent t han in t he past , is t he m ost com m on side
effect in t hese pat ient s and can affect t he t herapeut ic
program and w orsen qualit y of life. I t occurs in several
phases of t he t r eat m ent , init iat es w it h m ild int ensit y
and can dev elop t o an int ense degr ee, hinder ing t he
con t in u it y of applicat ion s. Th is v ar iet y of in t en sit ies
depends on fact or s r elat ed t o r adiat ion and individuals.
Th u s , i n t h i s s t u d y, t h e s e p a r a m e t e r s w e r e
c h a r a c t e r i z e d i n t h e s t u d y p o p u l a t i o n a n d s k i n
r eact ion s w er e cor r elat ed.
An t eced en t ca n cer h i st o r y i s a n ex p ect ed
f a ct o r. Si x t y - f i v e p e r ce n t o f ca n ce r i n ci d e n ce i s
obser v ed in our pat ient s’ fam ilies, w hile an incidence
of u p t o 8 2 . 5 %( 3 ) is f ou n d in lit er at u r e. I t w as n ot
p ossib le t o sh ow sig n if ican ce, p r ob ab ly d u e t o t h e
sam ple n u m ber.
Regarding t he different levels of skin react ions,
t he result s reveal low incidence of degree 3 react ions
( 17. 4% ) in com par ison t o degr ees 1 and 2 ( 82, 6% )
( Table 1) . These dat a ar e com parable t o t hose found
in lit erat ure, in w hich st udies show evolut ion t o degree
3 fr om 10 t o 15% and fr om 7 t o 20%( 9). When t he
b r east r eg ion an d t h e d eg r ee of sk in r eact ion ar e
ev alu at ed, 1 0 0 % of degr ee 3 r eact ion s w er e in t h e
i n f r a m a m m a r y r e g i o n . Su ch r e su l t s a r e f o u n d i n
sev er al st u d i es, w h i ch sh o w t h e p r ed o m i n an ce o f
d e g r e e 3 r e a ct i o n s i n t h i s r e g i o n b e ca u se o f t h e
const ant frict ion and higher hum idit y in t his area( 3,10).
Wit h r egar d t o sm ok in g, t h is f act or did n ot
show st at ist ical significance, pr obably due t o t he low
in ciden ce of sm ok er s in t h is popu lat ion . Th e r esu lt s
show ed only 1 1 . 6 % of sm ok er s ( 1 0 pat ient s) , w hile
only one pat ient pr esent ed degr ee 3 r eact ions. Ther e
is con t r ov er sy in t h e lit er at u r e r egar din g t h is issu e
an d, accor din g t o som e au t h or s, sm ok in g does n ot
i n c r e a s e t h e r i s k s f o r s k i n r e a c t i o n s( 1 ). A n o x i a
c h r o n i c a l l y c a u s e d b y t h e s m a l l e r i n d e x o f
ox y h em og lob in cou ld ev en d im in ish t h e ch an ces of
causing sk in r eact ion because ox y gen funct ions as a
radiosensit izer and it s absence on skin w ould provide
r esist an ce t o t h e r eact ion( 1 ). How ev er, con sid er in g
r ad i o b i o l o g i cal asp ect s, o x y g en d o es n o t sen si t i ze
t issues w it h phy siological lev els of ox y gen but t hose
w it h low lev els. Nev er t h eless, t h e r eact ion cou ld be
w o r s e n e d b e c a u s e o f t h e n i c o t i n e a n d c a r b o n
m on ox id e( 1 1 ) act ion , w h ich can h am p er t h e h ealin g
p r o cess. Th u s, f u r t h er r esea r ch i s n eed ed o n t h e
m ech an ism s of lesion cau sed b y t h e associat ion of
r adiat ion an d sm ok in g an d it s im por t an ce as a r isk
fact or for sk in r eact ions and healing pr ocess.
Regar ding diabet es, only 8.1% of pat ient s in
t h is st u dy pr esen t ed t h e disease. Th e sm all sam ple
size possibly did not per m it st at ist ical significance for
t his param et er. How ev er, no ot her st udy has show ed
diabet es as a pr edisposing fact or for t he incidence of
m or e int ense skin r eact ions. Because it is a syst em ic
pat hology t hat int er fer es in healing phases, how ev er,
it can d elay h ealin g an d ex p ose p at ien t s t o h ig h er
r isk s of infect ion( 6).
I n t e r m s o f h y p e r t e n si o n , o n l y 2 4 . 4 % o f
p a t i e n t s i n t h i s st u d y w e r e h y p e r t e n si v e a n d n o
st at ist ical sign if ican ce w as obt ain ed w it h r elat ion t o
t h e sev er i t y o f sk i n r eact i o n . Hy p er t en si o n i s n o t
consider ed a predict ive fact or of skin react ions, t hough
i t i s a d i sea se f r eq u en t l y a sso ci a t ed t o o t h er co
-m or b id it ies.
The aver age age of pat ient s w ho had degr ee
3 r eact ion s w as h ig h er. Dif f er en ces w er e ob ser v ed
bet w een t h e av er age age of pat ien t s w it h degr ee 1
or 2 ( 58.31) and degr ee 3 r eact ions ( 64.47) , but t hey
per m it t ed bor der line significance, pr obably due t o t he
size of t he sam ple ( p = 0.062) , t hough it suggest s a
t e n d e n cy o f d e g r e e 3 r e a ct i o n s i n o l d e r w o m e n .
Lit erat ure show s t hat radiot herapy is w ell t olerat ed in
old pat ient s and it is not t he only cont raindicat ion for
t h e t r eat m en t( 3 ). Yet , so m e au t h o r s su g g est t h at ,
becau se old people pr esen t sm aller m it osis in dices,
t hey w ould be less sensit ive t o radiat ion, w hich dest roy
w ou ld cau se w eak er sk in r eact ion s( 3 ). How ev er, t h e
elderly also present dim inished product ion of collagen
a n d f i b r o b l a s t s w h i c h , w h e n a s s o c i a t e d t o c o
-m or bidit ies ( -m ost fr equent in older w o-m en) , can har -m
t he healing pr ocess( 3).
The r esear cher s hav e obser v ed in t heir daily
p r act ice t h at ag e p er se is n o r eason f or con cer n .
N e v e r t h e l e s s , w h e n a g e i s a s s o c i a t e d t o c o
-m or bidit ies, pat ient s deser ve a car e pr ogr a-m focused
not only on skin r eact ions, but also on encour agem ent
t o self care and m aint enance of healt h in ot her levels,
lik e t he em ot ional and phy sical, am ong ot her s.
Reg ar d in g t r eat m en t ch ar act er ist ics, it w as
obser v ed in t his st udy t hat pr ev ious or concom it ant
chem ot her apy w it h r adiot her apy w as not a significant
fact or for t he sever it y of skin r eact ions, pr obably also
b ecau se of t h e sm al l n u m b er of p at i en t s i n t h ese
sit u at ion s. Dif f er en t pr ot ocols an d dr u gs w er e u sed
for t he t reat m ent . Lit erat ure does not show significant
int er fer ence of pr e- r adiot her apy chem ot her apy in skin
r eact ion, but explains t hat young pat ient s have a high
cellu lar t u r n - ov er, w h ich in cr eases su scep t ib ilit y t o
adverse react ions in t he sit e( 12). How ever, st udies have
s h o w n t h a t c h e m o t h e r a p y c o n c o m i t a n t w i t h
r adiot her apy significant ly incr eases sk in r eact ions in
t h e s e p a t i e n t s . S t u d i e s h a v e a l s o s h o w n t h a t
ant r acy clic dr ugs cause m or e adv er se r eact ions t han
t h e associat ion of Cy clop h osp h am id e, Met h ot r ex at e
an d 5 - Flu or ou r acil ( CMF) , t h ou gh bot h can in t er fer e
in t he int ensit y and sev er it y of sk in r eact ions( 2).
No st at ist ically significant difference w as found
i n t h i s s t u d y r e g a r d i n g t h e u s e o f c o n c o m i t a n t
h or m on ot h er apy. Again , t h is r esu lt m igh t be du e t o
t he sm all num ber of pat ient s w it h t his char act er ist ic.
Th e i n f l u e n c e o f t a m o x i f e n o n t h e i n c i d e n c e o f
pulm onar y fibr osis has been show ed, but it s effect on
sk in has not been r epor t ed( 10).
Recon st r u ct iv e su r ger ies w er e per f or m ed in
1 1 pat ient s ( 1 2 . 7 % ) . The sm all sam ple size did not
p er m it v er if y in g st at ist ical sig n if ican ce in t h is case
eit her, but no pat ient s developed degr ee 3 r eact ions
in t h is st u dy. Th er e is con t r ov er sy in t h e lit er at u r e
r eg ar d in g r ad iot h er ap y af t er b r east r econ st r u ct ion
su r ger y, t h ou gh t h e gr eat con cer n is r elat ed t o t h e
lat e effect s of r adiot her apy and not t o sk in r eact ions
dur ing or r ight aft er t he t r eat m ent( 13). I n r elat ion t o
d a t a o b t a i n e d i n t h i s s t u d y, p o s s i b l y b e c a u s e
r econst r uct ed br east s ar e sm aller and not flab, t hey
d o n o t f av o r h u m i d i t y, f r i ct i o n an d h i g h er d o sag e
d i s t r i b u t e d o n t h e s k i n , w h i c h w o u l d p r e v e n t
in f r am am m ar y r eact ion s.
Regar ding t opical t her apy, 65. 1% ( N= 56) of
p at ien t s u sed cr eam s p r escr ib ed b y r ad iot h er ap ist s
and t her e w as a gr eat v ar iet y of pr oduct s. Ther e is
con t r ov er sy on t h eir goal, r egar din g t h e pr ev en t ion
of sk in r eact ion s, r elief of sy m p t om s or t r eat m en t
w i t h t h e s e v e r a l p r o d u c t s s t u d i e d( 3 - 4 , 6 , 1 1 - 1 4 ).
Cor t icost er oid s an d n on - st er oid al an t i- in f lam m at or y
d r u g s ar e f r eq u en t ly u sed f or m od er at e t o in t en se
r eact ions. How ever, t hey do not dim inish inflam m at or y
response, delay all phases of t he healing process and
in cr ease t h e r isk of local in f ect ion . Th u s, t h ey ar e
indicat ed for a lim it ed t im e per iod( 3).
Sev er al st udies consider br east size of gr eat
im por t ance because t he v olum e ir r adiat ed is a fact or
r elat ed t o r ad iat ion an d in t er f er es in t h e in cid en ce
and sever it y of side effect s. Ther e ar e sever al m odels
of br east m easu r e t o r elat e w it h sk in r eact ion . Th e
br a size, m axim um br east diam et er( 10) and volum e in
cen t im et er s3 w er e con sid er ed( 1 4 ). Th e b r east cu r v e
dr aw ing obt ained in t he planning for dosage calculat ion
w as u sed in t h is st u dy as pr ev iou sly r epor t ed. Th is
m easu r e is con sid er ed r eliab le an d easy t o ob t ain
a n d r e p r o d u c e . Th e m e a s u r e s w e r e s t a t i s t i c a l l y
analy zed r egar ding t heir influence on sk in r eact ion.
B r e a s t d i s t a n c e w a s n o t a s t a t i s t i c a l l y
significant fact or in t he dat a analysis. The researchers
b e l i e v e t h a t t h i s r e su l t o ccu r r e d b e ca u se b r e a st
dist ance does not necessarily represent larger breast s.
I n r elat ion t o t he br east height , t his par am et er show ed
st at ist ical significance for t he occur r ence of degr ee 3
r eact ions ( Figur e 2) . Pat ient s w it h degr ee 3 react ions
pr esent ed a higher aver age br east height t han pat ient s
w it h degr ee 1 and 2 r eact ions ( 8.15 cm and 6.53cm
r esp ect i v el y ) . La r g er b r ea st v o l u m es r eq u i r e t h a t
lar ger doses be applied on sk in t o r each t he desir ed
dosage in t issue and deeper st r uct ur es. I n addit ion,
adipose t issue has lit t le vascularizat ion and can delay
any healing pr ocess( 6). These result s corroborat e w it h
t h ose f ou n d in lit er at u r e t h at sh ow a pr opor t ion ally
m o r e i n t e n se sk i n r e a ct i o n i n m e d i u m a n d l a r g e
br east s( 15). Dat a in t he pr esent st udy also show t hat
t he chance of degr ee 3 r eact ions incr eases 2.61 t im es
at each height unit ( cm ) ( Table 2) .
Re g a r d i n g t h e t r e a t m e n t t e ch n i q u e u se d ,
st at ist ical differ ence w as found in univ ar iat e analy sis
bet w een t he isocent er and SSD t echniques, show ing
t hat t he isocent er t echnique w ould increase t he chance
of d eg r ee 3 sk in r eact ion s. Nev er t h eless, n o st u d y
w as found com par ing t hese t w o t echniques or show ing
higher incidence of sk in r eact ion w hen t he isocent er
Recebido em : 9.5.2007 Apr ovado em : 10.8.2008
Th er ef or e, m u lt iv ar iat e an aly sis h ad t o b e
u s e d t o v e r i f y t h e i m p o r t a n c e o f t h e t r e a t m e n t
t ech n iqu e an d br east h eigh t for sk in r eact ion s. Th is
r esu lt def in it ely sh ow ed t h at t h e t ech n iqu e is n ot a
significant par am et er for t he occur r ence of degr ee 3
sk i n r e a ct i o n s, w h e n b r e a st h e i g h t i s co n si d e r e d
( Figur e 3) .
When t he r esult s w er e j oint ly analyzed, t hey
r ev ealed low incidence of degr ee 3 sk in r eact ions in
t h e st u d y p o p u l a t i o n , a n d a l so t h a t , w h e n t h e y
occu r r ed , t h e i n f r am am m ar y r eg i on w as t h e m ost
fr equent ly affect ed ar ea. They also show t hat br east
v olum e is t he m ost im por t ant fact or for t he sev er it y
of skin r eact ions in pat ient s subm it t ed t o r adiot her apy
in t h e b r east r eg ion . Desp it e t h e low in cid en ce of
sev er e sk in r eact ion, car e w it h t he ir r adiat ed sk in is
a r elev an t f act or f or r ad iot h er apy in b r east can cer.
Th e r e i s l i t t l e c o n s e n s u s b e t w e e n i n v o l v e d
p r o f e s s i o n a l s , a n d k n o w l e d g e a d v a n c e m e n t s
r egar din g t h e car e of w ou n ds h av e lit t le im pact on
pat ient s w it h skin r eact ions caused by r adiat ion( 16- 18).
I n t his cont ext , t he nurse is an im port ant professional
in care for t hese pat ient s. Such care has t o be based
on each p at ien t ’s- in d iv id u al d at a, b r east p h y sical
ex am , an d dat a collect ion on plan n in g, w it h special
at t en t ion t o b r east h eig h t . Th ese p r oced u r es allow
for bet t er ev aluat ion of t he pr obabilit y of undesir able
effect s of r adiot her apy and, t hen, adequat e planning
and individualized car e w it h a view t o an unint err upt ed
t r eat m ent and, consequent ly, bet t er clinical r esponse.
These m easur es allow for opt im izat ion of r adiot her apy
and nur sing car e deliv er ed t o t hese pat ient s.
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